March 3, 2006

This Week in Washington
1. Congressional Briefing Addresses the HIV Prevention Budget

In the News
1. Research Team Favors HIV and STD Prevention Campaigns for General Public, Not High Risk Populations

The CARE Act in Brief
1. Senate HELP Committee Holds Ryan White CARE Act Hearing
2. Senator Coburn Introduces CARE Act Reauthorization Bill
3. GAO Releases Ryan White CARE Act Report

Announcements
1. “AIDS Forum” on Bronx Treatment, Survival, and Community Issues
2. National Women & Girls HIV/AIDS Awareness Day Observed
3. The Balm In Gilead Holds 17th Annual Black Church Week of Prayer for the Healing of AIDS

This Week in Washington
1. Congressional Briefing Addresses the HIV Prevention Budget
On Wednesday, March 1, a Congressional briefing, entitled Budgeting for an AIDS-Free Nation: An Examination of the Federal AIDS Prevention Budget, took place on Capitol Hill. The briefing was sponsored by Senators Gordon Smith; Hillary Rodham Clinton; Jeff Bingaman; Representatives Eliot Engel; Jesse Jackson; and Barbara Lee in conjunction with The AIDS Institute; amFar, The Foundation for AIDS Research; the National Alliance of State and Territorial AIDS Directors; and the HIV Prevention Action Committee of the Federal AIDS Policy Partnership. AIDS Action, a member of the HIV Prevention Action Committee, had staff in attendance.

Moderating the briefing was Jesse Milan, Jr., co-chair of the CDC/HRSA Advisory Committee on HIV and STD Prevention and Treatment. Mr. Milan began his remarks by recognizing this year as the 25th anniversary of the discovery of HIV. Twenty-five years later, he remarked, those working on HIV prevention have an opportunity to re-assess our efforts and make changes where appropriate. Such a reassessment is especially important for two reasons, he added. First, the Centers for Disease Control and Prevention (CDC) failed to meet its strategic goal for 2005 , which was to reduce by half the annual number of new HIV infections in the United States, from an estimated 40,000 to 20,000. Second, this past summer the agency increased its estimate of people living with HIV in the U.S. by 20 percent to an estimated total of 1,039,000 to 1,185,000 individuals.

Jennifer Kates was the first speaker to present. Ms. Kates is vice president and director of HIV Policy for the Kaiser Family Foundation, a nonpartisan health policy organization. Ms. Kates focused her presentation on how federal funding for international and domestic HIV programming, including prevention, has changed since the U.S. Government began appropriating money to respond to the epidemic. She pointed out that overall funding for HIV programs is less than one percent of the entire federal budget. Within the HIV portfolio itself, prevention funding has decreased as a percentage of the total portfolio. This situation is true for domestic funding alone and in combination with international funding. For example, in 1995, nine percent of funding—both international and domestic—went to prevention; whereas in 2006, only four percent did.

Following Ms. Kates, Dr. David Holtgrave spoke. Dr. Holtgrave is both professor and chair of the Department of Health, Behavior, and Society at the Johns Hopkins Bloomberg School of Public Health. Dr. Holtgrave pointed out that the CDC’s national estimate for new HIV infections annually has not decreased in 16 years—remaining at roughly 40,000 a year.

Continuing, Dr. Holtgrave said that 33 states now report name-based, HIV incidence data to the CDC. Referencing the November 18, 2005 issue of the Morbidity and Mortality Weekly Report, a CDC publication, he reported that data from these 33 states for the last four years total 157,252 HIV diagnoses, which amounts to roughly 40,000 new infections a year in these states alone. Moreover, he said that HIV incidence usually exceeds the reported number of diagnoses. Thus, he concludes, the number of new annual HIV infections nationally may be significantly higher than the CDC’s estimate.

Pointing out that the CDC did not meet its 2005 goal of reducing new infections by 50 percent, Dr. Holtgrave said that when the CDC revises the goal, they should monitor “annual progress toward the goal…in terms of (a) national investment, (b) process measures (in terms of policy implementation, barrier reduction [to the achievement of prevention goals], and service delivery), and (c) annual outcomes assessment.”

The final speaker on the panel was Dr. Deborah Cohen from the RAND Corporation, who presented her findings on “Using Cost Effectiveness to Build a New HIV Prevention Strategy.” Dr. Cohen’s study “compared the cost effectiveness of 26 different interventions to prevent HIV infection.” She identified the following interventions as the most cost effective (in order of cost per infection averted, from least to greatest): video in sexually transmitted disease (STD) clinics ($4,700), partner notification ($6,100), community mobilization for men who have sex with men ($12,000), STD screening in HIV clinics ($12,000), needle exchange-high and medium prevalence ($13,000-47,000), explicit mass media campaigns ($18,000), opinion leader program for MSM ($23,000), and condom availability ($47,000). Counseling and testing (CT), she said, was an intervention notably absent from this list, even though an estimated 50 percent of the prevention funds that go to states and localities is spent on this intervention. She argued that public prevention funding should not be focused on CT but should instead be spent on the eight most cost-effective preventions that the study identifies. According to Dr. Cohen, CT costs should be shifted to public/private health insurance and Medicaid/Medicare.

To see a webcast version of this briefing, go to the Kaiser Family Foundation Web site: http://www.kaisernetwork.org/healthcast/amfar/01mar06. And to access RAND’s HIV prevention planning tools, go to http://www.rand.org/health/tools/hiv_prevention.html.

In the News
1. Research Team Favors HIV and STD Prevention Campaigns for General Public, Not High Risk Populations
Targeting populations that are considered to be at highest risk for HIV infection and sexually transmitted disease (STD) may not be the best approach. That is the conclusion of an article appearing in the March issue of the International Journal of STD & AIDS. According to researcher and public health expert Tom Farley of Tulane and his coauthor Deborah Cohen of the RAND Corporation, a nonprofit research and analysis institution, broader campaigns for the general public may be more effective.

As Dr. Farley explained to Newswise, an online service for journalist, “This idea might appear intuitive, but often in public health we have focused on profiling individuals at high risk of getting or spreading HIV and other STDs, and then talking directly to them.

“In this article,” he continued, “we argue that directing our efforts towards changing the overall acceptability or opportunity for risky sexual decision-making might be more effective than the one-on-one interventions.”

To illustrate this principle, Dr. Farley draws on the history of efforts to reduce excessive alcohol consumption. Identifying heavy drinkers at clinics or the doctors' offices and then attempting to help them individually was not as effective in reducing overall excessive consumption as increasing taxes, changing laws and limiting access to alcohol, he commented.

In the past, Dr. Farley and Ms. Cohen have shown that it is cost-effective to target efforts towards very narrow populations who are at highest risk for HIV transmission, such as men who have sex with men and injection drug users. However, as Newswise reports, they also believe it would be cost effective to develop larger campaigns for a broader audience, and to evaluate social and policy issues to determine whether they are enabling or inhibiting healthy behaviors. The goal of such efforts should be to reduce the number of lifetime sexual partners across the board, Dr. Farley notes, thereby reducing the disease risk for everyone.

According to Dr. Farley, broader campaigns could be more effective because “people influence each other.” In addition, he said that focusing solely on populations at highest risk for infection can be difficult because they are changing constantly. “A person who engages in high risk behaviors today might not make the same decisions in six months, and another person might take his or her place.”

To read the press release on which this news brief is based, link to Newswire at.
http://www.newswise.com/articles/view/518459/

CARE Act in Brief:
A frequently occurring series on Ryan White CARE Act reauthorization
1. Senate HELP Committee Holds Ryan White CARE Act Hearing
The Senate’s Health, Education, Labor and Pensions (HELP) Committee held a hearing, entitled Fighting the AIDS Epidemic of Today: Reauthorizing the Ryan White CARE Act, on March 1. Elizabeth Duke, the administrator of the Health Resources and Services Administration, was the sole witness at the hearing. Along with the HELP committee chair, Senator Mike Enzi (R-WY), and ranking member, Senator Ted Kennedy (D-MA), the hearing was attended at various times by Senators Richard Burr (R-NC), Hilary Clinton (D-NY), Mike DeWine (R-OH), Orrin Hatch (R-UT), Patty Murray (D-WA), and Jeff Sessions (R-AL).

Opening Statements by Senators Enzi and Senator Kennedy
Senator Enzi opened the hearing by thanking the other Senators who were present and stating that he felt that there had been a “real spirit of cooperation” within the committee. He said, “To defeat this disease we must focus on the epidemic of today, not yesterday,” and went on to note that the disease is now affecting more women, minorities, and people in rural areas. He also said that the epidemic was “moving to the South” and that the CARE Act needed to take into these shifts into account

Senator Kennedy opened by noting that when the United States was first faced with the epidemic, both political parties “put aside ideology” and based the federal response to the epidemic on science, which resulted in passage of the CARE Act. He then expressed hope that the committee would “follow in that tradition.”

Testimony from Dr. Duke
Dr. Duke began her testimony by noting that the Ryan White CARE Act provides anti-retroviral treatment, primary care and support services to more than half a million people in the United States and its territories.

“In 2004,” she said, “an estimated 65 percent of individuals [served by the CARE Act] were racial minorities, 33 percent were women and 87 percent were either uninsured or received public health benefits.”

Dr. Duke went on to describe the Administration’s principles.* She stated, “The President has made fighting the spread of HIV/AIDS a top priority of his Administration and he will continue to work with Congress to encourage prevention and the provision of appropriate care and treatment to those suffering from the disease.”

Question and Answer Session
Senators Enzi, Kennedy, Burr, Clinton, and Sessions each asked questions for Dr. Duke. Senator Enzi asked how the Administration’s principles would best ensure that underserved populations or populations with growing HIV infection rates (including minorities, women, and people living in rural areas) are served by the CARE Act. Dr. Duke replied that the Administration sought to focus more resources on “core medical services” and, she said, there was a need to bring the HIV community together to create a severity of need index which would take into account the populations that Senator Enzi had mentioned.

Senator Enzi also asked about the President’s inclusion of $70 million in his budget request for HIV medications and how the Administration intends those funds to be spent. Dr. Duke said that the Administration intended to allocate those funds to areas that had waiting lists for the AIDS Drug Assistance Program or that had otherwise demonstrated need. Using the existing formula allocation “may give funds to states who can’t use them and not to states who desperately need them,” she said.

Senator Kennedy asked whether or not the President’s principle of serving the neediest applied to states or to jurisdictions. Dr. Duke responded by saying that, while health comes down to the individual, it was important to have jurisdictions use the available funds to their best advantage.

Senator Kennedy then followed up by asking if it was fair to use a state’s “investment” in the Ryan White CARE Act as an indicator of severity of need. “We need to not punish communities who do a good job nor to advantage those who have not provided [CARE Act resources],” he stated

Finally, Senator Kennedy asked about the need to change from code-based systems to names-based reporting. To him, it appeared that the code-based system had demonstrated success. Dr. Duke said that her understanding was that the Centers for Disease Control and Prevention (CDC) could not certify code or name-plus-code states and said that she would bring Senator Kennedy’s concern back to the CDC.**

Senator Burr began by asking whether or not it was possible for the CARE Act to recapture unobligated funds that had not spent by CARE Act grantees and thus were required by law to revert back to the U.S. Treasury. Dr. Duke said that when this issue came up last year, the Department of Health and Human Services did not have the authority to recapture unobligated funds. However, in her opinion, enacting a provision based on the Administration’s principle of flexibility would allow unobligated funds to be recaptured by the CARE Act.

Senator Burr followed up by asking for an explanation of why some states like California received “$5,200 per case” that is eligible for CARE Act funding while his home state of North Carolina received only $3,400. Dr. Duke stated that the difference was due to the complex interaction of the Titles in the CARE Act, which allocate separate “pots of money.” Since some states do not have Eligible Metropolitan Areas (EMAs), and the formula allocation in Title II counts EMAs at a rate of 80 percent, there is “partial double counting” that results in inequity on a per case basis. Senator Burr responded by stating that he thought that the Title structure was too complicated and that there was a need to eliminate “double counting.”

Senator Clinton stated that the Administration’s principles “would require 75 percent of funds to be spent on a yet-to-be-defined list of medical services, establish a severity of need index that would take into account state spending, and make changes in the Title II formula that would shift funding away from areas with Title I eligible metropolitan areas.” She then asked Dr. Duke to explain how the Administration's proposal for reauthorization would help heavily impacted communities, such as New York State. Dr. Duke said that the Administration’s principles were an attempt to “lay out what we see as problems with the statute as it currently exists,” and to ask the question of whether or not it was possible to address “the reality ... that we have to have some equity for states that don’t have an EMA.” Senator Clinton followed up by asking what the Administration proposes to include as “core medical services.” Dr. Duke stated that HRSA had looked at what the CARE Act was spending funding on and that mental health care, substance abuse care, and case management were on the list of services provided.

Senator Session asked questions about the interactions of the Titles and whether or not funding was being equitably distributed. In response, Dr. Duke said that there were disparities created by the “unintended interaction of the Title system” and cited the 80/20 rule (see above). She said that HRSA would work with the committee to try to find a point at which funds were allocated more equitably. Senator Sessions followed up with a statement that he was not sure whether there was actually an inequity caused by unintended interactions of the Titles or by “clever legislators,” but that he wanted to see change.

After Senator Session’s questions ended, Senator Enzi allowed Senator Burr to make a last statement. Senator Burr said, “Our focus needs to go on how we get meds (medications) to those who need it. We know it’s impossible to do so without winners or losers and that’s okay as long as, in the loser category, it’s not people living with HIV or AIDS.” With that, the hearing ended almost precisely at the one-hour mark.

*Link to The Weekly Update from August 5, 2005 to read the Administration’s principles in full: http://www.aidsaction.org/communications/weekly_updates/2005/080505.htm.

** Link to The Weekly Update from July 1, 2005 to read a short explanation of name-based vs. code-based reporting (Article #4 “Senate Subcommittee Holds Ryan White CARE Act Hearing” in the section entitled “name-based reporting”): http://www.aidsaction.org/communications/weekly_updates/2005/070105.htm

2. Senator Coburn Introduces CARE Act Reauthorization Bill
Senator Tom Coburn (R-OK) held a press conference on Tuesday, February 28 to announce the introduction of a bill in the Senate that, if passed, would reauthorize the Ryan White CARE Act. AIDS Action staff attended.

During the press conference, Representative David Weldon (R-FL) stated that he planned to introduce an identical bill in the House.

Introduction of the bill, titled the Ryan White CARE Act Amendments of 2006, is viewed as controversial by some HIV advocates because Senator Coburn is not a member of the Senate Health, Education, Labor and Pensions (HELP) committee which has responsibility (jurisdiction) for reauthorizing the bill in the Senate. The HELP committee has been working with the House Energy and Commerce committee to introduce a “bicameral, bipartisan” bill—meaning the creation of a bill in both the House and the Senate (bicameral) that has the support of Republicans and Democrats (bipartisan).

Senator Coburn, who maintains a doctor’s practice in addition to his work as a Senator, noted that he had cared for people living with HIV and that he believed the CARE Act needed to be restructured to meet changes in the epidemic. He stated that his bill would result in a CARE Act that can “better respond to changes in the epidemic by targeting federal resources to communities most in need, prioritizing early diagnosis, and expanding access to life-saving medical care and treatment.” In responding to a question, Senator Coburn stated that one reason he was introducing reauthorization legislation was that he believed it was “time that someone put something on the floor,” and further stated that he had hoped that, by this point, legislation would already have been accomplished by the committee.

The bill that Senator Coburn introduced would have a number of effects on the CARE Act. Among other things, it would do the following:

• Restrict 75% of all CARE Act spending to tightly defined “primary medical services,” Such services would not include case management for “non-medical services,” substance abuse, or transitional housing.
• Eliminate some funding in Title II of the CARE Act that is based on counting residents of urban areas which are also eligible for Title I funds. *
• Annually increase funding for the AIDS Drug Assistance Program (ADAP) by $70 million.
• Redirect unspent CARE Act funds into an ADAP supplemental grants program and guarantees a minimum of $35 million per year for the program.
• Add Hepatitis B and C co-infection as diseases which CARE Act programs may treat.
• Require rapid routine testing of all clients at any “health facility, provider, clinic, or entity” receiving funding from Department of Health and Human Services programs, which are explicitly identified in the bill.

The Coburn bill also adds language which would change the authorizing language of the AIDS Housing Opportunity Act. The AIDS Housing Opportunity Act created the Housing Opportunities for Persons with AIDS (HOPWA) program. The main difference would be a change in the basis for HOPWA funding formulas. Rather than being based on the number of AIDS cases in a given jurisdiction, it would be based on the number of HIV cases.

A summary of the bill can be viewed at
http://coburn.senate.gov/documents/Ryan%20White%20CARE%20Act%20website%20materials.pdf (PDF Format)

According to AIDS Action Political Director William McColl, AIDS Action opposes elimination of the 80/20 allocation. The organization’s position can be found in AIDS Action’s Recommendations To Create an Effective, Efficient and Equitable Ryan White CARE Act at http://www.aidsaction.org/legislation/rwca/index2.htm.

In a statement issued to the press on February 28, AIDS Action noted that Senator Coburn had called for more funding for ADAP. “It is significant that Senator Coburn, who has long urged Congress to reduce spending on many federal programs, has recognized that the AIDS Drug Assistance Program (ADAP) requires new funds to ensure that thousands of people living with HIV will be able to access life-saving medications,” said Ronald Johnson, co-chair of the AIDS Action Public Policy Committee.

* The provision that allows this funding is often referred to as the “80/20” provision. The “80/20” provision provides a formula for counting residents of urban areas eligible for Title I funds at a rate of 80% of non-eligible residents. Senator Coburn’s bill would include a “hold harmless” provision that would slow the elimination of 80/20 to 5% per year.

3. GAO Releases Ryan White CARE Act Report
On Wednesday, March 1, the Government Accountability Office (GAO) released a report entitled, Changes Needed to Improve the Distribution of Ryan White CARE Act and Housing Funds. The report updates preliminary findings which were first released as testimony on June 23, 2005 at a subcommittee hearing* of the Senate’s Homeland Security and Governmental Affairs Committee. (For more information on this hearing, see The Weekly Update from July 1, 2005: http://www.aidsaction.org/communications/weekly_updates/2005/070105.htm).

For the report, the GAO examined criteria for distributing funds under the CARE Act and under the Housing Opportunities for Persons with AIDS (HOPWA) program. The GAO states that it reported on three specific issues related to the distribution of funds: “(1) how CARE Act and HOPWA funds are allocated by grantees among the types of services each program supports, (2) the extent of funding differences among CARE Act and HOPWA grantees and how specific CARE Act and HOPWA funding-formula provisions contribute to these differences; and (3) what distribution differences could result from using HIV cases in CARE Act and HOPWA funding formulas.”

In relationship to these questions, the GAO makes three specific findings. They are as follows:

1. The CARE Act and HOPWA use measures of AIDS cases that do not accurately reflect the number of people living with AIDS (including case counts that use deceased cases).
2. The CARE Act Title I and II provisions for metropolitan areas result in variability of funding per estimated living AIDS case grantees; and
3. The funding of grantees is protected due to hold harmless provisions under Title I and II and a grandfather-clause protection for eligible metropolitan areas (EMAs).

The report offers five specific matters for consideration by Congress, if Congress wants CARE Act funding to more closely reflect the distribution of people living with HIV/AIDS. They are:

1. Revising the funding formulas used to determine grantee eligibility and grant amounts using a measure of living AIDS cases that does not include deceased cases and reflects the longer lives of persons living with AIDS.
2. Eliminating the counting of cases in EMAs for Title I base grants and again for Title II base grants.
3. Modifying the hold harmless provisions for Title I, Title II and ADAP base grants to reduce the extent to which they prevent funding from shifting to areas where the epidemic has been increasing.
4. Modifying the Title I grandfather clause, which protects the eligibility of metropolitan areas that no longer meet the eligibility criteria, and
5. Eliminating the two-tiered structure of the Emerging Communities program.”

In addition, the report recommends considering revisions to the Title II hold-harmless provision funded with amounts set aside for ADAP Severe Need Grants as well as changing the HOPWA program so that grant eligibility (both for bonus grants and base grants) are based on a measure of living AIDS cases.

During last year’s hearing, Dr. Marcia Crosse, director of the Government Accountability Office Public Health and Military Health Care Issues, was asked if the preliminary GAO report, would include information about the impact of funding in Titles III and IV of the CARE Act on state grantees in addition to the information provided on Titles I and II. Advocates have not been told when the additional Title III and IV information will be available, and the updated report does not include that information.

The inclusion of HOPWA in the report is new, and the document contains more extensive information about the impact of changing from estimated living AIDS cases to a standard of living HIV/AIDS cases in formula allocations. Advocates have been told that a second GAO report is due to be released in approximately six weeks. It will report on anticipated changes to ADAP when the CARE Act transitions to a funding formula based on living HIV cases rather than living AIDS cases. However, according to a Senate staffer, it is not likely not provide additional information about Titles III and IV.

The new report is located at http://www.gao.gov/cgi-bin/getrpt?GAO-06-332

*The subcommittee was the Subcommittee on Federal Financial Management, Government Information, and International Security.

Announcements
1. “AIDS Forum” on Bronx Treatment, Survival, and Community Issues
On Friday, March 17, Cutting Edge: The Bronx Treatment, Survival, and Community Issues AIDS Forum will be held in the Cherkasky Auditorium of the Montefiore Medical Center from 9:00 a.m. – 4:30 p.m. The forum in presented by Health People: Community Preventive Health Institute, and co-sponsored by the Albert Einstein College of Medicine, Bronx CREED Project, and the Bronx HIV Care Network. Unrestricted Educational grant provided by Gilead Sciences, Inc.

During this day-long event, clinicians and advocates will present on a range of issues related to HIV care, treatment, and programs and policy. Pat Ware, former executive director, of the Presidential Advisory Council on HIV/AIDS will serve as moderator.

Montifiore Medical Center is located at 111 East 210 Street, Bronx, NY. Sign-in begins at 8:30, and lunch is from 12:30 to 1:15 p.m. Lunch spots can be reserved by contacting Jann Baxter at 718-585-8585 ext.237 or JannBaxter@HealthPeople.org

2. National Women & Girls HIV/AIDS Awareness Day Observed
March 10 marks the first ever National Women & Girls HIV/AIDS Awareness Day. In commemoration of this day, there will be an observation, Women & Girls: Saving Ourselves…Saving our Families…Saving Our Future, in the Great Hall of the U.S. Department of Health and Human Services (DHHS). Mike Leavitt, secretary of DHHS, and Dorothy Height, president emeritus of f the National Council of Negro Women are tentatively scheduled to present.

The U.S. Department of Health and Human Services is located in Washington, DC at 200 Independence Ave, SW.

3. The Balm In Gilead Holds 17th Annual Black Church Week of Prayer for the Healing of AIDS
Black faith communities worldwide are invited to participate in The Balm in Gilead’s Black Church Week of Prayer for the Healing of AIDS, which will take place from Sunday, March 5 to Saturday, March 11. Now in its seventeenth year, this annual week of action and prayer is the largest HIV awareness campaign targeting the Black faith community.

Under the theme “United We Stand Against HIV/AIDS,” The Balm In Gilead, an AIDS Action member, invites churches to join together to support, encourage, and empower African Americans, Africans, and all people of the Diaspora to take action to stop the transmission of HIV in Black communities and to support accessible services and resources for people who are living with and affected by HIV infection.

For more information on the Black Church Week of Prayer for the Healing of AIDS, link to The Balm in Gilead at http://www.balmingilead.org/programs/weekofprayer2006/default.asp

The AIDS Action Weekly Update
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