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Public Statements

Continuing Appropriations

Location: Washington, DC

CONTINUING APPROPRIATIONS -- (Senate - February 13, 2007)

Mr. COBURN. Mr. President, I want to spend a few minutes talking about the importance of what we are doing with this bill and why amendments ought to be allowed in order. I have a very specific amendment I have filed that has to do with health care in this country. Basically, it has to do with the health care of the most vulnerable in this country, babies.

In the early 1980s, an epidemic of an unknown virus started in this country. We now know it as HIV/AIDS, and a lot of progress has been made in that fight. During the Reagan Presidency, his AIDS Commission recommended routine testing. That was in 1986. In 2005, the CDC finally recognized the wisdom of that AIDS Commission recommendation, and it is now CDC policy that routine testing from the ages of 17 to 64 be carried out on everybody in this country who encounters health care.

The Ryan White bill, which was recently passed in the 109th Congress, took note of those recommendations. And within the HIV community, there has been debate about the CDC guidelines. But some of that was put to rest on the basis of what we know has been an exemplary program in two States that have all but eliminated HIV transmission to babies.

The policies in many States in this country require extensive counseling before anybody can be tested. What was found by the CDC, and many other organizations, is that a small number of people who are pregnant will actually get tested. New York, led by a courageous Democratic legislator by the name of Nettie Mayersohn, passed a law in 1996. In that year they had 500 babies born with HIV. In the last 2 years, since that law has been passed, they have had less than 7.

Now, what happened? What did they do? What they did was they used commonsense public health, and they said: we test women who are pregnant for lots of diseases antenatally so we can know how to handle them and take care of their infant should they have one of those problems. They applied that same common sense to HIV, and hundreds of babies are born every year in New York who do not get HIV because commonsense public health policies were applied.

It is very simple. If we know your HIV status, and you are positive, 99 percent of the time we can keep your child from getting HIV. There is not hardly any other disease we have in obstetrics--and I am an obstetrician--that is that effective.

What we have done in the bill before us is take away all the money for that, take all the money away the CDC says now is the guideline, their recommendation, the recommendation of the American Medical Association, the American College of Obstetricians and Gynecologists. Why are we doing that? There is a claim it was an earmark. I will not spend the time to bore everybody with the definition of an ``earmark.' This came as part of the Enzi-Kennedy Ryan White bill because it is good public health policy and it applies as an incentive to every State out there to start doing something that will make a difference in someone's life.

The Centers for Disease Control and Prevention recommends that HIV be a routine testing procedure. Washington, DC, has a wonderful Director of their AIDS Commission, Marsha Martin. Last June they started routine testing in this city. This city has 3.5 percent, it would seem, of its population infected with HIV--about three and half to four times the rest of the Nation. They have identified almost 1,600 HIV patients.

Now, why is that important? The reason that is important is because 70 percent of the infections that are now occurring in HIV are occurring in people who do not know they are infected. And if they do not know they are infected, they will transmit the disease without knowing they are transmitting it.

Before the Nettie Mayersohn law in New York State, only 62 percent of the women who were pregnant knew their HIV status. After that, we are at almost 96 percent. The difference is 500 babies a year born with HIV versus 7--a very significant difference.

What does that mean in terms of the children? It means a life not having a disease, not being stuck, not being given medicine, and having a life expectancy of less than 25 years of age. That is what that means.

So with that leadership in the State of New York, what has been accomplished is 99 percent of the prenatal transmission of HIV has been prevented. It also means those pregnant women who are HIV positive are now being treated at a much earlier stage in their disease, which gives them far greater--probably the same life expectancy as you or I because of the tremendous advances in medicine. What we do know is the later the diagnosis, the shorter their life expectancy and the higher the cost.

Now, let me walk you through, for a minute, what others say about this. CDC also recommends prenatal testing and treatment of newborns. Here is what they have said:

Considering the potential for preventing transmission, no child in this country should be born whose HIV status or whose mother's status is unknown.

It costs $10 to test, it costs $75 to treat, to prevent 99 percent of them. It makes a major difference in thousands of children's lives every year. It makes a major difference in thousands and thousands of women's lives every year to have this diagnosis.

What happens if we do not do it, if we do not encourage it? And this part of the Ryan White Act was meant to incentivize States to move to the CDC recommendation. It costs $10,000 a year to treat a newborn who is infected with HIV.

One of the problems with this tremendous epidemic that we face is it narrows in on a group of people, a large percentage of whom happen to be African-American women. They account for two-thirds of the infection in women yet are 13 percent of our population. How dare us take this away.

Multiple organizations have supported this policy. The Early Diagnosis Grant Program was established by the Ryan White HIV/AIDS Treatment Modernization Act. It provides $30 million for grants that will be utilized for States that become eligible to do the testing and the treatment for both mothers and their infants.

To be eligible for the funds, they have to offer a voluntary opt-out HIV testing program for pregnant women. They have to commit to universal HIV testing of newborns when the HIV status of their mother is unknown. They have to offer voluntary opt-out HIV testing of clients at sexually transmitted disease clinics. And they have to offer voluntary opt-out HIV testing of clients at substance abuse treatment centers, where we know most of the disease tends to be seen.

This is current CDC policy--the people whom we trust to tell us what to do. Funding for this grant is provided out of existing HIV moneys at CDC, prevention funds that are already there, which they know will have tremendous positive effects.

Now, think about it: 500 infants at $10,000 a year, every year. Multiply it, multiply it, multiply it, and it only takes 4 1/2 years to spend $30 million if we do not do this. These funds are targeted for those most at risk of infection, as well as those most likely to benefit from treatment.

President Bush, in his budget, asked for this money to be directed as well. So this is not something that does not have broad support, both in the health community, with the President, and many of those most active in the HIV community.

The point we should not forget is baby AIDS can be virtually eliminated if expectant mothers with HIV are identified and treated for HIV during their pregnancy. When treatment is provided during pregnancy, labor, and delivery, and to infants after birth, the risk of transmission goes down to less than 1 percent. Without treatment, 25 percent of the infants will become HIV infected.

But how do we treat? We cannot treat unless we know they have it. We cannot know they have it unless they are tested. We cannot test unless we have the incentives to test. So this creates the incentive programs for States to copy what both New York and Connecticut did. Connecticut has not had an HIV-infected baby since 2001.

They have eliminated it in Connecticut. Why should we not do the same thing? Why should we disallow an amendment to restore this funding that goes to the heart of those most vulnerable in our country? It also goes to help those who are most disaffected, those who are on the poorer spectrum, those who have less opportunity because that is where we see more infection.

For the 1 percent who would not be cured, what we know is, we are treating early. We are not waiting until they get the disease in a full-blown state. What we know is, your likelihood of dying, if you are diagnosed when your CD 4 count is below 50, exponentially goes up. So early diagnosis with HIV is of paramount importance.

It also needs to be said that one out of every four people in this country who have HIV don't know it. They have no knowledge that they have it. That one out of four accounts for 70 percent of the new infections in this country. So the CDC policy of frequent testing, opt-out testing, more testing is a policy that makes absolute sense from a public health perspective.

Because only a few States have similar laws to Connecticut and New York, hundreds of babies will still become infected this year. To take this money out, to say none of the money can be spent for this program, condemns hundreds of newborn babies to a life of HIV infection and AIDS. That is what this bill does. It condemns hundreds of babies in this country to a life with HIV. It is a preventable disease. Why would we do that? Why would we come anywhere close to that?

I mentioned Marsha Martin. Since last year, they started a policy of routine frequent testing, and 16,000 individuals in Washington, DC, have been tested. Five hundred eighty people who would not have otherwise been tested have been diagnosed with HIV at a stage at which we can save their life. Some of those were pregnant women. People say: You don't need to do this. Why is it important for every woman to know whether she is HIV positive or negative if she gives birth to a baby? Because only 25 percent of the time does this virus get transmitted to the baby at birth. But what they don't think about is, if they breast-feed the baby, they will transmit the virus as well. So your baby may not be infected at birth, but if you breast-feed your baby and you are carrying HIV, it is a death sentence for the baby. So to not know your status puts your baby at risk, even though it was not infected at birth.

Here is what happened in Connecticut. They went from 28 percent of the women who knew their HIV status before they passed the law to 90 percent of the women. What does that translate into? That translates into saving lives, not just the women who were HIV positive who found out and had early treatment but their children as well. Why would we not want to incentivize the rest of the States to do what has been successful in New York and Connecticut and several other States?

The health commissioner of New York is pushing to change State law to make testing more convenient for patients and health care providers:

We are aggressively offering testing to patients who come to us for routine physicals, heart disease, a sprained ankle. We are lessening the stigma sometimes associated with HIV and helping connect many more HIV-positive individuals with early treatment.

Here is the other difference I would hope the esteemed Members of the Senate would recognize. By doing early testing, the cost to treat is $10,000 a year. By doing late testing, the cost to treat is $40,000 a year, with much more in terms of complications. Again, to test costs $10, to treat a newborn is $75, versus $10,000 a year at a minimum.

Women, children, and African Americans will be most affected by the termination of this program. Since the beginning of the HIV epidemic, African Americans have accounted for almost 400,000 of the estimated 1 million AIDS diagnoses in our country. According to the 2000 census, African Americans made up 13 percent of our population. However, in 2005, 49 percent of the estimated 40,000 new cases were African American. It is 24 times the rate in African-American women than it is in white women. Why would we not want to intercede with testing to save their lives?

Between 120 and 160,000 women in the United States are infected with HIV. In 2001, the National Congress of Black Women issued a report entitled ``African American Women and the HIV/AIDS Initiative,' that outlined that group's strategy to combat HIV/AIDS among black women. Among their recommendations: Every State should be required to screen all pregnant women for HIV and test all newborns for the virus and Congress should appropriate funds for such initiatives. Every year that passes results in hundreds of more cases of baby AIDS that could have been prevented.

Who supports doing this perinatal testing and treatment? The American Medical Association, the U.S. Preventative Services Task Force, the AIDS Health Care Foundation, the Children's AIDS Fund, multiple medical groups, and, yes, the Centers for Disease Control and Prevention, the one agency we fund to tell us what we should do. It is their policy. We are denying their policy. We are denying infants the right to live without HIV.

Here is what they said:

Based on information presented in the MMWR, the available data indicate that both ``opt-out' prenatal maternal screening and mandatory newborn screening achieve higher maternal screening rates than ``opt-in' prenatal screening.

The status quo.

Accordingly, CDC recommends that clinicians routinely screen all women for HIV infection, using an ``opt-out' approach and that jurisdictions with statutory barriers to such prenatal screening consider revising them. In addition, CDC encourages clinicians to test for HIV any newborn whose mother's HIV status is unknown ..... CDC recommends rapid testing of the infant immediately postpartum so that antiretroviral prophylactics can be offered to HIV-exposed infants.

Ninety-nine percent, we can prevent. We have taken out the capability for other States what New York and Connecticut have done, and we are refusing to allow the replacement of that to save the weakest and most vulnerable in our country.

What are the claims we have heard? Here is the first claim: Even without funding for this particular HIV testing grant program, Federal funds will still be available for HIV testing. What is true is that other Federal funds can provide HIV testing. As written, section 20613(b)(1) of this bill specifies that none of the funds appropriated for 2007 can be used for any early diagnosis grants. This would specifically forbid Federal funding for HIV testing of pregnant women in any area--newborns, patients receiving treatment for substance abuse, and those accessing services at STD clinics. These populations include those most at risk for HIV, as well as those who can most benefit from early treatment and intervention. It is counterintuitive that this would be a part of this bill.

What are the activities that are supported by this $30 million that are going to be prohibited, including HIV AIDS testing, including rapid testing? It only costs $10. It precludes prevention counseling. It excludes treatment of newborns exposed to HIV. It excludes treatment of mothers infected with HIV or AIDS and the costs associated with linking the diagnosis of AIDS to care and treatment for that disease. The $30 million instead will revert to other CDC HIV/AIDS program activities which in recent years have included the following: Beachside conferences, flirting classes, erotic writing seminars, zoo trips, and other dubious initiatives that do not have any lifesaving impact or near lifesaving impact as early diagnosis and treatment.

This $30 million is either going to be spent effectively or it is going to be wasted. President Reagan's AIDS Commission was right. They said it in 1986. The CDC caught up last year in 2005 to the policies that were recommended to this Congress in 1985-1986.

Few, if any, States would benefit from the funding provided by this program. The point of this program is to encourage States to update their policies to reflect CDC's recommendations for HIV testing and baby AIDS treatment. That is the whole purpose. That is part of the whole Ryan White grant. It is to improve our approach to HIV, to eliminate newborn infections, and to eliminate transmission from those who don't know. While few States would immediately qualify for early diagnosis grants, the availability of the funds was intended to get them to move to the point where they would take advantage of that, which means they would be saving hundreds of babies' lives every year and protecting the lives of the mothers who were there to nurture them. It makes no sense that we would prohibit money for this process.

Many States, including Illinois, are already moving in this direction. States such as New York and Connecticut have had the policies in place for over a decade. And the proof is there.

What is the other claim? This bill defunds all earmarks. The Early Diagnosis Grant Program is an earmark and, therefore, has not been singled out but has been removed, along with other special funding projects.

Fact: The Early Diagnosis Grant Program is not an earmark. All States with routine testing policies are eligible for the funding provided by this grant. Those which are not currently eligible can become eligible by passing the law or implementing State regulations to meet funding eligibility.


Mr. COBURN. This program doesn't match the definition or criteria of an earmark approved by the Senate in January or used by the Congressional Research Service. On January 16, 2007, the Senate approved an amendment by a vote of 98 to zero, defining the term ``earmark' as a provision or report language included primarily at the request of a Member, delegate, resident commissioner, or Senator, providing, authorizing or recommending a specific amount of discretionary budget authority, credit authority or spending authority for a contract loan, loan guarantee, loan authority or other expenditure with or to an entity or targeted to a specific State, a specific locality or a specific congressional district, other than through a statutory or administrative formally driven competitive war process.

This doesn't come anywhere close to that definition. It doesn't meet any of criteria that the Senate has defined as earmark. It is not directed to any specific State, any entity, any location, and does not bypass the statutory award process.

CRS defines an earmark as funds set aside with an account for specific organization or location, either in the appropriations act or the joint explanatory statement of the conference committee. CRS notes that such designations generally bypass the usual competitive distribution of awards by a Federal agency. This doesn't meet any of that. It is hogwash to call this an earmark,

and everybody knows it. Everybody knows it.

Claim: This program would violate the privacy rights of women by requiring mandatory HIV testing.

This doesn't require mandatory HIV testing. It offers women to have testing and they can say, ``I don't want to be tested,' rather than for them to have to ask to be tested.

Current laws mandating extensive pre- and post-test counseling make HIV testing the most overregulated diagnostic and thereby discourage health providers from offering patients screening for HIV.

Testing newborns for HIV is too little too late. That is the other point I have heard. The science doesn't support that at all. If the baby has HIV antibiotics, 99 percent of the time we can prevent them from becoming infected. Of those who do, the 1 percent who do become infected, we can treat so much better by knowing it at an early stage. We can extend their life for years at less than $40,000 a year, at $10,000 a year. By not knowing and waiting until their CD4 counts come down precipitously low, we go from $10,000 a year in treatment to $40,000 a year in treatment.

I will finish with a couple of comments.

In the early eighties, I delivered a little girl. Her name was Megan. Two years later, her mother re-presented to me with full-blown AIDS. The mother died 3 weeks later. Megan lived an additional 8 years.

Had we done this and had we known to have done this, Megan would be alive and flourishing. Her mother would be alive with HIV. Megan would have never gotten HIV.

I will never have that little girl's face removed from my memory. We, by this bill and not allowing the reestablishment, are creating thousands of Megans in this country--thousands, thousands. If this body wants that on their shoulders, continue what we are doing today. But if we claim to be here to help the helpless, to put in place policies that, No. 1, the best of the science tells us are the right policies, and No. 2, makes a massive difference in individual lives, then make in order this amendment to restore this money. By not doing so, you walk out of here condemning hundreds of infants, thousands of infants to death, at worst, and a life on medicines for the rest of their life.

You also condemn a large group of African-American women to the lack of knowledge and the lack of effective drugs that can give them a normal life. You can decide. The power is on the majority side. They get to decide this issue. But you dare not come back into this Chamber saying that you care for children, that you care for minorities, and at the same time have gutted one of the programs that will give hope to those same groups of people. You can't have it both ways. You can't single out good medicine, good public health care, and true compassion for those most at risk, and then come back and claim you care.

Mr. President, I yield the floor.

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