On April 24, the House Foreign Affairs Committee held a hearing to evaluate the President’s Emergency Plan for AIDS Relief (PEPFAR) (P.L. 108-25). PEPFAR is scheduled to be reauthorized during this Congress.
Noting that the number of people with HIV/AIDS has risen by 2.6 million in the past three years, Chair Tom Lantos (D-CA) said, “Congress will reauthorize this crucial HIV/AIDS law and will fully fund HIV and AIDS programs in the poorest of countries on our planet.” Concerning the provision requiring 33 percent of funding for prevention initiatives to be used for abstinence-until-marriage education, Rep. Lantos expressed the need to “take a hard look at the consequences of this funding scheme and consider its wisdom.” He cited a recent report from the Institute of Medicine, which “says that this provision has impeded the prevention arm from achieving its goals,” and he quoted a Government Accountability Office report specifying that the 33 percent clause challenges “the country teams’ ability to integrate the components of the ABC model and respond to local needs, local epidemiology, and distinctive social and cultural patterns.”
Ranking Member Ileana Ros-Lehtinen (R-FL) stated, “Through PEPFAR, the American people have helped provide care for 2.4 million people affected by HIV/AIDS, in addition to 2 million orphans and vulnerable children. We have supported the provision of antiretroviral treatment for 820,000 people, with an estimated 50,000 new people gaining access to treatment each month.” She added, “UNAIDS estimates that in 2006 alone, 4.3 million people became infected. An estimated 12 percent of those new infections occurred among children, 90 percent of which occurred as a result of mother-to-child transmission…As a mother, I cannot accept this as a foregone conclusion.” Referring to the IOM report, Rep. Ros-Lehtinen said, “As medical experts rather than politicians, it was believed the IOM would be well-suited to provide the type of unbiased, scientifically verifiable data that Congress would need in order to make evidence-based decisions when and if it came time to reauthorize PEPFAR. Unfortunately, IOM has asserted that it could not provide this data because the program is not mature enough to truly assess its impact.”
U.S. Global Coordinator Ambassador Mark Dybul outlined the strategies, successes, and challenges of PEPFAR, asserting, “Not since the Marshall Plan has the world seen such a massive commitment to international development.” He noted that, by the end of FY2006, PEPFAR had “partnered with host nations to support antiretroviral treatment for 822,000 people in the 15 focus nations,” adding, “The number of PEPFAR-supported treatment sites increased by 139 percent over 2005, with 93 new sites coming on line each month. Of those for whom PEPFAR provided site-specific treatment support, almost nine percent were children, and approximately 61 percent were women.”
Dr. Dybul highlighted PEPFAR’s role in the prevention of mother-to-child transmission (PMTCT): “Since PEPFAR’s inception, we have supported PMTCT services for women during more than 6 million pregnancies. Through FY2006, there are 4,863 PEPFAR-supported PMTCT service outlets in the focus countries, and PEPFAR has supported ARV prophylaxis for HIV-positive women during 533,700 pregnancies. This has saved an estimated 101,500 infants from HIV infection. In addition, by promoting the routine, voluntary offer of HIV testing to women who visit antenatal clinics, host nations have increased the rate of uptake among pregnant women from low levels to around 90 percent at many sites.”
Addressing PEPFAR’s impact on women and girls, Dr. Dybul said, “Around the world, girls and women are contracting HIV at an alarming rate. The reasons are complex, but they are invariably tied to pervasive, powerful, and often brutal gender inequities. In many of the most heavily affected countries, women and girls are simply powerless to protect themselves against contracting HIV/AIDS. Because of this, PEPFAR places a priority on gender. Our program is the only major international initiative to require data reporting by gender. We do so to track whether girls and women are receiving the services they need, and we know that girls comprise 51 percent of the more than 2 million orphans and vulnerable children receiving PEPFAR-supported care.” He detailed five high-priority gender strategies specified in the authorizing legislation for PEPFAR:
- increasing gender equity in HIV/AIDS activities and services;
- reducing violence and coercion;
- addressing male norms and behaviors;
- increasing women’s legal protection; and
- increasing women’s access to income and productive resources.“These five strategies are monitored annually during the Country Operational Plan (COP) review process,” he explained, adding, “In FY2006, a total of $442 million supported more than 830 interventions that included one or more of these gender strategies, including $104 million for activities specifically addressing gender-based violence and sexual coercion. In addition, last year we convened some 120 experts and stakeholders to discuss the latest findings on gender and HIV/AIDS, and to clarify programming priorities. Two months later, PEPFAR allocated an initial $8 million in central funding to launch new, gender-specific initiatives in the high-priority areas that had been identified. Beginning in FY2007, an increased number of programs will seek to change male norms, respond to gender-based violence, and address adolescent vulnerability.”
Regarding the ABC prevention strategy, Dr. Drybul stated, “Long before PEPFAR was initiated, many nations with generalized epidemics had already developed their own national HIV prevention strategies that included the ‘ABC’ approach to behavior change (Abstain, Be faithful, correct and consistent use of Condoms where appropriate). The new data from time periods that pre-date PEPFAR scale-up link adoption of all three of the ABC behaviors to reductions in prevalence. Learning from this evidence, PEPFAR will continue to support all three elements of the evidence-based ABC strategy in ways that are appropriate to the epidemiology and national strategy of each host nation. In focus countries during fiscal year 2006, approximately 61.5 million people were reached by community outreach programs promoting ABC and other related prevention strategies.” Dr. Dybul clarified that countries having concentrated HIV/AIDS epidemics with high percentages of infections “among persons who participate in prostitution” require “a response more heavily focused on B and C interventions.” He added, “The U.S. Government has supplied 1.3 billion condoms from 2004 to 2006, lending support to comprehensive ABC approaches based on the epidemiology of each country. As UNAIDS Executive Director Dr. Peter Piot recently observed, the U.S. is by far the biggest supplier of condoms to the developing world, providing more than all other sources combined.” Concerning new prevention methods, Dr. Dybul said, “In regard to circumcision and any other new prevention methods and technologies such as an HIV vaccine or topical microbicide PEPFAR will incorporate these new approaches, as the evidence is accumulated and normative guidance is provided.”
During questions, Rep. Lantos asked Dr. Dybul to respond to critics of funding for the ABC strategy. Dr. Dybul stressed the importance of acting on evidence-based data and reiterated his view that data show that “a comprehensive ABC approach…is the most effective approach in a generalized epidemic because 90 percent of infections are sexually transmitted and so we are fundamentally changing behaviors.” Pointing out that the “most at-risk people are young adults,” he said that, in countries such as Kenya, Namibia, Ethiopia and Uganda, there is a clear correlation between declines in HIV/AIDS prevalence and delayed debuts of sexual activity. Dr. Dybul said that “the approach has always been to provide information” and then let people make their own decisions. He stressed that this is a “gender issue,” stating that “young women need to know they don’t have to engage in sexual activity.”
Rep. Russ Carnahan (D-MO) noted the concerns expressed in the IOM and GAO reports over the funding formula and said that “more flexibility” may be needed. Dr. Dybul assured the committee that there is “enormous flexibility in the system” and emphasized that the ABC strategy was “designed in Africa.” He affirmed that “the evidence and the data are there” and said that a comprehensive ABC program helps young people “to respect themselves, to respect others” and “does wonders for gender rights.”
Rep. Chris Smith (R-NJ) stressed that “the ABC model is evidence based” and that “people’s behavior can change.” Regarding HIV/AIDS and prostitution, he said that we should “try to ensure that we do not become enablers of sex trafficking and prostitution,” citing the need to “differentiate between those organizations that help women in brothels” while not partnering with brothel owners.
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