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Focus on Global Health Continues with House Hearing on HIV/AIDS

On March 11, the House Foreign Affairs Subcommittee on Africa and Global Health held a hearing on “U.S. Investments in HIV/AIDS: Opportunities and Challenges Ahead.”

Chair Donald Payne (D-NJ) said, “PEPFAR [the President’s Plan for Emergency AIDS Relief] programs have had a remarkable international impact. As of December 2008, approximately four million people in low and middle income countries were receiving antiretroviral therapy (ART) about ten times more than just five years ago. The number of new HIV infections among children has declined as a result of expanded access to medicine for the prevention of mother-to-child transmission (PMTCT). About 45 percent of HIV-positive pregnant women worldwide had access to PMTCT services in 2008. This is a significant improvement from 10 percent in 2004…Despite tremendous efforts made by the United States and the international community, AIDS is still among the biggest infectious killers the world has ever seen. Sub-Saharan Africa remains the region most severely impacted by HIV/AIDS…Although the rate of new infections is slowly declining, the number of people living with the virus continues to grow, due in large part to greater access to antiretroviral medication. While coverage rates have improved across Africa, mother-to-child transmission continues to account for a substantial portion of new HIV cases. It is unconscionable that children continue to be born with the virus when we have the tools to prevent transmission. We must make it our goal to eliminate mother-to-child transmission of HIV.”

Peter Mugyenyi M.D., executive director of the Joint Clinical Research Centre (JCRC) in Kampala, Uganda, testified that, “Recently, excitement has built around the potential to both reverse the pandemic and to have a major impact on overall health through effective AIDS programming.Evidence has shown significant strengthening of health systems by AIDS programming. For instance, PEPFAR assisted my Institution, the JCRC, to establish diagnostic and clinical facilities. It has also helped us improve our standards of care by supporting our training program, which has so far trained thousands of health care providers who are now providing crucial services to both the public and private sectors in Uganda. There is also significant evidence that AIDS programming, where it has reached community-wide coverage, has been among the most successful interventions for broader health. Studies in Uganda have shown the increase in services for HIV/AIDS was accompanied by a reduction innon-HIV infant mortality of 83 percent as parents not only lived but thrived. The DART [Development of Anti-Retroviral Therapy] study, which I co-chaired, found that of 300 HIV-positive pregnant women with very low CD4 counts, ARVs prevented their children from being infected 100 percent of the time. Essentially, it also found a 75 percent reduction in malaria associated with anti-retroviral therapy.”

Dr. Mugyenyi also provided on-the-ground implications of level-funding for PEPFAR, saying, “Let me tell you what I have seen: I have witnessed desperate patients unable to access therapy, including pregnant women, resorting to desperate and dangerous measures including sharing drugs with their family members, ignoring the good counseling they receive advising against this dangerous practice. Recently, an HIV-infected poor woman who was breastfeeding her HIV-negative child because she could not afford formula milk came to our clinic, having been turned away from three other clinics in Kampala because they had no slots. She knew that every day she breast fed her baby without being on treatment greatly increased the chances of her child getting infected, but she had no alternative. As we were trying to find her a treatment center that still had a slot, we were repeatedly told that they were turning away similar cases. We have a situation where some people in need of therapy get it, yet their family members in similar need don’t. Through our long experience, we learned that it is virtually impossible to have a successful public sector AIDS treatment program where some people get therapy and others in dire need don’t.”

Dr. Joanne Carter, executive director of RESULTS/RESULTS Educational Fund, also discussed shortfalls in global HIV/AIDS funding: “The administration’s budget suggests a new approach to our global health portfolio in which U.S. funding supports a response to AIDS that is more closely linked to other health priorities. This is a welcome sentiment, but the evidence shows that this approach only works when programs are fully funded. Smart linkages between programs are not free. This approach to broaden the set of priorities on which we focus without necessarily adequately funding any of them could have serious consequences for people living with or at high risk of contracting HIV. The President’s FY2011 budget request essentially flat-funds our global AIDS programs. The budget includes an additional $141 million or two percent increase in bilateral AIDS funding this in the face of seven to ten percent inflation in Africa. If we were on pace to reach the Lantos-Hyde authorizationlevels, the request this year for global AIDS should be $2.2 billion more. The budget also proposes a $50 million cut to the highly effective Global Fund to Fight AIDS, TB [tuberculosis], and Malaria at the very time when the Global Fund’s impact is accelerating, and a miniscule $5 million increase for bilateral TB, the leading killer of people with HIV/AIDS. As I will discuss in further detail, under-funding these initiatives will prohibit us from seizing major opportunities in our global AIDS response, and undermine efforts to cut deaths due to TB and malaria as well. My colleagues on this panel are better equipped to discuss the impact on the ground of halting the scale-up of HIV/AIDS funding, but I share their concern that our departure from the vision of the Lantos-Hyde Act will leave too many waiting in line for treatment, prevention, and care.”

Two months ago I traveled to Zimbabwe with my colleagues from PSI and with staff from UNAIDS to learn more about the HIV pandemic in sub-Saharan Africa,” said actress Debra Messing on behalf of Population Services International (PSI), a global health organization. She continued, “What I saw in Zimbabwe was that the investment and strong support from PEPFAR, the Global Fund to Fight AIDS, Tuberculosis, and Malaria, and other donors is paying off in dramatic ways…But it also became heartbreakingly clear to me that resources still fall short of what is needed to reach everyone at risk for HIV. In particular, I learned that further gains can be made through a combination of proven biomedical, behavioral, and structural HIV prevention tools and strategies available to us. I would like to tell you today about two prevention tools that could make a difference if there is continued investment: male circumcision and HIV testing and counseling…There is now strong evidence that male circumcision reduces the risk of heterosexually-acquired HIV infection in men by about 60 percent, yet only about one in ten Zimbabwean adult men are circumcised. PSI and its partners run circumcision clinics in Zimbabwe and other countries, with support from PEPFAR and other donors…It is estimated that if male circumcision is scaled up to reach 80 percent of adult and newborn males in Zimbabwe by 2015, it could avert almost 750,000 adult HIV infections—that equals 40 percent of all new HIV infections that would have occurred otherwise without the intervention and it could yield total net savings of $3.8 billion U.S. dollars between 2009 and 2025. Male circumcision programs get robust support from the U.S. government in Zimbabwe and other countries, but greater resources would yield greater results.”

With regard to counseling, Ms. Messing said, “An estimated 72 percent of Zimbabweans with HIV are unaware that they are infected. To better understand the HIV counseling and testing process, I was tested for HIV at a PSI New Start center in Harare that is funded by PEPFAR, the Global Fund, and the British government…A lab technician gave me the confidential test, a tiny pin prick to the finger that turned out to be painless. Then, I waited for about 15 or 20 minutes for my results. In a private room, with a trained counselor, I was given my results and felt a great sense of relief. I was counseled on staying negative. Had I tested positive, I would have been counseled on what that means and I would have been referred to a post-test center where I would receive additional counseling and referral services for anti-retroviral treatment. 35,000 Zimbabweans go through this HIV counseling and testing experience every month just as I did, emerging with a greater awareness of measures they can take to protect themselves and others. New Start centers also integrate family planning services, provide screening for tuberculosis, and offer other health services.”

Dr. Norman Hearst, professor of family and community medicine and of epidemiology and biostatistics at the University of California, San Francisco, and Vuyiseka Dubula, general secretary for the Treatment Action Campaign, also testified.