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PUBLIC HEALTH CHALLENGES IN OUR 

NATION’S CAPITAL 

HEARING 

BEFORE THE

OVERSIGHT OF GOVERNMENT MANAGEMENT, 

THE FEDERAL WORKFORCE, AND THE 

DISTRICT OF COLUMBIA SUBCOMMITTEE 

OF THE

COMMITTEE ON 

HOMELAND SECURITY AND 

GOVERNMENTAL AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED ELEVENTH CONGRESS 

FIRST SESSION 

MAY 19, 2009 

Available via http://www.gpoaccess.gov/congress/index.html 

Printed for the use of the Committee on Homeland Security 

and Governmental Affairs 

( 

(II) 

COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS 

JOSEPH I. LIEBERMAN, Connecticut, Chairman 

CARL LEVIN, Michigan 

DANIEL K. AKAKA, Hawaii 

THOMAS R. CARPER, Delaware 

MARK L. PRYOR, Arkansas 

MARY L. LANDRIEU, Louisiana 

CLAIRE MCCASKILL, Missouri 

JON TESTER, Montana 

ROLAND W. BURRIS, Illinois 

MICHAEL F. BENNET, Colorado 

SUSAN M. COLLINS, Maine 

TOM COBURN, Oklahoma 

JOHN MCCAIN, Arizona 

GEORGE V. VOINOVICH, Ohio 

JOHN ENSIGN, Nevada 

LINDSEY GRAHAM, South Carolina 

MICHAEL L. ALEXANDER, Staff Director 

BRANDON L. MILHORN, Minority Staff Director and Chief Counsel 

TRINA DRIESSNACK TYRER, Chief Clerk 

OVERSIGHT OF GOVERNMENT MANAGEMENT, THE FEDERAL 

WORKFORCE, AND THE DISTRICT OF COLUMBIA SUBCOMMITTEE 

DANIEL K. AKAKA, Hawaii, Chairman 

CARL LEVIN, Michigan 

MARY L. LANDRIEU, Louisiana 

ROLAND W. BURRIS, Illinois 

MICHAEL F. BENNET, Colorado 

GEORGE V. VOINOVICH, Ohio 

LINDSEY GRAHAM, South Carolina 

LISA M. POWELL, Chief Counsel and Acting Staff Director 

CHRISTINE S. KHIM, Counsel 

JENNIFER A. HEMINGWAY, Minority Staff Director 

THOMAS A. BISHOP, Minority Professional Staff Member 

BENJAMIN B. RHODESIDE, Chief Clerk 

(III) 

C O N T E N T S 

Opening statement: Page 

Senator Akaka .................................................................................................. 1 

WITNESSES 

TUESDAY, MAY 19, 2009 

Pierre N.D. Vigilance, M.D., MPH, Director, District of Columbia Department 

of Health ............................................................................................................... 3 

Shannon L. Hader, M.D., MPH, Senior Deputy Director, HIV/AIDS Administration, District of Columbia Department of Health ......................................... 5 

Raymond C. Martins, M.D., Chief Medical Officer, Whitman-Walker Clinic, 

and Clinical Professor of Medicine, George Washington University ............... 7 

ALPHABETICAL LIST OF WITNESSES

Hader, Shannon L., M.D., MPH: 

Testimony .......................................................................................................... 5 

Prepared statement .......................................................................................... 38 

Martins, Raymond C., M.D.: 

Testimony .......................................................................................................... 7 

Prepared statement .......................................................................................... 51 

Vigilance, Pierre N.D., M.D., MPH: 

Testimony .......................................................................................................... 3 

Prepared statement .......................................................................................... 23 

APPENDIX 

Background .............................................................................................................. 55 

Paul Strauss, a U.S. Senator for the District of Columbia (Shadow), prepared 

statement .............................................................................................................. 67 

(1) 

PUBLIC HEALTH CHALLENGES IN OUR 

NATION’S CAPITAL 

TUESDAY, MAY 19, 2009 

U.S. SENATE,

SUBCOMMITTEE ON OVERSIGHT OF GOVERNMENT

MANAGEMENT, THE FEDERAL WORKFORCE,

AND THE DISTRICT OF COLUMBIA,

OF THE COMMITTEE ON HOMELAND SECURITY

AND GOVERNMENTAL AFFAIRS,

Washington, DC. 

The Subcommittee met, pursuant to notice, at 2:48 p.m., in room 

SD–342, Dirksen Senate Office Building, Hon. Daniel K. Akaka, 

Chairman of the Subcommittee, presiding. 

Present: Senator Akaka. 

OPENING STATEMENT OF SENATOR AKAKA 

Senator AKAKA. This hearing will come to order. 

Good afternoon, everyone. Thank you for joining us today as the 

Subcommittee on Oversight of Government Management, the Federal Workforce, and the District of Columbia meets to evaluate the 

current state of public health in the District, examining the health 

challenges facing its residents, and the steps being taken to respond to those challenges. 

D.C. has the highest rate of HIV/AIDS in the Nation, a distinction that is cause for great concern. The 2008 HIV/AIDS Epidemiology Update concluded that at least 3 percent of District residents 

live with HIV or AIDS. More than one-third of those infected are 

unaware of their HIV status. Data from the Centers for Disease 

Control (CDC) confirm that infection rates among D.C. residents 

have remained among the highest in the Nation for a number of 

years now. These figures also show HIV infection cutting across all 

demographics, highlighting the need for initiatives designed to 

reach people of every race, income level, and orientation. 

The HIV statistics have not been all negative. Overall, the District’s publicly supported HIV testing increased by 70 percent from 

2007 to 2008. In 2007, only one baby was born with HIV in the 

District compared to 10 babies in 2005, indicating that pregnancy 

initiatives are taking root. 

These improvements are due in no small part to the D.C. Department of Health (DOH) and HIV/AIDS Administration, which have 

focused their efforts on increased testing and prevention, working 

with the D.C. Public Schools to offer education and sexually transmitted disease (STD) testing. Also in place is a drug assistance proVerDate Nov 24 2008 14:22 Mar 09, 2010 Jkt 051030 PO 00000 Frm 00005 Fmt 6633 Sfmt 6633 P:\DOCS\51030.TXT SAFFAIRS PsN: PAT
2 

gram under which some residents receive free medication to treat 

their HIV. 

While HIV/AIDS Administration initiatives offer promise, there 

is still much work to be done, especially in the area of testing. If 

residents do not know their HIV status, they cannot seek treatment and they may be at greater risk of spreading the virus to others. 

In addition to HIV/AIDS, D.C. has a disproportionately high 

chronic disease burden compared with the rest of the Nation. Onethird of D.C. residents suffer from heart disease, diabetes, or kidney disease. These diseases share common risk factors including 

high blood pressure and being overweight. In 2007, 55 percent of 

D.C. adults and 18 percent of youths were obese or overweight. The 

District must promote proper diet and exercise to lessen the burden 

of chronic disease. 

Late last year, Mayor Adrian Fenty announced the Chronic Care 

Initiative to increase chronic disease testing and treatment. The 

Initiative also aims to address common risk factors by promoting 

a healthy lifestyle. 

I want to highlight two work groups focused on addressing obesity and preventing health risks early in life. The D.C. Obesity 

Work Group is charged with creating a citywide obesity action plan 

to be released later this year. The School Health Work Group focuses on providing healthier food options, especially to students in 

the D.C. Public Schools. 

The DOH participates in the Obesity and School Health Work 

Groups and has developed the Child Health Action Plan, which addresses a range of health risks including obesity and encouraging 

students to make healthy and informed decisions. I am pleased the 

DOH recognizes the need to prevent health risks early in life. 

It will not be easy to ensure that people seek routine testing and 

primary health care, especially when they do not have insurance or 

qualify for special assistance. Nevertheless, we must act to slow the 

growth of all diseases and to promote health. I have long supported 

programs to prevent, detect, and more effectively treat chronic diseases and medical conditions. In addition, I have led efforts to improve access to quality health care for indigenous people as well as 

racial and ethnic minorities who often lack access and suffer disproportionately from certain diseases such as diabetes. 

The DOH cannot overcome health challenges alone. It is important to work with community organizations to reach as many people as possible. I am encouraged by partnerships between the DOH 

and community groups and hope more alliances are formed to address all of D.C.’s health issues. 

Today’s hearing is meant to foster an ongoing dialogue on these 

important issues as we gain a greater understanding of D.C.’s 

health challenges and possible solutions to those challenges. I look 

forward to hearing from our witnesses today. 

I would now like to welcome today’s witnesses to the Subcommittee: Dr. Pierre Vigilance, who is the Director of the D.C. Department of Health; Dr. Shannon Hader, who is the Senior Deputy 

Director of the HIV/AIDS Administration; and Dr. Raymond Martins, who is the Chief Medical Officer at the Whitman-Walker Clinic in D.C. 

3 

1The prepared statement of Dr. Vigilance appears in the Appendix on page 23. 

It is the custom of this Subcommittee to swear in all witnesses. 

I would ask all of you to stand and raise your right hand. Do you 

swear that the testimony you are about to give this Subcommittee 

is the truth, the whole truth, and nothing but the truth, so help 

you, God? 

Dr. VIGILANCE. I do. 

Dr. HADER. I do. 

Dr. MARTINS. I do. 

Senator AKAKA. Thank you very much. Let the record show that 

the witnesses responded in the affirmative. I want the witnesses to 

know that while your oral statements are limited to 5 minutes, 

your entire statements will be included in the record. 

Dr. Vigilance, please proceed with your statement. 

TESTIMONY OF PIERRE N.D. VIGILANCE, M.D.,1 DIRECTOR, 

DISTRICT OF COLUMBIA DEPARTMENT OF HEALTH 

Dr. VIGILANCE. Thank you, Chairman Akaka, distinguished 

Members of the Subcommittee. I am Pierre Vigilance, and I am the 

Director of the District of Columbia’s Department of Health. I am 

honored to testify before you today on public health challenges in 

the Nation’s capital, and I am pleased to be joined by Drs. Hader 

and Martins as we discuss the HIV/AIDS epidemic in the District 

as well. Thank you, Chairman Akaka, for your significant work and 

your service in the health care arena. It goes to some extent to 

show how dedication to this particular field has benefited us significantly, and hopefully today’s testimony will assist you in your 

work. 

Public health prevents illness, it promotes wellness, and it protects the people from health threats. Public health saves lives, and 

at a time when health care reform is front and center in our national policy debate, many agree that public health is the missing 

factor that can lead to cost-saving solutions needed to save our Nation’s health. Effective public health practice educates people, advocates for the conditions that promote wellness, links people to care, 

and provides access to treatment. 

The District’s Department of Health is an agency of 836 staff 

with an annual budget of $268 million. Our work spans the public 

health spectrum from oversight, inspection, and regulation of 

health facilities to emergency preparedness, addictions prevention, 

community health, and HIV/AIDS. Annually, the department provides immunizations to over 3,600 people. Last year, we facilitated 

access to care through a network of community clinics that serve 

some 93,000 people. We investigated 775 communicable disease 

cases, removed approximately 130,000 potentially tainted needles 

from the street, and inspected 388 health facilities. 

The District boasts a high rate of health insurance relative to 

similar jurisdictions across the country, with 90.5 percent of our 

residents being insured but only 20 percent of them indicating that 

they have a regular source of care. In fact, some 3,000 District residents die each year from preventable causes of death: Heart disease, cancer, cerebrovascular disease, accidents, and HIV/AIDS. 

4 

We understand that the reasons for this are a combination of factors affecting lifestyle, including poverty, illiteracy, unemployment, 

poor health conditions, social inequities that influence access to 

health care, and other resources that influence health themselves. 

Behavior plays a part, but all poor health outcomes cannot be attributed to this alone. 

The breadth of problems facing our communities require that we 

partner with our local non-government agencies, businesses, and 

sister agencies, such as Health Care Finance, Parks and Recreation, Homeland Security, Fire and Emergency Medical Services 

(EMS), just to name a few. 

Obesity is a health challenge to which we have taken a collaborative approach. It is a major contributing factor, as you mentioned, to many chronic illnesses, including hypertension, cardiovascular disease, and stroke. Youth in the District suffer disproportionately from obesity, and our work in the D.C. Public Schools 

shows that 17.5 percent of D.C. Public School students self-report 

that they are obese. The Obesity Work Group that you mentioned 

comprised a number of different community stakeholders, workforce leaders, and others coming together to strategize on ways to 

combat obesity. 

I am fortunate to work for an executive who understands the importance of effective public health. We also work for an empowered 

City Council, which in 2007 asked us to develop a 5-year strategic 

plan targeting cardiovascular disease, diabetes, and kidney disease, 

a plan that serves as a tool for coordinating services to reduce poor 

health outcomes. 

Since the major causes of chronic kidney disease are high blood 

pressure and diabetes, the Department has funded programs to address risk factors such as blood pressure and blood glucose control. 

The Cardiovascular Diseases, Diabetes, and Kidney Diseases 

(CDK) Plan laid the groundwork for the Chronic Care Initiative 

which will guide our city’s service delivery system toward high reliability, high value, and high quality care. 

In 2006, nearly $250 million in tobacco settlement funds were 

dedicated to public health. Initially, funds were directed to cancer, 

tobacco cessation, chronic disease, and health information technology. We have invested in the consortium of community-based 

providers to provide a comprehensive tobacco cessation program, 

and we have also invested significantly in health information technology, a regional health information organization with six diverse 

community health centers as well as two emergency departments. 

In 2007, the Rand Report provided us with a backdrop that will 

guide our distribution of the remaining tobacco settlement funds, 

and we have continued to invest in primary and emergency care, 

and will be investing shortly in a health care facility on the old 

D.C. General site, as well as in other locations in the city. 

We will also be working significantly with the incoming American Recovery and Reinvestment Act funds which will allow us to 

move some of our health empowerment activities further into the 

communities that we serve. 

Lives can be saved through a very collaborative preventionfocused approach to health and wellness. The significant economic 

burden of disease requires that we pay particular attention to preVerDate Nov 24 2008 14:22 Mar 09, 2010 Jkt 051030 PO 00000 Frm 00008 Fmt 6633 Sfmt 6633 P:\DOCS\51030.TXT SAFFAIRS PsN: PAT
5 

1The prepared statement of Dr. Hader appears in the Appendix on page 38. 

vention. More work needs to be done on policies that will impact 

the root causes of health problems, policies that effectively address 

food, content and availability, and physical activity opportunities in 

communities where the health disparities are most pronounced. 

More needs to be done to help people understand for what they 

are at risk. Effecting long-term improvements in health will take 

concerted effort and time. From the classroom to the boardroom, 

public health can facilitate the discussion between previously disconnected partners and lead us to living healthier, more productive 

lives. 

Senator AKAKA. Thank you very much for your statement. Now 

we will hear from Dr. Hader. Please go ahead with your statement. 

Thank you. 

TESTIMONY OF SHANNON L. HADER, M.D., MPH,1 SENIOR DEPUTY DIRECTOR, HIV/AIDS ADMINISTRATION, DISTRICT OF 

COLUMBIA DEPARTMENT OF HEALTH 

Dr. HADER. Chairman Akaka, Ranking Member Voinovich, and 

Members of the Subcommittee, I am Shannon Hader, Senior Deputy Director of the HIV/AIDS Administration in the District of Columbia Department of Health. I appreciate this opportunity to 

present testimony for you on the HIV/AIDS epidemic in the District 

of Columbia, and my oral testimony will cover highlights about our 

new statistics, our strategies and initiatives, and, of course, my 

written testimony covers these topics in much more detail. 

Overall, as you mentioned, 3 percent of all District residents in 

our city are currently known to be diagnosed and living with HIV 

and AIDS. To put that in context, U.S. Centers for Disease Control 

and Prevention and the World Health Organization (WHO) have 

historically defined an HIV epidemic as ‘‘severe’’ when just 1 percent of the overall population is affected. These numbers, as you 

stated, however, reflect only the people who have been diagnosed 

with HIV/AIDS. Targeted studies in D.C. show that between onethird and one-half of our residents who are already infected with 

HIV may be unaware of their infection. In the District, nearly 

every population group, age group, and ward is experiencing a substantial epidemic. 

The District has also one of the most complex epidemics in the 

world, with all three major modes of transmission at high levels. 

Among new cases, heterosexual contact is the highest at nearly 40 

percent, followed by sex between men who have sex with men at 

about 25 percent, and injection drug use still at 15 percent. 

I am pleased to share some of the promising results of the District’s efforts to reduce the disease. Particularly, the District’s HIV 

testing programs have greatly increased timely testing and early 

diagnosis among residents and have reduced the number of babies 

born with HIV, as you mentioned in your testimony. In addition to 

reducing the number of babies born, we have also seen a 70-percent 

increase in the number of people tested in publicly supported testing from 40,000 in 2007 to over 70,000 in 2008. 

The District was actually just recognized by the CDC as one of 

the top three jurisdictions in the country in expanded HIV testing. 

6 

D.C. nearly equaled both New York City and the entire State of 

Florida in absolute numbers of persons tested as well as new HIV 

cases identified. 

These achievements are the mark of true committed leadership 

to reverse the epidemic by our Mayor Adrian Fenty. Our modern 

epidemic requires a modern response. I can summarize this in 

Mayor Fenty’s directives to me since I started this position, which 

are essentially go fast, go far, and do not go it alone. 

Go fast. The Mayor has repeatedly emphasized a clear urgency 

for response marked by actions that are not just a flash in the pan, 

but are focused for a sustained and impactful response. An example 

of this is our HIV testing program which, as I described earlier, 

has rapidly expanded and already shown an earlier diagnostic impact in the course of just 2 years, yet is sustainable and scalable. 

It aims to mobilize our health care system to make HIV as regular 

a test as blood pressure, blood sugar, cholesterol, and other vital 

signs tests. In a city where HIV is a common disease, an annual 

test for HIV must be a standard vital sign for every resident’s 

health. 

Go far. The Mayor has directed us to bring the District’s response to scale and impact. We are ramping up our enrollment in 

care and treatment programs. Through marketing and outreach, 

we have increased enrollment in our AIDS Drug Assistance Program by over 50 percent in just an 18-month period. This is now 

the highest level ever. 

We are also reaching more residents with tools to prevent transmission. The District is one of only two cities with a large public 

sector free condom distribution program, and we have distributed 

over 1 million condoms in the past 6 months and are on target to 

reach 3 million condoms per year. In addition, following Congress’ 

lifting the ban on the use of our own local dollars to support needle 

exchange, we have implemented comprehensive harm reduction 

programs which in just the first 6 months have already enrolled 

900 people into the services, linking 40 percent of them to detox 

and treatment services, and removed 130,000 used needles from 

the street. 

The District is also breaking new ground in the country with innovative programs, including a couples HIV testing initiative, expansion of the Parents Matter curriculum, and an evidence-based 

intervention that trains parents to communicate with their young 

pre-sexual children that has been very successful elsewhere in the 

world. 

Do not go it alone. One of the cornerstones of our Mayor’s directive is to build strong partnerships. In terms of community partnerships and outreach through the Effi Barry Program, we have 

engaged more than 50 small organizations, many of which who do 

not designate HIV as their primary mission, to mainstream HIV/ 

AIDS into their daily programming. We are expanding our faithbased partnerships through our Places of Worship Advisory Board, 

and we have funded an umbrella organization to work with faith 

leadership of multiple denominations to take on the mantle of HIV. 

For young people, we are partnering with D.C. Public Schools in 

curriculum development implementation, a rollout of voluntary 

school-based STD screening and treatment, and in offering free inVerDate Nov 24 2008 14:22 Mar 09, 2010 Jkt 051030 PO 00000 Frm 00010 Fmt 6633 Sfmt 6633 P:\DOCS\51030.TXT SAFFAIRS PsN: PAT
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1The prepared statement of Dr. Martins appears in the Appendix on page 51. 

formation for STD and HIV, as well as screening and treatment to 

young people who are in our Summer Youth Employment Program. 

I have reached my time limit, so I am going to truncate my oral 

report. So, in summary, I think there are also many opportunities 

for us to work even more collaboratively and effectively with our 

Federal partners, both in coordination of the Federal support for 

our programs as well as in response to specific requests for funding 

supplements we have made that will help us not just scale up our 

programs but to catch up for the years where this response has not 

been marked by aggressiveness, by evidence base, or by leadership. 

Finally, we might have the most complex epidemic in the country, but the current state of our epidemic is now emerging in other 

urban areas across the country as well. The increase in heterosexual contact is now surfacing in cities like Atlanta and Miami, 

and many urban areas have hot spots within them that reflect 

similar patterns and challenges to what is seen just citywide here 

in D.C. 

So we have reached the proverbial fork in the road for the domestic HIV response. The trends in our city’s epidemic are now 

emerging in other urban areas, so turning the tide in the District, 

right here in your backyard, is an important model for other urban 

area hot spots as well. We assure you that our leadership, innovation, and capacity are present to return the Federal investment in 

our city and turn the corner for District residents for the HIV/AIDS 

epidemic. 

Senator AKAKA. Thank you very much for your testimony. Now 

we will hear from Dr. Martins. 

TESTIMONY OF RAYMOND C. MARTINS, M.D.,1 CHIEF MEDICAL 

OFFICER, WHITMAN-WALKER CLINIC, AND CLINICAL PROFESSOR OF MEDICINE, GEORGE WASHINGTON UNIVERSITY 

Dr. MARTINS. Good afternoon, Chairman Akaka and Members of 

the Subcommittee. Thank you for inviting me to provide testimony 

about public health challenges that face the District of Columbia, 

specifically in regards to HIV. 

I am a primary care and HIV physician in the District, which is 

also where I completed my medical training and I currently reside. 

I have been the Chief Medical Officer (CMO) of the Whitman-Walker Clinic for the past 15 months. Through our two District health 

centers, Whitman-Walker Clinic acts as part of the health care 

safety net in D.C., providing care to the lesbian, gay, bisexual, and 

transgender (LGBT) community, persons living with HIV, and others who face barriers to care. We provide a primary medical home 

to more than 3,000 HIV-positive patients. My experiences there, as 

well as from my previous practices, and recent data and research 

results form the basis of my comments. 

The District of Columbia is in a unique situation with respect to 

HIV as compared with other cities in the United States. The 2008 

HIV/AIDS Epidemiologic Update for the District reported that 3 

percent of District residents have been confirmed to be living with 

HIV. However, random sampling research shows that the number 

infected with HIV is likely closer to 5 percent. These numbers far 

8 

exceed most cities within the United States and are truly staggering. 

A major factor that contributes to this, especially in comparison 

with other major metropolitan areas, is the increased prevalence of 

HIV in multiple communities. HIV in the District finds itself in 

every race, economic status, and social network. Throughout the 

rest of the United States, men who have sex with men is the predominant mode of transmission for new HIV infections. In contrast, 

Washington, DC is the only major city in the United States where 

heterosexual intercourse is the main mode of transmission for new 

infections. 

Why is this the case? According to a recent study, District residents who report being in heterosexual committed relationships are 

infrequently monogamous and often do not use condoms. This sex 

outside the relationship, along with the lack of condom use in a 

population with a high prevalence of HIV, likely explains the increased incidence of HIV in the heterosexual community. 

My response to this is three-fold. One, the District should continue an aggressive HIV testing campaign. I think we are all in 

agreement on that. Two, the clinical guidelines regarding treatment for HIV need to be re-evaluated. And three, health care providers within the District need to increase their own collaborative 

efforts. And allow me to expand on my recommendations. 

First, testing people for HIV early, often, and repeatedly helps to 

assure that we are focusing our energies. I do not believe we should 

give up on education, prevention, and behavioral change models; 

but, I think it would be unwise to focus all resources solely on education and behavioral change. Rather I propose that we should rely 

on aggressive HIV testing to identify everyone who is HIV positive 

and change clinical treatment strategies to lessen new infections. 

HIV opt-out testing was started in 2007 by the D.C. Department 

of Health. Through this program, more HIV tests are being performed, and we are catching people earlier in their disease. The 

District is now diagnosing people with HIV on average before they 

develop AIDS and any associated complications. 

Second, current HIV treatment guidelines recommend following 

a patient with regular blood tests until their CD4 count falls below 

350 and then to recommend initiating antiretroviral therapy. During those years off medications, the patients often have a large 

amount of HIV in their blood (i.e., a high HIV viral load) and can 

easily infect others. Alternatively, if we treated patients with HIV 

medications soon after infection, the viral load should be suppressed to very low levels much sooner, and it would be more difficult for them to transmit HIV to someone else. 

Additionally, recent clinical trials have shown benefit to the individual patient when starting HIV medications earlier. This change 

in public health protocol will only work with the change in guidelines from the International AIDS Society (IAS), the Infectious Disease Society of America (IDSA), the Department of Health and 

Human Services (HHS), and other agencies. If accumulating data 

does not support generalized clinical benefit, there should be at 

least a recommendation specific to the District to offer HIV medications earlier to potentially curb new transmissions. 

9 

Third, I strongly believe that one of the only ways we can change 

the course of the District’s HIV epidemic is through a coordinated 

and aggressive response. Collaboration between local health authorities, universities, research centers, community health centers, 

and private practices will be critical. Many programs such as the 

D.C. Center for AIDS Research have focused on increasing grants 

for HIV clinical and basic research. 

One program that should have immediate impact on the HIV epidemic is the D.C. Cohort. This collaboration will allow the District 

to follow nearly 10,000 clients to better understand the HIV epidemic in real time and the ongoing issues surrounding care, treatment, and survival. 

In closing, the 2008 D.C. HIV/AIDS Epidemiologic Update served 

as a call to action, with much media attention to the increased HIV 

numbers. However, it appears to have been quickly forgotten. The 

District would benefit from an aggressive media campaign so the 

public is frequently reminded of the severity of HIV along with the 

recommendation for everyone to be tested on a regular basis. 

By using the Treatment as Prevention strategy, patients will be 

started on antiretrovirals earlier in their disease and will be less 

likely to transmit to others. Through these programs, more individuals will be diagnosed with HIV and will need an expanded HIV 

primary care infrastructure within the District. 

Whitman-Walker Clinic appreciates the leadership of the Subcommittee in holding this hearing, and we look forward to providing whatever guidance or support that we can offer. 

Thank you. 

Senator AKAKA. Thank you very much, Dr. Martins. 

I have a few questions for you all. Dr. Hader, the District has 

increased publicly supported HIV testing by 70 percent in 1 year. 

That remarkable achievement was possible in part because the District has implemented HIV Opt-Out testing, where individuals no 

longer have to request a test but may choose to decline it. Yet the 

2008 epidemiology report on HIV/AIDS indicated that more than 

one-third of D.C. residents who are infected with HIV do not know 

their status. 

How extensively is the Opt-Out testing program used in the District and how could it be more effective? 

Dr. HADER. Thank you for that question. Yes, while we are very 

proud of the gains we have made in expanded HIV testing over the 

past 2 years, we also know we have a long way to go. The District 

is one of the first jurisdictions in the country that formalized the 

policy for routine opt-out testing in medical settings as well as 

going one step further and said we do not want you to just get tested once, we want you to get tested routinely and repeatedly 

through your health care provider. 

So in translating policy to implementation, our major steps have 

been in emergency room settings as well as primary care settings, 

developing the models, and achieving enough results that inform 

our further scale-up. For example, we have two emergency rooms 

(ER) out of six that would be useful for routinely testing for HIV. 

We are on target to expand with the participation of those other 

four ERs during the next 18 months. 

10 

Likewise, we started with one major primary care network, our 

Unity Health Care provider, that routinely provides services, primary care services to 80,000 District residents to help roll out 

amongst their 17 main clinics routine HIV testing, and they are 

the ones who actually developed this fifth vital sign model so that 

you get offered an HIV test automatically when you are getting 

your vital signs done. If you say no the first time, your doctor is 

going to also follow up before you leave and say, ‘‘Are you sure you 

do not want one?’’ Because we offer it to everyone. 

So our goals for this year are to expand those lessons learned in 

the first primary care network amongst our other Medicaid and 

D.C. Alliance-funded managed care networks of primary care to get 

to scale. 

Now, what is going to help us achieve these results faster? And 

I think this highlights that although we have a progressive policy, 

we have a lot of catch-up to do from people who have not known 

their status for a long time. So one of the requests we have put into 

the CDC is actually saying if we have a one-time doubling of our 

overall budget for HIV testing, we can rapidly get up to scale 

across our ERs and our primary care networks, as well as continuing to drive demand among clients so that 18 months from now 

we will have completely doubled our entire results from that onetime investment. 

So we hope that we will hear back from the CDC that is a positive investment because without the additional resources, we will 

keep on track, but we will not get there as quickly. 

Senator AKAKA. Well, thank you very much for what you are 

doing. 

Dr. Martins, Whitman-Walker Clinic has long been a part of the 

community response to HIV/AIDS. I understand that WhitmanWalker has had to adjust for limited resources, high demand for 

services, and changing demographics of those that you serve. 

Will you please describe the steps your clinic is taking to keep 

pace with these pressures? 

Dr. MARTINS. Sure. So, Whitman-Walker, a few years ago 

changed the way it offered services. As of a few years ago, it was 

mainly a grant-based organization that only saw patients with 

HIV, and it was started by the LGBT community here in Washington. At that time it was decided to expand services to the larger 

community in Washington, and so while continuing to serve its 

main constituents, it offered services to a larger group. 

To me, I like that we have decided to expand our offering because, previously in the older model, if you were in the LGBT community but you were HIV negative, Whitman-Walker really could 

not help you. We could do some STD testing for you, but we could 

not be your primary care center. 

So now I feel like we are the primary care center for a larger 

community. 

What is true is that finances, as a community health center in 

an urban environment, are always tough and we have tried not to 

cut back on any kind of large-scale medical or mental health services. However, we have had to cut back some of the additional services we offer, but keep the medical and mental health ones going 

strong. That is how we have adjusted to the pressures. 

11 

Senator AKAKA. What about the demand for services? Is that 

overwhelming? 

Dr. MARTINS. The demand is always there. We have a large number of new patients; we have a large number of new HIV clients. 

We have the largest STD clinic in the city on Tuesday and Thursday nights. We see on average 30 to 40 individuals each night, and 

we have to turn people away because it is so popular. And the sad 

part of those statistics is amongst those 30 to 40 people, it is not 

uncommon to have two to three to four new HIV diagnoses each 

night. 

So it is programs like that where I wish we could expand our offerings and offer an additional night a week we could accept more 

patients, but to do that, we would need additional funding. 

Senator AKAKA. Dr. Martins, you mentioned that Whitman-Walker provides primary care services. Can you please explain why it 

is necessary to focus on a person’s overall health rather than focusing only on one particular health risk? 

Dr. MARTINS. Sure. So HIV, as a perfect example, with the advent of good HIV medications, people are living for much longer, 

and perhaps decades longer than before. Those people, due to the 

medications they are on, the disease itself, and the fact that they 

are getting older, are at increased risk of getting diabetes, heart 

disease, and all the things that we predict as a population ages. 

So I think to truly be an HIV primary care provider for a person, 

you would have to look at the whole person and be comfortable 

with treating the entire individual, because otherwise those diseases will probably kill the person long before the HIV will. 

Senator AKAKA. Thank you for your response on that. 

Dr. Vigilance, I commend the Department of Health for its many 

health initiatives and programs, and I also commend you for your 

work as its director. As you well know, the District faces the challenge of coordinating effectively with a variety of Federal agencies, 

nearby States, and many local entities to effectively protect public 

health. 

What steps are DOH taking to promote coordination and to minimize waste and miscommunication? 

Dr. VIGILANCE. Well, there are a number of different places in 

which we work very closely, as you mentioned, with local and Federal partners. I think a very good example of a coordinated activity 

with which we are regularly involved is our emergency preparedness work. Recently, the H1N1 situation that swept the Nation and 

is still in play, if you will, provided an opportunity for us to work 

not only as the National Capital Region with our colleagues in 

northern Virginia and in southern Maryland but also with our colleagues at the CDC and colleagues in other Federal agencies who 

provided us with guidance and expertise as we needed moving forward. That activity was mirrored by our activities around the inauguration, where we also were very involved with those entities at 

a time when there was a need for that collaboration. 

I think that is a good model for ongoing activity with respect to 

some other aspects of the Health Department’s activity. I know 

that the HIV/AIDS Administration is very closely involved with not 

only the National Institute of Health (NIH) but also with the CDC, 

and the investments in that particular practice are evident. 

12 

We have some investments in chronic disease related to the CDC 

activity that we have around diabetes, for example, but there certainly is a need for us to be a bit more thoughtful about how it is 

that we can make best use of those partners, not only the obvious 

partners, but also partners who are in the District that receive 

funds from those agencies. So we have a lot of other agencies within the District of Columbia, such as academic institutions, that receive funding that we would do well to partner with a bit more effectively around chronic disease. We do some work with them now, 

but we could do well to do more. 

Senator AKAKA. Dr. Hader, I understand that in the past the Department of Health and D.C. Public Schools (DCPS) have not always coordinated effectively. What steps have you taken to improve 

communication and collaboration with DCPS specifically? 

Dr. HADER. Well, for young people, we are partnering with D.C. 

Public Schools on multiple fronts. First, is on health curriculum, so 

D.C. Public Schools and the Office of the State Superintendent of 

Education (OSSE) about a little over a year ago passed health 

learning standards that included learning objectives on sexual 

health. Since that time, we have been actively participating in the 

DCPS school health curriculum to identify, roll out, and develop 

evaluation processes asking, do kids actually learn this stuff for elementary, junior high, and high school schools? Now, many of these 

curricula are already in place, but the formalized, multi-school curriculum will be starting in September. 

Second, we work directly with the D.C. Public Schools to roll out 

this innovative, school-based STD screening program for kids. It is 

both an education, a diagnostic and treatment, but also a transmission interruption program. We have modeled it after New York 

City and Philadelphia and the objective is to go into schools, diagnose kids voluntarily and confidentially who might not know they 

have an STD, and treat them rapidly for their infection while we 

are also providing them information and sharing that information 

that would be helpful with partners. 

In our initial activities there, we have diagnosed STD infection 

rates between 8 percent and 20 percent on any given day in any 

group of kids. We have expanded—because of the Mayor’s advocacy, we have expanded this program to our Summer Youth Employment Program as well. 

Third, through our Community Health Administration, in collaboration with D.C. Public Schools, we support training of all the 

school health nurses to be able to counsel students effectively on 

sexual health issues, including STDs and HIV. 

So I believe our collaboration has improved dramatically, and we 

look forward to gaining the results of that collaboration. 

Senator AKAKA. Thank you for that response. 

Dr. Hader, the Youth and HIV Prevention Initiative was introduced in 2007 and is set to end next year. Please elaborate on what 

the initiative has accomplished and whether there are plans to extend programs under this initiative. 

Dr. HADER. Sure. I think the Youth and HIV Prevention Initiative, as marked by our Youth and HIV Prevention Strategic Plan, 

has been a fantastic collaboration, and what that initiative did was 

it brought together the Department of Health along with many of 

13 

our youth HIV and AIDS focused service providers from the community to identify not only what the needs were from what the 

data showed, but what the needs were based on their experience 

on the ground, and to support the capacity organizations to reach 

more kids with more useful services. And some of the highlights 

that came out of that are a lot of the D.C. Public Schools collaborations that I highlighted are direct results of the planning, 

prioritization, and advocacy of that group. In addition, youth HIV 

testing has expanded dramatically, and I think the specific numbers are in our written testimony. 

Third, one of the things we are very proud of is there has been 

the development of a specific youth social marketing campaign with 

one of our youth providers, Metro TeenAIDS, that had direct involvement in young people saying, ‘‘Yes, that makes sense to me. 

I understand it. It will catch my attention,’’ to encourage kids to 

learn about their sexual health, to ask questions, to get tested, and 

to really make some, hopefully, safer decisions with respect to their 

relationships. 

Another thing we are very proud about is now that we have got 

our core service providers delivering more services and more results, we want to expand our circles of influence. So one of the activities we funded this year for the first time was for one of our 

HIV/AIDS expert youth organizations to work with a whole bunch 

of other young organizations that were not health-related or HIVrelated organizations to be able to mainstream basic information 

about HIV, sexual health, and where to get more services and information into their day-to-day implementation. 

So we have increased funding dramatically through this initiative. We have also increased results, and absolutely I can tell you 

that the commitment to ongoing youth programming is there. And 

the end of the first plan will just be the beginning of a new plan, 

I am quite sure. 

Senator AKAKA. Thank you for that response. 

Dr. Vigilance, your testimony mentioned the Child Health Action 

Plan and also states that children in the District are at greater risk 

of obesity than children in the United States generally. Improving 

residents’ nutrition and exercise habits are critical to reducing 

chronic diseases. This is especially true for children whose habits 

are just being formed. 

I would like to hear more about the Child Health Action Plan, 

in particular how it addresses nutrition and exercise. 

Dr. VIGILANCE. So there are a number of components to the Children’s Health Action Plan, and obesity is just one of them. Another 

piece that has been mentioned is the sexual health piece of things. 

What is interesting and important to remember is that, in order 

to make good choices, the cornerstone is actually some knowledge. 

And so education is one of the major pieces of the plan that sort 

of just assumes that this is about children who are getting educated and educated appropriately with respect for what they are at 

risk and what it is that they need to do in order to live healthy 

lives. 

But there is some work that is going on right now within the 

school system with respect to changing the actual food choices that 

children can have available to them, and some of that work is 

14 

going to reap some long-term benefits for us. But we understand 

that children only spend so much of their day in school; there is 

a need for environmental changes outside of the school. And so as 

part of the Obesity Action Plan and the Children’s Health Action 

Plan, too, we have looked at what the environments are in which 

these children live, especially in some of our poorer neighborhoods, 

with respect to their food access. When we refer to food access, we 

are referring to not only the availability of grocery stores in those 

neighborhoods, but actually the availability of fresh fruits and 

vegetables, food that is low in fat, low in carbohydrates, etc., and 

also the availability of that food in the local corner stores. And so 

the Healthy Corner Store Initiative, while it is separate from the 

Children’s Health Action Plan, definitely affects children’s health 

by making corner stores more aware of the choices that are available to their clients so that children who go into those stores might 

be able to gain access to something other than potato chips or 

candy and be able to make use of those stores to buy things that 

are actually nutritious for them. 

Again, this is an education process on the vendor side, and there 

is an economic development piece to that. But there is also a choice 

piece on the child’s side and having an understanding of what is 

good for them helps them make better choices. 

We understand very well, too, that the Children’s Health Action 

Plan will also influence adults because children come home and influence parents and family members in a particularly special way. 

So we want to make sure that the information that we impart 

to children in schools is something that they can translate and take 

home and make use of in the home so that hopefully adults change 

their behaviors as well. Sometimes that is a little more difficult 

than we would like for it to be, but it is certainly a piece of the 

pie as we look forward. 

So the Children’s Health Action Plan is one of a number of different initiatives that come together to try to change not only behaviors and attitudes towards food, diet, and exercise, but also 

seeks to educate the children and those who the children influence 

themselves as we try to make people a little bit more healthy from 

the child’s perspective. 

Senator AKAKA. Thank you for that response. 

Dr. Hader, I highlighted the drop in HIV infections among newborn babies in the District in my opening statement. I commend 

you and others who have joined in this effort for the progress D.C. 

has made in prenatal HIV testing, which allows an infected mother 

to get treatment that greatly reduces the risk of transmission to 

the baby. 

How is the District working toward its goal of HIV testing for all 

pregnant women? 

Dr. HADER. Well, we took an urgent response to that problem of 

ongoing perineal transmission, and we actually started our intervention at the last opportunity for intervention to prevent motherto-child transmission, which is the labor and delivery suite. And we 

started by working with all of our labor and delivery suites to be 

able to not only recognize that they want to make sure they know 

a mother’s HIV status when she rolls through their door, but if she 

does not have that in her medical record, to be able to offer an onVerDate Nov 24 2008 14:22 Mar 09, 2010 Jkt 051030 PO 00000 Frm 00018 Fmt 6633 Sfmt 6633 P:\DOCS\51030.TXT SAFFAIRS PsN: PAT
15 

site rapid test while there is still time to intervene with 

antiretroviral therapy during delivery to prevent transmission to 

the baby. 

So that was our urgent point of intervention, and we have been 

successful in scaling up from one hospital center that was already 

doing that to, I believe, some amount of screening and testing in 

five of our six delivery sites. 

Second then is reaching out—and we have been doing this—to all 

providers, in particular the obstetrician/gynecologist (OB/GYN) providers, including in collaboration with the American College of Obstetrics and Gynecology (ACOG) to fully implement routine screening recommendations not only during the first prenatal visit but 

also, because we are a highly affected city and per CDC and ACOG 

guidelines, repeat screening in the third trimester to catch that 

very rare occasion where someone gets newly infected during pregnancy, but those people we know who get newly infected are much 

more likely to transmit to their baby. 

So how are we going to measure the impact of all those outreach 

efforts in real time, not just waiting for a baby to fall through the 

cracks, but know how well are we doing with mothers? We have 

been working directly within the Department of Health with our 

Center for Policy and Epidemiology to update the vital registration 

process so that the information that is reported during the regular 

vital statistics birth record process includes that information about 

when the mother was tested and did you have those test results 

and what action was taken based on those test results. And I think 

by being able to monitor routinely how much success we are getting in the overall screening and implementation of guidelines will 

tell us how to target additional technical assistance and efforts for 

providers or delivery sites that might be falling down on the job. 

Senator AKAKA. Thank you for that response. 

Dr. Martins, in your testimony, you suggested using treatment as 

a form of prevention, and you recommend changes to national and 

international clinical guidelines. If those changes are not possible, 

how would you recommend D.C. implement a Treatment as Prevention program? 

Dr. MARTINS. So I think that program would only work if there 

was a recommendation from a level higher than the provider to 

offer treatment earlier. I am not sure if that would be the Department of Health or what would be the most appropriate for the District, because for this to be effective, it would have to get to all the 

physicians who are in private practice, who are at the community 

health centers, at the universities, where everyone is being treated. 

Current guidelines say that we can offer treatment at a CD4 count 

higher than 350, so it is an option. We are not going against current guidelines. It would just require a recommendation so that we 

could improve the public health of the city as well as possibly the 

individual benefit of the patient, because recent trials have shown 

that the actual individual patients benefit from being treated earlier. And hopefully decrease the transmission rate in the city. 

Senator AKAKA. Thank you. 

Dr. Vigilance, as elevated blood lead levels are especially dangerous in young children and cause developmental delays, what 

types of lead screening and treatment programs exist in D.C.? 

16 

Dr. VIGILANCE. Well, until last year, those activities did sit within the Department of Health, and now we work very closely with 

the Department of Environment to actually have those programs 

covered. So the children who need to be screened for lead are actually referred to their private providers and work with the Department of Environment to determine what is necessary for them 

moving forward, and they work very closely with a couple of the 

universities in the area regarding the lead in children specifically. 

We recently provided some clinical guidance for parents who had 

questions about whether or not their children had been exposed as 

a result of an exposure that came up recently from some years ago 

and assisted in that regard by providing some basic guidelines for 

parents to follow. But the program itself no longer sits within the 

Department of Health. 

Senator AKAKA. Dr. Vigilance, given the high rate of HIV/AIDS 

and chronic diseases in the District, some residents suffer from a 

combination of diseases, as Dr. Martins noted. How is DOH coordinating its HIV outreach and public campaigns with the other 

chronic disease initiatives? 

Dr. VIGILANCE. So as Dr. Hader has mentioned, the data drives 

a lot more of what the Department of Health does now, and certainly having the Center for Policy, Planning, and Epidemiology 

now in my office, we are paying a great deal of attention to the 

data and what the data was telling us with respect to where to go. 

I think that if you look at any map of the District with respect 

to the prevalence of poverty, the prevalence of tobacco use, the 

prevalence of HIV, the prevalence of homicide, those things are all 

overlaid there, very similarly distributed. And we can see that, 

using our data, we will need to be putting a number of different 

resources into some particular parts of the city. Without wanting 

to stigmatize any one particular area, basically either side of the 

river, Wards 5, 6, 7, and 8 typically bear the brunt of our chronic 

disease burden and our HIV burden, and HIV is becoming more, 

as Dr. Martins mentioned, a chronic disease. 

So we have no choice but to coordinate our efforts, and I think 

that one of the things that is going on with respect to HIV and 

with respect to the Chronic Care Initiative (CCI), is that we are 

trying to move HIV testing away from the sort of community-based 

organization, only special event testing, into the regular routine 

medical encounter. And in doing that and by investing in the primary care settings that we are investing in with the tobacco settlement funds and by investing in the Chronic Care Initiative, which 

gets providers to think a little bit more holistically about their patients and not just think about the traditional boxes of chronic disease but add HIV and asthma and some other conditions to their 

list of concerns that they query patients about, we can do a better 

job of aligning providers with the needs that our patients actually 

have. 

But that is the patient-provider conversation. There is a separate 

conversation that we are also having which relates to people and 

place, and this refers more to what we refer to as the ‘‘social determinants of health,’’ those things that go into making communities 

healthy that are outside of the health care system. Since we understand that only about 15 to 25 percent of your health is a function 

17 

of the actual health care encounter, there are a number of other 

factors that go into you being healthy. They include, as mentioned 

before, availability of various resources, such as healthy food options, jobs, good education, etc. So we understand that we have to 

work more collaboratively with the school system, with Parks and 

Recreation, with the Mental Health Administration, and with other 

non-health agencies as well—businesses and non-government organizations, to create a bit more of a network where health and 

wellness is just the baseline as opposed to something that we are 

actually reaching for. We should understand that it is something 

that everybody needs to have at a bottom line, and that requires 

that we do a lot more in the way of collaboration. And we are 

reaching out to a number of partners to continue to do that, especially in the areas that are of greatest need in the city. Again, 5, 

6, 7, and 8 are the wards of greatest concern, but we understand 

that across the city we have high rates of chronic diseases across 

the board, and we need to be looking at more than just those areas 

and more than just one particular socioeconomic and/or ethnic 

group. 

Senator AKAKA. Dr. Vigilance, your testimony states that the 

DOH will seek funds to improve health information technology. 

Health Information Technology (IT) often requires a large up-front 

investment with the promise of improving efficiency and the quality of care over the long run. Additionally, health IT systems, 

which allow greater sharing of patient information among health 

professionals, must be implemented with great attention to protecting patients’ privacy. 

I would like to hear more about your plans for this initiative. 

What is the scope of the project in terms of the financial investment and patients who will be served? 

Dr. VIGILANCE. Your question with respect to scope is timely and 

important, because health IT, as we typically discuss it, is placed 

in the box of the patient-provider conversation. So, appropriately, 

it refers to electronic medical records, personal health records, and 

health information exchange opportunities such as those involved 

in the regional health information organizations (RHIOs). We have 

a small RHIO here in the city. Six of our community health centers 

and two of our hospital emergency departments are involved in 

that activity, and it is important to make sure that we share information appropriately and make sure that people’s privacy is maintained. 

The stimulus package funds that are coming down through the 

American Recovery and Reinvestment Act (ARRA) will actually assist the District in being able to provide potentially set-up funds, 

as you mentioned, to some of those providers who are taking care 

of the Medicaid and Alliance population that we have here in the 

city. We would want to ensure that those providers, as well as others, have access to the start-up funds and the maintenance dollars 

potentially to be able to start an electronic medical record system 

within their practice and one that is interoperable and completely 

transparent, and at the same time highly secure. 

We have recently had conversations with a number of partners, 

health care partners and business partners, around what exactly is 

the definition of health information technology for the District, and 

18 

we would like to take the conversation a little further than the traditional conversation has gone and start talking a little bit about 

tools that we can use on the technology side to assist people in 

managing their illnesses, managing their diseases; broadband access improvement so they actually have access to some of these 

many tools that are available on the Web, for example, because 

there is a digital divide that the city still very much lives in; and 

also helping people just gain access to information through a number of different technology applications that sit, again, outside of 

the patient-provider conversation. 

And so we have the stimulus funds that have not come to the 

city yet, but there is an anticipation that there will be stimulus 

funds for the Medicaid and Alliance provider population, but we 

are also looking to invest some of our tobacco settlement funds in 

filling some of the holes that the stimulus package money is actually not going to fill because there were some specific eligibility criteria around those stimulus funds that may allow us to do certain 

things but not others, and we want to make sure that we cast a 

wide net and appropriately invest in health information technology 

that benefits people and providers, no matter where they are. 

Senator AKAKA. Dr. Vigilance, the recent H1N1 outbreak has 

highlighted the need for pandemic preparedness. I have been impressed with the response so far at all levels of government. The 

District faces a particular challenge preparing for and responding 

to a potential disease outbreak. As our Nation’s capital and a major 

hub for tourism, government, and business, the District could be a 

focal point for infectious disease transmission, and an outbreak in 

the District could disrupt government operations nationally. 

What steps is DOH taking to respond to the H1N1 flu, and what 

preparation is ongoing to respond to any future wave of H1N1 infections? 

Dr. VIGILANCE. So prior to H1N1 coming, and for some time now 

we have been involved in pandemic flu preparedness planning, and 

that has involved not only being able to effectively monitor the situation, quickly diagnose people, appropriately isolate them, if necessary, and provide them access to medical treatment, but also 

have the right staff on hand within the Department of Health and 

also within our partner population, if you will, in the National Capital Region to be sure to be able to have a timely response to any 

issues that come around. 

We are fortunate in this region to have a very strong group that 

is involved in planning around issues that are related to all hazards, and we take an all-hazards approach to this situation. So the 

same sort of surge capacities, the same sort of disease surveillance 

activities would be what we would engage in no matter what the 

disease was. 

The H1N1 situation allowed us to engage in real time with a 

number of different partners in the immediate area, and I think 

that one of the biggest lessons learned from that has been that our 

ongoing communications with our partners put us in a very good 

place to be able to react quickly and appropriately to the situation 

at hand. 

There were some particular challenges that H1N1 provided with 

respect to school closures, and I think that is one area where, as 

19 

you have mentioned, the ability for a disease to actually create a 

situation that spills over into the everyday lives of people who are 

not actually infected with the disease is important to note, and the 

fact that we have such good relationships with the school system 

now made it very easy for us to get people onto conference calls 

quickly and make quick decisions about what to do about particular students in particular schools on particular days. And so we 

were fortunate to be able to do that, again, in part because of the 

ongoing conversations that we have on a regular basis. 

We are not through H1N1 yet, but we are still monitoring that 

situation and had a stakeholders meeting last week to pull together 

a number of the people from the District who dealt with the situation and hear from them what exactly it is that we need to be 

doing better. We have had regular conference calls with our hospital partners. Our primary care partners are very well engaged 

with us. The emergency preparedness side of things with Homeland Security and Emergency Management, again, a strong partner 

with us, and has been with us from the beginning on this. 

And so these ongoing communications allow us to mount a 

stronger and more unified response on a regular basis, and we are 

confident, never comfortable but confident, that we will be able to 

rise to the occasion if needed on a larger-scale basis. 

For businesses, one thing that was important, we recognized the 

need to reach out to them early and to actually advise them on 

dusting off their continuation of operations plans, those plans that 

need to be put in place should, in fact, a good number of their staff 

are not able to come to work. We ourselves have those plans and 

have identified essential services as we instruct all businesses to 

do the same, so that if there is a situation where people have to 

stay home in large numbers, the business can continue as usual. 

I am not sure that as a region we are necessarily there. We have 

not reached the destination of being completely prepared, but we 

are certainly moving in the right direction with respect to our Continuity of Operations (COOP) planning and, therefore, with respect 

to our pandemic planning as a whole. We hope to never have to 

necessarily enact the entire plan, but should we have to, then we 

think we are in pretty good shape. 

Senator AKAKA. Thank you. 

Dr. Martins, as you testified, in 2008 Whitman-Walker alone reported 541 new cases of HIV. This number, along with what we 

know from the behavior and epidemiology reports concerns me 

greatly. You provide several specific recommendations for addressing this epidemic. Given limited resources, what should be the top 

priorities for the District Government and for Congress? 

Dr. MARTINS. I think when you are facing a large amount of the 

population being infected with HIV, with a certain number not 

knowing they are infected, the biggest thing is you want to get as 

much information as possible. So I think more collaborations and 

networks that we can get real-time information on people who are 

newly infected, resistance patterns, all those kind of data, having 

it come together. 

One of the collaborations that will help us with that is called the 

DC Cohort, and that is a collaboration between NIH, the HIV/AIDS 

Administration, George Washington University (GWU), and a large 

20 

amount of the HIV providers. It is going to give us real-time numbers based on patient data. The data is going to be de-identified, 

but it is going to give us kind of real-time—where is the epidemic 

going and what are we doing that is effective? So especially when 

it comes to how are we going to change the epidemic, we want to 

know when it is effective immediately, not wait a year or two for 

data to know if we are doing a good job. 

But I think if we are going to focus energies, I think it is on finding more information and on testing people more. I think that 

would be probably—at least the first place to kind of put all your 

money. And then from that standpoint on, my biggest push is to 

test people—I mean, to treat people with HIV medications earlier 

in their disease, and the main reason I push for that is the fact 

that we know—when we have looked at all the HIV studies trying 

to change behavior, none have been effective in reducing HIV or 

other STDs. And so I do not want to push everything into behavioral change models. I like the idea of using what we know about 

science to effect change and not just going back to the behavioral 

change models. 

Senator AKAKA. Well, thank you. That is my last question for you 

as Chief Medical Officer. 

Dr. Vigilance, I held a hearing in April during which the D.C. 

Chief Financial Officer projected that the District may have revenue shortfalls due in part to the recession. Reduced revenue will 

create pressures for budget reductions. 

In this climate, how will the District address the health care 

needs of its residents? And what programs will be prioritized? 

Dr. VIGILANCE. Sir, that is a great question, and I think we can 

look at this time as a period when the glass is half-full or a time 

when the glass is half-empty. The opportunity to do better work 

when you have less resources is obviously a challenge, but it is necessary. And I think that one of the things that we need to do a better job of within the Department of Health is defining exactly what 

are the most essential services and where are the areas of greatest 

impact for us, which is why when we discuss the three major 

things that affect the city with respect to health, we speak to obesity, we speak to infant mortality, and we speak to HIV. And having that focus on those three main areas that actually branch out 

into a number of other areas themselves, we can actually potentially be more efficient not only in our thought processes but also 

in our financial investments. 

We are fortunate to be able to have some funding available to us 

to do capital development at the moment. We recognize that even 

though we do that capital development, we have to also change behaviors in order for people to make use of the facilities that we 

build. And that process in and of itself requires that we do better 

partnering. 

So the first part of the answer to your question is that we have 

to actually focus ourselves a bit more specifically on some areas 

that may have gotten some focus before, but now require greater 

focus from us because of what they portend, what they lead us to; 

and then, second, to actually do a better job of partnering with potentially non-government agencies, be they private businesses or 

for-profit or nonprofit agencies that have reached into communities; 

21 

and, third, to do actually that, which is reach out to communities 

a bit more effectively and teach communities to actually be more 

able to do what they need to do to sustain and maintain their own 

health and wellness. I think providing people with those tools will 

require not only that we actually spend some time and resources, 

but that we actually make use of some of the resources that are 

already available within communities to get some of those things 

done. So those would be the three parts to the answer. 

Senator AKAKA. Yes. My last question, of course, was on priorities. Dr. Hader, do you have anything to add to Dr. Vigilance’s or 

Dr. Martins’ responses regarding what the priorities should be for 

the District’s HIV/AIDS initiatives given the limited resources? 

Dr. HADER. Of course I do, and I will build on a few themes and 

add a little bit more. 

First, to reiterate, testing, testing, testing, testing for HIV is absolutely the linchpin, and it is the linchpin for both prevention and 

better care and treatment outcomes. Testing is a prevention intervention. We know the vast majority of people, once they find out 

they are HIV positive, immediately take action to help prevent 

transmitting their infection to other people. It is estimated at a national level that at least half and up to 70 percent of new infections 

from HIV are transmitted from people who do not know they are 

positive. And so testing is prevention. 

But where do we go from there? Care and treatment. We know 

that if people get immediately into care and treatment, that ongoing contact with a supportive care system not only can deliver information tools and messages for prevention on a consistent and repetitive basis, but we also suspect and hope, as Dr. Martins mentioned, the antiretroviral treatment itself by lowering viral load 

makes people less infectious. 

A complement to that on the prevention side, though, is, I think, 

some of the basic shifts and scaled interventions that we are investing in as a priority do make a difference. First tools, having 

prevention tools available and available at the scale of our epidemic. And for us, those major tools include information—real, 

real, real information—condoms, and clean needles. 

Second, it is actually addressing risk perceptions. We are in a 

paradigm shift, I think, in the District because of the better information and data we have. For a long time, I think, human nature 

is ‘‘HIV is everybody else’s disease.’’ I think with our new data that 

shows nearly every ward, nearly every group, nearly every age is 

affected by HIV. We can take that and run with that and say, it 

is a new world for risk perception. You do not have to have a whole 

lot of risky behavior in an environment that has got a lot of HIV 

out there to come in contact with HIV. So each individual needs to 

be aware that they are living in a risky environment. 

And then, third—and I think this is a fundamental paradigm 

shift as well—is highlighting as part of our priorities that HIV is, 

in fact, not just about the individual; it is about relationships. It 

is about the individual and their romantic partners. It is about an 

individual and their family. It is about an individual and their 

communities. So if we can help to expand the conversation from not 

just ‘‘What do I do for me?’’ but ‘‘What do I do for the people I care 

about? What are the kind of difficult issues I need to grapple with 

22 

to keep the people I love safe, to keep myself safe? How do I support my partners, my friends, and families to make choices and decisions that will take us as a community to a better state for HIV 

and AIDS?’’ That is a cheap priority, but it is a really important 

one because it is one we cannot do just as the District Government 

ourselves. It requires absolute investment by all leaders across the 

board and all sectors in the District Government. 

So we hope to stimulate and start those conversations for a paradigm shift that make all of our other services more effective. 

Senator AKAKA. Well, thank you very much for that. I want to 

thank you again for your testimonies today. Based on your testimonies, we have learned a great deal about HIV/AIDS, chronic diseases, and other health challenges in the District, as well as the 

progress that has been made. I would encourage D.C. to continue 

its aggressive HIV testing campaign and to strengthen partnerships with organizations like Whitman-Walker Clinic. 

This hearing has highlighted the need for effective communication not only within the D.C. Government but also within the community, and I must say that your responses have echoed that need. 

It is important that you move forward together as you work to improve the health of all D.C. residents. 

The hearing record will remain open for 1 week during which 

time Members of the Subcommittee may submit additional questions. 

Again, I want to thank you very much. Your testimonies have 

been helpful, and we look forward to your future success in this 

health program. 

The hearing is adjourned. 

[Whereupon, at 4:05 p.m., the Subcommittee was adjourned.] 

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