World AIDS Day Podcast Transcript


November 16, 2007

Mr. Christopher Bates: Welcome to this World AIDS Day webcast sponsored by I'm your moderator Christopher Bates. This webcast is for the Department of Health and Human Services grantees who are leading the domestic fight against HIV. As we move towards World AIDS Day, we want to have a conversation about domestic HIV prevention, testing, care, treatment, and research.

The goals of this webcast are to engage you in a dialogue on HIV and AIDS in the-and as we prepare to recognize World AIDS Day on December 1, we want to talk about the state of the domestic HIV/AIDS epidemic, and our efforts to combat it. We also want to highlight the departments' resources and programs. Today, we'll talk with the departments leading experts on HIV prevention, care, treatment, research, and substance abuse.

Our panelists include Dr. Parham from the Health Resources and Services Administration, Dr. Kevin Fenton from the Centers for Disease Control and Prevention, Ms. Beverly Watts Davis from the Substance Abuse and Mental Health Services Administration, and we are very pleased to have Dr. Anthony Fauci from the National Institutes of Health, but in order to make this a conversation, we need your participation. So please e-mail your questions for our panelists to

We have some participants today who were unable to log onto the webcast. They're going to be joining us by phone. We've also invited Federal employees working on HIV/AIDS issues to join us. A transcript and video of this webcast will be available at Please send in your e-mails. Now all of you have been working in the fight against HIV for a long time. Can you explain your respective roles here in the department? Dr. Fauci, can we start with you?

Dr. Anthony Fauci: Our role at the National Institutes of Health is the responsibility for the research that goes into the understanding of everything from fundamental pathogenesis of HIV, up through and including the relationship between epidemiology and the molecular virology, the development of treatments, the clinical trial of treatments after they've been developed and importantly the ultimate development of vaccine. So it really is the research arm of the department's comprehensive approach towards HIV.

CB: Thank you. Dr. Parham same question.

Dr. Deborah Parham: At the Health Resources and Services Administration, we are more-we concentrate on providing care and treatment for people with HIV. We provide grants to cities, to states and to community-based organizations such as health departments and health centers to provide care for people living with HIV and AIDS who don't have any other way to pay for their care.

CB: Thank you. Same question, Dr. Fenton?

Dr. Kevin Fenton: At CDC, I'm the Director of the National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention. We're really concerned about the prevention, control and elimination of HIV as well as other infectious diseases in our center. As with HRSA, we're involved with providing grants to a number of stakeholders including state and local health departments, community based organizations and other grantees to really push forward on prevention of HIV/AIDS in United States.

CB: Same question to you Ms. Davis.

Ms. Beverly Watts Davis: Well the Substance Abuse and Mental Health Services Administration really focuses in on providing HIV services to substance abuse and mental health providers across the country. There is such a nexus between substance abuse and HIV/AIDS and when we are able to actually leverage the resources within our grantees organizational capacity and community capacity. We're able to actually reduce both the incidence and prevalence of HIV/AIDS.

CB: Thank you. Dr. Fenton, as we approach World AIDS Day can you share with us the state of HIV prevention in the US?

KF: Sure. Maybe what I'll do is just begin on reflecting on the state of HIV/AIDS in the United States today. As you and many of our listeners are aware, we estimate that there are more than a million people in the US currently living with HIV, and we think that there are approximately a quarter of these individuals are undiagnosed. In other words, about 250-300 thousand people in the United States are still not aware of their HIV status.

Over the past decade we've seen tremendous changes in HIV incidence as well as prevalence in the US. As people are on treatment for HIV/AIDS, they're living longer and healthier lives with HIV. But we're also seeing changes in those that are affected by the disease. We're seeing increasing numbers of minorities affected by the disease. We're seeing increases in HIV in some rural parts of the United States, especially in the Southeastern parts of the US. And we're also seeing a concentration of the epidemic among those who are socially disadvantaged. And I think these are some of the challenges that we'll face as we think about prevention and control of HIV moving forward.

CB: Thank you. Dr. Parham, as the lead for the management of the Ryan White Modernization Act, which it is presently called, you focus on care and treatment, can you tell us about the status of services for people living with HIV and AIDS?

DP: Yes. There are many services that are provided under the Ryan White HIV/AIDS Program. We're mainly concerned about making sure that people have the proper medical care, oral health care, certainly as Ms. Davis has mentioned, substance abuse treatment, other services such as support services that people need in order to get into care and remain in care. So we focus on a whole range of services. We call them core services. We also have support services we provide for people living with HIV. There are about 500,000 people in care under the Ryan White programs, so about half of the people that Dr. Fenton mentioned are in care in the Ryan White programs.

CB: Thank you. I'd just like to take a moment to remind our listeners to please send your questions to us at Dr. Fauci, as a leader in the forefront of drug and vaccine development, can you give us the status of where we are with both drugs and vaccines?

AF: Yes. We're obviously, given what has been going on over the last several years, are doing extremely well with regard to drug development clinical trials and a real transformation of people who are HIV infected in their ability to lead relatively normal lives if put on appropriate drugs. If put on drugs at an appropriate time and monitored carefully, the results have been nothing short of spectacular. For example, last summer, there was a study that estimated from the time of the initiation of the triple combination therapy, until-which were around 1996 to the end of 2005, an estimated 3 million years of life have been saved in the United States alone.

The data from Europe, Australia, Canada and the developed world are quite similar. We are also starting to make inroads in the availability and accessibility of drugs in the developing world through a variety of programs. PEPFAR, the global fund, the Clinton Foundation, the Gates Foundation, etc. We also have, which we feel good about, in addition to the twenty-two, twenty-three drugs approved by the FDA, just this past year, there have been a couple of new drugs that have gotten into the pipeline and approved by the FDA that are actually directed at additional targets that would make much more comprehensive our menu of being able to attack HIV from a treatment standpoint.

From a vaccine standpoint, things are not looking as well, certainly, as in the treatment. Vaccine is a particularly problematic issue with regard to HIV for the simple reason that the body itself does not handle HIV and the immune response is not adequate against HIV. Most vaccines that we develop you try to mimic natural infection because in most cases, even with terrible diseases, ultimately the body overcomes the microbe and you have lasting protection. Unfortunately, that's not the case with HIV. The body does not handle HIV from an immunological standpoint. There's a lot of work ahead with regard to vaccine.

CB: Thank you very much. Ms. Davis, can you tell us about the ongoing efforts to address HIV from a substance abuse and a mental health standpoint?

BWD: Well SAMHSA has three different centers, our Center for Substance Abuse Prevention, our Center for Substance Abuse Treatment, and our Center for Mental Health Services. Each one of them has a capacity grant. We have approximately $112 million that we give out to grantees to actually make sure that they're connecting up people who are walking into a treatment center. It makes so much sense, if someone is walking into treatment, it makes perfect sense for them to be tested at that point, for them to-for us to make sure that we're checking them for sexually transmitted diseases and to make sure that we know treatment works, but that they have the recovery support services that go with it. Treatment works, but recovery is what helps people have a lifelong productive life. So we focus on prevention efforts to make sure that we are working with young people so that they don't ever-so they reduce their high risk behaviors. That we're working in treatment centers to make sure that those who are in treatment get tested and refereed, and that those who are in mental health centers also get tested and referred. So we connect all those efforts up to make sure that we are dealing with a population that has engaged in some risk behavior, particularly those with substance abuse, but also trying to prevent that risk behavior in the efforts that we're doing in prevention.

CB:Great. Thank you. Before we take our first question, I'd like to remind our viewers to send in their questions and please mail them to-e-mail them to us at We'll work to answer as many questions as possible. Some we may miss and hopefully we can get back to you at some time in the future.

Okay. It seems as if we have a question here for Dr. Fenton. Is the CDC developing new incident estimates, and if so, what are they and when can we expect them to be released?

KF: Thank you very much for this question, Christopher. As you are very much aware and many of our listeners are aware, there's been quite a bit of buzz about this recently. And yes, we are developing new incidents estimates and CDC and our partners are very excited about this, because this is finally providing us with information on where the epidemic is located, and one could almost say the cutting edge aspect of the epidemic. Who is getting HIV now? Who is the most recently effected with HIV? And therefore we're better able to refine prevention and intervention by understanding where the virus is evolving today. However, these incident estimates are very new.

We've used new methods to develop these estimates. We have some different estimates from what had been published previously, and it's very important that CDC has robust external scrutiny of these estimates in order to feel confident and to be absolutely confident that we are both providing the correct estimates and that our methodologies are also robust as well. So CDC has been working with peer reviewed journals to have the methodologies and the estimates, externally reviewed and we're looking forward to publishing the results in the very near future.

Until then, I think the key message for me is the same. We have good data now that gives us information on how the disease is spreading in the United States. Prevention really is the key. We cannot treat our way out of this epidemic. And certainly from CDC's perspective, we believe that there are three key components to our strategy. First of all, testing individuals, so people are aware of their HIV status, second and showing that people who test positive are linked to appropriate treatment and care services and for those people who test negative and showing that we are working with them to maintain safer sex practices or to reduce their risk behaviors. Prevention really is the key as we look forward on this epidemic.

CB: Wow. Thank you for that response. Our next question comes from Rochester, NY. Oh. It's for you, Dr. Fauci. What is the status of treatment research for women? Are they being overlooked? Are they being included? Where are we?

AF: They certainly are being included. With women, as is often the case when you have diseases, that affect women but also affect other populations, that women are almost naturally self-sacrificing themselves when they gave children who are affected or a spouse that is infected. You have to go the extra mile to include women in some of our research protocols. Research with regard to women that involves women fall into two categories, and they need to be distinguished. It's research in and of themselves and research on women as child bearers. The research on women as child bearers and preventing the mother to child transmission. The successes in that have been spectacular. The incidence of transmissibility from a pregnant women to her baby early on before therapy ranged from 25% in the developed world to 35% in the developing world. Right now with proper and adequate treatment you can get down to less than 1% and in fact, the incidences of children being infected from their mother at a perinatal area in the United States has vanished, practically. Then there's the more problematic research. Getting women into the standard research protocol.

Understanding the special difficulties that women have. Co-morbidities. How does HIV affect other diseases related to women? That's one of the important things. Also the future of microbocidal research. We have not been successful in getting a safe and effective microboside. And although microbosides can be used in men and in women-gay men with rectal protection and women with vaginal protection, still we have not been able to have and to develop a safe and effective microboside. This is particularly important in the developing world and in subcultures of the developed world where women do not have the empowerment to protect themselves by standard ways such as condom use. So that to me is a goal that we really need to keep our focus on which is microbocidal research particularly for women in their prevention.

CB: Well, perinatal transmission is exciting news.

AF: It is.

CB: I think we should all be very happy about that. We have a question from Michigan, for you, Ms. Davis. The question is how does one go about getting resources from you as it relates to mental health resources.

BWD: Well in particular the Center for Mental Health Services provide capacity grants for mental health centers all across the country to expand those services to provide services for people who are living with AIDS or people who are at risk. Again, mental health is something, that as we address the whole issue of HIV and AIDS, we believe at SAMHSA that it is critical that no matter what we're doing with any of the grants that we actually address the mental health issues of all people who come in. Because, again, if you can imagine somebody walking into a center, finding out that they are HIV-positive, understanding at that moment, at that one moment thinking what's going to change in my life and what am I going to do. All the things that are going to go through. There's things to deal with. Depression. We certainly have addressed-we certainly see rises in suicide. It is incumbent upon us to actually expand our services in our mental health centers to address that. I do want everyone to understand that that is a part of the comprehensive services that are in mental health centers today.

CB: Hm. It seems like our next question is coming from New York. There is a rising number of young MSM's, especially in communities of color where resources seem to be questionable in terms of their availability. I think this is a question for you, Dr. Fenton; can you speak to prevention services being made available for men who have sex with men?

KF: Absolutely, and this is a very, very important question for us to consider today. In part because gay and bisexual men or men who have sex with men, still continue to bear the brunt of the HIV epidemic in the United States today. In fact, we estimate at CDC that about 67%, nearly two thirds of new diagnoses of HIV/AIDS are occurring among gay and bisexual men or men who have sex with men. So as we think about our prevention efforts, we need not only focus on different ethnics group which are differentially impacted by the disease, but we also need to focus on preventing disease among men who have sex with men.

Now among MSM, we know that younger MSM are particularly high risk. And CDC has done a number of studies in urban areas across the country which have highlighted very high incidence rates of HIV among young MSM, those age sixteen to twenty years who are just beginning their sexual career. So thinking about the prevention efforts, what are some of the things that we can do. Again, I think there are three key principles of prevention. We need to encourage HIV testing among young MSM and, in fact, all MSM. We need to encourage those who are tested HIV-positive and ensure that those MSM gay men are in care. That they're receiving proper therapy. We also need to deliver appropriate prevention intervention for HIV-negative and HIV-positive MSM and CDC have been developing a number of prevention interventions specifically targeting those MSM that may be at high risk.

Finally, we need to encourage those MSM who are HIV-negative to ensure that they stay negative, and that there is a benefit to remaining HIV-negative, even today, twenty five years into the epidemic.

CB: Great. Next question is for you Dr. Parham. What is happening with people living with AIDS in Puerto Rico? We know that they are having some challenges around the availability of care services.

DP: Yes. We at HRSA are very aware of the situation in Puerto Rico with people living with HIV and AIDS trying to access the services. The good news is that people in Puerto Rico are able to get services. There are some challenges with some of our grantees. We continue to work with them to provide technical assistance so that the Commonwealth of Puerto Rico as well as San Juan, the people are able to access services in those jurisdictions. We are very aware of the challenges that remain and we are very committed to working with them to address those challenges. The key thing is that we want to make sure that wherever you live in Puerto Rico, if you are living with HIV, that you're able to access services and there are many Ryan White services that are being provided by the healthcare practitioners in Puerto Rico for those patients.

CB: Thank you. Our grantees often ask about resources for preventing HIV or providing care and treatment, can you name some resources that you think would be particularly helpful for our listeners. Dr. Fauci? I pose this question to you first.

AF: From the standpoint of questions we often get asked. It generally relates to the availability of clinical trials. Someone is infected. Someone has been on therapy and wants to see if there's a trial that is available for people who are not succeeding on therapy. Someone is newly infected and want to see if they can get on a clinical trial. We have a website that is very easy to access. You go in and you're there. You go to the NIH website, and you can just go and it will just put you right on the face page. You go right there to clinical trials and you click in. It's right there in front of you. All the possibilities that are available to you and the location where the trials are being carried out.

CB: Great. Well before I pose the same question a similar question to Dr. Fenton, I want to remind the viewers that we need your questions. I suggest that you send your questions through e-mail to Dr. Fenton, you, the same question about resources that our viewers can easily get to.

KF: I think that's a great question. I want to thank the listener who asked that because that's often a question that I get asked a lot. How can we access CDC's prevention resources and where can we get more information. Well, first of all, I'd like to encourage our listeners to go to because I think it's a great new website which is providing an overarching view of HIV/AIDS activities across the US government, but of course, I'm also going to tell people to locate the CDC's site at and that will take you to-our HIV portal and there you can get information on the epidemiology of the HIV/AIDS in the United States as well as internationally information on prevention programs. Information on groups that are at high risk of acquiring HIV and what CDC is doing to prevent HIV in those groups as well. We also are linking much more effectively as well across all infectious diseases in our national center. And this is part of our move towards looking towards more holistic prevention services, so really maximizing opportunities for preventing STD's, hepatitis, and even tuberculosis by those who are infected by or infected with HIV infections. So again, the website will be a great location in partnership with the site to get more information on what we're doing at CDC and how individuals can access resources as well.

CB: Dr. Parham, the same question.

DP: The Ryan White resources are available in all states and territories, Washington DC, Puerto Rico, Virgin Islands as well as the jurisdictions in the Pacific. There are resources available in each of those states. The way that you access those resources might be different. There is money that goes directly from the Federal government to certain community based organizations. We also give money to each of the states for them to distribute because we know the states would know better where to distribute those funds. We look at the data that they get from the CDC to determine who is living with HIV in those states and try to target those Ryan White resources to meet the needs of those affected populations. We also give moneys to cities. Those cities that have the most people living with HIV and AIDS in their jurisdictions. We give money to them. It's the same thing. We give the money to the city. To the governor. I'm sorry-I mean to the chief elected official, usually the mayor of the city. And that person appoints a counsel that has community members on it and they're the ones who make the determination of where the resources should be best spent into their community. We work in partnership with the cities and with the states and with the community based organizations to make sure that the Ryan White Resources. And it's funded at $2.1 billion. We make sure that those resources are available throughout the United States and the territories.

CB: If one of our viewers wanted to reach you, what web address site would you send them to? What's that address?

DP: Again, you could go through or also to the HRSA website

CB: Dr. Fenton, before we go to Ms. Davis, could you talk a little bit about your web messaging project-text-I think text messaging.

KF: Yes. Our text messaging project. This is a really exciting development and at CDC we're partnering with and The Kaiser Family Foundation on really making access to our HIV testing sites, much more readily available to anybody who has a mobile phone.

Essentially, here's what you have to do. Hopefully you all know how to text. Simply text "KNOWIT" and the number is "566948" and in the body of the message type in your zip code. Within a few minutes-I think you tried it earlier. Within a few seconds, even, you will get the top three to five nearest HIV testing sites to your zip code in your residential location. This really is making wider availability and more easily available information on HIV testing site which really is a key step for everybody to know their HIV status. Again, I want to acknowledge the fact that we're collaborating very closely with the Kaiser Family Foundation and colleagues here at HHS in this really new and exciting development to provide better information on HIV testing sites for every tong.

CB: Great. Thank you. And the resources question for you and how our listeners can get to you?

BWD: What I do want to encourage all the listeners to do focus in on because it is a collection of all of our efforts in one place. It's a one stop shop.

At SAMHSA, aside from the capacity grants, you all should know that in many of our states, twenty five of our states we have a 5% set aside in the block grant, all states receive a substance abuse prevention and treatment block grant, but in the states that have a high incidence rate, there is an additional 5% funds that come from the block grant that can be made available to be used for treatment and/or prevention. But in addition, each one of the centers that I spoke of earlier has a capacity building grant and those grants are actually open to the entries public. So that you can't-if you have innovative practices that you believe have a nexus to substance abuse and there are so many things that have a nexus to substance abuse. If you are working on family violence, there is a nexus to substance abuse. If you are working on crime prevention, there is a nexus to substance abuse. If you're working on sexually transmitted diseases, there's a nexus to substance abuse. So I share with people all the time. Broaden your thinking and thinking about how do you leverage resources to blend those funds together, to weave that fabric of community you need, but at SAMHSA, our email address-at SAMHSA our website address is and all of our grants are posted on there.

CB: Wow. I think we're getting a few more questions in. Well-wow-could, you know-we know that disproportionately men who have sex with men are being impacted by the epidemic now. And of that group African American men, who have sex with men, are highly impacted. Could you talk a little bit about CDC's response to this particular subgroup?

KF: Thank you so much for that question and this builds upon the response I gave earlier about what we can all do to combat HIV/AIDS among men who have sex with men.

The data are, in fact, quite startling and studies which CDC has done across the US looking in major urban areas, not only do we see high incidence of disease but also high prevalence of disease as well. In other words, the number of men, black gay men, who are living with HIV, often ranges between 30-40% on average up to 50% of black men in these urban centers. Why black gay men may be at high risk-particularly high risk for acquiring HIV, the data are still being analyzed and we know that there are multiple factors to explain this-in part it could be because of patterns of sexual mixing in the population.

We know that there are some higher prevalence's of viral and bacterial STDs among African Americans in the United States and of course STI's facilitate HIV transmission. We also know that factors such as drug use, or other types of concurrent or cofactors for HIV transmission may be differentially impacting black, gay men. So when CDC is thinking about strategies for preventing HIV among black gay men, not only do we focus on the overarching principles of HIV prevention, testing, working with positives, working with individuals who are negative, but also we are looking at strengthening our activities in four key areas.

First of all, investing in numerous research studies to better understand why black gay men are impacted, and how we can develop new prevention interventions to meet the needs of black gay men. Second we need to ensure that our prevention programs are penetrating far more deeply into the black gay men community. In other words, how do we use our DEBIs other prevention and intervention and ensure that we scale them up across the community. Thirdly, we need to mobilize within the black community. We need to be working in partnership with our black MSM partners and our work with the national black gay men's advocacy coalition, which is a very new group, bringing together black gay men who are concniered about the impact of this disease on their community. And then finally we need to show that we are spreading the message and having authentic conversations about the impact of the disease in this group. So there are a number of things that we can all do to prevent the impact of HIV/AIDS in black gay men.

CB: We have a question from a viewer about our work with faith communities and this question comes from Texas, and directed to you Ms. Davis. Could you talk a little bit about where SAMHSA is in working with faith communities around substance abuse and mental health issues?

BWD: This is one topic I'm excited about-thank you for asking this question, because it gives us a chance to really broaden that, because we want to make sure that people really understand, particularly in the black community one of the institutions that is trusted, has credibility and has far reach, both wide and deep, in the black community, is our churches and the faith community and SAMHSA actually has-we've developed a program for the minority AIDS initiative fund that actually funds faith based organizations who are partnering with community coalitions to actually spread the word to be able to weave the messages within faith services to add testing into churches. And I have to just tell you, the results of that have been amazing. We have had-in particularly, in one church, they tested literally within six months over 11,000 people. I mean, and again, it speaks to the credibility. And when we address an epidemic such as HIV/AIDS. There is, at the table. There is a seat for everyone. No one is excluded from that table. No one can be. One of the things that we do with our faith imitative is really about bringing people together to really use that collective community wisdom. To build the community capacity. To use the gathering and everyone putting their resources together to create a safety net and a net that begins to help the people who are impacted by HIV/AIDS to get the services that they need. Many of those needs are fulfilled by the faith community. So SAMHSA has stepped out to really engage and fund-we're funding over seventy different faith organizations that are across this country have done an amazing job in terms of spreading the word and also making sure that people get tested.

CB: Oh. Great. Great. Great. Dr. Fauci, we have a question for you from another physician who's listening. This physician asks, if you could talk about a study that I believe you're involved in relative to the eradication of this epidemic?

AF: Yes. That's obviously a question on the mind of many people who are taking care of HIV-infected individuals. Particularly individuals who are on therapy and have viral loads in their blood, their plasma that is below detectable level. And the question arises you have a patient. You've been treating that patient for several years. They're clinically doing very well. No detectable virus. What is the chance of actually eradicating the virus from the body, and by eradication, we mean, no trace of virus and when you do the ultimate test of discontinuing therapy, that the virus does not rebound.

Several years ago, we and others throughout the country and in some other European countries, did studies where we kept people suppressed with no detectable viral load after several years CD4 counts of 600-700 and empirically stopped therapy and in essentially every single one of those individuals, the virus within a period of a few weeks rebounded back to what was felt to be their original set point. So clearly, what would have thought to have been the perfect opportunity to eradicate was not successful. So the study that's being done now, is to get a group of individuals who were treated, and this is the best case scenario, and perhaps we can extrapolate it from there, who were treated very early in the course of their infection who actually have no detectable viral load, but also when you look at that very recalcitrant reservoir particularly in resting CD4-positive T-cells, you find very, very, very low levels of proviral DNA integrated into the genome of the cell. In those individuals, if you could accelerate therapy, particularly by adding on other new targeted antivirals such as intergrace inhibitors or entry fusion inhibitors. If you could do that for an additional year or so, could you actually get to the point where you truly eradicate. If you can do it in those selected patients who are the best possibility, then we'll look a little bit later on.

We don't recommend that physicians try that now, because we want to make sure that we have a good scientific foundation to do that. But, there are studies that are ongoing we're involved, as the groups in Canada and groups in other parts of the United States that are looking at just that question. Hopefully, within the next few years we'll be able to answer that question.

CB: Wow. That almost sounds like a cure.

AF: I hate to use that word. Because when you use the word "cure", that gets taken out of context and people start talking about who's cured, and right now we're doing very well with suppressing the virus, but it really behooves us to see if we could push the envelope a little bit further to see if we can actually eradicate it.

CB: Very promising. Very promising. Dr. Parham, this is a question for you. What is the care act doing to target services to people of color living with HIV and AIDS? This question comes from a woman in Washington DC.

DP: Most of the Ryan White services are addressed and targeted towards people of color. About 70% of the patients we see in the Ryan White Care Act are people of color, and in Washington DC that percentage is even higher. So there are services available. As we look across the country, we try to focus on everyone who is living with HIV and AIDS who doesn't have any other resources to pay for their care regardless of their race and ethnicity. Anyone who meets those criteria is eligible to access services under the care act. But yes, we do target to those populations that really need the services and can't pay for them otherwise and a majority of the patients that we do provide care for under the Ryan White program are African American, Latino and Hispanic, Asian American as well as Native American and Alaskan Natives.

CB: Once again, I'd like to remind our viewers to send your e-mail questions to us at Okay. We have a question coming in. It's for you, again Dr. Parham and I believe also for you, Dr. Fenton. Could both of you speak to how we're addressing HIV/AIDS Services for native Americans living both on reservations and off the reservation? Dr. Parham.

DP: Native Americans are certainly one of those populations that are affected by this epidemic. And we want to make sure that we do have services available for them. Yes, there is the Indian Health Service, but we also do allow people who are Native Americans to access services through the Ryan White program. So there are people, Native Americans who live in urban areas, for example and they're able to access services at any of our Ryan White clinics and on the reservations it's more limited to the Indian Health Service and the Tribal organizations to provide HIV/AIDS care. But, yes, there is no restriction in terms of Native Americans being able to access services through the Ryan White Healthcare Act.

CB: The same question for you, Dr. Fenton.

KF: Again, I think this is such a wonderful question and it really highlights another sector of the population, which is also disproportionately affected by this disease, and in fact, Dr. Parham and I were only at a meeting this morning where we were actually reflecting on the epidemic among Native Americans and what our agencies were doing to respond to this epidemic.

From the CDC's perspective, again, we fund states which have developed programs specifically targeted at Native peoples to not only target only HIV prevention activities, but are beginning to look at some of the social determinants of HIV transmission within this community. What do I mean by social determinants? Remember that HIV transmission is not only being driven by high risk sexual behaviors, but if we are ever going to get a handle on the epidemic, and, in fact, get ahead of the curve, it's really going to be important to focus on issues such as access to care, behaviors such as drug use, alcoholism, which may be ravaging through communities across the United States, issues such as dislocation of population and stigma and discrimination. So CDC funds, state and local health departments and we also fund a number of community based organizations which are doing innovative work, targeting not only risk behaviors but promoting testing, but are beginning to look at some of those social factors which are driving HIV in the community.

CB: Wow. Thank you for that response, both of you. We really have a tough question here before us now. I'm going to open this one up for response from any or all of you. The listener asks could you address the impact of racism, homophobia and poverty on HIV and AIDS. Dr. Fauci?

AF: They are three of the most insidious and destructive aspects of our society that have to do with diseases of any type. With HIV when you're dealing with homophobia and racism, poverty transcends all diseases, but homophobia and racism, particularly, when you have a disease which disproportionately affects gay men. And which disproportionately affects people of color. Then you have a difficult situation, for reasons that we've actually discussed-Dr. Fenton made a comment a little while ago about the number of people in this country who are infected and 25% of whom don't even know that they're infected. It is very difficult for people to come forward and get into the system of being tested and making themselves available for counseling and making themselves available for treatment when that would reveal things that disenfranchise them from the society. Homophobia is one. Racism is another. Poor people don't have access to hardly anything. They don't have access to health care. Therefore they don't have access to testing. They're poor. They don't have a doctor. They can't get into clinical trials. So all of those three things are, in my mind, obstacles that we must get over if we are going to address the HIV epidemic in this country. Each and every one of them contributes in a very negative way to what we're trying to do.

CB: We have four responses coming from that same three question point. But I think we're going to move on to yet another question. Okay. Thank you for your response. World AIDS Day. Tell us what you think-what makes World AIDS Day important? What can our listeners and folk in their community do to help us promote World AIDS Day? I'm going to start with you, Dr. Parham.

DP: I think it's important to do a couple of things for World AIDS Day. One, I think it's important to pause and remember. There are many people who we have lost to this epidemic. There are many people, though, that are living, with the virus and is living fairly healthy lives. That's because they know their status and they have gotten into care. Once you get into care, as Dr. Fauci said earlier, you're able to get the medications that you need and you're able to leave fairly healthy lives for long periods of time. It's important to know your status. To get into care. There is care available in your communities, generally. It's important that you do know your status, and get into care.

CB: Ms. Davis, same question.

BWD: Most important, people get involved. The health of your community is really incumbent upon your action. Getting people-understanding-finding out what you can do-finding out whether it's to be able to talk with young people about risk behaviors. Be able to help someone get to care. Drive someone. Figure out there are small things and wonderful things that every-each one of us can do to help in communities.

If you don't have HIV/AIDS, figure out how you can help someone who does. Figure out how you can spread the word. Get your local TV stations to put things on the air, in your newspapers, in the media. Put pamphlets in your church bulletins so that you're spreading the word and not the disease. Get involved. It's through citizen action that we change this country, and citizen action will make a difference.

CB: Wow. That was pretty complete. Thank you. I think I'm going to pose this next question to Dr. Fenton. We're now seeing a percentage of folk fifty years of age and older having to cope with HIV and AIDS, what prevention interventions are you all moving towards for this segment of the population?

KF: Thank you very much for that question. It's funny-I'm often asked this question when I go to conferences and often it's by individuals with slightly grayer hair than mine two are really interested in knowing what are we doing and how can we meet the needs of people who are older and who are at risk of acquiring HIV.

I think there are two things that we need to remember. First of all, there's an aging cohort of individuals who are diagnosed HIV-positive and who are living longer and healthier lives and who are now just aging. There are also people who live through the first twenty five years of this epidemic, who practiced safer sex and who were in relationships which placed them at lower risks during the epidemic who are now saying, I've practiced and kept myself good for many years, it's time for me to relax. And those are individuals who are now seroconverting. So we have two effects occurring in the over forty-fives in the United States. CDC has really been focusing on prevention interventions across the age spectrum, but particularly among those who are at greatest risk of the disease, particularly those young people and those in the twenty to forty-five year old age group. That's where we see most of the new diagnoses occurring. But we do encourage many of our prevention interventions to be delivered across the entire spectrum of the population. I'll give you an example. Last year we announced our new HIV testing recommendation and we encouraged routine HIV testing to occur between-for individuals who were attending medical services who are between the ages of thirteen to sixty-four years. Yes. We could have gone a little bit older, but again, that's where we see the majority of new infections occurring.

Again, we are encouraging all Americans to get tested. People who feel they may be at risk. People who feel they may still enter risk for acquiring HIV to be aware of their HIV status. To have authentic conversations about HIV and to, of course, get tested.

CB: Wow.

AF: As physicians who actually take care of patients, we shouldn't be afraid to ask a sexual history to somebody who's older than thirty years old. Back in the old days, if you asked a sexual history of a fifty-five year old woman, you'd get smacked and she'd walk out of the office. But it really is very important, as you've mentioned, not only testing, but to talk about these things, with your patients who are over fifty years old.

CB: Wow. Okay. We have a completely different direction we're going. This is a question for you, Ms. Davis. The listener is asking for more information about and understanding the set aside and how they in fact can get in touch with those resources at the state and local level.

BWD: Very good. Thank you for asking that question. That is, I think one of the best kept secrets, quite frankly in the HIV prevention world.

SAMHSA does have, as I said, a block grant. And the block grant goes to every state. It's for substance abuse prevention and treatment, but as a part of that, 5% of the funding that goes to that state is actually set aside for HIV activities. This allows for funding testing, counseling, referral services, and actually there is-some people have used this to help pay for housing, support services. For those with HIV/AIDS. Again, I want to be very clear that that funding goes to the states that have the top incidence rates based on the data from CDC. So we have approximately twenty-five states that have the funding. And I would hope that one day we would be forward thinking and that all states be able to have that 5% set aside. It makes sense for us to use-I would hate to think that we have to get to a point that we always have to get to the crisis level before we do anything about it. That's what we're all about. We're all about prevention and expanding that. Again, that funding is accessed through your single state agency. And the single state agency is the Agency that actually administers the block grant. It will be your alcohol and drug abuse agency.

CB: Thank you very much for that. It seems as if we've also gotten several questions around individuals who've been incarcerated or who are being released from our correctional facilities. I'd like all of you or at least a couple of you to respond to that and tell us a little bit about what the departments response has been in relationship to our partners at the state and local level?

BWD: One of the things-I can start with that. One of the things for the past two years the Center for Substance Abuse Prevention decided to targeted incarcerated people and the grants that they actually gave out were for organizations to come together and actually address those people who were recently incarcerated. And amazingly enough with the grants, not only were people who were recently incarcerated, immediately as they stepped out of jails, and prisons, they were embraced by, quite frankly, a coalition of people who would help them get housing, etc. But most importantly, to get tested. And then they're also working inside of the prisons to actually begin to speak to the prisoners about same sex practices, all those kinds of things. In some cases there are truly movements among STAR grantees to begin to help change their state laws to allow for preventative measures in prisons, such as the distribution of condoms. Many-most recently, at the National Conference on AIDS or the US Conference on AIDS. Again, I think one of the things that startled many people is to find that in prisons condoms are not allowed, which, again, doesn't make a whole lot of sense.

DP: I would just like to follow up with Ms. Davis' comments that it's certainly one of the populations that we're very concerned about because many of the people who are incarcerated know that they're HIV-positive when they go into prisons and when they come out, they go right back into the same community. We are very concerned that while they maintained their care while they're incarcerated. We want to make sure they're linked into care when they are released from jail as well. We have a special initiative that we just began last month, actually, partnering with jails and the community in which the jails are located and we know where the people would be released back into the community to figure out ways that we can work with those jails and the community based organizations to form those linkages before the people are released from prison, so that when they are released they are able to maintain care so that the don't then transmit the virus to other people.

CB: That's great. Very briefly.

KF: Very briefly. In addition to what my colleagues have said of importance at looking at pre-entry, while one is in prison and then on release, prevention interventions. One of the things we're certainly concerned with and moving forward with at CDC is thinking about linking prevention services because, again, we have opportunities for tackling not only HIV with corrections but STDs, tuberculosis and viral hepatitis as well. How can we bundle and package services so that we use every opportunity for testing and screening as efficiently as possible, and CDC is really looking at supporting out state and local partners around these interventions as we move forward.

CB: Well, this has been exciting. I'd like to thank our listeners for their questions. And those who sent in questions that didn't get answered this time, we apologize. But we were restricted by time. Before we leave today, I'd like to ask our panelists to give us brief closing remarks. Highlight something that you think we may have missed as it relates to the area which you work. I'll start with you, Dr. Parham, and then we'll work our way around.

DP: One thing I want to emphasize is that the Ryan White program is available for people who are living with HIV and AIDS to get care and treatment. We know that if we are able to give you treatment, you're able to live long and healthy and productive lives and that's what we try to encourage and we do have programs available-as I said, earlier in all of the states and many of the cities, and even in rural areas around this country. Know your status. Get into care.

CB: Ms. Davis.

BWD: I would like to say to everyone that as we're getting ready to celebrate Thanksgiving, there's a lot to be thankful about, in terms of how far we have come. We still have a ways to go. But it's important that you recognize that as you look at the panel here, we are working together better. We are coordinating. We are collaborating. We are communicating and we ask you all to do that too.

As you see these agencies here, find out who else in your community also has received funding. I recognize that people who often receive SAMHSA grants don't necessarily connect with the people who receive CDC grants or HRSA grants. And my key message to you all is to get connected. Truly connect the dots in your community so you can truly create the kinds of continuums of care that will help people, again, maintain their status and that we don't-we do reduce the prevalence of HIV/AIDS. Together-working together actually works.

CB: Great. Dr. Fenton.

KF: Very briefly. I have nothing much more to add to what my colleagues have said but I do want to encourage people who are listening to visit the site, which really has great resources in preparation for World AIDS Day. We need to create a movement in this country around HIV/AIDS. It is no longer acceptable that this should be ravaging our communities in the way it is. And we've got to stop it now. This website, provides wonderful resources for everyone to make a difference: at the individual level, at their churches and in their families, in their schools. We have got to create a movement and it has to start with us.

CB: Thank you. Dr. Fauci. You get to have the last word.

AF: When you asked the question, I couldn't help but think about what you asked a little while ago about what the meaning and importance of World AIDS Day is, and to me it really is what I'd like to have my closing comment be is that it's been twenty six years and five months since we first recognized the first cases of what turned out to be HIV/AIDS in the summer of 1981 and there have been spectacular advances in research and treatment and prevention and public health over those twenty six years, but the model that I try to drive myself with is that although there's much accomplished, there really is much to do. And we, as a group, all of us, are going to be judged as much by what we do in the next twenty-six years as what we've been accomplished in the past twenty six years. That's what World AIDS Day in my mind needs to remind us about.

CB: Wow. That's fabulous. Now, on that note, as we close, we want to remind you that the Federal government also has excellent resources in the international fight against HIV and AIDS. For more information about our international activities, please go to As a reminder, if you missed any part of our conversation today, or if you'd like to view it again, we will be posting this webcast on Thank you, and have a great day.

Last revised: 04/03/2008