    [Senate Hearing 111-298]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 111-298

                        PUBLIC HEALTH CHALLENGES IN OUR
                                NATION'S CAPITAL

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

                                    HEARING

                                   before the

                      OVERSIGHT OF GOVERNMENT MANAGEMENT,
                         THE FEDERAL WORKFORCE, AND THE
                       DISTRICT OF COLUMBIA SUBCOMMITTEE

                                     of the

                                  COMMITTEE ON
                             HOMELAND SECURITY AND
                              GOVERNMENTAL AFFAIRS
                              UNITED STATES SENATE

                         ONE HUNDRED ELEVENTH CONGRESS

                                 FIRST SESSION

                                   __________

                                  MAY 19, 2009

                                   __________

           Available via http://www.gpoaccess.gov/congress/index.html

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

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    51-030 PDF                WASHINGTON : 2010
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    20402-0001

            COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS

                   JOSEPH I. LIEBERMAN, Connecticut, Chairman
    CARL LEVIN, Michigan                 SUSAN M. COLLINS, Maine
    DANIEL K. AKAKA, Hawaii              TOM COBURN, Oklahoma
    THOMAS R. CARPER, Delaware           JOHN McCAIN, Arizona
    MARK L. PRYOR, Arkansas              GEORGE V. VOINOVICH, Ohio
    MARY L. LANDRIEU, Louisiana          JOHN ENSIGN, Nevada
    CLAIRE McCASKILL, Missouri           LINDSEY GRAHAM, South Carolina
    JON TESTER, Montana
    ROLAND W. BURRIS, Illinois
    MICHAEL F. BENNET, Colorado

                      Michael L. Alexander, Staff Director
         Brandon L. Milhorn, Minority Staff Director and Chief Counsel
                      Trina Driessnack Tyrer, Chief Clerk

      OVERSIGHT OF GOVERNMENT MANAGEMENT, THE FEDERAL WORKFORCE, AND THE
                       DISTRICT OF COLUMBIA SUBCOMMITTEE

                       DANIEL K. AKAKA, Hawaii, Chairman
    CARL LEVIN, Michigan                 GEORGE V. VOINOVICH, Ohio
    MARY L. LANDRIEU, Louisiana          LINDSEY GRAHAM, South Carolina
    ROLAND W. BURRIS, Illinois
    MICHAEL F. BENNET, Colorado

            Lisa M. Powell, Chief Counsel and Acting Staff Director
                           Christine S. Khim, Counsel
                 Jennifer A. Hemingway, Minority Staff Director
              Thomas A. Bishop, Minority Professional Staff Member
                       Benjamin B. Rhodeside, Chief Clerk

                                C O N T E N T S

                                     ------
    Opening statement:
                                                                       Page
        Senator Akaka................................................     1

                                   WITNESSES
                             Tuesday, May 19, 2009

    Pierre N.D. Vigilance, M.D., MPH, Director, District of Columbia
      Department of Health...........................................     3
    Shannon L. Hader, M.D., MPH, Senior Deputy Director, HIV/AIDS
      Administration, District of Columbia Department of Health......     5
    Raymond C. Martins, M.D., Chief Medical Officer, Whitman-Walker
      Clinic, and Clinical Professor of Medicine, George Washington
      University.....................................................     7

                         Alphabetical List of Witnesses

    Hader, Shannon L., M.D., MPH:
        Testimony....................................................     5
        Prepared statement...........................................    38
    Martins, Raymond C., M.D.:
        Testimony....................................................     7
        Prepared statement...........................................    51
    Vigilance, Pierre N.D., M.D., MPH:
        Testimony....................................................     3
        Prepared statement...........................................    23

                                    APPENDIX

    Background.......................................................    55
    Paul Strauss, a U.S. Senator for the District of Columbia
      (Shadow), prepared statement...................................    67

                PUBLIC HEALTH CHALLENGES IN OUR NATION'S CAPITAL

                                  ----------

                             TUESDAY, MAY 19, 2009

                                     U.S. Senate,
                  Subcommittee on Oversight of Government
                         Management, the Federal Workforce,
                                and the District of Columbia,
                          of the Committee on Homeland Security
                                            and Governmental Affairs,
                                                        Washington, DC.
        The Subcommittee met, pursuant to notice, at 2:48 p.m., in
    room SD-342, Dirksen Senate Office Building, Hon. Daniel K.
    Akaka, Chairman of the Subcommittee, presiding.
        Present: Senator Akaka.

                   OPENING STATEMENT OF SENATOR AKAKA

        Senator Akaka. This hearing will come to order.
        Good afternoon, everyone. Thank you for joining us today as
    the Subcommittee on Oversight of Government Management, the
    Federal Workforce, and the District of Columbia meets to
    evaluate the current state of public health in the District,
    examining the health challenges facing its residents, and the
    steps being taken to respond to those challenges.
        D.C. has the highest rate of HIV/AIDS in the Nation, a
    distinction that is cause for great concern. The 2008 HIV/AIDS
    Epidemiology Update concluded that at least 3 percent of
    District residents live with HIV or AIDS. More than one-third
    of those infected are unaware of their HIV status. Data from
    the Centers for Disease Control (CDC) confirm that infection
    rates among D.C. residents have remained among the highest in
    the Nation for a number of years now. These figures also show
    HIV infection cutting across all demographics, highlighting the
    need for initiatives designed to reach people of every race,
    income level, and orientation.
        The HIV statistics have not been all negative. Overall, the
    District's publicly supported HIV testing increased by 70
    percent from 2007 to 2008. In 2007, only one baby was born with
    HIV in the District compared to 10 babies in 2005, indicating
    that pregnancy initiatives are taking root.
        These improvements are due in no small part to the D.C.
    Department of Health (DOH) and HIV/AIDS Administration, which
    have focused their efforts on increased testing and prevention,
    working with the D.C. Public Schools to offer education and
    sexually transmitted disease (STD) testing. Also in place is a
    drug assistance program under which some residents receive free
    medication to treat their HIV.
        While HIV/AIDS Administration initiatives offer promise,
    there is still much work to be done, especially in the area of
    testing. If residents do not know their HIV status, they cannot
    seek treatment and they may be at greater risk of spreading the
    virus to others.
        In addition to HIV/AIDS, D.C. has a disproportionately high
    chronic disease burden compared with the rest of the Nation.
    One-third of D.C. residents suffer from heart disease,
    diabetes, or kidney disease. These diseases share common risk
    factors including high blood pressure and being overweight. In
    2007, 55 percent of D.C. adults and 18 percent of youths were
    obese or overweight. The District must promote proper diet and
    exercise to lessen the burden of chronic disease.
        Late last year, Mayor Adrian Fenty announced the Chronic
    Care Initiative to increase chronic disease testing and
    treatment. The Initiative also aims to address common risk
    factors by promoting a healthy lifestyle.
        I want to highlight two work groups focused on addressing
    obesity and preventing health risks early in life. The D.C.
    Obesity Work Group is charged with creating a citywide obesity
    action plan to be released later this year. The School Health
    Work Group focuses on providing healthier food options,
    especially to students in the D.C. Public Schools.
        The DOH participates in the Obesity and School Health Work
    Groups and has developed the Child Health Action Plan, which
    addresses a range of health risks including obesity and
    encouraging students to make healthy and informed decisions. I
    am pleased the DOH recognizes the need to prevent health risks
    early in life.
        It will not be easy to ensure that people seek routine
    testing and primary health care, especially when they do not
    have insurance or qualify for special assistance. Nevertheless,
    we must act to slow the growth of all diseases and to promote
    health. I have long supported programs to prevent, detect, and
    more effectively treat chronic diseases and medical conditions.
    In addition, I have led efforts to improve access to quality
    health care for indigenous people as well as racial and ethnic
    minorities who often lack access and suffer disproportionately
    from certain diseases such as diabetes.
        The DOH cannot overcome health challenges alone. It is
    important to work with community organizations to reach as many
    people as possible. I am encouraged by partnerships between the
    DOH and community groups and hope more alliances are formed to
    address all of D.C.'s health issues.
        Today's hearing is meant to foster an ongoing dialogue on
    these important issues as we gain a greater understanding of
    D.C.'s health challenges and possible solutions to those
    challenges. I look forward to hearing from our witnesses today.
        I would now like to welcome today's witnesses to the
    Subcommittee: Dr. Pierre Vigilance, who is the Director of the
    D.C. Department of Health; Dr. Shannon Hader, who is the Senior
    Deputy Director of the HIV/AIDS Administration; and Dr. Raymond
    Martins, who is the Chief Medical Officer at the Whitman-Walker
    Clinic in D.C.
        It is the custom of this Subcommittee to swear in all
    witnesses. I would ask all of you to stand and raise your right
    hand. Do you swear that the testimony you are about to give
    this Subcommittee is the truth, the whole truth, and nothing
    but the truth, so help you, God?
        Dr. Vigilance. I do.
        Dr. Hader. I do.
        Dr. Martins. I do.
        Senator Akaka. Thank you very much. Let the record show
    that the witnesses responded in the affirmative. I want the
    witnesses to know that while your oral statements are limited
    to 5 minutes, your entire statements will be included in the
    record.
        Dr. Vigilance, please proceed with your statement.

    TESTIMONY OF PIERRE N.D. VIGILANCE, M.D.,\1\ DIRECTOR, DISTRICT
                    OF COLUMBIA DEPARTMENT OF HEALTH

        Dr. Vigilance. Thank you, Chairman Akaka, distinguished
    Members of the Subcommittee. I am Pierre Vigilance, and I am
    the Director of the District of Columbia's Department of
    Health. I am honored to testify before you today on public
    health challenges in the Nation's capital, and I am pleased to
    be joined by Drs. Hader and Martins as we discuss the HIV/AIDS
    epidemic in the District as well. Thank you, Chairman Akaka,
    for your significant work and your service in the health care
    arena. It goes to some extent to show how dedication to this
    particular field has benefited us significantly, and hopefully
    today's testimony will assist you in your work.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Dr. Vigilance appears in the Appendix
    on page 23.
    ---------------------------------------------------------------------------
        Public health prevents illness, it promotes wellness, and
    it protects the people from health threats. Public health saves
    lives, and at a time when health care reform is front and
    center in our national policy debate, many agree that public
    health is the missing factor that can lead to cost-saving
    solutions needed to save our Nation's health. Effective public
    health practice educates people, advocates for the conditions
    that promote wellness, links people to care, and provides
    access to treatment.
        The District's Department of Health is an agency of 836
    staff with an annual budget of $268 million. Our work spans the
    public health spectrum from oversight, inspection, and
    regulation of health facilities to emergency preparedness,
    addictions prevention, community health, and HIV/AIDS.
    Annually, the department provides immunizations to over 3,600
    people. Last year, we facilitated access to care through a
    network of community clinics that serve some 93,000 people. We
    investigated 775 communicable disease cases, removed
    approximately 130,000 potentially tainted needles from the
    street, and inspected 388 health facilities.
        The District boasts a high rate of health insurance
    relative to similar jurisdictions across the country, with 90.5
    percent of our residents being insured but only 20 percent of
    them indicating that they have a regular source of care. In
    fact, some 3,000 District residents die each year from
    preventable causes of death: Heart disease, cancer,
    cerebrovascular disease, accidents, and HIV/AIDS.
        We understand that the reasons for this are a combination
    of factors affecting lifestyle, including poverty, illiteracy,
    unemployment, poor health conditions, social inequities that
    influence access to health care, and other resources that
    influence health themselves. Behavior plays a part, but all
    poor health outcomes cannot be attributed to this alone.
        The breadth of problems facing our communities require that
    we partner with our local non-government agencies, businesses,
    and sister agencies, such as Health Care Finance, Parks and
    Recreation, Homeland Security, Fire and Emergency Medical
    Services (EMS), just to name a few.
        Obesity is a health challenge to which we have taken a
    collaborative approach. It is a major contributing factor, as
    you mentioned, to many chronic illnesses, including
    hypertension, cardiovascular disease, and stroke. Youth in the
    District suffer disproportionately from obesity, and our work
    in the D.C. Public Schools shows that 17.5 percent of D.C.
    Public School students self-report that they are obese. The
    Obesity Work Group that you mentioned comprised a number of
    different community stakeholders, workforce leaders, and others
    coming together to strategize on ways to combat obesity.
        I am fortunate to work for an executive who understands the
    importance of effective public health. We also work for an
    empowered City Council, which in 2007 asked us to develop a 5-
    year strategic plan targeting cardiovascular disease, diabetes,
    and kidney disease, a plan that serves as a tool for
    coordinating services to reduce poor health outcomes.
        Since the major causes of chronic kidney disease are high
    blood pressure and diabetes, the Department has funded programs
    to address risk factors such as blood pressure and blood
    glucose control. The Cardiovascular Diseases, Diabetes, and
    Kidney Diseases (CDK) Plan laid the groundwork for the Chronic
    Care Initiative which will guide our city's service delivery
    system toward high reliability, high value, and high quality
    care.
        In 2006, nearly $250 million in tobacco settlement funds
    were dedicated to public health. Initially, funds were directed
    to cancer, tobacco cessation, chronic disease, and health
    information technology. We have invested in the consortium of
    community-based providers to provide a comprehensive tobacco
    cessation program, and we have also invested significantly in
    health information technology, a regional health information
    organization with six diverse community health centers as well
    as two emergency departments.
        In 2007, the Rand Report provided us with a backdrop that
    will guide our distribution of the remaining tobacco settlement
    funds, and we have continued to invest in primary and emergency
    care, and will be investing shortly in a health care facility
    on the old D.C. General site, as well as in other locations in
    the city.
        We will also be working significantly with the incoming
    American Recovery and Reinvestment Act funds which will allow
    us to move some of our health empowerment activities further
    into the communities that we serve.
        Lives can be saved through a very collaborative prevention-
    focused approach to health and wellness. The significant
    economic burden of disease requires that we pay particular
    attention to prevention. More work needs to be done on policies
    that will impact the root causes of health problems, policies
    that effectively address food, content and availability, and
    physical activity opportunities in communities where the health
    disparities are most pronounced.
        More needs to be done to help people understand for what
    they are at risk. Effecting long-term improvements in health
    will take concerted effort and time. From the classroom to the
    boardroom, public health can facilitate the discussion between
    previously disconnected partners and lead us to living
    healthier, more productive lives.
        Senator Akaka. Thank you very much for your statement. Now
    we will hear from Dr. Hader. Please go ahead with your
    statement. Thank you.

      TESTIMONY OF SHANNON L. HADER, M.D., MPH,\1\ SENIOR DEPUTY
        DIRECTOR, HIV/AIDS ADMINISTRATION, DISTRICT OF COLUMBIA
                          DEPARTMENT OF HEALTH

        Dr. Hader. Chairman Akaka, Ranking Member Voinovich, and
    Members of the Subcommittee, I am Shannon Hader, Senior Deputy
    Director of the HIV/AIDS Administration in the District of
    Columbia Department of Health. I appreciate this opportunity to
    present testimony for you on the HIV/AIDS epidemic in the
    District of Columbia, and my oral testimony will cover
    highlights about our new statistics, our strategies and
    initiatives, and, of course, my written testimony covers these
    topics in much more detail.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Dr. Hader appears in the Appendix on
    page 38.
    ---------------------------------------------------------------------------
        Overall, as you mentioned, 3 percent of all District
    residents in our city are currently known to be diagnosed and
    living with HIV and AIDS. To put that in context, U.S. Centers
    for Disease Control and Prevention and the World Health
    Organization (WHO) have historically defined an HIV epidemic as
    ``severe'' when just 1 percent of the overall population is
    affected. These numbers, as you stated, however, reflect only
    the people who have been diagnosed with HIV/AIDS. Targeted
    studies in D.C. show that between one-third and one-half of our
    residents who are already infected with HIV may be unaware of
    their infection. In the District, nearly every population
    group, age group, and ward is experiencing a substantial
    epidemic.
        The District has also one of the most complex epidemics in
    the world, with all three major modes of transmission at high
    levels. Among new cases, heterosexual contact is the highest at
    nearly 40 percent, followed by sex between men who have sex
    with men at about 25 percent, and injection drug use still at
    15 percent.
        I am pleased to share some of the promising results of the
    District's efforts to reduce the disease. Particularly, the
    District's HIV testing programs have greatly increased timely
    testing and early diagnosis among residents and have reduced
    the number of babies born with HIV, as you mentioned in your
    testimony. In addition to reducing the number of babies born,
    we have also seen a 70-percent increase in the number of people
    tested in publicly supported testing from 40,000 in 2007 to
    over 70,000 in 2008.
        The District was actually just recognized by the CDC as one
    of the top three jurisdictions in the country in expanded HIV
    testing. D.C. nearly equaled both New York City and the entire
    State of Florida in absolute numbers of persons tested as well
    as new HIV cases identified.
        These achievements are the mark of true committed
    leadership to reverse the epidemic by our Mayor Adrian Fenty.
    Our modern epidemic requires a modern response. I can summarize
    this in Mayor Fenty's directives to me since I started this
    position, which are essentially go fast, go far, and do not go
    it alone.
        Go fast. The Mayor has repeatedly emphasized a clear
    urgency for response marked by actions that are not just a
    flash in the pan, but are focused for a sustained and impactful
    response. An example of this is our HIV testing program which,
    as I described earlier, has rapidly expanded and already shown
    an earlier diagnostic impact in the course of just 2 years, yet
    is sustainable and scalable. It aims to mobilize our health
    care system to make HIV as regular a test as blood pressure,
    blood sugar, cholesterol, and other vital signs tests. In a
    city where HIV is a common disease, an annual test for HIV must
    be a standard vital sign for every resident's health.
        Go far. The Mayor has directed us to bring the District's
    response to scale and impact. We are ramping up our enrollment
    in care and treatment programs. Through marketing and outreach,
    we have increased enrollment in our AIDS Drug Assistance
    Program by over 50 percent in just an 18-month period. This is
    now the highest level ever.
        We are also reaching more residents with tools to prevent
    transmission. The District is one of only two cities with a
    large public sector free condom distribution program, and we
    have distributed over 1 million condoms in the past 6 months
    and are on target to reach 3 million condoms per year. In
    addition, following Congress' lifting the ban on the use of our
    own local dollars to support needle exchange, we have
    implemented comprehensive harm reduction programs which in just
    the first 6 months have already enrolled 900 people into the
    services, linking 40 percent of them to detox and treatment
    services, and removed 130,000 used needles from the street.
        The District is also breaking new ground in the country
    with innovative programs, including a couples HIV testing
    initiative, expansion of the Parents Matter curriculum, and an
    evidence-based intervention that trains parents to communicate
    with their young pre-sexual children that has been very
    successful elsewhere in the world.
        Do not go it alone. One of the cornerstones of our Mayor's
    directive is to build strong partnerships. In terms of
    community partnerships and outreach through the Effi Barry
    Program, we have engaged more than 50 small organizations, many
    of which who do not designate HIV as their primary mission, to
    mainstream HIV/AIDS into their daily programming. We are
    expanding our faith-based partnerships through our Places of
    Worship Advisory Board, and we have funded an umbrella
    organization to work with faith leadership of multiple
    denominations to take on the mantle of HIV.
        For young people, we are partnering with D.C. Public
    Schools in curriculum development implementation, a rollout of
    voluntary school-based STD screening and treatment, and in
    offering free information for STD and HIV, as well as screening
    and treatment to young people who are in our Summer Youth
    Employment Program.
        I have reached my time limit, so I am going to truncate my
    oral report. So, in summary, I think there are also many
    opportunities for us to work even more collaboratively and
    effectively with our Federal partners, both in coordination of
    the Federal support for our programs as well as in response to
    specific requests for funding supplements we have made that
    will help us not just scale up our programs but to catch up for
    the years where this response has not been marked by
    aggressiveness, by evidence base, or by leadership.
        Finally, we might have the most complex epidemic in the
    country, but the current state of our epidemic is now emerging
    in other urban areas across the country as well. The increase
    in heterosexual contact is now surfacing in cities like Atlanta
    and Miami, and many urban areas have hot spots within them that
    reflect similar patterns and challenges to what is seen just
    citywide here in D.C.
        So we have reached the proverbial fork in the road for the
    domestic HIV response. The trends in our city's epidemic are
    now emerging in other urban areas, so turning the tide in the
    District, right here in your backyard, is an important model
    for other urban area hot spots as well. We assure you that our
    leadership, innovation, and capacity are present to return the
    Federal investment in our city and turn the corner for District
    residents for the HIV/AIDS epidemic.
        Senator Akaka. Thank you very much for your testimony. Now
    we will hear from Dr. Martins.

        TESTIMONY OF RAYMOND C. MARTINS, M.D.,\1\ CHIEF MEDICAL
       OFFICER, WHITMAN-WALKER CLINIC, AND CLINICAL PROFESSOR OF
                 MEDICINE, GEORGE WASHINGTON UNIVERSITY

        Dr. Martins. Good afternoon, Chairman Akaka and Members of
    the Subcommittee. Thank you for inviting me to provide
    testimony about public health challenges that face the District
    of Columbia, specifically in regards to HIV.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Dr. Martins appears in the Appendix
    on page 51.
    ---------------------------------------------------------------------------
        I am a primary care and HIV physician in the District,
    which is also where I completed my medical training and I
    currently reside. I have been the Chief Medical Officer (CMO)
    of the Whitman-Walker Clinic for the past 15 months. Through
    our two District health centers, Whitman-Walker Clinic acts as
    part of the health care safety net in D.C., providing care to
    the lesbian, gay, bisexual, and transgender (LGBT) community,
    persons living with HIV, and others who face barriers to care.
    We provide a primary medical home to more than 3,000 HIV-
    positive patients. My experiences there, as well as from my
    previous practices, and recent data and research results form
    the basis of my comments.
        The District of Columbia is in a unique situation with
    respect to HIV as compared with other cities in the United
    States. The 2008 HIV/AIDS Epidemiologic Update for the District
    reported that 3 percent of District residents have been
    confirmed to be living with HIV. However, random sampling
    research shows that the number infected with HIV is likely
    closer to 5 percent. These numbers far exceed most cities
    within the United States and are truly staggering.
        A major factor that contributes to this, especially in
    comparison with other major metropolitan areas, is the
    increased prevalence of HIV in multiple communities. HIV in the
    District finds itself in every race, economic status, and
    social network. Throughout the rest of the United States, men
    who have sex with men is the predominant mode of transmission
    for new HIV infections. In contrast, Washington, DC is the only
    major city in the United States where heterosexual intercourse
    is the main mode of transmission for new infections.
        Why is this the case? According to a recent study, District
    residents who report being in heterosexual committed
    relationships are infrequently monogamous and often do not use
    condoms. This sex outside the relationship, along with the lack
    of condom use in a population with a high prevalence of HIV,
    likely explains the increased incidence of HIV in the
    heterosexual community.
        My response to this is three-fold. One, the District should
    continue an aggressive HIV testing campaign. I think we are all
    in agreement on that. Two, the clinical guidelines regarding
    treatment for HIV need to be re-evaluated. And three, health
    care providers within the District need to increase their own
    collaborative efforts. And allow me to expand on my
    recommendations.
        First, testing people for HIV early, often, and repeatedly
    helps to assure that we are focusing our energies. I do not
    believe we should give up on education, prevention, and
    behavioral change models; but, I think it would be unwise to
    focus all resources solely on education and behavioral change.
    Rather I propose that we should rely on aggressive HIV testing
    to identify everyone who is HIV positive and change clinical
    treatment strategies to lessen new infections.
        HIV opt-out testing was started in 2007 by the D.C.
    Department of Health. Through this program, more HIV tests are
    being performed, and we are catching people earlier in their
    disease. The District is now diagnosing people with HIV on
    average before they develop AIDS and any associated
    complications.
        Second, current HIV treatment guidelines recommend
    following a patient with regular blood tests until their CD4
    count falls below 350 and then to recommend initiating
    antiretroviral therapy. During those years off medications, the
    patients often have a large amount of HIV in their blood (i.e.,
    a high HIV viral load) and can easily infect others.
    Alternatively, if we treated patients with HIV medications soon
    after infection, the viral load should be suppressed to very
    low levels much sooner, and it would be more difficult for them
    to transmit HIV to someone else.
        Additionally, recent clinical trials have shown benefit to
    the individual patient when starting HIV medications earlier.
    This change in public health protocol will only work with the
    change in guidelines from the International AIDS Society (IAS),
    the Infectious Disease Society of America (IDSA), the
    Department of Health and Human Services (HHS), and other
    agencies. If accumulating data does not support generalized
    clinical benefit, there should be at least a recommendation
    specific to the District to offer HIV medications earlier to
    potentially curb new transmissions.
        Third, I strongly believe that one of the only ways we can
    change the course of the District's HIV epidemic is through a
    coordinated and aggressive response. Collaboration between
    local health authorities, universities, research centers,
    community health centers, and private practices will be
    critical. Many programs such as the D.C. Center for AIDS
    Research have focused on increasing grants for HIV clinical and
    basic research.
        One program that should have immediate impact on the HIV
    epidemic is the D.C. Cohort. This collaboration will allow the
    District to follow nearly 10,000 clients to better understand
    the HIV epidemic in real time and the ongoing issues
    surrounding care, treatment, and survival.
        In closing, the 2008 D.C. HIV/AIDS Epidemiologic Update
    served as a call to action, with much media attention to the
    increased HIV numbers. However, it appears to have been quickly
    forgotten. The District would benefit from an aggressive media
    campaign so the public is frequently reminded of the severity
    of HIV along with the recommendation for everyone to be tested
    on a regular basis.
        By using the Treatment as Prevention strategy, patients
    will be started on antiretrovirals earlier in their disease and
    will be less likely to transmit to others. Through these
    programs, more individuals will be diagnosed with HIV and will
    need an expanded HIV primary care infrastructure within the
    District.
        Whitman-Walker Clinic appreciates the leadership of the
    Subcommittee in holding this hearing, and we look forward to
    providing whatever guidance or support that we can offer.
        Thank you.
        Senator Akaka. Thank you very much, Dr. Martins.
        I have a few questions for you all. Dr. Hader, the District
    has increased publicly supported HIV testing by 70 percent in 1
    year. That remarkable achievement was possible in part because
    the District has implemented HIV Opt-Out testing, where
    individuals no longer have to request a test but may choose to
    decline it. Yet the 2008 epidemiology report on HIV/AIDS
    indicated that more than one-third of D.C. residents who are
    infected with HIV do not know their status.
        How extensively is the Opt-Out testing program used in the
    District and how could it be more effective?
        Dr. Hader. Thank you for that question. Yes, while we are
    very proud of the gains we have made in expanded HIV testing
    over the past 2 years, we also know we have a long way to go.
    The District is one of the first jurisdictions in the country
    that formalized the policy for routine opt-out testing in
    medical settings as well as going one step further and said we
    do not want you to just get tested once, we want you to get
    tested routinely and repeatedly through your health care
    provider.
        So in translating policy to implementation, our major steps
    have been in emergency room settings as well as primary care
    settings, developing the models, and achieving enough results
    that inform our further scale-up. For example, we have two
    emergency rooms (ER) out of six that would be useful for
    routinely testing for HIV. We are on target to expand with the
    participation of those other four ERs during the next 18
    months.
        Likewise, we started with one major primary care network,
    our Unity Health Care provider, that routinely provides
    services, primary care services to 80,000 District residents to
    help roll out amongst their 17 main clinics routine HIV
    testing, and they are the ones who actually developed this
    fifth vital sign model so that you get offered an HIV test
    automatically when you are getting your vital signs done. If
    you say no the first time, your doctor is going to also follow
    up before you leave and say, ``Are you sure you do not want
    one?'' Because we offer it to everyone.
        So our goals for this year are to expand those lessons
    learned in the first primary care network amongst our other
    Medicaid and D.C. Alliance-funded managed care networks of
    primary care to get to scale.
        Now, what is going to help us achieve these results faster?
    And I think this highlights that although we have a progressive
    policy, we have a lot of catch-up to do from people who have
    not known their status for a long time. So one of the requests
    we have put into the CDC is actually saying if we have a one-
    time doubling of our overall budget for HIV testing, we can
    rapidly get up to scale across our ERs and our primary care
    networks, as well as continuing to drive demand among clients
    so that 18 months from now we will have completely doubled our
    entire results from that one-time investment.
        So we hope that we will hear back from the CDC that is a
    positive investment because without the additional resources,
    we will keep on track, but we will not get there as quickly.
        Senator Akaka. Well, thank you very much for what you are
    doing.
        Dr. Martins, Whitman-Walker Clinic has long been a part of
    the community response to HIV/AIDS. I understand that Whitman-
    Walker has had to adjust for limited resources, high demand for
    services, and changing demographics of those that you serve.
        Will you please describe the steps your clinic is taking to
    keep pace with these pressures?
        Dr. Martins. Sure. So, Whitman-Walker, a few years ago
    changed the way it offered services. As of a few years ago, it
    was mainly a grant-based organization that only saw patients
    with HIV, and it was started by the LGBT community here in
    Washington. At that time it was decided to expand services to
    the larger community in Washington, and so while continuing to
    serve its main constituents, it offered services to a larger
    group.
        To me, I like that we have decided to expand our offering
    because, previously in the older model, if you were in the LGBT
    community but you were HIV negative, Whitman-Walker really
    could not help you. We could do some STD testing for you, but
    we could not be your primary care center.
        So now I feel like we are the primary care center for a
    larger community.
        What is true is that finances, as a community health center
    in an urban environment, are always tough and we have tried not
    to cut back on any kind of large-scale medical or mental health
    services. However, we have had to cut back some of the
    additional services we offer, but keep the medical and mental
    health ones going strong. That is how we have adjusted to the
    pressures.
        Senator Akaka. What about the demand for services? Is that
    overwhelming?
        Dr. Martins. The demand is always there. We have a large
    number of new patients; we have a large number of new HIV
    clients. We have the largest STD clinic in the city on Tuesday
    and Thursday nights. We see on average 30 to 40 individuals
    each night, and we have to turn people away because it is so
    popular. And the sad part of those statistics is amongst those
    30 to 40 people, it is not uncommon to have two to three to
    four new HIV diagnoses each night.
        So it is programs like that where I wish we could expand
    our offerings and offer an additional night a week we could
    accept more patients, but to do that, we would need additional
    funding.
        Senator Akaka. Dr. Martins, you mentioned that Whitman-
    Walker provides primary care services. Can you please explain
    why it is necessary to focus on a person's overall health
    rather than focusing only on one particular health risk?
        Dr. Martins. Sure. So HIV, as a perfect example, with the
    advent of good HIV medications, people are living for much
    longer, and perhaps decades longer than before. Those people,
    due to the medications they are on, the disease itself, and the
    fact that they are getting older, are at increased risk of
    getting diabetes, heart disease, and all the things that we
    predict as a population ages.
        So I think to truly be an HIV primary care provider for a
    person, you would have to look at the whole person and be
    comfortable with treating the entire individual, because
    otherwise those diseases will probably kill the person long
    before the HIV will.
        Senator Akaka. Thank you for your response on that.
        Dr. Vigilance, I commend the Department of Health for its
    many health initiatives and programs, and I also commend you
    for your work as its director. As you well know, the District
    faces the challenge of coordinating effectively with a variety
    of Federal agencies, nearby States, and many local entities to
    effectively protect public health.
        What steps are DOH taking to promote coordination and to
    minimize waste and miscommunication?
        Dr. Vigilance. Well, there are a number of different places
    in which we work very closely, as you mentioned, with local and
    Federal partners. I think a very good example of a coordinated
    activity with which we are regularly involved is our emergency
    preparedness work. Recently, the H1N1 situation that swept the
    Nation and is still in play, if you will, provided an
    opportunity for us to work not only as the National Capital
    Region with our colleagues in northern Virginia and in southern
    Maryland but also with our colleagues at the CDC and colleagues
    in other Federal agencies who provided us with guidance and
    expertise as we needed moving forward. That activity was
    mirrored by our activities around the inauguration, where we
    also were very involved with those entities at a time when
    there was a need for that collaboration.
        I think that is a good model for ongoing activity with
    respect to some other aspects of the Health Department's
    activity. I know that the HIV/AIDS Administration is very
    closely involved with not only the National Institute of Health
    (NIH) but also with the CDC, and the investments in that
    particular practice are evident.
        We have some investments in chronic disease related to the
    CDC activity that we have around diabetes, for example, but
    there certainly is a need for us to be a bit more thoughtful
    about how it is that we can make best use of those partners,
    not only the obvious partners, but also partners who are in the
    District that receive funds from those agencies. So we have a
    lot of other agencies within the District of Columbia, such as
    academic institutions, that receive funding that we would do
    well to partner with a bit more effectively around chronic
    disease. We do some work with them now, but we could do well to
    do more.
        Senator Akaka. Dr. Hader, I understand that in the past the
    Department of Health and D.C. Public Schools (DCPS) have not
    always coordinated effectively. What steps have you taken to
    improve communication and collaboration with DCPS specifically?
        Dr. Hader. Well, for young people, we are partnering with
    D.C. Public Schools on multiple fronts. First, is on health
    curriculum, so D.C. Public Schools and the Office of the State
    Superintendent of Education (OSSE) about a little over a year
    ago passed health learning standards that included learning
    objectives on sexual health. Since that time, we have been
    actively participating in the DCPS school health curriculum to
    identify, roll out, and develop evaluation processes asking, do
    kids actually learn this stuff for elementary, junior high, and
    high school schools? Now, many of these curricula are already
    in place, but the formalized, multi-school curriculum will be
    starting in September.
        Second, we work directly with the D.C. Public Schools to
    roll out this innovative, school-based STD screening program
    for kids. It is both an education, a diagnostic and treatment,
    but also a transmission interruption program. We have modeled
    it after New York City and Philadelphia and the objective is to
    go into schools, diagnose kids voluntarily and confidentially
    who might not know they have an STD, and treat them rapidly for
    their infection while we are also providing them information
    and sharing that information that would be helpful with
    partners.
        In our initial activities there, we have diagnosed STD
    infection rates between 8 percent and 20 percent on any given
    day in any group of kids. We have expanded--because of the
    Mayor's advocacy, we have expanded this program to our Summer
    Youth Employment Program as well.
        Third, through our Community Health Administration, in
    collaboration with D.C. Public Schools, we support training of
    all the school health nurses to be able to counsel students
    effectively on sexual health issues, including STDs and HIV.
        So I believe our collaboration has improved dramatically,
    and we look forward to gaining the results of that
    collaboration.
        Senator Akaka. Thank you for that response.
        Dr. Hader, the Youth and HIV Prevention Initiative was
    introduced in 2007 and is set to end next year. Please
    elaborate on what the initiative has accomplished and whether
    there are plans to extend programs under this initiative.
        Dr. Hader. Sure. I think the Youth and HIV Prevention
    Initiative, as marked by our Youth and HIV Prevention Strategic
    Plan, has been a fantastic collaboration, and what that
    initiative did was it brought together the Department of Health
    along with many of our youth HIV and AIDS focused service
    providers from the community to identify not only what the
    needs were from what the data showed, but what the needs were
    based on their experience on the ground, and to support the
    capacity organizations to reach more kids with more useful
    services. And some of the highlights that came out of that are
    a lot of the D.C. Public Schools collaborations that I
    highlighted are direct results of the planning, prioritization,
    and advocacy of that group. In addition, youth HIV testing has
    expanded dramatically, and I think the specific numbers are in
    our written testimony.
        Third, one of the things we are very proud of is there has
    been the development of a specific youth social marketing
    campaign with one of our youth providers, Metro TeenAIDS, that
    had direct involvement in young people saying, ``Yes, that
    makes sense to me. I understand it. It will catch my
    attention,'' to encourage kids to learn about their sexual
    health, to ask questions, to get tested, and to really make
    some, hopefully, safer decisions with respect to their
    relationships.
        Another thing we are very proud about is now that we have
    got our core service providers delivering more services and
    more results, we want to expand our circles of influence. So
    one of the activities we funded this year for the first time
    was for one of our HIV/AIDS expert youth organizations to work
    with a whole bunch of other young organizations that were not
    health-related or HIV-related organizations to be able to
    mainstream basic information about HIV, sexual health, and
    where to get more services and information into their day-to-
    day implementation.
        So we have increased funding dramatically through this
    initiative. We have also increased results, and absolutely I
    can tell you that the commitment to ongoing youth programming
    is there. And the end of the first plan will just be the
    beginning of a new plan, I am quite sure.
        Senator Akaka. Thank you for that response.
        Dr. Vigilance, your testimony mentioned the Child Health
    Action Plan and also states that children in the District are
    at greater risk of obesity than children in the United States
    generally. Improving residents' nutrition and exercise habits
    are critical to reducing chronic diseases. This is especially
    true for children whose habits are just being formed.
        I would like to hear more about the Child Health Action
    Plan, in particular how it addresses nutrition and exercise.
        Dr. Vigilance. So there are a number of components to the
    Children's Health Action Plan, and obesity is just one of them.
    Another piece that has been mentioned is the sexual health
    piece of things.
        What is interesting and important to remember is that, in
    order to make good choices, the cornerstone is actually some
    knowledge. And so education is one of the major pieces of the
    plan that sort of just assumes that this is about children who
    are getting educated and educated appropriately with respect
    for what they are at risk and what it is that they need to do
    in order to live healthy lives.
        But there is some work that is going on right now within
    the school system with respect to changing the actual food
    choices that children can have available to them, and some of
    that work is going to reap some long-term benefits for us. But
    we understand that children only spend so much of their day in
    school; there is a need for environmental changes outside of
    the school. And so as part of the Obesity Action Plan and the
    Children's Health Action Plan, too, we have looked at what the
    environments are in which these children live, especially in
    some of our poorer neighborhoods, with respect to their food
    access. When we refer to food access, we are referring to not
    only the availability of grocery stores in those neighborhoods,
    but actually the availability of fresh fruits and vegetables,
    food that is low in fat, low in carbohydrates, etc., and also
    the availability of that food in the local corner stores. And
    so the Healthy Corner Store Initiative, while it is separate
    from the Children's Health Action Plan, definitely affects
    children's health by making corner stores more aware of the
    choices that are available to their clients so that children
    who go into those stores might be able to gain access to
    something other than potato chips or candy and be able to make
    use of those stores to buy things that are actually nutritious
    for them.
        Again, this is an education process on the vendor side, and
    there is an economic development piece to that. But there is
    also a choice piece on the child's side and having an
    understanding of what is good for them helps them make better
    choices.
        We understand very well, too, that the Children's Health
    Action Plan will also influence adults because children come
    home and influence parents and family members in a particularly
    special way.
        So we want to make sure that the information that we impart
    to children in schools is something that they can translate and
    take home and make use of in the home so that hopefully adults
    change their behaviors as well. Sometimes that is a little more
    difficult than we would like for it to be, but it is certainly
    a piece of the pie as we look forward.
        So the Children's Health Action Plan is one of a number of
    different initiatives that come together to try to change not
    only behaviors and attitudes towards food, diet, and exercise,
    but also seeks to educate the children and those who the
    children influence themselves as we try to make people a little
    bit more healthy from the child's perspective.
        Senator Akaka. Thank you for that response.
        Dr. Hader, I highlighted the drop in HIV infections among
    newborn babies in the District in my opening statement. I
    commend you and others who have joined in this effort for the
    progress D.C. has made in prenatal HIV testing, which allows an
    infected mother to get treatment that greatly reduces the risk
    of transmission to the baby.
        How is the District working toward its goal of HIV testing
    for all pregnant women?
        Dr. Hader. Well, we took an urgent response to that problem
    of ongoing perineal transmission, and we actually started our
    intervention at the last opportunity for intervention to
    prevent mother-to-child transmission, which is the labor and
    delivery suite. And we started by working with all of our labor
    and delivery suites to be able to not only recognize that they
    want to make sure they know a mother's HIV status when she
    rolls through their door, but if she does not have that in her
    medical record, to be able to offer an on-site rapid test while
    there is still time to intervene with antiretroviral therapy
    during delivery to prevent transmission to the baby.
        So that was our urgent point of intervention, and we have
    been successful in scaling up from one hospital center that was
    already doing that to, I believe, some amount of screening and
    testing in five of our six delivery sites.
        Second then is reaching out--and we have been doing this--
    to all providers, in particular the obstetrician/gynecologist
    (OB/GYN) providers, including in collaboration with the
    American College of Obstetrics and Gynecology (ACOG) to fully
    implement routine screening recommendations not only during the
    first prenatal visit but also, because we are a highly affected
    city and per CDC and ACOG guidelines, repeat screening in the
    third trimester to catch that very rare occasion where someone
    gets newly infected during pregnancy, but those people we know
    who get newly infected are much more likely to transmit to
    their baby.
        So how are we going to measure the impact of all those
    outreach efforts in real time, not just waiting for a baby to
    fall through the cracks, but know how well are we doing with
    mothers? We have been working directly within the Department of
    Health with our Center for Policy and Epidemiology to update
    the vital registration process so that the information that is
    reported during the regular vital statistics birth record
    process includes that information about when the mother was
    tested and did you have those test results and what action was
    taken based on those test results. And I think by being able to
    monitor routinely how much success we are getting in the
    overall screening and implementation of guidelines will tell us
    how to target additional technical assistance and efforts for
    providers or delivery sites that might be falling down on the
    job.
        Senator Akaka. Thank you for that response.
        Dr. Martins, in your testimony, you suggested using
    treatment as a form of prevention, and you recommend changes to
    national and international clinical guidelines. If those
    changes are not possible, how would you recommend D.C.
    implement a Treatment as Prevention program?
        Dr. Martins. So I think that program would only work if
    there was a recommendation from a level higher than the
    provider to offer treatment earlier. I am not sure if that
    would be the Department of Health or what would be the most
    appropriate for the District, because for this to be effective,
    it would have to get to all the physicians who are in private
    practice, who are at the community health centers, at the
    universities, where everyone is being treated. Current
    guidelines say that we can offer treatment at a CD4 count
    higher than 350, so it is an option. We are not going against
    current guidelines. It would just require a recommendation so
    that we could improve the public health of the city as well as
    possibly the individual benefit of the patient, because recent
    trials have shown that the actual individual patients benefit
    from being treated earlier. And hopefully decrease the
    transmission rate in the city.
        Senator Akaka. Thank you.
        Dr. Vigilance, as elevated blood lead levels are especially
    dangerous in young children and cause developmental delays,
    what types of lead screening and treatment programs exist in
    D.C.?
        Dr. Vigilance. Well, until last year, those activities did
    sit within the Department of Health, and now we work very
    closely with the Department of Environment to actually have
    those programs covered. So the children who need to be screened
    for lead are actually referred to their private providers and
    work with the Department of Environment to determine what is
    necessary for them moving forward, and they work very closely
    with a couple of the universities in the area regarding the
    lead in children specifically.
        We recently provided some clinical guidance for parents who
    had questions about whether or not their children had been
    exposed as a result of an exposure that came up recently from
    some years ago and assisted in that regard by providing some
    basic guidelines for parents to follow. But the program itself
    no longer sits within the Department of Health.
        Senator Akaka. Dr. Vigilance, given the high rate of HIV/
    AIDS and chronic diseases in the District, some residents
    suffer from a combination of diseases, as Dr. Martins noted.
    How is DOH coordinating its HIV outreach and public campaigns
    with the other chronic disease initiatives?
        Dr. Vigilance. So as Dr. Hader has mentioned, the data
    drives a lot more of what the Department of Health does now,
    and certainly having the Center for Policy, Planning, and
    Epidemiology now in my office, we are paying a great deal of
    attention to the data and what the data was telling us with
    respect to where to go.
        I think that if you look at any map of the District with
    respect to the prevalence of poverty, the prevalence of tobacco
    use, the prevalence of HIV, the prevalence of homicide, those
    things are all overlaid there, very similarly distributed. And
    we can see that, using our data, we will need to be putting a
    number of different resources into some particular parts of the
    city. Without wanting to stigmatize any one particular area,
    basically either side of the river, Wards 5, 6, 7, and 8
    typically bear the brunt of our chronic disease burden and our
    HIV burden, and HIV is becoming more, as Dr. Martins mentioned,
    a chronic disease.
        So we have no choice but to coordinate our efforts, and I
    think that one of the things that is going on with respect to
    HIV and with respect to the Chronic Care Initiative (CCI), is
    that we are trying to move HIV testing away from the sort of
    community-based organization, only special event testing, into
    the regular routine medical encounter. And in doing that and by
    investing in the primary care settings that we are investing in
    with the tobacco settlement funds and by investing in the
    Chronic Care Initiative, which gets providers to think a little
    bit more holistically about their patients and not just think
    about the traditional boxes of chronic disease but add HIV and
    asthma and some other conditions to their list of concerns that
    they query patients about, we can do a better job of aligning
    providers with the needs that our patients actually have.
        But that is the patient-provider conversation. There is a
    separate conversation that we are also having which relates to
    people and place, and this refers more to what we refer to as
    the ``social determinants of health,'' those things that go
    into making communities healthy that are outside of the health
    care system. Since we understand that only about 15 to 25
    percent of your health is a function of the actual health care
    encounter, there are a number of other factors that go into you
    being healthy. They include, as mentioned before, availability
    of various resources, such as healthy food options, jobs, good
    education, etc. So we understand that we have to work more
    collaboratively with the school system, with Parks and
    Recreation, with the Mental Health Administration, and with
    other non-health agencies as well--businesses and non-
    government organizations, to create a bit more of a network
    where health and wellness is just the baseline as opposed to
    something that we are actually reaching for. We should
    understand that it is something that everybody needs to have at
    a bottom line, and that requires that we do a lot more in the
    way of collaboration. And we are reaching out to a number of
    partners to continue to do that, especially in the areas that
    are of greatest need in the city. Again, 5, 6, 7, and 8 are the
    wards of greatest concern, but we understand that across the
    city we have high rates of chronic diseases across the board,
    and we need to be looking at more than just those areas and
    more than just one particular socioeconomic and/or ethnic
    group.
        Senator Akaka. Dr. Vigilance, your testimony states that
    the DOH will seek funds to improve health information
    technology. Health Information Technology (IT) often requires a
    large up-front investment with the promise of improving
    efficiency and the quality of care over the long run.
    Additionally, health IT systems, which allow greater sharing of
    patient information among health professionals, must be
    implemented with great attention to protecting patients'
    privacy.
        I would like to hear more about your plans for this
    initiative. What is the scope of the project in terms of the
    financial investment and patients who will be served?
        Dr. Vigilance. Your question with respect to scope is
    timely and important, because health IT, as we typically
    discuss it, is placed in the box of the patient-provider
    conversation. So, appropriately, it refers to electronic
    medical records, personal health records, and health
    information exchange opportunities such as those involved in
    the regional health information organizations (RHIOs). We have
    a small RHIO here in the city. Six of our community health
    centers and two of our hospital emergency departments are
    involved in that activity, and it is important to make sure
    that we share information appropriately and make sure that
    people's privacy is maintained.
        The stimulus package funds that are coming down through the
    American Recovery and Reinvestment Act (ARRA) will actually
    assist the District in being able to provide potentially set-up
    funds, as you mentioned, to some of those providers who are
    taking care of the Medicaid and Alliance population that we
    have here in the city. We would want to ensure that those
    providers, as well as others, have access to the start-up funds
    and the maintenance dollars potentially to be able to start an
    electronic medical record system within their practice and one
    that is interoperable and completely transparent, and at the
    same time highly secure.
        We have recently had conversations with a number of
    partners, health care partners and business partners, around
    what exactly is the definition of health information technology
    for the District, and we would like to take the conversation a
    little further than the traditional conversation has gone and
    start talking a little bit about tools that we can use on the
    technology side to assist people in managing their illnesses,
    managing their diseases; broadband access improvement so they
    actually have access to some of these many tools that are
    available on the Web, for example, because there is a digital
    divide that the city still very much lives in; and also helping
    people just gain access to information through a number of
    different technology applications that sit, again, outside of
    the patient-provider conversation.
        And so we have the stimulus funds that have not come to the
    city yet, but there is an anticipation that there will be
    stimulus funds for the Medicaid and Alliance provider
    population, but we are also looking to invest some of our
    tobacco settlement funds in filling some of the holes that the
    stimulus package money is actually not going to fill because
    there were some specific eligibility criteria around those
    stimulus funds that may allow us to do certain things but not
    others, and we want to make sure that we cast a wide net and
    appropriately invest in health information technology that
    benefits people and providers, no matter where they are.
        Senator Akaka. Dr. Vigilance, the recent H1N1 outbreak has
    highlighted the need for pandemic preparedness. I have been
    impressed with the response so far at all levels of government.
    The District faces a particular challenge preparing for and
    responding to a potential disease outbreak. As our Nation's
    capital and a major hub for tourism, government, and business,
    the District could be a focal point for infectious disease
    transmission, and an outbreak in the District could disrupt
    government operations nationally.
        What steps is DOH taking to respond to the H1N1 flu, and
    what preparation is ongoing to respond to any future wave of
    H1N1 infections?
        Dr. Vigilance. So prior to H1N1 coming, and for some time
    now we have been involved in pandemic flu preparedness
    planning, and that has involved not only being able to
    effectively monitor the situation, quickly diagnose people,
    appropriately isolate them, if necessary, and provide them
    access to medical treatment, but also have the right staff on
    hand within the Department of Health and also within our
    partner population, if you will, in the National Capital Region
    to be sure to be able to have a timely response to any issues
    that come around.
        We are fortunate in this region to have a very strong group
    that is involved in planning around issues that are related to
    all hazards, and we take an all-hazards approach to this
    situation. So the same sort of surge capacities, the same sort
    of disease surveillance activities would be what we would
    engage in no matter what the disease was.
        The H1N1 situation allowed us to engage in real time with a
    number of different partners in the immediate area, and I think
    that one of the biggest lessons learned from that has been that
    our ongoing communications with our partners put us in a very
    good place to be able to react quickly and appropriately to the
    situation at hand.
        There were some particular challenges that H1N1 provided
    with respect to school closures, and I think that is one area
    where, as you have mentioned, the ability for a disease to
    actually create a situation that spills over into the everyday
    lives of people who are not actually infected with the disease
    is important to note, and the fact that we have such good
    relationships with the school system now made it very easy for
    us to get people onto conference calls quickly and make quick
    decisions about what to do about particular students in
    particular schools on particular days. And so we were fortunate
    to be able to do that, again, in part because of the ongoing
    conversations that we have on a regular basis.
        We are not through H1N1 yet, but we are still monitoring
    that situation and had a stakeholders meeting last week to pull
    together a number of the people from the District who dealt
    with the situation and hear from them what exactly it is that
    we need to be doing better. We have had regular conference
    calls with our hospital partners. Our primary care partners are
    very well engaged with us. The emergency preparedness side of
    things with Homeland Security and Emergency Management, again,
    a strong partner with us, and has been with us from the
    beginning on this.
        And so these ongoing communications allow us to mount a
    stronger and more unified response on a regular basis, and we
    are confident, never comfortable but confident, that we will be
    able to rise to the occasion if needed on a larger-scale basis.
        For businesses, one thing that was important, we recognized
    the need to reach out to them early and to actually advise them
    on dusting off their continuation of operations plans, those
    plans that need to be put in place should, in fact, a good
    number of their staff are not able to come to work. We
    ourselves have those plans and have identified essential
    services as we instruct all businesses to do the same, so that
    if there is a situation where people have to stay home in large
    numbers, the business can continue as usual.
        I am not sure that as a region we are necessarily there. We
    have not reached the destination of being completely prepared,
    but we are certainly moving in the right direction with respect
    to our Continuity of Operations (COOP) planning and, therefore,
    with respect to our pandemic planning as a whole. We hope to
    never have to necessarily enact the entire plan, but should we
    have to, then we think we are in pretty good shape.
        Senator Akaka. Thank you.
        Dr. Martins, as you testified, in 2008 Whitman-Walker alone
    reported 541 new cases of HIV. This number, along with what we
    know from the behavior and epidemiology reports concerns me
    greatly. You provide several specific recommendations for
    addressing this epidemic. Given limited resources, what should
    be the top priorities for the District Government and for
    Congress?
        Dr. Martins. I think when you are facing a large amount of
    the population being infected with HIV, with a certain number
    not knowing they are infected, the biggest thing is you want to
    get as much information as possible. So I think more
    collaborations and networks that we can get real-time
    information on people who are newly infected, resistance
    patterns, all those kind of data, having it come together.
        One of the collaborations that will help us with that is
    called the DC Cohort, and that is a collaboration between NIH,
    the HIV/AIDS Administration, George Washington University
    (GWU), and a large amount of the HIV providers. It is going to
    give us real-time numbers based on patient data. The data is
    going to be de-identified, but it is going to give us kind of
    real-time--where is the epidemic going and what are we doing
    that is effective? So especially when it comes to how are we
    going to change the epidemic, we want to know when it is
    effective immediately, not wait a year or two for data to know
    if we are doing a good job.
        But I think if we are going to focus energies, I think it
    is on finding more information and on testing people more. I
    think that would be probably--at least the first place to kind
    of put all your money. And then from that standpoint on, my
    biggest push is to test people--I mean, to treat people with
    HIV medications earlier in their disease, and the main reason I
    push for that is the fact that we know--when we have looked at
    all the HIV studies trying to change behavior, none have been
    effective in reducing HIV or other STDs. And so I do not want
    to push everything into behavioral change models. I like the
    idea of using what we know about science to effect change and
    not just going back to the behavioral change models.
        Senator Akaka. Well, thank you. That is my last question
    for you as Chief Medical Officer.
        Dr. Vigilance, I held a hearing in April during which the
    D.C. Chief Financial Officer projected that the District may
    have revenue shortfalls due in part to the recession. Reduced
    revenue will create pressures for budget reductions.
        In this climate, how will the District address the health
    care needs of its residents? And what programs will be
    prioritized?
        Dr. Vigilance. Sir, that is a great question, and I think
    we can look at this time as a period when the glass is half-
    full or a time when the glass is half-empty. The opportunity to
    do better work when you have less resources is obviously a
    challenge, but it is necessary. And I think that one of the
    things that we need to do a better job of within the Department
    of Health is defining exactly what are the most essential
    services and where are the areas of greatest impact for us,
    which is why when we discuss the three major things that affect
    the city with respect to health, we speak to obesity, we speak
    to infant mortality, and we speak to HIV. And having that focus
    on those three main areas that actually branch out into a
    number of other areas themselves, we can actually potentially
    be more efficient not only in our thought processes but also in
    our financial investments.
        We are fortunate to be able to have some funding available
    to us to do capital development at the moment. We recognize
    that even though we do that capital development, we have to
    also change behaviors in order for people to make use of the
    facilities that we build. And that process in and of itself
    requires that we do better partnering.
        So the first part of the answer to your question is that we
    have to actually focus ourselves a bit more specifically on
    some areas that may have gotten some focus before, but now
    require greater focus from us because of what they portend,
    what they lead us to; and then, second, to actually do a better
    job of partnering with potentially non-government agencies, be
    they private businesses or for-profit or nonprofit agencies
    that have reached into communities; and, third, to do actually
    that, which is reach out to communities a bit more effectively
    and teach communities to actually be more able to do what they
    need to do to sustain and maintain their own health and
    wellness. I think providing people with those tools will
    require not only that we actually spend some time and
    resources, but that we actually make use of some of the
    resources that are already available within communities to get
    some of those things done. So those would be the three parts to
    the answer.
        Senator Akaka. Yes. My last question, of course, was on
    priorities. Dr. Hader, do you have anything to add to Dr.
    Vigilance's or Dr. Martins' responses regarding what the
    priorities should be for the District's HIV/AIDS initiatives
    given the limited resources?
        Dr. Hader. Of course I do, and I will build on a few themes
    and add a little bit more.
        First, to reiterate, testing, testing, testing, testing for
    HIV is absolutely the linchpin, and it is the linchpin for both
    prevention and better care and treatment outcomes. Testing is a
    prevention intervention. We know the vast majority of people,
    once they find out they are HIV positive, immediately take
    action to help prevent transmitting their infection to other
    people. It is estimated at a national level that at least half
    and up to 70 percent of new infections from HIV are transmitted
    from people who do not know they are positive. And so testing
    is prevention.
        But where do we go from there? Care and treatment. We know
    that if people get immediately into care and treatment, that
    ongoing contact with a supportive care system not only can
    deliver information tools and messages for prevention on a
    consistent and repetitive basis, but we also suspect and hope,
    as Dr. Martins mentioned, the antiretroviral treatment itself
    by lowering viral load makes people less infectious.
        A complement to that on the prevention side, though, is, I
    think, some of the basic shifts and scaled interventions that
    we are investing in as a priority do make a difference. First
    tools, having prevention tools available and available at the
    scale of our epidemic. And for us, those major tools include
    information--real, real, real information--condoms, and clean
    needles.
        Second, it is actually addressing risk perceptions. We are
    in a paradigm shift, I think, in the District because of the
    better information and data we have. For a long time, I think,
    human nature is ``HIV is everybody else's disease.'' I think
    with our new data that shows nearly every ward, nearly every
    group, nearly every age is affected by HIV. We can take that
    and run with that and say, it is a new world for risk
    perception. You do not have to have a whole lot of risky
    behavior in an environment that has got a lot of HIV out there
    to come in contact with HIV. So each individual needs to be
    aware that they are living in a risky environment.
        And then, third--and I think this is a fundamental paradigm
    shift as well--is highlighting as part of our priorities that
    HIV is, in fact, not just about the individual; it is about
    relationships. It is about the individual and their romantic
    partners. It is about an individual and their family. It is
    about an individual and their communities. So if we can help to
    expand the conversation from not just ``What do I do for me?''
    but ``What do I do for the people I care about? What are the
    kind of difficult issues I need to grapple with to keep the
    people I love safe, to keep myself safe? How do I support my
    partners, my friends, and families to make choices and
    decisions that will take us as a community to a better state
    for HIV and AIDS?'' That is a cheap priority, but it is a
    really important one because it is one we cannot do just as the
    District Government ourselves. It requires absolute investment
    by all leaders across the board and all sectors in the District
    Government.
        So we hope to stimulate and start those conversations for a
    paradigm shift that make all of our other services more
    effective.
        Senator Akaka. Well, thank you very much for that. I want
    to thank you again for your testimonies today. Based on your
    testimonies, we have learned a great deal about HIV/AIDS,
    chronic diseases, and other health challenges in the District,
    as well as the progress that has been made. I would encourage
    D.C. to continue its aggressive HIV testing campaign and to
    strengthen partnerships with organizations like Whitman-Walker
    Clinic.
        This hearing has highlighted the need for effective
    communication not only within the D.C. Government but also
    within the community, and I must say that your responses have
    echoed that need. It is important that you move forward
    together as you work to improve the health of all D.C.
    residents.
        The hearing record will remain open for 1 week during which
    time Members of the Subcommittee may submit additional
    questions.
        Again, I want to thank you very much. Your testimonies have
    been helpful, and we look forward to your future success in
    this health program.
        The hearing is adjourned.
        [Whereupon, at 4:05 p.m., the Subcommittee was adjourned.]

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