Save Lives First Act of 2008

Mr. President, 5 years ago, Africa was in crisis and in despair. HIV/AIDS was decimating whole communities. Some countries, such as Botswana, were literally on a path to extinction, with rates of HIV infection among pregnant women in some locations reaching as high as 40 and even 50 percent. In South Africa, while a third of pregnant woman were infected with the virus, the country's political leaders were actually denying that AIDS was caused by HIV infection, an ominous sign that little help was on the way for the over 4 million South Africans--over 10 percent of the population--dying of AIDS.

In 2003, if a woman in sub-Saharan Africa was infected with HIV, the familiar story was all too oft-repeated. She would very likely watch her husband die first, and then her youngest children would also become infected either at birth or through breastfeeding, as she languished under her own death sentence. Within a short time, her children would be orphans, left to fend for themselves in the streets and slums of Nairobi, or Soweto, often getting sick with their own HIV infections and dying alone, without food or shelter or medicine.

The sheer numbers at the time were staggering. The disease affected well over 20 million people in sub-Saharan Africa by the year 2000, roughly equivalent to the total number of American children under 6 years old. The problem seemed overwhelming, indeed hopeless.

What was the world doing to stop the carnage? Were there armies of doctors sweeping in with the miracle drugs that had been saving lives in America and other rich countries for nearly a decade? No. The U.S. was spending under $200 million a year on HIV/AIDS overseas, mostly on report-writing, some condom marketing, and ``capacity-building'' programs that never actually used any of the capacity supposedly built and that had no measurable impact on the devouring epidemic.

Treatment was the demand of most global health activists of the day. An indignant group gathered in South Africa in 2002. ``While a necessary component of the response to HIV/AIDS, prevention will never be enough,'' insisted Winston Zulu of the Network of Zambian People Living with HIV/AIDS (NZP+). ``When will the world wake up to the fact that the 16 million Africans that have already died of HIV/AIDS? This is only the beginning if we continue down the prevention-only path. This movement will make treatment, which we all know strengthens prevention efforts, our priority demand.'' Domestic and international chapters of ACT-UP and others were heckling U.S. officials at international health conferences, demanding antiretroviral treatment for people with HIV/AIDS in the developing world, especially in Africa.

And then something remarkable happened. On a cold January night in

Washington, DC, far from the overcrowded, underequipped clinics of Africa, an American president made a promise--a $15 billion promise to provide treatment to millions of Africans, within 5 years.

Anti-retroviral drugs can extend life for many years. And

the cost of those drugs has dropped from $12,000 a year to

under $300 a year--which places a tremendous possibility

within our grasp. Ladies and gentlemen, seldom has history

offered a greater opportunity to do so much for so

many...tonight I propose the Emergency Plan for AIDS Relief--

a work of mercy beyond all current international efforts to

help the people of Africa. This comprehensive plan will

prevent 7 million new AIDS infections, treat at least 2

million people with life-extending drugs, and provide humane

care for millions of people suffering from AIDS, and for

children orphaned by AIDS.--President George W. Bush, State

of the Union Address, Jan. 28, 2003.

Glimmers of hope ignited around the world that night, as the U.S. policy against providing treatment in a foreign aid program came to an abrupt and inspiring end. The Congress took up the challenge, and passed a bill a few months later that was ground-breaking, a seismic shift in current policy and funding levels. The first and perhaps most dramatic policy shift was the statutory requirement that over half, a full 55 percent of all $15 billion of the program's funding be spent on life-saving medical treatment for people with HIV/AIDS.

People said it couldn't be done. The naysayers said that Africans would not be able to adhere to complex drug regimens. They said that there simply wasn't the capacity to absorb all those dollars and build new clinics and expand hospital wings. They said people wouldn't come from miles around to get tested and treated. We wouldn't be able to use mopeds and bicycles to deliver drugs to the rural hinterlands. There weren't enough doctors. There wasn't sufficient logistic ability to store so many drugs. These arguments are being repeated today. They were uninspired and uninformed in 2003 and they still are today. The President's Emergency Plan for AIDS Relief, PEPFAR, has proven them all wrong.

Since PEPFAR started, over 1.4 million people who would either be dead or dying today have received life-saving antiretroviral treatment. That's millions of children who didn't become orphans. Millions of parents who get to see their children grow up. Millions of moms whose babies were protected from infection. Countless communities across the plains and prairies, streets and slums of Africa and the Caribbean, where hope has taken a foothold. Where once stigma and despair kept people from even getting tested, people now come out by the thousands on HIV testing days in Kampala and elsewhere.

PEPFAR is a comprehensive program, investing heavily in prevention and care as well as treatment. However, the majority of the funds have been spent on treatment. The true nature of PEPFAR, the appeal of the program, the miracle that has raised millions from the dead is the program's commitment to life-saving anti- retroviral treatment. If you ask Africans what PEPFAR is, they'll tell you it's about AIDS treatment. It is the treatment component of PEPFAR that has made it the most successful U.S. humanitarian effort in history because it has literally saved the lives of millions, preserved families and communities, and rescued countless babies from being born with an AIDS death sentence.

Five years later, the American people stand at a crossroads. PEPFAR is expiring and the true test of our commitment to life-saving treatment is before us. We have a choice. Will we lose heart? Will we lose our focus? Will we allow a program that was ambitious, inspiring, targeted and tangibly and measurably effective at saving lives become diluted, vague, ill-defined and lose its life-saving impact? Will we allow partisanship and competing priorities and even some good intentions cloud and subvert the long-term success of PEPFAR? Will we turn PEPFAR into just another bloated, unmeasured and unmeasurable foreign aid program with no accountability and no real impact, a program that tries to do too much and accomplishes too little? As funding increases and rhetoric builds, will we, in this moment of testing, betray our historic commitment to Africa and the lives of millions of its inhabitants?

It is embarrassing to admit that we find ourselves on a direct path to that shameful outcome. The once loud and indignant voices demanding treatment for Africans have found other priorities, it would seem. Inexplicably and inexcusably, the House and Senate PEPFAR reauthorization bills, negotiated with the approval of the Administration, reverse what was undoubtedly the most important element of PEPFAR the requirement that the majority of funding be spent on HIV/ AIDS treatment. What's more, the bills more than triple PEPFAR funding, but only increase treatment targets by 50 percent. Despite their $50 billion price-tags, the House-passed bill and the Senate committee- reported bill would only add an additional one million people, of the many more millions in need, to the treatment rolls over the next five years. It seems that, after five years focusing on helping people with HIV/AIDS, the focus of the program under these proposed reauthorizations would shift to helping the foreign aid ``industrial complex'' of USAID contractors based in the U.S. and European capitals. The proposed reauthorization bills would prioritize literally every possible development cause except HIV diagnosis and treatment.

It is this glaring policy reversal that is the impetus for S. 2749, the ``Save Lives First Act of 2008.'' The bill reinstates the current policy requiring at least 55 percent of funding to go to life-saving medical treatment for people infected with HIV/AIDS. It also allocates a small percentage of funding for the critical diagnostic screening that must be ramped up dramatically if we are to locate and treat every infected person in the countries where PEPFAR operates. Finally, the bill acknowledges that every baby infected with HIV by her mother during birth or breastfeeding is a largely preventable tragedy that should be eliminated.

Although we have grave concerns about many other policies in the House and Senate reauthorization bills, including the prevention policy, the expansion of funding to rich countries, the ``mission creep'' that diverts funding from high-priority HIV/AIDS programs to lower-priority development programs, and others, we chose to focus in the Save Lives First Act on the critical problem of the House and Senate bills' betrayal of the President's and the 108th Congress' historic commitment to life-saving HIV/AIDS treatment.

There is no question that PEPFAR has been the most successful foreign aid program since the Marshall Plan. The structural reason for its success is that it approaches and addresses AIDS for what it is--a viral epidemic. Though much may have changed in the past four years, this simple fact has not, and will not, change.

Regardless of location, demography, mode of transmission, and so forth, the basic method of combating an epidemic, any epidemic, is the same: find the infected, provide them care, and help them prevent transmission to others. There are 33 million people living with HIV, and only they can prevent the transmission of the disease. If we find the people with HIV, we could not only treat them, but yes, prevent new infections as well. That's why treatment and testing are critical to prevention efforts. They are not the whole story--behavior change programs are needed--but diagnosis and treatment are two of the foundations of disease control. What's more, prevention through education is far less costly than treatment. Uganda's success in the 1990s proved that with the proper message and political leadership, behavior change that reduces transmission rates dramatically can be achieved fairly inexpensively. The current PEPFAR program and its original authorizing legislation are appropriately structured on this foundation of diagnosis, treatment and successful prevention.

So what are the mechanics of treating people? First, you must diagnose those who are infected. That is why this bill designates specific funding for performing rapid tests, and sets testing target goals. If we test 1 billion people over the next 5 years, we will discover the vast majority of all those living with HIV. However, experience shows that people will not get tested, no matter how much they may want to, without an incentive to know their status. It cannot be disputed that people

known to be HIV positive suffer enormous stigma and discrimination throughout the world, and therefore need an incentive strong enough to overcome this.

The incentive is treatment. If people know that, should they be found to be HIV positive, there is hope and health in their future, they will have an incentive to get tested. The promise of a longer and healthier life is necessary to overcome the stigma--and, in a self-reinforcing loop, the presence of treatment, and the effect of people literally returning from the dead, goes a long way to reduce HIV stigma. That is one of the reasons why the Save Lives First Act maintains the 55 percent allocation of PEPFAR funding for treatment, and seeks to increase the number of people treated proportionally to the increase in overall funding.

The AIDS drug nevirapine, which costs only $4 per treatment, can dramatically reduce the likelihood that a newborn will become infected with HIV. Yet a new U.N. report delivers the news that only a quarter of HIV-positive pregnant women in poorer countries are receiving the medication needed to prevent baby AIDS. Furthermore, the number of AIDS orphans in poorer countries continues to increase, and in sub-Saharan Africa an estimated 12.1 million children in 2007 had lost one or both parents to HIV.

By sticking to the fundamental disease control methods of testing and treatment, new infections are prevented. First, we have seen here in the U.S. that people who know their HIV status are less likely to engage in risky behavior--they seek to protect themselves and their partners. The Centers for Disease Control and Prevention reports that the 25 percent of Americans who don't know their HIV status transmit 50-75 percent of new infections. What's more, a recent study has suggested that increased testing in the U.S. reduced infection. Further, people who are receiving treatment have less of the virus in them, and are less infectious. There is increasing evidence documenting this phenomenon. Behavior change programs targeted to the general population, most of whom are uninfected, may help reduce infection rates to a point, but it is hard to think of a more direct preventive measure than rendering an HIV positive person less infectious and less likely to infect others.

Therefore, claims that the bill does not address prevention are simply untrue. First, billions and billions of dollars not dedicated to treatment and testing are available for prevention in the House and Senate bills. After spending 55 percent of the $50 billion in the bills on lifesaving treatment, there will still be $27.5 billion left over from which prevention programs could be funded, dramatically more programs than under the current, $15 billion program. Second, and to an important extent, testing and treatment are part of an effective prevention approach.

In addition, some have claimed that the Save Lives First Act significantly increases costs, anywhere from $13-$17 billion. These claims miss the point of the Save Lives First Act--which is not to add to costs, but to prioritize how authorized funds are spent. As the attached treatment cost analysis shows, the total dollar amount for all drugs, test kits, and prevention-of-mother-to-child-transmission materials needed to meet the goals in the bill is just over $11 billion (using conservative assumptions about costs that are likely to be lower in reality due to government discounts). A reauthorization bill containing $50 billion plus numerous ``such sums'' authorities, such as the bills under current consideration in the House and Senate, would contain sufficient money to meet these goals as well as procure the infrastructure necessary to deliver these drugs and diagnostic tests. These costs are not added on top of the proposed reauthorization spending levels, as some have claimed. Rather, the Save Lives First Act takes the first 55 percent of all funding in any reauthorization bill-- whatever the ultimate amount of funding turns out to be--$30 billion, $50 billion or more (as is actually likely given the current appropriations frenzy in the Congress)--and directs it to treatment costs. If meeting the heroic targets in our bill--adding 5 million new people to treatment (in addition to the 2 million already in treatment), conducting a billion HIV tests, and saving babies from being infected by their moms--ends up costing more than 55 percent of PEPFAR funding, we challenge any critic to think of a better use of funds. However, as the attached chart demonstrates, there will be plenty of money in a $50 billion bill left for prevention and care after meeting the requirements of the Save Lives First Act.

The current alternative to this approach, as embodied by the House and Senate bills containing no money dedicated to testing and treatment--is that millions of people will die for lack of treatment. In addition, the vast majority of people with HIV will remain ignorant of their status, and will continue to unknowingly infect others, continuing the cycle that led to the devastating epidemic we now face. Letting people die, and keeping people ignorant of their status, is not the way to end this epidemic. We recognize this truth here in the U.S., where we spend 11 percent annually on prevention, but 67 percent on treatment out of a total budget of $23.3 billion spent on AIDS domestically.

Some have argued that a heroic American commitment to testing and treatment such as the targets in the Save Lives First Act will discourage other donors from supporting diagnosis and treatment. The truth is that other donors have yet to demonstrate substantial commitment to bilateral treatment programs. Most other donors prefer to fund treatment through their contributions to the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria, a multilateral organization affiliated with the United Nations, to which the U.S. is the largest (by far) contributor. That is what the Global Fund is for--to create efficiencies of scale and allow smaller donors to contribute to those more efficient programs rather than reinventing the wheel and starting up their own bilateral programs. When other donors do invest in bilateral efforts, it is almost always on the prevention side--funding needle exchanges for drug users, condom and ``empowerment'' programs for prostitutes, and other prevention efforts in Africa, Asia and eastern Europe, usually based on behavior change programs. This is all the more reason why one donor, the U.S., needs to focus on diagnosis and treatment--the rest of the donor community is not as committed to these programs compared to other approaches. But let's say that other donors want to support treatment--great! We welcome their participation. There is so much to do--between 7 and 8.4 million people still need treatment today. PEPFAR certainly can't treat everyone in a given year, and will have to rely on the efforts of others going forward, if we want to bring hope to everyone affected by this dreadful disease.

We are proud of PEPFAR and the millions of miracles it has created already in its first four years of operation. The American people can look at PEPFAR and, unlike what they'll find with most government programs, they can see measurable and tangible results in the faces of the millions saved and cared for with U.S. funding. PEPFAR isn't ``broken,'' and it doesn't require ``fixing'' in its reauthorization-- it's a stunning success. The burden of proof is on those who want to radically change PEPFAR policies, not on those of us who want to preserve them. We look forward to working with the President and House and Senate leaders to ensure that PEPFAR continues its successful, miraculous, life-saving track record.

Bertha, a 23-year-old PEPFAR treatment client in Tanzania speaks for millions when she says, ``If it is not these ARVs, I think I was dead long time ago because I use and I am still using these drugs. Now I can do anything. I'm healthy and I'm strong.''

Mr. President, I ask unanimous consent that my endnotes and graph be printed in the Record.

Mr. President, I ask unanimous consent the order for the quorum call be rescinded.

I ask I be allowed to speak in morning business for 30 minutes.

Mr. President, I want to speak about the bill which we had hoped to have taken up by now, the PEPFAR Reauthorization Act. Because of some procedural questions, we are not on the bill right now, but I thought I would utilize this time to make some remarks about the bill which I hope we will be able to begin dealing with in the not too distant future.

This bill is called PEPFAR, as I said, but that stands for the President's Emergency Plan for AIDS Relief. It is a program that President Bush brought to the Congress in 2003 and was enacted. It authorized $15 billion over a 5-year period for the purpose primarily of supporting the treatment of AIDS in Africa and elsewhere.

Between 2004 and 2008, according to the Bush administration, PEPFAR has supported a cure for about 10 million people infected by HIV/AIDS, including children orphaned by AIDS. It prevented 7 million new HIV infections. It supported efforts to provide support to another 2 million HIV-infected people.

As a result, I think when the President indicated in his State of the Union speech that he wanted to reauthorize the program, most of us in the Congress, in the House and in the Senate, were supportive of that. I supported the initial legislation and fully intended to support the reauthorization.

There is one little catch. When the President made his announcement, he offered to double the amount of the authorization from $15 billion to $30 billion. I swallowed rather hard because doubling the amount is a big change in the amount of money available, but I assumed I would be able to support the reauthorization of the bill. However, when the bill was written in the House of Representatives and then sent over to the Senate, two things happened. First, one of the things that made the legislation effective in the first place was that we had several conditions attached to it as to how the money would be spent. We were very careful to ensure that the money was spent appropriately. That is one of the reasons it has been effective.

And, secondly, when the bill was written in the House of Representatives, lo and behold, it was not doubled from $15 to $30 billion, it was more than tripled to $50 billion.

Now, there was not anything magical about $50 billion; it seemed like a nice, round, symbolic number. As a result, several of us at that point said: Wait a minute. That is a lot of money. In Washington when a program doubles, that is something. When it more than triples, it bears some looking into.

Because of many of the problems with the substance of the bill, as well as this tripling of the amount from $15 to $50 billion, several of us began to take a harder look at it. Then, as the gas crisis hit, the housing crisis hit, and we find that more and more Americans are feeling the real pinch of a downturn in our economy, the question began to solidify: Should America be committing to spend $50 billion on this program, which at $15 billion was quite successful, without at least considering whether we can reduce the amount and certainly taking a look at the substantive provisions of it to see if it can get back to the original purpose rather

than some of the expanded purposes under the House bill.

That is why several of us said, when the bill came through the Senate Foreign Relations Committee: We object to simply passing the bill out of the Senate without any opportunity to amend it, certainly without any opportunity to reduce the amount of it and without an opportunity to fix it. I know some of us were criticized. But I would hope that when we talk about some of the changes that have already been agreed to, those who were critical of us who said: No, we are not going to automatically pass it, would at least acknowledge there have been numerous improvements in the bill because of the negotiation process which ensued.

I wish to particularly thank Senators Coburn, Burr, and Enzi for working on several provisions of the bill and, frankly, restoring the original purpose of PEPFAR in the process. They did a good job. Let me note two or three of the areas with which I think they did a good job. One key to PEPFAR working in the first place was that at least 55 percent of the funding had to go directly to the treatment of AIDS patients. That was a good thing. Once the House said: No, we can spend this money on other things, too, you could see the same kind of problems with some other foreign aid bills, where money is going to governments or NGOs and you never see it again.

As a result, what Senators Coburn, Burr, and Enzi did was say: Look, we need to get back to the proposition that at least half the bilateral AIDS funding is spent on treatment, for treatment for HIV/AIDS. That, in fact, was agreed to. But I would note, again, that the original House and Senate bills proposed simply eliminating that treatment floor.

Another thing they negotiated was to strengthen the protection of funding for abstinence and fidelity programs, clarifying that 50 percent of any funding had to go to those kinds of programs. I would note, again, that the original House and Senate bills eliminated the requirement in the previous law that a third of the prevention funds would go to abstinence education.

Another thing that they did to make the bill better was to protect faith-based groups and others from discrimination in all funding. Again, the House and Senate bills had very weak conscience clauses, so- called conscience clause provisions. This was, again, an improvement of the bill which would not have occurred if we had simply agreed to the unanimous consent that we pass the bill that had been posed earlier and that some of us had objected to.

To some extent, it strengthens the Global Fund transparency and accountability. This is an area that needs additional strengthening. But there is a part of this bill that is not the bilateral U.S. money, it goes into this big Global Fund. And the Global Fund is not well monitored. It is very possible for our funding to be wasted as a part of that.

Again, there was nothing in the original House and Senate bills on this and they at least got some strengthening of the Global Fund transparency and accountability provisions.

Another provision was to protect AIDS patients from substandard medicine, which again was not in the original language. There were other things. My point is that when those of us objected originally to passing the bill as it came out of the House, we were criticized: Well, this is a perfect bill, we were told. It turns out it was not so perfect after all.

That is point No. 1. Point No. 2, there are some additional things which should be done to the substance of the bill. Point No. 3 deals with the amount of money that is being spent.

Here are some of the remaining areas that are problematic: The bill would not prohibit funding for countries such as China, Russia, and India, countries that are quite wealthy, that have their own nuclear weapons and space exploration programs. Russia is awash in petrodollars. China has hundreds of billions of dollars in its foreign currency reserve, has an exploding military budget, and so on. So, certainly, we ought to limit the funding of the bill to countries that actually need the money.

Secondly, it adds a variety of lower priority programs to spend the extra money above the $15 billion, including--well, I am not going to mention all of these, but educating males about the dangers of visiting prostitutes. That is a fine thing, but is that a priority that we need to spend this money on? Addressing the inheritance rights of women and orphans. There is money in here for legal aid and the like, legal aid services.

There is mission creep in the new legislation. It calls for PEPFAR dollars to support nutrition programs, drinking water and sanitation and income-generation activities and livelihood activities--legal services, as I said.

All of these might be fine, but this is not the PEPFAR program, this is foreign aid. There are not any kind of constraints on this mission creep that ought to be in existence if we are going to authorize this kind of money for it.

The bill diverts funding from AIDS treatment for other purposes. I mentioned legal services and substance abuse and so on. It doubles the funding for the U.N.-affiliated Global Fund, which disregards U.S. policies on positions such as abortion and needle exchange and has been linked to funding for corrupt and criminal regimes.

It strikes current law regarding the inadmissibility into the United States of HIV-positive aliens. It calls for a strategy and objective over the next 5 years with these funds to train and hire 140,000 new nurses and other health care professionals in these countries.

This at a time when the United States is drastically in need of health care professionals and nurses. We are wealthy and can afford to be a very generous country, but we also have needs in this country. I mentioned the water development projects and so on. I happen to be familiar, and Senator Thune has offered an amendment on this, with the needs in the United States of America for water development in our Native American communities, on Indian reservations.

There is a study out right now that demonstrates the need that many, thousands of our Native Americans have to rely on water being hauled to their communities, which they then take to their individual hogans or residences. We need water development right here in the United States for American citizens, and I might add to whom we have a trust responsibility, at least as a priority before we send money abroad for folks who do not fall into that same category.

The final point I wished to make is that this legislation, at $50 billion of authorization, is more than we can afford. The Congressional Budget Office, in fact, says that if it is authorized at $50 billion, we cannot efficaciously spend more than about $34 billion. In other words, it is very hard to spend that much money, at least to do so without a lot of waste, fraud, and abuse.

As a result, even the Congressional Budget Office, the nonpartisan entity that we ask for advice on such things, said we could not spend more than $34 billion in that event. As I said, $50 billion is the amount of the authorization here.

To put it in perspective, what is $50 billion? What could we spend $50 billion on? We passed a new GI bill. It could pay for the GI bill twice. It could pay for the Apollo Program to land a man on the Moon twice. It could pay for about half the entire interstate defense highway system. It could pay the pensions of our military veterans for over a year. Now, $50 billion is a lot of money. As I said, I do not know of anybody who would not be willing, especially if we are able to clean up some of the other language in the bill, to authorize it at $15 billion, maybe to even double it to $30 billion, but $50 billion?

I note President Bush has, at least in more recent months, begun to focus on the wasteful Washington spending, the programs he believes spend too much money, and to put some fiscal discipline on the Congress. In fact, since the Democratic Party takeover of the Congress, the President has threatened to veto more than 25 authorization and appropriations bills. This amounts to about $188 billion in spending because of his view that this is excessive beyond what the American taxpayer can be burdened with.

I will note a couple of those. But it illustrates where the President has been willing to say: I am going to veto a bill. That is his ultimate authority here. In the case of the Labor-HHS 2008 Appropriations Act, the President

would have vetoed the bill by exceeding his request by $9 billion. Now, this is $35 billion more than the previous funding, $20 billion more than the President announced in his State of the Union speech that he would be willing to reauthorize the bill at.

He would have vetoed $2.3 billion beyond the budget in the Commerce State and Justice Appropriations Act in 2008; $2.2 billion in the Department of Homeland Security Appropriations Act.

Then, for some authorizations--because this is an authorization, not an appropriation--the Water Quality Financing Act, H.R. 720, which authorizes Federal spending for State clean water revolving funds, that bill would have been vetoed for providing $14 billion in excess above the current $5.6 billion authorization.

I know many of my colleagues have said a $50 billion authorization for PEPFAR is not a big deal because it is only an authorization, not an appropriation. But that certainly was not the position of the administration when it threatened to veto this bill that was over $14 billion more than what the President wanted, or H.R. 1495, the Water Resources Development Act, which authorized water infrastructure projects. That bill was vetoed for going about $7 billion over what the President had authorized or had budgeted.

So it is kind of difficult to understand how the administration or my colleagues can support more than tripling a foreign aid program by spending $50 billion on PEPFAR when the administration was so keen, and I believe correctly so, to finally put the stake down in the ground and say: I am going to veto legislation that is $2 billion or $3 billion or $7 billion over what it should be, including authorizations.

As I said before, we are very wealthy and therefore should be and can be a very generous country. But we also have to establish our priorities. Changing this legislation and tripling the money is not necessarily going to make it triply effective. In fact, if anything, as I said, I think it is going to make it less effective.

I make this point: We have now an American economy which is struggling and American families who are struggling with their budgets. They do not need additional liabilities, either in terms of taxes or more debt, which they and their children and grandchildren are going to have to pay. Someone has to pay for the $50 billion. I do not know where the money is going to come from. Are we going to take it from other spending? Not likely. Are we going to increase taxes to pay for it? Quite conceivably. Or are we going to add it to the deficit? That is the only other choice.

So $50 billion does not grow on trees. It is very easy to be generous with other people's money. But we are talking about the taxpayers' money. I think, when we are taking about taxpayer money, we need to be good stewards of it. More than tripling a program to get it up to $50 billion in foreign aid is more than I think most Americans--if you put the question to them and said: Is this what you want to do with $50 billion of your money, I would bet you the vast majority of Americans would say: Look, we are willing to be generous, provide something for that program but not $50 billion.

That brings me to my final point. In prioritizing, and that is what Congress needs to do, prioritizing what we spend our money on, we have to look at our domestic needs as well. I have supported some increases in funding for years on programs that I think are very important. The answer has always been: Well, there is not enough money. We would love to help you out, Senator Kyl, but there is not enough money. OK. Now we have gone from $15 billion to $50 billion that we are ready to spend on

Will the assistant minority leader yield for one quick point?

Having mentioned my name and alluded to the fact that we had a hard time getting the Indian health bill to the floor, I hope my colleague would acknowledge the fact that one of the people central in getting that bill to the floor and getting it passed was the Senator from Arizona. It was because of my strong commitment to get that done. I will work with anybody, not only to deal with the Indian health matter but also local law enforcement and the water development problems that we talked about with Native Americans. I know my colleague understands that is my position.

Mr. President, I ask unanimous consent that I be allowed to speak for the remainder of the time on this side in morning business.

Mr. President, I thank the Senator from Indiana for his and Senator Biden's leadership in getting this legislation to the floor.

This Senator has just returned from Africa over the July 4th recess. Four countries in southeastern Africa--Kenya, Tanzania, Uganda, and Rwanda--is where PEPFAR has been concentrated. Out of the $3 billion that is being spent per year in Africa, for example, $500 million of that goes just to the country of Kenya.

As the distinguished Senator from Indiana has said, it is very true that the attitudes about the United States--as a result of us being out there with this very effective program that is turning people's lives around, which, in fact, is taking people who were nothing but skin and bones and now being able to live a somewhat normal life, it has increased the favorability toward the United States enormously all over the continent. It has had a tremendous effect. For example, in Kampala, Uganda, I visited a PEPFAR program. It was not only giving the antiviral drugs--and these were to a lot of the children of the refugees who live in this squalor you could not believe, but, in addition, if their bodies won't take the drugs because they are malnourished, there is a food program that goes along with it through USAID. The combination of the two--a year ago in Ethiopia, the same thing--by getting their little bodies up to where, nutritionally, they can accept the HIV antiviral drugs, it has had a tremendous effect.

On this particular PEPFAR Program, there was much more--a school for the children. The children wore uniforms. The children were learning science, math, English, and all the studies that will give them some opportunity for a fruitful and productive life. So now, as the leadership of our Senate Foreign

Relations Committee has come forth with an extension and expansion of this program, it is absolutely necessary that we pass it.

You cannot do any better than the good will--just think about the globe and about where America may not be held in the highest of esteem. But it is held in the highest esteem in Africa. It is in large part as a result--

I yield to the majority leader for that purpose.

Mr. President, I say to the majority leader, I would have asked that, but this Senator thought that was locked in with the previous unanimous consent. I thank the majority leader for the opportunity.

Mr. President, the United States has benefited enormously because of the good will. That is one thing. But when you see these folks who have been bedeviled with this terrible, terrible infliction suddenly have a chance for a normal life as a result of these lifegiving drugs, when properly administered, along with the food programs as well, indeed it is one of the least things we can do.

Is it not in the capacity of the United States to help the rest of the world? Of course it is. Is it not within our ethos to want to help the rest of the world? It certainly is. Just as a byproduct of that, the people of Africa are recognizing the leadership that the United States has taken. They are appreciative.

I must say that there was a part of this African trip that was very disturbing to me, and that was the grave situation in Zimbabwe. That is as a result of the disastrous regime of Robert Mugabe.

Last Friday, a bunch of us Senators had joined Senators Feingold and Isakson, who are leaders on the African Affairs Subcommittee of the Foreign Relations Committee, in introducing a resolution to rebuke Robert Mugabe and support U.S. efforts at the United Nations to impose tougher sanctions on the Mugabe regime. Although the U.S.-sponsored resolution failed to overcome the vetoes of China and Russia--listen to that: the vetoes of China and Russia--in the Security Council on Friday--we kind of get an indication of where their attitude is about a democratically elected government in Zimbabwe--it is critical for us to continue to work with the U.N. and our African Union partners to help bring about a political solution for the desperate people in Zimbabwe.

On this most recent trip, I didn't go to Zimbabwe. I wasn't welcome. It was a striking survey of the governments that I saw in those four countries, a new African leadership, strong economic growth, the rule of law, political stability--what a contrast with the old ways of dealing with people such as Mugabe, in a government that is marked with autocracy, corruption, and the rule of law through the barrel of a gun. Well, what is clearly in the interest of the people of Zimbabwe and the rest of the world is stability in Zimbabwe. And it is important that we continue to press forward.

In east Africa, the rule of law does have some new applications--for example, the Government of Kenya. There, the whole place was being torn apart because of a dispute in the December election. Finally, after much violence and with as many as 5,000 deaths--if you can believe it-- because of the violence following the election, the business community, the government community, and the two opposition parties came together and said: We have to have a better way. They formed this unity government. Thus far, it has worked. Let's see how it continues.

But in the aftermath of September 11, we know all too well how instability and weak governance and corruption can sow the seeds of radicalization and terrorism. Now, however destitute and downtrodden the heroic people of Zimbabwe, however, those heroic people have risen up against Mugabe's machine at the ballot box on March 29 and they cast their votes overwhelmingly for Morgan Tsvangirai and his Movement for Democratic Change. That opposition party won 48 percent of the vote against 43 percent for Mugabe.

But then, of course, Mugabe initiated a reign of terror and intimidation in the lead-up to this farce of a runoff election. His state-sponsored violence against opposition members, against supporters, against civilians, in an attempt to consolidate his power, ultimately caused the opposition candidates to withdraw from the election. He had to take refuge in the Dutch Embassy. This recent runoff was declared neither credible nor fair by independent election monitors. Mugabe was the only candidate left. He was declared the winner.

Since the initial election back in March, the opposition party said that 86 of its supporters have been killed and 200,000 of its supporters forced from their homes by militias loyal to Mugabe's party.

If you will go back decades, Mugabe took over in a new country of Zimbabwe when he had thrown off the colonial rule under the old Rhodesia. Mugabe was looked upon as a freedom fighter and someone who was going to bring a fresh break, a fresh government that was going to be a democratic government. He has long been celebrated by his fellow African leaders for his role as a liberation leader for Zimbabwe. In recent years, Mugabe has too often been coddled as his failings have come to light. Two weeks ago, unfortunately, the African Union allowed him to take his seat as the head of state among the leaders in their annual meeting that was in Sharm el-Sheikh.

Those African Union leaders were split over how to deal with Mugabe, but they allowed him to be seated. Many leaders, including South African President Mbeki, who serves as the South African Development Community's designated mediator, have stood by as Mugabe has trampled human rights, as he has silenced the press, as he has undermined the rule of law, and he has run the once-thriving Zimbabwean economy into the ground.

South Africa worked behind the scenes to sink the U.S.-sponsored resolution on Zimbabwe at the U.N. last week. This is quite distressing, given that South Africa is where it is today because of the international sanctions to end apartheid.

So now because of these ruinous economic policies, Zimbabwe is the world's fastest shrinking economy. It has a negative GDP of minus 6 percent. It has skyrocketing inflation. Zimbabwe's central bank stopped posting inflation figures in January when inflation stood at, unbelievably, over 100,000 percent. A loaf of bread cost 30 billion Zimbabwean dollars--a loaf of bread.

The sinking economy and the government-orchestrated political intimidation and murder has caused a massive refugee flight into the neighboring countries. According to a recent report by Human Rights Watch, there is now estimated to be 1.5 million Zimbabweans who have fled across the border into South Africa.

The international community must honor the courage of the Zimbabwean people and help them take back their country from the brink of ruin.

Recent reports show that a Chinese ship loaded with more than 1 million pounds of arms bound for Zimbabwe was eventually turned away by the dock workers in Durban, South Africa, a reminder of the support Mugabe continues to receive from around the world.

The United States is going to have to continue to work in the U.N. and with the African Union to immediately call for Robert Mugabe to step down and to push for a number of practical solutions for the crisis in Zimbabwe.

First is an international arms embargo and stricter sanctions. Although our backed resolution in the United Nations last Friday failed, we must continue to work on an international framework to impose sanctions on international arms, travel, and an asset embargo. We have to get Mugabe

to understand that his totalitarian, dictatorial ways have to change.

Then we need to press for any new power sharing arrangement. Any new mediation must secure agreement with the opposition, with Tsvangirai in the lead, and provide support in setting up new institutions. We can assist the transitional government by helping to provide a framework for future elections and reforms.

We need to help them economically. The African Union, led by Zimbabwe's largest trading partners, including South Africa, Zambia, Congo, and Botswana, should put together a package of aid and reconstruction funding to help the ravaged people of Zimbabwe stand on their feet. The United States and Europe can play a leading role in backing that effort with the support that we are so generously quick to offer.

The situation in Zimbabwe is dire, and the United States must take the lead in rebuking Robert Mugabe in calling for a new dawn for Zimbabwe.

It is a time in which when you see the success, the beginnings of political stability, the beginnings of economic blossoming in countries such as Kenya and Tanzania and Uganda and Rwanda, we know the same thing can be done in a place such as Zimbabwe.

Just think, in those last two countries I mentioned, Uganda and Rwanda, look from where they have come. It was not too many years ago that there was a brutal dictator named Idi Amin. A lot of people have seen the movie ``The Last King of Scotland,'' which tells about the brutality of that regime. But as soon as Idi Amin was gone, the former President came in again and became almost as bad, Obote. It wasn't until another strong man, a general named Museveni, came on that he has brought stability for the last couple of decades.

Look at the country immediately to the south of Uganda. Look at Rwanda. Look at what has happened to Rwanda, a country, just 14 years ago, in 1994, because there was the hatred between the two tribes, the Hutus and the Tutsis--the Hutus were in charge of the government. They allowed the militias, the gangs, the thugs to reign and use as an excuse the downing of the President's airplane, and they unleashed a reign of terror that was nothing short of mass slaughter, genocide, of which, unbelievably, within 100 days, 1 million people were slaughtered and hacked to death by machetes. That was 14 years ago.

The general who took over and is now the President of Rwanda, the opposite tribe, a Tutsi, said: We are not going the same way. We are not going to take revenge.

You can imagine when his army came in and invaded the capital city of Rwanda and they saw bodies strewn all over the streets rotting, corpses that dogs were eating the flesh, and when his soldiers found out that their entire families had been wiped out, hacked to death with machetes, you can imagine the problem of discipline that general, now the new President of Rwanda, had in trying to exert discipline.

The President told me in our meeting that was a very difficult time because a soldier would go to his home and find his entire family slaughtered, and he felt that he would have to take the revenge into his own hands, despite the order that the general had given him. The general, the new President, then would have that soldier arrested, even though you can understand the feeling of outrage of seeing 50 members of his family slaughtered.

The President told me also the story about the notes that he would get from members of his army that said: Mr. President, it is not going to please you because you have given orders to the contrary, but I could not stand by and see these people who have slaughtered my family get away with it. And then that soldier would take the revenge and that soldier would then turn the gun on his own self and commit suicide.

But the general's orders took hold. He established a government. It was a government where they would go through under Rwandan law and try those people. They would try to bring about reconciliation. And 14 years later, after 1 million people were slaughtered in a 100-day period, Rwanda is on its way back with some stability, some economic promise, and some economic progress.

This is what can happen in Africa, and this is what needs to happen in Zimbabwe. Soon there are going to be elections in South Africa bringing in a new President. If present President Mbeki will not move, since they are the biggest influence on Zimbabwe because of their trade relationship, if he will not move, then there is another election in South Africa that will elect a new leader, and maybe that new leader will move to bring sanctions on Zimbabwe so that, once again, the promise of Africa will become realized, as so many countries in Africa today are realizing.

Madam President, I yield the floor, and I suggest the absence of a quorum.

Mr. President, I ask unanimous consent that the order for the quorum call be rescinded.

Mr. President, I ask unanimous consent that I be allowed to speak in morning business for approximately 10 to 12 minutes.

Mr. President, I have supporting material related to PEPFAR that I will ask to be printed in the Record, which I will deliver to the desk.

PEPFAR's unique contribution has been treatment. By any measure, PEPFAR has been a success. We have helped almost 2 million people with AIDS live longer. We have prevented millions of new infections. We have cared for millions of people more. And we have prevented hundreds of thousands of babies--newborn children--who were born to infected moms from being infected with the HIV virus.

PEPFAR was different from all our previous efforts precisely because we treated it like a disease rather than a development problem. We ran it like a medical program and not a foreign aid poverty program. Rather than funding the usual beltway contractors who like to write reports, give advice, and convene meetings, we put pills in the hands of doctors, nurses, and a legion of community-based health care workers riding out to the bush on mopeds with medicine in their backpacks. We treated people with HIV like patients we can save instead of victims. And we told them the truth about where HIV comes from.

If you go to Nairobi or Soweto or Kampala and ask people what PEPFAR is about, they will tell you it is about treatment. Have we spent billions on prevention? Yes. But ask anyone in Africa what PEPFAR is, and they will say: It is about HIV and AIDS treatment. It was AIDS treatment that was the innovation of PEPFAR. We had been funding prevention messages long before we had PEPFAR, although certainly not to the extent as we did after PEPFAR started. But what was new, what was miraculous, what rocked Africa, was the medical treatment.

And it has worked. It was not easy. With a tiny staff, the AIDS coordinator achieved the impossible--what many had said could not be done--bringing high-tech medical innovation to the lowest tech settings on Earth. It is still just as hard today as it was then, especially as we start in new countries.

The path of least resistance is always the status quo: contractors and ``social marketing'' and reports and ``technical assistance'' and ``capacity building'' and meetings. Without statutory mandates, that path will always look more appealing to people who have been asked to do the impossible. That is why PEPFAR reauthorization could not retreat on its mandated treatment priority.

Take it out of the law, and despite all the rhetoric and good intentions, it will always be easier to fund something else. Maybe treatment would not have been eliminated, but it would have taken a back street, maybe by small cuts, by not building new clinics in the harder places, by letting the shortage of doctors become an excuse to not get creative. The commitment to treatment would have eroded over time, and before we knew it, PEPFAR would have become just another failing foreign aid program like so many others.

It does not matter what people say their intentions are, because people come and go and promises are hard to keep. What matters is what the law requires, and so it is encouraging to be able to assure the American people today that PEPFAR's unique innovation--cutting-edge HIV/AIDS medical care--has been preserved in this bill.

For that, there are a lot of people to thank, starting first with the President and his staff, who first reached out to try to broker this critical compromise. Of course, the bill managers, Chairman Biden and Senator Lugar, and their staff were patient, constructive, and deserve all the thanks in the world. They were quick, thorough, honest, and at all times operated in good faith. Senators Enzi and Burr and their staff were incredible to work with, and their commitment to this cause is commendable.

The compromise language has a number of critical features that make it worthy of passage.

First and most important, the compromise restores the critical focus of PEPFAR on medical treatment. The House bill eliminated the provision in current law that required that 55 percent of all funding go to ``therapeutic medical care'' of people with HIV. The managers' substitute preserves this focus by requiring that ``more than half'' of the money goes to that medical care. This time, the law will also clarify what was meant by ``therapeutic medical care,'' so that there is no longer any confusion that this treatment money can be spent on ARV--antiretroviral--treatment, care for opportunistic infections, and medical monitoring of folks who do not yet need antiretroviral therapy.

Prioritizing treatment is not a radical policy. It is the same policy we have right here in the United States. In this country, this year, we are spending 63 percent of all domestic AIDS funding on treatment and 14 percent on prevention. Prevention is cheap, so you can still make prevention a big priority without spending nearly the money necessary for treatment.

The substitute also restores an ambitious target linked to funding. The original law had the 55-percent allocation, but it also had an ambitious target of treating 2 million people with antiretroviral drugs. The House-passed reauthorization only targeted 3 million people on treatment--a pretty underwhelming figure that meant adding only 1 million people on PEPFAR treatment rolls. That 1 million would have been a 50-percent increase in results, while funding was more than tripling in the bill.

Some have argued that this funding includes a lot of other things besides AIDS and so you cannot make that comparison. That is just not true. The original bill included malaria, it included TB, and it included the Global Fund. So it is an apples-to-apples comparison to say that the funding for AIDS, TB, malaria, and the Global Fund was $15 billion the first time this bill was authorized and that then, in this bill, $50 billion is authorized for those same things at this time.

That is a tremendous amount of money, and the targets for what we expect to achieve with that money must go up at the same rate the funding goes up. The compromise language appropriately links the target number to appropriations. As the funding goes up from the current funding level, the treatment target has to go up by the same percentage above the current goal of 2 million people. That means that if all the money authorized in this bill is appropriated, the number of people treated will exceed more than 5 million. Those extra millions of lives saved are a major accomplishment of the Senate bill. Those are lives. Those are individuals who would otherwise succumb to HIV.

However, the formula does not end there. Treatment costs per patient right now are fairly high--anywhere from $800 to $1,000 per patient. Some drugs are as low as $80 or at most around $200 per person, so we are talking 80 percent of the treatment costs that are not being spent on direct medical care now. That 80 percent represents overhead and infrastructure which should be reduced over time as the efficiencies are built in and clinics are expanded.

To account for that, the compromise language also requires that the target number for treatment increases by the same percent that cost- per-patient decreases over time. This ensures that the cost savings are reinvested right back into treatment rather than diverted to other activities.

Another key element of the compromise is the protection of PEPFAR patients from substandard medicines. From the earliest days of PEPFAR, there were some calling for the United States to buy cheap, copycat drugs for PEPFAR patients, including drugs that were not approved by the FDA or any other rigorous regulatory body of any country. These are drugs we would never treat our domestic patients with here in the United States. This is no abstract threat. Today, under the Orwellian named ``quality assurance'' process at the Global Fund, American dollars may be used to purchase drugs that have met no standard except that they have been put on an application for a WHO prequalification.

When this conflict arose shortly after PEPFAR was first authorized, the President rightly insisted that we would not treat the African AIDS patients like lab rats or guinea pigs. We would treat them with the same standards we treat American patients: They would only receive drugs with FDA approval or equivalent. To help expedite the approval of some international products that were likely safe and effective but had not been through the FDA process, the President established an emergency review process to speed up approval while still ensuring that PEPFAR patients get the same standard of care we expect for our domestic patients. Since then, others have generally agreed that all appropriate safe and effective drugs make it through this new process with proper and direct speed.

In direct contradiction of this more moral approach, the House bill took bilateral PEPFAR programs down the same scary path that the Global Fund has gone. It required that PEPFAR purchase the cheapest drugs available on the world market, without requiring any standard of safety and efficacy. Under such a provision, African patients would have been treated worse than lab rats--receiving drugs that the United States would never use for its patients, never purchase through Medicaid, Medicare, or the Ryan White Care Act.

The bill managers are to be commended for modifying this provision in their substitute to require that drugs purchased by PEPFAR have FDA approval or its equivalent in other developed countries. We can all breathe a little easier as we seek to put 5 million people on ARVs. We want those 5 million people to thrive as long as possible on first-line drugs before they experience a treatment failure. You should not be relegated to unsafe drugs just because you are poor and living in Africa.

There are quite a few other improvements in this substitute bill that the managers and the President helped to broker, but I will not take any more time. Suffice it to say that most of my outstanding concerns have been met through our negotiations, and I am confident that PEPFAR's success in the future is no longer in jeopardy.

PEPFAR was not broken. It did not need fixing. It just needed reauthorization. The managers' substitute does that. I am confident that lives are going to be saved because of the good faith in the bill and of the bill managers and the President and my other colleagues who are associated with it.

Mr. President, I ask unanimous consent to have the supplementary material I referred to printed in the Record.

Mr. President, I yield the floor.

I thank the leader.

I rise today in support of S. 2731, the Tom Lantos and Henry J. Hyde United States Global Leadership Act Against HIV/AIDS, Tuberculosis, and Malaria. I thank Chairman Joe Biden for working with me and other Republicans to achieve a bipartisan approach for the reauthorization of our Nation's program to combat these diseases. I believe we will have an excellent bill before us that will preserve the best aspects of the President's Emergency Plan For AIDS Relief--PEPFAR--and expand the efforts of the United States to stem the tide of AIDS, tuberculosis, and malaria worldwide.

The HIV/AIDS pandemic, coupled with the impact of tuberculosis and malaria, is rending the socioeconomic fabric of communities, nations, and an entire continent. The U.S. National Intelligence Council and innumerable top officials, including President Bush, have stated the HIV/AIDS pandemic is a threat to national and international security.

Communities are being hobbled by the disability and the loss of consumers and workers at the peak of their productive, reproductive, and care-giving years. In the most heavily affected areas, communities are losing a whole generation of parents, teachers, laborers, health care workers, peacekeepers, and police.

United Nations projections indicate that by 2020, HIV/AIDS will have depressed GDP by more than 20 percent in the hardest hit countries. The World Bank recently warned that while the global economy is expected to more than double over the next 25 years, Africa is at risk of being left behind.

Many children who have lost parents to HIV/AIDS are left entirely on their own, leading to an epidemic of orphan-headed households. When they drop out of school to fend for themselves and their siblings, they lose the potential for economic empowerment that an education can provide. Alone and desperate, they sometimes resort to transactional sex or prostitution to survive and risk becoming infected with HIV themselves.

I believe that in addition to our own national security concerns, we have a humanitarian duty to take action. Five years ago, HIV was a death sentence

for most individuals in the developing world who contracted that disease. Now there is hope. We should never forget that behind each number is a person--a human being--a life the United States can touch or even save.

PEPFAR has provided treatment to an estimated 1.4 million men, women, and children infected with HIV/AIDS in Africa and elsewhere. Before the program began, only 50,000 people in all of sub-Saharan Africa were receiving lifesaving antiretroviral drugs. Today, three times that many are being treated in Kenya alone. PEPFAR also has focused on prevention programs, with the target of preventing 7 million new HIV infections. As Americans, we should take pride in our Nation's efforts to combat these diseases overseas.

We should understand that our investments in disease prevention programs have yielded enormous foreign policy benefits during the last 5 years. PEPFAR has helped to prevent instability and societal collapse in a number of at-risk countries; it has stimulated contributions from other wealthy nations to fight AIDS; it has facilitated deep partnerships with a generation of African leaders; and it has improved attitudes toward the United States and Africa and other regions of the world. In my judgment, the dollars spent on this program can be justified purely on the basis of the humanitarian results we have achieved, but the value of this investment clearly extends to our national security and to our national reputation.

I wish to emphasize three points that should guide our deliberations. First, it is important that Congress move now to reauthorize the program. The authorization expires in 2\1/2\ months. Partner governments and implementing organizations in the field have indicated that without certainty of reauthorization of this bill, they may delay expanding their programs to meet PEPFAR goals. Certainty of U.S. action is an important matter of perception, delivering something similar to consumer confidence to these nations. It may be intangible, but it will profoundly affect the behavior of individuals, groups, and governments engaged in the fight against HIV/AIDS. The continuity of our efforts to combat aids, malaria, and tuberculosis, and the impact of our resources on the commitments of the rest of the world will be maximized if we act now.

Underscoring this point, last fall the Ministers of Health of the 12 African focus countries receiving PEPFAR assistance wrote to us saying:

Without an early and clear signal of the continuity of

PEPFAR's support, we are concerned that partners might not

move as quickly as possible to fill the resource gap that

might be created. Therefore, services will not reach all who

need them. . . . The momentum will be much greater in 2008 if

we know what to expect after 2008.

Secondly, our bill expands the flexibility of current law so that U.S. efforts in each country can be tailored to its unique situation. I have consulted extensively with American officials who are implementing PEPFAR. Most believe that adding new restrictions to the law can limit the flexibility of those charged with implementation in 2009 and beyond. We don't know who that will be and, more importantly, we don't know what the challenges of 2013 will be, although we can probably say with confidence the landscape will be very different than it is today. As the Institute of Medicine said, the Global Leadership Act is a ``learning organization.'' We should pass a bill that allows PEPFAR to expand and evolve its program implementation, utilizing the experience it has gained in its initial years of operation.

I understand some Members identify concerns or areas that they believe deserve specific emphasis. As Senators study the record of PEPFAR to date, I believe they will find that the vast majority of the authorities needed for the next phase of our efforts already are in existing legislation. This flexibility is preserved in the House bill and in the bill before us today.

The one directive in the Leadership Act that I believe must be maintained holds that 10 percent of funding be devoted to programs for orphans and vulnerable children. There were few programs focused on the needs of these children before the Leadership Act, and we remain in the early stages of the effort to serve them. Before the advent of PEPFAR, neither the United States nor anyone else had much experience in programs that support children infected with or affected by HIV/AIDS. After several years of effort, we have made some progress, but our programs are not yet as firmly established as they can be.

The AIDS orphans crisis in sub-Saharan Africa has implications for political stability, development, and human welfare that extend far beyond that region. The American people strongly back this effort, and the maintenance of this directive will help to ensure that we remain attentive to those who need our support the most. The directive will also help ensure the success of the Assistance for Orphans and Other Vulnerable Children in Developing Countries Act of 2005, a bill I drafted and which was cosponsored by 11 Senators. That bill was signed into law on November 8, 2005.

The third point I would underscore is this is an authorization bill subject to the annual budget and appropriations process. It is meant to establish policy and the overall parameters of spending on the PEPFAR program. The $50 billion figure is based on what we believe can be spent efficiently and effectively in the years ahead. It presumes that funding will gradually increase over the coming 5-year period. Of the $50 billion authorized, $5 billion has been reserved for malaria and $4 billion has been reserved for tuberculosis.

I understand some Members would spend less than $50 billion, while others would choose to spend more.

But this is a reasonable target that has emerged from good-faith negotiations between Congress and the White House. I believe it will maximize the humanitarian and foreign policy benefits of the PEPFAR Program.

We have an opportunity this week to establish policy on a bipartisan basis that will be a triumph for the United States of America. We have the opportunity to save lives on a massive scale and preserve the fabric of numerous fragile societies. I ask my colleagues to continue to work together for this very important result.

I look forward to the passage of this important legislation.

Mr. President, I yield the floor.