Official Transcripts
Close Window
Rep. Chris Smith speaking at International Scientific Practical Conference on HIV/AIDS in developed countries
Excerpts from Remarks by Representative Chris Smith at International Scientific Practical Conference on HIV/AIDS in developed countries
Moscow, Russia
December 4, 2008
Chairman Seltsovskiy, I would like to thank you, the distinguished Mayor of Moscow Yuri M. Luzhkov, the Russian National AIDS Center, the Ministry of Health and Labor, the Ministry of Education, and MiraMed Institute, for sponsoring this important and timely conference on combating the spreading pandemic of HIV/AIDS. It is a privilege for me to be here with you. Russia, the United States and other interested parties need to find more ways like this one to cooperate on humanitarian and human rights initiatives. And I especially want to thank Dr. Juliette Engel for her extraordinary work, including her pioneering work to combat human trafficking. As the prime sponsor of the Trafficking Victims Protection Act of 2000, I and my Congressional colleagues have greatly benefited from her counsel, insight and compassion for victims of human trafficking.
HIV-AIDS is a particularly devastating factor in the inherently horrifying phenomenon of human trafficking. Women and girls, in particular, who are tricked and sold into sexual slavery, not only suffer extreme human degradation, but also the deadly possibility of contracting the HIV virus. Dr. Engel and the organization that she founded, the MiraMed Institute which is a co-sponsor of this conference, have been working tirelessly to help the victims of human trafficking. In 2007 alone, the MiraMed Institute held international counter-trafficking conferences in Russia and neighboring countries, provided training sessions for over 3000 Moscow police officers through the Angel Coalition, sponsored rehabilitation programs for trafficked children in 13 Moscow shelters and juvenile detention centers, published six textbooks on the methodology of working with exploited and traumatized children, and undertook numerous other important activities.
I will be speaking today in part about the legislative approach that the U.S. Congress has taken to the global AIDS crisis, and some of the challenges we have struggled to overcome.
As most of you probably know, close to 70% of the estimated 33 million people with HIV live in Sub-Saharan Africa. Of the 2.5 million children afflicted with this dreaded disease, 90% live in Africa as well. When combined with opportunistic infections like Tuberculosis—the number one killer of individuals with HIV—the HIV/AIDS pandemic compares among humanity’s worst and compares with the bubonic plague—the black death—an epidemic that claimed the lives of over 25 million people in Europe during the mid-1300’s.
Of course, developed countries are not immune from the scourge of HIV/AIDS. A report that came out last July indicated that the African-American population in the United States suffers from the pandemic to almost the same extent as peoples in developing countries. The study shows that almost 600,000 African Americans are living with HIV, and up to 30,000 are becoming infected each year. If African Americans were considered apart from the American population in general, they would rank 16th in the world in the number of people living with the HIV virus. The estimated total number of all Americans in 2008 who are HIV positive today is about 1.1 million. To combat this horrific disease and mitigate the suffering of those who have it, the US government spent over $17 billion in FY 2008 to assist Americans—63 percent of this earmarked for treatment, 13 percent for research, 14 percent for prevention and 10 percent for income support. Billions more were expended by state and local governments, philanthropic organizations and private insurance companies.
Obviously this conference will be focusing on the impact of the disease within your own country’s context and how the crisis can be addressed and what lessons from abroad might be relevant and applicable in Russia and how the rest of us can learn from you. As you well know, a particularly tragic aspect of the HIV scourge here in Russia is that young people, aged 15 to 24, constitute almost one-third of the new HIV infections. Almost two-thirds of all known HIV cases are transmitted through injection drug use, and the second leading mode of transmission is heterosexual intercourse. Numerous experts at this conference will discuss risk avoidance and reduction strategies and potentially life saving research that may have application here, including Dr. David Metzger of the University of Pennsylvania, who is working with 500 HIV negative Uyghur injection drug users in China, who are at risk of HIV due to needle sharing. Dr. Metzger is testing Suboxone which works best when taken under the tongue rather than by injection to treat opiate addiction—which of course includes heroin addiction.
The U.S. President’s Emergency Plan for AIDS Relief was initiated in 2003 by President George W. Bush and it achieved bipartisan support in Congress. PEPFAR, as it has been known, has been an effort of unprecedented size and scope. With a funding level of $18.8 billion for its initial five years, it has been the largest international health initiative in history dedicated to a single disease. PEPFAR also was structured not only to commit resources, but perhaps more importantly to ensure that the money that was dedicated achieved results. The most recent numbers reported for FY 2007 show that PEPFAR is living up to expectations:
- 57.6 million people have been reached with support for prevention of sexual
transmission using the ABC approach;
- From FY 2004 through FY 2007, PEPFAR supported prevention of mother-to-child
transmission (PMTCT) for women during more than 10 million pregnancies;
- For PMTCT clients who have been found to be HIV-positive, antiretroviral
prophylaxis has been provided in over 827,000 pregnancies, preventing an estimated
157,000 infant HIV infections;
- Of PEPFAR’s 15 “focus countries” – those countries with the highest prevalence
of HIV and where PEPFAR resources were concentrated to stem the new infections
and deaths overwhelming those societies – eleven of those countries now meet
more than half of their annual demand for safe blood – up from just four when
PEPFAR started;
- PEPFAR has supported HIV counseling and testing for over 33 million people;
and
- While only 50,000 people living with HIV in all of sub-Saharan Africa were receiving antiretroviral treatment just five years ago, PEPFAR has helped provide the treatment to approximately 1.45 million men, women and children.
This year, Congress passed, and on July 30th President Bush signed into law, the re-authorization of PEPFAR for another five years. The legislation was the result of a long and contentious struggle between many special interests and ideological approaches. The final product represented a delicate balance and numerous compromises between those interests and ideologies.
Many Members of Congress winced at the cost of the legislation—$50 billion over five years for PEPFAR, the Global Fund, Tuberculosis, and Malaria—but that sum of money will likely prevent 12 million new HIV infections worldwide, and support treatment for 3 million people including an estimated 450,000 children. That sum of money, however, will also provide care to 12 million individuals with HIV/AIDS including 5 million orphans and vulnerable children and will help train and deploy at least 140,000 new health care professionals and workers for HIV/AIDS prevention, treatment, and care. However, this spending was authorized prior to the financial and economic crisis that we are all facing. It will be a major challenge to ensure that the U.S. Government maintains its commitment in the midst of other numerous and increasing demands now being made on our national budget.
One of the most contentious issues during the negotiation of the legislation was how to allocate funding for prevention of sexual transmission. Since most the program’s focus countries have a generalized epidemic, prevention funding needed to be focused on this mode of transmission. The legislation as finally agreed to requires that the U.S. Global AIDS Coordinator provide balanced funding for sexual transmission prevention including abstinence, delay of sexual debut, monogamy, fidelity and partner reduction. If less than 50% of sexual transmission prevention monies are spent on the Abstinence and the Be faithful parts of the ABC model, the Coordinator must provide a written justification.
Five years after PEPFAR first began, the efficacy and importance of promoting abstinence and be faithful initiatives have been demonstrated. The evidence is compelling.
According to joint comments by the U.S. Department of State, USAID, and Department of Health and Human Services on PEPFAR “Congressional directives have helped focus U.S. Government (USG) prevention strategies to be evidence-based. Because of the data, ABC is now recognized as the most effective strategy to prevent HIV in generalized epidemics…. The legislation’s emphasis on AB (Abstinence and Be faithful) activities has been an important factor in the fundamental and needed shift in USG prevention strategy from a primarily C approach prior to PEPFAR to the balanced ABC strategy. The Emergency Plan developed a more holistic and equitable strategy, one that reflects the growing body of data that validate ABC behavior change.”
“Recent data from Zimbabwe and Kenya…mirrors the earlier success of Uganda’s ABC approach to preventing HIV. These three countries with generalized epidemics…have demonstrated reductions in HIV prevalence, and in each country the data point to significant AB behavior change and modest but important changes to C. Where sexual behaviors have changed… HIV prevalence has declined.”
In Zimbabwe, Science reported in February 2006 that among men aged 17 to 29 years in eastern Zimbabwe, HIV prevalence fell by 23% from 1998 to 2003. Even more impressively, the prevalence among women aged 15 to 24 dropped by a remarkable 49%.
- Abstinence (delay in sexual debut): Among men aged 17 to 19, the percentage who had begun sexual activity dropped from 45% to 27% and among women aged 15 to 17, it dropped from 21% to 9%.
- Be faithful: Among those men who were sexually active, the proportion reporting a recent casual partner fell by 49%.
In Kenya, the Ministry of Health estimates that HIV prevalence dropped from approximately 10% in 1998 to approximately 7% in 2003.”
Fifteen months ago, the Foreign Affairs Committee heard testimony from a leading expert, Dr. Norman Hearst, who said; “Five years ago, I was commissioned by UNAIDS to conduct a technical review of how well condoms have worked for AIDS prevention in the developing world. My associates and I collected mountains of data…. we looked for evidence of public health impact for condoms in generalized epidemics. To our surprise, we couldn’t find any. No generalized HIV epidemic has ever been rolled back by a prevention strategy primarily based on condoms. Instead, the few successes in turning around generalized HIV epidemics, such as Uganda, were achieved not through condoms but by getting people to change their sexual behavior.”
“These are not just our conclusions,” Dr. Hearst said. “A recent consensus statement in The Lancet was endorsed by 150 AIDS experts, including Nobel laureates, the president of Uganda, and officials of most international AIDS organizations… [it said] the priority for adults should be B (limiting one’s partners). The priority for young people should be A (not starting sexual activity too soon….” “This contrasted with other funders that often officially endorse ABC but in practice continue to put their money into the same old strategies that have been unsuccessful in Africa for the past 15 years….”
An article published in the New York Times, June 13, 2004, by Helen Epstein, pointed out “that many efforts aimed at stopping the spread of HIV have had disappointing results. Epstein said that ignoring the need to promote fidelity in sexual relations ‘may well have undermined efforts to fight the epidemic.’ She wrote: ‘Government planning documents, United Nations agency reports, AIDS awareness campaigns and AIDS education curricula are strangely silent on the subject.’”
In a Washington Post article by Craig Timberg, March 2, 2007 it was noted that; “Men and women in Botswana continued to contract HIV faster than almost anywhere else on Earth… Researchers increasingly attribute the resilience of HIV in Botswana – and in southern Africa generally – to the high incidence of multiple sexual relationships. Europeans and Americans often have more partners over their lives, studies show, but sub Saharan Africans average more at the same time….”
“Researchers increasingly agree that curbing behavior is key to slowing the spread of AIDS in Africa. In a July report, southern African AIDS experts and officials listed ‘reducing multiple and concurrent partnerships’ as their first priority for preventing the spread of HIV in a region where nearly 15 million people are estimated to carry the virus – 38 percent of the world’s total.”
“There has never been equal emphasis on ‘Don’t have many partners,’ said Serara Selelo-Mogwe, a public health expert and retired nursing professor at the University of Botswana, who recalled stepping past broken bottles and used condoms as she arrived on campus each Monday morning. ‘If you just say use the condom…we will never see the daylight of the virus leaving us.’”
“Fidelity campaigns never caught on in Botswana. Instead, Botswana focused on remedies favored by Western AIDS experts schooled in the epidemics of America’s gay community or Thailand’s brothels…”
“These experts brought not just ideas but money, and soon billboards in Botswana touted condoms. Schoolchildren sang about them. Cadres of young women demonstrated how to roll them on. The anti-AIDS partnership between the Bill & Melinda Gates Foundation and drug-maker Merck budgeted $13.5 million for condom protection – 25 times the amount dedicated to curbing dangerous sexual behavior.”
But soaring rates of condom use have not brought down high HIV rates. Instead they rose together, until both were among the highest in Africa.”
The U.S. Government’s 2008 Annual Report to Congress noted that “perhaps the most important [development] in recent years is the growing number of nations in which there is clear evidence of declining HIV prevalence as a result of changes in sexual behavior” and “behavior change will remain the keystone of success.”
Even for countries that do not have generalized epidemics, but where heterosexual transmission is a major cause of new HIV infections, these lessons learned with respect to behavioral change are an important indicator of where efforts need to be focused.
In addition to ABC, the HIV legislation that passed this year retains legislation I sponsored called anti-prostitution/sex trafficking pledge – a policy designed to ensure that pimps and brothel owners don’t become, via an NGO that supports such exploitation, U.S. government partners.
Current law ensures that the U.S. government is not in the position of “promoting or advocating the legalization of prostitution or sex trafficking.” Prostitution and sex trafficking exploit and degrade women and children and exacerbate the HIV/AIDS pandemic. Americans do not want to see their tax dollars subsidizing and promoting prostitution and/or sex trafficking.
Last February, the U.S. Court of Appeals for the District of Columbia upheld the “prostitution pledge” and said in pertinent part: “In this case the government’s objective is to eradicate HIV/AIDS. One of the means of accomplishing this objective is for the United States to speak out against legalizing prostitution in other countries. The Act’s strategy in combating HIV/AIDS… speaks of fostering behavioral change and spreading educational messages.”
The Court of Appeals goes on to say, “It would make little sense for the government to provide billions of dollars to encourage the reduction of HIV/AIDS behavioral risks, including prostitution and sex trafficking, and yet to engage as partners in this effort organizations that are neutral toward or even actively promote the same practices sought to be eradicated. The effectiveness of the government’s viewpoint-based program would be substantially undermined, and the government’s message confused….”
There has been some confusion in the American press (but not in the implementation of the law) as to whether or not prostitutes and other victims can receive treatment, palliative care, and commodities. And the answer is absolutely yes. The U.S. Office of the Global AIDS Coordinator (OGAC), which oversees the U.S. HIV/AIDS programs, has made it clear in its guidance that such assistance can – and is – provided to prostitutes and victims of sex trafficking. According to OGAC, scores of NGOs have signed and pledged to provide such assistance.
Unfortunately, private donors are not following the example of the U.S. Government in ensuring that HIV funds go to help victims and not the victimizers. The White House held a summit on HIV/AIDS last month, and one of the presenters was Ms. Ruchira Gupta, the founder of an organization in India called Apne Asp Women Worldwide that is helping approximately 10,000 women, men and children to develop strategies to escape human trafficking. Ms. Gupta stated that, “we are trying to keep sex-trafficking profiteers from legalizing sex slavery in India even though more Foundation funds are spent on the supposed protection of sex buyers from AIDS than the protection of women and children from sex buyers. This has created a vested interest in the preservation of brothels in some parts of India for the distribution of condoms rather than protecting the women and children, even though there is no evidence that increased condom distribution in brothel districts is leading to condom usage or a decrease in AIDS.”
One issue that is closely related to abstinence and be faithful prevention is the critical involvement of faith-based organizations (FBOs) in the development and provision of HIV prevention – as well as treatment and care – services. This is just as true here in Russia as it is throughout the world. It is well-known that the Russian Orthodox Church is actively involved, both pastorally and through social services, in overcoming the spread of HIV/AIDS and in working with people living with the disease. For example, the Church currently is carrying out a project funded by the United Nations Development Programme at over $2 million to provide such needed assistance as palliative care, the promotion of behavioral changes among vulnerable youth, capacity development for FBOs, and policy-level initiatives through inter-faith coordination mechanisms.
A serious and pervasive obstacle to the participation of churches and other FBO’s in HIV programming was the mandate that such groups provide services, such as the distribution of condoms to young people, that are contrary to the faith and moral conscience of these organizations. After a contentious debate in 2003, the initial PEPFAR legislation recognized the importance of removing this obstacle for FBOs by including an amendment that I authored—the conscious clause. The conscious clause provides that no organization is required to endorse or utilize a prevention method or treatment program to which the organization has a religious or moral objection as a condition for funding. With the re-authorization that was approved this year, that language was strengthened to specify that an organization also need not make referrals to or become integrated with any objectionable activity, and cannot be discriminated against in the solicitation or issuance of funding for refusing to be involved in such activity. This language is intended to both protect and encourage the active involvement of faith-based organizations in the provision of U.S.-funded HIV programs.
On the other hand, the Global Fund to Fight AIDS, Tuberculosis and Malaria, a major international funding resource, historically has had a reputation of omitting churches and faith-based institutions in the list of grantees and sub-grantees for its funding. Apparently in recognition of this omission and the consequent negative impact on the effectiveness of its overall efforts, the Global Fund has issued a “primer” and has held meetings during the past year to encourage and facilitate the involvement of FBOs in the solicitation of grants. I encourage others to join me in closely following these developments to determine whether FBOs are beginning to acquire a percentage of Global Fund resources commensurate with the enormous amount of service they are providing in the provision of HIV/AIDS, malaria and tuberculosis –related services.
