[Senate Hearing 111-298]
[From the U.S. Government Publishing Office]
S. Hrg. 111-298
PUBLIC HEALTH CHALLENGES IN OUR
NATION'S CAPITAL
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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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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
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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
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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.
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\1\ The prepared statement of Dr. Vigilance appears in the Appendix
on page 23.
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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.
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\1\ The prepared statement of Dr. Hader appears in the Appendix on
page 38.
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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.
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\1\ The prepared statement of Dr. Martins appears in the Appendix
on page 51.
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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.]
A P P E N D I X
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