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Issue #157: December 28, 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, New England Journal of Medicine, Philadelphia Inquirer, Reuters
HealthPartners dumps Temple, St. Joe's; 500 PWAs affected
Cats implicated in bacterial threat to PWAs
Cesareans can reduce vertical HIV transmission
API AIDS awareness campaign kicks off
City lawyer opens AIDS legal website
FDA approves new PI for clinical trial
HealthPartners dumps Temple, St. Joe's; 400 PWAs affected
More than 500 people living with HIV/AIDS have been told to switch their doctors or find a new Medicaid HMO as a result of a decisions by Temple University Medical Practices and HealthPartners, the primary provider of AIDS care to Medicaid recipients in southeastern Pennsylvania.Temple has canceled its contract with HealthPartners, citing low reimbursements and long delays -- which it says average from 15 to 18 months -- in getting payments from the Medicaid managed care company. HealthPartners itself canceled its contract with St. Joseph's Hospital in October, effective December 31st.
Both primary care programs are located in North Philadelphia, which has the highest incidence of HIV infection in the region. The majority of people with HIV/AIDS seeking care from the hospitals, mostly people of color in the city's poorest neighborhoods, were forced into the state's new Medicaid managed care program, HealthChoices, this past July.
Sources said that about 500 of the PWAs receiving care through Temple University Medical Practices, which is part of Temple's Medical School, are currently members of HealthPartners. A much smaller number, estimated at less than 20, are at St. Joseph's Hospital, which is part of the financially-strapped North Philadelphia Health System (NPHS).
Over 4,000 other Medicaid recipients are also affected by the decisions.
NPHS also operates Girard Medical Center, which has the only AIDS-specific skilled nursing unit in the region outside of the city's own Philadelphia Nursing Home. It was unclear whether HealthPartners recipients would still be able to gain admission to the Girard nursing unit.
In each of the hospitals, PWAs will be told that the only way they can keep their current doctors is if they switch to a Medicaid HMO -- either HMA or Keystone/Mercy -- which covers their doctor. Oxford/OakTree, the fourth Medicaid HMO, apparently has no contract with Temple. If the PWAs don't want to switch HMOs, or their doctor is not in one of the other two Medicaid HMOs, they will have to switch to another doctor who may or may not be experienced in HIV care.
HealthPartners has been the most vocal of the four Medicaid HMOs in complaining that the HealthChoices program provides too little reimbursement for the care of patients with AIDS, and has cut back on other services several times since the HealthChoices program began last February. Earlier this year, four Delaware County hospitals canceled their HealthPartners contracts because of the high cost of AIDS care and low state reimbursements, according to published reports.
HealthPartners is believed to be the most popular of the Medicaid HMOs in terms of AIDS care, with the highest number of experienced AIDS physicians on its panels and greater attention to standards of HIV care. The state does not require a common standard of HIV care among the HealthChoices HMOs, despite commitments to establish such a standard when the plan was first seeking approval from the federal government.
According to informed sources, HealthPartners has also unilaterally eliminated special rates for AIDS care it had negotiated with several local community health centers in Philadelphia and Delaware counties.
At this printing it was unclear what impact the HealthPartners actions will have on its highly-touted plans to create "centers of excellence" for AIDS care, which they claim will provide state-of-the-art care to people with HIV/AIDS, other than the fact that no center will be located in North Philadelphia, where most people with AIDS in the region reside.
Temple's decision to pull out of HealthPartners affects Medicaid recipients who have been receiving care from about 350 doctors at its hospital and medical school. Temple is one of six Philadelphia medical centers which owns HealthPartners, which claims it lost $1.5 million over the last quarter on revenues of $60.2 million.
Peg Dierkers, the former AIDS activist who now serves as policy director for the state Department of Public Welfare, told the Philadelphia Inquirer that DPW would take no action on the Temple decision. She called it an "internal contractual matter" and would not comment on whether the state has penalized HealthPartners for delays in reimbursing providers, according to the Inquirer report.
The federal regional Medicaid director for the Health Care Financing Administration, Dennis Gallagher, said that current patients who are affected by the Temple and St. Joseph's actions would be covered by a "safety-net" provision included in the federal contract with DPW, which requires that patients be allowed to see the same health care provider until they can be "safely transitioned" to a new provider.
The 4,000 Medicaid recipients at Temple who are currently part of HealthPartners will be informed of the actions by letter, and assisted in picking a new HMO or primary care physician when they come in for routine clinic visits, according to Temple officials quoted in the Inquirer.
The Temple and St. Joseph's situations, combined with the earlier decision to disenroll HealthPartners members in Delaware County, highlight the concerns of AIDS activists that low reimbursement rates under HealthChoices are a direct barrier to quality care for people living with HIV/AIDS in the region. State officials have said that DPW's second attempt to implement Medicaid managed care programs, in southwestern Pennsylvania, has recognized the high cost of AIDS care and is implementing special reimbursement rates for AIDS patients in that region. No change in Philadelphia area rates are contemplated at present, they have said, and will await a review of HealthChoices activity when the program is scheduled to be renewed in 1999.
For more information on advocacy efforts on HealthChoices issues, contact Anna Forbes of the Philadelphia Coalition on HealthChoices at 215-985-4448.
Clinton seeks HOPWA reduction
The Clinton Administration's Office of Management and Budget (OMB) has rejected a request from the Office of Housing and Urban Development (HUD) for a $21 million increase in funding for the federal Housing Opportunities for People with AIDS (HOPWA) program in the new federal budget.Clinton officials have also rejected a $1 billion increase in the federal HOME program. Both the HOPWA and HOME programs support the AIDS rental assistance and emergency financial assistance programs, which serve close to 1000 people with HIV/AIDS in the Philadelphia region.
The $21 million HOPWA increase had been proposed by HUD in order to avert cuts in local HOPWA grants which would be necessary if the program is renewed at only its current level of funding of $204 million. Level funding for the program will probably result in a reduction of funds for Philadelphia-area AIDS housing initiatives, local officials have said.
OMB and HUD must agree on a final administration budget by the end of December. Sources say that federal HUD secretary Andrew Cuomo intends to be "aggressive" in defending HUD's budget request with OMB.
According to the National Low Income Housing Coalition, OMB has also rejected HUD's effort to create 18,000 new Section 8 housing subsidies, some of which are locally allocated to people with HIV/AIDS and other disabilities. There have been no new Section 8 subsides included in the federal budget since 1994, according to NLIHC.
Advocates are asked to contact President Clinton to demand that the original HUD funding levels be protected. The White House can be contacted at 202-456-1414 (fax 202-456-2883) or by email to president@whitehouse.gov. Secretary Cuomo can be contacted at 202-708-3750.
Cats implicated in bacterial threat to PWAs
Cat owners, homeless people, and people living with HIV disease are all at risk for infection with a tiny bacterium that can cause a wide variety of health problems, according to the largest study to date of infected individuals.The bug is known as Bartonella, according to a report in the current issue of The New England Journal of Medicine. One particular type, B. henselae, is carried by fleas and can cause cat scratch disease, a relatively mild illness that strikes 40,000 people in the U.S. every year. It causes swollen lymph nodes, fever and malaise after a cat bite or scratch.
A second strain, known as B. quintana, is carried by lice, and is found more often in homeless individuals and others exposed to head or body lice. B. quintana can cause "trench fever," a relapsing fever that earned its name from an epidemic that struck thousands of soldiers during World War I.
And either strain spells disaster for people with HIV/AIDS or anyone with a compromised immune system who gets infected, the study says. In that case, the bacteria can cause bacillary angiomatosis, a Kaposi's sarcoma-like disease where lesions form in the skin, bone and brain; or bacillary peliosis, where lesions form in the liver or spleen.
Indeed, it wasn't until people with AIDS began coming down with the disorders, that doctors discovered that B. henselae was the cause of cat scratch disease.
In a new study of people with the bacillary angiomatosis or peliosis, those with bone lesions were almost always infected with the lice-associated B. quintana, and all people with liver lesions were infected with B. henselae. The study included 49 people, 45 of whom were HIV-positive.
The new study sheds light on the mysterious Bartonella organisms, which are extremely difficult to grow in the laboratory, and can cause a variety of symptoms depending on the infected person's immune status.
The researchers found that B. quintana outbreaks occurred simultaneously in Seattle and San Francisco in 1993. However in Seattle, predominantly Native American, non-HIV infected men developed blood infections, while in San Francisco, the mainly white, HIV-infected patients developed bacillary angiomatosis.
The study confirms the importance of the human body louse as a carrier of B. quintana, noted Dr. Lucy Tompkins in an editorial accompanying the study. And with the cat now the most popular pet in the U.S., more B. henselae infections might be expected.
"Even though most cases of cat scratch disease resolve spontaneously (without treatment), there are sometimes serious consequences and substantial morbidity," wrote Tompkins, of the Stanford University Medical Center in California. "Although uncommon, bacillary angiomatosis-peliosis may be life threatening if it is not recognized early and treated promptly with antibiotics."
Cesareans can reduce vertical HIV transmission
A Spanish team of researchers reports that in the absence of zidovudine (AZT) prophylaxis, Cesarean section can reduce the rate of vertical transmission of HIV-1 to infants. Dr. Jordi Casabona and members of the Working Group on HIV-1 Vertical Transmission in Catalonia report their findings in the December issue of the journal AIDS.Dr. Casabona's group evaluated the potential risk factors influencing vertical transmission of HIV-1 among 599 infants born to 520 HIV-infected mothers. The study was conducted before the benefits of AZT during pregnancy were established. Factors considered included mode of delivery, gestational age, breast feeding, maternal age, maternal route of HIV transmission and stage of infection. None of the women received AZT prophylaxis.
Overall, they found that the "...rate of vertical transmission was 18.6%." Lower rates of vertical transmission were associated with Cesarean section and maternal HIV infection through injection drug use. Higher rates of vertical infection were associated with breasting-feeding, very low birth weight and p24 antigenemia. Dr. Casabona's group calculated the crude rate of HIV transmission to be "...6% among Cesarean births compared with 21% for infants born via vaginal deliveries."
Although they point out that current research should focus on the effects of combining antiretroviral agents with Cesarean section on reducing vertical HIV-1 transmission, the findings may be applicable to cases in which "...the mother-to-be is identified too late to be able to comply with the AZT protocol."
API AIDS awareness campaign kicks off
The Asian/Pacific American Community Health & HIV/AIDS Awareness Campaign has launched its 1998 initiative with the debut of its centerpiece, a 1998 Calendar in the form of a poster. A Campaign Debut Reception was held on Wednesday, December 17th to announce the campaign, which follows the theme of "It's about us. Learn about HIV/AIDS."Few people in the Philadelphia AIDS leadership attended the reception, with the exception of those active in Asian communities, according to Richard Liu, executive director of AIDS Services in Asian Communities.
The mass distribution of 10,000 free multi-ethnic, multi-lingual, and decorative 1998 Poster/Calendars will occur throughout Philadelphia over the next two months, Liu said. These full-color poster/calendars features the message "It's about us. Learn about HIV/AIDS." in Chinese, Korean, Japanese, Vietnamese, Laotian, Cambodian, Tagalog, Hindi, and English. Volunteer models representing the diversity within the Asian/Pacific American community in Philadelphia are pictured.
This campaign is targeted to Philadelphia's diverse Asian/Pacific American communities. Its goals are to increase community-wide awareness of HIV/AIDS, change attitudes about the risk of infection, improve knowledge of available services, encourage volunteerism, and promote the health and well-being of Asian/Pacific Americans. The primary vehicle of this campaign is the production and distribution of the 10,000 multi-lingual, multi-ethnic 1998 calendars.
The Asian/Pacific American Community Health & HIV/AIDS Awareness Campaign is a joint effort between Intercultural Family Services, AIDS Services In Asian Communities (ASIAC), Korean Community Development Services Center, and the Southeast Asian Mutual Assistance Associations Coalition (SEAMAAC). It is funded by the Centers for Disease Control and Prevention through Intercultural Family Services.
Free copies of the poster/calendar are available by calling the following: Intercultural Family Services, Inc., (215) 386-1298; AIDS Services In Asian Communities, (215) 563-2424; Korean Community Development Services Center, (215) 276-8830; or the Southeast Asian Mutual Assistance Associations Coalition, (215) 476-9640.
"This year's theme for the Asian/Pacific American Community Health & HIV/AIDS Awareness Campaign is "It's about us. Learn about HIV/AIDS" because AIDS is about us," said Lalaine Lambo, Intercultural Family Services. "As Asians & Pacific Islanders, we believed for so long that AIDS was some other community's problem. We thought such a disease would never affect our own people. We believe that AIDS would never be about us. But how long could we stay in denial about AIDS? How long could we hide behind cultural taboos? How much longer can we afford to be silent? I say we can no longer be in denial about AIDS in our communities. I say that we can no longer hide behind cultural taboos. I say that we can no longer be silent about AIDS. This virus will continue to spread until we make this a priority in our community. That is why I say that AIDS is about us. AIDS is our problem. This disease is about us, our communities, our families, about each other, and about ourselves. It's about us. Learn about HIV/AIDS."
Judy Kim, of the Korean Community Development Services Center, said that the campaign emphasizes the need for the Asian and Pacific Islander communities to take a stand to fight AIDS in their own communities. "It's about our health, she said. "It's about a virus. It's about safer sex. It's about using clean needles. It's about voluntary HIV testing. It's about education. It's about awareness. It's about taking care of each other."
"Do you see who we are? Do you see that we are Korean, Chinese, Japanese, Vietnamese, Cambodian, Laotian, Hmong, Filipino, South Asian, and mixed heritage?," said ASIAC's Jon Park. "Do you see our history? Do you see us as Asian born? Do you see us as American born? Do you see the span of our generations? Do you see our different faiths? Do you see that we are strong women and proud men? Do you see us as productive members of society? Do you see us as family members, mothers, fathers, sons, daughters, husbands, wives, significant others, boyfriends, and girlfriends? Do you see that we are straight, gay, lesbian, and bisexual? Do you see we are from all parts of Philadelphia? Do you see our culture, our traditions, and our lives? Do you like my hair? I have something to tell you. We have come together and crossed the many lines that divide our community. We have worked together in meeting rooms to develop this campaign. We have brought together people from our diverse community who graciously out of concern and commitment to our community's health, volunteered to be models in our beautiful poster calendar. And, we have assembled here tonight and in one unified voice tell you one very simple message...It's about us. Learn about HIV/AIDS."
Lawyer opens AIDS legal website
David Webber, a local attorney who has represented people with HIV/AIDS for over a decade and is the founder of the AIDS Law Project of Pennsylvania, has announced a new website devoted to HIV/AIDS law and policy issues. The website is located at http://www.critpath.org/aidslaw.The website provides, among other items, an overview of return-to-work issues for individuals with HIV who have been receiving disability benefits (topics include Social Security Administration return-to-work incentives, nondiscrimination standards that protect job applicants, and health insurance access and portability); info about "HIV-Law" (the Internet e-mail discussion list), including instructions on how to request a subscription; and info about the new edition of the book "AIDS and the Law," including a detailed table of contents. Webber is the editor and author of the book.
Also included are other HIV/AIDS policy resources, both on and off the Internet, including categories of general interest (U.S. law); international and non-U.S. law; blood product transmission; syringe exchange; medicinal marijuana; and reporting services/newsletters.
"Because this website is new, I have plans to expand it significantly in the near future," Webber said. "Future expansion will be responsive to the interests expressed by visitors. The website is designed without graphic images that might otherwise delay viewing. The legal issues pages are intended to be 'client friendly' by providing the reader with the option of navigating through only those topics that are relevant or of interest. Visitors are encouraged to provide comments and pose questions," he said.
FDA approves new PI for clinical trial
Triangle Pharmaceuticals has received FDA approval to begin phase I studies of the HIV-1 protease inhibitor DMP-450, according to company information posted on PR Newswire.The DMP-450 HIV-1 protease inhibitor trial will begin in January, according to company officials.
"We are very pleased that we have been able to rapidly reach agreement with the FDA to re-initiate clinical studies with DMP-450, Dr. David W. Barry, Triangle CEO said. "DMP-450 belongs to a novel chemical class, appears to have good bioavailability and enhances the breadth of our anti-HIV portfolio."
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