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Issue #152: November 23, 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 The Mining Company, M2 Presswire, American Medical News
MAPP revamping tied to takeover plan
NIH revises AIDS treatment guidelines
PWA wins $82,000 in dental case
Immunet opens online AIDS bookstore
MAPP revamping tied to takeover plan
Ernest Jones, executive director of the Greater Philadelphia Urban Affairs Coalition (GPUAC), has informed the staff of the Minority AIDS Project of Philadelphia (MAPP), that he will terminate the project at the conclusion of MAPP's current contract with the city health department.MAPP has been a program of GPUAC since 1988.
The action will formally lead to the termination of James Roberts, MAPP's executive director, and Jena Nottingham and Gerald Wright, its deputy directors, as well as other program monitoring and administrative staff.
Jones said, in a memo to the affected staff, that GPUAC intends to develop a proposal to the city next spring to restore MAPP's "capacity building" among communities of color in the Philadelphia region, under a new organizational structure reporting directly to him. MAPP has received about $500,000 per year from the city to help create a network of minority AIDS services since 1994, but has faced severe criticism -- mostly from people of color themselves -- for failing to develop a network of AIDS services and for ignoring people with HIV/AIDS in determining its agenda and priorities.
Criticism of MAPP's performance led the city's AIDS Activities Coordinating Office to announce earlier this fall that it would put the contract up for competitive bid next spring.
MAPP has been faulted for using over 75% of the city funding for administrative services, and for concentrating its efforts primarily on the development of AIDS prevention activities rather than direct care services for people with HIV/AIDS, which is the focus of the capacity building funds. MAPP has also been condemned for concentrating its efforts on the city's African American communities and shortchanging efforts to develop AIDS services for the Puerto Rican and Latino population.
Sources at GPUAC said that Jones intends to lay off the MAPP staff when the city's current contract for capacity building services formally expires at the end of February. However, GPUAC has also requested an extension of its contract until the end of June, 1998, since the city does not intend to issue a Request for Proposals (RFP) for the capacity building functions until the spring.
MAPP staff members have told fastfax that if the city grants the extension, their employment would likely be extended to June as well.
MAPP has been on the ropes since last winter, when it joined forces with Sen. Hardy Williams, a state legislator from West Philadelphia, in arranging a secret deal with health commissioner Estelle Richman to divert $200,000 of city AIDS funds from existing services to support the Philadelphia EMA HIV African American Planning Group (PEHAAP). PEHAAP, which publicly claimed to be the "recognized planning vehicle for the African American community in Philadelphia," had been appointed by Williams from among his political allies and MAPP staff, but did not include people living with HIV/AIDS or the leadership of any of the African American AIDS service organizations in the region.
In February, Williams and his close ally, Barbara Chavous, forcibly excluded a group of people with HIV/AIDS from participating in a public PEHAAP planning session, threatening to call the police unless the PWAs left.
Following the February incident, it was revealed that Richman and Jones had agreed to an arrangement which would have effectively given control over MAPP's technical assistance and capacity building programs directly to Williams and his allies. After intense opposition from a coalition of African American AIDS and community organizations -- including EIARC, BEBASHI, Colours, Unity, GALAEI, the Craig Foundation, and others, and led by African American people living with HIV/AIDS from We The People and elsewhere, Richman backed off from the deal.
The Philadelphia EMA HIV Commission, which is formally mandated by federal law to determine priorities for most AIDS funding in the region, also opposed the action.
GPUAC, through MAPP, has also acted as an administrative agent for the city in the distribution of over $3 million in direct care and prevention funding for minority agencies in the city. In that role, GPUAC has made monthly payments on invoices to minority agencies and monitored service delivery in over 50 contracts for AIDS care and prevention services in the region. It was unclear whether GPUAC intends to pull out of the contract administration and program monitoring role as well as the capacity building function, although it is known that the city intends to reduce the amount of funding it provides to GPUAC to perform those functions.
Sources said that the capacity building and contract administration funding provides about one-fourth of the total budget of GPUAC.
Almost $240,000 of the $500,000 technical assistance and capacity building funding provided to GPUAC has been used annually to pay the salaries of Roberts, Nottingham and Wright, according to city budget documents. Another $150,000 has been used to pay program monitors and clerical staff associated with MAPP, leaving only about $110,000 for actual technical assistance services. Critics have said that all of the funds were supposed to be used to develop new AIDS services and coordinate a network of AIDS care in the region, and that their use for administrative purposes was inconsistent with the city's supposed priority for expanding the AIDS service system to include more minority providers and neighborhood organizations.
MAPP's latest crisis occurred when the city announced earlier this year that it intended to make about $2.7 million in AIDS case management funds available for competitive bid this fall, a competition that is currently underway. MAPP officials announced that they had no technical assistance funds available to help AIDS care organizations in minority communities to prepare for the case management RFP, and until last week had not contacted MAPP-funded agencies to coordinate a response to the city's effort. The deadline for applications is December 1st.
On November 13th, MAPP convened a meeting of AIDS prevention organizations and says it is building a network for which it intends to apply for case management funds. However, none of the major minority AIDS case management providers intends to participate in the network, and most of the participating organizations have provided only AIDS education services.
Two organizations who are generally seen as "white" AIDS case management agencies -- ActionAIDS and Philadelphia Community Health Alternatives -- have agreed to provide clinical assistance to MAPP's case management network, according to MAPP staff.
The case management proposal is being prepared by Barbara Chavous, a close aide to Williams, who is also working on developing a new program to replace MAPP if its wins funding through the city's RFP process next spring.
It was unclear whether MAPP intends to go forward with a proposal for the case management funding, given the decision to terminate its operations.
Sources told fastfax that Jones' plan is to formally layoff most of the MAPP staff but to rehire Wright, who among the three MAPP leaders is the most closely identified with Sen. Williams. They say that Wright and Chavous will put together a new program which will seek the city's capacity building money in the competitive process planned for next spring, and that Williams will play a significant role in determining how the new program is implemented.
When asked by fastfax if the information reported to fastfax was accurate, Jones said that "no final decisions have been made." He said that MAPP staff who are talking about his plans are "digging their own graves" and refused further comment.
"This is obviously a continuation of the scam that Sen. Williams and his cronies tried to get away with earlier this year," said Curtis Osborne, executive director of We The People, a predominately African American coalition of people with HIV/AIDS. "Neither Sen. Williams nor Ms. Chavous can ever be found to help African American PWAs in their daily struggle to survive. They've never cared about AIDS before. They don't do anything to help us. They've never said anything that indicates they have the slightest idea what we need or how to help us. And they've turned their backs on the organizations that are already there doing the job and the hundreds of volunteers who sacrifice to help black and Latino PWAs."
"Instead," Osborne said, "they seem to spend all their time trying to work back room deals and figure out ways to make money on our suffering." He said that Jones' decision to terminate most of the MAPP staff appeared to be little more than an attempt to "clear the decks of anyone who might stand in the Senator's way so he can corrupt the system without having to watch his back."
The capacity building and technical assistance services have been a major priority for minority PWAs and minority AIDS service organizations for several years. They note that the lack of minority AIDS services qualified to perform AIDS direct care functions has resulted in over 80% of the region's AIDS funding going to predominately white organizations, even though over 70% of people with HIV/AIDS in the region are African American or Latino.
"Instead of dedicating their efforts to building minority AIDS services, MAPP and Sen. Williams have spent all their time playing the race card in the hope they can get control of the funding. They obviously think they can use our suffering for their own financial gain. Since they have no plan, no experience, no history of caring about us, why would anyone want to give them the money we need for services that help us stay alive?"
MAPP and PEHAAP have routinely tried to silence criticism of their activities from other people of color, Osborne said, with the argument that the white-dominated AIDS system will take advantage of the division to keep its hold on the lion's share of resources for AIDS services.
"What they really want us to do is cover up their corruption and their incompetence in getting for black and Latino PWAs what we need," Osborne said. "It didn't work before and it's not going to work now. We're not afraid to stand up in our own community, the African American community, and tell the truth. We don't determine our allies by what color they are, but by whether they can do the job. MAPP and PEHAAP have already proven they don't know how to get the job done. They've already proven they're not about helping us and we intend to make sure that everybody knows it."
The controversy over MAPP comes at a critical juncture in AIDS services in the region, as both the city and the state intend to re-allocate much of the available AIDS funding over the next few months. In addition to the $2.7 million being redistributed for AIDS case management, over $3 million in AIDS prevention funds and over $6 million in state and federal care and prevention funding will be made available through requests for proposal over the next several months. Together, the re-allocations comprise over half of all available AIDS service funding in the region.
"The games being played by Sen. Williams, MAPP and GPUAC have prevented minority organizations from truly preparing for the first opportunity we've ever had to get the resources we need," Osborne said, noting that the re-allocation process has been planned for months. "By the time the dust settles, most of the funding will be re-allocated and it looks like minority groups will be left out again."
"After spending over $2 million since 1994 which was supposed to create new, minority-based AIDS service networks -- and having hardly anything to show for it -- the responsibility for that failure rests securely with GPUAC, MAPP and Sen. Williams," he said. "And who suffers in the end? We do, the African American people living with HIV and AIDS they only pretend they care about."
"It's not going to happen," Osborne said. "We're not going to let it happen. We hope they'll just give it up rather than force us to waste our time when we all have much more important things to do."
NIH revises AIDS treatment guidelines
The U.S. Public Health Service has issued an updated draft of its Guidelines for the Use of Antiretroviral Agents in HIV-Infected Adults and Adolescents. The Guidelines were first published in June 1997, with a request for comments from the public. According to one of the authors, Gabriel Torres, MD, the panel received 179 written submissions in response to the draft, which have been taken into consideration in the latest version.The final recommendations are expected to be published in January, but will remain subject to regular updates.
There have been minor changes and modifications through the Guidelines. Among them are:
Viral load monitoring: The new draft recommends viral load monitoring every 3-4 months among untreated people, while the previous draft suggested 3-6 monthly monitoring.
After treatment is initiated, the updated Guidelines suggest that viral load should be checked after 4-8 weeks to ensure that there has been an adequate fall, whereas previously a time point of 4 weeks was recommended.
Since the summer, there has been growing interest in new tests that can measure viral load that is lower than the current limit of detection (around 400 to 500 copies/mL). The new Guidelines address these tests cautiously, noting: "As more sensitive assays are developed, the level of detectability will undoubtedly be lower; however, the significance of suppression even beyond the current recommended level, given the variability of test results at the lower limits of detectability, is unknown."
The recommendation that treatment decisions should be based on two viral load tests, taken closely together, still stands. However, the Guidelines now also note: "However, in patients who present with advanced HIV disease, antiretroviral therapy should generally be initiated after the first viral load measurement is obtained in order to prevent a potentially deleterious delay in treatment. In addition, it is recognized that the requirement for two measurements of viral load may place a significant financial burden on patients or payers. Nonetheless, the Panel feels that two measurements of viral load will provide the clinician with the best information for subsequent follow-up of the patient."
Finally, the use of viral load in assessing an individual's likely risk of disease progression has been recalculated. Previous estimates of the risk of progression at specific levels had been adjusted to take account of the possibility that some of the virus in the stored samples might have been lost.
However, more recent research has found that very little viral RNA is likely to have been lost in the stored samples. Overall, the estimated risk of disease progression for an individual with a certain viral load is likely to have increased.
Starting treatment: The list of recommended regimens for people starting treatment has now been extended to take account of studies of the combination of saquinavir and ritonavir. The panel note that this combination, without any additional drugs such as nucleoside analogues (also known as NRTIs: namely AZT, ddI, ddC, 3TC or d4T), "appears to be potent in suppressing viremia below detectable levels, and has convenient BID [twice daily] dosing." However, they also note that the safety of the combination "has not been fully established", and it has not formally been compared to triple combinations consisting of two NRTIs plus a protease inhibitor (PI). For the time being, then, the panel recommends that "at least one additional NRTI be used when the physician elects to use 2 PIs as initial therapy."
The panel now also address the differences between the two licensed NNRTI drugs, nevirapine and delavirdine. The Guidelines suggest that nevirapine should normally be used in preference to delavirdine, because of the former's superior effects on viral load.
In an addition to this section, the new draft states: "When initiating antiretroviral therapy, all drugs should be started simultaneously at full dose with the following three exceptions: dose escalation regimens are recommended for ritonavir, nevirapine, and in some cases, ritonavir plus saquinavir."
Finally, the tables on Drug Interactions Between Protease Inhibitors And Other Drugs and Drug Interactions Between Protease Inhibitors and Non-Nucleoside Reverse Transcriptase Inhibitors have been updated and expanded.
Changing therapy: The recommendation for changing therapy if the viral load reduction is inadequate has been changed slightly. It now suggests changing therapy if there reads "change therapy if there has been "less than a 0.5-0.75 log reduction in plasma HIV RNA by 4 weeks following initiation of therapy, or less than a 1 log reduction by 8 weeks."
The Guidelines now give more detailed recommendations for people who have achieved undetectable viral load on a treatment regimen consisting only of two NRTIs alone. They argue: "Patients currently receiving 2 NRTIs who have achieved the goal of no detectable virus have the option of continuing this regimen or may have modification to conform to regimens in the preferred category. Prior experience indicates that most of these patients on double nucleoside therapy will eventually have virologic failure with a frequency that is substantially greater compared to patients treated with the preferred regimens."
An expanded list of recommended regimens for people who started treatment on two NRTIs now suggests:
* 2 new NRTIs plus a protease inhibitor
* 2 new NRTIs plus ritonavir and saquinavir
* 1 new NRTI plus 1 NNRTI plus a protease inhibitor, or
* 2 protease inhibitors plus 1 NNRTI.
The new draft contains a fuller discussion of the likelihood of a successful response to a new regimen among people for whom a triple therapy regimen has failed, stating: "At present there are very few clinical data to support specific strategies for changing therapy in patients who have failed the preferred regimens that include PIs; however, a number of theoretical considerations should guide decisions. Because of the relatively rapid mutability of HIV, viral strains with resistance to one or more agents often emerge during therapy, particularly when viral replication has not been maximally suppressed. Of major concern is recent evidence of broad cross-resistance among the class of PIs. It appears that viral strains that become resistant to one PI will have reduced susceptibility to most or all other PIs. Thus, the likelihood of success of a subsequently administered PI + 2 NRTI regimen, even if all drugs are different from the initial regimen, may be limited, and many experts would include 2 new PIs in the subsequent regimen."
In the light of new data, the combination of nelfinavir and saquinavir plus two new NRTIs is now a recommended salvage option for people experiencing treatment failure with two NRTIs plus either ritonavir or indinavir.
An entirely new section now addresses Considerations for Antiretroviral Therapy in the HIV-Infected Adolescent, which suggests that those infected sexually or via injecting drug use may have a different disease course than those infected perinatally or via blood products, and makes recommendations for dosing regimens during puberty.
Treatment during pregnancy: An expanded section on the use of anti-HIV drugs during pregnancy -- a subject covered in detail in a separate set of draft guidelines -- now notes that diabetes can be a complication of pregnancy in some cases, and it is not yet known whether protease inhibitors (which can themselves cause or exacerbate diabetes) increase this risk.
The Guidelines now contain a fuller discussion of the pros and cons of prescribing AZT monotherapy to reduce the risk of mother-to-baby transmission among pregnant women whose own condition would not normally merit anti-HIV therapy -- for example, those with a CD4 count greater than 500 and viral load below 10,000 to 20,000. They explain that the risk of developing resistance is probably lessened by the low level of HIV replication in such individuals, and their relatively short period of exposure to monotherapy in the second and third trimesters of pregnancy. However, "for women with more advanced disease and/or higher levels of HIV RNA, concerns about resistance are greater and they should be counseled that a combination antiretroviral regimen that includes ZDV for reducing transmission risk would be more optimal for their own health than use of ZDV chemoprophylaxis alone."
Seroconversion illness: Finally, this latest draft of the Guidelines now includes estimates of the frequency of various symptoms during primary HIV infection (also known as seroconversion illness).
PWA wins $82,000 in dental case
A New Jersey federal court has awarded an HIV-positive man $82,000 after it was found that his dentist refused to provide treatment because of his HIV status.The dentist, who offered no defense to the charges, was informed of the patient's HIV status after consultation about general anesthesia for a tooth extraction had been sought from the patient's physician. With consent from the patient, the medical director of the hospital where the patient's physician worked informed the dentist of the patient's condition. At that time, the dentist refused to treat the patient and referred him to a "special clinic for HIV," which provided care for the medically indigent and mentally ill.
The patient, who sued the dentist under the Americans with Disabilities Act and the New Jersey Law Against Discrimination, was awarded $25,000 in compensatory damages, $25,000 in punitive damages, and $32,000 to cover legal costs.
Immunet opens online AIDS bookstore
Immunet, a non-profit AIDS organization that offers up-to-date treatment information and education services via the World Wide Web, has joined with online bookseller Amazon.com and the University of Illinois' "AIDS Book Review Journal" to launch the Immunet AIDS Bookstore at http://www.immunet.org/.Scheduled to open on Dec. 1 -- World AIDS Day -- the bookstore will offer access to all AIDS/HIV-related books in Amazon.com's inventory, as well as reviews of those offerings. Immunet has been recognized by the Centers for Disease Control and Prevention for "content and overall quality," and by the New York Times as one of the leading sites in "maneuvering the maze" of HIV/AIDS information.
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