[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
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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
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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
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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.
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