**Presidential Advisory Council on HIV/AIDS**

**Full Council Meeting**

June 15-18, 1998

Madison Hotel

Washington, D.C.

**MINUTES**

**Present**: R. Scott Hitt, M.D., Chair; Stephen N. Abel, D.D.S.; Terje
Anderson; Regina Aragon; Judith Billings; Charles Blackwell, J.D.;
Nicholas Bollman; Jerry Cade, M.D.; Lynne M. Cooper; Rabbi Joseph A.
Edelheit; Robert Fogel; Debra Fraser-Howze; Kathleen Gerus; Phyllis
Greenberger; Nilsa Gutierrez, M.D., M.P.H.; Robert Hattoy; B. Thomas
Henderson; Ronald Johnson; Jeremy Landau; Alexandra Mary Levine, M.D.;
Steve Lew; Miguel Milanes, M.P.A.; Helen H. Miramontes; Rev. Altagracia
Perez; Robert Michael Rankin, M.D.; H. Alexander Robinson; Debbie
Runions; Sean Sasser; Benjamin Schatz, J.D.; Richard W. Stafford; Denise
Stokes; Bruce Weniger, M.D.; and Daniel Montoya, Executive Director for
PACHA within the Office of National AIDS Policy (ONAP). **Present from
ONAP:** Sandra Thurman, Director; Todd Summers, Deputy Director; Brad
Austin, representative from Substance Abuse and Mental Health Services
Administration (SAMHSA); Matthew Murguia, Office on Minority Health
(OMH); Robert Soliz, Health Resources and Services Administration
(HRSA); J. Todd Weber, M.D., Centers for Disease Control and Prevention
(CDC); staff members Julianna Bynoe and Sarah Holewinski; and interns
Dory Cohen, Lisa Gonzales, and Mandi Leissoo.

**Absent**: Michael T. Isbell and Charles Quincy Troupe.

**June 15, 1998**

**Opening and General Council Business**

Dr. Hitt, Chair, opened the Tenth Meeting of the Presidential Advisory
Council on HIV/AIDS (PACHA) with a review of interim activities and
meeting goals. He thanked members, Mr. Montoya, and Office of National
AIDS Policy (ONAP) staff and representatives for their ongoing efforts
in behalf of the Council. Noting that agency liaisons Mr. Austin,
Mr. Murguia, Mr. Soliz, and Dr. Weber will be leaving ONAP soon,
Dr. Hitt stressed the need to quickly find replacements to ensure
continuity in their projects. He also welcomed new ONAP interns
Ms. Cohen, Ms. Gonzales, and Ms. Leissoo.

**The primary focus **of this meeting was to be strategic and long-range
planning through the end of PACHA's charter (July 1999) and the current
Administration (January 2001). Other meeting goals were to study youth
issues, review outstanding issues, and decide on the establishment of a
PACHA Executive Committee.

**Interim Council Activities**

**Needle exchange:** With the President's ban on Federal funds for
needle exchange, PACHA and ONAP must formulate appropriate followup. A
letter from President William J. Clinton to PACHA defining his response
was provided to members, along with media reactions that included
editorials from *POZ* and *The Advocate* (by Dr. Hitt). Several members
had written Mr. Clinton in protest, and a letter to the President from
PACHA has been drafted by Mr. Anderson (see June 18 section).

**Vaccine recommendations:** Dr. Levine, Ms. Miramontes, and Dr. Hitt
attended an ONAP meeting with Dr. Harold Varmus, Director of the
National Institutes of Health (NIH), Dr. Anthony Fauci, Director of the
National Institute of Allergy and Infectious Diseases (NIAID), and
others involved in the International AIDS Vaccine Initiative (IAVI). NIH
is enthusiastic about helping implement the recommendations, including
the addition of a key person at ONAP to coordinate vaccine efforts. In
response to a letter to *Science* magazine which misstated some of the
vaccine recommendations, Dr. Levine and Dr. Hitt drafted a letter to
those who signed the letter. The letter of response became the focal
point of a new process discussion on June 18.

**African-American and Latino issues** have been addressed in a call for
a State of Emergency and in two Subcommittee conference calls. The
issues have been added to all other Subcommittee agendas, and PACHA is
monitoring Department of Health and Human Services (DHHS) and Health
Resources and Services Administration (HRSA) responses to the emergency.

**HIV surveillance:** Progress is seen in the CDC's continuing revision
of its guidelines, and a draft model confidentiality law with respect to
public health information will be issued in the future. New York is
proposing an HIV registry with mandatory reporting and partner
notification. Ms. Fraser-Howze's and other organizations are working to
remove criminalization aspects of the bill. (Ed. Note: Since the
meeting, the New York bill passed, and Mr. Johnson was cited by the
media on concerns about the program.)

**Military HIV personnel policy and HIV-positive health care worker
**issues are being followed by the Discrimination Subcommittee, with
updates to the Council forthcoming.

**Appropriations** issues will be addressed by a new ad hoc Subcommittee
being set up by Mr. Hattoy, who asked for volunteers to serve with the
group. Mr. Bollman complied.

**Youth issues:** Dr. Hitt thanked Mr. Sasser for developing the panel
presentation (see June 16 section for further discussion) and
recommendations that will be moved into Subcommittees for followup.

**Prison issues:** The Subcommittee is working on surveillance, a
national prison summit meeting, and a Federal interagency meeting on
compassionate release.

**Services** has followed the **HIV Cost Utilization Study (HCSUS)** and
development of the CDC National Hotline; Dr. Hitt noted that Ms. Ami
Israel of the CDC would be available at Subcommittee meetings to discuss
the latter.

**Meeting with the Vice President:** Dr. Hitt met with Vice President Al
Gore during another conference and found the Vice President to be
"frustrated" on issues such as needle exchange and HRSA delays on
access-to-care action. He is continuing discussion with the
pharmaceutical industry on drug costs and vaccine research, however.
Dr. Hitt told the Vice President that without his strong leadership,
these issues will languish.

**Long-range strategic planning:** Since the last meeting, the Process
Committee began formulating a plan and brought in outside facilitators
to help develop a process for setting Council priorities through the end
of this Administration. Dr. Hitt introduced facilitators from the firm
of MOSAICA---Emily Gantz McKay, President; Cristina Lopez, Vice
President; and Kayla Jackson, Senior AIDS Specialist. Several
Subcommittees have held conference calls to assess outstanding issues
and ongoing objectives for the process.

**ONAP Update**

Ms. Thurman thanked her staff and outgoing agency representatives and
PACHA members for their support, welcomed new interns, and presented an
update on recent ONAP activities.

**Needle exchange:** Saying the refusal of Federal funding for needle
exchange was not a total defeat, Ms. Thurman told the Council that it
helped move this issue to the front pages for the first time. Seeking a
continuance of the debate, ONAP has met with General Barry R. McCaffrey,
Director of the Office of National Drug Control Policy (ONDCP).
Legislatively, needle exchange has been locked into the Senate Omnibus
Drug Bill in a measure to permanently ban the use of Federal funds, and
a similar bill has passed in the House of Representatives. She stated
that ONAP must be realistic and move forward, but the debate does
continue within the Administration. ONAP was urged to keep the
Administration and agencies involved, and increased pressure on Gen.
McCaffrey was recommended. Dr. Hitt and others thanked ONAP for its
strong and brave stand on needle exchange.

**Appropriations:** ONAP does not believe the current Republican bill
will pass, and the Office will monitor all matters involved with
HIV/AIDS and keep the Council informed during the summer. Mr. Stafford
urged ONAP to include effects of tax cuts on social programs.

**International issues:** Ms. Thurman said that the international
community is willing to work together and is enthusiastic about U.S.
goals for vaccines. More involvement is needed by Members of Congress
with interest in international affairs to help obtain funding for
special projects overseas. To this end, she met with Representative Jim
McDermott (D-WA), Chair of the Congressional Task Force on International
HIV/AIDS. In addition, Mr. Murguia (OMH) facilitated a meeting of the
**Interagency HIV/AIDS Working Group **on international issues, with
presentations by representatives from the Department of State on the
revision of its HIV/AIDS strategic planning and from the Peace Corps.

Noting that by the year 2010 there will be more than 40 million AIDS
orphans, Ms. Fraser-Howze asked if this issue is being addressed in
internationally focused meetings. Ms. Thurman said that it is, along
with programs on AZT for pregnant mothers. As these figures greatly
affect economic, security, and humanity factors in the poorest of
nations, conversations are being held with national security agencies as
well as health organizations, and money is being sought for programs
such as institutions for the orphans. Other countries, even those most
affected, are not willing to own or discuss this problem, especially
when they want to talk about economic development, and it is also
difficult to convince the American people that this is a real crisis.
There is a need to address the issues of orphans, poverty, and
unemployment all over the world. A world summit on AIDS orphans was
suggested. Mr. Stafford urged the President to stay involved in
international issues. Ms. Thurman said that President Clinton is doing
so, and ONAP is working to engage Mrs. Hillary Rodham Clinton and
Mrs. Tipper Gore in the issue of orphans. It was suggested that the
International Issues and Communities of African and Latino Descent
Subcommittees address the orphan issue and formulate specific
recommendations and strategies.

**Vaccines:** The meeting with Dr. Varmus was a great first step toward
cooperation, Ms. Thurman said. It was noted that there has been positive
followup from the meeting participants, including a commitment from
Dr. Donald Francis of VaxGen to participate in a Research Subcommittee
conference call, open to all Council members, on June 23.

**Names-reporting surveillance:** Mr. Summers said that ONAP is working
with the CDC (Kevin DeCock) and the Office of Secretary Donna Shalala on
changes in data collection guidance, and is encouraging a focus on
quality of data rather than how they are gathered. ONAP has also met
with Kevin Thurm, Deputy Director, and Dr. Eric Goosby, Director of the
Office of HIV/AIDS Policy, DHHS, and members of the AIDS community, and
has found alarming problems surrounding the linkage of funds to these
results and a trend toward mandatory testing. Of concern to the Council
is that gaps in the data will affect the true status of AIDS in the
African-American and Latino communities, with testing, funding, and care
reflecting these gaps. Mr. Summers said the CDC understands both the
value and the limitations of the data. Ms. Aragon noted that Mayor
Willie Brown of San Francisco had hosted a national conference on the
creation of non-names-based reporting that included States (Maryland,
Massachusetts, and Hawaii) that have developed such programs.

**Women's issues:** A session with women leaders and philanthropists was
to be held in the White House in June, to help put women and HIV/AIDS on
a larger women's agenda. DHHS is holding many informational meetings on
these issues as well.

**Prison issues:** Mr. Summers said that PACHA has played a major role
in pushing reforms forward within the Bureau of Prisons (BOP) and the
Department of Justice, and ONAP is focusing on prison issues with
Administration officials and the community.

**Health care worker guidelines:** Mr. Summers discussed the results of
a conference call between the Discrimination Subcommittee (Mr. Schatz,
Dr. Abel, and Mr. Montoya) and the CDC. Mr. Schatz thanked ONAP for
setting up the call with Dr. Helene Gayle, Director of the CDC Center
for HIV, STD, and TB Prevention, and those writing the new guidelines.
An internal working draft is due in August, with the final version
possibly available by the end of the year. The CDC will eliminate the
requirement for prospective notification of patients by affected health
care workers, and special review panels and conformity with the
Americans with Disabilities Act may be included.

**Council meeting with the President:** Ms. Thurman said that the
President's Chief of Staff, Erskine B. Bowles, has committed to setting
up a full Council meeting with the President, possibly in September
(discussed further in the June 18 section).

**DHHS Treatment Guidelines:** Mr. Robinson noted that the Congressional
Black Caucus has supported the call for a State of Emergency and raised
questions with DHHS about disparities in health outcomes. The proposed
Treatment Guidelines would be an important opportunity to make
significant changes, and he asked where they stand. Mr. Summers said
that this has stalled at DHHS, partially because of the lack of a method
for information dissemination within the medical community. The document
is overwhelmingly complex and in constant flux, as rapid changes occur
in the disease and treatment science. Underlying this situation is the
question of whether it is worthwhile to disseminate information on a
mass basis to health care workers who most likely cannot keep up with
the changes. The Council insisted that the Guidelines are extremely
important, and Ms. Thurman promised to ask for an update.

**Council member attendance:** Although the Council cannot ask members
who do not regularly attend PACHA meetings to resign, Dr. Hitt said that
individual members can make known their frustrations and opinions to the
persons in question and to the White House.

**Long-Range Strategic Planning Introduction and Overview**

Dr. Hitt introduced the process to assess past Council accomplishments
and determine future desired outcomes and strategies, noting that,
although PACHA's charter is up in July 1999, the assumption is that it
will be reauthorized for another 2 years. (With a new Administration
coming in January 2001, however, a new Council could be chosen.)
Ms. McKay gave details about the strategic planning process and
summarized consensus points that emerged during a preliminary poll of
members: At this stage, it is valuable to focus on a relatively small
number of objectives where the Council can make a difference---goals
that are achievable by PACHA and/or the Administration---and to
concentrate on fewer and more specific recommendations. Achievable
issues should be targeted for the first year (through July 1999), and
all others assigned to a longer-term segment. This raised concerns about
losing momentum on the longer-term issues, but Ms. McKay cautioned
members not to assume that the achievable issues are more important than
the others or that the latter would be ignored. Other issues needing
resolution included the end-of-term Council Progress Report; changes in
how members work together, to allow for more effective operations;
ramifications of Council member protest resignations; and change in the
current direction and structure of the Council. Planning session ground
rules were outlined by Ms. Jackson and accepted by the Council.

Two questions were asked to gauge the current feelings of members: (1)
How do you feel about the ethics of remaining on the Council versus
resigning, and what is your planned response? (2) How should the Council
address the tensions regarding response to the changed face of the
epidemic and issues of race, power, and influence?

**Resignation:** Each member was asked to make a personal statement, and
the consensus was that, although members feel a strong sense of
frustration and disillusionment with the Administration, they will not
resign (28 were not prepared to resign; 1 was not sure; 1 did not
address the issue). The Council can continue to help by monitoring the
Administration (12 mentions); Council members' role as representatives
for millions of people in communities most affected by the epidemic who
have no voice is important (9) and can best be achieved through unity,
rather than acting as individuals; and resignation even by the entire
Council would not make a big enough statement to override the benefits
of remaining. Some (8) could identify conditions that might lead to
their resignation, for example, if they feel that the Council is no
longer effective for the people they represent, or if they believe that
no one is listening. Some suggested that the Council is already being
ignored by the Administration and that nothing is being accomplished.
Others pointed out that, although the Council has not done everything it
wanted to, it has made significant progress in bringing such issues as
needle exchange; access to treatment for minorities, women, and
children; and vaccine development to the forefront, and that it must
continue this work. Members who themselves are persons living with AIDS
noted that just being able to serve on the Council is a "miracle";
Ms. Stokes, whose grandparents helped start the civil rights movement,
said she would not "give up my seat on this bus." (Later in the meeting,
Mr. Fogel, who has called for Council resignation several times, said he
would not resign but would continue to fight the epidemic.) Dr. Hitt
said that the determination of resignation should be based on whether
Council members truly are not being listened to and if they have no more
creative ways to get their message across.

**Response to change in the epidemic:** Several cross-committee groups
met to discuss Council response to the changes in the epidemic and
issues of race, power, and influence. One member of each group
summarized what was said.

Ms. Billings: Money and power remain the most influential factors in
politics and in determining what the Council can accomplish; communities
without these resources cannot do much. Since PACHA cannot bring
millions of dollars to the fight to influence the process, all of us,
regardless of how we came to the Council and what our experience and
biases are, must look realistically at where the epidemic is. We must be
willing to put aside personal issues and be driven by reality to refocus
and do things differently.

Dr. Gutierrez: The main questions are: (1) How can the Council as a
whole operate consistently to put the epidemic in the context of race
and class? (2) How can the African and Latino Descent Subcommittee serve
to facilitate this? Conclusions were: (1) The Council must recognize
that the work of the Subcommittee is changing and expanding. (2) We must
look at how people in all Subcommittees can help. The Council must avoid
single issues that do not represent the true face of the epidemic and
that steer us away from the necessary focus. Structurally, the Council
may need an Executive Committee instead of a Process Committee to ensure
that the core issues are always addressed and to "deprioritize"
recommendations as necessary.

Mr. Hattoy: The concerns are whether all-inclusiveness of particular
communities can reflect general diversity and how this will affect other
groups with specific needs; whether the Council can educate itself, let
alone America, on these issues; and whether all members will feel
comfortable attending meetings of a Subcommittee focused on ethnic
groups to which they do not belong. The Council must concentrate on
African-American and Latino issues, but not all members know how to do
that; there must be an all-inclusive, broad picture of race.

Mr. Schatz: Most members have come to this Council table with a sense of
exclusion; all concerns of sensitivity and exclusion---race, gender,
homophobia, and others---need to be faced by the membership as a whole.
We have to recognize that raising concerns about one group does not mean
excluding others; however, things must be put in context so as not to
exclude certain groups. We need to recognize that there are tensions
among and within groups, and that there is a disparity among members in
terms of power and influence. To balance our efforts we must develop
mechanisms to help those on the Council who have ideas but not the
ability, experience, or confidence to write recommendations or follow
through. We must provide an atmosphere in which these people can ask
other members for help. Ms. Stokes added that the Council must put
principles before personalities and avoid stalling the process with
personal problems. Finally, the Council should not make the same mistake
the President is making---if something is hard, shy away from it.
Mr. Sasser noted that there must be a higher level of trust than now
exists within the Council, and resources need to be shifted to
accomplish what is needed to stay ahead of the game.

Individuals were then asked to comment on issues of concern, primarily
trust within the membership, matters of power imbalance on the Council,
and the need for significant changes in structure and thinking. Some saw
the Council's problems as universal: Rabbi Edelheit wrote that issues of
power and race affecting the Council are indicative of the more
pervasive issues in the community at large. Ms. Miramontes said that the
racist society we live in has contaminated all of us. First we must
acknowledge that and understand that we are trying to do something not
seen in the larger society---overcome these prejudices, then help each
other do it.

Some saw problems within the Council and its structure: Mr. Robinson
said that trust has been betrayed; issues have gotten deprioritized;
things agreed upon have not happened. To move forward, trust must be
rebuilt and some of those priorities must be carried out. Mr. Anderson
reinforced this idea, saying that lip service has been paid to issues
focusing on communities of color. Dr. Rankin noted that the best way to
defeat a group is to split it into warring camps. The Council must be
aware that this could happen within its ranks, and that efforts will be
hurt if issues cannot be discussed openly and honestly.

Ms. Aragon seconded the recommendation for an Executive Committee and
addressed the dynamic of "formal and informal" power on the Council. The
interests of the African-American and Latino communities, as well as the
Subcommittee that represents these interests, have been diminished,
diluted, or dismissed. Dr. Abel said that cross-committee work is
necessary to develop better understanding among cultures and more
effective followthrough. The Council has erred in making recommendations
it assumed would be understood by and have the same impact on all
cultures. The mechanism of recommendations is no longer working well,
and the need for an Executive Committee to coordinate issues and actions
is indicated.

Dr. Weniger felt that the Council needs to move to a more neutral and
facilitative mode of leadership (i.e., Subcommittee Chairs), encouraging
ideas to flow up from the grassroots, rather than being dictative. It
may be time for the less aggressive members to exert more subtle,
healing powers, and for others to recognize that subtlety does not mean
weakness. Dr. Levine said that this Council is unique in its openness
and its common goals, and that it should be an absolute given that
anyone can come to any other member for help at any time.

Ms. Greenberger said that the Council tends to go off on tangents and
needs to focus on a very few achievable issues. To accomplish many of
its recommendations, members have to trust those with access to
resources and the Administration on a regular basis to use these
contacts appropriately. Ms. Fraser-Howze noted, however, that if the
Council looks at the issues from a public health perspective, most will
be race-related. Dr. Cade felt that the Council has avoided the
difficult issues and now must recreate the infrastructure to direct
services to the neediest groups in order to address the disease in the
next decade.

The consensus was that, although primary focus must be directed toward
the African-American and Latino communities, the needs of all other
unique groups must not be forgotten. It was pointed out that the Council
needs to be mindful of other people of color who are affected in this
country. For example, the Native American population, although
relatively small, is disproportionately affected by HIV/AIDS. This is
not just a matter of race but a legal responsibility of this Government
(DHHS and the Indian Health Service), because of the Trust relationship
it has with Native Americans, to include this responsibility in all
efforts to combat this and other diseases. Mr. Blackwell does not want
to be excluded from concerns with other communities of color, or for
others who are not Native American to feel excluded from support to his
community. Mr. Hattoy said that we all have to trust each other, working
together to make sure all groups are considered.

Some members stressed practical issues: Mr. Henderson noted that the
Council must realize it cannot resolve these issues in society at large,
even if they are resolved within the Council itself. He cautioned
against spending too much time working out the process and not
addressing the substance of the issues, noting the limits of Council
time. Dr. Gutierrez said that, in order to accomplish its goals, the
Council needs to understand and use the power and politics issues and
the impact of discrimination that exists within the structure in such
areas as funding.

Mr. Bollman defined the question at three levels: (1) Personal---How can
we make a constructive contribution and draw out the best in everyone on
the Council? (2) Political---How can we best present ourselves to the
President as a unified but diversified factor? (3) Organizational---How
do we operate as a group, between the personal and the political?
Changes are needed with respect to resources, how we organize tasks, and
how we treat each other to round off sharp edges created by too few
resources and too little time.

Reverend Perez made two overarching recommendations: (1) Develop a
checklist that will be applied to every issue and recommendation to view
it from the perspectives of all unique populations---women, youth,
African-Americans, Latinos, Native Americans, white gay men, and
others---acting as a prism representing the total face of the epidemic,
always in front of our faces. (2) Recreate the Council structure so that
every voice is always heard equally.

Dr. Hitt summarized themes in the responses: a need for openness on
differences, dealing directly with issues, and awareness that it is OK
to pass resolutions that do not name every unique group; developing a
process and structure that can more effectively address the issues; and
awareness of our time and resource limitations, leading us to focus on a
few achievable objectives.

**Subcommittee Meetings, June 15**

**Prevention:** Members present were Mr. Robinson, Co-Chair;
Ms. Billings; Ms. Gerus; Mr. Landau; Mr. Milanes; Reverend Perez;
Ms. Runions; Mr. Sasser; Mr. Schatz; and Ms. Stokes. Also present were
Dr. Weber; Tracy Allaman and Vladimir I. Edmondson, AIDS Action Council
(AAC); Ms. Israel; and Ms. Jackson. Discussion focused on long-range
planning.

**Research:** Members present were Dr. Levine, Chair; Dr. Cade;
Ms. Greenberger; Mr. Johnson; Ms. Miramontes; and Dr. Weniger. Also
present were Mr. Murguia; Sunil Iyergar, *The Blue Sheet*; Monica Le,
AIDS Action Council; Margaret Scarlett, DHHS; and Terri Wong, U.S.
Department of State (DOS). An update on microbicide development was
given to members by Penelope Hitchcock, D.V.M., M.S., NIAID; Ann Marie
Corner, President, Biosyn, Inc.; and Polly Harrison, Ph.D., Alliance for
Microbicide Development. A full written report---*Topical Microbicides
Program Update 1997*---also was provided by NIAID to the full Council.

**Services:** Members present were Mr. Bollman, Chair; Dr. Abel;
Mr. Anderson; Ms. Aragon; Mr. Blackwell; Ms. Cooper; Dr. Gutierrez;
Mr. Henderson; Mr. Lew; Dr. Rankin; and Mr. Stafford. Also present were
Mr. Montoya; Dr. Weber; Hushel Contes, HIV/AIDS Bureau; Heidi Ecker,
*AIDS/STD News Report*; Ernest Hopkins, San Francisco AIDS Foundation
(SFAF); and Ryan LaLonde, Native Affairs and Development Group (NADG).
The Subcommittee was briefed on the Ryan White CARE Act reauthorization
by John Palenick, Ph.D., HRSA; HIV-Positive Health Care Worker
Guidelines by Dr. Weber; and Native American issues by Mr. Blackwell.

**Subcommittee Meetings, June 16**

**Discrimination:** Members present were Mr. Schatz, Chair;
Mr. Henderson; and Mr. Johnson. Discussion centered primarily around
priority issues for strategic planning.

**International Issues:** Members present were Mr. Anderson;
Ms. Runions; and Dr. Weniger. Also present were Victor Barnes, CDC/DHAP;
Paul Boneberg, Global AIDS Action Network (GAAN); Cowen Devine, SAMHSA;
Kate Gorney, American Bar Association (ABA); Susan Kalagher and David
Kinch, NCADI/SAMHSA; and Terri Wong, DOS. Nancy Carter-Foster, DOS,
briefed the Subcommittee on the revised HIV/AIDS Strategic Plan, saying
that the final version was expected by the end of the year.

**Communities of African and Latino Descent:** Members present were
Ms. Fraser-Howze and Reverend Perez, Co-Chairs; Ms. Aragon; Dr. Cade;
Rabbi Edelheit; Dr. Gutierrez; Mr. Milanes; and Mr. Robinson. Also
present were Mr. Montoya, Mr. Murguia, and Ms. Leissoo; Ms. Ecker;
Ms. Israel; Martin Ornelas-Quintero, National Latino/a Lesbian and Gay
and Bisexual and Transgender Organization (LLEGO); Eva Seiler, CDC; and
Monsanto Alf, National Black Leadership Commission on AIDS (NBLCA). The
Subcommittee discussed long-range planning, concerns with the
relationship between ONAP and PACHA, a conference call on Latino issues,
the Harvard AIDS Institute study, an African-American issues update, and
Subcommittee structure. Mr. Murguia reported on the DHHS Race and Health
Initiative National Minority HIV Plan and the President's Initiative on
Race. In response to Council concerns about focusing attention on all
racial/ethnic issues, the group changed its name to Subcommittee on
Racial and Ethnic Populations.

**Prisons Issues:** Members present were Mr. Landau, Chair; Dr. Abel;
Ms. Billings; Mr. Blackwell; Dr. Cade; Ms. Cooper; Ms. Gerus; and
Dr. Rankin. Others present were Mr. Austin, Ms. Gonzales, and Rick
Lines, Prisoners' HIV/AIDS Support Action Network (PASAN), Toronto.
Discussion centered around planning, prison site visits, the Federal
Interagency Meeting on Compassionate Release, National Summit Meeting on
Prisons, National Minority Health Plan, and assessment of
recommendations.

**Prevention:** Members present were Mr. Robinson, Mr. Anderson,
Ms. Gerus, Mr. Landau, Rev. Perez, Ms. Runions, Mr. Schatz, and
Ms. Stokes. Also present were Dr. Weber; Renalyn Cuadro, American
Foundation for AIDS Research (AmFAR); Mr. Edmondson, Amy Hsu, and Brian
Toynes, AIDS Action Council; Mr. Lines; and John Miles and Eva Seiler,
CDC/NCHSTD. The Subcommittee developed a list of priorities to be
considered in the strategic planning session.

**Research:** Members present were: Dr. Levine; Dr. Cade;
Ms. Greenberger; Mr. Johnson; Ms. Miramontes; and Dr. Weniger. Also
present were Mr. Murguia and Ms. Wong. The primary concern was
long-range planning and Subcommittee priorities.

**Services:** Members present were: Mr. Bollman; Dr. Abel; Ms. Aragon;
Ms. Cooper; Rabbi Edelheit; Dr. Gutierrez; Mr. Hattoy; Mr. Henderson;
Mr. Lew; Dr. Rankin; and Mr. Sasser. Also present were Ms. Gonzales and
Ms. Leissoo; Joseph Kelly, National Alliance of State and Territorial
AIDS Directors (NASTAD); Ms. Le; and Jane Silver, AmFAR. Samuel
Bozzette, M.D., Ph.D., University of California, San Diego, and Martin
F. Shapiro, M.D., Ph.D., University of California, Los Angeles, briefed
the Subcommittee on HCSUS data, which cover approximately 335,000
persons being treated for HIV/AIDS in the United States.

**Panel Presentation on HIV and AIDS Among Youth**

Dr. Hitt said HIV and AIDS among youth is an issue we all feel strongly
about but have not adequately covered. Mr. Sasser, moderator, noted that
this issue is of extreme importance because of the unique devastation
that occurs when the young are affected. He thanked Mr. Bollman and the
Services Subcommittee, Mr. Montoya, and the AIDS Policy Center for
Children and Families, especially Clark Moore, for assistance in
assembling the presentation. He recognized young people and other
persons involved with youth and HIV/AIDS programs in the audience and
introduced the panel.

**Donna C. Futterman,** M.D., Director of AIDS Programs, Montefiore
Medical Center, Bronx, New York, described care and treatment among
three primary groups involved in this hidden population: those coming of
sexual age, those affected by AIDS through infected family members or
friends, and infected youth. Currently, half of the transmissions
worldwide are among those under 25 years of age, the majority being
youth of color; in the United States, 25 percent of new cases are
persons who are under 22 years of age. Of particular vulnerability are
young males who have sex with males and young women who cannot identify
risk behaviors in partners. Susceptibility factors are behavioral,
biological, and socioeconomic, with girls especially vulnerable both
biologically and because of gender power imbalances (among teenagers,
the highest percentage of cases of HIV are females). Many youth lack
health care coverage, sex education is inadequate, communications are
poor, and issues of confidentiality are not understood.

A HRSA-funded pilot campaign has been developed in New York to target
youth, using language they understand, and funds are being sought to
move it into a national arena. Focus is on critical factors in
treatment: early intervention (youth being an ideal target), basing
treatment on adult guidelines with puberty staging, keeping programs as
simple and doable as possible, and obtaining prospective data.
Challenges include youth vulnerability, multiple risk factors,
immaturity in coping ability, cognitive barriers, and lack of disclosure
and family support. Dr. Futterman recommended that the Council advocate
for:

· Innovative intervention programs that span the gaps between this group
and others infected with HIV/AIDS;

· Outreach and linkage to care for youth;

· Youth-centered programs, including confidentiality/parental
notification, adherence and relevant research, and peer and psychosocial
support; and

· Funding streams that allow young people to get care in centers of
excellence where research is available (not in managed care situations
where they may be excluded from access to appropriate levels of care
needed and important research programs).

**Todd Summers** updated the Council on the Presidential Youth Directive
to Federal Agencies as to their specific HIV-related youth programs,
saying that most of the reports are in and being put into a database.
This will be analyzed and followed up with recommendations for
integration of youth programs into currently operating HIV prevention,
care, and treatment programs and a report to PACHA and the President. In
addition, the Vice President has met with a group of young people who
either have HIV/AIDS or are involved in care and prevention, which
prompted him to request large budget increases in appropriate areas and
to include youth and HIV in his agenda. Ms. Thurman also met with
participants in a national youth efficacy coalition.

**Audrey Smith Rogers,** Ph.D., epidemiologist at the National Institute
for Child Health and Human Development (NICHD), cited issues presented
in the March 1996 ONAP report on research among adolescents: inadequate
surveillance, resulting in inaccurate estimates of the scope of HIV in
this population, and insufficient attention to influences on behavior,
disease progression, effects on immune and reproductive systems as well
as interaction, growth, and development around puberty. Factors that
could lead to therapeutic benefit remained unidentified. A prime factor
to be addressed is how youth interact and become engaged with the health
care system and specifically, why adolescents are not in care in greater
numbers.

Encouraging news is that the NIH-funded Adolescent Medicine-HIV Research
Network has developed a substantial, nationally distributed clinical
research infrastructure and a study group called Project Reach (a
cooperative agreement between the Government and 15 clinical sites in 13
U.S. cities) to seek answers to HIV disease progression and HIV
interaction with adolescent comorbidities. Ryan White Title 4 money
helped fund these programs, produce a monograph on clinical management,
and launch a drug-adherence initiative. Project Reach has already
dispelled some concerns about the capacity of youth to adhere to a
program, as more than 90 percent of 375 youth (12 to 18 years of age)
have remained in the program since starting 3 years ago. This is due in
large part to the use of interdisciplinary teams providing a wide array
of adolescent-specific services on site. One-stop settings like this
traditionally attract youth to care. Research with adolescents is
exceptionally labor-intensive, and funds are needed to adequately
support staff to track and encourage subjects. This population may
require a clinical trials network of its own and may not be suited for
Phase I and Phase II trials. Reach is establishing normative
immunological data that may make future therapeutic drug trials
possible; the project has also identified unique adolescent
characteristics that allow NICHD to attempt immune reconstitution with
aggressive early therapy. Sharing early data with pediatric AIDS
clinical trial groups has produced ACTG-381, an adolescent-specific
study on immune reconstitution expected to be in the field this summer.
Recommendations to the Council were to advocate for:

· Collection of observational data to define and examine
population-unique characteristics to identify and implement an array of
therapeutic interventions;

· Improved surveillance;

· Additional youth-targeted and effective outreach for HIV counseling
and testing;

· Improved linkages between counseling/testing, social service networks,
and health care to bring youth into settings where they can participate
in research;

· Portability of health coverage to support research participation;

· Effective coordination of an HIV adolescent research agenda, including
biomedical, behavioral, and health services; and

· Reallocation of research resources for more targeted funding to expand
youth-focused research. Resources and effort must be committed to
studying them in settings that can attract, recruit, and retain them as
subjects of research.

**Bret Rudy,** M.D., Director of Adolescent HIV Issues, University of
Pennsylvania School of Medicine, Chair of Adolescent Public Policy
Committee for the AIDS Policy Center for Children and Families, said
youth continue to be underrepresented in epidemiology and care. The need
for early intervention, counseling, testing, and treatment is critical,
as is research in this group because of adolescents' relative ability
for immune reconstitution. Important factors affecting counseling and
testing include these: Youth cannot be looked at as adults; they have
special needs during stages of psychosocial development; they can be
lost easily; and one must understand where they live, what their support
system is, and the unique services they need. Prevention is vital, and
ordinary risk assessment cannot be used to identify HIV-infected young
people. Social factors include homophobia; poor role models, peer
support, and self-esteem; lack of choices; poverty; and inability to
negotiate. We must be realistic about adolescent sexuality,
understanding that abstinence-only programs have little effect on safe
sex. Programs that have worked are culturally sensitive, based on
cognitive theory of behavior change, social skills, and norms.
Recommendations to the Council are:

· Youth need access to free, confidential, age-appropriate, and
unrestricted counseling and testing. Advocate to the CDC for
youth-targeted funding to develop models in appropriate sites and
education. Successful models do exist and can be replicated.

· Look for improved coordination among all services, Government, and the
private sector so that youth services are integrated into the whole
system (including such programs as family planning, sexually transmitted
disease \[STD\] care, and runaway shelters).

· Advocate for enhanced funding to CDC, HRSA, and NIH to find the most
effective strategies around counseling and testing and to get infected
youth into care programs based on theory and with outcome measures.
Enhance funding to disseminate that information.

· For prevention, seek Federal funding on sexuality programs in schools,
starting very early, and for children in the community who are not in
school, and call for better support for bisexual, gay, and lesbian
youth.

**Margaret Campbell,** Youth Support Advocate, Multicultural AIDS
Coalition, Boston, presented a youth's perspective, saying she would
like to see this Council have a long-term commitment to the youth of our
country. "I need you to do more---for me, and for the children to come,"
she said. Key recommendations to help youth include the following:

· Provide comprehensive sex education to every child and young person,
starting in the first grade or even kindergarten.

· Have aggressive prevention initiatives that will pull youth into the
programs, using their terminology. If you do not use their language, you
will not get them to listen.

· Address programs to the real priorities of youth, and make a
connection with HIV.

· The term youth cannot be used just as a buzzword. When young people
come to the table, their opinions must be validated. (She thanked David
Harvey for setting up a forum where policymakers listened to young
people.)

· Outreach and access to care are critical, and staying linked to health
care is difficult. To decrease the gap between infected youth and the
care system, follow and link into other successful social programs for
young people, such as YMCA, Boys and Girls Clubs, and
violence-prevention programs, that young people access otherwise for
help and information. For example, a Boston domestic abuse program is
teaching negotiation skills that will help young women use barrier
control methods to prevent disease spread.

· In communities of color there is a huge trust issue, especially for
males; we need realistic communications about these issues so they will
trust the prevention messages.

· Programs need to be highly culture-specific, aiming not just at ethnic
populations, but at groups within groups---like the "hip-hop" culture.

Asked what could have helped her in earlier years, Ms. Campbell
responded: "education for myself and my mother; knowledge of HIV;
knowledge of how to negotiate with an older man for my own protection;
honest conversations with adults on these subjects."

**David C. Harvey,** founder, AIDS Policy Center for Children, Youth &
Families, Co-Chair of National Organizations Responding to AIDS (NORA),
provided a perspective on Federal policy issues for youth and what PACHA
members can do. He thanked important allies of his organization and
resources for information on youth issues: Chad Martin and Victor
Barnes, CDC; Ms. Silver, AmFAR; Michael Shriver, NORA; Dr. Michael
Kaiser, HRSA; Michael Iskowitz, consultant; Ms. Thurman; Mr. Montoya;
Dr. Hitt; and Mr. Bollman. He also thanked Mr. Sasser for his long, hard
work on youth issues. Organizations doing important work in this area
include Advocates for Youth; National Youth Advocacy Coalition; and
NORA, which is forming a youth and HIV work group under David Mariner.

To help policymakers understand this population, at the AIDS Policy
Center Voices 98 conference youth forums were run by and for youth with
HIV. Tough questions were asked, such as, Why can't the Federal
Government mandate HIV prevention education programs in all schools? We
came away with a lot of work to do. A performance of the rap group TOPS
(youth against HIV/AIDS) showed that youth do not "hear" or perceive the
world in the same way adults do. We at the national level have not
figured out how to tap into the resources, energy, and brain power of
youth; we need to let them drive policy on their issues. Recommendations
for moving the Administration, Congress, and the Nation toward solving
these issues include:

· Stop studying the issues; put what we already know to be true into
action. Remarkable consistency is found among all the documents.

· Push the political will to drive these solutions, remembering that
Washington moves slowly.

· Ask in a specific, powerful way for a status report on implementation
of the White House Report on Youth and HIV. That report contains a
wealth of recommendations.

· On the Presidential Directive, request a detailed report on what has
come in and what has resulted---what initiatives have been started and
what concrete actions have been taken to allocate more money to
implement new programs.

· Take seriously the recommendation to have a youth provider and a
person under 24 years of age living with AIDS appointed to PACHA.

· Focus on prevention, counseling, testing, care, and research.

· Use youth (13--24 years) and their unique needs as a filter for all
recommendations made by the Council, and for all new programs coming out
of CDC, HRSA, and NIH.

· In prevention and services, equitably address targeted funding to
youth, especially of color. Look at current funding (for example, under
Ryan White, only 2 percent of funds is used for care for youth) to see
where we are failing and how we can expand developmentally appropriate
services for youth.

· Request information on the new Children's Health Insurance Program
passed by Congress. Determine how it is affecting youth. States have
much latitude on implementation; what is the Federal Government doing to
provide guidance to States?

· In research, develop a coordinated Federal agenda on youth with
appropriate funding.

Other general points were made by panelists during discussion:
Adolescent-specific programs are lagging because youth came into the
epidemic late and because these programs are difficult and expensive to
put together. On education efforts, the Federal Government should not be
bypassed for other organizations such as the Parent Teachers Association
(PTA), because the Government can help prod States into setting up
training and model programs. One reason for not doing more to
incorporate HIV into existing programs is that other basic social
problems must be solved first; we must get the children to school
safely, then teach them about AIDS. Sex education has to be accepted
before we can move on to HIV/AIDS. One barrier, Dr. Rogers said, is that
Americans are living in an era of profound deconstruction, with few
consistent structures other than the media. People are extremely
anxious, fearful, and cynical about Government, religion, and the social
establishment. In discussing the media---where youth is getting its
information---Dr. Futterman encouraged the Council to seek help from the
corporate world in its advertising to spread messages about methods of
safe sex and dangers of HIV. Special areas needing improved
understanding include lesbians and HIV, youth and injection drug use,
the spread of HIV among youth in rural settings, and legal barriers to
providing services to youth.

Dr. Hitt thanked the panel and asked for several things: ONAP for a full
briefing on the Presidential Directive at the next meeting; Dr. Rudy for
findings in a study on sexual abstinence; Ms. Campbell and others, for
updated lists of specific recommendations in writing. Mr. Bollman also
thanked the guests and asked that late PACHA member Ed Gould be
remembered for his passion and work on the issues of youth. Mr. Sasser
closed the session by introducing Miguel Bustos, co-author of the White
House Report on Youth and HIV and currently an advisor to Vice President
and Mrs. Gore, who told the Council that PACHA **does** have the power
to make things happen and that it is the responsibility of us all to
make sure that these issues are addressed.

**Long-Range Strategic Planning, Session 2**

Members discussed and agreed on the key steps needed in the overall
planning process:

· To address sensitive issues (such as resignation, race/ethnicity,
power) that may impede the ability of the Council to do its work and
resolve them to the extent possible; to help the group work together
effectively (begun in Session 1);

· To agree on a small number of short-term, achievable (mostly
time-sensitive) action items/objectives and the strategies and
structures needed to implement them;

· To identify additional objectives that are extremely important, but
which may not be achievable in the short term, and determine strategies
to keep them in the public view;

· To agree on the development of a final Progress Report or any other
action that should be taken to coincide with the end of the current
Council charter in July 1999; and

· To address Council and Subcommittee structure, processes, target
audiences, and external relationships to ensure that they maximally help
meet Council goals.

Another objective---to outline a plan for August 1999 to January
2001---was shelved until later. Concerns were raised about the
definition of "achievable" and the distinction between "short-term" and
"not achievable in the short term." Ms. McKay explained that specific
evaluation criteria would be established later in the process but that,
first, the concepts needed to be approved and all possible priority
issues put forward. Each Subcommittee then presented key and
time-sensitive objectives it would like to see on a final agenda. (The
recommendations given below include revisions given to facilitators
after this presentation.)

**Racial and Ethnic Populations:** Ms. Fraser-Howze said that the
primary focus is on HIV/AIDS issues in African-American and Latino
communities, with these specific recommendations:

1\. The Council should embrace the principle of eliminating the
disparities across racial/ethnic communities in all recommendations.
(Overarching principle/goal.)

2\. The Subcommittee should serve as a focal point (or clearinghouse)
within the Council for collaboration with and review of recommendations
from governmental agencies, national advisory councils, and special
initiatives that relate to the HIV epidemic in communities of color and
provide guidance to the Council for the development of formal
recommendations. (Internal.)

3\. The Subcommittee should aid in coordination of activities within the
Council by serving as a data repository for policy, surveillance,
prevention, care, and treatment data and analyses on racial/ethnic
communities. (Internal.)

4\. The Council should request that the President convene a special
meeting with the Black and Hispanic Congressional Caucuses to have a
discussion on the State of Emergency in these communities.
(Time-sensitive, external.)

5\. Based on our outlook and the tone we want the President to set for
the Nation, the Council should call for a special White House Conference
on AIDS within communities of color at the end of the Council's current
term. (Time-sensitive, external.)

**Discrimination**: Mr. Schatz presented two time-specific objectives
and two longer-term objectives:

1\. Follow through on HIV-positive health care worker guidelines.
(Time-sensitive, limited effort. Mr. Schatz and Dr. Abel will be
responsible for any action taken.)

2\. Having to do with the legal status of HIV: If the Supreme Court
rules that HIV is not a disability under the Americans with Disabilities
Act (ADA), work to regain recognition of HIV as a disability.
(Time-sensitive.)

3\. Work for legislative repeal of the immigration ban on HIV-positive
visitors and immigrants to the United States. (Not immediately
achievable, but morally important.)

4\. \[Background: This epidemic is significantly fueled by a lack of
self-worth among society's marginalized populations. Government failure
to adequately address pervasive racism, sexism, and homophobia---or
worse, Government actions that actively promote them---only serve to
create a climate in which the epidemic will flourish.\] If the Council's
perceived mandate expands in July 1999, the Discrimination Subcommittee
will make it a top priority to focus the Council's attention on bigotry,
social divisions, and their impact in fueling HIV, and on proposed
Government remedies. (Future, longer term.)

**International Issues:** Mr. Anderson presented the Subcommittee's
agenda, based on the fact that 95 percent of all HIV infections are
outside of North America:

1\. To provide input to the new strategic plan of the Department of
State and help ensure that its provisions are implemented. (Short-term.
The Subcommittee wants to provide input on issues such as vaccine
development, orphans, and access to treatment.)

2\. Work to increase the budget for international AIDS spending, both
for United Nations and international nongovernmental organization
programs and for U.S. Government programs. (Short-term, achievable. The
U.S. budget regarding foreign issues has been stagnant since 1993, with
cuts on AIDS spending. The Subcommittee hopes to ensure that the next
budget increases support such programs as UNAIDS and USAIDS, without
cutting other health programs.)

3\. Work to identify and support U.S. leadership in the international
arena (within the State Department and other Federal agencies) so that
the AIDS issue is raised in all available forums. (Longer-term.)

4\. Work to increase ONAP staff resources for international work.
(Longer-term.)

**Prevention:** Mr. Robinson said the Subcommittee's goals and
objectives are partially in response to events concerning needle
exchange and involve more resources for substance abuse treatment:

1\. Putting prevention at the top of the national agenda must be a
priority for PACHA. To accomplish this goal, the Council will work to
increase funding for prevention, ensure that those funds are
appropriately targeted, and promote the cultivation of effective
interventions. The following are specific objectives to reach this
broad-based goal:

a\. Increased funding---PACHA should:

\(1\) Support NORA FY 1999 Appropriations Requests, and work with the
community to develop an FY 2000 budget request. Recommend that part of
any new funds must provide increased funding for SAMHSA drug treatment
programs and build capacity in racial/ethnic communities.

\(2\) Work to advance the call for a State of Emergency in the
African-American population and advocate appropriate funding.

\(3\) Recommend that CDC establish a youth initiative.

b\. Targeting funds---PACHA should:

Work with the CDC to ensure that funds are more appropriately targeted
by racial/ethnic factors, risk factors, age, gender, and geography. In
line with this, the Prevention Committee will (1) work with the CDC in
the development of its guidance for HIV Prevention Community Planning
and (2) work with the CDC to evaluate the compliance of State planning
groups and health departments.

c\. Effective interventions---PACHA should:

\(1\) Work with CDC to ensure the cultivation of effective
interventions.

\(2\) Work to ensure the immediate release of new guidance regarding the
content of HIV prevention efforts (content restrictions).

\(3\) Work to ensure the expeditious completion of revised infected
health care worker guidelines.

\(4\) Recommend the appropriation of necessary funds to ensure substance
abuse treatment on demand.

2\. The Prevention Subcommittee will evaluate the progress on previous
recommendations regarding surveillance and work to establish an
effective method for monitoring the epidemic.

3\. The Subcommittee recommends that PACHA work with the Administration
to ensure that the CDC establishes a national initiative to encourage
the knowledge of sero-status and effectively targets at-risk
populations.

**Prison Issues:** Mr. Landau presented Subcommittee priorities, as
follows:

1\. Standards of Care: Implementation of Standards of Care in Federal
Prisons (including outreach from Department of Health and Human Services
to Bureau of Prisons).

2\. Discharge planning: Comprehensive services/discharge planning must
be provided to all individuals, including social services, housing,
food, financial assistance, and medical care to the extent needed.

a\. The spread of HIV and other STDs during and after incarceration must
be arrested through adequate drug treatment, health interventions, and
discharge planning with available community resources.

b\. Medical summaries must follow the individual from prison to
postrelease treatment.

3\. Federal/State dialogue: Federal guidelines, technical assistance,
and funding streams have policy implications in State and local prisons
and jails. The Federal/State dialogue must be enhanced.

**Research:** Dr. Levine discussed one achievable objective on
microbicides, for which the Subcommittee will bring specific
recommendations to the November meeting, and three longer-term
objectives:

1\. Push the microbicide agenda by addressing the following:

a\. Changing the structure of the FDA in terms of toxicity/pharmacology
reporting on microbicides (eliminate the requirement that microbicides
have to be reviewed by five committees).

b\. Issues of liability and access (similar to those for vaccines).

c\. Increased funding.

d\. Development of methods that empower women to prevent the spread of
HIV.

2\. Move the research agenda forward on behavioral interventions---what
works and what does not work. (This is longer-term, extremely important,
and all Subcommittees need to be involved. Dr. Levine requested that a
panel presentation be considered for the November meeting.)

3\. Support having ONAP assume the role of coordinating the vaccine
agenda, and ensure that it has sufficient staff to do so. (Longer-term,
extremely important.)

4\. Follow up on vaccine recommendations. (Long-term.)

**Services:** Mr. Bollman presented several categories of objectives for
the Subcommittee. (Several of the following were added later in answer
to Council member concerns about service issues.)

**Overarching goal:**

1\. Seek alignment of the full range of medical and social services to
reflect current and projected needs and demographics, evolving treatment
standards, and a realistic assessment of potential resources, both
public and private. Specifically, services and supporting funding
streams must be both equitably available and targeted to special-needs
populations (e.g., youth, African-American, Latino, and Native
American).

**Short-term leadership targets of opportunity:**

2\. Engage the President, especially through his interest in race issues
and relations, to take action on the racial/ethnic implications around
HIV/AIDS service delivery.

3\. Convince the President to establish a concrete goal regarding
provision of services for people in need, as he has done with vaccine
development and infection rates.

**Short-term legislative targets:**

4\. Work for reauthorization of the Ryan White CARE Act, including
reform of the AIDS Drug Assistance Program (ADAP) to ensure funding for
providing and maintaining a comprehensive set of therapies (without
emergency supplemental appropriations).

5\. Work for reauthorization of Housing Opportunities for Persons With
AIDS (HOPWA).

6\. Work on the FY 2000 appropriations process.

**Short-term administrative targets:**

7\. Continue to track and advocate for the expansion of Medicaid as a
source of funding for early intervention, at the national policy level
(Health Care Financing Administration \[HCFA\] and the White House) and
with regard to State waiver applications.

8\. Ensure that the information from HCSUS is readily available, and
that it is used to help Federal officials and other entities align
services to address the demographics of the epidemic and implement the
treatment guidelines.

9\. Urge broader dissemination and education by HRSA related to the
treatment guidelines, with emphasis on ensuring that underserved
populations receive appropriate treatment.

10\. Work for the establishment of a longitudinal file for women who
received AZT and all antiretrovirals while pregnant, to monitor them and
determine the long-term effects of treatment.

11\. Ensure that the Patient Bill of Rights for Health Care includes
clear, explicit reference to HIV care needs, including access to care
and implementation of the treatment guidelines.

**Structure:**

12\. Work on the development of a services-focused research agenda
(joint effort of the Services and Research Subcommittees).

Questions were raised about timing, appropriations, and reauthorizations
(especially ADAP), and Mr. Bollman said a timetable and more detailed
recommendations or other strategies would be developed by the
Subcommittee. Regarding ADAP, it will not be ignored, but the feeling is
that the Council should not try to reform it in the context of
reauthorization.

Facilitators called for discussion on perceived problems or gaps, and
the main concerns were how objectives would be prioritized and how
elimination of important issues from the agenda could be avoided. The
fear was that pressure would be removed from certain important
objectives that could not be achieved within the year. To expedite the
process of prioritization, facilitators would draft a preliminary list
breaking out all Subcommittee objectives into these categories:
specific, short-term achievable objectives; specific, not short-term
achievable, but morally important objectives; broad
principles/longer-term objectives; and followup objectives requiring
limited or individual member effort only. The objectives would be
assessed as to overall importance in the fight against the epidemic,
amount of work each will take, and whether it is actually achievable
within the year. Ms. McKay and Dr. Hitt again assured members that no
objective would be left out of strategic planning; all would be
considered important, even those relegated to longer-term and/or limited
effort categories.

Dr. Hitt asked that the Council be realistic about what it can
accomplish in terms of resources and suggested that members be as
concrete as possible about expected outcomes, to think about new ways of
getting things done. Mr. Summers also asked the Council to be mindful of
ONAP's staff limitations when it comes to implementation of PACHA
objectives.

**June 17, 1998**

Dr. Hitt asked members to complete a questionnaire on the proposed
Executive Committee and for Subcommittees to submit conference call
schedules to Mr. Montoya. The Council wished Ms. Thurman and
Ms. Holewinski a good trip on the AIDS Bike-A-Thon and thanked
Ms. Holewinski, who is leaving ONAP in September, for her work on PACHA
issues. Ms. Thurman addressed ONAP considerations in PACHA's strategic
planning, asking for a narrower focus on doable objectives because of
the agency's limited staff and agenda. She encouraged strong advocation
for more ONAP and PACHA staff and for keeping agency representatives for
longer periods of time to ensure continuity. HIV/AIDS efforts in
progress where the quickest possible movement can be seen include
vaccine development and access to care, particularly Medicaid expansion.
Other, broader issues in the immediate works deal with racial, women's,
and youth goals.

**Long-Range Strategic Planning, Session 3**

As working documents for the day-long strategic planning session,
MOSAICA provided a guide to developing a framework for the plan, a list
of Subcommittee objectives, and a preliminary categorization of the
objectives. Ms. McKay asked that the Council consider its mandate and
scope of activities and determine how broad it wants to be and choose
targeted audiences. As part of the framework, members were asked what
accomplishments they would like to see attributed to PACHA as of the end
of July 1999. The following are a representative selection voiced by
Council members:

· The President (and the Administration) is engaged, or reengaged, as an
actively involved leader and advocate.

· Public awareness of particular issues and activities is raised.

· The Administration and the Nation respond more rapidly to the
epidemic.

· PACHA's role expands from solely advisory to include advocacy and
education.

· PACHA helps the CDC streamline its process so it can respond more
rapidly to changes in the epidemic and institutionalize those changes.

· The President considers his work on AIDS as part of his legacy and
completes some of the work begun by PACHA.

· The point is made in the political arena that this is very much an
issue of ethnicity and race, so that the fight against AIDS is linked
with the fight against discrimination.

· PACHA broadens its constituency within the Government and the country
so that the Council's work becomes a higher priority.

· The Council exerts leadership in the overall community, working more
closely with other AIDS organizations to have strength in numbers and to
play a greater role in initiatives such as that of the Harvard
Institute.

· The Council leaves a clearer understanding of the political process
and its importance for local communities.

· Members work more closely in their own communities and with local
media to vocalize what the Council is doing and what the issues mean.

· The Council sees the big picture and provides the national vision of
what it will take to fight the epidemic.

· It also should be said that the Council sees the small and specific
things, that it was responsible for giving one person with AIDS one more
year to live.

· The legacy of the Council is that we were unafraid to speak the truth
to the American people, not just to the President, and to deal with the
consequences.

· This Council recognizes its own accomplishments and continues to work
with this Administration and fights to get into the next.

Rabbi Edelheit reminded others that the Council may not be able to
measure its accomplishments until the next PACHA or Administration comes
into power.

Ms. McKay summarized: The Council wants to focus on and advise the
President but sees its targets as broader than the President. There are
specific things that can be done in agencies, and there are steps that
can be taken to make a difference in people's lives. But the Council
also wants to see itself as a conscience, a voice of leadership, taking
the high road and speaking out on issues that are not being dealt with,
focusing on populations not covered, and making it as hard as possible
for the Administration to ignore these issues. "Winning" can mean
getting things into the public eye, increasing the debate, making people
more aware of the issues. In addition, there is a need to balance the
broad picture with some specific battles the Council can win.

**Primary audiences**: The Council selected the following as audience
targets: the President, the Secretary of HHS, ONAP, the media, the Vice
President, the Director of ONDCP, the Administration, Congress, the
American public (via the media), and people with HIV and their families
(via the media).

**Resources:** Realistically, members understand that their current
resources are limited to Mr. Montoya (full time); Council member
volunteer time (plus any organizational resources individual members may
bring); limited ONAP personnel time to help support and implement
Council activities (with the attendant problems of interrupted
continuity); and very limited help from Government and national
organizational partners on specific issues. The Council has no
operational budget. Some members believe it is a waste of time to
discuss resources at length rather than address the issues, while others
feel it is necessary to fully understand resource limitations so that
the Council can make a realistic implementation plan. The general
agreement was that the Council must find ways of obtaining more
resources to accomplish its agenda. Mr. Bollman suggested that this
should be the job of the Executive Committee, with individual members
coming forward with any help they can provide to obtain additional
outside resources.

During discussion of resources the following views were expressed: (1)
too many things get done without a consensus or general knowledge among
the full membership, and (2) most things necessarily happen through
people involved in the administrative process on a day-to-day basis,
through "those on the Council who know the political process and have
the Administration contacts." Reverend Perez suggested developing
mechanisms for keeping everyone informed and strict strategies so
everyone knows who does what. Dr. Hitt pointed out that in the past most
recommendations and suggestions were left with the Process Committee,
without any strategy being delineated to accomplish them.

**Criteria for short-term achievable objectives**: The Council agreed on
the following general criteria for judging priority objectives for the
coming year:

First-tier criteria:

1\. Achievability --- That measurable progress can be made within the
next year.

2\. Timeliness/urgency --- That this is the right time to address the
issue.

3\. Comparative value/importance, appropriateness --- That the objective
is deserving of time and attention.

Second-tier criteria:

4\. Responsibility/accountability --- A specific individual or entity is
able, willing, and highly motivated to take primary responsibility for
the work required to accomplish the objective and ensure followthrough.

5\. Resource requirements --- Know the resource requirements for meeting
the objective and evaluate what is available and if it is reasonable, in
the context of what may be achieved.

**Cross-committee planning**: Given a suggested planning format, the
Council was divided into cross-committee groups to discuss
prioritization of the objectives on the preliminary list. Groups were
instructed to look closely at each category and try both to determine
top priorities and to move objectives as necessary. At the conclusion of
the working session, one person was asked to summarize the priorities
for each group. The facilitators then listed those objectives mentioned
most often as achievable goals. For each of 13 objectives, members were
asked to determine the amount of work involved to accomplish the
objective and who the target audience(s) would be. Members were asked to
vote for six objectives they considered eligible by these criteria for
the short-term achievable priority list. Those objectives chosen are
listed below, in abbreviated form, in order of the number of votes cast,
and with perceived level of work involved, audience, and Subcommittee(s)
that will spearhead each. (The complete list of objectives by types as
voted on by the Council is included as Attachments A and B to the
Minutes.)

**Short-term achievable priorities:**

1\. Call for a State of Emergency in the African-American and Latino
communities and engage the President through meetings with the
Congressional Black and Hispanic Caucuses and call for a White House
conference on the emergency. (23 votes; much work; within the White
House; spearheaded by Ethnic and Racial Populations and Discrimination
Subcommittees)

2\. Influence CDC prevention activities around youth, high-risk
populations, and community participation. (22; much work; within the
White House and the CDC; Prevention Subcommittee)

3\. Push for Medicaid expansion and State waivers. (15; much work;
within the White House and HCFA; Services Subcommittee)

4\. Work for higher appropriations for HIV/AIDS programs, services, and
research. (11; much work; within the White House and Congress;
Appropriations Subcommittee)

5\. Provide input to DOS international strategic planning. (11; limited
work; within the White House and DOS; International Issues Subcommittee)

6\. Advocate for attention to women-centered prevention methods. (11;
much work; within administrative agencies; Research Subcommittee)

Other objectives included in the preliminary list and moved to followup,
limited-effort columns were:

7\. Work for Ryan White reauthorization. (8 votes)

8\. Follow through with ONAP on youth programs status report. (6)

9\. Work with the Attorney General and the BOP for mandatory discharge
planning. (2)

10\. Work for HOPWA reauthorization. (0)

Major points during the discussion revolved around the following:

**Suggested new structures and strategies:** Strategies for more
effective Council work included: allotting more meeting time for the
Subcommittees spearheading the main objectives during full Council
sessions; using cross-committee working groups and ad hoc subcommittees
for specific tasks; using highly targeted letters, meetings, and other
methods rather than formal recommendations to get things done;
developing standard messages and information for individual members to
use in meetings; developing (by Subcommittees) specific, limited-effort
strategies for moving issues forward; and advocating for increased
resources within ONAP and PACHA.

**Ways to keep other issues active**: Focus on them through special
conference calls and continued monitoring and advocacy by individuals
and Subcommittees specifically involved with those issues, calling for
Council support when necessary.

**June 18, 1998**

**Establishment of Executive Committee**

The proposal to establish a PACHA Executive Committee to supersede the
Process Committee resulted in a lengthy discussion on insider/outsider
and power issues. Although it was agreed that a small (and wieldy) group
was needed for planning and coordination, several members questioned the
need for a change. Others felt that the name "Executive Committee" would
further enhance the insider/outsider feeling on the Council. Further, it
was noted that this proposal was made without preamble; no notice was
sent to members prior to the meeting to explain why a change was needed.
To some, this was indicative of a current internal problem---that
actions are taken in the name of the Council, and many meetings are held
by those with power on the Council without full-Council awareness or
consensus. Cases in point were the letter to *Science* magazine,
Dr. Hitt's meeting with Vice President Gore, and the lack of a written
report on the May meeting with Drs. Varmus and Fauci. Dr. Hitt explained
that the letter to *Science* was sent from two individuals, not the
Council (see discussion below), that the meeting with Vice President
Gore was a happenstance at a separate meeting of gays and lesbians with
the Vice President, and that the May meeting was ONAP's meeting, and
Subcommittee members were simply invited to attend. Ms. Thurman would be
asked to submit a report to the full Council membership. Also noted was
the perception that Prevention Subcommittee issues had been usurped by
others on the Council (e.g., needle exchange). Dr. Hitt agreed that this
was a problem, and that an Executive Committee could better monitor and
prevent this from happening by following the dictates of the Council.

Ms. Fraser-Howze summarized the history of the PACHA Process Committee,
which was established in the early days of the Council as a short-term,
ad hoc committee, primarily to facilitate logistics of meetings and
intracouncil communications. These duties have since been taken over by
Mr. Montoya and the conference planners. The Process Committee, per se,
was never intended to last 3 years. Also, to the outside world, an
Executive Committee has more meaning as to its functions of coordination
and facilitation. It was suggested that having a formal Executive
Committee, with clearly defined functions and processes, might enhance
intracouncil communications and bring back some control to the
membership through a better flow of information, and that, structured
properly, this might ensure that power is shared equally and the
perception of insider/outsider is abolished.

It was noted that a primary function of an Executive Committee could be
to help the Council get a handle on other resources available to further
its causes, particularly important since the Council has adopted an
ambitious set of priorities and is underresourced. A formal Executive
Committee can represent the changing, diverse face of the epidemic
better in the public eye and, finally, can be held accountable.

**Composition:** The majority of Council members suggested that
membership consist of all Subcommittee Chairs and/or Co-Chairs plus
others necessary to achieve a balance in diversity. Some felt that
Subcommittee designees, rather than Chairs, be appointed; however,
Dr. Hitt and Mr. Montoya pointed out that this would make the
intracouncil communications more involved, difficult, and duplicative.
It was agreed that membership should be open to anyone who was willing
to attend all meetings and commit to doing the necessary work of the
Executive Committee; some members of the Process Committee (notably
Ms. Miramontes and Rabbi Edelheit) pointed out that this was not a
matter of having power or privilege, but of doing hard work. All members
should be notified of Executive Committee meetings and be able to attend
whenever they want.

**Functions**: Many suggestions were made as to the functions of the new
Executive Committee, and Dr. Hitt summarized the responses (both written
and verbal): plan meetings, suggest Council policies, follow up on
long-term planning and help complete the work plan, review all
recommendations through the "filter" of issues affecting special-needs
populations (as defined by the Council), help develop strategies for
achieving the objectives, and report to the full Council on all that is
happening. It should act as a sounding board to make sure the Council is
not missing someone or something and help monitor specific issues, along
with the appropriate Subcommittees. Other suggestions were that the
Executive Committee work with ONAP and Mr. Montoya to move issues
forward, monitor implementation of Council recommendations, respond to
the media, resolve conflicts, monitor external relationships, monitor
adherence work programs, ensure that all Council members' opinions are
considered and all individual Subcommittee issues are given equal
priority, and seek outside resources for furthering Council causes.

**Meetings**: It was agreed that the Executive Committee should meet in
1‑ to 2‑hour conference calls every 4 weeks. Agendas should be sent to
the full Council in advance, and Mr. Montoya noted that this is possible
only if Subcommittees provide him with agenda items in a timely fashion.

**Reporting:** It was strongly urged that the Executive Committee have
someone responsible for taking notes or minutes of its meetings and
disseminating them quickly to all Council members. A process suggested
was for the note taker to make a preliminary draft for Executive
Committee review and revision, then send the approved minutes to the
membership.

**The New Executive Committee**

By a 22 to 8 vote the Process Committee was replaced with a formal
Executive Committee comprising the Chairs and Co-Chairs of all
Subcommittees, as well as any self-elected member-at-large who would
commit for 1 year to be present at **all** monthly conference call
meetings and carry out the tasks assigned. The core membership will be
able to recruit new Executive Committee members if a gap in Council
interests is perceived, and Chairs of any new Subcommittee that may be
formed will join the membership. The initial membership will include
Subcommittee Chairs/Co-Chairs Mr. Bollman (Services), Mr. Fogel
(International), Ms. Fraser-Howze and Rev. Perez (Racial and Ethnic
Populations), Mr. Isbell and Mr. Robinson (Prevention), Mr. Landau
(Prisons), Dr. Levine (Research), and Mr. Schatz (Discrimination);
Dr. Hitt (Chair of the Process Ad Hoc Committee and PACHA); and at-large
members Dr. Cade, Rabbi Edelheit, Ms. Miramontes, and Dr. Sasser.
Executive Committee conference calls will be open to all members, and
the agenda will be provided in advance by Mr. Montoya.

The Executive Committee will have no voting rights and will not make
decisions on Council matters (these will continue to be made through
full-Council conference calls). Its duties will include: development of
Council meeting schedules/agendas (with input from Subcommittees and
individuals); filtering all recommendations and suggested actions
through special-interest populations; sending out pro forma responses to
invitations (to outside meetings, etc.) and thank-you letters as
appropriate; facilitating review and adoption (among all members) of
proposed full-Council actions, such as recommendations, letters from the
Council to the President and others; hearing and resolving, as possible,
any conflicts that arise; and reporting back to the Subcommittees on all
activities of Council members. If any member is dissatisfied with any
action of the Executive Committee, that individual should send a memo to
the full Council for deliberation. (See Attachment C for Council
responses to Executive Committee options.)

**General Business**

**Letter to President Clinton on needle exchange:** Mr. Anderson, at the
request of Dr. Hitt and the Prevention Subcommittee, had written a
letter to the President presenting the Council's response to the needle
exchange action. This preliminary draft had not been reviewed by the
Subcommittee or the Process Committee; rather, it should be reviewed at
this point by the membership and the new Executive Committee in the
context of the overall strategic plan. Members were asked to submit
suggestions to Mr. Anderson or other members of the Subcommittee for
revision. (Text of the draft is Attachment D to the Minutes.)

**Letter to* Science***: A final draft of the letter from Dr. Hitt and
Dr. Levine was provided to Council members, and it was agreed that it
should be sent as revised. Dr. Hitt explained that this letter had been
written as a quick response to misstatements about the vaccine
recommendations and was not intended as a letter sanctioned by the
Council. Mr. Montoya added that the draft had been reviewed by the
Subcommittee at one of its sessions and members not present were later
given the opportunity to make corrections to the letter. (This letter
appears as Attachment E to the Minutes.)

It was agreed that individuals and Subcommittees must remain sensitive
to the fact that any activity that concerns PACHA and its stated
priorities should be reported to every member and that any
correspondence or activity seen as full-Council action must be voted on
by the membership. Activities initiated by individual members (such as
correspondence and outside meetings) should not be attributed to the
Council. Mr. Henderson suggested that, when corresponding as
individuals, members use their personal stationery to avoid the
assumption that the letter has been sanctioned by the Council.

**Meeting with President Clinton:** The intent of the meeting is for the
full Council to sit with the President and convey their concerns about
priority issues, particularly in view of the fact that many new members
have not had a chance to meet with Mr. Clinton. Dr. Hitt said that a
separate meeting would be preferable to one held in conjunction with the
fall meeting and he thought that funds could be found for this purpose.
The consensus was that the meeting should be held in September, if
possible, and that the Council should spend a day in advance preparing
the order and substance of the session, and a postmeeting statement
should be issued to the press. To most efficiently present the Council's
agenda in the time allotted (30 minutes to 1 hour), certain members
would be selected to address specific topics. (It was suggested that the
Subcommittees also might hold planning meetings during the advance
preparation day.)

**Subcommittee Reports**

**Services:** Mr. Bollman reported that the Subcommittee had received an
excellent introduction to HIV/AIDS issues of the Native American
community by Mr. Blackwell, and related materials are available to all
members. A request was made for Mr. Blackwell to present to the full
Council in November, as this is a population whose special needs must be
addressed forthwith. The Subcommittee heard preliminary findings from
the HCSUS study by the Rand Corporation and the University of
California. Members asked that time be allotted for a more complete
report at the next Council meeting, as the data will tell much about
where this epidemic is and who is getting services, who is not, and why.

Mr. Sasser presented two leadership youth recommendations requesting
reports on results of the 1996 White House Report on Youth and HIV/AIDS
and the Presidential Directive. The two recommendations were adopted
unanimously (see Attachment B), and Mr. Summers said that ONAP is
already working on the requested reports. The recommendation for the
appointment of a person under 24 years of age to the Council was
shelved, because this is already under way at the White House.
(Mr. Bollman said that the Council will ask that this be accomplished
before July 1999.) Other youth recommendations are being moved to
appropriate Subcommittees for development of strategies.

**Research:** Ms. Miramontes reported, in Dr. Levine's absence, that the
Subcommittee received a full report on microbicides, and that specific
recommendations would be presented to the Council in November. Further
information must be obtained from the Food and Drug Administration
(FDA), DHHS, and NIH. Vaccine issues continue to be monitored, and
special attention is being given to behavioral research, especially as
regards communities of color and youth. The Subcommittee asked for help
on this issue from other Subcommittees and requested time for a
full-panel report on behavioral research in November. Dr. Weniger
provided an agenda and background material for the conference call with
Dr. Donald Francis.

**Prevention:** Mr. Robinson said that the Subcommittee had formulated
three recommendations directed to the CDC: to establish a youth
initiative, to establish a national initiative to encourage HIV testing
that effectively targets high-risk populations, and to work with the
Council in developing HIV prevention community planning guidance. In
line with the new strategic planning results, these issues will go back
to the Subcommittee for determination of specific strategies. Other
members expressed concern that these important, time-sensitive issues
might be delayed by this process, saying that they preferred making
general recommendations to losing momentum; all agreed that these should
be addressed as quickly as possible as part of the work plan.

Another issue to be included in the working strategy is the need for
increased dollars for substance abuse treatment. Mr. Summers said that
it will be helpful to ONAP for the Council to consider the mechanisms
through which these funds are administered as part of any recommendation
it might make, and to stand behind ONAP's efforts in this area.

**Prison Issues**: Mr. Landau said some progress has been made, with
issues on substance abuse treatment, prevention, quality of care, and
compassionate release being brought to the attention of the BOP and the
Justice Department. There is concern, however, about the lack of
effective response from the BOP and because prison issues are not
considered among the achievable priorities of the Council. He noted
that, since people of color account for more than 80 percent of the
population in prisons, this is an issue of race as well. The
Subcommittee is trying to increase the pressure and is looking for more
information on issues of incarcerated women and youth, managed care in
prison settings, the relationship between State and Federal prison
issues, and HIV testing. Upcoming activities include participation in
the National Meeting on Prisons in October and site visits in
conjunction with the November Council meeting.

A Subcommittee recommendation regarding CDC technical assistance for
corrections systems surveillance was reviewed and passed unanimously by
the Council (see New Recommendations, Attachment B). A letter to
Dr. Kathleen Hawk Sawyer, BOP, on protective barriers was tabled until
the November meeting, partially at the request of ONAP, which feels that
the letter could elevate this very problematic issue above others
involved in current agency efforts. It was suggested that the
Subcommittee put this issue into context of the overall priorities of
the Council. Another letter, to Secretary Donna Shalala and Attorney
General Janet Reno on Standards of Treatment, was also tabled until the
November meeting. (Both letters are included as Attachments F and G.)
Mr. Summers said that ONAP has met with the Assistant Attorney General
for Policy, the Superintendent of the BOP, and Surgeon General David
Satcher on the status of health care in prisons, and he believes there
is a spirit of cooperation and good opportunity for progress. Mr. Landau
thanked Mr. Summers and Mr. Austin for their work in moving these issues
to the next level.

**International Issues:** In Mr. Fogel's absence, Mr. Anderson discussed
funding for international efforts, a matter that demands attention from
the Appropriations Ad Hoc Subcommittee and within the full Council. He
presented a resolution, tabled in December 1997, to amend the Embargo
Act of 1961. In answer to questions about the timeliness of making this
recommendation, Mr. Landau noted that this AIDS-specific issue greatly
affects such countries as Cuba. Mr. Bollman pointed out that it affects
Africa as well, elevating this to an even higher status, given the
increased focus on communities of color by the Council. The
recommendation was adopted with two opposed.

**Discrimination:** There was no formal report; however, Mr. Henderson
presented a brief resolution regarding the Americans with Disabilities
Act (text in Attachments A and B) which passed with two opposed.

**Racial and Ethnic Populations:** Ms. Fraser-Howze said that the
Subcommittee had changed its name in a desire to be sensitive to all
ethnic populations. To round out the diversity of the membership,
Mr. Lew and Mr. Blackwell have offered to help out as needed. During
this session, the Subcommittee heard a report on the Latino Leadership
meeting at Harvard, which produced positive followup and good media
attention.

Mr. Murguia summarized information presented to the Subcommittee on the
Race Initiatives of the Office of Minority Health (OMH) and the
President. The National Minority HIV Plan, he said, under development at
OMH for a year and a half, is looking at implementation steps that
answer recommendations by community-based minority organizations, the
first time that all Public Health Service (PHS) agencies have
collaborated with these groups. Currently, the working group (of which
Mr. Milanes is a member) is reviewing the final draft, and it is hoped
that the Plan will be released in September at the U.S. Conference on
AIDS in Dallas. The Subcommittee has been asked to review the document,
and OMH hopes it will write a letter of endorsement for the Plan and an
encouragement for the Secretary of HHS to ensure its implementation as
soon as possible.

On the President's Race Initiative, DHHS has six working groups on
various areas, including HIV, where the health status of racial and
ethnic populations is vastly different from that of the majority
population. The HIV working group, under Co-Chairs Dr. David Holtgrave,
CDC, and Dr. Michael Johnson, HRSA, has been given a very wide charge to
look at how DHHS addresses HIV/AIDS issues, including funding, services,
prevention, research, and information dissemination. The mandate
includes making recommendations for any perceived changes needed in the
structure and prioritization of programs and funding, and determination
as to whether the community is appropriately involved. Ms. Fraser-Howze
asked for time at the November meeting for a full-Council update on the
two initiatives.

Ms. Fraser-Howze presented a letter from Secretary Shalala to
Representative Maxine Waters (D‑CA), Chair of the Congressional Black
Caucus, indicating that DHHS is responding immediately to the call for a
State of Emergency and is reviewing every program on HIV/AIDS within
HRSA, SAMHSA, and its other agencies. DHHS will meet with Congresswoman
Waters, and the Subcommittee will follow up on this and other
activities, including use of available emergency funds for this purpose,
and is calling for the CDC to review its programs in terms of the State
of Emergency.

Reverend Perez reviewed recommendations calling for a Presidential
meeting with the Congressional Black and Hispanic Caucuses and a special
White House Conference on the State of Emergency, which were adopted
unanimously by the Council (see Attachment A). The Subcommittee will
follow up on responses to these and develop specific strategies on all
other Subcommittee issues specified as priority goals or objectives.

Ms. Fraser-Howze suggested that, given the major changes in structure,
focus, and emphasis on ethnic communities adopted at this meeting, the
Council should issue a press release on the new working plan. Ms. Cooper
said that such a statement should stress the positive---that PACHA is
concentrating its efforts on communities most affected by the
epidemic---rather than on the changes being made within Council
structures and operations. Although the Council normally does not issue
press statements at the end of its meetings, it was agreed that this
could be an exception. Ms. Fraser-Howze was asked to write a first draft
of the release and submit it to the Executive Committee for
dissemination to the Council for approval.

The question was asked how the White House will be informed of events at
this meeting, and Dr. Hitt said that ONAP sends a memo summarizing every
meeting to the President, the Secretary of HHS, and other appropriate
members of the Administration.

**Final Review of the Strategic Plan**

The Council received a draft of the list of priority objectives chosen
on June 17 (the full text is in Attachment A), and Ms. McKay asked that
all members review the document and send any suggested corrections to
MOSAICA as soon as possible. The facilitators will draft a final report
to the Council. A formal motion was made to adopt the six short-term
achievable objectives as priorities for the remainder of the Council's
term, and it was passed unanimously. Appropriate Subcommittees were
asked to use the planning format provided to develop specific strategies
in time for the first Executive Committee meeting (proposed for July
18), where the strategies will be combined in a final working plan for
the year. The importance of developing these strategies very quickly was
stressed.

It was also agreed that objectives and goals in the longer-term,
limited-effort categories would be addressed by the Subcommittees and
interested individuals, although it might not be realistic to apply the
full planning format to each at this time.

The Executive Committee was to schedule upcoming meetings and develop
process strategies for Council communications, activities,
recommendations review and filtering, and coordination of strategic
plans. Mr. Montoya was asked to provide an orientation to new members,
including the important members in the Administration.

**Next Meetings and Closing**

**Next Council meetings**. The next full Council meeting is scheduled
for November 16--19, 1998, at the Madison Hotel in Washington, D.C. The
full schedule of upcoming Executive Committee and Subcommittee
conference calls will be sent to all members.

Dr. Hitt thanked Council members, Mr. Montoya, Ms. Thurman and the ONAP
staff, facilitators from MOSAICA, the conference staff, and guests for
their participation. The Tenth Meeting of PACHA was adjourned at 12:50
p.m., June 18, 1998.

**Attachments to the Minutes**

A. Strategic Planning Results (Adopted June 17, 1998)

B. New Council Recommendations (Passed)

C. Council Responses to Executive Committee Options

D. Letter to the President Regarding Needle Exchange from the Prevention
Subcommittee (Preliminary Draft, In Review)

E. Letter to *Science* Magazine (Revised Draft)

F. Letter to Dr. Kathleen Hawk Sawyer, Federal Bureau of Prisons, from
Prison Issues Subcommittee (Tabled)

G. Letter to Secretary Donna Shalala and Attorney General Janet Reno
from Prison Issues Subcommittee (Tabled)

H. Private Organizations, Government Agencies, and Media Represented at
the PACHA Meeting

**A: Strategic Planning Results**

**Adopted June 17, 1998**

**Short-Term Achievable Priorities**

Six objectives chosen as top priorities were described as to the amount
of work each will require ("much" or "limited") and its targeted
audiences of action (i.e., the White House, administrative agency,
and/or Congress \[indirect\]), as shown in the following table:

+-----------------------------+-----------+----------+--------------+
| **Objectives**              | **Votes** | **Amt.** | **Targets**  |
|                             |           |          |              |
|                             | **For**   | **Work** |              |
+-----------------------------+-----------+----------+--------------+
|                             |           |          |              |
+-----------------------------+-----------+----------+--------------+
| **1. Work to advance the    | 23        | Much     | White House  |
| call for a State of         |           |          |              |
| Emergency in the            |           |          |              |
| African-American and Latino |           |          |              |
| communities** through a     |           |          |              |
| variety of strategies, such |           |          |              |
| as the following:           |           |          |              |
|                             |           |          |              |
| · Engage the President by   |           |          |              |
| requesting that he convene  |           |          |              |
| a special meeting with the  |           |          |              |
| Congressional Black Caucus  |           |          |              |
| and Hispanic Congressional  |           |          |              |
| Caucus to develop a         |           |          |              |
| strategy regarding the      |           |          |              |
| State of Emergency.         |           |          |              |
|                             |           |          |              |
| · Call for a Special White  |           |          |              |
| House Conference on the     |           |          |              |
| State of Emergency in       |           |          |              |
| Communities of Color.       |           |          |              |
|                             |           |          |              |
| (Also mentioned were:       |           |          |              |
| advocating for increased    |           |          |              |
| funding to serve            |           |          |              |
| African-American and Latino |           |          |              |
| communities and calling for |           |          |              |
| the President, through his  |           |          |              |
| interest in race and race   |           |          |              |
| relations, to take action   |           |          |              |
| on the racial/ethnic        |           |          |              |
| implications around         |           |          |              |
| HIV/AIDS service delivery.  |           |          |              |
| Council action will be      |           |          |              |
| focused through the         |           |          |              |
| Subcommittee on Racial and  |           |          |              |
| Ethnic Minorities.)         |           |          |              |
+-----------------------------+-----------+----------+--------------+
| **2. Influence CDC policies | 22        | Much     | White House; |
| and programs related to     |           |          |              |
| HIV/AIDS prevention,**      |           |          | Admin agency |
| including:                  |           |          |              |
|                             |           |          |              |
| · Establish a youth         |           |          |              |
| initiative.                 |           |          |              |
|                             |           |          |              |
| · Ensure that the CDC       |           |          |              |
| establishes a national      |           |          |              |
| initiative to encourage     |           |          |              |
| testing that effectively    |           |          |              |
| targets high-risk           |           |          |              |
| populations.                |           |          |              |
|                             |           |          |              |
| · Ensure that the CDC       |           |          |              |
| includes in its HIV         |           |          |              |
| Prevention Community        |           |          |              |
| Planning guidance language  |           |          |              |
| requiring that use of       |           |          |              |
| community prevention funds  |           |          |              |
| be linked to the local      |           |          |              |
| demographics of the         |           |          |              |
| epidemic, and that the CDC  |           |          |              |
| evaluates compliance with   |           |          |              |
| the direction in the        |           |          |              |
| guidance. (Prevention       |           |          |              |
| Subcommittee)               |           |          |              |
+-----------------------------+-----------+----------+--------------+
| **3. Track and advocate for | 15        | Much     | White House; |
| access to care and funding  |           |          |              |
| for early intervention      |           |          | Admin agency |
| through expansion of        |           |          |              |
| Medicaid,** working at the  |           |          |              |
| national policy level (HCFA |           |          |              |
| and the White House) and    |           |          |              |
| with regard to State waiver |           |          |              |
| applications. (Services     |           |          |              |
| Subcommittee)               |           |          |              |
+-----------------------------+-----------+----------+--------------+
| **4. Work for higher        | 11        | Much     | White House; |
| appropriations for HIV/AIDS |           |          |              |
| prevention, services, and   |           |          | Congress     |
| research**, including the   |           |          |              |
| following:                  |           |          |              |
|                             |           |          |              |
| · Support NORA's FY 1999    |           |          |              |
| HIV/AIDS appropriations     |           |          |              |
| request.                    |           |          |              |
|                             |           |          |              |
| · Develop an appropriate    |           |          |              |
| strategy for FY 2000        |           |          |              |
| appropriations.             |           |          |              |
|                             |           |          |              |
| · Focus on increased        |           |          |              |
| funding for substance abuse |           |          |              |
| treatment, building service |           |          |              |
| capacity in communities of  |           |          |              |
| color, youth, and           |           |          |              |
| international HIV/AIDS      |           |          |              |
| programs. (Appropriations   |           |          |              |
| Ad Hoc Subcommittee,        |           |          |              |
| others)                     |           |          |              |
+-----------------------------+-----------+----------+--------------+
| **5. Provide input to the   | 11        | Limited  | White House; |
| new international strategic |           |          |              |
| plan on HIV/AIDS being      |           |          | Admin agency |
| developed by the Department |           |          |              |
| of State and help ensure    |           |          |              |
| that its provisions are     |           |          |              |
| implemented.**              |           |          |              |
| (International              |           |          |              |
| Subcommittee)               |           |          |              |
+-----------------------------+-----------+----------+--------------+
|                             |           |          |              |
+-----------------------------+-----------+----------+--------------+
| **6. Advocate for attention | 11        | Much     | Admin agency |
| to women-centered           |           |          |              |
| prevention methods          |           |          |              |
| (microbicides).** (Research |           |          |              |
| Subcommittee. Language of   |           |          |              |
| recommendation to come by   |           |          |              |
| November.)                  |           |          |              |
+-----------------------------+-----------+----------+--------------+
|                             |           |          |              |
+-----------------------------+-----------+----------+--------------+

**Specific, Not Short-Term Achievable, But Morally Important
Objectives**

The following objectives are not listed in priority order.

1\. If the Supreme Court rules that HIV is not a disability under the
ADA, work to regain recognition of HIV as a disability. (Discrimination
Subcommittee)

2\. Continue to advocate for a policy that permits the use of Federal
funds for needle exchange. (Prevention Subcommittee)

3\. Work for legislative repeal of the ban on immigration to the United
States by HIV-positive individuals. (Discrimination, International
Subcommittees)

4\. Support the appropriation of the necessary funds to ensure substance
abuse treatment on demand. (Prevention, Appropriations Subcommittees)

5\. Work to establish an effective method for monitoring the epidemic.

6\. Move the research agenda on behavioral interventions \-- to learn
more about what works and what does not work. (Research Subcommittee)

7\. Work to identify and support U.S. leadership in the international
arena (within the State Department and other Federal agencies) so that
the AIDS issue is raised in all available forums. (International
Subcommittee)

**Broad Principles/Longer-Term Goals**

1\. Seek the alignment of the full range of prevention, medical, and
social support services (including such basic needs as food and housing)
so their funding streams are both equitably available and targeted to
special needs and disproportionately affected populations. (Services
Subcommittee)

2\. Address bigotry and social divisions and their impact on fueling HIV
and on proposed Government remedies. (Discrimination Subcommittee)

3\. Put HIV/AIDS prevention at the top of the national agenda.
(Prevention Subcommittee)

4\. Push the microbicide agenda forward by:

· Changing the structure of the FDA in terms of toxicity/pharmacology
reporting on microbicides.

· Addressing liability and access issues.

· Obtaining increased funding.

(The Research Subcommittee will propose specific objectives and
recommendations on this issue in November.)

5\. Work to improve adherence to treatment guidelines by all providers
of care. This includes broader dissemination and education by HRSA
related to the treatment guidelines, and their implementation in Federal
prisons, as well as emphasis on ensuring that underserved populations
receive appropriate treatment. (Prisons, other Subcommittees)

6\. Work for the establishment of a longitudinal file for women who
received AZT and all antiretrovirals while pregnant, to monitor them and
determine the long-term effects of treatment. (Research?)

7\. Help ensure that the information from the HIV Cost, Services, and
Utilization Study (HCSUS) is readily available, and that it is used to
help Federal officials and other entities align services to address the
demographics of the epidemic and implement the treatment guidelines.
(Services Subcommittee)

8\. Ensure that comprehensive services/discharge planning is provided to
all individuals leaving prisons, including social services, housing,
food, financial assistance, as well as medical care, to the extent
needed. This includes linkages with available community resources to
provide drug treatment and health interventions. (Prison Issues
Subcommittee)

9\. Enhance the Federal/State/local dialogue regarding HIV and prisons,
with emphasis on State/local input to the Bureau of Prisons (BOP).
Address Federal guidelines, technical assistance, and funding streams
that have policy implications in State and local prisons and jails.
(Prison Issues Subcommittee)

**Followup Objectives: Limited or Individual Member Effort**

1\. Follow through on HIV-positive health care worker guidelines.

2\. Convince the President to establish a concrete goal regarding
provisions of services for people in need, as he has done with vaccine
development and infection rates. (Services Subcommittee)

3\. Work for reauthorization of the Ryan White CARE Act, including
reform of ADAP to ensure funding available for providing and maintaining
a comprehensive set of therapies (without the need for emergency
supplemental appropriations).

4\. Followup on vaccine recommendations. (Research Subcommittee)

5\. Get the Attorney General to provide a directive to the Bureau of
Prisons that mandates pre-discharge planning, including appointments
with service agencies, and requirement that medical summaries follow the
individual from prison to postrelease treatment. (Prison Issues
Subcommittee)

6\. Work for reauthorization of HOPWA. (Services Subcommittee)

7\. Work to increase ONAP staff resources, including both full-time
employees and the continuity of personnel, with special emphasis on (1)
greater involvement in international issues and (2) a coordinating role
on the vaccines issue. (Executive Committee)

8\. Ensure that the Patient Bill of Rights for Health Care includes
clear and explicit reference to HIV care needs, including access to care
and implementation of the treatment guidelines. (Services Subcommittee)

9\. Follow through with ONAP on youth programs status report and plan.
(Mr. Sasser)

10\. Evaluate progress on previous PACHA recommendations regarding HIV
surveillance. (Prevention Subcommittee)

**B: New Council Recommendations**

**Passed During the PACHA Meeting June 15-18, 1998**

**Discrimination Subcommittee** (Passed with 2 opposed)

Regardless of the U.S. Supreme Court determination of the legal rights
of those with HIV/AIDS under the Americans with Disabilities Act, the
Administration should develop and vigorously pursue a comprehensive
strategy to provide the strongest possible protections from
HIV/AIDS-based discrimination.

**International Subcommittee** (Passed with 2 opposed)

The Presidential Advisory Council on HIV/AIDS recommends that the
President support efforts in Congress directed at amending the Embargo
Authority in the Foreign Assistance Act of 1961 so that any such embargo
[shall not apply with respect to the export of any food, medicines,
medical supplies, or medical equipment, or with respect to travel
incident to the delivery of food, medicines, medical supplies, medical
instruments, or medical equipment]{.underline}. The embargo of such
supplies contributes to the suffering of persons with HIV/AIDS and other
diseases.

**Prison Issues Subcommittee** (Passed unanimously)

The Centers for Disease Control and Prevention should offer technical
assistance to Federal and State correctional systems for the development
of data collection instruments on incidence and prevalence of
HIV/STD/TB. The CDC should also assist with the assessment of the data
collected in order to implement appropriate prevention activities,
primary health care, and substance abuse therapies.

**Racial and Ethnic Minorities Subcommittee** (Passed unanimously)

. Request that the President convene a special meeting with the
Congressional Black Caucus and Hispanic Congressional Caucus to develop
a strategy regarding the State of Emergency in the African-American and
Latino communities.

2\. Call for a special White House Conference on the State of Emergency
in Communities of Color at the end of the Council's current term (July
1999).

**Leadership Recommendations on Youth Issues** (Passed unanimously)

1\. The Council requests that the Office of National AIDS Policy present
a detailed status report on the implementation of the recommendations
outlined in the White House ONAP report, "Youth and HIV/AIDS: An
American Agenda."

2\. The Council requests that the Office of National AIDS Policy present
a detailed status report on the implementation of recommendations from
the Presidential Directive.

  ------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------
  **C: Council Responses to Executive Committee Options**                         
                                                                                  
  **Number of responses**                                                         **Response**
                                                                                  
  **1. Who should be on the Executive Committee?**                                
                                                                                  
  15                                                                              Subcommittee Chairs (Process Group), plus several others to achieve diversity and balance
  2                                                                               The Executive Committee should be elected by the Council
  1                                                                               Two designees from each Subcommittee (not necessarily Chairs) and Scott Hitt
  1                                                                               Tom Henderson, Joseph Edelheit, Regina Aragon, Nick Bollman, Alexandra Levine, Helen Miramontes, Alexander Robinson, Scott Hitt, Denise Stokes, Mike Isbell
  1                                                                               A diverse representation of affected communities
  1                                                                               Council members who are not involved in key decision making opportunities
                                                                                  
  **2. What should the Executive Committee do?**                                  
                                                                                  
  10                                                                              Plan meeting agendas
  10                                                                              Set political priorities, policies, and the strategic moving of issues
  6                                                                               Work with ONAP and Daniel to move issues/monitor implementation of Council recommendations
  4                                                                               Respond to media
  4                                                                               Resolve conflicts, deal with process issues
  3                                                                               Ensure communication between ONAP and PACHA
  3                                                                               Monitor external relationships, delegate requests for information, meetings, and advice to appropriate Committees, Subcommittees, and Council members
  2                                                                               Advise Chair regarding between-meeting activities (media, meetings with Administration officials)
  1                                                                               Monitor and report adherence to work programs
  1                                                                               Ensure all Council members' opinions are considered
  1                                                                               Ensure all individual Subcommittee issues are given equal priority
  1                                                                               Makes decisions in absence of the Council
  1                                                                               Select new Council members
                                                                                  
  **3. Given the above duties, how often should the Executive Committee meet?**   
                                                                                  
  10                                                                              Every 2 to 4 weeks, more frequently as meetings get closer, and on an as-needed basis
  4                                                                               Every other month, or as needed
  3                                                                               During each Council meeting or before the start of the Full Council meeting. Should visit each Subcommittee
  1                                                                               As determined by Executive Committee and Full Council
                                                                                  
  **Additional Responses**                                                        
                                                                                  
  3                                                                               Meetings should be open to all Council members; however, voting rights maintained by Executive Committee
  3                                                                               Special attention must be given to people of color and youth issues
                                                                                  
  **No Executive Committee should be appointed**                                  
                                                                                  
  4                                                                               
                                                                                  
  ------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------

Total Responses Received: 24

**D: Letter to the President Regarding Needle Exchange**

**Preliminary First Draft**

(Letter drafted by Mr. Anderson, to be reviewed by the Executive
Committee and the Prevention Subcommittee, and submitted to the full
Council before sending it to the President.)

Dear Mr. President:

As members of your Presidential Advisory Council on HIV/AIDS, we must
convey the profound disappointment, frustration, and anger we feel about
the course of action you have chosen to take relative to needle
exchange. The belated willingness to certify that needle exchange
programs help reduce HIV infection without increasing drug use was an
important step forward; unfortunately, the accompanying refusal to allow
States and localities to use Federal funds to support this successful
intervention represents nothing more than the triumph of political
expediency over scientific evidence and compelling human need. Your
stated commitment to ending new HIV infections is seriously called into
question by this action.

The issue is not resolved---injection drug use continues to drive the
HIV epidemic in our country, taking a particularly heavy toll on
African-American and Hispanic communities. Your decision on this matter
simply accentuates the failure of your Administration (and the country
as a whole) to take effective action to stem the twin epidemics of HIV
and drug use in our country.

While we continue to strongly believe that allowing Federal funds to be
used for needle exchange programs is one vital part of an effective
response to the spread of HIV among drug users, failure to take this
step must be accompanied by a willingness to take other significant and
bold steps to meet this public health challenge.

First, it is not enough to simply talk about drug treatment without
taking significant steps to increase and improve drug treatment capacity
in this country. It will require a significant investment of resources
to create a system where all drug users have immediate access to
effective drug treatment, resources your Administration as of yet has
failed to put into place. We must set a goal of providing treatment on
demand for any drug user in this country. It is our intention to work
with members of your Administration and community advocates to shape a
national commitment to universal drug treatment access, and to support
the resources necessary for these programs.

Second, we must do a better job of coordinating the diverse Federal
efforts to prevent HIV infection among drug users and their sexual
partners. During the White House Summit on HIV/AIDS in December of 1995,
you called for a national meeting bringing together public health and
substance abuse providers to address this issue. An August 1997 meeting
was held in Tampa, but since that time, no discernible action has taken
place on this matter. You must instruct the leaders of the relevant
Federal agencies to implement the recommendations that came out of that
meeting.

Third, programs to reach out-of-treatment drug users with education,
counseling, support, and HIV testing services must be enhanced,
including an increased financial commitment to the CDC's HIV prevention
programs. The failure to seek budget increases for these prevention
programs is one more serious reason to question your commitment to
effective HIV prevention.

Fourth, we have previously urged Federal efforts to change the Model
Drug Paraphernalia Act to allow possession of small numbers of syringes,
a step that numerous studies have indicated have been highly effective
in preventing new HIV infections in those States that have changed their
laws. We have yet to see any meaningful action on this recommendation,
and we urge you to make this happen.

Fifth, we urge you to instruct the various agencies of the Federal
Government to determine ways to effectively link prevention and
substance abuse programs with needle exchange programs in communities
where they operate. In addition, these same agencies should be
instructed to, when appropriate, participate in efforts to advance
scientific and public understanding of needle exchange programs, and to
study and advance knowledge of successful programs around the country.

Finally, we remind you that the decision not to allow Federal funds to
be used for needle exchange programs will result in unnecessary new HIV
infections. In response to these many new infections, we urge you to
allocate sufficient resources to meet the medical and social service
needs of those who are infected. Future budget levels for Ryan White,
HOPWA, Medicaid, and other Federal programs funding these services must
take into account these new infections.

As your advisors on HIV/AIDS, we must urge you to seriously and
effectively address the continuing crisis of HIV among injection drug
users and their sexual partners. In light of your decision on needle
exchange, action of the items outlined above becomes even more
imperative.

Sincerely,

PACHA

[Presidential]{.smallcaps}

[Advisory]{.smallcaps}

[Council on]{.smallcaps}

[HIV/AIDS]{.smallcaps}

736 Jackson Place, N.W.

Washington, DC 20503

August 26, 1998

Floyd Bloom, M.D.

Editor, *Science* Magazine

American Association for the

Advancement of Science

1200 New York Avenue, N.W.

Washington, D.C.

Dear Dr. Bloom:

As members of the Presidential Advisory Council on HIV/AIDS (PACHA), we
would like to clarify our position and recommendations made to President
Clinton regarding the development of a vaccine against HIV. It is clear
from the letter published in *Science* on May 8, 1998, by Agosto et al.
that the authors had either not read or not understood the
recommendations which we made.

First, under no circumstance did PACHA recommend that the
"\...responsibility for the development of an HIV vaccine should be
removed from the NIH and transferred to other Federal agencies." What we
did recommend, in fact, was that the NIH should continue its major
responsibility in terms of defining the scientific basis for further
vaccine development. We also recommended, however, that other Federal
agencies with known experience and expertise in vaccine development be
brought onto the team. With the daunting tasks ahead, it would seem
obvious that one agency alone, no matter how accomplished, would be less
than optimal. Further, since multiple existing agencies---such as the
CDC, DoD, and others---have already had years of experience in various
aspects of vaccine generation and testing, it appeared clear to us that
all existing expertise should be employed, if the President's goal of
finding an effective HIV vaccine within a decade is to be realized.

A second major emphasis of our recommendations relates to the fact that
no administrative mechanism currently exists to ensure the ongoing
communication and collaboration of all existing Federal agencies
involved in HIV vaccine work. While the Levine commission recommended
such coordination in its report to the NIH, and while occasional and
sporadic meetings have been held among members of various Federal
agencies, no one, in fact, has been given responsibility for ensuring
ongoing coordination of the Federal vaccine effort. Further, multiple
complex and interrelated social and political issues also must be
addressed for successful implementation of an AIDS vaccine. It is clear,
for example, that the pharmaceutical and biotechnology industries must
be involved, yet there is no existing mechanism to ensure their ongoing
communication and collaboration with the NIH and other Federal agencies.
It is clear that representatives of the international community must be
involved, including groups such as the World Bank, the United Nations,
and the International AIDS Vaccine Initiative. However, no
administrative mechanism exists to ensure the requisite ongoing
communication among these groups and the NIH and other Federal agencies.
After spending years in studying these issues, PACHA has recommended
that the role of administrative coordination of the Federal vaccine
effort be placed within the White House, implemented through the Office
of National AIDS Policy, which reports directly to the President of the
United States.

The authors of the letter to *Science* indicate that PACHA has advocated
the widespread testing of existing empiric vaccine approaches. In fact,
based upon the continuing increase in HIV-infected persons throughout
the world---despite all efforts at behavioral intervention---we have
recommended that both empiric and traditional scientific methods be
employed in an attempt to develop an effective AIDS vaccine as quickly
as possible.

We hope that these comments will clarify the position of PACHA in terms
of the Federal HIV vaccine effort. Clearly the goals of PACHA and the
authors of the letter are the same: development and implementation of a
successful AIDS vaccine as quickly as possible. Toward this end we
believe that expertise from all relevant agencies within the Federal
Government and administrative coordination on a national and
international level will be required to actually achieve this goal.

Sincerely yours,

R. Scott Hitt, M.D.

Chair, Presidential Advisory Council on HIV/AIDS

Alexandra Levine, M.D.

Chair, Research Subcommittee

Presidential Advisory Council on HIV/AIDS

\*This letter was never sent.

**F: Letter to Dr. Kathleen Hawk Sawyer**

**Federal Bureau of Prisons**

**Draft by the Prison Issues Subcommittee**

(Letter tabled until the November meeting.)

Dr. Kathleen Hawk Sawyer

Federal Bureau of Prisons

Dear Dr. Sawyer:

We, the members of the Presidential Advisory Council on HIV/AIDS, are
extremely concerned about your unwillingness to discuss the use of
protective barriers in Federal prisons. We are aware of the many
difficult issues that this question poses for you. However, these
concerns pale compared to the risk of transmission of HIV, Hepatitis B,
Hepatitis C, and other sexually transmitted diseases (STDs) in prison.
(As reported in the 47.21MMWR.)

We all know that sexual behavior continues among incarcerated
individuals. In light of this reality, we must do all we can to prevent
life-threatening illnesses. We do know that protective barriers reduce
the transmission of HIV and other STDs. Numerous State and international
prison experts have recommended the use of protective barriers in the
prison setting. Furthermore, several State, county, and city prison
systems in our country, as well as several Federal institutions in other
countries, have introduced the use of protective barriers in their
institutions as one means of preventing the spread of HIV disease. Of
course, this should be part of an overall prevention strategy that
includes education, appropriate medical intervention, and other
harm-reduction models.

Protective barriers can save lives.

Certainly the lack of protective barriers does not discourage sexual
behavior. The lifetime cost of taking care of one new case of HIV
disease is hundreds of thousands of dollars. The prison population
offers us a unique opportunity for a comprehensive prevention effort;
protective barriers must be a part of this effort if it is to be
effective.

We again request that you meet with our Prison Issues Subcommittee at
the earliest opportunity prior to our next Council meeting.

Sincerely yours,

Prisons Issues Subcommittee

cc: Eleanor Acheson

Janet Reno

**G: Letter to Secretary Shalala and Attorney General Reno**

**Draft by the Prison Issues Subcommittee**

(Letter tabled until the November meeting.)

Dear Secretary Donna Shalala and Attorney General Janet Reno:

We want to be assured that the PHS AIDS Treatment Guidelines are the
standard of medical care in our Nation's prisons and jails.

We have the following questions:

· Have those guidelines been put into place?

· Can you provide us with documentation of their implementation?

· How are you ensuring that all appropriate providers are being trained
in the use of these guidelines?

· How has the use of these guidelines been evaluated?

On behalf of the Presidential Advisory Council on HIV/AIDS, we are
requesting a report that specifically outlines the use of the PHS
Treatment Guidelines in our Federal corrections system. Please provide
us with that information within 90 days. If you cannot do so, please
provide us with an explanation as to why this information is not yet
available.

Sincerely,

Prison Issues Subcommittee

PACHA

**H: Private Organizations, Government Agencies, and Media**

**Represented at the PACHA June 1998 Meeting**

**Private Organizations**

Advocates for Youth

AIDS Action Council (AAC)

AIDS Policy Center for Children, Youth, and Families

AIDS Vaccine Advocacy Coalition (AVAC)

Alliance for Microbicide Development (AMD)

American Bar Association (ABA)

American Civil Liberties Union (ACLU), National Prison Project

American Foundation for AIDS Research (AmFAR)

Asian and Pacific Islander Wellness Center

Biosyn, Inc.

Children's Hospital of Philadelphia/University of Pennsylvania

Church of Saint Philip the Evangelist

Committee of Ten Thousand (COTT)

DOORWAYS, St. Louis

Drug Policy Foundation

Gay and Lesbian Medical Association (GLMA)

Gay Men's Health Crisis (GMHC)

Global AIDS Action Network (GAAN)

Hilfman and Fogel

HIV/AIDS Bureau

HIV/AIDS Indians

James Irvine Foundation

Midwest AIDS Prevention Project

Montefiore Medical Center

MOSAICA

Multicultural AIDS Coalition

National Alliance of State and Territorial AIDS Directors (NASTAD)

National Association of People With AIDS (NAPWA)

National Black Leadership Commission on AIDS

National Hemophilia Foundation

National Latino/a Lesbian and Gay and Bisexual and Transgender
Organization (LLEGO)

National Organizations Responding to AIDS (NORA)

National Youth Advocacy Coalition

Native Affairs and Development Group (NADG)

Pacific Oaks Medical Group

Prisoners' HIV/AIDS Support Action Network (PASAN)

St. Clare's Hospital

San Francisco AIDS Council

San Francisco AIDS Foundation (SFAF)

Sexual Minority Youth Assistance League (SMYAL)

Society for the Advancement of Women's Health Research (SAWHR)

Southern Colorado AIDS Project

Southwest Medical Associates

Targeted Alliances

Temple Israel

Texas General Land Office

University of California, Los Angeles

University of California, San Diego

University of California, San Francisco

University of Pennsylvania School of Medicine

University of Southern California School of Medicine

Washington Center

**Government Agencies**

Centers for Disease Control and Prevention (CDC)

Department of Children and Families, Miami/Dade County

Department of Health and Human Services (DHHS)

Department of the Interior (DOI)

Department of State (DOS)

Health Care Financing Administration (HCFA)

Health Resources and Services Administration (HRSA)

Indian Health Service (IHS)

National Institute of Child Health and Human Development (NICHD)

National Institute of Allergy and Infectious Diseases (NIAID)

Office of National AIDS Policy (ONAP)

Office of Representative Nancy Pelosi (D-Calif.)

Office of the Vice President

Substance Abuse and Mental Health Services Administration (SAMHSA)

**Media**

*AIDS/STD News Report*

*Bay Area Reporter*

*The Blue Sheet*