|
 |
|
|
|
Issue #155: December 14, 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 American Journal of Public Health, Archives of Internal Medicine, Reuters, Wall Street Journal, US Newswire
Gore orders more effort on Medicaid coverage
Clinton advisory panel faults AIDS leadership
HIV doesn't affect pregnancy: study
Perinatal program reports success with combo
D&A treatment doesn't reduce HIV risk: study
Gore orders more effort on Medicaid coverage
Efforts to expand access to antiretroviral drugs to all HIV-infected Americans who need them are not over, Vice President Al Gore has announced.In April, Vice President Gore directed the Health Care Financing Administration and the Office of National AIDS Policy to examine the feasibility of expanding Medicaid coverage to include antiretroviral drugs for asymptomatic HIV-positive recipients. However, last week HCFA announced that this could not be done in a "budget-neutral" matter, as required for demonstration projects. Currently, Medicaid covers antiretroviral drugs only for people formally diagnosed with AIDS.
"I am extremely disappointed that they could not find a way to achieve our goal through this mechanism," Gore continued. "But reports that this marks the end of our efforts are mistaken. In fact, I am directing the Department of Health and Human Services and Office of National AIDS Policy to continue to work on ways to expand access to life-saving drug therapy for people living with HIV and AIDS."
Gore reaffirmed the Administration's commitment to "...work with Congress, patient advocates, states, pharmaceutical manufacturers and others to find innovative ways to provide access to these life-saving therapies."
The drugs have proved highly effective in keeping patients healthier but cost about $12,000 per person per year.
Officials had hoped the plan would pay for itself by keeping people healthy and saving money on future hospital care.
Before abandoning the nationwide expansion, the Health Care Financing Administration, which oversees Medicaid, had studied four scenarios under which Medicaid would provide the benefits to HIV-infected people at 100 percent, 200 percent, 250 percent or 300 percent of the poverty level.
They concluded that, in the first year, that expansion would help 44,000 to 114,000 HIV-infected Americans. "Unfortunately, none of [the scenarios] are revenue neutral -- or close," a HCFA source said.
According to one AIDS activist, health officials said it would cost about $800 million a year to cover people at 100 percent of poverty.
"In the scheme of things, this isn't a whole lot of money," said Joseph Kelly, deputy director of the National Alliance of State and Territorial AIDS Directors. "What we need is the political will to do it."
People with AIDS already qualify for Medicaid coverage because they are disabled, even if they are not poor enough to participate under the program's normal guidelines. No such provisions exist for people with HIV.
Several AIDS advocacy groups have expressed disappointment in the decision not to go forward with Gore's original plan. "It's the equivalent of putting the air bag in the car after it crashes," Daniel Zingale, executive director of the AIDS Action Council said. "I don't think it makes sense to anybody in the Administration either."
Michael Weinstein, president of the Los Angeles-based AIDS Healthcare Foundation, pointed to the Administration's "splashy April announcement" expressing the desire to extend HIV treatment benefits to the poor. "Eight months later, we get a press release saying they're abandoning that effort. That's an unacceptable abdication of leadership."
Clinton advisory panel faults AIDS leadership
A White House advisory panel has charged the federal fight against AIDS had stalled in recent months in the absence of bold leadership by President Clinton's administration.The 32-member panel in its second "progress report" faulted the administration, like its predecessors, for failing "to lay out a coherent plan of action" to prevent transmission of HIV.
"Funding for HIV prevention remains inadequate, particularly when compared with the monumental American bill for medical expenses," it said. In addition, "far too many Americans lack access to effective medications," it added.
"Although powerful evidence of the effectiveness of HIV prevention demands a robust and energetic response, the administration has failed to provide such bold leadership," the report said.
Overall, it said Clinton had "dramatically" improved the national response to AIDS since he took office in 1993. Funding for AIDS research at the National Institutes of Health had grown 50 percent since the start of the administration and funds were being spent "more efficiently and strategically," it said.
"However, most of these important strides occurred during the president's first term," which ended in January, it added.
"Despite substantial and diligent efforts ... progress in the federal response to AIDS has stalled in recent months, contributing to a sense of diminished priority for AIDS issues during the president's second term," the report said.
Specifically, it criticized the administration's failure to find ways to expand Medicaid, the combined federal and state health program for the poor, to cover all low-income people with HIV early in the course of the disease.
It called on the administration to push for the removal of a congressionally mandated ban on federal funding for needle exchange programs.
"Perhaps most disturbing is the continued prohibition on federal funding for needle exchange programs despite clear scientific evidence of the efficacy of such programs in preventing new HIV infections without increasing substance use," the panel wrote.
Sandra Thurman, director of the White House office of National AIDS policy, said she shared the advisory panel's "sense of urgency and frustration" but rejected the notion that progress had stalled.
"There is no absence of will to meet this challenge," she said in a statement. "There is, however, a different sense of what can be accomplished in an often polarized political environment in which ideology can overwhelm science."
"The struggle to get the best quality of care and the best medications to all HIV-positive Americans is a very difficult fight and one I know the president is committed to winning," Thurman added.
The Human Rights Campaign, the largest national lesbian and gay political organization, endorsed the panel's conclusions, calling for bolder leadership "to continue its strong record on HIV and AIDS issues."
HIV doesn't affect pregnancy: study
The results of a prospective study, conducted at 14 clinical centers in Italy, indicate that HIV-positive women are likely to carry a pregnancy to term. Furthermore, "...pregnancy does not appear to influence the rate of progression of HIV disease," according to members of the Italian Seroconversion Study Group, who report their findings in the Archives of Internal Medicine.Dr. Maria Barbara Alliegro followed 331 women for a median of 5.5 years after seroconversion. "Thirty-eight women (11.5%) were pregnant at the time of HIV seroconversion and 31 (9.4%) became pregnant after HIV seroconversion." Of these 69 pregnancies, 45 were carried to term. Overall, Dr. Alliegro's group found "...no discernible differences in these findings by age or exposure group."
The pregnant women with HIV infection "...did not experience a more rapid rate of progression of disease, even when adjusting for age, exposure group, CD4 cell count, or use of treatment."
They note that "...knowledge of HIV infection per se did not significantly alter the decision to continue the pregnancy," and during the follow-up period, 14 women became pregnant more than once. "Overall, a large proportion of women in our cohort became pregnant (28.9%...) within 8 years form seroconversion."
Dr. Alliegro's group concludes that "...the frequent occurrence of pregnancy and the repeated pregnancies observed in our study suggest that counseling, education, and medical services for women with HIV infection need to be developed and strengthened."
The most interesting finding of the study is that "...65.2% of the women decided to carry pregnancy to term despite HIV infection," Dr. Len Scarpinato of the Racine Family Practice Residency in Wisconsin commented. "Internists, family physicians, and obstetricians need to get more used to and comfortable with their pregnant patients with HIV."
Based on recent data, counseling HIV-positive women against pregnancy may not be the best option, he points out.
Combo helps fight dementia
New protease inhibitor combination drug therapies can either stall or reverse the progressive dementia caused by AIDS, according to experts."Our study showed a statistically significant improvement with protease inhibitors and suggests that many more patients may benefit from these drugs," said Dr. Christopher Filippi, director of neuroradiology at the Albert Einstein College of Medicine's Weiler Hospital in New York City.
Filippi presented his findings at this week's annual meeting of the Radiological Society of North America, held in Chicago, Illinois.
Late-stage AIDS patients often suffer from HIV-encephalopathy, a progressive degeneration of the white matter of the brain which occurs as HIV invades the central nervous system. HIV-encephalopathy induces steady, incremental losses in both mental and motor function.
Filippi took neurological magnetic resonance imaging (MRI) scans of the brains of nine AIDS patients already suffering from HIV-encephalopathy. Each of the patients were enrolled in AIDS-fighting protease inhibitor drug combination therapies. MRI scans of each patient were taken at intervals ranging from two months to a year.
Eight out of the nine patients showed either stabilization of white matter degeneration on MRI (four patients), or its near-total reversal (four patients). One patient displayed slight progression of HIV-encephalopathy.
Filippi notes that these results mirrored ongoing improvements in the daily mental and motor function of the patients, observed throughout the study period.
He also conducted MRI exams on seven late-stage AIDS patients who were not taking protease inhibitors. Unchecked progression of HIV-encephalopathy was noted in the MRIs of six out of the seven patients. The MRI of the seventh patient displayed no detectable change in disease progression.
Filippi notes that all 16 patients also received alternate AIDS medications, such as Zidovudine (AZT). "Our results suggest that protease inhibitors in combination with drugs like AZT may be particularly effective because the two types of drugs target the HIV virus at different phases in its life-cycle," he said.
Perinatal program reports success with combo
Since April, 1995, none of the 56 HIV-positive pregnant women receiving care at the Bay Area Perinatal AIDS Center (BAPAC) have delivered an HIV-positive infant, according to a University of California, San Francisco press release.The UCSF-affiliated program, based at San Francisco General Hospital, uses counseling, support, and careful monitoring, along with combination antiretroviral therapies to prevent perinatal HIV transmission, program director Dr. Karen Beckerman explained.
"Our ultimate goal used to be to prevent transmission from mother to child," she said. "Now our ultimate goal is to get the mom to her child's high school graduation. We still don't know if that is an achievable goal."
In June of 1996, BAPAC replaced Zidovudine monotherapy, which was routinely offered to all women, with combination therapy. Dr. Beckerman attributes the switch to combination therapy as the factor primarily responsible for the lack of HIV transmission.
One of the big difficulties has been to persuade new mothers to continue on the demanding combination regimen. "So far it appears to be a significant challenge to stay on the drugs and take care of a newborn baby at the same time," she said. "So we have seen their viral burden increasing." However, she adds that BAPAC is committed to intensive intervention to help mothers with these problems of adherence."
ACT UP plans anti-Ridge demo
ACT UP/Philadelphia has scheduled a demonstration for decent health care on Wednesday, December 17 at noon at the state capitol building in Harrisburg."We have a problem here in Pennsylvania," the group said in a play on the state's public relations slogan, "You have a friend in Pennsylvania. "Governor Ridge has been very bad this year! Time to bring him his lump of coal..."
Buses from Philadelphia will leave Broad and Walnut Streets at 9:00 a.m. for the demonstration.
ACT UP's Julie Davids said that among the reasons for the demonstration is that Pennsylvania is the only state in the region that provides no access to NNRTI's, an important new class of drugs. "Year after year, activists must fight the Department of Public Welfare to add the drugs we need to survive to the state's list of covered treatments, even though the Federal government gives more and more money to the state program," she said. "Time for the state to stop playing doctor."
The group will also focus on the state's unwillingness to reimburse managed care companies in the Medicaid HealthChoices program to prevent them from losing money on AIDS care. Some HealthChoices plans have reduced services to people with AIDS because of the low reimbursement rates.
"HealthChoices doesn't pay enough per-head to provide decent care to people with expensive diseases like HIV," Davids said. "The state admits southeastern Pennsylvania was 'a
failure' and plans to increase payments for chronic illnesses as HealthChoices moves into the rest of the state," she continued. "But there is no plan to increase payments in Philadelphia, even though HMOs are closing admissions."
"Instead of paying the HMOs the money they need to provide adequate care, the state is making it up to the companies by allowing HMOS to cover fewer drugs than are approved," Davids noted. Although these "restrictive formularies" mean higher profits for HMOs, she said, "they also mean that people may not be able to get the drugs they need if their medications cost too much."
For more information on the demonstration, call ACT UP at 215-731-1844.
D&A treatment doesn't reduce HIV risk: study
Extending residential drug abuse treatment programs beyond 6 months does not appear to have any benefit in reducing HIV risk behaviors or preventing resumption of drug use, according to a multicenter team of researchers reporting in the American Journal of Public Health.
Dr. Jane McCusker of St Mary's Hospital in Montreal, Canada and colleagues evaluated outcomes of two trials of residential drug abuse treatment programs. The first compared two traditional therapeutic community programs of 6-month or 12-month duration. The second compared a 3-month and a 6-month version of a modified therapeutic community program that included a relapse prevention program.
Dr. McCusker's group assessed outcomes using factors such as time to resumption of drug use, high risk injection drug use, high risk sexual behaviors, and problems with alcohol, the law, and employment. Follow-up time was 16.5 months or longer.
The investigators found "...no significant effects of planned duration of treatment upon Addiction Severity Index scores or HIV risk behavior." Overall, there is "...little support in this study for the notion that longer treatment programs are more effective," and they conclude that "...residential treatment programs can be shortened to 3 months without significant negative effects."
To obtain a weekly email version of fastfax, contact with the message: "subscribe".