[Senate Hearing 113-863]
[From the U.S. Government Publishing Office]


                                                       S. Hrg. 113-863

                     OLDER AMERICANS: THE CHANGING
                            FACE OF HIV/AIDS

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

                                HEARING

                               BEFORE THE

                       SPECIAL COMMITTEE ON AGING

                          UNITED STATES SENATE

                    ONE HUNDRED THIRTEENTH CONGRESS


                             FIRST SESSION

                               __________

                             WASHINGTON, DC

                               __________

                           SEPTEMBER 18, 2013

                               __________

                            Serial No. 113-9

         Printed for the use of the Special Committee on Aging
         
         
 [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]        
         

         Available via the World Wide Web: http://www.fdsys.gov
         
         
         
                               __________
                               

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
25-450 PDF                  WASHINGTON : 2017                     
          
----------------------------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Publishing Office, 
http://bookstore.gpo.gov. For more information, contact the GPO Customer Contact Center, 
U.S. Government Publishing Office. Phone 202-512-1800, or 866-512-1800 (toll-free). 
E-mail, [email protected].                        
                       
                       
                       
                       
                       
                       SPECIAL COMMITTEE ON AGING

                     BILL NELSON, Florida, Chairman

RON WYDEN, Oregon                    SUSAN M. COLLINS, Maine
ROBERT P. CASEY JR, Pennsylvania     BOB CORKER, Tennessee
CLAIRE McCASKILL, Missouri           ORRIN HATCH, Utah
SHELDON WHITEHOUSE, Rhode Island     MARK KIRK, Illinois
KIRSTEN E. GILLIBRAND, New York      DEAN HELLER, Nevada
JOE MANCHIN III, West Virginia       JEFF FLAKE, Arizona
RICHARD BLUMENTHAL, Connecticut      KELLY AYOTTE, New Hampshire
TAMMY BALDWIN, Wisconsin             TIM SCOTT, Scott Carolina
JOE DONNELLY, Indiana                TED CRUZ, Texas
ELIZABETH WARREN, Massachusetts
                              ----------
                              
                  Kim Lipsky, Majority Staff Director
               Priscilla Hanley, Minority Staff Director
                                CONTENTS

                              ----------                              


                                                                   Page

Opening Statement of Ranking Member Susan M. Collins.............     1
Statement of Chairman Bill Nelson................................     2
Statement of Senator Elizabeth Warren............................     3
Statement of Senator Joe Donnelly................................     4
Statement of Senator Tammy Baldwin...............................     4

                           PANEL OF WITNESSES

Ronald O. Valdiserri, MD, MPH, Deputy Assistant Secretary for 
  Health, Infectious Diseases and Office of HIV/AIDS and 
  Infectious Disease Policy, U.S. Department of Health and Human 
  Services.......................................................     6
Daniel Tietz, RN, JD, Executive Director, AIDS Community Research 
  Initiative of America (ACRIA)..................................     8
Carolyn L. Massey, CEO, Massmer Associates, LLC, and HIV/AIDS 
  Education Activist.............................................    10
Kenneth Miller, Executive Director, Down East AIDS Network.......    12
Rowena Johnston, Ph.D., Vice President and Director of Research, 
  amfAR, The Foundation for AIDS Research........................    14

                                APPENDIX
                      Prepared Witness Statements

Ronald O. Valdiserri, MD, MPH, Deputy Assistant Secretary for 
  Health, Infectious Diseases and Office of HIV/AIDS and 
  Infectious Disease Policy, U.S. Department of Health and Human 
  Services.......................................................    34
Daniel Tietz, RN, JD, Executive Director, AIDS Community Research 
  Initiative of America (ACRIA)..................................    39
Carolyn L. Massey, CEO, Massmer Associates, LLC, and HIV/AIDS 
  Education Activist.............................................    40
Kenneth Miller, Executive Director, Down East AIDS Network.......    43
Rowena Johnston, Ph.D., Vice President and Director of Research, 
  amfAR, The Foundation for AIDS Research........................    54

                  Additional Statements for the Record

The American Academy of HIV Medicine.............................    58
Michael Horberg, MD, MAS, FIDSA, Chair, HIV Medicine Association.    61
Jason Cianciotto, Director, Public Policy, Gay Men's Health 
  Crisis.........................................................    63
Shane Snowdon, Director of Health and Aging, Human Rights 
  Campaign Foundation............................................    66

 
                     OLDER AMERICANS: THE CHANGING
                            FACE OF HIV/AIDS

                              ----------                              


                     WEDNESDAY, SEPTEMBER 18, 2013

                                       U.S. Senate,
                                Special Committee on Aging,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 2:06 p.m., in 
Room SD-562, Dirksen Senate Office Building, Hon. Bill Nelson, 
Chairman of the Committee, presiding.
    Present: Senators Nelson, Baldwin, Donnelly, Warren, and 
Collins.
    The Chairman. The meeting will come to order. We are 
expecting Senator Collins momentarily.
    Let me say before the hearing that the Ranking Member, 
Senator Collins, and I have checked with the members of this 
committee and we have found favorable replies to proceed 
tomorrow to file the resolution for the committee budget for 
the remainder of the 113th Congress. If there are any further 
questions, I encourage members to contact our staff. But what 
we will do is, either between the first and second vote 
tomorrow, or if there is only one vote, immediately after that 
vote, we will convene in the anteroom off of the Senate floor 
and take care of that administrative matter.
    I want to thank all of you for coming today. We have made 
great gains in the national and international fight against 
HIV/AIDS.
    Senator Collins, I literally just started----
    Senator Collins. Sorry, my fault.
    The Chairman. [continuing]. And what I am going to do is, 
since I will be introducing the panel members, I am going to 
flip it to you first. I have made an administrative 
announcement that tomorrow, we will convene off the floor after 
the first vote to take care of the matter of the resolution for 
the committee budget.
    So, let me turn to you for your comments.

         OPENING STATEMENT OF SENATOR SUSAN M. COLLINS

    Senator Collins. Thank you, Mr. Chairman. I apologize, 
first of all, for being late. I never like to be late for 
anything, but much less your hearings.
    I want to also thank you for holding this hearing to 
examine the many challenges associated with an HIV/AIDS 
population that is aging. Since today is National HIV/AIDS and 
Aging Awareness Day, it is particularly appropriate that we 
take this opportunity to focus attention on the issues facing 
older Americans with regard to HIV prevention, testing, care, 
and treatment.
    The face of AIDS in America is aging. Thanks to major 
scientific advances in anti-retroviral drugs, HIV is no longer 
an early death sentence and people with HIV/AIDS can now live 
near normal lifespans. By 2015, the average age of an HIV 
patient will be 50. While that is a testament to just how 
successful our research and treatment efforts have been, the 
fact is that the increasing numbers of older adults being 
diagnosed with HIV has also contributed to the graying of the 
population. According to the CDC, people older than 50 
accounted for 17 percent of new diagnoses in 2011, up from 13 
percent in 2001. The success of HIV treatments combined with 
the increasing number of newly diagnosed older individuals 
means that people age 50 and older will account for the 
majority of people living with HIV in our country by the year 
2015.
    At the beginning of the AIDS epidemic in the 1980s, people 
who were diagnosed with HIV could expect to only live a year or 
two after their diagnosis. Consequently, issues associated with 
aging were simply not a major focus for people with HIV. But 
new medications and treatments have changed all that. These 
individuals now have to face the challenges of aging with HIV.
    While living with HIV is not easy at any age, older 
individuals face different issues than their younger 
counterparts. HIV is still viewed by many people as a young 
person's disease and older adults with HIV may encounter ageism 
and additional stigma. This may make it even more difficult for 
them to disclose their status to family and friends, limiting 
their access to emotional and practical support and increasing 
their sense of social isolation.
    The CDC only recommends routine HIV testing up to age 64, 
which prevents some older adults from learning their status. 
This can delay a diagnosis, which, in turn, delays treatment 
and reduces its effectiveness. It also increases the 
opportunity for further HIV transmission.
    While HIV patients are living longer, many appear to be 
aging prematurely and are coming down with chronic conditions 
related to aging, such as dementia and cardiovascular disease, 
a decade sooner than their uninfected peers. Anti-retroviral 
drug therapy can affect and perhaps even worsen these medical 
conditions. Moreover, the decreased immune function that 
naturally results from aging makes older persons more 
vulnerable to a rapid progression from HIV infection to AIDS.
    Before closing, I would like to welcome today Kenny Miller, 
the Executive Director of the Down East AIDS Network in 
Ellsworth, Maine. Kenny is here to talk about the special 
challenges faced by older individuals with HIV/AIDS who live in 
rural areas, and I am very much looking forward to his 
testimony and the testimony of our entire panel.
    Thank you, Mr. Chairman.

       OPENING STATEMENT OF SENATOR BILL NELSON, CHAIRMAN

    The Chairman. Thank you, Senator Collins.
    So, today, we are going to look at AIDS and the aging. And 
when you consider the fact that today, 30 percent of all AIDS 
cases are age 50 or older, and in two years, 50 percent--half--
with HIV will be over the age of 50. You come into a State like 
mine, Florida, that as a percent of the population has a higher 
percent of elderly, it is even higher. Today, not 30 percent, 
39 percent of those with the disease are over the age of 50. 
And so this so-called graying of the population of AIDS comes 
with the need to refocus our work on these new challenges.
    Now, we want to reaffirm again that aging with HIV, some 
people think that just because they are older, they are not 
going to get HIV. Well, regardless of how you look at it, we 
still have to find a cure for it, no matter what age you are. 
So, our work for a cure should take into account the fact that 
any such drug or vaccine will miss half an epidemic if it is 
not tested and proven effective for the elderly population.
    Now, out in the State of Oregon, there is this 
extraordinary experiment right now successfully on a vaccine 
that is eliminating HIV in monkeys. It is called SIV. It is 
even more virulent in monkeys. And they now have a vaccine that 
in this first test out in Oregon University has stopped it by 
creating the vaccine that does something to the t-cell that 
goes and attaches itself to the virus. So there is some real 
promise. But that, needless to say, has to go then into a test 
with humans, and as we get into a test with humans, is there 
going to be a difference in what we are experimenting with on 
how it will affect the young and how it will affect the old? In 
fact, many conditions that often occur in the elderly, such as 
diabetes or Alzheimer's, that has implications, then, when you 
combine AIDS with that.
    So, we are going to hear from our witnesses about how our 
research dollars contribute to our understanding of how to 
treat AIDS and we are going to do so today in the context of 
those other diseases that often occur in the elderly.
    Now, we want to hear also from the witnesses about 
providing HIV services and support to seniors. Are our programs 
that train providers and offer housing and assistance with 
medication and the medication cost, are they prepared for an 
aging population?
    So, as we continue this battle against AIDS, now, we want 
to refocus today's hearing on the aging population.
    I want to thank our committee. I want to thank Senator 
Collins for her contribution here. And I want to introduce our 
panel.
    Is there anybody on our committee that is compelled to make 
a statement at this point?
    Senator Warren. Could I make a statement?
    The Chairman. Of course.

         OPENING STATEMENT OF SENATOR ELIZABETH WARREN

    Senator Warren. Mr. Chairman, I just want to take this--
because I am going to have another hearing at the same time and 
may not be able to stay for all of this----
    The Chairman. Yes, ma'am.
    Senator Warren. [continuing]. So I do want to say, when you 
are talking about the magnitude of the problem, in 
Massachusetts, 52 percent of those who are HIV-positive are 50 
or older, and 15 percent are 60 or older. This is an issue that 
now is profoundly affecting an aging population and I want to 
commend you and the Ranking Member for having a hearing on 
this.
    But I want to add on this, there really are moments of hope 
in this battle. We have made tremendous progress in treating 
HIV and are making exciting headway toward a cure. Just a few 
months ago, researchers in Boston presented exciting clinical 
results that two patients had undetectable HIV after bone 
marrow transplants. And Fenway Health has been engaged in 
important population studies, clinical research studies with 
the LGBT community, since the very beginning of the HIV 
epidemic and they have really helped bring forward our research 
and our understanding of this issue.
    I just want to make the point that progress is made 
possible by smart investments in basic research and population 
research by the government, by private industry, and by 
nonprofit groups. And as our population living with HIV and at 
risk for HIV ages, we need to make sure that we are gathering 
and coordinating data on the long-term effects of HIV drugs, on 
HIV drug interactions with medications used by an older 
population, and on how best to treat older HIV patients who are 
developing common comorbidity problems.
    So I just want to thank you for having this hearing, for 
getting us this focus, and I hope we will talk more about the 
importance of continuing research in this area.
    Thank you, Mr. Chairman.
    The Chairman. So you are already over 50 percent today?
    Senator Warren. Yes, we are. Yes, we are. This is an 
urgent----
    The Chairman. Over 50 percent of your HIV population is age 
50 or over.
    Senator Warren. [continuing]. That is right. This is an 
urgent problem in Massachusetts. It is a coming problem for all 
the rest of the country. And that is why it is so important 
that we continue research in this area, Mr. Chairman.
    The Chairman. Senator Donnelly.

           OPENING STATEMENT OF SENATOR JOE DONNELLY

    Senator Donnelly. Thank you, Mr. Chairman.
    I would just like one minute to mention that my home State 
is also the home State of Ryan White, who was such an American 
hero, but also such an historic figure in this fight. And when 
you head into the city of Indianapolis, you go down the street, 
Meridian Street, and there is a huge cathedral there. It was 
one of those days when I think American history changed, when, 
after Ryan passed away, there was not only no seats to be 
filled, but the parking lots were filled, as well, to honor 
this young man and his fight. And so many people who are still 
challenged with this, there is the Ryan White Program that 
provides assistance to so many who do not have the financial 
means to help themselves.
    So I just wanted, on a day like today where we are trying 
again to make sure we can beat this, that we had a real 
American hero early on in the fight.
    The Chairman. Senator Baldwin.

           OPENING STATEMENT OF SENATOR TAMMY BALDWIN

    Senator Baldwin. Now, I cannot pass on the opportunity to 
actually make the opening statement live rather than submit 
it----
    [Laughter.]
    The Chairman. Of course.
    Senator Baldwin. [continuing]. Because I know some of you 
will not be reading the record. I am guessing.
    But, anyway, I want to thank you, Mr. Chairman and Ranking 
Member Collins, for holding this really important hearing.
    This topic holds real special meaning for me. I think it is 
fair to say that the AIDS epidemic really shaped my early 
career in public service and helped me focus squarely on what 
became my goals of achieving quality, affordable health care 
for all and achieving equality and equal rights for all.
    It was in 1986 that I was first elected to public office, 
the Dane County Board of Supervisors, and in my home county, it 
was in that year that the first cases of HIV/AIDS were being 
reported in my county and in the State of Wisconsin. Many of 
the men who had been diagnosed in larger cities on the coast--
Boston, New York, Los Angeles, San Francisco--and at that time, 
it was accurate to say we were only hearing about cases 
involving men--they were coming home and they were coming home 
at that point to die. And there was a tremendous amount of fear 
and paranoia and sorrow in our community, and I would say that 
it was not just fear of the epidemic, it was an epidemic of 
fear and both needed to be grappled with.
    At that time, society, government, and our health care 
system was not responding adequately or appropriately to the 
crisis. So little was known about the disease that we found 
ourselves waging the war on two fronts, against a deadly virus 
and against discrimination and fear.
    Three decades later, I can honestly say that it has gotten 
better. But the significant improvements raise important new 
challenges, and so one of Wisconsin's AIDS providers, the AIDS 
Network, recently shared with our office, quote, ``The HIV-
positive population that we serve is indeed growing and aging. 
Over 50 percent of the patients and clients we serve are over 
45 years old and our oldest is over 80 years old. We are seeing 
the benefits of better treatment. That means services and care 
must be available as the demographic change and our clients 
age. We need to make sure that we have great medical and dental 
care and that we are able to help with public benefits like 
Medicare and that we provide mental health counseling and other 
integrated services.''
    So, though the landscape has changed, myriad challenges 
remain and we cannot lose sight of eradicating the epidemic 
once and for all, as you said, Mr. Chairman. Hearings like this 
are a very important part of that effort, so thank you again 
for holding and convening us today.
    The Chairman. First, we are going to hear from Ronald 
Valdiserri. Dr. Valdiserri is the Deputy Assistant Secretary 
for Health, Infectious Diseases, and the Director of the Office 
of HIV/AIDS and Infectious Disease Policy at HHS.
    Next, we will hear from Daniel Tietz, who serves as the 
Executive Director for the AIDS Community Research Initiative 
of America. Mr. Tietz is heavily involved in his organization's 
mission of training and educating older adults on HIV, 
including several training sessions in Florida.
    And then we will hear from Carolyn Massey, a lifelong HIV 
activist.
    Next, we will hear from Kenneth Miller, the Executive 
Director of the Down East AIDS Network based in the State of 
Maine.
    And then we will hear from Rowena Johnston. Dr. Johnston 
serves as Vice President and Director of Research at amfAR, The 
Foundation for AIDS Research.
    Welcome to the committee. If each of you could give us a 
presentation of around five minutes apiece, your written 
testimony will be entered as part of the committee's record.
    Dr. Valdiserri, we will start with you and go right down 
the line. Please.

    STATEMENT OF RONALD O. VALDISERRI, M.D., M.P.H., DEPUTY 
ASSISTANT SECRETARY FOR HEALTH, INFECTIOUS DISEASES, OFFICE OF 
  HIV/AIDS AND INFECTIOUS DISEASE POLICY, U.S. DEPARTMENT OF 
                   HEALTH AND HUMAN SERVICES

    Dr. Valdiserri. Thank you. Good afternoon, Chairman Nelson 
and members of the Special Committee. I am pleased to be able 
to offer testimony on the challenges of human immunodeficiency 
virus infection among persons age 50 or older and how the 
national HIV/AIDS strategy and other Federal initiatives are 
helping to address their prevention, treatment, and care needs.
    Now, we have heard both from Senators Collins and Nelson 
about the aging of the AIDS epidemic in the United States, so I 
will not repeat those statistics. I will share with you another 
statistic from CDC that it is estimated that of the 50,000 or 
so new HIV infections that occur every year in the United 
States, 11 percent of new infections are occurring in older 
Americans.
    Prevention for this age group is complicated by a number of 
factors. First, as is true for younger age groups, there are 
large racial and ethnic disparities in HIV diagnoses among 
persons who are age 50 or older. Between 2005 and 2008, the 
rates of HIV diagnoses for older African Americans and 
Hispanics and Latinos were respectively 13 and five times 
higher than the rate for whites.
    Second, although a large fraction of Americans remain 
sexually active into their mid-60s and beyond, including people 
living with HIV, many lack the awareness of the risks of 
infection, take few precautions against HIV acquisition, and do 
not discuss their sexual health with care providers.
    Third, prevention for this age group may also be 
complicated by established health risk behaviors, like alcohol 
and substance use.
    Now, treating persons aging with HIV presents its own 
special challenges. Older persons are more likely to be 
diagnosed late in the course of their HIV infection and have an 
inferior, a less robust, immune response to anti-retroviral 
therapy compared to younger people. This can be remediated in 
part by fully implementing the routine HIV screening for all 
persons between the ages of 15 and 65 years of age in accord 
with the recent U.S. Preventive Services Task Force 
recommendations.
    Yet, even among those diagnosed and receiving HIV 
treatment, persons age 50 or older may prematurely experience 
chronic comorbidities common to advancing age, including 
cardiovascular disease, infectious and non-infectious cancers, 
liver disease, renal disease, and neuro-cognitive decline.
    And, finally, because HIV disproportionately affects 
sexual, racial, and ethnic minorities who often have fewer 
economic and social resources, optimizing health outcomes for 
those aging with HIV requires care services that address 
housing instability, food insecurity, and social isolation.
    Our progress toward achieving an AIDS-free generation in 
the United States has been assisted by three recent 
developments. First, the Affordable Care Act is expanding 
access to quality care for millions of uninsured Americans, 
some of whom were previously refused health care due to 
preexisting conditions like HIV infection. The law also 
includes new provisions to support patient-centered medical 
homes, which are expected to increase care coordination, 
improve health outcomes, and lower treatment costs.
    Certainly, the National HIV/AIDS Strategy that was released 
in 2010, which strives to reduce new HIV infections, improve 
access to care, and reduce health-related disparities for all 
Americans, including older Americans, promises to have a great 
payoff in terms of improving health. Other parts of the Federal 
Government and agencies are also addressing the needs of older 
adults as they age to implement the goals of the National HIV/
AIDS Strategy. Much of the data that we have heard so far 
presented comes from CDC, who collect and analyze HIV 
surveillance data. They support routine HIV testing and 
prevention services and educate practitioners on the HIV 
prevention needs of persons who are 50 years and older.
    I do also want to comment that the National Institutes of 
Health has been very active in looking at the issue of HIV and 
aging. They have commissioned a special work group which has 
led to a number of new initiatives focused on studies 
addressing many of the medical complications that you have 
heard referred to, and I will not repeat them here.
    Third, I want to let you know that there is a new Executive 
Order that was released by the White House just in July of this 
year which is attempting to come up with further responses to 
improve the health outcomes of all Americans living with HIV, 
including people who are over the age of 50.
    We have a very shocking statistic in the United States in 
that it is estimated that only 25 percent of the 1.1 million 
Americans living with HIV have achieved virologic suppression. 
That means that over 800,000 people in the United States, 
including those over the age of 50, do not receive the full 
benefits of current medical care that we have available in the 
United States.
    So, in conclusion, while we have made progress, more 
remains to be done. We look forward to working with partners 
across all segments of society to improve the health of older 
Americans living with HIV.
    This concludes my testimony. I appreciate the opportunity 
to appear before you and will be happy to answer any questions 
you might have.
    The Chairman. Thank you.
    Mr. Tietz.

STATEMENT OF DANIEL TIETZ, R.N., J.D., EXECUTIVE DIRECTOR, AIDS 
        COMMUNITY RESEARCH INITIATIVE OF AMERICA (ACRIA)

    Mr. Tietz. Thank you, Chairman Nelson and Senator Collins 
and members of the committee, for this opportunity. I greatly 
appreciate it.
    As the Chairman noted, ACRIA has delivered training and 
technical assistance in Florida, most notably in Broward and 
Dade Counties, where there is a significant number of older 
adults with HIV and a host of providers struggling to serve 
them.
    I will not repeat some of the statistics that the Chairman 
and the Ranking Member have already given, as well as were 
repeated by Dr. Valdiserri, but I will note that folks with HIV 
who are in their 50s and early 60s who make up the bulk of the 
above-50 crowd have the same number of age-associated 
comorbidities as an uninfected person ten to 20 years older. 
These may include cardiovascular diseases, cancers, 
osteoporosis, hypertension, and depression. Older adults with 
HIV have a host of health and services needs that really 
neither HIV nor aging services providers are fully prepared to 
meet, and their significantly greater disease burden is often 
complicated by social isolation and stigma.
    Older adults with HIV have rates of depression, for 
example, that are five times higher than their HIV-negative 
peers. Depression is arguably the most reliable predictor of 
medication non-adherence and is associated with poorer 
treatment outcomes. Much of this depression is fueled by HIV 
and LGBT-related stigma and social isolation. Studies, 
including those done at ACRIA, have shown that almost 70 
percent live alone and less than 15 percent have a partner or 
spouse. With often distant families and fragile social 
networks, they lack instrumental and emotional support. 
Moreover, many of these older adults have disabling conditions 
that limit employment and often live at or below the poverty 
line.
    In the context of the National HIV/AIDS Strategy and the 
new HIV Care Continuum Initiative that Dr. Valdiserri 
mentioned, I believe we will not reach the end of AIDS unless 
we effectively address the barriers to routine HIV testing and 
consistent engagement in HIV treatments among middle-aged and 
older adults.
    As with younger people, HIV disproportionately affects 
older gay and bisexual men, especially men of color, and 
African American and Latina women. These disparities are often 
fueled by homophobia, HIV stigma, racism, and ageism. We need 
targeted, evidence-based efforts, including cultural competency 
training, to address these alarming disparities.
    Therefore, I urge you and your colleagues in the Senate and 
the House to promptly reauthorize the Older Americans Act and 
to include people with LGBT and HIV persons as groups with 
greatest social need. This would lead State and regional aging 
services agencies to explicitly incorporate the unique needs of 
these populations into their five-year planning efforts. The 
National Resource Center on LGBT Aging, which is funded by the 
Administration on Aging in a reauthorized OAA, would continue 
to fight HIV and LGBT stigma and discrimination among 
providers.
    Likewise, I urge adequate support for the Health Resources 
and Services Administration for targeted demonstration projects 
and other funding for training HIV and aging services 
providers.
    I further urge adequate resources for the HIV initiatives 
of the CDC. Research shows that most older adults, including 
those with HIV, remain sexually active. One in every six new 
diagnoses, as we heard, occurs in adults 50 and older, and as 
Dr. Valdiserri noted, that is to be distinguished from folks 
who are newly infected. So among that sort of 16, 17 percent 
who are diagnosed, fully half of those older adults are found 
to have AIDS. They are sick enough to be concurrently diagnosed 
with AIDS. And, in short, they have had HIV for some time but 
were never tested and treated. Older adults rarely seek HIV 
testing and many, many providers are unaware that current CDC 
guidelines recommend routine testing up to age 65. Therefore, 
we need CDC-funded HIV primary and secondary prevention 
campaigns for older adults.
    For older adults living with HIV today, as Dr. Valdiserri 
noted, ensuring the success of the Affordable Care Act is 
really critical. This includes the expansion of Medicaid in all 
States and robust HIV medication coverage as part of the 
essential health benefits package as defined by CMS for both 
the new insurance marketplaces as well as the expanded Medicaid 
programs. Unfortunately, 40 percent of Americans with HIV live 
in States that are not presently planning to expand Medicaid. 
These include several States with the highest new infection 
rates, lowest rates of overall insurance coverage, and worst 
health disparities.
    Today, half of all Americans with HIV rely on Medicaid to 
cover their health services. The Kaiser Family Foundation notes 
that people with HIV are about three times more likely to be 
covered by Medicaid than the U.S. population overall. Almost 75 
percent of Medicaid beneficiaries with HIV qualify because they 
are both low income and permanently disabled, and nearly a 
third are dually eligible for Medicaid and Medicare. As they 
develop multiple chronic conditions at a relatively young age, 
most will require long-term care.
    In a related vein, older adults with HIV need the Ryan 
White Care Act, as Senator Donnelly had noted earlier, to be 
fully funded to meet current needs, or at the very least, at 
the level requested by the President for fiscal year 2014. In 
inflation-adjusted dollars, Ryan White has essentially been 
flat for the last decade, and that is even as the number of 
people with HIV grows and the need grows among those who are 
living.
    So Ryan White is vital for many reasons, not least because 
the median age for older adults with HIV is 58, which means 
that they are not eligible for Medicare in many instances or 
other services from the Older Americans Act. Most older adults 
with HIV rely on Ryan White funded programs, including the AIDS 
Drug Assistance Program. Ryan White funded completion services, 
such as transportation support and case management, are also 
vital to ensure sustained engagement in care and treatment 
success. With about half the States choosing not to expand 
Medicaid, the Ryan White Program will remain vitally important 
for essential services.
    In sum, if we are to effect real improvements in the HIV 
treatment cascade, particularly the very large gap between 
those initially linked to care and those retained in care, we 
will need to pay close attention to the intersection of the 
Affordable Care Act and the Ryan White Program.
    In addition, we must not only maintain but increase funding 
for NIH-targeted research on HIV and aging. The NIH Office of 
AIDS Research Special Working Group on HIV and Aging, which was 
convened in April of 2011, was a unique gathering of scientific 
experts from biomedical, clinical, and social science 
disciplines tasked with identifying critical research areas to 
better inform the treatment and care of this growing 
population.
    One of the four subgroups, which included ACRIA's Dr. Mark 
Brennan-Ing, focused on societal infrastructure, mental health, 
and substance use issues, and the caregiving challenges that 
have been identified as critical to better treatment outcomes 
for these older adults.
    Specific recommendations include----
    The Chairman. I need you to wrap up, Mr. Tietz.
    Mr. Tietz. [continuing]. All right. Let me scoot right to 
the end, then.
    The last thing I might mention is that we really need the 
FDA to look at multi-drug resistance for this population in 
finding new treatments for folks with HIV who are aging.
    Thank you for the opportunity.
    The Chairman. Thank you.
    Ms. Massey.

   STATEMENT OF CAROLYN L. MASSEY, CHIEF EXECUTIVE OFFICER, 
    MASSMER ASSOCIATES, LLC, AND HIV/AIDS EDUCATION ACTIVIST

    Ms. Massey. Chairman Nelson, Senator Collins, and the 
distinguished members of the committee, thank you for the 
opportunity to address the very important subject of HIV and 
aging.
    I am here to issue a clarion call, to give you the inside 
story on HIV and aging and the real cost of continuing to 
minimize the impact that HIV, left unchecked in aging adults, 
will have on our country and aging citizens. My prayer is that 
by sharing some of my personal experiences and those of people 
who have died from HIV and AIDS or are currently living with 
the disease, you might consider them as you determine how best 
to meet the needs of more than 1.2 million persons who are 
known to be living with this disease in our country today. I 
say ``known to be'' because estimates are that approximately a 
quarter of the people who are HIV-positive in the United States 
right now do not know their HIV status.
    We are fast approaching the point where truly 50 percent of 
those that are living with this disease are at least 50 years 
of age. This pivotal study, Research on Older Adults and HIV, 
was conducted by the AIDS Community Research Initiative of 
America years ago and it told us years ago that HIV and AIDS 
has a major impact on the quality of life for older adults 
living with the disease. I ask that you consider the economic 
impact, the loss of life, loss of productivity, loss of tax 
revenues, trauma to families and loved ones, that will only 
grow if HIV in aging adults is left unchecked.
    I was initially diagnosed with HIV in the fall of 1994, the 
same year that my only brother died as a result of 
complications associated with AIDS. His name was Theodore 
Anthony Jackson, a budding young businessman having just opened 
his third and what was to be a franchise of barber shops called 
Tony's. He would be 55 years old today. Our country lost the 
benefit of his gifts and of the contributions that he would 
have made for more than 19 years.
    Only months after his death, I was diagnosed. I was 38 
years old then. During that time, the only drug widely 
available and prescribed was AZT, and in Anthony's case, we 
believe that it did him more harm than good. As our family 
struggled emotionally with Anthony's rapid decline in his 
physical health and mental state, we were traumatized yet 
further by my diagnosis. I am convinced that only because I 
moved my family to Philadelphia in 1996 and vigorously pursued 
medical treatment there and ever since that I am alive today.
    The sad fact is that many of the people who are aging with 
HIV today do not know that less stigmatized environments and 
more knowledgeable physicians are available to them. In fact, 
many of the people who are living with HIV today still do not 
know that there are lifesaving treatments and care available to 
them. This is especially true of people known as baby boomers, 
those of us who are over 50 years of age. The older a person 
is, the less likely they are to be health literate about HIV, 
their HIV risk levels, how to establish healthy relationships, 
how to self-advocate, and how to access the life-saving 
services that they need.
    One of the things for which I am immensely grateful is 
that, with your support, health information technology will be 
used more. I believe that as the technology matures, you will 
see that HIV is truly not particular about infecting a 
particular group of people, but that there are more people 
already infected than we think and that each of us is at higher 
risk for infection than we ever imagined. In fact, if any of us 
have had unprotected sex, we are at risk for HIV infection.
    As you are aware, the field of geriatrics and gerontology 
is a relatively new one, still emerging within the larger 
medical community. I urge you and your Senate and House 
colleagues to provide increased resources to study, better 
understand, establish, and widely implement the best care and 
treatment practices to address the needs of people who are 
aging with HIV. Support people who want to study medicine and 
work on these complex, difficult, and intersecting problems of 
aging and HIV. The aging adults being diagnosed with and living 
with HIV, if left unattended, is one of the next big health 
challenges that we will face as a nation.
    We have learned a lot over this 30-year journey with HIV in 
the United States. Among the things that we have learned is 
that most successful prevention interventions and approaches to 
care are those that begin with and continue to meaningfully 
involve the affected communities.
    The Ryan White Care Act has provided a tremendous gift 
through lessons learned in the creation of a continuum of care 
that actually works. That continuum should be informing our 
work going forward in order to undergird the health care reform 
that is now underway.
    Another lesson we have learned is that the approach to 
ending HIV must involve many sectors and various disciplines 
that must be--this must be an interwoven and integrated effort 
that involves academic, scientific, political, at-risk 
populations, and other community stakeholders. We must find 
ways to effectively improve and measure the change and the 
quality of life for persons who are living longer with HIV and 
to begin to connect them, to the extent that they are able, to 
more productive lives. Too often, in our zeal to solve one 
problem, we create other challenges.
    With improving care and services and wider access for all 
people living with HIV, we can expect that some will be able to 
return to work and will want to do so. Therefore, we need to 
develop ways to help support them as they do that and ensure 
that supports and approaches are realistic and age and 
culturally appropriate. This improves [sic] working with 
employers and industries to develop new ways to work and 
developing more thoughtful outcome-driven benefit structures 
that do not perpetuate poverty but support progress and hope.
    Finally, I strongly support and urge that you not let our 
mothers, fathers, and elders die simply because we refuse to 
sensibly and effectively act. We have the means and wherewithal 
to better serve older adults with and at risk for HIV and to 
end this terrible epidemic, but only if we learn the lessons of 
the past and commit the resources to get there.
    Please, dear Senators, do not forget us.
    The Chairman. Thank you.
    Mr. Miller.

STATEMENT OF KENNETH MILLER, EXECUTIVE DIRECTOR, DOWN EAST AIDS 
                            NETWORK

    Mr. Miller. Good afternoon, Chairman Nelson, Senator 
Collins, and distinguished members of the Senate Special 
Committee on Aging. Let me start by saying that I am honored to 
be here today.
    I look at my fellow panelists and I see representatives 
from the DHHS Office of HIV, ACRIA, a lifelong activist, and 
amfAR, and then there is me, Kenny Miller, Executive Director 
of Down East AIDS Network, a small rural HIV service 
organization in Down East Maine with about four employees 
providing case management services to about 55 to 66 people 
living with HIV, around 57 percent of which are age 50 and up. 
I am also proud to say that I was recently elected Vice Chair 
of Maine's HIV Advisory Committee, which provides--advises the 
Governor's cabinet, the legislature, and--the State 
legislature, that is--and public and private organizations with 
regards to HIV issues.
    Maine is one of the greatest States in the nation, with 
about 17.5 percent of the population age 65 and up. With about 
43.1 persons per square mile, it is also one of the most rural. 
And while information concerning population density may seem 
out of place, it is important to note that people living with 
HIV and the providers that serve them face a complex set of 
challenges resulting from the rural nature of the State.
    Rural patients, in general, face increased barriers to 
care. These are exacerbated by health complications, stigma, 
and the expertise of local providers. A number of studies 
indicate that local health systems in rural areas lack the 
knowledge and experience required to treat specialty conditions 
like HIV and this affects patients' perceptions of providers' 
capacity to help them manage HIV and is associated with 
increased likelihood that a patient will not be taking anti-
retroviral medications.
    Beyond knowledge, some studies also indicate that increased 
levels of provider stigma and discrimination exist in rural 
areas. Take a client of ours, we will call him Adam Lawrence. 
His name has been changed for confidentiality reasons. Fifty-
five years old, Adam contracted HIV through the use of 
injection drugs a number of years ago. When you talk to him, 
you get a sense that there is some moderate psychological 
disturbance there that could also be a sign of early 
neurocognitive dysfunction.
    Over the course of a year, Adam cycled from one doctor to 
another seeking treatment for an open wound that just refused 
to heal. And just as quickly as he entered into care, he was 
ejected, labeled a difficult patient due to some of those 
things related to his psychological issues, prone to outbursts, 
a kind of narrative that he had created about the wound.
    There was no overt provider stigma in this case. There 
would not be, but it is difficult to imagine that his status 
and his history with injection drugs did not play a role in 
their decision to discharge him. Such stigma as seen in Adam's 
case has a negative relationship to people's ability to receive 
the care that they need.
    It is further complicated by concerns over confidentiality. 
As some of you may be able to attest to, in small towns, 
everybody knows everybody else's business. So keeping your 
status secret when you are seeking medical services in those 
situations is rather difficult.
    This suggests another issue felt particularly strongly in 
rural areas and that is community stigma. Rural persons living 
with HIV indicated more severe community stigma towards people 
living with HIV than their urban counterparts did in some 
studies. This is not particularly surprising. Many rural 
communities remain hostile towards gay and bisexual males. 
People who use injection drugs continue to be stigmatized 
throughout the U.S. And in spite of ongoing attempts to turn 
the narrative regarding HIV towards one of a medical issue as 
opposed to a character flaw, in rural America, it is still 
linked to these marginalized communities in many ways, these 
marginalized and often looked down upon communities.
    Such stigma raises another question as to whether or not 
depression and isolation experienced by people living with HIV 
throughout the U.S. due to such stigma is also felt more 
sharply in these rural contexts, and as pointed out earlier, 
depression is a serious adherence risk.
    We see this in the case of Hayden Mitchellson, again, his 
name changed for confidentiality reasons, in his late 40s. 
Hayden was born and raised in rural Maine. A gay man, Hayden 
suffered family and community rejection and eventually fled his 
home town to build a new space in one of Maine's bustling 
tourist communities. Very outgoing, very vocal about HIV 
issues, he is nonetheless very protective of his status, an 
isolation of a whole different sort. Burdened by his past and 
his secret, Hayden sank into depression, self-medicated with 
alcohol, and ended up bouncing from job to job until he wound 
up on the streets, floating from couch to hotel to park bench. 
Without stable housing, another important factor in adherence, 
Hayden was unable to seek medical care for his HIV.
    The last point, and most simple point, in some respects, is 
one of geography, of distance and transportation. Lacking 
adequate health providers, people living with HIV are often 
forced to travel long distances to urban areas, and the 
inconvenience incurred is enough to prevent many people from 
seeking care.
    These are just a few of the challenges faced by rural 
populations. Others include housing, access to mental health 
providers, and on and on. But the issue is not just challenges 
faced by people with HIV in rural areas. It is people aging 
with HIV in rural areas. There has been a lot written and said 
about aging and HIV and HIV in rural contexts, but there 
appears to be a dearth of information concerning the 
intersection of the two as they relate to HIV.
    I think it is a reasonable hypothesis that the challenges 
posed by aging and living in a rural area amplify one another. 
People aging with HIV in a rural environment face significantly 
greater stigma, isolation, and barriers to care compared with 
their younger counterparts--younger or urban counterparts. 
Receipt of care is negatively affected by their functional and 
neuro-cognitive decline, the adequacy of local providers, 
provider stigma, and geographic distance. Community stigma is 
exacerbated by ageism and functional and neuro-cognitive 
decline articulate with the experience of stigma to lead to 
greater levels of depression. The end result threatens a 
patient's adherence to their HIV treatment regimen and, 
consequently, their health.
    Thank you, and I am happy to take any questions.
    The Chairman. Thank you.
    Dr. Johnston.

    STATEMENT OF ROWENA JOHNSTON, PH.D., VICE PRESIDENT AND 
 DIRECTOR OF RESEARCH, amfAR, THE FOUNDATION FOR AIDS RESEARCH

    Ms. Johnston. Chairman Nelson, Ranking Member Collins, 
members of the Special Committee, thank you very much for 
inviting amfAR to participate in today's hearing on Older 
Americans: The Changing Face of HIV/AIDS. I am pleased to share 
our views on what we see as the difficulties as well as the 
opportunities of this growing challenge in the United States.
    In the next few years, there are projected to be half-a-
million people living with HIV over the age of 50. Some of 
these people will be people who have been living with HIV for 
many years or even decades, and others will be people who are 
newly infected, but they will all face the difficulties of 
aging and of doing so with a serious and a potentially fatal 
disease.
    For many years, as was noted before, we never expected to 
have to deal with HIV infection in older Americans. But anti-
retroviral therapy has dramatically lengthened the lives of 
those living with the infection. However, that means that 
increasing numbers of people are living with HIV who are older 
than ever, and our challenge is that we do not know enough 
about the biological causes and consequences of aging with HIV 
infection or about the social burdens borne by those living 
with HIV.
    HIV and aging is at the intersection of several of the most 
pressing health challenges that face Americans who are aging, 
and these include cardiovascular disease, cancer, osteoporosis, 
liver and kidney disease, hepatitis C, and neurological 
diseases like dementia. People living with HIV face an 
increased rate of all of those diseases and at a younger age 
than those who do not have HIV.
    And underlying all of these diseases is the aging of the 
immune system itself. Older adults, even in the absence of HIV, 
experience a reduction in the ability of stem cells to develop 
into immune cells. They experience a shrinking of the thymus, 
which is a key organ that generates new immune cells, a 
decrease in the ability to respond to new infections, and an 
increase in the production of hormones that lead to an immune 
inflammation, which in turn perpetuates the cycle of the loss 
of ability to respond to new infections.
    Evidence from the HIV research field suggests that this 
collection of immune phenomena occurs in both aging and in 
normal HIV infection. That means older Americans living with 
HIV are subject to immune inflammation on two fronts. Any 
research that can shed light on the process of inflammation in 
HIV disease will, by definition, benefit millions of Americans 
who will face diseases associated with aging now and in the 
future.
    In addition, researchers currently believe that many of the 
manifestations of this inflammation of the immune system pose a 
significant barrier to our ability to cure HIV and, therefore, 
a greater understanding of the fundamental cellular processes 
underlying aging, such as inflammation, will help us to address 
many, perhaps even most, of the diseases that take the lives of 
older Americans living with or without HIV and may at the same 
time help us to achieve one of the greatest medical challenges 
that we face this century, namely, curing an infection that has 
taken the lives of tens of millions of people around the world.
    And I did note with interest the introductory comments 
about the cases of HIV cure that have already taken in place, 
in particular, the Boston patients, the research on our way to 
finding a cure for HIV. I would also like to bring your 
attention to a Mississippi child who was cured earlier this 
year. And I am very proud to tell you that these are both 
cases--pieces of research that were supported and funded by 
amfAR. We understand, as you do, too, that curing HIV infection 
is going to be critical to bringing an end to HIV in the United 
States.
    Robust support for a strong research agenda will be crucial 
to understanding and addressing these challenges. Research has 
resulted in drugs that are saving the lives of millions of HIV-
infected people around the world, but the fact is that many new 
treatments for diseases such as cancer, heart disease, 
hepatitis, and osteoporosis have also arisen from research 
aimed at preventing, diagnosing, and treating HIV.
    Protease inhibitors are being tested in the treatment of 
cancers. Some cancers require treatment by transplantation and 
the immune suppression that can lead to opportunistic 
infection, such as cytomegalo virus and pneumocystis pneumonia 
are treated using treatments that came out of AIDS research. 
Protease inhibitors are also being tested in the treatment of 
Alzheimer's disease and along with neucleocyte analogs, which 
were also developed to treat HIV, are being used to treat 
hepatitis C.
    Biomedical research saves lives and it generates economic 
benefits and it yields scientific insights that catalyze future 
medical breakthroughs. And although the U.S. has long been 
recognized as the world leader in biomedical research, stagnant 
funding, which actually translates into funding reductions when 
you take into account inflation, imperils the U.S. leadership 
and jeopardizes future life-saving research advances.
    Funding for health research at the National Institutes of 
Health lost 22 percent in purchasing power in the decade from 
2003 to 2012. The sequester which went into effect this year on 
March 1 resulted in the inability to fund 700 research 
projects. And this will inevitably delay--in some cases prevent 
altogether--the exploration of potentially transformative new 
approaches to understanding and treating the leading causes of 
death and disability.
    When we invest in HIV research, we are committing to 
understanding and solving the health challenges faced by 
millions of aging Americans. The benefits accruing from an 
investment in AIDS research spread well beyond people who are 
infected with HIV in ways that we might not initially predict, 
but which have a track record of having improved the health of 
millions of Americans.
    amfAR strongly supports an increase in funding for the NIH 
and research on HIV and aging, understanding that the knowledge 
that we gain from that research has the potential to touch the 
lives of all of us.
    Thank you again for giving amfAR the opportunity to testify 
on this important topic. I would be happy to answer any 
questions you may have.
    The Chairman. Thank you.
    I am going to turn first to Senator Collins for her 
questions.
    Senator Collins. Thank you very much, Mr. Chairman. Very 
gracious of you, as always.
    Mr. Miller, I am obviously very familiar with the two 
counties where you are providing case management services. One 
of them, Washington County, is one of the most rural counties 
in a State that is a rural State. Could you talk to us a little 
bit more about the barriers that individuals with HIV/AIDS who 
are living in very rural parts of Maine have in obtaining 
access to the care and services they need.
    Mr. Miller. Certainly. So, our service area covers Hancock 
and Washington County, and as Senator Collins mentioned, 
Washington County is one of the most rural counties in Maine 
and also one of the most economically disadvantaged. So it 
faces a lot of challenges both in terms of the economy as well 
as geography in terms of its rurality.
    Like most rural people living with HIV and other specialty 
health conditions, people in rural areas face significant 
barriers when accessing care. In Maine, the majority of HIV 
care is provided by infectious disease doctors, of which there 
are currently about eight HIV medical providers operating in 
the State. And with a population of about 1,654 people living 
with HIV, this amounts to about 236 high-needs patients per 
provider, if all were seeking treatment.
    Senator Collins. Are any of those in Washington County?
    Mr. Miller. None of them are in Washington County. We do 
have one in Ellsworth, in Hancock County, but he has about--he 
works about two days a week, and, bless his heart, the patients 
love him. The clients love him. But he is semi-retired. And 
Ellsworth is about a two-hour drive one way, so four hours 
roundtrip from Calais, the most distal part of Washington 
County. We have one client, in particular, who lives on a 
reservation up there in Washington County and has very little 
income and is facing a four-hour roundtrip for about a 30-
minute visit with her doctor.
    Lacking transportation of their own, lacking financial 
security and a reliable support system to provide them with 
transportation, it often leads to frequently missed or skipped 
visits. We try and work with them around these things, so we 
get some funding through Ryan White Part C administered by the 
Regional Medical Center of Lubec in order to provide some 
transportation assistance in the form of gas cards. It does not 
cover everything. It does not cover an entire visit, but it 
helps to defray the costs a bit.
    We also maintain two offices. So we have one office in 
Ellsworth and one in Machias, as well as an outreach office in 
Calais to try and reach out to some of those people in more 
distant areas, at least to provide case management services 
through those means. And our case managers are willing and 
frequently do conduct home visits, so they will go directly out 
to people living in the more distant areas of the county there.
    Senator Collins. Thank you.
    Dr. Valdiserri, it was startling to me to learn that the 
State of Maine has already reached the threshold where 50 
percent of those living with HIV or AIDS, full-blown AIDS, are 
already age 50 or older. And yet when I look at the messaging 
that is done on AIDS, whether it is public announcements, PSA 
announcements, it is targeted at young people. And when I look 
at the CDC recommendation for testing, it is up to age 64. Do 
we need to revisit those policies and our educational awareness 
campaigns in light of the fact that the population is aging? I 
was thinking of what Ms. Massey was saying about that very 
issue.
    Dr. Valdiserri. Certainly. Let me answer that question. 
First, in terms of the testing, I would say, actually, that the 
ruling by the U.S. Preventive Services Task Force this spring, 
which is up to the age of 65, routine testing between the ages 
of 15 and 65, was widely viewed in the AIDS community as a 
tremendous step forward, because prior to that time, CDC since 
2006 had the recommendations that you had in place.
    The reality, though, is, as several of the panelists have 
noted, nationally, about 20 percent of all infected individuals 
are unaware of their diagnosis, and one of the reasons for 
that--there are many reasons. One is stigma. But the other is 
that many of these people are in health care and they are not 
willing to talk to their providers about risk or the provider 
is not comfortable talking to the patient about risk. And so 
moving to routine testing--I would start out by saying, I 
agree, it is not all the way up to 65, but it is a tremendous 
step forward.
    Also, as you likely know, in the Affordable Care Act, if 
the U.S. Preventive Services Task Force has given a Grade A 
recommendation to a clinical preventive service, and they did 
do that when they recommended routine testing, it will be 
covered without copay.
    So, let me start by saying that is widely viewed as 
movement forward. I think where we are still challenged is the 
fact that too many health care providers do not know how to 
talk to their clients and patients about sex, and they also 
make an assumption that older Americans are not sexually 
active. So, I do agree with you that we have to continue to 
work with medical and nursing and other professional 
organizations to get the word out.
    Just briefly on the issue of public education campaigns, I 
would say that, certainly, there is the need for more campaigns 
that are specifically targeted to older Americans and that is 
why having a day like today where we can come together and 
recognize the special needs of older people with HIV is 
extremely important. There are some examples of some very fine 
targeted campaigns across the United States, but I would agree 
with you, we need to do more.
    Senator Collins. Thank you.
    The Chairman. Senator Donnelly.
    Senator Donnelly. Thank you, Mr. Chairman.
    To Mr. Valdiserri, you have a long and storied name, your 
family and relatives in Indiana, and we greatly appreciate 
everything they have done.
    I want to follow up with a question for you, which is this, 
and to you and then to Dr. Johnston, and that is the status of 
the research that is being done. We heard what our Chairman was 
referring to and I was wondering about the path forward, how 
you see that, when you see--you know, we are making such 
progress, but when do you see the day when we can look and 
say--and I am not asking for an exact date, but--although I am.
    [Laughter.]
    Senator Donnelly. But how do you see the status of research 
right now?
    Dr. Valdiserri. So, let me say that I am old enough to 
remember when a former Secretary of Health at HHS made a 
prediction, so I am not going to go there.
    Senator Donnelly. Right.
    Dr. Valdiserri. I think when you talk about research, and 
you understand this, Senator, that is a huge, huge domain. I 
mean, we talk about virus--Senator Nelson mentioned viral 
research. We have continued research into drug treatments. We 
have research into basic science, about, as Dr. Johnston said, 
what is actually happening. How does the virus impact the aging 
process?
    You know, it is really hard to predict, but I will say that 
in the last few years, there have been some really amazing 
breakthroughs, and in my field, in the world of public health, 
the randomized control trial that demonstrated unequivocally 
that early treatment of HIV infection--we always knew that was 
good for the individual person, but this study demonstrated 
that early treatment of HIV infection actually helped to 
prevent transmission to partners. And that is why so much now 
in the field of public health, we are hearing great interest 
around the issue of treatment as prevention. So I cannot 
predict, but we are definitely making substantial progress and 
we will keep making progress----
    Senator Donnelly. Just a follow-up on that. You are coming 
at it from a number of different directions. Who helps to 
coordinate so that they do not stay in their stovepipes, that 
they are talking to one another?
    Dr. Valdiserri. Good idea. So, that is the job--in the 
Federal Government, that is the job of the Office of AIDS 
Research at NIH, which is an entity that spans all of the 
Institutes and offices at NIH, and as a result of direction 
from you and your colleagues, every year develop a strategy 
with priorities that they are going to organize.
    Now, as Mr. Tietz and others referred to, the Office of 
AIDS Research also will--they have a Federal Advisory Committee 
that will also identify important areas that need special 
attention. So a lot of the newer studies that I just very, very 
briefly referred to do come out of the OAR discussion on HIV 
and aging. So, in the Federal Government, it is the Office of 
AIDS Research.
    Senator Donnelly. Ms. Massey, in terms of the effect of 
HIV/AIDS on seniors, do you find that there are more 
depression-related challenges, there are more psychological-
related challenges than other age groups, or is there any 
difference in that? And, Mr. Tietz, if you would----
    Ms. Massey. I will just respond by saying, for many people, 
growing older is not always a good thing.
    Senator Donnelly. Right.
    Ms. Massey. So there are depression issues anyway, 
particularly when you start talking about folks that are more 
disproportionately affected by HIV and AIDS based on the data 
we have now. You are talking about people that are poorer, with 
less education, less health literate, that do not have as 
strong of support networks around them. So, yes, you are going 
to have that. And when you add the HIV and AIDS and the stigma 
and the unsurety and lack of access and supports to that, yes, 
there is more. There is a lot of it. And it really does impact 
people wanting to know their status.
    Senator Donnelly. Okay.
    Ms. Massey. And then once they do, doing something about 
it.
    Mr. Tietz. Yes. The study that I cited, the ACRIA data is 
consistent with others where several times, five times or so 
the rate for similarly aged older adults without HIV. So 
depression is pretty significant.
    Senator Donnelly. Okay.
    Mr. Tietz. And I think, you know, for some of the reasons 
we mentioned--so thinking about some of the most affected 
populations, as Ms. Massey just noted, and I think as Mr. 
Miller noted, as well, so I think social isolation, stigma, 
discrimination, and feeling like you could not disclose, so 
there is nobody to talk to, if you will, except for, say, maybe 
your provider, who is going to give you these days ten minutes, 
maybe once every three months. So I think there are those 
challenges about small community.
    But I would say small community is small community 
everywhere, right? So the community which you are living in New 
York City may seem like a small community, too, and you may not 
want to go to your church and tell those folks that you have 
HIV. You may not want to tell your geographically or 
emotionally distant relatives that you have HIV. So I think 
that can play out a lot of places, and I think it has a real 
impact in terms of adherence.
    So depressed people do not take their meds, and they do not 
take any of their meds. They have not saved it up just for the 
anti-depressant that they do not like, but they do not take the 
other ones, either.
    Senator Donnelly. Thank you very much. Thank you, Mr. 
Chairman.
    The Chairman. Senator Baldwin.
    Senator Baldwin. Thank you, Mr. Chairman.
    We know in general that access to health care coverage has 
a strong relation to accessing medication, accessing services. 
And so I wanted to hone in on something, Dr. Valdiserri, that 
you said at the end of your testimony, that only 27 percent of 
Americans older than age 65 are able to suppress their viral 
load. This is significantly less than the rates for infected 
Americans between 44 and 64, and it is especially troubling 
because Americans older than 65 have much greater access to 
health care through Medicare. So I am wondering if you can give 
us a sense of why this is happening and whether HHS is doing 
anything to examine this issue more closely.
    Dr. Valdiserri. Certainly. Let me start out by saying, 
generally, just to state that across the board, across all age 
groups, we have not yet as a nation achieved an optimal 
response to addressing the epidemic, and that is the essence of 
the concern about the so-called care cascade. So, across the 
board, it is 25 percent.
    Your point is well taken, though, that when you break that 
down, and those data come from a CDC study and they look at 
differences, they looked at gender, they looked at race, 
ethnicity, they looked at age, and they did find some very 
distinct differences.
    The bottom line is, we do not know for certain, but I think 
there is a strong indication of a couple of things in play. 
Number one, the statistic that several of my colleagues 
mentioned of late diagnosis, the fact that nearly half of all 
older Americans, the first time they are diagnosed with HIV go 
on to develop AIDS within a year, essentially means they have 
been, as Mr. Tietz said, essentially means they have been 
infected for years and not diagnosed. All the while, the virus 
is damaging their immune system. So, probably late diagnosis.
    It is probably also an issue related to, as we heard from 
Dr. Johnston, the older immune system is not quite as nimble as 
the younger immune system.
    And I would say just a comment about--your last comment 
about many of these, especially 65 and older are Medicare 
eligible, I think this gets back to the need to educate health 
care providers that older people can be infected with HIV. 
Older people are sexually active. And older people, older 
Americans need to be counseled about HIV infection and be 
tested if they have not been tested.
    Senator Baldwin. Mr. Tietz, I was also interested in 
something you said at the very last moment of your testimony, 
also, that I think I would love to hear you expand on a little 
bit, and that is the resistance that can be developed to HIV 
medications in the population over 50. And you suggest that the 
FDA and the drug industry should do more to help address this 
problem. I wonder if you could delve a little bit more deeply 
into that topic. Are high drug costs a factor here? What action 
do we need to be taking at the Federal level, in particular, to 
address the resistance to medications that are effective in 
other age groups?
    Mr. Tietz. So, right now, we--thank you, Senator. I think, 
right now, we have, essentially, six classes of HIV drugs on 
the market, some very good new treatments for folks who are 
newly diagnosed, particularly if they are younger and have an 
HIV which appears on testing not to be resistant to much of 
anything. So there are lots of options there.
    But for folks who are much older, particularly those who 
have aged into this, so they have had HIV for 15, 20, 25, 30 
years, may have participated in early studies before we knew 
better. We were giving people one drug at a time or two drugs 
at a time and they promptly developed, then, resistance to 
those classes of drugs or similar drugs and that means they 
have run out of options. So there is sort of an unknown number. 
Our guess is somewhere around ten percent--I do not know if Dr. 
Valdiserri would agree, but somewhere around there, probably 
cannot put together a fully suppressive regimen. So, they 
cannot come up with a mix of different medications such that 
they are ever undetectable in terms of viral load, and as a 
result, are always in fear of, if you will, everything going to 
hell quickly and their dying.
    So, for those folks, what we really need is for industry 
and the FDA to work together to have sort of multi-drug 
combination trials, so having more than one investigational 
agent at the same time with a background regimen in an effort 
to get them to viral suppression. Thanks.
    The Chairman. Let me describe a situation not only in 
Florida, but in 19 other States, where the Governors and the 
State legislatures have refused to expand Medicaid. Therefore, 
if one has AIDS, they are not poor enough to be eligible for 
Medicaid at a very low threshold in those States, but they are 
not old enough for Medicare and they are uninsured. What do you 
think? Please, Doctor.
    Dr. Valdiserri. Well, what I think is it is wonderful that 
we have a very important safety net program known as the Ryan 
White Program that is the payer of last resort and was put into 
place specifically to provide HIV care, services, to uninsured 
and underinsured Americans. So I think it is very important to 
recognize, and certainly the Department, my Department and 
administration is on record as saying that the Ryan White 
Program is a very important program, even as we enter into a 
reformed health care environment.
    So, I would begin by saying that, Senator Nelson, that we 
do have that safety net program.
    The Chairman. Well, that is a positive, but several of you 
have testified about how AIDS and/or other maladies reinforce 
each other. And so the Ryan White is going to directly affect 
or try to help with AIDS, not all these other things.
    Dr. Valdiserri. Well, if I might----
    The Chairman. In other words, my questions make a point.
    Dr. Valdiserri. [continuing]. Sure, and I do not want to 
minimize that point. It is an excellent point. But I would say 
that the Ryan White Program has also been a leader in showing 
the medical establishment how to integrate a variety of 
different services for people living with HIV, how to integrate 
services for viral hepatitis, for mental health, for treating 
opioid addiction, as well as all of the very critical social 
needs that everyone you have heard express here. But I suspect 
my fellow panelists want to comment on this, as well.
    Mr. Tietz. Yes, if I may. I agree, Senator. I think there 
is a big gap there. It is a big worry in the community in terms 
of providing treatment for all those who need it and getting 
them the services they need. Ryan White is, right now, about 
$2.3 billion, I think, and if you look at the sort of numbers 
of people with HIV and their needs, given what you pointed out, 
the sort of comorbid conditions as the epidemic ages, versus 
the Ryan White Program, it goes like this. I mean, we are not 
keeping up here with what we need.
    So I think that there is a real challenge there and that is 
partially solved because of the Affordable Care Act, without a 
doubt, greater access, and, in fact, the ability that I think 
the Secretary's wise moving in terms of giving States the 
ability to use their Ryan White resources to, if you will, 
cover the deductibles and copays and, in fact, even the 
premiums for the new exchanges, for the new marketplace, is a 
very wise move.
    But there is no doubting that the point you are making is 
the right one, which is that there is going to be a gap in 
there. There has always been a gap in there and that is not 
likely to get solved, particularly in those States that are not 
going to expand Medicaid.
    The Chairman. For the record, hypertension, diabetes, 
dementia, Alzheimer's, cancer, and hypercholesterolemia--that 
is a long one.
    Okay, now, Ms. Massey, tell me, in your AIDS activism, if I 
recall, you reached out to the faith-based community. Tell me 
about that.
    Ms. Massey. Well, on a personal basis, I reached out to my 
bishop and explained to him that--at the time, I was trying to 
return to work. I was working at University of Maryland, and to 
be honest, I was doing more of the church's work than I was the 
University's, so I let the bishop know that I really had a 
heart to work with HIV in women.
    But the faith communities are ready to be engaged. There is 
more work going on now in faith communities than there ever 
was. I am lucky enough to co-chair the Places of Worship 
Advisory Board for the District of Columbia and we have more 
members at the table now than we have ever had. Wesley 
Theological Seminary is there. The National Children's Center 
is there. The large churches, the big churches. The Black 
Leadership Council on Age is there. And these are folks that 
are--some of them have been doing this work a long time. Others 
are brand new to it. And so it is a ripe time for getting 
people at the table. That is one of the gifts that God has 
given me, is to be able to get people to the table. I truly 
believe if the right folks are at the table, anything is 
solvable. And so the faith community, we do a lot of good work 
that is done and covered in programs like Ryan White, to be 
honest.
    The public health, they do a lot of good work. They are 
talking--they are speaking German, we are speaking Chinese. 
They keep a certain kind of records. We measure other things. 
There has to be a way to culturally sensitize each one of us to 
each other and find ways to communicate and to show benefit of 
what we do, what they do, and ways to enhance both of them.
    So, we are very lucky to have some conversations that 
involve ecumenically communities of faith and we are very good 
partners with the public health agencies here in the District 
and in Baltimore, Maryland, as well. I was lucky enough to 
chair the Ryan White Greater Baltimore Health Services Planning 
Council. So we involve faith community there, too. It is just 
continuing to have the right people at the table, the 
conversation.
    The Chairman. Dr. Valdiserri, you talked about the 
President's Executive Order, that there are going to be 
recommendations forthcoming. When?
    Dr. Valdiserri. The Executive Order called for the 
recommendations within a certain time period, and I believe 
that the Office of National AIDS Policy is committed to having 
those available in December. So, we are actually actively 
working--and the ``we'' here is not just Department of Health 
and Human Services, but other Federal partners. And we are also 
soliciting input from outside of government about how we can 
address some of these very critical gaps in the care continuum. 
So, those are expected to be issued by the White House sometime 
in December.
    The Chairman. Will you send a copy to this committee?
    Dr. Valdiserri. It would be my pleasure to do so.
    The Chairman. Okay. Dr. Johnston, I talked about the 
research on primates. From the initial look at this research, 
this works in primates. That does not mean it is going to work 
in humans. Tell us, in your professional opinion, what do you 
think about this research?
    Ms. Johnston. Thank you, Senator Nelson.
    The Chairman. This is for vaccine.
    Ms. Johnston. That is right. The research that you have 
brought up is, indeed, very interesting. This was led by a 
researcher by the name of Louis Picker, who works in Oregon, 
and he has been developing a vaccine that is actually based on 
another virus, interestingly enough. He has developed this 
vaccine out of cytomegalo virus, which is a virus that can--it 
is quite dangerous in AIDS patients, actually, or at least it 
can be, which is something to keep in mind when we look at this 
research.
    But one of the features of cytomegalo virus is it is very 
persistent, and this is, I think, the secret behind the success 
of the vaccine that he has developed. Some of the challenges 
the previous vaccine researchers have faced is that you can 
generate an immune response--an immune response is what we want 
when we are developing an AIDS vaccine--but it does not persist 
for very long. And what he has done is he has used this virus 
that does persist for a very long time and he has seen that it 
works in monkeys, as you have mentioned. It works in about 50 
percent of those monkeys.
    This research is very interesting also from a couple of 
other angles. Mostly when people think about a vaccine, they 
think about a way to prevent HIV. And initially, he designed 
this vaccine because he was hoping that this was going to be a 
vaccine that would prevent HIV. What is interesting about this 
vaccine is he actually gave it to monkeys who were already 
infected with SIV, the very closely related virus, and this 
vaccine was able to clear the virus out of about half of those 
monkeys. And so what that, of course, introduces to us is the 
notion that we might be able to use a vaccine to cure HIV if 
this concept were to work in humans.
    And, of course, it does need to be tested in humans. I 
think we are probably a little ways away from that just yet. I 
know the researchers I have spoken to about this very finding 
are very interested in knowing why did it not work in the other 
half of the monkeys. It is going to be critical for us to 
understand that.
    It is going to be critical for us to come up with a form of 
cytomegalo virus that would be safe to give to humans because 
it really can cause disease in patients who have AIDS.
    And then let us be very hopeful and optimistic, as we are 
at amfAR, that we are going to be able to find a cure for HIV. 
We do believe that is going to be crucial to ending HIV and 
AIDS. It is going to be a critical component to that.
    And in addition to that research, of course, we are keeping 
a close eye on all of the other research that is going on. We 
are supporting a lot of research around a cure and we do 
believe, to reiterate a point that I had been making, that if 
there is the right investment made in HIV research, we really 
do believe that we are going to be able to bring an end to AIDS 
via, for example, a cure, in our lifetime.
    The Chairman. Well, it would be the request of this 
committee, because of the subject matter of this hearing, that 
when we get to the point of testing a vaccine for AIDS cure, 
that we particularly designate part of the clinical trial for 
aging patients, as well, in case there is a difference with 
regard to the vaccine, and we would appreciate if you would 
share that with your colleagues.
    Let me ask you all about when a person can get Social 
Security Disability benefits, they encounter a 24-month waiting 
period before Medicare coverage begins. Can anyone comment on 
whether this waiting point is a significant issue for HIV?
    Dr. Valdiserri. I regret that I do not know enough to be 
able to respond to that question, but I am willing to go back 
and get information and submit it to the committee.
    The Chairman. Okay. There is no cap on out-of-pocket 
expenses for Medicare beneficiaries. What support do you think 
is available to those Medicare beneficiaries who can no longer 
afford the expensive and lengthy treatment other than the Ryan 
White that you mentioned?
    Dr. Valdiserri. That, too, is a complicated issue in that 
Ryan White, as you likely know, is the payer of last resort. 
And so by legislation, the clients who are in the Ryan White 
program, and actually, I just heard from the leader of that 
program this morning that about 70 percent of all of the 
current clients enrolled in Ryan White have some level of 
health insurance. But the way that it works is that primary 
insurance has to pay down first and then the Ryan White kicks 
in.
    I am not--in terms of Medicare, I would have to get more 
details for you, but I know that--and again, I heard this this 
morning. It just so happens the Presidential Advisory Council 
on HIV and AIDS is meeting at the Department today and they are 
talking about the Ryan White Care Act and the future of the 
Ryan White Care Act, and one of the presentations at this 
public meeting was from a member of the committee who is from 
Massachusetts who was sharing essentially the experience in 
Massachusetts, which essentially underwent health care reform 
much earlier than other parts of the country.
    The major point there is that even in a reformed health 
care environment where Medicaid is expanded, they actually use 
their Ryan White dollars to help, in some instances, to help 
buy private insurance for clients. And I think, Daniel, you 
were referring to that. Maybe you can provide a little more 
detail about how that works in the real world.
    Mr. Tietz. I am not sure that I can. I got that from Laura 
Cheever.
    Dr. Valdiserri. Oh, okay.
    Mr. Tietz. But--so----
    Dr. Valdiserri. Well, that is a good source.
    Mr. Tietz. [continuing]. It is a good source. But, I think 
that is right. So, I mean, one of the options here--I think you 
are referring, Mr. Chairman, to the Medicare eligible over 65--
mostly 65 and older. If they are poor enough, of course, 
particularly with Medicaid expansion, well, then they can 
become dual eligible and that will cover a lot of costs, 
although still worth noting, as Dr. Cheever at HRSA would point 
out, that still leaves about 30 percent who are getting some 
services--it could be transportation, it could be nutrition, it 
could be some case management service--that neither Medicaid 
nor Medicare will pay for, and then they turn to Ryan White to 
fill in that gap.
    The Chairman. Senator Warren.
    Senator Warren. Thank you, Mr. Chairman.
    I, again, apologize. I am trying to cover two hearings at 
once. But I want to go back to the screening question. I know 
that we started down the line on it, but there is something 
else I would like to press about screenings, and that is when I 
look at the information we have, that the risk of HIV is rising 
for the older population, that a larger proportion of older 
Americans, that our risk profile is changing, that those who 
are 50 and older have the lowest use of condoms, rate of use of 
condoms. Those who are 50 and older have the lowest rates of 
screening for HIV. And that for those who are 50 and older, it 
is harder to screen because of comorbidities, symptom 
identification. So it is more difficult sometimes to catch it 
simply by symptoms or other factors.
    So, what I would like to do is I would like to start the 
question by asking you, Mr. Tietz, could you just identify and 
really push on the point for us about the importance of 
screening and how screening older Americans for HIV would make 
a difference.
    Mr. Tietz. Yes. Thank you, Senator. I think, as Dr. 
Valdiserri also noted earlier, the current recommendation, of 
course, from the U.S. Preventive Services Task Force is up to 
65 and CDC up to 64 for routine screening. Lots of use in what 
routine means here. But the point would be that we should 
encourage providers and patients alike to think about HIV 
screening as getting your blood pressure done, as getting your 
cholesterol checked. It just becomes routinized. It becomes 
normal, that this is the thing we do. So there is a big need 
for education here, both public and private provider.
    We think that the--the CDC, I think, thinks that the bulk 
of the above-50 new diagnoses and new infections and greatest 
risk is really in the 50 to 65. So, yes, I personally would 
like to see the recommendation go higher, and I think there are 
some good economic data. CDC has to consider the cost of 
everything they recommend. So, considering the cost, there are 
some good data that suggest that HIV testing is cost effective 
up to the low 70s. So, yes, I would like to see it go higher, 
but, frankly, we are not doing very well with the 50 to 65, so 
maybe we could just start with that.
    Senator Warren. But, Mr. Tietz, if I can, just because I 
want to be sure we get it on the record, just identify for us, 
if we do the screening--you cannot do cost without talking 
about the benefit----
    Mr. Tietz. Yes.
    Senator Warren. [continuing]. If we do the screening, what 
are the benefits of the detection?
    Mr. Tietz. Oh, sure.
    Senator Warren. That is the part I would like to hear.
    Mr. Tietz. Oh, well, you will find folks who are younger, 
closer to the point at which they got infected. We all know 
that treatment outcomes are much, much better the sooner you 
find folks. The closer you get to treating them after their 
infection, the more likely they are going to have a good 
outcome.
    We, as Dr. Valdiserri noted earlier, and I think Dr. 
Johnston, as well, older folks have, you know, just in general, 
an immune system that, for lack of a better way of putting it, 
is wearing out. So--and it just does not respond as well. So 
you will see that even though older adults tend to be better 
about taking their meds, particularly above 65, the response is 
not quite as good for that reason.
    So, the sooner the better. I think the truth is with HIV, 
the sooner the better with all.
    Senator Warren. Okay. So we get better outcomes. Anything 
you want to add to that, perhaps about transmission?
    Mr. Tietz. Well, yes, of course.
    Dr. Valdiserri. I was going to say that if he did not.
    [Laughter.]
    Senator Warren. All right. I think that was known as 
leading the witness, Mr. Chairman.
    [Laughter.]
    Mr. Tietz. Right. Yes.
    Senator Warren. Please.
    Mr. Tietz. You are very good at leading the witness.
    [Laughter.]
    Mr. Tietz. So, yes. So, the study that Dr. Valdiserri noted 
earlier, HDTN052, I think, 96 percent reduction in terms of 
risk of transmission for someone who has an undetectable viral 
load. So, the better we do at this cascade, at this nice 
picture that Dr. Valdiserri gave us, the better we do on this 
end, the low end here, the greater likelihood we get to the end 
of AIDS by preventing that many more new cases.
    Senator Warren. Okay. Good. So----
    Dr. Valdiserri. And may I add one thing, Senator, that we 
know from a variety of research studies--this is not just 
specific to older Americans--but the vast majority of people, 
when they find out they are infected with HIV, are very 
motivated to not transmit that infection to partners. That is 
aside from the treatment issue, which is tremendous in itself. 
But that information is empowering and most people want to take 
and will take steps to interrupt transmission.
    Senator Warren. [continuing]. Okay. So, better treatment 
outcomes and lower rates of transmission, substantially lower 
rates of transmission.
    So, Dr. Valdiserri, what are you doing to increase 
screening among older Americans?
    Dr. Valdiserri. Well, as I had mentioned when you were out 
of the room, we actually think the U.S. Preventive Services 
Task Force recommendation, ruling, was a tremendous advance 
forward, because in conversations--frankly, in conversations 
with large payers and large insurance systems, there was some 
concern sometimes among medical directors about, well, the CDC 
says we should be doing routine screening, but the U.S. 
Preventive Services Task Force does not recommend it. So I 
would start by saying--now, that just happened this spring, in 
April. So that was a tremendous step forward.
    I can also tell you, wearing another hat, still government 
but not HHS, I spent four years at the Department of Veterans 
Affairs and one of the major efforts that we undertook--I was 
part of the team that led that--is that we got the legislation 
changed across the entire VA system which required scripted 
pre-test counseling and signature consent before any veteran 
could be tested for HIV. And what that translated into, because 
health care providers are busy, the HIV testing rate was, like, 
ten percent across the entire VA system.
    Now, certainly, we still want informed consent. We do not 
want people tested without their knowledge. But we were able to 
change the Federal law, change the regulation, change policies 
in health care settings to verbal consent documented in the 
chart, some basic information, and that rate has shot up and is 
continuing to go up.
    So what we need to do is get--also, as Daniel said, we need 
to have providers and clients alike start thinking about the 
HIV test like they think about cholesterol screening and not as 
some kind of special test that just these high-risk people from 
who knows where have to take, that everyone needs to take the 
test.
    Senator Warren. Good. So, let me just push on that just a 
little bit. I understand the point about trying to get people 
to change how they think about it. What I want to know is does 
HHS have any programs in the works as you did at VA to try to 
move toward that----
    Dr. Valdiserri. Oh, absolutely----
    Senator Warren. [continuing]. So we get better screening?
    Dr. Valdiserri. Absolutely. I mean------
    Senator Warren. I will give you a chance to showcase it.
    Dr. Valdiserri. [continuing]. Sure. Absolutely. CDC has a 
number of major public information and awareness campaigns that 
are targeted to various populations about the importance of 
early diagnosis, also trying to destigmatize testing, because 
as we heard from Ms. Massey, that is still an issue. Many 
people are still fearful about learning their status. So we 
have those kinds of efforts underway.
    And I think, also, a lot of work with professional 
organizations. We also want to try to influence the care 
providers to develop more of a culture of prevention in primary 
care settings.
    And then, finally, I would say the other really important 
avenue and opportunity to increase HIV testing is through the 
Community Health Centers. We are talking about, as you know, a 
national system serving individuals, many of whom are at high 
risk for or living with HIV and undiagnosed. So efforts to get 
HIV testing into Community Health Centers where we currently do 
not have testing are a very active part of what HHS is doing to 
try to promote awareness.
    Now, I do want to say that is just the first part of the 
cascade. So, once the testing takes place, we need to make sure 
we have systems in place to link people actively in care and to 
meet their needs so that, you know, if they are depressed, if 
they have unstable housing, if they cannot eat, all of these 
things are going to impact their ability to stay in care. So we 
have to work all the way down the cascade. But you are right. 
It begins with diagnosis.
    Senator Warren. Thank you, Mr. Chairman. Thank you for your 
generosity on the time.
    The Chairman. Thank you.
    Senator Collins.
    Senator Collins. Thank you, Mr. Chairman.
    I have just one final question. Dr. Johnston, I am going to 
direct it to you, but then ask our other witnesses if they have 
any comment, as well. While HIV patients are living longer, as 
I mentioned in my opening remarks, many people with the virus 
appear to be aging prematurely and coming down with diseases 
and conditions that are associated with people who are older 
than they are. Has amfAR done any research on the relationship 
between HIV and aging that might shed light on the cause of 
this? Is it the result of the disease itself or the drugs or 
some combination, or do we just not know?
    Ms. Johnston. Thank you, Senator Collins, for that 
question. amfAR is very interested in this issue. I think I 
have probably demonstrated that a lot of the research that 
amfAR supports pertains to finding a cure for HIV, and although 
it is not necessarily expected, I think there really is a very 
tight interlinking between the issues of aging with HIV and 
curing HIV for this particular reason that they are both very 
concerned with immune activation, and immune activation is at 
the center of the challenges of aging with HIV.
    I think we do have a very good sense that of all the 
diseases that are associated with aging with HIV that occur at 
a younger age in people with HIV, the ones that you have 
listed, cardiovascular disease, cancer, dementia, these are at 
least in part attributable to the increase in immune 
activation, which is the increase in the activity of the immune 
system exactly because the HIV is in the body. The HIV persists 
in the body and, therefore, the immune system keeps trying to 
fight off that infection and it never gets to rest from being 
able to do that.
    So, with this persistent immune inflammation, it actually 
runs itself down. The immune system literally gets tired out 
and is unable to function properly anymore. And this directly 
contributes to this higher prevalence of these aging diseases 
at younger ages in people with HIV.
    And to the extent that we also think that this is a barrier 
to curing HIV, a lot of our research is centrally focused on 
understanding what it is that drives the immune system, how it 
is that we can break that cycle of the immune system being in 
constant overdrive that leaves people susceptible to these 
diseases of aging.
    And to be honest with you, there are also pieces of 
evidence that suggest that the drugs, in some cases, do 
contribute to this, too, in particular, protease inhibitors. 
Unfortunately, protease inhibitors are probably the most 
powerful drugs that we have to treat HIV. They are also those 
that can cause--possibly cause the greatest level of bone 
damage, for example, that could lead to osteoporosis, liver and 
kidney damage, and some of these other diseases that we 
associate with aging.
    But to circle back to your original point, I think immune 
inflammation is increasingly understood to really be central to 
all of these issues of why can we not cure HIV and what is 
happening in terms of people who are aging with HIV.
    Senator Collins. Thank you very much.
    Dr. Valdiserri----
    Dr. Valdiserri. Yes, if I might add, in addition to the 
virus itself and the treatments, host factors, including co-
infection, viruses like hepatitis C virus, which are known to 
cause persistent liver damage that can develop into cirrhosis 
and hepatocellular carcinoma.
    This has not come up at all, but wearing a public health 
hat, the issue of smoking among older Americans with HIV, there 
have been some startling studies that have shown now--the study 
was in Scandinavia, but in a country that has essentially open 
access to treatment, very good retention and care, Denmark, 
some researchers demonstrated that more years of life were lost 
from cigarette smoking than from HIV.
    So, I think, to answer your question, there are a lot of 
factors at play here. I will tell you that the NIH does have a 
number of studies. I cannot give you the exact number, but 
there are a number of studies that are looking specifically at 
what you questioned. What is the interaction of the virus and 
how does the inflammation that Dr. Johnston referred to, the 
persistent activation, for instance, how does that contribute 
to cardiovascular disease? How does it contribute to neurologic 
disease? So, there are studies underway looking at that 
particular issue, typically within the context of an organ 
system or a disease set.
    Senator Collins. Thank you.
    Mr. Tietz, you get the last word, I believe.
    Mr. Tietz. Thank you, Senator Collins, and I would just add 
with regard to the NIH, as was earlier mentioned, the Office of 
AIDS Research, as a result of a White House Conference, a half-
day meeting on HIV and Aging in late 2010, the NIH Office of 
AIDS Research put together that Working Group on HIV and Aging 
in early 2011 and we have referred to the recommendations from 
that.
    I think, given Senator Donnelly's earlier question about 
stovepiping, almost one of the greatest benefits of that effort 
that is ongoing is that it is across the NIH. It is across all 
the Institutes, you know, Aging, NIMH, NIDA. So, folks are 
looking in a very sort of multidisciplinary way across the 
Institutes because aging, in fact, so much of it is across 
organ systems, it is across--there are a whole lot of needs 
there. And so I think that is particularly valuable in terms of 
the thinking about this going forward.
    Senator Collins. Thank you.
    Thank you, Mr. Chairman, for an excellent hearing.
    The Chairman. Thank you, Senator Collins.
    And on that note, at the end of October, NIH will be having 
a two-day conference on all of its research Institutes, the 
ones that you just talked about the stovepiping, to look at 
aging, the end of October, two-day conference.
    On that note, it has been an excellent hearing. Thank you.
    The meeting is adjourned.
    [Whereupon, at 3:52 p.m., the committee was adjourned.]


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


                                APPENDIX

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

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


                      Prepared Witness Statements

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


[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

Prepared Statement of Daniel Tietz, Executive Director, AIDS Community 
                 Research Initiative of America (ACRIA)
    Chairman Nelson, Senator Collins and distinguished Members of the 
Committee, on behalf of my colleagues at ACRIA, I thank you for holding 
this hearing. ACRIA has long conducted and participated in research on 
older adults with HIV in the U.S. and abroad. We have also delivered 
training, technical assistance and capacity building services to HIV 
and senior services providers across the U.S., including in Miami/Dade 
and Broward counties in Florida. I am pleased for the opportunity to 
join you.
    From the epidemic's start, most people diagnosed with AIDS faced 
death within a few years, if not a few months. With the effective 
antiretroviral treatments available since the mid-1990s, HIV infection 
has become a manageable chronic illness, best demonstrated by the 
``graying'' of the epidemic. The CDC predicts that half of all 
Americans diagnosed with HIV will be age 50 or older by 2015. That 
proportion will rise to more than 70% by 2020.
    In 2000, a 20 year old infected with HIV could, on average, expect 
to live to age 36. Today, that same 20 year old can expect to live to 
age 71. This extraordinary success is a result of the remarkable 
commitment of scientists, clinicians, and activists, and the 
investments made by the American people. But that success has also 
brought new and ever-increasing prevention and care challenges for 
those aging with HIV.
    People with HIV who are in their 50s and early 60s have the same 
number of age-associated comorbidities as an uninfected person 10-20 
years older. These may include cardiovascular disease, cancers, 
osteoporosis, hypertension, and depression. Older adults with HIV have 
a host of health and services needs that neither HIV nor aging services 
providers are fully prepared to meet. And their significantly greater 
disease burden is often complicated by social isolation and stigma.
    Older adults with HIV have rates of depression that are five times 
higher than their HIV-negative peers. Depression is arguably the most 
reliable predictor of medication non-adherence and is associated with 
poorer treatment outcomes. Much of this depression is fueled by HIV- 
and LGBT-related stigma and social isolation. Studies, including 
ACRIA's research, show that almost 70% live alone and less than 15% 
have a partner or spouse. With often distant families and fragile 
social networks, they lack instrumental and emotional support. 
Moreover, many of these older adults have disabling conditions that 
limit employment and often live at, or below, the poverty line.
    In the context of the National HIV/AIDS Strategy, and the new HIV 
Continuum of Care Initiative announced by the White House in July, I 
believe we won't reach the end of AIDS unless we effectively address 
the barriers to routine HIV testing and consistent engagement in HIV 
treatment among middle-aged and older adults. As with younger people, 
HIV disproportionately affects older gay and bisexual men, especially 
men of color, and African-American and Latino women. These disparities 
are fueled by homophobia, HIV stigma, racism and ageism. We need 
targeted, evidence-based efforts, including cultural competency 
training, to address these alarming disparities.
    Therefore, I urge you and your colleagues in the Senate and the 
House to promptly reauthorize the Older Americans Act (OAA) and to 
include people with HIV and LGBT persons as groups with ``greatest 
social need.'' This would lead state and regional aging services 
agencies to explicitly incorporate the unique needs of these 
populations into their five-year planning efforts. The National 
Resource Center on LGBT Aging, which is funded by the Administration on 
Aging in a reauthorized OAA, would continue to fight HIV and LGBT 
stigma and discrimination among providers. Likewise, I urge adequate 
support for the Health Resources and Services Administration for 
targeted demonstration projects and other funding for training HIV and 
aging services providers.
    I further urge adequate resources for the HIV initiatives of the 
CDC. Research shows that most older adults, including those with HIV, 
remain sexually active. One in every six new HIV diagnoses occurs in 
adults 50 and older. And fully half of older adults first diagnosed 
with HIV above age 50 are sick enough to be concurrently diagnosed with 
AIDS. In other words, they have had HIV for some time but were never 
tested and treated. Older adults rarely seek HIV testing, and many 
providers are unaware that current CDC guidelines recommend routine HIV 
testing up to age 65. Therefore, we need CDC-funded HIV primary and 
secondary prevention campaigns for older adults.
    For older adults living with HIV today, ensuring the success of the 
Affordable Care Act is critical. This includes the expansion of 
Medicaid in all states and robust HIV medication coverage as part of 
the Essential Health Benefits packages as defined by the Centers for 
Medicare and Medicaid Services_for both the new health insurance 
marketplaces and expanded Medicaid programs. Unfortunately, about 40% 
of Americans with HIV live in states that are not presently planning to 
expand Medicaid. These include several states with the highest new HIV 
infection rates, lowest rates of overall insurance coverage, and worst 
health disparities. Today, half of all Americans with HIV rely on 
Medicaid to cover their health services. The Kaiser Family Foundation 
notes that people with HIV are about three times more likely to be 
covered by Medicaid than the U.S. population overall. Almost 75% of 
Medicaid beneficiaries with HIV qualify because they are both low-
income and permanently disabled. And nearly a third are dually-eligible 
for Medicaid and Medicare. As they develop multiple chronic conditions 
at a relatively young age, most will require long-term care.
    In a related vein, older adults with HIV need the Ryan White CARE 
Act to be fully funded to meet current needs or, at the very least, to 
the level requested by the President in his FY14 budget. In inflation-
adjusted dollars Ryan White has been essentially flat-funded for the 
last decade, even as the number of people with HIV continues to grow. 
Ryan White is vital for many reasons, not least because the median age 
for older adults with HIV is 58, meaning many are not eligible for 
Medicare or other services funded through the Older Americans Act. Most 
older adults with HIV rely on Ryan White-funded programs, including the 
AIDS Drug Assistance Program. Ryan White-funded completion services, 
such as transportation support and case management, are also vital to 
ensure sustained engagement in care and treatment success. With about 
half the states choosing not to expand Medicaid, the Ryan White program 
will remain vitally important for essential services.
    In sum, if we are to effect real improvements in the HIV treatment 
cascade, particularly the very large gap between those initially linked 
to care and those retained in care, we will need to pay close attention 
to the intersection of the Affordable Care Act and the Ryan White 
program.
    In addition, we must not only maintain, but increase funding for 
NIH-targeted research on HIV and aging. The NIH Office of AIDS Research 
Special Working Group on HIV and Aging, convened in April 2011, was a 
unique gathering of scientific experts from bio-medical, clinical, and 
social science disciplines tasked with identifying critical research 
areas to better inform the treatment and care of this growing 
population. One of the four subgroups, which included ACRIA's Dr. Mark 
Brennan-Ing, focused on societal infrastructure, mental health and 
substance use issues, and the care giving challenges that have been 
identified as critical to better treatment outcomes for these older 
adults. Specific recommendations included prioritizing research into 
co-morbidity management, behavioral health needs, and caregiving social 
support resources. The program announcements issued by NIH in April 
2012 were sponsored by seven NIH institutes in recognition of the 
complex nature of aging with HIV and the multidisciplinary expertise 
necessary for relevant research. As will be further discussed by my 
amfAR colleague, Dr. Rowena Johnston, HIV research has and will 
continue to inform our understanding of other diseases, including age-
related diseases.
    Similarly, older adults with HIV need the FDA to support and 
encourage pharmaceutical companies to conduct combination drug trials 
for people with resistance to most HIV medications. A significant 
proportion of individuals with such resistance are above age 50. We 
also need the FDA and industry to examine the impact of long-term 
antiretroviral use in an older adult population.
    Lastly, it is our hope that HHS will soon develop formal guidelines 
for providers treating older adults with HIV. Last year, ACRIA, the 
American Academy of HIV Medicine, and the American Geriatrics Society 
issued a report entitled The HIV and Aging Consensus Project: 
Recommended Treatment Strategies for Clinicians Managing Older Patients 
with HIV (http://www.aahivm.org/Upload_Module/upload/HIV%20and%20Aging/
Aging%20report%20working%20document%20FINAL%2012.1.pdf). These 
treatment strategies were developed by an expert national panel, which 
included ACRIA's Dr. Stephen Karpiak, and could serve as a starting 
point for formal guidance from HHS.
    Again, I greatly appreciate this opportunity to speak on the 
subject of HIV and aging. I'm happy to answer any questions.
                               __________
Prepared Statement of Carolyn L. Massey, CEO, Massmer Associates, LLC, 
                    and HIV/AIDS Education Activist
    Chairman Nelson, Senator Collins and the distinguished Members of 
the Committee, thank you for the opportunity to address the very 
important subject of HIV and aging.
    I am here to issue a clarion call, to give you the ``inside story'' 
on HIV and aging, and the real cost of continuing to minimize the 
impact that HIV, left unchecked in aging adults, will have on our 
country and aging citizens. My prayer is that by sharing some of my 
personal experiences and those of people who have died from HIV and 
AIDS, or are currently living with the disease, you might consider them 
as you determine how best to meet the needs of more than 1.2M persons 
who are known to be living with HIV in our country today. I say ``known 
to be'' because estimates are that approximately 25% of the people who 
are HIV-positive in the United States right now do not know their HIV 
status. We are fast approaching the point where truly 50% of the people 
who are living with this disease are at last 50 years of age. The 
pivotal study, Research on Older Adults with HIV, conducted by the AIDS 
Community Research Initiative of America, told us years ago that HIV/
AIDS has a major impact on the quality of life for older adults living 
with the disease. I challenge you to consider the economic impact, the 
loss of life, loss of productivity, loss of tax revenues, trauma to 
families and loved ones that will only grow if HIV in aging adults is 
left unchecked.
    I was initially diagnosed with HIV in the fall of 1994, the same 
year that my only brother died as a result of complications associated 
with AIDS. His name was Theodore Anthony Jackson, a budding young 
businessman, having just opened his third in what was to be a franchise 
of barbershops, called Tony's. He would be 55 years old today; our 
country lost the benefit of his gifts and the contributions that he 
would have made over the past 19 years. Only months after his death, I 
was diagnosed_I was 38 years old. During that time, the only drug 
widely available and prescribed was AZT_and in Anthony's case, we 
believe that it did him more harm than good. As our family struggled 
emotionally with Anthony's rapid decline in his physical health and 
mental state, we were traumatized yet further by my diagnosis.
    I am convinced that only because I moved my family to Philadelphia 
in 1996 and vigorously pursued medical treatment there (and ever since) 
that I am alive today. The sad fact is that many of the people who are 
aging with HIV today did not know that less stigmatized environments 
and more knowledgeable physicians were available then. In fact, many of 
the people who are living with HIV today still do not know that there 
are life-saving treatments and care available to them. This is 
especially true of people known as `Baby Boomers', those of us who are 
over 50 years of age. The older a person is, the less likely they are 
to be health literate about HIV, their HIV risk levels, how to 
establish healthy relationships, how to self-advocate and how to access 
the life-saving services that they need.
    One of the things for which I am immensely grateful is that, with 
your support, health information technology will be used more. I 
believe that as that technology matures, you will see that HIV is truly 
not particular about infecting a particular group of people, but that 
there are more people already infected than we think and that each of 
us is at higher risk for infection than we ever imagined. In fact, if 
any of us has had unprotected sex we are at risk for HIV infection.
    As you are aware, the field of geriatrics and gerontology is a 
relatively new one; still emerging within the larger medical community. 
I urge you and your Senate and House colleagues to provide increased 
resources to study, better understand, establish and widely implement 
the best care and treatment practices to address the needs of people 
who are aging with HIV. Support people who want to study medicine and 
work on these complex, difficult and intersecting problems of aging and 
HIV. The aging adults being diagnosed with and living with HIV, if left 
unattended, is one of the next big health challenges that we will face 
as a nation.
    We have learned a lot over this 30-year journey with HIV in the 
United States. Among the things we have learned is that the most 
successful prevention interventions and approaches to care are those 
that begin with and continue to meaningfully involve the affected 
communities. The Ryan White CARE Act has provided a tremendous gift 
through lessons learned and the creation of a continuum of care that 
works. That continuum should be informing our work going forward in 
order to undergird the healthcare reform that is now underway.
    Another lesson we have learned is that the approach to ending HIV 
must involve many sectors and various disciplines; this must be an 
interwoven and integrated effort that involves academic, scientific, 
political, at-risk populations, and other community stakeholders. We 
must find ways to effectively improve and measure the change in the 
quality of life for persons who are living longer with HIV and begin to 
connect them, to the extent that they are able, to more productive 
lives. Too often in our zeal to solve one problem, we create other 
challenges. With improving care and services, and wider access for ALL 
people with HIV, we can expect that some will be able and want to 
return to work. Therefore, we need to develop ways to help support them 
as they do so and ensure that those supports and approaches are 
realistic and age and culturally appropriate. This involves working 
with employers and industries to develop new ways to work and 
developing more thoughtful, outcomes-driven benefit structures that 
don't perpetuate poverty, but support progress and hope.
    Finally, I strongly urge you to not let our mothers, fathers, and 
elders die simply because we refuse to sensibly and effectively act. We 
have the means and wherewithal to better serve older adults with and at 
risk for HIV and to end this terrible epidemic; but only if we learn 
the lessons of the past and commit the resources to get there. Please, 
dear Senators, do not forget us.
    Thank you for this opportunity to share some of my story. I welcome 
your thoughts and questions.
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

Prepared Statement of Rowena Johnston, Ph.D., Vice President, Director 
          of Research, amfAR, The Foundation for AIDS Research
    Chairman Nelson, ranking member Collins and members of the special 
committee, thank you for inviting amfAR to participate in today's 
hearing on Older Americans: The Changing Face of HIV/AIDS in America. I 
am pleased to share our views on the difficulties_and the 
opportunities_of this growing challenge in the United States.
    By 2015, there are projected to be half a million people living 
with HIV over the age of 50. Some of these will be people who have been 
living with HIV infection for many years or even decades, and others 
will be people who are newly infected. They will all face the 
difficulties of aging, and of doing so with a serious and potentially 
fatal disease.
    For many years, we never expected to have to deal with HIV 
infection in older Americans. The good news is that research has given 
us antiretroviral therapy, which has dramatically lengthened the lives 
of those living with the infection. A young person who is infected 
today, and who enters into and stays in medical care, can expect a 
lifespan that may not differ dramatically from that of a person who 
does not have HIV. While this is good news, it means that increasing 
numbers of people living with HIV are older than ever, and our 
challenge is that we do not know enough about the biological causes and 
consequences of aging with HIV infection, or about the social burdens 
borne by those living with HIV. Hundreds of thousands of people will be 
entering into a phase of their life in which they and their caregivers 
are not sure whether their health issues are due to HIV infection or 
aging, or how these challenges should be met. Meanwhile, many older 
Americans are unaware of their own risk for acquiring HIV, or how to 
deal with the stigma of being an older person with a disease that is, 
even today, more commonly associated with young people.
    Aging with HIV is at the intersection of several of the most 
pressing health challenges that face Americans who are aging. These 
include cardiovascular disease, cancer, osteoporosis, liver and kidney 
disease, hepatitis C and neurological diseases like dementia. People 
living with HIV face an increased rate of all of these diseases, and at 
a younger age, than those who do not have HIV.
    Teasing apart the contribution of HIV versus its treatment towards 
the increased risk for these diseases is difficult, but most 
researchers believe the virus plays a pivotal role. While studies have 
found higher rates of cardiovascular disease in HIV-infected 
populations than in age-matched HIV-uninfected populations, the 
mechanisms underlying this difference are not fully understood. 
However, we know that patients who can control their virus even in the 
absence of antiretroviral treatment have higher rates of carotid 
disease. Several cancers that are believed to be caused by chronic 
infections, such as anal cancer, Hodgkin's disease and liver cancer, 
occur at a higher than expected rate. The dysfunction in the immune 
system caused by persistent HIV infection is believed to be the major 
contributor to these higher rates of cancers. Liver and kidney disease 
are particularly problematic, as the virus can cause damage to these 
organs, either directly by viral replication or indirectly by 
destroying immune cells. These tissues are also susceptible to damage 
caused by all medications, including those used to treat HIV infection. 
The same is true for bone weakness and damage manifested as 
osteoporosis and probably caused by a combination of the virus and the 
drugs used to treat it.
    Underlying all of these diseases is the aging of the immune system 
itself. Older adults, even in the absence of HIV, experience a 
reduction in the ability of stem cells to develop into immune cells; a 
shrinking of the thymus, a key organ that generates new immune cells; a 
skewing of existing immune cell populations away from the ability to 
respond to new infections; and an increase in the production of 
hormones that lead to immune inflammation and perpetuate the cycle of 
the loss of ability to respond to new infections.
    Evidence from the HIV research field suggests that inflammation, an 
increase in cellular and hormone activity in the immune system, occurs 
in both aging and in HIV infection. Older Americans living with HIV are 
therefore subject to immune inflammation on two counts. Both for aging 
as well as in HIV, it is believed to be a major cause of damage to 
blood vessels and for the increased risk of heart disease. Any research 
that can shed light on the process of inflammation in HIV disease will 
by definition benefit millions of Americans who will face heart disease 
now and in the future.
    Researchers currently believe that many of the manifestations of 
this inflammation of the immune system pose a significant barrier to 
our ability to cure HIV. Therefore, a greater understanding of the 
fundamental cellular processes underlying aging, such as inflammation, 
will help us to address many, perhaps even most, of the diseases that 
take the lives of older Americans living with_or without_HIV and may at 
the same time help us to achieve one of the greatest medical challenges 
of this century, namely curing an infection that has taken the lives of 
tens of millions of people around the world.
    Robust support for a strong research agenda will be crucial to 
understanding and addressing these challenges. Research will help us 
understand how to reach older Americans and provide them with the 
information and support they need to prevent HIV infection. It will 
also allow us to improve our HIV testing outreach so that all people 
who are infected know their status and enter into appropriate medical 
care. Once we bring people into care, research will help us to provide 
new and improved tools to help treat not only the HIV but also all of 
the other diseases we most often associate with aging but that occur 
more frequently in HIV infection.
    Research has resulted in drugs that are saving the lives of 
millions of HIV-infected people around the world. The fact is that many 
new treatments for diseases such as cancer, heart disease, hepatitis, 
and osteoporosis have also arisen from research aimed at preventing, 
diagnosing, and treating AIDS. Protease inhibitors, initially developed 
to treat HIV, are now being tested in the treatment of cancers, for 
example breast cancer. Treatments developed for Kaposi's sarcoma are 
now being tested in bladder, vulvar, breast and colon cancer. Some 
cancers require treatment by transplantation, and the immune 
suppression can lead to opportunistic infections such as gg and 
pneumocystis pneumonia. Treatments for those infections came out of 
AIDS research. Protease inhibitors are also being tested in the 
treatment of Alzheimer's disease. Along with nucleoside analogs, which 
were also developed for treating HIV, protease inhibitors are also used 
to treat and even cure hepatitis C.
    Biomedical research saves lives, generates economic benefits, and 
yields scientific insights that catalyze future medical breakthroughs. 
Although the U.S. has long been recognized as the world leader in 
biomedical research, stagnant funding (which translates into actual 
funding reductions when adjusted for inflation) imperils U.S. 
leadership and jeopardizes future life-saving research advances. 
Funding for health research at the National Institutes of Health (NIH) 
lost 22 percent in purchasing power in the decade from 2003 to 2012. 
The federal budget sequester, which went into effect March 1, 2013, 
resulted in an inability to fund 700 worthy research projects. Limited 
funding will inevitably delay (and in some cases prevent altogether) 
exploration of potentially transformative new approaches to 
understanding and treating the leading causes of death and disability.
    When we invest in HIV research, we are committing to understanding 
and solving health challenges faced by millions of aging Americans. 
This committee is well aware that the population of this country is 
growing older and that tens of millions of people will face the serious 
health issues being discussed here today. The benefits accruing from an 
investment in AIDS research spread well beyond those with HIV in ways 
we may not initially predict, but which have a track record of 
improving the health outcomes for millions of Americans. amfAR strongly 
supports an increase in funding for the NIH and for research on HIV and 
aging, understanding that the knowledge we gain from such research has 
the potential to touch on the lives of all of us.
    Thank you again for giving amfAR the opportunity to testify on this 
important topic. I would be happy to answer any questions you may have.

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


                  Additional Statements for the Record

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

[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
  

                                  [all]