The Weekly Update

May 14, 2004

This Week in Washington
1. IOM Releases HIV/AIDS Public Financing Report
2. Briefing Notes Little Progress on Budget Debate
3. NORA Holds Monthly Coalition Meeting
4. Role of Fixed Dose Combination Drugs Explored
5. Impact of HIV on Agricultural Economies
6. Hill Briefing Highlights Successful Prevention in California

In the News
1. Carol Thompson Named Permanent Head of ONAP
2. The World Health Organization Focusing on Treatment

Announcements
1. AIDS Action Council Welcomes Lifelong AIDS Alliance as Full Member
2. CDC/HRSA Committee on HIV and STD Prevention and Treatment to Meet

This Week in Washington
1. IOM Releases HIV/AIDS Public Financing Report
On Thursday, May 13, the Institute of Medicine’s (IOM) Committee on Public Financing and Delivery of HIV Care released its long awaited report, Public Financing and Delivery of HIV/AIDS Care, Securing the Legacy of Ryan White, the third and final report mandated by the 2000 Ryan White CARE Act Reauthorization. The committee’s key conclusion is that the federal government should expand its role in the financing of HIV/AIDS treatment for Americans with low income to ensure that HIV positive people who are not receiving care through existing systems gain access to treatment and medical services. The committee’s recommendation would create a new entitlement program for persons living with HIV who have incomes less than 250% of the federal poverty level (under $23,000). Individuals who earn more but do not have access to private health insurance would be allowed to participate in the new program by paying a monthly premium based on income.

Lauren LeRoy, PhD, the president and CEO of Grantmakers in Health and chair of the Committee on Public Financing and Delivery of HIV Care and five additional panelists participated in the public briefing which was open to members of the press and the public. The five panelists were:

1) David Holtgrave, PhD, professor, Rollins School of Public Health, Emory University, Atlanta
2) James G. Kahn, MD, MPH, professor, Institute for Health Policy Studies, University of California, San Francisco
3) David R. Nerenz, PhD, senior staff investigator, Institute for Health Services Research, Henry Ford Health System, Detroit
4) Andreas G. Schneider, JD, principal, Medicaid Policy LLC, Washington D.C.
5) Paul Volberding, MD, professor and vice chair, Department of Medicine, University of California, San Francisco, and chief of the medical service, San Francisco Veterans Affairs Medical Center

Dr. LeRoy, gave an overview of the report and then asked panelists to answer specific questions from both a live and an Internet audience.

Dr. LeRoy noted that by law the committee had been asked to consider the feasibility of funding HIV treatment through the public health system, the ability to extend Medicaid coverage, and to assess the costs of current barriers as well as the cost and potential savings of any proposed changes. The committee determined that the primary goal of a publicly funded system of HIV care for individuals with low income should be “to improve the quality and duration of life for those with HIV and promote the effective management of the epidemic by providing access to comprehensive care to the greatest number of low income individuals with HIV infection.”

• The committee identified the following as secondary objectives:
• Ensuring that HIV positive individuals with low income receive early and continuous access to appropriate and comprehensive medical and ancillary services;
• Promoting the delivery of high quality services;
• Facilitating the provision of services with a minimum of both administrative costs and duplication of effort; and
• Ensuring financing system and service delivery accountability for meeting established standards of treatment and health outcomes for all eligible individuals.

In addition to identifying a recommended approach, the committee reviewed alternative approaches including the following: a review that would expand the Ryan White CARE Act; systems expansion of Medicaid coverage in some capacity; creation of a federal block grant; and finally, the creation of a federally funded, state-administered program. The committee evaluated four factors for each approach. Those factors included:

• The extent to which each approach provides uniform access to services for all people;
• Inclusion of a benefit package that meets the standard of care for HIV;
• Inclusion of a financing structure ensuring continuity of care; and
• Reduction of barriers to access services and administrative structures that support program accountability.

As a result of its process, the committee made seven specific recommendations. Those recommendations, drawn from the report and presented in their entirety, are:

1) The federal government should establish and fully fund a new entitlement program for the treatment of low-income individuals with HIV that is administered at the state level.
2) The new program should extend coverage for treatment to individuals determined to be infected with HIV whose family incomes do not exceed 250 percent of the federal poverty level. Individuals with HIV infection whose family incomes exceed this standard should be allowed to establish eligibility for coverage by spending down or by buying in on a sliding scale basis.
3) The new program should entitle each eligible individual with HIV to a uniform, federally defined benefit package that reflects the standard of care for HIV/AIDS.
4) The new program should reimburse providers who elect to participate at rates comparable to those paid by Medicare for comparable services.
5) To ensure that the new program is a prudent purchaser of drugs used in the treatment of HIV/AIDS, the Congress should implement measure that lower the cost of these drugs such as applying the Federal Ceiling Price or the Federal Supply Schedule price currently used by some major federal programs. Implementation of this recommendation would lead to an estimated discount of Medicaid ARV prices of 9 percent to 25 percent.
6) The new program should adequately fund a nationwide demonstration of the effectiveness of Centers of Excellence in delivering covered services to eligible individuals with HIV.
7) The new program should coordinate closely with the Ryan White CARE Act, which should be refocused to meet the needs of low income individuals who are not eligible to be served by the new program.

The committee believes that its recommended approach will refocus programs on the most vulnerable patients and will result in expanded outreach and greater enrollment of HIV positive people with low income into care. In addition, funding will follow individuals living with HIV rather than being stopped at state or jurisdiction lines. The committee estimates that 59,000 people will be eligible for the program and it believes that within a group of this size, its recommendations will reduce mortality by 56%. Further, they expect that up to 3,000 new infections will be averted. The committee also explored whether or not their pharmaceutical recommendations would create a disincentive for research on new drugs. Committee members estimate that under their recommendations pharmaceutical companies will discount drugs up to 27% without a reduction in profitability. The companies will be able to do this since the increase in individuals eligible for coverage will result in more drugs being sold.

Finally, the committee released a chart (table 6-7 in the report) which shows a comparison of estimated expenditures and savings for the first year. If the program were implemented, it is expected that the federal government would expend an additional $2.61 billion in Medicaid and Medicare. However, the states would save $1.15 billion. Additionally, there would be savings of $880 million in care for the uninsured with a total increase in expenditures of $574 billion.

After Dr. LeRoy’s overview, the live and Internet audiences were invited to ask questions. Dr. Marsha Martin, executive director of AIDS Action, asked why the committee had chosen to create a parallel program to the Ryan White CARE Act.

Dr. LeRoy explained that the committee had a primary goal of creating national uniformity in HIV care. She also noted that the committee’s evaluation process led it to decide that uniformity of care could be best achieved by the creation of a broader, federally funded program. The committee was concerned about the CARE Act’s variability of funding from locality to locality, she also said. Finally, the committee noted that, since the CARE Act is not an entitlement, it is a less secure funding source for achieving the recommended goals.

Dr. Holtgrave also responded stating that the committee expected that two-thirds of $1.9 billion in the CARE Act would remain. He also said that he expected that planning councils would continue to play a role in the distribution of funding and determining local needs. Finally, he noted that the CARE Act would continue to play a large role in services such as transportation.

A reporter from NPR asked the committee whether or not Congress could accept these recommendations. She also asked whether the committee had discussed public perceptions of the “hegemony of certain diseases.” Dr. LeRoy noted that the panel had discussed this issue and that Congress had already chosen to single out HIV by asking for the report. Dr. Volberding further noted that there is a real problem with disparities in the current patchwork system and that these recommendations were designed to identify and deal with that issue.

The committee received the request for the report in the fall of 2001. The HIV advocacy community has been particularly interested in the report since it makes recommendations that have a direct bearing on the reauthorization of the Ryan White CARE Act which will take place next year. Given the interest, additional analysis is likely to become available as various HIV organizations obtain the report and review it. The report can be read and ordered on the IOM Web site at http://www.iom.edu/report.asp?id=20147.

2. Briefing Notes Little Progress on Budget Debate
On Tuesday, May 11, AIDS Action staff joined a large group of labor, education, environmental, civil rights, human relations, and health organizations at a budget briefing sponsored by the Center for Budget and Policy Priorities (CBPP). The meeting featured an update and analysis of several House budget process bills that may be taken up on the House floor as soon as next week. Such analysis is important to HIV advocacy work because it identifies possible challenges and roadblocks to increased funding for federal programs, including those for HIV research, prevention, treatment, and care.

Bob Greenstein of the Center on Budget and Policy Priorities briefed presenters on the House Budget Committee-passed bill (H.R. 3973). This bill would place tight caps on discretionary spending (spending that is not mandated by law but determined annually by Congress) over five years. According to the CBPP’s analysis, the caps in this bill are so tight that they would lead to a total cut of $113 billion from domestic, non-Homeland Security or defense programs by FY 2009, reaching a full $36 billion cut in FY 2009 alone.

In addition, H.R. 3973 enforces discretionary spending and the PAYGO rules. PAYGO rules require that all funding increases to programs over the next five fiscal years be offset by cuts in other programs in the same appropriation. Further, H.R. 3973 applies PAYGO rules only to entitlement programs, not to tax cuts (as was done under PAYGO rules in the early 90's when budget deficits were high). Without the inclusion of tax cuts, the PAYGO rules will contribute to a rise in the deficit and could cause more cuts to discretionary programs like the Ryan White CARE Act, Housing for Persons with AIDS, and research dollars at NIH.

The current debate over PAYGO is centered on tax cuts and whether or not they too should be offset. Given the growing deficit, many Members of Congress believe that it is not fiscally responsible to continue the tax cuts without an offset. As we go to press, the House and Senate budget conferees have not reached agreement, and the budget bill still has not been scheduled for a vote in the House or the Senate.

At least two other major budget process bills have been introduced. The first, which is supported by 102 Republican co-sponsors, including a number of moderate Republicans, is H.R. 3800 – Representative Jeb Hensarling's (R-TX) Family Budget Protection Act. This bill would potentially cut discretionary spending further than it has already been cut by the last two rescissions by creating a sub-cap for non-defense programs. This sub-cap would allow domestic spending to shift over to defense programs, but not the reverse. The bill would also change the Congressional Budget Office’s (CBO) budget baseline calculations to eliminate inclusion of inflation. The CBO budget baseline for the Labor-H portion of the budget has always included the cost of inflation. If this were to change, a Member of Congress offering an amendment just to keep the status quo (i.e., the current level of service plus the cost of inflation) on HIV programs would be accused of budget increases similar to those for new programs. This Hensarling bill caps entitlement spending over ten years, exempting only Social Security, for a total cut of $1.8 trillion by 2014. According to CBPP, the proposed legislation further stipulates that Congress must make authorization changes to keep the spending under the budget cap, and if the cap were exceeded in any given year, automatic across-the-board cuts would be made. The cuts would be tiered, with some programs being exempt, others receiving only 2% cuts, and the rest being cut by any percent necessary to stay below the cap.

A second bill, authored by Representative Mark Kirk (R-IL) and co-sponsored by 20 moderates, is H.R. 3925, which cuts entitlement spending and caps discretionary spending for the next ten years. This bill, which cuts entitlement spending and caps discretionary spending for the next ten years, would severely decrease both categories of spending.

According to the May 13, 2004 issue of Congressional Quarterly, Representative Bill Young (R-FL) has met with the 13 appropriation subcommittee chairs, or cardinals, and explained that they will begin the appropriation mark-up process (where the subcommittees amend their bills to reflect their priorities and move the appropriations process to the full committee and then House floor for votes,) whether or not a budget resolution is passed. The chairs have been instructed to use the total discretionary figure as reported in the House bill, which is $821 billion. The Labor-Health and Human Services (Labor-H) portion of this figure is $142.5 billion—less than a 2% increase over the FY 2004 amount of $139.8 billion. The mark up process is scheduled to begin in early June.

AIDS Action staff will monitor the budget and appropriations process as it unfolds in Congress. We will keep you informed as the process continues. For more information on the budget, visit the Center for Budget and Policy Priorities' web site: http://www.cbpp.org

3. NORA Holds Monthly Coalition Meeting
On Monday, May 10, the National Organizations Responding to AIDS (NORA) coalition, for which AIDS Action serves as the convener, held its monthly meeting. The meeting featured two presentations. The first was an update on the status of health disparities legislation from Aranthan S. Jones, Senior Health Policy Advisor to Congresswoman Donna Christian-Christiansen (D-VI) and the Congressional Black Caucus Health Braintrust. The second offered an overview of the Community Health Centers and their role in delivering care to HIV positive people by Craig Kennedy and Lisa Cox of the National Association of Community Health Centers.

During his presentation Mr. Jones outlined two pieces of proposed legislation to minimize health disparities, a problem of particular concern to NORA members because HIV continues to have a disproportionate impact on communities who have traditionally been unable to access heath care services. However, he opened by providing coalition members with some historical background. According to Mr. Jones, racial and ethnic health disparities first emerged as an issue in an 1899 publication by W.E.B. DuBois. However, the emergence of “Jim Crow” (laws that mandated segregation and defined African Americans as inferior to whites) put an end to discussion about disparities until the mid-1960s.

Passed in 1964, the historical Civil Rights Act brought attention to a number of inequities—including access to heath care. The passage of this monumental legislation was followed in 1965 by the creation of Medicaid and Medicare, which led to the desegregation of health care institutions. Then, in 1985, Secretary of Health and Human Services Margaret Heckler released Report of the Secretary's Task Force on Black and Minority Health, which led to the creation of the Office of Minority Health at the Department of Health and Human Services. However, Mr. Jones noted, despite this progress, racial and ethnic health disparities are still a grave problem the United States.

In an attempt to address this crisis, there are currently two bills pending in Congress “The Healthcare Equality and Accountability Act” (H.R. 3459, S. 1833), which is sponsored by Congressman Elijah Cummings (D-MD) in the House and Senator Tom Daschle (D-ND) in the Senate, and “Closing the Health Care Gap Act of 2004” (S. 2217), which is sponsored by Senator Bill Frist (R-TN). While both bills look at addressing the question of health disparities, Mr. Jones believes that H.R. 3459/S.1833 does a better job of considering the varying levels of disparity that exist for different groups while it also acknowledges that health disparity is both a civil rights issue and an issue of adequate public health infrastructure. In addition, this bill contains provisions that specifically address the HIV epidemic within communities of color in the U.S. Building on the successes of the Minority HIV/AIDS Initiative, this legislation includes provisions for increased funding and capacity building assistance so that communities can continue to implement models and interventions to reduce the rates of new HIV infections and help people living with HIV access medical care.

Mr. Jones was followed by Craig Kennedy and Lisa Cox of the National Association of Community Health Centers, who provided NORA members with a brief overview of the Community Health Centers (CHCs) system and the ways in which health centers are working to provide care for people living with HIV. CHCs provide primary health care services in medically under-served areas throughout the U.S. They are funded through a federal grant program authorized by Section 330 of the Public Health Service Act. CHCs currently serve 15 million individuals through 1,000 CHCs at 4,500 sites.

Both Mr. Kennedy and Ms. Cox indicated that CHCs have a long history of providing much-needed medical care to many HIV positive people. In 2002 alone, CHCs provided 317,699 HIV-related medical visits and 312,000 HIV antibody tests, Ms. Cox stated. It is also worth noting that in addition to receiving funding from the Bureau of Primary Care at the Health Resources and Services Administration (HRSA), many CHCs are also funded through the Ryan White CARE Act to provide services for people living with HIV. In fact, 34% of grantees funded through Title III of the CARE Act are CHCs.

In addition to the presentation by guest speakers, NORA members also got a first look at the newly available Fiscal Year 2005 HIV/AIDS Appropriations Recommendations, the coalition’s annual examination of the federally-funded HIV/AIDS portfolio and the impact of the President’s proposed funding levels for the upcoming fiscal year. NORA members were on the Hill on Wednesday, May 12, to deliver copies of the book to all Members of Congress. In the coming days, AIDS Action will provide its member organizations with a copy of this new publication.

4. Role of Fixed Dose Combination Drugs Explored
On Monday, May 10, AIDS Action staff attended a meeting held by the Children’s AIDS Fund (CAF) to discuss what it called “the role of fixed dose combination drugs and drug resistance in the fight against HIV/AIDS.” On hand to make presentations to the audience and answer any questions were respected members of the scientific community as well as representatives from the public and private sector.

The use of fixed dose combination drugs, or FDCs, has been vigorously debated in Washington over the past several months, and the CAF meeting’s purpose was to inform this debate with important scientific and regulatory information. The following summary of the meeting focuses on the most salient points brought up at the meeting in relation to the FDC drug issue.

In the United States, of the current U.S. Food and Drug Administration (FDA)-approved medications available to treat HIV disease, three are fixed dose combination drugs; that is, multiple, FDA-approved drugs combined into one pill. These fixed dose combination drugs should be considered unique medications even though they are comprised of medications whose safety and effectiveness have already been proven individually because drugs combined may act differently than they do when taken individually.

In globally directed efforts against HIV, a new and controversial player has entered the marketplace. Non-FDA approved FDCs are being produced and distributed by non-U.S. companies (most notably, India’s Cipla, which combines the ARVs stavudine, lamivudine, and nevirapine to make a medication called Triomune). Since these drugs are not “branded,” they are much cheaper. What’s more, they have been approved by the World Health Organization (WHO). They do not, however, have the approval of any regulatory drug agency, including the FDA. Due to this fact, the U.S. government has stated that its HIV treatment dollars will not be used to purchase FDC drugs like those manufactured in India.

The decision not to use non-branded fixed dose combination drugs has placed the Bush Administration and the Office of the Global AIDS Coordinator under a great deal of fire. Proponents of their use argue that non-branded FDCs are much cheaper than brand-name drugs; purchasing them would therefore be a more efficient use of U.S. funds. Moreover, because non-branded FDCs are cheaper, the government could purchase more of them than their brand-name equivalents; thereby providing treatment to more people. The Administration, however, argues that the safety and effectiveness of these drugs has not been verified.

Speaking about the FDA approval process for new, generic, and fixed-dose combination drugs, Mary Pendergast, former prosecutor with the FDA, confirmed the uniqueness of FDC drugs. According to Pendergast, these combination medications must go through the drug approval process before entering the U.S. market, just as if they were a brand new medication. That is, companies wishing to gain FDA approval of these drugs must submit what is called a new drug application (NDA), just as they do for any medication that is considered a new molecular entity. This application begins the comprehensive approval process which the FDA goes through to ensure the safety and effectiveness of any new drug. It is important to note that the non-FDA approved FDC drugs being used in some HIV treatment programs abroad are technically not considered “generic.” To be categorized as generic, a drug must be copied from a “reference listed drug” or an FDA-approved drug.

Ms. Pendergast went on to compare the approval processes of the FDA and the WHO. Although the non-branded FDC drugs have been approved by the WHO, such an approval does not carry the weight of an FDA approval, or the approval of any regulatory agency for that matter. There are serious structural limitations to the WHO which limit the authority of the agency. According to Ms. Pendergast, the WHO does not have career staff to review all of the drugs that it needs to approve. Instead, she explained, it relies on volunteer reviewers from the WHO membership countries to review all drug applications. The variety of reviewer backgrounds jeopardizes any consistency in message or uniformity in decisions, she opined. What’s more, she continued, the pharmaceutical companies simply present their data to the WHO reviewers, and the reviewers have no capacity to delve into the documents and determine their validity. The WHO also has no authority to punish the companies if they submit fraudulent information. The organization does not conduct separate reviews of how drugs interact with each other or a consistent review of each drug it approves, she added. According to Ms. Pendergast, the WHO does not have the resources to adequately review all the drugs that are submitted for approval; it must rely heavily on the truthfulness of pharmacy applications. The bottom line: the WHO is not a regulatory agency formed by the laws of a country or region; it is a voluntary member organization

She explained that one option for companies that have manufactured a truly generic drug is to apply to the FDA for a waiver approval. The FDA could then designate the drug as “approvable,” meaning that the drug accomplishes the desired result, but is not eligible for a final approval because there is still a patent on the brand-name drug it copies. The U.S. government would then know that the drug was safe and could be used for the international market. She explained that this process has in fact occurred at the FDA for years. Then, the full FDA approval would be issued the day the patent expired, instead of waiting for the submission of the application after the patent expired. (For more information on this topic, see The Weekly Update Special Report on PACHA, April, 2, 2004: https://www.aidsaction.org/communications/weekly_updates/040204.htm.)

In addition to the regulatory approval issue, there is also the pricing issue. It has been asserted that these non-branded FDC drugs would be much cheaper than brand-name FDA-approved drugs. The Clinton Foundation agreement with the Indian drug company Cipla to offer ARV treatment with the company’s FDC product at the price of $140 per person per year has received much media and public health attention. Unfortunately, the research done by Jeremiah Norris, adjunct fellow at the Hudson Institute, has found no concrete evidence of this price. Norris has found that to date, no orders of the Cipla product have been made at the $140 price. Further, he has gotten confirmation from the Indian manufacturer that all of the conditions for this price deal have not yet been met. Moreover, even if this price were concrete, it would not account for the various add-on charges that would be imposed on the product by the receiving country actually offering the treatment. Norris therefore concluded that the publicized low price, while dramatic, does not exist in any real terms.

Nevertheless, there has been some significant movement on the FDC drug issue in the global community. Justina A. Molzon from the FDA’s Center for Drug Evaluation and Research gave an overview of the important document that came out of the Conference on Fixed-Dose Combination Drug Products in March 2004. The document is entitled Scientific and Technical Principles for Fixed Dose Combination Drug Products. According to Molzon’s presentation, the “document is not: intended to be a therapeutic or regulatory guideline; about specific clinical or non-clinical, bioavailability, bioequivalence or quality issues; about procurement/distribution of specific products; [or] about treatment guidelines, patient adherence or compliance with national regulatory requirements.” The intent of the document is “to provide points to consider when developing, evaluating, and considering combination products for use in programs intended to address optimum drug treatment combinations such as FDCs; [and] to facilitate the administration of drug regimens for the treatment of HIV/AIDS, TB, malaria and their associated infectious diseases.”

The document, which came out of the conference, does not indicate that the U.S. position on non-FDA approved FDC drugs will change. After all, there is some anecdotal evidence to suggest that the FDC position is appreciated around the globe. Deborah Birx, director of the U.S. Military HIV Research Program at the Walter Reed Army Institute of Research, said that workers in many U.S.-funded treatment programs abroad would rather use U.S. FDA-approved drugs only because of concerns about the side-effects of non-U.S.-approved drugs. Further, Dr. Joe O’Neill, Deputy Coordinator and Chief Medical Officer in the Office of the Global AIDS Coordinator, said in his remarks that no one is going without treatment in U.S. funded HIV treatment programs because of the Administration’s position on consumer safety.

Closing out the day’s presentations was Dr. Robert R. Redfield, Jr., associate director and co-founder of the Institute of Human Virology, University of Maryland Biotechnology Institute. Focusing on the scientific technical issues of the global treatment of the epidemic, Redfield claimed that, in order to successfully respond to the global HIV epidemic, we need to expand treatment and maintain a durable response, avoiding as many drug resistances as possible. This consideration, according to Redfield, far outweighs any financial one. In the U.S. response, for example, treatment options have been expanded over the years, but the durability of that expansion has become complicated due to the high rate of drug resistances patients are experiencing. The physician claimed that we must always be considering the devastating effects of drug resistances, as they can potentially eliminate entire classes of treatment options. He further contributed to the FDC conversation by reminding us that drugs need to be combined only when it makes sense pharmacologically. In the current case of the non-brand FDCs, however, drugs are being co-formulated because they are the cheapest. This motivation will translate into improper dosing of medications and may lead to widespread drug resistances.

The Children’s AIDS Fund succeeded in offering meeting participants a wealth of information to inform the discussion of the use of non-branded FDC drugs—or “knock-off” drugs, as many have come to call them. AIDS Action will continue to monitor this latest issue in global HIV policy as it unfolds.

5. Impact of HIV on Agricultural Economies
On May 11, representatives from the United States Agency for International Development (USAID) and the United Nations (UN) World Food Program testified before the Senate Foreign Relations Committee. AIDS Action attended the hearing, which was led by Committee Chairman Senator Richard Lugar (R-IN). Also attending the hearing were Senators Russ Feingold (D-WI), Barbara Boxer (D-CA), and Joseph Biden (D-DE). The hearing was held to discuss USAID’s findings on the intersection of nutrition and HIV infection in sub-Saharan Africa, and to identify infrastructure gaps that contribute to high rates of HIV infection as well as priority actions to reduce HIV.

The hearing coincided with the 50-year anniversary of the U.S. Food for Peace program implemented under The Mutual Security Act of 1954. The Food for Peace program introduced food aid to The Mutual Security Act’s international initiatives on development assistance and security assistance.

At the hearing, UN World Food Program Administrator James Morris identified the HIV crisis in sub-Saharan Africa as the “most extraordinary humanitarian crisis in the world today.” He outlined U.S. efforts in agricultural production, adequate nutrition and food, and clean water as key infrastructural elements in the care and treatment of individuals living with HIV.

Mr. Morris also discussed the impact HIV has had on the agricultural economy of sub-Saharan countries, including the loss of farm workers to AIDS-defining conditions, which decreases the amount of food that can be harvested. The result, he stated, is that individuals without access to food migrate to other communities or nearby countries for food relief. Although he provided no supporting argumentation, Mr. Morris asserted that migration increases the risk of HIV transmission. In addition, he noted that in many places, men do the farming and are the main source of income for their households. When these men are lost to AIDS, women and children are often forced to rely on prostitution for economic sustenance; consequently, their risk for HIV increases because they cannot always negotiate the use of condoms.

He further described the role of the UN World Food Program as long-term agricultural and economic development. The agency works with communities to ensure that agricultural knowledge and techniques are passed from experienced farmers to younger, less-experienced farmers to increase crop production now and in the future. Agricultural production, Mr. Morris stated, ensures that individuals receive adequate nutrition. A healthy diet is particularly important for people living with HIV because it boosts the immune system’s capacity to fight off infection. On a broader level, agricultural production encourages greater self-sufficiency on the part of developing countries, thereby reducing their need for foreign aid.

Mr. Morris’ presentation was followed by remarks from Ambassador Randall L. Tobias, Coordinator for the U.S. Office of Global AIDS at the State Department. Ambassador Tobias discussed the role that his office has played in addressing short-term strategies to rapidly mobilize resources to address HIV in sub-Saharan Africa. His office’s immediate actions include food relief and HIV prevention education for youth, ages 5 to15 years-old. Both initiatives, he stated, are part of the President’s Emergency Plan for AIDS Relief (PEPFAR).

Under PEPFAR, the U.S. has developed and implemented a comprehensive, five-year strategy that guides efforts to provide care and treatment to HIV positive individuals in Africa. The three goals outlined in the President’s initiative include antiretroviral treatment for 2 million people, care for 10 million HIV positive individuals, and prevention of 7 million new infections through HIV testing and behavior modification.

Ambassador Tobias further stated that under the first round of funding for PEPFAR, $350 million was given to service providers and non-governmental agencies to provide relief from the pandemic’s impact. The relief includes antiretroviral therapy medication, prevention education, medical services, and care for orphans and vulnerable children. He stated that under current efforts, abstinence-only education will be provided to 500,000 individuals and 60,000 children will receive basic care and assistance.

Tobias informed the committee that a report will be submitted to Congress. The report, he explained, will detail how the money awarded in the first round of funding was spent and what it accomplished. He then revealed that his office would seek $300 million for the next round of funding.

To learn more about the President’s Emergency Plan for AIDS Relief, go to www.usaid.gov/about/hivaids/excerpts.html.

6. Hill Briefing Highlights Successful Prevention in California
On May 6, representatives from AIDS Action attended a Capitol Hill briefing entitled, Get Real about Teen Pregnancy, hosted by Washington, D.C.-based Advocates for Youth with Representative Barbara Lee (D-CA) and Senator Diane Feinstein (D-CA). Speakers at the briefing included Dr. Clair Brindis, from the Center for Reproductive Health Research and Policy at UC San Francisco, Advocates for Youth Director of Public Affairs Marcela Howell, and youth activists Kayley Harrington and Christina Davies. The briefing was held in an effort to both educate Congressional staff and garner support for the Family Life Education Act (H.R. 4182), which would provide funding for comprehensive sexuality education programs intended to aid in the reduction of teen HIV, sexually transmitted disease (STD), and pregnancy rates.

Dr. Brindis’ presentation on California’s investment in teen pregnancy prevention and its resulting benefits sent a clear message to the attendees: investing in prevention education and health services produces concrete results and saves taxpayers billions of dollars. Although Dr. Brandis did not mention HIV in her remarks, the content of her presentation was of value to the HIV community because it showed that prevention can improve the health of targeted communities and reduce the cost of medical and social services.

According to Ms. Brindis, California has a compelling reason to invest in prevention education and health services for young people as one out of every seven U.S. adolescents lives in California. From 1995 to 2000, California experienced a 34% increase in teens compared to a teen population increase of 13% in the nation as a whole. To better ensure that its young people grow up healthy, the state of California invested $128 million from 1998 to1999 to develop an integrated teen pregnancy prevention initiative. This investment resulted in a 44% decline in teen birth rates (TBR) compared to a 30% decline in the national rate. She noted that the investment “saved California taxpayers $968 million by averting costs related to teen births, and saved society $2.2 billion in related social costs.”

The California initiative was prompted by a national initiative designed to meet the reproductive health objectives for youth, as outlined in Healthy People 2010 (HP 2010). The objectives included a reduction in teen pregnancies and adolescent cases of HIV and an increase in the proportion of adolescents (both male and female) who attend STD and/or family planning (FP) clinics. In addition, HP 2010 calls for an increase in the proportion of teens who abstain from sexual intercourse or who, if already sexually active, use condoms.

However, despite the emphasis on abstinence in this last goal, the California Department has opted to maintain a comprehensive approach to co-ed sex education. In doing so, California became ineligible for $7 million in federal funding through Section 510 of Title V of the Social Security Act (P.L. 104-193), which is administered by the Maternal and Child Health Bureau. Under Section 510, recipients agree not to provide adolescents with information about “sexual conduct,” including the prevention of pregnancy, HIV, and other sexually transmitted diseases through the use of recognized methods of contraception.

In lieu of the federal funding, California supported its initiative through other public funding and inter-agency collaborations with over 1,500 public and private organizations, including California’s Departments of Health Services, Social Services, Education, and Justice. It has also obtained $4 million of in-kind matches.

In addition to reducing teenage birth rates, California’s financial investment has yielded an increase in the proportion of young people who engage in safer sexual behavior. California teenagers between the ages of 14 and 19 have reported reduced sexual risk behaviors, Dr. Brandis reported, and the proportion of middle- and high school-aged young people who have sex is decreasing in the state as well.

Dr. Brindis shared what she termed “lessons learned” in California’s successful response to teenage pregnancy prevention. Here, she stressed the importance of developing strong bi-partisan support, identifying state leadership, and committing long-term to reducing teen pregnancy.

Further information on California’s “Get Real about Teen Pregnancy” initiative can be found at http://www.letgetreal.org.

In the News
1. Carol Thompson Named Permanent Head of ONAP
This Wednesday, May 12, President Bush named Carol Thompson the permanent Director of the Office of National AIDS Policy (ONAP)—a post Ms. Thompson had held on an interim basis since August 2003, the Associated Press reported on Yahoo! Ms. Thompson succeeds Joseph O’Neill who, in August, left his position at ONAP to serve as Deputy Coordinator and Medical Director of the Office of Global AIDS Coordinator, the office that manages the President’s Emergency Plan for AIDS Relief (PEPFAR).

Ms. Thompson had served as ONAP’s deputy director and, according to AP, she has also held posts at the Department of Health and Human Services and the White House as a domestic policy adviser. The AP reported further that Ms. Thompson helped to enact and implement PEPFAR, and her colleagues describe her as “passionate about the AIDS issue.”

To read the AP report on which the news brief is based, link to http://news.yahoo.com/news?tmpl=story&u=/ap/20040512/ap_on_go_pr_wh/bush_aids_adviser_1.

2. The World Health Organization Focusing on Treatment
The World Health Organization (WHO) released its annual World Health Report this week. As reported in an Associated Press (AP) article posted on Yahoo News, the 169-page report recommends that funds from the Global Fund to Fight AIDS, Tuberculosis and Malaria be steered toward opening more small clinics within developing countries to treat HIV positive people.

According to the report, not enough facilities exist in developing countries for HIV positive people to obtain treatment to keep them healthy. The WHO estimates that between 36 and 46 million people are living with HIV in the world, two-thirds of whom are in Africa. However, the WHO estimates that only 400,000 people living with HIV in developing nations were receiving HIV medical treatment at the end of 2003. ‘Without treatment, all of them will die a premature and in most cases painful death,’ warns the WHO in the report (as quoted by AP).

The World Health Report is being released on the heels of a commitment from Canada to donate $72 million to WHO for treatment of HIV positive people around the world. The Boston Globe reported on May 11 that Canada’s pledge to WHO will be essential for the organization to reach its goal of treating three million people with HIV by end of 2005, a campaign called the “3 by 5” initiative. ‘With this money, we are going to send a group of people all over the world and help ministries of health set up programs to treat people with AIDS, remarked Jim Yon Kim, the director of WHO’s department of HIV/AIDS.

Despite Canada’s pledge, The Boston Globe reports that WHO is still about $70 million short of what WHO says it needs in order to fully carry out the “3 by 5” initiative. In the introduction to the World Health Report—as quoted by the AP—WHO Director General Lee Jon-wook challenges countries to do more. “Future generations will judge our era in large part by our response to the AIDS pandemic,” noted the General. “This is an historic opportunity that we cannot afford to miss.”

To read the AP article about the WHO report, link to: http://story.news.yahoo.com/news?tmpl=story&cid=541&ncid=541&e=14&u=/ap/20040511/ap_on_he_me/un_world_health_report_2. The Boston Globe article about Canada’s pledge to WHO can be viewed at: www.boston.com/news/world/articles/2004/05/11/canadas_pledge_revives_global_aids_bid/. To read the WHO report, link to http://www.who.int/whr/en/.

Announcements
1. AIDS Action Council Welcomes Lifelong AIDS Alliance as Full Member
On Saturday, May 7, the AIDS Action Council Board held its quarterly meeting and welcomed Seattle, Washington’s Lifelong AIDS Alliance as a full-member organization. Formed in 2001 through the merger of Northwest AIDS Foundation and Chicken Soup Brigade, Lifelong AIDS Alliance provides a host of services, including housing and home-chore assistance, food and nutrition services, insurance continuation, transportation, case management, and emergency assistance to HIV positive people. Its services also include prevention education and national public policy advocacy.

The meeting, held in West Hollywood, CA, began with greetings by John Duran, the mayor of West Hollywood, CA and one of the country’s five openly HIV positive mayors. He expressed appreciation for the work that AIDS Action members do on behalf on his city before the Council Board began its proceedings.

2. CDC/HRSA Committee on HIV and STD Prevention and Treatment to Meet
The Centers for Disease Control and Prevention (CDC)/HRSA [Health Resources and Services Administration] Advisory Committee on HIV and STD Prevention and Treatment will meet Thursday, May 20 and Friday, May 21 at the Sheraton Buckhead Hotel in Atlanta, Georgia. The advisory committee will address various issues including CDC's HIV and STD Prevention program, HRSA's HIV Care and Support Programs and Budget and the CARE Act Reauthorization, plus a presentation on the Institute of Medicine (IOM) Report on public financing and delivery of HIV care. The meeting is open to the public and there is a public comment period scheduled for Friday morning. For further information feel free to contact http://hab.hrsa.gov.

(Source: Health Resources Services Administration (HRSA) HIV AIDS Bureau (HAB) Information E-mail — Volume 7, Issue 10, May 13, 2004)

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The AIDS Action Weekly Update
The Weekly Update is written with a mind toward the interests of AIDS Action members. If you read the Weekly Update and value the information you receive through this service but are not yet a member of AIDS Action, we invite you to learn more about AIDS Action membership and its benefits by contacting Ryan Palsrok at AIDS Action (202) 530-8030, ext. 3015 rpalsrok@aidsaction.org.