[Congressional Record (Bound Edition), Volume 149 (2003), Part 9]
[Senate]
[Pages 11822-11849]
[From the U.S. Government Publishing Office, www.gpo.gov]




 UNITED STATES LEADERSHIP AGAINST HIV/AIDS, TUBERCULOSIS, AND MALARIA 
                         ACT OF 2003--Continued

  Mr. REID. Mr. President, what is the regular order?
  The PRESIDING OFFICER (Mr. Coleman). H.R. 1298.
  Mr. REID. Is that the global AIDS bill?
  The PRESIDING OFFICER. Yes, it is.
  Mr. REID. I ask unanimous consent that the Feinstein amendment be 
next in order and there be 20 minutes equally divided in the usual 
form.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The Senator from West Virginia.
  Mr. BYRD. Mr. President, may I inquire of the leadership how much 
longer the leadership expects to keep us in session today?
  I inquire of the leadership as to how much longer the Senate will be 
in session today. It is now 22 minutes until the hour of midnight.
  The PRESIDING OFFICER. The Senator from Indiana.
  Mr. LUGAR. Mr. President, I respectfully respond to my colleague that 
clearly we can pass the bill now, and that would end the session. I 
would hope we would do that. If Members wish to continue offering 
amendments,

[[Page 11823]]

I will do the best I can to encourage each amendment be defeated so we 
will have a clean bill.
  In any event, I hope it will not be long, and with the cooperation of 
all Members we can expedite it.
  The PRESIDING OFFICER. The majority leader.
  Mr. FRIST. Mr. President, I reiterate what the chairman of the 
Foreign Relations Committee said. As I said at the outset of this week 
and through this week, the intent is to finish this bill this week. A 
number of Members on both sides of the aisle have requested that we 
continue. If we are going to finish this bill, which we will, we will 
finish it tonight. The plans are to finish the bill tonight. I know 
there are a number of amendments. As my colleagues can see from the 
amendments so far, the expectations are that we will be able to defeat 
each amendment as it comes forward.
  I encourage the other side of the aisle to look at the amendments. I 
do not believe we have any amendments on our side of the aisle. I 
encourage the other side to look at their amendments. This is the first 
step, at least from my standpoint, in addressing this complex issue. We 
are taking advantage of an opportunity at this point in time to move 
forward in the best interest of the United States with the global 
health community.
  I can tell the Senator this is not the bill I started with, and 
myself, Senator Kerry of Massachusetts, and a number of us have worked 
on a whole range of bills--the Lugar-Biden, Biden-Lugar bill. We are 
going to have plenty of opportunity to address this issue. This little 
virus, I have said again and again, is going to be with us for the next 
30 years. Even if we invent a vaccine tomorrow, we will have plenty of 
opportunity to refine this bill or the framework upon which this bill 
was started at a later date.
  I again encourage all people who are considering amendments to not 
offer those amendments. Our intent is to defeat each one. I remind 
everybody, this is a bipartisan bill.
  It did come from the House of Representatives, built on lots of other 
bills on which we have been working, and only one Democrat and a 
handful of Republicans voted against this bill. Therefore, I encourage 
our colleagues to withdraw amendments.
  We will be working together in a bipartisan fashion to improve this 
fight against a devastating virus. The intent is to complete this bill 
tonight.
  The PRESIDING OFFICER. The Senator from West Virginia.
  Mr. BYRD. If the majority leader will yield, would the majority 
leader seek to ascertain how many amendments will indeed be called up 
yet?
  Mr. FRIST. Mr. President, indeed I hope the managers can agree on a 
list of amendments. Again, I know a lot of people--we have been working 
on colloquies, and we will continue to do that, if necessary, to show 
what our intent is. Again, I am not sure if a final list has been 
settled upon. I encourage it to be as small as possible. I inquire of 
the other side.
  The PRESIDING OFFICER. The Democratic leader.
  Mr. DASCHLE. Mr. President, we are working on a definitive list as we 
speak. There are some amendments that may only require a voice vote, 
but at this point there are at least three or four amendments that may 
require rollcalls but with very short time limits. I know of no one on 
our side requesting more than 10 minutes in an effort to offer their 
amendments. So we should be able to move these quickly.
  Mr. FRIST. Mr. President, I do not believe we have any amendments on 
our side to be offered tonight. I encourage my colleagues to yield back 
time, again after careful explanations on their amendments so people 
know what they are voting on, but yield back time accordingly.
  I ask unanimous consent that all rollcall votes be 10 minutes.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. BYRD. Mr. President, will the leadership try to determine how 
many amendments are really going to be called up? We have cast 30 or 31 
rollcall votes already today. It is now 17 minutes until midnight. We 
used to ask for a show of hands as to which Senators were serious about 
calling up amendments, and I would hope the leaders would do that. I 
would like to stay around and finish action on the bill, but I am not 
bound to do so. If we are going to have several, I will ask unanimous 
consent for a leave of absence from the Senate for the rest of the 
evening and be on my way home.
  I would love to stay around and finish voting with other Senators. I 
do not want to presume to be the leader tonight, but I have been known 
to ask other Senators for a show of hands as to which Senators were 
serious about calling up amendments.
  The PRESIDING OFFICER. The majority leader.
  Mr. FRIST. I respond by saying I am scared to death to ask the other 
side how many amendments we actually have. We heard from the Democratic 
leader that there are four amendments that will likely require rollcall 
votes.
  From our side of the aisle, we have no amendments. We made it very 
clear what our strategy is, and that is to defeat the amendments. Why? 
Because it is the clearest way to help the hundreds of thousands of 
people who we know will benefit if we pass this bill tonight and get it 
to the G-8 so that the President can use it appropriately.
  The PRESIDING OFFICER. The Democratic leader.
  Mr. DASCHLE. I suggest we get on with these amendments. The sooner we 
do so, the sooner we will finish.
  Mr. BYRD. I ask unanimous consent that I be granted a leave of 
absence for the remainder of the evening.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The Senator from California.


                           Amendment No. 682

  Mrs. FEINSTEIN. Mr. President, I send an amendment to the desk.
  The PRESIDING OFFICER. The clerk will report.
  The legislative clerk read as follows:

       The Senator from California (Mrs. Feinstein), for herself, 
     Mr. Leahy, Mrs. Clinton, Mr. Durbin, Mr. Jeffords, Mr. 
     Harkin, Mr. Lautenberg, Mr. Reid, Mr. Schumer, Mr. Corzine, 
     Mrs. Boxer, Mr. Feingold, and Mr. Biden, proposes an 
     amendment numbered 682.

  Mrs. FEINSTEIN. Mr. President, I ask unanimous consent that the 
reading of the amendment be dispensed with.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The amendment is as follows:

(Purpose: To modify provisions relating to the distribution of funding)

       Beginning on page 94, strike line 19 and all that follows 
     through line 17 on page 95, and insert the following: ``301 
     of this Act), including promoting abstinence from sexual 
     activity and encouraging monogamy and faithfulness and 
     promoting the effective use of condoms for sexually active 
     people; and
       ``(4) 10 percent of such amounts for orphans and vulnerable 
     children.

     ``SEC. 403. ALLOCATION OF FUNDS.

       ``(a) Therapeutic Medical Care.--For fiscal years 2006 
     through 2008, not less than 55 percent of the amounts 
     appropriated pursuant to the authorization of appropriations 
     under section 401 for HIV/AIDS assistance for each such 
     fiscal year shall be expended for therapeutic medical care of 
     individuals infected with HIV, of which such amount at least 
     75 percent should be expended for the purchase and 
     distribution of antiretroviral pharmaceuticals and at least 
     25 percent should be expended for related care.''.

  The PRESIDING OFFICER. The Senator from California.
  Mrs. FEINSTEIN. I rise today with Senators Leahy, Clinton, Durbin, 
Jeffords, Harkin, Lautenberg, Reid, Schumer, Corzine, Boxer, Feingold, 
and Biden to offer an amendment to strike the earmark included in the 
bill which mandates that 33 percent of all prevention funds must be 
used exclusively for abstinence before marriage programs.
  I deeply believe this bill has one major flaw. I appreciate the bill, 
and I know the effort that went into it. It is a big step forward. But 
when it comes to AIDS, prevention is the name of the game.
  Over one-half of the AIDS cases that are expected between today and 
2010 can be prevented. The World Health Organization says of the 45 
million new HIV cases anticipated, 29 million could be averted with 
effective prevention.
  I was mayor of San Francisco when AIDS was discovered. We had one of 
the first AIDS program in the country.

[[Page 11824]]

I spent 9 years of my life as Mayor developing AIDS prevention 
programs, seeing what worked and what did not work. What I found was 
that there has to be flexibility. What works for one group of people or 
community might not necessarily work for another.
  I believe one of the major flaws of this bill is the earmark which 
would require that 33 percent of the prevention funds--that is $1 
billion over 5 years or $200 million a year--must be spent exclusively 
on abstinence before marriage programs. Abstinence will not work for 
everyone.
  We offer this amendment not because we are opposed to abstinence 
programs or do not want to see them funded. Rather, there are many 
additional approaches that are also effective and we believe it is 
critical that there be the necessary flexibility for a particular 
community or country to design a prevention program that best meets the 
needs of its people.
  I deeply believe that when we look at prevention, we have to consider 
a number of programs. Let me give a few examples of prevention programs 
that should be funded under this bill:
  Voluntary counseling and testing. This is an important component to 
stop the spread of the virus. Access to testing is important to ensure 
that one knows they are infected. Often, the disease is spread from 
husband to wife because he does not even know he is HIV positive. So 
testing is prevention.
  Another form of prevention is stopping the spread of HIV from mother-
to-child. Nevirapine is effective in preventing the transmission of HIV 
from a mother to her child. Studies have shown that combining drug 
therapy with counseling and instruction on use of such drugs can reduce 
transmission by 50 percent.
  Blood safety is also an important preventive measure. While the U.S. 
has taken the necessary steps to nearly eliminate the transmission of 
HIV by blood transfusion, many countries lack resources and 
infrastructure to take similar action including the creation of a 
national blood supply, use of low-risk blood donors, screening of blood 
donations, and reducing the number of unnecessary transfusions.
  Sexually transmitted disease control is another prevention tool. Left 
unchecked, sexually transmitted diseases can expand the risk of HIV/
AIDS two to five times.
  Lastly, empowering women is an important component to prevention. In 
Africa, women account for 58 percent of HIV/AIDS cases, and the number 
is rising. This means that providing women around the world with health 
and educational opportunities, equal rights before the law, protection 
from sexual violence and sexual trafficking, can help them take control 
of their lives and help reduce the spread of HIV.
  It is unrealistic to think that sexual abstinence is the most 
appropriate prevention strategy in every community. There has been 
research conducted in our own society on how an abstinence only 
approach fails to reach everyone. Therefore, I fail to understand then 
how this approach will work in the developing world.
  I deeply believe that the 33 percent earmark is the wrong approach to 
take with this bill. The amendment we have submitted would replace that 
33 percent earmark with language that would give local communities the 
flexibility necessary to design prevention programs that work for them. 
It includes abstinence. It includes faithfulness. It would also include 
the use of condoms for sexually active people.
  I believe our amendment is simple and straight forward. Let local 
communities, working in conjunction with the USAID and others, develop 
prevention programs that work for them. Congress should be passing 
legislation that simply gives local communities and health care 
providers the necessary resources to implement programs that are 
effective given their unique cultural, social, and medical 
circumstances.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Indiana.
  Mr. LUGAR. I yield to the Senator from Kansas.
  The PRESIDING OFFICER. The Senator from Kansas.
  Mr. BROWNBACK. Mr. President, I thank the leader for yielding the 
floor. I thank the Senator from California for the spirit in which she 
is putting this amendment forward. She wants to see the best possible 
happen. I appreciate the tenor and spirit she is putting forward.
  I reiterate what the chairman of the committee said: We want to get a 
bill through. If we put this amendment in, it is not going to get done 
in time for the G-8 meeting.
  The second issue, this week the First Lady of Uganda was visiting and 
spoke to a number of us. Uganda has been a wonderful model with great 
success thus far working on reducing the incidence of AIDS from a 21 
percent level of infection of AIDS in their country in 1991 to 6 
percent in 2002. She said very clearly and directly this is about a 
change of culture, about pushing a model of ABC which started with 
abstinence and be faithful. That was the key, the key area they needed 
to push in that they got the most success, the right thing to do.
  I point out in this area, the way the bill reads, in this actual 
provision, 33 percent of 20 percent would be used for abstinence 
programs, but not just abstinence programs. It would be abstinence and 
other programs along with it. Effectively, we are talking about roughly 
6.5, 6.7 percent of the money. This is a small amount. It is a clear 
message we think needs to be sent along with an effective model that 
worked very well in Uganda and is being implemented in Senegal, Zambia, 
Ethiopia, and Jamaica because it has proven so successful.
  This is an important provision to leave in because if we change it, 
even with the good intentions of the Senator from California, it will 
stall, if not really put the bill way back, because this issue involved 
a major dispute with the House.
  Second, the abstinence programs have worked, in the clear places they 
have been used, particularly in Uganda, the model that has been most 
frequently cited.
  Third, it is a small portion of the funding; 6.7 percent is actually 
in use here.
  I urge for all those reasons my colleagues vote down the Feinstein 
amendment and stay with the provisions of the bill as sent over from 
the House.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Vermont.
  Mr. LEAHY. Mr. President, I have heard this interesting discussion by 
two Senators I like a great deal. I cannot add to the experience the 
distinguished Senator from California had as mayor of San Francisco 
and, in fact, in her work as a national leader in efforts to prevent 
AIDS.
  I say also to my good friend from Kansas that I remember being in 
Uganda at a time when they were first becoming aware of the fact they 
had an AIDS problem. I was sitting with President Museveni when he got 
his first real briefing, by USAID officials, of the calamity of AIDS in 
his country. At that time he switched from opposing the use of condoms 
as an acceptable way to protect against AIDS to supporting it.
  It is one of the reasons Uganda is a model for Africa today. Of 
course they support abstinence. So does the Senator from California. Of 
course they support fidelity. So does the Senator from California. But 
also in Uganda they know that does not always work. And they also 
support the use of condoms.
  I commend the Senator from California for her amendment. This 
amendment addresses one of the serious flaws in a bill that has much 
else to recommend it.
  This bill, assuming the President requests the funds to implement it, 
will be a major step forward in the fight against HIV/AIDS, 
tuberculosis, and malaria.
  I have pressed for significantly more funding to combat AIDS ever 
since I first traveled to Africa in 1990 and saw the ravages of AIDS in 
Uganda, South Africa, and Kenya.
  We have had amendments brought up here within the past year to 
appropriate emergency funds to combat AIDS, that were opposed by the 
White

[[Page 11825]]

House. Now the majority party has its own bill, a House bill and they 
want us to pass it without amendment. I understand that. But this is 
the Senate, not the House.
  The amendment of the Senator from California would clarify several 
matters.
  First, we all support programs to promote abstinence among young 
people who are not yet sexually active. We support that and her 
amendment reaffirms that.
  We also support programs to promote fidelity, because multiple 
partners is a major cause of HIV transmission. The Senator's amendment 
promotes fidelity.
  But in many instances, and especially for women and girls in 
countries like Uganda, Cambodia, India, or South Africa, abstinence is 
not a realistic option. And fidelity may be an option for women, but it 
makes no difference because they have no control over their male 
partners. And that also goes for married women.
  In many developing countries, women and girls have no say over when 
or even with whom they have sexual relations. And for them, a condom is 
their only protection against HIV. It is a matter of life and death.
  That is true in Uganda, where I have been. We have heard a lot said 
about how Uganda's rate of HIV infection was reduced because of 
abstinence. That is not the whole story. In fact it is a distortion. 
Promoting abstinence has been very important there, but it has been no 
more important than other interventions, like promoting the use of 
condoms.
  Senator Feinstein's amendment supports abstinence. It supports 
fidelity. And it supports the use of condoms. Like the Uganda model, 
her amendment does not give one approach any more weight than the 
other.
  Most importantly, it does not mandate a certain amount of funds for 
any one approach.
  Whether 33 percent or 13 percent or 3 percent of the funds we make 
available for AIDS prevention are used to promote abstinence is a 
public health decision that should be made not by Congress, but by 
experts working in the field.
  The same goes for the amount spent on condoms. It is not for us to 
decide that. It varies depending on the country and the target 
population.
  Among younger populations abstinence may be the best approach. Among 
others it may be irrelevant and condoms may be the only practical 
protection. That is consistent with Uganda's experience. It is 
consistent with the experience of exports everywhere who are working to 
stop the spread of AIDS. And it is consistent with what President Bush 
himself has said.
  It is also important to mandate that abstinence, fidelity, and 
condoms are only three of the necessary approaches to AIDS prevention.
  There is also counseling. There is voluntary testing. There is 
treatment for sexually transmitted diseases. These are all essential to 
any AIDS prevention strategy. Again, this has been true in Uganda, and 
in many other countries.
  So let us not earmark one approach--abstinence--when it is only one 
of several necessary approaches. Senator Feinstein's amendment leaves 
it to the Administration, and to the experts who implement these 
programs, to decide. That is the only sensible and workable approach.
  I yield the floor.
  The PRESIDING OFFICER. Who yields time?
  Mrs. FEINSTEIN. I yield to the Senator from Wisconsin.
  Mr. FEINGOLD. It is late, but I cannot let the characterization of 
the AIDS program in Uganda pass without suggesting that the 
characterization by the Senator from Kansas is an oversimplification of 
how they reduced the AIDS incidence in Uganda.
  Most importantly, what Uganda did is to destigmatize AIDS, to not 
make people who have AIDS pariahs, and to talk about a range of 
alternatives, not simply abstinence.
  The House approach to this does not characterize the way in which 
they succeed in Uganda. In fact, I suggest it does just the opposite.
  I object to the use of the Uganda example, which is one of the 
leading examples of the world. Without the ABC, all three of them, it 
would not have succeeded. The House approach is too limited to save the 
lives we all want to save.
  Mr. LUGAR. Mr. President, let me clarify that if $2 billion is spent 
in the first year for bilateral HIV programs and if 20 percent is for 
prevention, only $132 million will be involved in the abstinence 
programs. I simply say, it is a fairly small amount.
  When the President addressed this issue at the White House, he 
specifically said, there are three elements. There is abstinence, 
faithfulness, and condoms. He said all three. There is a liberal amount 
of money for a lot of flexibility.
  I don't argue with the distinguished Senator from California. I just 
say essentially the language accomplishes that.
  Once again, we are faced with the fact that if we are determined to 
amend it, we are back into the problem with the House, which debated 
this. This was an important part of the compromise that brought those 
375 votes in favor of the bill.
  I yield back our time.
  Mrs. FEINSTEIN. Mr. President, how much time remains on our side?
  The PRESIDING OFFICER. Two minutes 10 seconds.
  Mrs. FEINSTEIN. I yield 1 minute to Senator Durbin.
  Mr. DURBIN. Having been to Uganda and having seen the success of this 
program, the characterization on the floor is not correct. Secretary of 
State Powell has made it clear the United States approach involves all 
three--abstinence, fidelity, and condoms. And in the country of Uganda, 
it has been successful.
  Why in the world are we establishing a 33 percent requirement when it 
comes to the abstinence programs? This afternoon we had tea with the 
First Lady of Uganda, and we had a conversation with her and asked, 
wouldn't you want to have the flexibility to apply these programs to 
the communities and villages and situations in the most effective way 
to fight this disease? She said, of course we would.
  This House bill, which is now so sacred that we cannot change one 
word, has put in 33 percent--not in the interest of global health but 
in the interest of an American political agenda. That is unfortunate.
  Mrs. FEINSTEIN. Mr. President, I yield the remaining balance of the 
time and I ask for the yeas and nays.
  The PRESIDING OFFICER. Is there a sufficient second?
  There is a sufficient second.
  The question is on agreeing to the amendment of the Senator from 
California.
  The clerk will call the roll.
  The assistant legislative clerk called the roll.
  Mr. McCONNELL. I announce that the Senator from New Mexico (Mr. 
Domenici) is necessarily absent.
  Mr. REID. I announce that the Senator from West Virginia (Mr. Byrd) 
and the Senator from Massachusetts (Mr. Kerry) are necessarily absent.
  I further announce that, if present and voting, the Senator from 
Massachusetts (Mr. Kerry) would vote aye.
  The PRESIDING OFFICER (Mr. Talent). Are there any other Senators in 
the Chamber desiring to vote?
  The result was announced--yeas 45, nays 52, as follows:

                      [Rollcall Vote No. 180 Leg.]

                                YEAS--45

     Akaka
     Baucus
     Bayh
     Biden
     Bingaman
     Boxer
     Breaux
     Cantwell
     Carper
     Clinton
     Conrad
     Corzine
     Daschle
     Dayton
     Dodd
     Dorgan
     Durbin
     Edwards
     Feingold
     Feinstein
     Graham (FL)
     Harkin
     Hollings
     Inouye
     Jeffords
     Johnson
     Kennedy
     Kohl
     Landrieu
     Lautenberg
     Leahy
     Levin
     Lieberman
     Lincoln
     Mikulski
     Murray
     Nelson (FL)
     Pryor
     Reed
     Reid
     Rockefeller
     Sarbanes
     Schumer
     Stabenow
     Wyden

                                NAYS--52

     Alexander
     Allard
     Allen
     Bennett
     Bond
     Brownback
     Bunning
     Burns
     Campbell
     Chafee
     Chambliss
     Cochran

[[Page 11826]]


     Coleman
     Collins
     Cornyn
     Craig
     Crapo
     DeWine
     Dole
     Ensign
     Enzi
     Fitzgerald
     Frist
     Graham (SC)
     Grassley
     Gregg
     Hagel
     Hatch
     Hutchison
     Inhofe
     Kyl
     Lott
     Lugar
     McCain
     McConnell
     Miller
     Murkowski
     Nelson (NE)
     Nickles
     Roberts
     Santorum
     Sessions
     Shelby
     Smith
     Snowe
     Specter
     Stevens
     Sununu
     Talent
     Thomas
     Voinovich
     Warner

                             NOT VOTING--3

     Byrd
     Domenici
     Kerry
  The amendment (No. 682) was rejected.
  Mr. LUGAR. Mr. President, I move to reconsider the vote, and I move 
to lay that motion on the table.
  The motion to lay on the table was agreed to.
  Mr. DASCHLE. Mr. President, the majority leader and I have been 
discussing how we will continue. I know of no one who has asked for a 
rollcall vote on final passage. It would be our hope that we could 
voice vote final passage.
  I also encourage my colleagues, to the degree possible, to accept 
voice votes on these amendments as well. The hour is late, and each 
vote takes at least 10 minutes. There will be a voice vote on final, 
assuming everyone has agreed. To the extent possible, I encourage voice 
votes on amendments as well.
  The PRESIDING OFFICER. The Senator from Massachusetts.


                           Amendment No. 681

  Mr. KENNEDY. Mr. President, I send an amendment to the desk.
  The PRESIDING OFFICER. The clerk will report.
  The legislative clerk read as follows:

       The Senator from Massachusetts [Mr. Kennedy], for himself 
     and Mr. Feingold, Mr. McCain, Mrs. Feinstein, Mr. Levin, Mr. 
     Schumer, Mr. Pryor, and Mr. Johnson, proposes an amendment 
     numbered 681.

  Mr. KENNEDY. Mr. President, I ask unanimous consent that reading of 
the amendment be dispensed with.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The amendment is as follows:

(Purpose: To provide for the procurement of certain pharmaceuticals at 
       the lowest possible price for products of assured quality)

       On page 54, strike lines 7 through 24, and insert the 
     following: ``medicines to treat opportunistic infections, at 
     the lowest possible price for products of assured quality (as 
     provided for in subparagraph (D)). Such procurement shall be 
     made anywhere in the world notwithstanding any provision of 
     law restricting procurement of goods to domestic sources.
       ``(B) Mechanisms for quality control and sustainable 
     supply.--Mechanisms to ensure that such HIV/AIDS 
     pharmaceuticals, antiviral therapies, and other appropriate 
     medicines are quality-controlled and sustainably supplied.
       ``(C) Distribution.--The distribution of such HIV/AIDS 
     pharmaceuticals, antiviral therapies, and other appropriate 
     medicines (including medicines to treat opportunistic 
     infections) to qualified national, regional, or local 
     organizations for the treatment of individuals with HIV/AIDS 
     in accordance with appropriate HIV/AIDS testing and 
     monitoring requirements and treatment protocols and for the 
     prevention of mother-to-child transmission of the HIV 
     infection.
       ``(D) Lowest possible price and assured quality.--
       ``(i) Lowest possible price.--With respect to an HIV/AIDS 
     pharmaceutical, an antiviral therapy, or any other 
     appropriate medicine, including a medicine to treat 
     opportunistic infections, the lowest possible price means the 
     lowest delivered duty unpaid price at which such medicine 
     (which includes all products of assured quality with the same 
     active ingredients) may be obtained in sufficient quantity in 
     either the United States or elsewhere on the world market.
       ``(ii) Assured quality.--An HIV/AIDS pharmaceutical, an 
     antiviral therapy, or any other appropriate medicine, 
     including a medicine to treat opportunistic infections, shall 
     be considered a product of assured quality if it is--

       ``(I)(aa) approved by the Food and Drug Administration;
       ``(bb) authorized for marketing by the European Commission;
       ``(cc) on the most recent edition of the list of HIV-
     related medicines prequalified for procurement by the World 
     Health Organization's Pilot Procurement Quality and Sourcing 
     Project; or
       ``(dd) during the period that begins on the date of 
     enactment of this section and ending on December 31, 2004, 
     authorized for use by the national regulatory authority of 
     the country where the product will be used unless the 
     President determines that the product does not meet 
     appropriate quality standards; and
       ``(II) in compliance with--

       ``(aa) the intellectual property laws of the country where 
     the product is manufactured;
       ``(bb) the intellectual property laws of the country where 
     the product will be used; and
       ``(cc) applicable international obligations in the field of 
     intellectual property, to the extent consistent with the 
     flexibilities provided in the Agreement on Trade-Related 
     Aspects of Intellectual Property Rights (TRIPS), as 
     interpreted in the Declaration on the TRIPS Agreement and 
     Public Health, adopted by the World Trade Organization at the 
     Fourth Ministerial Conference at Doha, Qatar on November 14, 
     2001.
       ``(iii) Prices publicly available.--Prices paid for 
     purchases of HIV/AIDS pharmaceuticals, antiviral therapies, 
     and other appropriate medicines, including medicines to treat 
     opportunistic infections, of assured quality shall be made 
     publicly available.
       ``(iv) Application to appropriated funds.--Funds 
     appropriated under title IV of the United States Leadership 
     Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 that 
     are used for the procurement of HIV/AIDS pharmaceuticals, 
     antiviral therapies, and other appropriate medicines, 
     including medicines to treat opportunistic infections, shall 
     be used to procure products of assured quality at the lowest 
     possible price, as determined under this subparagraph.
         (E) Rule of construction.--Nothing in this paragraph 
     shall be construed to affect a decision regarding which 
     medicine is most medically appropriate for a specific disease 
     or condition.

  Mr. KENNEDY. Mr. President, we know that 30 million people in Africa 
are afflicted with HIV/AIDS, and millions more around the world are 
also ill. Eight thousand people die in Africa each day from AIDS, and 
many of them are children. Only 50,000--1 in every 600--receive the 
drugs that we know can turn a deadly disease into a chronic one.
  This legislation promises that funds will finally be available to buy 
these lifesaving drugs. Our amendment is intended to see that these 
drugs will help the largest number of people possible. It does that by 
requiring that products be purchased at the lowest possible price. It 
does not add a penny to the cost of this bill. But it also means that 
we will get the greatest value for this very urgently needed investment 
to stop the HIV/AIDS epidemic.
  President Bush emphasized in his State of the Union Address 
``antiretroviral drugs can extend life for many years. And the cost of 
these 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.''
  The best way to take advantage of this opportunity as identified by 
the President is to require the purchase of AIDS drugs of assured 
quality at the lowest possible price. That is now $300 a year--not 
$12,000.
  It is important that we understand the significance of this 
difference. If we use the funds in this bill to buy a year's supply of 
drugs for $12,000 a person, we will help only 100,000 persons. But if 
we buy the drugs for $300, we will help over 4 million.
  This amendment is based on the successful program of the Global Fund 
to Fight AIDS, Tuberculosis, and Malaria. This program is proven to 
work in getting safe, high-quality drugs to people in need in the 
developing world at the lowest price.
  The essence of this amendment is simple. It fulfills the President's 
pledge to treat AIDS patients with drugs costing $300 per case. It 
protects America's intellectual property rights. It assures that drugs 
will be of the highest quality. But, most of all, it means we will be 
able to save millions of lives instead of thousands.
  Let us put patients first--not the profits of the drug companies. Let 
us buy drugs at the lowest possible price to treat the maximum number 
of patients. Let us deliver the best medicine at the best price.
  I yield to the Senator from Wisconsin.
  The PRESIDING OFFICER. The Senator from Wisconsin.
  Mr. FEINGOLD. Mr. President, I rise to speak in support of Senator 
Kennedy's important amendment. The Senate should not be silent on this 
issue. Senator Kennedy's amendment requires that pharmaceuticals 
procured

[[Page 11827]]

by the United States for treatment initiatives authorized in this bill 
be purchased at the lowest possible cost while maintaining high quality 
standards.
  In the past, Congress has been reluctant to address treatment issues, 
shying away from the complexities associated with providing treatment 
and resources. But just because it has been difficult does not mean it 
is impossible. And recognizing and accepting complexity is no excuse 
for ignoring urgent needs.
  I have served on the African Affairs Subcommittee in the Senate now 
for almost 11 years, and I am pleased to be able to say that it appears 
that the tide is finally beginning to turn on this issue after so many 
years with people cavalierly dismissing the notion of providing access 
to antiretroviral drugs in the developing world.
  I often recall the very end of almost a marathon meeting with the 
Senegalese public health community. An extraordinary group of 
Senegalese doctors, nurses, and volunteers and religious leaders had 
come out on a Saturday to spend hours talking with me and others about 
their coordinated campaign to fight AIDS. We were wrapping up when a 
gentleman who had been among those briefing me stood up, and speaking 
softly he told me that he was HIV positive. He wanted to know if there 
would be any help for him, any assistance with the kind of treatment 
that is out of reach for some in Africa.
  There has to be an answer to his question. I heard the President of 
the United States answer positively in the State of the Union that 
basic human decency tells us that we cannot stand by while tens of 
millions die and societies collapse.
  Recently, in South Africa I met with pediatricians whose exhaustion 
showed on their faces and their posture and in their tired, angry 
voices. They were tired of watching children die when they know that 
the treatment actually exists to save them.
  There is much more to say about what we have seen in Africa. But what 
we are talking about here is a tremendous commitment of U.S. resources 
in this bill and in this time of crises. I think we have to get the 
most that we can for our money.
  The amendment is about using taxpayer dollars wisely. It would be 
beyond shameful and almost reprehensible for us to use the resources 
authorized in this bill for what might end up being sweetheart deals 
with big pharmaceutical companies for their products if we could get 
equally safe and effective products at a better price.
  The amendment is in no way targeted to the pharmaceutical industry. 
It does not prejudge anyone's intentions. It does not exclude any 
single provider of safe and effective drugs. It simply demands that the 
U.S. Government get the quality we need at the best available price.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Indiana.
  Mr. LUGAR. Mr. President, just as a matter of common sense, the U.S. 
Government will attempt to purchase pharmaceutical products of the 
highest quality at the best price. But I would just simply urge my 
colleagues to consider the fact that mandating this, while it appears 
reasonable, and has some reliance upon the World Health Organization's 
pilot program, we ought to recognize that the World Health Organization 
actually dealing in countries with a high incidence of HIV/AIDS does 
not guarantee the quality of the medicine. It is probably unable to do 
that.
  The facts are--and I respect the distinguished Senator from 
Massachusetts and, likewise, the Senator from Wisconsin; they have 
experience, I am sure, in the field looking at these programs--the 
testimony of people I have visited with at Indiana University, who have 
been in the field, indicates that the whole idea of the treatment is a 
very provisional situation.
  We are grasping as a world at what works. And this is why flexibility 
has been encouraged thus far. We also are simply up against the fact 
that the problem is so overwhelming that attempting to obtain 
pharmaceutical products from anybody around the world has been 
extremely difficult. And a good number of pharmaceutical companies have 
been prepared to make enormous price concessions. And most physicians 
then point out, you need a physician to help the patient make certain 
the doses are right, the combination of drugs is right, the discipline 
of dealing with this is correct.
  It is not a matter of mandating the lowest cost drugs, and failing to 
do that denying people treatment. The fact is, 80 percent of the people 
with AIDS in the world are getting no treatment at all. That is why we 
are trying to pass a bill tonight as opposed to having several months 
more discussion, attempting to perfect the bill. I have said from the 
beginning, as Dr. Frist, that all of us could perfect this bill in a 
number of ways. Our problem is to get a bill through two Houses now so 
it might be of some benefit to our President in his diplomacy and 
advocacy as he approaches the other wealthy countries of the world, 
starting at least on the first of January, if not before.
  Therefore, Mr. President, I am hopeful that Members understand the 
importance of getting drugs at the best price and mandating the highest 
quality and attempting to get as many companies all over the world 
interested in this as we can. But the amendment, it seems to me, once 
again, obstructs the fact of getting any bill at all, any relief for 
the people we are talking about. Therefore, I ask Senators to vote no.
  The PRESIDING OFFICER. The Senator from Massachusetts.
  Mr. KENNEDY. Mr. President, we have just seen the World Health 
Organization deal with one of the great challenges of modern times; and 
that is with SARS. The World Health Organization has been commended all 
over the world for the way it has worked with countries all over the 
world, and we have joined in that commendation.
  We have been working with the Global Fund to Fight AIDS, 
Tuberculosis, and Malaria to ensure quality products are used to treat 
patients with HIV/AIDS. We are investing money in these quality 
products through the Global Fund to Fight AIDS, Tuberculosis, and 
Malaria. All we are saying in this amendment is that you are going to 
have the same assured product at the lowest possible price.
  If the American Government is, through the Global Fund, buying these 
quality products, then you ought to be willing to accept this 
amendment. All it does is make sure we have the best prices for these 
products of assured quality. We are not saying we have to buy the 
antiretroviral drugs for HIV for $300, but they do have to be purchased 
at the best available price, with the quality assured.
  I do not understand how we can refuse to say, if we are going to 
invest the taxpayers' money in this endeavor, then we should get the 
maximum in terms of the results, in terms of the number of people 
helped. We should make sure that helping the most people possible is 
the policy of the United States.
  Mr. GREGG. Will the Senator from Massachusetts yield?
  Mr. KENNEDY. I am happy to yield.
  Mr. GREGG. I was wondering if the Senator from Massachusetts would be 
willing to enter into a time agreement, say, 2 minutes on each side, 
and then have a vote?
  Mr. KENNEDY. We were trying to reach 10 minutes for ourselves. We 
probably have 2 more minutes for the Senator to speak and then we are 
finished.
  The PRESIDING OFFICER. The Senator from Wisconsin.
  Mr. FEINGOLD. Mr. President, one quick point to reinforce what 
Senator Kennedy said in response to what the Senator from Indiana said.
  Obviously, the Senator from Massachusetts and I are not going to 
offer an amendment to provide unsafe treatments. In fact, the WHO 
guarantees the bioequivalency of a given product. And that just means 
they actually verify that it is exactly the same as a product that has 
been thoroughly tested for safety by an institution such as the FDA.
  So it is not a valid point that somehow this approach that we are 
suggesting will lead to products that are not safe. They are as safe as 
the ones we would use ourselves.

[[Page 11828]]


  Mr. McCAIN. Mr. President, this amendment, like this bill, addresses 
a specific pandemic that demands our attention and our action. 
According to the most recent data available, at least 20 million people 
have died of HIV/AIDS globally, orphaning 14 million children. On the 
African continent, approximately 30 million people have the AIDS 
virus--3 million of whom are children under the age of 15.
  In the spirit of the underlying bill, I have joined my friend Senator 
Kennedy in cosponsoring this amendment to ensure that this bill saves 
as many lives as possible. Our amendment will allow for the purchase of 
many more drugs to treat those suffering from HIV/AIDS, stretching the 
taxpayers' dollars as far and as effectively as possible.
  This amendment allows U.S. taxpayer dollars to go towards the 
purchase of safe, but less expensive equivalent medications on the 
global market if they are available. It enables the U.S. Agency for 
International Development (USAID) to use Federal funds to procure drugs 
at the lowest possible price on the global market to treat HIV/AIDS 
patients, provided that they are approved for treatment in the U.S.; 
the EU; have been selected by the World Health Organization's, WHO, 
Pilot Procurement Quality and Sourcing Project for HIV-related 
medicines; or are authorized for use by the country where the product 
will be used. These are the same qualifications used by the United 
Nations Global Fund to procure drugs.
  This amendment does not give preference to a particular treatment for 
HIV/AIDS. Patients will not be precluded from receiving the drug 
treatments that are medically necessary; however, if there is a less 
expensive equivalent drug included in that treatment, this amendment 
will require the purchase of that lower-cost drug.
  As a proponent of free trade and a staunch supporter of upholding our 
global trade obligations, I don't believe this amendment violates 
carefully negotiated agreements on intellectual property rights at the 
World Trade Organization, WTO, nor does it weaken the position of our 
trade representatives in future intellectual property negotiations. The 
language of this amendment closely tracks the most recent intellectual 
property rights agreements at the WTO.
  I urge my colleagues to choose to make treatments available to many 
more people suffering from this terrible disease and vote for this 
amendment.
  The PRESIDING OFFICER. Is there further debate on the amendment?
  The Senator from Nevada.
  Mr. REID. Mr. President, I have checked with both managers of the 
bill. I ask unanimous consent that the only amendments in order be the 
following: Senator Feingold, who is going to offer his amendment; 
Senator Clinton; Senator Lautenberg; Senator Leahy; Senator Landrieu; 
Senator Dodd; Senator Boxer. And it is my understanding the manager of 
the bill has an amendment to offer. Oh, I am sorry. There he is. And 
the Boxer amendment will be 20 minutes, equally divided.
  Mrs. BOXER. I don't need that much time.
  Mr. REID. Five minutes equally divided.
  Mrs. BOXER. Ten minutes.
  Mr. REID. That is what I said.
  Mrs. BOXER. You said 20 minutes. I need 10 minutes.
  Mr. REID. OK, Senator Boxer, 20 minutes, equally divided. Senator 
Dodd, 20 minutes.
  Mr. LUGAR. Senator Boxer, 10 minutes, evenly divided.
  Mr. REID. I think we have been here 17 hours. What do you think?
  Senator Clinton is going to speak for a short time. She will take a 
voice vote. Senator Lautenberg is going to enter into a colloquy. 
Senator Leahy is going to offer and withdraw. Senator Landrieu is going 
to enter into a colloquy. Senator Feingold is going to offer and 
withdraw.
  I ask unanimous consent that the order of the amendments be: 
Feingold, Clinton, Lautenberg, Leahy, Landrieu, Dodd, and Boxer, and 
the final vote be that of Senator Biden, and there be no second-degree 
amendments in order.
  The PRESIDING OFFICER. Is there objection?
  Mr. DODD. Reserving the right to object, I don't mind going last. I 
will be happy going last.
  Mr. BIDEN. No, Mr. President, I will go last.
  The PRESIDING OFFICER. Is there objection?
  Without objection, it is so ordered.
  Mr. KENNEDY. Mr. President, I ask for the yeas and nays.
  The PRESIDING OFFICER. Is there a sufficient second?
  There appears to be a sufficient second.
  The question is on agreeing to amendment No. 681.
  The clerk will call the roll.
  The legislative clerk called the roll.
  Mr. McCONNELL. I announce that the Senator from New Mexico (Mr. 
Domenici) is necessarily absent.
  Mr. REID. I announce that the Senator from West Virginia (Mr. Byrd), 
the Senator from Hawaii, (Mr. Inouye) and the Senator from 
Massachusetts (Mr. Kerry) are necessarily absent.
  I further announce that, if present and voting, the Senator from 
Massachusetts (Mr. Kerry) would vote ``aye.''
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The result was announced--yeas 42, nays 54, as follows:

                      [Rollcall Vote No. 181 Leg.]

                                YEAS--42

     Akaka
     Bayh
     Biden
     Bingaman
     Boxer
     Cantwell
     Clinton
     Conrad
     Corzine
     Daschle
     Dayton
     Dodd
     Dorgan
     Durbin
     Edwards
     Feingold
     Feinstein
     Graham (FL)
     Harkin
     Hollings
     Jeffords
     Johnson
     Kennedy
     Kohl
     Landrieu
     Lautenberg
     Leahy
     Levin
     Lieberman
     Lincoln
     McCain
     Mikulski
     Murray
     Nelson (FL)
     Pryor
     Reed
     Reid
     Rockefeller
     Sarbanes
     Schumer
     Stabenow
     Wyden

                                NAYS--54

     Alexander
     Allard
     Allen
     Baucus
     Bennett
     Bond
     Breaux
     Brownback
     Bunning
     Burns
     Campbell
     Carper
     Chafee
     Chambliss
     Cochran
     Coleman
     Collins
     Cornyn
     Craig
     Crapo
     DeWine
     Dole
     Ensign
     Enzi
     Fitzgerald
     Frist
     Graham (SC)
     Grassley
     Gregg
     Hagel
     Hatch
     Hutchison
     Inhofe
     Kyl
     Lott
     Lugar
     McConnell
     Miller
     Murkowski
     Nelson (NE)
     Nickles
     Roberts
     Santorum
     Sessions
     Shelby
     Smith
     Snowe
     Specter
     Stevens
     Sununu
     Talent
     Thomas
     Voinovich
     Warner

                             NOT VOTING--4

     Byrd
     Domenici
     Inouye
     Kerry
  The amendment (No. 681) was rejected.
  Mr. LUGAR. Mr. President, I move to reconsider the vote.
  Mr. REID. I move to lay that motion on the table.
  The motion to lay on the table was agreed to.
  Mr. DASCHLE. Mr. President, we have two other amendments that require 
rollcalls. Very short time limits will be used to present the 
amendments is my understanding. We have no other requests for 
rollcalls. Other Senators will be offering amendments requiring voice 
votes. I think at that point Senators will be free to leave. I ask that 
the Boxer amendment be the next in order.
  Mr. LUGAR. Mr. President, I ask for information now on the time 
limits on the two amendments.
  Mr. REID. The Boxer amendment is 10 minutes. It is already an order.
  Mr. LUGAR. On the Dodd amendment?
  The PRESIDING OFFICER. There was no time limit established.
  Mr. DASCHLE. It is my understanding that there was 20 minutes on the 
Dodd amendment, 10 minutes on the Boxer amendment, evenly divided.
  The PRESIDING OFFICER. There was no time limit--
  Mr. DASCHLE. I ask unanimous consent for that.
  Mr. REID. Mr. President, I don't want to belabor the point, but when 
I said we were in the 17th hour, we did ask for time on the Boxer 
amendment.
  The PRESIDING OFFICER. Yes, the Boxer amendment has a 10-minute time 
limit.

[[Page 11829]]


  Mr. REID. Senator Dodd has agreed to 20 minutes.
  The PRESIDING OFFICER. The Senator from Wisconsin.
  Mr. FEINGOLD. Mr. President, I withdraw my amendment.
  The PRESIDING OFFICER. The amendment of the Senator from Wisconsin is 
withdrawn.
  The Senator from California is recognized.


                           Amendment No. 684

  Mrs. BOXER. Mr. President, I know we are all exhausted and I am 
really sorry to be here for an extra few minutes. I feel I don't 
deserve to really be in the Senate because we are talking about global 
AIDS, which is turning into a weapon of mass destruction. I feel very 
bad about what we are doing here tonight.
  First, I send my amendment to the desk.
  The PRESIDING OFFICER. The clerk will report.
  The legislative clerk read as follows:

       The Senator from California (Mrs. Boxer) proposes an 
     amendment numbered 684.

  Mrs. BOXER. Mr. President, I ask unanimous consent that further 
reading of the amendment be dispensed with.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The amendment is as follows:

       (Purpose: To require a specific plan to help AIDS orphans)

       On Page 29, line 15, insert before the semicolon the 
     following: ``, including the development and implementation 
     of a specific plan to provide resources to households headed 
     by an individual who is caring for one or more AIDS 
     orphans''.

  Mrs. BOXER. Mr. President, I feel very badly about what we are doing 
tonight. We are passing an inferior bill that was passed by the other 
body so that the President can hold in his hand a piece of AIDS 
legislation. How better it would be if it were a fine piece of 
legislation, if it were a more thoughtful piece of legislation, if it 
were a more effective piece of legislation.
  But the fix is in. All amendments are being voted down because of the 
President's schedule. Well, I didn't get elected from the largest State 
in the Union, that has been fighting the AIDS epidemic ever since 
Senator Feinstein was a mayor and I was on the county board of 
supervisors, to rush through something like this. I think it is really 
very sad that we are being governed by the schedule of the executive 
branch.
  I want to tell you very quickly what my amendment does. It restores a 
focus on AIDS orphans. You cannot think of anything more tragic. AIDS 
orphans were the focus of the bills that passed the Senate before. They 
are no longer the focus. More than 10 million children have been 
orphaned by AIDS. It is estimated that, by the year 2010, there will be 
over 40 million children left orphaned by this horrendous disease. That 
is a population so large that it is more than California's 37 million 
residents. It is 8 Wisconsins or 70 North Dakotas. You get the point. 
In the vast majority of cases, single women and young girls, 16 years 
old, 17 years old, 15 years old, are taking responsibility for the care 
of these orphaned children. Just read about it. It is heartbreaking.
  All my amendment says is that a specific plan will be developed by 
the AIDS coordinator and implemented to provide resources, especially 
to households headed by an individual who is caring for one or more 
AIDS orphans.
  This bill is silent on this point. We do nothing specific about this. 
This bill is vague. Even though you have committed to vote against 
everything, it will take only 2 minutes for the President to call Tom 
DeLay and say: Help the orphans, vote for this amendment. I hope we 
will all vote aye.
  The PRESIDING OFFICER. Who yields time?
  Mr. LUGAR. Mr. President, I am unfamiliar with the amendment of the 
distinguished Senator from California. I have listened carefully to her 
argument, and obviously the bill before us addresses the needs of women 
and orphans in a great number of places. I must argue again, I suspect 
that the best in this case should not be the enemy of the better.
  We have a bill here that I believe is sound on these issues. As we 
have admitted again and again, each one of us might perfect it in 
various ways. The distinguished Senator from California is attempting 
to do so now. But I encourage Senators to vote against the amendment 
for the same reasons I have encouraged Senators to vote against each of 
the perfecting amendments--realizing that each one of us, in the event 
we were to write the bill, could do better. But we have two bodies 
working on a procedure whereby we are on the threshold of having a 
significant breakthrough for the people we are attempting to assist and 
save.
  The Senator has made an eloquent case for why we ought to have action 
now and ought to encourage other countries to join us. I ask Senators, 
once again, to oppose the Boxer amendment.
  The PRESIDING OFFICER. Who yields time?
  Mrs. BOXER. I yield back the remainder of my time.
  Mr. LUGAR. We yield back our time.
  Mrs. BOXER. I ask for the yeas and nays.
  The PRESIDING OFFICER. Is there a sufficient second?
  There is a sufficient second.
  The question is on agreeing to amendment No. 684. The clerk will call 
the roll.
  The legislative clerk called the roll.
  Mr. McCONNELL. I announce that the Senator from New Mexico (Mr. 
Domenici) is necessarily absent.
  Mr. REID. I announce that the Senator from West Virginia (Mr. Byrd), 
the Senator from Hawaii (Mr. Inouye), the Senator from Massachusetts 
(Mr. Kerry), and the Senator from Louisiana (Ms. Landrieu) are 
necessarily absent.
  I further announce that, if present and voting, the Senator from 
Massachusetts (Mr. Kerry) would vote ``aye.''
  The result was announced--yeas 45, nays 50, as follows:

                      [Rollcall Vote No. 182 Leg.]

                                YEAS--45

     Akaka
     Baucus
     Bayh
     Biden
     Bingaman
     Boxer
     Breaux
     Campbell
     Cantwell
     Carper
     Clinton
     Conrad
     Corzine
     Daschle
     Dayton
     Dodd
     Dorgan
     Durbin
     Edwards
     Feingold
     Feinstein
     Graham (FL)
     Harkin
     Hollings
     Jeffords
     Johnson
     Kennedy
     Kohl
     Lautenberg
     Leahy
     Levin
     Lieberman
     Lincoln
     Mikulski
     Murray
     Nelson (FL)
     Nelson (NE)
     Pryor
     Reed
     Reid
     Rockefeller
     Sarbanes
     Schumer
     Stabenow
     Wyden

                                NAYS--50

     Alexander
     Allard
     Allen
     Bennett
     Bond
     Brownback
     Bunning
     Burns
     Chafee
     Chambliss
     Cochran
     Coleman
     Collins
     Cornyn
     Craig
     Crapo
     DeWine
     Dole
     Ensign
     Enzi
     Fitzgerald
     Frist
     Graham (SC)
     Grassley
     Gregg
     Hagel
     Hatch
     Hutchison
     Inhofe
     Kyl
     Lott
     Lugar
     McCain
     McConnell
     Miller
     Murkowski
     Nickles
     Roberts
     Santorum
     Sessions
     Shelby
     Smith
     Snowe
     Specter
     Stevens
     Sununu
     Talent
     Thomas
     Voinovich
     Warner

                             NOT VOTING--5

     Byrd
     Domenici
     Inouye
     Kerry
     Landrieu
  The amendment (No. 684) was rejected.
  Mr. LUGAR. Mr. President, I move to reconsider the vote.
  Mr. LEAHY. I move to lay that motion on the table.
  The motion to lay on the table was agreed to.
  The PRESIDING OFFICER. The Senator from Connecticut.


                           Amendment No. 685

  Mr. DODD. Mr. President, I send an amendment to the desk and ask for 
its immediate consideration.
  The PRESIDING OFFICER. The clerk will report.
  The assistant legislative clerk read as follows:

       The Senator from Connecticut [Mr. Dodd] proposes an 
     amendment numbered 685.

  Mr. DODD. Mr. President, I ask unanimous consent that the reading of 
the amendment be dispensed with.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The amendment is as follows:

   (Purpose: To add CARICOM Countries and the Dominican Republic to 
                 Priority List of HIV/AIDS Coordinator)

       On page 31, line 19, insert the following after the second 
     comma on that line:

[[Page 11830]]

       ``Antigua and Barbuda, the Bahamas, Barbados, Belize, 
     Dominica, Grenada, Jamaica, Montserrat, St. Kitts and Nevis, 
     St. Vincent and the Grenadines, St. Lucia, Suriname, Trinidad 
     and Tobago, Dominican Republic,''

  Mr. DODD. Mr. President, I apologize to my colleagues. I know it is 
now after 1 in the morning. People are tired. It has been a long day. I 
have great respect for this institution and do not normally like to 
test the patience of my colleagues, but as tired as all of us are at 
this very hour, there are some 250,000 orphans right now, 80,000 of 
whom live in the Caribbean, who are orphaned because their families, 
their parents, contracted AIDS.
  There are half a million people in the 14 CARICOM countries who will 
not be included as a part of this bill, for reasons that have never 
been explained adequately to me, who are suffering a lot more than just 
fatigue tonight because they will not get the kinds of medicines and 
support they deserve.
  I apologize for raising an amendment that is brought up at a late 
hour. I am sorry we are not going to be here tomorrow to debate some of 
these issues. The decision to be here at this hour is certainly not 
that of those who are offering these amendments.
  This is a very important bill. I have great respect for the 
President, who has made this an important issue, who wants to bring it 
up and see to it that these issues can be debated when he goes to the 
G-8.
  My amendment simply says that for the countries that suffer the 
second largest incidents of AIDS in the world, the Caribbean countries 
where 10 million American tourists go every year, ought to be included 
as part of this package.
  I do not think our colleagues in the House of Representatives, 
Democrats or Republicans, would reject this legislation because we add 
14 countries where 5 million people live, where half a million people 
are suffering from AIDS, second only to that of sub-Saharan Africa. If 
they would object to the bill on that grounds, I do not understand 
this. Yet we have excluded all but two countries from being recipients 
of this aid. So my amendment merely says we ought to include these 
countries as part of this package.
  The average age of death in the Caribbean countries is 45 years of 
age. Twenty-five percent of all hospital beds in these Caribbean 
countries are now filled with people infected by AIDS. Few of these 
patients receive any treatment at all. The mother-to-child 
transmissions are the highest in the Americas. The AIDS epidemic has 
already left 80,000 orphans in these Caribbean countries. Globally, 
half of all infected are in children between the ages of 15 and 24, 
except in the Caribbean. There it is, 10 years of age.
  I know it is late, but it is getting later for these kids. It is 
getting a lot later for them. So I am asking my colleagues in the 
Senate to ask our colleagues in the House to accept an amendment that 
would include people who live only a few minutes from our shores, who 
deserve a little more than they are getting tonight. If you are a 10-
year-old child and you are suffering from AIDS, you are one of 80,000 
orphans in the Caribbean and you deserve better than being told that 
this bill cannot be changed, not one dot, not one comma, not one word.
  I know in fact this bill will be changed before we leave tonight. So 
the argument somehow that we cannot do this is specious. We ought to be 
doing better than that. We are the Senate. We are dealing with a 
critically important global issue. It deserves more of our time, 
attention, and concern than the argument that we are fatigued and 
tired, that we do not have the patience to go back to our colleagues in 
the House and say we can do better. I urge my colleagues to support 
this amendment. It is not asking too much to say to half a million 
people who are a few miles from our shore that we want to include them 
as part of this effort to make this world a better and safer place. I 
urge its adoption.
  Mr. BIDEN. Mr. President, how much time is remaining?
  The PRESIDING OFFICER. The Senator has 6 minutes.
  Mr. BIDEN. Will the Senator yield?
  Mr. DODD. I will be happy to yield.
  Mr. BIDEN. Mr. President, I, quite frankly, not only agree with every 
point the Senator has made, but, quite frankly, I have not heard a more 
compelling case, a more logical case, and a more--how can I say it?--
reasoned indictment of our failure to be willing to confront the House 
with what I cannot believe, particularly if the President said he 
supported this, that we would not be able to get it done.
  It is true that I believe the House is willing to accept some changes 
in this bill. The fact is, as the Senator knows, the bill we had did 
exactly what he is talking about providing for these folks.
  Even though everyone says there is no possibility of anything being 
accepted beyond this, I find it hard to believe, if this body, which 
passed this before, which unanimously said this made sense, and a 
President who says he is overwhelmingly concerned not only about AIDS 
worldwide but about our Latin American friends to our south--remember, 
he started his whole initiative in foreign policy; he was looking in 
this hemisphere south.
  I realize everyone thinks this would not happen, many think this 
would not occur, but it is clearly worth taking a chance. I am willing 
to bet, if it passes, it gets accepted. I cannot imagine it being 
turned down. I cannot imagine the President of the United States saying 
he would not accept this amendment.
  All these amendments have been important, but there is simply no 
logic whatever--none--to refuse this amendment.
  I yield the floor.
  Mr. DODD. I am prepared to yield back my time.
  Mr. GRAHAM of Florida. I would like to add to your comments and those 
of Senator Biden that we have talked mainly this evening about the 
humanitarian aspects of this issue.
  If I could bring it a little closer to home, in large part because of 
the health care conditions in the Caribbean, my State has suffered from 
time to time outbreaks of tuberculosis and other serious diseases. We 
now have a significant percentage infected with HIV. These are not 
5,000 miles away; they are just a few minutes away.
  We have a very direct national interest in arresting this problem, 
preventing its outbreak in the future, and therefore protecting the 
people of the United States. I hope this amendment will be adopted. It 
not only is the right thing to do for the people involved, it is the 
right thing to do for our people involved.
  Mr. LUGAR. Mr. President, I will make a short comment and yield to my 
distinguished colleague from Pennsylvania.
  I point out, without for a moment arguing with the distinguished 
Senator from Connecticut about the urgency of Latin America, our 
friends right here in the Caribbean, that the language of the bill with 
regard to the United States coordinator does list 14 countries, but it 
also then has these words: ``and other countries designated by the 
President.''
  It appears to me this language is fairly flexible. It might have been 
better if all of the countries had been listed, but it does enumerate 
the Latin American countries that the Senator from Connecticut has 
pointed to and gives the power of the President to designate other 
countries.
  I yield to the distinguished Senator from Pennsylvania and then the 
distinguished Senator from Kansas.
  Mr. SPECTER. I have not spoken on this bill. From my experience, I 
know that few, if any minds, are changed by speeches. But I think it is 
important to note that we are not fatigued. We have almost 100 Senators 
on the floor. We have been here since 9:15, but we are robust and we 
are able to take on the country's business and we are not fatigued. We 
will give ample consideration to any amendments which anyone seeks to 
offer.
  But it ought to be a point of focus that it is possible--barely, but 
possible--that somebody might be watching these proceedings on C-SPAN. 
And you might think those who are voting against these amendments are 
hard-hearted. But the fact is that unless we pass a bill, a clean bill, 
a virtually

[[Page 11831]]

clean bill, what is agreed to by the House, this bill is not going to 
be ready when the President has to make a very important international 
trip. The President will be carrying a legislative package of $15 
billion. That is a hefty sum of money and can go a long way on this 
hideous disease. With that kind of a package, the President will be in 
a position to leverage and get funds from other countries.
  I certainly agree with the Senator from California who talked about 
prevention. I certainly agree it would be good to cover more children. 
It would be good to have lower prices. It would be good to have an 
explicit coverage to the Caribbean, although as the Senator from 
Indiana pointed out, there is flexibility to do that.
  When we vote against these amendments, it is not because we do not 
think they are good or that we are in a hurry or we are fatigued. We 
are focused. But the principal objective is to get it passed and get it 
signed.
  People ought to know, if they have not seen the beltway scene, that 
relations between the Senate and the House are not too good. If we put 
a lot of amendments on this bill, nothing will happen. We ought to get 
on with it. Fifteen billion is significant. It will really go to the 
heart of the matter. And then it can be revisited at a later time.
  The PRESIDING OFFICER. The Senator from Kansas.
  Mr. BROWNBACK. Mr. President, the hour is late and I point out to my 
colleagues, I am told this is the 36th vote of the day. According to 
some, that is a record for this body in a 24-hour period. This appears 
to be the last one.
  I appreciate the spirit in which this is being put forward by my 
colleague from Connecticut who has a lot of interest and is focused on 
this region a great deal. This is coming from his heart.
  However, we can do this, and what he is asking for, under this bill 
as it is. What is in this bill would provide that opportunity to do it. 
Really, by his raising this, it will elevate the focus, the 
possibilities in the Caribbean.
  I read directly from the bill, ``directly approving all activities of 
the United States relating to combating HIV/AIDS,'' and it lists some 
14 countries. Then it says ``and other countries designated by the 
President.''
  I hope the facts he has put forward tonight will be considered by the 
administration. I believe they will be in combating this and we would 
use the funds--this is a large portfolio of funds we put forward, $15 
billion--to focus and get results. We are on the edge of accomplishing 
something historic, of helping a lot, and we can do what our colleague 
from Connecticut says under the plain language of this bill.
  I hope we can go ahead and vote on this.
  I yield the floor.
  Mr. DODD. I am happy to yield.
  Mr. LEAHY. Mr. President, we want to get this bill off to the 
President so he will have it when he goes abroad. I agree with that, 
although I don't think that was a reason for opposing the amendments 
that were offered tonight. We could have passed those amendments, gone 
to conference with the House, and sent this bill to the President in 
plenty of time. But that was not what the majority wanted. They wanted 
to rubber stamp the House bill, despite its defects which were obvious 
to everyone.
  Let's be realistic about what is going on here.
  This is an authorization bill. It does not actually appropriate one 
dime. The President will be taking a promise when he goes abroad, 
nothing more. In fact, his budget request for 2004 does not include the 
amount authorized in this bill that people have been talking about. Not 
only that, while this bill authorizes $1 billion for the Global Fund to 
Fight AIDS, TB and Malaria, the President's 2004 budget includes only 
$200 million for the Global Fund, a $150 million cut from last year.
  And not only does this bill not appropriate any money, his 2004 
budget would cut many other global health programs. It would cut 
funding for child survival and maternal health by 12 percent. It would 
cut funding for programs to protect vulnerable children by 63 percent. 
It would cut programs to combat other infectious diseases--diseases 
which kill millions of children each year, by 32 percent. I wonder how 
many Senators know this.
  So I hope that soon after the President signs this bill he will send 
us a budget amendment for the rest of the $3 billion authorized here 
that is missing from his 2004 budget request.
  I hope he also asks for the funds to replace the cuts his budget 
makes in other global health programs. Because those cuts are going to 
mean fewer children will be vaccinated against measles and polio, and 
fewer pregnant women will have access to medical care. Each year, over 
half a million women die needlessly from pregnancy related causes. 
There are real consequences to cutting these programs.
  Mr. LUGAR. Mr. President, I am prepared to yield back time on our 
side. Before doing so, may I clarify with the Chair that the only two 
remaining amendments are to be offered by the distinguished Senator 
from New York, Senator Clinton, and the distinguished Senator from 
Delaware, Senator Biden, and that these will have voice votes at the 
conclusion of the two amendments, and then we will have final passage 
on a voice vote. Is that interpretation correct?
  The PRESIDING OFFICER. There were other amendments authorized, 
amendments by Senators Lautenberg, Leahy, and Landrieu.
  Mr. LUGAR. Mr. President, I ask unanimous consent the only two 
remaining amendments be amendments of Senator Clinton and Senator 
Biden, with voice votes to follow, and a voice vote on final passage.
  The PRESIDING OFFICER. The Senator from Vermont.
  Mr. LEAHY. Reserving the right to object, and I shall not, I will 
withhold my amendment.
  Mr. LUGAR. I thank the Senator.
  The PRESIDING OFFICER. Is there objection? Without objection, it is 
so ordered.
  Mr. DODD. I appreciate the comments of the chairman of the committee 
about the discretion of the President and, certainly, going on record 
as this being important, that additional countries are to be included 
as part of this package.
  I ask unanimous consent a letter signed by the Ambassadors of all 
these countries asking these nations be included as part of this bill 
be printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                                                     May 14, 2003.
     President George Bush,
     The White House,
     Washington, DC.
       Dear Mr. President: Addressing the AIDS pandemic in the 
     Caribbean has been a major concern of the Caribbean Community 
     of countries (CARICOM), we therefore commend your efforts to 
     address the AIDS epidemic in the Caribbean through your 
     Emergency Plan for AIDS Relief. We are writing however, 
     because we believe that a more inclusive approach to 
     addressing AIDS in the region is needed, which is why we are 
     requesting that you expand your initiative to include all 
     Caribbean countries in the region.
       As you know, the number of HIV/AIDS infection rates in the 
     Caribbean is only surpassed by that of sub-Saharan Africa. In 
     fact, prevalence rates in the Caribbean region are similar to 
     what they were in sub-Saharan Africa prior to the explosion 
     of the virus in the general population.
       Like you, we're greatly concerned about the AIDS crisis in 
     the Caribbean and realize that aid from international donors 
     such as the U.S. is necessary if we are to address the 
     crisis. The slumping tourism industry has negatively affected 
     our already weakened economies, making it difficult for our 
     countries to provide resources that will adequately address 
     the AIDS epidemic. Inadequate funding is then increasingly 
     putting us at-risk for the further spread of the epidemic to 
     the general population commensurate with current prevalence 
     rates in sub-Saharan Africa.
       We realize that high prevalence rates can overwhelm our 
     health care capacity, destabilize our economies, and increase 
     migration flow--which could pose a real security risk for the 
     U.S. due to its proximity to the Caribbean. It is for these 
     reasons that we are interested in supporting approaches to 
     fighting the AIDS epidemic that fully take into consideration 
     our special circumstances on the Caribbean.
       Our AIDS epidemic is driven by heterosexual contact and a 
     mobile population. For

[[Page 11832]]

     example, over 10 million persons from the U.S. visit the 
     Caribbean annually. Population movements between the U.S. and 
     the Caribbean for business purposes and tourism, including 
     large numbers of U.S. and Caribbean students moving back and 
     forth for study and leisure purposes, argue strongly for an 
     inclusive approach to combating AIDS in the Caribbean.
       As such, our own AIDS initiatives have been developed in 
     response to the high mobility of the region. For example, the 
     Pan Caribbean AIDS Partnership, administered through CARICOM 
     is a collaboration between Caribbean countries, Caribbean 
     regional institutions, and international agencies that work 
     together to fight AIDS across the region. Similarly, programs 
     implemented by your government have also taken regional 
     approaches. USAID administers AIDS initiatives in the 
     Dominican Republic, Guyana, Haiti, Jamaica, and through the 
     Caribbean Regional Program, which is a Caribbean wide program 
     that targets countries where USAID does not have a presence.
       Because a regional approach is crucial to addressing the 
     AIDS epidemic in our highly mobile population, we are 
     requesting that you expand under your Emergency AIDS 
     Initiative to the entire Caribbean region. Expansion of the 
     program would allow for your initiative to include countries 
     such as the Bahamas, which has an adult AIDS prevalence rate 
     of 3.5 percent, and Trinidad and Tobago and the Dominican 
     Republic who are suffering with prevalence rates of 2.5 
     percent. Additionally, countries such as Barbados and Jamaica 
     with AIDS rates approaching 2 percent could receive funding 
     for prevention efforts.
       Without a regional approach to the Caribbean AIDS crisis, 
     we fear that AIDS will lower life expectancy, increase the 
     number of AIDS orphans, further threaten our already fragile 
     economies, increase migration flow out of the region, and 
     increase the threat to the U.S.
       We therefore hope that you will seriously consider our 
     request to include the entire Caribbean in your Emergency 
     AIDS Relief Initiative.
           Sincerely,
         Lionel Hurst, Ambassador of Antigua and Barbuda. Joshua 
           Sears, Ambassador of Bahamas. Michael King, Ambassador 
           of Barbados. Lisa M. Shoman, Ambassador of Belize. 
           Denis G. Antoine, Ambassador of Grenada. M.A. Odeen 
           Ishmael, Ambassador of Guyana. Seymour Mullings, 
           Ambassador of Jamaica. Izben Williams, Ambassador of 
           St. Kitts and Nevis. Elsworth John, Ambassador of St. 
           Vincent and the Grenadines. Sonia Johnny, Ambassador of 
           St. Lucia. Henry Lothar Illes, Ambassador of Suriname. 
           Marina Annette Valere, Ambassador of Trinidad and 
           Tobago. Harry Franz Leo, Minister Counsellor, Charge d' 
           Affaire a.i., of Haiti.

  Mr. DODD. Mr. President, I ask for the yeas and nays on my amendment.
  The PRESIDING OFFICER. Is there a sufficient second?
  There is a sufficient second.
  The yeas and nays were ordered.
  The PRESIDING OFFICER. Is all time yielded back? All time is yielded 
back.
  The majority leader is recognized.


                                Schedule

  Mr. FRIST. Mr. President, in regard to the schedule, as mentioned, 
the votes as outlined will be planned for the remainder of the evening. 
The vote we are about to have will be the last rollcall vote of the 
evening. I thank all Members for their patience. We have been here 
about 17 hours of consecutive voting.
  The Senate will not be in session tomorrow. We will return for 
business on Monday.
  Mr. REID. We won't be in session today.
  Mr. FRIST. That's right, we will not be in session later today. We 
will return for business on Monday.
  On Monday, the Senate will begin consideration of the Department of 
Defense authorization bill. The next rollcall vote will occur at 5:30 
on Monday.
  Again, this will be the last rollcall vote of the morning.
  The PRESIDING OFFICER. The question is on agreeing to the amendment. 
The yeas and nays have been ordered. The clerk will call the roll.
  The assistant legislative clerk called the roll.
  Mr. McCONNELL. I announce that the Senator from New Mexico (Mr. 
Domenici) is necessarily absent.
  Mr. REID. I announce that the Senator from West Virginia (Mr. Byrd), 
the Senator from Hawaii (Mr. Inouye), the Senator from Massachusetts 
(Mr. Kerry) and the Senator from Louisiana (Ms. Landrieu) are 
necessarily absent.
  I further announce that, if present and voting, the Senator from 
Massachusetts (Mr. Kerry) would vote ``aye''.
  The result was announced--yeas 44, nays 51, as follows:

                      [Rollcall Vote No. 183 Leg.]

                                YEAS--44

     Akaka
     Baucus
     Bayh
     Biden
     Bingaman
     Boxer
     Breaux
     Cantwell
     Carper
     Clinton
     Conrad
     Corzine
     Daschle
     Dayton
     Dodd
     Dorgan
     Durbin
     Edwards
     Feingold
     Feinstein
     Graham (FL)
     Harkin
     Hollings
     Jeffords
     Johnson
     Kennedy
     Kohl
     Lautenberg
     Leahy
     Levin
     Lieberman
     Lincoln
     Mikulski
     Murray
     Nelson (FL)
     Nelson (NE)
     Pryor
     Reed
     Reid
     Rockefeller
     Sarbanes
     Schumer
     Stabenow
     Wyden

                                NAYS--51

     Alexander
     Allard
     Allen
     Bennett
     Bond
     Brownback
     Bunning
     Burns
     Campbell
     Chafee
     Chambliss
     Cochran
     Coleman
     Collins
     Cornyn
     Craig
     Crapo
     DeWine
     Dole
     Ensign
     Enzi
     Fitzgerald
     Frist
     Graham (SC)
     Grassley
     Gregg
     Hagel
     Hatch
     Hutchison
     Inhofe
     Kyl
     Lott
     Lugar
     McCain
     McConnell
     Miller
     Murkowski
     Nickles
     Roberts
     Santorum
     Sessions
     Shelby
     Smith
     Snowe
     Specter
     Stevens
     Sununu
     Talent
     Thomas
     Voinovich
     Warner

                             NOT VOTING--5

     Byrd
     Domenici
     Inouye
     Kerry
     Landrieu
  The amendment (No. 685) was rejected.
  Mr. LUGAR. I move to reconsider the vote.
  Mr. BROWNBACK. I move to lay that motion on the table.
  The motion to lay on the table was agreed to.
  The PRESIDING OFFICER. The Senator from New York is recognized.


                           Amendment No. 652

  Mrs. CLINTON. Mr. President, I call up amendment No. 652, which is at 
the desk.
  The PRESIDING OFFICER. The clerk will report.
  The legislative clerk read as follows:

       The Senator from New York [Mrs. Clinton] for herself, Mrs. 
     Boxer, Mrs. Murray, and Mr. Leahy, proposes an amendment 
     numbered 652.

  Mrs. CLINTON. Mr. President, I ask unanimous consent reading of the 
amendment be dispensed with.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The amendment is as follows:

(Purpose: To improve women's health and empowerment and reduce women's 
                       vulnerability to HIV/AIDS)

       On page 23, line 24, insert before the semicolon the 
     following: ``, including the pursuit of sexual relations with 
     adolescent girls''.
       On page 24, strike lines 2 through 4, and insert the 
     following: ``developed to address the access of women and 
     adolescent girls to employment opportunities, income, 
     education and training, productive resources, and 
     microfinance programs;''.
       On page 27, strike lines 19 through 23, and insert the 
     following:
       (W) An analysis of strategies to reduce deaths from 
     cervical cancer caused by high risk strains of human 
     papillomavirus in women over 30 living in sub-Saharan Africa.
       (X) A description of a comprehensive 5-year global AIDS 
     plan that shall be developed by the President to address 
     issue effecting, and promote specific strategies to overcome, 
     the extreme vulnerability of adolescent girls to HIV 
     infection, including self esteem, access to education, safe 
     employment and livelihood opportunities, pressures to marry 
     at an early age and bear children, and norms that do not 
     allow for safe and supportive family life and marriages.
       (Y) A description of the programs, and the number of women 
     and girls reached through these programs--
       (i) to increase women's access to currently available 
     prevention technologies and the steps taken to increase the 
     availability of such technologies;
       (ii) that provide prevention education and training for 
     women and girls;
       (iii) addressing violence and coercion; and
       (iv) increasing access to treatment.
       (Z) A description of the progress made on developing a 
     safe, effective, and user-friendly microbicide.
       On page 51, line 8, strike ``and''.
       On page 51, line 12, strike the period and insert a 
     semicolon.
       On page 51, between lines 12 and 13, insert the following:
       ``(I) assistance for programs to dramatically increase 
     women's access to currently

[[Page 11833]]

     available female-controlled prevention technologies and to 
     microbicides when these become available, and for the 
     training and skills needed to use these methods effectively;
       ``(J) assistance for research to develop safe, effective, 
     and usable microbicides;
       ``(K) assistance for programs to provide comprehensive 
     education for women and girls, including health education 
     that emphasizes skills building on negotiation and the 
     prevention of sexually transmitted infections and other 
     related reproductive health risks and strategies that 
     emphasize the delay of sexual debut;
       ``(L) assistance for strategies to prevent and address 
     gender-based violence and sexual coercion of women and 
     minors;
       ``(M) assistance to reduce the vulnerability of HIV/AIDS 
     for women, young people, and children who are refugees or 
     internally displaced persons; and
       ``(N) assistance for community-based strategies to reduce 
     the stigma faced by women affected by HIV and AIDS.
       On page 52, line 3, strike ``; and'' and insert a 
     semicolon.
       On page 52, line 10, strike the period and insert a 
     semicolon.
       On page 52, between lines 10 and 11, insert the following:
       ``(D) assistance for programs that promote equitable access 
     to treatment and care for all women, by--
       ``(i) reducing economic and social barriers faced 
     disproportionately by women;
       ``(ii) directly increase women's access to affordable 
     drugs; and
       ``(iii) providing adequate pre- and post-natal care to 
     pregnant women and mothers infected with HIV or living with 
     AIDS to prevent an increase in the number of AIDS orphans; 
     and
       ``(E) assistance to increase resources for households 
     headed by females caring for AIDS orphans.
       On page 81, after line 24, add the following:
       (9) At the United Nations Special Session on HIV/AIDS in 
     June 2001, the United States also committed itself to the 
     specific goals with respect to reducing HIV prevalence among 
     youth, as specified in the Declaration of Commitment on HIV/
     AIDS adopted by the United Nations General Assembly at the 
     Special Session.

  Mrs. CLINTON. Mr. President, I offer this amendment on my own behalf, 
along with Senators Boxer, Murray, and Leahy.
  First, I commend the leadership as well as the President for bringing 
this important issue of global HIV/AIDS to the floor this evening, 
although the hour is obviously very late.
  While I am pleased with many aspects of this bill, and the commitment 
it represents, I do believe the bill is flawed in a very important and 
fundamental respect; and that is, with regard to the treatment of and 
concern for girls and women.
  As many of us know who have traveled in Africa, the Caribbean, and 
other places where the HIV/AIDS pandemic has ravaged so many people, 
young girls, girls barely in their teens, adolescents, young women, are 
all too often the victims of this disease because of the way they are 
treated.
  I believe in abstinence. I went to Uganda in 1997. I was impressed, 
as many of my colleagues have been, by what I saw with respect to the 
program that Uganda undertook and certainly the results.
  But I am concerned that abstinence is not a prevention tool 
realistically available to many girls and women throughout Africa. So 
many of the prevention tools are controlled by men, and by customs and 
by traditions, in communities where the expectation may very well be 
for a young girl to be married at a very young age.
  In Africa, the seroprevalence for women ages 15 to 17 is five times 
the rate it is for boys of the same age. Now, why does that happen? 
Certainly the leaders in Africa who are now undertaking their own 
campaigns against HIV/AIDS are well aware of the uphill climb they 
face.
  Two years ago, Mozambique's Prime Minister, after a comprehensive 
study, found that there was an explanation for the higher rates among 
young women, and it was--and I quote him--

       Not because the girls are promiscuous, but because nearly 
     three out of five are married by age 18, [and] 40 percent of 
     them [are married] to much older, sexually experienced men, 
     who may expose their wives to HIV/AIDS. Abstinence is not an 
     option for these child brides. Those who try to negotiate 
     condom use commonly face violence or rejection.

  That is why I have offered this amendment to specifically address not 
just women's health but also women's empowerment, because empowering 
women and girls is the clearest way to give them the tools to be able 
to not only say no but to actually implement that belief.
  It is also imperative to reduce economic and other dependence, to 
combat gender discrimination and stigma, to recognize that the 
effective prevention strategies for women, who now represent the 
majority of people worldwide suffering from HIV/AIDS, must be addressed 
immediately, urgently, and with resources.
  Research shows that the most effective policies are those that 
include an understanding of the relevance and impact of the roles that 
culture and society assign men, women, boys, and girls. But the bill 
that we are considering overlooks and neglects this important aspect of 
the problem.
  Our amendment would correct that neglect by providing assistance for 
programs that increase women's access to female-controlled prevention 
technologies, including microbiocides when they become available; and 
by providing assistance for programs that improve the health education, 
and skills-building efforts for women and girls, increasing women's 
ability to protect themselves from unwanted sex, safeguarding 
themselves when they are sexually active, and reducing the stigma faced 
by women affected by HIV and AIDS.
  One of the reasons the prevalence of HIV/AIDS among younger and 
younger girls is occurring in Africa is for two interrelated causes: 
One, because many of these young girls are available, they are healthy; 
and, secondly, because there is this myth that very young girls will 
not transmit HIV. And because we do not have widespread testing, many 
of the men do not even know that they are infected.
  Thirdly, we have to recognize that gender inequality is a part of 
this epidemic. Women who lack access to education, or any kind of 
skills training, who are exposed to gender-based violence in their home 
or their larger community, who are sexually coerced or otherwise 
vulnerable, make up many of the victims that, unfortunately, suffer 
from HIV/AIDS.
  We also should be boosting women's access to pre- and postnatal care, 
and increasing resources for female-headed households caring for 
orphans and victims of AIDS, as my colleague from California, Senator 
Boxer, so eloquently argued.
  In addition, we should increase focus on other women's health 
threats, including cervical cancer, which can be caused by high-risk 
strains of human papilloma virus.
  I hope we can assure we pay particular attention to young people.
  Much of the language that is included in this amendment has already 
passed the Senate unanimously last year in S. 2525. It is not 
controversial, at least in this body.
  I understand the fast track we are on, and the fact that the majority 
does not wish to have any amendments, but I hope that when we revisit 
this, as we must, in the appropriations process--when we take the bill 
and rid it of the contradictions and the conflicts that it inherently 
has in its language--that this amendment will be accepted. It will help 
to guarantee that we address these very particular problems that affect 
women.
  When we are talking about women's health and looking at all of the 
problems women have, it is important that we not focus just on HIV/AIDS 
as though that is some separate, abstract problem that can be removed 
from cervical cancer and sexually transmitted diseases and other 
problems that women suffer from so grievously, not only in Africa but 
in many countries around the world.
  I ask the positive, affirmative support of those who remain in the 
Chamber on a voice vote for this amendment that specifically stands up 
for the girls and women of Africa in this important cause we are now 
undertaking.
  The PRESIDING OFFICER. Is there further debate on the amendment? The 
Senator from Indiana.
  Mr. LUGAR. Mr. President, the Senator from New York has made a very 
eloquent and important statement, and I appreciate it. My response has 
to be the one I have made throughout the

[[Page 11834]]

evening, and that is that it is different, and it will cause 
conference. In my judgment, there is merit in what she has to say. That 
has been true of many amendments this evening. But it is something that 
I must oppose. I am hopeful Senators will vote no on the Clinton 
amendment.
  The PRESIDING OFFICER. Is there further debate on the amendment?
  If not, the question is on agreeing to amendment No. 652.
  The amendment (No. 652) was rejected.
  Mr. LUGAR. Mr. President, I move to reconsider the vote.
  Mr. BROWNBACK. I move to lay that motion on the table.
  The motion to lay on the table was agreed to.
  Mr. BIDEN. Mr. President, 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. BIDEN. Mr. President, I ask unanimous consent that the order for 
the quorum call be rescinded.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. BIDEN. Mr. President, I understand the regular order is that my 
amendment on debt relief would be in order now.
  The PRESIDING OFFICER. The Senator is correct.


                           Amendment No. 686

  Mr. BIDEN. Mr. President, the hour is extremely late. The bottom line 
of this is that this provides for debt relief for the very countries we 
are trying to help with AIDS. They are swamped by debt. It is 
legislation that we have been through before. My staff and I sat with 
the White House, the National Security Agency. We sat down with the 
White House today, the National Security Agency representative for 
hours. We negotiated the exact language.
  I send the amendment to the desk and ask for its immediate 
consideration.
  The PRESIDING OFFICER. The clerk will report.
  The legislative clerk read as follows:

       The Senator from Delaware [Mr. Biden], for himself and Mr. 
     Leahy, proposes an amendment numbered 686.

  (Purpose: To amend the International Financial Institutions Act to 
    provide for modification of the Enhanced Heavily Indebted Poor 
                      Countries (HIPC) Initiative)

         At the end of the bill, insert the following:
             TITLE V--INTERNATIONAL FINANCIAL INSTITUTIONS

     SEC. 501. MODIFICATION OF THE ENHANCED HIPC INITIATIVE.

       Title XVI of the International Financial Institutions Act 
     (22 U.S.C. 262p--262p-7) is amended by adding at the end the 
     following new section:

     ``SEC. 1625. MODIFICATION OF THE ENHANCED HIPC INITIATIVE.

       ``(a) Authority.--
       ``(1) In general.--The Secretary of the Treasury should 
     immediately commence efforts within the Paris Club of 
     Official Creditors, the International Bank for Reconstruction 
     and Development, the International Monetary Fund, and other 
     appropriate multilateral development institutions to modify 
     the Enhanced HIPC Initiative so that the amount of debt stock 
     reduction approved for a country eligible for debt relief 
     under the Enhanced HIPC Initiative shall be sufficient to 
     reduce, for each of the first 3 years after the date of 
     enactment of this section or the Decision Point, whichever is 
     later--
       ``(A) the net present value of the outstanding public and 
     publicly guaranteed debt of the country, (i) as of the 
     decision point if the country has already reached its 
     decision point, or (ii) as of the date of Enactment of this 
     Act, if the country has not reached its decision point, to 
     not more than 150 percent of the annual value of exports of 
     the country for the year preceding the Decision Point; and
       ``(B) the annual payments due on such public and publicly 
     guaranteed debt to not more than--
       ``(i) 10 percent or, in the case of a country suffering a 
     public health crisis (as defined in subsection (e)), not more 
     than 5 percent, of the amount of the annual current revenues 
     received by the country from internal resources; or
       ``(ii) a percentage of the gross national product of the 
     country, or another benchmark, that will yield a result 
     substantially equivalent to that which would be achieved 
     through application of subparagraph (A).
       ``(2) Limitation.--In financing the objectives of the 
     Enhanced HIPC Initiative, an international financial 
     institution shall give priority to using its own resources.
       ``(b) Relation to Poverty and the Environment.--Debt 
     cancellation under the modifications to the Enhanced HIPC 
     Initiative described in subsection (a) should not be 
     conditioned on any agreement by an impoverished country to 
     implement or comply with policies that deepen poverty or 
     degrade the environment, including any policy that--
       ``(1) implements or extends user fees on primary education 
     or primary health care, including prevention and treatment 
     efforts for HIV/AIDS, tuberculosis, malaria, and infant, 
     child, and maternal well-being;
       ``(2) provides for increased cost recovery from poor people 
     to finance basic public services such as education, health 
     care, clean water, or sanitation;
       ``(3) reduces the country's minimum wage to a level of less 
     than $2 per day or undermines workers' ability to exercise 
     effectively their internationally recognized worker rights, 
     as defined under section 526(e) of the Foreign Operations, 
     Export Financing and Related Programs Appropriations Act, 
     1995 (22 U.S.C. 262p-4p); or
       ``(4) promotes unsustainable extraction of resources or 
     results in reduced budget support for environmental programs.
       ``(c) Conditions.--A country shall not be eligible for 
     cancellation of debt under modifications to the Enhanced HIPC 
     Initiative described in subsection (a) if the government of 
     the country--
       ``(1) has an excessive level of military expenditures;
       ``(2) has repeatedly provided support for acts of 
     international terrorism, as determined by the Secretary of 
     State under section 6(j)(1) of the Export Administration Act 
     of 1979 (50 U.S.C. App. 2405(j)(1)) or section 620A(a) of the 
     Foreign Assistance Act of 1961 (22 U.S.C. 2371(a));
       ``(3) is failing to cooperate on international narcotics 
     control matters; or
       ``(4) engages in a consistent pattern of gross violations 
     of internationally recognized human rights (including its 
     military or other security forces).
       ``(d) Programs To Combat HIV/AIDS and Poverty.--A country 
     that is otherwise eligible to receive cancellation of debt 
     under the modifications to the Enhanced HIPC Initiative 
     described in subsection (a) may receive such cancellation 
     only if the country has agreed--
       ``(1) to ensure that the financial benefits of debt 
     cancellation are applied to programs to combat HIV/AIDS and 
     poverty, in particular through concrete measures to improve 
     basic services in health, education, nutrition, and other 
     development priorities, and to redress environmental 
     degradation;
       ``(2) to ensure that the financial benefits of debt 
     cancellation are in addition to the government's total 
     spending on poverty reduction for the previous year or the 
     average total of such expenditures for the previous 3 years, 
     whichever is greater;
       ``(3) to implement transparent and participatory 
     policymaking and budget procedures, good governance, and 
     effective anticorruption measures; and
       ``(4) to broaden public participation and popular 
     understanding of the principles and goals of poverty 
     reduction.
       ``(e) Definitions.--In this section:
       ``(1) Country suffering a public health crisis.--The term 
     `country suffering a public health crisis' means a country in 
     which the HIV/AIDS infection rate, as reported in the most 
     recent epidemiological data for that country compiled by the 
     Joint United Nations Program on HIV/AIDS, is at least 5 
     percent among women attending prenatal clinics or more than 
     20 percent among individuals in groups with high-risk 
     behavior.
       ``(2) Decision point.--The term `Decision Point' means the 
     date on which the executive boards of the International Bank 
     for Reconstruction and Development and the International 
     Monetary Fund review the debt sustainability analysis for a 
     country and determine that the country is eligible for debt 
     relief under the Enhanced HIPC Initiative.
       ``(3) Enhanced hipc initiative.--The term `Enhanced HIPC 
     Initiative' means the multilateral debt initiative for 
     heavily indebted poor countries presented in the Report of G-
     7 Finance Ministers on the Cologne Debt Initiative to the 
     Cologne Economic Summit, Cologne, June 18-20, 1999.''.

     SEC. 502. REPORT ON EXPANSION OF DEBT RELIEF TO NON-HIPC 
                   COUNTRIES.

       (a) In General.--Not later than 90 days after the date of 
     enactment of this Act, the Secretary of the Treasury shall 
     submit to Congress a report on--
       (1) the options and costs associated with the expansion of 
     debt relief provided by the Enhanced HIPC Initiative to 
     include poor countries that were not eligible for inclusion 
     in the Enhanced HIPC Initiative;
       (2) options for burden-sharing among donor countries and 
     multilateral institutions of costs associated with the 
     expansion of debt relief; and
       (3) options, in addition to debt relief, to ensure debt 
     sustainability in poor countries, particularly in cases when 
     the poor country has suffered an external economic shock or a 
     natural disaster.
       (b) Specific Options To Be Considered.--Among the options 
     for the expansion of debt relief provided by the Enhanced 
     HIPC Initiative, consideration should be given to making 
     eligible for that relief poor countries for

[[Page 11835]]

     which outstanding public and publicly guaranteed debt 
     requires annual payments in excess of 10 percent or, in the 
     case of a country suffering a public health crisis (as 
     defined in section 1625(e) of the Financial Institutions Act, 
     as added by section 501 of this Act), not more than 5 
     percent, of the amount of the annual current revenues 
     received by the country from internal resources.
       (c) Enhanced HIPC Initiative Defined.--In this section, the 
     term ``Enhanced HIPC Initiative'' means the multilateral debt 
     initiative for heavily indebted poor countries presented in 
     the Report of G-7 Finance Ministers on the Cologne Debt 
     Initiative to the Cologne Economic Summit, Cologne, June 18-
     20, 1999.

     SEC. 503. AUTHORIZATION OF APPROPRIATIONS.

       (a) In General.--There are authorized to be appropriated to 
     the President such sums as may be necessary for the fiscal 
     year 2004 and each fiscal year thereafter to carry out 
     section 1625 of the International Financial Institutions Act, 
     as added by section 501 of this Act.
       (b) Availability of Funds.--Amounts appropriated pursuant 
     to subsection (a) are authorized to remain available until 
     expended.

  Mr. BIDEN. Mr. President, as we consider legislation today on the 
global epidemic of HIV/AIDS, I urge my colleagues to think about this: 
While the poorest nations of the world lack the resources to provide 
the most basic public health care and the most basic education, they 
still send money to the international financial institutions 
established by the wealthiest nations of the world.
  The 26 countries currently qualified to receive debt relief under the 
heavily indebted poor country--HIPC--program continue to pay more than 
$2 billion annually on debt service.
  That money goes to the World Bank and the International Monetary Fund 
here in Washington, as well as other lenders, to pay the interest on 
loans they have received over the years.
  Unless we act now on this HIV/AIDS bill to reduce that debt burden, 
we run the real risk that the resources we are providing them today 
will find their way back, not only to Washington, but to other lenders, 
such as France, Germany, and Japan.
  Deeper debt relief for those poor countries is essential to make the 
work we are doing on this HIV/AIDS legislation as effective as 
possible, and to make sure that funds do not leak out through the 
mandatory spending these countries must do to service their debts every 
year.
  Money is money and the problem of these debt payments is very real 
for these poor countries. As long as they face these mandatory debt 
payments, the resources we are providing in this HIV/AIDS bill will be 
less effective.
  But deeper debt relief is also needed because the current HIPC 
Program is not working.
  In fact, last year the Bank and the fund honestly admitted that under 
the current formula, many countries will simply not reach a sustainable 
level of debt.
  The amendment I am offering tonight aims to make the HIPC Program 
itself more likely to succeed.
  It is essentially the legislation Senator Santorum and I introduced 
in the last Congress, with the support of Senators Frist, Nickles, 
Chafee, DeWine, and Specter on the majority side, along with Senators 
Kerry and Sarbanes, Feingold, Murray, and others on this side of the 
aisle.
  Specifically, for the many countries facing a public health crisis--
such as the HIV/AIDS epidemic--we say that no more than 5 percent of 
their revenues should go to service their debt to other nations and 
international institutions.
  For those who do not face such a crisis, debt service should exceed 
no more than 10 percent of their budget.
  Some debate remains about the most appropriate way to measure a 
country's ability to pay its debt and still provide basic public goods 
in the areas of health, education, and infrastructure.
  So our amendment gives the administration the flexibility to find an 
alternative measure that would achieve an equivalent level of debt 
reduction--a level that these poor countries can sustain.
  Only countries that quality for the existing HIPC Program--that sets 
standards of economic reform and human rights--will participate.
  The bottom line is that unless the U.S. and our G-7 partners reduce 
debt service payment to manageable levels--no more than 10 percent of 
Government revenue, 5 percent if the country has a major health 
crisis--these nations will be unable to devote the necessary resources 
to the fight against HIV/AIDS.
  This amendment was part of the HIV/AIDS bill that passed the Senate 
last year. It belongs on this legislation, too.
  Although there is some confusion about how we got there, I believe in 
retrospect the chairman, quite frankly, unknown to me, was not brought 
into the loop on this. I assure him the reason I agreed to a voice vote 
is because we had every Democrat, and I believe from personal 
discussion we had at least four Republicans supporting the amendment. I 
understand, without getting into all the detail, the bottom line is the 
amendment has been signed off on by the White House in direct 
discussions with my staff this afternoon. I would move the adoption of 
the amendment.
  I ask for a voice vote.
  The PRESIDING OFFICER. The Senator from Utah is recognized.
  Mr. BENNETT. Mr. President, I would like to ask the distinguished 
ranking member of the Foreign Relations Committee if he knows--and I 
see the majority leader here and I will ask him the same question--if 
the House of Representatives has indicated they would accept this 
amendment? I have been standing shoulder to shoulder with the chairman 
of the full committee all night, voting against every amendment on the 
basis that the House would not accept an amendment.
  Now, the ranking member, Senator Biden, has said the White House has 
indicated they would accept this amendment and that is very powerful 
medicine for us. I do not want to abandon my chairman and the position 
he has taken in support of the House bill, unless I can be assured that 
on this amendment, unlike all of the others, the House leadership has 
indicated they are willing to accept it.
  I ask the ranking member and the majority leader, if either one of 
them could respond, would the House be willing, contrary to what we 
have been told about all the other amendments, to accept this 
amendment?
  Mr. BIDEN. Mr. President, I will respond to what I know firsthand. I 
can only speak firsthand to the White House. It is my understanding, 
and it has been asserted to me, that there have been discussions with 
senior Republicans--I assume that that was shared by everybody, with 
both the speaker and with Mr. DeLay, and that they had signed on to 
this. But I will respectfully suggest that I yield to Senator Santorum, 
who may be able to give you a more direct answer. I personally, for the 
record, have not spoken with anybody in the House of Representatives.
  Mr. SANTORUM. Mr. President, this amendment has been agreed to by the 
White House and has been agreed to by the Speaker and the Majority 
Leader. This, in the amended form, has been changed substantially from 
the proposal that the Senator from Delaware originally put forward. It 
is now not mandating the State Department to do anything; it is 
suggesting that they should do this.
  So it is a flexible amendment. It expresses the sentiments of this 
body, and it will express the sentiment of the House when they agree to 
this amendment as well as the underlying bill. This is an issue they 
should take seriously and give due consideration to. Both the speaker 
and the majority leader, having talked to their people in their 
respective committee jurisdictions, are comfortable with this 
language--the ``should'' language as opposed to the ``shall'' language. 
That was the main issue. Because of its advisory nature, as opposed to 
a mandatory nature, they are willing to accept it.
  Mr. BIDEN. If the Senator will yield. In addition, I agreed with the 
White House to further amend my amendment to change the effective date, 
which was a very important element to the White House. They wanted the 
original language we had in Lugar-Biden that we moved off of to go to 
the House bill, and in previous language

[[Page 11836]]

that we had in other bills, including the original bill which came out 
of the committee and passed out of here. It had language relating to 
the effective date when countries could qualify to meet the test for 
this. The White House wanted it tighter, wanted it more stringent.
  We took the better part of the afternoon, 3 or 4 hours, negotiating 
back and forth. We yielded on that point as well. That is the point at 
which the White House spokesperson from the National Security Agency 
said to us, ``We have a deal.'' That is when it then got scrubbed. That 
was even more palatable, I am told, to the speaker and the majority 
leader. That is as much as I can say firsthand.
  Mr. BENNETT. I thank the Senator. Mr. President, I had stayed here 
prepared to vote against the amendment, to vote against all amendments, 
not knowing that the Senator from Delaware had these conversations with 
people at the White House and the Senator from Pennsylvania had these 
conversations with the leadership of the House. Therefore, I feel 
released from my previous commitment to oppose all amendments when I 
discover that passage of this amendment will not only not impede 
passage of the bill--as was the case with the other amendments--it 
would in fact enhance passage of the bill on the basis that both the 
House and the White House were willing.
  So I appreciate knowing this new information. On the basis of this 
information, it will cause me to change my position. I thank the 
Senator for sharing this information with me.
  Mr. LUGAR. Mr. President, I have been listening to all of this 
information. Let me simply say that, throughout the evening, I have 
asked Senators to vote against amendments. That was based upon the 
feelings of our colleagues in the House of Representatives, who passed 
the bill--namely, my friends Henry Hyde, Tom Lantos, and likewise in 
the course of this debate, I have mentioned conversations with the 
President himself, who wanted this bill unamended so there would not be 
a need for a conference and for difficulty. I have not been apprised by 
anybody at the White House, or in the House leadership, of any other 
situation.
  I am perfectly willing to accept, on good faith, the assertions of my 
colleagues who have had these conversations. But for the sake of the 
Record, when the voice vote comes, I will vote no because I have asked 
my colleagues to vote no on each amendment. I will continue in that 
frame of mind.
  But I have listened carefully and I understand what, apparently, have 
been conversations and agreements and I appreciate that.
  I know of no reason to extend the debate, unless the majority leader 
has something.
  The PRESIDING OFFICER. The question is on agreeing to the amendment.
  The amendment (No. 686) was agreed to.


                microbicides: hiv prevention's new hope

  Mr. CORZINE. Mr. President, today we are considering landmark 
legislation to provide $15 billion to expand prevention, treatment, and 
care in the developing world to address the AIDS epidemic and other 
infectious diseases.
  We know that the heart of the global HIV epidemic is in Africa. We 
also know that the center of the epidemic in Africa is among women. 
Biologically, women are four times more vulnerable to HIV infection 
then men. And tragically, in Africa, and indeed throughout the 
developing world, it is widely understood that a woman's single 
greatest risk factor for contracting HIV is being married and 
monogamous.
  This astounding and tragic fact bears repeating: The typical woman 
who gets infected with HIV has only one partner--her husband. Women's 
vulnerability increases due to their lack of economic and social power 
in many societies, where they often cannot control sexual encounters or 
insist on protective measures such as abstinence or mutual monogamy. 
This trend devastates families and puts children at risk.
  If we pass legislation today that ignores this stark reality, we will 
be back here a few years from now, scratching our heads and wondering 
what we can do to stem the tide of infections. If we want to contain 
the epidemic, we have to help women.
  Women need HIV-prevention tools that they can control to safeguard 
their health and that of their families and communities. One of the 
most promising prevention tools is microbicides. Once developed, 
microbicides and vaccines would serve as complimentary prevention 
technologies, with microbicides giving women the power of prevention.
  It is important to emphasize that microbicides are being designed 
first and foremost to protect against infections, not necessarily 
against pregnancy. This issue has nothing to do with birth control. It 
has nothing to do with spermicide Nonoxynol-9, which prevents 
pregnancy, but not disease. Microbocides are about preventing HIV. 
Scientists are hopeful that they can develop microbicides that would 
allow women to protect themselves from this and other sexually 
transmitted diseases--while also enabling them to conceive a child.
  While the bill we are considering today acknowledges microbicides as 
a promising prevention tool, it does not go nearly far enough in 
supporting this area of research and development. I introduced 
legislation last Congress and again this session to give greater 
Federal support to microbicides research and development.
  While microbicides are not a magic bullet, once available, many 
researchers believe that could prevent millions of infections. And with 
leading scientists concluding that a vaccine is likely to be more than 
10 years away, we need to make a strong commitment to developing 
complementary prevention tools such as microbicides. Even when we get a 
vaccine or vaccines to tackler this epidemic, complementary prevention 
strategies such as microbicides will be needed for decades to come.
  Let me take a minute to review the state of the science in this 
field. Scientists are currently testing approximately 65 different 
microbicide compounds to determine whether they will help to protect 
against HIV and/or other STDs. Of these, I7 are in clinical trials that 
will assess their safety for human use, and 4 are being readied for 
large trials that will assess their effectiveness. If one of these 
leads proves successful and investment is sufficient, a microbicide 
could be publicly available in 5 to 7 years.
  The cost of developing the existing pipeline of microbicide candidate 
products has been estimated at $775 million over 5 years. Currently, 
however, U.S. Federal funding for microbicides is only about $75 
million annually. Microbicides are a public health good for which the 
social benefits are high but economic incentives to private investment 
are low. Despite the potential market size, neither pharmaceutical nor 
major biotech companies have made large investments in the field 
because many of the benefits of microbi-
cides are public benefits for which manufacturers will not be directly 
compensated. Like other public health goods, such as vaccines, public 
funding must fill the gap left by market failure.
  The National Institutes of Health, principally through the National 
Institute of Allergy and Infectious Diseases, NIAID, spends the 
majority of Federal dollars in this area. However, microbicide research 
at NIH is currently conducted with no single line of administrative 
accountability or specific funding coordination. What is needed is for 
the Director of NIAID to establish a branch dedicated explicitly to 
microbicide research and development, and to provide this new branch 
with appropriate staff and funding.
  In addition, other Federal agencies such as CDC and USAID undertake 
microbicides research and development activities. Because there is no 
Federal coordination, however, there is a risk of inefficiencies and 
duplication of effort. Through a variety of committees, Congress has 
requested that NIH and its Office of AIDS Research provide Congress 
with a ``Federal coordination plan'' for research and development in 
this area, but formal submission of this plan has been repeatedly 
delayed.

[[Page 11837]]

  Will the Senate majority leader join me in urging NIH to consider 
establishing a branch dedicated explicitly to microbicide research and 
development, and to provide this new branch with appropriate staff and 
funding?
  Mr. FRIST. I agree with the Senator from New Jersey about the 
critical importance of research on microbicides, and I commend him for 
his leadership on this important issue. I applaud his efforts to better 
coordinate research conducted at USAID, CDC, and NIH, and to increase 
Federal funding. I urge the leadership at NIH to five his proposal 
prompt and careful consideration.
  Mr. CORZINE. I thank the distinguished majority leader for his 
comments and for his support of this important initiative.


  ASSISTANCE FOR ORPHANS AND VULNERABLE CHILDREN AFFECTED BY HIV/AIDS

  Ms. LANDRIEU. Mr. President, to date, approximately 14 million 
children have lost their parents to the AIDS virus. In many cases, this 
devastating disease has robbed them of their parents, their aunts, 
uncles, cousins, brothers and sisters. At a time when they are most in 
need of the care of loving adults, millions of children are left 
without anyone to call their own. Some of them are sick themselves, 
infected often at birth. If we are serious about $1.5 billion for 
programs aimed at assisting children orphaned by AIDS, then we must do 
all that we can to ensure that these programs reflect their many needs.
  I would suggest that the language in the underlying bill is remiss in 
that it does not address perhaps their most urgent need, the need for a 
permanent, loving home. I would like to commend the majority leader and 
the committee chairman for their foresight in insisting that 10 percent 
of the funds allocated in the bill be used to serve the educational, 
development and health needs of these young people. Yet, if these 
programs are not also focused on connecting children to at least one, 
caring adult, these programs will undoubtedly fall short of their 
potential. Every child needs a home. A child whose family has been 
devastated by disease is no exception. As a member of the Foreign 
Operations Appropriations subcommittee, I hope that we could address 
this issue at some point. Again, I thank the majority leader for his 
leadership and look forward to working with him.
  Mr. FRIST. Mr. President. I commend the Senator from Louisiana for 
her leadership in the area of adoption. She is right to suggest that we 
focus these programs on an orphan child's need to find a permanent, 
loving home. I would be happy to work with her toward this end.


                       eligibility for assistance

  Mr. LAUTENBERG. Mr. President, I see the distinguished majority 
leader, Senator Frist, and wonder if I could ask him to address a 
concern I and other Senators have about a provision entitled 
``Eligibility for Assistance'' which is located on page 61, line 18 of 
the bill.
  Mr. FRIST. I would be happy to.
  Mr. LAUTENBERG. This provision says that an organization that is 
otherwise eligible to receive assistance authorized by this Act to 
prevent, treat, or monitor HIV/AIDS, shall not be required, as a 
condition of receiving that assistance, to endorse or utilize a 
multisectoral approach to combating HIV/AIDS, or to endorse, utilize, 
or participate in a prevention method or treatment program to which the 
organization has a religious or moral objection.
  Again, I support this provision, because there are faith-based groups 
that are playing a crucial role in HIV/AIDS prevention and treatment 
which do not, for example want to distribute condoms. I understand 
that. There are other ways that they can be effective, through 
counseling, treatment, care and other services. They should not have to 
distribute condoms if they have a religious or moral objection.
  But there is a problem, which this provision fails to explicitly 
address. Some of these same groups that object to distributing condoms, 
have actively sought to discourage people from using condoms. They have 
told people who have come to them for advice and counseling that 
condoms are bad, that they should not use them, and, erroneously, that 
condoms usually fail.
  This is wrong. It is wrong from a medical point of view and it is 
wrong from an ethical point of view, because the consequence of 
providing this type of inaccurate or misleading information can quite 
possibly be death. Yet this provision does not address this very real, 
and very serious, problem. I would ask the majority leader how we can 
be sure that when these organizations, receive Federal funds, any 
information they provide about approaches to HIV/AIDS prevention is 
complete and medically accurate, including both the public health 
benefits and failure rates of the approach involved.
  Mr. FRIST. I thank the Senator from New Jersey for his question. This 
is an important issue. I fully agree that it is essential that 
information about approaches to HIV/AIDS prevention be medically 
accurate, including both the public health benefits and failure rates 
of the approach involved. That is what is intended by this provision. 
In fact, the provision uses the words ``an organization that is 
otherwise eligible to receive assistance''. I believe that ``otherwise 
eligible'' should be interpreted to require explicit assurances by such 
organization that when it provides information about HIV/AIDS 
prevention approaches it will meet this standard of accuracy.
  Mr. LAUTENBERG. I thank the majority leader. I agree that these 
assurances are needed and that they should be routinely spelled out in 
any contract or grant agreement between the U.S. Government and such 
organization in order to clarify the intent of this provision.


                    Global Epidemic of Tuberculosis

  Mrs. BOXER. Mr. President, I want to highlight one critical area of 
this important legislation, and that is the global epidemic of 
tuberculosis. While I appreciate the language on TB that was included 
in this bill at my request, I am disappointed that there is not a 
specific earmark for TB programs.
  The Kerry-Frist bill that passed the Senate last year included 
specific increases for funding for international tuberculosis programs. 
That bill authorized $150 million bilaterally for international 
tuberculosis in fiscal 2003 and $200 million for 2004.
  It is critically important that funding for tuberculosis remain a 
priority. There is a particular need to highlight the need for expanded 
tuberculosis funds given that the President's 2004 budget request calls 
for a reduction in funding to combat TB. We must not only protect but 
significantly expand funds for programs that combat tuberculosis. Here 
is why:
  TB is an immense global killer. Nine million people become sick with 
active TB every year and 2 million people are killed by the disease. 
Tuberculosis is medically linked with the global AIDS pandemic. TB is 
the leading killer worldwide of people with HIV, because those who 
contract HIV suffer from weakened immune systems and they develop 
active TB. TB rates have increased five-fold in some African nations in 
conjunction with AIDS.
  But there is hope. Basic TB treatment is incredibly effective and can 
cure over 90 percent of cases even in resource-poor settings, even in 
people with HIV/AIDS. This treatment, called DOTS, which stands for 
Directly Observed Therapy Short-course, uses drugs that cost just $10, 
for a full 6 months of treatment. Few health interventions are so 
effective and affordable.
  There is even a mechanism for getting high-quality drugs to poor 
countries, called the Global TB Drug Facility. The TB Drug Facility is 
a critical part of the global effort to combat TB. The TB Drug Facility 
needs just $50 million per year in order to reach its goals of averting 
25 million TB deaths by 2020, but the U.S. has only contributed a 
little over $3 million to the Drug Facility so far. The U.S. must 
contribute more to this important mechanism.
  And, the U.S. must do more to help expand access to DOTS treatment 
for those who are sick with TB. Currently, fewer than one in three 
people who need basic TB treatment have access to

[[Page 11838]]

it. And only a fraction of those with drug-resistant TB are receiving 
needed treatment. The need is clear. We must do everything we can to 
ensure that access to treatment for tuberculosis is expanded, before 
drug-resistance and TB's interaction with HIV make this into an 
unstoppable epidemic.
  I want to thank my friend from Oregon, Senator Smith, who has been so 
helpful in working with me over the past several years to make sure 
that international TB programs remain a priority.
  Mr. SMITH. Mr. President, it has been my great pleasure to work with 
my colleague, Senator Boxer, over the past years to put global 
tuberculosis control on the map as an important priority for U.S. 
funding.
  I share the Senator's concern that the United States continue to 
protect and expand the funds we allocate to this important cause.
  We must indeed not lose our focus on combating global TB even as we 
respond efficiently and effectively to SARS. We must remember that 
failing to protect and expand funds to combating TB means needless 
death for 2 million people in the developing world each year--people 
who are teachers, doctors, civil servants, and people who are parents 
to young children who need their protection, financial support, and 
guidance. We must remember that the problem of tuberculosis is 
inextricably linked together with the growing problem of global HIV. TB 
is the biggest killer of those with HIV, and TB also accelerates the 
course of AIDS. Treating TB can save lives and slow the progression of 
AIDS.
  We also must remember that treating tuberculosis works. We know what 
to do and that we have some of the key elements in place to 
successfully control this disease. As Senator Boxer mentioned, we have 
the Global TB Drug Facility in place. And we have a Global Plan to Stop 
TB. And the new Global Fund to Fight AIDS, TB, and Malaria is adding to 
the bilateral efforts of the U.S. and other nations.
  So we must use these mechanisms and use our window of opportunity to 
expand access to TB treatment before it is too late, before drug-
resistant TB and HIV/AIDS turn TB into a disease that is nearly 
untreatable and an epidemic that is at best very difficult to deal with 
and at worst perhaps uncontrollable.
  Does the majority leader agree that global tuberculosis control ought 
to receive adequate increased funds from the U.S. in the next fiscal 
year?
  Mr. FRIST. Mr. President, I appreciate the points raised by Senator 
Boxer and Senator Smith and will work with them to ensure that adequate 
funding is provided for U.S. bilateral TB programs.
  Mr. DeWINE. Mr. President, this is an historic day. I am very pleased 
that the Senate is moving forward with this AIDS relief bill--a bill 
that represents an unprecedented commitment to fighting the global 
scourge of HIV and AIDS. It is a good bill. It is a bill that has both 
bicameral and bipartisan support. It is a place to start--a beginning, 
not an end.
  I would like to take just a moment to thank my colleagues both in the 
Senate and in the House who have been working tirelessly in this fight 
against AIDS. They have spent countless hours crafting a bill that is 
going to make a difference--a bill that is going to help save and 
prolong the lives of millions worldwide. I especially commend Majority 
Leader Frist for his leadership and vision and Senators Lugar, Durbin, 
Santorum, Biden, and Kerry for their dedication to this fight, as well 
as Representatives Hyde and Lantos for crafting a bill in the House 
that recently passed by an overwhelming vote of 375 to 41.
  I thank them all for their efforts, for their compassion, and for 
their commitment.
  I also applaud the President and Secretary of State Powell for their 
dedication to easing the worldwide suffering caused by the HIV/AIDS 
pandemic. They understand that we, as a nation, have an obligation to 
fight this disease. We have the ability to fight it. We have the tools. 
And, it is our duty--as a leader in the world--to move forward now and 
do the right thing.
  To be sure, there are a number of issues--very important public 
policy issues--and differences that still need to be resolved as we 
move ahead. However, while those issues are important, we must not lose 
sight of the urgent need to do something about AIDS now. This HIV/AIDS 
relief package is a public health initiative of a magnitude never 
before undertaken in this country.
  It is an enormous task that will require a coordinated effort among 
the State Department, Department of Health and Human Services, and 
USAID and multiple NGOs and faith-based organizations. Because of that, 
we need to start putting the infrastructure in place--today.
  We need to start coordinating efforts--today.
  We need to get the programming started--today.
  We need to do all of these things so we can be ready to go when the 
money gets appropriated--so that on ``Day One'' when the money is 
available in the field, people in these impoverished nations who 
desperately need anti-retroviral treatment drugs can start receiving 
them and prolong their lives--so that pregnant, HIV-infected mothers 
can get the drugs they need so they don't transfer the disease to their 
children.
  Ultimately, Mr. President, this bill represents a starting point. 
Each one of us who has studied the HIV/AIDS issue would have changes to 
the bill if we were writing it just ourselves, and frankly, no one 
knows the future and can see exactly the landscape of the new ground we 
are plowing here. So really, none of us here can be sure that the 
precise approach we have taken or the precise figures and precise 
percentage allocation of dollar amounts for certain things is correct. 
But, we have to start somewhere. The most important thing is that we 
start--and this is the start. This is the beginning. It is a major 
first step.
  This bill is different than anything we have done in the past. It is 
a holistic approach to fighting global AIDS. It will have to be 
followed with appropriations money, and we will need to come back year 
after year to get that funding, but this bill gives us a place to 
start. It takes a balanced, comprehensive approach to combat the 
scourge of HIV/AIDS, Tuberculosis, and Malaria.
  It will focus funds on education and prevention and treatment--
treatment in terms of mother-to-child transmission, treatment of 
mothers who already have children, and treatment of all infected adults 
and children who have AIDS. This type of comprehensive approach, Mr. 
President, can and will make a difference.
  As I said, Mr. President, I believe this is a good bill--a good 
starting place--a major first step. Underscoring all of the major 
provisions of this bill is the moral imperative to fight this horrible, 
tragic disease. Over the last few months and years, we have heard 
countless statistics about the devastation AIDS is causing. Those 
statistics are troubling. They are disturbing. But, until there is a 
face and a name attached, those suffering from the disease remain 
statistics. I would like to take a few minutes to talk to my colleagues 
about the faces I have seen--the faces of children and babies with 
AIDS.
  In February, my wife Fran and I traveled to Haiti--our 12th trip--and 
we saw once again what this disease is doing to this nation and its 
people.
  In Haiti today, a nation of approximately 8 million people--300,000 
currently live with AIDS. We have seen the devastation this is causing. 
We have held dying babies in our arms--babies who could have been 
saved--babies who could live and grow up if they only could get the 
treatment drugs they need to stay alive.
  We traveled to Guyana in February, as well, and saw the same 
devastation--too many children and adults dying of this horrible 
disease and too few drugs to go around to help treat them and keep them 
alive. Right now in Guyana--a nation of roughly 800,000 people, 35,000 
have been identified as HIV-positive or as having AIDS. Of those 35,000 
people, only 200--less than one percent--are getting anti-

[[Page 11839]]

retroviral drug treatment. And, of the many children in Guyana with 
AIDS, only one of those children--only one--is receiving anti-
retroviral drugs!
  In Haiti, we visited an orphanage that has an entire floor just for 
AIDS babies. What you see is truly tragic--row after row of steel cribs 
with babies at various stages of the disease--none of whom are 
receiving any sort of anti-retroviral drug treatment.
  I remember seeing a little boy--he was about four or five years old--
named Francois. He had AIDS and was very close to death. He was laid 
out on a makeshift bed on the cold, concrete floor. He had an I.V. 
attached to him, and he was getting some fluids. The wonderful people 
who were caring for him explained that little Francois was no longer 
able to keep any food down. He was within days of death. There were no 
drugs available to treat him. So, the people caring for him were loving 
him, nurturing him, and were doing what they could to make him as 
comfortable as possible in the little time he had remaining.
  I will never forget that child--I will never forget little Francois. 
I will never forget him for the rest of my life.
  Another little boy who I will never forget appeared the opposite of 
little Francois. This little boy was about 7 years old, and also has 
AIDS, but he seemed to be very healthy. He was lively and content and 
thriving. But, that won't last.
  Very likely, unless something changes--unless he gets the treatment 
drugs that he'll eventually need--this 7 year-old boy, whom I cannot 
get out of my mind, will also eventually die.
  His death will be a needless one. It will be needless because these 
drugs are available. It is just that the folks caring for this little 
boy do not have access to them. Money is not available. The drugs are 
not available. That is an injustice. It is wrong. And, it is a great 
human tragedy.
  Let me conclude, Mr. President, by again thanking my colleagues for 
their efforts in getting this bill passed. We are telling the world 
that the United States cares and that we will lead the fight against 
this dreaded disease. We can make a difference, Mr. President--and we 
will make a difference. There is hope. This bill gives us more hope.
  We are moving ahead. We are moving in the right direction. We are 
finally doing the right thing.
  Mr. McCAIN. Mr. President, Senate passage of this bill authorizing 
the expenditure of $15 billion over 5 years to combat HIV/AIDS sends an 
important message: that the United States is committed not only to 
making this a safer world, by ending threats posed by terrorists and 
rogue states, but also a better, more humane world, by helping people 
in need in Africa, Asia, and elsewhere cope with the ravages of the 
HIV/AIDS pandemic.
  The spread of HIV/AIDS, and the efforts of the international 
community to combat it, will be remembered by history as one of the 
defining issues of our time. Until recently, we have been losing the 
battle: the disease has infected 68 million people to date. It has 
already brought disaster to Africa, where AIDS has taken over 20 
million lives and has surpassed malaria as the leading cause of death. 
UNAIDS estimates that by 2020, an additional 55 million Africans will 
lose their lives to the disease. There are currently 11 million AIDS 
orphans in Africa. Average life expectancy in Sub-Saharan Africa is 
currently estimated at 47 years, but it would be 62 years in the 
absence of AIDS.
  These numbers are staggering. The ethical implications of not doing 
everything in our power to slow the spread of this disease are severe. 
The most basic morality requires that we commit ourselves to combating 
HIV/AIDS everywhere. The social and political implications of allowing 
this disease to claim its grim toll are grave: countries cannot survive 
the death of a quarter or more of their populations without severe 
unrest, impoverishment, even radicalization and revolution. In Africa, 
more women are infected with HIV/AIDS than men; their central role in 
family life means their deaths have disproportionate effect. Millions 
of children cannot lose their parents without lasting damage to 
themselves and their societies. In many countries, the army has higher 
infection rates than the general population. Mass death among uniformed 
personnel will have profound implications for political stability and 
national security in these countries, as armies literally become unable 
to fulfill their basic duties.
  As the CIA assessed in 2000 for the 20-year period through 2020,

       At least some of the hardest-hit countries, initially in 
     sub-Saharan Africa and later in other regions, will face a 
     demographic catastrophe as HIV/AIDS and associated diseases 
     reduce human life expectancy dramatically and kill up to a 
     quarter of their populations over the period of this 
     estimate. This will further impoverish the poor, and often 
     the middle class, and produce a huge and impoverished orphan 
     cohort unable to cope and vulnerable to exploitation and 
     radicalization.

  As the World Bank and others have reported, AIDS affects the most 
economically vibrant group within society, the working-age men and 
women who account for most national output. With one quarter of a 
country's population facing impending death, labor markets would be 
ravaged, the benefits of education lost, and health-care spending 
rationed on what should be a society's most fit citizens. Resources 
that would have been used for productive investments would instead be 
apportioned for health care, orphan care, and funerals. Decades of 
gains in social welfare could be rolled back. National productivity and 
economic growth would be set back for generations.
  HIV/AIDS is decimating Africa, but its next frontier lies in Eurasia. 
More than 7 million people in China, Russia, and India carry the 
disease, but as we have seen in Africa, an infection rate of that 
magnitude can jump into the tens of millions within a decade. As 
Nicholas Eberstadt has written, ``The coming Eurasian pandemic 
threatens to derail the economic prospects of billions and alter the 
global military balance.'' Africa's plight alone is reason enough to 
pass this bill. Given the economic size and military stature of India, 
China, and Russia, the world will simply not be able to ignore the 
consequences of the coming AIDS crisis in Eurasia.
  Given the scale of human disaster and socio-political turmoil we 
confront from HIV/AIDS, enactment of the bill before us represents a 
critical step in the direction of leading the world in a common 
response to a crisis that affects us all. This bill nearly triples the 
U.S. commitment for international AIDS assistance. It targets most 
assistance at the 14 most afflicted countries in Africa and the 
Caribbean, but can incorporate other afflicted countries if necessary. 
It demonstrates the United States' commitment to leading a global 
campaign against a disease that has already killed 25 million people.
  As Uganda in particular has shown, AIDS can be managed and contained. 
Often the biggest challenges are political will, which has been sorely 
lacking in much of Africa, and government competence to effectively 
diagnose and treat victims, backed by a decent health care 
infrastructure. Afflicted nations with whom we partner to fight this 
disease must know that we expect a level of governance, transparency, 
and effectiveness from them in order to make the fullest use of AIDS 
assistance.
  The scale of the AIDS crisis, and the consequences of inaction in the 
face of a pandemic that threatens the global order, call for the type 
of bold leadership reflected in this bill. Our commitment must be 
sustained, and we must enjoy the partnership of other wealthy nations 
in this effort. We cannot afford to fail.
  Mr. ENZI. Mr. President, I rise today in support of H.R. 1298, the 
United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria 
Act of 2003. I urge my colleagues to join me in passing this bill 
without amendment.
  Why am I speaking on this subject? Why I am so committed to the swift 
passage of this bipartisan global AIDS bill? No one in my family and 
none of my close friends has AIDS. Nor have I traveled to Africa to 
care for people suffering from AIDS, as has our distinguished majority 
leader, Dr. Frist.

[[Page 11840]]

  Well, I am speaking on this subject for one reason and one reason 
only: I believe that passing this bill as soon as possible is the right 
thing to do. We have a responsibility to fulfill--and an opportunity we 
cannot squander.
  Millions of people are dying needlessly. We have the ability to make 
an investment that will save millions of lives and give hope and 
security to millions more. Doing nothing is not an option.
  We live in a highly interconnected world. Today more than ever, 
creating a more peaceful and secure environment for the people of one 
region translates into more peace and security for people around the 
globe. By increasing our commitment to fight AIDS in Africa and the 
Caribbean, we also will be helping our nation and the rest of the 
international community. The world awaits our response.
  As the cries for help from Africa increase, and the world watches to 
see what we will do, President Bush has challenged the Congress to 
provide the assistance that would begin to rid the world of this deadly 
menace.
  If we pass this bill, we will provide the people of Africa with hope 
for a better and more secure future. If we do not, history will not 
soon forgive--or forget--that a nation blessed with all the resources 
we have at our disposal failed to act when we heard the cries of the 
people of Africa.
  Let me remind my colleagues what the President has challenged us to 
do. He asked us to send him a bill that would prevent 7 million new 
infections--or 60 percent of the projected new infections in the target 
countries. He asked for a bill that would treat 2 million HIV-infected 
people in the target countries--as opposed to fewer than 100,000 
today--using the latest advances in drug therapy. He also asked for a 
bill that would provide care and comfort for 10 million HIV-infected 
people and AIDS orphans.
  The bill before us today would do all of these things. It represents 
the first global effort to provide advanced anti-retroviral treatment 
on such a large scale in the poorest and most afflicted countries. This 
bill also would make the successful Ugandan model of prevention--in 
other words, putting abstinence first--the basis of our global 
prevention strategy.
  The bill would require accountability and transparency from both the 
Global Fund and our bilateral efforts. The recent GAO report on the 
Global fund raises some legitimate concerns about how this 16-month-old 
organization manages its contributions and monitors its projects. The 
bill before us would mandate careful scrutiny of and accounting for how 
the Global Fund spends the contributions it receives.
  In short, this bill both reflects American values and recognizes that 
we need the active involvement of all countries in the struggle against 
AIDS. It also reflects a bipartisan compromise. This bill passed the 
House 375 to 41, with only 1 Democrat in opposition.
  Now I realize that no one is completely satisfied with this bill. I 
have colleagues on both sides of the aisle who might prefer to change 
one section or another to make it a better bill. However, we cannot 
afford to let the perfect be the enemy of the good.
  We don't have time to let the legislative process drag on while 
people around the world are dying--waiting for us to act. Time is not 
on our side--or theirs!
  I know many of my colleagues strongly support the Global Fund. 
President Bush supports the Global Fund too. In fact, his Secretary of 
Health and Human Services, Tommy Thompson, is the fund's new chairman.
  The President has pledged to continue our commitment to the Global 
Fund even as he proposes expanding and targeting our bilateral country-
to-country initiatives to fight AIDS. By providing both bilateral and 
multilateral funding, this bill doesn't pin all of our hopes--or our 
taxpayers' money--on any one approach to addressing this crisis.
  If you support the Global Fund, you know that the Senate's delay 
would mean a missed opportunity to increase the international 
commitment to fighting AIDS globally.
  The United States is the single largest donor to the Global Fund. As 
of April 1, the United States had pledged nearly half of the $3.37 
billion in total pledges to the Global Fund. We have already 
appropriated $650 million to the Global Fund, and we have pledged an 
additional $1 billion over the next 5 years.
  We are already doing more than our fair share for the Global Fund. 
What we need to do now is to encourage the rest of the international 
community to step up to the plate.
  President Bush is traveling to France next month for the G-8 Summit. 
This summit is a meeting of the political leaders of the world's 
largest economies. When would there be a better time to encourage other 
countries to increase their own contributions to the Global Fund?
  If you are concerned with the future viability of the Global Fund, 
you also should be concerned about passing this bill now. Our swift 
action will demonstrate our commitment to seeing this battle through. 
It will also give the President a great tool with which to leverage 
additional funding from other nations.
  On the other hand, amending this bill will result in a lengthy 
conference with the House. If we don't get this bill to the President 
until the summer, we will miss a golden opportunity to encourage more 
financial support for the Global Fund from the G-8 members. If we don't 
finish action on this bill until the fall, then the State Department 
will have lost the time it will need to get ready for the coming year's 
appropriations for our expanded bilateral AIDS initiatives.
  Clearly, these are not artificial timelines. Even less artificial are 
the timelines that AIDS places on a person's life and a family's 
future.
  In the 3 months since President Bush announced his emergency plan, 
nearly 800,000 people have died from AIDS. In those 3 months, 1.2 
million people have been infected with HIV, and more than 175,000 
babies have been born with the virus. Every day we spend debating this 
bill on the Senate floor or in a conference with the House means more 
lives lost--lives that could have been saved had we acted sooner.
  Our Founding Fathers were never more inspirational than when they 
wrote that our Creator has endowed us with certain unalienable rights--
and among these are life, liberty and the pursuit of happiness.
  Swift passage of this bill will again show the world that these 
aren't just words on a piece of paper. Swift passage will again show 
that these words apply to every citizen of every country--not just our 
own.
  In Africa and the Caribbean, the scourge of AIDS is robbing people of 
their natural rights. We know the thief is a virus. We also know how we 
can stop this thief from stealing the lives of people--from stealing 
fathers and mothers from their children. But with this knowledge comes 
an obligation to use it.
  For so long we could only treat the symptoms of AIDS and provide 
comfort to the dying. Today, we have the ability to fight back against 
HIV itself. Today we have medicines that can effectively halt the 
evolution of HIV and help people live a normal life. In other words, we 
have the technology and the know-how to stop AIDS from killing people, 
destroying families, and destabilizing societies.
  By sending this legislation to the President, we will save the lives 
of millions of people and liberate them from the tyranny of AIDS. And 
we will demonstrate, once again, that we are a principled nation that 
leads through actions, not words.
  I urge my colleagues to vote for this bipartisan bill and send it 
without amendment to the President.
  Mr. HATCH. Mr. President, I rise to speak in support of the pending 
legislation.
  I think it is important for the Senate to endorse the work of the 
House on the issue of international AIDS funding.
  As with many of our colleagues, I was absolutely thrilled to hear 
President Bush use the State of the Union Address as an occasion to 
display his

[[Page 11841]]

leadership on the critical issue of the pandemics of HIV, tuberculosis, 
and malaria in Africa, the Caribbean, and the developing world.
  We must give President Bush, Vice President Cheney, and Secretaries 
Powell and Thompson a lot of credit for urging the Congress and 
American public to give a higher priority and more resources to these 
deadly, intertwined epidemics. An estimated 30 million of our African 
neighbors are infected with HIV. About 11,000 Africans become infected 
each day.
  Tragically, of the 25 million who have died due to HIV infection 
worldwide, about 20 million, or 80 percent, were Africans. 
Unfortunately, it is likely that many more millions will follow them to 
an early death unless significant efforts are made to turn the tide of 
these epidemics. For example, about 40 percent of the citizens of 
Botswana are infected with HIV and the infection rate in many other 
countries is in the 1-in-5 and 1-in-4 range.
  The Bush administration deserves a lot of credit for making this 
issue a priority at a time when the Federal budget is once again facing 
severe strains.
  If our Nation takes a leadership role in helping nations in the 
developing world address the problems associated with infectious 
diseases such as HIV, TB, and malaria, these nations will remember us 
as an ally who helped them when they most needed aid.
  Let me be frank. There are many citizens in the developing world who 
sometimes question the motives of the United States in international 
affairs. We saw this dynamic at play in the debates leading up to and 
in the aftermath of the recent war in Iraq.
  It seems to me that in undertaking this important public health 
initiative at this time when we are once again struggling to regain 
control of the Federal budget--there can be no question that the motive 
of our country is nothing more than to try to help millions of people 
from perishing from a group of deadly infectious diseases that threaten 
to destabilize sub-Saharan Africa and the Caribbean for decades to 
come. If such longtime NATO allies such as France and Germany do not 
see eye to eye with us on certain aspects of Mideast policy, perhaps 
they and the rest of the developed world can agree with us that now is 
the time to roll up our sleeves and make the commitment of necessary 
resources to help those developing nations fight the interconnected 
scourge of HIV, TB, and malaria.
  This is exactly the type of challenge that President Bush will issue 
at the upcoming G-8 meeting. I hope and trust that the leaders of these 
countries will work together with us on reversing the course of these 
epidemics.
  I have been active in developing legislation related to AIDS since 
the onset of the epidemic. In my former capacity as a member--and 
chairman--of the Senate Labor Committee, I was a coauthor of the Ryan 
White CARE Act, the Terry Beirn AIDS Research Act, and worked to 
increase appropriations for research and services related to AIDS.
  I am a conservative. I share the concerns many have expressed that 
this bill could fund activities with which we disagree. To be clear, I 
very much disapprove of many of the behaviors by which HIV is 
transmitted.
  That being said, early on in this epidemic, I learned the wisdom of 
the old adage, ``Hate the sin, but love the sinner.''
  High-risk behaviors--for example, intravenous drug abuse--are hard to 
break. But, as a society, can we use behaviors with which many of us 
vigorously disagree as an excuse to abandon our responsibility to help 
individuals who are trying to kick their dependency on drugs? I think 
not.
  It is important to employ proven public health strategies to prevent 
the spread of HIV, even if some of these techniques and educational 
messages can be viewed as controversial if taken out of context of a 
public health crisis. We must also recognize geographic differences in 
what strategies are most proven and acceptable. Appropriate public 
health education prevention and education tactics are often different 
in Salt Lake City and New York City, or for that matter, Ho Chi Minh 
City.
  There was a spirited debate in the House over the proper balance 
between abstinence and other risk reduction techniques such as the role 
of condoms. I don't want to replay the whole debate over the rule that 
33 percent of prevention funds must be devoted to reenforcing an 
abstinence message. I believe in abstinence. I also am mindful of the 
fact that in some geographic regions such an inflexible rule may not 
represent an optimum use of prevention dollars.
  There are elements of the House bill that I do not like. But I must 
salute the efforts of Chairman Hyde and Representative Lantos for 
working so long and hard to find a consensus and get this legislation 
out of the House.
  Let me just add that I have heard the frequent--and not unjustified 
complaints to my mind--of the House leaders who observe that they are 
often faced with the prospect of passing what they consider watered 
down Senate versions of legislation after the House has taken action. 
It is well known that the House majority leadership views the tax 
legislation we just adopted earlier this evening to be a prime example 
of this dynamic.
  When all is said and done, the Constitution set forth a bicameral 
legislative body with different membership criteria and different 
election cycles. It is not surprising that it is often the case that 
the House and Senate come up with different legislative provisions. In 
the normal case, these differences can be ironed out by the vehicle of 
a conference committee.
  However, sometimes the regular order of the conference report is in 
tension with outside events. The case of the upcoming G-8 meeting is 
just one of those circumstances. As my friend Chairman Hyde wrote in an 
op-ed piece earlier this week, the development of a Senate version of 
the bill--normally a positive--may have a material adverse effect on 
the very type of international cooperation that the bill seeks to 
kindle and redouble.
  As Congressman Hyde noted, ``A new bill only delays the pressure on 
House and Senate appropriators to pony up the $15 billion requested by 
the President over the next five years. . . .
  `` . . . for the President in his meeting with G-8 leaders in June, a 
new bill only delays an opportunity he will have at this meeting to use 
enactment of this legislation to leverage support for worldwide AIDS 
efforts from our wealthy partners.''
  We need to take this view into account. I say this as one for whom 
the version of the bill developed and introduced by Senators Lugar, 
Kerry, and Biden is more attractive than what emerged from the House. 
All in the Senate should commend Senators Lugar, Kerry, Biden, and 
Frist for their longstanding leadership in this area. From a purely 
public health standpoint, I think their legislation has a number of 
advantages over the House bill that we are taking up on the floor 
today.
  I also have the utmost respect and praise for what the House 
accomplished by passing a bill that resolved a number of very difficult 
issues that lingered for many months. I want to associate myself with 
the remarks made earlier today by Chairman Lugar and Senator Biden in 
which they took the position that, despite the Lugar-Kerry-Biden bill's 
many virtues, the bottom line reality is that to go to conference with 
a new Senate version of the bill is to risk losing a critical 
opportunity at the G-8 meeting.
  Our majority leader, Dr. Frist, who has spent so much of his own time 
helping the people of Africa, also noted that the bill he called up may 
not be the perfect bill, but it represents a major step forward in 
advancing the program that President Bush laid out in the State of the 
Union Address.
  As the great philosopher Mick Jagger once noted, you can't always get 
what you want, but sometimes you find you get what you need.
  I think that the President's $15 billion proposal and the House bill 
are exactly what the people of Africa and the Caribbean need. Although 
I can think of some ways to refine the House language--as Senators 
Lugar, Kerry, and

[[Page 11842]]

Biden have suggested, my view is that we cannot let the perfect become 
the enemy of the very good.
  I urge my colleagues to support H.R. 1298. It is a good bill. The 
House worked for a long time and came up with a product of which we can 
all be proud and supportive. We will have ample opportunity in the 
months ahead and during the appropriations process to fine tune this 
legislation. But I agree with Senator Frist, let's get this done job 
done.
  Now is the time to send the President to France with an enacted bill 
with which he can attempt to leverage additional support from our 
closest allies. Being able to put the $15 billion bill on the table as 
a finished product will do much more benefit than a progress report on 
the Conference Committee.
  I believe that H.R. 1298 will be viewed as an important step forward 
with respect to public health. I cannot help but think that many of the 
developing world--the very same people we want to enlist with us to 
fight the battle against terrorism and to resist the entreaties of 
those who seek to undermine the role of America in world affairs--will 
take note of our action tonight. They will see that, even at a time 
when the domestic U.S. economy is struggling to recover, Americans 
found both the will and wallet to launch a major humanitarian effort 
against diseases that are severely lowering the quality of life in the 
developing world.
  Mr. President, I support H.R. 1298 as a clean bill. I urge my 
colleagues to support this important measure.
  Mrs. DOLE. Mr. President, I rise in strong support of H.R. 1298.
  Our world is in the midst of a crisis. HIV/AIDS has taken hold of 
many parts of the world and left death and destruction in its wake. 
Millions have been affected, wives have lost husbands, parents have 
lost sons and daughters, small children have been left alone, orphaned 
after AIDS took the life of parents.
  The Joint United Nations Program on HIV/AIDS reports that as of the 
year 2002, there were 29.4 million people living with this disease. 
Sadly, most of them are in sub-Saharan Africa. Estimates are that by 
the year 2020, an additional 55 million Africans will lose their lives 
to the epidemic.
  Women are particularly affected and make up 58 percent of the HIV-
positive population in sub-Saharan Africa. Perhaps even more troubling, 
6 to 11 percent of women aged 15 to 24 were HIV positive in 2001, 
compared to 3 to 6 percent of young men. Women are dwarfed by men in 
economic and political affairs, and far too many of these women have no 
way to protect themselves. The political and cultural standards in many 
countries have left them unable to defend themselves from unwanted 
sexual activity and advances and their reluctance to submit to male 
domination. With this pandemic, these women are victimized yet again.
  During my time as President of the American Red Cross, I saw 
firsthand the poverty and countless other socio-economic factors that 
make Africa particularly vulnerable to the spread of AIDS. Rwanda, for 
instance, is one of the areas with a high rate of adults infected with 
HIV. And Mr. President, while there, and in Goma, Congo, where a 
million Rwandans had fled from the bloodshed in their country, I saw 
100s of children with no parents, no home, no food, no clothes, no 
hope. To this day, I can close my eyes and see a little boy sitting by 
himself on a mound of dirt. He was probably 13 or 14, his face was 
covered with dust and he was crying. The tears left little paths down 
his cheeks. I sat beside him and put my arm around him to try to 
comfort him but there was no reaction. Nothing moved, not a muscle 
moved, as the tears flowed. He was traumatized. This is the challenge 
we face, ending the poverty and despair of that little boy, and 
replacing them with hope and life.
  Due to AIDS, the region is in a dangerous cycle that affects global 
health, the global economy and global security. Consider this: labor 
forces are decreasing because of the disease. Since there are fewer 
workers to farm the land, harvests are depleted, and famine is running 
rampant. As hopelessness sinks in, people become vulnerable and 
susceptible to evil terrorist predators. It is an endless cycle of 
despair, a boiling pot that cannot go unchecked.
  This Nation, the world's global leader, cannot sit idly by. We must 
pass this bill today. An entire generation is in danger of being wiped 
out by HIV/AIDS.
  This legislation takes a historic step in fighting this battle. It 
commits $15 billion dollars over the next five years to fight AIDS, 
tuberculosis and malaria. It establishes within the Department of State 
a coordinator of United States Government Activities to Combat HIV/AIDS 
so that the U.S. can continue to lead on this issue. And it commits $1 
billion dollars for the Global Fund to fight AIDS, Tuberculosis and 
Malaria.
  The legislation is the important springboard to real changes in 
Africa related to AIDS. It brings together many nations to participate 
in this effort, and through the conscience clause, allows for non-
governmental and faith-based organizations to lend their efforts to 
eradicating this epidemic. This clause and the participation of 
community and faith-based organizations are vitally important.
  The funding will work two-fold, through public private partnerships, 
to offer prevention and treatment.
  At the Red Cross, I was also able to work firsthand on AIDS 
prevention education. Ours was the first nationwide effort, so I know 
the benefits. The Red Cross has provided AIDS prevention education to 
more than 18 million people across the United States since 1985. More 
than 30,000 have been trained as HIV/AIDS education instructors. In the 
time since, our nation has made great strides in battling AIDS. People 
are taking precautions and living longer.
  But I also know firsthand that prevention efforts can sometimes get 
bogged down in controversy. There are so many different views and 
beliefs. But this is not the time for the Senate to engage in partisan 
or ideological delays. America is needed in this crisis; we are needed 
now, not next month, not next year. Lives are literally hanging in the 
balance on this bill. Saving them should be our only focus. We must 
step forward now to help our global neighbors, to offer a helping hand 
to those who need it, to end the death and destruction. We must pass 
this bill.
  Ms. STABENOW. Mr. President, I rise today to support the United 
States Leadership against HIV/AIDS, Tuberculosis, and malaria Act of 
2003.
  This legislation authorizes $15 billion over 5 years, $3 billion per 
year through 2008. This bill also establishes an HIV/AIDS response 
coordinator and advisory panel, and requires a 5-year comprehensive, 
integrated, global strategy to fight this deadly disease. I am pleased 
to join a bipartisan group of Senators supporting this legislation.
  According to the United Nations, more than 65 million people 
worldwide have been infected with HIV, more than 25 million have died 
of the disease, and more than 14 million children have been orphaned.
  At the end of 2002, an estimated 42 million people were infected with 
HIV or were living with AIDS, of which more than 75 percent live in 
Africa or the Caribbean. AIDS is the leading cause of death in sub-
Saharan Africa, where more than 19.4 million have died.
  Basic interventions to prevent new HIV infections and to bring care 
and treatment to people living with AIDS have achieved meaningful 
results. Nonetheless, of the more than 30 million people in Africa with 
HIV, only 50,000 receive necessary medicines.
  We must do everything to reverse this horrible trend and fight this 
pandemic. But we can't do it on the cheap. Fighting this disease will 
take a lot of money because the problem is so widespread.
  The Global H.I.V. Prevention Working Group, funded jointly by the 
Kaiser Family Foundation and the Gates Foundation, has issued a report 
stating that: ``Globally, fewer than one in five people have access to 
basic HIV prevention programs--the information and services that can 
help save lives and reverse the AIDS epidemic.''

[[Page 11843]]

  The Working Group's analysis of global HIV prevention funding finds 
that annual spending from all sources in 2002 was $3.8 billion short of 
what will be needed by 2005.
  The report also finds that access to proven prevention interventions 
is extremely limited, and highly variable, depending on region and the 
intervention.
  As you can see, this problem is bigger than what our response will be 
here today. We must view this legislation as the first step in an 
ongoing battle to end the AIDS epidemic once and for all.
  The bill before us is an important bill, but it is only an 
authorization bill. Now, we must focus on the upcoming appropriations 
bills to make good on the promise of the bill before us today.
  Mr. SMITH. Mr. President, I support the global AIDS bill. I, like 
many of my colleagues, do not believe the House version of this 
legislation is perfect. I have reservations about the bill--in 
particular more funding is needed to fight the spread of tuberculosis 
and malaria. Nevertheless, I enthusiastically support this legislation 
as a vital first step in the international response to the global AIDS 
pandemic. Coupled with expanded--though still relatively small--
bilateral resources to fight tuberculosis, the leading killer of people 
infected with AIDS, this initiative will save many, many lives. I 
commend the President for his leadership in this effort, and the 
House's overwhelming support of this important legislation and the 
global fund.
  Today, there are an estimated 42 million people worldwide living with 
HIV. Of the 42 million people infected with the virus, 3.2 million are 
children and half women. These numbers will tragically increase. In 
2002, there were 14,000 new HIV infections each day, resulting in an 
estimated 5 million new cases worldwide.
  The HIV/AIDS pandemic is devastating for millions of men, women, 
children, and families. Moreover, it threatens the economic and 
political stability of many developing countries. More than 95 percent 
of the new HIV/AIDS cases were contracted in developing countries. It 
is estimated that AIDS will diminish economic growth by up to 1 percent 
of GDP annually and consume more than half of health care budgets in 
the hardest-hit countries. With ever fragile infrastructures and 
inadequate funding for health, this economic drain will further hamper 
developing nations' prospects for a peaceful transition to democracy.
  The ability of these developing countries to prevent the further 
spread of the AIDS virus is limited without our help. Accordingly, it 
is imperative that we join with the President and House and offer our 
assistance to those struggling countries. This bill will provide the 
much-needed support and financial assistance to foreign countries 
struggling to combat the spread of HIV/AIDS, tuberculosis, and malaria. 
Along with a comprehensive 5-year plan to combat the global spread of 
HIV and AIDS, the bill authorizes funding and enables the U.S. to 
participate in the global fund through 2008.
  While passage of this legislation is essential, it ought to be 
remembered that this effort has just begun. This initiative is just a 
first downpayment by the U.S. in our fight against the global spread of 
AIDS. We must fully fund this bill in 2004 and still do more. We must 
invest wisely to protect and save as many lives as possible and as soon 
as possible. These funds are needed immediately, and if we do not 
invest enough now, we will pay far more later--in money, in lives lost, 
and in the social, economic, and spiritual cost to the families, 
communities, nations, which are hardest hit. There are ten million 
children in sub-Saharan Africa alone--children who ought to be free to 
play, to learn, to enjoy their young lives--who have lost one or both 
parents to AIDS. This represents a country the size of Belgium. In 10 
years, at current rates, this number will quadruple. But we have a 
choice. Will we allow this to happen? Every year we delay, the greater 
the cost. This epidemic is not waiting for us, it is here and 
accelerating. So, we too must accelerate our response.
  I again salute President Bush for his compassionate leadership and 
commitment to fighting HIV/AIDS at the global level. With passage of 
this bill, the U.S. will demonstrate its unwavering belief in the 
dignity of life, and as a nation, that we take seriously our moral duty 
to bring an end to preventable human suffering. I urge my colleagues to 
consider this just a first step in our response to fighting global HIV/
AIDS, to invest our resources judiciously, and to act immediately. We 
must not wait another day to pass this legislation, because we cannot 
afford to have another life needlessly taken by AIDS. I look forward to 
ensuring that this legislation will be full funded in this year's 
appropriations bills.
  Mr. SARBANES. Mr. President, pending before the Senate is legislation 
that marks a major step forward in addressing the HIV/AIDS pandemic. 
Although in my view we have been slow to come to terms with the 
enormity of the problem, we now have a broad bipartisan consensus on 
the urgent need for increased funding to address the HIV/AIDS crisis, 
which is reflected in two proposals before the Senate: H.R. 1298, the 
United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria 
Act of 2003 and S. 1009, the United States Emergency Plan for AIDS 
Relief Act of 2003.
  While they are broadly similar in their provisions, one, in my view, 
will equip us better with the tools we need. That is S. 1009, which I 
am cosponsoring. Within its overall authorization figures of $2.8 
billion for fiscal year 2004 and $3.2 billion for fiscal year 2005 for 
HIV/AIDS initiatives, it obligates specified amounts for bilateral 
programs, The Global Fund to Fight Aids Tuberculosis, TB, and Malaria, 
The Vaccine Fund, The International AIDS Vaccine Initiative, 
tuberculosis programs and the Malaria Vaccine Initiative. It promotes 
an integrated and balanced approach to fighting the disease, while at 
the same time embracing a wide range of established HIV/AIDS treatment 
and prevention programs. Indeed, S. 1009 is designed to complement and 
support existing development and relief funds, which have already 
proved their value.
  Today in sub-Saharan Africa and other parts of the globe we confront 
the tragic consequences of ignorance about HIV/AIDS, indifference to 
its effects and delay in marshalling worldwide efforts to contain and 
ultimately to eliminate it. First diagnosed in Los Angeles just over 20 
years ago, it rapidly spread worldwide, especially as major mechanisms 
of transmission, like blood transfusions and unsterilized needles, were 
overlooked. While concerted efforts of the medical community and the 
public at large have helped control the number of new cases and reduced 
the death rate, the disease continues to spread in some parts of the 
world. According to the most recent report of the Joint United Nations 
Programme on HIV/AIDS, UNAIDS, on the Global HIV/AIDS Epidemic, 3.5 
million people were infected last year in Africa alone.
  If not effectively treated, HIV/AIDS takes a truly terrible toll. In 
economic terms, the pandemic has turned back the clock on decades of 
development gains, creating a vicious cycle that exacerbates poverty 
among the already poor and reduces others to poverty. It displaces or 
marginalizes populations, making them even more susceptible to HIV 
infection. In South Africa, where the epidemic's grip has been 
especially deadly, AIDS has caused major social and economic 
disruption. What began as a health issue is now also a development 
crisis.
  In every country where HIV/AIDS rages out of control, all sectors are 
affected. Public health services have been particularly hard hit, 
because the demand from the services of public health workers has 
increased. IMF indicators suggest that in the most afflicted countries 
health services have been overwhelmed by the epidemic, even as the 
number of patients is projected to double over the next few years.
  HIV/AIDS has hit hardest in countries with limited budget resources. 
Scarce funds have been allocated to rising health care costs, at the 
expense of other critical public services. Additionally, because the 
disease debilitates and incapacitates well before it

[[Page 11844]]

kills, and because it crosses all socioeconomic lines, it has 
effectively deprived struggling governments of a generation of civil 
servants--of urgently needed leadership, experience and expertise. This 
loss of human resources constitutes a new and insidious form of brain 
drain that governments can ill afford as they work to promote economic 
growth, alleviate poverty and improve the quality of life for its 
citizens.
  Education in the affected countries has been particularly hard hit. 
Even if the demand for education falls over time as fertility rates 
decline, it will be difficult, if not impossible, to maintain pupil-
teacher ratios at constant levels. IMF indicators suggest that by 2010 
the proportion of newly trained teachers replacing teachers who have 
died of AIDS will reach a staggering 67 percent--two in every three. 
The magnitude of this tragic epidemic further complicates the challenge 
of raising literacy rates in the developing world. The World Bank 
estimates that even absent the impact of HIV/AIDS, 55 of the world's 
poorest countries will be unable to achieve universal primary 
enrollment by 2015.
  HIV/AIDS affects the private sector just as much as the public 
sector. As mortality rates rise and the working-age population declines 
in size, employers lose trained, experienced and productive workers. 
Medical care, death-related benefits and also absenteeism--a very 
important factor--all contribute to rising personnel costs.
  The macroeconomic impacts are clear. When the HIV infection rate 
exceeds 5 percent in a country, HIV/AIDS begins to have significant 
economy-wide impacts. At least 24 African nations, along with Haiti, 
now fit into this category. The consequences are grim. UNAIDS estimates 
a loss of more than 20 percent of GDP by 2020 in the worst affected 
countries. The number of destitute families will rise as they face 
lower incomes, greater numbers of dependents and sharply higher 
healthcare expenditures. The ripple effects of continued reductions in 
labor, savings, and investment will mean lower economic output in the 
affected countries, inevitably slowing economic growth and causing 
trade balances to deteriorate further.
  The economic ramifications of HIV/AIDS are one aspect of the crisis; 
the human dimension is another. According to UNAIDS, 42 million people 
worldwide are living with HIV. Of these cases, more than 28 million are 
in Africa alone. In 2002, 5 million people were newly infected with 
HIV; 28 million people have thus far died from the disease; 14 million 
children have been orphaned by AIDS without having contracted the 
disease themselves. Given the high mortality rates among young adults, 
the orphan population will inevitably increase; a recent report issued 
jointly by UNICEF/UNAIDS/USAID estimates that by the end of this decade 
the number of orphans will reach 25 million, an increase of nearly 80 
percent. Social support systems in the affected countries are 
tragically inadequate in the face of the crisis. Children thus become 
part of a vicious cycle, with no one to care for them, still vulnerable 
to the disease, seeking to survive in a gang or militia--exacerbating 
social problems in these countries.
  Available statistics tell only part of the story, since AIDS often 
goes unreported. There is no system of accessible AIDS testing and many 
cases go undiagnosed, given the sensitivity and social stigma too often 
surrounding AIDS. On the basis of what is available, however, experts 
agree that in Africa alone the disease threatens an entire generation 
that will either be lost to HIV/AIDS or severely affected by plummeting 
life expectancy, collapsing social institutions and decimated 
workforces.
  As we consider our approach to AIDS, our recent experience with SARS 
should be instructive. With SARS we have learned in a few months what 
it took years to understand about HIV/AIDS: awareness, early 
intervention and international cooperation are critical factors in 
keeping the disease from spreading and in saving lives. We must apply 
the lessons we are learning from SARS to our efforts to treat and 
control HIV/AIDS.
  A person infected with the HIV/AIDS virus may appear to show signs of 
the flu, or no symptoms at all for months or even years. Yet diagnosed 
in time, the disease is treatable. In the industrialized world, for 
example, research and intervention have reduced mother-to-child 
transmission of the HIV virus to less than 2 percent. Rigorous testing 
and surveillance can keep the blood supply safe. Effective, low-cost 
interventions have been developed. In high-risk groups in 
industrialized countries intensive education, vigorous political action 
and extensive drug therapy have been combined to bring the disease 
largely under control. Now we must apply these strategies in the 
developing world, where the disease is raging out of control. Of the 
total HIV population worldwide, 95 percent live in the developing 
world. While there is no cure, we know that prompt intervention 
mitigates the terrible effects of the disease.
  S. 1009 is not directed exclusively to HIV/AIDS; it includes 
important provisions addressed to tuberculosis and malaria. Unlike HIV/
AIDS, which was first diagnosed less than a quarter-century ago, these 
two terrible diseases have been known and feared for centuries. 
Tuberculosis claims nearly 3 million lives every year--more than all 
other infectious diseases combined. Among HIV/AIDS patients, it is the 
single most common cause of death. In fact, HIV patients are up to 50 
percent more likely to convert the latent form of TB into the active, 
contagious form. Unlike many other infectious diseases, tuberculosis is 
an airborne disease transmitted like the common cold. Nearly one-third 
of the world's population is already infected, and cases of multidrug 
resistant strains, which are far more difficult and expensive to treat, 
are rising. Overall, tuberculosis is responsible for 25 percent of all 
preventable deaths in the developing world. S. 1009 authorizes $150 
million for fiscal year 2004 and $170 million for fiscal year 2005 for 
programs devoted to tackling TB.
  The developing world, especially sub-Saharan Africa is also in the 
grip of resurgent malaria, as resistance grows to traditionally 
effective antimalarial drugs. Resurgent malaria is estimated to cause 1 
to 3 million deaths annually, and WHO projects between 300 to 500 new 
cases every year. S. 1009 authorizes $105 million for fiscal year 2004 
and $125 million for fiscal year 2005 to malaria programs and to the 
Malaria Vaccine Initiative.
  With the worst effects of the pandemic still to come, S. 1009 is 
timely and urgent. It will help to stop the terrible downward spiral in 
living standards in the countries it has ravaged, and the 
destabilization that occurs when families and communities are torn 
apart. It can save lives.
  We can beat back this disease. In my view, S. 1009 provides us with 
the tools most urgently needed by those on the front lines in the fight 
against HIV/AIDS. It is vastly superior in its provisions to H.R. 1298. 
Nonetheless, I will work with my colleagues to strengthen the 
underlying bill. I urge my colleagues to join me in this effort.
  Mr. SESSIONS. Mr. President, I rise today to discuss the issue of 
health care transmissions of HIV/AIDS in Africa. I want to clarify some 
important provisions of the bill addressing the spread of HIV/AIDS and 
other infectious diseases in Africa and the developing world through 
the health care setting and more specifically the reuse of syringes and 
needles, in other words, injection devices.
  The reuse of syringes and needles is a well-documented practice in 
the developing world. Scientists from the WHO, Duke University and the 
Gates Children Vaccine Program report that the percentage of unsafe 
injections in sub-Saharan Africa vary from greater than 50 percent to 
as high as 90 percent in Burkina Faso. In some countries in the study, 
60 percent of centers reused syringes/needles. The Safe Injection 
Global Network, SIGN, an organization affiliated with the World Health 
Organization, WHO, reports that, ``Transmission of bloodbourne 
pathogens, including hepatitis B virus, HBV, Hepatitis C virus, HCV, 
and acquired immunodeficiency virus, HIV, through

[[Page 11845]]

unsafe injections has long been reported and causes a heavy burden of 
disease.''
  A December, 2002 paper co-authored by physicians from WHO and CDC 
estimated that in the developing regions that were studied, almost 40 
percent of injections were given with reused injection devices. The 
same study found that unsafe injection practices in developing 
countries in the year 2000 alone caused 22 million hepatitis B 
infections, 2 million Hepatitis C infections and resulted in the 
transmission of the HIV virus to 260,000 people.
  The cumulative number of people with HIV, Hep B and Hep C over the 
years is a significant number that cannot be ignored.
  In response to the overwhelming evidence of diseases spread through 
needle and syringe reuse, and the recognition of the effectiveness of 
needles with technology features that prevent reuse to stop the spread 
of disease, Section 306 of this bill includes legislative language 
``promoting sterile injection practices and technologies.''
  I want to make the point that sterile injection practices and 
technologies referred to in Section 306 include injection devices with 
reuse prevention features.
  Furthermore, it is my understanding that ``sterile injection 
practices and technologies'' referred to in Section 306 should include 
injection devices with reuse prevention features, especially since 
needles or syringes that can be reused are only guaranteed to be 
sterile during their use. This section should not be interpreted to 
support needle exchange programs. It is also my understanding that 
availability and use of reuse prevention injection devices will limit 
not only the spread of HIV/AIDS, but also have the additional benefit 
of reducing the incidence of Hepatitis B, Hepatitis C, and other 
infectious diseases such as the Ebola virus, through non-sterile and 
unsafe injection practices.
  This clarification is important to ensure that the Coordinator of the 
HIV/AIDS Program at the State Department understands the importance of 
providing injection devices with reuse prevention features to prevent 
the spread of HIV/AIDS and other infectious diseases.
  Studies may vary as to exact percentage of infectious disease spread 
by various known causes. But all should agree that the use of sterile 
injection devices with reuse prevention features is one effective, 
economical, and immediately available step that can be taken to prevent 
one of the most significant causes of the spread of infectious 
diseases, especially among children who receive injections for 
immunization and other health care.
  It has been estimated that there are about 1.5 billion injections 
administered in Africa each year. Since some injection devices with 
reuse prevention features can be obtained for as little as 
approximately 5 cents each, the entire continent of Africa could be 
supplied with safe injection devices at a cost of less than $100 
million dollars per year. Doing so could virtually eliminate the spread 
of HIV and other diseases in Africa from injection device re-use, in a 
manner that is cost-effective and with measurable results.
  During a March 27, 2003 hearing I chaired in the Senate Health, 
Education, Labor and Pensions Committee on the transmission of AIDS in 
Africa, David Gisselquist, PhD, testified that, ``From the 16 available 
large studies in Africa with sufficient data on injections, an average 
of 28 percent of HIV infections is associated with medical 
injections.''
  In a December 2002 WHO report the authors list four studies with 
findings of 8 percent, 15 percent, 41 percent and 45 percent 
attributable to contaminated injections resulting in HIV infections, 
thus suggesting that the WHO 2.5 percent model was conservative. Even 
the WHO in its own report stated ``[i]n the year 2000, four decades 
after the widespread availability of single-use injection equipment and 
two decades into the HIV pandemic, contaminated injections account for 
close to a third of new HBV infections, 40 percent of new HCV 
infections and 5 percent of new HIV infections. These infections 
translate to a substantial preventable burden of acute hepatitis, AIDS, 
hepatocellular carcinoma and end-stage liver disease.''
  Even if the proportion of cases from injections is much lower than 
that by heterosexual transmission, it is an important component of the 
problem and we must act quickly. If healthcare procedures account for a 
high percentage of the cases of HIV infections in Africa, then we must 
immediately and radically change our prevention procedures.
  Therefore, I plan to work with the Secretary of the Department of 
Health and Human Services to request an independent group to examine 
the available studies on the number of HIV/AIDS cases that are caused 
by the unsafe re-use of needles. This study will help clarify and 
highlight the dangerous impact of needle re-use in the spread of HIV/
AIDS. I recommend that the independent organization draw a panel of 
experts from different public health organizations to compile this 
study and make available their findings in 90 days.
  I plan to request this study to help understand the true impact of 
health care transmission and especially unsafe needle re-use in the 
spread of HIV in Africa and to ensure that our policies reflect the 
best science about the causes of the HIV/AIDS epidemic in Africa and 
other parts of the developing world.
  I am glad this evening to join with my colleagues in support of the 
President's initiative to combat global HIV/AIDS and to deliver a bill 
prior to his departure for the G-8 summit in France which commences on 
June 1, 2003. The bill authorizes $15 billion over 5 years for HIV/AIDS 
programs and it is my desire that some of this money be used to 
eliminate the transmission of HIV/AIDS in the health care setting and 
especially by the re-use of injection devices.
  Mr. ALEXANDER. Mr. President, this is an historic moment for us. The 
United States Senate is going to step up to the plate and declare in a 
bipartisan manner that we will meet our moral obligation and help those 
countries most afflicted by HIV/AIDS.
  The scourge of AIDS knows no borders; it is the greatest plague of 
our time. Over 40 million people worldwide are infected with HIV/AIDS 
today. Thirty million of those are in Africa. Nearly half, or twenty 
million, of those infected are in the fourteen countries highlighted 
for special attention in the President's Emergency Plan for AIDS 
Relief, which is authorized in the bill before us today.
  Now is the time for the Senate to act. I support the bipartisan 
global AIDS bill that passed the House, and urge my colleagues to do 
the same. The Bipartisan Global AIDS bill authorizes the President's 5-
year, $15 billion plan to combat HIV/AIDS, mirroring President Bush's 
emphasis on treatment and care. The bill provides funding to the Global 
Fund to Fight AIDS--up to $1 billion per year--but it limits 
contributions to be no more than one-third of those monies contributed 
by other sources. This limitation provides the President with leverage 
to encourage other countries to donate to the global fund.
  The bill supports the approach that Uganda has had so much success 
with called ``ABC,'' which stands for: abstain, be faithful, and use a 
condom. When I met with the First Lady of Uganda Tuesday, she told me 
how this approach of emphasizing abstinence was a return to traditional 
African values that is working well. From 1991 to 2001, the prevalence 
of HIV/AIDS among pregnant women in Uganda has declined from 21 percent 
to 6 percent, thanks largely to ``ABC.'' In Botswana, by contrast, a 
nurse told me 97 percent of the pregnant patients she saw were HIV-
positive, and the national rate was 43 percent among pregnant women in 
2000--seven times Uganda's rate. In fact, on Monday, I will be chairing 
a hearing in the African Affairs Subcommittee to look more closely at 
the Ugandan model and how it can be applied in other countries.
  Thirteen million ``AIDS orphans'' around the world have lost their 
parents to AIDS--the bill authorizes funds to aid those children. Time 
is of the essence. Every moment we delay, more

[[Page 11846]]

people are dying and becoming infected.
  I know many of us see imperfections in the bill, and want to amend 
it. I'm one of them. In fact, I've introduced an AIDS Corps bill that 
would make a great amendment to this bill. I'm going to withhold that 
amendment in the interest of getting a good bill quickly to the 
President's desk, but I want to take a moment to talk about it in hope 
that we can adopt this proposal or something similar in the future.
  The House bill includes language to establish a program where health 
professionals can volunteer their services to travel abroad to 
countries most afflicted by HIV/AIDS and provide training and care. 
This is a needed service. One exacerbating problem for poorer countries 
afflicted by HIV/AIDS Is the lack of a strong health care 
infrastructure. In many African countries, traditional healers are more 
relied upon than medical doctors--these traditional healers may have 
little or no knowledge about testing for HIV or providing advice on how 
to prevent or treat it.
  Health professionals from countries like the United States can take a 
couple of months away from their practice to travel to other countries 
in need and provide necessary training to allow in-country care-
providers to better respond to the HIV/AIDS pandemic.
  And American health professionals have shown an interest in answering 
the call. A number of non-profit groups help doctors volunteer their 
services, groups like Doctors Without Borders, US Doctors for Africa, 
and the International Medical Corps.
  My amendment takes the language from the House bill and improves on 
it in three important ways:
  No. 1, it names the volunteers the ``AIDS Corps'' to help increase 
the profile of the group so as to better attract qualified medical 
professionals to give of their time and volunteer.
  No. 2, it provides more flexibility for the length of time health 
professionals can serve--so that those who can only volunteer for a few 
months won't be excluded.
  No. 3, it provides the same liability coverage to volunteering 
doctors as is provided for federal employees who provide health care 
services.
  I hope that at some future date we can consider these changes that 
will allow any new corps of medical volunteers established by the 
President under this act to function more effectively.
  Now is not the time to put such an amendment forward.
  We need to pass this bill quickly so the administration can begin its 
implementation and President Bush can use it to encourage other 
countries to join us in this effort at the upcoming G-8 summit.
  I urge my colleagues, let us pass this bill without amendment tonight 
so that the President can sign it as early as tomorrow, and we will be 
one step closer to reversing the trend of this growing menace and start 
reducing its impact around the world.
  Mr. DODD. Mr. President, no challenge is more daunting in scope or 
immediate in need than the Global AIDS crisis. I rise today with the 
utmost urgency to speak of this modern-day plague and to urge my 
colleagues to ensure that the legislation currently pending before the 
United States Senate is both swift in its passage and effective in its 
nature.
  The global AIDS pandemic threatens to undermine all of our other 
efforts to bring stability and prosperity to the world. AIDS is an 
unparelled crisis, and it threatens to have a potentially irreversible 
effect. Every country around the globe will, in one way or another, 
feel the devastating impact of this disease; no nation will be spared.
  Certainly, I applaud the administration for its initiative on this 
important issue. We all do. And, the bill currently before this 
chamber--which closely reflects the Administration's requests--provides 
a good framework for battling this crisis. However, it has some serious 
shortcomings--shortcomings that will greatly impact its chances of 
success. That is why this chamber must ensure that any AIDS legislation 
it passes will be effective on the ground. In order to do this, we must 
look carefully at the facts, and at the reality of the situation. This 
must be our first priority.
  Mr. President, there are well over 42 million people currently living 
with HIV/AIDS. In 2001 alone, there were approximately five million new 
infections. Even worse is that the number of infections continues to 
grow at an alarming rate. There are 15,000 new infections every day, 
and half of these infections--half--are in children between 15 and 24 
years of age.
  Without a doubt, the region hardest hit by this pandemic is sub-
Saharan Africa. Approximately 70 percent of the worldwide total of 
people with HIV/AIDS live in that part of the world, and well over 29 
million people are currently infected. The overall rate of infection 
among adults in the region is close to nine percent, compared with 1.2 
percent worldwide, and in seven countries, the infection rate is over 
20 percent.
  Experts contend that the severity of the AIDS pandemic in that region 
is directly related to its wide-spread poverty, lack of education, ill-
equipped and underfunded health systems, and local taboos that 
stigmatize and ostracize those who are infected. Even more devastating 
to the region is that the AIDS pandemic creates a vicious circle of 
events that, despite international aid, increasingly hinders the 
ability of affected societies to help themselves.
  This vicious circle is pervasive throughout all sectors of society. 
Skilled workers, teachers, farmers, management executives, and 
government officials alike are falling prey to AIDS. In fact, according 
to UNAIDS, by 2020, the most affected countries will experience a loss 
of more than 20 percent of their gross domestic product.
  AIDS is also having a debilitating effect on our hemisphere. In 
Guyana, almost 3 percent of the adult population is infected, and in 
Haiti, a nation long-suffering from substantial economic and political 
instability, more than 6 percent of its adult population are living 
with the virus. Indeed, throughout Latin America and the Caribbean, 
over 1.9 million people are infected, and in some Caribbean countries, 
the rates of prevalence are second only to sub-Saharan Africa.
  Throughout the world, AIDS is killing millions of parents, and often 
leaves young children in the precarious position of having to supply 
food, money, and medicine for their families. The World Bank estimates 
that there are currently 15.6 million AIDS orphans, and this number is 
expected to double by 2010. Many of these children, especially girls, 
quit school and become victims of sexual violence or commercial sex 
workers. And, due to lack of resources and education, only a fraction 
of these children know that they are infected. Most do not even believe 
that they are at risk or know how AIDS is spread.
  I urge my colleagues to carefully examine this situation. Many of 
these children are not promiscuous because of childish recklessness. 
Certainly, children do not desire to become commercial sex workers. 
They are children. Given the chance, they would play games and go to 
school, as do most children. However, in many cases, their reality, as 
well as the obligation to provide for their families, forces them into 
this lifestyle.
  I know that citing the successful efforts in the nation of Uganda, 
some of my colleagues argue that United States AIDS assistance should 
focus on the promotion of abstinence among children. Certainly, 
encouraging young, unmarried children to abstain is a worthy goal. We 
can teach them to abstain, we can urge them to abstain, and we should. 
However, we can not ignore the multitude of factors with which we are 
faced. We must remember that the Uganda plan worked because it 
encouraged abstinence, monogamy, and distributed condoms--the ``ABC'' 
model. Most of all, it worked because the President of that nation made 
it a national priority to educate his people about HIV/AIDS.
  In my view, the most important distinction among regions of the world 
has been the ability of affected nations to deal with the AIDS crisis 
and to educate their people about it, as well as the ability of 
infected people to pay

[[Page 11847]]

for a variety of life-saving or life-prolonging treatments.
  I know we can all remember a time in the United States when in 
schools, television advertisements, and billboards, we strove to 
educate Americans about HIV/AIDS. In fact, this effort continues, and 
with much success. Coupled with access to state-of-the-art treatments, 
Americans with HIV are able to live longer and healthier lives than 
ever before. But it is important to realize that the methods used to 
progress in one area of the world will not necessarily be effective in 
another. In many regions, AIDS infection stems from an intricate social 
reality--one with many contributing factors. In most of these 
countries, poverty deprives the people of effective systems of health 
information, health education, and health care. AIDS counseling is 
often unavailable, and HIV testing is difficult for many to obtain. 
Lack of resources to buy and distribute the expensive drugs that 
prolong life for those infected with HIV, as well as the rarity of sex 
education and prevention methods, have compounded these problems.
  Therefore, we must not ignore the widespread destitution caused by 
this disease, which forces many people--children and adults--into a 
lifestyle that dramatically increases their risk of infection. Any 
effort to fight AIDS must be accompanied by an effort to fight poverty 
and build infrastructure; it must be focused on helping people to help 
themselves. It is my hope that as the Senate addresses the issue of 
foreign aid in the coming year, it pays particular attention to the 
other myriad needs on the continent of Africa, as well as in other 
poverty-stricken regions throughout the world.
  In addition, we must not ignore existing institutions, such as the 
Global Fund to Fight AIDS, Tuberculosis, and Malaria. While I strongly 
support the provision in this bill authorizing up to $1 billion for the 
Global Fund in fiscal year 2004, I am concerned that the Bush 
Administration will instead choose to follow its fiscal year 2004 
budget request, and only allocate $200 million for this important 
institution. Indeed, such a decision would threaten the ability of the 
Global Fund to continue its important work; it would be a step 
backwards in our fight against AIDS.
  And lastly, although this bill will serve to combat HIV/AIDS in 
twelve African countries, as well as Haiti and Guyana, it is absolutely 
essential that we focus our efforts not only on these countries, but on 
the world at large. HIV/AIDS is a global problem and it needs a global 
response. My amendment designating Caribbean countries as priority 
countries for United States support was an attempt to give additional 
attention where it is most needed.
  To highlight the necessity of this global approach, I would like to 
bring to the attention of my colleagues a report on AIDS, which was 
published in January 2000 by the Central Intelligence Agency, CIA. This 
report states that by 2010, the focal point of infections will most 
likely shift from sub-Saharan Africa to Nigeria, Ethiopia, India, 
Russia, and China. There will be approximately 50 to 75 million 
infected people in these countries alone, and according to the CIA, the 
AIDS crisis will contribute to political instability and slow 
democratic development. These are dire predictions, and we have an 
obligation to address them.
  Our intentions are noble and our conviction is real. But in order to 
achieve all of these vital goals, we must fully and sensibly commit 
ourselves to the fight against AIDS. That means providing the necessary 
resources to prevent and treat this illness, sufficiently funding 
important organizations and vaccine research, educating people about 
AIDS, providing a truly global response, and ensuring that our efforts 
are effective and grounded on the realities of those in need. And, as 
we consider this bill, it is crucial to remember that it is only a 
first step. In order to succeed, we must also change the reality in 
which this disease thrives.
  If we don't act with urgency, sensibility, clarity, and deliberation, 
we will be condemning to death countless men, women, and children 
throughout the world. We must act now. We can not afford to fail.
  Mr. SESSIONS. Mr. President, the underlying bill provides too much 
money to the global fund. The administration requested $200 million 
next year for the global fund. This bill funds the global fund to the 
tune of $1 billion.
  Let me begin by saying I do not think we should be giving the global 
fund anything. They have not earned our trust. They have not proven 
they can do a better job of fighting AIDS than the President can do 
through direct assistance.
  Let me share an exchange I had with Sir Elton John at a hearing on 
the AIDS issue.

       Mr. Sessions. Thank you for that commitment. It has made a 
     difference. I talked to a businessman who does a lot of work 
     around the world, and he said that in developing nations, the 
     absolute key is not to give the money too high up the ladder. 
     If you are giving the money to the people doing the work, 
     they will work wonderfully, and things will happen 
     beautifully. If you give it too high up, it does not get to 
     the people who do the work in an effective way. Many of you 
     have foundations and are leading groups that are smaller, 
     where you can be more effective. We are talking about, if we 
     were to do what Ms. Thurman asked, tripling our contribution 
     to $2.5 billion. Do you have any suggestions as to how we can 
     make sure that that money actually reaches its greatest 
     potential?
       Sir Elton John. I concur with you totally. What that money 
     has to go toward is training people to build an 
     infrastructure so that people can get the drugs they need in 
     remote parts of countries, and it needs to run on a 
     government level. But I know what you are saying. I do not 
     know how you do that, because I am just a singer. This is 
     something that the politicians have to make sure that when 
     the money goes to governments, the money is spent in the 
     right way. I have said before that we are a very small AIDS 
     organization; we can control where everything goes, and we 
     do. We know where every penny goes. But when you get to these 
     vast sums of money that we are talking about there today, you 
     are going to run into those kinds of problems, and I do not 
     personally know myself how you solve them, but I do concur 
     with you that that is a major problem.

  Sir Elton John's statement is relevant to the issue of whether to 
take massive amounts of money and give it to this global bureaucracy.
  The General Accounting Office recently completed an exhaustive study 
of the global fund. I strongly recommend that my colleagues read this 
report.
  Here are some of the findings.
  The Secretariat's office has 63 staff members who have an average 
salary of $174,603. This is the average.
  Compared to recipient countries' average annual salaries, or even to 
the U.S.'s average annual salary, no country even comes close.
  The average annual salary of the 73 recipient countries where such 
figures are known is $3,020, over $171,000 less than the average global 
fund salary.
  Even the average U.S. citizen only makes $36,300 a year. A job with 
the global fund would give a U.S. worker a potential $138,000 payraise.
  Americans work hard to pay their taxes. In times of economic trouble, 
they have to work even harder. We have a fiduciary duty to the 
taxpayers.
  We owe it to them to make sure these precious resources are used as 
wisely as possible, especially when we are deciding how to address a 
deadly epidemic.
  Disease specialists within the United Nations estimate that it would 
cost $1,400 to $4,200 a year per patient to treat HIV/AIDS effectively 
in sub-Saharan Africa with antiretroviral drugs. That means that by 
simply eliminating one average Secretariat employee's wages, between 42 
and 125 AIDS patients could be helped to lead better lives.
  I want these funds in the hands of someone I can trust. Do I have 
concerns about giving money to the Federal bureaucracy? Of course. But 
this is a judgment call. Who do you trust most with these dollars, the 
global fund, or President Bush?
  I trust President Bush. I trust the United States of America.
  Out of $862 million in funds received, the global fund has only 
distributed $20 million to actual AIDS prevention grants. Meanwhile, 
they are spending exorbitant amounts on salary and bureaucracy.
  President Bush has a proven record. He gets results. I cannot say the 
same for the global fund.

[[Page 11848]]

  The Democratic Leader says he will offer an amendment to ``guarantee 
a robust American commitment to the Global Fund to fight AIDS.''
  This statement implies three things--
  1. That America's current commitment to the global fund is not 
robust. Not true.
  2. That the bill we are considering does not provide a robust 
commitment. Not true.
  3. By voting for this amendment, you will guarantee a commitment to 
the global fund that is more robust than you would by voting against 
it. Not true.
  Let me take these one at a time. First, Is America's current 
commitment to the global fund robust? Absolutely.
  To date, we have contributed a total of $300 million out of a total 
$862 million, 32 percent. Our commitment next year is $350 million out 
of $832 million. The next highest nation is Italy at $100 million.
  Does the bill we are considering represent a robust commitment to the 
global fund? I submit that $1 billion is an overly robust commitment.
  The President stated that $200 million for the global fund is what is 
needed next year. This bill authorizes $1 billion. This bill is five 
times what the President requested.
  The bill is more than every nation's pledges combined. Last year, the 
total was $832 million. This bill provides $1 billion. I guess too much 
is never enough for the other side.
  Third, the majority leader is implying that by voting for this 
amendment, you will guarantee a commitment to the global fund that is 
more robust than you would by voting against it.
  The House is not going to spend more than $1 billion on the global 
fund. So you can vote to increase the funding, but that will just send 
the bill to conference where the funding will be reduced to the House 
amount, or preferably, lower.
  Here is the real point. The President has indicated his determination 
in having Congress send him a final bill before he departs for the June 
1-3 G8 Summit in Evian, France.
  At the G8 Summit, the President intends to use this bill as a 
catalyst and leverage in requesting that the world's leading powers 
make combating global HIV/AIDS a significant element in their foreign 
assistance programs.
  If this amendment is adopted, the President will not have it for the 
G8 summit. He will not be able to use our $1 billion commitment to 
leverage other nations to make similarly generous commitments.
  The other G8 countries contributions are paltry compared to ours. The 
next highest country is Italy who contributed $100 million. The rest 
are half that amount. The Gates Foundation contributes more to the 
global fund than most G8 countries.
  If my colleagues want to maximize the global contribution to the 
global fund, they should vote against this amendment so we can get this 
bill signed into law and President Bush can have the strongest possible 
hand at this summit.
  In conclusion, there is a lot in this bill I do not like. There are 
provisions I would change. I think there is way too much money in this 
bill for the global fund.
  I have amendments I would like to offer. Some are pretty important. 
Some would be adopted overwhelmingly. But if it means we avoid a 
lengthy conference and allow the President to make the strongest 
possible case at the summit in June, I am willing to withhold. There 
will be other chances to improve this bill. I urge my colleagues to do 
the same.
  Ms. MIKULSKI. Mr. President, I support the United States Leadership 
Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003.
  For 20 years, HIV/AIDS has spread from the devastated region of sub-
Saharan Africa to the entire world. It is the fourth leading cause of 
death in the world, killing over 22 million people.
  But HIV/AIDS doesn't just kill people. It destroys economies. It 
ruins nations. It menaces our children and stifles hope.
  Forty-two million people worldwide have HIV/AIDS. Thirteen million 
children are now orphans because of its wrath. Three million children 
are infected. The vast majority of the afflicted live in Africa, but 
the disease continues to spread at an alarming rate. The peoples of 
Eastern Europe, China, India and Central Asia are under assault. The 
world cannot afford a mediocre response to this disease's assault on 
human life.
  While the experts know how this disease spreads, we can't afford to 
rely on one solution. Abstinence, being faithful and condoms is an 
approach that has been successful in Uganda. The ABC approach is now 
being followed in other countries as well. But this won't stop rape, 
sexual abuse and prostitution. We cannot expect women and children 
refugees to overcome their vulnerability to HIV/AIDS by themselves. 
They deserve real help--help with empowerment, help in fighting the sex 
and trafficking industries, and help in keeping their predators away.
  We also need to help the families that are ruined by AIDS. The costs 
of caring for a family member afflicted with AIDS are severe, even 
worse if the person affected is the family's primary wage earner. 
America must stand up and ensure that families can afford the treatment 
and care they need to dull the spread and impact of HIV/AIDS.
  This disease affects whole societies and nations, not just the 
infected individuals and their families. Economies suffer when labor 
forces can no longer survive, much less be productive. When the most 
educated and vital members of society get HIV, economies contract 
rather than grow. National security suffers when military forces 
contract HIV, often at rates up to 5 times as high as civilians.
  But the HIV/AIDS pandemic is not the only threat we need to fight. 
Tuberculosis and malaria compound the problems of HIV/AIDS in 
developing countries, where 6 million people died of HIV/AIDS, 
tuberculosis, or malaria in 2002.
  The nations and peoples of the world must share the burden of 
responding to the HIV/AIDs pandemic. Eliminating the scourge of AIDS 
won't be easy and it won't be cheap.
  That's why the U.S. needs to make a real contribution to the Global 
Fund to Fight AIDS, Tuberculosis, and Malaria. The $500 million the 
U.S. has pledged to the fund falls far short of the $7 billion it will 
need over the next two years to carry out its critical mission. We can 
do better. We must.
  America also needs to encourage concerted international action beyond 
these important monetary contributions. HIV/AIDS is not a unilateral 
threat. The world must make a sustained, comprehensive global effort to 
provide a coordinated program of treatment, care and prevention. 
Together, we must combine the best of our values, service, technology, 
expertise and diplomacy to fight the great international menace of HIV/
AIDS.
  The United States Leadership Against HIV/AIDS, Tuberculosis, and 
Malaria Act of 2003 is a good step toward this goal. I applaud 
President Bush for joining our cause by proposing an Emergency Plan for 
AIDS Relief, a new mission to help countries in Africa and the 
Caribbean region address the HIV/AIDS pandemic by providing money, 
expertise and training. This measure recognizes the critical link 
between HIV/AIDS care, treatment, prevention, and education efforts. It 
also responds to the need for health care systems that actually provide 
the right treatment.
  I'm proud to vote for this bill because I see as a culmination of our 
efforts here in the Senate to make this issue less about partisanship, 
and more about people. I've fought for so many years to provide a more 
adequate response to HIV/AIDS. I commend my colleagues for uniting in 
this effort.
  There are certainly provisions in this bill that concern me. I've 
voted to try to change some of them. But I'm not going to let those 
concerns stand in the way of my support for a stronger U.S. and 
international response to the AIDS pandemic. While this bill is not 
perfect, it is a good start that may save millions of lives.
  By passing this bill, the United States is taking real action to live 
up

[[Page 11849]]

to its responsibilities as the strongest country in the world. We can 
show that we really do care about improving the lives and futures of 
people in the developing world. The American people should be proud of 
this American leadership.
  The PRESIDING OFFICER. The question is on the engrossment and third 
reading of the bill.
  The bill was ordered to be engrossed for a third reading, was read 
the third time, and passed, as follows:
  (The bill will be printed in a future edition of the Record.)
  Mr. LUGAR. Mr. President, I thank all Senators for their diligence 
and faithfulness in working to this late hour. I thank our leader, 
Senator Frist; likewise, Senator Daschle. I always appreciate working 
with my colleague, Senator Biden. We have a good relationship on the 
committee, and we are very appreciative that the Senate has given us 
this bill this evening.
  The PRESIDING OFFICER. Does the Senator move to reconsider the vote?
  Mr. LUGAR. I move to reconsider the vote, and I move to lay that 
motion on the table.
  The motion to lay on the table was agreed to.
  The PRESIDING OFFICER. The majority leader.
  Mr. FRIST. Mr. President, what we have just done is significant in 
many ways. We have addressed for the first time in a comprehensive way 
one of the greatest humanitarian, moral, and public health challenges 
this country has ever seen, and, I would argue, the greatest 
humanitarian challenge we have had to face in the last 100 years.
  We addressed this health challenge in a comprehensive way. We 
addressed it with an authorization for $15 billion over 5 years. It was 
just a few years ago we were spending a total of $100 million a year, 
and now it is going to be approximately $3 billion a year.
  As has been stated again and again over the course of the evening, 
the afternoon, and around lunch when we first began talking on the 
bill, what we have done is shown that the United States is not just a 
good nation but is indeed a great nation, that we will lead in the 
global fight against this destructive virus that has killed 23 million 
people, that is affecting the lives of over 45 million people today, 
and that, as we have said today, will likely take the lives of 60 
million others and will create probably another 40 million orphans over 
the next two decades.
  This is our first step. I congratulate the chairman of the Foreign 
Relations Committee for bringing us to this point. Many of us have been 
working for 3, 4, and 5 years even to bring us to this point. I thank 
him for his tremendous leadership in accomplishing this goal.
  I will be happy to yield to my colleague, Senator Enzi.
  The PRESIDING OFFICER. The Senator from Wyoming.
  Mr. ENZI. Mr. President, I congratulate everybody who was involved in 
the bill. This was not easy work. There were a lot of different 
personalities and opinions. It is a huge issue with a lot of detail. 
There is a lot of room for error and misunderstandings and different 
amendments.
  I am so pleased that people on both sides of the aisle worked through 
all the difficulties, both ends of the building worked through all the 
difficulties, and that we arrived at this position.
  I particularly congratulate the majority leader for the outstanding 
job he has done through all the years he has worked on AIDS. This would 
not have come to our attention and a vote tonight if it had not been 
for the diligence of Senator Frist.
  I also thank the chairman of the Foreign Relations Committee for all 
the work he has done on the bill. He has been through more variations 
of this bill than almost anybody, except Senator Frist, and was willing 
to find a position that would get this bill passed. He did that in the 
best kind of spirit and took some stands against a bill that had his 
name on it. That is very difficult work for a Senator to do, and he did 
it in the best spirit of making sure we were taking care of the work.
  It is one of the more universal bills we have done since I have been 
in the Senate.
  I congratulate everyone for coming together and finishing this bill.

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