On September 29, the House Committee on Foreign Affairs held a hearing, “PEPFAR: From Emergency to Sustainability and Advances Against HIV/AIDS.”
In providing an overview of the successes and challenges of the President’s Emergency Plan for AIDS Relief (PEPFAR), Chair Howard Berman (D-CA) said, “PEPFAR faced many challenges during its first five years, including weak health care delivery systems, poor infrastructure, expensive and unavailable drugs, and limited workforce…Social barriers like stigma, gender inequality, and prejudices against men who have sex with men, commercial sex workers, and intravenous drug users, compounded the challenges to expanding services to those in need. But PEPFAR successfully invested in strengthening health care systems, training new health care personnel, purchasing affordable drugs, and helped to remove stigma and empower women and girls and other at-risk populations.” Rep. Berman added, “Today we have some good news in spite of the sobering impact the pandemic continues to have in poor countries. Globally, the overall rate of new HIV infections has slowed and prevalence rates have leveled off. According to the 2009 UNAIDS report, new HIV infections have been reduced by 17 percent over the past eight years. In 2008, Sub-Saharan Africa reported 14 percent fewer new infections than in 2001. In East Asia, new HIV infections declined by nearly 25 percent and in South and South East Asia they declined by 10 percent. Scientists from the U.S. and Africa are conducting research on the use of anti-retroviral drug treatment as part of prevention. Preliminary results demonstrated that ARVs [antiretroviral drugs] could both keep people well and prevent infections. For example, in Africa, a seven-country study was undertaken in which one partner was infected and the other was not. After three years, only one uninfected partner was HIV-positive when the infected partner was on antiretroviral therapy. And in South Africa, researchers recently identified a new microbicide that may significantly reduce HIV infection rates in women. Based on these and other promising developments, it’s fair to conclude that our ambitious investment in AIDS prevention, treatment, and care programs has helped make a historical difference and there is sufficient epidemiological evidence to give us hope that this scourge on humankind can be defeated within our lifetime.”
While praising the success PEPFAR has had in saving lives around the world, Ranking Member Ileana Ros-Lehtinen (R-FL) expressed her concerns about its funding and linkage to the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) in a statement, saying, “For the United States, supporting universal access to treatment in just the original 15 PEPFAR focus countries would absorb more than half of the entire foreign assistance budget by 2016 – just a little over five years from now. Meanwhile, here at home, domestic funding deficits have forced states, including Florida, to create waiting lists and cut benefits for Americans who rely on AIDS Drug Assistance Programs (ADAPs). Obviously, the global economic crisis and our crushing national debt are undermining the ability of the American taxpayer to continue to shoulder over 58 percent of the entire global response to the HIV/AIDS crisis. The apparent preference to reorient PEPFAR toward the same old ambiguous, inefficient, and ineffective development programs that have failed for the past 20 years is therefore deeply troubling. To succeed, PEPFAR must remain focused on its core objectives: providing care and treatment to those affected by HIV/AIDS, while expanding efforts to prevent new infections from occurring. Funds must not be diverted for other purposes, particularly those which the majority of American people regard as morally repugnant. I also am concerned by the inclination of some – in the name of sustainability – to shift increasing amounts of United States assistance toward the Global Fund. While increased burden-sharing to fight HIV/AIDS is desirable, the Global Fund is fraught with structural challenges that must be addressed if we are going to continue our support. For example, the amount of funds that middle-income countries have drawn from the Fund – at the expense of less developed nations with higher prevalence rates – is shocking. China, with the world’s second largest economy and over $2.5 trillion in foreign reserves, is the fourth largest recipient of Global Fund grants. Additionally, massive fraud and the outright theft of Global Fund grants continually rob intended beneficiaries of life-saving support. The unwillingness of the Global Fund’s Secretariat and Board to press for greater accountability from its implementing partners, particularly the UN Development Program, is disgraceful. As the single largest donor to the Fund, the United States owes a duty of care to the intended beneficiaries.”
Ambassador Eric Goosby, U.S. Global AIDS Coordinator, addressed the implementation of the five-year strategic plan for PEPFAR and highlighted the importance of meeting the needs of women and girls. He said, “The president’s GHI [Global Health Initiative] recognizes that focusing on women, girls, and gender equality is a force multiplier: it improves the health status of women, and in turn that of their families and communities. For PEPFAR, this focus is essential. AIDS is the leading cause of death of women of reproductive age worldwide, and nearly 60 percent of those living with HIV in sub-Saharan Africa are women. In the countries where PEPFAR works, HIV is a women’s health issue, and prevention, care and treatment services must be tailored to the gender realities within a country. During its first phase, PEPFAR began a five-point gender strategy, through which we seeded country programs with multiple small initiatives. To build on this important foundation, in the next phase we are working to improve implementation of our gender strategy, and scale up efforts and heighten impact with a focus on PMTCT and country-led gender projects. One risk factor for HIV infection for women is the tragic epidemic of gender-based violence. Earlier this year we launched an initiative to invest $30 million in activities to combat gender-based violence in three countries severely burdened by it. We’re supporting post-exposure prophylaxis and other care for women victimized by rape, but also seeking to prevent sexual violence in the first place…Innovation to provide women with prevention interventions they can control is a critical priority. With PEPFAR funding in 2007-2010, USAID supported two trials with specific antiviral agents and unique delivery regimens which might increase user acceptability and compliance as well as product effectiveness. In July 2010, the landmark results of the CAPRISA trial of one percent Tenofovir Vaginal Gel were announced, providing the first-ever proof of concept that a microbicide can significantly reduce the risk of HIV infection in women. Volunteers using it had an overall reduction in HIV infection of 39 percent, and in volunteers who were most compliant in using the gel, the reduction was even higher, at 54 percent. With continued U.S. technical and financial leadership, this breakthrough in development of a woman-controlled method of HIV prevention has the potential to reduce the spread of HIV and empower women to protect their health and lives.”
Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health (NIH), testified about NIH’s role in developing new technologies and treatments to extend the lives of people living with HIV and AIDS. Specifically, he noted that “One of the compelling features of PrEP [pre-exposure prophylaxis, which involves providing ARVs to HIV-negative people who are at high risk of HIV infection] is that women and other vulnerable individuals can control its use independent of their sexual partners. Safe and effective topical microbicides, such as vaginal gels, foams, and creams, represent another potentially important method of HIV prevention for women, who now often rely on male-controlled prevention modalities, such as the male condom. NIH currently supports a robust research portfolio to develop topical microbicides to prevent HIV infection, to evaluate new products and formulations, as well as to establish different routes of administration.” Dr. Fauci continued, “The early clinical trials of microbicides tested candidates that had physical properties that were thought to be potentially protective. These trials, however, were not successful. After these disappointing results, researchers shifted their focus to a new generation of candidate microbicides, which utilize ARVs formulated for topical application. The first results from a large clinical trial using such a product – the CAPRISA 004 trial in South Africa – were announced this summer at the XVIII International AIDS Conference in Vienna. The CAPRISA study found that the incorporation of an ARV drug – in this case tenofovir – into a vaginal gel was more than 50 percent protective against HIV infection, when used as directed. With women constituting the majority of new HIV infections throughout the world, this finding is an important step toward empowering an at-risk population with a safe and effective HIV prevention tool. The CAPRISA study was sponsored primarily by the U.S. Agency for International Development using the clinical trial infrastructure established with NIH support.”
In urging continued funding for PEPFAR, Paula Akugizibwe, advocacy coordinator for the AIDS and Rights Alliance for Southern Africa, said, “Unfortunately, the marginal increases in the PEPFAR budget – estimated to be two percent in 2010 – have barely been adequate to sustain treatment programs given current inflation rates. PEPFAR reduced its budget for treatment for the first time in 2009, from $1.56 billion in 2008 to $1.4 billion in 2009. Additionally, the Global Fund allocation requested by President Obama for 2011 was $50 million less than what was given last year – and at current levels approximating $1.1 billion, still falls far short of the $2 billion per year that was authorized in the Lantos-Hyde legislation.” Ms. Akugizibwe added, “Much like the establishment of PEPFAR changed the landscape of the global AIDS response in the direction of universal access, so the current slackening of U.S. government financial commitment to HIV, rather than encouraging an invigorated response from other countries, is instead leading a regression back to the landscape where HIV was a death sentence because the price tag of life was deemed too high by governments. However, the longer-term price tag will be even greater. The World Bank warned in a 2009 report about the impact of the economic crisis on HIV that ‘responding to immediate fiscal pressure by reducing spending on HIV treatment and prevention will reverse recent gains and require costly offsetting measures over the longer term.’ Even more disappointingly, this reduced spending on HIV comes at a time when the fight against AIDS is showing encouraging signs of success, and when advocacy to hold national governments accountable – both for adequate investment in health as well as responsible usage of health funds – is rapidly gaining momentum. The extensive community networks and movements that have been created through the HIV response have presented extraordinary platforms for mobilization around the broader challenge of holding national governments accountable for their action on resource allocation for health, including HIV treatment; on optimal use of these resources through improved policy and programming; and on intensified efforts to fight corruption. Decreasing funding will contribute to dismantling these platforms and undo the momentum that has begun to build up – at a time when we need it most.”
Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention, and Dr. Wafaa El-Sadr, director of the International Center for AIDS Care and Treatment Programs and director of the Center for Infectious Disease Epidemiologic Research at Columbia University, also testified.
