[Senate Hearing 110-441]
[From the U.S. Government Publishing Office]
S. Hrg. 110-441
PERSPECTIVES ON THE NEXT PHASE OF THE GLOBAL FIGHT AGAINST AIDS,
TUBERCULOSIS, AND MALARIA
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON FOREIGN RELATIONS
UNITED STATES SENATE
ONE HUNDRED TENTH CONGRESS
FIRST SESSION
__________
DECEMBER 13, 2007
__________
Printed for the use of the Committee on Foreign Relations
Available via the World Wide Web: http://www.gpoaccess.gov/congress/
index.html
U.S. GOVERNMENT PRINTING OFFICE
43-704 PDF WASHINGTON DC: 2008
---------------------------------------------------------------------
For Sale by the Superintendent of Documents, U.S. Government Printing Office
Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; (202) 512�091800
Fax: (202) 512�092104 Mail: Stop IDCC, Washington, DC 20402�090001
COMMITTEE ON FOREIGN RELATIONS
JOSEPH R. BIDEN, Jr., Delaware, Chairman
CHRISTOPHER J. DODD, Connecticut RICHARD G. LUGAR, Indiana
JOHN F. KERRY, Massachusetts CHUCK HAGEL, Nebraska
RUSSELL D. FEINGOLD, Wisconsin NORM COLEMAN, Minnesota
BARBARA BOXER, California BOB CORKER, Tennessee
BILL NELSON, Florida JOHN E. SUNUNU, New Hampshire
BARACK OBAMA, Illinois GEORGE V. VOINOVICH, Ohio
ROBERT MENENDEZ, New Jersey LISA MURKOWSKI, Alaska
BENJAMIN L. CARDIN, Maryland JIM DeMINT, South Carolina
ROBERT P. CASEY, Jr., Pennsylvania JOHNNY ISAKSON, Georgia
JIM WEBB, Virginia DAVID VITTER, Louisiana
Antony J. Blinken, Staff Director
Kenneth A. Myers, Jr., Republican Staff Director
(ii)
C O N T E N T S
----------
Page
Daulaire, Dr. Nils, president and CEO, Global Health Council,
Washington, DC................................................. 17
Prepared statement........................................... 19
Hackett, Ken, president, Catholic Relief Services, Baltimore, MD. 25
Prepared statement........................................... 27
Kazatchkine, Dr. Michel, executive director, Global Fund to Fight
AIDS, Tuberculosis, and Malaria, Geneva, Switzerland........... 6
Prepared statement........................................... 9
Lugar, Hon. Richard G., U.S. Senator from Indiana................ 3
Menendez, Hon. Robert, U.S. Senator from New Jersey.............. 1
Smits, Dr. Helen, vice chair, Committee for the Evaluation of
PEPFAR Implementation, Institute of Medicine, Washington, DC... 13
Prepared statement........................................... 15
Sununu, Hon. John E., U.S. Senator from New Hampshire............ 5
Additional Material Submitted for the Record
Prepared statement of Global AIDS Alliance submitted by Dr. Paul
Zeitz, executive director, Washington, DC...................... 43
Responses from witnesses to questions submitted for the record by
Senator Biden:
Responses of Dr. Michel Kazatchkine.......................... 46
Responses of Dr. Helen Smits................................. 48
Responses of Dr. Nils Daulaire............................... 49
Responses of Ken Hackett..................................... 52
(iii)
PERSPECTIVES ON THE NEXT PHASE OF THE GLOBAL FIGHT AGAINST AIDS,
TUBERCULOSIS, AND MALARIA
----------
THURSDAY, DECEMBER 13, 2007
U.S. Senate,
Committee on Foreign Relations,
Washington, DC.
The committee met, pursuant to notice, at 2:37 p.m., in
room SD-419, Dirksen Senate Office Building, Hon. Robert
Menendez, presiding.
Present: Senators Menendez, Kerry, Feingold, Lugar, and
Sununu.
OPENING STATEMENT OF HON. ROBERT MENENDEZ, U.S. SENATOR FROM
NEW JERSEY
Senator Menendez. This hearing will come to order.
The purpose of today's hearing is to discuss our efforts to
combat HIV/AIDS, tuberculosis, and malaria. In 2003, Congress
passed the United States Leadership Against HIV/AIDS,
Tuberculosis, and Malaria Act to authorize funds for the
President's Emergency Plan for AIDS Relief, known as PEPFAR,
created the Office of the Global AIDS Coordinator, and
authorized funds for the Global Fund to Fight AIDS,
Tuberculosis, and Malaria.
We are here today to look at the progress and challenges to
date as we look ahead toward next year's reauthorization of
this important legislation.
I want to welcome our distinguished panel of experts, and
we look forward to a productive discussion.
The issues that we are here to discuss remain as relevant
and devastating as ever. Today, 6,800 people around the world
will become infected with HIV, and 5,700 people will die of
AIDS-related diseases. This year, more than 1 million people
will die of malaria, most of whom will be children under 5, and
tuberculosis will kill 1.6 million people, including 195,000
who are also infected with HIV/AIDS.
On May 30, President Bush requested that Congress authorize
$30 billion to extend the Global HIV/AIDS Initiative an
additional 5 years. In this call for reauthorization, the
President emphasized the responsibility to continue to support
those who have already been reached by PEPFAR, especially the
continuation of antiretroviral treatment.
In reacting to the President's proposal, some advocates for
the fight against AIDS, including a number of Members of
Congress, while praising progress to date, have called for $50
billion over 5 years to combat HIV/AIDS, TB, and malaria,
rather than $30 billion. These resources would represent a
significant increase over current funding levels.
The reauthorization of PEPFAR cuts across many of the most
prominent challenges of foreign assistance. For example,
regardless of the type of programs we are funding, many of the
same local factors complicate the intervention. Culture,
behavior, tradition, faith all play a role.
In terms of managing and implementing programs, many of the
same structural challenges exist: Low government capacity,
abject poverty, absence of government systems, lack of
accountability, lack of data, and corruption.
And then, in terms of our strategy and design of programs,
many of the same dichotomies are also at play. Centralized
versus decentralized management, bilateral versus multilateral,
country-driven versus donor-driven, targeted versus diffused,
and Washington-driven versus field-driven.
Finally, how do we best monitor and evaluate programs,
respect intellectual property rights, and incorporate the
private sector and other partners?
None of these questions are easy. A few of the responses
may not be fully satisfying, but we are here today to talk
about PEPFAR and the Global Fund, and we hope to apply your
insights to the wider universe also of foreign assistance.
As the chairman of the Subcommittee of Foreign Assistance,
I'm interested in the overall management of the PEPFAR program
in the context of our larger development goals and programs.
Are we getting the most for our money? Are we doing the right
mix of programs? How do we balance priorities in education,
health, economic growth, social investment, and the
environment? What oversight mechanisms are in place to ensure
that the funds are being used for the purposes Congress
intended? If increased resources are authorized, will those
authorizations and resources--where would they come from, and,
particularly, how well could they be used?
It's a unique opportunity today, because we have a chance
to be both proactive and forward-thinking. While the
devastation of these issues does not pause, certainly we need
to be thoughtful and deliberate on how we approach them. Some
of the best strategic and medical minds are working on these
issues, so I'm confident we are on the path toward success, but
this upcoming authorization will establish an important
framework within which the next 5 years of work will take
place.
There is good news and there is bad news. The good news is
that the global health community has made great strides with
HIV/AIDS. The bad news is that the questions are now even
harder. While the U.S.-led effort has made substantial advances
in providing access to treatment, the need still far outweighs
the availability of services. The rate at which individuals
become infected with HIV continues to outpace the rate at which
they are treated. And, once begun, treatment is a lifelong
obligation and expense.
Also, in looking at future costs of these programs, UNAIDS
estimates that, to achieve universal access to antiretroviral
medications, the global resource needs for 2010 would be
approximately $40 billion. This figure does not include costs
for prevention or care. In the current zero-sum appropriations
environment, no single intervention is funded in a vacuum; each
one has an impact on all the others. In this case, I certainly
reject the idea of a zero-sum budget environment, and I
believe, as I have said before, that more resources need to be
provided overall for foreign assistance, and this is a critical
part of that effort.
So, the question is: How do we leverage additional
resources within the government, from other countries, and from
the private sector to help cover these costs?
And, last, even with the revised UNAIDS numbers, prevention
is considered to be of particular importance in the next 5-year
phase of PEPFAR and other programs. The only way that we are
going to make inroads against HIV/AIDS is to improve
prevention, and it cannot just be behavioral interventions that
we have supported in the past, but we must find new medical
ways of stopping the disease, whether that is medical male
circumcision or microbicides or something that we don't yet
understand. The important thing is that we keep our focus on
the core issues.
I also believe that we cannot blind ourselves to the
possibilities of a wave of new infections that may be coming. I
believe that people lean toward talking about treatment because
it's comfortable and measurable, but prevention needs to be a
priority, moving forward. We can treat, forever; but until we
learn how to slow the disease, we will not make a lasting
difference.
So, we look forward to this incredibly important panel and
what they have to say. We commend you for the work that you
have all done, individually and collectively. You're making
great contributions to lifesaving efforts around the world.
We are going to turn to our other colleagues here, starting
with the ranking member of the full committee. We are,
hopefully, not going to be challenged too early by votes on the
floor, for which there will be several lined up. So, we will
get through all of the witnesses' testimony, and then we'll see
where our questioning session begins.
And, with that, I recognize the distinguished member of the
full committee, Senator Lugar.
OPENING STATEMENT OF HON. RICHARD G. LUGAR, U.S. SENATOR FROM
INDIANA
Senator Lugar. Well, thank you very much, Mr. Chairman.
As you pointed out, the Foreign Relations Committee is
meeting again to discuss the reauthorization of the Leadership
Act Against HIV/AIDS, Tuberculosis, and Malaria. The Leadership
Act, recognizing that the devastating AIDS crisis required an
overwhelming response, created the $15 billion President's
Emergency Plan for AIDS Relief--PEPFAR. This program has
provided treatment to an estimated 1.1 million men, women, and
children infected with HIV/AIDS in Africa and elsewhere.
Before the program began, only 50,000 people in all of sub-
Saharan Africa were receiving lifesaving, but costly,
antiretroviral drugs. Today, three times that many are being
treated in Kenya alone. The Leadership Act also focuses on
prevention programs, with the target of preventing 7 million
new HIV/AIDS infections.
As Americans, we should take pride in our Nation's efforts
to combat these diseases overseas. However, we must act with
dispatch to build on these efforts, or lives will be lost
needlessly.
On October 24, the committee heard testimony from the
Department of State's Global AIDS Coordinator, Ambassador Mark
Dybul. He noted that there is increasing concern about United
States intent with regard to the AIDS programs. While there is
little doubt that the Leadership Act will eventually be
reauthorized, the uncertainty with regard to the timing and
amount of American funding means that fewer new patients will
receive lifesaving treatment. Partner governments and
implementing organizations in the field have indicated that,
without early reauthorization of the Leadership Act, they may
not expand their programs in 2008 to meet PEPFAR goals.
At our last hearing, I cited a letter from the Ministers of
Health of the 12 African focus countries receiving PEPFAR
assistance. They wrote: ``Without an early and clear signal of
the continuity of PEPFAR support, we are concerned that
partners might not move as quickly as possible to fill the
resource gap that might be created; therefore, services will
not reach all those who need them. The momentum will be much
greater in 2008 if we know what to expect after 2008.''
The committee also received support for early
reauthorization from AIDS Action, which believes that our
global partners need to be assured that the U.S. commitment and
leadership will continue and grow.
We heard from the Foundation and Donors Interested in
Catholic Activities, which argues that early reauthorization,
``will encourage implementing partners to expand the number of
patients receiving antiretrovirals at the 2008 target levels
rather than holding back on the new services for fear the
program's ending or being seriously curtailed. This means many
more lives will be saved.''
Part of the original motivation behind the PEPFAR program
was to use American leadership to leverage other resources in
the global community and the private sector. According to the
United Nations, ``every dollar invested by the United States
leverages two dollars from Europe,'' in the battle against
AIDS. The continuity of our effort to combat this disease, and
the impact of our resources on the commitments of the rest of
the world will be maximized if we act now.
The Leadership Act is due to expire in September 2008. This
past August, I introduced Senate bill 1966, which reauthorizes
the Leadership Act and doubles the funding to $30 billion. If
the United States signals to the world that it is reaffirming
its leadership on HIV/AIDS, that will guarantee critical
continuity in the effort, and will save more lives.
After consulting extensively with American officials who
are implementing PEPFAR, I included several modifications in my
bill which I believe will enjoy broad congressional support. My
bill clarifies the provision on prevention programs, to make
more money available for mother-to-child transmission and
blood-supply safety. It also proposes new benchmarks to
strengthen accountability and transparency at the Global Fund
to Fight AIDS, Tuberculosis, and Malaria, which has been a
critically important partner. I believe we should avoid changes
that limit programs' flexibility, which has been at the heart
of success.
I join the chairman in welcoming our distinguished panel of
expert implementers who are engaged now in the fight against
these diseases, and we look forward to their testimony.
I thank you, Mr. Chairman.
Senator Menendez. Thank you, Senator Lugar.
Senator Sununu.
STATEMENT OF HON. JOHN E. SUNUNU, U.S. SENATOR FROM NEW
HAMPSHIRE
Senator Sununu. Thank you very much, Mr. Chairman.
This is an extremely important hearing, and I think both
Senator Lugar and Senator Menendez have done a great job of
outlining the scope of the problem, and our--the panelists here
probably have much deeper experience than any Member of
Congress in understanding the scope of the crisis we face, its
impact, not just on health, but on society, across the world,
on governments, on security, on economic development. All of
these are tied into the devastation that we've seen brought to
people around the world as a result of the HIV/AIDS crisis.
Senator Lugar emphasized, and it is worth emphasizing, the
importance of American leadership. Our leadership in addressing
the problem, our leadership in providing funding, our
leadership in making this a priority here in the United States
and with all of the developed nations that we know, can provide
significant assistance, as well. And I think it's important for
Congress to bear in mind that that leadership will be
demonstrated, and can be demonstrated in one very specific way,
and that is by moving a strong and timely reauthorization bill
for PEPFAR and related programs. Putting forward legislation
early provides the clarity and the continuity that Senator
Lugar emphasized. Sometimes in Congress we forget how that's
received around the world, that other countries, whether they
are Health Ministers, Foreign Ministers, Presidents, and Prime
Ministers around the world, watch and see what kind of steps
the United States is taking in an area as important as this.
So, moving aggressively with real leadership on PEPFAR
reauthorization is critical. We have some important issues to
discuss in that reauthorization, issues like the funding
levels. The President has proposed a doubling of funds--$30
billion--but it's important that that's an issue that's
addressed early so that our counterparts around the world know,
in a sense, what is expected from them in the way of matching
support. We need to talk about what obstacles are out there to
delivering services, and, of course, what the priorities ought
to be with respect to prevention and treatment, all the while
keeping in mind that, without flexibility, we're going to make
problems--we have the potential to make problems worse, and
have the potential to limit the ability of individuals in
countries around the world to respond to this crisis.
We have a real need--and I think, and I hope, our panelists
will talk about the real need--for developing health care
capacity in order to deliver prevention and treatment and
information and support around the world. And ``health care
capacity'' can mean infrastructure, it can mean workforce, it
can mean communication, it can mean data collection. But we
have a lot of work to do to develop systems that can adequately
address the scope of the HIV/AIDS epidemic, you know, not over
the next 1 or 2 years, but over the next two or three decades
that we know it will still be with us.
This is something that has bipartisan support, and it--that
makes it, in some ways, very enjoyable to work on. And it's
something that we've seen experts around the world really focus
upon and engage in. And the panelists we have here today are no
exception. I want to welcome all those panelists.
I certainly want to particularly welcome Dr. Nils Daulaire.
Dr. Daulaire and I had the opportunity to be together at an
event that marked World AIDS Day, and talked about a lot of
these issues. I've seen his presentation before, and I have no
expectations that he's updated it in the last 10 days or so,
but it was outstanding when he presented it at Dartmouth, and
I'm sure it's still outstanding. I welcome him, as a fellow New
Englander.
And I look forward to all of your testimony.
Thank you, Mr. Chairman.
Senator Menendez. Thank you, Senator.
Again, we want to thank all of our distinguished witnesses
for joining us today: Dr. Michel Kazatchkine, executive
director of the Global Fund to Fight AIDS, TB, and Malaria; Dr.
Helen Smits, the vice chair of the committee, of the Institute
of Medicine; Dr. Nils Daulaire, the president and CEO of the
Global Health Council; and Mr. Ken Hackett, the president of
Catholic Relief Services.
We'll start with all of your opening statements. In the
interest of time, so there can be a dialog here, we ask you to
summarize your written statements to around 5 minutes or so. Of
course, all of your written statements will be included fully
in the record.
And, with that, we'll start with Dr. Kazatchkine.
STATEMENT OF DR. MICHEL KAZATCHKINE, EXECUTIVE DIRECTOR, GLOBAL
FUND TO FIGHT AIDS, TUBERCULOSIS, AND MALARIA, GENEVA,
SWITZERLAND
Dr. Kazatchkine. Thank you, Chairman Menendez.
Senator Menendez. If you would push your button on.
Dr. Kazatchkine. Chairman Menendez, Ranking Member Lugar,
Senator Sununu, I am honored to be here to present an overview
on the progress that the Global Fund to Fight AIDS, TB, and
Malaria has achieved so far, the challenges ahead of us, and
issues that will be important to consider as you renew the
PEPFAR program. Thank you for your leadership and commitment to
the fight against the three diseases.
Through the creation of the Global Fund in 2002, and PEPFAR
in 2003, as well as a number of other bilateral and
multilateral programs, world leaders have engaged in health
interventions in an unprecedented way.
To date, through the Global Fund, 1.4 million people living
with HIV in developing countries have been reached with
antiretroviral therapy. Together with PEPFAR, it is 2.8 million
people receiving treatment. We are also starting to see results
of large-scale HIV prevention efforts in a number of countries.
And, in addition, through Global Fund support, 3.3 million
people have been treated with anti-TB drugs, and 46 million bed
nets have been distributed to families at risk of contracting
malaria.
The creation of the Global Fund was inspired by the vision
to make a difference. In 5 years, the Fund has approved over 10
billion U.S. dollars for grants in 137 countries all across the
globe, providing, currently, nearly a quarter of all
international donor financing for AIDS and two-thirds of all
international funding for TB and for malaria.
Since its initial founding pledge in 2001, the United
States has played a critical role in the Fund's work, providing
2.5 billion U.S. dollars, nearly one-third of all Global Fund
financing. Overall,
G-8 countries continue to be the largest contributors to the
Global Fund, providing 60 percent of all contributions. The
Global Fund is extremely grateful to the Congress and the
American people for its support and for their commitment to
defeating AIDS, TB, and malaria. Be assured, your support to
the Global Fund is bringing hope and saving lives.
As you know, the Global Fund approach is based on strong
founding principles. The one principle underlying every aspect
of Global Fund financing is country ownership. Within its
national strategy, each country is responsible for determining
its own needs and priorities based on consultation with a broad
range of stakeholders, including government, but also civil
society. The Global Fund is also committed to performance-based
funding, meaning that only grant recipients that demonstrate
measurable and effective results receive resources on an
ongoing basis.
The Global Fund has a strong commitment to transparency and
accountability. This includes working with recipient countries
to identify key indicators to measure progress. We're presently
in the process of consolidating a range of activities within a
comprehensive risk-assessment and management framework that
will include improving the overall quality of our local funding
agents, the Global Fund's independent observers on the ground,
and strengthening our data management systems in order to
better capture information concerning grants and recipients.
As part of our commitment to transparency and
accountability, the Global Fund recognizes the importance of
having an independent and objective inspector general. The
Global Fund board recently announced the appointment of a new
IG and approved the policy to publicly disclose reports issued
by that office. This policy requires that the inspector general
post all final reports on the Global Fund's Web site not later
than 3 working days after they are issued. While restrictions
can be approved by the board, the presumption is that all the
inspector general's reports will be made public, and that
restrictions will be invoked rarely.
As you renew the PEPFAR program, I ask you to keep in mind
some key issues. At the Global Fund, resource mobilization and
sustainability of financing, which Senator Lugar mentioned in
his remarks, are among our highest priorities. Earlier this
year, the Global Fund board estimated that the Global Fund
would have to commit $6 billion, and perhaps up to $8 billion
annually, to meet country demand for the three disease areas by
2010.
In September 2007, the Global Fund completed its second
replenishment cycle in which many donors made long-term pledges
to the Fund for the period 2008 to 2010. Through this process,
the Global Fund received strong up-front pledges and other
estimated contributions, totaling approximately $10 billion for
the next 3 years. This level of funding will allow the Global
Fund to renew existing programs and approve new funding rounds
at existing levels over the next 3 years, but additional
contributions from existing and new donors are absolutely
needed if the Fund is to reach its funding targets for 2008-
2010.
We will pursue strong resource mobilization efforts in the
coming years, including attracting more contributions from the
private sector and from key emerging economies and other
innovative ways to generate resources. As the largest
contributor to the Global Fund, U.S. leadership will be
critical. As you renew PEPFAR, I hope that the United States
will achieve its original commitment to provide one-third of
all contributions to the Global Fund.
Another priority for me is strengthening the Global Fund as
a partnership, which is essential, particularly at the country
level. All constituencies involved in the Fund have crucial
roles to play in governance, in generating demand, and
implementing Global Fund-supported programs. The partnership
includes recipient countries' own commitments, bilateral
programs, multilateral agencies, such as World Bank, WHO,
UNAIDS, but also NGOs, faith-based organizations, the private
sector, and academic institutions. A strong partnership with
PEPFAR is particularly important for the Global Fund,
especially at the country level.
I would like to express, here, my thanks to Ambassador Mike
Dybul for his dedication and leadership in building an
excellent relationship between PEPFAR and the Global Fund, and
I look forward to working even more closely with him in the
future. In the next phase, we can do more to strengthen
national strategies and planning processes, and ensure that our
joint efforts are fully consistent with them.
AIDS has also highlighted the fragility of health systems
in many developing countries. As you said, Senator Sununu, it
has revealed that personnel, equipment, medicines, and
infrastructures in many countries were never adequate to
address the basic primary health care needs of the population,
let alone a new epidemic. Implemented in strategic ways,
investments to fight AIDS can be the fuel that keeps the entire
health system's engine going.
Because of the many potential benefits of disease-specific
programs, the Global Fund is engaging strongly with the broader
health systems agenda. In November, the Global Fund board
approved a new set of principles to guide Global Fund financing
of health-system strengthening as part of approaches to the
three diseases. The Global Fund is also the first major donor
to give in-principle approval to accepting national strategies
as financing instruments, which will be a major step in
harmonizing the efforts of all donors as they come together to
provide finance around a single national health plan, rather
than multiple plans and strategies.
Finally, the Global Fund is currently working hard to make
adjustments to the structures and operations of both its
secretariat and grantmaking processes so that it is equipped to
deal with the next phase of growth. In order to preserve our
hard-won reputation as a lean, flexible, country-owned
mechanism that provides financing rapidly, reliably, and in a
sustainable manner, we're currently taking stock and working to
streamline our processes so that interacting with the Global
Fund is as simple as possible for countries.
During the past 5 years, PEPFAR and the Global Fund,
together, have shown that significant impacts can be made
against the major diseases of poverty. The world needs 5 more
years of PEPFAR, and it needs the U.S. leadership and
generosity in the field of global health. A well-funded Global
Fund, along with PEPFAR, ensures that health benefits extend
beyond the 15 PEPFAR focus countries, including communities
affected by TB and malaria.
Mr. Chairman, distinguished Senators, AIDS, TB, and malaria
continue to take a terrible toll on millions of people around
the world. I ask for your ongoing concerted attention to
fighting these diseases through the critical support of the
U.S. Congress for PEPFAR and the Global Fund. Tackling these
major diseases of poverty remains the most pressing public
health challenge of our time.
Thank you very much.
[The prepared statement of Dr. Kazatchkine follows:]
Prepared Statement of Dr. Michel Kazatchkine, Executive Director, The
Global Fund to Fight AIDS, TB and Malaria, Geneva Switzerland
Chairman Menendez and Ranking Member Lugar, and distinguished
members of the Senate Foreign Relations Committee, I am honored to be
here to present an overview on the progress the Global Fund has made so
far, the challenges ahead of us and the issues that will be important
to consider as you renew the PEPFAR program. As a physician who has
treated people living with AIDS for over 20 years, I have seen first-
hand the dramatic gains we have made in the fight against AIDS, TB, and
malaria. Your work to reauthorize the AIDS program will undoubtedly
help to leverage other donors to do more as well.
At the beginning of this decade a revolution was set in motion. The
world used to think that health came as a consequence of development;
but the AIDS crisis has shown us the reverse--that if you do not
address health, other development efforts will falter. Within this new
paradigm, it has become apparent that health needs to be looked at as a
long-term investment that is essential to achieving development.
Through the creation of the Global Fund in 2002 and the PEPFAR program
in 2003, as well as a number of other bilateral and multilateral
programs, world leaders have begun to engage in health in an
unprecedented way by devoting attention and resources to fighting the
diseases that take the greatest toll on the poor: AIDS, tuberculosis,
and malaria.
As a result of this unprecedented effort, in just 6 years we are
seeing dramatic change in the landscape of the countries where we work
as more people have access to treatment and lives are being saved. In
concert with what the PEPFAR program has achieved in its 1.5 focus
countries, the Global Fund is translating the hope of access to
prevention, treatment, and care into reality around the world. As we
recently reported, results from Global Fund-supported programs show
that millions of people are receiving essential health services and
that coverage is at least doubling each year. To date, through the
Global Fund, 1.4 million people living with HIV have been reached with
life-saving antiretroviral (ARV) therapy and together with PEPFAR, 2.8
million people have received treatment. In addition to its focus on
HIV/AIDS, the Global Fund has become the largest international financer
for TB and malaria programs by far, providing two-thirds of all donor-
funding for these two diseases. To date, 3.3 million people have been
treated with anti-TB drugs and 46 million bed nets have been
distributed to families at risk of contracting malaria.
These 2007 figures emphasize a strong and steady increase in the
number of people treated for AIDS and TB, and a spectacular growth in
coverage of malaria interventions. Those who have regained their health
are able to care for their children, return to work and lead
meaningful, productive lives. In Ethiopia, for example, as a result of
comprehensive HIV prevention and treatment programs, HIV prevalence has
declined from 8.6 percent to 5.6 percent among women who visit
antenatal clinics. A multicountry malaria grant in Southern Africa has
contributed to an 87-96 percent decline in malaria incidence.
Eventually, societies most affected by declines in human capital
resulting from illness and death will be able to translate these gains
into growth and opportunity. Building on what we have achieved, it is
realistic to think that we can have an even more significant impact on
AIDS, TB, and malaria in the future.
the global fund to fight aids, tuberculosis and malaria
The creation of the Global Fund to Fight AIDS, Tuberculosis and
Malaria was inspired by the vision to ``make a difference.'' Simply
put, the Global Fund is investing the world's money to save lives. This
is a huge responsibility, and one that inspires me every day as the
Global Fund's executive director. This vision has also allowed the
Global Fund to come a long way in a very short period of time. Since
2002, the Global Fund has now approved over $10 billion for grants in
137 countries around the world, supplying nearly a quarter of donor
financing for AIDS and providing two-thirds of donor funding for both
TB and malaria.
Since its initial founding pledge in 2001, the U.S. has played a
critical role in the Global Fund's dramatic scale-up, providing $2.5
billion in just 6 years, nearly one-third of all Global Fund financing.
In total, G-8 countries continue to be the largest contributors to the
Global Fund, providing 60 percent of all contributions. Other countries
are doing their part. The Global Fund is grateful to Congress and the
American people for its support and for their commitment to defeating
AIDS, TB, and malaria.
With this massive amount of resources, the Global Fund has achieved
significant impact. In mid-June, we estimated that 1.8 million lives
had been saved through Global Fund supported programs, with an
estimated 100,000 additional lives saved every month. In addition, the
Global Fund is now disbursing more funds to more grants faster than
ever before. More than half of the total amount disbursed (53 percent)
has been to sub-Saharan Africa, with the remainder disbursed to East
Asia and the Pacific, Latin America and the Caribbean and Eastern
Europe and Central Asia, roughly equal at 10-14 percent. The Middle
East/North Africa and South West Asia have received 5 percent and 6
percent respectively of the total amount disbursed.
The Global Fund supports integrated prevention and treatment
strategies in the three disease areas. Although the portfolio has so
far favored treatment, the proportion of spending for prevention is
significant. For example, in 2006, one-third of the $926 million
budgeted for HIV grants were allocated for prevention. Drugs and
commodities account for nearly half of Global Fund spending, while
broad health systems strengthening leveraged through disease programs,
including human resources, management capacity-building, monitoring and
evaluation and infrastructure/equipment represents between one-third
and half of spending. This is consistent with the objectives of the
Paris Declaration on aid effectiveness and highlights how AIDS, TB, and
malaria funding can have a positive effect on health systems. The
Global Fund has been among the first to transparently measure and
report against the Paris indicators.
As well as supporting programs in 137 countries around the world,
the Global Fund is also an integral partner with PEPFAR in its 15 focus
countries. A strong partnership with PEPFAR is particularly important
for the Global Fund, especially at the country level, where it provides
additional leverage to PEPFAR resources, including addressing TB, which
is a major cause of death for people living with HIV. The Global Fund
provides a vehicle by which U.S. resources can be harmonized and
leveraged with other major international donors, as well as civil
society and private sector implementers, in the fight against AIDS, TB,
and malaria.
Since I came on board as the Global Fund's Executive Director, I
have been working closely with Ambassador Dybul to ensure that the U.S.
bilateral program and the Global Fund are working effectively and
efficiently together. We are seeing many examples of this coordination
in the field. In Rwanda, Ethiopia, Cote d'Ivoire and Haiti, we are
seeing increasingly strong collaboration and synergy, and I have made a
number of joint country visits with Ambassador Dybul this year. In many
other countries, coordination and information sharing are excellent. We
are also working together on reporting results, to avoid duplication of
efforts and ``double counting.''
global fund founding principles
Based on strong founding principles, the Global Fund has
experienced dramatic growth in a short period of time. At its core, the
Global Fund was created to provide a new channel for significant
additional resources for the fight against AIDS, TB, and malaria by
investing the world's money to make a difference and to save lives. The
Fund has been, and remains, primarily a financing instrument. As a
result, for the Global Fund to continue its scale-up, multilateral and
bilateral programs, including USAID, civil society, the private sector
and others need to come together to assist in the development of
country-driven funding proposals and to support the implementation of
programs.
The guiding principle underlying every aspect of Global Fund
financing is the concept of country ownership. Within its national
strategy, each country is responsible for determining its own needs and
priorities, based on consultation with a broad group of stakeholders
that includes not only government, but other bilateral and multilateral
organizations, civil society, faith-based organizations, the private
sector and people living with or affected by the diseases. Global Fund
grants are country-owned, but that does not mean they are always
government-led. In fact, NGOs, faith-based organizations and the
private sector are implementing about 40 percent of Global Fund grants.
This multi-stakeholder approach is key to ensuring that resources reach
programs for men, women and children who are suffering from and are at
risk of AIDS, TB, and malaria.
The Global Fund is also committed to performance-based funding,
meaning that only grant recipients who can demonstrate measurable and
effective results will be able to receive additional resources. In
other words, initial funding is awarded solely on the basis of
technical quality of applications, but continued and renewed funding is
dependent on proven results and achieved targets. In order to measure
performance, the Global Fund has put in place a rigorous measurement
and evaluation system that reviews program goals and objectives put in
place by each of the recipient countries. This begins at the time the
grant agreement is signed, when targets and indicators are agreed upon
based on objectives outlined by the countries. Results are tracked at
every point in the process, from disbursement requests to performance
updates, and requests for continued funding at the 2-year point of the
grant.
The Global Fund also has a strong commitment to transparency and
accountability. This is illustrated by the broad range of information
available on our Web site. All approved proposals, signed grant
agreements and grant performance reports are available for review in
unedited form, as are documents discussed at board meetings. The public
is also able to track the progress of local programs by reviewing
grantee reports. Additional efforts are underway to enhance available
information concerning the performance and impact of grants.
As part of its commitment to transparency and accountability, the
Global Fund recognizes the significant role and importance of an
independent and objective Office of the Inspector General (OIG). The
OIG reports directly to the Global Fund Board, not to the Secretariat,
ensuring the integrity and effectiveness of Global Fund programs and
operations. At its recent meeting in November the Global Fund Board
announced the appointment of a new inspector general, and approved a
policy for publicly disclosing reports issued by the OIG.
This new policy requires that the Inspector General post all final
reports on the Global Fund's Web site no later than 3 working days
after they are issued. In the case of some reports, the IG has the
discretion to recommend, based on limited exceptions listed in the
disclosure policy, that restrictions on publication be applied. Such
exceptions are intended to allow for ``exceptional circumstances where
legal or practical constraints would limit the Global Fund's ability to
achieve full transparency if it is to protect the interests of the
Global Fund and its stakeholders or legitimate interests of those who
deal with the Global Fund.'' \1\ The restrictions would require the
approval of the Global Fund's Board, following advice from the
organization's legal counsel and review by its Finance and Audit
Committee. It is important to emphasize that while restrictions can be
approved by the board, the presumption is that reports would be made
public and this restriction would be invoked rarely.
---------------------------------------------------------------------------
\1\ Policy for Disclosure of Reports Issued by the Inspector
General, GF/B16/8, Annex 3.
---------------------------------------------------------------------------
The Global Fund is also pioneering practical systems that balance
the demand for accountability with the need for efficiency. This
includes working with recipient countries to identify key indicators to
measure progress, and ensuring that where possible, Global Fund
reporting requirements rely on existing processes. The use of Local
Fund Agents (LFA) is another accountability mechanism designed to
provide appropriate oversight while respecting local implementation.
LFAs are independent organizations that act as the Global Fund's eyes
and ears on the ground, and play an important role in assessing the
financial management systems and capacity of grant applicants, the
performance of grants and the reporting of results.
The Global Fund is currently bringing together various risk
management and oversight functions into a comprehensive risk assessment
and management framework. It has also recently undertaken a process of
retendering its LFA contracts to improve overall quality of these
agents. The new LFA statement of work will contain more explicit
requirements on the monitoring of Principal Recipients and
subrecipients.
Finally, the Global Fund is working on improving its data
management systems in order to better capture information concerning
grant subrecipients. Starting in January 2008, the Fund will begin
implementation of the Enhanced Financial Reporting system which will
entail requesting a minimum set of budget and expenditure information
from Principal Recipients on a yearly basis, including cost category,
program activity, and implementing entity. As part of an integrated
information system, by January 2009, the Fund will have collected a
full set of data on all grants and will be able to provide a very
comprehensive analysis of the portfolio.
challenges and priorities for the future
Resource Mobilization and Sustainability
Resource mobilization and sustainability are among our highest
priorities. Our commitment to treating millions of people with life-
long ARV treatment means that long-term sustainability is a key issue
for the future. We must not relent in building on our success. Slowing
down would present an enormous risk in reversing the significant gains
we have made in fighting AIDS, TB, and malaria.
Earlier this year, the Board estimated that the. Global Fund would
have to commit $6 billion, and perhaps up to $8 billion annually, to
help meet country demand by 2010 for prevention, treatment, and care in
the three disease areas. At least tripling in size over the next 3
years will require significant effort on numerous fronts. The Global
Fund is now receiving increasing support and trust from major donors,
predominantly the G-8 countries, and solid progress has also been made
in private sector engagement through Product (RED) and the development
of new sources of funding, such as the Debt2Health initiative.
In September 2007 the Global Fund engaged in its Second
Replenishment cycle which was a process to acquire long-term pledges
for 2008-2010. At the Replenishment Meeting held in Berlin, the Global
Fund received strong upfront pledges of $6.3 billion. Additional
minimum contributions are anticipated at $3.4 billion, resulting in an
approximate total of $10 billion for the next 3 years. These
commitments ensure that we will have the resources we need to approve
the continuation of all ongoing programs over the next 3 years--
estimated at a total of $6.5 billion--and will also be in a position to
support new programs valued at $3.2 billion. It is important to
emphasize that this level of funding will essentially be more complex.
In order to preserve our hard-won reputation as a lean, flexible,
country-owned mechanism that provides financing rapidly, reliably and
in a sustainable manner, we are currently taking stock and working to
streamline our processes so that interacting with the Global Fund is as
simple as possible for countries.
In order to focus on its mission to rapidly disburse resources, at
its founding the Global Fund contracted with the World Health
Organization to provide administrative services and human resources
support. Having now matured as an organization, the Global Fund Board
decided in November 2007 that the agreement with WHO will terminate at
the end of 2008. As we evolve to become an independent foundation with
its own systems and human resource policies, I am confident that the
Global Fund Secretariat will become one of the most modern, dynamic and
attractive workplaces in the field of global health.
conclusion
During the past 5 years, PEPFAR and the Global Fund together have
shown that significant impacts can be made against the major diseases
of poverty. The world needs 5 more years of PEPFAR and it needs U.S.
leadership and generosity in the field of global health.
The U.S. also needs a strong and well-funded Global Fund to
compliment its work, ensuring that health benefits extend beyond the 15
PEPFAR focus countries, helping to harmonize U.S. support with that of
other major donors and linking AIDS programs to those of the other
major infectious diseases.
The progress that has been achieved to date in the field of global
health is the result of both our efforts. PEPFAR and the Global Fund
are showing that well-implemented bilateral and multilateral efforts
can be mutually reinforcing, and that health and socio-economic
development and stability are intertwined. They are showing that health
programs can be a force--not only for development--but for
international stability and security.
We recognize that AIDS, tuberculosis, and malaria continue to take
a terrible toll on millions of people around the world. Continuing the
fight against these diseases remains the most pressing public health
challenge of our time.
Thank you again for the opportunity to testify. I look forward to
answering your questions.
Senator Menendez. Thank you.
Dr. Smits.
STATEMENT OF DR. HELEN SMITS, VICE CHAIR, COMMITTEE FOR THE
EVALUATION OF PEPFAR IMPLEMENTATION, INSTITUTE OF MEDICINE,
WASHINGTON, DC
Dr. Smits. Good afternoon, Mr. Chairman and members of the
committee. I'm Dr. Helen Smits, and I was honored to serve as
the vice chair of the Institute of Medicine Committee that
evaluated the early implementation of PEPFAR.
As you know, you mandated this study in the original
Leadership Act. It was executed under contract with the
Department of State and carried out by an interdisciplinary
committee of experts from many nations who visited the PEPFAR
focus countries to talk with people, funding and implementing
programs.
I'd like to thank my fellow committee members and the IOM
staff for all their hard work, as well as all the people in the
focus countries and in OGAC who spent so much time with us.
The opportunity to visit focus countries in this context
was very moving to me. I met an amazingly diverse group of
people--individuals living with HIV, doctors, nurses,
traditional healers, government ministers--and they gave one
very consistent message; that was, ``Thank you.'' It was very
moving, at times. They sang for me, they danced, you know, they
served me homemade cakes. At one point, I was given a gift of
two live birds. They thanked me, as a representative of the
American people, even though I was an evaluator, but I want to
convey to you how heartfelt the appreciation is for the program
you have funded--conceived and funded.
As my written statement, I've submitted a copy of the
actual summary of the IOM report, and--with all of the
committee's recommendations. I'll summarize them very briefly,
and then focus a little bit more on the one recommendation
applicable to Congress, which is that you remove all budget
allocations.
We saw that the U.S. Global AIDS Initiative has made a very
strong start, and our recommendations are intended to
strengthen a good program, not to criticize the program.
The recommendations involve placing even greater emphasis
on prevention. We're all agreed you can't treat your way out of
this epidemic. We need to use a variety of strategies that are
targeted to the local problem, and we need to be very careful
to understand how well those strategies are working. We must
continue to pay a great deal of attention to the vulnerability
of women and girls, with emphasis on the legal, economic,
social, and educational factors that make them so vulnerable.
I'm sure you've all seen the charts that show that the disease
rate of HIV infection rises very rapidly in young women in the
late teen years in all of these countries, and it's very
important to tackle that problem.
We have to strengthen and enhance our commitment to
harmonization. The committee particularly suggested that an
important step toward harmonization would be for us to work
toward use of the WHO prequalification process as the single
standard for approving generic medications. If there are
problems with that process, we should specify what they are,
and we should use our expertise to help the WHO change them.
We also thought that all services--prevention, treatment,
and care--can be better integrated, and that the resulting
synergies will improve all of the programs.
As we continue to strengthen country capacity, we need to
support the expansion of local human resources. It doesn't help
to shift tasks from doctors to nurses if there aren't enough
nurses. Expanding nursing schools and schools for clinical
officers, appears very practical and something that we should
be able to support.
And we need to know what works. We need to keep focusing on
learning and reporting what have been the effective strategies
so that the various participants in this program and the
individuals implementing other programs, can learn from one
another.
In order to support these improvements, we recommend that
Congress eliminate all budget allocations, but shift to a focus
on setting priorities and holding PEPFAR accountable. I want to
make clear, we're not suggesting you decrease accountability;
in fact, we think accountability for results will be better
than simply accountability for how you spend the money.
We saw some very impressive staff out there in the field,
working very hard. If Congress can specify the results it would
like to see, we're sure that they can figure out how to get
those results.
Let me just run very quickly through some specific reasons
why we want allocations eliminated.
First of all, conditions vary greatly in the different
countries. The challenge of reaching the rural poor in
Mozambique and Tanzania across very bad roads is very different
from the challenge of reaching urban patients in Nairobi. We
didn't study the relative costs, but we assume that the cost of
treatment where you have very serious travel problems, is going
to be higher.
Second, the epidemic varies greatly in different countries.
The strategy for Vietnam, where it's an injecting-drug-user
epidemic, is very different from the strategy to be used in
South Africa, where it's primarily an epidemic of heterosexual
spread.
Interestingly enough, situations change very rapidly, and
sometimes very much for the better, and the program needs to
respond. Budget allocations can limit flexibility. We're in a
new phase of prevention where male circumcision will become
very important. It's a relatively expensive intervention, but
it's a one-time intervention, where you have demand among adult
men. If, at the same time, you begin circumcising newborn boys,
eventually the need to provide that service will go--will
greatly decrease.
Changes in drug prices, changes in the climate can make
costs change. In Mozambique every few years, the north of the
country is cut off from the south of the country, and you need
to have the flexibility to have the money to help the country
get its drugs out to the north so that people's treatment is
not interrupted.
We saw the rigid separation among treatment, prevention,
and care that results from the budget allocations as being very
difficult. Predictions, for example--and I could give you many
arguments about this--but the predictions are that many of the
new cases in the next year, particularly in the countries with
the greatest success to date in changing overall behavior, the
new cases will come from faithful, discordant couples, where
one is positive and one is not. And, unfortunately, the
fidelity message may mislead them into thinking they're safe.
We need to focus on identifying them at the point of treatment
or care, testing them and giving them very sophisticated
message about how prevention applies to them.
In closing, I'd just like to say that in 2003 this Congress
set the standard for international leadership in the fight
against AIDS, and I'm certainly very proud, as an American, to
see that you did that. You now have the opportunity to take the
response to the next level and to leave a truly lasting legacy
of American leadership. I hope you will seize this opportunity,
and I hope, also, that you'll visit, for yourselves, and get
some of those thank yous.
Thank you for the opportunity to testify. I'd be happy to
address any questions you may have.
[The prepared statement of Dr. Smits follows:]
Prepared Statement of Helen L. Smits, M.D., MACP, Vice Chair, Committee
on the President's Emergency Plan for AIDS Relief, (PEPFAR)
Implementation Evaluation, Board on Global Health, Institute of
Medicine, The National Academies, Washington, DC
Good morning, Mr. Chairman and members of the committee. I am Dr.
Helen Smits, and it was my privilege to serve as the vice chair of the
Institute of Medicine committee that evaluated the implementation of
PEPFAR. As you know, this study was mandated by the Leadership Act and
executed under a contract with the Department of State. It was carried
out by an interdisciplinary committee of experts from many nations who
visited the PEPFAR focus countries to talk with people funding and
implementing programs. I would like to thank my fellow committee
members and the IOM staff for their hard work as well as all of the
people in the focus countries and at OGAC who spent so much time
meeting with us.
The opportunity to visit focus countries was a very moving one. I
met as diverse a group of people as you could imagine: Doctors and
nurses, groups of people living with HIV, village councils and the
orphans they cared for, missionaries and traditional healers, heads of
government ministries, representatives of our partner countries, as
well as the dedicated American staff members who make PEPFAR work.
There was one consistent message: ``Thank you.'' I was sung to; I
attended special dance performances; I was served tea and homemade
treats; I was even at one point given a gift of a pair of live birds.
All of these people thanked me as a representative of the American
people; I want to convey those thanks to you for conceiving and funding
this program.
I have submitted as my written statement a copy of the Summary of
the IOM committee's report with all of the committee's recommendations.
I will summarize them briefly and spend a bit more time on the one
recommendation that is directed to Congress--namely, to eliminate the
budget allocations.
The U.S. Global AIDS Initiative has made a strong start and is
progressing toward its 5-year targets. The challenge now is to maintain
the urgency and intensity that have led to early success while placing
greater emphasis on long-term strategic planning for an integrated
program in which prevention, treatment, and care are much more closely
linked, and on capacity-building for sustainability.
The committee recommendations to the Global Aids Coordinator, many
of which are already in the process of implementation, are as follows:
Even greater emphasis on prevention is needed. This must be
based on a greater understanding of exactly where the latest
cases have occurred.
There should be increased attention to the vulnerability of
women and girls with emphasis on the legal, economic, social,
and educational factors that lead to spread of the disease.
We must continue and strengthen our commitment to
harmonization--with the host countries and with other donors.
In particular, we should work with the World Health
Organization to accept their prequalification process as the
single standard for assuring the quality of generic
medications.
All services--prevention, treatment, and care--must be
better integrated. The resulting synergies will improve
programs in all areas.
As we continue to strengthen country capacity to fight the
local epidemic, we should support expansion of local human
resources. Many of these countries have too few nurses and
clinical officers. Helping to train new ones will be more
productive that only retraining the ones who exist.
We need to know what works. A focus on learning from
experience will only strengthen the program.
In order to support all of these improvements, we recommend that
Congress shift from a budget allocation approach to one of setting
priorities and holding PEPFAR accountable--from a focus on how the
money should be spent to a focus on what the money is accomplishing.
Allocations have unfortunately made spending money in a particular way
an end in and of itself rather than a means to an end. They have
reduced the program's ability to adapt to local conditions and to
respond effectively to changes either in the epidemic or in our
constantly growing knowledge of how to fight it.
In eliminating budget allocations, Congress should retain the
results-oriented nature of the program. Let me be clear that the IOM
committee is not suggesting the diminishment of accountability.
Instead, we are recommending an approach that we believe will result in
more meaningful targets and greater accountability. Congress should
hold the Global AIDS Coordinator accountable for demonstrating that we
are actually succeeding against the pandemic, not simply succeeding in
spending money on it. If Congress can specify the results it would like
to see, program staff can figure out how to get those results. The
increase in flexibility that will result from the elimination of budget
allocations will make us a better partner with the host countries and
with other donors.
PEPFAR is not a single, uniform program the details of which can be
specified by the Global AIDS Coordinator or Congress. In the focus
countries PEPFAR is 15 distinct programs reflecting the unique
circumstances and epidemics of each. I realize that this is nothing new
for Congress--you contend with the uniqueness of 50 States everyday.
But if you magnify many fold the variation that you see between
Delaware, Indiana, Florida, and Alaska, you will begin to get a sense
of the challenge of trying to apply a single approach across countries
as different from one another as Guyana, South Africa, Mozambique, and
Vietnam.
The specific reasons for eliminating allocations are as follows:
Conditions vary greatly in the different countries. The
challenge of treating the rural poor in Mozambique and Tanzania
is very different from that of treating urban residents in the
slums of Nairobi.
The epidemic varies greatly in different countries. The
strategies for reaching patients with treatment and for
prevention are very different in Viet Nam, where the epidemic
is driven by injecting drug users, from those in South Africa,
where the spread is heterosexual.
Situations change rapidly and the program needs to respond;
budget allocations can limit crucial flexibility. We are in a
new phase of prevention with adult male circumcision added to
the armamentarium of effective strategies--and altering the
cost of prevention. Changes in drug prices, availability of
specific medications, approaches to testing, or even climate
can have the same effect. Floods in Mozambique frequently cut
the northern section of the country off from the south; means
must be found to continue the regular delivery of medications
when that happens.
The rigid separation among treatment, prevention, and care
that results from allocations should be ended. Predictions are
that many of the new infections in affected countries over the
next years will come from discordant couples where one partner
is positive and one is not. Ensuring that treatment and care
both carry a strong prevention message can make a real
difference in our ability to reach the people we wish to
target.
In closing, in 2003 Congress set the standard for international
leadership in the fight against AIDS. You now have the opportunity to
take the United States response to the global AIDS epidemic to the next
level and leave a truly lasting legacy of American leadership.
I hope you will seize this opportunity. I also hope you will visit
for yourselves to see the remarkable accomplishments of the program to
date--and to receive in person the gratitude of those who benefit.
[Editor's note.--The Summary of the IOM committee's report and
additional material mentioned above was too voluminous to include in
this hearing. It will be maintained in the Foreign Relations
Committee's permanent record. It can also be viewed at: http://
www.nap.edu/catalog/11905.html.]
Senator Menendez. Thank you. Thank you, Dr. Smits. What did
you do with the two live birds?
Dr. Smits. Oh----
[Laughter.]
Dr. Smits [continuing]. I didn't think I'd do very well in
Customs with them. We gave them----
[Laughter.]
Dr. Smits [continuing]. To the nice young woman from the
NGO who had taken us to visit the village.
Senator Menendez. Dr. Daulaire.
STATEMENT OF DR. NILS DAULAIRE, PRESIDENT AND CEO, GLOBAL
HEALTH COUNCIL, WASHINGTON, DC
Dr. Daulaire. Thank you, Mr. Chairman, for your approach to
looking at PEPFAR in the broader context of U.S. foreign
assistance; you, Ranking Member Lugar, for starting this
process for reauthorization of PEPFAR; Senator Kerry, for your
work as cochair of the CSIS Task Force on HIV/AIDS over the
past several years; and my neighbor and colleague, Senator
Sununu, with whom I had the pleasure of spending a snowy Sunday
in his home State of New Hampshire just a couple of weeks ago.
I request that my written statement be entered into the
record, and I will keep this short so that we will have time
for some dialog.
But let me say, in summary of my written statement, the
Leadership Act has been both historic and constructive. And the
Global Health Council and our membership, both here in the
United States and around the world, endorse its speedy and
thoughtful reauthorization.
The Global Health Council is a worldwide membership
alliance representing over 480 organizations around the world
and over 5,000 health professionals. Our members are on the
front lines of global health. They're the ones who are dealing
with these issues, face to face. And, personally, I'm a
physician and a public-health scientist, so I'm speaking to
this issue from that standpoint.
Now, evidence is at the heart of everything that we try to
do, and the evidence is this: PEPFAR and the Global Fund have
begun to show substantial impact, in terms of reducing the toll
of HIV/AIDS, reducing mortality, and we are beginning to show
signs of reducing new incidents, as recent UNAIDS statistics
have shown. So, in a sense, what we've had over the past 4
years, with the emergency plan is the public-health equivalent
of an emergency room in full swing. But now it's time, under
reauthorization, to start looking at this issue from the
standpoint of managing the community health center. Someday
we'd like to be able to close the emergency room and deal with
this in the communities themselves, through prevention and
early care, rather than having, as we've had to do, to mount an
emergency campaign of this sort. But we must recognize that
AIDS will be with us, no matter what the scenario, for a very,
very long time; and so, we need to start thinking about AIDS
like other chronic diseases.
The evidence in dealing with all chronic diseases, and the
mounting evidence about HIV/AIDS globally at this point, is
that thoughtful integration of treatment, care, and prevention
can, and does, lead not only to better outcomes, but to fewer
infections. And that certainly is an area that needs attention.
As my colleague has just said, it's critical that PEPFAR-2, the
next iteration, scale up prevention using the growing body of
information and evidence that we have about the varying
characteristics of how HIV is spread. It's also very clear, as
we just heard, that one size does not fit all, and that there
has to be more flexibility built into the future authorization,
whether that's a softening of earmarks or their elimination
altogether.
Our members tell us that allowing decisions on prevention
to be made by those who are actually dealing with it on a daily
basis, dealing with the microaspects of this epidemic, has far
better impact than having a one-size-fits-all determination
coming out of Washington. And the facts on the ground do call
for greater flexibility.
And, second, another provision in the existing law that has
been deeply counterproductive, from the standpoint of our
members who are on the front lines implementing, is the APP,
the so-called ``antiprostitution provision,'' which has made it
more difficult, even though that was not its intent, for many
of our members to engage constructively in dialog with
prostitutes and commercial sex workers, and to really have an
impact. That should be stricken from the new act.
We've been talking about AIDS this morning, but obviously
it's an AIDS, TB, and malaria act, and the next point I'd like
to make is the importance of integration across a wider range
of issues.
First, it is critical to address TB and malaria, but,
fundamentally, we must recognize the importance of
strengthening health systems, especially human infrastructure,
and to work much more closely with other health efforts. This
is fundamentally important because if you've got a sick mother
and an unhealthy child, whether they have HIV or not, they
deserve attention. We have the same systems, the same health
care workers, the same clinics that deal with them. And it's
notable that, with the remarkable technical success of dealing
with neonatal AIDS with the use of nevirapine, we've still had
very little impact, because many women don't come to the HIV/
AIDS clinics, because adequate maternal and child health
services and family planning services aren't available there;
their children don't come in because they don't have good basic
child health care services. All of these services are
critically important and need to be strengthened together.
Finally, it's important that PEPFAR move increasingly
toward becoming a learning organization. Operations research,
which is very different from the kind of clinical and
scientific research carried out by the NIH, is vital to
improving programs, to refining them; and sometimes it seems
that there's been a little bit of a barrier between the
operations research and the implementation side. Learning from
operations research needs to be encouraged. We would not have
eliminated smallpox around the world without on-the-ground
operations research. And few of us would be using Apple
computers and iPods and iPhones if Apple weren't doing that. So
it's an important component.
Let me close by saying that many of us look forward to the
day when not only AIDS and malaria, but the broad sweep of
global health development and poverty alleviation is seen as
critical to the U.S. engagement with the world. We strongly
endorse continued and growing support of vital agencies, like
the Global Fund, and recognize that the United States must
provide its fair share of funding for international and
multilateral activities. We also hope someday to see a
Department of International Development. It is as vital to
America's interests in the world as our diplomatic and military
engagements, but that's for another hearing. [Laughter.]
Dr. Daulaire. Thank you very much.
[The prepared statement of Dr. Daulaire follows:]
Prepared Statement of Nils Daulaire, M.D., MPH, President & CEO, Global
Health Council, Washington, DC
Chairman Menendez and members of the committee, thank you for
holding this important hearing today on the future of the United States
response to global AIDS, tuberculosis, and malaria. I am Dr. Nils
Daulaire, President and CEO of the Global Health Council, the world's
largest membership alliance of over 5,000 health professionals and 480
service organizations working to save lives and improve health
throughout the world.
Before I begin my remarks, let me applaud this committee for its
commitment and dedication to global health issues, most notably HIV/
AIDS. I congratulate the committee for its bipartisan work on the
United States Leadership Act Against HIV/AIDS, Tuberculosis and
Malaria, the law that authorized the President's Emergency Program for
AIDS Relief--PEPFAR. This historic legislation set the stage for an
unprecedented U.S. Government investment in the fight against a serious
global health challenge. The importance of this massive investment
cannot be overstated; it has literally transformed the concept of what
is possible in the realm of global health. On behalf of the Council's
members working in over 100 countries across the globe, and the
millions whose lives are improved by U.S. Government-supported global
health programs, we thank you.
The Global Health Council's members include nonprofit service
organizations, faith-based organizations, schools of public health and
medicine, research institutions, associations, foundations, private
businesses and concerned global citizens whose work puts them on the
front lines of global health--delivering programs, building capacity,
developing new tools and technologies, and evaluating impact to improve
health among the world's poorest citizens. Our members work on a wide
array of issues, including, of course, HIV/AIDS, but also other
infectious diseases, child and maternal health, family planning, water
and sanitation, and health systems strengthening.
I am a physician and have been personally engaged for more than
three decades in the global effort to improve the health of the poor.
When AIDS was first recognized just 26 years ago, few anticipated that
it would grow to become the worst pandemic of modern times, and the
world's initial slow response gave the virus a chance to establish its
death grip on the lives of millions. But the past decade has been
heartening to those of us who have taken on the challenge of building
health programs and services in the forgotten corners of the world.
U.S. leaders, as well as leaders from other countries; the U.N.; the
Global Fund to Fight AIDS, TB, and Malaria; and the Bill and Melinda
Gates Foundation, have recognized both the severity and the moral call
of HIV/AIDS, and the response has been unprecedented.
In fact, the response has begun to make a difference. As UNAIDS
recently reported, new data show that the global HIV prevalence--the
percentage of people living with HIV--has leveled off and that the
number of new infections each year has fallen, in part as a result of
the impact of HIV programs. However, in 2007 33.2 million [30.6-36.1
million] people were estimated to be living with HIV, 2.5 million [1.8-
4.1 million] people became newly infected and 2.1 million [1.9-2.4
million] people died of AIDS.\1\ When the reality is that every person
with a new infection will need years of treatment and care, it remains
clear that now is not the time to step back from U.S. leadership on
this issue.
We need to continue the signal accomplishment of this new century--
PEPFAR--the partnership between the Bush administration and a solid
bipartisan majority of the U.S. Congress that made PEPFAR the
cornerstone of the largest prevention, care and treatment effort the
world has ever seen. It is clear that PEPFAR has had some enormous
successes over the last 4 years. We are here today in order to build on
them and to make them lasting.
The things that have worked well need to be reinforced, and those
that haven't worked so well need to be fixed. The reauthorization
process provides us with an opportunity to examine ways to make this
program more effective for the long run. To help provide constructive
and informed input into the PEPFAR reauthorization process, the Global
Health Council has for months now engaged a wide network of experts,
implementers, and advocates through the Global AIDS Roundtable and the
more programmatic HIV Implementers Group. We look forward to continuing
our work with this committee to ensure that the next generation of this
program continues its forward momentum.
This administration's commitment to the fight against the global
spread of HIV/AIDS has resulted in extraordinary accomplishments.
Similarly impressive efforts have begun for malaria under the
President's Malaria Initiative (PMI). But one thing is clear to those
of us who engage daily in delivering these services: While an emergency
response focused on a single disease can have remarkable, short-term
results, it will not succeed as a model for the long-term response that
is necessary for reversing the HIV/AIDS pandemic.
Early in his tenure, the President's first Global AIDS Coordinator,
Ambassador Randall Tobias, was asked about the inter-relationships
between the HIV/AIDS response and other public health interventions
such as maternal and child health, family planning, nutrition, clean
water, and other diseases. His response was to acknowledge that these
were important problems, but that his charter was to combat HIV/AIDS
through the sharp lens of prevention, care and treatment. Congress had
set very ambitious targets, he told us, and he had to stay completely
focused on them.\2\
His point was understandable. But I believe that, with experience,
that view was short-sighted, a mistake of first principles. Over the
past few years, it has become very apparent that, in the long run, we
cannot succeed in our efforts against HIV/AIDS without linking PEPFAR
much more closely with these other interventions and with strengthening
health systems more broadly.
Let me take as an example the issue of newborn infection with HIV,
a preventable tragedy that occurs over half a million times a year.\3\
PEPFAR addresses this through a program to test pregnant women and
provide those who are HIV positive the drug nevirapine, a low-cost
highly effective intervention. This has been a priority program under
PEPFAR. Yet throughout the world, most women are never tested for HIV,
a small proportion of those who could benefit receive nevirapine, only
a small dent has been made in the numbers of infected children born in
poor countries, and even less impact has been seen on overall child
death rates.3,5 Why is this?
First, because women generally come to the health care system in
the first place not for HIV care but for routine family planning and
maternal and child health care.\6\ Most of them don't even know they
are HIV positive. So unless the HIV services are deeply integrated with
family planning and maternal and child health services, most who need
them will never know they need them, much less get them.
These women need help not just with their HIV infections. Their
first priority is for a safe pregnancy and delivery. They and their
newborns need to sleep under malaria bed nets. They need access to
nutritious food. They need to know how they can prevent or delay their
next pregnancy.
And their babies, whether HIV infected or not, need basic newborn
and childhood care. After all, most children who die, even most
children dying as a consequence of HIV infection, die from diarrhea,
pneumonia, malaria, and other common preventable or treatable childhood
diseases.\7\ Antiretroviral drugs alone can't save HIV-positive babies
without the child health services that are currently not available
because resources and manpower are being redirected toward HIV/AIDS.
The Global AIDS Coordinator, Ambassador Mark Dybul, acknowledges
this reality, and has begun to explore programmatic linkages. I think
he could use some help, and I believe that the Congress can provide
that help by granting specific authority for, and even requiring, the
Global AIDS Coordinator to link directly to the other U.S. agencies and
programs that deliver these services and, when they are weak or
inadequate, to support them directly with PEPFAR funds. Far from being
a diversion of resources, this would assure that our HIV/AIDS dollars
are spent most effectively.
Should PEPFAR then be the platform for all basic health services or
bear the programmatic burden for the full array of health issues facing
communities in the developing world? No. The appropriate U.S. policy
approach must encompass, but not be based upon, responses to any single
disease.
I will return to specific thoughts on PEPFAR reauthorization in a
moment. But let me first offer you the bottom line here: While beyond
the scope of this hearing alone, the U.S. Government ultimately needs a
comprehensive strategy to guide its engagement in improving the health
of the world's citizens and, in turn, protecting the health of its own.
This is my fifth appearance before Congress this year. I have testified
about maternal and child health, malaria, tuberculosis, and HIV/AIDS. I
appreciate the opportunity to share perspective on each of these
topics, but budget line items and various agency authorities have
dissected a single experience--health--into disparate funding,
policies, and programmatic approaches that undermine our ultimate goal:
Healthier individuals and families and therefore more stable and
productive global communities. Investing in health is not just a
humanitarian response. The returns on its investments are also seen in
growing and stable political systems. With U.S. Government investments
in global health on the order of $6 billion (with nearly $5 billion
committed to AIDS alone), don't we want to make the most of our
investment? \8\ I have been at this for decades, and I can tell you
with confidence that single-disease, single-intervention, or any other
siloed approach simply will not succeed over the long run.
This hearing is about transitioning the U.S. response to the global
AIDS crisis through PEPFAR from an emergency program to a sustainable
one, because we recognize that the AIDS virus will be in our midst for
generations to come. Our response to HIV/AIDS must now expand from a
model designed to help get the emergency room up and running to one
where the community clinic can successfully keep people out of the
emergency room in the first place.
Of course, HIV-affected people must have access to antiretroviral
drugs, but no one can survive on drugs alone. Just like everyone else,
people who are living with HIV/AIDS--especially those who have gotten
drugs to keep their infections in check--need good nutrition, clean
water, vaccines, pre- and post-natal care for mothers and children and
prevention, care and treatment for all the other major health threats
that they face.
Let's face it, we are in a struggle to beat HIV/AIDS for the long
haul--just like our battles to overcome cancer and heart disease at
home. Now that HIV/AIDS is treatable, it has become a chronic disease,
and chronic diseases require functioning health systems, working every
day.9,10 Clinics must be open, staffed, and supplied--and
that can't be done just for HIV alone. Health providers must be
trained, supervised, supported, and paid--and no one dreams that this
could be an AIDS-specific cadre. Ministries of health and
nongovernmental organizations alike must function smoothly and
efficiently, with solid leadership and management skills--and these
must be generalized skills because the systems they must support are
necessary for each and every health intervention.
This is why beating HIV/AIDS demands more than HIV-specific
prevention, care and treatment programs operating in isolation from
other global health interventions. This is why the delivery of all
essential health care services through strong and efficient health
systems is necessary for the fight against AIDS. This is why greater
integration and coordination of PEPFAR programs with other global
health programs and services is the single-most important step the U.S.
can take right now to maximize the program's effectiveness in the
future. I call on Congress to make sure that this is supported and
encouraged in your reauthorization bill.
PEPFAR can and should be better integrated on four different
levels:
Internally between its own prevention, treatment and care
programs;
Laterally across other U.S. global health programs
addressing issues other than HIV;
Nationally through the strengthening of health systems and
support of expanded health manpower in countries with high
burdens of disease; and
Externally through enhanced coordination between PEPFAR and
other HIV- and non-HIV specific programs managed by focus
country governments and by other international donors.
internal integration
To date, PEPFAR's programs have been separated into the categories
of prevention, treatment or care, with the focus and lion's share of
funding largely on treatment. This approach can work with certain
targeted populations, but there is always the risk that this
construction will prove too rigid to optimize the use of resources and
most effectively save lives.
Those who are at high risk of contracting HIV need to know how to
stay HIV free and what treatment options exist if they do become
infected. Those who are HIV positive need to have access to the full
range of prevention methods in order to improve their own health and to
protect the health of those around them. It remains fundamentally true
that treatment for people who are HIV positive still needs to be
expanded, but as we find that for every individual treated there are
six new infections, it is clear that we will never be able to treat our
way out of this epidemic. Prevention activities must be significantly
scaled up and built upon interventions that go beyond medical models to
address the behavioral and social components of this disease.
I would be remiss if I did not flag two provisions within the
current legislation that, if left unrevised, will undermine prevention,
care and treatment activities. The first provision is the specific
target that one-third of prevention funds be dedicated to abstinence-
until-marriage activities. In communities where many young girls' first
sexual encounter is by force or where being a young bride to an older
man who has not limited his sexual encounters is the cultural norm, the
current abstinence policy does not move us toward the desired
outcomes--fewer HIV infections. Delayed sexual debut is ideal. However,
a fundamental tenet of public health is that you tailor the
intervention to local circumstances. A blanket abstinence target
ignores this tenet and leaves too many young women without realistic
recourse to protect their health.
The second provision is the antiprostitution pledge which all
organizations receiving PEPFAR funds must sign. This provision must be
repealed. Although not politically correct, the truth is that in many
areas including India, Thailand, and the former Soviet Union the AIDS
epidemic is driven in part by high-risk behaviors such as commercial
sex work. Ideally, individuals would not engage in these activities.
But, we cannot let the epidemic continue to spread because we take
ideological issue with the behavior of a subset of men and women. Let
us not tie the hands of organizations that are committed to providing
the best interventions for people in their very real, complex,
imperfect yet valuable lives. I strongly encourage the committee to
consider the social and cultural complexities of the lives of people
who experience this epidemic and to program accordingly.
integration and coordination across u.s. global health programs
Most people who are battling AIDS actually die from infections
caused by other organisms that have found an open door due to HIV's
suppression of the immune system; these are called Opportunistic
Infections (OIs). Currently, tuberculosis (TB) kills about one-third of
AIDS victims.\11\ Pregnant women who contract malaria are at greater
risk of HIV infection and those who are HIV-positive are at greater
risk of malaria.3,12 And as I have noted, most children
dying with HIV die as a direct result of common childhood infections
whether or not their immune systems are compromised.\13\
By only addressing the HIV/AIDS-specific aspects of the health of a
person with coinfections and multiple susceptibilities, PEPFAR is, in
some ways, saving lives only to leave them vulnerable to death or
debilitating illness from other causes whose effects could have been
minimized or eliminated with a more thoughtful and thorough
programmatic response. A more comprehensive view of multiple disease
risk and the appropriate response is needed. PEPFAR programs must have
explicit linkages between their services and those other critical
global health programs that focus on other diseases and health
conditions.
A number of our member organizations do an excellent example of
integrating HIV/AIDS programs with other health and development
efforts. CARE has done some enormously creative and productive work
toward that end. Family Health International (FHI) has also
demonstrated the positive impact of an integrated response. A number of
other Global Health Council members are engaged with RAPIDS--a PEPFAR-
funded project that covers 53 districts in Zambia to provide home- and
community-based care for people living with HIV/AIDS and support for
orphans and vulnerable children through a coordinated response.\15\ In
this example of successful coordination across U.S. programs, USAID,
CDC, DOD, Peace Corps, and the State Department have developed an
intense, integrated, and coordinated response in which it funded
various organizations to take on projects that cut across all sectors.
The project funds agriculture, economic growth, health, education and
democracy while at the same time aiming to scale up prevention,
treatment and care. As a result, thousands of people living with HIV in
Zambia are accessing basic health and development services, and not
just antiretroviral therapy.
When PEPFAR was first announced, it was with assurances that this
funding would be additive to funds already in place for global health
and international development efforts. Sadly, we are seeing instances,
such as in Ethiopia, in which PEPFAR and PMI funds have increased,
while maternal and child health funds have been significantly cut.\16\
Can the majority of that country's women and children who are dying
despite being HIV-free, and whose deaths could readily be averted with
effective, proven, low-cost interventions, consider this a victory?
strengthening health systems and building health manpower
HIV/AIDS has taken weak health systems in the most highly afflicted
countries, particularly those in sub-Saharan Africa, and stressed them
to the point of collapse. A major contribution of PEPFAR was revealing
the utterly desperate conditions of the world's national health
systems. Once money and resources began to flow, we quickly realized
that we lacked the trained professionals to deliver life-saving
interventions; we lacked the management systems to implement programs
and handle large infusions of resources--nearly every link in the
health system left something to be desired. Weak health infrastructure
and lack of an adequate human resource supply in developing countries
limit the ability to support the integration and coordination of HIV/
AIDS services.
While there is much to be done, perhaps the most pressing issue is
the supply, type and training of health workers, particularly in the
areas of expanding prevention services and detecting opportunistic
infections. As the Institute of Medicine (IOM) recommends, PEPFAR must
contribute to strengthening health systems and adequately train and
support critically needed new health workers.\17\
external coordination between pepfar and non-u.s. hiv and non-hiv
programs
Coordination is absolutely necessary within programs of the U.S.
Government. It is also essential with the governments of focus
countries if we are to continue to build upon PEPFAR's successes.
According to the IOM's report, PEPFAR country teams ``have been largely
successful in aligning their plans'' with a recipient country's
national HIV/AIDS strategies.\18\ Serious concerns remain, however,
about ensuring that the siren call of available PEPFAR resources
doesn't result in situations where national HIV/AIDS strategies become
seriously misaligned in proportion to countries' specific disease
burdens.
When lives are at stake every dollar has to count. The U.S.
Government also must take care to chart whether other public or private
donors are investing in the same kinds of programs and in the same
places as PEPFAR so that duplication--or worse, destructive
competition--is avoided.
Any discussion about vital coordination between PEPFAR and other
HIV/AIDS efforts is incomplete without mention of the other cornerstone
of the global response to this pandemic: The Global Fund to Fight AIDS,
TB and Malaria. Early years saw aspects of unproductive competition
between PEPFAR and the Global Fund. I applaud Ambassador Dybul for his
efforts to assure closer coordination and cooperation with the Global
Fund, and encourage efforts to assure that this continues and is
expanded, since each of these mechanisms has its own particular
strengths and advantages.\19\
Successful multidonor coordination on HIV/AIDS programs is not only
possible, it makes for better programs. In Malawi, the U.K.'s
Department for International Development, the Global Fund to Fight
AIDS, TB and Malaria, and Malawi's Ministry of Health together designed
the Emergency Human Resource Plan to build human resource capacity to
address the severe HIV/AIDS crisis in the country. This joint planning
and coordination helped Malawi to double its output of nurses in just 3
years and increase preservice training for doctors. The strategic
coordination avoided duplicative efforts, allowing the program to
address a wide range of problems related to health systems.\20\
looking forward
Even with its remarkable accomplishments over the past 4 years,
PEPFAR faces an uphill battle against a virus that manages to stay
ahead of the world's best efforts to defeat it. Just a few months ago,
we heard about the failure of what had been considered our most
promising vaccine candidate.\21\ There is no doubt that more
disappointments will follow. This will be a long struggle requiring
persistence and patience.
As PEPFAR evolves with Congress's oversight, a number of issues
must be addressed. First, the structure of U.S. global health
assistance must be seriously reviewed and, I would recommend,
redesigned. Each agency currently working as a part of the U.S. global
AIDS response has a separate funding and procurement mechanism,
different benchmarks for reporting, and different targeted communities.
Under the current model, coordination and integration of HIV/AIDS is
more difficult than it needs to be. Congress should take steps to
correct this.
Congress must also assure that health systems and health manpower
development are front and center in expanded efforts to address HIV/
AIDS and other major causes of ill-health and death in highly affected
countries.
Finally, the U.S., other donors, and national governments must take
under serious consideration the financial implications of a sustainable
response to global AIDS, specifically, and basic health more broadly.
While U.S. funding for global AIDS grew from $125 million in 1997 to
$5.4 billion in 2007, it still remains below the levels needed for
fully scaling up prevention and treatment in the focus countries, much
less the need for HIV/AIDS services in nonfocus countries where
millions of people are infected or at-risk.\22\ Treatment costs will
rise with the need for second-line drugs and HIV-positive individuals
living longer and requiring a wider array of health services.\4\
Effective and widespread prevention services, although a wise long-term
investment, will add significant costs.
This need for expanded funding will continue from a finite pool of
resources. Still, the funding currently available for global AIDS
programs dwarfs the U.S. investments currently made in other global
health programs. For example, USAID's child and maternal health and
reproductive health accounts have remained at around $360 million and
$400 million a year respectively, and yet three times as many children
and women die globally each year from non-HIV related causes than from
AIDS.23,24 Resource constraints as well as policy
restrictions have impeded the successful ``wrap around'' of non-HIV
services with HIV services.
Increased support for global AIDS programs must not come at the
expense of other global health programs if we are to achieve both the
goal of establishing an effective HIV/AIDS program and the goal of
building comprehensive and efficient national approaches to all major
global health threats.
conclusion
The President's Emergency Plan for AIDS Relief may be relatively
new, but the fight against the global spread of HIV/AIDS is not. We
have reached a point where the emergency response is still necessary
but no longer sufficient in our fight against HIV/AIDS. HIV/AIDS is
inextricably linked with other diseases. To effectively combat this
pandemic, we must expand our response, and a comprehensive approach to
global health in developing countries is needed to do that
successfully.
Today, I have proposed steps that could be taken in the near future
to strengthen PEPFAR by better integrating PEPFAR services internally,
across U.S. global health programs, with national health systems, and
with external partners addressing HIV/AIDS in the developing world. We
can improve upon the lessons learned through PEPFAR to improve our
global AIDS response and reverse the HIV/AIDS pandemic.
In the long term, I urge Congress and the administration to also
consider the role of PEPFAR in the context of developing a
comprehensive U.S. strategy for addressing all critical global health
issues. The Global Health Council and our members stand prepared to
help address the realities in which a third of the world's people
live--and in which a disproportionate number die.
Thank you again for the opportunity to testify before you today. I
welcome your questions.
----------------
References
\1\ UNAIDS, World Health Organization. 2007. AIDS Epidemic Update.
Available from: http://data.unaids.org/pub/EPISlides/2007/
2007_epiupdate_en.pdf.
\2\ H.R. 1928. United States Leadership Against HIV/AIDS,
Tuberculosis and Malaria Act of 2003. Public Law 108-25. Available
from: http://thomas.loc.gov/.
\3\ UNAIDS, World Health Organization. 2006. AIDS Epidemic Update:
December 2006. Available from: http://www.unaids.org/en/HIV_data/
epi2006/default.asp.
\4\ World Health Organization. 2007. Towards Universal Access:
Scaling Up Priority HIV/AIDS Interventions in the Health Sector.
Available from: http://www.who.int/hiv/mediacentre/
universal_access_progress_report_en.pdf.
\5\ Global Health Council. 2007. Our Global Responsibility to the
World's Children. Available from: http://www.globalhealth.org/images/
pdf/conf_2007/child_health.pdf.
\6\ World Health Organization. 2005. World Health Report 2005: Make
Every Mother and Child Count. Geneva: WHO. Available from: http://
www.who.int/whr/2005/en/.
\7\ Bryce J, Boschi-Pinto C, Shibuya K, Black RE, WHO Child Health
Epidemiology Reference Group. 2005. WHO Estimates the Causes of Death
in Children. Lancet 365(9465):1147-52.
\8\ Global Health Council. 2007. Global Health Funding. Available
from: http://www.globalhealth.org/view_top.php3?id=172.
\9\ Travis P, Bennett S, Haines A, Pang T, Bhutta Z, Hyder AA, et
al. 2004. Overcoming Health-Systems Constraints To Achieve the
Millennium Development Goals. Lancet 364:900-6.
\10\ World Health Organization. 2006. World Health Report 2006:
Working Together for Health. Geneva: WHO. Available from: http://
www.who.int/whr/2006/en/.
\11\ World Health Organization. Joint HIV/Tuberculosis
Interventions. (Accessed September 24, 2007). Available from: http://
www.who.int/hiv/topics/tb/tuberculosis/en/.
\12\ Breman J, Alilio M, Mills A. 2004. Conquering the Intolerable
Burden of Malaria: What's New, What's Needed: A Summary. American
Journal of Tropical Medicine & Hygiene 71:1-15.
\13\ Prendergast A, Tudor-Williams G, Burchett S, Goulder P. 2007.
International Perspectives, Progress, and Future Challenges of
Paediatric HIV Infection. Lancet 370:68-80.
\14\ Reynolds H, Janowitz B, Homan R, Johnson L. 2006. The Value of
Contraception To Prevent Perinatal HIV Transmission. Sexually
Transmitted Diseases 33(6):350-6.
\15\ USAID. HIV/AIDS multisector. (Accessed September 20, 2007),
RAPIDS. Available from: http://www.usaid.gov/zm/hiv/hiv.htm.
\16\ Global Health Council. 2007. Global Health Spending: An
Analysis of the President's Fiscal Year 2008 Budget Request. Available
from: http://www.globalhealth.org/.
\17\ Institute of Medicine. 2007. PEPFAR Implementation: Progress
and Promise Report Brief. Available from:http://www.iom.edu/
Object.File/Master/41/807/PEPFAR%20report%20brief.pdf.
\18\ Sepulveda J, Carpenter C, Curran J, Holzemer W, Smits H, Scott
K, et al., editors. PEPFAR Implementation: Progress and Promise.
Washington, DC: Institute of Medicine, 2007.
\19\ Wakabi W. 2007. Global Health Agencies Agree to HIV/AIDS
Partnership. Lancet 370:
15-6.
\20\ Medecins San Frontieres. 2007. Help Wanted: Confronting the
Health Care Worker Crisis To Expand Access to HIV/AIDS Treatment, the
MSF Experience in South Africa. Available from: http://www.msf.org/
source/countries/africa/southafrica/2007/Help wanted.pdf.
\21\ Kaiser Family Foundation. Merck Halts International HIV
Vaccine Trial. Kaiser daily HIV/AIDS report. September 24, 2007.
Available from: http://www.kaisernetwork.org/daily_reports/
print_report.cfm?DR_ID=47688&dr_cat=1.
\22\ Global Health Council. 2007. 10-year chart explanation.
Available from: http://www.globalhealth.org.
\23\ U.S. Appropriations 1997-2007. 2007 (Accessed March 12, 2007),
Available from: http://www.thomas.gov/.
\24\ World Health Organization. 2004. WHO Global Burden of Disease
(GBD) 2002 Estimates (revised). Available from: www.who.int/healthinfo/
bodestimates/en.
Senator Menendez. Thank you.
Mr. Hackett.
STATEMENT OF KEN HACKETT, PRESIDENT, CATHOLIC RELIEF SERVICES,
BALTIMORE, MD
Mr. Hackett. Thank you very much, Chairman Menendez and
Ranking Member Lugar, Senator Sununu, and Senator Kerry. Thank
you for allowing us to be here and share our perspectives on
the next phase of PEPFAR and the global fight on AIDS.
I'm president of Catholic Relief Services, an organization
which reaches out around the world to assist people in their
state of poverty, and to try to give them the dignity and the
help to rise above it.
We have been involved in addressing the HIV and AIDS
questions and pandemic for more than 20 years. I must admit, we
haven't done enough, or we haven't done it well enough. But,
through PEPFAR, CRS, and our partners are providing
antiretroviral therapy to 100,000 people and care right now to
nearly a quarter of a million people living with HIV and AIDS
in 12 out of the 15 focus countries. And we're also engaged in
40 other countries with our own private funds, nongovernmental
funds, in reaching out and providing assistance to people
living with AIDS.
Let me echo what my colleagues have said before. I believe
that PEPFAR is an outstanding success for which the President,
this Congress, and the American people can be most proud. The
strong leadership and broad bipartisan support have resulted in
an initiative that shows the best possible face of the American
people.
PEPFAR has come through its gestation period. It was, at
times, difficult, I'll tell you that. But now it is through it,
and it's ready to take off. PEPFAR is, above all, a program of
hope.
Just 2 weeks ago, during the World AIDS Day commemorations
here in Washington, President Bush literally embraced a woman
from Zambia by the name of Bridget Chisenga. Everybody who
knows Bridget calls her ``Auntie Bridget.'' She actually works
for us in Zambia, promoting adherence to antiretroviral therapy
and fighting stigma associated with AIDS. She gave President
Bush a message that seemed to move him and caused him to
embrace her. She said, ``I've seen the Lazarus effect. I've
seen people coming back to life.'' Auntie Bridget isn't just a
PEPFAR implementer, she's also receiving antiretroviral therapy
through the PEPFAR program; and, without PEPFAR, she and many
millions of others would not be alive. She herself was part of
that Lazarus effect.
The HIV prevention efforts that are part of PEPFAR have
also shown progress, particularly through the AB model of
``abstinence and be faithful.'' Data about the effectiveness of
abstinence and faithfulness have been largely ignored. However,
there is a widespread consensus among many public health
experts that partner reduction and the delay of sexual debut
are critical and necessary components of any comprehensive
approach to reduce the spread of AIDS.
Finally, I'd like to share some of what we consider to be
the key issues for the next phase of PEPFAR.
First, I think we've learned how to control the disease.
Now we must put adequate resources into initiatives that treat
and prevent HIV. And we are now in a position to really pick up
the momentum. ``We,'' in that context, are that range of
agencies that are out there on the front lines, in the villages
beyond the end of the road, that are providing assistance.
Second, it's important to create linkages between PEPFAR
and other U.S. assistance programs, particularly in the areas
of nutrition, of livelihood, of income generating and
education. And we'd like to emphasize that these complementary
needs should be funded through other accounts, not through
PEPFAR, but they should be coordinated at the country level.
Third, our model focuses on long-term sustainable
development by building the capacity of local partners. That
includes physicians and health care staff. But it will be a
long time, in the poorest of countries, before they can really
completely and independently take on the burden of addressing
this pandemic. And, until then, providing these vital services
through PEPFAR is the right thing to do.
Fourth, because we believe that PEPFAR, as implemented,
has, so far, been widely successful, we urge you to preserve
the basic programming model, but with several improvements.
First, we feel that there must be a provision to maintain
funding for abstinence and faithfulness programs. Without
dedicated funding, these activities will be ignored. We've seen
it before, we've been down that road before, and, until there
was dedicated funding, we just couldn't access those programs.
Second, do not require PEPFAR implementers to offer family
planning and reproductive services. Such a requirement runs
counter to the moral values of some organizations, and may
constrain or hinder some organizations from participating in
the program. That will mean the program will not be offered to
many millions of people.
Third, the therapeutic feeding program, called Food by
Prescription, should be expanded to all PEPFAR countries
providing antiretroviral therapy.
Fourth, increase the support in PEPFAR for children,
including pediatric antiretroviral therapy and assistance for
orphans and vulnerable children.
And, finally, maintain the centralized model for
implementing antiretroviral therapy within PEPFAR.
In conclusion, I'd like to, once again, express my
appreciation to you, Mr. Chairman and Ranking Member Lugar and
all of the members of the committee, for calling this hearing
to discuss the next phase of this--what we consider a most
successful program, one of which our Nation can be proud. We
urge timely authorization of this initiative so that the vital
health of some of the world's poorest and most vulnerable
people can be sustained and improved.
I'd be happy to take any questions, as well. Thank you.
[The prepared statement of Mr. Hackett follows:]
Prepared Statement of Ken Hackett, President, Catholic Relief Services,
Baltimore, MD
Good afternoon Chairman Menendez, Ranking Member Lugar, and members
of the committee. I commend you for calling this timely hearing and
giving Catholic Relief Services the opportunity to share our
experiences as an implementer of the President's Emergency Plan for
AIDS Relief (PEPFAR) programs.
My name is Ken Hackett, President of Catholic Relief Services
(CRS). For over 60 years and currently operating in more than 100
countries, CRS--the international relief and development agency of the
United States Conference of Catholic Bishops--has been responding to
the needs of people around the world in emergencies, humanitarian
crises, and in development--especially for the poor, marginalized, and
disenfranchised in the developing world. CRS has supported HIV and AIDS
interventions for more than 20 years, almost since the beginning of the
pandemic. Our 250 HIV and AIDS projects in 52 countries provide
comprehensive and holistic services for orphans and other vulnerable
children (OVC), home-based care, antiretroviral therapy (ART), other
treatment support, education for religious leaders on HIV and AIDS and
stigma reduction, and prevention education for sexually transmitted
HIV--focusing on promotion of abstinence and behavior change.
successes of pepfar
First and foremost, let me say that PEPFAR is one of the most
outstanding programs our government has ever created. Strong leadership
and broad bipartisan support have shown the best possible face of the
U.S. Government toward our world neighbors, and reflect the
overwhelming compassion and generosity of the American people toward
those affected by HIV and AIDS. And above all, PEPFAR is working. In a
relatively short time, this massive new program was put in place and is
literally saving lives everyday.
I remember returning to Kenya in 1992 after a 7-year absence, and
hearing that so many of the Kenyans I had known had died. When I asked
why, I was told it was tuberculosis or pneumonia. But when I probed a
little deeper, I found they had died of AIDS. It was absolutely
shocking. In those days, AIDS was a death sentence.
In contrast, just 2 weeks ago, during a World AIDS Day
commemoration, President Bush embraced someone the Washington Post
called ``a regal-looking Zambian woman.'' Her name is Bridget Chisenga,
but everybody who knows her calls her ``Auntie Bridget.'' She works for
CRS in Zambia promoting adherence to ART and fighting stigma associated
with HIV. She gave President Bush a message that seemed to move him:
``I've seen the Lazarus effect,'' she said. ``I have seen hopes being
raised. I have seen people coming back to life. And my message is, `We
are celebrating life to the fullest.' ''
But Auntie Bridget is not just a crusader and implementer for
PEPFAR--she is also receiving the same antiretroviral therapy as the
people she counsels. Without PEPFAR, Auntie Bridget would not be alive.
She is a beneficiary of the PEPFAR transformation.
Now PEPFAR is providing life-saving ART for nearly 1.5 million men,
women, and children in 15 countries in Africa, Asia, and the Caribbean.
It has supported outreach activities to more than 61.5 million people
to prevent sexual transmission of HIV. It is providing care and support
for more than 2.7 million orphans and vulnerable children, and more
than 4 million people living with HIV and AIDS.\1\ This is nothing
short of astounding. This miracle is being repeated thousand of times
as antiretroviral therapy provided through PEPFAR is bringing hope
where there was none. A complicated medical solution is now available
to the poorest and most vulnerable people living in very remote areas.
---------------------------------------------------------------------------
\1\ From Statement of Ambassador Mark Dybul, U.S. Global AIDS
Coordinator, Before the Committee on Foreign Relations, United States
Senate, Washington, DC, October 24, 2007. http://www.senate.gov/
foreign/testimony/2007/DybulTestimony071024pp.pdf.
---------------------------------------------------------------------------
And there are other benefits as well. This successful treatment
offered through PEPFAR has actually become part of the prevention
strategy. The fact that people are beginning to live with this disease,
returning to their families and resuming their livelihoods, has reduced
stigma in communities and has encouraged others to get tested for HIV.
catholic relief services' experience with pepfar
Mr. Chairman, members of the committee, CRS has responded to the
emergency of the HIV and AIDS pandemic as we do in all our emergency
responses--with deliberate local capacity-building of existing partners
and with an eye toward long-term sustainable development.
CRS' work is built on a vision rooted in the Church's teaching that
values human life and promotes human dignity. The local Catholic Church
is often our primary partner, and we work at the invitation of the
local Catholic Bishops' conference in each country. However, we also
work with partners of other faiths, as well as other nongovernmental
and local community-based organizations to serve people based solely on
need, regardless of their race, religion, or ethnicity.
CRS works through local church and religious partners because of
their extensive network and reach. Every community in the world has a
community of faith with credible leadership. Working with them and
other local community-based organizations assures that programs are
grounded in the local communities' reality. Equally important, this
extensive network of contacts ensures the widespread delivery of
comprehensive HIV treatment, prevention, and support programs.
HIV and AIDS programming is a major priority for Catholic Relief
Services. Our FY 2008 HIV and AIDS budget of $171 million will account
for nearly a third of the agency's annual programmatic expenses
overseas.\2\ With projects in 12 of the 15 PEPFAR focus countries, we
are a major implementer of PEPFAR programs.\3\
---------------------------------------------------------------------------
\2\ 57 percent ($98 million) projected to come from PEPFAR.
\3\ Ivory Coast, Namibia, and Mozambique are the only PEPFAR focal
countries where CRS does not have PEPFAR programs--because we do not
work in those countries at this time.
---------------------------------------------------------------------------
Our largest PEPFAR award--AIDSRelief--is a $335 million CRS-led
consortium that includes the Institute of Human Virology of the
University of Maryland, Constella Futures, Catholic Medical Mission
Board, and IMA World Health. AIDSRelief provides ART in nine PEPFAR
focus countries by building the capacity of 164 local partners--the
majority of them local faith-based health care providers. As of 31
October 2007, over 90,000 people are on ART and almost 146,000 are
enrolled in care and support services. AIDSRelief has exceeded its
overall targets each year of the grant to date.
Our model of care trains and mentors, local physicians, and health
care staff to better manage high-quality treatment services to a
growing number of patients. These locally trained community health
workers and volunteer and paid treatment coaches and expert patients
are expanding followup and support services for stabilized patients in
the community. Many of the health care institutions we support now are
exhibiting their growing capacity to access resources through the
Global Fund locally and through other international donors. However, it
will be a long time before the poorest countries of the world can
completely and independently take on this burden. Until then, providing
these vital services through PEPFAR is the right thing to do.
More than half of the AIDSRelief treatment sites are in rural areas
where ART services would otherwise be unavailable. In war torn northern
Uganda, where moving around safely is difficult, AIDSRelief is one of
the few organizations supporting ART through local faith-based
institutions. For the past 2 years, AIDSRelief has partnered with Dr.
Ambrosoli Memorial Hospital in Kalongo where 302 patients are on ART
and 1,246 receive care. And in Kassesse District, a remote mountainous
area in western Uganda, AIDSRelief was the first to support the
delivery of antiretroviral therapy in a health center run by the
Banyatereza Sisters. Often walking long distances, the Sisters have
developed an extensive community outreach program reaching 324 patients
on ART and 725 in care. Without PEPFAR, these people would not have
access to this life-saving treatment. In fact, without the ministry and
care of this faith-based hospital and this religious community, the
local population would probably not have access to health care at all.
Catholic Relief Services currently operates a $9 million, 5-year,
PEPFAR-supported Orphans and Vulnerable Children Program that provides
quality services to children in Botswana, Haiti, Kenya, Rwanda,
Tanzania, and Zambia. As of 30 September 2007, this program is reaching
56,066 OVC, exceeding cumulative FY07 targets. The program provides
education and vocational training, health care, psychosocial support,
food and nutrition, protection services, shelter and care, and economic
strengthening.
Our third PEPFAR central award addresses prevention of sexually
transmitted HIV programming through age-appropriate abstinence and
behavior change among youth in three focus countries--Rwanda, Ethiopia,
and Uganda. Drawing upon extensive experience in HIV prevention in the
target countries, as well as similar programs in more than 30 other CRS
prevention programs worldwide, the ``Avoiding Risk, Affirming Life''
prevention program works with a broad range of faith- and community-
based partners that share CRS' commitment to equip youth with the
values, attitudes, skills, and support to either abstain from sex prior
to marriage or recommit to abstinence before marriage, and then to
remain faithful in marriage. As of 30 September 2007, the program has
provided 346,768 youth and adults with information to help them make
informed decisions about sexual behaviors and encourage health-seeking
behaviors.
In addition to these PEPFAR central awards, we also have received
numerous country-specific mission level grants to provide more or
additional HIV services.
challenges and recommendations
PEPFAR programs in which CRS is involved have all been successful--
often exceeding their targets. They have all faced numerous
challenges--and overcome them. However, there are certain broader and
more systemic challenges that need to be addressed by Congress as it
prepares to reauthorize PEPFAR.
Prevention: HIV infection in Africa is driven mostly by
sexual transmission. The prevention of sexually transmitted HIV
through promotion of abstinence (delay of sexual debut) and
fidelity (partner reduction) is promoted by the Catholic Church
and other religious health providers. Current PEPFAR
legislation specifically allocates funds for abstinence and
behavior change as part of wider ABC approach. As a result, CRS
and other religious organizations have been able to expand
their prevention programs. Prior to PEPFAR virtually no funding
for abstinence and faithfulness was available.
There is widespread consensus among public health experts that
fidelity and abstinence are necessary components of any
comprehensive approach to reduce the spread of AIDS. Evidence
has shown that condoms alone are insufficient for a generalized
epidemic.\4\ According to the Centers for Disease Control and
Prevention (CDC), the surest way to avoid transmission of HIV
is to abstain from sexual intercourse, or to be in a long-term
mutually monogamous relationship with a partner who is known to
be uninfected. For persons whose sexual behaviors place them at
risk for HIV, correct and consistent use of latex condoms can
reduce the risk of HIV transmission. No protective method is
100 percent effective, however, and condom use cannot guarantee
absolute protection against any STI, including HIV. In order to
achieve the protective effect of condoms, they must be used
correctly and consistently.
---------------------------------------------------------------------------
\4\ Halperin DT, Epstein H., ``Concurrent Sexual Partnerships Help
to Explain Africa's High HIV Prevalence: Implications for Prevention.''
The Lancet 2004; 363: 4-6.
---------------------------------------------------------------------------
Partner reduction is considered to have been the single greatest
factor in reducing HIV prevalence in Uganda,\5\ with an
estimated 65 percent decline in the number of people reporting
nonregular partners between 1989 and 1995.\6\ Data show that
the majority of Africans already practice A or B behaviors and
that these behaviors are thus realistic for most people. In
African countries for which Demographic and Health Surveys were
available, an average of 77 percent of men and 97 percent of
women ages 15 to 49 had 0 or 1 sexual partners in the past
year; and 59 percent of unmarried young men and 68 percent of
unmarried young women ages 15 to 24 were abstinent in the past
year.\7\
---------------------------------------------------------------------------
\5\ Green, E. 2003. Testimony at Harvard University before the
African Subcommittee, U.S. Senate.
\6\ Low-Beer, D. and R. Stoneburner. 2003. ``Behavior and
Communication Change in Reducing HIV: Is Uganda Unique?'' African
Journal of AIDS Research. 2: 9-12.
\7\ Demographic and Health Surveys. Available at
www.measuredhs.com.
---------------------------------------------------------------------------
The promotion of abstinence-until-marriage and mutual fidelity
within marriage has long been the cornerstone of CRS' HIV
prevention programming. Abstinence and mutual fidelity
reinforce the precise values and norms necessary for mobilizing
people to avoid risk, and for reversing the epidemic.\8\ In
short, these approaches work and work well. Without designated
funding these excellent programs will be under-resourced and
the high quality faith-based health structures and services in
PEPFAR countries will be sidelined in the battle against HIV.
---------------------------------------------------------------------------
\8\ CRS. 2004. ``AB Narrative Final for PEPFAR AB Grant.''
Baltimore.
Certain Add-on Services: We are similarly very concerned
about efforts to define ``comprehensive services'' for HIV-
positive women as necessarily including family planning and
reproductive health services. CRS regrets these efforts and
asks that such proposals be rejected. Moral tenets of religious
organizations like Catholic Relief Services prevent them from
offering these ``comprehensive services.'' Our experience is
that high quality care, treatment, and prevention can be
provided without these additional services. If these services
were mandated or given preferential treatment in awarding
PEPFAR funds, then Catholic Relief Services and other religious
implementers would be unable to participate in PEPFAR. Patients
served through our networks, especially in the poorest, most
remote areas of the globe, would face interrupted therapy or
even cessation of life-saving therapy for lack of qualified
---------------------------------------------------------------------------
providers.
Lack of Nutrition and Food Security: Lack of food--or the
money to buy it--is the No. 1 concern expressed by ART
patients, OVC and their households. All aspects of food
security are exacerbated by high rates of HIV and AIDS. The
chronic and debilitating progression from HIV infection to
full-blown AIDS, accompanied by loss of work and income while
seeking treatment lead to poor nutrition, lack of food, hunger
and food insecurity. Women and children are disproportionately
affected.
The low nutritional status of many ART patients compromises the
effectiveness of their medications. To fully benefit from ARVs,
many patients need therapeutic feeding for a limited period of
time. PEPFAR provides funding through USAID for therapeutic
feeding, through a pilot program called ``Food by
Prescription.'' The program has very clear biometric indicators
for determining patient eligibility. However, this program is
not available to all due to insufficient funding. Expansion of
``Food by Prescription'' to all PEPFAR countries providing ART,
with commensurate increased funding, is desperately needed.
The majority of CRS' 250 HIV and AIDS projects that target food-
insecure people living with HIV as well OVC, include an
integrated food element. Where possible, CRS partners with
USAID Title II Food for Peace (FFP) and the World Food Program
(WFP) to provide necessary food and nutrition. Where public
resources are not available, CRS uses private resources to meet
this need. In addition, CRS supports increased funding for
nutrition support in ART programs. Congress needs to evaluate
on a priority basis with the Office of the Global Aids
Coordinator (OGAC) and USAID the requirements for additional
food aid resources.
Health Care Workforce: Care and treatment involves complex
interventions that can either strengthen or weaken the health
care systems in PEPFAR countries. The pandemic has greatly
stretched the existing health care workforce, especially
professionals--doctors, nurses, and pharmacists. Many
AIDSRelief local partner treatment facilities will soon be
unable to serve additional clients because of the lack of
trained staff. PEPFAR needs to provide additional resources to
increase the number of health care professionals, appropriately
train for task shifting of care and treatment, as well as
provide for training, supervision, and remuneration of other
nonprofessional community and volunteer health care workers
Commitment to Meeting Pediatric ART Targets: HIV is eroding
gains made in child survival. Mortality and morbidity is high:
50 percent of HIV infected children below 2 years of age die
without care and ART. In order to improve the outcome of
pediatric HIV infection, programs that address prevention of
maternal to child transmission (PMTCT) need to be strengthened
and a definitive diagnosis of HIV-exposed infants needs to be
made as soon after birth as possible. Moreover, health care
professionals will require additional training in order to
provide care and treatment for infected children and care;
pediatric ARV formulations are not readily available, and
affordable pediatric treatment programs need to be put into
place.
PEPFAR is results-driven and implementers of antiretroviral
therapy (ART) projects are evaluated based on their ability to
deliver ART to specific targets--10-15 percent for pediatric
ART. Achieving this target is challenging for a number of
reasons. Pediatric ART dosing according to complicated regimens
based on changing age, weight, and height of growing children
is very challenging. Also, pediatric formulations are more
expensive than ART regimens for adults. Implementers are more
likely to initiate adults on ART because it is easier and
cheaper and thus they are more likely to achieve their ``number
of people on ART'' targets.
If PEPFAR implementers are to meet or exceed a 10-percent
pediatric ART goal, as they should, they will need targeted
funding.
High Numbers of Orphans and Vulnerable Children: Older
children in AIDS-affected households are often forced to quit
school because of deteriorating family finances and/or because
they need to care for their ailing parent. A most disturbing
phenomenon is the reality of young girls forced into
transgenerational sex to meet their own and their family's food
needs. Younger children of school age often never even start
school. Those lucky enough to attend school often don't have
enough to eat. Linkages with WFP in Tanzania and USAID FFP in
Kenya and Haiti enable us to provide critical nutritional
support for these children. As Congress reconsiders PEPFAR
reauthorization, there is an urgent need for increased funding
for OVC support as well as a requirement to systematically link
PEPFAR programming with food programming. Unfortunately, in
other countries, rigid regulations, program requirements, or
other bureaucratic problems have made it impossible to link
PEPFAR OVC support with other funding for nutrition, education,
or other critical needs.
As Congress reconsiders PEPFAR reauthorization, there is an urgent
need for increased funding for OVC support as well as a
requirement to systematically link PEPFAR programming with
food, education, and other programming.
Complicated PEPFAR Funding Mechanism: The number of USG
agencies involved in PEPFAR, the multiple levels of programming
and budget consultation, decisionmaking, and grant management
procedures (Central and Mission-level), and the number of
countries involved, all contribute to increased costs and
complicated/cumbersome reporting, cash disbursement, and
decisionmaking. The CRS-led AIDSRelief ART project is a
centrally awarded 5-year cooperative agreement through HRSA,
but administered in the field by both CDC and USAID. Since year
2, a static portion of AIDSRelief funding continues to be
obligated centrally through HRSA, while another increasingly
larger portion is awarded each year through the Country
Operating Plan (COP) at the local USG mission. The onerous COP
process combined with late obligation of funds causes
particular challenges for implementing partners in the field 10
months of the year.
Furthermore, since we cannot predict out-year resources in the
context of the current ``annually renewable commitment'' COP
funding mechanism, long-term planning is extremely difficult.
This affects the confidence of our partner sites to continue
expanding their activities to meet their targets. As a result,
many sites have taken a very conservative approach to scale-up
due to fears that funding will be reduced or cut, and will
result in the sites themselves needing to bear ongoing
treatment costs--which most cannot afford.
PEPFAR needs to institute multiyear funding for multiyear awards;
strengthen the centralized funding mechanism; change the
funding cycle to correspond to the fiscal year, and streamline/
standardize the COP process.
The Global Fund: Through Round 7, only 5-6 percent of the
total funding channeled through the Prime Recipients (PR) of
the Global Fund for AIDS, TB and Malaria (GF) were faith-based
organizations. Even including subrecipients of Government or
secular prime recipients, less than 15 percent of GF-support
programs are faith-based organizations.\9\ The nascent ``dual
track'' financing mechanism hopes to put civil society on equal
footing with national governments in the country coordinating
mechanism (CCM)--Churches Health Association of Zambia is a
poster-child for this innovation. However, the idea of pairing
an NGO principal recipient with a government one is only a
recommendation by GF to national CCMs. Religious health care
providers account for 30-50 percent of health care services
done in many developing countries--up to 70 percent in some
countries.\10\ Many religious health care providers report that
they do not have access to the CCMs to help plan and achieve
the national plan responding to AIDS, TB, and malaria. The huge
potential of religious health care providers is not being
adequately recognized and engaged in the fight. Since the U.S.
Government is providing one-third of the resources for the
Global Fund, Congress should take steps to make sure that local
religious health care providers are meaningfully engaged in
their countries' CCM and adequately resourced to participate in
achieving their countries' national plan. This will insure the
most productive allocation of scarce resources to achieve the
maximum impact possible in terms of lives saved and protected.
---------------------------------------------------------------------------
\9\ ``Distribution of Funding After 6 Rounds'' on http://
www.theglobalfund.org/en/funds_raised/distribution/.
\10\ African Religious Health Assets Programme. 2006.
``Appreciating Assets: The Contribution of Religion to Universal Access
in Africa.'' Report for the World Health Organization. Cape Town:
ARHAP, October 2006.
---------------------------------------------------------------------------
conclusion
Finally, CRS strongly supports increased funding for PEPFAR--above
$30 billion. The program, however, must maintain its focus on HIV,
malaria, and TB and should not be expected to fund the many other
related development needs that poor HIV-affected communities have.
Similarly, an expanded PEPFAR must not come at the expense of urgently
needed increases in other core poverty development accounts, including
Child Survival, Title II Food for Peace, agriculture, and microfinance.
I would like to once again express my appreciation to Chairman
Menendez, Ranking Member Lugar, and all the members of the committee
for calling this hearing to discuss the next phase of this highly
successful program. We urge timely reauthorization for this initiative
that preserves the best and most effective elements of this program
that is so vital for the health of some of the world's poorest and most
vulnerable people. We and our partners stand ready to continue and
expand the lifesaving work that PEPFAR has enabled us to accomplish. I
would be happy to respond to any questions the committee may have.
TABLE 1.--CRS-LED AIDSRELIEF ART PATIENT ENROLLMENT
[As of October 31, 2007] 1,2
----------------------------------------------------------------------------------------------------------------
% of total
Current # of PEPFAR-funded
Current # Pediatric ART patients Cumulative
Country Current # of Patients Patients (<15 who are # of
of LPTFs* on ART years old) on enrolled Patients in
ART (% of through Care
total) AIDSRelief**
----------------------------------------------------------------------------------------------------------------
Guyana................................... 3 524 47 (9.0%) 22 1,462
Haiti.................................... 8 2,347 479 (20.4%) 18 7,471
Kenya.................................... 20 17,795 1,808 (10.2%) 11 38,499
Nigeria.................................. 22 11,706 492 (4.2%) 10 31,819
Rwanda................................... 13 1,553 155 (10.0%) 5 3,174
Shared w/MAP............................. 5 1,018 76 (7.5%) -- 3,126
South Africa............................. 26 12,900 1,092 (8.5%) 6 30,523
Tanzania................................. 31 13,825 993 (7.2%) 16 35,993
Uganda................................... 16 13,788 1,037 (7.5%) 17 49,133
Zambia................................... 14 15,407 990 (6.4%) 11 35,242
----------------------------------------------------------------------------------------------------------------
Total.............................. 153 90,638 7,169 (7.9%) 11 233,699
----------------------------------------------------------------------------------------------------------------
\1\ ``World AIDS Day 2007: The Power of Partnerships,'' Factsheet. PEPFAR, U.S. Government, December 1, 2007,
available at: http://www.pepfar.gov/documents/organization/96070.pdf.
\2\ ``HRSA Monthly Report, October 2007.''
* LPTF = Local Partner Treatment Facility.
** This column calculated based on September 30, 2007, PEPFAR and AIDSRelief data.
*** This is also the total percent of patients on ART in Kenya.
Senator Menendez. Thank you, Mr. Hackett.
Thank you all for very insightful testimony.
We'll start with 5-minute rounds, and I think we'll have
time before the first round of votes take place on the floor.
The Chair will recognize himself.
Dr. Kazatchkine, the Global Fund and PEPFAR seem to appear
most successful when they are able to coordinate their
activities. What countries offer the best examples of that
coordination? And what are those best practices being followed
by others?
Dr. Kazatchkine. Thank you. Yes, indeed. Countries where
both PEPFAR and Global Fund are strongly coordinating are
making very rapid and impressive--particularly rapid and
impressive progress.
Let me cite Ethiopia, where PEPFAR and Global Fund have
been coordinating their efforts with regard to HIV/AIDS under
the leadership of the Minister of Health. We work together so
that either first-line treatment--what we call first-line
treatment; that is, the first treatment that is prescribed to
patients--or second-line treatment, the treatment that is
prescribed to patients who have become resistant to first-line
treatment, are financed either by one or the other source,
either PEPFAR or Global Fund, depending on what's more
appropriate and easily available.
We have aligned, both of us, PEPFAR and Global Fund, on the
national strategy, as established by the Ethiopian Government.
The Ethiopian Government is in leadership. And that has led to
spectacular increases in the number of people treated in
Ethiopia.
This is--the same is happening in Kenya, in Cote d'Ivoire.
I have been traveling to Cote d'Ivoire recently, together with
Ambassador Dybul. We have also been to Rwanda, to Haiti.
Wherever we go, our message is: We're working hand in hand,
and----
Senator Menendez. Are there a series of best practices that
you----
Dr. Kazatchkine. Country best practices? Yes.
Senator Menendez [continuing]. Are trying to promote with
others?
Dr. Kazatchkine. Yes, indeed; particularly with regard to
antiretroviral therapy, modalities of prescribing and
distributing antiretroviral therapy. And, in fact, I think that
it now, basically, in the 15 focus countries of PEPFAR, these
practices--best practices are being implemented.
Senator Menendez. Let me ask both Dr. Smits and any others
who want to address this, I read the recent report by the
Global HIV Prevention Working Group, which, in its report
entitled ``Bringing HIV Prevention to Scale, an Urgent Global
Priority,'' opened up with, ``We should be winning in HIV
prevention. There are effective means to prevent every mode of
transmission. Political commitment has never been stronger.
Financing for HIV programs in low- or middle-income countries
increased sixfold between 2001 and 2006. However, while
attention to the epidemic, particularly for treatment access,
has increased in recent years, the effort to reduce HIV
incidence is faltering.'' And I know some of you touched upon
this.
I'd like to know what we and the rest of the world should
be doing more aggressively on the question of prevention and
what are we doing well, and what are we not doing that we
should be doing in this regard? There are promising
technologies, such as male--medical male circumcision. I'd like
to hear what we should be doing on the prevention side that we
are not.
I'll start with you, Dr. Smits, and any others who want to
address it.
Dr. Smits. First, I wouldn't be--personally, and I think
the committee--would not be as negative as that statement
appears to be. Certainly, the new U.N. numbers suggest very
strongly that, in some countries, we're really moving ahead on
prevention. But we need to do a great deal more in terms of
very precise evaluation of what's happening. We ought to be--
we're--in a sense, we're waiting, now, to see the epidemic
change in order to figure out whether the behavior changes
we're teaching are really making a difference. I think we can
look more carefully at behavior changes with targeted surveys.
I was privileged to go to the implementers meeting last
June, and I heard several very good talks, particularly one by
David Apuli, who is the head of the program in Uganda, who says
that the way to fight AIDS is to know where your last thousand
cases came from, and to target your prevention efforts there so
that you don't keep doing what you were doing very successfully
2 years ago. I think there's a risk of that. He particularly
emphasized the discordant couples and the need to develop
different messages for them, not just condom distribution, but
a lot more counseling in the treatment and care settings with
someone known to be HIV positive, about what the implication is
for their partner.
I think that message--What were the last thousand cases,
and how can we best attack them?--is really the most useful.
So, I don't think we can tell people in these countries how
to do their programs. I think that they know a great deal about
it. We need to give them the flexibility, and we need to give
them the scientific support to look at the results of what
they're trying to do.
Senator Menendez. Dr. Daulaire.
Dr. Daulaire. Thank you, Mr. Chairman.
I would concur. I think there is starting to be good
evidence that the tide is beginning to be turned. Certainly, in
some places like Thailand and Uganda, there has been
substantial impact from prevention activities. And what's
striking there is how very different the prevention activities
that those two countries undertook were. In Uganda, as my
friend Ken Hackett has pointed out, the issues of partner
reduction, faithfulness, abstinence have been very important
components. In Thailand, the issue of condoms was much more
important, and that was because the dynamics of the epidemic
were very different in the two places.
Clearly, in order to turn--really turn the tide, in terms
of prevention, recognizing that AIDS is, fundamentally, an
asymmetric kind of disease, it doesn't spread the same way
everywhere, it really depends on different populations,
different routes of transmission. What is most important is
making prevention, the reduction of new infections of HIV, a
priority--a stated priority, that has to be measured, that has
to be tracked and followed. And those new infections,
particularly, should be focused on those most likely to
continue the chain of transmission, because, when you're
looking at the numbers over time, that's where successful
interventions can have the biggest impact.
So, I don't believe that a prescription is called for here,
in terms of the new legislation, in terms of ``do this or that
at these percentages,'' but I do believe that prevention should
be clearly prioritized. I think the first Leadership Act
rightfully focused on treatment, because there was virtually no
treatment in the world. And I think there is good justification
for its focus on abstinence, because that was a neglected part
of the equation. I think the world, and the world of
implementation, has changed a great deal since that time.
Senator Menendez. Thank you.
I'd love to hear from all of you, but I need to get to
Senator Lugar, so maybe in the next round I can hear some of
your further answers on this.
Senator Lugar.
Senator Lugar. Thank you very much, Mr. Chairman.
Dr. Kazatchkine, I appreciated your thoughts about
transparency and accountability. These are virtues that are
shared by the Congress, and our oversight, really, is dedicated
to this. I just want to, more specifically, inquire about the
Global Fund's ability to attract the most effective, efficient
contracts for medicines and services at the lowest possible
prices. What are your largest contracts, and how do you go
about bringing about transparency, accountability, and auditing
of those contracts?
Dr. Kazatchkine. Yes; we have a number of mechanisms in
place in order to ensure transparency and accountability.
First, we do have portfolio managers in the secretariat at
the Global Fund that track every single grant throughout the
grant cycle, from grant signing to implementation, and follow,
from our Geneva office, everything that happens during the
grant cycle.
On the ground in countries, the--what we call the country
coordinating mechanism, which is a collective group of
stakeholders, government, civil society, multilaterals,
bilaterals--the U.S. Embassy or USAID is usually represented in
most of our CCMs--are--have, also in their functions, to
provide oversight on the country program.
And then, at the country level, we have an independent
observer with whom we subcontract, which we call the local
funding agent, and that local funding agent reports to us every
3 months, or sometimes, when necessary, more often, on both the
financial aspects of the grant, the disbursements, but also on
the programmatic results and how those match.
Whenever something appears going wrong, we call the--we
trigger--this triggers what we call an early alert response
system, and, if necessary, we call on an outside investigation
or we call on an audit by the inspector general from the Global
Fund. That inspector general this year, as you know, has been
the inspector general of WHO, as an interim inspector general,
from January this next year, a new inspector general has now
been appointed, John Parsons, who, until now, has been the
inspector general of UNESCO.
Senator Lugar. Why, thank you very much for that testimony.
I have a second question with regard to China and its
participation. I understand that China is a member of the
board. It makes a contribution to the Global Fund. But, at
least our information is, it receives from the Global Fund a
very large multiple of that amount of money for various
reasons. Do you follow that? With the insight of what China may
be able to do for itself in due course; that is, replace those
particular services and funds now that are received from the
Fund, as there may be others who are in much more difficult
financial condition, given the practicalities of world growth,
Chinese growth, and so forth. Can you make a comment about the
Chinese situation?
Dr. Kazatchkine. Yes. Thank you.
I see two aspects to your question. One is the specific
issue of China, the other is funding, by Global Fund, of grants
in-country with, let's say, rapidly emerging economies, and
that, in addition to China, is also India and Russia.
Now, the Global Fund has played a key role in triggering
access to prevention and to treatment of HIV in China. We are,
indeed--have a very large portfolio of grants there, over 400
million U.S. dollars. If there had not been the Global Fund, we
wouldn't have seen prevention among IV-drug users that are one
of the drivers of the epidemic, particularly in southern China,
we wouldn't have seen developed the efforts of prevention among
truck drivers and among some of the vulnerable populations that
are reached by our funding through civil society.
I do agree with you that, following that first phase, it is
time for China, progressively, as it is for emerging countries,
not to only be a recipient, but also become a larger donor to
the Global fund.
Now, Russia has just given an example. Russia, that has
received $270 million from the Global Fund, and where the
Global Fund has also been a key trigger of access to services
for vulnerable populations, has decided, last year, to
reimburse, actually, every single donor dollar that it has
received from the Global Fund by 2010, and they came to our
recent replenishment conference with signing a first check of
70 million U.S. dollars.
I do hope that China and India will progressively follow
that example. And my advocacy with these countries--I'll be in
India next week--is to ask them to provide a percent of their
annual increase in wealth for global health.
Senator Lugar. Very good news.
Thank you very much, sir.
Senator Menendez. Thank you.
Senator Kerry.
Senator Kerry. Mr. Chairman, thank you. And thank you very
much for having this important hearing.
Obviously, dealing with this issue is not a partisan issue,
as the record of this committee well displays. As we know, over
90 percent of all the children infected with HIV live in
Africa, so that's 2 million out of the 2.3 million kids that we
know are affected. And 1,800 more become infected every single
day. And more individuals are becoming infected than are being
treated, which is the challenge, obviously.
I just came back from South Africa and Botswana, and got an
up-close-and-personal reminder of how devastating it is, and
the threat that it poses to an entire continent's stability. I
had the privilege of visiting the Umgeni primary school and
talking with people in Kwankalosi and Kwazulu-Natal, near
Durban, and I saw very inspiring, but, at the same time,
heartbreaking situations. I remember one woman in a mud hut,
tiny mud hut, cooking some--with a caregiver, a caregiver who
was trying to help her, comes once a week. She has three kids.
They are in school. Her sister has already died of the disease.
And it just--you know, you can just extrapolate that, you know,
thousands upon thousands of times. I was inspired by the work
of the Valley Trust caregivers, but I also met orphans who, at
a young age, have become the caretakers of their whole family,
assuming adult responsibilities. And, again and again, I heard,
from those on the front lines of this pandemic, that their
greatest challenges is the public-relations battle to educate
their communities.
I was struck, also, in a session that I had with some of
those folks responsible for educating and caregiving, as I
tried to elicit from them the figures. Because there was some
press around, and some other public people, they just were very
clammed up. They wouldn't want to talk about it. They were
fearful of retribution for telling the truth about what's going
on. And, privately, they pulled me aside later and, sort of,
told me why they were fearful and couldn't tell me, sort of,
the real numbers of kids in the school. I asked, How many kids
here? In fact, they're--how many kids are orphans--and so
forth.
We have to work incredibly hard. And we all know the
problem that existed with President Mbeke and the government
itself in South Africa in getting this truth out. But it
reaffirmed for me the fact that, while AIDS has done the
killing, the disease's best allies have been denial,
indifference, and ignorance. And that's what we have to, sort
of, fight here, partly, in whatever we structure here as the
follow-on.
Let me also nitpick for a tiny moment, if I may, on a
personal level. As I was walking out of one of those locations,
I saw this poster up on the wall, and it said, ``The
President's Emergency Program.'' And it, sort of, hit me, to be
honest with you. I said, ``What do you mean, the President's?
First of all, which President?'' But, second, that legislation
was written right here in this committee by Bill Frist and
myself, and Jesse Helms joined into writing that. Remember,
Senator Lugar? And Senator Lugar and others put that together.
And it's not the President's, it's the American people's, it's
the United States, and it would do us a lot more good, frankly,
if more people knew what the United States of America is doing,
and what the American people are doing, with respect to this.
And so, Mr. Chairman and Mr. Ranking Member, I hope when we
redo this, we're going to clarify that. I think that's
important as a matter of policy.
Equally importantly, if I may say, that--you know, we did
that in 2002, and we proposed the futures of $15 billion; and
so--but we're delighted the President came and picked it up,
and we're delighted, without his leadership and involvement--
obviously we wouldn't, probably, have gotten the money, in the
end. But I think we ought to, sort of, see this for what it is,
in its reality.
But what I want to focus on with the panel that's here
right now as we think about this is, sort of--we're all aware
of the 2-7-10 goal for 2008. My fear is that, unless we can
break through more effectively on this education--my daughter,
incidentally, went over for a summer as a medical student;
she's now an intern. But she went to Ghana, and she went to
Rwanda, and she worked in AIDS for the entire summer. And she
wrote her paper--her graduate paper on the truck routes and how
that is. You were speaking, Dr. Smits, about knowing where the
last thousand cases is. Well, that's where the last--how many--
tens of thousands of cases have come through, is the truck
routes, and obviously there are other causes. But it seems to
me that there has to be a much more intensive focus on
coordinating the prevention, slash, education breakdown and
mythology, and engagement of the governments themselves. I
mean, the leaders have got to go out there and have these
tests, not just guests. And they've got to do it regularly. And
they've got to really prove the importance of this. And,
otherwise, these dollars are just, kind of, going to go
incessantly at this increasing population of people that we're
not treating. And, you know, I don't think we want to make this
like Sisyphus pushing the rock up the hill, if we don't have
to. And I don't think we have to. So, my hope is that we could
do that.
One of the things I heard at the University at
Witzwatersrand, where we met with public health folks, was
their concern about PEPFAR being a separate track, completely,
and not integrated enough into the rest of the health care
delivery system. Now, to some degree, when you started up, that
may have been necessary. But, at this point in time, it strikes
me, we may want to try to create a greater integration. So, I
wonder if you'd just take a moment--I've exceeded my time in
questioning--just ask the one question: What do each of you
see, in terms of that potential of integration, and how do we
frame this better to deal with this ad infinitum added
population and break down the mythology and get greater
accountability in these countries?
Dr. Kazatchkine, do you want to start? And then we'll go
right down the line.
Dr. Kazatchkine. Yes; I'll--very briefly. And then, Mr.
Chairman, I regret, but I'll ask the committee's permission
that I leave; I have to fly back to Geneva right this
afternoon.
Thank you for your question, Senator Kerry. Right before
you came in, I had a question from Senator Menendez on
integration between PEPFAR and the Global Fund. Actually, in
countries where PEPFAR and Global Fund are both present--that
is, in fact, in the 15 focus countries--there is a very strong
integration of both programs around the national priorities.
The Global Fund itself that is in the other countries--and
we're currently funding grants in 137 countries around the
world--is, as I discussed in my remarks, a country-owned
mechanism. We're funding what the countries request us to fund.
So, in fact, we do align, by definition, on the national
program. So, there is full integration of Global Fund grants
with national programs. And we're currently moving into, as I
also very briefly discussed in my remarks, going to fund
national strategies, rather than pieces of national strategies,
in the future.
Senator Kerry. Dr. Smits.
Dr. Smits. I only did--the committee visited in small
groups, so I only visited----
Senator Menendez. Before you continue, Dr. Smits--
Doctor, we're going to excuse you. We were told that you
had a flight. We appreciate your testimony. There may be
questions submitted for the record, that we'd ask you to
respond to, subsequently. And have a safe journey.
Dr. Kazatchkine. I will be pleased to. Thank you very much.
Senator Menendez. Thank you.
Dr. Kazatchkine. I'm sorry.
Senator Menendez. Dr. Smits.
Dr. Smits. I only visited three countries on a formal
basis, but I would say that the degree of coordination that I
saw in all of those was really quite good, and the response of
PEPFAR to government priorities was very good. For example, in
one, the ministry responsible for orphans said, ``It's so
wonderful to have you here. We've had all these plans for these
programs, and PEPFAR's commitment to orphans will make a huge
difference. And I want you to promise to come back in 2 years
and see how much we've accomplished, because I'm just starting
now.''
In another country, we visited with the Ministry of
Defense, which is doing some very exciting things. As you know,
African countries with a strong military earn money by sending
their soldiers into other countries on peacekeeping missions,
and must send them out HIV negative, and protect them when
they're away. And they've done a marvelous job. That ministry
told us that they believed that PEPFAR was the result of divine
intervention. I thought maybe the Congress would have something
to do with it. But that sense that we had come----
Senator Kerry. We are very divine these days. [Laughter.]
Dr. Smits. We had come and brought resources to something
they wanted to do, and they had planned, that was important to
them on a national basis. So--and we certainly saw a number of
examples, the other team members did, in many of the countries,
very close coordination with the Global Fund. It's a bit
variable, country by country. A lot has to do with how strong
the country leadership is. But I think you can't dictate it.
You can say it's very important, but you can't say how to do
it. But I think it really is happening.
Senator Menendez. Thank you.
Senator Feingold.
Senator Feingold. When I was in Uganda recently, I met with
key representatives from the HIV/AIDS community, and we
discussed the importance of building national capacity so that
these countries will be increasingly able to meet the health
needs of their own citizens. But some of the health experts
have argued that international HIV/AIDS programs might worsen
overall health in developing countries because of the
phenomenon of local health workers being attracted to the
United States and multilateral initiatives that provide higher
compensation and benefits than those offered by public health
centers. This migration of HIV/AIDS programs could also leave
fewer health workers available to treat people suffering from
other health complications. Do you think this is a valid
criticism and concern?
Dr. Daulaire. Let me start, Senator Feingold. It is a valid
concern. We are seeing, all over sub-Saharan Africa, the
migration of health care workers; in some cases, from Africa to
more affluent countries--brain drain--because of better
salaries; in some cases, moving from low-paid government jobs
in clinics doing maternal and child health services into HIV/
AIDS programs. This is not to argue that we shouldn't be doing
these things, and that we shouldn't be funding them, but it
certainly is a clear argument that health workforce development
and support, as part of a broader approach to health systems
strengthening and development, is critical.
Ultimately, at the end of the line, the person who
administers the antiretroviral therapy, who does the health
education for prevention, is the same person who takes care of
the mother during her pregnancy, who takes care of the child
when the child gets ill with pneumonia or diarrhea, the HIV-
negative child. And unless we work to strengthen the
integration of the HIV programs into the broader primary health
care system, we're going to be at risk of turning this into a
two-track system which could have negative consequences for
health.
Senator Feingold. Sure.
Mr. Hackett. If I could just add to that with a specific
example, because I agree with Nils.
Recently--well, 3 months ago, in Kenya, the Catholic
bishops made an appeal to the President; a personal appeal.
They were losing most of their good staff from the Catholic
hospitals, which represent a sizable portion of health care in
Kenya, and they were losing them to those government programs
that got a recent grant, both from the Global Fund and UNAIDS.
I think we would all agree, here, that there has to be a better
coordination of all kinds of approaches, both programs, in a
national sense, and also local programs.
For instance, we, the U.S. Government, directly and through
the World Food Program and through agencies like mine, provide
food assistance, sometimes, in the country, or money for
agricultural activity. It is not generally coordinated with the
AIDS program, so that those people that you met in South
Africa, those young orphaned kids, one of their worries is
where they're going to get a meal. And we could do a much
better job in integrating services. What about the woman who
has gone through the antiretroviral therapy, comes out of the
hospital. She's sold everything--pots, pan, tin roof. She's got
nothing. What she needs is a way to start her life again.
Senator Feingold. Well, how do we make sure that another
aspect of the United States or the NGOs that we contract with
do not actually hire away these scarce professionals who do the
AIDS work? How do we deal with that?
Dr. Daulaire. I think a question, Senator, is you're
dealing with a finite resource, and if we focus on putting a
cap on that relatively small bottle of trained health care
providers, I don't think that's going to resolve the problem,
because the bottom line is, there is a huge deficit of health
care workers in these countries to begin with. We have to be
intimately involved, along with our partners, along with the
host countries, in supporting the development and training of a
much larger cadre of health care providers, not primarily
doctors, I would say, because they are the most fluid of all--
they migrate like crazy--but nurses, paramedics, people who are
actively involved in community health in their own communities,
and who can be trained to do 95 percent of what needs to be
done, in terms of HIV care and the other aspects of primary
health care. So, training, deployment, management, and support
are critical here.
Senator Feingold. Thank you, Mr. Chairman.
Senator Menendez. Senator Lugar.
Senator Lugar. Thank you, Mr. Chairman.
I just wanted to ask Mr. Hackett, as someone in the field
to respond to this. We have premised this hearing, the one we
had before, and early introduction of legislation, on this
basis that other countries and other contributors need to have
assurance that we are going to have continuity of our support.
As all of us have witnessed our appropriation process this
year, we're coming into the final days of calendar year with 11
of our 13 bills not passed, and this is noted by other
countries. They understand that we're going to be there for
them in due course, but have been raising questions, in terms
of the continuity of support, and therefore, what they are
likely to contribute in the process. Now, they can go ahead
without us. But, as we are a leader and a large contributor, we
think, at least, that this is very important.
I would just like a confirmation statement from you, or
other members of the panel, as to the importance of the
timeliness of action, as opposed to the fact that, evenutally,
it will happen but maybe after many lives have been lost if
there is a break in service.
Mr. Hackett. Senator, I couldn't emphasize more that the
message you are sending is heard. And if there is a swift and
robust action to authorize the second PEPFAR at a level that
we're talking about, either at the higher level, or even at the
$30 billion level, that will be heard, and it will send, to the
richer nations, a clear message that they must step up to the
plate. And I think--it was said earlier, those people, our
partners that we work with, want to know that there is a
future. They've started people on antiretroviral treatment.
Those people are alive. They want to keep them alive. So, they
want to be sure about this. And there are many millions of
people affected.
Senator Lugar. Thank you very much.
Dr. Daulaire. Senator, if I may, it is critical to get this
done over the next several months. Particularly concerning
antiretroviral treatment, if we get a break in the chain of
treatment of people who are already under care, we are at risk
of building a cataclysm, in terms of drug-resistant HIV, so
we're no longer dealing with infections that are susceptible to
the first line of treatment. It is vital that this program be
reauthorized and refunded quickly.
Senator Lugar. Yes.
Dr. Smits. Can I just add? First of all, to second that,
one of the accomplishments of PEPFAR is that we have not yet
experienced any major disruption in drug availability, and we
need to keep up that record. But many of the people doing the
implementation of all aspects of the programs are employees of
NGOs in these countries; and if the program is not reauthorized
in a timely manner, those NGOs may have legal obligations to
begin issuing layoff notices. So, it's really critical, in
terms of moving forward, to have early reauthorization--I know
you know that, but I--at least I can say it for the record.
Senator Lugar. Well, this is important testimony. I know
that the chairman has been working with Senator Kennedy, who is
very instrumental, at the HELP committee. We all have at stake,
and we're attempting to do our part.
I am encouraged by Dr. Kazatchkine's comments about the
Russian contribution and this whole premise that many countries
now, surprisingly, have economies that are growing, and growing
rapidly. There is substantial new wealth and ability to step up
to the plate, in terms of world responsibility, as opposed to
being, necessarily, recipients. It could very well be the
timeliness of our action that would be helpful as he works with
members of his board, who may now be able to turn large
recipients to substantial contributors. This is, I think, a
facet that's arisen from this hearing. This knowledge, at least
for me, about how others may be taking a look at it, may mean a
lot in the future in terms of their own contributions.
Thank you, Mr. Chairman.
Senator Menendez. Thank you. Thank you, Senator.
Two last questions before we'll break. And we thank you all
for the time you've spent with the committee.
Dr. Smits, one of the central recommendations of the IOM
report is to the U.S. Global AIDS Initiative to maintain its
urgency and its intensity, but to shift to a more sustainable
approach. As we talk about reauthorization, especially--the
timeliness of it and, the importance of it--the question is,
presumably, that same recommendation could be extended to the
Global Fund, as well. How do you believe, for example, that
PEPFAR and other programs can begin this transition to
sustainability?
Dr. Smits. There are many details in the report that move
that way--longer term planning cycles, total coordination with
the country coordinating mechanism--and we saw some very good
examples of that--so that the country is doing the planning,
and we are supporting it, not us doing the planning and then
just, sort of, showing them the papers. Then there is the
support of training programs. I worked in Mozambique several
years, I know the details of nurse training and clinical
officer training in Mozambique. It would not be expensive to
expand those programs. You just need the money to keep the
schools open. The teachers are paid on a module basis; pay the
teachers for more modules. You could expand workforce quite
reasonably. And my understanding is, many other of these
countries have similar arrangements. Expanding medical schools,
there, as here, is probably slower and more expensive, but that
can be done, as well. We need to be a participant in that. Many
other donors already are. But--so, long-term planning, more
workforce, and the most efficient use of our dollars,
particularly by eliminating the separation across prevention,
treatment, and care.
Senator Menendez. One last question. A leading killer of
people with HIV/AIDS is tuberculosis. It is inextricably linked
to the epidemic. And, given the high rates of TB/HIV co-
infection in the 12 PEPFAR focus countries in Africa, TB
programs present an opportunity to identify additional HIV-
positive individuals who are eligible for treatment. Similarly,
the HIV clinics provide an opportunity to screen for TB. PEPFAR
has been in the process of expanding efforts to combat
tuberculosis in HIV patients, but we could be doing far more in
this area. Should addressing TB/HIV by increasing integration
and coordination among programs be a greater focus in PEPFAR
reauthorization?
Dr. Daulaire. Yes.
Senator Menendez. That's about as clear as it gets around
here, you know. [Laughter.]
Dr. Daulaire. The----
Senator Menendez. It's a refreshing answer, but I know you
want to embellish a little bit on it.
Dr. Daulaire. Very short. [Laughter.]
Dr. Daulaire. The reality is that, currently, one-half of
one percent of people receiving HIV/AIDS care and treatment are
tested for TB. You've got to look for it before you can start
doing anything.
Senator Menendez. Dr. Smits.
Dr. Smits. I'll also say yes. One of the impressive things
PEPFAR does is hold the implementers conference every year.
People working in the field have a lot of very good things to
say about that conference. The discussion about the TB
integration made it clear there, that that is an area that has
lagged. But people are very concerned, and there are some best
practices being put in place. Yes; I agree it's an important
aspect.
Senator Menendez. Well, seeing no other members before the
committee, I want to thank all of you for your testimony today.
It's been incredibly important as we move to what will
hopefully be a timely reauthorization.
The record will remain open for 2 days so that committee
members may submit additional questions to the witnesses. We
would ask the witnesses respond expeditiously to these
questions.
Senator Menendez. And, if no one has any additional
comments, the hearing is adjourned.
[Whereupon, at 4:05 p.m., the hearing was adjourned.]
----------
Additional Material Submitted for the Record
Prepared Statement of Dr. Paul Zeitz, Executive Director, Global AIDS
Alliance, Washington, DC
Global Aids Alliance,
Washington, DC, December 13, 2007.
Hon. Joseph R. Biden,
Chairman, U.S. Senate Committee on Foreign Relations, Dirksen Senate
Office Building, Washington, DC.
Dear Senator Biden: On behalf of the Global AIDS Alliance and the
Health Gap coalition, I would like to formally request that the
attached document be submitted as part of the record of the Senate
Foreign Relations Committee hearing held on December 13, 2007.
The document details recommendations for the next phase of the U.S.
global AIDS initiative developed by African civil society organizations
and people living with HIV/AIDS working on the front lines of the AIDS
pandemic.
The Global AIDS Alliance is dedicated to mobilizing compassionate
and comprehensive response to the global AIDS crisis, and we believe
that the voices of African civil-society stakeholders--and the
communities they represent are essential to ensuring that U.S. global
AIDS policies and programs effectively meet the needs and priorities of
the people they are meant to serve.
Sincerely yours,
Dr. Paul S. Zeitz,
Executive Director.
Attachment.
African Civil-Society Recommendations on the Next Phase of U.S. Global
AIDS Assistance--December 11, 2007
On December 10-11, 2007, representatives of 21 civil-society
organizations, including representatives of PLHA organizations as well
as large PEPFAR AIDS treatment providers, met in Nairobi to provide
feedback and recommendations on the future of U.S. global AIDS policy.
The meeting was hosted by the Kenyan AIDS Treatment Access Movement,
Global AIDS Alliance, and Health GAP. In light of the upcoming debates
on PEPFAR reauthorization, we respectfully submit the following
recommendations from people living with HIV/AIDS and working on the
front lines of the AIDS pandemic. The following summarizes our
prioritized recommendations, and a full report will be made available
shortly.
1. Numbers on treatment versus measuring healthy patients: PEPFAR
is doing a historic and important job of getting people on ARV
treatment. However, counting a person who is receiving AIDS drugs is
not the same as supporting health for people with HIV. The urgent and
important work of attempting to meet treatment targets is not
integrated with more comprehensive support for actual patient health.
When patients are only provided one part of what we need to survive,
however important, the end result is poor health outcomes, questionable
accounting practices, and unacceptable loss to follow up.
The second five years of U.S. global AIDS initiatives should
measure longer term patient health outcomes in addition to
simple numbers of people on ARV treatment. This should be
backed up by independent patient satisfaction surveys and spot
audits of PEPFAR-supported medical facilities.
2. Opportunistic infection drugs are not available: Many programs
provide free ARVs, which are urgently required and profoundly
appreciated. However, efforts to scale up access to AIDS treatment is
taking place without an eye toward actually increasing patient
survival. While anti-AIDS medicines are almost always free, medicines
to treat the opportunistic infections that accelerate our death are
often unavailable from clinics and too costly for patients to purchase
from pharmacies. Stock-outs at medical facilities and dispensaries are
also common and very harmful to patient health.
PEPFAR should provide free and accessible OI treatment and
services at all health facilities.
3. Unequal standards of care: Powerful new antiretroviral drugs are
transforming the lives of people with HIV in the United States,
producing much more durable viral suppression, greatly reduced toxicity
and side effects, and improved prospects for long-term adherence. With
few exceptions, these new drugs are not available through PEPFAR-
supported ART sites or other treatment support programs. We recognize
that drug regimen decisions are largely made at the country level, but
guidance from PEPFAR strongly influences treatment formularies.
Support provision of quality regimens that are less toxic
and more accessible, affordable, and manageable for people
living with HIV/AIDS.
The U.S. should work with countries, generic drug
manufacturers, and PEPFAR recipient programs to ensure that
there are equitable standards of medical care between the North
and South.
4. Services for young adults: HIV prevalence is mostly impacting
children and young people between the ages of 9 and 24.
Funding and programs should specifically target children and
young people, and meet the needs of the increasing number of
orphans and other vulnerable children. The age bracket
receiving support from the OVC earmark should be increased to
include young adults, and the percentage of funding for
orphans, vulnerable children, and youth should be increased.
5. Efforts to reach marginalized populations should be expanded:
Programs should be designed and implemented with respect for the human
rights of marginalized groups, such as people living with HIV/AIDS,
orphans and other vulnerable children, women, prisoners, commercial sex
workers, men who have sex with men, people with disabilities, migrants,
people living in conflict or post-conflict situations, pastoralists,
rural populations, ethnic minorities and the elderly. PTMCT services
are the privilege of a few, and many poor mothers cannot afford
recommended services, such as alternatives to breast milk. There is a
new wave of stigma due to existing PEPFAR prevention policies, and
current programs are insensitive to age, culture, and gender-specific
needs. The abstinence-only earmark is a distraction from meaningful
work to reduce rates of new infections in our countries.
Services should be tailored to meet the needs of vulnerable
populations and be accessible, affordable, and within reach.
Prevention programs should invest in evidence-based
preventive strategies that strengthen community-based and peer-
led awareness creation and behavior change programs, placing
vulnerable populations at the center of prevention responses,
and addressing the social, economic, and cultural issues that
drive new infections.
Prevention program should be context-specific, include
prevention services for people living with HIV/AIDS, and step
up efforts to address AIDS-related stigma and gender-based
violence.
New efforts should be launched to support active outreach to
underserved, high-risk groups such as prisoners and people in
post-conflict areas.
PMTCT services should be scaled up to provide nutritional
support, alternative infant nutrition, and affordable Cesarean
sections for pregnant HIV-positive women.
PMTCT programs should be linked to AIDS treatment and sexual
and reproductive health programs, including family planning,
pre-, post-, and antenatal services, and socioeconomic support
for mothers.
6. Lack of medical equipment: Many health facilities--especially in
rural areas--are poorly equipped in terms of equipment and supplies. In
particular, countries urgently need CD4 machines and reagents as well
as x-ray machines. People with HIV are required to show CD4 results or
x-rays in order to medically qualify for AIDS or tuberculosis treatment
and to monitor therapies. Too often, the machines are not available in
any accessible medical facility, or the tests are prohibitively
expensive.
Procure and maintain medical equipment needed to provide
AIDS care, including x-ray and CD4 machines and necessary
reagents.
7. Shortages of trained health workers and facilities: There is a
shortage of health care providers in our countries, and provision of
primary health care suffers when PEPFAR-supported programs hire away
scarce health professionals from public sector primary care facilities.
Training of existing health professionals has not kept pace with the
scale-up of AIDS programs at the country level, and improved quality
assurance measures are necessary. Women and people with HIV serving as
community health workers and home-based care providers bear the brunt
of providing care and services to people living with HIV/AIDS, but are
not recognized, supported, or paid. Additionally, access to functioning
care facilities can be very difficult outside of urban centers, and too
many rural clinics are understaffed, inadequately equipped, and
inconsistently supplied.
U.S. AIDS initiatives should invest to substantially
increase the supply of health professionals, support pre- and
ongoing in-service training of all cadres of new and existing
health workers, and work with countries and professional
associations to develop HIV care provider accreditation
standards and monitoring.
Much more should be done to retain existing health workers,
including increased remuneration and improved working
conditions.
Community health workers should be trained, certified,
equipped, and supported by a functioning referral systems and
increased number of health professionals. Community health
workers should be paid a wage sufficient to support a family
and be integrated into the mainstream health system.
More health facilities are needed in rural areas, as well as
transportation support for patients.
8. PEPFAR country plans are not aligned with national plans or
accountable to civil society: U.S. programs are too often operated as
parallel systems--duplicating, undermining, or even weakening country-
level capacity to respond effectively to health issues. While civil-
society organizations have been at the forefront of the fight against
AIDS, we are not consulted or meaningfully able to contribute to U.S.
efforts, policies, plans, and priorities.
Broader and transparent consultation is needed to ensure
that PEPFAR programs are more responsive to country contexts,
complement country plans and priorities, and strengthen the
country ownership necessary to ensure sustainability.
PEPFAR should prioritize integrating services into existing
programs, especially in public-sector health facilities, rather
than running parallel services. Parallel efforts such as the
Supply Chain Management System (SCMS) should be required to
work with in-country partners to transfer operations over time.
PEPFAR programs should be developed in consultation with
civil-society organizations, including networks of people
living with HIV/AIDS and other vulnerable groups, to ensure
community ownership, leadership, and sustainability. Future
U.S. AIDS initiatives should adopt a bottom-up approach to
empower communities to take leadership in policy design and
implementation.
The following organizations developed these recommendations, and
thank you for considering their inclusion as the U.S. global AIDS
initiative is reauthorized, reformed, and renewed:
Alex Margery, Tanzanian Network of People Living with HIV/AIDS
(TANEPHA)
Alice Tusiime, National Coalition of Women with AIDS in Uganda (NACOA)
Ambrose Agweyu, Health Workforce Action Initiative, and Kenya Health
Rights Advocacy Forum (HERAF)
Ann Wanjiru, GROOTS Kenya
Beatrice Were, Global AIDS Alliance (Africa)
Carol Bunga Idembe, Uganda Women's Network (UWONET)
Caroline A. Sande, UNAIDS Consultant
Elizabeth Akinyi, International Community of Women Living with HIV/AIDS
(ICW)
Everlyne Nairesicie, GROOTS Kenya
Flavia Kyomukama, National Forum of PLWHAs Networks in Uganda
(NAFOPHANU)
James Kamau, Kenyan AIDS Treatment Access Movement (KETAM)
Joan Chamungu, TNW+ and Tanzanian National Council of People Living
with HIV/AIDS (NACOPHA)
Linda Aduda, Kenyan AIDS Treatment Access Movement (KETAM)
Paddy Masembe, Uganda Network of Young People Living with HIV/AIDS
(UNYPA Positive)
Maureen Ochillo, ICW
Micheal Onyango, Men Against AIDS in Kenya
Nick Were, East Africa AIDS Treatment Access Movement (EATAM)
Prisca Mashengyero, Positive Women Leaders, Uganda
Rose Kaberia, EATAM
Plus two additional individuals representing large AIDS treatment
programs supported largely by PEPFAR, who wish to remain anonymous to
protect their ability to offer candid assessments.
Sponsors:
James Kamau, Kenyan AIDS Treatment Access Movement (KETAM)
Alia Khan, Global AIDS Alliance (DC)
Paul Davis, Health GAP (Global Access Project)
______
Responses of Dr. Michel Kazatchkine to Questions Submitted for the
Record by Senator Biden
Question. The Center for Global Development issued a report
entitled, ``Following the Funding for HIV/AIDS,'' which analyzed
PEPFAR, Global Fund, and World Bank funding practices. In its
recommendations to the Global Fund, the Center advised the Fund to keep
its focus on funding gaps or underresourced priorities and to reexamine
strategies to build local capacity. Could you explain your strategy to
address each of these two important issues over the next 5 years?
Answer. One of the principal challenges to scaling-up efforts to
mitigate the impact of HIV/AIDS, tuberculosis and malaria has been a
country's capacity to effectively deliver services in a given setting.
These capacity limitations exist within the governmental as well as
nongovernmental sector and at the national as well as subnational
level. Despite an increase in overall international resources to
enhance the response, limitations in financial management, human
resource management, M&E, training, remuneration for staff,
communication/information technology and strategic planning may be
preventing countries from effectively implementing programs and
reaching their targets.
In recognition of the comparative advantage of the different
sectors involved in mitigating the three diseases, and areas where
added capacity may not be harnessed, the Global Fund Board passed a key
Decision Point in April 2007 entitled ``Strengthening the Role of Civil
Society and the Private Sector in the work of the Global Fund.'' The
Decision Point calls upon the Global Fund to strengthen key areas of
its architecture in order to improve upon the effectiveness of the role
of nongovernmental stakeholders in Global Fund processes, such as
increasing the participation of key affected populations on Country
Coordinating Mechanisms (CCMs), providing further guidance on the
representation of civil society and private sector representatives to
be members of CCMs, simplified access to CCM funding, and of particular
relevance, the utilization of dual-track financing (DTF) \1\ and the
funding of community systems strengthening (CSS) to address gaps and
constraints to national scale-up.
---------------------------------------------------------------------------
\1\ DTF refers to the recommendation that CCMs routinely select
both government and nongovernment sector Principal Recipients to lead
program implementation in proposals submitted the the Global Fund.
---------------------------------------------------------------------------
Both dual-track financing and community systems strengthening are
designed to increase the role and effectiveness of both the
governmental and nongovernmental sectors in implementation and service
delivery, as well as to develop a longer term strategy for
institutional development of the weaker sectors, to take on a greater
role in service provision in the future.
Dual Track Financing: Starting in Round 8, countries submitting
applications to the Global Fund will be encouraged to nominate both a
governmental and nongovernmental PR and will be required to provide a
detailed explanation in the case that the proposal does not nominate,
at a minimum, one Principal Recipient (PR) from each sector. The
governmental sector has often demonstrated its comparative advantage in
the provision of health infrastructure, the procurement of essential
medicines, the training of national, district and local-level health
professionals, as well as implementing larger scale programs at the
national level.
Civil society organizations, similarly, are becoming increasingly
recognized for their role in scaling up access to treatment, through
the targeting of communities to increase uptake in more formal health
settings and treatment literacy; as well as their acknowledged role in
reaching vulnerable and marginalized populations which the governmental
sector may have more difficulty accessing. Through working together at
a national level, these sectors would be able to provide a more
holistic and comprehensive response to the three diseases as well as to
develop sustainable partnerships for service delivery for the long
term.
Community Systems Strengthening: Proposals submitted may already
include activities that strengthen the community-level response to the
three diseases. However it is recognized that weaknesses at the
community level affect the performance of existing grants, as well as
overall demand for and access to services. The proposal form and
guidelines for Round 8 therefore provide greater encouragement to
applicants to include provision for strengthening and/or further
development of community systems and institutional capacity to ensure
improved outcomes for the three diseases. This encouragement takes the
form of increased information on potential indicators, and also
commentary on anticipated improvement in community systems. In this
context, the Global Fund describes CSS as funding to build the capacity
of community-based organizations, including NGOs, to improve and expand
service delivery (for example, home-based care, outreach, prevention,
orphan care, etc.).
Funding for CSS may go to:
Subrecipients (SRs), and as relevant, sub-subrecipients
(SSRs) of existing Global Fund grants in anticipation of
building sufficient capacity for a PR nomination in a future
round;
Other already existing local and subnational CBOs who do not
already have established relationships within the Global Fund
framework, but have the potential to be key partners in the
delivery of services; and
Young or emerging CBOs (initiated within approximately the
last 5 years) and/or organizations little or no track record in
attracting or managing outside finances.
CCMs will be required to demonstrate and identify in future
proposals all gaps to enhanced service delivery, and in this particular
case, gaps which prevent it from utilizing the capacity of both sectors
at the PR-level to implement dual track financing and gaps and
constraints in the ability of governmental and nongovernmental
organizations at the subnational level to scaling up effective
responses to the three diseases. From Round 8, applications which seek
to implement the DTF model or demonstrate the need for CSS funding at
the subnational level, in particular among CBOs, would therefore be
eligible for funding throughout the life of the grant.
Question. U.S. law requires a ``snapshot'' of international
contributions that have been made to the Global Fund as of July 31 of
each year. How does the timing of this snapshot affect the funding
process? As Congress considers reauthorization of global HIV/AIDS,
tuberculosis, and malaria programs, are there alternatives to current
practice that would provide a window into--and perhaps help spur--
international contributions but that might remedy reported difficulties
stemming from the July 31 deadline?
Answer. The July 31 deadline poses problems because almost all
other major donors have different financial years. For example, most
European donors follow their own calendars and pay their contributions
at the end of the year. Therefore, the July deadline is problematic to
these donors, essentially forcing them to transfer their money earlier.
To date, other donors have obliged, but to improve our relationships
with donors, it would be helpful to have this deadline shifted or
removed.
Question. The Global Fund does not have a particular grant category
to address the needs of women and girls, but all involved recognize
that women are physically, economically, and socially more vulnerable
to HIV/AIDS. Could you tell us how the Global Fund is helping to
address these gender issues within its grants?
Answer. The Global Fund fully recognizes the particular
vulnerability of women and girls to HIV/AIDS and is already funding a
number of programmes supporting activities that benefit this population
directly.
There is evidence that many of the Global Fund programmes are
reaching women. Of the 1.1 million people on antiretroviral therapy by
mid-2007, 57 percent were women who represent 48 percent of infections.
Other activities currently underway range from care and treatment
programs for sexually exploited underage girls in Costa Rica, to
supporting grandmothers who care for orphans in Swaziland and financing
a network of HIV-positive women in Kenya working on antidiscrimination
and the social integration of women living with HIV and AIDS.
Despite the many interventions that can be catalogued, the Global
Fund is acutely aware of the disproportionate burden placed on women by
AIDS and of their unique vulnerability. Therefore, the Global Fund is
emphasizing the need to develop and expand programs targeted at women
and girls in future proposal rounds. In addition, in November 2007 the
Global Fund Board made a key decision regarding the importance of
gender and the particular importance of women and girls:
scaling up a gender-sensitive response to hiv/aids, tuberculosis, and
malaria by the global fund
Decision Point GF/B16/DP26:
The Board recognizes the importance of addressing gender issues,
with a particular focus on the vulnerabilities of women and girls and
sexual minorities, in the fight against the three diseases, more
substantially into the Global Fund's policies and operations.
The Board authorizes the Secretariat as a matter of priority to
immediately appoint senior level ``Champions for Gender Equality,''
with appropriate support, who will:
a. Work with technical partners and relevant constituencies
to develop a gender strategy.
b. As an immediate priority, provide guidance to the
Portfolio Committee on revisions to the Guidelines for
Proposals for Round 8 to encourage applicants to submit
proposals that address gender issues, with a particular
reference to the vulnerability of women and girls and sexual
minorities.
The Board requests the Policy and Strategy Committee to review the
Gender Strategy and present it to the Board for approval at the 17th
Board meeting.
The Global Fund Secretariat has recruited a consultant to ensure
that work on this initiative starts immediately. In addition, an
intense consultation process was undertaken to ensure the Round 8
Guidelines for Proposal are appropriately adjusted to reflect this
priority and encourage countries to ensure their programming takes into
account gender as a factor of the epidemics and that they plan
accordingly.
The recruitment of the gender champions will begin as soon as the
role has been properly defined in the context of a strategic framework.
The Global Fund is working with partners to ensure that appropriate
technical assistance is available to ensure evidence-based and
technically sound proposals on this area are prepared for submission
for Round 8.
______
Responses of Dr. Helen Smits to Questions Submitted for the Record by
Senator Biden
Question. PEPFAR has made real strides in addressing issues of
gender and the special needs of women and girls, but we have not been
able to keep pace with the spread of the pandemic or the fact that
women are increasingly among its victims. Women and girls are
physically more vulnerable to HIV/AIDS, but economic, political, and
legal disparities make them more so. In many countries, such as South
Africa, young women are four times more likely to be HIV-infected than
young men.
Specifically, how can efforts to address the special
vulnerabilities and needs of women and girls be expanded and
improved in the next phase of our HIV/AIDS efforts?
Answer. The IOM report recommends that the U.S. Global AIDS
Initiative continue to increase its focus on the factors that put women
at greater risk of HIV/AIDS and to support improvements in the legal,
economic, educational, and social status of women and girls. The IOM
committee believes such improvements are necessary to create conditions
that will facilitate the access of women and girls to HIV/AIDS
services; support them in changing behaviors that put them at risk for
HIV transmission; allow them to better care for themselves, their
families, and their communities; and enhance their ability to lead and
be part of their country's response to its HIV/AIDS epidemic.
Specifically, the IOM committee was encouraged by OGAC's formation
of the Technical Working Group on Gender and the focus that it could
bring on the needs of women and girls and approaches to meet them. The
IOM committee also urges the Global AIDS Coordinator to keep his
commitment to implement expeditiously the recommendations developed as
a result of the June 2006 ``Gender Consultation'' hosted by PEPFAR.
Although the IOM study was not designed to judge the effectiveness
of individual programs, I would like to add my personal impression,
from the country visits, of the very exciting and relatively low-cost
programs underway. Many of the ones I saw are based in local NGOs with
a strong sense of what local women can do to achieve economic
independence. In the legal sense, these include programs to counsel
women when traditional practices (such as the personal dwelling
reverting to the husband's family at his death) are in conflict with
national law. I met a number of women who had been able to retain their
control over their home and its contents--a huge step in surviving
widowhood. I also saw programs which provided women with both training
and modest capital in order to become independent entrepreneurs; these
programs included raising chickens and selling them in the market,
selling soft drinks, and creating crafts with a ``western'' look that
has enabled the groups of women to sell to major international
distributors.
I am sure with the experience already gained, the Technical Working
Group on Gender will be able to advise all PEPFAR countries in the
development of strong programs in this important area.
Question. Are current targets and indicators on gender sufficient?
Answer. The IOM committee did not find any ``targets'' per se for
women and girls, and is in principle supportive of meaningful targets
for desired program outcomes. PEPFAR reports on the number of programs
and services it supports that are directed at reducing the risks faced
by women and girls in the following categories: (1) Increasing gender
equity, (2) addressing male norms, (3) reducing violence and sexual
coercion, (4) increasing income generation for both women and girls,
and (5) ensuring legal protection and property rights. However, no
information of the kind the IOM committee would like to see was yet
available--that is, information with which to determine either the
individual or collective impact of these activities on the status of,
and risks to, women and girls.
Consistent with its call for better data about focus country
epidemics, support for country monitoring and evaluation systems, and
evaluation of the impact of PEPFAR-supported programs, the IOM
committee would want the U.S. Global AIDS Initiative to develop and be
accountable for harmonized indicators of the health and other status of
women and girls. The kinds of indicators that are under discussion
include the length of schooling for girls, evidence of implementation
of property right laws, and numbers of women engaged in productive work
that generates an income sufficient for family survival.
______
Responses of Dr. Nils Daulaire to Questions Submitted for the Record by
Senator Biden
Question. PEPFAR has made real strides in addressing issues of
gender and the special needs of women and girls, but we have not been
able to keep pace with the spread of the pandemic or the fact that
women are increasingly among its victims. Women and girls are
physically more vulnerable to HIV/AIDS, but economic, political, and
legal disparities make them more so. In many countries, such as South
Africa, young women are four times more likely to be HIV-infected than
young men.
Specifically, how can efforts to address the special
vulnerabilities and needs of women and girls be expanded and
improved in the next phase of our HIV/AIDS efforts?
Are current targets and indicators on gender sufficient?
Answer. One of the first ways to address the special
vulnerabilities and needs of women and girls is linking PEPFAR with an
overall health and development strategy. To date, PEPFAR has been
implemented in a vertical, medical model which does not allow for
addressing nonmedical concerns such as access to basic services. This
lack of access exacerbates the vulnerability of women and girls. U.S.
investments in HIV/AIDS must be coupled with adequate and increased
assistance to core health and development programs.
Better wraparound programs are needed to adequately address the
needs of women and girls including better referral services to non-HIV
health services such as maternal health, reproductive health, etc.
Prevention and treatment programs need to be integrated into maternal
and child health clinics in order to better reach women. Women also
need increased access to basic health services.
The means of evaluating PEPFAR programs success need to be revised
across the board. Currently, OGAC is primarily focused on output
indicators. Output indicators do not really help in determining how to
improve a program. They help generate quantifiable results. Our
implementing agencies are calling for more outcome indicators including
those used for gender assessments.
PEPFAR also needs to strengthen programs that address gender-based
violence by working with countries to establish better social, medical,
and legal referral systems for victims of sexual violence, integrating
gender-based violence screening into HIV programs and providing post-
exposure prophylaxis and emergency contraception.
Overall, GHC implementing agencies feel that OGAC is on the right
track for addressing gender needs. It is a question of how to scale up
projects and integrate PEPFAR services with other health services.
Implementing agencies are also calling for increased focus on stigma as
this affects women and girls more. We need to know more about OGAC's
work around stigma and discrimination to better help address the
vulnerabilities of women and girls.
Modification of policy restrictions such as the antiprostitution
pledge and abstinence until marriage earmarks would also help increase
outreach to women.
Question. How do shortages of health care workers and shortcomings
in health systems affect your organization's (or your member
organizations') efforts to combat HIV/AIDS, TB, malaria, and other
health challenges? What are the most important steps to take in the
next phase of our HIV/AIDS, TB, and malaria programs to try to address
these challenges?
Answer. Global Health Council member organizations implementing
HIV/AIDS programs have cited lack of human resource capacity as a
critical issue. According to our agencies, achieving PEPFAR targets in
a sustained way is going to be practically impossible without an
appropriate strategy for addressing the human resource issue.
Currently, according to our member partners, not enough PEPFAR
resources are available for training new health care workers or for
building health infrastructure. As such, organizations often have to
rely on using their own health personnel or have to pull health
personnel away from non-HIV primary health care services. This results
in scaling back in other non-HIV programs and services.
Furthermore, there currently is no support to assist countries in
conducting national human resource forecasting to help determine
capacity required to implement a project. Organizations have called for
scaling up of community-based workers but these workers must be
integrated into a primary health care system. While the task shifting
approach can have positive impacts by allowing nurses to manage ART
patients, this approach must be carefully implemented so as not to
further siphon away health personnel from non-HIV health services.
Another challenge is the type of training. Most PEPFAR health care
worker training is limited to administering ARV drugs. However, there
remains a significant lack of trained health care workers in pediatrics
and palliative care. According to our members, many patients on ART are
dying of opportunistic infections in part due to lack of trained health
care workers to diagnose and treat opportunistic infections.
Our member organizations are also concerned about not having enough
trained professionals in the area of pediatric HIV/AIDS. A number of
children and infants are not being reached through treatment, care or
prevention programs and even if they are, services are limited due to a
shortage of trained health professionals.
Training also needs to be increased in the areas of counseling and
testing, prevention education and other activities, and in other types
of counseling such as nutritional counseling. Ideally trained health
professionals working in HIV/AIDS also need to be able to detect other
global health needs such as childhood malnutrition, preventable
diseases such as pneumonia.
Lack of health infrastructure is even a bigger challenge than
trained health care workers. PEPFAR must start building primary health
care infrastructure instead of HIV-only infrastructures. Only recently
has OGAC begun to use the primary health care model for delivering HIV
programs and services.
Many have called for greater linkage between food and
nutrition assistance and efforts to combat HIV/AIDS.
How does food insecurity affect efforts to combat HIV/AIDS?
What are the barriers to greater integration?
What are the dangers of providing food assistance only to
those who are AIDS-affected when food insecurity in an area
is widespread and help for those who are not HIV positive
may not be available? Should we have an individual-centered
approach, a family-centered approach, or a community-
centered approach?
According to many experts, World Health Organization, UNAIDS, and
our own implementing agencies, high malnutrition rates are present in a
number of HIV-affected communities, particularly in sub-Saharan Africa.
Food is often identified as most immediately needed by people living
with HIV/AIDS. Our implementing organizations are concerned about
scaling up care and antiretroviral therapy without planning for
appropriate nutrition. They have found that adherence to ARV is low
when an individual with HIV/AIDS lacks proper nutrition.
However, Global Health Council implementing agencies have found it
difficult to integration nutrition and HIV. Barriers to integrating
food and nutrition assistance with HIV/AIDS programs and services are
the same for any ``wrap around'' activity. There are two challenges: 1.
Coordination; 2. Funding.
The first problem is that there appears to be a lack of
coordination amongst agencies. Currently, to our knowledge, there is
not a joint assessment among agencies on the needs of an HIV-affected
community (not just for HIV programs and services but what else is
needed: Food, water, doctors, etc). Individual implementing
organizations have to tie the various pieces together themselves. For
example, if an organization is working in an HIV-affected community
that also lacks access to food or water, the organization itself must
coordinate with other agencies like World Food Programme or USAID's
Public Law 480 rather than OGAC coordinating ahead of time with the
World Food Programme. Organizations must then rely on availability of
funding through other sources and must also address different
procurement mechanisms and a different funding cycle which adds to the
reporting burdens.
Furthermore, PEPFAR programs and food programs are often in
different locations which makes coordinating even more difficult.
Finally, funding is an issue. Core programs, including food aid,
have not grown at the same rate as PEPFAR. Additional funding to
support non-HIV services in PEPFAR programs has not been available. If
it is available, it is coming at the expense of services accessed by
nonheavily affected HIV communities.
As far as providing assistance is concerned, a number of our
implementing agencies have long called for a community-centered
approach. Several implementing agencies, particularly partners working
with orphans and vulnerable children have experienced problems as they
are seen as favoring HIV-positive families in communities where those
who are HIV negative are still coping with significant health issues.
global health council recommendations for pepfar reauthorization
We would also request that attached recommendations be inserted
into the record.
In addition to the attached recommendations, we also call on
Congress to remove the antiprostitution pledge (APP). There is no
evidence that the APP has improved HIV prevention. It has alienated
some U.S. Government partners and created uncertainty for others. It is
a disincentive for innovative programming with sex workers as program
implementers fear inadvertently breaching the pledge requirement. The
``pledge'' further stigmatizes the vulnerable people we are trying to
reach and serve, making prevention efforts more difficult. It has also
raised constitutional issues and has been struck down by two Federal
district courts, though the appeals process is still under way. We see
no point in the Congress prolonging a legal battle with the
government's partners in the fight against AIDS over a provision that
does not improve public health outcomes.
Finally, the Global Health Council, recommends that the U.S.
Congress and the U.S. President work together to develop a more
comprehensive response to global health needs, which would include
developing a longer term global health strategy that guides all U.S
global health programs, including PEPFAR. A comprehensive approach to
global health would be informed by analyses of the causes of the
greatest burden of disease in the world's poorest countries and a
commitment to supporting long-term development needs in partner
countries as well as taking advantage of public diplomacy opportunities
to strengthen America's reputation abroad. With the support of the U.S.
Congress, this administration has achieved extraordinary results in
global health through PEPFAR and increasingly through the President's
Malaria Initiative. However, as an alliance of public health experts,
we know that health is not achieved by fighting specific diseases in
isolation. In order to combat HIV/AIDS successfully, U.S. programs on
global HIV/AIDS must evolve from an emergency response to a long-term
investment in global health that is connected to achieving our other
goals in areas, such as reducing maternal and child mortality,
combating other infectious diseases and access to basic development
services such as water and sanitation.
[Attachment follows:]
summary of the global health council member recommendations for
strengthening pepfar
The President's Emergency Plan for AIDS Relief (PEPFAR), is a 5-
year, $15 billion, comprehensive approach for combating HIV/AIDS in 15
focus countries. The program, and the legislation that supported it,
will expire in 2008. To assure the continuation of PEPFAR and
strengthen the U.S. Government response to the pandemic, the Global
Health Council convenes a group of its members with expertise in
implementing HIV programs. Under the Council's leadership,
representatives of its member organizations developed the following
recommendations.
recommendations for improving the implementation of pepfar programs and
services:
1. HIV/AIDS Prevention Efforts Must Be Scaled Up
Council members endorse the administration's proposal to increase
the number of people reached by HIV/AIDS prevention programs from 7
million to 12 million. Members support developing prevention strategies
tailored to the needs of specific types of epidemics and populations
that are designed at the country level and based on evidence of what
interventions are effective. In order to provide prevention programs to
significantly more people, members recommend eliminating the
prostitution pledge and modifying guidance on harm reduction, which
currently only allows for prevention interventions among HIV-positive
injecting drug users.
2. More Flexibility Is Needed in PEPFAR's Budgetary Allocations
Members support modifying budgetary allocations to allow for
country-specific and epidemic-specific programming.
3. Increase Ability To Use PEPFAR Resources Between Program Areas and
Between HIV and non-HIV Health Services
Create the policy and budgetary environment to support more
wraparound services or linkages between HIV and non-HIV services. This
includes allowing the flexibility in use of funds for integrated
programming such as child immunizations in a PEPFAR pediatric treatment
site.
4. Expand Treatment and Care Programs and Improve Quality of Treatment
Programs
Members support expanding access to antiretroviral therapy through
public-private partnerships; expanding technical support and resources
to increase access to palliative care; increasing acccess for infants
and children for diagnosis and care and treatment services; improving
patient followup practices; and recognizing the World Health
Organization (WHO) prequalification process for availability of drugs.
5. Train Additional Health Care Workers and Strengthen Health Systems
Members support using PEPFAR resources to increase the number of
health care workers in HIV-affected communities to contribute to, not
draw down from, the total number of health care workers. Members
recommend training more workers particularly in providing palliative
care, pediatric treatment and diagnosis, and in the ability to provide
other sets of services for HIV patients. Members support using PEPFAR
resources to strengthen the health system in HIV-affected communities
6. Improve and Expand Operations Research
PEPFAR is a learning organization and as such it should modify and
improve its current monitoring and evaluation process and devote more
resources to operations research. Members recommend that PEPFAR
communicate more with implementing agencies to share best practices and
lessons learned to help inform policy and budgetary decisions in the
future.
______
Responses of Ken Hackett to Questions Submitted for the Record by
Senator Biden
Question. PEPFAR has made real strides in addressing issues of
gender and the special needs of women and girls, but we have not been
able to keep pace with the spread of the pandemic or the fact that
women are increasingly among its victims. Women and girls are
physically more vulnerable to HIV/AIDS, but economic, political, and
legal disparities make them more so. In many countries, such as South
Africa, young women are four times more likely to be HIV-infected than
young men.
Specifically, how can efforts to address the special
vulnerabilities and needs of women and girls be expanded and
improved in the next phase of our HIV/AIDS efforts?
Answer. It is true that PEPFAR has made real strides in addressing
issues of gender and the special needs of women and girls during the
first 4 years of its implementation. However, it has not done enough to
prevent HIV transmission among women, which is now the largest growing
population of PLHIV. Catholic Relief Services, a major implementing
partner of PEPFAR, is managing the AIDSRelief project under which
nearly a quarter of a million PLHIV are in care; consistent with other
PEPFAR ART providers, close to 70 percent of PEPFAR-supported ART
patients are women. Moreover, of the 153 CRS AIDSRelief local partner
treatment facilities which provide care on a daily basis to the
patients, more than 30 offer Prevention to Mother to Child Transmission
services.
To improve our capacity to address gender issues in our HIV
response, CRS will carry out a study in 2008 to determine how best to
improve gender mainstreaming across the agency, including an assessment
of current strengths and gaps in gender programming and an industrywide
review of State of the Art gender programming.
CRS believes that PEPFAR can address the special vulnerabilities
and needs of women and girls by recognizing that simply by being female
is to be at high risk of HIV and AIDS. PEPFAR can implement a global
HIV prevention strategy that emphasizes the root causes of these
vulnerabilities and the factors that affect their rate of HIV
infection. Some of the activities which should be included in this HIV
prevention strategy are:
girls education and life skills
Supporting expanded and safe educational opportunities for
women and others at risk, including curricular and
infrastructural reforms to address social nouns and reduce risk
of school dropout of girl children.
Supporting age-appropriate life skills education for young
girls so that they are informed how best to protect themselves,
from HIV infection, through delay of sexual debut (abstinence
until marriage) and partner reduction (faithfulness in
marriage).
women's economic empowerment and strengthening their livelihoods
Supporting the development of livelihood initiatives, access
to markets, job training and literacy and numeracy programs,
and other such efforts to assist women and girls in developing
and retaining independent economic means.
Supporting the development and expansion of local and
community groups focused on the needs and rights of women and
girls; and involving these organizations at the community level
in program planning and implementation.
reducing stigma and discrimination
Preventing violence against women, including intimate
partner and family violence, sexual assault, rape and domestic
and community violence against women and girls.
Encouraging the participation and involvement of local and
community groups representing different aspects of women's
lives in drafting, coordinating, and implementing the national
HIV/AIDS strategic plans of their countries.
Promoting changes in social norms attitudes and behavior
that currently condone violence against women, especially among
men and boys, and that promote respect for the rights and
health of women and girls, reduce violence, and support and
foster gender equality.
legal support for women affected by hiv/aids
Protecting the property and inheritance rights of women
through direct services as well as legal reforms and
enforcement.
Question. Are current targets and indicators on gender sufficient?
Answer. No; current targets and indicators are not sufficient.
PEPFAR should invest in the disaggregation of data by age as well
as sex to better understand HIV infection trends among different age
groups; expand operations research and evaluations of gender-responsive
interventions in order to identify and replicate effective models;
develop gender indicators to measure both outcomes and impacts of
interventions, especially interventions designed to reduce gender
inequalities; develop and encourage the utilization of gender analysis
tools at the country level, and disseminate lessons learned among
different countries.
PEPFAR must not only disaggregate its data, but also must develop
indicators to measure the effectiveness of gender programming, and the
extent to which gender is being mainstreamed into PEPFAR. PEPFAR must
be able to report which programs are working to address the needs of
women PLHIV, such as expanding PMTCT, but also which programs are
working to reverse discrimination and stigma, such as sensitivity
training for men. Moreover PEPFAR must report which programs are
working to increase women's education and economic empowerment, as well
as increase young women's life skills. PEPFAR should not only state how
many projects or programs support these strategies, but also measure
the impact of these programs through evidence-based reporting.
Question. How do shortages of health care workers and shortcomings
in health systems affect your organization's (or your member
organizations') efforts to combat HIV/AIDS, TB, malaria, and other
health challenges? What are the most important steps to take in the
next phase of our HIV/AIDS, TB, and malaria programs to try to address
these challenges?
Answer. Catholic Relief Services leads a consortium which
implements a PEPFAR-funded antiretroviral therapy project AIDSRelief--
that provides life-saving antiretroviral medications for 90,000
patients and provides care for another 146,000 HIV-positive people
through 153 local partners in nine countries. Some AIDSRelief partners
are approaching a ``ceiling'' in the number of people that they can
treat and care for, not because of lack of drugs, but because of lack
of trained health care personnel.
Most countries lack sufficient trained medical professionals and
other trained health personnel to support and supervise care and
treatment as they scale-up beyond the large numbers of people in need
of ART. It is estimated that the African Continent has a shortage of 2
million trained health professionals. Brain-drain, emigration, and
poaching of trained health professionals to meet the health
professional shortages in the developed world (principally North
America and Europe), as well as attrition by death due to AIDS, are all
contributing factors to this shortage.
As a result, CRS-led AIDSRelief has been working with alternative
nurse-led models of care and task shifting from physicians to nurses,
and nurses to community health workers (CHWs) and volunteers. Our
partners train and supervise many CHWs and volunteer treatment
``buddies'' (or treatment coaches)--many of whom are PLHIV on ART
themselves.
Because of task shifting and the resultant mobilization of large
numbers of CHWs and volunteers among CRS-led AIDSRelief partners, we
are experiencing 85-95 percent retention rates of our patients in the
program. Those who remain in the program are 80-95 percent adherent to
their antiretroviral medication regimen. This results in successful
viral suppression and the ability to keep most patients on less-
expensive first-line drugs.
What can be done to ensure sufficient health care workforce and
thus the ability to maintain current patients on successful therapy and
also to scale-up? More funding in PEPFAR for training, supervision,
continuing education, upward mobility in the health care workforce, and
some kind of compensation package (salaries for full-time CHWs and
stipends/incentives for volunteer treatment buddies/coaches) would help
ensure the ability of CRS-led AIDSRelief partners to continue and
expand services.
In addition, in several developing countries, there is an
intermediary level of trained professional between that of physicians
and nurses called a ``clinical officer,'' a level that does not exist
in North America and Europe. As a result, clinical officers are not
``exportable'' to other health systems outside of their home country
and are therefore more likely to provide long-term HIV diagnosis, care,
and treatment services in their home country. Training more ``clinical
officers'' would thus provide one avenue for a more stable workforce.
Question. Many have called for greater linkage between food and
nutrition assistance and efforts to combat HIV/AIDS.
How does food insecurity affect efforts to combat HIV/AIDS?
Answer. The No. 1 issue that we hear from people living with HIV
and AIDS and their families in the 52 countries where we have HIV
programming, is lack of food and the money to purchase it. All aspects
of food insecurity availability, access and use of food--are
exacerbated by high rates of HIV and AIDS. The chronic and debilitating
progression from HIV infection to full-blown AIDS (if untreated or
treated late) accompanied by the loss of work and income while seeking
treatment leads to hunger, poor nutrition, and food insecurity.
HIV significantly undermines a household's ability to provide for
basic needs because HIV-infected adults may be unable to work, reducing
food production and/or earnings. Healthy family members, particularly
women, are often forced to stop working to care for sick relatives,
further reducing income for food and other basic needs. Households may
have trouble paying costs associated with heath care and nutritional
support. They may also be severely restricted in participating in
community activities. Children may be withdrawn from school because
families can no longer afford school fees and/or because children are
needed to care for ill parents. This affects opportunities for future
generations. Furthermore, as a result of this HIV-to-poverty or
poverty-to-HIV cycle, the quantity and quality of diet diminishes for
the entire PLHIV household.
The interaction between nutrition and ART is well documented.
Inadequate nutrition causes malabsorption of some ARVs. Some
medications have to be taken on an empty stomach, while others with a
fatty meal. Preliminary evidence from the 153 CRS AIDSRelief ART sites
suggests that patients initiating ART with access to food respond to
treatment better than those lacking adequate nutrition. Continued data
collection is important for a more comprehensive picture.
Question. What are the barriers to greater integration?
Answer. Short-term food/nutrition supplements and household basket
rations, while necessary, do not address underlying food insecurity.
Food and nutrition and HIV activities are not well-integrated
across various USG agencies and programs. Title II food programs are
targeted to geographical regions with the greatest food insecurity,
which does not always allow us to reach food insecure PEPFAR-supported
OVC and PLHIV living in other regions of the same country. In addition,
interagency coordination and integration of services is not always
consistent across countries.
CRS' AIDSRelief ART Project uses PEPFAR funding to provide ``Food
by Prescription'' to ART patients meeting certain stringent physical
biometric criteria in Kenya and Uganda where other food/nutrition
resources are not available. This creative and needed approach is not
currently available in other PEPFAR focus countries.
Cutbacks in Title II funding have exacerbated the challenge.
Successful projects like I-LIFE, RAPIDS, SUCCESS, and Return to Life in
the southern Africa region have led to better integration of HIV and
nutrition programs with sustainability by targeting the causes of food
insecurity. All have not received continued or expanded funding because
of Title II cutbacks. A recent SUCCESS (Scaling Up Community Care to
Enhance Social Safety-nets) evaluation report shows the overwhelmingly
positive impact of nutritional supplements on HIV-positive home-based
care clients not taking ARVs that also met household food insecurity
criteria for targeted nutritional supplementation.
In addition, shortages of health care workers, including
nutritionists, limit the time and ability of existing staff to provide
food/nutrition counseling.
Question. What are the dangers of providing food assistance only to
those who are AIDS-affected when food insecurity in an area is
widespread and help for those who are not HIV positive may not be
available?
Answer. From our almost 50 years of food aid experience with Title
II, when food is given only to the patient, we have observed that
individual food rations are usually shared with the rest of the
household--diminishing the intended benefit to the individual. As a
result, CRS strives to use other resources--from Title II, WFP, and our
private funds--to distribute basket rations to families and households
affected by HIV. The key to avoiding unintended jealousy or conflict in
the community is to involve the community in targeting these basket
rations to those most in need.
While the following is not from a PEPFAR-supported program, it
illustrates the value of basket rationing to households--the preferred
model of nutritional support for HIV-affected families. Through the
Public Law 480 Title II-supported I-LIFE program in Malawi, CRS and its
partners provide food assistance to the chronically ill (most of whom
are PLHIV) and their households. This helps entire households maintain
a healthy nutritional status, provides for increased calorie and
protein needs of those infected, eases the time and resource
constraints of caregivers, and allows other members living in
vulnerable households to pursue productive livelihoods. I-LIFE also
provides community education programs that incorporate information
about HIV prevention, health and nutrition, and challenge the stigma
associated with the disease. Through these interventions CRS and its
partners reduced food insecurity and eased the effects of the HIV and
AIDS epidemic in the region. Unfortunately, many beneficial Title II-
supported programs like I-LIFE have either ended or are in their last
year because of Title II funding cuts.
Question. Should we have an individual-centered approach, a family-
centered approach, or a community-centered approach?
Answer. The approach has to be flexible to respond to the varying
needs in any given HIV-affected population. However, family and
household basket food rations will be most appropriate in cases where
affected individuals live in families that have used all available
resources and coping mechanisms to meet the needs of the HIV-infected
individual and have nothing left to meet the nutritional needs of
either the patient or the household. Providing food to the HIV-infected
individual in a food insecure household will lead the infected
recipient of an individual ration to share the ration with all members
in the household; this then fails to meet the urgent nutritional need
of the targeted HIV-infected recipient and is also insufficient to meet
the food security needs of the other members of the household. Done
correctly, community involvement is key to successful identification of
individuals and households in need of nutrition and food assistance
without causing jealousy among the rest of the community.