**Minutes of the 19th Meeting**

**Presidential Advisory Council on HIV/AIDS**

**March 14--15, 2002**

**The White House Conference Center**

**Washington, D.C.**

*Members Present:*

Thomas A. Coburn, M.D., Co-Chair

Louis W. Sullivan, M.D., Co-Chair

Stuart C. Burden

Philip P. Burgess, R.Ph., M.B.A.

Joseph A. Cristina

The Honorable Ronald V. Dellums

James P. Driscoll, Ph.D.

Ingrid M. Duran

Mary Fisher

Charles Francis

Vera Franklin

Mildred Freeman

John F. Galbraith

Cheryl-Anne Hall

Karen Ivantic-Doucette, M.S.N., F.N.P., A.C.R.N.

Rashida Jolley

Caya B. Lewis, M.P.H.

Abner Mason

Sandra S. McDonald

Joe S. McIlhaney, M.D.

Hank McKinnell, Ph.D.

Brent Tucker Minor

Nathan M. Nickerson, R.N., M.S.N.

Debbie Rock

Reverend Edwin Sanders II

Prem Sharma, D.D.S.

Lisa Mai Shoemaker

Anita Smith

M. Monica Sweeney, M.D., M.P.H.

*Members Not Present:*

Katryna Gholston

Cynthia A. Gomez, Ph.D.

Joseph Jennings

Dandrick Moton

John A. Perez

*Present from ONAP:*

Patricia Ware, PACHA Executive Director

Tracy Carson

Scott Evertz

Greg Smiley

Ken Thomas

**[Thursday, March 14, 2002 -- General Council Session]{.underline}**

**Welcome and Introduction of New Members**

Ms. Ware, PACHA Executive Director, welcomed the Council members and
guests. She explained that PACHA was established in 1995 to make
recommendations to the President and to provide advice, information, and
recommendations to the Secretary of Health and Human Services (HHS)
regarding programs and policies intended to promote prevention, advance
research, and provide high-quality services to people living with
HIV/AIDS.

The Council members introduced themselves, and Ms. Ware called roll.

**Introduction of Co-Chairs and Co-Chair Remarks**

The new PACHA co-chairs, Thomas A. Coburn, M.D., and Louis Sullivan,
M.D., were introduced. Dr. Sullivan would preside on the first day and
Dr. Coburn on the second day of the Council meeting.

Dr. Sullivan stated that the HIV/AIDS situation has improved greatly
during the past 20 years. With the investment in research, the disease
is better understood, and people are living productively for many years
with the virus suppressed. However, no cure exists for HIV/AIDS.

Dr. Sullivan explained that the Council is charged with recommending
policies and strategies for Government and the private sector to find
more effective therapies and a cure. The current meeting was intended to
brief the Council members on the status of the HIV/AIDS situation, not
to debate issues or give policy speeches. Dr. Coburn added that he
envisions a day when there are no new HIV infections, when no babies are
born with HIV, when addicted drug users have treatment options, and when
HIV/AIDS treatment is widely available. He said he hopes to see the
Council build a consensus to make recommendations in the near future.

**Remarks from the Secretary of HHS and Swearing-In of PACHA Members**

Ms. Ware introduced Tommy G. Thompson, Secretary of HHS. She noted that
the Secretary is very committed to fighting the HIV/AIDS epidemic, to
providing care and treatment to those who are infected or affected by
the disease, and to raising awareness of the epidemic. Secretary
Thompson will visit Africa in the near future to increase his
understanding of the epidemic there.

Secretary Thompson thanked the members for their participation in the
Council and, on behalf of President Bush, thanked the members for their
dedication. He also thanked Dr. Coburn and Dr. Sullivan for their
leadership in raising public awareness and tackling the issue of
HIV/AIDS and recognized Ms. Ware and Mr. Evertz of the Office of
National AIDS Policy (ONAP).

The Secretary stated that in the United States more than 450,000 people
have died from AIDS and one million people are living with HIV/AIDS.
Worldwide, 40 million people have HIV and more than 22 million people
have died from AIDS. PACHA, he said, seeks to develop effective,
tangible steps to make HIV/AIDS a distant memory. The PACHA members have
a mission to help arrest the spread of HIV/AIDS, advance effective
treatment, and find a cure for the disease.

The Secretary explained that a management review is now underway within
HHS to look at ways to make the Department's activities more
accountable, better coordinated, and more efficient. He then spoke about
the U.S. investment in tackling HIV/AIDS through the National Institutes
of Health (NIH), Medicare and Medicaid, and the Centers for Disease
Control and Prevention (CDC). Some of the Federal funding is
specifically targeted to addressing the epidemic within racial and
ethnic minority populations. The Secretary also stated that the global
HIV/AIDS epidemic is a concern to the United States and that he serves
with Secretary of State Colin Powell on a global task force that will
travel to Africa and the Caribbean. The United States has also
contributed \$500 million to the Global Fund to Fight AIDS,
Tuberculosis, and Malaria (the Global Fund). Secretary Thompson asked
the Council members to provide constructive criticism and recommend
solutions to the Department.

The PACHA members then were sworn into service.

Secretary Thompson then opened the floor to questions. Questions
concerned the "flat funding" allocated to address the epidemic in
minority communities and for Ryan White Comprehensive AIDS Resources
Emergency (CARE) Act programs, the U.S. contribution to the Global Fund,
and the need to build the public health infrastructure. The Secretary
noted that significant funding will be committed to strengthening the
state and local public health departments' infrastructure, which will
help address the HIV/AIDS epidemic and homeland security concerns. He
also said the United States has made a major contribution to the Global
Fund.

**Briefing from the U.S. Department of Health and Services**

Joe O'Neill, M.D., Acting Director, Office of HIV/AIDS Policy, thanked
Secretary Thompson, Dr. Coburn, Dr. Sullivan, and Ms. Ware for their
leadership. He reflected on the progress made in tackling the HIV/AIDS
epidemic, but noted that much more must be done. He said the management
review within HHS is looking at a range of programs, including HIV/AIDS
programs, to find ways the Department can better manage and coordinate
programs and to become as accountable as possible. He also expressed a
need to identify successful HIV/AIDS program models.

Bill Steiger, Special Assistant to the Secretary for International
Affairs, discussed the U.S. Government's multi-agency involvement in
fighting HIV/AIDS, tuberculosis, and malaria worldwide. He noted that
President Bush, Secretary Thompson, and Secretary Powell have provided
leadership. He also recognized Paul DeLay of USAID and others who helped
to establish the Global Fund, which is a public-private partnership.
With the \$200 million U.S. contribution in FY 2003, the total U.S.
contribution to the Global Fund will be \$500 million, or one-fourth of
the funding from all of the donor governments. The Global Fund is a
non-profit, staffed organization that is located in Geneva and
incorporated under Swiss law. Most of the staff will be hired and
contracted throughout the World Health Organization, assuring the Global
Fund's independence. The funds are held in trust at the World Bank.

The Global Fund's board of director comprises 18 members who represent
donor nations, recipient Governments, private-sector organizations, and
nongovernmental organizations (NGOs), or are *ex officio* members. A
technical review panel with expertise in HIV/AIDS, tuberculosis, and
malaria is reviewing the first round of grant applications, and grantees
will be announced in April 2002. A total of \$700 million will be
granted in 2002. Mr. Steiger said the PACHA members can advise HHS on
how best to monitor the success of the Global Fund as a true
public-private partnership.

The floor was opened to questions and comments. Mr. Dellums noted that
the Global Fund is expected to leverage private-sector funding and asked
to what extent the private sector has been educated about the Fund. Mr.
Steiger said that outreach to the global private sector must be
strengthened and that Secretary Powell is organizing a forum to discuss
private-sector involvement, which is essential to the fund's success.
Dr. Sullivan noted that the expectation for private-sector involvement
may be different in the United States than in other countries. A
suggestion was made to involved the Global Business Council on HIV/AIDS
and other large organizations in raising dollars for the Global Fund.

A Council member asked whether the funds will be divided among HIV/AIDS,
tuberculosis, and malaria. Mr. Steiger explained that the United States
has taken the position that the funds should not be earmarked for
specific diseases or interventions, and that proposals can address the
interrelated nature of the diseases and cross-sectoral approaches. The
funds, however, are limited to programs concerned with HIV/AIDS,
tuberculosis, and malaria.

Ms. Rock mentioned that there is a need for the Health Resources and
Services Administration (HRSA) to streamline paperwork so
community-based organizations (CBOs) can spend more time in service
delivery and less time doing paperwork. Mr. Steiger agreed, saying that
CBOs can play an important role in improving processes and advising
about how to reduce mandated paperwork.

**Full Council Presentation: The State of the Domestic Epidemic**

Robert Janssen, M.D., Director, Division of HIV/AIDS Prevention,
Surveillance, and Epidemiology, CDC, explained that surveillance begins
with submission of information by health care providers and
laboratories. The information is sent to local health departments, which
may collect additional information, and then send it on to the CDC. As
of mid-2001, more than 822,000 AIDS cases and more than 470,000 deaths
of persons with AIDS had been reported to the CDC. Since 1995, annual
AIDS cases and deaths have dropped sharply, but the decreases have
reached a plateau, racial and ethnic disparities persist, and only half
of infected people are in care. In general, people with HIV are living
longer and better. Furthermore, mother-to-child transmission declined 80
percent between 1992 and 2001 because of treatment.

Dr. Janssen reflected that the epidemic in this country began among
whites, but the proportion of African Americans and Hispanics affected
has increased. The highest rate of AIDS reported to the CDC is 74 per
100,000 in the African-American population. The lowest rate is in the
Asian and Pacific Islander population. The epidemic began among men who
have sex with men (MSM) and injection drug users (IDU), but there has
been a steady increase in cases of heterosexual contact, especially
among African Americans.

Dr. Janssen noted that surveillance data are useful in targeting
prevention programs. Prevention programs must be tailored to the
population, interventions must be science-based, and peers are important
in the development and delivery of HIV prevention. He also noted that no
single intervention is universally effective, and knowledge alone is not
enough to prevent the spread of the disease.

The CDC funds prevention services through health departments and CBOs,
and provides training and assistance to service providers. The largest
portion of funds goes toward prevention through HIV Prevention Community
Planning, a collaborative process that is locally planned and based on
priorities of the local epidemic. One-third of the CDC's prevention
funds are used for counseling, testing, and referral to care, and to
partner notification. Forty percent of the funds are used for health
education programs, and funds are also used for school-based and other
youth interventions. Publicly funded counseling, testing, and referral
services were initiated in 1985, and over 11,000 sites are now funded.
Health education and risk reduction efforts are directed at reducing or
preventing behaviors that result in transmission. AIDS community
demonstration projects provide community-level intervention in five
cities and are targeted at high-risk groups.

Dr. Janssen explained that the overall national HIV prevention goal is
to reduce by half the number of new infections in United States---from
40,000 to 20,000 per year---by 2005. Objectives include to: decrease the
number of persons at high risk for acquiring or transmitting HIV;
increase the proportion of persons who learn they are infected; increase
the proportion of infected persons who are linked to prevention, care,
and treatment services; and improve systems to monitor and evaluate
prevention programs.

A recent survey found that HIV prevalence among men 23 to 29 years old
who have sex with men was 13 percent, and the prevalence among African
American men in that group is 32 percent. There have been several
outbreaks of HIV among MSMs in several cities. New data suggest that
much of the increase in unsafe behavior may be because people view AIDS
as a chronic, treatable disease.

Dr. Janssen stressed, however, that it is more useful to look at the
incidence of new HIV infection rather than at the prevalence of
infection. Now testing technology that can distinguish recent and remote
infections, and infection incidence data can be used to target
prevention programs and evaluate their impact. About 75 percent of
infected people are aware of their infection and about half of that
group have received care. An important message, therefore, is to get
tested, get treated, be safe.

Important challenges include determining whether prevention dollars are
tracking the epidemic, and finding ways to build the capacity of new
CBOs, improve service coordination among grantees, and improve community
planning.

Dr. Coburn asked if the CDC still conducts blinded surveys. Dr. Janssen
said there is a movement away from such surveys and more emphasis on
measuring incidence through testing history. Other questions concerned
measurement of heterosexual risk, surveillance in the incarcerated
population, and the population of people exiting prison. A member
suggested that reports and recommendations from a congressional
commission studying the incarcerated population be reviewed. Dr. Janssen
also noted that the CDC is evaluating laws that restrict syringe
availability, educating state legislators about that issue, and
examining interventions to prevent sexual transmission by IDUs. He said
the CDC welcomes the PACHA members' recommendations for reaching its
five-year goal of halving the number of new infections by 2005.

**Briefing from the State Department/USAID**

Paul DeLay, Acting Director, Office of HIV/AIDS, Bureau for Global
Health, U.S. Agency for International Development (USAID), spoke about
the global HIV/AIDS epidemic. An estimated 65 million people have been
infected, and 40 million adults and children were living with HIV/AIDS
at the end of 2001. New data to be released in July 2002 will show
significant increases in HIV prevalence in sub-Saharan Africa. In
Zimbabwe, for example, the prevalence was 25-35 percent in 2001. In nine
sub-Saharan countries, between one-fifth and one-third of children have
lost a parent to HIV/AIDS, and in some countries the average life
expectancy is 29. HIV prevalence is also increasing in countries such as
Indonesia.

Mr. DeLay said that USAID's HIV/AIDS program includes prevention, care,
and mitigation, and a primary goal is to reduce risk behaviors and
efficiency of transmission. However, infrastructure challenges and other
issues are significant in developing countries, and each program must be
tailored to the dynamics within the country. Despite the epidemic,
prevention programs have shown success among sex workers in Cambodia and
Thailand and among adolescent girls in Uganda.

Many countries have insufficient budgets to keep pace with the pandemic,
Mr. DeLay said. Care and treatment are critical, but challenges faced
include lack of standardized treatment regimens, lack of infrastructure
(minimal lab capacity, trained health care workers), equity of access to
treatment, nutritional requirements of HIV-infected persons, and the
cost of treatment. The cost of treatment in developing countries has
been reduced to \$1,200 per year, but *per capita* health care
expenditures are much less (e.g., \$16 in Haiti, \$91 in the Dominican
Republic, and \$319 in Brazil).

Mr. DeLay offered to provide resources to assist the Council members as
they make recommendations. He closed by saying that investment in
infrastructure and training is critical. Intellectual property rights,
the balance of prevention and care, and funding for education and other
services are also important issues.

David Kramer, Senior Advisor for Global Affairs, U.S. Department of
State, said that President Bush has demonstrated interest in the global
HIV/AIDS pandemic and Secretary Powell has reinforced the U.S.
commitment to tackling the global challenge. In addition, the Deputy
Assistant Secretary of State is working to reach out to the NGO
community and legislators on Capitol Hill.

HIV/AIDS is prominent on the foreign policy agenda because of the
economic and security impact, and because it threatens countries'
stability and undermines development activities. For example, countries
in sub-Saharan Africa will face demographic upheaval. Botswana is
expected to experience negative population growth by 2010. Therefore, he
said, time is of the essence, and sustained global cooperation is
essential.

Mr. DeLay and Mr. Kramer responded to questions from the PACHA members.
It was noted that the State Department tries not to permit the political
situation in any country result in the country's population suffering.
Mr. DeLay added that USAID has "notwithstanding language" that allows
work in any country regardless of the political situation. For example,
USAID likely will establish small programs in Burma. Mr. Kramer also
noted that it is important for the Secretary of State to speak out on
the issue of HIV/AIDS and to work with countries in need of assistance.

**Office of National AIDS Policy Update**

Scott Evertz of ONAP thanked Dr. Coburn, Dr. Sullivan, and Mr. Dellums
for their Council leadership and he welcomed the new PACHA members. Mr.
Evertz said he had just come from a meeting at the Inter-American
Development Bank at which President Bush stressed that HIV/AIDS must be
confronted along with poverty and other issues in developing countries.
Mr. Evertz reported that a new initiative will significantly increase
funding for global assistance for HIV/AIDS and other issues over the
next 3 years through the Millenium Challenge Account. He also said that
the United States has contributed \$500 million to the Global Fund and
will increase contribution as the fund proves successful. There is
recognition in the Administration that the United States cannot separate
itself from the global community.

Mr. Evertz then presented an overview of ONAP, which focuses on the
domestic struggle with HIV, especially in communities of color; efforts
to alleviate the global HIV/AIDS pandemic and to develop global policy,
especially as it relates to U.S. efforts to combat the disease abroad;
and coordination of PACHA. ONAP will participate in national campaigns
such as National Testing Day and promotes the need to encourage
individuals to seek treatment early in the disease rather than waiting
until they have AIDS-related complications. The office also is studying
the impact of regulations that eliminate Federal benefits if people with
AIDS return to work. In addition, ONAP is concerned with the need to
provide resources to people living with HIV/AIDS and with empowering
people to choose organizations that have funding to serve them.

Mr. Evertz challenged the PACHA members to develop recommendations that
will force ONAP to respond, and he recognized the ONAP staff for their
contributions. He provided his fax number (202-456-7315) to use for this
purpose.

Dr. Sullivan said he is encouraged by Mr. Evertz's report of President
Bush's comments and suggested that the Council send a resolution to the
President to commend those comments. Mr. Evertz then responded to
comments and questions from the floor. He agreed with a Council member
that the Council should review the Surgeon General's report on sexual
health and could identify information in the report to which the
Administration should respond. Dr. Sullivan said that copies of the
report will be distributed to the membership. Mr. Evertz said that ONAP
will develop a response to the report for review by the Council.

Other topics raised by Council members included Medicaid and Medicare
involvement in treatment, the movement to upgrade public health
infrastructure at the State and local levels, the need to focus on the
epidemic in racial and ethnic minority populations, the need for
effective care and health care professional training, the role of dental
professionals in prevention, the need for better women's services, and
creation of an HIV/AIDS medical specialty.

Dr. Sullivan said that the topics suggested would be considered as
agenda items at future Council meetings.

**Full Council Presentation: Substance Abuse Issues and HIV/AIDS**

James H. Autry, M.D., Deputy Administrator, Substance Abuse and Mental
Health Services Administration (SAMHSA), spoke about SAMHSA's
involvement in confronting HIV/AIDS and the close relationship of
HIV/AIDS with substance abuse and mental health. SAMHSA's mission is to
strengthen the capacity of the Nation's health care delivery system to
provide substance abuse prevention, addiction treatment, and mental
health services in order to reduce the human and economic cost to
society of mental and addictive disorders. Mental health and substance
abuse service systems need to be built according to community needs and
to be representative of the community to be served, he said.

SAMHSA's HIV/AIDS program goals are to increase access to care, to
develop strong infrastructure through targeted technical assistance, and
to institutionalize critical linkages to maximize program effectiveness.
Initiatives within all three SAMHSA centers---theCenter for Substance
Abuse Prevention (CSAP), the Center for Substance Abuse Treatment
(CSAT), and the Center for Mental Health Services---are designed to
achieve these goals. HIV/AIDS is a high priority for SAMHSA, and the
agency's investment in HIV/AIDS in FY 2003 will be \$174 million, Dr.
Autry said. He explained that many AIDS cases are related to injection
drug use, but that alcohol and other drug use also have a profound
influence HIV transmission (e.g., because of unsafe sex practices). In
addition, the mental health impact of HIV on people affected by HIV is a
critical concern of SAMHSA.

Dr. Autry said that SAMHSA plays an important role in developing the
Minority AIDS Initiative and funds technical assistance centers that
serve CBOs and indigenous service providers. The agency has received
significant increases in its HIV/AIDS funding since 1999. In FY 1999, it
was provided \$22 million from the Minority AIDS Initiative for
comprehensive substance abuse treatment and prevention programs for
minority populations affected by HIV/AIDS. CSAP and CSAT were designated
to administer the Congressional Black Caucus (CBC)-funded initiatives.
In FY 2000, SAMHSA received almost \$50 million from the CBC initiative,
and in FY 2002, it received \$102.5 million to expand and continue
programs.

Dr. Autry said that CSAP has augmented the ability of 47 grantees to
implement HIV/AIDS prevention programs in communities of color that were
targeted by the CBC. These programs seek to reach high-risk,
sero-negative people to provide prevention counseling, to increase the
number of people who learn their HIV status, and to increase efforts to
provide counseling to prevent transmission and reinfection of
individuals who are already infected. Grants will also support technical
assistance and organizational development essential to sustaining the
work of CBOs.

In CSAT, the Targeted Capacity HIV program provided services to 4,300
clients in communities that are disproportionately affected by HIV/AIDS.
An HIV/AIDS outreach program has also been operating for a number of
years. The program recently funded 25 sites, which have exceeded the
projected number of individual and group contacts and HIV tests to be
provided.

Dr. Autry also stressed that mental health issues associated with
HIV/AIDS must be addressed. Better outcomes result when mental health,
substance abuse, and primary care services are integrated. Under the CBC
initiative, the Center for Mental Health Services will expand
traditional and nontraditional mental health treatment for racial and
ethnic minorities who are living with HIV/AIDS.

SAMHSA continues to collaborate with Federal Government partners,
particularly HRSA and CDC, by jointly sponsoring programs, activities,
and conferences. Dr. Autry concluded by saying that in FY 2002, SAMHSA
will continue existing grant programs and will provide increased
technical assistance to serve minority communities that have not been
successful grantees.

Dr. Autry responded to questions and comments from the floor. Topics
raised included funding of drug abuse treatment and HIV, and SAMHSA
funding for HIV services.

**Full Council Discussion: Report from the Previous Council**

Mr. Dellums, former PACHA Chair, congratulated the Council co-chairs on
their appointment and recognized the contributions of former PACHA
Executive Director Daniel Montoya. Mr. Dellums also acknowledged and
commended the efforts of the President, the Vice President, and the
Administration, and applauded ONAP's leadership.

Mr. Dellums urged the Council members to read the previous Council's
final report, entitled *AIDS -- No Time to Spare: Final Report to the
President of the United States.* Citing the report, he said that
HIV/AIDS is the greatest threat faced by the human family and that the
disease's devastation around the globe during the past 20 years is
severe. Globally, the communities with the greatest HIV/AIDS challenges
are those that are poorest and those of people of color. In today's
increasingly interconnected world, no community or nation can afford to
respond in isolation, so a global action plan should be developed.
Investments in biomedical research have paid off, but these efforts
should be expanded.

In *AIDS -- No Time to Spare*, PACHA made 64 recommendations, offering
an initial challenge to the Administration and signaling a shift to a
global perspective that should be maintained. The following
recommendations were presented by Council members:

-   Support full funding of the Minority HIV/AIDS Initiative at \$540
    million in FY 2002, ensure that the funds are used to support
    minority CBOs and HIV service providers, and declare an AIDS-related
    emergency in communities of color and respond accordingly;

-   Increase appropriations for U.S. and global HIV/AIDS programs,
    including efforts to increase the U.S. contribution to the Global
    Fund to Fight AIDS, Tuberculosis, and Malaria;

-   Support passage of the Early Treatment for HIV Act to improve access
    to care for low-income, uninsured people living with HIV;

-   Prioritize vaccine and microbicide research, support policy reforms
    to speed vaccine and microbicide development, and ensure access to
    such prevention tools worldwide;

-   Improve coordination and continue U.S. leadership in the global
    fight against HIV/AIDS; and

-   Commit to providing comprehensive sexuality education programs
    consistent with sound public health research presented in the
    Surgeon General's *Call to Action to Promote Sexual Health and
    Responsible Sexual Behavior* and avoid the politicization of HIV
    prevention through emphasis on abstinence-only education.

Mr. Dellums emphasized that more treatment should be available to the
global community. He said the previous Council grappled with the concept
of globalism, and he hopes that the new PACHA will continue to do so.

Dr. Sullivan said that the previous Council's recommendations will be
reviewed. Confronting the epidemic globally requires cooperation from
other Governments, which involves greater challenges, he added. Council
members noted that the Council might frame its response to the issue of
developing a global initiative in the context of national security.

**Public Comment**

Members of the public addressed the Council. Comments and questions
concerned: HIV/AIDS in the incarcerated population; the HHS management
review; the need to improve information about and access to services;
the need to develop leadership at the community level; the need to fund
programs to address the HIV/AIDS epidemic in minority communities and
among minority populations; and the importance of building on the
Council's past recommendations, specifically in the area of HIV/AIDS and
substance abuse.

Members of the public also recommended that Secretary Thompson take the
same leadership role in confronting HIV/AIDS as he took in confronting
the anthrax crisis; asked the Council to look at how the issues of
homeland security and HIV/AIDS relate, especially in building the public
health infrastructure; and requested that the Council consider issues
related to therapies, vaginal and anal microbicide research, and vaccine
development research.

A representative of HRSA's AIDS Advisory Committee said the Committee is
working with CDC's Advisory Committee on the need for ongoing care for
HIV and welcomes PACHA's support of these efforts. Dr. Sullivan
requested that Ms. Ware obtain copies of the HRSA Advisory Committee's
report.

## Full Council Discussion

Ms. Duran recommended that the PACHA members discuss involving Mrs.
Bush, Mrs. Cheney, or other public figures in addressing HIV/AIDS.

Ms. Smith stated that there is a need to address rural issues in
addition to urban issues.

Ms. Shoemaker recommended that HIV/AIDS education for K-12 school
children and their parents be improved. Ms. Freeman added that there is
a need to increase messages targeted to young people.

Rev. Sanders reiterated the need to frame HIV/AIDS in the broader
contexts of public health and homeland security. Ms. Ware said that the
HHS management review includes review of homeland security and
bioterrorism programs, and that there is a need to look at how the
review can address the issue of HIV/AIDS in the context of these issues.

Dr. Driscoll pointed out that increasing global funding is important,
but that it is also important to find ways to persuade countries to
change their policies and to recognize the basic human rights of their
people. He also stated that more priority should be placed on HIV/AIDS
in the Caribbean and Mexico because immigration of people from these
countries directly impacts the U.S. HIV/AIDS problem.

A Council member suggested that the Council's previous recommendations
and President Reagan's report on HIV be provided to the Council members.

Dr. Sullivan said that the PACHA co-chairs will work with Ms. Ware to
develop agendas for future Council meetings. Dr. Coburn noted that the
Council should consider choosing two or three major issues that will
have the greatest impact.

## Adjournment

The March 14, 2002, session adjourned at 5 p.m.

**[Friday, March 15, 2002]{.underline}**

**Welcome**

Ms. Ware took roll call. Dr. Coburn introduced the first panel of
presenters.

**Full Council Presentation: Financing of AIDS Medications**

Deborah Parham, Acting Director, HIV/AIDS Bureau, HRSA, described the
programs operated under the Ryan White CARE Act, which was reauthorized
in 2000 and provides \$1.9 billion in funding. The Ryan White CARE Act
program is the largest Federal Government program to pay for care for
poor and uninsured people living with HIV/AIDS and provides services for
half of the people living with HIV/AIDS in this country.

Ryan White CARE Act programs include: Title I, which provides funds to
51 eligible metropolitan areas that have high populations of people
living with HIV/AIDS; Title II, which provides funds to states for AIDS
Drug Assistance Programs (ADAPs) and other services; Title III, which
provides funds directly to CBOs for early intervention services, care,
and treatment; Title IV, which provides funding to serve women, children
and youth; the AIDS Education and Training Centers, which provide
training of health care providers; the Dental Reimbursement Program,
which provides funding to dental training programs; and Special Projects
of National Significance.

Ms. Parham then focused on the ADAP component, which is managed by
individual states. The program, which includes 56 ADAPs, provides funds
to pay for medications for people who have no or limited health
insurance. The drug formularies and eligibility criteria vary across the
ADAPs. The formularies include between 17 and 453 drugs.

In 2000, ADAPs served 125,000 clients and in 2002, an estimated 138,000
will be served, Ms. Parham said. In any given month, approximately
79,000 people receive services through the programs. Demand for ADAP
services outstrips the supply, so some states have implemented cost
saving strategies, such as using ADAP funds to purchase health
insurance, encouraging clients to enroll in programs that have
negotiated discounts with drug companies, and maintaining close
coordination with Medicaid programs. Some states also have limited the
number of drugs in their formularies, capped the amount spent per
patient on drugs, capped program enrollment, implemented waiting lists
for clients, and added program eligibility requirements. Most ADAPs have
established consumer advisory boards to help them make choices about how
to use funding.

The reauthorized CARE Act sets aside 3 percent of funds for states that
have severe needs. In 2001, \$17 million in funding was set aside for
this purpose, and \$19.2 million was set aside in 2002.

Randy T. Graydon, Deputy Director, Division of Advocacy and Special
Issues, Centers for Medicaid and Medicare Services (CMS), then described
the CMS HIV/AIDS program. He began by stating that CMS administers four
programs: Medicaid, Medicare, the State Child Health Insurance Program,
and the Health Insurance Portability and Accountability Act (HIPAA)
Program. HIPAA is an important piece of legislation for persons living
with HIV/AIDS because it protects those who change jobs. Medicaid and
Medicare are the two largest payers for care of AIDS. In 2002, Medicaid
will spend \$7.2 billion and Medicare will spend \$2.1 billion for this
care. In 2002, Medicaid will serve 218,000 people with AIDS and Medicare
will serve 46,000 persons with AIDS, but may pay for services for many
more people who are not reflected in these figures.

Medicaid includes mandatory eligibility groups, most of whom are covered
by SSI. Optional eligibility groups include persons who are medically
needy, Ticket to Work and Work Incentive Act groups (i.e., the working
disabled), individuals in medical institutions, and individuals who
receive home- and community-based services. Medicaid pays for mandatory
services (e.g., inpatient hospital, laboratory, and X-ray services) and
optional services (e.g., prescription drugs, nursing care, and dental
services). All states do not have to cover prescription drugs, and
states have their own drug formularies.

States can use Medicaid waivers to circumvent rules. These waivers
include: 1915(b) waivers (allow states to mandate enrollment of people
into managed care); 1925(c) waivers (home- and community-based services
waivers); 1915(b)/(c) combined waivers; and 1115 waivers. The 1115
waivers, which are approved for 5 years, must be budget neutral to the
Medicaid program. CMS has oversight in developing 1115 waivers, which
are flexible enough to allow testing of new ideas of merit. Evaluation
is required under 1115 waivers.

Medicaid pays services for 55 percent of people living with AIDS and for
90 percent of children living with AIDS. Special income levels have been
set for pregnant women to improve access to care. Income levels and
family size for eligibility in each state are listed on the CMS Web site
at www.hcfa.gov/hiv/subpg1.htm.

Tom Liberti, Chief, Bureau of HIV/AIDS, Florida Department of Health,
described the Florida AIDS Drug Assistance Program, a \$75 million
program that has 55 drugs in its formulary. The Florida ADAP is
administered through 67 county health departments. Drugs are purchased
from drug wholesalers with a discount through a state central pharmacy
and shipped to the county health departments. More than 15,000 clients
currently are enrolled in the Florida ADAP. Of these clients, 71 percent
are men and 29 percent are women, mirroring the epidemic in Florida.
Seventy percent of the clients are racial and ethnic minorities.
Ninety-two percent of the clients receive at least triple combination
antiretroviral drugs by prescription.

Mr. Liberti highlighted reasons for increasing ADAP costs. Most
importantly, he said, public health and community partners have been
successful in encouraging patients to know their HIV status. In 1999,
public health departments performed 231,000 HIV tests, and in 2001 the
number grew to 271,000. Between 1985 and 2002, a total of 2.9 million
tests were done in the state. Reportable cases of HIV was 5,772 in 2001,
with growth reflecting increased testing. As a result, enrollment in
ADAP has increased.

Mr. Liberti said that other reasons that ADAP costs continue to rise
include new infections, the success of minority AIDS initiatives in
bringing more people into care, the rise in drug costs, the reduction in
insurance plans' pharmacy benefits, and drug resistance that requires
additional antiretroviral therapies. Neighboring states' ADAP waiting
lists, client expenditure caps, and drug access restrictions also impact
Florida's ADAP funding needs.

Bill Arnold, Chairman, ADAP Working Group, described his group's
activities. The Working Group is a coalition of almost 40 AIDS
organizations, care providers, and pharmaceutical companies that lobbies
at the Federal level for adequate ADAP funding and works at the state
level to address other funding issues. The ADAP Working Group began
meeting in late 1995 and has received support from legislators and the
Administration.

ADAPs are the heart of the states' systems to support people with
HIV/AIDS, Mr. Arnold said. The ADAP funding crisis did not receive any
public attention until combination treatments were introduced, and
today, many people are not being served.

The FY 2001 ADAP budget was at least \$60 million lower than the ADAP
Working Group's projected need, and the FY 2002 budget is \$162 million
less than what is needed. Mr. Arnold said that an \$82 million emergency
supplemental appropriation is needed now or the program will not be able
to assist all the people who need drug assistance. He asked the PACHA
members to support an emergency supplement and an adequate FY 2003
budget. A Medicaid drug benefit, Medicaid expansion, and Medicare drug
benefit would be help to relieve the lack of funding.

John Palen, Ph.D., George Washington University, discussed methods of
expanding access to HIV-related therapeutics for low-income persons with
HIV disease through the Medicaid and Ryan White CARE Act programs.
Administrative procedures used by grantees, management and
organizational activities, integration and coordination of program
activities, and legal and regulatory proposals may be useful.

Better integration and planning of services within states could result
in significant administrative savings and improved access to drugs, Dr.
Palen said. Rebate programs are available to Medicaid programs that
could reduce costs further. For example, the Medicaid program could be
evaluated regarding reimbursement and rebates and may be a program where
cost savings can be derived. He also said there may be ways to leverage
Medicaid buying opportunities, and assessment of appropriate
utilization/drug prescribing is important.

Management and organizational activities to expand access to therapies
for low-income people living with HIV may include private health
insurance or continuation of coverage for drugs for ADAP clients. In
addition, Medicaid programs can influence drug utilization and
prescribing patterns, create drug formularies, and encourage the use of
generic drugs. Medicaid waivers available to states provide
opportunities to address drug needs.

Dr. Palen also suggested that program activities could be better
integrated and coordinated to help improve access to medications. For
example, there has been discussion within the Federal Government
regarding simplifying funding streams or allowing states to use funding
in more flexible ways. This could result in administrative savings. For
example, integrating ADAP into the Medicaid program could provide
greater continuity of care.

Legal and regulatory proposals include using the provisions in Section
603 of the Veterans Health Care Act, modifying formulas, and expanding
Medicaid eligibility criteria to include low-income persons who are
HIV/AIDS asymptomatic.

Hank McKinnell, Ph.D., Chairman of the Pharmaceutical Research and
Manufacturers Association (PhRMA), and Chairman and Chief Executive
Officer of Pfizer Inc., noted that highly active antiretroviral therapy
(HAART), introduced in 1990s, has transformed AIDS into a manageable,
although difficult chronic disease. HIV was first characterized in 1981.
Today, physicians can prescribe more than 64 medications to treat
HIV/AIDS and more than 100 clinical studies are underway. Success in
finding new medicines presents the challenge of how to pay for them,
however. Much of the progress seen (e.g., fast track approval by Food
and Drug Administration) reflects the work of the HIV/AIDS activist
community.

Dr. McKinnell said that a critical issue is when to start therapy. He
presented data from controlled studies suggesting that beginning therapy
late results in high relative risks of progression to AIDS and death.
When therapy is begun early, the risk is halved and costs are lower.
There is also a good argument for starting treatment earlier because
doing so improves quality of life and allows those with HIV/AIDS to
remain in the workforce and pay taxes.

Dr. McKinnell said that Medicaid covers more than half of all
HIV-infected people who are in therapy, but states are reducing funding.
Sixteen states reduced Medicaid funding in 2001 and more are expected to
do so this year. The current system pays for care late in the disease
cycle, when the disease is most expensive to treat. Dr. McKinnell
suggested changing the system to treat people earlier in the disease
cycle. Several states and the District of Columbia are experimenting
with this approach, and other states are considering it.

Pfizer Inc. is committed to working with advocacy groups to ensure there
is adequate ADAP funding and wants to ensure that as many patients as
possible have access to needed medications. With \$32.3 billion in
annual sales, Pfizer is the world's largest pharmaceutical company. The
company invests \$100 million a week to find new medicines.

Dr. McKinnell announced to the PACHA members that Pfizer will not
increase the price of Viracept, a leading protease inhibitor, for the
next two years. He also described the Pfizer for Living Share Card
program, which is designed for low-income, uninsured Medicare
recipients. The program offers a 30-day supply of Pfizer drugs for \$15
per prescription and is designed as a bridge to help modernize Medicare.

One concern is that most people fail in the initial course of therapy.
Therefore, the pharmaceutical industry must continue to look for new
therapy options, and there are new pressures on product discovery firms
and on sources of medical care funding. Dr. McKinnell recommended that
the PACHA members examine the trade-off between better access today and
new options for the future. When patents expire, there will be a
financial dividend in making generics available. The pharmaceutical
industry also can work to create new drug options, including simpler
regimens that are better tolerated by patients.

The pharmaceutical industry is working in the developing world to deal
with the global crisis, and partnerships are important in dealing with
global crisis, Dr. McKinnell said. Pfizer has formed alliances in
sub-Saharan Africa to create a training and treatment facility in Uganda
and has created a partnership program in South Africa that dispenses
Diflucan, processes prescriptions, and trains professionals.

Dr. McKinnell concluded by saying that the financing situation is barely
in a state of equilibrium, and pressures on the system will continue to
increase. Half of all HIV-positive people are not insured, but that
group has little influence on Government. When HIV/AIDS emerged,
activist groups were more vocal, but today's population is less vocal.
He recommended that the Council maintain a focus on the human aspects of
the disease, make education a national priority, look at earlier
treatment, encourage and reward research, and forge true partnerships to
manage the disease and care for its victims. He said that Pfizer is
committed to early treatment and supports expanded Medicare and Medicaid
coverage, continuing incentives for research and innovation, increased
recognition for an HIV medical specialty, and ongoing collaborations
with NGOs and patient support groups.

The speakers then responded to questions and comments from the Council.
Ms. Ivantic-Doucette noted that the ADAP consumes one-fourth of all Ryan
White CARE Act funds, but many drugs are prescribed inaccurately or
inappropriately. She also expressed concern that HIV/AIDS care has
become institutionalized in the United States and that this
institutionalization is being exported to programs to other countries
(e.g., in providing training for physicians who may not provide the bulk
of the care). Ms. Parham responded that HRSA is very concerned about
providers' accountability in spending CARE Act dollars and noted that 5
percent of CARE Act dollars can be spent on quality improvement. HRSA
also conducts site visits to determine if care is being provided
according to standards.

**Full Council Presentation: HIV and Co-Infection with Other Infectious
Diseases**

Jules Levin, Founder and Executive Director, National AIDS Treatment
Advocacy Project, said that one of the most problematic issues for
people with HIV is co-infection with hepatitis C virus (HCV). In the
United States, four million people have HCV, 2.7 million with HIV have
chronic HCV, and 300,000 are co-infected with HCV and HIV. HCV often is
spread is through injection drug use, and the disease transmits more
easily than HIV.

Co-infection with HCV and HIV can cause problems that are unrecognized
and not well understood by many health care workers and case managers.
For example, HIV accelerates HCV progression because HIV impairs the
immune system, and HCV progresses differently with HIV co-infection.

Mr. Levin said that people who are co-infected are among the most
vulnerable groups, including current or former IDUs, sexual partners of
IDUs, African Americans, Hispanics, women, people who are poor and
uneducated, and people with poor access to medical care. It is often
very challenging to educate people who are co-infected about their
disease. Many people who are co-infected learn that they have HCV long
after they are infected, and many people with HIV are not tested for
HCV. Therefore, everyone who is tested for HIV should also be tested for
HCV.

Mr. Levin also noted that large gaps exist in reimbursement treatment of
hepatitis C. Public reimbursement for diagnostics and treatment is
inconsistent, and it is difficult to get treatment and all diagnostics
covered. Many ADAPs do not pay for HCV treatment and diagnostics.

Mr. Levin concluded by listing the following needs: education about
co-infection, including among health professionals; funding to improve
care for co-infection; more and better research on co-infection (e.g.,
the effect of HAART on HCV progression); funding for treatment and
diagnostics (e.g., by adjusting ADAP formularies and earmarking ADAP
funds for HCV treatment); outreach to Congress and the Administration to
prioritize this issue; and increased awareness about testing and
education about co-infection and HCV prevention.

Dickens Theodore, M.D., University of North Carolina Chapel Hill,
presented an overview of HCV, with a focus on special populations. There
are a number of genotypes, or subtypes, of HCV. Genotype 1 is more
resistant to therapy, and genotypes 2 and 3 are easier to treat.
Approximately 30 percent of people clear infection, leaving at least 70
percent with chronic infection. The effects of HCV usually are mild, but
may progress to cirrhosis of the liver. Models show that prevalence of
cirrhosis of the liver will increase five-fold by 2008, and
liver-related deaths, decompensation, and the need for liver
transplantation will increase.

Injection drug use is the most common means of HCV infection, although
the prevalence is also high among hemophiliacs and people on
hemodialysis. Blood transfusion has decreased as a risk factor during
past 15 years. The estimated incidence of HCV in the United States
decreased between 1982 and 1996 because of HIV preventive measures.

Dr. Theodore said that risk for HCV varies across groups in the United
States. African Americans and Mexican Americans have higher rates than
whites, probably because of lower socioeconomic status. The disease also
is different in African Americans and Caucasians. Genotype 1 is more
common in African Americans.

Dr. Theodore explained that perinatal transmission of HCV is higher in
people with HIV. There is also evidence that people with HCV progress to
HIV-related illness much faster than people without HCV, particularly
with HCV genotype 1.

The goals of therapy are to eliminate the HCV infection, delay fibrosis
progression, and prevent negative clinical outcomes. Pegylated
interferon is the current focus of treatment. More than half of people
respond to pegylated interferon, but those with genotype 1 are less
likely to respond to this therapy. There are few data on the safety and
efficacy of HCV treatments in the HIV-co-infected population, although
some studies are in progress.

Dr. Theodore recommended that directions for the future include more
research on the interaction between HCV and HIV, hepatoxicity, and
pathogenesis; development of improved therapy; increased education of
patients and providers; and increased funding for research, education,
and treatment.

Joe McIlhaney, M.D., Founder and President, Medical Institute for Sexual
Health, discussed the relationship between HIV and other sexually
transmitted diseases. Most studies show that genital ulcer disease (GUD)
increases susceptibility to HIV in both men and women. Genital herpes
doubles the risk of subsequent HIV infection, and syphilis and chancroid
also increase the risk of HIV infection. Data showing an association
between non-ulcerative disease (NUD) and HIV also continue to
accumulate. NUD may increase HIV susceptibility for women by increasing
the pH of the vagina.

Dr. McIlhaney said that risk behavior is an important issue. For
example, when syphilis rates in a population rise, HIV rates often
follow, suggesting an association with increased risk behavior in the
population. In addition, GUDs and NUDs seem to increase the
infectiousness of people with HIV, and HIV-infected individuals may be
more susceptible to sexually transmitted infections (STI) and their
effects. Therefore, he suggested, STI monitoring and control programs
should be a part of all HIV prevention efforts, and STI and HIV programs
must be integrated. Programs should include counseling, screening,
treatment, and prevention.

Dr. Coburn opened the floor to comments and questions. Mr. Levin stated
that because people are living longer with HIV/AIDS, they are having
complications that did not arise in the past.

Mr. Levin suggested that IDUs be educated about HCV and HIV prevention
and treatment. Likewise, HCV awareness and testing programs offer
opportunities to encourage IDUs to enter drug treatment. Case managers
and health care professionals must also be educated about the
relationship between HCV and HIV. Today's reimbursement systems result
in physicians spending less time with patients, so HCV and co-infection
with HIV do not receive adequate attention, Mr. Levin said. The problem
of co-infection will become more of an issue as the HIV-infected
population ages.

Ms. Ware noted that health care providers are talking about the
relationship of HCV and HIV, but that policy makers are not. She also
pointed out that tattooing has increased incidence of HCV in teens.
Tattoo parlors are not regulated and teens sometimes tattoo one another.
Education of young people about HCV and HIV may be an appropriate topic
for a future PACHA meeting, she said.

**Full Council Presentation: The State of HIV/AIDS Research**

Anthony Fauci, M.D., Director, National Institute of Allergy and
Infectious Diseases (NIAID), presented an update on the HIV/AIDS
pandemic and the NIH and NIAID research agendas. Dr. Fauci said that NIH
HIV/AIDS research funding has increased dramatically during past 21
years, with continuing growth. HIV/AIDS resources now comprise 10
percent of NIH resources and 50 percent of NIAID resources. Therapeutic
and drug development research increases each year, but there is even
greater emphasis on vaccine development.

Dr. Fauci noted that HIV/AIDS epidemic trends drive the NIH strategic
plan. Globally, 40 million people are living with HIV and most new
infections are in the developing world. Sub-Saharan Africa has been hard
hit, but there is potential for an explosion in the epidemic in Asia and
India. NIH international AIDS projects are now conducted at 345 sites in
105 countries. International research involves studying vaccine
development, topical microbicides, prevention of disease transmission
and progression, women and AIDS, prevention and treatment of HIV
infection in children, prevention and treatment of opportunistic
infections, capacity building and training of foreign scientists, and
research collaboration.

The Comprehensive International Program of Research on AIDS (CIPRA) was
launched last year. Major goals are to provide long-term support to
developing countries to plan and implement comprehensive HIV/AIDS
prevention and treatment agendas relevant to their populations and to
enhance the infrastructure needed to conduct such research.

HIV Vaccine and Prevention Trials Networks (HVPTNs) are located
worldwide. These networks are developing programs for non-vaccine
prevention of HIV infection and building infrastructure for Phase II and
Phase III trials.

Dr. Fauci then discussed the domestic HIV/AIDS situation. As of June 30,
2001, 793,000 AIDS cases and 457,000 AIDS deaths had been reported to
the CDC. Between 850,000 and 950,000 U.S. residents are living with HIV
infection; half of them are untested, untreated, or both. In addition,
40,000 new infections, half in people younger than 25, occur annually.
The rate of AIDS cases per 100,000 people is 10 times higher among
African Americans than in the non-Hispanic white population.

The Multicenter AIDS Cohort Study is being extended to focus more on
minority groups, Dr. Fauci said. In the past, the proportion of
minorities in clinical trials was smaller than in the population,
limiting access to new drug trials and limiting the ability to study
differences in the disease across populations.

Dr. Fauci also discussed NIH-supported HIV/AIDS pathogenesis research
and briefly described the HIV replication cycle and the typical course
of HIV infection. An understanding of the life cycle and clinical course
has allowed researchers to develop targeted drugs and to know when to
begin and when to modify therapy. Studies are looking at fusion/entry
inhibitors and integrase inhibitors, in addition to reverse
transcriptase and protease inhibitors. There has been a 70 percent
decrease in deaths in the past few years, but the recent plateau
reflects individuals' inability to tolerate some drugs. Current anti-HIV
drugs are limited because of the persistence of viral reservoirs.
Therefore, there will be an evolution of drug resistance, providing good
reason to sustain drug development research. The questions of when to
begin treatment and the effectiveness of structured intermittent therapy
also require further study.

Prevention research is an important part of the NIH HIV/AIDS research
agenda, and expenditures for vaccine and non-vaccine prevention research
at NIH are increasing, Dr. Fauci said. This research examines prevention
of maternal-fetal transmission, topical microbicides, behavior
modification, reducing transmission from injection drug use, and STD
control.

NIH HIV vaccine research funding will increase in FY 2003. A major focus
of this research is on the use of attenuated adenovirus with HIV genes
inserted. The NIAID Vaccine Research Center on the NIH campus opened
less than 2 years ago and now has trials underway.

Dr. Fauci then responded to questions from the Council. Questions and
comments focused on the importance of leadership and infrastructure in
tackling the HIV/AIDS crisis in developing countries, the importance of
behavior modification in prevention, progress in developing an HIV
vaccine, parallels between the HIV/AIDS situation in developing
countries and among underserved groups in United States, and drug
toxicity.

Dr. Fauci suggested that the Council discuss the importance of
developing a uniform leadership front within the African-American and
Hispanic communities, and the importance of U.S. leadership in
confronting the global pandemic.

**Full Council Discussion**

Dr. Coburn began the full Council discussion by stating that all input
about Council's work and operations is welcome, noting that individuals
affected by HIV/AIDS, not politics, should be the Council's focus. He
also suggested that the Council committees consider both policy changes
and legislative recommendations.

Ms. Ware said that the Council meeting was designed to provide
background information and that future meetings will include more time
for interactive discussions and development of policy recommendations.
Presenters will be made available to the Council committees as they
meet, and it is hoped that committee reports will be presented at the
next Council meeting.

The PACHA members then recommended topics they felt should be addressed
by the Council. The topics suggested included:

-   Medicaid waivers and issues related to cost neutrality and quality
    of care;

-   Increase of HIV/AIDS services funding, including for ADAPs;

-   HIV/AIDS prevention and involvement of communities in prevention
    planning and implementation;

-   The need for more HIV/AIDS education among children and adolescents,
    and the involvement of youth in education;

-   HIV/AIDS services within the prison system;

-   Program and funding efficiency and accountability;

-   Preservation and support of established minority group leadership;

-   The role of dental professionals and professional organizations in
    HIV prevention;

-   The need for national and international moral leadership and
    activism to ensure that funding for drugs and research is available;

-   The need to ensure that early treatment is available;

-   U.S. leadership in confronting the global epidemic and the need for
    balance in addressing the global and domestic HIV/AIDS epidemics;

-   Best practices in containing the epidemic;

-   Concerns about industrialization of HIV/AIDS prevention and
    treatment and the hazards of exporting the "industry" to other
    countries;

-   The need to look at the President's priorities and areas where the
    Administration's and PACHA's concerns dovetail (e.g., in upgrading
    the public health system);

-   Barriers posed by regulations and increased administrative costs on
    the work of CBOs; and

-   Whether the nation's level of commitment is commensurate with the
    gravity of the problem.

A member suggested that the Council revisit past Council recommendations
to determine which are still relevant and have not been addressed.
Choosing only two or three powerful themes could have the greatest
impact. Another member suggested that the Council move quickly to
deliver a first set of recommendations to the President; that *ad hoc,*
topic-focused working groups be established; and that the Council
members make concrete, specific recommendations. A recommendation was
also made to seek input from the public and organizations (e.g., the
National Minority AIDS Council) and to raise PACHA's visibility.

Dr. McKinnell offered to make specialized resources (e.g., meetings with
researchers) available to the Council.

**Other Business**

Ms. Ware expressed her pleasure with the Council meeting proceedings.
She noted that the President was very clear that HIV/AIDS is not
partisan and that the Council membership composite reflects this.

She also encouraged members to find opportunities to speak about
HIV/AIDS and the Council's work in the community or at meetings.
However, Council members must receive approval from the Council
co-chairs for speaking engagements on behalf of the Council.
Furthermore, Council members are not permitted to express personal
opinions when speaking on behalf of the Council.

Ms. Ware added that the Council can meet three more times in the next
year, and committees will be established.

Dr. Coburn suggested that the Council develop a consensus on immediate
recommendations to the Administration. The points he suggested were:
markedly increase the U.S. contribution to the Global Fund; increase
ADAP funding; and change the Medicaid 1115 waiver. Council members also
suggested that the Council support funding for prevention and early
treatment of HIV/AIDS; that the President raise awareness of HIV/AIDS
through a "know your status" campaign; that the President, Mrs. Bush, or
another high-level public figure become directly involved in raising
awareness (e.g., by getting tested on National Testing Day); and that
assurances be made that that the Global Fund is being used effectively
and as intended.

Dr. Coburn recommended that options for immediate Council
recommendations be disseminated by e-mail to the Council members for
review and comment the week of March 25, 2002. Immediate input on the
suggested recommendations will be requested.

**Public Comment**

The Council members heard comments from the public. Members of the
public recommended that the Council: take action because small steps are
better than no steps; open its meetings to the public; discuss the
behavioral and attitudinal aspects of HIV/AIDS; address the mental
health aspects of the disease; address the impact of HCV/HIV
co-infection, particularly in the prison population; and encourage the
public to "know your status."

**Other Business**

Mr. Smiley said he has enjoyed working with past and present Councils
and is highly encouraged by the Council's discussion during the 2-day
meeting. He offered to serve as a resource in the future.

Dr. Coburn said the PACHA members will be polled regarding future
Council meeting dates.

**Adjournment**

The 19th meeting of the Council adjourned at 4 p.m.