Written Statement by The Honorable Mark Dybul: The House Appropriations NSRP Subcommittee
Written Statement by The Honorable Mark Dybul, MD
Professor of Medicine, Georgetown University Medical Center Chairperson, Purpose Africa
The House Appropriations NSRP Subcommittee April 8, 2025
Good morning Chairman Diaz-Balart, Ranking Member Frankel and distinguished members of the Committee. It is a great privilege to come before this group, which I have had the opportunity to testify on PEPFAR and the Global Fund to Fight AIDS, Tuberculosis and Malaria since the days of Jim Kolbe in and Nita Lowey in 2006.
It has been the honor of a lifetime to have been one of the architects of the original PEPFAR plan, and to have been deeply engaged with the program for two-thirds of my professional life. Please accept heartfelt thanks to all the Members and Staff who have provided steadfast support in a bipartisan way for more two decades.
I hope we can all agree that this Committee and the American people’s investment in PEPFAR have made our country safer, stronger and more prosperous. In that regard, please accept deep appreciation for maintaining appropriations for the most effective US development programs, including PEPFAR and the Global Fund to Fight AIDS, Tuberculosis and Malaria despite substantial reductions in the Subcommittee’s overall envelop.
Averting Disaster
It seems important to recall the state of the epidemic at the turn of the Century. In the most impacted countries, more than 30 percent of the adult population was infected with HIV. In certain districts in Botswana, 75% of pregnant women carried the virus. There were entire villages run by orphans or grandparents because there were no adults left alive.
Unlike many diseases that target the young and the old, HIV infects those who are not only in their reproductive – but also their productive – years. There was a persistent misunderstanding that the poorest were most vulnerable. The greatest risk was among those who had begun to climb the economic ladder - factory and mine workers, doctors and nurses, corporate executives and government officials. There were projections for substantial decreases in economic growth. Indeed, Ford was among the first Corporations to provide life-saving treatment to its workers in Africa so they could keep their assembly lines moving.
Soldiers were at very high risk. Africa struggled to field peace keeping forces. There were reports from the US national security sector raising the alarm about the risks of HIV. It had the potential to tumble fragile states and leave a huge cadre of desperate young people susceptible to terrorist recruitment. So we ensured that the first ever UN Security Council meeting on an infectious disease was on HIV.
Fortunately, and largely because of US led global intervention, the dire predictions of global instability and economic harm did not occur.
Our great country acted decisively and effectively to avert disaster and, in doing so, offered the world a shining example of who and what we are when we are at our best.
Helping America to be Safer, Stronger and More Prosperous
PEPFAR has been called – and I believe in fact is - “the most successful global health program in history.” That powerful statement is no small part due to the astounding success of the program:
• More than 26 million lives saved – that bears repeating – more than 25 million lives saved.
• More than 7.5 million babies [AV1] saved from HIV infection around the time of birth.
• More than 8 million children [AV2] saved from becoming orphans.
Buts it’s impact is much wider and deeper -- from villages to State Houses, from Africa to Asia to Latin America -- in improved diplomatic relations – which translates directly to our national security, stronger health systems, in particular remarkably robust data systems for a results- focused, transparent accountability that can serve as a foundation for enhanced health security and pandemic preparedness and response, and potential for a healthy, growing market for US goods and services – legacies that have helped America to be safer, stronger and more prosperous in the future.
In other words, PEPFAR has been a transformational model that helped drive reforms throughout US and international development programs.
With your indulgence, I would like to tell a story that remains vivid in my memory. In 2006, while I was the US Global AIDS Coordinator, I was fortunate the visit Axum, Ethiopia, believed to be the birthplace of Christianity in Africa. At dawn, with the mist over the town blocking the electrical wires, it looked as it might have centuries ago. Local farmers winding through the streets with donkey-drawn wagons, the spires of the churches peeking through the haze, bells ringing to call all to prayers and the market. We were met at the local clinic by the director and his team. In a town that small, the clinic director was also a town elder and leader in the community. He kept referring to PEPFAR. I was cranky from too little sleep so asked him what PEPFAR means. His answer knocked me over. He said, “PEPFAR means the American people care about us.”
That wonderful phrase captured the sentiments I have heard from nearly every corner of Africa. And that soft power – as many leading generals, admirals and commanders on the ground have clearly said is essential for our national security - can be quantified. Senators Frist and Daschle, who were the Senate’s Majority and Minority leaders when PEPFAR was first authorized, led an assessment by the Bipartisan Policy Center of the impact of the program on perceptions of the United States in Sub-Saharan Africa. In PEPFAR supported countries, 68 percent of respondents had a positive view of our country, compared to only 46 percent in non- PEPFAR supported countries. In fact, many PEPFAR-supported countries have a higher percent positive view of the United States than people in the United States.
The sentiment expressed in Axum has grown with every life saved and as individuals, families, communities and nations moved from total despair to hope for the future. Hope is not just a matter of faith or a good feeling. It awakens a lost desire to find a job, go to school, feed a family, care for your community. It is, in fact the basis for economic growth and the development of markets for US goods and services. That is not just a theory. The Kaiser Family Foundation reported that PEPFAR-supported countries had a 2.1 percentage point increase in the GDP growth rate per capita from 2004 to 2018[AV3] .
Indeed, prior to the COVID pandemic, Africa, as region, had the second fastest growing regional economy in the world. It also has a rapidly growing population. By the 2030s Africa will be larger than either India or China. While the latter has an aging population, 70% of Africa is under the age of 30.[AV4]
Africa is a key and growing market for US goods and services.
While PEPFAR is an HIV program it has remarkable ripple effects on the broader health system. Treatment and prevention of HIV is a life-long enterprise requiring well trained health care providers including community health care workers, pharmacists and pharmacies, lab technicians and laboratories, logistics, supply chains and communications systems and much more. These systems are public but also private, including faith-based organizations.
At the beginning, because of stigma and discrimination, many HIV services were provided in separate locations. However, the vast majority of HIV-related activities now occur in general health care settings. So the doctors, nurses, lab techs, pharmacists, community health workers – and all the support systems – serve non-HIV roles as well.
In that regard, a recent analysis by the American Foundation for AIDS Research (amfAR) found that countries supported by PEPFAR have seen a 235% greater increase in the number of trained nurses and midwives than countries not supported by the program. For that reason, it is not surprising that studies have shown that PEPFAR is associated with a significant improvement in 6 out of 7 key indicators of maternal and child health including rates of mortality for women and children and childhood immunization.
The dramatic life-saving results are linked to prevention as well as treatment. Effective prevention is key to reducing the number of new infections which is essential for sustainability. For example, male-circumcision is a remarkably cost-effective intervention. More recently, using treatment to prevent infections has shown great promise. Similar to taking anti-malaria drugs when traveling, pills – and recently a single injection that can last three to six months – provided to those most at risk of infection including women and men of reproductive age could help bring new infections down to very low-levels. Combined with an expected increase in deaths as those who started treatment more than 20 years ago begin to die of natural causes, it is possible to substantially reduce the number of persons requiring treatment in 7 to 10 years. With expected advances in other technologies, including vaccines, it is now possible to conceive of nearly eliminating HIV in our lifetime.
Among the most important investments in systems were transparent data for monitoring and evaluation to help drive rapid and continual pivots to maximize results and taxpayer investments. Those systems also provide a backbone of transparency and accountability for Congressional oversight, but also for country management and ownership.
The power of those improved health systems was clearly demonstrated during the height of the COVID pandemic. PEPFAR-supported HIV testing was used to detect SARS-Cov-2. Clinics, hospitals and community workers, and commodities procured were all used to help combat the deadly disease. Looking to the future and the threat of another pandemic, the best way to ensure early detection and to respond rapidly is to maintain and strengthen the capacity to respond to an ongoing pandemic, such as HIV, with an intentional design for surge capacity when needed promoting our health security and national security.
Key Role of the Global Fund
As a former Executive Director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, I’m proud the partnership has saved over 65 million lives from AIDS, TB and malaria. I would like to thank the Committee for its support of that important organization. With the 33 percent cap on contributions from the United States, it is a potent means to help ensure the American taxpayer is not alone in this fight. The Global Fund also plays a key, and complementary, role in building health systems and pandemic preparedness and response. In fact, the success of PEPFAR and the President’s Malaria Initiative are intertwined with the Global Fund and serve as a model for how US investments in bilateral and international programs can be synergistic. And our engagement in a results-driven international organization contributes to our diplomatic relations.
Transitioning from Funding to Stronger Economic, Diplomatic and National Security Partnerships
I hope we can all agree that few US Government programs have been as impactful as PEPFAR. It has rightly been called the best policy decision by any President in the past half Century. And few international programs have been as impactful as the Global Fund. However, neither PEPFAR nor the Global Fund can or should be forever.
The health care capacity that has been built provides a foundation for a structured transition to fully country led and owned programs. In addition, countries have also increased their financial commitments to health and HIV programs. Domestic sources accounted for 59% of all HIV- related spending in 2023. However, the increases are very uneven and much work remains to be done.
While substantial work has been done to prepare for transitions, now is the time to execute a comprehensive plan with clear, annual and transparent benchmarks on progress, including reductions – beginning now in funding.
Countries are in different stages on their journey to self-reliance. It could be useful to group them based on the amount of external funding they receive, socio-economic factors and others and, in working with countries within each group, to set accountable, clear targets for progress within each category and progress towards a final transition.
In my view, there are a handful of countries – in particular in Asia and Latin America - who could rapidly have full transitions. There are least a dozen countries, some with large PEPFAR and Global Fund allocations, could successfully transition within a few years, including regular reductions in funds during that time. Others will take longer – some much longer, but they can and should begin now.
It is essential that PEPFAR and the Global Fund function as a single team, working with Heads of State, Ministries of Finance, Health, Economic Planning and others as well as sub-national structures, e.g., Governors and States as appropriate. Grants, loans and private sector investments must be available in a coherent way with a different mix of mechanisms based on where each country is on their journey to self-reliance. For too long, the various Departments and Agencies responsible for grants, loans and effective engagement of the private sector have acted – and receive appropriations – in disparate and unaligned ways. Sustainability and effective transitions will require bold, new approaches to an “all of government” approach here in Washington, in partner countries and by International Organizations and Development Finance Institutions.
It is also essential that faith- and community-based organizations, who often provide substantial health services, be fully engaged from the beginning. Those organizations are likely to bear the brunt of rapid resource reductions. Many partner governments have no clear systems to transfer funds to faith- and community-based organizations. But with time and effort, those mechanisms can be created.
The strong data systems that have been developed are key to effective and rapid transitions. It is essential that they remain active to help ensure that countries to maximize impact and to have visibility into current externally financed programs – in particular for faith- and community-based organizations – to ensure the vital services they provide do not fall through the cracks. Overtime, the countries can fully absorb the systems to enhance transparency and accountability within the health sector as a model for other sectors – as has already been done
in several places. Finally, those data systems are indispensable for continued oversight by the Administration and Congress.
The private sector must be at the table from the outset. Often, the private sector is a second, third or fourth thought – or not even considered at all. We also approach them from a public sector lens rather than working with them based on their needs and limits. There can be no sustainability without revenue generation from health programs – moving from “health to wealth”. There are opportunities for American investors and companies to reap rewards and for Asian, African and Latin American investors and companies to grow their economies to create markets for our goods and services. There are important US Government financing instruments as well as African, Asian and Latin American Development Finance Institutions – some have already begun to engage in health – which could play key roles identifying projects, co-financing including providing first-loss investment.
While it is important that every country transitions from external financing for their HIV and health services, it is equally important that they transition to become stronger economic and diplomatic partners of the United States for the long-term.
I have remained very active in Sub-Saharan Africa, and I can assure you that there are ready and willing partners to enact clear, accountable and successful transition plans from State Houses to Ministries of Finance and Health to villages, faith and community-based organizations, private sector investors who see “health to wealth” opportunities and African Development Financing Institutions, including the African Export-Import Bank and African Development Bank. Indeed, those key actors have already been engaged in increased health financing towards sustainability.
The alternative to successful transitions is frightening to contemplate. Moving too rapidly to dismantle one of the most successful programs in history threatens millions of lives, reverses decades of stronger diplomatic gains effecting national security, and substantially limit opportunities for stronger economic partnerships and markets for US goods and services.
As this Committee knows, the United States is now in a worldwide struggle to remain a beacon on the hill and to ensure that we are safe, strong and prosperous. While we must lead, we must have allies including, and perhaps particularly, in Africa where democracy is threatened and where we have lost ground as the number one trading partner – and where the opportunity for the future is so vast. Clearly, PEPFAR alone is not sufficient.
But after nearly a quarter Century of working with and supporting Africans at all levels, the wisdom of the words from Axum 15 years ago rings truer than ever.
People know what we stand for when we stand with them. With your continued support and a clear plan for successful transitions from external financing and to stronger economic and diplomatic partners, untold millions of lives will continue to be lifted up and saved,
strengthened health systems for the ongoing HIV pandemic will continue to improve the health of mothers, children, communities and nations. Those systems will better prepare us for, and help respond to, the next pandemic threat. And our values and our economy will flourish. That will be another remarkable legacy for this Committee and the American people.
The choice before us is clear: do we have a well-planned, structured, successful transition over time that begins today – one that helps make America safer, stronger and more prosperous – or do we squander one of America’s greatest achievements, retreating too quickly and chaotically, risking the lives of millions and leaving a void for others to fill. That choice is ours to make.
Thank you for listening and I look forward to your questions.