World AIDS Day Federal Conference Call
World AIDS Day Conference Call for Federal Staff and Grantees
On November 17, 2009, AIDS.gov hosted a World AIDS Day Conference Call for Federal staff and grantees. The call provided a brief update on the state of the HIV/AIDS epidemic in the U.S. and a brief overview of the global epidemic.
Participants had a chance to ask these representatives about Federal HIV/AIDS programs: Dr. Howard Koh (HHS); Mr. Christopher Bates (Office of HIV/AIDS Policy); Ambassador Eric Goosby (PEPFAR); Dr. Kevin Fenton (CDC); Mr. David Vos (HUD); Dr. Deborah Parham Hopson (HRSA); Dr. Carl Dieffenbach (NIH/NIAID); Ms. Beverly Watts Davis(SAMHSA); Dr. Ronald Valdiserri (VA) and James Albino (Office of National AIDS Policy).
Below are the audio files and transcript.
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Listen to the Podcast
- Entire call: Duration 1.5 hours (MP3 129 MB)
- Section 1: Welcome and Statement by Dr. Koh, HHS (MP3 10 MB)
- Section 2: Remarks by Ambassador Goosby, PEPFAR (MP3 8.4 MB)
- Section 3: Remarks by Dr. Fenton, CDC (MP3 10.2 MB)
- Section 4: Questions and Answers with Full Panel (MP3 84.9 MB)
- Section 5: Closing Remarks by Dr. Parham Hopson, Mr. Albino, Mr. Bates and Mr. Gomez (MP3 15.7 MB)
Read the Transcript
- Welcome and Statement by Dr. Koh, HHS
- Remarks by Ambassador Goosby, PEPFAR
- Remarks by Dr. Fenton, CDC
- Questions and Answers with Full Panel
- Closing Remarks by Dr. Parham Hopson, Mr. Albino, Mr. Bates and Mr. Gomez
Moderator: Miguel Gomez, Director, AIDS.gov
November 17, 2009 2:30 pm EST
Mr. Miguel Gomez: Good afternoon and welcome to the World AIDS Day Conference Call for Federal staff and grantees. My name is Miguel Gomez and I’m the Director of AIDS.gov. And I’m going to be your moderator for today’s call.
We’re really grateful for your participation today and I believe that we’re really lucky today to have many of our most senior Federal HIV officials joining us. We have senior leadership from the U.S. Department of Health and Human Services, HUD, the State Department and VA. And at the end of the call we’ll be joined by a representative from the Office of National AIDS Policy from the White House. I will announce each of these speakers after our opening comments. And I really want to note this call is for you. So during the call you will have many opportunities to ask questions of these senior managers about our Federal efforts to respond to the epidemic both here in the United States and abroad.
We’ll be taking questions in simply two formats. One on your phone which you can simply do is push “star 1” or if you want you can email me at email@example.com. And I also have a request. At the end of the call would you please fill out your evaluation form that we’ll be sending you?
I’d like to start the call by introducing our first speaker. Our first speaker is the Assistant Secretary for Health for the U.S. Department of Health and Human Services, Dr. Howard Koh. Dr. Koh was appointed to his post by President Obama. He joined HHS and prior to that he was serving at the Harvard School of Public Health. And prior to that from 1997 to 2003, Dr. Koh was the Commissioner of Public Health for the Commonwealth of Massachusetts. Dr. Koh has a history of working on HIV issues and today he is the HHS Secretary’s primary advisor on matters involving the nation’s public health.
And Dr. Koh, we’re honored to have you here with us to start the call, sir.
Dr. Howard Koh: Thank you very much, Mr. Gomez, for that kind introduction and thank you to everyone for being part of this very, very important call. We have on this call today Federal HIV/AIDS grantees and also Federal workforce members and everyone is critical to advancing this critical public health agenda forward.
This year marks the 21st observance of World AIDS Day. And each December 1, we not only remember and honor those we have lost, but we also celebrate the energy and talent of everyone, especially people on this call, who is working to end this epidemic. We recognize that our most successful responses to HIV/AIDS can only come through the commitment and cooperation of those on the front lines and our Federal partners and that’s why we’re having this meeting today.
This call is an opportunity for all of us to hear an update on the HIV/AIDS epidemic both in the U.S. and globally and for us to engage in a dialogue about the challenges we face as we work together to respond to HIV/AIDS. The World AIDS Day theme this year is “Working Together” and we are working together particularly in this new Administration both domestically and internationally to share best practices and to improve the lives and health of those we serve.
I want to stress that with the leadership of President Obama, all senior Federal HIV officials are now recommitted to promoting a high-level dialogue and the President has already articulated three HIV/AIDS priorities and they are to: first, reduce HIV incidence; second, increase access to care and optimize health outcomes; and third, reduce HIV-related health disparities.
In order to reach these goals the White House is developing a National HIV/AIDS Strategy which will be based on input from a series of community forums that are currently being held around the country. Here at HHS we have an Office of HIV/AIDS Policy, under the direction of Christopher Bates, who’s also on this call.
And our office is also hosting a series of community discussions and these forums will provide opportunities for individuals to provide HHS, the White House and other policy makers with their recommendations for achieving the President’s three goals for the National Strategy. In fact, I recently attended an HIV community meeting in Memphis, Tennessee several weeks ago and it was moving, memorable and motivating to hear about challenges and also the successes that we are seeing in the field.
I’ll be attending a similar community meeting in Seattle, Washington on December 9, so if you’re in the area I invite you to come and give your input. And of course to learn more about any of these community conversations please go onto AIDS.gov.
Now I want to stress that in this new administration we can already celebrate some recent Federal accomplishments. First, the revitalization of the Presidential Advisory Council on HIV/AIDS or PACHA and then naming Christopher Bates as PACHA’s new Executive Director. Secondly and very importantly, the reauthorization of the Ryan White Program which, as you know, is the source of over $2 billion annually in funding for care and treatment for people living with HIV/AIDS in the U.S. And third, and also very importantly, the elimination of the entry ban for HIV positive travelers and immigrants who wish to come to the United States.
So, these are some early accomplishments that we can celebrate and we are looking forward to much, much more. Today we have a rare opportunity to have senior government HIV leaders on one call to engage in a dialogue with you and hear your questions. So first, as Mr. Gomez mentioned, we’re going to be hearing from officials who direct HIV programs at the Department of Health and Human Services, at Housing and Urban Development (HUD), at the VA, as well as the State Department and then also from the White House Office of the National AIDS Policy. And then we’re going to be very pleased to hear from you, receive your questions and comments, and engage in a very vibrant dialogue.
So thank you very, very much for taking time to be with us today. I look forward to this call and also for many more good meetings where we coordinate our activities at the Federal and national level about HIV/AIDS and push forward a very, very important agenda for public health.
Now our moderator Miguel Gomez will introduce Ambassador Goosby and Dr. Kevin Fenton who will give us an overview of the state of the epidemic and then our panel will take your questions. Thank you very much.
Mr. Gomez: Thank you very much, sir. And as Dr. Koh said, we’d like to welcome Ambassador Eric Goosby, the U.S. Global AIDS Coordinator and the Ambassador-at-Large for the President’s Emergency Plan for AIDS Relief (PEPFAR).
Many people know, but before the President appointed him to his current post, Dr. Goosby was the CEO of the Pangaea Global AIDS Foundation. He was also a Professor of Clinical Medicine at the University of California, San Francisco. He played a key role in the development and implementation of HIV/AIDS national treatment scale up plan in South Africa, Rwanda, China and the Ukraine and domestically. Not only did he work directly as a doctor with people living with HIV/AIDS, he also worked with the Federal government. Domestically he worked at HRSA, the White House and he also directed the [Office of] National AIDS Policy, which today, as Dr. Koh mentioned, is directed by Christopher Bates.
Dr. Goosby, thank you for joining us. Ambassador Goosby, could you describe for us the state of the epidemic internationally?
Ambassador Eric Goosby: Sure Miguel. Thank you. It’s a pleasure to have an opportunity to talk with everyone and my regards to the distinguished panel you assembled to make this address. You know after the last 25 years, the global health community has made significant strides in the fight against HIV and deserves recognition as we kind of approach our World AIDS Day. Many of these strides have occurred due to the contributions from the American people. The American people have provided more than $25 billion to fight global AIDS collectively, cumulatively.
And the U.S. President’s Emergency Plan for AIDS Relief, also known as PEPFAR, is the largest commitment in history by any nation to combat a single disease. PEPFAR as an interagency effort, again somewhat unique, has as part of it a number of difficulties around orchestrating and working together with agencies that have ongoing activities in many of these countries to converge in partnership with the partner country to develop delivery systems that are both responsive and effective in prevention and treatment.
An estimated four million individuals in low and middle income countries have access to antiretroviral treatment because of it. And more than half of these men, women and children are supported by the PEPFAR activities since September 2008 and we’ll be able to update those numbers in the next couple of weeks as new data comes in during our country operating plan process. Prior to 2003, there were only 50,000 people in Sub-Saharan Africa out of the 27 million infected who were receiving antiretroviral therapy, so really quite a response.
PEPFAR has also provided compassionate care for more than 10 million people affected by HIV/AIDS, including more than four million orphans and vulnerable children. We’ve supported prevention of mother to child transmission programs that to date prevented [sic] nearly 245,000 babies to be born HIV-free. While significant progress has been made, the global fight against is far from won. UNAIDS estimates that there are 33 million people living with HIV/AIDS around the world, that 2.7 million people were newly infected in 2007 alone, and that two million people lost their lives to AIDS in that same year.
These statistics highlight the needs for a continued commitment by affected countries with strong support from the U.S. Government through our bilateral programs as well as The Global Fund for HIV, AIDS, TB and Malaria as well as increased support from other funding sources in the private sector.
Moving forward, we’ll work with other countries to build the sustainability of their national HIV/AIDS responses and support country-led efforts to make universal access a reality for their citizens. The Administration is committed to continuing to turn the tide against AIDS, both domestically and globally, and on World AIDS Day I hope that these commitments will be re-kindled and re-established to rededicate ourselves for the joint efforts to defeat HIV/AIDS.
I also want to say that the ability to mount an effective response has always been realized through the concerted effort of government, non-governmental organizations, and community based organizations in partnership with patients and people who are infected, affected by HIV/AIDS. It’s this collaborative effort that holds everybody to the task. It allows us to further point and direct our programs so they effectively address the needs of what is a changing population and community.
I think that these collaborative efforts, which I have watched the U.S. Government both in its domestic and international programs support and nurture, are critically needed and it’s really an honor to be able to continue to participate in this response in the Obama Administration.
So I want to thank you. Thank [you] Dr. Koh and others on the panel for giving me an opportunity to make a brief statement and look forward to the questions.
Mr. Gomez: Thank you, Ambassador Goosby. And also to help you answer questions could you introduce your Deputy, sir?
Ambassador Goosby: Yes, Tom Walsh is also here and will be taking questions in the question-and-answer period.
Mr. Gomez: Thank you. We’re going to jump from international to domestic and going to introduce Dr. Kevin Fenton who’s the Director of the National Center for HIV, STD and TB Prevention (NCHHSTP) at the CDC -- our leading voice for prevention here in the United States. Before assuming his current position, Dr. Fenton was the Chief of the CDC’s National Syphilis Elimination Effort and before that he served as the Director of the British Health Protection Agency HIV and Sexually Transmitted Infections Department.
Dr. Fenton, here in the United States for – how would you describe the state of the epidemic today?
Dr. Kevin Fenton: Great. Thank you so much Miguel and Dr. Koh for organizing this call and good afternoon, everyone. Thank you for joining us. Miguel, World AIDS Day 2009 really marks a challenging time for HIV prevention in America, but also a moment of hope and opportunity.
As many of us on the call realize HIV/AIDS continues to exact a tremendous toll in the United States. As of today more than one million Americans are living with HIV and every year more than 56,000 Americans are estimated to become infected with HIV. That’s actually one person every 9.5 minutes. And each year more than 14,000 Americans with HIV/AIDS will die.
So the impact of this epidemic among some communities in the United States remains especially severe and pervasive. Gay and bisexual men are about half of new HIV infections and half of those living with HIV and they remain the group most severely affected by this epidemic. African American and Latino communities are also disproportionately affected with African Americans becoming infected at seven times the rates of whites and Hispanics at three times the rates of whites.
We also know that populations at greatest risk are unable to access proven prevention intervention and we continue to have challenges in targeting effective intervention to those in greatest need. So for example, CDC suggests that just about 20% of gay and bisexual men report being reached by prevention programs in the previous year. A particularly concerning statistic when we know that the HIV incidence in this group is increasing. Furthermore about one in five people infected with HIV, more than 200,000 adults, don’t even know they have the virus and maybe unknowingly spreading the virus to others.
We also see challenges about the level of awareness of HIV in the United States. Recent data have shown that the level of concern about HIV in America has in fact declined and that some of the populations at highest risk either do not recognize their risk or simply believe that HIV is no longer a serious threat. But of course it is also a challenging time as the recession has taken a toll on HIV prevention programs across the country and many states and localities have faced dwindling resources.
So taken in concert, we must strengthen our result, continue to mount a fight against the HIV epidemic in the United States in the face of these and other challenges. We know that there is no simple solution to stop the epidemic, but we now know more than ever before about what works to prevent HIV infection and we see positive signs when we use all of the prevention tools at our disposal. So for example, we know that HIV incidence has in fact been stable in the United States over the past decade and the HIV transmission rates have actually decline considerably during this time period. These are important and early signs of success. We know that HIV testing, prevention and treatment programs are having population level impact from the epidemic. Indeed the latest estimates indicate that U.S. prevention efforts such as these have averted at least 350,000 HIV infections and more than $125 billion in AIDS treatment costs alone. So we know that HIV prevention works.
Prevention can and prevention does work and we need to do much more to expose that risk. This severe and continued burden of HIV in this nation are neither accessible nor is it inevitable. Significant process will require that we strengthen our national response and this will require urgent and scaled action in four domains.
First, all Americans must know their HIV status, so they can protect themselves and their partners. I envision and am committed to the day when HIV testing becomes as standard as a blood pressure check in the United States. Second, we must work collectively across all levels of government, through communities and the private sector to expand access to effective, evidence-based prevention programs for the populations at greatest risk, especially gay and bisexual men of all races, African Americans, Latino and injecting drug users, as well as people living with HIV to prevent the onward transmission of this infection.
And yes, these effective interventions include expanding access to HIV testing, access to male and female condoms, comprehensive prevention programs for drug users which include syringe exchange programs, high quality and STD treatment and care programs, reproductive health services and comprehensive and integrated programs to address substance abuse and mental health.
Third, we must continue our search for new tools and approaches to prevent HIV infection, whether biomedical or behavioral or structural approaches. And because no tool will be 100% effective, our future success will be determined by how best we collaborate, integrate, combine and implement effective prevention interventions.
Finally, because HIV does not occur in a vacuum, it is imperative that we confront the social determinants of HIV transmission in the United States today, including racism and discrimination of all forms of socioeconomic deprivation, lack of housing and limited educational attainment and opportunities. We must tackle the complacency about HIV and a false sense of security that hides what remains a serious epidemic in the United States.
We know that under this Administration prevention is in fact on the map as it has never been before and I’m hopeful that working together we can meet the challenges that we face using science based prevention strategies that we know work. Thank you very much.
Mr. Gomez: Thank you, sir. Really appreciate that Dr. Fenton.
Mr. Gomez: And today as I mentioned earlier, we’re joined by several other senior HIV program staff across the United States Federal Government. They are Dr. Ronald Valdiserri at the Department of Veterans Affairs; Ms. Beverly Watts Davis from SAMHSA; Dr. Carl Dieffenbach from the NIH; Mr. David Vos from HUD; Dr. Deborah Parham Hopson from HRSA; Mr. Christopher Bates from the Office of the Secretary (Office of HIV/AIDS Policy). And, Mr. James Albino from the Office of National AIDS Policy will join us at the end of the call.
I noted earlier that today’s call is for our Federal grantees and staff to ask our senior leaders questions. I want folks to know that listening in on today’s call are some of our other colleagues and we want to thank them for joining us. We will be taking questions as I mentioned earlier in two formats. One you can push “star 1” on your phone or you can email me your questions at firstname.lastname@example.org and we’ll get to as many questions as possible.
Operator, do we have our first – do we have people queued up for questions?
Operator: Yes, sir and the first question is from Pediatric AIDS/HIV Care from D.C.
Mr. Gomez: Bless you I think. Please ask your question.
Woman: Can you guys hear me?
Miguel Gomez: Yeah.
Woman: I would like to know what role does stigma play in addressing HIV/AIDS domestically?
Mr. Gomez: Sure. Dr. Fenton, you actually talked about stigma. If you’d like to answer the question and Beverly Watts Davis, if you’d like to complement that.
Dr. Fenton: I’d be happy to, Miguel. Stigma is a critical component which really presents an expected HIV/AIDS response, not only in the United States, but in fact around the world and it manifests itself in many ways. It can be the stigma against a fear of HIV testing, knowing one’s HIV status. It can be the stigma that is faced by many people who are HIV positive when it comes to seeking and accessing effective treatment and care for their disease.
It can be the stigma which is associated with some of the risk behaviors that may place individuals at high risk of acquiring HIV. So it may be homophobia, fear of stigma of or stigma against people who inject drugs or use drugs, et cetera. So it manifests itself in many ways. Therefore if we are thinking about an effective response, prevention, treatment and care response to HIV not only do we address the issues at the individual level, but we must confront stigma and discrimination which occurs within families, communities and society as a whole, because these provide a change in the context within effective prevention treatments and care services can be delivered. So, in summary, stigma is a very, very important factor that has to be addressed as part of an effective prevention, treatment, and care response to HIV.
Ms. Beverly Watts Davis: And this is Beverly Watts Davis and I want to truly thank Dr. Koh, Dr. Fenton, Dr. Christopher Bates, Dr. Goosby and to all of you all who are the heroes and [inaudible] out there who really get up every day to make the real difference that we have in this country and across the world.
Stigma is one of those things, it’s kind of like slaying the invisible dragon. Everybody knows it’s there. It’s the elephant in the room, but people don’t quite know. They walk around it. You know, they look at it, they talk about it, but then when it comes to actually addressing it, I think it’s going to be really incumbent upon is in partnership with communities all over America to really begin to really look at how we actually fund effective stigma reduction activities.
Being from the Substance Abuse and Mental Health Services Administration, we address stigma all the time with substance abuse and mental health and so I can tell you even within our field as we recognize that there are some nexus and connection with substance abuse and risk taking behavior and sometimes not wise decision making which may result in putting oneself at higher risk for transmitting or contracting HIV/AIDS. People shy away within our own field from really wanting to talk about stigma associated with HIV/AIDS which is of the top of stigma associated with mental health disorders and substance abuse. At SAMHSA, one of the key things that we have really focused in on is working on effective universal strategies and this really goes back to something that this Administration will be very well familiar with and that is really talking about how do you really mobilize and organize communities, because along with just having national public awareness campaigns, you really have to have that at the local level.
I mean national campaigns are wonderful, but I think as one of the key things we need to be doing as federal partners is making sure that we help all of you all localize that. Having worked in the field of substance abuse for a long time and worked with the 31st Partnership for a Drug Free America we recognize then that having a national commercial may grab some attention, but it was on the radar screen for a very little time. What we had to do to make that real in communities is to be able to take all of those ads and all of those things and literally send these to communities for them to make all of those messages real in their communities.
And I think that’s something that we can play a part in, because as Dr. Fenton said, we have to work on the individual, the family and the community all at the same time. So you have to have effective strategies working in complement to each other and all occurring at the same time and at that allows for the table around this whole issue to be a lot broader, because even though someone may not be a clinician, they may be able to be a very effective advocate on their block, you know, in their workplace, in their school, in their whatever setting they’re in to be able to help change people’s attitudes. And we need to begin to broaden that table that allows everyone to have a roll and see themselves as a part of this whole effort to reduce sigma and to again think about who we normalize everyone – by testing being a part of – of people when they get a physical. Just how people is a part of their medical care, how we open up the conversations about HIV/AIDS and its transmission. How we begin to make sure there is no wrong door for access to be getting help and services. No wrong door in the community at all. And that we begin to engage people in making sure that we end discrimination and those kinds of things.
And that’s where I think we as a Federal government have to figure out how we can fund mobilization efforts at the local level and then provide tools to you all, to the communities, so that they can begin to make these national – so they can geometrically increase the impact of a national campaign, because they’re not only hearing it, you know, once in while on the television commercial, but they’re also hearing it every day in their newspapers, that they’re seeing these ads in the electrical bills.
That when people are walking around the neighborhood that they’re passing out, you know, messages with flyers. That there in the grocery store and on the grocery bags. That they are in church bulletins – that it begins to be a part of the fabric of the community and that we leave a message within what we do to impact stigma. And I think that’s one of the ways coming from what you all have told us that will really help us change stigma throughout our country.
Miguel Gomez: Beverly, thank you. And that was our Senior Advisor on Substance Abuse form the Office of the Administrator at SAMHSA. And the question was from Washington D.C.
We got a follow up email question for our colleagues at NIH. Challenging us that Washington D.C. more than one in 20 residents are HIV positive. NIH has talked about a new initiative in Washington D.C. Dr. Dieffenbach, can you talk about NIH’s efforts in Washington D.C.?
Dr. Carl Dieffenbach: Sure. We have a number of programs that are really focused on helping the Washington, D.C. area attack the HIV/AIDS epidemic through research. So from the NIH perspective, we have a couple of clinical trials that we have recently opened that work to see if we can identify the highest risk people in terms of focusing on specific populations in a very neighborhood-by-neighborhood approach, so that these people can be identified and brought into trials, learn their HIV status. They can get improved outcomes for their health.
Additionally we’re launching a fairly large trial that has a name now. It’s called HPTN 065. This is through the HIV Prevention Trials Network . It’s actually being launched within the next several months in Washington, D.C., as well as in the Bronx, New York. And really what it’s about is looking at the process of everybody who gets tested for HIV, what happens to them as they enter the care system and can we optimize getting those individuals who test HIV positive into care and into successful HIV treatment programs so that they take their medications and control their HIV disease. So really it’s about optimizing every step of the way through research, so that we improve the outcome of the health of the individual.
And so bringing people into care and bringing people into a situation where they know their HIV status, we will also indirectly reduce the risk of transmission, by reducing the number of people who are walking around in whatever city who don’t know their HIV status. That’s a short answer to a question that I could talk about for an hour or more.
Mr. Gomez: I know I appreciate that. We’re actually getting tons of questions in. So I appreciate our senior officials if you could keep your answers brief I’d appreciate that, Dr. Dieffenbach. And if people want to find out more about the initiative – they can go to AIDS.gov or email@example.com for more information. Operator, could you give us our next question?
Operator: Alright. Next question is from Seven Points Inc. from Washington, D.C.
Mr. Gomez: Washington’s popular today. Please go ahead.
Coordinator: Seven Points Inc. Go ahead. If you have your mute button on please. [Silence].
Mr. Gomez: Can we take our next question?
Coordinator: Your next question is from African Services Community from New York.
Woman: Hi, thanks for taking my call. You know at this point we’re facing the most enormous challenge to financing a full response to global AIDS prevention treatment and care, since we began massive global scale efforts 2002/2003. I wonder whether the Obama Administration is prepared to support the medicines patent pool which is being established through Unitaid. The patent pool will enable collective management of patents. It will stimulate innovation and it will make medicines more affordable faster. At this point in this economic climate, we need to reduce prices as fast as we can to get more drugs to more people. What’s the Obama Administration’s position on this? Thanks.
Mr. Gomez: Thank you very much for your question. Also, Dr. Goosby, if you could help answer our last participant’s question, we also got several emails about how the recession is impacting PEPFAR’s reach and some questions about if you could speak to PEPFAR’s current and future fiscal commitments, so there’s several things there at once sir, but if you could help answer.
Mr. Tom Walsh: Hi, this is Tom Walsh. I’m the Acting Deputy.
Mr. Gomez: Well, thanks for joining us, Tom.
Mr. Walsh: Ambassador Goosby had to step off, so let me address some of those questions. On the first one on the patent pool, that’s one where I’m afraid I really have to punt. That’s not something PEPFAR or the State Department is involved in. That’s really in the purview of the U.S. Trade Representative. I’m not sure there’s anyone on the call who’s really in a position to speak to that.
I will say that we’ve really found that the cost of antiretroviral in the developing world is decreasingly the main barrier to treatment scale up. The costs really have come down quite a bit for the antiretrovirals that we’re using. Our programs are now using predominantly new generic drugs. And it’s really a testament to the expedited review process that FDA establishing in 2004 that we have now I believe over 100 antiretroviral products that have been reviewed and approved by the FDA. And those are now freely available for use in our PEPFAR programs and indeed most of our partners are using them.
I think the main constraints we’re facing towards on scale up these days have to do more with the health worker training crisis or health worker availability in most of the countries where we’re working, particularly in Africa. And the situation varies from country to country. But Mozambique is an often-cited example, because in that country there are approximately 600 physicians, you know serving a population that’s about 20 million people.
And so this next phase in PEPFAR, these upcoming five years, we’re really focusing on investing to expand the number of health workers available in these countries. Not just at the physician level, but also nurses, also community health workers. We just need more of everyone if we’re going to get not just treatment, but also prevention and care, scaled up as it needs to be.
At the same time infrastructure is also a big constraint in a lot of these countries. We’ve been building, supporting construction of facilities and renovation of facilities and we plan to do more of that as well.
In terms of where PEPFAR is from a funding standpoint, going forward we’re in the same boat as everyone else in terms of waiting for a 2011 budget and you know, this is something I think all my colleagues can relate to as well. We very much see it as a moral obligation to continue to support on treatment those whom we already support. And we are really looking at continued scale up of treatment prevention and care with the resources available to us.
But this economic downturn definitely presents a challenge and we are looking at it as an opportunity to try to get more efficient in what we’re doing, so that whatever the outcome of the budget discussions we’ll be in a position to serve more and more people, because there is still a tremendous unmet need in these countries where we’re working and we want to meet as much of it as we can.
However, the last point I’ll make on that is that it really is a global responsibility. The U.S. Government is producing such a really disproportionate share of the global resources that are going into global HIV/AIDS. The other developed economies need to do a lot more. And so as part of the President’s global health initiative we’re looking forward to engaging in a dialogue with the other developed nations to say, yes we understand, we’re all facing economic constraints, but this really is a global responsibility we all need to share together.
And importantly, we also need to look to the countries themselves where we’re working. They all have different states of economic development. Many of them are at very low levels, but in all of them, you know, HIV/AIDS – if HIV/AIDS is a major issue, they really need to be doing what they can based on their economy. So we’re entering into what we call partnership frameworks with these governments where we’re kind of indicating what we plan to put on the table and we’re asking the government the partner government to also come forward with what they’re willing to do in terms of financing, in terms of policy reforms, if any are needed and in terms of technical assistance we really want to be a provider of technical support to governments, so they can increasingly step up to the plate and meet the needs of their own people. So I hope I covered at least a few of the questions there.
Mr. Gomez: Tom, thank you very much. Operator, do we have the next question?
Operator: Okay and the next question is from Isaiah House from East Orange, New Jersey.
Miguel Gomez: Hello, your question.
Dr. Glenda Kirkland: Yes, this is Dr. Kirkland from Isaiah House. I don’t remember asking to ask a question. Sorry.
Mr. Gomez: No problem. Glad you’re listening. Actually, as we’re queued up for our next question, David [Vos] at HUD, we’ve had several questions about housing and several have focused around that studies have show that housing plays an important role in the treatment and prevention of HIV/AIDS, improving health outcomes and therefore decreasing overall healthcare cost. Is and how are you going to be addressing things differently based on these findings? And that’s a question from Delaware.
Mr. David Vos: Okay, Miguel and thank you to you and our partners in this. It – I definitely agree with Dr. Fenton, it requires all sectors to be involved and that’s why the U.S. Department of Housing and Urban Development is so pleased to join with our other Federal agencies in this effort. The studies include a direct study that HUD did with CDC and also a study done in our Chicago grantee in which people were moved out of hospitals and into supportive housing programs.
That study which the findings have been reported and will shortly be issued show that there’s a drop of enormous amount of reduction in hospital days and nursing home days, so there’s a lot of cost savings to health care systems if we can stabilize our clients and get them into care in addition to the good health benefits just from regular participation in that care. So housing as a base to receive care, I totally agree with that analysis and our programs are set up to try to do that.
So at HUD we’re going to be looking at this in terms of our budget. We’re now working on our 2011 budget that will be released later at the beginning of the year. We are also working on a strategic plan to look at the Department in the next five years. Where can we take this agency to transform it, to get a better result for all clients who have housing needs and there are many across the country like that? And then also we’re working of course in partnership on the National AIDS Strategy and I think that forum itself will be a great place in which we can discuss and try to come to some agreement on moving forward as all sectors again addressing the challenges facing us.
Mr. Gomez: David, appreciate that and there were some other housing questions and Dr. Deborah Parham Hopson that also deal with Ryan White and housing. And both of them revolve around how are the two programs working together or individually trying to address the increased need around housing. Dr. Parham Hopson.
Dr. Deborah Parham Hopson: Thank you for that question and thank you, David Vos, for your response. Yes, the Ryan White Program does work with HUD’s HOPWA program, the Housing Opportunities for People with AIDS. We both joined together in providing a funding for housing, for people living with HIV/AIDS. The Ryan White Program does have some limitations. The housing funds come from – you can spend 25% of your grant funding on housing for people with HIV. But again, the major portion of housing for people with HIV/AIDS is funded from the HOPWA program.
Mr. Gomez: Ma’am, thank you very much. Operator, do we have another question?
Operator: Alright. We have a question from amfAR.
Mr. Gomez: Thank you.
Mr. Chris Collins: Yes, this is Chris Collins. Thanks very much for doing the call. Accountability and coordination are really themes of the National HIV/AIDS Strategy effort, as you know. And so I’m wondering if your speakers could give us an idea of a couple of things consistent with that. What’s being done to assess the degree to which local and state level prevention efforts are truly strategic in that services and programming are targeted in line with epidemic profiles? What’s being done to make sure there’s programs there to reach young gay and MSM which is one of the groups at greatest risk?
But secondly on a coordination issue, what’s being done to achieve improved coordination between Federal agencies, such CMS, HRSA, CDC, VA and HUD to ensure more outcomes-oriented strategic delivery of prevention and treatments? Are there monthly meetings between these groups? Are they strategy sessions? How is that coordination going to work?
Mr. Gomez: Sure. How’s that working. I’m going to turn to Christopher Bates. And Christopher if you could start answering the gentleman’s question and also explain your role here and if Dr. Koh is with you if he could join you.
Mr. Christopher Bates: Okay, Dr. Koh has moved from the call unfortunately, so it’s just me. Several efforts are taking place at the Federal level. We are not only meeting in the Departments among all the AIDS portfolios in having discussions about how we can coordinate and collaborate our efforts to eliminate duplications of efforts, to gain more efficiency, but we are actually, as a part of developing the National AIDS Strategy will be taking a closer look at just how we do our work and how we will work towards collaborations and what kind of supportive elements in our system we need to put in place to support collaboration and to analyze overall just where our systems deficiencies are and strengths in them and hopefully to work together with state and local governments to share our experience so that they can take some of the practices that we uncover and discover and apply them to the work that they do.
We’ll also be looking at what the state and local governments are doing. And ways to get greater accountability and efficiency and hopefully we will try to apply those to the ways in which we do our work here at HHS and across the Department.
Mr. Gomez: Christopher, thank you. And if you could share with -- some folks on the line here might not know your role here.
Mr. Bates: Okay. As Director of the Office of AIDS Policy and in the Office of AIDS Policy, we have a responsibility for looking across the Department at work that’s being done and hopefully serving as the point-of-coordination for those things that go across the Department and then aren’t solely existing in one of the agency activities that several agencies are engaged in. We also have a responsibility to report the work that’s being accomplished by the Federal investment to the Assistant Secretary for Health and also to advise the Secretary.
Mr. Gomez: And you do that work under the leadership of Dr. Koh. Thank you very much, sir.
We’ve got some emails for our colleagues at VA. Dr. Valdiserri, from Newport News, Virginia, some questions about what we are doing to bridge the gap between the veterans and the military population and the rest of the population as it relates to HIV. Some other questions we’ve gotten online is what are we doing for the men and women while they’re at combat to provide information on HIV prevention and what we’re doing for them upon their return, sir.
Dr. Ronald Valdiserri: Thank you, Miguel. I’ll focus on the veteran portion of it, because while the men and women are in combat of course, that’s not the Department of Veterans Affairs. That’s the Department of Defense. Of course.
But I think that probably most of the people on the call are aware of the extensive efforts that have been undertaken by the Department of Veterans Affairs to address many of the short and longer-term medical and health needs of veterans who have served in the Middle East and Afghanistan and there are a number of activities that are underway. The group that I work with at the VA is responsible for conducting a large population-based survey on a periodic basis to determine a number of health needs related to mental and physical health for newly-minted veterans and we have worked with that those individuals to make sure that we’re also asking questions related to sexual health as well as HIV testing.
To summarize, although much of the initial focus has been on mental issues understandably, we’re also concerned longer term to make sure that veterans have access to a variety of public health services and having said that I’d like to take the opportunity to mention that as of August this year, the entire Veteran’s Health Administration has implemented new policies around HIV testing across the United States, consistent with CDC recommendations.
We now encourage routine rather than risk-based testing. And we’ve changed the Federal law and subsequent questions that Congress changed the central law and we subsequently changed the Federal regulation that now permits verbal consent for HIV testing rather than signature consent. And as with many health care facilities and institutions across the United States unfortunately we were finding that the requirements for signature consent rather than verbal consent prior to HIV testing was acting as an inadvertent barrier to veterans being tested in a timely manner.
So certainly there’s much work to be done, but we’ve made I think some very important strides in promoting early diagnosis of HIV infection and then of course once we determine or learn that a veteran is infected with HIV - rapidly facilitating their entry into ongoing treatment and care.
Mr. Gomez: Thank you very much, sir. Operator, do we have our next question?
Operator: Your next question is from Mount Vernon Hospital in New York.
Miguel Gomez: Our next question then.
Operator: Okay. Our next question is from Planned Parenthood in Indiana.
Woman: Yeah, thank you for taking this question. And it does relate to routine HIV antibody testing versus risk-based. I’m a little puzzled, because that seems to suggest that everybody regardless of whether they are at risk or not should have a routine HIV antibody test. And I guess my concern is for people who virtually have no risk, have not, will not, isn’t that a waste of testing? If this were, you know, an infection that were airborne and could be transmitted to everyone I certainly would understand. But I’m still puzzled why we are going to more of a routine testing versus risk-based.
Mr. Gomez: Absolutely. We’re going to turn to Dr. Fenton to answer your question.
Dr. Fenton: Great. Thanks Miguel. Thank you so much for asking this question which is one that I think a number of colleagues have a little bit of difficulty in understanding. So let me try to explain the rationale for routine HIV testing and the evidence behind it. So first of all, CDC recommends routine HIV testing with the routine offer of an HIV test aged 13 to 64 years in the United States at least once in their lifetime.
And depending on continued risk that will dictate the frequency of onward HIV testing. So the idea here is to ensure that all individuals in that age group are able to obtain and know their HIV status.
A number of studies have been done on the cost effectiveness on routine HIV screening. And it does demonstrate that at or above the prevalence of 0.01% that routine HIV testing would in fact be cost effective and for most locations and jurisdiction across the United States is likely to be cost effective.
Now in areas where the prevalence is less that 0.01%, the CDC recommends that physicians or clinicians begin the process of screening and if they’re prevalent less than 0.01% than they can discontinue routine HIV screening.
Now the second part of your question related to what happens to people who have no risk and this is one of the challenges that we have with promoting HIV testing in the United States. On the one hand, clinicians find it difficult to do a proper risk assessment and really spend the time to assess risk and therefore we know that many individuals who are at risk are never offered a test by their clinician or people who may be perceived at low risk, but who actually are at risk are not offered an HIV test either. So making the offer of HIV testing routine takes pressure off of the clinician to do a detailed risk assessment by making it a standard clinical practice for all individuals.
From the patient’s perspective, we often see that people are not in fact aware of the risk that they may be undertaking and therefore it really is important that we have recommendations that really reduce those barriers to HIV testing and the offer of HIV testing as much as is possible.
Now this is classically seen for example among women in the United States, especially African American women who may perceive themselves to be at low risk, because they have one partner or low numbers of partners. But in fact the risk to women is really born by high-risk behavior either among their male partners either through the male partners multiple sexual partners, injection drug use or by sexual behavior.
So, just in summary, routine HIV screening offered to individuals age 13 to 64 years is cost effective if it’s done in areas where the prevalence is above 0.01% and the reason why we moved towards routing HIV screening is to reduce barriers for doing detailed risk assessments within a clinical setting which often misses individuals either because it’s not offered or patients perceive themselves to be at low risk.
Dr. Valdiserri: And if I might – this is Dr. Valdiserri if I might add to that question just the reality is that with risk-based testing policies in place essentially since 1985 when the HIV antibody test was first licensed, we know that in the United States still almost 40% of all individuals who have an initial HIV positive test go on to develop AIDS within a year of that first test which means they have been infected for years and years and years before they were diagnosed.
So it doesn’t mean that you should ignore risk factors if you have a patient that comes in with let’s say with syphilis or a history of injection drug use, you certainly want to think about HIV testing, but as Dr. Fenton said the risk-based approach has clearly been shown to be missing people who can now benefit from life saving treatments for HIV infection and as with many diseases early diagnosis is preferable to late diagnosis. So that’s what the focus is here. Getting people who are infected get into treatment and care as soon as possible.
Mr. Gomez: Thank you, Dr. Valdiserri and Dr. Fenton. Operator, do we have another question?
Operator: Yes. Next question is from SisterLove, Inc from Georgia.
Mr. Gomez: Hi, your question please.
Dazon Dixon Diallo: Hi, everyone. This is Dazon. Thanks, Miguel, and everyone for organizing this call today. I think I have two which are somewhat related. And one is, is that I haven’t heard a whole lot of discussion about the plans going forward in terms of better integration around understanding social determinants and how we promote HIV prevention and/or treatment.
Especially with regarding to access and demands attention and maintaining focus and care in some of the what I call developing communities, particularly in the South and in the rural communities around the country and in urban areas that have larger pockets of the prevalence of HIV. So in terms of Chris’ earlier question that at the state, local and federal level of integration – I’m wondering where the costs are around better integration of the – not just the research, but the potential of dealing more with structural intervention that address some of those social determinants directly or indirectly as they’re related to HIV risk and care.
Mr. Gomez: Sure and thank you. And any of our panelists would like to start to answer her question?
Dr. Fenton: Yes. Kevin Fenton here. I’ll begin. Dazon, thank you so much for your question and I couldn’t agree with you more. Increasingly we now understand that the epidemic is not only be driven by individual-level risk behaviors, but also the context within which these risk behaviors occur are important driving factors. As I said at the beginning of this call, factors such as discrimination, stigma, lack of access to effective care, poor educational opportunities, unemployment, etcetera, these are all social determinants which operate either at the community level or the societal level and which have an influence on individual level risk behaviors.
So CDC is certainly interested and committed to looking at diversifying the range of effective prevention interventions which are operating not only at the individual level, but moving upstream to tackle some of these social determinants of health. And there are three ways in which we’re doing this to structure intervention.
The first is really looking at promoting better collaboration and integration of services, that’s a type of structured interventions. So as you heard today looking at how we developed services, preventive services and treatment services, how we integrate prevention into treatments and care. How we integrate across HIV/STDs prevention programs to provide more holistic services to patients. We’re not only dealing with one thing, but we’re dealing with multiple conditions as well as the risk factors for those conditions.
Another structural intervention is policy-level intervention, so really changing laws and policies that can operate at both the societal and community level. And again there are many examples of where this is taking place. At the beginning of the call you heard about the legislation on for example, removing the ban on syringe exchange programs, Federal funding for syringe exchange programs, removing the HIV travel ban. There are many other polices which can be put in place that can really operate and facilitating on changing the contextual environment from which risk behaviors occur.
And then the third type of intervention with CDC is particularly interested in investigating and supporting our economic interventions or interventions which really lift individuals and communities out of socioeconomic deprivation and therefore provide a better context for effective preventions to take root. We have been looking at interventions for example in partnership with HUD on housing interventions and its impact on HIV.
We’ve been looking at micro-enterprise intervention. Looking at the effect of poverty alleviation on HIV risk behaviors and HIV incidents, looking at community-wide campaigns to change stigma discrimination and to tackle stigma and discrimination in an effort to provide a more welcoming context and environment for prevent intervention.
So a great question. It is imperative that as we move forward with the HIV response that we move upstream to tackle the determinants which are community and at the societal level.
Ms. Watts Davis: This is Beverly Watts Davis and if I could just make one follow-up on to that. As we talk about that one of the key things we talk about is what will the Federal – what all the Federal partnerships are doing, but this is also – we need to be also asking the same question of states and local community infrastructures, meaning county governments and city government.
And one of the key things that we have talked about is the Federal partners that we – that I hope to see that we will be supporting this year is having and taking that conversation to another level. In the sense is that we should be convening at a – what we call a – it’s almost connecting the dots, but a state connection conference, so that we are connecting the state directors of Medicaid, the state directors of alcohol and drug abuse, the state director of mental health agencies, the state all of the state directors who are oversight over community health centers, state directors who have oversight over health centers, the added joint generals of the National Guard and housing authority directors, so that we do that at the state level.
Because as Dr. Fenton talked about, laws and policies we can do that here at that level, but again the implementation of that will be slow holding if we’re going through Congress. But again at the state level when there is interest – you can also help state level change in the legislature is a lot faster. But also, too, policy change can actually happen, because you have state directors who are vested with the authorities to change policy at the state level. When they come together and realize that there are things that they can do to better integrate services and to better improve the services for all of the people across the country. That is one of the fastest changes, because local people can solve local problems best.
And they will in fact make that a lot more quicker, so again as we begin to – as the Federal partners begin to convene and to begin to work with us – to work together to hold a conference where we can bring in the state team of state directors, so they can better collaborate, better coordinate and hopefully have resources stretch a lot farther, because we are – because they begin to start figuring out how they fund a comprehensive approach as opposed to a solid approach from based on the solid money they get from the Federal government.
Mr. Gomez: Thank you both. And operator, do we have another question?
Operator: The next question is from Maryland University Research Company Center for Human Services.
Woman: Hi. Thanks for taking my question. HIV is a crucial issue for women who partner with other women, not only in an institutional setting, but also in the larger communities to which incarcerated women return. Now new studies in the U.S. have found that substance abuse in women who partner with other women have cell conversion rates that are actually three to five times higher than those of women who are identical in every other way. And my question is what are – are there any Federal initiatives to address this phenomenon?
Mr. Gomez: I’m going to first turn to Dr. Fenton and ask Christopher Bates to help answer the question. And I also want our listeners to know that we’ve gotten a bulk of additional questions about the prevalence among women – HIV among women and asking our colleagues what they are doing to respond to this need. I’ll start with Dr. Fenton.
Dr. Fenton: Great. Thank you, Miguel. Thank you very much for the very, very important question and one that I think posed a bit of a challenge to us working at the Federal level in both characterizing and the nature of the epidemic, but also looking at the response to HIV infection among women who have sex with women.
As you rightly say it, the risk that accrues women who have sex with women result from a number of factors, either the individual level substance abuse which may place that individual at high risk for HIV and multiple sexual partnership. The risk may well be because women may have women – female actually have male partners and those male partners may in turn be at high risk. As well as other risk behaviors that women may in fact have.
The challenge that we have both at the surveillance level is characterizing the epidemic by the sensitivity of our surveillance system to either clearly – unclearly allocate risk to women who have sex with four men, so because we are a hierarchical method for allocating risk, if a women who has sex with women injects drugs she will be classified primarily as an injection user rather than of WSW in terms of her risk of acquisition. If she has sex with male partners as well as female partners than her risk will be allocated differently. So there are challenges when it comes to characterizing the nature of and the impact of the epidemic among women who have sex with women.
We therefore rely on ad hoc surveys to give us a better sense of the nature of the risk, prevalence of HIV within this population and HIV incidence. And you’re absolutely right in the importance of the overlapping epidemic for substance abuse as it relates to HIV risk among women who have sex with women. As far as our prevention programs are concerned, we do not have any national programs which are specifically targeting women who have sex with women, but we do work with and fund or state and local partners, as well as community based organizations who at the local-level may be able to determine their relative prevention needs and their relative prevention priorities and therefore fund accordingly. So I’ll end there. And just to say thanks to this really important question.
Mr. Gomez: And did any of our other panelists want to make any additional comments about woman-centered care?
Dr. Dieffenbach: This is Carl Dieffenbach at the NIH. We have a number of research programs that are focused on developing bio-medical prevention strategies specifically for women and the primary one of which are microbicides which are vaginally applied products that could potentially block HIV transmission. So in the situation right now we’ve had studies that we’ve completed that showed a marginal effectiveness of one product and that there are other ongoing studies of additional products that may show higher efficacy. But this is a work in progress. Nothing is ready for license right now, but it is a promising area.
Mr. Gomez: Thank you very much. Operator, can we get our next question?
Operator: Okay. Your next question is from Delaware HIV Consortium.
Mr. Gomez: Hello.
Woman: Hi. One of the things that we’ve noted is that education throughout the United States in schools, alternative schools, home schools, correctional institutions is either lacking either in availability and/or consistency. And since HIV has become a treatable disease it’s fallen under the radar in terms of concern among youth. What is the possibility of there being a developed standardized basic HIV educational program for use that could be age and grade appropriate that would contain basic transmission prevention information which all different types of institutions could use despite differences in religious orientation setting and so forth, with possible add-ons that could be used for certain settings that want to provide additional information?
Mr. Gomez: Thank you for your question. I’ll open that up to our panelists. Who would like to respond?
Dr. Fenton: I’ll begin to respond, Miguel. It’s Kevin Fenton here. So thank you very much for that question. And you’re absolutely right I think there’s a number of challenges that we face on one level health literacy among adults and adolescents is really a problem and that effects our ability to have effective prevention responses, not only for HIV but for other medical conditions as well.
Specifically, sexual health literacy is also a challenge and it is difficult, because of challenges in providing comprehensive sexual education in schools, targeting out-of-school use and then having ongoing programs of HIV health promotion and awareness for individuals as they progress through their adolescent and early adult sexual career.
CDC has been working with partners to develop a school-based curriculum which looks not only at sex education, but also looks at other health-related behaviors and interventions that can be provided within the school setting. This was developed by our Division of Adolescent and School Health and is available both on the CDC website and it may also be available on AIDS.gov. And Miguel, you may want to confirm that.
But essentially, it does provide a framework for an evidence-based curriculum that could be adopted and applied in schools across the country. Now the main challenge as you are aware is the decision to implement such a curriculum really resides at the school board or the local level and that really is where a lot more work has to be done to educate school boards on the needs for such a curriculum to ensure that in the packed school agenda that time and space is given for these curriculums to be implemented and that we have systems to measure and hold accountable schools and local school boards regarding the implementation of this curriculum – these curriculum.
But the reality is that it really is up to the local level when it comes to the implementing – the implementation of these curriculums and that’s really where we do need to work with our partners, not only within health departments, but within other sectors at the local level to promote the implementation of these curriculum.
Mr. Gomez: Thank you, Dr. Fenton. And Dr. Fenton, you might also be able to help along with our colleague at SAMHSA the next question. We have an email from a Federal employee to ask for a description about the role of the incarcerated and ex-offenders as they serve as a driver in the epidemic and what prospects of better coordination among our Federal colleagues. In other words, if you can talk about what prevention efforts are happening for the incarcerated ex-offenders and I’ll turn to our other colleagues to help answer that question.
Dr. Fenton: Sure. I shall begin. So thanks again very much for that question, it’s incarcerated populations are an important target population for prevention, treatment and care, but in part because of this very high proportion of men and women in the United States who are incarcerated even brief or extended periods.
It’s important to note that incarceration itself may not be a particular risk factor for escalating HIV incidence within the prison, but remember that because we are pooling individuals who may enter the prison system with HIV and there may be ongoing transmission risks in prison, as well as the release to these prisoners back to the community. These influence not only the transmission dynamics within prisons, but also within communities themselves.
There’s also another factor that we need to bear in mind with incarcerated populations and that is by removing a disproportioned number of men from the community, especially in the African American community it does have an impact in changing the male to female ratio in communities and that results in a reduction in eligible males within communities, it may contribute to partner concurrency, it may contribute to lack of negotiation skills among women who are really looking for a male partner who may enter into transactional sex or high-risk sexual partnerships in order to maintain a relationship. So we recognize the importance of incarceration and incarcerated populations in the HIV transmission dynamic.
CDC has been partnering with other Federal agencies, as well as with our colleagues in the Department of Justice, to look at opportunities for promoting HIV screening in prison, linkage to care, as well as them showing that the prisoners who are being released that we have community-based structures which are available to promote ongoing management of HIV among prisoners, as well as to assist prisoners to maintain reduced risk behaviors. It is challenging, however in part, because of the economic downturn and many state and local health departments disinvesting in their prison programs.
It’s also difficult for prison systems many of which are private to prioritize HIV screening or STD screening or TB screening within the current fiscal environment. And we have been hearing across the country, many prisons, as well as many health departments disinvesting in the screening program for HIV in this setting. So this is a huge challenge for us. We do recognize the importance of this population and the importance of vigilance going forward.
Ultimately, I think what we’ve heard is the importance only of tackling the status quo, but we also need to look at a structural intervention which is geared towards reducing the proportion of young men who actually enter the prison system in total. So this would be a structure intervention, to really look at opportunities for reducing incarceration rates in the U.S. as we move forward.
Mr. Gomez: Thank you and we have a lot more questions. I’m going to turn it back to the operator in a second. We have another question for our colleague at NIH to describe current research efforts towards a cure. Dr. Dieffenbach?
Dr. Dieffenbach: Thank you for that question. I just took a bite of something. I shouldn’t have done that.
Mr. Gomez: No problem, sir. Do you want me to take another question and then I’ll come back to you?
Dr. Dieffenbach: Sure.
Mr. Gomez: Operator, could we take a question?
Operator: All right, the next question is from U.S. Department of Veteran Affairs.
Mr. Gomez: Your question, please.
Man: Hi, thanks for taking my question. The question I had is for the panel and it is whether there were any thoughts or strategies in which we as HIV researchers who work for the Federal government could maybe think about novel ways to use the research knowledge that we have acquired over the years fighting the epidemic here in the U.S. and to maybe think about transferring and using this knowledge to collaborate with countries that have a combination of high seroprevalence and weak healthcare infrastructures, such as many countries in Africa to help them with the knowledge we’ve acquired to help them try to mitigate the epidemic that they’re fighting.
Mr. Gomez: And thank you for that question from our colleague at VA. Tom, I’m going to have you start and then I’ll ask – actually Dr. Valdiserri. It’s an important question. It was from VA. I’ll ask you to follow up, but any of our other panelists if they’d like to join answer that question.
Mr. Walsh: Well thanks for that. This is Tom Walsh from the State Department. Yes, you make a good point and quite a bit of that is happening. More than you may imagine. PEPFAR is the President's Emergency Plan for AIDS Relief is an interagency initiative. So you know it’s led here at the State Department. Almost all of the Health and Human Services operating divisions are involved in it. CDC is our second large implementing agency after the U.S. Agency for International Development, HRSA, SAMHSA, NIH, all of them are involved, as well as the Department of Defense and so all of them bring some of the insights from their domestic activities. Some of the data and research findings to bear on what we do here.
And quite a few of the people who work on PEPFAR are people with a domestic background like Ambassador Goosby himself or people who’ve been working in CDC or other domestic agencies. So I think there’s already a lot of cross fertilization taking place, but we would certainly welcome ideas for on what more we can do. We do have a – what’s called a public health evaluations system which is a forum for research to take place.
I would say PEPFAR is not primarily a research program. We’re primarily into program implementation. We do have a research component, but we rely quite a bit on NIH for research as well. Let me stop there and see if any of my colleagues have any.
Dr. Valdiserri: Hi. This is Dr. Valdiserri from the VA. Let me say that the – my short answer to your question would be that I do think that the Department of Veterans Affairs that healthcare providers who work in the Department of Veteran Affairs have a lot to offer to the global AIDS efforts. I think that when you consider that the VA is the single largest provider of HIV care in the United States, we have over 23,000 veterans who are currently in care for HIV in the VA system. And we’re also – and many of you with a healthcare background will appreciate that the VA is a major training resource not just for physicians, but for nurses, for mid-level practitioners, for psychologists, for pharmacists.
So I think that there probably are opportunities to think about and I’m talking more along clinical lines now, not research lines, to think about how the experience of VA providers might be used to help other healthcare professionals in other settings across the United States. I will also say that the VA has a great deal of experience in dealing with what most of the healthcare field now is coming to deal with, thank goodness as we have better treatment and people with AIDS are living longer and longer. Lo and behold, healthcare providers are not just taking care of someone’s HIV disease, but they have to now take care of their hypertension and their diabetes and maybe even their depression.
So the average age of our veteran who’s under care for HIV is 53 years of age. And these individuals tend to have a number of other medical conditions, so again our experience in dealing with a variety of co-morbidities that we can expect to see as – particularly in the developing world in the industrialized nations, as patients age with HIV disease, again I think many of the VA providers have a great experience with this that can be useful in other similar settings.
Mr. Gomez: Thank you both. I’m going to jump back to Dr. Dieffenbach.
Dr. Dieffenbach: Thanks, Miguel. So the question was what is the NIH doing to facilitate research on the cure?
Mr. Gomez: Or towards the cure.
Dr. Dieffenbach: Towards a cure and I think towards a cure is an important way of framing the question, because the cure remains a target and a goal and to date remains a heavily elusive one. To that end there are a number of grant-based programs and research opportunities to investigate the nature of the persistence of HIV, the nature of latency and then also to develop strategies for eliminating the latent pro-virus, as well as combating persistence.
So again there’s another sort of interim step that we can think about in terms of what we would call a functional cure. Where with in the absence of antiretrovirals or under the cover of antiretrovirals establish a state where somebody had a very low viral load, so they didn’t progress in their HIV infection and they also were not at a level of virus in their bloodstream where they could transmit, so two things, keeping an eye on how to take the first step towards a functional cure and then continuing to work towards the cure.
Mr. Gomez: I appreciate that, and as we’re moving towards the end of the call, I want to recognize that some of you are still waiting in queue and we’ve got a lot of questions about housing, the inclusion of people living with HIV/AIDS in our work, several questions about the status of our efforts to ensure that we respond effectively to HIV/AIDS in the African American community and other minority communities. Several questions from tribal communities and I’m sorry that we haven’t been able to get all of the questions, but as we start this call for World AIDS Day it was really to have a conversation to get out some of the key issues and I really want to thank all of our speakers and participants today.
Mr. Gomez: And there’s some final comments that I’m going to turn to our speakers to ask them respond. And first I’m going to turn to our colleague at HRSA, Dr. Deborah Parham Hopson. You know, this is a World AIDS Day call and on behalf of the Federal government, could you highlight some of the reasons why World AIDS Day is important, ma’am?
Dr. Deborah Parham Hopson: Thank you, Miguel. I’d be happy to. First of all, on behalf of all Federal HIV and AIDS programs I’d like to thank all of you for joining us today and for asking so many critically important questions. As Dr. Koh noted when he opened the call, December 1, 2009 will be the 21st Annual World AIDS Day. It’s a time for us to stop, reflect and remember those who have died. It is also a time to acknowledge our accomplishments and all of the hard work we are doing every day to address the epidemic.
As mentioned earlier on this call I have the lead responsibility for the Ryan White HIV/AIDS care and treatment program. I feel very hopeful because of the good work that is happening as an outcome of this program. World AIDS Day is a reminder for all of us domestic and global, funders and grantees, advocates and government employees that it is essential that we continue working together with and on behalf of people living with HIV and AIDS. Today you have heard overviews of the domestic and global epidemics. In both cases, local responses are critically important. Those of you on the front lines here in the U.S. and your counterparts around the world are making a real difference for those at risk for and living with HIV and AIDS. What’s happening on the front lines is critically important and we are committed to supporting you in that work.
It’s hard work, but it’s important work and together we can reach those three goals as outlined by President Obama of reducing HIV incidence, increasing access to care and optimizing health outcomes and reducing HIV related care disparities. On the 21st World AIDS Day we have a lot to be proud of. But as [President] Obama has noted, that ending the HIV epidemic will take a one-world effort and you are key players in that endeavor. We know that many of you continue to have concerns.
You have questions about funding. Questions about advancement in care and treatment, questions about the impact of healthcare reform on your ability to meet the needs in your communities. These concerns reflect the realities of the HIV epidemic, but I’m very glad of the fact that regardless of these challenges we are working together to respond effectively to HIV and AIDS. At HRSA’s HIV/AIDS Bureau we are offering employee education events for World AIDS Day and they have our Ryan White funded grantees are doing the exact same thing.
We hope that you are too and that you will take this day to take action. You can take action by joining AIDS.gov’s Facing AIDS campaign mentioned earlier on the call. You can take action by carrying what you have learned from this conversation today back to your colleagues and to those you serve. So again, thank you for participating today. Thank you for your questions and for the hard work that you continue to do.
Mr. Gomez: Ma’am, thank you so much. And I’d like to introduce Mr. James Albino, the Senior Program Manager at the Office of the National AIDS Policy at the White House. In this role, he oversees the operations of the Office and is the policy lead on HIV health disparities and a range of other issues. Sir, could you share with us as our nation prepares to observe World AIDS Day, your thoughts?
Mr. James Albino: Sure, Miguel. Thanks so much. Thank you, Miguel very much for putting this together. It has been a pleasure to participate in today’s call and to hear the concerns and questions from our Federal partners. I want to thank Ambassador Goosby, Dr. Koh, Dr. Fenton, Dr. Parham Hopson, David Vos and others for talking about the President’s priorities and the importance of the National AIDS Strategy.
As you heard, as you may have heard, President Obama is committed to developing a National AIDS Strategy that’s focused on reducing the HIV/AIDS incidence, increasing access to care and optimizing health outcomes and reducing HIV/AIDS related disparities. The White House – I’m sorry.
Mr. Gomez: Go ahead, sir.
Mr. Albino: The White House Office of National AIDS Policy has held more than three and has three more community discussions that are planned. And we are looking forward to the active participation of other community in these events. The events that are upcoming are in Fort Lauderdale on November 20 and New York City on December 4 and we will close out our community discussions in Caguas, Puerto Rico on December 14.
As Dr. Koh mentioned earlier if you are in those areas we encourage you and implore you to please step forward and come out to those community discussions. But you can also provide your input via our call to action on the White House web page and you can go to whitehouse.gov and type “ONAP” in the search engine and it will take you right to our page and you can provide input on the call to action there.
With respect to Worlds AIDS Day, the President will renew his commitment to the strategy and to the global effort and you’ll be hearing more about that very soon. We’re grateful to Federal partners that have participated and look forward to continuing to work with them. Thanks, Miguel.
Mr. Gomez: Thank you, very, very much. And before I turn our call over to Christopher Bates, the Director of the Office of HIV/AIDS Policy and the Executive Director of the President’s Advisory Council on AIDS, I want to let all of the folks who are still sending in questions at firstname.lastname@example.org that we – and those who were in the queue if you do send us your questions, next Tuesday we will be blogging about this call.
We will make a podcast available and I do want to encourage you to fill out your evaluation form that you’ll receive right after today’s call. And I want to thank our colleagues who also invited you to join us in the Facing AIDS for World AIDS Day campaign -- which you can learn more about at AIDS.gov- which is an online photo initiative. But we’ve had our senior staff across the Federal government join us today. And I’d like to turn to our lead coordinator here at HHS, Mr. Christopher Bates to provide us a summary of some of the key things he heard and close our call. Mr. Bates?
Mr. Bates: I’d like to join my colleagues in thanking all of you today for joining this call. As Dr. Koh noted, we hope that you have found this call useful and definitely helpful to the work that you do.
I just want to highlight a couple of things that I heard in today’s conversation and questions. One is I think that we made it very clear that the Obama Administration is placed the domestic HIV response as a key public health issue and has prioritized it domestically, that we will continue our efforts internationally and we hope to strengthen both international and domestic response to a scale that makes a very serious and lasting impact on the epidemic.
You also heard in today’s call that the U.S. will continue to expand our commitment to HIV prevention care and treatment. That resource has definitely not fallen off the page and that we will be continuing in a bio-medical and our behavioral research, particularly be able to research so that we can better position our prevention intervention and move ourselves to a place where we have fewer new infections occurring in the U.S.
We will continue to expand our efforts to address HIV complacency and we will join with our partners at the state and local level to fight HIV-related stigma which as Dr. Fenton pointed out still continues to be a significant barrier to us identifying people who are HIV positive, to continue to keep into care and, treat those individuals who are positive and hopefully to turn this epidemic around.
And last but not least, we will use this strategic plan as a tool to help better understand what our national investment is in this epidemic, to be able to use this tool to report out to the public. The continued progress we hope to make in turning this epidemic around and we hope to engage all of you in this ongoing conversation both in terms of the domestic response and also our international.
And last but not least, I know that all of you have joined this call in part, because you’re going to be planning World AIDS Day events for Federal employees and local employees and the general public, we are grateful to your efforts in that behalf. And we hope as you’ll have questions that you’ll, you know, utilize yourself and one another as spring points and points of reference for that. Also don’t hesitate to call Miguel Gomez and his team, because the folks at AIDS.gov have years of experience in these events and have been very successful in reaching out to the public.
And finally I want to thank those members of the Federal World AIDS Day Planning Group and I’d like to thank the International World AIDS Day Federal Planning Group who helped plan this call. Those individuals who represent both the international and domestic HIV/AIDS programs and those among you who have labored to ensure that we are all working together expanding the reach of our program and using Worlds AIDS Day to highlight our programs and to bring focus to those things we still need to do. I’d like to thank all of you for this call. Miguel, I’ll turn it back to you.
Mr. Gomez: Thank you so much, Christopher. And I just again just want to ask everyone to please fill out their evaluation form and I want to everyone to know that you were joined by over 1,000 registered sites across the United States from Oklahoma to Florida, to New York, New Jersey, Michigan, Wyoming, et cetera and we really want to share our gratitude for the work you do. And thank you very much. Have a good afternoon.