[Senate Hearing 106-410]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 106-410
 
                       FUNDING AIDS RESEARCH AND
                                SERVICES

=======================================================================

                                HEARING

                                before a

                          SUBCOMMITTEE OF THE

            COMMITTEE ON APPROPRIATIONS UNITED STATES SENATE

                       ONE HUNDRED SIXTH CONGRESS

                             FIRST SESSION

                               __________

                            SPECIAL HEARING

                               __________

         Printed for the use of the Committee on Appropriations



                                



 Available via the World Wide Web: http://www.access.gpo.gov/congress/senate

                                 ______
                    U.S. GOVERNMENT PRINTING OFFICE
61-419                      WASHINGTON : 2000
_______________________________________________________________________
            For sale by the U.S. Government Printing Office
Superintendent of Documents, Congressional Sales Office, Washington, DC 20402
                           ISBN 0-16-060342-0



                      COMMITTEE ON APPROPRIATIONS

                     TED STEVENS, Alaska, Chairman
THAD COCHRAN, Mississippi            ROBERT C. BYRD, West Virginia
ARLEN SPECTER, Pennsylvania          DANIEL K. INOUYE, Hawaii
PETE V. DOMENICI, New Mexico         ERNEST F. HOLLINGS, South Carolina
CHRISTOPHER S. BOND, Missouri        PATRICK J. LEAHY, Vermont
SLADE GORTON, Washington             FRANK R. LAUTENBERG, New Jersey
MITCH McCONNELL, Kentucky            TOM HARKIN, Iowa
CONRAD BURNS, Montana                BARBARA A. MIKULSKI, Maryland
RICHARD C. SHELBY, Alabama           HARRY REID, Nevada
JUDD GREGG, New Hampshire            HERB KOHL, Wisconsin
ROBERT F. BENNETT, Utah              PATTY MURRAY, Washington
BEN NIGHTHORSE CAMPBELL, Colorado    BYRON L. DORGAN, North Dakota
LARRY CRAIG, Idaho                   DIANNE FEINSTEIN, California
KAY BAILEY HUTCHISON, Texas          RICHARD J. DURBIN, Illinois
JON KYL, Arizona
                   Steven J. Cortese, Staff Director
                 Lisa Sutherland, Deputy Staff Director
               James H. English, Minority Staff Director
                                 ------                                

 Subcommittee on Departments of Labor, Health and Human Services, and 
                    Education, and Related Agencies

                 ARLEN SPECTER, Pennsylvania, Chairman
THAD COCHRAN, Mississippi            TOM HARKIN, Iowa
SLADE GORTON, Washington             ERNEST F. HOLLINGS, South Carolina
JUDD GREGG, New Hampshire            DANIEL K. INOUYE, Hawaii
LARRY CRAIG, Idaho                   HARRY REID, Nevada
KAY BAILEY HUTCHISON, Texas          HERB KOHL, Wisconsin
TED STEVENS, Alaska                  PATTY MURRAY, Washington
JON KYL, Arizona                     DIANNE FEINSTEIN, California
                                     ROBERT C. BYRD, West Virginia
                                       (ex officio)
                           Professional Staff
                            Bettilou Taylor
                             Mary Dietrich
                              Jim Sourwine
                               Aura Dunn
                        Ellen Murray (Minority)

                         Administrative Support
                             Kevin Johnson
                       Carole Geagley (Minority)



                            C O N T E N T S

                              ----------                              
                                                                   Page
Statement of Willie L. Brown, Jr., Mayor, San Francisco, CA......     1
Opening statement of Senator Arlen Specter.......................     1
Opening statement of Senator Tom Harkin..........................     2
Opening statement of Senator Dianne Feinstein....................     4
Opening statement of Senator Barbara Boxer.......................     6
Summary statement of Willie L. Brown, Jr.........................     9
Prepared statement of Willie L. Brown, Jr........................    11
Ryan White Comprehensive AIDS Resources Emergency (CARE) Act 
  Programs.......................................................    12
The AIDS Drug Assistance Program (ADAP)..........................    12
HIV/AIDS initiatives for communities of color....................    13
HIV Prevention, Surveillance and Behavioral Research Programs at 
  the Centers for Disease Control and Prevention (CDC)...........    13
Substance Abuse and Mental Health Services Administration 
  (SAMHSA).......................................................    13
Statement of Ronald V. Dellums, President, Healthcare 
  International Management Co....................................    14
Prepared statement of Ronald V. Dellums..........................    18
Development of the fund..........................................    19
Pharmaceutical companies and other corporate support.............    20
Administration of the AMPFA......................................    20
Education, prevention, and treatment.............................    20
Statement of Dr. Anthony Fauci, Director, National Institute of 
  Allergy and Infectious Diseases, National Institutes of Health, 
  Department of Health and Human Services........................    23
Prepared statement of Dr. Anthony S. Fauci.......................    25
The scope of the epidemic........................................    25
HHS spending on HIV/AIDS.........................................    26
The success--and limitations--of antiretroviral therapy..........    26
The critical role of HIV prevention..............................    26
HIV vaccine development..........................................    27
Statement of Dr. Paul Volberding, Director of AIDS Research, San 
  Francisco General Hospital.....................................    28
Statement of Lonnie Payne, Board Director, San Francisco AIDS 
  Founda- 
  tion...........................................................    30
Statement of Sean Sasser, Director, Ryan White CARE Title IV 
  Project........................................................    32
Statement of Kate Shindle, Miss America 1998.....................    34
Statement of Jeanne White, Ryan White Foundation.................    36
Prepared statement of Representative Barbara Lee.................    44



                   FUNDING AIDS RESEARCH AND SERVICES

                              ----------                              


                          FRIDAY, JULY 9, 1999

                           U.S. Senate,    
    Subcommittee on Labor, Health and Human
     Services, and Education, and Related Agencies,
                               Committee on Appropriations,
                                                 San Francisco, CA.
    The subcommittee met at 10 a.m., in the Main Chambers of 
the Board of Supervisors, One Dr. Carlton B. Goodlett Place, 
San Francisco, CA, Hon. Arlen Specter (chairman) presiding.
    Present: Senators Specter, Harkin, and Feinstein.
    Also present: Senator Boxer.
STATEMENT OF WILLIE L. BROWN, JR., MAYOR, SAN 
            FRANCISCO, CA


               opening statement of senator arlen specter


    Senator Specter. Good morning, ladies and gentlemen. The 
hearing of the Appropriations Subcommittee on Labor, Health and 
Human Services, and Education will now begin. We express our 
thanks at the outset to the distinguished Mayor of the City of 
San Francisco, and the Board of Supervisors for accommodating 
us in these very elegant chambers.
    I've had the pleasure of visiting San Francisco on many 
occasions in the past, but I've not had the pleasure of being 
in this building before. It is truly spectacular, a phenomenal 
setting to have this hearing.
    We will be considering today the subject of AIDS and 
Federal funding. We approach this subject as one of enormous 
importance, noting that in the 18 years since the AIDS epidemic 
struck, some 690,000 Americans have been reported to have AIDS, 
and 410,000 Americans have died as a result of AIDS.
    The problem on AIDS has received very considerable 
attention in Federal funding. Not enough, but considerable. The 
U.S. Government began funding AIDS as a National Institute of 
Health research in 1982, at a cost of $3.3 million. Now the NIH 
funding is $1.8 billion, and the total funding of the Center 
for Disease Control, the Ryan White program and various other 
categories brings the total funding to $4.1 billion.
    We have seen in the immediate past a decline in the death 
rate, dropping by some 42 percent to approximately 22,000 in 
1996. Still many too many, but these are issues which we are 
tackling. One of the concerns that this subcommittee has is the 
Federal allocation, the caps on funding where, at this sitting, 
we are looking at about a 10-percent cut. So the budget would 
probably be in the $90 billion range, it may only be $80 
billion.
    One of our purposes in having this hearing, as well as 
other hearings around the country--mostly in Washington, of 
course--is to develop public awareness of the need to maintain 
the funding. This subcommittee has taken the lead in recent 
years to increase funding, the year before last by almost $1 
billion, and last year by $2 billion. It is our philosophy that 
in a country which has a Federal budget of $1.7 trillion there 
is no higher priority than health.
    Even increasing by $2 billion, we're still granting the 
applications only in the 30-percent range. That means that 70-
percent of the doors are not open to say what might be able to 
be done. Our view is that our priorities are such that we ought 
to be able to fund all the applications which are meritorious 
as a prior. Of course, AIDS is a matter of tremendous 
importance.
    We have a very distinguished panel assembled here today. 
Senator Harkin is a ranking Democrat, we're pleased to welcome 
both of our California Senators, Senator Feinstein and Senator 
Boxer. We just had occasion to see Senator Feinstein's statue, 
very impressed with that. There aren't any Senator statues in 
Washington, so it's nice to come to San Francisco and see Mayor 
Feinstein's statue there.
    We welcome Senator Boxer here, who took the lead on 
introducing the National Pediatric AIDS Awareness, along with 
Senator Hatcher earlier this year. We will have opening 
statements from all of our panel.
    Now, it's my pleasure to turn to my distinguished ranking 
member, Senator Harkin.


                opening statement of senator tom harkin


    Senator Harkin. Mr. Chairman, thank you very much for 
calling this hearing. More than that, thank you very much for 
your strong leadership on health research, generally, and AIDS 
research more specifically. I'd also like to thank our mayor, 
Willie Brown, for hosting us today, and the board of 
supervisors for letting us use this impressive room.
    I want to thank my two colleagues, Senator Feinstein and 
Senator Boxer, not only for being here, but again for their 
very strong support for medical research in this country. I 
must say I'm so impressed by this room, I just asked Senator 
Feinstein and she said she'd been sitting right here at this 
desk 27 years ago.
    It's usually an axiom in politics that you always move up 
the ladder. I'm sitting in this room wondering why would you 
step down and become a U.S. Senator, when you could be sitting 
in this wonderful room?
    But I'm especially pleased, also, to see Mrs. Jeanne White 
here representing the foundation named after Ryan, her son. Her 
strength and commitment spearheaded the grassroots effort in 
the fight against AIDS.
    Mr. Chairman, it's significant that we're having this 
hearing in San Francisco today. This city has been devastated 
by the tremendous loss of life and human potential that this 
disease has wreaked on its young men and women. It is the 
birthplace of the grassroots movement that's been so important 
in fighting this epidemic.
    If I might just say in a personal aside, I can remember in 
1982 and 1983 I was a Member of the House of Representatives. I 
was preparing to run for the U.S. Senate. I was invited to come 
to San Francisco by some of my friends for a fund-raiser. I 
came out here in early 1983. I remember it was winter and it 
was nice getting out of Iowa in the middle of the winter.
    As usual, you stand up and you say a few words. One of the 
first questions I was asked was, ``What do you intend to do 
about AIDS?'' I got caught flat-footed. I said, ``What's 
AIDS?'' I'd never heard of it. That was probably, January or 
February of 1983. So, for me, this was the birthplace of my 
knowledge about what AIDS was. How devastating the disease 
became in the 1980s. All of us have lost many, many close and 
personal and dear friends to this disease.
    But as Senator Specter said, we have increased our 
investment in research and treatment dramatically. My thanks to 
Tony Fauci, who will be testifying, and the National Institute 
of Allergy and Infectious Diseases for his great leadership, 
and for what they have done in helping to unlock the mysteries 
of AIDS over the last 10 years.
    I'd like to say one other thing. Last month I went to NIH 
with President Clinton to participate in the laying of a 
cornerstone for a new vaccine research facility at NIH, which 
will be finished next year. It's going to be called the Dale 
and Betty Bumpers Vaccine Research Center, after the former 
Senator Dale Bumpers and his wife, Betty.
    This building will be used by scientists at NIH working on 
the development of new vaccines, in particular, the challenge 
of finding a vaccine against AIDS. Until an AIDS vaccine is 
tested and approved, it will remain the primary mission of the 
Dale and Betty Bumpers Vaccine Research facility at NIH.
    Last, as Senator Specter so adequately and poignantly 
pointed out, the AIDS epidemic is far from over. But this 
subcommittee has $8 billion less to spend this year than we did 
last year. That's a 10-percent cut from last year. Senator 
Specter is working hard to find the money to fund not only AIDS 
research, but also the Ryan White program and the Centers for 
Disease Control HIV/AIDS Prevention program.
    I know I speak for myself and my colleagues, when I say we 
are committed to do everything we can to help Senator Specter 
find the money to do this. This is not any kind of a partisan 
issue, I can assure you.
    We are close to some great breakthroughs in the fight 
against AIDS. Now is not the time to back down, now is the time 
to really pour on the coals. Put the money into it. We are so 
close to so many breakthroughs, and that's why we just can't 
back down.
    So, again, Mr. Chairman, I thank you for having this 
hearing. I thank my good friends and my colleagues, Senator 
Feinstein and Senator Boxer for all of their strong support in 
always prodding us. I say to those of you from California, you 
ought to be rightfully proud of these two Senators. There isn't 
a day or a week goes by that they aren't prodding us in the 
Senate, either in committee or on the floor of the Senate, to 
do more, and to make sure that we keep our promise to provide 
adequate funding for these programs.
    I've had their feet in my back quite often, as a matter of 
fact, and I appreciate that. Because we need that constant 
prodding and that pushing, and I just personally want to thank 
Senator Feinstein and Senator Boxer for their leadership. Thank 
you, Mr. Chairman.
    Senator Specter. Thank you, Senator Harkin. We turn now to 
Senator Feinstein, who is a legend in this building and a 
growing legend in the Senate. We saw the statue which noted her 
election to the Board of Supervisors in 1970, and also to the 
chairman of the board the same year. I was a little surprised 
when she was elected and became chairman immediately, but I 
shouldn't have been.
    Then, of course, mayor from 1978 to 1988, and then the U.S. 
Senate since 1992. Senator Feinstein is a member of the full 
Appropriations Committee, and is a member of this subcommittee. 
We thank her for extending the hospitality of San Francisco to 
our subcommittee. Senator Feinstein.


             opening statement of senator dianne feinstein


    Senator Feinstein. Thank you very much, Mr. Chairman. I 
want to thank you and the ranking member for your comments. I 
want to thank you for being here, and I want to thank both of 
you for your commitment to AIDS. I think with your leadership 
and the concurring leadership on our side, led by Senator 
Harkin, we should be able to achieve some advances.
    I want to thank the mayor for his hospitality. It's a kind 
of deja vu for me, because I haven't been back in this room 
since I left. That was January of--well, I guess the last state 
of the city message, whenever, in 1977. So it's a kind of deja 
vu. After I left the dias in 1972, as Senator Harkin said, I 
sat in this seat for 2 years. That was 27 years ago, and how 
fast time goes by.
    It's good to see Congressman Dellums here. I remarked that 
I don't know what he does to stay so trim and fit, but you 
truly look great and it's wonderful to welcome you here as 
well.
    The work we were able to accomplish in San Francisco for 
people with AIDS is really one of the proudest achievements of 
my 9-year tenure as mayor. When I became mayor of San Francisco 
in 1978, no one had heard of AIDS, much like you, Senator 
Harkin. In 1981, in a meeting with a group of gay and lesbian 
activists in my office, I was told of a rumored gay cancer, 
particularly purple lesions turning up on people.
    I called Dr. Mervyn Silverman, the Director of Public 
Health, and asked him to investigate. He called the Center for 
Disease Control in Atlanta, and learned that New York and Los 
Angeles were reporting a similar syndrome that was appearing in 
gay men. Later that year, there were 76 diagnosed cases, and we 
provided our first local funding, $180,000 for prevention and 
social services for people with what was then called AIDS. 
This, I believe, was the first local funding ever committed to 
AIDS in the United States.
    I also formed the Mayor's AIDS Advisory Group to advise me 
on the implications of the AIDS epidemic. I was fortunate to 
have some of the most talented physicians in the nation right 
here in the Bay Area to work with, such as Dr. Paul Volberding, 
who is here today, Marcus Conen and Don Abrams. I thank you, 
Mr. Chairman, for agreeing to invite Dr. Volberding to testify 
today and tell us about his long history and continuing efforts 
to eradicate AIDS.
    With the physicians, researchers and particularly the 
community groups, we were able to craft what became known as 
the San Francisco AIDS model. This innovative initiative 
eventually became the model for other cities through the nation 
and the world for AIDS management. I chaired the AIDS Task 
Force of the United States Conference of Mayors in a day, I'm 
sorry to say, when mayors didn't really want to come to sit at 
the table, and sent their chiefs of public health. And San 
Francisco became the transmission point for information about 
AIDS throughout the nation.
    By 1983, there were 242 AIDS cases diagnosed in San 
Francisco. Later that year, I cut the ribbon and opened the 
first AIDS hospital section at San Francisco General Hospital, 
I believe the first in the nation. We increased funding that 
year to $4.3 million of property tax dollars for AIDS services, 
including support services for people with AIDS as well as for 
their families and loved ones. We launched several prevention 
and education programs, all of which the communities 
participated in.
    We focused on public education as well. As more was learned 
about the transmission of the disease, San Francisco started an 
aggressive outreach program on HIV/AIDS prevention to educate 
our total community; men and women, straight and gay, young and 
old, and in particular those at high risk.
    That same year we took a tough approach, closing bath 
houses and other facilities that encouraged unsafe sexual 
practices. As an aside, I was very pleased to see that the San 
Francisco Public Health Commission recently rebuffed efforts to 
reopen those bath houses. Commercial businesses cannot be 
allowed to profit at such a great human price.
    I also urged the United States Conference of Mayors to 
establish the AIDS Task Force, which I just mentioned to you. 
In 1983, I chaired that first meeting. In addition, here in San 
Francisco we mobilized county governments in the Bay Area. We 
lobbied the State and Federal governments to increase AIDS 
funding and to support research grants in the Bay Area.
    In 1987, my last full year as mayor, there were 20,000 AIDS 
deaths in the nation. That year, in San Francisco, we increased 
spending to $20 million, all local property tax dollars. This 
was more than the rest of the cities and the country combined, 
and for most of the time, more than the State of California.
    There was no Federal Ryan White program then, and we found 
money in the city budget. This money was used for a new AIDS 
care at San Francisco General Hospital for housing programs, 
hospice programs, mental health services, and medication. We 
developed a food program to ensure that any person with AIDS 
had a hot meal in their own home.
    In addition, people with AIDS were provided with nursing 
support and home health care. In short, we led the way. As a 
member of the U.S. Senate I have continued to work for a cure 
for AIDS. Since 1992 I'm pleased to be a small part, along with 
the leadership of my colleagues on the right and Senator Boxer. 
We have increased Federal AIDS research funding at the NIH from 
$1 billion in 1992 to $1.8 billion in fiscal year 1999.
    We strengthened and expanded the Ryan White Care Act, 
providing $1.4 billion in 1999, with California receiving $96 
million. The Ryan White programs are a critical safety net, 
particularly the part known as ADAP, which helps people with 
HIV/AIDS buy critical prescription drugs like protease 
inhibitors. We have maintained the Medicaid program despite 
efforts to repeal it and scale it back, but the battle is not 
yet won.
    First and foremost, we must find a cure for AIDS. We must 
sustain and accelerate our Federal research effort. Last year, 
we were able to increase NIH funding, thanks to this committee, 
by 15 percent. I've called for doubling NIH research. At 
current levels NIH can only fund 31 percent of the 
applications, and AIDS research is done throughout all of the 
NIH institutes. This is unacceptable.
    We must find more effective treatments. Incident rates and 
deaths are on the decline for some groups. Many people with 
HIV/AIDS have been able to become healthier, return to work, 
live productive lives because of protease inhibitors and other 
treatments that did not exist in 1980. But these drugs don't 
help everyone.
    The May study reported in the New England Journal of 
Medicine concluded that HIV lingers in cells so long that ``the 
virus cannot be eradicated at all with current treatments. It 
remains tucked away longer than thought.'' NIH's Dr. Anthony 
Fauci, who will testify today, has said what all these studies 
underscore is the pressing need to develop more effective, less 
toxic medications.
    We must eliminate disparities in health care. A June 23 
Rand study was reported with headlines like the Washington 
Post's, ``Two Worlds of HIV Care.'' This study found that white 
men are likely to get the best care compared to African-
Americans, Latinos, women, the uninsured and those with 
Medicaid.
    Dr. Martin Shapiro, a UCLA physician who worked on the 
study said, ``The message is that we need better strategies, 
and a stronger commitment to ensuring optimal care for HIV on 
an equitable basis.'' I couldn't agree more. Continuing Ryan 
White services are a critical component, an important challenge 
for the Congress.
    Mr. Chairman, I can't thank you enough for being here. 
Senator Harkin, my friend and colleague Senator Boxer. I was 
there at the beginning, and I want desperately, very much to be 
there at the end. Thank you very much.
    Senator Specter. Thank you very much, Senator Feinstein. We 
now turn to Senator Boxer. She served 10 years in the House of 
Representatives, first elected in 1982. Elected to the U.S. 
Senate in 1992 and reelected in 1998. A member of the 
Appropriations Committee in the 105th Congress, and took the 
lead, along with Senator Orrin Hatch, in introducing the 
resolution on May 27 designating a National Pediatric AIDS 
Awareness Day. She solicited and got 49 co-sponsors, a large 
number from her active work on the Senate floor, and has been 
the leader in many fields, and an outstanding advocate for 
funding for AIDS.
    Senator Boxer.


               opening statement of senator barbara boxer


    Senator Boxer. Thank you so much, Senator Specter, Senator 
Harkin, Senator Feinstein, the one and only Mayor Willie Brown, 
and my dear friend, Ron Dellums, who I miss so much in the 
Congress. Let me just try to be as brief as I can, and make a 
couple of points to you, Mr. Chairman, and to our ranking 
member.
    No. 1, is to tell the people who are assembled here today, 
who care so deeply about this issue just how extraordinary this 
team is of Specter and Harkin. I want to say this because it is 
so refreshing in a Senate that has turned sadly partisan to see 
two people who really share a common concern about working to 
ensure that our people are healthy, that we continue to make 
progress in fighting all these enemies we face, like cancer and 
Alzheimer's and Parkinson's and AIDS. I could go on with the 
list.
    Every time I've gone to either one of these colleagues, and 
they're always very busy and they're always working hard, they 
always have time to listen to me. I know Senator Feinstein 
feels the same way.
    In California, we have more of the problem than anywhere 
else by virtue of our size. We are 34 million, almost, 
residents of this State. Therefore when you have a horrible 
tragedy, we just get more of it than any other place. So, 
forgive us if at times we seem rather forceful, but I think 
that is what our people expect from us. And you are always 
there for us, and I cannot thank you enough. And I'm glad to 
have this opportunity to thank you in an open setting such as 
this.
    A quick bit of nostalgia for myself, as I think back to 
1983, that very year that Senator Harkin talked about. That 
year the great Phil Burton passed away. I found myself as a 
freshman Member of the House representing San Francisco. I was 
the only one. I represented about 30 percent of the city.
    When this new disease came forward, there was no one else 
to go and fight for the very scarce funding. I found myself in 
a room with Bill Natcher from Kentucky, who was the chairman of 
appropriations. I think it was the Health Subcommittee of 
Appropriations.
    He had never heard of AIDS, he was completely stunned to 
hear about it. I remember just getting all the courage that I 
had and saying, ``Could we have $50 million as a first 
appropriation.'' We wound up getting about $12 million, it was 
the very first appropriation. I remember feeling so frightened 
at that time, facing this situation.
    We're still--although we have a great deal of hope, we are 
still frightened about AIDS. There are reasons for it. An 
estimated 650,000 to 900,000 people are living with HIV or AIDS 
in the United States alone. In the United States, the highest 
percentage of infection is in those between ages 24 and 44. The 
male cases, it's 80 percent, the female cases are 20 percent. 
The female cases are increasing at a faster rate than the male 
case.
    From 1985 to 1998 the proportion of U.S. AIDS cases in 
women reported each year increased from 7 percent to 23 
percent. Most of it is acquired through sexual contact with a 
man who is HIV positive. So, we have a problem. Senator 
Feinstein pointed out the minority community.
    Of U.S. AIDS cases reported in 1998, 45 percent were among 
African-Americans, 33 percent among Caucasians, 20 percent 
among Hispanics, and worldwide, 33.4 million people living with 
HIV/AIDS. That's about the size of California, this huge State. 
There are that many people living in the world. I know we tend 
to have a short span of attention in this country, it's sort of 
the nature of who we are as a people. We always want to solve a 
problem and move on.
    As Senator Feinstein said, she wants to be here to see the 
end. We need to see the end, and I would just simply say, as I 
look at the request I made of both my friends--and now Senator 
Feinstein is on the Appropriations Committee--we are pushing 
very hard for the maximum we can get for the CDC and the NIH, 
and for Ryan White and for the Hemophiliac Relief Fund, and for 
pediatric AIDS, and all the things we need. For local funding 
for local groups here that can get the services out.
    So, I want to close and say to you that we've got to do 
more, as much as we can do. I don't want to let this go by 
without saying that Nancy Pelosi is a tireless fighter against 
AIDS, and she couldn't be here today for a very good reason. 
The fact is that there's not a day that goes by that she's not 
working on this issue.
    Let me just close. We are going back to the Senate to work 
on the Patient's Bill of Rights. I know all the Senators here 
support one version or another. I would just pose a rhetorical 
question, which is how ironic--wouldn't it be ironic, and 
tragically ironic if after all the progress we're making, where 
we have these treatments and these drugs, that people couldn't 
access these treatments and these drugs. They were not allowed 
to because of the health care system.
    So, we need to get the funding, we need to get the access, 
we have to fight today as hard as we fought when we found 
ourselves at the beginning of this epidemic. Again, my deepest 
thanks to all of you here today, and to the good people of San 
Francisco. I might say, of all the other cities in this State 
and across the country, you have kept our feet to the fire. 
Thank you very, very much.
    Senator Specter. Thank you very much, Senator Boxer. 
Congresswoman Barbara Lee had been here, and she may return. 
She has gone to a meeting with the U.S. Secretary of 
Transportation. Congresswoman Pelosi is not able to attend 
today's hearing because she is a congressional delegate to a 
visit to Belfast, Northern Ireland, where there are meetings in 
process with the political leaders in anticipation of the 
deadline on the 15th.
    Congresswoman Pelosi has been an ardent advocate on funding 
on AIDS, and on one late-night session in 1997 when the AIDS 
Drug Assistance Program was funded at $167 million, she took 
the lead in insisting on an additional $100 million. And with 
her leadership, that particular fund has grown, so it's now 
$461 million.
    A good part of this city is Congresswoman Pelosi's area. So 
I think it important to take just a few moments to read the 
statement, since she could not be here to do it herself. But 
these are her words:

    Today's hearing is being held in a city that has been 
devastated by AIDS. In responding to that tragedy, San 
Francisco has mounted a response that is a model for the 
nation. San Francisco's system of HIV prevention and care 
programs teach us that with the will and the resources we can 
dramatically reduce new HIV infections, provide state of the 
art health care, and make essential support services available.
    But across the country, one of the greatest dangers is that 
we will mistake programs for victory. Powerful treatments are 
improving and prolonging lives, but we are far from a cure. 
Funding for AIDS care has increased, but there are now more 
people living with AIDS than ever before, and there are waiting 
lines at the 10 State AIDS program drug assistance units. 
Communities of color are winning victories by expanding 
targeted prevention and treatment services, but research 
released last month documents continuing serious disparity in 
AIDS care. Prevention interventions have proved effective, but 
funding for prevention at the Centers for Disease Control has 
remained relatively static for years. Internationally, the HIV 
epidemic spirals out of control, yet our government dedicates 
precious few resources to meet the need.
    We can respond to this growing national and global health 
catastrophe by pitting disease against disease and seeing who 
wins. Or we can accept our ability and responsibility to build 
a comprehensive system of health promotion and health care. 
AIDS prevention care and research is a model. It must not 
become a scapegoat.
    This hearing is an important opportunity to hear about the 
growing need for resources to fight AIDS. As a member of the 
House Appropriations Subcommittee on Labor, Health, Human 
Resources and Education, I have made increased funding for HIV 
her top priority. Today we must acknowledge how profoundly our 
investment in HIV has paid off. Prevention interventions are 
working, death rates have fallen, research is steadily 
advanced. There is a renewed hope for a vaccine. Were it not 
for the Ryan White CARE, HIV prevention funding system, NIH 
research and other Federal programs, we would not be making the 
strides they are.
    We cannot forget that we are in the midst of an epidemic. 
In San Francisco, 17,000 of our neighbors, family members and 
friends have died, and 500 people are newly infected each year. 
We must adopt a program for pushing for increased 
appropriations for prevention, treatment, housing a research; 
expanding Medicaid to cover the HIV in its early infectious 
stage; improving health care and services to better help 
communities of color and disenfranchised.

    Senator Specter. We hope that Congresswoman Lee returns to 
make her own statement. If she doesn't we will read it into the 
record later in the hearing. But we know that the mayor has 
other commitments, so we will turn now to the distinguished 
Mayor of San Francisco, who has had an extraordinary record. A 
native of Texas, Mayor Willie Brown served 31 years in the 
California Assembly, 15 years as its Speaker.
    He's had a variety of occupations, shoe-shine, janitor, 
crop harvester, messenger--this is from the mayor's biography. 
I haven't dug these out especially. Worked his way through the 
high school, San Francisco State University and Hastings 
College of Law.
    Thank you for your hospitality, Mr. Mayor, and we look 
forward to your comments.


               summary statement of willie l. brown, jr.


    Mayor Brown. Thank you very much, Mr. Chairman. I'm 
delighted to welcome you, the ranking member, my own two 
Senators, Feinstein and Boxer, as well as my friend for so many 
years, Congressman Ron Dellums, the words of Nancy Pelosi and 
the words soon from Congresswoman Barbara Lee. Welcome to our 
San Francisco Board of Supervisors chambers.
    We are delighted that you are here. You honor our city by 
holding your hearing here. You also give an opportunity for 
this great array of incredible medical talent, both on the 
treatment side and the research side, that have been a part of 
this San Francisco model as so eloquently described by Senator 
Feinstein, that now has almost a 20-year history of attempting 
to address the issue.
    Senator Feinstein laid out for you how San Francisco became 
involved. The State of California followed San Francisco's 
leadership fairly quickly on the AIDS/HIV issue. In 1983, when 
George Deukmejian, a Republican, was the Governor of the State 
of California, the very first State in this nation--preceding 
the Federal Government, I may add--provided $3 million at my 
insistence and my orchestrating for research.
    The idea for the $3 million came, of course, from 
experiences San Francisco had already had as a city, plus the 
great advocacy of the incredibly talented healthpersons, led at 
the University of California by Marcus Conen, the Republican 
Governor was persuaded and convinced that this was a disease 
that required public dollar investment, without reference to 
the so-called group of persons that it directly affected. In 
this case, gay white males.
    Since 1983, as described by Senator Feinstein and Senator 
Boxer, and Congresswoman Nancy Pelosi, there has been a great 
degree of improvement and commitment by not only the city, the 
State, but as well as the nation. The money provided for NIH, 
for CDC, for the Ryan White CARE Council and the other 
organizations and institutions and programs that have been 
funded, have played a marvelous role in expanding and extending 
the lives of people who are HIV positive.
    Incredible achievements that have come from the adherence 
to a group of pharmaceutical products that grew out of some of 
this financed research with public dollars, has prolonged the 
lives of any number of human beings.
    Many people have written the great success story. People 
going from one level of positive report to virtually no 
positive report, HIV or AIDS being anywhere near their system. 
That has, in some cases, dissuaded people from continuing their 
private charity and their private contributions, as well as 
some elected types from thinking that in fact it's OK to no 
longer be concerned.
    The cap which you refer to would play a devastating role on 
the San Francisco model, as well as other cities who have 
replicated the San Francisco model in their addressing of the 
issue of AIDS and HIV. It will definitely have a decided 
adverse affect on those communities of color that are just now 
becoming a regular part of what attention is given in the San 
Francisco model and the other models. I'm sure that some of the 
witnesses who will come before you will so state that today.
    My words are very, very simple. We must exhaust--and I hope 
you'll understand the importance of that--you must exhaust 
every effort that you have at your disposal not to allow this 
struggle to be limited in its application by an absence of 
resources imposed by some artificial caps that have no basis in 
fact as it relates to the need.
    The need is greater now than it ever was before. The 
numbers as originally reported by Senator Feinstein at the 
outset were relatively modest, but the numbers referred to by 
Senator Boxer are just the tip of the iceberg. In the words 
that Barbara Lee has left, I think written--and I think Ron 
Dellums will so state--the issue is no longer San Francisco or 
just this nation. It is now worldwide.
    This is one disease that has the potential to wreak havoc 
on the human population as we know it. A cure must be found, a 
vaccine must be produced. But in the meantime, the marvelous 
techniques that have come about through the pharmaceutical 
products, the result of the great research, plus the incredible 
of education for prevention and care that has been orchestrated 
must be generously and liberally supported and pushed, until at 
such time that that end that Senator Feinstein described as her 
goal and her dream will be a reality.
    Until then, this struggle must be more intense from our 
perspective, year-in and year-out. San Francisco would be 
devastated in particular by any cessation or reduction in 
resources. We have always been the leader in the process of 
applying and effectively using the dollars that come from the 
Federal, from the State and from the local treasury, from the 
taxpayers. And our record clearly reflects that. Other cities 
are similarly situated.


                           prepared statement


    Our numbers are not getting smaller, they are getting 
larger. We estimate 1 in every 50 San Franciscans is HIV 
positive. That is an awesome figure. The fact that that is not 
the headlines surprises me. We know we need the resources. You 
honor us by coming, I hope you will listen closely, and I hope 
your colleagues will then follow the recommendation that you, 
Senator Harkin, and your colleagues on your subcommittee will 
make. Thank you for being here.
    [The statement follows:]

               Prepared Statement of Willie L. Brown, Jr.

    Good afternoon, Chairman Specter and members of the Committee. My 
name is Willie Lewis Brown, Jr., and in 1995 the voters of the City and 
County of San Francisco elected me their Mayor. Prior to that, I served 
for 15 years as Speaker of the California State Assembly. I come before 
you today to request the Committee's support for vital increases in 
fiscal year (FY) 2000 funding for federal HlV/AIDS-related programs 
administered by the U.S. Departments of Health and Human Services and 
Labor, and to address the role of federal-state-local partnerships in 
addressing the AIDS crisis.
    San Francisco has long been a leader in the fight against AIDS. We 
have provided local support for our community-based response since the 
first desperate days prior to Federal funding, when health departments 
in major cities were staggering under the weight of increasing 
caseloads of young, terminally ill individuals presenting at hospital 
emergency rooms with obscure and deadly ailments. The City and County 
has provided significant leadership and financial resources to combat 
this epidemic since 1981 and we remain committed to doing so.
    In 1983, as a member of the California Assembly representing San 
Francisco, I secured the first state funding in the nation for AIDS 
programs--a $3 million appropriation that set the stage for the federal 
and state support we are talking about today. In that time, the fear 
surrounding this illness served as the major obstacle to securing these 
desperately needed funds. Today, this fear has been replaced with a 
premature sense of victory and an unacceptable level of complacency.
    Last October, the Centers for Disease Control and Prevention (CDC) 
reported a 47 percent decline in AIDS-related deaths between 1996 and 
1997, and a corresponding 12 percent increase in the number of people 
living with AIDS. During this same time period, new HIV infections have 
remained steady at about 40,000 per year. As a result, local 
communities such as San Francisco will continue to experience steadily 
increasing demand for HIV-related medical and supportive services. Not 
only are more persons living with HIV disease, but their needs are much 
more complex and the cost of care continues to escalate unabated.
    The Federal response to AIDS has literally prevented the collapse 
of local public health systems, and has enabled hundreds of thousands 
of low-income, uninsured individuals living with HIV/AIDS to receive 
high-quality health care and supportive services. These Federal 
resources have also helped to leverage millions of dollars in state, 
local and private funding for HIV/AIDS programs.
    I fully and strongly support the fiscal year 2000 HIV/AIDS 
appropriations recommendations of the National Organizations Responding 
to AIDS (NORA). In my testimony today, I would like to highlight 
several programs and initiatives that play a particularly important 
role in the City and County of San Francisco's response to this 
epidemic, and discuss our partnership with the Federal government to 
bring an end to this crisis.
 ryan white comprehensive aids resources emergency (care) act programs
    I strongly support the community request that the Committee 
provides $625.2 million overall, or a $120 million increase for Title I 
of the Ryan White CARE Act in fiscal year 2000. This funding for Title 
I is required to maintain access to medical care, treatment and 
supportive services for those individuals already in care, and to 
ensure access to care for those who will enter care for the first time.
    In response to recent HIV treatment advances, the number of 
individuals seeking medical care and treatment, as well as the cost of 
care, has grown markedly in recent years. A 1998 study by the Cities 
Advocating Emergency AIDS Relief (CAEAR) Coalition reported an average 
increase of 43.5 percent in the number of new HIV/AIDS clients entering 
CARE-funded systems between 1995 and 1997. In fiscal year 2000, the 
number of new clients seeking care is expected to increase by 20 
percent. This study also demonstrated that the overall cost of care 
grew substantially during the same time period. This increase in the 
cost of care is related to three factors: (1) increases in the number, 
length and complexity of medical visits (65 percent increase in length 
of each visit and a 27 percent increase in the number of visits); (2) 
new and expensive diagnostic tests, and; (3) the use of lifesaving 
pharmaceuticals not covered by the state-based AIDS Drug Assistance 
Programs (ADAP).
    The fifty-one Eligible Metropolitan Areas (EMAs) funded through 
Title I of the CARE Act are home to 74 percent of all reported AIDS 
cases in the United States. Together, an estimated 156,000 people with 
HIV/AIDS will be served in these epicenters in fiscal year 2000.
    Because more communities are becoming hard hit by AIDS despite our 
best efforts, in fiscal year 2000, up to three new communities may 
become eligible for Title I funding. These emerging epicenters must be 
funded adequately, and not at the expense of existing Title I areas 
that are also continuing to experience growing service needs. Because 
of inadequate appropriations in fiscal year 1999, seven Title I areas 
actually received less funding than in fiscal year 1998, including the 
Californian communities of San Francisco/San Mateo/Marin and Santa 
Rosa/Petaluma. At a time when the nation continues to see approximately 
40,000 new HIV infections annually, with many individuals thankfully 
living longer due to treatment advances, funding cuts run counter to 
common sense and good public health practice.
    As the second decade of the epidemic comes to a close, it is clear 
that the HIV/AIDS epidemic is far from over. It is also apparent that 
HIV medical care and treatment will continue to be complex, expensive 
(albeit less expensive than inpatient hospital-based care), and 
unavailable or unworkable for some. Despite the promise of new drugs, 
there continues to be a significant number of individuals who cannot 
tolerate side effects, or whose bodies have become resistant to them 
rendering the medications ineffective. These individuals, as well as 
those struggling to continue their treatment, will need essential 
support services.
    According to the Health Resources and Services Administration 
(HRSA), approximately 64 percent of Title I clients nationally are 
people of color. Despite aggressive outreach to disenfranchised 
communities, medical care and anti-HIV treatment utilization by 
communities of color continue to lag. These continued disparities 
translate into poorer health outcomes, including slower reductions in 
AIDS-related deaths. For this reason, in addition to the request for an 
overall increase in support for Title I programs, I support requests 
that the Committee increase funding for the Title I-specific 
appropriation that was approved as part of the fiscal year 1999 
Congressional Black Caucus HIV/AIDS Initiative. A significant increase 
in this targeted funding would allow Title I communities to protect and 
expand targeted programs in the African American community and other 
communities of color that are disproportionately affected by HIV/AIDS.
                the aids drug assistance program (adap)
    I strongly support the request that the Committee provides $544 
million overall, or an $83 million increase for the AIDS Drug 
Assistance Program (ADAP) in fiscal year 2000. This funding level is 
necessary to provide ongoing services to the 53,765 clients who 
utilized state ADAPs in June of 1998 and to extend access to the 
estimated 500-600 new clients that will enter the program monthly in 
fiscal year 2000. The National ADAP Monitoring Project reports that, 
compared to July 1997, in June 1998, ADAP programs served 22 percent 
more clients and the cost of treatment had grown by 37 percent due to 
increases in the cost per client, the number of clients served, and the 
increasing costs of combination anti-HIV drug therapies. ADAP spending 
for anti-HIV drugs grew by 54 percent between July 1997 and June 1998. 
Today anti-HIV drug costs represent 88 percent of ADAP expenditures.
    I want to thank the Committee for its considerable support of ADAP 
in recent years. Since 1996, Congress has responded to the critical 
pharmaceutical needs of people living with HIV disease through 
significant increases in funding. Yet, despite these efforts, many 
states continue to face shortfalls and must restrict the number of 
drugs covered because of insufficient resources.
    In California, Federal support for AIDS-related drugs last year 
leveraged an additional $51.6 million in state funding in fiscal year 
1998, allowing adequate access to ADAP for all eligible Californians 
living with HIV/AIDS. The California ADAP formulary provides access to 
all 14 anti-HIV medications approved by the Food and Drug 
Administration (FDA). In addition, California's ADAP also includes over 
80 FDA approved drugs that are used to treat opportunistic infections 
and symptoms associated with HIV disease. From 1997 to 1998, the 
national expenditures on drugs to treat opportunistic infections and 
other conditions actually decreased by 31 percent--a further indicator 
of the success of early care, treatment and support services.
    The anti-HIV medications used in combination to create Highly 
Active Antiretroviral Therapy (HMRT), while not a cure, will continue 
to offer opportunities for improved health to many individuals living 
with HIV/AIDS. Additional resources would also improve access to AIDS-
related medications for African Americans and women living with HIV/
AIDS who continue to have lower utilization rates. For all of these 
important reasons, I urge Committee support for this request.
             hiv/aids initiatives for communities of color
    I request that the Committee provide a minimum of $250 million for 
targeted emergency assistance to address the severe and ongoing health 
crisis related to HIV/AIDS in the African American community and other 
communities of color. I want to thank members of the Committee, as well 
as members of the Congressional Black Caucus, for approving targeted 
resources in fiscal year 1999 to respond to this growing health 
emergency. These successful efforts establish a foundation to increase 
financial support and technical assistance to respond to the AIDS 
crisis in African American, Hispanic/Latino, Asian and Pacific 
Islander, and Native American communities. My hope is that the impact 
of these targeted efforts will become evident in all HHS agencies that 
provide HIV services.
    The majority of people living with HIV/AIDS in the U.S. are people 
of color. Communities of color often face additional health care and 
social service challenges. Therefore, targeted initiatives, which focus 
resources on emerging crises, may provide the most strategic Federal 
response to address these intractable and longstanding problems. The 
CARE Act continues to provide an effective response to the 
fragmentation that exists in the U.S. health care system overall. 
Although the CARE Act cannot and should not be expected to eliminate 
longstanding health disparities that exist between groups, CARE Act 
grantees, providers and clients can and should act as agents for 
change. Targeted funding will help them do so. As Mayor of San 
Francisco, I am fully committed to working with Congress and the 
Administration to reduce racial disparities and improve access to 
quality care for all individuals living with HIV/AIDS.
 hiv prevention, surveillance and behavioral research programs at the 
            centers for disease control and prevention (cdc)
    I request that the Committee provide $848 million in total funding 
for HIV prevention, surveillance, and behavioral research at the CDC. 
This $191 million increase over fiscal year 1999 levels would provide 
increased resources to reduce the 40,000 new HIV infections that occur 
annually in the U.S. Over 85 percent of the HIV prevention funds are 
allocated to state and local health departments, national and regional 
minority organizations and community-based organizations to provide 
both primary and secondary HIV prevention services.
    HIV surveillance is an important component of effectively 
responding to the changing AIDS epidemic. Many states have taken the 
CDC's direction to implement HIV reporting to heart, and are developing 
systems that meet the needs of their communities. In California, 
Assembly Bill 103 (Migden) would create a non-names based system of HIV 
reporting, which I strongly support. Additional resources are necessary 
to ensure that these reporting systems are established in a timely 
manner. An increased appropriation for HIV surveillance should allow 
and promote flexibility in implementing systems that will be most 
successful in their respective states, and must allow the option of 
names or non-names based reporting.
   substance abuse and mental health services administration (samhsa)
    According to CDC, the majority of new HIV infections in the U.S. 
are now directly or indirectly related to drug use. Of those diagnosed 
with AIDS to date, drug use is linked to more than 30 percent of adult 
cases, 60 percent of cases among women and 53 percent of pediatric 
cases. I support strongly community requests that the Committee provide 
$255 million to the Center for Substance Abuse Treatment (CSAT) and 
$255 million for the Center for Substance Abuse Prevention (CSAP).
    In closing, I also want to urge the Committee to support increased 
funding for HIV/AIDS research at the National Institutes of Health, as 
well as $1.7 million in funding for the Office of HIV/AIDS Policy 
(OHAP) at HHS. CHAP will continue to play a key role in the development 
of policies and priorities regarding HIV/AIDS, including the ongoing 
review of Clinical Guidelines on the Management of HIV Infection.
    Thank you for this opportunity to testify before the Committee. I 
know that you share my commitment to ending this epidemic, and will 
work with diligence and integrity to see this worthy goal through.

    Senator Specter. Thank you very much, Mayor Brown, for that 
very profound statement. And we will fight to maintain the 
funding. I know you have commitments, Mr. Mayor. My suggestion 
would be that we hear briefly from former Congressman Dellums 
and then I will waive my first round of questions. I make the 
same recommendation that my distinguished ranking member allow 
our California colleagues to do the questioning on the first 
round, if that comports with your schedule, Mr. Mayor.
    Mayor Brown. Yes.
    Senator Specter. We have the great pleasure of seeing our 
former colleague, former Congressman Ron Dellums here today. He 
served in the House of Representatives for 27 years, 
representing the City of Berkeley. Rose to the rank of chairman 
of the House Armed Forces Committee, and brought a new 
perspective to a very challenging responsibility. Was the 
chairman of the District of Columbia Committee. Perhaps the 
only Member of the Congress to chair two committees. Now 
president of the Healthcare International Management Company, 
and still an activist and still very, very busy. One of the 
world leaders on the problems of AIDS.
    A great pleasure to see you here, Congressman. We look 
forward to your testimony.
STATEMENT OF RONALD V. DELLUMS, PRESIDENT, HEALTHCARE 
            INTERNATIONAL MANAGEMENT CO.
    Mr. Dellums. Thank you very much, Mr. Chairman. And to 
Senator Harkin, and to my two distinguished colleagues and 
friends, Senator Feinstein and Senator Boxer, and Mayor Brown. 
It's both a pleasure and a privilege and an honor for me to 
address you today. I think that this hearing is significant, 
and in one sense, very historic.
    My two colleagues from California mentioned wanting to be 
there at the end. In one sense, if we step back and look at 
this issue from a global perspective, we're only at the 
beginning, and at a very tragic beginning. Make no mistake 
about it, Mr. Chairman and Senators, what we are looking at 
here is an extraordinary human tragedy that is evolving 
rapidly.
    This is no longer an American problem, it is a global 
pandemic and requires a global response. It's an issue that has 
an incredible moral dimension, compelling self-interest and 
dictates a major global response. I mentioned that this is a 
global pandemic. Time does not permit me, nor allow me to go 
into all of that, so I will at this moment confine my remarks 
to Sub-Saharan Africa where the problem is manifesting itself 
most profoundly, and most dramatically.
    Since the first reported case of AIDS in Sub-Saharan 
Africa, 11.5 million human beings have died. This is an 
estimate from the United Nations AIDS Project. It is estimated 
that in Sub-Saharan Africa 2.5 million people will die in Sub-
Saharan Africa each year. Extrapolating out to the year 2010, 
well in excess of 20 million human beings will die.
    How can any of us as human beings get our minds around 20 
million human beings dying? That means, Mr. Chairman, that 
every day in Sub-Saharan Africa in excess of 6,000 human beings 
are dying. Now, if we suggested that a major superpower was 
waging war on a developing country, that they had already 
killed 11.5 million people, and that over 6,000 were dying a 
day as a part of this incredible warlike tragedy, and that 20 
million people more would die over the next several years, we 
would be outraged.
    The fact of the matter is that a war is waging in Sub-
Saharan Africa, and millions of human beings are quietly dying 
and suffering. Mr. Chairman, as we speak there are 7.8 million 
children who are orphaned as a result of AIDS. The World Health 
Organization suggests that if you extrapolate that figure out 
to the year 2010, we're talking about nearly 40 million 
children orphaned as a direct result of AIDS.
    One does not have to be a brilliant sociologist to 
understand the psycho-social implications, the sociological 
implications, the hopelessness and desperation of 40 million 
people orphaned, without families, and the havoc that that can 
wreak. The economic implications are absolutely astonishing. 
The national security implications are absolutely astonishing. 
Forty million human beings.
    Third, as we speak the life expectancy in Sierra Leone has 
now dropped to 34.7 years of age. In Zimbabwe, that at one 
point had the longest life expectancy in Sub-Saharan Africa, 
has now dropped into the mid-40s and falling. All over Southern 
Africa the life expectancy has dropped through the 50s into the 
40s and falling.
    All over Africa what you are seeing is all of the gains 
that took place in the 1960s, where life expectancy creeped up 
over the 60s and started to move toward the 70s, are now 
crashing down upon us. This is an amazing, incredible thing. 
The moral dimension, how can the world stand by and allow 20-
plus million human beings to die and do nothing? How can the 
world allow 40 million orphans to evolve, and the world stand 
by and do nothing? How can the world stand by and allow the 
life expectancy of Sub-Saharan Africans to drop as rapidly as 
its dropping?
    It's like the last person to leave the continent, turn off 
the lights, because it's over. But we cannot. We cannot, for 
moral and ethical and self-interested reasons, turn off the 
light. We have to do something. What can be done?
    First, we have to abandon the conspiracy of silence, and we 
must begin to talk about this issue out in the open. This is a 
global problem that threatens the human family. And get beyond 
our parochial interest in this issue. This is an issue that 
challenges the entire family of human beings on this planet.
    Second, we must move beyond the state of denial, ``Well, 
maybe it's not quite that bad.'' Folks, it may not be that bad 
at one place, or it's worse in other places, but both of those 
points miss the point. It is progressing and progressing 
rapidly. If you took a map of the last 12 to 15 years in Sub-
Saharan Africa, and plotted the progress of HIV/AIDS across 
Africa each year, the staggering speed with which this is 
evolving would frighten all of you here. This is moving with a 
degree of alacrity that is absolutely incredible.
    Third, we must make a commitment to do something. All of us 
here know that one of the great problems of Washington is that 
we tend to engage each other in the debate on how to do 
something, before we commit to do something. The first question 
must now be a question of governance. Do we have the courage, 
the compassion, the sense of caring to do something about this 
issue at the moral level?
    We can figure out how to do it, the important thing now is 
to commit to do something. There are brilliant minds out there 
in the medical and scientific community that can help us figure 
out how to do it, but we must do something.
    Fourth, we must take, Mr. Chairman and Senators, a great 
leap of scale. The first leap of scale is in the volume to talk 
about this issue. We must talk about this issue as loudly and 
as urgently as the dimension and the urgency of the problem. We 
cannot whisper AIDS in the world, we have to talk about it 
loudly, and be compassionate and caring about millions of human 
beings dying. So, we have to take a leap of scale.
    The second leap of scale has to be a leap of scale in 
resources. We are no longer at the project level, Senators. 
This is not a couple hundred thousand dollars in this project, 
or a few million dollars in this project. When we're talking 
about in excess of 20 million people dying, 40 million orphans, 
life expectancy falling, we have to talk about big money, and 
big resources. It's not going to take a few millions, it's 
going to take a few billion dollars to really address this 
issue just in Sub-Saharan Africa, let alone--we could talk all 
day about what's getting ready to explode in India. That's a 
time bomb ticking as well.
    But right here, that's why we came up with the idea back in 
October, we had to do something. So I came up with this idea of 
the AIDS Marshall Plan. I only use the term Marshall Plan to 
connote bigness, elegance, follow-through. It has to be 
something large that we must do. I realized that the public 
sector's not going to do it alone, the private sector's not 
going to do it alone, so let's achieve a partnership. A public/
private partnership.
    Let's raise several hundred million dollars from the 
private sector of our Nation, and match that with several 
hundred million dollars over the next few years from the 
Federal Government. Then let's challenge the global community 
to also participate in this. Because it is, at the end of the 
day, a global responsibility. So the AIDS Marshall Plan is 
simply a way of bringing together public and private resources.
    Let me conclude with a couple of points. Ethical issue. In 
1995, the peak year for deaths for AIDS in the United States, 
approximately 50,700-plus people died of AIDS in 1995. Last 
year, between 16,000 and 18,000 people died. Conclusion, if you 
have access to treatment and care, you can prolong life and 
improve the quality of human life.
    Ethical issue. Eighty to 90 percent of the AIDS cases in 
the world are in developing countries where virtually no 
treatment and very little is being done. Can we handle the 
ethical issue of placing a death sentence on millions of 
people, simply because they live in third-world countries? 
Because we're debating how to do it before we commit ourselves 
to do something? I am here to say let's now take the moral high 
ground, and understand the implications.
    Final point. AIDS is not simply and singularly a health 
issue. It is an issue that cuts across the entire span of human 
experience. It is a health problem, it's an educational issue, 
it's a developmental question, it's an economic issue, it's a 
political issue, it is a national security issue. If you step 
back and grasp it in this fashion, and see that it is not out 
of a sense of noblesse oblige, of noble obligation, that I'm 
suggesting that we address the issue of Sub-Saharan Africa.
    We must also address it based on our mutual self-interest. 
Virus travels. What makes us think that we live in a cocoon 
here? Just because we're coming down in the United States 
doesn't mean that we're not at the beginning of a great storm 
that will also engulf the United States.
    You've been generous, Mr. Chairman. I hope that these 
remarks stimulate some discussion. We can talk about these 
matters further, but I think that--you know, I've spent my 
entire adult life as a peace activist. This is a war, and maybe 
this is now the new peace movement. To save the planet and 
address this issue of millions of human beings dying as a 
result of HIV/AIDS. I thank you for your----
    Senator Specter. Thank you very much, Congressman Dellums, 
for those very important remarks. We had not wanted to 
abbreviate you in any way, but we have taken quite a lot of 
time up to this point. We have quite a number of witnesses yet 
to hear from. Senator Harkin and I are going to waive our first 
round of questions, although Senator Harkin has a comment or 
two for an old colleague.
    Senator Harkin. I just wanted to say one of the great 
privileges I've had in my adult lifetime was to serve in the 
U.S. Congress for 10 years with Ron Dellums, and then to work 
with him as I moved to the Senate.
    During all of those years that I served there, it was just 
one of the great uplifting moments of any day of the week to 
watch Ron get on the floor and prod us morally, and to prod our 
thinking about who we were as legislators, and what, really, we 
were about. He always made us lift our eyes slightly above the 
horizon, not just to look at our own little self and what our 
constituencies were, but to look at the broader ethical and 
moral things that we were about in the Congress.
    That's just my way of saying I really miss you. It's nice 
to be back with you, and it's nice to hear your voice again. 
Thank you, Ron Dellums.
    Senator Specter. Thank you very much, Senator Harkin. We'll 
now move to five rounds of questioning, and start with Senator 
Feinstein.
    Senator Feinstein. Thanks very much.
    Senator Specter. Five-minute rounds of questioning.
    Senator Feinstein. Thanks very much, Mr. Chairman. I want 
to thank the mayor for his comments, and Ron Dellums for his as 
well.
    Let me address the question that you so eloquently raised, 
and that is the real decimation of the African continent by 
AIDS, which is primarily heterosexual in Africa. You spoke of a 
Marshall Plan, but without specificity. From the little that 
I've been able to learn, a great deal of the problem is to 
encourage a change in behavior and enable people not to feel a 
sense of shame, but to be able to come forward and get help. 
But there is a reluctance to come forward.
    What would you--if you had to pick one thing the United 
States could do--because, as you know, the foreign operations 
budget is down every year, less and less--what would it be that 
could provide the greatest--to use a colloquialism, bang for 
the buck, in terms of reaching large numbers of people with 
either prevention or treatment that could effectively make a 
difference?

                           prepared statement

    Mr. Dellums. Thank you. First, let me say--I forgot to 
mention that I did submit some prepared remarks and I would ask 
unanimous consent that they appear at the appropriate point in 
the record.
    Senator Specter. Congressman Dellums, they will be made a 
part of the record without objection.
    [The statement follows:]

                Prepared Statement of Ronald V. Dellums

    Good morning Chairman Specter and distinguished Members of the 
Committee, it is indeed a pleasure for me to testify before you 
regarding a subject of utmost importance. I believe that the global 
pandemic pertaining to the spread of HIV/AIDS is the most critical 
problem facing our planet. As you know, I served in Congress for 27 
years, in that span of time I have witnessed many problems, which have 
included wars, human rights violations, and many more too countless to 
name. I submit to you, however, that the spread of HIV/AIDS threatens 
to surpass all of the problems of the past.
    Mr. Chairman, I believe it is important that I put my remarks in 
perspective. For your information, I have been elected as the Chairman 
of the Constituency for Africa (CFA). The organization's first Chairman 
was our colleague Congressman Andrew Young, who was succeeded by my 
good friend Mayor David Dinkins. CFA is an organization that is 
committed to educating the U.S. public about Africa and the African 
issues, and to strengthen linkages and cooperation between and among 
American organizations, groups, and companies and their counterparts in 
Africa. CFA's Board of Directors has passed a resolution recently 
stating that a priority for the organization will be advocating 
solutions for the growing problems caused by HIV/AIDS on the continent 
of Africa. Mr. Chairman, please note that my remarks today also echo 
the sentiments of CFA.
    It is also important to note that I am also a member of the board 
of director's for Aids Action. I am sure you are familiar with the work 
and activism of Aids Action. It is my belief that this organization has 
been a major player in the domestic fight against HIV/AIDS. However, I 
was asked to join the board, I believe to help expand the scope of the 
organization to include the growing problem of HIV/AIDS across the 
globe. Mr. Chairman, please know that that my statements today also 
represent the sentiments of Aids Action.
    In the course of my new position I have had the opportunity to 
travel to Africa. In my travels to Africa I could not escape the ever-
increasing spread of HIV/AIDS and the devastation it has brought to 
most nations. Last year, my company helped to sponsor the International 
Medical Exchange conference on HIV/AIDS in Swaziland in Africa. Nearly 
two dozen ministers of health, representing various African nations 
were in attendance to begin a dialogue about preventive strategies and 
the development of solutions for the problem.
    Please realize that HIV/AIDS is a threat to the survival of many 
developing nations around the globe, which include India, Brazil, and 
many of countries in Asia. However, because the problems of HIV/AIDS is 
currently ravaging the continent of Africa, I feel obligated to put my 
initial efforts towards a place in most need and the home of my 
ancestors. I will now proceed with my testimony.
                              introduction
    HIV/AIDS has wreaked havoc in Sub-Saharan Africa. Of the 30 million 
people in the world currently affected by HIV, 26 million (86 percent) 
reside in this region and over 90 percent of all AIDS deaths come from 
this region. In South Africa over 360,000 people have died from the 
disease. The UNAIDS program estimates that more than 3 million South 
African are currently infected with HIV, with 1,500 new infections each 
day. Some estimates predict that more than 25 percent of the working 
age population in South Africa will be infected with HIV by the year 
2010. HIV/AIDS has greatly reduced the life span of the citizens of 
Southern African countries. Life expectancy in Botswana has declined 
from 61 years five years ago to 47 years, and is expected to drop to 41 
years between 2000 and 2005. In Zimbabwe one out of every five adults 
is affected and is significantly reducing population growth from 3.3 
percent in 1980-85 to 1.4 percent currently and is projected to be less 
than one percent beginning in the year 2000. This pandemic is of a 
scale in Southern Africa last seen in the late 18th century epidemics 
of smallpox or the 16th century epidemics of bubonic plague. The effect 
on growth and development of this region is large and will only become 
more evident in the years to come.
    The United Nations AIDS programs (UNAIDS) and The World Bank have 
spent time and energy gathering information and setting up programs to 
encourage AIDS prevention and education. The scientific, medical and 
pharmaceutical sectors have focused energy and resources on developing 
effective treatments for people who are living with HIV/AIDS, design 
studies for development of a vaccine to prevent HIV infection, and 
efforts toward the ultimate goal of a cure for AIDS.
    I have conceived the AIDS Marshall Plan For Africa (AMPFA) as a 
means to bring treatment to those affected with the HIV/AIDS virus. 
Treatment is an imperative because it does prolong life and helps to 
improve the quality of life for those affected. There are estimates 
provided by UNAIDS that over 20 million Africans will die in the next 
decade as a result of HIV/AIDS. At the same time, there are currently 
over 7.8 orphans as a direct result of the virus; it is conservatively 
estimated that in the next ten years the number could swell to 40 
million. Presently, if one attracts the virus in Africa, it is 
tantamount to a death sentence because they will certainly die. I am 
certain you realize the consequences are devastating and crippling. The 
major intention of the AMPFA is to provide treatment for those in need.
                        development of the fund
    With the advent of effective drug treatment regimens for people 
living with HIV/AIDS combination drug therapy has proved it's ability 
to prolong life and decrease severe health complications brought on by 
AIDS. The cost of treatment with these new discoveries can cost upwards 
of U.S. $10-15,000 per person per year. Even with a minimalist 
approach, cost per person, per year could exceed $5,000.
    We must take some large first steps to save the current generation 
of Africans from complete devastation.
    The plan for the development of the AIDS Marshall Plan Fund (AMPFA) 
would be the funding of one billion dollars over a period of five 
years. This would mean annual funding of $200 million. These funds 
would then be leveraged in seeking additional funds for multinational 
companies and that would initially concentrate its efforts on the 
region of Southern Africa. In development of the fund, private industry 
would be called upon to contribute the first $200 million and the U. S. 
government would be asked for a matching $200 million. Billions of 
dollars would be needed to adequately address the problem, but we 
believe that an initial focus in Southern Africa is warranted based on 
the concentration of the pandemic in this region.
    The fund would be developed in such a way to promote contributions 
from the African countries, based upon their economic ability. European 
and Asian countries will be encouraged to participate in the AMPFA in 
the future, thus adding to the growth potential of the fund. Clearly, 
all G7 countries will need to play a leadership role.
          pharmaceutical companies and other corporate support
    We believe that pharmaceutical companies will be interested in the 
establishment of the fund for various reasons. As the HIV/AIDS virus 
continues to spread across the continent of Africa, it affects a very 
valuable market. Presently, 750 million people form the basis for a 
very strong market for the pharmaceutical companies. However, the 
present situation threatens a potentially potent market for the 
companies.
    In order for the AMPFA to be a success the cooperation of 
multinational corporations is a must. Recently, I was made aware of 
interesting statistics that speak to the capacity of the corporate 
community. It was revealed to me that of the 100 largest economies in 
the world 51 are corporations and 49 are countries. For example, the 
economy of Wal-Mart is larger than Indonesia, and the economy of The 
Shell Oil Company is bigger than the country of Norway. We therefore 
have an obligation to call upon the corporate community to assist in 
this modern ``holocaust'', which threatens the universe.
    It is my belief that with the combined resources of the United 
States, the corporate community, countries of the European Union and 
Asia, that huge strides can be made to arrest the spread of HIV/AIDS in 
Africa. This is a massive problem that deserves an equally massive, 
elegant response in order to successfully combat the virus. The 
corporate communities support is an essential portion of the AMPFA.
                      administration of the ampfa
    A Board of Trustees composed of ``distinguished persons'' would 
administer AMPFA. The collection of ``distinguished persons'' allows 
the fund to be perceived as a serious effort above reproach and 
politics. In order for the AMPFA to be successful it must be an idea 
which commands the attention of the entire world. A Board of Trustees 
which includes those at the highest moral, spiritual, political and 
scientific level will help AMPFA gain instant credibility in the AIDS 
community
    To avoid conflicts of interest and to prevent AMPFA from being 
mired down within another group, our vision would have AMPFA as an 
independent entity that develops appropriate linkages at the local 
level to assure treatments reach those in need.
    AMPFA would be dedicated to the treatment of people living with 
HIV/AIDS. The Fund would secure appropriate drugs, assure the training 
of healthcare professionals and the development of a pipeline to bring 
the drugs to where they are needed most.
    The steps that need to be accomplished first include:
  --Enlist the support of governments, international institutions and 
        the pharmaceutical industry,
  --Recruit a ``Steering Committee'' of distinguished persons as a 
        preliminary step toward a Board of Trustees, and
  --Obtain initial donations to develop the organizational structure 
        and hire a manager for the Fund.
    Currently, my friend and Representative, Congresswoman Barbara Lee 
is working to introduce legislation that will embody the concept of the 
AMPFA. This legislation must be taken seriously and should be a 
priority for the Congress. I cannot emphasize enough the necessity to 
expedite the passage of this legislation. It is very difficult for me, 
and it should be difficult for you, to withstand the continuous death 
and destruction caused by HIV/AIDS. As a former colleague and friend, I 
call upon you to do all within your power to continue funding to combat 
this deadly virus. I believe the future of humanity rests upon your 
decision. Please do not let the children of my children and their 
children down. They deserve a future of hope and opportunity. It is my 
hope that you will agree with me that this legislation is an imperative 
and passage is ultimate.
    Mr. Chairman again, thank you for allowing me to testify this 
morning.

                  education, prevention, and treatment

    Mr. Dellums. Thank you. The reason why I suggested that, 
Senator Feinstein, is that I do talk in greater specificity 
about the AIDS Marshall Plan in my prepared remarks. To come to 
your point, that's a very good question. Let me first say, I'm 
not an AIDS expert, I'm a political activist with a big mouth, 
and I think it's time to take this issue to a political level.
    Now, to try to answer your question, I perceive this very 
complex issue as an issue that has to stand minimally on three 
legs. A stool can stand minimally only on three legs--
education, prevention and treatment. The reason why I raised 
the treatment issue is because I'm trying to challenge us at an 
important moral and ethical level.
    In the United States and in Europe, the death rate is 
falling because of access. You know, I watched ABC News last 
night, and one of the people at the tail end of the program 
looking at the issue of AIDS was to say the government of 
Zambia must then embrace a strategy to allow thousands of 
people to die in order for thousands of people to live.
    I don't accept that as--I do not accept that. We cannot 
stand by and allow this generation or the next generation of 
Africans to die, or people in developing countries, to let the 
third generation live. We don't do that in this country. We're 
no more human than anybody else. So I'm suggesting that we do 
all three things.
    That we have to expand our educational capabilities, expand 
our prevention capabilities, but we also must be committed to 
treat people. We cannot say, ``We will not treat you because we 
can't figure out how.'' I'm saying, accept this as a moral 
challenge, and intellectually and scientifically and 
politically, we'll figure out how to do it. But that's what we 
have to do.
    So, it's not a simple answer. I would suggest that the 
first thing we need to do is put together a fund of resources. 
Now, the reason why I'm advocating, for example, an independent 
international agency that can receive both public and private 
monies--and because I'm an African-American, I want the United 
States to take a lead on that. But the world community needs to 
come in.
    The reason why I see it as an independent agency, with all 
due respect to the other agencies, they've failed miserably. 
One thing we all know about institutions is that they don't 
tend to re-invent--they've failed. They don't tend to re-invent 
themselves to succeed, they tend to re-invent themselves to 
fail another new way.
    So what I want to see is a new Federal agency, a new 
international agency that can receive the kinds of resources 
that truly will allow us to address this problem. There's no 
project. We're past the project stage, we can't just do one 
little thing. We have to confront this entire issue. It is 
moving too profoundly and too rapidly.
    Senator Feinstein. Thanks very much. Thank you very much, 
Mr. Chairman.
    Senator Specter. Thank you very much, Senator Feinstein. 
Senator Boxer?
    Senator Boxer. Mr. Chairman, I have no questions. But I do 
have a comment that will impact, I think, on what our friends 
have spoken to us about. You know, after 20 years--and I was 
struck by each of us kind of putting this battle into our own 
personal careers, and how it impacted on us. After 20 years, it 
is very, very tempting to turn away from this fight. Because 
it's hard, because it's taking a long time, because it costs so 
much, because we make progress and we want to focus on that 
progress.
    I think what Mayor Brown has done for us today, and 
Congressman Dellums, they have done--at least for me--they have 
put urgency back on the face of AIDS. Mr. Chairman, I think 
this is a lesson for us that cannot go unnoticed. They have put 
urgency back on the face of AIDS.
    They have challenged us because this urgency is here in San 
Francisco, as the mayor has pointed out. It is in Los Angeles, 
I would point out. It is in Philadelphia, it is in New York, it 
is across the Nation. As Congressman Dellums has pointed out, 
it is an urgent matter across the world.
    Congressman Dellums, your proposal for an AIDS Marshall 
Plan is a very important proposal, and a very serious one. I 
think it fits into a larger debate, which is also a very 
difficult debate over the surplus. We will all be in that 
debate momentarily. I ask myself this question, as much as 
putting it out there for everyone to think about. You know, how 
large is this surplus?
    Isn't it true that if you have a leak in your roof, and you 
get some extra money in the door, but you still have the leaky 
roof and you've got to take care of it, you may not have a 
surplus. It seems to me what we're doing today by seeing this 
urgent face back on AIDS, is to think about that. And to think 
about the other urgent matters that have not been faced, this 
worldwide fight that we have to engage in, the fight right here 
at home on AIDS, Alzheimer's, Parkinson's. You name the 
disease. School buildings falling down, lots of things.
    So before we can have this vision--and I'm honored that I'm 
here to hear Congressman Dellums talk--we need to really think 
about these fundamental things. I can't imagine, you know, a 
better mix of Senators, in my opinion, in terms of geographic 
distribution or philosophy, et cetera to chair this challenge. 
It has impacted me very deeply, and I thank you both.
    Senator Specter. Thank you very much, Senator Boxer. Thank 
you, Mayor Brown. Thank you, Congressman Dellums, for your very 
important testimony. This subcommittee is committed to do its 
utmost to provide adequate funding.
    Mr. Dellums. Might I make just one quick comment, Senator?
    Senator Specter. Sure.
    Mr. Dellums. First, I failed in my opening remarks to say 
that I have been working diligently with my distinguished 
colleague, Barbara Lee, who is now the Representative from 
across the bay, who is placing this idea in legislative form.
    Just one other quick point. I'm also suggesting to you, 
Senator Boxer, that a number of economies in Africa are going 
to collapse if we don't do something about this. The sugar 
industry in Kenya, the agricultural industry in other 
countries. There are insurance companies that are now stepping 
back from providing insurance because they can't figure out the 
actuarial charts because the life expectancy is dropping so 
fast.
    The implications here are absolutely astonishing. I simply 
suggest to all of you that the more you look into this issue, 
the more you see that it touches all aspects of life. And the 
one thing all of us, I think, in this room agree on is that the 
world is very tiny, interrelated and interdependent. We cannot 
allow Sub-Saharan Africa to drop through the tubes without also 
taking us with them. We have to deal with this because it's in 
our self-interest.
    You've been very kind.
    Senator Specter. Thank you, Congressman Dellums. We're now 
going to move to the next two panels to try to expedite the 
proceeding a bit. We're going to reduce the time from 5 minutes 
to 4 minutes. Thank you very much, Mayor Brown. Thank you, 
Congressman Dellums.
    I'd like to call now Tony Fauci, Director of the National 
Institute of Allergy and Infectious Diseases at NIH since 1984. 
He has been at NIH, generally, since 1968, receiving numerous 
awards. He's been central to the AIDS research strategy at NIH. 
In addition to his leadership role, he continues to do research 
himself. M.D. from Cornell University in 1966. Welcome, Dr. 
Fauci. The floor is yours.
STATEMENT OF DR. ANTHONY FAUCI, DIRECTOR, NATIONAL 
            INSTITUTE OF ALLERGY AND INFECTIOUS 
            DISEASES, NATIONAL INSTITUTES OF HEALTH, 
            DEPARTMENT OF HEALTH AND HUMAN SERVICES
    Dr. Fauci. Thank you very much, Senators Specter, 
Feinstein, and Boxer. I really appreciate the opportunity to be 
here with you today. In my very brief period of time I would 
like to underscore some of the points that were made by the 
panel from a perspective of a scientist and a public health 
official.
    The first thing I'd like to do with this poster is put up a 
cover from Newsweek from a few years ago that really created a 
lot of confusion in the general public. That had to do with the 
onset and the availability of powerful drugs to treat HIV/AIDS. 
That was the question, of whether or not we were at the end of 
the AIDS epidemic.
    Now, there's good news and very sobering news about these 
advances. The good news, as I'm going to outline for you in a 
moment, is that we've made an extraordinary amount of progress. 
The sobering news is that we are far from the end of AIDS. I 
think I want to underscore everything the panel said. To assume 
that we're anywhere near the end of this is really quite naive.
    Now, with regard to the support that we need, where we've 
come from and where we're going, the support for research on 
HIV/AIDS has been substantial. If you look at the growth of 
resources, this for the fiscal year 2000, is $1.8 billion for 
the NIH, and $666,000 for the Centers for Disease Control and 
Prevention. If you look at the totality of this, this is about 
$15 billion. Senator Harkin asked me that right before we went 
into the hearing. If you add all of this, it's more than $15 
billion in research.
    This cannot stop. Because the advances that I'm going to 
very briefly outline for you now were predicated on that type 
of support. The kinds of research have led to striking, 
unprecedented advances in diagnostics, therapeutics, 
pathogenesis and vaccines. I'm going to focus, for the couple 
of minutes that I have, on the therapeutic aspects, as well as 
the need, the critical need for a vaccine.
    This slide is a very good news slide, because it tells you 
about the deaths of HIV/AIDS, and how they've taken a dramatic 
turn downward with a 47 percent decrease between 1996 and 1997. 
Again, with all good news, there always comes with HIV sobering 
news. Because if you look at this curve, it's starting to 
plateau, and in fact even now starting to rise a bit.
    The reason for that is that although the drugs had a 
dramatic effect, positively, on people's lives, their longevity 
and quality of life; the fact is that many people cannot 
tolerate the drug, there's breakthrough of the viral 
replication. There's a discovery that we made in our lab and 
other laboratories of the presence of a very persistent latent 
reservoir of virus, that when you discontinue drugs 
individuals, the virus inevitably comes back down, up to its 
baseline level.
    In addition, people are starting to become complacent that 
in fact this is the end of AIDS, when in fact we know that it's 
not. What about drugs? There are now 16 approved anti-HIV drugs 
available in the United States and developed countries, 10 of 
which are approved for pediatric use.
    These are the drugs, their names are very familiar with 
you, including a handful or more of protease inhibitors. Of 
importance is the price of these drugs. I bring this out 
because of several comments that were made by Congressman 
Dellums, as well as others, about the lack of availability of 
adequate treatment for most of the world who's HIV-infected. 
It's estimated that 90 percent of the people in the world who 
are infected with HIV, do not have availability or 
accessibility to these drugs.
    Which brings us to the globality of the epidemic, a point 
again that was underscored by several members of the panel. If 
you look at this--I know you can't see it in the back. But to 
just reiterate, 33.4 million people living with HIV. Last year 
alone 5.8 million people were infected, and 2.3 million people 
died last year worldwide from HIV. The demography is changing.
    Here in the United States we're seeing a shift to minority 
populations. The numbers are very striking. Sixty-six per 1,000 
for African-Americans are infected, 66 per 100,000. If you 
compare that with whites, it's only 8.7. Hispanics are 28 per 
100,000.
    If you look at the marching of the epidemic throughout the 
continent, India is the next epicenter, will probably dwarf 
what we're seeing here in Sub-Saharan Africa, another point 
that is often missed when people think about ``the end of 
AIDS.''
    With regard to prevention, there are a number of modalities 
of prevention. We don't have time to go through all of them. 
One of them that I want to mention is the interruption of 
transmission from the mother to a child. We'll get to vaccine 
in just a moment. This has had a major impact on prevention of 
transmissibility from infected mother to their newborn infant.
    If one looks at the effect of drugs on this, the numbers 
are rather striking. In fact, this mimics the curve of treating 
adults. These were the infections in children, perinatally-
acquired AIDS cases, now a dramatic downturn. However, this 
will be much more important in developing countries. They 
cannot afford the AZT regimen.
    However, recent studies are suggesting that you can 
truncate the length of time that's required to treat the 
mother, and there are studies going on now that we'll hopefully 
have the results of within a period of a month that we may be 
able to give to a mother during labor a drug, in a very small 
amount of doses that are affordable, that could have a profound 
impact on transmissibility.
    Finally, what has been the bottom line of prevention has 
been vaccine development. A point again that was brought up by 
the panel. There has been an acceleration of vaccine 
development resources at the NIH over the past few years, such 
that now we're spending $204 million on vaccine. If we don't 
get the kinds of funding that the panel was talking about, this 
is the kind of research that will slow down. Residence that in 
fact has the potential impact to save tens of millions of lives 
per year.

                           prepared statement

    I'd like to close by again mentioning something that 
Senators Specter and Harkin are very familiar with, because I 
almost always end my testimony before the Appropriations 
Committee hearing by pointing out that despite the specific 
benefit to AIDS and AIDS patients by the AIDS resources, AIDS 
research has extraordinarily positive spinoff for other 
diseases and other disciplines.
    So, the investment in AIDS research is saving in real times 
tens of thousands of lives per day. But the projection of that 
for other diseases is also enormous.
    Senator Specter. Dr. Fauci, thank you very much for that 
accelerated testimony.
    [The statement follows:]

               Prepared Statement of Dr. Anthony S. Fauci

    I am pleased to appear before you today to discuss the human 
immunodeficiency virus (HIV) epidemic, recent developments in HIV 
research, and the many challenges that remain in the fight against HIV 
and the acquired immunodeficiency syndrome (AIDS).
                       the scope of the epidemic
    AIDS was recognized eighteen years ago this summer, and continues 
to exact an enormous toll throughout the world, in both human and 
economic terms. In the United States, an estimated 650,000 to 900,000 
people are living with HIV. In this country, 688,200 cumulative cases 
of AIDS and 410,800 AIDS-related deaths were reported to the Centers 
for Disease Control and Prevention (CDC) through 1998.
    Despite an encouraging downturn in the overall number of new AIDS 
cases and AIDS-related deaths in the United States during the past 
three years, the rate of new HIV infections in this country--
approximately 40,000 per year--continues at an unacceptably high level. 
Of these newly infected individuals, the CDC estimates that half are 
people younger than 25 who were infected sexually.
    The HIV virus continues to affect minority populations 
disproportionately. The rates of AIDS cases (per 100,000 population) 
reported in 1998 in the United States were 66.4 for African-Americans, 
28.1 for Hispanics, 8.2 for Whites, 7.4 for American Indians/Alaska 
Natives and 3.8 for Asian/Pacific Islanders. Women are increasingly 
affected: the proportion of U.S. AIDS cases reported among adult and 
adolescent females more than tripled from 1985 to 1998, from 7 percent 
to 23 percent.
    In the developing world, the HIV/AIDS epidemic continues to 
accelerate, notably in sub-Saharan Africa, southeast Asia and on the 
Indian sub-continent. There are also signs of burgeoning epidemics in 
Russia and the former Soviet Union nations. As of the end of 1998, more 
than 33 million people worldwide were living with HIV/AIDS, 43 percent 
of them female, according to estimates by the Joint United Nations 
Programme on HIV/AIDS (UNAIDS). An estimated 5.8 million new HIV 
infections occurred worldwide during 1998--approximately 16,000 new 
infections each day. More than 95 percent of these new infections 
occurred in developing countries. In 1998, HIV/AIDS was the fourth 
leading cause of mortality worldwide, resulting in an estimated 2.3 
million deaths.
    Beyond the human tragedy of HIV/AIDS, the economic costs of the 
epidemic are staggering, posing a significant impediment to the growth 
and stability of many countries. A 1999 WHO publication, Removing 
Obstacles to Healthy Development, estimates the annual economic burden 
of HIV to be $14 billion in prevention and health care costs alone. In 
many countries, the epidemic is decimating a limited pool of skilled 
workers and managers, and will likely wipe out gains in development by 
slashing life expectancy. According to UNAIDS, life expectancy in the 
nine countries in Africa with the highest HIV prevalence rates will 
fall, on average, 17 years by 2015.
                        hhs spending on hiv/aids
    Clearly, HIV remains one of the greatest threats to global health, 
and requires a sustained commitment by the many partners in AIDS 
research and prevention, including federal, state and local health 
agencies, foreign governments, UNAIDS, the World Bank, non-governmental 
and philanthropic organizations, academia, industry, and the activist 
community. In this regard, overall funding for AIDS-related programs 
within the U.S. Department of Health and Human Services (HHS) has 
increased by 122 percent under the current Administration. The fiscal 
year 2000 President's Budget includes $8.2 billion in total HIV/AIDS 
funding within HHS. At the National Institutes of Health (NIH), HIV/
AIDS funding increased 68 percent from fiscal year 1993 to fiscal year 
1999; the fiscal year 2000 President's budget includes $1.834 billion 
in HIV/AIDS research funding at the NIH, as well as $666. 5 million for 
HIV prevention funding at CDC.
    The Ryan White Care Act, which helps states and highly impacted 
communities provide primary and supportive services to people living 
with HIV and AIDS, was funded at over $1.4 billion in fiscal year 1999. 
President Clinton has proposed an increase of approximately $100 
million for fiscal year 2000 in recognition of the critical role that 
the CARE Act continues to play in helping people access and maintain 
themselves in care.
        the success--and limitations--of antiretroviral therapy
    In the United States and other developed countries, new AIDS 
diagnoses and deaths have fallen significantly during the past three 
years. In the United States, the age-adjusted death rate from AIDS 
declined 47 percent from 1996 to 1997, according to the Centers for 
Disease Control and Prevention. Similar decreases have been noted in 
western Europe and Australia. These trends are probably due to several 
factors, particularly the increased use of potent, albeit expensive, 
anti-HIV drugs, generally administered in combinations of three or more 
agents. Such combinations are known as ``highly active antiretroviral 
therapy'' or HAART. Sixteen anti-HIV drugs are now licensed by the Food 
and Drug Administration, 10 of which are approved for pediatric use.
    Consensus guidelines have been developed for the use of HAART in 
adults and adolescents; separate treatment guidelines have been 
formulated for pediatric patients, as well as for the use of 
antiretroviral drugs in HIV-infected pregnant women. These guidelines 
are regularly updated on the World Wide Web (see http://
www.hivatis.org) and when appropriately applied have greatly improved 
the prognosis for HIV-infected individuals and markedly reduced the 
risk of HIV transmission from mother to baby.
    Unfortunately, many HIV-infected individuals have not responded 
adequately to current medications, cannot tolerate their toxicities, or 
have difficulty complying with treatment regimens that involve 
extremely complicated and demanding dosing schedules, large numbers of 
pills, and myriad interactions with other drugs and foods. This can be 
particularly difficult for those who are struggling to maintain the 
basic necessities of life such as housing and food, the very people in 
the path of this epidemic.
    Even in patients who are successfully treated with HAART and have 
extremely low bloodstream levels of HIV, the virus persists in 
sanctuaries where the drugs cannot reach it or in a latent form upon 
which drugs have no effect. In addition, the emergence of HIV strains 
resistant to current drugs is a growing problem. Although there is 
evidence of immune system reconstitution in certain patients who 
receive combination antiretroviral therapy, the goals of completely 
``rebuilding'' the immune system or eradicating the virus from its 
hiding places in the body appear unlikely with current approaches to 
treatment.
    Therefore, the development of a next generation of therapies 
remains a priority. Currently, all licensed antiretroviral medications 
are directed at one of two viral enzymes, reverse transcriptase or 
protease. Many new drug targets and novel treatment strategies are now 
being pursued, including drugs that prevent the virus from entering a 
cell, approaches to ``purging'' the virus from its hiding places in 
certain cells and tissues, and methods to boost an infected person's 
immune response.
                  the critical role of hiv prevention
    In developing countries where per capita health care spending may 
be only a few dollars a year, anti-HIV therapies are frequently beyond 
the reach of all but the privileged few, underscoring the urgent need 
for effective, low-cost tools of HIV prevention that can be used in 
these settings as well as in the United States.
    CDC estimates that there are at least 200,000 HIV positive persons 
in the United States who do not know they are infected, and the Health 
Resources and Services Administration estimates that approximately 
300,000 HIV positive persons in the United States are not currently 
being treated for their HIV infection. The benefits of HAART, and the 
likelihood of reduced sexual risk behaviors after a diagnosis of HIV 
infection have made it increasingly important for people infected with 
HIV to know their serostatus early and to be linked with a system of 
medical care and prevention.
    Researchers have shown that several approaches to HIV prevention 
can reduce the number of new infections when properly executed, 
including education and behavior modification, the social marketing and 
provision of condoms, treatment of other sexually transmitted diseases, 
drug abuse treatment (for example, methadone maintenance for injection 
drug users), and the use of antiretroviral drugs to interrupt the 
transmission of virus from mother to infant.
    For example, in one of the true ``success stories'' of HIV 
research, the rate of mother-to-child transmission of HIV in the United 
States has been cut to negligible levels among women and infants 
treated with an extended regimen of AZT therapy developed by NIH-
supported investigators. Subsequent studies by CDC, NIH and others have 
shown that substantially shorter regimens of antiretroviral drugs, 
which would be more feasible in resource-poor settings, can also reduce 
perinatal HIV transmission significantly.
    Other methods of preventing HIV transmission may also help slow the 
HIV/AIDS epidemic. For example, researchers are developing and testing 
topical microbicides, substances that a woman could use in her vagina 
before sex to prevent the transmission of HIV and other sexually 
transmitted diseases. UNAIDS and others also have facilitated the 
widespread use in Africa of the female condom. These interventions may 
help empower women to protect themselves in situations where they are 
unable to avoid sex with HIV-infected partners, and/or cannot persuade 
their partners to use a condom.
                        hiv vaccine development
    Historically, vaccines have provided safe, cost-effective and 
efficient means of preventing illness, disability and death from 
infectious diseases. The development of a safe and effective vaccine 
for HIV infection remains the ultimate goal of AIDS research, and a 
necessary tool to bringing the HIV epidemic under control. To speed the 
pace of HIV vaccine discovery, many public and private agencies have 
dramatically increased the resources devoted to HIV vaccine research. 
For example, at the NIH, HIV vaccine funding rose from $100.5 million 
in fiscal year 1995 to nearly $200 million in fiscal year 1999. A 
number of experimental vaccines have been examined in animal models and 
have shown some promise. As part of this expanded effort, NIH has 
awarded numerous grants to foster innovative research on HIV vaccines 
and to conduct clinical trials of candidate HIV vaccines. To date, more 
than 3,000 non-infected volunteers have enrolled in more than 50 NIH-
supported HIV vaccine studies (including two ``phase II'' intermediate-
sized trials), involving 27 vaccines. In addition, NIH has established 
the Dale and Betty Bumpers Vaccine Research Center within the NIH 
intramural research program to stimulate multidisciplinary vaccine 
research.
    As part of a broad portfolio of research, recent NlH-supported 
studies have assessed so-called ``vectored vaccines'': harmless viruses 
(e.g. canarypox) which are genetically altered to make HIV proteins. 
These vaccines have been administered to volunteers in combination with 
a separate vaccine made of a purified HIV protein. Results have been 
encouraging: in phase I and phase II studies, the combination approach 
has appeared safe and evoked several types of immune responses that may 
have a role in protection from HIV. NIH-funded researchers are now 
comparing three different vectors, as well as other HIV proteins to 
determine which combination produces the most vigorous immune response.
    Meanwhile, a large-scale study of a vaccine based on the surface 
proteins of two HIV strains was recently undertaken in the United 
States by a private company, with an additional phase III study to be 
conducted in collaboration with CDC in Thailand. NIH will collaborate 
with the company in evaluating the immunological responses to the 
vaccine.
                               conclusion
    As we work to contain the global HIV/AIDS epidemic, it is essential 
to sustain and enhance our commitment to HIV prevention, to caring for 
HIV-infected people, to developing the next generation of HIV therapies 
and prevention tools, and to producing a safe and effective HIV 
vaccine. Though we have been battling against AIDS for nearly 20 years, 
we are in no position to let down our guard. On the contrary, if we are 
ever to hope for a day without AIDS, we will need to sustain and 
increase our efforts both here in the United States and across the 
globe.

    Senator Specter. I'm going to yield my time for the 
introduction of fellow San Francisco Dr. Paul Volberding.
    Senator Feinstein. Thank you very much, Mr. Chairman. It's 
a great pleasure and a great honor for me to be able to 
introduce Dr. Volberding. He's just a wonderful human being, 
he's a wonderful doctor, he's dedicated his life to AIDS. I've 
watched him with patients, and he does it year in, year out.
    He has been the Director of the Center for AIDS Research at 
the University of California in San Francisco since 1988. He's 
been a professor of medicine in residence at the university 
since 1990. He's Director of the UCSF Positive Health Program. 
He's been active in the HIV community for nearly two decades. 
During this time, he's participated in numerous AIDS-related 
committees, and I won't go into all of them. But one of them 
certainly was mine.
    He's a founding member of the International AIDS Society, 
and since 1995 he's been a member of the Chancellor's Advisory 
Board on AIDS and Emerging Infections at UCSF. He's been active 
on the AIDS Institute Scientific Advisory Board at UCLA since 
1997. His commitment is simply unparalleled.
STATEMENT OF DR. PAUL VOLBERDING, DIRECTOR OF AIDS 
            RESEARCH, SAN FRANCISCO GENERAL HOSPITAL
    Dr. Volberding. Thank you. Good morning. It's a pleasure to 
have you here, it's a true honor to be here, and especially to 
be back in City Hall with Senator Feinstein, and to have 
Barbara Boxer here as well.
    It's a challenge, obviously, in 4 minutes to summarize some 
of my concerns. They are small, perhaps, in comparison to the 
concerns that Ron Dellums raised, which I think all of us have 
a strong feeling for. I direct AIDS care at San Francisco 
General Hospital. It's the largest HIV care center on the West 
Coast, one of the largest in this country.
    We've been involved since the absolute ground zero days of 
this epidemic in 1981. We currently provide in the Positive 
Health program comprehensive care for over 3,000 persons 
infected with HIV. We conduct an aggressive clinical research, 
professional education program, and relevant to the discussion 
today, we're very fortunate to receive substantial Federal 
supports for our activities. We receive Ryan White funds that 
are essential for patient care, and we receive NIH funds for 
our research as well.
    We could not do what we do with patient care without the 
Federal support from the Ryan White Act. As an example of the 
kind of services that we provide with that funding, women's 
services through a coalition in San Francisco, evening and 
weekend urgent care, and community-based care for homeless San 
Franciscans with HIV.
    Our Center for AIDS Research grant, one of our grants, is 
one that I'd like to just mention as an example. It's a grant 
that allows us to link the most promising basic investigators 
with the most promising clinical investigators to launch into 
new areas of research in this disease. We still need new ideas 
to explore.
    Steve Deeks, a clinician working with me, Mike McCune, an 
immunologist who's a laboratory-based immunologist, are working 
together through this funding to understand how the immune 
system recovers with the therapies that our patients 
fortunately have available.
    We've made incredible progress in treating HIV. We've heard 
reference to that. Many people that we now care for would have 
been dead of AIDS were it not for the treatment that we've been 
able to provide. But, as a paradox, perhaps, of that success, 
our outpatient facilities are coming under increasing pressure. 
It's a problem of success, but we can't ignore the fact that we 
have more and more people to take care of because of the 
treatments that we have.
    Many of our patients are doing well, but as Dr. Fauci 
suggested, many other patients are beginning to fail these 
therapies. It turns out that continued control of this virus 
requires absolute strict adherence to the medication 
prescriptions. Many patients aren't able to maintain that 
degree of adherence, and as a result their virus is becoming 
resistant to the drugs.
    One patient that I saw recently is an example of this. A 
man in his mid-40s who came to me for help. He's been a good 
patient, he's taken his medicines as prescribed. But he's been 
treated for more than a decade, and now his virus is resistant 
to absolutely every medicine that I have to offer. His immune 
system now is totally devastated, he's losing weight, and I 
have nothing to offer him. That patient, and many others like 
him, will die unless something is done very soon to design new 
classes of drugs that are active against his virus.
    Another problem that we face is that our systems of care 
for AIDS, including mine at San Francisco General Hospital, are 
based on academic teaching hospitals. Academic hospitals are 
facing a true crisis in the reduction of Federal reimbursements 
for our care. Because of this reduced Federal reimbursement for 
care, my own program is this week facing a $500,000 budget cut, 
despite our continuing commitment, despite our success and 
despite the growing problem that we, in fact, face with this 
disease.
    HIV care and research need more help, not less. Any cuts 
that you might have to impose on this would be truly 
disastrous. Where could we use more help? More Federal help, 
along with the drug companies, to design and develop and launch 
new drugs. New drugs that are active in my patient who is 
otherwise resistant to the drugs we have now.
    Expanding the programs. The successful center's program, 
like ours here in San Francisco, the Center for AIDS Research, 
which is, I think, a model of how we can link our most 
promising scientists and reducing the caps that now keep us 
artificially constrained.
    Finally, again coming back to the teaching hospitals issue, 
I'm not sure it's your committee's purview, but the teaching 
hospitals are facing a real crisis. The reimbursements are 
inadequate for us to continue our efforts, and I don't think 
I'm exaggerating to say that the survival of teaching hospitals 
and the excellent centers that we've been able to develop as a 
result, are really threatened here, and depend on the help that 
you can provide.
    So, again, I appreciate the invitation to be here. I'm 
really honored, and I appreciate your efforts. And if there's 
anything I'm sure any of us can do to help you, we'd be glad to 
help in the future. Thank you.
    Senator Specter. Thank you very much, Dr. Volberding.
    We now turn to Mr. Lonnie Payne, Board Director of the San 
Francisco AIDS Foundation. It provides social support and other 
services to patients with HIV. Mr. Payne has lived with HIV 
infection for over a decade. He's a Manager at AT&T, earned his 
college Master's Degree in Music at the University of South 
Carolina. I thank you for joining us, Mr. Payne, and we look 
forward to your testimony.
STATEMENT OF LONNIE PAYNE, BOARD DIRECTOR, SAN 
            FRANCISCO AIDS FOUNDATION
    Mr. Payne. Thank you, Senator. Good morning, Senators. My 
name is Lonnie Payne, and I'm a member of the Board of 
Directors of the San Francisco AIDS Foundation, and I'm a 
person living with AIDS/HIV. I want to thank you for holding 
this field hearing today.
    The San Francisco AIDS Foundation was established in 1982 
as a private community-based response to what was then an 
emerging public health crisis. To date, the AIDS Foundation 
provides direct services to approximately 2,600 persons living 
with AIDS and HIV disease, and reaches another 145,000 through 
our treatment publications, prevention campaigns, toll-free 
hotline, public policy and community outreach efforts.
    Of the foundation's $19 million annual budget, 
approximately 70 percent comes from the private sector. The 
individuals, foundation and corporations committed to end the 
pandemic and the human suffering caused by AIDS. The 
Foundation's clients reflect national trends indicating that, 
increasingly, the HIV epidemic is affecting disenfranchised 
individuals with multiple problems in addition to HIV, 
including substance abuse, mental health issues and 
homelessness.
    As a result, San Francisco and other local communities have 
appropriately prioritized CARE Act services and other HIV 
services for those individuals most in need. Additionally, 
nationwide in fiscal year 2000, the number of new clients 
seeking HIV-related are is expected to increase by 20 percent. 
We certainly see this at the AIDS Foundation.
    More than 800 of the 2,600 people who will be served by the 
AIDS Foundation this year will be new clients to the agency. 
Forty-seven percent of our clients are people of color, 84 
percent are male, and a majority of clients have monthly income 
under $750. Thirty percent of our clients are homeless, 58 
percent of the Foundation's clients are gay and bisexual men. 
However, over time we are serving an increasing number of 
heterosexuals.
    In the written testimony I have submitted to the committee, 
I have identified the Foundation HIV/AIDS Federal funding 
request for fiscal year 2000, but because of time limitation I 
would like to highlight several issues of great importance to 
people living with HIV/AIDS.
    Mr. Chairman, I know that there's pressure in Washington, 
D.C. to mark-up appropriation bills that would require cuts in 
current spending levels for a variety of very important health 
programs. I'm asking you to resist this pressure, and not to 
cut back on any of the HIV/AIDS programs. To sustain recent 
successes and to care and treat people living with AIDS, and to 
prevent new infections in San Francisco, current Federal 
programs are essential.
    At this critical juncture in the epidemic, when more people 
are living with HIV longer than ever before, please do not set 
a precedent of cutting back when the need is greater than ever. 
The Foundation asks that the committee provide $625.2 million 
to Title 1 of the Ryan White CARE Act for fiscal year 2000. 
That's an increase of $120 million over fiscal year 1999.
    Title 1 funding continues to make up the core of the 
medical and supportive service system in San Francisco. Please 
increase the Federal support to the 51 metropolitan areas 
funded under Title 1. They continue to be the home to more than 
74 percent of individuals diagnosed with HIV/AIDS. These 
jurisdictions cannot continue to sustain and provide new access 
to essential medical services, supportive services and 
treatment for people living with HIV/AIDS without the 
additional $120 million requested.
    The Foundation also asks that the committee provide a 
minimum of $544 million to the AIDS Drug Assistance Program, 
ADAP, in the next fiscal year. This is an $84 million increase 
over current funding levels. This program has provided access 
to HIV drugs to tens of thousands of individuals in California, 
making a significant difference in their quality of life, and 
in some instances saving their lives.
    The antiretrovirals have made a real difference in my 
quality of life. My hope is that an increasing number of 
individuals, especially the poor and the disenfranchised living 
with HIV, are able to achieve similar successful results 
because of ADAP. I understand only too well the problems 
associated with the complex drug regimes currently available, 
and the resulting side effects that require ongoing medical 
monitoring, supportive services, and the development of new 
drugs in order to ensure that all people living with HIV can 
benefit from treatment.
    Finally, Mr. Chairman, I could not leave here today without 
expressing to you my continued disappointment in the lack of 
Federal support for needle exchange programs.
    Here in San Francisco, with strong support from the city 
government, as well as private sources, the AIDS Foundation has 
established an affiliate organization called the San Francisco 
AIDS Foundation HIV Prevention Project. This highly-successful 
needle exchange program has helped slow the spread of HIV among 
injectors and has provided a much-needed link to medical care 
and substance use for many individuals at grave risk for HIV.
    The Federal Government should promote local efforts such as 
the HIV Prevention Project, and at the very least should do 
nothing to impede the success of these programs, like the 
damaging amendment introduced by Senator Coverdell that would 
destroy the relationship between directly-funded Federal 
service programs and needle exchange programs funded through 
non-Federal sources.
    I thank you very much for your time today, and your efforts 
to end the pandemic and the human suffering caused by AIDS.
    Senator Specter. Thank you very much, Mr. Payne.
    Mr. Payne. Thank you.
    Senator Specter. We turn now to Mr. Sean Sasser, well-known 
AIDS activist stemming from his featured portrayal on the 
television show, ``The Real World.'' That show documented how 
the AIDS virus influenced his life, and how it inspired him to 
promote AIDS awareness. I thank you very much for joining us, 
Mr. Sasser, and the floor is yours.
STATEMENT OF SEAN SASSER, DIRECTOR, RYAN WHITE CARE 
            TITLE IV PROJECT
    Mr. Sasser. Thank you. Good morning. I am testifying today 
on behalf of Health Initiatives for Youth, a community-based 
organization here in San Francisco. Health Initiatives for 
Youth is a unique partnership of youth and adults working 
together to increase young people's access to quality health 
care.
    I'm the Director of the Ryan White Care Title IV Project 
led by Health Initiatives for Youth called Project Ahead. 
Project Ahead is a 10-agency community collaboration effort 
that provides a continuum of health services to HIV positive 
and at-risk young people. Together, these organizations have 
provided life-saving services to hundreds of youth, and they 
are known throughout the country for their efforts.
    I am also a member of the Presidential Advisory Council on 
HIV/AIDS, and a board member of the AIDS Policy Center for 
Children, Youth and Families. The AIDS Policy Center is a 
national nonprofit organization founded to help respond to the 
unique concerns of children, youth, women and families living 
with HIV/AIDS.
    Chairman Specter, I would like to thank you for holding 
this hearing, and for your ongoing leadership on AIDS. I would 
also like to thank Senators Boxer, Feinstein, Harkin and 
Representative Pelosi, who have all been leaders in the fight 
against AIDS. I'm here to remind you that the AIDS epidemic is 
not over, and resources are still desperately needed for 
prevention, care and research. As you know, we still have not 
found a way to eradicate this virus. It would be a travesty to 
begin lessening our commitment to finding a cure and helping 
those who need help.
    I tested positive for HIV in 1988 when I was just 19 years 
old. A lot has changed since then. When I tested positive I was 
told that if lucky I'd have 5 years to live. When I didn't die 
by age 24, I realized that I might beat HIV and live much 
longer than expected. Beating this disease has not been an 
option for many people living with HIV.
    I was 25 when my 22-year-old partner, Pedro Zamora, died of 
AIDS. He was an incredibly intelligent, compassionate and 
articulate advocate for youth and HIV prevention. Thanks to our 
Nation's investment in AIDS prevention, research and care 
programs, there's now hope that fewer young people like Pedro 
will die from AIDS.
    There are new treatments that have helped many people 
living with HIV/AIDS, including me. My personal hope that HIV 
will not be the cause of my death in the next 10 to 15 years 
has never been stronger. But I know, and it is critical for you 
to know, that the new treatments for HIV do not work for 
everyone, and their long-term efficacy is still unknown. Do not 
let anyone tell you that people with HIV are no longer getting 
sick and dying.
    Just last week, Jeff Poltl, a former peer educator at 
Health Initiatives for Youth, passed away. He had been 
diagnosed with AIDS since he was 16 years old. Jeff died of 
Burkett's Lymphoma, a cancer that easily outmatched an immune 
system weakened by 12 years of battling HIV. Jeff was 28 years 
old.
    It is also a sad reality that despite all of our progress 
in the area of prevention, there are still 40,000 new 
infections each year in the United States. It is estimated that 
half of those new infections occurred in people under the age 
of 25, and that one-quarter occur in people under the age of 
22.
    We have only recently acknowledged how the AIDS epidemic is 
decimating African-American communities and other communities 
of color across the country. Among young people with AIDS, 57 
percent of males and 77 percent of females are African-American 
or Latino. It is also important to know that young people are 
less likely to be insured by Medicaid or private insurance than 
any other age group.
    This lack of health care access, coupled with lack of 
adequate HIV outreach, counseling and testing programs 
targeting at-risk youth, have resulted in a large gap between 
the total number of HIV-infected youth and the number of youth 
in care. I could continue with statistics, but I think the 
point is clear. More resources, not less, are needed for HIV/
AIDS prevention, care and research programs.
    As you are all well aware, there is a major impediment to 
this committee's effort to adequately fund AIDS and other 
health programs, and that is the Balanced Budget Act of 1997. 
As a result of this act, the budget allocation to this 
subcommittee is about $8 billion less than last year. This 
could mean cuts to critical AIDS programs such as the Ryan 
White CARE Act, and HIV prevention programs at the Centers for 
Disease Control.
    It seems ironic that we are in this situation at the time 
when the economy is booming, and there's been a huge increase 
of projected Federal budget surplus. Surely there is a way to 
use a small portion of these surpluses to keep AIDS programs 
and other important health, education and social service 
programs afloat. So I want to lend my voice to those who are 
calling upon the House and Senate Budget committees, the 
congressional leadership and the White House to raise the 
discretionary spending tax.
    Chairman Specter, and members of this subcommittee, I 
turned 30 this past year. I know that part of the reason I'm 
still here is because I had access to the Project Ahead 
services when I was a young person trying to find my way living 
with HIV. I also believe I'm still here because the Federal 
Government has made significant investments in those programs, 
so that they could help people like me access health care, and 
learn to live and thrive with the disease.
    Today, there are many more young people testing positive 
for HIV who will more than likely rely on federally-funded 
programs to survive. We cannot abandon these young people now, 
we must continue to take steps forward to fight this epidemic. 
Thank you for your time.
    Senator Specter. Thank you very much, Mr. Sasser.
    Our next witness is Ms. Kate Shindle, Miss America for 
1998, who used the position to promote AIDS awareness and 
prevention for the entire year. Graduated from Northwestern 
University in Chicago, she's now Pedro Zamora Fellow with AIDS 
Action Council, where she continues her work. Thank you for 
joining us, and look forward to your testimony.
STATEMENT OF KATE SHINDLE, MISS AMERICA 1998
    Ms. Shindle. Thank you. It's a pleasure to be here. Good 
morning. My name is Kate Shindle. As you heard, during my year 
as Miss America 1998, I had the opportunity to travel over 
20,000 miles a month, and spent about 90 percent of my time as 
an activist and educator, and particularly a student, I think, 
of the HIV/AIDS movement.
    I am participating in AIDS Action's Pedro Zamora Fellow 
program, I'm also the national spokesperson for the National 
AIDS Fund, and an honorary board member of the AIDS Policy 
Center for Children, Youth and Family.
    Thank you so much for holding this hearing, Senators. Many 
of the dramatic advances in care and treatment and research of 
HIV disease would not have been possible without the courageous 
commitment to a Federal response to this epidemic that this 
committee has provided over the course of the epidemic.
    As you may know, HIV is decimating our world, but 
especially our young generation. It's come to my attention that 
two American teenagers contract HIV every hour, and that 
college-age students have a rate of infection that is 10 times 
higher than that of the general public.
    A new report released by the Henry J. Kaiser Family 
Foundation indicates that American teenagers are well aware of 
HIV prevention, but still engage in risky behavior. The report 
also noted that if teenagers are in a youth-friendly, 
respectful situation, and a confidential HIV testing option is 
offered, the majority would accept.
    Moreover, I would argue strongly that the availability of 
anonymous testing is critical for young people. The Kaiser 
Foundation is teaming up with MTV and Black Entertainment 
Television to educate viewers on sexual health issues. I urge 
this subcommittee to do all it can to ensure that the Federal 
Government partners with private, State and local efforts to 
stem the tide of new HIV infections.
    Young people are at risk for HIV, as are gay men, and a 
subset of those two populations is especially at risk: young 
gay men of color. Safer sex practices among New York City's gay 
men in particular have increased significantly, resulting in a 
marked recent decline in HIV cases. Statistics show that 
prevention is working, but indicate a dramatic need to tailor 
our prevention messages to communities of color, and to become 
much more educationally aggressive in such communities.
    Our traditionally reactive approach to dealing with HIV has 
to be revamped, and it is up to all of us to set a positive and 
proactive example. American teens in the 1990s are having less 
sex, and using condoms more often, in part, due to public high 
school HIV/AIDS education and prevention programs. But CDC 
researchers warn that although some numbers reflect a positive 
trend, more efforts are needed to identify and disseminate 
appropriate and accurate health education curricula for 
American students.
    The stories I would like to relate about the lack of 
adequate health education in our nation's schools would take up 
far more than my allotted time. But as one example, I find it 
both astonishing and deplorable that after 12 years of public 
high school education taking place in an age where HIV and 
other sexually transmitted diseases are rampant, one high 
school senior told me that the only sex education received by 
she and her peers had been a video on animal mating. I expect 
that you will join the CDC in their efforts to correct such 
neglect.
    We must do more to prevent HIV infection, quite simply. 
First, because it's humane to protect individuals from any 
deadly disease. Second, because unlike many health-related 
challenges, we all know that this one is 100 percent 
preventable. Certainly, third, because this committee will find 
it difficult in the coming years to find the funds to pay for 
all the new individuals who will need drugs and care if they 
are to survive.
    Last year AIDS Action unveiled its Virtual Vaccine, a 
comprehensive 10-point proactive national prevention plan to 
reduce the number of new HIV infections. Congress needs to 
support a major voluntary, safe, HIV testing awareness 
campaign. As you know, the CDC spearheads the Federal 
Government's prevention strategy by funding community-based HIV 
prevention efforts, and monitoring the epidemic.
    Absent a cure or a vaccine, prevention strategies are the 
most effective use of the precious resources appropriated by 
this committee. The CDC estimates that less than 4,000 
infections must be prevented annually to result in cost savings 
to this committee and to the taxpayer.
    Equally important in developing a comprehensive HIV 
prevention plan is addressing issues surrounding substance 
abuse. Approximately half of HIV cases are directly or 
indirectly linked to substance abuse, especially the 
disproportionate increase in infection rates among women, 
communities of color and adolescents.
    Substance abuse prevention and treatment programs prevent 
HIV disease, cost far less than medical care, and drastically 
reduce human suffering. Well-designed needle exchange programs 
are based on science and sound public health practices that 
have been endorsed by many Federal organizations, and show 
their ability to decrease HIV transmission rates without 
increasing drug use. No one wants more drugs on our streets.
    As a result, we urge you to oppose legislation that would 
place a ban on the use of funds for needle exchange programs. 
AIDS Action is joining House Appropriations Chairman, 
Representative Bill Young, and Senate Appropriations Chairman 
Ted Stevens in calling for an increase in the discretionary 
spending cap----
    Senator Specter. Ms. Shindle, I notice you turning many 
pages. Are you close to the end?
    Ms. Shindle. I am so close to the end.
    Senator Specter. OK.
    Ms. Shindle. However, as you know, the House and Senate 
Appropriations committees are gearing up for subcommittee mark-
up tentatively scheduled for July 15 and July 26, with funding 
levels far less than fiscal year 1999 funding levels. The cuts, 
totalling over tens of billions of dollars, are being fought, 
and every effort is being made to increase the spending caps 
that Congress has imposed.
    We will continue to urge Congress to raise the spending cap 
and maintain their commitment to those affected by HIV/AIDS and 
those that serve them. We must not allow our politics on a 
local, State or national level to stand in the way of our 
business of protecting lives. Thank you so much for your time.
    Senator Specter. Very good. Thank you, Ms. Shindle.
    Our final witness is Ms. Jeanne White, head of the Ryan 
White Foundation named after her son, who was born with 
hemophilia and contracted AIDS through contaminated blood 
products. Mrs. Ryan's son inspired congressional action for the 
Ryan White AIDS CARE Act of 1990, which has now grown in size 
to be funded at $1.4 billion. She's a national, international 
activist. A great tragedy about your son, Mrs. White, but we 
thank you for your leadership on this important subject, and 
the floor is yours.
STATEMENT OF JEANNE WHITE, RYAN WHITE FOUNDATION
    Ms. White. OK. I thank you all. Thank the committee for 
having everyone here today. I think it's very important. I've 
been with the Ryan White CARE Act ever since the beginning in 
1990, when I lost my own son to AIDS. I would like to really 
especially--because I don't want to see any funding go down, I 
want to see, really, prevention efforts increased. Because I 
think prevention is our cure for our young people for tomorrow.
    I'd like to tell everybody that I'm just a mom. I'm--you 
know, if you ever told me I'd be in this situation talking to 
anybody, believe me, I would have said you were crazy. I did 
not want this role, and I did not want my son, of course, to 
have AIDS. But, because of a misunderstood disease called AIDS 
in 1984 my life changed overnight.
    My son was one of the first children and first hemophiliacs 
to come down with AIDS. We had nowhere to turn. There was no 
information, there was no education. I can remember Ryan's 
doctor saying, you know--I said, ``I want to know everything 
there is to know about this disease.'' He said, ``There isn't a 
lot of information out there.'' I said, ``Don't tell me that.'' 
I said, ``Every cough, every fever, I'm going to worry about 
whether it's going to be the last.''
    I said, ``How long do you think Ryan has?'' And he said 3 
to 6 months. I said, ``You know, that's not good enough.'' I 
said, ``I want to know more.'' So, he told me to call the 
American Foundation for AIDS Research. I called the American 
Foundation for AIDS Research.
    Before that, I was kind of warned, even, about--because I 
was raised such a strong Christian and I believed that 
homosexuality was wrong, that I was kind of warned ahead of 
time that I might not want to call and get this information.
    So, I called and I tell you, it was the best thing I ever 
did. On the other line was a man, and his name was Terry Beirn, 
who has since died of AIDS. Terry, he told me--he said, ``You 
know, you can call me any hour of the night.'' He said, ``No 
matter what time. If you have a question or a concern, you call 
me and I'll try to get you the answers.''
    Believe me, I spent many, many nights on the phone talking 
to Terry Beirn. Yes, I kind of maybe hoped that he wasn't gay 
at first, but at the same time I thought that he probably was 
gay. When I finally got the opportunity to meet Terry, I found 
out that Terry was gay.
    It started us being involved in trying to educate a 
nation--because Ryan wanted to go to school--that I started 
meeting a lot of people with AIDS. When I started meeting a lot 
of people with AIDS, yes, most of them were gay. The more gay 
people I met, was also the more people I liked. So, I thought 
when I needed my church the most, my church was not there for 
me.
    Because we knew how the gay community was being treated, 
because we were being treated the same way. People thought 
somehow, some way Ryan White had to do something bad or wrong, 
or he wouldn't have got this disease. So we had to fight that 
discrimination, fear and panic. So, yes, my friends became the 
gay community, because that was my support team.
    The sad thing about this epidemic is from very early on in 
1984 when Ryan was first diagnosed, I met many people. The more 
people I met became the more people I knew that died of AIDS. 
Sadly to say, in 1990, very few of them that I first started 
working with on the Ryan White CARE Act are alive today. That 
really saddens me, because I wish they could see all the 
progress that's been made, and the funding that's been made 
available.
    But I don't want to disappoint anybody in the future to see 
decreases. I want to see more people living with AIDS. My son 
lived 5\1/2\ years, a lot longer than what they told me he was 
going to live. I feel very fortunate in that. We ask about 
miracles, and believe me, I--as far as being raised a 
Christian, I believed in miracles, and I believed in cures. I 
thought if anybody was going to beat AIDS, it was going to be 
Ryan White.
    But I think sometimes we get miracles in different ways. I 
think when I get to heaven I always say, ``You know, I'm going 
to have a big old argument with the Lord, and I hope that's 
permittable.'' I hope--I'm going to say, you know, ``Why? Why 
didn't I get a miracle?'' I get a feeling He's going to say: 
``You know, Ryan was only supposed to live 3 to 6 months. He 
lived 5\1/2\ years, and look, you're still not happy.''
    You know, I'm not happy. Because I'm still seeing people 
die. I am still seeing people that I've worked with over the 
years that have done so much in this AIDS epidemic. Yes Ryan 
White's face and his name is up in these--with the Ryan White 
CARE Act, but you don't see the faces and the names of the 
people that are no longer here, and the people that have put in 
so much time and so much effort in this disease.
    I'd just like to take this time, I think, to say thank you 
to all the people that have put their lives in the forefront 
that have never gotten the recognition that they deserved.
    In 1987 my son was asked to speak before the Presidential 
AIDS Commission. When he was asked to do this he was only 16 
years old, and he was a very shy and scared kid. He went to 
speak, and Senator Kennedy happened to hear that speech. That 
was the initial response when, in 1990, they called the 
hospital when Ryan was very ill and asked if they could name 
this bill after Ryan. I'd like to share a little bit of this 
speech with you now.
    It says:

    Thank you, Commissioners. My name is Ryan White, I am 16 
years old, I have hemophilia and I have AIDS. When I was 3 days 
old the doctors told my parents I was a severe hemophiliac, 
meaning my blood does not clot. Lucky for me, there was a 
product just approved by the Food and Drug Administration. It 
was called Factor 8, which contains the clotting agent found in 
blood.
    The first 5 to 6 years of my life were spent in and out of 
the hospital, but all in all I led a pretty normal life. Most 
recently my battle has been against AIDS and the discrimination 
surrounding it. On December 17, 1984 I had surgery to remove 
two inches of my left lung due to pneumonia. After a 2-hour 
surgery, the doctors told my mother I had AIDS. I contracted 
AIDS through my Factor 8, which is made from blood. When I came 
out of surgery I was on a respirator and had a tube in my left 
lung. I spent Christmas and the next 30 days in the hospital. A 
lot of my time was spent searching, thinking and planning my 
life. I came face to face with death at 13 years old. I was 
diagnosed with AIDS, a killer.
    Doctors told me I'm not contagious, and given only 6 months 
to live. And being the fighter that I am, I set high goals for 
myself. It was my decision to live a normal life, go to school, 
be with my friends and enjoy day-to-day activities. However, it 
was not going to be easy. The school I was going to said they 
had no guidelines for a person with AIDS.
    The school board, my teachers and my principal voted to 
keep me out of the classroom, even after guidelines were set by 
the Indiana State Board of Health, for fear of someone getting 
AIDS from me from casual contact. Rumors of me sneezing, 
kissing, tears, sweat, and saliva spreading AIDS caused people 
to panic.
    We began a series of court battles for 9 months while I was 
attending classes by telephone. Eventually I won the right to 
attend school, but the prejudice was still there. Listening to 
medical facts was not enough. People wanted 100 percent 
guarantees. There are no 100 percent guarantees in life. But 
concessions were made by my mom and me to help ease their fear. 
We decided to meet everyone halfway.
    I had a separate restroom, I took no gym, I had a separate 
drinking fountain, I ate off disposable eating utensils and 
trays; even though we knew AIDS was not spread through casual 
contact. Nevertheless, parents of 20 students started their own 
school. Because of lack of education on AIDS, discrimination, 
fear, panic, and lies surrounded me.
    I became the target of Ryan White jokes. They told lies 
about me biting people, they said I spitted on vegetables and 
cookies in the supermarket, they said I urinated on bathroom 
walls. And yes, some restaurants even threw away my dishes. My 
school locker was vandalized inside, and folders were marked 
``fag'' and other obscenities. I was labeled a troublemaker, my 
mom and unfit mother, and I was not welcome anywhere.
    People would get up and leave so they would not have to sit 
anywhere near me. Even at church, people would not shake my 
hand. This brought on the news media, tv crews, interviews, and 
numerous public appearances. I became known as the AIDS boy. I 
received thousands of letters of support from all around the 
world, all because I wanted to go to school.
    Mayor Koch of New York was the first public figure to give 
me public support, then entertainers, athletes and stars 
started giving me support. I met some of the greatest, like 
Elton John, Greg Louganis, Max Headroom, Alyssa Milano--my teen 
idol--Howie Long and Lyndon King from the Los Angeles Raiders, 
and Charlie Sheen. All of these plus many more became my 
friends, but I had very few friends at school.
    How could these people in the public eye not be afraid of 
me, but my hometown was? It was difficult at times to handle, 
but I tried to ignore the injustice because I knew the people 
were wrong. My family and I held no hatred for those people 
because we realized they were victims of their own ignorance.
    We had great faith that with patience, understanding and 
education that my family and I could be helpful in changing 
their minds and attitudes around. Financial hardships were 
rough on us, even though my mom had a good job at General 
Motors. The more I was sick, the more work she had to miss, and 
bills became impossible to pay.
    My sister, Andrea, was a championship roller skater who had 
to sacrifice, too. There was no money for her lessons or her 
travel. AIDS can destroy a family if you let it, but lucky for 
my sister and me, mom taught us to keep going, don't give up, 
be proud of who you are and never feel sorry for yourself.
    After 2\1/2\ years of declining health, two attacks on 
pneumocystis, shingles, a rare form of whooping cough, and 
liver problems, I faced fighting chills, fevers, coughing, 
tiredness, and vomiting. I was very ill and being tutored at 
home. The desire to move into a bigger house to avoid living 
AIDS daily, and a dream to be accepted by community and school 
became possible with a movie about my life called ' ``The Ryan 
White Story.''
    My life is better now. At the end of the school year 1986-
1987, my family and I moved to Cicero, Indiana. We did a lot of 
hoping and praying that the community would welcome us, and 
they did. For the first time in 3 years we feel we have a home, 
supportive school, and lots of friends.
    The communities of Cicero, Arcadia and Novisville, Indiana 
are what we call home, and I'm feeling great. I'm a normal, 
happy teenager. I have a learner's permit, I attend sport 
functions and dances, my studies are important to me. I made 
the Honor Roll just recently with two As and two Bs, and I'm 
just one of the kids.
    All because of students at Hamilton Heights High School 
listened to the facts, educated their parents themselves, and 
believed in me. I believe in myself as I look forward to 
graduating from Hamilton Heights High School in 1991. Hamilton 
Heights High School is proof that AIDS education in schools 
works. Signed, Ryan White.

    Senator Specter. Thank you very much, Mrs. White. Those are 
very poignant remarks and we appreciate your appearing here 
today.
    The hour is late, so I'm going to make just a couple of 
concluding remarks before turning to Senator Harkin and Senator 
Boxer.
    On the subject of needle exchange, your testimony is very, 
very powerful. There had been a provision in law for a long 
time which limited Federal funding on the subject, unless there 
was a certification that the needle exchange--a certification 
by the Secretary of Health and Human Services that unless a 
needle exchange was effective--that the funds would not be 
provided unless the Secretary made a finding first that the 
needle exchanges were effective in preventing HIV. Second, that 
they did not encourage the use of illegal drugs.
    Our subcommittee in 1997 pressed hard to get that kind of a 
study made by HHS. We got back a report which was candidly 
enough to our liking, but it was ambiguous. We have found a 
very, very tough battle. What I would encourage you to do, and 
I say this all the time, is to identify those Members of the 
Senate and the House who are on the other side of this issue.
    We have very tough, knock-down, drag-out fights, and 
there's a lot of political power in the segment of the 
community which wants to advance the needle exchange program. 
And if you go to those House districts and those Senate 
districts, and you have people there--don't write them a letter 
from out of State. Find your colleagues in-state to contact 
their representatives and identify them.
    If I receive a dozen letters in Pennsylvania with a 12 
million population, that's a sign as to what's going on. You 
don't have to have thousands of letters, you have to have a 
showing in-state. Let me ask our two doctors, Dr. Volberding 
and Dr. Fauci, to submit a written response to the question 
which is very much on the minds of the community here as to 
their efforts to try to get generic drugs and the costs down.
    We've heard Dr. Volberding's testimony about needing more 
research. This is the complexity of the issue, that if the 
companies which spend the money on research do not get 
compensation, but have the drugs turned to licensing or 
generics, then they're discouraged from doing the research.
    So, we'd like your judgment as to what the Congress ought 
to say. Should we say that there ought to be a turning away 
from the property rights of the patents to generic drugs? Or 
should we not do so? What's the balance? We'd like to have the 
medical experts. There are a lot of questions we could ask, but 
we're over time now, and I do not want to stop anybody from 
fulfilling the time. We don't like the time limitations, but 
the testimony has been important.
    Now, let me yield to my colleague, Senator Harkin.
    Senator Harkin. Thank you very much, Mr. Chairman. And I 
thank all of you for all your great, eloquent and poignant 
testimony. I have a question I want to ask of Dr. Fauci, and 
then I want to make a couple of statements.
    Dr. Fauci, one area that has become very contentious in 
Washington is this issue of whether or not we should be 
providing money to the NIH for stem cell research. I have 
spoken out a lot on it in the past, I'm not going to talk any 
more about it right now. But I want to hear from you as to what 
promises there could be in stem cell research that are 
applicable to preventing or treating AIDS.
    Dr. Fauci. Thanks for that question, Senator Harkin. It's 
an important question. The answer is that one of the key areas 
that we're probing now in research with HIV is the 
reconstitution of the immune system following successful 
suppression of virus by the powerful antiretroviral agents. 
There's partial reconstitution in many people.
    We do not know yet, and we doubt that there will be 
complete immunological reconstitution spontaneously in people 
because of the already severe damage that has been incurred by 
the virus' destruction of the immune system.
    The potential for stem cells, which as you know, are 
totally potential, and they can differentiate into any organ 
system--heart, liver, lungs--also immunologically competent 
cells. So the possibility that we might be able to restore 
immunological competence is very closely wedded to advances 
that will be made in stem cell research.
    So, as a biomedical researcher, and also as an 
immunologist, which is my subspecialty in infectious diseases, 
I think that the opportunities in stem cell research for 
immunological reconstitution are enormous, Senator.
    Senator Harkin. Well, I'm glad to have that on the record, 
because we're engaged in a battle right now, as you know, as to 
whether or not we're going to be permitted to engage in this 
kind of research. The potential is just enormous, not only for 
AIDS but for Parkinson's Disease and everything else.
    There is right now, a kind of a gray area, as you know as 
to whether or not we can. There is legislation now being 
prepared in the Senate, and I think in the House both that 
would cut off this research. Absolutely cut it off. I can't 
think of anything more short-sighted than to do that when it 
holds so much promise.
    I thank you, Ms. Shindle. I don't know you personally. 
Obviously, I know who you are, I've seen you on television a 
lot. But I thank you for your leadership on this issue. You are 
a person that a lot of young people look up to, and your 
outspokenness on this, and especially on needle exchange, is 
really gutsy of you to attempt. That is just what I call real 
gusty. Because a lot of people don't take on such hot issues.
    I want to say here publicly that I am, and have been upset 
for 2 years with Secretary Shalala. I'll say that publicly. We 
had the legislation championed by him and Barbara Boxer and 
others that permitted the Secretary to determine whether a 
needle exchange program would be effective in preventing HIV 
and yet not encourage the use of illegal drugs.
    In February of 1997 the Secretary acknowledged that needle 
exchange programs can be effective as a component of a 
comprehensive strategy to prevent HIV, but she did not certify 
that it would be effective in preventing HIV and that it would 
not encourage the use of illegal drugs.
    I was very dismayed by that, because it gave the green 
light to do away with that language, and that is just what 
happened. Now Senator Specter's leading the charge to put the 
language back in. So we're back on base one where we started 
back in 1996.
    So I'm very dismayed by the incomplete findings by the 
Secretary in 1997, but I thank you, Ms. Shindle, for your 
leadership on that issue. Keep speaking out on it. We need your 
leadership.
    Last, I would like to mention two other things. There is a 
home test kit that has been FDA-approved now. Do any of you 
know about that? Do you know about that, Mr. Sasser? The home 
test kit that has been approved by the FDA that a person can 
voluntarily--I forget who had mentioned it, one of you had 
mentioned that if it was anonymous that people would come and--
was that you, doctor? I forget who it was. Was that you, Mr. 
Payne? Somebody said that, because it caught my attention.
    Someone stated that people have reported that if you could 
have a test and it was anonymous, they would use it? The vast 
majority of people said they would use it. Well, we now have a 
home test kit that is FDA-approved designed to test for HIV. It 
is totally anonymous. Totally anonymous.
    Now we're trying to get some money in our bill, again this 
year, to provide some programs to demonstrate that this would 
be effective. It seems to me if we want it to be effective we 
ought to provide the money. Anybody that suspects that they're 
HIV positive ought to be able to get that test kit, and we 
ought to pay for it publicly. It would be, I think, in our 
national interest to do so, to provide that on a broad basis 
for people.
    Last, Ms. White, I thank you for all of your leadership. 
Seven years ago my daughter was a sophomore in high school, 
1992. Because of Ryan White she got interested in AIDS. I 
remember I took her out to NIH, introduced her to Dr. Fauci. 
She wanted to know about AIDS and what it was all about because 
of Ryan White and because of his story.
    For her science project that year she wanted to do a test 
in her high school to find out the level of knowledge of kids 
regarding AIDS and HIV. So she developed a questionnaire. The 
school principal wouldn't let her do it; he wouldn't even let 
her do it.
    Well, that got my dander up. So I went to the school 
principal, and we worked out an agreement, but it was the 
school board. Oh, they didn't want to get into this, you see. 
Because you're asking kids questions about how it's 
transmitted, how do you get AIDS, HIV?
    Well, we worked it out and finally the kids had to take the 
questionnaire home and have their parents approve it. I'm just 
saying that's the kind of mindset that you had among people, 
and I know we still have it.
    Senator Specter. We're really going to have to move ahead 
here.
    Senator Harkin. Well, I thank you, Mr. Chairman. This is 
just an issue. I appreciate it, I know we have to move ahead, 
but I just wanted to say to all of you, thank you for your 
leadership on this issue. Don't give up, keep pushing.
    Senator Specter. Senator Boxer.
    Senator Harkin. Wait a minute. I am going to say one other 
thing.
    Senator Specter. Is this last?
    Senator Harkin. Last. This is it, Mr. Chairman. I'm sorry. 
We're talking about all the lack of money we got? We put $16 
billion in Federal spending into AIDS that Dr. Fauci talked 
about, $16 billion in total. People said, ``Oh, boy, that's a 
lot of money.'' Our NIH budget alone for this year is about $14 
billion to support research for all diseases.
    Senator Specter. $15.6 billion.
    Senator Harkin. $15.6 billion. People said, ``Oh, it's a 
lot of money.''
    Senator Specter. $15.6 billion and falling, Senator Harkin.
    Senator Harkin. People said, ``Well, that's a lot of money. 
Why shouldn't we find these results and stuff?'' Well, I preach 
this everywhere I go. You remember the Gulf war, and you 
remember the recent war in Kosovo? You saw these smart bombs go 
down chimneys and you see the laser-guided missiles go after 
tanks and we didn't bring home one body bag from Kosovo, and we 
won the war.
    We feel good that this has made us a very secure nation. 
Made us the most powerful nation on earth. But that's because 
we put a lot of research funding into the military, a lot of 
research funding. Now, this is what I'm going to leave with you 
all. We have spent more money on military research and 
development in the last 5 years than we have on all biomedical 
research since the turn of the century.
    In case you didn't get it, I'll say it again. You add up 
all the research we've done on polio, on cancer, on smallpox, 
on anything you can imagine. Heart disease. Since the turn of 
this century, this investment does not equal the amount of 
money that our taxpayers have put into military research in the 
last 5 years. So, don't tell me that we're spending enough 
money on biomedical research. We haven't even scratched the 
surface yet.
    Senator Specter. Senator Boxer.
    Senator Boxer. Thank you. I will be very brief. I will talk 
fast, and finish in 3 minutes. First, I am so honored, Mr. 
Chairman, that you brought this incredible group of people 
together today. That you honor us as Californians just by your 
presence and that of Senator Harkin.
    In this issue we are partners, the three of us. I know I 
speak for Senator Feinstein, although not as eloquently as she 
can say it herself. This fight to make research, have research 
a priority, this fight against AIDS, these are very important 
issues. We struggle hard in the Senate.
    Two points and the quickest question. Senator Specter's 
right on this needle exchange. I was able to stop--by the 
stroke of luck I was on the Senate floor when Senator Coverdell 
tried to stop Washington, D.C. from spending its own money--not 
Federal money--on needle exchange. The good news about the 
Senate is that anyone can say, ``I object.''
    Luckily, I was on the floor and was able to object, and the 
thing went away for the moment. It's going to come back and I'm 
very worried about it. I think what Senator Specter said was 
just for all of us to really get together and focus on this 
matter. Because it seems to me we should make all of our 
decisions based on what physicians know. Physicians are telling 
me that it's worth it.
    You're all heroes here. I mean, this is--I would say, Mr. 
Chairman, what you've put together here today is an historic 
panel. When I look at these two physicians sitting next to each 
other, they will go down in history for their commitment, 
intelligence and creativity in this battle. I am so honored to 
be sitting across from them.
    These two heroes here, living with the disease and showing 
that you can do it. They are living proof, if you will, that we 
need to get these drugs to people because for a lot of people 
it works. We know we have to find a vaccine, but in the 
meantime we know a lot of people can be helped.
    To the former Miss America, who could have picked any other 
topic and chose this controversial topic, I say God bless you. 
To Mrs. White, I just would say to you there are reasons for 
everything we never really, truly understand. But your voice 
today and remembering Ryan has inspired us all to triple our 
commitment to this fight. You're heroes all.
    In closing, I have one question. There's a bill that I'm a 
co-sponsor, and I think it's real important, co-sponsored with 
Senator Toricelli. It's called the Early Treatment for HIV Act. 
I would like to ask Dr. Volberding quickly, currently 
vulnerable low-income HIV positive Americans can't receive AIDS 
preventive drugs under Medicaid until they've developed full-
blown AIDS. By that time, the preventive value has really 
diminished, according to most reports that I've read.
    This bill, which is S. 902, will expand Medicaid coverage 
for asymptomatic HIV positive, low-income persons. Is that 
something we ought to really push, because it seems to me we're 
committing murder if we're not getting the drugs to people who 
need it early.
    Dr. Volberding. You're absolutely right. The medical 
community, I think, is united in agreeing that the early 
treatment of HIV can prevent the progression to the point when 
you can't restore the immune system.
    As Dr. Fauci was saying, these drugs are capable of 
substantial immune recovery. The longer you wait, the worse 
that gets. So, you're absolutely right, and I support it 
completely.
    Senator Boxer. Thank you, Mr. Chairman, so much again.
    Senator Specter. Thank you very much, Senator Boxer. And 
thank you all. I want to extend our thanks especially to Mr. 
Bill Barnes, Advisor to the Mayor on AIDS, and Mr. Bill 
Bourden, Special Assistant to the Mayor. Unfortunately, 
Congresswoman Barbara Lee cannot return, and I hope to have her 
testimony read into the record because it's very important. 
But, in view of the lateness of the hour we will have it made a 
part of the record without objection.
    [The statement follows:]

            Prepared Statement of Representative Barbara Lee

    I applaud the efforts of my colleagues for developing today's 
Senate Hearing on the fiscal year 2000 AIDS appropriations. I cannot 
begin to describe the need for increased funding to attack this 
enormous crisis. Combating HIV/AIDS locally, nationally and 
internationally is a mortal imperative.
    The devastating effects of HIV/AIDS is staggering. While the number 
of new diagnoses for virtually every segment of the population is 
declining--it is rapidly moving in the opposite direction for African-
Americans. Through the leadership of the Congressional Black Caucus, we 
worked with Clinton Administration including the Secretary of Health 
and Human Services Donna E. Shalala to develop a comprehensive package 
which would allow us to launch our efforts to address the disparate 
number of AIDS cases in our Nation's African-American community.
    As the migration patterns of AIDS has shifted many times over, and 
as new strains of the HIV virus are becoming ever present, it is 
extremely necessary that we evolve our strategies in dealing with the 
disease as it continues to change. Only then will we move forward to 
eliminate AIDS from all our communities. We must increase our efforts 
in developing innovative HIV prevention and education programs, expand 
existing AIDS care services, and press forward in all aspects of AIDS 
research. Not only has AIDS research been crucial to the advancement 
and development of treatments, but it has also rendered positive 
outcomes for cancer research and other chronic and terminal illnesses.
    This past Wednesday, I had the distinguished pleasure to host a 
site visit for Dr. Eric Goosby and Dr. Marsha Martin representatives 
from the Office of the Secretary of Health and Human Services, Donna. 
E. Shalala, in my district. Throughout the site visit, Dr. Eric Goosby 
and Dr. Marsha Martin were able to assess first hand how the AIDS 
crisis is affecting Oakland and Alameda County. Stemming from the 
declaration of a ``Public Health Emergency'' on AIDS in Alameda 
County's African-American community, and with over one year of planning 
and implementing a community-wide response, the Department of Health 
and Human Services has prioritized Alameda County as a ``Metropolitan 
Statistical Area'' (MSA) and will deploy a Crisis Response Team to 
further assess the needs and current barriers to care and HIV related 
services, as well as to include technical assistance to address the 
identified needs. In order to continue on a path that serves the 
greatest new populations being affected by HIV/AIDS, it is imperative 
that we garner federal support to win this battle throughout our great 
nation and throughout the world.
    In May, the World Health Organization announced that HIV/AIDS is 
now the ``world's most deadly infectious disease'' and that it is the 
fourth leading cause of death in the world. While nearly every region 
of the world has been affected by the pandemic, Sub-Saharan Africa has 
been ravaged by the disease, suffering 11.5 million deaths since the 
epidemic emerged, with a projected 22.5 million more in the next 10 
years. To date our response has been sorely inadequate. In Africa AIDS 
is not only a health crisis, but is also directly related to the social 
and economic conditions of the continent. Thus, in my capacity on the 
International Relations Committee's Sub-Committee on Africa, I along 
with my esteemed colleague, former Congressman Ronald V. Dellums, 
President of Health Care International Management Company, are 
developing and will introduce comprehensive legislation designed to 
address the devastating effects of AIDS in sub-Saharan Africa. Entitled 
the ``AIDS Marshal Plan for Africa,'' this legislation would create a 
public-private partnership to establish a comprehensive fund dedicated 
to education, research and treatment of men, women, and children living 
with HIV/AIDS in Africa. The fund would be seeded and leveraged with 
federal money, calling upon private industry to contribute significant 
resources for this global effort.
    Again, I am extremely pleased with the work of my colleagues to 
ensure that the eradication of HIV/AIDS from the face of the earth 
becomes a priority in the new millennium.
    Thank you.

                         conclusion of hearing

    Senator Specter. Thank you all very much for being here, 
that concludes our hearing. The subcommittee will stand in 
recess subject to the call of the Chair.
    [Whereupon, at 12:20 p.m., Friday, July 9, the hearing was 
concluded, and the subcommittee was recessed, to reconvene 
subject to the call of the Chair.]

                                 
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