Remarks to Committee to Evaluate the President's Emergency Plan for AIDS Relief

Thank you very much for the invitation to join you today to discuss President Bush’s Emergency Plan for AIDS Relief. This Committee is performing a great service by exploring Emergency Plan implementation, and I know that it entails a tremendous commitment of time on the part of each of you. But your service offers the opportunity to save lives around the world, and I hope that each of you will take great satisfaction in that. Thank you for your contribution to our efforts. I look forward to receiving your report.

At the most basic level, hope is what we bring when we confront HIV/AIDS. Hope is needed on the ground overseas -- and here in America and other donor nations as well. If people don’t see any hope of defeating this killer, our work will be at risk.

It is thus essential to be able to point to real progress. It’s one thing to urge people to have hope, but it is something quite different to demonstrate that there is a basis for hope. The good news is that, increasingly, we are in a position to do that.

In the time since funds were first appropriated in January 2004, the Emergency Plan has worked throughout the world, with a special focus on 15 severely burdened nations. We believe that dramatic success in these nations, many of them among the world’s poorest, will enable us to demonstrate to the entire world what intensive leadership and commitment of resources can do in this fight.

I am pleased to report that the U.S. has begun to make real progress. As our recent Annual Report to Congress makes clear, the Emergency Plan is on track to meet the ambitious 5-year prevention, care, and treatment goals the President set for it. Let me take a moment to highlight some of the early results.

We are committed to care for those infected and affected by HIV/AIDS. We have scaled up our programs under national strategies for orphans and vulnerable children, and for palliative care for HIV-positive people.

In the early months of implementation, the U.S. supported care for more than 1.7 million people infected and affected by HIV/AIDS, including over 630,000 orphans and vulnerable children. Speak for the Child, a community-based program in Kenya, offers an example of the activity the U.S. is supporting for children. The program focuses on young children, who are especially vulnerable to disease, malnutrition, and psychosocial harm when their families are affected by AIDS. With dramatically increased support thanks to the Emergency Plan, Speak for the Child was able to expand from serving 400 children in March 2004 to 3,300 by the end of September. When people see that those who are infected with HIV, or who lose parents to AIDS, are well cared for, that too brings hope. There’s so much more to do, but it is a promising start.

As you know, the Emergency Plan also seeks to make drug treatment available in the developing world on a scale never before attempted. To put our initial results in perspective, in December 2002, one month before President Bush announced the Emergency Plan, an estimated 50,000 people were receiving antiretroviral therapy in all of sub-Saharan Africa.

In its first eight months, the Emergency Plan worked under national strategies in the 15 focus countries to support treatment for nearly 155,000 HIV-infected adults and children. And that data is as of September 30^th. The number is now certainly much higher, as we have continued to scale up treatment programs.

I think it’s fair to say that there was a lot of doubt about whether treatment could successfully be delivered in resource-poor settings on a large scale. But the answer is becoming very clear that, if we work with our host nations and invest in system-wide improvements, indeed we can do it. Success today is the best foundation for hope for the future.

I’d also like to note that 56% of persons newly receiving treatment were women, among the sites reporting such numbers. We are the first major donor to require that our partners report the gender of those they serve, to ensure that our prevention, treatment and care services are fully available to women. This is very important, because the burden of this disease is increasingly falling on women and young girls.

Prevention is another area in which we consider it essential to work in support of national strategies. Our approach is based very specifically on what works for the culture and circumstances of each place we are working, with the individuals and groups we are targeting. Our prevention strategies are informed by the experiences of a number of countries around the world that have achieved successes in HIV/AIDS prevention. Implementation on the ground is being developed in consultation with the people and governments of our host nations.

I’m pleased to report that the Emergency Plan reached over 120 million people with targeted prevention messages through media and community-based interventions during the program’s initial eight months. One example of targeted outreach is the Emergency Plan’s initiative to reach out to men and boys, helping them keep themselves and their loved ones safe from HIV. In South Africa, a U.S.-supported workshop offered lifesaving prevention information, getting men involved in fighting HIV/AIDS.

Our prevention activities also address medical transmission of HIV through blood transfusions and medical injections. We are supporting host country efforts to improve the quality of their blood supplies by supporting needed policies, infrastructure, commodity procurement, and management capacity. We are also supporting national strategies to reduce unnecessary injections and make injections safer. In our first eight months, we supported training of 2,200 individuals in blood safety and 4,300 in injection safety, as well as providing support for 250 programs focused on blood safety.

Another key prevention strategy involves preventing transmission of HIV from mothers to children. Last year, we were able to reach 1.2 million women with services to prevent the infection of newborns and infants. Once again, that number is as of six months ago, so the figure is much higher today. In Guyana, for example, Emergency Plan support helped a clinic reach more than 25% of all pregnant women in the nation, offering testing and, as needed, antiretroviral prophylaxis.

I believe that a key to this initial success has been our commitment to work with our host nations, supporting their national strategies and responses. This approach has been the heart of the President’s Emergency Plan all along, and many examples of it may be found in the Annual Report. I am convinced that it deserves much of the credit for the results we have been able to achieve in its early days.

Moving forward, I believe that our success in meeting the implementation challenges we face will also depend on making our partnerships with our host nations even stronger. Among the greatest challenges we have faced, and will continue to face for the indefinite future, is that of helping our host nations build the capacity to respond to their HIV/AIDS emergencies.

In so many of the nations where we are working, the capacity to deliver health care is severely limited by a history of poverty and neglect, war and political instability. Our ability to put resources to work in a nation is constrained by its health care infrastructure and supply of trained health workers. Of course, these same constraints also cripple many nations’ ability to deal with other pressing health issues such as polio, malaria, and tuberculosis. The benefits of improved health capacity, therefore, will go well beyond HIV/AIDS.

This is why we have invested so much effort in expanding that capacity in nations hard-hit by HIV/AIDS. The initial success we have been able to achieve gives us confidence that we can put steadily increasing resources to effective use.

Of course, our capacity-building work is not primarily about making it possible for the United States to do more in the future. Rather, the Emergency Plan is building local and host-nation capacity so that national programs can achieve results, monitor and evaluate their activities, and sustain their responses for the long term. So for me, the challenge of capacity is completely entwined with the challenge of sustainability. We are addressing them, and we must do more.

Without local capacity, nations cannot fully "own" the fight they must lead against HIV/AIDS. I am pleased to note that we are seeing these hard-hit nations take ownership of their own responses.

Here’s one way we are seeking to facilitate that development: fully 80% of our more than 1,200 partners working on the ground were indigenous organizations including faith- and community-based partners. That hasn’t been easy to do, but we are committed to bringing even more indigenous partners into the Emergency Plan.

Let me highlight some of our initial strides in helping host nations develop their capacity to respond. These are discussed at length in our recent Report to Congress.

Health infrastructure is a major challenge. In the early days of the Emergency Plan, the U.S. has had success in promoting the expansion of existing health care networks and the development of new public and private network systems to enhance the delivery of HIV/AIDS services in remote areas.

For those networks to be effective, they require trained personnel. Responding to the critical shortage of trained health workers at all levels, the Emergency Plan has supported training that covers a broad range of services, from prevention -- including mother-to-child prevention -- to antiretroviral treatment, to palliative care, to counseling and testing, to orphan care. The American people, through the Emergency Plan, are helping people in our host nations develop the skills to meet their neighbors’ needs.

The Emergency Plan has also fostered indigenous leadership in the fight against the HIV/AIDS pandemic. The U.S. has provided technical assistance for appropriate policy development, including policies protecting women and girls, and for strengthening local institutions and organizations, including organizations of persons living with HIV/AIDS.

Other components of local capacity on which we have focused include surveillance, reporting, evaluation, and strategic information. These tools allow us to maintain the accountability that is a cornerstone of the Emergency Plan, and to adjust our programming based on what works. Even more importantly, these tools allow host nations to monitor and adjust their national responses.

Our host nations have warmly welcomed our commitment to partnership with them, and our support for their national responses. At this early stage, U.S. support is still needed -- in fact, it is indispensable. Our support is essential to allowing host nations that have recently been able to begin antiretroviral therapy on a broad scale to maintain and expand that work. We can help to ensure that the gains we have made are not allowed to slip away, but are built upon.

Let me emphasize this once again, however: while I believe we are on the right track, in terms of our focus on capacity-building and sustainability, we have a long way yet to go. Issues this fundamental cannot be resolved in a few months, or a few years. They will require a continued, concentrated focus over many years. We plan to maintain that focus. Another area where I believe we have made a good start, but which will remain very important, is international cooperation among donors.

When I addressed the Bangkok conference last summer, I emphasized the need for the world to come together, in order to provide "Access for All." Three months ago, I was pleased to join the leaders of UNAIDS, the World Health Organization, and the Global Fund in Davos, Switzerland at the Annual Meeting of the World Economic Forum. Each of us presented what the organizations we lead have been able to contribute toward that goal.

This announcement culminated months of cooperative work by the staff in our respective organizations. From my perspective, coming together there symbolized our commitment to work side by side to bring hope to those most in need.

Of course, what really matters is not what those of us at headquarters do -- it’s what happens on the ground in host nations. Last April, the Emergency Plan collaborated with UNAIDS, the World Bank, and the U.K. to adopt key principles for coordinated country-driven action against AIDS. These principles became known as the "Three Ones" -- One national plan, One national coordinating authority, and One national monitoring and evaluation system in each of the host countries in which we work.

All major stakeholders and donors have endorsed these principles and committed themselves to their country-level implementation, and it is happening. As part of our Emergency Plan implementation efforts, for example, U.S. missions in our focus countries now include progress reports on coordination efforts in all country operational plans.

In February, I visited Haiti and was pleased to see the depth of coordination under the Three Ones. The Emergency Plan and the Global Fund have both made a commitment to support antiretroviral treatment there, and we are collaborating successfully. I believe you’ll hear more on this from Dr. Pape.

The most important message of the Three Ones, to me, is this: it’s not really about us! The U.S. and other donors have roles to play, but we have all now acknowledged the point I made earlier: this fight must be owned by the nations facing the crisis themselves. The Three Ones represents our promise to developing nations that we will work within their national plan, under their coordinating authority, using their monitoring and evaluation systems. We certainly want to help them to improve their systems where that assistance is needed, but they must own them.

It’s true that working within national strategies may mean doing things in ways that aren’t necessarily as convenient for us, the donors, and that may complicate our task of monitoring and evaluation. It would certainly simplify our task if we just went into countries, built brand new clinics from the ground up, staffed them with Americans, enrolled people, and then provided them with all the prevention, care, and treatment they ever needed. Another donor could do the same thing right across the street, I suppose -- as long as they didn’t try to poach any of our patients!

It turns out that most countries don’t prefer to have that kind of help. They don’t want donors to set up "stovepipe" systems; they want us to be helpful to them, meeting identified needs in their strategies where we have capabilities. So the Emergency Plan is going to have a very different face in Vietnam than in Botswana. The onus is on donors to be flexible, and the Three Ones is our agreement to be flexible.

Let me make this more concrete by discussing it in the context of treatment. Antiretroviral drugs are actually a small component of treatment -- usually accounting for only one-third to one-quarter of its cost.

What is the rest of that cost? Quality treatment includes trained clinical and laboratory personnel and counselors for adherence, prevention and healthy living. It includes physical infrastructure, such as laboratory equipment, distribution, logistics and management systems for drugs and other commodities. It means medical treatment for opportunistic infections and other basic care. And, finally, it means the drugs themselves.

It may make sense under a country’s national strategy on treatment, for example, that one donor focuses on drug procurement, distribution, logistics, and management, while another donor focuses on training personnel and providing clinical and laboratory support.

On prevention, to give another example, one donor may have a comparative advantage on school programs for youth, while another has strengths in working with persons who engage in high-risk activity. This division of tasks can take place either in a specific program or at the national level.

Clearly, many of the people being served are going to receive support from multiple donors. Some people might refer to that as "overlap," but I think "collaboration" is a better term. If it makes sense under the national strategy, then it’s a good thing.

The Global Fund is among the organizations with which we collaborate – and it is also a vehicle through which we offer leadership in the worldwide response to HIV/AIDS, augmenting our own bilateral programs. The Fund’s success is crucial to the success of the Emergency Plan, so its challenges are our challenges in a very real way.

One of those challenges is the reluctance of other donors to support the Fund adequately. The United States has been by far the Fund’s largest donor, contributing approximately 33% of its funds to date -- the limit under U.S. law, and which Dr. Feachem and most observers consider quite generous. Other governments and private entities, unfortunately, have been markedly less supportive of the Fund’s work than we have.

Later today I will fly to Geneva for a board meeting of the Global Fund. I will be assuming the U.S. seat that Secretary Tommy Thompson is vacating. I have worked with Dr. Feachem to try to get other donors to step up, and I will continue to do so this week, and I will seek other opportunities to do so. The current situation simply must change if the world is going to turn the tide on HIV/AIDS.

Because the issues we face are so challenging, it’s essential that the leadership structures we set up, beginning with my office, be well suited to the task. The United States is bringing unparalleled human resources, including many years of valuable experience, to this initiative. It would be disastrous if we were to pursue a bureaucratic model that fails to utilize those resources to the utmost.

I have thus instituted a number of structures to ensure that we work together as a unified team, both in Washington and in the field. At OGAC headquarters, I chair a weekly policy team of principals from the lead implementing agencies, and there is also a weekly meeting of deputy principals to manage specifics related to implementation. There are also interagency technical working groups in key program and operations areas.

I seek to make the Emergency Plan as "field-driven" as possible, relying on the strengths of our extraordinary American personnel in the field. In each focus country, the U.S. Ambassador leads an interagency HIV/AIDS team that includes all the implementing departments and agencies in-country. These teams have been rapidly organized, and are helping to ensure a unified U.S. strategy and voice in working with host governments and other partners.

Constant communication between the field and headquarters is also a priority. An interagency Core Team, with a coordinator in OGAC, serves as a liaison, facilitating a two-way flow of information and assistance. In addition, next month the second annual Emergency Plan implementation meeting will take place in Addis Ababa, Ethiopia, furnishing further opportunities to reflect on which structures have worked well and which ones need adjustment. Continuous improvement of our management structures is essential, and I will continue to make it a high priority for me personally.

Another issue we are focusing on is that many focus countries lack adequate systems and resources to operate a safe, secure and reliable supply chain management system. Such a system is important for procurement of pharmaceutical and other products needed to provide care and treatment of people with HIV/AIDS and related infections.

A new contract is being competed that will provide countries with an enhanced ability to receive key technical assistance on all aspects of the supply chain process. This 3-year contract, with options for additional segments, will be used initially by U.S. Government country teams in the 15 focus countries and will eventually be available for use around the world and by Global Fund recipients. While not mandatory, we expect that U.S. Government teams and national programs will find the dependability and economy of scale costs of this system very attractive.

I hope that my comments have been able to convey a sense of where we are, and of what we see on the horizon. This global emergency remains a uniquely daunting one. Yet I believe that we have made a good start in these initial 15 months of our response, and that we are beginning to offer hope to those who have been without it. Once again, thank you for your service. I’d be pleased to address any questions you may have.