Tracking PEPFAR in the Senate — PEPFAR Approved Despite Flaws; Deal to Lift HIV Travel Ban Reached!

Scott Swenson

The Senate passes PEPFAR, removes the HIV travel ban, and reinforces some ideological restrictions that should have been removed. More people will be helped, and that is good.

This post was created during the Senate deabte on PEPFAR July 15 and 16, 2008. Time stamps have been used throughout as the piece was updated.


Given the number of quorum calls and diversions to morning business, its hard to call this "live blogging" but we’ll be updating threads here today as the Senate makes its way through the amendments on the President’s Emergency Plan for AIDS Relief (PEPFAR). See our extensive expert coverage for the reality of the debate that should have been, and why the debates in the Senate are so far removed from the reality of where these negotiations started before Rep. Tom Lantos (D-CA), died.


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11:50 a.m.
DeMint Defeated. Sen. Jim DeMint (R-SC) tried to make PEPFAR sound like a bill to force women to have abortions, but failed as the Senate voted to table his bill 70-24. DeMint broke from Senate protocol to spread this misinformation, PEPFAR has nothing to do with abortion. He forced supporters of PEPFAR to table an amendment to reduce the number of countries PEPFAR could work in from 120 to 15, another bad idea promoted by DeMint, in order to defeat the attached abortion amendment applying Kemp-Kasten to PEPFAR.


12:05 p.m.
Sen. Dick Durbin (D-IL) calls President Bush’s decision to pursue PEPFAR "inspired" after seeing a time when it seemed like there was little that could be done to help slow HIV infections and get treatments to people living with AIDS.

Durbin says if you want to understand the developing world, to evaluate a nation’s ability to overcome their problems, you should ask "How do you treat women," explaining that women’s needs in the developing world are paramount. "If women are treated like property, slaves, or chattel; if they have no voice in decisions of the family or community; it is likely that some of the worst medical and economic conditions will continue, and worsen. But if women have a role, if they are educated, if they have a voice in their communities and their government it makes all the difference in the world," said Durbin.

While the language on the Senate floor sounds great, the reality of these negotations is that many of the issues impacting women, especially the integration of HIV and reproductive health services, have been completely ignored by the negotiators.

And yes, this is an important and good bill, as many will say today and the mainstream media will soon proclaim, we just maintain it could have been better.


12:37 p.m. Senate adjourns until 2:15 p.m.


2:50 p.m. Sen. Jon Kyl (R-AZ) introduces an amendment to appropriate no more than $10 billion in the final fifth year of PEPFAR, suggesting that we should, in essence, spend $10 billion per year. This amendment has some AIDS activists anxious because they are unclear about how the vote will go. One note here is that Kyl does seem to be giving in on the fact that the $50 billion dollar pacakge will not be reduced to $35 billion as a DeMint amendment yet to be voted on proposes.

The issue that Kyl doesn’t address is the fact that it takes time to ramp up programs, especially complex global public health programs. Kyl did acknowledge that under the current PEPFAR, appropriations have increased in later the years, totalling $6 billion in the final year. The Congressional Budget Office and other organizations have looked at the ability for PEPFAR countries to absorb the additional capacity. While there are concerns about increasing capacity over time, the best way to ramp up is to do it over the five years, which may require appropriating larger sums at the end of the five year program, which the Kyl amendment would prohibit.


3:00 p.m. Sen. Judd Gregg (R-NH) raises issues of fraud and abuse as a reason for more oversight of PEPFAR, essentially accusing African nations of misusing funds. But so far most of the abuse and misuse of funds in PEPFAR has been a result of continuing to fund failed abstinence-only programs, and people like:

Anita Smith: to the President’s Advisory Council on
HIV/AIDS (PACHA), a body established during the Clinton administration
to provide policy recommendations on the U.S. government’s response to
HIV/AIDS. An outspoken opponent of comprehensive sexuality education
with close ties to the Bush administration, Smith is vice president of
the Institute for Youth Development and head of the Children’s AIDS
Fund (CAF). CAF was originally founded as Americans for Sound AIDS/HIV
Policy by Smith and her husband, Shepherd Smith, in the 1990s. In 2004
their organization applied for funding from the President’s Emergency
Plan for AIDS Relief (PEPFAR) to implement an "abstinence-only" HIV
prevention program in Uganda, but a federal expert panel deemed their
project "not suitable for funding." Without explanation, the Office of
the Global AIDS Coordinator overrode the panel’s decision and
authorized the grant to CAF. On February 15, 2005, Rep. Henry Waxman
(D-CA) wrote to the Global AIDS Coordinator’s office to learn why the
grant was made despite the proposal’s negative rating, but to date he
has received no response.

Sen. Gregg is right to be concerned about abuse, and about making sure that the money is spent on actually delivering HIV treatment and prevention services where it is necessary — he should just be looking a little closer to home for where the problems are.


3:21 p.m. Sen. Dick Lugar, (R-IN), rises to oppose the Gregg amendment, citing many ways in which various agencies already pay very close attention to how PEPFAR money is being spent, thus making additional oversights redundant. Lugar cites extensive reviews of monies spent in ten PEPFAR countries, with five reports still in the field. He then says, "the review of [PEPFAR] comes down to the saving of hundreds of thousands of lives, the alleviation of extraordinary suffering on this planet, and I would simply say, from the standpoint of our foreign policy, one of the strongest ways the United States has made an impact, on a number of countries, in which our public diplomacy, or diplomacy of any sort has not been very successful in the past."


3:30 p.m. Sen. Gregg engages Sen. Lugar in questions about Inspector General issues, Lugar points out the Gregg’s approach does not save money. Sen. Joe Biden (D-DE) lifts large binders to demonstrate the oversight that already exists, and says that USAID and others "know how to know" about tracking dollars overseas, which the people already charged with oversight do. Sen. Gregg seems to be done.


3:57 p.m. Jim Bunning (R-KY) speaks to his amendment reauthorizing the current PEPFAR program at existing funding levels. Sen. Biden says the Bunning amendment belies an important point, that the $15 billion original authorization was insufficient, and that understanding the challenge of AIDS means that we share expertise of how to fight AIDS with all nations, even developed nations like Russia and China. Biden talks about what has been learned during the first five years from reports by the General Accoutning Office, noting that some of the earmarks in the original PEPFAR for certain kinds of prevention activities were actual impediments to progress. The Institutes of Medicine and GAO notes that abstinence-only programs presented imediments and programs to prevent mother-to-child transmission were underfunded, that HIV and reproductive health services should be integrated — all issues that have not been dealt with openly in these debates, limiting the program’s success.

Um, Sen. Biden, you might want to look at the bill you are leading the debate for and double check where the improvements suggested by IOM and GAO about abstinence-only and women have gone. We have learned a great deal more, Sen. Biden, too bad the bill you support isn’t actually putting all of the lessons to use to make this the most effective bill possible.


4:14 p.m. Sen. Bob Menedez (D-NJ) speaks uses supportive talking points in brief remarks.


Sen. Sam Brownback (R-KS) says PEPFAR is one of the foreign policy programs that work. Brownback, talking about uniting people behind the PEPFAR mission, raises the very issues his colleagues on the far-right have used to divide, suggesting that it is those on the left trying to change PEPFAR. He said, PEPFAR "needs to stay true to its mission. I want to make sure it stays true to its life-saving program, not slip into other areas, perilous waters that some may want it to do, but that get divisive for the United States. Some people may want to push these funds into family planning, or population control and possibly abortion and that gets us divided."

No, Sen. Brownback, no one has suggested anything of the sort. The GAO, IOM and World Health Organization reports did suggest the integration of reproductive health and HIV services for women to more efficiently deliver prevention and health care needs, for cost efficiency, and to stregthen mother-to-child prevention efforts. No one has suggested that PEPFAR be used for abortion, except those of you on the far-right, who have skillfully used it to scare the negotiators from doing what they know is right based on experience in PEPFAR coutnries and many independent reports.

Brownback goes on to champion the fact that this negotiated bill maintains and increases funding for failed abstincence-only provisions, prohibits organizations from delivering prevention services to sex workers, and strengthens the conscience clause that allows people to deny help to other marginalized populations, based on personal judgments.


4:34 p.m. Sen. Clinton (D-NY) says the bill "focuses on the needs of women and girls." I know she’s been busy. She would have been the ideal person to lead efforts to make sure that statement were really true given all the work the Clinton Foundation has done on AIDS around the world, and her life-long commitment to women and girls. She then moved on the Medicare and the Bush veto, it’s better politics afterall.


5:30 p.m. The Bunning Amendment is defeated by a vote of 80-16 . The amendment sought to reauthorize PEPFAR at current levels, reducing the proposed $50 billion package to $15 billion over the next five years.

With 70 votes defeating the DeMint amendment and 80 votes defeating the Bunning amendment, it appears the Senate will have the 60 votes necessary to clear the "Point of Order" threshold on the HIV travel ban. Without 60 votes on that amendment, the entire bill will be defeated, forincing negotiators to strip out the HIV travel ban and then resubmit PEPFAR authorization for another full vote.


Wednesday, July 16, 2008

11:10 a.m. – Senator Thune (R-ND) speaks to his amendment for use on American Indian
reservations authorizing $1 billion for water and infrastructure
needs for Indian Health Services for Native Americans. Sen. Byron Dorgan (D-ND)
describes third world conditions on indian reservations and need in support of Thune Amendment.

11:38 a.m. Sen. Cornyn (R-TX) discusses his amendment establishing the US Authorization and Sunset Commision to oversee and make reccomendations
on PEPFAR spending and decide when to end the program. Sen. Lugar speaks opposing Cornyn Amendment saying, "I do not believe that
we should be turning oversight of this program to an unelected
commission." He notes that Senate Committees already must oversee the spending of the
bill and can hold up spending in committee.

Senator Lugar is right about the amount of oversight, but fails to mention that even with mounds of testimony about minor changes to improve PEPFAR, submitted to Congress by GAO, WHO, IOM and others, Congress can still provide "oversight" without listening to the substance. The Cornyn Amendment would not have changed that either, just added another layer of reporting that Congress could ignore.

Sen. Biden says the Cornyn Amendment would be bad idea for PEPFAR as fighting AIDS requires a long term commitment, calling it "dangerous" and noting that the program requires resuthorization again in five years, so in fact it has a Sunset Clause built into it already.

Defending his amendment, Sen. Cornyn said, "people have the right to know their money is being spent


10:58 a.m. Sen. Kyl speaks to the Thune Amendment saying, "while the total spending earmarked for PEPFAR was too
high according to the CBO, it at least indicated that we were willing to
spend that money abroad on a worthy humaitarian case. The Thune Amendment
wants the Senate to consider the similarly dire conditions that exist
on our indian reservations."

The Thune Amendment is adopted on a voice vote, taking $2 billion from the global AIDS policy and redirecting to Native American water, heatlh and infrastructure needs. This amendment appears to be a literal price paid to get overall support for the bill from some fiscal conservatives. Western Senators and others found it difficult to vote against for various reasons.


12:16 p.m. – Cornyn Amendment to include a Sunset Commission is defeated on a vote of 63 against and 32 in favor.


2:30 p.m. Sen. John Sununu (R-NH) speaks in favor of PEPFAR saying that the increased price tag is worth paying because of the success PEPFAR demonstrated in its first five years.


3:50 p.m. Sen. Jim DeMint takes the floor, again, to discuss America’s problems, energy crises, home loan mortgages, deficit spending, national debt. He forgets that prior to the Bush Administration, there were budget surpluses, cheaper oil, low gas prices, and a booming economy. I wonder how many votes he made in the past seven years that contributed to the crisis he now uses to oppose PEPFAR. Roll Call is reporting that Sen. DeMint is also in hot water with his Republican colleagues for his stall tactics on PEPFAR, a bill the President is "deeply committed to" seeing passed. Roll Call says,


Sen. Jim DeMint (R-S.C.) went
into damage-control mode Tuesday as his GOP colleagues complained that
his stalling tactics on the Senate floor have gone too far. After
demanding — and then missing — a Friday vote on President Bush’s global
AIDS program, DeMint used the Republicans’ weekly policy lunch to
explain his position but stopped short of an apology, his office


Sen. DeMint proposes an amenmdnet to reduce the amount of the bill from $50 billion as is currently proposed, to $35 billion, the amount the Congressional Budget Office estimates PEPFAR can absorb and move into PEPFAR countries.

Sen. Jeff Sessions (R-AL) speaks in support of DeMint Amendment to reduce spending, stating that he supports a bold increase, but that spending this much money in developing countries is unwise. Sessions, quoting Sir Elton John, says that politiicans should make sure that the money is spent wisely, then reads a list of recent spending bills passed by Congress.

These arguments ring hollow. We apend $10-12 Billion a month in Iraq, for six years, and will be there for at least two more. The U.S. has given tax cuts to its wealthiest citizens, bailed out Wall Street investment firms, and have given financial incentives to oil companies at the same time they are making record prices and manipulating markets.

The question before the Congress is not which piece of the pie won’t get funded, it is whether or not we believe AIDS is a problem worthy of our attention as a global leader. If it is, then the bill deserves support – flawed as it is.

Sen. Biden indicates that they are hoping to wrap this up, and moves that the Vitter Amendment be passed, which it was by a voice vote. The Vitter Amendment establishes an Inspector General for PEPFAR, differing slightly from an amendment for an IG defeated yesterday.

Sen. Sessions resumes speaking about people he’s met from Africa with AIDS and how moved he was.He again cites Elton John and the importance of spending the money wisely. That would require listening to people about what is really happening on the ground and not loading the bill with ideological baggage that has proven not to work, like abstinence-only earmarks, but its too late for that Sen. Sessions.


4:40 p.m. Sen. Biden moves to allow a new Sessions Amendment on blood swafety to be agreed to under Unanimous Consent, and it was.


BEAKING NEWS — This substitute amendment removes an effort by Sen. Sessions to change language in the bill lifting the ban on HIV positive people travelling to the US. According to sources close to the negotiations it appears that an agreement has been reached and the travel ban will be lifted in the Senate Bill. The House will have to agree to the Senate version before the ban is actually lifted.

The ban prohibited travel to the US by any HIV+ person without a waiver and comes as especially good news to one reader who wrote earlier today following the debate online from the United Kingdom. A 24 year old HIV+ man spearated from his partner because of the ban, he wrote,

It’s been a nightmare thinking that I might never get to see my partner
again, with his job not permitting him to travel often, and me not
being allowed in the country to visit him, it means our relationship is
suffering. I also dream about seeing a yellow taxi for the first time, and all the other American sights I see on British TV everyday. I’ve never felt so discriminated against and it pains me to be seperated from the man I love. My close friends all
travelled to the states recently and all I could do was cry alone
knowing they were all free to visit the same country my partner lives
in and see all the fantastic things in America that we see in films and
the media. I won’t go on, this is such an emotional time for me right now, I just want to visit my partner.


Sen. Biden announced there will be a series of four votes with limited debate on each starting at 5:00 p.m. and that they expect the bill to be wrapped up at that time.


5:00 p.m. Sen. Gregg (R-NH) speaks to his amendment to put an independent Inspector General in PEPFAR. I thought there was a voice vote on an IG earlier, so I’ll have to sort those out.

The Gregg Amendment to establish an indpendent Inspector General for PEPFAR was defeated with 51 votes, and 44 votes .

5:30 p.m. Sen. Kyl speaks to his amendment to force $10 billion dollars to be spent in the fifth year, as debated yesterday and detailed above. Sen. Lugar rises to oppose and argues that we should "retain flexibility" to ramp up spending in the most effective way. Sen. Biden also argues for for "rational ramping up" of the program. Sen. Kyl’s amendment could result in significantly curtailed monies being available for appropriations in the fifth year because of the amount of time it will take to ramp up programs in the first few years.

The Kyl Amendment was defeated with 67 votes against and 28 votes in favor.


5:49 p.m. Sen. DeMint speaks to his amendment to reduce to $35 billion (the CBO estimate of what can be spent effectively) the amount authorized to be appropriated to combat HIV/AIDS, tuberculosis, and malaria in developing countries during the next five years. DeMint continues to use the housing and economic crises created by policies he supported as an excuse to reduce the amount of money being spent to contribute to the global fight against AIDS. Sen. Lugar urges the Senate to oppose the amendment. Sen. Biden reminds the Senate that the program is not starting from zero dollars, the baseline the CBO used, but instead funneling money into already well established programs.

The DeMint amendment was defeated with 63 votes against and 32 votes in favor.


6:10 p.m.  Senators began speaking for a few minutes of debate (er, reading talking points) and the deal is done.


PEPFAR is passed with 80 votes in favor and 16 votes opposed. 


Congratulations on Passage!

Rewire has made no secret of its disappointment at how the bill was negotiated, with such early promise to make minor fixes that would have honored the indpendent reports to Congress about PEPFAR’s first five years of experience.  Subtlety is not my strong suit.

While the Senators wrap-up with their platitudes and self-congratulatory comments about "bi-partisanship", I’d like to say a quick thanks to the dozens of public health experts who have written with us throughout the past few months on this issue. 

The fact that abstinence-only requirements have been increased to 50 percent is one of the most significant disappointments because it continues a string of votes by the Democratic Majority, that give credence to programs that are proven failures, complicate US global AIDS policy in terms of our ability to work with other international efforts, and are recognized by American parents as being failures for their own children. That is why many states have rejected federal abstinence-only dollars. But Congress continues to make votes to support failed abstinence-only policies at home and abroad, thinking somehow it will make them appealing to social conservatives.

The failure by negotiators to follow recommendations to integrate reproductive health and HIV services for women and girls, the codification of discrimination through an ill-advised conscience clause, the inability to see the need to explicitly address the needs of marginalized populations like young people, sex workers, drug users, are all huge disappointments. It is a shame that a progressive majority could not stand up for these common sense policies and force the minority to accept a bill that reflected the majority, as happened in 2003 when the GOP was in control and PEPFAR was first passed.

Having noted all of this, congratulations are in order for those who have worked to bring this bill to a successful conclusion.  The money is important, just not the only thing that makes a difference in preventing the spread of HIV.

PEPFAR will make a huge difference in the lives of many people. We hope that as it does, advocates will speak out on the issues of abstinence failures, sexual and reproductive health issues, and marginalized populations in such a way that will never again allow smart public health strategies to be compromised for ideology. It is important that if anything is marginalized moving forward, it is the ossification of far-right ideologues in Congress and the Democrats that allow them to dictate policy on these most fundamental of human issues.






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