Testimony before the House Committee on Foreign Affairs

The charts that Ambassador Dybul presented during his testimony are available online.

Ambassador Mark Dybul, U.S. Global AIDS Coordinator
Testimony before the House Committee on Foreign Affairs
Washington, DC
April 24, 2007

Mr. Chairman, Ranking Member Ros-Lehtinen, and Members of the Committee: Thank you for this opportunity to discuss President Bush’s Emergency Plan for AIDS Relief, or PEPFAR. We are grateful for this committee’s longstanding, bipartisan support of our nation’s commitment to fight HIV/AIDS in the developing world.

When the history of global public health is written, the launch of the President’s Emergency Plan – both its size as the largest international health initiative in history dedicated to a single disease and its focus on results with ambitious goals for prevention, treatment and care – will be remembered as one of the boldest and most important actions – ever.

But PEPFAR is part of a broad and bold development agenda. Not since the Marshall Plan has the world seen such a massive commitment to international development. President Bush, with strong bipartisan support, has doubled resources for development overall and with his 2008 budget request, will have quadrupled them for Africa. And that does not include massive debt relief and a doubling of trade with Africa – fueling economic development, the ultimate engine for people to lift themselves out of poverty and despair.

In many ways, this new era is more ambitious than the Marshall Plan. Unlike the rebuilding of Europe, the American people are building life, liberty and opportunity where they have never existed in modern times.

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. In Sub-Saharan Africa, this age group accounted for only 20 percent of all AIDS deaths from 1985 to 1990, but today it accounts for nearly 60 percent.

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 care giving 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, 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, the equivalent of two-thirds of all newly trained teachers are being lost to HIV/AIDS.

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 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

HIV/AIDS has serious public health implications. An ever-expanding pool of immune-suppressed people worldwide can more readily contract and spread disease, including 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. This should be of great concern to all of us, because XDR-TB is literally untreatable and almost always fatal. In one highly publicized outbreak in South Africa, 52 out of 53 XDR-TB patients in the original report died. Of these, 44 patients had been tested for HIV, and all were positive. In this era of globalization, infectious diseases have no boundaries. Today it is XDR-TB – tomorrow it may be avian flu, or something even worse.

Security Implications of HIV/AIDS

HIV/AIDS is a threat to national and international security. It is limiting nations’ abilities to protect their own citizens and to provide peacekeepers for other conflicts, fueling national and regional instability, because it 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.

By destroying the social fabric caused and leaving a generation of orphans HIV/AIDS is creating a long term breeding ground for radicalism. General Wald, the former Deputy Commander, Headquarters U.S. European Command, has called HIV/AIDS the third greatest threat to our national security, behind only weapons of mass destruction and terrorism.

PEPFAR and the Transformational Development Agenda

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 this strategy.

The focus of PEPFAR is on prevention, treatment, and care of people living with HIV/AIDS, and I am pleased to report that we are on track to meet the President’s ambitious goals in these areas. Yet the impact of our program is not – and need not be – limited to HIV/AIDS. PEPFAR’s programs are increasingly linked to other important Presidential initiatives in other areas of health and development – the Millennium Challenge Corporation, the President’s Malaria Initiative, the African Education Initiative, the Women’s Justice and Empowerment Initiative and others. Together, they represent a renaissance in development.

Fundamentally, this new philosophy rejects the failed “donor-recipient” approach developed during the Cold War and returns to the vision of the Marshall Plan. It is a philosophy rooted in a hand-shake rather than a hand-out. It is rooted in the power of partnership between people.

Just a few years ago, the success that PEPFAR’s partnerships have achieved would have been unthinkable. It is now clear that this hope and faith was justified – that the power of partnership is “transformational,” as Secretary Rice would say.

Individuals, communities and nations are taking control of their lives and are beginning to turn the tide against the HIV/AIDS pandemic. This new model of partnership is already producing encouraging results and is, as an Institute of Medicine (IOM) committee recently noted in its review of the first two years of PEPFAR, “off to a very good start” and has “demonstrated what many doubted could be done.”

Broader Impacts of HIV/AIDS Interventions

According to the World Health Organization’s most recent report, treatment coverage in the developing world has increased by 54% in just three years, to 2.1 million people. The most dramatic expansion of treatment scale-up has been in sub-Saharan Africa, where the number of people on treatment has grown from 50,000 at the beginning of 2003, when President Bush first announced PEPFAR, to 1.3 million at the end of 2006. Mr. Chairman that is a twenty-six-fold increase in just four years.

There is no doubt that the support of the American people has been the catalyst for this transformation. The part that is sometimes missed is the broader impact of successful HIV/AIDS interventions. People who survive contribute to their society as teachers, workers, and peacekeepers. And one of the most important impacts is that every parent kept alive prevents new orphans.

We have begun work with international partners to develop models that quantify the impact of treatment and prevention in preventing orphaning of children. These are preliminary estimates at this point as we refine the methodology, but there is no doubt that the impact is very great. We estimate that PEPFAR support for treatment has averted the orphaning of 229,000 children to date, and through 2008 as we scale up to our treatment goal of 2 million, we estimate that that figure will grow to roughly 874,000.

Just as treatment of parents can prevent their children from being orphaned, so too can effective prevention. If we meet our goal of 7 million infections averted for this first phase of PEPFAR, our preliminary estimate is that up to 13.5 million children will be saved from orphaning or heightened vulnerability.

Strikingly, a recent study revealed that children who lose a parent to HIV face a three times higher risk of death than other children – and that’s true even if the child is not HIV-infected. Truly, preventing orphan hood is the best way to ensure child survival and health – just another remarkable consequence of the rapid growth of effective HIV/AIDS programs. [see chart]

For children who do become orphaned or vulnerable due to HIV/AIDS, PEPFAR includes services traditionally associated with the Child Survival and Health program. Such services include tuberculosis (TB) and malaria screening; provision of antibiotics; education; and provision of food, nutrition, shelter, protection, and psychosocial support.

Health Workforce and Systems

From its inception, the President’s Emergency Plan has been focused on meeting the emergency of today while building capacity for a sustainable response for tomorrow. When we build capacity for HIV/AIDS services, we build the overall health systems of nations for the long term.

At least one quarter of PEPFAR’s total resources are devoted to capacity-building in the public and private health sectors – supporting physical infrastructure, health care 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.

As the IOM committee noted, health workforce shortages are a severe problem in the developing world – one we take very seriously. To date, PEPFAR has supported the training or retraining of 1.7 million workers. We are working with the World Health Organization (WHO) on task-shifting, to expand the available workforce through the use of community health workers and other health professionals. Also, in 2008 we will triple our allocation for pre-service training of doctors, nurses and other health professionals.

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. Eighty-three percent of our partners are local organizations, and the successes are primarily theirs, not ours. When such organizations expand their capacity in order to meet USG fiduciary accountability requirements, they are in a better position to support them in the future.

PEPFAR’s capacity-building initiatives have positive spillover effects: Whenever a country upgrades its health systems and strengthens the health workforce it improves overall healthcare delivery. In a recent study conducted at 30 primary health centers in Rwanda, 21 of 22 measured basic (i.e., non-HIV/AIDS) health service indicators showed improvement after 6 months of offering a full package of basic HIV care. Of the 21 indicators, 17 showed a statistically significant improvement. [see chart]

As IOM committee Chairman Dr. Jaime Sepulveda said, “[O]verall, PEPFAR is contributing to make health systems stronger, not weakening them.”¹

In addition to strengthening health systems, building infrastructure, expanding health services, increasing capacity and stimulating economic growth, such improvements enable developing countries to cultivate good governance and build freer and more stable societies.

PEPFAR is a dynamic program that is continually being expanded, evaluated, and reshaped in real time. As the IOM Committee noted, “Beginning with its strategy, PEPFAR has been committed to learning, and the program has displayed many of the characteristics of a successful learning organization.” With each year, PEPFAR is expanding its knowledge base of best practices and lessons learned, sharing them globally and having an impact far beyond PEPFAR programs. In fact, long before the IOM committee report was released, we had already taken action to address the issues identified in the report – and we will continue to draw on its input to further strengthen the program.

Now let me offer a brief overview of PEPFAR’s progress toward 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.

Treatment

Through the end of fiscal year 2006, PEPFAR partnered with host nations to support antiretroviral treatment for 822,000 people in the 15 focus nations. By September 2006 in PEPFAR’s focus countries, approximately 50,000 more people were being put on life-saving treatment every month. The number of PEPFAR-supported treatment sites increased by 139 percent over 2005, with 93 new sites coming on line each month. Of those for whom PEPFAR provided site-specific treatment support, almost nine percent were children, and approximately 61 percent were women. We also supported training or retraining of approximately 52,000 people in the provision of antiretroviral treatment.

In order to deepen our understanding of the impact of treatment, we have worked with the WHO and other international partners to develop a methodology for estimating years of life added by treatment. We estimate that over 3.4 million life-years will be added by PEPFAR support for treatment as we reach our goal of 2 million people on treatment – and that’s just through Fiscal Year 2009. If we were to look beyond that timeframe, of course, the numbers would be far higher. [see chart]

PEPFAR also has increased the availability of safe, effective, low-cost generic antiretroviral drugs (ARVs) in the developing world. 43 generic ARV formulations have been approved or tentatively approved by the U.S. Department of Health and Human Services/Food and Drug Administration (HHS/FDA) under the expedited review process established in 2004, including eight fixed-dose combination formulations. Three of these are triple-drug combination tablets and ten are double combinations, of which five are co-packaged with a third drug. In addition, eight 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 continue to work with partners to utilize the safest, cheapest drugs wherever possible. As a side benefit, the process has also expedited the availability in the United States of six generic versions of ARVs whose U.S. patent protection has expired.

PEPFAR has also achieved significant progress in reducing the cost of ARVs through its Supply Chain Management System, or SCMS. We have determined that SCMS secured better purchase prices on 72 percent of first-line ARVs and 40 percent of second-line ARVs compared with other selected benchmark pricing sources and buyers. SCMS has achieved savings by purchasing generic medicines whenever possible, pooling procurement (such as consolidating multiple orders to buy in larger volumes), and establishing long-term, indefinite quantity contracts (IQCs) with manufacturers, thereby leveraging lower prices through bulk purchases. SCMS has signed IQCs with two producers of the same generic ARV, thereby bringing down prices through competition between the two and ensuring a reliable supply by having more than one supplier. During IQC negotiations, the price of the drug was reduced by 7 percent with one supplier and by 23 percent with the other. SCMS’s purchase of Didanosine 200 mg and Efavirenz 200mg, two generic drugs recently approved by HHS/FDA, resulted in cost savings of more than $46,000 (53 percent) and $116,000 (52 percent) respectively, compared with the Accelerated Access Initiative (AAI) Unit Price. From January to March 2007, SCMS saved more than $30 million (70 percent). SCMS has increased its share of ARV purchases that are generics from 72 percent in April to September 2006 to 88 percent (by volume) in January to March 2007.

Prevention

Turning to prevention, according to UNAIDS, there were approximately 4.3 million new HIV infections in 2006. There can be no doubt that prevention is the most imperative mission in the global fight against HIV/AIDS. When we prevent an infection, we keep one person alive and healthy, but we do so much more. We keep that person’s spouse from being infected, and his or her children from being orphaned. We keep that person’s community intact, and keep a worker in the workforce. Finally, we keep scarce resources from having to be directed to that person’s treatment and care. If the number of people newly infected continues to increase, the growing number of people in need of treatment and care will overwhelm the world’s ability to respond and to sustain its response.

In recent years, in a growing number of nations, we have seen 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.

PEPFAR supports the most comprehensive, evidence-based prevention program in the world, targeting interventions based on the epidemiology of HIV infection in each country. We support 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.

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 that are 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.

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. However, 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.

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. As UNAIDS Executive Director Dr. Peter Piot recently observed, the U.S. is by far the biggest supplier of condoms to the developing world, providing more than all other sources combined.

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

In addition, by promoting the routine, voluntary offer of HIV testing to women who visit antenatal clinics, host nations have increased the rate of uptake among pregnant women from low levels to around 90 percent at many sites.

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

Last month, in light of compelling evidence that medical male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 60 percent, the WHO and UNAIDS recommended that circumcision be included as part of a comprehensive HIV prevention package. Male circumcision does not provide complete protection against HIV infection, and additional research still needs to be conducted, but since WHO and UNAIDS have endorsed and provided normative guidance for it, if any host nations would like to add safe medical male circumcision to their prevention programs, PEPFAR will support their efforts.

In regard to circumcision and any other new prevention methods and technologies – such as an HIV vaccine or topical microbicide – PEPFAR will incorporate these new approaches, as the evidence is accumulated and normative guidance is provided.

Care

Through Fiscal Year 2006, PEPFAR supported care for nearly 4.5 million people, including two million orphans and vulnerable children (OVCs) . PEPFAR has scaled up HIV/AIDS programs for OVCs on a larger scale than had ever been attempted. In fiscal year 2006, PEPFAR also began requiring OVC programs to report on how many of six key services they provide – food/nutrition; shelter and care; protection; health care; psychosocial support; and education.

To date, we have counted both OVC care programs and pediatric AIDS treatment programs toward the Congressional directive that 10 percent of program funds be devoted to programs for OVCs. Beginning in Fiscal Year 2008, we plan to meet the directive with care programs alone, reflecting our deepening knowledge base of best practices for OVC care.

As noted, PEPFAR now covers many services that were traditionally part of Child Survival and Health programs. In Fiscal Year 2003, 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.

PEPFAR also has increased support for national efforts to provide high-quality care for opportunistic infections related to HIV/AIDS, especially TB. I will discuss this in more detail momentarily.

We also have developed ‘preventive care packages’ for HIV-infected children and adults, to help keep them healthy and delay the need for treatment. Care packages can be adapted to local circumstances, and we are working to disseminate them broadly.

Knowing one’s HIV status provides a gateway for critical prevention, treatment, and care. To date, PEPFAR has supported more than 18 million counseling and testing encounters – close to a third of these were with women seeking PMTCT services.

To increase the number of people being tested for HIV, PEPFAR is working with host nations to implement routine, provider-initiated “opt-out” HIV testing, in selected health care settings. We also are supported the use of rapid HIV tests to improve 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.

PEPFAR as a Foundation to “Connect the Dots” of Development

PEPFAR’s prevention, treatment and care results, as important as they are, are only part of the story. At this point, I would like to highlight some specific areas in which PEPFAR is “connecting the dots” of development, leveraging HIV/AIDS investments to achieve a broader, transformational impact.

Fighting Tuberculosis

Since TB is the number one killer of HIV-infected people, it has always been an integral part of PEPFAR and will continue to be an area of increasingly high priority. Before PEPFAR, total U.S. support for bilateral TB and TB/HIV initiatives was approximately $79 million. In fiscal year 2006, PEPFAR’s support for TB/HIV initiatives increased by 104 percent over 2005, supporting care for 301,600 co-infected people in the focus countries. In fiscal year 2007, we anticipate at least $120 million for TB/HIV in the focus countries – combined with approximately $91 million for bilateral TB programs, which is nearly three times the funding for TB just four years ago.

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 TB. We are working with international partners such as the Global Fund and WHO, 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 PMTCT initiatives, 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;
• Joint funding of 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

Although addressing the broad issue of food insecurity is beyond the scope of PEPFAR, we do support limited food assistance for specific, highly vulnerable populations. 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. In collaboration with interagency partners, we are engaging on food and nutrition issues with six focus countries in a pilot program. 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 treatment, and care givers. In Haiti, PEPFAR and Food for Peace have begun 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

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 PEPFAR’s coordination 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 becoming infected with HIV/AIDS.

Addressing Gender Inequities

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 priority on gender. Our program is the only major international initiative to require data reporting by gender. We do so to track whether girls and women are receiving the services they need, and we know that girls comprise 51% of the more than 2 million orphans and vulnerable children receiving PEPFAR-supported care.

The authorizing legislation for PEPFAR specifies that we will support five high-priority gender strategies:

• Increasing gender equity in HIV/AIDS activities and services;
• Reducing violence and coercion;
• Addressing male norms and behaviors;
• Increasing women’s legal protection; and
• Increasing women’s access to income and productive resources.

These five strategies are monitored annually during the Country Operational Plan (COP) review process. In fiscal year 2006, a total of $442 million supported more than 830 interventions that included one or more of these gender strategies, including $104 million for activities specifically addressing gender-based violence and sexual coercion.

In addition, last year we convened some 120 experts and stakeholders to discuss the latest findings on gender and HIV/AIDS, and to clarify programming priorities. Two months later, PEPFAR allocated an initial $8 million in central funding to launch new, gender-specific initiatives in the high-priority areas that had been identified. Beginning in fiscal year 2007, an increased number of programs will seek to change male norms, respond to gender-based violence, and address adolescent vulnerability.

Supporting Technology to Expand Health Workforce and Systems

I have noted PEPFAR’s commitment to health workforce and systems development. We are using technology to do more than build health information systems and foster two-way communication with our partners. We recently announced the $10 million public-private partnership, Phones For Health. It 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 phone 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.

Supporting Systems for Accountability

In order to ensure quality and sustainability of its programs, the Emergency Plan is committed to the strategic collection and use of information for program accountability and improvement. 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.

Supporting countries as they develop accurate and sustainable reporting systems is not about creating bureaucratic paperwork. It is about enabling these developing nations to construct a solid framework for a more equitable and transparent society. As one young Namibian told me: “PEPFAR is actually building democracy through its accountability systems focused on country ownership and good governance.” In this and other ways, PEPFAR is serving as a fulcrum for international development. Entire regions of the world that had been devastated by HIV/AIDS are regaining hope and building a foundation for freedom and opportunity – in much the same way the Marshall Plan enabled Europe to revive after the devastation of World War II.

Consistent with the model of accountability, PEPFAR strives to be transparent and forthcoming. We communicate regularly with the American people, through our Annual Report to Congress and the www.PEPFAR.gov website, where users can find everything from individual Country Reports to our program’s legislative guidance. We also keep in touch with our program implementers, through a private “Extranet” website, which 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, the ways in which we leverage U.S. 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 on which we intend to focus include supporting micro-enterprise initiatives and addressing neglected tropical diseases.

HIV/AIDS does not exist in a vacuum. It is inextricably tied to other threats to public health, and it has ramifications for a wide range of development-related issues. Thus, PEPFAR’s efforts to “connect the dots” of international development are integral to the larger picture of U.S. foreign affairs. As IOM committee chairman Dr. Sepulveda noted, “The PEPFAR initiative should be seen not only as an important investment in the lives of many individuals and their families, but also as an investment in global security. This is a good example of the kind of health diplomacy needed on a global scale.”

Today, the Emergency Plan 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.

In addition, 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 set 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.

PEPFAR’s 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.

As the IOM committee report observed, PEPFAR and its partners have successfully demonstrated that HIV/AIDS programs can be implemented, even in under-resourced settings. Millions of people are receiving life-saving care in many of the world’s most challenging settings. Hope is being restored through the power of partnerships.

The people of severely affected nations have accomplished so much in their fight against HIV/AIDS, and the American people are privileged to partner with them through PEPFAR. Yet, the HIV/AIDS pandemic remains an emergency, and so any challenges still lie ahead. We are on a long journey. The American people must continue to stand with our global sisters and brothers as they take control of the pandemic and restore hope to individuals, families, communities and nations.

Mr. Chairman, once again, I am deeply grateful for our strong partnership with this Committee. I believe PEPFAR is a truly historic initiative, and one in which every American can take pride. With that, let me turn to your questions.