**Presidential Advisory Council on HIV/AIDS**

**Twenty-Eighth Meeting**

**Hubert Humphrey Building**

**200 Independence Avenue, S.W.**

**Room 800**

**Washington, DC 20201**

**November 14, 2005**

**Council Members---Present**

Anita Smith, Co-Chair, Presidential Advisory Council on HIV/AIDS (PACHA)

Abner Mason, Chair, International Subcommittee

David Reznik, D.D.S., Chair, Treatment and Care Subcommittee

M. Monica Sweeney, M.D., M.P.H., Chair, Prevention Subcommittee

Rosa M. Biaggi, M.P.H., M.P.A.

Cheryll Bowers-Stephens, M.D., M.B.A.

Jacqueline S. Clements

Mildred Freeman

John F. Galbraith

Edward C. Green, Ph.D.

Cheryl-Anne Hall

Jane Hu, Ph.D.

Karen Ivantic-Doucette, M.S.N., FNP, ACRN

Deborah Jacobs-Rock

Rashida Jolley

Sandra McDonald

Joe McIlhaney, M.D.

Jose Montero, M.D., FACP

Dandrick Moton

Beny Primm, M.D.

Reverend Edwin Sanders

Ram Yogev, M.D.

**Council Members---Absent**

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

Franklyn N. Judson, M.D.

Henry McKinnell, Jr., Ph.D.

Prem Sharma, D.D.S., M.S.

Lisa Mai Shoemaker

**Council Staff---Present**

Joseph Grogan, Esq., Executive Director, PACHA

Dana Ceasar, U.S. Department of Health and Human Services (HHS)

***Welcome Remarks***

PACHA Co-Chair Ms. Anita Smith welcomed members to the full Council
meeting and thanked them for their heavy involvement in and commitment
to the draft report entitled *Achieving an HIV-Free Generation:
Recommendations for a New American HIV Strategy* to be discussed and
voted on today. She noted members had devoted more time to the report
than their schedules permitted, but without that level of participation,
the report draft would not be ready for consideration.

Ms. Smith thanked Mr. Joseph Grogan and his staff, particularly Ms. Dana
Ceasar, for the amazing amount of work they had done on the report as
well, which met with a round of applause from members. She asked Mr.
Grogan for his remarks.

***Executive Director Remarks***

Mr. Grogan thanked members for their graciousness and patience with the
report's numerous drafts. He expressed gratitude for the members' input
and time. He noted that mockups of what the report could look like are
currently available. He noted that all the report's graphics are in the
public domain, as published by the Centers for Disease Control and
Prevention (CDC).

Mr. Grogan noted the unavoidable absences of PACHA Co-Chair Dr. Louis
Sullivan, Dr. Prem Sharma, Dr. Franklyn N. Judson, Ms. Lisa Mai
Shoemaker, and Dr. Henry McKinnell, Jr. Mr. Grogan noted that Ms.
Shoemaker would not be able to attend this, her last meeting, due to
high winds in her home State. He relayed her best regards to the Council
and her prayers that the meeting would go well. Mr. Grogan noted that
Dr. McKinnell would be absent for this, his last meeting, because
President George W. Bush had asked him to go to Pakistan to help with
earthquake relief.

Mr. Grogan then read a letter from Dr. McKinnell expressing regret that
he could not attend. Dr. McKinnell wrote that his experience with the
Council was a "life-affirming experience." He expressed respect for all
the members and gratitude for all the years of open and candid
discussion, as well as trust. He believes the Council report
recommendations will act as a catalyst for action by the Administration.
He expressed strong support for the domestic and international goals of
the report and hope that the Council would adopt, in particular, the
recommendations of the International Subcommittee, of which he is a
member. He noted progress and reason for hope in the fight against the
pandemic.

***Structuring Council Work on the Draft Report***

Ms. Smith said Dr. McKinnell's letter was a fitting segue for discussion
of the draft report, which all members have now seen. Work on the report
will proceed as follows: Subcommittee Chairs will summarize their
Subcommittees' sections of the draft, then lead and moderate Council
discussion of their sections. Ms. Smith asked members to confine their
remarks to the section at hand. At the end of the day, members will
discuss and vote on the report's Preface and Introduction.

Ms. Smith asked members who wish to speak to the report to consolidate
their thoughts and try to speak only once. She asked Subcommittee Chairs
to recognize each member one time. If a member who has already been
recognized wishes to speak again, that person will be placed on a list.

Ms. Smith asked members to focus on the larger issues in the report and
to avoid wordsmithing. She noted that each Subcommittee has voted to
move the draft forward and that a great deal of editorial work has
already been done. Time limits will not be placed on member comments;
rather, members should impose time limits on themselves. A full Council
vote will be taken after presentation and discussion of each
Subcommittee section.

***International Subcommittee Motion***

Ms. Smith noted that, after lunch, the full Council will consider a
motion proposed by the International Subcommittee entitled "Resolution
on HIV/AIDS and Prostitution and Trafficking of Women."

***Public Comment and Presentation by Ms. Carol Thompson, Director,
Office of National AIDS Policy***

Ms. Smith noted that public comment will be taken after lunch, and, at
the end of the day, Ms. Thompson will address the Council, in part to
recognize members rotating off of the Council.

***Treatment and Care Subcommittee Presentation***

Treatment and Care Subcommittee Chair Dr. David Reznik presented the
Subcommittee's section of the draft report.

Dr. Reznik began by acknowledging the team effort of the Subcommittee
members and thanked each one for their compassion and wisdom: Dr.
Cheryll Bower-Stephens, Assistant Secretary of the Office of Mental
Health in the State of Louisiana; Ms. Jacqueline S. Clements, of the
Lincoln Community Health Center, in Durham, North Carolina; Ms. Sandra
McDonald, President and Founder of OUTREACH, Inc., in Atlanta, Georgia;
Dr. Jose Montero, of the Infectious Disease Center, Tampa General
Hospital, and Associate Professor of Medicine at the University of South
Florida; "living legend" Dr. Beny Primm, Executive Director, The
Addiction Research and Treatment Corporation, New York City, New York;
and Rev. Edwin Sanders, Senior Servant, Metropolitan Interdenominational
Church, and Executive Director, the First Response Center, in Nashville,
Tennessee.

Dr. Reznik used slides to provide background on the Subcommittee's
recommendations. He also provided printouts of graphics to be
incorporated into the Subcommittee's section of the report regarding the
estimated number of AIDS cases and rates for male adults and adolescents
by race and ethnicity, 2003, for all the States and the District of
Columbia; the estimated number of AIDS cases and rates for female adults
and adolescents by race and ethnicity, 2003, for all the States and the
District of Columbia; the estimated number of persons living with AIDS
by race and ethnicity, 1993-2003, in the United States; and the
proportion of AIDS cases among adults and adolescents by race and
ethnicity and year of diagnosis, 1985-2003, in the United States.

***Historical Context:*** Dr. Reznik asked members to step back in time
and remember when we first learned about AIDS:

-   The first cases of what would become known as AIDS were reported in
    the United States in June 1981. Since that time, more than 1.5
    million people in the United States have been infected with HIV,
    including 500,000 who have died.

-   Of the first five young men identified as infected, two died. All
    were treated for biopsy-confirmed pneumocystis carinii and had
    confirmed previous or current cytomegalovirus (CMV) and candidal
    mucosal infection. Subsequently, 26 cases of Kaposi's sarcoma were
    reported among gay males, and 8 died, all within 24 months of
    diagnosis.

-   In 1982, the CDC links the new disease to blood, and the term AIDS
    is coined. Two years later, the virus that causes AIDS is
    discovered.

-   In 1985, the U.S. Food and Drug Administration (FDA) approves the
    first HIV antibody test.

-   In 1987, FDA approves the first anti-HIV medication---AZT
    (zidovudine, Retrovir).

-   In 1988, the United States bans discrimination against Federal
    workers with HIV.

-   In 1988, 107 million copies of the Surgeon General's "Understanding
    AIDS" booklet are distributed.

-   In 1990, the Americans with Disabilities Act and the Ryan White CARE
    Act (RWCA) are signed into law, the latter named for an Indiana
    teenager suffering from HIV/AIDS.

-   In 1993, the CDC revises its definition of AIDS to include new
    opportunistic infections, and researchers in Europe show that AZT
    has no benefits to patients in the early stage of the disease.

-   In 1995, the first protease inhibitor is approved for use in the
    United States (Saquinavir).

-   In 1998, the U.S. Supreme Court decides its first case related to
    HIV/AIDS and the Americans with Disabilities Act.

-   Through 2003, nearly 930,000 cases of AIDS have been diagnosed in
    the United States, including 43,171 cases in 2003 alone---a 4.6
    percent increase over AIDS cases diagnosed in 2002.

-   Up to 2003, some 524,060 people with AIDS have died, including
    18,017 in 2003 alone.

-   In 2003, the CDC estimates that more than a million people are
    living with HIV or AIDS in the United States, including nearly
    406,000 in the most advanced stages of the disease.

***Impact on Racial and Ethnic Minority Americans:*** Today, African
Americans have the highest AIDS case rates of any racial/ethnic group,
followed by Latinos, American Indian/Alaska Natives, whites, and
Asian/Pacific Islanders. In 2003, the AIDS case rate per 100,000
population for African Americans was 9.5 times that of whites. In
addition, African Americans accounted for 55 percent of all deaths due
to HIV in 2002, with Latinos accounting for 13 percent. Survival after
diagnosis is lower for African Americans than for other racial/ethnic
groups.

Other specifics about the disproportionate impact of HIV/AIDS on
racial/ethnic minorities are:

-   In 2003, minority Americans represented 71 percent of new AIDS cases
    and 64 percent of those estimated to be living with AIDS. African
    Americans alone account for almost half of all those living with
    HIV/AIDS in the United States.

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-   In 2003, African American women accounted for 67 percent of
    estimated new AIDS diagnoses among women.

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-   In 2002, teenage girls represented about half of HIV cases reported
    among 13-19-year-olds, with young African Americans representing 65
    percent of AIDS cases reported among 13-19-year-olds.

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-   In 2002, some 60 percent of children born to HIV-infected mothers
    were African American.

***Treatment and Care Subcommittee Recommendations***

Given the data and the current trends of the epidemic, the Subcommittee
decided that its first recommendation should address resource allocation
and the disproportionate impact of HIV disease on African American and
other communities of color.

Recommendation 1:"Programmatic initiatives and resource allocations
should follow the epidemic and address the devastating and
disproportionate impact HIV disease currently has among African
Americans and other communities of color."

Because early diagnosis and getting patients into effective treatment
and care programs are vital to stopping the spread of HIV and
prevention, and treatment programs cannot be conceived and executed in
isolation, the Subcommittee's second recommendation links prevention and
treatment.

Recommendation 2: "Treatment and care should be integrated into
prevention efforts."

The Subcommittee's third recommendation addresses the need for HIV
testing to become a routine part of medical care in the United States,
acknowledging that early diagnosis of HIV not only prolongs healthy
productive lives but also increases the effectiveness of antiretroviral
medication and is cost-effective over time.

Recommendation 3: "Because HIV testing is the gateway to HIV treatment
and care, testing should be encouraged wherever possible."

Because life-sustaining antiretroviral medications should be available
for all those who qualify for treatment and services under RWCA and yet,
in some States, RWCA AIDS Drug Assistance Program (ADAP) funding
shortfalls have led to waiting lists and broken drug therapy regimens,
the Subcommittee's fourth recommendation addresses the need for more
effective distribution of ADAP funds.

Recommendation 4 "Funds distributed under ADAP of the Ryan White CARE
Act need to be distributed more effectively."

Dr. Reznik elaborated on the background of the Subcommittee's fifth
recommendation, regarding core medical services. The Subcommittee agreed
that these services should be provided in a culturally sensitive and
linguistically appropriate manner and include:

-   Physician and other medical provider visits, such as for adherence,
    subspecialty care related to HIV, and/or HIV treatments related to
    HIV, such as obstetric and gynecological and pediatric services

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-   Medically necessary medications

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-   Laboratory tests to monitor effectiveness and safety of treatment
    prior to initiating and during therapy

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-   Oral health services

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-   Mental health services

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-   Substance abuse treatment

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-   Prevention counseling in HIV clinical settings

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-   Nutrition counseling

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-   Hospice care

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-   Essential support services that enable people living with HIV
    disease to access and stay in care.

Recommendation 5: "The core medical service model should include a range
of services to keep those needing HIV care in treatment, adhering to HIV
medications, and leading healthy, productive lives."

In its sixth recommendation, the Subcommittee addressed mental health
because depression frequently accompanies initial diagnosis and can
hinder access to and retention in care, complicated HIV medication
regimens require stringent adherence, and mental health screening and
comprehensive care, including access to mental health medications, must
be included in any definition of core medical services.

Recommendation 6: "Mental health services need to be included in the
core medical services of the Ryan White CARE Act."

The Subcommittee agreed in its seventh recommendation that substance
abuse treatment and counseling are essential for people living with HIV
to help patients stay in care and to adhere to complicated medication
regimens. Substance abuse treatment and counseling also play a
significant role in secondary prevention.

Recommendation 7: "Substance abuse treatment must be part of core
medical services available under the Ryan White CARE Act."

The Subcommittee's eighth recommendation addresses the need for
treatment of comorbidities such as hepatitis C (HCV). Dr. Reznik noted
that HIV is a cofactor that accelerates HCV progression, leading to more
rapid fibrosis and cirrhosis as well as other sequelae of end-stage
liver disease. He also noted that whereas the effects of HCV on the
natural history of HIV remain under investigation, there may be an
impact on the management of HIV infection due to the risk of
hepatotoxicity, more rapid progression of HIV-related disease, and
impaired CD4+ cell recovery while on antiretrovirals. Access to core
medical services should include treatments for comorbidities such as HCV
in order to increase survival and allow for effective responses to HIV
medications for a large subset of those HIV-infected.

Recommendation 8: "Treatment of comorbid conditions accompanying HIV
infection, such as hepatitis B and C, must be covered under core medical
services."

Dr. Reznik emphasized Ms. Clements' contribution to the Subcommittee's
ninth recommendation, the essence of which is that HIV/AIDS patients
should become independent, not dependent. The goal of HIV case
management specifically should be to educate and empower patients to
adhere to treatment regimens and follow up with medical visits. In
addition, people are healthier when empowered.

Recommendation 9: "Medical case management and adherence counseling must
be covered under core medical services."

The Subcommittee's tenth recommendation addresses oral health. Dr.
Reznik emphasized that oral manifestations of HIV disease, such as
thrush, warts, rapidly progressing dental decay, and periodontal
disease, occur in a very high percentage of people living with HIV/AIDS.
Unchecked oral diseases can lead to malnutrition and the inability to
adhere to HIV medication regimens, yet access to oral health services
for those receiving care and services through RWCA "remains a top unmet
need nationwide."

Recommendation 10: "Oral health care must be a part of core medical
services available under the Ryan White CARE Act."

In its eleventh recommendation, the Subcommittee emphasized the need for
a reinvigorated communication campaign on domestic HIV/AIDS,
specifically a public service awareness campaign to promote prevention
that will also serve to increase HIV testing and reduce stigma
associated with the disease. Americans must be reminded that HIV is
life-threatening yet infection is preventable.

Recommendation 11: "The Federal Government needs a comprehensive,
invigorated communication campaign of our domestic HIV/AIDS policies."

The Subcommittee's twelfth recommendation, which addresses incarcerated
populations, emphasizes that the link between care while incarcerated
and care upon release should not be broken. There should be HIV testing
of inmates upon incarceration and upon release. Access to care must be
available for those who test positive.

Recommendation 12: "Prisons should have intensive HIV education and
counseling programs to protect inmates and the communities they return
to."

The Subcommittee's thirteenth recommendation addresses the need to
ensure the availability of more medical professionals willing and able
to treat HIV/AIDS patients, because HIV/AIDS patients have better
outcomes when they receive health care from providers and facilities
with experience in treating HIV-positive patients. At present, there is
a shortage of such providers, in part because HIV medicine is not a
lucrative profession. Potential solutions could include:

-   Providing reimbursement for health care workers who choose HIV care
    in medically underserved areas

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-   Encouraging the recognition of HIV care as a medical specialty

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-   Providing incentives for more medical health care professionals to
    be certified through their respective associations

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-   Ensuring adequate reimbursement for HIV care

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-   Promoting programs to increase the diversity of HIV health care
    professionals.

Recommendation 13: "Creative solutions must be found to encourage more
doctors, physician assistants, and advanced practice nurses to choose to
develop the skills necessary to treat HIV."

The Subcommittee's fourteenth recommendation addresses the need to
maintain quality care while expanding care capacity. Specifically,
outcome measures should be adopted to ensure that mainstream care is
effective and competent, and continuing medical education should be
provided and---if necessary---subsidized by Federal and State
Governments to effect dissemination of the latest HIV medical knowledge.

Recommendation 14: "As we attempt to expand our capacity to treat
HIV-positive Americans, we must not forget quality."

The Subcommittee's last recommendation focuses on research.
Specifically, research must focus on limiting toxicities and metabolic
abnormalities associated with existing therapies, and specific
incentives should be provided for development of treatments that assist
small-patient groups, as well as incentives to encourage the development
of new medicines for broader HIV/AIDS management.

Recommendation 15: "Research into new and novel pharmaceutical agents to
better manage HIV infection is of vital importance and must be
encouraged."

***Treatment and Care Subcommittee Section Discussion:*** Ms. Smith
asked for and received a motion and a second to discuss the Treatment
and Care Subcommittee's section.

Dr. Ram Yogev asked for more emphasis on rapid testing and mention, in
Recommendation 8, of tuberculosis (TB). In terms of Recommendation 15,
pharmaceutical companies will need strong incentives to do the necessary
research.

Dr. Edward C. Green noted the domestic focus of the Treatment and Care
Subcommittee's recommendations and asked whether some of them apply
internationally as well, such as treating comorbidities.

Dr. Reznik expressed the hope that the Treatment and Care and
International Subcommittees could work together more closely in the
future.

Ms. Deborah Jacobs-Rock asked for more emphasis on peer counseling and
outreach workers. Perhaps those living with the disease could be
credentialed, for example, as substance abuse counselors.

Dr. Reznik said he would take that into consideration.

Dr. Beny Primm said the Subcommittee's draft is very complete and that
many of the recommendations are applicable to the Caribbean.

***Proposed Amendments to the Section and Adoption:*** It was proposed
that Dr. Yogev's recommendations regarding rapid testing and TB be added
to the Subcommittee's section. It was proposed that the section also
include some discussion of the effectiveness of outreach workers in
promoting case management.

Ms. Smith entertained both of these proposals as amendments to her
motion to adopt the draft, which was seconded, and the Subcommittee's
section was unanimously adopted by a show of hands.

***Break***

***Reconvening***

Ms. Smith noted that the intention of the report before the Council
today is to reflect the Council's work over the past 4 years. She noted
that this would be the last meeting of about half the Council's members.
Remaining members and new will in the future consider a number of other
issues raised today that are outside the scope of the current report.
Ms. Smith assured those waiting to provide public comment that their
comments would be taken into consideration as Subcommittee Chairs
finalize the report in the days to come.

***Prevention Subcommittee Presentation***

Prevention Subcommittee Chair Dr. M. Monica Sweeney thanked Subcommittee
members for all their hard work: Ms. Smith, Ms. Rosa M. Biaggi, Ms. Lisa
Mai Shoemaker, Dr. Franklyn N. Judson, Ms. Rashida Jolley, Dr. Joe
McIlhaney, Mr. Dandrick Moton, Ms. Mildred Freeman, and Ms. Deborah
Jacobs-Rock. She also thanked Treatment and Care Subcommittee members
Dr. Reznik and Dr. Primm for their input.

Dr. Sweeney noted extensive discussion has already occurred on key
aspects of the Subcommittee's draft. She emphasized that one way to view
the Subcommittee's recommendations is to recognize that it costs
\$10,000-\$20,000 per year to treat each newly diagnosed case of HIV. If
there are at least 20,000 new cases each year, we will need \$400
million each year to treat just those coming onto the treatment rolls.
In short, we cannot treat our way out of this disease. We have to focus
on prevention. All of the Subcommittee's recommendations are designed to
recognize this.

Additional facts include that 22 States now have or are preparing
waiting lists for those in need of HIV/AIDS medication. When the Council
last considered this issue, there were only 10. Also, the number of
professionals prepared or preparing to treat people with HIV is
decreasing. Just this morning, a Council member mentioned that a large
clinic in a major city in the United States has closed, stranding 450
HIV/AIDS patients. One reason for these trends is that the epidemic has
shifted. Those previously infected were middle- or upper-class white
males, who were well educated for the most part and who had resources.
Now those who are becoming infected at an increasing rate are dependent
on public insurance. They are poor and poorly educated. And
professionals who were previously willing to treat HIV/AIDS patients are
no longer willing to treat them.

***Recommendations and Background:*** Dr. Sweeney thanked Dr. McKinnell
for his hard work on the Subcommittee's draft and acknowledged him as
the originator of the concept of an HIV-free generation. She noted other
infections that were thought to be unbeatable, such as smallpox. But
when someone articulated the goal of eradication, many efforts were made
to achieve it. While HIV/AIDS is a greater challenge than smallpox, an
HIV-free generation is still possible.

Therefore, the Subcommittee's Recommendation 1 is: "The goal of United
States domestic HIV prevention policy should be to have zero new
infections, and all our prevention policies should be targeted to
achieve that goal."

Dr. Sweeney noted another theme of the Subcommittee's draft: routinizing
HIV testing. Here, medical health professionals need to catch up with
the public, which assumes that if their blood has been drawn, they have
been tested, even if they have not signed a consent form or subsequently
been contacted about results. What is needed is a general consent form
that will include HIV testing. New York State is making advances in this
area, where all pregnant women are counseled about the need to know
their status. The exceptionalism that has existed around HIV/AIDS needs
to end.

Therefore, the Subcommittee's Recommendations 2, 3, and 4, respectively,
are: "Every pregnant woman in the United States should be tested for
HIV"; "HIV testing should be a routine part of primary care in the
United States"; and "We must seek out opportunities to get people
tested."

Dr. Sweeney said other general themes in the Subcommittee's section are:

-   The need for science-based solutions

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-   The need for notification of partners to be part of public health
    policies everywhere, including in jails and prisons

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-   The need for HIV testing in jails and in prisons upon entry and exit

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-   The need for leadership at every level and the involvement in
    solutions of everyone infected and affected ("HIV stops with me" is
    an attitude that will greatly assist secondary prevention)

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-   The need for name-based reporting to be the standard of data
    collection and care and for appropriately reported data from all 50
    states and territories

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-   The need for funding to follow the epidemic

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-   The need to tie mental health and substance abuse treatment to
    prevention

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-   The need to acknowledge and address in prevention programs and with
    appropriate messages the disparity of the infection rate among
    minority communities

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-   The need for adolescents to be involved in planning and targeting
    prevention programs

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-   The need for pharmaceutical advertising to be truthful and
    appropriate and for media treatment of HIV/AIDS to be more truthful
    and appropriate

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-   The need for all those infected to be treated with dignity and to be
    able to access care

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-   The need to reduce the stigma associated with the disease and with
    care of those infected (treatment needs to be mainstreamed so all
    those infected and affected can freely access care)

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-   The need for private sector partners to continue to invest in new
    treatments

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-   The need to end anonymous testing.

Dr. Sweeney continued to provide brief background for the Subcommittee's
Recommendations 5-25, which are as follows:

Recommendation 5: "Contact tracing and partner notification should be
standard."

Recommendation 6: "Anonymous testing should be eliminated."

Recommendation 7: "The Federal Government needs a major HIV prevention
initiative in America's prisons and correctional systems."

Recommendation 8: "States accepting Federal dollars should demonstrate
to the Department of Health and Human Services that they have developed
a prevention action plan to combat new infections."

Recommendation 9: "The Health Resources and Services Administration
(HRSA) and CDC need to fully integrate their treatment and prevention
efforts."

Recommendation 10: "Those in HIV treatment and care must have access to
mental health and substance abuse treatment."

Recommendation 11: "The links between depression, isolation, substance
abuse, and risky behaviors must be confronted wherever possible." (All
those fighting HIV watch with increasing foreboding the rise in
methamphetamine use accompanied by a rise in risky behaviors. Illegal
drugs and alcohol abuse decrease inhibitions and compound mental
illness, fueling the HIV epidemic. We must integrate HIV treatment and
prevention campaigns with substance abuse prevention and treatment
campaigns.)

Recommendation 12: "The Federal Government needs a comprehensive,
multimedia HIV prevention campaign." (...Media elites and television
stars should be enlisted to help relay important HIV prevention
messages....)

Recommendation 13: "A particular emphasis in any prevention effort is
needed for the African American, Hispanic, and minority communities."

Recommendation 14: "In all messages to the public, we need to be honest,
focusing on the realities of HIV."

Recommendation 15: "An HIV prevention campaign must be appropriate to
age, culture, and risk behavior." (...Behaviors that put people at risk
are found in every demographic group, regardless of age, race,
ethnicity, or socioeconomic status. We must strive to make prevention
messages culturally relevant....Many people in the United States are at
risk and do not know it because they perceive HIV as a problem that only
affects "other" people. HIV is now moving to affect people who did not
think they were at risk. The recent data showing a dramatic increase of
infections among women, particularly African American women, and an
increase in HIV infections among young men who have sex with men
\[MSM\], make it all too clear that stopping the spread of HIV is
everyone's responsibility.)

Recommendation 16: "People of good will working to control the spread of
HIV must be respected." (Parents who choose to educate their children
that abstinence until marriage should be their first line of defense
should be respected. In the same way, those who choose to make frequent
testing and condoms their primary prevention approach should be
respected. But every American should be aware of the risks associated
with various sexual and drug-using behaviors, as well as the
consequences should their prevention approach fail. Every American must
be confronted with messages portraying the reality of HIV in America and
the risk behaviors that lead to transmission.)

Recommendation 17: "Care should be taken to ensure the dignity and
humanity of those infected with HIV." (The recommended prevention
campaign must confront difficult issues, but it must reaffirm our
commitment to Americans infected with HIV. Done well, this campaign
would galvanize Americans to fight HIV together while we care for those
who need help.)

Recommendation 18: "Government officials should work with pharmaceutical
companies to ensure continued caution and responsibility in the
marketing of HIV pharmaceuticals."

Recommendation 19: "Schools and parents must be challenged to tackle
discussions of HIV prevention with youth." (Federal officials must use
the bully pulpit to reinforce the efforts of parents and teachers to
help children make healthy choices....We must deliver messages they can
relate to, messages that are relevant to their experience, and real....)

Recommendation 20: "Young people should be educated about the importance
of delaying sexual debut and reducing the number of lifetime partners."
(Young people should be encouraged and educated to make the choice to
delay sexual activity until adulthood and to remain faithful to one's
sexual partner. It is the number of lifetime partners that is the
greatest indicator of HIV risk through sexual activity. The data are
increasingly clear that delaying sexual debut drastically reduces the
chances of HIV transmission.

Recommendation 21: "HIV education should be a part of an overall program
to reduce risky behaviors." (We must encourage young people to make
healthy choices whenever possible and make it clear that healthy choices
convey freedom, while unhealthy choices can ensnare someone for life.)

Recommendation 22: "More research is needed on adolescent brain
functioning, specifically as it relates to addiction and risk-taking
behaviors."

Recommendation 23: "We need to have one standard and CDC-compatible data
system." (Confidential HIV name-reporting must be in place in every
State and jurisdiction accepting Federal dollars....At present, the CDC
accepts data from only 36 States because it deems data from 14 States
unreliable. We have been in the fight against HIV for 25 years, yet we
still do not have reliable data... \[which\] are essential to deploy
resources intelligently....)

Recommendation 24: "Those States that refuse to adopt reliable,
confidential, name-based systems should be required to surrender dollars
to States that use sound policies in fighting this disease." (We note
that RWCA requires States to have reliable data systems in place in time
for appropriations to be disbursed for 2007. Many States will not meet
that deadline. These States must be held accountable. States without
reliable, confidential, name-based systems...have had 25 years to build
these systems, and the RWCA statutory deadline has been in place for 7
years....)

Recommendation 25: "The President and the Executive Branch should
encourage States to pass health laws that advance sound HIV policies."
(One of the complicating factors in developing a comprehensive national
HIV strategy is that health policies and laws are primarily the province
of State Governments....The Federal Government should give serious
consideration to creating a task force of experts from HHS and the U.S.
Department of Justice to develop and promote model public health laws.)

***Prevention Subcommittee Section Discussion and Adoption***

Ms. Smith asked for and received a motion and a second for discussion of
the Subcommittee's section of the draft report. By a show of hands,
Council members approved the motion.

Dr. Bowers-Stephens asked that community mental health clinics and
institutes for mental diseases be added to Recommendation 4. She asked
that language stating that mental health and risky behaviors must be
confronted whenever possible be added to Recommendation 11.

Dr. Sweeney said these suggestions are good. She noted that rapid
testing is already conducted in nontraditional medical settings. Now it
must be offered in traditional medical settings as well, and that point
should also be made in the Subcommittee's section.

Dr. Yogev commented that Recommendation 2 is not specific enough.
Second, he agreed we need to advance rapid testing because, at present,
people are not returning to get their results. He suggested that rapid
testing be mentioned in any recommendation regarding partner
notification. Testing should be offered "on the spot," after counseling.
Third, commenting on Recommendation 12, he suggested that the
Subcommittee propose specific mechanisms to get the private sector
involved, and he suggested that messages to adolescents be emphasized.
Specifically, he suggested that we need to do more than simply "enlist"
the help of media elites and movie and television stars in a prevention
campaign.

Ms. Karen Ivantic-Doucette commented that Recommendation 9's background
text statement---"Every health care provider treating a patient should
pledge to do everything in their power to make sure that 'HIV stops with
my patient'"---is excellent. She proposed additional language on
training and providing incentives to medical providers for integrated
treatment.

Rev. Edwin Sanders proposed that support for continued funding of the
Minority AIDS Initiative (MAI) be specifically addressed in the draft
report, in both the Prevention Subcommittee and Treatment and Care
sections. He commented that MAI has been the single most significant
source of support for increasing capacity and resources to fight the
disproportionate impact of HIV/AIDS in minority communities. He noted
the Administration had supported growth of the initiative; therefore,
PACHA should do so as well.

It was agreed that Dr. Sweeney will discuss specific language with
Reverend Sanders after the meeting.

Ms. Cheryl-Anne Hall recommended that the mention of 25 years be
stricken from the background text of Recommendation 24. There seemed to
be consensus for that. There was further discussion of the accuracy of
the text. Ms. Ivantic-Doucette suggested that the text simply mention
that States need to meet the statutory deadline imposed by RWCA. It was
agreed that the background would be restructured to deflect arguments
that imposing such a deadline on States is an unexpected and unfunded
mandate.

Dr. Green made a broad comment about the need for the draft report to
make distinctions between generalized and other types of epidemics
because strategies to address them differ to a certain extent. In
addition, the President's Emergency Plan for AIDS Relief (PEPFAR)
addresses this and the need for avoidance as a primary strategy.

Dr.Yogev responded that now that the disease trend is more heavily
heterosexual, special efforts should be tailored to special populations.
Second, he stated that we need to protect the status of those found to
be positive so that they don't lose their medical health insurance, for
example. Third, he asked if what is recommended for prevention
domestically will differ from what is recommended for prevention abroad.
Last, he commented that if circumcision is referenced, such references
should be cross-referenced in the draft report.

Dr. Sweeney responded to Drs. Green and Yogev. She noted concern about
special populations who think they are not at risk and, therefore, may
not accept the concept of risk-based testing. She added that the goal of
normalizing testing is to encourage testing. She noted that circumcision
is addressed in the International Subcommittee's section of the report.
She asked the Council if the report should address concern over the loss
of insurance due to positive test results.

To the last point, Mr. Grogan noted that this issue has not been
discussed fully to date nor has the Council received a presentation on
it. He suggested the topic be addressed at a later meeting. Questions to
be explored could include how big the problem is and whether loss of
insurance is a barrier to testing.

Dr. Sweeney agreed the topic should be explored in the future.

Dr. McIlhaney apologized for having been out of the country without
access to e-mail. He proposed that the draft more strongly emphasize
behavior change, particularly to encourage no sexual behavior among
young adults.

Dr. Sweeney noted that delay of sexual debut is discussed in the
background text of Recommendation 20. Mr. Mason noted that behavioral
change as a social vaccine is addressed in the International
Subcommittee section of the report.

Rev. Sanders commented that he appreciated Dr. McIlhaney's and Dr.
Green's statements, but that consensus seems to have been reached
already on the topic of behavior change, as addressed in the draft
report. It is difficult to create a hierarchy of risk. We have to say
we're all at risk and make it clear that one of the ways that risk could
be addressed and even eliminated is through behavior change.

Dr. Green commented that the epidemiological truth is that we're not all
at equal risk. Those partners who are tested and who are monogamous and
faithful to each other are at zero risk. Either we tailor our message to
the groups at risk and the behaviors that need to be changed or we
don't. He proposed changing the background text for Recommendation 20
for youth so that it calls for a decrease in casual, multipartners sex.
He proposed that a new, similar recommendation be added for adults.

Discussion ensued on how the majority of new infections are among MSM
and how that kind of issue needs to be addressed, particularly in
communities of color, where the infection rates are high. Dr. Reznik
commented that he knows from his work that reducing partners works. Our
prevention messages should be two-fold: we need a general message for
our country, along the lines of delaying sexual debut, but we also need
messages targeted to those who are at risk.

It was agreed that Dr. Sweeney would work on the issue with Dr.
McIlhaney and Mr. Grogan.

Mr. Grogan clarified questions about process regarding the draft report
and issues to be discussed in the future in the Prevention Subcommittee.
He noted the number of member terms expiring today. After today, he
expects further wordsmithing of the report and double-checking of data.
He will not make any changes not approved by the Council Co-Chairs. He
noted that the process to date has been collaborative and has proceeded
on the basis of consensus.

Ms. Smith proposed that the Council reread Recommendation 15, suggesting
that some of the issues under discussion were either addressed there or
could be addressed there. Dr. Yogev suggested that condoms be mentioned
in Recommendation 20. It was noted that the intention of Recommendation
16 was to mention different prevention messages that are felt to be
appropriate in different settings.

Ms. Mildred Freeman suggested that Recommendations 20 and 21 could be
combined. She added that, if condoms are mentioned, the message should
be for them to be used each and every time.

Discussion ensued on whether the document states often enough that HIV
is 100 percent preventable. It was noted that the Preface states this.

Discussion ensued about whether to add language to the Prevention
Subcommittee section regarding casual, multipartners sex and consistent
and correct use of condoms. Dr. McIlhaney proposed that Recommendation
20 for youth state that youth should be encouraged to make best choices,
which are abstinence and, after sexual debut, lifelong or long-term
faithfulness. He proposed not mentioning condoms in Recommendation 20.

Further discussion ensued on what can reasonably be expected of youth.

Dr. Sweeney clarified that unanimous votes are not necessary for changes
to the draft. Ms. Smith noted that votes will be taken, and members who
wish to vote against a motion or abstain are within their rights.

Ms. Smith asked and received a motion and a second for a vote on adding
consistent and correct condom use to Recommendation 20. By a show of
hands, the Council agreed to add language of this kind to the
recommendation. The vote was 14 for; 5 against; and 1 abstaining.

Further discussion ensued on whether casual, multipartners sex and
consistent and correct condom use would be added to Recommendation 15.

The Council then took up Ms. Ivantic-Doucette's proposed changes to
Recommendation 9. It was agreed that there was general consensus in
favor of the changes and that specific language would be crafted and
shown to the Co-Chairs and the Subcommittee Chairs.

The Council then took up a proposal by Rev. Sanders to add the word
"jails" to Recommendation 7. There seemed to be consensus to do so.

Ms. Smith and Mr. Grogan then summarized Council action on the
Prevention Subcommittee's section of the draft report:

-   Recommendation 2 will be changed to reflect Dr. Yogev's concern.

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-   Recommendation 3 will refer to rapid testing.

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-   Recommendation 4 will be changed to reflect Dr. Bowers-Stephens'
    proposals.

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-   Recommendation 5 will make clear that contact tracing and partner
    notification should be the standard, and partners who have not been
    tested should be encouraged to do so.

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-   Recommendation 7---the word "jails" will be inserted.

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-   Recommendation 9---training incentives will be mentioned.

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-   Recommendation 11---Mr. Grogan will work with Dr. Bowers-Stephens on
    specific language to insert here.

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-   Recommendation 12---a stronger word than "enlist" will be inserted.

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-   Recommendation 13 will refer to MAI.

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-   Recommendation 15 will be altered to reflect Dr. Green's and Dr.
    Yogev's concerns.

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-   Recommendation 20---condom use will be mentioned as voted on.

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-   Recommendation 24---the reference to 25 years will be removed and
    something else substituted for it, and the reference to the deadline
    under the RWCA will be checked.

Ms. Smith asked for and received a motion and a second for a vote to
adopt the Prevention Subcommittee section of the draft report as
amended. By a show of hands, the vote was unanimous to adopt.

Ms. Jacobs-Rock asked that the record reflect her concern about
over-the-counter testing, as it could compromise the benefits of pre-
and post-test counseling and the possibility that those who test
positive would seek care. In addition, those who test positive could be
subject to domestic violence.

The issue was placed on a list of issues for the Council to take up in
the future.

***Working Lunch***

Ms. Smith acknowledged members who are rotating off of the Council after
today's meeting. She noted many of them were members of the Prevention
Subcommittee. She said all will be missed. She asked those present to
state their top three issues for the Council to take up in the future.

Mr. Dandrick Moton responded that the hope of the young in the African
American community is a top issue for him. Knowing what a healthy
relationship feels and looks like is not as simple as choosing to have
sex or not. It must be understood on a holistic level, and it requires a
sense of hope.

Ms. Rashida Jolley thanked the Council for all the friends she has made.
Her top issue is for young people to realize they have a purpose, that
brighter days are to come. She noted that if we believe in them,
eventually they will believe in themselves.

Ms. Jacobs-Rock thanked the Council and said her top issue is the need
to work with parents. At present, there are so many children raising
each other. She also hopes Council dialogue will impact policies that
merge education and economics---that recognize and support HIV/AIDS
patients who are living longer who want to return to school and work, in
order to be productive citizens again.

Ms. Freeman said her experience on the Council was an honor and a
pleasure. She noted she is a strong believer in prevention and in the
ABC model of prevention. A top issue is that we can't treat our way out
of this disease. But with budget cuts being proposed by the
Administration, minorities will not be able to afford treatment when it
is needed. With decisions like that, it will be difficult to send
realistic messages to young people about delaying sex.

Rev. Sanders expressed the certainty that relationships built over the
years on the Council will continue. A top issue for him is that the
Council continues to be willing to deal with the tough issues
surrounding this disease. He said he's convinced that the President
doesn't choose members to be "yes" people. Therefore, the Council should
deal specifically with issues such as injection drug use and needle
exchange. While a great deal of scientific research has been done on
this issue, it is also a political issue, like condoms. The Council
needs to represents all sides of the dialogue on such issues, against
the tide of "harm reduction." Last, the Council needs to continue to
advance the day the disease is no longer stigmatized.

Mr. John Galbraith, who has just returned from 2 weeks in Africa, said
the United States should be proud for having instilled a tremendous
sense of hope in the developing world, through PEPFAR. While prevention
is critical, he hopes we will continue to treat people because he found
that treatment has been very successful in places he visited, such as
Zambia. A year ago, hospices were critical for the dying. That has
changed. On his trip a Zambian asked him what to call hospices when
people don't go there to die anymore. A top question for him and our
partners abroad is, what will happen with PEPFAR.

Ms. Cheryl-Anne Hall commented that it was important for her, as a
Caribbean, to be on the Council because to PEPFAR, the region is
composed only of Haiti and Guyana. She now hopes that, someday, the
Caribbean will be viewed as an entire region, not just two countries.
She thanked the Council for helping her to do a better job working on
HIV/AIDS in the Caribbean through a grant she received shortly after
coming to the Council.

Ms. Ivantic-Doucette noted that when she first came to the Council she
had some assumptions and fears about how the Council might work, based
on her ideology and the fact that she is a field person and an activist.
But she learned a great deal, including about building bridges and
achieving consensus, and she is grateful for that mentoring. She
believes that progress against the disease will be achieved through
consensus, which is needed in order to be able to ask the hard
questions. She very much admires the HIV- free generation paradigm. Hard
work and finding a common language will be necessary to achieve it. The
report represents a good start. Now she will be working closer to home,
at the local, State, and city scene to try to get HIV/AIDS patients back
into care.

Mr. Abner Mason thanked the Council and its staff for a wonderful
experience. He enjoyed working with the International Subcommittee, the
other Subcommittee Chairs, and the Co-Chairs. He commented that his
fellow Subcommittee members are incredibly talented, have strong
opinions, and are not easily led. Nonetheless, each member always wanted
to end up in the right place. His reason for hope is the passion of
people like his fellow Subcommittee members.

***World AIDS Day Presentation***

Mr. Miguel Gomez of HHS gave a brief presentation about World AIDS Day
for members to take back to their communities. He asked everyone to get
involved, as a major issue facing the event is that not everyone is as
involved as in the past. Mr. Gomez noted that World AIDS Day events have
been held for nearly 18 years. Women and girls will be specifically
recognized and honored in March, and Native Americans in May.

For World AIDS Day, HHS will be demonstrating what is hoped will be
replicated elsewhere, such as testing HHS employees. There will be
employee education events across the Department, as well as an HHS-wide
conference call to provide examples of what others can do to recognize
the day, the lives lost, and the need for awareness. Key issues will be
focused on, such as changes to Medicare Part D. In addition, Secretary
Michael Leavitt is sending all HHS employees an e-mail about the day,
providing updated statistics on HIV/AIDS and urging individuals to get
tested.

Key events will include faith and civic events. This year an event will
be held in Salt Lake City, Utah. Mr. Gomez noted that the metropolitan
region has two mayors, one at the county level and one at the city
level. Other participants will be Buddhist, Baptist, Episcopalian,
Catholic, and Latter Day Saints churches, the last of which has never
been involved in an AIDS event. In Detroit, Michigan, a report will be
released in partnership with the Arab Muslim and Christian communities.
It will address silence in those communities about HIV/AIDS. In Kansas
City, 300 female students will conduct assemblies in their school
systems challenging their peers to become more aware of the HIV/AIDS
epidemic.

Mr. Gomez provided to members a sample e-mail and downloadable posters
for use in members' communities. He noted that key officials will travel
across the country, possibly announcing news about PEPFAR.

Mr. Gomez emphasized the need for World AIDS Day to get more exposure,
and he proposed a joint marketing venture with PACHA and its new goal
and supporting report on achieving an HIV-free generation. He noted that
it would be particularly effective to provide mixed cultural messages,
which is what American youth and young adults seem to prefer. He noted a
Web page where members can download facts and tools.

***Public Comment***

Ms. Smith announced the opening of public comment. She said she would
read the names on the list of speakers, then Mr. Grogan would inform
speakers of their 3-minute time limit at 1 minute left, then 30 seconds
left, then time.

Ms. Smith read the following names. None of the speakers named appeared
when called:

Mr. William Arnold

Mr. Terrence McDonald

Ms. Laura Hannon

Ms. Jennifer Johnson

Ms. Janice Sykes

Ms. Genevieve Grabman

Ms. Smith then read the name of Dr. Gene Copello.

Dr. Copello, Executive Director, The AIDS Institute, commended the
Council for imagining an HIV-free generation as a common hope of many
advocates. He agreed that ending HIV/AIDS will require new strategies by
the United States and other countries around the world. Continued U.S.
leadership is crucial to ending the domestic epidemic and global
pandemic. Dr. Copello asked the Council to consider the following core
principles as it finalizes its recommendations:

-   HIV prevention efforts must be based on public health science that
    leads to a reduction in HIV infection.

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-   High-quality medical treatment and care must be provided to all
    Americans living with HIV/AIDS regardless of where they reside in
    the United States, including the availability of trained HIV medical
    providers in all jurisdictions.

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-   Research to find better medical treatments and, ultimately, an HIV
    preventative vaccine and curative therapies is an essential
    component of any strategy to end HIV/AIDS.

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-   HIV medical comorbidities, including hepatitis B, HVC, TB, and STDs,
    must be addressed as part of the overall plan to provide adequate
    medical treatment of HIV/AIDS.

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-   A number of factors contributing to HIV infection and disease
    progression must be addressed, including cultural issues,
    socioeconomic factors---particularly the relationship between HIV
    infection and poverty; and stigma and discrimination.

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-   Internationally, barriers to the provision of HIV prevention,
    treatment, and care must be overcome. These include lack of
    infrastructure, trading regulations that impede the donation of
    medications and medical supplies, and alarming rates of other
    infectious diseases, such as malaria.

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-   Adequate Government funding will be required to achieve an HIV-free
    generation.

Dr. Copello asked the Council to consider the following factors in
finalizing its recommendations:

-   Emphasis should be placed on strategies to reduce HIV infection in
    MSM, as 47 percent of all new cases are MSM and half of those are
    among African Americans. Strategies to reduce HIV infection of this
    kind are a key component in controlling the domestic epidemic.

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-   Several jurisdictions in the United States have legal needle
    exchange programs that are not funded by Federal sources. These
    programs should be noted as part of the domestic effort to curb HIV
    infection.

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-   Rapid testing in public health and community settings should be made
    widely available and legal and funding barriers removed.
    Over-the-counter HIV test kits should be piloted and the results
    assessed.

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-   Generally, The AIDS Institute supports the treatment and care
    principles articulated by the Administration regarding
    reauthorization of RWCA. The Institute strongly recommends that
    language be added to discuss the relationships between Medicaid and
    Medicare and RWCA at both systems and client levels and how those
    relationships can be improved.

Ms. Smith called Ms. Donna Sabatino.

Ms. Sabatino spoke on behalf of the Association of Nurses in AIDS Care
(ANAC). Ms. Sabatino stated ANAC support for full funding
reauthorization of RWCA. She attributed success of HIV/AIDS care and
treatment in the United States as related to RWCA's comprehensive
services programs. She said the Administration's principles regarding
reauthorization are based on a flawed assumption;---that there are
adequate resources/funding for HIV/AIDS care and treatment and that
funding streams simply need to be restructured. Unfortunately, at least
150,000 more Americans are living with HIV/AIDS than when President Bush
took office in 2001. The problem is not that we are spending funds
unwisely but that there is not enough funding to meet the continually
increasing need.

Other principles not addressed by the Administration when addressing the
needs of people living with HIV/AIDS include:

-   There is a need to recognize that quality HIV/AIDS care and
    treatment involves more than a narrow definition of medical care.
    Support services, such as case management, adherence counseling, and
    mental health and substance use/abuse programs, enhance appropriate
    care and contribute to the decrease of disease exacerbation. Disease
    exacerbation leads to poorer outcomes with increases in morbidity
    and mortality.

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-   There is a direct relationship between medical outcomes and regular
    participation in care. Success of care and treatment is jeopardized
    when there is not access to services. Health disparities are the
    manifestation of not getting into care in a timely manner or not
    being able to stay in care due to lack of access to and availability
    of vital services.

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-   Treatment and effective secondary prevention have well-defined
    links. Those in routine care can get prevention counseling,
    education, and support to help curb further transmission. Therefore,
    secondary prevention strategies should be integrated into primary
    care and treatment programs and settings. Decreasing funding for
    services not currently considered "core" would be short-sighted and
    could potentially lead to higher costs.

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-   Providers of care, services, and treatment must be highly qualified
    to provide an appropriate level of care and treatment. There must
    also be a sufficient supply of qualified providers. Ongoing
    education and training is needed to maintain adequate skill levels
    and to ensure knowledge of the latest treatment and care
    information.

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-   Nurses are essential to care and treatment of those living with
    HIV/AIDS. They provide services in all areas of care. As nurse
    practitioners, they provide front-line HIV primary care, and are
    often case managers as well as caregivers. They also work in
    community-based clinics and organizations, educate and train other
    providers, are educators in schools and communities, and provide
    prevention counseling, substance abuse counseling, and palliative
    care. They are involved in program planning and development, are
    expert consultants to national programs, and serve on many Federal
    advisory councils and boards. Many nurses work in RWCA programs and
    therefore have a unique perspective on the critical role of RWCA
    programs.

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-   HIV/AIDS is expanding primarily into low-income and poor
    communities, communities of color, and increasingly among women.
    These are the same citizens who are bearing the brunt of cutbacks in
    Federal assistance programs such as Medicaid. If we are honest about
    our commitment to address HIV/AIDs in the United States, the need
    for appropriate care and treatment of those living with HIV/AIDS
    must be addressed.

Ms. Smith called Ms. Diana Bruce.

Ms. Bruce introduced herself as the manager of government affairs at
AIDS Alliance for Children, Youth, and Families (AIDS Alliance). She
thanked PACHA for including the needs of pregnant women and their
children in the Prevention Subcommittee section of the draft report.

AIDS Alliance supports universal, routine HIV testing, with informed
consent and pretest counseling, for all pregnant women. It also supports
routine offering of HIV testing for newborns. In addition, it supports
additional clinical research on the elimination of MTCT. The Alliance
recommends that the draft report acknowledge that existing treatment of
MTCT is highly effective. This fact can best be built on by making sure
that all pregnant women have access to this treatment.

In addition to testing and research, the Alliance urges PACHA to focus
on supporting additional resources for programs that work. For example,
increased funding is needed for HRSA and the CDC to engage in intensive
case management for pregnant women, in order to identify, reach, and
serve the remaining 200 U.S. women annually who give birth to
HIV-positive babies. If \$10 million was devoted to this purpose, we
could come closer to MTCT elimination.

Ms. Smith called Mr. Jeff Tomhave.

Mr. Tomhave spoke on behalf of the National Native American AIDS
Prevention Center (NNAAPC) in Oakland, California. He noted that RWCA
excludes the Indian Health Service from any direct AIDS treatment
funding. The Indian Health Service has no line item within its annual
budget for HIV/AIDS treatment for American Indians and Alaska Natives,
despite CDC estimates that American Indians and Alaska Natives have the
third highest rate of AIDS diagnosis. CDC also estimates that the AIDS
infection rate among American Indians is 40 percent higher than among
whites.

Two weeks ago in Tulsa, Oklahoma, NNAAPC convened a group of grassroots
direct- service AIDS treatment providers, known as the Policy Advisory
Committee, to promulgate recommendations to be forwarded to the U.S.
Senate and House Health Committees as they consider reauthorization of
RWCA. Among the recommendations are provisions for: a comprehensive,
coordinated system of care for Native peoples; elimination of current
obstacles to funding that bar Tribal providers from access to existing
RWCA funds; culturally competent treatment and care; and mandatory
Tribal representation on all Federal advisory committees, such as PACHA.

Mr. Tomhave offered NNAAPC assistance to PACHA and expressed hope that
PACHA will seek to remedy the stated disparities.

Ms. Smith called Ms. Genevieve Grabman again.

Ms. Grabman is a legislative and policy associate with the Center for
Health and Gender Equity. She said the Center notes with concern PACHA's
International Subcommittee's proposed resolution on HIV/AIDS and
prostitution and trafficking of women. She said current U. S.
international AIDS policy and PEPFAR programs bar funding groups from
working with sex workers to protect them from violence. Such groups are
accused of facilitating prostitution. At present, relevant U. S. policy
and implementing regulations are being challenged in Federal Courts in
two districts (the District of Columbia and New York).

Ms. Grabman said PEPFAR is encouraging short-term programs to move sex
workers out of prostitution, such as rescue and restore, as opposed to
long-term strategies, such as providing micro credit and education.

She asked PACHA to demand evidence demonstrating the linkage of
elimination of prostitution and sex trafficking. She said her Center is
unaware of such evidence at this time. PACHA should also demand evidence
showing the efficacy of rescue and restore programs. She said her Center
is unaware of such evidence at this time.

In summary, the proposed resolution should not be approved in its
current form.

Ms. Smith called Ms. Myla Moss.

Ms. Moss said that the American Dental Education Association (ADEA) and
the American Association for Dental Research (AADR) join Secretary
Leavitt in calling for the reauthorization of RWCA as crucial to the
health and well-being of the estimated 1,185,000[^1] people living in
the United States with HIV/AIDS, as well as the some 40,000 individuals
estimated to become newly infected with the disease this year.

The ADEA represents academic dental institutions, educators,
researchers, residents, and students training in these institutions. The
AADR represents the oral health research community by advancing research
and increasing knowledge for the improvement of oral health. Together
these organizations constitute the entirety of members and institutions
that are dedicated to the advancement of research, education, and the
delivery of oral health care for the improvement of the health of the
public.

RWCA funds dental and oral health services through Titles I, II, III,
and IV, and Part F. Part F consists of two programs, the Dental
Reimbursement Program (DRP) and the Community-Based Dental Partnership
Program (CDPP). The DRP helps repay uncompensated dental care, and the
CDPP links providers to communities with high unmet oral health needs.
Part F is designed specifically to develop the skills of dental students
and dental residents in recognizing the oral pathology associated with
HIV/AIDS, how to properly care and treat HIV/AIDS patients, how to
identify persons at risk for infection, and how to recognize changes in
the oral cavity associated with infection. Skills are also developed in
HIV counseling and testing, as well as appropriate and timely referral
to initial and ongoing medical care.

RWCA reauthorization should be a high priority for the U.S. Congress, as
it expired on September 30, 2005. Through reauthorization, improvements
can be made to respond appropriately to the needs of those suffering
from HIV/AIDS, to ensure that dental and medical treatment are
compassionate and comprehensive, to promote prevention efforts, and to
foster greater coordination of services.

Commenting on President Bush's principles for RWCA reauthorization, Ms.
Moss emphasized the following:

-   The need to service the neediest first, by establishing objective
    indicators to determine the severity of need for funding core
    medical services

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-   The need to focus on life-saving and life-extending services by
    establishing a set of core medical services.

Addressing the first point, Ms. Moss said that although HHS plans to
revise its Severity of Need for Core Services Index (SNCSI) using
objective criteria, including HIV incidence, poverty, and the
availability of other resources, the organizations she represents have
reservations about SNCSI's impact on those who desperately need access
to oral health care.

Specifically, a thorough explanation is needed of how HHS will account
for the "availability of other resources, including local, State, and
Federal programs and support, and private resources" and how the
"requirement of maintenance of effort on the part of State and local
governments" is intended to work.

Addressing the second point, Ms. Moss said it is essential that HHS
include oral health as a core medical service. Oral manifestations of
HIV infection are a fundamental component of disease progression and
occur in approximately 30-80 percent of the affected patient population.
The unmistakable link between oral health and systemic health is
demonstrated by conditions commonly found in HIV/AIDS patients. Ms. Moss
went on to list those conditions, including hairy leukoplakia and
candidiasis.

Ms. Smith concluded the public comment period and thanked all
participants.

***International Subcommittee Presentation***

International Subcommittee Chair Mr. Mason summarized how the United
States has become the leader in the global fight against HIV/AIDS in a
mere 4 years, primarily through PEPFAR, which has demonstrated that
treatment is possible even in the poorest parts of the world. He said
PEPFAR's achievements should not go unnoticed in the face of a pandemic
that represents the greatest challenge to human life we have ever known.
As Americans, we have good reason to be proud of the challenge we took
on and what we've accomplished. Now it is vitally important for us to
maintain that leadership.

In writing its section of the draft report, the Subcommittee kept in
mind two overarching goals:

-   Achieving an HIV-free generation, which is important both
    domestically and internationally

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-   Continuing U. S. leadership through reauthorization of and changes
    in PEPFAR.

***Recommendations:*** Mr. Mason read the Subcommittee's
recommendations.

Recommendation 1: "The United States should continue to fund HIV efforts
through both multilateral collaboration and bilateral agreements."

Recommendation 2: "As we maintain our commitment to those we helped
place in care, the next phase of the emergency plan should broaden the
focus from personal health to public health."

Recommendation 3: "All of America's foreign aid should complement public
health by spurring development of basic infrastructure and supporting
economic and political stability."

Recommendation 4: "The United States should broaden partnerships with
indigenous faith-based organizations, nongovernmental organizations
(NGOs), and the private sector to strengthen the nongovernmental social
safety net of host countries."

Recommendation 5: "Host nations must repeal taxes and tariffs on
HIV-related medical supplies and pharmaceuticals."

Recommendation 6: "Host nations must vigorously combat corruption and
bureaucratic red tape in their public health delivery systems."

Recommendation 7: "The U. S. Government should consider making basic
education campaigns a prerequisite of HIV assistance."

Recommendation 8: "As a demonstration of commitment to fighting HIV, we
must encourage prominent political and social leaders of host nations to
speak publicly about the causes of HIV and the basic biological facts of
the disease."

Recommendation 9: "The U. S. Government must support basic research and
maintain incentives for companies to invest in preventatives, vaccines,
and treatments to meet the needs of the developing world."

Recommendation 10: "The U. S. Government should support, in conjunction
with other donor nations, the harmonization of data collection and
reporting requirements."

Recommendation 11: "Ensure that health professionals are trained in a
broad range of interventions and increase economic incentives for
trained health professionals to remain in their countries of origin."

Recommendation 12:" The United States should promote successful
prevention strategies."

Recommendation 13: "Prevention of MTCT should be a major component of
the post-emergency plan." (Mr. Mason noted that this recommendation
could be the fulcrum for a shift from personal to public health.)

Recommendation 14: "Human trafficking must be eliminated."

Recommendation 15: "Careful consideration should be given to programs
that encourage circumcision." (Mr. Mason noted that the latest data
indicate circumcision could have a positive effect on the scale of a
partially effective vaccine.)

Mr. Mason concluded by saying that the United States can help the world
achieve the goal of an HIV-free generation through continued leadership
and by making connections between domestic and international policies.

***Discussion:*** Rev. Sanders asked if the International Subcommittee
section refers to vaccine development. Mr. Mason said Recommendation 9
refers to incentives for pharmaceutical companies, and there is a role
for Governments and academic institutions in basic research as well.
Both basic and applied research should be encouraged.

Dr. Green noted that supporting text for Recommendation 12 states that
"Assumptions cannot be the basis for measuring effectiveness." He asked
that the word "consensus" be added or that perhaps both the words
"assumptions" and "consensus" be used. Ms. Ivantic-Doucette suggested
"consensus based on assumptions." The Council seemed to agree to this
suggestion.

Regarding Recommendation 15, which he supports, Dr. Green asked for
recognition that striking declines in transmission from circumcision are
usually found in heterosexually driven epidemics. He also suggested that
the International Subcommittee section contain cross-references to the
Treatment and Care Subcommittee section. He added that if we can't treat
our way out of the pandemic globally, this should be clearly stated in
the International Subcommittee section.

Mr. Mason noted that the Subcommittee attempted to address some of Dr.
Green's comments in Recommendation 2. The recommendation does not
suggest we should not treat those in need; rather, it suggests that
while we continue to maintain a commitment to treatment, we should also
shift focus from personal to public health. Mr. Grogan noted that the
International Subcommittee section states early on that we can't treat
our way out of the pandemic.

Dr. Jane Hu commented on the issue of drug resistance and the projected
greater need in the future for second-line drugs. One way to prevent
resistance is comprehensive care, but it is not certain that sufficient
funding will be available. PACHA should address this problem, if not
now, in the future.

Dr. Sweeney suggested that Recommendation 8 refer not only to first
ladies but to first husbands.

Dr. Primm asked that the circumcision studies underlying Recommendation
15 be mentioned. Mr. Grogan summarized the Subcommittee's earlier
discussions on this, which noted that the early data for circumcision is
striking, but the effect needs further study. Dr. Primm wondered how
developing countries would react to the recommendation. Dr. Green said
tribal societies in Africa are receptive.

Addressing Recommendation 11, Dr. McIlhaney asked whether the
Subcommittee discussed the appropriateness of faith-based organizations
following their own beliefs in what they teach. Mr. Mason said the topic
was not discussed. It was noted that this subject has been dealt with in
an amendment to the PEPFAR legislation.

Dr. Yogev suggested in text outlining "HIV Prevention Successes" on page
6 that the words "are effective messages" not be used in conjunction
with delay of sexual debut for youth, partner fidelity, and correct and
consistent condom use in Uganda. Dr. Yogev also suggested that text
providing background for Recommendation 13 mention the connection
between breastfeeding and MTCT as an unresolved issue.

Mr. Mason proposed changes to respond to Dr. Yogev's suggestions,
substituting "most appropriate measures" for "are effective messages" in
the page 6 text and mentioning the need to educate mothers about safe
breastfeeding in Recommendation 13.

Ms. Jacobs-Rock asked that Recommendation 11 be changed to mention
training to become peer educators. Mr. Mason accepted the change.

Dr. Bowers-Stephens asked that Recommendation 11 also mention community
health workers.

Rev. Sanders suggested that the Preface or perhaps the Introduction
mention that the unresolved issue of breastfeeding and MTCT needs to be
addressed in the larger context of economics and development in the
developing countries.

Mr. Mason asked Rev. Sanders to review Recommendation 3 as well as
general text preceding it. Rev. Sanders then asked if debt relief had
been reviewed as an incentive to developing countries. Mr. Mason said
Recommendation 3 might also address this. Mr. Grogan said the concepts
that would lead to debt relief are in that text. Rev. Sanders said the
text might need clarification.

Rev. Sanders then addressed the issue of circumcision as requiring
trust. He suggested that its "potential usefulness" be stressed in
Recommendation 15, and Dr. Hu agreed. She suggested that the text speak
to enlisting the help of Tribal leaders.

Mr. Mason said Subcommittee members think not enough is known to take
Recommendation 15 to the implementation stage.

Further discussion ensued. Ms. Ivantic-Doucette and Ms. Jacobs-Rock
suggested that additional language be added that shows careful review of
new data is needed.

Dr. Sweeney objected and said the recommendation already has many
caveats in it. She then moved that it be adopted as presented. Further
discussion ensued on the need to provide explanatory cites in the
International section of the draft report. Ms. Clements said mentioning
circumcision and early data supporting it for prevention is the kind of
bold, unusual step that might need to be taken if the goal of an
HIV-free generation is going to be achieved. There was further
discussion of altering the recommendation language to remove words such
as "programs" and "encourage."

Dr. Primm and Rev. Sanders suggested that if circumcision is going to be
mentioned as an international recommendation, it should also be
mentioned as a domestic recommendation.

It was proposed that Recommendation 15 be tabled. A motion was made and
seconded. Dr. Reznik said the scientific evidence is too strong to table
the recommendation.

Ms. Smith called for a vote on the motion to table. By a show of hands,
the motion failed 18-4, with no abstentions.

Dr. Green proposed new language for the recommendation, as follows:
"Careful consideration should be given to review of the evidence that
male circumcision reduces the likelihood of HIV transmission."
Discussion ensued on whether the proposed language changes were
acceptable.

Dr. Bowers-Stephens suggested that the report note, perhaps in a
"Breaking Science" section, that the scientific evidence regarding
circumcision is worthy of further study and possibly programmatic action
both internationally and domestically. Mr. Grogan said something like
that could be placed in the Introduction.

Dr. Sweeney suggested that new circumcision text adopted for the
International Subcommittee section could be repeated in the Prevention
Subcommittee section of the report. Further discussion ensued. Dr. Primm
asked about the rate of HIV in Israel, where males are routinely
circumcised. Dr. Yogev noted that the rate is close to zero, and Dr.
Primm said that then needs to be stated.

Mr. Mason and Ms. Smith asked for a vote by show of hands in favor of
the new language proposed by Dr. Green. By a show of hands, the vote was
16 for; 2 against; and 1 abstention.

Rev. Sanders then made a motion that the Prevention Subcommittee section
reflect the language just adopted for the International Subcommittee
section. He proposed that another section of the report address Dr.
Bowers-Stephens' proposal regarding "Breaking Science." Dr.
Bowers-Stephens summarized what was under discussion as "scientific
evidence that is worth further study to translate into practice,
domestically and internationally." In addition, she proposed that the
report state: "We recognize that there are social and cultural
implications to this that might prove to be barriers to implementation."
She added that it takes about 10 years to take science to practice.

Dr. Bowers-Stephens clarified that she is proposing that such language
be added to both the International and Prevention Subcommittee sections.

Mr. Mason stated that there seemed to be consensus around Dr.
Bowers-Stephens' proposal and asked for her exact wording.

Mr. Mason and Ms. Smith asked for and received a motion and a second to
vote on the entire International Subcommittee section, as amended. By a
show of hands, the vote was unanimous to adopt.

***Draft Motion on HIV/AIDS and Prostitution and Trafficking of Women:
Discussion and Adoption***

Mr. Mason asked members to review the International Subcommittee's draft
motion on HIV/AIDS and prostitution and trafficking of women.

Dr. Yogev made a number of suggestions for minor changes, which were
then integrated into the draft motion.

Mr. Mason and Ms. Smith asked for and received a motion and a second to
adopt the draft motion. The draft motion as follows was adopted
unanimously by a show of hands.

**Presidential Advisory Council on HIV/AIDS**

**International Subcommittee**

**Motion on HIV/AIDS and Prostitution and Trafficking of Women**

WHEREAS, women, children, and men in prostitution and trafficking have
consistently higher HIV prevalence than other people in the same region
and, therefore, may contribute to higher levels of HIV infection in the
general population;

WHEREAS, HIV infection rates may increase when a high proportion of
males frequent people in prostitution;

WHEREAS, HIV incidence and prevalence in general populations can be
reduced if HIV infection rates in high-prevalence groups are reduced;

WHEREAS, approximately 10 million children worldwide have been recruited
and trafficked into prostitution by individuals who exploit them
ruthlessly, placing them in brutal conditions that may result in
physical, sexual, and psychological devastation and trauma (ref: *The
Lancet*, Vol. 359, April 20, 2002);

WHEREAS, the trafficking of women across international borders (global
estimate is 600,000 to 800,000 per year) is a violation of human rights;

WHEREAS, many women in prostitution are physically and psychologically
abused;

WHEREAS, President George W. Bush has taken a strong stand against human
trafficking---condemning it as "a special kind of evil in the abuse and
exploitation of the most innocent and vulnerable" and that "we must
combat this trafficking and protect and assist its victims both
domestically and globally";

WHEREAS, the United States and other developed countries commit billions
to HIV/AIDS treatment, while efforts to curb one of the epidemic's
significant drivers, human trafficking and prostitution, lag;

BE IT THEREFORE RESOLVED that PACHA commends the President for his
initiatives to stop the spread of HIV/AIDS and to reduce and eliminate
trafficking and forced prostitution of children, women, and men.

PACHA further recommends:

1\. Development of programs to eliminate the sex trade, extending the
President's advocacy of worldwide freedom for all;

2\. Support of further development and funding of programs and practices
to rescue and rehabilitate those trapped in the sex trade and protect
them from violence. These programs should support effective short- and
long-term strategies;

3\. Development of programs to train healthcare workers in state-of-the
art risk reduction programs (such as condom use and STD diagnosis and
treatment) and in referral techniques to enable rescue and
rehabilitation services;

4\. Continued vigorous investigation and prosecution of individuals
supporting human trafficking; and

5\. Advocacy and funding of further research on the link between the sex
trade and the HIV epidemic.

***Preface and Introduction of the Draft Report: Discussion and
Adoption***

Ms. Smith asked members to consider any issues they might have with
these sections of the report. She then announced a break.

***Break***

***Reconvening***

After the break, Ms. Smith asked for and received a motion and a second
for discussion of the Preface. She then asked for a motion and a second
for a vote on the section. The section was adopted unanimously by a show
of hands.

Ms. Smith asked for and received a motion and a second for discussion of
the Introduction.

Dr. Green proposed that the important role of nutrition in treatment be
mentioned in the Introduction. This seemed to meet with consensus.

Dr. Yogev asked if the potential for a vaccine should be mentioned in
the Introduction. After discussion, it was agreed that the Introduction
would mention the need for continued research on a vaccine.

Dr. Hu proposed that drug resistance be mentioned. Dr. Yogev proposed
that when research is mentioned in the Introduction, discussion of a
vaccine, drug resistance, and effective treatments be grouped together.
There seemed to be agreement on this proposal.

There was discussion of various sentences in the Introduction, and there
seemed to be agreement on changing bullet 7 on page 2 to mention the
need for leadership throughout the public and private sector, both
domestically and internationally; on changing bullet 4 on page 2 to add
oral health as an essential component of HIV prevention, treatment, and
care; and on changing bullet 10 on page 2 to substitute "addressed" for
"alleviated."

There also seemed to be agreement to change the last sentence of
paragraph 1 on page 1 to read "...has now become a pandemic
stretching..."; to strike the term "planet earth" from paragraph 2 on
page 1 and substitute the word "worldwide"; and to specify African
Americans as well as other minority communities in paragraph 4 on page
1.

Ms. Smith asked for and received a motion and a second to adopt the
Introduction as revised. By a show of hands, the vote was unanimous in
favor to adopt.

Ms. Smith announced that the Council's business on the report was now
concluded.

***Availability of the Report***

Mr. Grogan announced the plan for publication of the report. He hopes it
would be printed by December 1, 2005, and appear on the HHS Web site
within a day or two after that. He will provide at least one copy of the
printed report to each member.

***Presentation by Ms. Carol Thompson, Director, White House Office of
National AIDS Policy***

Ms. Smith introduced Ms. Thompson to make a statement on behalf of
President Bush.

Ms. Thompson voiced the President's regret at not being able to attend
the PACHA meeting. He is on his way to Asia with Mrs. Bush to attend
high-level meetings.

Ms. Thompson noted that because she hasn't been part of the HIV/AIDS
world for the past 20 years, she has very much relied on the Council to
keep her up to date. She particularly appreciates the Council's advice
and counsel regarding reauthorization of RWCA. She asked members who are
rotating off of the Council to continue to be in touch with her.

Ms. Thompson congratulated departing members for all their hard work.
She said they had served the Administration, the Nation, and the world
well and promised that their time and efforts will result in the best
possible Administration policies on HIV/AIDS. She particularly noted how
the Council has advanced debates inside and outside the Administration.

Ms. Thompson noted with enthusiasm the title and goals of the report
adopted by the Council. Achieving an HIV-free generation is a very bold
statement, but it needs to be said. This challenge is one the United
States should be leading. It is a challenge that needs to be looked at
seriously. She endorsed the report for recognizing all of us as AIDS
activists. She agreed that reaching the goal will take effort and
leadership across the world and at all levels, not just at the
Government level, but among all citizens. She noted the report's
recommendation for routine care and testing as comporting with
statements made by the President last year. She noted that a great deal
of work needs to be done on Capitol Hill to get reauthorization of RWCA
moving faster. She added that the International section of the report
will serve as a resource for the Administration and the White House as
policy teams look for ways to continue PEPFAR's advances.

Ms. Thompson said she personally guarantees that all the report's
recommendations will be seriously considered by the President and the
Administration's policy teams as they review new HIV/AIDS initiatives to
be taken over the course of his remaining years in office.

Ms. Thompson called the Council an amazing group of compassionate,
committed, incredibly experienced Americans who bring to the table just
the kinds of advice needed from advisory boards. She expressed sadness
at the departure of members rotating off of the Council. She noted that
they had given of their expertise and insight without compensation and
had taken time away from their families and jobs in the service of the
Government and those in need of their help. "There are a lot of people
in need who will benefit from what you've done here," she added.

Ms. Thompson then presented plaques and small gifts from the White House
to the departing members. A round of applause followed.

***Final Comments***

Ms. Smith thanked the members on behalf of herself and Co-Chair Dr.
Sullivan. She hopes to continue to hear from departing members on future
issues before the Council.

***Adjournment***

Ms. Smith adjourned the meeting at 4 p.m. She concluded that the Council
can be proud of its work on the report.

[^1]: A Glance at HIV/AIDS Epidemic, Centers for Disease Control and
    Prevention, <http://www.cdc.gov/hiv/PUBS/Facts/At-A-Glance.htm>