tion has been there for at least a dozen years. They said, well, we should have something in the next 3 or 4 years on a Federal level. Willie Brown went back to California and introduced his bill on health care for all Californians, effective 1993, unless there is a Federal national health insurance program on the books.

As the issue has been enlarged, I don't know that we will have it by then but we certainly will work toward it. It is clear as the issue is viewed in the larger sense that the basic problem we have, funding, as Ms. McGuire said earlier, all health care, and as some of our other witnesses have testified, just makes it all the worse for AIDS, because we haven't been doing a good job all along. But we are optimistic that maybe with this encouragement from California, we can prod our legislators along here to a national health insurance program.

Having said that, I have to catch a plane. I want to thank you very much, Mr. Chairman, for calling these wonderful witnesses who have given such great testimony for the record and given us quite a bit to deal with, with the administrators coming next week and, more particularly, for your leadership, sensitivity, and great compassion on this issue, which only serves to have you be a leader on the issue and not bragging about your compassion without matching the rhetoric with great work. When a book is written on this, I'm sure there will be a great chapter about Ted Weiss as chair of this subcommittee. We are fortunate, indeed.

Mr. WEISS. Thank you very much, Ms. Pelosi. Again, it goes without saying how much we appreciate your effective role and participation, not only in today's hearing but throughout your entire service in Congress, on this, and many other important issues.

MS. PELOSI. Thank you.

Mr. WEISS. I want to thank this particular panel of witnesses, as well as all our witnesses today. Again, I know that sometimes, Ms. Christen, it gets to be sort of discouraging, but then none of us would be doing the kind of work we are doing on either side of this table if we weren't optimists. I am hopeful that there are better days ahead.

Thank you very much. The hearing now stands adjourned until next Tuesday.

[Whereupon, at 3:25 p.m., the subcommittee adjourned, to reconvene, Tuesday, August 1, 1989.]

TREATMENT AND CARE FOR PERSONS WITH

HIV INFECTION AND AIDS

TUESDAY, AUGUST 1, 1989

HOUSE OF REPRESENTATIVES,

HUMAN RESOURCES AND

INTERGOVERNMENTAL RELATIONS SUBCOMMITTEE

OF THE COMMITTEE ON GOVERNMENT OPERATIONS,

Washington, DC.

The subcommittee met, pursuant to notice, at 10:03 a.m., in room 2247, Rayburn House Office Building, Hon. Ted Weiss (chairman of the subcommittee) presiding.

Present: Representatives Ted Weiss, Nancy Pelosi, Donald M. Payne, and Larkin I. Smith.

Also present: James R. Gottlieb, staff director; Patricia S. Fleming, professional staff member; Pamela H. Welch, clerk; and Wayne Cimons, minority professional staff, Committee on Government Operations.

Mr. WEISS. Good morning. The Human Resources and Intergovernmental Relations Subcommittee is now in session. We will shortly be joined by our other colleagues. The House is in session at this point, so it is possible that we may be interrupted from time to time with votes on the floor, but we will attempt to go through as expeditiously as we can and have as few interruptions as possible.

Six years ago today, this subcommittee held its first hearing on AIDS. At that time, there were already 2,000 cases and 730 people had died. This summer, we sadly marked the 100,000th case of AIDS reported to the Centers for Disease Control, realizing that there are many more persons affected by HIV who have gone unreported. According to the General Accounting Office, this number could quadruple by the end of 1991.

Last Friday, the subcommittee had the opportunity to hear from 11 outstanding witnesses who are professionally involved with HIV infection and AIDS. This morning we will hear from one more. A person with HIV infection also spoke to us.

They told us that there was a crisis in AIDS care that has illuminated appalling inequities and weaknesses in the U.S. health care system, especially for the large number of HIV-infected persons who depend on public hospitals and Medicaid or have no insurance coverage at all.

Early treatment interventions hold out enormous hope to those who are infected but many community health centers and outpatient clinics do not have the resources to provide such treatment.

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Even those cities that have had successful programs to care for persons with AIDS are finding those systems crumbling under the weight of cases and inadequate funding. It is up to the Federal Government to assure access to care for persons in need.

Today, we will ask representatives of the administration what their plans are to manage these and other issues related to treatment and care for persons with HIV infection and AIDS. Once again we will ask what the Federal Government is doing about these issues, how early treatment intervention will be provided and financed and what it will include; how to provide quality primary care to those who depend on public support; how to provide immediate assistance to those communities that are hardest hit by the epidemic; and how to ensure that scientists have the resources and programs to get promising new drugs and treatments to all who need them.

The New York Times this morning carried a story indicating that yesterday the New York City planning agency announced that Federal officials have failed to commit the billions of dollars needed to address the AIDS epidemic in New York. They said that unless funding is provided soon, the health care system in New York could collapse under the weight of the increasing number of cases. The city's health commissioner, Dr. Steven Joseph, asked the question that I ask the administration's witnesses today. How tight and how bad will it get before there is action?

Before we ask the administration witnesses to come to the witness table, we will hear from Dr. Paul Volberding, who has been involved in the fight against AIDS from the beginning and continues today. Dr. Volberding will testify as to the current conditions of the San Francisco model of AIDS patient care. Before I call on him, let me call on our distinguished ranking minority member, Mr. Smith, for his opening comments.

Mr. LARKIN SMITH. Thank you, Mr. Chairman.

Mr. Chairman, following up on the issues I raised at our first hearing this past Friday, I'm deeply concerned that funding for AIDS treatment is just half the story in fighting this deadly disease. I'm extremely interested in learning about how our Federal health officials plan to combat the spread of this disease and learning about what steps, if any, are being taken to modify behavior which can lead to AIDS.

Another issue I would like to learn more about is the recently proposed parallel track distribution system for experimental drugs. In addition to having broad policy implications for our entire drug approval process, fears have been raised that the parallel track will adversely affect the safety of new drugs made available to the public. Furthermore, care should be taken not to destroy incentives for the pharmaceutical industry to develop new drugs.

While all of us would welcome improvements in the drug approval process that could bring safe, life-saving products in the marketplace as quickly as possible, the parallel track deserves close attention in the Congress.

I look forward, Mr. Chairman, to hearing from our witnesses today and I commend you for calling this hearing.

Mr. WEISS. Thank you very much, Mr. Smith. Let me call on our other distinguished member who is present, Ms. Pelosi from California.

MS. PELOSI. Thank you, Mr. Chairman. I think you have said it all in your opening statement. This is indeed a very important hearing and the witnesses that you have gathered here, both the end of last week and this week, will be a tremendous resource as we approach the next phase of the epidemic.

I'm particularly pleased that we are going to pay some attention to the parallel track which was presented since this hearing was called. I have the special privilege of acknowledging, as you said at the end of your statement, that our witness list today is headed off by Dr. Paul Volberding from San Francisco. Dr. Volberding, as you know, was an early researcher in the fight against AIDS. He is a member of the National Academy of Sciences' AIDS panel and has been a tremendous resource to San Francisco, to our community, but more importantly, to the country on fighting the HIV epidemic.

I'm delighted he is going to give us the benefit of his thinking and his experience. I must say and thank him publicly, that he has been enormously generous in addition to everything else he has to do, in being readily available on the occasion of visits of Members of Congress to California, to take time in his busy schedule to show them around and to show them the model of what has been done in San Francisco.

For all that you have done, Dr. Volberding, we are delighted that you are here, we thank you publicly and also look forward to hearing what you have to say.

Mr. WEISS. Mr. Smith.

Mr. LARKIN SMITH. Mr. Chairman, if I could ask unanimous consent to submit questions in writing for the panelists. I may have to be in and out.

Mr. WEISS. Without objection, that will be done.

Dr. Volberding.

[Witness sworn.]

Mr. WEISS. Thank you very much. Again, let me express my appreciation to you for working us into your schedule. As you know, we had the nongovernmental witnesses at our hearing on Friday and since it was impossible for you to participate in that, we are pleased you are able to be here today. We will be hearing from Government witnesses today, but I think it is helpful to have you lead off because it will provide the continuity from Friday's hearing.

You may proceed as you desire.

STATEMENT OF PAUL A. VOLBERDING, M.D., ASSOCIATE PROFESSOR OF MEDICINE, UNIVERSITY OF CALIFORNIA, SAN FRANCISCO, CA, AND CHIEF, AIDS PROGRAM, SAN FRANCISCO GENERAL HOSPITAL

Dr. VOLBERDING. Thank you. I appreciate your willingness to accommodate my schedule. It was very helpful.

The HIV disease epidemic continues to evolve. As it does, new stresses are being introduced into the health care system and into

the organization and conduct of our clinical research trials. Stresses, among other sources, can be traced to increases in volume of patients, ongoing problems with reimbursement, especially for experimental drugs, increasing fragmentation of care, and the unmet need for the training of health care professionals. I would like to touch on each of those briefly.

In San Francisco, as I'm sure you have heard and know, we are seeing an increasing epidemic. We see now more than 200 new cases of AIDS per month, as well as an increase in demand from patients with earlier forms of the disease. At San Francisco General, a facility with an excellent reputation for AIDS care, our outpatient AIDS clinic has operated at maximum capacity for nearly 2 years. We have found it difficult to provide care for the broadening face of the epidemic, including those infected with HIV from parental as well as sexual routes and for patients with early as well as late forms of the disease.

Additionally, we continue to struggle to provide direct patient care while still responding to the need for rapid large scale investigations of promising new AIDS drugs.

Along with pressure on space, reimbursement problems are an issue for many hospitals, including our own. Although many of the most debilitating problems we see in AIDS require hospitalization, if experimental drugs are administered during hospitalization, public and private insurers often refuse to pay anything for that entire hospital stay.

At San Francisco General Hospital, we have attempted to use the federally supported research beds in our general clinical research center for this type of hospital admission. The center, however, has only six beds, is often unavailable because of limited capacity, and is unable to care for severely ill research subjects.

One response that many institutions are unfortunately following in response to the pressures of the situation, is to fragment the care for patients with HIV disease. As the reality of the serious prognosis of early HIV infection is appreciated, individuals and organizations are lobbying with success to build separate systems for the care of these patients with early forms of the disease. These programs are often well intentioned but incompletely conceived. Some, for example, do not provide for medications, only counseling services for patients with early disease. Also, they may create discontinuities in the care of patients, as we realize that patients with early forms of the disease will later on develop more advanced forms of disease including AIDS.

Other sources of fragmentation are seen in the competition between routine care and experimental drug testing. Despite the fact that most of our standards of AIDS care and our ability to reduce the invasiveness and cost of this care have been derived directly from experimental programs, the benefits of clinical research are often forgotten when hospitals and medical centers face the increasing volume of patients with HIV disease.

Clinics that have attempted to combine patient care with clinical research must more and more defend themselves to their sources of support for their ongoing maintenance.