[Senate Hearing 118-53]
[From the U.S. Government Publishing Office]
S. Hrg. 118-53
PEPFAR AT 20: ACHIEVING AND
SUSTAINING EPIDEMIC CONTROL
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON FOREIGN RELATIONS
UNITED STATES SENATE
ONE HUNDRED EIGHTEENTH CONGRESS
FIRST SESSION
__________
APRIL 19, 2023
__________
Printed for the use of the Committee on Foreign Relations
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via http://www.govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
52-968 PDF WASHINGTON : 2023
COMMITTEE ON FOREIGN RELATIONS
ROBERT MENENDEZ, New Jersey, Chairman
BENJAMIN L. CARDIN, Maryland JAMES E. RISCH, Idaho
JEANNE SHAHEEN, New Hampshire MARCO RUBIO, Florida
CHRISTOPHER A. COONS, Delaware MITT ROMNEY, Utah
CHRISTOPHER MURPHY, Connecticut PETE RICKETTS, Nebraska
TIM KAINE, Virginia RAND PAUL, Kentucky
JEFF MERKLEY, Oregon TODD YOUNG, Indiana
CORY A. BOOKER, New Jersey JOHN BARRASSO, Wyoming
BRIAN SCHATZ, Hawaii TED CRUZ, Texas
CHRIS VAN HOLLEN, Maryland BILL HAGERTY, Tennessee
TAMMY DUCKWORTH, Illinois TIM SCOTT, South Carolina
Damian Murphy, Staff Director
Christopher M. Socha, Republican Staff Director
John Dutton, Chief Clerk
(ii)
C O N T E N T S
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Page
Menendez, Hon. Robert, U.S. Senator From New Jersey.............. 1
Risch, Hon. James E., U.S. Senator From Idaho.................... 3
Nkengasong, Hon. John N., Ph.D., U.S. Global Aids Coordinator,
U.S. Special Representative for Global Health Diplomacy, United
States Department of State, Washington, DC..................... 4
Prepared Statement........................................... 6
John, Sir Elton, Founder, Elton John Aids Foundation, London,
United
Kingdom........................................................ 18
Prepared Statement........................................... 20
Dybul, Hon. Mark, M.D., Professor of Medicine and Chief Strategy
Officer, Georgetown University Medical Center for Global Health
Practice and
Impact......................................................... 22
Prepared Statement........................................... 24
Additional Material Submitted for the Record
Testimony of Dr. Eric Goosby and Dr. Richard Marlink............. 25
Responses of Dr. John Nkengasong to Questions Submitted by
Senator Bill Hagerty........................................... 38
Statement From David J. Kramer, George W. Bush Institute, Dated
April 19, 2023................................................. 41
(iii)
PEPFAR AT 20: ACHIEVING AND
SUSTAINING EPIDEMIC CONTROL
----------
WEDNESDAY, APRIL 19, 2023
U.S. Senate,
Committee on Foreign Relations,
Washington, DC.
The committee met, pursuant to notice, at 10:03 a.m., in
room SD-419, Dirksen Senate Office Building, Hon. Robert
Menendez presiding.
Present: Senators Menendez [presiding], Cardin, Coons,
Kaine, Booker, Van Hollen, Risch, Young, Barrasso, and
Ricketts.
OPENING STATEMENT OF HON. ROBERT MENENDEZ,
U.S. SENATOR FROM NEW JERSEY
The Chairman. This hearing of the Senate Foreign Relations
Committee will come to order.
To speak about ending the scourge of HIV/AIDS is to speak
of a miracle. When the President's Emergency Plan for AIDS
Relief was established in 2003, for most people around the
world an HIV/AIDS diagnosis was a death sentence, but 20 years
later, through the generosity of the American people and one of
the most successful foreign assistance programs in history, we
have changed the course of human history.
We have given millions of people access to lifesaving
treatment and today's hearing comes at a critical time as we
prepare to reauthorize the President's Emergency Plan for AIDS
Relief, or PEPFAR as it is known.
This next 5 years will determine whether we meet the goal
of ending the global HIV/AIDS epidemic by 2030. We must not
take our foot off the accelerator if we hope to be successful.
I would like to thank our witnesses, Dr. John Nkengasong,
Sir Elton John, and Professor Mark Dybul for appearing before
us today. I look forward to your frank assessment of the state
of HIV/AIDS epidemic, your thoughts on what the United States
and our partners in the international community can do to
achieve the goal of ending this epidemic by 2030 because, as
you know, major challenges still remain.
It is not just that COVID-19 slowed access to HIV services.
New infections are not declining as fast as we would like.
There are more and more cases among Africa's surging young
populations with young women and adolescent girls twice as
likely to be affected--infected, I should say--as young men.
Children, the most vulnerable population, continue to be at
the highest risk. According to UNAIDS, at the end of 2021, 76
percent of adults living with HIV were assessing treatment
compared to only 52 percent of children.
We have also seen a disturbing trend towards criminalizing
key high-risk populations like Uganda's recently approved anti-
homosexuality act of 2023. These laws drive vulnerable
communities underground, keeping them from accessing testing,
prevention technologies, and essential medicines, all of which
increases the number of infections and undermines years of
investment.
We cannot eradicate this epidemic if we leave communities
behind nor can we sustain the progress that has already been
made unless our partners fulfill their commitments.
During the Abuja Summit in 2001, African leaders pledged 15
percent of their budgets for health. Today, only three
countries are honoring that commitment.
Of course, while we cannot achieve our goals without
support from heads of state in PEPFAR countries, the United
States must continue to show leadership at this crucial time.
Our country has not overcome our greatest challenges by
taking them on half-heartedly. When it comes to defeating one
of the most devastating epidemics we have ever seen, we need to
make sure our investments in PEPFAR have the greatest impact
possible.
That means ensuring that PEPFAR activities strategically
strengthen health systems to improve overall health security,
including at the community level. It means doubling down on
building secure supply chains, on training health workers, on
building lab capacity, and on the ability of partner countries
to prevent, detect, and respond to infectious diseases,
especially those with pandemic potential.
It also means tailoring our investments to reflect partner
nations' priorities. If we do this right we not only lower
costs and improve efficiencies in health systems across the
board, we can end the AIDS epidemic as a public health threat
by 2030.
The gains we have already seen speak for themselves.
Twenty-five million lives have been saved, 5.5 million babies
have been born HIV-free in over 50 countries, and more than 20
million people are on antiretroviral treatment.
Since 2004 we have reduced the number of people being
infected with HIV/AIDS across PEPFAR countries by 52 percent.
PEPFAR has achieved far more beyond the disease itself than any
one of us could have envisioned.
We have seen declines in mortality, improvements in
maternal and child health, more girls and boys staying in
school, and more than 2 percent GDP gains in PEPFAR-supported
countries.
The initiative is a testament to what the Congress and the
executive branch can do and we agree to lead collective action
to address global challenges.
Today, as we stand on the brink of an even greater
achievement, the end of the epidemic, we cannot and should not
turn back. Success is within our grasp.
I look forward to hearing from our witnesses about how we
cross the finish line. It is the chair's intention to get this
legislation reauthorized. We look forward to working with the
ranking member on this.
With that, we turn to the ranking member for his opening
statement.
STATEMENT OF HON. JAMES E. RISCH,
U.S. SENATOR FROM IDAHO
Senator Risch. Thank you very much, Mr. Chairman. Despite
which party controls Congress, the White House, over the last
20 years the bipartisan coalition that supports PEPFAR remains
strong.
That is because the basic principles of effective
resourcefulness, transparency, accountability, and results were
part of PEPFAR's DNA from the very beginning.
Also, through PEPFAR we have helped transform health
systems and build foundations for broader health security,
including for pandemic preparedness, but more than anything, I
believe support for PEPFAR remains strong because its success
is measured in lives saved, and we have saved millions of
lives.
PEPFAR, clearly, is a model. That is why it served as the
model for my recently enacted Global Health Security and
International Pandemic Prevention, Preparedness and Response
Act, but it is also an undeniable expression of the values and
interests that make us uniquely American.
This is a legacy which we can all be proud of. I urge my
colleagues to join me in working to reauthorize PEPFAR without
delay and without new mandates and directives.
As our witnesses I am sure will testify, the coordinator
already has the authorities required to ensure PEPFAR remains
fit for purpose while preserving core U.S. values and advancing
longstanding sustainability and self-reliance.
This includes authority to direct funds set aside for
orphans and vulnerable children, towards supporting adolescent
girls who are the most vulnerable to new infections, as well as
for closing gaps in pediatric treatment.
It also includes authority to ensure that PEPFAR-supported
maternal and child health activities deliver results by
preventing mother-to-child transmission.
The requirement to devote not less than half of the budget
toward lifesaving treatment and care must be preserved, which
is all the more appropriate now that treatment has become a
proven form of prevention.
Finally, we must extend the 33 percent cap on U.S.
contributions to the Global Health Fight to AIDS, Tuberculosis
and Malaria, which was put in place to ensure other donors were
generously providing their fair share rather than expecting the
United States to do it all.
It also includes other withholding requirements relating to
transparency and accountability at the fund. This is a
reauthorization and we do not need to recreate the wheel. Also,
we do not need to incorporate new directives relating to
sustainability. We already did that back in 2013.
Let us not bog down the process by wordsmithing what
already exists. This program is too important for that.
Instead, let us advance a clean reauthorization and get on with
the business of rigorous oversight, including close scrutiny of
PEPFAR's local implementing partners.
I hope we can all agree and commit to advancing a timely,
clean reauthorization of this values-based lifesaving program.
Thank you, Mr. Chairman.
Mr. Chairman, I would like to include for the record a
statement from the George W. Bush Institute.
The Chairman. Without objection, and thank you for your
statement.
[Editor's note.--The information referred to above can be found
in the ``Additional Material Submitted for the Record'' section
at the end of this hearing.]
The Chairman. Let us turn to our first panel.
With us on behalf of the Administration is Dr. John
Nkengasong, who serves as the U.S. Global AIDS Coordinator
Special Representative for global health diplomacy.
In his role, Dr. Nkengasong leads, manages, and oversees
the U.S. President's Emergency Plan for AIDS Relief where he
works to prevent millions of HIV infections, save lives, and
make progress towards ending the HIV/AIDS pandemic.
Prior to this role, Dr. Nkengasong was appointed as the
first director of the Africa Centers for Disease Control and
Prevention. During his tenure, he was also appointed as one of
the World Health Organization's special envoys on COVID-19
preparedness and response.
He has also served in the division of global HIV and
tuberculosis at the U.S. Centers for Disease Control and
Prevention. It was good to join you in Africa in February, Dr.
Nkengasong, where we saw firsthand some of the work that we are
doing.
We welcome you to the committee and please proceed with
your testimony.
STATEMENT OF THE HONORABLE JOHN N. NKENGASONG, PH.D., U.S.
GLOBAL AIDS COORDINATOR, U.S. SPECIAL REPRESENTATIVE FOR GLOBAL
HEALTH DIPLOMACY, UNITED STATES DEPARTMENT OF STATE,
WASHINGTON, DC
Dr. Nkengasong. Thank you, Chairman Menendez, Ranking
Member Risch, and other distinguished committee members. I am
deeply honored to appear before the Senate Foreign Relations
Committee, which has provided visionary leadership for PEPFAR
since its inception in 2003.
In the past 20 years PEPFAR has saved 25 million lives.
PEPFAR has strengthened health systems and PEPFAR has changed
because of HIV/AIDS pandemic. The American people should be
proud of these remarkable achievements of their achievements.
We all know that these gains are fragile and without
continued leadership of this Congress, we risk reversing the
gains with every surging of the HIV/AIDS pandemic.
Back in 2003, HIV/AIDS was a death sentence and, for
instance, in Africa, average life expectancy had dropped
significantly by 35 years in Zimbabwe, 12 years in South
Africa.
This year we are celebrating the 20th anniversary of PEPFAR
and it has been without doubt the greatest act of humanity in
the history of fighting infectious diseases. Thanks to the
generosity of the American people, PEPFAR's investments are
supporting over 20 million people on lifesaving treatments and
have prevented HIV infections in 5.5 million babies.
PEPFAR has also played a key role in transforming
societies. For example, in PEPFAR-supported countries GDP per
capita has grown two percentage points faster, and girls and
boys are nine percentage points more likely to be in school.
The previously unthinkable goal of ending HIV/AIDS as a
public health threat is now within our grasp, all due to the
unwavering commitment of the members of this committee and the
bipartisan bicameral support of 10 Congresses and four
administrations.
Our focus is on the goal of ending HIV/AIDS pandemic by
2030. On December 1, World AIDS Day, we released a 5-year
strategy that provides a plan for how to get there and I want
to share a few highlights.
One key area of focus is health equity. There are still 1.5
million new HIV infections globally and over 650,000 AIDS-
related deaths each year. A disproportionate number of these
are in three categories: adolescent girls and young women,
children, and five key populations. We must continue to know
our gaps and close our gaps.
To lead with data and follow the science, we must align our
programs to locations and populations where HIV/AIDS is the
most concentrated. We will work with affected communities,
partner governments, the private sector, and civil society
partners to ensure the dignity of all people.
Another key area of focus is sustaining the response. HIV
is a lifelong disease and our partner countries will be
responsible for supporting millions of people on treatment for
the remainder of their lives.
For the first time in PEPFAR's history I had the honor of
addressing a special session of 33 heads of states at African
Union's summit in February.
That session resulted in a declaration that the head of
states will host a dedicated summit later this year to develop
a roadmap of action and investment through 2030. As PEPFAR we
work hand-in-hand with partner country governments to advance
these commitments.
Mr. Chairman and all members of this distinguished
committee, what once was unimaginable is now very possible.
That is ending HIV/AIDS as a public health threat by the year
2030.
Yet, our gains are incredibly fragile. If a person living
with HIV does not have access to medication for just 3 weeks
their viral load will increase and they will be a risk for
transmission and developing AIDS.
With your leadership we can protect our gains and reach the
2030 goals. That is why I look forward to working with this
committee to reauthorize PEPFAR. Thank you for the ongoing
support for PEPFAR's work and I look forward to your questions.
[The prepared statement of Mr. Nkengasong follows:]
Prepared Statement of Dr. John Nkengasong
Thank you, Chairman Menendez, Ranking Member Risch, and other
distinguished Committee members. I am deeply honored to appear before
the Senate Foreign Relations Committee, which has provided visionary
leadership for PEPFAR since its inception in 2003.
In the last 20 years, PEPFAR has saved 25 million lives, PEPFAR has
strengthened health systems, and PEPFAR has changed the course of the
HIV/AIDS pandemic. The American people should be proud of these
remarkable achievements as they are their achievements. We all know
that these gains are fragile and without continued leadership of this
Congress, we risk reversing the gains with a resurgence of the HIV/AIDS
pandemic.
Back in 2003, HIV/AIDS was a death sentence and for instance in
Africa, average life expectancy had dropped significantly by 35 years
in Zimbabwe and 12 years in South Africa.
This year, we are celebrating the 20th anniversary of PEPFAR--and
it has been, without a doubt the greatest act of humanity in the
history of infectious disease. Thanks to the generosity of the American
people, PEPFAR's investments are supporting over 20 million people on
lifesaving treatment and have prevented HIV infections in 5.5 million
babies.
PEPFAR has also played a key role in transforming societies. For
example, in PEPFAR-supported countries, GDP per capita has grown 2
percentage points faster, girls and boys are 9 percentage points more
likely to be in school.
The previously unthinkable goal of ending HIV/AIDS as a public
health threat is now within our grasp, all due to the unwavering
commitment of the members of this Committee and the bipartisan,
bicameral support of 10 Congresses and four Administrations.
Our focus is on the goal of ending the HIV/AIDS pandemic by 2030.
On December 1, World AIDS Day we released a 5-year strategy that
provides a plan for how to get there and I want to share a few
highlights.
One key area of focus is health equity. There are still 1.5 million
new HIV infections globally and over 650,000 AIDS-related deaths each
year. A disproportionate number of those are in three categories--(1)
adolescent girls and young women, (2) children, and (3) the five key
populations. We must continue to know our gaps and close our gaps.
To lead with data and follow the science, we must align our
programs to locations and populations where HIV/AIDS is the most
concentrated. We will work with affected communities, partner
governments, the private sector and civil society partners to ensure
the dignity of all people.
Another key area of focus is sustaining the response. HIV is a
lifelong disease, and our partner countries will be responsible for
supporting millions of people on treatment for the remainder of their
lives.
For the first time in PEPFAR's history, I had the honor of
addressing a special session of 33 Heads of State at the African Union
Summit this February. That session resulted in a declaration that the
Heads of State will host a dedicated summit later this year to develop
a roadmap of actions and investments to 2030. As PEPFAR, we work hand-
in-hand with partner country governments to advance these commitments.
Mr. Chairman and all members of this distinguished Committee, what
once was unimaginable is now very possible--ending HIV/AIDS as a public
health threat by 2030. Yet our gains are incredibly fragile. If a
person living with HIV does not have access to medication for just 3
weeks, their viral load will increase and they will be at risk for
transmission and developing AIDS. With your leadership, we can protect
our gains and reach the 2030 goal.
That is why I look forward to working with this committee to
reauthorize PEPFAR. Thank you for the ongoing support for PEPFAR's
work. I look forward to your questions.
The Chairman. Thank you, Dr. Nkengasong. Maybe you could do
a little seminar for your colleagues at the Department of
State. You did not use your full 5 minutes. It is welcome so
that you gave us some time back.
Let me start off--we will start a round of 5-minute
questions, and let me just say for the record there are a
series of our colleagues who are very interested in this
subject matter, but unfortunately there is a hearing at the
same time before the Foreign Operations Appropriations
Committee with Samantha Power and so both the chairman, Senator
Coons and Senators Shaheen, Murphy, and Schatz have all of
their members there.
I just want to express that they are very interested in
reauthorization and could not be here because of that conflict.
Ambassador, our respective staffs have engaged as we work
towards reauthorization. I understand your office has provided
data related to the earmarks on care and treatment in orphans
and vulnerable children that already currently reside in the
PEPFAR statute.
Can you say with 100 percent certainty that in the next 5
years you will not need to pursue a waiver for earmarks
currently in law through the appropriations process? If you are
not 100 percent sure, what steps do we need to take to the
reauthorization process to ensure you have the tools and the
flexibility that you need?
Dr. Nkengasong. Thank you. Thank you, Mr. Chairman.
Absolutely certain that in 5 years, currently. The current
authorities that we have has enabled us to get this far and we
believe that----
The Chairman. Is your microphone on? I am sorry.
Dr. Nkengasong. Oh. Excuse me.
Mr. Chairman, I can absolutely state that we do not need
any additional authority. The current authority that we have
will enable us to continue to respond appropriately as we have
done over the last 20 years.
The Chairman. Okay. Can I have your commitment that our
staffs can meet within the next week to discuss further the
data that you provided to the committee, which has led to the
conclusion that earmarks will not need to be adjusted before
2028?
Dr. Nkengasong. We would certainly continue to work with
your staff as we have done previously, Mr. Chairman.
The Chairman. Now, one of the issues your office has
identified as a challenge to ending AIDS by 2030 is that PEPFAR
needs to reach the vulnerable 24- to 35-year-old cohort. Young
women and adolescent girls in sub-Saharan Africa remain
disproportionately vulnerable to infection.
If we do not break that cycle, I fear that the decline in
new infection rates will continue to slow and may stagnate,
preventing countries from reaching epidemic control.
The DREAMS program--Determined, Resilient, Empowered, AIDS
Free, Mentored, and Safe--targets young women ages 15-24 and
has proven quite effective in providing young women with the
tools to prevent infection.
My question is how are you reaching women aged 24-35 with
targeted interventions to reduce their vulnerability? What
about men in that age cohort?
Dr. Nkengasong. Thank you, Mr. Chairman.
As you already said that--the age group 24-35 is extremely
concerning, especially adolescent girls and young women. Our
statistics from UNAIDS indicate that adolescent girls and young
women in that age group are 14 times more vulnerable than the
corresponding males in that category.
We have continued to develop a comprehensive prevention
program that includes the DREAMS, that program you just
mentioned, but also very importantly continue to expand and
scale up a PrEP, which is a pre-exposure prophylaxis.
We believe that these interventions as a basket or a
collective of odd interventions is what is required in this age
group.
The Chairman. Given the youth bulge in Africa and the
decline in new infections, what might PEPFAR need to do
differently, if anything, to ensure that we meet the 2030
targets?
Dr. Nkengasong. I believe, Mr. Chairman, that we have to,
as we at PEPFAR are promoting, to really scale-up awareness
campaigns in the youth population. If you recall, as we have
all said in this session that 20 years ago the young people
that we are seeing now did not see the ugly face of HIV/AIDS.
Across the board, regardless of whether males or females,
now we see that young age are sexually active and we need to
create a movement initiative that will create awareness and
make sure that this young age understands that HIV/AIDS is not
over.
The fact that they are not seeing it every day, they do not
see people lying in hospital beds means that it is over. It is
far from over.
The Chairman. Finally, at the International AIDS Conference
in 2022 participants launched a new global alliance to end AIDS
in children by 2030.
Twelve African countries committed to integrate pediatric
treatment into their national HIV/AIDS plans in the wake of the
conference, a laudable goal, given that 52 percent of HIV
positive children worldwide aged zero to 14 years were on
treatment compared to 76 percent of HIV positive adults.
Children account for 15 percent of all AIDS-related deaths,
despite making up 4 percent of total HIV positive cases.
What are the obstacles to reaching children with treatment
and how do you plan to address them, and how are you as the
Global AIDS Coordinator working with African leaders to support
them in honoring their commitments, including ending AIDS in
children by 2030?
Dr. Nkengasong. Thank you, Mr. Chairman.
The issue of HIV infections in children is critical. If
you--as I stated in my statement, it is the top priority, one
of the three key areas that--or priority populations that we
are engaging, which is the children, adolescent girls, and
young women and key populations.
PEPFAR is completely committed and aligned with UNAIDS and
Global Fund in the lands you just mentioned. After the AIDS
conference in Montreal, an initiative was launched in Tanzania
just recently in February where we are all committed to
ending--to fighting HIV/AIDS in children.
There are several obstacles that age group--that particular
population segment faces: ability to access diagnostics, point-
of-care diagnostics, finding those children in communities, and
issues of stigmatization.
We would have to work collectively with partner countries,
with our Global Fund colleagues and UNAIDS, of course, with WHO
to continue to advance our basic critical priority, an area of
inequity that a new strategy highlights clearly.
As to what we are doing with engagement with the partner
countries, as I just indicated in my statement, that is a top
priority for me personally.
I was on the continent of Africa in February and actually
for the first time address territory head of states and asked
for their commitment to the Abuja Declaration as well as to
recommitting their political will and domestic resources to
financing HIV/AIDS.
A special summit is planned for October this year and we
are working with UNAIDS and, of course, the African Union to
host that summit, which will focus uniquely on a roadmap to
getting to 2030, what political commitment, domestic financing,
and programming are required to partner with us to get us
there.
The Chairman. We look forward to that conference.
Senator Risch.
Senator Risch. Thank you, Mr. Chairman.
Ambassador, we have before us a reauthorization, which is
not uncommon in these legislative halls, and what we are
talking about here, hopefully, is we use the word ``clean''--a
``clean'' reauthorization. It is a legislative term of art.
``Clean'' is in air quotes, I guess.
What is your position on that? The reason I raise this is
frequently when we do reauthorizations, people strive to make
something better, but sometimes cause a lot more grief as they
try to make it better.
Are you satisfied with what would be a clean
reauthorization here and that is reauthorizing what we have in
front of us. Are you satisfied with that?
Dr. Nkengasong. Senator, I am very satisfied with that.
As I indicated earlier, I have the authorities in the
current format to continue to advance our programming. It is
what has brought us this far to saving 25 million lives,
preventing 5.5 million children born free of HIV/AIDS, and
strengthening our health systems that are being used--currently
used in sustaining the gains in HIV/AIDS, but also positioning
it to fight other infectious diseases such as Ebola and COVID,
as we saw.
I am very convinced that I do have the authority that is
necessary in the current format of PEPFAR law.
Senator Risch. I share that view and I hope others do so
that we can move it rapidly through and not get hung up. We get
high-centered once in a while when we try to reinvent the
wheel.
I do not want to get too far in the weeds here, but we are
told the Administration has decided to give you some additional
responsibilities for global health security, but placed the
additional resources for global health security at USAID.
Can you speak to this issue at all?
Dr. Nkengasong. Thank you, Senator.
As you know, in December of last year Secretary Blinken
announced the establishment of a new bureau, the Bureau of
Global Health, Security, and Diplomacy within the State
Department, which will be headed by myself, and I believe it is
a very exciting moment because it offers a unique opportunity
for us to coordinate global health security efforts, to
leverage assets across USG, and continue to lead with diplomacy
across the board and those are elements that I believe are so
critical for protecting ourselves and protecting the world as
we see and will continue to fight emerging infectious diseases,
including the current pandemic.
In doing so, the goal is to consolidate PEPFAR and, of
course, health security into one bureau that I believe will
create more efficiencies underneath one roof and under my
leadership. I am looking forward to when the bureau will be
fully launched.
Senator Risch. You are satisfied that you can overcome any
of the challenges about this dichotomy with responsibility for
execution versus responsibilities?
Dr. Nkengasong. Senator, I think we will continue to work
across the agencies. I think the only way to make the bureau as
successful as it is intended is to work in unison across the
Department and across the agencies.
I think that is the whole intent to increase efficiencies
and coordination within the global health security space.
Senator Risch. Thank you. Thank you, Mr. Chairman.
The Chairman. Thank you.
Senator Kaine.
Senator Kaine. Thank you, Mr. Chair, and Dr. Nkengasong,
thank you for your long, passionate service in this area.
I want to ask some questions about Latin America, where
trends are not going in a positive direction. Between 2010 and
2021, the number of new infections in Latin America increased
by about 5 percent. That was at the same time as global
infections were dropping by 32 percent, and even in the
Caribbean nearby, infections were dropping 28 percent.
In May, about a year ago during a visit to Panama, the
First Lady announced some significant additional funding from
PEPFAR to Latin America, including direct funding to Panama.
I wanted to ask you, just, how can PEPFAR prioritize its
engagement in Latin American countries to try to deal with this
trend that is going in the wrong direction?
Dr. Nkengasong. Thank you, Senator.
Any trends in HIV new infections that are headed in the
new--in a different direction is really concerning because it
will not--it will continue to be a challenge for us to get to
our 2030 goals, which we see differences in countries that have
prioritized HIV response and where resources, especially PEPFAR
resources and assets, have been applied to. Those tendencies
are in the right direction and at times are really speeding
towards the 2030 goals.
We currently are investing $80 million per year in
supporting regional programs in the Western Hemisphere. That is
excluding Haiti, which has a budget envelope of about $100
million a year.
We just had a regional meeting in that region just a few
weeks ago where we brought our countries together to
strategically develop plans to continue to fight HIV/AIDS in
the region.
I think we also want to be sure that it continues to be at
the fore of the political agenda in the region. I really hope
that in the coming months I should be able to go to the region
and continue to maintain that political momentum, which I
believe is so critical in elevating the issue, because as I
said earlier, Senator, the HIV/AIDS phase--ugly phase has
disappeared thanks to our efforts.
I call that being vulnerable to our own success and we have
to continuously elevate that issue to the political leadership
so that it remains visible.
We will continue to work with the 11 countries in the
region as equally as we are working in other regions of the
world.
Senator Kaine. Excellent. I would encourage you in that,
and I think one of the challenges in Latin America has been
political instability, COVID, economic challenges that push
migrating populations so folks who are disproportionately
likely to have HIV/AIDS are also pushed, because of factors, to
move country to country.
It is a little bit harder sometimes to deal with migrating
populations, but I would encourage you in that way.
The second thing I want to ask, really my last question, is
just for folks following this from the 20th anniversary, we
think of PEPFAR as a very successful strategy to deal with HIV/
AIDS.
It also involved the dramatic investments and improvements
in the public health infrastructure in many of these countries
that have benefits far beyond just in the HIV/AIDS space. When
you build up a public health infrastructure, you are better
able to deal with COVID, you are better able to deal with other
conditions.
Talk a little bit about how PEPFAR's investment in public
health infrastructure has had benefits even beyond HIV/AIDS.
Dr. Nkengasong. Thank you, Senator, for that question.
I usually refer to--when I look back at PEPFAR 20 years ago
the biblical Lazarus effect reminds me and that is true for
lives saved, but it is also true for health systems that have
been improved in countries that we have worked in and
supported.
We currently have supported over 3,000 laboratories across
PEPFAR partner countries, supported over 340,000 healthcare
workers, invested in over 70,000 health facilities, which are
really--and several networks and supply chain systems, which
are currently being used in advancing our goal to ending HIV/
AIDS by the year 2030, but, in addition, to enabling us to
fight other emerging infectious diseases, which are occurring
unfortunately very frequently--the Ebola outbreak in DRC in my
previous life at the African Union--Africa Centers for Disease
Control as the director.
I went to DRC almost twice a year and it is fair to say
that a lot of infrastructure that we put in place has been very
handy there. Massive cholera outbreaks, Ebola outbreak recently
in Uganda benefited a lot from the infrastructure that we have
put in place, and COVID.
The PEPFAR infrastructure was very critical early on in
advancing testing for COVID in Africa, expanding vaccination--
COVID vaccinations--and infection control prevention measures.
That effect is there, which has completely transformed
public health systems in several countries.
Senator Kaine. I appreciate you describing that clearly.
The reauthorization is very, very important to get to the
global goal about eradication of HIV/AIDS by 2030 as a public
health crisis.
The additional benefits that we gained by investing in this
public health infrastructure are virtually incalculable and I
think that this is why this program has been so successful and
so supported in a bipartisan way.
I yield back, Mr. Chair.
The Chairman. Thank you.
Senator Booker.
Senator Booker. Thank you very much, Chairman, and I want
to thank our witness for his extraordinary leadership for many,
many years.
I want to just start by--I think it is really something
that is good. I strongly support this idea that the established
PEPFAR infrastructure was so critical during the COVID pandemic
in helping to meet a lot of the challenges.
There have been concerns, though, expressed about the
potential that this approach has to the integrity of the HIV
and AIDS efforts.
From where you sit, what have been the benefits of using
PEPFAR infrastructure for strengthening overall health
infrastructure and has it negatively impacted the mission
around HIV and AIDS care and related services?
I say that understanding that more and more we are seeing
co-morbidities associated with the deaths, but I am curious,
from your perspective, what are you seeing?
Dr. Nkengasong. Thank you, Senator, for that question.
The way I would describe it is that we need to continually
support health systems, which is really the workforce,
laboratory systems, supply chain management, that are required
primarily in supporting the goal of ending HIV/AIDS as a
threat--a public health threat by the year 2030.
Again, just repeating some numbers, we still have a big
HIV/AIDS pandemic issue with 1.5 million new infections
occurring every year and 650,000 deaths a year. Of that number,
about 425,000 deaths occurred in Africa so the pandemic is not
over.
By continuously investing in those health systems to
advance a goal to get to 2030, we very directly or indirectly
provide a platform for responding to other emerging infections
without deviating from our core mission, which is to fight HIV/
AIDS.
Senator Booker. There is a disconnect right now. Children
make up 4 percent, roughly, of the global AIDS cases. They make
about 15 percent of the people that are dying globally from
HIV/AIDS, and I am wondering where you think--and I know the
mission, by 2030, there has been a lot of resources focusing on
this disproportionate levels of death.
I am wondering what do you see right now as the gaps to
addressing issues with children, to addressing issues with
mother-child transmission and more?
Dr. Nkengasong. Thank you, Senator.
As I stated earlier, this is a top priority the next 5-year
strategic plan, which we released on December 1. Children,
adolescent girls, and young women and the five key populations
are a top priority.
We were very intentional in elevating attention to children
because of the gaps you just outlined. The mantra is knowing
our gaps and addressing our gaps using science. There are a
couple of things that we have done in the past.
As I indicated, 5.5 million children have been born free of
HIV/AIDS, so we have made progress. In 15 countries we have
seen remarkable reduction in pediatric HIV/AIDS, including
Botswana, where, if you recall, Botswana had one of the largest
burden of HIV in terms of the prevalence of the disease, about
80 percent of the population. Botswana is very close to
eliminating pediatric HIV/AIDS.
There is a lot of work that needs to be done. As you
already said, there are a lot of inequities in terms of
bringing in those children--identifying the children, bringing
them to treatment, and making sure that their viral load is
suppressed.
There are a couple of things that we believe we must do:
increase the testing, develop new tests, especially the point
of care test that will identify the children early and then
link them up to treatment.
Issues of stigmatization--make sure that we have very
aggressive campaigns that continue to make sure that we
identify these women in the community and, of course, community
mobilization because the children are in the communities. If we
are not finding them; they are in the community.
That is why we are very proud to be part of the alliance
that was launched in Montreal at the AIDS conference and also
recently in Tanzania by--through a combination of UNAIDS,
Global Fund, WHO, and, of course, member states in Africa. That
is an alliance that we are committed to because of the unique
nature of HIV/AIDS in children.
Senator Booker. My time is running out. I want to point out
two issues and then maybe hope you can follow up with them.
One is the significant connection between violence and
sexual violence against women, child marriages, and the spread
of HIV/AIDS to women has me deeply concerned, and then the
other--and the chairman mentioned this, but I want to just
rehighlight it.
The Ugandan Government's passage of legislation that
criminalizes the LGBTQ community is really, really concerning.
If this bill is signed, there are implications on PEPFAR
funding and programs in Uganda, given the bill's broad
criminalization of activities that encourage or observe, ``the
normalization of LGBTQ issues.'' This bill can actually affect
our operations and the distribution--and then the work that we
do, given that criminalization.
I would love to follow-up with you about the strategies--
both on what we are seeing in some places, and the high levels
of violence against women, and I would love to hear your
thoughts.
I am the subcommittee chair of the Africa and Global Health
Subcommittee and really want to find ways that this committee
could, perhaps, address a lot of these other issues that are
underlying the spread of HIV and AIDS. The great thing about
this--and I just want to say that this has been a bipartisan
issue in my conversations with colleagues on both sides of the
aisle on this committee. There is a lot of hope for more that
we could be doing besides just the funding.
I do want to agree with both the chairman and the ranking
member. Getting a clean reauthorization is really, I think,
something that is urgent, given the light of the progress we
have made and the challenges that we still have.
Mr. Chairman, thank you.
The Chairman. Ambassador, just one final--since we have you
here and I hope to have only just this hearing--I hear the
chorus on a clean reauthorization. I get it. I have been around
here long enough to know that we do not need to complicate our
lives, but it would be a crime that if we know that there is
something that we can do today that we did not when we
envisioned this program originally or through its
reauthorizations, that we did not do it in the search for a
clean reauthorization.
Can you tell me--for example, I am thinking about PrEP--can
you tell me that you have the authority to be able to adjust to
whatever is discovered and/or whether it be in terms of a
medicine, a vaccination, a cure, a procedure, that you have the
wherewithal to be able to adjust so that we can take advantage
of that?
Dr. Nkengasong. Let me state, Senator, very clearly that I
am certain definitely that we have the authorities to do that.
We currently, as PEPFAR, we have supported over 1.4 million
PrEP and we hope to continue to use the current authority in
advancing that especially in the light of new molecules or new
interventions like the long-acting PrEP that you and I
discussed when we were in South Africa, the CODEL visit, that
we have the right authority to scaling that office exactly
built on the backbone of what we have been doing already that
we will be able to expand such interventions.
The Chairman. Okay. Then two last questions.
In response to a request that I made, the Government
Accountability Office issued a report entitled, ``The
President's Emergency Plan for AIDS Relief.'' State has taken
actions to address coordination challenges, but staffing
challenges persist.
The report indicated that PEPFAR has neither identified nor
addressed underlying causes of persistent workload and
retention issues at the Department of State, specifically noted
that 70 percent of the positions at the Office of Global
Health, the global AIDS coordination headquarters, were vacant.
Eighty-nine percent of major positions overseas were filled on
an acting basis.
I understand that you are working on filling those
positions and I appreciate your efforts to do so, but what
impact, if any, has staffing vacancies had on program
implementation and what are we doing to mitigate those
challenges?
Dr. Nkengasong. Thank you, Senator.
When I came in about 9 months ago, that issue--I read your
report and we have been working very actively and aggressively
in that. Out of the 90 vacancies that I met, we have filled in
34 of them in 9 months, which I believe is remarkable--good
progress.
I hope that we will continue to work aggressively to fill
in those positions because they have very direct consequences
on morale, burn-out, and the ability to have work-life balance,
which is so critical in our ability to continue to supporting
countries, the 55 partner countries that we have.
The same issues we see in the field and that is a major
focus of us to continue to work with the partner country--our
programming in the countries to make sure that the vacancies
are actually filled in a timely fashion.
My priority, again, was to fill in those headquarters
positions aggressively as much as possible and I think I am
very encouraged with the progress we have made so far.
The Chairman. Okay.
Then, finally, in the course of briefings on the FY24
budget requests, it has been mentioned of an Ambassadors Fund.
Can you tell me exactly what is the purpose of that? Are you
familiar with it?
Dr. Nkengasong. Senator, I will need to check on that. Then
we will get back to you.
The Chairman. Okay. If you could inform the committee of
what is the purpose of the Ambassadors Fund, how much money is
currently in it, how have funds been used in past years, and
how do you plan to use them for your priorities over the next 5
years, it would be helpful as we deal with the budget process.
Dr. Nkengasong. I will definitely get back to you.
[Editor's note.--The requested information referred to above
follows:]
While we do not have a formal fund called the Ambassador's Fund. It
is possible this question refers to funding that S/GAC has in reserve,
which some may have referred to as an ``Ambassador's Fund.'' The
primary purpose of the reserve is to ensure sufficient funding is
available for responsible programming as we take into account all
available funding and needs and to address two primary risks: 1)
unforeseen circumstances; and 2) the risk of further decreases in
available pipeline funding that PEPFAR relies on to continue
operations.
S/GAC has a robust pipeline management process where unused funds
from prior years are explicitly brought forward into the next Country
Operational Plan (COP) cycle as applied pipeline, thereby ensuring that
resources are spent on the most current needs based on the most up-to-
date data, and also preventing the buildup of pipeline that cannot be
effectively utilized during a COP cycle.
In the COP22 process we are relying on a total of $336 million in
applied pipeline, which enables us to run a program that is larger than
we would be able to if we were to rely on newly appropriated funds
alone. However, that means that if applied pipeline declines in the
future, we would have to reduce programming under a flat appropriation,
unless we have reserve funding available. Applied pipeline has come
down from $813 million in COP19 to about $251 million in COP23 as
agencies have effectively programmed and spent the full amount budgeted
in each COP year.
In addition to the two primary purposes noted above, some funds in
reserve at the beginning of the current Administration were there to
ensure that Ambassador Nkengasong would have flexibility for new
programming to address high priority needs related to reaching and
sustaining the 95-95-95 goals.
At the start of the COP23 planning process, the reserve totaled
approximately $400 million. While COP and Headquarters Operational Plan
(HOP) 23 planning is still underway, we expect that at the conclusion
of COP/HOP23 planning and subsequent Congressional Notification, the
reserve would be approximately $170 million. With the reserve, we were
able to: 1) plan for a total of $42 million in increased funding to
several counties due to contingencies or changing circumstances
(Angola, Ethiopia, Haiti, Mozambique, and Ukraine), 2) prioritize $40
million for high priority health equity initiatives across more than 30
countries in the COP, and 3) plan for approximately $71 million for
critical surveys that will enable us to understand the needs of our
populations as we aim to reach 95-95-95 and beyond. Additionally, we
planning to fund $95 million in critical priority initiatives related
to youth, national public health institute strengthening, injectable
prep, nursing and community health worker leadership, people-centered
care and advancing the enabling environment for regional manufacturing.
At $170 million, the reserve is approximately 3 percent of the
total $5.1 billion that we plan and spend annually in the COP and HOP.
If applied pipeline drops further in the future, the reserve would be
used in future cycles to help slow the pace at which decreases would
need to be made to programs. If applied pipeline approached zero, the
need for the reserve would be greatly reduced with the need for only a
limited amount for unforeseen contingencies.
The Chairman. Senator Cardin has gotten here in the nick of
time.
Senator Cardin. Thank you.
First, thank you very much for your service. We appreciate
it very much. I want to follow up on Senator Booker's point in
regards to the benefits of PEPFAR being far beyond just dealing
with HIV/AIDS.
It builds up capacity, healthcare, infrastructure to deal
with the challenges in the countries in which we are operating,
and it has been transformational and it has been extremely
successful. We are very proud of that part of it.
We know that the PEPFAR strategy notes that there is a goal
of 70 percent of the resources going for localization. Senator
Hagerty and I held a subcommittee hearing dealing with USAID
and localization, building up local capacity, but we also
understand there is challenges in meeting that particular
commitment.
Can you just share with us your commitment to make sure
that we have tried--that we reach that goal, that we do make a
significant commitment to making sure the resources are going
locally so that it not only deals with the direct challenges of
PEPFAR, but it provides the type of infrastructure in the
country to deal with the healthcare challenges?
Dr. Nkengasong. Thank you, Senator.
I think when I came on board about 9 months ago that was
one of my top priorities, the priority of sustainability, and I
see that in the lens--the light of programmatic sustainability,
that we will be able to sustain these programs if we have many
more local partners that are capable.
I have taken a very hard look at that and what I am
currently doing now is to make sure that we do not really get
to 70 percent, but we get to 70 percent with strong local
partners that have good fiscal systems, procurement systems,
governance as a whole.
I am currently developing tools that will be used in
assessing all our local partners, identifying gaps that we need
to apply ourselves to and support them, and not punish them,
but support them so that they can build that capacity in a
sustained manner, which is a top priority for me in doing that,
at the same time recognizing that we need to continue to have a
mixture of those local partners and international partners to
get us to 2030 because that is the ultimate goal that we have
set for ourselves.
Senator Cardin. I totally agree that there has to be
capacity locally. We want to make sure our resources are
appropriately used. Completely agree with you on that, but many
times it is used as an excuse because of the existing partners
that we have trying to preserve their share of our foreign
assistance and, therefore, we do not really build the type of
local capacity because of the existing contracts that we have
in country.
How do you guard against that type of natural bias against
bringing in new partners that are sharing the resources?
Dr. Nkengasong. Thank you, Senator.
That is exactly why I have decided to develop a tool that
will truly tell us where--using evidence and data that where we
are with this partner.
Say, for example, if we have 400 partners where are they--
where is the capacity so that the discussion about the capacity
does not exist or exists should be off the table.
It is only through an evidence-based, systematic, and
standardized process that we can be able to answer that
question and provide you with the right answer there.
I am committed to that process.
Senator Cardin. Will you provide this committee with where
you are on reaching that 70 percent goal and the challenges
that you are having per country as far as capacity building so
that we understand the challenges you are confronting and,
perhaps, can be your partner to expedite local capacity?
Dr. Nkengasong. Absolutely, Senator. I will do that.
Senator Cardin. Thank you.
[Editor's note.--The requested information referred to above
follows:]
Regarding the goal of 70 percent of PEPFAR funding going towards
local partners, the PEPFAR program is currently estimated at 59 percent
based on the COP22 budget (see chart below). We expect further progress
towards the 70 percent target be made over the next 2 years as part of
the COP23 implementation.
In the PEPFAR 5-year strategy released in December, we highlighted
the importance of national capacity building to enable the long-term
sustainability of the HIV response. We believe that the key to
operationalizing this component of the strategy will be to accurately
assess the current capabilities of our local implementing partners in a
standardized manner across the program--especially on operational
dimensions like financial management and governance. Post this, the
PEPFAR program will provide targeted capability building support to
critical local partners in order to measurably advance their
capabilities. This will ultimately enable those partners to take on a
greater responsibility for the future service delivery needs of the
program.
We have set up an interagency national capacity building taskforce
within PEPFAR who is responsible for advancing this work. We have and
will also continue to invest meaningful time and effort to increase the
depth and breadth of the financial and operational data we collect on
all our partners (including local partners) to improve our oversight
and prevent any fraud, waste and abuse.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
The Chairman. Thank you, Senator Cardin.
Thank you, Dr. Nkengasong, for your service, for your
testimony here today. We may still call upon you as we get to
the final reauthorization. There are a couple of pending
questions you are going to get back to us on, and with the
thanks of the committee you are excused at this point.
Dr. Nkengasong. Thank you, Senator.
The Chairman. As Dr. Nkengasong leaves the dais, let me
begin to introduce our two next witnesses.
Joining us virtually today from London is Sir Elton John, a
world-renowned singer, songwriter, philanthropist. In 1992, Sir
Elton established the Elton John AIDS Foundation, which today
is the sixth largest AIDS funder globally.
Through more than 3,000 projects in 90 countries, the
foundation has helped save the lives of over 5 million people
and raise awareness of HIV. Sir Elton has traveled extensively
in Africa, where I was privileged to join him in February,
Eastern Europe, and across the United States.
He has spoken several times at the United Nations here in
the Senate using his platform to advocate for people living
with or at risk of HIV.
In 2022, Sir Elton was awarded the Humanitarian Medal by
President Biden at the White House. In 1998, he was knighted by
Queen Elizabeth II for his charitable achievements. We welcome
him.
Joining him on the panel here in Washington is Dr. Mark
Dybul, a professor at Georgetown University Medical Center,
where he serves as chief strategy officer at the Center for
Global Health Practice and Impact, executive chair of Platform
Life Sciences, and CEO of Enochian Biosciences.
Dr. Dybul has worked on HIV and public health for more than
25 years as a clinician, scientist, teacher, and administrator.
Dr. Dybul was appointed by President Bush as the second
U.S. Global AIDS Coordinator in 2006, served in that capacity
until 2009, has served as executive director of the Global Fund
to Fight AIDS, Tuberculosis, and Malaria from 2013 to 2017.
Welcome to both of our witnesses and I would ask Sir Elton
to please proceed with your testimony.
STATEMENT OF SIR ELTON JOHN, FOUNDER, ELTON JOHN AIDS
FOUNDATION, LONDON, UNITED KINGDOM
Sir Elton. Good morning, Chairman Menendez, Ranking Member
Risch, and distinguished members of the committee. I am
delighted to join you today to wholeheartedly support your
commitment to extending the lifesaving work of the landmark
PEPFAR program.
I was humbled to have been part of your recent bipartisan
fact-finding mission to South Africa to experience the awe-
inspiring impact this program is having on the ground. It was
an inspirational visit that shows the immense gratitude of the
African people.
I want to begin by thanking you for your continued focus on
the global fight against AIDS. We are living in deeply troubled
times with countless global challenges, all of which I know
beckon your time and attention.
Beyond that, I am boundlessly grateful for the bipartisan
cooperation that has been the hallmark of PEPFAR for two
decades now. While this effort was initially conceived by
President Bush, it has been enthusiastically supported by four
presidents and 10 Congresses and consistently championed by the
generosity of the American people.
As I testified to the Senate 21 years ago this week, what
America does for itself has made it strong, but what America
does for others has made it great. Bravo, my friends. There is
no better symbol of American greatness than PEPFAR and you
should all be very proud of your extraordinary efforts.
Before PEPFAR, much of Africa was in freefall. Infant child
mortality was skyrocketing, life expectancy plummeting, and
decades of development progress being rolled back.
Families across the continent were walking miles to bring
their loved ones to hospitals in wheelbarrows where they were
piled up three to a gurney in hallways because every inch of
the hospital was already full.
In some communities, half of the adults were HIV positive.
In others, 80 percent of pregnant women were. A generation of
young parents and workers were being wiped out, leaving
grandparents and older siblings to raise millions of orphans.
More than 30 million individuals were already HIV-positive,
but less than 50,000 in poor countries had access to lifesaving
drugs. GDP was dropping and coffin-making was the booming
business of the day, including mountains of 24-inch coffins for
babies. It was beyond bleak and the future projections even
worse.
In those dark days there was little my AIDS Foundation
could do for the millions suffering in secret because of the
stigma of AIDS. In South Africa, where more than a quarter
million people were dying of AIDS each year, we provided basic
care to nearly a million people in hopes that they could at
least die with dignity.
We gave them food, clean water, bedding, blankets,
aspirins, ointments, a hand, a prayer, and a plan for their
children once they were gone, but those were the only tools we
had at our disposal at the time.
I looked into the eyes of way too many dying people begging
for help and hope that was just not possible and available. For
them, AIDS was a death sentence every time.
Then came you, compassionate American leaders who decided
that it was better to light a candle than to curse the
darkness, who decided that whether a mother or child lived or
died should not be left to a lottery or geography, and who
decided that American generosity and genius could literally
change not just the course of the pandemic, but the course of
history, and it has.
Thanks to PEPFAR, horror finally gave way to hope. ARV
treatment became available and people all of a sudden living
with HIV literally rose out of their hospital beds and went
home to resume their lives and livelihoods.
In the 20 years since, PEPFAR has saved 25 million lives,
more than twice the number of people living in New Jersey and
Idaho. That is a lot of lives, and AIDS deaths have been cut by
60 percent and new HIV infections by more than half.
Hundreds of thousands of doctors, nurses, and community
health workers have been trained, lab and surveillance systems
have been established, and community-based organizations or
mobile clinics have been created to bring essential prevention
treatment and support services closer to the people in need.
Part of PEPFAR's power was demonstrating the art of the
possible. Nelson Mandela often said, they all say it is
impossible until it is done, and that is true for PEPFAR. Many
said we could never provide lifesaving treatment in Africa. It
was too complicated and too expensive, but PEPFAR proved that
was nonsense and now millions of people--20 million people in
Africa are being supported on treatment and 6 million people in
South Africa alone, and mostly paid for by their own
government.
As a result, life expectancy is up by 12 years in South
Africa, 20 years in Zambia, and the PEPFAR platform has not
only transformed HIV into a chronic disease for tens of
millions, it has been leveraged to fight COVID and made
countries far better prepared for whatever viral nightmare
comes next.
This is great news and a tribute to American leadership,
persistence, and strategic investment. We are not done yet.
According to UNAIDS, our progress is faltering as one person
with AIDS dies and three new people become infected with HIV
every minute.
While AIDS deaths and new infections are falling for most
age groups, they remain on the rise for young people between
the ages of 15-24, particularly young women and girls, and this
is especially concerning in Africa where the average age is 18
and where AIDS remains the leading cause of death among teens.
For young people who are not yet born during the horrors of
AIDS, they need a wakeup call, accurate information, and the
power to use it. In South Africa my AIDS Foundations have
partnered with digital platforms to reach young people where
they are, on their smart phones, with relatable information and
services that resonate with them.
Twenty thousand have joined the platform in the first month
and they expect 100,000 in 3 months, just in South Africa. In
Kenya, we are working with the first drone delivery company
that enables young people with cell phones to order affordable
medicine and supplies and receive them within 1 hour. These
innovations not only engage and empower young people, they save
both money and lives.
In conclusion, you should be rightfully proud of what you
have created and the impact that this had and is still having.
We have the tools and we need to turn the tide and,
increasingly, national leadership, capacity, and ingenuity are
taking what is good and making better and more sustainable.
We need to keep our foot on the accelerator. We have come
so far in such a short time relatively. By extending PEPFAR for
another 5 years and fully funding it, together we can continue
the march towards ending AIDS for everyone everywhere and leave
no one behind.
Thank you so much for all you do. I give you so much love
from United Kingdom. Thank you.
[The prepared statement of Sir Elton follows:]
Prepared Statement of Sir Elton John
Good morning, Chairman Menendez, Ranking Member Risch and
Distinguished Members of the Committee. I am delighted to join with you
today to wholeheartedly support your commitment to extending the
lifesaving work of the landmark PEPFAR program.
I was humbled to have been a part of your recent bipartisan fact-
finding mission to South Africa to experience the awe-inspiring impact
this program is having on the ground.
I want to begin by thanking you for your continued focus on the
global fight against AIDS. We are living in deeply troubled times with
countless global challenges--all of which I know beckon your time and
attention. Given that, I am boundlessly grateful for the bipartisan
cooperation that has been the hallmark of PEPFAR for 2 decades now.
While this effort was initially conceived of by President Bush--it
has been enthusiastically supported by 4 Presidents and 10 Congresses
and consistently championed by the generosity of the American people.
As I testified to this Senate 21 years ago this week--``what America
does for itself has made it strong--but what America does for others
has made it great.'' Bravo my friends--there is no better symbol of
American greatness than PEPFAR--and you should all be very proud of
your extraordinary efforts.
Before PEPFAR--much of Africa was in free fall. Infant/child
mortality was skyrocketing, life expectancy plummeting, and decades of
development progress being rolled back. Families across the continent
were walking miles to bring their loved ones to hospitals in
wheelbarrows where they were piled up three to a gurney in hallways . .
. because every inch of the hospital was already full. In some
communities, half of the adults were HIV positive. In others, 80
percent of pregnant women were. A generation of young parents and
workers were being wiped out, leaving grandparents and older siblings
to raise millions of orphans. More than 30 million individuals were
already HIV positive but less than 50,000 in poor countries had access
to lifesaving drugs. GDP was dropping and coffin making was the booming
business of the day--including mountains of 24-inch coffins for babies.
It was beyond bleak and the future projections even worse.
In those dark days, there was little my AIDS Foundation could do
for the millions suffering in secret because of the stigma of AIDS. In
South Africa, where more than a quarter of a million people were dying
of AIDS each year, we provided basic care to nearly a million people in
hopes that they could at least die with dignity. We gave them food,
clean water, bedding, blankets, aspirin, ointments, a hand, a prayer,
and a plan for their children once they were gone--but those were the
only tools we had at our disposal at the time. I looked into the eyes
of way too many dying people begging for help and hope that was just
not available. For them--AIDS was a death sentence, every time.
And then came you--compassionate American leaders who decided that
it was better to light a candle than to curse the darkness. Who decided
that whether a mother or child lived or died should not be left to a
lottery of geography. And who decided that American generosity and
genius could literally change, not just the course of the pandemic, but
the course of history. And it has.
Thanks to PEPFAR, horror finally gave way to hope. ARV treatment
became available and people--suddenly ``living'' with HIV--literally
rose out of their hospital beds and went home to resume their lives and
livelihoods.
In the 20 years since, PEPFAR has saved 25 million lives--more than
twice the number of people living in both New Jersey and Idaho. That's
a lot of lives. AIDS deaths have been cut by 60 percent and new HIV
infections by more than half. Hundreds of thousands of doctors, nurses
and community health workers have been trained. Lab and surveillance
systems have been established, and community-based organizations and
mobile clinics have been created to bring essential prevention,
treatment, and support services closer to the people in need.
Part of PEPFAR's power was demonstrating the art of the possible.
As Nelson Mandela often said: ``They always say it's impossible until
it's done.'' And that's true for PEPFAR. Many said we could never
provide lifesaving treatment in Africa--it was too complicated and too
expensive. But PEPFAR proved that was nonsense and now millions of
people 20 million people in Africa, are being supported on treatment, 6
million in South Africa alone, and mostly paid for by their own
government. As a result, life expectancy is up by 12 years in South
Africa . . . 20 years in Zambia. And the PEPFAR platform has not only
transformed HIV into a chronic disease for tens of millions--it has
been leveraged to fight COVID and made countries far better prepared
for whatever viral nightmare comes next. This is great news and a
tribute to American leadership, persistence, and strategic investment.
But we are not done yet. According to UNAIDS, our progress is
faltering as one person with AIDS dies and 3 new people become infected
with HIV every minute. While AIDS deaths and new infections are falling
for most age groups--they remain on the rise for young people ages 15-
24, particularly young women and girls. And this is especially
concerning in Africa where the average age is 18 and where AIDS remains
the leading cause of death among teens. For young people who were not
yet born during the horrors of AIDS--they need a wake-up call, accurate
information, and the power to use it.
In South Africa, my AIDS Foundation has partnered with digital
platforms to reach young people where they are--on their smartphones--
with relatable information and services that resonate with them. Twenty
thousand have joined the platform in its first month and they expect
100,000 in 3 months, just in South Africa. In Kenya, we are working
with the first drone delivery company that enables young people with
cell phones to order affordable medicine and supplies and receive them
within an hour. These innovations not only engage and empower young
people--they save both money and lives.
In conclusion, you should be rightfully proud of what you have
created and the impact it has had and is still having. We have the
tools we need to turn the tide and increasingly national leadership,
capacity and ingenuity are taking what is good and making it better and
more sustainable--but we need to keep our foot on the accelerator. By
extending PEPFAR for another 5 years and fully funding it, together, we
can continue the march toward ending AIDS for everyone everywhere and
leave no one behind. Thank you.
The Chairman. Well, thank you, Sir Elton, and let me return
the compliment. Thank you for what you have done. Some people
use their fame in a way that only enriches themselves.
Others use their fame in a way that saves the lives of
others, and in your case that has certainly been the case, so
thank you for what you have done.
Dr. Dybul.
STATEMENT OF THE HONORABLE MARK DYBUL, M.D., PROFESSOR OF
MEDICINE AND CHIEF STRATEGY OFFICER, GEORGETOWN UNIVERSITY
MEDICAL CENTER FOR GLOBAL HEALTH PRACTICE AND IMPACT
Dr. Dybul. Chairman Menendez, Ranking Member Risch, and
distinguished members of the committee, thank you for the
privilege to be before this body again to discuss the
reauthorization of PEPFAR, which has been called and I believe,
in fact, is the most successful global health program in
history.
Thank you for the--to the members and staff who have
provided steadfast support in a bipartisan way for two decades.
Ambassador Nkengasong and Elton have provided you with the
breathtaking data on the lifesaving impact of PEPFAR. I would
like to spend a few moments focusing on other lasting legacies
including the diplomatic benefit from villages to state houses,
health system strengthening, and enhanced health security.
In 2006 when I was the U.S. Global AIDS Coordinator, I was
fortunate to visit Axum, Ethiopia, which is believed to be the
birthplace of Christianity in Africa. At dawn, with the mist
over the town, which blocked the electrical wires, it looked as
it might have centuries ago.
Local farmers were winding through the streets with donkey-
drawn carriages. The spires of the churches peek through the
haze. Bells rang all to prayers in the market. We were met at
the local clinic by the director and his team.
Now, in a town that small the director of the clinic is an
elder, a very important person in the village. He kept
referring to PEPFAR. I was a little bit cranky from not
sleeping for a couple of days and so I asked him what does
PEPFAR mean.
His answer knocked me over. He said, PEPFAR means the
American people care about us. The American people care about
us. That wonderful phrase captured the sentiments I have heard
from nearly every corner of Africa, sentiments that have grown
with every life saved and as individuals, families, communities
and nations have moved from total despair to the hope for the
future.
Now, hope is not just a matter of faith or a good feeling.
It awakens a lost desire to find a job, go to school, feed your
family, care for your community. It is, in fact, the basis of
economic growth and the development of markets for U.S. goods
and services.
Indeed, prior to COVID, Africa as a region had the second
fastest growing economy in the world. Ambassador Nkengasong
noted the positive impact of PEPFAR on GDP. However, there is
also a diplomatic benefit.
Senators Risch and Daschle, who were majority and minority
leaders when PEPFAR was first authorized, led an assessment of
the Bipartisan Policy Center on the impact of PEPFAR on the
perceptions of the United States in sub-Saharan Africa.
In PEPFAR-supported countries, 68 percent of respondents
had a positive view of our country compared to only 46 percent
in non-PEPFAR-supported countries. In fact, many African
countries have a higher view of the United States than the
United States.
Those results could be in part due not only to the direct
impact of HIV on programs, but also because of the broader
health system strengthening benefits of PEPFAR. Treatment and
prevention of HIV is lifelong, requiring well-trained health
providers including community health workers, pharmacists, and
pharmacies, lab technicians and laboratories, logistics supply
chains, communication systems, and much more.
These systems are public, but also private, including the
faith community. Now, at the beginning, because of stigma and
discrimination, many of these services were found in separate
locations.
However, over time they have become integrated. They are in
one place. Doctors, nurses, lab techs, pharmacists, community
health care workers, and all the support systems are there for
HIV, but also for non-HIV. For that reason, it is not
surprising that studies have shown that PEPFAR is associated
with a significant improvement in six out of seven key
indicators of maternal and child health, including reducing
rates of mortality for women and children and childhood
immunization.
The power of improved health systems was clearly
demonstrated during the height of the COVID pandemic as has
been discussed. PEPFAR systems were used to respond to the
pandemic and Africa would have had a difficult time without it.
As a former executive director of the Global Fund to Fight
AIDS, TB, and Malaria, which as you know is also authorized by
the legislation, I would like to thank the committee for your
support for that program as well.
The 33 percent cap there ensures that the American people
are not the only taxpayers supporting the response to the
pandemic. The Global Fund plays a key and complementary role
and our engagement in it also helps us diplomatically by being
involved multilaterally.
It has been an extraordinary 20 years. PEPFAR is often
compared to the Marshall Plan without exaggeration, given what
you have heard from Elton and Ambassador Nkengasong about the
ravages of HIV in Africa.
As this committee knows, it is now a world--we are now in a
worldwide struggle to ensure that democracy and the global
economy thrives. While we must lead we also need allies,
including an Africa where democracy is threatened and where we
have lost ground as the number-one trading partner.
Clearly, PEPFAR is not sufficient, but after nearly a
quarter century of working with Africans at all levels, the
wisdom of the words from Axum 15 years ago ring truer than
ever.
PEPFAR means the American people care about Africans.
People know what we stand for when we stand with them. With
your continued support, untold millions of lives will continue
to be lifted up and saved, strengthened systems for health will
occur, and we will be in a better position to respond to future
pandemics and our values will flourish. That will be another
remarkable legacy for this committee and the American people.
Thank you for listening and I look forward to your
questions.
[The prepared statement of Dr. Dybul follows:]
Prepared Statement of Dr. Mark Dybul
Good morning Chairman Menendez, Ranking Member Risch and
distinguished members of the Committee. Thank you for the privilege to
be before this Body again to discuss the Reauthorization of PEPFAR,
what has been called--and I believe in fact is--``the most successful
global health program in history.'' It has been the honor of a lifetime
to have been one of the architects of the original plan adopted by this
Committee in 2003, and to have been deeply engaged with the program for
two-thirds of my professional life. Please accept heartfelt thanks to
all the Members and Staff who have provided steadfast support in a
bipartisan way for two decades.
Ambassador Nkengasong and Elton have provided you with breathtaking
data on the life-saving impact of PEPFAR. I would like to spend a few
minutes focusing on other lasting legacies, including the diplomatic
benefit from villages to State Houses, health systems strengthening and
enhanced health security.
With your indulgence, I would like to begin with a story that
remains vivid in my memory. In 2006, while I was the U.S. Global AIDS
Coordinator, I was fortunate the visit Axum, Ethiopia, believed to be
the birthplace of Christianity in Africa. At dawn, with the mist over
the town blocking the electrical wires, it looked as it might have
centuries ago. Local farmers winding through the streets with donkey-
drawn wagons, the spires of the churches peaking through the haze,
bells ringing to call all to prayers and the market. We were met at the
local clinic by the director and his team. In a town that small, the
clinic director was also a town elder and leader in the community. He
kept referring to PEPFAR. I was cranky from too little sleep so asked
him what PEPFAR means. His answer knocked me over. He said, ``PEPFAR
means the American people care about us.''
That wonderful phrase captured the sentiments I have heard from
nearly every corner of Africa--one that has grown with every life saved
and as individuals, families, communities and nations moved from total
despair to hope for the future. Hope is not just a matter of faith or a
good feeling. It awakens a lost desire to find a job, go to school,
feed a family, care for your community. It is, in fact the basis for
economic growth and the development of markets for U.S. goods and
services. Indeed, prior to the COVID pandemic, Africa, as region, had
the second fastest growing economy in the world.
Ambassador Nkengasong noted the positive impact of PEPFAR on GDP
growth. However, there is also a diplomatic benefit. Senators Frist and
Daschle, who were the Senate's Majority and Minority leaders when
PEPFAR was first authorized, led an assessment by the Bipartisan Policy
Center of the impact of the program on perceptions of the United States
in Sub-Saharan Africa. In PEPFAR supported countries, 68 percent of
respondents had a positive view of our country, compared to only 46
percent in non-PEPFAR supported countries. In fact, many PEPFAR-
supported countries have a higher percent positive view of the United
States than the United States.
Those results could, in part, be the result not only of the direct
impact on HIV, but also because of the broader health systems
strengthening benefits of PEPFAR. Treatment and prevention of HIV is a
life-long enterprise requiring well trained health care providers
including community health care workers, pharmacists and pharmacies,
lab technicians and laboratories, logistics, supply chains and
communications systems and much more. These systems are public but also
private, including faith-based organizations that have been estimated
to provide 30-50 percent of health care in Africa, particularly in the
poorest communities.
At the beginning, because of stigma and discrimination, many HIV
services were provided in separate locations. However, over time, the
vast majority of HIV-related activities occur in general health care
settings. So the doctors, nurses, lab techs, pharmacists, community
health workers--and all the support systems--serve non-HIV roles as
well. For that reason, it is not surprising that studies have shown
that PEPFAR is associated with a significant improvement in 6 out of 7
key indicators of maternal and child health including rates of
mortality for women and children and childhood immunization.
The power of those improved health systems was clearly demonstrated
during the height of the COVID pandemic. PEPFAR-supported viral testing
was used to detect the virus, clinics, hospitals and community workers,
and commodities procured were all used to help combat the virus.
Looking to the future and the threat of another pandemic, the best way
to ensure early detection and to respond rapidly is to maintain and
strengthen the capacity to respond to an ongoing pandemics, such as
HIV, with an intentional design for surge capacity when needed.
As a former Executive Director of the Global Fund to Fight AIDS,
Tuberculosis and Malaria, which, as you know, the legislation also
authorizes, I would like to thank the Committee for its support of that
important organization. With the 33 percent cap on contributions from
the United States, it is a potent means to help ensure the American
taxpayer is not alone in this fight. The Global Fund also plays a key,
and complementary role in building health systems and pandemic
preparedness and response. And our engagement in a results-driven
international organization contributes to our diplomatic efforts.
It has been an extraordinary 20 years. PEPFAR has recently been
hailed as the best policy decision of the past 50 years and is often
compared to the Marshall Plan--without exaggeration given what you have
heard from Elton and Ambassador Nkengasong about the ravages of HIV in
Africa.
As this Committee knows, the United States is now in a global
struggle to help ensure that democracy and a global economy thrives.
While we must lead, we must have allies including, and perhaps
particularly, in Africa where democracy is threatened and where we have
lost ground as the number one trading partner. Clearly, PEPFAR alone is
not sufficient. But after nearly a quarter Century of working with and
supporting Africans at all levels, the wisdom of the words from Axum 15
years ago rings truer than ever: PEPFAR means the American people care
about Africans.
We are fortunate to have Amb. Nkengasong, an African-born American,
leading the effort. He has been with PEPFAR since day 1, first building
laboratory capacity in Cote d'Ivoire, and then leading that effort
globally for the U.S. CDC. He went on to be the founding Director of
the Africa CDC. In that capacity, he led the most successful regional
response to COVID in the world. As a result, he is still on speed dial
with many Heads of State, Ministers and providers. He uniquely knows
how to build systems to effectively respond to HIV while promoting
health systems. He will lead a renewed diplomatic effort on the
Continent and help prepare for the next pandemic. He will be the best
U.S. Global AIDS Coordinator yet.
People know what we stand for when we stand with them. With your
continued support, untold millions of lives will continue to be lifted
up and saved, strengthened health systems for the ongoing HIV pandemic
will continue to improve the health of mothers, children, communities
and nations. Those systems will better prepare us for, and help respond
to, the next pandemic threat. And our values will flourish. That will
be another remarkable legacy for this Committee and the American
people.
[The testimony of Dr. Eric Goosby and Dr. Richard Marlink
follows:]
Testimony of Dr. Eric Goosby and Dr. Richard Marlink
Ambassador Eric Goosby, M.D.
Distinguished Professor of Medicine
Director of Global Health Delivery and Diplomacy
Institute of Global Health Sciences
University of California, San Francisco
Richard Marlink, M.D.
Founding Director of Rutgers Global Health Institute
Inaugural Henry Rutgers Professor of Global Health at Rutgers
The State University of New Jersey
We are at a remarkable time in history. We are celebrating the 20th
year of the most ambitious health program ever undertaken with
phenomenal impact and continuing promise. It is an honor to offer our
perspectives as the Committee addresses the important task of
reauthorizing PEPFAR and ensuring this life-saving work continues. It
is a sign of America at its best.
When each of us began working on the issue of HIV/AIDS in the early
1980's, no one knew what this silent killer was or the impact it would
have on the world. What we were faced with was a mysterious disease
that was a certain death sentence for those in its path, a time we will
never forget. With the advances of science, the world was changed with
the discovery of anti-retroviral therapies (ART), restoring lives and
giving hope to families and whole communities here in America. Yet, for
many countries including those across Africa most heavily burdened by
HIV/AIDS, millions were dying and doctors and caregivers could do
nothing to save them. The sale of coffins was a booming industry. In
2003, an estimated 3 million people died from AIDS, a quarter million
in South Africa alone.
That all changed with the advent of PEPFAR.
In 2003, President George W. Bush took the historic step of
creating the U.S. President's Emergency Response for AIDS Relief,
declaring that ``seldom has history offered a greater opportunity to do
so much for so many.'' In the last 20 years PEPFAR has changed the
course of the HIV/AIDS pandemic and the course of history. You have
seen the numbers--as of FY 2022, 25 million lives have been saved and
millions more are HIV-free, more than 20 million people are on ART, and
64.7 million people have received testing services. And there's more--
2.9 million adolescent girls and young women reached with comprehensive
HIV prevention services, 7.7 million orphans, vulnerable children and
their caregivers provided with critical support, and 30 million
voluntary medical male circumcisions performed to prevent HIV
infections in men and boys.
But the success of PEPFAR goes beyond these statistics. We have
witnessed the restoration of livelihoods and communities thriving
where, previously, a generation of young and working parents had been
lost to AIDS. Economies of countries and local stability have been
restored as life expectancy has recovered, enabling a better future for
so many. For this, and for the many benefits investment in the global
HIV/AIDS fight has afforded, America has earned appreciation and
respect across Africa due to the generosity of the American people.
Time is never static. To date, 10 Congresses and four
Administrations have reauthorized the program, reaffirming the
important work that PEPFAR carries out. This unwavering support
continues to demonstrate U.S. leadership in advancing effective
strategies to end HIV/AIDS as a public health threat by 2030 while also
strengthening systems of care that advance our global health security.
Now, under the leadership of U.S. Global AIDS Coordinator Ambassador
John Nkengasong, the role of PEPFAR as a model for effective
partnerships continues towards the goal of countries managing and
sustaining effective responses to epidemics now and into the future.
We have learned much over time. In the earliest days, PEPFAR
provided urgent support and technical assistance to bolster health care
capabilities, including diagnostic capacities and ARVs that began to
change the wave of AIDS across Africa. Working together with national
authorities and partners, PEPFAR has supported 70,000 clinics, 3,000
laboratories and country data systems for surveillance and monitoring,
and trained over 340,000 health workers. Collectively, this work has
undergirded the response to infectious diseases and the associated
morbidity and mortality among the population at large. We must also
seriously address the all too often unmet need to screen for and treat
the diseases that are now taking the lives of HIV positive patients on
ARVs, including hypertension, diabetes mellitus and coronary heart
disease, as we have done for cervical cancer.
In the long run, it is the responsibility of each country and its
Ministry of Health to address the health needs of its population, and
tremendous progress has been made towards overcoming HIV/AIDS in
countries where PEPFAR is active. All PEPFAR-supported countries are
making concrete progress towards sustainability. The level of funding
countries has invested in their own response to HIV increased to 56
percent of all funding in 2020. As an example, in South Africa, the
country with Africa's largest number of people living with HIV, 7.5
million--of whom 5.5 million are on ARVs paid for by the government.
South Africa also funds 80 percent of its HIV/AIDS response. Nigeria
funds almost 80 percent and Botswana funds approximately 50 percent.
The path towards a sustainable national response has risen from a model
of partnerships, with country ownership being at its heart.
Building partnerships by bringing stakeholders to the table is the
key driver of long-term success. With PEPFAR, host country governments,
the private sector, faith-based organizations, multilateral
institutions, civil society and communities of people living with HIV
have come together in new ways to work towards a coordinated, effective
response. Ambassador Nkengasong has put partnerships and sustainability
of national responses at the center of PEPFAR's 5-year strategy,
``Fulfilling America's Promise to End the HIV/AIDS Pandemic by 2030.''
It is through partnerships that programs to prevent mother-to-child
HIV transmission (PMTCT) have been hugely successful, with healthy
babies born and spared the tragedy of pediatric AIDS. And thanks to
PEPFAR's Orphans and Vulnerable (OVC) treatment expansion program, the
number of children who have lost one or both parents due to AIDS has
nearly been cut in half since the high point of 1.8 million children in
2010. Remarkable partnerships have been formed to screen women for
cervical cancer, a major risk for women living with HIV.
Despite the many gains made in the HIV/AIDS response, there is more
work to do. AIDS is still the leading cause of death among teens and
young adults, with adolescent girls and young women disproportionately
at risk.
PEPFAR's DREAMS program is a unique public-private partnership
dedicated to providing girls and young women with opportunities to stay
in school safely and access prevention services, along with strategies
to reduce gender-based violence and expand economic opportunities to
lead better and healthier lives.
The work that lies ahead rests in ensuring that the partnerships
PEPFAR has fostered continue to focus on the outcomes that define
PEPFAR's success--lives saved, infections prevented and strong health
systems in place to prepare us for the inevitable future pandemics.
As the former U.S. Global AIDS Coordinator, I am proud of the work
we did to establish these vital partnerships to ensure that countries
would reach the ultimate goal of sustainability. We went from an
emergency phase to one that centered on the ability of countries to
eventually move and take up to greater country leadership. We were
laser-focused on our efforts to save lives through smart investments
and the shared responsibility of all partners to reach the goal of an
AIDS-free generation. Now, as Director of Global Health Delivery at the
University of California San Francisco (UCSF) I am continuing to focus
on the work we started during my time at PEPFAR to bring together the
skills and talents of academic institutions to support this and next
generation of health leaders.
As was true with Ambassador Goosby's work to establish partnerships
that would enable countries to take care of their people, in the late
1990's I helped create the Botswana-Harvard Partnership through the
Harvard AIDS Institute, in partnership with the Government of Botswana.
This partnership also was initially formed with the Bristol Myers
Squibb Foundation and then expanded to involve the Merck and Bill &
Melinda Gates Foundations, with a focus on scaling up HIV/AIDS care,
treatment and prevention nationwide. Later, I was fortunate to work
with multiple African governments, leading the U.S. side of the PEPFAR
partnerships in Botswana and in five other African countries for over
10 years. I have seen first-hand how PEPFAR's HIV/AIDS prevention and
treatment services were literally lifesaving, with hospitals emptying
as people returned to their families and workplaces. Now, as director
of Rutgers Global Health Institute, my colleagues and I are able to
build on the stronger health systems created by PEPFAR in many
developing countries, helping to address both HIV/AIDS and other
infectious and noncommunicable disease threats around the world.
We applaud the leadership of Chairman Menendez, Ranking Member
Risch, Subcommittee Chairman Booker and all Senators on the Senate
Foreign Relations Committee who have recognized that PEPFAR, as the
largest global health program in the world, is an investment that has
achieved extraordinary results. We also applaud the fact that they are
champions in working to ensure, through reauthorizing PEPFAR, that its
vital work continues. Much important work remains.
We strongly support Ambassador Nkengasong's call to accelerate
progress in reducing new infections, working together with countries
and partners to strengthen health systems, and ensuring HIV/AIDS gains
continue while also leveraging PEPFAR as a critical backbone of
pandemic preparedness and response.
When PEPFAR was launched it brought hope to millions. PEPFAR must
remain this beacon of hope. With the leadership and continued
commitment from this Congress, it will.
The Chairman. Thank you, Dr. Dybul. Thank you both for your
testimony. We will go through a round of 5-minute questions.
Sir Elton, hopefully we got--we still have you online. I
had an opportunity to visit some of the sites supported by your
foundation in South Africa. The Foundation's work with youth
has really been transformative.
What are some of the unique challenges that are faced by
adolescent boys and girls in assessing prevention care and
treatment services, and from your experiences of the foundation
is there anything you can recommend that that we need to do to
overcome those challenges?
Sir Elton. Well, thank you, Senator.
Most teens are not connected to the healthcare system and
they think it is for old and sick people, basically, and not
for them.
As we do with all age groups, we need to work with young
people to develop messages that are meaningful and relevant to
them and engage youth where they already are, in this case,
online, as well as in sports, music, and other youth-focused
events.
There is no point in designing services that do not get
used because they do not work for a particular group. Young
people have a saying, ``Nothing is for us without us,'' and
that makes sense to me.
It is so important that you engage the youth of Africa with
where they are. As I said, online and, on their phones is the
best way of getting to them and they listen. It has been proven
that when we do things like that, they listen.
That is what we are trying to do is to get more programs
out in the field that can get people on their phones and then
they talk to each other, and it helps get rid of the stigma.
Whenever you talk about an issue, it does not seem as bad
as it is, especially when you are talking with someone of your
same age group.
I remember many years ago when we went to Cape Town and
established the first helpline on Cape Town University where
people who were afraid of saying they were HIV positive because
of their families and the university. We set up a helpline that
they could phone other people and talk about their infections
and it was a great relief.
If you inform the young and give them a message and they
can communicate with each other, it will be fantastic. The most
powerful tool for someone who is struggling or afraid is #MeToo
and I know that firsthand.
My foundation funded a program called Zvandiri in Zimbabwe.
It means ``taken as I am.'' Youth living with HIV go on into
their communities and connect with young people like them who
need advice and HIV testing and treatment.
The program has been recognized by the World Health
Organization and UNICEF, funded by PEPFAR with a 5-year game
changer grant scaled countrywide in Zimbabwe and replicated in
nine other African countries.
Young people are amazing. We just need to give them the
tools to help them help each other.
The Chairman. Well, thank you. Thank you very much. I saw
some of those tools at work when we were in South Africa.
Dr. Dybul, the anecdote that you shared in your testimony
about hearing the clinic director in Axum, Ethiopia saying
PEPFAR means the American people care about us is incredibly
powerful, especially as how we distinguish ourselves against
strategic competitors around the world.
Do you think we are effectively messaging PEPFAR as a
program provided by the American people as a commitment to
saving lives and ending this pandemic with no strings attached?
Dr. Dybul. Thank you, Mr. Chairman. It is an excellent
question.
I believe we are doing a great job, but it could be better
and I think Ambassador Nkengasong is the perfect person to
deliver that message. He has heads of state on speed dial from
his role as head of Africa's CDC leading the COVID response.
He is known by ministers throughout the continent. It is
well known. It is well understood, but I think we can do even
better and Ambassador Nkengasong will be able to deliver that
for us and it is absolutely essential because we are in a
struggle and we need to show the American people's heart and
our values, which PEPFAR does.
The Chairman. Thank you.
Senator Risch.
Senator Risch. Dr. Dybul, one of the things that we always
struggle with up here is the bureaucracy and you have been at
this from the beginning and have a lot more experience than
anybody in this room probably on that particular issue.
I want to ask you your thoughts on how important it is to
have a single accountable entity at the Department of State
coordinating the activities of PEPFAR's implementing agencies,
particularly as to USAID and CDC, which occasionally have
differences.
Could you--the kindest way I can say it--could you comment
on that, please?
Dr. Dybul. Yes. Thank you, Senator Risch.
I have to say, having had the job it was--is absolutely
essential. Without a single responsible person who determines
how the resources are allocated, it is very difficult to move
things--that piece. Now, that was then.
We still need it and it maintains the impact of the
program. By running it through the State Department it also
contributes to what Chairman Menendez was talking about because
it is seen as part of the entire U.S. Government, not
individual agencies.
That founding piece, which we kind of stumbled on, to be
honest, was absolutely essential to discuss success of PEPFAR.
It remains essential to the success of PEPFAR.
Senator Risch. Well, thank you for that and I assume that
is advice as much as anything else. We will endeavor to follow
that advice and appreciate you for the work you have done on
this.
Thank you, Mr. Chairman.
The Chairman. Senator Kaine.
Senator Kaine. Thank you, Mr. Chair, and just add my
congratulatory comments, and thanks to Sir Elton for the
passion and the work that you have done through your
foundation, using your own reputation around the world to
really advance, and we appreciate this.
Dr. Dybul, I want to ask questions of you that were similar
to those that I asked the previous witness about the Latin
American reality.
I am the chairman of the Western Hemisphere Subcommittee of
this committee, and it just seems like often when we are in the
public health space we are sort of not paying sufficient
attention to Latin America--just using COVID as an example.
The chair and I were advocating strongly that the
Administration really prioritize Latin America in terms of
COVID vaccine distribution and what we did was, we did about 8
percent of our vaccine distribution to Latin America.
About 8 percent of the global population is in Latin
America, but 30 percent of deaths were in Latin America, and
the migration of Latin Americans to the U.S. back and forth
also created a greater risk of public health infection
transmission. We felt like those stats--those kind of facts on
the ground really warranted a more robust allocation in Latin
America that was not the case.
Here, I am troubled by the stats showing that while global
infections are dropping by 32 percent from 2010 to 2021, and
even infections in the Caribbean, thank goodness, are dropping
in the mid to high twenties, the infection rate in Latin
America is increasing by about 5 percent.
Why is this happening, and what more can we do to
prioritize really going after this battle and succeeding in
Latin America?
Dr. Dybul. It is an excellent question, Senator Kaine, and
it is one that I have struggled with both when I was at PEPFAR
and then at the Global Fund, which has a fairly large presence
in Latin America as well and, in fact, what you point out in
the Caribbean, I think, is largely because of the engagement of
PEPFAR, which has always been heavy in the Caribbean and less
so in deeper Latin America.
Brazil had a very strong program at the beginning, but then
it collapsed a bit, and I think what you are pointing to has a
lot to do with the political instability we are seeing in Latin
America and the shifts in governments and the shifts in
prioritization which used to focus more on health.
It is complicated because there tend to be higher income
countries and so foreign assistance money is often not seen or
used in the same way.
As Ambassador Nkengasong said, we can still play a role and
the role we can play is at the political level, but also at the
higher systems level and at the International Development Bank
level to use our capacity to support with fairly small amounts
of money those community-based links that will reach the people
in need.
Also, in Latin America, as in Africa, we have seen younger
people forgetting about HIV because they are--they do not see
everyone dying anymore and you are seeing marginalized groups,
for example, in the Amazon region that are affected.
We can respond. It will just be different because of the
high income nature of the countries, but if we engage there, I
think we can see a difference as we have seen in the Caribbean.
Senator Kaine. I will just say this and conclude. I know
the chairman and I are both focused on this. A number of the
programs that we have whether through USAID or other
international accounts put income limitations. You can go to
countries and they might have a high income under some median
measure and yet you find deep and intense poverty and
incredible isolation in communities. I worry sometimes that
just taking a rough cut with a median income figure does not
really do justice to needs and particularly in our own region.
I think there can--there is just so much good to be gained by
the U.S. being more engaged, not less.
I want to continue to work with my committee colleagues on
that, but thank you for that answer. I yield back, Mr. Chair.
The Chairman. Thank you, Senator Kaine. I share your
concern. I think we are being locked out of a lot of
opportunities to help our southern neighbors and help ourselves
in the context and we look forward to working with you to see
if we can find a better pathway forward and I appreciate your
focus on the hemisphere.
Senator--Dr. Barrasso.
Senator Barrasso. Thanks so much, Mr. Chairman.
Sir Elton, thanks for all of your work on this. I know you
have had bipartisan cooperation. I know you have been recently
with Chris Coons and Lindsey Graham in our efforts on this.
Could you talk a little bit about what is happening with
private donors following COVID-19? Are you seeing any decrease
in the private donations to this effort here and given the
current state of the economy? What strategy do you have working
with others to increase the funding?
Sir Elton. Well, I think--thank you, Senator. I think we
are seeing a decrease in private donors, which is dismaying,
but there are a lot of other diseases around, and sometimes
AIDS falls into the background. We have had COVID to deal with.
I am confident that we can turn that around. That is why
PEPFAR is really so important because when people see that this
is working so well I think the private donors will get back on
board.
We are doing everything we can to because we rely as a
foundation on private donors, and so far it really has not
affected us so much as an organization, as an AIDS foundation,
because I think we do really great work and people know that we
are reliable.
In general, we have to get people back on board and that is
why PEPFAR is the shining light in all of this, and HIV funding
is being used for COVID as well. I mean, it is just a no-
brainer. We just have to put our feet in the sand and say,
right, this is going down at the moment, but we can pick it
back up.
It has not affected the AIDS Foundation, but it has
affected funding in general, I think, for every kind of charity
on health--regarding health. Am I optimistic? Well, I am always
optimistic, but it is because of you guys out there that I am
optimistic. Thank you.
Senator Barrasso. Thank you.
For Dr. Dybul and then for Sir Elton as well, kind of
looking forward the next 5 years what do you see as some of the
challenges plus opportunities for PEPFAR?
Dr. Dybul. Thank you, Senator Barrasso and--Dr. Barrasso,
as a fellow physician. The challenges will be two-fold, one
financial, and secondly, lack of interest or shifting focus--
other pandemics.
However, the best way to respond to future pandemics is to
fight current pandemics and build the capacity so that you have
that surge capacity, and there is the opportunity. We actually
have the opportunity to get people to focus on pandemics in a
way that was--we were moving away from, but COVID could bring
us back to and that is where the opportunity is.
The other opportunity, I think, relates to what was
discussed earlier on localization. There is enormous talent
capacity at the community level, which relates to the
diplomatic benefits.
We can actually reach to community level to shape hearts
and minds and to introduce them again to the United States and
our values, which are better values than the--what others are
offering. I think there is lots of opportunity for us on
multiple levels.
Senator Barrasso. Thank you.
Sir Elton.
Sir Elton. I think stigma and discrimination--shame stops
progress and this is what we are finding in America as well. We
must stop this. We must get the opportunity in the hands of
young people to stop this.
Stigma is always a challenge--we have the medicine here to
shut this disease down, which is truly amazing, but it is the
stigma that stops the progress, and the shame.
As I say, I am optimistic and I think with young people, if
you give young people the gauntlet they will run with it.
Criminalization of LGBT people affects progress as well in
certain countries.
We mentioned Uganda earlier on in forum, and it is
dismaying to see this. It hinders not only people who have to
go underground, but it is inhumane and it will eventually
hinder their economy and the global economy and it is just a
dead-end situation.
As I have said, I am optimistic, but we have a lot of work
to do. We are not just sitting here clapping our hands. We have
a hell of a lot of work to do.
Having seen how you guys today--you senators have come
together, I am so moved by your enthusiasm, your commitment.
When you get a life force like PEPFAR, I think is like that
ball that came down in Indiana Jones or ``Raiders of the Lost
Ark.''
It is an immovable force, and having seen what you senators
have to say--I call you guys, sorry--you senators have to say
today and your intelligence and your commitment behind this
incredible PEPFAR organization that has done so much. I feel so
moved to do even more than I am at this present moment in time.
It is an inspirational thing, as I said in my speech
before, and I think together we can get rid of this disease. I
really believe that, but we have a lot of work to do, and you
guys are doing a hell of a lot of work in there and in the
background, and you are full of intelligent questions and you
have done your homework.
Now, if we do the homework together, we can stop it. We
actually can. Thank you for all you do. Thank you for your
wonderful time and effort today.
Senator Barrasso. Thanks to both of you. Thank you, Mr.
Chairman.
The Chairman. Sir Elton, we have been called worse than
``you guys.''
[Laughter.]
The Chairman. Senator Booker.
Senator Booker. For the record, I would like a Mother's Day
card. I have been called ``mother'' so many times followed by
something else.
[Laughter.]
Senator Booker. Dr. Dybul, I appreciate all your leadership
and work. Senator Menendez made a very insightful point about
the efforts--really encouraging efforts to get a clean
reauthorization, but if there were any changes in the program,
is there anything that you would see that could help us to even
improve our efforts?
Dr. Dybul. Thank you, Senator Booker.
Having been involved since the beginning and actually being
one of the architects of the original plan you approved in
2003, I do not think they are--I think the 2008 reauthorization
did everything that needed to be done and a clean
reauthorization is fine.
Report language around issues that are important to you
help steer the Administration, but as a piece of legislation, I
do not think there is anything that needs to be changed in the
legislation itself.
Senator Booker. Are there some things that concern you that
you hear people calling for that would be bad if it got into
the--a reauthorization?
Dr. Dybul. You always hear rumors in this town as part of
the job and so there are things out there you hear. I think the
biggest risk or dangers opening up for conversations the
chairman mentioned and the ranking member endorsed that we just
keep relitigating the same things over and over again and the
legislation as it is is actually not just fine; it is
excellent. It has served well for 20 years.
Senator Booker. You heard my concerns earlier about,
obviously, the effort with COVID, I think, educated a lot of
people about how co-morbidities contribute to death and,
obviously, that is the same thing with HIV and AIDS.
Are there some strategies that we are using to deal with
other--TB and other challenges that are going to help us with
this effort?
Dr. Dybul. Definitely, and tuberculosis has actually been
part of PEPFAR from the beginning because it is one of the
leading causes of death, but in Africa, as in the United States
people are living. People have now been on drugs for 20 years
in Africa. They are in their fifties. They have co-morbid
conditions, and that is the importance of the systems that have
been built--the health systems that have been built and, again,
I go back to this is a chronic disease like heart disease,
diabetes. It is not like tuberculosis or malaria. You have to
take drugs your entire life.
Prevention is a lifelong activity. You are at risk for HIV
your entire life so the behavioral issues and things that we
have to deal with, with diabetes, hypertension, and other
noncommunicable diseases, as we call them, actually PEPFAR was
built for that and the systems were built for that because it
is a chronic disease.
I think the pieces are there and we just need to use them
and I think we are using them. Countries are using them wisely
as we move from isolated HIV programs to something that is, in
fact, part of the health system itself.
Senator Booker. Sir Elton John mentioned in a really
tactical way about how you get to this new generation that is
growing up when you do have people living for 50 years not in
an atmosphere where the fear sears into you a sense of urgency,
and maybe the young people are not taking it as seriously as
possible.
Meeting them where they are on social media and more--I was
happy to hear Sir Elton John and his focus on this, but there
is another group that still causes concern for me that are
younger, young girls in particular, which I think necessitates
other tactics as well.
Could you mention some of those?
Dr. Dybul. Yes. In fact, PEPFAR and the Global Fund and
actually are deeply engaged there. There are structural issues
related to young girls, their menstrual period, for example,
and how--what they do and do not have access to in schools that
affects HIV.
Abuse--sexual abuse is a major problem that leads to
transmission of HIV because the woman cannot protect herself,
and so that is where some of the new therapies--long-acting
injectables, for example--could allow women to prevent HIV as a
prophylactic.
Instead of taking pills--PrEP--you can do an injectable
that will last for 3 months, which actually happens to match
family planning injectables.
There are a lot of things coming and--but going back to the
legislation that can all be done within the current
legislation, but dealing with young girls is a major issue--a
structural issue--and there has been a lot of progress, but a
lot more needs to be done and it involves some medical
intervention, but also behavioral interventions. There has been
significant change.
We have seen it and the DREAMS program and other programs
that the United States has supported help, but we have to take
that bigger picture.
It is not just medical. It has to do with societal and
behavioral issues, but it is changing and the United States has
played a significant part in that change.
Senator Booker. Thank you very much to both of our
witnesses.
Mr. Chairman.
The Chairman. Senator Van Hollen.
Senator Van Hollen. Thank you, Mr. Chairman, and let me
thank both of our witnesses who are here today. I was honored
to be part of a congressional delegation along with Senator
Menendez, the chairman, as well as Senator Graham and other
members of the committee to South Africa to celebrate the 20th
anniversary of the PEPFAR program, a program that more than any
other public health program, I think, in history has saved
millions and millions of lives.
First, Sir Elton John, thank you for your leadership. It
was good to have a chance to meet and talk with you and your
team during our visit to South Africa.
I have been bouncing between hearings so you may have
covered this, but as my friend, Senator Booker said, because of
the success of the PEPFAR program, you have the younger
generation of South Africans and others around the world--
younger generations not seeing AIDS/HIV as a death sentence and
that is a good thing.
On the other hand, the question is making sure that we
provide those young people with the information they need to
get the help when they need it, and I know you have got an
active social media program going through Facebook. We talked
about expanding that to other platforms as well, like
Instagram.
Sir Elton John, first, thank you, and then if you could
just provide us an update on how many young people are
currently using the platform, what you see is the future of the
platform, and I should say that we had a chance to meet with
some of the young people that were using it while we were
there.
It is off to a good start. How do you see the future of
that social media program?
Sir Elton. I am very optimistic because God knows the
internet is responsible for so many awful things, but it can
also be responsible for so many wonderful things and the
wonderful thing it can do is we provide young people with
information to stay healthy, services like HIV testing,
treatment, PrEP, mental health services, and more.
It is really important to get online services to young
people where they need it, not them have to travel, but they
need to get it locally, and expanding programs across multiple
countries and linked to health systems and it is going really,
really well.
I think we have, hopefully, nearly 100,000 people using
this now and when we were in South Africa about 30,000 were
using it, so it is coming along very well and it is nice to see
you again after our wonderful trip.
My adamant thing is use the internet to get to the young.
The young are taking this up and they really are responding to
the information and the fact that they can talk to each other
online about it or on their phone is really, really important
and they are the future.
They are our future no matter what it was, whether it is
HIV, the world, or whatever. The young people are the ones that
are going to take this forward and they are responding to it
and that is a great sign.
Senator Van Hollen. Well, thank you. As you said, the way
to connect with so many of these young people is to meet them
where they are on social media and we know that there is a huge
take up of social media in South Africa and so many of these
other countries. Thank you for all those efforts--your
continuing efforts.
Dr. Dybul, one of the goals of the HIV/AIDS program--that
PEPFAR program--has been to make it sustainable over time and
we have wanted to work with governments to transition more and
more responsibility to those national governments.
Some partner countries have demonstrated both the political
will, as well as the capacity to take ownership of managing.
Some of them have taken on a larger and larger share of the
budgets for administering the program.
Other countries have not shown the political will nor
provided the budget support for the program. Can you talk about
how we navigate that and how we continue to support the
countries that are trying to take responsibility, but also how
we address those countries that have not?
Dr. Dybul. It is an excellent question, Senator, and it is
one that all international organizations struggle with. I think
PEPFAR has probably done as well or better than any ever have,
as you pointed out.
For the countries that are not moving, and here again I go
back to Ambassador Nkengasong will be the best Global AIDS
Coordinator of any of us by far.
He has the capacity, the contacts, the ability to move that
in ways that I do not think any of the rest of us could and
part of that is from his time as Africa's CDC director, but
also before that when he was leading the laboratory effort in
Africa for PEPFAR.
It is a complex issue that involves political, but also
ground--top level political, but also ground up forcing,
pushing and we have been doing some of this work, actually.
PEPFAR has been doing this work to build that strong community
push for health services to the government and it is actually
worked in Kenya and Eswatini and other places.
We have seen governors double, triple their budgets because
of the ground up pressure, not because of the external
pressure, and so some of it is the political engagement, but it
is also supporting those community groups where it goes back to
some of the localization that then puts pressure on the
governments to step up healthcare because it is good politics
for them.
I have that conversation with heads of state. I used to
bore them to tears with statistics and I learned to start off
saying health is good politics. They get that in a second and
then you can play that out.
Senator Van Hollen. Well, thank you. I appreciate that, and
you mentioned Dr. Nkengasong and I am sorry I was not able to
make his testimony.
I know this is an area he is focused on and appreciate your
laying out the challenges and as well, but I think you hit it
on the head, which is to make sure that leaders in those
countries understand that this is a good thing for their public
and a good thing for their own politics as well.
Thank you.
The Chairman. Thank you.
Senator Coons.
Senator Coons. Thank you, Chairman Menendez, Ranking Member
Risch.
Thank you, Chairman Menendez, for the opportunity to travel
with you to southern Africa and in particular to South Africa
with Sir Elton John and Dr. Nkengasong to celebrate the 20th
anniversary of this landmark program that has saved more than
25 million lives, I think the single best thing President Bush
did, I think something that has been sustained over
presidencies and majorities of both parties.
I was just at a hearing with the administrator of USAID.
One of the significant portions of this year's budget request
is to sustain and extend our PEPFAR investment, our investment
in transforming public health systems around the developing
world.
Sir Elton John, it is great to see you again. It was
wonderful to get some time with you and to see the connection
that you are able to create and sustain with young people and
the services that your foundation is helping facilitate and
scale for young people online is a great investment and an
encouraging story.
If I could, Mr. Dybul, I just would be interested--I have
missed most of the hearing and I suspect you have covered
this--what you think are the areas where we most need to invest
in innovation, in policy.
As many countries are transitioning towards epidemic
control we need to better understand what our sustained
investment in PEPFAR will accomplish and what are the key
challenges to moving towards an AIDS-free generation.
Dr. Dybul. Thank you, Senator Coons. In terms of
innovation, there are many areas of innovation. There is
scientific innovation, for example, the long-acting, anti-
virals that I mentioned, which could be prophylactic, but also
a treatment potentially; better diagnostics, local diagnostics,
so people can be diagnosed and treated rapidly, which we think
would then reduce the transmission.
The innovation that we really need relates to localization,
which I am sure came up in your conversation with
Administrative Power. Reaching communities and sustaining those
communities, funding those communities--the faith communities,
the community-based organizations--that will not only enhance
our ability to reach those most at risk because that is where
they are in the communities, but will also then give us the
ability to detect and respond to the next pandemic threat.
The innovation, some of that is technological and how
people connect with each other, but some of it is just human-
to-human innovation and this is a fundamental area. Most of the
innovation that we have seen in PEPFAR and Global Fund and
other development programs comes from the individuals. We can
say go do X, Y, or Z. They figure out in a setting with almost
no resources how to make that work.
Supporting that innovation will do two things--one, lead to
greater success, and two, provide that ground up pressure for
change that will not only be related to health, but
democratization and many other things.
The challenges will be financing, the challenges will be
distraction from--to other things, and the challenge will be
global competition for whose voice are they listening to, and I
think the United States is well-positioned and PEPFAR has put
us in a position to be able to do that extraordinarily well.
Senator Coons. Last question, if I might. I just spent
several days at a retreat looking at nutrition and food
security in particular. I assume there are overlaps--Dr.
Nkengasong may agree--because those who are immunocompromised,
those who are most at risk of infection, those who are living
with HIV/AIDS, also need sustained high-quality food and
nutrition.
There is a food as medicine movement that I have been
trying to better understand and this is one population, or one
area of focus, those who are at risk, where I think our work in
strengthening food systems can learn a lot from the
groundbreaking work that PEPFAR has done in strengthening and
transforming public health systems, particularly in rural
communities, particularly in communities where food security is
also aligned with being at risk for new infections.
I look forward to staying in touch. Thank you, Mr.
Chairman, for allowing me to question here at the very end and,
again, to both Sir Elton John and to Dr. Nkengasong, thank you
for your engagement and leadership in this area.
Thank you, Mr. Chairman.
The Chairman. Thank you, Senator Coons. Thank you for your
work, particularly on the Appropriations Committee. It is
incredibly important.
I want to thank our witnesses for appearing before the
committee and for speaking with such knowledge and passion
about PEPFAR and the fight against HIV/AIDS.
I think it is appropriate to recognize President George W.
Bush for his leadership and vision over 20 years ago. Some may
not have thought that it would be possible to achieve what we
achieved today, but it was his leadership at that time that
began us on this course so it is appropriate and fitting to
recognize it.
I think we can all agree that PEPFAR shows the
extraordinary power of American determination, compassion, and
ingenuity marshaled for the purpose of making the world a
better place.
I look forward to working with my colleagues across
Congress, with the Administration, with experts and advocates
to ensure that PEPFAR is equipped to continue its mission to
end the HIV/AIDS epidemic.
I asked unanimous consent at this time to enter testimony
for the hearing record from former Global AIDS Coordinator, Dr.
Eric Goosby, and founding director of Rutgers Global Health
Institute, Dr. Richard Marlink, and ask that it appear
immediately after the testimony offered by our witnesses on our
second panel.
Without objection, so ordered.
[Editor's note.--The information referred to above can be found
immediately following the ``Prepared Statement of Dr. Mark
Dybul'' in this hearing.]
The Chairman. Sir Elton, we wish you good luck on your
world tour. I know it will be a smash, and thank you again for
joining us virtually from across the pond.
Dr. Dybul, thank you for your extraordinary leadership over
this period of time.
The record for this hearing will remain open until the
close of business on Thursday, April 20. Please ensure that
questions for the record are submitted no later than that date.
With that and with the thanks of the committee, this
hearing is adjourned.
[Whereupon, at 11:42 a.m., the hearing was adjourned.]
----------
Additional Material Submitted for the Record
Responses of Dr. John Nkengasong to Questions
Submitted by Senator Bill Hagerty
Question. How do you assess the ways in which PEPFAR contributes to
overall U.S. foreign policy goals with respect to recipient countries,
including U.S. diplomatic, economic, and security objectives? What
metrics do you use to measure these linkages and impacts?
Answer. PEPFAR has continued to be an expression of U.S. values and
demonstrates our deep commitment to health security and prosperity
globally. It is one of our strongest foreign policy tools in partner
nations, helping to advance all our diplomatic, economic, and security
objectives, directly and indirectly. PEPFAR's impact on our diplomatic
efforts is immeasurable, strengthening partnerships for over 20 years.
PEPFAR has also played a direct role in saving lives, increasing GDP,
and in some countries, ensuring the readiness of Armed Forces for UN
peacekeeping missions.
Question. How does PEPFAR integrate with broader U.S. public
diplomacy efforts in recipient countries? What quantitative and
qualitative data does PEPFAR collect on the impact of its programs on
public perceptions of the United States in recipient countries?
Answer. PEPFAR programs in all countries fall under the direct
authority of U.S. Ambassadors, and PEPFAR Program Coordinators residing
in-country report to the Deputy Chief of Mission or Ambassador. In some
countries, PEPFAR employs communications staff, but works in tandem
with embassies' Public Affairs offices that have primary responsibility
for public affairs and public diplomacy programs in recipient nations.
Independent entities such as the Kaiser Family foundation conduct such
assessments of PEPFAR's impact.
Question. Under what conditions will PEPFAR be able to claim it has
largely eradicated HIV/AIDS? When do you anticipate these conditions
will be met?
Answer. Our focus is on the goal of ending the HIV/AIDS as a public
health threat by 2030, a state where new HIV infections and mortality
of PLHIV have dramatically declined. The millions of people living with
HIV will continue to need ongoing HIV treatment. Eradicating HIV is not
possible without a vaccine. Controlling the HIV pandemic with high
coverage of effective antiretroviral therapy (ART), pre-exposure
prophylaxis (PrEP) and other prevention interventions is possible. The
use of data, HIV testing, treatment and prevention strategies will
continue to evolve.
Question. PEPFAR's funding request has steadily increased over
time. Under what conditions would the program require less resourcing
to accomplish its goals?
Answer. While PEPFAR funding has increased over the past decade,
those increases have not kept pace with inflation. Additionally, there
are costs to transitioning programs from a scale up mode to a
sustainment mode, as well as some additional costs required to find the
hardest to reach populations. As countries near epidemic control, we
will continue to evaluate what is needed to sustain those HIV gains in
consultation with Congress and host-country governments.
Question. How is PEPFAR working to improve domestic resource
mobilization in recipient countries? Specifically, how is the program
working to strengthen local health systems, so they are sustainable
without foreign assistance?
Answer. PEPFAR has always invested in host government systems and
capabilities, as can be seen in the COVID-19 response, which depended
heavily on HIV systems. Over the next year each country will develop a
measurable Sustainability Roadmap that will document responsibility for
the development of core government systems and functions and a
financing component that supports the capabilities the PEPFAR program
invests in. Over time responsibility for treatment and prevention
programs will also be transitioned.
Question. How do changes in the epidemiological landscape--such as
a decline in HIV/AIDS--affect funding requirements for recipient
counties?
Answer. PEPFAR has saved more than 25 million lives and prevented
millions more new infections. This vital mission should be continued,
expanded and shared with other donor and partner countries. As
countries near epidemic control and PEPFAR continues to engage partner
governments on the sustainability of the HIV response, we will continue
to evaluate what is needed to sustain those HIV gains both from a
financial and programmatic standpoint in a country-specific manner.
Question. How does PEPFAR programming complement the efforts of the
Global Fund? Are there areas in which PEPFAR duplicates the efforts of
the Global Fund?
Answer. PEPFAR works in close coordination and collaboration with
the Global Fund on all levels (at headquarters, regionally and in
country) to ensure our efforts are well-aligned and complimentary. The
PEPFAR Country Operational Planning (COP) co-planning process
incorporates staff from the Global Fund to ensure joint programming
with the country. At the country level, PEPFAR participates in the
Global Fund's Country Coordinating Mechanisms. At headquarters, PEPFAR
implements resource alignment activities to deduplicate jointly funded
areas.
Question. What percentage of global HIV/AIDS pandemic assistance is
conducted by PEPFAR compared to the Global Fund and other initiatives?
Answer. Globally, most HIV-specific funding comes from PEPFAR and
the Global Fund. Of total HIV funding, PEPFAR has a program level of
about $4.5 billion and the Global Fund about $2.1 billion for HIV,
including $1.95 billion in PEPFAR funded countries. PEPFAR and the
Global Fund have detailed aligned data on spending in countries where
both programs operate. There are also initiatives from other donors and
multilateral development banks that make important investments in
health systems and health financing that amplify the HIV effort but are
not HIV specific.
Question. Why do you believe PEPFAR has been so successful in
moving toward localization? What lessons can be drawn for other U.S.
foreign assistance programs?
Answer. In the first few years of PEPFAR, there was limited local
capacity to provide HIV treatment and prevention services. Over the
past 20 years, PEPFAR has made tremendous progress building national
capacity to implement, while gaining experience through the ``Track 1
transition'' which identified how to manage and effectively implement
clinical services through local partners. PEPFAR has also continued to
invest meaningful time and effort to increase the depth and breadth of
the financial and operational data we collect on partners to improve
our oversight and prevent any fraud, waste and abuse.
Question. What barriers remains to full localization of PEPFAR
programming?
Answer. There is still need for local organizations to scale up
their programming in many PEPFAR-supported countries. To do so will
require effectively assessing the technical and operational
capabilities of our local partners and helping to support them to
strengthen those underlying capabilities so they can manage a portfolio
of services. There will also be an ongoing need for international
organizations to provide targeted expertise, especially to deploy new
innovations and share global best practices.
Question. What implications does localization have for PEPFAR's
overall costs?
Answer. Localization does have potential to lower overall costs.
However, the cost savings will be more modest than it may appear. For
example, most staff of implementing partners are already locally
employed and there are unavoidable costs of doing business when working
with the U.S. Government around reporting requirements and systems. To
the extent that PEPFAR uses local government systems there is the
potential for more robust savings, but those savings must be weighed
against the risks that government-to-government arrangements bring.
Question. How does PEPFAR navigate the challenge or vetting and
measuring the performance of local implementing partners rather than
larger international organizations?
Answer. PEPFAR uses the same high standards for both initially
vetting the qualifications of any partner, international or local, as
well as the performance management during the contract. In our planning
process, every partner is aligned with specific measures of performance
for the services they have been enlisted to provide and those
performance indicators are tracked quarterly during implementation and
steps are taken to remediate any issues with performance if they exist.
Question. How does USAID conduct the vetting of local implementing
partners to ensure any funding is consistent with the Helms Amendment
and other restrictions?
Answer. PEPFAR has the oversight mechanisms in place which seek to
ensure that PEPFAR funds, including funds provided to USAID, are
implemented in a manner consistent with all applicable federal
statutory restrictions, including those related to the Helms Amendment.
We work with and provide guidance to our implementing partners on
implementation of these requirements and implement partner management
activities through our USG staff at our embassies.
______
Statement From David J. Kramer, George W. Bush Institute,
Dated April 19, 2023
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