PROGRESS AND PROMISE
Helen L. Smits, M.D., M.A.C.P.
Vice-Chair, Committee on the President's Emergency Plan for AIDS Relief (PEPFAR)
Board on Global Health
Institute of Medicine
The National Academies
Committee on Foreign Relations
December 13, 2007
Good morning, Mr. Chairman and members of the Committee. I am Dr. Helen Smits, and it was my privilege to serve as the Vice-Chair of the Institute of Medicine committee that evaluated the implementation of PEPFAR. As you know, this study was mandated by the Leadership Act and executed under a contract with the Department of State. It was carried out by an interdisciplinary committee of experts from many nations who visited the PEPFAR focus countries to talk with people funding and implementing programs. I would like to thank my fellow committee members and the IOM staff for their hard work as well as all of the people in the focus countries and at OGAC who spent so much time meeting with us.
The opportunity to visit focus countries was a very moving one. I met as diverse a group of people as you could imagine: doctors and nurses, groups of people living with HIV, village councils and the orphans they cared for, missionaries and traditional healers, heads of government ministries, representatives of our partner countries, as well as the dedicated American staff members who make PEPFAR work. There was one consistent message: “thank you.” I was sung to, I attended special dance performances, I was served tea and homemade treats, I was even at one point given a gift of a pair of live birds. All of these people thanked me as a representative of the American people; I want to convey those thanks to you for conceiving and funding this program.
I have submitted as my written statement a copy of the Summary of the IOM committee’s report with all of the committee’s recommendations. I will summarize them briefly and spend a bit more time on the one recommendation that is directed to Congress – namely, to eliminate the budget allocations.
The U.S. Global AIDS Initiative has made a strong start and is progressing toward its 5-year targets. The challenge now is to maintain the urgency and intensity that have led to early success while placing greater emphasis on long-term strategic planning for an integrated program in which prevention, treatment and care are much more closely linked, and on capacity building for sustainability.
The Committee recommendations to the Global Aids Coordinator, many of which are already in the process of implementation, are as follows:
• Even greater emphasis on prevention is needed. This must be based on a greater understanding of exactly where the latest cases have occurred.
• There should be increased attention to the vulnerability of women and girls with emphasis on the legal, economic, social and educational factors that lead to spread of the disease.
• We must continue and strengthen our commitment to harmonization—with the host countries and with other donors. In particular, we should work with the World Health Organization to accept their prequalification process as the single standard for assuring the quality of generic medications.
• All services—prevention, treatment and care—must be better integrated. The resulting synergies will improve programs in all areas.
• As we continue to strengthen country capacity to fight the local epidemic, we should support expansion of local human resources. Many of these countries have too few nurses and clinical officers. Helping to train new ones will be more productive that only retraining the ones who exist.
• We need to know what works. A focus on learning from experience will only strengthen the program.
In order to support all of these improvements, we recommend that Congress shift from a budget allocation approach to one of setting priorities and holding PEPFAR accountable – from a focus on how the money should be spent to a focus on what the money is accomplishing. Allocations have unfortunately made spending money in a particular way an end in and of itself rather than a means to an end. They have reduced the program’s ability to adapt to local conditions and to respond effectively to changes either in the epidemic or in our constantly growing knowledge of how to fight it.
In eliminating budget allocations, Congress should retain the results-oriented nature of the program. Let me be clear that The IOM committee is not suggesting the diminishment of accountability. Instead, we are recommending an approach that we believe will result in more meaningful targets and greater accountability. Congress should hold the Global AIDS Coordinator accountable for demonstrating that we are actually succeeding against the pandemic, not simply succeeding in spending money on it. If Congress can specify the results it would like to see, program staff can figure out how to get those results. The increase in flexibility that will result from the elimination of budget allocations will make us a better partner with the host countries and with other donors.
PEPFAR is not a single, uniform program the details of which can be specified by the Global AIDS Coordinator or Congress. In the focus countries PEPFAR is 15 distinct programs reflecting the unique circumstances and epidemics of each. I realize that this is nothing new for Congress – you contend with the uniqueness of 50 states everyday. But if you magnify many fold the variation that you see between Delaware, Indiana, Florida, and Alaska, you will begin to get a sense of the challenge of trying to apply a single approach across countries as different from one another as Guyana, South Africa, Mozambique, and Vietnam.
The specific reasons for eliminating allocations are as follows:
• Conditions vary greatly in the different countries. The challenge of treating the rural poor in Mozambique and Tanzania is very different from that of treating urban residents in the slums of Nairobi.
• The epidemic varies greatly in different countries. The strategies for reaching patients with treatment and for prevention are very different in Viet Nam, where the epidemic is driven by injecting drug users, from those in South Africa, where the spread is heterosexual.
• Situations change rapidly and the program needs to respond; budget allocations can limit crucial flexibility. We are in a new phase of prevention with adult male circumcision added to the armamentarium of effective strategies—and altering the cost of prevention. Changes in drug prices, availability of specific medications, approaches to testing, or even climate can have the same effect. Floods in Mozambique frequently cut the northern section of the country off from the south; means must be found to continue the regular delivery of medications when that happens.
• The rigid separation among treatment, prevention and care that results from allocations should be ended. Predictions are that many of the new infections in affected countries over the next years will come from discordant couples where one partner is positive and one is not. Ensuring that treatment and care both carry a strong prevention message can make a real difference in our ability to reach the people we wish to target.
In closing, in 2003 Congress set the standard for international leadership in the fight against AIDS. You now have the opportunity to take the United States’ response to the global AIDS epidemic to the next level and leave a truly lasting legacy of American leadership.
I hope you will seize this opportunity. I also hope you will visit for yourselves to see the remarkable accomplishments of the program to date—and to receive in person the gratitude of those who benefit.
Thank you for the opportunity to testify. I would be happy to address any questions the Committee might have.