[Senate Hearing 109-846]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 109-846
 
                 ENSURING EARLY DIAGNOSIS AND ACCESS TO
                  TREATMENT FOR HIV/AIDS: CAN FEDERAL
                RESOURCES BE MORE EFFECTIVELY TARGETED?

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



                                HEARING

                               before the

                FEDERAL FINANCIAL MANAGEMENT, GOVERNMENT
                     INFORMATION, AND INTERNATIONAL
                         SECURITY SUBCOMMITTEE

                                 of the

                              COMMITTEE ON
                         HOMELAND SECURITY AND
                          GOVERNMENTAL AFFAIRS
                          UNITED STATES SENATE


                       ONE HUNDRED NINTH CONGRESS

                             SECOND SESSION

                               ----------                              

                             APRIL 26, 2006

                               ----------                              


       Printed for the use of the Committee on Homeland Security
                        and Governmental Affairs



                    U.S. GOVERNMENT PRINTING OFFICE

28-242 PDF                  WASHINGTON : 2007
------------------------------------------------------------------
For sale by Superintendent of Documents, U.S. Government Printing 
Office Internet: bookstore.gpo.gov  Phone: toll free (866) 512-1800;
DC area (202) 512-1800 Fax:  (202) 512-2250. Mail:  Stop SSOP, 
Washington, DC 20402-0001



        COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS

                   SUSAN M. COLLINS, Maine, Chairman
TED STEVENS, Alaska                  JOSEPH I. LIEBERMAN, Connecticut
GEORGE V. VOINOVICH, Ohio            CARL LEVIN, Michigan
NORM COLEMAN, Minnesota              DANIEL K. AKAKA, Hawaii
TOM COBURN, Oklahoma                 THOMAS R. CARPER, Delaware
LINCOLN D. CHAFEE, Rhode Island      MARK DAYTON, Minnesota
ROBERT F. BENNETT, Utah              FRANK LAUTENBERG, New Jersey
PETE V. DOMENICI, New Mexico         MARK PRYOR, Arkansas
JOHN W. WARNER, Virginia

           Michael D. Bopp, Staff Director and Chief Counsel
   Joyce A. Rechtschaffen, Minority Staff Director and Chief Counsel
                  Trina Driessnack Tyrer, Chief Clerk


FEDERAL FINANCIAL MANAGEMENT, GOVERNMENT INFORMATION, AND INTERNATIONAL 
                         SECURITY SUBCOMMITTEE

                     TOM COBURN, Oklahoma, Chairman
TED STEVENS, Alaska                  THOMAS CARPER, Delaware
GEORGE V. VOINOVICH, Ohio            CARL LEVIN, Michigan
LINCOLN D. CHAFEE, Rhode Island      DANIEL K. AKAKA, Hawaii
ROBERT F. BENNETT, Utah              MARK DAYTON, Minnesota
PETE V. DOMENICI, New Mexico         FRANK LAUTENBERG, New Jersey
JOHN W. WARNER, Virginia             MARK PRYOR, Arkansas

                      Katy French, Staff Director
                 Sheila Murphy, Minority Staff Director
            John Kilvington, Minority Deputy Staff Director
                       Liz Scranton, Chief Clerk


                            C O N T E N T S

                                 ------                                
Opening statements:
                                                                   Page
    Senator Coburn...............................................     1
    Senator Carper...............................................     4

                               WITNESSES
                       Wednesday, April 26, 2006

Kevin Fenton, M.D., Director, National Center for HIV, STD, and 
  TB Prevention, Centers for Disease Control and Prevention, U.S. 
  Department of Health and Human Services........................     6
Deborah Parham Hopson, Associate Administrator, HIV/AIDS Bureau, 
  Health Resources and Services Administration, U.S. Department 
  of Health and Human Services...................................     8
Marcia Crosse, Director, Health Care, U.S. Government 
  Accountability Office..........................................     9
M. Beth Scalco, Director, HIV/AIDS Program, Louisiana Office of 
  Public Health, and Past Chair, National Alliance of State and 
  Territorial AIDS Directors.....................................    20
Michael Weinstein, President, AIDS Healthcare Foundation.........    23

                     Alphabetical List of Witnesses

Crosse, Marcia:
    Testimony....................................................     9
    Prepared statement...........................................    55
Fenton, Kevin, M.D.:
    Testimony....................................................     6
    Prepared statement...........................................    31
Hopson, Deborah Parham:
    Testimony....................................................     8
    Prepared statement...........................................    46
Scalco, M. Beth:
    Testimony....................................................    20
    Prepared statement...........................................    64
Weinstein, Michael:
    Testimony....................................................    23
    Prepared statement...........................................    76

                                APPENDIX

Questions and responses for the Record from:
    Dr. Fenton...................................................    80
    Ms. Hopson...................................................    94
    Ms. Crosse...................................................   100
    Ms. Scalco...................................................   105
    Mr. Weinstein with an attachment.............................   108
Charts submitted by Senator Coburn for the Record................   129
Additional copy submitted by Senator Coburn for the Record.......   134


                  ENSURING EARLY DIAGNOSIS AND ACCESS



                       TO TREATMENT FOR HIV/AIDS:



                     CAN FEDERAL RESOURCES BE MORE



                         EFFECTIVELY TARGETED?

                              ----------                              


                       WEDNESDAY, APRIL 26, 2006

                                     U.S. Senate,  
               Federal Financial Management, Government    
    Information, and International Security Subcommittee,  
                      of the Committee on Homeland Security
                                          and Governmental Affairs,
                                                    Washington, DC.
    The Subcommittee met, pursuant to notice, at 2:27 p.m., in 
room SD-342, Dirksen Senate Office Building, Hon. Tom Coburn, 
Chairman of the Subcommittee, presiding.
    Present: Senators Coburn and Carper.

              OPENING STATEMENT OF SENATOR COBURN

    Senator Coburn. Thank you. We are going to start early. We 
are going to have a vote here in a few minutes which will mean 
we will have to interrupt the hearing, so I am going to go on 
and start, if I may.
    I want to welcome all of our witnesses today. I want to 
thank you for the timeliness of your testimony and thank you 
for taking the time to be here.
    Today's hearing examines domestic efforts to promote early 
diagnosis of HIV infection and ensure access to AIDS treatment.
    It has been nearly 25 years since the first cases of what 
would become known as AIDS were recognized. As a physician 
during much of this time period, I experienced the heartbreak 
of watching some of my patients, including mothers and 
children, succumb to this mysterious and incurable illness in 
the early days of the epidemic when effective treatments had 
not yet been developed.
    Even today, with the availability of revolutionary anti-
retroviral treatments that have transformed a disease that was 
a death sentence into a manageable disease for many, it is 
still heartbreaking to deliver an HIV diagnosis to a patient 
and agonize with each one to determine how they can afford 
these life saving, yet extremely expensive, medications.
    As a physician, I believe it is essential that if we are to 
end this epidemic, we must make every effort to promote early 
diagnosis and ensure access to treatment for all those who are 
infected. We must also empower those who are infected and those 
who are not infected to prevent HIV from taking another life. 
This may require rethinking and reevaluating past and present 
policies and reconsidering ideas that have long ago been 
abandoned or even demonized.
    It is no secret that I have had many differences with some 
within the AIDS community, Federal health agencies, and even 
with the drug companies that produce the miraculous AIDS drugs 
that now many take for granted regarding how we could best 
address this disease. But we must not let our differences of 
opinions allow us to make enemies of those with different 
viewpoints, for we all hold the same common goal: Ending AIDS 
and the same common enemy, HIV.
    So many of the medical advances that my patients and those 
affected by HIV around the world benefit from today are the 
result of activists who forced the government to act on this 
epidemic when so many preferred to look away because they 
disapproved of the behaviors that were associated with this 
disease.
    Unfortunately, so much of how we have all reacted to the 
AIDS epidemic has been based on fear. Lack of knowledge led to 
fear. Fear led to discrimination and stigma. Discrimination and 
stigma led to fear. And fears became the basis of our response 
to HIV/AIDS. The results have been tragic.
    Consider that the U.S. Government spends more than $20 
billion a year on HIV/AIDS prevention, care, and research 
annually, yet more than one million Americans are now living 
with HIV/AIDS. Up to 59 percent of those Americans are not in 
regular care. More than 40,000 Americans become newly infected 
with HIV every year. It has not changed over the last 6 to 7 
years, and this number has actually been unchanging for over a 
decade, as that chart will show.\1\ There are some estimates 
that it is as high as 60,000 new cases a year. The fact that we 
don't know for sure tells us we have a problem.
---------------------------------------------------------------------------
    \1\ The chart referred to appears in the Appendix on page 132.
---------------------------------------------------------------------------
    More than a quarter of those who are infected do not know 
they are infected. Hundreds of patients are on waiting lists 
for AIDS drugs, and more than half a million Americans have 
already died from this disease. As many as 45 percent of 
persons testing positive for HIV received their first positive 
test result less than a year before the AIDS was diagnosed. 
With an average of 10 years between HIV infection and an AIDS 
diagnosis, this suggests that people are living with HIV for 
many years before they are aware of their infection and may be 
unknowingly spreading the virus to others.
    To address these shortcomings, fear must be replaced with 
hope. We have the knowledge, the resources, and the commitment 
to provide hope to every American who is living with HIV/AIDS. 
But to do so, we must update our policies to ensure that all of 
those living with HIV have access to the hope that treatment 
can provide.
    This means we must also remove the barriers to testing. 
Fear-based policies continue to serve as deterrents to testing 
and diagnosis and deny the benefits of those miraculous AIDS 
drugs that the early activists fought so hard to make available 
to thousands of Americans today, often until it is far too late 
to prevent the inevitable.
    One example of the hope that can result from eliminating 
barriers to testing is the great success that has resulted from 
the baby AIDS laws in New York and Connecticut that require 
every newborn to be tested for HIV antibodies and treatment 
provided to affected mothers and infants.
    New York passed a law requiring HIV testing of all newborns 
in 1996. According to data we received just this week, the 
results of this law have been dramatic.\1\ The proportion of 
all pregnant women being aware of their HIV status at delivery 
has increased from 64 percent in 1997 to 95 percent in 2004. 
The number of HIV-infected infants in New York dropped from 
more than 500 a year to 8 in 2003. Furthermore, mothers and 
impacted infants are receiving care.
---------------------------------------------------------------------------
    \1\ The chart referred to appears in the Appendix on page 131.
---------------------------------------------------------------------------
    Connecticut passed a similar law in 1999 requiring that 
newborns be tested for HIV antibodies if their mother's HIV 
status was unknown. Prior to the law, only 28 percent of 
pregnant women were documented as being tested for HIV.\2\ 
Prenatal testing rates for other diseases were over 90 percent, 
which demonstrates how the unusual counseling regulations for 
HIV testing discouraged testing. After the law was enacted, 
this number of pregnant women being tested for HIV jumped to 90 
percent. In the year that the law passed, 70 HIV-exposed 
newborns were born with five infants infected with the virus. 
Since that time, over 300 HIV-exposed infants have been born 
with only five infants becoming infected. The last baby 
infected with HIV to be recorded in the State was in 2001, 
meaning Connecticut's laws essentially eliminated baby AIDS.
---------------------------------------------------------------------------
    \2\ The charts referred to appear in the Appendix on pages 129-130.
---------------------------------------------------------------------------
    The success of these laws are rare victories in our battles 
against HIV and AIDS.
    The Government Accountability Office (GAO) today releases 
its second report this year that examines some of the issues 
involved in providing access to treatment and early 
intervention. The report reminds us of facts that we already 
know, such as most new HIV infections originate from HIV-
infected persons not yet aware of their status. This emphasizes 
the need to identify HIV-infected persons and link them with 
appropriate services as soon as possible.
    It raises other issues of concern, such as ADAPs with 
waiting lists may not represent all eligible individuals who 
are not being served. And it points to opportunities where 
policy makers can do a better job to maximize the impact of the 
tens of billions of dollars that we are directing every year 
towards our HIV/AIDS efforts.
    Coincidentally, GAO's reports come at a time when Congress 
is faced with reauthorization of the Ryan White CARE Act, which 
is the largest HIV/AIDS-specific Federal care program. While 
the program's authorization expired 6 months ago, efforts are 
currently being made to renew the program, and I know of at 
least one bill that has been introduced in both the House of 
Representatives and the Senate that would do so taking account 
of many of GAO's findings as well as the issues I have outlined 
and others that we will explore today.
    I look forward to hearing from our witnesses today, who 
include Dr. Marcia Crosse, Director of Government 
Accountability Office's Public Health and Military Health Care 
Issues; Dr. Deborah Hopson, Associate Administrator of the 
Health Resources and Services Administration, HIV/AIDS Bureau; 
Dr. Kevin Fenton, Director of the National Center for HIV, STD, 
and TB Prevention at the Centers for Disease Control and 
Prevention; Ms. Beth Scalco, Director, HIV/AIDS Program, 
Louisiana Office of Public Health; and Michael Weinstein, 
President of the AIDS Healthcare Foundation, the Nation's 
largest provider of HIV/AIDS medical care.
    Prior to you coming in, Senator Carper, I announced that we 
were going to have a vote. I will go vote if you will do youre 
opening statement. I will be right back and we will try to keep 
things going.
    Senator Carper. OK, sounds good.

              OPENING STATEMENT OF SENATOR CARPER

    Senator Carper [presiding]. Thanks, Mr. Chairman, and 
before you leave, let me just say that the Chairman of the 
Subcommittee has been very involved in these issues for some 
time and is one of the co-authors of the last reauthorization. 
I know he has been very much involved in our efforts to 
reauthorize the Ryan White CARE Act this time, as well.
    Thank you for joining us. We look forward to your testimony 
and to the opportunity to ask some questions of you, and our 
second panel, as well.
    The Ryan White CARE Act was first enacted, I believe in 
1990. I was still in the House of Representatives at the time. 
Since then, we have made great progress, both in combatting the 
stigma that was once associated with the disease, but I think 
also in combatting the disease itself. We still have a long 
ways to go, but the CARE Act has been, I think, one of the 
chief Federal programs, at least, in the fight against HIV and 
AIDS.
    I think we can all agree that our goal in examining the 
Ryan White Act today is to ensure that Americans living with 
HIV/AIDS can get needed care and needed services. The Ryan 
White program is working to do that, at least that is what I am 
told, for over 500,000 people each year. The program provides 
not only vital prescription drugs, but also needed support 
services to help patients stay on those drugs and adhere to 
complex drug regimens.
    In my State of Delaware, we have done, we think, a good job 
of providing needed health services to those with HIV and AIDS. 
We can always do better. Everything we do, we can do better, 
and that includes here. But we have made quality health care a 
priority and are fortunate to be able to offer what we think is 
a generous Medicaid program, a very generous AIDS drug 
assistance program, and high-quality Ryan White services.
    The witnesses that are here today before us, this panel and 
our next panel, will discuss a number of issues, largely 
focusing on the AIDS drug assistance program, on prevention and 
testing efforts, and on notification efforts. However, they 
will also be addressing a number of issues pertaining to the 
Ryan White authorization as a whole. At least, that is what I 
am told.
    I understand that the Senate HELP Committee and the House 
Energy and Commerce Committee are working together in a 
bipartisan way to come to agreement on the Ryan White 
Reauthorization Act, and I hear they are making significant 
progress and I hope that the authorization can be completed 
this year.
    As we consider reauthorization of this program, I think it 
is important that we keep in mind that the program, on the 
whole, is working. We have lengthened the time from HIV 
infection to the onset of AIDS, which is a good thing. People 
with HIV and AIDS are living longer and living healthier. That 
is obviously a good thing. Of course, we can, as I said 
earlier, do more to strengthen the program, and we now face new 
challenges as the face of the disease itself evolves. I think, 
for the most part, we have done a good job, a commendable job.
    One of the goals of reauthorization should be to ensure 
that we can get the most out of our Federal investment in this 
program. We should ensure that the distribution of funding to 
States and cities under the CARE Act both supports the existing 
treatment infrastructure that we have built up over the last 
several years and also ensures that we address discrepancies in 
funding where they are present. We should ensure that the Ryan 
White dollars are spent in a smart way and that they are spent 
as a payer of last resort. We should also ensure that any 
unused funds are reinvested in the program in some way.
    I hope that the issues that are brought up before us today 
can inform the upcoming debate on reauthorization. Ryan White 
has always been seen as a bipartisan issue and I am hopeful 
that this year, the Congress will continue that tradition and 
that we can work together with the House to produce a 
bipartisan reauthorization package to send to the President for 
his signature.
    I think with that having been said, I am going to recess 
the Congress, go and vote myself, and I suspect that the 
Chairman will be back very shortly and begin your testimony. So 
I would just ask that we stand in recess for a few moments 
until the return of the Chairman and I will see you all then. 
Thank you.
    [Recess.]
    Senator Coburn [presiding]. Let me introduce, if I may, our 
first panel. I would ask our panel members to limit their 
testimony to 5 minutes. We have read your testimony. Then we 
will have questions afterward.
    Dr. Kevin Fenton is Director of the National Center for 
HIV, STD, and TB Prevention, Centers for Disease Control and 
Prevention. He joined CDC in January 2005 as Chief of the 
National Syphilis Elimination Effort, leading a revitalization 
of this program to end the sustained transmission of syphilis 
in the United States. Prior to his work at CDC, Dr. Fenton was 
the Director of the HIV and Sexually Transmitted Infections 
Department of the United Kingdom's Health Promotion Agency.
    Dr. Deborah Parham Hopson is the Associate Administrator 
for HIV/AIDS in the U.S. Department of Health and Human 
Services' Health Resources and Services Administration. Dr. 
Hopson was appointed Associate Administrator for HIV/AIDS at 
HRSA on July 29, 2002. As Associate Administrator for the AIDS 
Bureau, Dr. Hopson is responsible for directing the Ryan White 
Comprehensive AIDS Resources Emergency Care Act Program, which 
provides medical care, treatment, referrals, and social 
services to people living with and affected by HIV/AIDS 
throughout the United States. She administers a budget of $2.02 
billion that funds services for some 530,000 individuals each 
year.
    Dr. Marcia Crosse is Director for the Health Care Group at 
the Government Accountability Office. She has been responsible 
for overseeing multiple projects in the areas of biomedical 
research, bioterrorism, disease surveillance, HIV/AIDS, medical 
product safety, organ transplantation, and pharmaceutical 
regulation. She has been employed at GAO since 1985.
    I want to thank each of you again for being here, and I 
want to express publicly how much I depend on GAO, what a great 
functioning component of the U.S. Government they are, and how 
valuable they are to us as Members of Congress in being able to 
do our work.
    Dr. Fenton, I will recognize you first and then we will go 
to Dr. Hopson and then to Dr. Crosse. Welcome.

 TESTIMONY OF KEVIN FENTON, M.D.,\1\ DIRECTOR, NATIONAL CENTER 
 FOR HIV, STD, AND TB PREVENTION, CENTERS FOR DISEASE CONTROL 
  AND PREVENTION, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

    Dr. Fenton. Good afternoon. Thank you. Good afternoon, Mr. 
Chairman. My name is Kevin Fenton and I am the Director of the 
National Center for HIV, STD, and TB Prevention at the Centers 
for Disease Control and Prevention. Thank you for the 
opportunity to discuss CDC's progress in reducing barriers to 
HIV testing and improving opportunities for early diagnosis and 
linkage to care.
---------------------------------------------------------------------------
    \1\ The prepared statement of Dr. Fenton appears in the Appendix on 
page 31.
---------------------------------------------------------------------------
    Twenty-five years ago, the first cases of HIV were reported 
in the United States. Although the struggle to prevent new 
infections is not over, we have made substantial progress and 
achieved major successes. For instance, the dramatic decrease 
in mother-to-child or perinatal HIV transmission is one of the 
great success stories of HIV prevention. We have also seen 
declines in the number of HIV and AIDS cases attributed to 
injecting drug use.
    Despite such major successes, HIV infection and AIDS remain 
a leading cause of illness and death in the United States. The 
numbers are sobering. CDC estimates that currently, 1 to 1.2 
million people in the United States are infected with HIV, and 
of these, roughly a quarter are undiagnosed and at high risk of 
transmitting HIV. This undiagnosed group is of great concern to 
us because they are not able to take advantage of medical 
treatment and because we believe that transmission by people 
who are unaware that they are HIV positive account for more 
than half of new HIV infections every year.
    Currently, CDC has a number of efforts underway to 
encourage early diagnosis of HIV infection. In 2003, CDC 
launched the Advancing HIV Prevention Initiative, or AHP, which 
reinforces CDC's evidence-based approach that routine HIV 
testing implemented in a variety of settings will reduce 
barriers to HIV testing, improve opportunities for early 
diagnosis and linkage to prevention and care, and help reduce 
the number of new infections.
    CDC also encourages its funded partners to take HIV testing 
out into the community by using rapid tests in non-traditional 
settings and in health care settings that provide episodic 
care. In addition, CDC is currently updating guidelines for 
testing in health care settings, making HIV testing more 
routine.
    Finally, the President's 2007 budget contains an increase 
in funding aimed at increasing the number of people who know 
their HIV serostatus through promoting rapid testing in areas 
of high HIV incidence.
    I would like to highlight one AHP demonstration project 
that we are particularly encouraged about. This project used 
social network strategies to reach persons at high risk of HIV 
infection in communities of color and demonstrated the 
feasibility of using these social networks to encourage HIV 
counseling, testing, and referral services. This strategy has 
proved to be very successful in reaching persons with 
undiagnosed HIV infection.
    In addition to reducing barriers to HIV testing and 
increasing the opportunity for early diagnosis, CDC is 
proposing to revise our guidelines for HIV testing of adults, 
adolescents, and pregnant women in health care settings. The 
revised guidelines will focus on increasing routine HIV 
screening of patients in health care settings, fostering the 
earlier detection of HIV infection, identifying and counseling 
persons with unrecognized HIV infection, and linking them to 
clinical and preventive services and further reducing perinatal 
transmission of HIV in the United States.
    Detecting HIV infection earlier through HIV screening has 
been shown to be cost effective, even in settings of low 
prevalence. The new guidelines will recommend routine or opt-
out HIV screening in health care settings and are intended for 
providers in all health care settings. The guidelines do not 
modify existing guidelines for HIV counseling, testing, and 
referral for high-risk persons who seek HIV testing in non-
clinical settings.
    As you know, to further support the goal of diagnosing HIV 
infections earlier and increasing access to care, the 
President's 2007 budget includes an increase of $93 million for 
CDC HIV prevention programs. Three major testing components are 
included: Testing in health care and non-clinical settings, in 
jails, and with injecting drug users. CDC will work 
collaboratively with other HHS agencies in these efforts. We 
anticipate testing more than three million persons and 
identifying over 46,000 infections.
    In closing, over the past 25 years, our Nation has made 
progress in preventing morbidity and mortality related to HIV. 
CDC remains committed to helping people live longer, healthier 
lives by preventing new HIV infections and protecting the 
health of those already infected.
    Thank you again for this opportunity and I look forward to 
answering any questions.
    Senator Coburn. Thank you, Dr. Fenton. Dr. Hopson.

TESTIMONY OF DEBORAH PARHAM HOPSON,\1\ ASSOCIATE ADMINISTRATOR, 
HIV/AIDS BUREAU, HEALTH RESOURCES AND SERVICES ADMINISTRATION, 
          U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

    Ms. Hopson. Mr. Chairman, thank you for the opportunity to 
meet with you today on behalf of the Health Resources and 
Services Administration. Last year, I testified before the 
Subcommittee regarding the domestic HIV/AIDS care programs and 
I am happy to be here today to discuss ways to ensure early 
diagnosis and improve access to treatment for Americans living 
with HIV and AIDS. I certainly appreciate your continuing 
support for the Ryan White CARE Act programs.
---------------------------------------------------------------------------
    \1\ The prepared statement of Ms. Hopson appears in the Appendix on 
page 46.
---------------------------------------------------------------------------
    The Ryan White CARE Act is the centerpiece of our domestic 
response to care and treatment for low-income, uninsured, and 
under-insured individuals living with HIV/AIDS. Currently 
funded at over $2 billion, it provides primary health care, 
live-saving medications, and support services to individuals 
who lack health insurance and financial resources to provide 
adequate health care for themselves.
    As you noted, the authorization of the Ryan White CARE Act 
expired 6 months ago. President Bush in his State of the Union 
Address stressed the importance of this program and asked 
Congress to reform and reauthorize the Ryan White CARE Act and 
provide new funding to States so that we can end the waiting 
list for AIDS medicines in America.
    Since its last reauthorization, we have been able to 
provide anti-retroviral treatment, primary care, and support 
services to over half a million people annually in the United 
States, Puerto Rico, Guam, the Virgin Islands, and eligible 
U.S. territories in the Pacific. In 2004, an estimated 65 
percent of these individuals were racial minorities, 33 percent 
were women, and 87 percent were either uninsured or received 
public health benefits. The Ryan White CARE Act programs have 
provided important benefits to these populations.
    Overall, AIDS mortality is down and lives have been 
extended through HIV medications purchased through the AIDS 
Drug Assistance Program, also known as ADAP. Pregnant HIV-
positive women have been provided with care that has allowed 
them to give birth to children free from HIV infection, and 
thousands have received support services that have allowed them 
to access and remain in health care.
    Although we are making progress in providing services to 
people living with HIV, the epidemic continues and will be in 
need of our attention for some time to come. The President and 
Secretary understand the dynamics and severity of the epidemic 
and they are committed to ensuring the Department's HIV/AIDS 
programs are as effective as possible in preventing infection 
and treating those who become infected.
    We have recognized that as essential as the Ryan White CARE 
Act has been to serve Americans with HIV and AIDS, it is in 
need of revitalization to safeguard its critical mission. 
Despite record levels of funding, we continue to face waiting 
lists for life-saving funds through the ADAP and there are 
marked disparities in access to quality medical treatment 
across the country. As minority populations are increasing and 
disproportionately impacted by HIV/AIDS, changes to the 
existing systems of care designed for an earlier epidemic are 
increasingly urgent.
    Each year, CARE Act programs, primarily through grants to 
States, metropolitan areas, providers, and educators, we reach 
an estimated 571,000 people. Since AIDS was first recognized, 
the pattern and treatment of HIV disease has shifted. We now 
strive to manage HIV/AIDS as a chronic disease. Early diagnosis 
and improved access to HIV care and treatment are key to what 
the CARE Act stands for.
    The CARE Act programs are successful at counseling and 
testing. More than 800,000 HIV tests were administered in CARE 
Act sites. And the important thing to note is over 85 percent 
of the people tested in CARE Act sites returned for their 
results. We think that this is because the CARE Act sites are 
not only testing sites, but they are primary care delivery 
sites, as well.
    Going forward, we take great pride in the advances of HIV/
AIDS care and treatment that have been made by the CARE Act 
programs over the past 16 years. However, we are humbled by the 
significant challenges that remain for people living with HIV/
AIDS who have nowhere else to go for care in an age of 
increasing HIV/AIDS prevalence, increasing health care costs, 
and a growing burden of HIV among the uninsured and under-
insured.
    The Administration has emphasized five key principles for 
reauthorization of the CARE Act: Serve the neediest first; 
focus on life-saving and life-extending services; increase 
prevention efforts; increase accountability; and increase 
flexibility.
    The President has made fighting the spread of AIDS a top 
priority of his Administration and he will continue to work 
with Congress to encourage prevention and provide appropriate 
care and treatment to those suffering from the disease.
    Today, people with HIV/AIDS are living longer, healthier 
lives, in part because of the CARE Act. In order to make this 
legislation more responsive in the future, the Administration 
urges Congress to take into account the above-stated principles 
in the reauthorization of the CARE Act.
    Thank you for the opportunity to discuss the Ryan White 
CARE Act today and for your dedication and interest in this 
important piece of legislation.
    Senator Coburn. Thank you, Dr. Hopson. Dr. Crosse.

  TESTIMONY OF MARCIA CROSSE,\1\ DIRECTOR, HEALTH CARE, U.S. 
                GOVERNMENT ACCOUNTABILITY OFFICE

    Ms. Crosse. Mr. Chairman, I am pleased to be here today to 
discuss the AIDS Drug Assistance Programs, or ADAPs, that 
receive funds under the Ryan White CARE Act and to provide a 
summary of our report that we are releasing today, prepared at 
your and others' request. The report discusses ADAP's program 
design, their funding sources, and drug purchasing. It also 
discusses our examination of State prenatal HIV testing and 
perinatal HIV transmission rates and State approaches to 
identifying and notifying partners of HIV-infected individuals.
---------------------------------------------------------------------------
    \1\ The prepared statement of Ms. Crosse appears in the Appendix on 
page 55.
---------------------------------------------------------------------------
    Despite progress in drug treatments and the reduction of 
AIDS mortality in the United States, challenges remain 
concerning the availability of these drugs for individuals with 
HIV or AIDS. Because of the variation in program criteria, an 
individual eligible for ADAP services in one State may not be 
eligible for or receive the same ADAP services in another. ADAP 
income ceilings for individuals, program enrollment caps, and 
drug formularies vary considerably among ADAPs.
    For example, each ADAP determines a maximum income level or 
income ceiling as a criterion for an individual's eligibility 
for enrollment. ADAPs reported income ceilings that range from 
125 percent of the Federal poverty level in North Carolina to 
556 percent in Massachusetts. Sixteen ADAPs reported that they 
had limits on the assets that individuals enrolled in the 
program are allowed to have. Twelve ADAPs reported having caps 
on program enrollment or on amounts expended per individual. 
And the total number of drugs ADAPs included on their 
formularies ranged from 20 in Colorado to 1,000 in 
Massachusetts, New Hampshire, and New Jersey.
    In order to make maximum use of the funding they receive, 
ADAPs are expected to secure the best prices available for the 
drugs on their formularies. ADAPs may, but are not required to 
purchase their drugs through the 340B Federal drug pricing 
program, under which drug manufacturers provide discounts on 
certain drugs. HRSA has identified the 340B prices as a measure 
of ADAPs' economical use of grant funds, but HHS does not 
disclose 340B prices to the ADAPs.
    We found that some ADAPs reported prices that were higher 
than the 340B prices for selected HIV/AIDS drugs. However, 
these reported prices may not have reflected any rebates ADAPs 
eventually received. While HRSA is responsible for monitoring 
whether ADAPs obtain the best prices available for drugs, it 
does not routinely compare the drug prices ADAPs report to the 
340B prices, and without the final ADAP rebate amount on a drug 
purchase, HRSA cannot determine whether the final drug prices 
paid were at or below the 340B price.
    We are recommending that HRSA require ADAPs to report the 
final prices they paid for drugs, net of any rebates, and that 
HRSA routinely determine whether these prices are at or below 
the 340B prices.
    Turning to approaches to reduce the spread of HIV, all 50 
States, the District of Columbia, and Puerto Rico have policies 
or have enacted laws regarding HIV testing of pregnant women to 
help reduce the transmission of HIV to newborns. However, among 
the eight States we examined, three States followed CDC's 
recommendations to routinely include HIV tests in standard 
prenatal testing while allowing a woman to refuse to be tested 
for HIV. The other five States require that a woman 
specifically consent to an HIV test, usually in writing, before 
the test can be performed. But two of these States, as you 
noted, Connecticut and New York, have mandatory newborn testing 
if the mother has refused an HIV test. Six of the eight States 
report that the number of HIV-positive newborns has declined, 
however, in a positive development.
    Among other efforts to reduce the transmission of HIV, 
States used various approaches in eliciting information from 
known HIV-infected individuals about their sexual partners. But 
the participation of these individuals varies and not all 
partners can be reached to be notified. For example, CDC data 
showed that States interviewed between 46 percent and 100 
percent of known HIV-infected individuals to elicit the 
identities of their partners and were able to notify between 42 
percent and 83 percent of those partners that they had been 
exposed to HIV.
    Further, in the 12 States we examined, 10 have statutory or 
regulatory provisions that require or permit the notification 
of partners, including spouses, without the consent of the 
known HIV-infected individual. However, in the remaining two 
States, Massachusetts and Minnesota, public health officials or 
the health department may notify partners, including spouses, 
only with the consent of the HIV-infected individual.
    Mr. Chairman, this concludes my prepared remarks. I would 
be happy to answer any questions you or other Members of the 
Subcommittee may have. Thank you.
    Senator Coburn. Thank you, Dr. Crosse.
    Dr. Fenton, I am going to start with you, if I may. Four 
years ago, Dr. Gerberding stated in her first speech as 
Director of CDC that 40,000 or more new HIV infections occur 
every year in the United States and it was unacceptable and our 
goal is to substantially reduce and ultimately prevent. If you 
look at that chart \1\ and the fact that CDC now admits at 
least 40,000 new infections every year, which has not declined, 
what is the explanation for that?
---------------------------------------------------------------------------
    \1\ The chart referred to appears in the Appendix on page 132.
---------------------------------------------------------------------------
    Dr. Fenton. In reviewing that chart and in assessing our 
successes of our prevention interventions, I think there are 
two key questions that we need to ask ourselves. First, are we 
doing the right prevention interventions or do we have 
effective interventions and are we delivering them at the right 
level to have the necessary impact on our HIV epidemic? Or, 
second, as the epidemic is evolving, are we actually targeting 
our prevention interventions in the right areas for the right 
communities at risk?
    CDC has a program of continually evaluating the 
effectiveness of our prevention programs. Over the past decade, 
we have been involved in monitoring the outcomes of our 
prevention activities and using our surveillance data to 
evaluate the effectiveness of our prevention interventions. We 
have systematically developed effective behavioral 
interventions and we have embarked upon a program of diffusing 
these effective interventions to communities and individuals at 
high risk of acquiring HIV.
    We have also used core prevention indicators to evaluate 
the effectiveness of programs at the local level. Program 
consultants are required to interview our grantees to ensure 
that local implementation of our prevention programs are being 
done as anticipated.
    Senator Coburn. Let me ask it in a little different way. We 
are going to spend over $20 billion this year in this country 
on domestic HIV/AIDS and we are climbing every year as we work 
on this very difficult problem. When are we going to see a 
decline in the new infections? Maybe we are not having more new 
infections, maybe we are diagnosing more that were in the 
resilient population. That may be the answer. But if you were 
an average American out there paying their taxes and--$18 
billion to $20 billion, we started out very low and through the 
great work of AIDS activists, we are where we are today, when 
are we going to see that go this way? And this opinion, you are 
not going to be held to this. Just give us an opinion. 
[Laughter.]
    I have got 4 more years here. I promise I won't hold you to 
it.
    Dr. Fenton. I am not in a position to say exactly when we 
are going to be seeing a decline or a change in the epidemic 
curve, but I do know that we have had successes in preventing 
HIV transmission in some areas. We are beginning to see 
declines in new HIV diagnoses among injecting drug users. And 
earlier in my testimony, I mentioned the declines and the 
successes in perinatal HIV.
    Senator Coburn. Right.
    Dr. Fenton. More recently, our surveillance data is 
suggesting that we are seeing reductions in new diagnoses among 
African-American women. So taken as a whole, it may be very 
difficult to predict exactly when we will see declines in new 
diagnoses, but we are seeing successes. I think the key is 
actually identifying what elements of our--why are we seeing 
the successes----
    Senator Coburn. What is working and what isn't?
    Dr. Fenton [continuing]. And ensure that we either extend 
these and continue to implement these nationally.
    Senator Coburn. Fifteen months ago, CDC unveiled its 
Advancing HIV Prevention Initiative. How many States have 
enacted the recommendations and what is being done to assist 
all the States to adopt those recommendations? And by the way, 
for our audience, those are recommendations that just follow 
common public health precepts that have been proven for years 
to work which were just introduced by CDC 15 months ago.
    Dr. Fenton. The Advancing HIV Prevention Initiative was 
actually launched in 2003 and there are a number of 
interventions which were included in those, including universal 
HIV testing of pregnant women, confidential partner 
notification, and rapid testing. I would like to report on our 
progress on each of these.
    Senator Coburn. OK.
    Dr. Fenton. As far as our interventions for pregnant women 
are concerned, in 2004, CDC recommended implementation of an 
opt-out testing approach in which women are notified that an 
HIV test will be routinely included in the standard battery of 
tests to be done. Since CDC's recommendation for opt-out 
testing, seven States have specifically authorized opt-out 
prenatal HIV screening in legislation. In November 2005, the 
American College of Obstetricians and Gynecologists further 
published a legislative tool kit of State laws and suggested 
legislative language that should be used to actually aid the 
requirement of opt-out testing for pregnant women.
    As far as monitoring States and what exactly is happening 
as far as HIV testing and counseling is concerned, CDC 
conducted a survey and analysis of all relevant State statutes 
addressing HIV testing and counseling. An electronic database 
of these State laws will be posted on the agency website within 
the next month. This information really has provided a very 
comprehensive inventory of laws which really gives a sense of 
where States are in terms of requiring mandatory HIV testing, 
pre-testing and post-test counseling, and testing of pregnant 
women.
    As far as our progress on partner notification is 
concerned, it is a condition for all States receiving Federal 
funds for HIV and STD prevention that they should have 
confidential partner notification as a component of partner 
counseling and referral services. So all CDC grantees are 
expected to deliver on this intervention.
    And then finally, as far as rapid HIV testing is concerned, 
all CDC grantees are encouraged to use their HIV prevention 
funds to purchase rapid HIV tests for various clinical and non-
clinical sites.
    Senator Coburn. Dr. Hopson, Department of HHS has announced 
the Ninth Annual Ryan White CARE Act Grantee Conference in 
August, and according to the invitation letter, all 
participants and presenters are responsible for their own 
travel, hotel, and registration fees; which should come from 
CARE Act funds. I have two questions for you. One is, is it 
really a necessity to have that conference every year when the 
bill hasn't changed? And number two, couldn't that money be 
much better spent by redirecting it to an ADAP program?
    Ms. Hopson. Thank you. The Ryan White CARE Act grantee 
meeting is held every other year, so we don't hold it every 
year, and we began holding it when the CARE Act programs were 
combined into the HIV/AIDS Bureau. So this is the fourth 
biannual meeting. What we have found is that it is the time 
where we are able to provide technical assistance to our 
grantees.
    As I said in my testimony, this is a time when the CARE Act 
hasn't changed but the environment in which we are operating 
has changed. There are lots of changes in Medicare. There are 
changes in Medicaid. There are changes in other parts of the 
health care financing world, as well. There are also clinical 
changes and clinical updates. And so we use this as a time to 
provide technical assistance to our grantees. Because we have 
so many grantees, we are not able to get out and visit each one 
of them and we find that when we bring them together, they are 
able to learn from each other. This is a time that is well 
spent and money that we also believe is well spent.
    Senator Coburn. How much money is it?
    Ms. Hopson. I will have to provide that for the record.
    Senator Coburn. Thank you. The President's reauthorization 
principles that he put forward would require at least 70 
percent of all CARE Act funds to be spent on primary medical 
care and treatment, and I heartily endorse that. Titles II and 
III are already spending more than 75 percent of their funds on 
such purposes, according to GAO. Title I does not, and I 
understand that most Title IV consumers already have their 
primary care paid for by either SCHIP or Medicaid. How do you 
envision the 75 percent primary care floor affecting the roles 
and services impacted by Title I and Title IV?
    Ms. Hopson. For Title I, we do realize that most of the 
money does pay for primary care medical services or medications 
and we believe most of the grantees--when you look at it 
overall about 54 percent is the amount that they spend on 
primary care services. So we believe that if the law does pass 
and it says 75 percent must be spent on primary care and 
treatment, then the grantees will have to look and see how they 
will reallocate funds so that they could meet that requirement.
    In terms of Title IV, we realize that there are many of the 
patients who are eligible for Medicaid and receive their care 
paid for that way and we are looking to see what would be 
included in the primary care services. We broadly define that 
as not only services that are provided for people when they 
come in for care, but also, we need to provide outreach to get 
people in care and keep them in care. Those services are 
vitally important, particularly when you look at the Title IV 
population, which is largely minority women and their children. 
There are unique challenges that they face in order to get to 
care and to remain in care, and so we look at a package of 
services as part of comprehensive primary care. The Title IV 
program will try to reprioritize those services, or prioritize 
such that the Ryan White CARE Act does pay for the primary care 
services and the necessary support services to get people into 
care and to keep them in care.
    Senator Coburn. OK. I have gone over my 5 minutes. Senator 
Carper, I am going to come back for another round.
    Senator Carper. Good. Thanks. On our second panel, one of 
our panelists is Beth Scalco, who is, I think, the Director of 
the Louisiana HIV/AIDS program. Louisiana is, as we all know, 
now struggling with the aftermath of Hurricane Katrina, so it 
is arguably necessary that they have the flexibilities to 
address some of the new challenges.
    I have two questions. One is does the current Ryan White 
program do enough to give States like the Gulf Coast States and 
the localities the flexibility to address their specific needs? 
That is my first question. And second, is there anything more 
that we ought to be doing in this area?
    Dr. Hopson would you start with that and we will just take 
it from there.
    Ms. Hopson. Hurricane Katrina was certainly something that 
we have never seen the likes of before in this country and 
there are many systems that were impacted by that, including 
the Ryan White CARE Act program. There were many, many evacuees 
from New Orleans and the other parts of the Gulf region. 
Included in that evacuation were people who are living with HIV 
and AIDS. Many of them went to other parts of Louisiana, 
Alabama, Mississippi that were not impacted by the hurricane. 
Others went to neighboring States like Texas or Georgia, but 
the evacuees ended up in many places around the country.
    The challenge has been to find all of those patients who 
were enrolled and receiving care in the affected area and get 
them into care.
    Senator Carper. That is a pretty big challenge.
    Ms. Hopson. That is a big challenge, and one of the 
concerns that we have is that we have not found all of those 
patients. So that is a continuing challenge that we have. We 
are continually in contact with the States and with all of our 
grantees around the country to ask if they are still receiving 
patients who were displaced.
    Senator Carper. Any idea if they have found as many as half 
of them, three-quarters of them? Just roughly?
    Ms. Hopson. We do have that information. I just don't have 
it off the top of my head.
    Senator Carper. All right.
    Ms. Hopson. I can give you some specifics. We know that in 
Texas, there are over 800 evacuees who are receiving CARE Act 
services. Louisiana received 700 evacuees from New Orleans. We 
let the grantees know that they were able to have some 
flexibility so that Title I New Orleans dollars were able to be 
used by the Title II State. Also, Louisiana Medicaid provided 
funding to the Texas ADAP to purchase pharmaceuticals for 
Louisiana Medicaid-eligible clients. In Texas, they really did 
a yeoman's job of decreasing the complexity of people being 
eligible for ADAP and were able to very quickly get people 
enrolled in ADAP, and many of the pharmaceutical companies, as 
well, immediately stepped up to the plate and were able to 
provide some free medications for people who were evacuees.
    So again, there were lots of things that were done. We were 
limited, though, by the statute. There were people who were 
asking me constantly, well, can't you just waive this and waive 
that? And I said, no, I don't have the power to waive the 
statute. We still have to follow the law.
    Senator Carper. Excuse me for interrupting, but as we look 
toward reauthorizing the Act, and people especially like my 
colleague here, shouldn't we be involved along with folks on 
the HELP Committee? What ought we be doing to provide more 
flexibility, if that is appropriate?
    Ms. Hopson. Yes.
    Senator Carper. You can answer that for the record, but it 
is a timely question.
    Ms. Hopson. It is a great question. We have been having 
lots of discussions within the Department and I think I would 
like to provide that answer for the record.
    Senator Carper. Sure. That would be great.
    Let me go back, if I could, to Dr. Fenton. I don't think 
you have been asked enough questions yet, so I will ask you a 
few more. I understand CDC has suggested that HIV screening be 
conducted in maybe not all health care settings, but a whole 
lot of them, unless the patient declines. This seems like a 
laudable goal, but could you speak a little bit about how this 
would work on a practical level and how much it might cost to 
implement that kind of an approach? Finally, how would we pay 
for it? It is like a three-part question.
    Dr. Fenton. It is. To address the first question first, 
which is which settings and how is this going to be 
implemented, the real background to this is really to begin to 
have a systematic strategy to really reduce the undiagnosed 
fraction of HIV in the general population, and we know that 
certainly in the American population, approximately 75 percent 
of individuals attend their health care provider or are seen by 
a health care provider in the previous year. So this is a huge 
opportunity for us to really escalate the uptick of HIV testing 
in the population.
    In our revised screening guidelines, the objective is to 
involve as many health care settings in this process by 
routinizing HIV testing and removing the barriers to HIV 
testing in the health care setting. In this respect, we are 
looking at involving all different kinds of health care 
settings where individuals aged 13 to 64 would be seen for 
routine health care.
    Senator Carper. Do you have some idea how much something 
like this might cost, and finally, who might pay for it? How 
might we pay for it?
    Dr. Fenton. OK. I don't have the figures as to how much 
this might cost and I would like to provide that for the 
record?
    Senator Carper. All right. Who might pay for it?
    Dr. Fenton. We are looking at various strategies for paying 
for this. Certainly one area that we are looking at that we 
would be keen to pursue is exploring the ability for third-
party payment for HIV rapid tests, or HIV tests, similar to 
other screening tests which are done in the population which 
are paid for by third-party payers. The objective would be to 
have HIV testing as being paid for in this manner.
    We also should remember that additional funds are being 
provided by the Administration through CDC to support the 
purchase of rapid tests and we will be working very closely 
with our partners at State and local government as well as 
other HHS agencies to ensure that rapid tests are provided in 
as many settings, both clinical and non-clinical settings, as 
possible.
    Senator Carper. All right. One last question for you, Dr. 
Fenton. I understand that CDC has stated that prevention 
counseling need not be conducted in conjunction with HIV 
testing. It seems like testing would be a logical point at 
which to give people information about how to reduce the risk 
of HIV infection. I am wondering if you can give us some more 
detail about CDC's thinking in this area.
    Dr. Fenton. Absolutely. In thinking about the future of HIV 
testing in the United States, it is important to unlink the 
testing which is being recommended in clinical settings from 
that which is being recommended in non-clinical or community 
settings. There are no plans afoot to separate prevention 
counseling in the non-clinical settings. However, in clinical 
settings, what we are looking at is streamlining the HIV 
testing process so it becomes shorter, more efficient, and 
therefore, we begin to remove some of the barriers to HIV 
testing in the clinical settings.
    Individuals who are diagnosed positive as a result of the 
HIV tests would still have intensive prevention counseling to 
enable them to access appropriate treatment and care and 
prevention services. So that part of the process counseling for 
HIV-positive individuals would not be lost. But it is crucial 
that if we are moving away from exceptionalization of HIV 
testing, that we really look at streamlining the HIV testing 
process, especially in clinical care settings, and removing the 
barriers, which are time constraints, concerns about 
stigmatization in providing HIV tests by health care providers, 
etc.
    Senator Carper. Dr. Crosse, would you care to comment on 
Dr. Fenton's response?
    Ms. Crosse. Senator, I don't believe that we have the 
information from the work that we have undertaken to be able to 
speak specifically to his remarks. If you would like us to 
review that, I would be happy to do that and provide 
information subsequently.
    Senator Carper. Thank you, ma'am.
    All right, Mr. Chairman. That is it for me. Thanks.
    Senator Coburn. I think the answer to your question lies in 
the chart to your right.\1\ A study released last August showed 
what the cost per infection prevented by the different 
intervention strategies, and to do HIV counseling with opt-in, 
one-on-one, the average cost is $110,000.
---------------------------------------------------------------------------
    \1\ The chart referred to appears in the Appendix on page 133.
---------------------------------------------------------------------------
    I find it very interesting that in 1996, the Ryan White 
CARE Act reauthorization contained a requirement that as a 
condition of Federal funding, all States require that a good 
faith effort be made to notify spouses of known HIV-infected 
patients that such spouse may have been exposed. We just heard 
testimony from Dr. Crosse that there are two States now that 
have to have the permission of the person who is infected, and 
the CDC has certified that all States are requiring with this 
requirement.
    How can CDC certify that if I am a spouse of somebody who 
is infected who doesn't want to tell me that I am infected that 
they are, in fact, complying with the Ryan White Act? How can 
the CDC take that position in those States that require that? 
You don't have to answer for the record. You can answer in 
written response, but it is very concerning to me because you 
hear Dr. Parham say she can't waive the law, and yet my big 
problem through the years with CDC seems to be that oftentimes 
what is expedient is waived and what isn't, isn't. So I would 
love for you to answer that in writing for us because you all 
have certified that, but we have had testimony today that is 
something different from that.
    Ms. Crosse. Mr. Chairman, if I could just add, in our 
review, we only examined the statutes in 12 of the States and 
so there may be additional States beyond those two----
    Senator Coburn. Right.
    Ms. Crosse [continuing]. That have similar requirements.
    Senator Coburn. The two out of the 12, you had two where 
the trump card is if I am HIV infected and I don't want my wife 
to know, she can't know. The law says you have to not give 
people money who do that, and yet you certify they are all in 
compliance. Something isn't right there.
    But go back to the chart, which I think is very revealing, 
and I think what the CDC is trying to address with their 
specialized non-clinical setting testing and everything else is 
how do we spend money most effectively to take this large group 
of undiagnosed people, 300,000, and find out their status so 
that we don't enlarge the number of people who are unknown in 
their HIV status who are HIV-positive. But I think this chart 
is very revealing to us to know where to, in fact, spend our 
money most efficiently.
    Dr. Crosse made some mention about 340B testing in her 
reports, although they can't be sure because they don't have 
discounted net prices, rebate net prices. There is some concern 
that maybe efficiency of the present dollars in ADAP programs 
aren't as good as they should be because we are not getting a 
comparison of whether or not they are getting value. Based on 
what you have heard and based on what your plans are, what are 
HRSA's plans to do about holding accountable and within the 
340B to get more bang for our buck in terms of the dollars 
spent by ADAP?
    Ms. Hopson. There are a number of things that we do 
currently. One, HRSA does require the ADAP, as a condition of 
their grant award, to participate in a cost-saving measure that 
is equal to or more economical than the 340B program. Now, the 
problem comes is that HHS cannot disclose the 340B-covered 
entities, such as ADAPs, what the prices are because of 
confidentiality agreements between the government and the drug 
companies. So there is that challenge that we have.
    Senator Coburn. But her point was that you are not working 
with a real number because the numbers they are reporting to 
you is not rebate-adjusted. Is that correct?
    Ms. Hopson. Yes, that is correct.
    Senator Coburn. So basically, whatever you are doing with 
it, it is not a real number. So is there something you all plan 
on doing to say, you have to give us rebate-adjusted pricing?
    Ms. Hopson. There is another program within HRSA, the 
Office of Pharmacy Affairs, and they are not part of my Bureau, 
so that is why I am turning around to make sure I get the right 
answer. I know what we are doing in the HIV/AIDS Bureau. But we 
are working with the Office of Pharmacy Affairs that manages 
the 340B program to make sure that the information that we get 
from our ADAPs is the information, the net price, essentially, 
of the drugs that we purchase through the ADAPs and that we 
give that information to the Office of Pharmacy Affairs who 
then can give us a range. They can't give us the exact price, 
but they can give us, within range, as to what price--are we 
paying a fair price close to the 340B price or not.
    There are a number of things that Dr. Duke, the HRSA 
Administrator, has put forward to the Department and has put in 
the 2007 budget request so that we can improve the ability of 
the Office of Pharmacy Affairs to report to us and work with us 
so that we can have the accurate prices. On our end, in the 
HIV/AIDS Bureau, we are working with our grantees, the ADAPs, 
so that they will report the net price to us so that we then 
have an accurate number to compare to the 340B prices.
    Senator Coburn. So their observation has already been 
addressed by HRSA.
    Ms. Hopson. Yes.
    Senator Coburn. The observation of GAO----
    Ms. Hopson. We are in the process of--this is something we 
have proposed in the 2007 budget. We don't have that----
    Senator Coburn. Dr. Crosse, would you respond to that?
    Ms. Crosse. Our understanding based on HRSA's response to 
our draft report was that the Office of Pharmacy Affairs was 
developing a system that would assist the ADAPs in determining 
for themselves whether or not they were obtaining economical 
prices in their drug purchasing, but HRSA's response indicated 
that it would be logistically difficult and require resources 
that they don't have to carry out the kind of oversight and 
monitoring that we recommend they do and that this would not 
require the sort of manual comparison they indicated in their 
comments, but could be carried out electronically and could be 
carried out for a subset of the drugs.
    We, for example, in our review looked at just 10 drugs that 
accounted for 73 percent of the expenditures by the ADAPs so 
that they could, likewise, examine either on some rotating 
basis or with some subset that account for a substantial 
portion of spending, particularly on the anti-retrovirals, what 
the actual prices finally are or are paid. But our 
understanding, our reading of their comments back to us was 
that they did not at this time intend to do that.
    Senator Coburn. I just want the panel to know, we are 
coming back to this, because every dollar wasted is somebody 
not treated. This is something that the law says and isn't 
being carried out. You can't waive it and I am going to be the 
enforcer. So just plan on about 4 months from now finding out 
what the response is, make sure it is in place, because we are 
going to have another hearing to ask about it.
    If Congress does not reauthorize the CARE Act by October 1, 
what will happen to the funding of States without names 
reporting or immature reporting systems? Dr. Hopson.
    Ms. Hopson. As you know, sir, because you were there in 
2000, there is a requirement that by 2007, we must use HIV, not 
just AIDS, in the formula by which we distribute the Title I 
and Title II dollars. We are discussing that within the 
Department right now as to the options that we will use for 
those States that do not have that HIV data that is certified 
by the CDC, because we use data that is certified by CDC in 
order to make the funding decisions for Title I and Title II.
    Senator Coburn. So tell me again, what is going to actually 
happen?
    Ms. Hopson. We are having discussions on various options 
now within the Department----
    Senator Coburn. So you haven't made a decision what is 
going to happen?
    Ms. Hopson. That is correct.
    Senator Coburn. OK. That is what I was wanting to get to. 
Is it important what the Ryan White CARE Act said in terms of 
the 2001 bill?
    Ms. Hopson. Absolutely.
    Senator Coburn. OK. Well, I have several other questions 
for all of you. I am not going to keep you here for that. I 
will submit the rest in terms of written format. I would very 
much appreciate your response in 2 weeks, if you can, and I 
know those have to be cleared, so I am patient.
    But this one issue on ADAP pricing and comparison, whether 
or not we are getting a good deal, the drug companies don't 
need to make any more money. They can afford to sell at a 
reasonable price to ADAPs if they can afford to sell to 
anybody. It is my concern that this be addressed very quickly 
because it is money going out of the door that shouldn't be 
going out of the door. Or, it may not be a problem at all, but 
the point is, we need to know whether it is. The GAO seems to 
think it may be, but we don't know. So I want to make sure that 
is addressed.
    I would also invite you to stay to hear our next panel, 
because I think they have information you all can use, and 
oftentimes government witnesses don't stay and they don't have 
the benefit of really getting the feedback that would be 
beneficial.
    Thank you all so much for your testimony and thank you for 
being here.
    Senator Coburn. Our next panel consists of Michael 
Weinstein, who is President of HIV Healthcare Foundation, the 
Nation's largest provider of HIV/AIDS medical care. Since 1986, 
Mr. Weinstein has been a leader in the fight against HIV and 
AIDS. As President and co-founder of AIDS Healthcare 
Foundation, he oversees a $140 million organization whose 
mission is to provide cutting-edge medicine and advocacy 
regardless of one's ability to pay. They currently serve 30,000 
clients in the United States, Africa, Central America, and 
Asia. The Foundation now operates 14 outpatient AHF health care 
centers in California and Florida. They also operate seven 
pharmacies, a clinical research unit, a disease management 
program through the State of Florida, and the first capitated 
Medicaid managed care program for people with AIDS.
    Beth Scalco is Director of the HIV/AIDS program for the 
State of Louisiana's Office of Public Health. The HIV/AIDS 
program under her direction has the primary responsibility for 
overseeing Louisiana's response to the AIDS epidemic, including 
all prevention and care activities. Her office administers the 
Ryan White Title II program, including the ADAP program, the 
HOWPWA program, the Centers for Disease Control and Prevention 
surveillance cooperative agreements, and the State general 
funds for AIDS. She has been working in the field of HIV/AIDS 
since 1985.
    Welcome, both of you. Ms. Scalco, I think I will ask you to 
go first, since I introduced you second.

  TESTIMONY OF M. BETH SCALCO, DIRECTOR,\1\ HIV/AIDS PROGRAM, 
   LOUISIANA OFFICE OF PUBLIC HEALTH, AND PAST CHAIR OF THE 
   NATIONAL ALLIANCE OF STATE AND TERRITORIAL AIDS DIRECTORS 
                            (NASTAD)

    Ms. Scalco. Good afternoon, Mr. Chairman. My name is Beth 
Scalco and I am the Director of the HIV/AIDS program for the 
State of Louisiana. I am also the past Chair of the National 
Alliance of State and Territorial AIDS Directors (NASTAD). I 
want to thank you for inviting me to speak with you today.
---------------------------------------------------------------------------
    \1\ The prepared statement of Ms. Scalco appears in the Appendix on 
page 64.
---------------------------------------------------------------------------
    State AIDS directors appreciate the longstanding support of 
the U.S. Senate for the Ryan White CARE Act programs, and 
assuring that all persons with HIV/AIDS, regardless of their 
geographic location, have equal access to appropriate and high-
quality HIV/AIDS services is our highest priority. I would like 
to share with you some views of my fellow State AIDS directors 
in addition to some views from the State of Louisiana. I have 
limited my comments to those that address increasing access to 
prevention services provided by State health departments, 
including testing and access to life-saving drugs provided by 
the AIDS Drug Assistance Program.
    As you said, Louisiana HIV/AIDS program administers the 
HIV/AIDS prevention and care programs funded by both State and 
Federal funds. HIV infections have penetrated both our 
metropolitan areas as well as our rural areas in our State. In 
2004, the State of Louisiana had the 11th highest number of 
AIDS cases reported and the fifth highest AIDS incident rates 
in the Nation. There were a total of 25,846 cumulative cases of 
AIDS reported in Louisiana and there are currently 14,793 
individuals living with HIV/AIDS in Louisiana as of March 2006.
    In 2005, we identified 967 new HIV/AIDS cases in Louisiana. 
We normally identify around 1,100 cases in Louisiana, and I am 
sad to say, I do not think that HIV infection decreased. I 
believe that is a result of the impact on our ability to test 
in the months following Hurricane Katrina.
    In the Federal fiscal year 2006, Louisiana received over 
$22 million in Ryan White CARE Act funding. We received $6 
million for Title II base, $15 million for ADAP, and $950,000 
for our emerging communities, which is Baton Rouge, Louisiana. 
Our Title I EMA, which is New Orleans, received $7.4 million. 
We received close to $5 million in HIV prevention cooperative 
agreement funds and $1.6 million for our surveillance 
cooperative agreement.
    The State of Louisiana contributes approximately $2.5 
million specifically for HIV prevention activities in 
Louisiana. In addition, they contribute over $9 million for 
care and treatment of people who are HIV infected through the 
State's public hospital system. This is in spite of Louisiana's 
ongoing budget deficits both prior to the hurricane, and I, 
unfortunately, have to say, I do not believe that they will not 
be able to continue this contribution as a result of the 
hurricane.
    State public health agencies serve an essential and a 
unique role in the delivery of HIV/AIDS prevention, care, and 
treatment programs. The agencies are entrusted through the U.S. 
law as the central authorities of the Nation's Public Health 
System and as such bear the primary public sector 
responsibility for health. State Public Health responsibilities 
include disease surveillance, epidemiology, prevention 
programs, immunizations, emergency preparation, provision of 
primary health care services for the uninsured and the 
indigent, and overall planning and coordination, 
administration, and physical management of Public Health 
Services.
    The President's 2007 budget includes $93 million, of which 
$86 million is new funding, to increase testing in medical 
settings, make voluntary testing a routine part of medical 
care, and to create new testing guidelines, models, and best 
practices. The President's initiative will prioritize funding 
for regions with the highest number of new cases as well as 
focusing on incarcerated persons and injection drug users.
    State AIDS directors support the President's request for 
$86 million in new funding for domestic HIV prevention and 
believe that this funding should be allocated via the 
prevention and surveillance cooperative agreements with State 
and local health departments. State and local health 
departments already fund HIV testing in a variety of venues in 
communities and they are in the best position to maximize the 
potential of the President's testing initiative.
    However, testing alone will not prevent new infections. 
Funds must be increased to make up for 3 years of cuts, which 
have hampered the ability of State health departments to 
implement CDC's Advancing HIV Prevention Initiative.
    In addition, resources for surveillance are sorely needed, 
as the Federal Government shifts prioritization from AIDS to 
HIV case reporting and funding for core surveillance activities 
has eroded significantly in recent years.
    State AIDS directors support the delivery of HIV prevention 
services in primary care settings as a standard of care. 
Studies indicate that HIV-positive individuals who are aware of 
their status take steps to protect their partners from 
infection, with 70 percent reporting reductions in risky 
behaviors. Health departments use partner counseling and 
referral services as one tool to identify HIV-positive 
individuals and ensure their linkages to medical support and 
prevention services.
    Research has found PCRS to be a very cost-effective 
strategy for identifying HIV-infected persons who are unaware 
of their serostatus. State AIDS directors support the 
continuation of funding for PCRS through CDC cooperative 
agreements with States and the directly-funded cities.
    The State AIDS programs have been one of the largest 
implementors of HIV rapid testing programs. We have long 
supported the development and approval of rapid testing and 
worked collaboratively with Congress and the Administration to 
ensure rapid tests were considered for a CLIA waiver. In 
several jurisdictions and in certain settings, barriers to 
rapid testing exist. It is a complex testing technology. In 
addition, it is more costly to implement than traditional 
testing.
    The CARE Act is a safety net under other public programs, 
such as Medicaid and Medicare. The Ryan White programs must 
adapt to fill gaps particular to the individual State. ADAPs 
work closely with the State Medicaid programs and Medicare Part 
D to ensure that ADAPs remain the payer of last resort. 
Annually, ADAPs serve approximately 136,000 clients, or about 
30 percent of the people living with HIV/AIDS estimated to be 
receiving care in the United States.
    In fiscal year 2005, States were dependent on State 
contributions to their ADAP programs and pharmaceutical 
discounts and rebates to sustain their ADAP programs, as the 
increase in Federal dollars for ADAPs was extremely limited. 
ADAPs receive the lowest prices in the country for anti-
retroviral therapies. In 2003, NASTAD established the ADAP 
Prices Task Force to negotiate with the pharmaceutical industry 
on behalf of all ADAPs, and as a result of this highly 
successful public-private partnership, the task force achieved 
supplemental discounts and rebates beyond those mandated by the 
340B program and price freezes that have resulted in over $300 
million in savings over the past 3 years.
    Ten years after the advent of highly active anti-retroviral 
therapy, the lives of people living with HIV/AIDS have been 
greatly extended. Therefore, individuals are remaining on our 
ADAP programs for lifetimes. ADAPs across the country continue 
to encounter significant challenges in fiscal stability while 
adequately serving the growing number of people with HIV and 
AIDS.
    For 2007, State AIDS directors seek an increase of $197 
million for ADAPs to maintain those that are currently enrolled 
and to meet the growing demand of new clients and to strengthen 
ADAPs' abilities across the Nation to provide the PHS standard 
of care and treatment.
    Senator Coburn. Could you summarize, please? You have gone 
past your 5 minutes.
    Ms. Scalco. Sure. I would like to summarize by saying that, 
first of all, State waiting lists for the ADAP programs are 
only one indicator of need, that many ADAPS have other 
restrictions in place, and to solely distribute money on the 
basis of a waiting list is not an equitable way to do it.
    I would also like to take one moment to address the issue 
of Hurricane Katrina and the State of Louisiana, and 
particularly since you asked the question about the flexibility 
provided by our Federal partners. What we found is that the 
flexibility was lacking and that, in fact, what occurred is 
that while we were trying to piece programs back together and 
provide services to clients, what basically was occurring is 
that we were also having to meet administrative requirements 
that could not be waived, which was not nearly as important as 
assuring that people had access to treatment and care. We also 
needed to have waivers of certain conditions of award and that 
has not been possible. The transfer of funding between Title I 
and Title II, which should have been an easy thing to do, 
actually could not be done without amending 20 contracts 
through the State of Louisiana's contract system.
    And so in that, I would say I would appreciate in the Ryan 
White CARE Act reauthorization if there is an emergency 
provision that would address this problem. Thank you.
    Senator Coburn. Thank you. Mr. Weinstein.

 TESTIMONY OF MICHAEL WEINSTEIN,\1\ PRESIDENT, AIDS HEALTHCARE 
                           FOUNDATION

    Mr. Weinstein. Senator Coburn, Senate staff and the 
audience, as President of the largest AIDS organization in the 
United States, I am deeply concerned about the lack of access 
to HIV medical care for half a million Americans. As we 
approach the 25th anniversary of the identification of the 
first cases of AIDS, I am troubled by our lack of progress in 
treating HIV and controlling the epidemic in this country.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Weinstein appears in the Appendix 
on page 76.
---------------------------------------------------------------------------
    Our No. 1 priority in all matters relating to AIDS should 
be protecting the public health. With half the people who are 
positive not in treatment, including many who do not even know 
their status, we cannot control the spread of this disease nor 
adequately help the people who have it.
    AIDS Healthcare Foundation's primary mission is the medical 
treatment of HIV in this country and across the globe, serving 
32,000 patients. In several of the communities AHF serves, HIV 
patients are dangerously underserved. As an example, Alameda 
County, which includes the City of Oakland, is only spending 10 
percent of its Ryan White CARE Act monies on primary medical 
care. The Magic Johnson Clinic, which we operate in Oakland, is 
largely unfunded and specialty referrals are almost impossible 
to obtain. Despite the fact that Alameda County has declared a 
state of emergency around HIV, much more money is being spent 
on social services than medicine. At our Magic Johnson Clinic 
in Jacksonville, Florida, the situation is similar.
    Ten years after the discovery of the miraculous drug 
cocktails that have made HIV a treatable illness, we are 
treating HIV as if it is a death sentence that it was in the 
1980s. We reauthorized the Ryan White CARE Act 5 years ago 
without making the necessary adjustments to reflect the 
progress we have made in treating patients, and there are some 
who would have us do this again this year.
    We know what it takes to control this disease. We must 
identify most of the carriers and get them into treatment, and 
we must effectively educate the uninfected population. Despite 
billions of dollars a year in expenditures to combat AIDS, we 
are failing on all counts. One need merely look at the numerous 
countries, both rich and poor, that are succeeding where we 
have failed to understand why. We don't do enough tests. We 
don't provide enough money to treat. We are spending too much 
money on drugs. We are not putting sufficient responsibility on 
the infected person to protect their partners.
    Until we have treatment readily available to everyone who 
needs it, we will continue to have more and more AIDS cases. 
Until testing is taken out of the rarified atmosphere of an 
anonymous test site and integrated into mainstream medical care 
in hospitals, clinics, and doctors' offices, we will not 
identify many of the people who are positive. Until we tell the 
drug companies that the U.S. Government will not write a blank 
check for purchasing HIV drugs, we will continue to have 
waiting lists for the AIDS Drug Assistance Program. Until we 
are honest with people about the consequences of becoming 
infected by HIV, which is not a day at the beach, as the drug 
company ads portray it as, we will fail to fight AIDS 
effectively in America.
    The solutions are quite simple. If you want to improve 
access to care, require that the lion's share of Federal 
dollars be spent on treating the disease. We are doing this in 
Los Angeles. The result is an extensive network of outpatient 
clinics, both public and private, across the vast geography of 
Southern California. Alameda County would have the same 
diversity of treatment options if most of their money were not 
being spent on food, housing, transportation, case management, 
and everything else.
    If you want to find more positives, you need to test more 
people in a fast, convenient, and cost-effective manner. 
Routine testing in health care settings without onerous 
counseling requirements is the only way to go.
    If you want to make drugs more accessible to more patients, 
you cannot pay higher and higher prices for each new generation 
of drugs, including those that are developed at government 
expense, thus eating up most of the new money that Congress has 
appropriated.
    If we identify more people who are positive and get them 
into treatment, the number of new infections will go down. If 
it goes down below the number of deaths, then the number of 
people living with HIV will be less each year rather than more.
    We need to resolve to put the money where it is most needed 
to stop AIDS. Rural areas and cities with emerging epidemics 
must get a bigger piece of the pie. Distributing funds based on 
where the epidemic was 10 years ago will not help us fight it 
where it is found today. The people most hurt by this are 
people of color, who represent the overwhelming majority of new 
cases of AIDS.
    Public health and politics are a dangerous mix. Too many 
decisions about how to address AIDS have been made on the basis 
of how one constituency or another must be appeased. This has 
led to a piecemeal, half-hearted approach that has led us to 
where we are now. There is no more fundamental function of 
government than the protection of the public health.
    I strongly urge the Congress to reauthorize the Ryan White 
CARE Act in a fashion that will protect generations to come 
from this devastating illness, and I would ask you to take 
another look at other areas of AIDS spending, such as vaccines 
and research, where there is enormous waste of public 
resources. If these changes are adopted now, I am confident 
that in the United States--this has happened in a country like 
Uganda, that I returned from last week and I have visited eight 
times--we will have less AIDS down the road rather than more. 
Thank you.
    Senator Coburn. Thank you.
    Ms. Scalco, I may have heard you wrong, and I skimmed your 
testimony. Was it your testimony that rapid testing is more 
expensive than standard counseling testing and results? Is that 
your testimony?
    Ms. Scalco. Rapid testing is more expensive to implement 
than doing Orasure testing and it has to do with the cost of 
the kit and the cost of the controls and the cost of the other 
supplies related to rapid testing.
    Senator Coburn. As compared to an Orasure test?
    Ms. Scalco. Yes.
    Senator Coburn. OK, which can be, in fact, done very 
easily?
    Ms. Scalco. Yes. However, with the Orasure, you have to 
wait approximately 2 weeks for results. We are very much in 
favor of rapid testing. It has given us the ability to get 
results to people much quicker and it assists with people who 
don't return for their results.
    Senator Coburn. We know many thousands of people don't come 
back every year----
    Ms. Scalco. Right.
    Senator Coburn [continuing]. Who test positive.
    Ms. Scalco. So, yes, we would like to implement more rapid 
testing.
    Senator Coburn. But you are looking at the cost of the test 
only. You are not looking at the cost of the test to identify.
    Ms. Scalco. Yes. We are looking at the costs of the actual 
test as being more expensive.
    Senator Coburn. But the cost to identify that somebody is 
HIV-positive, a rapid test is far less expensive than the 
other----
    Ms. Scalco. That is correct.
    Senator Coburn. OK. I wanted to clarify that.
    Mr. Weinstein, we have known each other for quite some 
time. You just espoused in your testimony a true public health 
approach to HIV. My thought on this as I listened to the 
testimony from CDC, 10 years ago, I tried to get the CDC to do 
testing for newborn infants. It was blocked. The American 
College of Obstetricians and Gynecologists was against it. Gary 
Ackerman and myself, bipartisan, one Democrat liberal, one 
Republican conservative, were totally blocked by the political 
forces.
    So I take what you say very seriously, but my response is, 
how do we get other people embracing public health strategies 
instead of political strategies when it comes to HIV? How do 
you help me do that?
    Mr. Weinstein. Just in the last 2 weeks, we passed historic 
legislation in California to bring about names reporting for 
the first time. It took us a long time, but we built a 
coalition and in the end, it was unanimous.
    Senator Coburn. Why did that happen?
    Mr. Weinstein. It happened, first of all, I believe 
immodestly, because groups like us were willing to stand up and 
say it was necessary. I think also, when we enacted the code 
system, it was horrible. And then lastly, the threat of losing 
Ryan White CARE Act funds. But whatever it took, it happened.
    We have a bill in the legislature now to simplify testing. 
We are talking about routine testing. Let me tell you how it 
actually works in the field today. It takes longer to do a 
routine test because of the regulations of CDC and the State of 
California than it took previously to do the other test. It 
takes 40 minutes to do a test. Now, how many people can we test 
if we do that?
    Also, in this country, if you want to get a free test in 
most places, you are required to answer a long list of intimate 
sexually explicit questions to a total stranger. If you go to a 
doctor, you don't have to do it. But if you want to do it in a 
public setting, the price you have to pay is to answer 
questions about the most intimate aspects of your life. I don't 
think that is right.
    Also, it was said earlier by the CDC that in a doctor's 
office, we are going to uncouple counseling from testing. But 
in the public setting, we are not going to do it. Well, that is 
wrong, I would say, because 80 percent of the people we test, 
and we have the largest testing program in California, are 
repeat testers. No. 1, they have the information, and No. 2, 
the last word they hear in that counseling session is 
``negative'' or ``positive.'' If a person is positive, they 
need intensive counseling not just on that occasion, but 
following it, as well, to make sure they get into care. We have 
to be practical.
    If we are actually going to test more people, we have to do 
it differently, and also, I would say, I am sure this will not 
be a surprise to you to hear, but what is enacted in Congress 
is not implemented in many cases. The reality is across this 
country that women are not informed that their husbands or 
boyfriends are infected with HIV. Most women who we treat, and 
we have a large women's program, have no known risk factor for 
HIV. I don't know how long we have been talking about it, but 
it is not happening. And I think, again, going back to your 
question about how we enacted names reporting, unless there is 
a concrete penalty for not doing it, it will never be done, and 
I think that is a terrible thing.
    Senator Coburn. Why is that? I mean, if this is a public 
health strategy we use in other areas, why is it that CDC won't 
move to a common sense public health strategy that works? I am 
not saying that they haven't made some movement. They have, and 
I compliment them on that. But I am the author of informed 
science about the effectiveness of condoms that passed this 
Congress in the year 2000 which still hasn't been implemented 
by the CDC saying people ought to know the level of protection 
they get from a condom. With HIV, it is wonderful. It is great. 
With many other diseases, it is not. But that is never a part 
of the counseling.
    The point being is how do we get to the point where we 
embrace public health strategies where we can save lives, where 
we can prevent, in fact? How do we move past the politics? In 
other words, you are out there on the activist side of this. 
Ms. Scalco is on the implementation side of it. How do we move 
to where we get policies that are efficient and effective, that 
save lives, move the ball forward, spend the money where it is 
going to give us the best return in terms of life and quality 
of life? How do we move to that? How do we build that?
    Mr. Weinstein. Well, I would argue that since we are 
fighting AIDS as a global effort, and I know there is always a 
tension between States' rights and Federal directives, but 
there are laws in California and elsewhere that prevent many of 
these things from being done, as you heard earlier. Therefore, 
I think that because you can't fight AIDS town by town and city 
by city and State by State, I think there ought to be a Federal 
standard that is enforced, at least in some of these areas.
    And I think that when it comes to partner notification, it 
shouldn't be voluntary, because if there is a group of sexually 
active people and they know that they have a risk, they are 
making that as an informed choice. But a woman who is not aware 
that her husband or a woman who is not aware that her boyfriend 
is using drugs or is bisexual is not able to make that choice. 
I think that is a societal obligation and I don't see any 
problem, really. Given the fact that the Federal Government is 
the primary funder, I don't see a problem with the Federal 
Government requiring in exchange for that funding that this be 
universal.
    Senator Coburn. If somebody is diagnosed with syphilis in 
one of your clinics, is there mandatory reporting of that?
    Mr. Weinstein. Yes.
    Senator Coburn. Is there partner notification?
    Mr. Weinstein. Ineffectively, but it is supposed to. It is 
not done effectively, but yes, there is.
    Senator Coburn. It is supposed to be, though?
    Mr. Weinstein. It is supposed to be. It is done to some 
extent, but not as fully as it should be.
    Senator Coburn. But it is supposed to be.
    Mr. Weinstein. Yes.
    Senator Coburn. And there are statutes and regulations to 
back that up.
    Mr. Weinstein. Yes.
    Senator Coburn. Would you consider HIV more deadly than 
syphilis?
    Mr. Weinstein. Oh, there is no question about that.
    Senator Coburn. So why would we not have the same policy 
for a disease that is more deadly?
    Mr. Weinstein. How I look at it is if you look back over 25 
years and you look at the ineffective Federal response, you 
look at the stigma and discrimination that was even more 
intense then but still exists now, myself and many activists 
felt that the first order of business was privacy, protection, 
and rights. I think that what the problem is, that we had a 
revolution in treatment of HIV and when the disease goes from 
being a death sentence to being a manageable illness, things 
change. When you look back historically about how we used to 
handle breast cancer, when Betty Ford and Nancy Reagan came out 
publicly about it, all of a sudden, the paradigm shifted and 
now there is public discussion and advocacy. It is totally 
transformed.
    So, I mean, it takes a while to catch up to these 
technological changes, but I think guidance needs to be given, 
again, by the Federal Government, which is the most expert. The 
Centers for Disease Control is the most expert. They know what 
works. I think they should give that guidance.
    Senator Coburn. Thank you. Ms. Scalco, you all have an EMA 
in New Orleans. Were funds transferred from that EMA to help 
you with some of the programs that you had during the midst of 
this hurricane and the things that followed thereafter and the 
disruption in care and treatment for patients?
    Ms. Scalco. Yes. We ultimately were able to transfer funds 
through contractual arrangements so that the funding could 
follow clients who had evacuated to other parts of the State.
    Senator Coburn. Is Louisiana put at a disadvantage because 
under the former formula we are using former AIDS diagnosis 
instead of HIV? Would Louisiana benefit in terms of funding 
formulas if the basis was where the disease is now and not 
where it used to be?
    Ms. Scalco. We believe that we may benefit. We believe that 
we could have benefitted if that had been instituted earlier in 
the epidemic. I think right now, we need to see where other 
States stand in terms of their HIV infections. But we 
definitely----
    Senator Coburn. We have run those numbers. You will 
benefit, I promise you.
    Ms. Scalco. Yes, we may benefit, and in actuality, we are 
serving people who are HIV infected and so we would like them 
counted in the formula distribution.
    Chairman Coburn. I have several other questions, but I am 
going to shorten our hearing because we have something on the 
floor at 4 o'clock. I want to thank you for your testimony. I 
am committed for us to getting the Ryan White CARE Act 
reauthorization. It doesn't have to be mine. It does need to 
address the public health aspects of this. It does need to 
address diagnosis, prevention, but also care and medical 
treatment of those who have it. We know this is a disease that 
can be controlled. We also know that with the early testing, we 
can markedly decrease the number of potential infections in the 
future coming from that one vector, and so it is important that 
we all figure out where we can find the most common ground and 
get this to happen before the end of this year.
    I appreciate your work, both of you, in terms of trying to 
get this done, and the others that have been here today. My 
commitment is to work to get that done.
    Thank you very much. The hearing is adjourned.
    [Whereupon, at 4:07 p.m., the Subcommittee was adjourned.]
                            A P P E N D I X

                              ----------                              

[GRAPHIC] [TIFF OMITTED] 28242.001

[GRAPHIC] [TIFF OMITTED] 28242.002

[GRAPHIC] [TIFF OMITTED] 28242.003

[GRAPHIC] [TIFF OMITTED] 28242.004

[GRAPHIC] [TIFF OMITTED] 28242.005

[GRAPHIC] [TIFF OMITTED] 28242.006

[GRAPHIC] [TIFF OMITTED] 28242.007

[GRAPHIC] [TIFF OMITTED] 28242.008

[GRAPHIC] [TIFF OMITTED] 28242.009

[GRAPHIC] [TIFF OMITTED] 28242.010

[GRAPHIC] [TIFF OMITTED] 28242.011

[GRAPHIC] [TIFF OMITTED] 28242.012

[GRAPHIC] [TIFF OMITTED] 28242.013

[GRAPHIC] [TIFF OMITTED] 28242.014

[GRAPHIC] [TIFF OMITTED] 28242.015

[GRAPHIC] [TIFF OMITTED] 28242.016

[GRAPHIC] [TIFF OMITTED] 28242.017

[GRAPHIC] [TIFF OMITTED] 28242.018

[GRAPHIC] [TIFF OMITTED] 28242.019

[GRAPHIC] [TIFF OMITTED] 28242.020

[GRAPHIC] [TIFF OMITTED] 28242.021

[GRAPHIC] [TIFF OMITTED] 28242.022

[GRAPHIC] [TIFF OMITTED] 28242.023

[GRAPHIC] [TIFF OMITTED] 28242.024

[GRAPHIC] [TIFF OMITTED] 28242.025

[GRAPHIC] [TIFF OMITTED] 28242.026

[GRAPHIC] [TIFF OMITTED] 28242.027

[GRAPHIC] [TIFF OMITTED] 28242.028

[GRAPHIC] [TIFF OMITTED] 28242.029

[GRAPHIC] [TIFF OMITTED] 28242.030

[GRAPHIC] [TIFF OMITTED] 28242.031

[GRAPHIC] [TIFF OMITTED] 28242.032

[GRAPHIC] [TIFF OMITTED] 28242.033

[GRAPHIC] [TIFF OMITTED] 28242.034

[GRAPHIC] [TIFF OMITTED] 28242.035

[GRAPHIC] [TIFF OMITTED] 28242.036

[GRAPHIC] [TIFF OMITTED] 28242.037

[GRAPHIC] [TIFF OMITTED] 28242.038

[GRAPHIC] [TIFF OMITTED] 28242.039

[GRAPHIC] [TIFF OMITTED] 28242.040

[GRAPHIC] [TIFF OMITTED] 28242.041

[GRAPHIC] [TIFF OMITTED] 28242.042

[GRAPHIC] [TIFF OMITTED] 28242.043

[GRAPHIC] [TIFF OMITTED] 28242.044

[GRAPHIC] [TIFF OMITTED] 28242.045

[GRAPHIC] [TIFF OMITTED] 28242.046

[GRAPHIC] [TIFF OMITTED] 28242.047

[GRAPHIC] [TIFF OMITTED] 28242.048

[GRAPHIC] [TIFF OMITTED] 28242.049

[GRAPHIC] [TIFF OMITTED] 28242.050

[GRAPHIC] [TIFF OMITTED] 28242.051

[GRAPHIC] [TIFF OMITTED] 28242.052

[GRAPHIC] [TIFF OMITTED] 28242.053

[GRAPHIC] [TIFF OMITTED] 28242.054

[GRAPHIC] [TIFF OMITTED] 28242.055

[GRAPHIC] [TIFF OMITTED] 28242.056

[GRAPHIC] [TIFF OMITTED] 28242.057

[GRAPHIC] [TIFF OMITTED] 28242.058

[GRAPHIC] [TIFF OMITTED] 28242.059

[GRAPHIC] [TIFF OMITTED] 28242.060

[GRAPHIC] [TIFF OMITTED] 28242.061

[GRAPHIC] [TIFF OMITTED] 28242.062

[GRAPHIC] [TIFF OMITTED] 28242.063

[GRAPHIC] [TIFF OMITTED] 28242.064

[GRAPHIC] [TIFF OMITTED] 28242.065

[GRAPHIC] [TIFF OMITTED] 28242.066

[GRAPHIC] [TIFF OMITTED] 28242.067

[GRAPHIC] [TIFF OMITTED] 28242.068

[GRAPHIC] [TIFF OMITTED] 28242.069

[GRAPHIC] [TIFF OMITTED] 28242.070

[GRAPHIC] [TIFF OMITTED] 28242.071

[GRAPHIC] [TIFF OMITTED] 28242.072

[GRAPHIC] [TIFF OMITTED] 28242.073

[GRAPHIC] [TIFF OMITTED] 28242.075

[GRAPHIC] [TIFF OMITTED] 28242.076

[GRAPHIC] [TIFF OMITTED] 28242.077

[GRAPHIC] [TIFF OMITTED] 28242.078

[GRAPHIC] [TIFF OMITTED] 28242.079

[GRAPHIC] [TIFF OMITTED] 28242.074

[GRAPHIC] [TIFF OMITTED] 28242.080

[GRAPHIC] [TIFF OMITTED] 28242.081

[GRAPHIC] [TIFF OMITTED] 28242.082

[GRAPHIC] [TIFF OMITTED] 28242.083

[GRAPHIC] [TIFF OMITTED] 28242.084

[GRAPHIC] [TIFF OMITTED] 28242.085

[GRAPHIC] [TIFF OMITTED] 28242.086

[GRAPHIC] [TIFF OMITTED] 28242.087

[GRAPHIC] [TIFF OMITTED] 28242.088

[GRAPHIC] [TIFF OMITTED] 28242.089

[GRAPHIC] [TIFF OMITTED] 28242.090

[GRAPHIC] [TIFF OMITTED] 28242.091

[GRAPHIC] [TIFF OMITTED] 28242.092

[GRAPHIC] [TIFF OMITTED] 28242.093

[GRAPHIC] [TIFF OMITTED] 28242.094

[GRAPHIC] [TIFF OMITTED] 28242.095

[GRAPHIC] [TIFF OMITTED] 28242.096

[GRAPHIC] [TIFF OMITTED] 28242.097

[GRAPHIC] [TIFF OMITTED] 28242.098

[GRAPHIC] [TIFF OMITTED] 28242.099

[GRAPHIC] [TIFF OMITTED] 28242.101

[GRAPHIC] [TIFF OMITTED] 28242.100

[GRAPHIC] [TIFF OMITTED] 28242.354

[GRAPHIC] [TIFF OMITTED] 28242.355

[GRAPHIC] [TIFF OMITTED] 28242.102

[GRAPHIC] [TIFF OMITTED] 28242.103

[GRAPHIC] [TIFF OMITTED] 28242.104

[GRAPHIC] [TIFF OMITTED] 28242.105

[GRAPHIC] [TIFF OMITTED] 28242.106

[GRAPHIC] [TIFF OMITTED] 28242.107

[GRAPHIC] [TIFF OMITTED] 28242.108

[GRAPHIC] [TIFF OMITTED] 28242.109

[GRAPHIC] [TIFF OMITTED] 28242.110

[GRAPHIC] [TIFF OMITTED] 28242.111

[GRAPHIC] [TIFF OMITTED] 28242.112

[GRAPHIC] [TIFF OMITTED] 28242.113

[GRAPHIC] [TIFF OMITTED] 28242.114

[GRAPHIC] [TIFF OMITTED] 28242.115

[GRAPHIC] [TIFF OMITTED] 28242.116

[GRAPHIC] [TIFF OMITTED] 28242.117

[GRAPHIC] [TIFF OMITTED] 28242.118

[GRAPHIC] [TIFF OMITTED] 28242.119

[GRAPHIC] [TIFF OMITTED] 28242.120

[GRAPHIC] [TIFF OMITTED] 28242.121

[GRAPHIC] [TIFF OMITTED] 28242.122

[GRAPHIC] [TIFF OMITTED] 28242.123

[GRAPHIC] [TIFF OMITTED] 28242.124

[GRAPHIC] [TIFF OMITTED] 28242.125

[GRAPHIC] [TIFF OMITTED] 28242.126

[GRAPHIC] [TIFF OMITTED] 28242.127

[GRAPHIC] [TIFF OMITTED] 28242.128

[GRAPHIC] [TIFF OMITTED] 28242.129

[GRAPHIC] [TIFF OMITTED] 28242.130

[GRAPHIC] [TIFF OMITTED] 28242.131

[GRAPHIC] [TIFF OMITTED] 28242.132

[GRAPHIC] [TIFF OMITTED] 28242.133

[GRAPHIC] [TIFF OMITTED] 28242.134

[GRAPHIC] [TIFF OMITTED] 28242.135

[GRAPHIC] [TIFF OMITTED] 28242.136

[GRAPHIC] [TIFF OMITTED] 28242.137

[GRAPHIC] [TIFF OMITTED] 28242.138

[GRAPHIC] [TIFF OMITTED] 28242.139

[GRAPHIC] [TIFF OMITTED] 28242.140

[GRAPHIC] [TIFF OMITTED] 28242.141

[GRAPHIC] [TIFF OMITTED] 28242.142

[GRAPHIC] [TIFF OMITTED] 28242.143

[GRAPHIC] [TIFF OMITTED] 28242.144

[GRAPHIC] [TIFF OMITTED] 28242.145

[GRAPHIC] [TIFF OMITTED] 28242.146

[GRAPHIC] [TIFF OMITTED] 28242.147

[GRAPHIC] [TIFF OMITTED] 28242.148

[GRAPHIC] [TIFF OMITTED] 28242.149

[GRAPHIC] [TIFF OMITTED] 28242.150

[GRAPHIC] [TIFF OMITTED] 28242.151

[GRAPHIC] [TIFF OMITTED] 28242.152

[GRAPHIC] [TIFF OMITTED] 28242.153

[GRAPHIC] [TIFF OMITTED] 28242.154

[GRAPHIC] [TIFF OMITTED] 28242.155

[GRAPHIC] [TIFF OMITTED] 28242.156

[GRAPHIC] [TIFF OMITTED] 28242.157

[GRAPHIC] [TIFF OMITTED] 28242.158

[GRAPHIC] [TIFF OMITTED] 28242.159

[GRAPHIC] [TIFF OMITTED] 28242.160

[GRAPHIC] [TIFF OMITTED] 28242.161

[GRAPHIC] [TIFF OMITTED] 28242.162

[GRAPHIC] [TIFF OMITTED] 28242.163

[GRAPHIC] [TIFF OMITTED] 28242.164

[GRAPHIC] [TIFF OMITTED] 28242.165

[GRAPHIC] [TIFF OMITTED] 28242.166

[GRAPHIC] [TIFF OMITTED] 28242.167

[GRAPHIC] [TIFF OMITTED] 28242.168

[GRAPHIC] [TIFF OMITTED] 28242.169

[GRAPHIC] [TIFF OMITTED] 28242.170

[GRAPHIC] [TIFF OMITTED] 28242.171

[GRAPHIC] [TIFF OMITTED] 28242.172

[GRAPHIC] [TIFF OMITTED] 28242.173

[GRAPHIC] [TIFF OMITTED] 28242.174

[GRAPHIC] [TIFF OMITTED] 28242.175

[GRAPHIC] [TIFF OMITTED] 28242.176

[GRAPHIC] [TIFF OMITTED] 28242.177

[GRAPHIC] [TIFF OMITTED] 28242.178

[GRAPHIC] [TIFF OMITTED] 28242.179

[GRAPHIC] [TIFF OMITTED] 28242.180

[GRAPHIC] [TIFF OMITTED] 28242.181

[GRAPHIC] [TIFF OMITTED] 28242.182

[GRAPHIC] [TIFF OMITTED] 28242.183

[GRAPHIC] [TIFF OMITTED] 28242.184

[GRAPHIC] [TIFF OMITTED] 28242.185

[GRAPHIC] [TIFF OMITTED] 28242.186

[GRAPHIC] [TIFF OMITTED] 28242.187

[GRAPHIC] [TIFF OMITTED] 28242.188

[GRAPHIC] [TIFF OMITTED] 28242.189

[GRAPHIC] [TIFF OMITTED] 28242.190

[GRAPHIC] [TIFF OMITTED] 28242.191

[GRAPHIC] [TIFF OMITTED] 28242.192

[GRAPHIC] [TIFF OMITTED] 28242.193

[GRAPHIC] [TIFF OMITTED] 28242.194

[GRAPHIC] [TIFF OMITTED] 28242.195

[GRAPHIC] [TIFF OMITTED] 28242.196

[GRAPHIC] [TIFF OMITTED] 28242.197

[GRAPHIC] [TIFF OMITTED] 28242.198

[GRAPHIC] [TIFF OMITTED] 28242.199

[GRAPHIC] [TIFF OMITTED] 28242.200

[GRAPHIC] [TIFF OMITTED] 28242.201

[GRAPHIC] [TIFF OMITTED] 28242.202

[GRAPHIC] [TIFF OMITTED] 28242.203

[GRAPHIC] [TIFF OMITTED] 28242.204

[GRAPHIC] [TIFF OMITTED] 28242.205

[GRAPHIC] [TIFF OMITTED] 28242.206

[GRAPHIC] [TIFF OMITTED] 28242.207

[GRAPHIC] [TIFF OMITTED] 28242.208

[GRAPHIC] [TIFF OMITTED] 28242.209

[GRAPHIC] [TIFF OMITTED] 28242.210

[GRAPHIC] [TIFF OMITTED] 28242.211

[GRAPHIC] [TIFF OMITTED] 28242.212

[GRAPHIC] [TIFF OMITTED] 28242.213

[GRAPHIC] [TIFF OMITTED] 28242.214

[GRAPHIC] [TIFF OMITTED] 28242.215

[GRAPHIC] [TIFF OMITTED] 28242.216

[GRAPHIC] [TIFF OMITTED] 28242.217

[GRAPHIC] [TIFF OMITTED] 28242.218

[GRAPHIC] [TIFF OMITTED] 28242.219

[GRAPHIC] [TIFF OMITTED] 28242.220

[GRAPHIC] [TIFF OMITTED] 28242.221

[GRAPHIC] [TIFF OMITTED] 28242.222

[GRAPHIC] [TIFF OMITTED] 28242.223

[GRAPHIC] [TIFF OMITTED] 28242.224

[GRAPHIC] [TIFF OMITTED] 28242.225

[GRAPHIC] [TIFF OMITTED] 28242.226

[GRAPHIC] [TIFF OMITTED] 28242.227

[GRAPHIC] [TIFF OMITTED] 28242.228

[GRAPHIC] [TIFF OMITTED] 28242.229

[GRAPHIC] [TIFF OMITTED] 28242.230

[GRAPHIC] [TIFF OMITTED] 28242.231

[GRAPHIC] [TIFF OMITTED] 28242.232

[GRAPHIC] [TIFF OMITTED] 28242.233

[GRAPHIC] [TIFF OMITTED] 28242.234

[GRAPHIC] [TIFF OMITTED] 28242.235

[GRAPHIC] [TIFF OMITTED] 28242.236

[GRAPHIC] [TIFF OMITTED] 28242.237

[GRAPHIC] [TIFF OMITTED] 28242.238

[GRAPHIC] [TIFF OMITTED] 28242.239

[GRAPHIC] [TIFF OMITTED] 28242.240

[GRAPHIC] [TIFF OMITTED] 28242.241

[GRAPHIC] [TIFF OMITTED] 28242.242

[GRAPHIC] [TIFF OMITTED] 28242.243

[GRAPHIC] [TIFF OMITTED] 28242.244

[GRAPHIC] [TIFF OMITTED] 28242.245

[GRAPHIC] [TIFF OMITTED] 28242.246

[GRAPHIC] [TIFF OMITTED] 28242.247

[GRAPHIC] [TIFF OMITTED] 28242.248

[GRAPHIC] [TIFF OMITTED] 28242.249

[GRAPHIC] [TIFF OMITTED] 28242.250

[GRAPHIC] [TIFF OMITTED] 28242.251

[GRAPHIC] [TIFF OMITTED] 28242.252

[GRAPHIC] [TIFF OMITTED] 28242.253

[GRAPHIC] [TIFF OMITTED] 28242.254

[GRAPHIC] [TIFF OMITTED] 28242.255

[GRAPHIC] [TIFF OMITTED] 28242.256

[GRAPHIC] [TIFF OMITTED] 28242.257

[GRAPHIC] [TIFF OMITTED] 28242.258

[GRAPHIC] [TIFF OMITTED] 28242.259

[GRAPHIC] [TIFF OMITTED] 28242.260

[GRAPHIC] [TIFF OMITTED] 28242.261

[GRAPHIC] [TIFF OMITTED] 28242.262

[GRAPHIC] [TIFF OMITTED] 28242.263

[GRAPHIC] [TIFF OMITTED] 28242.264

[GRAPHIC] [TIFF OMITTED] 28242.265

[GRAPHIC] [TIFF OMITTED] 28242.266

[GRAPHIC] [TIFF OMITTED] 28242.267

[GRAPHIC] [TIFF OMITTED] 28242.268

[GRAPHIC] [TIFF OMITTED] 28242.269

[GRAPHIC] [TIFF OMITTED] 28242.270

[GRAPHIC] [TIFF OMITTED] 28242.271

[GRAPHIC] [TIFF OMITTED] 28242.272

[GRAPHIC] [TIFF OMITTED] 28242.273

[GRAPHIC] [TIFF OMITTED] 28242.274

[GRAPHIC] [TIFF OMITTED] 28242.275

[GRAPHIC] [TIFF OMITTED] 28242.276

[GRAPHIC] [TIFF OMITTED] 28242.277

[GRAPHIC] [TIFF OMITTED] 28242.278

[GRAPHIC] [TIFF OMITTED] 28242.279

[GRAPHIC] [TIFF OMITTED] 28242.280

[GRAPHIC] [TIFF OMITTED] 28242.281

[GRAPHIC] [TIFF OMITTED] 28242.282

[GRAPHIC] [TIFF OMITTED] 28242.283

[GRAPHIC] [TIFF OMITTED] 28242.284

[GRAPHIC] [TIFF OMITTED] 28242.285

[GRAPHIC] [TIFF OMITTED] 28242.286

[GRAPHIC] [TIFF OMITTED] 28242.287

[GRAPHIC] [TIFF OMITTED] 28242.288

[GRAPHIC] [TIFF OMITTED] 28242.289

[GRAPHIC] [TIFF OMITTED] 28242.290

[GRAPHIC] [TIFF OMITTED] 28242.291

[GRAPHIC] [TIFF OMITTED] 28242.292

[GRAPHIC] [TIFF OMITTED] 28242.293

[GRAPHIC] [TIFF OMITTED] 28242.294

[GRAPHIC] [TIFF OMITTED] 28242.295

[GRAPHIC] [TIFF OMITTED] 28242.296

[GRAPHIC] [TIFF OMITTED] 28242.297

[GRAPHIC] [TIFF OMITTED] 28242.298

[GRAPHIC] [TIFF OMITTED] 28242.299

[GRAPHIC] [TIFF OMITTED] 28242.300

[GRAPHIC] [TIFF OMITTED] 28242.301

[GRAPHIC] [TIFF OMITTED] 28242.302

[GRAPHIC] [TIFF OMITTED] 28242.303

[GRAPHIC] [TIFF OMITTED] 28242.304

[GRAPHIC] [TIFF OMITTED] 28242.305

[GRAPHIC] [TIFF OMITTED] 28242.306

[GRAPHIC] [TIFF OMITTED] 28242.307

[GRAPHIC] [TIFF OMITTED] 28242.308

[GRAPHIC] [TIFF OMITTED] 28242.309

[GRAPHIC] [TIFF OMITTED] 28242.310

[GRAPHIC] [TIFF OMITTED] 28242.311

[GRAPHIC] [TIFF OMITTED] 28242.312

[GRAPHIC] [TIFF OMITTED] 28242.313

[GRAPHIC] [TIFF OMITTED] 28242.314

[GRAPHIC] [TIFF OMITTED] 28242.315

[GRAPHIC] [TIFF OMITTED] 28242.316

[GRAPHIC] [TIFF OMITTED] 28242.317

[GRAPHIC] [TIFF OMITTED] 28242.318

[GRAPHIC] [TIFF OMITTED] 28242.319

[GRAPHIC] [TIFF OMITTED] 28242.320

[GRAPHIC] [TIFF OMITTED] 28242.321

[GRAPHIC] [TIFF OMITTED] 28242.322

[GRAPHIC] [TIFF OMITTED] 28242.323

[GRAPHIC] [TIFF OMITTED] 28242.324

[GRAPHIC] [TIFF OMITTED] 28242.325

[GRAPHIC] [TIFF OMITTED] 28242.326

[GRAPHIC] [TIFF OMITTED] 28242.327

[GRAPHIC] [TIFF OMITTED] 28242.328

[GRAPHIC] [TIFF OMITTED] 28242.329

[GRAPHIC] [TIFF OMITTED] 28242.330

[GRAPHIC] [TIFF OMITTED] 28242.331

[GRAPHIC] [TIFF OMITTED] 28242.332

[GRAPHIC] [TIFF OMITTED] 28242.333

[GRAPHIC] [TIFF OMITTED] 28242.334

[GRAPHIC] [TIFF OMITTED] 28242.335

[GRAPHIC] [TIFF OMITTED] 28242.336

[GRAPHIC] [TIFF OMITTED] 28242.337

[GRAPHIC] [TIFF OMITTED] 28242.338

[GRAPHIC] [TIFF OMITTED] 28242.339

[GRAPHIC] [TIFF OMITTED] 28242.340

[GRAPHIC] [TIFF OMITTED] 28242.341

[GRAPHIC] [TIFF OMITTED] 28242.342

[GRAPHIC] [TIFF OMITTED] 28242.343

[GRAPHIC] [TIFF OMITTED] 28242.344

[GRAPHIC] [TIFF OMITTED] 28242.345

[GRAPHIC] [TIFF OMITTED] 28242.346

[GRAPHIC] [TIFF OMITTED] 28242.347

[GRAPHIC] [TIFF OMITTED] 28242.348

[GRAPHIC] [TIFF OMITTED] 28242.349

[GRAPHIC] [TIFF OMITTED] 28242.350

[GRAPHIC] [TIFF OMITTED] 28242.351

[GRAPHIC] [TIFF OMITTED] 28242.352

[GRAPHIC] [TIFF OMITTED] 28242.353

                                 
