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Senate Committee Addresses PEPFAR Reauthorization

On October 24, the Senate Foreign Affairs Committee held a hearing, “The Next Phase of the Global Fight Against HIV/AIDS,” which centered on reauthorization of the President’s Emergency Plan for AIDS Relief (PEPFAR). PEPFAR’s current authorization, known as the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (P.L. 108-25), expires at the end of FY2008. The House Foreign Affairs Committee has held similar hearings on the plan (see The Source, 9/28/07, and The Source, 10/12/07). President Bush has called for PEPFAR to be reauthorized at $30 billion over five years, double the initial $15 billion five-year authorization.

Chair Joseph Biden (D-DE) noted that there are 6,000 new HIV infections each day, and he applauded PEPFAR for providing anti-retroviral treatment to over a million of those infected with HIV in PEPFAR’s 15 focus countries. “But that’s still less than a quarter of those who need treatment in poor and middle-income countries,” he said. “We are not keeping pace with the pandemic. For every person who enrolled in a treatment program last year, six more became newly infected. The United States and its partners need to devote more funds to this effort, but it’s not just a question of more money, it’s a question of how we spend it.” Sen. Biden said his goals for reauthorization included improving prevention; eliminating earmarks or allocations that stipulate how funds should be spent, because “we are not facing a single pandemic, but rather 15 or more local epidemics”; addressing gender-based violence and inequity; and improving efforts against tuberculosis and malaria.

Ranking Member Richard Lugar (R-IN) also applauded PEPFAR’s support for treatment. But he called for its swift reauthorization, citing a letter from health ministers of the 12 African focus countries that read, “Without an early and clear signal of the continuity of PEPFAR’s support, we are concerned that partners might not move as quickly as possible to fill the resource gap that might be created…The momentum will be much greater in 2008 if we know what to expect after 2008.” Sen. Lugar said, “Congress can reach an agreement expeditiously on this reauthorization. Most of the Leadership Act’s provisions are sound and do not require alteration. The authorities in the original bill are expansive, and they are enabling the program to succeed in diverse nations.” Sen. Lugar introduced the HIV/AIDS Assistance Reauthorization Act of 2007 (S. 1966) that would provide $30 billion over five years for the reauthorization, as well as mandate that at least 50 percent of the funds for HIV prevention “shall be dedicated to abstinence and fidelity as components of a comprehensive approach, including abstinence, fidelity, and the correct and consistent use of condoms.”

Ambassador Mark Dybul, U.S. Global AIDS coordinator, was the only witness at the hearing. “PEPFAR is well on the way to achieving its ambitious five-year targets of supporting treatment for two million people, prevention of seven million new infections, and care for 10 million people infected [with] and affected by HIV/AIDS, including orphans and vulnerable children,” he said. Ambassador Dybul noted that PEPFAR prevention messages have reached 61 million people, and the government has supplied 1.67 billion condoms. Currently, he said, 46 percent of funds are spent on treatment, 29 percent on prevention, and the remainder on care.

But prevention, he said, should receive more attention. There are indications of declining HIV prevalence in some African nations, and there have been “dramatic declines” in Uganda, he said. He advocated “ABC behavior change: abstain, be faithful, and correct and consistent use of condoms.” “ABC requires significant cultural change,” Ambassador Dybul said, including delaying a young person’s first sexual experience, reducing casual sexual relationships with multiple people, and changing gender norms that now make women dependent on men. “PEPFAR has been a leader in addressing gender issues,” he said, noting that it was the first international program to differentiate between men and women in its data, thereby helping to identify gender disparities in treatment and prevention.

Ambassador Dybul said that the original authorization is “not perfect, but it’s very good,” and said that expeditious reauthorization should have “a solid foundation in the first, good law.”

During questions, Sen. Russ Feingold (D-WI) asked about the deficit of health care workers in sub-Saharan Africa, which by some accounts totals one million workers. Ambassador Dybul said the best way to retain workers was to “give them hope…a sense they can do something.” He said PEPFAR funding has helped retain medical professionals in critically needed locations, including rural areas.

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