Meetings

Present from the Office of National AIDS Policy (ONAP):

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Monday, June 5, 2000
Morning General Council Session

Mr. Ron Dellums opened the Sixteenth Meeting of the President's Advisory Council on HIV/AIDS (PACHA) and welcomed five new Council members.

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Daniel Montoya, Executive Director, PACHA
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Regina Aragon, Chair, Appropriations Subcommittee

Update on Interim Activities and Appropriations Overview

Mr. Dellums asked Mr. Stuart Burden, in his capacity as chair of PACHA's International Committee, to give a brief overview of the meeting held on Sunday, June 4, 2000, that was organized by the Global Health Council. The overarching theme of this meeting was the urgent necessity of linking domestic and international efforts toward effective prevention and treatment of HIV/AIDS.

Mr. Daniel Montoya then reviewed agenda items, including recent correspondence with the Department of Health and Human Services (DHHS) concerning a framework for needle exchange, the Institute of Medicine correspondence to the President on Medicaid expansion, and a memo to the Secretary from the Chair regarding outstanding issues—health care worker guidelines, access to care, prevention issues, and others.

He asked members to notify him during the course of the meeting whether they plan to attend the upcoming conference in Durban, South Africa. He reminded Prevention and Service Subcommittee members to schedule standing conference-call times to discuss issues that emerge during those meetings that are relevant to the progress report and other PACHA items.

Funding/Appropriations: Mr. Montoya introduced Ms. Regina Aragon, chair of the Appropriations Committee, who provided an update on Federal appropriations and funding for both domestic and international HIV/AIDS programs, as well as the Minority HIV/AIDS Initiative and the Congressional Black Caucus (CBC) initiative.

Ms. Aragon referred to comments she made at PACHA's March meeting about the release of the President's budget in February, in which she said that on the whole, the budget was strong. Approximately $125 million was recommended as an increase for the Ryan White CARE Act, and, for the first time in many years, an increase in funding was also recommended for Centers for Disease Control and Prevention (CDC). Although not sufficient to combat the HIV/AIDS epidemic domestically, the budget is commendable as a first step in the process, hopefully setting the stage for an elevated discussion of the need for increased domestic and international funding.

In early May, both the House and the Senate allocated additional funding for HIV/AIDS. She characterized this effort as "half empty" rather than "half full." Ms. Aragon acknowledged that it is still early in the funding process, and that traditionally the most substantial increases, particularly for the Minority AIDS Initiative, have occurred toward the final stages. However, although in some cases the House of Representatives met and even exceeded the President's request, several substantial exceptions occurred, including substantial funding cuts for prevention, care, and housing. The Substance Abuse and Mental Health Services Administration (SAMHSA)'s budget was also substantially reduced, which will negatively impact efforts by states and cities to stem the epidemic, now that it is clear that a majority of new infections are related to injection drug use in the United States.

Ms. Aragon said that the House Labor and Health and Human Services Subcommittee oversees AIDS funding. Given their comparatively smaller allocation, she commended them for providing more to HIV/AIDS programs than the Senate subcommittee, which in most cases did not even meet the President's budget. Ms. Aragon expressed hope improvements will appear by late summer.

She noted the President's addition of $100 million to the global AIDS initiative, in addition to $50 million for the global vaccine and immunization fund, but said her understanding is that Congress has not committed to those increases. The Global Health Council is calling for an emergency supplemental bill that would more than double U.S. expenditures by providing $500 million for international HIV/AIDS treatment and prevention efforts. She enjoined Congress to step up to the plate in a more significant way to respond to the President's budget request.

Ms. Aragon spoke about funding of the Congressional Black Caucus or Minority HIV/AIDS Initiative. The Initiative is currently funded at approximately $250 million and is now in its second year. The funds are distributed across a number of Federal agencies. Requests from African American, Latino, CBC members, and the Congressional Hispanic Caucus are substantially higher, at $540 million. Asian American and Native American advocates are also now included, and efforts have increased to ensure coordination among stakeholders. The President's budget represents only a modest increase at approximately $20–25 million, or 10 percent, which does not approach the community's substantial unmet need in targeted programs, which are intended to supplement base AIDS programs.

Ms. Aragon suggested that both the Senate and the House of Representatives have failed to take bold action to increase funding for HIV/AIDS and asked PACHA members for assistance in their respective capacities as monitors of the appropriations process to move Congress in this direction.

Questions/Comments: A question for Ms. Aragon concerned the possibility that the funding process could be submerged by the August political conventions. She affirmed the possibility that during an election year, it may be unrealistic to anticipate timely action on the part of Congress, but enjoined participants to be at the table when decisions regarding appropriations are taking place.

Another question concerned the necessity of restoring SAMSHA funding cuts and whether any advocacy was occurring on this front. Ms. Aragon suggested that Terji Anderson might be more knowledgeable and asked Sandra Thurman to clarify this issue, if possible, in her remarks.

One speaker commented that his organization has been working with a broad coalition of minority health organizations to support a budget request that covers all minority health issues, including HIV/AIDS, for the Minority Health Initiative at the $540 million level. Although the process is potentially complicated by the inclusion of other health issues, the National Medical Association and similar organizations representing the minority health community are becoming increasingly involved in focusing on HIV/AIDS.

Sandra Thurman
Office of National AIDS Policy Update

Representing the Office of National AIDS Policy (ONAP), Ms. Sandra Thurman said that significant efforts have been devoted to supporting the reauthorization of the Ryan White CARE Act and on addressing HIV/AIDS as an international epidemic. An intergovernmental working group has been in place, comprised of senior Administration officials and chaired by Sandy Burger and Ms. Thurman, that addresses domestic response to the global epidemic.

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She commented that increased focus on the epidemic has been fueled by the realization that HIV/AIDS is a global security threat. Significant press and other response has led to the elevation of the issue to the agendas of the EU and G8 summits as well as to that of President Putin in Russia.

In considering how ONAP and other groups will be organized within the White House to escalate response to HIV/AIDS as an international epidemic, Ms. Thurman said that additional State Department staff will be added to respond to increased agency involvement and interest. Members of the National Security Council (NSC), the Departments of Treasury and State, and other Federal agency personnel who are new to HIV/AIDS policy require background on domestic approaches (e.g., the rationale for not instituting mandatory testing, names reporting, etc.). This effort provides an opportunity to advocate support of domestic funding and expansion of international funding.

Several meetings have transpired with deputy assistants to the President and deputy secretaries that have addressed questions of policy, and final decisions with regard to issues that emerged are expected from the President within the next 4 to 6 weeks.

Conversation and press articles reporting South African President Mbeki's interest in scientific questions regarding the impact of HIV/AIDS in that country have been in evidence. Both President Clinton and Vice President Gore have spoken with President Mbeki, and ONAP has engaged with many members of his staff. Ms. Thurman has met with his health advisors, including the Minister of Health and South Africa's ambassador to the United States, to ensure open lines of communication and the continuation of a scientific panel that President Mbeki has formed to examine these issues. Dr. Helene Gayle is on this panel, along with other established U.S. scientists. Ms. Thurman affirmed the importance of this panel's success in terms of its impact on future policy for the rest of Africa, Asia, the former Soviet Union, and the Caribbean.

The LIFE initiative, discussed by Dr. Gayle in Sunday's briefing, continues to grow. ONAP has requested an additional $100 million for this program. Additional work is needed to increase the U.S. Agency for International Development (USAID) and Labor Department budget. Ms. Thurman spoke of the importance of taking a multidimensional approach to the epidemic and that this was missed in earlier efforts. This has been the key to success in several other countries. HIV/AIDS was considered only as a health issue in the United States, which in hindsight was not an optimal approach. Greater insight into and a more tailored response to the pandemic would have resulted in greater progress than has been made to date.

The DHHS budget has provided $10 million for the LIFE initiative to use organized labor in the context of the global epidemic, particularly in South Africa, as a tool to provide education and treatment.

The Department of Defense has allocated $10 million for military-to-military training, which has been hard won, although the military has been disproportionately affected by HIV/AIDS in Africa and elsewhere. In Congolese armies, infection rates run from approximately 40 percent among Angolans to more than 80 percent in Zimbabwe's army, for all ground personnel.

This is particularly sobering when considering that the military constitutes the backbone of burgeoning democracies throughout Africa and maintains stability in the region. The best-educated professionals often advance through the military into positions of political power and are disproportionately infected. This has implications in terms of military engagement across national boundaries, in which, like other migrant activity, sexual conduct and the spread of the disease results.

Education programs developed and conducted through military research and prevention programs in the United States have been good, but leadership has been lacking. Ms. Thurman affirmed that this trend appears to be changing for the better.

Expanded programming is in effect for CDC surveillance and prevention, including mother-to-child transmission programs, and for USAID to continue focusing on AIDS as a fundamental development issue in terms of child health.

Ms. Thurman said that many gains made over the last several years have been eradicated as a result of the epidemic, which now has security implications; this constitutes much of what is driving current policy evaluation. Twenty to twenty-five percent of adult infections in hardest hit countries is profoundly destabilizing and has to be addressed, as this is a completely unprecedented event with unique global implications and cultural ramifications.

A paradigm shift is occurring in the understanding of the impact of HIV/AIDS and the mutual responsibilities of members of the global community. Although it is possible to talk about this phenomenon, understanding is still limited as to how what happens to individuals in one part of the world affects citizens in another, particularly in more remote areas of the globe.

Ms. Thurman accompanied Under Secretary of State Strobe Talbot to Africa in mid-May to address the South African Development community meeting, a coalition of 14 southern African countries. This marked the first time that HIV/AIDS was considered during a plenary session of this body and was attended primarily by ministers of State and Finance. She remarked on the fact that powerful and educated people continue to harbor myths and misperceptions about the epidemic and its impact, but that it was encouraging to engage leaders in discussions. Because funding for health and education is uniformly at the "bottom of the barrel," support from these leaders will begin to result in increased responsiveness and resources devoted to prevention and treatment.

Ms. Thurman will accompany Secretary of the Treasury Larry Summers on June 10, 2000, on a visit to 5 African countries in 10 days. This marks the first time the U.S. "Minister of Finance" will address HIV/AIDS as a fundamental economic global issue and will highlight the U.S. domestic response in urging focused attention on and resources for HIV/AIDS. This is an extremely significant and unprecedented event that will include specific HIV/AIDS-related meetings and activities in Tanzania and South Africa.

Ms. Thurman also led the U.S. delegation to the United Nations AIDS Programme (UNAIDS) meeting in Geneva, Switzerland. Progress has occurred in terms of increased international attention to the epidemic. However, global contributions to the fight against HIV/AIDS in Africa total only about $350 million, which can easily be spent in one U.S. city. Annually, $3 billion is required for an effective global campaign.

ONAP is working with the UNAIDS within the intergovernmental working group, including Gene Sperling of the President's Economic Council and Secretary Summers at the Treasury Department, to address closing the gap between current resources and the level of need, modeled on the U.S. approach. World leaders are often surprised to hear that funding gaps exist within the United States and tend to assume universal access to treatment in this country, even though only around 50 percent of those with HIV actually benefit. Significant work remains to be done in the United States to reduce major gaps in service; sharing this information helps to "level the playing field" when addressing the problem on an international level.

Work is continuing in the former Soviet Union through collaborations on vaccine research and other projects. The Caribbean and Latin America have not received sufficient focus. The Caribbean currently has the fastest rising rate of infection in the world, followed by Asia. A fact-finding mission will visit India in the fall to provide another report to the President, at his request, on the status of HIV/AIDS in Asia. Ms. Thurman commented that it is important to provide blueprints for the next Administration that focus on this region, as well as on African countries.

Ms. Thurman referred to Ms. Aragon's presentation on appropriations and confirmed that the President requested $50 million in additional funding to focus on vaccines and immunizations as part of the LIFE initiative. The President has also asked for a $1 billion tax credit as an incentive to drug companies to develop HIV, tuberculosis, and malaria vaccines for the developing world, where there is relatively low market demand for those products.

The World Bank Trust fund, initiated by Ron Dellums, has received support from the Administration (with the support of Chairman Leach and Barbara Lee in the House of Representatives).

The Beijing Plus Five conference took place at the UN, which Ms. Thurman plans to address this afternoon. The global women's community is also placing HIV/AIDS at the top of its agenda as a fundamental women's issue because of the sharp increase in infection worldwide among women.

Ms. Thurman said that the Ryan White CARE Act reauthorization was unanimously voted out of committee in the Senate, and ONAP is reviewing the possibility of having the bill considered under unanimous consent. In the House of Representatives, Rep. Coburn has sponsored the reauthorization bill and has conferred with Rep. Waxman in the process. Although problems within the bill include the use of funds for surveillance and other prevention activities, including partner notification, Ms. Thurman expressed optimism that the bill would be passed in 2000. This will require PACHA to monitor and encourage the process.

The possibility that the next Administration's HIV/AIDS policy would not be favorable to the Council's recommendations was broached. Ms. Thurman recommended a review of PACHA's accomplishments to affirm accomplishments and recognize gaps. She urged a visionary approach that includes concrete steps on both the micro and macro levels, thus setting the tone for policy direction for the next Administration. Even if Mr. Gore is elected, a lag will occur between his inauguration and placing of key individuals within the Administration. It is likely that focused support will not be forthcoming for at least 1 year.

It is essential that PACHA's report contain the energy, enthusiasm, and clear vision to inspire key players and should include past reviews, while not getting bogged down in them.

Questions and Answers: A question was raised regarding specific actions the Administration can take to elevate the issue of HIV/AIDS in the Caribbean. Ms. Thurman responded that meetings have occurred and that large-scale action will take time. USAID and the State Department can be engaged in the region. This issue has been on the agenda and will continue to be, recognizing that 2 ½ years were required to focus attention on HIV/AIDS in Africa and on the disease as a global pandemic. This issue can be included in the progress report by noting that in terms of rates of HIV/AIDS infections, Africa is the "tip of the iceberg" and that rates will escalate in the Caribbean, Asia, and elsewhere.

Rabbi Joseph Edelheit asked for a realistic description of how far down change will occur within the Administration HIV/AIDS "strata," either with a Democratic or Republican candidate. He expressed the concern that normal bureaucratic indifference might account for issues getting "pushed off the table," and that this information was necessary to form a visionary approach to the progress report. He also questioned whether ONAP would survive a possible Republican presidency.

Ms. Thurman replied that little change would occur within the HHS bureaucracy and that greater change would occur internationally, since the State Department is more driven by the international climate. Career diplomats should be in place who are focusing only on HIV/AIDS, although higher level leadership is desired within the State Department. The next series of recommendations by the President will hopefully result in an improvement, so that more staff will be appointed, both at the NSC and within the State Department.

She said that ONAP is taking steps to ensure its continued existence by seeking to pattern itself on the NSC, with staff detailed to the White House from the agencies. Although ONAP was not initially structured this way, it will be less vulnerable to unfavorable administrations.

She expressed concern that a Bush presidency might result in the international response being focused only within the State Department, which has not been traditionally as forthcoming as other agencies, and that leadership regarding HIV/AIDS has not been integrated at all levels within the bureaucracy. Ms. Thurman affirmed that this work would be ongoing regardless of whether her position at ONAP remains in tact.

A question was raised as to the possibility of legislative institutionalization of ONAP. Ms. Thurman responded that this possibility is attended by both pros and cons. One problem is that oversight of the office would then come from the Congress, rather than the White House. ONAP has been sounded out by Congress about this possibility and feels that its ability to be a viable part of an Administration is to its advantage and that it can be more effective by being more closely aligned with the White House. She acknowledged this could change, given a less receptive Administration.

Stuart Burden raised a question about the involvement of the Under Secretary of Global Affairs and whether behind-the-scenes activities were taking place that were not readily apparent regarding that office's activities. He also asked Ms. Thurman to share her impressions of the Durban conference and asked for clarification about what the inter-governmental working group hoped to accomplish before the election.

Ms. Thurman said that ONAP's AIDS program has a liaison with Nancy Carter Foster in the office of the Under Secretary for Global Affairs and now includes Jack Chou, who is doing legislative and policy work. She said that it is important to focus not on one agency but on the Secretary's "shop," which ensures that HIV/AIDS is an integral part of each agency and division within the State Department.

Much of what is happening in the State Department is conducted out of the Africa Bureau, which is engaged "150 percent." However, because very little movement has occurred in either the Asia or former Soviet Union bureaus, HIV/AIDS should be institutionalized, rather than be driven solely by the Africa Bureau. Career officers will continue to set the pace, but institutionalization is key.

A presidential envoy on AIDS is being considered. This would be a senior-ranking diplomat who would work exclusively on HIV/AIDS. This person will negotiate inside the State Department and the Bureaus as well as with other governments on AIDS policy and work with heads of state and other ministers. Ms. Thurman referred to a conversation she had with John Podesta on June 2, 2000, in this regard and that progress is being made.

Ms. Thurman commented that the Durban conference will be a very interesting meeting, but that it remains unpredictable. She considers the threatened boycotting to be unproductive and that concerned parties should stay at the table to dialogue and encouraged PACHA members to attend.

The inter-governmental working group will serve on an ongoing basis, but will temporarily conclude its activities within the next 4 to 8 weeks. She commented that historically, inter-agency working groups constitute part of the culture of the NSC and form the basis of its decision-making process. ONAP has learned the culture of these groups and believes that now that they have taken on the issue of HIV/AIDS, the issue will become integrated into their structure.

A question was asked about PACHA's recommendations regarding needle exchange in terms of its inclusion in the progress report. Ms. Thurman commented that more than half of new infections are related to injection drug use in the United States and more than 80 percent in the former Soviet Union. She has renewed dialogue with her counterpart in the Office of National Drug Control Policy (ONDCP); they are not in accord on this issue. She said that it is important to be extremely aggressive in discussing needle exchange and how we interpret and respond to the science regarding it.

Remarks: Mr. Dellums thanked Ms. Thurman. He said that the Council's major responsibility is to prepare a report for the next Administration. PACHA's next meeting is scheduled for September 21–22. A report should be prepared by that meeting or ideally in early July. He suggested that the committee should collectively regard this as its final act. The question then is what to say and how to frame this content for optimal impact on the next Administration. He urged that the document be visionary, progressive, and comprehensive in terms of its assessment of the global pandemic and that it should be clear and far-sighted enough to be relevant to future generations. He was emphatic about addressing the moral, ethical, human rights, and "self-interested" implications of HIV/AIDS, as millions of people are dying. He suggested that the commitment has been lacking to address the human rights of people who suffer from the disease and that decisions impacting HIV/AIDS policy should not be left only to a few individuals.

Mr. Dellums referred to the original concept of a "Marshall Plan" to address the global implications of the pandemic, but that this idea had been reduced to "a piece of legislation." This idea transcends legislation, and he asked whether PACHA's report should recommend debt forgiveness to developing countries so that infrastructure could be developed to enhance quality of life and more effectively address HIV/AIDS. He reminded the Council that although individually they represent professional specialties, collectively they are a political body rather than a scientific or medical one, and they are tasked with advising the Administration. To that end, he urged members to draw up a report whose tone is too compelling to ignore.

He recommended that high visibility should attend the Council's submission of the report, rather than quietly handing the report to a staff person. The report should be politicized and brought forward to the American people. He suggested that the August conventions be used as an opportunity to inform the platforms of every political party about the HIV/AIDS pandemic. The reports should be powerful enough to compel the President of the United States to address the issue.

In referring to the security implications of the HIV/AIDS epidemic and attendant fears, Mr. Dellums mentioned the disenfranchised constituents of many of PACHA's participants and that now, for the first time, the issue has been elevated into the "rare air" of international security. If this is genuinely a security issue, then appropriate response should be mobilized at the same level. How can $50 billion be rationalized for missiles to address security issues, while only allocating $100 million for HIV/AIDS?

He said that members should take advantage of the brief "window of opportunity" to encourage the Administration to implement debt forgiveness, needle exchange programs, and to focus on the global responsibility of the United States to address the HIV/AIDS pandemic.

Angela Thrasher, MOSAICA
Questions and Issues in Preparation for Progress Report

Mr. Montoya introduced Angela Thrasher, a consultant from MOSAICA, who had been engaged to assist members stay on message to complete the progress report on time. He referred to a list of questions and answers that MOSAICA provided to guide the drafting of the report, as well as an initial compendium of issues to be considered by the Services Subcommittee.

Purpose of the Progress Report: Angela Thrasher introduced herself and passed out copies of the Question and Answer list designed to guide structuring of the progress report. She referred to the May 22 Executive Committee conference call and suggestions regarding themes for the report. She suggested that the current time period could be used to focus on content, tone, vision, and themes. Subcommittee meeting results would then be funneled into discussions among the larger group. She then asked the Council to frame the purpose of the report.

Mr. Montoya encouraged the Council to draw on the expertise of Administration staff who were present, and he suggested that those who were involved in the previous evening's Executive Subcommittee meeting contribute items from that discussion to set the tone for the ensuing discussion.

Michael Rankin acknowledged the National Commission on AIDS under former President George Bush, saying that the agency established a comprehensive vision regarding the epidemic and agreed with Mr. Dellums in stressing that the report should be visionary and evoke a strong response from the public.

Ignatius Bau suggested that one approach to the report might entail a discussion of how domestic and international accomplishments are facilitated as a function of political will, of availability of resources, of community engagement, and of mobilizing of governments. Examples of strategies such as combination therapies, the condom campaign in Thailand, and education efforts in Uganda can be cited. Barriers to those successes should be removed.

Regina Aragon said that the report could be purposeful in clarifying the language that frames the discussion of domestic versus international approaches to HIV/AIDS and that both examples of sufficient and insufficient political leadership in terms of its impact on the epidemic could be offered. An unfinished domestic agenda does not have to be sacrificed toward global efforts on the part of the United States. She repeated the emphasis on the document as a political statement that incorporates powerful "sound bytes."

A suggestion was made that more political pressure should be put on the Federal Government by writing in laymen's terms about key issues that the media can effectively transmit.

Rabbi Joseph Edelheit urged a consideration of history in that the report emerges during a paradigm shift from a consideration of HIV/AIDS from a gay activist perspective to one including communities of color, and now an international perspective. The first paragraph should reflect some sense of that history and how perspective has shifted as the multicultural "face" of the epidemic has appeared.

He argued that a significant part of the document should be apolitical or ethical in that it refuses to compromise to political realities. He said that currently no section of the report refers to the Council's discussions of ethics in relation to HIV/AIDS policy and that questions should be raised about ownership and production of an AIDS vaccine. He wondered who is having these discussions at this juncture. In light of the "vaccine czar's" prioritizing vaccine development, conversations about ownership, production, trials—the ethical boundaries around these questions—must occur to avoid a reactive mentality.

He commented that he is not aware of any ongoing serious, 21st century, ethical conversations that address issues of racism, disparities in access to care in developed versus undeveloped countries, and related concerns.

Mr. Dellums expressed his agreement with Rabbi Edelheit that the report should be grounded in ethical considerations related to the HIV/AIDS pandemic. He said that when he referred to the report as a political document, he was not speaking in partisan terms.

Ms. Debra Fraser-Howze commented that the Council did not broach the issue of racism in the United States in relation to the AIDS epidemic for 3 years, although statistics clearly supported racism as a factor in prevention and treatment. She spoke to the importance of incorporating the Council's previous domestic focus and writing a far-reaching report that does not lose sight of work accomplished during the previous 4 years. She urged joint consensus toward adopting recommendations of the current Council so that the Council can work proactively and keep the Administration, whether Democrat or Republican, focused on accomplishing the recommendations. The importance of referring to the epidemic signaling a "state of emergency" in the United States was emphasized.

Mr. Dellums urged that the domestic and international dimensions of the epidemic not be viewed as mutually exclusive. Although a state of emergency exists within communities of color, it is impossible to characterize the global ramifications of HIV/AIDS. To view the domestic problem as integral to the international dimension does not detract from the responsibility to address it.

Dr. Cynthia Gomez spoke about how the initial response to HIV/AIDS occurred within communities and that 10 years later, the emphasis shifted to the scientific/medical approach to finding a cure. In the year 2000, we are now at the level of economic and security-related concerns and that extrapolating from this point, in another 10 years, in the absence of a cure for HIV/AIDS, humanity could become endangered as a species. She envisioned the necessity of legislation that would prohibit killing in any form due to the need to preserve the race. The report should spell out that we are on a trajectory that we have not been able to alter in 20 years, and that we have to imagine how the epidemic could manifest at that time and work from that perspective.

Stuart Burden commented that the report should be a long-standing reference document and be meaningful beyond this election cycle. The report should also be educational as well as ethical and political in scope. Linkages between the domestic and global effort should be understood. He raised the question of what the United States would be called on to do, should a foreign economy, such as that in Rwanda, collapse. With a decrease throughout Africa in GDP, military and government collapses are possible and the U.S. response should be evaluated.

Another comment pertained to the need to think of prevention and treatment as a continuum, rather than as distinct approaches. He said that the Council had been rightfully critical of some of the Administration's prevention efforts, which need to be heightened, while maintaining an awareness of issues related to treatment and care.

Charles Blackwell focused on legal aspects of the AIDS epidemic regarding rights promised but not enforced to adequate and sufficient health care for indigenous peoples.

The next speaker agreed on the importance of not pitting domestic issues against global ones and that visionary ideas should be incorporated into the report. She mentioned that among those she works with, many people remain uneducated about HIV/AIDS and that basic education and outreach messages around prevention are essential.

The following speaker suggested that HIV/AIDS activists are often "preaching to the choir" and that he is not sure whether the larger domestic or global community understand AIDS in that context. This document should tie HIV/AIDS to poverty, racism, and homophobia.

Dr. Ernesto Parra said that debt forgiveness and needle exchange are controversial issues and felt that specific direction as to how to address them could deter from the overall impact of the document. While acknowledging the importance of focusing on solutions, he stressed caution regarding the way they are couched.

John Perez remarked on the "richness" of the drug czar's staffing, in contrast to the Council's, that has had to beg and borrow staff from other agencies. He said that this reflects the Administration's half-hearted commitment to ONAP and the Council. He recommended that the report urge the assignment of staff specifically dedicated to support the Council's efforts.

Ms. Valerie Reyes-Jimenez stressed the importance of remembering the human component of the epidemic, that those suffering with HIV/AIDS are not "PWA's" (persons with AIDS) but human beings throughout the world who have been infected with the virus.

Tom Henderson was remembered by Todd Summers, who applauded his ability to clearly articulate complex issues. Mr. Summers then suggested that the Council request a meeting with the President and that the press should solely focus on the report's submission as the "message event" of the day. A February meeting of the Council should be scheduled. He then echoed comments about uniting prevention, service, and research along one continuum of HIV/AIDS policy. Regarding the content of the report, he advocated that it be focused and succinct and that it should be framed through the stories of actual HIV/AIDS sufferers, rather than couched only from policy perspectives.

Terje Anderson said that the final report should be visionary, but is concerned about distancing from specific recommendations. As a delegate to the 1992 Democratic convention, he heard Bill Clinton pledge that, in contrast to George Bush, he would implement the recommendations of his AIDS commission. The final report of that commission was 180 pages long, contained a blueprint for care and prevention, and was one of the first to be referred to by the Council to begin assessing what programs and policies had been implemented. His concern is that without defining measurable goals, politicians can evade responsibility for producing substance.

As a person with HIV, he stressed the importance of substance as well as principle in the report and that future Administrations should be held accountable for producing results. He suggested that as President Clinton reflects on his legacy, there is much that he can still do to address the global dimensions of the HIV/AIDS epidemic. One of the purposes of this report would be to focus attention on those actions that have not been taken over the past 7 years of the Administration so that effective strategies can be implemented to combat the epidemic.

Another purpose of the report is to provide clear guidance that the next Administration's appointees will be judged against. It was noted that President Bush's Commission produced a useful report. Mr. Anderson said that lacking recommendations toward objective, measurable activities, the report will be significantly diminished as an effective tool to guide future Administrations.

Mr. Dellums mentioned Dr. Parra's comments that debt forgiveness is too controversial, and contrasted them with Mr. Anderson's emphasis on specific recommendations for inclusion in the report. He said that the Council is now embracing a unique analysis of the global nature of AIDS that is ultimately larger than the Office of the President or of the country. He invited consideration of how to best address specific strategies that are within the purview of the U.S. Government to enact in relation to strategies toward resolution of the global AIDS problem and whether particular recommendations such as debt forgiveness can be included in that context.

Mr. Anderson responded that it is important to remember the Council's identity as the presidential advisory council on HIV/AIDS, that its primary target is the office of the President, and that its purpose is to make recommendations toward viable action. Because the United States has influence beyond our own domestic programs, it sets a tone for leaders throughout the world. The Council can therefore legitimately "weigh in" on what the Government can do to influence the World Bank or the International Monetary Fund (IMF).

He said he would debate whether debt forgiveness is such a controversial issue, as President Clinton's affirmative stand has been clearly articulated in this regard, as well as those of leaders of the G-7. It is important to recognize that the Council is not solely qualified to provide a framework to address the global epidemic and that others have been involved in the process for years. PACHA's mandate is to clarify the unique role of the U.S. Government in relation to global HIV/AIDS and to set specific standards based on that capability.

Mr. Anderson said the report should identify when and why effective action did not occur when it should have in this country. He posited that the country's hatred of drug users explains why needle exchange was not implemented and that racism, homophobia, and gender should be discussed. Policies should be implemented to mitigate them in relation to the epidemic. U.S. history is a vital element for consideration in getting to the core of these issues, and valuable lessons can be learned through this approach.

Rabbi Edelheit suggested that MOSAICA inform the Council that the focus of the discussion had moved from a discussion of purpose to organization of the report. He raised the question of what is actually meant by a "PACHA progress report" (i.e., accomplishments of the Administration versus internal progress report versus offering a policy critique, etc.). He suggested focusing on and determining the content of the report (e.g., does the report represent the current Council's reflections or will it be inclusive?). He also suggested that the word "final" might imply that the content of the report is specific only to the Clinton administration, in contrast to a "progress" report, which refers to future policy. Perspective should be decided, not only in terms of that of the framers but also of the readers of the report.

Ms. Thrasher suggested that at this juncture, the Council might consider and come to consensus about the scope of the report; the initial plan was for a 20–25 page document.

Mr. Montoya said that he would prepare the budget to accommodate three Council meetings in 2002. The report is a "progress" report because it will convey the ongoing activities of the Council and the state of global HIV/AIDS; however, the report for this Administration should be couched as the "final" report.

Scope of the Progress Report: A comment was made that the report can provide vision while still offering specific recommendations, and that it may not be necessary to separate these approaches. This may have been easier with the Bush Commission because the reports were extraordinarily detailed. It may be challenging to determine which strategies were the most far-reaching and effective. Although the Council is mandated to advise the President, it was urged that members consider different paradigms, rather than remaining limited to perspectives of the Washington bureaucracy in order to offer a truly transformative worldview. Past recommendations may be considered, but many have been mechanical.

Homophobia is a prime reason for the proportions of the epidemic as well as the hatred of drug users. To make a difference, the report should offer hopeful alternatives rather than getting mired in past failures.

Patsy Flemming said that PACHA submitted its first report while she was director of AIDS policy in the White House. She noted the concern among White House staff over the Council's critical review of administration policy and referred to headlines that reflected this critique. She enjoined members to consider that major national newspapers and reports would be focusing on the report and that, in contrast, upcoming headlines and reports should suggest that the Council has set out a blueprint for solving the worldwide epidemic. The report should also detail effective interventions, such as needle exchange or new treatments (e.g., microbicides), as well as address the vision and ethics of the Government and private sector, particularly the drug companies, in dealing with HIV/AIDS.

Ms. Fraser-Howze commented that the President has acknowledged that debt relief should be a component of HIV/AIDS strategy. She emphasized recognition of the causes of health conditions in the minority community that have propelled the health crisis in the United States such as lack of focus and economic will. The report must be truthful in clarifying that although viewed as a "homosexual" disease in the past, the global epidemic is now based in heterosexual populations. She said that even in communities that have been benefited by AIDS medicines, people are still dying and a cure is still elusive. Thus, the Council should ensure that the media reflect these truths within the report.

Brent Tucker Minor remarked that when he wrote the working draft for the Council, he reviewed the previous report and adopted its purpose. He also viewed the report as having three parts: a philosophical statement (i.e., using public health strategies and science as a foundation as well as citing statistics); subcommittee reports, each with a separate statement so that issues are not lost in a larger document; and a vision statement that cites the President's goal of finding a cure for HIV/AIDS in 10 years and reducing disparity in care. Much content has already been written. The report should be structured in this way to build on consensus regarding the philosophical approach to HIV/AIDS so that agreement about the approach would be a logical consequence.

Ron Dellums expressed appreciation for ideas expressed by the Council. He cited Mr. Burden's recommendation that the report be educative and that the overriding responsibility of politicians is to educate the public about the moral and ethical dimensions of the AIDS crisis. The report should thus be instructive in analyzing a global strategy and seek a balance between vision and specific recommendations, as well as past and future perspectives. The document must not single out individuals for censure, but has a larger mandate to challenge the nation toward commitment to resolving the pandemic. Thus, if the report is educative, it will be comprehensive in embracing individual objectives of the members. It is imperative to "think out of the box" rather than stay within traditional confines and that rather than be concerned that the report may be too controversial, perhaps it is not controversial enough, given the prolonged delay in building momentum.

Dr. Parra agreed and clarified his earlier statement by saying that it is important that the report's vision statement not be lost because of controversial elements as it is covered by the press.

Rabbi Edelheit suggested that the internal draft document drop the term "subcommittee" because the term "issues" is broader and that by referring to them as "task forces," the Council can avoid explaining past, present, and future internal organization. In this way, the Council is not limited to subcommittee reports, which limits vision and historical review. The focus can be broadened in a discussion of issues rather than couching them in an overly literal review of subcommittee reports.

Ms. Campbell expressed hope that the document would address the needs of youth and "be real" in informing them truthfully about HIV/AIDS, because many are still thinking in outmoded terms about the disease.

Mr. Bau addressed the theme of security by suggesting that although he is not comfortable with military analogies, the imperatives of the epidemic require a declaration of war, such as the "war on drugs" to effectively combat it, and that if HIV/AIDS has been elevated to a security issue, the same commitment of resources should be deployed as would be in a military operation. Clarification is needed that "targets" of the disease are not the people living with it but discrimination, ignorance, stigmatization, lack of resources, and political will, and that "weapons" of science, medicine, and other resources should be brought to bear.

Mr. Summers said that only a third of people living with HIV/AIDS are actually receiving care, and that the Government has no target for reducing infections, as evidenced by a steady rate of 40,000 infections per year for the last 5 years. He would like the document to be candid in reporting what has and has not been done to address the epidemic.

Mr. Burden agreed that the report should be ambitious but urged caution in referring to HIV/AIDS prevention in militaristic terms. Those addicted to drugs are often demonized because of the "war on drugs," and some are not sophisticated enough to know the difference between HIV/AIDS and those infected with it.

Rabbi Edelheit acknowledged that Mr. Bau's suggestion underscores a tone of urgency, but that the discourse of war is one of "dangerous ambiguity." The metaphor can lead to a mentality of enemies and polarization. He suggested an inclusive paradigm that does not allow for triaging and dismissal of those who can be easily stigmatized and, therefore, dismissed.

Ms. Thrasher suggested that the Council devote Monday afternoon to achieving consensus on four specific issues: purpose, target, tone, and specificity. She recommended that Tuesday's meeting could focus on more pragmatic issues such as structuring the report.

Discussion: Dr. Gomez asked whether each issue should be approached by section. For example, should the Prevention Subcommittee begin by forming a visionary statement within that section and then outline specifics.

Ms. Thrasher said that an overarching issue is the relative weight of themes versus pragmatic issues and that each committee, in focusing on its specific contributions, would contribute to the larger picture and could decide this question on Tuesday.

Mr. Montoya proposed that subcommittees meet from 11:30 – 3:30 rather than 11:30 – 4:30 as per the original agenda to allow Mr. Dellums to be present.

Ms. Aragon proposed, as co-chair of the Services Subcommittee, that it focus on issues and examples—both domestic and international— rather than on specific structure, as each committee may come up with different approaches to structure.

A discussion ensued as to alternatives for the remaining agenda. Mr. Dellums agreed that the Council should convene on Tuesday morning as a policy group to further refine the report and asked for feedback from members.

Rabbi Edelheit asked whether the committees should be submitting information to MOSAICA and whether MOSAICA is then writing the report. Mr. Montoya said that chairs of the Executive Committee would develop and outline a draft of what the Prevention and Services Subcommittees should include and that a foreword would be developed. He said that MOSAICA would assist in further enhancing this framework. The document is currently in segments that will be refined as a clearly articulated report. He encouraged members to gather in caucuses (i.e., women, Latino, and others) to ensure thorough community representation. A request was made for a restatement of the Council's objectives as well as a recommendation to design a framework for subcommittee reports.

Mr. Dellums said that the Council is still engaged in a "work in progress" and that as Subcommittees engage, these questions would be clarified. Ms. Aragon suggested that a small subcommittee convene at the end of the day to review notes and outline major themes to form the work of subcommittee meetings on Tuesday.

Mr. Montoya asked MOSAICA for an outline of highlights of the morning's discussion and suggested that subcommittees appoint notetakers. He acknowledged that the process may seem cumbersome but that it is effective, particularly with MOSAICA's facilitation.

A suggestion was made that the Executive Committee meet quickly to agree on objectives before breaking into subcommittees and take a working lunch. A conversation ensued to decide on an optimal agenda. It was decided that afternoon meetings would convene at 1:00 and that MOSAICA would provide members with a copy of notes from the morning session prior to that time.

Afternoon General Council Session

Mr. Dellums convened the afternoon session. Mr. Montoya introduced two White House interns: Melissa Henderson and Amanda Cornette.

Ms. Thrasher, representing MOSAICA, reviewed the agenda for the afternoon session and said that Subcommittee chairs would have time to present a summary of their discussions.

Rabbi Edelheit urged that the report build a bridge to the 21st century by describing the paradigm shift in public perception of HIV/AIDS and the ethical imperatives underlying it. He said that the truth may be sacrificed if political considerations are valued over moral ones and that this has implications for the business community and is important in resisting the forces of institutionalized homophobia, poverty, and racism.

Dr. Gomez, chair of the Prevention Subcommittee, then presented a review of their session. Major points involved the need to educate the United States to the reality of the AIDS crisis through the implementation of a national campaign and alerting this country to statistics of the worldwide HIV/AIDS pandemic. Solutions exist but have not been successfully implemented. The media should begin focusing on the stories of people suffering with HIV/AIDS to more effectively motivate the public toward a national prevention strategy. Lessons can be learned from our own prior experience as well as that of other countries.

She further stated the subcommittee's views that HIV/AIDS should be viewed in isolation and that prevention is a constant issue. Comprehensive systems should be designed that focus on prevention, and President Clinton should be enjoined to organized a summit that focuses the media on this objective. Messages are needed to offer alternatives when condoms are not used, including those that educate the public to the use of microbicides.

The Subcommittee had an extensive discussion about testing and how it should be addressed in the report. Issues included methods of encouraging people to get tested, structural and institutional barriers, access, and immigration policies.

Other topics included (1) education to address myths as to who becomes infected with HIV/AIDS, (2) dissemination of skill development and training, and (3) successful, multifaceted interventions. No single solution exists, which is a difficult "sell" as it relaters to prevention, but multiple issues exist with multiple populations and may have multiple solutions. Questions concern the design of community-based organizations, support of infrastructure to provide services, and linkages between public and private sectors.

Vaccine development was discussed in terms of its potential impact. Questions were raised as to whether the United States is prepared for implications regarding access and whether surveillance be conducted. Sexual health should be emphasized beyond HIV/AIDS, including STD prevention, which has been a taboo topic in this country.

Specific recommendations to address HIV/AIDS on a global scale include its inclusion in G-8 meeting discussions and the World Economic Forum. Increased funding should be discussed in the context of increased efficiency relative to the World Bank.

Dr. Gomez stressed that the common threads of stigma and discrimination should not be lost between the two committees, adding that travel restrictions should be eliminated for people with HIV/AIDS.

Ms. Aragon, chair of the Services Subcommittee, reviewed several principles or goals regarding the right to access to treatment for HIV/AIDS. Provision of clean water, medical services, and roads are all infrastructure-related components of this issue. In the United States, barriers to care include lack of support services, cost of drugs and treatment, and the overarching issues of homophobia and racism. People with HIV/AIDS should benefit equally from scientific discoveries and achievements.

Within the category, state-of-the-art care (versus "standard of care," which is often specific to the United States and assumes a level of infrastructure not currently available on a global scale) and treatments can be highly effective. Ms. Aragon raised the issue of the basic right and responsibility to ensure access to them. Needle exchange and other prevention programs work but are not always implemented where appropriate.

Leadership was another item addressed by the Subcommittee. Sustained and bold leadership and investment are called for to highlight domestic resource needs. The Council could request that the President issue an executive order within the last 100 days of his administration.

Joe Cristina will flesh out some of the youth issues that were not fully detailed during the Subcommittee session.

In conclusion, Ms. Aragon spoke about the Service Subcommittee's effort to design a comprehensive yet sensitive report that integrates domestic and global issues, and acknowledged the gulf between the two dimensions of access to health care and health care infrastructure. She said that this may be an ongoing issue for the Council as a whole as the report proceeds.

Ms. Thrasher involved members in a discussion on where to focus the remainder of the discussion. Ms. Aragon suggested that the Council's final objective for the 2-day meeting would determine their process. Mr. Dellums suggested that the optimal outcome would be a specific outline for the report, to be amplified by those completing the draft. Ms. Aragon suggested that, before breaking into subcommittees again in subsequent sessions, the Council make collective decisions. Mr. Dellums agreed that the first hour and a half of the meeting should be attended by all members.

Target of the Progress Report: Further discussion ensued on achieving consensus about the target of the report. Mr. Bau referred to the consensus that the report would be a defining document and should focus on targets versus themes, as was previously suggested by Ms. Aragon. The decision was made to concentrate the day's remaining time on a discussion of purpose and targets and reserve themes for Tuesday's session.

Mr. Summers said that the document does not have to be structured based on the identification of themes. In commenting on the report's target audience, he reminded the Council that the report should be specifically targeted to President Clinton, and then beyond him, to the American people. He said he views the document as relevant to a broad spectrum of the public, rather than Washington insiders.

Ms. Fraser-Howze said that President Clinton's legacy should be invoked, but that the issue is not bipartisan and that the future Administration must also be addressed and held accountable to following the guidelines of the report. She agreed that the American public constitute the third target audience of the report.

Dr. Parra said that the report should be a springboard to a national debate and addressed to both the current President and President elect.

Mr. Anderson supported the idea that the report should include an open letter to President Clinton, with a clear understanding of the target audiences beyond him. National and international media should also disseminate the report's contents.

Rabbi Edelheit said that religious communities should also be recipients of the letter, including the American Conference of Bishops, the national offices of Protestant churches, and others. He spoke about the fact that in the past, policy debates pertaining to HIV/AIDS were filtered through a "religious prism." He urged that these coalition partners continue to keep this issue on their respective radar. A recommendation was made to focus public attention through a kind of "Martin Luther" approach to delivering the report by figuratively nailing the document to the door of the White House so that it would be viewed as a public letter. The report should not "pull punches" but be used to leverage national and international attention.

Ms. Thrasher reviewed the previous discussion. President Clinton will be the direct target of the report, rather than the Administration as a whole and, subsequently, the next U.S. President and the American public. The report will include an open letter, and be a springboard for national debate before the upcoming election. It will also be addressed to original coalition members, including religious institutions, and further consideration will be given to disseminating the document. Finally, the report should avoid accusation.

Other Suggestions: Mr. Anderson urged members to resist what he considered to be an overly domestic focus of the report and to target it to a global audience, particularly to those suffering with HIV/AIDS

Mr. Burden suggested that a description of Council members' professional roles and responsibilities be included to emphasize that they have been selected because of their respective credentials and constituencies.

Mr. Bau approved the idea of an open letter but recommended that it be succinct and similar to an Executive Summary that might be available first, subsequently supported by detail presented in a meeting.

A recommendation was made that the Council draft headlines pertaining to the report, rather than allowing the media to determine the salient points. Dr. Gomez recommended that the Council name the report with marketability in mind. Mr. Montoya suggested that it be referred to as "A Call to Action," so that its title encompasses an overall description of its ultimate intention.

Ms. Fraser-Howze emphasized that the report, before being released to a wider audiences, should be considered by President Clinton.

A suggestion was made that a media consultant might be called in to maximize public dissemination and "spin."

Purpose of Report: Ms. Thrasher suggested that Monday's remaining time be devoted to a discussion of the report's purpose. Ms. Fraser-Howze responded by saying that in her view, the report has two purposes, which are to inform President Clinton and to educate the public. Rabbi Edelheit added that the report should represent a "carefully honed balance" between a critique of the past into the present, and a vision of the present as it relates to future policy with regard to the HIV/AIDS pandemic.

Ms. Aragon said that the report should not focus on identifying accomplishments as a primary objective but that these will be subsumed within a review of examples.

Mr. Summers suggested that a "USA Today" approach including sidebars and graphs could be used to review the status of the response to the HIV/AIDS epidemic. Bipartisan accomplishments should be acknowledged.

Dr. Stephen Boswell said that a major thrust of the report should be to promote innovative approaches and more concrete action.

Ms. Thrasher again summarized by saying that the report will inform the President, educate the public, and promote action. Content issues include less documentation of accomplishments and more discussion of examples of successful strategies in combating HIV/AIDS. Bulleted items will be included. The report will primarily address the status of the response to the epidemic, rather than the status of the epidemic, per se.

A comment was made that the next Administration should keep AIDS in the forefront of their agenda and that this should be emphasized by the report. Mr. Burden suggested assigning weights to different elements of the report. Mr. Summers suggested "inviting" rather than "promoting" action. He said that it might be important to include references to key target groups rather than a more anonymous call to action that might not result in as much action. Dr. Gomez then emphasized that the key word is "action," although further discussion might clarify an optimal approach.

Mr. Montoya said that in the past, notices have been sent out to organizations that subscribe via a clearinghouse including the CDC, HRSA (Health Resources and Services Administration), Ryan White planning councils, and others, so that they can request a copy of the report. A letter can be included within that copy to the community at large, asking them to apply the document in a call to action at the local level.

A recommendation was made to request specific items within the report so that presidential candidates would have to respond.

Ms. Aragon raised a point concerning the dichotomy in many people's thinking between the domestic and global dimensions of the HIV/AIDS crisis, and said that the links and synergy between these two dimensions of the crisis can be illustrated. She questioned whether this constituted purpose or a thematic element of the report. The response was that as an aspect of education, it falls under purpose.

Tone of the Progress Report: Ms. Thrasher focused Council members on determining the relative weight of various components of the report. Dr. Gomez, in referring to discussion held earlier by the Executive Committee, said that consensus had not emerged regarding this question. A recommendation was made that greater weight be placed on future strategies, particularly because the nature of the HIV/AIDS epidemic is changing.

Mr. Anderson agreed that the report's tone should be very forward looking and build the case for implementing successful strategies. He suggested that the Council may not be realistic in assessing its role as a presidential advisory body viewed as comprising national experts. He said that if PACHA weighs in in the middle of a presidential campaign with a review of the Administration's accomplishments or shortcomings, it will be viewed as President Clinton's partisan advocates. He stressed the need to transcend the political context of the report.

Dr. Gomez urged that both hope and commitment would characterize the tone of the report and that this would serve to motivate the public toward greater commitment.

Dr. Boswell said that the tone and balance of the report have to address both short- and long-range goals: short-range is to engage President Clinton; long-range must be practical and hard-hitting, based on practical, scientific approaches that can be implemented both nationally and internationally.

Ms. Cooper said that another element that relates to the report's tone is to address concerns of those who fear that a focus on the global level of the epidemic would reduce efforts on the national front. A comment was made that the report should be characterized by a tone of moral and ethical urgency. Dr. Parra said that the report's discussion of vision, direction, and leadership should be accompanied by recommendations, particularly development of infrastructure in developing countries and elsewhere.

Ms. Thrasher reviewed comments regarding how the report will be organized. Some discussion followed as to whether the report should include a literal "open letter." Mr. Anderson said that the purpose of the report would resemble that of open letter but was not making assumptions about the literal format of the Executive Summary.

Mr. Summers said that the report's tone should be set by a discussion of ethical implications of prevention and treatment policy, followed primarily by a discussion of specific recommendations. A question was raised as to whether recommendations would be based on ethical, scientific, or financial arguments, and how to balance these factors.

Ms. Thrasher then suggested the Council focus on framing the vision the report will put forth. Rabbi Edelheit said that the Council has an opportunity to frame the final statement of the Clinton administration, which will serve as a bridge to the new Administration. He stressed that the time does not call for "pragmatics" but that ethics should infuse economic and scientific perspectives. A vacuum currently exists in those discussions. He urged that ethics be viewed as the lens through which the Council focus President Clinton on his legacy as he leaves office.

Mr. Bau suggested that an open letter be drafted that identifies the Council and why it is engaged in this conversation with President Clinton, to be followed by a discussion of the ethical dimensions of the report.

Mr. Anderson said that if the report is a call to action, a case should be made for action. He affirmed the moral and ethical focus, but stressed economics and security-related issues and that the report should address them at the outset. He said that it is impossible to predict what people will respond to in reading the report and that all the facts should be succinctly presented in both making the case that HIV/AIDS must be dealt with and in informing the public how to do that.

Ms. Caya Lewis asked whether Mr. Minor's draft was relevant to the discussion, as many concrete items were included that could be applied. Ms. Fraser-Howze said that the opening statement, in whatever format, must be impactful and comprehensive. Ms. Aragon agreed that Mr. Minor's draft can be melded with the current draft. She said that she would like to see the listing of accomplishments from the first draft downplayed. Mr. Minor suggested that topics can be bulleted with these items addressed indepth later in the report.

In reviewing previous comments, Ms. Thrasher said that Mr. Minor's foreword might meld information pertaining to values or be left as a separate section after the Executive Summary. It could then make the case regarding the human, economic, security, and other costs of the HIV/AIDS epidemic.

Mr. Summers suggested that the Executive Summary should recap the ethical and then other arguments made in the body of the report. Mr. Montoya said the Executive Summary will describe the report's recommendations and that in previous sessions, it was referred to as a "preamble" or lead-in to various sections of the report. Judith Billings asked whether the Forward or Preamble precedes the Executive Summary.

Dr. Gomez said that the Executive Summary is a separate document and that the Preamble is the first section of the report, followed by a separate summary. It is traditionally included as an abbreviated version on top of the body of the report.

Mr. Montoya said that what has been referred to as the "Executive Summary" actually is the report. In this instance, a Preamble will be followed by the Executive Summary, and then the report, which will include all recommendations, correspondence, list of members, background information including charters and executive orders, and other material pertaining to the Council.

Mr. Summers suggested that a brief opening letter or three-page Executive Summary be sent to the President in advance. This would be more easily digested by public audiences, to be followed by a 10- to 15-page report that goes into further detail, with an addendum that includes the report. This could be more widely distributed and then published on the Web.

Dr. Gomez affirmed that President Clinton would receive the entire report. She asked whether, given this structure, a Preamble would precede the 10-page report. Mr. Summers said that when printed, all components should be bound as one document to preserve the context of the report. Ms. Billings agreed with and stressed Rabbi Edelheit's view that the Preamble, as the first visible document, should underscore the ethical perspective of the report.

Dr. Gomez clarified that the Executive Summary is a related but independent document. The report will include the Preamble, a 10-page report, and some 200 pages of attachments. The Executive Summary will include a summary of the Preamble and further abbreviation of the 10 to 14 pages written by the Council. Some readers will only focus on the Executive Summary, and it is crucial that elements of the Preamble are contained within it.

Rabbi Edelheit suggested that once the document is written, the Executive Summary can be distilled.

The session was adjourned until 8:30 Tuesday morning.

June 6, 2000