SPEAKERS CONTENTS INSERTS
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72–978PS
2001
THE UNITED STATES' WAR ON AIDS
HEARING
BEFORE THE
COMMITTEE ON
INTERNATIONAL RELATIONS
HOUSE OF REPRESENTATIVES
ONE HUNDRED SEVENTH CONGRESS
FIRST SESSION
JUNE 7, 2001
Serial No. 107–17
Printed for the use of the Committee on International Relations
Available via the World Wide Web: http://www.house.gov/international—relations
For sale by the Superintendent of Documents, U.S. Government Printing Office
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Internet: bookstore.gpo.gov Phone: (202) 512–1800 Fax: (202) 512–2250
Mail: Stop SSOP, Washington, DC 20402–0001
COMMITTEE ON INTERNATIONAL RELATIONS
HENRY J. HYDE, Illinois, Chairman
BENJAMIN A. GILMAN, New York
JAMES A. LEACH, Iowa
DOUG BEREUTER, Nebraska
CHRISTOPHER H. SMITH, New Jersey
DAN BURTON, Indiana
ELTON GALLEGLY, California
ILEANA ROS-LEHTINEN, Florida
CASS BALLENGER, North Carolina
DANA ROHRABACHER, California
EDWARD R. ROYCE, California
PETER T. KING, New York
STEVE CHABOT, Ohio
AMO HOUGHTON, New York
JOHN M. McHUGH, New York
RICHARD BURR, North Carolina
JOHN COOKSEY, Louisiana
THOMAS G. TANCREDO, Colorado
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RON PAUL, Texas
NICK SMITH, Michigan
JOSEPH R. PITTS, Pennsylvania
DARRELL E. ISSA, California
ERIC CANTOR, Virginia
JEFF FLAKE, Arizona
BRIAN D. KERNS, Indiana
JO ANN DAVIS, Virginia
TOM LANTOS, California
HOWARD L. BERMAN, California
GARY L. ACKERMAN, New York
ENI F.H. FALEOMAVAEGA, American Samoa
DONALD M. PAYNE, New Jersey
ROBERT MENENDEZ, New Jersey
SHERROD BROWN, Ohio
CYNTHIA A. McKINNEY, Georgia
ALCEE L. HASTINGS, Florida
EARL F. HILLIARD, Alabama
BRAD SHERMAN, California
ROBERT WEXLER, Florida
JIM DAVIS, Florida
ELIOT L. ENGEL, New York
WILLIAM D. DELAHUNT, Massachusetts
GREGORY W. MEEKS, New York
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BARBARA LEE, California
JOSEPH CROWLEY, New York
JOSEPH M. HOEFFEL, Pennsylvania
EARL BLUMENAUER, Oregon
SHELLEY BERKLEY, Nevada
GRACE NAPOLITANO, California
ADAM B. SCHIFF, California
THOMAS E. MOONEY, SR., Staff Director/General Counsel
ROBERT R. KING, Democratic Staff Director
ADOLFO FRANCO, Counsel
LIBERTY DUNN, Staff Associate
C O N T E N T S
WITNESSES
The Honorable Andrew Natsios, Administrator, U.S. Agency for International Development
His Excellency Mamadou Mansour Seck, Ambassador E&P, Republic of Senegal
Stephen Hayes, President, Corporate Council on Africa
Rupert Scofield, Executive Director, Foundation for International Community Assistance
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Charles Dokmo, President and CEO, Opportunity International
Dr. Paul Zeitz, Co-Director, Global AIDS Alliance
LETTERS, STATEMENTS, ETC., SUBMITTED FOR THE HEARING
The Honorable Henry J. Hyde, a Representative in Congress from the State of Illinois, and Chairman, Committee on International Relations: Prepared statement
The Honorable Andrew Natsios: Prepared statement
His Excellency Mamadou Mansour Seck: Prepared statement
Stephen Hayes: Prepared statement
Rupert Scofield: Prepared statement
Charles Dokmo: Prepared statement
Dr. Paul Zeitz: Prepared statement
APPENDIX
The Honorable Andrew Natsios: Supplemental Statement
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The Honorable Barbara Lee, a Representative in Congress from the State of California: Prepared statement
THE UNITED STATES' WAR ON AIDS
THURSDAY, JUNE 7, 2001
House of Representatives,
Committee on International Relations,
Washington, DC.
The Committee met, pursuant to call, at 11:10 a.m. in Room 2127, Rayburn House Office Building, Hon. Henry J. Hyde (Chairman of the Committee) presiding.
Chairman HYDE. The Committee will come to order.
While the modern world has made great progress in medicine over recent decades, there is one horrific new killer that is stalking the globe, and particularly an entire, defenseless continent, Africa. Many of us believed that such a horrible epidemic, which cuts down people in the prime of their lives, was a thing of the past, but we now know that despite all of the wonderful medical progress of the 20th century, new killers can emerge.
The statistics speak for themselves. Twenty-two million people have died of AIDS worldwide, including more than 3 million last year. That is over 8,000 per day—or nearly six deaths every minute.
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Tragically, the number is growing. By the year 2010, 80 million persons could be dead of AIDS. That is more deaths than all the military and civilian forces suffered during World War II. For someone who lived through that horrific period in war, this is a mind boggling statistic.
In Africa, where 70 percent of the AIDS cases are, the virus has been particularly devastating. Let me recite just a few of the alarming statistics. I am sure that our witnesses today will expand on the devastation and the challenges confronting the African continent and the rest of the developing world.
Life expectancy has been reduced by nearly half in many countries of Sub-Saharan Africa, including Botswana, Swaziland, and South Africa. The death of parents with HIV/AIDS will result in 40 million orphans this decade alone. In some southern Africa countries, 20 percent or more of the adult population is infected with HIV. The HIV infection rate has reached 35 percent in Botswana. In Swaziland, the statistic is estimated to be nearly the same.
National economies are being devastated, as trained personnel in key sectors die, these include teachers, health care personnel, and law enforcement personnel.
To date, eastern and southern Africa have been far more affected than west Africa, but infection rates in West Africa are climbing. The infection rate exceeds 10 percent in the Ivory Coast, and is increasing in Nigeria. An estimated 600,000 African children became infected with the AIDS virus each year through mother-to-child transmission, either at birth or through breast feeding. These children have a short life expectancy, and the number of HIV-infected children in the region is currently estimated at 1 million.
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Sub-Saharan Africa is the only region in the world where HIV/AIDS infection rates for women exceed the AIDS virus infection rate for men.
The United States Government has already made major contributions to the fight against the AIDS virus. Currently, the United States is contributing 300 million through the Agency for International Development to fight the scourge of HIV/AIDS in the developing world. The Center for Disease Control, Department of Labor, and Department of Defense have all also brought their expertise to bear on the pandemic. Government funding is helping to create a powerful coalition of Government, foundations, United Nations organizations, pharmaceutical companies, academic institutions, and scientific institutions to combat the HIV/AIDS pandemic.
The focus of our government's bilateral efforts are, of course, channeled through the Agency for International Development. To that end, this Committee will consider legislation to authorize AID funding for Fiscal Year 2002 at the highest level to date, $469 million in prevention and health infrastructure, and $50 million for a pilot treatment program for those who already suffer from HIV/AIDS.
Our first priority for Agency for International Development programs is prevention through education. Until medical research produces an effective vaccine, prevention through changes in behavior will remain the best and only truly effective means of overcoming the AIDS threat.
At the same time, recent initiatives by the pharmaceutical companies point the way toward less expensive medication aimed at treating those with AIDS. With sufficient resources, it is now possible to improve treatment options—provided that the health systems are able to deliver and monitor the medications. That is why we are eager to authorize funding for a pilot treatment program, including the purchase of medicines to help the poorest of the poor.
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I am confident that in administering these programs, USAID will continue to rely on the fine work performed by community-based organizations, both religious and secular, to ensure the success of delivering not just medicine, but the health infrastructure to service endangered populations. Again, delivery systems and health infrastructures are absolutely essential if individuals are to benefit from the medications, as provided for by our bill.
This Committee will consider the authorization of microenterprise development and other similar programs that help HIV-infected individuals and their families cope with this challenge. I have also advocated the promotion of foster care-type programs in Africa as a way to help families and children suffer so much from the loss of parents who have succumbed to this deadly disease.
Lastly, the Committee will also consider an authorization of appropriations for the President to contribute to multilateral assistance efforts as mechanisms and appropriate levels are determined by the Administration in conjunction with governments of other developed countries, the United Nations, and private foundations engaged in the battle to stem the tide of the AIDS pandemic.
I wish to thank the many organizations that have assisted us in drafting this legislation to authorize bilateral HIV/AIDS programs. I am especially grateful to the President for his leadership and for elevating to the White House National Office on AIDS Policy International programs designed to combat the spread of the deadly virus.
I am appreciative of the contributions of Opportunities International, the Foundation for International Community Assistance, and the Log Cabin Republicans in promoting awareness on the growing threat of the HIV/AIDS pandemic.
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In closing, I want to reiterate what I think is a consensus in Congress. Simply stated, the AIDS virus is one of the great moral challenges of our era for it is a scourge of unparalleled proportions in modern times. Every citizen has a stake in what tragically could be the black plague of the 21st century.
Accordingly, we should do all we can to meet this test by reaching out now to those most in need—it is the right thing to do for our children, our country, and our world. Let us not fail the challenge.
I am pleased to recognize the Ranking Democratic Member on the Committee, the gentleman from California, Mr. Lantos.
[The prepared statement of Mr. Hyde follows:]
PREPARED STATEMENT OF THE HONORABLE HENRY J. HYDE, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF ILLINOIS, AND CHAIRMAN, COMMITTEE ON INTERNATIONAL RELATIONS
While the modern world has made great progress in medicine over recent decades, there is one horrific new killer that is stalking the globe, and particularly an entire, defenseless continent, Africa. Many of us believed that such a horrible epidemic, which cuts down people in the prime of their lives, was a thing of the past, but we now know that despite all the wonderful medical progress of the 20th century, new killers can emerge.
The statistics speak for themselves. Twenty-two million people have died of AIDS worldwide, including more than 3 million last year. That is over 8,000 per day—or nearly 6 deaths every minute. Tragically, the number is growing. By the year 2010, 80 million persons could be dead of AIDS. That is more deaths than all military and civilian forces suffered during World War II. For someone who lived through that horrific period and war, this is a mind boggling statistic. In Africa, where seventy percent of the AIDS cases are, the virus has been particularly devastating. Let me recite just a few of the alarming statistics. I am sure that our witnesses today will expand on the devastation and the challenges confronting the African continent and the rest of the developing world.
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Life expectancy has been reduced by nearly half in many countries of sub-Saharan Africa, including Botswana, Swaziland, and South Africa. The deaths of parents with HIV/AIDS will result in 40 million orphans this decade alone. In some southern African countries, 20 percent or more of the adult population is infected with HIV. The HIV infection rate has reached 35 percent in Botswana. In Swaziland, the statistic is estimated to be nearly the same.
National economies are being devastated, as trained personnel in key sectors die; these include teachers, health care personnel, and law enforcement personnel.
To date, eastern and southern Africa have been far more affected than West Africa, but infection rates in West Africa are also climbing. The infection rate exceeds 10% in the Ivory Coast, and is increasing in Nigeria.
An estimated 600,000 African children become infected with the AIDS virus each year through mother-to-child transmission, either at birth or through breast-feeding. These children have a short life expectancy, and the number of HIV-infected children in the region is currently estimated at 1 million.
Sub-Saharan Africa is the only region in the world where HIV/AIDS infection rates for women exceed the AIDS virus infection rate for men.
The United States Government has already made major contributions to the fight against the AIDS virus. Currently, the United States is contributing $300 million through the Agency for International Development to fight the scourge of HIV/AIDS in the developing world. The Center for Disease Control, Department of Labor, and Department of Defense have also all brought their expertise to bear on the pandemic. Government funding is helping to create a powerful coalition of Government, foundations, United Nations organizations, pharmaceutical companies, academic institutions, and scientific institutions to combat the HIV/AIDS pandemic.
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The focus of our government's bilateral efforts are, of course, channeled through the Agency for International Development. To that end, this Committee will consider legislation to authorize AID funding for FY 2002 at the highest level to date, $469 million in prevention and health infrastructure, and $50 million for a pilot treatment program for those who already suffer from HIVAIDS.
Our first priority for Agency for International Development programs is prevention through education. Until medical research produces an effective vaccine, prevention through changes in behavior will remain the best and only truly effective means of overcoming the AIDS threat.
At the same time, recent initiatives by the pharmaceutical companies point the way toward less expensive medication aimed at treating those with AIDS. With sufficient resources, it is now possible to improve treatment options—provided that the health systems are able to deliver and monitor the medications. That is why we are eager to authorize funding for a pilot treatment program, including the purchase of medicines to help the poorest of the poor.
I am confident that in administering these programs, USAID will continue to rely on the fine work performed by community-based organizations, both religious and secular, to ensure the success of delivering not just medicine, but the health infrastructure to service endangered populations. Again, delivery systems and health infrastructures are absolutely essential if individuals are to benefit from the medications, as provided for by our bill.
The Committee will also consider the authorization of microenterprise development and other similar programs that help HIV-infected individuals and their families to cope with this challenge. I have also advocated the promotion of foster care-type programs in Africa as a way to help families and children who suffer so much from the loss of parents who have succumbed to this deadly disease.
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Lastly, the Committee will also consider an authorization of appropriations for the President to contribute to multilateral assistance efforts as mechanisms and appropriate levels are determined by the Administration in conjunction with governments of other developed countries, the United Nations, and private foundations engaged in the battle to stem the tide of the AIDS pandemic.
I wish to thank the many organizations that have assisted us in drafting legislation to authorize bilateral HIV/AIDS programs. I am especially grateful to the President for his leadership and for elevating to the White House National Office on AIDS Policy international programs designed to combat the spread of the deadly virus. I am appreciative of the contributions of Opportunities International, the Foundation for International Community Assistance, and Log Cabin Republicans in promoting awareness on the growing threat of the HIV/AIDS pandemic.
In closing, I want to reiterate what I think is a consensus in Congress. Simply stated, the AIDS virus is one of the great moral challenges of our era for it is a scourge of unparrelled proportions in modern times. Every citizen has a stake in what tragically could be the black plague of the 21st century. Accordingly, we should do all we can to meet this test by reaching out now to those most in need—it is the right thing to do for our children, our country, and our world. Let us not fail the challenge.
Mr. LANTOS. Thank you very much, Mr. Chairman. Let me first commend you for your eloquent and powerful statement, for holding this hearing and for the leadership you are providing.
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Let me also state at the outset how deeply disappointed I am that the Administration, as I understand it, pulled out its witness in the last minute for reasons that I do not know and perhaps we will learn later, but I think it would have been singularly appropriate for the Administration to have its coordinator here.
Mr. Chairman, this week marks the 20th anniversary when the HIV/AIDS virus first was identified. In 1991, the World Health Organization projected around 18 million cases worldwide by the year 2000. In fact, there are over 36 million cases, double the earlier prediction.
The tragedy of HIV/AIDS is reflected most harshly in the lives of the young and the poor around the globe. Today, a 15-year-old boy in Botswana has a 90 percent chance of dying from AIDS or an AIDS-related disease. This last week, 12-year-old Nkosi Johnson, South Africa's youngest AIDS activist, died having lived his whole short life with this disease.
I am very pleased that today the House International Relations Committee is holding a hearing on the global HIV/AIDS crisis. Without a doubt, this pandemic may threaten the very survival of entire nations in the third world.
Often we begin these meetings by reciting statistics, but the numbers in this instance are truly staggering and awe inspiring:
There are 36 million people living with HIV/AIDS globally.
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Last year, there were over 5 million new HIV infections, 2.2 million women and 600,000 children under the age of 15.
Last year, 3 million people died, including half a million people.
Since the beginning of the epidemic, 22 million people lost their lives.
As we all know, the continent of Africa has borne the brunt of this disease, so far accounting for some 75 percent of those living with and dying of AIDS. Southeast Asia is just beginning to manifest as the next epicenter of this tragic disease. No continent or country is spared.
While HIV/AIDS knows no national, religious, ethnic or economic boundaries, the fact remains that globally this disease is linked directly to poverty. Those most vulnerable are likely to be poor, female and of color.
As Secretary Powell said recently in Nairobi, Kenya, this is more than a health issue, this is a social issue, this is a political issue, this is an economic issue, this is an issue of poverty.
As this epidemic has swept from continent to continent, an international consensus has emerged. No one country can deal with the HIV/AIDS crisis by itself. A bold new multilateral initiative with a long-term view toward preventing, treating, monitoring and eventually curing this disease is required. Nothing less will do.
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Mr. Chairman, I personally want to commend you on the HIV/AIDS legislation you have introduced this week. Your willingness to bring forth this legislation clearly states the sincerity and the intent of yourself and of this Congress to fight this epidemic. Surely the policy framework that you propose steers our government efforts in the right direction and I look forward to working with you over the coming weeks to strengthening your bill and it is my hope that we can have a strong bipartisan initiative that will help guide the rest of the world, particularly the wealthiest nations, toward shouldering our responsibilities collectively for the sake of human kind.
At the African summit on HIV/AIDS held in Abuja, Nigeria this past April, my good dear friend Kofi Annan called on the world to rally together and create a global fund to combat this disease and related opportunistic infectious diseases.
Mr. Annan estimated an annual cost of $7 to $10 billion. According to UNAIDS, currently one-tenth of that is being spent to combat this disease.
Kofi Annan appealed to governments, foundations and the private sector to join together and make the global fund a reality and, as you will recall, Mr. Chairman, when we had breakfast with Mr. Annan a couple of weeks ago, I offered to do my best to assist in raising in the private sector the funds that might make his dream a reality.
Mr. Chairman, this is where the United States' role as the world leader in the battle against HIV/AIDS must begin. I want to commend the Administration for the attention it is beginning to give to the global HIV/AIDS crisis. The Administration has decided to retain the critical Office on AIDS policy in the White House. The Administration announced a $200 million initial contribution to a global trust fund and it has requested $369 million for U.S. aid for 2002 and I want to commend you, Mr. Chairman, for going above the Administration figures.
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Secretary of State Powell's recent comments in Africa offering hope directly to the poorer victims of this disease have been very helpful in signaling our willingness to step up and lead the fight against this dreaded disease.
I regret to conclude, however, that our financial commitment to fight HIV/AIDS globally does not reflect the leadership the United States should be exercising among the nations of the world. With the number one priority of the Administration in the field of tax cuts skewed to the wealthy, at a time when every hour of the day some poor woman somewhere is stricken, and some poor child is orphaned, we ought to be able to do better than what the Administration is proposing.
While our total annual financial commitment to fighting AIDS globally may sound good in terms of raw numbers to some, it is a paltry sum in terms of our wealth and what we can truly afford to fight this disease.
I believe the United States should commit itself more aggressively to at least doubling our bilateral assistance and making a major contribution to the global HIV/AIDS trust fund.
Mr. Chairman, I hope during this Congress we will move boldly in this direction and I pledge my efforts to achieve our goals.
Thank you, Mr. Chairman.
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Chairman HYDE. The gentleman from New York, Mr. Gilman.
Mr. GILMAN. Thank you, Mr. Chairman.
Mr. Chairman, I want to commend you for holding this important timely hearing. It is heartening that we have made some progress, though we have much more to accomplish, in fighting the AIDS virus in the United States and throughout the world. And now thanks to the efforts of the Agency for International Development, the Center for Disease Control, the Department of Labor, the Defense Department and the private sector, hopefully, we will begin to make similar progress in the fight against AIDS in other lands.
To this end, I strongly support our Committee's intention to authorize AID funding for fiscal year 2002 to the highest level to date, $469 million in prevention and health infrastructure, and an additional $50 million for a pilot treatment program for those who already have the HIV virus.
I understand that even though you have increased some of the funding, that is about as much as could be absorbed at the present time and we are hoping that we can work together to find other means.
A Central Intelligence Agency National Intelligence Estimate report on the infectious disease threat made public in the unclassified version in the year 2000 forecast grave problems over the next 20 years and they state in that report, and I quote, ''At least some of the hardest hit countries, initially in Sub-Saharan and later in other regions, will face a demographic catastrophe as HIV/AIDS and associated diseases reduce human life expectancy dramatically and kill up to a quarter of their populations over the period of this estimate. This will further impoverish the poor, and often the middle class, and produce a huge and impoverished orphan cohort unable to cope and vulnerable to exploitation and radicalization.'' That is from a CIA report entitled ''The Global Infectious Disease Threat and Implications for the United States.''
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Dealing with this devastating illness, the AIDS virus has been one of the great moral tests of our era. Having made some progress at home, the question is whether we can now act to help those in more distant lands.
The Chairman's legislation, H.R. 2069, meets that challenge head on and I am proud to support this significant legislative initiative that builds on the Committee's previous work on infectious diseases.
Mr. Chairman, I look forward to listening to our distinguished panelists who are here this morning as we review our Committee's consideration of this devastating problem.
Thank you, Mr. Chairman.
Mr. SMITH. Thank you.
The gentleman from Ohio, Mr. Brown.
Mr. BROWN. Thank you very much, Mr. Chairman. The U.S., as others have said, must increase its involvement in the fight against AIDS. Over the next decade in Sub-Saharan Africa alone, AIDS will kill more people than the total number of casualties from all of the World Wars of the 20th century.
We also must more actively engage in global tuberculosis control. TB is AIDS's deadly partner in the worst pandemic in human history. TB is the leading killer of people with AIDS. To fully and effectively address the AIDS pandemic, we must also address the skyrocketing HIV–TB co-epidemic. In many parts of Africa, these diseases are inseparable. It is often assumed that when someone has TB they also have AIDS.
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It has been estimated that half of the people with AIDS worldwide will develop TB. In parts of Sub-Saharan Africa, TB rates have quadrupled since 1990 due to AIDS. In some countries in Africa, 70 percent of TB patients are HIV positive.
HIV severely weakens the immune system, which in turn renders a person more susceptible to becoming sick with tuberculosis. An HIV positive person is 30 times more likely to develop active TB and become infectious to others. There is also growing evidence that active TB actually accelerates the course of AIDS, making an individual sicker sooner.
TB treatment is one of the best ways to increase the life span and improve the quality of life of someone with AIDS. There are few more important things we can do right now to combat AIDS than to combat TB. A person with AIDS who has become sick with TB has a survival time on the average of five to 6 weeks. Directly Observed Treatment, short course, so called DOTS, at a cost of less than $50, that treatment can extend a person's survival time to 2 to 5 years and protect against the spread of TB in areas of high AIDS incidents. However, DOTS is reaching only one in four of those sick with TB worldwide.
In our fight against AIDS, it is imperative that we also address the deadly co-infection of AIDS and TB. We should provide a major increase in bilateral AIDS funding. $200 million for the treatment of TB is a crucial component in the fight against AIDS.
We should provide funding for the new global TB drug facility. $20 million—only $20 million annually—for this TB drug facility could provide TB drugs to 1 million people.
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I also urge the Committee to ensure a major U.S. commitment to the new global AIDS health fund, as my friend Mr. Lantos mentioned, which has been proposed by the U.N. Secretary General Kofi Annan, on the order of a billion dollars or more of new money for proven, on-the-ground prevention and treatment.
I would also echo Mr. Lantos' comments that the tax cut that the President is signing today, hundreds and hundreds of billions of dollars, is money we could have used for this treatment. We talk over and over about how generous we are as a Congress—we are increasing these dollars to unprecedented numbers, more than we ever have in the past. Well, in the past we never did nearly enough and we are still not doing nearly enough.
Tackling TB means tackling HIV/AIDS as the most potent force driving the TB epidemic and tackling HIV/AIDS means tackling TB as a leading killer of people with HIV/AIDS.
I thank the Chairman.
Chairman HYDE. The gentleman from Iowa, Mr. Leach.
And I wonder if Mr. Leach would yield to me briefly.
Mr. LEACH. Of course. I would be delighted to yield.
Chairman HYDE. Thank you, Mr. Leach.
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I would like to respond to the comments that this is a paltry sum and that we are not doing enough. I fully expected that. I asked the staff to come up with a figure that is the maximum possible to be absorbed by the recipients and to be effectively administered. There are limits to how much you can spend that can be usefully used, especially in programs like this.
We are providing $1 billion for 2 years—$1 billion for 2 years—bilateral aid. That is from us to agencies around the world. One billion.
Next, there is a comprehensive $1.2 billion that is spent on research in this country.
We are providing for up to 25 percent of whatever funds are contributed to an international fund.
And so those are substantial—not immodest—sums of money and I just wish that we could get past the politics and talk about trying to get some cures going.
Mr. BROWN. Would the Chairman yield?
Chairman HYDE. Sure.
Mr. LEACH. I would be delighted to yield.
Mr. BROWN. Oh, I am sorry. It is still Mr. Leach.
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Thank you, Mr. Leach.
Yes, we should get beyond the politics and that is what we always say around here after we accomplish a public policy that is very different from what I think most people in this country want. When we do a tax cut like that, it does put a straight jacket on efforts of this Congress and with USAID, we have cut USAID over the years to the point that the infrastructure is not in place to deliver a lot of these services and, second, there are places this money could go. More money could go to WHO, more could go to CDC, both also cut under the Bush budget.
Chairman HYDE. The gentleman will have an opportunity to offer amendments that line up the money the way he prefers. He can do it better, he is sure welcome.
Mr. Leach?
Mr. LEACH. Thank you, Mr. Chairman. First, I want to thank you for your thoughtful introductory comments and identify with the wisdom of your decision to move forward in this arena so forthcomingly.
I would just like to comment a little bit on process and about the past and the future.
In the last Congress, we passed a bill called H.R. 3519, which was entitled ''The Global AIDS and Tuberculosis Relief Act'' which was a 2-year, $300 million authorization to establish an AIDS trust fund, a multilateral trust fund, to be administered by the World Bank. Unfortunately, only a small amount of appropriations came to be attended to that, in no small measure because the U.S. Agency for International Development objected, the White House objected, and the Treasury did not support it. And there was a phenomenal opportunity at the end of the last Congress for this to proceed.
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Now it is clear in the international community there is an increasing consensus about a multilateral approach and recognition that the World Bank is the appropriate place to leverage other countries' monies, as well as use resources of the United States, and that it has an infrastructure perhaps second to none, although there is some competition. AID has a decent infrastructure, the U.N. in another area has a decent infrastructure.
But all I am stressing is in terms of process that I think there is a significant role for AID, there is a significant role for the World Bank, there is a significant role for other U.N. agencies, but I would hope that the AID would reassess some of its singular concerns that were evidenced at the end of the last Administration. I am very concerned about this because self-centeredness at a domestic institution can have massive ramifications for the worldwide approach. I am for everyone participating and I am particularly anxious to see that the international multilateral efforts also get off the ground.
I want to end by being complementary of your institution because you have begun to take steps with this approach of our distinguished Chairman and they will be even more significant and I am very appreciative of Chairman Hyde and his leadership in this area.
Thank you.
Chairman HYDE. I thank the gentleman.
We will take two more opening statements and then the rest of you, if you have any, may submit them for the record and they will be made a part of the record.
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Mr. Sherman next and then Mr. Smith and then we will get to the witness.
So Mr. Sherman?
Mr. SHERMAN. Thank you, Mr. Chairman. I have incredible regard for the good gentleman from Iowa, but I could not disagree with him more as to whether it is better to go through USAID and institutions we control versus using the same amount of money through the international institutions.
We have seen the U.N. Human Rights Commission taken over and turned into a mockery. It has a good name—Human Rights is a good name. United Nations sounds like a good name. And yet just giving money to an organization that has a good name does not mean that good things or good control will result.
I know you mentioned the World Bank. I keep it hidden in my district because I want to keep voting for foreign aid, but the World Bank has taken our tax money and given it to the government of Iran just last year, over American objections. I asked the president of the World Bank for some assurance that his organization, in the guise of helping the poorest of the poor or helping those with AIDS, not give our tax money to the government in Khartoum and he refused to give me—could not give me—that assurance.
So multilateral organizations sound very good, but what can actually happen, and sometimes we even see it and it is blatant. For example, when we are kicked off the U.N. Human Rights Commission and Sudan and Syria are put in our place. Sometimes it is less, sometimes it is just unavoidable corruption, but we see our tax dollars going or potentially going to the most putrid regimes and it is not just that the money would be wasted. I am sure sometimes our bureaucracy will waste some money. It is that that money is then spent to oppress people, then spent to kill people. But it is not just that.
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It is that if 20 or 50 million of our dollars are used for the worst possible purposes, then how do we defend foreign aid as a concept from those who would cut it back even further? And, as a result, we may lose billions of dollars over a decade because we allowed our foreign aid to go to sources that the American people simply cannot tolerate.
So I agree with the gentleman from Iowa, that in designing our tax and budget policy we should provide for the greatest possible within reason expenditures on dealing with problems like AIDS particularly in Africa, but we also have to be very careful as to how that money is spent. And once you give it to an organization where we lack control, then it is going to be given to Iran, as the World Bank did, and it may be given to the government of Sudan, not just to the people, but to the government of Sudan. And then those of us who advocate even more expenditures on foreign aid can do nothing more than hope that our constituents become unaware of how their money is being spent.
Mr. LEACH. Will the gentleman yield?
Mr. SHERMAN. How much time do I have? I will yield for 30 seconds.
Chairman HYDE. You have a long 1 minute and 52 seconds.
Mr. SHERMAN. I will yield 30 seconds to the gentleman from Iowa.
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Mr. LEACH. Well, you are gracious to give me——
Mr. SHERMAN. I will yield a minute to the gentleman from Iowa.
Mr. LEACH. Thank you for your graciousness.
I would only say to the gentleman, for whom I have great respect, that critiques of certain lending policies of all of these institutions are virtually always valid at any point in time. But I think one has to look at the AIDS issue itself and how they are performing on this subject. And I will tell you from firsthand knowledge that the U.N. is doing a pretty good job with limited resources with AIDS. The World Bank is doing a very good job.
I am not suggesting that we only go multilateral. I am suggesting we go all directions, multilateral and bilateral.
I am also suggesting, sir, that if you do not go multilateral, you cannot utilize the resources of many other countries in this effort. And if we want to put our heads in the sand, we have that option.
Finally, at the risk of true presumption, I mean, it should be understood the World Bank is headed by an American, it has always been American-led. It has to be attentive to the concerns of other countries the way decision making is made, but in this AIDS arena, I think we can take it out of the whole context of many of the concerns that people have, whether they be Middle Eastern issues, whether they be terrorist issues, whether they be anti-democratic issues in some countries. This is simply about human life and I think we have to take our blinders off.
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Mr. SHERMAN. Reclaiming whatever remains of my time, I would simply say——
Chairman HYDE. Would the gentleman like an additional minute?
Mr. SHERMAN. I would love an additional minute.
Chairman HYDE. Without objection.
Mr. SHERMAN. Thank you, Mr. Chairman.
I do not think that those of us who are wary of what could happen have our heads in the sand. You cannot rise above politics, I would love to, but my tax dollars are going to the government of Iran right now and is it not wonderful that we have an American who heads the World Bank, but I have talked to him and he cannot assure you or me that this money will not go in the name of AIDS to guns to the government of Sudan, packaged as money to fight AIDS.
So I think our domestic organizations do an outstanding job. I have seen it. You have seen it. Neither one of us has any criticism of USAID. And I would point out that, yes, our unilateral efforts also do just as much to leverage because when legislatures in Belgium or in Germany or in Tokyo look at the total amount we spend, they will decide to spend as well. They may decide to do it through their own organizations, they may do it in cooperation with us, but I do not think the nations of the world are going to say, oh, well, we do not have to do anything because the Americans are working through USAID rather than the World Bank. They will also act, either unilaterally or multilaterally. And if they do not, shame on them.
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Chairman HYDE. The gentleman's time has expired.
The final opening statement will be delivered by the gentleman from New Jersey, Mr. Smith.
Mr. SMITH. Thank you very much, Mr. Chairman. I would ask that my full statement be made a part of the record and I will be very brief.
Chairman HYDE. Without objection.
Mr. SMITH. Thank you.
First of all, I want to thank Chairman Hyde for his foresight and for his vision in offering this new and, I think, very urgently needed legislation to help combat this epidemic of worldwide HIV/AIDS. It is compassionate legislation and, as I said, it is vitally needed.
I also want to welcome Mr. Natsios, who has a distinguished career at USAID and the State Department. I remember when he worked as the Director of Office of Foreign Disaster Relief. If ever there was a disaster that cries out, even though it is not an earthquake or tsunami, it is this AIDS epidemic and I cannot think of anyone better to be at the helm in trying to mitigate and hopefully end this cruelty than Mr. Natsios, so the money and the policy are in good hands with him at the lead.
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I also just want to make one brief point. Government-wide, we spent in fiscal year 2000 $10.9 billion on AIDS, which is a tremendous and very worthwhile commitment. It is worth nothing, though, how that money is divided up: 58 percent is for treatment programs, research gets about 19 percent, income support programs 13, and prevention programs about 10 percent.
It seems to me that on the international side, the treatment side has been neglected for far too long. The slims—whatever one wants to call it in Sub-Saharan Africa, the devastation that is visited upon the individual and their family who waste away with little or no treatment, that has to come to an end and it seems to me that this bill is a significant down payment in saying treatment matters.
Also, the mother-to-baby transmission, I remember when Glaxo Wellcome some years back offered that they would at cost provide the drugs that lessened the possibility of transference of HIV to the child during childbirth.
When Brady Anderson from AID and others would come, I repeatedly would ask the Administration to be doing more in that regard. I do believe they did some, but much more needs to be done to make sure that those powerful drugs that can mitigate and even stop the transference of AIDS will be given and administered during the birthing of a child to save at least another generation from contracting this horrific disease.
So, Mr. Hyde, I want to salute you and thank you for taking the lead. I personally will be out chairing my own hearing. I will come back. It is on the GI bill which is totally unrelated, but I want you to know I look forward to working with you, Mr. Hyde, and, again, thank you for the leadership.
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Chairman HYDE. Thank you.
I would like to welcome Andrew Natsios, Administrator, U.S. Agency for International Development.
Congratulations, Mr. Administrator, on your recent confirmation and we do look forward to working closely with you and the President on the HIV/AIDS pandemic and other development challenges throughout the world.
Mr. Natsios' distinguished career includes service as the First Director of the Office of Foreign Disaster Assistance from 1989 to 1991 and as Assistant Administrator for the Bureau of Humanitarian Response at AID. Before assuming his current position, he was Chairman and Chief Executive Officer of the Massachusetts Turnpike Authority and Secretary for Administration and Finance for the Commonwealth of Massachusetts. He has also served as Vice President of World Vision, a distinguished academic, author, public servant and retired Colonel.
We are honored to have you appear before us today and please proceed with a 5-minute summary, if possible. Your full statement will be made a part of the record.
Mr. Natsios.
STATEMENT OF THE HONORABLE ANDREW NATSIOS, ADMINISTRATOR, U.S. AGENCY FOR INTERNATIONAL DEVELOPMENT
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Mr. NATSIOS. Thank you, Mr. Chairman. First, I would like to thank you for having me before the Committee and allowing me to testify. I have been on the job just about a month now.
I would also draw your attention to the map we have put up here which is a color-coded map of the infection rates. The maroon countries in the southern part of Africa are the highest rates; next are the red; then the yellow is the next highest. The lowest rates are the blue and the dark green. This will give you some sense of the pathology of the disease from a geographic standpoint.
We have copies of the maps to you directly, you can see the countries more closely there.
We submitted one piece of testimony to you which is an analytical piece, which I will not read, and then we submitted a second one today which is a more scholarly piece that precisely goes through our program over the last 15 years in AIDS because we are not new to this. We started our programming in Africa in 1986 during my service in the first Bush Administration in AID. This was a major issue even then.
What I would like to do is verbally, extemporaneously sort of summarize what is in the testimony and then perhaps answer some questions.
The President decided to focus on this issue just after he was sworn in as President and he did three things. The first is that he appointed Secretary Powell and Secretary Thompson to co-Chair a task force, a presidential task force, on the pandemic in the United States and worldwide.
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Second, we made the first and the only donor contribution to this international trust fund. There are conversations going on literally among donor governments right now, I think there were two meetings this week on it, as to the governance system and the strategy. There is still discussion as to how we should spend this money and where it should be spent, how it should be focused, who should be on the board of governors of this trust fund.
The third thing that happened, I think the most significant in some ways, is that the President dispatched Secretary Powell and I and other senior people from the State Department to go to Africa—we just came back last Wednesday—to focus international attention on the pandemic. We visited AIDS clinics, we visited AIDS research centers, we visited AIDS orphans, community programs that take care of these orphans. We met with heads of state and health ministers to focus international attention on what is happening.
There is a lot of talk about how much is spent, but just as a matter of course, the U.S. Government through AID and CDC spends more money on the pandemic than all governments of the world, sovereign governments, donor governments, multilateral agencies and U.N. agencies combined.
The HIV pandemic is one of the most serious crises, not the only crisis, but one of the most serious crises facing the developing work, particularly Africa where 70 percent of the HIV positive people live. In some areas of South Africa, and the secretary and I were in South Africa very recently, funerals are being held continuously from dawn until night because there simply are not enough funeral homes to deal with the number of people who have the disease who are now dying.
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We have reports from our mission in Zimbabwe, in Harare, where metal street signs are disappearing every night. No one could understand at first what was happening and the newspapers in Harare are reporting that they are being stolen to be used for handles for coffins.
There is one report from one area, I heard from an NGO in South Africa, that they are burying people vertically instead of horizontally because there is no space left in many of the cemeteries in South Africa.
We know when the infection rate exceeds 4 to 5 percent, that is the threshold above which the pandemic grows at geometric proportions and the infection begins to spread almost out of control out of that level.
Three countries in Africa will have negative population growth rates by 2003 and five countries will have zero population growth by 2003. Zimbabwe, which has a population of 12 million people, will have 9 million people by 2010 because of the progress of the disease. It is so acute in Zimbabwe.
There are now 12 million AIDS orphans in Africa alone. In Uganda, another country that the secretary and I visited, there is a famous grandmother who lost her husband and 11 of her 12 children to AIDS. She has one daughter still alive. And they are caring for 31 grandchildren and four great-grandchildren.
Several NGOs have been formed in several countries because there are so many elderly people taking care of grandchildren. All they do is plow the fields because the elderly are simply too old to physically plow the fields. And if you do not plow the fields, agricultural production, which is already in trouble in Africa, deteriorates further.
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There are three reasons why in Africa we are now seeing famine-like conditions in areas where there should be no famine. Africa is plagued by civil wars, that is one cause of the collapse in agricultural production and starvation. The second is there are droughts sometimes, but the third is the AIDS pandemic. People are not able to plant the crops because there is no one functional. Everybody is either very young or very elderly and there is no one left in between to plant crops and so you are seeing famine-like conditions arising in rural areas which should be prosperous.
In Zimbabwe, more teachers are dying each year than are being trained in the teachers' colleges.
Now, this disease, unlike most of the infectious diseases that agencies like AID and the NGO community have to deal with, is a new disease. It developed in the 1920's and there is a great deal we still do not know about the pathology of the disease. That is why the National Institute for Health is spending $2.2 billion a year on research. Research, by the way, which is critical toward finding a cure, a vaccine, which can help us understand how to prevent the spread of the disease over a period of years. So we are spending nearly $3 billion between research and prevention programs alone.
This year, AID is spending $340 million in CDC, another $100 million internationally in the developing world on this disease. The fastest rates of growth are now in the subcontinent, South Asia, and in the former Soviet states. There the rates are more rapidly expanding. Asia is basically where Africa was 10 years ago and we are seeing rising rates in a number of Asian countries.
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Now, we have learned a lot since 1986 about what works and what does not work. What we have done is field tested a whole series of different programs and as soon as we know something works to drive the rates down of infection, we begin scaling that up to a national scale. That is the strategy AID has been using and our principal objective is to save the largest number of lives with our given resources.
There are six strategies we are pursuing. The first one is prevention. I say that and I have to say it again, prevention is the center of the AID approach. There is no cure for AIDS, there is no vaccine for AIDS. And, therefore, the way to stop the pandemic is to stop it from spreading.
We know that, for example, if we treat sexually transmitted diseases like syphilis and gonorrhoea that the infection rate for AIDS drops by 50 percent. The spread of the disease drops by 50 percent when we treat just sexually transmitted diseases. We know if we give one pill to a mother and to her newborn child at birth that the infection rate will drop by 50 percent, as will the chances for that child being infected. So there are a series of things we know from a medical standpoint that work.
We also know that counselling programs, especially direct counselling for teenage girls in particular, have been very successful in postponing sexual debuts by several years and has dramatically dropped the rates of infection, particularly in countries like Uganda where they have done a national program with our support to do that.
The essence of the prevention program is abstinence, faithfulness, and the use of condoms. Last year, AID alone distributed 300 million condoms in Africa, so we have a massive program in condom distribution now all over Africa. We have a huge infrastructure we have built up over the last 15 years to do that.
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We are beginning a new faith-based initiative in Africa. The two principal institutions that influence people's behavior at the local level are the mosque and the church. I met with Muslim and Catholic leaders in Mali and in Uganda, I met with Muslim doctors and Muslim leaders and Pentecostal, Anglican and Catholic bishops to talk to them about what they are doing at the parish level to prevent the spread of the disease because they are the most influential institution in changing people's behavior. They have been doing things for years. We need to support them in doing that and there is a program that we are about to launch, we are doing the RFP now, to help us help them to do this work at the grassroots level where it is most effective.
We know that voluntary testing has a profound effect on behavior. Now, when I first heard this from our staff, I thought that if a person found out that they were HIV positive they would behave better, and they do. But we also find out when a person knows that they are HIV negative and they do not have the disease, that they also change their behavior. In other words, what encourages bad behavior is not knowing and once they do know, it encourages much more responsible behavior. So testing programs are being revamped in many countries now because we know that that information has a profound effect on people's behavior.
In terms of care for people who have the disease, because 29 million people have the disease in Africa right now, the first strategy is the treatment of opportunistic diseases. Congressman Brown mentioned this earlier. Tuberculosis is the principal disease that we focus on. Secondly is malaria. If you get malaria and you are HIV positive, your death rate is very high, very likely and very quick. And pneumonia is another problem. If you get pneumonia and you have HIV/AIDS, you shorten your life very quickly. And you do as well with dysentery, which is a problem among children in particular. So we do not treat this alone. It has to be treated in the context of other infectious diseases.
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We also know that because of the serious problem we have with AIDS orphans. For example, we were in Kenya recently, the secretary and I, and there were a million AIDS orphans. It is overwhelming even the traditional capacity of the tribes to adopt children. Africa is not a place where orphanages make a lot of sense. They make more sense in the west, they do not in Africa, because there is a tribal tradition that when a child is orphaned someone in the tribe adopts the child very quickly. It is an old tribal tradition, actually, we have something to learn from the Africans, in my view. And they do that very easily and very quickly. The problem is it is overwhelming in the system.
So we just announced in Uganda a $40 million, 5-year program to provide food to the grandmothers of Uganda who are caring for their great-grandchildren and grandchildren or for parents who adopt a lot of orphan children so they can feed them and pay their school fees as well to keep them in school.
We need to know more about surveillance. If we do not know how the disease spreads, we cannot combat it, so one of the things we are doing with Ministries of Health and through the NGO community is to set up surveillance systems to study the statistical data, the movement of the disease and how we can deal with it.
We need to get other donor governments involved in this. While we are spending $440 million this year, the next biggest donor is the European Union and they are at $90 million; the World Bank is at $70 million. This global trust fund, one of the purposes of it was to act as an incentive for other donor governments to give money and, secondly, to develop a unified strategy.
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We believe all the technical people in the donor governments all agree, prevention has to be the focus. The problem is when you step above that at the political level, there starts getting a lot of debate about other approaches which may not be, from a clinical standpoint, the best way to approach this.
And, finally, my last comment, Mr. Chairman, is we need to take a multi-sectoral approach. The Secretary of State said that repeatedly; he is absolutely right. There are public safety problems when you have half a million young men in Kenya with no parents, no tribal leaders, no religious leaders to guide their growth. There is a public safety problem when you have schools that have no teachers because the teachers have all died. The schools cannot produce enough new teachers to take their places quickly enough.
The business community is being devastated. Business figures have told me they cannot replace employees fast enough who die from the disease.
We need to finally get the political leaders in these countries—Africa is a very hierarchical society, they look toward their leaders in a very powerful way. One of the reasons the epidemic has been under control in Uganda is because President Museveni has gone on a national campaign personally on this issue. By him focusing attention, it has changed people's behavior and their focus on it. We know that African leadership can make a big difference.
We look forward, Mr. Chairman, to working with you and Members of the Committee to stop this horrendous epidemic, this catastrophe that is threatening much of the developing world. Thank you very much.
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[The prepared statement of Mr. Natsios follows:]
PREPARED STATEMENT OF THE HONORABLE ANDREW NATSIOS, ADMINISTRATOR, U.S. AGENCY FOR INTERNATIONAL DEVELOPMENT
It is particularly timely that I am here this morning to talk about one of the greatest challenges faced by the United States and the rest of the world—HIV/AIDS. Sunday marked the 20th anniversary of the first diagnosis of a case of HIV/AIDS. If we had known then what we know now, we might have saved many of the 22 million people from around the world who have already died and spared many of the more than 13 million children already orphaned.
Fortunately, with national leadership like that shown by members of this Committee, we can and are doing more. and WeWe have successful programs and partnerships upon which to build. Slowing the HIV/AIDS pandemic and helping those already infected and affected are priorities for this Administration, Secretary of State Powell, the Agency for International Development, and me.
As you know, less than a month ago, President Bush, Secretary Powell and Secretary Thompson met with United Nations Secretary General Kofi Annan and Nigerian President Olusegun Obasanjo. Noting that ''We have the power to help,'' President Bush said, ''The United States is committed to working with other nations to reduce suffering and to spare lives.'' Currently the U.S. spends more money through USAID and the CDC on HIV/AIDS work internationally than all other donors combined. Since 1986, USAID has provided $1.6 billion in HIV/AIDS assistance. President Bush has pledged $200 million to the Global HIV/AIDS and Health Fund. This is in additionthat to the $350 million requested for USAID in 2002, the nearly $300 million for international HIV/AIDS work planned by other U.S. agencies, and the billions of dollars which the U.S. spends on HIV/AIDS domestic research and treatment.
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I have just returned from a trip to four African countries with Secretary Powell, to talk to leaders about the problem of HIV/AIDS. We saw first-hand:
The devastation caused by the pandemic: Most of those with HIV live in Africa although infection rates are rising rapidly in the rest of the world. In Africa because of HIV/AIDS, many families are no longer able to farm and many will go hungry. We are seeing famine caused for the first time not by war, drought or pestilence but by the HIV/AIDS pandemic.
Too high a human toll: Already more than 17 million Africans have died, 12 million have been orphaned and another 25 million are living with HIV/AIDS. Unfortunately, many of these individuals will suffer alone; receive no modest care; die too young and in pain; and leave behind destitute families and children.
The strategic importance of prevention programs to reduce the rate of new infection. Tragically, in developing countries, about half of all new HIV infections are to 15–24 year olds. The behavior of today's youth will shape the course of the AIDS pandemic in the future.
The courageous response of many, especially at the community level, who are speaking out, mobilizing their neighbors and caring for those infected and affected by HIV/AIDS. Both the Secretary and I were moved by the compassion, courage and love demonstrated by community groups who are supporting infected persons and their families.
The important work the United States, particularly USAID, is doing to prevent transmission, care for the sick and provide support to families and children affected by HIV/AIDS.
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Let me share with you a few of the highlights of what I saw and heard:
In Kenya, I saw a wide array of HIV/AIDS prevention, care and support programs, which receive support from USAID. These range from HIV/AIDS community education through the Kenya Girl Guides to state of the art pilot programs to prevent mother-to-child transmission. I heard from one HIV positive mother of her need, and that of the women she counsels for family planning services and HIV/AIDS care and treatment. In Kenya, as well as elsewhere in Eastern and Southern Africa, the number of children who have lost one or both parents continues to grow rapidly. My visits to community-based projects, which care for orphans and families, convinced me that this is the most viable, humane and cost-effective way to help children. Faith-based organizations such as the Kenya Catholic Secretariat, Christian Health Association of Kenya and the Council of Imans play a critical role in enabling communities to take care of their own.
In Mali, I learned from my colleagues and our partners that we are not waiting until the epidemic is out of hand before acting. Working with national leaders in Mali, USAID is already helping providing edecision-makers with accurate information on the situation through its support for the first national population-based survey of HIV infection levels in the world and special policy-making presentations to key opinion-makers and leaders. Special education, reproductive health, and cross-border programs target youth and groups with high-risk behaviors. Acting now may spare Mali the tragedy of Southern and Eastern Africa. My discussions with religious leaders underscored the important role of faith-based organizations in mobilizing people for education, care and support. We will be working more closely with such leaders through a new Africa-wide initiative with faith-based organizations to get the word out through churches and mosques on how individuals can protect themselves and their families.
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In South Africa, I visited an HIV/AIDS community care and support program, Hope Worldwide, in Soweto, the largest township in Africa. I heard from citizens of Soweto about how hard it is to be HIV positive in that community and the discrimination and poverty they face every day. USAID is helping HIV positive mothers to lessen the risk that they will pass on this terrible disease to their yet unborn infants through a pilot mother-to-child transmission prevention program. USAID support links the Hope Worldwide Community Center to Baragwanath Hospital and ensures that mothers receive the follow-up and community support needed for them to protect their babies.
In Uganda, I gained new understanding of the human costs of HIV/AIDS as I listened to the personal testimony of widows with HIV/AIDS seeking to leave some legacy through memory books for their children, many of whom will soon be orphaned. Uganda's successes underscore both the importance of the longstanding partnership between the U.S. Government, the government of Uganda and Ugandan non-governmental organizations and of high-level and sustained political leadership in mobilizing public opinion as a basis for effective behavior change.
USAID is the lead U.S. agency at the country level. We have led the global fight against HIV/AIDS since 1986. We are the largest supporter of multilateral, bilateral and private non-governmental HIV/AIDS programs. We provide about 25 percent of the total funding for UNAIDS. We develop the U.S. HIV/AIDS country assistance programs that provide the framework for collaborative partnerships between the U.S., host countries, and other donors.
USAID is well positioned to play this critical leadership role because we have:
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on the ground country and technical expertise with recognized preeminence in reproductive health in developing and transitional countries.
established relationships with other donors, U.S. private voluntary organizations and host country governments and private organizations.
a tough minded, evidence-based approach which uses applied, field research to identify, test and demonstrate effective interventions to ensure that every dollar of USAID assistance counts.
directly relevant experience from other development programs such as social marketing, mass media communication and peer education.
successful ongoing HIV/AIDS programs which can be expanded rapidly or replicated to help more people.
comprehensive country assistance programs which enable us to address HIV/AIDS from a national perspective and use multi-sectoral approaches to reach substantial populations and meet critical needs outside of the health sector.
USAID has made a difference in Africa and the rest of the world. We have:
helped more than 35 million people protect themselves and their families through programs that have reached them directly with the ABCs of prevention: Abstinence, Be Faithful, and Condoms.
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increased world knowledge on the nature, magnitude and impact of the pandemic: We now know that no country is safe. Because of injected drug use, the former Soviet Union has the highest percentage HIV infection growth rate of any region in the world. Parts of the Caribbean and Central America are also experiencing very rapid increases in HIV infection. There is evidence that Asia will be the hardest hit region in the next decade.
identified, tested and implemented pragmatic, field-tested approaches to HIV/AIDS prevention, care and support for orphans and other children affected by HIV/AIDS.
shared U.S. expertise, resources and products. USAID is the largest supplier of condoms. Research in developing countries has shown that good quality condoms used consistently work well.
leveraged other donor and private funding and other support. In Zambia, for example, a private South African firm, Sasol, which imports large quantities of fertilizer has printed an easy-to-read HIV prevention message on 800,000 fertilizer bags. The message reads:
''To grow properly, your crops need fertilizer. To grow properly, your children need you. Use a Condom Every Time. Protect Yourself Against HIV/AIDS. Thank You. Maximum—Use it! Be wise, be Condom wise.''
With the additional resources provided by Congress, we have adopted an expanded response which:
focuses the majority of resources on four ''rapid scale up'' countries: Cambodia, Kenya, Uganda and Zambia, and 16 ''intensive focus countries'' to achieve greater results in critically affected countries.
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continues a strong focus on prevention. It is especially critical that we do a better job of reaching young people.
provides more support for the care and treatment of those with HIV/AIDS, especially of the opportunistic infections such as tuberculosis which is the greatest cause of AIDS deaths in Africa.
helps countries, communities and families deal more comprehensively with the consequences of the pandemic through special programs and multi-sector approaches such as community-based education, micro-credit and other help for families caring for orphans and other vulnerable children.
improves our understanding of the epidemic and the impact of assistance through increased surveillance of the epidemic in key countries, tracking of HIV/AIDS related behavior and increased monitoring of USAID assistance impacts.
With the lives of millions at stake, it is critical that current and future programs are based on informed choices about the most effective and efficient ways to prevent transmission and to care for those affected. With the extra resources we are receiving, USAID can and will build on program successes like:
partnerships with private organizations, such as those with faith-based organizations in Haiti and Kenya, which have provided critical information on HIV risk and prevention to parents and to youth. I came away from Africa with an increased awareness of the important role of faith-based organizations in mobilizing people for education, care and support activities.
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peer education and other targeted programs, which meet the needs of youth and special high-risk populations. Kenyan youth are using the stage to challenge HIV/AIDS myths and stigmas. There are now more than 270 youth theatre groups who have reached more than 400,000 people. In Jamaica, innovative theater groups are used to educate youth groups and parents in HIV prevention methods, including abstinence. In Russia, rock concerts are reaching thousands of at-risk youth with healthy life style messages. The South African ''Lesedi'' or ''we have seen the light'' project forms multi-sectoral partnerships between mining companies and health departments to provide education and treatment of sexually-transmitted infections to miners and other migrant workers at high risk of HIV infection.
voluntary counseling and testing (VCT) programs, which provide individuals with the information they need to protect themselves and their families. A multi-site research study in Tanzania, Kenya and Trinidad and Tobago found that VCT reduced sexual risk behavior, especially in HIV positive persons. VCT also empowers HIV positive people. In the face of violence and discrimination, courageous people living with HIV/AIDS throughout India have built a national network to raise awareness, improve care and support for HIV-positive people and advocate for more enlightened, effective HIV/AIDS policies.
social marketing programs, which make information and commodities widely available to citizens through private sector channels in more than 50 countries. In Kenya, monthly sales of the socially marketed condom, ''Trust,'' total 1.2 million.
technical assistance: USAID works with both governments and private groups to strengthen HIV/AIDS preventio n, care and support programs. In Brazil, USAID's HIV/AIDS program works at the state and national government levels to increase management capacity, improve efficiency and integrate detection and treatment methods into public health facilities.
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community-based care and support for people living with AIDS: In Cambodia, KHANA, the Khmer HIV/AIDS NGO alliance, which USAID supports, has piloted community home care teams. This approach reduces suffering, helps forge linkages between care and prevention and reduces discrimination against people living with AIDS. One widow explained how with the help of a KHANA Home Care Team, she was able to remain healthy, continue her business of selling food and keep her children in school.
care and support for Orphans and Vulnerable Children: USAID is developing new community and family-based programs to help the 12 million children who have already been orphaned. In Uganda where there are now 1.7 million orphans, the Uganda Women's Effort to Save Orphans (UWESO) serves as an advocate for children's rights and supports activities to assist orphans and their families. With support from USAID and the Peace Corps, UWESO shifted its program emphasis from school fees and grants to micro-finance activities to provide an opportunity for income generation for households headed by widows, grandmothers, and a few children in addition to families providing foster care for AIDS orphans. One legendary grandmother in her 70s, Bernadette, now cares for 31 grandchildren, three great grandchildren and four of her brother's children orphaned from AIDS, with the help of her daughter. Eleven of her 12 children have died of AIDS. She has successfully used and repaid three micro-finance loans and used the proceeds to launch two successful projects: one raising and selling pigs and the other buying and selling small fish in the market. The profits from these projects are used to support and pay schools fees for the children.
The job is not done. The challenge remains extraordinary, and so do our needs:
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Resources: Even with significant increases in U.S. support, total world financial and human resources allocated to date to HIV/AIDS are still inadequate to control the pandemic, heal the sick and care for those infected and affected. These limits have required USAID to set priorities, focus and concentrate our dollars and people in countries where the need is greatest and where USAID can make a difference.
— USAID continues to work with governments, media, private organizations and citizens to ensure that those at risk now have the knowledge and means to protect themselves and their families.
— USAID is pioneering and testing new approaches to care, prevention of mother-to-child transmission and help for orphans and other vulnerable children. We recently sent you reports on our work on mother-to-child transmission and on our help to orphans and other vulnerable children.
— USAID is working with other donors, other U.S. agencies, national governments and private organizations to identify and train more people.
— USAID, along with CDC and NIH, is supporting biomedical and operations research to develop affordable, feasible approaches. This includes research to develop a vaccine and microbicides to prevent HIV transmission.
Sustained Effort: We are just at the beginning of a long battle which will determine the fates and well being of many of the world's citizens for the remainder of the century. Because of infections that have already happened, 44 million children in the 34 countries hardest hit by HIV/AIDS will have lost one or more parents by 2010. Still,
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— Too few national leaders have stepped forward to take the actions needed to prevent an HIV/AIDS pandemic in their countries or to slow the epidemic already decimating their populations. We have seen in the Philippines, Senegal, Thailand and Uganda what a difference such leadership can make.
— Too much attention is paid in the world press to the anti-retroviral drug issue when an integrated strategy emphasizing prevention and including treatment and strengthened health care delivery is the only real answer to this crisis.
— Too few citizens know how to protect themselves and their children.
— Too few of those infected with HIV/AIDS receive even basic care not to mention anti-retroviral treatments, which could extend their lives. Many are shunned, abandoned and die prematurely in pain.
— Too many infected persons and their loved ones are stigmatized. This causes unnecessary suffering and makes prevention and care more difficult.
— Too few families and children affected by HIV/AIDS have the minimal essentials necessary for life and a future—food, shelter and a basic education. Children, often very young children, are trying to care for sick and dying parents and even their younger siblings.
I am determined, as the Administrator of USAID, that with your support we will meet this challenge. When we look back 10 years from now at our legacy, we will be able to say that the generosity and know-how of the American people made a difference and saved many from the worst epidemic in human history.
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Chairman HYDE. Thank you very much, Mr. Natsios.
Mr. Lantos, we will do questioning now, all right?
Mr. LANTOS. Thank you very much, Mr. Chairman.
Mr. Natsios, I want to commend you for your presentation. There are so many questions on so many issues that I think I need to focus on just one or two. And I want to underscore that the enormity of the crisis and the many faceted nature of the crisis must be an overwhelming experience for you because you have probably never faced anything of this scope. None of us have.
And I think I need to underscore that those of us who would like to see us do more are not engaged merely in a numbers game of asking for more for whatever reasons, but I would like to zero in on, in fact, absorptive capability and I would like to zero in on what, in fact, these numbers mean.
You made the point that the United States spends over 60 percent of all funds being spent on this disease. Am I correct?
Mr. NATSIOS. That is correct.
Mr. LANTOS. That certainly is a very impressive figure on a comparative scale, but the fact remains that if we are speaking of 275 million people when we spend $275 million on something, that is $1 a person, so that is really the meaningful criterion of our spending. A half a billion dollars, which I think is the broad overall proposal, is less than $1.70 per person in the United States. I mean, that is the scope of our spending, however generous it is.
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Without first asking you what the absorptive capability would be, could we double spending, could we increase spending by 50 percent? USAID, as I understand it, has designated three African countries, Kenya, Uganda, and Zimbabwe, for a significant scale-up of HIV/AIDS programs. Is that correct?
Mr. NATSIOS. We have actually focused on 21 countries, but those three in particular because we started there earlier we were able to ramp up faster there.
Mr. LANTOS. Well, you are focusing on 21.
Mr. NATSIOS. Right.
Mr. LANTOS. But these three are moving more rapidly.
Mr. NATSIOS. That is correct.
Mr. LANTOS. Now, is the reason why others are not added to this list of three because they are incapable of absorbing more aid or is it because of inadequacy of funds?
Mr. NATSIOS. One of the problems we are facing——
Mr. LANTOS. Let me rephrase it.
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Mr. NATSIOS. Yes.
Mr. LANTOS. If you had adequate funds, if you had twice what you now have, could you have designated six countries for a rapid scale up?
Mr. NATSIOS. Let me sort of put this in perspective. There are 50 countries in which we run—51, to be precise—HIV/AIDS programs. Twenty-one of them are on a substantial scale and three we are scaling up with some new pilots that were successful and therefore we are scaling those up. Every time we find an approach that works, we scale it up.
The problem in some countries is that the national leadership finds this an embarrassment. And I've had heads of state actually tell me that, you know, they have an unorthodox view. Some heads of state do not believe the HIV virus causes AIDS.
Mr. LANTOS. We know that, yes.
Mr. NATSIOS. That causes serious problems in the ministries because when we want to do certain things they say, wait a second, we cannot do that. So if we do not have the cooperation of the ministries of health and of the heads of state, it does put a serious constraint on what we are doing.
I met with the President of one East African country who is a very capable national leader and I said, ''You know, your country has a serious problem.''
And he said, ''We do.''
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I said, ''When did you decide to allow us to help you ratchet this up?''
He said, ''Six months ago.''
But this has been a problem there for 8 years. Now he is taking this very seriously and we are able to move it up. We have conversations with them, we talk with them, but there are some limits, political limits.
In the United States, we have gotten over the point of ostracizing people or viewing them as pariahs.
Mr. LANTOS. Yes, I understand what you are saying, but let me be specific. If you had the resources, could you scale up the AIDS program not in three countries, but in nine countries?
Mr. NATSIOS. We have in 21 countries. What I am saying is in those three countries, we have tried new pilots recently and we have scaled up in those countries because we tried them and they worked.
Mr. LANTOS. Well, attach some dollar figures. How much are we spending in Kenya?
Mr. NATSIOS. Kenya is $12 million.
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Mr. LANTOS. Uganda?
Mr. NATSIOS. Uganda is 15.
Mr. LANTOS. And Zambia?
Mr. NATSIOS. Zambia is 12. Cambodia is the fourth one, that is 9 million.
Mr. LANTOS. That is 9 million?
Mr. NATSIOS. Yes. Another thing that I would mention, have you looked at Kofi Annan's budget figures?
Mr. LANTOS. Yes?
Mr. NATSIOS. It is 7 to 10 billion. Most of that is not for prevention programs, to stop the spread of disease. Fifty percent of it is for antiretrovirals. The problem with antiretrovirals for some of these countries is there are no roads or the roads are so poor it takes—I have been on many of them for 12 years—it is very difficult to get to the areas where the infection rates are.
Mr. LANTOS. I understand. I have just one more question because I think my time is running out.
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You mentioned you have distributed, I believe, last year, 300 million condoms.
Mr. NATSIOS. Yes.
Mr. LANTOS. What was the sexually active male population in the countries where those condoms were distributed? What number of people are we dealing with?
Mr. NATSIOS. Up to 30 to 40 percent of males between 15 and 49 years old.
Mr. LANTOS. I need an absolute number. You have this figure that 300 million condoms, to how many people?
Mr. NATSIOS. I can get you that figure.
Mr. LANTOS. What is your ballpark estimate now?
Mr. NATSIOS. Between 50 to 75 million high risk males. In some Muslim countries in Africa, for example, you notice the statistics of the blue countries there in the north or the green countries? Because Islam is so pervasive, there is a much lower infection rate and that does affect people's behavior.
Mr. LANTOS. Yes, I understand that, but what you are saying, if you say 50 to 75 million, that is somewhere between four to six condoms per year per active male.
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Mr. NATSIOS. Some men will not use——
Mr. LANTOS. That does not appear to be adequate.
Mr. NATSIOS. Right. The problem, Congressman, is that we cannot get, even in the United States, people to use condoms. We can encourage them, we can give them but we cannot force them to use them. And there is a portion of people in the United States we are now having trouble with. The infection rate, as you know, has gone back up again among at risk populations in this country and it is because people do not like to use condoms. Some people. So there is a portion of that population that simply will not use condoms. We can advertise, we can have the head of state talk, we can make them available, they will not use them.
And the other problem is the remoteness of some of the locations——
Mr. LANTOS. I understand all that, but are you suggesting the number of condoms you distributed last year is adequate for your needs?
Mr. NATSIOS. We need 3 billion condoms in Africa if we were to make complete coverage.
Mr. LANTOS. Ten times what you had.
Mr. NATSIOS. That is right.
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Mr. LANTOS. Thank you, Mr. Chairman.
Chairman HYDE. The gentleman from California, Mr. Royce.
Mr. ROYCE. Thank you, Mr. Chairman. Thank you for holding these hearings. I do have some questions, but I think Mr. Houghton was next so I am going to allow you to recognize Mr. Houghton.
Chairman HYDE. Well, I like to work it by seniority on the Committee.
Mr. ROYCE. Mr. Chairman, I appreciate that.
Chairman HYDE. So we will have to get used to that.
Mr. ROYCE. I will ask my questions, then.
Chairman HYDE. Please.
Mr. ROYCE. Thank you, Mr. Chairman.
My first question would be what effect extending foster care to HIV orphans is having in Africa and whether particularly AID is involved in an effort to do that?
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Mr. NATSIOS. We do not use the term foster care. That is more of an American term. It is simply adoption. Families adopt orphan children within the African tribal traditional quite readily. The problem is there are so many of them now that they are overburdening the tribal tradition and we are supplementing that with food. I think I announced before you came in, Congressman, that we just announced in Uganda a 5-year, $40 million food program that will direct food toward families that have adopted a number of HIV/AIDS orphan children because they cannot care for all of them at the same time.
Also, there are programs now—in some areas, we cannot find people to—where there are teenagers in the household—to take care of the kids, to adopt them. So what we do is we have community workers who go in and check on them every day, make sure they are cooking the food, they have adequate assistance. There is a community network that is being set up when that adoption system does not work. But there are community-based, home-based programs which are by far the most effective given the volume of people we are dealing with and given African tribal traditions which we want to be respectful of.
Mr. ROYCE. I have seen in countries like Uganda where President Museveni is really engaged in explaining the dangers of HIV and AIDS to the populous and in setting up a program of constant governmental information about it a very real difference in terms of the level of awareness versus other states like Zimbabwe.
What is the significance of political commitment by heads of state in Africa, by governments in Africa, in confronting HIV/AIDS?
Mr. NATSIOS. African society is very centralized, it is very hierarchical in the sense that people look toward strong leaders. I think it has something to do with tribal custom and structure of society. And so when a leader or head of state says there is a problem and says it over and over and over again, it has a real effect of focusing public attention, media attention, ministry attention on that problem. That is why the program has been so successful in Uganda and in other countries no matter we try to do, it has not been as successful because the heads of state are too embarrassed to talk about it.
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Mr. ROYCE. Thank you.
Thank you, Mr. Chairman.
Chairman HYDE. Ms. Lee, the gentlelady from California.
Ms. LEE. Thank you, Mr. Chairman. Thank you very much for conducting these hearings.
Welcome. I am very happy to meet you. Let me ask you a couple of questions.
First, on the $200 million that the President announced as it relates to this international trust fund, could you explain the accounts that it is coming out of?
We have heard that it may be coming out of infectious disease, allergy control, or some of the accounts that I do not want to see attached. I think that we should look for new money, we certainly have it, $200 million is not adequate at all, but to take it from other programs does not make any sense.
Could you respond to that?
Secondly, I would like to ask you a little bit about the United Nations special session on AIDS. What exactly is the United States' position on it in terms of helping shape the declaration?
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I have heard—it has only been rumors, but I have heard that USAID will not be participating because of vulnerable populations that are at issue with regard to the declaration.
Could you explain a little bit about our participation in the session and what our role is?
Mr. NATSIOS. In terms of the first question, where the $200 million is coming from, $100 million is coming from international trust fund from HHS. I cannot tell you since I do not know their budget system at all or where it is coming from in their budget. You would have to ask them that.
Ms. LEE. But it is coming from HHS.
Mr. NATSIOS. That is correct. Another $20 million is coming out of our budget, but that money was already put there by the Congress——
Ms. LEE. That was last year.
Mr. NATSIOS. For a trust fund. No, this is for this year.
Ms. LEE. Well, okay. But it was put there.
Mr. NATSIOS. It was put there. It is appropriated, it was sitting in a reserve waiting for us to move it into this trust fund.
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Ms. LEE. It was for the World Bank AIDS trust fund, I believe, which Congressman Leach and I worked on last year.
Mr. NATSIOS. That is correct.
Ms. LEE. Which he mentioned earlier.
Mr. NATSIOS. That is correct.
Ms. LEE. Okay.
Mr. NATSIOS. The rest of the money is coming out of a reserve in the State Department budget.
At the beginning, I have to be very candid with you, there were people who said, ''That is fine for the $200 million, AID—find it out of your existing budget.''
And I said, ''Well, that is moving money from one group of poor people to another group of poor people.''
And the person who stopped it was Colin Powell and the President. They said, no, no, no, no, that is not how we are doing this, find the money somewhere else.
And so we had a National Security Council meeting, their orders were pretty clear, and that is what happened. So I did not have to cut one dollar out of any existing budget in AID other than the money that was in these reserves that was specifically designated for these trust funds.
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Now, the answer to your second question is we are participating at the technical level in the preparation for these U.N. meetings. We work with the U.N., with CDC, with other donor governments on a regular basis on these issues. There really is not a big impediment. And, frankly, there is a lot of political pressure on all of you and all of us at senior levels on this issue. But if you talk to the epidemiologists, the public health people, the people who actually work, it is pretty clear what we have to do. The problem is there are other options, other things that are being discussed which sometimes——
Ms. LEE. Right. Could you talk about what other things are being discussed so we can——
Mr. NATSIOS. Well, there is a big focus in Kofi Annan's paper on antiretrovirals. If the health care structure and systems exist in a country, they make sense—but in most of these countries, there are no systems, let alone modes systems.
For example, there is one doctor for 360 people in the United States. There is one doctor for 48,000 people in Mozambique. This is not like a shot or one pill once a year, like a Vitamin A therapy, you give it twice a year. A nurse could do that. These drugs are extremely toxic. Some people cannot take them and survive. Forty percent of the people in the United States who are HIV positive do not take the drugs, many of them, because they get so sick from the drugs.
Ms. LEE. Okay. So what is the problem?
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Mr. NATSIOS. So you have to have a physician administering the drugs and in many of these countries there are no physicians to administer. One. There are no roads. There is no cold chain——
Ms. LEE. Sure. But how does that relate to the declaration or the problems with regard to the special session?
Mr. NATSIOS. Because the debate is whether—how much of the proportion is to be used on those antiretrovirals versus on prevention, which is only 10 percent of what Kofi Annan's budget is about. Our budget is heavily invested in prevention.
Ms. LEE. I see. So there is a question with regard to——
Mr. NATSIOS. Strategy.
Ms. LEE [continuing]. Strategy.
Mr. NATSIOS. Yes.
Ms. LEE. And we are trying to work that out.
Mr. NATSIOS. We are trying to work it out. Clearly, the drugs that we give a woman at birth and the newborn at birth, they do work. You only have to administer it once and it has a profound effect.
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Ms. LEE. Who is going to lead our delegation? Who will be leading the United States delegation?
Mr. NATSIOS. We are discussing that now, but it will be a very senior person. And AID is involved at the technical level.
Ms. LEE. Will you be attending?
Mr. NATSIOS. If they ask me to attend, I will attend.
Ms. LEE. You will be attending. Okay.
Thank you, Mr. Chairman, and if I get another chance, I would like to ask more questions.
Chairman HYDE. Well, we have five more witnesses, so I am pleading with the membership to be succinct.
And with that admonition, I recognize the white haired gentleman from Massachusetts, Mr. Delahunt.
Mr. DELAHUNT. The Chairman looks at me sometimes askance because I have served with the Chairman as one of his minions on the Judiciary Committee, so he knows there are moments when I tend to go on, but I always abide by his commands.
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Let me just say this, to disagree for a moment with the Ranking Member who is no longer here, Mr. Natsios and I have some history together. We both served in the Massachusetts legislature. I come here today to not only ask a question or two, but also to welcome him. He is an outstanding appointment. And if anyone could deal with the Big Dig in Massachusetts, this prepares him well for the challenge that he meets as the director of AID.
Andy, welcome.
Mr. NATSIOS. Thank you.
Mr. DELAHUNT. I look forward to working with you.
Just to follow up with the questions that Congressman Lee was proposing, can you describe some of the absorption issues that AID faces? Because I think what I am hearing from you is that the lack of infrastructure for the disbursement of the appropriate medicines is so primitive that it makes sense at this point in time, while that particular strategy by necessity is going to have to be more long-term in nature, that the efforts that AID and presumably this government's recommendation to the international community is an emphasis on the prevention because of its immediate results.
Can you just pick out some selected examples of the absorption problems that you are confronted with?
Mr. NATSIOS. The problem in many countries is that there is not a health care system that is comprehensive, the reaches whole populations. The great tragedy in this epidemic in terms of one country is Botswana. Botswana is one of the best managed countries in the developing world. There is almost no corruption. The ministries do their work very well. It has a 38 percent infection rate. And it is not because they do not have a good ministry of health, it is because there is a big mining sector and the miners are away from their wives for a large part of the year. That causes a lot of sex workers and that spreads the disease very rapidly in a country that actually has infrastructure.
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So the biggest problem, if you look at Kofi Annan's budget, half the budget is for antiretrovirals. If we had them today, we could not distribute them. We could not administer the program because we do not have the doctors, we do not have the roads, we do not have the cold chain.
This sounds small and some people, if you have traveled to rural Africa you know this, this is not a criticism, just a different world. People do not know what watches and clocks are. They do not use western means for telling time. They use the sun. These drugs have to be administered during a certain sequence of time during the day and when you say take it at 10:00, people will say what do you mean by 10:00? They do not use those terms in the villages to describe time. They describe the morning and the afternoon and the evening. So that is a problem.
The problem of clean water is an issue in many areas. So the focus that we and other donor governments have taken at the technical level and the NGO level have been focused on prevention. First, because we have the drive and we have the absorptive capacity. The ministries of health that do have some infrastructure through their clinical workers—radio stations, for example, are very effective means for getting the word out, posters and radio stations, because people in very remote areas have radios and they listen in the villages. I have been there when they have played them in the evening. So that is a very powerful weapon to stop the spread of the disease.
The biggest problem on the infrastructure side is the administration of drugs which have to be administered daily and kept frozen and all that. The drugs for tuberculosis and those for malaria, those are much easier for us to administer than the antiretrovirals would require. So there is a focus in our program on treating the opportunistic diseases that lead to death.
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Most people do not die of HIV per se, they die of a disease because their immune system is collapsed, as I am sure you know, Congressman.
Chairman HYDE. The gentleman's time has expired.
Ms. Davis, do you have any questions?
Ms. DAVIS. Yes, Mr. Chairman. Thank you so much for holding this hearing.
And thank you, Mr. Natsios.
I would like to know, we have talked about HIV. Is HPV a problem in Africa?
Mr. NATSIOS. We have Dr. Delay here who will answer the question.
Dr. DELAY. Human papilloma virus is a major problem in Sub-Saharan Africa and in many parts of the world. The thing that is most concerning is that it is one of the major factors that causes cervical cancer and cervical cancer is a very prevalent cancer in Sub-Saharan Africa.
Ms. DAVIS. Given that, then, with respect to the condom distribution, what effort have USAID made to educate Africans that condoms do not protect against the HPV?
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Dr. DELAY. To be quite honest, not a lot. Condoms do not protect against HPV completely, nor herpes, which are the two viruses that are not in the actual bodily fluids, where it can be a skin-to-skin contact. Most of our programs do not talk about HPV, primarily to not make the messages too complicated. Also, understanding of what HPV is very limited. It is not a term that people know.
Ms. DAVIS. So they may have a false sense of security if they are using these 300 million condoms and think they are perfectly safe when in fact they may not be, but there is no warning that there is a problem or possibility.
Mr. NATSIOS. Our two preferred strategies before condoms, and I say this very seriously, are abstinence and faithfulness. It has changed the social structure in many African countries. There are people who do not get married now deliberately and will be abstinent their entire lives because they know the risk of infection is so high that they may die. And so I have met many people in Africa who have made a decision and those strategies are very powerful and they do work and they work particularly among young women. We have noticed a dramatic drop in the infection rates when we do that. And, of course, once that happens, there is protection against those other diseases as well.
Ms. DAVIS. Just real quick, Mr. Chairman, do you have the cervical cancer rate in Africa?
Dr. DELAY. I could get that number for you. I believe it is about 500,000 deaths per year caused by cervical cancer, but I will need to check that.
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Ms. DAVIS. Thank you, Mr. Chairman.
Chairman HYDE. Well, unfortunately, we have a vote and we have five more witnesses, so I am going to recess the Committee. Let us come back at 1 and ask the other witnesses if they want to grab a sandwich of something similar. We will resume at 1 and we will try to finish up.
Is that acceptable to you, Mr. Natsios?
Mr. NATSIOS. It is. Do you want me to be back at 1 or are you going to go on with the other witnesses?
Chairman HYDE. No, I think we can dispense with your——
Mr. NATSIOS. You can dispense with me.
Chairman HYDE. Yes. You have been——
Mr. NATSIOS. I appreciate that, Mr. Chairman. Thank you.
Chairman HYDE. Thank you very much.
[Recess.]
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Chairman HYDE. The Chair announces that pursuant to our rules we need two Members to take testimony and we have waited a sufficient time. I am reluctant to impose on our witnesses any more and so I am going to flaunt the rules and proceed.
Your statements will be made a part of the record, but you are here and we would like to hear you testify and so we will begin on our second panel.
We have the distinguished Ambassador from Senegal General Mamadou Mansour Seck. He holds considerable influence as the Dean of the West African Diplomatic Corps and has worked closely with the U.S. Departments of State and Defense in the design phase of the African Crisis Response Initiative and the African Center for Strategic Studies.
Prior to his appointment 9 years ago, Ambassador Seck was General Chief of Staff, Chairman of the Joint Chiefs of Staff, of Senegal.
It is an honor to welcome the Dean of the West African Diplomatic Corps.
Thank you, Mr. Ambassador.
Also joining us today is Stephen Hayes, currently President of the Corporate Council on Africa. From 1996 to 1999, he served as North American Director for Winnington Limited of London. Mr. Hayes was President of the American Center for International Leadership and has chaired and directed over 30 international conferences.
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Mr. Rupert Scofield is Co-Founder and Executive Director for Foundation for International Community Assistance (FINCA). He has previously held positions as CEO of Rural and Development Services and Country Program Director for AFL–CIO's Labor Program in El Salvador. Mr. Scofield, is a renowned expert on micro-financing and has designed innovative programs to assist the poor economically while enduring challenges, such as the HIV/AIDS pandemic.
Mr. Charles L. Dokmo has served as President of Opportunity International for the last 3 years. From 1994–1997, he was Regional Director of World Vision, Bucharest, Romania and has 20 years of experience with international non-governmental organizations. He is a pioneer in the micro-finance field and has dedicated his entire life to helping those in need. It's an honor to have Mr. Dokmo testify before the Committee.
Dr. Paul Zeitz is the founder and co-director of Global AIDS Alliance. He is a medical doctor with a specialization in international public health and epidemiology and holds a Master of Public Health from Johns Hopkins University School of Hygiene and Public Health.
Dr. Zeitz has served as Intercountry Coordinator for the U.N. Special Program Against HIV/AIDS Intercountry Coordinator for Eastern and Southern Africa and as Senior Policy and Technical Advisor for HIV/AIDS, Population, Child Health and Nutrition, Government of the Republic of Zambia, and USAID/Zambia. Dr. Zeitz is a dedicated professional and a leading advocate for those afflicted with HIV/AIDS.
We welcome the insights you gentlemen today offer and ask that you proceed with a 5 minute summary of your written statements. Your complete statements will be made a part of the record.
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We will begin with Ambassador Seck.
STATEMENT OF HIS EXCELLENCY MAMADOU MANSOUR SECK, AMBASSADOR E&P, REPUBLIC OF SENEGAL
Ambassador SECK. Mr. Chairman, good afternoon and thank you.
Ladies and gentlemen, Members of the House Committee on International Relations, thank you for your interest in Africa. I have to apologize because in my country we speak in French, so if you do not understand my English, I have to apologize in advance.
Ladies and gentlemen, Mr. Chairman, you highlight all those staggering numbers about HIV/AIDS all over the world. Those numbers, 35 million in the world and among them 26 in Africa infected; 11 million orphan children are living in this world. So 15,000 people are dying, as newly infected among them 5000 in Africa.
Even in this country with the high tech and the resources, still more than 1 million were infected for the last 20 years and a half million died. This means it is a global threat.
Of course, Africa is at the forefront of the fight. Last week, we read that a very young man, 12 years old, Nkosi Johnson, died. He was 12 years old. He was the hero of the International Conference on AIDS in Durban, South Africa—South Africa, where there are the highest number of infected, almost 5 million people.
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Ladies and gentlemen, what is the story of Senegal in this context? Sometimes when we talk about HIV/AIDS or assistance, we have the impression that there is nothing in Africa, there is no expert, we are not doing anything, but I think the burden is on the Africa shoulders first. Of course, we are friends to the Americans and we want them to be on board of this global pandemic because America, like Senegal, is a democracy.
That means that we cannot close our borders. Even in the case of Senegal, if we talk about the success stories, we still cannot close our border. If we have one of the lowest prevalences, still we are in bodies and institutions like the Economic Cooperation of West African States (ECOWAS) countries in West Africa where we have the free circulation of service and persons.
What happened in Senegal? In 1969, Senegal already started the registration and regular medical checkups of sex workers. Prostitution was legalized. In 1969, we began the blood bank testing. In 1986, the government designed the Plan National De-Lutte-Contre-Le-SIDA, National Plan to Fight HIV/AIDS. In 1992, Senegal