US Rep. Chris Smith (R-NJ), Senior Member of the House Foreign Affairs Committee and Ranking Member of the Subcommittee on Africa and Global Health today gave excerpts of the following statement during House floor debate of HR 5501 the “Tom Lantos and Henry Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008" which passed the House of Representatives today 308-116:

    Mr. Speaker, I rise in strong support of the “Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008”—an admittedly long, but appropriate title for a bill that is long on substance, meaningful intervention, tangible compassion, and relief. 

    Aptly named for two of the giants of this institution who shepherded President George W. Bush’s PEPFAR initiative through the Congress in 2003, H.R. 5501 will literally mean the difference between life and death to millions, especially in sub-Saharan Africa. 

    The Bill before us today is consensus legislation, a delicate balance that if kept intact—and only if kept intact—will be signed into law. So I want to thank Chairman Berman and Ranking Member Ros-Lehtinen and the other Members and staff for helping to forge today’s “PEPFAR Consensus.” I want to specifically thank Sheri Rickert, Mary Noonan, Autumn Fredericks, Yleem Poblete, Peter Yeo, Pearl Alice Marsh, and David Abramowitz. 

    As Members 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—and Malaria alone kills 1 million each year, again mostly in Africa—the HIVAIDS pandemic compares among humanity’s worst. Former Chairman Hyde frequently compared the sickness to the bubonic plague—the Black Death—an epidemic that claimed the lives of over 25 million people in Europe during the mid-1300’s. 

    I know some Members are likely to wince at the cost—$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 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. 

    On the prevention side, the legislation requires that the 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. (Currently the Coordinator exercises waiver authority in this regard without notifying Congress so this language ensures greater taxpayer transparency and accountability.) 

    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 HHS 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 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.” 

    So thanks Mr. Pitts for writing the AB earmark into the original law. 

    It goes on to say; “ABC-Abstinence, Be Faithful and Correct and Consistent Condom Use – is the most effective, evidence-based approach to sexual transmission of HIV infection. 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, as evidenced by increased primary and secondary abstinence, fidelity, and condom use, 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.” 

    This past September, in 2007, the Foreign Affairs Committee heard from Dr. Norman Hearst who said; “the key to sustainability must be prevention. We cannot treat our way out of this epidemic… Most PEPFAR priority countries have generalized epidemics.” 

    He went on to say: “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, and here’s what we found…. we then looked for evidence of public health impact for condoms in generalized epidemics. To our surprise, we couldn't’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. 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….” 

    Dr. Hearst concluded by saying, “Decisions are often made by expatriates and westernized locals trained in rich countries who have internalized prevention models from concentrated epidemics.” And, “In most countries with generalized epidemics, the rich have higher HIV infection rates than the poor….Anything that dilutes the focus of AIDS prevention in Africa from changing sexual behavior may do more harm than good.” 

    An article published in the New York Times, June 13th, 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 curriculums 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, where condom use became so routine it slowed the spread of HIV.” 

    “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 drugmaker 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.” 

    In addition to ABC, the legislation before us retains the 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 of sex trafficking.” Prostitution and sex trafficking exploit and degrade women and children and exacerbate the HIV/AIDS pandemic. Our tax dollars should not subsidize and promote 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 is not merely to ship condoms and medicine to regions where the disease is rampant. Repeatedly, the Act 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….” 

    Let me be clear on an important point because there has been some confusion in the 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 including test kits and condoms. And the answer is absolutely yes. During the markup of 2003, Mr. Berman asked me if such assistance was precluded by my anti-prostitution/sex trafficking pledge amendment, and I said no. OGAC has made it clear in its guidance that such assistance can – and is – provided to prostitutes and victims of sex trafficking. According to OGAC, and I have a list in front of me, scores of NGOs have signed and pledged to provide such assistance. 

    Finally, we have come a long way since 2003 when significant opposition materialized against an amendment I offered to include faith-based providers with conscience clause protection. 

    The conscience clause in HR 5501 restates, improves, and expands conscience protection in a way that ensures that organizations like Catholic Relief Services, which has a remarkable record of HIV/AIDS prevention, treatment, and care, are not discriminated against or in any way precluded from receiving public funds.