This is an archived USAID document retained on this web site as a matter of public record.

Testimony of Andrew Natsios
Administrator, USAID

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Submitted to the House International Relations Committee
Washington, D.C.
June 7, 2001

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It is particularly timely that I am here this morning to talk about one of the greatest challenges faced by the United States and the rest of the world - HIV/AIDS. Sunday marked the 20th anniversary of the first diagnosis of a case of HIV/AIDS. If we had known then what we know now, we might have saved many of the 22 million people from around the world who have already died and spared many of the more than 13 million children already orphaned.

Fortunately, with national leadership like that shown by members of this Committee, we can and are doing more. We have successful programs and partnerships upon which to build. Slowing the HIV/AIDS pandemic and helping those already infected and affected are priorities for this Administration, Secretary of State Powell, the Agency for International Development, and me.

As you know, less than a month ago, President Bush, Secretary Powell and Secretary Thompson met with United Nations Secretary General Kofi Annan and Nigerian President Olusegun Obasanjo. Noting that "We have the power to help," President Bush said, "The United States is committed to working with other nations to reduce suffering and to spare lives." Currently the U.S. spends more money through USAID and the CDC on HIV/AIDS work internationally than all other donors combined. Since 1986, USAID has provided $1.6 billion in HIV/AIDS assistance. President Bush has pledged $200 million to the Global HIV/AIDS and Health Fund. This is in addition to the $350 million requested for USAID in 2002, the nearly $300 million for international HIV/AIDS work planned by other U.S. agencies, and the billions of dollars which the U.S. spends on HIV/AIDS domestic research and treatment.

I have just returned from a trip to four African countries with Secretary Powell, to talk to leaders about the problem of HIV/AIDS. We saw first-hand:

• The devastation caused by the pandemic: Most of those with HIV live in Africa although infection rates are rising rapidly in the rest of the world. In Africa because of HIV/AIDS, many families are no longer able to farm and many will go hungry. We are seeing famine caused for the first time not by war, drought or pestilence but by the HIV/AIDS pandemic.
• Too high a human toll: Already more than 17 million Africans have died, 12 million have been orphaned and another 25 million are living with HIV/AIDS. Unfortunately, many of these individuals will suffer alone; receive no modest care; die too young and in pain; and leave behind destitute families and children.
• The strategic importance of prevention programs to reduce the rate of new infection. Tragically, in developing countries, about half of all new HIV infections are to 15-24 year olds. The behavior of today's youth will shape the course of the AIDS pandemic in the future.
• The courageous response of many, especially at the community level, who are speaking out, mobilizing their neighbors and caring for those infected and affected by HIV/AIDS. Both the Secretary and I were moved by the compassion, courage and love demonstrated by community groups who are supporting infected persons and their families.
• The important work the United States, particularly USAID, is doing to prevent transmission, care for the sick and provide support to families and children affected by HIV/AIDS.

Let me share with you a few of the highlights of what I saw and heard:

In Kenya, I saw a wide array of HIV/AIDS prevention, care and support programs, which receive support from USAID. These range from HIV/AIDS community education through the Kenya Girl Guides to state of the art pilot programs to prevent mother-to-child transmission. I heard from one HIV positive mother of her need, and that of the women she counsels for family planning services and HIV/AIDS care and treatment. In Kenya, as well as elsewhere in Eastern and Southern Africa, the number of children who have lost one or both parents continues to grow rapidly. My visits to community-based projects, which care for orphans and families, convinced me that this is the most viable, humane and cost-effective way to help children. Faith-based organizations such as the Kenya Catholic Secretariat, Christian Health Association of Kenya and the Council of Imans play a critical role in enabling communities to take care of their own.

In Mali, I learned from my colleagues and our partners that we are not waiting until the epidemic is out of hand before acting. Working with national leaders in Mali, USAID is providing decision-makers with accurate information on the situation through its support for the first national population-based survey of HIV infection levels in the world and special policy-making presentations to key opinion-makers and leaders. Special education, reproductive health, and cross-border programs target youth and groups with high-risk behaviors. Acting now may spare Mali the tragedy of Southern and Eastern Africa. My discussions with religious leaders underscored the important role of faith-based organizations in mobilizing people for education, care and support.

We will be working more closely with such leaders through a new Africa-wide initiative with faith-based organizations to get the word out through churches and mosques on how individuals can protect themselves and their families.

In South Africa, I visited an HIV/AIDS community care and support program, Hope Worldwide, in Soweto, the largest township in Africa. I heard from citizens of Soweto about how hard it is to be HIV positive in that community and the discrimination and poverty they face every day. USAID is helping HIV positive mothers lessen the risk that they will pass on this terrible disease to their yet unborn infants through a pilot mother-to-child transmission prevention program. USAID support links the Hope Worldwide Community Center to Baragwanath Hospital and ensures that mothers receive the follow-up and community support needed for them to protect their babies.

In Uganda, I gained new understanding of the human costs of HIV/AIDS as I listened to the personal testimony of widows with HIV/AIDS seeking to leave some legacy through memory books for their children, many of whom will soon be orphaned. Uganda's successes underscore both the importance of the longstanding partnership between the U.S. Government, the government of Uganda and Ugandan non-governmental organizations and of high-level and sustained political leadership in mobilizing public opinion as a basis for effective behavior change.

USAID is the lead U.S. agency at the country level. We have led the global fight against HIV/AIDS since 1986. We are the largest supporter of multilateral, bilateral and private non-governmental HIV/AIDS programs. We provide about 25 percent of the total funding for UNAIDS. We develop the U.S. HIV/AIDS country assistance programs that provide the framework for collaborative partnerships between the U.S., host countries, and other donors.

USAID is well positioned to play this critical leadership role because we have:

• on the ground country and technical expertise with recognized preeminence in reproductive health in developing and transitional countries.
• established relationships with other donors, U.S. private voluntary organizations and host country governments and private organizations.
• a tough minded, evidence-based approach which uses applied, field research to identify, test and demonstrate effective interventions to ensure that every dollar of USAID assistance counts.
• directly relevant experience from other development programs such as social marketing, mass media communication and peer education.
• successful ongoing HIV/AIDS programs which can be expanded rapidly or replicated to help more people.
• comprehensive country assistance programs which enable us to address HIV/AIDS from a national perspective and use multi-sectoral approaches to reach substantial populations and meet critical needs outside of the health sector.

USAID has made a difference in Africa and the rest of the world. We have:

• helped more than 35 million people protect themselves and their families through programs that have reached them directly with the ABCs of prevention: Abstinence, Be Faithful, and Condoms.
• increased world knowledge on the nature, magnitude and impact of the pandemic: We now know that no country is safe. Because of injected drug use, the former Soviet Union has the highest percentage HIV infection growth rate of any region in the world. Parts of the Caribbean and Central America are also experiencing very rapid increases in HIV infection. There is evidence that Asia will be the hardest hit region in the next decade.
• identified, tested and implemented pragmatic, field-tested approaches to HIV/AIDS prevention, care and support for orphans and other children affected by HIV/AIDS.
• shared U.S. expertise, resources and products. USAID is the largest supplier of condoms. Research in developing countries has shown that good quality condoms used consistently work well.
• leveraged other donor and private funding and other support. In Zambia, for example, a private South African firm, Sasol, which imports large quantities of fertilizer has printed an easy-to-read HIV prevention message on 800,000 fertilizer bags. The message reads:

  "To grow properly, your crops need fertilizer. To grow properly, your children need you. Use a Condom Every Time. Protect Yourself Against HIV/AIDS. Thank You. Maximum - Use it! Be wise, be Condom wise."

With the additional resources provided by Congress, we have adopted an expanded response which:

• focuses the majority of resources on four "rapid scale up" countries: Cambodia, Kenya, Uganda and Zambia, and 16 "intensive focus countries" to achieve greater results in critically affected countries.
• continues a strong focus on prevention. It is especially critical that we do a better job of reaching young people.
• provides more support for the care and treatment of those with HIV/AIDS, especially of the opportunistic infections such as tuberculosis which is the greatest cause of AIDS deaths in Africa.
• helps countries, communities and families deal more comprehensively with the consequences of the pandemic through special programs and multi-sector approaches such as community-based education, micro-credit and other help for families caring for orphans and other vulnerable children.
• improves our understanding of the epidemic and the impact of assistance through increased surveillance of the epidemic in key countries, tracking of HIV/AIDS related behavior and increased monitoring of USAID assistance impacts.

With the lives of millions at stake, it is critical that current and future programs are based on informed choices about the most effective and efficient ways to prevent transmission and to care for those affected. With the extra resources we are receiving, USAID can and will build on program successes like:

• partnerships with private organizations, such as those with faith-based organizations in Haiti and Kenya, which have provided critical information on HIV risk and prevention to parents and to youth. I came away from Africa with an increased awareness of the important role of faith-based organizations in mobilizing people for education, care and support activities.
• peer education and other targeted programs, which meet the needs of youth and special high-risk populations. Kenyan youth are using the stage to challenge HIV/AIDS myths and stigmas. There are now more than 270 youth theatre groups who have reached more than 400,000 people. In Jamaica, innovative theater groups are used to educate youth groups and parents in HIV prevention methods, including abstinence. In Russia, rock concerts are reaching thousands of at-risk youth with healthy life style messages. The South African "Lesedi" or "we have seen the light" project forms multi-sectoral partnerships between mining companies and health departments to provide education and treatment of sexually-transmitted infections to miners and other migrant workers at high risk of HIV infection.
• voluntary counseling and testing (VCT) programs, which provide individuals with the information they need to protect themselves and their families. A multi-site research study in Tanzania, Kenya and Trinidad and Tobago found that VCT reduced sexual risk behavior, especially in HIV positive persons. VCT also empowers HIV positive people. In the face of violence and discrimination, courageous people living with HIV/AIDS throughout India have built a national network to raise awareness, improve care and support for HIV-positive people and advocate for more enlightened, effective HIV/AIDS policies.
• social marketing programs, which make information and commodities widely available to citizens through private sector channels in more than 50 countries. In Kenya, monthly sales of the socially marketed condom, "Trust," total 1.2 million.
• technical assistance: USAID works with both governments and private groups to strengthen HIV/AIDS prevention, care and support programs. In Brazil, USAID's HIV/AIDS program works at the state and national government levels to increase management capacity, improve efficiency and integrate detection and treatment methods into public health facilities.
• community-based care and support for people living with AIDS: In Cambodia, KHANA, the Khmer HIV/AIDS NGO alliance, which USAID supports, has piloted community home care teams. This approach reduces suffering, helps forge linkages between care and prevention and reduces discrimination against people living with AIDS. One widow explained how with the help of a KHANA Home Care Team, she was able to remain healthy, continue her business of selling food and keep her children in school.
• care and support for Orphans and Vulnerable Children: USAID is developing new community and family-based programs to help the 12 million children who have already been orphaned. In Uganda where there are now 1.7 million orphans, the Uganda Women's Effort to Save Orphans (UWESO) serves as an advocate for children's rights and supports activities to assist orphans and their families. With support from USAID and the Peace Corps, UWESO shifted its program emphasis from school fees and grants to micro-finance activities to provide an opportunity for income generation for households headed by widows, grandmothers, and a few children in addition to families providing foster care for AIDS orphans. One legendary grandmother in her 70s, Bernadette, now cares for 31 grandchildren, three great grandchildren and four of her brother's children orphaned from AIDS, with the help of her daughter. Eleven of her 12 children have died of AIDS. She has successfully used and repaid three micro-finance loans and used the proceeds to launch two successful projects: one raising and selling pigs and the other buying and selling small fish in the market. The profits from these projects are used to support and pay schools fees for the children.

The job is not done. The challenge remains extraordinary, and so do our needs:

• Resources: Even with significant increases in U.S. support, total world financial and human resources allocated to date to HIV/AIDS are still inadequate to control the pandemic, heal the sick and care for those infected and affected. These limits have required USAID to set priorities, focus and concentrate our dollars and people in countries where the need is greatest and where USAID can make a difference.
  • USAID continues to work with governments, media, private organizations and citizens to ensure that those at risk now have the knowledge and means to protect themselves and their families.
  • USAID is pioneering and testing new approaches to care, prevention of mother-to-child transmission and help for orphans and other vulnerable children. We recently sent you reports on our work on mother-to-child transmission and on our help to orphans and other vulnerable children.
  • USAID is working with other donors, other U.S. agencies, national governments and private organizations to identify and train more people.
  • USAID, along with CDC and NIH, is supporting biomedical and operations research to develop affordable, feasible approaches. This includes research to develop a vaccine and microbicides to prevent HIV transmission.
• Sustained Effort: We are just at the beginning of a long battle which will determine the fates and well being of many of the world's citizens for the remainder of the century. Because of infections that have already happened, 44 million children in the 34 countries hardest hit by HIV/AIDS will have lost one or more parents by 2010. Still,
  • Too few national leaders have stepped forward to take the actions needed to prevent an HIV/AIDS pandemic in their countries or to slow the epidemic already decimating their populations. We have seen in the Philippines, Senegal, Thailand and Uganda what a difference such leadership can make.
  • Too much attention is paid in the world press to the anti-retroviral drug issue when an integrated strategy emphasizing prevention and including treatment and strengthened health care delivery is the only real answer to this crisis.
  • Too few citizens know how to protect themselves and their children.
  • Too few of those infected with HIV/AIDS receive even basic care not to mention anti-retroviral treatments, which could extend their lives. Many are shunned, abandoned and die prematurely in pain.
  • Too many infected persons and their loved ones are stigmatized. This causes unnecessary suffering and makes prevention and care more difficult.
  • Too few families and children affected by HIV/AIDS have the minimal essentials necessary for life and a future - food, shelter and a basic education. Children, often very young children, are trying to care for sick and dying parents and even their younger siblings.

I am determined, as the Administrator of USAID, that with your support we will meet this challenge. When we look back 10 years from now at our legacy, we will be able to say that the generosity and know-how of the American people made a difference and saved many from the worst epidemic in human history.

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