[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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        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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