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Issue #150: November 9, 1997
FASTFAX is available by fax in the 215 and 610 area codes at no cost, or by mail anywhere for $20.00 per year, by calling 215-545-6868, and by E-mail by contacting and type the message SUBSCRIBE in the message section. Sources for some information in this issue include AIDS Action, Associated Press, Journal of Virology, New England Journal of Medicine, New York Times, Reuters .
NIH panel endorses acupuncture
Congress moves towards AIDS funding increase
HPV "persistent" in HIV+ women
HIV vaccine may combat different strains
Costs threaten prison AIDS care
New poll confirms support for needle exchange
NY HIV scare seen as educating teens
Consumers still "wary" on managed care
NIH panel endorses acupuncture
In one of the first formal statements from an official government agency endorsing an "alternative" therapy, a 12-member panel convened by the National Institutes of Health (NIH) has concluded that acupuncture treatment is effective for postoperative pain, chemotherapy-induced nausea and vomiting, nausea of pregnancy, and postoperative dental pain.Acupuncture has been popular among people living with HIV disease for relief from nausea, vomiting, and pain associated with various ailments. Some former cocaine addicts claim it has helped them overcome their craving for the drug and withdrawal symptoms in conjunction with more traditional substance abuse therapy.
There are a number of other pain-related conditions in which acupuncture could be considered an effective adjunct therapy, an acceptable alternative or part of a comprehensive treatment program, the experts said. While there is less convincing scientific data to support acupuncture's impact on these pain-related conditions, panelists listed stroke rehabilitation, headache, addiction, menstrual cramps, tennis elbow, fibromyalgia, low back pain, carpal tunnel syndrome, and asthma as conditions for further investigation.
The panel found that the rate of adverse effects associated with acupuncture is low and often less than side effects associated with conventional treatments for these painful conditions.
NIH Consensus Development panelists acknowledged that the evidence may not demonstrate that acupuncture is efficacious in other conditions such as smoking cessation. However, acupuncture may be effective in smoking cessation if combined with a comprehensive medical program that involves behavioral modification techniques, panel member Dr. Leonard A. Wisneski of NIH said.
The panel concluded that there is sufficient evidence of acupuncture's value to expand its use into conventional medicine and to encourage study designs that can withstand rigorous scientific scrutiny.
The experts drew attention to a shortcoming of many of the studies that involved acupuncture. The problem, according to Dr. Marjorie A. Bowman of the University of Pennsylvania, is that inserting needles into the body anywhere will have some biologic effects and the fact that sham acupuncture has intermediate effects that may complicate study findings.
The consensus panel advocated uniform licensing, certification, and accreditation of acupuncturists among states, and increased patient communication skills for both acupuncturists and physicians. The panel also called for broader public access to acupuncture treatment, which could involve expanded coverage by government and private payers.
The panel issued their consensus statement following an extensive review of the existing medical literature and a series of presentations by acupuncture research experts at a three-day NIH Consensus Development Conference on Acupuncture.
Acupuncture can be traced back for at least 2,500 years. The general theory of acupuncture is based on the premise that there are patterns of energy flow (Qi) through the body that are essential for health. Disruptions of this flow are believed to be responsible for disease, and the belief underlying the technique is that the acupuncturist can correct imbalances of flow by inserting needles at identifiable points in the skin.
More than one million Americans are estimated to use acupuncture. In 1993, the Food and Drug Administration reported that Americans spent $500 million annually and made about 9 to 12 million patient visits for acupuncture treatments.
One focus of attention by the conference was the role of endogenous opioids in acupuncture analgesia. Evidence supports the claim that opioid peptides are released during acupuncture and that the analgesic effects of acupuncture are at least partially explained by these actions. The finding that opioid antagonists such as Naloxone reverse the analgesic effects of acupuncture further strengthens this hypothesis, Wisneski said.
Stimulation by acupuncture could also activate the hypothalamus and the pituitary gland and result in a broad spectrum of systemic effects.
The experts presented data suggesting that acupuncture alters the secretion of neurotransmitters and neurohormones and regulation of blood flow, both centrally and peripherally. There is also evidence of immune function alterations associated with acupuncture. It is presently unclear which of these and other physiological changes mediate clinical effects, the panelists noted.
Despite efforts to understand the anatomy and physiology of the acupuncture points, the definition and characterization of these points remains elusive. The panel stated that further studies are needed to validate the approach.
Congress moves towards AIDS funding increase
The House and Senate conference committee on the FY 98 Labor, Health and Human Services, and Education (Labor/HHS) appropriations bill has largely finalized agreements which will increase AIDS funding for fiscal year 1998 (which began October 1st) even beyond amounts originally appropriated by each body earlier this year.The Washington-based group AIDS Action said that "Although the entire conference report has not been completed, it appears that agreement has been reached on the portions of the bill addressing the programs that are critical to our communities."
The final bill, which has been delayed by unrelated debates on national school testing and other issues, is expected to go to President Clinton for signature no later than next week.
Funding for AIDS programs has continued during the debate as a result of various "continuing resolutions" which provided stopgap funding at fiscal year 1997 levels. A small increase in funding for the Housing Opportunities for People with AIDS (HOPWA) program was cleared by Clinton in late October.
Funding increases (over FY97 funding levels) for prevention programs at the Centers for Disease Control and Prevention (CDC), Ryan White CARE Act programs, and AIDS research at the National Institutes of Health (NIH) are expected in the final conference report, according to AIDS Action. They include an additional $17.3 million for HIV prevention activities funded by the U.S. Centers for Disease Control, bringing the total to $643.3 million, and $439.4 million towards Ryan White CARE Act programs, bringing the total to over $1.4 billion.
The Ryan White increase includes $14.9 million extra for Title I programs, allocated locally by the Philadelphia Health Dept. according to priorities established by the Philadelphia HIV Commission; it is believed that this increase will provide slightly over $1 million for Philadelphia area AIDS care programs. Under Title II, which is allocated by the Commonwealth of Pennsylvania and distributed by the Philadelphia AIDS Consortium, the increase is only $7.5 million, bringing the national total to $257.5 million.
The conference agreement allocates an additional $118.5 million to state AIDS drug assistance programs, which provides AIDS medications to uninsured people with HIV/AIDS. In Pennsylvania, this program, called the Special Pharmaceuticals Benefits Program, is also supported by state funding, and covers drugs related to other diseases as well.
The bill also increases Title IIIb funding, which supports programs in clinics and hospitals, by $6.7 million, or a total of $76.3 million; and increases funding for Title IV programs for women and children to $41 million nationally, up $5 million from last year.
Support for AIDS education and training centers, such as that operated locally by Allegheny University, was raised only $1 million, to $17.3 million. A small increase of $300,000 was awarded to the AIDS dental reimbursement program.
Funding for AIDS research at the National Institutes of Health increased to $1.6 billion, up $105 million over last year.
Another critical issue during the conference was a House provision that would prohibit the secretary of health and human services from granting federal funds to support syringe exchange programs. Although the conference report retains the secretary's current authority to release federal funds to these programs, it also would enact a 6-month moratorium - or waiting period - (until March 31, 1998) on the secretary's ability to exercise this authority. AIDS Action said it expects Congress to direct the secretary to develop requirements for these programs that would ensure that they are "exchange" and not "distribution" oriented. The group said it is working with conferees to ensure that any congressional directive is not unnecessarily restrictive.
AIDS Action said that there is still a possibility that President Clinton may veto the bill if he believes it does not adequately address national education testing standards. A veto, however, would probably not endanger AIDS funding levels in the bill.
HPV "persistent" in HIV+ women
The New England Journal of Medicine has published a report which describes a high rate of persistent human papillomavirus (HPV) infection in the cervix of HIV-positive women, and another paper reports the presence of HPV in most anal cancer specimens.In the first paper, Dr. Xiao-Wei Sun of Columbia University in New York and colleagues investigated the incidence of HPV infection in 220 HIV-positive women and 231 HIV-negative women. The women were evaluated at two or more semiannual gynecologic exams.
"HIV-seropositive women were about seven times as likely to have persistent infection as HIV-seronegative women, and women with CD4+ counts of less than 200 per cubic millimeter were more than twice as likely to have persistent infection as those with counts of 500 or more per cubic millimeter," the investigators report. Also, persistent infection with HPV 16 or 18 viral types occurred in 20% of seropositive women compared with 3% of seronegative women.
Dr. Sun's group concludes that "HIV-seropositive women have a high rate of persistent HPV infections with the types of HPV that are strongly associated with the development of high-grade squamous intraepithelial lesions and invasive cervical cancer." They suggest that this association may explain the high frequency of squamous intraepithelial lesions in HIV-positive women.
In the second paper, Scandinavian investigators found "...strong evidence that a sexually transmitted infection causes anal cancer." Dr. Morten Frisch of the Statens Serum Institut in Copenhagen, Denmark, and associates identified risk factors for anal cancer in an adult cohort of 417 patients with anal cancer, 534 patients with adenocarcinoma of the rectum and 554 controls. They also tested specimens for HPV.
Dr. Frisch's team reports "...consistent and statistically significant associations between measures of sexual promiscuity and the risk of anal cancer in both men and women." They also noted an association between anal cancer in women who had a sex partner with an STD. Compared with the controls, men and women who reported anal intercourse also had higher rates of anal cancer.
Most of the anal cancer specimens, 84%, contained a high-risk HPV, primarily HPV-16, whereas HPV was not detected in any rectal adenocarcinoma. Dr. Frisch's group concludes that the findings "...suggest that in the majority of cases, anal cancer is a sexually transmitted and thus a potentially preventable disease."
Dr. Keerti V. Shah of Johns Hopkins School of Public Health believes that "...the evidence that HPV causes cervical cancer is as strong as that for any other human carcinogen." However, the Baltimore, Maryland-based researcher says that the role of HPV in the pathogenesis of cancers at other anogenital sites is less clear.
Overall, most men and women with anal cancer do not have a history of anal intercourse, Dr. Shah points out. Therefore, the question of how these patients acquire HPV-related cancer is still unanswered. Another area of investigation, Dr. Shah adds, is the potential role of cutaneous HPVs in the pathogenesis of nonmelanoma skin cancers.
HIV vaccine may combat different strains
If researchers develop an effective AIDS vaccine, it should be able to combat different strains of HIV found around the world, a new study suggests.Most researchers are trying to make a vaccine with HIV-1 clade (or type) B, the strain most common in the U.S. and Western Europe. The new study suggests that these potential vaccines may also be effective against other types of HIV, including clades A, C, D, E, and G, found in Africa and elsewhere in the world.
"The varying geographic distribution of HIV type I (HIV-1), with the relative absence of clade B HIV-1 outside the developed world, is considered a major obstacle to the development of a single efficacious vaccine," reported senior investigator Dr. Bruce Walker in the current issue of the Journal of Virology. Walker is the director of the Partners AIDS Research Center at Massachusetts General Hospital in Boston.
However, Walker and colleagues found that cytotoxic, or killer T cells in patients infected with clade B HIV-1 can recognize other types of non-B clade viruses. What's more, cytotoxic T cells collected from 14 African patients infected with clade A, C or G viruses can recognize clade B viruses found in the U.S.
Cytotoxic T cells or lymphocytes (CTL) are thought to control HIV early in the infection, but the effectiveness of the immune reaction wanes over time. However, strong CTL responses have been seen in HIV-infected individuals who remain healthy for years or even decades, and also in those exposed to HIV who remain uninfected.
The new finding suggests that vaccines -- several of which are in the first stages of clinical trials -- that stimulate CTL responses in clade B HIV-1 infected individuals should work in countries where other clades predominate. "CTL cross-reactivity exists between clade B and non-B epitopes, suggesting that CTL cross-recognition among HIV-1 clades is more widespread than anticipated and that a vaccine based on a single clade may be broadly applicable," wrote the study team. The findings "provide support for initiating trials with clade B immunogens in Africa," they concluded.
Costs threaten prison AIDS care
A published report says medical costs have soared in Illinois prisons in the last year as hundreds of inmates have been treated for AIDS with a combination of drugs to fight the disease, the leading cause of death behind bars.Similar financing crises face other states and localities which provide the latest AIDS therapies to their HIV+ prisoners, the report said. The growing cost is also seen as discouraging providing new treatments, especially combination therapies involving protease inhibitors, in prison systems across the country that have not yet implemented the newer therapies.
Illinois prison officials said that the cost of AIDS drugs has jumped from $30,000 a month to $300,000 a month over the last couple of years.
The state's prisons have 633 inmates who are known to be infected with HIV.
In 1994, Illinois taxpayers spent $600,000 annually to buy AIDS drugs for prisoners. This year, the state spent that amount in just two months.
Illinois prisons spend between $8 million and $9 million annually filling prescriptions for prisoners. A prison spokesman was unable to give an exact figure, he said, because the exact figure is "buried in various contracts."
State Rep. Cal Skinner, R-Crystal Lake, was not surprised by the figures.
Skinner told the newspaper, "Why should anybody be surprised that the Department of Corrections has high costs for the treatment of HIV when the department... has done nothing significant to stop it?"
Skinner said most prisoners crave sex and drugs when released from prison, both primary modes of transmission, and is worried inmates will spread HIV into their communities upon release.
Skinner suspects that many more of the 38,000 Illinois prisoners than the 633 known AIDS victims carry HIV and is calling for mandatory testing so the state can segregate and treat prisoners infected with the virus.
New poll confirms support for needle exchange
Most Americans, especially those who learn more about needle exchange programs, support their implementation in their communities, according to a new poll conducted by the Harris organization.Americans also believe that cities and states -- and not the federal government -- should decide whether federal HIV prevention funds can be spent on needle exchange programs, according to the poll, commissioned by the Lindesmith Center. The poll, which surveyed 1,003 American adults by telephone from October 15 through 19, found that 71% of American adults agree that current law should be changed so that decisions on how to use federal funding for HIV prevention programs be made by states and localities rather than the federal government. Currently, federal law bans the use of federal HIV prevention funding, for needle exchange programs.
Numerous studies have concluded that needle exchange programs dramatically reduce the spread of HIV and do not encourage drug use. Needle exchange programs are supported by the American Medical Association, the National Academy of Sciences, the Centers for Disease Control and Prevention, the American Public Health Association as well as other prestigious medical and public health organizations. In addition, the American Bar Association and the U.S. Conference of Mayors have urged the federal government to allow states and localities to use federal HIV prevention funds to implement needle exchange programs.
"The U.S. is virtually alone among advanced, industrialized nations in prohibiting the funding of needle exchange programs," said Ethan Nadelmann, Director of the Lindesmith Center. "Americans want crucial decisions about funding for needle exchange and other HIV prevention efforts made at the state or local level, not in Washington."
Despite the controversies in Congress and public health circles around the viability of needle exchange and other "harm reduction" prevention techniques, the poll found that few Americans are familiar with needle exchange programs. Only 45% of those surveyed said they were "somewhat familiar" or "very familiar" with needle exchange programs. 55% said they were "not very familiar" or "not familiar at all" with needle exchange programs.
Of those who said they were "familiar" with needle exchange programs, 58% supported them being implemented in their communities.
When first asked if they favor or oppose needle exchange programs, 44% of those surveyed favored needle exchanges while 42% opposed.
When informed of which organizations support such programs (the American Medical Association) and those who oppose (the Family Research Council) 50% of Americans support needle exchange programs while 45% oppose.
Compared to previous polls on needle exchange programs, support for needle exchange was similar to that found in polls conducted annually from 1995 to 1997 by Peter D. Hart Research Associates (46-50% support needle exchange programs).
A poll on HIV and AIDS commissioned by the Kaiser Foundation in 1996 found 66% of Americans support needle exchange programs. An April 1997 poll commissioned by the Human Rights Campaign and conducted by Tarrance Group and Lake Sosin Snell & Associates found 55% of Americans support needle exchange programs.
The only poll conducted which has found opposition to needle exchange programs was commissioned in 1997 by the Family Research Council and found 62% in opposition to needle
exchange. That poll, however, presented needle exchange programs and treatment as either/or choices.
Across party lines, Americans believe state and local governments should be able to decide whether to use federal HIV prevention funds for needle exchange programs: -- 72% of Republicans, 70% of Democrats and 74% of Independents agree that states and cities should be allowed to make decisions concerning the funding of needle exchange programs.
Even those who oppose needle exchange believe current law should be changed -- 69% of those who oppose needle exchanges agree that decisions on how to use federal HIV prevention funding should be made at the state and local level.
NY HIV scare seen as educating teens
With reports of numerous young women in Jamestown, NY having contracted HIV from one man, experts said last week that more teens will realize they are vulnerable to the disease."Events like this really do increase a young person's sense of vulnerability," said Michael Resnick, a sociologist at the University of Minnesota.
"That's why Mothers Against Driving Drunk drag crashed-up cars to the front lawns of high schools on prom night. It's not just a warning. The message is transmitted. It gets internalized, then a person says, `Hey, it could happen to me, too."'
Authorities say at least nine girls, the youngest now 14, tested positive for HIV from contact with Nushawn Williams, a 20-year-old drifter who would compliment their looks and sometimes offer them drugs. One man contracted the virus after sex with one of the girls.
Authorities estimate more than 100 people may be at risk of HIV through direct or secondary contact with Williams.
For some young people who admit to having risky sex, the much-repeated warnings about AIDS are sinking in.
"Reality hit me like a ton of bricks," said a 16-year-old named Bill who was tested after hearing about the mini-epidemic. "I didn't know (HIV) was that big a deal until it came to Jamestown."
No lecture could have been more powerful, experts said.
"You can point out statistics and they always think they're immune to this," said Marguerite Kermis, a psychology professor at Canisius College in Buffalo.
Fifty-three percent of U.S. high school students are sexually active, and 47 percent of them don't use condoms, according to the latest federal survey on the topic, in 1993.
"In some ways I think this is a seminal event, in the same way Magic Johnson announcing his HIV status, or Arthur Ashe," said Dr. John Klein of the University of Rochester School of Medicine.
Williams is currently jailed on a drug charge in New York. Chautauqua County District Attorney James Subjack has filed a statutory rape charge against Williams and plans assault charges for each of the six women he is believed to have infected after learning he had the virus.
Consumers still "wary" on managed care
Consumers are generally satisfied with their own HMO or health plan but their overall perception of managed care is more negative than positive, according to findings of a new study.Harvard University and Kaiser Family Foundation researchers surveyed 1,200 adults and discovered a wariness about the effects of managed care on health care quality. The general consensus, Kaiser President Drew Altman said, was that people are worried that managed care companies care more about costs and profits than patients and that managed care won't be there for them in the future.
More than half of those surveyed said that managed care plans have made it harder for sicker people to see medical specialists and decreased the quality of care for those patients. In addition, three of five consumers said that managed care pressures have reduced the amount of time that physicians can spend with their patients.
Survey results revealed that consumers enrolled in an HMO or other managed care arrangement are more worried about healthcare quality issues than persons with less restrictive traditional insurance coverage. Sixty one percent of those in "heavy" managed care, which include the most restrictive arrangements, are "somewhat worried" that their health plan is more concerned about saving money than providing the best treatment.
The so-called managed care horror stories that have regularly appeared in the media are viewed more as the rule than the exception, according to survey respondents. Two-thirds of those surveyed believed that cases in which an HMO restricts the treatment of a child with cancer happens often or sometimes. Nearly 40% of those surveyed thought that neonates were sent home from the hospital too soon because of a managed care plan's coverage policy.
Managed care did come out well in terms of preventive care. Nearly half of those surveyed said that HMOs have made it easier to get immunizations and health screenings and physicals.
A striking finding in the study was the public's perception about who benefits from managed care. Some 72% of consumers thought that health insurance companies stood to benefit the most in terms of greater profits.
Although the rate of increase in overall health costs has slowed, consumers didn't seem convinced: 55% said that they didn't think managed care had affected the overall cost of healthcare in the US.
"People think they are paying more and getting less," Harvard professor and pollster Robert Blendon said. While employers may be seeing a benefit from slower rates of increase in premiums, Blendon said that consumers felt that they were paying more out of pocket for healthcare even in an environment of managed care.
Despite the skittishness about managed care, the public, like the politicians, were not sure how far to regulate the industry. A slight majority of those surveyed said that the government should institute regulations to protect consumers in managed care but 40% worried that such action could raise health costs. "It is not unqualified support..." for regulation, Altman noted, adding that "...the arguments against [regulation] have some resonance with the American people."
In fact, public reaction about who should regulate the industry continued to be mixed. Nineteen percent said it should be the federal government, 18% said state government, and 34% said it should be an independent group. Americans felt anxious about a particular set of problems with managed care, according to Blendon, but "...there [was] nothing in this poll that suggests a massive new government agency..." should be created to deal with those issues."
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