[Congressional Record Volume 153, Number 191 (Thursday, December 13, 2007)]
[Senate]
[Pages S15464-S15467]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. DODD (for himself and Mr. Smith):
  S. 2472. A bill to amend the U.S. Leadership Against HIV/AIDS, 
Tuberculosis, and Malaria Act of 2003; to the Committee on Foreign 
Relations.
  Mr. DODD. Mr. President, I am pleased to rise today with my colleague 
Senator Gordon Smith to introduce the Global Pediatric HIV/AIDS 
Prevention and Treatment Act. Millions across the world recently 
observed the 20th World AIDS Day on December 1, a day of mourning, 
solidarity, and hope: mourning for the more than 25 million killed 
already in the AIDS pandemic; solidarity with the 33.2 million living 
with HIV today; and hope that this plague will be conquered in our 
time--with an achievable goal of realizing the birth of an HIV-free 
generation.
  In the U.S., we have reached a point where a child living with HIV/
AIDS no longer faces certain death. Thanks to anti-retroviral, ARV, 
therapy, many children born infected with HIV/AIDS now have the 
opportunity to grow up healthy. However, long-term survival is a dream 
that eludes most of the 2.5 million HIV-infected children around the 
world.
  Of the more than 2.5 million new HIV infections in 2007, more than 
420,000 were in children. But while children account for almost 16 
percent of all new HIV infections, they make up only 9 percent of those 
on treatment under the President's Emergency Plan for AIDS Relief, 
PEPFAR. Without proper care and treatment, half of these newly-infected 
children will die before their second birthday and 75 percent will die 
before their fifth.
  Every day, approximately 1,100 children across the globe are infected 
with HIV, the vast majority through mother-to-child transmission during 
pregnancy, labor or delivery or soon after through breastfeeding. 
Approximately 90 percent of these infections occur in Africa. With no 
medical intervention, HIV-positive mothers have a 25 to 30 percent 
chance of passing the virus to their babies during pregnancy and 
childbirth. Yet, a single dose of an ARV drug given once to the mother 
at the onset of labor and once to the baby during the first three days 
of life reduces transmission of HIV by approximately 50 percent. 
Providing the full range of interventions, as is the standard of care 
in the U.S., can further reduce the rate of mother-to-child 
transmission of HIV to as little as 2 percent. However, according to 
UNAIDS, the Joint United Nations Programme on HIV/AIDS, less than 10 
percent of pregnant women with HIV in resource-poor countries have 
access to prevention of mother-to-child transmission, PMTCT, services.
  Significant barriers to PMTCT and the equal care and treatment of 
HIV-infected children continue to exist. Among the barriers to PMTCT 
services is their poor integration into the healthcare system, the lack 
of infrastructure and poor quality health facilities, low utilization 
of pre-natal services, and a high percentage of unattended at-home 
births. Because children are not just small adults, providing care and 
treatment presents special challenges such as limited access to 
reliable HIV testing for the youngest children, a shortage of providers 
trained in delivering pediatric care, weak linkages between services to 
prevent mother-to-child transmission and care and treatment programs, 
and the need for additional, low-cost formulations of HIV/AIDS 
medications.
  The unfortunate reality of current HIV/AIDS treatment programs is 
that they will become unsustainable in the long-term unless the number 
of new HIV infections is reduced globally. The importance of PMTCT for 
the prevention of the spread of HIV cannot be overstated. According to 
UNAIDS, prevention of mother-to-child HIV transmission requires a 
comprehensive package of services that includes preventing primary HIV 
infection in

[[Page S15465]]

women, preventing unintended pregnancies in women with HIV infection, 
preventing transmission from HIV-infected pregnant women to their 
infants, and providing care, treatment and support for HIV-infected 
women and their families. A 2003 study found that by adding family 
planning through PMTCT services in 14 high prevalence countries, more 
than 150,000 unintended pregnancies were averted, child infections 
averted nearly doubled, and child deaths averted nearly quadrupled. 
Studies also show that current levels of contraceptive use in sub-
Saharan Africa are already preventing an estimated 22 percent of HIV-
positive births.
  For many pregnant mothers, PMTCT services may be the only entry point 
for health care services for themselves and their families. That is why 
it is essential that PMTCT services be integrated with prevention, care 
and treatment services. With adequate integration of those services and 
strategies to ensure successful follow-up and continuity of care, we 
can significantly improve the outcomes for HIV-affected women and 
families.
  The legislation I am introducing today, the Global Pediatric HIV/AIDS 
Prevention and Treatment Act, will help prevent thousands of new 
pediatric HIV infections in the years to come and improve the treatment 
of children living with HIV/AIDS throughout the world. The legislation 
will bring our international HIV/AIDS efforts in line with the 
infection rate of children, by establishing a target that, within 5 
years, 15 percent of those receiving care and treatment under PEPFAR 
should be children.
  The legislation establishes another 5-year target to help prevent 
mother-to-child transmission of HIV. In those countries most affected, 
80 percent of pregnant women should receive HIV counseling and testing, 
with all those testing positive receiving anti-retroviral medication 
for the prevention of mother-to-child transmission of HIV.
  Under the legislation, the U.S. comprehensive, 5-year global strategy 
to combat global HIV/AIDS must also integrate prevention, care and 
treatment with prevention of mother-to-child transmission programs, as 
soon as feasible and consistent with the national government policies 
of the foreign countries of PEPFAR countries in order to improve 
outcomes for HIV-affected women and families and to promote follow-up 
and continuity of care.
  Lastly, the legislation authorizes the creation of a Prevention of 
Mother-to-Child Transmission Expert Panel to provide an objective 
review of PMTCT activities funded under PEPFAR and to provide 
recommendations to the Office of the Global AIDS Coordinator for scale-
up of mother-to-child transmission prevention services under PEPFAR in 
order to reach the newly-established target for PTMCT. The Panel 
consists of no more than 15 members, to be appointed by the 
coordinator, and will terminate once it submits its report containing 
recommendations, findings and conclusions to the coordinator, Congress, 
and is made public.
  To be clear, this legislation does not establish any earmarks within 
PEPFAR. It does not dictate how much money should be spent on specific 
activities. I, for one, oppose the current policy under PEPFAR which 
dictates that one-third of all prevention funds be reserved for 
abstinence-until-marriage programs, to the detriment of other more 
effective programs that are producing better results. Certainly 
abstinence programs have a role to play in PEPFAR, but they should not 
draw funding away from other, more effective programs. Therefore, it is 
my hope that Congress does away with that earmark when it reauthorizes 
PEPFAR, and instead allows for flexibility within PEPFAR.
  Instead, the legislation sets 5-year targets that are focused on 
those receiving services without specifying how much money any given 
country should spend on specific services to reach the target. I 
believe this approach is consistent with the April 2007 Institute of 
Medicine report on PEPFAR which called on Congress to replace arbitrary 
budget directives with specific targets accounting for the unique 
epidemics in specific countries, as well as existing available 
resources. Removal of budget restrictions and the implementation of 
program targets, such as those authorized under this legislation, would 
allow local providers to invest in the services and activities most 
needed to achieve national goals for prevention, care, and treatment.
  The struggle against this disease continues on all fronts. Just 
recently, a report showed that right here in Washington, D.C., the city 
is in the grip of a ``modern epidemic,'' with one in 20 residents HIV-
infected, a rate ten times the national average. In my own State of 
Connecticut, the need for care and treatment services is at an all time 
high, while the funding to meet this increased need has declined.
  As we take stock of the HIV/AIDS pandemic and our progress against 
it, we must bear in mind the special vulnerability of the world's 
children. With this legislation we can increase the number of children 
receiving care and treatment under PEPFAR and expand access to PMTCT 
services in order to prevent thousands of new pediatric HIV infections.
  I urge my colleagues to support this important legislation.
  Mr. President, 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. 2472

       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 ``Global Pediatric HIV/AIDS 
     Prevention and Treatment Act''.

     SEC. 2. FINDINGS.

       Section 2 of the United States Leadership Against HIV/AIDS, 
     Tuberculosis, and Malaria Act of 2003 (26 U.S.C. 7601) is 
     amended--
       (1) in paragraph (3), by adding at the end the following:
       ``(D) In 2007, the rate at which children accessed 
     treatment failed to keep pace with new pediatric infections. 
     While children account for almost 16 percent of all new HIV 
     infections, they make up only 9 percent of those receiving 
     treatment under this Act.'';
       (2) by amending paragraph (16) to read as follows:
       ``(16) Basic interventions to prevent new HIV infections 
     and to bring care and treatment to people living with AIDS, 
     such as voluntary counseling and testing, are achieving 
     meaningful results and are cost-effective. The challenge is 
     to expand these interventions to a national basis in a 
     coherent and sustainable manner.''; and
       (3) by amending paragraph (20) to read as follows:
       ``(20) With no medical intervention, mothers infected with 
     HIV have a 25 to 30 percent chance of passing the virus to 
     their babies during pregnancy and childbirth. A simple and 
     effective intervention can significantly reduce mother to 
     child transmission of HIV. A single dose of an anti-
     retroviral drug given once to the mother at the onset of 
     labor, and once to the baby during the first 3 days of life 
     reduces transmission by approximately 50 percent. Other more 
     complex drug regimens can further reduce transmission from 
     mother-to-child. A dramatic expansion of access to prevention 
     of mother-to-child transmission services is critical to 
     preventing thousands of new pediatric HIV infections.''.

     SEC. 3. POLICY PLANNING AND COORDINATION.

       Section 101(b)(3) of the United States Leadership Against 
     HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (22 U.S.C. 
     7611(b)(3)) is amended by adding at the end the following:
       ``(X) A description of the activities that will be 
     conducted to achieve the targets described in paragraphs (1) 
     and (2) of section 312(b).''.

     SEC. 4. BILATERAL EFFORTS.

       (a) Assistance to Combat HIV/AIDS.--Section 104A of the 
     Foreign Assistance Act of 1961 (22 U.S.C. 2151b-2) is 
     amended--
       (1) in subsection (d)(1)--
       (A) by amending subparagraph (E) to read as follows:
       ``(E) assistance to--
       ``(i) achieve the target described in section 312(b)(1) of 
     the United States Leadership Against HIV/AIDS, Tuberculosis, 
     and Malaria Act of 2003; and
       ``(ii) promote infant feeding options for HIV positive 
     mothers that are consistent with the most recent infant 
     feeding recommendations and guidelines supported by the World 
     Health Organization ;'';
       (B) in subparagraph (G), by striking ``and'' at the end;
       (C) in subparagraph (H), by striking the period at the end 
     and inserting ``; and''; and
       (D) by adding at the end the following:
       ``(I) assistance to achieve the target described in section 
     312(b)(2) of the United States Leadership Against HIV/AIDS, 
     Tuberculosis, and Malaria Act of 2003.''; and
       (2) in subsection (e)(2)(C)--
       (A) in clause (iii), by striking ``and'' at the end;
       (B) in clause (iv), by striking the period at the end and 
     inserting ``; and''; and
       (C) by adding at the end the following:
       ``(v) the number of HIV-infected children currently 
     receiving antiretroviral medications in each country under 
     the United

[[Page S15466]]

     States Leadership Against HIV/AIDS, Tuberculosis, and Malaria 
     Act of 2003.''.
       (b) Assistance to Children and Families.--Subtitle B of 
     Title III of the United States Leadership Against HIV/AIDS, 
     Tuberculosis, and Malaria Act of 2003 (22 U.S.C. 7651 et 
     seq.) is amended by striking sections 311 and 312 and 
     inserting the following:

     ``SEC. 311. FINDINGS.

       ``Congress makes the following findings:
       ``(1) Every day, approximately 1,100 children around the 
     world are infected with HIV, the vast majority through 
     mother-to-child transmission during pregnancy, labor or 
     delivery or soon after through breast-feeding. Approximately 
     90 percent of these infections occur in Africa.
       ``(2) With no medical intervention, mothers infected with 
     HIV have a 25 to 30 percent chance of passing the virus to 
     their babies during pregnancy and childbirth. A single dose 
     of an anti-retroviral drug given once to the mother at the 
     onset of labor, and once to the baby during the first 3 days 
     of life reduces transmission by approximately 50 percent.
       ``(3) Providing the full range of interventions, as is the 
     standard of care in the United States, could reduce the rate 
     of mother-to-child transmission of HIV to as little as 2 
     percent.
       ``(4) Global coverage of services to prevent transmission 
     from mother-to-child remains unacceptably low. The Joint 
     United Nations Program on HIV/AIDS (UNAIDS) reports that 
     fewer than 10 percent of pregnant women with HIV in resource-
     poor countries have access to prevention of mother-to-child 
     transmission services.
       ``(5) Prevention of mother-to-child transmission programs 
     provide health benefits for women and children beyond 
     preventing the vertical transmission of HIV. They serve as an 
     entry point for mothers to access treatment for their own HIV 
     infection, allowing them to stay healthy and to care for 
     their children. Efforts to connect and integrate prevention 
     of mother-to-child transmission and HIV care, treatment and 
     prevention programs are crucial to achieving improved 
     outcomes for HIV-affected and HIV-infected women and 
     families.
       ``(6) Access to comprehensive HIV prevention services must 
     be drastically scaled-up among pregnant women infected with 
     HIV and pregnant women not infected with HIV to further 
     protect themselves and their partners against the sexual 
     transmission of HIV/AIDS.
       ``(7) Preventing unintended pregnancy among HIV-infected 
     women is recognized by the World Health Organization and the 
     Office of the United States Global AIDS Coordinator to be an 
     integral component of prevention of mother-to-child 
     transmission programs. To further reduce infection rates, 
     women accessing prevention of mother-to-child transmission 
     services must have access to a range of high-quality family 
     planning and reproductive health care, so they can make 
     informed decisions about future pregnancies and 
     contraception.
       ``(8) In 2007, the rate at which children were accessing 
     treatment failed to keep pace with new pediatric infections. 
     While children account for almost 16 percent of all new HIV 
     infections, they make up only 9 percent of those on treatment 
     under this Act.
       ``(9) Of the more than 2,500,000 people who were newly 
     infected with HIV in 2007, more than 420,000 were children.
       ``(10) Without proper care and treatment, half of newly 
     HIV-infected children will die before they reach 2 years of 
     age, and 75 percent will die before 5 years of age.
       ``(11) Because children are not just small adults, 
     providing HIV care and treatment presents special challenges, 
     including--
       ``(A) limited access to reliable HIV testing for the 
     youngest children;
       ``(B) a shortage of providers trained in delivering 
     pediatric care;
       ``(C) weak linkages between services to prevent mother-to-
     child transmission and care and treatment programs; and
       ``(D) the need for low-cost pediatric formulations of HIV/
     AIDS medications.

     ``SEC. 312. POLICY AND REQUIREMENTS.

       ``(a) Policy.--
       ``(1) In general.--The United States Government's response 
     to the global HIV/AIDS pandemic should place high priority 
     on--
       ``(A) the prevention of mother-to-child transmission of 
     HIV/AIDS; and
       ``(B) the care and treatment of all children affected by 
     HIV/AIDS, including children orphaned by AIDS.
       ``(2) Collaboration.--The United States Government should 
     work in collaboration with foreign governments, donors, the 
     private sector, nongovernmental organizations, and other key 
     stakeholders.
       ``(b) Requirements.--The comprehensive, 5-year, global 
     strategy required under section 101 shall--
       ``(1) establish a target for prevention of mother-to-child 
     transmission efforts that by 2013, in those countries most 
     affected by HIV--
       ``(A) 80 percent of pregnant women receive HIV counseling 
     and testing; and
       ``(B) all of the pregnant women receiving HIV counseling 
     and testing who test positive for HIV receive anti-retroviral 
     medications for prevention of mother-to-child transmission of 
     HIV;
       ``(2) establish a target requiring that by 2013, children 
     account for at least 15 percent of those receiving treatment 
     under this Act;
       ``(3) integrate prevention, care, and treatment with 
     prevention of mother-to-child transmission programs, as soon 
     as feasible and consistent with the national government 
     policies of the foreign countries in which programs under 
     this Act are administered, to improve outcomes for HIV-
     affected women and families and to promote follow-up and 
     continuity of care;
       ``(4) expand programs designed to care for children 
     orphaned by AIDS; and
       ``(5) develop a time line for expanding access to more 
     effective mother-to-child transmission prevention regimens, 
     consistent with the national government policies of the 
     foreign countries in which programs under this Act are 
     administered and the goal of moving towards universal use of 
     such regimens as rapidly as possible.
       ``(c) Application of Requirements.--All strategic planning 
     documents and bilateral funding agreements developed under 
     the authority of the Office of the United States Global AIDS 
     Coordinator, including country operating plans and any 
     subsequent mechanisms through which funding under this Act is 
     obligated, shall be consistent with, and in furtherance of, 
     the requirements under subsection (b).
       ``(d) Prevention of Mother-to-Child Transmission Expert 
     Panel.--
       ``(1) Establishment.--The Coordinator of United States 
     Government Activities to Combat HIV/AIDS Globally (referred 
     to in this section as the `Coordinator') shall establish a 
     panel of experts to be known as the Prevention of Mother to 
     Child Transmission Panel (referred to in this section as the 
     `Panel') to--
       ``(A) provide an objective review of activities to prevent 
     mother-to-child transmission of HIV that receive financial 
     assistance under this Act; and
       ``(B) provide recommendations to the Coordinator and to the 
     appropriate committees of Congress for scale-up of mother-to-
     child transmission prevention services under this Act in 
     order to achieve the target established in subsection (b)(1).
       ``(2) Membership.--The Panel shall be convened and chaired 
     by the Coordinator, who shall serve as a nonvoting member. 
     The Panel shall consist of not more than 15 members 
     (excluding the Coordinator), to be appointed by the 
     Coordinator not later than 60 days after the date of the 
     enactment of this Act, including--
       ``(A) 2 members from the Department of Health and Human 
     Services with expertise relating to the prevention of mother-
     to-child transmission activities;
       ``(B) 2 members from the United States Agency for 
     International Development with expertise relating to the 
     prevention of mother-to-child transmission activities;
       ``(C) 2 representatives from among health ministers of 
     national governments of foreign countries in which programs 
     under this Act are administered;
       ``(D) 3 members representing organizations implementing 
     prevention of mother-to-child transmission activities under 
     this Act;
       ``(E) 2 health care researchers with expertise relating to 
     global HIV/AIDS activities; and
       ``(F) representatives from among patient advocate groups, 
     health care professionals, persons living with HIV/AIDS, and 
     non-governmental organizations with expertise relating to the 
     prevention of mother-to-child transmission activities, giving 
     priority to individuals in foreign countries in which 
     programs under this Act are administered.
       ``(3) Duties of panel.--The Panel shall--
       ``(A) review activities receiving financial assistance 
     under this Act to prevent mother-to-child transmission of HIV 
     and assess the effectiveness of current activities in 
     reaching the target described in subsection (b)(1);
       ``(B) review scientific evidence related to the provision 
     of mother-to-child transmission prevention services, 
     including programmatic data and data from clinical trials;
       ``(C) review and assess ways in which the Office of the 
     United States Global AIDS Coordinator and programs funded 
     under this Act collaborate with international and 
     multilateral entities on efforts to prevent mother-to-child 
     transmission of HIV in affected countries;
       ``(D) identify barriers and challenges to increasing access 
     to mother-to-child transmission prevention services and 
     evaluate potential mechanisms to alleviate those barriers and 
     challenges;
       ``(E) identify the extent to which stigma has hindered 
     pregnant women from obtaining HIV counseling and testing or 
     returning for results, and provide recommendations to address 
     such stigma and its effects;
       ``(F) identify opportunities to improve linkages between 
     mother-to-child transmission prevention services and care and 
     treatment programs;
       ``(G) evaluate the adequacy of financial assistance 
     provided under this Act for mother-to-child transmission of 
     HIV prevention services; and
       ``(H) recommend levels of financial assistance and specific 
     activities to facilitate reaching the target described in 
     subsection (b)(1).
       ``(4) Report.--
       ``(A) In general.--Not later than 14 months after the date 
     of the enactment of this Act, the Panel shall submit a report 
     containing a detailed statement of the recommendations, 
     findings, and conclusions of the Panel to the appropriate 
     congressional committees.
       ``(B) Availability.--The report submitted under 
     subparagraph (A) shall be made available to the public.

[[Page S15467]]

       ``(C) Consideration by coordinator.--The Coordinator 
     shall--
       ``(i) consider any recommendations contained in the report 
     submitted under subparagraph (A); and
       ``(ii) include in the annual report required under section 
     104A(e) of the Foreign Assistance Act of 1961 (22 U.S.C. 
     2151b-2(e)) a description of the activities conducted in 
     response to the recommendations made by the Panel and an 
     explanation of any recommendations not implemented at the 
     time of the report.
       ``(5) Authorization of appropriations.--There are 
     authorized to be appropriated to the Panel such sums as may 
     be necessary for each of the fiscal years 2009 through 2011 
     to carry out this section.
       ``(6) Termination.--The Panel shall terminate on the date 
     that is 60 days after the date on which the Panel submits the 
     report to Congress under paragraph (4).''.
       (c) Annual Report Elements.--Section 313(b)(2) of the 
     United States Leadership Against HIV/AIDS, Tuberculosis, and 
     Malaria Act of 2003 (22 U.S.C. 7653(b)(2)) is amended--
       (1) in subparagraph (C), by striking ``and'' at the end;
       (2) in subparagraph (D), by striking the period at the end 
     and inserting a semicolon; and
       (3) by adding at the end the following:
       ``(E) coordination and collaboration with governments, 
     donors, the private sector, nongovernmental organizations, 
     and other key stakeholders to achieve the target described in 
     section 312(b)(1); and
       ``(F) the number of women offered and receiving the 4 
     components of a comprehensive strategy to prevent mother-to-
     child transmission of HIV, as recommended by the World Health 
     Organization.''.
                                 ______