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Senate Committees Examine PEPFAR Reauthorization

Senate Health, Education, Labor, and Pensions (HELP) Committee

On December 11, the Senate HELP Committee held a hearing on the reauthorization of the President’s Emergency Plan for AIDS Relief (PEPFAR), “Meeting the Global Challenges of AIDS, TB, and Malaria.” PEPFAR’s current authorization, the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (P.L. 108-25), expires at the end of FY2008. President Bush has called for PEPFAR to be reauthorized at $30 billion over five years, double the initial $15 billion five-year authorization.

Chair Edward Kennedy (D-MA) said, “I commend President Bush for launching the PEPFAR global AIDS initiative to help meet this challenge, and for joining Democrats and Republicans in calling for its renewal…PEPFAR currently supports treatment with lifesaving anti-retroviral drugs for nearly one and a half million people. The program has supported services to prevent mother-to-child transmission of HIV for over 10 million pregnancies. And it has provided help for 2.7 million orphans and vulnerable children. We must build on these successes, and examine where the program needs improvement.”

Ranking Member Mike Enzi (R-WY) said, “As we take another look at a program that has been so successful, we must maintain a high level of accountability and measurable results. Any additional flexibility in this program must be met with corresponding accountability to make sure our tax dollars are spent wisely and efficiently, and our fight against global AIDS is successful…The global AIDS program must keep its focus on HIV/AIDS. However, it will be most successful if it is linked to programs that provide food, clean water, safe roads, and transportation.”

The central dispute during the hearing involved the requirement that one-third of funds spent on prevention go to abstinence-until-marriage programs, a part of the ABC (Abstain, Be faithful, correct and consistent use of Condoms) approach. The Institute of Medicine’s (IOM) 2007 report on PEPFAR found that “rigid congressional budget allocations among categories, and even more so within categories, have…limited PEPFAR’s ability to tailor its activities in each country to the local epidemic and to coordinate with the level of activities in the countries’ national plans.” Dr. Helen Smits, vice chair of the IOM Evaluation Committee, said budgetary allocations in the legislation, including the ABC earmark, decrease the flexibility of the program. She said legislators should “eliminate all earmarks but substitute accountability” in the reauthorization.

Dr. Julie Gerberding, director of the Centers for Disease Control and Prevention, testified that PEPFAR should have “the freedom to adjust to whatever issue [exists] in any specific environment.” She added, “The Emergency Plan should place additional emphasis on…maximizing behavior-change interventions with all infected persons to decrease the rate of HIV transmission, such as the evidence-based, balanced ‘ABC’ approach.”

Ambassador Mark Dybul, U.S. Global AIDS coordinator, said he supports the ABC approach. He noted that the current earmark only mandates that 33 percent of prevention funds be spent on abstinence programs throughout all of PEPFAR, “not on a country-by-country basis and certainly not to countries with concentrated epidemics. Even speaking of the epidemic at a country level can be misleading, in fact, because a country can have both a concentrated epidemic and a generalized one…In Uganda, for example, ABC behavior change had such a significant impact that we now see the highest infection risk in discordant couples.” One member of a discordant couple is infected with HIV, and the other is not.

Sen. Tom Coburn (R-OK) showed a poster that had advertised condom use in Africa, picturing a 14-year-old girl who said that she always used a condom during intercourse. He criticized the poster, saying that it encouraged children to start sexual activity before they should. “Prevention is key,” he said. “Don’t fall back on a ‘condoms only’” approach. Ambassador Dybul echoed his support for a “comprehensive” approach to prevention, and added, “We also recognize that one size does not fit all.” He said there had been a “delay in sexual debut” in countries that emphasized abstinence until marriage. “We’re starting to see behavior change.”

Also testifying were Princess Kasune Zulu, HIV/AIDS educator with World Vision; Dr. Norman Hearst, a professor at the University of California San Francisco; and Dr. Peter Piot, executive director of UNAIDS.

Senate Foreign Relations Committee

On December 13, the Senate Foreign Relations Committee held a hearing on “Perspectives on the Next Phase of the Global Fight Against AIDS, Tuberculosis and Malaria.” The committee held a similar hearing on the plan (see The Source, 10/26/07).

Sen. Robert Menendez (D-NJ) said, “While the U.S.-led effort has made substantial advances in providing access to treatment, the need still far outweighs the availability of services the rate at which individuals become infected with HIV continues to outpace the rate at which they are treated, and, once begun, treatment is a lifelong obligation and expense. Also, in looking at future costs of these programs, UNAIDS estimates that to achieve universal access to [antiretroviral] medications, the global resource needs for 2010 will be approximately $40 billion. This figure does not include costs for prevention or care…The only way that we are going to make inroads against HIV/AIDS is to improve prevention.

Ranking Member Richard Lugar (R-IN) called for a quick reauthorization of PEPFAR, citing the views of the Foundation and Donors Interested in Catholic Activities. Sen. Lugar said the Foundation “argues that early reauthorization will ‘encourage implementing partners to expand the number of patients receiving [antiretrovirals] to 2008 target levels rather than holding back on new services for fear of the program ending or being seriously curtailed. This means more lives will be saved.’” Sen. Lugar said his PEPFAR reauthorization bill, the HIV/AIDS Assistance Reauthorization Act of 2007 (S. 1966), “clarifies the provision on prevention programs to make more money available for mother-to-child transmission and blood supply safety. It also proposes new benchmarks to strengthen accountability and transparency at the Global Fund to Fight AIDS, Tuberculosis and Malaria, which has been a critically important partner.” The U.S. has given the Fund $2.5 billion in six years, about one-third of its financing.

Dr. Nils Daulaire, president and chief executive officer of the Global Health Council, testified, “Budget line items and various agency authorities have dissected a single experience health into disparate funding, policies, and programmatic approaches that undermine our ultimate goal: healthier individuals and families, and therefore more stable and productive global communities… I can tell you with confidence that single-disease, single-intervention, or any other siloed approach simply will not succeed over the long run.” He emphasized that PEPFAR needed to be “integrated” internally, across other global U.S. health programs, nationally, and with other international donors and countries. Asked by Sen. Russ Feingold (D-WI) about the deficit of health care workers in some focus countries, Dr. Daulaire called for more nurses, who can do “95 percent of what’s needed in HIV care,” instead of doctors, who often leave their native countries.

Dr. Daulaire also said the reauthorization is “critical to get done over the next several months. If there is a break [in funding], it will be a cataclysm in terms of resistant HIV. It’s vital that this program be reauthorized quickly.”

Ken Hackett, president of Catholic Relief Services, said, “Prior to PEPFAR, virtually no funding for abstinence and faithfulness was available. There is widespread consensus among public health experts that fidelity and abstinence are necessary components of any comprehensive approach to reduce the spread of AIDS. Evidence has shown that condoms alone are insufficient for a generalized epidemic.” He said he opposed the addition of “comprehensive services,” such as family planning and reproductive health services, because “moral tenets of religious organizations like Catholic Relief Services prevent them from offering these ‘comprehensive services.’ Our experience is that high quality care, treatment, and prevention can be provided without these additional services.”

Dr. Helen Smits, vice chair of the IOM Evaluation Committee, and Dr. Michel Kazatchkine, executive director of the Global Fund to Fight AIDS, TB and Malaria, also testified.

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