ÿWPCÖ Õ{X;¤îjfÛ2Õœ_Ÿ@c(Bª:žJ XÉymvó(Í‹ƒšmòw$ž\\öø¨·ªë‚§æ¬Žß ‰xC NëŠcªÁ¾íÏ~ŽÌíbS ÿ® q²SpÔ $ÒTëi^È|áËõVÅô£î{¨Ñ؈¹  •ãÀ34Sh¤nHpSœ?¡rŠ½¸B\Ÿ42´5é8È}Mdf=UOZi¡lŠk»ìñrÊÐd [æÏÎ/Áñ|lÊ+V~2 ÉstÜ3T1µ»ß’§‘óGà%ô]©V÷¯º NéÃ|Ê`æÂ…º¥Z3=BžoÓíÙ7ñRÛ‡þôÍô¿ÕÁT¹#ï:S1Þ|9¬»õlçžloÇcæÎ =˜06 þ™;r®Î¡j*Î!jØ•C±ÌÃÄ/œY„5@bU‰QibI™léSÁ½¦Œ)B¢½ÐáODÅvÔµxaàjåS cÒ ÁSûBKla©à~šåÿ(g¨ïÙýØér2š¹ôf½—b}<@çðëø£öNž+ ³Á:4.c£á~{;“êÑl1‰{èŽMÔRMC#ƒ—D”ß:»tEꧣ®l}Eóî\y±Iz•‚c² “Ž©H,UNh %¶¶¶¼ 0¼r 0D..Br 0“´ D+G Ær 0“8 0=Ë 0“ AQ› › › 1eì Q n®a 0x‡ 1mU<üw@84xŒ mŽUN¥Æóóóóóóóóóóóóó B¹(ÈhH  Z6Times New Roman RegularX ' Î  1G:\PUBS\AR3\01A5\Minutes PACHA.wpd2 F,0William B. Fisher .   (l(3X$¤¤Ý ƒ‰à!ÝÑ8€O.XXdìdì8ÑÑ  ÑÔ  ÔÝ  Ýà  àòòÚ  Ú0Ú  Úóó(#Ã$òòÚ  Ú0Ú  Úóó 8Ñ°°ÑÑà°ÑÒ°°ÒÒ°°Ò(k2™p$©©Ý ƒ‰à!ÝÑ8€O.XXdìdì8ÑÑ  ÑÔ  ÔÝ  Ý'ÈÈÈÈdxdƒ Level 1 Level 2 Level 3 Level 4 Level 5(k2™p$££Ý ƒ‰à!ÝÑ8€O.XXdìdì8ÑÑ  ÑÔ  ÔÝ  Ý(ÿÿ$””Ú  ÚÚ  Ú(k2™p$¢¢Ý ƒ‰à!ÝÑ8€O.XXdìdì8ÑÑ  ÑÔ  ÔÝ  Ý  Cþÿ<< cÿÿ$ÿÿ35;AGMSY_11.1.1.1.1.1.1.1.3|x#«ô\  `*Times New RomanTTôôCô\  PŽ6QôP"ÞB è 0*Times New RomanTTXXbÞB è€ 0“*¹QX0ô\  `*Times New RomanTTXXPô\  PŽ6QXP2xÐðA`ArialTTomanTTXXxÐðPö»7ûXP(P‰à$¡¡Ñ8€ÔXXdìXXdì8ÑÑ  ÑÔ  Ô # e37=CIQYag­­1.a.i.(1)(a)(i)1)a)%ô\  `$Times NewRoman ////// /!/"D#V`}/&< Fil:ÿU‹ÿÀÀÀxÖÃ9 Z‹6Times New Roman Regular1, 2, 3,Level 1Level 2Level 3Level 4Level 5 dÝ ƒ‰à!ÝÑ8€O.XXdìdÈ8ÑÑ  ÑÔ  ÔÝ  Ý›ññÓ=€O.ÐXdÐd=ÓññÑ  ÑÓ  Óò òÑ€ÑññÓ=€oXÐXdÐd=ÓññPresidential€Advisory€Council€on€HIV/AIDSó óÐ ° Ðò òFull€Council€Meetingó óÐ œì ÐÌNovember€16ð!ð19,€1998ÌÌMadison€HotelÌWashington,€D.C.ÌÌññò òDRAFTó óÌÌññò òMINUTESó óÐ  ` ÐÓÀÓÌÌò òPresent:ó ó€R.€Scott€Hitt,€M.D.,€Chair;€Stephen€N.€Abel,€D.D.S.;€Terje€Anderson;€Regina€Aragon;Ð Ô$  ÐJudith€Billings;€Charles€Blackwell,€J.D.;€Jerry€Cade,€M.D.;€Lynne€M.€Cooper;€Rabbi€Joseph€A.ÏEdelheit;€Robert€Fogel;€Debra€Fraser„Howze;€Kathleen€Gerus;€Phyllis€Greenberger;€NilsaÏGutierrez,€M.D.,€M.P.H.;€Robert€Hattoy;€B.€Thomas€Henderson;€Michael€T.€Isbell;€RonaldÏJohnson;€Jeremy€Landau;€Alexandra€Mary€Levine,€M.D.;€Steve€Lew;€Miguel€Milanes,€M.P.A.;ÏHelen€H.€Miramontes;€Rev.€Altagracia€Perez;€Michael€Rankin,€M.D.;€H.Alexander€Robinson;ÏSean€Sasser;€Benjamin€Schatz,€J.D.;€Richard€W.€Stafford;€Denise€Stokes;€Bruce€Weniger,€M.D.;Ïand€Daniel€Montoya,€Executive€Director€for€PACHA€within€the€Office€of€National€AIDS€PolicyÏ(ONAP).€ò òPresent€from€ONAP:ó ó€Sandra€¢Thurman£,€Director,€and€Todd€Summers,€DeputyÐ 8ˆ ÐDirector.€Also€present€were€Paul€Bouey,€Ph.D.,€National€Native€American€AIDS€PreventionÏCenter;€Ô‡XO.XXXÔHelene€Gayle,€M.D.,€Centers€for€Disease€Control€and€Prevention€(CDC);€MatthewÐ d ÐMurguia,€Office€on€Minority€Health;Ô#†XO.XXXO.Ñ#ÔÔ‡XO.XXXO.Ô€Jeffrey€Koplan,€M.D.,€M.P.H.,€CDC;€Ô#†XO.XXXO.˜#ÔDavid€¢Satcher£,€M.D.,Ð P ÐÔ‡XO.XXXO.ÔSurgeon€General€of€the€United€StatesÔ#†XO.XXXO.)#Ô;€and€staff€members€Emily€Seymour€and€Kelly€Stewart.€Ð ì< ÐÌò òAbsent:ó ó€Nicholas€Bollman,€Debbie€Runions,€and€Charles€Quincy€TroupeÐ Ä ÐÌÌÓ  Óò òMonday,€November€16,€1998Ð ŒÜ ÐÌOpening€and€General€Council€Businessó óÐ d ´ ÐÓ:ÓÌññÓš™ÓññDr.€R.€Scott€Hitt,€Chair,€opened€the€Eleventh€Meeting€of€the€Presidential€Advisory€Council€onÏHIV/AIDS€(PACHA)€with€a€review€of€interim€activities€and€meeting€goals.€He€dedicated€theÏmeeting€to€those€living€with€HIV/AIDS,€and€especially€to€Drs.€Jonathan€Mann€and€Mary€LouÏClements„Mann.€He€stressed€the€importance€of€the€Council€membersðð€striving€to€achieve€asÏmuch€as€is€possible€in€the€short€time€remaining€in€the€Councilððs€charter,€which€will€end€in€JulyÏ1999,€and€to€focus€their€efforts€on€those€things€that€can€be€achieved.€He€also€reminded€theÏmembers€that€they€are€an€advisory€group,€not€a€lobbying€group.€Dr.€¢Hitt£€complimented€theÏcommittees€on€their€work€but€suggested€that€an€effort€be€made€to€pare€down€the€number€ofÏconference€calls.€In€addition,€an€excess€of€letters€sent€to€the€White€House€(six€recently€on€theÏbudget,€emergencies€in€communities€of€color,€needle€exchanges,€etc.)€might€have€reduced€theirÏimpact,€although€some€positive€results€are€evident.€This€yearððs€budget,€he€said,€has€the€largestÏincrease€in€AIDS€funding€in€any€year,€and€he€thanked€Ms.€¢Thurman£€and€Mr.€Summers€ofÏ¢ONAP£for€their€tireless€efforts€in€bringing€about€this€budget.Ð L-œ(, ÐÑÑâ âÑ°°ÑÑà°ÑÒ°°ÒÒ°°Òâ âÑ  ÑÐ ° ÐDr.€¢Hitt£€mentioned€that,€because€of€ññexpanded€ññwork€demands,€Nicholas€¢Bollman£€has€announcedÏthat€he€must€step€down€as€Chair€of€the€Services€Subcommittee.€Mr.€¢Bollman£€was€unable€toÏattend€the€November€meeting,€but€will€remain€on€the€Council.€Dr.€¢Hitt£€thanked€Mr.€¢Bollman£€forÏhis€services€and€announced€that€Regina€Aragon€and€Tom€Henderson€have€agreed€to€serve€as€Co„¼Chairs€of€the€Services€Subcommittee.ÌÌDr.€¢Hitt£€praised€the€work€done€by€Ms.€Fraser„¢Howze£,€Mr.€Robinson,€and€Mr.€Johnson€with€theÏCongressional€Black€Caucus€(CBC),€and€Ms.€Fraser„¢Howze£ððs€arrangement€of€a€town€hallÏmeeting€sponsored€by€CBC€on€HIV/AIDS€that€was€broadcast€to€a€network€of€African„AmericanÏchurches€and€colleges€nationwide.€Dr.€Hitt€thanked€the€Council€members€and€Mr.€Montoya€andÏthe€ONAP€staff€and€representatives€for€their€ongoing€efforts€on€behalf€of€the€Council.€He€thenÏwelcomed€new€White€House€interns€working€with€ONAP:€Ms.€Seymour€from€the€University€ofÏPennsylvania€and€Ms.€Stewart€from€the€University€of€Utah.ÌÌDr.€Hitt€described€the€role€of€Executive€Director€of€ONAP€on€behalf€of€the€Council,€which€hasÏexpanded€over€the€past€year.€Much€time€and€effort€are€put€into€contacting€agencies€and€groups€toÏapprise€them€of€the€role€of€the€Council€and€to€make€them€aware€of€the€CouncilððsÏrecommendations.€Mr.€Montoya€briefly€described€his€responsibilities,€stating€that€he€is€theÏdesignated€Federal€official,€and€as€such,€he€oversees€the€Federal€law€that€affects€the€CouncilððsÏactivities€and€makes€certain€that€the€information€the€Council€agrees€to€support€reaches€the€correctÏGovernment€agencies.€As€Executive€Director,€he€is€the€liaison€with€the€NIH€Office€of€AIDSÏResearch€(OAR)€and€provides€feedback€from€the€Council€on€various€Government€projects.ÌÌDr.€Hitt€stated€that€the€primary€focus€of€this€meeting€was€to€be€strategic€planning€for€the€periodÏthrough€the€end€of€PACHAððs€charter€(July€1999),€with€an€emphasis€on€points€to€be€brought€up€atÏthe€White€House€meeting€with€President€William€J.€Clinton€scheduled€for€December€18,€1998.ÏThis€meeting€should€focus€on€items€that€could€be€accomplished€by€the€end€of€this€AdministrationÏ(January€2001).ÌÌDr.€Hitt€asked€Council€members€to€review€the€strategic€plan.€The€Council€must€organize€itsÏefforts€and€focus€to€ensure€that€the€plan€will€be€accomplished.€To€present€more€than€six€items€atÏthe€meeting€with€the€President€would€be€counterproductive.€The€Executive€Committee€willÏfinalize€the€wording€of€the€questions€listed€below€and€determine€who€can€best€present€them.ÏMr.¢Montoya£€suggested€that€all€the€questions€be€worded€to€fall€in€the€categories€of€research,Ïprevention,€or€service.ÌÌ1.à0  àCBC€has€brought€attention€to€the€state€of€emergency€in€the€black,€Latino,€and€otherÐ Ì&"% Ðcommunities€of€color.€How€can€the€community€follow€up€in€all€populations€at€risk?Ð (#(# ÐÌ2.à0  àWhat€does€CDC€plan€to€do€about€AIDS€prevention?€There€is€little€concrete€informationÐ )à$( Ðexcept€that€Federal€funding€for€any€needle„exchange€program€is€prohibited.Ð (#(# ÐÌ3.à0  àEarly€intervention€is€vital.€More€services€must€be€available€earlier.€What€can€be€done€toÐ T,¤'+ Ðspeed€up€Medicaid€waivers€for€the€States?Ð (#(# ÐÐ ,.|)- Ð4.à0  àWhat€is€being€done€to€get€more€funding€for€AIDS€into€the€Federal€budget?а(#(# ÐÌ5.à0  àWhat€can€be€done€for€HIV/AIDS€worldwide?€What€is€the€policy€of€the€U.S.€StateÐ ˆØ ÐDepartment?€Is€there€a€place€for€community€input?Ð (#(# ÐÌ6.à0  àWhat€can€the€Food€and€Drug€Administration€(FDA)€and€OAR€do€to€improve€work€on€aÐ L œ Ðvaccine€or€a€microbicide?Ð (#(# ÐÌThere€are€other€very€important€issuesð"ðgetting€prevention€measures€and€treatment€available€inÏprisons€and€reaching€youth€in€dangerð"ðbut€all€cannot€be€brought€up.ÌÌDr.€Hitt€reviewed€the€agenda€for€the€meeting,€noting€that€there€would€be€a€full€CouncilÏpresentation€on€the€disparities€in€HIV/AIDS€in€health€programs€for€Native€Americans,€AlaskaÏNatives,€and€Native€Hawaiians.€Dr.€¢Satcher£€and€Dr.€Koplan€are€scheduled€to€address€the€Council,Ïand€he€noted€that€both€want€to€help€in€this€ð ðsevere€and€ongoingðð€health€care€crisis.€The€recentÏelection€outcome€bodes€well€for€getting€appropriations€for€these€purposes.€It€is€important€to€knowÏhow€and€where€the€new€funds€will€be€spent.€HIV/AIDS€prevention€is€receiving€the€mostÏattention,€but€needle€exchange,€specifically,€is€not€a€politically€acceptable€prevention€method.ÏNeither€the€White€House€nor€Congress€is€very€responsive€to€it,€although€sound€data€show€that€itÏdoes€prevent€the€spread€of€disease.ÌÌò òÓ  ÓUpdate€on€Activities€of€the€Office€of€National€AIDS€Policyó óÐ  \ ÐÓ› ÓÌMs.€Thurman,€Director€of€ONAP,€thanked€Council€members€for€their€support€and€their€usefulÏmaterials€in€support€of€common€interests.€She€stressed€the€importance€of€the€Councilððs€stayingÏfocused€on€deliverable€issues,€but€not€to€the€point€where€other€issues€get€lost.ÌÌThe€major€issues€include€the€following:ÌÌ1.à0  àWhat€role€will€the€Council€urge€CDC€to€take?Ðl¼(#(# ÐÌ2.à0  àHow€will€the€funds€in€the€FY€1999€and€FY€2000€budgets€be€allocated?ÐD!”(#(# ÐÌ3.à0  àHow€should€the€State€Department€support€the€worldwide€attack€on€AIDS?Ð#l!(#(# ÐÌ4.à0  àWhat€should€be€the€focus€of€the€Councilððs€December€meeting€with€President€Clinton?Ð ô$D # ÐHow€can€the€hot€political€issue€of€needle€exchange€be€included?Ð (#(# ÐÌ5.à0  àHow€can€the€delivery€of€services€to€various€communities€be€promoted?€How€canÐ ¸'#& ÐHispanics,€Native€Americans,€Hawaiians,€and€other€minorities€at€risk€be€reached?Ð (#(# ÐÌThe€CBC€initiative€was€introduced€on€October€26.€On€October€28,€the€President€declared€€aÏð ðsevere€and€ongoing€health€care€crisisðð€of€HIV€and€AIDS€in€the€African„American€and€otherÏminority€communities,€and€announced€a€$156€million€initiative€to€target€this€problem.€TheÏâ âquestion€is,€How€will€these€funds€be€spent?€The€agencies€and€Congress€must€be€convinced€thatÐ @-(, ÐHIV/AIDS€is€not€a€medical€problem€that€affects€only€gay€white€men,€but€a€disease€with€wideÏsocial€and€political€implications.Ìâ âÌMs.€Thurman€acknowledged€the€tremendous€support€and€assistance€of€Ms.€Fraser„Howze,ÏRepresentatives€Maxine€Waters,€Louis€Stokes,€Nancy€¢Pelosi£,€and€John€Porter;€Senator€ArlenÏSpector;€Secretary€Donna€¢Shalala£;€Deputy€Secretary€Kevin€¢Thurm£;€Dr.€¢Koplan£;€and€Dr.€EricÏGoosby€in€making€this€initiative€happen.ÌÌVice€President€Al€Gore€is€extremely€interested€in€the€HIV/AIDS€crisis.€He€and€Ms.€ThurmanÏhave€met€with€African„American€ministers€and€with€members€of€the€National€Association€for€theÏAdvancement€of€Colored€People€(NAACP)€and€the€Southern€Christian€Leadership€ConferenceÏ(SCLC)€to€get€the€issues€on€their€agendas.€At€the€insistence€of€Vice€President€Gore,ÏMs.¢Thurman£€will€meet€with€African„American€ministers€in€Atlanta€to€continue€the€dialogue.ÏThe€Hispanic€community€and€other€minority€communities€feel€they€are€not€fully€represented;Ïhowever,€it€was€noted€that€CBC€took€the€lead€in€this€effort€and€was€lobbying€for€help€for€theÏAfrican„American€òòandóó€other€communities€of€color.€The€Council€will€have€to€work€more€closelyÐ „Ô  Ðwith€the€Congressional€Hispanic€Caucus€on€these€issues€in€the€future.€President€ClintonððsÏannouncement€on€the€CBC€initiative€indicated€his€support,€and€his€recognition€of€CouncilÏmember€Denise€Stokes€as€a€person€living€with€HIV/AIDS€helped€put€a€face€on€the€statistics.ÌÌò òNeedle€Exchange.ó ó€The€issue€of€needle€exchange€is€politically€provocative.€The€FederalÐ  p Ðappropriations€bill€for€the€District€of€Columbia€specifically€states€that€no€Federal€funds€can€go€toÏan€agency€that€is€using€any€funds€for€needle€exchange,€thereby€putting€some€100€agencies€at€risk.ÏTiming€is€bad€for€supporting€needle€exchange;€both€needle€exchange€and€drug€use€have€been€tiedÏto€gun€use,€and€the€foes€of€drug€use€have€co„opted€the€issue.€The€Administration€supports€theÏrationale€behind€needle€exchange€and€its€value€in€prevention€of€disease,€but€there€will€be€a€realÏfight€to€educate€Members€of€Congress.€There€is€serious€concern€that€insofar€as€reauthorization€ofÏthe€Ryan€White€CARE€Act€is€concerned,€those€in€Congress€opposed€to€needle€exchange€willÏinsist€that€its€ban€be€included€in€the€reauthorization€bill.ÌÌDr.€Rankin€noted€that€needle€exchange€gets€some€people€into€drug€treatment,€and€as€such€itÏappeals€to€some€more€conservative€groups,€including€the€military.€Rabbi€Edelheit€suggested€thatÏthe€best€way€to€approach€the€needle„exchange€issue€might€be€to€include€it€as€one€measure€in€allÏpreventive€programs€instead€of€letting€the€issue€stand€on€its€own.ÌÌò òFederal€FY€1999€Budget.€ó óThe€FY€1999€budgetò ò€ó óhas€about€$500€million€in€new€funds€forÐ ø$H # ÐHIV/AIDS€prevention,€treatment,€research,€and€services.€However,€it€is€spread€over€a€numberÏofprograms.€With€respect€to€the€Housing€Opportunities€for€People€With€AIDS€(HOPWA)Ïincrease,€the€housing€appropriations€bill€contained€an€increase€of€only€$11€million.€An€additionalÏ$10€million€was€received€through€the€Department€of€Labor„Department€of€Health€and€HumanÏServices€(¢DHHS£)€appropriations€process.€The€Office€of€Minority€Health€within€¢DHHS£€gets€aboutÏ$8€million.€What€makes€the€budget€confusing,€however,€is€that€funding€was€earmarked€forÏHIV/AIDS€without€new€fundsðð€being€added.€It€is€hard€to€find€more€than€$102€million€of€theÏfunds€claimed€by€CBC€to€have€been€appropriated.€Funding€for€international€efforts€againstÏHIV/AIDS€was€increased€by€$5€million.ÌÐ 4.„)- ÐMr.€Anderson€noted€that€the€total€figure€appropriated€by€Congress€was€more€than€requested€byÏthe€President.€Ms.€Thurman€explained€that€the€requested€increase€was€the€largest€ever,€but€that€ifÏeverything€had€been€included,€Congress€might€have€cut€other€items€the€President€wanted.ÏPolitically,€it€was€better€to€leave€some€leeway€for€Congress€to€add€funding€for€special€activities.ÌÌ¢ONAP£€will€work€with€the€Office€of€Management€and€Budget€(OMB)€on€all€line€items€in€theÌFY€2000€budget€that€affect€AIDS€prevention,€primary€care,€and€support€of€patients.€PreventionÏfunding€has€been€emphasized€in€the€budget,€with€a€targeted€focus€on€spending,€particularlyÏgetting€people€of€color€into€HIV€testing€facilities€so€that€they€know€their€status.€ONAP€is€lookingÏfor€better€ways€of€integrating€sexually€transmitted€disease€(¢STD£),€HIV,€and€maternal„fetal€healthÏprograms.€Additional€funds€are€being€sought€for€the€Substance€Abuse€and€Mental€HealthÏServices€Administration€(¢SAMHSA£)€for€drug€treatment€and€prevention,€with€increases€in€blockÏgrants€and€a€better€delineation€of€how€funds€are€being€spent.ÌÌMs.€Thurman€spent€2€days€in€Boston€at€meetings€that€focused€on€care€for€minority€groups.ÏEmphasis€at€the€meeting€was€on€prevention€and€testing€and€on€integrating€them€with€maternalÏand€child€care.€Funding€has€been€cut;€it€was€argued€that€since€AIDS€deaths€are€down,€lessÏfunding€is€needed.€This€policy€disregards€the€costs€of€supporting€those€living€with€the€disease.ÌÌMr.€Summers€suggested€that€the€various€agencies€that€received,€or€are€targeted€to€receive,€newÏfunds€supply€information€to€the€Council€about€how€these€funds€are€being€used.ÌÌò òYouth€Programs.ó ó€The€December€1996€Executive€Order€gave€¢DHHS£€the€responsibility€toÐ øH Ðoversee€youth€programs.ò ò€ó óWorld€AIDS€Day€is€a€program€that€came€out€of€this€Executive€Order.Ð è8 ÐThe€Council€should€attempt€to€determine€what€is€being€done€in€all€the€programs€under€thisÏExecutive€Order€and€whether€it€can€make€recommendations.€For€example,€the€Selective€ServiceÏmailing€to€all€males€17€years€of€age€now€includes€information€about€AIDS€prevention.€TheÏCouncil€should€look€into€what€can€be€done€to€reach€females€in€this€age€group.€Vice€PresidentÏGore,€an€outspoken€advocate€of€AIDS€prevention€and€care,€will€address€the€problems€of€reachingÏyouths€at€risk€for€HIV/AIDS€and€housing€for€those€living€with€AIDS.ÌÌò òVaccines.ó ó€Ms.€Thurman€noted€that€there€has€been€some€progress€but€not€as€much€as€one€wouldÐ L!œ Ðlike.€Dr.€Neal€Nathanson,€OAR€Director,€is€working€with€an€interagency€task€force€to€advanceÏvaccine€development.€Meetings€will€commence€in€the€near€future€and€will€be€rotated€through€theÏvarious€responsible€agencies,€which€should€help€in€moving€vaccine€development€forward.ÏBuilding€of€the€new€Vaccine€Center€is€progressing,€and€the€work€of€the€Center€is€continuingÏunder€the€direction€of€Dr.€Nathanson€and€Dr.€Anthony€¢Fauci£,€National€Institute€of€Allergy€andÏInfectious€Diseases.€Search€for€a€director€of€the€Vaccine€Center€is€continuing.€President€ClintonÏand€Vice€President€Gore€are€both€interested€in€vaccine€development.€Dr.€Robert€Gallo,ÏUniversity€of€Maryland,€recently€announced€that€an€AIDS€vaccine€will€be€available€withinÏ4years.€Ms.€¢Thurman£€said€that€in€her€opinion€this€projection€is€extremely€optimistic.ÌÌò òPrisons.ó ó€Working€with€the€Bureau€of€Prisons€on€AIDS€prevention€is€frustrating.€Mr.€SummersÐ t+Ä&* Ðrecently€met€with€representatives€from€the€Health€Care€Financing€Administration€(¢HCFA£),ÏHealth€Resources€and€Services€Administration€(¢HRSA£),€U.S.€Department€of€Justice,€and€BureauÏof€Prisons€to€examine€the€complicated€issues€involved.€For€example,€although€there€is€a€networkÐ <.Œ)- Ðof€medical€care€for€those€who€are€released€from€prison€and€require€treatment,€people€who€are€inÏð ðhalfway€houseðð€programs€are€not€eligible€for€other€Federal€funds€because€they€are€consideredÏwards€of€the€Federal€Government.€The€programs€are€voluntary,€and€prisoners€must€sign€a€waiverÏstating€that€they€will€be€self„sufficient.€The€Bureau€of€Prisons€is€obligated€to€give€them€only€a€30„¼day€supply€of€medication.€Mr.Summers€noted€that€a€recent€bill,€Correctional€Officer€Health€andÏSafety€Act,€House€Resolution€2070,€will€change€the€mandatory€testing€of€prisoners€forÏHIV/AIDS€from€the€time€of€leaving€prison€to€the€time€of€entering€prison€for€prisoners€receivingÏsentences€of€6€months€or€more.€Additionally,€there€is€a€requirement€that€the€results€of€the€studiesÏbe€confidential€and€that€care€and€services€be€given.€He€stressed€the€need€for€confidentiality€ofÏtesting€results€for€those€in€custody€as€well€as€those€in€the€general€community.ÌÌò òInternational€Issues.ó ó€For€the€first€time,€the€National€Security€Council€(NSC)€staff€now€includesÐ Ô$  Ða€health€care€specialist,€Dr.€Kenneth€Bernard€of€¢DHHS£.ÌÌIndia:€The€Human€AIDS€meeting€to€discuss€HIV€and€AIDS€is€scheduled€for€December€1998.€AÏmeeting€was€recently€convened€in€Washington€with€officials€from€India€and€includedÏrepresentatives€from€the€World€Bank€and€¢DHHS£€to€discuss€the€issues€and€how€the€entities€canÏmore€effectively€coordinate€and€communicate€their€efforts.€The€World€Bank€has€arranged€a€loanÏof€$200€million€for€HIV/AIDS€control.ÌÌSouth€Africa:€Technical€assistance€is€needed€to€address€the€problem€of€HIV/AIDS.€At€theÏsuggestion€of€Vice€President€Gore,€Mr.€¢Thabo£€¢Mbeki£,€Deputy€President€of€South€Africa,€willÏwork€with€ONAP.€Representatives€from€HRSA€and€DHHS€will€be€sent€to€South€Africa€to€workÏwith€the€AIDS€program€to€develop€technical€assistance€programs€for€HIV/AIDS.€A€coalitionÏfrom€the€AFL„CIO€was€established€to€work€with€South€African€trade€unions€in€training€theirÏmembers.€Industry€representatives€are€to€work€with€the€new€Business€Council€on€HIV/AIDS€toÏdetermine€what€kind€of€leadership€role€they€want€to€take.ÌÌUganda,€Rwanda,€and€Kenya:€Work€continues€in€these€countries,€and€international€financialÏsupport€is€increasing.€A€delegation€will€be€sent€to€those€countries€in€early€1999.€Considering€theÏcurrent€opposition€in€Congress€to€any€foreign€aid,€it€may€be€necessary€to€separate€the€needs€andÏgo€after€them€individually,€specifically,€the€case€of€AIDS€orphansð"ðby€the€year€2010,€there€willÏbe€nearly€40€million€AIDS€orphans€worldwide.€Ms.€Thurman€noted€that€there€should€be€supportÏfrom€some€conservative€Members€of€Congress€to€fund€programs€for€children.Ìò òÌAIDS€as€a€Human€Rights€Issue.ó ó€The€Carter€Center€recently€held€a€conference€on€religion€andÐ ø$H # ÐAIDS.€The€disease€increasingly€seems€to€be€concentrated€on€the€poor,€children,€women,€andÏpeople€of€color,€but€it€affects€everyone.€It€is€important€that€the€Council€work€with€organizationsÏthat€traditionally€work€for€human€rights€and€ensure€that€HIV/AIDS€is€on€their€agenda€and€thatÏtheir€issues€are€on€the€Councilððs€agenda.ÌÌMr.€Hattoy€asked€if€anything€could€be€done€to€put€pressure€on€the€Immigration€andÏNaturalization€Service€(INS)€to€eliminate€its€discrimination€against€persons€with€AIDS.€€€€€€€€€€ÏMr.€¢Fogel£€noted€that€the€State€Department€was€developing€a€new€global€AIDS€strategy€and€askedÏwhy€DHHS€and€NIH€were€not€offering€their€cooperation.€Ms.€Thurman€conceded€that€there€hadÏbeen€a€lack€of€cooperation€in€the€past,€but€this€situation€seems€to€be€improving.€The€StateÐ 4.„)- ÐDepartment€was€slow€to€distribute€its€plans,€and€other€agencies€had€little€time€to€contribute€theirÏinput.ÌÌò òWhere€Do€We€Go€From€Here?€ó óGetting€recognition€of€an€AIDS€epidemic€was€the€easy€part€ofÐ tÄ Ðan€ongoing€crusade,€said€Ms.€Thurman.€Progress€will€be€slower€now,€but€it€is€important€toÏcontinue€until€prevention,€treatment,€and€care€are€available€to€all€people.€She€stressed€the€pointÏthat€the€Council€and€the€country€must€support€the€Patientsðð€Bill€of€Rights,€managed€care€for€allÏpersons€with€HIV/AIDS,€the€¢Jeffords£„Kennedy€bill,€which€enables€those€who€lose€their€jobs€toÏkeep€health€benefits,€and€privacy€bills€to€protect€those€who€are€tested€for€HIV.€The€Council€notÏonly€must€raise€these€issues€but€also€must€be€aggressive€to€get€action€on€them.ÌÌMr.€Robinson€noted€that€the€CBC€initiative€broadened€the€discussion€of€HIV/AIDS€andÏsuggested€that€the€DHHS€Office€of€Minority€Health€be€included€in€this€effort.€The€energy€levelÏshould€not€be€allowed€to€slow€down.ÌÌMr.€Henderson€commented€that€the€Councilððs€Executive€Committee€meeting€with€PresidentÏClinton€must€be€more€than€a€photo€opportunity,€that€the€Committee€must€make€good€use€of€theÏmeeting.€Ms.€¢Thurman£€assured€Council€members€that€the€meeting€will€include€all€senior€staff,Ïand€that€they€will€be€thoroughly€briefed€on€the€issues.€It€is€important€to€script€the€meeting€toÏreach€the€issues.ÌÌññññÓ=€oXÐXdXÐXd=ÓññññMs.€Aragon€expressed€concern€that€a€number€of€local€needle„exchange€programs€are€under€attackÏand€are€in€urgent€need€of€funding.€Even€though€Federal€funds€are€noññtññññwññ€available,€the€President€andÏSecretary€have€said€that€they€support€the€scientific€rationale€behind€needle€exchange.€It€willÏtherefore€be€important€for€the€Administration€to€provide€such€information€to€health€officialsÏlocally€in€a€way€that€would€be€helpful,€not€harmful,€to€local€exchange€programs.€Ms.€AragonÏurged€the€Administration€to€ask€local€exchange€providers€what€would€be€most€helpful€to€them.ÌÌMs.€Billings€applauded€the€CBC€initiative€as€a€model€for€AIDS€advocacy€and€questioned€whatÏthe€Council€could€do€now€to€help€Latinos€and€other€at„risk€communities.€Ms.€Thurman€noted€thatÏAsian€Americans,€Latinos,€and€Native€Americans€have€all€voiced€support€of€the€CBC€initiative.ÏMr.€Lew€voiced€some€concerns€about€the€use€of€the€new€funds€and€asked€whether€strategic€plansÏare€in€place€for€their€use.€How€will€communities€with€lower€AIDS€incidence€be€reached?€HowÏcan€cultural€barriers€be€breached?ÌÌMr.€¢Montoya£€said€that€since€members€of€ONAP€would€not€be€able€to€attend€all€the€committeeÏmeetings,€it€was€very€important€to€provide€minutes€that€indicate€which€issues€are€most€importantÏto€the€Council.ÌÌMr.€Schatz€commented€that€the€Council€does€not€always€make€the€best€use€of€its€time.€He€askedÏwhether€the€Council€could€do€anything€to€get€ONAP€a€larger€support€staff.€Ms.€Thurman€repliedÏthat€ONAP€could€use€more€staff€but€that€various€agencies€provide€help€for€many€of€ONAPððsÏactivities,€including€very€good€support€from€the€senior€staff€at€the€White€House.€Unfortunately,Ïsupport€for€AIDS€programs€is€low€throughout€the€Government.Ìâ âÐ D-”(, ÐMr.€Robinson€reiterated€that€AIDS€prevention€had€been€the€first€item€on€the€Councilððs€agendaÏâ âfrom€the€very€beginning,€and€it€continues€to€be€the€first.€CDC€knows€some€prevention€measuresÏthat€work,€but€distribution€of€this€information€has€been€minimal.€He€asked€why€the€bestÏpreventive€measures€have€not€yet€been€spelled€out€and€what€the€spending€priorities€should€be.ÌÌMs.€Thurman€closed€her€presentation€with€a€question€for€the€Council,€ð ðGiven€the€current€politicalÏclimate,€where€do€we€go€from€here?ððÌÌà@ïï ìàò òSubcommittee€Meetingsó óˆÐ  ` ÐÌò òAppropriations€Subcommittee:ó ó€Discussion€of€the€FY€1999€and€FY€2000€Budgets.Ð è 8  ÐÌò òInternational€Issues€Subcommittee:ó ó€Update€on€ð ðU.S.€International€Response€to€HIV/AIDS.ððÐ Ä  ÐNancy€Carter„Foster€and€David€Wagner,€U.S.€Department€of€State,€invited€participants.ÌÌò òRacial€Ethnic€Populations€Subcommittee:ó ó€National€Minority€HIV€Plan.€Matthew€¢Murguia£,Ð ŒÜ  ÐOffice€of€Minority€Health,€invited€participant.€ÌÌPeople€of€Color€Initiatives.€Helene€Gayle,€CDC,€invited€participant.ÌÌò òPrevention€Subcommittee:ó ó€Needle„Exchange€Issues.€Marsha€Martin,€Ph.D.,€¢DHHS£,€invitedÐ ,| Ðparticipant.ÌÌò òServices€Subcommittee:ó ó€ð ðHousing€as€an€Access€to€Health€Care€Issue,ðð€presentation.€Angela€A.Ð ôD ТAidala£,€Ph.D.,€Joyce€Moon€Howard,€¢Dr.Ph£.,€¢M.H.£,€and€Robert€¢Sember£,€M.A.,€ColumbiaÏUniversity€School€of€Public€Health,€invited€participants.ÌÌð ðMassachusetts€State€Medicaid€Waiver€Planning€Process,ðð€presentation.€Robert€Greenwald,ÏBoston€AIDS€Action€Committee;€Annette€Hanson,€M.D.,€Massachusetts€Division€of€MedicalÏAssistance;€and€Jeanne€McGuire,€Massachusetts€State€AIDS€Director,€invited€participants.ÌÌÓ  Óò òTuesday,€November€17,€1998Ð X!¨ ÐÌDisparities€in€HIV/AIDS€Health€Programs€for€American€Indians,€Alaska€Natives,ÏandNative€Hawaiiansó óÐ $l" ÐÓeÓÌCharles€Blackwell€opened€the€session€by€thanking€Council€members€for€the€opportunity€toÏdevote€a€portion€of€the€meeting€to€the€disparities€in€HIV/AIDS€health€programs€for€AmericanÏIndians,€Alaska€Natives,€and€Native€Hawaiians.€Mr.€Blackwell€taught€English€on€the€NavahoÏreservation,€received€his€law€degree€from€the€University€of€New€Mexico€(UNM),€and€served€onÏthe€UNM€faculty€as€Associate€Dean€of€the€Law€School€for€5€years.€He€has€been€working€inÏWashington,€D.C.,€for€15€years,€10€of€those€as€the€Chickasaw€Nation€Ambassador€to€the€UnitedÏStates.€As€the€Director€of€¢Pushmataha£€House,€he€represents€19€tribes€in€their€Washington€affairs.ÏHe€went€on€to€describe€the€sovereign€status€of€the€American€Indian€tribes:€All€have,€by€treaty€orÏExecutive€Order€or€Supreme€Court€decision,€rights€under€the€Federal€trust€relationship€asÏdomestic€sovereign€nations.€The€American€Indian€population€is€approximately€2.1€million.€TheÐ @.)- Ðprimary€concern€of€the€Council€regarding€HIV/AIDS,€he€said,€covers€Indian€people€who€areÏmembers€of€federally€recognized€tribes;€however,€a€large€segment€of€the€Native€AmericanÏpopulationð"ðe.g.,€Hawaiians€and€Pacific€Islandersð"ðare€not€members€of€federally€recognizedÏdomestic€sovereign€governments,€and€many€are€members€of€State„recognized€tribes,€as€in€NorthÏCarolina.€These€groups€are€no€less€Native€American.ÌÌThe€focus€of€this€meeting,€he€said,€is€on€deliverables€and€staying€within€the€Councilððs€StrategicÏPlan.€Mr.€Blackwell€referred€members€to€the€March€CDC€òòMorbidity€and€Mortality€WeeklyÐ $ t ÐReport.óó€The€report€focused€on€American€Indians,€stating€that€1,783€cases€of€AIDS€were€reportedÐ  ` Ðand€verified€in€the€American€Indian/Alaska€Native€population.€These€data€reflect€only€federallyÏrecognized€tribesð"ðthe€exact€number€of€American€Indians€and€Alaska€Natives€infected€withÏHIV/AIDS€is€not€known.€The€report€shows€data€from€25€States€on€HIV€infection,€but€no€dataÏfrom€the€States€of€Alaska,€California,€New€Mexico,€and€Washington,€all€of€which€have€largeÏpopulations€of€American€Indians€and€Alaska€Natives.€Available€AIDS€data€reflect€cases€dating€toÏ10€years€ago.€More€than€half€of€the€American€Indian/Alaska€Native€cases€were€reported€in€5ÏStates:€California,€25€percent;€Oklahoma,€11€percent;€Washington,€7percent;€Arizona,€6€percent,Ïand€Alaska,€4€percent.€Of€the€States€for€which€data€were€available,€the€following€was€reported:Ï(1)€Native€adolescents€made€up€5.2€percent€of€HIV€cases€versus€less€than€1€percent€of€the€AIDSÏcases,€and€(2)€11€percent€fewer€men€are€infected€from€sex€with€men€and€5€percent€more€peopleÏinfected€from€heterosexual€intercourse.€According€to€National€Center€for€Health€StatisticsÏmortality€data,€AIDS€is€the€8th€leading€cause€of€death€for€American€Indian€and€Alaska€NativeÏmales€10€to€14€years€of€age,€the€10th€leading€cause€for€those€15€to€24€years€of€age,€the€5thÏleading€cause€for€those€25€to€34€years€of€age,€and€the€8th€leading€cause€for€those€35€to€44€years€ofÏage.€With€respect€to€the€female€population,€AIDS€is€the€8th€leading€cause€of€death€for€women€25Ïto€34€years€of€age€and€for€infants€1€to€4€years€of€age.€The€last€¢seroprevalence£€survey€wasÏconducted€from€1989€to€1991€and€published€in€the€June€1992€issue€of€the€òòJournal€on€AIDSóó.Ð ¼  ÐÌThe€American€Indian,€Alaska€Native,€and€Native€Hawaiian€communities€need€the€help€andÏsupport€of€the€Council.€It€is€imperative€to€ensure€that€prevention€resources€are€available€to€theseÏpopulations€through€CDC.€The€disease€surveillance€system€for€these€groups€is€less€reliable€than€itÏwas€5€years€ago.€There€is€a€critical€lack€of€surrogate€marker€data€to€help€target€limited€resourcesÏin€prevention.€Misreporting€of€race€and€ethnicity€is€another€serious€problem.€No€standardizedÏdisease€reporting€for€race€and€ethnicity€exists€across€all€States.€Lack€of€attention€to€the€need€forÏimproved€disease€surveillance€for€Native€populations€by€CDC€suggests€that,€regardless€of€the€realÏpicture,€resources€will€remain€minimal€and€probably€decline€for€HIV€prevention.ÌÌThe€situation€has€been€made€more€serious€by€the€restructuring€and€decline€of€Indian€HealthÏService€(¢IHS£)€services€to€a€majority€of€the€Indian€population€and€the€increased€use€of€PL„93638,Ïthe€Indian€Self„Determination€and€Education€Assistance€Act.€The€IHS€is€underfunded€and€inÏdecline,€and€has€not€been€in€tune€with€the€people€that€it€serves.ÌÌPL„93638€enables€tribes€as€governments€to€contract€with€the€Federal€Government€for€their€shareÏof€the€budget€to€provide€services€for€themselves.€They€can€take€the€money€that€the€FederalÏGovernment€spends€on€those€services€(i.e.,€education€and€health€services)€and€administer€thoseÏservices€themselves.€Mr.€Blackwell€commented€that,€after€this€process€occurs,€¢IHS£€is€not€givingÏinformation€out€and€not€informing€tribes€about€such€matters€as€HIV/AIDS.€The€Indian€populationÐ ,.|)- Ðneeds€the€help€of€PACHA€to€urge€the€IHS€and€CDC€to€address€this€problem.€¢IHS£,€as€the€primaryÏagency€to€provide€health€services€to€Indians,€does€not€as€a€policy€matter,€unless€the€funds€areÏavailable,€cover€the€cost€of€the€new€AIDS€drugs€that€are€available€to€American€Indians€andÏAlaska€Natives€who€are€dependent€on€IHS€or€tribal€health€systems€for€medical€care.€There€is€noÏbudget€request€for€this€funding.€It€is€a€matter€of€finance€and€priorities.€Congress€has€made€fundsÏavailable€to€the€States€to€cover€the€cost€of€these€drugs€through€the€AIDS€Drug€AssistanceÏProgram€(¢ADAP£);€Native€America,€however,€was€not€included€in€¢ADAP£.€Mr.Blackwell€quotedÏthe€Director€of€¢IHS£,€Dr.€Miguel€Trujillo,€who,€in€an€article€in€òòAmerican€Indian€Report,€óósaid:Ð $ t Ðð ðThere€is€no€cure€for€AIDS,€and€its€prevention,€ultimately,€is€an€individual€responsibility.€AnÏunlimited€amount€of€funds€for€AIDS€treatment€will,€unfortunately,€not€save€a€life.€HealthyÏbehaviors€are€what€will€save€our€tribes€and€communities.ððÌÌCongress€has€made€provisions€in€the€Ryan€White€CARE€Act€for€Native€American€care€resourcesÏin€its€Special€Projects€of€National€Significance€(¢SPNS£)€program.€The€program€has€a€ceiling€ofÏ$25€million,€of€which€only€$1.25€million€goes€to€Native€Americans.€Mr.€Blackwell€imploredÏPACHA€to€work€to€have€the€ceiling€lifted€on€the€¢SPNS£€program€and€set€aside€a€portion€to€beÏdirected€to€Native€American€AIDS€care€programs.€He€referred€Council€members€to€the€handoutÏlisting€members€of€the€Congressional€Native€American€Caucus.€ÌÌPaul€¢Bouey£,€Ph.D.,€Director€of€Research€and€Surveillance,€National€Native€American€AIDSÏPrevention€Center,€the€longest„standing€national€organization€on€American€Indian€HIV/AIDSÏissues,€then€addressed€the€Council.€Focusing€on€surveillance€and€statistics,€he€noted€first€that€theÏissue€of€numbers€underlies€every€decision€in€the€health€sector€as€well€as€in€the€PACHA€StrategicÏPlan.€Numbers€are€fundamental€to€discussing€CDC€policies,€to€expanding€access,€to€increasingÏappropriations,€and€to€increasing€research.€Dr.€¢Bouey£€stressed€three€domains€in€the€discussion:Ïdenominator,€¢misclassification£,€and€data€reporting.ÌÌò òDenominator.ó ó€This€term€refers€to€the€U.S.€Bureau€of€the€Census€and€the€issue€of€ð ðwho€isÐ ”ä ÐIndian,ðð€which€has€become€an€increasingly€complicated€problem€for€American€Indians,€AlaskaÏNatives,€and€other€groups.€The€major€issue€is€the€increase€in€the€number€of€American€IndiansÏdocumented,€which€is€attributed€to€decreases€in€mortality€rates€and€increases€in€fertility€rates.€ButÏwhat€must€be€considered€also€is€the€changing€number€of€federally€recognized€tribes€and€the€factÏthat€many€tribes€have€changed€the€criteria€by€which€tribal€membership€is€determined.€MixedÏancestry€has€increased€dramatically€as€well.€People€have€to€self„report€on€the€U.S.€Census,€andÏthe€issue€then€becomes€who€is€attributed€as€head€of€householdð"ðmother€or€fatherð"ðand€otherÏdemographic€issues.€At€one€time€American€Indians€would€not€identify€themselves€as€such,€but€inÏrecent€years€it€has€become€acceptable€to€identify€with€marginal€populations.€The€issue€of€mixedÏancestry€will€continue,€and€it€is€estimated€that€sometime€in€the€next€century€the€proportion€of€theÏIndian€population€that€is€half€to€full€blood€will€be€less€than€8€percent.ÌÌò ò¢Misclassification£.ó ó€A€tremendous€amount€of€¢underreporting£€occurs.€¢Misclassification£€applies€toÐ ”)ä$( Ðfertility,€mortality,€and€morbidity€data.€According€to€the€literature,€individuals€filling€out€censusÏforms€do€not€ask€for€racial€or€ethnic€identity€but€make€assumptions€by€observation€or€byÏsurnames.€A€cooperative€study€by€CDC€and€¢IHS£€examined€racial€¢misclassification£€of€AmericanÏIndians€in€Oklahoma€pertaining€to€STD€surveillance.€Researchers€took€1995€State€of€OklahomaÏSTD€surveillance€data€and€compared€them€with€the€¢IHS£€User€Registry.€The€findings€showed€thatÐ 4.„)- Ðmany€of€those€registered€on€the€State€list€were€not€found€on€the€¢IHS£€list€and€that€many€who€self„¼reported€to€the€State€as€American€Indian€were€not€on€the€¢IHS£€list.€Another€marker€used€toÏdetermine€status€as€an€American€Indian€was€blood€quantum,€the€percentage€of€Indian€blood.ÌÌò òData€Reporting.ó ó€The€problems€of€data€reporting€are€more€serious€than€¢misclassification£.€TwoÐ `° Ðcategories€are€available€for€understanding€such€problemsð"ðtribal€and€¢nontribal£.€In€tribalÏcommunities,€the€issue€is€not€¢misclassification£€but€a€failure€to€report€data€either€because€ofÏinsufficient€time€or€resources€or€as€a€result€of€tribal€sovereignty.€Tribes€have€a€relationship€withÏthe€Federal€Government€but€not€the€States.€Numbers€are€not€being€reported.€A€recent€needs„¼assessment€meeting€revealed€that€two„thirds€of€tribal€communities€do€not€report€HIV/AIDS€dataÏto€the€State€or€to€CDC.€Regarding€¢nontribal£€communities,€including€urban€ññIndianññññtribalññ€clinics,Ï¢misclassification£€is€not€an€issue,€but€getting€good€data€to€the€State€or€CDC€is€a€problem.ÌÌDr.€¢Bouey£€suggested€recommendations€for€consideration€by€the€Council€in€each€category.ÌÌò òDenominator:ó ó€The€issue€has€been€evident€for€decades€and€still€has€not€been€resolved.€DiscussionÐ ˆØ  Ðmust€continue.ÌÌò ò¢Misclassification£:ó ó€A€national€standard€of€classification€of€race/ethnicity€should€be€promoted,€andÐ P  ÐStates€should€not€be€given€the€freedom€to€develop€their€own€systems.€Self„reporting€should€beÏpromoted.€Training€should€be€instituted€in€the€new€system.ÌÌò òReporting:ó ó€HIV€reporting€should€be€promoted€in€all€50€States.€A€collaborative€team€made€up€ofÐ T ÐCDC,€¢IHS£,€and€representatives€from€tribes,€States,€and€local€jurisdictions€should€be€instituted€toÏlook€at€States€where€reporting€is€working,€develop€a€reporting€model,€and€then€implement€it€inÏStates€that€do€not€have€a€good€system.ÌÌFollowing€through€on€these€recommendations€will€involve€tremendous€cost€and€time,€but€theÏcost€of€doing€nothing€will€only€further€the€disparities.€In€reviewing€its€Strategic€Plan,€the€CouncilÏmust€examine€the€issue€of€surveillance.ÌÌDiscussion€ensued,€raising€the€following€considerations:ÌÌððà0  àThe€¢IHS£€has€no€contact€with€urban€health€clinics.Ð,#|!(#(# ÐÌððà0  àSixty€percent€of€the€American€Indian€population€is€urban;€of€the€total€¢IHS£€budget,€onlyÐ %T # Ð$25€million€goes€to€60€percent€of€the€American€Indian€population,€which€is€less€than€2Ïpercent€of€total€¢IHS£€funding.Ð (#(# ÐÌððà0  àTribes€see€themselves€as€governmental€entities€and€are€reluctant€to€report€to€the€States.д($'(#(# ÐÌððà0  àThe€¢IHS£€Utilization€List€does€not€include€all€Indians€in€a€given€State,€and€not€all€IndiansÐ Œ*Ü%) Ðuse€¢IHS£€clinics.Ð (#(# Ðâ âÐ d,´'+ ÐDaniel€C.€Simpson,€a€Choctaw€from€Oklahoma,€Director€of€HIV/AIDS€Services€and€AIDSÏProgram€Coordinator,€¢IHS£,€spoke€next,€offering€to€respond€to€PACHA€recommendations€relatingÏto€¢IHS£.Ìâ âÌMr.€Simpson€referred€Council€members€to€the€¢IHS£€Certificate€of€Degree€of€Indian€Blood,€whichÏis€the€ticket€for€health€care€for€Indians.€Different€tribes€require€different€blood€¢quantums£€forÏhealth€care;€e.g.,€the€Choctaw€require€that€a€person€be€one„half€Indian€to€receive€health€careÏservices€from€the€tribe.€Regardless€of€the€degree€of€Indian€blood,€¢IHS£€must€abide€by€the€criterionÏset€by€each€tribe.€Mr.€Simpson€stated€that€the€identification€card€is€for€health€care,€land,Ïeducation,€social€services,€and€in€some€instances€resources.€If€a€person€does€not€meet€theÏcriterion€for€health€care€and€other€services€of€a€particular€tribe,€that€person€is€still€recognized€asÏpart€of€the€tribe.ÌÌOf€543€Indian€direct€care€delivery€service€units,€¢IHS£€has€146€facilities€and€tribally€run€facilitiesÏnumber€397.€Urban€programs€have€34€facilities.€Urban€programs€advocate€for€their€funds€throughÏTitle€V€provisions€and€get€100€percent€of€funds€appropriated.€¢IHS£€provided€¢antiretroviral£€drugsÏthrough€a€memorandum€of€understanding€with€CDC€until€about€1993.€After€that€time,€no€fundsÏexisted€to€maintain€the€warehouse€for€drug€storage.€Currently,€¢IHS£€is€contracting€with€the€U.S.ÏDepartment€of€Veterans€Affairs€for€its€drugs,€with€Indian€tribes€negotiating€with€the€VA€forÏdrugs€at€cost.ÌÌTribes€are€becoming€more€involved€in€their€health€programs,€and€they€must€be€recognized€andÏincluded€in€mailings€of€grant€proposals,€invitations€to€HIV/AIDS€meetings,€and€recognition€byÏStates,€agencies,€and€programs€as€sovereign€nations€capable€of€providing€health€care€to€thoseÏwith€HIV/AIDS.€¢IHS£€does€not€provide€prevention€and€health€care€to€all€557€federally€recognizedÏIndian€tribes.€Approximately€one„third€of€tribes€run€their€own€hospitals€and€clinics.ÌÌRegarding€entitlement€issues,€Indians€often€are€not€recognized€as€eligible€for€health€care.€TheyÏhave€been€automatically€denied€health€care€by€other€providers€outside€of€¢IHS£€or€tribal€healthÏprograms€because€of€the€commonly€held€belief€that€¢IHS£€provides€all€services€to€all€Indians.€AÏconcerted€effort€by€¢IHS£,€tribes,€urban€programs,€other€American€Indian/Alaska€NativeÏorganizations,€and€Government€agencies€is€needed€to€resolve€these€discrepancies€and€overcomeÏthis€¢misperception£.ÌÌ¢IHS£€data€as€of€December€1997€on€AIDS€cases€show€a€cumulative€total€for€AmericanÏIndian/Alaska€Natives€of€1,783€cases,€of€which€544€are€HIV€cases.€Of€the€1,783€cases,€¢IHS£Ïprovides€services€to€only€400;€of€the€544€HIV€cases,€it€provides€services€to€only€350.€TheÏremaining€receive€care€from€tribal€health€care€programs,€urban€programs,€Medicare,€Medicaid,Ïprivate€insurance,€and€other€sources.ÌÌDiscussion€ensued,€resulting€in€the€following€points:ÌÌððà0  à¢IHS£€clinics€provide€primary€care€and€prevention€services€through€doctors,€nurses,€socialÐ h+¸&* Ðworkers,€outreach€workers,€public€health€nurses,€and€other€providers.Ð (#(# Ðâ âÐ @-(, Ðððà0  àCurrent€data€do€not€reflect€the€use€of€combination€therapy,€¢antiretroviral£€drugs,€orÐ ° Ðâ âreference€to€Federal€Standards€of€Care.Ð (#(# ÐÌððà0  àRegarding€increased€health€care€services€for€American€Indians€under€the€Ryan€WhiteÐ tÄ ÐCARE€Act,€Mr.€Simpson€will€meet€with€Dr.€Joseph€¢OððNeil£,€Associate€Administrator€forÏAIDS,€¢HRSA£,€to€discuss€issues,€including€what€has€not€been€done€about€¢IHS£€services€andÏinclusion€of€American€Indians/Alaska€Natives€in€the€language€of€the€Ryan€White€CAREÏAct€programs.Ð (#(# ÐÌððà0  à¢IHS£€provides€the€majority€of€health€services€to€larger€facilities€serving€this€population€(37Ð ü L  Ðhospitals,€46€health€stations).€Tribal€operations€include€12€hospitals€and€233€healthÏstations.€Within€the€next€few€years,€the€larger€¢IHS£€hospitals€and€the€funds€involved€willÏgo€to€the€tribes.Ð (#(# ÐÌððà0  àAppropriations€need€to€include€funding€for€rehabilitation€of€hospitals€and€clinics.ññИè (#(# ÐÌÌññññИè (#(# ÐññññññÌññ›œññññÌÌÌññññññÌÌññ›ÌññññññÌÌññññññÌÌññò òÓ  ÓCouncil€Recommendations€Addressing€American€Indian/Alaska€Native€Issuesó óÐ \¬ ÐÓ6¥ÓÌò ò¢II.P.5.£ó ó€Direct€the€Director€of€the€Indian€Health€Service€(¢IHS£)€to€develop€a€comprehensive€AIDSÐ 4„ Ðprevention€and€care€plan€for€Indian€country€(within€90€days)€with€the€input€from€consumers€ofÏ¢IHS£€services.ÌÌThe€Council€requests:ÌÌò ò¢V.P.1.£ó ó€That€the€President€instruct€the€Secretary€of€Health€and€Human€Services€to€reassess€theÐ À Ðlegislative€intent€of€the€¢reauthorized£€Ryan€White€CARE€Act€regarding€needs€of€the€NativeÏAmerican€community€to€ensure€appropriate€support€for€Native€American€care,€infrastructureÏdevelopment,€and€coordination€on€a€national€level.ÌÌò ò¢V.P.2.£ó ó€That€the€Secretary€of€Health€and€Human€Services€instruct€the€Director€of€¢IHS£€toÐ ` ° Ðdemonstrate€within€90€days€the€adequacy€of€HIV€prevention,€care,€and€treatment,€includingÏaccess€to€needed€drugs,€for€American€Indians€and€Alaska€Natives€living€on€or€near€reservations.ÏThis€should€include€documentation€of€needs€assessments€completed,€barriers€and€gaps€identified,Ïand€proposed€solutions.€It€should€also€include€a€discussion€of€how€¢IHS£€plans€to€work€with€theÏprivate€nonprofit€sector€to€improve€AIDS„related€services.€ÌÌò ò¢V.P.3.£ó ó€That€the€Secretary€of€Health€and€Human€Services€instruct€the€Director€of€¢IHS£€to€developÐ Ø&("% Ðcase€management€oversight€guidelines€which€are€appropriately€oriented€to€the€specific€needs€ofÏNative€American€people€with€HIV/AIDS€and€assure€the€provision€of€health€care€and€in€a€safe€andÏculturally€appropriate€manner.ññÌñññ#ñÐ   )ð$( Ðñ#ñò òÓ  ÓññÌÌñññ ñññÌñññ ñññññÌññÌÌñññ ñññÌÌñññ ññ!ññ ñÌÌñ ñÌñ!ññ"ññ!ñÌñ!ññ!ñÌñ!ññ"ñUpdate€on€HIV/AIDS€Racial€and€Ethnic€Disparities€in€HealthÐ ° ÐDr.€David€¢Satcher£,€Assistant€Secretary€of€Health€andÌSurgeon€General€of€the€United€States,ÌU.S.€Department€of€Health€and€Human€Servicesó óÐ tÄ ÐÓÊ«ÓÌDr.€¢Satcher£ððs€presentation€centered€on€three€areas€of€concern:€Healthy€People€2010,€the€initiativeÏto€eliminate€disparities€in€health,€and€the€HIV/AIDS€initiative.ÌÌIn€1979€Dr.€Julius€Richmond,€Assistant€Secretary€of€Health€and€Surgeon€General€of€the€UnitedÏStates€during€President€Jimmy€Carterððs€administration,€issued€the€Surgeon€Generalððs€ReportÏð ðHealth€Promotion€and€Disease€Prevention,ðð€which€initiated€the€Healthy€People€1990€objectives.ÏIn€the€late€¢1980s£,€the€Healthy€People€2000€Report€was€released.€More€than€60€percent€of€theÏHealthy€People€2000€objectives€have€been€achieved€(e.g.,€decrease€in€teenage€pregnancy);Ïhowever,€certain€objectives€have€yielded€no€data,€and€data€on€other€objectives€show€that€theÏPublic€Health€Service€(PHS)€is€not€making€the€progress€anticipated€(e.g.,€lessening€of€childhoodÏand€adult€obesity).ÌÌThe€PHS€is€in€the€process€of€finalizing€the€plan€for€Healthy€People€2010,€which€has€two€majorÏgoals:€(1)€to€increase€the€quality€and€years€of€healthy€life,€and€(2)€to€eliminate€disparities€inÏhealth€among€different€racial€and€ethnic€groups.€The€current€plan€includes€500€draft€objectivesÏand€26€areas€of€objectives.€Health€communication,€PHS€infrastructure,€and€disabilities,€withÏHIV/AIDS€included€as€a€disability,€are€new€areas€of€objectives.€A€community€health€system€hasÏbeen€designed€that€should€allow€these€objectives€to€be€realized.€Dr.€¢Satcher£€asked€CouncilÏmembers€to€review€the€objectives€and€participate€in€the€regional€meetings€being€scheduled.€ÌÌThe€initiative€to€eliminate€disparities€in€health€will€focus€on€six€areas:€the€HIV/AIDS€epidemic,Ïimmunization€for€both€children€and€adults,€infant€mortality,€cardiovascular€diseases,€cancer,€andÏdiabetes.€President€Clinton€asked€for€an€$80€million€budget€including€$30€million€to€fundÏcommunities€to€develop€model€programs,€but€Congress€appropriated€only€$65€million€in€theÌFY€1999€budget,€primarily€in€CDC€and€¢HRSA£.€Only€$10€million€was€appropriated€forÏdevelopment€of€the€model€community€programs.€Two€types€of€programs€will€be€funded€in€ÌFY€1999:€some€community€model€programs€and€some€community€developmental€programs.€ÌDr.€¢Satcher£€hopes€that€the€HIV/AIDS€initiative€can€be€the€model€program€for€closing€gaps€andÏeliminating€disparities.ÌÌThe€Surgeon€General€referred€to€President€Clintonððs€October€28€declaration€that€HIV/AIDS€inÏracial€and€ethnic€minority€communities€represents€a€severe€and€ongoing€health€crisis.€WhileÏoverall€AIDS€deaths€have€declined,€AIDS€remains€the€leading€killer€of€African„American€menÏbetween€the€ages€of€25and€44€and€the€second€cause€of€death€for€African„American€women.ÏEighty€percent€of€new€cases€occur€in€African„American€and€Hispanic€women.€The€PHS€plans€toÏunveil€a€series€of€initiatives€that€will€invest€the€$156€million€earmarked€to€address€this€problem.ÏThe€Administration€intends€to€outline€a€comprehensive€initiative€that€includes€unprecedentedÏefforts€to€improve€the€Nationððs€health€in€preventing€and€treating€HIV/AIDS€in€minorityÏcommunities.€This€problem€will€be€addressed€in€three€areas:€new€prevention€efforts,€improvedÏaccess€to€treatment,€and€training€of€health€professionals.€Strategies€for€implementation€includeÏthe€following:Ð ,.|)- Їððà0  àSend€crisis€response€teamsð"ðphysicians,€nurses,€¢epidemiologists£,€and€othersð"ðto€highlyÐ ° Ðaffected€areas€to€assess€existing€prevention€and€treatment€services€and€develop€newÏstrategies.Ð (#(# ÐÌððà0  àFund€enhanced€HIV/AIDS€prevention€programs€in€racial€and€ethnic€minorityÐ `° Ðcommunities,€primarily€as€grants€for€minority€community„based€organizations€to€workÏwith€local€communities,€to€make€testing€and€counseling€available,€and€to€developÏeducational€programs,€community€workshops,€prevention€programs,€and€treatmentÏprograms€for€African„American€and€Hispanic€women€and€men€at€high€risk.Ð (#(# ÐÌððà0  àReduce€disparities€in€treatment€and€health€outcomes€for€minorities€with€HIV/AIDS€andÐ è 8  Ðthe€problem€of€access€to€care€and€treatment.Ð (#(# ÐÌððà0  àFund€the€education€of€health€care€providers.€CDC€started€the€distance€learning€(throughÐ ¬ü  Ðsatellite€technology)€programs€to€introduce€to€health€care€workers€in€the€field€newÏguidelines€for€immunization€and€AZT€treatment€to€reduce€maternal„child€spread€of€HIV.Ð (#(# ÐÌCommunication€has€been€enhanced€with€the€advent€of€satellite€downlinks€providing€access€toÏ30,000€to€40,000€doctors€and€nurses.€A€$262€million€increase€has€been€seen€in€the€Ryan€WhiteÏCARE€Act,€which€provides€primary€HIV€health€care€services,€treatment,€and€training€for€healthÏcare€professionals€on€the€guidelines.€The€treatment€funds€include€a€more€than€60€percent€increaseÏfor€the€AIDS€drug„assistance€program€for€those€who€cannot€afford€the€cost€of€HIV/AIDS€drugs.ÏNIH€has€received€a€12€percent€increase€for€HIV/AIDS€research.ÌÌDr.€¢Satcher£€mentioned€the€programs€that€were€not€approved€by€Congress,€namely,€the€PatientsððÏBill€of€Rights€and€the€¢Jeffords£„Kennedy€bill€to€allow€people€with€disabilities€to€buy€intoÏMedicaid€and€Medicare.€These€initiatives€must€be€pushed€forward€at€the€community€level.ÌÌThe€ensuing€discussion€included€the€following€exchanges:ÌÌ1.à0  àòòHow€does€the€Administration€intend€to€implement€the€Race€and€Health€initiative€on€aÐ X ¨ Ðbroad€scale€and,€in€particular,€the€new€funding€approved€as€part€of€the€CBC€initiative?ÏHow€will€your€Office€work€with€¢ONAP£€and€within€¢DHHS£€to€implement€these€initiatives?óóÐ0"€ (#(# ÐÌOf€the€$156€million,€$50€million€is€emergency€funding.€The€PHS€must€present€Congress€withÏspecific€strategies€for€using€the€funds.€Whether€Congress€provides€these€funds€in€the€futureÏdepends€on€how€the€funds€are€used€and€the€projected€need€for€funds.€The€hope€is€that€fundingÏwill€be€ongoing€through€the€regular€budget€and€that€out€of€the€funds€model€programs€for€reducingÏdisparities€will€be€developed.ÌÌTwo„thirds€of€the€$156€million€is€new€funding;€the€remaining€is€money€set€aside€by€¢DHHS£,€e.g.,Ï$15€million€to€¢HRSA£€for€community€health€centers€to€work€with€the€HIV/AIDS€strategy.ÏPrograms€at€CDC€will€work€with€funds€set€aside€from€other€sources.ÌÌA€steering€committee€has€been€proposed€that€will€work€with€the€Surgeon€General€and€aÏrepresentative€from€¢ONAP£,€meeting€regularly€to€review€strategies.Ð ,.|)- Ðœ‡2.à0  àòòWhat€is€the€Office€of€the€Surgeon€Generalððs€strategy€toward€prevention?óóа(#(# Ѐ€òòà0  àHow€do€you€as€Surgeon€General€reconcile€the€decision€by€this€Administration€on€theÐ œì ÐFederal€ban€on€funding€needle„exchange€programs,€and€what€are€your€plans€to€moveÏforward€on€this€issue,€especially€as€it€limits€prevention€of€HIV€infection?óóÐtÄ(#(# ÐÌCDC€will€take€on€a€special€initiative€to€address€the€HIV€prevention€needs€of€youth,€a€campaign€toÏpromote€a€wider€use€of€HIV€testing€and€to€promote€individual€knowledge€of€¢serostatus£,€and€aÏmore€aggressive€phase€of€public€accountability€regarding€leadership€in€the€HIV€community.€TheÏCDC€initiative€relates€to€improving€strategies€for€prevention.€CDC€will€be€working€with€otherÏagencies€and€looking€at€what€is€needed€in€communities.€CDC€will€have€a€large€portion€of€theÏemergency€funds€to€use€to€improve€prevention€strategies.ÌÌCDC€and€other€agencies€looked€at€several€studies€on€needle€exchange,€concluding€that€needle„¼exchange€programs€conducted€appropriately€in€the€context€of€community€prevention€strategiesÏwith€access€to€treatment€could€significantly€reduce€the€spread€of€HIV,€and€that€no€evidence€existsÏthat€these€programs€increase€the€use€of€drugs.€However,€it€is€believed€that€the€FederalÏGovernmentððs€funding€of€needle„exchange€programs€might€send€the€wrong€message€to€youngÏpeople,€particularly€if€little€or€no€funding€for€prevention€and€treatment€of€drug€abuse€wasÏincluded.€The€Surgeon€Generalððs€Office€wants€to€be€supportive€of€local€community€needle„¼exchange€programs,€although€Federal€funds€cannot€be€used.ÌÌ3.à0  àòòAs€Surgeon€General,€what€do€you€see€as€your€role€in€advocating€for€and€using€yourÐ  \ Ðposition€to€both€educate€and€promote€implementation€of€the€PHS€standards€of€care€andÏtreatment€for€HIV/AIDS?óóÐä4(#(# ÐÌÔ‡XO.XXXO.ÔThe€Surgeon€Generalððs€responsibility€is€clear€in€terms€of€the€need€to€communicate€clearly€withÐ ¼  Ðthe€American€people€and€to€educate€them.€In€terms€of€the€standards€of€care,€however,€programsÏmust€interact€with€providers€on€the€front€line.€The€Surgeon€Generalððs€Office€must€make€sure€thatÏproviders€know€what€the€standard€of€care€is€and€that€the€Office€is€pursuing€that€standard.€TheÏSurgeon€Generalððs€Office€also€must€work€with€providers€to€break€down€the€barriers€to€access.ÌÌEducation€is€somewhat€broader€than€the€Surgeon€Generalððs€role,€and€the€Assistant€Secretary€forÏHealth€should€be€working€with€the€agencies€to€ensure€that€quality€programs€exist€to€inform,Ïmotivate,€and€mobilize€people€with€respect€to€guidelines€for€quality€health€care.Ô#†XO.XXXO.(Î#ÔÐ #l! ÐÌ4.òòà0  àAs€Assistant€Secretary€of€Health,€what€role€do€you€plan€to€play€in€ensuring€that€¢HCFA£Ð ô$D # Ðdoes€all€in€its€power€to€determine€how€to€expand€Medicaid€coverage€and€to€aid€the€StatesÏin€applying€for€and€receiving€approval€of€Medicaid€1115€waivers€to€expand€access€toÏearly€intervention€therapies€and€care?óóи'#&(#(# ÐÌ¢DHHS£€takes€its€relationship€with€¢HCFA£€seriously€and€is€serious€about€implementing€a€broadÏbase€for€public€health,€which€includes€universal€access€to€care,€and€the€role€of€¢HCFA£.€RegardingÏthe€Medicaid€waivers,€the€Federal€Government€is€willing€to€work€with€States€in€developingÏprograms€in€which€persons€with€HIV/AIDS€can€be€covered€through€Medicaid€waivers,€but€muchÏof€the€work€is€at€the€State€level.ÌÐ ,.|)- ÐDr.€¢Hitt£€noted€that€one€of€the€big€problems€is€that€a€person€must€be€disabled€to€receive€MedicaidÏcoverage.€Some€barriers€originate€at€¢DHHS£;€for€example,€at€the€policy€level€generalÏpronouncements€have€been€made€and€general€direction€given,€but€the€message€has€not€beenÏcommunicated€to€those€who€have€the€responsibility€to€determine€what€should€be€done.ÌÌòò5.óóà0  àòòIs€there€a€mechanism€in€place€to€document€implementation€of€a€standard€of€care€for€HIVÐ L œ Ðhealth€care€in€Federal€prisons,€since€anecdotal€evidence€shows€otherwise?€Do€you€intendÏto€use€your€position€to€encourage€State€and€local€prison€officials€to€follow€the€standardsÏof€care€for€inmates€and€the€transition€of€ex„offenders€to€health€care€providers?óóÐ `(#(# ÐÌCDC€works€with€the€American€Association€of€Correction€Facilities€in€the€areas€of€HIV/AIDS,Ïtuberculosis,€and€violence€prevention€in€the€prisons.€Dr.€Kenneth€¢Moritsugu£,€Deputy€SurgeonÏGeneral,€has€worked€with€the€Federal€prisons€and€has€knowledge€of€the€prison€system.€HisÏbackground€should€help€in€addressing€the€many€problems€relating€to€health€care€in€prisons.ÌÌThe€Federal€prison€system€has€an€exemplary€program€for€education,€testing,€and€access€toÏtreatment€for€persons€with€HIV/AIDS.€Major€problems€exist€in€prevention,€namely,€the€lack€ofÏneedle€exchange€and€distribution€of€condoms.€Problems€are€seen€also€in€following€up€treatmentÏfor€prisoners€once€they€are€discharged€into€the€community.€CDC€and€¢HRSA£€are€being€asked€toÏcoordinate€case€management€of€persons€in€prison€and€¢followup£€care€with€their€transition€into€theÏcommunity.òòÐ  p ÐÌóó6.à0  àòòWhat€has€been€done€to€follow€up€on€the€CBCððs€People€of€Color€Initiative€with€otherÐ øH Ðcommunities?óóÐä4(#(# ÐÌThe€People€of€Color€Initiative€has€not€worked€very€well€for€certain€minority€populations.€¢DHHS£Ïis€attempting€to€define€the€appropriate€strategy,€part€of€which€will€be€the€crisis€response€team.€AÏbalanced€team€will€be€sent€into€communities€requesting€assistance€to€examine€the€barriers€toÏreceiving€prevention€messages,€to€testing,€and€to€accessing€care.€A€better€job€must€be€done€inÏtargeting€other€resources€to€communities€that€are€disproportionately€affected.€CDC€is€working€toÏassist€communities€who€have€the€need€and€commitment€but€lack€the€infrastructure€to€beÏcompetitive€in€attracting€grants.ÌÌ7.à0  àòòWhat€can€be€done€to€strengthen€the€levels€of€coordination€needed€among€the€manyÐ #l! Ðgroups€working€on€prevention?óó€òòWhat€will€be€done€to€increase€¢ONAP£ððs€and€Dr.€GoosbyððsÐ $X" Ðstaffs?óóÐô$D #(#(# ÐÌDr.€¢Satcher£€will€look€into€the€possibility€of€detailing€representatives€from€CDC,€¢SAMHSA£,Ï¢HRSA£,€and€NIH€to€¢ONAP£€to€fulfill€its€mandate.€¢DHHS£€is€committed€to€promoting€global€healthÏand€to€working€with€the€World€Health€Organization€and€the€State€Department€in€this€effort.ÌÌò òÓ  ÓFocus€for€the€Centers€of€Disease€Control€and€PreventionÐ |*Ì%) ÐJeffrey€¢Koplan£,€M.D.,€M.P.H.ó óÐ h+¸&* ÐÓ  ÓÌBefore€Dr.€¢Koplan£€met€with€the€Council,€members€discussed€the€questions€they€would€pose€asÏwell€as€what€they€hoped€Dr.€¢Koplan£€would€gain€from€this€meeting€with€the€Council,€specificallyÐ ,.|)- Ðrealization€of€their€level€of€frustration€with€the€national€prevention€strategy€and€their€lack€ofÏconfidence€in€the€Administrationððs€prevention€plan.ÌÌDr.€¢Koplan£€is€working€with€senior€staff€at€CDC€in€setting€priorities€for€the€agency.€The€fourÏbroad€cross„cutting€areas€that€have€been€established€as€priorities€provide€a€cohesive,€coherentÏnature€to€the€work€of€CDC:ÌÌððà0  àStrengthening€science€for€public€health€action.€Science€is€what€drives€public€healthÐ $ t Ðaction,€and€gaining€new€knowledge€is€crucial€to€this€end.Ð (#(# ÐÌððà0  àCollaborating€with€health€care€partners,€particularly€for€prevention:€private€health€careÐ è 8  Ðproviders,€organized€medicine,€business,€¢HCFA£,€and€Medicare/Medicaid.€Examples€ofÏthis€priority€are€reducing€racial€and€ethnic€disparities€in€HIV/AIDS€and€integrating€HIVÏprevention€and€treatment€programs.€CDC€can€do€only€so€much€from€a€population„basedÏperspective.€Much€that€needs€to€be€done€requires€coordination€with€health€care€providersÏand€other€partners.Ð (#(# ÐÌððà0  àPromoting€healthy€living€at€every€stage€in€life,€broadened€to€target€key€health€concerns€atÐ \¬ Ðyouth,€adolescents,€adults,€and€older€adults.Ð (#(# ÐÌððà0  àBroadening€CDCððs€role€in€international€health.Ð p(#(# ÐÌRegarding€the€role€of€CDC€in€the€HIV/AIDS€arena,€Dr.€¢Koplan£€responded€to€questions€posed€byÏCouncil€members.ÌÌ1.à0  àòòWhat€is€your€vision€for€how€we€can€reverse€the€historical€failures€of€our€preventionÐ ¼  Ðefforts?€What€principles€will€guide€your€efforts€in€leading€the€Nationððs€HIV€preventionÏstrategy?€Will€we€move€beyond€the€self„reported€behavior€surveys€and€connect€preventionÏefforts€with€objectives?óóЀÐ(#(# ÐÌPrevention€programs€are€the€appropriate€approach€with€HIV/AIDS€and€other€diseases.€CDCððsÏrole€is€to€make€a€case€on€a€scientific€basis€for€what€can€be€done€by€taking€advantage€of€data€fromÏstudies,€experiences€in€the€field,€and€literature€reviews€to€demonstrate€what€will€work.ÌÌThe€Administrator€cannot€set€policy€for€the€CDC€but€can€present€the€case€from€scientific,€publicÏhealth,€and€social€perspectives.€Myriad€scientific€information€will€be€required€to€sway€public€andÏpolitical€opinion.€(Tobacco€as€a€health€problem€is€an€example€of€an€issue€in€which€the€scientificÏdata€were€available€but€little€public€will€existed€to€effect€change.€The€combination€of€scientificÏdata€with€public€relations,€activists€groups,€and€other€influences€moved€public€opinion,€which€inÏturn€moved€political€opinion.)€The€questions€now€concern€what€measures€are€still€needed€to€swayÏopinion€and€how€quickly€can€they€be€implemented.ÌÌ2.à0  àòòWhat€has€been€done€to€follow€up€the€CBCððs€People€of€Color€Initiative€with€otherÐ h+¸&* Ðcommunities?óóÐT,¤'+(#(# Ðâ âÐ @-(, ÐCDC€will€expand€the€groups€and€community€directions,€which€will€allow€greater€opportunity€toÏâ âreach€more€groups.€Dr.€Gayle€responded€to€this€question€by€stating€that€it€is€understood€that€theÏepidemic€is€disproportionately€affecting€some€groups,€but€it€is€important€that€informationÏdisbursed€to€communities€be€relevant€to€all€groups.€Efforts€will€be€expanded€in€theÏHispanic/Latino€community.ÌÌ3.à0  àòòWhat€can€be€done€to€strengthen€the€levels€of€coordination€needed€among€the€manyÐ 8 ˆ Ðgroups€working€on€prevention€issues?€What€will€be€done€to€increase€¢ONAP£ððs€and€€€€€€€ÏDr.€¢Goosby£ððs€staffs?óóÐ `(#(# ÐÌCDC€will€work€with€agency€representatives€at€the€highest€levels€to€ensure€that€¢IHS£,€NIH,€andÏ¢HRSA£€do€what€is€needed€to€strengthen€coordination€among€the€groups€working€in€the€preventionÏarena.€Regarding€the€need€for€increased€staff€in€Washington,€D.C.,€Dr.€¢Koplan£€suggested€that€theÏfocus€be€on€what€is€not€taking€place€that€needs€to€take€place€and€what€could€be€done€better,€andÏthen€determine€how€to€best€achieve€the€goals.ÌÌ4.à0  àòòCDCððs€recently€issued€guidance€indicates€that€States€now€will€be€held€accountable€forÐ pÀ Ðdocumenting€that€their€resources€are€targeting€the€epidemic€in€their€jurisdictions.€UnderÏcommunity€planning,€CDC€has€been€reluctant€in€the€past€to€play€a€heavy€role€in€directingÏthose€resources.€What€will€CDC€be€doing€differently€to€ensure€accountability€andÏenforcement€of€the€new€guidance?óóÐ p(#(# ÐÌOutcome€accountabilityð"ðe.g.,€reduction€in€incidenceð"ðdetermines€whether€a€program€continuesÏto€receive€funding.€Many€steps€in€the€process€take€place€before€outcome€is€measured.€BeforeÏoutcome€accountability€can€be€determined,€agreement€must€be€reached€on€what€is€to€beÏmeasured.ÌÌCDC€is€receiving€two€messages:€from€communities,€the€message€is€ð ðgive€us€the€money,€andÏleave€us€aloneðð;€from€agencies,€the€message€is€ð ðmeasure€it€and€do€not€give€funds€unless€theÏcommunities€are€accountable€for€the€outcomes.ððÌÌResponding€to€Dr.€¢Koplan£,€Mr.€¢Isbell£€commented€that€it€is€CDCððs€accountability€that€is€inÏquestion.€At€the€community€planning€level,€in€many€cases€CDC€is€largely€absent€in€terms€ofÏleadership.€CDC€has€a€public€health€responsibility€to€ensure€that€planning€bodies€that€are€makingÏdecisions€about€how€funds€are€allocated€benefit€from€CDC€leadership.€There€was€someÏagreement€within€the€group€that€giving€communities€funds€without€leadership€does€not€work.€ÏDr.€Gayle€responded€that€CDC€needs€outside€groups€such€as€PACHA€to€make€recommendations.ÏDr.€¢Hitt£€commented€that€PACHA€has€worked€hard€to€develop€consensus€recommendations€andÏthat€CDC€should€review€and€evaluate€those€recommendations.ÌÌ5.òòà0  àHow€will€CDC€publicly€account€for€the€40€percent€of€CDC€HIV€resources€in€terms€ofÐ )à$( Ðtracking€the€epidemiology€and€other€aspects€of€this€epidemicóó?Ð|*Ì%)(#(# ÐÌDr.€Gayle€stated€that€some€of€those€funds€go€directly€to€community„based€organizations,€andÏthese€groups€produce€good€data€on€targeted€populations.€Some€funds€go€to€State€and€local€healthÏdepartments€for€surveillance€for€tracking€the€epidemic€overall,€and€some€go€to€school€healthÐ ,.|)- Ðprograms.€No€funds€are€not€accounted€forð"ðsome€funds€are€not€targeted€but€go€to€the€generalÏpopulation.ÌÌMr.€¢Schatz£€commented€that€the€guidelines€passed€in€1991€by€CDC€have€resulted€in€many€healthÏcare€workersðð€losing€their€jobs.€The€CDC€guidelines€have€been€used€recently€in€court€cases€toÏjustify€discrimination€against€HIV„infected€health€care€workers.€Dr.€Gayle€has€been€working€toÏresolve€this€issue.€Dr.€¢Koplan£€concurred€that€he€is€willing€to€support€Dr.€Gayle€in€her€efforts€andÏthat€he€will€look€into€the€issues€posed€by€Mr.€¢Schatz£.ÌÌ6.òòà0  àWhat€emphasis€will€CDC€place€on€primary€versus€secondary€prevention€efforts€inÐ ü L  ÐHIV/AIDS?óóÐè 8 (#(# ÐÌCDCððs€major€concern€is€primary€prevention.€Dr.€Gayle€commented€that€the€interface€betweenÏprevention€and€treatment€is€not€clear€and€that€a€better€job€of€interfacing€prevention€with€treatmentÏneeds€to€be€done.€It€is€important€to€focus€on€persons€who€are€HIV€positive€in€order€to€get€themÏcare,€but€much€needs€to€be€done€for€those€already€infected€with€AIDS€and€to€support€theirÏprevention€needs.ÌÌ7.òòà0  àWhat€can€be€done€to€get€increased€funding€for€CDC€in€HIV€prevention?òòóóÐH˜(#(# ÐÌóóCDC€must€justify€what€it€does€as€a€public€health€program€that€delivers€results€that€the€publicÐ  p Ðwants€to€support.€Budget€appropriation€requests€are€based€on€demonstrated€results€and€likelyÏimpact€if€a€message€is€disseminated.ÌÌÐ  Ð  Ðà@ïï ìàò òSubcommittee€Meetingsó óˆÐ ° ÐÌò òPrevention€Subcommittee:ó ó€Discussion€on€HIV/AIDS€Prevention€Issues.€¢Helene£€Gayle,€CDC,Ð ˆØ Ðinvited€participant.ÌÌò òServices€Subcommittee:€ó óUpdate€and€Discussion€on€Ryan€White€CARE€Act€¢Reauthorization£.Ð P   ТTerje£€Anderson,€¢HRSA£€Advisory€Committee;€David€Harvey€and€¢Miguelina£€¢Maldonado£,€NationalÏOrganizations€Responding€to€AIDS;€John€¢Palenicek£,€¢HRSA£;€and€Daphne€Long€Rankin,€NationalÏAssociation€of€AIDS€Education€Training€Centers,€invited€participants.ÌÌUpdate€on€¢HRSA£/Title€IV€Programs€and€Focus€on€Youth.€Wayne€¢Saucedo£,€¢HRSA£,€invitedÏparticipant.ÌÌò òRacial€Ethnic€Populations€Subcommittee:ó ó€HIV/AIDS€Data€Policy.€Olivia€Carter„¢Pokras£,Ð ´  ÐOffice€of€Minority€Health,€invited€participant.ÌÌà@ššìàò òWednesday,€November€18,€1998ˆÐ |Ì ÐÌà@ïï ìàSubcommittee€MeetingsˆÌÌRacial€Ethnic€Populations€Subcommittee:ó ó€Update€on€Healthy€People€2000/2010.€Ð ,| ÐDeborah€¢Maiese£,€¢DHHS£,€invited€participant.ÌÌò òPrison€Issues€Subcommittee:ó ó€Overview/Briefing€of€Prison€Site€Visit€Agenda€and€NationalÐ ôD ÐPrisons€Meeting.€Todd€Summers,€¢ONAP£,€invited€participant.ÌÌò òServices€Subcommittee:ó ó€Future€Leadership€on€Access€to€Care€and€Treatment€Issues.€DavidÐ ¼  ТBeier£,€Chief€Domestic€Policy€Advisor€to€the€Vice€President;€Kathy€King,€¢HCFA£;€€MarshaÏMartin,€Ph.D.,€€¢DHHS£;€Steve€¢Schondelmeyer£,€Ph.D.,€University€of€Minnesota;€and€ToddÏSummers,€¢ONAP£,€invited€participants.ÌÌSubcommittee€meeting€in€the€afternoon€focused€on€HIV€Cost€Services€and€Utilization€Study,ÏTransition€to€Co„Chair€Model€for€Subcommittee€and€Division€of€Responsibilities,€and€ReviewÏand€Update€of€Subcommittee€¢Workplan£.ÌÌò òResearch€Subcommittee:€ó óUpdate€and€Discussion€on€Microbicide€DevelopmentÐ  %\ # ÐRecommendations.€Penelope€J.€Hitchcock,€D.V.M.,€and€¢Zeda£€Rosenberg,€Ph.D.,€NationalÏInstitute€of€Allergy€and€Infectious€Diseases,€NIH,€invited€participants.ÌÌò òÓ  ÓThursday,€November€19,€1998ó óÐ À($' ÐÓ  ÓÌRepresentatives€from€AIDS€Action€and€the€Human€Rights€Campaign€(¢HRC£)€were€invited€toÏattend€this€last€dayððs€session.€New€substantive€ideas€and€a€stronger€action€plan€are€coming€out€ofÏthe€Council,€and€Dr.€¢Hitt£€felt€that€these€groups,€because€they€are€an€integral€part€of€how€PACHAÏdeals€with€the€Administration,€should€be€made€aware€of€the€Councilððs€agenda.ÌÐ H.˜)- Ðò òÓ  ÓOverview€of€the€Strategic€Planó óÐ ° ÐÓ ÓÌò òÓ  ÓSubcommittee€Reportsó óÐ ˆØ ÐÓt Óò òÌRacial€Ethnic€Populations:ó ó€Reverend€Perez€reported€that€the€subcommittee€revisited€theÐ `° ÐPACHA€Strategic€Work€Plan€and€came€to€a€consensus€that€the€plan€as€it€stands€is€appropriate.ÏShe€pointed€out€that€the€following€recommendations€still€need€to€be€implemented€and€should€beÏaddressed€at€the€meeting€with€President€Clinton.ÌÌð"ðà0  àInstruct€the€Secretary€of€Health€and€Human€Services€to€declare€that€the€rates€of€HIVÐ  P  Ðinfection,€compounded€by€the€disparate€health€outcomes€for€people€with€HIV€disease€inÏcommunities€of€color,€constitute€a€national€public€health€emergency€requiring€targetedÏinitiatives€and€additional€resources.Ð (#(# ÐÌð"ðà0  àConvene€a€meeting€with€key€civil€rights,€social€justice,€youth,€and€childrenððs€advocates€asÐ œì  Ðwell€as€health€care€leaders€in€communities€of€color€to€encourage€a€¢communitywide£€effortÏto€respond€to€the€HIV/AIDS€public€health€emergency.Ð (#(# ÐÌð"ðà0  àMeet€with€the€Congressional€Black€and€Hispanic€Caucuses€to€develop€a€strategy€toÐ Lœ Ðrespond€to€the€urgent€HIV€prevention€and€HIV/AIDS€health€care€needs€of€theseÏcommunities.Ð (#(# ÐÌò òRecommendation€1,€Subcommittee€Strategic€Work€Plan.ó ó€Despite€the€communityððs€efforts,€theÐ üL ÐPresidentððs€announcement,€and€extra€funding,€these€do€not€comprise€an€adequate€response€to€theÏpresent€situation€in€minority€communities.€There€is€a€sense,€voiced€by€one€Council€member,€thatÏthe€President€is€getting€more€press€for€something€that€he€did€not€do€directly,€and€that€most€of€theÏfunds€contributed€to€the€initiative€were€already€in€the€budget.€Ms.¢Thurman£€responded€that€$100Ïmillion€is€new€money.€Dr.€¢Hitt£€noted€that€the€Council€has€a€perception€that€Congress€is€doingÏmost€of€the€work€and€the€Administration€and€¢DHHS£€are€not€involved€in€appropriations,€which€isÏnot€the€case.€It€was€noted€that€the€highest€priority€of€the€Council€is€to€ensure€that€racial€and€ethnicÏpopulations€in€the€pandemic€do€not€get€overlooked.€Also,€it€is€important€that€the€nature€of€theÏcrisis€not€be€diminished.ÌÌDr.€¢Hitt£€added€that€he€does€not€believe€that€the€Councilððs€goal€of€having€the€AdministrationÏdeclare€the€current€pandemic€a€ð ðstate€of€emergencyðð€will€be€realized.€Ms.€Fraser„¢Howze£Ïresponded€that€the€CBC€was€still€asking€for€a€ð ðstate€of€emergency,ðð€regardless€of€the€lack€ofÏsupport€earlier€from€either€the€Administration€or€the€AIDS€community.€Had€the€CBCððs€requestÏfor€a€state€of€emergency€been€granted,€98€percent€of€its€requests€would€have€been€granted.€A€stateÏof€emergency€allows€certain€legal€events€to€happen€on€an€emergency€basis€in€the€short€term,€forÏinstance,€a€limited€needle„exchange€program.€A€state€of€emergency€would€have€permittedÏmovement€outside€the€law;€needle€exchange€could€not€be€overturned€by€Congress.€It€becomes€theÏresponsibility€of€the€President€and€the€Secretary€of€¢DHHS£€to€end€the€death€and€destructionÏimmediately.ÌÌResponding€to€concerns€that€one€meeting€with€the€CBC€is€not€sufficient€because€the€issues€areÏongoing,€Ms.€Thurman€assured€the€Council€that€the€President€has€met€with€both€the€CBC€and€theÐ 4.„)- ÐCongressional€Hispanic€Caucus€and€that€he€meets€with€the€caucuses€frequently.€Ms.€GutierrezÏcommented€that€HIV€prevention€strategy€has€not€been€discussed€in€a€comprehensive€way€by€theÏHispanic€Caucus€because€it€has€not€been€actively€involved€in€this€area.€Mr.€Robinson€said€thatÏthe€CBC,€although€supportive,€came€forward€on€this€issue€because€some€individuals€asked€themÏto.€He€stressed€that€declaration€of€a€state€of€emergency€remains€the€Racial€Ethnic€PopulationsÏSubcommitteeððs€top€priority€and€that€it€must€be€the€top€agenda€item€at€the€meeting€with€theÏAdministration.€Ms.€Thurman,€however,€rejoined€that€the€first€recommendation€as€worded,€ð ð[theÏPresident€would]€instruct€the€Secretary€of€¢HHS£€to€declare€a€state€of€emergency,ðð€is€not€realisticÏbecause€the€system€does€not€work€that€way.€Information€is€funneled€to€the€President€from€theÏCabinet€Secretaries,€and€it€is€the€Surgeon€Generalððs€and€Secretaryððs€responsibility€to€makeÏrecommendations€to€the€President.€Ms.€Thurman€suggested€rewording€the€recommendation€toÏð ðthe€community€continues€to€be€very€concerned€that€we€have€not€declared€a€state€of€emergency;Ïwould€he€ask€the€Secretary€to€report€to€him€on€why€we€have€not€done€so.ððÌÌò òRecommendation€2,€Interim€National€Minority€HIV€Report.ó ó€At€a€recent€meeting,€theÐ ˜è  ÐNational€Minority€HIV€Working€Group,€composed€of€veteran€and€current€providers,€put€togetherÏrecommendations€that€direct€agencies€how€to€improve€services€for€minorities€in€their€particularÏsystems.€Every€minority€group€was€represented€at€the€meeting,€suggesting€a€possible€consensus.ÏThe€recommendations€have€not€yet€been€approved,€however,€because€¢DHHS£€wants€the€workingÏgroup€to€review€the€document€and€verify€that€it€matches€the€CBC€initiative€and€other€minorityÏgoals.€The€subcommittee€will€write€a€letter€to€Secretary€¢Shalala£€asking€that€she€support€theÏefforts€of€the€working€group€and€discuss€concerns€about€timing€and€implementation.€Some€of€theÏrecommendations€submitted€by€the€working€group€are€not€new€but€have€been€on€¢DHHS£ððs€agendaÏfor€up€to€10€years.€These€will€be€highlighted€in€the€letter€to€Secretary€¢Shalala£.€(Dr.€¢Hitt£€suggestedÏto€the€Council€members€that€any€letters€generated€by€subcommittees€should€be€reviewed€by€theÏExecutive€Committee.€If€approved,€they€can€go€out€under€the€subcommittee€signatures;€if€alteredÏto€include€other€information,€then€full€Council€approval€is€needed.)ÌÌò òRecommendation€3,€CDCððs€People€of€Color€Initiative.ó ó€CDC€intends€to€contract€withÐ „Ô Ðconsultants€to€assess€the€current€programs€and€their€responsiveness€to€the€changing€needs€ofÏcommunities€of€color.€The€subcommittee€in€its€meeting€formulated€two€responses€to€this€decisionÏto€be€incorporated€in€the€letter€to€the€Secretary€(mentioned€above),€which€will€be€copied€to€theÏvarious€agencies€and€to€Dr.€¢Koplan£.€The€responses€are€as€follows:ÌÌð"ðà0  àSince€the€PACHA€meeting€in€Atlanta,€the€subcommittee€was€informed€that€the€People€ofÐ $`" ÐColor€Initiative€would€be€responded€to,€which€they€interpreted€to€mean€that€it€would€beÏfunded,€but€it€is€now€an€internal€assessment.€The€subcommittee€requests€CDCððs€plan€forÏthe€use€of€its€findings€in€responding€to€the€state€of€emergency€in€communities€of€color.Ð (#(# ÐÌð"ðà0  àThe€subcommittee€would€like€the€dates€of€the€meetings€with€leaders€from€the€Hispanic,Ð ¬(ü#' ÐAsian€Pacific€Islander,€and€Native€American€communities.Ð (#(# ÐÌAt€the€end€of€the€discussion€of€the€Racial€Ethnic€Populations€Subcommittee€report,€€€€€€€€€€€€€€€€ÏMs.€Fraser„¢Howze£€described€how€the€CBC€and€the€conferees€produced€the€CBC€HIV/AIDS€€€€ÏFY€1999€Appropriations€Conference€Report€Proposal.€She€distributed€to€the€members€the€finalÏreport€language€and€the€Declaration€of€a€National€ð ðState€of€Emergency.ððÐ 4.„)- Їò òRecommendation€4,€HIV/AIDS€Data€Policy.€ó óA€report€from€the€Office€of€Minority€Health€€€Ð ° Ð(Dr.€Olivia€Carter„¢Pokras£)€states€that€an€expanded€minimum€data€set€developed€by€the€¢DHHS£ÏData€Council€will€allow€more€specific€information€to€be€collected€on€communities€of€color.ÏDifferent€agencies€use€different€data€sets,€and€the€expanded€set€will€provide€one€data€set€for€allÏ¢DHHS£€agencies€to€use€and€thereby€establish€the€consistency€needed€to€cross„match€the€data€sets.ÏThe€recommendations€to€be€included€in€the€letter€to€Secretary€¢Shalala£€will€be€(1)€that€the€¢DHHS£Ïrequest€more€specific€ethnic/nationality€information€from€more€sources,€(2)€that€the€impact€ofÏundercounting€be€ameliorated€by€improved€sampling,€and€(3)€that€the€classification€of€poorÏpopulations€and€racial€ethnic€populations€living€in€poor€communities€be€distinguished€so€thatÏdata€can€be€better€interpreted.€There€is€concern€that€$8€million€of€Office€of€Minority€HealthÏresources€has€been€mistakenly€omitted€in€the€final€legislation.ÌÌò òRecommendation€5,€Disparities€in€HIV/AIDS€Health€Programs€for€American€Indians,Ð Ä  ÐAlaska€Natives,€and€Native€Hawaiians.ó ó€The€subcommittee€will€include€in€the€letter€to€theÐ °  ÐSecretary€a€request€that€the€resolutions€submitted€by€the€Services€Subcommittee€be€addressedÏmore€thoroughly€and€that€the€Council€be€¢apprised£€of€the€implementation€of€the€resolutions.ÌÌò òRecommendation€6,€Healthy€People€2000/2010.€ó óThe€draft€plan€is€out€in€hard€copy,€on€CDÐ d´ ÐROM,€and€on€the€Internet.€The€Council€has€been€asked€to€review€it,€including€those€areas€that€areÏconnected€to€HIV€but€are€not€specific€to€HIV.€The€program€goal€for€the€years€2000€to€2010€wasÏchanged€from€reducing€disparities€to€eliminating€disparities;€the€sole€exception€is€HIV/AIDS.ÏThis€exception€poses€a€problem€in€the€message€going€to€communitiesð"ðallowing€disparities€toÏcontinue€insofar€as€HIV€is€concerned.ÌÌDr.€¢Hitt£€asked€Jeff€Jacobs€from€AIDS€Action€and€Seth€¢Kilbourn£€from€¢HRC£€whether€theirÏorganizations€are€doing€anything€from€a€grassroots€perspective€to€address€this€concern.€TheyÏreplied€that€they€were€not€aware€of€the€Healthy€People€2000/2010€issue€but€would€address€thisÏproblem.€It€was€suggested€that€all€Council€members,€national€organizations,€and€grassrootsÏorganizations€make€it€known€that€they€find€this€discrepancy€unacceptable.€The€subcommittee€willÏdraft€a€paragraph€addressing€that€concern€to€be€included€in€the€letter€to€Secretary€¢Shalala£.ÌÌRegarding€the€discrepancies€in€the€Healthy€People€report,€Rabbi€¢Edelheit£€commented€that€if€inÏthe€next€10€years€a€person€does€not€fit€in€the€categories€on€the€scale€determined€by€the€CDC,€thenÏthat€person€will€not€be€accounted€for€in€the€data.€Dr.€¢Hitt£€will€draft€a€¢followup£€letter€to€€€€€€€€€€€€ÏDr.€¢Satcher£€highlighting€some€of€the€issues€discussed€during€this€meeting.€Ms.€ThurmanÏsuggested€that€the€Council€draft€a€letter€to€the€large€national€organizations€asking€them€to€reviewÏthese€initiatives€and€respond€to€the€issues.€This€is€an€opportunity€for€the€Council€to€reach€out€toÏthe€community€and€work€together€to€ensure€that€everyone€is€addressing€these€much€larger€issues.ÏMr.€Robinson€stated€that€he€was€outraged€by€the€statement€in€the€report€that€implied€ð ðit€was€[allÏright]€for€African„American€men€to€have€the€highest€rate€of€HIV€infectionðð€and€asked€€€€€€€€€€€€€ÏMs.€¢Thurman£€to€discuss€this€with€people€at€the€White€House.€She€responded€that€the€report€isÏsending€out€a€mixed€messageð"ðon€the€one€hand€saying€that€HIV€services€must€be€integrated€intoÏthe€continuum€of€health€care€delivery€and€on€the€other€that€the€Nation€will€accept€HIV.ÌÌA€representative€from€CDC€responded€to€the€groupððs€concerns.€When€Healthy€People€2000€cameÏout,€agencies€were€asked€to€confirm€that€they€would€meet€its€objectives;€most€of€the€objectivesÐ 8.ˆ)- Ðwere€not€met.€With€the€Healthy€People€2010€initiative,€CDC€attempted€to€be€more€realistic€in€itsÏgoals.€The€data€show€that€98.5€percent€of€the€epidemic€is€among€white,€African„American,€andÏHispanic€persons,€and€these€data€were€used€to€set€targets.€She€suggested€that€the€Council€send€theÏmessage€to€CDC€that€it€needs€to€be€ð ðthe€best€of€the€best,ðð€but€reminded€them€that€representativesÏfrom€¢SAMHSA£,€¢HRSA£,€the€Office€of€Minority€Health,€and€the€Office€of€Womenððs€Health€asÏwell€as€community€groups€were€also€involved.€Dr.€¢Hitt£€stated€that€¢ONAP£€should€have€beenÏinvolved€in€the€process€and€that€this€issue€would€be€brought€out€during€the€December€meetingÏwith€President€Clinton.ÌÌMr.€¢Milanes£€addressed€the€Council.€He€came€to€the€meeting,€he€said,€with€high€hopes€that€theÏneeds€of€the€Hispanic€community€would€be€addressed.€He€felt€that€he€was€leaving€the€meetingÏnot€knowing€what€would€happen€next€or€who€would€take€the€lead.€The€African„AmericanÏcommunity€has€some€organization€that€is€a€catalyst€for€action.€He€voiced€concern€that€this€type€ofÏorganization€does€not€exist€in€the€Hispanic€community,€and€that€unless€a€recognizable€entity€suchÏas€CDC€takes€the€lead€to€address€the€Hispanic€communityððs€needs,€they€will€be€no€further€aheadÏa€year€from€now.€Ms.€Fraser„¢Howze£€responded€that€the€CBC€would€be€meeting€with€theÏCongressional€Hispanic€Caucus€and€the€Native€American€Caucus€next€week,€and€they€willÏrequest€a€meeting€with€President€Clinton.€They€are€developing€an€agenda€for€congressionalÏaction€asking€for€a€tripling€of€the€$156€million€in€funding.ÌÌMs.€Fraser„¢Howze£€distributed€a€report€entitled€ð ðHIV/AIDS€and€Public€Health,€AfricanÏAmericans€in€Crisis,€A€National€State€of€Emergencyðð€and€gave€a€brief€overview€of€how€theÏinitiatives€were€developed.€She€thanked€Ms.€Thurman€for€the€last„minute€work€to€get€the€WhiteÏHouse€to€agree€to€present€funding€for€the€initiative€at€the€final€negotiation€meeting.ÌÌò òAppropriations€Subcommittee.ó ó€Ms.€Aragon€noted€that€the€Appropriations€Subcommittee€isÐ ¼  Ðfocusing€on€the€Presidentððs€FY€1999€and€FY€2000€budgets.€Three€issues€arose€during€theirÏmeeting€regarding€the€FY€1999€budget:ÌÌð"ðà0  àRequest€from€the€Administration€clarification€on€the€CBC€initiative,€specifically,€the€€Ð pÀ Ð$46€million€that€is€from€other€sources€within€¢DHHS£.Ð (#(# ÐÌð"ðà0  àThe€Administration€is€committed€to€bringing€to€Congress€the€details€of€how€the€€€€€€€€€€Ð 4"„  Ð$50€million€of€emergency€funding€will€be€spent€among€the€various€agencies.Ð (#(# ÐÌð"ðà0  àKeep€track€of€the€$8€million€in€the€Office€of€Minority€Health,€in€that€the€AdministrationÐ ø$H # Ðrequested€that€it€be€included€as€a€technical€amendment.Ð (#(# ÐÌThe€subcommittee€will€also€track€the€Prevention€Subcommitteeððs€recommendation€that€¢ONAP£€beÏgiven€funding€to€develop€a€national€testing€campaign.ÌÌFor€FY€2000,€the€overarching€concern€voiced€during€the€meeting€is€that€the€momentum€of€theÏFY1999€appropriations€bill€in€terms€of€funding€and€the€emphasis€on€targeted€funding€toÏcommunities€of€color€be€maintained.€The€Presidentððs€FY€2000€budget€must€address€allÏHIV/AIDS€issues,€testing,€global€health€funding,€and€access€to€treatment€and€other€services.ÌÐ 0.€)- Ðò òServices€Subcommittee.€ó óAs€Co„Chair€of€the€Services€Subcommittee,€Ms.€Aragon€presented€theÐ ° Ðsubcommitteeððs€report.€Because€of€time€constraints,€she€referred€Council€members€to€theÏsubcommitteeððs€written€report€and€proceeded€with€a€brief€overview€of€its€findings.ÌÌRegarding€housing€as€an€access€to€health€care€issue,€recent€study€findings€show€that€housing€is€aÏhealth€care€issue€that€is€critical€to€stabilizing€peopleððs€lives€and€encouraging€access€to€andÏmaintenance€of€treatment.€A€joint€¢SPNS£€program€from€¢HRSA£€and€the€Department€of€HousingÏand€Urban€Development€is€also€being€evaluated,€and€the€initial€results€will€be€available€forÏ¢reauthorization£€of€the€Ryan€White€CARE€Act.ÌÌThe€Massachusetts€Medicaid€Waiver€Planning€Process€involving€cooperation€among€State€publicÏhealth€officials€and€the€advocacy€community€enabled€the€development€of€a€1115€waiver€proposalÏthat€will€be€submitted€to€¢HCFA£€before€the€end€of€1998.€Two€important€findings€came€out€of€theÏprocess:ÌÌð"ðà0  àThe€cost€differential€between€a€full€benefits€package€and€a€partial€package€is€17percent.ÐˆØ (#(# ÐÌð"ðà0  àThe€benefits€package€could€be€cost„neutral€if€it€used€a€10„year€¢timeframe£,€if€drugs€wereÐ `° Ðdiscounted€an€additional€10€percent,€or€if€Supplemental€Security€Income€(SSI)€or€SSIÏDisability€savings€were€included.Ð (#(# ÐÌMs.€Aragon€noted€that€although€¢HCFA£€says€the€agency€encourages€State€applications,€StateÏrepresentatives€do€not€see€it€that€way.€Dr.€¢Hitt£€commented€that€short€of€drug„pricing€changes,Ï1115€waivers€are€the€best€hope€of€getting€access€to€care.€Mr.€Henderson€responded€that€action€atÏthe€State€level€is€important€but€the€drug„pricing€issue€is€most€important.€If€something€is€not€doneÏabout€drug€pricing,€the€objective€of€cost€neutrality€and€access€to€drug€treatment€cannot€beÏattained.€States€are€able€to€move€some€people€to€managed€care,€which€allows€increasedÏflexibility.ÌÌWork€is€being€done€on€¢reauthorization£€of€the€Ryan€White€CARE€Act,€which€will€not€take€placeÏuntil€FY€2000.€National€groups€are€attempting€to€identify€issues,€policy€or€legislative,€to€come€upÏwith€a€community€consensus.€¢HRSA£€also€is€engaged€in€a€detailed€planning€process€to€identifyÏissues.€¢HRSA£€Title€IV€programs€fund€the€Adolescent€Initiative€under€the€Ryan€White€CARE€Act.ÏFunding€for€youth€programs€totals€$1.9€million,€and€the€Administration€hopes€to€double€theÏfunding€and€the€number€of€programs€within€the€next€year.ÌÌThe€issues€of€leadership€and€expanding€access€to€care€and€treatment€were€discussed€by€a€diverseÏpanel€of€representatives€from€the€Administration€and€the€University€of€Minnesota.€Pricing€ofÏHIV/AIDS€drugs,€cost„neutral€intervention€care,€expanding€coverage,€and€leadership€from€theÏPresident€and€Vice€President€were€discussed€in€terms€of€access€to€care.ÌÌAn€update€on€the€¢Jeffords£„Kennedy€Work€Incentives€Improvement€Act€was€given€by€ConnieÏGarner€from€Senator€Edward€Kennedyððs€office.€The€goal€of€the€bill€is€to€reduce€the€disincentivesÏfor€people€with€disabilities€to€enter€and€stay€in€the€labor€force,€such€as€losing€Medicaid€coverageÏand€SSI/¢SSDI£€benefits.€A€demonstration€project€in€the€bill€will€allow€States€to€create€MedicaidÏð ðbuy„in€programs.ððÐ 0.€)- ЇThe€subcommittee€discussed€the€meeting€with€President€Clinton€and€how€to€address€the€issue€ofÏMedicaid€expansion€and€drug€pricing.ÌÌò òPrevention€Subcommittee.€ó óMr.€Robinson€recounted€the€subcommittee€meeting€with€Dr.€MarshaÐ tÄ ÐMartin€of€¢DHHS£,€stating€that€she€recommended€that€the€Administration€needed€a€nationalÏstrategy€for€HIV.€She€did€not€have€an€answer€when€asked€how€it€would€differ€from€the€formerÏnational€strategy;€however,€she€did€say€that€the€national€strategy€is€a€significant€document€and€isÏmore€a€national€statement€of€what€the€Governmentððs€response€will€be.€The€issue€of€needleÏexchange€was€also€discussed.€The€subcommitteeððs€recommendation€is€that€¢DHHS£€provide€theÏCouncil€and€the€White€House€(and€copy€to€¢ONAP£)€with€an€executive€summary€of€the€scientificÏresearch€on€needle€exchange,€specifically€addressing€the€Canadian€study.ÌÌDr.€¢Hitt£€explained€the€importance€of€being€¢proactive£€and€going€into€communities€explainingÏwhat€the€science€is€(e.g.,€on€needle€exchange)€and€promoting€the€science€through€programs€suchÏas€rapid€response€teams.€Ms.€Thurman€responded,€saying€that€legislation€is€pending€to€banÏFederal€funding€for€any€form€of€treatment€for€any€program€that€either€directly€or€indirectlyÏsupports€needle€exchange.€Dr.€¢Hitt£€believes€there€is€little€likelihood€that€the€bill€as€written€wouldÏpass€the€House€of€Representatives,€but€concern€was€voiced€by€others€that€it€could€pass.€The€onlyÏdata€in€the€field€at€this€time€are€data€supplied€by€General€Barry€R.€McCaffrey,€Director€of€theÏOffice€of€National€Drug€Control€Policy€(¢ONDCP£).€The€Administration€needs€to€be€¢proactive£Ïabout€promoting€the€science,€and€communities€need€information€they€can€use€to€convinceÏlegislators€of€the€validity€of€a€needle„exchange€program.ÌÌSubcommittee€members€reviewed€their€planned€priorities€and€their€belief€that€CDC€is€makingÏprogress€in€its€efforts€to€effectively€monitor€the€community€prevention€planning€process.€On€theÏrecommendation€for€increased€resources,€the€subcommittee€will€continue€to€promote€moreÏresources€for€community€planning,€but€additional€resources€also€need€to€be€made€available€forÏtesting€and€counseling€and€evaluation€of€existing€programs.€CDCððs€process€of€internalÏassessment€of€its€effectiveness€in€reaching€communities€of€color€is€another€area€to€be€included€inÏthe€letter€to€Secretary€¢Shalala£.ÌÌMr.€Robinson€directed€members€to€the€subcommitteeððs€proposed€recommendation€on€testing.ÏThe€subcommittee€is€suggesting€that€the€recommendation€be€revised€to€read€that€the€¢ONDCP£Ïmodel€now€being€used€for€the€national€youth€¢antidrug£€media€campaign€be€adopted€for€a€similarÏcampaign€to€promote€national€HIV€testing€and€coordinated€within€¢ONAP£.€It€is€felt€that€thisÏcampaign€would€offer€the€President€an€opportunity€to€have€a€highly€visible€positive€HIV/AIDSÏmessage.€Dr.€¢Hitt£€voiced€concern€over€whether€broad€community€support€would€be€available€andÏwhether€barriers€would€be€raised€to€doing€it.€Ms.€Fraser„¢Howze£€stated€that€much€of€the€campaignÏshould€be€targeted€to€communities€of€color.€However,€the€issues€of€whether€services€are€availableÏand€whether€¢ONAP£€will€have€a€policy€in€place€to€ensure€that€services€are€available€must€beÏconsidered.€Ms.€Gutierrez€responded€that€the€Council€should€not€think€twice€about€pushing€thisÏissue.€Resistance€to€delivering€the€right€kind€of€message€should€also€be€expected.€AnotherÏconcern€is€how€the€proposed€testing€campaign€will€interface€with€the€Administrationððs€policy€onÏreporting€HIV/AIDS€cases.Ìâ âÐ D-”(, ÐThe€final€consensus€of€the€Council€was€to€recommend€getting€out€a€coordinated€message€thatÏâ âstresses€promoting€knowledge€of€oneððs€HIV€¢serostatus£€rather€than€just€being€tested€for€HIV;€theÏpromotion€should€be€organized€through€¢ONAP£.€The€Executive€Committee€must€be€¢proactive£€inÏpresenting€to€the€President€its€concerns€about€access€to€care€and€names€reporting.€Dr.€¢Hitt£Ïmentioned€drafting€a€letter€to€go€to€advocacy€organizations€that€would€stress€the€importance€ofÏtheir€support€regarding€FY€2010€issues€and€the€above€recommendation.ÌÌò òInternational€Issues€Subcommittee.ó ó€Ms.€Billings€summarized€issues€discussed€by€theÐ $ t Ðsubcommittee.€Why€is€there€flat€funding€when€the€epidemic€is€increasing€internationally?€It€wasÏsuggested€that€a€joint€letter€be€sent€from€Secretary€¢Shalala£€and€Secretary€of€State€MadeleineÏAlbright€to€the€Appropriations€Committee€pointing€out€the€enormity€of€the€international€healthÏcrisis€and€asking€for€an€increase€in€global€AIDS€funding.€It€was€hoped€that€the€update€to€the€1995ÏU.S.€International€Strategy€on€HIV/AIDS€would€be€ready€by€World€AIDS€Day,€December€1.€TheÏState€Department€did€not€go€through€channels,€and€as€a€result€received€little€or€no€response€fromÏthe€agencies€involved.€The€agency€took€statements€from€other€documents€and€presented€them€asÏa€response€to€the€International€Strategy.€There€is€much€concern€about€this€approach,€as€it€looksÏlike€a€compendium€of€programs€with€little€substance€being€put€forth€as€a€strategy.€To€solve€theseÏproblems,€it€was€recommended€that€the€Council€request€that€the€U.S.€International€Strategy€andÏthe€issue€of€funding€be€addressed€at€higher€leadership€levels€within€the€State€Department.ÌÌMs.€Thurman€recommended€that€the€Council€send€a€letter€to€Brian€Atwood,€Administrator€of€theÏU.S.€Agency€for€International€Development€(¢USAID£)€and€Secretary€of€State€AlbrightÏemphasizing€the€importance€of€the€international€situation€and€asking€for€additional€funding.€AÏletter€will€be€drafted,€reviewed€by€the€Executive€Committee,€and€presented€to€the€full€Council€forÏapproval.€Asked€whether€the€subcommittee€had€discussed€the€issue€of€orphaned€children,€€€€€€€ÏMr.€¢Fogel£€responded€that€the€Administration€is€taking€a€¢proactive£€stance€on€this€issue.ÌÌò òPrison€Issues€Subcommittee.ó ó€Mr.€Landau€mentioned€that€the€subcommittee€was€scheduled€to€goÐ ˜è Ðon€a€site€visit€to€Cumberland€Prison.€Dr.€¢Hitt£€noted€that€because€of€problems€the€Council€has€hadÏwith€the€Bureau€of€Prisons,€the€scheduled€visit€will€not€proceed€as€originally€expected;€ratherÏthan€including€interaction€with€the€prisoners€and€discussion€of€their€problems,€the€visit€will€be€anÏinteraction€with€the€prison€system.ò òÐ L!œ Ðó óÌThe€subcommittee€is€attempting€to€set€up€a€meeting€with€the€director€of€the€Federal€Bureau€ofÏPrisons,€Dr.€Kathleen€Hawk€Sawyer.€Dr.€Gayle€stated€earlier€that€the€CDC€agreement€with€theÏBureau€of€Prisons€on€testing€is€moving€forward€and€that€intervention€models€are€being€set€up€inÏsix€States€and€the€District€of€Columbia.€A€tentative€date€for€the€national€meeting€on€prisons€isÏscheduled€for€March€11,€1999.€Discussion€will€focus€on€standards€of€care,€prevention,€substanceÏabuse,€case€management,€and€compassionate€release.€The€subcommittee€is€planning€to€invite€ÌDr.€Sawyer€as€the€main€speaker.€The€subcommittee€is€waiting€for€a€response€from€¢ONAP£€on€theÏMarch€Council€meeting€date€to€ensure€that€there€is€no€conflict€between€these€two€events.ÌÌMr.€Summers€has€been€convening€an€interagency€meeting€to€review€discharge€procedures.€TheÏBureau€of€Prisons€offers€a€voluntary€transition€period€through€transitional€facilities€for€prisonersÏwho€are€being€discharged€into€the€community.€Prisoners€are€given€a€30„day€supply€of€medicationÏwhile€in€these€facilities;€however,€they€are€often€kept€in€these€facilities€for€up€to€90€days,€and€noÐ 4.„)- Ðother€agency€assumes€responsibility€for€providing€medication€during€the€period€after€the€initialÏ30€days.€Voluntary€consent,€compliance,€and€the€potential€that€these€individuals€will€end€up€inÏthe€community€with€treatment„resistant€HIV€need€to€be€addressed€and€should€be€included€inÏdiscussion€with€President€Clinton€on€inadequate€access€to€care.€It€was€noted€that€the€number€ofÏpersons€involved€is€quite€small.ÌÌò òResearch€Subcommittee.€ó óA€paper€presenting€the€subcommitteeððs€recommendations€onÐ 8 ˆ Тmicrobicides£€was€distributed€to€Council€members.€Ms.¢Greenberger£€commented€that€the€sixÏrecommendations€listed€are€the€culmination€of€3€years€of€work€by€the€subcommittee.ÏRepresentatives€from€NIH€and€FDA€have€thoroughly€reviewed€these€recommendations,€and€it€isÏthe€impression€of€the€subcommittee€that€a€consensus€exists€and€that€the€recommendations€touchÏon€areas€that€need€to€be€addressed.€It€was€noted€that€current€annual€expenditures€for€microbicideÏresearch€are€at€$25€million.ÌÌThe€Research€Subcommittee€recommendations€were€voted€on€by€the€Council€and€unanimouslyÏapproved€as€presented.ÌÌò òÓ  ÓGeneral€Business€Ô  Ôand€Closingó óÐ `° ÐÓ†qÓÌDr.€¢Hitt£€mentioned€that€organizations€are€sending€letters€to€the€Administration€with€a€list€ofÏrecommendations€that€include€those€discussed€above€as€well€as€others€and€are€requesting€that€theÏCouncil€sign€on€to€the€letters.€The€consensus€of€the€Executive€Committee€is€that€members€asÏindividuals€may€sign€on€if€they€wish;€the€Council€as€a€unit€would€agree€to€sign€on€only€ifÏmembers€have€the€opportunity€to€thoroughly€review€the€recommendations€and€vote€on€them.€ÌDr.€Levine€said€that€the€Research€Subcommittee€will€convene€at€the€next€PACHA€meeting€toÏdiscuss€the€list€of€recommendations.ÌÌWhen€the€letter€to€Secretary€¢Shalala£€is€completed,€it€will€be€circulated€to€the€ExecutiveÏCommittee€and€the€full€Council,€and€if€approved,€the€letter€will€be€mailed€out.€SubcommitteeÏcontributions€to€the€letter€must€be€received€at€¢ONAP£€by€December€1€in€order€for€Mr.€¢Montoya£€toÏcoordinate€this€effort€and€circulate€a€draft€for€review€and€finalizing€by€the€Council€ExecutiveÏCommittee.€The€issues€to€be€addressed€in€the€letter€will€include€the€HIV€minority€health€plan,Ïdata€issues,€Healthy€People€2010,€¢IHS£€recommendations,€and€an€executive€summary€on€needleÏexchange.ÌÌDr.€¢Hitt£€reminded€members€that€only€five€short€(2„day)€meetings€remain€for€the€Council;€theÏgoals€have€been€set,€and€no€time€is€available€for€new€issues€to€be€considered.€SomeÏsubcommittees€or€key€subcommittee€people€may€be€brought€to€Washington,€D.C.,€once€duringÏthe€year€to€meet€with€other€organizations€to€move€the€Council€goals€forward€as€quickly€asÏpossible.€Conference€calls,€he€said,€are€to€be€limited€to€two€calls€between€now€and€the€MarchÏmeeting.€Members€were€asked€to€inform€Dr.€¢Hitt£€when€their€two€conference€calls€are€to€takeÏplace€and€to€inform€Mr.€¢Montoya£€which€dates€are€best€for€them€for€the€March€meeting€and€whoÏwill€not€attend€the€meeting€with€President€Clinton.€Mr.€¢Montoya£€reminded€members€that€SocialÏ&€Scientific€Systems€was€handling€travel€logistics€for€the€December€meeting€and€that€travelÏrequirements€must€be€in€no€later€than€December€1.ÌÐ 0.€)- ÐRegarding€the€meeting€with€President€Clinton,€Dr.€¢Hitt£€cautioned€that€the€¢timeframe£€willÏprobably€be€only€about€half€an€hour€and€that€it€is€important€that€the€group€remain€focused.€Also,Ïit€is€imperative€that€the€Council€prepare€a€background€memorandum€for€the€President€that€is€hardÏhitting€and€that€preempts€any€anticipated€arguments€against€a€given€issue.€The€memorandum€willÏstate€what€is€ò ònotó ó€being€done,€which€will€allow€the€President€to€question€whether€he€is€being€wellÐ `° Ðadvised.€Issues€to€be€addressed€in€the€memorandum€will€include€the€FY€2000€budgetÏ(¢microbicides£,€international€funding,€etc.),€people€of€color€and€youth€initiatives,€prevention,Ïaccess€to€care€including€drug€pricing,€and€vaccines.€Dr.€¢Hitt£€will€request€an€interim€meeting€withÏthe€Chief€of€Staff€to€discuss€the€memorandum€before€sending€it€to€the€President.€Ms.€¢Thurman£Ïsuggested€that€the€memorandum€be€sent€to€the€President€on€December€13,€which€will€allow€himÏtime€€to€review€it€during€his€return€flight€from€Israel.€Council€members€will€meet€the€day€beforeÏthe€meeting€with€President€Clinton.ÌÌDr.€¢Hitt£€thanked€Council€members,€Mr.€¢Montoya£,€Ms.€¢Thurman£€and€the€¢ONAP£€staff,€theÏconference€staff,€and€guests€for€their€participation.€The€meeting€was€adjourned€at€12:00.