[Senate Hearing 108-616]
[From the U.S. Government Publishing Office]
S. Hrg. 108-616
SAVING LIVES: THE DEADLY INTERSECTION OF AIDS AND HUNGER
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON FOREIGN RELATIONS
UNITED STATES SENATE
ONE HUNDRED EIGHTH CONGRESS
SECOND SESSION
__________
MAY 11, 2004
__________
Printed for the use of the Committee on Foreign Relations
Available via the World Wide Web: http://www.access.gpo.gov/congress/
senate
COMMITTEE ON FOREIGN RELATIONS
RICHARD G. LUGAR, Indiana, Chairman
CHUCK HAGEL, Nebraska JOSEPH R. BIDEN, Jr., Delaware
LINCOLN CHAFEE, Rhode Island PAUL S. SARBANES, Maryland
GEORGE ALLEN, Virginia CHRISTOPHER J. DODD, Connecticut
SAM BROWNBACK, Kansas JOHN F. KERRY, Massachusetts
MICHAEL B. ENZI, Wyoming RUSSELL D. FEINGOLD, Wisconsin
GEORGE V. VOINOVICH, Ohio BARBARA BOXER, California
LAMAR ALEXANDER, Tennessee BILL NELSON, Florida
NORM COLEMAN, Minnesota JOHN D. ROCKEFELLER IV, West
JOHN E. SUNUNU, New Hampshire Virginia
JON S. CORZINE, New Jersey
Kenneth A. Myers, Jr., Staff Director
Antony J. Blinken, Democratic Staff Director
(ii)
C O N T E N T S
----------
Page
Boxer, Hon. Barbara., U.S. Senator from California, submissions
for the record:
``Iraq Prison Scandal; A Double Ordeal for Female
Prisoners,'' article from the Los Angeles Times, May 11,
2004....................................................... 57
Letter to Ambassador Randall Tobias, dated March 26, 2004,
expressing serious concerns of efforts to block affordable
generic HIV/AIDS drugs, from 370 national and international
organization............................................... 58
Catholic Relief Services, Baltimore, MD, position paper and
additional material and charts, submission for the record...... 65
Coalition for Food Aid, Washington, DC, letter to Senator Lugar,
dated April 27, 2004, transmitting information for the record.. 86
Feingold, Hon. Russell D., U.S. Senator from Wisconsin, prepared
statement...................................................... 38
Lugar, Hon. Richard G., U.S. Senator from Indiana, opening
statement...................................................... 1
Morris, Hon. James T., Executive Director, World Food Program,
United Nations, New York, NY................................... 4
Prepared statement........................................... 9
World Food Program news release, dated May 11, 2004, titled
``AIDS Complicating Battle Against Hunger, Says WFP
Executive Director''....................................... 13
Natsios, Hon. Andrew S., Administrator, U.S. Agency for
International Development, Washington, DC...................... 18
Prepared statement........................................... 21
``Nutrition and HIV/AIDS: Evidence, Gaps, and Priority
Actions,'' a research paper prepared jointly by the Academy
for Educational Development and USAID, submission for the
record..................................................... 24
Cable to USAID field missions: sent by Administrator Natsios
on June 1, 2001............................................ 32
Tobias, Hon. Randall L., Global AIDS Coordinator, U.S. Department
of State, Washington, DC....................................... 14
Prepared statement........................................... 21
World Vision, ``Integration of Food Security and HIV/AIDS
Programming: A Rapid Review of World Vision's Experience and
Lessons Learned,'' a series of briefing charts submitted for
the record..................................................... 88
(iii)
SAVINGS LIVES: THE DEADLY INTERSECTION OF AIDS AND HUNGER
----------
TUESDAY, MAY 11, 2004
U.S. Senate,
Committee on Foreign Relations,
Washington, DC.
The committee met at 10:02 a.m., in room SD-419, Dirksen
Senate Office Building, Hon. Richard G. Lugar (chairman of the
committee), presiding.
Present: Senators Lugar, Alexander, Feingold, and Boxer.
opening statement of senator richard g. lugar, chairman
The Chairman. This meeting of the Senate Foreign Relations
Committee is called to order.
During the past 16 months, the Foreign Relations Committee,
on multiple occasions, has addressed the horrific consequences
of the HIV/AIDS pandemic and global hunger. We are charged with
overseeing international food assistance and the implementation
of the United States Leadership Against HIV/AIDS, Tuberculosis,
and Malaria Act of 2003, which was signed into law last May.
This 5-year, $15 billion initiative is unprecedented in its
scope and its importance.
In February 2003, we held a hearing on global hunger
issues. The hearing reminded us that in many parts of the
world, food shortages are resulting in massive loss of life and
threatening regional security. At that hearing, the issue of
the AIDS crisis and its impact on food security was raised
repeatedly. Today we intend to focus specifically on this
catastrophic connection between the AIDS pandemic and hunger.
This hearing was originally scheduled for February 4 of
this year, but was canceled due to the ricin incident that
closed the Senate office buildings. We are fortunate to have
another opportunity to pursue this important topic today. I
want to thank our distinguished witnesses for their patience
and their willingness to work with us in the rescheduling of
the hearing.
We welcome today three close friends who have applied their
extraordinary talents to bringing hope and relief to people
around the world. We will hear from James Morris, Executive
Director of the World Food Program; Ambassador Randall Tobias,
Global AIDS Coordinator; and Andrew Natsios, Administrator of
the U.S. Agency for International Development. It is a personal
privilege to introduce fellow Hoosiers Jim Morris and Randy
Tobias. Indiana is proud of the work they are doing. I also
would extend a very warm welcome to Andrew Natsios who has been
a good friend of the Foreign Relations Committee and is working
closely with us on many projects.
I would note parenthetically that Secretary General Kofi
Annan sent Jim Morris to head a U.N. humanitarian assessment
mission to the Darfur region of Sudan less than 2 weeks ago.
His findings have been reported to the Security Council. He may
wish to comment, to the degree that he can, on the disturbing
situation that has seized the attention of the world in that
country.
Given the infrequent opportunity to bring together all
three of these well-traveled public servants, our hearing today
is devoted to giving committee members an extended opportunity
to engage with them. However, we also recognize the critical
contributions of private voluntary organizations in addressing
the twin problems of AIDS and hunger. Last week committee staff
received an extensive briefing on this topic from members of
the NGO community, including CARE, World Vision, and Catholic
Relief Services. These private voluntary organizations are on
the front lines in confronting AIDS and hunger, and we will
continue to tap their extensive expertise.
Most of us by now are well aware of the devastation caused
by the AIDS crisis. We have heard the figures: approximately 40
million people around the world are currently living with HIV.
The epidemic killed more than 3 million people last year.
Similarly, many of us know that millions of people go to bed
hungry every night and that many, especially children, die of
malnutrition caused by food shortages or famine.
What many people do not realize, however, is how each of
these two crises exacerbate the conditions that contribute to
the other. It is no coincidence that the prevalence of HIV/AIDS
is highest in countries where food is most scarce. Because the
disease affects people in their productive years, it has
decimated the agricultural sector of sub-Saharan Africa, where
approximately 80 percent of the population depends upon small-
scale subsistence agriculture for their livelihood and food.
Since 1985, more than 7 million agricultural workers have died
of AIDS in 25 African countries. This places the burden of
producing food on children and the elderly. In many places,
fields lay untended with no one to work them. The AIDS crisis
has left some 14 million orphans without parents to farm or
otherwise provide food. In many rural households, AIDS has
turned what used to be a food shortage into a food crisis.
This food crisis, in turn, is accelerating the devastation
of AIDS. Without high-protein, nutrient-rich food, HIV-positive
individuals become weaker, do not respond to drug treatment,
and are more susceptible to other illnesses such as
tuberculosis. Good nutrition is crucial for helping HIV-
positive individuals maintain their strength and productivity
as long as possible. This means that parents can continue to
care for their children, teachers can continue to teach, and
farmers can continue to farm. The head of UNAIDS, Peter Piot,
said that when visited by relief workers, often the first thing
people with AIDS ask for is not care or drugs or relief from
stigma; they ask for food.
Food assistance is essential if we are going to make any
headway in the struggle against the virus. Today we have a
unique opportunity to explore the relationship between these
deadly crises. If we are serious about battling the AIDS
epidemic, it is imperative we fully understand the AIDS-hunger
cycle and examine our response to both problems in relation to
each other. According to the World Food Program, more than
24,000 people die daily from hunger and related causes.
According to USAID, nearly 8,500 people die daily from AIDS,
and an estimated 14,000 people are infected every day. Every 14
seconds, as a matter of fact, AIDS turns a child into an
orphan. Clearly we cannot afford to waste a single day in
developing the most effective response possible.
In addition to exploring the complex dynamic between AIDS
and hunger, we will discuss U.S. and multilateral efforts to
address these related crises, including those of the Department
of State, USAID, and the World Food Program. I am optimistic
that today's discussion will enable us to understand more
completely the deadly nexus between AIDS and hunger and to move
forward on a more effective policy for their eradication.
I will, of course, yield to the distinguished Senator from
Delaware, Senator Biden, should he attend later this hearing,
for any statement that he may have.
I will ask Senator Boxer, who is here, if she has an
opening comment for this hearing.
Senator Boxer. With your indulgence, Mr. Chairman, I would
like to take just about 2 or 3 minutes here to thank you so
much for holding this important hearing on the relationship
between hunger and HIV/AIDS.
While this relationship is often overlooked, I am confident
that this hearing will leave little doubt that these two issues
are linked. You cannot prevent and treat AIDS without also
addressing malnutrition, hunger, and poverty. Malnutrition
makes AIDS sufferers so weak that they cannot work in their
fields to feed themselves and their families. Lack of food
leads to malnutrition and a weakened immune system. A weakened
immune system makes one more vulnerable to AIDS. So, Mr.
Chairman, what you have hit upon today is this deadly cycle.
The impact of this terrible epidemic is becoming clearer
every day. As you said, there are an estimated 40 million
people living with HIV/AIDS in the world. I come from the
largest State in the Union. We have 35 million people in our
State. So you could just think about every single person in my
State suffering from HIV/AIDS, what that would do.
In closing, let me just throw a couple of statistics out
here. Five million people were newly infected in 2003. Three
million people died last year as a result of AIDS. Seven
million agricultural workers in Africa have died of AIDS since
1985. And 16 million more agricultural workers in Africa could
die by 2020. The most affected African countries could lose up
to 26 percent of their agricultural labor force within the next
two decades, and last, according to Bread for the World, HIV/
AIDS and food insecurity have a disproportionate impact on
women. Women are more vulnerable physically and culturally to
HIV infection. At the same time, women produce up to 80 percent
of the total food supply in sub-Saharan Africa.
So, Mr. Chairman, you have called it a crisis. You are
right, but it is almost that there is no word that we could
truly use today to describe this. I just want to again thank
you very much for your leadership.
The Chairman. Thank you very much, Senator Boxer.
We turn now to our three witnesses. First of all, I will
mention that the text of your messages will be made part of the
record in their entirety. Summarize if you wish or proceed in
any way, but the purpose of the hearing really is to hear from
you and to have as complete an understanding as possible of the
interconnection and the importance of the subject matter.
I would like for the witnesses to testify in this order:
first of all, James Morris; second, Randall Tobias; and third,
Andrew Natsios. I introduce, first of all, the Honorable James
G. Morris, Executive Director of the World Food Program of the
United Nations, headquartered in New York, New York, but
likewise in Rome, Italy where much of his time is spent. Jim,
would you please proceed.
STATEMENT OF HON. JAMES T. MORRIS, EXECUTIVE DIRECTOR, WORLD
FOOD PROGRAM, UNITED NATIONS
Mr. Morris. Thank you, Mr. Chairman, Senator Boxer. First,
thank you both for your extraordinary, insightful opening
statements. You have described the problem perfectly. Also,
thank you for having met with CARE and World Vision and
Catholic Relief, Save the Children. These are extraordinary
private voluntary organizations that do remarkable work all
around the world, and none of us would be able to achieve our
objectives without these exceptional partners.
I appreciate your making some reference to the mission I
headed a few days ago. I led the humanitarian mission to the
Darfur region of the Sudan, including all of the U.N.
humanitarian agencies. My partner was Ambassador Vraalsen from
Norway who had been the Norwegian Ambassador to the United
States and is the Secretary General's Special Envoy to the
Sudan. We spent time conferring with the leadership of the
country and then spent 3 days in the field in Darfur. I led the
team to west and north Darfur and Ambassador Vraalsen took the
team to the south.
I must report to you that this humanitarian crisis is of
extraordinary seriousness. Today there are more than 1 million
people displaced from their homes. They have been displaced in
the most violent, mean-spirited way possible. Their homes have
been burned. Their possessions have been taken. Their livestock
has been stolen. The women have been raped. It would be hard to
overstate how unpleasant this issue is.
I then went for a couple of days on my own just in my WFP
role to Chad where I visited camps of another 100,000 refugees,
half registered, half have just congregated. The conditions
these people are living in are tragic, sad. It would break your
heart. I visited a camp in Mornei, 60,000 people in the camp,
17,000 women, 9,000 men, and 34,000 children. Like most
tragedies around the world, children are disproportionately
affected and at risk.
This is all complicated by the rainy season which is
approaching. But the fundamental issue is the government's
willingness to provide protection and security, to get the
Janjaweed and marauding militia from the north under control.
The cease-fire between the rebels in the south and the
government is doing pretty well, but the government has the
responsibility under the humanitarian cease-fire to look after
and to control and manage the rebels from the north. And that
is not happening.
I must tell you that I have never in my life seen a group
of people so frightened, people frightened to leave the camp,
people frightened to go home.
The rest of Sudan had a bumper agricultural crop this year,
but the crop in the Darfur region was lost and the crop in the
Darfur region will not be planted next year. So we will be
sitting here a year from now with this same crisis on our
hands. And the government's ability to get control of the
rebels is the key.
We are making progress on humanitarian access. Our folks
reported that we are now feeding about 800,000 of the people at
risk, but the issues of water and sanitation and shelter and
health care--at the same camp, Medecin Sans Frontiere from
France, just a few people providing all of the health care for
the camp. Five weeks ago, a few hundred children under 5
chronically malnourished; today, more than 2,000. So the
humanitarian tragedy is enormous.
I must pay tribute to Andrew Natsios and my colleagues at
USAID for their extraordinary work in making it possible for
the humanitarian community to respond. But this is an issue
that is of great tragedy.
When I left, I was asked by the media, Jim, is this most
serious humanitarian crisis in the world today? Clearly, 1.2
million, 1.3 million are at risk. By year end, it could be
double that. And I said, this is a very serious problem. But in
all candor, I have to report in my own view that the crisis of
HIV, especially in sub-Saharan Africa, is the most
extraordinary humanitarian crisis in the world today. You both
correctly point out that more than 40 million people are
infected. And 75 percent of them are in sub-Saharan Africa.
Seven million farm workers have lost their lives. To put that
in context, that is more than twice the entire on-the-farm
population of the United States and Canada.
An overwhelming burden on the health care system in Africa,
a system that is almost nonexistent, but now overwhelmed by
HIV/AIDS. The number of orphans, 14 million today, going to 20
million. And 2.2 million people died in sub-Saharan Africa.
The life expectancy in many parts of Africa has been
absolutely cut in half. Years ago, the life expectancy in
Zimbabwe was 67 years. Today it is 33. A staggering impact on a
population.
Think about a country that has a population of 11 million
to 12 million people. Thirty-five percent of the adults are
infected with HIV. With 800,000 to 900,000 orphans. A
dramatically deteriorated agricultural system. No foreign
exchange. Tough weather issues. Challenges of governance.
Dramatically diminished health care. Virtually dramatically
diminished public finance system. Tens of thousands of
households headed by children. It is not uncommon to see a
little girl the size of my 8-year-old granddaughter, she is 15,
listless, sick, sad, not educated, hungry playing mother and
father to a family of five or six children. If it was a few, it
would be one thing, but it is there by the hundreds of
thousands.
The burden on the elderly, almost beyond comprehension. The
7 million lives that have been lost in agriculture or the 2-
plus million that were lost are the most productive people. You
will see a grandmother in her 70s, very slight, often looking
after 20 or 30 children, and she has nothing.
WHO would tell you that undernourishment is the most
serious health problem in the world. The lack of
micronutrients, a top 10 health problem, the lack of iodine,
iron, vitamin A, zinc. You correctly state that 24,000 people
die of issues related to hunger every day, 18,000 of them
children. You need to know that they do not die in high profile
crises. The world is focused today on the Sudan. It has been
focused on Ethiopia. But 90 percent of people who die of
hunger-related issues die off in the back woods on a dusty road
somewhere totally unnoticed.
It is easier for us to raise resources for high profile
crises. Our great need is to have resources to address hunger
and nutrition and now HIV/AIDS in places that do not make the
headlines. AIDS has become the sinister element in hunger.
If I could just, as I head into my comments, thank the
United States. As an American, I have been overwhelmed the last
2 years with the generosity of cash and resources and caring
and brain power of USAID and the U.S. missions around the
world. Last year the United States provided well over half our
budget of a billion and a half dollars. The President's
commitment, which Randy leads, to address AIDS is the single
most important step forward that has happened in the history of
this crisis. Eighty percent of the research for HIV comes from
the National Institutes of Health in the United States.
This committee should take time this year to celebrate the
50th anniversary of Food for Peace started by President
Eisenhower in 1954. This initiative now for 50 years has saved
millions of lives and enhanced the lives of millions more.
Food and nutrition, critically important. You correctly
quote Peter Piot when he says, I go to a village in Malawi and
talk about what are the needs of people infected with HIV, and
the first thing they ask for is food.
The burden on women is enormous. Women provide 80 percent
of the agricultural production in sub-Saharan Africa. They now
have close to 60 percent of the HIV infections, and they
provide 100 percent of the care in the household. They ask for
food.
I think it is always good advice to listen to the people
who are most seriously affected by a crisis. They need food,
but they also need water, clean water, and they need access to
education. AIDS and hunger interact. AIDS dramatically
undermines food production. The loss of 7 million agricultural
workers, to say nothing of the 16 million on the horizon, and
the debilitating effect AIDS has had on people still living and
their inability to be productive. Malnourished bodies are more
receptive to HIV and more receptive to the opportunistic
diseases that follow.
The exploitation of hungry, poor people is enormous.
Poverty increases vulnerability to HIV. AIDS increases the risk
of poverty.
The stigma attached to all of this is enormous and it makes
it much more difficult for us to target direct response to a
person infected. We generally find ourselves responding to
communities where we know there is a high rate of incidence.
We are very focused on children and orphans, an
unbelievable burden on children who have lost their parents to
HIV. The psychological loss, much more likely to be
malnourished, more vulnerable to abuse, more vulnerable to HIV
themselves, less likely to go to school, and less likely to get
health care if you are an orphan. Maybe the only thing worse
than being an orphan is being the child of a parent who is
dying of AIDS, to have that experience. The sacrifices of
children for their parents in these circumstances are
extraordinary.
I have talked about the impact on the elderly, on
grandparents, on the extended family. Africa has a great
tradition of the extended family taking care of kids at risk
and orphans. But the burden of 14 million HIV orphans, together
with 26 million more orphans in sub-Saharan Africa is becoming
an overwhelming burden on the extended family.
Food aid is critically important, and there has been a
substantial decrease in food aid in the world in the last
several years. But food aid is critical to feeding children,
especially children in shelters and centers. Food aid is
critical as an incentive to bring children in for vocational
training. Food aid is critical to help provide support for
foster families.
We are very focused on children being enrolled in school.
There are 820 million hungry people in the world, more than 300
million hungry children. Half of them do not go to school. Most
of those that do not go to school are girls. There is no
substitute for the power of the investment of feeding a child
to see that a child gets one good meal every day and using that
as an incentive for that child to go to school. We know what it
has meant to our own country. We know what it has meant to
Japan and the rest of the world is no different.
Education ultimately is the hope for addressing the HIV
epidemic. Kids come to school. They have a chance for HIV
education. More importantly, they have a chance to generally be
educated and begin to have some sense of what their lives might
be, to have more hope for their lives and who they might
become.
And I cannot overstate the importance of this particular
issue on young girls. A girl is fed, is incented to come to
school. If she only comes for a few years for primary
education, her life will never be the same. Her child-bearing
habits are different. Her aspirations for her children are
different. She will be a different kind of parent. She will be
a different kind of citizen.
When you think that we can feed a child in school for $35 a
year and for 30 cents provide the medicine to get rid of the
worms, there is no more powerful leveraged investment the world
can make in the future for its children but for itself than
providing food for kids to go to school. School feeding has
enormous nutritional impact, and clearly reduces the
vulnerability for HIV/AIDS.
The McGovern-Dole school feeding program, which this
Congress made possible, provided $300 million to feed 8 million
school children in 2001. Today in 2004, you provided $50
million and we are only able to feed 1 million school children.
We have done a good job of encouraging the rest of the world to
help us with this program. We have numerous countries helping
us now, and my hope is that as you think about ways you can
help us address the HIV issue, the orphans issue, that you will
be focused on the McGovern-Dole school feeding program. Nothing
more important than the well-being of children. The best chance
we have to make progress on the HIV/AIDS issue is to educate
children between the ages of 5 and 15 about the seriousness,
the hazards, the dimensions of HIV, and that best occurs in the
school.
Randy will talk in a few minutes, I am certain, about
antiretroviral drugs. People in the United States, the NGO
community, the pharmaceutical industry, all around the world
have done a terrific job in bringing down the price, the cost
of antiretroviral drugs, still not within the reach of very,
very poor people, but more accessible than historically has
been the case.
Antiretroviral drugs [ARVs], medicine generally, only work
in a well-nourished human being. For ARVs to work against HIV--
the same scenario applies to tuberculosis--a well-nourished
body with access to clean water, a strong diet is key to making
the ARV situation productive. We can feed a person who is
vulnerable, who is going to take ARV for 29 cents a day. Many
have said that adequate food and nutrition is the first line of
defense in the fight against HIV. A person that has access to
food and nutrition and water and antiretroviral drugs has a
chance to get back on their feet and to have a prolonged life.
I was in Haiti a few days ago, another tough, tough place,
once again a place where the U.S. mission is playing quite a
remarkable role. We have a great U.S. Ambassador there. But I
had a lady I visited with, working in clinics. The highest HIV
prevalence rate in the Western Hemisphere and the largest
calorie deficit of any country in the world, by the way. But a
lady said, you know, Mr. Morris, ``do I spend what I have to
feed my children today or do I pay for drugs I need to stay
alive for them tomorrow?'' A question none of us want to have
to answer, but it is a question that lots of people are facing.
And we know that at the end of the day, the poorest in the
world will be the last to have access to antiretroviral drugs,
and the most important investment we can make in them in the
interim is access to food and good nutrition.
I do not know what value we put on keeping someone alive,
giving someone a few more days or a few more months with their
children, but I suspect it is a very high value. So my message
is that the HIV crisis, especially in Africa, especially in
some countries in the deepest southern part of Africa, the
issues are so extraordinarily difficult that it will be curious
to know how these places will have a chance to survive and come
out of this. They will have no chance without help from the
rest of the world. Our investment in food and nutrition is at
the base of getting rid of poverty. It is at the base of good
health care. It is at the base of gender equity. It is at the
base of universal primary education. It is at the base of
solving infant mortality and addressing issues of maternal
health. And it is absolutely the key issue in getting on top of
the HIV crisis and all of the other health issues that stem
from it.
The World Food Program operates all over the world. We have
special HIV programs in 40 countries, 30 countries in Africa,
and we have special programs in 21 of the 25 most heavily
affected countries in Africa. I should tell you that we have
done all of this without financial incentive or encouragement
from anyone in the world. We have done it because it is at the
base of solving the problems of the hungriest and poorest
people in the world.
So I am grateful for this chance to tell this story. It is
an enormously important story to humanity, but it is likely a
story with the right focus and the right resources that we can,
over time, get on top of. The United States has been
extraordinarily generous, has set the pace. We have negotiated
a new partnership with the Clinton Foundation last week to work
in Tanzania and Mozambique and that is a good thing.
But as is usually the case, the world will continue to rely
on leadership from the United States to solve the toughest of
problems, and this is clearly one of them.
Thank you, sir.
[The prepared statement of Mr. Morris follows:]
Prepared Statement of Hon. James T. Morris
Mr. Chairman. During the course of this hearing several hundred
people will die from hunger. Most of the victims will be malnourished
young children too weak to fight off disease. Their deaths will occur
quietly in dusty villages in Malawi, the slums of Mumbai, the highlands
of Peru. These deaths will not make the news.
Hunger only captures the headlines at the height of crises caused
by politics and natural disasters--the war in Iraq, the violence in
Darfur, drought and civil conflict in Afghanistan. The fact is that
only 8 percent of the deaths from hunger occur in these types of
dramatic food emergencies. It is not that these operations are not
urgent--and right now we face severe shortages in funds for Angola and
the DPRK--but they are usually far better funded than efforts to combat
chronic hunger.
On average, 80 percent of the money donors give to the World Food
Program is earmarked for high profile emergencies. There is no clearer
confirmation of what people in the humanitarian community call the CNN
effect--money follows the media. If there are no horrible images of
skeletal babies, no food riots, no mass movements of starving people,
the cameras are soon gone. And often, so is the money.
Unfortunately, for over 800 million people, the struggle to find
enough food goes on off camera. Hunger and hunger-related diseases
still claim more lives than AIDS, tuberculosis and malaria combined.
Of the 10 greatest threats to public health, my colleagues at WHO
tell us that undernutrition is still number one and deficiencies in
micronutrients like iron, iodine and vitamin A rank number eight. (WHO,
2002) One in 4 of the world's children under 5 years old is
underweight--168 million all told; 181 million are stunted from
longterm undernutrition, and 51 million are wasted from short-term
severe malnutrition. The life of a child is lost every 5 seconds
because we have failed to end widespread hunger and malnutrition.
Much of the silent suffering from hunger today is among millions of
victims of AIDS and their families. AIDS has added a new, more sinister
element to the dynamics of hunger. I have been asked to give you an
overview of global food issues and then focus in on the lethal
connection between the AIDS pandemic and the growing incidence of
chronic hunger in developing countries, especially in Africa.
Before getting into the main portion of my testimony, I must point
out that the United States has been--and continues to be--extremely
generous to the World Food Program. The US provided nearly $1.5 billion
to WFP last year, once again ranking as the top donor.
WFP has also been working closely with our other top traditional
donors around the world to increase contributions, while we are
aggressively pursuing donations from more non-traditional donor states
as well as individuals throughout the world.
The struggle for resources is ongoing--and one that we share with
USAID, NGOs and others who are working to reduce hunger and poverty
around the world.
hunger and aids
Mr. Chairman, we are in danger of falling even farther behind in
the battle to end hunger unless we come to grips with the interaction
between hunger and the AIDS epidemic in the developing world. We tend
to see AIDS through the lens of our own experience here in the United
States, while the economic and sociological dynamics are very different
in Mozambique, Cambodia, or Zimbabwe.
The AIDS coverage in the media focuses heavily on the demand for
anti-retroviral drugs, but if you were to go out and talk to families
in southern Africa, the hardest hit region, you would get a very
different picture. These people talk about food.
My good friend Peter Piot, head of UNAIDS, often relates a story
about one of his first visits to Africa: ``I was in Malawi and I met
with a group of women living with HIV. As I always do, I asked them
what their highest priority was. Their answer was clear and unanimous:
food. Not care, not drugs for treatment, not relief from stigma, but
food.''
Is that so surprising? My colleagues at FAO calculate that 7
million farmers have been lost to AIDS in Africa alone, the continent
with the worst food security problems in the world. Eight out of 10
farmers in Africa are women, mostly subsistence farmers, and women are
disproportionately affected by the disease.
So my first message on AIDS to the Congress is simple--let's start
listening to people living with this horrible disease. As Randy
Tobias--a close friend for decades--shapes President Bush's great
initiative I know he will listen. Ending AIDS is not a battle we will
win with medicine alone--we need proper nutrition, education, clean
water. We need integrated packages of assistance or we run the risk of
tossing our money away.
AIDS and hunger interact. They feed off one another. Why is food
such a big issue for the families affected by them?
First, the disease is seriously undermining food
production. With millions fewer farmers working, there is less food.
Weakened HIV-positive farmers who can still work are not as productive
and less capable of earning off-farm income as well. As farmers earn
less, they cannot afford fertilizers and other farm inputs. Harvests
dwindle further and they enter a downward spiral, selling what assets
they have and sliding into abject poverty. Soon enough, their families
go hungry.
Then there is the nutritional dimension. Malnourished
bodies are more prone to disease, including AIDS. People who are both
HIV positive and malnourished are especially susceptible to
opportunistic infections, most notably tuberculosis.
Hungry people are also more vulnerable to exploitation.
Prostitution is especially rampant in poor communities where people
simply do not know where they will get their next meal. Poverty-
stricken families look the other way as uneducated girls earn money in
one of the few ways they can.
There is a vicious cycle at work here. Poverty increases
vulnerability to HIV infection. AIDS increases the risks of poverty.
But for communities seeking to find their way out of the cycle the way
forward is anything but clear. For one thing, the stigma of AIDS
discourages testing and we usually do not know who is HIV positive and
who is not. So successful interventions must often target whole
communities where we know the disease is taking its heaviest toll.
There are three specific ways WFP and our NGO and government
partners can intervene to help:
First, we must do everything that we can do TODAY to meet the needs
of the orphans and vulnerable children--in particular those in the most
affected communities.
The number of orphans in sub-Saharan Africa is huge, growing and
likely to continue to grow. By 2010, some 20 million children will have
lost one or both of their parents to AIDS.
Combined with other causes--including war and other diseases--the
total number of orphans is an almost incomprehensible 40 million young
people. That may seem a large burden for the world to bear. The real
burden is borne by the families and communities on the frontline of the
epidemic. And by the children themselves.
In addition to their deep psychological loss, orphans between 10
and 15 years old are subject to higher rates of malnutrition, physical
and sexual abuse, and exposure to HIV. And they are much less likely
than children whose parents are alive and well to go to school or get
health care.
These are brutal facts. But one even more jolting is that as bad
off as orphans are, many children whose parents are sick with AIDS can
be even worse off. They must watch their parents die, grow poor as the
household's income dwindles, and deal with the trauma of rejection as
neighbors--even some family members--shun them.
These kids are the ones who shoulder the real burden of the
pandemic. They are sacrificing their childhoods and futures to nurse
sick parents and earning money for their families' survival. AIDS has
turned a generation of children into parents--especially in Africa. It
is not unusual to see a 10 or 12-year old raising siblings without the
guidance of an adult.
Once orphaned, millions of children are shifted from household to
household--and sometimes from household to the street. It is the
elderly of Africa, especially women, whose backs are further bent under
the weight of providing these children with food, shelter and--in the
very best of circumstances--a school uniform and fees so they can
resume their education.
Food aid has an important role to play in helping families and
communities in supporting orphans and vulnerable children. For example,
we use food aid to:
directly feed children in shelters and centers;
support vocational training programs;
make sure that foster parents--including grandmothers who
are sometimes looking after a dozen of their grandchildren--can
feed them all; and
bolster the family larder with take home rations so kids can
be kids and go to school instead of working the fields or
running off to the nearest city.
Right now, we are only scratching the surface. We can do so much
more.
Second, we must do everything we can to help children in the most
affected communities and countries enroll in school--and attend
regularly.
There is such strong agreement that education is our most immediate
hope for addressing this epidemic. When it comes to HIV prevention,
it's been called the ``education vaccine''. I'm not just referring to
HIV prevention education, as important as that is. I'm talking about
something much more powerful than that--the skills and social norms
that we learn in a safe and nurturing school environment. It can shape
who we are, how we relate to others, and what we are able to do with
our lives--for ourselves and others.
Helping children to attend school longer--especially girls--has a
proven record for interrupting the spread of HIV. The longer a girl
attends school the more knowledgeable she becomes. Knowledge is power
and it's that personal power that enables young people to better manage
the circumstances around them and better judge the actions of others.
This translates into positive and healthy behaviors that last a
lifetime.
Mr. Chairman, food aid has an important role to play in
strengthening schools, particularly in those communities most affected
by AIDS.
We know that one nutritious meal a day at school can
improve enrolment, attendance and academic performance--we have seen
enrolment climb up to 300 percent in schools that provide meals.
We know that where school-feeding programs involve the
community, schools become platforms for AIDS awareness and HIV
prevention, health and nutrition education, agriculture and skills
training.
And we know that take-home rations for the most vulnerable
children can offset the family's cost of sending them to school--a
major issue in families where the breadwinner has AIDS.
School feeding both mitigates the nutritional impact the epidemic
has directly or indirectly on children and also helps reduce their
vulnerability to HIV infection by promoting education. It stands out as
one of the few interventions which we can effectively target at
communities with high HIV rates--and scale up rapidly.
I am concerned that funding for school feeding has dropped off. The
US has always been a generous contributor and we need other countries
to do more as well. In 2001, $300 million in USDA funds were allocated
to school feeding under the McGovern-Dole initiative and in the FY 2004
budget the figure fell to $50 million. With the $300 million we had in
2001, nearly 8 million children were being fed in school in countries
like Afghanistan, Nicaragua, and Kenya by WFP and our NGO friends.
Barely 1 million will now be receiving help from this worthwhile
program.
Knowing what we do about the benefits, this Congress should
actively support a drive to extend school feeding to every school in
every community currently most affected by the epidemic.
Congress should also look at funding a full package of assistance
needed by hungry, poor people. That is to say--food, water, medicine
and shelter are all needed together. All humanitarian organizations,
from WFP to UNICEF to our PVO partners, require this full package of
assistance to appropriately address the needs of the most vulnerable.
Third, Mr. Chairman, we must do all we can to use food and
nutritional assistance to maximize the benefits of therapeutic drugs
for AIDS and related conditions.
Medicine only fully works its magic, however, on a well-nourished
person who has access to clean water and good diet. In short, those
living with HIV/AIDS need food, water and medicine.
Leading nutritionists throughout the world tell us that adequate
nutrition is the first line of defense in the battle against HIV/AIDS.
We also know that the populations that are the poorest and most food
insecure, and currently receiving food aid, are not always the same
populations who are infected and affected by HIV/AIDS.
Therefore, WFP and our PVO partners need ADDITIONAL RESOURCES to
help feed this highly vulnerable population. In short, we are already
stretched thin by dozens of emergencies around the world--from Haiti to
Sudan--yet we are serving only 10% of the world's hungry population. We
need more resources to expand our efforts to fight the HIV/AIDS
pandemic. We cannot reprogram our limited resources that are already
deployed around the world to the poorest, most vulnerable areas.
Anti-retroviral drugs can work wonders. So can medications to treat
the most common opportunistic infection, tuberculosis. In hard hit
communities, these drugs can help put sick people back on their feet
again.
Food and nutrition programs have a vital support role to play here.
AIDS is no different from any other disease when it comes to one basic
fact--our bodies need good nutrition to fight off infection, regain
strength and live productively.
Good nutrition can help to make AIDS and TB drugs work their
miracles. Especially in symptomatic periods where caloric requirements
are greater and capacities to work compromised, food and nutritional
support can be critical. In countries like Cambodia, Lesotho and
Uganda, WFP has successfully used food rations as an incentive to keep
TB patients coming back for the full course of drug treatment which
helps prevent mutations that cause everyone concern, even here in the
United States.
conclusion
Last month, I was in Haiti visiting our operations there. The
island is the worst hit by AIDS in the entire hemisphere and
tuberculosis is widespread. I heard a saying Haitians use about TB I
found fascinating. ``Giving a TB patient medicine with no food is like
washing your hands and drying them in the dirt.'' It's a point we might
well remember as we grapple with AIDS.
I don't think any one of us could think of a worse choice than one
that faces so many parents with AIDS--``Do I spend what I have to feed
my children today or pay for the drug therapies I need to stay alive
for them tomorrow?'' Imagine that kind of choice in your life.
The World Health Organization, UNAIDS, the world's pharmaceutical
companies, private foundations, activists and governments are now doing
a tremendous job of reducing the cost of AIDS drugs for the poor.
But now, after having taken the bold leap to help the poorest with
ARVs, why would we not want to get the most out of those investments?
Why would we not ensure adequate nutrition for those receiving ARVs to
strengthen their bodies as they fight the disease? Why wouldn't we
ensure the food-security of their families while they regain their
strength?
Sadly, for many, anti-retroviral drugs will come too late or not at
all. Even under the most hopeful scenarios, millions of people won't
have access to them soon. I'm talking about poor people who live in
communities with no clean water and no health clinic. Rural villages
and poor subsistence farmers may well be last in line once ARV
therapies are more widely available and that will further damage
agriculture.
Mr. Chairman, when it comes to humanitarian aid, governments don't
lead, they follow. Already there are thousands of community and faith-
based organizations out there working in the greatest humanitarian
tradition, easing the suffering from AIDs and hunger. Before closing
I'd like to give you just one example.
There is an NGO that WFP works with in Uganda--the National
Community of Women Living with AIDS. One of our beneficiaries is Yudaya
Nazziwa, a forty-one year old widow. Yudaya is preparing to die. She
has AIDS and each day she writes into a journal something of her family
history and practical advice for her oldest daughter. The Ugandans call
these journals ``Memory Books''. Her tale is painful, but sadly, it is
not unusual--her husband died of AIDS and his relatives took over her
comfortable home and possessions. She and her four children now live in
a slum and depend on WFP food aid to survive. Yudaya is tough and wants
to hang on as long as she can--to work if possible and pass on what she
knows to her children. Food aid is keeping her nourished, helping her
fight off diseases. As she puts it: ``Now I have to eat for two--for
myself and the virus.'' Maybe one day--let's hope soon--Yudaya will be
on anti-retroviral drugs. President Bush's massive multi-billion dollar
campaign headed by my good friend Andrew Tobias, holds out that hope.
But for today, food aid is helping keep people like Yudaya alive and
even if she does get medication soon, we all know that a well nourished
patient stands a better chance of survival.
I want to add one more chapter to the Memory Books of these Ugandan
women--a chapter about how we all helped keep them alive and their
families together.
This is the greatest humanitarian challenge of our time. I am so
deeply proud that President Bush has made the enormous commitment he
has and called on talented people like Randy Tobias and Andrew Natsios
to take this challenge on. All of us at the World Food Program are
ready to give it all we've got to help.
The work is not done out there. We can and we should do more for
the 800 million people going to bed hungry every night. I know the US
Congress has limited choices with fewer dollars available. But, working
together--with the White House, with Congress, and with USAID, with
USDA, with the State Department, with our private, voluntary partners,
and with generous everyday Americans, we can make a difference.
World Food Programme
The Food Aid Organization of the United Nations
News Release--11 May 2004
AIDS COMPLICATING BATTLE AGAINST HUNGER, SAYS WFP EXECUTIVE DIRECTOR
Washington, DC.--James Morris, the Executive Director of the United
Nations World Food Program (WFP), today testified before Congress on
the growing hunger problem around the world and how it is exacerbated
by the AIDS crisis.
More than 40 million people are infected with HIV and some two-
thirds of them live in conditions of severe poverty in sub-Saharan
Africa. Morris highlighted to Congress the critical role that food aid
plays in helping people living with HIV/AIDS fight the disease.
``Ending AIDS is not a battle we will win with. medicine alone--we
need proper nutrition, education, and clean water,'' Morris told the
Senate Foreign Relations Committee. ``The AIDS coverage in the media
focuses heavily on the demand for anti-retroviral drugs, but if you
were to go out and talk to families in southern Africa, the hardest hit
region, you would get a very different picture. These people talk
aboutfood.''
People need good nutrition to fight off infection, regain strength
and live productively. Malnutrition breaks down people's immune
systems, and makes them more prone to disease, including AIDS.
Morris also appealed to Congress to put a greater priority on funds
for people suffering from chronic hunger, rather than just on the
victims of high-profile disasters and emergencies.
``During the course of this hearing several hundred people will die
from hunger,'' Morris told Congress. ``Most of the victims will be
malnourished young children too weak to fight off the disease. Their
deaths will occur quietly in dusty villages in Malawi, the slums of
Mumbai, the highlands of Peru. These deaths will not make the news.''
Every five seconds, a child dies from hunger-related diseases, and
malnutrition is still the number one public health threat around the
world. More people die from hunger-related causes than from AIDS,
tuberculosis and malaria combined.
The US government has been the top donor to WFP since its inception
in 1963 and continues to be the agency's most generous contributor.
Last year, the US government donated nearly US$1.5 billion for feeding
programs in countries ranging from Afghanistan to Iraq to Zambia.
Currently, more than 800 million people are chronically hungry, a
figure which increased by 18 million in the second half of the 1990s.
One in four of the world's children under five years old is
underweight--168 million all told. At the same time, WFP is facing a
shortfall in 2004 of 1.8 million metric tons of food or $1 billion for
critical operations in 2004.
Morris also recommended that Congress provide more food assistance
to AIDS orphans--expected to rise to 20 million children by 2010--and
increase school feeding programs. WFP provides nutritious school meals
to children in 69 countries to attract them to school, increase
retention rates and improve learning ability.
``Helping children attend school longer--especially girls--has a
proven record for interrupting the spread of HIV,'' said Morris. ``The
longer a girl attends school, the more knowledgeable she becomes. This
translates into positive and healthy behaviors that last a lifetime.''
In his testimony, Morris noted his concerns about the growing
humanitarian crisis in the Darfur region of western Sudan, which has
led to more than one million people being displaced from their homes
and more than 100,000 refugees fleeing to Chad. Morris led a high-level
UN inter-agency assessment mission to Darfur and Chad at the end of
April.
``What we witnessed throughout Darfur and in neighboring Chad is a
dramatic humanitarian crisis, no doubt one of the worst in the world
today. It is a crisis of massive displacement, critical humanitarian
needs and extreme levels of violence and fear,'' said Morris.
* * *
WFP is the world's largest humanitarian agency: in 2003 we gave
food aid to a record 104 million people in 81 countries, including 56
million hungry children.
WFP Global School Feeding Campaign--For just US$19 cents a day, you
can help WFP give children in poor countries a healthy meal at school--
a gift of hope for a brighter future.
Visit our website: www.wfb.org
The Chairman. Thank you very much, Mr. Morris, for that
very compelling testimony.
I want to introduce now the Honorable Randall Tobias,
Global AIDS Coordinator, Department of State, Washington, DC.
Mr. Tobias, would you proceed.
STATEMENT OF HON. RANDALL S. TOBIAS, GLOBAL AIDS COORDINATOR,
U.S. DEPARTMENT OF STATE
Ambassador Tobias. Mr. Chairman, thank you and thanks to
the members of this committee for the opportunity today to talk
about the very important relationship between the global HIV/
AIDS pandemic and hunger.
I am particularly pleased to appear this morning with my
U.S. Government partner in this effort, Andrew Natsios, and my
longtime friend, in fact, my friend for almost 43 years, Jim
Morris, the Executive Director of the World Food Program.
Mr. Chairman, I appear before you today, 7 months after my
confirmation hearing, my last appearance before this full
committee. Since that time, I have had the opportunity to visit
many of the countries in which we are focusing our efforts,
including South Africa, Uganda, Kenya, Botswana, Zambia,
Namibia, Rwanda, Ethiopia, and Mozambique, and I will be
leaving in the days ahead for a visit that will include
Nigeria, Cote d'Ivoire, and Tanzania.
I am pleased to report that in those 7 months, I think we
have made historic progress in beginning to achieve, the
President's, the Congress', and the American public's goal of
bringing prevention, treatment, and care to millions of adults
and children who are courageously living with HIV/AIDS, and
these efforts are replacing despair with hope.
Early this year, I submitted to you and to other
appropriate congressional committees a comprehensive 5-year
strategy to implement the President's Emergency Plan for AIDS
Relief. The strategy is guiding our efforts to rapidly expand
prevention, treatment, and care, to identify new partners, to
build capacity for long-term success, and to amplify the
worldwide response of HIV/AIDS by working with other partners.
Let me also note that in February, less than a month after
Congress appropriated funds for the first year of the
President's Emergency Plan, I announced $350 million in
initial, first-round awards to service providers, NGOs and
others who are bringing relief to suffering people in some of
the countries hardest hit by the HIV/AIDS pandemic. These
awards are already rapidly scaling up programs that provide
antiretroviral treatment, prevention programs, including those
targeted at youth, safe medical practices programs, and
programs to provide care for orphans and vulnerable children.
With just this first round of funds, an additional 50,000
people living with HIV/AIDS in the 14 focus countries of the
Emergency Plan will begin to receive antiretroviral treatment
which will nearly double the number of people who are currently
receiving treatment in sub-Saharan Africa. Today activities
have been approved for antiretroviral treatment in Kenya,
Nigeria, and Zambia, and patients are receiving treatment in
South Africa and Uganda because of the Emergency Plan.
In addition, prevention through abstinence messages will
reach about 500,000 additional young people in the plan's 14
focus countries in Africa and the Caribbean through programs
like those of World Relief and the American Red Cross' Together
We Can program.
The first release of funding from the President's plan will
also provide resources to assist in the care of about 60,000
additional orphans in the plan's 14 focus countries. Care will
include providing critical basic social services and scaling up
basic community care packages of preventive treatment and safe
water, as well as HIV/AIDS prevention education.
This is only the beginning of our efforts. Later this week
or early next week, Mr. Chairman, we will be providing this
committee and other congressional committees with the required
notification for the obligation of approximately an additional
$300 million which will be our next tranche of funding. I seek
your support in ensuring that we are able to move these
resources as quickly as possible so we can continue to respond
with urgency that these individuals so require.
As we make additional awards, the numbers of persons
receiving treatment and care will increase substantially. I
also expect an increase in our efforts to strengthen and expand
safe blood transfusion and safe medical injection programs, as
well as our efforts to strengthen human and organizational
capacity through health care twinning and volunteers.
The President's Emergency Plan has three clear goals to be
achieved over the next 5 years in 14 countries in sub-Saharan
Africa and the Caribbean: first, as you know, it is to treat 2
million HIV-infected people with antiretroviral therapy;
second, to prevent 7 million new infections through increased
HIV testing and through behavior change; and third, to provide
care for 10 million HIV-infected individuals and the children
that Jim has mentioned who have been so devastated by this
pandemic. This comprehensive and unparalleled approach through
integrated treatment, prevention, and care is essential if we
are to be successful, as we must be, in this global fight
against HIV/AIDS.
But, Mr. Chairman, as important as all of this is, clearly
this program, the President's Emergency Plan, is not the whole
answer. The President's initiative is intended to be part, but
only part, of the potential solution to a very complex and
multifaceted set of issues surrounding HIV/AIDS. This is a
global pandemic that requires resources well beyond the scope
of the President's Emergency Plan, resources focused on
additional aspects of human need.
The President's Emergency Plan is largely a health care-
based program focused on prevention, treatment, and care. It
does not directly address hunger, but as you and others have
correctly suggested, hunger and nutrition and a wide range of
other issues are clearly linked to successfully addressing HIV/
AIDS. We recognize that food security, good nutrition, and
clean water are inextricably linked to successfully fighting
AIDS. Without access to safe and adequate food, people are less
able to effectively respond to AIDS treatment.
Moreover, drug resistance grows if people fail to stay with
their treatment regimens. Persons living with HIV/AIDS but
without access to sufficient food have less time to focus on
care, and they pay less attention to issues of prevention. At
the same time, we know that HIV/AIDS exacerbates food
insecurity, production shortages, and long-term agricultural
knowledge loss.
To succeed in this battle, we must recognize the important
relationships between hunger and HIV/AIDS, and we must work
together in every way we can within our own government, as well
as with other partners, including other governments,
international organizations, the private sector, and
nongovernmental organizations, to tackle this problem and turn
the tide against HIV/AIDS. We must find every possible way to
coordinate our efforts with those of other programs that bring
resources to address hunger and the other related issues.
One of the most socially and economically destructive
aspects of HIV/AIDS is that it predominantly affects the most
productive members of society, those between the ages of 15 and
45. This directly impacts the size and the productivity of the
labor force, with negative outcomes for family income, assets
and agricultural knowledge and productivity. As has been
mentioned, 7 million agricultural workers have already died of
AIDS in Africa.
The World Health Organization has estimated agricultural
productivity losses from AIDS at the village and household
level at anywhere from 10 to 50 percent in a selection of sub-
Saharan African countries. In fact, a UNAIDS assessment in
Zambia showed that families in which the head of household was
chronically ill planted an astonishing 53 percent less than was
planted by households with a healthy head of household.
Families that lose their most productive members and are forced
to rely on the elderly or the young often resort to the sale of
livestock or the sale of other assets to pay for food, as well
as treatment or even funerals.
The short-term consequences of this devastation is often
food supply shortages which further lower agricultural
productivity and so it goes. But the problem is not only the
short term. Over time, agricultural techniques and knowledge
are lost potentially further reducing crop yields and overall
agricultural output in communities for extended periods of
time. Therefore, the better methods of transferring
agricultural knowledge between generations and better
agricultural techniques that are less labor-intensive are
needed to address the impact of HIV/AIDS on hunger and food
production.
But, Mr. Chairman, this is merely one side of the equation.
The other side is hunger's adverse impact on HIV/AIDS.
We know that adequate nutrition and food bolster the immune
system and allow people living with the virus to continue to be
productive members of society. In combination with the care and
the antiretroviral treatments that the President's Emergency
Plan will bring to millions of people, farmers can continue to
produce food, children can continue to attend school, and
parents can continue to provide for their families. I saw this
myself recently in Uganda when I visited a program funded by
the U.S. Government in a rural area in the Tororo District in
which we are already providing antiretroviral medicines to poor
families.
In the face of hunger and inadequate nutrition, however,
the disease will accelerate, expose the infected to new
illnesses, and reduce their ability to respond to treatment and
antiretroviral therapies. Hunger can also reduce the amount of
time families and others can realistically dedicate to care and
it may force people into activities that undermine our
prevention efforts. For example, people suffering from hunger
often migrate in search of emergency food relief or for
employment, a trend that exacerbates the spread of HIV into new
and possibly less-affected communities. Some evidence from some
countries suggests that hunger drives women and young girls
into prostitution to compensate for the lost income of a
deceased family member.
The linkages between hunger and HIV/AIDS will require the
coordinated attention of many domestic and international
partners.
Recognizing that HIV/AIDS is a global emergency, I intend,
with your support, to rapidly mobilize resources to prevent the
momentum of increasing HIV/AIDS infections and stem the
suffering through treatment and care. The focus of the
President's Emergency Plan is on achieving those targeted goals
within prevention, treatment, and care, and Congress'
commitment to this initiative, through its authorization and
appropriation of resources, is essential to its success.
And while we maintain our focus on the task at hand, we
recognize the complexity of the crisis and that addressing
other issues, such as hunger and food security, are absolutely
vital in the success of this total effort. It is crucial,
therefore, that we in the HIV/AIDS field recognize the
importance of coordinating with those who are addressing hunger
and nutrition, as well as other issues like gender
discrimination and economic development, to achieve success in
the fight against the epidemic.
Toward that end, I look forward to working with other U.S.
Government agencies such as the Department of Agriculture,
Health and Human Services, and the Agency for International
Development to ensure that our food aid and HIV/AIDS efforts
are mutually reinforcing. And I also look forward to
strengthening our relationships with our international partners
like the World Food Program and UNAIDS and the Global Fund to
Fight AIDS, Tuberculosis, and Malaria, as well as with the
World Health Organization.
In fact, I want to take this opportunity this morning to
commend Jim and the World Food Program for their recently
expanded focus on HIV/AIDS in southern Africa as a clear
example of the type of increased response to which we aspire.
Under Jim Morris' leadership, beginning last month the World
Food Program began adding nutritious food baskets to help those
living with HIV/AIDS. The World Food Program is integrating
HIV/AIDS prevention programs into its school feeding programs
and it spent nearly $200 million on HIV/AIDS programs in 2002
alone. This is exactly the kind of sustained, coordinated
effort that we need.
Mr. Chairman, thank you and thanks to the members of this
committee for the opportunity to share my views on the
relationship between HIV/AIDS and hunger and to update you
briefly on our progress in implementing the President's
Emergency Plan. I am grateful to you for your resolve in
defeating this pandemic. Your leadership and support has
facilitated the speed with which we are responding to people in
need and that commitment will help ensure our success, success
that over time will be measured in lives saved and families
held intact and nations continuing to move forward with
development.
Thank you very much.
The Chairman. Thank you very much, Ambassador Tobias. Thank
you especially for illustrating the strong cooperation between
your agency and the Department of State, the United Nations,
and the World Food Program. You have illustrated the
interdependence well.
I would now like to introduce the Honorable Andrew Natsios,
Administrator, United States Agency for International
Development from Washington, DC, a good friend of our
committee. We welcome you. Please proceed.
STATEMENT OF HON. ANDREW S. NATSIOS, ADMINISTRATOR, U.S. AGENCY
FOR INTERNATIONAL DEVELOPMENT
Mr. Natsios. Thank you, Mr. Chairman, members of the
committee. Good morning. I am pleased to be with you, along
with my good friends, Ambassador Randy Tobias and Jim Morris of
WFP, to discuss the relationship between AIDS and hunger.
I do want to testify to the leadership that Jim Morris has
brought to WFP and not just in HIV/AIDS, but in emergencies
around the world. We are a very close cooperating supporter of
WFP. He and I talk often, and he led the team into Darfur, a
major focus of USAID right now because a famine is brewing. It
has not taken place yet, but we want to avoid it happening.
Randy Tobias' leadership in the fight against HIV/AIDS is of
critical importance to the U.S. Government.
USAID has long been a leader in fighting both the HIV/AIDS
pandemic, going back actually to the mid-1980s, even though it
had a very small budget then, and in preventing hunger and food
insecurity. I am pleased to report that with USAID's funding we
are providing food aid resources for food, prevention
education, care, and support to over 700,000 people in African
communities that are the focus countries of the President's
Emergency Plan for AIDS Relief. In addition, we have
prevention, care, and treatment programs for HIV/AIDS across
the continent, which of course is the area of the world most
severely affected by AIDS. Seventy-five percent of the people
who are HIV/AIDS-positive in the world live in sub-Saharan
Africa.
The world has recently come to see how deeply these two
problems are intertwined. We have a research paper \1\ that is
at the back of the room here on the table that was done with
one of our partner organizations, the Academy for Educational
Development, and USAID on the effect of poor nutrition on the
development of AIDS, which is quite useful I think from a
clinical standpoint.
---------------------------------------------------------------------------
\1\ The research paper referred to can be found on page 24.
---------------------------------------------------------------------------
The majority of the world's hungry and food insecure live,
unfortunately, where HIV/AIDS is also highest in terms of
prevalence, and that is in sub-Saharan Africa. HIV/AIDS and
food insecurity are a devastating combination.
On June 1, 2001, almost 3 years ago, I issued my first
cable,\2\ having just been sworn in as USAID Administrator on
May 1, 2001, to our field missions asking them to not just have
a health response to the AIDS pandemic but an integrated
response that affects and integrates all our funding streams
and all our programs in response to this catastrophic epidemic.
---------------------------------------------------------------------------
\2\ The cable Mr. Natsios refers to can be found on page 32.
---------------------------------------------------------------------------
In many villages across Africa, HIV/AIDS has wreaked havoc
on food production, as Randy just mentioned. When someone is
debilitated by disease, the food security of his or her family
is in clear jeopardy. All too often families are forced to sell
livestock and valuable assets to care for the sick or to pay
funeral expenses. This then compromises any future earning
potential.
For people living with AIDS, good nutrition is essential
for continued good health. It can also slow down or speed up
the onset of the actual manifestation of the disease, depending
on their nutritional circumstance. For too many people living
with AIDS, getting enough to eat adds enormously to life's
daily challenges.
We do know in the last decade that chronic malnutrition has
increased significantly in sub-Saharan Africa and we know that
the AIDS pandemic is exacerbating this problem.
The United States has a long history of support for food
programs and has recently made an unprecedented commitment to
fighting the AIDS pandemic. This year marks the 50th
anniversary of the creation or the passage of what we call
Public Law 480, which created the U.S. Food Aid Program. We are
going to have a big celebration later this year.
Since the inception of this program, the U.S. Government
has provided 100 million metric tons of food aid valued at $33
billion and has affected the lives of over 3 billion people in
150 countries. Last year, the United States provided through my
agency almost $1.1 billion of food aid to the World Food
Program for their worldwide programs. The rest of our food
budget goes to the NGO community. The vast majority of this
goes through the Office of Food for Peace in USAID, which
includes $6 million we send to WFP for their administrative
expenses for emergency programs.
The Bush administration has provided unprecedented support
for the fight against HIV/AIDS through the President's
Emergency Plan for AIDS Relief. USAID is helping fight the
pandemic from a health perspective, as well as through our
agriculture, education, and food aid programs. In fact, I
mentioned earlier this cable that was sent out. We now have 3
years of experience in how to integrate these programs
together.
The Office for Food for Peace in USAID has invested $17
million for 40,000 metric tons of food through NGOs for the
most part to almost 700,000 HIV/AIDS infected children and
adults in Haiti, Ethiopia, Kenya, Mozambique, Rwanda, South
Africa, Uganda, and Zambia. We are doing grants to treat HIV/
AIDS and to prevent HIV/AIDS and to care for people with HIV/
AIDS simultaneously to the same NGOs and the same community-
based organizations in the same regions. This allows for more
integration of these three functions together.
One of the families we support is that of Pascasie Mukamana
who is an orphan. She lives in Rwanda and she cares for her two
sisters, one of whom is HIV-positive. With our funding,
Catholic Relief Services provides a monthly food ration to her
and her sisters.
In addition to responding to the AIDS pandemic and to food
emergency, USAID is addressing the long-term consequences of
food insecurity. Through the President's Initiative to End
Hunger in Africa, we are working toward fulfilling the
Millennium Challenge goal of halving the number of hungry
Africans by 2015. We are doing this, of course, through
sustainable agricultural growth and efforts to augment rural
family incomes, which usually means agriculture in sub-Saharan
Africa. We believe, over the longer term, the best way to deal
with food insecurity in Africa is for Africans to grow their
own food.
Through USAID's Harvest Plus Program, researchers are
developing new varieties of wheat, rice, maize, and cassava to
enhance the nutrient content, quality, and yield of these
important staple crops. What we are doing is breeding into,
working with the World Bank subsidiary, the CGIAR network of
agricultural research stations, different micronutrients into
different food crops where there is evidence that in the normal
diet of these people, there is a micronutrient deficiency.
Just one example of this, there is a serious problem with
vitamin A deficiency in the Mozambiquean diet, which is why
there is high child mortality rates. So what we did is we
introduced a regular sweet potato, not an improved variety,
which is very high in vitamin A--into the food chain. We taught
people, women particularly, how to cook this and how to grow
it. Using 125 community-based organizations, we introduced this
crop into Mozambique. It has now taken off and it is part of
the agricultural system of Mozambique. Through the agricultural
system, not through vitamin supplements, we are actually
getting vitamin A now into the Mozambiquean diet working with
the Ministry of Agriculture in that country.
HIV/AIDS also, unfortunately, is heavily prevalent. I think
there is an 18 percent prevalence rate in Mozambique. So you
see, by combining agricultural programs with the nutrition
programs and with HIV/AIDS programs, you can, in an integrated
fashion, address the pandemic.
We are in a unique position because of our integrated
programming at the mission level. Three-quarters of our staff
at USAID are in the field, not in Washington. We have a highly
decentralized program. I leave it to our mission directors as
to how to do this technically. But by building on these
strengths, we can ensure that assistance gets to the neediest
in a timely and transparent fashion.
Without the World Food Program, I want to add, as the
wholesaler, in terms of doing the massive requirements needed
both for development food but also particularly for emergency
food, we could not function. Without the World Food Program, we
could not be doing what we are doing now in Darfur province,
for example, which is in terms of emergencies, the worst in the
world, apart from the AIDS pandemic itself.
Thank you for allowing us to testify today.
[The prepared statement of Mr. Natsios follows:]
Prepared Statement of Hon. Andrew S. Natsios
Mr. Chairman, members of the Committee.
Good morning. I am pleased to be with you, along with Ambassador
Randy Tobias and Jim Morris, to discuss the relationship between AIDS
and hunger. The U.S. Agency for International Development has long been
a leader in both fighting the AIDS pandemic and in preventing hunger
and food insecurity. The world has recently come to see how deeply
these two problems are intertwined. The majority of the world's hungry
and food insecure live where HIV prevalence is highest--in sub-Saharan
Africa, where HIV and food insecurity are a devastating combination.
I am pleased to report that with USAID's funding, we are providing
food aid to 700,000 people in African communities heavily impacted by
HIV/AIDS. In addition, we have prevention, care and treatment programs
for HIV/AIDS across the continent, as well as food aid programs for
millions of Africans.
There is much to be done. Unlike other diseases, AIDS strikes
people in the prime of their lives. This has profound effects on
families, communities and nations. As Secretary of State Colin Powell
has pointed out, ``the disease decimates a society's most productive
members. It sickens those . . . who take care of the very young and the
very old. It destroys those who teach and trade, support their families
and otherwise contribute to their nation's development. AIDS saps
global growth. Unchecked, AIDS can lay waste to whole countries and
destabilize entire regions of the world.''
In many villages across Africa, HIV/AIDS has wreaked havoc on food
production. When someone is debilitated by disease, the food security
of his or her family is in jeopardy. All too often families are forced
to sell livestock and other valuable assets to care for the sick or to
pay funeral expenses. This then compromises any future earning
potential.
For people living with HIV/AIDS, good nutrition is essential for
continued good health. Yet, for too many people living with AIDS,
getting enough to eat adds enormously to life's daily challenges.
A lack of food can sometimes cause the epidemic to spread. We have
heard too many stories of mothers who will trade the only resource they
have--themselves--in exchange for food to feed their hungry children.
how food and aids interrelate
Chronic malnutrition is increasing in sub-Saharan Africa. And the
AIDS pandemic is exacerbating it.
Let me take this opportunity to praise Jim Morris's leadership in
responding to last year's food crisis in southern Africa. In his role
as the UN Secretary General's Special Envoy, he helped alert the world
and made an emergency request for funding. I'm proud that the U.S.
Government took the lead in responding to the crisis and provided
880,000 metric tons of food aid for the region, valued at $529 million
over the past two years.
We need to draw lessons from such experiences and apply them to our
fight against the AIDS pandemic. We now realize that HIV/AIDS
exacerbates food insecurity. But there is still much to be learned
about the causes and consequences of this relationship. As we expand
anti-retroviral treatment for people living with AIDS, there will be
further issues to explore.
We do know that HIV/AIDS affects a household's ability to produce
food and earn income in several ways by:
Reducing labor for farming due to illness, death and
additional caregiving responsibilities;
Depleting food reserves, savings and productive assets, such
as livestock;
Increasing household expenses, due to the costs of caring
for a chronically ill person or children orphaned by AIDS.
Food assistance is the number one request made by people living
with AIDS. It is key to improving overall health and quality of life.
Malnutrition worsens the effects of HIV by further weakening the immune
system and increasing susceptibility to infections. Good nutrition
helps people living with HIV/AIDS manage symptoms and effectively
respond to treatment.
Conversely, HIV compromises the nutritional status of infected
individuals. It creates additional nutritional requirements, causing
symptoms that limit food intake and reducing the use of nutrients by
the body.
The World Health Organization believes that better nutrition
increases survival rates, primarily because of its effects on immune
functions. Increased caloric intake is recommended for HIV-infected
adults because of their higher energy requirements. Once they have
symptomatic HIV and full-blown AIDS, caloric intake needs to increase
by 20 to 30 percent. For HIV positive children, once a child begins to
experience weight loss, he or she must increase consumption by 50 to
100 percent.
Good nutrition is also important for patients receiving
antiretroviral drugs, or ARVs, which are potent medications that often
need to be taken with food. The use of the right combination of food
and ARV treatment is important to ensure drug compliance and
effectiveness.
We know that food insecurity and HIV/AIDS have profound
consequences for nation states. We are only just beginning to
appreciate the implications of the halving of adult life expectancy and
the massive loss of human capital in many countries. In the most
affected countries, HIV/AIDS has the potential to cripple the
socioeconomic and political infrastructure, which is vital for
stability as well as development.
usaid and presidential initiatives
President Bush launched the Initiative to End Hunger in Africa in
2002. It is a multi-year effort designed to help fulfill the Millennium
Development Goal of halving the number of hungry Africans by 2015. We
are urgently addressing the need to rapidly increase sustainable
agricultural growth and augment rural incomes in sub-Saharan Africa.
This approach will reduce the need for future food aid to the
continent.
Last year, P.L. 480 programs to prevent HIV and care for HIV-
infected children and their families reached at least 2.2 million
people. Approximately 110,000 thousand tons of commodities, valued at
$51 million, went into these programs.
I would like to take this opportunity to note that this year marks
the 50th anniversary of Food for Peace. P.L. 480 was enacted on July
10, 1954, and for 50 years Title II has affected over 3 billion lives
in over 150 countries. Since the inception of this program, which is
implemented by USAID's Office of Food for Peace, the U.S. Government
has provided over 100 million metric tons of food aid, valued at more
than $33 billion, to reach people around the world. This is a program
we can all be proud of because of its central role in helping save
lives and alleviate suffering.
USAID has been involved in the fight against AIDS since 1986, and
today more than 100 countries around the world receive assistance from
USAID in this fight.
As President Bush has said, ``fighting AIDS on a global scale is a
massive and complicated undertaking.'' That's why, just over a year
ago, he announced the President's Emergency Plan for AIDS Relief, a
visionary plan to increase spending on AIDS to $15 billion over 5
years. I'm pleased that USAID is a key part of the team implementing
this emergency plan. We are working closely under the leadership of the
Global AIDS Coordinator, Ambassador Randall Tobias, who you will also
hear from today.
president's emergency plan for aids relief
The Emergency Plan sets out three key goals to be achieved by 2008
in 14 focus countries: Provide treatment to 2 million people, prevent 7
million new infections, and provide care and support to 10 million
people living with and affected by AIDS, including orphans and other
vulnerable children.
Today, I would like to discuss how USAID is assisting President
Bush and Ambassador Tobias in meeting each of these goals, as they
relate to food and HIV/AIDS.
As we expand anti-retroviral treatment for people living with AIDS,
there is much we can do to ensure a good relationship between food,
nutrition and ARVs. We know that interactions between ARVs, food and
nutrition can influence the success of treatment by affecting drug
efficacy, adherence to drug regimens, and nutritional status of people
living with HIV and AIDS.
By strengthening food access and coping strategies of households
and communities affected by HIV/AIDS, USAID is contributing to the goal
of preventing seven million new HIV infections. In the area of food and
nutrition, USAID programs are strengthening household resiliency
through food-for-work programs and other income-generation activities.
Food assistance is used for education and vocational training programs
for children. And HIV/AIDS prevention messages are incorporated in all
of these programs.
Food and nutrition are critical components in the care of people
living with HIV/AIDS and their families. Nutritional support has the
potential to delay the beginning of life-threatening infections and
ultimately prolong the lives of HIV-positive individuals. Family
members who may depend on an infected person benefit as well.
USAID is supporting a variety of activities to care for people
living with AIDS, including:
Food aid and nutrition counseling for people living with
AIDS and their families;
Improved infant and child feeding for HIV-affected
households;
Food aid to assist in management of opportunistic infections
such as tuberculosis; and
Direct food aid to orphans and vulnerable children and
families looking after them.
USAID's Office of Food for Peace invested over $17 million and
approximately 40,000 metric tons of food aid to almost 700,000 HIV-
infected and affected adults and children in Haiti, Ethiopia, Kenya,
Mozambique, Rwanda, South Africa, Uganda and Zambia--all focus
countries of the President's Emergency Plan for AIDS Relief.
Pascasie Mukamana is an orphan in Rwanda's Gitarama province. After
her parents died of AIDS, she was forced to quit school to provide for
her two sisters, one of whom is HIV-positive. With USAID funding,
Catholic Relief Services provides a monthly food ration to Pascasie and
her sisters. This is the story of just one of the 29,000 people USAID
funding supports in Rwanda.
In Uganda, for example, our partners report that in communities
receiving food aid, school attendance is improving, there are fewer
underweight children and people are able to work more regularly.
The Consortium for Southern Africa Food Security Emergency is made
up of World Vision, Catholic Relief Services and CARE. They focus on
reducing food insecurity in targeted communities in Malawi, Zambia and
Zimbabwe. Approximately 76,000 adults and children who are infected and
affected by HIV/AIDS receive food through this consortium funded by
USAID.
USAID's agricultural programs are also important in addressing the
HIV/AIDS prevention response by ensuring that food is available to
vulnerable households throughout the year. Other programs assist small
farmers in accessing agricultural technology, or help them diversify
their livelihoods to improve their food and nutrition security.
For example, USAID supports the Regional Network of HIV/AIDS, Rural
Livelihoods and Food Security in sub-Saharan Africa. The Network is
analyzing the impact of AIDS on small farmers and focusing on how to
maintain the productivity of staple crops in Malawi and analyzing the
impact of AIDS on the agricultural programs in Uganda.
Often, people do not have access to enough food to meet their basic
daily caloric needs. Through the Harvest Plus Program, researchers are
developing new varieties of wheat, rice, maize and cassava to enhance
the nutrient content, quality and yield of these important staple
crops. USAID is also supporting highly regarded universities in the
U.S. and abroad who are turning their considerable expertise toward
these issues.
The Agriculture and Nutrition Advantage Program supports strategies
that bring together national governments, non-governmental
organizations, and research institutions to combat poverty, hunger and
under-nutrition. It is critical to include these different stakeholders
in efforts to address the complex challenges of food security,
nutrition and HIV/AIDS.
USAID is working with Michigan State University and Kenya's Egerton
University to examine the relationship between AIDS and agriculture.
Other research we've sponsored has found that relatively poor
households do not recover quickly from head-of-household deaths.
partnership with world food program
USAID has a long history of partnership with the World Food Program
to provide food aid, and is the single largest donor to WFP. Last year,
USAID's Office of Food for Peace provided over a billion dollars of
food aid resources to the WFP. In addition, WFP receives support from
USAID through the Joint United Nations Programme on HIV/AIDS, the
umbrella organization for all of the U.N.'s work on HIV/AIDS, which
will receive $26 million from my agency this year.
Just last year, USAID's Office of HIV/AIDS entered into a new
project partnership with WFP to specifically work on food aid for
children affected by AIDS and their families. USAID is funding a unique
partnership between the World Food Program and World Vision that is
designed to use food to help keep children in school and reinforce and
expand home-based care programs. WFP will provide food assistance that
will complement World Vision's work and be linked to efforts to improve
the overall family situation.
conclusion
I am proud of the work USAID is doing in the global fight against
AIDS, poverty and hunger. By working through many different areas,
USAID will help President Bush and Ambassador Tobias achieve a historic
success.
USAID is in the unique position of having technical expertise in
development, health and emergency response, as well as an extensive
network of programs throughout the developing world. By building on
these strengths, we will ensure that assistance gets to the neediest in
a timely and transparent manner.
I appreciate the opportunity to testify today on this important
topic.
______
Nutrition and HIV/AIDS: Evidence, Gaps, and Priority Actions
In Africa, where more than 25 million people are living with HIV/
AIDS, malnutrition and food insecurity are endemic. Today, nearly 40%
of African children < 5 years old are stunted due to chronic
nutritional deprivation.\1\ Underweight, an indicator of chronic and
acute malnutrition, was the leading cause of mortality worldwide,
responsible for 3.7 million deaths in 2000.\2\ Nearly half of these
deaths (48.6%) occurred in sub-Saharan Africa.
The effects of malnutrition on the immune system are well known and
include decreases in CD4 T-cells, suppression of delayed
hypersensitivity, and abnormal B-cell responses.\3\-\4\ The immune
suppression caused by protein-energy malnutrition is similar in many
ways to the effects of HIV infection.\5\ This document summarizes the
evidence, gaps, and priority actions related to nutrition and HIV/AIDS.
nutrition and hiv/aids: the evidence and gaps
HIV-infection increases energy requirements. HIV infection affects
nutrition through increases in resting energy expenditure, reductions
in food intake, nutrient malabsorption and loss, and complex metabolic
alterations that culminate in weight loss and wasting common in
AIDS.\6\-\7\ The effect of HIV on nutrition begins early in the course
of the disease, even before an individual may he aware that he or she
is infected with the virus.\8\-\10\ Asymptomatic HIV-positive
individuals require 10% more energy, and symptomatic HIV-positive
individuals require 20%-30% more energy than HIV-negativc individuals
of the same age, sex, and physical activity level.\11\
The impact of pre-existing malnutrition on HIV susceptibility and
disease progression is difficult to study, and knowledge in this area
is still limited. A systematic review of the literature is now underway
by the World Health Organization (WHO).\11\ Early studies demonstrated
that weight loss and wasting were associated with increased risk of
opportunistic infections \12\ and shorter survival time in HIV-positive
adults, independent of their immune status.\13\ \14\ Other studies
showed that clinical outcome was poorer and risk of death was higher in
HIV-positive adults with compromised micronutrient intake or
status.\15\-\20\
Micronutrient deficiencies may contribute to disease progression.
Deficiencies of vitamins and minerals, such as vitamins A, B-complex,
C, and E and selenium and zinc, which are needed by the immune system
to fight infection, are common in people living with HIV.\9\ \21\
Deficiencies of anti-oxidant vitamins and minerals contribute to
oxidative stress, a condition that may accelerate immune cell
death\22\-\23\ and increase the rate of HIV replication.\24\-\26\
Daily micronutrient (antioxidant) supplementation improved body
weight and body cell mass \27\ reduced HIV RNA levels; \28\ improved
CD4 cell counts;\28\ and reduced the incidence of opportunistic
infections \29\ in small studies of adults with AIDS, including those
on antiretroviral therapy. Larger clinical trials demonstrated that
daily micronutrient supplementation increased survival in adults with
low CD4 cell counts; \30\ prevented adverse birth outcomes when given
during pregnancy; \31\ and reduced mother-to-child HIV transmission in
nutritionally vulnerable women with more advanced HIV disease.\32\ The
optimal formulation of a daily multiple micronutrient supplement for
HIVpositive individuals requires further study.\11\
Antiretroviral therapy improves nutritional status, but ARVs may
also have side effects and metabolic complications. Highly active
antiretroviral therapy (HAART) improves nutritional status, independent
of its effects on viral suppression and immune status,\33\ although
wasting still develops in some patients.\34\ ARV side effects such as
nausea and vomiting may affect adherence to therapy, particularly in
the first months of treatment.\35\ Additional metabolic complications
such as derangements in glucose and lipid metabolism, bone metabolism,
and lactic academia have been associated with the use of certain ARV
drugs.\36\ Research on the metabolic consequences of ARV therapy and
appropriate strategies for their management is a growing field in
industrialized countries. Further research is needed in resource-
limited settings, where management options and follow-up monitoring may
be more limited.
HIV-exposure and infection exacerbates problems of child
malnutrition. Children living with HIV or born into families affected
by HIV are a high-risk group with special needs. HIV-positive women
have a higher incidence of preterm and low birth weight deliveries,
and, as a result, HIV-exposed infants may start life with impaired
nutrition.\37\-\38\ HI V-positive infants experience slower growth and
are at greater risk of severe malnutrition.\39\-\40\ Studies show that
severe malnutrition in HIV-positive children can be reversed with
hospital and home-based therapeutic feeding, though the time to
recovery is longer than with uninfected children.\41\ Studies also
indicate that periodic vitamin A supplementation reduces morbidity and
mortality in HIV-positive children and improves their growth.\42\-\44\
Optimal infant and young child feeding practices are crucial in the
context of HIV/AIDS. Breastfeeding practices may also affect the health
of HIV-exposed children. The risk of HIV transmission through
breastfeeding is directly related to the health, viral load, and immune
status of their mothers. Infection occurs at an average rate of about
8.9 HIV transmissions per 100 child-years of breastfeeding.\45\ HIV-
positive mothers are recommended to avoid breastfeeding if replacement
feeding is feasible, affordable, and safe.\46\ In many resource-limited
settings, this cannot be assured, and many HIV-positive women initiate
breastfeeding.\47\-\48\ For these women, exclusive breastfeeding and
early breastfeeding cessation are recommended.\46\ Infants who are not
breastfed or who stop breastfeeding early and do not have access to
safe and nutritious replacement foods are at increased risk of
malnutrition, diarrhea and other illnesses, and death.\49\
livelihoods, food security, and hiv/aids: complex interactions
Food security is the state in which all people have both physical
and economic access to sufficient food to meet their dietary needs for
a productive and healthy life at all times.\50\ Achieving this state is
contingent on food being available, accessible, and utilized by the
body. The relationship between HIV/AIDS, livelihoods, and food and
nutrition security is complex and multidimensional.
Food insecurity and poverty may lead to high-risk sexual behaviors
and migration, increasing the risk of acquiring HIV infection.\51\-
2\52\ HIV/AIDS, in turn, significantly undermines a household's ability
to provide for basic needs. Livelihoods are diminished when HIV-
infected adults cannot work and food production and/or earnings
decrease. Healthy family members, particularly women, are often forced
to stop work to care for sick family members, further reducing income
for food and other basic needs. Household labor constraints can cause
reductions in cultivated area, shifts to less labor- or cash-intensive
crops, and depletion of livestock.\53\
Food-insecure households frequently struggle to meet ordinary
household needs without the added stress of HIV. Their capacity to
absorb the costs associated with HIV-related illnesses, to provide
enhanced nutritional support, and to participate in community programs
is severely restricted, and many find themselves in a rapid downward
economic spiral.\54\ The spiral is made worse when disabled parents are
unable to pass on practical crop and livestock knowledge,\51\ \55\ and
when children are withdrawn from school because of difficulty paying
fees or the need for the young to care for ill family members,
jeopardizing their future income-earning potential.
HIV/AIDS is impacting entire communities, with rippling effects,
particularly in areas that are highly dependent on labor. For example,
in rural Kenya, when HIV affects a relatively wealthy household and
spending on health care increases, money to hire laborers declines.
Poorer households become increasingly more vulnerable--food insecure,
less able to send their children to school, and less able to meet their
own health needs--when they can no longer find work because the
wealthier families can not afford to hire them.\56\ Entire communities
are weakened by HIV, not just individuals, and traditional community
safety nets are being stretched to their limit in highly affected
areas.
priority actions
Nutrition counseling, care, and support are integral to
comprehensive HIV care, including care given to HIV-positive
individuals and orphans and vulnerable children (OVC). There are
several nutrition and food-related interventions to consider.
Appropriate actions depend on the local conditions, the HIV-positive
individual's lifecycle state (e.g., child, pregnant or lactating, other
adult), degree of disease progression (e.g., asymptomatic, symptomatic,
AIDS), and whether they have initiated ARV therapy. Integrating
nutritional care and support interventions strengthens home-, clinic-,
and community-based care, ARV services, OVC activities, and national
policies and strategies addressing the pandemic. Nutrition
interventions may improve the quality and reach of care and promote
successful treatment.
The main nutrition interventions are counseling on specific
behaviors, prescribed/targeted nutrition supplements, and linkages with
food-based interventions and programs. Three different types of
nutrition supplements are considered: food rations to manage mild
weight loss and nutritional-related side effects of ARV therapy and to
address nutritional needs in food-insecure areas; micronutrient
supplements for specific HIV-positive risk groups; and therapeutic
foods for rehabilitation of moderate and severe malnutrition in HIV-
positive adults and children. Priority actions are:
Nutrition for positive living. This includes nutrition counseling
and support to improve food intake and maintain weight during
asymptomatic HIV infection and to prevent food and waterborne
infections. Food rations may be provided in food-insecure areas and for
nutritionally vulnerable pregnant and lactating women. Daily multiple
micronutrient supplements may be provided to HIV-positive pregnant
women in areas where malnutrition rates are high, although the optimal
formulation for such supplements is not yet known.
Nutritional management of HIV-related illnesses. This includes
counseling to manage nutrition-related symptoms of common HIV-related
illnesses/opportunistic infections (e.g., loss of appetite, oral sores,
fat malabsorption). Home-based care programs, community efforts, and
clinical services can provide counseling to help HIV-positive
individuals and their households optimally use available foods to
manage symptoms and maintain food intake. Guidance and materials to
support nutritional management of symptoms, developed with USAID
assistance, are already available in many countries.
Management of ARV interactions with food and nutrition. This
includes providing information and support to help ARV clients manage
side effects such as nausea and vomiting and prevent drug-food
interactions. Side effects and interactions can negatively affect
medication adherence and efficacy. Supporting ARV clients in
appropriate dietary responses to manage these conditions helps ensure
successful treatment. In addition to nutrition counseling, food rations
may be provided in food-insecure areas, particularly in cases where
lack of food is interfering with treatment adherence and among those
experiencing weight loss that is not reversed after treatment is
initiated.
Therapeutic feeding for moderately and severely malnourished HIV-
positive children and adults. This includes hospital-based
stabilization and home- or community-based care using therapeutic
(nutrient-dense) foods, per WHO or local nutrition rehabilitation
protocols. The foods and protocols used to treat severe malnutrition in
the general population may be used for HIV-positive patients, although
some adaptations may be required for adults and those experiencing
severe symptoms.
Infant and young child nutrition for HIV-exposed children. This
includes counseling on feeding options for HIV-exposed children,
including orphans, and support for safer breastfeeding or replacement
feeding, per WHO or local protocols. Food rations, therapeutic foods,
and micronutrient supplements may also be provided, depending on local
circumstances such as food availability, diet quality, and malnutrition
rates. Vitamin A supplementation is recommended, per WHO protocols.
Palliative care and community coping mechanisms. This includes
nutrition counseling and supplements for HIV-positive and HIV-affected
households delivered through home-, clinic-, and community-based care
programs and strengthening links to social support organizations,
building community food stocks, sharing labor, modifying costly customs
(funerals, marriages), and providing food assistance and training to
widows, orphans, and vulnerable children. The U.S. Government, through
USAID, has Title II programs providing this type of assistance in
several countries, including Ethiopia, Haiti, Kenya, Mozambique,
Rwanda, Uganda, and Zambia. The USAID-funded C-Safe Program is linking
Title II food to HIV home-based care programs in Zambia, Malawi, and
Zimbabwe.
Summary of Nutrition Interventions According to HIV Disease Progression
----------------------------------------------------------------------------------------------------------------
Families Affected by
Interventions HIV+ Asymptomatic HIV+ Symptomatic AIDS an HIV-related Death
----------------------------------------------------------------------------------------------------------------
Counseling/care Nutrition education Nutrition management Nutrition management Counseling on
and counseling for of HIV-related of ARV therapy special food and
positive living. opportunistic (where available). nutritional needs
infections (OI), of orphans and
symptoms, and vulnerable infants
medications. and young children.
..................... ..................... Nutrition management ....................
in home-, clinic-
and community-based,
palliative care.
Prescribed/targeted For high-risk groups For high-risk groups. Therapeutic feeding For high-risk groups
nutrition only (e.g., pregnant for moderately and (e.g., HIV-exposed
supplementation and lactating HIV+ severely non-breastfed
women, HIV-exposed malnourished HIV+ children < 2 yrs or
non-breastfed adults and children. HIV-exposed
children). children with
growth faltering).
..................... For persons who are ..................... ....................
losing weight or do
not respond to
medications.
..................... Therapeutic feeding ..................... ....................
for moderately and
severely
malnourished HIV+
adults and children.
Other food To prevent To improve adherence/ To improve adherence/ To protect the
interventions nutritional participation in OI participation in ARV health of orphans
deterioration for treatment programs. and OI treatment and vulnerable
HIV-affected programs. children and for
families living in surviving family
highly food-insecure members when
communities. livelihoods are
compromised because
of HIVrelated
sickness or death.
..................... ..................... To use in home-, ....................
clinic-, and
community-based care
programs.
----------------------------------------------------------------------------------------------------------------
references
1. de Onis, M, Frongillo EA, Blossner M. Is malnutrition declining?
An analysis of changes in levels of child malnutrition since 1980.Bull
WHO 2000; 78(10): 1222-33.
2. WHO. The World Health Report. Geneva, 2002.
3. Gorbach SL, Tamsin AK, and Roubenoff R. Interactions between
nutrition and infection with human immunodeficiency virus. Nutr Rev
1993; 51: 226-234.
4. Scrimshaw NS and SanGiovanni JP, Synergism of nutrition,
infection and immunity: an overview. Am J Clin Nutr 1997; 66: 464S-
477S.
5. BeiselWR. Nutrition and immune function: Overview. J Nutr 1996;
126: 2611S-2615S.
6. Babamento C and Koder DP. Malnutrition in HIV infection.
Gastroenterology Clinics of North America 1997; 26: 393-415.
7. Macallan DC. Wasting in HIV infection and AIDS. J Nutr 1999;
129: 238S-242S.
8. Beach RS, Mantero-Atienza E, Shor-Posner G et al. Specific
nutrienr abnormalities in asymptomatic HIV-1 infection. AIDS 1992; 6:
701-708.
9. Semba RD and Tang AM. Micronutrients and the pathogenesis of
human immunodeficiency virus infection. Br J Nutr 1999; 81: 181-189.
10. Bogderi JD, Kemp FW, Han S et al. Status of selected nutrients
and progression of human immunodeficiency virus type I infection. Am J
Clin Nutr 2000; 72(3): 809-815.
11. WHO. Nutrient requirements for people living with HIV/AIDS.
Report of a technical consultation. World Health Organization, Geneva,
2003.
12. Wheeler DA,Gilbert CL, Launer CA et al. Weight loss as a
predictor of survival and disease progression in HIV infection. J
Acquir Immune Defic Syn 1998; 18: 80-85.
13. Kotler D, Tierney AR, Wang J, Pierson RN. Magnitude of bodycell
mass depletion and the timing of death from wasting in AIDS. Am J Clin
Nutr 1989; 50: 444-447.
14. Suttmann U, Ockenga J, Selberg O et al. Incidence and
prognostic value of malnutrition and wasting in human immunodeficiency
virus-infected outpatients J Acquir Immune Defic Syn 199S; 8: 239-246.
15. Baum MK, Shor-Posner G, Lu Y et al. Micronutrients and HIV
disease progression. AIDS 1995; 9: 1051-1056.
16. Tang AM, Graham NM, Kirby AJ et al. Dietasy micronutrient
intake and risk of progression to acquired immunodeficiency syndrome
(AIDS) in human immunodeficiency virus type 1 (HIV-1)-infected
homosexual men. Am J Epidemiol 1993; 138: 937-951.
17. Tang AM, Graham NM and Saah AM. Effectsof micronutrient intake
on survival in human immunodeficiency virus type 1 infection. Am J
Epidemiol 1996; 143: 1244-1256.
18. Tang AM, Graham NM, Chandra RK. Low serum vitamin B12
concentrations are associated with faster HIV-1 disease progression. J
Nutr 1997; 127(2): 345-351.
19. Tang AM, Graham NM, Semba RD et al. Vitamin A and E in HIV
disease progression. AIDS 1997; 11: 613-620.
20. Baum MK and Shor-Posner G. Micronutrient status in relationship
to mortality in HIV-1 Disease. Nutr Reviews 1998; 51: S135-S139.
21. Kupka R, Fawzi WW. Zinc nutrition and HIV infection. Nutr
Reviews 2002; 60(3): 69-79.
22. Banki K, Hutter E, Gonchoroff NJ et al. Molecular ordering in
HIV-induced apoptosis. Oxidative stress, activation of caspases, and
cell survival are regulated by transaldolase. J Biol Chem 1998; 273
(19): 11944-S3.
23. Romero-Alvira D, Roche E. The keys of oxidative stress in
acquired immune deficiency syndrome apoptosis. Medical Hypotheses 1998;
51(2): 169-73.
24. Rosenberg ZF, Fauci AS. lmmunopathogenic mechanisms of HIV
infection:cytokine induction of HIV expression. Immunol Today 1990; 11:
176-180.
25. Schwarz KB. Oxidative stress during viral infection: a review.
Free Rad Biol. Med 1996; 21: 641-649.
26. Allard JP,Aghdassi E, Chau J et al. Effects of vitamin E and C
supplementation on oxidative stress and viral load in HIV-infected
subjects. AIDS 1998; 12: 1653-1659.
27. Shabert JK, Winslow C, Lacey JM et al. Glutamine-antioxidant
supplementation increases body cell mass in AIDS patients with weight
loss: A randomized, double-blind controlled trial. Nutrition 1999; 15:
860-864.
28. Muller F, Svardal AM, Norday I et al. Virological and
immunological effects of antioxidant treatment in patients with HIV
infection. Euro J Clin Invest 2000; 30(10): 905-914.
29. Mocchegiani E, Muzzioli M. Therapeutic application of zinc in
human immunodeficiency virus against opportunistic infections. J Nutr
2000; 130(5S): 1424S-1431S.
30. Jaimton S, Pepin J, Suttent R et al. A randomised trial of the
impact of multiple micronutrient supplementation on mortality among HIV
infected individuals living in Bangkok. AIDS 2003; 17: 2461-2469.
31. Fawzi WW, Msamanga GI, Spiegelman D et al. Randomised trial of
effects of vitamin supplements on pregnancy outcomes and T cell counts
in HIV-1-infected women in Tanzania. Lancet 1998; 351: 1477-1482.
32. Fawzi WW, Msamanga GI, Hunter D et al. Randomized trial of
vitamin supplements in relation to transmission of HIV-1 through
breastfeeding and earlychild mortality. AIDS 2002; 16(14): 1935-1944.
33. Rousseau MC, Molines C, Moreau J, Delmont J. Influence of
highly active antiretroviral therapy on micronutrient profiles of HIV-
infected patients. Ann Nutr Metab 2000; 44 (5-6): 212-216.
34. Wanke CA, Silva M, Knox TA et al. Weight loss and wasting
remain common complications in individuals infected with human
immunodeficiency virus in the era of highly active antiretroviral
therapy. CID 2000; 31: 803-805.
35. Chen RY, Westfall AO, Mugavero MJ et al. Duration of highly
active antiretroviral therapy. CID 2003; 37: 714-722.
36. Shevirz AH, Knox TA. Nutrition in the era of highly active
antiretroviral therapy. CID 2001; 32: 1769-1775.
37. Brocklehursi P, French R. The association between maternal HIV
infection and perinatal outcome: a systematic review of the literature
and meta-analysis. BJOG 1998; 105: 836-848.
38. Coley JL, Msamanga G, Smith, Fawzi MC et al. The association
between maternal HIV-1 infection and pregnancy outcomes in Dares
Salaam, Tanzania. BJOG 2001; 108: 1125-1133.
39. Bakaki P. Kayita J, Moura Machado JE et al. Epidemiologic and
clinical features of HIV-infected and HIV-uninfected Ugandan children
younger than 18 months. J Acquir Immune Defic Syndr 2001; 28(1): 35-42.
40. Newell ML, Borja MC, Peckham C. Height, weight, and growth in
children born to mothers with HIV-1 infection in Europe. Pediatrics
2003; 111(1): e52-60.
41. Sandige H, Ndekha MJ, Briend A et al. Locally produced and
imported ready-to-use food in the home-based treatment of malnourished
Malawian children. J Pediatric Gastroenterology Nutr 2004; in press.
42. Coutsoudis A, Bobat RA, Coovadia HM et al. The effects of
vitamin A supplemen ration on the morbidity of children born to HIV-
infected mothers. Am J Public Health 1995; 85: 1076-1081.
43. Fawzi WW, Mbise RL, Hertzmark E et al. A randomized trial of
vitamin A in relation to mortality among human immunodeficiency virus-
infected and uninfected children in Tanzania. Pediatr Infect Dis J
1999; 18(2): 127-133.
44. Villamor E, Mbise R, Spiegelman D et al. Vitamin A supplements
ameliorate the adverse effect of HIV-1 malaria, and diarrheal
infections on child growth. Pediatrics 2002; 109(1): e6.
45. The Breastfeeding and HIV International Transmission Study
(BHITS) Group. Late postnatal transmission of HIV-1 in breastfed
children: an individual patient data meta-analysis. J Infect Dir 2004;
in press.
46. WHO. New Data on the Prevention of Mother-to-Child Transmission
of HIV and their Policy Implications: Conclusions and recommendations.
Geneva, 11-13 October 2000, approved January 15, 2001 [Cited 2001 Jan
19). Available at www.unaids.org/publications/documents/mtct.
47. Omari A, Luo C, Kankasa C et at. Infant-feeding practices of
mothers of known HIV status in Lusaka, Zambia. Health Policy Plan.
2003; 18: 156-162.
48. Kiarie JN, Richardson BA, Mbori-Ngacha D et at. Infant feeding
practices of women in a perinatal HIV-1 prevention study in Nairobi,
Kenya. J Acquir Immune Defic Syndr. 2004; 35: 75-81.
49. WHO. Collaborative Team on the Role of Breastfeeding in the
Prevention of Infant Mortality. Effect of breastfeeding on infant and
child mortality due to infectious diseases in less developed countries:
a pooled analysis. Lancet 2000; 355: 451-55.
50. Bonnard P. HIV/AIDS mitigation: using what we already know.
Technical Note No. 5. Food and Nutrition Technical Assistance Project,
Academy for Educational Development, Washington, DC, 2002.
51. Loevinsohn M and Gillespie S. HIV/AIDS, food security, and
rural livelihoods: understanding and responding. FCND Discussion Paper
No. 157. IFPRI: Washington, DC, 2003.
52. Harvey P. HIV/AIDS: What are the implications for humanitarian
action? A literature review (Draft). Overseas Development Institute,
2003.
53. UNAIDS. A review of household and community responses to the
HIV/AIDS epidemic in the rural areas of sub-Saharan Africa. Geneva,
1999.
54. Shah MK, Osborne N, Mbilizi T et al. Impact of HIV/AIDS on
agricultural productivity and rural livelihoods in the central region
of Malawi. Care International, Malawi, 2002.
55. Arndt, C and P. Wobst. HIV/AIDS and labor markets in Tanzania.
Trade and Marketing Division Discussion Paper 102. IFPRI: Washington
DC, 2002.
56. Boudreau T and Holleman C. Household food security and HIV/
AIDS: exploring the linkages. The Food Economy Group, Famine Early
Warning Systems Network (FEWS NET), 2002. Available at http://
www.fews.net/hazards/hazard/report/?g=1000087&i=1026.
The Chairman. Well, thank you very much for that testimony.
Let me ask Senator Alexander. Do you want to raise a
question before you depart?
Senator Alexander. No, thank you, Mr. Chairman. I did want
to come and hear the testimony and commend you for your focus,
and I have been following very carefully sub-Saharan Africa
through Ambassador Tobias. I thank you for the chance to hear
the testimony. Thank you, Mr. Chairman.
The Chairman. Well, thank you. Senator Alexander serves, as
you know, as the chairman of our Subcommittee on African
Affairs. Also, the distinguished ranking member, Senator
Feingold, is with us.
I will defer my questions and recognize Senators Feingold
and Boxer with perhaps a 10-minute limit on our first round.
Senator Feingold. Thank you very much, Mr. Chairman. I
thank the witnesses very much for your important testimony.
Mr. Morris, I appreciate your expertise on the issues
before us and your consistent efforts to call the world's
attention to the linkages between food security, HIV/AIDS, and
nutrition, but I want to take this opportunity to just followup
a little bit on the specific humanitarian crisis that has
already been discussed today, the situation in Darfur. You
acknowledged it, as did the chairman, obviously because it is
such a desperate and urgent situation.
Will you just lay out a little bit more for the record
today how many people are at risk of malnutrition in the
region? At this point, is the WFP able to get urgently needed
relief supplies to displaced people in Darfur, and what
specific conditions must change to enable the WFP to deliver
needed supplies to these vulnerable people?
Mr. Morris.
Mr. Morris. Thank you, Senator.
Today in the three provinces of Darfur, west, south, and
north, there are 1 million internally displaced people. There
are another 100,000 people affected by the conflict still in
Darfur. We believe that the number by the end of the year,
given the fact that this year's harvest will be lost, will
increase by another 800,000 people. Today there are 53,000
refugees in camps in Chad in five camps, another 42,000 people
who are living on the perimeter of the camps in ramshackle
conditions.
One of our great concerns is the number of refugees. People
are leaving the Sudan to Chad for security reasons. People are
very frightened and justifiably in the Sudan. They are afraid
to venture out of the camps. They know if they go to Chad and
live in the camps there, that security issue will be
diminished. Chad had anticipated five camps. The numbers are so
large that they will now have 10 camps because the water
available per camp is not adequate to handle the numbers that
are there now.
We have a rainy season ahead of us in a matter of days. We
will be able to preposition the food we need to preposition in
Chad. It will be something in the neighborhood of 7,000 metric
tons of food. It will be difficult. We will move part of it
across from Cameroon, and we now have a new understanding with
the Libyans that we can move food down from Libya into Chad and
the Chad Government has said that is acceptable.
Senator Feingold. What about those in Darfur?
Mr. Morris. I am coming to that. This is more difficult.
Half the people in Darfur are living in camps and half are
living in the hills or simply wandering about. As you drive
through the area, you see village after village that has been
destroyed. The homes have been burnt. The landscape is strewn
with pots and pans. Their clothing has been taken. The
livestock is gone. Maybe a village that once had 300 families
today might have three older men, each weighing about 75
pounds. Really tragic.
The report I read this week suggests that we have been able
to provide food for about 800,000 people in Darfur. That is a
substantial increase. We are working very, very hard to get
food prepositioned for the rainy season. It will be difficult
to do that job either satisfactorily or perfectly. We will do a
lot of it. USAID has food that will arrive toward the end of
the month. USAID has made another commitment in support of our
work. We have also had new commitments from the European
Community from Luxembourg, from the United Kingdom, and several
other places. We have committed resources from our own internal
emergency response account to buy sorghum which is available in
the country. We sort of have $30 million set aside to do that
now.
So we are working very hard to get it prepositioned. We
know that we are going to have to airlift some of that. The
World Food Program also operates the United Nations
Humanitarian Air Service, and so we provide air support for all
of the U.N. family, all of the NGO family. It is more
expensive, but we get in very difficult circumstances and we
will use it to air drop or transport by air some food.
Senator Feingold. Thank you, Mr. Morris. I appreciate your
answer. I just want to get in one more question of Mr. Tobias,
but I am grateful for your response and I will followup with
you afterward.
I have worked with Senator Brownback and Senator Alexander
and other members of the committee, including the chairman and
the ranking member, to pass a resolution last week addressing
this issue that you were very effectively addressing, Mr.
Morris. I think it is critically important that we not let this
issue slip off our radar screen.
Mr. Morris. I forgot that my comments took part of your 10
minutes. So forgive me.
Senator Feingold. They were incredibly important things you
were discussing and I did want some of that information on the
record. So I thank you.
Ambassador Tobias, it is good to see you again. I
appreciate your consistent efforts to be available to this
committee and to Members of Congress to ensure that the vast
coalition committed to fighting AIDS does not fray.
The last time we spoke, you were testifying at an African
Affairs Subcommittee hearing on implementation of the Emergency
Plan for AIDS Relief, and we discussed the issue of generic
fixed-dose combination therapy. As you know, I and many others
have been concerned about the administration's unwillingness to
use drugs that are prequalified as safe and effective by the
World Health Organization, which are actually easier to use and
cheaper than drug regimens that we are buying. You indicated
then that you were hopeful that we would be able to move
forward on this issue and to answer the underlying questions
that have led to this problem.
Would you please provide me with an update for the
committee on the progress that has been made since that hearing
to resolve that issue?
Ambassador Tobias. Well, Senator, I continue to be
optimistic that we are making progress on getting our hands
around this problem. As we have discussed before, the World
Health Organization's prequalification program is just that. It
is a prequalification program. It serves a very useful purpose
in those parts of the world where there is not a stringent
regulatory process.
But as we gear this up, we are dramatically expanding the
number of people who will be under treatment in the world, and
we are also going to dramatically expand, I suspect, the number
of entrants who are coming into this market. I have had two
heads of state in Africa tell me that they intended to go into
this business themselves, and we need to ensure that we have a
process in place that will provide assurances of safety and
effectiveness to the patients who will be treated. I have
spoken to a number of officials and medical people in Africa
who are as concerned about that as we are.
But I am even more, let me say, optimistic than when you
and I last talked that we are on a path that in the weeks ahead
we are going to have processes in place that will permit us to
take a good, hard, scientific look at the safety and efficacy
of drugs from all over. I certainly look forward to having that
done.
Senator Feingold. Well, I thank you for your update. This
is so incredibly urgent that I hope this can move as quickly as
possible, and I am interested in each and every step forward
that we can take.
Thank you, Mr. Chairman.
[The prepared statement of Senator Feingold follows:]
Prepared Statement of Senator Russell D. Feingold
I thank Chairman Lugar and Senator Biden for holding this important
hearing, and I thank all of our witnesses for being here today.
In July 2002, in the midst of the horrible headlines about food
crisis in Southern Africa, I asked the General Accounting Offices to
look into the underlying causes of the crisis and the U.S. response.
Their report, issued in June 2003, made clear that one cannot look
seriously at food security issues in Africa without also considering
the consequences of the HIV/AIDS pandemic. The report found that AIDS
had exacerbated the food crisis by reducing productivity and
agricultural output and by dramatically limiting the capacity of
communities to cope with hardships like a bad harvest, or rising food
prices. In other words, AIDS has made already vulnerable communities
more vulnerable, such that setbacks that might not have been
catastrophic before can now push people over the edge into crisis.
At the same time, no one who has been on the ground to look at the
nature of the AIDS crisis can escape the conclusion that good nutrition
and food security are necessary ingredients for the success of
initiatives to fight AIDS. Medical interventions must occur in a
context of sound nutrition if they are to succeed, and, more broadly,
overall economic insecurity, including food insecurity, can render
specific populations, like women and girls, especially vulnerable to
contracting AIDS.
We can all be proud of the efforts that the U.S. Government has
made thus far to fight hunger and to fight AIDS around the world. This
hearing is a good opportunity to explore how we might make our taxpayer
dollars go further by ensuring that our efforts on these interrelated
fronts are well thought out and well coordinated.
I look forward to exploring these important issues today.
The Chairman. Thank you very much, Senator Feingold.
Senator Boxer.
Senator Boxer. Thank you very much, Mr. Chairman.
I am going to take this opportunity to make a statement
about another issue for 5 minutes and then direct an important
question to the Honorable Randall Tobias.
Mr. Chairman, we have three individuals sitting before us
who exemplify the best in what America is all about, giving
themselves to an issue that needs leadership for the most
vulnerable people on the face of the Earth right now. And I am
very proud that you have asked them up here.
Now, in another part of the world, sadly to our horror, we
see other Americans with different agendas and different
values, albeit in a different job. I just want to take this
chance because this committee has been in many ways prescient
on the issue of Iraq, both sides saying where is the plan,
where is the plan.
I just want to take this moment to put into the record an
article \3\ that appeared today in the Los Angeles Times, if I
might. A double ordeal for female prisoners. It is written by
Tracy Wilkinson, who is a reporter that I've known for many
years, actually covered one of my races, my first race many
years ago, and now has been covering the Iraqi situation, got
injured in a blast in a restaurant and is still there
reporting. That is Tracy Wilkinson.
---------------------------------------------------------------------------
\3\ The article referred to can be found on page 57.
---------------------------------------------------------------------------
So I just want to read you one or two paragraphs of this
story, and keep in mind that in the Muslim culture--and, Mr.
Chairman, you know this--where it is forbidden to remove your
scarf in front of a strange man, ``One woman told her attorney
she was forced to disrobe in front of male prison guards. After
much coaxing, another woman described how she was raped by U.S.
soldiers. Then she fainted.
``A U.S. Army report on abuses at Abu Ghraib prison
documented one case of an American guard sexually abusing a
female detainee, and a Pentagon spokesman said Monday that
1,200 unreleased images of abuse at Abu Ghraib included
`inappropriate behavior of a sexual nature.'
``Whether it was one or numerous cases of rape, many Iraqis
believe that sexual abuse of women in U.S.-run jails was
rampant. As a result, female prisoners face grave prospects
after they are released: denial, ostracism or even death.
``A woman who is raped brings shame on her family in the
Islamic world. In many cases, rape victims have been killed by
their relatives to salvage family honor, although there is no
evidence this has happened to women who have been prisoners in
Iraq.
`` `It is like being sentenced to death,' said Sheik
Mohammed Bashar Faydhi, a senior cleric based at Baghdad's
largest Sunni mosque.''
The reason I took the time to read this is because I know,
Mr. Chairman, that you were working hard to set a hearing next
week on Iraq, and I am hoping that you can have some witnesses
at that time from very high up who could talk about what kind
of restitution and help we are going to give these women. They
face a special stigma in that culture, and since Secretary
Rumsfeld had talked about restitution, I think this is
something they ought to be prepared to discuss perhaps, if you
agree with me, in their opening remarks. If not, I will bring
it out in the questions.
The Chairman. I can respond quickly to the Senator. We have
been in touch with the Pentagon and the State Department. We
are advised that Secretary Wolfowitz and Secretary Armitage
will be with us.
Senator Boxer. That is wonderful.
The Chairman. So I will convey to them your questions so
they will be prepared.
Senator Boxer. Thank you so much. And I will make available
this article to them.
Mr. Chairman, now getting to the issue before us today.
Again, thank you to our witnesses, all.
I would ask unanimous consent to place in the record a
letter that was sent to Ambassador Tobias on March 26, 2004,
signed by 370 U.S. and international organizations.\4\ So I
would ask that that be included in the record.
---------------------------------------------------------------------------
\4\ The letter to Ambassador Tobias can be found on page 58.
---------------------------------------------------------------------------
The Chairman. It will be included in the record in full.
Senator Boxer. My question, Mr. Ambassador, is this. One
important link between hunger and HIV/AIDS is the high cost of
antiretroviral drugs. That forces people to sell their
farmland, thereby making food more scarce. Yet, there are
charges that the administration has worked to block the use of
affordable generic HIV/AIDS medicines that have been approved
by the World Health Organization. So this group--and I will not
read the entire letter--has in their last paragraph--and I
would like you to comment on this, whether you agree, disagree,
and where you stand on this--``Rather than disregarding the
drug procurement policies of developing nations to create
expensive new barriers that benefit U.S. drug companies, your
office should accept the WHO's internationally recognized drug
quality standards and promote access to affordable medications.
We object to any and all efforts by the administration and your
office to block the use of WHO prequalified generic
medications, and any efforts to discredit the standards of
WHO's prequalification project that would impose new barriers
to generics entering the global market.''
So, the charges in this letter by some of the most
respected organizations in this country and abroad are strong.
How do you respond to this charge given that only 50,000
Africans now have access to AIDS treatments and that 8,000
people are dying from AIDS every day? Ambassador, your answer
to this question is really important. It may link to what you
said to Senator Feingold, but frankly, I found that answer to
be so vague.
Could you tell me when you are going to respond to this
issue? Is there hope that this administration would back the
WHO plan? Because it is all well and good and we all bemoan
what is happening and it is all heartfelt, but if we are
withholding lifesaving medicine from people, Mr. Chairman, I do
not know how we can go to sleep at night, to tell you the
truth. So could you respond to that?
Ambassador Tobias. Senator, thank you.
The issue of the availability of antiretroviral drugs as a
component of making more broadly available treatment for
patients is obviously critically important. Right now, it is
not the limiting factor in expanding treatment. The limiting
factor in expanding treatment is the availability of physical
facilities and medical personnel, and we are working very hard
on all of these issues.
The WHO process, which plays a very important role, as does
the WHO, in the total effort to fight HIV/AIDS, I think has
been misconstrued by a number of people as an approval process,
and it is not. The WHO's own program has a caveat saying that
drugs that are listed on this prequalification list are not
warranted as to their safety and efficacy.
We need a more stringent process and we are working with
the WHO, with other officials in international agencies around
the world in a very cooperative effort to get a process in
place that can provide the kind of regulatory scrutiny that we
have come to expect here in the United States. We are about to
scale up. We are in the midst of scaling up treatment on a very
massive scale, and it is very, very important that we get this
right.
I am obviously very aware of the letter that you refer to.
I have other letters from other people, including a letter I
received yesterday from physicians at Stanford University
urging that we do exactly what we are doing. I think that shows
that reasonable people can disagree on what the proper approach
is here.
But no one is working any harder than I am to move this as
rapidly as we can because there will come a time when the
availability of drugs will be the limiting factor. That is not
really yet the case, but we need to move as quickly as we
possibly can and that is certainly what we are doing, Senator.
Senator Boxer. If I could just say this to you, I am a
person suffering, lost, sitting in some house with my oldest
child trying to raise my family and I have no drugs, yes, I
want the safest drugs. I want the safest, but if I have
nothing, I am in a worse situation.
I would just say to my friend--and I respect you very
much--when I look at the people who signed this--you said you
got letters from other people--this is not people. These are
thousands of people. The people who signed this letter: the
International Association of Physicians in AIDS Care, Oxfam,
the Ecumenical HIV Initiative in Africa, World Council of
Churches, African Jesuit AIDS Network, Episcopal Church USA,
Presbyterian Church USA, Unitarian Universalist Association of
Congregations, Amnesty International, American Foundation for
AIDS Research, ActionAid International USA, American Medical
Students Association, Church Women United, Commission on Social
Action of Reform Judaism. And it goes on and on. Operation USA.
This is just in America, not to mention the world.
So I would just say to my friend please understand that it
is all important, getting the medicine to the people, getting
the medicines approved, getting affordable medicines. It is all
important and I would just suggest to my friend that this is a
pretty powerful letter here, and there are charges out here
that there are drug companies that do not want to see this
happen. This is about an American value. So if there is
anything I can do to work with you on this, please let me know
because I know that you want us to be successful here.
And this is a question, Mr. Chairman, of our values. It
seems to me if we are caught in a values battle over providing
medicine to people versus protecting pharmaceutical companies,
I know where you would come down and I know where I would come
down. This is very worrisome to me. That is what these people
are saying and they are not people who do not think hard. So I
am very worried and I will continue to work with my chairman on
this in the hopes that we can get these generics out there as
soon as possible.
Thank you.
The Chairman. Thank you very much, Senator Boxer.
Let me begin my questioning by asking Mr. Morris about the
Zimbabwe life expectancy figure that you mentioned. If I got
the notes correctly, you indicated life expectancy at some
point was at 67 and this is now 33. Is that correct?
Mr. Morris. That is correct.
The Chairman. This is, just on the face of it, an awesome
result in one country. You made the point strongly, but it may
just simply float over most of us--that we are really talking
about the future of some countries on this Earth when you have
that dramatic a change in the life expectancy in a relatively
short period of time. This denotes that at least half of the
population is likely to be gone in a much shorter period of
time than anyone could have anticipated.
We have heard testimony on this subject from our
ambassadorial nominees. The committee asks each one, just
simply because their orientation now gets into malnutrition and
HIV/AIDS, about life expectancy, about the number of persons
infected in the countries. These statistics mount up as we have
each round of Ambassadorial nominees. So there is a
comprehension on the part of the Congress and the American
people of the severity of this, but it is so large that it is
almost beyond our understanding in a way.
We commented, I think, when we last had a hearing in which
you were involved that essentially, if anybody reported a
battle today somewhere on Earth in which a few hundred people
lost their lives, this would be of enormous significance in our
24-hour news coverage. From almost every angle, the devastation
of those lives and the circumstances would be very, very
important. But as you point out in your testimony, here we have
a situation in which approximately 24,000 people are losing
their lives every day from malnutrition, and an additional
7,000 to 8,000 people from HIV/AIDS, or a combination of that
and tuberculosis, a lack of immunity. They are passing away
without notice every single day.
As I said, the enormity of this figure is so large that
many people, before they even get into the issue, conclude that
this is beyond our ability to affect. You have not taken that
position, nor has our government. The purpose of the hearing
today is both to illustrate what we are doing, but even more
importantly to encourage the cooperation between agencies of
our government, the United Nations, and private voluntary
organizations that play such a vital role in this respect,
because that often is not evident. I just wanted to use the
Zimbabwe case as an especially dramatic example.
We have commented, for instance, on national security
hearings, during which we deal with Russia. Russia has had a
disturbing trend in terms of life expectancy. Some Russians
would say that that has been arrested. Male life expectancy has
declined over the course of the last 20 years from somewhere in
the mid-1960s to the mid-1950s. It may have leveled off in the
high 1950s for the average Russian male, but for a country of
that size and scope to have that kind of demographic change
already leads many Russians to believe that there will be many
fewer Russians, and that the population of the country is
already in decline. This comes at a time in which burgeoning
economies in Asia, for example, are gaining a huge population,
in addition to experiencing per capita growth of significant
percentages year by year, thus changing the whole perspective
both demographically and with regard to national security
issues for those countries.
This hearing is meant to illustrate and to serve as a
benchmark for the seriousness of the problem.
Now, second, Mr. Tobias. The normal questioning of the AIDS
program by Members of Congress comes down to two issues. First,
the President, in the State of the Union Address, and then in
subsequent messages, has talked about $15 billion of
expenditure over 5 years of time. During the debate that we had
on the Senate floor, many Senators were critical of the fact
that the initial request was for $2 billion. People say, well,
do the math. Take 15, divide by 5, it is 3. It is not 2.
Now, at the time--this is before you came along, and before
your confirmation--why, administration people said not to
worry. There is only so much you can do. We are gearing up in
the first year. Therefore, it makes sense not to promise more
than we can deliver, and besides, $1 billion is $1 billion. You
do not want to commit it and spend it before you really are
geared up to do that.
In any event, we debated this all year in one forum after
another. And at the end of the day, the 2 was raised to about
2.4 or thereabouts.
Now, the second year comes along and once again, the figure
is somewhere in the 2's, not 3. So members are saying, well,
all right. You had a year to gear up and yet we are not batting
very well. Friends of the program, such as the singer Bono,
came through. He is a good friend of the committee. We visit
frequently. I mention him as one who would say, why not? Why do
the math again and so forth? This is one area I want you to
address.
The other area was touched upon by Senator Boxer. Despite
all protestations, there is simply a fundamental conflict here
between the pharmaceutical companies, not just American
companies, but companies all over the world, who have a profit
objective. All of you talking here today, you have a
humanitarian objective. The people that we are talking about
are dirt poor. There is just no money involved, not very much
in the governments. Paying for these drugs and/or treatments,
as well as the infrastructure, which as you say, may be the
limiting factor now, is very expensive.
This comes over into our domestic debate frequently on
Medicare. We go back and forth over this subject. Why do senior
citizens go to Canada? Why do they go elsewhere to buy drugs
more cheaply? And why do we not price our drugs differently?
The pharmaceutical companies testify about their research
budgets and the need to amortize this. We go round and round.
When we come to the AIDS business, and people dying in
these numbers, as the Senator had mentioned, and the gaps
there, why, this becomes especially acute.
Why do we not spend $3 billion a year? Why is this dispute
persisting? If there is cooperation from the pharmaceutical
companies, tell us more about it. If there are problems,
discuss that too and how we could be constructive.
Ambassador Tobias. Senator, I am just back from Mozambique,
a country with a population of something between 17 million and
18 million people and physicians in Mozambique numbering
somewhere between 500 and 600. Those physicians are almost
entirely located in the urban areas. That is an equation that
illustrates the problem, a ratio of 1 physician on average, if
they were spread out all across the population, of something
between 1 and 20,000 to 30,000 people.
The Chairman. This is all the doctors there are in
Mozambique.
Ambassador Tobias. All the doctors there are in Mozambique.
Mozambique, because of the language, the Portuguese language,
is not losing doctors to other countries as is the case in some
other parts of Africa. For example, there are more physicians
who are Ethiopian citizens living in Chicago, Illinois, than
the entire country of Ethiopia.
So the problem that we face in getting treatment programs
geared up is not, with all due respect to concerns expressed by
many people, today largely one of the availability of drugs or
the price of drugs. It is in getting the infrastructure and the
people in place to deliver this treatment. Drugs are very
important to this, and I will come to that in a second. But it
is right now more an issue of getting the infrastructure in
place, getting different models in place. We need to get models
in place where physicians are saying to themselves, what am I
doing that does not absolutely have to be done by a physician
and we can bring someone else into the equation to help get
that done.
The Chairman. Just on that point, is there data that the
committee could have on how many physicians there are in each
of the African countries?
Ambassador Tobias. Yes, there is.
The Chairman. And then beyond that, as you mentioned, how
many nurses or other health professionals? This would help
Members of Congress to begin to get a perspective of this
delivery problem in a way that clearly many of us do not yet
have.
Ambassador Tobias. We can make that data available.
[The following response was subsequently supplied.]
United States Department of State,
Washington, DC, May 24 2004.
The Honorable Richard G. Lugar, Chairman,
Committee on Foreign Relations,
United States Senate.
Dear Mr. Chairman:
During Ambassador Randall L. Tobias's May 11 appearance before the
Committee to testify on the important issue of HIV/AIDS and hunger, you
and Ambassador Tobias discussed the challenge that the lack of human
capacity among the healthcare infrastructure presents to effective
delivery of HIV/AIDS treatment, care and prevention in the focus
countries of President Bush's historic Emergency Plan for AIDS Relief.
We are pleased to provide the enclosed tables that provide
additional information on the estimated numbers of physicians and
nurses in the twelve Emergency Plan focus countries in Africa. Please
note that some data are dated and not especially reliable. The most
current comprehensive list of health personnel per 100,000 population
is the database compiled by the World Health Organization's Statistical
Information Service (WHOSIS) in 1998. Figures are from one point in
time during any year between 1994-1998. Health personnel may be counted
who are not practicing, i.e. Minister of Health is a medical doctor and
counted but not practicing. We have updated several of those estimates
for countries for which we have more recent reports from U.S.
Government staff.
Key findings, shown in the attached tables (for physicians and
nurses respectively), are that:
1. The estimated staffing of health care workers is
dramatically lower than the United States, in some cases
approximately 100-fold lower, and
2. There is a substantial variation among the African focus
countries in the Emergency Plan.
As we implement the Emergency Plan for AIDS Relief, over the next
several months we will be working to obtain updated estimates for this
critical element of the Emergency Plan. We will update you and others
as these new estimates become available. As you know, under the
Emergency Plan we are committed to developing sustainable HIV/AIDS
healthcare networks. We recognize the limits of health resources and
capacity in many, particularly rural, communities. To more effectively
address that shortfall, we will build on and strengthen systems of HIV/
AIDS healthcare based on the ``network'' model. Prevention, treatment,
and care protocols will be developed, enhanced, and promoted in concert
with local governments and ministries of health. With interventions
emphasizing technical assistance and training of healthcare
professionals, healthcare workers, community-based groups, and faith-
based organizations, we will build local capacity to provide long-term,
widespread, essential HIV/AIDS services to the maximum number of those
in need.
Thank you again for your continuing leadership on international
HIV/AIDS issues and your support for the success of the Emergency Plan.
Sincerely,
Paul V. Kelly,
Assistant Secretary,
Legislative Affairs.
[Enclosure: As stated.]
------------------------------------------------------------------------
Clin. Lab
Countries Physicians Nurses Officer Pharmacists Techs
------------------------------------------------------------------------
United States 279 972 ........ -- .......
Mozambique 2.6 10.7 ........ -- .......
Ethiopia 2.9 18.7 ........ -- .......
Tanzania 4.1 20.2 ........ -- .......
Rwanda 5.5 24.5 ........ -- .......
Zambia 6.9 31.2 ........ -- .......
Haiti 8.4 47.2 ........ -- .......
Cote d'Ivoire 9 47.6 ........ -- .......
Uganda 10 66.1 ........ -- .......
Kenya 13.2 84.2 ........ -- .......
Guyana 18.1 85.2 ........ -- .......
Nigeria 18.5 90.1 ........ -- .......
Botswana 23.8 113.1 ........ -- .......
Namibia 29.5 168 ........ -- .......
South Africa 56.3 471.8 ........ -- .......
------------------------------------------------------------------------
Ambassador Tobias. So in part, we are addressing this using
a program called twinning, by matching up medical schools in
the United States, medical centers in the United States with
counterparts in the countries in Africa that can help them by
loaning them people, sending residents, developing programs
that can help in that regard. We have authorized a study that
the Institute of Medicine is conducting to look at how we can
best do that.
But in the meantime, we are off and going with the first
$350 million out the door and another $300 million coming up
here very shortly. So I am pleased with that, and even my
friend Bono has been very complimentary about the speed with
which we are getting these programs going.
Let me say a word about the drug issue because it is far
more complicated than one might assume on the surface. Those of
us here in the United States have come to understand what is
meant by the term ``generic drug.'' It means that if a
physician writes a prescription and you or I take that
prescription to our local pharmacy and get it filled, whether
it is filled with a generic drug or a drug that was
manufactured by the research-based pharmaceutical company that
originally made it, from our point of view as a patient, what
we are going to receive is exactly, precisely, identically the
same. It is the same because the FDA has processes to ensure
that it is the same.
When people describe generic AIDS drugs in Africa, they are
not generic drugs in that context. These are drugs that are
copies that have been manufactured by other companies without
the same access to the data and so forth that happens when a
drug is no longer under patent protection.
The World Health Organization has put together a process
that is called their prequalification list, through which they
do a paper review of data that is provided to them under a
confidentiality agreement by companies who wish to have their
drugs reviewed for this list. The World Health Organization
reviews that dossier. They make a visit to the manufacturing
site where it is to be manufactured and they make a preliminary
stipulation to countries who do not have regulatory processes
that this is a list that they should look at to acquire drugs.
There are many who believe that is good enough.
As we gear up this program, we are going to have not only a
lot of newcomers coming, but great risks of being sure we do
this right. So we have been working with scientific technology
people from the World Health Organization, from the Southern
African Development Community, from a number of nations to try
to determine what is the process we can use to ensure that the
drugs we are providing for the patients in Africa are, in fact,
safe and effective.
Nobody wants to move this along any more quickly than I do.
As I have said on a number of occasions, our policy is and will
be to buy the least expensive drugs we can find from wherever
we can find them as long as we have some reasonable assurance
of their safety and effectiveness and we are moving ahead
rapidly to get that kind of a process in place.
The Chairman. I thank you.
Mr. Natsios.
Mr. Natsios. May I just add another subtlety to this
discussion about treatment and care for people with HIV/AIDS?
I think the presumption in Washington is that somewhere in
the world where there is high incidence of HIV/AIDS is a list
of all the people in the country that have the disease. That is
not true. Only about 6 to 10 percent of the people who are HIV/
AIDS-positive know they have the disease because they have been
tested. The other 90 percent have the disease and may not be at
a stage where there is any manifestation of symptoms or they
may have symptoms but they may not know it is HIV/AIDS. And in
some cases, they may be later in the disease and not want to
tell anyone they have the disease because in some areas of the
world, if you tell people, they kill you or they will throw you
out of the village or your house because there is a terrible
stigma attached to being ill.
Now, you can do a prevention program generically through
the news media to tell people how you can prevent getting
infected because you do not have to know who gets it or does
not get it. You do it through the news media. But if you want
to feed someone or you want to provide ARVs, you have to know
individually who the person is. And 90 percent of the people
who have the disease we do not have a list of. We do not know
who they are and they do not know who they are.
The Chairman. On that point, now, how do we know that that
many people have the disease?
Mr. Natsios. We extrapolate the data from health clinic
surveys that are done in different countries. What will happen
is the NGOs that have grants and contracts from the Department
of Health and Human Services [HHS] and USAID and Randy's office
or other countries that provide funding will go in to a
particular health clinic and they will test everybody
voluntarily but they will test them. And they will get a
percentage.
The Chairman. I see.
Mr. Natsios. And they will do this at 10 different clinics
around the country and then they will extrapolate the data
based on sound principles of public health.
The Chairman. This is a sampling almost like a political
poll in a way.
Mr. Natsios. Exactly. I have never heard it compared that
way, Senator, but that is a good comparison. It is the same
principle. Yes.
The Chairman. It is part of our craft. We do these things
from time to time.
Mr. Natsios. Yes. But the complication for us, until we
have the systems set up that Randy talked about to do the
testing, we cannot very well treat people generically. We have
to treat people specifically. We cannot treat people as a
group. You treat them individually. So having the health care
infrastructure to do the testing first, then to do the
treatment and the care is a complex area.
In some of the areas we are working in, Senator, there are
no roads. There are no helicopters. There are no boats to get
to these people. They live in remote areas in villages where
the disease has spread, but they are very inaccessible. It is
not just that there are no doctors. There are no health
workers. There are no clinics and there are no hospitals. So
you have to train people on how you take the test properly, and
then you have to train them in how you administer the drugs
properly. Then you have to target them in order to provide the
food aid to them.
So it does not mean we cannot do it. We are going to do it.
We are already doing it to a substantial degree, but it is more
complex than it looks, which is why Randy properly said and Jim
has said, that we have to have the absorptive capacity in place
to absorb the resources we are directing toward this. We can do
it. We are doing it. We are setting up the systems now, but it
is not easy.
The Chairman. Well, now, trace for the record, Mr. Natsios,
since this is one of the purposes of our hearing, how USAID
and/or the new Millennium Challenge program intersect in these
areas. You have indicated the huge numbers of people being fed
through the World Food Program. USAID is interested in feeding,
and also in assisting with the treatment of HIV/AIDS. Clearly
we have a program that Mr. Tobias is heading, but you are
involved in this. Your people are involved in these programs.
One of the questions that Americans have is, is there
duplication? Do people talk to each other? Are they supporting
each other? Do they take various specific pieces of the
project, to avoid duplication? How would you describe the
organized effort governmentally, given the fact that you have
different agencies and also the United Nations involved? It is
obviously not a United States agency, but it is backed very
considerably by American gifts to the World Food Program.
Mr. Natsios. The respective roles of the World Food Program
and the NGOs and USAID and other donors are actually quite
defined. USAID does not actually go out and physically feed
people. We rely on our partner organizations to do that, and
our partners, in the case of food aid, are the World Food
Program and the NGO community and faith-based groups at the
village level who actually go door to door and distribute
assistance.
WFP is the wholesale distributor, which is to say if we
have a huge program in a country, we will go to WFP and say, we
want you to organize the national effort in x country. They
will work with the NGOs to do the retail distribution. But in
terms of the actual planning of the whole campaign nationally,
WFP does that with our planning staff and then they do the
logistical systems at the port facilities to off-load the food,
make sure it is cared for, and it is not diverted. Then they
put it on trucks. Their logisticians, by the way, are the best
logisticians in the U.N. system. In fact, not just the U.N.
system, I would say in the world. It is an excellent
organization from a logistics and planning point of view.
Our role is to do assessments, to determine what the need
is, working with other organizations, to target food
assistance, to develop the components of the food basket. In
some societies, some food is more appropriate than others. It
has to be nutritionally balanced. And each of us has our role.
We have our role. WFP has its role and the NGOs have their
role. If one of us dropped out, the system would not work. But
there is no overlap in it. And I think it works actually in a
very integrated way and a very efficient way. I do not know if
you want to disagree with any of that, Jim.
Do you have a comment, Mr. Morris?
Mr. Morris. Senator, I agree that it works really superbly
well, especially on the ground. It works extra-effectively as
it relates to the HIV/AIDS issue because everyone understands
it takes all of the ingredients to get at this. No one approach
will solve the problem. And I think you would generally be very
pleased to see the way that UNICEF and UNAIDS and WFP work with
Save the Children and World Vision and the Red Cross and
Catholic Relief and CARE, the way we work with USAID. Their
counterpart in the UK DFID is also very good.
Of course, the magnitude is so enormous that we are only
getting at a piece of it, and we do not run over each other. In
southern Africa, as Andrew said, they have come to us to manage
the port issues so that we do not have six people competing for
port pricing and manage the distribution on rail links or
trucks to points where the NGOs receive the food and distribute
it. They have the best expertise to work community by
community. We have 1,500 partners, NGOs, 300 international,
1,200 local, and some of the best international NGOs are
working very hard to partner with local NGOs so that capacity
gets stronger.
The Chairman. Both of you have defined the fact that USAID
and the World Food Program work on a national plan for whatever
the country may be, and then the wholesale delivery comes from
the World Food Program. The retail delivery comes from the
private organizations. They carve out those spaces where they
can be of service. Mr. Natsios has pointed out that obviously a
hunger problem carries a different burden from HIV/AIDS. You
have to know that you have a patient, first of all, in the case
of HIV/AIDS, as opposed to an extrapolation of a problem. This
may involve social stigma or even denial by politicians in high
leadership positions in some African countries until recently.
This creates real problems. Nevertheless, in your comprehensive
planning, you take all this in consideration.
How do you define how the AIDS program works with USAID?
What are the carve-outs or responsibilities there?
Mr. Natsios. Well, Randy is in charge and he makes the
assignments. He allocates the budget. He sets the policies. We
meet with him weekly; our staffs do.
We have a global health bureau. I had a count done
worldwide. We have 400 people working on this who are USAID
staff people. These are not people who work for the NGOs or the
U.N. or the ministries of health. These are USAID public health
officers. As I said, three-quarters of our staff are in the
field. We have USAID missions around the world. In all but one
of the PEPFAR countries, the 14 target countries, there is a
USAID mission. It has been there, in many cases, for many
years. They know the networks. They know the villages. Half of
our worldwide staff are not Americans. They are Mozambiqueans.
They are Zambians. They are Brazilians. They are Colombians. We
call them Foreign Service nationals [FSNs] but they are a
critical part of our staff. Many of them are physicians or
public health officers, and they are the ones who carry these
programs out at the national level.
But Randy is in charge and I have told all our staff that
we are to take his leadership on this. We contribute, I think,
technical expertise, research data, our networks, our
procurement systems, our officers in the field to carry out the
decisions that he makes.
The Chairman. Randy.
Ambassador Tobias. I might just add that while we have put
together the strategy that has been submitted to the Congress
here in Washington, the implementation of what we are doing is
very much driven on a country-by-country basis where the U.S.
Chief of Mission has been asked to--and they each have done a
fine job--step up to provide integrated leadership, bringing
together the people in USAID, CDC, and the other U.S.
Government organizations on the ground. And that local
orientation, I think, better enables us to coordinate the
prevention and particularly the treatment and care aspects of
what we are doing with other programs that are available
through USAID or elsewhere, so that we are combining with our
treatment and care efforts the nutrition needs and the other
needs that are requirements of fighting this disease.
The Chairman. You have identified another especially
important aspect. The Chief of Mission is often our ambassador
to the country. This gives some idea of how, in a diplomatic
way, the State Department Secretary deals with ambassadors,
USAID, the U.N. agency and the World Food Program. The reason I
have tediously gone through this is that this is not well
understood. It is the purpose of our hearing today to delineate
the parameters more carefully so that members will have some
idea of how this works, and that it works well. And if it does
not work well, we will have some way of trying to get a handle
on the problem to help you make sure that it will work better.
I just want to ask one further question. Mr. Natsios, you
offered very valuable testimony as the committee considered the
Millennium Challenge idea. You were there to celebrate with the
President yesterday the announcement of the first 16 nations
that will be major participants in the program.
Now, how do things change if you are a Millennium Challenge
account, as opposed to being a normal recipient, let us say, of
foreign aid or however we want to describe the assistance our
country gives? Are there some new definitions of the problem?
Mr. Natsios. The existing foreign aid program of the United
States comes out of half a dozen spigots of money, which is
heavily earmarked and directed by the Congress. We can debate
whether that is useful or not, but it has a lot of specificity
as to how we will spend the money. Population money, a $435
million earmark, must be spent on population programs.
The money for the Millennium Challenge Account is
unearmarked. There are no directives. There are no earmarks by
sector, by region, or anything else.
The Chairman. So it goes to the State of Georgia, for
instance.
Mr. Natsios. That is right. The country of Georgia.
The Chairman. Yes, the country of Georgia. Pardon me.
Mr. Natsios. I do not want to think Atlanta is getting our
foreign assistance program.
The Chairman. Good point.
Mr. Natsios. Not that they need it.
But let us say it was the country of Georgia, which is one
of the 16 eligible countries. The way this will work, according
to Paul Applegarth, who is the Director of the program and is
the CEO of the Millennium Challenge Corporation. I sit on the
board. He will decide with his staff which countries will use
which mechanisms for implementation. He is not going to be the
implementing agent in the sense of actually carrying things
out. He has said in public testimony I think before this
committee. He said to me, can we in some countries use the
USAID mission as the implementing agent with the ministries of
the government in the country, and the answer is yes. Whatever
he wants us to do, we will do.
The Chairman. That would be their choice.
Mr. Natsios. That is their choice.
Now, the most important thing about the Millennium
Challenge Corporation program, which relates directly to what
we are talking about here, is this. There are certain things
where there really is not a lot of international funding, for
example, roads. The banks got out of doing roads. We got out of
doing roads except in Afghanistan where we are doing roads. We
do roads here and there, but there is not an enormous amount of
funding and there are no earmarks or directives to do them.
If you ask people in the developing world what is the most
important thing they need in the rural areas, they need roads.
Why is that? They cannot move. They grow extra food and it
rots. Why? Because they cannot move it to the food-deficit
areas. They cannot move seed in. They cannot move fertilizer
in. They cannot move their kids to a hospital if they are sick
or to a clinic, or they cannot move their kids easily to
school.
So many countries are telling us they want this money
invested in infrastructure. They are going to make the decision
through the compact that they draft with the U.S. Government.
Paul Applegarth's staff will have to approve or not approve the
compacts. Then the board of directors will be involved in that.
But this is country-driven, and it will be country-
implemented with some assistance from perhaps other
institutions like USAID or OPIC or other institutions within
the U.S. Government that might be carrying out parts of this
program.
But I think what we will see is that in many cases the
areas that they cannot get donors to give money, but they need
desperately like infrastructure, which has been neglected for
too long, you will see these proposals, these compacts, coming
back heavily focused in an area. Not entirely. Some of them may
decide they want to build school buildings and they want to
train more teachers. That is up to them to decide. We will help
implement it as they wish. But again, Paul Applegarth is in
charge.
Whatever they do with it I suspect will facilitate the work
that all of us are doing. If they build rural roads, it is much
easier for Randy and me to get the AIDS clinics built and the
pharmaceuticals delivered properly, and Jim and I will have an
easier time delivering the food assistance because there is now
a way to get to it much more efficiently.
One of Jim's biggest costs is trucks. Some of the roads
that they get through now, you cannot even imagine they are
roads that are so unbelievable. In some areas there are no
roads whatsoever.
So these things do work together particularly at the
country level which is where, to put it crassly, the rubber
meets the road.
The Chairman. Let me indicate that reluctantly I am going
to bring the hearing to a conclusion because the Senate is
about to have an important rollcall vote, which hopefully will
expedite our business on the floor.
My colleagues, Senator Feingold and Senator Alexander, as
our chairman and ranking member of the African Affairs
Subcommittee, asked Mr. Morris about the Sudan and his travels
there. To say the least, this is an extraordinarily dangerous
situation, quite apart from a humanitarian one.
I was impressed that five members of our committee were
privileged to have breakfast with our Secretary of Defense, Mr.
Rumsfeld, and General Myers this morning at the Pentagon. They
were describing how difficult it was to either get people to
the peace process or to extract them from the peace process,
leaving aside the roads that Mr. Morris described that carry
any humanitarian food, the 800,000 people, for example. The
feat of trying to feed people in Sudan presently is prodigious.
So is the fact that it can be done at all under these
conditions, which are daunting even to our military as it
attempts to bring peace.
That is true for each of you in the work that you are
doing. The terrain that you are covering is not easy. I
appreciate Mr. Natsios' point that we do not do roads anymore,
although the Millennium Challenge countries may decide we have
to do roads in order to have the kind of delivery that we want.
All of these are factors in the humanitarian predicament, quite
apart from the infrastructure of the country.
I thank each one of you very much for your forthcoming
testimony, your statements, and your response to our questions.
We look forward to renewing this conversation at future
hearings when we have some more benchmarks along the road.
With that, the hearing is adjourned.
[Whereupon, at 12:01 p.m., the committee adjourned, to
reconvene subject to the call of the Chair.]
----------
Additional Material Submitted for the Record
[From the Los Angeles Times, May 11, 2004, Tuesday Home Edition]
Iraq Prison Scandal; A Double Ordeal for Female Prisoners
(By Tracy Wilkinson, Times Staff Writer)
One woman told her attorney she was forced to disrobe in front of
male prison guards. After much coaxing, another woman described how she
was raped by U.S. soldiers. Then she fainted.
A U.S. Army report on abuses at Abu Ghraib prison documented one
case of an American guard sexually abusing a female detainee, and a
Pentagon spokesman said Monday that 1,200 unreleased images of abuse at
Abu Ghraib included ``inappropriate behavior of a sexual nature.''
Whether it was one or numerous cases of rape, many Iraqis believe
that sexual abuse of women in U.S.-run jails was rampant. As a result,
female prisoners face grave prospects after they are released: denial,
ostracism or even death.
A woman who is raped brings shame on her family in the Islamic
world. In many cases, rape victims have been killed by their relatives
to salvage family honor, although there is no evidence this has
happened to women who have been prisoners in Iraq.
``It is like being sentenced to death,'' said Sheik Mohammed Bashar
Faydhi, a senior cleric based at Baghdad's largest Sunni mosque.
Some Iraqi women said they were struggling to come to terms with
the alleged abuses of female detainees at Abu Ghraib and other U.S.-
controlled lockups. Few female inmates will talk about it. Their
lawyers lower their voices when the subject of rape comes up.
``I hope it's not true, because were it to be true, it is just too
horrible to imagine,'' said Rajaa Habib Khuzaai, an obstetrician who is
one of three women on the Iraqi Governing Council.
This week, Khuzaai was allowed access to a detention center housing
women--a privilege rarely granted to outsiders before the scandal.
But female lawyers who visited the prison in March said their
clients provided accounts of abuse and humiliation.
To enter the prison west of Baghdad, the attorneys waded through
dirt and coils of barbed wire, and waited for hours.
Inside, they met with nine female detainees--four of whom, they
said, had not been charged with any crime. U.S. military officials said
at the time that there were 10 or 11 women being held at Abu Ghraib.
One lawyer, Sahra Janabi, said her clients found it difficult to
talk about their experiences in prison. Seemingly minor actions by U.S.
soldiers, such as removing a woman's head scarf, represented a
violation to these Muslim women.
A prison translator was present in the meetings and took notes,
Janabi said.
``We could not talk freely,'' she said. ``The women were
devastated. They broke down crying.''
According to Janabi, only one prisoner, a middle-aged owner of a
cigarette stand, would speak openly, and said she did not care if the
guards punished her.
She told the lawyers that she had been forced to disrobe in front
of male guards, an action that an Iraqi translator found so disgraceful
he turned his head away in embarrassment.
Janabi and her colleagues said many women who had been detained are
wives or relatives of senior Baath Party officials or of suspected
insurgents. U.S. Army officials have acknowledged detaining women in
hopes of persuading male relatives to provide information. The lawyers
said interrogators sometimes threatened to kill detainees.
Dozens of people--lawyers, Iraqi officials, Iraqi and foreign human
rights activists--have sought access to the prisons during the last
year with minimal success. Stories of physical and sexual torture were
rampant for much of that time. Iraqi officials and lawyers say U.S.
military and governmental secrecy created a climate that allowed
abuses.
Women represented a small percentage of about 40,000 detainees
processed by U.S. authorities.
Once the women are freed, a new trauma begins, Iraqis say.
Khuzaai, the Governing Council member, said most female detainees
cannot talk about what they've been through. They and their families
try to pretend nothing ever happened, she said.
Another lawyer, Amul Swadi, said her client fainted before
providing further details of being raped and knifed by U.S. soldiers.
Five former detainees described to their lawyers having been
beaten. But they did not say they had been raped.
``They are very ashamed,'' Janabi said. ``They say, `We can't tell
you. We have families. We cannot speak about what happened.' ''
In Iraq, silence may be their best protection.
Faydhi, the cleric, said an Iraqi man cannot acknowledge having had
a female relative in prison. The shame, he said, is bad enough if the
woman was in an Iraqi jail. To have been taken by the Americans
compounds the humiliation.
Her life may be in danger especially if the woman is from a large,
prominent tribe, he said, and her family believes she has been raped,
Faydhi said.
Faydhi, an official with Iraq's Board of Islamic Clergy and a
professor at the Islamic University, said a man will be discouraged
from killing his female relative who has been released from prison if
he seeks permission of an imam to restore the family's honor. But the
cleric also said imams have limited ability to prevent this kind of
murder.
``I would remind him that she is a victim, and ask, how can we
victimize her even more? I would tell him to keep it secret, but that
if word gets out, I would try to convince him that she should be seen
as a patriotic symbol,'' Faydhi said. ``But it is really difficult to
convince an Iraqi to think in such a manner.''
Khuzaai said the stigma would be unbearable.
``Like any woman who is raped, there is the mental, psychological
breakdown and everything that is related to the self,'' she said. ``But
then there's the family and society. If a rape has happened, a family
will never talk about it, not to the public, and maybe not even among
themselves.''
______
26 March 2004.
Ambassador Randall Tobias
Global AIDS Coordinator,
U.S. Department of State,
Washington, DC.
Dear Ambassador Randall Tobias,
We, the undersigned organizations, are writing to express our
serious concerns about efforts by the Bush administration and by your
office to block the use of affordable generic HIV/AIDS medicines in
U.S.-financed programs in poor countries. In order to mount a rapid and
successful response to the growing AIDS pandemic, we call upon you to
ensure that programs use the most affordable medicines available, and
accept the current drug quality standards of World Health
Organization's drug prequalification program.
We are particularly concerned about the U.S.-initiated ``Conference
on Fixed-Dose Combination (FDC) Drug Products: Scientific and Technical
Issues Related to Safety, Quality, and Effectiveness,'' 29-30 March
2004 in Gaborone, Botswana. This meeting needlessly casts doubt upon
the clinically proven quality of generic AIDS medicines, and disregards
the WHO's internationally recognized Drug Prequalification Program. The
meeting is intended to justify the use of expensive, more complex
branded treatment regimens, and will be used by the US as the minimum
basis to justify its efforts to use bilateral assistance programs to
lock generics out of developing countries. Of particular concern is
your attempt to discredit the use of urgently needed fixed-dose
combinations (FDCs) of antiretroviral AIDS medications.
Single-pill combinations promote adherence, decrease the risk of
resistance, and facilitate stock and procurement management, and are
widely recognized as a core element in efforts to scale up ARV
treatment in developing countries. FDCs are strongly preferred over
blister packs and other multi-pill regimens. In addition to ease of use
and other advantages, FDCs, which are taken in the form of one pill
twice a day, are also by far the least expensive option: today, triple
FDCs from generic manufacturers are available for less than $140 per
person per year. The same combination from brand-name companies costs a
minimum of $562 per person per year and must be taken in the form of
six pills a day. Forcing people with HIV/AIDS to accept higher pill
burdens, wasting limited taxpayer resources on brand name products,
and, most importantly, using scarce resources to treat one person when
the same amount of money could treat four is unacceptable.
If the ambitious goals of the President's Emergency Plan for AIDS
Relief (PEPFAR), and the WHO's ``3 by 5'' initiative are to be met,
triple combination FDCs pre-qualified by WHO must be made widely
available. FDCs are recommended in WHO treatment guidelines, and
several generic FDCs have been certified by WHO as meeting stringent
international standards for drug quality, safety and efficacy through
its Prequalification Project. The WHO's standards for prequalification
are supported by UNICEF, the World Bank, the Global Fund to Fight AIDS.
TB, and Malaria, Columbia University's MTCT-Plus program, many national
governments in developing countries, international humanitarian
organizations such as Medecins Sans Frontieres (MSF), and other
programs with experience treating people living with HIV. Clinicians in
resource poor settings are already using triple combination generics
with tens of thousands of patients, with efficacy and adherence rates
equal-to-or-better than treatment success and adherence rates in the
United States.
Rather than disregarding the drug procurement policies of
developing nations to create expensive new barriers that benefit US
drug companies, your office should accept the WHO's internationally
recognized drug quality standards and promote access to affordable
medications. We object to any and all efforts by the Bush
Administration and your office to block the use of WHO prequalified
generic medications, and any efforts to discredit the standards of
WHO's prequalification project that would impose new barriers to
generics entering the global market.
Signed,
International Organizations
International Association of Physicians in AIDS Care (IAPAC), Int'l
Partners In Health, Int'l
Oxfam International
International Council of AIDS Service Organizations (ICASO), Int'l
International Planned Parenthood Federation, Western Hemisphere Region,
Int'l
CAFOD International--Catholic Agency for Overseas Development, Int'l
AIDSETI-AIDS Empowerment & Treatment International, Int'l
Ecumenical HIV Initiative in Africa, World Council of Churches, Int'l
European AIDS Treatment Group (EATG), Int'l
Health Action International, Int'l
Health Alliance International, Int'l
ILGA--International Lesbian and Gay Association, Int'l
International Community of Women (ICW) living with HIV/AIDS, Int'l
People's Health Movement Global Secretariat, Int'l
Red Centroamericana de Personas que Viven con VIH/SIDA (REDCA+), Int'l
Third World Network, Int'l--Malaysia
African Jesuit AIDS Network, Int'l
Artists for a New South Africa, Int'l/USA-CA
Asociacion para la Salud Integral y Ciudadania de America Latina
(ASICAL), Int'l
COLEGA, La Federacion Espaola COLEGAS de Lesbianas, Gays, Bisexuales y
Transexuales, Int'l
Comite Latinoamericano y del Caribe para Defensa de los Derechos de la
Mujer (CLADEM), Int'l
International Health and Development Associates, Int'l
International Peoples Health Council, Int'l
INTERSECT Worldwide, Int'l
Joint Mongolian-German Reproductive Health Project, Deutsche
Gesellschaft fir Technische Zusammenarbeit (GTZ), Int'l
Kenya AIDS Intervention Prevention Project Group (KAIPPG) Int'l
Latin American and Caribbean Women's Health Network, (LACWHN), Int'l
Movimiento Latinoamericano y del Caribe de Mujeres Positivas (MLCM+),
Int'l
Pastoral de la Esperanza Iglesia Catolica CentroAmericana, Int'l
People's Health Movement East Africa, Int'l
Red de Salud de las Mujeres Latinoamericanas y del Caribe (RSMLAC),
Int'l
The River Fund, Int'l
Ukimwi Orphans Assistance, Int'l
Voluntary Services Overseas (VSO), Int'l
WE-ACT--Women's Equity in Access to Care & Treatment, Int'l
U.S. National Organizations
Episcopal Church USA
Presbyterian Church, USA
Unitarian Universalist Association of Congregations, USA
Amnesty International, USA
American Foundation for AIDS Research (AmFAR), USA
National Gay and Lesbian Task Force, USA
ActionAid International USA
Africa Action, USA
AIDS Treatment News, USA
AIDS Vaccine Advocacy Coalition (AVAC), USA
American Jewish World Service, USA
American Medical Students Association (AMSA), USA
Center for Health and Gender Equity (CHANGE), USA
CHAMP, USA
Church Women United, USA
Commission on Social Action of Reform Judaism, USA
Consumer Project on Technology, USA
Essential Action, USA
Gay Men's Health Crisis (GMHC), USA
Global AIDS Alliance, USA
Global Exchange, USA
Health GAP (Global Access Project), USA
Jubilee USA Network, USA
Maryknoll Office for Global Concerns, USA
National Minority AIDS Council (NMAC), USA
Our Bodies Ourselves, USA
Physicians for Human Rights, USA
POZ Magazine, USA
Project INFORM, USA
Reformed Church in America Mission Services Program in Africa, USA
Student Global AIDS Campaign, USA
TII CANN--Title II Community AIDS National Network, USA
Treatment Action Group, USA
Washington Office on Africa, USA
Women's International League for Peace and Freedom, United States
Section
50 Years Is Enough: U.S. Network for Global Economic Justice, USA
Adrian Dominican Sisters, USA
Africa Faith and Justice Network, USA
AIDS Treatment Data Network, USA
The Praxis Project, USA
AIDS.ORG, USA
Corporate Responsibility Program, Province of St. Joseph of the
Capuchin Order, USA
Health Professional Student AIDS Advocacy Network, USA
Institute for Agriculture and Trade Policy, USA
Keep A Child Alive, USA
Maryknoll AIDS Task Force, USA
Medical Mission Sisters' Alliance for Justice, USA
Missionary Oblates, Justice/Peace & Integrity of Creation, USA
National Association for Victims of Transfusion-Acquired AIDS (NAVTA),
USA
Operation USA
Share International USA
South Africa Development Fund, USA
Universities Allied for Essential Medicines, USA
Foreign Country Organizations
Act Up-Paris, France
Agua Buena Human Rights Association, Costa Rica
AIDES, France
Bread for the World, Germany
Deutsche AIDS-Hilfe, Germany
Grupo de Incentivo a Vida, Brazil
Royal Tropical Institute, Holland
Treatment Action Movement, Nigeria
Action for Southern Africa (ACTSA), UK
Advancement of Rural People And Nature (ARPAN), India
African Research Institute, LaTrobe University, Australia
African Services Committee, Ethiopia
Agency for Cooperation and Research in Development (ACORD), UK
AGIHAS PLWHA Support group, Latvia
AIDS ACCESS Foundation, Thailand
AIDS Access Foundation, Thailand
AIDS Council of New South Wales (ACON), Australia
AIDS Law Unit, Legal Assistance Centre, Namibia
AIDS Task Force (HIV/AIDS Division of Africa Japan Forum), Japan
AKINA MAMA, Sweden
Alnaemissamtokin a Islandi, The AIDS Organization of Iceland, Iceland
AMAS/AFAS, Mali
APPRENDE, Peru
Asian-Pacific Resource & Research Centre for Women (ARROW), Malaysia
Asoc. Gente Positiva (GP), Guatemala
Asociacion ACCRAD, Argentina
Asociacion Amigos de Ayacucho, Spain
Asociacion Atlacati Vivo Positivo, El Salvador
Asociacion Comunitaria Anti SIDA, Spain
Asociacion Coordinadora de Sectores de Lucha Contra el SIDA (ACSLCS),
Guatemala
Asociacion Costarricense De Personas Viviendo Con VIH/SIDA, Costa Rica
Asociacion de Mujeres Contra la Violencia Intrafamiliar, Mexico
Asociacion por la Vida (ASOVIDA), Venezuela
Associcao Brasileira Interdisciplinar de AIDS (ABIA), Brazil
Associcao de apoio a pessoas corn VIH/SIDA (ABRACO), Portugal
Associcao Justica, Paz e Democracia (AJPD), Angola
Association Bondeko, France
Association de Lutte Contre le SIDA (ACLS), Morocco
Association Kenedougou Solidarite, Mali
ATTAC Japan, Japan
Australasian Society for HIV Medicine, Int'l/Australia
Australian Federation of AIDS Organisations, Australia
Australian People for Health, Education and Development Abroad
(international humanitarian agency of the Australian Council of
Trade Unions), Australia
Australian Red Cross, (Lao PDR Office), Australia
AVERT--Averting HIV and AIDS Worldwide, UK
Begin (learning & living with HIV), UK
BolivaGAY.com, Bolivia
British Columbia Persons With AIDS Society (BCPWA), Canada
Campagne pour les Droits de l'Homme au Congo (CDHC), Congo
Campaign for Improved Access to Treatment for AIDS in resource poor
countries (ImpAcTAIDS), Scotland
Canadian African Partnership on AIDS (CAP-AIDS), Canada
Canadian Hiv/AIDS Legal Network, Canada
Canadian Union of Public Employees (CUPE), Canada
CARE Raks Thai Foundation, Thailand
Casa del Paso del Peregrino, Argentina
CASI--ComitE d'Action Sociale et Internationale of the UniversitE de
MontrEal, Canada
Catholics for AIDS Prevention & Support (CAPS), UK
Center for Health and Gender Equity (CHANGE), Peru
Center for Information and Advisory Services in Health, Nicaragua
Centers of Excellence--Substance Abuse & HIV/AIDS, India
Centre for International Health (Cih) of the Macfarlane Burnet
institute for Medical Research and Public Health, Australia
Centro Regional de Farmacovigilancia, Argentina
Cheshire Homes, South Africa
ChildrenFIRST, South Africa
Children's Rights Centre, South Africa
Christian Health Association of Nigeria (CHAN), Nigeria
Christian Medical Association of India
CICOP Argentina
CIIEMAD/National Poytechnic Institute, Mexico
Citizen's Health Initiative, Malaysia
Coalicion ONGSIDA y de la Licda, Dominican Republic
Comite Ciudadano Anti-Sida de Castilla-La Mancha, Spain
Comite Dominicano de los Derechos Humanos CDH, Dominican Republic
Comite Orgullo Mexico
Committee of Arab and African Families United to Survive AIDS, France
Community Health Cell, India
Consultants for Health and Development, The Netherlands
Consumer Education Trust (CONSENT), Uganda
Coordinadora de AnimaciOn Socio Cultural (CASCO), Dominican Republic
COPROMOR, Burundi
Dame Una Mano, Chile
Departamento Acceso a Tratamiento Via Medidas Cautelares (DATVMC),
Dominican Republic
Department of Pharmacology, School of Medicine, National University of
La Plata, Argentina
Difaem--German Institute for Medical Mission, Germany
Discipline of Clinical Pharmacology, Faculty of Health, University of
Newcastle, Australia
d'Unis-Cite, France
Ecumenical Pharmaceutical Network, Kenya
EDU-PRO Foundation, Albania
Egyptian Initiative for Personal Rights, Egypt
Family Aids Caring Trust, Zimbabwe
FarmacEuticos Mundi (ONL), Spain
Farmacia Siglo XXI Foundation, Spain
Farmamundi Extremadura, Spain
Five Loaves of Bread Christian Community for Homosexuals, Hungary
Foundation For Social Concerns Inc., West Indies
Foundation for Studies and Research on Women (FEIM), Argentina
Freedom Foundation, India
Fundacion CIPRESS (Centro de Investigacion y Promocion de la Salud y la
Sexualidad), Chile
Fundacion Henry Ardila, Colombia
Fundacion Nimehuatzin, Nicaragua
Fundacion para el Desarrollo Humano y Social de la Region del Pueblo
Mam (FUNDAMAM), Guatemala
Fundacion para la Prevencion del VIH/SIDA (PRESIDA), Nicaragua
Fundacion PRESIDA, Nicaragua
Fundacion Proyecto Gente, Columbia
Fundacion Schorer, The Netherlands
Genesis Panama+
Ghana AIDS Treatment Access Group (GATAG), Ghana
Gram Bharati Samiti, India
Green Scenery, Sierra Leone
Grupo Argentino Uso Racional de Medicamentos (GAPURMED), Argentina
Grupo de apoyo de personas viviendo con VIH-SIDA (FUNDASIDA), El
Salvador
Grupo De Mujeres De La Argentina
Grupo Desde el pie, Argentina
Grupo Desida Por La Vida, Argentina
Grupo Portugues de Activistas sobre Tratamentos de VIH/SIDA (GAT),
Portugal
GTP+ grupo de Trabalhos em Prevencao Posithivo, Brazil
Health Issues Centre, Australia
Helpless Rehabilitation Society (HRS), Nepal
HIV i-Base, UK
Human Genome Analysis, Wellcome Trust Sanger Institute, UK
Imbiza Intersect Coalition, South Africa
Interact Worldwide, Int'l--UK
Interchurch Organisation for Development Cooperation (ICCO), The
Netherlands
International Cooperation Area, Foundation Institut Catala de
Farmacologia, Spain
International Family Health, UK
International Gender Equality Network (IGEN), Hungary
Ipas Mexico A.C., Mexico
Irish Missionary Union, Ireland
Jamaica-Japan Network, Japan
Jana Arogya Andolana (PHM--Karnataka), India
Kenya AIDS Intervention Prevention Project Group (KAIPPG), Kenya
Kenya Treatment Access Movement, Kenya
KwaZulu Natal Intersect Coalition, South Africa
l'Association des Femmes Avocates au Congo (AFEAC), Congo
LGBT Organization of Venezuela
Liga Colombiana De Lucha Contra el SIDA, Columbia
Living Hope Organization, Nigeria
LOCOST (Low Cost Standard Therapeutics), India
Massive Effort Campaign, Switzerland
McGill International Health Initiative, Canada
MCS-Consult, Utrecht, The Netherlands
MICHOACANOS POR LA SALUD Y CONTRA EL SIDA, Mexico
Misiones Diocesanas Vascas, Spain
Mulher e Saude--Centro de Referencia de Educacao em Saude da Mulher,
Brazil
Myarimar Buddhist Association of South Africa (MBASA), South Africa
National Association of People Living With HIV/AIDS (NAPWA), Australia
National Forum of People Living with HIV/AIDS Networks and
Organisations, Uganda
Nazareth Hospital-Holy Family Center, Kenya
Network Earth Village Japan, Japan
Network of People Living with HIV/AIDS in Nigeria (NEPWHAN), Nigeria
Network of Sex Work Projects, Int'l--Brazil
Organizacion de Apoyo a una Sexualidad Integral frente al SIDA (OASIS),
Guatemala
Organization for Social Development of Unemployed, Bangladesh
Pan-African Organisation in Sweden
People Living With HIV/AIDS New South Wales, Australia
People's Health Coalition for Equitable Society, South Korea
Point of View, India
Positive Life Association of Nigeria (PLAN), Nigeria
Positive Living, Malaysia
Positive Movement, Belarus
Positive Women Victoria, Inc., Australia
Prodemur significa Promocion de la Mujer Rural, Argentina
Programa de Prevencion y Atencion a las personas afectadas por eli VIH-
SIDA en Asturias (PAVSA), Spain
Programa de Soporte a la Autoayuda de Personas Viviendo con VIH
(PROSA), Peru
Progressive Organization of Gays in the Philippines (PROGAY),
Philippines
Proyecto de Vacunacion y Desarrollo Comunal de Nicaragua (PROVADENIC),
Nicaragua
Public Personalities Against Aids Trust, Zimbabwe
Radio Rhino International Africa, Germany
Reach Out Mbuya HIV/AIDS Initiative, Uganda
Red Argentina de Genero, Ciencia y Tecnologia (RAGCyT), Argentina
Red Colombiana de Mujeres por los Derechos Sexualers y Reproductivos,
Colombia
Red Hispana de Derechos Humanos en vih--sida y minorias sexuales,
Columbia
REDBOL, Bolivia
REDVIHDA, Bolivia
Regional AIDS Initiative of Southern Africa (RAISA) initiative of VSO,
Zimbabwe
Regional Committee for the Promotion of Community Health, Nicaragua
Reproductive Health Matters, UK
Reseau des associations des PVVIH, Togo
Reseau du Burundi des PVVIH (RBP+), Burundi
RESULTS, Canada
RNP+ Nucleo RJ, Brazil
Salud Integral para la Mujer, A.C. (SIPAM), Mexico
SAPES Trust, Zimbabwe
Seccion Sindical de la Confederacion General del Trabajo del Ministerio
de Fomento, Spain
Sida Info Service, France
SIDACTION--Ensemble Contre le SIDA, France
Social Welfare Association for Men (SWAM), India
Sociedad Wills Wilde, Venezuela
Society for Women and AIDS in Africa--Cameroun (SWAA), Cameroon
Solidarite Sida, France
Southern African AIDS Information Dissemination (SAfAIDS), Zimbabwe
Spanish National Community Advisory Board (CACSIDA), Spain
Spiritia Foundation (Indonesian Peer Support Network for PLHAs),
Indonesia
St. Joseph's Matale Youth Organization, Uganda
Synthesis, Greece
Tanzania Network Of Organization Of People Living With HIV/AIDS
(TANOPHA), Tanzania
Targeted AIDS Interventions, South Africa
Tertulia Feminist Magazine, Guatemala
Thandanani Childrens Foundation, South Africa
The Ark Foundation, Ghana
TREE, Training & Resources in Early Education, South Africa
Trocaire, Ireland
Tuyakula Group, Namibia
Uganda Coalition for Access to Essential Medicines, Uganda
UK Coalition of People Living with HIV and AIDS (UKC), UK
United Nations Association Of Uganda
University of Manitoba Medical Students' AIDS Outreach, Canada
University of Toronto International Health Program, Canada
Vanguardia Mexicana de Personas Afectadas por el VIH/SIDA (VANMPAVIH),
Mexico
Vida Positiva Quilpue, Chile
VIH/SIDA de la Iglesia Catolica de Honduras
Waverley Care Trust, Scotland
Wemos Foundation, The Netherlands
Western Cape Intersect Coalition, South Africa
Wits Pediatric HP! Working Group, South Africa
Women on Waves, The Netherlands
Women's Dignity Project, Tanzania
WTO Watch Qld, Australia
Xtending Hope Partnership, St. Francis Xavier University, Canada
Youth (OSDUY), Bangladesh
YWCA of Albania
US Local and Regional Organizations:
ACT UP Cleveland, OH
ACT UP East Bay, CA
ACT UP New York, NY
ACT UP Philadelphia, PA
ActionAIDS Philadelphia, PA
Africa Bridge, OR
African Services Committee, NY
AIDS Action Baltimore, MD
AIDS Foundation of Chicago, IL
AIDS Policy Project, PA
AIDS Survival Project, GA
Balm in Gilead, NY
Blood: Water Mission, TN
Brown University Center for AIDS Research, RI
Catholic Mission Office, Diocese of St. Cloud, MN
Citizens for Consumer Justice, PA
COLOURS Organization, PA
Concerned Medical and Health Care Professionals, MD
Drexel University (Public Health Interest Group) PHIG, PA
George Washington University Student Global AIDS Campaign, DC
God's Love We Deliver, NY
HIV Law Project, Inc, NY
Housing Works, NY
International AIDS Empowerment, TX
Liberty Research Group, NY
Loyola AIDS Awareness Coalition, MD
Lutheran Campus Ministry at the University of Arizona, AZ
Migration & Refugee Services, Diocese of Trenton, NJ
NCATA (NW Coalition for AIDS Treatment in Africa), WA
New Mexico POZ Coalition, NM
New York AIDS Coalition, NY
Office of Religion, Catholic Diocese of Scranton, PA
PA Civil Rights Initiative, PA
Pacientes de SIDA pro Politica Sana, PR
Pediatric HIV/AIDS program at The Children's Hospital of Philadelphia,
PA
Pennsylvania Lesbian and Gay Task Force (PLGTF), PA
Philadelphia College of Medicine Public Health Club, PA
Philadelphia International Action Center, PA
Philadelphia NORML, PA
Planet Poz, NM
Positive Health Clinic, PA
Prevention Point Philadelphia, PA
Princeton Student Global AIDS Campaign, NJ
Priority Africa Network (PAN), CA
Queers For Racial & Economic Justice, NY
Rescue Childhood, PA
RESULTS Seattle, WA
Rochester Area Task Force on AIDS, NY
Rochester Global AIDS Project, NY
Sisters Mobilized for AIDS Research and Treatment (SMART University),
NY
Sisters of St. Joseph of Carondelet, St. Louis Province, MO
Starfish Project, New York Presbyterian Hospital, NY
Survive AIDS, CA
The Washington State Africa Network, WA
Universities Allied for Essential Medicines, University of Minnesota,
MN
Village Care of New York AIDS Day Treatment Program, NY
Vukani Mawethu Choir, CA
Washington Biotechnology Action Council, WA
Women's Environment and Development Organization (WEDO), NY
Yale AIDS Network, CT
Youth-Health Empowerment Project (Y-HEP), PA
______
Position Statement of Catholic Relief Services
impact of nutrition on hiv/aids affected communities
Many communities in sub-Saharan Africa are experiencing a food
crisis. This crisis has been accelerated by the HIV/AIDS epidemic.
AIDS-affected households have dramatically decreased their capacity to
maintain farms, thus they are increasingly dependent on food aid for
survival. In the past, these communities have demonstrated resilience
in the face of drought and poverty. The deaths of the adult members of
these communities have created a permanent loss of valuable human
resource that will be difficult to nearly impossible to replace.
While we recognize the enormous benefit of the President's
Emergency AIDS Fund, we are concerned that malnutrition will hamper our
efforts to reduce the morbidity and mortality associated with HIV.
Malnutrition and the concomitant infections are common health problems
experienced by people who live in countries hardest hit by the HIV/AIDS
epidemic. These conditions significantly compromise the immune system
of those who are also infected with HIV, and as such, they are
medically fragile. Nutritional deficiencies hamper immune function and,
as such, the viral replication is accelerated. This process increases
the rate of progression to AIDS and to death.
People with HIV/AIDS have greater macronutrient and micronutrient
requirements. These nutrients are required to restore the immune
system, to improve response to (absorption of) anti-retroviral therapy,
and to restore the muscle mass of those who experience body wasting due
to HIV infection. It is estimated that the energy can increase by 10-
15% and protein requirements by 50% in persons living with HIV/AIDS.
Individuals living in communities where malnutrition is endemic are
likely to experience vitamin and mineral deficiency. While these
deficiencies may not be clinically apparent at an early stage, their
presence will have a direct adverse effect on one's ability to fight
infections. Such deficiencies compound the level of immune dysfunction
experienced by those infected with HIV. It is evident that
micronutrients deficits will speed the progression of HIV infection to
AIDS, and are predictive of AIDS mortality.
Weight loss and wasting in HIV infection is due to the interaction
of several processes:
Decreased food intake (due to anorexia, fatigue and oral
diseases such as esophagitis).
Poor absorption of nutrients (due to diarrhoea, intestinal
infections and intestinal abnormalities which result in
malabsorption of fat and vitamins).
Metabolic alterations (there is increased energy and protein
requirements caused by altered production of production of
hormones such as glucagons, insulin, and cortisol).
Most patients in resource-poor countries continue to present for
care during the late stages of the HIV disease, where there is already
severe wasting. Severe wasting requires a more complicated and
expensive approach to restore patients to their nutritional state, and
it may be difficult to reverse the vicious cycle of malnutrition and
HIV disease that exists stage. These patients may benefit from high
protein, high-energy diets, containing special supplements rich in
vitamins and minerals. It is therefore our opinion that a more
practical strategy, involving community food aid and early HIV
intervention be implemented as a more cost-effective approach. Still,
these efforts will need to be maintained and coordinated with a larger
strategy to treat HIV/AIDS in Africa and the Caribbean.
As antiretroviral therapy becomes increasingly available in Africa
and the Caribbean, we must consider that inadequate diet can decrease
the effectiveness of anti-retroviral therapy. Intestinal dysfunction in
the malnourished, HIV-positive patient leads to reduced absorption of
medications and hence limited effectiveness of the prescribed drug
regimen. Many antiretroviral medications have GI side effects such as
nausea and vomiting, that directly impact the amount of drug that is
absorbed. Some medications require special dietary preparations to
maximize their effectiveness, such as a full stomach. Antiretroviral
therapy requires adherence to rigid dosing schedules to decrease the
chances of developing drug resistance. These requirements will be
impossible to realize in communities struggling to secure enough food
for survival. Therefore, a successful antiretroviral program must
consider nutritional intervention as a core component of the essential
HIV/AIDS care package.
Clearly, our efforts to provide emergency assistance with ART will
not succeed without additional financial support for food distribution.
Those communities that have struggled with high rates of malnutrition
now have the added burden of an HIV/AIDS epidemic. We therefore believe
that funding should be expanded to address the special nutritional
needs of those in the early stages of the disease and those with full-
blown AIDS. Evidence proves that this will result in an enhanced
ability to fight infection and an improved response to drug therapy.
references
1. HIV/AIDS and Nutrition, SARA project, November 2000 http://
sara.aed.org/publications/cross_cutting/hiv_nutrition/
HIV%20and%20Nutrition.pdf
2. Nutrition and HIV/AIDS: Nutrition Policy Paper #20 UNACC/SCN
(2001) http://www.unsystem.org/scn/Publications/NPP/npp2O.PDF
3. Melchior JC, Niyongabo T, Henzel D, Durack-Bowen I, Henri SC,
Bouli A. Malnutrition and wasting, immunodepression, and chronic
inflammation as independent predictors of survival in HIV-infected
patients. Nutrition. 1999 15(11-12):865-9.
4. Tang AM, Graham NM, Kirby AJ, McCall LD, Willett WC and Saah AJ.
Dietary micronutrient intake and risk of progression to acquired
immunodeficiency syndrome (AIDS) in human immunodeficiency virus type I
(HIV-1)--infected homosexual men. Am J. Epi 1993 138(11):937-951.
5. Tang AM, Graham NM, and Saah AJ. Effects of micronutrient intake
on survival in human immunodeficiency virus type I infection. Am J Epi
1996 143(12):1244-56.
Food Aid and HIV/AIDS Programming: Lessons from CRS Field Experience
nutritional and food security issues where aids is prevalent
Nutritional Issues
Food insecurity increases vulnerability to HIV/AIDS--
physiologically and behaviorally (zinc, vitamin A deficiencies
increase risk of STDs; iron deficiency reduces resistance to
disease; harmful coping strategies to address food insecurity
result in increased exposure to HIV).
HIV/AIDS increases food insecurity and poor nutrition
(illness, demands of care-giving reduce production and cash;
health care costs cause HH to eat fewer meals of lower quality
foods).
People with HIV/AIDS have greater macronutrient and
micronutrient requirements (more Kcal, protein,
micronutrients).
Poor nutrition speeds progression of HIV/AIDS.
Inadequate diet can decrease effectiveness of anti-
retroviral (ARV) treatment--affects absorption, metabolism,
distribution or excretion of the drugs.
ARV therapy can increase nutrient tosses and affect food
consumption.
Other Food Security Issues
AIDS attacks the most productive segment of the population.
One result: reduced labor for farm work--in Ethiopia one study
found that households spend between 1/2 and 2/3 less time on
agriculture than households not directly affected by HIV/AIDS.
Programs must work with communities to develop alternative
production that is less labor-intensive, produces more
nutritious and more high-value crops, located closer to family
homes and carried out on a scale that can be managed by
children.
As productive adults become ill and die, there are fewer
teachers for schools, few staff to provide government services,
so new approaches are needed to fill the gaps. Support for
community-based foster care and for alternatives to government
service provision are essential. Building capacity of local
community organizations becomes critical.
Orphaned children have no parents to teach them how to
become productive adults. Programs must help communities
develop new family structures, and new ways to transfer
livelihood knowledge to the next generation. Comprehensive
programs must provide children and youth with life skills as
well as marketable skills. Affected families have often lost
all assets to medical and funeral bills. Approaches to
rebuilding food security need to address the broader livelihood
security concerns as well, developing assets that will protect
and support children both now and in the future.
how current hiv/aids programming mechanisms address these issues
One major issue with HIV/AIDS funding is that much of it is
currently stove-piped. ARV funding is for drugs. OVC funding is for
orphans and vulnerable children. Palliative care funding will be for
home-based and community-based care. . . . There is no clearly
identified mechanism for promoting the integration of funding and other
resource streams that the complex responses on the ground require.
Addressing HIV/AIDS at the community level requires coordination and
program design that will ensure the multiple needs of affected
communities are met. Otherwise, funds spent for ARV therapy without
incorporation of appropriate food and nutrition is not only wasted, but
also detrimental due to increased drug resistance. Provision of drugs
and food to affected adults doesn't meet the current and future needs
of their children.
how food aid programs can address these issues
Increased availability of and access to micronutrient-fortified
food is needed to
decrease transmission of HIV,
reduce progression of the disease in those living with HIV
reduce mother to child transmission and improve health of
children born to HIV+ mothers
increase effectiveness of ARV therapy
HIV/AIDS & Food Programming
May 2004
CRS is invoWed in state-of-the-art and innovative programs targeted
at reducing food insecurity among those affected and infected by HIV/
AIDS in various regions in Africa, Latin America and Asia. Below are
examples of current CRS food security and HIV/AIDS programs.
Project LISTEN (Livelihood Strategies Eliminating Needs)
Countries: Malawi and Zambia (FY 2004)
Program Area: HIV/AIDS, Food Security, Integral Human Development
Total Cost: $556,890
Total Beneficiaries: 21,500
Description:
Project LISTEN complements existing food aid programs in Malawi and
Zambia by stimulating agriculture production as a short-term
intervention while also building the capacity in 30 communities to
mitigate risk in the long-term. The community resilience approach of
Project LISTEN helps households adapt positive coping strategies to
shocks by analyzing existing assets and resources that households can
access to improve their livelihoods. Project LISTEN complements
existing developmental relief and recovery programs, namely C-SAFE and
JEFAP II, which are necessary in helping communities recover and
rebuild assets lost due to shocks.
Title II PL 480 Development Assistant Program
Country: Ghana (FY 2004-2008)
Program Area: Nutrition, Safety Net, HIV/AIDS, TB DOTS
Total Cost: $19,523,227
Total Beneficiaries: 427,601
Description:
The safety net portion of the program targets 15,000 vulnerable
persons throughout Ghana each year. Primary beneficiaries include
individuals infected with or affected by HIV/AIDS, TB patients, and
orphans. Working through the Christian Health Association of Ghana, the
Ghana National Association of People Living with HIV/AIDS, and MOH TB/
AIDS wards, CRS/Ghana provides wet rations to institutionalized HIV/
AIDS and TB patients, home-based People Living with AIDS, and those
under the Directly Observed Therapy program. Take home rations are
designed to supplement daily intakes and will provide 20 percent of the
caloric requirements of an average Northern Ghanaian family. For TB
patients, food assistance will provide needed nutritional support
during the time of recovery, and provide an incentive to patients to
comply with the DOTS regimen.
St. Joseph's Catholic Youth Group HIV/AIDS ``Siyakekela'' Youth Support
Project
Country: South Africa (FY 2002-2004)
Program Area: Life skills, Food and other support, Youth affected by
HIV/AIDS
Total Cost: $9,796
Total Beneficiaries: 2,500
Description:
The Community Outreach Center at St. Mary's Hospital runs an HIV/
AIDS Community support program that offers counseling services and
support. In the past, services at this center were designed for adults.
This program is geared toward children affected by HIV/AIDS between the
ages of seven and eighteen. A youth group has been formed and trainings
have been given on taking care of themselves and those ill at home. In
addition to these awareness campaigns and trainings, psychological and
material support (i.e. nutritional support) are included as part of the
comprehensive package. Life skills are also promoted through business
and computer skill building as a component of the youth group.
Coalition for Food Aid,
1201 F Street, N.W., Suite 1100,
Washington, DC, April 27, 2004.
The Honorable Richard G. Lugar, Chairman
Senate Committee on Foreign Relations,
United States Senate,
Washington, DC 20010.
Dear Chairman Lugar:
The Coalition for Food Aid welcomes the opportunity to submit this
letter and attached information for the record for the May 11, 2004
hearing on HIV/AIDS and hunger. The Coalition is comprised of sixteen
US private voluntary organizations and cooperatives (jointly referred
to as ``PVOs'') that conduct food aid programs overseas to improve the
health, living conditions and incomes of millions of people who live in
poverty and suffer from hunger. All of the members do much more than
deliver food--they implement developmental and relief programs in
cooperation with local communities, governments and organizations.
Food aid is the expression of American goodwill through ``people-
to-people'' programs. American farmers produce the food, American
businesses process, package and transport the food, and American PVOs
make sure it is used effectively to help people in need. US food aid
programs have great reach and impact among the poor and
disenfranchised, helping people overcome despair and improving people's
lives. The PL 480 Title II program, which focuses on food security
needs of vulnerable populations, is the largest US food aid program and
PVOs are the primary partners for the implementation of Title II
developmental programs.
Nutrition and food security are critical and integral issues to
address in the HIV/AIDS pandemic. Since US Government HIV/AIDS funds
focus on particular treatment, care and prevention goals, PVOs find
that it is necessary to identify other sources of funds to address
nutritional and food security needs. They raise private funds and in
some cases are able to use PL 480 Title II resources for these
purposes, as explained in the attachments. However, much more could be
done to expand the amount of funding available under Title II for HIV/
AIDS and to make it easier to integrate food and cash resources.
If Title II was administered as intended by law, the United States
could provide additional assistance to help people who suffer from
chronic hunger, which is greatly needed in communities with high
prevalence of HIV/AIDS. Many communities that had promise 10 years ago
are falling behind today because of the HIV/AIDS pandemic. Income-
earners in the community who are infected become weak and many die,
family incomes plummet, agricultural fields lie fallow, children often
quit school to work or care for siblings, and extended families that
serve as caregivers fall into poverty. Poor diets hurt many in the
community, and children and people living with HIV/AIDS are
particularly vulnerable. PVOs are ready to expand Title II nutritional
and food security programming for HIV/AIDS-affected communities. This
disease threatens people's lives as much as any emergency.
Attached are illustrative examples of how PVO food aid programs are
used to address special needs dues to the prevalence of HIV/AIDS.
Of the funds appropriated for Title II, more must be used to expand
non-emergency programs from 1,000,000 metric tons to the 1,875,000
metric ton statutory level in order to address chronic hunger. PL 480
Title II requires 1,875,000 metric tons of food aid to be provided for
non-emergency programs each fiscal year in order to reduce chronic
hunger. Despite this mandate, in FY 2004, we expect only 1,000,000
metric tons of Title II will be used for non-emergency programs--about
half of the minimum requirement. Yet, chronic needs are growing due to
the prevalence HIV/AIDS and other chronic diseases and setbacks caused
by natural disasters, civil strife and economic downturns. Currently,
the Office of Management and Budget (OMB) is seeking both to limit the
amount of tonnage used for these programs and to cutback program
duration from five-years to three-years, even though studies have shown
that five-year programs are more effective.
Addressing nutritional and food security problems associated with
HIV/AIDS and helping communities that are prone to emergencies are two
tangible examples of the types of non-emergency programs that need to
be expanded. These programs would be in addition to current Title II
non-emergency programs that have proven results in poor communities,
such as increasing agricultural productivity and diversifying
production, decreasing chronic under-nutrition among children, and
improving the nutritional status of women.
It is important to have adequate funds for emergencies, but Title
II was not intended to be an emergency reserve. Instead, the Bill
Emerson Humanitarian Trust Act provides contingency funds and
commodities for emergencies. The BEHT can be tapped before USAID cuts
into the 1,875,000 metric tons of Title II commodities available for
non-emergency programs.
In this time of international stress, US assistance programs
conducted by PVOs directly show America's care and compassion to people
in developing countries. PVOs are supported by Americans through
private contributions, which cover general operations and enable them
to have a strong presence in many developing countries. However,
private donations cannot supply the level of funding needed for
procuring, transporting, implementing, monitoring and administering
food aid programs. Thus, US Government funding for food aid is
critical. PVOs provide expertise in program development and
implementation; transparency and accountability for the use of US
Government resources; strengthen the management capabilities of local
institutions so efforts can be sustained; provide a network of local
contacts and relationships; and encourage entrepreneurship and private
sector development.
Mr. Chairman, we appreciate the opportunity to submit these
comments and the attached information on HIV/AIDS programs and hunger.
Thank you very much for helping to assure that the US response to HIV/
AIDS is comprehensive and field-driven, seeking solutions within
affected communities and supporting the implementation of successful
strategies for long-term impact. We would be pleased to answer any
questions you may have.
Sincerely,
Ellen S. Levinson, Executive Director.
[Attachment.]
EXAMPLES OF TITLE II PVO FOOD AID PROGRAMS THAT ADDRESS NUTRITIONAL AND
FOOD SECURITY PROBLEMS ASSOCIATED WITH HIV/AIDS
The first column shows how food rations can be used. Because food
aid must be integrated with other activities to have a long-term
impact, the second column describes the types of complementary
activities that would be funded through monetization or from other
sources.
------------------------------------------------------------------------
Activities Funded by Monetization
Food is Provided as: or Other Sources:
------------------------------------------------------------------------
An incentive for people to HIV/AIDS prevention
receive HIV/AIDS testing and education programs conducted by
counseling. community-based organizations and
health facilities.
Part of home-based care Training village health
for people living with HIV/AIDS workers and caregivers in home-
and their families. based care and support, including
preventing mother-to-child
transmission of HIV/AIDS.
Part of community-based Care and support of
nutrition programs, i.e. to meet orphans and vulnerable children,
the nutritional needs of people i.e. providing school fees and
living with HIV/AIDS, people child care for younger siblings so
receiving anti-retroviral school-aged children can attend
treatment, and orphans and class and providing access to
vulnerable children. psychosocial counseling, health
care and social services.
An incentive to Training and support for
participate in agricultural and the implementation of community-
work programs that increase family based nutrition, education,
incomes and assets and improve agricultural and work programs.
community infrastructure.
...................................
An incentive for Coordination with HIV/AIDS
participation in treatment service providers to increase
programs for TB patients. access to critical services, such
as voluntary testing and
counseling, medical care and
social services.
------------------------------------------------------------------------