[Congressional Record Volume 153, Number 141 (Friday, September 21, 2007)]
[Senate]
[Pages S11940-S11943]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




     U.S. LEADERSHIP AGAINST HIV/AIDS, TUBERCULOSIS AND MALARIA ACT

  Mr. LUGAR. Madam President, I rise today to discuss S. 1966, a bill 
that I introduced last month to reauthorize the U.S. Leadership Against 
HIV/AIDS, Tuberculosis, and Malaria Act of 2003--known as the 
Leadership Act. Under the Leadership Act, the American people have 
catalyzed the world's response to the HIV/AIDS epidemic. It is not 
often that we have an opportunity to save lives on such a massive 
scale. Yet every American can be proud that we have seized this 
opportunity. My message to Senators today is a simple one: let's agree 
that we should sustain this success, and let's move now to pass a 
reauthorization bill.
  I believe that Congress should reauthorize the Leadership Act this 
year, rather than wait until it expires in September 2008. Partner 
governments and implementing organizations in the field have indicated 
that, without early reauthorization of the Leadership Act, they may not 
expand their programs in 2008 to meet the goals that we set for the 
President's Emergency Plan for AIDS Relief also known as PEPFAR. These 
goals include providing treatment for 2 million people, preventing 7 
million new infections, and caring for 10 million AIDS victims, 
including orphans and vulnerable children.
  Many partners in the fight against HIV/AIDS want to expand their 
programs. But to do so, they need assurances of a continued U.S. 
commitment beyond 2008. We may promise that a reauthorization of an 
undetermined funding level will happen eventually--but partners need to 
make plans now if they are to maximize their efforts. Today, they have 
only a Presidential proposal, not an enacted reauthorization bill. This 
is an important matter of perception, similar to consumer confidence. 
It may be intangible, but it will profoundly affect the behavior of 
individuals, groups, and governments engaged in the fight against HIV/
AIDS.
  I recently received a letter from the Ministers of Health of the 12 
African focus countries receiving PEPFAR assistance. They wrote:

       Without an early and clear signal of the continuity of 
     PEPFAR's support, we are concerned that partners might not 
     move as quickly as possible to fill the resource gap that 
     might be created. Therefore, services will not reach all 
     those who need them.  . . . The momentum will be much greater 
     in 2008 if we know what to expect after 2008.

  I realize that a PEPFAR reauthorization bill will face a crowded 
Senate calendar this year. But maintaining the momentum of PEPFAR 
during 2008 is a matter of life or death for many. Part of the original 
motivation behind PEPFAR was to use American leadership to leverage 
other resources in the global community and the private sector. The 
continuity of our efforts to combat this disease and the impact of our 
resources on the commitments of the rest of the world will be maximized 
if we act now.
  Although the Leadership Act is an extensive piece of legislation, I 
believe that Congress can reach an agreement expeditiously on its 
reauthorization. Most of its provisions are sound and do

[[Page S11941]]

not require alteration. In fact, the act has provided for substantial 
flexibility of implementation that has been one of the keys to success 
of the PEPFAR program. The authorities in the original bill are 
expansive, and they are enabling the program to succeed in diverse 
nations, each with its own unique set of cultural, economic, and public 
health circumstances.
  In developing S. 1966, I have consulted extensively with American 
officials who are implementing PEPFAR. Most believe that preserving the 
existing provisions of the Leadership Act would give them the best 
chance at continued success. Adding new restrictions to the law can 
limit the flexibility of those charged with implementation in 2009 and 
beyond. We don't know who that will be, and more importantly, we don't 
know what the challenges of 2013 will be--though we can probably say 
with confidence that the landscape will be very different then than it 
is today.

  This is not to say that Senators may not have good ideas for 
improvement that should be adopted. But new provisions must not unduly 
limit the flexibility of the program, and Congress should avoid 
descending into time-consuming quarrels over provisions that are 
unnecessary or that have little to do with the core mission of the 
bill.
  As Senators study the record of PEPFAR to date, I believe they will 
find that the vast majority of the authorities needed for the next 
phase of our effort already are in the existing legislation. I would 
like to outline how the existing legislation is dealing successfully 
with several specific areas of concern.
  The first is Strengthening Health Systems. Some have expressed the 
view that additional authorities are needed to improve health systems 
in target countries. I agree that this area is a vital one if hard-hit 
nations are to have truly sustainable programs. Yet the current 
Leadership Act already contains ample authorities to help build health 
systems, and the United States is making extensive use of those 
authorities. To date, the emergency plan has supported nearly 1.7 
million training and retraining encounters for health care workers and 
more than 25,000 service sites. In fiscal year 2007, PEPFAR estimates 
it will have invested nearly $640 million in network development, human 
resources, and local organizational capacity and training.
  A recent study of PEPFAR treatment sites in four countries--Nigeria, 
Ethiopia, Uganda, and Vietnam--found that PEPFAR supported 92 percent 
of the investments in health infrastructure designed to provide 
comprehensive HIV treatment and associated care, including facility 
construction, lab equipment, and training. In these countries, PEPFAR 
also supported 57 percent of personnel costs and 92 percent of training 
costs.

  In a separate study focused on Rwanda that examined 22 non-HIV/AIDS 
health indicators, 17 showed significant improvements as PEPFAR scaled 
up. Improvements in family planning and infant care, among other 
achievements, were deemed to have stemmed from ongoing HIV/AIDS 
programs. According to the chairman of the Institute of Medicine 
Committee, which recently completed a congressionally mandated study of 
the emergency plan:

       PEPFAR is contributing to make health systems stronger . . 
     . doing good to the health systems overall.

  In the Senate Foreign Relations Committee, we have paid particular 
attention to the devastating toll of HIV/AIDS on females. Women, and 
young girls in particular, are especially vulnerable to HIV and AIDS 
due to a combination of biological, cultural, economic, social, and 
legal factors. The Leadership Act's authorities in this area are 
robust. The emergency plan is already leading the world in 
incorporating gender considerations across its prevention, treatment, 
and care programs and addressing gender issues that contribute to the 
spread of HIV/AIDS. For example, in 2006, a total of $442 million 
supported more than 830 interventions that included one or more of the 
five priority gender strategies identified in the Leadership Act. These 
strategies include increasing gender equity in HIV/AIDS services, 
reducing violence and coercion, addressing male norms and behaviors, 
increasing women's legal protections, and increasing women's access to 
income and productive resources.
  In Namibia, PEPFAR supports the Village Health Fund Project, a micro-
credit program that provides vulnerable populations, such as widows and 
grandmothers who care for orphaned grandchildren, with start-up capital 
for income-generating projects. In South Africa, PEPFAR supports a 
project that seeks to have men take more responsibility for preventing 
HIV infection and gender-based violence.

  Another issue of special concern is food and nutrition. In 2004, I 
chaired a hearing of the Foreign Relations Committee on this subject 
that underscored how HIV/AIDS and hunger exacerbate each other in many 
African nations. The AIDS crisis has led to a food crisis for both its 
victims and their communities. It is no coincidence that the prevalence 
of HIV/AIDS is highest in countries where food is most scarce. PEPFAR 
has adopted guidance providing for the inclusion of nutritional 
assessment and counseling in care and treatment programs. It has also 
facilitated food support for targeted populations and assistance to 
long-term food security for orphans and vulnerable children. PEPFAR 
seeks to build on the comparative advantages of its partners in 
addressing food needs. These include USAID, the U.S. Department of 
Agriculture, and the United Nations World Food Program. These partners 
provide more direct support in food commodities and food security with 
a focus on overall communities. The PEPFAR approach of targeting 
individuals complements these efforts.
  In Kenya, for example, PEPFAR is supporting a ``food by 
prescription'' approach and is working with the Kenyan government, the 
World Food Program and others to ensure that broader communities, as 
well as individuals who may fall outside of PEPFAR guidelines for 
support, are reached. In Haiti, PEPFAR works with partner organizations 
to support orphans and vulnerable children using a community-based 
approach. Children participate in a school nutrition program using 
USAID-title II resources. This program is also committed to developing 
sustainable sources of food. Thus, the program aggressively supports 
community gardens for children's consumption and for generating revenue 
through the marketing of vegetables.

  On education, too, the Leadership Act's existing authorities are 
being put to productive use. In 2006, approximately $100 million in 
PEPFAR funding went toward programs that address barriers to school 
attendance for orphans and vulnerable children. This figure is expected 
to increase to $127 million in 2007. As it does with its nutrition 
programs, PEPFAR seeks to leverage its resources by ``wrapping around'' 
other programs that promote access to education, such as the 
President's African Education Initiative, or AEI.
  For example, in Zambia, PEPFAR and AEI fund a scholarship program 
that helps nearly 4,000 orphans who have lost one or both parents to 
AIDS or who are HIV-positive stay in grades 10 through 12. Similar 
partnerships exist in Uganda, where PEPFAR and AEI are working together 
to strengthen life-skills and prevention curricula in schools. This 
program targets 4 million children and 5,000 teachers. Also in Uganda, 
through the AIDS Support Organization, PEPFAR helps almost 1,000 
children by providing school fees and supplies for both primary and 
secondary school.
  The emergency plan has dedicated nearly $191.5 million to pediatric 
treatment, prevention, and care during the last 2 years. The program 
has made steady progress, increasing the share of those receiving 
PEPFAR-supported treatment who are children from 3 percent in 2004 to 9 
percent in 2006. The intent is to increase this figure to 15 percent.
  PEPFAR has focused much effort on early identification of HIV-
positive children. In many countries, an HIV test is used that cannot 
identify children as positive until they are 18 months old. Recognizing 
that 50 percent of HIV-positive children will die by age two if 
untreated, PEPFAR is working hard to introduce new diagnostic 
technology that can discern the HIV status of children at a much 
younger age.
  Along with supporting treatment for children who are already 
infected, PEPFAR is devoting resources to ensuring that fewer children 
are infected

[[Page S11942]]

in the first place. To date, PEPFAR has dedicated more than $453 
million to the prevention of mother-to-child transmission programs. In 
Botswana, Guyana, Namibia, Rwanda, and South Africa the percentage of 
pregnant women receiving mother-to-child transmission prevention 
services now exceeds 50 percent--the goal of the President's 
International Initiative to Prevent Mother and Child HIV. In the past 
few years, nearly all of the focus countries have adopted ``opt-out'' 
testing where pregnant women are given an HIV test during routine 
antenatal care unless they refuse the test.

  Under the highly successful national program in Botswana, where 
approximately 14,000 HIV-infected women give birth annually, the 
country has increased the proportion of pregnant women being tested for 
HIV from 49 percent in 2002 to 96 percent in 2006. The number of infant 
infections has declined by approximately 80 percent, to a national 
transmission rate of less than four percent.
  Although the authorities in the Leadership Act allow for an expansive 
array of activities, I am suggesting a few basic changes in this 
reauthorization. First, my proposal would increase to $30 billion the 
authorization for the years 2009 through 2013--a doubling of the 
initial U.S. commitment. Senators may wish to revisit this proposed 
funding level, and I look forward to that discussion.
  I believe we need to keep the bill as free of funding directives as 
possible to ensure maximum flexibility for implementation. This was 
recommended by the Institute of Medicine. I am proposing that only two 
funding directives be included--one modified from its current form, the 
other maintained as it is.
  The first modification would seek to address the abstinence directive 
in current law. The administration has interpreted and implemented this 
provision so as to include both abstinence and faithfulness programs, 
the `AB' of `ABC,' which stands for Abstinence, Be faithful, and the 
correct and consistent use of Condoms. The ABC paradigm for prevention 
was developed in Africa by Africans, to address the wide range of risks 
faced by people within their nations. Recent evidence from a growing 
number of African countries shows a correlation between declining HIV 
prevalence and the adoption of all three of the ABC behaviors. PEPFAR 
implements a program that teaches young children to respect themselves 
and others. Part of that respect is to refrain from sexual activity and 
to be faithful to a single partner. As children grow older, they learn 
about other ways to protect themselves so that they have the 
information and tools they need to live healthy lives. These are not 
revolutionary concepts. Rather they are commonsense approaches to 
public health based on broad experience garnered from many cases and 
studies.
  The problem with this directive, however, is that it has applied to 
all prevention funding--not just to funding for prevention of sexual 
transmission. This has had the effect of squeezing funding for 
prevention activities that have nothing to do with sexual prevention--
such as prevention of mother-to-child transmission and blood 
transfusion safety. The language I propose would address this by 
applying the directive only to funding for prevention of sexual 
transmission, rather than to prevention funding as a whole. This will 
enable greater flexibility.
  At the same time, the language would ensure the continuation of 
funding for abstinence and faithfulness programs as part of 
comprehensive, evidence-based ABC activities. Rather than maintaining 
the existing directive of 33 percent of all prevention funding, the 
proposal would require that 50 percent of the sexual prevention subset 
of prevention activities be spent to support abstinence and 
faithfulness. It also acknowledges that different strategies are needed 
depending on the facts of the epidemic in each country--something 
PEPFAR is already doing. I think this compromise approach is one that 
can win support from across the political spectrum and provide 
increased flexibility while ensuring continued support for 
comprehensive, evidence-based prevention. I look forward to working on 
this with my colleagues.
  The one directive in the Leadership Act that I believe must be 
maintained holds that 10 percent of funding be devoted to programs for 
orphans and vulnerable children. There were few programs focused on the 
needs of these children before the Leadership Act, and we remain in the 
early stages of the effort to serve them. Before the advent of PEPFAR, 
neither the United States, nor anyone else, had much experience in 
programs to support children infected with, or affected by, HIV/AIDS. 
After several years of effort, we have made some progress, but our 
programs are not yet as firmly established as they can be. This year 
PEFPAR invited proposals for orphans programs from the field--but the 
number of proposals that came back was far less than the available 
funding. This indicates that we still have much work to do in this 
area, and maintaining this directive will help to ensure that we do it.
  The AIDS orphans crisis in sub-Saharan Africa has implications for 
political stability, development, and human welfare that extend far 
beyond the region. The American people strongly back this effort, and 
the maintenance of this directive will help to ensure that we remain 
attentive to those who need our support the most. The directive will 
also help ensure the success of the Assistance for Orphans and Other 
Vulnerable Children in Developing Countries Act of 2005, a bill I 
drafted, which was cosponsored by 11 Senators. That bill was signed 
into law on November 8, 2005.

  My bill also includes some new language regarding the Global Fund, an 
organization that enjoys wide support in Congress. The Global Fund is a 
critically important partner in our fight against HIV/AIDS. In addition 
to our contributions, we are active on its board, and U.S. personnel 
provide the Global Fund with extensive technical assistance. The Global 
Fund is an avenue for the rest of the world to make contributions to 
antidisease initiatives. The United States is the largest supporter of 
the Global Fund, having provided more than $2 billion so far. The 
American people have contributed approximately one-third of all moneys 
received by the fund.
  The fund is subject to pressures from many donors, and it is widely 
acknowledged that it would benefit from greater transparency and 
accountability. As chairman of the Senate Foreign Relations Committee 
from 2003 through 2006, I oversaw the passage of legislation that 
strengthened the transparency and accountability of international 
organizations that receive U.S. funding, including the World Bank and 
the International Monetary Fund. My proposed language would establish 
similar benchmarks for U.S. funding for the Global Fund. I address such 
benchmarks at some length in my proposed legislation--not because of 
concerns over specific Global Fund activities--but rather to ensure 
sound practices and give members confidence that U.S. contributions are 
being monitored carefully. Most of these benchmarks are based on 
provisions contained in past appropriations bills, and I do not believe 
they will be controversial.
  S. 1966 would maintain the limitation in the existing Leadership Act 
that U.S. contributions to the Global Fund may not exceed 33 percent of 
its funding from all sources. This limitation has proven to be a 
valuable tool for increasing contributions to the fund from other 
funding sources, including other governments, and I believe there is 
wide agreement that this provision should be maintained.
  Lastly, let me turn from the details of the proposed legislation to 
add some perspective to this reauthorization effort. The U.S. National 
Intelligence Council and innumerable top officials, including President 
Bush, have stated that the HIV/AIDS pandemic is a threat to national 
and international security.
  The pandemic is rending the socio-economic fabric of communities, 
nations, and an entire continent, creating a potential breeding ground 
for instability and terrorism. Communities are being hobbled by the 
disability and loss of consumers and workers at the peak of their 
productive, reproductive, and care-giving years. In the most heavily 
affected areas, communities are losing a whole generation of parents, 
teachers, laborers, health care workers, peacekeepers, and police.

  United Nations projections indicate that by 2020, HIV/AIDS will have 
depressed GDP by more than 20 percent in the hardest-hit countries. The 
World

[[Page S11943]]

Bank recently warned that, while the global economy is expected to more 
than double over the next 25 years, Africa is at risk of being ``left 
behind.''
  Many children who have lost parents to HIV/AIDS are left entirely on 
their own, leading to an epidemic of orphan-headed households. When 
they drop out of school to fend for themselves and their siblings, they 
lose the potential for economic empowerment that an education can 
provide. Alone and desperate, they sometimes resort to transactional 
sex or prostitution to survive, and risk becoming infected with HIV 
themselves.
  I believe that in addition to our own national security concerns, we 
have a humanitarian duty to take action. Five years ago, HIV was a 
death sentence for most individuals in the developing world who 
contracted the disease. Now there is hope. We should never forget that 
behind each number is a person--a life the United States can touch or 
even save.
  At the time the Leadership Act was announced, only 50,000 people in 
all of sub-Saharan Africa were receiving antiretroviral treatment. 
Through March of this year, the act has supported treatment for more 
than 1.1 million men, women, and children in 15 PEPFAR focus countries. 
During the first three and a half years of the act, U.S. bilateral 
programs have supported services for more than 6 million pregnancies. 
In more than 533,000 of those pregnancies, the women were found to be 
HIV-positive and received antiretroviral drugs, preventing an estimated 
101,000 infant infections through March 2007.
  Before the advent of PEPFAR, there was little concerted effort to 
meet the needs of those orphaned by AIDS, or of other children made 
vulnerable by it. We have now supported care for more than 2 million 
orphans and vulnerable children, as well as 2.5 million people living 
with HIV/AIDS, through September 2006.
  Effective prevention, treatment, and care depend to a large extent on 
people knowing their HIV status, so they can take the necessary steps 
to stay healthy. The United States has supported 18.7 million HIV 
counseling and testing sessions for men, women and children.
  Our financial investment in this fight has been critical to our 
success, and thanks in large part to the flexibility of the Leadership 
Act, we have been able to obligate more than 94 percent of its 
available $12.3 billion appropriated through this fiscal year.
  PEPFAR, led by its coordinator, Ambassador Mark Dybul, has utilized 
the existing Leadership Act authorities well and has listened to the 
Congress and many other stakeholders. We should maintain the 
flexibility to respond to the changing dynamics of the epidemic, rather 
than locking in particular approaches that might be appropriate for 
2007, but that might prove problematic for future years. As the 
Institute of Medicine said, the Global Leadership Act is a ``learning 
organization.'' We should pass a bill now that allows PEPFAR to expand 
and evolve its program implementation utilizing the experience of these 
past 3\1/2\ years.
  I believe that we will save more lives and prevent more infections if 
we reauthorize this remarkable program this year. I ask my colleagues 
to work with me to achieve a truly bipartisan triumph of which we can 
all be proud.
  I thank the Chair, and I suggest the absence of a quorum.
  The PRESIDING OFFICER. The clerk will call the roll.
  The assistant legislative clerk proceeded to call the roll.
  Mr. REID. Madam President, I ask unanimous consent that the order for 
the quorum call be rescinded.
  The PRESIDING OFFICER. Without objection, it is so ordered.

                          ____________________