Hearing Of The Senate Foreign Relations Committee - Nomination

Statement

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SEN. RUSS FEINGOLD (D-WI): I'll call the hearing to order and welcome you all here.

I thank our nominee for his willingness to serve again. I'm honored to be joined, of course, by the ranking member of the Foreign Relations Committee, Senator Lugar. I will keep my remarks brief and then invite Dr. Goosby to deliver some opening remarks in just a moment.

Over the last decade and especially in recent years, we've seen an historic and unprecedented expansion in U.S. leadership in global health, especially in fighting HIV/AIDS, and I continue to applaud former President Bush for his leadership in his regard.

And I was pleased that Congress came together last year across party lines to authorize $48 billion over the next five years for U.S. efforts to combat HIV/AIDS, tuberculosis, and malaria. That was a courageous commitment to save millions of lives, and it is critical that the United States deliver on our promises.

I've seen firsthand, as I know many Americans have, the tremendous work we are undertaking to help save lives and the corresponding good will being generated for the United States for our leadership in global health. This has been especially true in sub- Saharan Africa.

Now, of course, there are areas we need to improve our programs and our approach in fighting HIV/AIDS.

First, we cannot treat our way out of this pandemic alone. The number of infections continues to rise in some countries. We need to continue exploring and investing in new prevention strategies to stem the spread of HIV.

Second, we need to strengthen the coordination of all of our global health programs and ultimately bring them together under one overarching strategy. The failure to integrate our programs is not only inefficient, but it places a grave burden on patients and can ultimately render our efforts ineffective.

Third and finally, we need to ensure our assistance supports strong local health systems that include trained health care professionals. In doing so, we not only help to build such systems, but ensure their durability and expand economic opportunities.

In last year's reauthorization of PEPFAR, Congress set the target of training and supporting the retention of 140,000 new health professions in PEPFAR partner countries, and I look forward to seeing that target realized.

Achieving these goals, as well as many others, will not be easy, but I'm pleased that President Obama has announced them as priorities for his new global health initiative. That is a good first step, and he has nominated a global AIDS coordinator who has a wealth of experience and expertise.

Dr. Eric Goosby has been working to combat HIV/AIDS both here at home and abroad for over 25 years. Since 2001, he has been CEO and chief medical officer of Pangaea Global Aids Foundation. In that capacity, he has played a key role in the development and/or implementation of HIV/AIDS and national treatment scale-up plans in Rwanda, South Africa, China, and Ukraine.

Prior to that, he worked in the Clinton administration as deputy director in the White House National AIDS Policy Office and the director of the Office of HIV's Policy of the Department of Health and Human Services. As a practicing physician, Dr. Goosby has worked on HIV/AIDS since the 1980s when we began to see some of the first cases here in the United States.

From my conversation with him, I know that Dr. Goosby has given a lot of thought to how far we've come over the years in fighting this pandemic and where we need to go in the years ahead, and I look forward to continuing that conversation today.

So, Dr. Goosby, I welcome you here, sir. I want to thank you again for embracing the responsibilities that come with this work as well as extend a warm welcome to your family and friends, and please feel free in a few moments to introduce any family or friends when you begin your testimony.

But now I'd like to invite my colleague and the ranking member of the full committee, Senator Lugar, to offer some opening remarks.

SEN. RICHARD LUGAR (R-IN): Well, thank you very much, Senator Feingold, for welcoming Dr. Goosby, and I join you.

He's been nominated to be the Department of State's global AIDS coordinator. I had the opportunity to meet with the doctor last year as the committee was crafting legislation reauthorizing the global HIV/AIDS program, as you mentioned, and his insights were very valuable to our work.

I am particularly pleased that the committee is moving forward on this nomination. Given the importance of maintaining the momentum of our global HIV/AIDS programs, the coordinator position is not one where we can afford an extended vacancy. Ambassador Mark Dybul deserves great credit for his work in managing the program and assisting Congress during consideration and passage of the authorization bill last year.

The main focus and function of the global AIDS coordinator is to oversee the President's Emergency Plan for AIDS Relief, PEPFAR, and, by the end of the fiscal year, this program will have provided treatment to an estimated 3.28 million people. Before the program began, only 50,000 people in all of sub-Saharan Africa were receiving lifesaving antiretroviral drugs. Today, three times that many are being treated in Kenya alone. PEPFAR also focuses on prevention programs, with a target of preventing 12 million new HIV infections, including medical interventions that allow HIV-positive mothers to give birth to HIV-negative babies. As Americans, we should take pride in our nation's efforts to combat these diseases overseas.

We also should understand that our investments in disease prevention programs have yielded enormous foreign policy benefits. PEPFAR has helped to prevent instability and societal collapse in a number of at-risk countries. It has stimulated contributions from other wealthy nations to fight AIDS. It has facilitated deep partnerships with a new generation of African leaders. It has improved attitudes toward the United States in Africa and other regions.

Last year's effort to garner overwhelming support for a reauthorization bill was a tremendous bipartisan achievement. The Tom Lantos and Henry J. Hyde United States Global Leadership Act Against HIV/AIDS, Tuberculosis, and Malaria, which President Bush signed into law last summer, extended and modified the U.S. global HIV/AIDS program for five additional years, at an authorization level of $48 billion, including $4 billion for tuberculosis and $5 billion for malaria.

In addition to the increased authorization level, the legislation expands the flexibility of the original legislation so that U.S. efforts in each country can be tailored to its unique situation. I have consulted extensively with American officials who are implementing PEPFAR. Most believe that flexibility is imperative to the continuing success of the program.

We don't know what the challenges of 2013 will be when the present authorization expires, though we can say with confidence that the landscape will be very different than it is today, and I'm optimistic that the administration and Congress will continue to work together to ensure that the United States lives up to our commitments and we fund the program at a level that allows us to meet and possibly exceed the goals that Congress set forth last year.

I congratulate Dr. Goosby and look forward to our discussion today.

I thank you, Mr. Chairman.

SEN. FEINGOLD: Thank you, Senator Lugar.

Dr. Goosby, you may begin your testimony.

DR. GOOSBY: I'm sorry. Excuse me.

Members of the committee, it's a privilege to be here with you today as President Obama's nominee to serve as the United States global AIDS coordinator and to lead the implementation of the President's Emergency Plan for AIDS Relief. I am honored to be considered for this position and deeply appreciative of the president and Secretary Clinton's support for my nomination.

I also want to thank my wife Nancy (sp), who is not here today, but remains home with my son Eric and daughter Zoey (sp) to finish up school.

Let me express my gratitude for the committee's bipartisan support of PEPFAR which has been a success. I would also like to recognize the efforts of the many dedicated career staff and voice my deep appreciation to President Bush and his administration for creating PEPFAR and permanently changing the landscape of global HIV.

I am currently CEO and chief medical officer of the Pangaea Global AIDS Foundation. Prior to my time with Pangaea, I served as the deputy director of the White House National AIDS Policy Office, director of the Office of HIV/AIDS Policy for the Department of Health and Human Services, and the first director of the Ryan White CARE Act. I am also an HIV-dedicated physician who has practiced through the transition from years where death was a daily event to times of hope and then certainty that death need not be the inevitable result of contracting HIV.

When I first visited the countries in Africa so devastated by AIDS, I felt like I had been transported back in time to America before the advent of antiretroviral drugs, and I recall my frustration standing in hospitals -- hospital wards in Zambia, Rwanda, South Africa. I knew that we had and could find a way to bring treatment to the people in the many countries heavily burdened with HIV and work to find strategies that would be effective in reducing HIV incidence and dedicated myself to doing what I could do personally to make that happen in a sustainable fashion.

I was pleased when PEPFAR was created, and the accomplishments that have been achieved over the last five years can only be characterized as enormous. But there is still more ground to cover.

Last year, your committee's leadership was essential in securing passage of the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008. This legislation recognized the success of PEPFAR and challenged the program to meet new targets and goals. I believe we can and must achieve these goals, but will do so only through a collective action and strong effective collaboration and strategic positioning of our efforts with the rest of the global community, including the Global Fund. PEPFAR investments must be transformed as sustainable programs, while at the same time be scaled up to reach millions both at risk for HIV and those in need of care and treatment.

If confirmed, my approach would include building strong relationships with government, an essential ingredient; working within existing health structures and strategies; mentoring capable health care provider teams; and engaging community-based peer educators to reach out to meet the needs of women, men who have sex with men, and drug users.

Looking forward, I believe four major themes should guide our work: intensifying the focus on HIV prevention; pursuing strong country partnerships, country ownership and coordinated multilateral engagement; supporting health systems strengthening through programs and country-driven planning; and taking effective interventions to scale to achieve population-level health outcomes.

PEPFAR has shown strong leadership in promoting combination prevention using multiple prevention interventions simultaneously to achieve broad population coverage and impact that is based on country- level epidemiological data, local social and cultural factors, et cetera. Combination prevention presents an ideal opportunity to focus on prevention with positives, integrating care with prevention strategies for infected individuals, their partners, families, and contacts. If confirmed, I will place a special emphasis on women and girls to address gender inequities and access linkages to broader health care.

The most effective responses in HIV and other diseases is one tailored to the specific situation in each country. Host country governments carry the long-term responsibility of responding to their respective epidemics, and long-term, durable, and sustainable interventions are those which are integrated into each country's overall health planning and grounded in local capacity.

By using HIV treatment as a platform, PEPFAR support has strengthened and extended health systems in many areas, including human resources, infrastructure, informatics, commodities logistics, and laboratory services. Continued and intensified investment in strengthening health care systems, including the health workforce, will be crucial to scaling up proven interventions and adding to sustainability of PEPFAR and other health and development programs.

The history of PEPFAR has demonstrated what can happen when we dare to think big. My mission, if confirmed, will be to ensure that PEPFAR continues to be a visionary program, a program that continues to exceed our expectations of what can and should be provided to people in resource-poor settings and a program that puts an expanded capacity in place that lasts. Working closely with our global partners, we can help reclaim the lives of millions of people who will otherwise be lost to the infection.

Thank you, and I look forward to your questions.

SEN. FEINGOLD: Thank you, Doctor.

We'll begin with seven-minute rounds.

Doctor, I want to first ask about local health systems. This is an area that needs special focus. In announcing his global health initiative, the president acknowledged that and that we will not be successful unless we, quote, "do more to improve health systems around the world," unquote. If confirmed, how will you work to ensure that we're leveraging PEPFAR to help build stronger health systems, including health workforce capacity?

DR. GOOSBY: Thank you, Senator.

I think that's a critical issue. The ability to build on the platform that PEPFAR has already put in place, both in prevention and treatment services, is a wise and economic decision to take that medical infrastructure which is already in place and use it as the platform on which to extend medical services.

I think the same can be said to use the existing infrastructure both in the country that is not PEPFAR and also the PEPFAR-linked programs to be the training sites and sites in which health care workers at mid-level nurse and physician level, laboratory level, can be trained to extend that capability into satellite and extension sites.

SEN. FEINGOLD: Now I mentioned this figure of the 140,000, the goal of the new health professionals and paraprofessionals, especially nurses and doctors, and I want to stress, of course, that Congress intended for those to be new health workers that would add to the total number of health workers within PEPFAR-focused countries. What do you view as the key steps to achieve this, and, if confirmed, will you ensure that we're focusing our efforts on training new health workers who will add to a country's capacity?

DR. GOOSBY: Well, Senator, I think you're correct in identifying that as a critical element. Health care workers are difficult to identify in many of these settings and more difficult to retain in these settings. Our ability to reach individuals, train them, and keep them in the clinics and hospitals that we are in has been very difficult with individuals getting to a skill level, then getting offered a position somewhere else for more money.

I think we have to take a short-term and a long-term approach to this. One is acknowledging that we don't have enough providers in many of these settings to allow the physician to be the only prescriber of antiretroviral drugs, to be the only orchestrator of prevention efforts out into the community, and we need to target mid- level providers, such as nurses and health care workers who can be trained into an expanded function, cross-training ideas, support, but at all times keeping in mind a referral capability so when they are put in a position where the clinical complaints or the medical issues are more complicated than they feel comfortable with that they have a place to turn to get that dealt with.

That concomitant with -- that being a more immediate response needs to be matched with a long-term view of what we need to put in place to continue to put out trained nurses and trained physicians. I think looking for opportunities to partner with medical schools, nursing schools in the PEPFAR countries that we're involved with is critical for that long-term conduit to continue to feed.

SEN. FEINGOLD: A study published in the Annals of Internal Medicine in 2007 showed that PEPFAR's prevention efforts had fallen short and, therefore, one of the goals in last year's PEPFAR reauthorization was to increase the United States efforts to prevent the number of HIV infections, and if you're confirmed, how do you intend to deliver on that goal? What do you see as the priorities in terms of scaling up the prevention efforts and, at the same time, how can PEPFAR funds for prevention be used more effectively?

DR. GOOSBY: I think that the prevention focus that PEPFAR has had has been actually quite extensive. The outreach to identify populations that are participating in high-risk behaviors, taking that population, so letting the demographics lead you, identifying where they are, and then creating access points, conduits to target that population for continued and repeated prevention messages is critical.

It's difficult to measure those outcomes, it's difficult to see the impact, but it is critical to continue a sustained effort on the prevention aspects because of our inability to really treat this infection out of existence -- for every one person that goes on antiretrovirals, we have three to give people who seroconvert -- our efforts in maternal to child programs, our efforts in condom distribution for discordant couples, our efforts in sexually transmitted disease treatment sites, looking at TB treatment sites, as other opportunities to identify individuals who are in high-risk settings, behaviors, that can be targeted for prevention interventions.

Prevention interventions are not going to be a one-time shot. They are not effective unless they are continuously and repeatedly delivered. The population changes and moves, and those considerations need to be taken into account, and the concept of combination prevention really does describe that coordinated multifaceted convergence of prevention strategies on the population over time. So it would be all of those efforts that need to be put in place in addition to linking to treatment.

SEN. FEINGOLD: Thank you.

There's also been significant discussion in recent years about the need to better integrate HIV/AIDS efforts with child nutrition programs and maternal health efforts. Obviously, this is important, particularly given the fact that an estimated two-thirds of HIV- infected pregnant women do not receive the medicines they need to prevent transmission of HIV to their babies. So how can the Office of the U.S. Global AIDS Coordinator better promote integrated family- centered services in order to reach mothers, children, and other family members in one setting?

DR. GOOSBY: I think this is a critical need. PEPFAR has been aggressive in trying to test women who are pregnant, have tested really millions of women who are pregnant, and identified hundreds of thousands of children who have averted seroconverting by being started on antiretroviral therapy. This needs to be intensified and better linked to the treatment arms of the PEPFAR activity.

Women are often the first member of the family that enter the medical delivery system, frequently in and around concerns with their children, and that needs to be taken advantage of where the woman becomes the entry point, but the medical system quickly identifies serostatus of the woman, her partner or partners, and embraces the child in a continuum of care and services.

We need to be more aggressive at making those links to maternal and child programs in country and making sure that our technical assistance is aggressive enough to raise that medical delivery site, maternal and child site, as another treatment site for the PEPFAR activity.

SEN. FEINGOLD: Thank you very much, Doctor.

Senator Lugar?

SEN. LUGAR: Doctor, the United States is obviously the largest contributor to the Global Fund to Fight AIDS, Tuberculosis, and Malaria. Can you describe to us what sort of issues there have been with other countries over board decisions, whether there have been disputes or differences among the country's represented around the board of the global fund and, when and if those positions run counter to our policies, what recourse should the United States have or do we have in addressing those predicaments?

DR. GOOSBY: Well, Senator, I think that the Global Fund for which PEPFAR contributes $600 million and then $300 million from the NIH, as you know, has been an extraordinary instrument for moving resources to settings that really have none to mount an antiretroviral response, a prevention response, a maternal and child response, as well as TB and malaria. So they have a panoply of obligations that those resources can be presented to.

The process is an in-country process with a country coordinating committee that sits and identifies unmet need, usually convened by the ministry of health, prioritizes that unmet need, and then makes allocation requests to the Global Fund to fill those needs. The United States in its donation to the Global Fund sits on the appropriations committee, the planning committee, the program committee, and the financial committee, and in that committee activity is able to influence on a policy level how and where these funds are used.

But I think appropriately the Global Fund resources are being defined most closely at the ground level, and in a closer communication with the host government, and I believe enriching a technical assistance capability that can help not only give the money to the host country, but also work with the host country to implement these programs would be a clear way that we could better ensure that these resources are used appropriately.

SEN. LUGAR: But are there ever differences? I don't know. I can't identify -- you could perhaps -- the other countries that are around these boards prior to receiving this information from the host country. Have there been debates as to how the response ought to come to the host country?

DR. GOOSBY: Senator, that's a good question.

I am not personally sure I can conjure up a specific conflict, but I would be happy to look into that and get an answer for you.

SEN. LUGAR: Well, that would be helpful.

DR. GOOSBY: Thank you.

SEN. LUGAR: Thank you.

Let me ask about the five million orphans and vulnerable children that were a part of our discussion when we had the Reauthorization Act. What services is PEPFAR providing for these five million persons?

DR. GOOSBY: PEPFAR's focus on orphans and vulnerable children have been partnering with both NGOs, frequently in the faith-based communities, to support orphanages where housing, food, social support, and services are part of the constellation of services. They've taken in the addition of medical evaluation and nutrition support for these children as well. Educational support has also converged on the orphan and vulnerable population in many countries, and links to testing for HIV, some instances of sexually transmitted diseases as well, are also available for these children.

This activity needs to be expanded as the orphan burden in many of these countries continues to increase.

SEN. LUGAR: Do you have any idea how close we are to the goal of five millions children being served?

DR. GOOSBY: We are close to the goal, probably about a million and a half short of that figure, but I will check that number for you, Senator, and get it for you.

SEN. LUGAR: I want to follow up on the chairman's question about health professionals, that the Reauthorization Act provided specifically that there ought to be a goal of 120,000 new health professionals, and this was set forth in the legislation. Now that is a very large number, and, as you've pointed out, as potential health professionals are found and then trained, frequently, they find other callings in due course. Where are we -- can you give us any metrics as to how well we are trying to identify 120,000 at any point, coming or going, as the case may be?

DR. GOOSBY: Much of the PEPFAR activity and activity in many of the host governments has been to try to expand the mid-level provider activity. Physicians take a long time to train.

SEN. LUGAR: Yes.

DR. GOOSBY: It's four years of medical school and then three to four years in addition to that before they are ready to practice independently. I think, as we discussed, trying to partner with medical schools in these countries to not just speed up activity and the curriculum, but to work with the medical schools to develop a curriculum that is effective at putting out independently thinking physicians -- I think most of the activity really needs to be focused on mid-level providers, nurses in particular, to expand their treatment scope and comfort level, putting in a referral support capability that allows them not to work in settings or in situations that exceed their comfort level, but, at the same time, gives them an opportunity to see more patients with physician backup.

A lot of the opposition to this has come from the medical community within these countries. I think we have to start and persist in a dialogue that allows that to move more effectively because we really have no other alternatives. There are some innovative ideas that have been used by PEPFAR to try to create twinning relationships with U.S.-, North American-, European-based medical schools to try to share training, especially as you move into subspecialty training for mostly physician activity. That needs to be increased, amplified, and I think pushed back more to in-African medical schools as the sites of training, again trying to create that capability on the continent and not export it.

The third aspect needs to be a serious look at creating incentives. Individuals who are engaged in this very difficult work and develop a skill set that then is marketable to another country for more money, they, with concerns and constraints around their own families, clearly make a decision to take the higher-paying position and we lose that individual, as you've alluded to. We need to work with countries and their medical public health pay infrastructure systems, their human resource system, to try to create an incentive that doesn't disrupt their hierarchies, but, at the same time, allows us to retain people who have been trained for these positions in their positions.

SEN. LUGAR: Thank you.

SEN. FEINGOLD: Unless Senator Lugar has something further, I want to thank you, Doctor. I look forward to as prompt consideration by the full committee as possible of your nomination, and the record will remain open for 24 hours.

That's the conclusion of the hearing.

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