[Senate Hearing 109-846]
[From the U.S. Government Publishing Office]
S. Hrg. 109-846
ENSURING EARLY DIAGNOSIS AND ACCESS TO
TREATMENT FOR HIV/AIDS: CAN FEDERAL
RESOURCES BE MORE EFFECTIVELY TARGETED?
=======================================================================
HEARING
before the
FEDERAL FINANCIAL MANAGEMENT, GOVERNMENT
INFORMATION, AND INTERNATIONAL
SECURITY SUBCOMMITTEE
of the
COMMITTEE ON
HOMELAND SECURITY AND
GOVERNMENTAL AFFAIRS
UNITED STATES SENATE
ONE HUNDRED NINTH CONGRESS
SECOND SESSION
----------
APRIL 26, 2006
----------
Printed for the use of the Committee on Homeland Security
and Governmental Affairs
U.S. GOVERNMENT PRINTING OFFICE
28-242 PDF WASHINGTON : 2007
------------------------------------------------------------------
For sale by Superintendent of Documents, U.S. Government Printing
Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800;
DC area (202) 512-1800 Fax: (202) 512-2250. Mail: Stop SSOP,
Washington, DC 20402-0001
COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS
SUSAN M. COLLINS, Maine, Chairman
TED STEVENS, Alaska JOSEPH I. LIEBERMAN, Connecticut
GEORGE V. VOINOVICH, Ohio CARL LEVIN, Michigan
NORM COLEMAN, Minnesota DANIEL K. AKAKA, Hawaii
TOM COBURN, Oklahoma THOMAS R. CARPER, Delaware
LINCOLN D. CHAFEE, Rhode Island MARK DAYTON, Minnesota
ROBERT F. BENNETT, Utah FRANK LAUTENBERG, New Jersey
PETE V. DOMENICI, New Mexico MARK PRYOR, Arkansas
JOHN W. WARNER, Virginia
Michael D. Bopp, Staff Director and Chief Counsel
Joyce A. Rechtschaffen, Minority Staff Director and Chief Counsel
Trina Driessnack Tyrer, Chief Clerk
FEDERAL FINANCIAL MANAGEMENT, GOVERNMENT INFORMATION, AND INTERNATIONAL
SECURITY SUBCOMMITTEE
TOM COBURN, Oklahoma, Chairman
TED STEVENS, Alaska THOMAS CARPER, Delaware
GEORGE V. VOINOVICH, Ohio CARL LEVIN, Michigan
LINCOLN D. CHAFEE, Rhode Island DANIEL K. AKAKA, Hawaii
ROBERT F. BENNETT, Utah MARK DAYTON, Minnesota
PETE V. DOMENICI, New Mexico FRANK LAUTENBERG, New Jersey
JOHN W. WARNER, Virginia MARK PRYOR, Arkansas
Katy French, Staff Director
Sheila Murphy, Minority Staff Director
John Kilvington, Minority Deputy Staff Director
Liz Scranton, Chief Clerk
C O N T E N T S
------
Opening statements:
Page
Senator Coburn............................................... 1
Senator Carper............................................... 4
WITNESSES
Wednesday, April 26, 2006
Kevin Fenton, M.D., Director, National Center for HIV, STD, and
TB Prevention, Centers for Disease Control and Prevention, U.S.
Department of Health and Human Services........................ 6
Deborah Parham Hopson, Associate Administrator, HIV/AIDS Bureau,
Health Resources and Services Administration, U.S. Department
of Health and Human Services................................... 8
Marcia Crosse, Director, Health Care, U.S. Government
Accountability Office.......................................... 9
M. Beth Scalco, Director, HIV/AIDS Program, Louisiana Office of
Public Health, and Past Chair, National Alliance of State and
Territorial AIDS Directors..................................... 20
Michael Weinstein, President, AIDS Healthcare Foundation......... 23
Alphabetical List of Witnesses
Crosse, Marcia:
Testimony.................................................... 9
Prepared statement........................................... 55
Fenton, Kevin, M.D.:
Testimony.................................................... 6
Prepared statement........................................... 31
Hopson, Deborah Parham:
Testimony.................................................... 8
Prepared statement........................................... 46
Scalco, M. Beth:
Testimony.................................................... 20
Prepared statement........................................... 64
Weinstein, Michael:
Testimony.................................................... 23
Prepared statement........................................... 76
APPENDIX
Questions and responses for the Record from:
Dr. Fenton................................................... 80
Ms. Hopson................................................... 94
Ms. Crosse................................................... 100
Ms. Scalco................................................... 105
Mr. Weinstein with an attachment............................. 108
Charts submitted by Senator Coburn for the Record................ 129
Additional copy submitted by Senator Coburn for the Record....... 134
ENSURING EARLY DIAGNOSIS AND ACCESS
TO TREATMENT FOR HIV/AIDS:
CAN FEDERAL RESOURCES BE MORE
EFFECTIVELY TARGETED?
----------
WEDNESDAY, APRIL 26, 2006
U.S. Senate,
Federal Financial Management, Government
Information, and International Security Subcommittee,
of the Committee on Homeland Security
and Governmental Affairs,
Washington, DC.
The Subcommittee met, pursuant to notice, at 2:27 p.m., in
room SD-342, Dirksen Senate Office Building, Hon. Tom Coburn,
Chairman of the Subcommittee, presiding.
Present: Senators Coburn and Carper.
OPENING STATEMENT OF SENATOR COBURN
Senator Coburn. Thank you. We are going to start early. We
are going to have a vote here in a few minutes which will mean
we will have to interrupt the hearing, so I am going to go on
and start, if I may.
I want to welcome all of our witnesses today. I want to
thank you for the timeliness of your testimony and thank you
for taking the time to be here.
Today's hearing examines domestic efforts to promote early
diagnosis of HIV infection and ensure access to AIDS treatment.
It has been nearly 25 years since the first cases of what
would become known as AIDS were recognized. As a physician
during much of this time period, I experienced the heartbreak
of watching some of my patients, including mothers and
children, succumb to this mysterious and incurable illness in
the early days of the epidemic when effective treatments had
not yet been developed.
Even today, with the availability of revolutionary anti-
retroviral treatments that have transformed a disease that was
a death sentence into a manageable disease for many, it is
still heartbreaking to deliver an HIV diagnosis to a patient
and agonize with each one to determine how they can afford
these life saving, yet extremely expensive, medications.
As a physician, I believe it is essential that if we are to
end this epidemic, we must make every effort to promote early
diagnosis and ensure access to treatment for all those who are
infected. We must also empower those who are infected and those
who are not infected to prevent HIV from taking another life.
This may require rethinking and reevaluating past and present
policies and reconsidering ideas that have long ago been
abandoned or even demonized.
It is no secret that I have had many differences with some
within the AIDS community, Federal health agencies, and even
with the drug companies that produce the miraculous AIDS drugs
that now many take for granted regarding how we could best
address this disease. But we must not let our differences of
opinions allow us to make enemies of those with different
viewpoints, for we all hold the same common goal: Ending AIDS
and the same common enemy, HIV.
So many of the medical advances that my patients and those
affected by HIV around the world benefit from today are the
result of activists who forced the government to act on this
epidemic when so many preferred to look away because they
disapproved of the behaviors that were associated with this
disease.
Unfortunately, so much of how we have all reacted to the
AIDS epidemic has been based on fear. Lack of knowledge led to
fear. Fear led to discrimination and stigma. Discrimination and
stigma led to fear. And fears became the basis of our response
to HIV/AIDS. The results have been tragic.
Consider that the U.S. Government spends more than $20
billion a year on HIV/AIDS prevention, care, and research
annually, yet more than one million Americans are now living
with HIV/AIDS. Up to 59 percent of those Americans are not in
regular care. More than 40,000 Americans become newly infected
with HIV every year. It has not changed over the last 6 to 7
years, and this number has actually been unchanging for over a
decade, as that chart will show.\1\ There are some estimates
that it is as high as 60,000 new cases a year. The fact that we
don't know for sure tells us we have a problem.
---------------------------------------------------------------------------
\1\ The chart referred to appears in the Appendix on page 132.
---------------------------------------------------------------------------
More than a quarter of those who are infected do not know
they are infected. Hundreds of patients are on waiting lists
for AIDS drugs, and more than half a million Americans have
already died from this disease. As many as 45 percent of
persons testing positive for HIV received their first positive
test result less than a year before the AIDS was diagnosed.
With an average of 10 years between HIV infection and an AIDS
diagnosis, this suggests that people are living with HIV for
many years before they are aware of their infection and may be
unknowingly spreading the virus to others.
To address these shortcomings, fear must be replaced with
hope. We have the knowledge, the resources, and the commitment
to provide hope to every American who is living with HIV/AIDS.
But to do so, we must update our policies to ensure that all of
those living with HIV have access to the hope that treatment
can provide.
This means we must also remove the barriers to testing.
Fear-based policies continue to serve as deterrents to testing
and diagnosis and deny the benefits of those miraculous AIDS
drugs that the early activists fought so hard to make available
to thousands of Americans today, often until it is far too late
to prevent the inevitable.
One example of the hope that can result from eliminating
barriers to testing is the great success that has resulted from
the baby AIDS laws in New York and Connecticut that require
every newborn to be tested for HIV antibodies and treatment
provided to affected mothers and infants.
New York passed a law requiring HIV testing of all newborns
in 1996. According to data we received just this week, the
results of this law have been dramatic.\1\ The proportion of
all pregnant women being aware of their HIV status at delivery
has increased from 64 percent in 1997 to 95 percent in 2004.
The number of HIV-infected infants in New York dropped from
more than 500 a year to 8 in 2003. Furthermore, mothers and
impacted infants are receiving care.
---------------------------------------------------------------------------
\1\ The chart referred to appears in the Appendix on page 131.
---------------------------------------------------------------------------
Connecticut passed a similar law in 1999 requiring that
newborns be tested for HIV antibodies if their mother's HIV
status was unknown. Prior to the law, only 28 percent of
pregnant women were documented as being tested for HIV.\2\
Prenatal testing rates for other diseases were over 90 percent,
which demonstrates how the unusual counseling regulations for
HIV testing discouraged testing. After the law was enacted,
this number of pregnant women being tested for HIV jumped to 90
percent. In the year that the law passed, 70 HIV-exposed
newborns were born with five infants infected with the virus.
Since that time, over 300 HIV-exposed infants have been born
with only five infants becoming infected. The last baby
infected with HIV to be recorded in the State was in 2001,
meaning Connecticut's laws essentially eliminated baby AIDS.
---------------------------------------------------------------------------
\2\ The charts referred to appear in the Appendix on pages 129-130.
---------------------------------------------------------------------------
The success of these laws are rare victories in our battles
against HIV and AIDS.
The Government Accountability Office (GAO) today releases
its second report this year that examines some of the issues
involved in providing access to treatment and early
intervention. The report reminds us of facts that we already
know, such as most new HIV infections originate from HIV-
infected persons not yet aware of their status. This emphasizes
the need to identify HIV-infected persons and link them with
appropriate services as soon as possible.
It raises other issues of concern, such as ADAPs with
waiting lists may not represent all eligible individuals who
are not being served. And it points to opportunities where
policy makers can do a better job to maximize the impact of the
tens of billions of dollars that we are directing every year
towards our HIV/AIDS efforts.
Coincidentally, GAO's reports come at a time when Congress
is faced with reauthorization of the Ryan White CARE Act, which
is the largest HIV/AIDS-specific Federal care program. While
the program's authorization expired 6 months ago, efforts are
currently being made to renew the program, and I know of at
least one bill that has been introduced in both the House of
Representatives and the Senate that would do so taking account
of many of GAO's findings as well as the issues I have outlined
and others that we will explore today.
I look forward to hearing from our witnesses today, who
include Dr. Marcia Crosse, Director of Government
Accountability Office's Public Health and Military Health Care
Issues; Dr. Deborah Hopson, Associate Administrator of the
Health Resources and Services Administration, HIV/AIDS Bureau;
Dr. Kevin Fenton, Director of the National Center for HIV, STD,
and TB Prevention at the Centers for Disease Control and
Prevention; Ms. Beth Scalco, Director, HIV/AIDS Program,
Louisiana Office of Public Health; and Michael Weinstein,
President of the AIDS Healthcare Foundation, the Nation's
largest provider of HIV/AIDS medical care.
Prior to you coming in, Senator Carper, I announced that we
were going to have a vote. I will go vote if you will do youre
opening statement. I will be right back and we will try to keep
things going.
Senator Carper. OK, sounds good.
OPENING STATEMENT OF SENATOR CARPER
Senator Carper [presiding]. Thanks, Mr. Chairman, and
before you leave, let me just say that the Chairman of the
Subcommittee has been very involved in these issues for some
time and is one of the co-authors of the last reauthorization.
I know he has been very much involved in our efforts to
reauthorize the Ryan White CARE Act this time, as well.
Thank you for joining us. We look forward to your testimony
and to the opportunity to ask some questions of you, and our
second panel, as well.
The Ryan White CARE Act was first enacted, I believe in
1990. I was still in the House of Representatives at the time.
Since then, we have made great progress, both in combatting the
stigma that was once associated with the disease, but I think
also in combatting the disease itself. We still have a long
ways to go, but the CARE Act has been, I think, one of the
chief Federal programs, at least, in the fight against HIV and
AIDS.
I think we can all agree that our goal in examining the
Ryan White Act today is to ensure that Americans living with
HIV/AIDS can get needed care and needed services. The Ryan
White program is working to do that, at least that is what I am
told, for over 500,000 people each year. The program provides
not only vital prescription drugs, but also needed support
services to help patients stay on those drugs and adhere to
complex drug regimens.
In my State of Delaware, we have done, we think, a good job
of providing needed health services to those with HIV and AIDS.
We can always do better. Everything we do, we can do better,
and that includes here. But we have made quality health care a
priority and are fortunate to be able to offer what we think is
a generous Medicaid program, a very generous AIDS drug
assistance program, and high-quality Ryan White services.
The witnesses that are here today before us, this panel and
our next panel, will discuss a number of issues, largely
focusing on the AIDS drug assistance program, on prevention and
testing efforts, and on notification efforts. However, they
will also be addressing a number of issues pertaining to the
Ryan White authorization as a whole. At least, that is what I
am told.
I understand that the Senate HELP Committee and the House
Energy and Commerce Committee are working together in a
bipartisan way to come to agreement on the Ryan White
Reauthorization Act, and I hear they are making significant
progress and I hope that the authorization can be completed
this year.
As we consider reauthorization of this program, I think it
is important that we keep in mind that the program, on the
whole, is working. We have lengthened the time from HIV
infection to the onset of AIDS, which is a good thing. People
with HIV and AIDS are living longer and living healthier. That
is obviously a good thing. Of course, we can, as I said
earlier, do more to strengthen the program, and we now face new
challenges as the face of the disease itself evolves. I think,
for the most part, we have done a good job, a commendable job.
One of the goals of reauthorization should be to ensure
that we can get the most out of our Federal investment in this
program. We should ensure that the distribution of funding to
States and cities under the CARE Act both supports the existing
treatment infrastructure that we have built up over the last
several years and also ensures that we address discrepancies in
funding where they are present. We should ensure that the Ryan
White dollars are spent in a smart way and that they are spent
as a payer of last resort. We should also ensure that any
unused funds are reinvested in the program in some way.
I hope that the issues that are brought up before us today
can inform the upcoming debate on reauthorization. Ryan White
has always been seen as a bipartisan issue and I am hopeful
that this year, the Congress will continue that tradition and
that we can work together with the House to produce a
bipartisan reauthorization package to send to the President for
his signature.
I think with that having been said, I am going to recess
the Congress, go and vote myself, and I suspect that the
Chairman will be back very shortly and begin your testimony. So
I would just ask that we stand in recess for a few moments
until the return of the Chairman and I will see you all then.
Thank you.
[Recess.]
Senator Coburn [presiding]. Let me introduce, if I may, our
first panel. I would ask our panel members to limit their
testimony to 5 minutes. We have read your testimony. Then we
will have questions afterward.
Dr. Kevin Fenton is Director of the National Center for
HIV, STD, and TB Prevention, Centers for Disease Control and
Prevention. He joined CDC in January 2005 as Chief of the
National Syphilis Elimination Effort, leading a revitalization
of this program to end the sustained transmission of syphilis
in the United States. Prior to his work at CDC, Dr. Fenton was
the Director of the HIV and Sexually Transmitted Infections
Department of the United Kingdom's Health Promotion Agency.
Dr. Deborah Parham Hopson is the Associate Administrator
for HIV/AIDS in the U.S. Department of Health and Human
Services' Health Resources and Services Administration. Dr.
Hopson was appointed Associate Administrator for HIV/AIDS at
HRSA on July 29, 2002. As Associate Administrator for the AIDS
Bureau, Dr. Hopson is responsible for directing the Ryan White
Comprehensive AIDS Resources Emergency Care Act Program, which
provides medical care, treatment, referrals, and social
services to people living with and affected by HIV/AIDS
throughout the United States. She administers a budget of $2.02
billion that funds services for some 530,000 individuals each
year.
Dr. Marcia Crosse is Director for the Health Care Group at
the Government Accountability Office. She has been responsible
for overseeing multiple projects in the areas of biomedical
research, bioterrorism, disease surveillance, HIV/AIDS, medical
product safety, organ transplantation, and pharmaceutical
regulation. She has been employed at GAO since 1985.
I want to thank each of you again for being here, and I
want to express publicly how much I depend on GAO, what a great
functioning component of the U.S. Government they are, and how
valuable they are to us as Members of Congress in being able to
do our work.
Dr. Fenton, I will recognize you first and then we will go
to Dr. Hopson and then to Dr. Crosse. Welcome.
TESTIMONY OF KEVIN FENTON, M.D.,\1\ DIRECTOR, NATIONAL CENTER
FOR HIV, STD, AND TB PREVENTION, CENTERS FOR DISEASE CONTROL
AND PREVENTION, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Dr. Fenton. Good afternoon. Thank you. Good afternoon, Mr.
Chairman. My name is Kevin Fenton and I am the Director of the
National Center for HIV, STD, and TB Prevention at the Centers
for Disease Control and Prevention. Thank you for the
opportunity to discuss CDC's progress in reducing barriers to
HIV testing and improving opportunities for early diagnosis and
linkage to care.
---------------------------------------------------------------------------
\1\ The prepared statement of Dr. Fenton appears in the Appendix on
page 31.
---------------------------------------------------------------------------
Twenty-five years ago, the first cases of HIV were reported
in the United States. Although the struggle to prevent new
infections is not over, we have made substantial progress and
achieved major successes. For instance, the dramatic decrease
in mother-to-child or perinatal HIV transmission is one of the
great success stories of HIV prevention. We have also seen
declines in the number of HIV and AIDS cases attributed to
injecting drug use.
Despite such major successes, HIV infection and AIDS remain
a leading cause of illness and death in the United States. The
numbers are sobering. CDC estimates that currently, 1 to 1.2
million people in the United States are infected with HIV, and
of these, roughly a quarter are undiagnosed and at high risk of
transmitting HIV. This undiagnosed group is of great concern to
us because they are not able to take advantage of medical
treatment and because we believe that transmission by people
who are unaware that they are HIV positive account for more
than half of new HIV infections every year.
Currently, CDC has a number of efforts underway to
encourage early diagnosis of HIV infection. In 2003, CDC
launched the Advancing HIV Prevention Initiative, or AHP, which
reinforces CDC's evidence-based approach that routine HIV
testing implemented in a variety of settings will reduce
barriers to HIV testing, improve opportunities for early
diagnosis and linkage to prevention and care, and help reduce
the number of new infections.
CDC also encourages its funded partners to take HIV testing
out into the community by using rapid tests in non-traditional
settings and in health care settings that provide episodic
care. In addition, CDC is currently updating guidelines for
testing in health care settings, making HIV testing more
routine.
Finally, the President's 2007 budget contains an increase
in funding aimed at increasing the number of people who know
their HIV serostatus through promoting rapid testing in areas
of high HIV incidence.
I would like to highlight one AHP demonstration project
that we are particularly encouraged about. This project used
social network strategies to reach persons at high risk of HIV
infection in communities of color and demonstrated the
feasibility of using these social networks to encourage HIV
counseling, testing, and referral services. This strategy has
proved to be very successful in reaching persons with
undiagnosed HIV infection.
In addition to reducing barriers to HIV testing and
increasing the opportunity for early diagnosis, CDC is
proposing to revise our guidelines for HIV testing of adults,
adolescents, and pregnant women in health care settings. The
revised guidelines will focus on increasing routine HIV
screening of patients in health care settings, fostering the
earlier detection of HIV infection, identifying and counseling
persons with unrecognized HIV infection, and linking them to
clinical and preventive services and further reducing perinatal
transmission of HIV in the United States.
Detecting HIV infection earlier through HIV screening has
been shown to be cost effective, even in settings of low
prevalence. The new guidelines will recommend routine or opt-
out HIV screening in health care settings and are intended for
providers in all health care settings. The guidelines do not
modify existing guidelines for HIV counseling, testing, and
referral for high-risk persons who seek HIV testing in non-
clinical settings.
As you know, to further support the goal of diagnosing HIV
infections earlier and increasing access to care, the
President's 2007 budget includes an increase of $93 million for
CDC HIV prevention programs. Three major testing components are
included: Testing in health care and non-clinical settings, in
jails, and with injecting drug users. CDC will work
collaboratively with other HHS agencies in these efforts. We
anticipate testing more than three million persons and
identifying over 46,000 infections.
In closing, over the past 25 years, our Nation has made
progress in preventing morbidity and mortality related to HIV.
CDC remains committed to helping people live longer, healthier
lives by preventing new HIV infections and protecting the
health of those already infected.
Thank you again for this opportunity and I look forward to
answering any questions.
Senator Coburn. Thank you, Dr. Fenton. Dr. Hopson.
TESTIMONY OF DEBORAH PARHAM HOPSON,\1\ ASSOCIATE ADMINISTRATOR,
HIV/AIDS BUREAU, HEALTH RESOURCES AND SERVICES ADMINISTRATION,
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Ms. Hopson. Mr. Chairman, thank you for the opportunity to
meet with you today on behalf of the Health Resources and
Services Administration. Last year, I testified before the
Subcommittee regarding the domestic HIV/AIDS care programs and
I am happy to be here today to discuss ways to ensure early
diagnosis and improve access to treatment for Americans living
with HIV and AIDS. I certainly appreciate your continuing
support for the Ryan White CARE Act programs.
---------------------------------------------------------------------------
\1\ The prepared statement of Ms. Hopson appears in the Appendix on
page 46.
---------------------------------------------------------------------------
The Ryan White CARE Act is the centerpiece of our domestic
response to care and treatment for low-income, uninsured, and
under-insured individuals living with HIV/AIDS. Currently
funded at over $2 billion, it provides primary health care,
live-saving medications, and support services to individuals
who lack health insurance and financial resources to provide
adequate health care for themselves.
As you noted, the authorization of the Ryan White CARE Act
expired 6 months ago. President Bush in his State of the Union
Address stressed the importance of this program and asked
Congress to reform and reauthorize the Ryan White CARE Act and
provide new funding to States so that we can end the waiting
list for AIDS medicines in America.
Since its last reauthorization, we have been able to
provide anti-retroviral treatment, primary care, and support
services to over half a million people annually in the United
States, Puerto Rico, Guam, the Virgin Islands, and eligible
U.S. territories in the Pacific. In 2004, an estimated 65
percent of these individuals were racial minorities, 33 percent
were women, and 87 percent were either uninsured or received
public health benefits. The Ryan White CARE Act programs have
provided important benefits to these populations.
Overall, AIDS mortality is down and lives have been
extended through HIV medications purchased through the AIDS
Drug Assistance Program, also known as ADAP. Pregnant HIV-
positive women have been provided with care that has allowed
them to give birth to children free from HIV infection, and
thousands have received support services that have allowed them
to access and remain in health care.
Although we are making progress in providing services to
people living with HIV, the epidemic continues and will be in
need of our attention for some time to come. The President and
Secretary understand the dynamics and severity of the epidemic
and they are committed to ensuring the Department's HIV/AIDS
programs are as effective as possible in preventing infection
and treating those who become infected.
We have recognized that as essential as the Ryan White CARE
Act has been to serve Americans with HIV and AIDS, it is in
need of revitalization to safeguard its critical mission.
Despite record levels of funding, we continue to face waiting
lists for life-saving funds through the ADAP and there are
marked disparities in access to quality medical treatment
across the country. As minority populations are increasing and
disproportionately impacted by HIV/AIDS, changes to the
existing systems of care designed for an earlier epidemic are
increasingly urgent.
Each year, CARE Act programs, primarily through grants to
States, metropolitan areas, providers, and educators, we reach
an estimated 571,000 people. Since AIDS was first recognized,
the pattern and treatment of HIV disease has shifted. We now
strive to manage HIV/AIDS as a chronic disease. Early diagnosis
and improved access to HIV care and treatment are key to what
the CARE Act stands for.
The CARE Act programs are successful at counseling and
testing. More than 800,000 HIV tests were administered in CARE
Act sites. And the important thing to note is over 85 percent
of the people tested in CARE Act sites returned for their
results. We think that this is because the CARE Act sites are
not only testing sites, but they are primary care delivery
sites, as well.
Going forward, we take great pride in the advances of HIV/
AIDS care and treatment that have been made by the CARE Act
programs over the past 16 years. However, we are humbled by the
significant challenges that remain for people living with HIV/
AIDS who have nowhere else to go for care in an age of
increasing HIV/AIDS prevalence, increasing health care costs,
and a growing burden of HIV among the uninsured and under-
insured.
The Administration has emphasized five key principles for
reauthorization of the CARE Act: Serve the neediest first;
focus on life-saving and life-extending services; increase
prevention efforts; increase accountability; and increase
flexibility.
The President has made fighting the spread of AIDS a top
priority of his Administration and he will continue to work
with Congress to encourage prevention and provide appropriate
care and treatment to those suffering from the disease.
Today, people with HIV/AIDS are living longer, healthier
lives, in part because of the CARE Act. In order to make this
legislation more responsive in the future, the Administration
urges Congress to take into account the above-stated principles
in the reauthorization of the CARE Act.
Thank you for the opportunity to discuss the Ryan White
CARE Act today and for your dedication and interest in this
important piece of legislation.
Senator Coburn. Thank you, Dr. Hopson. Dr. Crosse.
TESTIMONY OF MARCIA CROSSE,\1\ DIRECTOR, HEALTH CARE, U.S.
GOVERNMENT ACCOUNTABILITY OFFICE
Ms. Crosse. Mr. Chairman, I am pleased to be here today to
discuss the AIDS Drug Assistance Programs, or ADAPs, that
receive funds under the Ryan White CARE Act and to provide a
summary of our report that we are releasing today, prepared at
your and others' request. The report discusses ADAP's program
design, their funding sources, and drug purchasing. It also
discusses our examination of State prenatal HIV testing and
perinatal HIV transmission rates and State approaches to
identifying and notifying partners of HIV-infected individuals.
---------------------------------------------------------------------------
\1\ The prepared statement of Ms. Crosse appears in the Appendix on
page 55.
---------------------------------------------------------------------------
Despite progress in drug treatments and the reduction of
AIDS mortality in the United States, challenges remain
concerning the availability of these drugs for individuals with
HIV or AIDS. Because of the variation in program criteria, an
individual eligible for ADAP services in one State may not be
eligible for or receive the same ADAP services in another. ADAP
income ceilings for individuals, program enrollment caps, and
drug formularies vary considerably among ADAPs.
For example, each ADAP determines a maximum income level or
income ceiling as a criterion for an individual's eligibility
for enrollment. ADAPs reported income ceilings that range from
125 percent of the Federal poverty level in North Carolina to
556 percent in Massachusetts. Sixteen ADAPs reported that they
had limits on the assets that individuals enrolled in the
program are allowed to have. Twelve ADAPs reported having caps
on program enrollment or on amounts expended per individual.
And the total number of drugs ADAPs included on their
formularies ranged from 20 in Colorado to 1,000 in
Massachusetts, New Hampshire, and New Jersey.
In order to make maximum use of the funding they receive,
ADAPs are expected to secure the best prices available for the
drugs on their formularies. ADAPs may, but are not required to
purchase their drugs through the 340B Federal drug pricing
program, under which drug manufacturers provide discounts on
certain drugs. HRSA has identified the 340B prices as a measure
of ADAPs' economical use of grant funds, but HHS does not
disclose 340B prices to the ADAPs.
We found that some ADAPs reported prices that were higher
than the 340B prices for selected HIV/AIDS drugs. However,
these reported prices may not have reflected any rebates ADAPs
eventually received. While HRSA is responsible for monitoring
whether ADAPs obtain the best prices available for drugs, it
does not routinely compare the drug prices ADAPs report to the
340B prices, and without the final ADAP rebate amount on a drug
purchase, HRSA cannot determine whether the final drug prices
paid were at or below the 340B price.
We are recommending that HRSA require ADAPs to report the
final prices they paid for drugs, net of any rebates, and that
HRSA routinely determine whether these prices are at or below
the 340B prices.
Turning to approaches to reduce the spread of HIV, all 50
States, the District of Columbia, and Puerto Rico have policies
or have enacted laws regarding HIV testing of pregnant women to
help reduce the transmission of HIV to newborns. However, among
the eight States we examined, three States followed CDC's
recommendations to routinely include HIV tests in standard
prenatal testing while allowing a woman to refuse to be tested
for HIV. The other five States require that a woman
specifically consent to an HIV test, usually in writing, before
the test can be performed. But two of these States, as you
noted, Connecticut and New York, have mandatory newborn testing
if the mother has refused an HIV test. Six of the eight States
report that the number of HIV-positive newborns has declined,
however, in a positive development.
Among other efforts to reduce the transmission of HIV,
States used various approaches in eliciting information from
known HIV-infected individuals about their sexual partners. But
the participation of these individuals varies and not all
partners can be reached to be notified. For example, CDC data
showed that States interviewed between 46 percent and 100
percent of known HIV-infected individuals to elicit the
identities of their partners and were able to notify between 42
percent and 83 percent of those partners that they had been
exposed to HIV.
Further, in the 12 States we examined, 10 have statutory or
regulatory provisions that require or permit the notification
of partners, including spouses, without the consent of the
known HIV-infected individual. However, in the remaining two
States, Massachusetts and Minnesota, public health officials or
the health department may notify partners, including spouses,
only with the consent of the HIV-infected individual.
Mr. Chairman, this concludes my prepared remarks. I would
be happy to answer any questions you or other Members of the
Subcommittee may have. Thank you.
Senator Coburn. Thank you, Dr. Crosse.
Dr. Fenton, I am going to start with you, if I may. Four
years ago, Dr. Gerberding stated in her first speech as
Director of CDC that 40,000 or more new HIV infections occur
every year in the United States and it was unacceptable and our
goal is to substantially reduce and ultimately prevent. If you
look at that chart \1\ and the fact that CDC now admits at
least 40,000 new infections every year, which has not declined,
what is the explanation for that?
---------------------------------------------------------------------------
\1\ The chart referred to appears in the Appendix on page 132.
---------------------------------------------------------------------------
Dr. Fenton. In reviewing that chart and in assessing our
successes of our prevention interventions, I think there are
two key questions that we need to ask ourselves. First, are we
doing the right prevention interventions or do we have
effective interventions and are we delivering them at the right
level to have the necessary impact on our HIV epidemic? Or,
second, as the epidemic is evolving, are we actually targeting
our prevention interventions in the right areas for the right
communities at risk?
CDC has a program of continually evaluating the
effectiveness of our prevention programs. Over the past decade,
we have been involved in monitoring the outcomes of our
prevention activities and using our surveillance data to
evaluate the effectiveness of our prevention interventions. We
have systematically developed effective behavioral
interventions and we have embarked upon a program of diffusing
these effective interventions to communities and individuals at
high risk of acquiring HIV.
We have also used core prevention indicators to evaluate
the effectiveness of programs at the local level. Program
consultants are required to interview our grantees to ensure
that local implementation of our prevention programs are being
done as anticipated.
Senator Coburn. Let me ask it in a little different way. We
are going to spend over $20 billion this year in this country
on domestic HIV/AIDS and we are climbing every year as we work
on this very difficult problem. When are we going to see a
decline in the new infections? Maybe we are not having more new
infections, maybe we are diagnosing more that were in the
resilient population. That may be the answer. But if you were
an average American out there paying their taxes and--$18
billion to $20 billion, we started out very low and through the
great work of AIDS activists, we are where we are today, when
are we going to see that go this way? And this opinion, you are
not going to be held to this. Just give us an opinion.
[Laughter.]
I have got 4 more years here. I promise I won't hold you to
it.
Dr. Fenton. I am not in a position to say exactly when we
are going to be seeing a decline or a change in the epidemic
curve, but I do know that we have had successes in preventing
HIV transmission in some areas. We are beginning to see
declines in new HIV diagnoses among injecting drug users. And
earlier in my testimony, I mentioned the declines and the
successes in perinatal HIV.
Senator Coburn. Right.
Dr. Fenton. More recently, our surveillance data is
suggesting that we are seeing reductions in new diagnoses among
African-American women. So taken as a whole, it may be very
difficult to predict exactly when we will see declines in new
diagnoses, but we are seeing successes. I think the key is
actually identifying what elements of our--why are we seeing
the successes----
Senator Coburn. What is working and what isn't?
Dr. Fenton [continuing]. And ensure that we either extend
these and continue to implement these nationally.
Senator Coburn. Fifteen months ago, CDC unveiled its
Advancing HIV Prevention Initiative. How many States have
enacted the recommendations and what is being done to assist
all the States to adopt those recommendations? And by the way,
for our audience, those are recommendations that just follow
common public health precepts that have been proven for years
to work which were just introduced by CDC 15 months ago.
Dr. Fenton. The Advancing HIV Prevention Initiative was
actually launched in 2003 and there are a number of
interventions which were included in those, including universal
HIV testing of pregnant women, confidential partner
notification, and rapid testing. I would like to report on our
progress on each of these.
Senator Coburn. OK.
Dr. Fenton. As far as our interventions for pregnant women
are concerned, in 2004, CDC recommended implementation of an
opt-out testing approach in which women are notified that an
HIV test will be routinely included in the standard battery of
tests to be done. Since CDC's recommendation for opt-out
testing, seven States have specifically authorized opt-out
prenatal HIV screening in legislation. In November 2005, the
American College of Obstetricians and Gynecologists further
published a legislative tool kit of State laws and suggested
legislative language that should be used to actually aid the
requirement of opt-out testing for pregnant women.
As far as monitoring States and what exactly is happening
as far as HIV testing and counseling is concerned, CDC
conducted a survey and analysis of all relevant State statutes
addressing HIV testing and counseling. An electronic database
of these State laws will be posted on the agency website within
the next month. This information really has provided a very
comprehensive inventory of laws which really gives a sense of
where States are in terms of requiring mandatory HIV testing,
pre-testing and post-test counseling, and testing of pregnant
women.
As far as our progress on partner notification is
concerned, it is a condition for all States receiving Federal
funds for HIV and STD prevention that they should have
confidential partner notification as a component of partner
counseling and referral services. So all CDC grantees are
expected to deliver on this intervention.
And then finally, as far as rapid HIV testing is concerned,
all CDC grantees are encouraged to use their HIV prevention
funds to purchase rapid HIV tests for various clinical and non-
clinical sites.
Senator Coburn. Dr. Hopson, Department of HHS has announced
the Ninth Annual Ryan White CARE Act Grantee Conference in
August, and according to the invitation letter, all
participants and presenters are responsible for their own
travel, hotel, and registration fees; which should come from
CARE Act funds. I have two questions for you. One is, is it
really a necessity to have that conference every year when the
bill hasn't changed? And number two, couldn't that money be
much better spent by redirecting it to an ADAP program?
Ms. Hopson. Thank you. The Ryan White CARE Act grantee
meeting is held every other year, so we don't hold it every
year, and we began holding it when the CARE Act programs were
combined into the HIV/AIDS Bureau. So this is the fourth
biannual meeting. What we have found is that it is the time
where we are able to provide technical assistance to our
grantees.
As I said in my testimony, this is a time when the CARE Act
hasn't changed but the environment in which we are operating
has changed. There are lots of changes in Medicare. There are
changes in Medicaid. There are changes in other parts of the
health care financing world, as well. There are also clinical
changes and clinical updates. And so we use this as a time to
provide technical assistance to our grantees. Because we have
so many grantees, we are not able to get out and visit each one
of them and we find that when we bring them together, they are
able to learn from each other. This is a time that is well
spent and money that we also believe is well spent.
Senator Coburn. How much money is it?
Ms. Hopson. I will have to provide that for the record.
Senator Coburn. Thank you. The President's reauthorization
principles that he put forward would require at least 70
percent of all CARE Act funds to be spent on primary medical
care and treatment, and I heartily endorse that. Titles II and
III are already spending more than 75 percent of their funds on
such purposes, according to GAO. Title I does not, and I
understand that most Title IV consumers already have their
primary care paid for by either SCHIP or Medicaid. How do you
envision the 75 percent primary care floor affecting the roles
and services impacted by Title I and Title IV?
Ms. Hopson. For Title I, we do realize that most of the
money does pay for primary care medical services or medications
and we believe most of the grantees--when you look at it
overall about 54 percent is the amount that they spend on
primary care services. So we believe that if the law does pass
and it says 75 percent must be spent on primary care and
treatment, then the grantees will have to look and see how they
will reallocate funds so that they could meet that requirement.
In terms of Title IV, we realize that there are many of the
patients who are eligible for Medicaid and receive their care
paid for that way and we are looking to see what would be
included in the primary care services. We broadly define that
as not only services that are provided for people when they
come in for care, but also, we need to provide outreach to get
people in care and keep them in care. Those services are
vitally important, particularly when you look at the Title IV
population, which is largely minority women and their children.
There are unique challenges that they face in order to get to
care and to remain in care, and so we look at a package of
services as part of comprehensive primary care. The Title IV
program will try to reprioritize those services, or prioritize
such that the Ryan White CARE Act does pay for the primary care
services and the necessary support services to get people into
care and to keep them in care.
Senator Coburn. OK. I have gone over my 5 minutes. Senator
Carper, I am going to come back for another round.
Senator Carper. Good. Thanks. On our second panel, one of
our panelists is Beth Scalco, who is, I think, the Director of
the Louisiana HIV/AIDS program. Louisiana is, as we all know,
now struggling with the aftermath of Hurricane Katrina, so it
is arguably necessary that they have the flexibilities to
address some of the new challenges.
I have two questions. One is does the current Ryan White
program do enough to give States like the Gulf Coast States and
the localities the flexibility to address their specific needs?
That is my first question. And second, is there anything more
that we ought to be doing in this area?
Dr. Hopson would you start with that and we will just take
it from there.
Ms. Hopson. Hurricane Katrina was certainly something that
we have never seen the likes of before in this country and
there are many systems that were impacted by that, including
the Ryan White CARE Act program. There were many, many evacuees
from New Orleans and the other parts of the Gulf region.
Included in that evacuation were people who are living with HIV
and AIDS. Many of them went to other parts of Louisiana,
Alabama, Mississippi that were not impacted by the hurricane.
Others went to neighboring States like Texas or Georgia, but
the evacuees ended up in many places around the country.
The challenge has been to find all of those patients who
were enrolled and receiving care in the affected area and get
them into care.
Senator Carper. That is a pretty big challenge.
Ms. Hopson. That is a big challenge, and one of the
concerns that we have is that we have not found all of those
patients. So that is a continuing challenge that we have. We
are continually in contact with the States and with all of our
grantees around the country to ask if they are still receiving
patients who were displaced.
Senator Carper. Any idea if they have found as many as half
of them, three-quarters of them? Just roughly?
Ms. Hopson. We do have that information. I just don't have
it off the top of my head.
Senator Carper. All right.
Ms. Hopson. I can give you some specifics. We know that in
Texas, there are over 800 evacuees who are receiving CARE Act
services. Louisiana received 700 evacuees from New Orleans. We
let the grantees know that they were able to have some
flexibility so that Title I New Orleans dollars were able to be
used by the Title II State. Also, Louisiana Medicaid provided
funding to the Texas ADAP to purchase pharmaceuticals for
Louisiana Medicaid-eligible clients. In Texas, they really did
a yeoman's job of decreasing the complexity of people being
eligible for ADAP and were able to very quickly get people
enrolled in ADAP, and many of the pharmaceutical companies, as
well, immediately stepped up to the plate and were able to
provide some free medications for people who were evacuees.
So again, there were lots of things that were done. We were
limited, though, by the statute. There were people who were
asking me constantly, well, can't you just waive this and waive
that? And I said, no, I don't have the power to waive the
statute. We still have to follow the law.
Senator Carper. Excuse me for interrupting, but as we look
toward reauthorizing the Act, and people especially like my
colleague here, shouldn't we be involved along with folks on
the HELP Committee? What ought we be doing to provide more
flexibility, if that is appropriate?
Ms. Hopson. Yes.
Senator Carper. You can answer that for the record, but it
is a timely question.
Ms. Hopson. It is a great question. We have been having
lots of discussions within the Department and I think I would
like to provide that answer for the record.
Senator Carper. Sure. That would be great.
Let me go back, if I could, to Dr. Fenton. I don't think
you have been asked enough questions yet, so I will ask you a
few more. I understand CDC has suggested that HIV screening be
conducted in maybe not all health care settings, but a whole
lot of them, unless the patient declines. This seems like a
laudable goal, but could you speak a little bit about how this
would work on a practical level and how much it might cost to
implement that kind of an approach? Finally, how would we pay
for it? It is like a three-part question.
Dr. Fenton. It is. To address the first question first,
which is which settings and how is this going to be
implemented, the real background to this is really to begin to
have a systematic strategy to really reduce the undiagnosed
fraction of HIV in the general population, and we know that
certainly in the American population, approximately 75 percent
of individuals attend their health care provider or are seen by
a health care provider in the previous year. So this is a huge
opportunity for us to really escalate the uptick of HIV testing
in the population.
In our revised screening guidelines, the objective is to
involve as many health care settings in this process by
routinizing HIV testing and removing the barriers to HIV
testing in the health care setting. In this respect, we are
looking at involving all different kinds of health care
settings where individuals aged 13 to 64 would be seen for
routine health care.
Senator Carper. Do you have some idea how much something
like this might cost, and finally, who might pay for it? How
might we pay for it?
Dr. Fenton. OK. I don't have the figures as to how much
this might cost and I would like to provide that for the
record?
Senator Carper. All right. Who might pay for it?
Dr. Fenton. We are looking at various strategies for paying
for this. Certainly one area that we are looking at that we
would be keen to pursue is exploring the ability for third-
party payment for HIV rapid tests, or HIV tests, similar to
other screening tests which are done in the population which
are paid for by third-party payers. The objective would be to
have HIV testing as being paid for in this manner.
We also should remember that additional funds are being
provided by the Administration through CDC to support the
purchase of rapid tests and we will be working very closely
with our partners at State and local government as well as
other HHS agencies to ensure that rapid tests are provided in
as many settings, both clinical and non-clinical settings, as
possible.
Senator Carper. All right. One last question for you, Dr.
Fenton. I understand that CDC has stated that prevention
counseling need not be conducted in conjunction with HIV
testing. It seems like testing would be a logical point at
which to give people information about how to reduce the risk
of HIV infection. I am wondering if you can give us some more
detail about CDC's thinking in this area.
Dr. Fenton. Absolutely. In thinking about the future of HIV
testing in the United States, it is important to unlink the
testing which is being recommended in clinical settings from
that which is being recommended in non-clinical or community
settings. There are no plans afoot to separate prevention
counseling in the non-clinical settings. However, in clinical
settings, what we are looking at is streamlining the HIV
testing process so it becomes shorter, more efficient, and
therefore, we begin to remove some of the barriers to HIV
testing in the clinical settings.
Individuals who are diagnosed positive as a result of the
HIV tests would still have intensive prevention counseling to
enable them to access appropriate treatment and care and
prevention services. So that part of the process counseling for
HIV-positive individuals would not be lost. But it is crucial
that if we are moving away from exceptionalization of HIV
testing, that we really look at streamlining the HIV testing
process, especially in clinical care settings, and removing the
barriers, which are time constraints, concerns about
stigmatization in providing HIV tests by health care providers,
etc.
Senator Carper. Dr. Crosse, would you care to comment on
Dr. Fenton's response?
Ms. Crosse. Senator, I don't believe that we have the
information from the work that we have undertaken to be able to
speak specifically to his remarks. If you would like us to
review that, I would be happy to do that and provide
information subsequently.
Senator Carper. Thank you, ma'am.
All right, Mr. Chairman. That is it for me. Thanks.
Senator Coburn. I think the answer to your question lies in
the chart to your right.\1\ A study released last August showed
what the cost per infection prevented by the different
intervention strategies, and to do HIV counseling with opt-in,
one-on-one, the average cost is $110,000.
---------------------------------------------------------------------------
\1\ The chart referred to appears in the Appendix on page 133.
---------------------------------------------------------------------------
I find it very interesting that in 1996, the Ryan White
CARE Act reauthorization contained a requirement that as a
condition of Federal funding, all States require that a good
faith effort be made to notify spouses of known HIV-infected
patients that such spouse may have been exposed. We just heard
testimony from Dr. Crosse that there are two States now that
have to have the permission of the person who is infected, and
the CDC has certified that all States are requiring with this
requirement.
How can CDC certify that if I am a spouse of somebody who
is infected who doesn't want to tell me that I am infected that
they are, in fact, complying with the Ryan White Act? How can
the CDC take that position in those States that require that?
You don't have to answer for the record. You can answer in
written response, but it is very concerning to me because you
hear Dr. Parham say she can't waive the law, and yet my big
problem through the years with CDC seems to be that oftentimes
what is expedient is waived and what isn't, isn't. So I would
love for you to answer that in writing for us because you all
have certified that, but we have had testimony today that is
something different from that.
Ms. Crosse. Mr. Chairman, if I could just add, in our
review, we only examined the statutes in 12 of the States and
so there may be additional States beyond those two----
Senator Coburn. Right.
Ms. Crosse [continuing]. That have similar requirements.
Senator Coburn. The two out of the 12, you had two where
the trump card is if I am HIV infected and I don't want my wife
to know, she can't know. The law says you have to not give
people money who do that, and yet you certify they are all in
compliance. Something isn't right there.
But go back to the chart, which I think is very revealing,
and I think what the CDC is trying to address with their
specialized non-clinical setting testing and everything else is
how do we spend money most effectively to take this large group
of undiagnosed people, 300,000, and find out their status so
that we don't enlarge the number of people who are unknown in
their HIV status who are HIV-positive. But I think this chart
is very revealing to us to know where to, in fact, spend our
money most efficiently.
Dr. Crosse made some mention about 340B testing in her
reports, although they can't be sure because they don't have
discounted net prices, rebate net prices. There is some concern
that maybe efficiency of the present dollars in ADAP programs
aren't as good as they should be because we are not getting a
comparison of whether or not they are getting value. Based on
what you have heard and based on what your plans are, what are
HRSA's plans to do about holding accountable and within the
340B to get more bang for our buck in terms of the dollars
spent by ADAP?
Ms. Hopson. There are a number of things that we do
currently. One, HRSA does require the ADAP, as a condition of
their grant award, to participate in a cost-saving measure that
is equal to or more economical than the 340B program. Now, the
problem comes is that HHS cannot disclose the 340B-covered
entities, such as ADAPs, what the prices are because of
confidentiality agreements between the government and the drug
companies. So there is that challenge that we have.
Senator Coburn. But her point was that you are not working
with a real number because the numbers they are reporting to
you is not rebate-adjusted. Is that correct?
Ms. Hopson. Yes, that is correct.
Senator Coburn. So basically, whatever you are doing with
it, it is not a real number. So is there something you all plan
on doing to say, you have to give us rebate-adjusted pricing?
Ms. Hopson. There is another program within HRSA, the
Office of Pharmacy Affairs, and they are not part of my Bureau,
so that is why I am turning around to make sure I get the right
answer. I know what we are doing in the HIV/AIDS Bureau. But we
are working with the Office of Pharmacy Affairs that manages
the 340B program to make sure that the information that we get
from our ADAPs is the information, the net price, essentially,
of the drugs that we purchase through the ADAPs and that we
give that information to the Office of Pharmacy Affairs who
then can give us a range. They can't give us the exact price,
but they can give us, within range, as to what price--are we
paying a fair price close to the 340B price or not.
There are a number of things that Dr. Duke, the HRSA
Administrator, has put forward to the Department and has put in
the 2007 budget request so that we can improve the ability of
the Office of Pharmacy Affairs to report to us and work with us
so that we can have the accurate prices. On our end, in the
HIV/AIDS Bureau, we are working with our grantees, the ADAPs,
so that they will report the net price to us so that we then
have an accurate number to compare to the 340B prices.
Senator Coburn. So their observation has already been
addressed by HRSA.
Ms. Hopson. Yes.
Senator Coburn. The observation of GAO----
Ms. Hopson. We are in the process of--this is something we
have proposed in the 2007 budget. We don't have that----
Senator Coburn. Dr. Crosse, would you respond to that?
Ms. Crosse. Our understanding based on HRSA's response to
our draft report was that the Office of Pharmacy Affairs was
developing a system that would assist the ADAPs in determining
for themselves whether or not they were obtaining economical
prices in their drug purchasing, but HRSA's response indicated
that it would be logistically difficult and require resources
that they don't have to carry out the kind of oversight and
monitoring that we recommend they do and that this would not
require the sort of manual comparison they indicated in their
comments, but could be carried out electronically and could be
carried out for a subset of the drugs.
We, for example, in our review looked at just 10 drugs that
accounted for 73 percent of the expenditures by the ADAPs so
that they could, likewise, examine either on some rotating
basis or with some subset that account for a substantial
portion of spending, particularly on the anti-retrovirals, what
the actual prices finally are or are paid. But our
understanding, our reading of their comments back to us was
that they did not at this time intend to do that.
Senator Coburn. I just want the panel to know, we are
coming back to this, because every dollar wasted is somebody
not treated. This is something that the law says and isn't
being carried out. You can't waive it and I am going to be the
enforcer. So just plan on about 4 months from now finding out
what the response is, make sure it is in place, because we are
going to have another hearing to ask about it.
If Congress does not reauthorize the CARE Act by October 1,
what will happen to the funding of States without names
reporting or immature reporting systems? Dr. Hopson.
Ms. Hopson. As you know, sir, because you were there in
2000, there is a requirement that by 2007, we must use HIV, not
just AIDS, in the formula by which we distribute the Title I
and Title II dollars. We are discussing that within the
Department right now as to the options that we will use for
those States that do not have that HIV data that is certified
by the CDC, because we use data that is certified by CDC in
order to make the funding decisions for Title I and Title II.
Senator Coburn. So tell me again, what is going to actually
happen?
Ms. Hopson. We are having discussions on various options
now within the Department----
Senator Coburn. So you haven't made a decision what is
going to happen?
Ms. Hopson. That is correct.
Senator Coburn. OK. That is what I was wanting to get to.
Is it important what the Ryan White CARE Act said in terms of
the 2001 bill?
Ms. Hopson. Absolutely.
Senator Coburn. OK. Well, I have several other questions
for all of you. I am not going to keep you here for that. I
will submit the rest in terms of written format. I would very
much appreciate your response in 2 weeks, if you can, and I
know those have to be cleared, so I am patient.
But this one issue on ADAP pricing and comparison, whether
or not we are getting a good deal, the drug companies don't
need to make any more money. They can afford to sell at a
reasonable price to ADAPs if they can afford to sell to
anybody. It is my concern that this be addressed very quickly
because it is money going out of the door that shouldn't be
going out of the door. Or, it may not be a problem at all, but
the point is, we need to know whether it is. The GAO seems to
think it may be, but we don't know. So I want to make sure that
is addressed.
I would also invite you to stay to hear our next panel,
because I think they have information you all can use, and
oftentimes government witnesses don't stay and they don't have
the benefit of really getting the feedback that would be
beneficial.
Thank you all so much for your testimony and thank you for
being here.
Senator Coburn. Our next panel consists of Michael
Weinstein, who is President of HIV Healthcare Foundation, the
Nation's largest provider of HIV/AIDS medical care. Since 1986,
Mr. Weinstein has been a leader in the fight against HIV and
AIDS. As President and co-founder of AIDS Healthcare
Foundation, he oversees a $140 million organization whose
mission is to provide cutting-edge medicine and advocacy
regardless of one's ability to pay. They currently serve 30,000
clients in the United States, Africa, Central America, and
Asia. The Foundation now operates 14 outpatient AHF health care
centers in California and Florida. They also operate seven
pharmacies, a clinical research unit, a disease management
program through the State of Florida, and the first capitated
Medicaid managed care program for people with AIDS.
Beth Scalco is Director of the HIV/AIDS program for the
State of Louisiana's Office of Public Health. The HIV/AIDS
program under her direction has the primary responsibility for
overseeing Louisiana's response to the AIDS epidemic, including
all prevention and care activities. Her office administers the
Ryan White Title II program, including the ADAP program, the
HOWPWA program, the Centers for Disease Control and Prevention
surveillance cooperative agreements, and the State general
funds for AIDS. She has been working in the field of HIV/AIDS
since 1985.
Welcome, both of you. Ms. Scalco, I think I will ask you to
go first, since I introduced you second.
TESTIMONY OF M. BETH SCALCO, DIRECTOR,\1\ HIV/AIDS PROGRAM,
LOUISIANA OFFICE OF PUBLIC HEALTH, AND PAST CHAIR OF THE
NATIONAL ALLIANCE OF STATE AND TERRITORIAL AIDS DIRECTORS
(NASTAD)
Ms. Scalco. Good afternoon, Mr. Chairman. My name is Beth
Scalco and I am the Director of the HIV/AIDS program for the
State of Louisiana. I am also the past Chair of the National
Alliance of State and Territorial AIDS Directors (NASTAD). I
want to thank you for inviting me to speak with you today.
---------------------------------------------------------------------------
\1\ The prepared statement of Ms. Scalco appears in the Appendix on
page 64.
---------------------------------------------------------------------------
State AIDS directors appreciate the longstanding support of
the U.S. Senate for the Ryan White CARE Act programs, and
assuring that all persons with HIV/AIDS, regardless of their
geographic location, have equal access to appropriate and high-
quality HIV/AIDS services is our highest priority. I would like
to share with you some views of my fellow State AIDS directors
in addition to some views from the State of Louisiana. I have
limited my comments to those that address increasing access to
prevention services provided by State health departments,
including testing and access to life-saving drugs provided by
the AIDS Drug Assistance Program.
As you said, Louisiana HIV/AIDS program administers the
HIV/AIDS prevention and care programs funded by both State and
Federal funds. HIV infections have penetrated both our
metropolitan areas as well as our rural areas in our State. In
2004, the State of Louisiana had the 11th highest number of
AIDS cases reported and the fifth highest AIDS incident rates
in the Nation. There were a total of 25,846 cumulative cases of
AIDS reported in Louisiana and there are currently 14,793
individuals living with HIV/AIDS in Louisiana as of March 2006.
In 2005, we identified 967 new HIV/AIDS cases in Louisiana.
We normally identify around 1,100 cases in Louisiana, and I am
sad to say, I do not think that HIV infection decreased. I
believe that is a result of the impact on our ability to test
in the months following Hurricane Katrina.
In the Federal fiscal year 2006, Louisiana received over
$22 million in Ryan White CARE Act funding. We received $6
million for Title II base, $15 million for ADAP, and $950,000
for our emerging communities, which is Baton Rouge, Louisiana.
Our Title I EMA, which is New Orleans, received $7.4 million.
We received close to $5 million in HIV prevention cooperative
agreement funds and $1.6 million for our surveillance
cooperative agreement.
The State of Louisiana contributes approximately $2.5
million specifically for HIV prevention activities in
Louisiana. In addition, they contribute over $9 million for
care and treatment of people who are HIV infected through the
State's public hospital system. This is in spite of Louisiana's
ongoing budget deficits both prior to the hurricane, and I,
unfortunately, have to say, I do not believe that they will not
be able to continue this contribution as a result of the
hurricane.
State public health agencies serve an essential and a
unique role in the delivery of HIV/AIDS prevention, care, and
treatment programs. The agencies are entrusted through the U.S.
law as the central authorities of the Nation's Public Health
System and as such bear the primary public sector
responsibility for health. State Public Health responsibilities
include disease surveillance, epidemiology, prevention
programs, immunizations, emergency preparation, provision of
primary health care services for the uninsured and the
indigent, and overall planning and coordination,
administration, and physical management of Public Health
Services.
The President's 2007 budget includes $93 million, of which
$86 million is new funding, to increase testing in medical
settings, make voluntary testing a routine part of medical
care, and to create new testing guidelines, models, and best
practices. The President's initiative will prioritize funding
for regions with the highest number of new cases as well as
focusing on incarcerated persons and injection drug users.
State AIDS directors support the President's request for
$86 million in new funding for domestic HIV prevention and
believe that this funding should be allocated via the
prevention and surveillance cooperative agreements with State
and local health departments. State and local health
departments already fund HIV testing in a variety of venues in
communities and they are in the best position to maximize the
potential of the President's testing initiative.
However, testing alone will not prevent new infections.
Funds must be increased to make up for 3 years of cuts, which
have hampered the ability of State health departments to
implement CDC's Advancing HIV Prevention Initiative.
In addition, resources for surveillance are sorely needed,
as the Federal Government shifts prioritization from AIDS to
HIV case reporting and funding for core surveillance activities
has eroded significantly in recent years.
State AIDS directors support the delivery of HIV prevention
services in primary care settings as a standard of care.
Studies indicate that HIV-positive individuals who are aware of
their status take steps to protect their partners from
infection, with 70 percent reporting reductions in risky
behaviors. Health departments use partner counseling and
referral services as one tool to identify HIV-positive
individuals and ensure their linkages to medical support and
prevention services.
Research has found PCRS to be a very cost-effective
strategy for identifying HIV-infected persons who are unaware
of their serostatus. State AIDS directors support the
continuation of funding for PCRS through CDC cooperative
agreements with States and the directly-funded cities.
The State AIDS programs have been one of the largest
implementors of HIV rapid testing programs. We have long
supported the development and approval of rapid testing and
worked collaboratively with Congress and the Administration to
ensure rapid tests were considered for a CLIA waiver. In
several jurisdictions and in certain settings, barriers to
rapid testing exist. It is a complex testing technology. In
addition, it is more costly to implement than traditional
testing.
The CARE Act is a safety net under other public programs,
such as Medicaid and Medicare. The Ryan White programs must
adapt to fill gaps particular to the individual State. ADAPs
work closely with the State Medicaid programs and Medicare Part
D to ensure that ADAPs remain the payer of last resort.
Annually, ADAPs serve approximately 136,000 clients, or about
30 percent of the people living with HIV/AIDS estimated to be
receiving care in the United States.
In fiscal year 2005, States were dependent on State
contributions to their ADAP programs and pharmaceutical
discounts and rebates to sustain their ADAP programs, as the
increase in Federal dollars for ADAPs was extremely limited.
ADAPs receive the lowest prices in the country for anti-
retroviral therapies. In 2003, NASTAD established the ADAP
Prices Task Force to negotiate with the pharmaceutical industry
on behalf of all ADAPs, and as a result of this highly
successful public-private partnership, the task force achieved
supplemental discounts and rebates beyond those mandated by the
340B program and price freezes that have resulted in over $300
million in savings over the past 3 years.
Ten years after the advent of highly active anti-retroviral
therapy, the lives of people living with HIV/AIDS have been
greatly extended. Therefore, individuals are remaining on our
ADAP programs for lifetimes. ADAPs across the country continue
to encounter significant challenges in fiscal stability while
adequately serving the growing number of people with HIV and
AIDS.
For 2007, State AIDS directors seek an increase of $197
million for ADAPs to maintain those that are currently enrolled
and to meet the growing demand of new clients and to strengthen
ADAPs' abilities across the Nation to provide the PHS standard
of care and treatment.
Senator Coburn. Could you summarize, please? You have gone
past your 5 minutes.
Ms. Scalco. Sure. I would like to summarize by saying that,
first of all, State waiting lists for the ADAP programs are
only one indicator of need, that many ADAPS have other
restrictions in place, and to solely distribute money on the
basis of a waiting list is not an equitable way to do it.
I would also like to take one moment to address the issue
of Hurricane Katrina and the State of Louisiana, and
particularly since you asked the question about the flexibility
provided by our Federal partners. What we found is that the
flexibility was lacking and that, in fact, what occurred is
that while we were trying to piece programs back together and
provide services to clients, what basically was occurring is
that we were also having to meet administrative requirements
that could not be waived, which was not nearly as important as
assuring that people had access to treatment and care. We also
needed to have waivers of certain conditions of award and that
has not been possible. The transfer of funding between Title I
and Title II, which should have been an easy thing to do,
actually could not be done without amending 20 contracts
through the State of Louisiana's contract system.
And so in that, I would say I would appreciate in the Ryan
White CARE Act reauthorization if there is an emergency
provision that would address this problem. Thank you.
Senator Coburn. Thank you. Mr. Weinstein.
TESTIMONY OF MICHAEL WEINSTEIN,\1\ PRESIDENT, AIDS HEALTHCARE
FOUNDATION
Mr. Weinstein. Senator Coburn, Senate staff and the
audience, as President of the largest AIDS organization in the
United States, I am deeply concerned about the lack of access
to HIV medical care for half a million Americans. As we
approach the 25th anniversary of the identification of the
first cases of AIDS, I am troubled by our lack of progress in
treating HIV and controlling the epidemic in this country.
---------------------------------------------------------------------------
\1\ The prepared statement of Mr. Weinstein appears in the Appendix
on page 76.
---------------------------------------------------------------------------
Our No. 1 priority in all matters relating to AIDS should
be protecting the public health. With half the people who are
positive not in treatment, including many who do not even know
their status, we cannot control the spread of this disease nor
adequately help the people who have it.
AIDS Healthcare Foundation's primary mission is the medical
treatment of HIV in this country and across the globe, serving
32,000 patients. In several of the communities AHF serves, HIV
patients are dangerously underserved. As an example, Alameda
County, which includes the City of Oakland, is only spending 10
percent of its Ryan White CARE Act monies on primary medical
care. The Magic Johnson Clinic, which we operate in Oakland, is
largely unfunded and specialty referrals are almost impossible
to obtain. Despite the fact that Alameda County has declared a
state of emergency around HIV, much more money is being spent
on social services than medicine. At our Magic Johnson Clinic
in Jacksonville, Florida, the situation is similar.
Ten years after the discovery of the miraculous drug
cocktails that have made HIV a treatable illness, we are
treating HIV as if it is a death sentence that it was in the
1980s. We reauthorized the Ryan White CARE Act 5 years ago
without making the necessary adjustments to reflect the
progress we have made in treating patients, and there are some
who would have us do this again this year.
We know what it takes to control this disease. We must
identify most of the carriers and get them into treatment, and
we must effectively educate the uninfected population. Despite
billions of dollars a year in expenditures to combat AIDS, we
are failing on all counts. One need merely look at the numerous
countries, both rich and poor, that are succeeding where we
have failed to understand why. We don't do enough tests. We
don't provide enough money to treat. We are spending too much
money on drugs. We are not putting sufficient responsibility on
the infected person to protect their partners.
Until we have treatment readily available to everyone who
needs it, we will continue to have more and more AIDS cases.
Until testing is taken out of the rarified atmosphere of an
anonymous test site and integrated into mainstream medical care
in hospitals, clinics, and doctors' offices, we will not
identify many of the people who are positive. Until we tell the
drug companies that the U.S. Government will not write a blank
check for purchasing HIV drugs, we will continue to have
waiting lists for the AIDS Drug Assistance Program. Until we
are honest with people about the consequences of becoming
infected by HIV, which is not a day at the beach, as the drug
company ads portray it as, we will fail to fight AIDS
effectively in America.
The solutions are quite simple. If you want to improve
access to care, require that the lion's share of Federal
dollars be spent on treating the disease. We are doing this in
Los Angeles. The result is an extensive network of outpatient
clinics, both public and private, across the vast geography of
Southern California. Alameda County would have the same
diversity of treatment options if most of their money were not
being spent on food, housing, transportation, case management,
and everything else.
If you want to find more positives, you need to test more
people in a fast, convenient, and cost-effective manner.
Routine testing in health care settings without onerous
counseling requirements is the only way to go.
If you want to make drugs more accessible to more patients,
you cannot pay higher and higher prices for each new generation
of drugs, including those that are developed at government
expense, thus eating up most of the new money that Congress has
appropriated.
If we identify more people who are positive and get them
into treatment, the number of new infections will go down. If
it goes down below the number of deaths, then the number of
people living with HIV will be less each year rather than more.
We need to resolve to put the money where it is most needed
to stop AIDS. Rural areas and cities with emerging epidemics
must get a bigger piece of the pie. Distributing funds based on
where the epidemic was 10 years ago will not help us fight it
where it is found today. The people most hurt by this are
people of color, who represent the overwhelming majority of new
cases of AIDS.
Public health and politics are a dangerous mix. Too many
decisions about how to address AIDS have been made on the basis
of how one constituency or another must be appeased. This has
led to a piecemeal, half-hearted approach that has led us to
where we are now. There is no more fundamental function of
government than the protection of the public health.
I strongly urge the Congress to reauthorize the Ryan White
CARE Act in a fashion that will protect generations to come
from this devastating illness, and I would ask you to take
another look at other areas of AIDS spending, such as vaccines
and research, where there is enormous waste of public
resources. If these changes are adopted now, I am confident
that in the United States--this has happened in a country like
Uganda, that I returned from last week and I have visited eight
times--we will have less AIDS down the road rather than more.
Thank you.
Senator Coburn. Thank you.
Ms. Scalco, I may have heard you wrong, and I skimmed your
testimony. Was it your testimony that rapid testing is more
expensive than standard counseling testing and results? Is that
your testimony?
Ms. Scalco. Rapid testing is more expensive to implement
than doing Orasure testing and it has to do with the cost of
the kit and the cost of the controls and the cost of the other
supplies related to rapid testing.
Senator Coburn. As compared to an Orasure test?
Ms. Scalco. Yes.
Senator Coburn. OK, which can be, in fact, done very
easily?
Ms. Scalco. Yes. However, with the Orasure, you have to
wait approximately 2 weeks for results. We are very much in
favor of rapid testing. It has given us the ability to get
results to people much quicker and it assists with people who
don't return for their results.
Senator Coburn. We know many thousands of people don't come
back every year----
Ms. Scalco. Right.
Senator Coburn [continuing]. Who test positive.
Ms. Scalco. So, yes, we would like to implement more rapid
testing.
Senator Coburn. But you are looking at the cost of the test
only. You are not looking at the cost of the test to identify.
Ms. Scalco. Yes. We are looking at the costs of the actual
test as being more expensive.
Senator Coburn. But the cost to identify that somebody is
HIV-positive, a rapid test is far less expensive than the
other----
Ms. Scalco. That is correct.
Senator Coburn. OK. I wanted to clarify that.
Mr. Weinstein, we have known each other for quite some
time. You just espoused in your testimony a true public health
approach to HIV. My thought on this as I listened to the
testimony from CDC, 10 years ago, I tried to get the CDC to do
testing for newborn infants. It was blocked. The American
College of Obstetricians and Gynecologists was against it. Gary
Ackerman and myself, bipartisan, one Democrat liberal, one
Republican conservative, were totally blocked by the political
forces.
So I take what you say very seriously, but my response is,
how do we get other people embracing public health strategies
instead of political strategies when it comes to HIV? How do
you help me do that?
Mr. Weinstein. Just in the last 2 weeks, we passed historic
legislation in California to bring about names reporting for
the first time. It took us a long time, but we built a
coalition and in the end, it was unanimous.
Senator Coburn. Why did that happen?
Mr. Weinstein. It happened, first of all, I believe
immodestly, because groups like us were willing to stand up and
say it was necessary. I think also, when we enacted the code
system, it was horrible. And then lastly, the threat of losing
Ryan White CARE Act funds. But whatever it took, it happened.
We have a bill in the legislature now to simplify testing.
We are talking about routine testing. Let me tell you how it
actually works in the field today. It takes longer to do a
routine test because of the regulations of CDC and the State of
California than it took previously to do the other test. It
takes 40 minutes to do a test. Now, how many people can we test
if we do that?
Also, in this country, if you want to get a free test in
most places, you are required to answer a long list of intimate
sexually explicit questions to a total stranger. If you go to a
doctor, you don't have to do it. But if you want to do it in a
public setting, the price you have to pay is to answer
questions about the most intimate aspects of your life. I don't
think that is right.
Also, it was said earlier by the CDC that in a doctor's
office, we are going to uncouple counseling from testing. But
in the public setting, we are not going to do it. Well, that is
wrong, I would say, because 80 percent of the people we test,
and we have the largest testing program in California, are
repeat testers. No. 1, they have the information, and No. 2,
the last word they hear in that counseling session is
``negative'' or ``positive.'' If a person is positive, they
need intensive counseling not just on that occasion, but
following it, as well, to make sure they get into care. We have
to be practical.
If we are actually going to test more people, we have to do
it differently, and also, I would say, I am sure this will not
be a surprise to you to hear, but what is enacted in Congress
is not implemented in many cases. The reality is across this
country that women are not informed that their husbands or
boyfriends are infected with HIV. Most women who we treat, and
we have a large women's program, have no known risk factor for
HIV. I don't know how long we have been talking about it, but
it is not happening. And I think, again, going back to your
question about how we enacted names reporting, unless there is
a concrete penalty for not doing it, it will never be done, and
I think that is a terrible thing.
Senator Coburn. Why is that? I mean, if this is a public
health strategy we use in other areas, why is it that CDC won't
move to a common sense public health strategy that works? I am
not saying that they haven't made some movement. They have, and
I compliment them on that. But I am the author of informed
science about the effectiveness of condoms that passed this
Congress in the year 2000 which still hasn't been implemented
by the CDC saying people ought to know the level of protection
they get from a condom. With HIV, it is wonderful. It is great.
With many other diseases, it is not. But that is never a part
of the counseling.
The point being is how do we get to the point where we
embrace public health strategies where we can save lives, where
we can prevent, in fact? How do we move past the politics? In
other words, you are out there on the activist side of this.
Ms. Scalco is on the implementation side of it. How do we move
to where we get policies that are efficient and effective, that
save lives, move the ball forward, spend the money where it is
going to give us the best return in terms of life and quality
of life? How do we move to that? How do we build that?
Mr. Weinstein. Well, I would argue that since we are
fighting AIDS as a global effort, and I know there is always a
tension between States' rights and Federal directives, but
there are laws in California and elsewhere that prevent many of
these things from being done, as you heard earlier. Therefore,
I think that because you can't fight AIDS town by town and city
by city and State by State, I think there ought to be a Federal
standard that is enforced, at least in some of these areas.
And I think that when it comes to partner notification, it
shouldn't be voluntary, because if there is a group of sexually
active people and they know that they have a risk, they are
making that as an informed choice. But a woman who is not aware
that her husband or a woman who is not aware that her boyfriend
is using drugs or is bisexual is not able to make that choice.
I think that is a societal obligation and I don't see any
problem, really. Given the fact that the Federal Government is
the primary funder, I don't see a problem with the Federal
Government requiring in exchange for that funding that this be
universal.
Senator Coburn. If somebody is diagnosed with syphilis in
one of your clinics, is there mandatory reporting of that?
Mr. Weinstein. Yes.
Senator Coburn. Is there partner notification?
Mr. Weinstein. Ineffectively, but it is supposed to. It is
not done effectively, but yes, there is.
Senator Coburn. It is supposed to be, though?
Mr. Weinstein. It is supposed to be. It is done to some
extent, but not as fully as it should be.
Senator Coburn. But it is supposed to be.
Mr. Weinstein. Yes.
Senator Coburn. And there are statutes and regulations to
back that up.
Mr. Weinstein. Yes.
Senator Coburn. Would you consider HIV more deadly than
syphilis?
Mr. Weinstein. Oh, there is no question about that.
Senator Coburn. So why would we not have the same policy
for a disease that is more deadly?
Mr. Weinstein. How I look at it is if you look back over 25
years and you look at the ineffective Federal response, you
look at the stigma and discrimination that was even more
intense then but still exists now, myself and many activists
felt that the first order of business was privacy, protection,
and rights. I think that what the problem is, that we had a
revolution in treatment of HIV and when the disease goes from
being a death sentence to being a manageable illness, things
change. When you look back historically about how we used to
handle breast cancer, when Betty Ford and Nancy Reagan came out
publicly about it, all of a sudden, the paradigm shifted and
now there is public discussion and advocacy. It is totally
transformed.
So, I mean, it takes a while to catch up to these
technological changes, but I think guidance needs to be given,
again, by the Federal Government, which is the most expert. The
Centers for Disease Control is the most expert. They know what
works. I think they should give that guidance.
Senator Coburn. Thank you. Ms. Scalco, you all have an EMA
in New Orleans. Were funds transferred from that EMA to help
you with some of the programs that you had during the midst of
this hurricane and the things that followed thereafter and the
disruption in care and treatment for patients?
Ms. Scalco. Yes. We ultimately were able to transfer funds
through contractual arrangements so that the funding could
follow clients who had evacuated to other parts of the State.
Senator Coburn. Is Louisiana put at a disadvantage because
under the former formula we are using former AIDS diagnosis
instead of HIV? Would Louisiana benefit in terms of funding
formulas if the basis was where the disease is now and not
where it used to be?
Ms. Scalco. We believe that we may benefit. We believe that
we could have benefitted if that had been instituted earlier in
the epidemic. I think right now, we need to see where other
States stand in terms of their HIV infections. But we
definitely----
Senator Coburn. We have run those numbers. You will
benefit, I promise you.
Ms. Scalco. Yes, we may benefit, and in actuality, we are
serving people who are HIV infected and so we would like them
counted in the formula distribution.
Chairman Coburn. I have several other questions, but I am
going to shorten our hearing because we have something on the
floor at 4 o'clock. I want to thank you for your testimony. I
am committed for us to getting the Ryan White CARE Act
reauthorization. It doesn't have to be mine. It does need to
address the public health aspects of this. It does need to
address diagnosis, prevention, but also care and medical
treatment of those who have it. We know this is a disease that
can be controlled. We also know that with the early testing, we
can markedly decrease the number of potential infections in the
future coming from that one vector, and so it is important that
we all figure out where we can find the most common ground and
get this to happen before the end of this year.
I appreciate your work, both of you, in terms of trying to
get this done, and the others that have been here today. My
commitment is to work to get that done.
Thank you very much. The hearing is adjourned.
[Whereupon, at 4:07 p.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
[GRAPHIC] [TIFF OMITTED] 28242.001
[GRAPHIC] [TIFF OMITTED] 28242.002
[GRAPHIC] [TIFF OMITTED] 28242.003
[GRAPHIC] [TIFF OMITTED] 28242.004
[GRAPHIC] [TIFF OMITTED] 28242.005
[GRAPHIC] [TIFF OMITTED] 28242.006
[GRAPHIC] [TIFF OMITTED] 28242.007
[GRAPHIC] [TIFF OMITTED] 28242.008
[GRAPHIC] [TIFF OMITTED] 28242.009
[GRAPHIC] [TIFF OMITTED] 28242.010
[GRAPHIC] [TIFF OMITTED] 28242.011
[GRAPHIC] [TIFF OMITTED] 28242.012
[GRAPHIC] [TIFF OMITTED] 28242.013
[GRAPHIC] [TIFF OMITTED] 28242.014
[GRAPHIC] [TIFF OMITTED] 28242.015
[GRAPHIC] [TIFF OMITTED] 28242.016
[GRAPHIC] [TIFF OMITTED] 28242.017
[GRAPHIC] [TIFF OMITTED] 28242.018
[GRAPHIC] [TIFF OMITTED] 28242.019
[GRAPHIC] [TIFF OMITTED] 28242.020
[GRAPHIC] [TIFF OMITTED] 28242.021
[GRAPHIC] [TIFF OMITTED] 28242.022
[GRAPHIC] [TIFF OMITTED] 28242.023
[GRAPHIC] [TIFF OMITTED] 28242.024
[GRAPHIC] [TIFF OMITTED] 28242.025
[GRAPHIC] [TIFF OMITTED] 28242.026
[GRAPHIC] [TIFF OMITTED] 28242.027
[GRAPHIC] [TIFF OMITTED] 28242.028
[GRAPHIC] [TIFF OMITTED] 28242.029
[GRAPHIC] [TIFF OMITTED] 28242.030
[GRAPHIC] [TIFF OMITTED] 28242.031
[GRAPHIC] [TIFF OMITTED] 28242.032
[GRAPHIC] [TIFF OMITTED] 28242.033
[GRAPHIC] [TIFF OMITTED] 28242.034
[GRAPHIC] [TIFF OMITTED] 28242.035
[GRAPHIC] [TIFF OMITTED] 28242.036
[GRAPHIC] [TIFF OMITTED] 28242.037
[GRAPHIC] [TIFF OMITTED] 28242.038
[GRAPHIC] [TIFF OMITTED] 28242.039
[GRAPHIC] [TIFF OMITTED] 28242.040
[GRAPHIC] [TIFF OMITTED] 28242.041
[GRAPHIC] [TIFF OMITTED] 28242.042
[GRAPHIC] [TIFF OMITTED] 28242.043
[GRAPHIC] [TIFF OMITTED] 28242.044
[GRAPHIC] [TIFF OMITTED] 28242.045
[GRAPHIC] [TIFF OMITTED] 28242.046
[GRAPHIC] [TIFF OMITTED] 28242.047
[GRAPHIC] [TIFF OMITTED] 28242.048
[GRAPHIC] [TIFF OMITTED] 28242.049
[GRAPHIC] [TIFF OMITTED] 28242.050
[GRAPHIC] [TIFF OMITTED] 28242.051
[GRAPHIC] [TIFF OMITTED] 28242.052
[GRAPHIC] [TIFF OMITTED] 28242.053
[GRAPHIC] [TIFF OMITTED] 28242.054
[GRAPHIC] [TIFF OMITTED] 28242.055
[GRAPHIC] [TIFF OMITTED] 28242.056
[GRAPHIC] [TIFF OMITTED] 28242.057
[GRAPHIC] [TIFF OMITTED] 28242.058
[GRAPHIC] [TIFF OMITTED] 28242.059
[GRAPHIC] [TIFF OMITTED] 28242.060
[GRAPHIC] [TIFF OMITTED] 28242.061
[GRAPHIC] [TIFF OMITTED] 28242.062
[GRAPHIC] [TIFF OMITTED] 28242.063
[GRAPHIC] [TIFF OMITTED] 28242.064
[GRAPHIC] [TIFF OMITTED] 28242.065
[GRAPHIC] [TIFF OMITTED] 28242.066
[GRAPHIC] [TIFF OMITTED] 28242.067
[GRAPHIC] [TIFF OMITTED] 28242.068
[GRAPHIC] [TIFF OMITTED] 28242.069
[GRAPHIC] [TIFF OMITTED] 28242.070
[GRAPHIC] [TIFF OMITTED] 28242.071
[GRAPHIC] [TIFF OMITTED] 28242.072
[GRAPHIC] [TIFF OMITTED] 28242.073
[GRAPHIC] [TIFF OMITTED] 28242.075
[GRAPHIC] [TIFF OMITTED] 28242.076
[GRAPHIC] [TIFF OMITTED] 28242.077
[GRAPHIC] [TIFF OMITTED] 28242.078
[GRAPHIC] [TIFF OMITTED] 28242.079
[GRAPHIC] [TIFF OMITTED] 28242.074
[GRAPHIC] [TIFF OMITTED] 28242.080
[GRAPHIC] [TIFF OMITTED] 28242.081
[GRAPHIC] [TIFF OMITTED] 28242.082
[GRAPHIC] [TIFF OMITTED] 28242.083
[GRAPHIC] [TIFF OMITTED] 28242.084
[GRAPHIC] [TIFF OMITTED] 28242.085
[GRAPHIC] [TIFF OMITTED] 28242.086
[GRAPHIC] [TIFF OMITTED] 28242.087
[GRAPHIC] [TIFF OMITTED] 28242.088
[GRAPHIC] [TIFF OMITTED] 28242.089
[GRAPHIC] [TIFF OMITTED] 28242.090
[GRAPHIC] [TIFF OMITTED] 28242.091
[GRAPHIC] [TIFF OMITTED] 28242.092
[GRAPHIC] [TIFF OMITTED] 28242.093
[GRAPHIC] [TIFF OMITTED] 28242.094
[GRAPHIC] [TIFF OMITTED] 28242.095
[GRAPHIC] [TIFF OMITTED] 28242.096
[GRAPHIC] [TIFF OMITTED] 28242.097
[GRAPHIC] [TIFF OMITTED] 28242.098
[GRAPHIC] [TIFF OMITTED] 28242.099
[GRAPHIC] [TIFF OMITTED] 28242.101
[GRAPHIC] [TIFF OMITTED] 28242.100
[GRAPHIC] [TIFF OMITTED] 28242.354
[GRAPHIC] [TIFF OMITTED] 28242.355
[GRAPHIC] [TIFF OMITTED] 28242.102
[GRAPHIC] [TIFF OMITTED] 28242.103
[GRAPHIC] [TIFF OMITTED] 28242.104
[GRAPHIC] [TIFF OMITTED] 28242.105
[GRAPHIC] [TIFF OMITTED] 28242.106
[GRAPHIC] [TIFF OMITTED] 28242.107
[GRAPHIC] [TIFF OMITTED] 28242.108
[GRAPHIC] [TIFF OMITTED] 28242.109
[GRAPHIC] [TIFF OMITTED] 28242.110
[GRAPHIC] [TIFF OMITTED] 28242.111
[GRAPHIC] [TIFF OMITTED] 28242.112
[GRAPHIC] [TIFF OMITTED] 28242.113
[GRAPHIC] [TIFF OMITTED] 28242.114
[GRAPHIC] [TIFF OMITTED] 28242.115
[GRAPHIC] [TIFF OMITTED] 28242.116
[GRAPHIC] [TIFF OMITTED] 28242.117
[GRAPHIC] [TIFF OMITTED] 28242.118
[GRAPHIC] [TIFF OMITTED] 28242.119
[GRAPHIC] [TIFF OMITTED] 28242.120
[GRAPHIC] [TIFF OMITTED] 28242.121
[GRAPHIC] [TIFF OMITTED] 28242.122
[GRAPHIC] [TIFF OMITTED] 28242.123
[GRAPHIC] [TIFF OMITTED] 28242.124
[GRAPHIC] [TIFF OMITTED] 28242.125
[GRAPHIC] [TIFF OMITTED] 28242.126
[GRAPHIC] [TIFF OMITTED] 28242.127
[GRAPHIC] [TIFF OMITTED] 28242.128
[GRAPHIC] [TIFF OMITTED] 28242.129
[GRAPHIC] [TIFF OMITTED] 28242.130
[GRAPHIC] [TIFF OMITTED] 28242.131
[GRAPHIC] [TIFF OMITTED] 28242.132
[GRAPHIC] [TIFF OMITTED] 28242.133
[GRAPHIC] [TIFF OMITTED] 28242.134
[GRAPHIC] [TIFF OMITTED] 28242.135
[GRAPHIC] [TIFF OMITTED] 28242.136
[GRAPHIC] [TIFF OMITTED] 28242.137
[GRAPHIC] [TIFF OMITTED] 28242.138
[GRAPHIC] [TIFF OMITTED] 28242.139
[GRAPHIC] [TIFF OMITTED] 28242.140
[GRAPHIC] [TIFF OMITTED] 28242.141
[GRAPHIC] [TIFF OMITTED] 28242.142
[GRAPHIC] [TIFF OMITTED] 28242.143
[GRAPHIC] [TIFF OMITTED] 28242.144
[GRAPHIC] [TIFF OMITTED] 28242.145
[GRAPHIC] [TIFF OMITTED] 28242.146
[GRAPHIC] [TIFF OMITTED] 28242.147
[GRAPHIC] [TIFF OMITTED] 28242.148
[GRAPHIC] [TIFF OMITTED] 28242.149
[GRAPHIC] [TIFF OMITTED] 28242.150
[GRAPHIC] [TIFF OMITTED] 28242.151
[GRAPHIC] [TIFF OMITTED] 28242.152
[GRAPHIC] [TIFF OMITTED] 28242.153
[GRAPHIC] [TIFF OMITTED] 28242.154
[GRAPHIC] [TIFF OMITTED] 28242.155
[GRAPHIC] [TIFF OMITTED] 28242.156
[GRAPHIC] [TIFF OMITTED] 28242.157
[GRAPHIC] [TIFF OMITTED] 28242.158
[GRAPHIC] [TIFF OMITTED] 28242.159
[GRAPHIC] [TIFF OMITTED] 28242.160
[GRAPHIC] [TIFF OMITTED] 28242.161
[GRAPHIC] [TIFF OMITTED] 28242.162
[GRAPHIC] [TIFF OMITTED] 28242.163
[GRAPHIC] [TIFF OMITTED] 28242.164
[GRAPHIC] [TIFF OMITTED] 28242.165
[GRAPHIC] [TIFF OMITTED] 28242.166
[GRAPHIC] [TIFF OMITTED] 28242.167
[GRAPHIC] [TIFF OMITTED] 28242.168
[GRAPHIC] [TIFF OMITTED] 28242.169
[GRAPHIC] [TIFF OMITTED] 28242.170
[GRAPHIC] [TIFF OMITTED] 28242.171
[GRAPHIC] [TIFF OMITTED] 28242.172
[GRAPHIC] [TIFF OMITTED] 28242.173
[GRAPHIC] [TIFF OMITTED] 28242.174
[GRAPHIC] [TIFF OMITTED] 28242.175
[GRAPHIC] [TIFF OMITTED] 28242.176
[GRAPHIC] [TIFF OMITTED] 28242.177
[GRAPHIC] [TIFF OMITTED] 28242.178
[GRAPHIC] [TIFF OMITTED] 28242.179
[GRAPHIC] [TIFF OMITTED] 28242.180
[GRAPHIC] [TIFF OMITTED] 28242.181
[GRAPHIC] [TIFF OMITTED] 28242.182
[GRAPHIC] [TIFF OMITTED] 28242.183
[GRAPHIC] [TIFF OMITTED] 28242.184
[GRAPHIC] [TIFF OMITTED] 28242.185
[GRAPHIC] [TIFF OMITTED] 28242.186
[GRAPHIC] [TIFF OMITTED] 28242.187
[GRAPHIC] [TIFF OMITTED] 28242.188
[GRAPHIC] [TIFF OMITTED] 28242.189
[GRAPHIC] [TIFF OMITTED] 28242.190
[GRAPHIC] [TIFF OMITTED] 28242.191
[GRAPHIC] [TIFF OMITTED] 28242.192
[GRAPHIC] [TIFF OMITTED] 28242.193
[GRAPHIC] [TIFF OMITTED] 28242.194
[GRAPHIC] [TIFF OMITTED] 28242.195
[GRAPHIC] [TIFF OMITTED] 28242.196
[GRAPHIC] [TIFF OMITTED] 28242.197
[GRAPHIC] [TIFF OMITTED] 28242.198
[GRAPHIC] [TIFF OMITTED] 28242.199
[GRAPHIC] [TIFF OMITTED] 28242.200
[GRAPHIC] [TIFF OMITTED] 28242.201
[GRAPHIC] [TIFF OMITTED] 28242.202
[GRAPHIC] [TIFF OMITTED] 28242.203
[GRAPHIC] [TIFF OMITTED] 28242.204
[GRAPHIC] [TIFF OMITTED] 28242.205
[GRAPHIC] [TIFF OMITTED] 28242.206
[GRAPHIC] [TIFF OMITTED] 28242.207
[GRAPHIC] [TIFF OMITTED] 28242.208
[GRAPHIC] [TIFF OMITTED] 28242.209
[GRAPHIC] [TIFF OMITTED] 28242.210
[GRAPHIC] [TIFF OMITTED] 28242.211
[GRAPHIC] [TIFF OMITTED] 28242.212
[GRAPHIC] [TIFF OMITTED] 28242.213
[GRAPHIC] [TIFF OMITTED] 28242.214
[GRAPHIC] [TIFF OMITTED] 28242.215
[GRAPHIC] [TIFF OMITTED] 28242.216
[GRAPHIC] [TIFF OMITTED] 28242.217
[GRAPHIC] [TIFF OMITTED] 28242.218
[GRAPHIC] [TIFF OMITTED] 28242.219
[GRAPHIC] [TIFF OMITTED] 28242.220
[GRAPHIC] [TIFF OMITTED] 28242.221
[GRAPHIC] [TIFF OMITTED] 28242.222
[GRAPHIC] [TIFF OMITTED] 28242.223
[GRAPHIC] [TIFF OMITTED] 28242.224
[GRAPHIC] [TIFF OMITTED] 28242.225
[GRAPHIC] [TIFF OMITTED] 28242.226
[GRAPHIC] [TIFF OMITTED] 28242.227
[GRAPHIC] [TIFF OMITTED] 28242.228
[GRAPHIC] [TIFF OMITTED] 28242.229
[GRAPHIC] [TIFF OMITTED] 28242.230
[GRAPHIC] [TIFF OMITTED] 28242.231
[GRAPHIC] [TIFF OMITTED] 28242.232
[GRAPHIC] [TIFF OMITTED] 28242.233
[GRAPHIC] [TIFF OMITTED] 28242.234
[GRAPHIC] [TIFF OMITTED] 28242.235
[GRAPHIC] [TIFF OMITTED] 28242.236
[GRAPHIC] [TIFF OMITTED] 28242.237
[GRAPHIC] [TIFF OMITTED] 28242.238
[GRAPHIC] [TIFF OMITTED] 28242.239
[GRAPHIC] [TIFF OMITTED] 28242.240
[GRAPHIC] [TIFF OMITTED] 28242.241
[GRAPHIC] [TIFF OMITTED] 28242.242
[GRAPHIC] [TIFF OMITTED] 28242.243
[GRAPHIC] [TIFF OMITTED] 28242.244
[GRAPHIC] [TIFF OMITTED] 28242.245
[GRAPHIC] [TIFF OMITTED] 28242.246
[GRAPHIC] [TIFF OMITTED] 28242.247
[GRAPHIC] [TIFF OMITTED] 28242.248
[GRAPHIC] [TIFF OMITTED] 28242.249
[GRAPHIC] [TIFF OMITTED] 28242.250
[GRAPHIC] [TIFF OMITTED] 28242.251
[GRAPHIC] [TIFF OMITTED] 28242.252
[GRAPHIC] [TIFF OMITTED] 28242.253
[GRAPHIC] [TIFF OMITTED] 28242.254
[GRAPHIC] [TIFF OMITTED] 28242.255
[GRAPHIC] [TIFF OMITTED] 28242.256
[GRAPHIC] [TIFF OMITTED] 28242.257
[GRAPHIC] [TIFF OMITTED] 28242.258
[GRAPHIC] [TIFF OMITTED] 28242.259
[GRAPHIC] [TIFF OMITTED] 28242.260
[GRAPHIC] [TIFF OMITTED] 28242.261
[GRAPHIC] [TIFF OMITTED] 28242.262
[GRAPHIC] [TIFF OMITTED] 28242.263
[GRAPHIC] [TIFF OMITTED] 28242.264
[GRAPHIC] [TIFF OMITTED] 28242.265
[GRAPHIC] [TIFF OMITTED] 28242.266
[GRAPHIC] [TIFF OMITTED] 28242.267
[GRAPHIC] [TIFF OMITTED] 28242.268
[GRAPHIC] [TIFF OMITTED] 28242.269
[GRAPHIC] [TIFF OMITTED] 28242.270
[GRAPHIC] [TIFF OMITTED] 28242.271
[GRAPHIC] [TIFF OMITTED] 28242.272
[GRAPHIC] [TIFF OMITTED] 28242.273
[GRAPHIC] [TIFF OMITTED] 28242.274
[GRAPHIC] [TIFF OMITTED] 28242.275
[GRAPHIC] [TIFF OMITTED] 28242.276
[GRAPHIC] [TIFF OMITTED] 28242.277
[GRAPHIC] [TIFF OMITTED] 28242.278
[GRAPHIC] [TIFF OMITTED] 28242.279
[GRAPHIC] [TIFF OMITTED] 28242.280
[GRAPHIC] [TIFF OMITTED] 28242.281
[GRAPHIC] [TIFF OMITTED] 28242.282
[GRAPHIC] [TIFF OMITTED] 28242.283
[GRAPHIC] [TIFF OMITTED] 28242.284
[GRAPHIC] [TIFF OMITTED] 28242.285
[GRAPHIC] [TIFF OMITTED] 28242.286
[GRAPHIC] [TIFF OMITTED] 28242.287
[GRAPHIC] [TIFF OMITTED] 28242.288
[GRAPHIC] [TIFF OMITTED] 28242.289
[GRAPHIC] [TIFF OMITTED] 28242.290
[GRAPHIC] [TIFF OMITTED] 28242.291
[GRAPHIC] [TIFF OMITTED] 28242.292
[GRAPHIC] [TIFF OMITTED] 28242.293
[GRAPHIC] [TIFF OMITTED] 28242.294
[GRAPHIC] [TIFF OMITTED] 28242.295
[GRAPHIC] [TIFF OMITTED] 28242.296
[GRAPHIC] [TIFF OMITTED] 28242.297
[GRAPHIC] [TIFF OMITTED] 28242.298
[GRAPHIC] [TIFF OMITTED] 28242.299
[GRAPHIC] [TIFF OMITTED] 28242.300
[GRAPHIC] [TIFF OMITTED] 28242.301
[GRAPHIC] [TIFF OMITTED] 28242.302
[GRAPHIC] [TIFF OMITTED] 28242.303
[GRAPHIC] [TIFF OMITTED] 28242.304
[GRAPHIC] [TIFF OMITTED] 28242.305
[GRAPHIC] [TIFF OMITTED] 28242.306
[GRAPHIC] [TIFF OMITTED] 28242.307
[GRAPHIC] [TIFF OMITTED] 28242.308
[GRAPHIC] [TIFF OMITTED] 28242.309
[GRAPHIC] [TIFF OMITTED] 28242.310
[GRAPHIC] [TIFF OMITTED] 28242.311
[GRAPHIC] [TIFF OMITTED] 28242.312
[GRAPHIC] [TIFF OMITTED] 28242.313
[GRAPHIC] [TIFF OMITTED] 28242.314
[GRAPHIC] [TIFF OMITTED] 28242.315
[GRAPHIC] [TIFF OMITTED] 28242.316
[GRAPHIC] [TIFF OMITTED] 28242.317
[GRAPHIC] [TIFF OMITTED] 28242.318
[GRAPHIC] [TIFF OMITTED] 28242.319
[GRAPHIC] [TIFF OMITTED] 28242.320
[GRAPHIC] [TIFF OMITTED] 28242.321
[GRAPHIC] [TIFF OMITTED] 28242.322
[GRAPHIC] [TIFF OMITTED] 28242.323
[GRAPHIC] [TIFF OMITTED] 28242.324
[GRAPHIC] [TIFF OMITTED] 28242.325
[GRAPHIC] [TIFF OMITTED] 28242.326
[GRAPHIC] [TIFF OMITTED] 28242.327
[GRAPHIC] [TIFF OMITTED] 28242.328
[GRAPHIC] [TIFF OMITTED] 28242.329
[GRAPHIC] [TIFF OMITTED] 28242.330
[GRAPHIC] [TIFF OMITTED] 28242.331
[GRAPHIC] [TIFF OMITTED] 28242.332
[GRAPHIC] [TIFF OMITTED] 28242.333
[GRAPHIC] [TIFF OMITTED] 28242.334
[GRAPHIC] [TIFF OMITTED] 28242.335
[GRAPHIC] [TIFF OMITTED] 28242.336
[GRAPHIC] [TIFF OMITTED] 28242.337
[GRAPHIC] [TIFF OMITTED] 28242.338
[GRAPHIC] [TIFF OMITTED] 28242.339
[GRAPHIC] [TIFF OMITTED] 28242.340
[GRAPHIC] [TIFF OMITTED] 28242.341
[GRAPHIC] [TIFF OMITTED] 28242.342
[GRAPHIC] [TIFF OMITTED] 28242.343
[GRAPHIC] [TIFF OMITTED] 28242.344
[GRAPHIC] [TIFF OMITTED] 28242.345
[GRAPHIC] [TIFF OMITTED] 28242.346
[GRAPHIC] [TIFF OMITTED] 28242.347
[GRAPHIC] [TIFF OMITTED] 28242.348
[GRAPHIC] [TIFF OMITTED] 28242.349
[GRAPHIC] [TIFF OMITTED] 28242.350
[GRAPHIC] [TIFF OMITTED] 28242.351
[GRAPHIC] [TIFF OMITTED] 28242.352
[GRAPHIC] [TIFF OMITTED] 28242.353