[Congressional Record Volume 153, Number 90 (Wednesday, June 6, 2007)]
[Senate]
[Pages S7180-S7181]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mrs. FEINSTEIN (for herself, Ms. Snowe, Mr. Leahy, Mr. Durbin, 
        Mr. Lautenberg, Mrs. Clinton, Mr. Brown, Mr. Kerry, Mr. Dodd, 
        Mrs. Murray, Mr. Feingold, and Mrs. Boxer):
  S. 1553. A bill to provide additional assistance to combat HIV/AIDS 
among young people, and for other purposes; to the Committee on Foreign 
Relations.
  Mrs. FEINSTEIN. Mr. President, I rise today with Senator Snowe to 
introduce legislation to strengthen our international HIV prevention 
efforts and empower the people on the ground who are fighting this 
disease to design the most effective and appropriate HIV prevention 
program.
  The bill is cosponsored by Senator Leahy, Senator Durbin, Senator 
Clinton, Senator Lautenberg, Senator Brown, Senator Kerry, Senator 
Boxer, Senator Dodd, Senator Murray, and Senator Feingold.
  This bill simply strikes the provision in the United States 
Leadership Against HIV/AIDS, Tuberculosis and Malaria Act of 2003 that 
mandates that at least 33 percent of HIV prevention funding in the 
President's Emergency Plan for AIDS Relief, PEPFAR, be set aside 
``abstinence-until-marriage'' programs.
  Let me be clear from the beginning: this bill does not prohibit the 
administration from funding ``abstinence-until-marriage'' programs.
  In fact, if the bill becomes law, the administration would still be 
able to spend all of our HIV prevention funding on abstinence-until-
marriage programs if it decided do so.
  This bill is about giving the administration and HIV/AIDS workers the 
flexibility to design the most effective HIV prevention program without 
having to worry about artificial earmarks that are based on politics, 
not science.
  Indeed, in the fight against the HIV/AIDS pandemic, we cannot afford 
to tie ourselves down with undue restrictions.
  Worldwide, 40 million people are infected with HIV. Each day, 
approximately 12,000 people are newly infected with HIV. In 2006, there 
were 4.3 million new HIV infections around the world, 2.8 million in 
sub-Saharan Africa alone. Sub-Saharan Africa is home to almost two-
thirds of the estimated 40 million people currently living with HIV.
  Across sub-Saharan Africa, the prevalence rate for the adult 
population is 6 percent. Mr. President, 2.1 million adults and children 
died of AIDS in 2005.
  Despite these devastating numbers, according to UNAIDS, less than one 
in five people at risk for infection of HIV have access to basic 
prevention services. Studies have shown that two-thirds of new HIV 
infections could be averted with effective prevention programs.
  Clearly, we still have a long ways to go to rein in this disease.
  The 2003 HIV/AIDS legislation recognized that prevention, along with 
care and treatment, is an essential component of that fight and demands 
a multipronged approach. It endorsed the ``ABC'' model for prevention 
of the sexual transmission of HIV: abstain, be faithful, use condoms.
  Yet instead of allowing HIV/AIDS workers and doctors the ability to 
use all of the prevention tools at their disposal to respond to local 
needs, we required them to spend at least 33 percent on ``abstinence-
until marriage'' programs.
  The question has to been asked: Why 33 percent? Why not 15 percent? 
Why not 50 percent? What scientific study concluded that 33 percent of 
HIV prevention funds for abstinence only programs was appropriate?
  There was no study and it begs the question: when you are fighting a 
pandemic that has already cost so many lives, who should decide how to 
allocate funding among different types of HIV prevention programs, 
Congress or the people with the knowledge and expertise on how to fight 
this disease?
  I support abstinence programs as a critical part of our HIV 
prevention programs. But mandating an earmark has negative consequences 
for other effective tools.
  It means less money for funds to prevent mother-to-child 
transmission, less money to promote a comprehensive prevention message 
to high risk groups such as sexually active youth, and fewer funds to 
protect the blood supply.
  Indeed, the evidence clearly shows that the one-third earmark has 
inhibited the ability of local communities to design a multipronged HIV 
prevention program that works best for them.
  Last year, the Government Accountability Office issued a report that 
found ``significant challenges'' associated with meeting the 
abstinence-until-marriage programs. The report concluded that the 33 
percent abstinence spending requirement is squeezing out available 
funding for other key HIV prevention programs such as mother-to-child 
transmission and maintaining a health blood supply.
  Country teams that are not exempted from the one-third earmark have 
to spend more than 33 percent of prevention funds on abstinence-until-
marriage activities, sometimes at the expense of other programs, in 
order for the administration to meet the overall 33 percent earmark.
  The spending requirement limited or reduced funding for programs 
directed to high-risk groups, such as sexually active youth and the 
majority of country teams on the ground reported that meeting the 
spending requirement ``challenges their ability to develop 
interventions that are responsive to local epidemiology and social 
norms.''
  Last month, a congressionally mandated review by the Institute of 
Medicine on the first 3 years of the President's Emergency Plan for 
AIDS Relief also found significant problems with the abstinence 
earmark. It concluded: there is no evidence to support a 33 percent 
abstinence only earmark; the 33 percent earmark does not allow country 
teams on the ground the flexibility they need to respond to local 
needs.
  Our bill seeks to address the problems highlighted in the GAO and the 
Institute of Medicine reports and provide local communities the 
necessary flexibility to achieve the goal we all share: stopping the 
spread of HIV, especially among young people.
  Simply put, our bill balances congressional priorities with public 
health needs. Under our legislation, country teams can take into 
account country needs including cultural differences, epidemiology, 
population age groups and the stage of the epidemic in designing the 
most effective prevention program.
  One size does not fit all. A prevention program in one country may 
look a lot different than a prevention program in another country.
  A May 2003 report from the Bill and Melinda Gates Foundation and 
Henry J. Kaiser Foundation highlights that proven prevention programs 
include behavior change programs, including delay in the initiation of 
sexual activity, faithfulness and correct and consistent condom use; 
testing and treatment for sexually transmitted diseases; promoting 
voluntary counseling and testing; harm reduction programs for IV drug 
users; preventing the transmission of HIV from mother to child; 
increasing blood safety; empowering women and girls; controlling 
infection in health care settings; and devising programs geared towards 
people living with HIV.
  For example, studies have shown that combining drugs with counseling 
and instruction on use of such drugs reduces mother-to-child 
transmission by 50 percent.
  Such cost effective programs are not related to abstinence and should 
not be constrained by the 33 percent earmark on funds for prevention.
  I understand the importance of teaching abstinence. It is and will 
remain a key part of our strategy in preventing the spread of HIV.

[[Page S7181]]

  But let us listen to the words of someone with firsthand experience 
about the challenges sub-Saharan African countries face in combating 
HIV/AIDS and the constraints the ``abstinence-until-marriage'' earmark 
places on those efforts.
  In an August 19, 2005, op-ed in the New York Times, Babatunde 
Osotimehin, chairman of the National Action Committee on AIDS in 
Nigeria, wrote:

       Abstinence is one critical prevention strategy, but it 
     cannot be the only one. Focusing on abstinence assumes young 
     people can choose whether to have sex. For adolescent girls 
     in Nigeria and in many other countries, this is an inaccurate 
     assumption. Many girls fall prey to sexual violence and 
     coercion. . . . When dealing with AIDS, we must address the 
     realities and use a multipronged approach to improving 
     education and health systems, one that can reach all of our 
     people.

  He concludes:

       National governments must have the freedom to employ the 
     very best strategies at our disposal to help our people.

  I could not agree more.
  If we want to help the girls of Nigeria and the youth of sub-Saharan 
Africa, we cannot limit the information they receive about keeping them 
safe from acquiring HIV.
  We do not have time to lose. I urge my colleagues to support this 
legislation and support a pro-abstinence, multipronged approach to 
preventing the spread of HIV.
  I ask unanimous consent that the text of the bill be printed in the 
Record.
  There being no objection, the text of the bill was ordered to be 
printed in the Record, as follows:

                                S. 1553

       Be it enacted by the Senate and House of Representatives of 
     the United States of America in Congress assembled,

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``HIV Prevention Act of 
     2007''.

     SEC. 2. FINDINGS.

       Congress makes the following findings:
       (1) The President's Emergency Plan for AIDS Relief (in this 
     Act referred to as ``PEPFAR'') is an unprecedented effort to 
     combat the global AIDS epidemic, with $9,000,000,000 targeted 
     for initiatives in 15 focus countries.
       (2) The PEPFAR prevention goal is to avert 7,000,000 HIV 
     infections in the 15 focus countries--most in sub-Saharan 
     Africa, where heterosexual intercourse is by far the 
     predominant mode of HIV transmission.
       (3) According to the Joint United Nations Programme on HIV/
     AIDS, young people between the ages of 15 and 24 years old 
     are ``the most threatened by AIDS'' and ``are at the centre 
     of HIV vulnerability''. Globally, young people between the 
     ages of 10 and 24 years old account for \1/2\ of all new HIV 
     cases each year. About 7,000 young people in this cohort 
     contract the virus every day.
       (4) A recent review funded by the United States Agency for 
     International Development found that sex and HIV education 
     programs that encourage abstinence but also discuss the use 
     of condoms do not increase sexual activity as critics of sex 
     education have long alleged. Sex education can help delay the 
     initiation of intercourse, reduce the frequency of sex and 
     the number of sexual partners, and also increase condom use.
       (5) The United States Leadership Against HIV/AIDS, 
     Tuberculosis, and Malaria Act of 2003 (22 U.S.C. 7601 et 
     seq.) requires that at least \1/3\ of all prevention funds be 
     reserved for abstinence-until-marriage programs.
       (6) A congressionally mandated review by the Institute of 
     Medicine of the first 3 years of PEPFAR unequivocally 
     recommends greater flexibility in the global fight against 
     AIDS. The March 2007 Institute of Medicine report entitled 
     ``PEPFAR Implementation: Progress and Promise'' calls for 
     greater emphasis on prevention than the law currently allows 
     and says that ``removal of the abstinence-until-marriage'' 
     earmark, among other changes, ``could enhance the quality, 
     accountability, and flexibility'' of prevention efforts.
       (7) The Institute of Medicine report further found that the 
     abstinence-until-marriage earmark ``has greatly limited the 
     ability of Country Teams to develop and implement 
     comprehensive prevention programs that are well integrated 
     with each other and with counseling and testing, care and 
     treatment programs and that target those populations at 
     greatest risk''.
       (8) The Institute of Medicine report also found that the 
     earmark has ``limited PEPFAR's ability to tailor its 
     activities in each country to the local epidemic and to 
     coordinate with . . . the countries' national plans''.
       (9) The Institute of Medicine report is in keeping with the 
     conclusions of a report issued in 2006 by the Government 
     Accountability Office. The GAO report, entitled ``Spending 
     Requirement Presents Challenges for Allocating Funding under 
     the President's Emergency Plan for AIDS Relief '', found 
     ``significant challenges'' associated with meeting the 
     earmark for abstinence-until-marriage programs.
       (10) The Government Accountability Office found that a 
     majority of country teams report that fulfilling the 
     requirement presents challenges to their ability to respond 
     to local epidemiology and cultural and social norms.
       (11) The Government Accountability Office found that, 
     although some country teams may be exempted from the 
     abstinence-until-marriage spending requirement, country teams 
     that are not exempted have to spend more than the 33 percent 
     of prevention funds on abstinence-until-marriage activities--
     sometimes at the expense of other programs.
       (12) The Government Accountability Office found that, as a 
     result of the abstinence-until-marriage spending requirement, 
     some countries have had to reduce planned funding for 
     Prevention of Mother-to-Child Transmission programs, thereby 
     limiting services for pregnant women and their children.
       (13) The Government Accountability Office found that the 
     abstinence-until-marriage spending requirement limited or 
     reduced funding for programs directed to high-risk groups, 
     such as services for married discordant couples, sexually 
     active youth, and commercial sex workers.
       (14) The Government Accountability Office found that the 
     abstinence-until-marriage spending requirement made it 
     difficult for countries to fund medical and blood safety 
     activities.
       (15) The Government Accountability Office found that, 
     because of the abstinence-until-marriage spending 
     requirement, some countries would likely have to reduce 
     funding for condom procurement and condom social marketing.
       (16) In addition, the Government Accountability Office 
     found that \2/3\ of focus country teams reported that the 
     policy for implementing PEPFAR's ABC model (defined as 
     ``Abstain, Be faithful, use Condoms'') is unclear and open to 
     varying interpretations, causing confusion about which groups 
     may be targeted and whether youth may receive the ABC 
     message.
       (17) The Government Accountability Office found that the 
     ABC guidance does not clearly delineate permissible ``C'' 
     activities under the ABC model. Program staff reported that 
     they feel ``constrained'' by restrictions on promoting or 
     marketing condoms to youth. Other country teams reported 
     confusion about whether PEPFAR funds may be used for broad 
     condom social marketing, even to adults in a generalized 
     epidemic.
       (18) Young people are our greatest hope for changing the 
     course of the AIDS epidemic. According to the World Health 
     Organization, ``[f]ocusing on young people is likely to be 
     the most effective approach to confronting the epidemic, 
     particularly in high prevalence countries''.

     SEC. 3. ENSURING BALANCED FUNDING FOR HIV PREVENTION METHODS.

       (a) Sense of Congress on Abstinence-Until-Marriage Funding 
     Requirement.--Section 402(b)(3) of the United States 
     Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 
     2003 (22 U.S.C. 7672(b)(3)) is amended by striking ``, of 
     which such amount at least 33 percent should be expended for 
     abstinence-until-marriage programs''.
       (b) Elimination of Abstinence-Until-Marriage Funding 
     Requirement.--Section 403(a) of such Act (22 U.S.C. 7673(a)) 
     is amended by striking the second sentence.
                                 ______