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 ƒ   ! ÝÝ    Ý›òòÓ    ÓÑ €  üË  ÑÑ8 €   b  X  X       dì                  dì  8 ÑPresidential€Advisory€Council€on€HIV/AIDSóóÐ   	 °      ÐòòFull€Council€MeetingóóÐ   	 œì    ÐÌOctober€4„5,€1999ÌÌRadisson€¢Barcelo£€HotelÌWashington,€DCÌÓ       ÓÌòòÓ    ÓMINUTESóóÐ   	 `   ÐÓ   4   ÓÌòòPresent:óóÐ   	 è8	
   ÐÒ(        €X  €      °(#°(#( ÒR.€Scott€Hitt,€M.D.,€ChairÌStephen€N.€Abel,€D.D.S.ÌTerje€AndersonÌBarbara€Aranda„Naranjo,€Ph.D.,€R.N.ÌJudith€Billings,€J.D.ÌCharles€Blackwell,€J.D.ÌJerry€Cade,€M.D.ÌLynne€M.€CooperÌRabbi€Joseph€A.€EdelheitÌRobert€FogelÌDebra€Fraser„HowzeÌKathleen€GerusÌPhyllis€GreenbergerÌNilsa€Gutierrez,€M.D.,€M.P.H.€ÌRobert€HattoyÌB.€Thomas€HendersonÐ   	 ¨ø   ÐMichael€T.€Isbell,€J.D.ÌRonald€JohnsonÌJeremy€LandauÌAlexandra€Mary€Levine,€M.D.ÌSteve€LewÌMiguel€Milanes,€M.P.A.ÌHelen€H.€Miramontes,€R.N.ÌœReverend›€Altagracia€PerezÌMichael€Rankin,€M.D.ÌH.€Alexander€Robinson,€M.B.A.ÌDebbie€RunionsÌSean€SasserÌBenjamin€Schatz,€J.D.ÌDenise€StokesÌCharles€Quincy€TroupeÌBruce€Weniger,€M.D.Ð   
 ¨ø)   ÐÒ5        °(#°(#      €X  €     °À“  5 ÒòòPresent€from€ONAP:Ð   	 €Ð)   ÐóóÒ(        €X  €      °(#°(#( ÒSandra€Thurman,€DirectorÐ   	 l¼*   ÐœTodd€Summers,€Deputy€Director›Ð   	 X ¨+   ÐœDaniel›€Montoya,€Executive€Director,Ì€€€€PACHAÐ   
 X ¨,   ÐÒ5        °(#°(#      €X  €     °ÀÜ  5 ÒòòAbsent:óóÐ   	 0"€,   ÐÒ(        €X  €      °(#°(#( ÒRegina€Aragð;ðnÐ   	 #l-   ÐNicholas€BollmanÐ   
 #l-   ÐÒ5        °(#°(#      €X  €     °À  5 ÒòòÓ    ÓÐ   	 ô$D -   ÐMonday,€October€4,€1999óóÐ   	 à%0!.   ÐòòMorning€General€Council€SessionóóÐ   	 Ì&"/   ÐÓ   ¬   ÓÌDr.€R.€Scott€Hitt,€Chair,€opened€the€Fourteenth€Meeting€of€the€Presidential€Advisory€Council€onÏHIV/AIDS€(PACHA)€œby›€providing€a€summary€of€the€Councilððs€activities€since€the€June€meeting.ÏHe€said€he€had€met€several€times€with€Kevin€Thurm€of€the€Department€of€Health€and€HumanÏServices€(DHHS)€to€discuss€œprogress€on›€access€to€care,€the€œð ðKnow€Your€Statusðð›€campaign,Ð   	 h+¸&4   Ðneedle€exchange,€health€care€worker€guidelines,€the€Department€of€Labor„DHHS€appropriationsÏbill,€and€Medicaid€waivers.€At€their€most€recent€meeting,€Dr.€Hitt€and€Mr.€Thurm€discussedÏDHHS€Secretary€Donna€Shalalaððs€presentation€to€the€Council€and€specific€issues€the€CouncilÏwould€like€the€Secretary€to€address.€ÌÌDr.€Hitt€reported€that€the€Congressional€Hispanic€Caucus€Health€Care€Task€Force€held€hearingsÏduring€Spanish€Health€Awareness€Week€in€September,€and€a€œcongressional›€hearing€onÏHIV/AIDS€in€the€Hispanic€community€was€held€in€mid„September.€He€noted€that€Dr.€BarbaraÏAranda„Naranjo€testified€at€the€œcongressional›€hearing€and€summarized€the€Councilððs€prioritiesÏregarding€HIV/AIDS€and€the€Latino€community.€He€praised€her€testimony€and€encouragedÏCouncil€members€to€read€it€œprior€to€the›€panel€presentation€on€œthe€ð ðSevere›€and€OngoingÏHIV/AIDS€Health€Care€Crisis€in€Latino€œCommunitiesðð›€scheduled€for€Monday€afternoon.ÌÌDr.€Hitt€noted€that€there€had€been€a€lot€of€activity€over€the€summer€on€international€œissues›€andÏthanked€Robert€Fogel€for€bringing€the€compulsory€licensing€issue€before€the€Council€during€theÏJune€meeting.€He€said€Sandra€Thurman€had€been€doing€a€ð ðphenomenalðð€amount€of€work€on€theÏinternational€front€and€added€that€œthe€administration›€had€recently€reached€a€ð ðfriendly€resolutionððÏon€compulsory€licensing.ÌÌDr.€Hitt€summarized€the€dayððs€agenda.€Regarding€Dr.€Gary€Nabelððs€presentation€on€the€VaccineÏResearch€Center€(VRC)€at€the€National€Institutes€of€Health€(NIH),€Dr.€Alexandra€Mary€LevineÏsaid€Council€members€should€ask€Dr.€Nabel€to€outline€the€VRCððs€goals€over€the€next€1„2€yearsÏand€any€problems€that€may€be€encountered.€Council€members€should€also€ask€him€if€there€isÏenough€money€going€into€vaccine€research.€œDr.€Levine›€added€that€the€Research€SubcommitteeÏwould€propose€a€resolution€supporting€the€Vaccine€Technology€Act€for€the€full€CouncilððsÏapproval.ÌÌRabbi€Edelheit€suggested€that€Council€members€raise€the€question€of€vaccine€ownership€with€œÌDr.›€Nabel.€Dr.€Levine€said€she€had€not€addressed€the€issue€of€ownership€per€se€with€Dr.€NabelÏbut€that€part€of€the€agenda€for€developing€a€vaccine€would€be€to€use€it€in€resource„poor€areas.ÏHelen€Miramontes€noted€that€the€International€AIDS€Vaccine€Initiative€(IAVI)€is€currentlyÏworking€on€a€vaccine€candidate.€Dr.€Levine€said€Alan€Schultz€is€now€at€IAVI,€so€there€is€a€lot€ofÏcross„fertilization€between€NIH€and€IAVI.ÌÓ    ÓòòÌÓ   m   ÓóóDr.€Hitt€asked€the€Council€what€questions€might€be€posed€to€presenters€during€the€LatinoÐ   	 $X"   Ðpresentation.€Miguel€Milanes€said€Council€members€should€not€lose€sight€of€what€the€next€stepsÏare€and€what€actions€the€Council€needs€to€take€in€coming€months€on€Latino€issues.ÌÌDr.€Hitt€said€Secretary€Shalala€would€speak€for€10„15€minutes,€followed€by€a€45„minuteÏœquestion„and„answer›€period.€Dr.€Hitt€asked€Mr.€Thurm€to€request€that€Secretary€Shalala€discussÏsome€of€the€bureaucratic€limitations€faced€by€DHHS€on€actions€requested€by€the€Council.ÏSpecifically,€he€asked€the€Secretary€to€address€access€to€care€issues.€Dr.€Hitt€noted€that€a€DHHSÏdocument€outlining€the€Departmentððs€accomplishments€and€goals€on€access€to€care€had€beenÐ   	 h+¸&*   Ðdistributed€to€Council€members€in€their€supplemental€meeting€packets.€The€document€makes€itÏclear€that€much€remains€to€be€done€on€access€to€care.ÌÌHe€also€asked€that€the€Secretary€address€prevention€and€the€expected€outcome€of€the€Centers€forÏDisease€Control€and€Prevention€œ(CDC)/Institute›€of€Medicine€(IOM)€œreview.›€He€said€he€alsoÏexpects€the€Secretary€to€make€a€pointed€statement€on€needle€exchange€and€the€science€supportingÏit,€and€report€on€the€health€care€worker€guidelines,€DHHS€regional€meetings,€and€MedicaidÏwaivers.€Dr.€Hitt€said€Council€members€should€œprepare›€specific€questions€œin›€case€the€SecretaryÏdoes€not€touch€on€each€topic€during€her€presentation.€The€Executive€Subcommittee€will€meetÏduring€lunch€to€determine€which€questions€to€ask€the€Secretary.ÌÌRabbi€Edelheit€asked€if€there€would€be€a€conversation€about€the€membership€and€makeup€of€theÏCouncil.€Daniel€Montoya€said€Council€members€would€œreceive›€a€letter€œwithin€minutes€from›ÏSecretary€Shalala€informing€them€œof€their›€œCouncil›€œretirement€date.›€Since€the€Council€did€notÏinitially€build€in€staggered€terms€for€members,€members€will€be€œð ðtermed›€œoutðð›€randomly.€Mr.ÏMontoya€said€replacements€for€retiring€Council€members€would€be€determined€based€onÏgeographic,€racial/ethnic,€œand€sexual›€œorientation,›€œas€well€as›€gender€representation€on€the€Council.ÏHe€said€the€Council€had€already€received€100€to€150€names€of€potential€candidates.€The€firstÏCouncil€members€to€retire€will€do€so€at€the€end€of€1999,€marking€the€end€of€the€4„year€term€forÏmany€œmembers.›€Half€of€the€Council€members€slated€to€retire€will€œdo€so›€as€of€December€1999.ÏThe€other€half€will€retire€at€staggered€time€periods€so€there€is€no€mass€exodus€and€the€CouncilððsÏmomentum€can€be€maintained.ÌÌBenjamin€Schatz€asked€if€any€new€candidates€are€ready€to€assume€positions€on€the€Council.€œÌMr.›€Montoya€said€no€new€candidates€have€been€chosen.€He€added€that€the€DHHS€SecretaryððsÏoffice€and€the€White€House€wanted€to€ensure€that€Council€members€are€rotated€off€€ð ðin€the€rightÏwayðð€to€maintain€the€Councilððs€integrity.ÌÌòòÓ    ÓSandra€Thurman,€Director,€ONAP,€and€Todd€Summers,€Deputy€Director,€ONAPóóÐ   	 €Ð   ÐòòUpdate€on€ONAP€ActivitiesóóÐ   	 l¼   ÐÓ   Æ   ÓÌMs.€Thurman€began€by€recognizing€ONAP€staff€members€and€interns€for€their€hard€work€inÏrecent€months.€She€also€thanked€Paul€Gaist€of€the€Office€of€AIDS€Research€at€NIH,€RustyÏBennett€of€the€Department€of€Housing€and€Urban€Development,€and€Erica€Barth€from€theÏDepartment€of€State€for€helping€ONAP€œmanage›€a€number€of€issues.€She€reported€that€the€newÏONAP€and€PACHA€Web€sites€are€now€available€online.€She€noted€that€Todd€Summers€wasÏresponsible€for€launching€ONAPððs€Web€site,€which€she€called€ð ðthe€best€Web€site€at€the€WhiteÏHouse.ðð€She€also€reported€that€Matthew€œMurguia›€òò[?]óó€had€accepted€the€senior€staff€position€atÐ   	 Ì&"%   ÐœONAP›€and€œthat€she›€is€pleased€to€have€him€on€board€to€work€on€minority€issues.€ÌÌMs.€Thurman€noted€that€President€Clinton€attended€a€gay€and€lesbian€fundraiser€in€Los€AngelesÏon€October€2,€and€that€Dr.€Hitt€had€been€very€involved€in€organizing€the€event.€President€ClintonÏwas€complimentary€of€Dr.€Hittððs€work€and€publicly€thanked€him€during€the€fundraiser.€œÐ   	 l+¼&*   ÐMs.›€Thurman€thanked€Dr.€Hitt€as€well€for€his€leadership€and€enthusiasm€in€recent€months.ÌÌMs.€Thurman€then€recognized€her€predecessor€at€ONAP,€Patsy€Fleming,€who€in€turn€introducedÏElliott€Johnson,€the€new€director€of€the€Whitman€Walker€Clinic,€to€the€Council.ÌÌòòFY€2000€Budget:€óóMs.€Thurman€said€ONAP€had€secured€good€funding€levels€for€care€andÐ   	 L	œ   Ðresearch€in€the€FY€2000€budget,€but€the€levels€for€prevention€and€treatment€are€not€as€good.€UntilÏONAP€gets€a€sense€of€direction€on€prevention,€it€will€be€difficult€to€justify€making€additionalÏinvestments€in€this€area.€Thus,€the€CDC€review€process€will€be€important€in€securing€moreÏprevention€funding.€ÌÌShe€said€she€was€pleased€that€the€President€vetoed€the€œWashington,€DC,›€appropriations€bill€andÏpointed€to€the€needle€exchange€language€as€one€of€the€reasons€for€the€veto.ÌÌòòRefugee€Policy:óó€Mr.€Summers€said€ONAP€œhas›€been€working€with€the€National€Security€CouncilÐ   	 œì   Ðand€the€Immigration€and€Naturalization€Service€(INS)€on€œrefugee›€policy.€With€the€support€of€theÏINS,€the€waiver€requirements€have€been€streamlined.€The€Ryan€White€Act,€Medicaid,€and€theÏRefugee€Medical€Assistance€Act€exist€to€provide€care€to€refugees.€The€Surgeon€General€wrote€aÏletter€to€the€INS€director€stating€that€the€public€charge€test€could€be€satisfied€en€masse,€so€it€doesÏnot€have€to€be€satisfied€on€an€individual€basis.€ONAP€is€now€examining€how€to€apply€the€newÏrefugee€policy€to€¢asylees£.ÌÌòòPrison€Issues:óó€Mr.€Summers€noted€that€the€Council€had€a€good€meeting€with€Newt€Kendig,€theÐ   	  P   Ðnew€medical€director€for€the€Bureau€of€Prisons,€during€the€June€Council€meeting.€Mr.€Kendig€hasÏoffered€to€brief€the€Council€again€on€developments€in€HIV/AIDS€and€prisons.€The€Bureau€ofÏPrisons€and€the€Health€Resources€and€Services€œAdministration›€(HRSA)€have€signed€aÏmemorandum€of€understanding€to€establish€a€pilot€program€to€provide€care€to€persons€who€are€inÏpre„release€programs.€Attorneys€for€both€the€Bureau€of€Prisons€and€HRSA€are€looking€at€how€toÏcommingle€funds€for€the€program.€Mr.€Kendig€and€Joe€¢OððNeil£€have€been€working€aggressively€toÏaddress€the€pre„release€issue.ÌÌONAP€and€CDC€are€working€together€to€launch€a€new€prisoner€health€Web€site€under€theÏauspices€of€the€National€Prevention€Information€Network€(NPIN)€at€CDC.€The€site€will€includeÏinformation€on€HIV€prevention€and€care.€HRSA€and€the€Bureau€of€Prisons€are€examining€how€toÏcontribute€financially€to€the€site.ÌÌòòMinority€Initiative:óó€Ms.€Thurman€said€ONAP€had€held€a€series€of€meetings€with€theÐ   	 ì%<!$   ÐCongressional€Black€Caucus€(CBC)€over€the€last€4€or€5€weeks.€At€the€CBC€weekend€in€lateÏSeptember,€she€made€four€speeches€to€the€group€in€4€days;€she€addressed€the€health€braintrust,Ïthe€Africa€braintrust,€and€the€womenððs€group.€ÌÌThe€Congressional€Hispanic€Caucus€(CHC)€held€a€hearing€on€HIV/AIDS€in€mid„September.€œÌMs.›€Thurman€was€invited€to€testify€but€was€not€able€to€do€so.€The€Surgeon€General€did€testifyÐ   	 x+È&*   Ðbefore€the€CHC.€Ms.€Thurman€thanked€Mr.€Montoya€for€his€help€in€organizing€the€hearing.ÌÌòòCDC:óó€The€prevention€strategy€development€process€is€moving€forward.€The€CDC€communityÐ   	 ˆØ   Ðadvisory€board€has€been€engaged€in€the€review€process.€Ms.€Thurman€said€CDC€has€been€betterÏabout€answering€questions,€but€more€information€is€needed€to€justify€the€dollars€spent€onÏprevention.€CDC€is€talking€about€engaging€IOM€in€an€external€review€to€lay€out€a€vision€forÏCDC€over€the€next€few€years.€Ms.€Thurman€said€it€is€clear€that€œthe€administration›€is€not€on€theÏcutting€edge€of€prevention€but€needs€to€be.€IOM€would€be€expected€to€provide€some€objectiveÏrecommendations.€She€noted€that€she€is€not€happy€with€the€¢timeframe£€for€the€review€process;€itÏwill€take€a€long€time.€Mr.€Summers€and€Terje€Anderson€have€been€heavily€engaged€in€this€issue.ÌÌMr.€Isbell€said€he€appreciated€ONAPððs€efforts€on€prevention,€but€he€is€concerned€that€the€pushÏfor€additional€prevention€funding€is€being€held€up€pending€the€outcome€of€the€CDC€reviewÏprocess.€He€pointed€out€that€communities€of€color€badly€need€additional€funding€for€community„¼based€prevention,€and€there€is€only€one€more€real€budget€coming€out€of€the€currentÏœadministration.›€The€next€œadministration›€may€not€make€HIV/AIDS€a€priority.€He€suggested€thatÏœthe€administration›€insist€that€the€strategic€overview€on€prevention€proceed,€but€that€funding€forÏprevention€be€made€available€at€the€same€time.€ÌÌMs.€Thurman€agreed€that€œthe€administration›€must€continue€to€push€for€additional€preventionÏfunding€but€that€it€must€be€very€specific€about€how€the€funds€are€spent.€She€said€CBC€met€withÏJohn€¢Podesta£€on€October€1€and€discussed€the€need€to€distribute€funds€to€the€communities€thatÏhave€been€hardest€hit€by€HIV/AIDS.ÌÌMs.€Miramontes€said€she€attended€the€HIV€Prevention€Conference€in€Atlanta€in€August,€andÏthere€was€a€lot€of€anger€about€the€discriminatory€nature€of€the€criteria€for€granting€funds€throughÏthe€CBC€initiative.€The€feeling€was€that€significant€barriers€had€been€set€up€that€did€not€appear€inÏother€requests€for€proposals.€ÌÌMs.€Thurman€said€the€Council€should€address€this€issue€with€the€Surgeon€General€and€throughÏfrank€discussions€with€people€at€the€community€level.€She€asked€Ms.€Miramontes€if€anyoneÏspecified€what€the€criteria€were.€Ms.€Miramontes€said€the€representatives€from€CDC€hadÏacknowledged€that€the€criteria€for€technical€assistance€were€more€stringent.ÌÌœòòð ðKnow€Your€Statusðð›€Campaign:€óóMr.€Summers€said€œrepresentatives€of€ONAP,›€AlexanderÐ   	 $\"   ÐRobinson,€Mr.€œAnderson,›€and€representatives€from€CDC€held€an€initial€meeting€on€the€campaignÏfollowing€the€June€Council€meeting.€Over€the€summer,€the€group€conducted€biweekly€conferenceÏcalls€with€Dr.€Eric€¢Goosby£ððs€staff€to€keep€the€campaign€ð ðon€the€front€burner.ðð€He€said€CDC€hasÏproduced€an€outline€for€the€campaign,€which€identifies€specific€measurable€outcomes€over€theÏnext€3€œyears›€œ(i.e.,›€identifying€the€number€of€people€who€are€HIV„positive,€donððt€know€it,€and€willÏlearn€their€status€through€the€œcampaign).›€ÌÌHe€noted€that€the€œð ðKnow€Your€Statusðð›€œcampaign›€is€part€of€a€larger€initiative€called€ProjectÐ   	 p+À&*   ÐImpact.€The€project,€implemented€by€CDC,€NIH,€and€HRSA,€will€examine€how€the€PublicÏHealth€Service€can€better€link€prevention€and€care€services.€ÌÌMr.€Summers€reported€that€Dr.€Gaist€is€organizing€a€November€29€interagency€briefing€forÏFederal€officials€on€the€process€by€which€the€prevention€science€research€agenda€is€developed.ÏQuestions€to€be€addressed€at€the€briefing€will€include:€How€does€the€Government€articulateÏspecific€questions€for€prevention€science€researchers?€Which€questions€do€researchersÏthemselves€need€answered?€How€are€those€questions€translated€into€research€projects?€How€areÏthe€results€of€research€projects€applied?Ì€€ÌAttendees€will€include€Ms.€Thurman,€U.S.€Surgeon€General€David€Satcher,€Dr.€Neal€NathansonÏof€NIH,€Dr.€Jeffrey€Koplan€of€CDC,€Duff€Gillespie€of€the€U.S.€Agency€for€InternationalÏDevelopment€(USAID),€and€Dr.€œGoosby›€of€DHHS.€Briefers€will€include€researchers€from€NIH,ÏCDC,€and€USAID.ÌÌòòHIV€Surveillance€Guidelines:óó€Ms.€Thurman€said€it€is€her€understanding€that€the€guidelines€areÐ   	 „Ô   Ðnear€completion€and€will€include€the€ability€to€use€unique€identifiers.ÌÌòòHealth€Care€Worker€Guidelines:óó€Ms.€Thurman€reported€that€the€CDC€ethics€committee€hasÐ   	 Lœ   Ðcompleted€its€work,€and€the€guidelines€are€back€on€the€CDC€directorððs€desk.€They€are€on€the€wayÏto€DHHS.€Dr.€Hitt€said€Mr.€Thurm€indicated€that€the€process€is€moving€forward,€and€theÏDepartment€should€be€able€to€move€on€the€guidelines€within€days,€not€months.€Ms.€Thurman€saidÏthe€DHHS€Secretaryððs€office€has€been€adamant€that€CDC€respond€to€community€concerns,€so€theÏprocess€has€been€delayed.€ÌÌòòTreatment€Access:óó€Ms.€Thurman€reported€that€the€Councilððs€Executive€Subcommittee€has€beenÐ   	 Ä   Ðdiscussing€this€issue€with€œMr.€Thurm,›€and€that€the€Surgeon€General€and€Secretary€Shalala€areÏexpected€to€address€access€in€their€presentations€to€the€Council.€ONAPððs€senior„level€treatmentÏaccess€group€will€meet€in€November.€She€noted€that€Tim€Westmoreland€has€been€appointed€asÏthe€new€director€of€œMedicaid›€and€said€he€would€be€of€great€help€to€ONAP€and€the€Council.ÌÌòòJeffords„Kennedy€Bill:€óóMs.€Thurman€said€the€bill€had€passed€in€the€Senate€but€is€still€strugglingÐ   	 P!    Ðin€the€House.€It€remains€a€top€priority€for€œthe€administration.›ÌÌòòHealth€Care€Bill€of€Rights:€óóThe€bill€will€go€to€the€floor€this€week.€It€is€also€a€top€priority€for€œtheÐ   	 $h"   Ðadministration.›ÌÌòòYouth€Report:óó€Several€groups€are€meeting€to€prepare€an€update€to€the€1996€Youth€and€HIVÐ   	 à&0"%   ÐAgenda€in€time€for€World€AIDS€Day.€Mr.€Summers€said€ONAP€has€talked€to€a€number€ofÏcommunity€groups€and€young€people€to€formulate€recommendations€to€strengthen€prevention€andÏcare€for€young€people.ÌÌòòFY€2001€Budget:€óóMs.€Thurman€said€ONAP€is€just€beginning€to€discuss€the€FY€2001€budget€andÐ   	 €+Ð&*   Ðwill€solicit€input€from€the€Council€on€budget€priorities.ÌÌòòInternational€Issues:€óóIn€July,€ONAP€released€a€òòReport€on€the€Presidential€Mission€on€ChildrenÐ   	 ˆØ   ÐOrphaned€by€AIDS€in€Sub„Saharan€œAfricaóó.›€The€report€was€œwell€received›€by€both€Congress€andÐ   	 xÈ   Ðthe€White€House.€The€report€requested€an€additional€$100€million€for€international€AIDS€effortsÏand€laid€out€a€plan€of€action.€Ms.€Thurman€said€ONAP€is€currently€fighting€to€secure€the€$100Ïmillion.€The€Senate€has€allocated€more€money€than€ONAP€originally€requested.€It€is€the€firstÏmultisectorial€budget€request€ONAP€has€sent€to€Congress€and€includes€CDC,€USAID,€DHHS,Ïand€the€Department€of€Defense.€ÌÌONAP€organized€a€meeting€in€early€September€with€the€First€Lady€and€a€small€group€of€decisionÏœmakers›€to€discuss€the€international€initiative€and€how€to€leverage€additional€support€from€otherÏdonor€nations.€Attendees€included€Secretary€Shalala;€Jim€Wolfenson,€president€of€the€WorldÏBank;€œTreasury€Secretary€Lawrence€Summers;›€the€president€of€Black€Entertainment€Television;Ïthe€chief€executive€officer€of€Bristol€Myers€Squibb;€œDr.€Satcher;›€and€representatives€from€theÏGates€Foundation,€the€Soros€Foundation,€and€the€Rockefeller€Foundation.ÌÌOn€September€9,€Rory€Kennedyððs€12„minute€video€of€the€œWhite€House„sponsored€African›€tripÏwas€screened€on€Capitol€Hill€and€was€œwell€received.›€Ms.€Thurman€said€the€video€is€anÏeducational€tool€but€may€become€a€full„length€documentary.€ÌÌONAP€is€also€coordinating€œthe€administrationððs›€response€to€the€Pelosi€bill€on€vaccines.ÌÌMs.€Thurman€reported€that€the€U.S.€Trade€Representativeððs€Office€has€reached€agreement€withÏSouth€Africa€on€issues€relative€to€the€Medicines€œAct›€but€added€that€œthe€administration›€still€needsÏto€look€at€how€to€build€infrastructures€in€the€developing€world€to€deliver€AIDS€drugs€to€those€inÏneed.€She€concluded€by€stating€that€ONAPððs€international€efforts€do€not€detract€from€its€effortsÏon€the€domestic€front;€they€are€parallel€tracks€and€the€funding€streams€are€different.ÌÌòòQuestions/Comments:óó€Rabbi€Edelheit€asked€that€copies€of€the€report€to€the€President€beÐ   	 pÀ   Ðdistributed€to€Council€members.€Ms.€Thurman€said€she€would€bring€in€copies€on€Tuesday.€RabbiÏEdelheit€also€asked€if€the€Council€could€view€the€12„minute€African€video.€Ms.€Thurman€saidÏshe€would€be€happy€to€show€the€video.ÌÌDr.€Hitt€confirmed€that€Council€members€received€the€report€on€the€meeting€with€the€First€Lady.€ÌÌMr.€Isbell€thanked€Ms.€Thurman€for€her€leadership€and€hard€work€on€international€AIDS€issues.ÏMs.€Thurman€said€it€is€gratifying€to€travel€to€the€developing€world€to€share€the€lessons€thatÏAmericans€have€learned€since€the€early€days€of€the€epidemic.ÌÌSteve€Lew€thanked€Ms.€Thurman€and€Mr.€Summers€for€continuing€to€work€on€the€refugee€issue.ÏHe€asked€whether€letters€have€been€sent€to€INS€field€offices.€Mr.€Summers€said€the€INS€hasÏissued€a€field€guidance€in€memo€form€that€incorporates€the€œthree„pronged›€public€charge€test.€œÐ   	 p+À&*   ÐMr.›€Lew€asked€if€a€copy€of€the€field€guidance€is€available€to€send€out€to€community„basedÏorganizations.€Mr.€Summers€said€a€copy€is€available€on€the€ONAP€Web€siteÏ(www.whitehouse.gov/ONAP),€but€ONAP€is€trying€to€maintain€a€low€profile€on€the€issue.€ÌÌLynne€Cooper€asked€if€the€President€and€industry€leaders€have€shown€support€for€the€œð ðKnowÏYour€Statusðð›€œcampaign.›€Mr.€Summers€said€ONAP€is€focusing€on€developing€a€framework€for€theÏcampaign€before€soliciting€outside€support.€Ms.€Thurman€said€she€has€talked€to€Jesse€Jackson,Ïthe€National€Football€League,€and€Robert€Johnson€of€Black€Entertainment€Television€aboutÏbecoming€engaged€in€the€campaign,€but€ONAP€needs€to€have€a€plan€of€action€before€partnershipsÏcan€be€initiated.€Mr.€Summers€said€about€$10€million€of€œthe€administrationððs›€FY€2000€budgetÏproposal€was€allocated€for€the€campaign,€but€this€funding€was€not€included€in€the€œcongressional›Ïmarkup.ÌÌDr.€Hitt€noted€that€Regina€Aragð;ðn€will€receive€the€AIDS€Health€Project€Champion€Award€in€lateÏOctober€from€the€University€of€California„San€Francisco€AIDS€Health€Project.€Dr.€Jerry€CadeÏwas€honored€at€the€recent€œInterscience€Conference€on€Antimicrobial€Agents€and€Chemotherapy›Ïœòò[correct€organization?]óó›€meeting€with€the€Heroes€in€Medicine€Award€from€the€InternationalÐ   	 pÀ   ÐAssociation€of€Physicians€for€AIDS€Care.€Dr.€Aranda„Naranjo€was€appointed€to€a€new€positionÏas€the€œSpecial€Projects€of€National€Significance€(SPNS)›€Branch€Chief€and€will€be€leaving€theÏCouncil.ÌÌDr.€Hitt€thanked€Council€members€for€their€thoughts€and€medical€advice€during€the€summerÏrecess.€He€then€introduced€Dr.€Gary€Nabel€of€the€University€of€Michigan€and€the€VRC€at€NIH.ÏDr.€Nabel€is€well€known€for€his€research€in€gene€therapy€and€molecular€biology.€Dr.€Hitt€said€heÏwill€bring€an€important€scientific€credibility€to€the€AIDS€vaccine€effort€and€epitomizes€theÏPresidentððs€commitment€to€bringing€the€best€minds€together€in€that€effort.ÌÌòòÓ    ÓDr.€Gary€NabelÐ   	 ˜è   ÐDirector,€Vaccine€Research€Center€(VRC),€National€Institutes€of€Health€(NIH)ÌÓ   ÿY   ÓóóÌDr.€Nabel€began€by€stating€that€his€presentation€would€summarize€the€functions€and€goals€of€theÏVRC,€not€only€in€terms€of€the€science€occurring€within€the€œCenter›€itself,€but€including€interactionÏwith€academic€sites€across€the€world€and€with€various€Federal€agencies.ÌÌHe€showed€a€slide€of€an€artistððs€rendition€of€the€VRC€building,€which€is€scheduled€to€beÏcompleted€in€May€2000.€The€first€laboratories€will€be€functional€as€of€fall€2000,€and€theÏpersonnel€recruitment€process€has€already€begun.€ÌÌA€2„day€strategic€planning€retreat€was€held€in€May€to€bring€together€the€best€minds€in€HIVÏresearch€and€basic€virology€to€develop€a€mission€statement€and€a€statement€of€goals€for€theÏœCenter.›€Dr.€Nabel€repeated€the€mission€statement€formulated€by€the€strategic€planning€group:€òòToÐ   	 ”)ä$(   Ðconduct€research€that€facilitates€the€development€of€effective€vaccines€for€human€disease.€TheÏprimary€focus€will€be€the€development€of€a€vaccine€for€AIDS.€óóHe€said€the€statement€is€phrased€toÐ   	 l+¼&*   Ðconvey€the€hope€that€development€of€an€AIDS€vaccine€will€pave€the€way€for€applications€to€otherÏdiseases.€ÌÌœThe›€strategic€planning€group€formulated€the€following€statement€œdelineating€the€Centerððs€goalsÏfor€HIV:›€ÌÌòòThe€goals€of€the€œCenter›€are:€(1)€To€conduct€basic€research€to€establish€mechanisms€of€inducingÐ   	 8
ˆ   Ðœlong„lasting›€protective€immunity€against€HIV;€(2)€To€conceive,€design,€and€prepare€vaccineÏcandidates€for€HIV€and€related€viruses;€and€(3)€To€perform€laboratory€analysis,€animal€testing,Ïand€clinical€testing€necessary€to€advance€these€products€into€the€œclinic.›óóÐ   	 üL	   ÐÌDr.€Nabel€said€the€œCenter›€will€develop€a€comprehensive€program€of€research€and€will€facilitateÏinteractions€with€industry€to€secure€partners€to€help€market€and€manufacture€a€vaccine€once€oneÏbecomes€available.€In€sum,€activities€of€the€œCenter›€will€include:€(1)€promotion€of€scientificÏopportunities;€(2)€development€of€regulatory€guidelines;€and€(3)€engagement€of€theÏbiotechnology€and€pharmaceutical€sector.ÌÌœDr.€Nabel›€summarized€three€approaches€that€researchers€are€pursuing€to€develop€an€AIDSÏvaccine:€œ(1)›€to€stimulate€cells€of€the€immune€system€to€recognize€and€kill€the€virus;€(2)€toÏstimulate€cells€of€the€immune€system€to€make€antibodies€that€circulate€in€the€serum€and€reactÏwith€the€virus€to€neutralize€it;€and€(3)€to€generate€persistent€expression€of€viral€genes€so€that€theÏabove€responses€to€the€virus€can€be€maintained€chronically.€ÌÌœHe›€noted€that€each€approach€has€advantages€and€disadvantages,€and€researchers€have€notÏdetermined€which€approach€is€optimal.€Using€cell„based€vaccines€allows€researchers€to€recognizeÏand€eliminate€virally€infected€cells,€and€an€intact€virus€is€not€needed€for€this€to€occur.€It€alsoÏallows€for€elimination€of€virus€production€and€could€provide€a€mechanism€to€eliminate€aÏreservoir€of€unrecognized€virus.€But€there€are€ways€in€which€the€virus€can€evade€this€type€ofÏimmune€response,€and€this€approach€requires€maintenance€of€cells€that€are€continually€active.ÏSpecialized€molecules€are€needed€to€present€the€virus€to€the€immune€system,€and€this€approachÏcan€fail€when€the€virus€figures€out€how€to€eliminate€that€recognition.ÌÌAntibody„based€vaccines€are€predicated€on€the€view€that€if€one€can€neutralize€the€virus€withÏantibody,€the€virus€isnððt€able€to€infect€new€cells.€This€approach€has€frustrated€researchers€and€hasÏbeen€the€rate„limiting€step€in€the€field€of€developing€AIDS€vaccines;€it€has€not€been€possible€toÏgenerate€broadly€neutralizing€antibodies.€It€is€important€to€remember€that,€in€some€cases,Ïantibodies€can€make€the€disease€worse.€This€remains€a€major€scientific€hurdle,€and€the€VRC€willÏspend€a€significant€amount€of€time€examining€it.ÌÌUsing€a€live€attenuated€vaccine€has€attracted€a€lot€of€attention€and€has€worked€in€the€past€withÏviruses€like€polio,€but€the€AIDS€virus€is€a€different€œanimal:€It›€is€a€long„lasting€virus€that€is€able€toÏevolve€into€a€more€pathogenic€form.€Researchers€have€found€that€these€long„lasting€viruses€canÏbecome€toxic€and€cause€disease€in€immunosuppressed€individuals.€When€developing€a€liveÐ   	 h+¸&*   Ðattenuated€vaccine€that€will€be€administered€to€millions€of€people,€the€likelihood€that€adverseÏevents€can€occur€is€great.ÌÌDr.€Nabel€said€the€VRCððs€scientific€opportunities€relate€to€what€kind€of€vaccine€should€beÏdeveloped,€how€researchers€can€enhance€recognition€of€viral€components,€how€researchers€canÏexpose€regions€of€the€virus€that€are€hidden,€how€researchers€œcan€understand›€and€optimizeÏadjuvants€for€use€in€humans,€how€to€use€primates€as€a€model€for€human€infection,€and€how€to€useÏgenetics€and€genomics€to€determine€how€humans€respond€to€different€antigens.€ÌÌHe€added€that€the€VRC€must€develop€methods€to€facilitate€the€transition€of€studies€fromÏlaboratory€to€clinic.€Many€techniques€that€are€successful€in€animal€studies€are€not€translatable€toÏhumans,€in€part€because€animals€have€controlled€genetic€backgrounds€while€humans€haveÏdifferent€genetic€backgrounds.€The€œCenter›€will€focus€on€developing€sensitive€assays€of€humanÏimmune€responses.€One€approach€may€be€to€examine€immune€responses€in€individuals€who€areÏtaking€highly€active€¢antiretroviral£€therapy€(¢HAART£)€to€learn€whether€those€responses€areÏcomparable€to€those€of€an€uninfected€individual.€Researchers€must€also€investigate€the€range€ofÏ¢clades£€that€are€medically€important€throughout€the€world.ÌÌDr.€Nabel€said€the€VRC€would€address€the€lack€of€suitable€production€facilities€for€makingÏclinical€grade€vectors€and€review€how€clinical€trials€are€designed.€The€œCenter›€will€also€look€atÏhow€to€engage€œbiotechnology›€and€pharmaceutical€companies€in€manufacturing€a€vaccine,Ïconsidering€that€liability€issues€and€low€profit€margins€are€significant€deterrents.€To€provideÏincentives€to€pharmaceutical€companies,€the€œCenter›€can€help€facilitate€phase€1€and€2Ïdevelopment€of€vaccines€and€can€collaborate€with€industry€so€that€clinical€trials€yield€resultsÏmore€quickly.€Promoting€communication€among€industry€partners€will€be€a€priority.ÌÌDr.€Nabel€said€he€was€pleased€to€hear€about€the€January€2000€White€House€conference€toÏfacilitate€the€efforts€of€the€biotechnology€and€pharmaceutical€industry.€He€said€the€AIDSÏcommunity€must€consider€how€to€sustain€the€outcomes€of€the€conference.€The€VRC€has€alreadyÏrecruited€several€high„level€individuals€from€industry.ÌÌThe€VRC€hopes€to€engage€in€collaborative€efforts€with€the€CDC,€the€U.S.€Army,€œthe›€Food€andÏDrug€œAdministration,›€and€other€agencies.€ÌÌThe€structure€of€the€œCenter›€incorporates€an€NIH€Executive€Committee€that€includes€Dr.€AnthonyÏFauci,€Dr.€Michael€Gottesman,€Dr.€Richard€Klausner,€Dr.€Neal€Nathanson,€and€Dr.€HaroldÏVarmus.€The€centerððs€external€Scientific€Advisory€Committee€is€largely€drawn€from€the€AIDSÏVaccine€Research€Committee,€and€an€NIH€Board€of€Scientific€Counselors€will€review€theÏprogress€of€the€laboratory.€The€œCenterððs›€programs€include€basic€science,€translation,€and€clinicalÏscience.ÌÌDr.€Nabel€concluded€by€stating€that€the€VRCððs€major€activities€will€focus€on€addressing€theÏproblem€of€neutralizing€antibodies€and€on€clinical€trials€translation€and€facilitating€new€vaccineÐ   	 h+¸&*   Ðcandidates.€He€emphasized€that€the€research€community€needs€to€begin€to€educate€the€publicÏabout€a€potential€AIDS€vaccine€so€that€expectations€are€realistic.€He€said€the€public€needs€toÏrecognize€that€a€vaccine€may€not€be€completely€protective€and€that€complications€can€occur€whenÏa€vaccine€is€administered€en€masse€in€the€developing€world.€ÌÌòòQuestions/Comments:€óóMs.€Miramontes€commented€that€it€will€be€critical€to€retain€people€inÐ   	 L	œ   ÐAIDS€vaccine€clinical€trials€and€asked€Dr.€Nabel€if€vaccine€trials€would€combine€the€best€mindsÏin€biomedical€and€behavioral€research.€Dr.€Nabel€agreed€that€it€is€important€to€pay€attention€toÏbehavioral€œaspects›€and€noted€that€there€are€a€number€of€AIDS€vaccine€evaluation€groups€alreadyÏin€place€that€are€focusing€on€behavioral€and€ethical€issues.€ÌÌDr.€Levine€praised€Dr.€Nabel€for€his€presentation€and€said€she€was€pleased€that€the€VRCððsÏmission€statement€makes€it€clear€that€an€AIDS€vaccine€is€its€top€priority.€She€asked€Dr.€NabelÏwhat€the€œCenterððs›€budget€is,€what€mechanisms€are€available€to€deal€with€liability€issues,€and€howÏthe€œCenter›€will€bring€in€other€Federal€agencies€to€assist€in€the€vaccine€effort.ÌÌDr.€Nabel€responded€that€the€VRCððs€budget€was€$16.5€million€last€year,€with€a€$2€millionÏsupplement€at€yearððs€end.€He€projects€next€yearððs€budget€to€be€approximately€$22€million€andÏhopes€to€reach€$30€million€within€3€or€4€years.€He€noted€that€the€NIH€leadership€has€beenÏextremely€supportive€of€the€VRC€and€said€œthat›€backing€is€critical.€Dr.€Levine€commented€thatÏ$30€million€seems€like€an€extremely€small€amount,€especially€if€it€includes€funding€of€clinicalÏtrials.€Dr.€Nabel€said€some€of€the€money€supporting€clinical€trials€will€come€from€the€VRC,€butÏthe€AIDS€Vaccine€Trials€Network€and€the€National€Institute€of€Allergy€and€Infectious€DiseasesÏ(NIAID)€will€provide€support€for€œlarge„scale›€trials.€He€acknowledged€that€the€VRCððs€costs€couldÏbe€higher€than€projected.€He€added€the€VRC€staff€is€just€beginning€to€explore€liability€issues€andÏthat€he€didnððt€have€any€answers€yet.€ÌÌMr.€Summers€said€ONAPððs€discussion€on€the€Pelosi€bill€will€lead€to€a€broader€discussion€ofÏliability€issues.€He€said€Dr.€Goosby€is€organizing€a€briefing€to€which€NIH€leaders€will€be€invited.ÏHe€œnoted€that€when›€the€President€made€his€remarks€at€the€opening€of€the€VRC,€he€made€it€clearÏthat€HIV€vaccine€research€is€a€priority€for€œthe€administration.›€That€statement€was€approved€byÏDr.€Varmus.ÌÌDr.€Nabel€said€he€was€very€pleased€with€the€Presidentððs€remarks€at€the€VRC€dedication,€but€œhe›Ïnoted€that€it€is€important€not€to€be€so€restrictive€that€the€œCenter›€fails€to€take€advantage€of€otherÏmodels€that€may€be€informative€for€HIV€or€to€extrapolate€lessons€from€HIV€to€other€viruses.ÌÌIn€response€to€Dr.€Levineððs€third€question,€Dr.€Nabel€said€an€interagency€group€is€already€in€placeÏto€facilitate€cross„agency€collaboration.€He€said€he€had€started€conversations€with€CDC€and€theÏU.S.€Army.€œÌÌMr.›€Summers€said€some€of€ONAPððs€discussions€with€the€World€Bank€have€touched€on€vaccineÏresearch€collaboration.€He€accompanied€Dr.€Nathanson€and€Bill€Paul€of€NIH€on€a€trip€to€œÐ   	 l+¼&*   ÐSt.›€Petersburg€and€Moscow,€Russia,€to€look€at€the€possibilities€for€collaboration€with€Russia.€TheÏgroup€discussed€Russiaððs€primate€research€capacity,€vaccine€production€capacity,€and€theÏpossibility€of€carrying€out€clinical€trials€cohorts€in€Russia.ÌÌMr.€Fogel€asked€Dr.€Nabel€what€it€would€take€to€make€quantities€for€vector€candidates€and€howÏlong€it€would€take€to€develop€the€capability€to€manufacture€vaccine€on€a€large€scale.€He€alsoÏasked€Dr.€Nabel€to€comment€on€whether€the€Federal€Government€ought€to€get€into€the€businessÏof€manufacturing€a€vaccine€and€who€would€own€an€AIDS€vaccine€that€was€discovered€at€theÏVRC.€ÌÌDr.€Nabel€said€his€experience€with€œpharmaceutical›€œcompanies›€has€been€that€when€they€see€thatÏsomething€is€likely€to€work,€they€get€excited.€It€is€a€difficult€problem€because€the€vaccine€needsÏto€be€distributed€to€the€greatest€number€of€people€and€therefore€needs€to€be€affordable.€But€as€oneÏdoes€this,€the€liability€risk€increases.€The€World€Bank€and€others€have€begun€discussing€ways€toÏestablish€a€buffer€liability€reserve€fund€or€to€support€poor€countries€to€allow€them€to€buy€vaccinesÏat€market€prices.€He€said€it€may€become€necessary€for€the€Government€to€manufacture€œlarge„¼scale›€vaccines,€but€the€research€is€not€close€to€that€point.€The€question€that€must€be€answeredÏnow€is:€Do€we€have€the€capability€to€make€enough€vaccine€to€carry€out€an€efficacy€trial?€If€such€aÏtrial€works,€industry€will€step€forward.€He€said€he€would€prefer€to€see€incentives€for€industry€putÏin€place€rather€than€see€Government€laboratories€engage€in€production.ÌÌRegarding€the€ownership€question,€Dr.€Nabel€said€an€AIDS€vaccine€would€be€handled€in€theÏsame€way€as€any€other€vaccine€discovered€at€NIH:€œIt›€is€intellectual€property€and€would€beÏlicensed€out€by€NIH€to€whichever€company€wanted€to€develop€it.ÌÌMr.€Fogel€asked€for€Dr.€Nabelððs€thoughts€on€licensing€a€vaccine€to€the€World€HealthÏOrganization€(WHO)€or€the€United€Nations€so€it€could€be€made€available€worldwide.€Dr.€NabelÏsaid€he€could€not€imagine€NIH€denying€the€vaccine€to€the€international€community.€ÌÌRabbi€Edelheit€emphasized€the€need€to€begin€ethical€conversations€now€about€issues€such€asÏownership,€testing,€pricing,€education,€and€the€use€of€primates.€He€asked€where€theseÏconversations€are€taking€place€and€who€is€engaging€in€them.€Dr.€Nabel€said€such€discussions€œare›Ïnot€œcurrently€taking›€place€at€the€VRC;€the€œCenter›€does€not€have€the€expertise€to€handle€them.€HeÏsaid€the€NIH€¢bioethics£€program€has€become€involved€in€these€issues.ÌÌMr.€Summers€said€the€Joint€United€Nations€Programme€on€AIDS€(UNAIDS)€has€been€engagingÏin€discussions€on€ethical€issues€related€to€vaccine€research,€and€ONAP€supports€theseÏdiscussions.ÌÌDr.€Bruce€Weniger€expressed€his€concern€that€the€composition€of€the€VRC€strategic€planningÏcommittee€did€not€include€people€with€career€vaccine€research€œand›€development€experience.€HeÏrecommended€that€at€least€half€of€any€external€committee€be€composed€of€scientists€with€careerÏvaccine€experience.€Dr.€Nabel€told€Dr.€Weniger€not€to€read€too€much€into€the€composition€of€theÐ   	 h+¸&*   Ðcommittee.€He€said€the€committee€was€assembled€on€short€notice,€and€many€scientists€withÏcareer€vaccine€experience€were€invited€but€declined€to€participate.€He€stressed€that€he€valuesÏthose€with€career€œexperience›€and€that€œcommitment€would›€be€evident€as€the€vaccine€researchÏeffort€moves€forward.ÌÌMr.€Fogel€suggested€that€those€participating€in€conversations€about€liability€not€forget€that€theÏultimate€impact€of€an€adverse€event€rests€with€the€consumer.€Dr.€Nabel€said€it€would€be€helpfulÏto€look€at€other€examples€of€product€liability,€such€as€cases€involving€automobile€air€bags,€toÏlearn€how€to€be€more€constructive.ÌÌÓ    ÓòòAppropriations€ReviewóóÐ   	 è8	
   ÐÌÓ   	’   ÓDr.€Hitt€reminded€the€Council€that€Ms.€Aragð;ðn€is€currently€drafting€a€letter€to€the€President€onÏthe€œcongressional›€appropriations€process.€The€Council€will€have€the€opportunity€to€approve€theÏletter€or€make€changes€to€it€on€Tuesday.€He€introduced€Mr.€Anderson,€who€gave€the€Council€anÏoverview€of€the€appropriations€process.ÌÌMr.€Anderson€distributed€an€appropriations€policy€update€drafted€by€the€National€Association€ofÏPeople€With€AIDS€(NAPWA).€He€said€this€yearððs€appropriations€process€has€been€extremelyÏhard€to€decipher€and€the€outcome€is€uncertain.€Currently,€the€Government€is€operating€under€a€œÌ3„week›€continuing€resolution,€which€holds€funding€at€FY€1999€levels.€The€White€House€andÏCongress€will€continue€to€debate€the€budget€over€the€next€few€weeks,€and€another€continuingÏresolution€may€be€necessary.ÌÌHe€summarized€several€key€HIV/AIDS€accounts€that€will€be€affected€by€the€appropriationsÏprocess:ÌÌòòDepartment€of€Labor„DHHS€Bill:óó€Committees€in€both€the€House€and€Senate€have€taken€action.Ð   	 ”ä   ÐIn€the€House,€the€œsubcommittee›€œaddressing›€Labor„DHHS€appropriations€has€completed€aÏmarkup.€The€Ryan€White€œAct›€and€NIH€received€more€money€than€the€President€requested,€butÏprevention€programs€and€the€Substance€Abuse€and€Mental€Health€Services€AdministrationÏ(SAMHSA)€were€flat„funded€from€the€previous€year,€and€the€Housing€Opportunities€for€PeopleÏWith€AIDS€(HOPWA)€program€was€œlevel€funded.›€œLevel€funding›€HOPWA€is€problematicÏbecause€it€will€translate€into€cuts€in€programs.€Approximately€10„12€new€cities€will€be€eligibleÏfor€HOPWA€funding€in€the€next€year,€so€if€HOPWA€is€œlevel€funded,›€existing€programs€will€needÏto€be€cut.€ÌÌOn€the€Senate€side,€the€full€appropriations€committee€reported€out€a€bill€on€a€unanimous€vote.ÏThe€numbers€are€much€better€than€on€the€House€side.€Prevention€received€a€$5€million€increase,Ïand€the€Ryan€White€œAct›€numbers€are€fairly€good.€NIH€received€a€13€percent€increase,€SAMHSAÏreceived€an€8€percent€increase,€and€HOPWA€received€a€$7€million€increase,€which€may€beÏenough€to€absorb€the€10„12€new€cities.€ÌÐ   	 l+¼&*   ÐœIt€is€the›€AIDS€communityððs€hope€œthat›€the€Labor„DHHS€bill€will€be€vetoed.€It€is€likely€to€beÏœvetoed€because›€the€President€opposes€œcertain€education€language€in€the€bill.›€ÌœÌòòWashington,€DC,›€Appropriations€Bill:óó€The€President€vetoed€this€bill.€It€included€strictÐ   	 tÄ   Ðlanguage€prohibiting€any€private€entity€receiving€Federal€funds€from€operating€a€needle€exchangeÏprogram.€The€bill€will€now€go€back€to€Congress€where€a€number€of€riders€will€be€renegotiated.€ItÏonly€passed€by€two€votes€in€the€House,€so€there€was€no€veto„proof€majority.ÌÌòòVeterans€Administration€(VA)„Department€of€Housing€and€Urban€Development€(HUD)Ð   	 d   ÐBill:óó€HOPWA€was€œlevel€funded›€in€the€House€version€and€received€a€$7€million€increase€in€theÐ   	  P	   ÐSenate€version.€There€are€strong€indications€that€this€bill€may€be€vetoed€as€well.€ÌÌòòInternational€Funding:óó€Last€week,€the€House€and€Senate€Foreign€Operations€Committees€metÐ   	 È   Ðin€conference€and€approved€an€increase€in€the€foreign€operations€budget€to€$190€million€forÏHIV/AIDS,€up€from€$125€million.€Mr.€Anderson€called€this€a€significant€increase.€The€SenateÏLabor„DHHS€language€includes€$35€million€to€fund€international€activities.ÌÌMr.€Anderson€said€it€is€likely€that€the€AIDS€community€will€see€final€language€that€includesÏmost€or€all€of€the€$100€million€international€initiative.ÌÌòòCBC€Initiative:€óóThis€initiative€was€not€included€in€any€of€the€appropriations€bills.€The€hope€isÐ   	 ,|   Ðthat€the€CBC€initiative€will€be€funded€as€part€of€the€veto€negotiations.€Last€year,€the€initiativeÏwas€funded€at€$156€million;€it€is€expected€to€jump€to€$349€million€this€year.ÌÌMr.€Anderson€œrecommended›€œthat€the›€Council€œsend€a€strong€letter€to›€the€President€thanking€himÏfor€the€œWashington,€DC,›€œappropriations›€œbill›€veto€and€urging€him€to€stand€firm€on€HIV/AIDSÏnumbers€in€all€œareas.›ÌÌòòQuestions/Comments:óó€Mr.€Summers€commented€that€the€possible€ð ð¢trainwreck£€scenarioððÐ   	 à   Ðregarding€the€budget€may€provide€an€opportunity€to€add€money€in€important€areas,€such€as€theÏHOPWA€program.€It€is€important€to€make€sure€that€strong€HIV/AIDS€advocates€are€part€of€theÏfinal€negotiation€process.ÌÌMs.€Cooper€reminded€the€Council€that€œthe€administration›€had€asked€for€$286€million€forÏHOPWA,€which€HUD€called€a€ð ðrounding€error.ðð€She€said€HRSA€has€come€to€realize€that€theyÏare€paying€for€$60€to€$80€million€worth€of€housing€through€the€Ryan€White€œAct›€and€areÏbecoming€more€restrictive€about€housing€funds.€That€money€accounts€for€25€percent€of€allÏhousing€available€to€persons€with€HIV/AIDS,€so€the€increase€the€HOPWA€program€received€isÏnot€acceptable€considering€œthat›€AIDS€housing€is€under€fire€from€HRSA.ÌÌMr.€Summers€said€the€HUD€budget€in€particular€has€come€under€fire€from€conservative€groups,Ïso€it€will€be€a€challenge€to€obtain€more€funding€for€HOPWA.€Mr.€Anderson€noted€that€HRSA€isÏalso€under€œcongressional›€pressure€for€spending€too€much€money€on€primary€care€and€housing.Ð   	 |+Ì&*   ÐÑ   üË  Ñâ
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 ÑÌCharles€Troupe€asked€how€the€CBC€initiative€would€be€put€on€the€table.€Mr.€Anderson€said€theÏveto€process€opens€up€a€number€of€funding€opportunities,€which€is€how€the€initiative€was€fundedÏlast€year.€Mr.€Summers€clarified€that€œthe€administration›€included€a€request€for€$171€million€forÏthe€CBC€initiative€in€the€FY€2000€budget.€Mr.€Anderson€added€that€last€yearððs€money€wasÏincluded€in€the€base€number,€so€only€the€increase€is€up€for€debate.€Mr.€Troupe€suggested€that€theÏCBC€initiative€be€made€a€line€item€in€the€budget€to€keep€it€on€the€table.ÌÌMr.€Robinson€said€the€Council€needs€to€express€strong€support€for€the€CBC€initiative,Ïparticularly€œbecause€the›€CBCððs€clout€has€diminished€over€the€last€year.ÌÌMr.€Milanes€asked€about€the€chances€of€securing€funding€for€a€Latino€initiative€in€this€yearððsÏbudget.€Mr.€Anderson€said€conversations€with€the€œCHC›€have€not€led€to€a€separate€LatinoÏinitiative.€The€understanding€is€that€the€CBC€initiative€will€be€expanded€to€include€otherÏcommunities€of€color.€ÌÌDr.€Aranda„Naranjo€asked€if€the€Councilððs€letter€to€the€President€on€appropriations€shouldÏinclude€strong€language€on€the€œCBC›€initiative.€Mr.€Robinson€said€yes,€language€on€CBC€shouldÏbe€included.€He€added€that€the€Council€needs€to€make€sure€œthat›€resources€are€used€effectively.ÏMr.€Troupe€said€the€money€should€track€the€need€and€experience€in€the€minority€community.€Mr.ÏSummers€said€the€CBC€funds€amount€to€a€small€percentage€of€the€Governmentððs€total€outlay€onÏHIV/AIDS.€The€funds€were€meant€to€prime€the€larger€system,€not€replace€it.ÌÌDr.€Hitt€reiterated€that€the€Council€needs€to€send€œa€letter›€œon€appropriations€to›€the€President.€PatsyÏFleming€requested€that€the€Council€include€language€in€the€letter€requesting€a€new€needleÏexchange€rider€in€the€œWashington,€DC,›€œappropriations›€œbill.›ÌÌMr.€Montoya€provided€some€background€information€on€the€afternoon€panel€presentation€onÏLatino€communities.€He€said€speakers€had€been€asked€to€address€ethnic€¢subpopulations£€withinÏthe€Latino€community,€overall€health€indicators,€education,€labor€and€migration€issues,€lack€ofÏinsurance,€and€substance€abuse.€He€said€the€presentation€is€timely€because€the€CongressionalÏHispanic€Health€Care€Task€Force€and€the€œCHC›€have€held€recent€hearings€and€discussions€onÏHIV/AIDS.€In€addition,€the€National€Association€of€Latino€Elected€and€Appointed€Officials€willÏhold€a€2„day€briefing€this€fall€for€œState›€legislators€on€HIV/AIDS€issues,€and€in€November€aÏLatino€Critical€Issues€Forum€will€be€held€at€the€U.S.€Conference€on€AIDS.€€ÌÌMr.€Montoya€said€Lucille€¢Roybal£„¢Allard£,€chair€of€the€œCHC,›€and€¢Ciro£€Rodriguez,€chair€of€theÏHispanic€Health€Care€Task€Force,€are€very€engaged€on€HIV/AIDS€and€hope€to€devise€a€strategyÏfor€a€Latino€HIV/AIDS€initiative€for€FY€2001.ÌÌDr.€Levine€asked€Mr.€Montoya€to€clarify€that€funding€for€Latino€communities€will€come€out€ofÏthe€CBC€funding.€Mr.€Montoya€said€he€was€not€certain€of€this,€but€the€original€CBC€languageÏincluded€all€communities€of€color.€Ð   	 h+¸&*   Ð‡Mr.€Troupe€said€the€Council€needs€to€make€sure€that€the€CBC€money€is€being€spent,€not€beingÏheld€by€DHHS.€Mr.€Montoya€said€Secretary€Shalala€would€address€the€CBC€money€in€herÏpresentation.€Mr.€Summers€said€last€yearððs€CBC€money€was€allocated€through€œset„asides›€forÏvarious€Federal€agencies;€it€is€not€one€block€of€money.€Some€of€the€money€has€been€œdistributed,›Ïbut€there€are€questions€about€the€way€some€of€the€funds€have€been€handled.€Because€it€is€a€newÏinitiative,€distribution€of€funds€has€been€delayed.€Questions€about€this€should€be€directed€to€œÌDr.›€Satcher€and€Secretary€Shalala.ÌÌDr.€Nilsa€Gutierrez€said€one€of€the€purposes€of€the€Latino€panel€presentation€is€to€ask€agencyÏdirectors€about€their€agenciesðð€commitment€to€allocating€a€certain€amount€of€money€towardÏminority€initiatives.€On€œTuesday,›€representatives€from€community„based€organizations€will€talkÏto€the€Racial€and€Ethnic€Populations€Subcommittee€about€what€has€transpired€with€the€CBCÏfunding.€ÌÌMr.€Summers€said€Council€members€should€ask€presenters€on€the€Latino€panel€to€address€howÏthe€CBC€money€is€being€œdistributed›€and€how€the€agencies€are€addressing€minority€communitiesÏholistically.ÌÌÌÓ    ÓòòMonday,€October€4,€1999Ð   	 4„   ÐAfternoon€General€SessionóóÐ   	  p   ÐÓ   „·   ÓÌÓ    ÓòòFull€Council€PresentationÐ   	 øH   ÐSevere€and€Ongoing€HIV/AIDS€Health€Care€Crisis€in€Latino€CommunitiesóóÐ   	 ä4   ÐÌÓ   ¸   ÓDr.€Gutierrez€introduced€the€panel€by€describing€the€goals€of€the€presentation€as€identified€by€theÏRacial€and€Ethnic€Populations€Subcommittee.€She€said€the€subcommittee€wanted€the€Council€toÏbetter€understand€the€nature€of€Latino€subpopulations€in€the€United€States,€what€Latinosðð€nationalÏroots€are,€how€those€roots€affect€health€status€and€access€to€care,€œthe›€problems€œof€uninsured›€andÏundocumented€individuals€in€the€Latino€population,€and€the€impact€of€HIV€on€Latinos.ÌÌShe€introduced€Dr.€David€Satcher€and€said€his€presence€at€the€Council€meeting€sends€a€strongÏmessage€about€his€commitment€to€Latino€peoples€in€the€United€States.€ÌÌÓ    ÓòòDr.€David€SatcherÐ   	 $X"   ÐAssistant€Secretary€for€Health€and€U.S.€Surgeon€GeneralÌDepartment€of€Health€and€Human€Services€óóÐ   	 à%0!$   ÐÓ   1»   ÓÌDr.€Satcher€thanked€Council€members€and€Ms.€Thurman€for€their€leadership€in€calling€attentionÏto€the€HIV€epidemic€and€HIVððs€impact€on€communities€of€color€in€particular.€He€said€œtheÏadministration›€is€committed€to€fighting€the€HIV€pandemic€and€said€he€looked€forward€toÏstrengthening€œthe€administrationððs›€relationship€with€the€Council€in€enhancing€community„basedÏHIV€prevention,€care,€and€services€in€Latino€communities.€Ð   	 h+¸&*   Ð‡Dr.€Satcher€emphasized€that€he€does€not€always€speak€for€œthe€administration›€or€Congress€in€hisÏposition€as€the€Surgeon€General.€ÌÌHe€pointed€out€that€Latinos€are€disproportionately€affected€by€HIV/AIDS.€It€is€increasingly€anÏepidemic€of€people€of€color,€women,€and€œthe›€young.€One€out€of€two€new€infections€occurs€inÏpeople€under€25€years€old.€According€to€the€CDC,€46€percent€of€AIDS€cases€reported€in€theÏLatino€community€occur€among€men€having€sex€with€men,€and€39€percent€of€Latino€cases€occurÏamong€injecting€drug€users.€Among€Hispanic€women€with€AIDS,€52€percent€of€cases€are€due€toÏheterosexual€transmission,€and€44€percent€are€due€to€injecting€drug€use.€There€is€a€growing€trendÏof€women€becoming€infected€with€HIV€through€a€sexual€partner€who€is€using€injection€drugs.ÌÌAnother€area€of€concern€is€the€growing€number€of€Latinos€who€are€incarcerated.€Dr.€Satcher€saidÏthe€issue€of€prison€health€is€one€of€his€priorities,€and€there€is€a€lot€of€work€to€do€in€improvingÏHIV€prevention,€treatment,€and€care€in€prisons.ÌÌHe€emphasized€that€the€HIV€epidemic€is€most€virulent€when€it€is€ignored€by€leaders.€WhenÏleaders€do€not€acknowledge€HIV€is€a€problem,€people€suffer.€For€example,€Uganda€and€SenegalÏhave€been€much€more€successful€in€dealing€with€HIV€than€other€African€nations€because€leadersÏspoke€out€early.€€Leadership€is€also€needed€in€the€United€States.€ÌÌDr.€Satcher€said€people€disagree€about€which€cultural€approaches€to€use€in€communities€of€color.ÏHe€does€not€approach€HIV€from€the€standpoint€of€being€black€but€from€a€public€healthÏstandpoint.€He€said€the€church€is€an€important€institution€in€dealing€with€HIV,€whether€it€is€theÏwhite,€black,€or€Latino€church.€He€said€his€position€is€not€based€on€any€single€culture€but€onÏleadersðð€responsibility€to€protect€the€peopleððs€health.€ÌÌDr.€Satcher€said€he€recently€testified€before€the€œCHC›€on€HIV€in€Latino€communities€andÏœcontributed,€along€with›€Congresswoman€œRoybal„Allard,›€œto›€a€video€on€HIV/AIDS€and€œLatinosÏproduced€by›€the€National€Minority€AIDS€Council€and€NIH.€He€said€œthe€administration›€needs€toÏincrease€the€pool€of€leaders€who€are€talking€about€the€epidemic€and€reach€out€to€populations€whoÏhave€not€been€reached€before.€ÌÌLast€week,€Representative€Ciro€Rodriguez€and€a€coalition€of€Latino€AIDS€groups€called€for€aÏstate€of€emergency€in€recognition€of€the€disproportionate€impact€of€HIV€œon›€the€œNationððs›€LatinoÏpopulations.€Dr.€Satcher€said€he€would€be€looking€at€that€proposal€and€the€recommendations€ofÏthe€œCHC›€in€developing€effective€programs€in€the€Latino€community.€One€example€of€such€aÏprogram€is€the€crisis€response€œteam€initiative,›€which€œis›€active€in€several€communitiesÌÌIn€February€1998,€President€Clinton€announced€œthe€administrationððs›€commitment€to€work€towardÏeliminating€health€disparities.€This€is€one€of€two€goals€of€œòòHealthy›€People€œ2010.€óóDHHS›€will€focusÐ   	 ¤(ô#'   Ðon€six€areas€to€reach€this€goal:€cancer,€infant€mortality,€cardiovascular€disease,€childhood€andÏadult€immunization,€diabetes,€and€HIV/AIDS.€Last€week,€CDC€announced€the€funding€of€32Ïcommunities€in€the€initial€round€œof›€the€œñÜ4ñReaching€for€Excellence€in€Adolescent€CñÜ4ññ Ý4ññÜ4ñA4rñÜ4ññÝ4ññÞ4ñañÞ4ññ ß4ññÞ4ñ5eñÞ4ññß4ññà4ñre€and€HealthÐ   	 h+¸&*   Ðñà4ññÚ4ñ(ñÚ4ñREACHñÛ4ñ)ñÛ4ñ›€œñ á4ñPñá4ññâ4ñpñâ4ñroject.›€The€project€will€emphasize€eliminating€disparities€in€one€or€two€of€the€sixÏfocus€areas.€ÌœÌThe€administration›€is€also€working€with€the€œCongressional›€Latino€Health€Task€Force€to€buildÏbetter€partnerships.€The€CBC€initiative€will€be€expanded€to€include€Latino€and€other€minorityÏcommunities€to€enhance€community„based€HIV€prevention€services,€capacity„building€assistanceÏprograms,€and€curriculum€development€and€training€programs.€Dr.€Satcher€said€LatinoÏcommunities€will€be€directly€affected€by€the€32€grants€announced€by€the€CDC;€his€staff€canÏprovide€a€list€of€these€communities.€About€$1€million€in€targeted€funds€was€directed€to€developÏinnovative€service€delivery€models€for€HIV/AIDS€through€community€health€centers.€MinorityÏpopulations€rely€on€these€centers€as€a€source€of€primary€care.€Approximately€44.3€millionÏAmericans€are€uninsured,€and€Hispanics€are€the€group€most€likely€to€be€uninsured,€at€a€rate€of€34Ïto€35€percent.€ÌÌAbout€$3€million€was€directed€to€Title€III€planning€grants,€which€go€to€community€health€centersÏor€new€entities€that€are€linked€to€community€health€centers€with€HIV€primary€care€and€services.ÏThese€grants€will€reach€African€American€and€Hispanic€populations€who€need€services.€ÌÌœDr.›€Satcher€said€he€has€œalso€launched›€a€new€project€to€work€with€minority€leaders€to€helpÏovercome€the€stigma€of€AIDS€in€communities€of€color.€This€initiative,€formerly€called€ProjectÏLEAD,€has€been€renamed€the€Leadership€Campaign€on€AIDS.€ÌÌAccess€to€care€is€a€real€problem.€When€DHHS€launched€the€Child€Health€Insurance€ProgramÏ(CHIP),€it€became€clear€that€many€Latinos€were€afraid€to€come€forward€and€receive€benefitsÏbecause€they€were€afraid€of€repercussions€from€œthe›€INS.€œThe€INS›€has€made€it€clear€that€enrollingÏa€child€in€CHIP€or€Medicaid€will€not€result€in€any€penalty€against€families€seeking€citizenship.ÏThis€is€one€example€of€a€barrier€to€access.ÌÌIt€is€critical€to€note€that€disparities€also€exist€in€access€to€HIV€care€among€Latinos€whenÏcompared€œwith›€whites.€The€HIV€Care€and€Service€Utilization€Survey,€funded€by€DHHS,€foundÏthat€Latinos€learn€of€their€HIV€status€later€in€the€course€of€their€disease€and€are€referred€for€careÏmuch€later.€The€study€also€found€that€Latinos€are€slower€to€receive€antiretroviral€therapies€onceÏthey€are€in€care.€œThe€administration›€is€working€with€States€to€develop€opportunities€to€expandÏinsurance€coverage€through€Medicaid€waivers€for€people€living€with€HIV/AIDS,€but€insuranceÏdoes€not€guarantee€access.€Finding€culturally€competent€care€can€be€a€major€barrier.€There€is€aÏshortage€of€health€care€professionals€who€can€provide€care€and€counseling€to€the€LatinoÏœpopulation€and,›€as€a€result,€there€is€a€shortage€of€Latino€involvement€in€research.€This€translatesÏinto€populations€not€œbenefiting›€to€the€fullest€extent€from€recent€advances€in€prevention€andÏtreatment.ÌÌDr.€Satcher€noted€that€those€outside€the€Latino€community€must€be€willing€to€recognize€that€thereÏis€diversity€within€Hispanic€communities.€There€is€a€rich€social€texture€that€guides€behaviors,Ïbeliefs,€lifestyles,€and€responses.€He€said€he€started€his€career€developing€a€primary€care€center€inÐ   	 h+¸&*   Ðsouth€central€Los€Angeles.€When€he€wrote€the€proposal€for€the€center,€the€patient€population€wasÏ13€percent€Hispanic,€and€by€the€time€he€left,€the€population€was€60€percent€Hispanic.€In€thatÏcontext,€providing€quality,€culturally€appropriate€health€care€services€is€a€major€challenge€in€thisÏcountry.€Other€challenges€include€communication€and€language€barriers€and€traditional€genderÏroles€that€inhibit€open€discussion€about€sex,€HIV/AIDS,€and€drug€use.ÌÌIn€conclusion,€Dr.€Satcher€said€the€white,€African€American,€and€Latino€communities€faceÏcommon€challenges€despite€their€cultural€differences.€Leaders€must€educate,€motivate,€andÏmobilize€their€communities€around€effective€prevention€strategies.€He€quoted€œformer›€SurgeonÏGeneral€Leonard€œSheely,›€who€said€in€1948,€ð ðThe€world€cannot€exist€half€healthy€and€half€sick.ððÏThis€is€true€for€our€nation€and€communities€as€well.€ÌÌWhen€Dr.€Satcher€spoke€at€the€University€of€Texas„El€Paso€commencement€in€December€1998,Ïhe€quoted€his€son:€ð ðWe€are€one€community.ðð€He€emphasized€that€we€are€one€community€despiteÏall€of€our€struggles€and€differences.ÌÌòòÓ    ÓDr.€Jane€DelgadoÐ   	 pÀ   ÐExecutive€DirectorÌNational€Coalition€of€Hispanic€Health€and€Human€Services€Organizations€(COSSMHO)óóÐ   	 H˜   ÐÓ   „Û   ÓÌDr.€Jane€Delgado€noted€that€her€assignment€was€to€ð ðprovide€a€demographic€overview€of€LatinoÏcommunities,€including€insight€on€health€indicators,€the€impact€of€the€lack€of€health€insurance€onÏmorbidity€and€mortality,€education,€labor,€migration,€immigration€issues,€and€particularities€ofÏundocumented€persons.ðð€She€said€COSSMHO€is€unique€in€three€ways:€(1)€It€supports€the€ideaÏthat€the€diversity€of€any€community€is€its€strength,€(2)€It€is€committed€to€funding€local€programs,Ïand€(3)€It€accepts€no€alcohol€or€tobacco€funding.ÌÌBy€the€year€2000,€COSSMHO€estimates€that€25€percent€of€the€U.S.€population€will€be€HispanicÏor€black€(this€figure€includes€population€data€from€Puerto€Rico).€Dr.€Delgado€noted€that€this€is€anÏimportant€number;€it€is€changing€the€dynamics€of€many€œconversations›€because€it€is€no€longer€aÏsmall€number.€As€of€July€1999,€the€number€of€Hispanic€children€was€only€exceeded€by€theÏnumber€of€non„Hispanic€white€children.€Half€of€the€Hispanic€population€lives€in€California€andÏTexas,€and€in€New€Mexico,€Hispanics€make€up€40€percent€of€the€population.€ÌÌDescribing€the€demographics€of€various€Hispanic€population€groups,€she€said€MexicanÏAmericans€are€the€largest€group,€followed€by€Puerto€Ricans.€Median€household€income€dataÏshow€that€all€Hispanic€groups€make€less€money€than€non„Hispanic€whites€(data€do€not€includeÏPuerto€Rico).€For€the€last€25€to€30€years,€Hispanics€œhave€had›€the€highest€high€school€dropout€rateÏof€any€group.€ÌÌDr.€Delgado€summarized€several€access€indicators€for€Hispanics.€Hispanics€are€the€group€leastÏlikely€to€be€insured€because€they€work€at€jobs€that€do€not€provide€insurance€or€make€just€enoughÏmoney€to€be€disqualified€for€public€health€insurance.€Hispanics€are€also€the€group€most€likely€toÐ   	 h+¸&*   Ðhave€no€usual€source€of€care.€Hispanic€representation€in€the€health€care€professions€œisÏconcentrated›€among€social€workers€and€dietitians.€Less€than€14€percent€of€managers€in€medicineÏand€health€are€black€or€Hispanic.€Only€3.9€percent€of€full„time€U.S.€medical€faculty€are€membersÏof€minority€groups,€according€to€the€Association€of€American€Medical€Schools.€These€data€factorÏin€the€three€medical€schools€in€Puerto€Rico€and€medical€schools€œat€historically›€black€colleges.ÌÌA€1993€œJournal›€of€the€American€Medical€Association€study€showed€that,€after€controlling€forÏethnicity,€patient€status,€primary€language,€insurance€status,€and€other€covariates,€HispanicÏethnicity€is€a€strong€predictor€of€no€analgesic.€This€is€not€surprising;€researchers€have€found€thatÏwomen€do€not€get€the€care€they€want,€and€even€white€men€say€they€are€not€getting€the€care€theyÏneed.ÌÌThe€good€news€for€Hispanics€is€that€they€live€longer€than€non„Hispanic€whites.€Hispanic€infantÏmortality€rates,€even€in€the€low€income€Puerto€Rican€community,€are€not€as€high€as€the€blackÏcommunityððs,€and€Hispanics€have€less€heart€disease€than€other€minority€groups.€HypertensionÏrates€for€Mexican€Americans€are€the€same€as€for€non„Hispanic€whites€or€blacks.€High€cholesterolÏlevels€are€prevalent€among€one„third€of€Mexican€American€males,€and€undiagnosed€diabetesÏoccurs€among€12€percent€of€Puerto€Ricans.€There€is€also€a€high€incidence€of€cervical€cancerÏamong€Hispanic€women.ÌÌœFor€HIV/AIDS,›€men€having€sex€with€men€is€the€major€mode€of€transmission€among€Hispanics,Ïwith€the€exception€of€the€Puerto€Rican€community.€€Illicit€drug€use€is€higher€among€MexicanÏAmericans€and€Puerto€œRicans›€than€it€is€among€Cubans€and€Central€and€South€Americans.€ManyÏof€the€latter€group€are€immigrants,€and€immigrants€tend€to€œhave›€better€health€outcomes€than€U.S.„¼born€persons.€Mexican€Americans€and€Puerto€œRicans›€have€higher€rates€of€heavy€alcohol€use€thanÏother€subpopulations.€Hispanic€girls€also€have€the€highest€number€of€suicide€attempts€of€anyÏgroup.ÌÌIn€her€concluding€remarks,€Dr.€Delgado€quotedòò€Healthy€People€2010,óó€which€says€ð ðRecentÐ   	 €Ð   Ðresearch€indicates€that€the€preventive€approaches€that€hold€the€greatest€promise€are€community„¼based,€community„wide,€and€focus€on€both€individual€behavior€and€societal€influences.ðð€SheÏrecommended€that€public€health€professionals€speak€the€language€of€targeted€audiences,Ïconstantly€perform€needs€assessments,€be€accessible,€build€trust,€and€support€change,€policy,€andÏmedia€efforts.€Solutions€should€focus€on€local€funding,€aggressive€programs€to€educate€youth,Ïand€supporting€community„based€organizations.€ÌÌÓ    ÓòòDr.€Earl€FoxÐ   	 à%0!$   ÐœAdministrator€[?]›ÌHealth€Resources€and€Services€Administration€(HRSA)óóÐ   	 ¸'#&   ÐÓ   í   ÓÌDr.€Fox€said€HRSA€has€adopted€a€goal€of€100€percent€access€and€œ0›€percent€disparities.€UniversalÏinsurance€coverage€is€needed,€but€that€doesnððt€guarantee€access,€so€there€is€still€a€lot€to€do.€ÏHRSA€established€an€HIV/AIDS€bureau€in€1997,€and€the€majority€of€people€hired€for€leadershipÐ   	 h+¸&*   Ðpositions€in€the€bureau€have€been€black€or€Hispanic.€The€agency€will€continue€this€hiring€pattern.ÏAbout€60€percent€of€people€served€by€the€Ryan€White€œAct›€are€minorities,€and€20€percent€of€theseÏindividuals€are€Hispanic.€€One€problem€HRSA€faces€is€in€gathering€accurate€data€on€minorities;Ïthere€are€often€duplicated€counts.€HRSA€funded€six€sentinel€œsites›€and€spent€a€lot€of€money€tryingÏto€collect€data€from€those€sites.€These€data€are€being€extrapolated€nationally.ÌÌIn€1998,€Latinos€represented€about€13€percent€of€the€U.S.€population€and€accounted€for€œÌ20›€percent€of€AIDS€cases.€The€rate€of€AIDS€in€the€Latino€population€is€four€times€that€of€whites.ÏOf€all€Latino€HIV/AIDS€cases,€68€percent€report€Spanish€as€their€primary€language.€HRSA€isÏtrying€to€develop€a€service€system€that€addresses€language€barriers.€ÌÌDr.€Fox€said€HRSA€continues€to€look€at€expanding€access€to€care,€reducing€barriers€to€care,Ïimproving€adherence€to€treatment,€improving€early€detection,€and€promoting€cultural€competencyÏamong€providers.€€Latinos€make€up€a€disproportionate€number€of€AIDS€cases,€and€HRSA€isÏserving€a€large€number€of€Latinos€through€the€Ryan€White€Act.€œTwenty„one€percent€of€servicesÏprovided€by€Title€I›€(emergency€relief€for€metropolitan€areas€in€1997)€and€Title€II€(grants€to€StatesÏin€œ1997)€of€the€Ryan€White€Act€were€delivered€to€Latinos,€as€were€23€percent€of€servicesÏprovided€by€Title›€III€(early€intervention€grants)€and€Title€IV€(services€to€women,€children,€andÏœfamilies)€of€the€Act.›ÌÌHRSA€is€examining€several€initiatives€to€improve€services€to€minorities.€Last€year,€the€board€ofÏhealth€initiative€received€an€additional€$4€million.€HRSA€continues€to€work€to€secure€additionalÏfunding€for€this€project.€The€agency€is€also€targeting€its€Title€III€planning€grants€to€communitiesÏof€color,€with€an€emphasis€on€community€health€centers.€HRSA€anticipates€funding€four€grantsÏunder€the€œSPNS€project.›€These€grants€will€address€detection€of€HIV€and€increased€access€œto€careÏon›€the€U.S.„Mexico€border.€The€agency€is€working€with€the€Environmental€Protection€AgencyÏ(EPA)€to€address€environmental€exposure€issues€on€the€border.ÌÌHRSAððs€Airbridge€òò[name?]óó€Project€is€aimed€at€providing€quality€medical€and€social€services€forÐ   	 €Ð   ÐHIV„positive€individuals€traveling€between€Puerto€Rico,€New€York,€and€Connecticut.€TheÏagency€œhas€allocated›€$200,000€for€this€project.€HRSA€is€also€changing€the€way€it€funds€its€AIDSÏEducation€Training€Centers;€the€agency€will€not€fund€activities€that€drug€companies€intend€toÏfund.€ÌÌHRSA€is€trying€to€improve€the€œnationððs€community„based›€provider€œcapacity›€and€is€working€withÏGeorge€Washington€University€to€develop€easily€translatable€purchasing€specifications€that€canÏbe€given€to€State€Medicaid€agencies.€Data€on€adherence€œare›€being€reviewed,€and€HRSA€isÏworking€with€the€Health€Care€Financing€œAdministration›€(HCFA)€to€make€the€system€seamless€atÏthe€community€level.€This€involves€collaborating€with€Medicare€and€Medicaid€to€reduceÏadministrative€barriers€and€streamline€the€application€process.€Dr.€Fox€said€he€and€severalÏcolleagues€are€launching€a€formal€working€group€with€SAMHSA€to€address€mental€health€andÏsubstance€abuse€issues€and€HIV/AIDS.€HRSA€and€HCFA€are€also€working€together€to€facilitateÏ1115€œwaivers.›Ð   	 l+¼&*   Ð‡Ó    ÓòòDr.€Helene€GayleÐ   	 °      ÐDirector,€National€Center€for€HIV,€STD,€and€TB€PreventionÌCenters€for€Disease€Control€and€PreventionÌÌóóÓ   fü   ÓDr.€Gayle€began€her€presentation€by€discussing€the€demographics€of€Latino€AIDS€cases.€LatinosÐ   	 `°   Ðrepresent€13€percent€of€the€U.S.€population€and€20€percent€of€AIDS€cases.€Latino€subpopulationsÏexhibit€different€risk€factors€and€different€cultural€issues.€The€majority€of€AIDS€cases€that€areÏcategorized€as€Hispanic€occur€in€individuals€born€in€the€United€States.€Individuals€born€in€PuertoÏRico€account€for€the€largest€proportion€of€AIDS€cases€œamong›€those€born€outside€the€UnitedÏStates.òò€óóAbout€78€percent€of€Hispanic€AIDS€cases€occur€in€men,€21€percent€occur€in€women,€andÐ   	 üL	   Ð1€percent€occur€in€children.€ÌÌWhen€examining€risk€factors€for€men,€it€is€clear€that€men€who€have€sex€with€men€is€the€leadingÏmode€of€transmission€for€AIDS€(60€percent€of€all€male€cases),€followed€by€injecting€drug€use€œÌ(22›€percent€of€all€male€cases).€For€Latino€men,€men€having€sex€with€men€is€also€the€leadingÏmode€of€transmission,€but€injecting€drug€use€plays€a€much€larger€role.€In€women,€39€percent€ofÏAIDS€cases€occur€through€heterosexual€contact,€and€43€percent€of€cases€occur€through€injectingÏdrug€use.€Among€Latino€women,€heterosexual€transmission€plays€a€much€larger€role.ÌÌOverall€AIDS€deaths€have€declined€over€the€past€œ2€years,›€but€AIDS€deaths€are€not€equallyÏdistributed.€Since€1996,€Hispanics€have€experienced€10€percent€less€of€a€decline€in€AIDS€deathsÏthan€have€whites.€ÌÌDr.€Gayle€said€CDC€needs€to€continue€to€track€the€HIV/AIDS€epidemic€as€well€as€track€howÏHIV/AIDS€funding€is€allocated.€The€agency€needs€to€look€at€the€benefits€of€direct€funding€ofÏcommunity„based€organizations€versus€funding€of€health€departments.€About€$21€million€of€theÏCBC€funding€œwas€distributed€to€communities›€of€color€other€than€the€African€AmericanÏcommunity.€Of€that€amount,€about€30€percent€was€distributed€to€Latino€organizations.ÏAnnouncements€of€exact€awards€are€forthcoming.ÌÌThe€CDC€is€working€to€promote€greater€access€to€HIV€testing€services,€encourage€betterÏcollection€of€data,€eliminate€perinatal€transmission€of€HIV,€develop€better€HIV€prevention€andÏcare€programs€in€prisons,€and€secure€funding€for€major€international€initiatives.€As€the€lineÏbetween€HIV€prevention€and€care€becomes€increasingly€blurred,€it€is€incumbent€on€CDC€to€workÏwith€its€sister€agencies€(HRSA,€SAMHSA,€NIH)€to€eliminate€duplication€and€coordinate€efforts.€ÌòòÌÓ    ÓDr.€Joseph€AutryÌDeputy€AdministratorÌSubstance€Abuse€and€Mental€Health€Services€AdministrationÌóóÓ   Y  ÓÌDr.€Autry€began€his€talk€by€stating€that€data€œare›€œessential›€but€œare›€not€sufficient.€The€AIDSÏepidemic€is€a€changing€epidemic,€and€it€is€a€political€one€because€sex€and€drugs€are€at€the€root€ofÏit.€HIV/AIDS€is€a€growing€area€of€interest€for€SAMHSA,€and€it€is€working€with€other€FederalÐ   	 l+¼&*   Ðagencies€to€make€an€impact€on€the€disease.€Because€HIV€is€increasingly€spread€by€heterosexualÏactivity€and€injection€drug€use,€it€is€important€that€SAMHSA€become€more€involved.ÌÌThe€agency€already€has€several€programs€in€place€that€address€HIV/AIDS.€The€KnowledgeÏDevelopment€Application€Program€focuses€on€generating€new€knowledge€œthat€targets›€particularÏpopulations€and€œimplements›€best€practices,€while€the€Targeted€Capacity€Expansion€Program€aimsÏto€meet€unmet€needs€at€the€local€level.€The€Substance€Abuse€Block€Grant€set„aside€requiresÏStates€with€more€than€10€AIDS€cases€per€100,000€population€to€spend€from€2€to€5€percent€ofÏblock€grant€funds€on€HIV€early€intervention€services.€In€FY€1999,€26€States€fell€under€thisÏcategory,€and€HIV€service€expenditures€totaled€$54€million.€ÌÌHIV€treatment€services€in€the€Targeted€Capacity€Expansion€Program€are€funded€at€$16€billion,Ïthe€Community„Based€Substance€Abuse€and€HIV/AIDS€Program€is€funded€at€$7.5€billion,€GrantsÏto€Expand€Substance€Abuse€Treatment€are€funded€at€$2.5€billion,€and€the€Targeted€CapacityÏExpansion€Program€is€funded€at€$13.25€billion€œòò[note:€two€different€numbers€listed€for€thisÐ   	 ˜è   Ðprogram]óó.›Ð   	 ˆØ   ÐÌSAMHSA€is€currently€up€for€¢reauthorization£,€and€the€agency€has€requested€a€specific€authorizingÏactivity€allowing€allocation€of€money€from€the€block€grant€set„aside€for€screening€and€testing€forÏHIV,€tuberculosis,€sexually€transmitted€diseases,€hepatitis€C,€and€mental€disorders.€Dr.€AutryÏemphasized€that€substance€abuse€prevention€and€treatment€must€be€viewed€as€HIV€preventionÏmeasures.ÌÌòòPanel€Presentation€Questions/Comments:óó€Dr.€Levine€asked€Dr.€Gayle€if€CDC€has€broken€outÐ   	 ì<   Ðthe€data€for€AIDS€deaths€in€minority€women.€Dr.€Gayle€said€she€did€not€have€the€data€on€hand,Ïbut€CDC€could€provide€those€numbers.€She€said€AIDS€deaths€have€declined€for€all€race,€gender,Ïand€risk€categories.€ÌÌRabbi€Edelheit€asked€panel€members€what€they€are€doing€to€disseminate€the€science€on€needleÏexchange€and€support€local€needle€exchange€programs.€Dr.€Delgado€said€œthe€administrationððs›Ïposition€on€needle€exchange€is€an€example€of€a€decision€being€made€purely€on€a€political€basis.ÏShe€pointed€out€that€DHHS€wanted€to€support€needle€exchange.€Dr.€Autry€said€SAMHSA€hasÏtaken€an€active€stance€on€disseminating€the€research€knowledge,€but€œthe€administration›€made€aÏfunding€œdecisions,›€and€therefore€SAMHSA€encourages€local€communities€to€use€funds€fromÏother€œsources.›€ÌÌDr.€Gayle€said€the€decision€on€needle€exchange€was€a€painful€episode€in€DHHS€history,€but€theÏDepartment€is€committed€to€doing€what€is€legally€possible€to€support€needle€exchange.€DHHS€isÏplanning€to€issue€an€update€on€the€science€and€continues€to€fund€research€and€evaluation€onÏneedle€exchange.€Department€officials€have€not€retreated€from€the€issue€but€are€legally€prohibitedÏfrom€acting€on€it.ÌÌMr.€Lew€asked€Dr.€Autry€to€describe€specific€examples€of€community„based€SAMHSA€programsÐ   	 t+Ä&*   Ðtargeted€to€HIV€and€substance€abuse€among€Latinos.€Dr.€Autry€said€the€block€grant€set„asideÏmoney€is€used€for€early€assessment€and€referral€for€HIV€services€for€persons€receiving€substanceÏabuse€treatment.€Under€the€Knowledge€Development€Application€Program,€there€are€severalÏprojects€that€are€adapting€integrated€approaches€to€substance€abuse€and€HIV€screening€andÏtreatment.€SAMHSA€funded€a€series€of€grants€to€minority€communities€under€the€CBC€initiative,Ïand€the€Targeted€Capacity€Program€aims€to€develop€extra€treatment€capacity€so€that€there€areÏunits€set€up€specifically€to€deal€with€substance€abuse€and€HIV.€ÌÌMr.€Lew€asked€if€any€of€these€programs€specifically€target€Latino€populations.€Dr.€AutryÏanswered€yes.€Within€a€week,€SAMHSA€will€release€a€list€of€grants€awarded€in€the€last€year.ÌÌDr.€Gutierrez€asked€Dr.€Fox€to€comment€on€migrant€health€centers€and€the€methods€they€areÏusing€to€identify€HIV„positive€persons€through€testing€and€care.€Dr.€Fox€said€HRSA€is€hoping€toÏsecure€an€additional€$100€million€this€year€to€fund€migrant€health€centers.€The€agency€is€alsoÏexamining€Medicaid€reciprocity€for€migrants;€it€is€working€with€the€Milbank€Fund€and€theÏReform€States€Group€to€get€States€interested€in€such€a€program.€ÌÌDr.€Fox€pointed€out€that€Medicaid€spends€œ$4›€for€every€œ$1€HRSA›€spends€in€œAIDS€DrugÏAssistance€Program€(ADAP)›€funding.€œThe€limited›€œconstruction€of€Medicaid›€œcauses€problems€forÐ   	 H˜   ÐStates€with€drug€shortfalls.›€HRSA€is€working€with€several€Medicaid€consulting€firms€to€draw€upÏa€list€of€Medicaid€options€that€a€State€can€adopt€if€that€Stateððs€legislature€wants€to€expand€care€toÏHIV/AIDS„infected€populations.€ÌÌMr.€Troupe€asked€about€the€original€purpose€of€the€methadone€program.€Dr.€Autry€said€theÏprogram€aimed€to€provide€a€mechanism€for€medical€treatment€for€opiate€use.€He€said€it€is€aÏcomplicated€program€because€it€is€administered€by€both€DHHS€and€the€Drug€EnforcementÏAgency€œ(DEA),›€and€stringent€controls€have€been€imposed€on€it.€SAMHSA€hopes€to€move€theÏprogram€to€an€office„based€practice€approach.€Dr.€Gayle€stressed€that€American€society€does€notÏview€substance€abuse€as€the€disease€that€it€is;€it€is€seen€as€a€moral€failing€or€a€criminal€activity.€ItÏis€not€just€a€DHHS€issue,€it€is€a€national€issue€of€perception.€Mr.€Troupe€said€health€care€accessÏmust€be€expanded€for€drug€users,€regardless€of€the€politics.ÌÌDr.€Delgado€pointed€out€that€HRSA€and€SAMHSA€are€constantly€under€attack€because€they€dealÏwith€the€substance€abuse€population.€She€added€that€HCFA€needs€to€be€at€the€table€during€suchÏdiscussions.€Mr.€Montoya€stated€that€Mike€Hash€of€HCFA€was€œunable›€to€attend€the€CouncilÏmeeting,€but€that€does€not€mean€the€agency€is€not€committed€to€the€substance€abuse€orÏHIV/AIDS€issue.ÌÌMr.€Robinson€said€the€proposed€new€rules€for€methadone€treatment€must€be€examined.€He€saidÏthe€movement€toward€office„based€prescribing,€given€all€of€the€barriers,€is€not€an€achievableÏgoal.€Methadone€maintenance€is€another€avenue€of€getting€drug€users€into€the€system,€and€theÏhope€is€that€their€risk€for€HIV€œcan›€be€reduced.€He€urged€Council€members€to€read€the€proposedÏrulemaking€and€to€submit€œcomments.Ð   	 h+¸&*   Ð›‡Mr.€Robinson€asked€panel€members€to€describe€how€the€CBC€initiative€is€influencing€the€largerÏfunding€picture€for€HIV/AIDS€and€whether€funding€might€be€reallocated€to€where€œthe€infections›Ïare€or€œwhere€services›€are€needed.€Dr.€Gayle€said€most€of€CDCððs€money€flows€through€healthÏdepartments.€Health€departments€are€required€to€implement€a€community€planning€process€andÏallocate€dollars€proportionate€to€HIV/AIDS€data€on€risk€groups,€minorities,€and€other€factors.€ÌÌDr.€Autry€said€œStates›€receiving€œSAMHSA€block›€grant€funds€œmust€perform›€needs€assessments€toÏdetermine€where€the€money€should€be€directed.€Local€coalitions€are€assembled€to€work€withÏStates€to€assure€sustainability,€current€data€are€used€to€plan€for€the€next€budget€submission,€andÏdemographics€are€used€to€guide€policy€decisions.€ÌÌMr.€Fogel€expressed€dismay€at€Secretary€Shalalaððs€delay€in€disseminating€the€science€on€needleÏexchange.€He€asked€whether€the€Secretary€had€issued€any€directives€to€SAMHSA€to€becomeÏactively€involved€in€promoting€the€science€on€needle€exchange.€Dr.€Autry€said€SAMHSA€has€toÏbe€involved€in€the€issue€and€has€tried€to€refocus€itself€and€the€Secretary€on€the€fact€that€substanceÏabuse€prevention€and€treatment€œequal›€HIV€prevention.€Mr.€Fogel€œnoted€that€it€is€getting›€late€forÏmany€people.€Dr.€Gayle€said€she€would€update€the€Council€on€the€anticipated€DHHS€report€onÏneedle€exchange.ÌÌMr.€Milanes€asked€panel€members€to€describe€specific€steps€taken€to€address€theÏ¢underrepresentation£€of€Latinos€in€the€community€planning€process.€Dr.€Gayle€said€capacityÏdevelopment€grants€funded€through€the€704€and€CBC€initiatives€should€help€to€increaseÏrepresentation€of€Latinos€and€African€Americans.€CDC€has€also€become€more€stringent€inÏrequiring€that€funding€be€contingent€on€proportionate€representation.€She€said€CDC€has€seen€anÏincrease€in€representation€among€Latinos,€but€the€effectiveness€of€individuals€taking€part€in€theÏplanning€process€is€just€as€important€as€satisfying€the€numbers.€ÌÌDr.€Gutierrez€asked€Dr.€Gayle€to€provide€the€Council€with€numbers€showing€how€œcommunity›Ïplanning€group€membership€and€related€funding€have€changed,€as€well€as€a€State„by„StateÏdisparity€analysis.€Dr.€Gayle€said€she€would€provide€œthat›€information.ÌÌDr.€Levine€pleaded€with€panel€members€to€start€writing€letters€in€support€of€needle€exchange€toÏeducate€the€public€and€the€medical€community€about€the€science.€She€asked€whether€the€FederalÏGovernment€would€be€able€to€work€with€State„€or€locally€funded€drug€treatment€centers€to€pickÏup€individuals€who€want€to€get€off€the€streets.€She€noted€that€in€Los€Angeles€County,€there€isÏonly€one€residential€facility€for€drug„using€women€and€their€children,€which€means€that€womenÏmust€œoften€give›€up€their€children€to€enter€œtreatment€because€housing€is€not€available.›ÌÌDr.€Gayle€said€CDC€is€forbidden€to€spend€Federal€funds€on€anything€that€is€related€to€needleÏexchange.€DHHS€must€continue€to€push€for€more€of€œwhat€is›€already€available€in€the€realm€ofÏsubstance€abuse€treatment.€Dr.€Autry€added€that€several€new€SAMHSA€grants€are€paying€forÏassessment€and€referral€programs€that€are€attached€to€needle€exchange€programs.€As€knowledgeÏcomes€out€of€those€grants,€the€agency€will€disseminate€œthat€knowledge.›Ð   	 h+¸&*   Ð‡Ó    ÓòòTuesday,€October€5,€1999Ð   	 °      ÐMorning€General€Council€SessionÌÌóóÓ   --  ÓDr.€€Hitt€introduced€Dr.€Shalala€and€thanked€her€for€meeting€with€the€Executive€SubcommitteeÐ   	 tÄ   Ðand€making€her€staff€available€to€talk€to€Council€members.òòÐ   	 `°   ÐÓ   )   ÓÌDr.€Donna€ShalalaÌSecretary,€Department€of€Health€and€Human€Services€óóÐ   	 $t   ÐÌÓ   `.  ÓSecretary€Shalala€began€her€remarks€by€thanking€Dr.€Hitt€for€his€leadership€and€CouncilÏmembers€for€their€outstanding€work.€She€said€history€will€give€credit€not€only€to€AIDS€activistsÏbut€to€the€President,€Vice€President,€Ms.€Fleming,€Ms.€Thurman,€and€DHHS€staffers€who€keptÏpushing€on€HIV/AIDS€issues.€She€said€she€expected€Council€members€to€continue€to€hold€herÏfeet€to€the€fire.ÌÌThe€Secretary€said€she€would€address€the€Departmentððs€progress€on€five€or€six€issues€that€theÏCouncil€had€asked€to€be€updated€on.€She€said€DHHS€is€preparing€a€draft€strategic€plan€onÏHIV/AIDS.€œñÙ4ñMr.€ñÙ4ñThurm›€met€last€week€with€agency€œheads,€their›€œdeputies,›€and€œagency›€HIV/AIDSÏexperts.€The€group€is€working€on€a€written€document€that€will€guide€Federal€AIDS€activities€forÏthe€next€several€years.€The€Secretary€said€the€draft€document€should€be€ready€for€the€CouncilððsÏreview€by€later€this€fall,€and€the€final€document€should€be€ready€by€early€next€year.€ÌÌThe€plan€will€offer€principles€that€will€guide€Federal€HIV/AIDS€efforts,€including€prevention€andÏaccess€to€care,€elimination€of€racial€disparities,€research,€and€promoting€awareness€of€HIVÏ¢serostatus£.€Each€agency€will€continue€to€work€on€its€own€strategic€plan,€but€œeach€plan›€must€beÏconsistent€with€the€overall€DHHS€strategic€plan.€The€CDC,€for€example,€expects€to€set€specificÏtargets€that€set€a€course€to€decrease€the€number€of€new€infections€each€year€and€to€increase€theÏnumber€of€HIV„positive€persons€who€know€their€status.€HRSAððs€part€of€the€plan€will€call€for€Ïmoving€into€care€a€specific€percentage€of€the€300,000€people€who€know€their€status€but€are€not€inÏcare.ÌÌThe€strategic€plan€is€not€being€drawn€in€a€top„down€fashion;€every€piece€is€based€on€experiencesÏand€ideas€from€community€leaders.€It€will€be€very€specific€in€terms€of€targets€and€holding€DHHSÏaccountable€in€a€measurable€way.€The€Department€expects€to€set€the€bar€very€high€and€will€workÏwith€the€Council€and€community€leaders€to€clear€that€bar.ÌÌAddressing€access€to€care,€the€Secretary€said€DHHS€had€prepared€and€circulated€to€the€Council€aÏdetailed€summary€of€the€Departmentððs€activities€to€enhance€access€to€care€for€people€living€withÏHIV/AIDS.€An€updated€version€was€sent€to€the€Council€last€Thursday.€It€includes€a€discussion€ofÏthe€expansion€of€Title€III€of€the€Ryan€White€Act,€the€Departmentððs€efforts€to€improve€care€forÏuninsured€workers,€and€œthe€dispatch›€of€crisis€response€teams€in€major€urban€areas.€ÌÌSecretary€Shalala€œnoted€that,€on›€the€positive€side,€more€lives€are€being€saved€than€ever€before.Ð   	 h+¸&*   ÐToday€the€National€Center€on€Health€Statistics€is€releasing€a€new€report€showing€that€the€age„¼adjusted€death€rate€from€HIV€fell€another€21€percent€last€year,€for€a€2„year€decline€of€more€thanÏ70€percent.€Since€1987,€AIDS€has€fallen€from€the€number€one€killer€overall€to€number€16,€butÏthese€successes€are€not€shared€equally;€AIDS€is€still€the€number€one€killer€of€African€AmericanÏmen.€The€Department€wants€to€see€the€resources€follow€the€disease,€and€the€strategic€plan€willÏreflect€that.€ÌÌDHHS€is€spending€more€money€on€HIV€research€than€ever€œbefore,›€and€the€time€for€approvingÏnew€AIDS€drugs€is€shorter€than€ever€before.€There€is€more€rural€care,€more€primary€care,€andÏmore€treatment€than€ever€before.€œThe€administration›€will€not€be€satisfied€until€it€does€everythingÏpossible€to€prevent€HIV€or€until€everyone€who€needs€care€gets€it€early€enough.€ÌÌThe€Secretary€acknowledged€that€there€are€still€huge€gaps€in€treatment,€œin›€access€to€care,€and€œinÏresources›€but€said€she€is€proud€of€this€œadministrationððs›€record€on€AIDS€and€its€willingness€to€beÏcandid€on€what€remains€to€be€done.€œThe€administration›€has€increased€funds€for€AIDS„relatedÏprograms€by€more€than€90€percent€since€1993.€When€the€President€broke€ground€on€the€newÏVRC€at€NIH,€he€stated€that€finding€an€AIDS€vaccine€by€2007€œwill€be›€the€œCenterððs€top›€œpriority.›ÌÌœThe€administration›€is€also€investing€$100€million€in€research€to€find€a€female€¢microbicide£,€thanksÏto€Ms.€Flemingððs€advocacy.€The€Secretary€added€that€one€of€the€best€things€œthe€administration›Ïhad€done€in€recent€weeks€was€to€appoint€Tim€Westmoreland€as€director€of€the€MedicaidÏprogram.€She€gave€credit€to€Nancy€De€¢Parle£€and€Mike€Hash€for€supporting€Mr.€WestmorelandððsÏappointment.€ÌÌTinkering€with€the€Medicaid€law€is€not€ð ðon€the€agenda,ðð€but€DHHS€is€working€to€establish€1115Ïwaivers€to€expand€eligibility€to€people€with€HIV€who€are€not€yet€disabled.€This€will€be€a€topÏDHHS€priority€this€fall.€The€Maine€waiver€will€not€be€the€last€waiver;€a€number€of€States€areÏexpected€to€follow.€ÌÌThe€Secretary€pointed€out€that€the€President€and€Vice€President€œdesignated›€AIDS€œas›€one€of€theÏsix€areas€in€which€DHHS€œwill€work€to›€eliminate€racial€and€ethnic€disparities.€This€effort€is€partÏof€the€Presidentððs€overall€initiative€on€race.€For€the€first€time,€the€DHHS€òòHealthy€œPeople›óó€œòò2010óó›Ð   	 D!”   Ðgoals€will€not€have€separate€targets€for€minorities€and€for€whites.€This€is€a€high„risk€œmove,›Ïbecause€separate€targets€allowed€the€Department€to€measure€œhard„earned›€progress€in€minorityÏgroups€across€many€diseases.€As€DHHS€adds€additional€resources€in€the€six€areas,€the€goal€willÏbe€to€close€the€gaps€completely,€not€simply€to€measure€progress€within€separate€ethnic€groups.ÌÌTwo€weeks€ago,€the€Secretary€met€with€the€CBC€health€braintrust€and€told€them€DHHS€hasÏrequested€an€unprecedented€$4.2€billion€for€minority€health€overall€next€year.€The€Department€isÏalso€calling€on€Congress€to€expand€the€$156€million€CBC€initiative€to€$171€million€next€year.ÏShe€said€DHHS€intends€to€get€the€full€allocation€even€though€there€is€no€appropriations€bill.€TheÏCBC€funds€are€being€distributed€to€community€organizations€for€technical€assistance€and€theÏdevelopment€of€service€delivery€infrastructures.€DHHS€wants€to€help€community€organizations€atÐ   	 h+¸&*   Ðthe€front€end€so€they€have€the€expertise€to€respond€to€requests€for€proposals€and€administerÏgrants.€It€is€clear€that€the€Department€only€reaches€a€certain€percentage€of€sophisticatedÏorganizations€that€know€how€to€apply€for€funding.€Now,€œthe€administration›€is€reaching€out€toÏcommunity€organizations€to€try€to€broaden€participation€in€prevention€programs.€The€DepartmentÏis€making€an€effort€to€get€the€word€out€about€CBC€funds,€but€a€lot€more€technical€assistance€isÏneeded.€ÌÌDHHS€is€also€aware€of€the€need€to€focus€on€the€Hispanic€community.€Several€HispanicÏcommunity€organizations€received€funds€from€the€CBC€initiative€this€year,€including€the€NSTARÏòò[spell€out]óó€Human€Services€in€Los€Angeles,€California;€the€Hispanic€AIDS€Forum€in€New€YorkÐ   	 üL	   ÐCity;€the€Latino€American€Youth€Center€in€Washington,€DC;€the€Latino€Health€Institute€inÏMassachusetts;€and€the€University€of€Miami€in€Miami,€Florida.€The€second€round€of€funding€willÏtarget€new€community€organizations,€and€the€application€process€will€be€streamlined.ÌÌTo€accomplish€these€goals,€DHHS€needs€help€from€Congress.€The€budget€rules€require€thatÏDHHS€identify€cuts€for€every€new€spending€item,€but€the€Department€œwill€not›€ð ðrob€Peter€to€payÏPaul.ðð€Congressional€help€is€also€needed€on€drug€pricing.€The€Department€wants€to€work€withÏCongress€œand›€drug€companies€to€reduce€the€cost€of€AIDS€drugs€as€much€as€possible.€TheÏSecretary€said€Congress€needs€to€get€to€work€on€the€patientsðð€bill€of€rights,€the€Kennedy„JeffordsÏbill,€and€medical€privacy€legislation.€ÌÌWith€40,000€new€infections€occurring€each€year,€œthe€administration›€needs€to€take€a€new€look€atÏprevention.€CDC€has€established€a€working€group€to€review€funding€priorities€in€preventionÏprograms.€The€group€has€met€a€number€of€times€and€is€looking€at€process,€œat€funding›€gaps,€and€atÏmanagement.€CDC€is€exploring€broader€parameters€of€its€HIV€prevention€strategy€with€the€IOM.ÏThe€willingness€to€look€again€at€prevention€programs€should€be€seen€as€a€positive€step.€The€moreÏpeople€looking€at€these€programs,€the€better.ÌÌRegarding€œCDCððs›€œð ðKnow€Your€Statusðð›€campaign,€the€Secretary€said€œthe€administration›€wants€toÏconvey€the€message€that€ð ðknowing€your€status€can€save€your€life.ðð€The€President€has€requestedÏ$10€million€in€his€FY€2000€budget.€The€campaign€will€be€bold€and€imaginative€and€will€focus€onÏhigh„risk€populations.€While€Ryan€White€Act€funding€cannot€be€directed€to€the€campaign,€privateÏfunds€must€be€leveraged€to€expand€the€campaign.€The€Secretary€added€that€the€campaign€mustÏensure€that€people€who€learn€their€status€be€brought€into€the€health€care€system.ÌÌIn€her€concluding€comments,€the€Secretary€said€she€believes€that€the€œdecision„making›€processÏmust€be€conducted€from€the€bottom€up.€DHHS€for€the€first€time€has€convened€10€regionalÏmeetings€to€engage€consumers€and€providers€of€HIV€services.€Reports€from€these€meetings€areÏforthcoming.€All€agencies€will€read€the€regional€reports,€and€a€œfollowup›€strategy€will€beÏimplemented.€ÌÌShe€emphasized€that€DHHS,€the€Council,€and€community„based€organizations€are€part€of€oneÏteam.€œThe€administration›€has€made€progress€in€HIV/AIDS,€but€there€are€still€huge€gaps.€ThereÐ   	 l+¼&*   Ðwill€be€opportunities€over€the€next€year€to€fill€some€of€these€gaps,€but€most€importantly€there€isÏan€opportunity€to€set€a€course€so€that€the€next€œadministration›€has€a€very€clear€direction.€ÌÌòòQuestions/Comments:óó€Mr.€Robinson€commented€that€many€in€the€AIDS€community€feel€thatÐ   	 tÄ   Ðthe€Secretary€and€DHHS€have€ignored€or€avoided€efforts€to€promote€needle€exchange.€CouncilÏmembers€and€AIDS€advocates€have€received€numerous€assurances€from€the€Secretary€and€herÏstaff€that€DHHS€would€disseminate€the€science€on€needle€exchange,€yet€some€Council€membersÏhave€heard€that€these€efforts€have€been€deliberately€blocked.€He€asked€the€Secretary€theÏfollowing€questions:€Where€is€the€five„page€summary€on€needle€exchange€science€that€has€beenÏpromised€by€Mr.€Thurm€and€others?€Where€are€the€editorials€in€support€of€this€lifesavingÏintervention?€Where€have€you€been€when€needle€exchange€efforts€have€come€under€attack€fromÏthe€White€House€and€other€opponents?€When€was€the€last€time€Dr.€Varmus,€Dr.€œSatcher,›€or€anyÏother€DHHS€staff€member€visited€members€of€Congress€to€continue€the€effort€to€educate€themÏabout€the€value€of€this€intervention?€When€was€the€last€time€you€allowed€anything€about€needleÏexchange€to€be€distributed€on€CDC€letterhead?€Where€is€the€leadership?ÌÌSecretary€Shalala€said€DHHS€has€been€consistent€on€the€science€and€plans€to€issue€an€updatedÏreport€that€reinforces€the€conclusion€that€well€designed€needle€exchange€programs€can€reduce€theÏincidence€of€HIV€when€implemented€as€part€of€a€comprehensive€strategy€within€a€community.ÏDHHS€has€never€changed€that€position€and€has€testified€to€that€effect€at€œcongressional›€hearings.ÏShe€said€she€has€never€left€needle€exchange€out€of€her€discussions€with€members€of€CongressÏwhen€discussing€the€pieces€of€an€overall€prevention€strategy.€Dr.€Satcher€has€repeatedly€talkedÏabout€the€issue€as€he€has€traveled€œacross€the›€country.ÌÌThe€Secretary€said€she€would€check€about€Dr.€Varmus,€but€said€he€has€been€consistent€inÏrepeating€what€he€believes€is€the€science€on€needle€exchange.€In€every€community€she€hasÏvisited,€she€has€been€consistent€in€what€she€says€about€the€science.ÌÌDr.€Hitt€said€the€Council€has€heard€for€about€4€months€that€the€updated€report€on€the€science€willÏbe€released€within€weeks.€He€asked€the€Secretary€for€a€specific€date.€Dr.€Goosby€responded€thatÏthe€report€should€be€œmade€public›€within€2€weeks.€Secretary€Shalala€clarified€that€the€report€mayÏœbe€issued€in€the€form€of€a›€response€to€a€Congressional€inquiry.ÌÌDr.€Levine€commented€that€it€would€be€extremely€valuable€for€the€Secretary€to€œsend›€an€editorialÏon€needle€exchange€œto›€a€medical€journal.€Secretary€Shalala€said€she€had€done€that€initially€butÏwould€take€another€look€at€what€she€had€written.ÌÌMr.€Anderson€stated€that€SAMHSA€has€been€ð ðnearly€an€invisible€playerðð€in€HIV€prevention.ÏThis€is€especially€clear€in€the€lack€of€engagement€by€the€director€of€SAMHSA€on€HIV/AIDS.€HeÏsaid€members€of€the€AIDS€community€have€raised€the€issue€with€some€of€the€Secretaryððs€seniorÏstaff.€œÌÌThe›€Secretary€said€no€one€had€raised€the€issue€directly€with€her.€She€said€Dr.€Chavez€is€one€ofÐ   	 l+¼&*   Ðthe€few€people€in€the€country€who€supports€the€integration€œof€mental›€health,€substance€abuse,€andÏœHIV/AIDS€treatment.›ÌÌMr.€Anderson€said€there€has€been€a€complete€downgrading€of€AIDS€leadership€within€SAMHSA,Ïand€several€staffers€have€left€in€disgust€at€the€agencyððs€inability€to€follow€through€on€HIV/AIDSÏœinitiatives.›€He€asked€the€Secretary€to€assemble€an€external€panel€of€experts€to€review€SAMHSAððsÏrole€in€HIV€prevention€and€to€report€back€within€3€or€4€months€on€what€SAMHSA€can€andÏshould€be€doing.ÌÌThe€Secretary€said€she€would€take€a€look€at€the€recommendation€but€added€that€she€may€want€toÏaddress€the€integration€of€substance€abuse€and€HIV€services€as€part€of€the€strategic€planningÏprocess.€ÌÌReverend€Perez€said€the€Council€is€pleased€to€hear€œthat€the€strategic›€plan€œunder€development€atÏDHHS€will›€focus€on€prevention€issues.€She€said€the€Council€believes€that€an€aggressiveÏprevention€plan€could€and€would€reduce€new€infections€to€the€point€of€elimination.€She€said€theÏCouncil€expects€the€plan€to€include€real,€measurable€objectives€with€a€concrete€timetable€and€aÏconnection€to€job€performance€that€is€strong€enough€to€hold€anyone€accountable.ÌÌSecretary€Shalala€responded€that€the€plan€will€have€measurable€œgoals,›€and€œresources›€œtargeted€to›Ïracial€and€ethnic€minorities€will€be€included.€She€added€that€DHHS€is€prepared€to€hold€itselfÏaccountable€in€these€areas.ÌÌMr.€Isbell€stated€that€there€are€40,000€new€HIV€infections€each€year€and€asked€when€œthe€AIDS›Ïcommunity€can€expect€that€level€to€be€cut€in€half.€The€Secretary€said€DHHS€is€starting€toÏrecognize€where€the€infections€are€coming€from.€Programs€need€to€be€more€targeted,€moreÏcommunity„based,€and€more€accountable€in€terms€of€integration€in€order€to€reduce€the€number€ofÏnew€infections.€It€is€clear€that€HIV€services€must€be€integrated€with€housing,€substance€abuse,Ïand€mental€health€services.€ÌÌReverend€Perez€said€she€is€concerned€because€this€issue€is€not€new.€The€AIDS€community€hasÏbeen€advocating€for€integration€of€services€and€community„based€programs€for€at€least€10€years.ÏSecretary€Shalala€said€she€does€not€disagree€with€Reverend€Perezððs€concerns.€ÌÌMr.€Isbell€said€there€are€at€least€200,000€people€living€with€HIV€who€have€not€yet€beenÏdiagnosed,€and€there€are€at€least€300,000€HIV„infected€people€who€need€to€be€in€care€but€are€notÏcurrently€in€care.€He€asked€the€Secretary€whether€the€DHHS€strategy€will€identify€targets€toÏreduce€each€of€these€numbers€and€set€¢timelines£€to€achieve€these€targets.€The€œSecretary€urged›Ïœmembers€to€submit€comments€to€DHHS€if€the€draft›€strategic€plan€is€not€precise€enough€in€termsÏof€œtargets.›ÌÌReverend€Perez€reiterated€that€the€AIDS€community€has€waited€10€years€and€would€like€to€makeÏsure€that€the€first€draft€includes€specific€targets.€Secretary€Shalala€responded€that€this€is€œð ðfair›Ð   	 h+¸&*   Ðœenough.ðð›ÌÌMr.€Henderson€asked€the€Secretary€what€her€plan€is€to€encourage€State€submission€of€MedicaidÏwaiver€requests€and€expedite€their€review€and€approval.€Secretary€Shalala€responded€that€DHHSÏneeds€to€find€a€creative€way€to€develop€the€waiver€process€in€œa€revenue›€neutral€setting.€SheÏœcannot›€add€Medicaid€expenditures€as€part€of€the€waiver€process.€The€Department€needs€toÏapprove€two€or€three€ð ðquick€modelsðð€over€the€next€year,€which€States€can€use€to€submit€1115Ïwaivers.€She€said€it€is€her€experience€that€once€two€or€three€States€have€completed€the€process,Ïthe€rest€of€the€States€will€follow€using€those€models.€ÌÌMr.€Henderson€pointed€out€that€the€issue€of€budget€neutrality€has€been€the€major€stumbling€blockÏthroughout€the€process,€and€many€experts€have€noted€that€drug€pricing€must€be€addressed€first.€ÏThe€Secretary€said€the€Department€would€need€to€work€with€the€pharmaceutical€companies€onÏdrug€pricing;€earlier€intervention€is€needed,€and€that€requires€a€very€different€strategy€œto€addressÏdrug›€purchasing.ÌÌMr.€Henderson€asked€again€what€the€¢timeframe£€is€for€completion€of€the€process.€SecretaryÏShalala€said€she€could€not€answer€that€question€œat€present,›€but€she€will€get€the€answer.€œÌMr.›€Henderson€said€the€Council€is€frustrated€because€it€raised€the€issue€2€years€ago€when€œaccess›Ïto€care€guidelines€were€first€discussed.€The€Secretary€said€DHHS€has€made€enormous€progress,Ïbut€the€last€few€things€that€need€to€be€done€are€tough€to€carry€out€within€the€framework€of€theÏlaw.€The€best€œthe€administration›€can€do€is€to€get€the€most€talented€people€to€work€within€the€lawÏwithin€a€reasonable€¢timeframe£,€and€everything€needs€to€be€done€within€the€next€5€or€6€months.ÏThis€will€be€a€tremendous€push€for€DHHS€because€everything€needs€to€be€in€place€œbefore›€theÏtransition€to€the€next€œadministration›€œbegins.›ÌÌMr.€Henderson€asked€what€the€Secretary€intends€to€do€as€part€of€the€access€plan€to€extend€qualityÏHIV€care€to€persons€under€managed€care€programs.€ÌÌThe€Secretary€said€the€quality€issue€is€now€fundamental;€DHHS€has€spent€a€lot€of€time€trying€toÏextend€insurance€coverage€only€to€discover,€to€no€oneððs€surprise,€that€coverage€does€notÏguarantee€quality€health€care.€DHHS€is€pushing€the€quality€œmovement€to€develop›€measures€byÏwhich€the€Government€œeventually›€œcan€pay›€on€the€basis€of€quality€outcomes,œ€reach›€œa€consensus›€œon›Ïthose€measures,€and€œbuild€in›€requirements€for€all€managed€care€plans.€States€may€be€required€toÏtransfer€Medicaid€to€managed€care€so€that€States€œcan›€be€held€to€a€much€higher€standard€based€onÏquality€outcomes.€The€Department€has€also€encouraged€States€to€leave€the€disabled€outside€theÏmanaged€care€system,€particularly€in€cases€where€the€managed€care€system€is€new.€DHHS€mustÏdevelop€a€way€in€which€œquality€is€assured€in€all›€kinds€of€organized€œcare.›€This€is€the€only€way€toÏmanage€the€Federal€Governmentððs€health€care€expenditures€in€the€long€run.€The€Secretary€saidÏshe€has€a€completely€different€view€from€other€experts;€she€would€not€pursue€the€traditional€routeÏof€€ð ðbeating€on€the€industryðð€but€would€hold€them€accountable.ÌÌMr.€Troupe€asked€how,€in€the€black€community,€one€œcan›€have€quality€without€access.€TheÐ   	 h+¸&*   ÐSecretary€said€it€œis€necessary›€to€have€both.€She€stressed€that€ensuring€access€does€not€mean€thatÏseamless€services€are€guaranteed.€Mr.€Troupe€clarified€that€many€minority€communities€do€notÏhave€access€to€any€hospitals€or€health€care€facilities.€The€Secretary€said€œthe€administration›€hasÏpromoted€seamless€health€care€networks€by€providing€economic€incentives€to€communities€toÏjoin€community€health€centers,€public€hospitals,€private€hospitals,€and€academic€hospitals€in€oneÏnetwork.€These€networks€are€particularly€important€for€those€who€do€œnot›€have€access€to€MedicaidÏor€Medicare€but€do€have€access€to€an€entry„level€part€of€the€system.€This€requires€a€different€kindÏof€funding,€and€it€requires€communities€to€come€together€to€identify€where€the€gaps€are.€œTheÏadministration›€has€requested€an€initial€$25€œmillion,€which›€will€lead€to€a€$1€billion€commitmentÏover€the€next€3€to€4€œyears,›€to€assemble€these€integrated€networks.€ÌÌDr.€Hitt€asked€for€the€Secretaryððs€thoughts€on€how€to€achieve€the€15€percent€reduction€in€drugÏpricing€to€make€everything€revenue€neutral.€The€Secretary€emphasized€that€the€drug€pricing€issueÏis€œone›€that€affects€all€drugs,€not€just€AIDS€drugs.€œThe€administration›€must€deal€with€how€to€getÏdiscounted€drugs€across€the€board,€how€to€use€the€purchasing€power€of€the€Federal€Government,Ïand€how€to€achieve€fair€pricing€across€national€borders.€œThe€administration›€would€like€to€see€aÏpharmaceutical€benefit€this€year.€There€are€several€measures€in€Congress€that€would€allow€accessÏto€discounted€drugs€and€broader„based€purchasing€to€achieve€those€discounts.€The€Secretary€saidÏthe€goal€œshould›€be€more€than€15€œpercent;›€œthe€administration›€needs€to€straighten€out€drug€pricingÏin€general.€ÌÌDr.€Hitt€said€it€would€be€helpful€to€update€the€Council€and€the€public€on€drug€pricing€discussionsÏbeing€held€behind€the€scenes€and€in€Congress.€The€Secretary€said€DHHS€could€hold€a€briefing€onÏdrug€pricing.€Most€of€the€focus€is€on€long„term€and€chronic€diseases.€The€issue€œis€growing,›€and€itÏis€œbroad€based.›ÌÌReferring€to€the€Councilððs€panel€presentation€on€AIDS€in€Hispanic€communities€and€the€need€forÏbetter€coordination€of€agencies€in€communities€of€color,€Mr.€Lew€asked€the€Secretary€howÏDHHS€would€measure€its€implementation€of€the€CBC€initiative€to€support€communityÏinfrastructure€and€how€it€would€mobilize€its€own€infrastructure€and€resources€in€a€coordinatedÏapproach€to€communities€of€color.€The€Secretary€said€Council€members€would€be€able€to€tell€ifÏthe€CBC€initiative€is€making€an€impact;€the€interventions€will€be€very€measurable.€She€added€thatÏthere€are€many€organizations€that€need€to€participate€œbut€do€not›€have€an€adequate€infrastructure.ÏThese€organizations€need€ongoing€technical€assistance,€and€that€is€what€DHHS€intends€toÏœprovide.›ÌÌMr.€Lew€asked€the€Secretary€to€provide€examples€of€where€she€would€like€to€see€coordinationÏbetween€DHHS,€HRSA,€CDC,€and€SAMHSA€on€the€CBC€initiative.€She€said€coordination€Ïwould€be€led€by€Dr.€Satcher;€he€has€chosen€to€lead€the€initiative,€and€he€will€be€held€accountable.ÌÌMr.€Schatz€stated€his€disappointment€in€œthe€administrationððs›€lack€of€meaningful€action€onÏHIV/AIDS€during€his€4.5€years€on€the€Council.€He€cited€a€chronology€of€inaction€and€delay€onÏguidelines€for€HIV„positive€health€care€workers€and€asked€the€Secretary€to€provide€a€definitiveÐ   	 h+¸&*   Ðdate€for€release€of€the€guidelines.€The€Secretary€said€she€would€not€provide€a€date€because€DHHSÏhas€not€resolved€its€internal€debate€on€the€guidelines.€She€said€she€would€not€make€a€promise€sheÏcould€œnot›€keep.ÌÌDr.€Hitt€said€he€had€been€told€that€the€CDC€ethics€committee€had€signed€off€on€the€health€careÏguidelines,€and€they€would€be€forwarded€to€DHHS€within€œ1€to€2›€œweeks.›€Mr.€Thurm€told€Dr.€HittÏthat€DHHS€could€move€on€the€guidelines€within€days€once€they€reach€the€Secretaryððs€office.€œÌDr.›€Hitt€asked€the€Secretary€to€confirm€that€there€is€still€a€substantial€debate€going€on€at€DHHS.ÌShe€said€she€would€not€make€any€more€promises€on€the€guidelines€but€assured€the€Council€thatÏshe€would€not€delay€the€guidelines€once€the€pieces€are€in€place.€She€said€the€Council€should€beÏð ðvery€unsatisfiedðð€with€that€answer.ÌÌMr.€Blackwell€said€the€Councilððs€repeated€requests€for€statistics€and€reports€on€œHIV€and€Native›ÏœAmericans›€from€the€Indian€Health€Service€(IHS),€the€CDC,€and€other€agencies€have€beenÏignored.€In€April,€the€director€of€IHS€announced€œat€a›€top„level€staff€meeting€that€HIV/AIDS€isÏð ðnot€a€problem€in€Indian€country,€and€IHS€has€it€under€control.ðð€The€œIHS€director›€also€stated€thatÏvarious€people€were€ð ðemploying€manipulative€tactics€to€scare€Native€Americans€unnecessarily.ððÏMr.€Blackwell€stated€that€HIV€is€escalating€at€alarming€rates€on€Indian€reservations€and€œinÏAlaskan›€villages€and€asked€what€œactions€the€Secretary›€would€œtake€to›€address€the€IHS€directorððsÏnegative€attitude€and€œcomply›€with€the€Presidentððs€mandate€on€enhanced€tribal€services€and€tribalÏconsultation.€The€Secretary€said€she€needs€to€look€at€the€facts€that€Mr.€Blackwell€œpresented›€butÏœthat›€œthe€administration›€has€a€good€record€on€tribal€consultation.€IHS€will€receive€the€largestÏincrease€in€resources€this€year€in€the€history€of€IHS.€ÌÌMr.€Fogel€suggested€that€the€President€call€in€the€chairs€of€the€board€of€œpharmaceuticalÏcompanies›€and€ask€them€directly€for€a€discount€in€drug€prices.€He€went€on€to€state€hisÏdisappointment€and€dismay€at€the€Secretaryððs€lack€of€leadership€on€HIV/AIDS€and€theÏœsquandered›€opportunities€œto›€make€an€institutional€difference.€The€Secretary€said€she€was€happy€toÏhear€Mr.€Fogelððs€criticisms€and€stressed€that€it€is€important€for€the€Council€to€hold€herÏœaccountable.›€But€she€added€that€the€Council€needs€to€measure€how€far€œthe€administration›€hasÏcome€on€HIV/AIDS€since€1993.€She€said€DHHS€has€committed€to€a€bottom„up€process€and€hasÏconsulted€extensively€with€community„based€organizations.€She€acknowledged€that€œð ðthe›€finalÏœprogressðð›€has€yet€to€be€made,€and€œthe€administration›€is€willing€to€be€held€accountable€for€thatÏœprogress.›€œShe€said€no›€œadministration›€has€provided€more€leadership€to€get€more€resources€œonÏHIV/AIDS›€but€œadmitted€that€the€administration›€has€not€ð ðgone€all€the€way.ððÌÌMr.€Fogel€clarified€that€his€criticism€was€aimed€at€squandered€opportunities,€such€as€failure€toÏissue€the€health€care€worker€guidelines.€The€Secretary€said€she€was€willing€to€accept€thatÏcriticism.€Regarding€a€date€for€the€health€care€worker€guidelines,€she€said€she€was€not€willing€toÏlie€to€the€Council.ÌÌDr.€Aranda„Naranjo€concluded€the€œquestion„and„answer›€session€by€telling€the€Secretary€that€sheÏis€one€who€ð ðenduresðð€for€so€many€people€œwho€are€HIV„infected.›€The€Secretary€assured€theÐ   	 h+¸&*   ÐCouncil€that€she€and€œthe€administration›€would€ð ðnever€give€upðð€on€HIV/AIDS.ÌÌDr.€Hitt€thanked€the€Secretary€for€engaging€in€a€candid€discussion.€He€pointed€out€that€theÏCouncil€and€œthe€administration›€have€a€lot€riding€on€the€strategic€plan€œbeing›€developed€at€DHHS,Ïand€the€sooner€it€is€completed,€the€better.€The€Secretary€reiterated€that€the€plan€would€beÏcompleted€by€early€next€year.€ÌÌÓ    ÓòòTuesday,€October€5,€1999Ð   	 $t   ÐAfternoon€General€Council€SessionÌÌSubcommittee€ReportsÌóóÓ   ;“  ÓÌDr.€Hitt€began€the€afternoon€session€by€reviewing€œfive›€documents€œup€for€discussion€by€the€›ÏœCouncil:›€the€letter€to€Treasury€Secretary€Lawrence€Summers,€the€letter€stating€Council€membersððÏretirement€dates,€the€letter€from€Dr.€Hitt,€public€comment€from€the€Research€Subcommittee,€andÏthe€book€on€public€health.€Dr.€Hitt€also€praised€Ms.€Aragð;ðn€for€her€work€on€several€HIV/AIDSÏissues€in€California.ÌÌòòResearch€Subcommittee:óó€Ms.€Miramontes€asked€the€Council€for€its€approval€of€aÐ   	 H˜   ÐœSubcommittee›€resolution€in€support€of€H.R.€1274,€the€Lifesaving€Vaccine€Technology€Act.€TheÏCouncil€approved€the€resolution€on€a€unanimous€voice€vote.€Dr.€Hitt€noted€that€the€resolutionÏstates€that€the€Council€supports€ð ðthe€intentðð€of€the€œlegislation,›€in€case€the€wording€is€changed.€ÌÌMs.€Miramontes€asked€the€Council€to€approve€a€statement€of€public€comment€in€support€ofÏmaintaining€a€separate€study€section€and€expedited€process€for€HIV€at€NIH.€NIH€wants€to€spreadÏHIV€study€sections€across€its€Institutes€again.€The€Council€adopted€the€statement€on€a€unanimousÏvoice€vote.ÌÌòòRacial€and€Ethnic€Populations€Subcommittee:óó€Reverend€Perez€said€the€œSubcommittee›Ð   	 „Ô   Ðdiscussed€the€Latino€panel€presentation€and€concluded€that€it€did€not€adequately€inform€theÏCouncil€of€the€complexity€of€the€HIV€crisis€in€Latino€communities.€The€œSubcommittee›€will€writeÏletters€to€follow€up€with€the€œpanelists›€and€will€invite€the€œCHC›€and€other€groups€to€a€œsubsequent›ÏœSubcommittee›€meeting€to€discuss€how€the€Council€can€œsupport›€activities€œon€HIV€and€Latinos.›ÏThe€œSubcommittee›€will€also€prepare€a€summary€action€statement€on€proposed€next€steps€œas›Ïguidance€for€new€Council€members.€ÌÌThe€œSubcommittee›€would€like€to€organize€a€panel€presentation€on€HIV€and€Asian/PacificÏIslanders€and€will€bring€this€up€with€the€Executive€Subcommittee.€Reverend€Perez€said€there€is€aÏmovement€to€secure€$349€million€for€the€CBC€initiative€next€year.€She€suggested€that€theÏCouncil€send€a€letter€to€the€President€requesting€his€support€of€this€number€instead€of€œÌ$171.4›€million.€She€also€asked€that€the€œCouncil›€œcontinue›€the€œSubcommitteeððs€work›€after€currentÏmembers€have€retired.ÌÐ   	 p+À&*   ÐòòPrevention€Subcommittee:óó€Mr.€Robinson€said€the€œSubcommittee›€did€not€have€a€report€becauseÐ   	 °      Ðso€many€members€would€be€retiring€from€the€Council.€He€said€it€was€clear€from€the€SecretaryððsÏpresentation€that€prevention€still€has€not€received€priority€status€and€emphasized€that€the€CouncilÏmust€continue€to€press€the€issue.ÌÌòòInternational€Subcommittee:óó€Mr.€Anderson€reported€that€the€œSubcommittee›€discussed€theÐ   	 P	    Ðappropriations€process,€the€compulsory€licensing€agreement€with€South€Africa,€and€the€transitionÏprocess€as€new€Council€members€begin€their€terms.€The€œSubcommittee›€would€like€the€Council€toÏwrite€a€letter€to€the€U.S.€Trade€Representativeððs€office€prior€to€the€World€Trade€OrganizationÏ(¢WTO£)€Summit€in€November€regarding€the€U.S.€role€in€redrafting€any€¢WTO£€agreements€onÏcompulsory€licensing.€The€subcommittee€intends€to€invite€representatives€from€the€StateÏDepartment€and€USAID€to€present€testimony€at€the€Councilððs€February€meeting.€TheÏœSubcommittee›€will€schedule€a€number€of€conference€calls€through€the€fall€to€review€the€StateÏDepartmentððs€worldwide€strategy€on€AIDS.ÌÌMr.€Anderson€asked€for€the€Councilððs€approval€of€a€thank€you€letter€to€Treasury€SecretaryÏLawrence€Summers€on€the€issue€of€debt€relief.€Last€week€the€President€gave€a€speech€in€which€heÏpledged€œU.S.€support›€œfor›€100€percent€debt€relief€for€the€53€poorest€œnations,›€provided€that€theyÏagree€to€carry€out€a€dollar„for„dollar€trade€œon›€domestic€health€and€social€spending.€The€letterÏencourages€œthe€administration›€to€make€that€happen€in€an€expedient€manner€and€explore€otherÏopportunities€to€leverage€U.S.€international€development€funds€to€obtain€funding€for€AIDS€fromÏother€nations.€The€Council€approved€the€letter€on€a€unanimous€voice€vote.ÌÌMr.€Anderson€thanked€Mr.€Fogel€for€his€work€on€the€œSubcommittee.›€ÌÌòòServices€Subcommittee:óó€Mr.€Henderson€said€the€œSubcommittee›€heard€a€presentation€onÐ   	 Ä   Ð¢reauthorization£€of€the€Ryan€White€Act€from€DHHS€and€from€representatives€of€NationalÏOrganizations€Responding€to€AIDS€(NORA).€The€good€news€is€that€the€AIDS€community€isÏbuilding€a€consensus€around€areas€of€concern€regarding€the€Ryan€White€Act,€and€that€process€isÏgoing€smoothly.€The€community€has€also€begun€to€œeducate›€staff€members€on€Capitol€Hill.€ÌÌòòPrisons€Subcommittee:óó€The€œSubcommittee›€did€not€meet,€but€Mr.€Landau€provided€an€update€onÐ   	 P!    Ðprisons€issues.€He€commented€that€the€CBC€initiative€has€unlocked€some€doors€for€AIDS€inÏprisons€issues.€Several€Federal€agencies€(e.g.,€CDC,€HRSA,€National€Institute€of€Justice)€are€nowÏincluding€AIDS€within€their€prison€agendas.€ÌÌMr.€Landau€reviewed€the€Councilððs€accomplishments€and€proposed€next€steps€œon€prisons€issues.›ÏIn€the€area€of€prevention,€the€Council€still€has€not€received€a€copy€of€the€curriculum€that€isÏsupposed€to€be€standardized€by€the€Bureau€of€Prisons.€The€Council€has€not€seen€an€internalÏmemo€calling€for€all€health€officials€in€prisons€to€use€the€Standards€and€Practices€for€ClinicalÏCare€of€AIDS.€œThe›€Council€has€not€seen€a€review€of€public€law€on€the€disallowance€of€condomsÏin€prisons,€and€the€Bureau€of€Prisons€has€not€responded€to€the€Councilððs€request€on€substanceÏabuse€treatment.€Ð   	 x+È&*   Ð‡Mr.€Landau€encouraged€the€Council€to€make€sure€that€Federal€agencies€continue€to€have€anÏimpact€on€State€prison€care.€He€said€there€are€two€issues€that€ONAP€needs€œto€address:›€dischargeÏplanning€and€continuity€of€care,€and€planning€a€national€meeting€on€prisons.€The€meeting€is€notÏbeing€œplanned€by›€other€organizations,€so€ONAP€œmust›€sponsor€it.€Finally,€Mr.€Landau€encouragedÏthe€Council€to€meet€next€year€with€Marsha€Mason€of€DHHS,€John€Miles€of€CDC,€and€NewtÏKendig€of€the€Bureau€of€Prisons€to€get€an€update€on€prisons€issues.€He€added€that€theÏœSubcommittee›€will€submit€a€summary€report€to€the€full€Council€since€the€majority€ofÏœSubcommittee›€members€will€be€retiring.ÌÌòòCBC€Letter€and€Discussion€of€Council€Transition:óó€Dr.€Hitt€recommended€that€the€CouncilÐ   	 üL	   Ðvote€to€support€a€CBC€resolution€regarding€increased€funding.€The€Council€approved€theÏresolution€on€a€unanimous€voice€vote.ÌÌMr.€€Montoya€distributed€a€list€of€Council€œmembersðð›€retirement€dates.€€Dr.€Hitt€said€the€nextÏCouncil€meeting€is€tentatively€scheduled€for€February.€Mr.€Montoya€said€subsequent€meetingsÏare€planned€for€June€and€October€2000.€Mr.€Blackwell€asked€that€time€for€new€memberÏorientation€be€incorporated€into€the€February€meeting€schedule.€Mr.€Montoya€said€he€wouldÏconsider€including€an€extra€day€for€orientation.€ÌÌÓ    ÓòòDr.€Hittððs€Closing€RemarksóóÐ   	 8ˆ   ÐÓ   §®  ÓÌDr.€Hitt€said€his€resignation€letter€to€the€Council€reflects€what€he€has€felt€for€a€while.€He€said€heÏdecided€to€leave€the€Council€in€œJune€in€part€because€4›€years€is€a€long€time€to€maintain€a€strongÏcommitment.€He€said€he€feels€œstrongly›€that€the€next€Council€chair€œshould€be›€a€person€of€colorÏbecause€the€epidemic€is€out€of€control€in€communities€of€color.€œHe›€plans€to€stay€on€for€a€while€toÏhelp€with€the€transition.€He€will€continue€to€follow€up€on€issues€and€make€calls€to€people€in€œtheÏadministration.›€He€œalso›€œwill€try›€to€meet€with€the€Vice€President€to€œdiscuss›€the€œCouncilððs€role€asÏan€advisory€source›€œon›€HIV/AIDS€issues.€He€said€he€is€committed€to€working€on€the€nextÏPresidential€campaign€and€will€continue€to€work€to€ð ðturn€backðð€the€House€of€Representatives.€HeÏhas€learned€that€the€problem€lies€in€Congress,€and€a€few€people€are€preventing€a€lot€of€goodÏthings€from€happening.€ÌÌDr.€Hitt€said€goodbye€to€the€Council€members€who€are€leaving.€He€reminded€Council€membersÏthat€they€should€be€proud€of€their€accomplishments,€such€as€pushing€for€a€White€HouseÏConference€on€AIDS€and€the€implementation€of€health€care€worker€guidelines.€He€noted€that€theÏneedle€exchange€issue€did€œnot›€go€as€planned,€but€œhe€felt€that€the›€dollars€in€ADAP€and€otherÏfunding€were€allocated€to€keep€the€Council€quiet.€Hundreds€of€millions€of€dollars€are€in€theÏbudget€because€the€Council€was€œactive€on€certain›€issues.€The€vaccine€effort€is€moving€in€theÏdirection€the€Council€œwanted€it€to€go.›€The€Council€has€given€a€voice€to€a€lot€of€differentÏorganizations,€such€as€IAVI€and€AIDS€Action.€ÌÌDr.€Hitt€said€new€Council€members€will€bring€in€a€tremendous€amount€of€energy,€which€isÏneeded€as€complacency€œabout›€AIDS€œsets€in.›€He€said€Council€members€can€be€proud€of€the€factÐ   	 l+¼&*   Ðthat€they€have€been€principled.€He€thanked€the€Council€members€for€their€support€and€patience.ÏHe€said€he€had€learned€to€be€part€of€a€team.€He€also€said€he€appreciated€Ms.€Thurmanððs€and€Mr.ÏMontoyaððs€support€and€thanked€them€for€their€work.€ÌÌFinally,€Dr.€Hitt€charged€the€subcommittees€with€the€task€of€writing€summary€documents€thatÏgive€an€overview€of€each€subcommitteeððs€accomplishments,€frustrations,€and€recommendations.ÏHe€said€he€believes€the€Council€needs€to€write€a€closing€document€to€provide€direction€to€theÏnext€administration.€The€document€should€include€all€current€membersðð€names,€though€the€newÏCouncil€will€vote€on€it.ÌÌDr.€Hitt€suggested€a€conference€call€with€new€Council€members€to€impart€some€of€the€CouncilððsÏhistory,€in€addition€to€an€orientation€meeting€with€new€members€the€night€before€the€FebruaryÏmeeting€begins.€He€stressed€that€the€Council€should€take€advantage€of€the€White€House€transitionÏthat€is€already€under€way.€There€is€an€opportunity€to€accomplish€a€few€things€now€that€some€ofÏthe€Councilððs€enemies€have€departed.€He€urged€members€not€to€give€up.€ÌÌDr.€Hitt€adjourned€the€meeting€at€4:00€p.m.ñ ã4ñÌÌÌÌÌÌ€ÌÌÌÌÌÌÌÌÌÌÌ€ÌÌÌÌÌÌÌÌÌÐ   	 h+¸&*   Ð‡ÌÌÌÌÌÌÌÌÌÌÌÌÌÌÌ€ñã4ñ