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Testimony
Before the Committee on Foreign Relations
United States Senate

HHS's Role in Halting the Global Spread of HIV/AIDS

Statement of
Tommy G. Thompson

Secretary,
Department of Health and Human Services

For Release on Delivery
Expected at 10:30 AM
on Wednesday, February 13, 2002

Mr. Chairman, members of the Foreign Relations Committee, I am pleased to be here today to provide an overview of the activities of the Department of Health and Human Services (HHS) to combat HIV/AIDS worldwide.

Thank you, Mr. Chairman, for you leadership in responding to this devastating disease. And, I want to acknowledge Senators Frist and Kerry for their work as co-chairs of an important task force organized by the Center for Strategic International Studies (CSIS) on America's role in addressing the global HIV/AIDS pandemic. We at HHS, along with the U.S. Agency for International Development and the U.S. Department of State, are working with CSIS to ensure that this two-year project reaps benefits for both the U.S. and nations around the world hard-hit by HIV/AIDS.

We all know the dreadful statistics-- 40 million people worldwide now living with HIV/AIDS, 3 million deaths from AIDS last year-- but they don't begin to represent the devastation this disease wreaks upon the developing world. The relentless onslaught of AIDS has the potential to

devastate national economies and social systems, cause national instability and civil unrest, and draw the United States and other developed nations into national and regional conflicts. This Country has a moral obligation to provide leadership in mobilizing resources for this international health crisis.

Secretary of State Colin Powell and I serve as co-chairs of the Task Force on HIV/AIDS created by President Bush, and, under his leadership, the United States has continued its commitment to battle HIV/AIDS and other infectious diseases and assist the world in disease control, surveillance and treatment activities. At HHS, the Centers for Disease Control and Prevention (CDC), the Health Resources and Services Administration (HRSA), and the National Institutes for Health (NIH) are world leaders in research and assistance in the worldwide battle against this scourge.

Last May 11, President Bush announced the creation of the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria. I have the honor of serving as the U.S. representative to the Global Fund Board, a post I sought because I believe the Fund can make a real difference. Both Secretary Powell and I have championed the concept of a trust fund for these three diseases from our first days in office. And, I might add, so have many of you on this committee supported this effort. Thank you, Senator Frist, for your contributions in this area. Why is this idea so important? Because Africa and other parts of the world urgently need a public health delivery system that includes prevention of new infections; treatment for the sick, including the provision of drugs; and training of medical professionals.

The speed with which the Fund's architecture has been established is remarkable, and President Bush's founding pledge of $200 million has produced a 10-fold return on that investment in 9 months. I am pleased to report to you, Mr. Chairman, that the Fund is now up to just below $2 billion in promised resources.

The Global Fund held its first Board meeting on January 28 and 29, 2002, in Geneva. Because President Bush asked me to stay in Washington to meet with Ministers from the newly formed provisional government of Afghanistan, I was unable to attend. I did, however, address my fellow Board members by videoconference to announce the Presidentīs pledge to the Fund of an additional $200 million in FY 2003. This latest proposed contribution would bring the total U.S. contribution to half a billion dollars, by far the largest donation from any one country or entity, and over one-quarter of the overall commitments to the Fund.

The establishment of the Fund reflects the principles and priorities President Bush outlined last May. First, the President spoke of the need for partnerships across borders and among both the public and private sectors.  The Fund embodies this principle; it is an independent non-profit foundation under Swiss law, located in Geneva in space separate from the United Nations and any of its agencies. The Board of the Fund consists of 7 donor governments, 7 developing country governments, 1 representative from the philanthropic sector, 1 representative from the for-profit sector, and 2 representatives from non-governmental organizations (NGOs).

Second, the President wanted the Fund to pursue an integrated approach to the three diseases that emphasizes prevention, training of medical personnel, as well as treatment and care. We are pleased that the rest of our colleagues on the Fund Board have agreed that proposals may cover prevention, treatment, and care and support in dealing with the three diseases in ways that local partnerships deem appropriate.

The Board has decided not to institute quotas or percentages for particular interventions. Prevention is indispensable to any strategy of controlling a pandemic such as we now face, but so are treatment activities, including carefully designed programs employing anti-retroviral therapies.

Third, the Fund should concentrate on programs that work. We must know that the money is well spent, people living with HIV/AIDS are well cared for, and local populations are well served. To that end, the Fund Board has agreed that strong financial and programmatic accountability mechanisms must be put in place. The World Bank will serve as the trustee for the Fund, and have the responsibility for financial accountability, including collection, investment and management of funds, disbursement of funds to countries and programs, and financial reporting to stakeholders. All partnerships that receive grants will be subject to independent audits and provide assurances that adequate fiscal controls are in place. While the Board has not yet decided exactly how ongoing monitoring and post facto evaluation of grants will be done, the Board has embraced the principle that funding must be tied to measurable results. Grantees must be able to demonstrate that their approaches are having a real impact in reducing mortality and illness.

The Presidentīs fourth criterion asks for scientific accountability. All proposals must be reviewed for effectiveness by medical and public health experts, because a plague of this magnitude demands results. The Board will have ultimate decision-making authority and be accountable for results, but no proposal will move forward without a rigorous review and endorsement by a group of technical experts. This 17-member, independent Technical Review Panel, composed of 6 experts in HIV/AIDS, 3 in malaria, 3 in TB, and 5 from other disciplines, will evaluate all proposals for programmatic and medical soundness, feasibility, and financial management, taking into account local realities and priorities. Indeed, my Department hosted a meeting of eminent experts from around the world last month, at the NIH's Fogarty International Center, to develop recommendations to the Fund Board on the operating procedures of the Technical Review Panel--advice the Board has accepted.

And, finally, the President underlined the importance of innovation in creating lifesaving medicines that combat diseases. Our position has been that the fund must respect intellectual property rights, as an incentive for vital research and development.

I will not hesitate to admit that much work remains to be done, but the Fund is on track and open for business. Contracts with the World Bank and the World Health Organization for financial and administrative services should be finalized in the near future. We are also looking for an Executive Director. And, proposals for grants need to be written; in fact, applications are currently being taken for the first round of partnership grants. The Board plans to make decisions on applications during its next meeting in April.

So, as I have mentioned, the Fund is open for business and we at HHS intend to participate actively in helping partnerships to design their proposals and perhaps even join in monitoring and evaluation if asked. I see the Fund as a critical opportunity to force better coordination between bilateral and multilateral programs and to hone their focus on results and performance.

The President, Secretary Powell and I are all delighted that the Fund has surpassed even our most ambitious expectations, and we remain convinced that innovative approaches like the Fund are truly our best hope for curbing these diseases in the developing world.

HHS Programs in the Global HIV/AIDS Arena

My Department's contributions in this arena also include the efforts of the CDC, HRSA, and NIH. Let me briefly share with you the very important work that these agencies are performing. The President's Fiscal Year 2003 budget calls for $144 million for the HHS Global AIDS Program within the Centers for Disease Control and Prevention, the same funding level as this year. In addition, the CDC budget includes $11 million for international HIV prevention research.

The Department is on the ground in 25 countries in sub-Saharan Africa, South and Southeast Asia, Latin America, and the Caribbean, working intensively with governments, NGOs and community groups to build infrastructure and capacity, assist in prevention activities, and provide direct care and treatment.

Most developing nations lack the necessary infrastructure to address their HIV/AIDS epidemics. Disease surveillance systems and epidemiology are often nonexistent or greatly compromised, making it difficult if not impossible to accurately determine at-risk and infected populations.

HHS provides funding and technical assistance to Ministries of Health to bolster disease surveillance and essential laboratory services, including training for laboratory personnel, information systems program monitoring and evaluation, and purchasing needed equipment.

We also offer technical assistance and funding for a variety of prevention activities, including voluntary counseling and testing, preventing mother-to-child transmission, blood safety, sexually transmitted disease prevention and care, behavior change communications, and prevention for populations at high risk for acquiring or transmitting HIV.

For example, preventing mother-to-child transmission is a priority for our programs-- it is the only proven therapy to avert transmission from one person to another. HHS works with host countries and other partners to provide drug therapy to pregnant and post-partum women and their newborns and promotes replacement feeding strategies to avoid transmission via breastmilk.

Our treatment and care activities focus on tuberculosis and other opportunistic infections, palliative care, and, more recently, technical assistance on antiretroviral therapies, or ARVs. Within HHS, the HRSA and CDC are training local health care providers in safe and effective patient care and monitoring. Working together, our agencies are fostering hospital- and clinic-based care programs, as well as community- and home-based care, for people living with HIV/AIDS.

Let me say a few words about ARV treatment, a subject that has drawn intense interest here and around the world. ARV treatment is now more affordable in sub-Saharan Africa than ever, thanks to the assistance of drug manufacturers in this country and others. While most developing countries lack the sophisticated medical monitoring equipment and tests that are adjunct to ARV treatment, my team at HHS is assessing ways to effectively, safely and affordably bring these treatments to desperate countries and their people. CDC and HRSA are also examining the safety and effectiveness of what is known as "syndromic management," which means that diagnosis and continuing care are based on observable signs and symptoms, rather than sophisticated lab tests. These tests are not feasible in most countries in which the Fund will be working, so in such situations, clinicians there have to manage patient care by look and touch and feel - all skills that can be taught, and we hope that this effort will be another part of our contribution to the Fund.

Tuberculosis presents special dangers to those who are HIV-infected, and HHS currently is assessing a rapid TB diagnostic test that is effective among HIV-positive persons; the optimal duration of TB treatment among those who are HIV infected; and the acceptability of directly observed antiretroviral therapy for HIV. With the Botswana Ministry of Health, HHS research showed that TB is the leading cause of death for HIV-positive persons in Botswana and another showed that saliva tests for HIV can be used on TB sputum specimens, offering an effective tool for HIV surveillance.

Finally, the importance of research in attacking HIV/AIDS has long been recognized, and the

United States has long been the world's leader in research and practical assistance to battle HIV/AIDS. President Bush's proposed FY 2003 funding for the National Institutes of Health includes $2.77 billion for AIDS-related research, an increase of $255 million that includes expansions for vaccine, microbicide, and treatment research. Next year, we will devote more than $422 million to the search for an HIV vaccine, a 24 percent increase over FY 2002.

Last year, the NIH Office of AIDS Research developed the Global AIDS Research Initiative and Strategic Plan which reaffirmed NIH's long-standing commitment to international HIV/AIDS research. NIH supports a growing portfolio of HIV/AIDS research conducted in collaboration with investigators in developing countries, and supports international training programs and initiatives to help build research. Altogether, NIH expects to spend $222 million in FY 2003, an increase of $34 million over FY 2002, specifically related to international HIV/AIDS research.

The NIH supports the HIV Vaccine Trials Network (HVTN), composed of 16 domestic and 13 international sites. Directly and through collaborations with mostly university-based investigators worldwide, the HVTN also supports laboratory research to ensure vaccines are efficacious against a variety of HIV strains found around the world.

HHS also supports university-based biomedical and behavioral research on interventions to prevent sexual transmission, and strategies to reduce perinatal transmission. The NIH-sponsored HIV Prevention Trials Network (HPTN) is a worldwide collaborative network designed to conduct research in 16 international and nine domestic sites on promising and innovative biomedical/behavioral strategies for the prevention or reduction of HIV transmission among

at-risk adult and infant populations.

HHS works to strengthen - or create - the research and laboratory infrastructure of developing countries and train local investigators to conduct clinical trials of therapeutic and preventive therapies. These efforts include NIH's Fogarty International Center , which funds training in the U.S. for scientists from developing countries in Africa, Asia, Latin America and the Caribbean. Through grants to U.S.-based institutions, we have also conducted training courses in 60 countries. A new initiative, the Comprehensive International Program of Research on AIDS, also provides funding directly to foreign institutions for HIV research that is relevant to the host country. These grants focus on training of investigators and enhancement of laboratory and clinical capabilities, and to date, we have made five such awards.

None of the activities I've just outlined - infrastructure development and capacity building, prevention activities, care and treatment efforts, and research - could be accomplished or even

attempted without the integral cooperation and collaboration between CDC, HRSA and NIH, as well as other parts of the U.S. government, most particularly USAID. At HHS, I am working to ensure that research and activities conducted throughout the Department, as well as within other entities, is complementary and not duplicative, and that it sees practical application in programs. HHS has a 20-year history of international intervention research, established CDC field stations, and many NIH projects worldwide. We strive to keep these efforts coordinated, and with the help of our other government partners, I believe we are succeeding.

Conclusion

Enormous challenges lie ahead. Just last month, the president of Family Health International, one of our NGOs, asserted that without treatment and prevention, AIDS will outstrip the bubonic plague as the world's worst pandemic. Bubonic plague killed 40 million people in the 14th century. Seven centuries later, we stand at the brink of an even worse catastrophe. But working together, we can change the course of the AIDS epidemic. Our research and its practical application have shown us that prevention, care, and treatment work. It is our responsibility to ensure that those at risk and those already infected have the benefits of that knowledge.

We are seldom presented with such clear and pressing need and such clear means to intervene. The Administration stands ready to contribute to a comprehensive plan for Africa and other parts of the world where HIV/AIDS is rapidly expanding.

I thank you again for your support of this important endeavor.



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Last revised: February 20, 2002