▶ 0:00:04I want to be a guy.
▶ 0:11:07I'm dropping things here. Good morning the Subcommittee on National Security, Department of State, and Related Programs will come to order. I want to particularly thank um the ranking member, I know who had a big ordeal to try to get here this morning and she got here despite despite some difficulties in transportation. Uh let me start by like to all of you welcoming all of you uh to our hearing today to assess the President's Emergency Plan for AIDS Relief.
▶ 0:11:36Something that we all commonly refer to as PEPFAR. Uh, so let me first introduce our distinguished witnesses. Ambassador Mark Dybul is Professor in the Department of Medicine at Georgetown University Medical Center where he serves as Chief Strategy Officer of the Center for Global Health Practice and Impact. He is also chair of the board of Purpose Africa. Thank you for being here.
▶ 0:12:02Ambassador Dybul played a a key role, a lead role in the founding of PEPFAR, of the program during the Bush administration and served as the executive director of the Global Fund to Fight AIDS, Tuberculosis, and Malaria. Ms.
▶ 0:12:19Katherine Connor is the Vice President of Public Policy and Advocacy at the Elizabeth Glaser uh, Pediatric AIDS Foundation and has been with the organization for over 17 thrilled and honored to have both of you here. You both have a wealth of experience on this topic and we are grateful for your testimony this Again, thank you both for being here. I have long been a supporter of PEPFAR.
▶ 0:12:48since it was launched in 2003, the program has saved over 26 million lives and prevented 7.8 million babies from being born with HIV. Those numbers are frankly remarkable. It's an incredible feat. Over 20 million people are now on life-saving treatment and over 70 million people received testing services in more than 50 countries.
▶ 0:13:14The PEPFAR program through the generosity, the extreme generosity of the American people, really saved a generation of of of Much of the success, both in terms of impact, and a decade of trust and continued support from Congress, is due to the unmatched level of and transparency that President Bush and you, Ambassador, um, demanded from the very start and obtained from
▶ 0:13:44the very start. Excuse me. This is especially important, uh, for us, for appropriators. The data-driven approach that PEPFAR uses to justify budget allocations and the detailed, the detailed reports that this committee receives clearly, uh, outline results achieved through the annual funding.
▶ 0:14:07Now, unfortunately, under the previous administration, the Biden administration, the PEPFAR program was not immune from misguided campaign to push controversial ideologies using taxpayer dollars. You've all heard me say this before. I warned in every hearing, in every markup, and, frankly, in every engagement that using funds to promote radical or partisan will cost support for the program.
▶ 0:14:35Um, and for all programs that I and many other Republicans have historically But, even more egregious, under the Biden administration's watch, the PEPFAR program violated the Helms amendment and used taxpayer funds to pay for abortions. The very first time, for the very first time, as far as we know. Now, this is interesting. My staff was briefed on the violation literally hours before the Biden administration was out of the door.
▶ 0:15:05Even though, and this is key, even the facts had been uncovered months, months prior. I was obviously outraged, to say the least, to learn of this shocking betrayal. Funds provided by Congress to save lives were instead used to end lives.
▶ 0:15:26Now, this was despite my efforts as chairman to push for more training and oversight with respect to enforcement of long-standing provisions in law to protect life. The incoming Trump administration announced a review of all all foreign assistance programs on day one. And let me very I want to be crystal Given the circumstances and the gross mismanagement of the previous a review is necessary.
▶ 0:15:55So, I fully support this administration's doing a thorough scrub of PEPFAR programs as well as every other programs uh program. Frankly, it was sorely needed to ensure ensure that bipartisan support can actually Now, we understand the challenges that that entails and we understand that challenges remain in terms of ensuring programs that receive life-saving waivers get continued support and that uh old payments
▶ 0:16:26are provided in a timely So, here's a question. Where do we go from here? I trust that the administration is going to continue to work through these challenges in coordination with And I'm looking forward to continuing a full some uh discussion to understand implementation and the results of this thorough review.
▶ 0:16:52I want again, as I said before, I want to thank all of you uh here. Uh um I think all all of us here today would I think all of us here would agree that PEPFAR was never meant to go forever, right? I is this something that is there for forever in perpetuity? We're never going to have an ending to it.
▶ 0:17:13You know, these are things that that need to be talked about and we need to make decisions and financially we cannot continue spending at current rates uh for years to come. We all know that. Countries need to step up uh their own financial commitments and maintain a laser focus on achieving epidemic control.
▶ 0:17:34However, as we demand additional burden sharing and look to wind down, we also cannot afford to lose progress gained and create a bigger more expansive problem for the future. I believe that a failure to maintain HIV patients on anti uh retroviral means that means the likelihood of increased drug resistance and potentially threatens uh achieving control epidemic control.
▶ 0:18:03With new innovations coming online, notably American-made innovations, I believe that there are new opportunities to accelerate progress. As this committee begins the important work of crafting the fiscal year 2026 appropriation bill, this hearing will play an important role in shaping the recommendations ahead for us, for those of us putting these bills So, I look forward uh to hearing from our witnesses about the success, the successes, the challenges, and opportunities as
▶ 0:18:33we think about the future of the PEPFAR program. It is my assessment that PEPFAR has and if implemented correctly, will continue to make America safer, stronger, and more prosperous. Again, I want to thank the witnesses for being here today.
▶ 0:18:51I will now turn to my Florida uh friend and colleague, my dear friend and colleague, the ranking member of the ranking member Franklin, you're Thanks so much and thank you to both our witnesses for being here. I'm I'm sorry you've been shot you were shocked. Just let me take All right. that. I know that. He knows. Yes, I do.
▶ 0:19:14Listen, this is going to This may be one meeting we're going to Almost. Almost. For us, that's pretty good. But listen now, I just again thank you for joining us today just to discuss the future of PEPFAR, one of the most effective and most bipartis bipartisan global health achievements in American history.
▶ 0:19:39And uh I'll repeat a little bit because we all get uh I guess we all have to hear ourselves talking. What can I say? since it's launched under President George Bush, I'm going to give him credit. In 2003, PEPFAR has saved more than 26 million supported HIV testing for over 71 million people, prevented 5.5 million babies from being born with HIV HIV, and provided care to 7 million orphans and vulnerable children.
▶ 0:20:08It's trained over 330,000 healthcare workers and build a health systems that serve more than 50 countries across Asia, developing countries I'm sorry, I'm saying across Africa, developing countries in Asia, Latin America, and the Caribbean. And I want to say something. I don't know if you remember this. We served in the state legislature together. But my first assignment, maybe you weren't there yet.
▶ 0:20:31My first assignment I was made the chair of an HIV/AIDS task And that was in the late '80s, early '90s, and I I just remember cuz I I spent so much time it it was a and it still is obviously a horrible where people wasted away, got most got infections, lung infections, and it was a death sentence. Without any question, it was a death sentence.
▶ 0:21:02Uh until, you know, many years later finally we do have a way with a cure, or not a cure, but to put it in remission, and people can actually live normal lives. but you know, it's not just about the numbers. This is about communities that went from despair to survival, from and then opportunity.
▶ 0:21:21It's a kind of soft Soft power that makes the world safer and makes America stronger and more Uh before PEPFAR, HIV AIDS was wiping out entire generations across African countries and developing countries. And it decimated economies. It shattered families, created instability that threatened global security. But PEPFAR turned the tide.
▶ 0:21:47It showed the world what Americans do when we lead with compassion, science, and smart to my chair, I agree with you on this. Every administration has a right and a duty to evaluate government But what we've seen from the Trump administration, and this makes me very sad, especially with this program, is a reckless, dangerous sledgehammer that puts lives at risk and throws
▶ 0:22:17global partnerships into chaos. That's That's our diversion Uh and from what we have heard, and many PEPFAR programs have halted. Mainstream waivers may be well-intended, but they're not working. We've heard that. Staff has been left unpaid. We heard that. Medicines are not reaching those who need it. And health systems that rely on consistent support and that's scrambling and confusion.
▶ 0:22:43And I I'm going to just briefly touch on the this criticism that I we're hearing in 2024 and an audit and I'm glad there was an audit. It was an audit. It found that nurses in Mozambique had sub- sub-contracted sub- contracted through local partners had performed 21 abortions over 3 years. That's what the audit showed. And even though abortion is legal in Mozambique, the US law we know prohibits the use of foreign aid for abortion services.
▶ 0:23:14The What What was found was that the issue occurred because the nurses had not been trained on the restrictions under the Helms Amendment. But once it was identified, CDC immediately halted the funding and conducted a full review. It was $4,000. They collected $4,000 in salaries from the Mozambique government. It was an isolated incident and promptly addressed through improved training and accountability.
▶ 0:23:39And I just I have to emphasize, this represents a tiny tiny fraction of these PEPFAR 6.5 billion annual budget budget. I listen, nobody is perfect. Nobody, all right? I think they admitted the mistake, they repaid, let's move forward. Uh but PEPFAR is not just a public health story. It builds resilient societies, keeps children in schools, it strengthens local economies. It reduces the risk of extremist recruitment because people are in a stable situation.
▶ 0:24:10It builds trust in America. Boy, do we need that. And I'll say it again, it makes our country stronger, safer, and more prosperous. Uh and what we do through PEPFAR has a direct a direct impact on the health and safety of American people. The stronger the health systems are in other countries, the better we are all prepared to detect, detain, and respond to outbreaks. Uh We're at We're at this together.
▶ 0:24:37So now we're at a crossroads, and I hope this way I think we are going to work very very hard to find consensus. Uh because if we allow PEPFAR to be splintered, this cost will not just be measured in dollars, it'll be measured in lives lost, health systems weakened, trading partners diminish, diminish societies destabilized, and trust in the United States eroded in the world.
▶ 0:25:02So, today I'm going to join I'm going to join you today as we move forward with bipartisan cooperation, which what got this program started in the first to to ensure that this life-saving, globally respected program not only survives but continues to thrive, and as we move forward, we look for ways to strengthen PEPFAR's operations, make it more efficient, more so we can
▶ 0:25:32hopefully we're going to find a way to just stop this AIDS Well, it's not a pandemic anymore, but AIDS disease, but also leave in place some sustainable health systems. Uh so, let's work on this together. That's where we agree, and I yield back. Thank you to the distinguished ranking member. Now, I will yield to the ranking member of the full Appropriations Committee, Ms. Lowey, for her opening remarks. Thank you so much, Mr.
▶ 0:26:02Chairman, and want to thank both you and ranking member Frankel for your leadership on this subcommittee, and I'm really so very grateful to have the opportunity to raise awareness for the President's Emergency Plan for AIDS Relief, PEPFAR. I thank the chairman for calling this hearing, and and for your support of this program. Want to say a thank you to our witnesses here this morning.
▶ 0:26:30Thank you for your you know, your testimony, and but more importantly, I want to say thank you for your expertise, for your for your commitment to looking at trying to end the scourge of HIV, of moving over the years to address the issue that has rented so many people asunder and we can't
▶ 0:27:00put a high enough premium on the issue of saving lives. So, thank you so much. Um uh you've built up this program, Dr. Diebel, Ms. Connor, and you know, I'm just we're so grateful to you. Over two decades, it's been said, but it bears PEPFAR has saved 26 million lives around the world. Think about it. 26 million is roughly the population of the chairman's home state of Florida.
▶ 0:27:28The 26 million people saved by PEPFAR are mothers, fathers, sons, daughters, teachers, nurses, farmers. Instead of facing death and despair, they are raising families, they're building their communities, and helping their home countries grow and to be able to HIV AIDS is not the death sentence it was just decades ago, and HIV prevention efforts are effective.
▶ 0:27:55Do not take it from me, but State Department's website says, and I quote, "PEPFAR's life-saving work is enabled through the US government's unwavering unwavering commitment to the program and the American people's compassion and As PEPFAR ensures every US taxpayer dollar is optimally focused for impact, end quote.
▶ 0:28:20It was PEPFAR's platform that was utilized to help countries respond to COVID, and which is being used today to fight tuberculosis and more. Through Democratic and Republican administrations and Democratic and Republican Congresses, PEPFAR has held widespread bipartisan support. But, PEPFAR is in dire straits.
▶ 0:28:41In working to abolish foreign assistance, Elon Musk and President Trump froze funding for PEPFAR, halting testing and treatment for HIV AIDS patients around the world. And after funding abruptly stopped, the State Department determined that portions of the PEPFAR program met the criteria for quote life-saving and could be But PEPFAR is not fully functioning. Funding is not flowing.
▶ 0:29:09Medicine is not being distributed to those who need it. Among many short-sided and ill-informed actions, this funding freeze was made under the guise of eliminating waste, fraud, and abuse. I'm all for finding and eliminating waste, fraud, and abuse, something Inspector General Richardson and Martin at State and USAID, respectively, were tasked with doing before they were illegally purged in the dead of night.
▶ 0:29:38But millions of lives are not a waste. In fact, Musk and President Trump have created even more waste and made government less efficient. While portions of the PEPFAR program were allowed to continue, the key implementing partner agencies, USAID and CDC, are being destroyed, obstructing the path for resources to reach recipients. Public health abroad affects public health at home.
▶ 0:30:08Economic stagnation abroad affects our economy here in the United States, and when people are needlessly getting sick and dying overseas, it means weaker partners that diplomatically, militarily, and economically for For 20 years, we have invested in this program that saves lives, but that also strengthens our diplomatic But overnight, this administration has allowed decades of work to backslide and undermined our nation's
▶ 0:30:38greatest public health diplomacy effort. This does not put America first when we retreat from the world diplomatically and through our assistance to vulnerable people. America will be alone. We will be without allies in a less stable world without the support of the international community. And you know who will come out ahead?
▶ 0:31:02China, This chaos does not make America stronger, safer, or more prosperous. This administration is putting billionaire profits and our adversaries Americans and sick and vulnerable people around the world will be much worse off for it. This subcommittee, the full Appropriations Committee, and the Congress must commit to reasserting its power of the purse.
▶ 0:31:29Article 1 of the Constitution plainly states that government spending must and can be only a consequence of appropriations in law. We are not writing directives here. We are writing I'm hopeful that we will come together and fully fund PEPFAR and its implementing partners.
▶ 0:31:51We cannot let the fate of PEPFAR or any other critical program funded through acts of Congress rest on the whims of Elon Musk and Ross Vote. They must follow the law. Thank you and I yield back. Thank you very much. Uh Ambassador, your full written statement will be placed in the record. Please feel free to summarize your Thank you for being here. Now you're Uh Mr.
▶ 0:32:19Chairman, Ranking Member Frankel, uh Ranking Member DeLauro, and distinguished members of the of the subcommittee, uh first of all, please accept uh my deep thanks for your bipartisan support of PEPFAR and the Global Fund to fight AIDS, TB, and malaria despite decreases in your envelope over time. Um your investments on behalf of the American people have made the country safer, stronger, and more prosperous. The details uh of the results have been provided and are in the written statement, so I'll forego them.
▶ 0:32:49Uh, but I think it is worth noting that PEPFAR has been called, and I think rightly so, the the most successful global health program in history, and the best president the best policy decision of any president in over in three however, as the chair mentioned, PEPFAR and the Global Fund cannot and should not be forever. And I'd like to focus on that for the time I have remaining.
▶ 0:33:18The capacity that's been built provides a foundation for fully country-led and owned programs, and also provides a foundation for detecting and responding to outbreaks before they become It's also worth noting that domestic sources for HIV, domestic sources, not external, accounted for 59% of all related HIV-related spending in 2023, but much more remains to be done.
▶ 0:33:45There has been substantial work to prepare for transitions, which is what we should be working towards, transitions from external funding to local funding and implementation. But now is the time to execute in a comprehensive plan with clear, annual, transparent benchmarks, including starting this year, reductions and redirections on funding. Countries are in different stages on their journey to self-reliance.
▶ 0:34:11In my view, there are a number of countries who could rapidly have full transitions, rapidly. There are three to four dozen additional countries, many with very large PEPFAR and Global Fund allocations, who could successfully transition within a few years, including annual resources reductions during that time. Others will take longer, some much longer, but they can and should be getting out.
▶ 0:34:37PEPFAR and the Global Fund must function as a team because we have resources in both and they both function in most countries. They working with heads of state, ministries of finance, health, economic planning, as well as sub national entities such as governors and counties where appropriate to develop formal transition compacts with clear It is essential that the faith and community-based organizations fully engage.
▶ 0:35:04They are likely to bear the brunt of rapid reductions because many governments do not have mechanisms to fund faith and community-based organizations, but those mechanisms can be built over time. The strong data systems that have been developed and have been mentioned we have to remain active to help countries maximize impact. They are used to identify how to have greatest impact.
▶ 0:35:29And for visibility into externally financed programs to ensure that vital services don't fall through the cracks. And again, those are most likely to be faith and community-based organizations. Those systems are also indispensable for your ongoing oversight and the administration's ongoing oversight of the program. The private sector must be at the table from the outset. Too often we pay lip service to private sector engagement.
▶ 0:35:53There are opportunities for American investors and companies to reap rewards now and for Asian, African, and Latin American investors and companies to grow their economies, to create markets for our goods and services. And in fact, PEPFAR has proven that it increases the gross domestic product of countries in which it operates.
▶ 0:36:14There are also, as the chair mentioned, new technologies, American derived technologies, and American companies that have that are producing products that could help us end the AIDS epidemic that would be important to to provide not only in this country but globally.
▶ 0:36:30I can assure you there are partners from every sector, some of whom are already moving to work to develop and execute successful transitions in the countries in which we While it's important that every country transition from external funding for HIV and health services, it's equally important that they transition to become stronger economic, diplomatic, and national security partners of the United States for the long term.
▶ 0:36:55When I was the US Global AIDS Coordinator, I was fortunate to visit Axum, Ethiopia, believed to be the birthplace of Christianity in Africa. At dawn, when the mist is over the town, it looked as it might have centuries ago with local with local people and donkey and donkey-drawn wagons, spires of churches peaking through the haze, bells ringing to call all to prayers and to I visited the town clinic. The director of that clinic also was the elder and leader in the community.
▶ 0:37:26I was cranky that morning, and he kept referring to PEPFAR. I asked him what PEPFAR meant. His answer knocked me over. PEPFAR means the American people care about us. PEPFAR means the American people care about us. As this committee knows too well, the United States is locked in a global struggle to still be seen as a beacon on the hill. While we must lead, we must have allies including in Africa where democracy is threatened. We have lost ground as the number one trading partner, and the opportunity for the future is so vast.
▶ 0:37:55Clearly, PEPFAR and the Global Fund alone are not sufficient. But after nearly a quarter century of supporting Africans at all levels, the wisdom of the words from Axum ringed ring clearer than ever. People around the world know what we stand for when we stand with them. The choice is clear. Do we have a well-planned, structured, successful transition that helps make America safer, stronger, and more prosperous?
▶ 0:38:22Or do we do we retreat too quickly and chaotically, squandering some of America's greatest achievements, risking the lives of millions in the near term, a resurgence of drug-resistant virus, and losing control of the pandemic over time, and seeding the field to competitors and adversaries? The choices are ours to make. Thank you for your time, and I look forward to your questions. Thank you, Ambassador. Ms. Connor, you're also your full written statement will be in the record, and obviously feel free to summarize your testimony.
▶ 0:38:53You have the floor. Thank you, Chairman. Good morning, Chairman Bayh Bayart, Ranking Member Frankel, Ranking Member DeLauro, and members of the subcommittee. Thank you for the opportunity to speak with you today in support of PEPFAR and the local and global partners that make this life-saving program possible. My name is Katherine Connor. I'm the Vice President of Public Policy and Advocacy at the Elizabeth Glaser Pediatric AIDS Foundation or EGPAF. At EGPAF, we're in the front line of the fight to end AIDS and HIV.
▶ 0:39:23Our organization focuses on research, advocacy, and helping governments and communities respond to this ongoing health crisis. I'm deeply honored to be part of this mission-driven work, and I'm incredibly proud of PEPFAR's transformative role in driving us closer to an AIDS-free Today, I'm asking you not only to protect funding needed to control the AIDS epidemic, but urging you to be an active champion for PEPFAR's future.
▶ 0:39:47The success of this program and the lives it continues to touch depends on your Our organization began out of a mother's love and heartbreak. Elizabeth Glaser lost her daughter Ariel to AIDS and was fighting to save her son, Jake. She turned her grief into action and founded EGPAF to push for treatments and research to give children with HIV a chance at life. In the late 1990s, our board committed to taking that mission global.
▶ 0:40:14EGPAF believed that what worked for pregnant women and children here in the United States could work for women and children And then PEPFAR was created. PEPFAR allowed us to scale up our work in ways we could not imagine. Over the last 22 years, EGPAF has partnered with PEPFAR on HIV service delivery in more than 20 countries. We've worked alongside communities and governments to make sure families get the services they need not just to survive, but thrive.
▶ 0:40:42Last year alone, EGPAF helped test over million people, including 750,000 pregnant women. We supported treatment for 1.2 million people. We worked closely with PEPFAR, local governments, and other partners to keep evolving, to share innovations, and build the best models of care. Thanks to US leadership through PEPFAR and the Global Fund, millions of infections in children have been averted. Since 2000, new HIV infections in children are down by 75%.
▶ 0:41:12And AIDS-related deaths in children have dropped by 43% just since 2015. But progress is fragile, and right now it's at serious risk. Today, nearly half of all children living with HIV still do not have access to treatment. And without intervention, peak mortality occurs between 8 to 12 weeks of life. Only one in five children born with HIV will live to see their fifth birthday without treatment. Today, I'm deeply concerned.
▶ 0:41:39The future of PEPFAR is uncertain, and that uncertainty is already causing devastating harm. Two of our programs in Eswatini and Lesotho that had been granted life-saving waivers have now been terminated. Together, those programs were supporting around 200,000 people on HIV treatment, including thousands of pregnant women and These programs did everything from bringing medicines closer to the communities, supporting HIV testing counselors, training and mentoring nurses, providing cervical cancer screenings,
▶ 0:42:10and authorize offering specialized support for pregnant and breastfeeding women and children. National governments are stepping up where they can, but frankly, the emerging programmatic gaps are extensive and threaten to overwhelm health systems unprepared for such abrupt funding shifts. In many of these communities, people are scared.
▶ 0:42:29They're facing an unknown future, unsure whether their treatment and care that they depend on today will still be there for them What makes this especially heartbreaking is that Lesotho and Eswatini are success stories, leaders in ending HIV as a public health threat. Now, it feels like the rug's been pulled out from under them. Across eight PEPFAR programs, we are seeing troubling trends.
▶ 0:42:51Up to 50% of our sites are facing serious service disruptions, from viral load testing to early infant diagnosis, from CD4 counts to TB screening. Pediatric ARV stocks are dangerously low. And a significant amount of programming for orphans and vulnerable children has been cut. And these aren't just numbers. These are essential services.
▶ 0:43:12And when they break down, it directly affects whether people, especially children, live or PEPFAR's strength comes from a collaborative structure that emphasizes results, technical expertise, and strategic partnerships. This is also at risk. For example, as of last week, my understanding is that PEPFAR has lost all of its staff with specialized knowledge in pediatric and maternal HIV. That's deeply disturbing. This program started because Democrats and Republicans came together to save lives.
▶ 0:43:42Since then, as noted by um the chair, it's saved over 26 million of them. But its impact goes beyond HIV. The US is safer and stronger, more prosperous because PEPFAR's helped countries manage outbreaks like Ebola and Marburg, and reduced drug-resistant TB. It's strengthened public health systems, bolstered emerging economies, and improved how the US is seen around the world. So, we need that bipartisan leadership again.
▶ 0:44:06I ask you today to be an active participant in PEPFAR's future through the appropriations process because now is not the time to step Thank you and I look forward to your questions. Thank you very much. let me let me start with a a couple questions. I'm going to be pretty flexible on the time but I I'd ask everybody as always to try to keep an eye on the clock. Uh we know the the statistics. They are you know frankly very impressive.
▶ 0:44:33I'm not going to repeat those but you we've heard from you all and and all of us know that. And and and this subcommittee on both sides of the aisle has supported PEPFAR for many many years. But as I mentioned in my opening statement, uh I think we all need to agree that that we we have to look at what are the next steps. Are we going to fund this forever? In perpetuity? Is there going to be no ending? Um and uh you know, how can we hand these programs back to to the countries and to the private sector and other donors uh if necessary?
▶ 0:45:05while we talk about and I think rightfully so the really impressive accomplishments, historic accomplishments let me mention the price uh for that investment. So far, it's about 110 billion dollars since 2003. That's a heck of a lot of money. Even for federal standards, that's a lot of money.
▶ 0:45:26Um and we all have talked about and you heard it again this morning about well, how this also helps us with partnerships around the world and and it helps countries you know, be closer to us. But I think the American taxpayer looks at for example, South Africa. Let me just throw one example out there. this is a country that obviously, you know, we have a strong presence. PEPFAR has a strong presence. But uh but look what the government is doing. They're doing joint naval exercises with Russia.
▶ 0:45:56They're prosecuting Israel at the International Court of Justice and a number of other actions that that that are working against US national security interests. So, I think it's fair to ask these questions, which is is it working? Can we do better? And again, as I mentioned before, for how long? That's not being heartless or callous. That is standing up for the American taxpayer. And I would argue for the national security interests of the United States, as well. So, I'll start with you, Mr. Ambassador.
▶ 0:46:27you mentioned this in your opening statements, but what are some recommendations for next steps? could you please expand on your opening remarks in terms of shifting responsibilities uh to uh back to some of these governments and the private sector? And what's the best way potentially to go about that while keeping our gains, uh but also securing the national security interests of the United States, and not continue to do this forever? So, I'll yield to you.
▶ 0:46:55Thank you, um uh Mr. Chairman. And I actually fully agree with all of your comments. Um And as I mentioned in my open uh uh statement, and I'm really focused on it, it is very possible to begin a transition process. And South Africa's one of them. I mean, South Africa actually probably within a year or 18 months with with planning could fully transition without losing any lives, but also bringing our private sector in.
▶ 0:47:22And there are actually some private sector people here who would be very active You asked the best way to do it, and the best way to do it is to work with tangible with accountable benchmarks for transition in countries based on where they are from a socioeconomic standpoint, uh and report to you on that transition with reductions on an annual basis in the amount of money, eventually getting down to nothing, but at the same time,
▶ 0:47:53work closely with the private sector. And here, as I mentioned, we do not do this well. We have organs of the US government, the Development Finance Corporation, the US DTA, the Millennium Challenge Corporation, but they're off to the side. If we bring them all together and work with our private sector and with the private sector in countries, and I can tell you in South Africa for example, I work with high net worth individuals who invest in the health sector.
▶ 0:48:19They will come in and work with us and are hungry to work with us. So, we can transition. We can have plans. We can get within 2 years the majority of the vast majority of countries transitioning in a clear way, in a in a sustainable way, without an abrupt decline that will maintain the gains, increase the benefits, and also give us the diplomatic
▶ 0:48:50maintain the diplomatic and economic opportunity. The alternative is is chaotic, chaos, retreat, and loss of all the benefits that have been gained. So, it's not I completely agree with you. It's a matter of time. It is a matter of time, planning, and benchmarks, and those plans have to be presented to you with clear sustainable approaches to Thank you. The ranking member.
▶ 0:49:17Thank you You know, I I realize now you know, I have I have two grandchildren and I'm starting to think like I'm talking to And we There's a nursery rhyme but that I don't know if I think they even know what I'm talking about but I said it's called Humpty Dumpty. Humpty Dumpty sat on a wall. Humpty Dumpty had a great fall. All the king's men couldn't put Humpty together again. And this is what I'm thinking about right now when I'm thinking about foreign assistance. Because what First of all, thank you both.
▶ 0:49:47You're both terrific and what you've done for humanity is amazing. what I'm worried about I I do like the concept that we can work together to to let countries where they can be have a sustainable health system that they so go on their way that we get the private sector more involved. Very good ideas, I think. What I'm worried about I just want to know is but where what has happened in these last 30 days or so?
▶ 0:50:16There was supposed to be a waiver, as I understand it. A waiver to allow I thought to let PEPFAR continue its K- and I know people don't nobody likes to criticize this administration. Well, not nobody. Me. I I like to, but could you just just tell me factually what what's happened on the ground in terms of uh are these It's on and what's off. You talking to me?
▶ 0:50:46I just say what's on and what's off. Yeah, what's on and what's off. Cuz we heard people haven't been paid, that some of the programs have shut that the people were fired, they're not implementing. Could you just tell us where we are because I I as I said, I'm worried that it's could be so cracked up sledgehammer it up that we're not going to be able to go forward like you're suggesting. Who wants to answer that? You both? Okay. Happy to do so, Ranking Member. Um and I can speak to our our experience with it.
▶ 0:51:16I do think this has been a challenging period of time. Um most of us who work in the HIV community and as we've talked about, you know, every administration comes in with its own priorities and wants to review the program and that was expected. Uh I think the way that the review has been handled has been sort of challenging on the implementation side. Um it did start obviously with the start work stop work orders um for all of foreign assistance and that included PEPFAR at the time. And then there was this opportunity for the waivers to take hold and many of our projects did receive life-saving waivers.
▶ 0:51:45Um there was a small and that did shrink the scope of work. There were certain activities that were not considered life-saving like OBC uh and some preventive opportunities, but you know, mostly treatment and care were considered life-saving. Um, but those waivers were not implemented automatically. Um, there was a process that had to go through once the waivers were announced, then the implementing agencies had to apply those waivers to each individual project.
▶ 0:52:08So, because you can imagine with all the PEPFAR projects, looking at each project, determining which part is life-saving, which part is not, revising work plans and revising budgets. And even then we still had to get permission to restart those programs. So, we have been able to restart work in many places. But then what happened is that some terminations occurred. So, even um programs that did receive life-saving waivers were then terminated. Um, we had three countries actually with terminated care and treatment programs. One was then unterminated.
▶ 0:52:35Um, so again, as you can see, it's been very hard to sort of follow like, what should we be doing? Even when we get permission to work, it's been hard to tell and work with the mission and with the national government, are we ready to move forward? Can we move forward? Or is something else going to occur? So, I think from our standpoint, I think one of the major things that we're we really want to see happen sooner than later is to really sit down and and look at the capacity that's remaining. Is that once we get through this review period, what projects are standing, where can we continue work? And also all that work interconnects.
▶ 0:53:05Um, I had a colleague tell me yesterday, she's like, you know, the problem is by looking at all these projects individually, you you miss the interconnectivity. So, a project like ours, where we're working with pregnant women, we're able to get them tested. We're able to get them on ARVs. We help them through labor and delivery. But then the infant test happens. And that test has to be transported to a central lab to be processed. And that's where the but the transportation, the the organization was doing that transportation is no longer there.
▶ 0:53:31And so, that link in the chain, other parts of the chain are working, but one one link goes goes it falls apart, it all starts to fall apart. And so, I think until we get a sense of where that capacity is, where is the country able to fill gaps, where do we need to course correct after we look at what's happening in the field. I think we'll be able to move forward from there. All right. Well, that was very diplomatic of you. Thank Thank you for your good work. My understanding is that the PEPFAR is as it was established, it was not just for emergency, it was also for prevention.
▶ 0:54:02So, I mean cuz I think and Mr. Dybul, maybe you would know this, there's something like 20 million people who were who are on medicine that keeps them alive and well. My understanding that's been cut off. Is that that that is the part of the program that's not in effect right now? Am I Did I hear correctly? Either of you can answer the question. that. Um you can join in as well, Ambassador.
▶ 0:54:29Um yeah, so um that was not considered the work on prevention was not considered part of life-saving work. All right. So, so in other words, you know, you are going to get an A for diplomatic being diplomatic, but in other words, there are 20 million people plus out there who their medication has stopped. No, you're you say no, it hasn't. Go ahead. Mr. Dybul, you can you can speak.
▶ 0:54:54Uh I also have a in the world is a strange I am a PEPFAR implementer as well in Eswatini and we are still delivering antiretroviral therapy and supply chain system that delivers it has been given a green light to begin the procurement again. But it is unclear where things are going and that's the problem.
▶ 0:55:17And lack of clarity is a problem for producers, it's a problem for people in the country, and while some programs are continuing, some have stopped. Um the prevention programs are another story which we'd be happy to talk about because that is very important. PEPFAR was a prevention care and treatment. And in the end, if we don't prevent new infections, Yes. this epidemic is going to get out of control again, then all the gains of the past will be lost. And the prevention also has to do with the transmission. I'm going to just finish this up.
▶ 0:55:47With mother to baby, and that I'm my understanding that that's uh in demise. The The life-saving waivers were support were supposed to include those. We have had difficulty um getting them up and started again. And again, mostly because of how the services are provided. Like if you can't And HIV positive woman comes in and can't get tested, we can't even start the process. So, if you take HIV testing away, if you take HIV counseling away, if you take away prevention counseling, we can't get to the core ARV services.
▶ 0:56:16So, even where ARVs still exist and can be given out, we may not be able to get to that part of the care continuum because of all the other blockages that we're seeing. I I I I think I understand what you're saying. Uh prevention, people are just going to get sicker and sicker unless they unless And that's we're talking about millions and millions of people. Unless we have some kind of intervention. I hope that we can send a message to you know, to the administration.
▶ 0:56:45We We're with trying to become more efficient, accountable, transition to countries being able to where they can take over these operations, but would they have to have something to take And they And just get letting millions of people get more sick is just going to make things worse. Thank you. I I absolutely I'm absolutely I'm not going to cut off uh the the ranking member. Uh um Mr. Lowey, the the full committee uh ranking member, I don't know what your time constraints are.
▶ 0:57:15Do we go I want to Are you okay to go back back and forth uh or or do I I cuz I can recognize you now if you'd like. Do you want to have something to Go Go ahead. Go ahead, Paul. Go ahead. Go ahead. All right. I just want to make sure that I know that your time is You're I know that you've got a lot of other subcommittees that that you like to attend. All right. Uh to the vice chairman of the subcommittee you're you're recognized sir. Thank you Mr. Chair. To both of you thanks for being with us this morning.
▶ 0:57:42One of the allegations that I've heard over the PEPFAR program is that taxpayer dollars have been somehow used to fund And I can't help but think how can this committee appropriate funds for such a worthy cause it appears and yet they those funds be so egregiously misused.
▶ 0:58:11How How How does that happen and how does this committee ensure that with any other decision that we make the funds are actually used for the sole purpose that they're intended? Uh Mr.
▶ 0:58:26Vice Chairman you you raise a hugely important question and and let me just say from the outset and I think um anyone implementing would agree it is completely unacceptable when the US law is violated in any way but in particular on the Helms Amendment because that's such an important part and has been a benchmark of of uh foreign development and particularly HIV programs.
▶ 0:58:51Um there was in in Mozambique as as the ranking member mentioned uh a group of nurses that uh were not trained in the Helms Amendment and were active in abortion care. They were their salary was paid for by PEPFAR which you could say then funded the abortion but it doesn't matter. I mean I think we're getting into details. It never should have happened. The What has been put Excuse me.
▶ 0:59:18With all due respect we need to get into the details here. We need to understand how the United States sends money someplace else and then it gets used for a purpose totally different than what it was intended. I'm okay to hear the details. Yeah.
▶ 0:59:34So, as I understand the details, funding went to the government for nurse nurses to provide care, including HIV care, but they do other things as well because and that's an important piece of what happened is it what PEPFAR has done is funded a health system, which allows for pandemic response and many other things. So, those nurses were being funded in order to provide HIV care, but then they also performed abortions.
▶ 1:00:01Um uh and that is unacceptable because no one funded by the US government should engage in that those types of activity. And as was mentioned by the ranking member, they had not been trained in the Helms Amendment and weren't aware of it.
▶ 1:00:16And so, now and these have to be put in place and this is a problem with cutting money too quickly is it's difficult to have oversight then, especially if you don't have the the systems to do it is training of everyone who receives any money from the US government in the Helms Amendment and in the US government policies and practices uh so that they understand what they are, that they actually sign and attest to that they are aware of those policies and practices, and that very importantly that
▶ 1:00:46there be reviews, systematic reviews, and as the ranking member mentioned, this did happen, but it it didn't happen until after that there be regular reviews and everyone be aware that those reviews are happening to deter any um action against All right, that's the law. That that is helpful.
▶ 1:01:04Uh One of the key screens for this committee now is to make sure any funds that we spend abroad are in the best interest of our national Can you tell me how funds for PEPFAR and preventing AIDS abroad is in the United States national security interests?
▶ 1:01:32Perhaps I can speak to that as a uh a former ambassador and um level of assistant secretary of state. Uh Uh I can tell you uh let me give you an example. Um when I first went to Namibia, um I met with the president. This was early in the days of PEPFAR. And the president said to me, "You know, we hate the United States because you were on the wrong side of apartheid.
▶ 1:01:55But now we love the United States because you're the only one here supporting us in something that's going to destroy our country." So, the soft power the ranking member mentioned is hugely important because the United States actually if if you go back, it's hard to do a negative.
▶ 1:02:14But what we expected to happen, what the US intelligence community expected to happen, was literally Africa falling apart because there were countries where a third more than a third of the adult population was infected. There was a district in Botswana I visited, 75% of pregnant women were infected with HIV. They were all going to die, their kids were all going to die. There were entire villages run by orphans.
▶ 1:02:39The African continent could not put a peacekeeping force together because their soldiers were all infected with HIV. The and because HIV hit people in their reproductive age and productive age, it was factory workers and machine workers. Ford Motor Company in South Africa was among the first providing antiretroviral therapy because it was going to destroy their ability to produce cars.
▶ 1:03:04So, on a diplomatic front, on a stability front, and on a soft power it is in our interest. The other way it's in our interest, and this has been shown, is Africa is the fastest grow by 20 the 2030s Africa will have more people than India or China. Um and it is a young population. It is also among the fastest growing economies in the world. And it is the economy of the future.
▶ 1:03:34Virtually everyone predicts that. I CEO of Walmart told me that. Um Africa is our trading partner for the future. It's where we will make money, where our companies can make money and invest. There's company sitting right behind us that produces new technologies that could end the AIDS epidemic.
▶ 1:03:53So on a diplomatic dividend front, on uh on a on a future economic growth and development front, uh and economic opportunity, and on a national security front, both on the diplomatic and economic and stability side, um these this is in our national interest, which is why we did it. The first time the UN Security Council held a a meeting on an infectious disease was HIV for all the reasons I mentioned.
▶ 1:04:22It's What was averted a negative is hard to measure. This is in our national security. I can also be very clear because I spend a lot of time in Africa. We are losing ground rapidly because of uh recent events and because of the fact that China and Russia are all over Africa right now. All over Africa.
▶ 1:04:44And we have lost our status as the number one trading partner in Africa, and there are a lot of resources and minerals and that future economic opportunity, and if we cede that field to our adversaries, it will not be a pretty picture because it's a big part of the world. Thank you. Thank you. Um ranking member of the full committee, thank you. Thank you very very much, and thank you Ambassador Daigle for really answering the question about national security.
▶ 1:05:14Thank God for George Bush who understood the the the need and the fact that this was a uh a really in the best interest of the United States to be engaged in the PEPFAR program and we have uh and after him countless others, Democrats and Republicans, have understood the need and the necessity uh for not What gives?
▶ 1:05:40If you can't understand the humanity of all of this, then understand what it means in terms of our national security. Um uh and the stability of these economies in order for us to be able to participate in the world uh economy, though that may be under a threat as well these days. Um Let me just uh PEPFAR works. PEPFAR works. Okay?
▶ 1:06:1020 years, you had one incident. Not pushing it under the rug. But you've you you've talked about it, you explained it. The other issue is here I it's my understanding that these nurses were not trained um uh with the Helms amendment etc. And there there was a revision of the plan in order to be able to do that, but now we've got nothing but chaos. So, whether or not people are being trained or not trained or etc. is it's up for grabs.
▶ 1:06:41I think I'm going to ask my question, but I also wanted to just say this. I I believe we're looking at a pattern here. the domestic HIV programs are under attack.
▶ 1:06:57Uh I spent a lot of years on the Appropriations Committee with the domestic HIV um uh uh a program with the with the epidemic of trying to rid us of of that and very close to doing it except in money has been snatched back. So this is part of a pattern.
▶ 1:07:18Which I quite frankly don't understand how it comes out in terms of the mission of saving lives, yes. And of dealing with US national as of September 2024 PEPFAR was supporting the antiretroviral therapy ART for more than 20 million 20 million In 55 countries.
▶ 1:07:46That including 566 children living with HIV. As a result the use of ART led to 95% 89% of children being virally As a result of the funding cuts UNAIDS has warned that this will lead to more than 6 million excess deaths and an additional 2,000 new HIV infections each day or 730,000 a year over the next four years.
▶ 1:08:17ART suppresses the viral load to a level that makes HIV undetectable, prevents transmission. What is happening and will happen to more than the 20 million if they have to stop using ART? What do you expect to happen to transmission rates? I'll jump in here. Thank you Ranking Member.
▶ 1:08:39You know I I I appreciate your comments and I think it it bears repeating that I think in some ways our progress has masked the root of the problem which is that HIV is an incurable infectious and fatal disease. And because we've done such a good job in trying to control it we forget the devastation that it can bring and I think both the subcommittee members as well as Ambassador Dybul done a good job talking about that. And the disruptions we are seeing have the potential for to see some resurgence. You mentioned all the people that are on treatment.
▶ 1:09:08Right now the ARV stocks are low. There was a really good market analysis done by Chai that really looked at the supplies that are coming in. And right now there may be no ARV stock outs, but our own organization has looked and there's not a single country we work in that has more than two to three months supplies of pediatric ARVs right now. And children that experience treatment disruption die much faster than adults who have treatment disruptions. So I do think we can expect to see increased mortality, increased infection rates, and and a lot and a lot of despair if things aren't aren't corrected.
▶ 1:09:37And just a couple of other things here. So if if the administration fails to continue investing in a comprehensive program, do we then figure that we have squandered the billions we have provided over the last you know, 20 years? Have have we thrown have we thrown that money away given what you have just said about what what what happens for the future? Just an an adjunct question to this if I might.
▶ 1:10:07Um I I find that we've PEPFAR works with other agencies. You were looking at USAID, CDC, um and that that in essence helps to make it Right.
▶ 1:10:26So now if you're focused on maybe not investing in PEPFAR and then you are decimating or or dismantling USAID and you are decimating CDC at the moment which we are watching in real time here. How does that all play into what your mission is and again the squandering of billions of dollars?
▶ 1:10:52If you as I say if you can't get it to get people on the humanity of it, think about the money that we have spent here. You know? Um I choose humanity um and but also efficiency, but let's talk about efficiency and the use of dollars and what those dollars have created and what happens when these agencies that are you rely on crash and burn and where do you go from there? I'm going to ask you to try to get it's an important question but try to get to it concisely.
▶ 1:11:22That was a question Mr. Chairman and I'm sorry for the And and it's an interesting compliment to what Ambassador Dybul was talking about about planning and looking at capacities and and how we transition work. You know, right now, we've talked a lot already in this hearing about the disruptions we've seen at the country level. We've talked a lot about where countries can lean in and do more, where private sector can do more. But we're not just disrupting the the technical capacity that's in the field.
▶ 1:11:45We are disrupting the technical capacity at PEPFAR and the ability for these agencies and PEPFAR leadership to create a strategy to make a plan. You know, again, I I keep focusing on the area of my organization. You know, we've heard over and over again from the Trump administration officials that they want the focus of PEPFAR to be on eliminating mother-to-child transmission of HIV, but but we're seeing the services in country being disrupted and we're seeing the technical expertise that can help us create a strategy to do just that be diminished as well.
▶ 1:12:13So, this is why I think it's going to be very important for this committee and its oversight function, but as well as our conversations with the administration to look at this capacity. Where have we where have we diminished our capacity so much that we really have to rethink we need to lean back in because right now it is hard to see a way forward and to think that as Ambassador Dybul mentioned the confusion about where we're supposed to go, what are we supposed to do, how are we supposed to do this work if we don't have the structure at the top to help direct our work, we don't have the structure at the country level to do
▶ 1:12:43the work and do it in a way that we can transition and sustain it over a long period of time. Thank you. Thank you very much. member. Thank Um Mr. Mullin who also is the chairman of the bipartisan task force China task force. So, thanks for being here, sir. You're recognized. Thank you, Mr. Chairman.
▶ 1:12:57Thank you to our witnesses today and you know Ambassador Daigle, I want to follow up with you on some of the comments you've made about, you know, China's work in you know, we know about the Chinese Belt and Road Initiative. They uh They also have the Health Silk Road.
▶ 1:13:19you know, it seems that their purpose is really to expand their influence and and uh expand the reach of their surveillance state and use it for both, you know, economic as well as uh military purposes. Um I wonder if you could talk a little bit about some of the efforts they're making in Africa uh because I I agree with you.
▶ 1:13:42I think it The question I hear from uh ambassadors from African countries is, you know, where is We'd rather do business with the United States, but where is the United States? And uh I think it's important that we have a strategy on that, but I wonder if you could comment on that situation. Yes, thank you very much. And thank you for the work your uh committee does because I think it's hugely important. I was talking with um uh Marion Chris Smith, of course, a part of that committee as well.
▶ 1:14:11And um and I hope the Senate does one as well. Uh so, China is is all over Africa. And I can tell you I They have gone in and started to meet with governments to say, "Well, the US is pulling out here, so what can we do to support you?" Um and that is a massive risk to us for the long term. Um you know, the the diplomatic dividend to us of PEPFAR is is has been enormous because they see their lives saved.
▶ 1:14:39And this is down to the community level. I go back to that person and ask them, "PEPFAR means the American people care about us." Shocking state. Down to If we lose that, we lose a great deal and we lose a great deal for the future because of the mineral wealth that is there, the which are essential for all the things that we're doing as you know better than I do. Um but we also lose the the military uh capacity there and I the Department of Defense has been key part of PEPFAR. We forget about that.
▶ 1:15:09But in the beginning, the Department of Defense was as important as any other agency because the military's were so devastated by HIV. We spent a lot of our time supporting the military's and if it comes back, they're going to be the most impacted as well. But um uh related to China, they also have grown their pharmaceutical industry. Uh that was actually just for China. They now are trying to export their pharmaceuticals. They They're pretty good at copying pharmaceuticals and they're even inventing their own.
▶ 1:15:39They're going ahead on AI which is a massive area for the United States, as you know, as well. Who's going to win the AI war? Well, if you're First of all, you have a lot of the materials in in Africa that you need to make those chips for AI. But then you also have to have places to do AI and have a genetic pool, which Africa has a massive genetic pool that is untapped. So on every we are at risk of seeding ground to to China.
▶ 1:16:09Now, is PEPFAR and the Global Fund enough? No. But there are other parts of our government that could be And here's where the planning for sustainability is so important. The planning for sustainability should not just be around HIV, TB, and malaria. That is hugely important because that will protect a lot of lives, it'll protect the future, it won't squander, as as the ranking member said, our investments to date.
▶ 1:16:32But it has to involve a broader picture which includes our private sector, which includes our military, which includes And we can do that um if we integrate what we op- how we operate. And And I would just like to also mention, you know, when I read PEPFAR, President's Emergency Plan for AIDS Relief, I think of a plan for an emergency being something that needs to be modified, updated.
▶ 1:17:00And as you point out, you know, looking at how some countries can transition Uh, you mentioned South Africa. I'm sure there's other countries in that mix, but I don't know how often that plan is updated according to, you know, new conditions on the ground, new situations, because it it appears like it's an ongoing government program.
▶ 1:17:25But that's very different than a plan that is strategic, updated regularly, and as you point out, benchmarks and and evaluation. But I wonder if you could Is that something that can be redrafted in a new era? Yes, and that's exactly what needs to be done. No question about it. Um, that the transition needs to be be We are We have done it in some places.
▶ 1:17:50I mentioned 59% of all HIV funding now comes from domestic sources, and that's really increased over time. But it's nowhere near enough, and the plan we don't have clear plans, and that's what I think this committee and the administration can require. That they're And PEPFAR actually has been working on one, but it has with the Global Fund, because we also have sources there.
▶ 1:18:13But you can you should We do need to shift to a clear plan with compacts with every country. And there are some that I mentioned. There are There are about three dozen that could transition the next couple of years, literally the next couple of years. So, you could see what we need to do in that reduction in our investment.
▶ 1:18:32That hundred billion could go to something very low, but if you do it in a structured clear way with those benchmarks and you ask for that plan and the administration demand that plan and report to you regularly on that plan, it can be done and we can have a success. So instead of a rapid retreat that will be a total failure for us on every front and threaten our national security, we can actually turn it to a success and have that transition. 30 seconds more.
▶ 1:19:02Just one I have to leave for another meeting, but one thing that strikes me as public the public health community has lost trust over the years. And one of the reasons I think, you know, this issue of PEPFAR, this issue of abortion is so impactful and and I've heard it today this term abortion care.
▶ 1:19:31When someone says that as a health care it immediately diminishes their credibility in the minds of many Because when they hear something like they're interpreting it in a way that says, "You're concerned about children dying of AIDS." Many others are concerned about children dying from abortion and there's no difference in in terms of saving an innocent human
▶ 1:20:02And so I would just say as you speak to the PEPFAR community, to be very clear about the importance of that because, you know, all of us should be in the business of wanting to save human lives. And and I think in the public health community when terms are used like abortion care, it really diminishes the credibility. So with that, thank you. Thank you, Mr. Chairman. Um Ms. Meng. You're recognized.
▶ 1:20:30No, we're going to go You were here when we started, I believe. And if not, take advantage of Okay. Thank you. Go ahead. Pretend you were. Thank you, Mr. Chairman and Ranking Member Frankel and DeLauro and to our witnesses for being here. Um in June 1981, five cases of a mysterious illness appeared in Los Angeles.
▶ 1:20:52And that moment marked the beginning of the HIV epidemic in Since then, over 700,000 Americans have died from this illness, including 8,000 each year. But HIV AIDS didn't start here, but we knew that protecting Americans and addressing the AIDS epidemic meant fighting the the disease globally. And that's why PEPFAR is important.
▶ 1:21:20Since 2003, we have saved 26 million lives through PEPFAR and another 65 million through investments in worldwide HIV response programs like the Global We're actively helping to treat, you've heard the numbers, over 20 million people with life-saving medication, including pregnant women. We have prevented 7.8 million babies from being born with HIV.
▶ 1:21:47And as a mom, that last number means so much to me. Because of this program, millions of children have been able to grow up without worrying about treatment or passing HIV on to others. Meanwhile, PEPFAR's annual regular funding since 2009 has been flat.
▶ 1:22:06In fact, the cost of treating someone has dropped from $1,200 a year in 2003 to just $58 in 2023. And that sounds pretty efficient to me, Mr. Chairman.
▶ 1:22:23PEPFAR is a crown jewel, but this administration's illegal, uh and chaotic attacks on USAID our public servants and the programs they support are jeopardizing decades of Ms. Connor, I'm very worried about the impacts of the stop work order on ARVs.
▶ 1:22:47This is, as you know, medication that 20 million people receive that helps stop the spread of HIV. And each day of the foreign aid freeze, over 220,000 people, including 7,000 of them who are children, were blocked from receiving these. As you mentioned in your testimony, a study showed that one in five HIV-positive children who experienced treatment interruptions died.
▶ 1:23:15Interrupting ARV treatment risks creating drug-resistant HIV strains, correct? Can you talk a little bit about that? Absolutely, and and thank you for for raising this question. You know, when I started working at EGPAF, I had to go around to members of Congress and tell them there were 2,000 children that were acquiring HIV every day. And that number is down to 300, which is still too many by any measure, but that just kind of speaks to the success. And a lot of that is because of the ability to put pregnant women on on treatment.
▶ 1:23:45So I just want to thank you for raising that issue. You know, drug resistance and and treatment failure is a really big problem, especially in the pediatric community. A lot of children who are exposed to HIV are exposed again through pregnancy, labor, and delivery, and breastfeeding. And so if they do end up being HIV-positive, often they are resistant to the drugs that their mother may have been taking. And so we have to be very vigilant on that, and that's why treatment disruptions in the adult and the pediatric community are so important to to try to avoid.
▶ 1:24:15Is that we do find that when people's treatment is disrupted, not only do they get drug resistance, but their the they're to virus tends to spike, right? So, not only have they stopped treatment, they are actually they get sick very fast, and that means that they're able to infect other people, and they won't even really understand or know that.
▶ 1:24:32So, this is an area that we take really seriously, and as we're looking at sort of where the disruptions are, we are trying to make sure and work very closely with the ministries that at least where we can that ARVs are being supplied, and and and again, hopefully at the levels that people can adhere. But, we are starting to see some rationing of medications as well.
▶ 1:24:49Just because of the uncertainty, I want to be clear that uncertainty here is almost more dangerous than what's happening on the ground, is that ministries and and and partners are unable to plan ahead, unable to um to look at what's available, and sort of redistribute resources. It's just everyone's a little bit frozen in place, and that has its own damaging impacts. Thank you so much, and I'll pivot quickly to, if I still have time left, um to my home state of New York.
▶ 1:25:15Uh the administration's dismantling of USAID uh obviously will impact so many of the communities and districts that we all represent. Between 2022 and 2024, USAID contracts were responsible for over 12 billion dollars in grants and funding to organizations and universities here in the US.
▶ 1:25:35In my home state, we received over 185 million during that period, money that went to disease research and treatment and programs to help reduce the cost of everyday goods like coffee, and now the administration has canceled many of them. One of the impacted groups is the International AIDS Vaccine Alliance headquartered in New York City.
▶ 1:25:59This was They were developing a promising vaccine that was already in clinical trials, and the administration canceled their contract, resulting in the end of that clinical trial. You know, an American-led, taxpayer-funded HIV vaccine trial was actively underway, and if successful could have helped prevent almost 32,000 Americans and 1.3 million people around the world from getting HIV each year.
▶ 1:26:28Um Ambassador, can you discuss the impact that an HIV vaccine and other injectables would have had on treatment costs and PEPFAR's sustainability? Yeah, I I Yes, thank you for the question. I'll I'll I'll do it quite quickly. The vaccine uh uh was By the way, I used to be on the board of IAVI, so I want to make that clear. Um so, I was involved in some of that planning.
▶ 1:26:55Uh there the new technologies that are available, um there are in long-acting injectable drugs that actually prevent infection. So, like you would take malaria anti-malaria drugs when you travel. This is the same. It's called pre-exposure prophylaxis. You take antiretrovirals to prevent getting infected in the same way you treat, just like you do with malaria.
▶ 1:27:19So, a couple of companies have developed injectable products that you can have one injection every three or six months. And the six-month one um should be available, we hope, soon. By American technology and American companies, one injection every three to six months could prevent new infections, which is how we get to no more infections. And then the vaccine would add on to that uh as well.
▶ 1:27:45There are a couple of countries, the United Kingdom and the Netherlands, that are very close to achieving that. And the United States was getting close. The first Trump administration actually put the end of HIV as a top priority for them domestically. And it is possible, and these new technologies will make it possible. If you can give an injection once every three to six months and prevent new infections, there's a pill that does that as well that is being used. And it was starting to be used in Africa.
▶ 1:28:14So, for the long term, one of the key parts of sustainability transition is get the new infections down. And the second part of that, and this is a, you know, an unfortunate part, but it happens to all of us. If you do an actuarial analysis, there have been many people on therapy now for 20 years. So, they they've been estimates of the fact that they're going to start dying from natural causes, even if they retain their antiretroviral therapy. So, you reduce the number of new infections, you have an increase in death for natural causes.
▶ 1:28:45You get down to a very small number of people that will need treatment for the future. That's sustainability. But, that requires Countries are ready for that planning. I can't tell you, Africans want a transition. They are not looking for this to continue forever. They want a transition. But, they want a transition that they can manage because it shifts responsibility to them, and they want the private sector very much at the table. They want all the things we've been talking about. So, you have ready partners to go with.
▶ 1:29:15And but these technologies are hugely important to achieve that ultimate goal. And we can actually have an AIDS-free generation because of those new technologies, including the vaccine and including the long-acting injectable products. Thank you. Mr. Alford, you're recognized, sir. Well, thank you, Chairman Diaz-Balart and Ranking Member Frankel for holding this. I think this is a very important subcommittee hearing that we're having today. Thank you for being here.
▶ 1:29:42PEPFAR has saved the lives of millions of innocent people and strengthened global health for decades now. Dr. Diebel, I'd like to thank you for your work in establishing this program during the Bush administration. Your work has saved millions of lives. But, as we are doing today, we are confronting the fact that this last administration has somewhat turned this life-saving program um into something it should not be. Using taxpayer dollars to fund abortion is abhorrent.
▶ 1:30:12I know the number is 21. It would be abhorrent if we use taxpayer dollars just for one single abortion. And I know you've spelled out how this happened with the nurses in Mozambique and the um the money that was returned that was supposedly used for this, that was used for this. I want to focus on how we how we prevent that from happening again.
▶ 1:30:34So, Ambassador first off, does the use of taxpayer funds for abortions what does that do to the public trust in this program? Certainly for a lot of Americans that would undermine the trust in the program and that's something that needs to be rebuilt. And there's no question about the need to rebuild that. Any any violation of any law of the United States uh is is something the American people should be concerned about.
▶ 1:31:02If we move forward with funding for PEPFAR, what guarantees can you make that American taxpayer dollars will never be spent in this program again for another abortion? It's hard for me to guarantee that because I'm no longer in the administration. However, um what can be done, as often happens with other violations of law, are the a couple of the things that I mentioned. One is the training so that everyone is aware that of what the law is, which unfortunately these nurses were not.
▶ 1:31:32Secondly, is to require them to actually sign attestations that they are aware of that. And third is to do regular reviews, which is the most powerful thing you can do. But you need people and money for that. So, you have There are few countries, not many, but there are few countries that have legalized abortion where PEPFAR operates. That's where you really need to do your focus on those pieces and you need to go out to the field and you need to do program reviews.
▶ 1:31:59And you need to do them regularly, but you also do need to do them randomly because that will make people aware that if they're caught, there's going to be a penalty and a cost. So, those are the the tools that can be and must be used to ensure that this does not happen again. Let's talk about the transition plan. Ms. Connors, are you in agreement that this should have a transition to private entities, faith-based organizations in other countries?
▶ 1:32:26I think we view this as a really strong opportunity to start the sustainability and transition process. I think that uh Ambassador Dybul and I may disagree on the pace of that. Um you know, obviously we work at the project level. We have a lot of experience with transitioning projects to local ownership to governments over time. It on average it takes us a four to five period year period of time to really walk through, identify what we're going to transition, and how we're going to transition. I have 2 minutes left. So, you're in agreement should be transition, it's just a time difference that you have with the ambassador. process.
▶ 1:32:56The well-planned part of it is very important. Ambassador, what is your time frame for a transition? It's difficult for me to have a time frame again because I'm not operating, but I do work very closely with many African leaders. They want to work to transition as quickly as possible. And I do think Uh some countries could We can start the now. It's It's not as if you defund completely and then you just transition. It's a It's a constant reduction.
▶ 1:33:24What guarantee do you have that if we transition out, that China won't transition in filling in the void that we leave behind? Well, the thing is if you do the transitions right, there is no void left for them to fill because you would transition to local organizations, government, non-government, faith, community-based organizations doing the work. And we've seen this happen. We know it can happen. We already have 60% of domestic resources going to fund the programs.
▶ 1:33:53The issue is timing and planning, and we can It's going to be country specific. So there are there are some countries that have relatively large resources. For example, I talked with the people in South Africa. They could transition probably in a year or less, but they need to know where to put the money. Uh there are other countries in similar position.
▶ 1:34:13There Nigeria, Tanzania, Zam um Namibia, Botswana, countries that actually have decent incomes, but they would So you we we the risk is that if we go too quickly that void will be there. If we plan with them, bring in the private sector to invest as well, it's a gain for all of us. There will be no void and we will be the heroes. We will have successful transition versus failed transition. It's the failed transitions that will lead to that void and opportunity.
▶ 1:34:43Thank you. I yield Storch, thank you for your patience and uh you're recognized. Uh thank you, Chairman. Um thank you for holding this um meeting with such an important organization.
▶ 1:35:00Um but I have to say that I am extremely disappointed that we are continuing to hold uh briefings here in the US Capitol where people have no access unless they are escorted by a staff member um conducting a tour of the Capitol. You know, so much has happened.
▶ 1:35:28Um where is the transparency and Trump has completely destroyed our American brand. He and Elon Musk are isolating us and you know it, Mr. Chairman. It will not end well. In just 11 weeks, members, 11 weeks in office, Trump has taken $11 trillion out of our economy.
▶ 1:35:58Yet, here we are talking about a $4,000 illegal expenditure that was paid back. So, you are so concerned about $4,000, but head in the sand of the $11 trillion that has been taken, stolen out of the pockets of the retirement accounts of all of our constituents.
▶ 1:36:28This is insanity. Mr. Chairman, I'm going to request unanimous consent to submit for the record um an original undoctored DOJ webpage thanking USAID for critical support capturing and charging the MS-13 gang leaders.
▶ 1:36:50Because the truth is, USAID has done a great job for the American people keeping us safe, ensuring that the people that want to come and do us harm, working with other governments like Mexico, don't get to our southern border.
▶ 1:37:07But yet, when the Department of Justice recently arrested three of those top MS-13 gang in the world on terrorism charges and publicly thank USAID as providing critical support for the mission, a few weeks ago, the Trump administration, Mr. Chairman, shamelessly tried to erase that action by deleting this this document from the DOJ website.
▶ 1:37:38So, I want us to put it to the record so that we have some transparency and accountability about the good work that is being done by USAID. So you're again you're asking to submit that to the record. We'll do that without without objection. Thank you. Congress can fix this demise that is is And why have we not held a USAID hearing as of yet?
▶ 1:38:06Why have so many members forgotten their oath to uphold and defend our Breaking the law should be a concern for everyone regardless if you have an R or a D after your name.
▶ 1:38:24In this administration's blatant illegal acts and the ignoring of court orders should be at the top of our list, the law and order party that we say that we are. So here we are. Ms.
▶ 1:38:42Connor, PEPFAR is another example of successful programs that help both America and the world that are now under And it is estimated that over 30,000 adult deaths and over 3,000 child deaths have occurred that are associated with this administration's foreign aid funding freeze and discontinuation of the PEPFAR programs.
▶ 1:39:10Can you tell us as an HIV practitioner for many years, can you share with the committee what your assessment is of the orphans and vulnerable children programs and what it means for children now that they are that these programs have been completely shut down? Uh thank you for that question.
▶ 1:39:32You know, um I think part of the PEPFAR program has always included the desire to make sure that children grow up in stable uh and safe homes free of exploitation and violence. And that's been since the beginning of the epidemic as as Ambassador Dybul mentioned, um when when there was a real crisis. That still continues today. And in fact, what OVC really does is is it really strengthens the community and the caregivers around a child so that they can thrive. We see this a lot in our work.
▶ 1:40:01You know, we are largely a clinical organization, but we rely on our OVC partners and OVC programming to supplement what we can't do in that clinical setting. Um there was a recent one of our community health workers recently raised uh told us about a story is that he was sitting with a recently diagnosed 5-year-old girl. She was diagnosed HIV positive and TB positive. So, gravely ill 5-year-old from a poor family. Mother doesn't have money, father doesn't have money. And those situations, the first thing you do is reach out to your OVC providers.
▶ 1:40:29OVC providers provide nutritional support, economic support, caregiver support. They're the ones who really go to that household level, that community level, and say, "How can we make sure this children thrives?" And when our community health worker contacted that OVC program, they said, "I'm sorry, we've been terminated. There's nothing we can do." And so that's the level that we're facing. I mean, that's a real patient experience. But we're seeing in other places, too. Another health worker said there's a 10-year-old who'd been struggling to stay on medicine because of food. And there'd been food support through OVC, and now that wasn't available.
▶ 1:40:59So, I think it's a real struggle because OVC was sort of characterized as non-life saving that it has not been prioritized in the waiver process. That doesn't mean it may not be prioritized after the review is done, but we really are concerned about the hole that we're seeing there.
▶ 1:41:12And one last thing, there is a Lancet article that came out today that really puts a finer light on what's happening around children in orphanhood, and they uh you know, predict that there could be millions and millions more orphans if PEPFAR funding retracts too far, if it's ceded or retracted too far. Um thank you for the extra minute. I'm going to yield back. Thank you. Thank you. And know, this has been a very helpful uh hearing.
▶ 1:41:37Let Let me again first go to uh cuz people have to move on in other meetings and I think everybody's been very good. I think the witnesses been have been extraordinary. Let me recognize the ranking member for if you have any further questions or or closing. If you can just do your closing as well. with a question. Closing with a First of all, I want to thank our witnesses again. You are so obviously so competent and professional. It's just been an absolute pleasure to have you here today.
▶ 1:42:08Uh and I want to thank Mr. Chair for this for hold bringing this hearing and bringing these witnesses. Exceptional. And I just you know, I don't I don't mean to to I don't like to exaggerate or be trite, but I do think that what we listened to today is earth-shattering. It really it it it really is. Uh because there are millions of people whose lives are at stake.
▶ 1:42:34We have we're on the you know, the real possibility of losing opportunities uh with Africa, the the fastest growing I'm sorry, the fastest growing population in in the world. Opportunities in regards to security and but we also heard that we are on the brink of finding a way to keep people from ever uh having their HIV come
▶ 1:43:04back with with a simple injection every few months. These are I mean, that's just absolutely But here's what you both said. I think and that's what I want to end with the I was it before I end with the question. I I have to take one more pot shot, okay? Just one more. He He He understands me well. Listen, I just want to say this.
▶ 1:43:32A violation of the Helms Amendment which affects 21 affected 21 patients. I'm not going to minimize your I won't bring smelling salts with me in the in the future, but it doesn't it's not an excuse to put 20 million lives in jeopardy right now. It's not an excuse. We're going to move on and we're going to try to do this the right way.
▶ 1:43:58but I think what both of you have said as I've heard you is this and you can correct me. Let's not shatter. Let's not lose what we have had with PEPFAR. Let's find a way to transition to where other health systems in other countries can take over with this can be a sustainable program.
▶ 1:44:21It's which will mean really the United States being our taxpayers to be able to use their money in different ways, but maybe what we're going to be in other ways to stop other calamities. This is my last question that I want to make sure that I can from both of you.
▶ 1:44:40Do you both agree that it is very important that we do not let Humpty Dumpty on the ground all shattered before we try to make this transition that we have to make sure this prevention that the whole comprehensive PEPFAR piece is looked at before before we're able to even transition.
▶ 1:45:06I think that I'm trying to say that is diplomatically as I as I can and that and that does mean that uh other agencies that we have to make sure the CDC, USAID Well, we don't have USAID, but the Peace of USAID, the Defense Department, the Global Fund that those pieces are working, too. Did I Is my Did I make my question clear in my I think so. I'm I'm happy to go first.
▶ 1:45:31You know, I would hope uh Representative Frankel that your taxpayers and your constituents were proud of PEPFAR. Uh you know, I would hope that they would see the work that's been done and really consider it an American success story, not just an African success story. Um you know, it has been very personal, I think, to many Americans who are who are knowledgeable about the program that we've been able to save so many millions of lives. And one of the things I've reflected on is sort of, you know, in the polling that's done that shows that Americans really like this. You know, I think it resonates because it's some of the values that they see in their own communities.
▶ 1:46:02That we don't let families suffer unnecessarily. That Americans are uniquely built to tackle big problems. And this is a big problem that Americans have tackled. And I think they should be really proud of that. So, as we look ahead, we shouldn't forget those values and why that's so important. And again, I think Ambassador Dybul and I are aligned in many ways that, you know, we do need to think of a transition and sustainability plan. But but first, we have to look at the capacities that that are there. W- you know, and and really reassess what are those capacities we have?
▶ 1:46:28What are the strengths of of American ingenuity and American companies that we really want to bring to bear? I think we have to look at sort of the the the goals we still want to achieve. PEPFAR's mission has been very clear. It has been meant to save lives, reduce infections, put people on treatment, and stop people from dying, especially children dying of AIDS. Are those still the goals? And then you can look at a sustainability plan on a country country-by-country basis and say, "Here's where we can move. Here are the roles and responsibilities we're going to share.
▶ 1:46:56Here are the roles and responsibilities that have moved on to you. Here's where private sector can leverage this work and really help us bring those innovations like digital health, like AI, like those new prevention technologies to bear." It's a longer conversation. I don't think it's just a a US policy talking to the national governments discussion. I do think you need all the partners at the table to really go through it and assign those roles and really think to the future.
▶ 1:47:21Cuz I don't think we want arbitrarily pick a timeline and as you said sort of waste all the infrastructure, waste all the work we've done because we decided that we wanted to be out by a certain day and all those reasons we were doing this work no longer mattered. Mr. Dybul. Thank you to the subcommittee and to the chair and ranking member and to the whole committee for for holding this hearing first of all because there are so many other things to do and for your constant bipartisan support.
▶ 1:47:51I do think you framed it exactly right. We have the opportunity to have not only the legacy of the last 20 years, but a tremendous diplomatic, national security and economic success. So we do want to transition from financing over time, but we want to to stronger economic, national security, diplomatic partners and that we can do. It will be different country by country.
▶ 1:48:19There are some countries that will require long-term support because of their socioeconomic status. Others can move more rapidly and I would like to emphasize again that if we move too quickly, the groups most likely to be impacted are faith-based community based organizations because governments don't actually have mechanisms to fund them. But we know because we've done it in the past, we can create we can support them to create those mechanisms.
▶ 1:48:44So we have an opportunity before us similar to 25 years ago when PEPFAR was started. We have an opportunity to have a massive win for the United States on all levels by having successful transitions, by working with the countries and I can guarantee you that the countries want that transition, but they it has to be done in a staged, structured way rather than a chaotic, rapid retreat.
▶ 1:49:11Thank you and that I just I might ask another question, but I'm just waiting for the Um again, thank you both. Mr. Chair, I just have a a uh request if I don't know what to call this from this committee. This is You know, a lot of people I mean, I think what we heard today is so important. I hope that we can find some consensus to deliver a message.
▶ 1:49:42I'm not talking I'm not a political message. We have got to keep Pet Force stabilized, keep the component parts together now so that we can do this transition because you cannot transition from nothing or from a mess. It's It'll cost a lot more money.
▶ 1:50:00So, I hope that we can find some way to deliver this message that I think I've gotten from these two witnesses today in a in a very And then move towards the transition that we've heard about. And I with that I yield back. Thank you very much. Let me Let me again thank both of you. I think this was very helpful.
▶ 1:50:24It's amazing uh what you can done when we actually have folks who understand what they're doing and who understand the subject matter and and without the you know, I'm not cuz I I love activism, but it's nice to be able to do this in a in a year in a forum where we've been able to talk about it. So, uh it's clear we have a lot of work to do as we as we put the fiscal year 2016 bill together and I I think we've heard some great recommendations and some great ideas today.
▶ 1:50:53it is clear that we have to increase accountability, ensure transparency. Uh and we can always do more and better and we always have to strive to do more and better in that in that sense. And so, I think today's been very helpful. Uh with that um Ambassador Dieball and Ms. Connor, thank you again for your time. Uh one thing that we never get back, right? Is our time. And so, with that, this concludes today's hearing. The Subcommittee on National Security, Department of State, and related programs stands adjourned. Thank you.