[Congressional Record Volume 154, Number 52 (Thursday, April 3, 2008)]
[Senate]
[Pages S2428-S2432]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
THE SAVE LIVES FIRST ACT OF 2008
Mr. COBURN. Mr. President, 5 years ago, Africa was in crisis and in
despair. HIV/AIDS was decimating whole communities. Some countries,
such as Botswana, were literally on a path to extinction, with rates of
HIV infection among pregnant women in some locations reaching as high
as 40 and even 50 percent. In South Africa, while a third of pregnant
woman were infected with the virus, the country's political leaders
were actually denying that AIDS was caused by HIV infection, an ominous
sign that little help was on the way for the over 4 million South
Africans--over 10 percent of the population--dying of AIDS.
In 2003, if a woman in sub-Saharan Africa was infected with HIV, the
familiar story was all too oft-repeated. She would very likely watch
her husband die first, and then her youngest children would also become
infected either at birth or through breastfeeding, as she languished
under her own death sentence. Within a short time, her children would
be orphans, left to fend for themselves in the streets and slums of
Nairobi, or Soweto, often getting sick with their own HIV infections
and dying alone, without food or shelter or medicine.
The sheer numbers at the time were staggering. The disease affected
well over 20 million people in sub-Saharan Africa by the year 2000,
roughly equivalent to the total number of American children under 6
years old. The problem seemed overwhelming, indeed hopeless.
What was the world doing to stop the carnage? Were there armies of
doctors sweeping in with the miracle drugs that had been saving lives
in America and other rich countries for nearly a decade? No. The U.S.
was spending under $200 million a year on HIV/AIDS overseas, mostly on
report-writing, some condom marketing, and ``capacity-building''
programs that never actually used any of the capacity supposedly built
and that had no measurable impact on the devouring epidemic.
Treatment was the demand of most global health activists of the day.
An indignant group gathered in South Africa in 2002. ``While a
necessary component of the response to HIV/AIDS, prevention will never
be enough,'' insisted Winston Zulu of the Network of Zambian People
Living with HIV/AIDS (NZP+). ``When will the world wake up to the fact
that the 16 million Africans that have already died of HIV/AIDS? This
is only the beginning if we continue down the prevention-only path.
This movement will make treatment, which we all know strengthens
prevention efforts, our priority demand.'' Domestic and international
chapters of ACT-UP and others were heckling U.S. officials at
international health conferences, demanding antiretroviral treatment
for people with HIV/AIDS in the developing world, especially in Africa.
And then something remarkable happened. On a cold January night in
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Washington, DC, far from the overcrowded, underequipped clinics of
Africa, an American president made a promise--a $15 billion promise to
provide treatment to millions of Africans, within 5 years.
Anti-retroviral drugs can extend life for many years. And
the cost of those drugs has dropped from $12,000 a year to
under $300 a year--which places a tremendous possibility
within our grasp. Ladies and gentlemen, seldom has history
offered a greater opportunity to do so much for so
many...tonight I propose the Emergency Plan for AIDS Relief--
a work of mercy beyond all current international efforts to
help the people of Africa. This comprehensive plan will
prevent 7 million new AIDS infections, treat at least 2
million people with life-extending drugs, and provide humane
care for millions of people suffering from AIDS, and for
children orphaned by AIDS.--President George W. Bush, State
of the Union Address, Jan. 28, 2003.
Glimmers of hope ignited around the world that night, as the U.S.
policy against providing treatment in a foreign aid program came to an
abrupt and inspiring end. The Congress took up the challenge, and
passed a bill a few months later that was ground-breaking, a seismic
shift in current policy and funding levels. The first and perhaps most
dramatic policy shift was the statutory requirement that over half, a
full 55 percent of all $15 billion of the program's funding be spent on
life-saving medical treatment for people with HIV/AIDS.
People said it couldn't be done. The naysayers said that Africans
would not be able to adhere to complex drug regimens. They said that
there simply wasn't the capacity to absorb all those dollars and build
new clinics and expand hospital wings. They said people wouldn't come
from miles around to get tested and treated. We wouldn't be able to use
mopeds and bicycles to deliver drugs to the rural hinterlands. There
weren't enough doctors. There wasn't sufficient logistic ability to
store so many drugs. These arguments are being repeated today. They
were uninspired and uninformed in 2003 and they still are today. The
President's Emergency Plan for AIDS Relief, PEPFAR, has proven them all
wrong.
Since PEPFAR started, over 1.4 million people who would either be
dead or dying today have received life-saving antiretroviral treatment.
That's millions of children who didn't become orphans. Millions of
parents who get to see their children grow up. Millions of moms whose
babies were protected from infection. Countless communities across the
plains and prairies, streets and slums of Africa and the Caribbean,
where hope has taken a foothold. Where once stigma and despair kept
people from even getting tested, people now come out by the thousands
on HIV testing days in Kampala and elsewhere.
PEPFAR is a comprehensive program, investing heavily in prevention
and care as well as treatment. However, the majority of the funds have
been spent on treatment. The true nature of PEPFAR, the appeal of the
program, the miracle that has raised millions from the dead is the
program's commitment to life-saving anti-
retroviral treatment. If you ask Africans what PEPFAR is, they'll tell
you it's about AIDS treatment. It is the treatment component of PEPFAR
that has made it the most successful U.S. humanitarian effort in
history because it has literally saved the lives of millions, preserved
families and communities, and rescued countless babies from being born
with an AIDS death sentence.
Five years later, the American people stand at a crossroads. PEPFAR
is expiring and the true test of our commitment to life-saving
treatment is before us. We have a choice. Will we lose heart? Will we
lose our focus? Will we allow a program that was ambitious, inspiring,
targeted and tangibly and measurably effective at saving lives become
diluted, vague, ill-defined and lose its life-saving impact? Will we
allow partisanship and competing priorities and even some good
intentions cloud and subvert the long-term success of PEPFAR? Will we
turn PEPFAR into just another bloated, unmeasured and unmeasurable
foreign aid program with no accountability and no real impact, a
program that tries to do too much and accomplishes too little? As
funding increases and rhetoric builds, will we, in this moment of
testing, betray our historic commitment to Africa and the lives of
millions of its inhabitants?
It is embarrassing to admit that we find ourselves on a direct path
to that shameful outcome. The once loud and indignant voices demanding
treatment for Africans have found other priorities, it would seem.
Inexplicably and inexcusably, the House and Senate PEPFAR
reauthorization bills, negotiated with the approval of the
Administration, reverse what was undoubtedly the most important element
of PEPFAR the requirement that the majority of funding be spent on HIV/
AIDS treatment. What's more, the bills more than triple PEPFAR funding,
but only increase treatment targets by 50 percent. Despite their $50
billion price-tags, the House-passed bill and the Senate committee-
reported bill would only add an additional one million people, of the
many more millions in need, to the treatment rolls over the next five
years. It seems that, after five years focusing on helping people with
HIV/AIDS, the focus of the program under these proposed
reauthorizations would shift to helping the foreign aid ``industrial
complex'' of USAID contractors based in the U.S. and European capitals.
The proposed reauthorization bills would prioritize literally every
possible development cause except HIV diagnosis and treatment.
It is this glaring policy reversal that is the impetus for S. 2749,
the ``Save Lives First Act of 2008.'' The bill reinstates the current
policy requiring at least 55 percent of funding to go to life-saving
medical treatment for people infected with HIV/AIDS. It also allocates
a small percentage of funding for the critical diagnostic screening
that must be ramped up dramatically if we are to locate and treat every
infected person in the countries where PEPFAR operates. Finally, the
bill acknowledges that every baby infected with HIV by her mother
during birth or breastfeeding is a largely preventable tragedy that
should be eliminated.
Although we have grave concerns about many other policies in the
House and Senate reauthorization bills, including the prevention
policy, the expansion of funding to rich countries, the ``mission
creep'' that diverts funding from high-priority HIV/AIDS programs to
lower-priority development programs, and others, we chose to focus in
the Save Lives First Act on the critical problem of the House and
Senate bills' betrayal of the President's and the 108th Congress'
historic commitment to life-saving HIV/AIDS treatment.
There is no question that PEPFAR has been the most successful foreign
aid program since the Marshall Plan. The structural reason for its
success is that it approaches and addresses AIDS for what it is--a
viral epidemic. Though much may have changed in the past four years,
this simple fact has not, and will not, change.
Regardless of location, demography, mode of transmission, and so
forth, the basic method of combating an epidemic, any epidemic, is the
same: find the infected, provide them care, and help them prevent
transmission to others. There are 33 million people living with HIV,
and only they can prevent the transmission of the disease. If we find
the people with HIV, we could not only treat them, but yes, prevent new
infections as well. That's why treatment and testing are critical to
prevention efforts. They are not the whole story--behavior change
programs are needed--but diagnosis and treatment are two of the
foundations of disease control. What's more, prevention through
education is far less costly than treatment. Uganda's success in the
1990s proved that with the proper message and political leadership,
behavior change that reduces transmission rates dramatically can be
achieved fairly inexpensively. The current PEPFAR program and its
original authorizing legislation are appropriately structured on this
foundation of diagnosis, treatment and successful prevention.
So what are the mechanics of treating people? First, you must
diagnose those who are infected. That is why this bill designates
specific funding for performing rapid tests, and sets testing target
goals. If we test 1 billion people over the next 5 years, we will
discover the vast majority of all those living with HIV. However,
experience shows that people will not get tested, no matter how much
they may want to, without an incentive to know their status.
It cannot be disputed that people
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known to be HIV positive suffer enormous stigma and discrimination
throughout the world, and therefore need an incentive strong enough to
overcome this.
The incentive is treatment. If people know that, should they be found
to be HIV positive, there is hope and health in their future, they will
have an incentive to get tested. The promise of a longer and healthier
life is necessary to overcome the stigma--and, in a self-reinforcing
loop, the presence of treatment, and the effect of people literally
returning from the dead, goes a long way to reduce HIV stigma. That is
one of the reasons why the Save Lives First Act maintains the 55
percent allocation of PEPFAR funding for treatment, and seeks to
increase the number of people treated proportionally to the increase in
overall funding.
The AIDS drug nevirapine, which costs only $4 per treatment, can
dramatically reduce the likelihood that a newborn will become infected
with HIV. Yet a new U.N. report delivers the news that only a quarter
of HIV-positive pregnant women in poorer countries are receiving the
medication needed to prevent baby AIDS. Furthermore, the number of AIDS
orphans in poorer countries continues to increase, and in sub-Saharan
Africa an estimated 12.1 million children in 2007 had lost one or both
parents to HIV.
By sticking to the fundamental disease control methods of testing and
treatment, new infections are prevented. First, we have seen here in
the U.S. that people who know their HIV status are less likely to
engage in risky behavior--they seek to protect themselves and their
partners. The Centers for Disease Control and Prevention reports that
the 25 percent of Americans who don't know their HIV status transmit
50-75 percent of new infections. What's more, a recent study has
suggested that increased testing in the U.S. reduced infection.
Further, people who are receiving treatment have less of the virus in
them, and are less infectious. There is increasing evidence documenting
this phenomenon. Behavior change programs targeted to the general
population, most of whom are uninfected, may help reduce infection
rates to a point, but it is hard to think of a more direct preventive
measure than rendering an HIV positive person less infectious and less
likely to infect others.
Therefore, claims that the bill does not address prevention are
simply untrue. First, billions and billions of dollars not dedicated to
treatment and testing are available for prevention in the House and
Senate bills. After spending 55 percent of the $50 billion in the bills
on lifesaving treatment, there will still be $27.5 billion left over
from which prevention programs could be funded, dramatically more
programs than under the current, $15 billion program. Second, and to an
important extent, testing and treatment are part of an effective
prevention approach.
In addition, some have claimed that the Save Lives First Act
significantly increases costs, anywhere from $13-$17 billion. These
claims miss the point of the Save Lives First Act--which is not to add
to costs, but to prioritize how authorized funds are spent. As the
attached treatment cost analysis shows, the total dollar amount for all
drugs, test kits, and prevention-of-mother-to-child-transmission
materials needed to meet the goals in the bill is just over $11 billion
(using conservative assumptions about costs that are likely to be lower
in reality due to government discounts). A reauthorization bill
containing $50 billion plus numerous ``such sums'' authorities, such as
the bills under current consideration in the House and Senate, would
contain sufficient money to meet these goals as well as procure the
infrastructure necessary to deliver these drugs and diagnostic tests.
These costs are not added on top of the proposed reauthorization
spending levels, as some have claimed. Rather, the Save Lives First Act
takes the first 55 percent of all funding in any reauthorization bill--
whatever the ultimate amount of funding turns out to be--$30 billion,
$50 billion or more (as is actually likely given the current
appropriations frenzy in the Congress)--and directs it to treatment
costs. If meeting the heroic targets in our bill--adding 5 million new
people to treatment (in addition to the 2 million already in
treatment), conducting a billion HIV tests, and saving babies from
being infected by their moms--ends up costing more than 55 percent of
PEPFAR funding, we challenge any critic to think of a better use of
funds. However, as the attached chart demonstrates, there will be
plenty of money in a $50 billion bill left for prevention and care
after meeting the requirements of the Save Lives First Act.
The current alternative to this approach, as embodied by the House
and Senate bills containing no money dedicated to testing and
treatment--is that millions of people will die for lack of treatment.
In addition, the vast majority of people with HIV will remain ignorant
of their status, and will continue to unknowingly infect others,
continuing the cycle that led to the devastating epidemic we now face.
Letting people die, and keeping people ignorant of their status, is not
the way to end this epidemic. We recognize this truth here in the U.S.,
where we spend 11 percent annually on prevention, but 67 percent on
treatment out of a total budget of $23.3 billion spent on AIDS
domestically.
Some have argued that a heroic American commitment to testing and
treatment such as the targets in the Save Lives First Act will
discourage other donors from supporting diagnosis and treatment. The
truth is that other donors have yet to demonstrate substantial
commitment to bilateral treatment programs. Most other donors prefer to
fund treatment through their contributions to the Global Fund to Fight
HIV/AIDS, Tuberculosis and Malaria, a multilateral organization
affiliated with the United Nations, to which the U.S. is the largest
(by far) contributor. That is what the Global Fund is for--to create
efficiencies of scale and allow smaller donors to contribute to those
more efficient programs rather than reinventing the wheel and starting
up their own bilateral programs. When other donors do invest in
bilateral efforts, it is almost always on the prevention side--funding
needle exchanges for drug users, condom and ``empowerment'' programs
for prostitutes, and other prevention efforts in Africa, Asia and
eastern Europe, usually based on behavior change programs. This is all
the more reason why one donor, the U.S., needs to focus on diagnosis
and treatment--the rest of the donor community is not as committed to
these programs compared to other approaches. But let's say that other
donors want to support treatment--great! We welcome their
participation. There is so much to do--between 7 and 8.4 million people
still need treatment today. PEPFAR certainly can't treat everyone in a
given year, and will have to rely on the efforts of others going
forward, if we want to bring hope to everyone affected by this dreadful
disease.
We are proud of PEPFAR and the millions of miracles it has created
already in its first four years of operation. The American people can
look at PEPFAR and, unlike what they'll find with most government
programs, they can see measurable and tangible results in the faces of
the millions saved and cared for with U.S. funding. PEPFAR isn't
``broken,'' and it doesn't require ``fixing'' in its reauthorization--
it's a stunning success. The burden of proof is on those who want to
radically change PEPFAR policies, not on those of us who want to
preserve them. We look forward to working with the President and House
and Senate leaders to ensure that PEPFAR continues its successful,
miraculous, life-saving track record.
Bertha, a 23-year-old PEPFAR treatment client in Tanzania speaks for
millions when she says, ``If it is not these ARVs, I think I was dead
long time ago because I use and I am still using these drugs. Now I can
do anything. I'm healthy and I'm strong.''
Mr. President, I ask unanimous consent that my endnotes and graph be
printed in the Record.
There being no objection, the material was ordered to be printed in
the Record, as follows:
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