[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

                              ----------                              
                                                                   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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