June 9, 2009
Mr. Chairman, Ranking Member Lugar, Members of the Committee:
It is a privilege to be here with you today as President Obama�s nominee to serve as the United States Global AIDS Coordinator and to lead the implementation of the President�s Emergency Plan for AIDS Relief (PEPFAR). I am honored to be considered for this position, and deeply appreciative of the President and Secretary Clinton�s support for my nomination.
Let me take a moment to express my gratitude for the partnership developed between PEPFAR and the Senate Foreign Relations Committee over the last few years. The Committee�s bipartisan support for PEPFAR has been a key to its success, and, if confirmed, I look forward to continuing to work with you during this second phase of the initiative.
I would like to recognize the efforts of the many dedicated career staff, in the field and at headquarters, across the U.S. government, who have worked to make PEPFAR a success. I would also like to voice my deep appreciation to President Bush and the members of his Administration for creating PEPFAR and providing tangible and consistent resources that have permanently changed the landscape of global HIV and saved so many lives.
PEPFAR is the largest international health initiative in history dedicated to a specific disease. In the first five years of the program, the American people supported antiretroviral treatment for more than 2.1 million men, women, and children living with HIV/AIDS around the world; care for over 10.1 million people; and prevention of mother-to-child HIV transmission during nearly 16 million pregnancies. PEPFAR supported nearly 57 million HIV counseling and testing encounters. And PEPFAR has supported a strategic prevention portfolio which has included interventions promoting abstinence, delayed onset of sexual activity, being faithful in sexual relationships, and correct and consistent use of condoms. Providing prevention messages in hundreds of millions of encounters, in culturally appropriate ways, PEPFAR has and continues to play an important role in the global prevention effort. PEPFAR has also been a leader in the introduction of new technology, thus improving our ability to diagnose infant infections, treat cervical cancer and implement voluntary male circumcision programs for prevention.
PEPFAR has demonstrated unprecedented commitment to mobilizing leadership and building the capacity of local institutions to in the fight against AIDS. The program has also worked to build linkages with other donors and multilateral organizations, including the Global Fund to Fight AIDS, Tuberculosis and Malaria. As you are aware, the U.S. is the first and largest donor to the Global Fund. The strong partnership between the Fund and our bilateral programs in the field has been mutually beneficial.
But the impact of this program goes far beyond the millions of lives it has saved through prevention and treatment interventions � the program has become a potent symbol of American goodwill and concern for regions of the globe burdened by disease and poverty. Investing in health care is a critical component of smart power, because better health leads to improved safety, security, and prosperity for countries. Our efforts to fight the global AIDS epidemic reflect America�s leadership as a positive force for progress and, if confirmed, I look forward to leading this important diplomatic initiative.
I am currently CEO and Chief Medical Officer of the Pangaea Global AIDS Foundation, a position I have held since 2001. Prior to my time with Pangaea, I served as the Deputy Director of the White House National AIDS Policy Office and Director of the Office of HIV/AIDS Policy of the Department of Health and Human Services. I also worked as the first director of the Ryan White CARE Act at the Health Resources and Services Administration, overseeing establishment of this program that delivers care and treatment to people living with HIV in the United States.
In addition to experience in government, policy-making, and establishing and implementing HIV/AIDS strategies and programs, I am a physician. In that capacity, I have been actively practicing HIV and infectious diseases medicine since the earliest days of the HIV epidemic. My base of clinical practice has been treating clients with HIV at San Francisco General Hospital and later at DC General. I have practiced through the transition from years where death was a daily event, to times of hope � and then certainty � that death need not be the inevitable result of contracting HIV. I have served clients with complex social and medical problems and wholly support the idea that it takes a community to make treatment and prevention work.
I know firsthand about the good PEPFAR has done because my colleagues and I at Pangaea have worked extensively in countries across Africa, Asia, and Eastern Europe both before and after the inception of PEPFAR. We have witnessed the profound, life-saving impact that the program has had for the people in sub-Saharan Africa, who have been so devastated by the disease. My more than 20 years of domestic HIV work equipped me with experience, but did not fully prepare me for what I would see and experience first-hand abroad. When I first visited the countries in Africa so devastated by AIDS over 10 years ago, I felt like I had been transported back in time to America before the advent of antiretroviral drugs, before hope, and when AIDS meant certain death. The hospitals in Kwa-Zulu Natal, South Africa, were overflowing with people dying of HIV. The doctors and nurses could do nothing to stop it. I recall my incredible frustration standing in hospital wards in Rwanda and in South Africa knowing that these deaths were, indeed, preventable. I knew then that we had to find a way to bring treatment to the people in the many countries burdened with HIV and work to find strategies that would be effective in reducing HIV incidence, and dedicated myself to doing what I could do personally to make that happen in a sustainable fashion.
I have been fortunate enough to work firsthand with partners across Africa during my time with Pangaea, and have engaged in projects that have created sustainable, tangible results. In Uganda, Pangaea partnered with academia and the private sector to help create one of the leading regional HIV/AIDS training, research and infectious diseases clinics on the continent, the Infectious Diseases Institute (IDI). The IDI provides high quality treatment for HIV/AIDS patients while simultaneously using the clinic as a platform for training physicians, nurses and other health care workers, conducting research, and developing models of integrated HIV/AIDS prevention and care that are widely applicable throughout Africa. After managing the capital construction of the IDI, the design of the Institute�s treatment, prevention, training and lab programs and launch of one of the first public ART programs on the continent, ownership of the IDI was transferred to Makerere University in 2005. Today, it serves as a model of health systems strengthening and quality service delivery directed under complete local ownership and expertise.
Pangaea helped to create some of the first HIV/AIDS treatment clinics in Rwanda and South Africa. Confronted with high rates of HIV infection and limited systems to provide treatment, Pangaea helped to assist the national ministries of health in the development of comprehensive national treatment and prevention plans for HIV/AIDS.
More recently, with PEPFAR support, Pangaea has been privileged to partner with Muhumbili University in Tanzania on an initiative focused on developing a concept called The Youth Health Corps (YHC) for Integrated Prevention, Care and Treatment. The Youth Health Corps model is designed to strengthen grassroots health facilities in rural parts of the country by training a new generation of health care workers who can expand and improve delivery of services to relatively isolated communities. Youth at-risk for HIV with an interest in health care are recruited into a formal, Ministry of Health-approved training program which prepares them to work alongside clinical officers and nurses in their own communities. Youth will be mentored and eventually hired into the public health care system and provided with opportunities for advanced training to higher levels of health care work. The YHC model is innovative in that it seeks to protect vulnerable youth through economic and career opportunities while bolstering the human resources sector in health in the short term and cultivating new groups of doctors and nurses to be trained for the long term.
In addition to its long-standing interest and commitment to the continent of Africa, Pangaea is committed to regions and countries whose epidemics are growing but where opportunity still exists to get in front of the epidemic and prevent uncontrolled surges in HIV transmission. Our organization has worked in areas like Eastern Europe, Asia and South East Asia, where the epidemic is concentrated among specific populations, including injecting drug users and men-who-have-sex-with-men (MSM). Concentrated epidemics are best confronted by targeted prevention efforts that reduce the risk of further spread. While these countries do not have the breadth of the epidemics we see elsewhere, through targeted technical assistance, they present a real opportunity to avoid the catastrophic consequences seen in southern Africa.
PEPFAR�s accomplishments over the last five years can only be characterized as enormous. There are now many effective treatment centers like the IDI in Kampala, Uganda spread out over the African continent and beyond as a direct result of PEPFAR. Aggressive prevention programs have reduced HIV transmission and spoken directly to the needs of those most vulnerable � children, women, MSM and drug users. What you now see in the hospitals, clinics, and communities are people with hope. But, while much has been done, there is still even more ground to cover before the global community can collectively conclude the fight against HIV/AIDS.
Last year, your committee�s leadership was essential in securing passage of the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008. This legislation recognized the successes of PEPFAR and challenged the program to meet new targets and goals. I believe we can and must achieve these goals, but will do so only through collective action, strong collaboration and strategic positioning of our efforts with the rest of the global community including the Global Fund. PEPFAR investments must be transformed into sustainable programs, while at the same time be scaled up to reach millions both at risk for HIV and in need of care and treatment.
The context of each country�s HIV epidemic is different. However, areas of commonality in our response should include focusing on the marginalized, enabling health professionals and community providers, working to support and improve indigenous public health systems, and enhancing the use of monitoring and evaluation to improve programs and their impact. If confirmed, my approach would include building strong relationships with government, working within existing health structures and strategies, mentoring capable health care provider teams and engaging community-based peer educators to reach out to and meet the needs of women, MSM and drug users.
Looking forward, I believe four major themes should guide our work: intensifying the focus on HIV prevention; pursuing strong country partnerships, country ownership and coordinated multilateral engagement; supporting health systems strengthening through programs and country-driven planning; and taking effective interventions to scale to achieve population-level health outcomes.
Prevention is an essential component of PEPFAR and an increasingly critical priority. While treatment is incredibly important, treatment will not end the pandemic. In the absence of an HIV vaccine or cure, without effective prevention, the world will continue to face an ever-growing number of people requiring treatment, and inevitably, more death.
PEPFAR supports a range of prevention interventions, ranging from prevention of mother-to-child transmission, safe blood and medical injection, reducing the risks for injecting drug users, HIV counseling and testing, abstinence, partner limitation, and condom promotion, to biomedical interventions such as male circumcision. Globally, sexual transmission remains the primary driver of the epidemic, thus, prevention in this area is essential. Sero-discordant couples, socio-cultural practices, gender inequities, including economic dependency and violence against women, as well as discrimination and stigma directed toward vulnerable populations (for example, MSM, sex workers, or infected individuals) present significant challenges to effective prevention. The scientific and implementing communities continue to work tirelessly to identify evidence-based, effective and cost-effective behavioral, structural and biomedical interventions.
PEPFAR has shown strong leadership in promoting combination prevention � using multiple prevention interventions simultaneously to achieve broad population coverage and impact that is based on country-level epidemiological data, and local social and cultural factors. I strongly support the critical role of prevention and finding sustainable strategies that give careful consideration to real life � transient jobs, forced mobility, lack of economic opportunity, and the barrier of stigma in all its manifestations. In addition, I will support combination prevention, with a special emphasis on women and girls to address gender inequities, economic dependency, gender-based violence, lack of educational opportunity and access and linkages to broader health care. Finally, combination prevention presents an ideal opportunity to focus on prevention with positives; integrating care with prevention strategies for infected individuals, their partners, families, and contacts. Prevention has many success stories worldwide, but the continued need for rigorous evaluation of new prevention strategies remains paramount.
STRONG PARTNERSHIPS and COUNTRY OWNERSHIP
The most effective and durable response to HIV and other diseases is one tailored to the specific situation in each country. Host country governments carry the long term responsibility of responding to their respective epidemics, prioritizing the unmet need and coordinating all in-country and donor resources. Long�term, durable and sustainable interventions are those which are integrated into each country�s overall health planning and grounded in local capacity. PEPFAR is working with host country governments to develop Partnership Frameworks � five-year joint strategic frameworks designed to fully align PEPFAR HIV/AIDS assistance with national strategies. These frameworks will advance transparency and accountability, and leverage the investments and efforts of other donors, and international partners. They also provide a very strong opportunity to further strengthen our collaboration with the Global Fund. Partnership Frameworks are an important strategy in streamlining efforts and looking for efficiencies in designing the national response and will provide an essential opportunity to hold countries and partners accountable for their contributions and results. Working within these collaborative frameworks with the country, and with an agreed-upon definition of each country�s service constellation, will also allow for a strong multilateral donor approach to provide technical and financial assistance where most needed and avoid duplication or isolated program development.
HEALTH SYSTEMS STRENGTHENING
By using HIV treatment as a platform, PEPFAR support has strengthened and extended health systems in many areas including human resources, infrastructure, informatics, commodities logistics, and laboratory services. Although interventions supported through PEPFAR are for HIV/AIDS treatment and prevention, the systems established and expanded over the past five years have resulted in positive health outcomes extending well beyond HIV/AIDS. However, the existing systems are often sorely strained and in many countries, fragile. Continued and intensified investment in strengthening health care systems, including the health workforce, will be crucial to scaling up proven interventions and adding to sustainability of PEPFAR and other health and development programs.
In reauthorizing PEPFAR, Congress recognized that strengthening health systems is critical to achieving both PEPFAR�s goals and broader, long-term development goals. The legislation cites lack of health capacity as an important constraint on the transition toward greater sustainability of HIV/AIDS prevention, treatment and care efforts and broader public health initiatives � a reality faced each day by those who are implementing programs. Building health systems to adequately respond to HIV/AIDS means systems that can better respond to other health issues, and can become a focal point for the convergence of other development activities focused on broader health concerns, including women and children�s health, economic stability, gender equality and education. I firmly support the position that health is a critical factor in stabilizing families and communities.
Looking to the future, PEPFAR will work with host countries to develop a framework for strategic assessments and identification of priorities for health system strengthening. Country responses to critical shortages of health professionals are likely to require a multifaceted approach involving training, models for better use of mid-level providers and trained community health workforce, and policies supporting recruitment and retention of skilled workers. While recognizing that a disease-specific initiative cannot alone repair or build entire health systems, careful planning has already begun to define an appropriate scope of engagement, allowing for scaling of quality prevention and treatment interventions with an approach that is financially feasible for local governments to support and sustain. Health systems strengthening is a key factor in successfully improving health outcomes overall. If confirmed, I would like to ensure that PEPFAR plays a central role in the U.S. Government�s significant contribution to this global health effort.
TAKING EFFECTIVE INTERVENTIONS TO SCALE
The achievements of the PEPFAR program in scaling up access and delivery of treatment and prevention services have been remarkable, demonstrating that life-saving treatment can be provided in low-resource settings. PEPFAR programs have been innovative, tailored to local need and demonstrating significant achievements and outcomes. Innovation and new programming needs continue as we seek to find multiple ways to prevent HIV infection and establish improved treatment protocols and monitoring that extend the life of antiretroviral therapy and reduce viral resistance. Of equal importance is identifying effective interventions from the lab, clinical trials, and the field and taking these interventions to scale, reaching far greater portions of at-risk and infected populations with quality, effective service delivery. Basing decisions on concrete outcomes � medical, social and behavioral � has and will continue to uncover solutions to the challenges encountered on a daily basis by those delivering services or researching new interventions.
One area within prevention where we can improve positive health outcomes is prevention for pregnant women and their infants. Globally, over 90 percent of HIV infections among children occur through mother-to-child transmission. Children now constitute 14 percent of new global HIV infections and 14 percent of HIV/AIDS-related deaths annually. Through scientific studies and clinical trials we know unequivocally how to prevent mother-to-child HIV transmission. Yet in spite of this knowledge and best efforts, less than 40 percent of HIV-infected women receive antiretroviral drugs during pregnancy. Transferring knowledge to practice and doing so at scale is the challenge. Identifying the impediments to change and uptake, and finding practical solutions to these problems can and must be achieved in the coming years. We must ensure that women have access to health education and medication and that HIV positive children access quality treatment, but of equal importance, we must prevent HIV infection in the first place.
In closing, as I look back on my experiences over the past 25 years as I have worked with patients from San Francisco to South Africa, I am struck with the commonality of the human experience. I am sobered by the limited responses left to those dealing with the realities of HIV infection and the devastating impact of the disease on individuals, families and societies. To prevent the loss of so many people and so much unrealized potential continues to be the core of my motivation.
PEPFAR has introduced hope where there was none, and allowed those impacted by HIV to continue to live, to work and to support themselves and their families. I am continually inspired by their hope in the face of what seem like insurmountable obstacles. Hope brings people forward for testing because they see help on the other side of a positive HIV test. Hope brings people who know they are HIV positive into a clinic. Hope reduces stigma and improves the chance for success � success in both treatment and prevention.
The history of PEPFAR has demonstrated what can happen when we dare to think big. My mission, if confirmed, will be to ensure that PEPFAR continues to be a visionary program, a program that continues to exceed our expectations of what can and should be provided to people in resource-limited settings. PEPFAR has been an effective catalyst for change and the world is looking to us to continue our leadership � working closely with our global partners, we can help reclaim the lives of millions of people who will otherwise be lost to the infection. Thank you, and I look forward to your questions.
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