[Congressional Record (Bound Edition), Volume 154 (2008), Part 4]
[Senate]
[Pages 4983-4989]
[From the U.S. Government Publishing Office, www.gpo.gov]




                    THE SAVE LIVES FIRST ACT OF 2008

  Mr. COBURN. Mr. President, 5 years ago, Africa was in crisis and in 
despair. HIV/AIDS was decimating whole communities. Some countries, 
such as Botswana, were literally on a path to extinction, with rates of 
HIV infection among pregnant women in some locations reaching as high 
as 40 and even 50 percent. In South Africa, while a third

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of pregnant woman were infected with the virus, the country's political 
leaders were actually denying that AIDS was caused by HIV infection, an 
ominous sign that little help was on the way for the over 4 million 
South Africans--over 10 percent of the population--dying of AIDS.
  In 2003, if a woman in sub-Saharan Africa was infected with HIV, the 
familiar story was all too oft-repeated. She would very likely watch 
her husband die first, and then her youngest children would also become 
infected either at birth or through breastfeeding, as she languished 
under her own death sentence. Within a short time, her children would 
be orphans, left to fend for themselves in the streets and slums of 
Nairobi, or Soweto, often getting sick with their own HIV infections 
and dying alone, without food or shelter or medicine.
  The sheer numbers at the time were staggering. The disease affected 
well over 20 million people in sub-Saharan Africa by the year 2000, 
roughly equivalent to the total number of American children under 6 
years old. The problem seemed overwhelming, indeed hopeless.
  What was the world doing to stop the carnage? Were there armies of 
doctors sweeping in with the miracle drugs that had been saving lives 
in America and other rich countries for nearly a decade? No. The U.S. 
was spending under $200 million a year on HIV/AIDS overseas, mostly on 
report-writing, some condom marketing, and ``capacity-building'' 
programs that never actually used any of the capacity supposedly built 
and that had no measurable impact on the devouring epidemic.
  Treatment was the demand of most global health activists of the day. 
An indignant group gathered in South Africa in 2002. ``While a 
necessary component of the response to HIV/AIDS, prevention will never 
be enough,'' insisted Winston Zulu of the Network of Zambian People 
Living with HIV/AIDS (NZP+). ``When will the world wake up to the fact 
that the 16 million Africans that have already died of HIV/AIDS? This 
is only the beginning if we continue down the prevention-only path. 
This movement will make treatment, which we all know strengthens 
prevention efforts, our priority demand.'' Domestic and international 
chapters of ACT-UP and others were heckling U.S. officials at 
international health conferences, demanding antiretroviral treatment 
for people with HIV/AIDS in the developing world, especially in Africa.
  And then something remarkable happened. On a cold January night in 
Washington, DC, far from the overcrowded, underequipped clinics of 
Africa, an American president made a promise--a $15 billion promise to 
provide treatment to millions of Africans, within 5 years.

       Anti-retroviral drugs can extend life for many years. And 
     the cost of those drugs has dropped from $12,000 a year to 
     under $300 a year--which places a tremendous possibility 
     within our grasp. Ladies and gentlemen, seldom has history 
     offered a greater opportunity to do so much for so 
     many...tonight I propose the Emergency Plan for AIDS Relief--
     a work of mercy beyond all current international efforts to 
     help the people of Africa. This comprehensive plan will 
     prevent 7 million new AIDS infections, treat at least 2 
     million people with life-extending drugs, and provide humane 
     care for millions of people suffering from AIDS, and for 
     children orphaned by AIDS.--President George W. Bush, State 
     of the Union Address, Jan. 28, 2003.

  Glimmers of hope ignited around the world that night, as the U.S. 
policy against providing treatment in a foreign aid program came to an 
abrupt and inspiring end. The Congress took up the challenge, and 
passed a bill a few months later that was ground-breaking, a seismic 
shift in current policy and funding levels. The first and perhaps most 
dramatic policy shift was the statutory requirement that over half, a 
full 55 percent of all $15 billion of the program's funding be spent on 
life-saving medical treatment for people with HIV/AIDS.
  People said it couldn't be done. The naysayers said that Africans 
would not be able to adhere to complex drug regimens. They said that 
there simply wasn't the capacity to absorb all those dollars and build 
new clinics and expand hospital wings. They said people wouldn't come 
from miles around to get tested and treated. We wouldn't be able to use 
mopeds and bicycles to deliver drugs to the rural hinterlands. There 
weren't enough doctors. There wasn't sufficient logistic ability to 
store so many drugs. These arguments are being repeated today. They 
were uninspired and uninformed in 2003 and they still are today. The 
President's Emergency Plan for AIDS Relief, PEPFAR, has proven them all 
wrong.
  Since PEPFAR started, over 1.4 million people who would either be 
dead or dying today have received life-saving antiretroviral treatment. 
That's millions of children who didn't become orphans. Millions of 
parents who get to see their children grow up. Millions of moms whose 
babies were protected from infection. Countless communities across the 
plains and prairies, streets and slums of Africa and the Caribbean, 
where hope has taken a foothold. Where once stigma and despair kept 
people from even getting tested, people now come out by the thousands 
on HIV testing days in Kampala and elsewhere.
  PEPFAR is a comprehensive program, investing heavily in prevention 
and care as well as treatment. However, the majority of the funds have 
been spent on treatment. The true nature of PEPFAR, the appeal of the 
program, the miracle that has raised millions from the dead is the 
program's commitment to life-saving anti-
retroviral treatment. If you ask Africans what PEPFAR is, they'll tell 
you it's about AIDS treatment. It is the treatment component of PEPFAR 
that has made it the most successful U.S. humanitarian effort in 
history because it has literally saved the lives of millions, preserved 
families and communities, and rescued countless babies from being born 
with an AIDS death sentence.
  Five years later, the American people stand at a crossroads. PEPFAR 
is expiring and the true test of our commitment to life-saving 
treatment is before us. We have a choice. Will we lose heart? Will we 
lose our focus? Will we allow a program that was ambitious, inspiring, 
targeted and tangibly and measurably effective at saving lives become 
diluted, vague, ill-defined and lose its life-saving impact? Will we 
allow partisanship and competing priorities and even some good 
intentions cloud and subvert the long-term success of PEPFAR? Will we 
turn PEPFAR into just another bloated, unmeasured and unmeasurable 
foreign aid program with no accountability and no real impact, a 
program that tries to do too much and accomplishes too little? As 
funding increases and rhetoric builds, will we, in this moment of 
testing, betray our historic commitment to Africa and the lives of 
millions of its inhabitants?
  It is embarrassing to admit that we find ourselves on a direct path 
to that shameful outcome. The once loud and indignant voices demanding 
treatment for Africans have found other priorities, it would seem. 
Inexplicably and inexcusably, the House and Senate PEPFAR 
reauthorization bills, negotiated with the approval of the 
Administration, reverse what was undoubtedly the most important element 
of PEPFAR the requirement that the majority of funding be spent on HIV/
AIDS treatment. What's more, the bills more than triple PEPFAR funding, 
but only increase treatment targets by 50 percent. Despite their $50 
billion price-tags, the House-passed bill and the Senate committee-
reported bill would only add an additional one million people, of the 
many more millions in need, to the treatment rolls over the next five 
years. It seems that, after five years focusing on helping people with 
HIV/AIDS, the focus of the program under these proposed 
reauthorizations would shift to helping the foreign aid ``industrial 
complex'' of USAID contractors based in the U.S. and European capitals. 
The proposed reauthorization bills would prioritize literally every 
possible development cause except HIV diagnosis and treatment.
  It is this glaring policy reversal that is the impetus for S. 2749, 
the ``Save Lives First Act of 2008.'' The bill reinstates the current 
policy requiring at least 55 percent of funding to go to life-saving 
medical treatment for people infected with HIV/AIDS. It also allocates 
a small percentage of funding for the critical diagnostic screening 
that must

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be ramped up dramatically if we are to locate and treat every infected 
person in the countries where PEPFAR operates. Finally, the bill 
acknowledges that every baby infected with HIV by her mother during 
birth or breastfeeding is a largely preventable tragedy that should be 
eliminated.
  Although we have grave concerns about many other policies in the 
House and Senate reauthorization bills, including the prevention 
policy, the expansion of funding to rich countries, the ``mission 
creep'' that diverts funding from high-priority HIV/AIDS programs to 
lower-priority development programs, and others, we chose to focus in 
the Save Lives First Act on the critical problem of the House and 
Senate bills' betrayal of the President's and the 108th Congress' 
historic commitment to life-saving HIV/AIDS treatment.
  There is no question that PEPFAR has been the most successful foreign 
aid program since the Marshall Plan. The structural reason for its 
success is that it approaches and addresses AIDS for what it is--a 
viral epidemic. Though much may have changed in the past four years, 
this simple fact has not, and will not, change.
  Regardless of location, demography, mode of transmission, and so 
forth, the basic method of combating an epidemic, any epidemic, is the 
same: find the infected, provide them care, and help them prevent 
transmission to others. There are 33 million people living with HIV, 
and only they can prevent the transmission of the disease. If we find 
the people with HIV, we could not only treat them, but yes, prevent new 
infections as well. That's why treatment and testing are critical to 
prevention efforts. They are not the whole story--behavior change 
programs are needed--but diagnosis and treatment are two of the 
foundations of disease control. What's more, prevention through 
education is far less costly than treatment. Uganda's success in the 
1990s proved that with the proper message and political leadership, 
behavior change that reduces transmission rates dramatically can be 
achieved fairly inexpensively. The current PEPFAR program and its 
original authorizing legislation are appropriately structured on this 
foundation of diagnosis, treatment and successful prevention.
  So what are the mechanics of treating people? First, you must 
diagnose those who are infected. That is why this bill designates 
specific funding for performing rapid tests, and sets testing target 
goals. If we test 1 billion people over the next 5 years, we will 
discover the vast majority of all those living with HIV. However, 
experience shows that people will not get tested, no matter how much 
they may want to, without an incentive to know their status. It cannot 
be disputed that people known to be HIV positive suffer enormous stigma 
and discrimination throughout the world, and therefore need an 
incentive strong enough to overcome this.
  The incentive is treatment. If people know that, should they be found 
to be HIV positive, there is hope and health in their future, they will 
have an incentive to get tested. The promise of a longer and healthier 
life is necessary to overcome the stigma--and, in a self-reinforcing 
loop, the presence of treatment, and the effect of people literally 
returning from the dead, goes a long way to reduce HIV stigma. That is 
one of the reasons why the Save Lives First Act maintains the 55 
percent allocation of PEPFAR funding for treatment, and seeks to 
increase the number of people treated proportionally to the increase in 
overall funding.
  The AIDS drug nevirapine, which costs only $4 per treatment, can 
dramatically reduce the likelihood that a newborn will become infected 
with HIV. Yet a new U.N. report delivers the news that only a quarter 
of HIV-positive pregnant women in poorer countries are receiving the 
medication needed to prevent baby AIDS. Furthermore, the number of AIDS 
orphans in poorer countries continues to increase, and in sub-Saharan 
Africa an estimated 12.1 million children in 2007 had lost one or both 
parents to HIV.
  By sticking to the fundamental disease control methods of testing and 
treatment, new infections are prevented. First, we have seen here in 
the U.S. that people who know their HIV status are less likely to 
engage in risky behavior--they seek to protect themselves and their 
partners. The Centers for Disease Control and Prevention reports that 
the 25 percent of Americans who don't know their HIV status transmit 
50-75 percent of new infections. What's more, a recent study has 
suggested that increased testing in the U.S. reduced infection. 
Further, people who are receiving treatment have less of the virus in 
them, and are less infectious. There is increasing evidence documenting 
this phenomenon. Behavior change programs targeted to the general 
population, most of whom are uninfected, may help reduce infection 
rates to a point, but it is hard to think of a more direct preventive 
measure than rendering an HIV positive person less infectious and less 
likely to infect others.
  Therefore, claims that the bill does not address prevention are 
simply untrue. First, billions and billions of dollars not dedicated to 
treatment and testing are available for prevention in the House and 
Senate bills. After spending 55 percent of the $50 billion in the bills 
on lifesaving treatment, there will still be $27.5 billion left over 
from which prevention programs could be funded, dramatically more 
programs than under the current, $15 billion program. Second, and to an 
important extent, testing and treatment are part of an effective 
prevention approach.
  In addition, some have claimed that the Save Lives First Act 
significantly increases costs, anywhere from $13-$17 billion. These 
claims miss the point of the Save Lives First Act--which is not to add 
to costs, but to prioritize how authorized funds are spent. As the 
attached treatment cost analysis shows, the total dollar amount for all 
drugs, test kits, and prevention-of-mother-to-child-transmission 
materials needed to meet the goals in the bill is just over $11 billion 
(using conservative assumptions about costs that are likely to be lower 
in reality due to government discounts). A reauthorization bill 
containing $50 billion plus numerous ``such sums'' authorities, such as 
the bills under current consideration in the House and Senate, would 
contain sufficient money to meet these goals as well as procure the 
infrastructure necessary to deliver these drugs and diagnostic tests. 
These costs are not added on top of the proposed reauthorization 
spending levels, as some have claimed. Rather, the Save Lives First Act 
takes the first 55 percent of all funding in any reauthorization bill--
whatever the ultimate amount of funding turns out to be--$30 billion, 
$50 billion or more (as is actually likely given the current 
appropriations frenzy in the Congress)--and directs it to treatment 
costs. If meeting the heroic targets in our bill--adding 5 million new 
people to treatment (in addition to the 2 million already in 
treatment), conducting a billion HIV tests, and saving babies from 
being infected by their moms--ends up costing more than 55 percent of 
PEPFAR funding, we challenge any critic to think of a better use of 
funds. However, as the attached chart demonstrates, there will be 
plenty of money in a $50 billion bill left for prevention and care 
after meeting the requirements of the Save Lives First Act.
  The current alternative to this approach, as embodied by the House 
and Senate bills containing no money dedicated to testing and 
treatment--is that millions of people will die for lack of treatment. 
In addition, the vast majority of people with HIV will remain ignorant 
of their status, and will continue to unknowingly infect others, 
continuing the cycle that led to the devastating epidemic we now face. 
Letting people die, and keeping people ignorant of their status, is not 
the way to end this epidemic. We recognize this truth here in the U.S., 
where we spend 11 percent annually on prevention, but 67 percent on 
treatment out of a total budget of $23.3 billion spent on AIDS 
domestically.
  Some have argued that a heroic American commitment to testing and 
treatment such as the targets in the Save Lives First Act will 
discourage other donors from supporting diagnosis

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and treatment. The truth is that other donors have yet to demonstrate 
substantial commitment to bilateral treatment programs. Most other 
donors prefer to fund treatment through their contributions to the 
Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria, a multilateral 
organization affiliated with the United Nations, to which the U.S. is 
the largest (by far) contributor. That is what the Global Fund is for--
to create efficiencies of scale and allow smaller donors to contribute 
to those more efficient programs rather than reinventing the wheel and 
starting up their own bilateral programs. When other donors do invest 
in bilateral efforts, it is almost always on the prevention side--
funding needle exchanges for drug users, condom and ``empowerment'' 
programs for prostitutes, and other prevention efforts in Africa, Asia 
and eastern Europe, usually based on behavior change programs. This is 
all the more reason why one donor, the U.S., needs to focus on 
diagnosis and treatment--the rest of the donor community is not as 
committed to these programs compared to other approaches. But let's say 
that other donors want to support treatment--great! We welcome their 
participation. There is so much to do--between 7 and 8.4 million people 
still need treatment today. PEPFAR certainly can't treat everyone in a 
given year, and will have to rely on the efforts of others going 
forward, if we want to bring hope to everyone affected by this dreadful 
disease.
  We are proud of PEPFAR and the millions of miracles it has created 
already in its first four years of operation. The American people can 
look at PEPFAR and, unlike what they'll find with most government 
programs, they can see measurable and tangible results in the faces of 
the millions saved and cared for with U.S. funding. PEPFAR isn't 
``broken,'' and it doesn't require ``fixing'' in its reauthorization--
it's a stunning success. The burden of proof is on those who want to 
radically change PEPFAR policies, not on those of us who want to 
preserve them. We look forward to working with the President and House 
and Senate leaders to ensure that PEPFAR continues its successful, 
miraculous, life-saving track record.
  Bertha, a 23-year-old PEPFAR treatment client in Tanzania speaks for 
millions when she says, ``If it is not these ARVs, I think I was dead 
long time ago because I use and I am still using these drugs. Now I can 
do anything. I'm healthy and I'm strong.''
  Mr. President, I ask unanimous consent that my endnotes and graph be 
printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

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