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

Testimony of Kent R. Hill, Ph.D.,
Assistant Administrator of the Bureau for Global Health

HIV Prevention: How Effective is the President's Emergency Plan for AIDS Relief?

Before the Committee on Government Reform
Subcommittee on National Security, Emerging Threats and International Relations
U.S. House of Representatives
Washington, D.C.
September 6, 2006

Mr. Chairman, Ranking Member Kucinich, and Members of the Subcommittee: As Assistant Administrator of the Bureau for Global Health at the U.S. Agency for International Development, it is my privilege to testify on the importance of prevention in the President's Emergency Plan for AIDS Relief (PEPFAR/Emergency Plan). I will also address the broader topic of the fundamental importance of prevention addressing the HIV/AIDS pandemic.

This discussion is particularly timely, as only three weeks ago the 16th International AIDS Conference came to a close in Toronto, Canada. The International AIDS Conference is intended to be a scientific meeting, but it offers an opportunity to spotlight the HIV/AIDS epidemic on a global stage. Both Ambassador Dybul and I had the opportunity to engage conference participants in robust, frank dialogue about the critical interventions needed to accelerate the prevention of HIV. Against the backdrop of the conference, I returned to Washington with three overarching themes dominant in my thinking:

• One. The United States is recognized as the global leader in the fight against HIV/AIDS. The sheer magnitude of resources the U.S. has committed to this single disease is unprecedented, and beyond that of any other nation in the world. In both public comments and in the press, the Emergency Plan is repeatedly cited as the single greatest contributor to the fight against HIV/AIDS.
• Two. The fight against HIV/AIDS is far from over. In fact, I don't believe we've yet even turned the corner. Despite impressive achievements in the expansion of treatment numbers, four million new infections every year threaten to dwarf the global resources available to meet the treatment requirements in the years ahead. This simple arithmetic fact means that we have no alternative but to scale up significantly and strengthen the prevention of new HIV infections globally. And since the vast majority of new infections occur through sexual transmission, we must focus particularly on that area.
• Three. Although opinions can and do diverge regarding the relative importance of various prevention interventions, we must differentiate between legitimate debate and the much more common misinformation so often associated with discussion of the U.S. endorsement of ABC - "abstinence or delay of sexual debut," "be faithful and at the very least partner reduction," and "correct and consistent use of condoms." The ABC approach is an evidence-based, flexible, and common-sense based strategy which plays a major role in stemming the tide of the HIV/AIDS pandemic. It is too important to be bogged down in the politics of passion. Too much is at stake, too many lives hang in the balance, too many children are vulnerable to become orphans if we fail in our prevention efforts.

It should be noted that one way to raise the quality of the discussion of ABC prevention interventions is to insist that it take place in the context of gender issues. After all, many of the problems associated with the spread of HIV are intimately connected with the absence of gender equality, the presence of gender-based-violence and coercion typical of transactional and transgenerational sex. For all too many young girls, abstinence is not about being morally conservative, but about having the "right" to abstain. The double-standards of men who are not faithful while their wives are is a gender equity issue. In short, AB interventions must be seen as fundamentally linked to gender inequality issues - a topic which can unite Left and Right, liberals and conservatives. We need to focus on such common ground.

PEPFAR Reflects the New Direction of U.S. Foreign Assistance

Ambassador Dybul has spoken on Emergency Plan funding and the rationale behind its allocations. In addition, I'd like to offer a complementary perspective on why the U.S. commitment to HIV/AIDS is so important. Currently, USAID is distinguished to have at its helm the first U.S. Global AIDS Coordinator, who is now serving concurrently as the first Director of U.S. Foreign Assistance and as Administrator of USAID. Ambassador Randall Tobias has said he believes the early success of PEPFAR is due to its overall strategic framework, which reflects the new transformational nature of U.S. foreign assistance.

True transformational development requires far-reaching, fundamental changes in governance and institutions, human capacity and economic structure, so that countries can sustain further economic and social progress without permanently depending on foreign aid. To make a real difference, the resources of the U.S. must be focused on transformational initiatives that are owned over time by the developing nations themselves. Therefore, U.S. foreign assistance now centers resources around five overarching objectives: peace and security, governance and democratic participation, investing in people, economic growth, and humanitarian assistance. The ravages of HIV/AIDS threaten and undermine all of these inter-related elements of transformational development. PEPFAR's high-impact, strategic approach to comprehensive HIV/AIDS prevention, care and treatment serves as a basis for alleviating the suffering of those infected and affected by HIV/AIDS. In addition to implementing currently validated programs, PEPFAR is assessing potential new technologies and approaches, such as microbicides and male circumcision. In addition, U.S. foreign assistance supports a multi-sector approach to HIV/AIDS -- ensuring coordination between HIV programs and family planning, food security, agriculture, and education programs.

The Effectiveness of the ABC Approach to Prevent Sexual Transmission of HIV

The ABC approach to HIV prevention -- Abstain, Be faithful, correct and consistent use of Condoms - is good public health, based on respect for local culture. It is an African solution, developed in Africa, not in the United States, and has universally adaptable themes. Three qualities of the ABC strategy are important to understand its central role in the Emergency Plan's emphasis on prevention of sexual transmission of HIV.

• The ABC approach is a balanced strategy that, in its application, is adaptable to diverse epidemic circumstances;
• ABC has a proven and impressive track record, well beyond the most famous example of Uganda. There is a clear and compelling body of scientific study supporting its effectiveness. It also has the benefit of being firmly rooted in common sense;
• Also, the ABC strategy's effectiveness has been affirmed by other leaders in the international community as the most effective way to prevent sexual transmission of HIV.

At the International AIDS Conference in Toronto, I hosted a USAID session called Refining the Prevention Paradigm: Exploring the Evidence and Programmatic Models for Behavior Change. The discussion provided further acknowledgment that the appropriate mix of A, B, and C is absolutely essential in the fight against AIDS. In particular, the adaptability of this strategy allows responses to be tailored according to local epidemic circumstances. For instance, in places like Kenya, Uganda, and Zimbabwe, most new infections result from chains of overlapping sexual partnerships in the general population - fueling what we call a generalized epidemic. Through community mobilization efforts, education and awareness activities, the data indicated increased adoption of ABC behaviors, and pointed particularly to a reduction in multiple partners. Furthermore, the data showed associated declines in HIV. By contrast, epidemics such as those in Thailand and Cambodia are primarily associated with commercial sex work, and are therefore concentrated in identifiable population groups. In these instances, we also see the adaptation of certain ABC behaviors - particularly the B and C portions: vigorous correct and consistent condom use, as well as a decline in the proportion of men visiting prostitutes, thus decreasing the risk of HIV transmission to themselves and their spouses. In the cases of Thailand and Cambodia, although it is the C aspect of ABC that is the most well-known factor, other behavior change has clearly led to an associated decline in HIV.

More recently, as Ambassador Dybul has described, impressive new Demographic Health Survey evidence from a growing number of nations is expanding the evidence base for the ABC strategy in generalized epidemics, such as those in most of sub-Saharan Africa. These new data are only a snapshot of the undeniable success associated with the adoption of ABC behaviors around the world. This growing body of evidence paints a powerful picture: simply put, ABC works.

To amplify this point, in May 2006, the Southern Africa Development Community - an alliance of several countries in Southern Africa -- convened an expert, think-tank meeting to identify and mobilize key regional priorities for HIV prevention. The meeting report characterized multiple and concurrent sexual partnerships as central drivers of the HIV/AIDS epidemic in the Southern Africa region. They recommended that priority be given to interventions that:

• reduce the number of multiple and concurrent partnerships;
• address male involvement;
• increase consistent and correct condom use;
• and continue programming around delayed sexual debut.

Clearly, these are African-derived interventions that address ABC behaviors.

In the field, we are taking steps to find out how well our programs are working. In additional to our normal evaluation of program effectiveness, USAID is leading U.S. Government agencies in an independent evaluation of some PEPFAR-supported AB programs. An expert meeting was convened to develop new evaluation tools to measure program implementation and strengths. This will be followed by a longer term program evaluation that will be multi-country in nature and will provide important information on program strengths and outcomes. We are excited about this progress and look forward to the findings, which will be used to improve program performance.

Because it is a remarkably simple and easily translated message, ABC is often portrayed as simplistic, and even as a superficial approach to addressing much tougher issues underlying sexual transmission of HIV in a generalized epidemic, particularly in the developing world. One promising yet overlooked aspect of ABC's role in the Emergency Plan and in prevention efforts globally is its relevance to effectively address gender issues, including power relationships, women's sexual vulnerability, and destructive male sexual behaviors.

Critics of the Emergency Plan argue that the ABC does not speak to a woman's ability, or inability, to negotiate within a sexual relationship. But, in fact, central to the ABC strategy are parallel efforts to address the vulnerability of women and girls. In addition, within the ABC strategy there is very specific and growing attention to issues of male behavior, which of course lies at the heart of gender inequality and sexual coercion. This past June, there was a particularly interesting article that ran in the Boston Globe. The story highlighted the Emergency Plan's significant efforts to target HIV prevention in men. I will briefly discuss those efforts now, in light of how male behaviors can and often do affect women, particularly the women of sub-Saharan Africa.

The Emergency Plan is based on the firm belief that it is impossible to stem the spread of HIV without addressing the unbalanced power relations between men and women. Working with boys and men is and must be an ever greater integral focus of the Emergency Plan's HIV prevention programs, especially since male behavior is a prominent root cause of female vulnerability to HIV/AIDS. Among the many factors that help fuel the HIV epidemic, putting both men and their partners at risk are:

• Socially-structured norms and expectations related to men's behavior and roles;
• the acceptance of casual sex and multiple sexual partnerships;
• the encouragement of older men to have sexual relations with much younger women;
• viewing men in the household as the sole decision-maker;
• the likelihood that males will engage in risky sexual behavior - often made even more likely because of lowered inhibitions related to alcohol use; and
• use of illegal drugs, which often results in the spread of the disease through dirty needles, unprotected sex, and the descent into prostitution to acquire drugs.

Furthermore, men's reluctance to seek health services limits their ability to learn their HIV status, and limits the likelihood that they will be challenged to change their risky sexual behavior and adopt preventative behaviors. Through a variety of programs, the Emergency Plan is tackling these issues:

• In South Africa, the Emergency Plan works with the Institute for Health and Development Communication's Soul City, the most expansive HIV/AIDS communication intervention in the country, reaching more than 80 percent of the population through mass and interpersonal communication programming. Soul City emphasizes the role of men in parenting and caring. It challenges social norms around men's perceived right to sex, sexual violence, and transgenerational sex. There is a statistical correlation between exposure to Soul City programming and improved norms and values amongst men.
• Also in South Africa, the Emergency Plan supports a very successful male involvement program known as "Men as Partners." In addition to dealing with HIV/AIDS prevention issues that include masculinity, stigma, and domestic violence, men are encouraged to assume a larger share of responsibilities for family and community care by spending more time with their children, mentoring young boys in the community, and visiting terminally ill AIDS patients.
• In Zambia, the U.S. is working with the Zambian Defense Force to train peer educators and commanding officers to raise awareness among men in the military about the threat posed by HIV/AIDS, and to enlist their support in addressing it. Training workshops cover basic facts about HIV/AIDS and its impact, including transmission, prevention, stigma, sexuality, gender, positive living, counseling and testing, and care.
• In Uganda, the Empowering Africa's Young People Initiative includes a focus on masculinity and gender norms. Community advocacy and sensitization meetings are conducted for both younger and older males. For younger males, the focus is on challenging norms about masculinity, challenging the acceptance of early sexual activity and multiple sexual partners for boys and men, and challenging the dangerous and abusive practice of transactional sex. As for older males, the focus is on supporting counseling, peer education, community interventions, and the ending of the dangerous and abusive practices of transactional and cross-generational sex.
• Also in Namibia, the Lifeline Childline program addresses the root causes of gender violence. It uses age-appropriate messages to teach boys - as well as girls - about HIV/AIDS, sexual abuse, domestic violence, and the resources available to vulnerable children through specialized counseling and other services.

Prevention of Mother-to-Child Transmission: A Cross-Cutting Initiative

The area of Prevention of Mother-to-Child Transmission, or PMTCT, is one of the most dynamic and multidimensional interventions under the Emergency Plan. While PMTCT is budgeted under "Prevention" in PEPFAR country operational plans, not all PMTCT funding is captured in its line item in the PEPFAR budget. In fact, PMTCT is actually a cross-cutting program area that involves prevention, care, and treatment. The setting for PMTCT is often an entry-point for other services, including treatment with antiretroviral therapy. To view PMTCT as one-dimensional is to lose sight of the overall, strategic nature of the Emergency Plan.

In 2005, almost one-third of Emergency Plan-supported HIV counseling and testing was conducted in PMTCT settings. To put this in perspective, several health centers in Rwanda have initiated highly successful programs to engage men in PMTCT services. Partners are invited to accompany women to prenatal visits and receive voluntary HIV counseling and testing. They participate in the prenatal counseling, provided to their partners. Associated community services work to change male attitudes and behaviors that compromise their own health, as well as the health of women and children. In Uganda, Kenya, and South Africa, programs have begun to initiate partner testing within PMTCT settings.

Similarly, psychosocial support groups for pregnant women and mothers in the postnatal period are highly valued activities often budgeted under PMTCT. In addition, infant follow-up, which is necessary to minimize transmission during breastfeeding and to diagnose infants, is part of comprehensive PMTCT programs. Other PMTCT activities entail technical assistance to strengthen local PMTCT systems, training personnel in the provision of services, and building strong referral networks for children born to HIV positive mothers.

Preventing 7 Million HIV Infections: How USAID Fits into the Emergency Plan's Function of Strategic Information

Earlier I alluded to the Demographic Health Survey, or DHS. Data from the DHS, which collects behavior and HIV prevalence data at the population level, contribute to PEPFAR's work of calculating infections averted. USAID has supported such population-based surveys since 1982, and now continues to be the primary supporter of DHS under PEPFAR.

USAID's Office of HIV/AIDS makes important contributions to the design and successful implementation of PEPFAR's Strategic Information and Reporting system. The Office of the U.S. Global AIDS Coordinator has organized four interagency Technical Working Groups to manage PEPFAR's Strategic Information and Reporting system. USAID co-chairs each of these Technical Working Groups, along with HHS/CDC, and offers critical feedback on surveillance and surveys, health management information systems, capacity building with regard to monitoring and evaluation, as well as indicators and reporting. In addition, a number of USAID staff serve as Strategic Information Advisors to PEPFAR country teams overseas. Since the late 1980s, USAID has administered an interagency agreement with the Census Bureau to produce occasional reports on the state of the HIV epidemic and its effects on overall health status and social institutions.

Conclusion

I'd like to conclude by underscoring the 2004 Lancet commentary on finding common ground. This piece was signed by 150 AIDS experts from around the world noting that, "the ABC approach can play an important role in reducing the prevalence in a generalized epidemic"... and that "partner reduction is of central epidemiological importance in achieving large-scale HIV incidence reduction, both in generalised and more concentrated epidemics."

Congressional commitment to a comprehensive HIV prevention strategy is the correct approach, and one that is supported by the evidence. Through partnership with host nations, effective programs for HIV prevention are possible - even in the most difficult places. We will continue to support this common ground as we advance our massive response to HIV and AIDS.

Thank you -- I'm glad to respond to your questions.

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