On September 25, the House Committee on Foreign Affairs held a hearing on the President’s Emergency Plan for AIDS Relief (PEPFAR) (P.L. 108-25), “PEPFAR Reauthorization: From Emergency to Sustainability.” Enacted in 2003, the law provided $15 billion over five years for HIV/AIDS treatment in Africa, 55 percent of which was earmarked for treatment. President Bush said he would seek $30 billion over the next five years for the program.
“The legislation produced by our committee has yielded dramatic results particularly in the area of treatment,” said Chair Tom Lantos (D-CA). “But the task for the next five years is not only to solidify these gains, but to re-orient the program so that our efforts to combat HIV/AIDS will be sustainable for generations to come. To be sustainable, our HIV/AIDS program must dramatically strengthen the health care delivery systems in nations ravaged by the deadly virus. To be sustainable, our program must find new and creative ways to deliver the ABC [Abstinence, Being Faithful, Condom Use] prevention message.” He added, “For couples who don’t know whether they have HIV, or where one partner has been tested and found free of the virus, condoms are essential. Unlike the guidance issued by the Executive Branch, I do not believe that condoms are only for prostitutes and truck drivers.”
Ranking Member Ileana Ros-Lehtinen (R-FL) noted that PEPFAR had helped care for 4.5 million people affected by HIV and AIDS, including 2 million orphans and children. However, she said, “More and more people become infected each day. According to UNAIDS [the Joint United Nations Program on HIV/AIDS], an estimated 4.3 million new infections occurred in 2006 alone…There will be much discussion about how to transition PEPFAR from an emergency program to a sustainable one. To do this, some are advocating that PEPFAR take on additional challenges, including by placing greater emphasis on gender issues, deficits in health care systems, and the lack of food security for those with HIV/AIDS. While there is a great deal of merit to some of these arguments, I urge caution in this process. If PEPFAR is directed to take on a universe of problems that plague the focus countries, we risk reducing it to a program that is a mile wide and an inch deep…Abstinence and fidelity programs are working, where the traditional focus on condom promotion that dominated the U.S. strategy for the first 17 years of the pandemic has failed.”
Dr. Helene Gayle, president and chief executive officer of CARE USA, testified, “We must now transform PEPFAR into a program that is capable of responding to HIV and AIDS as a protracted challenge that has complex social, economic, and cultural dimensions, in addition to the obvious health dimension. That calls for addressing HIV and AIDS within a development framework, integrated with other key health issues. Otherwise, our investments may effectively address the consequences of HIV and AIDS in the short term, while making little headway in attacking the underlying drivers of the pandemic over the long term.” Dr. Gayle said that “PEPFAR’s tendency to fund short-term interventions often neglects the social processes vital for real local ownership; that its emphasis on quick results produces incentives to ‘demonstrate big numbers’; and that its narrow focus and compartmentalized approach to prevention, treatment, and care inhibit integrated, comprehensive programming.” Her recommendations included investing in “universal education for girls,” which would also increase their economic independence; improving food and economic security to reduce “survival sex”; creating micro-credit finance programs; and empowering women and meeting their family planning needs.
Dr. Gayle said PEPFAR needs to focus on women’s social vulnerability, “not only on their HIV-related needs but also on their ability to make independent decisions…their confidence to negotiate in relationships…laws and institutions that protect women’s rights (e.g., in relation to property and inheritance rights), and opportunities to link women together to promote solidarity and collective action.” This “ABC plus” approach, she said, would better meet the needs of women, who make up 60 percent of HIV and AIDS cases in sub-Saharan Africa. But she emphasized that there was no “one size fits all” solution for all nations.
Dr. Nils Daulaire, president and chief executive officer of the Global Health Council, said that PEPFAR initiatives must strengthen nations’ health systems more broadly and tackle public health issues, “such as maternal and child health, family planning, nutrition, clean water, and other diseases,” and not just focus on a “single-disease, single-intervention” approach. For instance, Dr. Daulaire pointed out that PEPFAR provides HIV-positive expecting mothers the drug nevirapine to reduce mother-to-child HIV transmission. But he noted that most women are not tested for HIV, and only a “small dent” had been made in the problem because “women generally come to the health care system in the first place not for HIV care but for routine family planning and maternal and child health care…So unless the HIV services are deeply integrated with family planning and maternal and child health services, most who need them will never even know they need them, much less get them. These women need help not just with their HIV infections…They need access to nutritious food. They need to know how they can prevent or delay their next pregnancy. And their newborns, whether HIV-infected or not, need basic newborn and child care.”
Dr. Daulaire’s recommendations included linking PEPFAR programs to other disease-prevention programs, such as tuberculosis and malaria; training and supporting new health workers; and increasing joint planning and coordination between PEPFAR and host nations’ HIV/AIDS strategies.
Dr. Norman Hearst of the University of California, San Francisco, disagreed, saying that “ABC plus” programs might take the focus away from AIDS prevention “to whatever other good cause people are promoting.” In particular, Dr. Hearst criticized the use of condoms in “generalized epidemics,” as HIV/AIDS is in sub-Saharan Africa. Dr. Hearst’s study, which was commissioned, but not published, by UNAIDS, found that condoms were effective in “concentrated epidemics,” such as among gay men in San Francisco. But, he said, “No generalized HIV epidemic has ever been rolled back by a prevention strategy based primarily on condoms. Instead, the few successes in turning around generalized HIV epidemics, such as in Uganda, were achieved not through condoms but by getting people to change their sexual behavior.”
Dr. Hearst endorsed the ABC approach, but thought there needed to be more emphasis on changing individual behavior to promote abstinence and fidelity in generalized epidemics. He said a statement endorsed by “150 AIDS experts, including Nobel laureates, the president of Uganda, and officials of most international AIDS organizations,” urged that “in generalized epidemics, the priority for adults should be B (limiting one’s number of partners). The priority for young people should be A (not starting sexual activity too soon). C (condoms) should be the main emphasis only in settings of concentrated transmission, like commercial sex.”
Rep. Chris Smith (R-NJ) applauded the 2003 law’s earmark requiring 33 percent of prevention spending to fund abstinence and fidelity programs; without the earmark, he said, “We are faced with the specter of returning to a failed condoms-centric approach and to the devastating loss of human life of the pre-PEPFAR era.” He also said he was “deeply disturbed by the insinuations of some that sexual behavioral change is not possible for Africans,” citing a National Review article that claims “prejudice against Africans with no self-discipline or control over the sex drive simmers just beneath the surface of much anti-abstinence propaganda.”
During questions, Rep. Smith pressed Dr. Gayle on whether CARE supported abortion procedures in its operations. Dr. Gayle said that the organization did not advocate for any specific reproductive health procedure, believing that it was each nation’s right to make their own laws, and that CARE wanted women to “have the option of avoiding pregnancy if that’s their choice.” Dr. Gayle said CARE hopes the reauthorization will “remov[e] arbitrary restrictions…[and] avoid budget allocations and restrictions, such as the abstinence-until-marriage earmark and the anti-prostitution pledge requirement, since they tend to work against evidence-based prevention approaches.”
