[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
THE DOMESTIC EPIDEMIC IS WORSE THAN WE THOUGHT: A WAKE-UP CALL FOR HIV
PREVENTION
=======================================================================
HEARING
before the
COMMITTEE ON OVERSIGHT
AND GOVERNMENT REFORM
HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
SECOND SESSION
__________
SEPTEMBER 16, 2008
__________
Serial No. 110-215
__________
Printed for the use of the Committee on Oversight and Government Reform
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COMMITTEE ON OVERSIGHT AND GOVERNMENT REFORM
HENRY A. WAXMAN, California, Chairman
EDOLPHUS TOWNS, New York TOM DAVIS, Virginia
PAUL E. KANJORSKI, Pennsylvania DAN BURTON, Indiana
CAROLYN B. MALONEY, New York CHRISTOPHER SHAYS, Connecticut
ELIJAH E. CUMMINGS, Maryland JOHN M. McHUGH, New York
DENNIS J. KUCINICH, Ohio JOHN L. MICA, Florida
DANNY K. DAVIS, Illinois MARK E. SOUDER, Indiana
JOHN F. TIERNEY, Massachusetts TODD RUSSELL PLATTS, Pennsylvania
WM. LACY CLAY, Missouri CHRIS CANNON, Utah
DIANE E. WATSON, California JOHN J. DUNCAN, Jr., Tennessee
STEPHEN F. LYNCH, Massachusetts MICHAEL R. TURNER, Ohio
BRIAN HIGGINS, New York DARRELL E. ISSA, California
JOHN A. YARMUTH, Kentucky KENNY MARCHANT, Texas
BRUCE L. BRALEY, Iowa LYNN A. WESTMORELAND, Georgia
ELEANOR HOLMES NORTON, District of PATRICK T. McHENRY, North Carolina
Columbia VIRGINIA FOXX, North Carolina
BETTY McCOLLUM, Minnesota BRIAN P. BILBRAY, California
JIM COOPER, Tennessee BILL SALI, Idaho
CHRIS VAN HOLLEN, Maryland JIM JORDAN, Ohio
PAUL W. HODES, New Hampshire
CHRISTOPHER S. MURPHY, Connecticut
JOHN P. SARBANES, Maryland
PETER WELCH, Vermont
JACKIE SPEIER, California
Phil Barnett, Staff Director
Earley Green, Chief Clerk
Lawrence Halloran, Minority Staff Director
C O N T E N T S
----------
Page
Hearing held on September 16, 2008............................... 1
Statement of:
Gerberding, Julie, Director, Centers for Disease Control and
Prevention, accompanied by Kevin Fenton, Director, National
Center for HIV/AIDS, Viral Hepatitis, STD and TB
Prevention, Centers for Disease Control and Prevention; and
Anthony S. Fauci, Director, National Institute of Allergy
and Infectious Disease, National Institutes of Health,
accompanied by Thomas Insel, Director, National Institute
for Mental Health, National Institutes of Health........... 14
Fauci, Anthony S......................................... 36
Gerberding, Julie........................................ 14
Holtgrave, David, Ph.D., professor and chair, Department of
Health, Behavior and Society, Johns Hopkins Bloomberg
School of Public Health; Adaora A. Adimora, M.D., Division
of Infectious Diseases, University of North Carolina School
of Medicine; George Ayala, Psy.D., research health analyst,
RTI International and AIDS Project Los Angeles; Heather
Hauck, director, AIDS Administration, Maryland Department
of Health and Mental Hygiene; and Frank Oldham, Jr.,
president, National Association of People with AIDS........ 89
Adimora, Adaora A., M.D.................................. 111
Ayala, George, Psy.D..................................... 127
Hauck, Heather........................................... 138
Holtgrave, David, Ph.D................................... 89
Oldham, Frank, Jr........................................ 155
Letters, statements, etc., submitted for the record by:
Adimora, Adaora A., M.D., Division of Infectious Diseases,
University of North Carolina School of Medicine, prepared
statement of............................................... 113
Ayala, George, Psy.D., research health analyst, RTI
International and AIDS Project Los Angeles, prepared
statement of............................................... 129
Davis, Hon. Tom, a Representative in Congress from the State
of Virginia, prepared statement of......................... 11
Fauci, Anthony S., Director, National Institute of Allergy
and Infectious Disease, National Institutes of Health,
prepared statement of...................................... 39
Gerberding, Julie, Director, Centers for Disease Control and
Prevention, prepared statement of.......................... 17
Hauck, Heather, director, AIDS Administration, Maryland
Department of Health and Mental Hygiene, prepared statement
of......................................................... 140
Holtgrave, David, Ph.D., professor and chair, Department of
Health, Behavior and Society, Johns Hopkins Bloomberg
School of Public Health, prepared statement of............. 92
Oldham, Frank, Jr., president, National Association of People
with AIDS, prepared statement of........................... 157
Waxman, Chairman Henry A., a Representative in Congress from
the State of California:...................................
HIV epidemic profile......................................... 79
Prepared statement of........................................ 4
THE DOMESTIC EPIDEMIC IS WORSE THAN WE THOUGHT: A WAKE-UP CALL FOR HIV
PREVENTION
----------
TUESDAY, SEPTEMBER 16, 2008
House of Representatives,
Committee on Oversight and Government Reform,
Washington, DC.
The committee met, pursuant to notice, at 10:08 a.m., in
room 2154, Rayburn House Office Building, Hon. Henry A. Waxman
(chairman of the committee) presiding.
Present: Representatives Waxman, Kucinich, Tierney, Watson,
McCollum, Sarbanes, Speier, Davis of Virginia, Shays, and
Turner.
Also present: Representative Waters.
Staff present: Caren Auchman and Ella Hoffman, press
assistants; Jen Berenholz, deputy clerk; Zhongrui ``JR'' Deng,
chief information officer; Miriam Edelman and Mitch Smiley,
special assistants; Earley Green, chief clerk; Karen Lightfoot,
communications director and senior policy advisor; Karen
Nelson, health policy director; Leneal Scott, information
systems manager; Naomi Seiler and Tim Westmoreland, counsels;
Lawrence Halloran, minority staff director; Jennifer Safavian,
minority chief counsel for oversight and investigations; Ellen
Brown, minority legislative director and senior policy counsel;
Jill Schmalz, minority counsel; Molly Boyl and Adam Fromm,
minority professional staff members; and Brian McNicoll,
minority communications director.
Chairman Waxman. The committee will come to order.
We are here today to discuss some alarming developments in
the fight against HIV and AIDS in the United States.
The Centers for Disease Control and Prevention recently
announced that the HIV epidemic in the United States is growing
at a rate far greater than was previously thought. The new
figures are a stark reminder that the HIV epidemic is far from
over, and that we must take new and urgent steps to strengthen
our national HIV prevention efforts.
The first cases of what later came to be identified as AIDS
were reported in Los Angeles in 1981. Over the next 2 years,
the case reports accumulated, and we learned that a distinct
syndrome was being diagnosed in different populations all
across the country. By the mid-1980's, there were an estimated
130,000 new infections every year in the United States.
As infections increased, so did our investment in HIV
prevention efforts. Even before the virus called HIV was
identified as the cause of AIDS, CDC experts had figured out
the transmission routes and issued early recommendations for
the prevention of infection. The Federal Government started
investing significant amounts of funding in prevention and
education efforts nationwide.
These investments paid off, and the infection rate dropped
dramatically, but this is a job that is never done. This was
recently demonstrated in dramatic fashion when CDC reported
that the real infection rate is much higher than we thought.
Over the past 10 years, CDC's official estimate for annual new
infections have been about 40,000, but last month CDC announced
that, in fact, there were over 56,000 new HIV infections in
2006. The higher figure was due to improved counting methods,
not to an actual jump in infections, but it tells us that the
epidemic in the United States is and has been growing faster
than we had thought.
The message these new findings send is clear: We are not
doing enough to limit the spread of this deadly disease.
What is more, we are still seeing severe disparities in
HIV's impact on different populations. Men who have sex with
men constitute 57 percent of new infections. Blacks, who make
up about 12 percent of the total population, account for 45
percent of new HIV infections. Hispanics are also
disproportionately affected.
Part of the problem is that the Federal Government has not
been doing enough for HIV prevention in the United States. In
adjusted dollars, the CDC's HIV prevention budget has dropped
more than 20 percent since 2002. This year the administration
actually asked for a $1 million decrease in HIV funds. This
didn't make sense to me, so I asked the Centers for Disease
Control to prepare a budget that reflects not what the White
House wanted, but rather the agency's professional scientific
judgment of what it would take to fully implement effective HIV
prevention in the United States.
As we will hear today, the administration asked for less
than half of what CDC's scientific professionals estimate is
necessary for effective HIV prevention. Instead of listening to
its own experts, the administration requested that Congress
fund HIV prevention programs at far lower levels.
What is even more senseless is that by underfunding
prevention, the Nation will incur greater treatment costs down
the road. It is indisputable that evidence-based HIV prevention
saves money in addition to saving lives by avoiding the high
cost of medical care and lost productivity. But on this issue
the administration apparently prefers to be penny wise and
pound foolish.
We are here today to learn from some of our Nation's top
HIV prevention experts what a truly robust national HIV
prevention program would look like. We will hear from leaders
at CDC and NIH about how they are attempting to roll out
effective programs and research potential new ones. We will
discuss barriers to evidence-based HIV prevention, like the
Federal needle exchange ban and this administration's stubborn
and irrational focus on abstinence-only programs. And because
HIV infections don't occur in a vacuum, we will hear
recommendations from all of our witnesses on how the Federal
HIV prevention response should address the societal factors
that contribute to risk, including poverty, homelessness,
racial and gender inequality, homophobia, and stigma related to
HIV status.
I look forward to a constructive discussion of these
questions today, but one point should be clear from the outset:
The status quo simply isn't acceptable. We undermine public
health, betray some of America's most vulnerable citizens, and
allow the further spread of a deadly and still incurable
disease by failing to invest in proven prevention methods. We
aren't doing everything we can and should, and I hope this
hearing will be the first step in returning the necessary
spotlight, resources, and political will to HIV prevention
efforts in the United States.
[The prepared statement of Chairman Henry A. Waxman
follows:]
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Chairman Waxman. Before recognizing our very distinguished
panel of witnesses, I want to recognize the gentleman from Ohio
Mr. Turner for an opening statement.
Mr. Turner. Thank you, Mr. Chairman. Thank you for holding
this hearing to examine new data on the incidence of HIV
infection on the United States. We appreciate your longstanding
dedication to public health issues and your abiding commitment
to meet the many challenges posed by the AIDS epidemic.
Using a more sensitive surveillance tool, the Centers for
Disease Control found 56,300 new HIV infections in 2006. That
is a 40 percent higher incidence than previous estimates. The
upward adjustment does not reflect an acceleration of the
epidemic, but a more precise capability to establish between
recent and longer-term infections. So it still appears the
epidemic has, in fact, plateaued in terms of new infections per
year over the last decade, but at a markedly higher rate than
we thought.
With this new knowledge about the path and the scope of the
epidemic, public health officials can better target efforts to
prevent the spread of the virus that causes AIDS. How to bring
those prevention tools to at-risk groups has always been a
challenge at every level. This more accurate data should inject
a renewed sense of urgency into the Federal, State, local, and
private-sector partnerships working to stop the spread of HIV.
But behind the figures lurks one deadly fact: No prevention
strategy works on a person who doesn't know he or she is
infected.
At any given time, it is estimated fully 25 percent of
Americans carrying HIV have not been diagnosed. They are far
more likely to engage in high-risk behaviors that expose still
others to the silent infection. Breaking that silence, research
has proven, the power of information is a barrier against the
virus.
Once diagnosed and properly counseled, HIV-infected
individuals are significantly less likely to engage in
behaviors that put others at risk. That leaves public health
officials to confront the hard questions: Who should be offered
testing? How often? And who pays for any broader HIV screening
that might detect latent or unknown infections?
HIV/AIDS is not curable, but it is treatable. With the
tools at our disposal, we need not consign thousands of our
fellow citizens each year to the devastation of preventable HIV
infection.
Since its outbreak, the United States has played a leading
role in research and treatment of HIV and AIDS. One of the
witnesses today, Anthony Fauci, is a recognized leader in
unlocking the lethal mechanisms by which the virus attacks the
immune system.
This is an important hearing about the implications of this
new CDC data for public health officials and public
policymakers. Mr. Chairman, I appreciate your attention to this
issue.
Chairman Waxman. Thank you very much, Mr. Turner.
[The prepared statement of Hon. Tom Davis follows:]
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Chairman Waxman. For our first panel, we are pleased to
have Dr. Julie Gerberding, who has been the Director of the
Centers for Disease Control and Prevention since 2002. In this
role she has led the CDC in its mission of health promotion and
disease prevention in the United States and abroad.
Dr. Gerberding has contributed to numerous peer-reviewed
publications and textbook chapters, and to guidelines and
policies on a range of health issues, including HIV prevention.
She has served on Federal and non-Federal advisory councils,
including the CDC's HIV Advisory Committee, and teaches
infectious disease medicine at both Emory University and the
University of California at San Francisco.
We want to welcome you back to the committee, Dr.
Gerberding, and we are pleased that you are here, coming right
from Texas where you have been trying to deal with the tragic
consequences of the hurricane.
Dr. Gerberding is accompanied by Dr. Kevin Fenton, who,
since 2005, has served as the Director of CDC's National Center
for HIV/AIDS, Viral Hepatitis, STD and TB Prevention. He leads
the U.S. Government's HIV surveillance and prevention efforts,
interacting with State and local agencies, community
organizations and researchers nationwide. Dr. Fenton has worked
in HIV research, epidemiology and prevention since 1995,
including as Director of the HIV and Sexually Transmitted
Infections Department at the United Kingdom's Health Protection
Agency.
Dr. Anthony S. Fauci has served as the Director of the
National Institute of Allergy and Infectious Diseases at the
National Institutes of Health since 1984. He oversees a broad
range of research on the prevention, diagnosis, and treatment
of infectious diseases, including HIV/AIDS. He continues to
conduct his own research on immune-mediated and infectious
disease, and has contributed to over 1,000 scientific
publications.
Dr. Fauci served as one of the key advisors to the White
House and the Department of Health and Human Services on AIDS
issues, and is a member of The National Academy of Sciences,
the American Academy of Arts and Sciences, and the Institute of
Medicine. Dr. Fauci has testified on numerous occasions before
this committee and other committees that I chaired in the
Congress since the early 1980's.
And we are happy to have you here as well.
Dr. Fauci is accompanied by Dr. Thomas Insel, the Director
of the National Institute for Mental Health at NIH. In that
role Dr. Insel oversees the agency's research on behavioral
prevention methods for HIV.
We are pleased that all of you are here today. It is the
practice of this committee that all witnesses who testify
before us do so under oath. So if you would please rise and
raise your right hands.
[Witnesses sworn.]
Chairman Waxman. Your prepared statements will be in the
record in full. We would like to ask each of you to make your
oral presentation in around 5 minutes. We will have a clock
that will allow you to see when the 5 minutes is up. It will be
green for 4 minutes, yellow for 1 minute, red when the 5
minutes has passed. And we won't be strict on it, but we would
like that to be a guide, so that when you see the red light,
since we have many witnesses yet to come, we would like to ask
you to try to reach your conclusion so that we can ask
questions and hear from the other witnesses as well.
Dr. Gerberding, we are pleased to have you.
STATEMENTS OF JULIE GERBERDING, DIRECTOR, CENTERS FOR DISEASE
CONTROL AND PREVENTION, ACCOMPANIED BY KEVIN FENTON, DIRECTOR,
NATIONAL CENTER FOR HIV/AIDS, VIRAL HEPATITIS, STD AND TB
PREVENTION, CENTERS FOR DISEASE CONTROL AND PREVENTION; AND
ANTHONY S. FAUCI, DIRECTOR, NATIONAL INSTITUTE OF ALLERGY AND
INFECTIOUS DISEASE, NATIONAL INSTITUTES OF HEALTH, ACCOMPANIED
BY THOMAS INSEL, DIRECTOR, NATIONAL INSTITUTE FOR MENTAL
HEALTH, NATIONAL INSTITUTES OF HEALTH
STATEMENT OF JULIE GERBERDING
Dr. Gerberding. Thank you very much.
I would like to start with my first slide, which is a
reflection on Ike striking in Galveston. I did visit the
hurricane territory yesterday, and for the record I would like
to acknowledge the tremendous effort of State health
commissioner Dr. Lehi and the whole pantheon of experts in
public health across the State that are performing miracles.
I think we all recognize that hurricanes represent urgent
public health threats, and when people recognize an urgent
threat, they hold nothing back in responding to it.
Unfortunately, on the next slide we have another urgency, and
that is the urgent reality of HIV/AIDS in America. Last month I
spent 2 weeks at San Francisco General Hospital taking care of
patients, and on my service I had two undiagnosed AIDS patients
die; I had several individuals come in with the opportunistic
infections that we started seeing in 1981 when I was an intern.
And in that community, we learned that there is an epicenter of
HIV transmission among men who have sex with men, and
particularly among African Americans.
Similarly, I visited Oakland earlier this year, and found
to my astonishment--and found an even grimmer situation in
terms of HIV transmission in that community.
On my next graphic I tried to represent the progress that
we have made despite these current situations. And we are
currently proposing federally a $24.1 billion HIV budget for
all AIDS-related activities at the Federal level. Of that, 4
percent is reflected in CDC's prevention budget. And I think
over time we have had some good news. We are definitely seeing
people live longer with HIV, and many are thriving despite the
complications of the drug treatment and everything else that
having a chronic illness represents.
In addition, we have made tremendous progress in perinatal
AIDS, in reducing the incidence among injection drug users and
among heterosexuals at high risk.
We have also seen the rate of transmission decline over
time. That means for every 100 HIV-infected individuals, the
number of new people that they infect has continued to drop
precipitously since the early phases of the epidemic.
And, finally, I think studies do show that prevention
interventions can work. We have evidence of efficacy in at
least 49 behavioral interventions, and several others are on
the docket for coming forward.
Let me just quickly show you the pictures of what these
statistics look like. The red line here is the number of people
in America living with HIV, and the blue line are the number of
new cases that were reported that precipitated this hearing.
And you can see that although the number of people with HIV in
our country continues to increase, the number of new infections
is holding steady over the past several years and declining as
the large picture in the United States; meaning that our
interventions are successful, or we would see that blue line go
up commensurate with the red line.
On the next graphic, you can see the picture of perinatal
transmission, again, evidence that prevention can work.
On the next graphic, the picture of what is happening
recently among people at high-risk heterosexual contact. And I
could repeat that for injection drug users and others.
But on the next graphic we have the sobering statistic that
is my frame for the urgent reality that we are facing, and this
is the incidence rates going up among men who have sex with men
in the United States.
On the next graphic I show some statistics that were
released last week which really reflect a detailed
understanding of the epidemiology of this risk, showing that
while overall the majority of men who have sex with men and get
HIV infection are White, there is disproportionate
representation of African Americans, and particularly young
African Americans and Hispanics. They are represented here way
out of proportion to their prevalence in society.
And on the next graphic we have the rates of HIV infection
which use as the denominator the number of people in our
society in those categories. So you can see that African
Americans have an infection rates that is about seven times
that of Whites, and Hispanics have a rate that is about three
times that of Whites across America.
So this is very serious information, and it tells us where
we need to target our prevention interventions.
So let me conclude by telling you what I think are the
priorities for those prevention interventions. We have
submitted a long professional judgment. We have tried to put
everything in there we could think of. We understand the
reality of the budget, but we wanted you to know what the
universe of possibility might be. So on the first slide, I am
trying to summarize some of those interventions that relate to
finding the leading edge of the epidemic.
The information we just published is the first time we have
ever been able to say in real terms, where is the infection
now, and how bad is it going, and who is getting it? So we need
to expand our ability to do that so that we have that
information at the community level and can target those
interventions that do work for those individuals.
We also need to integrate services. It is great that we
have representatives from mental health, substance abuse, and a
broad continuum, because there is a syndemic of these factors
that come together in the concept of social justice and in
social determinants of health that we have to address if we are
going to be successful here. And we need to conduct not just
individual interventions, but social marketing campaigns.
On the next graphic I am emphasizing the importance of
finding the people who are infected. This is Epidemiology 101,
but it is something that we still haven't been able to do
successfully in this disease. Twenty-five percent of infected
people still don't know they have the virus. So we need to
expand access to rapid testing. And, in particular, our Federal
facilities need to move to support the CDC guidelines and allow
screening for HIV, using the protocols that we have recommended
for the routine screening. We also need to have better tests,
and we need to focus those tests on finding people early,
hopefully as they are seroconverting, because that is the time
when they pose the biggest transmission risk, and we are
missing them, and they are highly infectious, and they account
for a disproportionate part of the epidemic.
Now, my last graphic, I mentioned those aspects that relate
to the need for new tools. We don't have all the answers here.
I wish we did. We have been working on it, but our research
budget hasn't really allowed us to update and modernize our
toolkit.
One area in particular, given the difficulties we are
having with the vaccine, are the preexposure treatment trials
to determine whether or not taking HIV drugs before you are
exposed could result in an overall health benefit and a reduced
risk of infection. CDC is conducting three of those studies and
are collaborating on a fourth, and I know NIH is doing one,
too, as well. So we are hoping that could put a new biomedical
toolkit or two in our toolbox while we are working on some of
these other measures that we think are important.
I just want to make one final point here. AIDS is a social
disease as much as it is a viral disease, and part of bringing
people to accept prevention is to create that expectation in an
environment of hope. Many of the people who are getting this
infection now are functioning in a society that offers them
very little hope for education, economic, or social attainment,
and if we don't address the underpinnings of the problem, we
are never going to be able to get where we need to be as a
Nation.
So thank you for allowing me to explode with a lot of
information in a very short period of time. But we are very,
very passionate about this and very committed to this issue.
Chairman Waxman. Thank you. It is very helpful information.
[The prepared statement of Dr. Gerberding follows:]
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Chairman Waxman. Dr. Fenton, you are just here to answer
questions?
Dr. Fenton. That is right.
Chairman Waxman. Well, we will have questions for you.
Dr. Fauci.
STATEMENT OF ANTHONY S. FAUCI
Dr. Fauci. Thank you, Mr. Chairman and members of the
committee. Thank you for giving me the opportunity to testify
before you here today on the role of the NIH research endeavor
in HIV prevention, the subject of this hearing. I guess the
slides don't work, so we will go with the--are they up? OK.
There they are.
OK. On the first slide shown on the board there, I want to
just emphasize that since the very early days of HIV that you
described in your opening statement, in the summer of 1981,
there have been some spectacular advances in AIDS research
ranging from the initial discovery of the virus to the
delineation of the pathogenesis, natural history, but,
importantly, treatment.
Now, treatment has been one of the more spectacular
successes in the development of now over 25 drugs that have
transformed the lives of HIV-infected individuals. The results
of this have been quite impressive.
On the next slide is a review paper showing the results of
the first decade of HIV written up in the Journal of Infectious
Diseases that there is a conservative estimate of about 3
million lives--years of life have been saved in the United
States alone from 1996 through 2005 on the basis of the
accessibility of treatment, particularly the combinations of
therapies. This has been repeated and verified in Europe,
Australia, and Canada.
Now, that is the very good news. But the subject of the
hearing is what is still going on? So on the next slide, just
to reiterate what Dr. Gerberding had said, we still have a
major ongoing problem globally and even here in the United
States with over one-half million deaths, 1.1 million people
infected with HIV, and, as underscored by Dr. Gerberding, 25
percent of them are unaware that they are infected. And we know
the majority of infections come from an individual who does not
know that he or she is infected, transmitted to another
individual.
And an example is something that is very close to home. We
make rounds three times a week at our clinic, up at the
clinical center at the NIH, and just last week a patient was
presented to me, a resident of the District of Columbia, 38
years old, who presented for the first time with advanced
tuberculosis, central nervous system lymphoma, and CB4 count of
3, which is about as low as you can get in a viral load. That
person clearly was infected for many years, has now compromised
his own ability to be treated because he is so advanced, and
who knows how many people that person exposed, mainly because
he did not know that he was infected.
Now, on the next slide, what about prevention? The NIH and
its multiple institutes, particularly our institute, NIAID,
NIMH, NIDA, Child Health, and others, have been heavily
involved in prevention research. And when I say prevention
research, it's to try and get some of the scientific facts that
would help inform some of the activities that are implemented
so well by the CDC.
On this slide we show that if you include vaccine,
behavioral change, and microbicides, about 38 percent of the
NIH budget is devoted to prevention activities. And I just want
to spend a minute to underscore some of the proven strategies
as well as those that are still investigational and for which
we have remaining challenges on the next slide.
Proven HIV prevention strategies again underscores what Dr.
Gerberding mentioned, that prevention does work when it is
applied and implemented. For example, preventing sexually
transmitted disease, cognitive behavior interventions when
applied have been shown to work. Behavioral changes regarding
sexual transmission are paramount in its prevention. Condom
promotion. In a study, a group of studies that were sponsored
by the NIH just a year and a half ago on adult male
circumcision in an international basis, predominantly in sub-
Saharan Africa, showed anywhere from a 55 to 65 percent
prevention in males who were circumcised that lasted for 3 to 4
years of followup and likely much more.
The prevention of blood-borne transmission. Clearly needle
exchange programs work. There is no doubt about that. Drug
treatment programs, methadone and related programs have been
shown in a number of studies by the CDC and by NIDA and NIH to
work.
And probably the most dramatic success story is the
prevention of mother-to-child transmission, by treating the
mother during pregnancy and the baby soon after delivery, and
most recent studies, weeks to months of breast feeding have
been truly a great success story.
The next slide.
There are also some investigational prevention strategies,
some of which are in the process of being proven, others that
are still challenging. The first is the prevention and
treatment of coinfections, such as tuberculosis, malaria, and
other sexually transmitted diseases. Not all STDs, or sexually
transmitted diseases, when you treat them result in a decrease
in HIV transmission, but some do. And we are now continuing our
studies to try and delineate that a little bit more clearly.
We have been challenged by topical microbicide studies. The
initial studies over the past several years have proven not to
be effective. They were the first generation of studies that
did not incorporate specific anti-HIV drugs; they were merely
chemicals that would block transmission, but not in a specific
anti-HIV manner. The products that are currently in the
pipeline we are cautiously optimistic about.
The last two I want to close on is antiretrovirals as
prevention and vaccines. By an antiretroviral as prevention, we
mean that if you treat people who are infected, you could
theoretically and in reality decrease their ability to transmit
to others. You can talk about population studies; if you treat
enough people in a population, you will get the mean viral load
in the population low enough that you might decrease the
incidence; but even more potentially exciting is what we call
PrEP, and Dr. Gerberding mentioned that on one of her slides,
or preexposure prophylaxis. There is a large study conducted by
the CDC, several other studies, some of which are conducted by
the NIH, looking at a large number of individuals to see if, in
fact, this treatment prior to infection would significantly
block transmission.
And then there is vaccines, which in the history of viral
diseases are generally the Holy Grail of how you stop the
transmission of a viral infection. We have not been successful
thus far. As shown on this slide, at the last meeting this
summer in Mexico city of the International AIDS Society, we
discussed some of the remaining challenges and the reality that
we will not have an HIV vaccine at least for several years at
best. I am cautiously optimistic that we will, but up until the
time that we do, we are going to be left with the prevention
measures that were discussed by Dr. Gerberding and myself and
in your own opening statement, Mr. Chairman.
So in the last slide, I want to emphasize that point; that
when we talk about prevention, it is not unidimensional, and it
is not one-size-fits-all. We refer to it as a comprehensive
prevention toolbox, of which a vaccine would be a major
contribution. But even if we get a vaccine that is effective,
we would still have to rely very heavily on the other
prevention measures that have been discussed in our various
statements.
So I will close here, Mr. Chairman, and be happy to answer
any questions.
Chairman Waxman. Thank you very much, Dr. Fauci.
[The prepared statement of Dr. Fauci follows:]
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Chairman Waxman. Dr. Insel, do you have a statement?
Dr. Insel. No statement, just to go on to questions.
Chairman Waxman. OK. I want to start off the questions for
you, Dr. Gerberding. I want to ask about CDC's HIV prevention
goals and its budget.
In January 2001, and I understand this was before your
tenure as Director, CDC released a document called HIV
Prevention Strategic Plan Through 2005. At the time, the
working estimate of annual new infections per year in the
United States was 40,000. The agency called this number
relatively stable, but unacceptably high, and stated that a new
strategic plan for HIV prevention was essential.
In this 2001 document, what was CDC's target for reducing
annual new HIV infections?
Dr. Gerberding. I would want to let you know that although
I was not the CDC Director during this period of time, I was on
an advisory committee before I went to the Center, before I
went to CDC, so I participated in the earliest phases of that
development. And the expectation optimistically at that time
was a 50 percent reduction in the number of new infections, to
be able to drive the infection rate down to 20,000. At that
time we didn't have a lot of evidence to model or base those
figures on, but we believed that if we did everything we knew
how to do, we could strive for that. It made sense to create a
stretch goal, and obviously we didn't make it.
Chairman Waxman. Because if we look at 2005, fast forward 5
years later, CDC's estimate of annual new infections at that
point was still 40,000 a year, and the figure hadn't budged.
Why do you think that nothing changed? Was it--what is your
assessment?
Dr. Gerberding. I think it is complicated, but there are
two factors that probably play a pretty big role. One is the
fact that our earlier estimates were made before we recognized
the benefits of drug treatment. And so what happened was we
suddenly had a larger and larger and larger number of people in
our country with HIV who presented a transmission risk to other
people because they were surviving instead of dying from the
disease. So it was a positive factor, but it clearly made our
earlier estimates fairly irrelevant.
The second thing is that I don't think we adequately
controlled for the generational effect. So as new young people
come into the risk environment, they don't behave--kids are not
little adults. They don't behave the way we would expect more
mature people who have lived through their friends dying to
behave. And so we saw increased infection rates, as we are
still seeing today, among the youngest people. So our estimates
did not adequately adjust for the generational problem of new
cohorts at risk.
Chairman Waxman. When we look at the CDC budget in 2001,
there was a steady growth in the prevention part. And by that
time, in 2007, CDC's HIV prevention budget actually dropped in
adjusted dollars by 20 percent. So while we didn't see the
decrease we had hoped for, we saw, in fact, a steady level,
which would be that--a failure of the prevention efforts to
succeed.
At that point, CDC put a document forward extending its HIV
prevention through 2010. And what was the goal in that
document, if you can tell us?
Dr. Gerberding. I would have to go back and review that
particular estimate.
Kevin, maybe you can answer that question.
Dr. Fenton. Thank you very much for that question.
In the 2007 revision of the HIV prevention strategy, what
we were attempting to do is to identify shorter-term goals for
HIV prevention as well as looking at goals which were
achievable within the resources that we had at CDC. One of the
experiences we had from 2001 to 2007, as you mentioned, was the
fact that our budget remained relatively flat over that time,
so it was crucially important that we looked at what was
achievable in the next 3 years. In the meantime----
Chairman Waxman. And the numbers that you found that you
thought was achievable was, rather than 50 percent, down to 10
percent; Is that right?
Dr. Fenton. That is correct.
Chairman Waxman. And was that 10 percent goal modeled on
the fact that you saw a decrease in the prevention side of the
HIV budget?
Dr. Fenton. It was modeled on the realities of the existing
prevention budget as well as the availability of better
information, better surveillance information, better data on
incidence which we knew were forthcoming in the next few years.
Chairman Waxman. And how much did the administration
request for HIV prevention for this next fiscal year, 2009?
Dr. Gerberding. The request in the proposed budget is less
than the request from last year by a percent or so. So it is a
reduction.
Chairman Waxman. As I understand, that is $752.6 million?
Dr. Gerberding. I believe that is correct.
Chairman Waxman. Now, according to your professional
judgment budget, the funding that CDC needs to conduct
appropriately scaled-up domestic HIV prevention programs and
research for 2009, I understand, is $1.63 billion; is that
right?
Dr. Gerberding. If we were able to walk out the door today
and do absolutely everything that we knew how to do to full
scale, it would be expensive, and those numbers reflect that
kind of best-case scenario. I think we also recognize we
couldn't go from where we are to where we would like to be as
fast as we probably reflected in our budget estimates, but we
wanted to give you the flavor that the scale here is one
challenge. The ``what to do'' is the other challenge.
Chairman Waxman. Well, and just to look at where we are and
where you would like us to be and where do you think the money
could wisely be spent, the administration is proposing half of
what CDC's experts say is necessary. And, in fact, that is an
actual decrease of $1 million from fiscal year 2008. So the
proportion, it appears to us, for domestic HIV funding for
prevention would be around 5 percent.
Dr. Gerberding. I think the figure for the large request
for domestic HIV, the $24.1 billion overall that has been
requested includes about a 4 percent prevention budget, at
least according to the analysis that we have been able to
review from Kaiser. So it is a very small piece of the overall
budget. And I think the concept of a dime of prevention is
worth a dollar of cure is what we need to relook at, especially
now that we have these new incidence data. In addition, we know
that it is cost-saving to prevent HIV because it is so
expensive to treat.
Chairman Waxman. You are telling us that information. Did
you tell the President? Did you tell the Secretary of HHS? Did
anyone in the administration ever come and ask you over the
last 6 years what you and your expert colleagues believed and
what you would need in order to turn the domestic epidemic
around?
Dr. Gerberding. We have had a lot of briefings on this
subject. And I think one of the challenges that I face at CDC
is my own expert judgment, that it isn't going to be enough to
just do more of the same. We have to really step back and say,
you know what? If you keep doing the same thing over and over
again, it doesn't matter how big you do it, you are not really
going to solve the problem.
So not only do we need to expand what we know can work, we
have to find new things. And so I really want to emphasize that
the research for new tools is also a very, very big part of
this. And I am sure that Dr. Fauci would agree with that, that
there is more we need to know and not just more that we need to
do.
Chairman Waxman. Well, just to conclude my questioning
here, you can't do more of the same with less money, even if
some of the same things you were doing were successful.
Dr. Gerberding. Unless you are a magician.
Chairman Waxman. And if you could get new tools, that would
be great. But you may not be able to even do the new tools if
your prevention budget is decreasing and the population of
people being infected is even more than we expected.
Dr. Gerberding. What I am really also--and what I have
asked Dr. Fenton to do is to look at whatever the pie is,
whatever the investment that we have, and make absolutely sure
that whatever we are doing with it, we are getting the absolute
maximum out of it that we can. We may need to rebalance. We
would like to have more, but we may need to also rebalance what
we are doing to make sure that it is making the biggest
difference.
Chairman Waxman. Thank you very much.
Mr. Davis.
Mr. Davis of Virginia. Of course, Congress appropriates the
money, not the administration. So this Congress has the
authority to move those numbers up or down appropriately, don't
they?
Dr. Gerberding. That is correct.
Mr. Davis of Virginia. OK. And are we spending more
internationally on AIDS prevention and treatment than we are
nationally now?
Dr. Gerberding. We are spending more internationally for
the President's emergency program as well as the global fund.
Mr. Davis of Virginia. So basically we have seen more
funding for AIDS and HIV prevention and treatment, but it is
going internationally instead of----
Dr. Gerberding. May I just qualify that for a statement?
Mr. Davis of Virginia. Please.
Dr. Gerberding. Because as I said, our total Federal budget
for HIV is $24-some billion a year because of the mass
investment that we make in treatment naturally. So we are not
spending $24 billion internationally a year.
Mr. Davis of Virginia. Now, a full 25 percent of
individuals with HIV, I think, are unaware of their infection,
and these individuals account for about 50 percent of new
infections?
Dr. Gerberding. It is about--it is probably close to 50
percent. We know that once people find out what--I think it is
actually 58 percent. The undiagnosed people are accounting for
about 60 percent of the infections that we are seeing. But we
are also learning more recently that probably early infection
is a special subset of that group. And so people who are newly
infected don't recognize it, aren't getting tested as they
develop the systems of the conversion illness, are highly
infectious with great----
Mr. Davis of Virginia. How long does it take after the
contact that you're infected and can pass it on? Is it a matter
of hours? Days?
Dr. Gerberding. It is not hours, but it happens faster than
we realize now that we have more and more sensitive tests. So
although the antibody test may not become positive for many
days, the virus is replicating very early on after exposure.
And that is why people can transmit even though they don't know
they have it.
Mr. Davis of Virginia. I recently spent about 10 days in
Africa touring some of our facilities that were there on AIDS
prevention. One of the problems there is the people that have
it now are getting medical care, they are keeping mothers from
passing it to their kids, they are able to live seminormal
lives. But over there, the men are just not as likely to go in
and turn themselves in, and there is still a lot of denial in
Africa. Is there anything similar in the United States?
Dr. Gerberding. There are many comparable social issues.
One of them is shame; the people are ashamed to have the
infection. The other is stigma; they are punished if someone
else finds out they have it. And then the third is ignorance.
There are still many people in this country and around the
world who don't recognize the risk and don't understand that
their behavior puts them at risk.
Mr. Davis of Virginia. Now, I understand that 38 percent of
the individuals, roughly, with newly diagnosed HIV are now
developing full-blown AIDS within a year of diagnosis. For
these individuals, prevention, testing, and treatment
strategies don't seem to have worked. What do you see? Is there
a granular understanding of this population, what leads to this
outcome in people who are being diagnosed and then moving
quickly to AIDS?
Dr. Gerberding. Well, the HIV diagnosis is happening
perhaps years after the infection has occurred at the time
people are beginning to develop symptoms. So it is a failure to
diagnose, a failure to reach out and get yourself tested, or a
failure for health professionals or people you encounter in----
Mr. Davis of Virginia. But that is a diagnosis question and
waiting so long?
Dr. Gerberding. So, D, the diagnosis of the prevention
paradigm, has to be a strong emphasis.
Mr. Davis of Virginia. Now, as the epidemic has progressed,
the perception of HIV/AIDS has changed. The success of
effective treatments may have the downside of creating a sense
of complacency about HIV/AIDS impact. What are the Federal
efforts that are under way in order to address complacency and
correct some of these misconceptions? Anything that we can do?
Dr. Gerberding. We need to do so much more than we are
doing right now. We need to get AIDS back on the radar screen.
We need to highlight the fact that this isn't just something
that happens underground; this is something that is still
posing a threat to college students and to young men and women
across our Nation's fabric. We need to engage community
leaders. We need to engage popular opinion leaders. We need to
make it clear that it is not a problem ``over there,'' it is a
problem at home. And all you have to do is look at the
statistics in the metropolitan D.C. area to see a picture that
would suggest we have nothing to be complacent about.
Mr. Davis of Virginia. It's remarkable, the medical
progress that has been made in this area over the last 10
years. I was very surprised. I mean, people who were diagnosed,
now it is no longer a death sentence if you take your
medication regularly. We are being able to stop it from being
passed on to kids and the like. I mean, getting treatment now,
if you are HIV-positive, going and getting treatment is
literally a lifesaver, Isn't it?
Dr. Gerberding. Treatment is lifesaving. And this is hard
to say, but as much as we want people with HIV infections to
live and thrive and survive, it is not good to have HIV. These
drugs are hard to take. They are fraught with complications and
side effects. It is not easy to have HIV and take these drug
treatments for a lifetime.
Mr. Davis of Virginia. And it is expensive.
Dr. Gerberding. And it is expensive. And it isn't a disease
that anyone should want to have, and it is certainly not a
disease that we should accept as just part of our advanced
society. We still need to prevent this disease.
Mr. Davis of Virginia. For the uninsured who are diagnosed
HIV-positive, obviously having to take the medication is, what,
$1,000 a month. What would it be?
Dr. Gerberding. It depends very much on which regimen you
are taking. And there are, fortunately, right now so many good
choices that there are a variety of options and a variety of
cost factors. But it is not inexpensive. It is one of the most
expensive chronic diseases to treat and manage.
Mr. Davis of Virginia. OK.
Chairman Waxman. Thank you, Mr. Davis.
Mr. Tierney.
Mr. Tierney. Thank you, Mr. Chairman.
Thank you all for your testimony here. You have testified
about the importance of implementing evidence-based prevention
programs, so I want to ask a few questions tying it in on the
evidence behind some of our policies that affect the prevention
programming.
The new CDC incidence numbers show that injection drug use
directly accounts for about 12 percent of the new infections.
The sexual partners, the children of injection drug users are
also indirectly at risk.
There is scientific consensus that needle exchange programs
reduce the transmission of HIV and other infectious diseases
without increasing the rate of drug use. Needle exchange
programs also connect people to important health and social
services, including drug treatment. These are conclusions that
have been reached, as far as I understand it, based on evidence
of at least 18 groups of experts and the most prominent
professional and public health societies in the world,
including the CDC and NIH. Just recently, when the CDC
published its August data, the authors noted that infections
among injection drug users dropped 80 percent, and they stated
that, among other factors, one reason was that drug users, and
I quote, have reduced needle sharing by using sterile syringes
available through needle exchange programs or pharmacies.
So despite this overwhelming mountain of evidence, every
year the Labor-HHS Department appropriations bill includes
provisions banning the use of Federal funds for the needle
exchange programs. So it looks like other programs around the
country and communities and States are doing all that they can
do, private people, but they are not really being supported by
the Federal Government.
So, Dr. Fauci, let me start with you, if I could. In your
professional scientific judgment, does the public health
evidence support the Federal ban on funding needle exchange
programs?
Dr. Fauci. No, it doesn't. Actually, I was part of a group
that I helped cochair years and years ago to look in a somewhat
meta-analysis way of all the data that you referred to asking
the two questions, A, does needle exchange help promote illicit
drug use; and, B, does it impede or block in many respects the
transmission of HIV? And the answer to both of those questions
were: It doesn't increase the injection drug use, and it does
prevent HIV infection.
So the scientific data are really rather firm and totally
convincing that injection drug use and the transmission of HIV
through injection drug use can be decreased significantly by
needle exchange programs.
Mr. Tierney. Dr. Gerberding and Dr. Fenton, in your
professional scientific judgment, do you agree with Dr. Fauci?
Dr. Gerberding. I agree. And I also ran a bridge program to
needle exchange in San Francisco, from San Francisco General
Hospital, so I had a chance to see first-hand.
I want to emphasize the word you used, though, ``program,''
because it isn't just the needle, it is the surrounding
education, the reduction in partners and sharing and so forth.
So it has to be done in the context of the overall program. And
my understanding is that there is actually for CDC a
congressional prohibition on using any of our appropriated
dollars for needle exchange. So we need to work on this.
Mr. Tierney. That was the dilemma that I was pointing out.
Dr. Fenton, do you also agree?
Dr. Fenton. I concur.
Mr. Tierney. OK. So let me move on now and ask a question
about programs for youth. The new CDC data shows that almost a
third of the new infections occur with people under the age of
30. There's been a number of comprehensive sex education
programs that appear to show a reduction of HIV or HIV risk
behaviors among young people. But aside from a small amount of
money in CDC's Department of Adolescent School Health, there
doesn't appear to be any Federal funds dedicated to
comprehensive sex education. In the meantime, we spend about
$1.5 billion on abstinence-only until-marriage programs.
I am aware that no evidence that this kind of narrow
program decreases HIV risk. In fact, a longitudinal,
independent, congressionally mandated study that came out last
year found that the programs had no impact at all on teen
behavior compared to the control group. In April, we heard from
the American Public Health Association, the American Academy of
Pediatrics, and others that these programs are not supported by
evidence.
So, I want to ask each of you individually, in your
professional scientific judgment, do you believe that evidence
at this time supports abstinence-only until-marriage programs
as an effective intervention to reduce HIV risk among youth?
Dr. Gerberding.
Dr. Gerberding. Let me say that I have spent a great deal
of time in preparation for this hearing reviewing those data,
and I agree with the conclusions that there is no evidence of
benefit from the 10 abstinence-only programs that have been
evaluated. And in looking at the comprehensive curricula
programs, there is more evidence of benefit, at least in terms
of benefit, in knowledge. And hopefully STDs in the long term--
although we have never studied an impact on HIV.
But I also want to emphasize that there are many in the STD
world of science who believe that delaying the entree to sexual
behavior is a good and very important part of a comprehensive
program. So, abstinence is not a dirty word, but programs that
deal with youths' sexual health need to bring to them the
entire compendium of tools that we know they may need in their
efforts to protect themselves.
Mr. Tierney. Dr. Fenton.
Dr. Fenton. I agree with the statements of Dr. Gerberding.
I know of no evidence supporting the effectiveness of
abstinence-only until-marriage programs in preventing STDs or
HIV incidence among young people. And I also support and concur
with Dr. Gerberding's statement regarding the role of
comprehensive sex education programs as an effective tool or as
part of an effective program toward better sexual health among
our youth.
Mr. Tierney. Dr. Fauci.
Dr. Fauci. Yes, I agree also. It is pretty clear that if
you look at abstinence only in a vacuum, that there is no data
to indicate that decreases transmission of HIV or other
sexually transmitted diseases.
But, again, to underscore what Dr. Gerberding says, as part
of a comprehensive program where you try to delay the sexual
debut, but you also inform people of what you need to do if you
do not practice abstinence has to go along with that;
otherwise, alone in a vacuum, it doesn't work.
Mr. Tierney. Let me, if I can, conclude by asking, has
Health and Human Services ever asked any of you for your
opinion on these two subjects?
Dr. Gerberding. We have had many briefings on this subject,
and say that as the data have come forward, it has only been
recently that we have had evaluation studies pulled together to
really ask the question. From a CDC standpoint, our total
investment in abstinence every year is about $2.2 million, and
I actually wish 15 years ago we had made a much bigger
investment because we would know the answers to the questions
that we are finally now being able to surface. So we erred,
perhaps, in retrospect, in not going into this with an open
mind and doing those kinds of programmatic, innovative
evaluation programs in the first place.
Mr. Tierney. I would be comforted if the budget reflected
the error and changed around and moved some of that money to a
more effective place. But we're going to have to fight for that
one, I think. Thank you.
Chairman Waxman. Mr. Shays.
Mr. Shays. Thank you.
A number of years ago, I chaired the committee that oversaw
HHS, and we had Donna Shalala come before us because HHS had
failed for a year to get the committee together that was to
begin to describe how we--and determine how we could protect
the blood supply. We had 25,000 hemophiliacs who died. And I
never saw it as my purpose to go after the Clinton
administration, nor do I think it is my purpose here to go
after the Bush administration. But I am really puzzled that
this would in any way be a political issue.
I would like to know from both our key witnesses have you
found in any way that the administration has been unresponsive
in trying to deal with this AIDS epidemic?
Dr. Gerberding. I would like to say that my intersection
with both Secretaries that I've worked for as individuals, as
well as staff from the White House that I have encountered on
the issue of domestic and international AIDS, has come to me to
ask for science, they have come to me to ask for the data. I
don't personally feel that I've come under any pressure to
comply with a particular policy.
Mr. Shays. Have you found them unresponsive?
Dr. Gerberding. No, I haven't. That has not been my
experience.
Mr. Shays. Dr. Fauci, have you found them unresponsive?
Dr. Fauci. No, I have not. They've listened, several
administrations, the current administration, the Clinton
administration, and the----
Mr. Shays. I mean, it seems like it's the one area where
politics has kind of not been part of it, so I would hate to
introduce it now.
What you have basically said to us is the upward adjustment
does not reflect an acceleration of the epidemic, but a more
precise capability to distinguish between recent and long-term
infections. So isn't it clear that we have new information, and
when there is new information, we need to respond to it? Dr.
Fauci.
Dr. Fauci. Yes. As we get new information, we certainly do
need to respond to it, and that is the reason for the
intensification.
Mr. Shays. Isn't this new information that we are learning?
I mean, we are learning that with the epidemic hasn't gone up,
it is just that our statistics were not as accurate as they
could be, correct?
Dr. Fauci. Yes. As Dr. Gerberding has mentioned, and I will
obviously leave for her to comment on that, the new, more
sophisticated and accurate counting measures indicate that the
incidence or number of new infections per year is higher than
we had thought it was. But it has been stable since the 1990's,
so it has not gone up. It is just higher numbers because of
better counting.
Dr. Gerberding. The new information is based primarily on
new testing activities in the States as well as new tests. What
it tells us is that there is no room for complacency; 55,600--
--
Mr. Shays. Absolutely, there is no room for complacency.
The issue is that we have new information, and from this new
information we can better act on it, correct?
Dr. Gerberding. That is exactly why----
Mr. Shays. Now, do either of you appear before the----
Chairman Waxman. If you will forgive me. I know it is your
5 minutes, but it seems to me you haven't let a witness
complete a sentence yet. And I know you only have a limited
time, but I would be glad to yield.
Mr. Shays. I am sorry, I just have a number of questions,
but I am delighted to have you continue.
Dr. Gerberding. I think the important message here is that
we need to be able to have this kind of information at the
community level, because it tells us right where we need to go.
This data tells us nationally we need to go to men who have sex
with men, African Americans and Hispanic people, and do a lot
more than we are doing right now in those targeted populations.
But in communities there will be even more specific information
that can tell us how to use the resources we have to get the
most benefit from it.
So you are absolutely right. This information has to--it
tells me that we need to reframe what we are doing. And I have
asked Dr. Fenton to bring in experts and really look at our
portfolio as it exists in light of this new information, and
say where are we and where should we be.
Mr. Shays. And I congratulate both the chairman and ranking
member, because I know they worked together in having this
hearing. This is a huge piece of information. It really isn't
political information, it is new knowledge, based on new
science, and we need to respond to it.
I would like to make sure, do you either, any of the four
of you, make presentations before the Congress on funding
requests?
Dr. Fauci. Yes. We defend the budget every year at our
appropriations hearing in front of the House and the Senate.
Mr. Shays. And you are never required to say something that
is not true before those hearings, correct?
Dr. Fauci. Correct.
Mr. Shays. So in other words, if a committee member asked
you a question about your funding needs, you would be very
candid with them; is that not correct?
Dr. Fauci. Yes.
Mr. Shays. Is that correct?
Dr. Gerberding. Yes.
Mr. Shays. So if someone on the committee said, is this
enough money to do your job, and you said--you didn't think it
was, you would tell them, well, we think we need more; and if
we had more, we would put it to this use. Is that correct?
Dr. Gerberding. Well, Mr. Shays, there is the reality as an
agency head, and I know Dr. Fauci feels this as an institute
head, we can always think of good ways to spend money to do
more than we are doing. But we also have to respond to the
realities of the budget proposals that are put in front of us.
But when you ask me for my professional judgment, I give you my
very best answer, unconstrained by any other realities.
Mr. Shays. So any member on that committee who says, do you
need more money in these areas, and how you would use it, you
would let them know?
Dr. Gerberding. I tell the truth.
Mr. Shays. Thank you.
Ms. McCollum. Mr. Chairman, if I may, as an appropriator on
that committee.
Mr. Shays. Sure.
Ms. McCollum. I think what Dr. Gerberding said was honest,
but I think it honestly needs to be said that she comes in and
she does her job as an utmost professional. She is very, very
honest, as everyone is from CDC, NIH. But they all defend--they
all defend the President's priorities and the President's
choices.
Mr. Shays. Right. And then you, as a member of the
committee, feel very inclined to ask very candid questions. And
I know that, based on the testimony, that they would give you a
candid response in return.
Ms. McCollum. And then if we do anything, it is called an
earmark by the President.
Mr. Shays. So I will just conclude by saying, in the end
this was a budget agreed to by a Democratic Congress, suggested
by a Republican President. It is a bipartisan budget. And in
the end, we have to work together to come up with the best
conclusions.
Thank you very much.
Chairman Waxman. Without objection, the Chair would like to
recognize himself for an additional minute. Hearing no
objection.
Dr. Fauci and Dr. Gerberding, as I understand it, when you
come before the Congress, you are defending the budget
submitted by the administration; isn't that correct?
Dr. Fauci. Correct.
Dr. Gerberding. Correct.
Chairman Waxman. Now, unless you are asked what your
professional judgment might be, you are there to represent the
administration.
Dr. Gerberding, when I asked you questions earlier, you
indicated that you thought that you should have had more money
in the prevention efforts going all the way back to the
beginning of your time. And I asked you about whether you heard
from people in the administration, the President, Secretary,
and others, whether they asked you what you really needed. You
said you had lots of meetings held with superiors who discussed
these needs.
I would like to ask you for the record to submit documents
and any other further information about the meetings you had to
tell them what you thought you needed to prevent the epidemic
from increasing in scope.
Dr. Gerberding. I will do my best to resurrect that.
I must also say that HIV isn't the only place that we have
gone to say we are concerned about.
Mr. Shays. Would the gentleman yield for a slight
intervention?
Chairman Waxman. Certainly.
Mr. Shays. Thank you.
I just want to make sure for the record, was this new data
available--and I don't know what the answer is. But was this
new data that is available today available when the President
and Congress were presenting their--doing their last budget?
Dr. Gerberding. The new data were published in August, at
the beginning of August of this year.
Mr. Shays. This year. So it was not available either to the
President or to Congress?
Dr. Gerberding. That's correct.
Mr. Shays. Thank you.
Chairman Waxman. In your developing your CDC budget do you
start from scratch from what you believe is needed or do you
receive a preset total from HHS or the Office of Management and
Budget into which you must fit your goals?
Dr. Gerberding. I think, like every agency, we're given
some parameters. They vary from year to year. When I started,
we were given parameters for increases. Recently, we have been
given parameters to have scenarios for a modest increase, a
flat line or a reduction. And we go forward with different
versions of our request based on what parameters are finally
selected by the administration to present the final budget to
Congress. I also present our request to the formal budget
council in the Department, and that is a factor that the
Secretary weighs when he looks at all of the agency budgets in
aggregate, because he has to finally bring the budget forward.
Chairman Waxman. Now, when all is said and done, your
budget now for domestic HIV prevention is around 5 percent, and
that's a drop in the percentage you've had in previous years,
isn't that correct?
Dr. Gerberding. I'm not sure of the 5 percent figure, but
most of our domestic HIV money is for prevention. But the
amount of money that our government is spending on prevention
is still hovering at about 4 percent of the total.
Chairman Waxman. OK, thanks.
Ms. Speier.
Ms. Speier. Thank you, Mr. Chairman.
I had the opportunity recently to spend some time at Gilead
which is a company in my district. And I'm going to preface my
questions based on that fact, because they provided me with
information that I thought was pretty astonishing. One is that,
of the 50,000 new HIV individuals in America, the vast
percentage of them are African American women. Now that seems
to be different from what you provided today. But their concern
to me was that African American women are the highest increase
in those contracting HIV. Is that not the case?
Dr. Fenton. No, that's incorrect. The majority of new HIV
infections are occurring among men, and the majority of those
are among men who have sex with men.
Ms. Speier. So the women, then, the African American women
are an increasing number?
Dr. Fenton. What you may have heard is that the largest
proportion of women who are newly infected with HIV are African
American women. So they account for nearly a substantial
proportion, more than half, or just about half of the new
infections which are occurring in women in the United States.
And then you have smaller proportions of infections occurring
among Hispanics and White women; that may have been the
statistic they were referring to.
Ms. Speier. What was most amazing to me was the regime now
for drugs has been reduced, at least with Gilead's work, to 1
pill a day, as opposed to 9 or 10 pills in which patients
oftentimes will not take one of the pills because it is
upsetting physically to them. And by being able to just take
one pill, you're getting greater compliance.
What they impressed upon me was the importance of testing,
because as I think one of my colleagues earlier said, it is not
a death sentence anymore. In fact, being diagnosed with HIV
means that you can in fact have a full life, a full life
expectancy. It is just being tested early, being diagnosed
early and getting the drugs and following the regime that is
offered; is that not the case?
Dr. Gerberding. That is the case. The one pill has many
drugs in it.
Ms. Speier. Correct.
Dr. Gerberding. But they are able to combine them into a
single tablet.
Ms. Speier. So listening to them and listening to you it
seems to me that we need to do two things, one is augment the
testing that goes on in this country everywhere. Two, we
require all other countries to come up with National HIV AIDS
plans if they are participating in PEPFAR, but we don't have a
national plan; is that true?
Dr. Gerberding. We have a national strategy, and we are
committed to updating it in light of the new incidence
information that we are receiving.
We also in, I think in December, Kevin, will be publishing
a new update on interventions that work that we can incorporate
into the national strategy.
Ms. Speier. So testing, what do we do to augment testing in
this country?
Dr. Gerberding. There are some things we are doing right
now. One of the biggest advances is the rapid test, that allows
people to be tested in non-medical environments. We are really
pushing hard to make testing a routine part of medical care so
that when you come in, you get tested. I was so pleased to see
this in action at San Francisco General, it is night and day
compared to even 5 years ago, but that's not happening
everywhere. It is particularly not happening in VA hospitals
and Federal facilities yet because they have regulations that
have to be changed in order for that to happen. But we need to
make testing universally accepted and acceptable in all kinds
of nontraditional environments.
Ms. Speier. Would it make sense to make Medicaid funding
contingent on participating in a program where testing is done
uniformly?
Dr. Gerberding. Well, I would like to see us work with CMS
around support for screening, because ultimately screening will
be cost effective for CMS and HRSA and the other federally
funded health programs, so I think that is an important lever
that we want to pull. And we are working on how to get those
regs changed.
Ms. Speier. Finally, in terms of microbicides, that was
heralded some years ago as being an outstanding opportunity for
us to address the issue, particularly in places around the
world, Africa in particular. It appears in your testimony that
I just read that there has been some disappointing results in
the clinical trials. Could you expand on that please and tell
us where you are going with microbicides?
Dr. Gerberding. The clinical trial so far with the
available compounds have been disappointing. They have failed
to prevent and in some cases may have actually enhanced
transmission because of irritation in the mucosal tissues in
contact with the microbicide, but that doesn't mean that we
won't find compounds that work. And there are studies ongoing
right now in animal models and early clinical studies looking
at both vaginal as well as rectal microbicides. So this is a
very important area for investment. It is one of those new
tools that I'm trying to make a plea for working
collaboratively with NIH, of course, as well as FDA.
Dr. Fauci. Most of those studies, Ms. Speier, were done
with microbicides that don't have a specific anti-HIV drug in
it. The second generations are those that are now incorporating
drugs that specifically block the virus, so the issue that Dr.
Gerberding mentioned is one we still haven't overcome, is the
propensity toward vaginal irritation which can sometimes
paradoxically make things worse, but also there has not been
potent anti-HIV drugs in the compounds, which now the second
and third generations ones that we feel a little bit more
optimistic about now are ones that do contain those compounds.
Ms. Speier. And my last question, Mr. Chairman, to both of
you, if you were being asked today how much money we should be
spending in the United States on HIV and AIDS, how much would
that budget be?
Dr. Gerberding. We have submitted that for the record, our
professional judgment without constraint. And as Kevin and I
sat down and walked through that budget, I think we recognize
that this isn't just a CDC question, it has to include the NIH,
it has to include SAMHSA for mental health because we can't
solve this problem without doing more for mental health and
substance use. And we need to addressthe correctional
facilities, because a disproportionate part of the population
at risk is in correctional environments. So we only have a
piece, and we probably need to sit down together as a
collaboration and really think through a true national
strategy, and that's what we are proposing to do as these new
data become available.
Ms. Speier. Give us a number nonetheless.
Dr. Fauci. I can give you an NIH number. Our budget, as you
know, has been essentially flat for the last 4 or 5 years. So
we have $29-plus billion in research that we've--that we spend,
which is a substantial amount of money. The difficulty is if
you have no increases for several years in a row, you're really
looking at a 3.2 percent decrease per year in actual real money
in the sense of inflationary index. So you are looking at a
minus 12, 13 or plus percent decrease over a period of 5 years.
So when people ask us, in our professional judgment, which I
will give you now, that if you're looking at what we could use
and spend quite well, the NIH budget is $2.9 billion for AIDS
on a budget that's $29 billion for all of NIH, so it is a
little more than 10 percent. With a $2.9 billion budget for the
NIH for AIDS, we could spend about $3.35 billion.
Chairman Waxman. Thank you, Ms. Speier, your time has
expired.
Ms. McCollum.
Ms. McCollum. Thank you, Mr. Chair.
People are dying every day in this country because of AIDS,
and the numbers continue to increase despite the fact that AIDS
prevention works. And I know this all too well, because I
recently lost a friend from AIDS. It was a story that could go
with maybe not being tested quick enough. It is a story that
you could talk about fear and discrimination, but it also
includes the Federal Government and the State of Minnesota not
doing what it could do to support people who are on anti-retro
viral treatment and the stress that these individuals go
through when their treatment is threatened or cutoff and then
they find themselves scrambling for treatment.
We're here today because we need to get our energy back
into the need for HIV prevention and education efforts, and I
appreciate sincerely the testimony of the panel. We know that
there are populations now that are more at risk than other
populations. We're here today because the CDC's report found
out this that there were 60, excuse me, 56,000 new HIV
infections last year focused in racial and ethnic minorities;
that's 70 percent of new cases. This is also true of Minnesota,
and I wish Mr. Shays was still here. Maybe he'll come back.
Minnesota has recorded the highest number of HIV cases seen
in the last 10 years in 2007. With 325 new cases, gay, bisexual
men are the highest group impacted with 77 percent of all
cases. Minnesota also is facing higher increases among young
men and among Latina women. We know that the HIV rate in
African American men and in the immigrant population is 20
times higher than the statewide average.
Mr. Chair, I would--I'll submit some issues for the record,
but one thing that was brought up in a question was, well, this
is new because we're testing better. Well Minnesota's been
testing since 1985, so it is going up in Minnesota. I'm--I--I
want to ask you, again, do you think the only reason why you're
seeing rates increase in the populations that I have mentioned
and across this country, the only reason is because testing is
more effective, knowing that States submit records to you on a
regular basis?
Dr. Gerberding. I regret if I implied that we thought the
reason for the number that this was related to testing. This
number is a new number because we have a new diagnostic test
that allows us to tell when somebody was infected, so we can
distinguish very old infections from recent infections, so
that's the test element of the number. But the number that we
are reporting today and the back calculations that we did using
the new methodology of extrapolation over time allows us to
recognize that we've been misunderstanding the true incidence
for a long period of time. In part it is complicated and I
would be happy to sit down an walk through some of the science
of it. But is not that we are doing more testing, and you're
right Minnesota was one of the first to have HIV reporting and
the first to take an aggressive perspective on that. But,
nevertheless, even in Minnesota, there are undiagnosed people
and there is ongoing transmission.
Ms. McCollum. Thank you.
One of the people who took it to the street, took it to
public officials was a wonderful person, our State
epidemiologist, Dr. Michael Osterholm, who made sure that we
kept track of records. And some people called him an alarmist
for going out and talking about it at the time. I think the
alarm needs to go off again, and so I thank you again for your
report.
Mr. Chairman, the Minnesota Department of Health Federal
CDC HIV prevention grant has been reduced by 8 percent in the
past 5 years. Federal CDC STD prevention grants, which is also
a precursor that's been used, has been reduced 4 percent since
2003. That's despite the number of STD cases has risen 14
percent since 2003.
Mr. Chair, I'm going to submit some information into the
record from the State of Minnesota and the profile of HIV
epidemic. I will be around if there's an opportunity for more
questions. I originally wasn't going to spend my time so much
talking about Minnesota, but I wanted to, for the public, clear
up any misunderstanding that might have been what these
statistics are really indicating to us, and that's to wake up
and to start getting correct information, and to let today's
youth know that treatment is not a cure; it is not a cure.
Thank you, Mr. Chair.
Chairman Waxman. Thank you very much, Ms. McCollum.
We will be, without objection, we will be pleased to
receive the information for the record that you would like to
submit.
[The information referred to follows:]
[GRAPHIC] [TIFF OMITTED] T6578.115
Chairman Waxman. Ms. Watson.
Ms. Watson. Thank you, Mr. Chairman.
I just want to clarify something that was said, and I'll
direct this toward you, Dr. Fenton, as I understood, HIV is
spreading more quickly among African American women than any
other group. Is that correct or not correct?
Dr. Fenton. HIV infection is spreading at the greatest rate
among gay and bisexual men. In fact the data shows that they
are the only group where we have seen consistent and sustained
increases in HIV incidence since the early 1990's.
Ms. Watson. Then, let me go back, because after the virus
was spread--I mean, identified around 1980, 1981, it was
believed to be among White males having sex with males. It
seemed that there was attention given to that segment of
society, and things improved, and that's where the funding was
going. Maybe 10 years later, there was data showing that it was
moving quicker among African American women, coming from
partners who injected themselves.
As I understand that, there is a disproportionate toll on
African Americans, males, females at this time, and they
account for 12 percent of the population but 45 percent of the
new infections in the year 2006. Is that true?
Dr. Fenton. That's true.
Ms. Watson. OK, I might have missed this part of your
testimony, so let me just refer back to it. But can you tell us
more about what CDC is doing in terms of the Heightened
National Response to address HIV and AIDS in the African
American community?
Dr. Fenton. Thank you. I would be delighted to tell you
about that. The Heightened National Response is an initiative
which was started in 2006, and it brings together CDC, our
Federal partners and our partners and leaders in the African
American community to focus on the epidemic among African
Americans and to accelerate our prevention efforts.
And the Heightened National Response is built on four key
pillars. The first is to expand HIV testing within the African
American community. The second is to expand the reach of our
prevention services; in other words, to scale up effective
prevention interventions with African Americans so we know it
will have an impact on the epidemic. The third is to mobilize
the African American community. And we have been really working
with a range of amazing African American leaders to focus and
to bring the conversation back to HIV and the importance of
community leadership on HIV/AIDS. And the fourth pillar is on
research, to ensure that we are investing in research for and
by African Americans, so that we're looking at culturally
competent prevention interventions moving forward.
Ms. Watson. Now, the main points that you are describing to
us, did you get new funding to be able to implement?
Dr. Fenton. No, this is a great example of what Dr.
Gerberding said of looking at our existing prevention portfolio
and having to make tough decisions to realign our existing
prevention dollars into what we believe are urgent threats or
urgent realities and to deal with the matters at hand. And so
this is part of the activities that we have to do in the
current environment.
Ms. Watson. Well, going back and looking at the history
because I chaired the health and human services in the
California Senate for 17 years. I was there when we identified
the virus, and I was there when money flowed in to address
White males having sex with White males. I was there, too, when
we discovered that it was moving among the African American
female community. And I never saw the funding keep pace with
the spread. So I will expect, in trying to reach your goals to
reduce the rate of infection, that you have not been able to
reach those goals of reducing the rate of infection among that
population.
Dr. Fenton. Well, actually, we do know that the
transmission rate of HIV has been declining in the United
States. There are more people living with HIV, but----
Ms. Watson. But what about African Americans? I really want
to see zero in, because this was a great concern. I carried the
needle exchange program for years. I was called on the carpet
by, particularly, the ministerial community. I had to go to San
Francisco and sit in the hot seat. And it was very, very
difficult to have an understanding that if we do a needle
exchange, at least we take a dirty needle out. And at that
time, as Dr. Gerberding has said, that we're able then to give
information about treatment and at the point of exchange. And
that program only was adopted after Willie Brown took over, and
I was gone at that point.
But I'm still concerned as to what is happening in that
community. And I'm still concerned about resources. And I would
like to know the status of mobilizing the community--I know we
are working through a lot of our churches now. Could you just
add to that, please?
Dr. Fenton. Sure. It has been an amazing couple of years in
which we've brought leaders from all walks of life into the
African American community to dialog with us and to plan with
us. Leaders from the African American faith communities, from
the academic sector, from the business sector, from grassroots
organizations who have come to Atlanta to talk about their
activities and their plans and look at ways is in which CDC can
accelerate efforts toward prevention. This has been a new way
for us to work as an agency. It is an important way for us to
work as an agency moving forward.
Ms. Watson. If I might take just another minute, Mr.
Chairman.
Chairman Waxman. Without objection, the gentlelady is
yielded another minute.
Ms. Watson. In the African American community, our churches
are the place where people come together. And that is a route
that I think should be more focused on. And if we had the
necessary budget items, and this is something I have in mind,
to impact those who are appropriators, we really need to--and I
understand also that HIV/AIDS is spreading among Hispanic
Americans now, where it wasn't as heightened as, 10 years ago,
as it appears to be now. So I think that we need a special
program expanded to deal particularly in the African American
community with our churches and other community programs.
With that, I will say thank you, Mr. Chairman.
And thank you, Dr. Fenton.
Chairman Waxman. Thank you, Ms. Watson.
Mr. Sarbanes.
Mr. Sarbanes. Thank you, Mr. Chairman.
Thanks to the panel.
I would imagine that just about any condition can be
treated or involves sort of two prongs at least in your
strategy combat it. One is sort of behavioral modification. The
other is treatment. So--but, obviously, there are certain kinds
of conditions, diseases and so forth where that interplay is
more relevant and elastic.
And--so I had a couple of questions. Is there any evidence,
or can you describe how progress on the treatment front may
have contributed to some backsliding on sort of the behavioral
practice or modifying behaviors up front? And if that has
happened, you know, how do you address that? What are the
strategies for--to maintain the intensity and focus on both
strands without having them sort of contribute to going in the
opposite direction with the other? And along those lines, and
this is my only question, so then I ask you all to just jump
in, are there conditions or diseases that have been good
reference points for you to look at where the analogy is strong
enough, in terms of what we are dealing with HIV and AIDS, of
what's happened in terms of how we've managed those is
instructive in terms of the strategies that we're trying to
employ with respect to HIV and AIDS?
Dr. Gerberding. I'll start. I think that the risk period
for people, all other things being considered, for the highest
chance of transmitting to others is very early after infection
and then again very late in infection when the viral load is
very high. But you can transmit at any time. So if treatment is
successful in suppressing viral load, it stands to reason that
people would be less infectious to others during that period of
time. They also tend to change their behavior when they know
they are infected and protect other people as a consequence of
their disease.
But we are experiencing anecdotal and I think more
systematically a cohort of people who have falsely been
reassured that their lives are going to be unaffected by this
treatment, and so there is some complacency and some recidivism
and increase in risk behavior. And we see that by indicators
such as the incidence of rectal syphilis going up in some
populations where there has been an increase in unsafe sexual
practices, so that is a phenomenon.
There is--it is very difficult to find a good analogy to
HIV in the context that you're asking the question. To some
extent, TB is like that. You have to treat it for a long time,
and people become less infectious when they are in treatment.
They can be falsely reassured by the therapy early on and be
less conscientious about infecting the people in their
households, but AIDS is a pretty unique infectious disease, a
chronic infectious disease for which we have a chronic
infectious disease treatment. And so we're kind of learning as
we go with this one.
Dr. Fauci. Just to underscore what you said about the
perceptions. The perception of something not being as bad as we
decades ago thought it was, if you look at the environment that
we're in, we used to have hospices and 20 to 40 percent of the
hospital beds in some cities were occupied by people with HIV
infection. It is mostly an outpatient disease right now.
The public perceptions that put on the face of someone with
HIV, if you look at some of the advertisements for some of the
drugs, you open up medical journals and you page through the
first 10 pages and they have these extraordinarily healthy
looking people rock climbing saying, I'm doing very well on my
Atripla or on my, whatever drug combination they are on, and it
really creates a false impression that we've been trying to
underscore here, and Dr. Gerberding mentioned it actually
formally in her presentation, is the issue that it is a bad
thing to get HIV infected. Even though with all the very, very
effective drugs we have, it is not a good thing. It's difficult
to take the medications. It is a lifelong disease. If you stop,
we have shown as others have, that the virus bounces right
back, and at this point, we have not been able to cure it.
Mr. Sarbanes. Would you attribute any of the increase that
has been talked about here today to this sort of misperception,
or is it--I'm sure it is hard to draw a straight line.
Dr. Fauci. No, I think there is no question in our mind
that when people practice risk behavior, if you question them
and talk about it with them, a significant amount, I can't give
you a number, is due to the feeling that it isn't as bad as it
was back in the early 1980's. Of course, there was an
incredible amount of fear. If you were in New York City or San
Francisco or Los Angeles or some of the other cities, the fear
among the community, particularly among the gay community, was
palpable. There is much less of that now because of the
perception that we can treat it very well.
Chairman Waxman. Thank you, Mr. Sarbanes.
Without objection, Representative Maxine Waters, who is not
a member of our committee, will be allowed to sit with us and
enter a statement in the record and to ask questions. Without
objection, that will be the order.
Ms. Waters. Thank you so much, Mr. Chairman. I am just so
pleased that you are holding this hearing and I would like to
thank you and Ranking Member Tom Davis for this hearing today.
I'd just like to give a little bit of background and ask a
few questions.
Many people in the Black community have long suspected that
the epidemic was worse than our Nation's leaders thought it
was, even before the CDC's new estimates were released. We knew
that African Americans accounted for about half of all of the
new AIDS cases, and we knew that HIV/AIDS was having a profound
impact on African Americans.
In 1998, we sounded the alarm in the halls of Congress on
April 24, 1998, while I was the Chair of the Congressional
Black Caucus, the CBC held a brain trust which was sponsored by
Congressman Louis Stokes. During that brain trust, those same
members were shocked by the presentation of Bennie Primm, the
executive director of the Addiction, Research and Treatment
Corp. Dr. Primm's presentation described the state of HIV/AIDS
crisis in minority communities, particularly the Black
community.
On May 11, 1998, the CBC held a meeting that brought
together many public health workers, AIDS activists and
representatives from all over the country to tell us about the
impact of the HIV/AIDS in minority communities. That same day,
the CBC called for President Bill Clinton to declare a public
health emergency to combat the crisis in minority communities.
In the fall of 1998, Lou Stokes, Donna Christensen and I
met with Donna Shalala, the Secretary of Health and Human
Services, to discuss the crisis. We agreed that what we really
needed was not a declaration of a public health emergency but
rather money for programs to address the crisis.
On October 28, 1998, the CBC held an event to roll out the
Minority Aids Initiative. The event featured the participation
of President Clinton, Secretary Shalala and representatives of
HIV/AIDS organizations from around the country.
At the 1998 roll out, we announced that the Minority Aids
Initiative would receive an initial appropriation of $156
million in fiscal year 1999. The minority AIDS initiative grew
significantly over the next 5 years, but since then, funding
has remained stagnant at about $400 million per year since
fiscal year 2003, and at some points, it dropped below the $400
million.
Having said that, African Americans again have been
seriously and disproportionately affected by HIV/AIDS. There
are more than one half million African Americans living with
HIV/AIDS today. African Americans account of about half of all
the new AIDS cases, although only 12 percent of the population
is Black. African American women represent somewhere between 66
and 75 percent of all the new AIDS cases among women. And
African American teenagers represent 69 percent of all the new
AIDS cases among teenagers. I could go on and on with this.
Are you shocked about this crisis? Are you bothered about
this crisis?
Let me start with Dr. Julie Gerberding. Does this
information shock you?
Dr. Gerberding. I, as I said before you were here, I
believe this is an urgent situation. Am I shocked by it? I'm
certainly not happy about it.
Ms. Waters. Do you think it's a crisis?
Dr. Gerberding. I think it is a crisis.
Ms. Waters. Mr. Fenton, are you shocked? Do you think this
is a crisis?
Dr. Fenton. I'm saddened, and CBC has portrayed this as an
severe and ongoing crisis among the community.
Ms. Waters. Do you do think it is a crisis?
Dr. Fenton. I do.
Ms. Waters. Dr. Anthony Fauci, do you think it is a crisis?
Dr. Fauci. Yes, I do, Ms. Waters.
Ms. Waters. OK, given we all believe this is a crisis and
these statistics and this information is shocking, what do you
recommend?
Dr. Gerberding. I would be happy to share the professional
judgment budget that we have presented to this committee with
you, which I think reflects three major focal areas. One is to
know not just who got it then or who is getting it now, but who
is going to do get it if we don't act and invest in the systems
that tell us what to do about that. Second is to get everybody
diagnosed who's had it, so they can benefit from treatment. And
the third is to put a significant effort into new research----
Ms. Waters. How long have you been at CDC?
Dr. Gerberding. Six years.
Ms. Waters. Six years? You heard my background on how I
created the Minority Aids Initiative. I created that because we
needed to focus on building capacity and getting communities
that had little or no resources involved in RFP processes.
We've been working very hard, and I come here, and I hear you,
Mr. Fenton, talk about all this great work you're doing with
minority leaders and minority communities. I don't know about
it. I've been involved in this issue for a long time, having
created this and watching the incidence of HIV/AIDS grow in
African American communities across the country.
And I want to know, because I don't get a sense that you
really feel this is a crisis. And when you tell me that, well,
I submitted a budget, take a look at the budget, how have you
sounded the alarm? What have you done to deal with this growing
crisis? Do you see what I just said about African American
teenagers from 13 to 19-years old representing 69 percent of
all the new AIDS cases among teenagers? Doesn't that bother
you?
Dr. Gerberding. Mrs. Waters, we will be briefing the Black
Caucus this afternoon, but if you would be able to participate
in our enhanced initiative, we would love to have your voice
because we need to get leaders involved in helping us----
Ms. Waters. No, no, no, no, no.
Dr. Gerberding. We need your help.
Ms. Waters. No.
Excuse me, Mr. Chairman.
I am involved and I have been involved. And the Black
Caucus has been screaming to the top of its voice for help. We
just got one portion of this reauthorized with Ryan White. The
other portions of the funding that we struggle with are not
even official in the budget. What are you going to do about
just getting CDC portion authorized? It is spread out among
several of these agencies, including CDC and NIH and SAMSA. And
I don't see any leadership from--I don't see any leadership
from you.
Now, I know that you think I'm being a little bit harsh,
and I am. I happen to be an African American woman. I don't
want gays and lesbian and African American men and women
fighting about who is worse off. We are all worse off. And I
don't like it when I go out into the communities and I see all
of these little groups struggling and fighting, and the way you
deal with the discretionary money. We need some leadership.
And I'm so pleased that I am able to be here today, Mr.
Waxman, and I thank you for indulging me in my frustration.
Chairman Waxman. Thank you very much.
The gentlelady's time has expired.
Dr. Fenton and Dr. Gerberding, one--once CDC identifies
effective programs, the next step is to disseminate them to the
States.
How does CDC identify effective programs?
Dr. Gerberding. I would like to ask Dr. Fenton to take on
this in detail, but just to tell you that there is a two-step
process. One is to review the evidence of efficacy by expert
scientists who are in a position to make those judgments, and
we respect that, and to get that up in the compendium, which
will be updated again. But in addition, there is a process of
diffusion where we work with an organization that trains and
helps disseminate people. Right now, there is a bottleneck in
the training, so that's one of the issues we addressed in our
professional judgment budget.
Chairman Waxman. So you have a research time that applies a
methodological review of studies of existing programs. They
identify the ones that are found to work. You put it up on the
compendium. Isn't that right?
Dr. Gerberding. Yes. And we expect the grantees who receive
our dollars when they are developing programs to use those
programs that are proven to be effective. But in order for them
to successfully implement them, they often need training and
support, and that's one of the areas that we are not able to
keep up with right now.
Chairman Waxman. When the compendium was first released in
1999, CDC said it would update it annually as effective new
programs were identified, and CDC's experts did identify a
number of additional programs that work, but as I understand
it, you said there is a bottleneck. CDC did not issue annual
updates to the compendium; is that right?
Dr. Gerberding. I can't go back to 1999, but we have done
two updates since I have been the director of the CDC. It is a
little hard to do it annually because the data from these
programs doesn't come forward that fast, but I think we are
accelerating our ability to do that.
Chairman Waxman. When did CDC last issue an update on the
compendium?
Dr. Gerberding. 2007.
Chairman Waxman. Did CDC attempt to get HHS approval to
release an updated compendium prior to that time?
Dr. Gerberding. I believe we did.
Chairman Waxman. And what was the response from HHS?
Dr. Gerberding. I would have to ask Kevin, who wasn't the
director at the time, to go into the details of this, because I
don't know all the steps involved. We can provide that paper
trail for you. But to suffice to say that it was not a speedy
process.
Chairman Waxman. OK. Well, I'd like the answer to that
question for the record. I'd also like to know why didn't HHS
approve any updates of the compendium until 2007?
Dr. Gerberding. I can't answer that.
Chairman Waxman. OK.
Dr. Gerberding. But I can say, in the recent years, we've
had I think a much more accelerated process, and I'm satisfied
that we are able do it in a timely way now. I hope we will have
the update for 2008 before the end of this calendar year.
Chairman Waxman. Well, it took 8 years to update the list
with crucial information about programs that have been shown to
save lives. And I'm concerned that instead of encouraging
effective HIV prevention, HHS seems to have been standing in
the way. In fact, the committee asked CDC for a list of dates
for which the compendium and other important HIV prevention
documents were submitted to HHS for clearance and when they
were actually released. And my understanding is that the
committee hasn't gotten a response because CDC's response is
still in clearance at HHS.
Does CDC provide training or technical assistance for
implementing the programs it identifies?
Dr. Gerberding. Yes, we do.
Chairman Waxman. And how many organizations are currently
on the waiting list?
Dr. Gerberding. About 2,000.
Chairman Waxman. So 2,000 organizations out there want to
provide identified effective HIV prevention programs, but they
are still on a waiting list. I think that's unconscionable
given the statistics we've been hearing about today, and I
think we need to address it.
Dr. Gerberding, just a clarification of your testimony, you
suggested earlier that one of the reasons that you lowered your
prevention goals is that there are more people with HIV living
because of treatment, but the data for 2000 estimated 945,000
people living with HIV, and for the data for the most recent
year, we find around a million people. This is about a 5
percent. Does a 5 percent increase in people living with HIV
produce an 80 percent decrease in your goal and a 20 percent
decrease in funding for prevention?
Dr. Gerberding. I'm not going to be able to do that math in
my head, but I think what you're getting to is, you know, what
is the full picture of the recalibration? And, again, I was on
the advisory committee when we were struggling to develop that
first 50 percent reduction. We recognized at that time that
there was a bell shaped survival curve for HIV, so the
projections were that we would see an excalation in death
rates, and that was factored into the projection of the
transmission. So it was a--I don't want to say it would be
easier to prevent if there were fewer people living because
that isn't our public health goal, but the calculus was
different then. And that's not the only reason, as I already
said, but that is one of the factors----
Chairman Waxman. Well, I asked that question----
Dr. Gerberding [continuing]. Different as opposed to now.
Chairman Waxman. Because I was troubled by the answer you
had given earlier so I just wanted to pursue that point. And I
thank you for responding.
This panel has been very helpful. I think it is unfair to
criticize the four of you for what you are trying to do. I
think you're trying to do the best you can, and you're trying
to do as much as you can without sufficient funds and without
the barriers to your efforts being removed. And the purpose of
having you here is not to criticize you but to try to be
constructive in working with you to be sure that you have the
ability to do the job, because we are all very concerned and
frustrated that there are so many people whose lives are at
risk and will be lost unless we in government do what's needed.
And if it is not coming from the U.S. Government, it is not
going to happen at all. I thank each of you for your testimony
today.
I want to now call forward the witnesses for our second
panel, Dr. David Holtgrave. We will wait a minute and have the
second panel come forward.
We're pleased that you are here today, and I want to
introduce those of you on the second panel.
Dr. David Holtgrave is founding Chair and professor at the
Department of Health, Behavior and Society at the Johns Hopkins
Bloomberg School of Public Health. He has served as director of
behavioral and social sciences at the Emory Center for AIDS
Research and as director of intervention research at CDC's
Division of HIV/AIDS Prevention. Dr. Holtgrave has focused on
the efficacy, effectiveness and economic evaluation of a
variety of HIV prevention interventions, contributing to over
175 professional publication.
Dr. Ada Adimora is associate professor of medicine at the
University of North Carolina School of Medicine and adjunct
associate professor of epidemiology at the School of Public
Health. She has been the principal investigator on multiple CDC
and NIH funded research projects and has published extensively
on the epidemiology of HIV in America, with a focus on African
Americans. Dr. Adimora a practicing clinician and a fellow of
the American College of Physicians.
Dr. George Ayala works as a research psychologist and
public health analyst at RTI International's Urban Health
Program in San Francisco, CA; and is also the executive officer
of the Global Forum on Men Who Have Sex with Men and HIV. He is
the former director of health promotion, community research,
and capacity building at AIDS Project LA where he managed HIV
prevention technical assistance and research. A clinical
psychologist by training, Dr. Ayala's research focuses on the
mechanisms through which social discrimination impacts health.
Heather Hauck is the director of Maryland Department of
Health and Mental Hygiene AIDS Administration, leading
statewide public health efforts to reduce HIV transmission in
Maryland and to help Marylanders with HIV/AIDS live longer,
healthier lives. Ms. Hauck is currently Chair-elect of the
National Alliance of State and Territorial AIDS Directors. She
has served as the section chief of the STD/HIV section for New
Hampshire and as a consultant on HIV program issues for
hospitals, national associations and State public health
agencies.
Frank J. Oldham, Jr., is the executive director for the
National Association of People with AIDS. He has spent over two
decades as a leader in HIV policy, administering HIV programs
for the cities of New York and Chicago, and working in numerous
AIDS service organizations. Mr. Oldham has served and is
currently serving on several planning and other policy bodies,
including the New York City Commission on AIDS; the National
Minority AIDS Council; CDC's 5-year strategic planning
committee; and Lambda Lesbian and Gay Community services.
We are pleased to have you here today. I want to inform you
that, in this committee's practice, all witnesses who appear
before us do so under oath, so we'd like to administer and oath
to you if you would please stand and raise your right hands.
[Witnesses sworn.]
Chairman Waxman. The record will indicate that each of the
witnesses answered in the affirmative.
Your prepared statements will be in the record in full.
We'd like to ask, however, that you limit the oral
presentation to 5 minutes. And we will have a clock that will
tell you, for 4 minutes, it is green; and the last minute, it
will turn orange; and when the time is up, it will turn red.
Dr. Holtgrave, let's start with you. There is a button on
the base of the mic. Be sure it is pressed so we can hear you.
STATEMENTS OF DAVID HOLTGRAVE, PH.D., PROFESSOR AND CHAIR,
DEPARTMENT OF HEALTH, BEHAVIOR AND SOCIETY, JOHNS HOPKINS
BLOOMBERG SCHOOL OF PUBLIC HEALTH; ADAORA A. ADIMORA, M.D.,
DIVISION OF INFECTIOUS DISEASES, UNIVERSITY OF NORTH CAROLINA
SCHOOL OF MEDICINE; GEORGE AYALA, PSY.D., RESEARCH HEALTH
ANALYST, RTI INTERNATIONAL AND AIDS PROJECT LOS ANGELES;
HEATHER HAUCK, DIRECTOR, AIDS ADMINISTRATION, MARYLAND
DEPARTMENT OF HEALTH AND MENTAL HYGIENE; AND FRANK OLDHAM, JR.,
PRESIDENT, NATIONAL ASSOCIATION OF PEOPLE WITH AIDS
STATEMENT OF DAVID R. HOLTGRAVE, PH.D.
Mr. Holtgrave. Chairman Waxman, Representative Davis and
distinguished members of the committee, thank you for the
opportunity to speak with you.
Today's hearing is truly urgent. CDC's HIV incidence
estimate suggests that there is a new infection every 9\1/2\
minutes in the Nation. There is an AIDS-related death every 33
minutes. The ratio in ethnic health disparities are staggering.
And the lifetime HIV care and treatment costs for one person
can easily top $275,000.
Because of the new incidence estimates, one might ask two
key questions: Are HIV prevention programs effective, and are
they delivered at a sufficient scale in the United States? My
answer will be yes to the first question and no to the second.
To assess prevention effectiveness at the National level, we
must examine HIV transmission rates. Obviously, HIV is spread
from a person living with the virus to someone who is HIV
negative. The transmission rate is the number of new HIV
infections in a year divided by the number of people living
with HIV in that year. As seen in this first slide the HIV
transmission rate dropped from over 92 in 1980 to 6.6 in 1991.
On the second slide, we see that the transmission rate
stayed at roughly this level until 1997 when, after the advent
of new therapies, the transmission rate actually went up
temporarily to 7.5. Thereafter it declined once again.
In 2006, the transmission rate appears to be just under 5.
This means over 95 percent of persons living with HIV in the
United States are not transmitting the virus to someone else in
a given year.
Another key measure of prevention success is the difference
between what we observed in the HIV epidemic and what would
have occurred had prevention programs not been in place in
slide three. From the beginning of the epidemic through 2006, I
estimate very conservatively that roughly 362,000 infections
were prevented in the Nation and over 3.3 million quality
adjusted life years were saved.
There is a clear relationship between HIV prevention
program funding and incidence, as seen in the fourth slide. The
bottom line is that, in terms of HIV prevention investment, the
Nation gets what it pays for. One must be concerned, therefore,
that when adjusted for inflation, CDC's HIV prevention budget
has fallen over 19 percent since fiscal year 2002, and in real
dollar terms, the investment in the Minority AIDS Initiative is
also in decline.
Further, CDC's data shows that a small fraction of gay men
in need of HIV prevention services report receiving them.
Clearly our investment in prevention is lacking. We must
therefore scale up the use of evidence-based HIV prevention
tools already at our disposal even as we hope for new
intervention, such as a vaccine. As seen in slide five, some
currently available evidence-based HIV prevention interventions
are readily available to us. What's most important to emphasize
is that we possess the technology to influence HIV-related risk
behaviors, and an extensive scientific literature leaves very
little doubt on that point.
So what is the right level of investment? I estimate that
CDC's HIV prevention budget, now at $0.75 billion, needs to
increase to about $1.32 billion per year and remain, on
average, at that level for about 4 years at least so as to undo
the damage done since fiscal year 2002 and to address HIV
prevention needs in the United States.
What new services could be delivered at this higher level
of investment? On the sixth and final slide, I list some of
these. I believe it would provide sufficient resources to field
the new very large-scale targeted HIV counseling and testing
campaign; a nationwide public information and anti-stigma
campaign; intensive client-centered, evidence-based prevention
services for the minority of persons living with HIV who engage
in any risk behavior that could result in transmission; in
brief, the science-based intervention for 15 million HIV
negative persons at risk of infection.
What public health impact would this achieve? After 4 years
of heightened service delivery, the United States could reduce
HIV transmission rates by 50 percent and HIV incidence by 50
percent. Further, we could achieve and maintain a 90 percent
level of serostatus awareness of persons living with HIV. This
is a great fiscal investment. The cost per infection averted
via this new heightened response would be roughly $27,000, and
that indicates the prevention programs could easily save more
medical resources than cost to implement.
But accountability is key. The proposed intensification of
these programs must be accompanied by a quick but careful
review of current HIV prevention resources across the Federal
Government, and we need a national AIDS plan. Further, the
performance of all HIV prevention resources should be
summarized in an annual report card so that mid-course
corrections can be made.
In conclusion, we are at a historic crossroads in the HIV
Epidemic in the United States. Doing more of the same will
achieve more of the same. And as asserted by a recent report of
Black AIDS Institute, the United States is indeed being ``left
behind.'' But we can find the national will to scale up
evidence-based HIV prevention programs sufficiently to change
the course of the epidemic in the United States once and for
all.
Thank you, again, sincerely for your strong interest in HIV
prevention.
[The prepared statement of Mr. Holtgrave follows:]
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Chairman Waxman. Thank you very much, Dr. Holtgrave.
Dr. Adimora.
STATEMENT OF ADAORA A ADIMORA, M.D.
Dr. Adimora. Thank you for this opportunity to speak with
you.
I have been asked to testify concerning HIV epidemiology in
the United States, particularly with respect to African
Americans, and structural and social forces that affect
individual and community vulnerability HIV.
These are some of the essential concepts. First, individual
level sexual behavior, such as partner number and condom use,
don't completely explain racial disparities in the U.S. HIV
rates. Second, sexual network patterns are critical in the
spread of HIV throughout the population.
A sexual network is a set of people who are linked directly
or indirectly through sexual contact. The distribution of
network characteristics that promote population HIV spread,
like concurrent partnerships and sexual mixing patterns,
appears to differ by race in ways that increase HIV
transmission among African Americans.
Third, social forces and social contacts that is social
macroeconomic and other features that are outside the
individual's control contribute to sexual network patterns that
spread HIV. So some potential pathways between HIV and several
social forces are relatively clear. For example, residential
segregation by race supported by structural mechanisms, like
mortgage lending practices, concentrates poverty in the
segregated group.
Segregation may especially influence young people's HIV
risk since residence often dictates school districts which
influence adolescents' social and sexual networks. Also the sex
ratio, the ratio of men to women, is a key determinant of the
structure of the networks. The sex ratio among African
Americans is strikingly low due to high mortality among Black
men and is further decreased by high incarceration rates.
The relative scarcity of men contributes to low marriage
and higher divorce rates. There is a strong association between
being unmarried and having concurrent partnerships. Poverty,
another force, works with the low sex ratio to help destabilize
marriage and makes marriage less feasible in many Black
communities.
The disproportionate incarceration of Black men
dramatically affects sexual networks in Black communities.
Incarceration disrupts existing partnerships, making it more
likely that each partner will have concurrent partnerships.
While inmates are in prison, they can join gangs and forge new
long-term links with antisocial networks. These new links can
then connect members of high-risk sub groups to previously low-
risk people and their networks. High incarceration rates
contribute to increased unemployment in poor minority
communities, shrinking the number of financially viable male
partners as well as the absolute number of men.
Rod Wallace showed how macro level forces shape social
contacts and AIDS death rates in a New York City borough. In
the 1970's, New York's fiscal crisis prompted city agencies to
embark on a deliberate policy of planned shrinkage of the
populations in Black and Hispanic neighborhoods. The plan
involved withdrawing critical city services, including fire
fighting services, from poor areas that already had high fire
rates. So neighborhoods burned. Many people moved to other
parts of the borough, and social networks and community
structure were disrupted. What was presumably not anticipated
when these policies were implemented were the changes in the
geography of drug abuse that resulted from this migration and
the resulting upsurge years later in HIV.
So, finally, the pathways between social forces and HIV
suggest that continuing to focus prevention efforts solely on
individual risk factors and individual determinants won't
significantly impact HIV rates among Blacks in the United
States. Certainly the search for and implementation of
effective biological and behavioral interventions must continue
and must certainly be funded. However, public health research
must also take into account the social forces that are driving
the extraordinary racial disparity in HIV rates in this
country.
I believe several steps, among others, should be taken
immediately. First, the HIV epidemic among African Americans
should be formally declared a national emergency, and moreover,
the United States should act as if the epidemic is a true
national emergency by developing and appropriately funding an
effective domestic HIV plan that addresses not only biological
and behavioral interventions but also the epidemic's social and
economic roots. This will require involving clinicians and
public health researchers as well as experts in sociology,
economics, political science, criminal justice and other
disciplines.
Second, incarceration affects the health of Black
communities. Attention should be given to the markedly
disproportionate incarceration of Black men.
Third, comprehensive sex education can be effective in
reducing risky sexual behavior and should be given in schools.
Thank you very much.
[The prepared statement of Dr. Adimora follows:]
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Chairman Waxman. Thank you very much, Dr. Adimora.
Dr. Ayala.
STATEMENT OF GEORGE AYALA, PSY.D.
Dr. Ayala. Chairman Waxman and distinguished committee
members, thank you for this opportunity to speak with you today
on the critical topic of HIV prevention in the United States.
It is my privilege to be here with you today.
Presently HIV prevention in the United States lacks the
resources and comprehensiveness that will significantly drive
down HIV incidence rates, as has been demonstrated by my
esteemed colleague Dr. Holtgrave. I ask that you consider the
following: Serious HIV-related health disparities often fueled
by stigma and discrimination continue to undermine HIV
prevention efforts in communities of color. Men who have sex
with men continue to make up the majority of new HIV infections
nationally, across race and ethnicity, with Black and Latino
men especially hard hit. Only four of the CDC's 49 recommended
evidence-based interventions specifically target gay men, and
only one of them is designed to address the needs the gay men
of color.
In addition, and just as important to consider, are these
facts: Substance abuse, prevention and treatment are
underfunded and not routinely viewed as integral to overall HIV
prevention efforts. Structural interventions are not commonly
researched or endorsed, even when sound science support their
broadbased adoption, as has been the case with multi-component
syringe access and disposal programs.
Other than new HIV treatments, we have not yet harnessed
the full potential of other promising biomedical interventions,
including pre-exposure prophylaxis and microbicides. And many
science-based prevention interventions are difficult for
community-based providers to implement because they were tested
under research conditions that are different from real-life
settings or tested on populations other than those currently
most vulnerable to HIV infection.
While HIV testing and treatment are crucial in our fight
against AIDS, a singular focus on testing and treatment is
inadequate and narrows an already sparse continuum of
prevention strategies. We need a comprehensive national HIV
prevention plan in the United States. At its core, such a plan
would, one, work to eliminate disparities in health access and
stigma associated with HIV, drug use, and homosexuality. The
personal benefits of knowing one's HIV status early are lost on
those who must overcome the significant barriers to treatment
and persistent stigma that keep so many away from care.
Two, target interventions to those most at risk to HIV
exposure and keep a steady and respectful focus on the
prevention needs of gay and bisexual men, substance users and
women at sexual risk. The alternative is that we accept silence
and denial about sexuality, drug use and economic and equality,
permitting stigma and discrimination to compromise our
provision efforts.
Three, ensure that priority be given to expanding social
science and intervention research aimed at gay and bisexual
men, especially men of color.
Four, make the prevention and treatment of drug and alcohol
addiction central to our HIV prevention efforts. The risk for
HIV infection is heightened by drug and/or alcohol abuse.
Five, research and adopt community-sensitive structural
interventions to compliment behavior modification programs.
Structural level changes buttress the gains and behavior change
made through individually geared prevention interventions by
addressing the social factors that were addressed by my
colleague Dr. Adimora that underline HIV vulnerability.
Six, support continued HIV treatment, vaccine and other
biomedical interventions that are safe, ethical, and show
promise of efficacy.
And finally, seven, balance the policy of promoting pre-
packaged evidence-based HIV prevention interventions by
supporting and evaluating more localized bottom-up and
collaborative HIV prevention strategies. It is critical to
respect on-the-ground responses to the HIV/AIDS epidemic by
protecting local control over how HIV prevention strategies are
developed, researched, prioritized and implemented.
In closing, HIV prevention efforts in general have not
received the funding needed to make them ubiquitous and
continuous, nor have our resources been adequately targeted to
reach those at highest risk for HIV infection. We need a
comprehensive national HIV prevention plan in the United States
that clear clearly calls for culturally relevant, multilevel
combination approaches that are well funded, targeted and
sustained over many years.
Thank you.
[The prepared statement of Dr. Ayala follows:]
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Chairman Waxman. Thank you very much Dr. Ayala.
Ms. Hauck.
STATEMENT OF HEATHER HAUCK
Ms. Hauck. Good afternoon, Mr. Chairman, Representative
Davis, members of the committee.
Thank you for inviting me to participate on this very
distinguished panel.
State Health Department AIDS directors appreciate that this
committee is focusing on domestic HIV prevention activities,
especially in light of the CDC's release of new HIV incidence
estimates and the alarming rates of infection among African
Americans and gay and bisexual men of all races and
ethnicities.
I will focus today on describing State Health Department
HIV prevention portfolios, including the central importance of
HIV/AIDS surveillance. I will also share key recommendations
from State AIDS directors for an HIV prevention response to end
the epidemic in our Nation.
State Health Department HIV directors are responsible for
implementing comprehensive HIV prevention care and treatment
strategies in our States. We are stewards of more than half of
CDC's $692 million budget for domestic HIV prevention
surveillance programs, as well as significant State resources.
All States implement CDC's required HIV prevention program
components, such as HIV counseling, testing, and referral,
partner services, health education risk reduction, community
planning, and program evaluation. Over the past 6 years,
however, CDC's funding to State and local health departments
has decreased by $30 million. For many States, especially
medium and low prevalence States, this decline in Federal
funding has resulted in significant reductions in core
components of HIV prevention services. At the same time, there
has also been an increased directive from CDC to focus
resources on HIV testing. When faced with such directives and
funding reductions, States are forced to eliminate effective
interventions that are needed to prevent HIV transmission in
our regions or among our populations.
HIV prevention efforts must be aligned to meet the needs of
those who bear the greatest HIV/AIDS burden in the United
States. As the recent CDC HIV incidence estimates clearly
illustrate, African Americans, men and women, and gay and
bisexual men of all races and ethnicities are significantly
impacted by HIV. State and local health department HIV programs
work to eliminate health disparities based on race, ethnicity,
gender, sexual identity, and class.
In Maryland, our data show that HIV largely
disproportionately impacts African Americans, regardless of
transmission risk category, and therefore we prioritize the
reduction of health disparities among racial and ethnic
communities as a cross-cutting theme for all of our HIV
initiatives.
A central activity of State HIV prevention programs is
measuring and describing the epidemic through HIV surveillance
activities. These activities are essential to understanding our
local HIV epidemics so that we can then target HIV prevention
activities appropriately. These data also determine the
allocation and distribution of resources for HIV care and
treatment via the Ryan White Program.
The CDC has been unable to adequately sustain funding for
core surveillance or for projects such as the incidence
surveillance projects which led to the new estimates released
in August. For example, Maryland's total budget for HIV/AIDS
surveillance was reduced by 40 percent in the last year, and
the State is no longer funded for incidence surveillance.
The loss of surveillance funds in the States jeopardizes
our ability to know the populations most impacted by the HIV
epidemic: in Maryland, heterosexuals ages 30 through 49,
disproportionately African American and living in the Baltimore
metro area, Prince George's and Montgomery Counties. If we
can't describe our epidemics, we can't plan effective HIV
prevention strategies and interventions appropriate for our
local communities. The CDC needs additional funding to restore
and expand incidence surveillance and to shore up core
surveillance across all jurisdictions.
AIDS directors articulated our vision for America's
prevention response in a new blueprint for the Nation, Ending
the Epidemic Through the Power of Prevention, and copies have
been made available to the committee.
Three key elements are required to successfully reduce the
number of new HIV infections. One, adequately fund CDC's HIV
prevention and surveillance program at the level of at least
$1.3 billion annually. Two, significantly invest in
interventions that work to prevent infection, including
research to develop new population specific interventions,
access to sterile injection equipment, enhanced program in
correctional settings, and establish a comprehensive sexuality
education as the standard. Three, meaningfully invest in
programs that support HIV prevention, including STD treatment,
hepatitis vaccinations, substance abuse prevention and
treatment, mental health services, housing, and expanded
research for biomedical intervention.
State and local health departments know that HIV prevention
works, and we know that health department, health care
providers, businesses, faith leaders, community based
organizations, and persons living with HIV and AIDS must all be
equipped with adequate tools and resources to help prevent new
infections.
Thank you again for holding this important hearing and for
your thoughtful consideration of our recommendations to
increase access to HIV prevention interventions provided by
State and local health departments. I look forward to answering
any questions you may have.
Chairman Waxman. Thank you very much.
[The prepared statement of Ms. Hauck follows:]
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Chairman Waxman. Mr. Oldham.
STATEMENT OF FRANK OLDHAM
Mr. Oldham. Chairman Waxman and the entire Oversight
Committee, people living with HIV/AIDS thank you for your
demonstrated leadership and an opportunity to speak with you
about the state of HIV prevention in the United States of
America.
As a trusted and representative voice of more than 1
million people living with HIV/AIDS in America, I say with
great confidence that we know our status, and that has enabled
us to save lives.
HIV-related stigma and homophobia, homo-hatred continue to
result in disproportionate HIV incidence among gay and bisexual
men, Black and Hispanic men and women, and individuals
challenged by poverty, incarceration, and mental illness. As a
Black gay man, a person living with AIDS, and as a proud
American, I ask, is this acceptable in our America?
HIV prevention can only succeed through access to evidence-
based interventions, accurate information and education,
protected and voluntary HIV testing and screening services,
effective use of care--HIV care and treatment as prevention,
reduced stigma, and increased support for sero status
disclosure, and by addressing structural, systemic, and
economic barriers that continue to perpetuate HIV vulnerability
among the most marginalized groups of Americans.
This is the basis of support for our communities' call for
a national AIDS strategy that is coordinated, evidence based,
outcome driven, and inclusive of people living with HIV/AIDS.
We have heard testimony from the Centers for Disease
Control that annual HIV incidence has been as much as 40
percent higher in the past 15 years. Prevention efforts have
been flat-funded in our country for more than two decades, and
the Minority AIDS Initiative has not been funded adequately to
address the real HIV needs in communities of color.
As we increase resources for minority AIDS initiatives, we
must be sure to hold organizations that receive MAI funds
accountable. We must scale up HIV prevention in America to an
annual investment of $1.3 billion. This investment will prove
to those at increased risk for HIV that we care about their
lives.
We hope that this will be a priority for the next
administration. In the meantime, we urge an initial investment
of $200 million for fiscal year 2009. The AIDS communities
consent to this request.
Eight years of abstinence only until marriage programs has
had dire human consequences. HIV risk reduction strategies such
as comprehensive sex education and syringe exchange programs
have been proven to reduce HIV infections; yet, these
interventions have not received the requisite level of Federal
funding. It is imperative that we make decisions based in
science and don't sacrifice lives and waste already constrained
resources on programs that have been proven to be ineffective.
The vast majority of individuals aware of their status are
making decisions about their health and behavior that are not
contributing to the spread of HIV. And I repeat, that are not
contributing to the spread of HIV. Diagnosis, care, and
treatment is effective HIV prevention, and our lives depend on
it. This is all the more reason why we must ramp up our efforts
to make sure people are aware of their HIV status.
Sixteen years ago, the National Association of People With
AIDS launched National HIV Testing Day, because we believe that
taking an HIV test makes it possible for people to protect
themselves and their loved ones. NAPWA supports increased in
targeted testing at-risk populations, routine opt out screening
for HIV in medical settings, and strongly believes there is an
obligation to link people who test positive to high quality
care, treatment, and support services. The Kaiser Foundation
continues to report that 45 to 55 percent of those with HIV are
still not in care; 45 to 55 percent of people who have HIV are
not in care.
Whether by the passing of the Early Treatment for HIV Act
or efforts to reform health care, America must ensure access to
comprehensive and coordinated care for all persons living with
HIV/AIDS. Aggressive research and treatment advances have
helped more people live with HIV than ever before. The benefits
of this research extend beyond HIV.
CDC needs more resources to do the requisite research and
work on the ground. HRSA, the National Institutes of Health,
and the substance abuse and health agencies also need
appropriate resources to identify new research opportunities
and collectively further expand the toolkit of prevention
strategies.
Perceptions of stigma directly impact an individual's
willingness to be open about their HIV status. NAPWA invites
more leadership from all sectors of American society in life to
increase the visibility of people living with HIV and AIDS, and
opposes stigmatizing or negative language toward them. This is
especially true in minority communities, in gay communities,
and all communities challenged with social and economic
inequality. The critical issue of AIDS in America must be a
priority for all of us.
NAPWA supports HIV prevention activities that are
culturally and gender specific. NAPWA supports community
mobilization strategies for all communities disproportionately
impacted by this disease, and will launch the first National
Gay Men's HIV Awareness Day on September 27th, later this
month, in Raleigh, North Carolina. They will seek to accomplish
increased awareness about the needs of gay men for HIV
prevention, care, and treatment, forums to strategize effective
responses to the epidemic in our community. We ask your support
on this historic day, Gay Men's HIV Awareness Day, September
27th. Thank you.
Chairman Waxman. Thank you very much, Mr. Oldham.
[The prepared statement of Mr. Oldham follows:]
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Chairman Waxman. I thank all of you for your testimony. Dr.
Holtgrave, you prepared for us your idea of what a budget
should be for HIV prevention, and it seems like what you've
suggested is pretty much in the same ball park as what CDC said
to us was their best professional judgment. Would you say that
is an accurate statement?
Mr. Holtgrave. I would say so. I would say there are more
points of agreement probably than disagreements. I think that
the central message probably from both is that we need to
substantially scale up our investment in HIV prevention. And,
also, that it is achievable to think about reducing
transmission rates and incidence by 50 percent in the United
States, and that it will take some years to do so.
I think some of the difference in terms of the $1.3 billion
versus, say, the $1.7 billion or so that CDC called for is that
they have some research funding, some activities on STD, TB,
and hepatitis, which are very important, but that allows for
some of the difference. And also, I think we could even be a
little bit more aggressive and achieve the 50 percent reduction
a bit sooner than CDC has estimated. But, again, I think there
is much more to agree than disagree between the two estimates.
Chairman Waxman. But both you and CDC suggest that we could
be preventing many more HIV infections than we are doing now,
as well as increasing the proportion of people who know their
HIV status, which of course goes together.
Do you think that the two estimates reflect a general
consensus among HIV experts that better outcomes are within
reach, even based on current knowledge?
Mr. Holtgrave. I believe so. I think there is a general
consensus scientifically that we have an outstanding array of
tools, some of which that Dr. Fauci mentioned earlier, that are
available to us now. And we need to make sure that we are using
those tools. We must develop vaccines, we must develop
microbicides. But we need to use immediately what we have
available at our disposal.
Chairman Waxman. Thank you.
Dr. Adimora, I thought your presentation was very
interesting. You presented a perspective that I hadn't heard
before within the African American community. One of the
aspects of the African American community, especially those who
have HIV and AIDS, is that they live--many of them, if not most
of them, live in poverty. How does poverty contribute to HIV
risk for African Americans?
Dr. Adimora. There are a variety of pathways between
poverty and HIV and population HIV transmission. In fact, I
would consider this to be consider the culprits to be not only
poverty, but also racial discrimination.
Among the pathways that I mentioned were segregation. And I
mentioned some of the ways by which it works in terms of
structuring people's social and sexual networks. Particularly
alarming is the way in which it can structure the sexual
networks of youth. Another issue concerning poverty is
homelessness. Homeless people are particularly at risk for HIV.
I mentioned just a few of the potential structural
interventions that could be implemented, but I think that
attention to homelessness and improved housing is certainly a
major consideration, and that relates certainly to poverty.
Another issue is incarceration, given the disproportionate
incarceration of Black men. And I think that it is important,
in thinking about incarceration, there is sometimes a tendency
to start talking about mandatory testing in prison. Certainly
everyone should have available to them a means for learning
their HIV diagnoses and for appropriate treatment; but in
addition, I think that incarceration is actually a major symbol
of racial discrimination and oppression in this country, and
there needs to be--significant attention needs to be paid to
because of the myriad of consequences that it is having--well,
certainly it is wrong in the first place. But the other issue
is that it is clearly having an impact on the health of people,
particularly Black people.
Chairman Waxman. You mentioned incarceration in your
original presentation to us. And you said, not only are people
getting HIV when they are incarcerated, but that there is a
social disruption that imprisonment causes. I thought that was
an interesting point. Do you see bias, racial bias as well as
discrimination among gay and bisexual men in the Black
community as factors that are important for us to take note of?
Dr. Adimora. Unquestionably. There are pathways between
racial discrimination and HIV infection. This is beyond a
matter of simply social justice because that is a good thing.
The absence of social justice is a major root cause of many of
the racial disparities in health that we are seeing in the
United States, and specifically of HIV infection.
Chairman Waxman. Dr. Ayala, do you have recommendations on
how programs should take into account the specific needs of gay
and bisexual men of color?
Dr. Ayala. As I said in my testimony, very, very few of the
recommended prevention interventions are specifically designed
or geared to men of color, gay men of color.
I think we have to do two things. One, we have to invest in
a greater research portfolio that build HIV prevention
interventions that are specifically geared to gay, gay men of
color. And the second thing is that we should take what we have
available and tailor them for use in the communities, both for
the target population in question, but also with consideration
to the needs of providers who have to ultimately implement the
interventions.
Chairman Waxman. Ms. Hauck, at the State level, you stated
surveillance measuring and monitoring the HIV/AIDS epidemic is
crucial to HIV prevention efforts. The surveillance data not
only helps you understand the epidemic but appropriately
targeting resources. And I understand that Maryland was among
eight States that actually lost funding, and you mentioned this
in your opening statement, to conduct the kind of new incidence
measurements in which the CDC based its recent estimates.
What has been the impact of this cut on Maryland and other
States?
Ms. Hauck. Thank you for the question. What happened at the
State level was that our surveillance activities had been
integrated. So we certainly received funding for core
surveillance, which is really the basics of HIV surveillance
and AIDS surveillance. And then we received these--funding for
these projects. And we had integrated all of the activities, so
that we were really gathering information in a holistic way
about our epidemic.
When you start to peel off special projects that have been
integrated into your core surveillance activities, you are no
longer able to fully fund the staff that are gathering the
information, you are not able to do the data collection that we
need to the level that we need the data in order to accurately
describe our epidemic. So we may be missing some important
components, like risk transmission categories, like race, like
ethnicity, as well as potentially missing cases, because it is
a rather intensive process to gather this information through
our surveillance activities.
So I think over time, what you will see is that States
aren't able to sustain even our core surveillance activities,
which again allow us to describe our epidemics, and, therefore,
use that funding to allocate, distribute, and plan prevention
as well as care and treatment services in our jurisdictions.
Chairman Waxman. CDC presented to us their professional
judgment of what the budget should look like; and they would
request more funding to strengthen behavioral and clinical
surveillance activities in the States. Do you think that they
have adequately funded that aspect, in their professional
judgment, budget?
Ms. Hauck. The National Alliance of State and Territorial
AIDS Directors certainly states that at least an investment of
$35 million in additional funding for surveillance is needed to
both restore the cuts in surveillance that we've seen over time
and to really bring all the jurisdictions up to standard
operating budgets.
Chairman Waxman. Dr. Fenton in the first panel testified
about the importance of integrating HIV services with services
for other sexually transmitted diseases. I want to ask you
about that at the State level.
Since 2000, the rate of syphilis in the United States has
increased by 76 percent. As you know, this epidemic is
primarily concentrated in the southeastern region of the United
States among heterosexual African Americans and men who have
sex with men. What will the States need to do to eliminate
syphilis in these impacted populations? And, should those
efforts be coordinated with HIV prevention efforts?
Ms. Hauck. Thank you for asking the question, Mr. Chairman.
I'll answer the first part first.
Yes, the CDC's budget for STD prevention has suffered many
of the same declines that the HIV prevention budget has
suffered over the years. Maryland is a southern State as well,
and has certainly seen a significant syphilis epidemic,
especially in Baltimore City and Prince Georges County, among
African Americans, particularly men who have sex with men, and
heterosexuals. And yet our funding has not kept pace with our
need to address the syphilis epidemic in our State and
certainly the majority of States that have had a syphilis
epidemic. So I would say that the increase in resources is also
needed. And we do integrate and do need to continue to
integrate STD prevention and HIV prevention at the State level
and at the local level.
Many of the clients who come to seek services certainly
need to be given similar messages, similar education, similar
screening, and need to receive that in a holistic manner when
they walk in the door of a clinic or an emergency room or a
community-based organization, and we need the resources to
enable the clients to receive those services at the time when
they see them. Thank you.
Chairman Waxman. Thank you. We have infection rates
continuing to rise among men who have sex with men, and in the
meantime, discrimination and marginalization of men who have
sex with men remains widespread.
Mr. Oldham, how does discrimination on the basis of sexual
orientation affect gay and bisexual men who are living with
HIV? And have any national campaigns in the U.S. HIV prevention
directly addressed this kind of discrimination?
Mr. Oldham. There have been campaigns from community-based
organizations, such as Gay Men's Health Crisis, the L.A. Gay
and Lesbian Center in Los Angeles, and AIDS-Positive Los
Angeles. However, there has not been the governmental
campaigns. Like, for example, we have National Black AIDS
Awareness Day, Chairman Waxman, we have National Hispanic AIDS
Awareness Day and a number--there are 12 of them.
Even though the new CDC numbers indicate that gay men of
all ethnic backgrounds make up the bulk of the epidemic and the
loss of life in the epidemic, we do not even have a Gay Men's
HIV/AIDS Awareness Day, which is why NAPWA is launching this on
the 27th, to make sure that gay men are aware and are involved
in this epidemic and not complacent about it themselves, and
the rest of society deals with the issues of homophobia and
homo-hatred, as barriers to HIV prevention and care services
for gay men.
Chairman Waxman. I want to thank all of you on this panel
for your presentation and your willingness to answer questions.
We may have members submitting to you additional questions,
which you may respond to in writing for the record, because I
know many members had a lot of things that they wanted to
pursue but there are so many competing things going on that not
everybody can be here.
I think the purpose of this hearing has been to sound an
alarm, because we have an increasing HIV epidemic in the United
States. It is different than where we were in the early days,
but it is very much with us. And unless we set a high priority
to do the things we know that will work and to try to research
and develop new ways of approaching the epidemic, we are going
to fall further and further behind.
We know that when budgets are sent to us, they are budgets
that are developed ultimately by the budget people in the
administration. They may get the input from the agencies and
the experts, but they are trying to figure out their overall
priorities. And the overall priority for this administration
has not been to deal with the HIV/AIDS epidemic in the way that
we need to, to stop and prevent the transmission of this
disease.
That is why I was pleased to have CDC and NIH present to us
what their best professional judgment would be. It is always
different when you ask that than what they have to say to us
when they are making presentations before Congress, because
then their presentations have to be consistent with the views
of the administration in which they serve.
Well, I think that presentation to us and your expanded
discussion of the groups that are primarily affected and all
the complications that we need to be aware of is going to help
us face this epidemic and, I hope, to defeat it. Thank you very
much for your presentation.
That concludes the presentations at this hearing, and we
stand adjourned.
[Whereupon, at 12:33 p.m., the committee was adjourned.]