[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


  Available via the World Wide Web: http://www.gpoaccess.gov/congress/
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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.]

                                 
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