Hearing of the Senate Foreign Relations Committee's International Development and Foreign Assistance Subcommittee: AIDS, Tuberculosis and Malaria

Interview

SEN. 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, create the Office of the Global Aids Coordinator and authorize 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 towards next year's reauthorization of this important legislation.

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 affected with HIV/AIDS.

On May 30th President Bush requested that Congress authorize 30 billion (dollars) to extend the global HIV/AIDS initiative an additional five 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 reaction 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 five years to combat HIV/AIDS, TB and malaria, rather than 30 billion (dollars). 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 -- these 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 on 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 will they come from and particularly how well can 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 five 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 lastly, even with the revised UNAIDS numbers, prevention is considered to be of particular importance in the next five-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. We must find new medical ways of stopping the disease. Whether that is medical male circumcision or micro (by size ?) or something we don't yet understand, the importance is that we keep our focus on the core issues.

I also believe that we cannot blind ourselves of the possibility of a wave of new infections that may be coming. I believe that people lean towards 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 and -- 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.

BREAK IN TRANSCRIPT

SEN. MENENDEZ: Thank you, Mr. Hackett.

Thank you all for very insightful testimony.

We'll start with five-minute rounds. And I think we'll have time before the first round of votes take place on the floor. And 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 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've 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've also been to Rwanda, to Haiti. Wherever we go, our message is we're working hand in hand. And --

SEN. MENENDEZ: Are there a series of best practices that you've --

DR. KAZATCHKINE: There are a series of --

SEN. MENENDEZ: -- that you are trying to promote in 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.

SEN. MENENDEZ: Let me ask both Dr. Smits and any others who want to address this.

You know, 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, quote, "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 the treatment access, has increased in recent years, the effort to reduce HIV incidents 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 but 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 thought: I wouldn't be personally, and I think as a 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 implementer's meeting last June. And I heard a very -- several very good talks, particularly one by David Apuuli, 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 just target your prevention efforts there so that you don't keep doing what you were doing very successfully two 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 to do 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.

SEN. 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 he epidemic were very different in the two places.

Clearly, in order to 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 population, different roots 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 a focus among those most likely to continue the chain of transmission because when you're looking at the numbers over time, that's where you're having 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 it 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.

SEN. 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 this -- some of your further answers on this.

Senator Lugar?

BREAK IN TRANSCRIPT

SEN. MENENDEZ: Thank you, Senator.

Two last questions before we'll break. And we thank you all for the time you spent with the committee.

One of -- Dr. Smits, one of the central recommendations of the IOM report is the -- to the U.S. Global AIDS Initiative is to maintain its urgency and its intensity but to shift to a more sustainable approach. As we talk about reauthorization -- the timeliness of it, 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 problems 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 -- support of training programs.

It's -- I know the -- 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 work force 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 work force and the most efficient use of our dollars, particularly by eliminating the separation across prevention treatment and care.

SEN. 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.

SEN. MENENDEZ: About as clear as it gets around here, you know. (Laughter.) It's a refreshing answer, but I know you want to embellish a little. (Laughs.)

DR. DAULAIRE: The reality is that currently, one-half of 1 percent of people receiving HIV/AIDS care and treatment are tested for TB. Got to look for it before you can start doing anything.

SEN. MENENDEZ: All right.

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. So I think it -- but yes, I agree it's an important aspect.

SEN. 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 two days so that committee members may submit additional questions to the witnesses. We would ask the witnesses to respond expeditiously to these questions. And if no one has any additional comments, the hearing is adjourned. (Sounds gavel.)

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