IYD: Testimony Before the Subcommittee on Health & the Environment Committee on Energy and Commerce

Congressional Testimony

Testimony Before The Subcommittee on Health & the Environment Committee on Energy & Commerce

U.S. House of Representatives, March 20, 2003

Shepherd Smith
President, Institute for Youth Development
Board Member, Children's AIDS Fund

Shepherd Smith Thank you, Chairman Tauzin, and all your committee members for holding this hearing on such an incredibly important issue. The first time we presented our views was in 1987 to your health subcommittee, and subsequently gave testimony on several other occasions as president of Americans for a Sound AIDS/HIV Policy in the 1990s regarding the spread of the HIV epidemic in the United States and abroad, and the need to address the epidemic from a medical/public health perspective. This committee is well recognized as the primary House sponsor of AIDS-related legislation throughout the history of the epidemic.

The attention the past chairmen of the full committee and the subcommittee have paid to this issue is remarkable. Congressmen Dingell, Waxman, Bliley, and now Congressman Bilirakis have all made HIV/AIDS a top priority. You’re following in that role, too: is very heartening to those of us who care deeply about this issue. In past legislation most HIV/AIDS programs and plans have focused domestically while some of the resources that were allocated went to international efforts. Now, because of the President's bold initiative, this committee is looking more broadly at the implications of such a plan.

This issue has never been simple, and broadening our focus with more intensity on a global level brings many challenges to bear. The State Department and USAID have historically dealt with many international issues, while the Department of Health and Human Services has often played a significant role of offering technical assistance on health related matters such as the successful campaign to eradicate small pox and the present campaign to eradicate polio. While HIV/AIDS is an issue that now impacts nearly all countries and has economic implications, it is primarily a health issue which needs incredible coordination between these three entities that have played historic roles at the international level.

I was privileged to be part of the US Delegation to the United Nations General Assembly Special Session on HIV/AIDS (UNGASS), and then to travel with Secretary Thompson last year to Africa as part of his delegation. We saw the consequences of this epidemic on that continent, as well as began to shape answers that will benefit all countries. Secretary Thompson's interest and leadership on HIV/AIDS has gone mostly unheralded, but not unnoticed by those of us deeply involved in this issue.
I was very impressed by the infrastructure established both by the State Department and USAID, as well as the support staff provided by HHS in many of the countries visited. Clearly the opportunity to help country by country is well defined by the folks we already have on the ground from the United States. It is my strong belief that we can help significantly given clear leadership and direction from the top of most parts of our government. Substantial and expanded United States resources can probably be better utilized by a United States effort than through the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global AIDS Fund). This is not to say that there should not be a role for the Global AIDS Fund, and indeed this Administration is giving significant resources to it, more than any other country in the world. However, when we're talking about mobilizing such a large effort in such a short period of time, the United States alone is positioned to do this much better than any international entity with all its different perspectives and participants that come into play.

The need for a strong coordinator at the State Department makes a lot of sense to us as well. It is the United States embassies and consulates in foreign countries that people look to for answers and information. Having the coordinator linked with the White House monitoring these activities for State, USAID and the Department of Health and Human Services will allow resources to be marshaled in a way that direct the greatest amount where they are needed most, and reduce the amount of resources that are underutilized or wasted. The coordinator's position needs to be closely linked to the Secretary of State, as well as to the White House National Office on AIDS Policy.

Having traveled to the southern regions of Africa in the early '90s, we were not prepared to see the rates of HIV rising in the countries we visited last year. The HIV epidemics were well defined in the early '90s and we felt that the emphasis on prevention would have led to either a stabilization or a decrease in the HIV epidemic. However, when we visited Mozambique, South Africa, and Botswana we saw that their HIV incidence rates continue to climb. We had to ask ourselves why. On our return we looked at data throughout the entire continent and found that there was one glaring exception to these rising rates, and that was Uganda.

Consequently, we put together two groups to visit Uganda, once in August and then again in December 2002, where we tried to carefully examine the US role as well as the role of the Ugandan government in combating HIV/AIDS. It is quite a story, and little wonder why the President in his State of the Union address singled out Uganda as a model country that we should examine carefully and follow. Many of you are aware of the story of Uganda and others here may highlight it as well, but I would like to share a few observations.

It is a relatively poor country, not unlike many of its neighboring African countries. We in the US spend on AIDS alone roughly forty times per capita what Uganda spends on all healthcare issues facing their citizens. They have a declining HIV epidemic; in the United States we either have a stable or rising HIV epidemic. Compared to South Africa, HIV trends are going in opposite directions.

They have promoted a traditional message of celebrating virginity at marriage, encouraging young people to be abstinent until marriage and then asking those who are married to be faithful to their partners, with little emphasis on condom promotion (what has become known as their ABC message). They have had some success in highly targeted condom campaigns, and no documented success in broader condom campaigns. America needs to become known as the biggest promoter of the A and B of ABC, not known as we are now as the biggest provider of C.

Uganda's message contrasts sharply with the messages given out in the southern part of Africa. There the dominant and primary message has been the promotion of condoms. We saw this in the early '90s and were surprised to see an even greater emphasis on our return trip last year. Very few government funded programs focus on abstinence or faithfulness, and certainly most US sponsored programs, whether government or private, focus on the broad social marketing of condoms. There is some emphasis on diagnosis, but even that is often anonymous in nature.
I would like to draw an analogy to what has happened in Africa regarding these two different approaches. It is as if a large group of experts have proclaimed a new method should be promoted regarding the teaching of reading skills. These experts have said this approach will help people read much better.

However, the more the new program is promoted, the worse the scores have gotten. But even though the results are abysmal, it's as if no one wants to stop and say that reading scores have declined and not gotten better. Yet in this one country that has pursued a more traditional approach, the scores have gotten incredibly better. It is very difficult to comprehend why we can't take a few steps back and look at the results of these two different approaches. One is highly effective; one is not. We need to pursue the one that is highly effective and either discontinue or highly modify the one that is not. It's really that simple. And we must allow faith-based groups to promote abstinence and be faithful without coercing them to also promote condoms which, unfortunately, happens all too often.

I'd like to also share with this committee that over the years we have sought to help families affected by HIV here in the United States and abroad. In Africa we not only support families and orphaned children, but we are helping fund a drug trial in Malawi that is looking at mother to child transmission in the context of the whole family. As we pursue trials, it is important to remember that the husband is the primary breadwinner and that without him the health of the mother will decline more rapidly and the children will become orphans more quickly. Consequently, the treatment program under trial through the Children's AIDS Fund is intended to save the whole family and offers a treatment regimen to the husband as well as the wife and children. And it also addresses other health related matters, which we feel is important in structuring all HIV treatment programs abroad.

In closing I would like to share that HIV/AIDS treatment and prevention are critically important for underdeveloped countries. Better prevention messages will ultimately result in less demand for treatment and less suffering from the consequences of HIV infection. We should remember that the biggest predictor of any sexually transmitted disease is the number of lifetime partners; the more partners the more risk, fewer partners less risk, and one uninfected partner in a faithful relationship virtually no risk. The President has it right, Uganda can teach us many important lessons.