PRESIDENTIAL ADVISORY COUNCIL ON HIV/AIDS

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TWENTY-SEVENTH MEETING

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TUESDAY,

JUNE 21, 2005

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The Presidential Advisory Council meeting was held in Room 800, Hubert
Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C.,
Louis Sullivan, M.D., and Anita Smith, Co-Chairpersons, presiding.

PRESENT:

LOUIS SULLIVAN, M.D., Co-Chairperson

ANITA SMITH, Co-Chairperson

ROSA M. BIAGGI, M.P.H., M.P.A.

JACQUELINE S. CLEMENTS

MILDRED FREEMAN

JOHN F. GALBRAITH

EDWARD C. GREEN, Ph.D.

CHERYL-ANNE HALL

PRESENT (Continued):

KAREN IVANTIC-DOUCETTE, M.S.N., FNP, ACRN

RASHIDA JOLLEY

FRANKLYN N. JUDSON, M.D.

ABNER MASON

SANDRA McDONALD

JOE McILHANEY, M.D.

HENRY McKINNELL, JR., Ph.D.

JOSE MONTERO, M.D., F.A.C.P.

BENY PRIMM, M.D.

DAVID REZNIK, D.D.S.

REVEREND EDWIN SANDERS

LISA MAI SHOEMAKER

M. MONICA SWEENEY, M.D., M.P.H.

RAM YOGEV, M.D.

> [PACHA STAFF PRESENT]{.underline}:
>
> JOSEPH GROGAN, ESQ.
>
> DANA CEASAR

C-O-N-T-E-N-T-S

Welcome Remarks and Call to Order

Anita Smith, Co-Chair

Presidential Advisory Council on HIV/AIDS

(PACHA) 5

Prevention, Continued

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

Prevention Subcommittee, PACHA 5

Model Health Laws

Edward Richards, III, J.D., M.P.H.

Professor, Paul M. Herbert Law Center

University of Louisiana 7

Discussion 43

Public Comment 66

National HIV Testing Day

Miguel Gomez

Director, The Leadership Campaign on AIDS

Office of HIV/AIDS Policy, HHS 78

Ryan White Reauthorization and Beyond:

Prevention and Next Steps

Carol Thompson 84

Director, Office of National AIDS Policy

and

Joe O\'Neill, M.D.

Senior Advisor, White House

Domestic Policy Council 86

Discussion 89

C-O-N-T-E-N-T-S

PAGE

Voting on Motions

International

Karen Ivantic-Doucette, M.S.N., Acting

Chair, International Subcommittee,

PACHA 156

Prevention

M. Monica Sweeney, M.D., M.P.H. 207

Council Response to New Centers for Disease

Control and Prevention (CDC) Numbers

Anita Smith 234

P-R-O-C-E-E-D-I-N-G-S

(8:35 a.m.)

MS. SMITH: Good morning. We thank you for being here and being ready to
work. I think that one of the things that we will be able to do today is
have some discussion based on the good work of the different committees
that have been convening between our last meeting and this meeting.
We\'ll have some time later to have some discussion.

I\'ve been privileged to attend the different committee meetings that
have gone on since the last full Council meeting and really congratulate
you all on the hard work that you\'ve been doing and the good work.
Interestingly, we talked a bit yesterday about the prevention outline
that you all had. The Prevention Committee did exactly what was
recommended by the full Council, which was to go and have a discussion
about what they would recommend if we were to try to eradicate HIV from
the population, or get to zero new infections. So that outline that
you\'ve been looking at is a result of what you tasked them to do.

We\'ll have a chance to have some discussion about that and some other
motions and an outline from the International Committee that will be
introduced a bit later.

Today we are trying to keep right on schedule. The challenge is we have
a lot of members that are leaving, and so we\'re trying to accomplish as
much business as possible with as many of us here as possible. So we
will be changing the schedule a little bit in that we won\'t be breaking
up into committees, but we will have a working lunch here together so we
can have ongoing discussion and accomplish, again, as much as possible
with as many members here as possible. If there needs to be some sidebar
conversations with different committees who need to discuss a few things
together, that can happen as well.

I think that we will introduce the motions at the time when we have that
working conversation just before lunch, after our session with Joe
O\'Neill and Carol Thompson.

With that, I\'ll ask Joe if he has ‑‑ no? No announcements? Then we\'ll
turn the microphone over to Dr. Sweeney for the next presentation on the
Prevention Committee.

DR. SWEENEY: Good morning, everyone, and it\'s good to see all of you
that were able to make it.

I had the pleasure this morning of riding in with our speaker who is
going to talk to us, Edward Richards, III, J.D., M.P.H. I\'ve been
forbidden to read his bio. It is in our books. It is impressive. Please
read it, but not now. He got here to us this morning from Louisiana, and
I want you to know he has worked in HIV ‑‑ no, he worked in STDs before
HIV, and he has a different perspective, and you\'re going to really be
enlightened, and it\'s a pleasure to welcome him this morning to be our
first speaker.

MR. RICHARDS: Good morning.

I actually worked in STDs when we called it VD, to tell you how long ago
that was. I feel like the ancient mariner. I\'m going to grab you by the
lapels and tell you a story that I hope will captivate you, but it\'s a
story very different from your experience.

I\'ll talk about AIDS law, but more importantly the history of public
health and public health law in this country in the critical period in
the \'70s and \'80s, when things shifted. All of this is seamless. I got
into this even before I was a lawyer. I came out of the medical
sciences. My wife is a physician, a specialist in public health, and her
first job out of residency was running the City of Houston\'s VD control
program in the mid-\'70s. That\'s when VD was big business, 80,000
patients a year through her clinics. As I went through law school over
the next couple of years, I became her lawyer because health departments
seldom have good local counsel, went on to get interested in this and
have kind of carved out a niche as a VD, then STD, then STI lawyer.

Last week, headlines from the Atlanta Journal Constitution from the
prevention conference. Suddenly the number of folks with HIV went up
100,000 from the week before. We have a quote: \"The HIV epidemic is not
over in the United States like many people think it is.\" That\'s really
the theme of my talk today. I think it\'s beginning, not over. We made
some critical mistakes early on, and there is still time to change
those. If we don\'t change them, I think this headline, every year
we\'ll see that number go up.

I want to put public health in historical context and explain the
breakdown in support for public health in the 1970s. For some of you,
you\'ll remember that. For some of you, this is going to be a history
lesson. It\'s so discouraging when I teach my students and realize that
what I think of current events might as well be the Punic Wars for them.

This breakdown led AIDS exceptionalism, and what I\'m really talking
about today is treating AIDS differently than other communicable
diseases and why that doesn\'t make sense. Finally, I want to explain
what we can do to change that, and in the narrow context of traditional
epidemiology. I could talk a lot about a lot of other things, but you
only gave me 40 minutes.

Traditional public health law dealt with external threats to the
individual, communicable diseases, environmental hazards. In the last 30
years, public health has wanted to redefine itself as everything that
makes you feel good. That may be a nice thing, and chronic diseases is
certainly an issue, but the core of public health is external threats,
not internal things you do through self-awareness and self-interest.

Many of the public health concerns put individuals or businesses in
conflict with society. A key thing to understand about public health is
that if education and self-enlightenment would cause people to do
what\'s right, we wouldn\'t need public health. We wouldn\'t need public
health laws. We\'ve gotten into this notion in the last two or three
decades that education is all there is in public health, at least in the
context of diseases like AIDS. That isn\'t the case, and that\'s what we
need to talk about.

Public health law is old. Leviticus is full of public health
admonitions. Things like, \"don\'t eat shellfish\" makes a lot of sense
if you live in the desert and don\'t have a refrigerator. The Romans
brought us waterworks, sewers. They didn\'t understand germs, but they
did sort of understand that you didn\'t want to drink the same water
that your toilet ran into. Venice brought us the 40-day cooling off
period for ships that came into the harbor, which we now call
quarantine. Blackstone was the great chronicler of the English and then
Anglo-American common law, and quarantine and public health is part of
that body of laws, that death was the penalty for breaking quarantine,
because in those days breaking quarantine could threaten the nation.

We lose track in the modern world that the U.S. colonies were all around
coastal areas, around rivers, because water was the major transport.
That meant that you had cholera, yellow fever, malaria, you had smallpox
and tuberculosis, especially in the urban areas. The average life
expectancy as late as 1850 was 25 years. That\'s a very frightening
number. In fact, if you read Colonial records and early records from the
Constitutional period, communicable diseases dominated people\'s lives.
The Constitutional Convention was almost disrupted by a yellow fever
epidemic.

Colonial America used traditional public health measures, quarantines,
areas of non-intercourse which are isolating different parts of the
country, inspecting ships and sailors, what we call nuisance abatement,
tanneries, noxious conditions. They had Draconian powers, and they used
them. These are called the police powers. It didn\'t have anything to do
with police departments. This was long before police departments were
invented.

In essence, public health was one of the major functions of the early
state. Powers were doled out between the states and the federal
government in the Constitution. Public health powers were one of the key
things they thought about. If you\'re a strict constructionist, this is
one of the areas where you probably have the best evidence of what went
on, because communicable diseases and the methods to control them were
within the personal knowledge of everyone at that Constitutional
Convention.

The federal government was given interstate commerce power,
international trade and travel, war, and national security. The states
were left with powers not given to the federal government, and of these
at that time, the most important were the police powers, all the public
health except that related to foreign shipping and commerce. One of the
first acts of Congress was establishing the Public Health Service and
the quarantine stations to deal with foreign trade.

Now, these powers were so great because in that period of time, public
health was seen as national security. There\'s a book called \"Bring Out
Your Dead,\" which is a description of the 1798 yellow fever epidemic in
Philadelphia. That epidemic killed 10 percent of the population of
Philadelphia in one summer and fall. The city was in chaos. The state
was paralyzed. It really brings home the notion that in that period
epidemic disease was seen as one of the most important security threats
to the state. They weren\'t that concerned with the health of
individuals. I mean, it was nice if people didn\'t die, but they were
really concerned about the state.

If you look at the history of the Black Death in Europe, \"Plagues and
Peoples\" by William H. McNeil talks about how the Black Death broke the
back of feudalism, changed the social order in Europe. So the courts and
the Constitution have always seen public health powers as national
security powers. In essence, public health is the state\'s component of
national security.

If you study national security law, you\'ll be frightened how far those
powers go. We\'d forgotten about that nexus until the anthrax letters,
that reminded us that there is a nexus between national security and
public health even in today\'s world. Public health in sort of the grand
period, what we call the sanitation movement from 1850 to 1970, dealt
with improving drinking water, disposal of waste water, pure food, also
pure drugs, housing codes, working conditions, and communicable disease
control, vaccinations, disease investigation and control.

This included the classic public health interventions, mandatory
reporting of cases by name, no anonymous testing. No one ever thought of
anonymous testing prior to AIDS. We have reporting cases of physicians
being disciplined for failure to report that go back into the 1800s. In
fact, we probably have more of them in the 1800s than we have now.

Disease investigation involved tracing contacts. This could be talking
to everyone who ate the bad potato salad at the picnic to interviewing
people about their personal sexual histories. We also did screening,
tuberculosis screening. I can remember when I was a kid, and a few of
you look like you\'re old enough to remember, when the truck would come
around and we\'d do our TB screening x-rays. We screened for syphilis
for years. In fact, syphilis was brought under control for the first
time in this country post-World War II. We screened folks who went into
hospitals, we screened folks who wanted marriage licenses, and we came
fairly close to eradicating syphilis, although the resurgence of
sexually transmitted diseases is sort of making that goal a lot more
difficult to contemplate than it was, say, in 1947.

We did interventions. We did contact notification, which was then turned
into partner notification, although somehow the notion of partner on
your thousandth and first anonymous sexual contact seemed a little bit
overblown. But it\'s the most important thing you do in public health.
It lets you warn the person that they\'ve been exposed to a disease. It
lets you help them get treatment, testing, social services, and it\'s
the best educational opportunity you ever get. We\'ll talk later about
why it\'s particularly important for HIV.

We educated people. There is a very important component to public health
of education. Education is not the only component, but it is a critical
one. We offered treatment. We frankly coerced people into treatment. We
don\'t like to talk about mandatory treatment. We just explain to people
how we\'ll keep them in a dank cell for the duration of their
tuberculosis unless they agree to be treated.

Sometimes the state doesn\'t want to have two deputies sitting on
someone to give them their tuberculosis medicine, but we do a lot of
things to encourage them. We do isolation and quarantine, when
necessary. Tuberculosis has been most of the focus of that in the last
couple of decades, but we have other restrictions. Typhoid carriers
still can\'t work in food handling. It\'s sort of a part of the large
public health picture that mostly is below the horizon. My wife was a
health director in some major cities for a while. I saw a lot of things
there. I\'ve worked with other health departments. There\'s a lot of
things going on the public doesn\'t really pay any attention to.

During this period, the law followed the best public health practices.
It\'s impossible to talk about public health law and public health
separately. Law is the core of public health. The courts uniformly
supported public health laws. There were some times when health
departments used public health laws as a subterfuge for other
activities. Laws were struck down that applied only to Chinese
laundries. Laws were struck down that were using public health
rationales to sort of have what we call non-tariff barriers to
interstate trade; a whole line of cases on milk. State A says the milk
can\'t be sold if it\'s more than 24 hours out of the cow. Well, maybe
that\'s good for State A, but it makes State B\'s milk impossible to
sell in State A.

The Supreme Court pretty thoroughly said you can\'t use public health
rules as trade restrictions. We still see that with the fight between us
and Europe. They want to sell us stinky cheese, and we want to sell them
hormone-laden beef. The WTO will weigh in later this summer.

Probably most importantly is public health departments had public
support. People cared who their health director was when they were
scared to death of dying of communicable diseases. The results were
phenomenal. Life expectancy almost tripled. Tuberculosis and polio were
under control. This is as of 1970. Food- and water-borne diseases are
rare. Yellow fever, malaria and smallpox are eradicated in the U.S.
Vaccinations and disease control are routine and not controversial.

For public health and support for public health departments, 1970 was
probably the high water mark. What changed was, frankly, public health
worked so well. Surgeon General William Stewart testified before
Congress in 1969, or at least is reported to ‑‑ I have yet to find the
actual transcript ‑‑ that it was time to close the book on infectious
disease. That was certainly the prevalent view in the medical community
at that time. There was a huge debate in, I think, \'70 and \'71 about
stopping smallpox vaccinations in this country because smallpox was
eradicated in the U.S., it was 10 years before worldwide eradication,
and we started to be more concerned about the risks. Most vaccines are
harmless; that one is not.

Some people said if we do this, in 30 years no one will be immunized,
and then what terrible things might happen? Well, it\'s 30 years later.
We run scared of smallpox bioterrorism. But this was a point where
people could talk about eradicating diseases. This was the high point of
antibiotics, the magic bullet. People were convinced that communicable
diseases were curable. My mother-in-law trained in medical school in the
late \'30s and early \'40s, really before effective antibiotics were
widely available. It\'s interesting to hear her talk about how medical
students were taught sanitation and hand-washing, because it was not
just a threat to their patients, it was a threat to themselves.

Now you see it\'s fashionable to run around in surgical greens in and
out of the hospital. Those were invented so we could make sure we knew
what was sterile and what wasn\'t. We don\'t care about infections
because they\'re easily treated, or so we thought until antibiotic
resistance reared its head.

This is a quote from an article a man named Rosenau wrote. Some of you
that are aficionados of public health know that Rosenau then went on to
write the first preventive medicine public health textbook,
Maxcy-Rosenau, \"Public Health and Preventive Medicine.\" I think the
last edition was in 1912. I think we\'re up to the 16th edition maybe.
\"Reasonable fear saves many lives and prevents much sickness. It\'s one
of the greatest forces for good in preventive medicine, and at times
it\'s the most useful instrument in the hands of the sanitaria.\" He was
talking about in those days why a few typhoid cases were good for the
public health department every year, because it kept people\'s attention
focused. He was quite a prophet.

Other things are going on in this period, Medicaid and the Great
Society. These are wonderful programs, but they created money for
indigent care, a lot of social services, which are very important, but
these started being done by health departments, and health departments
started becoming centers for personal medical services, not traditional
public health services. Personal medical care displaced public health
expertise. Look through your health departments at the state and local
levels, and look at how few board-certified public health physicians
there are in those departments. Most of the board-certified public
health physicians I know can\'t find work in public health, it\'s so
unfashionable now.

More importantly, medical values: autonomy, privacy, displaced public
health values, protection of society. Vaccine liability became important
in the \'60s, and particularly the \'70s. There was a major vaccine
incident with the very first polio vaccines. Some from Cutter Labs
didn\'t work very well, and some people got polio. But in 1965, a
restatement of the law of torts came out and invented this new concept
of products liability, strict liability even if you couldn\'t have
changed the outcome, even if you couldn\'t have known. This is what
fueled drug and vaccine liability.

Another piece of the puzzle, the Stonewall riots, 1969. This focused
public attention on the harassment by police of gay men and women. It
was an important move forward in human rights and in gay rights, but it
also showed politicians in big cities that the gay political groups were
powerful, and their supporters were powerful. That was critical because
it made public health actions ‑‑ well, I should say it made closing
bathhouses, which also arose in the wake of Stonewall, politically
impossible.

Now, keep our time frame in mind. We\'re sort of moving through the
\'70s. The pivotal event in most people\'s minds for public health, if
they think of it at all in the 1970s, was swine flu. We\'re worried
about avian flu pandemics this year. All of you worried about avian flu
should go back and read the HEW report on swine flu that was issued in
1978. I think it\'s referenced on my website. There\'s also a wonderful
book called \"The Epidemic That Never Was\" that analyzed our thinking
about swine flu. We were worried about a global flu pandemic, and that
was a perfectly legitimate worry. I worry more about global flu
pandemics than I do about bio-terrorism.

Vaccine was rushed into production. The vaccine manufacturers were
nervous about this. They demanded indemnification, complete protection
from liability from the federal government, and the federal government
set up its first big vaccine compensation program, although it kind of
did it by giving a blank check. There was a massive push to vaccinate
the public, and unfortunately ‑‑ well, fortunately for the public,
unfortunately for public health, there were no cases of swine flu. It
even turned out you could blow it up people\'s noses and they didn\'t
catch it. That was very embarrassing.

The epilogue is a critical part. Guillain-Barre syndrome surfaced.
There\'s no lab test for Guillain-Barre, at least there wasn\'t then. I
don\'t think there is now. It is an amorphous set of neurologic
symptoms, historically pretty rare but there\'s a whole lot of people
with strange neurologic symptoms. At the time we thought we had
Guillain-Barre secondary to the swine flu vaccine. We had a comp fund,
which means lawyers had a real interest in getting patients to
sympathetic docs. The docs were getting notes from the CDC that
Guillain-Barre is a big problem, so you\'ve got a patient with iffy
symptoms who\'s had a vaccination, like two-thirds of the people in the
country had, and Guillain-Barre makes sense.

Huge liability for the government. Got a case cited that discusses some
of that. But ultimately, it turned out there wasn\'t any scientific
support. There\'s a great piece of epidemiology done in \'99
reevaluating the data. The problem was, combine massive immunization
campaign done at the Presidential level because the world was going to
end, and then no cases show up, and then people get sick from your
vaccine. That hurt the credibility of public health terribly at the
local level, the state level and the federal level. It took years, I
would argue maybe until 9/11, for some public health departments to
start to recover their confidence.

Now, why does this matter? Because at the same time this is going on,
the reports on hepatitis B in the bathhouses are coming in. Hepatitis B
is not a nice disease. If AIDS hadn\'t come along and HIV, we\'d be
lamenting the enormous toll of the hepatitis B epidemic. But, hey, HIV
killed everybody who had hepatitis B, so we don\'t think much about the
hepatitis B epidemic. Almost everyone who was active in the bathhouses
‑‑ we\'re talking about hundreds of thousands of people ‑‑ became
infected with hepatitis B. We did great epidemiology. The gay men
cooperated with the epidemiologists. We did great studies that helped to
develop hepatitis B vaccines, but nothing was done to close the
bathhouses.

In fact, I\'ve talked to folks that are in charge of large HIV and AIDS
control programs who didn\'t even know this went on in the \'70s. It\'s
lost in the literature. I think one of the big reasons is health
departments were utterly and completely distracted by swine flu, and I
think in the aftermath of swine flu they were even less likely to
recommend unpopular actions, and the politicians who would have to sign
off on those actions were even less likely to support those actions. So
it\'s a confluence of hepatitis, the bathhouses and swine flu where I
think we have to really start looking at this.

You have to remember that HIV was rare, small introduction. HIV is hard
to catch, fortunately, because if we look at our gonorrhea and chlamydia
numbers, we\'d look like Africa if HIV was easy to catch. Bathhouses
amplify epidemics of diseases. They amplified everything, giardia,
syphilis. Syphilis was a better marker for being a gay man in 1980 than
HIV, or in \'81. You have a lot of contacts, a lot of different people,
a lot of co-infection with other sexually transmitted diseases, a lot of
IV drug users crossing over. These were the incubators for HIV between
\'76 and \'80, before it was on our public health horizon.

If the bathhouses had been closed in the \'70s, we might not be sitting
here. We\'d have HIV in this country, but it would be an enormously
smaller problem, because we never recovered from the initial seed, the
initial 300,000 or 400,000 gay men and IV drug users who were infected
during that period when we were figuring out what was going on, most of
those infected through the bathhouses. There are some tremendously
interesting mathematical models on this from a statistician at Rice.
This was also the start of AIDS exceptionalism before we even knew we
had AIDS. This was the point when public health, at least for AIDS,
broke free of traditional disease control and was seen as a political
issue, and the carnage has been terrible.

The first cases we called GRID, gay-related immunodeficiency disease.
Then it was AIDS. We worked out the epidemiology pretty quickly because,
gee, it was exactly the same as hepatitis B, which we understood from
the bathhouses, and it was exactly the same people. All the concerns
about privacy were really kind of silly because everybody\'s names were
already on the hepatitis B list.

There were enormous initial fears, and some of us remember those. They
wanted to fire all the gay waiters and hairdressers. There were claims
of housing discrimination, although those turned out to be fairly
difficult to substantiate. But there was fear and prejudice against
particularly gay men. Frankly, IV drug users have never had very good
press, so that didn\'t change a whole lot. Civil libertarians thought
the secret to this was to keep everything about AIDS confidential or
anonymous. That was probably where we should have said no in public
health. The bathhouses were still left open, even though we knew they
were part of the epidemic and were still spreading the disease.

In New York they closed them in 1985 when so many people died that the
resistance went down. Public health experts who pushed to close
bathhouses were fired. Bathhouse owners, gay activists, and even some
public health people who were probably fundamentally individual medical
services people said, \"No, no, we need to keep them open, they\'re good
places to educate about safe sex.\" Some were never closed, and others
have reopened. I believe all of your major cities now have active
bathhouses again. What have we learned?

HIV tests came around in 1985. This was the point where we could now
detect the carrier state, which for a disease with a very slow latency,
like HIV, is very critical. Some states just added this to their
communicable disease list. I believe it was North or South Carolina
reported HIV by administrative regulation. Colorado passed the first HIV
reporting law, which I had the honor to work with the folks there in
Colorado on. I think we have some folks in the audience who remember
that period.

We got enormous grief from gay activists and so-called public health
activists when we presented that to the legislature. They explained to
the legislature how we had invented communicable disease reporting just
to harass gay men. We were shocked to discover the legislature didn\'t
know we\'d been reporting 50 other diseases for the last 100 years.

None of the states that had high numbers of HIV required reporting. In
fact, they didn\'t require it until relatively recently in the epidemic,
and one of them still doesn\'t. California still has coded reporting.
Anonymous testing came around. This was probably the most troublesome
part of the whole epidemic. Health departments have always had people
who would register at the VD clinic as \"Minnie Mouse.\" You went with
the flow, you treated them, you didn\'t worry about it, but you sure
didn\'t encourage them to do it. There\'s no real evidence that
anonymous testing increases HIV testing, although there\'s certainly a
lot of rhetoric to that effect.

But anonymous testing stops reporting and investigation cold. It stops
epidemiology cold, and you\'re even left with a terrible problem that
significant people never come back for their test results. So you\'re
sitting there with a positive HIV test and nobody to go talk to. A very
frustrating business.

The federal government actually kind of coerced states through funding
requirements to offer anonymous testing because some states didn\'t want
to do it. It\'s still offered in most states. My friends in North
Carolina say it\'s not offered there, but I\'m not even sure that\'s
true.

Reporting is the key to all epidemiology. But all the disease reporting
in this country is local, flowing through the state and to the CDC.
There are no national standards or laws for communicable disease
reporting. HIV data is weak because of anonymous testing, lack of named
reporting, and no contact investigation. This is the most important sort
of scientific point I want to hammer today. All of our numbers on HIV in
this country are based on mathematical models, not on hard epidemiologic
data. I\'ve worked with mathematical models a lot, and they predict what
you want them to predict.

As I say, I was struck that over one week\'s time we came up with
another 100,000 cases of HIV. We went from less than a million to
1,100,000. Those models will generate almost any number you want
depending on how you deal with the assumptions you put into them. For
the last 10 years, it\'s been fashionable to say prevention is working
and education is working, and to say we\'ve reached an equilibrium. The
new populations keep popping up because you get infected with HIV and
you don\'t show up with AIDS for years later. We don\'t know where the
disease is going. We don\'t know the actual number infected. Maybe it\'s
lower. Maybe the models are wrong. But we don\'t know, and that, as an
epidemiologist, should make you crazy.

Contact tracing is the way you find hidden cases. Many states don\'t do
it because they see it as an invasion of privacy. It\'s also expensive.
It also requires named reporting and no anonymous testing, but it
doesn\'t have to be perfect. There\'s brilliant work by some folks,
Hethcote and Yorke, on gonorrhea that really explains to us about how
sexual contacts are this big web, and you start unwinding that web and
you\'ll eventually get to most of the people you need to get to, even
when people lie to you or won\'t talk to you. So for HIV it\'s
particularly effective because once you\'re infected, you\'re always
infected.

Contact tracing for 2 million cases of gonorrhea a year, when five
minutes after you\'re treated you can be reinfected, is hard to justify.
Contact tracing for a disease where once you\'re on the list, you\'re on
the list until we get your death certificate, is very cost effective.

It\'s natural. You\'ve got the contacts, you warn people. People have
said, well, this interferes with people\'s right to not know they have
HIV. That\'s a crazy notion, and there are times when you can\'t keep it
anonymous. If you\'re warning the monogamous, faithful wife, she\'s
going to figure out where she got it. My wife was running the VD
clinics, gunfire was not unknown in the parking lot. There were a lot of
marital disputes and partner disputes because Partner A thought Partner
B was faithful, and the VD clinic unfortunately disabused them of that
notion.

But the point is the person who is being exposed has a right to know,
particularly when it is a deadly disease. Remember that headline we saw
at the beginning? Secret bisexual sex is really a major problem for poor
women, particularly minority women. The most encouraging thing about
contact tracing and partner notification for HIV is because it\'s hard
to catch, you often warn people before they\'re infected, and that\'s
the best time for them to do something about it. It also allows you to
get them social services. For poor women who have a husband or boyfriend
who is exposing them, they may not be able to get away from him on their
own. They need the state to help, and they are the people who are left
out of HIV control when you don\'t do disease control.

A lot of talk about disease control costing too much, kind of the notion
that if a disease spreads wide enough, we don\'t do anything about it.
Well, if you\'re a public health department with no money, I\'m
sympathetic to this argument. The feds can\'t just say, \"Do it.\" The
feds are going to have to change funding priorities. But the human cost
and the financial cost of HIV dwarfs any amount of money we\'ll spend on
control, particularly because we don\'t know where this epidemic is
going. Since we don\'t even know why the epidemic looks the way it does
in Africa because epidemiology of HIV is not good anywhere, we should
worry about this.

HIV needs to be part of routine medical care. Every doc needs to think
about HIV the way every doc used to have to think about syphilis. But
you can\'t do that if you can\'t do routine testing the way you do for
every other medical test. It delays diagnosis, it delays disease
control, it hurts epidemiology, and I believe that until you mainstream
a disease, it will never end discrimination. Read the history of cancer.
Through the 1950s, cancer was a stigmatizing disease like HIV is, and it
wasn\'t until bioethicists and others made that point that we had to
talk about it, we had to be open, we had to treat it like other
diseases, that cancer became mainstream.

If we\'re worried about privacy, HIPAA will take care of that. HIPAA has
a lot of issues with it, but it certainly answers all the questions
about privacy and medical records, and it\'s a federal uniform standard.
Routine testing should be part of medical care and we should not have
state laws that put special requirements. It should be no different than
ordering a serum sodium or an x-ray.

Now, another point that\'s kind of been lost if you aren\'t an
aficionado of public health law, in 1980 I think there were about three
people who had anything to do with academics interested in public health
law. Frank Grad, who just got the career achievement from the Public
Health Law Association, and who I kid was Louis Pasteur\'s lawyer,
myself and one other person, and I was only interested in it because my
wife ran a VD control program and she\'s asking me for advice.

In the \'80s, as AIDS came along, every Constitutional lawyer, human
rights lawyer, mental health deinstitutionalization lawyer, and you know
what great things they did for our mental institutions, became retreaded
as a public health lawyer. They weren\'t public health lawyers; they
were AIDS lawyers. Public health law became AIDS law. Even the federal
government funded AIDS activist groups as public health researchers. Not
only did they screw up AIDS law, they attacked other public health laws,
quarantine laws, isolation laws. There was this drumbeat in the academic
literature, with a very small number of exceptions, that the courts
shouldn\'t uphold traditional disease control laws, that somehow the
Supreme Court had changed its standards.

I\'d usually flash a picture of Justice Rehnquist up and say you\'ve got
to be kidding. But they\'ve been very successful. States have adopted
emergency quarantine laws as part of their emergency public health laws
that require such a high standard for imposing quarantine that I expect
they\'re going to have a firestorm of litigation if they ever use them.
They increased the restrictions on the state in emergencies. I\'m not
even sure they knew they were doing that.

Where do we go from here? End AIDS exceptionalism everywhere it is.

Federal government\'s role. Public health departments in most states
only do what you pay them to do at the federal level. States don\'t
support public health. I can tell you, in Louisiana, if the feds aren\'t
paying for it, we don\'t do it. In fact, our problem is we get caught
taking the federal money and not even doing what we\'re supposed to with
it. That\'s not limited to my fair state.

Most of the things you need to do can be done through federal funding
incentives without changing federal laws. We don\'t need federal public
health laws, and that allows us to jump past that debate about whether
the feds have police power. It will require changing state laws and
rules.

I think federal funding ought to come with certain requirements. No more
anonymous testing. If you do anonymous testing, you don\'t get federal
AIDS money. Named reporting of all positive HIV tests, screen pregnant
women, end all special requirements for HIV testing. It should not be
different than any other medical test. Post-test counseling is nice, but
it shouldn\'t stand in the way of testing. There are a lot of bad
things, like cancer diagnosis, that have the same issues as HIV for
post-test. We don\'t stop docs from doing your cancer diagnosis because
they can\'t come up with post-test counseling, and pre-test counseling
should just vanish because it\'s one more thing that tells people this
is something special you should worry about.

Frankly, people don\'t trust the government. When the government says
you should think extra about this, people rationally say, \"Hmmm, I
probably don\'t want that.\" Now, the federal government has got to put
their money where their values are. You have to supply the money,
whether it\'s reallocating it from other AIDS program. That doesn\'t
bother me because in public health, I\'m more interested in preventing
the spread of a disease than treating the disease. I\'m interested in
treating the disease. In private medicine, we treat first. In public
health, we have to think about prevention first.

Contact tracing should be done. Partner notification and assistance. We
need uniform standards for HIV disease reporting, frankly for all
communicable disease reportings, and that should just be a condition of
funding. So when the CDC gets the data, they know what it\'s worth.

The National Clearinghouse for HIV Reports. HIV is a permanent
infection. It\'s worth spending the money and the technology to have a
really good database, and you could use that database to make sure
people who are infected are getting treatment, know about new advances,
know about things that are good for them. This is a two-way street.
Being infected with HIV and not knowing about it is bad for society and
it\'s bad for the individual.

We also need to start supporting public health law projects that
increase the state\'s traditional disease control powers and preserve
traditional public health law powers, rather than having even the
government involved in projects that weaken public health laws. The
government needs to understand that public health is not individual
rights, it\'s community rights. It has to be respectful of individual
rights, but that cannot be the only thing it\'s concerned with.

Now, one last thing. I\'ve been doing a lot with bio-terrorism since
9/11 because I did some with it before when nobody cared about it except
me and some folks at the CDC and anybody who really thought hard about
what not having anyone immune to smallpox implied. We have plans in
every major city about how we\'re going to do extensive contact tracing
and investigation to deal with outbreaks of smallpox, plague, other
diseases. Frankly, nobody has the manpower to do it. At the same time
this is going out, MMWR is reporting that the epidemiologists are being
fired around the country because departments don\'t have the money to
support the staff, positions are being filled with people with much
lower skills, maybe no public health training at all.

Putting money into a national control program for HIV, which would
require thousands of epidemiologists, tens of thousands of disease
investigators, good data collection, would give health departments the
actual infrastructure they need to do disease investigation, and it
would answer the biggest problem with the bioterrorism plan, which is
any plan that requires staff and resources that sits on the shelf until
somebody blows the whistle will not work. The military planning folks
are eloquent. If you aren\'t running people through the drill, if it
isn\'t part of your everyday activity, you can\'t make it work, because
you can\'t keep the people hired.

Health departments may have a bio-terrorism plan that says they\'ll take
care of things, because if they say anything different the health
director will be fired, but the health directors know they don\'t have
the staff for it, and the city won\'t pay them to keep the staff sitting
around at their desks twiddling their thumbs. This could be where we
fund the infrastructure to provide disease investigation capabilities
again in health departments, and it\'s going to take us 10 or 20 years
to make a big dent in HIV, and a lot of it is just changing the culture.
But we get some real good side benefits. We\'d have enough people to
actually deal with other diseases, because health directors will tell
you there are other things out there we wish we had the manpower to deal
with.

Well, that\'s my 40 minutes, and we\'ve got 20 minutes for questions
because I\'m a lot more interested in hearing from you than you may be
in hearing from me. This presentation is available on my website. The
link is in the handout, along with other materials.

Do you want to moderate?

DR. SWEENEY: I want to first thank you.

(Applause.)

DR. SWEENEY: You so eloquently expressed so many of the issues that we
dealt with in our prevention subcommittee meeting last month or the
month before that I\'m sorry that we didn\'t have you at that meeting.

I am going to moderate by asking questions. But I do have to say, we are
going to have to make sure, in order to give everybody a chance to get
their questions out there and to stay as close as possible to on time,
that we don\'t go on and on with our comments before questions. So
please try and limit it. I don\'t have a way of gonging you at one
minute or two minutes, but please just be mindful of your council
members.

The first person that said to me while you were speaking that they
wanted to speak was Lisa, Hank, Ted, Joe. I think I can put everybody\'s
name down. Reverend Sanders, Jackie, Frank, and David. Okay, let me just
do this to make sure I have everybody\'s name. It\'s Lisa, Hank, Ted,
Joe, Reverend Sanders, Jackie, Dr. Judson, and David. Did I get
everybody? Thank you.

Lisa?

MS. SHOEMAKER: Well, my question is how I can jump on board and help in
any way I can. I was one of six patients that was affected by a dentist
in Florida, and when I revealed what happened, I was told not to tell
anybody because of the stigma. I called everybody I had been involved
sexually with myself, and then the CDC also contacted people that I
could not get hold of. But this is something that I think is long
overdue, and I thank you very much for your presentation.

MR. RICHARDS: You\'re the commission. Start talking about this. It\'s
not been very fashionable in the past.

Before we go on, I\'m also happy to answer emails if anybody wants to
follow up after this.

DR. McKINNELL: Thank you for your presentation and, maybe more
importantly, your commitment to this arcane field, which is becoming
increasingly important.

I have two very brief questions. One is that sometimes I get the feeling
I\'m learning a foreign language, and you speak of contact tracing and
partner notification as different things. I don\'t get the difference.
So maybe answer that one and then I\'ll do the second.

MR. RICHARDS: I don\'t particularly either, but it became politically
correct to separate some of the stuff. I lose track of what\'s the
fashionable jargon at the moment.

Find them, warn them, investigate them. It should be a seamless
operation.

DR. McKINNELL: Okay, we\'re on the same page.

The second is kind of, to me, the key question. We have somehow, in
routine medical care, defined the standard of care. I don\'t know how we
did that, whether it\'s in the law or medical practice, but any
physician who conducted general medicine and did simple physicals but
refused to do a blood pressure test would probably be driven out of
practice. I don\'t know quite how, but why isn\'t a routine AIDS test
part of standard care and some physician who refuses to do an AIDS test
or doesn\'t do AIDS tests, what are the consequences to that person? Can
we connect this up to some accepted standard of care in the law or in
medical practice?

MR. RICHARDS: Well, perversely enough in our society, we tend to set
standards of care through tort law. I\'m an old torts teacher, which
doesn\'t mean I think it\'s the right thing, but I do unleash those
herds of locust on you. For some reason, AIDS has not been an issue in
tort law. There have been some cases holding physicians liable for not
diagnosing HIV, absolutely. But when folks expose their partners to risk
through HIV and docs don\'t test for HIV, it\'s like there\'s this blank
spot in tort law, because in any other area with any remotely comparable
risk, there\'d be an onslaught of litigation. There\'s a lot lost in the
history of torts and the politics of torts that\'s beyond our scope, but
the answer to that is that tort law, to some extent, is the public
relations, and it\'s been blind in this area; not that I\'m advocating
we increase litigation.

DR. SWEENEY: I would just like to add to that. There\'s been a lot of
confusion and lack of a clear message. In New York State for a very long
time, physicians had the right to tell or not to tell a partner of a
person, and a lot of discussion was that your responsibility is to your
relationship with your patient, and you could do it or not do it without
any penalty. It is much clearer now, and people do have the
responsibility of notifying the state and either CNAP or PNAP contact
tracing and partner notification for the city or the state when you have
a positive diagnosis. So when the law became clear on it and there was
no ambiguity, then it has to be followed.

DR. McKINNELL: May I follow up on that for one second? I see two
different issues here. I think contact tracing is one thing. I don\'t
practice medicine, but I don\'t know how you would practice medicine if
you didn\'t do routine tests like blood pressure and cholesterol level
and HIV status and 10 other things. That\'s my issue.

DR. McILHANEY: Just a quick thing. I think the standard of practice is
there for a lot of things. For example, the standard of practice for
gynecologists would be to do a Pap smear at the appropriate time. About
20 percent of women leave gynecologists offices who needed a Pap smear
who didn\'t get it, and yet there\'s generally no lawsuits that come
about because of that failure. So it\'s not a binding thing but just
standards of practice, if that helps.

MR. RICHARDS: The fact is docs aren\'t very good at a whole lot of
preventive tests. In that sense, they\'re worse with HIV because there
are so many roadblocks to testing. So it\'s not like they\'re doing all
the other things they\'re supposed to do, but they\'re busy.

DR. SWEENEY: I have to let Frank, who is the other practicing physician,
have a word.

DR. JUDSON: To continue with the standards of care goal, the standards
of care occur variably over time. The professional associations have a
lot to do with it when they end up debating and putting out
recommendations. Law courts also end up, one way or another, deciding
cases as to whether things were up to quality of care. But one of the
most important determinants of a standard of care are now these national
overriding organizations, like the National Committee for Quality
Assurance, which supplies something called HEDIS, or the Health
Employers Data Information Set. By the time it reaches that point,
there\'s general agreement that something should be done at a certain
rate to certain people. It may be testing sexually active women for
chlamydia who are less than 25 years of age. That becomes a standard by
which employers will evaluate the health plans that they choose for
their employees.

So it would be the same thing now for offering hepatitis B vaccine to
adolescents routinely. It\'s progressed through the Advisory Committee
of Immunization Practices, onto NCQA and HEDIS. The same will be true
for HIV. One would really hope that we\'re not very far away from
routine testing for HIV in every new patient encounter where there\'s
any chance of HIV at all. Hopefully, then, HEDIS and NCQA would evaluate
health care providers by whether they do this 90 percent of the time or
80 percent of the time or whatever is considered the standard.

DR. SWEENEY: Ted?

DR. GREEN: Thanks for a great presentation. I agree with what you\'ve
said. This focus on individual rights, not that they\'re not important
of course, but at the expense of public health principles has not only
harmed the United States, we\'ve exported this approach to the rest of
the world. For example, I was working in South Africa in the early \'90s
when that country was gearing up to respond to AIDS, and American and
European advisors were helping guide that national response. Well, South
Africa has the highest number of HIV infections in the world. It has one
of the highest infection rates. There\'s a lot of casual multi-partner
sex. It may lead the world in the incidence of rape. There\'s a lot of
cross-generational sex, older men/younger women.

I read a report this morning that the government is recommitting to
human rights. The focus is going to be on human rights. Meanwhile, and I
mentioned this yesterday, Jamaica has developed a somewhat different
kind of response to AIDS. It worked out an unusual relationship with
USAID and CDC in 1996 that basically said, \"Listen, give us the money.
Instead of most of the money going to U.S. advisors, we feel we have
some good venereologists in the Ministry of Health, so give us the money
and if we don\'t give you results in five years, then bring back your
American advisors.\"

I was one of the evaluators of their program. One of the things they did
when they were just given the money and allowed to prevent AIDS as they
thought best was contact tracing and partner notification. I mentioned
yesterday this was done in a way that didn\'t out anybody or compromise
anybody\'s anonymity. Jamaica was seen to have pretty much the same kind
of risk factors as South Africa, maybe with less rape. Infection rates
were about 1 percent instead of about 25 percent, and STD rates have
been coming down. They do contact tracing and partner notification for
STDs, and HIV is considered another STD.

So here is a country doing what you\'re suggesting ought to be done, and
we\'re seeing good results. Thanks.

DR. SWEENEY: Joe?

DR. McILHANEY: I just wonder how you\'ve been received when you\'ve
presented this to different groups around the country. It seems so
reasonable.

MR. RICHARDS: First, I don\'t get many opportunities to talk about it
because it seems so reasonable.

DR. McILHANEY: That\'s sad.

MR. RICHARDS: More generally I work on the larger scope of public health
powers. This just happens to be the one where the problems and the
disease have been so closely linked. Until 9/11, public health in this
country, both at the state and federal level, was dominated by the
personal medical care concerns because that\'s the way the politics
worked. It\'s ironic, the anthrax letters posed no real threat, but they
galvanized the country, and suddenly traditional public health, the
notions of the state needing to protect you, were revitalized, the way
they were up through 1970. So I\'ve gotten a lot of chances to talk,
although mostly on bioterrorism, which I have a lot less cheerful things
to say about.

I keep telling health departments, \"Don\'t worry about obesity, don\'t
worry about bio-terrorism. If you can\'t figure out how to solve a
communicable disease that\'s infecting more than a million people, work
on that.\" Anything you do to make that work will help everything else
you have to do.

DR. SWEENEY: Reverend Sanders?

REVEREND SANDERS: First, let me say thank you very much for the
presentation. Clearly, you bring a great degree of passion to what you
have to say.

I spend my life as a messenger, and I think you have a very important
message. I want to say some things about the message. I\'ve always said
that I thought that AIDS was going to be the vehicle by which we would
be able to solve many of the complex and painful problems that exist
within our society, because it forces us to deal with issues that we
have denied, tried to avoid and not deal with forthrightly.

To that end, one of the things that I found to be of some concern as you
did your report and made your presentation is when you give an
historical analysis, I think there\'s a bigger picture. I think it is
AIDS, I think it is what was going on in the gay community, but I think
the larger historical perspective is the era of civil rights, and I
think the way in which many people ended up with the language of Title
VII and \"suspect class\" and that kind of thing ends up being the
byproduct of historical discrimination, and the ways in which people
have legitimate rights to fears and concerns as to how they might be
treated within society if indeed they did not have some legal
protection.

Let me put it like this. Where you ended up, we would not argue in terms
of how public health needs to be done. How you got there is a different
issue, because I think how we get there in dealing with it forthrightly
is a part of how we deal with some of the issues that I think haunt us
in this society. So ultimately you have to deal with race and class, you
have to deal with gender discrimination, you have to deal with those
dynamics that have translated into the kind of stigmatization that have
caused some people to be compromised in terms of their ability to
realize the full potential of the American dream.

So I appreciate that, but the backdrop is ‑‑ I mean, for instance ‑‑ and
I\'m sure this was the quick version, so let me preface this by saying
that. But I find it very difficult to give an historical backdrop,
especially as it relates to where this disease is going today and the
change in its complexion, and you did not even mention the word
\"Tuskegee,\" because I think that in terms of folks who have suspicion
and people who have distrust and people who have concerns, then you\'ll
understand why there was some, perhaps, propensity towards leaning in
what ended up being a hurtful direction in terms of this whole issue of
‑‑ and I think you\'re right in terms of the whole question of how you
deal with exceptionalism. But I think there\'s a way in which you have
to appreciate how that came to be.

I guess the last thing I would want to say is that I think it\'s very
important, and we\'ve got to move aggressively, we\'ve got to move
quickly to deal with the whole issue of bringing to bear the best public
health strategies that we can to deal with HIV/AIDS. But I think that we
have to make sure that as we do that ‑‑ I\'ll give you this example, and
then I\'ll stop.

When you come to where we were in the 1960s and \'70s, the scales of
blind justice were clearly tilted in a way that represented a kind of
discrimination that had to be addressed. What we\'ve seen to some degree
is a correction. Whether we over-correct or whether in the process of
correcting we end up compromising some of the principles that I think
are solid, sound, and had to be used in terms of public health, we have
to understand how we got there, and we have to make sure that justice
remains blind, because there are a lot of instances that translate into
why we have the disparities, and the disproportionate impact of disease
upon some communities versus others has a lot to do with the fact that
the lady is peaking out from under her blindfold.

MR. RICHARDS: I couldn\'t agree more and in the long version develop the
same issues, the role of Tuskegee, the role of race in HIV. I mean,
maybe I didn\'t say it strongly enough. If poor black women in
particular, who are the most difficult ‑‑ they\'re getting the biggest
risk for HIV right now, were more politically powerful than gay men, the
whole shape of this, the epidemiology and the laws and the services,
would be entirely different. Race is the giant issue in this, race and
class, poor women, poor men, minority communities, and it comes from all
those things you talked about. If we\'re doing the two-hour version,
you\'d love it.

REVEREND SANDERS: Thank you. You\'re an important messenger. I think
we\'re going to help to make sure you get to carry that message. We\'re
probably going to include that message in some of what we report out
from this committee, but I would hate for our report not to reflect the
kind of historical backdrop that I\'m trying to suggest, because it
undermines our ability to turn HIV/AIDS into, I think, an important
response to a lot of other stuff in our society.

DR. SWEENEY: But the exceptionalism actually started before the epidemic
moved to the powerless. So it was not based on race and class then.

MR. RICHARDS: The exceptionalism started partly around the whole
rejection of support for public health as people quit worrying, but also
around the political issues in the gay bathhouses. But that didn\'t
change when we suddenly realized that there was this huge dimension of
other folks at risk.

DR. SWEENEY: Jackie?

MS. CLEMENTS: Thank you. I am an HIV pre- and post-test counselor in my
other life, my real life. I want to first say that I do believe in
routine testing. I do believe that with regard to HIV, the rights of the
public should outweigh that of the individual. I would even say do away
with pre- and post-test counseling. I\'d find another job if that would
make a difference.

However, pre- and post-counseling also, especially pre-test counseling,
is an opportunity to gather some information. I think that in your
presentation, you might include that providers, primary care providers
would need to have some training, some retraining in HIV and testing,
simply because there have been numerous occasions when a provider has
asked me about \-- couldn\'t find a result in a chart, and I looked, and
it\'s there, and I said in 2004 she tested negative, and he goes and
says, \"Oh, she\'s negative.\" That\'s not what I said. I said in 2004
she tested negative. There is a window period, a three-month window
period, oftentimes forgotten. You know, I had sex last week, you test me
today. We\'ve got to consider a three-month window period, and a lot of
people who do not deal with HIV, primary care providers, don\'t consider
that.

So in your presentation, consider that there would need to be some
retraining in order to do routine testing and ensure the validity of the
results that you\'re getting from your testing.

MR. RICHARDS: And I don\'t disagree. Dr. Judson really went to the heart
of that. I\'m really talking about removing the barriers, but it\'s
going to take professional standards and professional education to allow
docs to take advantage of this if we remove the barriers.

DR. SWEENEY: Dr. Judson?

DR. JUDSON: Well, Ed, that was terrific, as I\'ve learned to expect over
the years. I think that was a perfect response to the question that was
raised by the Prevention Committee regarding a key component of how we
would hope to reframe the whole prevention approach to HIV. Part of that
has to do with the law, which I think you very eloquently and completely
covered here. In fact, we might take your last three slides and use them
as the component that would tie together reauthorization of Ryan White
and certain other federal programs. It speaks to each of those issues.

There have been many missed opportunities, but we have another one
coming up now, and that\'s to make sure that all federal funding is
pushing in the same direction towards prevention and control, supports
prevention and control at every level. We were also hoping that it might
be possible, through CDC leadership or other leadership, to come up with
the model laws, or at least the standard components of modern law
towards public health control of HIV, and that would very clearly
include name-based HIV reporting on a national basis. It would start
with the states, but it would be plug-to-plug compatible all the way up.

So we know what\'s happening now and not 10 years ago. It\'s the same
thing we\'ve been saying, you and I and others, for 20 years, that if
you don\'t know who is infected and who is exposed, you can\'t control
any critical infectious disease.

As far as the civil rights go, we\'ve also been saying for 20 years
that, yes, this is a civil rights question. It\'s a question about the
right to life and pursuit of happiness. You can\'t do that if you\'re
dying of an incurable viral infection which could have been prevented.
So what is threatening the human rights and civil rights of individuals
in this country is simply a little piece of DNA and RNA that will kill
you eventually.

DR. SWEENEY: Thank you.

We have David Reznik.

DR. REZNIK: As is so often the case, the Reverend Sanders expressed many
of my concerns in a much more eloquent fashion than I could. I would,
though, like to look at the outline and the history of discrimination
that did face people with HIV and AIDS in the \'80s and in the \'90s,
which was a real thing, a very real thing, which is why I got involved
in this disease to start with, because people were denied access to oral
health care, people were denied access to housing, people did lose their
jobs, people did lose their homes, people weren\'t allowed to visit
people in the emergency room. There was an issue back in those days.

I think there is still an issue today. I think it\'s affecting a
different population, and still some of the traditional population. With
that being said, I still think we need to go to a much more proactive
name-based reporting and much more health-centered model that we\'re
talking about. But I don\'t want there to be any diminishment or lack of
emphasis placed on the many people\'s lives that were impacted by this
disease the first go around. I mean, the issues of discrimination, the
issue of lives being ruined, both those impacted, infected or affected,
were real.

I do believe that we need to go to a public health model, having said
that. So that was just my comment.

MR. RICHARDS: And there have been some major changes. The Americans with
Disabilities Act was to some extent driven by AIDS discrimination. There
are a lot of other issues to it, but that act is now in place. The HIPAA
privacy, we have a much stronger and federal framework for protecting
individual rights.

DR. SWEENEY: I\'ve been told that we are over time, but we have two
burning, short, and then the last two. Joe, then Reverend Sanders, Dr.
McIlhaney, and that Joe.

Reverend Sanders, very short, and then back to our co-chair, Anita
Smith.

DR. McILHANEY: I\'m on Dr. Gerberding\'s advisory committee, the
director of CDC, and I was speaking with her yesterday evening after a
meeting. I asked her twice if I should tell you this, and she said yes.
She said tell him to keep it quiet, though. With the audience, I don\'t
know how quiet that will be. But anyway, she said that they are moving
ahead at CDC with advancing HIV prevention, and she just wanted us to
know that that process was moving, and so she was happy about that.

I don\'t know if after this discussion we\'re going to have to go back
and say, hey, you need to change it again or not, but at any rate ‑‑

DR. SWEENEY: Reverend Sanders?

REVEREND SANDERS: I guess I just wanted to be sure to say that we still
live in a world where people are very prone to use scapegoating as a way
in which they\'re able to move quickly to justify doing all kinds of
things, and for that reason I don\'t quickly dismiss any issues that
compromise the question of civil rights.

A perfect example is if you take Dr. Richards\' presentation, especially
as he talked about if you had closed gay bathhouses down at a certain
point, we wouldn\'t be where we are today, you tread on shaky ground
when you start isolating an issue in a way that fuels the fire of people
who would say things like this is a curse from God. You just have to be
very clear that the message is always balanced.

I would hate for the disease ‑‑ at least gays can go and pretend to be
straight. At least Jews can go and pretend to be German. As this disease
changes its color, the last thing I want is any scapegoating
availability to exist for folks that would allow you to be able, on the
basis of the color of your skin, to be able to say you\'re the problem.
Now, you could probably end up with a lot of analysis about what you
could do in communities of people of color right now that you could
argue would change the disease as it\'s manifesting itself in the
future. We\'ve got to make sure that as we develop solutions and
responses, that it does not lend itself to that propensity in human
nature to use any group of people as a vehicle by which they scapegoat
and then justify injustice in relationship to those people.

I think that\'s what gays were dealing with, and I think that\'s where
we are in terms of people of color today.

DR. SWEENEY: Thank you for that, Reverend Sanders.

I want to say again how much we thank you, Mr. Richards, for an
outstanding presentation. You see the heat and light that you generated
around the room. Thank you very much.

MR. RICHARDS: Thank you.

(Applause.)

MS. SMITH: Thank you.

We are, as Dr. Sweeney said, running a little behind, but we\'re moving
right into public comment now. We had two participants yesterday who had
signed up, and we have some more today who are in the audience. What
we\'re going to do is Joe Grogan will be reading the names of the folks
who have signed up for public comment, and we\'d ask you to come to the
microphone at the time your name is read and make your comment. Thank
you.

MR. GROGAN: Thank you. You have three minutes for public comment, and I
will notify you when you have 30 seconds left and when time is up, and
we\'re going to be firm as to when time is up to keep this moving.

The first person on my list is Diana Bruce. Is she here?

(No response.)

MR. GROGAN: Robert Burns?

(No response.)

MR. GROGAN: Gene Copello?

DR. COPELLO: Good morning. I\'m Gene Copello from the AIDS Institute. I
have just three brief comments.

The first is that I want to encourage the Council to continue the
discussion that you had I believe several meetings ago about encouraging
the White House to convene a White House conference on AIDS. I don\'t
believe you\'ve discussed that recently. With so much happening in
prevention and care and research, I believe that that would be an
important meeting. There hasn\'t been one of that sort since the 1990s.
So I would encourage you to continue with that recommendation.

Second, I understand yesterday that there was some discussion about
PhRMA and PhRMA\'s donations to prevention programs. I just wanted to
comment that we hear often today, including from the administration, the
importance of dealing with this epidemic from all sectors, the private
sector, the government sector, the non-profit sector, and just to
comment, several pharmaceutical organizations have indeed provided funds
for prevention activities. One major example is Pfizer, which funded \$3
million to 24 agencies in the south for basic prevention services in a
region that really needs those kinds of services. But there are many
other examples.

So I wanted the record to reflect that, because those agencies across
the country need that kind of funding from the private sector, and it
should be encouraged rather than discouraged.

My final point is I believe all of you have received a copy of the
reauthorization position paper from the AIDS Institute electronically,
but there are copies outside with the staff if you don\'t have one.

Thank you very much.

MR. GROGAN: Genevieve Grabman?

(No response.)

MR. GROGAN: Lance Hogg?

(No response.)

MR. GROGAN: Brent Minor? An old friend.

MR. MINOR: Old?

(Laughter.)

MR. MINOR: Good morning, my friends. I\'m glad to join you and see so
many familiar faces around the table. Let me begin my comments by saying
how honored I was to serve with so many of you during my five-year
tenure on PACHA.

I\'m here today as a member of the board of the Federation of Gay Games.
As some of you may know, the Gay Games are an international sport and
cultural event that have been held every four years since 1982. Since
then, thousands of people, including over 11,000 at the 2002 Gay Games
in Sydney, Australia, have lived out the three principles of inclusion,
participation and personal best on which the Gay Games were founded. The
2006 Gay Games will be held in Chicago, and organizers estimate that
over 12,000 people from all corners of the world will participate.

The reason I\'m here today is that some of those athletes and artists
will be people like myself who are HIV-positive or living with HIV and
AIDS. As you know, the United States has a law that requires people with
HIV to receive a waiver in order to enter the country. In order to
comply with the law and lessen the stigma that HIV-positive travelers
may confront, the organizers of the Chicago Gay Games are making a
request of the Department of Health and Human Services to receive
designated event status, or DES, for all foreign HIV-positive Gay Games
participants during the 10-day period that the games will be held.

Designated event status has been given numerous times over the years to
various meetings and conferences, including the 1994 Gay Games in New
York City. I want to take this opportunity to alert you that this
request is being made, and I hope that PACHA members will consider,
either as individuals or as a whole, supporting this request. There is
strong bipartisan support from members of the Illinois Congressional
delegation on this issue.

Granting designated event status for the Chicago Games would not change
the HIV immigration law in any respect. Indeed, the same requirements of
not becoming a public burden would apply whether the participant
received an individual waiver or entered the country under the blanket
waiver through the designated event status. The DES simply allows
travelers who can demonstrate that they are participating in the Gay
Games from seeking an individual waiver. This will help encourage people
with HIV to participate more freely and with less stigma.

I have been active in gay sports for a number of years and have
completed 34 Olympic distance triathlons and two marathons since my own
HIV diagnosis. I see sports as a healthy and positive alternative, not
just for gays and lesbians but also particularly for people living with
HIV/AIDS. I feel that the kind of experiences offered by such events,
such as the Gay Games, help people feel better about themselves and
their community. I know it has helped me and feel that it can help
others.

Thank you for your time, and I will be happy to speak with any of you
further about this. I think you all know where to reach me. Thank you.
My copies of my letters to Dr. Beato and my comments are out on the
table. Thank you.

MR. GROGAN: Thank you, Brent.

Last we have Connie Jorstat.

(No response.)

MR. GROGAN: That\'s all I have on the list that was here. Was there
anybody ‑‑

MR. RUSSELL: I was on the list originally.

MR. GROGAN: Okay, we have time.

Can you state your name and your organization?

MR. RUSSELL: Yes. My name is Randall Russell. I\'m with the Southern
AIDS Coalition.

Good morning and thank you for allowing us this opportunity. The
Southern AIDS Coalition emerged from community-based crises in a region
of the United States with the most new cases of AIDS, the largest
proportion of waiting lists for persons in need of life-sustaining
medications, the region with the highest disproportionate infections in
communities of color, and a region with a wide geographic expanse
comprised of less urban settings for the population. It\'s my honor to
serve as the director of the Southern AIDS Coalition. We have several
hundred members in 14 states and the District of Columbia.

The reauthorization of the Ryan White CARE Act must occur in a manner
that, if possible, holds harmless all areas of the country as this
federal tax-supported program strives to achieve a distribution of
resources that ensures care and treatment in an equitable manner from
coast to coast.

In 1990, Congress and President Bush\'s administration achieved a
remarkable feat. They found a method to address a burgeoning infectious
disease with staggering stigma and, at the time, mostly fatal
consequences. Fifteen years and billions of dollars later, we stand on
the shoulders of those who came before us, who risked life in pursuit of
science, risked social rejection due to misunderstanding and fear, and
bravely confronted what most of us have the luxury to avoid facing, our
obvious ultimate fate, an end to our life as we are able to now know it.

What has happened to our courage to do the right thing? Have we come to
actually debate what is the right thing to do with federal resources
when it\'s clear at present it isn\'t fair? How can we consider other
alternatives than a fair distribution of resources to meet 100 percent
of everyone\'s treatment and care needs supported by comprehensive care?
No one of us deserves less than any other, and certainly no region
deserves to be overlooked due to population distribution based on
geography, history, and availability of resources.

Why in 2005 is it okay to double count cases in federal formulas for a
few selected urban settings? Why are 19 states, 8 of which are in the
south, left with the inexplicable burden in many cases to serve the same
number of people with less Ryan White money than other states? Why are
similar-sized populations and the numbers of living cases of HIV/AIDS
seen as less when it comes to disbursement for people in less urban
settings?

All people with HIV who live in the United States deserve access to a
full formulary with at least a minimum eligibility of 300 percent of the
federal poverty level, and a guarantee in the richest nation in the
world to not have to wait for life-saving medications, with access to
full care and housing.

Attention also must be paid to increase prevention funds that go beyond
abstinence when necessary and result in honest programs about behavior
and consequences, and the actions especially of our youth in all
communities across this great land.

Your leadership and our inborn will to do the right thing, our
conscience, our collective conscience, must guide us to recommend to
this administration that it\'s time to bring a quality of funds to care
and treatment for individuals and families who struggle day in and day
out living with a disease that continues to be more treatable, but only
if one is fortunate enough to live in the right part of the country.
This wrong can be righted with an exercise of courage and will. That
shouldn\'t be that hard, especially as we remember those who fought for
initial recognition by the federal government to care for us.

MR. GROGAN: Time. Your time\'s up. Thank you.

MR. RUSSELL: Thank you.

MR. GROGAN: That\'s it for public comment. Before we break real quickly,
I wanted to have Miguel Gomez make an announcement about testing day,
and I believe a member has a comment.

DR. McKINNELL: I just wanted to underscore the important work of the
Southern AIDS Coalition. In fact, it was Gene Copello\'s presentation
here almost two years ago now, the Southern AIDS Manifesto I think it
was called, but it convinced me that we had a problem, and I thought the
answer was in partnerships, which is what led Pfizer to step up to more
commitment to the area of prevention, contrary to what some people might
think about our work.

But I am particularly troubled by the latest CDC data. The southern
states as generally defined are a third of the population, but 76
percent of new HIV infections in women are in the southern states. So if
you combine women in the south and minorities, we have a real crisis
that I don\'t think is getting the attention it deserves. Now, it needs
funding, it needs partnerships, but to Reverend Sanders\' point, I think
it also needs messengers, that we do need trusted leaders in the
community to feel like I do, and I\'m sure they do, but we need them to
be clear and vocal on the clear and present danger that exists to
minority women in the south.

It\'s just incredible to me that there\'s probably three times the risk
if you\'re a minority and a woman in the south than anybody else in the
population, and that should just be unacceptable to us on moral grounds.

MS. SMITH: Thanks very much for the comment, Hank. I completely agree,
and I think as a follow-up to yesterday and what you\'re just saying,
when we have our discussion over lunch, we were hoping to craft a
resolution of some sort that would include the thoughts you just
expressed. Thank you.

Thank you all for your public comments. We really appreciate hearing
from you and taking the time to be here with us.

Miguel?

MR. GOMEZ: Good morning. Joe last night asked me if I could just provide
a brief update on National HIV Testing Day and some of the things that
are happening generated from Health and Human Services. So thank you,
Joe.

What I\'d like to do is just share that just so everyone knows next
Monday, June 27th, is National HIV Testing Day. It\'s the 11th
anniversary of the observance, which we here at HHS actually do believe
is a tool to actually increase awareness and get more people tested and
link them to care.

The theme for HHS is \"Then and Now: Twenty Years of HIV Testing.\"
I\'ll just very quickly tell you about some global goals for National
HIV Testing Day, and then talk about some internal and external things
that are happening here at HHS, and then a small call to action, both
for the audience and the PACHA members themselves.

Globally, this is just one tool to help us normalize HIV testing, to
encourage individuals to get tested, hopefully early, and link them to
care, and then perhaps even give us an opportunity to talk about the
Ryan White CARE Act, which many of you are anxious to hear about, in a
few minutes.

One thing that I\'d also like to acknowledge is that the National
Association of People with AIDS, in partnership with Health and Human
Services, takes a lead in coordinating activities around the United
States for this day, and there are multiple themes for this tool: \"Now
and Then: Twenty Years of HIV Testing,\" \"It\'s Better to Know.\"
Unfortunately, some focus groups recently told us it\'s better to know
what? Also, another theme is \"Take the Test, Take Control.\" Well,
people asked, what test?

The Kaiser Family Foundation is using \"Knowing is Spreading.\" Knowing
your HIV status is an essential part of prevention and treatment. Again,
we have to reassess the themes, but what\'s important globally is
encouraging HIV testing, taking away the stigma, linking people to care.
Here at HHS we\'re providing that information through employee education
events here. But what\'s also important is we\'re very proud that the
CDC is launching a series of op-eds through partnerships and with the
director of the CDC, getting the message out and doing some media tours.

What\'s also important is that the CDC has launched a very important
webpage which, for a webpage, has an unusual quality. It\'s easy to use.
It\'s called hivtest.org, and it doesn\'t say .gov, very important. All
you have to do is put your zip code in and it will tell you areas in
which HIV testing is available in your community. Very, very important.
Also, there\'s a handout on a webpage launched here at HHS over a year
ago that provides information for all HIV testing days. It\'s housed at
the Office of Minority Health, and it also promotes the multiple other
HIV/AIDS awareness days, from National Black HIV Awareness Day to, most
recently, National Asian and Pacific Islander AIDS Awareness Day.

As I mentioned internally, we\'re also working to educate our frontline
staff. In our employee education event activity, what\'s important is I
just want to share one of the pieces from the document we\'re going to
be sharing. By offering testing to all persons instead of those who
\"seem at risk,\" health care providers can help reduce stigma and
ensure that all persons with HIV, if they think they\'re at risk or not,
have an opportunity to learn their status. Stigma around HIV testing
remains a concern. Over 30 percent of people tested report that they
think people would think less of them if they found out they had a test.

So one of the things we will continue and we\'ve done in the past,
we\'re offering here at HHS is offering our employees HIV testing, and
we do that multiple times during the year. What\'s important is we want
to actually ‑‑ and we send the messages from our health clinic. We want
them to think of an HIV test as something I should do like a flu shot.

One thing that\'s also important is that we\'re also putting posters up,
hopefully, at the health clinics on the Hill to encourage staff members
from both the House and Senate to come over to HHS, if they wish, to get
an HIV test. We\'re also encouraging other local organizations in the
area that do have access to testing to offer it to their employees.

One thing that\'s also important here at HHS, we do promote our
webpages, resources, fact sheets, information, but twice a year we do
faith and civic events. Most recently we were in Deerborn, Michigan
having our first Arab and Muslim HIV testing day event. Dr. Deborah
Parham-Hopson, who is with the Ryan White CARE Act, the director, she
was the keynote speaker. But it\'s so important to us, so we do this in
conjunction with our faith office here at HHS. We have received some
criticisms that often our faith-based events are within the Christian
denomination and not outside that tradition. So we\'re very pleased that
we held our first Muslim and Arab event.

What was so striking is that we had both our public health officials,
our civic officials, the school board, and amans. We had over 70 leaders
in that community, and what the leaders and participants told us on the
evaluation what made a difference for them was having their faith leader
in the room declaring that HIV is an issue they must respond to in their
community.

One last tool we have is that we encourage all of our partners on HIV
Testing Day to send their staff and colleagues\' emails just giving
folks facts about the new CDC stats, but importantly, just telling your
employees and colleagues that you\'d like them to learn more about
testing and perhaps get tested. I\'d like to actually laud Joe for
sending an email to all the PACHA members, a sample email that they
could send to their networks. We\'d be more than willing to actually
provide sample emails to anyone in this room.

Again, HIV testing day is just one tool in the fight against HIV/AIDS.
Joe, I\'m glad you asked for an update. There\'s more information at the
back of the room for folks. Good luck with your day.

MS. SMITH: Thank you so much, Miguel.

At this point we\'re going to take a break before our next session. We
are going to cut the break to 10 minutes rather than 15, so we\'d like
to see all the members back at the table in 10 minutes. Thank you.

(Recess.)

MS. SMITH: We\'ll move into the next part of our program, which is
really something of interest to all three committees that have been
working on the issue, primarily Treatment and Care and Prevention on the
Ryan White reauthorization. Our discussion today will be with Carol
Thompson, who is the director of the Office of National AIDS Policy, and
Joe O\'Neill, who is the senior advisor to the Domestic Policy Council.
They both have experience with the Ryan White reauthorization in the
past, and we\'re privileged to hear from them today in terms of an
update. Also, I think the discussion will range into some other
prevention issues that we\'re interested in delving into with them and
hearing their thoughts about.

So we\'ll turn the time over to Carol and Joe.

MS. THOMPSON: Good morning, everyone, and thank you all for joining us
this morning. It\'s wonderful to be here. It sounds like you guys had a
very full day yesterday and have had some interesting discussions this
morning.

We wanted to take a little bit of time this morning to give you a brief
update on Ryan White reauthorization and the administration\'s
principles that are going to be coming out.

I wanted to take one minute briefly to acknowledge and say thanks to a
couple of folks. Deborah Parham is here, Christopher Bates is here,
Marty McGeein is here, and they and a lot of staff at HHS have been
working very hard on looking at the program, looking at the bill, and
really looking at best ways to make improvements and changes that will
really help us reach those that are in greatest need.

As far as from the White House, we are very, very, very close to
finalizing principles that we would like to release as soon as possible.
We know that the Senate has been looking at the bill, and we know that
the House has been focusing primarily on NIH reauthorization, but I know
that they are very aware and very interested in working on a bipartisan,
bicameral basis to get the bill worked out with the Senate and hopefully
passed, and get something to the President in due time. Obviously, the
bill ends in September of \'05, and ideally the President has stated
several times, including in the State of the Union, that he is anxious
and interested in reauthorizing Ryan White. So that\'s what we\'re all
working towards.

I would probably ask for your patience for a little while longer, but
we\'re close to finalization, and you\'ll certainly know as soon as
possible if we can get those principles out.

We can certainly take a couple of minutes if you all have any comments
that you have on Ryan White, and after that I thought we would move to
talk a little bit about prevention in the context of Ryan White and
outside Ryan White.

DR. O\'NEILL: I think one of the things that is really important to say
is that one of the reasons that we still haven\'t finalized and put into
stone the principles is that we wanted to have this conversation with
this group. We\'ve met multiple times and iterations where we\'ve talked
about this, but you\'ve received a lot of new information over the last
couple of days, some very important information even this morning, and
we did not feel it was timely to have moved forward until we had one
last opportunity to really sit with you all and have a discussion and
hear feedback. So here we are.

MS. THOMPSON: Yes, sir?

DR. REZNIK: I have a question that is related to the CARE Act but it\'s
not necessarily direct. The President came forward last year with a \$20
million initiative to help eliminate the waiting lists for ADAP, and
that initiative is going to run out in September. There are 1,500 people
who are benefiting from the initiative, which we\'re all very grateful
for. Are there any plans on how to address what happens when the funds
run out in September?

MS. THOMPSON: Is anyone here from OMB?

(Laughter.)

MS. THOMPSON: We\'re very much aware of the timetable for those folks,
and obviously with the overall goal of trying to reach more and more
people who are in need of medication. We\'re certainly working on making
sure that we\'re able to continue their treatment.

DR. O\'NEILL: I think that announcement, the President\'s announcement
of the \$20 million was in the context of his speech where he also
called for Ryan White reauthorization and called for a number of
concepts in the reauthorization. The thread that runs through that is
that this was a short-term fix, but the real fix for focusing our
resources and organizing our resources so that we don\'t continue to
have waiting lists has to do with taking a serious look at the Ryan
White CARE Act.

So I can tell you, finding that \$20 million was a heroic effort on the
part of HHS and OMB and HRSA to do that. It\'s no way to run this
business, which is why the Ryan White reauthorization is so important
that we actually all have to grapple with the issue. What kind of a
country do we ‑‑ how do we want to respond to this? There\'s an
appropriations process and there\'s an authorization process, and this
is the time we\'re looking at authorization. So if the conversation
degenerates into just more money and not looking at how we spend it and
how we organize it, we\'re not going to have a fruitful conversation
here. So we\'re taking that very, very seriously, to look at the
authorization first and how do we structure our resources in such a way
that we have equity and focus and we\'re not into these kinds of
situations.

DR. REZNIK: Can I just follow up briefly? The only reason I wanted to
follow up is because I know the reauthorization timetable has been
pushed back a tad. Originally I think the Senate wanted to get something
done by the end of September, and it looks like that\'s not going to
happen. I understand that we need to address, and hopefully the
administration and the House and the Senate will address the ADAP crisis
on a long-term basis. I\'m more worried about the short-term problems in
North Carolina and Alabama. I don\'t need to know the specifics, just
that the administration is aware that we have a problem and there\'s a
time gap there and that we can somehow manage to figure out a way to
pull a magic bullet out and help those people. That\'s all.

DR. YOGEV: There is a new population that is emerging in this disease
which is running into problems because of maybe state laws and the like,
which is the adolescent. We now have a whole population who were able,
through Medicaid, to bring to the point that they are adolescent, and at
least in two states ‑‑ one of them is mine, Illinois ‑‑ that I\'m aware
of, you have to have AIDS to get services when you\'re 18 and older.
Basically what happened is we just dropped those patients because
there\'s nothing to pick them up, no sufficient funding specifically for
a population which is growing. I\'m sure you\'re all aware that this is
the second fastest growing population that has no work, no insurance and
can\'t get Medicaid. I wonder if that\'s part of the new reauthorization
of Ryan White.

MS. THOMPSON: I\'m not sure. It\'s a problem that hasn\'t specifically
come to my attention, that once you turn 18, if you\'re HIV-positive,
that\'s not enough, that you have to have AIDS to get care.

DR. YOGEV: Yes, paid-for care.

DR. O\'NEILL: It raises a number of important issues. First of all,
states approach this differently, and states contribute different
amounts of resources themselves. For some of these issues, they\'re
different from state to state, and that\'s one of the important elements
that needs to be kept in our minds. The second thing is that there are
particular components of Ryan White that do specifically focus on
adolescents care. The third point is that the interdigitation between
Medicaid and Ryan White is an extremely important issue and one that is
ultimately going to be solved by a federal and state partnership to look
at those issues.

Finally, the federal government is a very blunt instrument to solve a
particular problem in a local jurisdiction or in a particular state. I
think our job is to create the environment by which state and local
expertise and communities and governments and people living with AIDS
can work together to figure out how to solve these problems in the
appropriate way for various communities. But there are as many different
problems and populations like this as there are states and communities,
which is why the structure of the CARE Act is that it allows different
communities to respond differently. That\'s an important one.

MS. SMITH: Frank?

DR. JUDSON: In formulating the principles guiding Ryan White
reauthorization, some of the ones that we\'ve discussed are really all
directed at not accepting the status quo of simply every year adding
26,000 new cases who need to be treated. That\'s the number of those
leftover after 16,000 to 18,000 die and you have 40,000 to 44,000 new
cases.

The principles are for a patient receiving Ryan White funds from his
fellow taxpayers or her fellow taxpayers is that \"HIV stops with me.\"
The principle for the physician who is taking care of patients who have
HIV is that \"HIV stops with my patient\" and you\'ll do everything to
understand whether there is a risk of ongoing transmission. For states
that receive federal Ryan White monies, a requirement that we\'ve tried
to have placed in these laws since 1993 or 1994 on is that the states
must have, as a condition for receiving Ryan White money, name-based
reporting systems in place, and they must use that information to
understand how the epidemiology is changing and to most efficiently
apply their limited prevention dollars to preventing new cases. For two
or three authorizations in a row, that day has continued to be put off.
So I think prevention just needs to be as tightly tied and conditioned
as possible on federal funding.

MS. SMITH: I just wanted to say I have two more questions or comments on
Ryan White, and then we can move the discussion to prevention. Joe needs
to leave at 11:00, so we want to be sure to have him as part of that
discussion.

So Joe McIlhaney, and then Dr. Primm.

DR. McILHANEY: Frank is always so eloquent, but what I want to ask bears
on what he said. Are you at liberty to talk about what prevention
efforts might be a part of Ryan White or your conversations about that?
If not, that\'s okay.

DR. O\'NEILL: I think it would be more helpful to hear what ‑‑ I mean,
like I said, we\'ve certainly given a lot of thought to it, and as you
said, it\'s been out there every reauthorization, the last couple of
reauthorizations, a prevention component. So I think it\'s certainly
something that\'s of great interest to us, and I\'d be most interested
in using this time to hear from you about what elements ‑‑ as you
formulate your recommendations or thoughts on this, what elements, if
any, which I assume you\'ve got some ideas on this, that we get that out
there.

But sort of backing up to the 50,000-foot level, we need to look broadly
at USG policy, I think recognizing that our response domestically is
part of the global response, number one. The world is looking to us as
models of the way to do things. So what we do in terms of public health
becomes, I think, very important.

The second thing is that we have to look not just narrowly. There\'s
care, treatment, prevention, research. How do these things come
together? Clearly, if we don\'t have some serious impact on the
prevention of this illness, Ryan White is never going to be big enough.
We\'re fighting a losing game here. How that works out legislatively is
another question. But clearly, knitting together care and treatment and
prevention and having the conversations between these stovepipes is
extremely important.

Parenthetically, when we\'re designing PEPFAR, one of the things that
was very important to me was let\'s not make the same ‑‑ let\'s try to
‑‑ if you remember the model of an integrated system, a network system
for integrating care, treatment and prevention, which is embedded in
PEPFAR, really came in my mind as a reaction to what I think was a
flawed approach, that we\'ve approached these things domestically in
very separate categories. That\'s why I made the initial comment about
looking to the domestic response as part of the global response, because
I think there\'s a lot of interchange back and forth. I think we learn
something from the domestic work that came into how we design PEPFAR,
and I think we\'re going to learn stuff in PEPFAR that may come back and
help us do a better job thinking through how we respond domestically,
because ultimately we\'re all human being struggling with this virus and
struggling with our good angels and bad.

DR. McILHANEY: Well, that\'s good reassurance that you\'re thinking
about incorporating prevention into the program.

MS. THOMPSON: I don\'t know, Dr. Primm, if you want to say something
else about Ryan White, but we do want to say a little bit more on the
prevention piece, which is having been at CDC ‑‑ I think, Dr. Judson, I
think it was you who said we can\'t treat away the disease. We\'re very
much on that line, which prevention is really a central focus in, as Joe
said, a comprehensive approach to fighting the disease, and we are
leading by example. So as we ask other countries, other nations to
implement voluntary counseling and testing throughout ‑‑

DR. O\'NEILL: And just to build on that ‑‑ we could just talk to each
other all day.

(Laughter.)

DR. O\'NEILL: In the last two reauthorizations, there was no
administration position, official position on reauthorization. This time
we\'ve got a President who has talked about it twice, once in the State
of the Union address. This is important, and the linkage between what\'s
happening between prevention and care is extremely important. The
routine HIV testing, the President has talked about routine HIV testing
already, on June 23rd of last year. It\'s a challenge to all of us.

MS. THOMPSON: Voluntary.

DR. O\'NEILL: Yes, always voluntary. But moving and integrating ‑‑
we\'ve got to end this thing. That\'s the point. We have got to end this
epidemic. A continuing pace of 40,000 or 50,000 new infections every
year does not look like ending to me.

MS. SMITH: Dr. Primm?

DR. PRIMM: My point was that the Treatment Committee of the Council
passed a resolution a couple of meetings ago that was unanimously voted
upon that any monies that are out there, prevention or treatment monies,
Ryan White reauthorization included, that it follow the epidemic, that
African Americans and Hispanic Americans is where this whole problem
today is focused primarily, and what Hank just talked about in terms of
the southeastern United States, and what the President talked about in
his State of the Union message, about reauthorization of Ryan White and
what\'s happening with African American women.

I think we need to take that into strong, strong consideration as we
talk about these issues, that it follows the epidemic, that the money
goes where the problem is. I\'d like to make sure that this committee
sees that, and that the White House sees that that happens.

MS. CLEMENTS: I was going to say exactly what Dr. Primm was saying.

DR. McKINNELL: Well, Carol and Joe, I applaud you for coming to talk
about what you can\'t talk about. You\'re doing a fine job so far.

(Laughter.)

DR. McKINNELL: You asked us for the 20,000-foot-level analysis, and
I\'ve been pushing this group, maybe too subtlely, to ask a different
question, and I would really encourage you to put a small group of
really good planners and strategists together to provide a comprehensive
strategy. Strategy would be, if our goal was an AIDS-free generation by
2020 ‑‑ you pick the date ‑‑ what would we do? We\'re setting out to win
a war, and you don\'t set out to lose, you set out to win. I don\'t have
a sense of a winning strategy here, and the goal is pretty clear. It\'s
eliminating this virus.

Now, that\'s going to take many hands and many generations and many
dollars. But if we don\'t have a strategy, we won\'t get there. When you
have that, then you need funding and partnerships and five other things.
But I think it all starts with the strategy, and I really think that has
to be articulated by the administration.

REVEREND SANDERS: I don\'t know if we\'re ready to transition a little
bit into prevention. I guess I want to speak to the issue of Ryan White
and prevention at the same time.

I don\'t want there to be the misnomer that prevention is not already
happening within the context of Ryan White, okay? Some of the things
that are happening in that regard, especially as it relates to the way
in which I know in Title III and some other instances we\'ve had the
opportunity to build capacity in communities that need desperately to be
involved in the response that we\'re trying to formulate is very
significant.

I think the issue for us is going to be ‑‑ and this kind of opens it up
in terms of the issue of prevention and Ryan White. The issue then ends
up being for us how we define the scope of prevention in the context of
care and treatment. I don\'t think that they are mutually exclusive, as
you suggested a minute ago, but I don\'t think we\'re looking to Ryan
White to suddenly begin to do what CDC is charged to do, and some
others. I would hope that a part of what we would focus on is ‑‑ and
I\'m especially encouraging the idea that a big part of prevention ‑‑
and I love Hank\'s idea of putting a time frame on a goal which will
talk about trying to eradicate this disease. Then we can talk about the
kinds of things that we would want to put in place under the umbrella of
Ryan White that would allow us to make sure that we\'re building the
capacity that allows us to bring into the arena all the players that we
need to effectively respond to the problem.

DR. O\'NEILL: I\'ve got to go.

I think that\'s absolutely correct, that the Ryan White CARE Act is not
a prevention piece of legislation. It provides us with some levers and
some ability to forward policy, and we\'re seriously looking at that.
But we want to be careful and we want to be clear and crisp that this is
a piece of legislation that has a particular focus, and we don\'t want
to lose that, because if we lose that, we lose it at our peril.

It\'s also important to recognize that a tremendous amount of prevention
gets done in the context of care, be that the nurse practitioner taking
the time to talk to somebody about cigarette smoking or sexual behavior,
all the way to fully integrated systems of care between CDC and state
and HRSA-funded activities. It also includes thinking about substance
abuse treatment, which is one of the most important things that we can
do for HIV prevention. By the way, that\'s probably true globally.

So we want to be crisp and not burden. Dr. Parham\'s got those broad
shoulder boards. She\'s got broad shoulders, but she\'s got a lot to
carry already without taking up that expectation that somehow this Act
is going to also handle all the prevention issues. Other agencies and
other departments have that responsibility. But it\'s the integration of
this and looking for those synergies and those points where we really
can find some of the creative solutions to these problems that we need
to really challenge ourselves.

MS. THOMPSON: And I would just say I agree about the integration piece.
Obviously, Ryan White is a \$2.1 billion program, and CDC has its own
prevention monies, over \$700 million working on prevention, but really
making sure that the two complement each other and that they\'re working
in tandem to maximize those benefits. So if Ryan White is there to pick
up as a payer of last resort, as a program that is looking to help
low-income individuals, CDC and HRSA do need to be, as I think they have
been, and maybe more so, really working in tandem to ensure that as
people come in and touch the health care system, that we\'re able to get
them into testing, and if there\'s an unfortunate diagnosis of positive,
that they\'re referred to the treatment piece, but to keep the
prevention efforts obviously high and accelerated if necessary.

MS. SMITH: Thanks, Joe, for being here.

He said he\'d try to get back in a little while, but we\'ll continue on
with our discussion.

Cheryl?

MS. HALL: We\'ve been talking a lot about testing, and I wondered if we
could tie the testing to Ryan White funding. We want to make sure people
are tested, and I\'m not sure how we can tie that into Ryan White
funding.

MS. THOMPSON: Tie testing to Ryan White funding?

MS. HALL: Yes.

MS. THOMPSON: There are prevention efforts that go on in Ryan White
currently. But I think prevention is not just testing. I mean,
prevention is a whole host of efforts, including behavior change and
partner notification and testing. But in looking at prevention
comprehensively, obviously testing is going to be crucial. As we come up
on National Testing Day, which is next Monday, that\'s sort of a focus
right now in making sure that you know your status, which is a majority
of the battle. I don\'t know if you can comment a little bit further.
I\'m not sure if I\'m answering your question correctly.

MS. HALL: I think it\'s a bigger question. I think we\'ll have a
discussion a little later on in terms of how we can really implement
testing as part of treatment. But again, if we\'re into Ryan White, I\'m
just thinking you would have probably done your test by now.

DR. REZNIK: Sticking on the testing theme, and actually a comment I
brought up at the last two meetings and yesterday, I work at a very
large urban hospital, and we have a women\'s urgent care center, we have
an urgent care center, we have an emergency room, and we don\'t offer
rapid testing. Jackie Clements yesterday, who works at a Title III
program, their state doesn\'t have enough money to buy tests. I did talk
to someone from the CDC who says the money goes to the states and the
states disburse the money in the way that they see fit.

I wonder if there\'s a way that we can emphasize or require that a
certain amount of the funds, or percentage of the funds goes to the
purchase of one form or another of rapid testing - I\'m not here to get
one company - and also a way to sort of help break down some of the
barriers that a public health hospital system might face in doing rapid
testing. This is an old CDC initiative that was 10 years old at least,
that the major urban hospitals, especially in the south now, would be a
place where you would catch a lot of people who were falling out of care
and that we could get them into care. So you have two examples. You have
one of the largest public health hospitals in the country, and you have
a Title III program in the south, and neither one of them are able to
afford or put in rapid testing, and I think the direction, if it\'s a
statewide direction, maybe some federal guidance can help us get more
rapid testing into places where it\'s needed. Is there something that we
can do in that realm?

MS. SMITH: Jackie?

MS. CLEMENTS: I appreciate your coming.

David, I will clarify that I work with a community health department,
but it does have a Title III program. But I\'m happy to see that
prevention is being tied in with care, and I think it\'s very important
in the sense that, myself being HIV-positive, I can say that people who
are HIV-positive spread HIV. So we have to have prevention in care so
that we can help people to understand how to live with this disease in a
very responsible manner.

In terms of that also, we see that the disease is increasing sharply in
the south, and the south is crying out for help in terms of care and in
terms of prevention funding. So I hope that that will be addressed as we
look into the future and in trying to eliminate this disease.

MS. SMITH: Dr. Primm?

DR. PRIMM: My concern, Carol, and I\'m greatly concerned about this, is
that there was a report out of North Carolina by Dr. Adamora from the
University of North Carolina, who looked at three counties up in the
north part of the state where prisoners were discharged from prison back
into those counties, and the incidence and prevalence of HIV became
high. In New York City, where I come from, as you know, in Harlem alone,
where a great number of people are discharged and come back from prison,
one in every seven African American men are reported by the health
commissioner as being infected with HIV.

I want something done specifically by this committee, some
recommendations relative to what can happen in the prison system. Is
there some relationship that we can have with the Bureau of Prisons, the
Department of Justice, so that there can be some amelioration of this
problem? Because it seeds our communities, and I\'ll bet you the same
thing is happening all over the south and the southeastern United
States. Mr. McKinnell talked about that a little earlier.

I think that unless we begin to focus this committee and the
President\'s focus on that, it\'s going to be even worse than it is
right now.

REVEREND SANDERS: Just a little footnote to that. In the syphilis
elimination initiative model, the five counties where we targeted to
reduce numbers, one of the most important components in all of our
initiatives was the jails and prisons. We were very effective in driving
numbers down, and it had a lot to do with appreciating the fact that
that was an opportunity to do education and testing. That was very
important.

MS. SMITH: Monica, you\'re next. Oh, I\'m sorry.

MS. THOMPSON: I agree with you, and we\'re definitely looking at the
prison system and how that adversely affects the impact or the spread of
the disease and how the federal government can more effectively ‑‑ I
mean, obviously, some prisoners are incarcerated in a federal prison and
some are in state prisons. But that\'s very much on the front burner of
looking at the spread of the disease.

DR. PRIMM: My point is after the discharge, they come out, they cannot
get Medicaid, so there\'s a break in their treatment even if they\'re on
medication. We need to look at CMS to see can we give them some way in
order to be able to continue their medication so there\'s no break and
so that they become more contagious, et cetera. I think that\'s most
important, too.

DR. SWEENEY: I just wanted to follow up on something that Dr. Judson had
mentioned earlier. In the Prevention Committee, we are trying to have an
overall prevention plan coming out of this committee, and it is because
the piper, he who pays the piper calls the tunes, it is a way to really
forward policy, and there are lots of policies that we think could go a
long way to reduce the epidemic if they were tied to funding, because
people cannot afford not to have federal funding. So they would be
brought into line with best practices, and states need to be given an
adequate amount of time to come up to best practices.

But the funding should definitely be tied to best practices. Many times
when we get data now for HIV and AIDS, we\'re getting it from 33 states.
We should be able to get it from all 50 states because we all should
have a uniform data system, name reporting, doing away with anonymous
testing, testing all pregnant women. There\'s a whole series of things
that can be done that, if we do them, it will follow public health tried
and true practices, and it will be a way of the federal government
having great control over it if we can tie the money and the practices
together.

MS. SHOEMAKER: Carol, I have a question. Would or could Ryan White be
used as an avenue for saturating areas with the message of \"Know Your
Status,\" which combines in my eyes the type of behavior change and
testing as one for taking the responsibility for yourself? Is that
something that would be there, or would that be more in the realm of CDC
or some other avenue?

MS. THOMPSON: Well, I think what we need to think about or have been
thinking about is really not just looking at one avenue to get those
kinds of messages out. I mean, I know that the private sector has been
doing some things in trying to raise awareness, and I think raising
awareness and understanding that HIV is not gone, there\'s still an
epidemic, that we still need to address the issue, yes, through CDC,
through Ryan White at HRSA, through SAMHSA and the programs that they
put out, and really throughout the Department, not only at a federal
level but at a state level, so that people are really much more aware
that they need to know their status regardless of whether they\'re part
of the Ryan White program.

Obviously, Ryan White, if they reach out to 500,000 or 600,000 people,
that\'s wonderful, but we do need to and we are hoping to really ramp up
the awareness.

DR. YOGEV: With an increasing number of patients who are alive, in the
last Ryan White one of the smallest parts was psychiatric and
psychological services. Are you considering expanding that? Because the
numbers are going to expand, especially if you connect it to prevention.
Those services are not supported as well in the current Ryan White. Are
there any thoughts of expanding it?

MS. THOMPSON: We\'re certainly working out the details, but obviously
mental health and substance abuse treatment is key, I think, in so many
aspects of either preventing the spread of the disease and keeping it
under control, anyone who is already HIV-positive. So absolutely, mental
health and substance abuse are important parts of medical services.

DR. YOGEV: The unfortunate thing is they really are connected now,
mental health and substance abuse, and I\'m trying to suggest to
separate them, because the substance abuse is part of the problem.
Mental health is a much bigger part, and there\'s no funding for that
because, at least in my state, they are connected, and you have now a
whole population with a greater amount of mental issues not connected to
substance abuse.

MS. SMITH: Karen, you\'re next.

MS. IVANTIC-DOUCETTE: Thanks, Carol.

A couple of thoughts, and hopefully I will bring them together in some
way.

One of the things, at least in my review of the way Ryan White has kind
of gone forward before, that I\'d like to see removed is this notion of
exceptionalism. We\'re trying to make HIV \-- remove some of the
exceptionalism around this in order to reduce stigma, and I think that
the way the Ryan White programs have been set up has encouraged some of
that by targeting populations and things along those lines, and you\'re
talking about wanting to integrate.

The other thought that we\'ve been talking about is HIV you get on a
personal level, and the treatment needs to be personal. Yet we\'re
putting a public health approach onto some of these things. So when I
hear integration, I think public health. When I think personal care and
treatment, I think holistic, integrated on a much more personal level.
So when I think about Ryan White and care and treatment on a personal
level, we\'ve been still doing too much of the public health piece of
that.

So when you talk about testing, CDC has testing to targeted populations.
But if we moved towards personal health in Ryan White where you
integrate routine testing as wellness, we\'ll figure out how to pay for
the testing if it becomes part of routine care in that personal
perspective.

The other thing we know is one-to-one messages between providers and
patients improves prevention activities, allows ongoing prevention,
those kinds of things. The notion of one-stop shopping, where primary
care providers are providing the holistic care, which they\'re forced to
do now, from HIV to gynecological care to mental health and substance
abuse all within their particular focused visit, I think you would get
better treatment, better prevention, and that notion of that kind of
personal care.

The problem with the way Ryan White seems to me set up is that you still
are fragmenting that on a provider level. If we could get better at
funding central city practices, I think providers would want to do more
of this. But the barriers under their productivity or reimbursement
plans right now, they can\'t do it all, they can\'t come up to best
practice, they can\'t spend the time that it takes, 45 minutes or an
hour, on a patient in order to do all of those various needs. If there
was a method to reimburse that instead of saying, okay, you\'re the
payer of last resort, you need to go to this clinic for this, but you
have to go over here in order to get your mental health or your
gynecological over here or things along those lines.

So on a provider standpoint, I think you have providers that would step
up to the plate to do this if there was a method to allow easy
reimbursement, higher reimbursement, within existing systems that
allowed them to meet the productivity needs that they need to do in
order to survive and provide a central city practice.

The other thing is the patient, removing the patient barriers to primary
care, which means allowing me a certain amount of money so that I can
provide bus tickets to some of my patients to come in, or pay for their
dollar co-pay because I\'m asking them to come in weekly to be seen.
They can\'t come up with a dollar per week to be seen by a provider. So
I think if you began to look at Ryan White as more of the personal
integrated and used the system and then look at the public health a
little differently, it just might be an interesting way to use dollars
more effectively.

MS. THOMPSON: I\'m not sure I completely understand. You\'re talking
about having less exceptionalism, so you\'re talking about people who go
to their regular doctor that they\'re \-- better trained, they\'re
better reimbursed, that there\'s \-- one-stop shopping as far as their
comprehensive medical needs? I\'m not sure ‑‑

MS. IVANTIC-DOUCETTE: I think it\'s a little bit of both. I think, first
of all, having HIV is part of your routine, part of your ongoing
screening for anybody that is in a care practice, but also scaling up
the providers that are caring for patients or things along those lines,
allowing whether it\'s a different reimbursement level, whether it\'s a
different way to begin to allow that care and intervention to happen
without segregating it out.

MS. THOMPSON: So you\'re talking about having more widespread capacity
for providers throughout the country, that if their patient comes in and
they find out that they\'re HIV, that there\'s more providers that are
capable of taking care of HIV patients so that they\'re not ‑‑

MS. IVANTIC-DOUCETTE: I think it\'s multiple level. I think in a rural
area you have to have some primary care providers that are willing to
step up to the plate. I find most primary care providers are not willing
to step up because they don\'t have the time or the ability or the time
to spend in the expertise. I think you still need to have partnership
with infectious disease or HIV-skilled treaters. But right now, the bulk
of the care is in primary care practices with limited amounts of time to
deal with this number of issues. So what happens is the patients get
lost, pieces of their care get lost, and, as a result, you aren\'t using
your medical dollars very effectively.

MS. SMITH: Frank, you were next on the list.

DR. JUDSON: Actually, when I had my hand up, we were still talking about
prisons.

(Laughter.)

DR. JUDSON: Which I think is a big issue that we have to continue to
come back and address. I think where this group probably, and certainly
I, lack the expertise and knowledge about how prisons are funded and
managed at a detailed level, I think most prisoners in America are in
state and county prisons. I know Denver has a jail that takes people for
24 hours. That would be a good place for rapid testing. The county
facility has people for an average, I think, of 30 or 35 days or so. The
more serious crimes and the longer terms are largely at the state level.
I don\'t think we have a federal prison that I know of in Colorado.

So it\'s going to come back to those issues of what the federal
government controls and what the states control and pay for. Prison care
is a huge, almost insurmountable budget demand right now in most states,
but that\'s the challenge, what leverage we have on states, moral,
financial, other ways to assure that nobody is released from prison
without being tested for HIV and, if positive, there isn\'t some
reasonable social follow-through to see that they don\'t just go back to
becoming the source of a continuing epidemic. But I don\'t think you can
do it from any federal jurisdiction that I know of would accomplish
that. I don\'t know how much of state prison care is actually paid for
by the feds. The unfunded mandate is a big deal in most states.

MR. GROGAN: That\'s true, but we don\'t get the data from the federal
prisons either. I mean, we\'ve asked, and it\'s not there. So the state
prisons are one issue, but we do have control over a lot of people who
flow through the federal system, and there\'s no data. We\'ve asked for
it, and nobody in the private sector or CDC seems to have it. There\'s a
rumor of a study coming out of Georgia, but that\'s the first thing
I\'ve heard about.

DR. JUDSON: Well, I\'d suggest before the feds mandate that they take
care of the federal system first, and then show the states how to do it
after.

MS. THOMPSON: I will doublecheck, but I\'m fairly certain that the
federal prisons do test before departure, before release, and I think
they refer. But you\'re right, there\'s some work to be done on the
state and local level.

MS. SMITH: Ted, you\'re next.

DR. GREEN: Actually, when I had my hand up, I wanted to make a comment
following on Dr. Sweeney\'s very reasonable sounding but radical
suggestion. What if we tied AIDS prevention funding to best practices? I
would suggest not using best practices, especially in the international
arena that I know best, but I suspect everywhere. Best practices has
meant what we\'re already doing, what\'s popular. It\'s been based on
consensus rather than some objective outside criteria.

So I would suggest what if we tied AIDS prevention funding to specific
impact outcomes that are agreed upon in advance? Like yesterday, we had
a presentation; there were two AIDS prevention ads that were deemed
highly successful. So I said on the basis of what? Well, they raised
awareness. Is that enough? If behavior change is important, and if one
of the behaviors we\'re promoting is not engaging in casual
multi-partner sex, wouldn\'t it be reasonable to tie AIDS prevention
funding to those kinds of outcomes, surveys that show a decrease in the
proportion of men and women reporting casual multi-partner sex?

So I think it\'s an important and a radical departure perhaps from what
we\'ve all been doing to date to actually tie funding with the kinds of
outcomes that are reasonable, maybe not at the level of HIV incidence
and prevalence, because there are too many intervening variables, but if
we\'re targeting behavior change, let\'s measure those behaviors and
look for change. Thanks.

MS. SMITH: I apologize. I know it\'s difficult because you want to speak
at the moment that a topic is underway, but we also have a number of
people who have already asked to speak. So it\'s not a problem to go
back to some of these issues again and again, because they\'re all
important.

Reverend Sanders, you\'re next on my list.

REVEREND SANDERS: I\'m going back to jails and prisons. I did fail to
say when I spoke the first time that I wanted to say a public thank-you
to Carol for when Carol and Claude Allen came to our meeting a couple of
months ago. That was an especially high point for us, and I think that
some of what you\'re hearing and some of our conversation and our effort
is the by-product of that conversation. So I didn\'t want to miss the
opportunity to say thank you for that.

Two things about jails and prisons, because we\'re dealing with two
dynamics. One is that in one instance the jails and prisons represent an
opportunity in terms of testing, okay? On another level, the jails and
prisons represent a breeding ground, and the strategies are not
necessarily the same in terms of how you deal with that. I think that
Frank\'s point is especially significant in terms of point of entry,
short term, and that kind of thing, I think testing \-- and that\'s
really what worked with syphilis elimination. It was more jails and
prisons that I think allowed us to have some effect there.

But if you deal with it in terms of a breeding ground, it\'s very
important for us to begin to move across departmental lines. We really
need to be involved in conversation with the Justice Department as well,
because then you have to deal with this whole issue of why our prison
populations are growing. If indeed we focus on treatment within the
arena of substance abuse over against the issue of incarceration, it
does help us to cut off that stream into the breeding ground. Little
things are happening, and I was talking to Rosa about this earlier.

I want to applaud the State of Connecticut, which made a very brilliant
move recently in terms of removing the disparity between cocaine
sentencing. It\'s amazing how something that simple has an impact
that\'s very significant upon us dealing with HIV and AIDS, because the
mere fact that they will not have as many people flowing into their
prison system means that the likelihood of the breeding ground
continuing to grow and manifesting itself the way it does is going to be
curtailed.

So it is important for us to begin, and if I\'m not mistaken, one of the
things that we have tried to do in the past is really talk about how
across agencies we need to be able to have input and make suggestions
that can have a tremendous impact upon this, because a lot of the prison
problem could be addressed if indeed we made some adjustments in terms
of policy with regard to sentencing over against incarceration.

MS. THOMPSON: I can do a lot. I don\'t know about changing sentencing
laws, but ‑‑

(Laughter.)

REVEREND SANDERS: I know, I understand. But speak to Justice, just
holler over to Justice, say, hey, we need your help.

DR. JUDSON: Congress still writes the laws.

MS. SMITH: Hank is next on the list. If it seems like it takes a while
to get to you, understand that you\'re here and it\'s in the order that
people raised their hands.

DR. McKINNELL: I have a genetic predisposition to optimism, but there\'s
a couple of things in the reauthorization of Ryan White that really
worry me. One is that our basis for planning for the research we do is
that those currently on therapy, 50 percent, will have failed all
available therapies in the next five years. Now, I hope we\'re wrong. In
fact, I think we might be wrong. But what that says to me is the plans
you put in place today really have to account for a dramatic increase in
the cost of treatment for those currently on therapy, and we also need
to make sure that those treated individuals have access to the medicines
they need when they fail available therapies. So we ought to be very
careful what we do here in our planning.

The second is I\'m very concerned about the very high comorbidity of HIV
and hepatitis C, and I think if we do our job we can make HIV a chronic
disease, as are diabetes and high blood pressure and everything else we
treat chronically, but there really are no good available therapies for
hepatitis C. I don\'t see any on the time horizon that will help us
where I think the problem is going to arise. We\'re looking at maybe a
20-year latency, and if you look at the populations that are alive today
that became infected 20 years ago, that\'s a fairly small population
today, but it\'s growing.

I think here, too, we\'re going to see quite a dramatic increase in the
cost of providing care to those who are currently HIV-positive. So we
could put in place a very good reauthorization that dealt with today,
but we ought to be careful that it also deals with tomorrow.

DR. REZNIK: First, I want to second Hank\'s emphasis on people who are
failing all existing therapies. That\'s something that I\'m dealing with
in my own home right now. There should be, not necessarily through Ryan
White, but there should be some emphasis or some kind of reward for the
companies who take the risk to develop new therapies. I do that for my
personal and very selfish perspective, but I know that there are very
many others in the country who are in the same position that I am, and
it will be a global issue after a while.

I think one thing that hasn\'t been said is that the Ryan White CARE Act
has done incredible things for thousands and thousands of people. It\'s
been a very successful model of care. It\'s been a health care as
opposed to a sick care model.

I also want to stress that this is an extremely complex disease. I had
the honor of speaking at HRSA\'s International AIDS Society Clinical
Care Update a few days ago in New Orleans with a tremendous group of
people. I think I\'m relatively smart, and I was coverwhelmed by the
detail of what people need to know about genetics and pharmacokinetics
and all the different things that are now involved. I\'m always somewhat
concerned when I hear about mainstreaming this disease, because there\'s
already evidence-based research that shows that people living with this
disease who access providers with \-- evidence-based, peer-reviewed
published, excellent work that shows that people who are living with the
disease who access providers who are experienced in providing this care
‑‑ I don\'t remember the exact number, over 50 or something like that ‑‑
had much better outcomes than those that didn\'t; that the level of
knowledge that you need to keep up with, that I try to keep up with on a
daily basis through some of the work of the AIDS education and training
centers and some of the wonderful programs that are out there, it\'s
really very complex.

I know we need to expand our reach to make sure that people in rural
areas have access to this kind of care, but we need to make sure that it
stays at an expert level.

Another point that I want to bring up is that many of our existing
treatment programs, such as the Infectious Disease Program, which I was
so glad that you got to visit, that\'s my home; I\'m there more than
I\'m at my home, actually ‑‑ that our providers are overwhelmed with the
realities of what\'s going on today, that there are more people coming
into care and people are living longer. So even though every part of our
program, whether it\'s mental health and substance abuse, and I have to
say oral health or I lose my oral health card \-- oral health, primary
care, our case managers and all the different people that we have in the
program are involved in some degree in secondary prevention, our main
job is providing care.

I\'d like to see HRSA get some help from the CDC by integrating some of
the CDC programs where you have your large or your Title III programs,
where you know the patients are, and not expect the physician or the
mid-level provider or the dental hygienist or the psychiatrist to do all
of the work, but to have where the prevention expertise is and have them
integrated in, because Ryan White, no matter what kind of changes come
from the administration\'s principles and the Congressional principles,
is a relatively small program in the grand scheme of things, and we can
only ask it to do so much.

So I\'d ask that we do have to integrate treatment, care, and
prevention. I always like working with my colleagues on the prevention
side. But I think we also need to know that that expertise lies at the
CDC. We also need to expand out those people who are able to do testing.
There was a wonderful abstract published at the prevention conference by
Jenny Cleland, who is a dentist at the CDC, and Lauren Patton, who is a
dentist at UNC, showing that if dental health care workers were involved
in testing, that we would bring in a significant number of new clients
into the system of care.

So there are multiple ways of addressing a very complex issue. So to
review, mainstreaming makes me nervous because we have evidence-based
research showing that it doesn\'t work and that our programs are
stretched, and that we need to keep that as a reality when we move
forward.

MS. THOMPSON: One question. When you talk about that mainstreaming makes
you nervous, how do you see HIV different than something else where if
your primary care physician finds out that you\'re HIV-positive, or if
your primary care physician finds out that something else is wrong with
you, as you progress or as the condition requires, that you would be
referred to more and more expert medical care? How does that differ then
in your eyes as far as someone who is HIV-positive? That they would need
immediately different care? I\'m sorry. Am I being clear? No.

DR. REZNIK: Well, no, you might be clear, because the way the Atlanta
EMA works is if you\'re asymptomatic, you haven\'t developed an
AIDS-defining condition or illness, you are seen by our health
departments, and no knock on our health departments but there\'s only a
certain level of expertise that\'s there. As you progress with your
disease, then you come to our program, where you do have this incredible
level of expertise. So if it was just doing testing, diagnosing, and
scaling a patient to see where they are as far as mainstreaming care,
I\'m for that. It\'s once the disease becomes complex.

My mother ‑‑ bless my mother \-- has to deal with me, and that\'s a
whole lot to deal with. She has an internist and about 17 specialists. I
am convinced she\'s at the doctor every other day. I normally call up
with her to get her medical checks. She goes to specialty care because
she needs specialty care, and HIV is such a complex disease that it
requires specialty care on multiple levels. You have to have mental
health specialty knowledge. You have to have substance abuse specialty
knowledge. You have to have oral health specialty knowledge. You have to
have primary care specialty knowledge.

So I think when you\'re talking about asymptomatics coming into care,
hooking them up where they need to go, that kind of mainstreaming is
fine because we want to reduce stigma. But because of the Ryan White
CARE Act, there is a system of expertise that exists in this country
that is unmatched anywhere in the world, and we need to make sure that
we keep that intact and take advantage of the systems that do work.

MS. THOMPSON: So, Karen, how does that wash with what you\'re saying as
far as ‑‑

MS. IVANTIC-DOUCETTE: I don\'t disagree as far as the expertise notion.
If you have a low population, we need HIV experts and those kind of
things. However, I think that most people aren\'t necessarily getting
that, and some of the fragmentation in the way they can access, say in
Wisconsin, we have a whole providers group that meets, all of the
various groups that are providing HIV care. We meet on an ongoing basis.
But the Medical College of Wisconsin, who has ID specialty, every
patient has to have a primary care provider and a GYN provider and a
substance abuse provider. They will only provide the specialty care. As
a result, the GYN person puts a person on contraceptives not knowing
that there\'s an interaction, and they end up pregnant because they
didn\'t know the interaction of the medication.

So I just think that ‑‑ I\'m not disregarding what you\'re saying. I\'m
thinking that primary care providers who are doing HIV expert work need
to be given some kind of ability to scale up the work that they\'re
doing, meaning an easier way to get higher fees reimbursed, productivity
time buy-out, so that they can integrate that care, not replace the
experts. If I need somebody to see ID, I\'m going to send them on to ID
or to GYN. But I don\'t have time to integrate it in that practice. Does
that make sense?

The other thing, too, just a note ‑‑ oh, I\'m sorry. Just the other
piece about that, because we\'ve talked about transmission, there are
increasing numbers of people that are transmitting drug resistance as
primary HIV infection. So they\'re already resistant to many of the HIV
medications, particularly in women. So I think the notion of doing
ongoing prevention within our primary care practices is something that
would be very useful. Does that make sense?

MS. THOMPSON: Yes.

MS. CLEMENTS: I\'ll be brief. We\'ve been talking about testing here,
and we\'ve been talking about routine testing, we\'ve been talking about
rapid testing, and a lot of out folks are being seen in community health
centers, where routine or rapid testing can be difficult just because of
cost. The cost of the test runs \$13 to \$15 per test. Is there any
conversation with the Bureau of Community Health Centers getting them
into the conversation and the funding stream so that some more testing,
routine or rapid testing, can be done at that level?

MS. THOMPSON: The short answer is yes. The community health centers and
the President have put forth an initiative to expand community health
centers greatly. So we\'re certainly looking at and working with HRSA
and the folks that are primarily responsible for community health
centers and looking at how best to integrate with not only existing but
the incoming and new community health centers that are coming up,
because obviously they\'re going to be reaching populations that may not
normally have access to something like that.

MS. SMITH: Mildred?

MS. FREEMAN: I wanted to support what Dr. Primm was saying about making
care available for inmates returning into the population. I find it
alarming that 70 percent of the new cases are in the south. I\'m alarmed
that the HBCUs are located in only 24 states in the country, and most of
them are all in the south. I think that if we provide this care
immediately where the epidemic is disproportionately affected,
especially by minority women, Afro-American women, we cannot wait for a
national policy when the outbreak right now seems to be concentrated in
the south.

So I wholeheartedly support that you include in continued care for
inmates returning to the general population as one thing that we can do
to sort of stop the spread of this epidemic to people of color in the
south.

MS. SMITH: Lisa?

MS. SHOEMAKER: Well, as a person living with AIDS in a rural area, I
just want to reinforce what both Karen and David said. Ryan White I
think could take the stigma away and have HIV become more generalized
into the mainstream, but also utilizing our specialists.

What happened to me just recently was our care specialists are two hours
away. I have one that\'s 30 minutes within my reach and one that\'s two
hours from me. So depending on who is listening to me, that\'s where I
would go. Karen helped me out in just these last couple of months when
they reassigned me a general practitioner or primary care doctor,
because they really don\'t know what to do with me because I\'m not
going into the AIDS mode. I\'m now getting older and going into the old
folks mode and having all the stuff happening that\'s happening there,
but they didn\'t know what to do with me with all the other ailments
because it\'s not pertaining to the HIV/AIDS.

What we\'ve been finding ‑‑ I\'m also a motivational speaker/teacher,
and I go in and teach the kids, and they\'re coming away with more
information about HIV/AIDS than most of our generalized doctors. This is
what\'s scary to me because they have more knowledge, and I say go tell
your siblings and your friends and your grandma and grandpa, and they
freak out when they find out that grandma and grandpa still do it. But
they\'re going and becoming teachers, whereas the doctors, they don\'t
want to touch anything, and this is the problem we have because in the
rural areas everybody is exhausted who is in the HIV/AIDS fight.

We\'ve got, like I said, two caregivers within two hours of each other.
But what happens to everybody in between? The doctor that I have now is
a gem. I feel he listens to me more than even my specialist did. I\'m
getting my needs met. He double-checks all the medication that I\'m
taking, which we had at the Thomas Judd Care Center. We had a pharmacist
and a counselor, but all of that slowly has been dying out because the
money hasn\'t been there. So now it looks like everybody else is going
to have to take up the slack. I\'m saying we need to teach our doctors,
no matter who they are, that they have to recognize HIV and AIDS, and
they have to accept it and deal with it, and appropriately send you on
to who you need to see, whether it be them or somebody else.

But it\'s got to be something that\'s generalized across the board. It
just can\'t be from state to state. It\'s got to be every state.
Everybody\'s got to be on board.

MS. SMITH: Dr. Primm?

DR. PRIMM: We were talking about collaboration and cooperation
particularly among governmental organizations, and I cannot help but
think about SAMHSA, Substance Abuse and Mental Health Service
Administration. And in that agency that the prevention efforts or the
testing efforts for using the rapid test is in the Center for Substance
Abuse Prevention, which is the lead agency in that agency. I think it
ought to be across all of those agencies, the Center for Mental Health
Services, and also the Center for Substance Abuse Treatment as well.

All of them have an opportunity to do testing. Instead of it just coming
out of one particular agency within that agency, I think also that the
Center for Substance Abuse Treatment, when I was in charge of that
center, I had a program with prisons, with the Bureau of Prisons and the
Department of Justice where I actually had monies to go into the prison
system and set up drug treatment programs where people would have a
continuity, if they were drug users, from when they went into prison,
they\'d come right out and go right into another drug treatment program
that was aligned with that prison, whatever that was.

So I think it\'s really important to have these bridges so that there\'s
a continuum of services. Plus, we can start to test, we can start to
treat, and then both substance abuse and the HIV treatment in the prison
system, and to begin to recognize what is the hepatitis C problem. In my
own patient population in New York where I run drug treatment programs,
I have 3,000 patients. Eighty percent of those 3,000 patients are
hepatitis C positive. So we\'re talking about a serious issue here if we
don\'t focus on all these things and begin where we can catch them
early, and that is in the prison system, very early in the jails and
prisons. It\'s most important.

And to insist from your perch that what happens in SAMHSA is across the
board and that there is communication between SAMHSA programs and the
BOP, Bureau of Prisons, and the Department of Justice. I mean, that has
to happen. You can knock those heads together and make that happen.

MS. THOMPSON: I appreciate that. I do think you\'re right. I mean,
obviously, working with prisoners, especially as they approach a release
date and they come back into the society and into the system, you\'re
right, the continuity of care is important. That seems like an obvious
sort of turning point or break point for us to be able to tackle their
health situation so that they don\'t continue to spread the disease. I
agree.

MS. SMITH: Rosa?

MS. BIAGGI: I think that this has been a rather hard to follow session
because of this back and forth between Ryan White and prevention, and I
think that speaks to the confusion that the community will have as we
try to integrate care and prevention. There\'s a lot of players here,
and that comes from the top. I mean, we have CDC, we have HRSA, we have
SAMHSA, and then we have in the community the same thing.

I\'m going to speak mainly around prevention programs, because the
sentiment I hear around the table is that confusion about the CDC
allocating funding to the states and the states doing whatever they want
to do. As director of the AIDS programs in Connecticut, I need to
clarify that point because the CDC does provide guidance on what to do
with the funding, and we have several mandates.

One of them is following the recommendations coming from the CPG, the
Community Planning Group, so that whatever the planning group puts
together for priority populations and priority interventions, it is done
because that\'s a mandate of the CDC that we follow the recommendations
of the Community Planning Group. So indirectly, whatever is being
implemented at the state level is because the CDC is allowing that to
happen.

The state, in communication and coordination with that community,
prepares these plans for prevention. On the other hand, the CDC has been
encouraging ‑‑ and this is like a dichotomy here. We have about two
years ago, when we had the advancing of HIV prevention initiatives,
there were four core elements included there. However, the CDC funded
several across the nation, AIDS services organizations to implement
these new initiatives, and they were really, really mandated to follow
the advancing HIV prevention initiative.

Now, for the jurisdictions, for the states and other jurisdictions, what
we have now, what the states receive is basically just that the CDC is
promoting the implementation of the DEBIs. Those are the Diffusion of
Effective Behavioral Interventions. It is not mandated. It\'s just a
promotion. The CDC is saying, well, we go better with doing away with
just the distribution of pamphlets or condoms and not having a long-term
prevention intervention that could probably result in a very positive
outcome in terms of behavioral change. So they are really encouraging
states to implement the DEBIs.

That is what\'s up to the states to decide, whether they want to go with
that or not, because it\'s not a mandate yet. In Connecticut, I\'m very
proud to say that we just conducted a competitive process for HIV
prevention funding, and under my management we decided that we are not
funding any program that is not part of a DEBI. So we\'re not doing any
outreach just for outreach or distributing condoms just for the sake of
distributing condoms. We are just purchasing services from organizations
that are implementing the DEBIs, or at least programs that have a
procedural guidance.

But again, not every state is doing that, and that\'s where we have
states still doing what has been done for many, many years, in some
instances very effective but hard to prove. So if anything, if we really
want to see these effective behavioral interventions being implemented
across the board with possibly better results for HIV prevention, it has
to come mandated by the CDC directly, because otherwise you have the
states drawn to fund other programs that are not following the epidemic.
So I would encourage the CDC to look into mandating the implementation
of the DEBIs with every single dollar that they put out there for the
jurisdictions.

In terms of the integration of care and prevention, definitely it has to
come also from the top. My experience is from all the federal agencies,
the only one that is really looking, from what I see, at a very
comprehensive spectrum of services, is SAMHSA. They are even
incorporating the HIV testing, using rapid testing and mental health
services and substance abuse. They\'re really looking at that. When you
look at the CDC, you look at testing and DEBIs. When you look at HRSA,
you look at care, care, care. Everything is good, but not one federal
agency is really looking at a comprehensive approach to this, and that
is translating into what\'s happening at the state and local level, a
great fragmentation of services that needs to be corrected from the top.

Thanks.

MS. THOMPSON: One thing I wanted to pick up on Dr. McKinnell\'s comment
about looking at the future. Obviously, you\'re sort of worried about
the next hour, the next day, the next week, what\'s going to happen by
the end of the summer, when is Ryan White going to be reauthorized. But
I\'d be interested to know what are your thoughts not only on ‑‑ I mean,
we\'ve been talking about prevention as it relates to HIV, but what are
your thoughts on really a bigger or a grander scheme of looking at
eradicating, eliminating, reducing extensively HIV from the United
States and hopefully from the rest of the world?

DR. JUDSON: That\'s the very question that we posed to ourselves in the
prevention group and that I hope our paper responds to or answers. We
began with the reality, which is that although the CDC has had a kind of
pull out of the air goal of reducing HIV infection incident cases by 50
percent by, actually, this year, here we are. So rather than being
reduced by 50 percent, if anything there\'s been a slippage in the other
direction.

So we started off by saying whatever we\'re doing, it isn\'t working or
it isn\'t taking us beyond an unacceptable status quo that will add
20,000 to 30,000 new HIV patients or add to the rolls of those living
with HIV, 20,000 to 30,000 patients per year. So we did go back and
consider everything from advertising, counter-advertising, public health
laws, criminal laws, reporting, incentives and disincentives for how
federal monies are spent.

One of the realities now is that as you move towards an entitlement, if
that\'s where things happen to be going for HIV, to me, by the way, I
think that\'s a disaster, because I think the public at some point, the
much larger taxpaying public is going to say why HIV and not all these
other infections that weren\'t even caused by elective behavior? To go
back and say do we want to continue to have almost an open door
entitlement system where we continue to pile on treatment benefits, like
hepatitis C, and where the more patients you have, the more money you
get? There needs to be some way to realign those incentives and
disincentives.

For individuals, the disincentives should certainly outweigh the
incentives for getting HIV or becoming exposed to HIV. For providers,
the incentives for keeping people on treatment and for learning their
potential source of infection and preventing potential subsequent
spread, there should be incentives to spend time to do that. Of course,
at the state level, the incentives really must be there to see that they
know who within their state is at risk for getting HIV now, not 10 years
ago, and who the new infections are, and that they develop a living
prevention plan to adjust to those changes in epidemiology and bring to
bear prevention resources.

DR. SWEENEY: Carol, Frank has gone over a lot of what we did in the
Prevention Subcommittee meeting. I\'m not going to read our two-page
draft to you, but I will ask Anita if it\'s okay if we make it available
to you. But we\'ve gone over many of the issues from policy changes
nationally to responsibilities that we think should be state and local
law, to federal responsibility in terms of moving policies in a certain
direction. It is just a draft, but I would be happy to make it available
to you, because we want to get all of the elephants out of the room.
That\'s Hank\'s word for it, an elephant in the room.

We have addressed a lot of the elephants, and we hope before today is
over we will have had time to address any more that our fellow Council
members have around the table and look at public health law in its
fullest and how it can be brought to bear to help change what has not
been successful. So we\'ll get you a copy of it.

MS. THOMPSON: Great.

DR. McILHANEY: Carol, I think, just to sum it up, for me, there\'s been
one concept that\'s been talked about here more than at any other time,
and it\'s really, really exciting to me. That is that the word
\"eradication\" or \"elimination\" of HIV has been used a lot around
these tables the past two days. Though it\'s been mentioned in the past,
primarily in the past we\'ve talked about prevention and so forth, but
we really hadn\'t talked about eradication or elimination before this
much. So I think that if you combine all of our thoughts about it,
including these that Monica is talking about, that you\'d find that that
probably is becoming our goal.

MS. THOMPSON: Great.

MS. SMITH: Cheryl?

MS. HALL: Carol, I just wanted to go back to something you alluded to
earlier. The President\'s initiative to increase health centers
throughout the country does not offer separate funding for rapid
testing. I think at the present time, if you offer it, you have to
absorb the cost. So at our sites we\'re offering it free, but we\'re
absorbing that cost, and it\'s to anyone walking into the health centers
or, obviously, if you got to the delivery room without getting a test.
So I wasn\'t sure if you were saying that this cost would now be covered
in his initiative or if you\'re saying that there\'s a separate line in
the new Ryan White funding for this. Can you clarify?

MS. THOMPSON: No, I did not mean to say that every new community health
center was going to be equipped with that, but we\'re certainly headed
towards circumstances, as we were talking about availability and
mainstreaming and having people so that folks that community health
centers are their closest and primary opportunity for any kind of health
care, that we\'d certainly like to see more and more that the ability to
test, the ability to counsel, if a person needs to be referred, that
that\'s more and more in the plans of what\'s going on.

MS. HALL: It\'s really certainly a great opportunity, and I think we
should follow through on that with all the health centers that the
President\'s initiative is going to add for the access points.

DR. YOGEV: To your question about the future, it\'s probably not in Ryan
White, but the solution to this infection is a vaccine, and there must
be major efforts through NIH and incentives to industry to produce one.
There is no disease that we\'re able to conquer by changing human
behavior. Look at the efforts at pregnancy, which is somewhere into that
effort, the HIV we\'re talking about. I\'m very much in favor of
everything that was said, but that\'s a definite.

One thing just before that my two colleagues were trying to express.
What we found ou \-- and the Ryan White is a little bit against it as it
stands now \-- is center of expertise that work with the physician.
I\'ll give an example that I\'m familiar with. We saw \-- for example
with a psychologist and a specialist in HIV and social worker, whatever,
and then sent patients to the community and connected to the physician
in such a way that we come to him, he comes to us, or she, and distances
even up to 300 or 400 miles away, that they look after the patient, we
do the expertise part, and let me give you an example why HIV is
different.

In syphilis, you have somewhere around 15 different antibiotics you can
give. In HIV, you do two mistakes and you\'re finished, basically. You
have to start from the beginning the right way, and that\'s why 50
percent of the patients fail within one year with their therapy, because
of this notion, and we already have a problem with them. Ryan White is
separated. Some people go to one place, some people go to another one,
and you need to consider encouraging center expertise that have to share
with others, not to become the center, the ivory tower, but the one
which relates.

Wisconsin has such a thing for children. There is one in Milwaukee who
is taking care of all the southern part of Wisconsin. Their physicians
pick up and send every three months, six months, it depends, just for a
tune-up.

MS. SMITH: I\'d like to ask if anyone, Karen or David, has something to
speak on behalf of your two committees to answer Carol\'s question
related to what we were discussing about how we move forward in terms of
the epidemic. I know that the International Committee has an outline, as
well as the Prevention Committee, in terms of discussion that was based
on that premise, and I don\'t know if, David, you have something from
the Treatment and Care related to that.

DR. REZNIK: You mean for long term?

MS. SMITH: Long term, right.

DR. REZNIK: That was actually going to be our lunchtime conversation
today because we met prior to that. But I beg the chair\'s patience to
make one more comment, if that\'s okay with you.

MS. SMITH: That\'s fine. I\'m just trying to get some answers to
Carol\'s question.

DR. REZNIK: Well, we know we can\'t treat our way out of this disease,
but treatment is an important way of making sure that the disease stays
under control. I\'m bothered by the word \"entitlement\" that was used.
It was in a document I saw earlier, and then, gratefully, it was no
longer there, but it came up today.

There was this wise lady, a patient of mine in 1988 \-- and once you\'re
in my chair you\'re scared to death \-- an African American lady,
administrator at our hospital, who said, David, you know, one day there
is going to be a problem, and the problem is going to be that the
disease isn\'t going to look like you any longer, it\'s going to look
like me. She was very wise.

I\'ve always been concerned that when the disease shifted from a group
that we heard this morning had some kind of political clout and power
and then started addressing others that may not be quite as empowered,
that words like \"entitlement\" would come into play and that the
systems of care that I find to be so exceptional, because I think Ryan
White takes care of at least 70 percent of our patients, I think, are
African American, and I don\'t want there to be any kind of dilution
because it\'s not affecting gay white males that are empowered, such as
myself, and are infecting those that I come here trying to represent,
which is my patient population, who have significant comorbidity
factors, who are dealing with levels of discrimination I never could
understand.

I\'m the child, as I told Dr. McIlhaney as we were walking yesterday, of
a holocaust survivor, someone who knows discrimination. But I can look
German, I can look a certain way. So I have a concern that those core
services that are vital to keeping people healthy, which is important to
eliminating this disease, stay in place during our five-year plan, our
10-year plan, that our prevention activities and our testing activities
get to the point where we do see a reduction and that people will be
living longer until Dr. McKinnell and his colleagues and our people at
NIH come up with a cure for this disease, and not try to pinhole it.

MS. SMITH: Rosa had a comment I think in response, and then Karen.

MR. GROGAN: I promised Carol that I\'d have her out of here at noon, and
we\'re two minutes from there. So if we can wrap this up.

MS. SMITH: So very short.

MS. BIAGGI: My comment is very short, and it\'s around the Ryan White
reauthorization. One of the things that we have now is the ADAP crisis,
and that is experienced almost across the nation. Some states have been
spared from that, including mine, because of the connection we have with
the Medicaid program and the ability for us to participate in the rebate
from the pharmaceuticals. That\'s helping a lot.

However, one of the things that I see as part of the crisis is not just
the money. It\'s also the use of the money. The ADAP for purchasing
medication is a great thing that we have. I would recommend ‑‑ this is
from the experience of Connecticut and other states ‑‑ more emphasis on
supporting treatment adherence, not just medication adherence but the
treatment adherence. I always wondered what is the good of purchasing
the medications if we don\'t have the ability of the clients to follow
through their treatment. It\'s very complicated. Many of our clients
have cognitive issues that will impair their ability to follow through
their treatment.

So we\'re putting the money there for purchasing the medications, but we
are not putting emphasis on medication or treatment adherence programs.
So I would recommend to take the opportunity of the reauthorization of
the CARE Act and look into the option or possibility of mandating the
use of portions, whatever percentage we want to name, to be used for
supporting medication adherence programs for every state that receives
ADAP for medications.

Thanks.

MS. SMITH: I think Karen will have the last word at this point.

DR. McKINNELL: Can I just support that? Will you yield? I\'d just like
to support that very important comment, because the data is very clear
that if a patient on therapy misses one or two doses per month, they
start to lose effectiveness. If they miss 10 doses per month, they might
as well not take the drug. Rather a sobering thought.

MS. IVANTIC-DOUCETTE: Well, on behalf of the International Committee,
first of all I\'d like to thank you, Carol, because one of your opening
comments was about the U.S. having some kind of modeling to the rest of
the world. So those are some of the comments that the International
Committee has been thinking about, or concepts. Key for your thinking
might be, again, that notion of we\'re looking beyond an emergency plan.
Right now we\'re in an emergency plan. Ryan White certainly needs to go
to the next phase. But are we ready for a forever plan? That notion of
entitlement, where are we in the process. So that\'s some of the
thinking.

We cannot be in an emergency mode forever, that the plan that is
developed needs to be marketed. We are the marketing of the U.S. plan,
and we think that it needs to be coherent and effective so that there\'s
impact in what we do in Ryan White on the international PEPFAR players.
Collaboration has been a key point all along, the notion that one size
does not fit all in both plans.

The notion of developing stretch goals, the AIDS-free generation and
HIV-free generation, eradicating HIV throughout the world. Goals drive
behavior and open up new thought processes. So those were some of the
key things, realistic obtainable goals need to flow from the stretch
goals, and that the U.S. really does need a road map for that.

So I think those were some of the key points from the International
Committee, and we thank you for maybe providing that road map.

MS. THOMPSON: Well, I appreciate everyone\'s comments and time today. I
have taken copious notes, and I understand we might have something
transcribed as well. But obviously, as we\'ve discussed before, you all
are out on a day-to-day basis interacting and seeing how the plan, the
program, the CARE Act is put into practice with patients every day. But
I do agree that sort of a long term and bigger thinking is important.

Obviously, as we\'re looking at Ryan White, which is a very important
piece, but one piece of the federal government\'s response to HIV and
caring for those that are HIV-positive in the United States. So we\'re
certainly working and doing our best to come up with changes in the
reauthorization that will really hit those in greatest need throughout
the country.

I appreciate this, and we\'ll certainly look forward to future
conversations.

MS. SMITH: Thank you so much, Carol. We appreciate your being here.
It\'s a lot of time for you to give us, and we\'re pleased if you have
other questions that you\'d like our response to, you can get them to
Joe in writing and we can try to respond to those as well. Thanks so
much.

(Applause.)

MS. SMITH: Now we will break for lunch. Joe can give us instructions.

MR. GROGAN: Yes, we\'re going to break for lunch, and instead of going
into our subcommittee separate rooms, we\'ll reconvene here in this room
at 12:30. They\'re going to bring in lunch right now, but we\'ll start
up again at 12:30.

For members of the public, there\'s a cafeteria across on the other side
of the elevators.

(Whereupon, at 12:06 p.m., the meeting was recessed for lunch, to
reconvene at 12:30 p.m.)

A-F-T-E-R-N-O-O-N S-E-S-S-I-O-N

(12:55 p.m.)

MS. SMITH: I think we\'ll try to start our discussion here, if we can
focus on our motions. Others who have later flights might be able to
change them and get home a little earlier.

In this section of our meeting, what we\'re going to do is consider
first two motions from the International Committee that Karen will be
introducing, representing the International Committee in Abner\'s
absence today; and then we will move to a discussion of the Prevention
Committee\'s outline. Then we also have had an International Committee
outline that\'s been distributed that we\'ll be talking about.

I just wanted to mention before we get into this discussion that the
next few months will be working very hard in each committee to prepare
some documents that will be geared to the November meeting. I wanted to
just alert all of you to the importance of your attention. When you
start receiving some emails with information that we\'re asking you to
review in preparation for our next meeting, please take the time to do
that and to respond and respond thoughtfully, and we\'ll be moving
together as a council as we work individually in the committees and
within the PACHA office.

You\'ll be hearing more about some of the timetables and things that you
can be expecting from your committee chairs. Joe and I and Dr. Sullivan
will be working with the committee chairs on the different documents
that we\'re preparing for November. So I thank you in advance for your
attention to these issues and your feedback, because that will be very
important as we move forward.

Cheryl, you had a comment?

MS. HALL: Just a question. Do we have a quorum to pass any of these
resolutions?

MS. SMITH: I believe so.

MR. GROGAN: Yes.

MS. SMITH: Yes, we do have a quorum.

So we will consider the two motions that are being put forward by the
International Committee, and they\'re both in front of you. Karen, if
you would be so kind as to go through them with us.

MS. IVANTIC-DOUCETTE: Well, thank you, Anita, and thank you, Council
members. I\'m filling in for Abner today, who I\'m sure would do a much
better job here.

The first resolution that the International Committee would like to put
forward is the resolution to eliminate taxes and tariffs on donated
medical tests and other materials used in the diagnosis and treatment of
HIV diseases. This is the resolution that we had that Mr. Bates spoke to
yesterday.

Do I need to read it into the record?

MS. SMITH: No. We simply have to have a motion to approve, and then we
can have discussion, and a motion second.

PARTICIPANT: So moved.

PARTICIPANT: Second.

MS. IVANTIC-DOUCETTE: Is there discussion?

DR. McKINNELL: One that\'s kind of editing. In the second line, I would
talk about provision of drugs, tests and other materials to make it
consistent with the bottom. It\'s just editing. We added \"tests\" here.
We didn\'t up here.

MS. IVANTIC-DOUCETTE: Okay.

DR. McKINNELL: And the second one is when drugs are provided at reduced
prices, free, or at cost, that sort of says the manufacturer has done
their part, and the government needs to do their part, which means not
tax it. But I wonder if we couldn\'t go a step further and make it
applicable to all medicines for HIV testing and treatment. Why just
those that are provided at concessionary prices?

MS. IVANTIC-DOUCETTE: So how would you edit that?

DR. McKINNELL: Well, in the resolution, it applies to free, reduced
price or donor funded medications. I guess donor funded would cover it.
If donor funded means anything used in compassionate use or
non-commercial use, I would say that\'s fine. I suppose that\'s clear.

MS. IVANTIC-DOUCETTE: So leave it.

DR. McKINNELL: Well, I don\'t know what people think.

MS. IVANTIC-DOUCETTE: Monica? And then Frank.

DR. JUDSON: Did we answer Frank\'s question or prepare a proposal?

MS. IVANTIC-DOUCETTE: I think he answered it himself. Is that correct?

DR. McKINNELL: Yes.

DR. SWEENEY: My question has to do with the fact that, again, it\'s AIDS
exceptionalism. What about tuberculosis and malaria and other things?
Why are the medicines for HIV only being singled out?

DR. JUDSON: I would answer that, that if we\'re thinking PEPFAR, because
that\'s really what PEPFAR is, and it keeps it clean and connected and
understandable. I would think that the Global Fund for HIV, TB, and
Malaria would do that, and I would think that any other international
group, Gates or whatever, who is donating medicines, would not accept
them being tariffed or otherwise taxed.

DR. SWEENEY: Then I think we should say it.

MS. IVANTIC-DOUCETTE: We did deal with that in terms of we included
medication. We took out the ARV provision, the HIV provision, because
tuberculosis drugs and malaria drugs are most likely used
internationally in HIV treatment, so we thought that that would be
broadened. But again to Frank\'s point, the thinking was keep it clean,
because you don\'t want it to be open to too many things.

DR. JUDSON: And you don\'t want to give them an excuse, the governments
in some of these countries, to say that you\'re arrogant, you\'ve gone
way beyond your mission, and that we maintain some control over our
taxing policies.

MS. IVANTIC-DOUCETTE: Does that answer it, Monica?

DR. SWEENEY: But PEPFAR is for HIV, tuberculosis and malaria. My point
is at least we should be inclusive enough to include those disease
states that we are addressing in PEPFAR.

DR. JUDSON: It\'s only through the Global Fund that it becomes TB and
malaria as well, right? Or has something changed?

PARTICIPANT: I think that is right, and not malaria outside the Global
Fund.

MS. SMITH: It depends on the country you\'re working in. In some of the
countries, the U.S. government team is requiring you to work on malaria
if you\'re doing PEPFAR because they have certain programs they want
everyone to participate in.

DR. JUDSON: So aside from the Global Fund, the 16 targeted countries,
some of them have ‑‑

MS. SMITH: Not officially. But when you\'re working in that country, you
sometimes are required to do things on malaria or TB.

MS. IVANTIC-DOUCETTE: Abner was the one that drafted this. But for the
International Committee, would we accept as an amendment to this the
treatment of HIV, malaria and tuberculosis?

MR. GROGAN: It\'s one of the things to consider, but we are the Advisory
Council on HIV and AIDS. So to what extent are we getting out of our
purview by talking about other diseases that may be part of other
administration efforts but aren\'t necessarily our issue?

MS. IVANTIC-DOUCETTE: So stick to HIV? Okay.

DR. GREEN: And also the price of ARVs is exceptionally high and is
higher than other drugs.

MS. IVANTIC-DOUCETTE: Well, this is a beginning, and you know that the
other diseases will follow suit, or at least you hope that that
expectation will be there.

Any other further discussion?

DR. YOGEV: Should we add at the bottom the consideration to other
medications should be given so we don\'t say it but we encourage it?

DR. JUDSON: I don\'t think so myself. I think that these are essential
AIDS drugs and we should keep it real clean and simple at this point.

MS. IVANTIC-DOUCETTE: Which it is at this point.

DR. McILHANEY: I just have a question. It makes me feel like I\'m
walking into the surf and don\'t know when it might drop off. Is there
anything that I don\'t understand about taxes and tariffs and stuff that
would affect this, or is this pretty clean and simple to do this?

MS. IVANTIC-DOUCETTE: It\'s very simple. The only thing that we want is
we want the elimination of the taxes and tariffs on medications that are
currently somewhere in the range of anywhere from 16 to 38 percent on
all the medications coming in.

DR. McILHANEY: To me, it\'s a \"duh, of course.\" I mean, I think it\'s
a great idea.

MS. IVANTIC-DOUCETTE: Thank you for your comments on that.

Any further discussion?

(No response.)

MS. IVANTIC-DOUCETTE: Can we call for a vote? All in favor?

(Show of hands.)

MS. IVANTIC-DOUCETTE: Any against?

(No response.)

MS. IVANTIC-DOUCETTE: Any abstain?

(No response.)

MS. IVANTIC-DOUCETTE: The resolution passes unanimously. Thank you.

The second resolution you have in front of you, it still looks like
it\'s in draft format. We will resubmit that. But it calls for ensuring
broader programs of AIDS prevention in implementing the President\'s
emergency plan for AIDS relief. We\'d like to introduce that as a
motion. Would someone like to introduce that?

PARTICIPANT: So moved.

PARTICIPANT: Second.

MS. IVANTIC-DOUCETTE: And I\'d like to have Ted and Ram take the lead on
explaining this. Any questions? It\'s open for discussion.

DR. YOGEV: It\'s just in a draft form, but this is the final.
Unfortunately, we gave it to Joseph at 5:30 yesterday afternoon. But the
way it\'s written with the one correction, that\'s the resolution.

MS. IVANTIC-DOUCETTE: Do you want to spend any time explaining why this
resolution is coming forward at this time?

DR. GREEN: I can make a little comment, yes. We had a so-called ABC
resolution last year or a year and a half ago, whenever it was, and
basically after PEPFAR ‑‑ well, first USAID adopted the ABC approach to
prevention for generalized epidemics. That was in late \'02. Then in
late \'03, the PEPFAR legislation and policy documents also adopted the
ABC approach to generalized epidemics. All we said in that first
resolution was we support the policy. Well, that was not doing very
much. We ought to support the policy of our President and administration
and PEPFAR and so forth.

This one recognizes that it has not been a seamless process of
implementation, that a lot of rank and file people working in developing
countries aren\'t really comfortable with this. They\'re used to doing
AIDS prevention the way it was done prior to the ABC adoption. So this
recognizes that all the elements of the ABC policy are not being
implemented. So all this does is select the impact indicators. All
PEPFAR-funded programs are supposed to have a monitoring and evaluation
component, and there are also impact indicators that have been worked on
by USAIDS and UNAIDS and various organizations. So there\'s a group of
impact indicators that PEPFAR has adopted, and they relate to stigma
reduction and condom promotion, a number of things, discrimination,
mother to child transmission, just to know that we\'re having some
impact, we\'re achieving our goals.

So the ones that relate to A, B and C, the basic ones are here, and what
this motion says is that unless there\'s some exceptional reason, such
as there\'s a project design that only targets commercial sex workers or
only targets youth in primary school, so that by design the first one
would not have an abstinence component, and the second example of the
primary school children would maybe only have an AB component,
abstinence and being faithful. There have been two rounds of
PEPFAR-funded programs that are called AB programs.

But other things being equal, unless there\'s an exceptional reason
having to do with a specific target group, a target audience, or a
project design, then all three of these elements should be in a
prevention program, and these are the basic indicators.

MS. IVANTIC-DOUCETTE: Questions?

Hank, then Monica.

DR. McKINNELL: I thought last night about our general discussion
yesterday and a couple of side discussions we had with my allied doctor,
McIlhaney, and it seems to me that to the ABC we need to add three AAAs,
which is appropriate messages to appropriate groups at the appropriate
time. If I could stretch to add a fourth A, it would be and exclude no
one. I think that kind of captures where I think most of us are, that we
know condom-only programs don\'t work, I think it\'s clear
abstinence-only programs won\'t work, but if we could draft a strategy
that included all three of ABC, and then added appropriate messages to
appropriate groups at the appropriate time and exclude no one, then I
think we\'ve got a comprehensive strategy.

DR. SWEENEY: I like your A cubed program. One question that I wanted to
know is why the age in B was 15 to 49, when so much intergenerational
sex takes place, especially between older men and younger girls? By
putting 49 on it, you exclude a very large number of people who are
sexually active. I think that that should not be the case.

MS. IVANTIC-DOUCETTE: Would you suggest just eliminating the age there?
Why couldn\'t you have the percentage of women and men who have sex with
more than one partner in the last 12 months?

DR. SWEENEY: Right. I would just eliminate the age.

DR. GREEN: Actually, I want to point out that these are from the list of
suggested PEPFAR indicators. You raise a good point, and I think a lot
of us would agree that we should start measuring and targeting younger
youth, maybe starting at the age of 12 rather than the age of 15. But
these are decisions that have been made by PEPFAR, and these are the
indicators, and those are the groups that are being primarily targeted.
So I think we use the ones that already exist. If we want to change
those, maybe we could think about doing that.

DR. SWEENEY: I just wanted to say if we did the A cubed also, it would
also say exclude no one. I think by saying 15 to 49, we\'re excluding a
lot of people. So I don\'t know, because these are already the PEPFAR
indicators, how you would want to handle that.

Just my last comment is, because we\'ve had people talking about
abstinence only and other people talking about condoms only, I was
giving a talk not long ago and there was a former Surgeon General there
who was commenting on my book. Somebody had asked a question to me
during that talk about condoms breaking, and afterwards I was told your
answer was good, but what you should have said is yes, condoms break,
but not nearly as often as vows of abstinence.

DR. JUDSON: My own opinion on the 15 to 49 is that we probably don\'t
want to be changing just for consistency sake, for clarity sake,
established terms. So I would agree with you that people are having sex
under 15 and over 49, but if that\'s the way it\'s established right now
in PEPFAR, unless it\'s a huge problem, we should probably leave it that
way so it continues to communicate consistently.

The other thing is on the appropriate, I tend to, when I edit things
down, I\'m always looking for simpler, shorter ways to say things, and
\"appropriate\" is one of the words that I strike out most often in
medical writing and communicating because it just has a subjective
quality to it. For some people, condoms may be appropriate for all
persons in all situations, and for others they\'re never appropriate,
maybe the Catholic Church.

MS. IVANTIC-DOUCETTE: I\'m going to ask Ram to answer that question, and
then we also have Joe and Lisa that have some questions, and David, and
then Ted, you also want to, and Reverend Sanders.

DR. YOGEV: Frank, I agree with you, and want to disagree on the other
one. You\'re right that, for bureaucratic reasons, it would be nice to
keep the 15 to 49. But being aware that one of the traditions in some
countries in Africa, if you want to get rid of AIDS, you sleep with a
virgin which is less than 15. That\'s where you get your data. We need
to put a standard and not to follow it, and I would highly encourage to
put any age and take the age out completely.

I agree with you on appropriate, and we had a big fight yesterday
because you put \"equal,\" and the word \"equal\" is even more dangerous
in a certain way because then you become too rigid. I thought the
solution is three times appropriate, which is subject to becoming
bigger, which is what you suggested before. Instead of the word
\"equal,\" as you can see, we put the word \"appropriate\" in one place
and leave it there instead of going on and on and on, that if it\'s not
appropriate in time, not appropriate in age, and really pushed the issue
that you need to take all three as much as you can, and you need to tell
us specifically why not and not the other way around.

DR. JUDSON: Well, it\'s also how far you go with a resolution.

MS. IVANTIC-DOUCETTE: Let me just ask this question about ‑‑

DR. YOGEV: It\'s an appropriate question.

MS. IVANTIC-DOUCETTE: Just a question. Can we just strike either
\"equal\" or \"appropriate\" so that the sentence reads \"intended with
balance\" between A, B and C?

DR. GREEN: I think we can.

DR. JUDSON: That\'s what I did. I just left the balance.

MS. IVANTIC-DOUCETTE: Ted?

DR. GREEN: I\'m okay with that.

Can I just make a comment? We\'re trying to decide whether we can change
this 15 to 24.

DR. SWEENEY: 15 to 49.

DR. GREEN: Is this supposed to be 15 to 49? The youth indicators,
though. I want to make the point that a lot of years of meetings and
consultations and reports and so forth have gone into developing these
impact indicators. We could change them, but after all this consensus
around these indicators, part of the reason for that is so that people
can have comparable data. If one project is targeting a younger group,
they wouldn\'t have maybe comparable data with those who have agreed to
these indicators.

I think changing the ages of people targeted for AIDS prevention would
be such an important departure that that should be maybe a separate
resolution. If we think there are reasons to do that, that should be a
separate resolution. But for purposes of this, selecting from the
existing list of recommended impact indicators the ones that closely
relate to A, B and C just to make sure that prevention is broad and
comprehensive. So I would argue for not changing the ages for those
reasons. But if we think it\'s important, make a separate resolution for
that.

MS. IVANTIC-DOUCETTE: Just a comment. Joe is next, Lisa, David. Reverend
Sanders, can you hold off on that thought?

But one question, Ted, for you. You\'re trying to get to the fact that
there\'s more objective, very specific indicators there, right? Would it
be possible to say in that paragraph the indicators should be specific
such as those recommended by PEPFAR? So it doesn\'t just marry it to
those particular things. But I think what I hear you saying is you\'re
trying to capture specific and objective targets. These are not all
inclusive, correct?

DR. GREEN: You mean all the things to do with prevention?

MS. IVANTIC-DOUCETTE: Right, for the outcome that you want.

DR. GREEN: This just relates to the ABC elements, and this is where we
have a lot of controversy and argument and non-implementation of the
policy. Other areas of prevention are not so controversial and you
don\'t need to have a motion from PACHA to say make sure you\'re
inclusive and you do all these things.

MS. IVANTIC-DOUCETTE: Joe?

DR. McILHANEY: I have two items to talk about. The first is exactly what
Ted was saying. My understanding would be that the indicators would
compare a program in Botswana to a program in Kenya so that you have
some idea of the relative impact of those programs. So since these have
been developed over a period of years, personally I think it would be
wise to keep it. I don\'t think it would suggest at all to have those
ages in there that we think it\'s fine for a 60-year-old guy to have sex
with a 13-year-old. So that\'s the first thing.

MS. IVANTIC-DOUCETTE: Your recommendation is to keep it as is?

DR. McILHANEY: Yes, I\'d recommend keeping it as it is.

The second is coming back to a mantra I\'ve had about the whole ABC
thing in the first place, and that is that paragraph 4 I would suggest
taking out. The reason I would say that is that ABC was a very defined
and specific program that had a major emphasis on A and B, and for those
people involved with risky sexual behavior, a C. I think almost
everybody agrees that it was A and B that really caused the dramatic
decline in HIV prevalence and incidence in Uganda.

Basically, all HIV programs around the world, and there are more than
100 countries now that have specific plans that they put in place,
virtually none of them have done what has happened in Uganda. I think
that this whole thing fits very well except that one paragraph. I
personally would keep the appropriate balance in that paragraph we were
talking about earlier, but I just think it\'s really imperative that we
not somehow cloud the fact that there has been one program in the world
that has had a countrywide impact such as we\'ve not seen anywhere else,
ever. So that\'s the only thought I have about that.

I like the resolution. I think it\'s good. I would suggest taking that
fourth paragraph out.

MS. IVANTIC-DOUCETTE: So your recommendation is to strike the fourth
paragraph? Do either of you want to comment?

DR. McILHANEY: And I would leave the \"appropriate\" in instead of
\"equal to.\"

PARTICIPANT: Just to clarify, which is the fourth paragraph?

DR. McILHANEY: It\'s the one \"whereas the ABC approach is not a one
size fits all population and emphasis placed on intervention components
need to coordinate the target population.\" I don\'t disagree with
interventions being custom fitted, but the suggestion to me is that any
time you do something with A and B and C, therefore it\'s going to
duplicate what happened in Uganda, and the fact that there hasn\'t been
but one ABC program that\'s really had the dramatic impact ‑‑

DR. GREEN: Well, just to maybe get the other side of the argument, one
of the PEPFAR countries is Vietnam. Vietnam is a different type of
epidemic. It\'s highly concentrated among IDUs, sex workers and their
clients. So maybe the argument there would be that the condom
intervention would be more important than A or B for sex workers and
IDUs. So that\'s why the emphasis placed on components according to the
different needs of the target population.

DR. McILHANEY: I don\'t disagree with that.

MS. IVANTIC-DOUCETTE: Lisa?

MS. SHOEMAKER: Pass.

MS. IVANTIC-DOUCETTE: David, you\'re next.

DR. REZNIK: I\'ll pass to the Reverend.

MS. IVANTIC-DOUCETTE: Okay. Reverend Sanders?

REVEREND SANDERS: Thank you.

One is I would strongly encourage that you keep the fourth paragraph in,
and you said it, because it speaks to exactly the point you just made,
that it really is the case that there are some variables in countries
that mean that you don\'t necessarily get the same result from the exact
same application. We also know that Uganda\'s success has not been
easily replicated in other places. I mean, it\'s being used, and we\'re
getting some results.

PARTICIPANT: It hasn\'t been tried in too many places.

REVEREND SANDERS: But I\'m just saying we do have one example.

I want to go back to something that was suggested a minute ago, and that
is that I heard you saying that what we want to do is be affirming of
the President\'s position and how he has shaped his message. I think we
can do that and not have this section in here with the indicators. I
think that that could easily be a separate motion, a separate
resolution, because there\'s nothing about I think what the President
was trying to achieve with the spirit of advancing ABC that requires us
to include the reference to the indicators as it is presented here.

I mean, what are we trying to achieve? This is the way I heard you say
it, that we\'re trying to achieve this council being affirmative in
terms of the President\'s position. I think that the President made his
position without the reference to the indicators, and I\'m saying we can
be affirming of his position, understanding that what has clearly come
to be the PEPFAR indicators that are accepted, they are what they are.
They also can change according to the country and what could be some
very different circumstantial realities. So I think we get our impact
without getting bogged down in that argument.

DR. GREEN: Well, if I could answer that, I don\'t think it\'s getting
bogged down. Programs around the world affirm the President\'s and
PEPFAR\'s ABC policy, but then they go ahead and do AIDS prevention as
before there was this policy. This requires programs to actually
implement all of the ABC policy. This whole program is for monitoring
the evaluation standard that is already out there. But if we say all
prevention programs should have all these elements, then we\'re going
beyond saying we agree with the policy or we\'re affirming it.

REVEREND SANDERS: That smacks in the face, though, of your example that
you gave earlier about Jamaica. You see, I think that you have to have
some affirming of the integrity of the countries that we work with and
support. You see what I\'m saying? I appreciated the argument that you
made earlier, and I don\'t think that we necessarily want to
superimpose. There\'s a way in which I think that we have to believe
that there will be some integrity within those countries.

Now, are you telling me that you think there\'s been already so much
evidence of inconsistency in it that you wonder whether or not that can
occur? And if we need to provide some guideline, perhaps there\'s a way
to do it without too narrowly defining the seascape.

DR. GREEN: To make sure I understand you correctly, are you feeling that
this policy or this motion is somehow pushing a model on all the
countries of the world, like a cookie cutter approach, something like
that? Is that what\'s behind your ‑‑

REVEREND SANDERS: That\'s at least a part of what I\'m saying, yes.

DR. GREEN: Well, what I\'m saying is that we\'re already doing that. All
the countries of the world ‑‑ is there one country in the world, any
country in the world that\'s not doing condom promotion, condom social
marketing, community-based distribution of condoms, any country that\'s
not doing voluntary counseling and testing, any country that\'s not
diagnosing and treating STDs? We already have a universal approach. All
the countries in the world are basically doing the same thing. The ABC
policy, I argue, broadens AIDS prevention beyond ‑‑ all those things I
mentioned are risk reduction. This adds risk avoidance to risk reduction
and broadens the approach.

REVEREND SANDERS: I don\'t see anything about what we\'ve said here,
though, that is not mandating exactly what you\'re asking, that ABC be
applied in all situations where the PEPFAR dollars go and that it has to
include A, B and C. That\'s already clearly stated here.

DR. YOGEV: But the unfortunate part is accountability. You go to a
country and you find out that they say they do A, B and C, and they\'re
really doing the A and the B. Just show me what you did in the C and why
you don\'t want to do the C. It\'s quite broad. That\'s not restrictive.
But we thought when we did it to put some accountability and not just
tell me ABC, and then tell me you did it. Show me what you did, how
much, so we see. How can we know if it\'s working or not? Look at the
controversy now about the ABC, even in Uganda itself. From a certain
area in Uganda, somebody comes around and says it\'s only the condom
which works, forget the A and B.

I don\'t personally believe that. I think it\'s important, but not the
only one. So if you have in Kenya versus Uganda versus Thailand I did
ABC, here\'s the change in the A, here\'s the change in B, here\'s the
change in C, very minimum, you have accountability to the program. You
see if it\'s working. That\'s the reason why it\'s here.

MS. IVANTIC-DOUCETTE: Joe wants to go on this subject as well, and then
Hank as well, before we come back to you, Reverend Sanders.

MR. GROGAN: When we were talking about scrapping paragraph four and some
of the discussion when we talked about Vietnam, to me, if we identify a
discrete population like in Vietnam that primarily is prostitutes, and
your intervention is C, that\'s still the U.S. government\'s ABC
approach because you\'ve identified why you\'re only using C. So I
don\'t think that\'s a justification for scrapping paragraph four,
necessarily, or saying that that\'s not in keeping with ABC, because
you\'ve analyzed the situation and you\'ve provided a justification for
weighing it in a certain way. We all agree it would be absurd to go in
there and lecture about abstinence.

So my only suggestion was that maybe you take out the ABC approach,
whereas no approach is one size fits all, an emphasis placed on
intervention components need to vary according to target populations,
recognizing the fact that in some populations it may be weighted more
towards A, others toward B, others AB, and others BC, or others C, or
whatever combinations you want to come up with.

MS. IVANTIC-DOUCETTE: Hank, can you go ahead? I\'ve got you on the list.

DR. McKINNELL: Well, I would keep paragraph four and I would keep the
indicators, for a very practical reason. These are public dollars being
spent, and there\'s a lot of public support. But there are reporters in
the field right now digging for horror stories, and they will come
forward. Unless we have real data to counter that wave of media that\'s
going to wash over us here, I think we could lose the whole program.

Secondly, I think we all know that some of these programs will be more
effective than others, and we need to know that. We need to continue
funding the ones that are successful and stop funding the ones that
aren\'t successful. I don\'t know how you do that without data, so I\'m
in favor of both paragraph four and the indicators.

MS. IVANTIC-DOUCETTE: I have Anita next, and then Frank.

MS. SMITH: I agree with you, Hank, on all the points you just made. I
had a suggestion here in the language where \"appropriate\" replaced
\"equal.\" We don\'t say anywhere in here that I see that we want the
approach to be appropriate based on the country in which the program is
being implemented, and we might be able to fit that in that paragraph.
You could read \"appropriate\" in many different ways, I agree. It\'s
very subjective. But if we qualified it by saying appropriate to the
culture or the country in which the program is being implemented, then
in Uganda you would have something that would be consistent with a
Uganda message, and in another country, Vietnam, you\'d have something
different. But at least we\'re acknowledging that that country\'s
culture needs to be considered, because that\'s not necessarily
happening right now.

We have U.S. government dollars being put into programs that may more
mirror a U.S. approach than they would an approach in those countries.
So it\'s just a suggestion.

DR. YOGEV: That\'s why paragraph four, Ted, in my opinion is so
important, to refer to countries and populations, whatever, and we all
agreed, unless I missed it, to delete the word \"appropriate\" and just
leave \"intended with balance between.\" So the balance will come, but
that\'s exactly what paragraph four is, if you\'re in a different
country, a different culture, a different population. It would address
most of the examples which we\'re giving here as long as you justify the
balance, why you\'re doing it.

MS. IVANTIC-DOUCETTE: Ted, did you want to say anything on that?

DR. GREEN: Not on that, but I just want to amend what I said about
Vietnam. Even though most infections in a country like Vietnam or
Thailand are found in commercial sex and among IDUs, there\'s also the
broad general population that you also want to target with an AB
message.

MS. IVANTIC-DOUCETTE: Just a quick clarification before I move on, and
I\'ve got Frank, Lisa, Monica next, and then Joe. Reverend Sanders, do
you want to come in here at some point? That\'s okay. Just raise your
hand when you\'re ready.

Just a question, though, for Anita. Are you saying no to putting in a
qualifying clause? You wanted to make a suggestion. I\'m not sure I know
what you said.

MS. SMITH: I understand what you\'re saying, and I think it could be
stronger than it is. To me, when I read through it, I didn\'t get the
sense that we\'re saying we want to focus on that culture. I mean, your
language is very broad, and I understand why.

MS. IVANTIC-DOUCETTE: Can you live with it the way it is?

MS. SMITH: Sure, especially knowing that that\'s the intent, but I
don\'t know that it will be read that way.

MS. IVANTIC-DOUCETTE: If you do come up with something that could be
specific, Anita, would you come back on board with that? That would be
great.

Frank, Lisa, Monica, Joe.

DR. JUDSON: I think we continue to get tied up with the ABC. I worry
about what Ed says, too, that you\'re taking almost a proprietary type
product and experience from one country. But the core of that experience
is in B, and it should be for every program that we deal with, that if a
program does not somehow accomplish a very large scale, sustainable
change in exposure behavior, sexual exposure behavior, it\'s probably
not going to work very well. So call it partner reduction, promiscuity
reduction, whatever you want. It\'s got to result in major reductions in
exposure behavior.

Uganda isn\'t our only experience in this area. We\'ve got a huge one
far closer to home in all developed countries where the epidemic was 75
to 85 percent starting off in white, educated gay men predominantly.
There was a 95 percent reduction over three years before we had any
federal program in rates of gonorrhea, syphilis, HIV, hepatitis B, and
it all occurred through unmeasurable but undoubtable change reduction in
numbers of partners, and that\'s what we\'re getting at. You can\'t just
treat gonorrhea to get out of this epidemic without changing sexual
behavior. You can\'t hand out condoms without fundamentally changing
exposure behavior. You\'ve got to get back to the sustainable, cultural,
normative changes in behavior.

MS. IVANTIC-DOUCETTE: Frank, is there some specific language that
you\'re suggesting to offer to the resolution to firm this up? Or is it
acceptable to you with your comments?

DR. JUDSON: It\'s acceptable to me, but I think we have to keep coming
back to really the core issue.

MS. IVANTIC-DOUCETTE: Okay, thank you.

DR. JUDSON: It isn\'t just numbers of partners. If nobody has HIV, it
doesn\'t matter how many partners you have.

MS. IVANTIC-DOUCETTE: Right. Did you need to make any more comments
before we go on? We\'ve got quite a few people left.

DR. GREEN: Frank just said getting back to the cultural normative, and
that\'s interesting. The implication is that in all cultures there\'s
normatively the idea of sanctity in marriage and not having all the sex
partners you want. Is that what you meant?

DR. JUDSON: Oh, no, I didn\'t mean that at all. I meant somehow we need
to come up with programs that change what is normative behavior, like
tobacco smoking in schools is no longer normative cultural behavior.

DR. GREEN: Because in the MSM subculture, there was a normative change.
There was massive behavior change.

MS. IVANTIC-DOUCETTE: This is a great conversation. Thank you. As long
as it\'s okay, I\'m going to ask Lisa to come on. Thank you.

MS. SHOEMAKER: Thank you.

I had a suggestion also for the paragraph that has \"appropriate and
equal.\" What about just slashing \"equal\" and \"appropriate\" and
having in the sentence, \"Be it resolved that PACHA will use its
influence to ensure that the ABC model be implemented, just as the
President and Congress intended, with balance between A, B and C
components.\"

DR. YOGEV: That\'s exactly the change we made here.

MS. SHOEMAKER: It is? Oh, I missed it.

DR. YOGEV: Yes.

MS. SHOEMAKER: Okay. I also wanted to say remember, everybody, AIDS is
ageless and it has no boundaries, period.

MS. IVANTIC-DOUCETTE: Is there a specific language change on that last
one, Lisa?

MS. SHOEMAKER: We did it.

MS. IVANTIC-DOUCETTE: Okay. I\'m going to just let Reverend Sanders jump
in in front of you. Is that okay?

REVEREND SANDERS: I need a question answered, and that is on the
indicators, this last piece that says \"an additional indicator,\" we
have indicators for A, B and C, and then there\'s a piece that comes in
which in our copy is highlighted.

MS. IVANTIC-DOUCETTE: \"And an additional indicator that provides a
measure.\" Is that the one that you\'re on?

REVEREND SANDERS: Right, right. Explain that to me in terms of why we ‑‑

DR. GREEN: Okay, I think I can explain that. The indicator that\'s most
often used and cited, at least in developing countries, and that\'s
where PEPFAR is ‑‑ the denominators are those either involved in
commercial sex or having multiple partners, and that\'s important. But
it\'s also important to have an idea of what all the people are doing in
that population. So it\'s good to have a condom indicator where the
denominator is everyone. So that indicator that is already out there,
condom use, last sex with any type of partner, any category of partner,
is a measure of condom use in the broad entire population rather than in
a subset of those practicing risky sex.

REVEREND SANDERS: The reason I ask is because I didn\'t understand. I\'m
appreciating the need for indicators and accountability, right? But
it\'s inconsistent even with the way in which we have framed the earlier
statements. I understand why you\'re saying you need indicators that
fall within some very exacting parameters. That\'s why I understand why
you didn\'t want to change the ages and the like. Then you throw one in
that seemingly is not driven by that same logic. I mean, are there some
indicators ‑‑ because I wanted to go along with the argument that Monica
raised a minute ago in terms of why did we limit the age, and then I
understood your argument about why you have very specifically said 15 to
24, 15 to 49. But I don\'t see how that holds up here because then we
kind of throw it back out again and say it\'s everybody.

So I don\'t understand that statement in relationship to the indicators.
I understand what you\'re trying to get at. If the objective is
measurable indicators that will allow us to deal with accountability,
that one does not fit in the same way.

MS. IVANTIC-DOUCETTE: So your recommendation, then ‑‑ and I\'m just
going to reply here ‑‑ might be to just scratch that, \"and an
additional indicator,\" and that would leave that clean? Would that be
what you\'re suggesting?

REVEREND SANDERS: That\'s what I\'m suggesting, because if what we\'re
trying to achieve is a method by which we\'re able to measure ‑‑

DR. GREEN: I\'m saying this is an argument to measure condom use in the
entire population, not only with those engaged in high-risk sex.

DR. YOGEV: So can you add 15 to 49 to that paragraph, the one in
brackets?

DR. GREEN: That comes under the 15 to 49.

DR. YOGEV: No. If you read C, number 1 would be percent of women and men
age 15 to 49. Number 2 would be percent of men 15 to 49 reporting sex
with a sex worker. Number 3 would be the percent of responders 15 to 49
years who say they use a condom.

REVEREND SANDERS: That at least makes it a logical indicator in terms of
the way the rest of them work.

DR. YOGEV: I would suggest to take all this black out and just put
numbers in. 1, percent of women. 2, percent of men 15 to 49 years of
age. 3, percent of responders 15 to 49 years of age who say they use
condoms.

DR. GREEN: Yes, take out the black, take out ‑‑

REVEREND SANDERS: I\'m just saying I\'m buying your argument. I think
you\'re right about the indicators and accountability. But if you\'re
going at it that way, then that does not fit.

MS. IVANTIC-DOUCETTE: I think that\'s an excellent suggestion. Does that
work for you?

DR. GREEN: That\'s fine, that\'s great. The reason it was this way is
just for our own thinking. This is one that\'s not often used but ought
to be, but you shouldn\'t go into our language here.

MS. IVANTIC-DOUCETTE: Thank you, Reverend Sanders. So we\'ll strike the
bolded paragraph there and leave it at percent of respondents.

DR. GREEN: Let me make sure we\'re doing this right.

MS. IVANTIC-DOUCETTE: We added the age.

DR. GREEN: So there are three indicators for condoms, and it\'s all age
15 to 49, last sex non-martial, last sex with a sex worker, and then
condom use last sex with any partner.

MS. IVANTIC-DOUCETTE: Okay, I think we have it.

REVEREND SANDERS: So we\'re using the parenthetical part of the
statement and just simply adding to it the age. That\'s it, that\'s it.

MS. IVANTIC-DOUCETTE: So it will all be consistent.

MS. IVANTIC-DOUCETTE: I have Monica and Joe left.

MR. GROGAN: Kit, did you get that?

MS. JOHNSON: Let me just read what I have. So there\'s C1, C2, C3,
percent of respondents aged 15 to 49 who say the used a condom the last
time they had sex of those who have had sex in the last 12 months. Is
that right?

DR. YOGEV: Correct, and also in 2.

MS. IVANTIC-DOUCETTE: The percent of men would also include that.

MS. JOHNSON: Oh, thank you very much.

REVEREND SANDERS: Right, so it will be consistent.

DR. YOGEV: It will be all three.

MS. IVANTIC-DOUCETTE: Is that all set?

MS. JOHNSON: Thank you.

MS. IVANTIC-DOUCETTE: Monica?

DR. SWEENEY: My question ‑‑ there are two questions, and I\'m sure you
all discussed it, but I would like to know how you resolved it. From a
lot of the reading that I\'ve done, and some of you who have gone to
Uganda a lot, Ted and Anita, can address this, one of the major
components of the success in Uganda was the leadership. We don\'t have
anything in this about any leadership.

Secondly, I hear and read that the President Museveni always talked
about a D, and if you don\'t do this, you\'re going to die. Is that
right?

DR. GREEN: Yes, that\'s right. That highlights the fear arousal
component that Frank and I were talking about yesterday and that, in
fact, I was asking one of our speakers about yesterday who mentioned
fear appeals in prevention messages.

MS. IVANTIC-DOUCETTE: A couple of things, Monica?

DR. SWEENEY: So my question was how you dealt with, when you were doing
this resolution, to account for those very important factors that were a
part of it, and if you decided not to, I need to hear what your thinking
was.

MS. IVANTIC-DOUCETTE: The idea was to keep this clean and focused with
one point. We\'ve already had an ABC motion that dealt with some
leadership issues.

The other issue around D, because we have had many discussions around
that, and I think there are several of us that would include D as
development, the other things that contributed besides die, whether
that\'s access to health care, nutrition, things like that. But this was
intended, I believe, to be clean, focused in this particular resolution.

DR. YOGEV: And we talk of the leadership in the last paragraph. That\'s
specifically why we say there has to be prevention. We also address
issues of stigma, gender equality, sexual coercion, so forth, without
basically saying to pay for you in charge of making sure the leadership
will pick it up because it\'s not in their task. But if those will not
be addressed, the A, B and C will not work, and that\'s where the appeal
to leadership through PEPFAR is.

MS. IVANTIC-DOUCETTE: Is that okay with you, Monica?

Okay Joe, you\'re up next. Frank, are you going to \-- anything else
registering after Joe?

DR. JUDSON: Are we seriously getting into D?

MS. IVANTIC-DOUCETTE: No, no. No, we\'re not doing anything. I\'m just
looking to get this passed. So I think Joe is the last one.

DR. McILHANEY: Because Reverend Sanders is so agreeable, he doesn\'t
have to listen to me again.

PARTICIPANT: Call the question.

MS. IVANTIC-DOUCETTE: I\'d like to call the question. Can I have a show
of hands for? Do I have to have a resolution to call the question?

All right, I\'m calling the question. All in favor?

(Show of hands.)

DR. YOGEV: With the changes.

MS. IVANTIC-DOUCETTE: With the changes, correct.

Against?

(No response.)

MS. IVANTIC-DOUCETTE: Abstaining?

(No response.)

MS. IVANTIC-DOUCETTE: Note that the resolution passes unanimously.

(Applause.)

MS. IVANTIC-DOUCETTE: Thank you.

Now, the final thing that I\'d like to introduce, and I\'m just going to
introduce it really, is our concepts that the International Committee
has been working on in terms of key items that we believe need to be
addressed before the end of November.

MR. GROGAN: I just want to say a couple of members did get me comments
late last week that I didn\'t incorporate into this draft. So I\'ll be
doing that on a continuous basis as comments are received and trying to
vet them, and I\'m going to work with Abner to try and set up some more
conference calls with International, obviously with all the
subcommittees, but to try to move this process along more quickly.

MS. IVANTIC-DOUCETTE: It looks like this. It\'s called \"Brief History
of the Global Epidemic to the Unveiling of the President\'s Emergency
Plan.\" It\'s just an outline, and why we\'re introducing it is so that
you have an idea of the items that we\'re working on. If you could
particularly get any comments that you have, if you could get them via
Joe to the International Committee of other things that you\'re thinking
about, but this is a way for us to communicate to you and into the
record.

MR. GROGAN: I just would like to implore the International Subcommittee.
We haven\'t done a good job on conference calls, and we need to make
sure that we have some of these so that we can move this forward.

MS. IVANTIC-DOUCETTE: And we\'d like to agree with you, Joe, on that,
and we\'d like to grab your calendar while the International Committee
is here to at least get some basis on that.

So I don\'t think we need any further action on that. Thank you,
everyone.

(Applause.)

MS. SMITH: Thank you, Karen.

So we just have two more things to discuss here, and I wanted to try to
put a time frame on this so that we can limit our discussion and focus
our discussion.

The first of the issues relates to the prevention draft that you have in
your notebooks. We had said we would discuss that a bit this afternoon
so people could respond, and we\'ll do that, if there\'s comment, for
the next 15 minutes, and then we\'ll move on to a third issue, which is
a letter that would be going from the Council or from the co-chairs
related to a response to the new numbers out of CDC. We felt that since
we didn\'t have our separate subcommittee meetings to be able to craft a
resolution to bring before you, yet we don\'t want to let that go
unresponded to, that we wanted to talk to you about what you would want
included in a letter from the co-chairs to the Secretary of HHS and the
President in terms of our concerns and issues related to the new CDC
numbers. So that\'s how we\'ll finish up our afternoon.

REVEREND SANDERS: Is there a draft?

MS. SMITH: No, there\'s not a draft. There\'s a draft of the prevention,
but there\'s not a draft because we didn\'t have our separate meetings
today.

So I\'ll turn the floor over to Monica to moderate the Prevention
Committee draft discussion.

DR. SWEENEY: Thank you, Anita.

There was a draft that I referred to several times yesterday and asked
everybody to read it overnight if they could so that you could come
prepared to make comments. In light of what we heard this morning from
the wonderful lecturer, we probably have more information to work with
after hearing Edward Richards this morning.

So what I\'m going to do is to ask those of you who read it and who are
ready to comment if you would please start raising your hands so I can
get you down and get to everyone. We\'re starting with Jackie, Hank.

REVEREND SANDERS: Monica, could you just say one more time what we want
to achieve with this?

DR. SWEENEY: What we want to do is we want to roll out here at our next
meeting a comprehensive prevention plan that we can put forward coming
from this committee to the Secretary, and we want everyone to comment on
what we\'ve done and to add ideas, to say whatever you have to say as
long as it\'s brief, because Anita doesn\'t want us to do it long, and
then we will take all the comments back, wordsmith it and get it out to
people to comment on after we wordsmith it and put all the ideas in it
so that we can have it ready to be voted on in November to pass it on.
Is everyone clear about what we need to do?

So we have Jackie, Hank, Karen, Sandra. We missed you this morning.
David, and we\'re sure there will be other people as people say things
who will need \-- counting on the senior leader to have something to
add.

Okay, Jackie.

MS. CLEMENTS: Thank you.

First I want to offer my apologies for my flippant remark about death.
I\'ve been reminded so many times I\'m going to die, I know that it\'s
true someday. But please forgive me. Dr. Sweeney, please.

I do have some comments about the prevention outline. One is in the
legal changes, I wonder if we might suggest that HIV-positive
individuals be required to inform about partners, sex partners or
IV-drug-using partners that they\'ve had for the past two years in order
to do partner notification and case tracking and identifying people who
may have been exposed over the past two years. We do that in North
Carolina.

DR. SWEENEY: Excuse me. Do you have language in North Carolina that is
regulatory?

MS. CLEMENTS: Yes, we do. We have what\'s called control measures for
people who are HIV-positive. One is that you must inform your partner or
IV-drug-using partner that you have HIV, and must use a condom even
though you informed them. Secondly, you must identify to the health care
professionals or the disease intervention specialists that will visit
you, identify your partners for the past two years so that they can be
tracked and notified of their potential exposure. Thirdly, you cannot
donate organs, blood, et cetera, cetera. Fourth, you must have a TB skin
test, and there is a fifth one, which also relates to partner
notification.

Our disease intervention specialists do, within 30 days, go out and
visit the person that\'s been notified because we have name reporting,
and they get that information and then seek their partners for the past
two years in order to inform them of their potential exposure.

MR. GROGAN: Can we get a copy of your language?

MS. CLEMENTS: I can\'t. I can get you a copy of the control measures.

Also, if I might suggest that you said that anonymous testing should be
available but is not preferable. In North Carolina, we fought, and I did
too, actually, to maintain anonymous testing for many years, at least
four I know, with the belief that if we did not have anonymous testing
that people would not come out and test for HIV because they would have
to give their name and identifying information. Though we were able to
put it off for many years, once anonymous testing was abolished, we saw
no change in the numbers of folks that actually came out and tested. Our
testing rates did not change in any significant manner.

So I do believe that anonymous testing, although I fought for it for
many years, I do think now can be a hindrance to identifying those who
are HIV-positive, because once again people may not return for their
test results and you\'re left with a positive test, and because at that
point you no longer can provide partner notification because you don\'t
get that information either. So I might think that you might want to
consider whether you want to maintain anonymous testing.

One last thing is that your messages must be targeted to various
populations, and I sort of thought all populations, be it not just for
now and those who are at risk now but for those who may become at risk
in the future as time moves on, that we should target messages to
everybody, because HIV is also a personal responsibility to keep
yourself safe. You might include \"Prevention for Positives\" and \"HIV
Stops With Me\" somewhere in here to encourage those with HIV to make
sure that they don\'t pass it to other people and somehow figure that in
this outline, and also include somehow getting the bureaus of community
health centers involved, because most of our folks are seen at that
level and we need to get them more involved with testing, which means
they need the money to do so.

DR. SWEENEY: Thank you very, very much for that, Jackie. I wanted to say
this today but Carol was running short of time, when Carol Thompson was
here. Just so all of you know, the National Association of Community
Health Centers already has a blueprint surveyed nationally for community
health centers to find out who has programs, what they have, what they
need, and we\'re getting together a package to help people get a
start-up who don\'t have HIV programs, and it\'s being done by the
National Association.

And thank you very much, because after the lecture this morning I went
from reluctantly saying keep anonymous testing to I was going to start
fighting for no anonymous testing, and thank you for bringing it up. How
long has North Carolina had it?

MS. CLEMENTS: We abolished anonymous testing I know about five to six
years ago.

DR. SWEENEY: Thank you very much.

Hank?

DR. McKINNELL: I have two points. One is second page, third bullet,
using fear as a behavior change. The continuing enslavement language I
personally find very offensive. But more importantly, it would be very
offensive to my 12,000 colleagues who devote their life to finding new
medicines to keep people alive and maybe one day cure this disease. So I
would only ask that we be a little more temperate in our language, and
that applies to all of us, by the way, not just whoever put that
language in.

The second is under .2 on the first page. It\'s bullets 2 through 4,
which seem to be kind of related around advertising. I\'m not quite sure
what we\'re trying to get at here. If whoever has these concerns talks a
little bit, I may be able to craft some language that\'s more precise
that gets at this, because I certainly agree that we shouldn\'t be using
rock climbers as models for HIV drugs, that we need to communicate the
benefits of medicine within the context of the horrors of HIV. I have no
problem with that at all. But I\'m not quite sure what your reaction
would be, for example, to an ad featuring Brent Minor running a
marathon, because it is true that these drugs bring enormous benefit to
some but not all people, and they\'re not the complete answers.

If whoever has these concerns talks a little bit about what you\'re
trying to get at in these four bullet points, I\'ll try to craft some
language that we can all agree to.

MR. GROGAN: I think it\'s easier to conceive of them as two different
concepts. The first two go together, and points 3 and 4 go together. The
message is targeted to various populations, and the model of tobacco is
geared toward government public service announcements and philanthropic
ads.

DR. McKINNELL: So 1 and 2 go together.

MR. GROGAN: Yes.

DR. McKINNELL: Okay, I understand that. And 3 and 4 go together you\'re
saying?

MR. GROGAN: Yes, I think so. I think that there was concern, and I think
some of that was alleviated yesterday based on what some members said to
me. But there was some concern about the direct-to-consumer marketing
images, and that\'s where those two points came out. But maybe some of
the members can ‑‑

DR. McKINNELL: Well, I share that concern. I\'d just like to get a sense
of where everybody is, and then I\'ll try to craft some more precise
language.

DR. SWEENEY: Is that to answer Hank\'s question directly right there?

DR. JUDSON: Pretty much.

DR. SWEENEY: Okay. Could you limit it to answering that so I can
continue on the list? So please answer him. Thank you.

DR. JUDSON: What I think we all agreed on is that anything that intends
to glamorize or minimize the extremely devastating consequences of a
lifelong incurable, expensive, terrible infection with drugs with lots
of side effects is not performing a service. The fear that we were
referring to was the fear that we discussed yesterday, that we want to
make sure that people know that getting HIV, however, will not get them
to where they want to go in life, just like tobacco smoking and the
Virginia Slims type ads.

So we are talking about eliminating promotional glamorization of HIV or
its treatment. We are also talking about going over the other side and
mounting what might be known as counter-advertising where we\'re not
really countering the pharmaceutical industry. What we\'re doing is
countering any advertising or any impression that tends to minimize what
HIV infection is and does. Being enslaved to drugs for those is a
reaction to the advertising that appears to make drugs totally
liberating. In fact, it isn\'t very liberating to have to take the
number of drugs that people do and to be subject to the clock, to
concerns about resistance, to side effects, to when they take their
meals, everything else.

\"Enslavement\" ‑‑ I don\'t know, maybe it\'s not the right term, but it
is being used out there. I have gay activist friends who are out doing
interventions in bathhouses and so forth, and that\'s exactly what
they\'re saying. They\'re saying \"I\'ve got HIV, and a number of my
colleagues do, and this is what I\'m having to do and put up with, this
is how my life is.\"

DR. McKINNELL: Well, I agree with all that, but we have to have some
balance here. There are some benefits to these drugs, too. Brent Minor
does run marathons, which he couldn\'t have done ‑‑ he wouldn\'t be here
if not for these drugs.

DR. JUDSON: But this is the Prevention Subcommittee, and what
information are we trying to get out to motivate people not to get HIV?
Does Brent running ‑‑ this is a different issue altogether. The drugs
have been an enormous success and are clearly lifesaving. But if we\'re
trying to prevent, get somebody to change their fundamental exposure
behavior so they don\'t get HIV, do we show them pictures of Brent
running a marathon or people repelling, or do we show them what a really
bad disease this is and that you need to do everything you can to avoid
it?

MS. CLEMENTS: I would hope that we would show them some of the truth,
too. I\'m not enslaved to any medication. It\'s not always easy, but a
lot of medications aren\'t easy. Cancer medications aren\'t easy. So we
who have them available to us are very grateful, most of us, to be able
to have them, though they may not be always easy.

DR. SWEENEY: I\'ll get your name on the list. Oh, your name is on the
list but you\'re not next. That\'s always difficult, but hold that
thought.

Let\'s see, Karen is next.

MS. IVANTIC-DOUCETTE: Well, just on that point, I agree with Hank. I
think using the term \"enslavement\" is not a good one. I also am
concerned again about language, which is really, really important. But
fear to promote positive behavior change seems bizarre to me. Maybe
something more like negative messages to promote behavior change.
Anyway, it\'s just a language thing that doesn\'t sit well with me. It
feels very punitive, fearful, enslavement. The language isn\'t good. I
think you\'re trying to say we need negative messages to get behavior
change.

But anyway, my key point goes under behavior change. There\'s a lot of
data out about behavior change, and I think the terminology again
becomes important. Under behavior change you have \"individual behavior
must be changed by changing what is accepted as a behavioral norm
through the law.\" I\'d like to suggest that we start thinking about
individual behavior change as personal behavior change, again separate
from public behavior change, which I think you\'re trying to get to when
you\'re trying to change a norm as acceptance within the public
spectrum.

So I think that thinking about that language differently, because I
think changing personal behavior is quite complex, it\'s ongoing, it
needs a variety of strategies, it\'s something different, and as I read
this statement it seems to me that you\'re saying by changing the law. I
mean, it seems too simple. I just wonder again, thinking in language,
saying something in terms of personal behavior change can be impacted by
public interventions such as changing what is acceptable behavioral
norms through legal methods or media messages, which comes in on your
second point, or changing concepts of education about what is
acceptable, so kind of tying in all your bullets under a public
intervention thing, but being very clear about what\'s personal and
what\'s public, that the public intervention does impact on the personal
but not confusing the two.

Then also looking at point number 3 under behavior change where you have
individual behavioral change, but you have consistent messages tailored
for various populations. That seems to me, again, public behavior
change, not personal or individual. So I\'m just thinking about if it
would be helpful, at least it would be helpful to me to kind of think
about those terms differently and the interventions associated with
those.

DR. JUDSON: Let me explain that this is not a resolution. I think the
problem we\'re having at this point ‑‑ and I\'m speaking because I\'m
one of the ones who initiated this. We need a new approach in a number
of different areas so that the newer concepts are listed here. I don\'t
think they\'re expressed well in certain instances, as you pointed out.
But the question is, are these new directions, new initiatives, new
approaches acceptable to the group? If we get the concepts right, then
the specifics and the wordsmithing I think can come out later, like
advertising, as you were saying. What are we trying to communicate to
change people\'s behavior?

When we got into the issue of laws, we were dealing with the subject of
what laws do we need, public health laws to criminal laws, to support
certain behavior change? One of the examples is DUI laws. DUI laws
clearly restrict people\'s ability to go out and drink and drive, but
they change a normative behavior and they result in people thinking real
hard about what\'s to gain and what\'s to lose if they went off drunk.

MS. IVANTIC-DOUCETTE: I\'m not disagreeing with any of your
interventions as you have them, just the language and the way you
conceptualized them, because I think, again, behavior change, education
message and communication contributes very little actually to overall
personal behavior change in this field.

DR. JUDSON: That\'s what we all agree on.

MS. IVANTIC-DOUCETTE: So I guess I\'m just saying that in terms of your
bullet points, yes, they\'re great, the concepts are good. But I think
the way you frame it in language does become kind of important.

DR. SWEENEY: Between personal behavior and public behavior.

Thank you, and we\'re on to Sandra McDonald.

MS. McDONALD: Thank you very much. I, first of all, appreciate that
you\'ve taken the time to develop a strategy, but I must say that your
first statement, that prevention must be the central component of any
effort to combat HIV, makes me feel like there is a contest between
prevention and care. I think \"must be central\" is not appropriate
language to also include care but should be one of the many components,
because again I think it\'s an only statement, and I think the only
statements don\'t work.

I also am appalled and feel that under number 1 the legal changes
absolutely demean people living with HIV. I think all of your words
where you say \"HIV-positive people should\" might need to be \"should
be encouraged.\" If you\'re not running an agency every day and looking
at people living with HIV, most of this is impossible because we\'re in
a fire. We\'re not in a place where we put the fire out and we\'re able
to do this in-depth sort of conversation.

Sure we need contract tracing, but a lot of our folks who have been
addicted for 25 years can\'t remember who they were with last night. So
that\'s the reality of the lives that we live in. I\'m sure your intent
wasn\'t punitive, but this wording actually sounds like it\'s an attack
on people with HIV, and I, for one, would not ever be able to lend my
vote to that language. So I\'d like to work with you and others who
might be interested in drafting some language that we might be able to
present that would certainly represent what you\'re doing. I think
Jackie has already hinted at something that\'s already in law. Also,
soften the attack on people who are positive.

MS. CLEMENTS: Can I respond to that?

DR. SWEENEY: Can you hold that thought?

MS. CLEMENTS: Yes.

DR. SWEENEY: Because we have to get to David, whom I asked to hold a
thought before.

DR. REZNIK: I\'m going back to the discussion between the two gentlemen
on the other ends of the table. We\'re talking about mainstreaming the
epidemic, we\'re talking about eliminating anonymous testing, we\'re
talking about a lot of changes, and I don\'t think while you\'re doing
all of these changes that you can eliminate hope because we have a group
of people that is dealing with this disease who are already used to
stigma and discrimination, but the hope should be based in reality.

So if Brent is the reality, he should be portrayed, and our lovely
southern belle over there should be portrayed, and my partner should be
portrayed. I think that we have to be real there. I thought that was too
much.

The other point that I wanted to make is that I know leadership is
mentioned here, but we need leadership within specific affected
communities to come forward, and whether that is political leadership or
religious leadership or leadership in entertainment, whatever that might
be, then it needs to really be a key part, because it\'s my
understanding that that\'s what helped the great reduction in Uganda.

DR. SWEENEY: Thank you, David.

We have it down, a spectrum of portrayals.

Ted?

DR. GREEN: I wanted to say something about the behavior change bullets.
But as far as the comment that was made about whether prevention ought
to be a central component, that\'s a fundamental principle of public
health, and I\'d say especially when we\'re dealing with a disease where
the treatment is very expensive and long term. I would be in favor of
keeping this for those two reasons.

The first two bullets on behavioral change, Frank made a very important
point a little while ago, and he\'s made it before, which is that
behavior change should be aimed at reducing the number of exposures, and
that is another fundamental principle of public health when we\'re
talking about an infectious disease, whether it\'s measles or mumps or
syphilis or HIV. When you think about it, before recent policy changes,
our programs were not aimed at that, at limiting the number of
exposures.

Risk reduction measures such as male and female condoms and
microbicides, when they\'re working, will not necessarily limit the
number of exposures, whereas partner reduction, monogamy, fidelity,
abstinence, delay, those things do limit the number of exposures, and I
think that\'s such an important point that it ought to be a bulleted
point, that behavior change should be aimed at limiting the number of
exposures.

DR. SWEENEY: That\'s also important because as you increase the number
of exposures, not only the absolute number of exposures but the earlier
you start, which also tends to increase the number of exposures, the
greater your risk. So we will definitely make sure we get it in.

Lisa?

MS. SHOEMAKER: My brain juices are flowing now. At first I thought
everything was good, but now I have a few things I\'d like to see happen
also. One of them is I\'d like to see personal responsibility built into
this, because as a person living with this disease, I have become
responsible for myself in many ways, to take the burden off the medical
field, medical doctors because they\'re overworked; number two, because
I\'m a very aggressive person when it comes to my own care and I know
what\'s best for my body, and I\'m not afraid to say no when I\'m forced
by someone else what they think is best for me when I know it\'s not.

That\'s one of the things, just for behavioral change, for a suggestion,
individual behavior must become personal responsibility by changing what
is accepted as behavioral norms through the law. That\'s just a
suggestion for maybe how we can get \"responsibility,\" that word in
there somewhere.

The other one would be on page 2 under \"Information Gathering and
Analysis,\" somehow getting testing, that HIV must become a routine part
of primary care in the U.S. Everyone should know their status and become
responsible for themselves. That\'s another suggestion.

The second one was I\'d like to see a change in number 2 under
\"Behavioral Change.\" The first bullet says messages must be targeted
to all people, groups or populations. To me, a population or a people
group is the same thing, or an ethnic group. Is that correct, or am I
mistaken? I\'m not sure, because to me population means everybody.

DR. SWEENEY: Just to clarify what that meant, we were talking about the
fact that there needs to be targeted messages for specific populations.
So the message that you would give to a senior group, which is often not
addressed at all anymore, would be different than the message you would
give for a subpopulation of adolescents. So that was our thinking. I
don\'t know how we ended up saying it, but that\'s what the thinking is.

MS. SHOEMAKER: Okay. That I think is fine for targeting various
populations, but it needs to include everybody.

DR. SWEENEY: Yes. The message should be specifically targeted to the
population it\'s hoping to reach and not think that one message is going
to reach everybody.

MS. SHOEMAKER: Okay, right.

DR. SWEENEY: Thank you, Lisa.

Joe McIlhaney?

DR. McILHANEY: Frank said what I was going to say, and that is that we
meant for this to be a concept paper, not a document to be published.
Ultimately perhaps it might become that, but there are a lot of really
significant issues here that I think are really important for us to deal
with.

Sandra, you were talking about how you never could vote for something
like this. Tell me if I\'m wrong, but I would assume that if I have HIV
and I offer myself to you to have sex and I don\'t tell you I have HIV,
that you\'d be highly offended at that.

MS. McDONALD: Well, I have the choice to either have sex with you or
not. It also is my choice.

DR. McILHANEY: Well, if I don\'t tell you I have HIV ‑‑

MS. McDONALD: It\'s still my choice. I\'m not going to take myself away
from making that choice.

DR. McILHANEY: You wouldn\'t care whether I told you I had HIV or not?

MS. McDONALD: I always care. I understand how HIV is transmitted. With
6,000 clients and counting, I certainly understand. But what I was
saying about the language is that all of it sounds so punitive. I\'m
sure that wasn\'t the intent, but it just sounds very punitive, each one
of the points.

DR. McILHANEY: That\'s my point. That\'s my point, that the language may
not read right the way it is right now, but I think probably most of us
would agree with most of the concepts here.

My point is, then, the goal of the committee was to get down to some of
these things that have sort of been elephants in the room that we really
haven\'t ever talked about or maybe haven\'t had time to work through
them so that we as a group can say, look, it\'s time for us to start
treating HIV as what it really is, and that is a disease that we need to
really get serious about, to eradicating.

So I hope that helps some, and maybe what we do is ‑‑ I don\'t know,
Monica. Maybe we work through each of these over the next meeting or
two?

DR. SWEENEY: No, not the next meeting or two. We\'re asking that
everyone ‑‑ we\'re putting down everything that\'s being said. We\'re
going to try and rework it.

There\'s something that hasn\'t been said that I\'m going to ask
everybody in a minute, but we have three more people on the list,
because we need to have a little discussion about it. But what we\'re
going to do is to incorporate what is being said, get it out to you, get
some comments on it, and when we come in November we hope to have it in
a form that we can have it adopted as a prevention plan from this
committee. That\'s what we\'re hoping to do.

Reverend Sanders?

REVEREND SANDERS: I think your last comment, Joe, was very important,
and that is the idea of a concept paper, because I think the real issue
in developing this to a point that we can embrace it as a council is
really going to have to do with language. If you noticed, over and over
again, what Hank said, it really is a matter of language. I would remind
you, though, that when you look at the issue of legal changes, even when
Ed Richards was talking, one of the things he said about what might have
been optimal in terms of being able to control the spread of disease, he
even framed it in terms of being at a period when Draconian powers
existed, and I think that we\'re not talking about reintroducing such an
era.

So one of the things we\'re going to have to do to make this work ‑‑ and
it\'s in his notes. I went back to make sure it was in the slide the way
he said it. What he\'s saying is that ‑‑ I often think that I might make
a good benevolent dictator. But I guess what I\'m saying is we want to
make sure that language does not lend itself to that kind of
interpretation.

Then the other thing we have to do in this ‑‑ and I will help work on
the language here ‑‑ is you want to make sure that you leave nothing
there that lends itself to any kind of selective enforcement. How do you
enforce \-- standards of culpability end up being very difficult to
frame in law. So we\'re going to probably have to get some good legal
minds to help us to make sure that in spirit we say what we\'re trying
to say in this concept paper but in no way introduce the suggestion that
we are advancing a posture that in any way compromises rights as we know
them in this country, and we have to do this all the time.

That\'s the great argument that\'s going on right now with regard to a
lot of the things that were the byproduct of 9/11 and the like. So that
argument is going to always be there. But I\'m saying that we ought to
make sure that we fine-tune in a way that gets us beyond that point.

The last thing is I would hope that in terms of process, that we could
figure out how to do this, and this is strictly a process question, in a
way that does not bring it back in November at a point where it really
has to be a consuming process for this group. I don\'t know if it\'s
going to be the conference calls or what, but I can see a lot of
hard-nosed, tough conversation, as well as language and wordsmithing is
going to have to occur. I just want to make sure that we set some kind
of procedural process that allows that to be done in advance.

MS. SMITH: That was part of what I was referring to at the beginning of
this session where I said you\'d be hearing more from your committee
chairs as to the process, timelines, et cetera, so that we can all be on
track for that.

DR. SWEENEY: It is important, however, mentioning timelines and process,
that you do know that anyone who wants to work with us on this during
this process, which is going to be difficult, know that we have a
conference call the first Friday morning of every month from 9:30 to
10:30, every single month, 9:30 to 10:30 eastern time, and it\'s very
important, eastern time, because we do have people in different time
zones, and we have been doing that for a long time. We will continue to
do it faithfully, and to make sure that everyone knows this, I will ask
Joe to make sure that everybody in the committee has the information
about calling and so forth so that you can participate.

The other thing that you said, Reverend Sanders, and I need to just say
this. I was just writing this to Anita, why we\'re going to take another
few minutes, or needed to. There was a physician working in the center
where I was working taking care of patients with HIV, and there was one
person who came in on four or five different occasions with a new
sexually transmitted disease. We actually lost this doctor over the fact
that nothing was done. He could not deal with the fact that there was no
way to have a person that was knowingly spreading HIV that he was
treating, to patch him up to go out and get another sexually transmitted
disease.

Of course, in the process of him getting a sexually transmitted disease,
he was probably transmitting HIV to someone. So when you say we don\'t
want to re-institute Draconian laws, one of the things that was talked
about this morning is the public health laws that are already on the
records, and there are times when there are people that need to be
subjected to some of those laws. I want us to try and keep our minds
open to the fact that we\'re not criminalizing a disease state. But
there are people, when you use a weapon of ‑‑ there\'s a term for it,
and I will get help.

But there are times when your body can become a weapon of destruction,
and people use it that way. When there are extreme cases of that, we
should have some recourse. So we are going to have to leave it on the
table.

REVEREND SANDERS: Monica, I definitely understand you. If you noticed,
there\'s one thing I said, and that is to make sure we structure what we
say in a way that does not lend itself to the exploitation of selective
enforcement. For instance, the same thing is true in terms of DUI, but
we do know that racial profiling is real. You understand what I\'m
saying? So we have to make sure that in our statement, we do the best we
can, not to lend it to that. But I think you\'re right, there has to be
some accountability.

DR. SWEENEY: Thank you for your caution.

REVEREND SANDERS: To Sandra\'s point, let me also say we need to
structure this such that we do say something about mutual
responsibility, because as much time as we spend dealing with trying to
get out messages of prevention, I would like to think in that scenario
that you proposed, Joe, that Sandra would have also been responsible
enough to say, if we\'re going down this road and I don\'t know any more
than I do about you, that I will take every step I can to guarantee
limiting my vulnerability.

DR. SWEENEY: Jackie?

MS. CLEMENTS: In response to that, I do very much agree with that. I
think we have to promote responsibility. However, I do know that moving
to zero transmission rate for HIV is going to take some tough, tough
changes, and some touch decisions. The language that we have in North
Carolina related to control measures is strong. Now, how we enforce them
is different because they can be difficult to enforce. But it is strong
language, and I tell you, I\'m tired of telling 14-year-old girls they
have HIV, okay?

Now, I got it, and how I got it, that\'s my business, but today is a
different day. We\'ve got to take some strong action. So I think that we
should have some responsibility. People who have HIV must take some
responsibility. Grown folk with HIV must take responsibility not to pass
this to anybody else, and that may not be a good, popular notion.

But another thing, one other thing is where you have fear to promote
positive behavior change, fear not of HIV-positive individuals. I don\'t
know how you\'re going to use fear to promote behavior change and not
let that overflow into fear of people with HIV, and I think you really
need to think about that.

DR. SWEENEY: I have been given my marching orders. Here\'s the story.
Committee members on Prevention can\'t talk. We can\'t talk anymore. I
can only talk to calling people. That\'s what I\'ve just been told.

So Cheryl Hall, then Hank, Karen and Ted.

MS. HALL: I recognize that we have lots of work to do on this document.
However, I do believe that the language in information gathering and
analysis is pretty decent, and I\'d like to make sure that we get that,
just this piece over to Carol Thompson as she prepares the final
document for Ryan White, because there\'s some stuff here that she
really needs to pay attention to.

DR. SWEENEY: Thank you.

Hank?

DR. McKINNELL: Well, as evidence of what many of you said, I guess Karen
started, what\'s important here is language that unites us rather than
divides us. Frank and I, who usually are on different ends of issues,
have now agreed to some language, which I think we would both accept,
and it\'s around this image of pharmaceuticals.

\"In the marketing and advertising of life-saving medications that
benefit HIV-positive individuals everywhere, pharmaceutical companies
should take great care not to detract from important messages of the
devastation resulting from HIV infection, a lifelong, incurable
illness.\" That\'s something I can support. I agree with that, but it\'s
said in a way that doesn\'t ‑‑ it\'s got fair balance I guess would be a
good way to put it. There\'s great benefit, and we can\'t detract from
other important messages.

MR. GROGAN: Hank, if you could give me 100 more pages of that, I could
take the summer off.

DR. SWEENEY: Karen?

MS. IVANTIC-DOUCETTE: Thank you, Monica.

Mine is on the information gathering and analysis, as well. In bullet
number 7, where you have \"data must be shared,\" prisons, the military,
blood banks, I was confused what \"all colleges, not just HBCUs\" meant.

DR. SWEENEY: Historically black colleges and universities, where
there\'s been a lot of media attention about the outbreak of HIV on
historically black colleges. So what that meant was that information
from all colleges about outbreaks of HIV and STDs should be shared, not
just HBCUs.

MS. IVANTIC-DOUCETTE: Okay. I interpreted that differently, like you
wanted the colleges to receive information about the people that were
HIV infected. So again, it goes to language in conveying your thoughts.
So if you could kind of clean that up a little.

DR. SWEENEY: Ted?

DR. GREEN: This is another example of where I had my hand up because of
an earlier comment. This is about accountability and responsibility.

I like what Jackie said, that if we\'re going to bring down infection
rates to zero, we have to make some tough choices and do some things
that we haven\'t been doing in the past. Amen to that.

There was an AIDS summit at Harvard a couple of months ago, and a young
man told a story, which is after he found out he\'s HIV-positive, he\'s
ever since been on sort of a spree, picking up sex partners through the
Internet, having lots of sex partners, not revealing his HIV status,
presumably infecting lots of people, and not one person in that
auditorium of hundreds of people said anything. We gave him a
humanitarian award.

I think we\'ve gone a little bit too far in only considering individual
rights, if you can even construe that as a right to live the lifestyle
you want to live, without balancing it with public health and social
responsibilities. But not one person said anything like maybe that\'s
not such a good idea.

DR. REZNIK: He was given an award for infecting 1,000 people?

DR. GREEN: Yes. I mean, he wasn\'t being given an award for that, but it
had already been planned to give him an award. I don\'t think the
organizers knew what he was going to say. So he said what he said, which
is that he\'s going around infecting people, and the award was still in
the works, so they gave him the award. Everybody clapped. Nobody said,
gee, you\'re killing people.

DR. SWEENEY: We have one more person before you.

David?

DR. REZNIK: Well, I guess I already started my response. That\'s not the
norm. I actually saw a copy of this and think that we need to
concentrate on the norm.

My question is a process question, because Treatment and Care will be
coming up with a similar document, and Prevention is going to have one,
and I assume International is going to have one. I don\'t want to come
to the next full meeting to see a draft. So make sure that we see this
as it goes ‑‑

MS. SMITH: We talked about this. You may have been out of the room. We
will be talking with all committee chairs in the next couple of weeks to
get a timeline and a process in place so that when we come back
together, we will have all had chances to see hopefully multiple drafts
and have many opportunities for input on the language, et cetera.

DR. REZNIK: Can you imagine all the wordsmithing on two pages, and if we
have 100 pages?

MS. SMITH: Oh, I know. That\'s why we started this session with little
discussion about what\'s coming up in terms of the work in the next few
months, between now and our next meeting.

MS. HALL: Could I just recommend that you put, like, Draft 1, 2, 3, as
we keep changing them, so we\'ll know which one is the last one?

DR. SWEENEY: Sandra?

MS. McDONALD: My final comment is I offered at the end of my comments
that I\'d be interested in working with this committee in doing some
language changing. I certainly understand the concept and would be
interested in the changes. Anyone who is insane needs to be known as
insane. Anyone who knowingly goes around and infects anybody is crazy
and insane. My comments weren\'t at all trying to protect people from
disclosing their status to others. We face that every day in one way or
another. But I do want to be a part of working with whoever is on the
committee as we do this language, and I\'d be interested in maybe Jackie
and I working together, seeing what North Carolina uses. Georgia has
similar laws, and we\'ve enforced it as an agency. We\'ve absolutely had
several people locked up, just locked them up if they weren\'t doing the
right thing.

So there are two parts of this equation. I just thought the language was
a little strong and punitive, and I\'d love to work with the committee
on that section.

DR. SWEENEY: We appreciate your joining us, and this is where we will
get it done, with all this input from so many experienced people.

I just wanted to say to what Ted said, I went to a PUSH meeting,
Reverend Jesse Jackson and that group. There was a man who had been in
prison, and he gave the same story, all the people he had been with in
prison. When he was asked whether he used any barriers or anything, he
said of course I didn\'t tell anybody or do anything because I didn\'t
want to be ostracized, didn\'t want to not have fun.

So I do think we have a lot to do. What we\'ve been doing has not
worked. The epidemic is still around and getting worse. So we do know we
need to try some new things, and we\'re looking forward to working with
all of you, and thank you for your input so far.

Back to you, Anita.

MS. SMITH: Hank, you had a comment?

DR. McKINNELL: Like David, I had a process question. It struck me for
some time now that the strength of this group is twofold. One is our
diversity. Second is the trust that we\'ve built up over many meetings
here. It\'s true that a number of us, at least the more active members.
are rotating off of this council at the next meeting. So to David\'s
point, I think we\'ve got a window in time here to actually get
something done, and we\'ve got to make sure our scheduling and meeting
schedule doesn\'t interfere. We need to produce a result by the next
meeting or a number of us won\'t be here.

MS. SMITH: That\'s right, and thank you. That\'s why the timeline. I
know it will be a challenge in many respects, but I think that it\'s
important for us to do it, and I think we can all be pleased with the
result.

One last thing, and I don\'t want to keep you much longer. We went about
an hour over the 15 minutes we were going to spend, but again, because
our concern is that we don\'t want to not respond to the new CDC
numbers, I think it would be a mistake for us to stay silent about that
as a body, yet we don\'t have a resolution crafted to adopt. I wanted
to, first of all, find out if you would be open to a letter going from
the co-chairs to Secretary Leavitt and the President expressing concern
about that, that would touch on some of the issues that we have
discussed here in the last couple of days: routine diagnosis, partner
notification, rapid testing deployment, and grave concern over the
disproportionate numbers in terms of these new numbers of cases.

If you\'re open to us doing that, we\'d like to open the conversation to
other things you would want to have included in that letter.

So I guess the first question is, show of hands, who would be open to
having a letter like that go from the co-chairs?

(Show of hands.)

MS. SMITH: Okay, thank you.

So the second question is, beyond those few things I mentioned that we
know we\'ve discussed, are there other things that you\'d want to be
included in that letter?

Hank?

DR. McKINNELL: Well, I would make two points. I would make a very strong
statement that we are at war with a virus, and we\'re losing. I don\'t
think many people understand that, actually, and the CDC data is
troubling in a number of respects. But the most troubling is if you\'re
a minority woman in the south, you\'ve got a big problem, and I don\'t
think that\'s well recognized either. So to me, those two messages, as
strongly as we can craft them, ought to lead in the letter.

MS. SMITH: Karen? Maybe we can just go around, and whatever someone has,
then it\'s easier, and there\'s not that many of us.

MS. IVANTIC-DOUCETTE: My comment was, just again, on leadership, not
only thinking for the current leadership but suggesting that there now
at this moment in time needs to be a very clear vocal leadership
announcement and that this is unacceptable, and that we are going to be
having to do some changes. And that will also at the stage, I think, for
the paradigm shift that we\'re going to be trying to promote. So again,
encouraging a point in time of vocal leadership that these are just
unacceptable and direction to change the paradigm. Thank you.

MS. SMITH: Cheryl, anything?

MS. HALL: I\'m not sure that we can put too many things in one letter.
So I\'d just have you be mindful of that as we figure out what are the
most important points we want to get across and send a short letter. I
think if we try to get too many points in one letter, we\'ll lose it.

MS. SMITH: Ted?

DR. GREEN: I agree with everything so far. I would say that after making
the point that we recognize that we\'re basically losing the war against
HIV/AIDS, that therefore we understand that we\'re going to have to do
some things differently. So PACHA is engaged in an exercise of what will
we need to do to reduce new infections to zero, and that we hope to have
a document by November to share with the Secretary and the nation.

MS. SMITH: Jackie?

MS. CLEMENTS: As we prepare our document to get infections to zero, I
think we need to make clear that as we\'re making changes and making
those new hard decisions, we\'re not attacking people with HIV but that
we\'re asking for their help in getting this disease under control.

MS. SMITH: Reverend Sanders?

REVEREND SANDERS: I think that it is a matter of saying that we
recognize we have to do some things differently, but I would encourage
you to use much of what we have already developed in this committee to
address the fact that we\'ve made some suggestions, especially as it
relates to the kind of question that Hank was raising a minute ago, and
I think that it just needs to be reiterated and we need to make sure
that that message comes across in very, very effectively.

The other thing in the letter that I think would be very important is to
do exactly as Cheryl was saying, and that is we ought to decide right
now, maybe if we can, and I think you\'re asking us for that, maybe what
the four or five basic points need to be, and I think we might have just
hit them.

I think that we do want to talk about spreading the net for screening as
broadly as we can, and we want to make sure that it\'s effectively done.
I think we want to talk about name-based reporting and frame it in a way
that does not compromise any of the things that we\'ve suggested as
being potentially problematic in it. I think we definitely want to talk
about the issue of racial disparity and the way in which our strategies
have to reflect some new thinking in terms of how we do this, and again
I\'d point you back to that very important resolution that we\'ve
already passed here. I might even make it an addendum to the letter so
it\'s something people could have. Thank you.

MS. SMITH: Thank you.

Sandra?

MS. McDONALD: When appropriate, increased funding for prevention, care
and treatment when and where appropriate.

MS. SMITH: Mildred?

MS. FREEMAN: It has to be short and precise, but I\'d like to add to the
letter that we are losing the war, but this committee is working on a
new strategy.

MS. SMITH: Joe?

DR. McILHANEY: I have about five points here, real quickly. I think that
with that announcement that there\'s more HIV than we all thought in the
country, I think CDC has been saying it\'s an absolutely perfect time
for a letter.

One thing I would say is that the administration is very sensitive to
criticism, and I think we just have to keep that in mind. I know
specifically, for example, in working with Dr. Gerberding, that there\'s
some changes that she would have liked to have made that she literally
could not do because she knew that she\'d be criticized publicly, and
she just couldn\'t do it.

So I think a very reasoned letter saying that because of this new
information and because we are losing, and I would include some of what
Hank said in his wonderful talk at our last meeting about medication is
not going to solve the problem, maybe what he said today, that in five
years 50 percent of the people are not going to be responding to drugs
that are available today, and therefore change is necessary, and that we
are going to be producing some recommendations for some significant
change in the way this is done.

I think what that can do is, first, it can announce that we\'re going to
be doing what we\'re supposed to be doing as PACHA. It can say why
we\'re doing it, and in doing that, then we protect the administration
from criticism that they will get when they change policy, which we all,
I think, know is necessary.

MS. SMITH: Monica?

DR. SWEENEY: With all of the good ideas that have come up, I just want
to reiterate, and someone else has already done it, that we keep the
letter fairly short, that we recognize the work that people working with
us have already done. I don\'t know if we should call anyone\'s name
specifically, like Carol or Joe O\'Neill or somebody, but we should
thank people for the support that they\'ve shown PACHA, and keep it
brief.

MS. SMITH: David?

DR. REZNIK: I think you mentioned rapid testing, anything to overcome
the barriers that states have put in place, that institutions have put
in place, and to think outside the box and have all providers, whether
they\'re Sandra McDonald and her team that already does outreach, or
health professionals or whatever, be involved in testing. We need to
test. As Dr. McKinnell was saying, you need to know your numbers.

MS. SMITH: Thank you.

Rosa, we were just going around talking about a letter, what should be
included in a letter. Did you have anything to add? No? Okay, thank you.

Cheryl?

MS. HALL: Can I just make a comment? I think someone made it either
yesterday or today, which was a conference, a White House conference on
AIDS. It just seems, with the new numbers and all the changes we\'re
planning, it probably would be good timing. Just a suggestion.

MS. SMITH: Thank you.

DR. McKINNELL: You know, some other language that really resonates with
me that may surprise you is I have a feeling we\'re all AIDS activists
now. That may be an interesting way to put it. I never thought I\'d say
that.

REVEREND SANDERS: I\'ll say amen to that. Mission accomplished. Say
mission accomplished.

MS. SMITH: Thank you all so much. I think that brings us to the end of
our time. We\'re early, which is great. It buys us a little extra travel
time, relaxation time.

Joe, were there any announcements for us?

MR. GROGAN: Just two announcements real quickly. I was informed about an
hour ago that our new website is actually live and up and running, if
you want to check it out and give me comments about how to improve it.

Then the fall meeting dates. I may be in touch in the next week or two.
They may be shifting, unfortunately, but I\'ll ask you to give me some
feedback about new dates. They may still hold, but there is some
movement on the part of the Department and maybe the White House to be
more involved in our scheduling and have some more activity around that
fall meeting. So when I ask for new dates or feedback, would you please
let me know as soon as possible so I don\'t schedule something that
provides a conflict for too many members? Thanks.

(Whereupon, at 2:57 p.m., the meeting was adjourned.)