Report Cites Poor Program Execution
By Susan Levine
Washington Post Staff Writer
Saturday, December 16, 2006; A01
A citywide HIV testing campaign, launched with bold pronouncements that brought the District national attention, has been hampered by poor planning and wasted resources in its first six months, according to a report released today by a public advocacy organization.
The D.C. Appleseed Center for Law and Justice supports the program's "laudable goals" of having residents know their HIV status through routine testing. But problems in execution must be corrected if the effort is to have lasting impact on the local HIV and AIDS crisis, it says.
Fewer than 20,000 people have been tested since the kickoff in June. The city's HIV administration director expects the count to grow by the end of the month, yet the total will fall far short of the city's goal of testing 400,000 men, women and adolescents ages 14 to 84.
Among the missteps identified by Appleseed: More than half of the government's $1.3 million initial budget was spent on 80,000 rapid oral-swab tests that were purchased with little input from the District's medical community. Unspecified numbers of kits have not been distributed or expired before they could be used. Others were donated to the Maryland health department for use before their expiration dates.
The campaign got early visibility with a $500,000 publicity push, weekly testing in mobile vans at Freedom Plaza and message cards handed out at Metro stations. However, the report notes that the Administration for HIV Policy and Programs has not produced a comprehensive strategy to sustain such widespread testing -- or to ensure that those who learn they're infected get help.
Appleseed questions the campaign's outreach to residents most at risk. An HIV test is now standard for inmates entering the D.C. jail, but not for all patients at the city's clinics for tuberculosis and sexually transmitted diseases. Although nearly one in 10 intravenous drug users were HIV-positive during a pilot project in Ward 7, that screening was neither continued nor replicated for addicts in other wards.
"DC Appleseed has both significant hopes about the future of the District's response to HIV/AIDS -- and significant concerns," the report concludes. It is the third time within 16 months that the organization has examined the epidemic locally.
Some community leaders, troubled from the start with the testing campaign's approach and cost, believe the assessment should be harsher. They see failed implementation, dubious expenditures and people still dying.
"To me, it's like Iraq," said A. Toni Young, who co-chairs the city's HIV Community Planning Group, a federally mandated advisory body.
Others are more sanguine. "We've made some inroads," said Gary Simon, a professor of medicine and infectious disease specialist at George Washington University Medical Center, who sits on a special HIV task force the mayor convened. "These things never leap forward."
In a jurisdiction with some of the worst HIV/AIDS rates in the country, Appleseed still credits the campaign with helping the District make substantial progress. Howard University Hospital signed on as a partner in the fall and became the first such facility in the nation to routinely offer free HIV screening to patients. Unity Health Care took the same step in its clinics, as did GWU's medical center in its emergency department. Private physicians are being lobbied to participate, too.
"We've done a lot here," said HIV administration director Marsha Martin, whose predecessor was fired after Appleseed's first evaluation in August 2005. Martin thinks her agency has achieved more than is acknowledged.
She dismissed criticism of the testing campaign as "off base," and in an interview, rejected the recommendation that at-risk individuals should receive distinct attention. "That misses the whole goal of the initiative," she said, "to raise the public health consciousness of a community about a virus." She also defended the number of HIV tests performed this year as a decided improvement: "What we're doing now . . . is double, triple at a minimum what we've done in previous years."
According to Martin, relatively few kits had to be discarded or given away.
The report gives the city grades ranging from B+ to D+ in nearly a dozen areas, from grant monitoring to syringe exchange services. The better marks, reflecting accomplishments on numerous fronts, were offset by what it describes as flagging leadership from top officials, inadequate collaboration among city agencies and continued delays or flaws in other initiatives.
Mayor Anthony A. Williams and the D.C. Council did not increase funding for substance abuse treatment in 2006, for example, despite the huge number of HIV infections traced to drug use. And condom distribution continued to fall, despite a new online order process.
Appleseed Executive Director Walter Smith warns that the city's grading curve will only get steeper.
"We're trying to measure performance compared to what should have been accomplished by now," he said yesterday. "Even if good things have been done, even if progress has been made, if it's less than we should have been able to expect, then we're going to grade them down."
The positive developments in today's report include the HIV administration's reorganized surveillance bureau, historically so deficient that the city could only guess the number of new HIV cases. The corrections department was praised for the jail's expanded testing, but the report cautions that inmates who test negative need prevention counseling.
Although the organization applauds Martin for strides she has made, it stresses that "she cannot manage the District's full response to HIV/AIDS alone." The report faults the mayor and other city leaders for not staying visibly engaged on such an urgent issue and not demanding coordinated action throughout city government. The public schools have no HIV/AIDS curriculum, despite resolutions and testimony by the Board of Education and Superintendent Clifford B. Janey that standards would be in place when classes began in September.
It will fall to Mayor-elect Adrian M. Fenty to make changes, the report suggests. "Unless the new administration gives HIV/AIDS the required attention at the highest levels, improvement will be difficult."
Adam Tenner, who works with District youths as executive director of Metro Teen AIDS, called the school system's delay "incredibly disappointing" and said the report highlights how far the city remains from stopping the epidemic.
Fenty's transition office did not comment yesterday. A spokesman for Williams addressed the report only generally. "We know there is a long way to go," Vincent Morris said, "and we won't give up until we reverse this trend and get more District residents tested, treated and educated about the terrible toll that AIDS can leave on people."