USAID: Testimony of USAID Dr. Anne Peterson, Assistant Administrator, Global Health, 02/14/02

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

Testimony of Dr. Anne Peterson
Assistant Administrator, Global Health

Before the Senate Foreign Relations Committee
February 14, 2002

I would like to thank Chairman Feingold and Dr. Frist for convening this important hearing and for inviting me to testify.

Over the past twenty years the AIDS pandemic has continued to surprise, shock and devastate us. Every country of the world has reported cases of HIV/AIDS. At the dawn of this 21st century, HIV/AIDS prevalence among adults exceeded 20% in 7 countries in the developing world (all in Africa) and was above 10% in 9 additional countries. In another 41 countries, prevalence equals or exceeds 1%. 22 of these are in Africa, 11 are in Latin America, 4 in Asia and 1 in Eurasia. In contrast, HIV/AIDS prevalence in the United States was 0.6% at the end of 2000.

The Epidemics of Sub-Saharan Africa:

As we learn more about these epidemics, we discover that there is no single pattern.

In the countries of east Africa, the oldest HIV epidemics in the world have occurred with slow, steady progression over the past 30 years. These are seen in the Great Lakes regions of East Africa - in the countries of Uganda, Tanzania, Malawi, Kenya, Zambia, and the Democratic Republic of the Congo (formerly Zaire).
In the countries of West Africa, where the epidemic seems to have started about 10 years later, progression of the epidemic has been more indolent and is further complicated by the presence of both HIV 1 and 2. The national prevalence rates are generally lower between 1 and 8%, except for Cote d'Ivoire, where the prevalence is estimated to be over 10%.
In Southern Africa, where the epidemic started in the mid-to-late 80's there have been a series of explosive epidemics over the past 8 years, reaching the highest prevalence levels on earth, 20-40%. These countries include South Africa, Namibia, Zimbabwe, Botswana, Swaziland, and Lesotho.

Specific aspects of the epidemics in this region include:

Currently in Africa, half of new infections are in the 15-24 age group, with young girls and women accounting for 75% of these. Over 80% of HIV transmission is heterosexual, with over 55% of infections in sub-Saharan Africa occurring in women. This is due to both increased biological and socio-economic vulnerability.
In parts of Kenya, fifteen percent of 15-19 year old girls are now infected compared with 6% of boys in the same age frame. Young girls are frequently infected by older men; these girls then infect their same age partners and husbands as they get older; then the men as they get older in turn infect young girls.
The increasing number of infected women has led to nearly 600,000 infants becoming infected with HIV annually. While simple interventions to reduce mother-to-child transmission are available, currently less than 5% of women in sub-Saharan Africa have access to these services. This is primarily due to the shortage of systems capable of delivering this care. The challenge of preventing mother-to-child transmission in Africa illustrates how difficult it can be to deliver even the simplest interventions in low resource settings.

These tragic statistics are well known to members of this Committee. Yesterday, the Administrator for USAID shared USAID's leadership role in fighting the pandemic. This has included developing the tools needed and providing direct assistance to countries for prevention and care services. Since 1986, USAID has been addressing HIV/AIDS in developing countries and has provided nearly $2 billion is support. In the late 80's USAID's programs were focused on prevention; in the mid-1990's USAID expanded its emphasis on sustainable prevention activities and launched new programs in care, treatment and support for people and communities coping with HIV/AIDS.

The HIV/AIDS pandemic presents some very special challenges. If one looks at health interventions from a development perspective, there is an ongoing predisposition toward "public health" strategies. These often rely on relatively simple interventions. For example, in the areas of child survival to reduce infant and child mortality most international assistance revolves around immunizations, use of oral rehydration salts packets to treat diarrhea, and more recently, the use of vitamin A to reduce infant mortality and impregnated bednets to reduce malaria transmission. Interventions have generally cost between a few cents for an ORS packet and vitamin A, to $20 per person for immunizations to approximately $300 to cure a case of TB.

HIV/AIDS is Different:

Responding to HIV/AIDS calls for a radically different approach. We must address multiple dimensions of the pandemic and recognize the essential synergies that enhance effectiveness of our investments. In developing country settings, we have never attempted such a complex and comprehensive approach to a single disease -- from primary prevention to care and treatment and finally support for those infected and for survivors, especially children orphaned by AIDS. The necessary response is not limited to a single sector. We are drawing upon USAID's broad development experience to design and implement multisectoral approaches. One of USAID's comparative advantages is that HIV/AIDS prevention and treatment can be incorporated into other ongoing development assistance efforts, such as school education programs and training of agricultural workers. Also very important is our strong partnership with indigenous community organizations throughout Africa.

Prevention continues to be critical. However care and treatment are also critical. Neither can be neglected.

We have HIV/AIDS programs in over 50 countries of which 23 receive priority attention. Thirteen of these priority countries are in sub-Saharan Africa.

A Look at Actual Programs

I would like to get down to specifics. What do our programs do in countries? How do they actually work? I will give you some real examples from USAID's country programs. Our programs fall into three broad areas: prevention; treatment/care/support; and children affected by AIDS. While all of these have substantial research elements, which ensure that what we learn is quickly shared and applied, today I will be focusing on the human impact of these programs.

Prevention Efforts

Preventing new infections continues to be the most urgent priority in the fight against HIV/AIDS - currently about 70 percent of USAID's HIV/AIDS budget is committed to prevention. Prevention programs are designed to slow - and ultimately reverse - rising HIV infection rates. We have now seen that these programs work in countries where ARVs and other treatments are not available.

Yet, there is no single intervention or magic bullet that can effectively deal with this pandemic. Changing behavior is complex and difficult and what works for one person may not work for others.

There are two basic principles of prevention. The first is to reduce the frequency of risky acts - by delaying the beginning of sexual activity and decreasing the number of sexual partners. The second is to decrease the efficiency of HIV transmission - by treating sexually transmitted infections, and using condoms. We hope that soon a microbicide will be developed that will help decrease the efficiency of transmission. Ultimately, a vaccine will serve this purpose.

All of these interventions require behavior change by individuals, communities and societies. Knowledge alone is not enough. Behavior change means far more than having basic knowledge about the disease AIDS, or even being disturbed or concerned about it. It requires knowing one's personal risk and how to lessen it. Promoting monogamy and condom use, and encouraging young people to wait, requires mobilizing women, men, and communities to rethink policies and social norms. It also involves creating environments where individuals who understand these messages are supported, not derided, shunned, or beaten. We have learned that HIV/AIDS risk reduction needs positive social change that eliminates stigma and links health, gender and human rights in new productive ways.

There are very important cultural factors which affect AIDS prevention programs. We should not be so surprised then, that in the absence of such social change, even in countries like Zimbabwe, Botswana, and South Africa, that have raging, visible epidemics, people have continued in a state of denial about their own personal danger of becoming infected. The stigma that is associated with AIDS means that AIDS is always someone else's problem. We have seen this phenomenon in virtually every country in the world - including our own.

To counter this lack of perceived personal risk, we are now mobilizing societies, providing skills to opinion and religious leaders and supporting intensive interpersonal counseling and HIV testing. Giving the results of an HIV test provides an opportunity for intervention, social support and increased knowledge about the disease itself.

Uganda shows how behavior can reverse a severe epidemic. There has been a delay in sexual debut by one to two years, decreased numbers of casual partners and increases in condom use. The proportion of Ugandan girls who have ever had sex declined by almost half between 1989 and 1995. Over half of young sexually active Ugandans report using condoms in their last sexual contact - this rate was close to zero at the outset of the epidemic. As a result of these two major changes in behavior, HIV infection rates among 15 to 19 year old girls have declined from 22 percent in the early 1990's to 8 percent by 1998. In the same period, national HIV adult prevalence has decreased from 14 percent to 8.3 percent.

In Zambia, we are also seeing the impact of behavior change on the number of new infections. Recent surveys are showing nearly a 50 percent reduction in prevalence rates for the 15 to 19 year olds in Lusaka and other urban areas from 28 percent to 15 percent between 1994 and 1998.

Until the mid-1990s, women's role in the AIDS crisis was little recognized. But women now comprise nearly half of all infections - and in Africa, more than half. In addition, women bear much of the burden of caring for HIV-infected family members and risk passing HIV on to their infants. They often also have the least control over their risk of contracting AIDS, for both cultural and economic reasons. Because USAID's HIV/AIDS programs recognize the difficulties women and girls face, they:

Work through maternal, child, and other health services that women use;
Help women develop action plans to reduce their risk of HIV infection and to increase their access to services:
Address economic and social issues that put women at a disadvantage.
Involve men as well as women in supporting the health and welfare of women and girls.
Involve women's organizations in the fight against AIDS. For example, in Senegal, traditional women's associations played a key role in increasing condom use.

In addition to behavior change, we need to apply what we have learned about medical interventions to reduce transmission. One critical area involves reducing mother to child HIV transmission. USAID now has programs in 4 countries.

In Zambia, USAID supports an innovative community based program in Ndola District that provides education on HIV and infant feeding choices and offers referral to the district health center for testing and counseling. This program is adding antiretroviral prophylaxis. This innovative model will be expanded to Malawi this year.
In South Africa, USAID is providing management support to the MTCT program at Chris Hani Baragwanath Hospital in Soweto. This hospital which performs 16,000 deliveries per year provides MTCT services to women delivering in the hospital and has established MTCT services in more than 10 outreach centers.
In Uganda, USAID is supporting MTCT services in Mulago Hospital (in Kampala) along with the Elizabeth Glaser Pediatric AIDS Foundation. USAID funds the testing and counseling components, while the hospital is providing the antiretroviral drugs and antenatal care.
In Kenya, USAID currently supports MTCT prevention projects in three sites. This is a collaborative effort with the government of Kenya, UNICEF, UNAIDS, WHO, and African researchers. An important part of this effort is a comprehensive operations research study, so that we can learn from the experience and share the knowledge gained.

Another important way that we can reduce transmission is through treating other sexually transmitted diseases (STIs). A study in Tanzania showed that treating these infections, such as syphilis and chancroid, reduced HIV transmission by almost half. Treating STIs is a standard part of our HIV/AIDS prevention programs. Recently we have begun applying an innovative approach, periodic presumptive treatment, to those at very high risk, such as truck drivers, migrant workers and prostitutes. This ensures that these populations get regular treatment even where there is not sophisticated laboratory support.

Finally a review of USAID's support to AIDS prevention would not be complete without mention of our substantial investments in vaccine and microbicide development.

The pursuit of a vaccine that will prevent transmission of all strains of HIV remains one of the most challenging scientific and technological problems facing the world today. USAID has finalized a two-year $16 million grant agreement with the International AIDS Vaccine Initiative (IAVI). IAVI provides scientific leadership by financing and managing promising international vaccine research and development projects in developing countries. USAID's funding will provide support for vaccine research and development and strengthening clinical and laboratory infrastructure in developing countries. Also because USAID has extensive developing country experience and on the ground infrastructure, we stand ready to partner with vaccine developers to facilitate the contacts with governments NGOs and academia that will be needed for successful vaccine trials. We will provide assistance with community preparation and mobilization and the necessary prevention interventions needed to support AIDS vaccine trials.

USAID has been supporting the development and evaluation of microbicides to prevent sexual transmission of HIV for almost a decade. In FY01 USAID invested $12 million for the development and testing of microbicides and plans to raise this to $15 million in 2002. One promising product to come from this process is the seaweed derived compound, Carraguard, that is currently receiving wide attention. USAID is supporting field trials of this product in Africa.

Treatment, Care and Support Activities:

Care and treatment is important for humanitarian reasons. It also enhances prevention by increasing utilization of voluntary counseling and testing, and helping to decrease stigmatization. It prolongs parenthood and economic productivity. By treating the most important opportunistic infection, tuberculosis, we have prolonged the lives of persons infected with HIV. We also help control the expanding TB epidemic, which threatens all countries.

People with HIV/AIDS have many needs in addition to health care. These include psychological support, legal assistance, economic support, and accurate information about HIV/AIDS. These are often as important as health care, since HIV infection remains symptom free for many years. USAID has supported and will expand our programs that provide non-medical services to people living with AIDS.

USAID produced "HIV/AIDS: A Guide for Nutrition, Care and Support" which shows that, compared with the average adult, a person with HIV requires 10 to 15 percent more energy a day, and 50 to 100 percent more protein a day. We are now incorporating food security activities into our care and support efforts.

Currently, we have 25 care and treatment projects in 14 countries. In Uganda, USAID has begun a five-year, $31 million program to provide food to HIV/AIDS-affected families, to help reduce the impact of AIDS on households. We can help people survive longer by treating opportunistic infections such as tuberculosis and continuing to help countries build up their health care systems and infrastructure

Antiretroviral therapy has had a dramatic impact in reducing AIDS mortality in the developed world. However, there are a number of challenges that limit the ability to offer treatment and support to a large number of people. USAID is actively trying to assess and solve these problems.

The U.S. currently spends close to $4000 per person per year on health care. In many countries in sub-Saharan Africa, annual spending is about $40 per person - a 100 fold difference. Providing antiretroviral therapy to one person for a year costs at least $600. Early on, approximately a quarter of those infected will need treatment. This may seem a manageable number. However, since therapy is lifelong, the numbers of people needing it will escalate, causing an ever increasing expenditure for treatment.
Persons with HIV infection generally lack access to health care. There are few health care workers trained to administer therapy, not enough laboratories capable of providing even the most basic tests to monitor patients for side effects, and drug management systems that are too weak to prevent leakage of extremely valuable drugs into the black market.
Without simple standard protocols for therapy and patient monitoring, it will not be possible to provide therapy to large numbers of people in Africa. With standard protocols, healthcare workers, under the supervision of a few physicians, can be trained to deliver therapy, adherence can be enhanced, and drug management can be streamlined,
Even with the most ambitious treatment plan, the demand for therapy will likely exceed the supply. National governments must address this issue. People living with HIV/AIDS must be actively engaged in this discussion.

USAID will be launching four antiretroviral (ARV) treatment sites in sub-Saharan Africa this year. These sites will not only save lives but will also provide critically needed answers to the challenges noted above and begin to build much needed local capacity.

All of these efforts must build on a solid prevention strategy. We must closely link treatment with prevention. Relying totally on treatment interventions will not stop the advance of the pandemic. Lessons from the U.S., France, Brazil and other countries that offer ARV therapy clearly demonstrate that the introduction of combination therapy does not retard the epidemic. In fact, the belief that HIV is no longer dangerous may result in increased transmission.

Children Affected by AIDS

More than 13 million children under age 15 have lost their mother or both parents due to AIDS. By 2010 some 44 million children in 34 countries will have lost one or both parents, primarily due to AIDS, The impact of such large numbers of orphans and other vulnerable children is substantial for the children themselves, their families and the communities in which they live.

In sub-Saharan Africa, where the majority of AIDS orphans reside, gains in child health achieved over recent decades are unraveling. In Zimbabwe, I worked with street children orphaned by AIDS. I also taught AIDS prevention in schools where the children's greatest fear was that they too would lose their parents. Orphaned children lose their families, their hope for education and the basic necessities of food and shelter. They become easy prey for violence, sexual exploitation and crime. In some settings, they are fodder for child militias.

While some communities have organized support for especially vulnerable children and households, many are weakened by the burden of illness and death as well as the economic deterioration caused by AIDS. Helping communities care for their own is a critical area where USAID can make a difference. We have models that work and that can bring hope to families and communities.

This is the foundation of USAID's support for children and families affected by AIDS. Since 1999, USAID's help for children affected by HIV/AIDS has increased to more than 60 different projects in 22 countries. Supporting communities and families is the most efficient and effective way to address this tragic problem and reach the millions who are and will be affected.

In Namibia, community groups work together to keep orphaned and vulnerable children in school.
In South Africa, the Nelson Mandela Children's Fund aims to reach an estimated 250,000 orphans and other vulnerable children through multisectoral initiatives in HIV/AIDS-affected communities.
In Zambia, an interactive radio and local volunteer program helps out-of-school and other vulnerable children continue to learn.
In Uganda, research is underway to identify effective ways to support families in planning for the care of children upon their parents' death.
In Rwanda, several programs work together toward the goal of providing food to 22,000 AIDS-affected children.

I have seen that these programs can have impressive impact. In Zimbabwe, I met with a local NGO that facilitated amazing community support to households headed by teenage siblings.

Working Together Matters

No one agency can do it all. With so many new partners, the coordination of our efforts becomes even more critical. This is as true among the U.S. government agencies as it is among our international partners, including the new Global Fund. Coordination efforts must occur at two levels: at headquarters and in the countries we are assisting.

A good example is our work with CDC over the past two years. We have decided upon a mutual list of priority countries, we have agreed upon strategic approaches and we are finalizing new areas of specific expertise. We have signed a Memorandum of Understanding, which defines our collaborative efforts and establishes on-going communication systems. Even more important is the coordination that must take place within the country between CDC and ourselves and with the host country government and community groups. It is there on the ground where we will realize the impact of our combined resources.

An example of how we work together is seen in the area of surveillance. CDC has taken the lead for the biologic surveillance of HIV prevalence while USAID is supporting behavior surveys. Together we use this information to track the epidemic, target our resources and measure impact.

In the past two years, we have learned important lessons on what works and what does not. We have successful models that are being replicated, and in six countries we are now seeing a reduction in new HIV infections at a national level. Drug costs have come down dramatically and treatment protocols have been simplified. We have the tools, we know they work. With your continued support and the new resources you have given, we can now move ahead to save lives of millions.