September 29, 2010
Chairman Berman, Ranking Member Ros-Lehtinen and members of the Committee: thank you for this opportunity to discuss the President’s Emergency Plan for AIDS Relief (PEPFAR) with you. I appreciate not only the attention you are bringing to global AIDS today, but your enduring focus on this issue. All Americans can be proud of the strong support global health efforts have received from Members from both sides of the aisle.
I am pleased to be here today with my friend and colleague, Dr. Tom Frieden. The Centers for Disease Control and Prevention (CDC) and the U.S. Agency for International Development (USAID) are the two largest PEPFAR implementing agencies. The populations we serve benefit immensely from these agencies, and our other implementing agencies such as the Department of Defense and Peace Corps, contributing their distinctive strengths to a unified, interagency effort.
I’m also pleased that Dr. Tony Fauci is with us today. Under his leadership, the National Institute of Allergy and Infectious Diseases (NIAID) of the National Institutes of Health (NIH) continues to build our understanding of this virus, and potential approaches to reversing its spread. NIH is a critical partner in the PEPFAR effort, and we rely heavily on the research that NIH supports.
I’m honored to serve with Dr. Frieden and Dr. Rajiv Shah, Administrator of USAID, as the Operations Committee for President Obama’s Global Health Initiative, or GHI. GHI is a signature initiative of the President and a concrete manifestation of the new approach to international development he announced last week at the United Nations High-Level Plenary on the Millennium Development Goals.
A key principle of the GHI focuses on strengthening health systems to save lives and achieve sustainable outcomes. It builds on the remarkable success of efforts to date with an operational model designed to integrate health programs for greater efficiency, evaluate new and innovative approaches, and make better use of taxpayer funding. It also leverages efforts of multilateral partners, other donors, and partner countries by working within a common national framework, which will allow us to better identify gaps where the U.S. should focus its contribution to achieve broader impact.
We’ve seen unprecedented progress through past health investments, and we can build on this success through an integrated and holistic approach that binds individual health programs together in a coordinated, sustainable way, with the countries themselves in the lead.
GHI builds on the deep experience of PEPFAR and other health programs, and PEPFAR is the cornerstone and largest component of GHI. I deeply appreciate the commitment of my colleagues and their agencies to our collaborative, interagency effort, in PEPFAR and GHI more broadly.
The reason we’re here today is because of the significant progress that has been made on global health over the past decade. Congress, with this Committee in a central role, and the Bush Administration responded to the crisis of HIV/AIDS by creating, and then reauthorizing, PEPFAR. This program has continued and expanded with the strong support of President Barack Obama and Secretary of State Hillary Rodham Clinton.
I am grateful for this Committee’s partnership in this effort, and am honored to have the responsibility to lead it today. In my 15 months as Global AIDS Coordinator, I have been privileged to make 16 visits to our partner countries, to see the impact of our work and meet the people who are carrying it out. I have also participated in three Global Fund Board meetings and two meetings of the UNAIDS Programme Coordinating Board. These activities, and many more, are in furtherance of our shared vision of HIV/AIDS programs that save lives effectively today and are sustainable for the long haul.
A foundation of success
Let me offer some perspective on how this investment has worked, and how far we’ve come. As a clinician, I’ve been working on HIV/AIDS issues both domestically and internationally for almost 30 years. A decade ago, those of us engaged in HIV work in sub-Saharan Africa were witnesses to daily tragedies on a huge scale. Hospitals were not just full of people dying of AIDS, they were overflowing with multiple patients to a bed, spilling out onto the floors and in the hallways – any place where they could rest while waiting for some care.
While antiretroviral treatment had become widely available here in the United States, fewer than 50,000 people in all of sub-Saharan Africa were receiving it at the beginning of 2003. Even to those of us who had been responding to HIV/AIDS for decades, the scope and inequity of this emergency were overwhelming. Many people thought treatment could never be scaled up because of weak health systems, the need for doctors and nurses, and the lack of resources in these countries.
Today, with American leadership, the task few thought was possible is well under way. Through Fiscal Year 2009, we directly supported almost 2.5 million individuals on treatment, the vast majority in Africa. And millions more are benefiting from prevention and care programs. In FY 2009 alone, PEPFAR supported HIV counseling and testing for nearly 29 million people, providing a critical entry point to prevention, treatment, and care. The program also supported care for nearly 11 million people affected by HIV/AIDS, including 3.6 million orphans and vulnerable children, through FY 2009. And it supported essential prevention of mother-to-child transmission services to millions of women, allowing nearly 100,000 babies of HIV-positive mothers to be born HIV-free in FY 2009 alone.
Of course, those results are as of 364 days ago -- tomorrow marks the end of another fiscal year. In the coming weeks, our country programs will be doing the hard work of reviewing and reporting the progress they made during FY 2010. Based on the remarkable efforts of our country teams and partners, we believe these latest results will show continued impressive progress. We look forward to sharing them with you as soon as they are ready.
There is much more work yet to be done, and a large, continuing unmet need. But when I visit African countries now, I see the dramatic transformation PEPFAR has brought about – not only for individuals, but for their families, communities, and nations. This change is not just reflected in hospitals and clinics, which are no longer overwhelmed by people dying of AIDS. It’s reflected in the day-to-day lives of people in so many ways, large and small.
Mr. Chairman and Ranking Member Ros-Lehtinen, this work is about saving lives, by meeting our shared, global responsibility to make smart investments. In our conversation today, I hope that we can maintain a focus on the human impact of this effort. It is always a challenge to make it real for people when those we serve are so far away, but we must do so, because the reality is truly inspiring.
It is the human impact of this effort to date that tells us much more is possible as we move forward. It is a strong foundation upon which we are building the next phase of PEPFAR, and a new phase of global health assistance.
My testimony today is far from an exhaustive catalogue of our efforts, and there is much more that can be said on all of these topics. I look forward to our conversation.
Areas of recent action
From my perspective, in this second phase of PEPFAR, we are realizing the vision and building on the remarkably successful foundation of its first phase. In the past year, we have released a Five-Year Strategy, outlining how we plan to do that in the next phase of PEPFAR.
We have also contributed to the rollout and implementation of GHI, and started to advance policies and programs that not only expand service delivery, but create the long-term partnerships needed for a sustainable program.
I’d like to highlight two broad categories of steps we have taken.
Saving lives through wise investments. The metric that PEPFAR and all GHI programs use to measure success is not dollars spent, but lives saved. In order to save as many lives as possible, we have focused on making smart investments that maximize the human impact of each dollar. PEPFAR has made encouraging progress in ensuring that investments are evidence-based, and in pursuing innovation to create efficiency gains in our programs.
In 15 countries, we have mapped our prevention programs, allowing us to evaluate our investments and adjust them based on the data. We have led the world in rapidly scaling up high-impact biomedical interventions for prevention such as male circumcision and prevention-of-mother-to-child transmission – in FY 2009 alone, PEPFAR programs averted nearly 100,000 infant infections. We’ve worked to ensure that activities target populations where new infections are concentrated, including marginalized populations such as injecting drug users, men who have sex with men, and people engaged in sex work.
PEPFAR has also increased expenditure reporting and cost-modeling efforts to identify significant reductions in treatment costs and identify how the program can expand service delivery through reinvestment of these savings. Building on this, we are developing a PEPFAR impact and efficiency acceleration strategy, and fostering a culture of explicit value consideration and efficiency at all levels of our operations.
New clinical data have made it clear that treatment has a clear prevention effect, by sharply reducing the infectivity of people on antiretroviral drugs (ARVs). Multiple mathematical models demonstrate that continued expansion of the treatment response could begin to have a substantial impact on the incidence of new infections. So it is more important than ever that our prevention, treatment and care programs be integrally linked. The choice between treatment and prevention is a false one.
Responding to feedback from our country teams, PEPFAR has moved to a two-year planning cycle, which will reduce the paperwork burden and allow the field to increase support for service delivery. We have also launched an effort to streamline our budget execution processes so the money moves as quickly as possible – from the appropriated account to the implementing agency headquarters, and then to the field, and finally to partners to be expended. I have made it a high priority to clear balances and reduce pipelines, and we are making significant progress.
Reflecting the GHI principle of support for research and innovation, another priority is operations research, which helps us quickly determine what is working and disseminate it widely. We are working intensively to identify innovations and best practices so that all of us can do more with each available dollar – and ultimately save more lives. In the difficult economic climate we face, this is an absolute obligation.
Building the long-term response by strengthening engagement with the Global Fund and other multilateral partners. A major theme of the Obama Administration’s new approach to health and development has been the shared responsibility of the U.S., partner countries, and other donors to ensure that we can build a sustained program that will result in more lives saved. Last year, the U.S. provided nearly 60 percent of donor government funding for HIV/AIDS. In many countries, our contribution to the total response is even higher.
The global need for HIV/AIDS prevention, treatment and care is a global responsibility, and all have roles to play in meeting it. Under the GHI principle of working through partnerships, the U.S. will remain strong in its commitment and seek to leverage heightened commitments from all sources -- including partner governments, donor nations, the private sector, civil society, philanthropic organizations, and others.
Building on the core strength of the State Department, we are also raising the profile of development in our diplomatic engagement with strategic allies, further engaging the global community in our shared responsibility.
A particularly important mechanism for this increased global commitment is the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund). The U.S. strongly supports the Fund’s collaborative, country-driven, performance-based approach to fighting HIV/AIDS, TB, and malaria.
Since the Global Fund was created, the U.S. has been its largest donor, providing more than $5.1 billion to date. We also provide key on-the-ground support for grant implementation through bilateral technical assistance, capacity-building, and procurement support. Such support has proven crucial to ensuring grants deliver on their potential. Given the size of the Global Fund grant portfolio and the global unmet need, it is essential that Fund resources are used as effectively and efficiently as possible.
We have also worked to expand collaboration with UNAIDS and the United Nations family, including UNICEF and the World Health Organization, around a common theme of shared, global responsibility and action to reverse the course of this epidemic.
Simply put, our bilateral programs and our multilateral engagement share a common purpose: saving lives, both now and into the future, through wise investments.
Plans for moving forward
As we continue implementation of PEPFAR’s Five-Year Strategy and the broader GHI, let me highlight three areas that reflect GHI principles and are among our top priorities going forward.
Leveraging the foundation established by PEPFAR programs in order to save more lives through the Global Health Initiative. During its first phase, PEPFAR focused on delivery of health care services and meeting ambitious goals for prevention, care, and treatment. Its success has largely been built on the ability to meet those goals. As PEPFAR now moves from an emergency to a sustainable response as part of the President’s GHI, make no mistake: we will maintain and support expansion of these core prevention, care, and treatment services that are at the heart of the program.
Part of the President’s GHI commitment included specific, ambitious PEPFAR goals: direct support of treatment for at least 4 million people, prevention of at least 12 million new infections, and care for at least 12 million people, including at least 5 million orphans and vulnerable children.
Despite these clear commitments, in some quarters, there has been a perception that GHI will diffuse the focus of PEPFAR and limit our ability to deliver on our core work. I want to address this head on. I firmly believe the approach the GHI implements is critical to the future success of PEPFAR.
As I have mentioned, I have been working with people living with, or at high risk of, HIV for my entire career. These people are not defined by the virus alone. Like everyone else, they have a range of health needs. That’s why integration of programs is a core GHI principle, and the GHI will make it easier for us, working with the partner country and other partners, to holistically address that range of needs. We’ll align our U.S. programs so they address people the same way our field staff have always seen them -- not just as a person with HIV, but as a person, period.
The reach and impact of PEPFAR are enormous, with programs in over 80 countries. In the 30 countries where we are most heavily invested, there are many other U.S. government health initiatives that span the majority of the population. Building additional services onto the PEPFAR platform – such as maternal and child health, tuberculosis, and nutrition support – not only expands the ability to provide care without building additional infrastructure, but also helps to create a basic package of health care services.
So on a concrete level, GHI means leveraging the systems we have built to ensure that a person with HIV has access to other U.S. programs that will improve his or her health outcome.
At the same time, PEPFAR is also eager to reach the clients of other U.S.-supported programs – such as maternal and child health (MCH) – with HIV interventions. For example, women who come to antenatal clinics in areas with high HIV burden are an ideal population for programs to prevent of mother-to-child transmission (PMTCT) of HIV to target.
So integrating MCH and PMTCT programs probably sounds like a no-brainer. But if it were already happening everywhere we wouldn’t be having this conversation. Integration under GHI offers us the possibility of increasing our impact on health, and making each dollar we spend go farther. And as we integrate programs like PMTCT and MCH and increase our effectiveness and efficiency, we’ll also seek through GHI to target additional investments to these high-impact activities.
Dr. Shah, Dr. Frieden and I all recognize that the mission is not program integration for integration’s sake, but smart integration to improve and save lives, focusing on the areas where we can add value by collaborating. So those opportunities are what we are working to identify, in all countries with U.S. global health programs and especially in eight initial “GHI Plus” countries. For people living with or affected by HIV, I am confident that this effort will achieve our ultimate goal of saving lives.
Addressing the impact of broader gender issues with HIV programming. The President’s GHI recognizes that focusing on women, girls, and gender equality is a force multiplier: it improves the health status of women, and in turn that of their families and communities.
For PEPFAR, this focus is essential. AIDS is the leading cause of death of women of reproductive age worldwide, and nearly 60% of those living with HIV in sub-Saharan Africa are women. In the countries where PEPFAR works, HIV is a women’s health issue, and prevention, care and treatment services must be tailored to the gender realities within a country.
During its first phase, PEPFAR began a five-point gender strategy, through which we seeded country programs with multiple small initiatives. To build on this important foundation, in the next phase we are working to improve implementation of our gender strategy, and scale up efforts and heighten impact with a focus on PMTCT and country-led gender projects.
One risk factor for HIV infection for women is the tragic epidemic of gender-based violence. Earlier this year we launched an initiative to invest $30 million in activities to combat gender-based violence in three countries severely burdened by it. We’re supporting post-exposure prophylaxis and other care for women victimized by rape, but also seeking to prevent sexual violence in the first place.
And last week, we joined with Ambassador Melanne Verveer to partner with the Together for Girls public-private partnership. This is a groundbreaking effort to address the epidemic of violence against girls, and we are pleased to be partnering with CDC, members of the United Nations family and the private sector to help end this global scourge.
Innovation to provide women with prevention interventions they can control is a critical priority. With PEPFAR funding in 2007-2010, USAID supported two trials with specific antiviral agents and unique delivery regimens which might increase user acceptability and compliance as well as product effectiveness.
In July 2010, the landmark results of the CAPRISA trial of 1% Tenofovir Vaginal Gel were announced, providing the first-ever proof of concept that a microbicide can significantly reduce the risk of HIV infection in women. Volunteers using it had an overall reduction in HIV infection of 39%, and in volunteers who were most compliant in using the gel, the reduction was even higher, at 54%. With continued U.S. technical and financial leadership, this breakthrough in development of a woman-controlled method of HIV prevention has the potential to reduce the spread of HIV and empower women to protect their health and lives.
The U.S. is supporting further research on -- and appropriate preparations for the future introduction, distribution, and use of -- these new technologies in developing countries. Country teams are already addressing the multiple social, cultural, economic, and political factors that will influence the acceptance and use of these new products at the individual and community levels.
All of these efforts support the GHI principle of implementing a woman- and girl-centered approach to health. In the HIV context, these are smart investments that will save lives.
Expanding country ownership and local capacity to build sustainable health care delivery systems. As we responded to the HIV emergency in the first phase of PEPFAR, we tended to work through international implementing partners with existing capacity, in order to save as many lives as possible. While successful, this had the by-product of establishing or strengthening systems of care and delivery parallel to country public health systems, which are typically weak.
Reflecting the GHI principle of support for country ownership, a major priority of PEPFAR’s second phase is to increase the capacity of countries at both the government and civil society level, so that countries are better able to manage, oversee, and operate their health systems – and increasingly to finance them, based on their available resources.
We are approaching countries in a spirit of true partnership to identify, prioritize and meet health needs. PEPFAR’s support for country ownership is demonstrated through Partnership Frameworks, 15 of which have been signed to date. These are five-year, high-level agreements between the U.S. and partner governments that leverage our investments to obtain measurable financial, programmatic, and policy commitments to HIV and health systems.
Through Partnership Frameworks, we are demonstrating by our actions that we see governments as partners, rather than recipients or obstacles. An important recent Partnership Framework is the one we have entered into with Nigeria, which includes the first public affirmation by that country’s government that they expect to self-fund 50 percent of the response to HIV by the end of the 5-year implementation period.
In addition, the U.S. has worked with specific governments, including the Government of South Africa, to establish responses that leverage initial U.S. investments for long-term increases in commitment and capacity by the partner government.
Another example of country ownership in action is the transition of treatment programs in 13 countries to the leadership of government structures and indigenous organizations. This transition is challenging but critical to ensure that these programs are deeply embedded in the national response and can be sustained for the long term.
Let me offer a template for thinking about the evolution of PEPFAR that may be helpful. During the initial, emergency phase of the program, we relied heavily on international NGOs, because they had the capacity to save lives quickly. In this second phase we have added to that activity a focus on sustainability and country ownership, which includes building the commitment and capacity of governments. As we move forward with that task, we will increasingly emphasize a third dimension of activity -- community empowerment. As we pursue the GHI principle of support for health systems for sustainability, it is local community and civil society organizations that can play the critical role of ensuring accountability for country structures in a way that outsiders never can. PEPFAR planners at the country level and at headquarters want to empower communities – including those directly affected by programs, such as people living with HIV – to have the ability to provide that feedback to government ministries, Global Fund Country Coordinating Mechanisms, and other country structures. That dialogue is essential for true sustainability.
In conclusion, I believe we are at a key moment in the global response to this disease.
In the last two months, there were two major international events at which HIV/AIDS played a significant part – the International AIDS Society meeting in Vienna, and the U.N. Millennium Development Goals Summit in New York.
While all acknowledge that there are significant challenges before us, both events provided many reasons to be hopeful. In Vienna we learned about the CAPRISA success and heard encouraging reports about the potential for innovation and increased efficiency to help us do much more to save lives. In New York, we heard from President Obama, the U.N. Secretary General and many others the continued strong commitment to meet the Goals – including the three health-related goals, in which effective HIV/AIDS responses play a central role.
Mr. Chairman and Ranking Member Ros-Lehtinen, under the President’s approach to health and development, I believe we are well-positioned for major strides forward in the fight against HIV/AIDS. As always, I remain grateful for your strong support.
Thank you. I look forward to your questions.
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