[Congressional Record Volume 157, Number 27 (Friday, February 18, 2011)]
[Extensions of Remarks]
[Pages E303-E305]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                    OPPOSITION TO AMENDMENT NO. 262

                                 ______
                                 

                          HON. DONALD M. PAYNE

                             of new jersey

                    in the house of representatives

                       Friday, February 18, 2011

  Mr. PAYNE. I rise today in opposition to Amendment No. 262, 
introduced by our colleague Representative Latta of Ohio, should it be 
offered during floor consideration of H.R. 1. Amendment No. 262 would 
eliminate all funding for international family planning programs in the 
proposed FY 2011 Continuing Resolution. This devastating cut would have 
severe immediate and long term impacts on women and their families in 
the world's poorest countries.
  Contrary to the rhetoric we are hearing from some of our colleagues, 
U.S. international family planning assistance in fact helps to reduce 
unintended pregnancies and abortions in the developing world. According 
to Population Action International, cutting this funding would result 
in: 7.8 million more unintended pregnancies; 3.7 million more 
abortions; 87,000 additional newborn deaths; and 12,000 additional 
maternal deaths.
  Moreover, this amendment would turn back the clock on U.S. 
investments in the global fight against HIV/AIDS. The integration of 
family planning and HIV/AIDS services is a vital and cost-effective way 
to prevent HIV infection, including through mother-to-child 
transmission. At the same cost, family planning services can avert 
nearly 30 percent more HIV-positive births than use of the nevirapine 
prophylaxis by HIV-positive pregnant women. A recent study found that, 
although PEPFAR has been associated with a reduction in HIV-related 
deaths, trends of increasing adult prevalence rates continue unabated. 
However, preventing unintended pregnancies, which is an international 
pillar of preventing mother to child transmission (PMTCT) programming, 
continues to receive insufficient attention in AIDS programs. The 
Guttmacher Institute noted in their report Hiding in Plain Sight: The 
Role of Contraception in Preventing HIV that helping HIV-positive women 
avoid unwanted pregnancies not only lowers the rate of new infections, 
but does so at a relatively low cost.
  I hope that you will join me in opposing this amendment, should it be 
offered.

            [From the Guttmacher Policy Review, Winter 2008]

   Hiding in Plain Sight: The Role of Contraception in Preventing HIV

                          (By Susan A. Cohen)

       As Congress embarks on the process of reauthorizing the 
     U.S. program to fight HIV and AIDS, and as other global 
     donors recalibrate levels and allocations of funding for HIV/
     AIDS programs, prevention seems to be making a comeback. At 
     the inception of the President's Emergency Plan for AIDS 
     Relief (PEPFAR) five years ago, both the funding and the 
     programmatic emphasis tilted heavily toward treatment. Yet, 
     the rate of new HIV infection continues to outpace the 
     world's ability to deliver antiretroviral therapy, despite 
     recent advances in access to such medications. A public 
     health consensus is emerging, therefore, in favor of 
     realigning the balance between treatment and prevention 
     efforts.
       Refocusing the priority on prevention is long overdue, as 
     is an acknowledgment, especially within Congress, that HIV 
     prevention cannot be accomplished with a disproportionate 
     emphasis on abstinence. Indeed, preventing the sexual 
     transmission of HIV requires going beyond the necessary but 
     hardly sufficient strategy of ABC: abstain, be faithful, use 
     condoms. It also requires increasing AIDS awareness through 
     counseling and testing programs, investing in programs 
     promoting the empowerment of women and girls, and increasing 
     access to male circumcision. Other critical prevention 
     interventions include ensuring a clean blood supply and clean 
     medical injections, needle exchange programs for intravenous 
     drug users and preventing the ``vertical'' transmission of 
     HIV from a pregnant woman to her newborn infant.
       Largely overlooked as an HIV prevention strategy, however, 
     is the simple and low-cost act of helping HIV-positive women 
     who do not want to have a child to avoid an unintended 
     pregnancy through increased access to contraceptive services. 
     Ward Cates, president for research of Family Health 
     International (FHI), has dubbed contraception the ``best-kept 
     secret in HIV prevention,'' and certainly, the significant 
     contribution of unintended pregnancy prevention toward 
     reducing the perinatal transmission of HIV has gone virtually 
     unrecognized. Yet, a revitalized and more robust effort 
     focused on HIV prevention cannot afford not to fully 
     capitalize on the critical role of contraceptive services in 
     fighting AIDS.


                  The Need for Progress on Prevention

       Women of reproductive age comprise more than half of the 33 
     million people currently living with HIV around the world. 
     The vast

[[Page E304]]

     majority of these women live in Sub-Saharan Africa, and thus, 
     it is not surprising that 90% of the 2.5 million children 
     younger than 15 living with HIV live there as well. Almost 
     all of these children became infected through their mothers 
     during pregnancy, birth or breastfeeding.
       An HIV-positive woman about to give birth can dramatically 
     reduce the likelihood of transmitting the virus to her 
     newborn by delivering in a hospital or a primary care setting 
     where she and her infant can receive even a single dose of 
     the anti-retroviral drug nevirapine. However, the challenges 
     to delivering even this seemingly simple prevention of 
     mother-to-child transmission (PMTCT) service are substantial, 
     especially in Sub-Saharan Africa. Pregnancy itself does not 
     usually drive women, especially those in rural areas, to 
     facilities where they could receive pre-natal care and, 
     potentially, an HIV test. In addition, many pregnant women 
     may not want to know their HIV status for fear of public 
     disclosure and the stigma that often results. Considering the 
     difficulties of delivering services to HIV-positive pregnant 
     women, and the simple fact that most women who are HIV-
     positive do not know it, it is not entirely surprising that 
     only 11% of all theoretically eligible women in poor 
     countries are benefiting from any PMTCT intervention. And 
     without intervention, about one-third of babies born to HIV-
     positive women likely will become infected.
       A long-standing goal of global prevention efforts, 
     therefore, is to ramp up PMTCT efforts so that more pregnant 
     women are tested and that those who are positive receive the 
     treatment that they and their infant will need. PMTCT 
     programs justifiably enjoy broad political support and are 
     certain to continue to be a funding priority within the U.S. 
     global AIDS effort.
       The United States does recognize the importance of at least 
     establishing linkages between PMTCT and family planning 
     programs, since PEPFAR requires family planning counseling 
     and referral as one of four elements comprising the minimum 
     package of services for preventing mother-to-child 
     transmission. However, a high-level consultation sponsored by 
     the World Health Organization (WHO} and the United Nations 
     Population Fund in 2004 went considerably further, concluding 
     that investing solely in narrowly defined PMTCT programs will 
     not succeed in dramatically reducing the incidence of 
     perinatal transmission. Rather, the Glion [Switzerland] Call 
     to Action on Family Planning and HIV/AIDS in Women and 
     Children emphasized that all four elements of the WHO 
     approach to preventing HIV infection in infants are 
     essential. PMTCT programs are key, but so are primary 
     prevention of HIV infection in women; the provision of care, 
     treatment and support for women living with HIV and their 
     families; and prevention of unintended pregnancies among 
     women living with HIV. Of these, the significant role that 
     unintended pregnancy prevention already plays--and the much 
     greater role it potentially could play--in averting new cases 
     of HIV has been least recognized and supported.
       According to a 2007 Guttmacher Institute study, one in four 
     married women in Sub-Saharan Africa is sexually active and 
     does not want to have a child or another child in the next 
     two years, but is not using any method of contraception. As a 
     result, unintended births are common, and occur in the very 
     countries that are a focus of PEPFAR--countries in which HIV 
     prevalence is high and 60% of all adults living with HIV are 
     women (see table).
       Indeed, research into the HIV/AIDS health care system 
     reveals that the unmet need for contraception among HIV-
     positive women and women at high risk of HIV is even greater 
     than among women in the general population. According to a 
     study published in JAMA in 2006, 84% of the pregnancies among 
     women in three PMTCT programs in South Africa were 
     unintended. Similarly, the Centers for Disease Control and 
     Prevention reported earlier this year that 93% of the 
     pregnancies among pregnant women receiving antiretroviral 
     therapy in Uganda were unintended. And according to FHI 
     research from 2006 of women in HIV counseling and testing 
     clinics (where most women are HIV-negative but are at high 
     risk for HIV), substantial majorities in Kenya (59%), 
     Tanzania (66%), Zimbabwe (77%) and Haiti

                                          HIV AND UNINTENDED PREGNANCY
 [In PEPFAR countries, high HIV/AIDS rates coexist with a high unmet need for contraceptive services and a high
                                         incidence of unplanned births.]
----------------------------------------------------------------------------------------------------------------
                                                                Unmet Need for     Unplanned         HIV/AIDS
              PEPFAR Focus Countries (selected)                 Contraception,  Births (as % of     Prevalence
                                                                Married Women    total births)     (ages 15-49)
----------------------------------------------------------------------------------------------------------------
Cote d'Ivoire................................................               28               28                7
Ethiopia.....................................................               34               35              1-3
Kenya........................................................               25               44                6
Mozambique...................................................               18               19               16
Namibia......................................................               22               45               20
Nigeria......................................................               17               14                4
Rwanda.......................................................               38               39                3
South Africa.................................................               15               53               19
Tanzania.....................................................               22               22                7
Uganda.......................................................               35               38                7
Zambia.......................................................               27               39               17
----------------------------------------------------------------------------------------------------------------
Source: Guttmacher Institute, 2007, and PEPFAR, 2007.

 (92%) said they did not want another child in the next two years.


                    Contraception as HIV Prevention

       To be sure, many women living with HIV do want to have a 
     child or another child, notwithstanding pressure to forego 
     childbearing from family members, people in their community 
     and health care providers. And, in fact, HIV-positive women 
     are likely to be able to sustain a healthy pregnancy and 
     safely deliver a healthy baby if they can avail themselves of 
     appropriate therapy (related article, Fall 2006, page 17). 
     Nonetheless, many HIV-positive women who know their HIV 
     status seek out contraceptive services specifically because 
     of their status--because they fear infecting their baby if 
     they become pregnant or leaving behind children, whether HIV-
     positive or not, as orphans. And many more women seeking 
     contraceptives services are, in fact, HIV-positive but do not 
     know it.
       FHI researchers estimate that if the HIV-positive women in 
     Sub-Saharan Africa who are currently using modern 
     contraceptive methods to prevent unintended pregnancy were 
     not able to do so, the number of HIV-positive births in the 
     region would be 31% higher than it is now. This would 
     translate to 153,000 more HIV-infected unplanned births each 
     year--or 419 more per day. Researchers at the Johns Hopkins 
     University Bloomberg School of Public Health and WHO 
     published an analysis in AIDS in 2004 demonstrating that even 
     a modest decline in the number of unintended pregnancies 
     among HIV-positive women in Botswana, Cote d'lvoire, Kenya, 
     Rwanda, Tanzania, Uganda, Zambia and Zimbabwe could lead to 
     the prevention of the same number of births of HIV-positive 
     infants as prevented by the current PMTCT programs in these 
     countries. ``It is clear from this analysis,'' they wrote, 
     ``that only a combined approach utilizing all three 
     intervention components simultaneously [reducing HIV 
     infection among women, reducing unintended pregnancy and 
     increasing the reach of PMTCT programs] will result in 
     significant reductions'' in new HIV infections among infants.
       Helping HIV-positive women avoid unwanted pregnancies not 
     only lowers the rate of new infections, but does so at a 
     relatively low cost. The U.S. Agency for International 
     Development (USAID) examined PMTCT programs in the 14 
     countries comprising the Bush administration's original 
     initiative starting in 2002 aimed at preventing mother-to-
     child transmission. USAID projected that over a five-year 
     period, adding family planning services to PMTCT programs 
     could prevent almost twice the number of infections to 
     children, and nearly four times the number of deaths to 
     children, as PMTCT alone could prevent (see chart). In 
     addition, a 2006 analysis by FHI concluded that for the same 
     cost, voluntary family planning services can avert not nearly 
     30% more HIV-positive births--that would have been 
     unintended--than averted by identifying HIV-positive women 
     during their pregnancy and providing nevirapine.
       Greater access to contraceptive services then--whether 
     among women in HIV treatment programs, PMTCT programs or 
     counseling and testing programs, or among women in 
     traditional family planning programs in high-HIV-prevelence 
     countries--is a ``win-win-win situation.'' it increases the 
     chances that women living with HIV can prevent future 
     pregnancies they do not want, thereby reducing the incidence 
     of perinatal transmission and the number of potential child 
     deaths, and it achieves these humanitarian ends in a highly 
     cost-effective way.


                   Implications for Prevention Policy

       Outside the context of HIV prevention, it is indisputable 
     that the health, social and economic benefits of investing in 
     contraceptive services--for women, their families and their 
     communities--are multiple and varied. By preventing 
     pregnancies that are too early, too late or too closely 
     spaced, contraception reduces the likelihood of infant 
     mortality. And by helping women to avoid high-risk 
     pregnancies and the need for unsafe abortions, it decreases 
     the risk of maternal death or disability. A woman who can 
     determine the timing and spacing of her children increases 
     her own and her existing family's opportunities for 
     educational, social and economic advancement. Moreover, the 
     evidence is compelling that increasing access to family 
     planning programs also amplifies the overall effort to slow 
     the rate of new HIV infection.
       Yet, despite the ever-rising demand for contraceptive 
     services and the fact that a woman's ability to control her 
     own fertility is integrally linked to almost all other 
     aspects of health and development, U.S. funding for family 
     planning has been lagging. Funding for family planning 
     programs in developing countries through USAID peaked at 
     about $550 million at the time of the international 
     Conference on Population and Development in Cairo in 1994 and 
     early 1995. It dropped precipitously in 1997, after control 
     of Congress shifted to lawmakers hostile to sexual and 
     reproductive health programs, plummeting to below $400 
     million. By 2001, the final year of the Clinton 
     administration, funding had regained some ground ($446 
     million), but that level has remained essentially constant 
     ever since.
       Clearly, USAID funding for family planning programs should 
     be increased--both on their traditional merits and, in high-
     prevalence countries, as an HIV strategy. At the same time, 
     as global donors to the fight against AIDS reconsider the new 
     priority emphasis on prevention, particularly the United 
     States through the reauthorization of PEPFAR, it would be an 
     opportune moment to legitimize contraceptive services as the 
     core HIV prevention intervention they are. This would mean 
     ensuring that HIV treatment programs, where women already 
     predominate, also provide contraceptive services directly or 
     by referral to make it easier for HIV-positive women to 
     coordinate their

[[Page E305]]

     treatment regimen with their pregnancy prevention goals. 
     Similarly, it would mean making family planning services more 
     widely available through PMTCT programs, because many HIV-
     positive new mothers wish to delay or prevent a subsequent 
     pregnancy. Finally, in high-prevalence countries, it would 
     mean promoting greater integration of HIV counseling and 
     testing services into family planning programs, so that more 
     sexually active women at risk of HIV are likely to be tested 
     and to receive appropriate counseling and treatment.
       These strategies are more than academic. The Elizabeth 
     Glaser Pediatric AIDS Foundation, the largest provider of 
     PMTCT services under PEPFAR, has been striving to incorporate 
     contraceptive services into its programs because ``care and 
     treatment staff members are uniquely positioned to address 
     HIV-positive women's needs concerning future pregnancy plans 
     and counsel them based on their social circumstances, health 
     status, and ART regimen.'' Indeed, as negotiations in 
     Congress got underway last month to reauthorize PEPFAR, the 
     Foundation wrote to the House Foreign Affairs Committee to 
     urge broadening the use of PEPFAR funds in order to support 
     these ``essential prevention services. . . . As implementers, 
     we cannot overstate the importance of [integration] to the 
     work we do on the ground to prevent the spread of HIV.''
       For individual women who live where HIV is rampant, the 
     interrelatedness of HIV prevention and unintended pregnancy 
     prevention is a practical reality. Yet most international 
     program donors, including the United States government, have 
     viewed them as complementary goals but separate and unrelated 
     outcomes. All along, the fact of contraception as HIV 
     prevention has been hiding in plain sight. It is time to seek 
     it.

                          ____________________