Testimony before the House Committee on Appropriations, Subcommittee on State and Foreign Operations

Ambassador Mark Dybul, U.S. Global AIDS Coordinator
Testimony before the House Committee on Appropriations, Subcommittee on State and Foreign Operations
Washington, DC
March 1, 2007

Madame Chairwoman and Members of the Subcommittee:

Thank you for this opportunity to discuss President Bush’s Fiscal Year 2008 budget request for his Emergency Plan for AIDS Relief, or PEPFAR.

The partnership between PEPFAR and the Foreign Operations Subcommittee over the years is one for which I am very grateful. Chairwoman Lowey and Ranking Member Wolf, thank you for your commitment to U.S. leadership in the fight against HIV/AIDS. Bipartisan support for this historic initiative has been a key to its success.

Thanks to the commitment of President Bush, Congress and the American people, the U.S. Government is indeed the global leader in this fight. Based on UNAIDS estimates, in 2005 our government contributed more than all other governments combined. With our overall contribution of approximately $4.6 billion for PEPFAR in the current fiscal year, and the President’s unprecedented $5.4 billion request for Fiscal Year 2008, there can be no doubt that the U.S. will continue to lead the world in responding. In fact, the program is on track to exceed its original commitment of $15 billion over five years. By the end of fiscal year 2008, the American people will have invested $18.3 billion in the global fight against HIV/AIDS and tuberculosis.

The majority of those resources are being invested directly into partnerships with host nations. By working with host nations to build quality health care networks and increase capacity, we are laying the foundation for nations and communities to sustain their efforts against HIV/AIDS and other diseases long after the initial five years of the Emergency Plan. In addition to those partnerships, PEPFAR amplifies the effects of other international HIV interventions by working with and contributing to the Global Fund to Fight AIDS, Tuberculosis and Malaria. PEPFAR is on track to more than double its original commitment to the Global Fund, and has provided nearly $2 billion to date. The U.S. Government is the largest contributor to the Fund, providing approximately one-third of all its resources.

Other key international partners include the World Bank; United Nations agencies, led by UNAIDS; other national governments; and – with growing commitment – the businesses and foundations of the private sector. All have vital contributions to make to the work of saving lives in the field.

Let me begin with an update on PEPFAR’s progress toward our five-year goals of supporting treatment for 2 million HIV-infected people, prevention of 7 million new infections, and care for 10 million people infected with or affected by HIV/AIDS, including orphans and vulnerable children. Our recent Report to Congress offers more detailed information.

Treatment
Let me turn first to the “2” of 2-7-10: treatment.

It was just a few years ago that many doubted that large-scale antiretroviral treatment programs could work in the world’s poorest nations. Now we know: they can. Hundreds of thousands of people are proving it.

Through the end of Fiscal Year 2006, approximately 822,000 people received treatment in the 15 focus countries with support from rapidly scaled-up bilateral PEPFAR partnerships with host nations. By September 2006 in the focus countries, 50,000 more people were being put on life-saving treatment every month. The number of treatment sites increased by 139 percent over 2005, as 93 new treatment sites came on line each month. It is important to note that the impact of treatment is far greater than individual lives saved. Every parent kept alive prevents new orphans – and preventing orphanhood is the best care for child survival and health – children without parents can have a three-fold higher rate of death than children with parents. People who survive contribute to their society as teachers, workers, and peacekeepers.

Of those for whom PEPFAR provided site-specific support for treatment in the focus countries, almost nine percent were children, and approximately 61 percent were women.

Beyond the focus countries, other bilateral PEPFAR treatment programs supported an additional 165,000 people (more than double the approximately 70,000 a year earlier). Thus the number of people receiving treatment with support from PEPFAR bilateral partnerships at the end of fiscal year 2006 was 987,100 – approximately half of the estimated 2 million on treatment in low- and middle-income countries.

PEPFAR also works with host nations to grow their capacity to provide quality treatment. We thus supported training or retraining of approximately 52,000 people in the provision of treatment.

The Emergency Plan’s impact on treatment access includes increased availability of safe, effective, low-cost generic antiretroviral drugs (ARVs) in the developing world. Through January 2007, 36 generic ARV formulations have been approved or tentatively approved by the Department of Health and Human Services/Food and Drug Administration (HHS/FDA) under the expedited review established in 2004, including eight fixed-dose combination formulations. Three of these are triple-drug combination tablets and seven are double combinations, of which three are co-packaged with a third drug. In addition, seven oral solutions or suspensions appropriate for pediatric use have been approved. In 2006, there was a significant increase in the use of generic products and in 2007 we will push to utilize the safest, cheapest drugs wherever possible. As a side benefit, the process has also expedited the availability in the United States of five generic versions of ARVs whose U.S. patent protection has expired.

The Global Fund, for its part, has reported support for treatment for 770,000 people globally as of the end of 2006; strikingly, 418,000 of those were reported in PEPFAR focus countries. For 2005, it was estimated that 80 percent of those receiving Global Fund support in the focus countries also benefited from Emergency Plan bilateral support; this year, it is estimated that all of them do. This is a testament to close country-level coordination in support of national programs.

Madame Chairwoman, the bottom line is this: because of the commitment of resources and talented people in-country, many focus countries have achieved massive improvements in national treatment coverage in recent years. This is their achievement, and the Emergency Plan has been privileged to support them as a partner.

Prevention
At this point I'll address the “7” of 2-7-10: prevention.

The most recent UNAIDS report indicates that there were approximately 4.3 million new HIV infections in 2006. Effective prevention is a prerequisite to significant progress against HIV/AIDS; if the number of people newly infected continues to increase, the growing number of people in need of treatment and care – and the growing number of orphans and vulnerable children – will overwhelm the world’s ability to respond and to sustain its response.

Of the countless developments taking place in the global fight against the pandemic, perhaps the single most important in recent years is the growing number of nations in which there is clear evidence of declining HIV prevalence as a result of changes in sexual behavior. In addition to earlier dramatic declines in HIV infection in Uganda, there is growing evidence of similar trends in other nations, including Botswana, Ethiopia, Haiti, Kenya, Tanzania, Zambia, and Zimbabwe. While the causes for decline of HIV prevalence are undoubtedly complex, these countries have demonstrated broad reductions in sexual risk behavior, suggesting that behavior change can play a key role in reversing the course of HIV/AIDS epidemics.

The Emergency Plan supports the most comprehensive, evidence-based prevention program in the world, targeting interventions based on the epidemiology of HIV infection in each country. PEPFAR supports prevention activities that focus on sexual transmission, mother-to-child transmission, the transmission of HIV through unsafe blood and medical injections, and greater HIV awareness through counseling and testing. The Emergency Plan will integrate new prevention methods and technologies, including the recently validated intervention of male circumcision and hopefully others such as microbicides, as evidence is accumulated and normative guidance is provided.

The vast majority of focus countries have generalized epidemics, meaning that HIV infection is not concentrated in specific and identifiable groups, but touches the general population. Long before PEPFAR was initiated, many nations with generalized epidemics had already developed their own national HIV prevention strategies that included the “ABC” approach to behavior change (Abstain, Be faithful, correct and consistent use of Condoms where appropriate). The new data – from time periods that pre-date PEPFAR scale-up – link adoption of all three of the ABC behaviors to reductions in prevalence. Learning from this evidence, PEPFAR will continue to support all three elements of the evidence-based ABC strategy in ways appropriate to the epidemiology and national strategy of each host nation. In focus countries during fiscal year 2006, approximately 61.5 million people were reached by community outreach programs promoting ABC and other related prevention strategies. In addition, the U.S. Government has supplied 1.3 billion condoms from 2004 to 2006, lending support to comprehensive ABC approaches based on the epidemiology of each country. PEPFAR also operates in countries with concentrated epidemics where, for example, 90 percent of infections are among persons who participate in prostitution. Hence, the epidemiology in these nations dictates a response more heavily focused on B and C interventions.

Prevention of mother-to-child transmission (PMTCT) is a key element of the prevention strategies of host nations, and PEPFAR is supporting their efforts. UNAIDS estimates that 12 percent of new infections globally in 2006 (530,000 infections) occurred among children, and that more than 90 percent of these were due to mother-to-child transmission. In the focus countries, PEPFAR also supports 4,863 service outlets for the prevention of mother-to-child-transmission, and since the program’s inception we have supported PMTCT services for women during more than 6 million pregnancies. Through Fiscal Year 2006, PEPFAR has supported antiretroviral prophylaxis for HIV-positive women during 533,700 pregnancies, which has saved an estimated 101,500 infants from HIV infection.

Hard-hit nations have sought to ensure that all women who visit antenatal clinics (ANCs) receive the option of an HIV test through pre-test counseling. By promoting the routine, voluntary offer of HIV testing – so that women receive testing unless they elect not to receive it – host nations have increased the rate of uptake among pregnant women from low levels to around 90 percent at many sites. A major PEPFAR focus in the past year was to support countries’ leadership in scaling up the voluntary “opt-out” approach at as many sites as possible, to reach many more women while improving the performance and efficiency of health workers. When comparing results from the first year of the Emergency Plan in fiscal year 2004 to fiscal year 2006, all countries have scaled up, and most have dramatically improved availability of PMTCT services to pregnant women.

PEPFAR also supports 3,846 blood safety service outlets, and we have supported the training or retraining of 6,600 people in blood safety and 52,100 in medical injection safety.

Care
Finally, the “10” of 2-7-10: care.

Through Fiscal Year 2006, PEPFAR supported care for nearly 4.5 million people around the world, including approximately two million orphans and vulnerable children (OVCs). In addition to scaling up HIV/AIDS programs for OVCs on a larger scale than has been attempted previously, in fiscal year 2006 PEPFAR took an important step forward in ensuring the quality of programs. OVC programs now are being required to track how many of six key services they provide, and to report accordingly.

Along with its OVC programs, PEPFAR has scaled up its support for national efforts to provide high-quality care for opportunistic infections related to HIV/AIDS. Especially important in this area is care for HIV/tuberculosis (TB) co-infection, a leading cause of death among HIV-positive people in the developing world. I will discuss this issue later in my remarks.

Another key improvement in fiscal year 2006 was the development and dissemination of ‘preventive care packages’ for children and adults living with HIV. These packages can help to keep HIV-positive persons healthy and to delay the need for treatment, and were crafted to be adapted to local circumstances. Like many best practices developed by the Emergency Plan, advances in the area of care for OVCs and people living with HIV/AIDS have the potential to have a wide impact beyond PEPFAR-supported programs. We are working to disseminate them broadly.

Knowing one’s status provides a gateway for critical prevention, treatment, and care. Millions of people must be tested in order for PEPFAR to meet its ambitious goals, and PEPFAR supported more than 18 million counseling and testing encounters through fiscal year 2006. Among these, more than 5.7 million encounters were with women seeking PMTCT services, a key population to target.

A key barrier to the universal knowledge of serostatus is the lack of routine testing in medical settings, including TB and sexually transmitted infection (STI) clinics, ANCs, and hospitals. In many focus countries, studies have found that 50 to 80 percent of hospital and TB patients are infected with HIV; many of these patients are in urgent need of treatment. Again, PEPFAR is working with host nations to build support for the model of routine “opt-out” provider-initiated testing, where, in selected health care settings, all patients are tested for HIV unless they refuse.

Another key policy trend in many nations that PEPFAR has supported is in favor of the use of rapid HIV tests; use of rapid testing improves the likelihood that those who are tested will actually receive their results.

In 2006, PEPFAR also supported training or retraining of approximately 143,000 individuals in providing care for orphans and vulnerable children; nearly 94,000 in providing care for people living with HIV/AIDS; and more than 66,000 in providing counseling and testing services.

The Role of PEPFAR in Transformational Development

Now I’d like to turn to the role of PEPFAR in our nation’s broader strategy for international development. We recognize that the President and Congress have entrusted many resources to this initiative on behalf of the American people. As stewards of those resources, we have at least two critical obligations:

1. To achieve specific HIV/AIDS goals, as I have discussed, and
2. To leverage these resources for our nation’s larger international development agenda.

PEPFAR is integral to President Bush’s vision, which Secretary Rice has called “transformational diplomacy.” This vision is one of partnership, as the U.S. leads the way in changing the development paradigm from the old “donor – recipient” mentality toward a model of genuine partnership. Ambassador Randall Tobias is leading the implementation of a new Strategic Framework for Foreign Assistance, with a mandate to “move countries from a relationship defined by dependence on traditional foreign assistance to one defined by full sustaining partnership status.”

Confronting HIV/AIDS is central to this approach as a critical lever for a nation’s sustainable progress and transformation. Unaddressed, HIV/AIDS threatens to erode the welfare and stability of developing nations by undermining the human and economic capacity of a nation to progress on its own.

Economic Impact of HIV/AIDS

The HIV/AIDS pandemic is unique in human history – not just because it is so widespread and debilitating, but because it strikes at the very heart of the population. Unlike other epidemics, HIV does not attack the oldest, or the youngest, or the weakest – it strikes people in the prime of life. This pattern has worsened in recent years. Since the 1990s, the single largest increase in HIV/AIDS mortality has been among adults aged 20 to 49. This age group accounted for only 20 percent of all AIDS deaths from 1985 to 1990 worldwide, but today it accounts for nearly 60 percent.

What does this mean? It means communities are being hobbled by the disability and loss of the very segment of the population which is normally the backbone of any society – consumers and workers at the peak of their productive, reproductive, and caregiving years. In the most heavily affected areas, communities are losing a whole generation of parents, teachers, laborers, healthcare workers, peacekeepers, and police.

Parents are dying from HIV/AIDS. Around the world, 14 million children under age 15 have lost one or both parents to HIV/AIDS. By 2010, that number is expected to exceed 25 million. In sub-Saharan Africa alone, the disease has left more than 11 million orphans, and by 2020 there will be 15.7 million.

Educators are dying from HIV/AIDS. Africa is seeing especially high HIV-related mortality rates among teachers and school administrators; in Zambia, for instance, two-thirds of all trained teachers are being lost to HIV/AIDS.

The loss of so many young and middle-aged adults is having a severe impact upon household, local, national, and regional economies. In HIV-affected households, the family’s earned income drops while health costs rise. Extended families and communities are faced with the financial burden of caring for an increasing number of children who have been orphaned by AIDS.

Many children who have lost parents to HIV/AIDS are left entirely on their own. When they drop out of school to fend for themselves and their siblings they lose the potential for economic empowerment that an education can provide. Alone and desperate, they often resort to transactional sex or prostitution just to survive, and risk becoming infected with HIV themselves.

The pandemic also affects the business sector – budgets are being strained by rising health care costs, increased absenteeism, a shrinking workforce, lost expertise, high turnover, and reduced productivity. In 2005 alone, more than three million workers worldwide were partially or fully unable to work because of HIV-related illness.

The ramifications for national economies are alarming. Between 1992 and 2004, HIV/AIDS caused 43 of the most heavily affected countries to lose 0.3 percent per year in employment growth and 0.5 percent in their annual rate of economic growth.

UNAIDS projects that, by 2020, HIV/AIDS will have caused the GDP to drop by more than 20 percent in the hardest-hit countries. The World Bank recently warned that, while the global economy is expected to more than double over the next 25 years, Africa is one of the few regions at risk of being “left behind.”

Public Health Implications of HIV/AIDS

In addition to the economic impact of the pandemic, HIV/AIDS has serious public health implications. An ever-expanding pool of immuno-suppressed people worldwide can both more readily contract and spread disease, including for more infectious diseases we cannot yet predict.

Take for example the recent rise in Extensively Drug Resistant Tuberculosis (XDR-TB) among HIV-infected people. To date, there has been a significant spread of XDR-TB in sub-Saharan Africa, and in South Africa, 44 of the 44 cases reported have been among HIV-positive persons. This must be of great concern to all of us, because XDR-TB is literally untreatable and almost always fatal. In this era of globalization, infectious disease knows no boundaries. Today it is XDR-TB – tomorrow it may be avian flu, or something even worse.

Security Implications of HIV/AIDS

Beyond the economic and public health implications, this pandemic is a threat to national and international security. In particular, the disease is taking a high toll on militaries: HIV-related deaths have reduced the size of Malawi’s armed forces by 40 percent. Seventy percent of all military deaths in South Africa are due to HIV/AIDS. In Uganda, more soldiers have died from AIDS than from the nation’s 20-year insurgency. This currently impacts nations’ abilities to protect their own citizens and to provide peacekeepers for other conflicts, fueling national and regional instability. In addition, the destruction of the social fabric caused by the socio-economic impact of HIV/AIDS and a generation of orphans provides a long term breeding ground for radicalism. For these reasons, General Wald, the former Deputy Commander, Headquarters U.S. European Command, has called HIV/AIDS the greatest threat to peace and security in Africa behind only weapons of mass destruction and terrorism.

PEPFAR as a Foundation to Connect the Dots of Development

The surest long-term strategy for addressing transnational threats is to promote the health, stability, and economic well-being of developing nations, and confronting HIV/AIDS is at the heart of our strategy.

While the focus of PEPFAR is on prevention, treatment, and care of people living with HIV/AIDS the impact of our program is not -- and need not be -- limited to HIV/AIDS. PEPFAR is central to U.S. efforts to “connect the dots” of international development. Our programs are increasingly linked to other important U.S. initiatives in other areas of health and development, such as child survival and health, TB, malaria, nutrition, education, and gender inequities, as well as supporting systems of sustainability and accountability. I would like to briefly address each of these.

Supporting Children

Although PEPFAR is and will remain focused on HIV/AIDS, it encompasses healthcare services that have built on earlier U.S. Government-supported initiatives, such as USAID’s Child Survival and Health program.

For instance, PEPFAR’s “core services” for orphans and vulnerable children include services traditionally associated with the Child Survival and Health program. Such services include TB and malaria screening; provision of antibiotics; education; and provision of food, nutrition, shelter, protection, and psychosocial support.

In FY2003, just prior to PEPFAR, USAID provided $34.3 million for services for orphans and vulnerable children; $26.8 million of this came from the Child Survival and Health fund. In fiscal year 2006, PEPFAR provided approximately $213 million to support focus country programs that are providing care for two million orphans and vulnerable children.

Fighting Tuberculosis

PEPFAR’s focus on tuberculosis has increased steadily since the program’s inception in fiscal year 2004. Before PEPFAR was established, the total U.S. Government contributions for bilateral TB and TB/HIV initiatives was approximately $79 million. Our level of support for combined TB/HIV initiatives in the focus countries in fiscal year 2006 marked an increase of 104 percent over fiscal year 2005, and we expect significant additional growth in funding during fiscal years 2007 and 2008. In fiscal year 2007, we anticipate funding of at least $120 million for TB/HIV in the focus countries – combined with approximately $91 million for bilateral TB programs, that is nearly a tripling of funding from just four years ago. In addition to people being served by the US Government’s bilateral TB initiatives, PEPFAR is supporting care for 301,600 people in the focus countries who are co-infected with TB and HIV.

Tuberculosis will continue to be an area of increasingly high priority for PEPFAR, because TB is the number one killer of HIV-infected people. In addition, there is growing concern about the advent of drug-resistant strains of TB among people who are HIV-positive. We are working closely with the U.S. Federal TB Task Force to develop a concerted U.S. Government response to tuberculosis. PEPFAR’s technical experts are in close contact with international partners such as the Global Fund and WHO, to address the urgent need to strengthen laboratory systems, establish infection-control measures, and expand programs to prevent, diagnose, and manage drug-resistant TB in people living with HIV/AIDS.

Fighting Malaria

PEPFAR continues to partner with the President’s Malaria Initiative (PMI) in countries that are targeted by both programs. In 2008, as PMI expands, 15 countries (7 PEPFAR focus countries and 8 other bilateral) will be jointly sponsored by the two Presidential initiatives. The collaboration of PEPFAR and PMI has already enabled countries to provide comprehensive services for some of the most vulnerable groups for both diseases, including pregnant women, people living with HIV/AIDS, and orphans and vulnerable children under age five.

Some of the key areas currently being supported through PEPFAR/PMI collaboration include:

• Provision of intermittent presumptive therapy for pregnant women and long lasting insecticide treated nets (ITNs) to pregnant mothers and children under age five as comprehensive components of HIV Prevention of Mother-to-Child Transmission (PMTCT) initiatives, Orphan and Vulnerable Children (OVC) care, and palliative care;
• Collaboration in Blood Safety to ensure a malaria free pool of voluntary blood donors and to reduce the need for transfusion due to malaria-related anemia;
• Jointly funding surveillance activities; and
• Joint training activities to enhance lab capacity and provision of quality laboratory services.

Finally, through this collaboration, PMI has the opportunity to build on the foundation of community-based structures and programs developed under PEPFAR. For example, in Uganda, PMI plans to deliver ITNs to 1,500 HIV-positive mothers identified through established HIV/AIDS support groups of a PEPFAR-funded partner. In Tanzania, PMI and PEPFAR will collaborate to provide a comprehensive package of palliative care services that includes the provision of ITNs for clients enrolled in HIV home-based care programs. Finally, PMI can build on the work of PEPFAR to strengthen national systems, guidelines, and programs.

Supporting Nutrition

Addressing the broad issue of food insecurity generally is beyond the scope of PEPFAR, but we recognize that there are very real nutrition issues facing the communities in which we work.

PEPFAR does support limited food assistance for specific, highly vulnerable populations. For instance, in a pilot program in Kenya, we are supporting a local food manufacturing company in distributing nutrient-dense foods to orphans and vulnerable children; clinically malnourished people living with HIV/AIDS; and HIV-positive pregnant and lactating women in PMTCT programs.

For the most part, however – in order to remain focused on HIV/AIDS – PEPFAR maximizes leverage with other partners that provide food resources. For instance, in collaboration with our interagency partners, we are engaging on food and nutrition issues with six focus countries in a pilot program. Some of these countries have established coordinating structures in the field that are beginning to bear fruit at the field level. In Ethiopia, for example, PEPFAR Ethiopia contributes to the World Food Program (WFP) and Food for Peace supports some HIV/AIDS programs. In fiscal year 2006, PEPFAR Ethiopia and the WFP collaborated to provide food resources to more than 20,000 beneficiaries, including orphans and vulnerable children, adult patients on ART, and care givers. Strong cross-program ties have also been established across the USG in Haiti, where PEPFAR and Food for Peace have begun work to develop a conceptual framework to guide their Food and Nutrition Strategy.

Key partners in our Food and Nutrition Strategy include, among others, the USDA’s Foreign Agriculture Service, USAID’s Food for Peace office, and the World Food Program – a key international partner. In fiscal year 2006, PEPFAR allocated $2.45 million to World Food Program initiatives, and that will increase to $4.27 million in fiscal year 2007.

Supporting Clean Water

In September 2006, First Lady Laura Bush announced a groundbreaking public-private partnership called the PlayPump Alliance. This $60 million alliance between PlayPumps International, the Case Foundation, USAID, PEPFAR, and other private sector partners will bring the benefits of clean drinking water to up to 10 million people in sub-Saharan Africa by 2010. The goal is for every USG tax dollar to be matched by five dollars from the private sector. This partnership will improve access to clean drinking water by installing PlayPump water systems throughout the region. The USG, through USAID and the Emergency Plan, will provide a combined $10 million to the alliance over three years. This investment will directly support the provision and installation of PlayPump water systems in approximately 650 schools, health centers, and HIV affected communities. In addition, HIV/AIDS messages on PlayPump billboards will spread the word about healthy behaviors.

Supporting Education

Education is also a crucial element of the human development equation, since it offers the hope of self reliance and an escape from poverty.

Although education per se is beyond the scope of PEPFAR’s mission, we do support OVC attendance programs which include providing school fees, books and uniforms, as well as HIV prevention and life skills programs. We also leverage our comprehensive OVC care program, to “wrap around” other programs that provide educational access to children who are infected with and affected by HIV/AIDS.

A key example is the way in which PEPFAR coordinates efforts with the President's African Education Initiative (AEI), implemented through USAID. Over the next four years, the U.S. will provide $400 million for the AEI to train half-a-million teachers and provide scholarships for 300,000 young people throughout Africa, predominantly girls. This is especially important, since studies show that girls who drop out of school are at significantly higher risk of being infected with HIV/AIDS.

Addressing Gender Inequities

Within the worldwide crisis of the HIV/AIDS pandemic there is another very serious crisis: young people account for half of all new HIV infections – and an estimated two-thirds of these new infections are among women. Around the world, girls and women are contracting HIV at an alarming rate. The reasons are complex, but they are invariably tied to pervasive, powerful, and often brutal gender inequities. In many of the most heavily affected countries, women and girls are simply powerless to protect themselves against contracting HIV/AIDS.

Because of this, PEPFAR places a high priority on addressing gender inequities. In fiscal year 2006, we allocated $442 million to support more than 830 HIV interventions that include a gender-related element.

Each of PEPFAR’s 15 focus countries is required to include programs that include one or more of these strategies:

• Increasing gender equity in HIV/AIDS activities and services;
• Reducing violence and coercion;
• Challenging negative male norms;
• Expanding women’s legal rights and protections; and
• Increasing women’s access to education, vocational training, and micro-financing.

Supporting Health Workforce and Systems

At least one quarter of PEPFAR’s total resources are devoted to capacity-building in the public and private health sectors – supporting physical infrastructure, healthcare systems, and workforce development. With support from our Supply Chain Management System (SCMS), focus countries are putting in place transparent and accountable delivery systems that ensure an uninterrupted supply of high-quality and low-cost drugs, lab equipment, testing kits, and other essential medical materials.

PEPFAR’s capacity-building initiatives have positive spillover effects: whenever a country upgrades its health systems and strengthens the health workforce it improves allover healthcare delivery. In addition to strengthening infrastructure, expanding health services, and stimulating economic growth, such improvements also enable developing countries to cultivate good governance and build freer and more stable societies.

We are also using technology to do more than build health information systems and foster two-way communication with our partners. Two weeks ago, we announced the $10 million public-private partnership, Phones For Health – which brings together mobile phone operators, handset manufacturers, and technology companies, working closely with Ministries of Health, global health organizations, and other partners – to strengthen healthcare services and monitoring systems through mobile technology. As with the development of national health information systems, the Phones for Health network will have applications for more than just HIV/AIDS. In the event of an outbreak of bird flu, XDR TB, or any other suddenly arising epidemic, this system and others like it will prove to be invaluable.

In addition, PEPFAR works closely with indigenous faith- and community-based organizations – supporting their efforts to grow their capacity to lead their nations' response to HIV/AIDS. When such organizations expand their capacity in order to meet USG fiduciary accountability requirements, they are in a better position to support themselves in the future.

Supporting Systems for Accountability

The so-called “burden of reporting” is actually a foundational feature of transformational development. Reporting is one of the principal means of establishing effective systems for transparency and accountability. PEPFAR’s rigorous reporting requirements serve a number of purposes. First and foremost, they are building an ever-increasing body of empirical data from which to develop, evaluate, and improve evidence-based HIV/AIDS interventions – and to do it in real time, as we go along, thus creating a culture of accountability that has impact beyond HIV.

Secondly, our reporting system is fostering the establishment of national health information systems in partner countries, many of which had weak or nonexistent systems prior to PEPFAR. Working with UNAIDS, WHO, Health Metrics Network, the World Bank, the Global Fund, and others, PEPFAR is expanding each country’s reporting infrastructures and increasing the number of personnel who are trained in the field of strategic information.

Consistent with the model of partnership, PEPFAR seeks to be transparent and accountable. In addition to communicating with the American people, through our annual report and the www.PEPFAR.gov website, we keep in touch with all of our implementers through a private “Extranet” website. This provides current research, best practices, reporting guidelines, and other programmatic information on a continually updated basis.

Supporting Public-Private Partnerships

Through PEPFAR’s growing network of public-private partnerships, we are working with businesses to bring their distinctive strengths to the fight. In 2006, PEPFAR invested $13.25 million in public-private partnerships, leveraging $59.25 million in additional resources for programs including PlayPumps and Phones for Health, previously mentioned in this testimony. Also in 2006, smaller scale public-private partnerships were developed in the field and launched in Zambia, South Africa, and Kenya. Finally, through a broad consultative group that includes members of the U.S. Government, the private sector, and NGOs, we are moving forward in developing additional public-private partnerships to scale up pediatric HIV treatment. These public-private partnerships make our dollars go further and harness the skills of the private sector making our programs more effective and sustainable. In addition, they can gain further leverage by connecting with other key USG initiatives like the African Education Initiative and the President’s Malaria Initiative.

Conclusion

As we move forward into 2007, these areas in which we are leveraging PEPFAR investments to address the full range of development issues will be a "growth area" for PEPFAR. In addition to those I have described, other areas in which we intend to focus on closer coordination and leveraging include microenterprise and neglected tropical diseases. These efforts will be an integral part of Ambassador Tobias’ leadership and efforts to coordinate US Government support for development. The scope of the President's vision of transformational diplomacy is very broad, and HIV/AIDS is central to so many of the key issues.

Despite the daunting challenges ahead, the United States will remain a partner with host nations in this fight. President Bush’s Emergency Plan was the first quantum leap in America’s leadership on global HIV/AIDS – and the American people must continue to stand with our global sisters and brothers as they take control of the pandemic and their lives and restore hope to individuals, families, communities, and nations.

Madame Chairwoman, once again, I am deeply grateful for our strong partnership with this Subcommittee, and I think 2007 will be another year of major accomplishments of which we can all be proud. With that, let me turn to your questions.