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HIV/AIDS
Section Newsletter
Fall 2004

Gearing Up for Washington!

The weeks remaining until the Annual Meeting in Washington, D.C., are dwindling. The final program is set, plans are being finalized for Section activities and events, and my year as Chair is coming to a close. It has been a tremendous honor and privilege to serve as the chair of the HIV/AIDS Section. It's been a great year and I think we've accomplished a lot. We assembled a great Section Leadership Group, had a very successful Mid-Year Meeting at APHA, and created some new partnerships within and outside of APHA. Each year, the size of our Leadership Group has grown, and I'm looking forward to a large turnout of members who are interested in stepping up to the plate to carry the torch forward.

I remember the first time I attended an HIV/AIDS SPIG meeting. We were in Washington, and I ventured forth to a business meeting to find out what was happening and to meet others involved in HIV/AIDS. It wasn't hard, folks. I simply showed up. When I left that meeting, I'd volunteered to assist with the program for the next year's Annual Meeting and, well, the rest is history. In these intervening years, we have achieved Section status (a feat not easily accomplished!), assembled impressive programs to offer at each Annual Meeting, placed members on APHA committees and task forces, and continue to experience growth and interest in the Section.

I look forward to turning the gavel over to the very capable Mike Case, but plan to stay very involved in Section activities. There are several committee chair positions that are available and a need for committee members. That is where you come in! If you want to serve on a committee, all you have to do is SHOW UP! It's that simple! We're a bunch of friendly, hard-working folks and we'll gladly welcome you as a partner in the fight against HIV/AIDS. You don't have to have a PhD or a fancy-sounding title to get involved (but we gladly welcome those of you who do!). Just bring your enthusiasm, your ideas, your commitment to this field, and a willingness to roll up your sleeves and help. I'll be one of the first ones to shake your hand and thank you for stepping up. We're all in this together.

As I first said in Atlanta in 2001: In the fight against HIV, EVERYONE is a V.I.P.!

See you in Washington in November!

Walk the Hill for Public Health!

PROTECT PEOPLE • • • SAVE LIVES • • • FUND PUBLIC HEALTH!!!

Calling all HIV/AIDS Activists!!!

Nov. 9, 2004

On Nov. 9, thousands of public health professionals attending APHA’s 132nd Annual Meeting will be walking the halls of Capitol Hill to tell Congress, it’s time to make public health funding a national priority!

Increasingly, the health of all Americans is at risk. Without additional resources for a continuum of medical research, prevention, treatment and training programs, our nation’s public health system will not be able to respond adequately to existing and emerging threats. Unfortunately, some of our nation’s leaders continue to not recognize the importance of fully funding the nations’ public health system that protects Americans and saves lives every day.

November is a critical time to advance our key issues to national policymakers. Both mandatory and discretionary public health budgets for the upcoming year face grossly inadequate allocations. Currently, appropriations for the CDC, HRSA, and other federal agencies stand to be either flat-funded or cut, despite the urgent need to greatly expand resources for disease prevention, wellness promotion, and safety preparedness in communities nationwide. Reduced expenditures on these essential programs both deprive and undermine the public health community’s ability to improve the health outcomes of the American public.

We need your participation to make this Hill day a success!
The rally will begin at 8:30 a.m. at the Upper Senate Park on Capitol Hill. At 10:30 a.m., participants interested in going to Capitol Hill will go with their state delegations. Let's be sure that the HIV/AIDS Section is represented………

1. Register today to attend the rally at <www.apha.org/legislative/walkhill/signup/>.
2. Send a brief e-mail invite to your colleagues, Section members and other APHA members to attend the rally.
3. If you are members of other organizations that send participants to our Annual Meeting, encourage them to attend the rally.

Your voice and presence on Nov. 9 are crucial to the visibility and effectiveness of this campaign to convince Congress on the importance of public health.

Together, we can ensure a powerful public health presence in our nation’s capital by displaying the solidarity and commitment of the public health community.

For more information on the march visit the Walk the Hill for Public Health web page at <www.apha.org/legislative/walkhill/index.htm>, or contact Lakitia Mayo, Director of Grassroots Advocacy, by e-mail at <lakitia.mayo@apha.org> or by telephone at (202) 777-2515.

Last Chance for Your APHA Policy this Year!

It's called "APHA Public Hearings" listed in the program for Sunday, Nov.r 7 from 3:30 p.m. – 6:00 p.m. The hearings are intended as an open forum provided for detailed exploration, discussion, and debate of assigned public policy proposals. Since online review of submitted policies for the year is available earlier in the year, these Hearings mainly focus on Late Breakers

[Q: So, what's a "Late Breaker"? – A: Resolutions which relate directly to important, emergent events occurring after the regular process deadline. The cut off date for Late Breakers is Saturday, Nov. 6, 2004 at 6:00 p.m. and should be emailed to <policy@apha.org> or submitted at the Association office in an electronic format. Since late-breaking resolutions cannot benefit from a full public and technical review of the established policy development process, any resolution adopted by the Council under "late-breaking" provisions will be considered valid, but interim, policy -- subject to full review and reaffirmation in the next annual policy development cycle.]

All APHA policy statements are available through a searchable database. They can easily be accessed through APHA's Policy Statement Database on the Web site. Policies are searchable by keyword, subject index, and by the year the policy was instituted. [Please Note: Specific and indirect information related to HIV is widespread throughout the polices and not always easily “found” by the searchable database.


For more information on the Policy Process and Policy Statements, please go to APHA's Web site at <www.apha.org> and click on Legislation, Advocacy & Policy. From there, members can click on "APHA Policy Statements" as well as "Guidelines for 2004 Policy Process," which will be helpful for 2005.

International Networking in Washington, D.C.

With the success and interest shown at the last networking event in San Francisco, we will be holding a similar one in Washington, D.C. this year. Sunday, Nov. 7 from 4-5:30 p.m., will be another networking opportunity for our Section members with those from the International Health Section. This forum will provide members of both groups with an opportunity to discuss such issues as: ARV treatment included in the universal package of care; challenges faced by professionals in fieldwork (e.g., adherence to ARV treatment in developed countries and the implications and issues involved in providing access to treatment in developing countries); practices that are most effective in the field; and areas in which more effort and improvement are needed, both nationally and internationally (e.g., addressing stigma in HIV/AIDS care). It is believed that there is a lot we can learn, as some whom attended last year’s event can attest to. There is much we can do together in abating the HIV/AIDS epidemic both here and abroad. Therefore, it is hoped that this forum will serve as an avenue of exploring the possibility of both Sections developing and working on a joint project together. All members of both sections are invited and encouraged to attend!

Executive Board Update

The Executive Board is encouraging all members who plan to attend the Annual Meeting to register for Walk the Hill for Public Health. The rally will be from 8:30-10:00 a.m. and the Hill day will be from 10:30 a.m.-12:00 p.m. [To learn more about Walk the Hill for Public Health Day, visit <www.apha.org/legislative/walkhill/index.htm> and register today at <www.apha.org/legislative/walkhill/signup/>, or see the Walk the Hill for Public Health! article in this newsletter.]

The section can help APHA by thinking about developing broad-based HIV/AIDS policy statements that will reflect your professional and best science-informed perspectives yet leaving APHA staff the flexibility to respond quickly. Thank you for reviewing and sunsetting current policy. And thanks to members of the Section who worked with APHA to develop an excellent response to the CDC materials revisions.

As this is my last year as an Executive Board member, I would like to extend my thanks to the Section for their courtesy in allowing me to sit in on business meetings and in communicating issues and concerns with me. It has been a privilege serving you. The role and voice you have in APHA is critical to world health and the continued advocacy for the elimination of HIV and AIDS. Thank you for your hard work in keeping the APHA aware and current.

Pat Mail, Executive Board Liaison to HIV/AIDS Section

A Week in Bangkok

I was fortunate to attend the XV International AIDS Conference held in Bangkok, Thailand, from July 11 – 16, 2004. There were nearly 20,000 attendees from over 120 different countries who participated in the six-day conference. Bangkok is a culturally diverse city of nearly 10 million inhabitants. The city includes many beautiful Buddhist temples, the king’s residence and governmental offices, gleaming new office buildings as well as impoverished areas. The Thai people are warm and friendly. They made the attendees feel welcome and comfortable.

Although there have been 14 international conferences prior to this one, in my opinion, this was the first time attendees could obtain a true sense of the global health impact of the pandemic. Past conferences focused on issues of importance to the United States and had less of a focus on developing countries. While some of this was still true, many of the panel presentations I attended had no representation from the United States. This provided me with the opportunity to learn from presenters from sub-Saharan Africa, India, China, Russia, Vietnam, Thailand, Haiti and other parts of the world that have been hard-hit by AIDS. The issues and concerns they have are very different from what we face in the United States. As a public health professional, this was both useful and important information. The statistics provided by epidemiologists from the World Health Organization and other groups were sobering – nearly 40 million people infected worldwide, with an estimated 5 million new infections during the past year.

There was a clear distinction between countries that have ready access to life-saving anti-retroviral therapies (like the United States) and those who cannot afford these medications. In fact, much of the political activism associated with the conference had to do with how to provide medications to resource-poor countries. Pricing of the medications is an obvious concern, but the issue is complicated by a lack of trained health care staff to administer the medications, as well as other infrastructure issues. There are other concerns that were voiced about the safety and efficacy of unlicensed generic drugs made by companies in India and elsewhere. There was little discussion of vaccine development, which was disappointing. There are some new directions that are being pursued in terms of attempting to eliminate the virus from viral reservoirs, but there is a clear recognition that there is no “magic bullet” in sight, and we are in for a long haul to conquer AIDS. There were several promises of funding that were made by the Global AIDS Fund, big pharmaceutical companies and the governments of several developing nations that have been significantly impacted by HIV/AIDS. One ambitious but obtainable goal is to provide antiretroviral therapy to 5 million HIV-infected people worldwide by 2005.

There were no significant clinical breakthroughs announced at the conference. While some attendees might not agree with my assessment, we did not have newsworthy scientific findings that could compare with the announcement of the success of protease inhibitors and combination or HAART therapy from the XI International Conference held in Vancouver in 1996.

It was a pleasure to listen to Nelson Mandela, Secretary of the United Nations Kofi Annan, and Dr. Anthony Fauci, director of the National Institutes of Allergy and Infectious Diseases. Upon my return to the United States, I was surprised by how little attention the conference received in both the print and broadcast media. Like most people who have been involved in fighting this battle for a long time, I look forward to the day when international conferences on AIDS will no longer be necessary because we have found a cure for this terrible scourge.

HIV Content Guidelines Comments

August 16, 2004

HIV Content Guidelines Comments
Centers for Disease Control and Prevention
1600 Clifton Road, N.E., Mailstop E56
Atlanta, GA 30333

RE: Proposed Revision of Interim HIV Content Guidelines for AIDS-Related Materials, Pictorials, Audiovisuals, Questionnaires, Survey Instruments, Marketing, Advertising and Web site Materials, and Educational Sessions in CDC Regional, State, Territorial, Local, and Community Assistance Programs

To Whom It May Concern:

On behalf of the American Public Health Association (APHA), the oldest and largest organization of public health professionals in the world, representing more than 50,000 members from over 50 occupations of public health, we appreciate the opportunity to comment on the notice for public comment entitled, “Proposed Revision of Interim HIV Content Guidelines for AIDS-Related Materials, Pictorials, Audiovisuals, Questionnaires, Survey Instruments, Marketing, Advertising and Web site Materials, and Educational Sessions in CDC Regional, State, Territorial, Local, and Community Assistance Programs,” 69 FR 33824.

We commend the CDC for taking the time to carefully review these guidelines. The past twelve years have seen great changes in technology, scientific information, public knowledge and public policy. We agree wholeheartedly that periodic review is necessary to make sure the public health of the nation is being considered on an ongoing basis, and appreciate the opportunity to play a role in shaping any amendments that are made.

It is with this in mind that we offer the following commentary on the proposed HIV Content Guidelines for AIDS-Related Materials, Pictorials, Audiovisuals, Questionnaires, Survey Instruments, Marketing, Advertising and Web site Materials, and Educational Sessions in CDC Regional, State, Territorial, Local, and Community Assistance Programs. Comments have been arranged sequentially by section for ease of reference.

CDC Proposed Guidelines
I. Basic Principles
“Messages must be provided to the public that emphasize the ways by which individuals can protect themselves from acquiring the virus. These methods include abstinence from illegal use of IV drugs as well as from sexual intercourse except in a mutually monogamous relationship with an uninfected partner. For those individuals who do not or cannot cease risky behavior, methods of reducing their risk of acquiring or spreading the virus must also be communicated.”


Suggestions and comments:
1. If the CDC requires accurate information to be provided on the effectiveness of condoms, they should also be required to present information on the effectiveness of abstinence-only programs. For the purposes of consistency, full disclosure and well-informed policy and programming decision making, this would be a sensible option. Given this, it would be imperative to report that the overwhelming evidence that comprehensive sex education does not hasten the onset of sexual activity. In addition, while more comprehensive and rigorous research on abstinence-only programs needs to be undertaken – some of which is under way – to date these programs have not been shown to impact onset of sexual behavior.

2. The phrase “as well as from sexual intercourse except in a mutually monogamous relationship with an uninfected partner” does not recognize that serodiscordant relationships do exist. It is important to find ways to appropriately encourage the ideal but recognize the need to teach risk reduction to those who are in serodiscordant relationships.

3. There are several compelling arguments for abstaining from injecting drug use: first, in most cases, it is illegal; second, it involves the introduction of often-toxic substances into the human body; and third, deleterious physical effects from long-term use are well documented. There is no such body of knowledge regarding sexual intercourse outside of a mutually monogamous relationship. Documented deleterious physical effects (transmission of HIV and most STI’s) can be prevented using appropriate interventions such as condoms. The federal government should appropriately discourage illegal activity. However, except in certain well-defined situations, sexual activity is not illegal. Monogamy as a risk-reduction approach is appropriate, but should not be the exclusive message if we are serious about reaching the at-risk population.

CDC Proposed Guidelines
“A. Web site-based HIV/AIDS educational materials, questionnaires or survey instruments should use terms, descriptors, or displays necessary for the intended audience to understand dangerous behaviors and explain practices that eliminate or reduce the risk of HIV transmission.” (Emphasis added)

Suggestions and comments:
1. Agreed. It is crucial to use terms, descriptors, or displays that are relevant to the target audience. The range of these terms, descriptors, or displays will vary greatly depending on the audience, and programs must have the freedom to use words employed by those they are trying to reach without fear of funding being stripped. As these terms, descriptors, and displays can be specifically targeted, it should be understood that what might make sense for one population may not be the first option for another. It is through this diversity and direct targeting of messages that we will have the greatest impact.

CDC Proposed Guidelines
“B. Written materials, audiovisual materials, pictorials, and marketing, advertising, Web site-based HIV/AIDS educational materials, questionnaires or survey instruments should be reviewed by a Program Review Panel established by a state or local health department.”

Suggestions and comments:
1. When reviewing Web site materials, is it the entire Web site, or only that portion in which funds are being supplied by the CDC? Clarification is needed, as there is a vast difference in impact (i.e., cost, personnel, time) on programs. This clarification is also needed in regards to marketing and advertising material. Agencies may advertise events for which they receive no CDC funding. Are those materials to be reviewed? This could represent both an enormous increase in needed resources to staff the review panels as well as an unacceptable intrusion of government into private agencies.

2. The Program Review Panel (PRP) must include members of the targeted community to ensure a balanced board. This should be stated explicitly to guarantee representation.

CDC Proposed Guidelines
“SEC. 2500. USE OF FUNDS.
(b) Contents of Programs.--All programs of education and information receiving funds under this title shall include information about the harmful effects of promiscuous sexual activity and intravenous substance abuse, and the benefits of abstaining from such activities.
(c) Limitation.--None of the funds appropriated to carry out this title may be used to provide education or information designed to promote or encourage, directly, homosexual or heterosexual sexual activity or intravenous substance abuse.


Suggestions and comments:
1. While abstinence is the only sure way of preventing HIV, those who choose to engage in sex or injecting drug use need to be properly informed of ways in which they can minimize the spread of disease, like condoms, cleaning needles or needle exchanges. Risk-reduction messages are appropriate and must be offered in addition to risk-elimination messages.

2. Few abstinence-only programs have been thoroughly evaluated for their effectiveness, and there is no persuasive evidence that these programs significantly change teens' sexual behavior. In contrast, comprehensive approaches to sexual education have been shown to delay sexual intercourse and increase condom and contraceptive use. The Association of Reproductive Health Professionals, the American Medical Association, the American College of Obstetricians and Gynecologists, the American Public Health Association and the American Academy of Pediatrics are among the numerous organizations that support comprehensive sexual education. Governmental agencies including the National Institutes of Health, the Institutes of Medicine and the Office of National AIDS Policy have also publicly stated their support of comprehensive sex education. Outside national and governmental organizations, the American public has stated a desire for comprehensive sex education: nearly nine in 10 American parents believe that sexuality education programs should cover all aspects of sexuality, including contraception and safer sex.

3. Although generally less explicitly stated, there is increasing interest in examining the concept of abstinence as a method of delaying sexual relations. Researchers are only just beginning to establish abstinence user-failure. Condom-method failure rates and user-failure rates are well documented in the literature. Evidence has shown that condoms effectively prevent pregnancies and most sexually transmitted diseases or infections (STIs), with method-failure rates between 0.5 percent and 7 percent, but with user-failure rates between 12 percent and 70 percent. Total abstinence presumably has a method-failure rate of zero, but research on periodic abstinence indicates user-failure rates between 26 percent and 86 percent.

4. Relying on abstinence as the sole method of delayed sexual interaction has been shown to be an ineffective approach. For example, a recent Minnesota Health Department study of the state's five-year, abstinence-only program found that sexual activity by students taking the program actually doubled. Further, a five-year study of 12,000 adolescents by Columbia University found unsafe sex much greater among youth who had pledged to abstain from premarital sex. Eighty-eight percent of those who had pledged chastity broke their pledge.

5. Given that HIV is a sexually transmitted infection, removing any discussion of sexuality and sex from the discussion of HIV prevention is bad policy.

6. Further description of “promiscuous sexual activity” is needed. This is an area of great controversy and varied community standards. Given the sweeping implications of the proposed policy revisions, such terms need to be carefully described.

CDC Proposed Guidelines
“SEC. 2500. USE OF FUNDS.
(d) Construction.--Subsection (c) may not be construed to restrict the ability of an educational program that includes the information required in subsection (b) to provide accurate information about various means to reduce an individual's risk of exposure to, or to transmission of, the etiologic agent for acquired immune deficiency syndrome, provided that any informational materials used are not obscene.”


Suggestions and comments:
1. Further clarification is needed for the obscenity test. It is far too vague and subjective as currently written. In addition, guidelines on what constitutes obscene material or “promoting sexual activity” are too vague. The “average person” may find two men hugging each other to be obscene or promoting sexual activity. The guidelines should perhaps be worded to say something like “the average person in that risk group,” “the average person working in the STD/HIV prevention field.”

2. Messages are often, and rightly, targeted to specific populations to increase the likelihood that they will be remembered. Such targeting can include terminology, visuals and concepts specific to the population. It is imperative that risk reduction messages continue to enjoy a level of creative freedom (presuming they also follow the proper channels of creation and approval) to decrease high-risk behaviors, using messaging to which these populations will respond.

3. Again, review panels need to be constructed to include those who are a part of the targeted population, to counter the subjectivity of the obscenity test.

CDC Proposed Guidelines
“SEC. 2500. USE OF FUNDS
E. When HIV materials include a discussion of condoms, the materials must comply with Section 317P of the Public Health Service Act, 42 U.S.C. Section 247b-17, which states in pertinent part: ‘educational materials * * * that are specifically designed to address STDs * * * shall contain medically accurate information regarding the effectiveness or lack of effectiveness of condoms in preventing the STD the materials are designed to address.’”


Suggestions and comments:
1. For consistency, this should include success, and lack of success, of abstinence-only education. See comments given for (b) Contents of Programs and (c) Limitation.

CDC Proposed Guidelines
“SEC. 2500. USE OF FUNDS
C. Educational sessions should not include activities in which attendees participate in sexually suggestive physical contact or actual sexual practices.”



1. Agreed.

CDC Proposed Guidelines
“II. Program Review Panel
§B1a. Panels that review materials intended for a specific audience should draw upon the expertise of individuals who can represent cultural sensitivities and language of the intended audience, either through representation on the panel or as consultants to the panels.”


Suggestions and comments:
1. Agreed. This will be crucial in ensuring relevance.

CDC Proposed Guidelines
“II. Program Review Panel
§B1d. Panels reviewing materials intended for racial and ethnic minority populations must comply with the terms of a-c above. However, membership of the Program Review Panel may be drawn predominantly from such racial and ethnic populations.”


Suggestions and comments:
1. This needs to be expanded to include other minority populations, including sexual minorities.

Again, we commend CDC for developing these guidelines. We encourage you to give careful consideration to the issues raised here and to the recommendations we have provided. We will be pleased to respond to any questions you might have about the intent and specifics of these recommendations. Please contact me and I will coordinate discussion and responses with all the organizations represented in this letter.

Very truly yours,

Georges C. Benjamin, MD, FACP
Executive Director
American Public Health Association

Susan Fulmer, MPH, MS, CSPP
HIV/AIDS Section Chair
American Public Health Association

Jodi Sperber, MSW, MPH
Lesbian, Gay, Bisexual & Transgender Caucus
American Public Health Association


FOR FURTHER INFORMATION CONTACT:
David Hale
Centers for Disease Control and Prevention
National Center for HIV, STD, and TB Prevention
1600 Clifton Road, N.E., Mailstop E07
Atlanta, GA 30333
Telephone: (404) 639-8008

Address all comments concerning this notice to:
HIV Content Guidelines Comments
Centers for Disease Control and Prevention
1600 Clifton Road, NE., Mailstop E56,
Atlanta, GA 30333
Comments may be e-mailed to <HIVComments@cdc.gov> or faxed to (404) 639-3125.