Statement on The President’s Emergency Plan for AIDS Relief and Food and Nutrition before the U.S. House of Representatives Foreign Affairs Committee, Subcommittee on Africa

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Statement on PEPFAR and Food and Nutrition
Ambassador Mark Dybul, U.S. Global AIDS Coordinator
Statement before the U.S. House of Representatives Foreign Affairs Committee, Subcommittee on Africa
Washington, DC
October 9, 2007

Mr. Chairman and Members of the Subcommittee:

I am grateful for this opportunity to discuss the President’s Emergency Plan for AIDS Relief (PEPFAR) and its links to the important issue of food and nutrition.

Just five years ago, PEPFAR was an idea, a vision shared by U.S. legislators and administrators -- including some of you who are on this subcommittee today -- to intervene in one of the world’s greatest threats to human life and dignity, the HIV pandemic. At that time, HIV was a death sentence in developing countries; only 50,000 people living with HIV in all of Sub-Saharan Africa were receiving treatment, and few mothers had access to therapy to stop transmission of HIV to their babies. The impact on families, communities, and societies was devastating, and many wondered whether prevention, treatment and care could be provided successfully in resource-limited settings. In this context, with leadership from President Bush and strong bipartisan support from Congress, our nation began to lead the world in combating the disease and nurturing hope.

Just one week ago, our PEPFAR country teams completed their fourth annual country planning process, a key element of the largest scale-up of HIV prevention, care, and treatment activities ever achieved globally. Due to the continued generosity of the American people, PEPFAR is well on the way to achieving its ambitious five-year targets of supporting treatment for two million people, supporting prevention of seven million new infections, and supporting care for 10 million people infected and affected by HIV/AIDS, including orphans and vulnerable children. Through March 2007, PEPFAR supported antiretroviral treatment for over 1.1 million men, women, and children. Through September 2006, PEPFAR-supported programs provided HIV testing and counseling to 18.6 million people; delivered antiretroviral prophylaxis during over half a million pregnancies, preventing an estimated 101,000 infant HIV infections; and supported basic care services for an additional 2.4 million adults and 2 million orphans and vulnerable children infected and affected by HIV. Country teams will submit their annual program results data to us shortly, and we expect that the data will demonstrate impressive continued progress.

PEPFAR has achieved this success by leveraging the core strengths of U.S. Government agencies; implementing partners; multilateral institutions such as the Global Fund to Fight HIV, TB, and Malaria and the World Health Organization; and other international partners. Strong partnerships to implement unified national plans under the leadership of host country governments are hallmarks of PEPFAR.

PEPFAR applies this collaborative approach to its food and nutrition activities. Many of the people infected and affected by HIV/AIDS in PEPFAR countries live in communities that are extremely poor and often food-insecure. Indeed, there is a complex relationship between food insecurity and HIV/AIDS. As people become sick with AIDS, they are less able to earn income for themselves and their families. Poverty and hunger can also lead to high-risk behaviors such as transactional sex, fueling transmission of the virus. The virus itself has an effect on metabolism, and can cause progressive wasting. On the other hand, evidence indicates that adequate nutrition, along with interventions such as cotrimoxizole, clean water, and malaria prevention, can help to delay the onset of disease and the need for antiretroviral treatment.

In addition to impacts on people who are themselves HIV-positive, PEPFAR has a key mandate to address the needs of children orphaned and made vulnerable (OVCs) as a result of HIV/AIDS. Our strategy for these children is to ensure that their needs are being met, either by PEPFAR programs or by other U.S. Government agencies and programs, other international partners, United Nations agencies, host Governments, or the private sector, in “six plus one” essential areas. One of the six essential areas is food and nutrition, and the “plus one” is economic strengthening.

In light of this relationship between HIV/AIDS and food and nutrition, PEPFAR has worked since its inception to address issues of food and nutrition within the context of our prevention, treatment and care goals. The Leadership Act provides ample authority for these efforts, specifying that PEPFAR support includes “assistance for the purpose of the care and treatment of individuals with HIV through the provision of … therapies for the treatment of opportunistic infections, nutritional support, and other treatment modalities.” Sec 104A(d)(2)(c). Moreover, PEPFAR is mandated to work with the U.S. Agency for International Development (USAID) to: “integrate nutrition programs with HIV activities, generally”; “provide, as a component of an antiretroviral therapy program, support for food and nutrition to individuals infected with and affected by HIV”; and “provide support for food and nutrition for children affected by HIV and to communities and households caring for children affected by HIV.” Sec. 301(c).

Recognizing this need and acting under the authority provided by Congress, PEPFAR has convened an interagency, multisectoral technical working group on food and nutrition, to guide incorporation of key components into HIV programs. In addition to our primary PEPFAR implementing agencies, the group includes other agencies and offices that work directly with issues of food security and nutrition, including USAID’s Office of Food for Peace and Bureau for Economic Growth, as well as the U.S. Department of Agriculture (USDA). The group’s first task was to develop a food and nutrition strategy through a consultative process, captured in the report to Congress entitled “Food and Nutrition for People Living with HIV/AIDS.” The group also provides guidance to PEPFAR country teams on integrating food and nutrition activities into HIV/AIDS programs.

A central precept of the U.S. Government strategy on food and nutrition and HIV/AIDS is to build on the comparative advantage of each partner, including U.S. Government agencies, host governments, non-governmental organizations, and international partners, to leverage resources. The Emergency Plan contributes to this strategy through its focused effort to integrate food and nutrition into HIV/AIDS programs and to provide longer term food security support for specific vulnerable populations. Our highest priority populations are orphans and vulnerable children born to HIV-positive parents, pregnant women enrolled in prevention of mother to child transmission programs, and patients in treatment and care programs with evidence of clinical malnutrition.

For orphans and vulnerable children and pregnant women, our nutritional support activities include: nutritional assessments and counseling; micronutrient supplementation; direct food support; and, in many cases, linkages with livelihoods programs.

For HIV-positive people, PEPFAR supports integration of food and nutrition into HIV care and treatment programs; micronutrient supplements for those whose diet may be inadequate to meet vitamin and mineral requirements; therapeutic and supplementary feeding for antiretroviral treatment patients who are clinically malnourished at entry; and food security assessments with linkages and support for food security and livelihood assistance for patients and their families.

To further food and nutrition support in HIV/AIDS programs, PEPFAR country teams also work closely with Ministries of Health and other partners to develop national policies, guidelines, and plans that provide a framework for linking food and nutrition activities within HIV/AIDS programs. For example, PEPFAR funds the development of training curricula; nutrition and dietary assessment tools; and other materials to be used within a given country, as well as health worker training in the use of these tools and materials.

PEPFAR also works closely with multilateral organizations. The United Nations World Food Programme (WFP) is an essential partner at both the global level as well as on the ground in countries like Ethiopia and Mozambique, where it receives PEPFAR funding for interventions linked to PEPFAR programs. PEPFAR also works with WFP, World Health Organization and other international partners to establish global guidelines on food and nutrition. PEPFAR partners on the ground help countries perform the difficult job of translating global guidelines and national policies into functional frameworks and plans at the clinic and community level.

As you know, however, supporting food and nutrition to HIV/AIDS-affected and -infected populations in what is often chronically food insecure environments poses challenging issues. While people living with HIV may identify food as one of their most pressing needs, so do their uninfected neighbors. In a context of widespread food insecurity, it is vitally important not to create an environment in which having HIV provides access to long-term food benefits that others in the community also desire. Thus, these issues cannot be addressed by any one program or agency alone: solutions can only be created through partnerships.

One of PEPFAR’s central partnership strategies is “wraparound” programming, whereby partners jointly plan and implement interventions to meet the full range of needs of an individual, household or community. Thus PEPFAR focuses resources for food and nutrition on our most vulnerable target populations, while other partners bring the expertise and infrastructure to support sustained food security programs to communities as a whole.

These approaches are proving successful. From the perspective of resources, we are increasingly able to account for funding applied to support food, nutrition and sustainable livelihoods for HIV-infected and -affected individuals and communities. Most U.S. Government food resources directed to support HIV-affected communities and individuals are allocated through USAID’s Food for Peace programs. In Fiscal Year 2006, Food for Peace estimates that it provided approximately $50 million in support of HIV-infected and -affected PEPFAR beneficiaries. Additionally, USDA, through its Food for Progress, Food for Education and market-development assistance programs, as well as WFP, provide direct support for food commodities and food security with a focus on overall communities. A notable example of USDA investments is support for the Humana People to People program in Mozambique, which reaches close to a million beneficiaries in a comprehensive program of food and nutrition support, income generation and HIV/AIDS prevention and care.

PEPFAR investment in food and nutrition complements these efforts. Although we have not historically tracked food and nutrition activities in PEFPAR, for the first time the Fiscal Year 2008 Country Operational Plans (COPs) estimate both PEPFAR and other partner resources going to food and nutrition. Preliminary information coming from the countries completing COPs indicates that country teams plan to spend over $20 million of PEFPAR resources on food and nutrition in Fiscal Year 2008. Country teams were also asked to estimate how much funding from other partners they were leveraging for food support. While this data is preliminary and more analysis is required, every focus country except Ethiopia reported leveraging food support from partners at more than dollar for dollar. While these budget numbers may change over the course of the year, the country plans demonstrate a significant and growing commitment by PEPFAR to support food and nutrition activities that support HIV/AIDS prevention, treatment and care.

Also for the first time, in Fiscal Year 2008 our annual program results reports will enumerate beneficiaries of food support. As with our improvements in planning, this step forward in reporting will soon provide more information, not only on how much is spent, but on how many people are being served with various food initiatives. This data will better inform our programs in the field as they continue to identify best practices.

Of course, numbers – whether funding or people reached -- only tell part of the story. What matters most is what is happening on the ground. In Kenya, the Emergency Plan is supporting a “food by prescription” approach, in which a clinician who diagnoses malnutrition in an HIV-positive patient may write a prescription for a fortified food product which is available and dispensed at the clinic. A similar approach is in place in Uganda, through a partnership with USAID’s Food For Peace program. In Ethiopia, the U.S. Government has established a strong multisectoral team; PEPFAR and WFP recently collaborated to provide food resources to more than 20,000 people affected by HIV, including children, caregivers, and HIV-positive adults.

As noted earlier, food and nutrition is one of the key areas for orphans and vulnerable children in many of PEPFAR’s programs. As with our food and nutrition programming for other vulnerable groups, support for children comes not only in form of direct food delivery, but also in sustainable approaches for community support. For example, in Namibia, one of our programs focuses not only on food support for 3200 children but also on training 1000 caregivers in nutrition.

In Haiti, the Emergency Plan works with partners to support children orphaned or made vulnerable by HIV/AIDS using a community-based approach, including a school nutrition program using USAID Food For Peace resources. This program also seeks to develop sustainable sources of food, so it has aggressively supported community gardens primarily for children’s consumption, and also to generate revenue through the marketing of vegetables. In Cote d’Ivoire, partners incorporate income-generating activities to build self-sufficiency for 6000 vulnerable children and their families, with links to school feeding programs in collaboration with other partners.

There are many more examples of innovative interventions PEPFAR supports to strengthen nutrition and food security for vulnerable children and their caregivers. Drip irrigation programs increase production for backyard gardens. Animal husbandry provides not only access to food, but can be an income-generating activity as well. Community gardens are another way communities address nutritional needs of high numbers of children. Finally, many of PEPFAR’s programs provide pre- and post-school meals. Across these programs, PEPFAR’s range of support is extensive, and in Fiscal Year 2008 and beyond, we look forward to bringing even more programs to scale.

As these examples make clear, our programs focus not only on direct food support but also on sustainability. Securing the future for vulnerable individuals, of course, goes beyond the immediate provision of food assistance and requires support for sustainable livelihoods and job creation. While there has been considerable attention to food, there has been less focus on the equally important issue of livelihoods. Many programs have introduced the concept of short-term food support, with the clear expectation that it will be time-limited. The ability of these programs to truly wean people off of food aid, however, is relatively unproven and highly dependent on other income sources for these individuals. Even more important than the short-term support, then, is the long-term transition into a healthier sustainable livelihood.

Comprehensive approaches provide important models that we can build on and we believe will play an important role as we move forward. A key example is AMPATH, or the Academic Model for the Prevention and Treatment of AIDS, in Kenya, whom you will hear from today. AMPATH partners Moi University in Kenya with Indiana University and other U.S. academic institutions. Its comprehensive prevention, care, and treatment program includes a sustainable model that offers work at one of its three training farms; food from the harvest for patients who need it; and education to help people live positively. In other words, AMPATH is not only providing people with drugs, but comprehensively addressing other needs, such as for school fees, food, and income-generating activities. PEPFAR is proud to be one of many partners in this program.

Another key to true sustainability is commitment from the private sector, both in the U.S. and in developing nations, so we are working to develop models for public-private partnerships. Earlier this year we convened a meeting of U.S. Government agencies and businesses to consider opportunities for public-private partnerships, which resulted in a commitment to collaborate on food fortification, which we are now working to implement.

Despite much progress, we remain aware that significant challenges remain. Our very expansive guidance concerning support to vulnerable children and women in PMTCT programs has still not had as wide uptake in the field as we might have expected, and we are working with country teams to address the obstacles they confront at the country level.

We are also assessing the impact of programs on HIV-positive people enrolled in care and treatment programs. While our current guidance limits support to individuals with a low “body mass index” indicative of severe malnutrition, we are considering changes to the guidance to align it with WHO guidance. We now have draft guidance with these changes in review by PEPFAR implementing agencies.

Another key challenge is cost. While there is ongoing work in this area, some cost estimates put the average cost per person rehabilitated through a basic supplemental feeding at between $118 per person/year (in Kenya) and $129.60 per person/year (in Mozambique). (It should be noted that these cost estimates noted are based on a year’s worth of supplemental or therapeutic food, which is longer than general nutritional rehabilitation would normally require.). For comparison, the cost of the most commonly used three-in-one first-line antiretroviral treatment regimen -- $89 per year, which is available through the Partnership for Supply Chain Management and is the lowest price available for that product from any source.

Also relevant to the issue of costs is the issue of how a food program “graduates” a person who has regained healthy weight and nutrition, and whether this improved nutritional status is sustainable over the long term. Further evidence is needed in this area. PEPFAR programs are also confronting the question of what are the most effective delivery mechanisms for supplemental food support and whether heavy reliance on the health care system to actually deliver food supplements is the most cost efficient, feasible, and reliable approach in the context -- which many of you have seen -- of dire shortages of health care workers. We don’t yet have all the answers we need, and thus we have launched Public Health Evaluations to address these questions. As a result of the combination of issues of high cost, unpredictable duration, and limited capacity, country programs must consider the difficult trade-off between enrolling more patients into treatment and providing a comprehensive food and nutrition program for those enrolled. This is why PEPFAR stresses the importance of linking HIV/AIDS programs supported by PEPFAR funds with other programs that focus on food and nutrition.

The Institute of Medicine has described PEFPAR as a “learning organization,” and the nexus of HIV/AIDS and food and nutrition is one area where our learning, experience and ability to adapt are being applied. We are, for example, directly addressing operational challenges together with our closest partners, like USAID’s Food for Peace, where we face issues of having different priority countries, target populations, procurement practices, reporting indicators and even calendar cycles for action. To address these issues we have established HIV/AIDS/food and nutrition interagency working groups at the country level. In Haiti, Ethiopia, Mozambique and Zambia these teams are working on more cohesive programming across the sectors.

Also promising is the “HIV and Food Security Conceptual Framework” on which PEPFAR and USAID’s Office of Food for Peace and Bureau of Global Health have collaborated. This document outlines practice and policy recommendations and proposes a host of joint activities, including mapping out current Food For Peace and PEPFAR programs for improved programming and monitoring and evaluation.

We believe our focus on the central mandate of prevention, care and treatment of HIV/AIDS has been a key to PEPFAR’s success. We recognize the entire range of issues confronting the people we serve are often beyond the ability of a single public health program, even a large one like PEFPAR, to address. We will continue to deepen our partnerships with U.S. Government and international partners as we identify challenges and opportunities for better collaboration and targeting of resources to meet the needs of the people we serve in a holistic way.

Much remains to be done; the epidemic and the suffering it causes are far from over. But with the continued bipartisan support of Congress, the President, and the American people, we believe PEPFAR and its partners can do even more. We can succeed together in meeting the needs of millions of people around the world who are struggling with the combined challenges of food and nutrition and HIV/AIDS.

Thank you very much.