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Issue #160: January 18, 1998
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 Associated Press, Clinical Infectious Diseases, Journal of the American Medical Association, American Journal of Public Health, Journal of Clinical Investigation, New York Times, Philadelphia Inquirer, Reuters, Science.
Study confirms value of followup for HIV inmates
TPAC acts on troubled AIDS agencies
Gene tied to delay in progression to AIDS
GMHC changes gears on HIV reporting
Study looks at improving protease drugs
State to require HIV testing for pro fighters
Acyclovir study questions survival benefit
Study confirms value of followup for HIV inmates
Correctional facility inmates require increased health care as a result of their high risk for tuberculosis, HIV, syphilis, and other sexually transmitted diseases, yet very few programs exist which follow up inmate health care after release from detention.In Philadelphia, only one AIDS case manager, at ActionAIDS, is formally charged with helping inmates being released from prison, and her services are limited primarily to prisoners in the city system. State prisoners -- the majority of incarcerated and formerly incarcerated people living with HIV/AIDS -- usually are forced to rely on less formal networks to maintain their access to AIDS treatments and meeting their social service needs once they are released,
The AIDS Law Project of Pennsylvania and We The People collaborate on a part-time program aimed at helping state prisoners. ALP has also developed, with Blacks Educating Blacks About Sexual Health Issues, a program called Transitions to Hope, which is seeking city funding to assure ongoing AIDS case management assistance to inmates being released from state institutions.
A recent study indicates that two facilities, however, may serve as models for follow up care due to their collaboration with local public health departments: The Hampden County Correctional Center in Ludlow, MA, and the Rhode Island Adult Correctional Institute in Cranston. A study of Rhode Island's prison release health care program for HIV-positive women, published in 1996 in the American Journal of Public Health, found that the program appeared to lower the recidivism rate and had positive effects on former inmates' high-risk behaviors. Recidivism rates were significantly lower than those of HIV-infected women -- released during the previous year -- who did not have the help of the release project. The Hampden County Correctional Center opened in 1992, and provides health care to HIV-positive inmates -- from various jails and prisons in metropolitan Springfield, MA -- before, during, and after incarceration. Dr. Thomas Conklin, the center's director of health services, said that the program costs $6 per inmate per day, which is lower than the cost of most other prison health care programs.
Furthermore, a two-year study of 162 HIV-infected former inmates found a recidivism rate of 46 percent, versus a rate of 72 percent for the correctional facility's overall population. According to Hampden physician Thomas Lincoln, this community-based model of correctional health care could be useful for other facilities located in similarly sized metropolitan centers.
TPAC acts on troubled AIDS agencies
With less than a third of its 24 board members present, The Philadelphia AIDS Consortium (TPAC), which is responsible for planning and managing over $6 million in federal Title II Ryan White AIDS funding for the Philadelphia region, took action this week on four agencies which have had financial difficulties or complaints about their services.Citing continued difficulty in getting formal audits of their finances, TPAC's board formally approved termination of contracts for two organizations -- the Ecumenical Information AIDS Resource Center (EIARC) and the William J. Craig Memorial Foundation. EIARC's contract was for respite care services for families with a child living with HIV/AIDS, and the Craig Foundation was funding for AIDS case management services.
EIARC's audit problems go back to 1995, when the organization had a different management staff and board of directors than it has today. The new management says it has had difficulty finding financial records for some activities during that period, and that federal income taxes were not paid to the Internal Revenue Service on a timely basis. The IRS has filed a lien against EIARC's Title I contracts with the city in an attempt to recover some of the money. City and EIARC officials are working on resolving the issues and the city has not yet taken action to deny EIARC its Title I funding.
TPAC said that the group has negotiated an arrangement with the Greater Philadelphia Urban Affairs Coalition (GPUAC) to take over financial management functions for the agency as it regroups.
The TPAC board voted to distribute some of EIARC's current grant to St. Mary's Respite Center, a West Philadelphia group, as well as some funding to GPUAC, to assure that EIARC's unique "in-home" respite services are maintained.
The Craig Foundation's money will be redistributed through a competitive bidding process.
TPAC's board also approved the termination of its contract with One Day At A Time's Holistic AIDS Project for failure to obtain liability insurance or fulfill 19 other provisions of its contract. ODAAT had received $12,500 to support access to holistic and natural foods for almost 400 people living with HIV/AIDS, mostly through the work of Aisha Bey, a local holistic practitioner. Bey's weekly "Natural and Holistic Healing" seminar at We The People's Life Center had been canceled by the WTP membership last year because of concerns about the validity of some of her claims.
In addition to ODAAT's failure to obtain the legally-required liability insurance for the program, TPAC staff also noted that it was unable to obtain documentation or verification for Bey on whether clients of the program were receiving the required individual counseling associated with the distribution of the foods, that a licensed physician had verified the safety of the foods, and that clients were giving informed consent to their participation in the program. Additionally, Bey was cited for failing to obtain a written evaluation of the program from the clients, maintain intake records, develop a grievance procedure and a client satisfaction survey, or fulfill requirements regarding submission of timely invoices and accurate lists of what foods were being distributed.
The TPAC board also discussed a complaint from six people living with HIV/AIDS against Unity, Inc., which receives Title II funds to provide referrals to case management services to low-income and minority people with HIV/AIDS. The PWAs has complained that Unity's Case Manager Assistant, Antwine Davis, had not participated in a support group at EIARC where, they said, he was supposed to work with the support group members to help them get case management services.
Tyrone Smith, executive director of Unity, said that Unity's TPAC contract does not require Davis to attend the EIARC support group meetings, although he confirmed that Unity and EIARC had their own agreement that his services would be available to members of the group. Davis, in an internal memorandum to Smith, had previously reported that he had attended several of the group meetings earlier last year but that the small group's meetings were sometimes canceled without his knowledge and that he assumed that the group's facilitator would contact him when his services were needed.
Smith also noted that TPAC had conducted its annual site visit and review only a few weeks ago and that no concerns were raised about Davis' performance.
The TPAC board voted to terminate the Unity contract in 15 days unless further documentation on Davis' efforts was submitted and a corrective action plan acceptable to the TPAC staff was provided.
In other action, TPAC announced that it had awarded over $150,000 in new HIV prevention grants to nine agencies. Groups receiving the new funds, for projects to be implemented before this June 30th, including The Colours Organization, Philadelphia Community Health Alternatives, One Day At A Time, the Women's AIDS Test Site, the Youth Health Empowerment Project, the Family Planning Council, ChesPenn Health Services, Planned Parenthood, and the American Red Cross.
Gene tied to delay in progression to AIDS
Researchers have found an altered gene that helps to explain why some people infected with HIV remain healthy and alive for years after their infection.In a study to be published in the journal Science, researchers at the National Cancer Institute said that alteration of a gene called SDF1 apparently helps the body defend itself against HIV.
The conclusion is based on the genetic analysis of specimens from about 3,000 HIV patients who have been followed over many years.
The researchers noted that about 5 percent of these longtime AIDS survivors had an alteration in both copies of their SDF1 genes. It was noted most frequently in patients whose HIV infection did not progress to AIDS for six to 12 years after infection.
Earlier research had revealed that long-term HIV survivors were protected by mutations in two other genes, CCR2 and CCR5. However, it takes a mutation in only one copy of the CCR2 or CCR5 gene to give protection, while both copies of the SDF1 gene must be altered to delay progression of the HIV infection, researchers said. People have two copies of most genes.
One goal of researchers is to identify how patients with these altered genes are protected from the typical rate of HIV progression. Once that mechanism is known, it is hoped that drugs can be developed to slow the disease progression in people who lack the protective gene alteration.
GMHC changes gears on HIV reporting
In a reversal of its previous position, the New York-based Gay Men's Health Crisis, the nation's largest AIDS service and advocacy organization, is calling for a system to track HIV infections in New York State, according to a GMHC press release.GMHC's change in positions takes place as the U.S. Centers for Disease Control, which maintains data on AIDS epidemiology, is pressuring states to begin requiring that all people living with HIV have their status reported to government agencies. To date, most states only require such a report when a person is formally diagnosed with AIDS.
In Pennsylvania, state officials have been debating whether to require HIV reporting. While there appears to be a general consensus both in government and in the advocacy community that such reporting would be beneficial to better understanding the epidemic -- as well as qualifying for more funding from the federal government -- there is serious contention over whether such reporting should include names and other specific information on the individuals reported, or whether some kind of code can be used that would protect the anonymity of those living with HIV.
Philadelphia's AIDS Activities Coordinating Office has said it will hold public forums on the issues involved in HIV reporting before requiring such reports in the city, although state law would probably prevail if the city attempted to come up with a different policy than Harrisburg.
"Shifts in HIV infections and new early treatment options demand new approaches," Ronald S. Johnson, GMHC spokesperson said in the organization's press release. The agency believes that the old system of reporting only AIDS cases, which was initiated in 1983, is now obsolete. "Counting only those who are hospitalized reveals yesterday's epidemic, not today's," he continued. "We are committed to fighting for a new system of tracking HIV infection with strong privacy protections that will help those most at risk: the poor, women, youth, especially gay youth, and young adults."
Although the agency did not specifically rule out name reporting, it did suggest the use of "unique identifier" system, and stressed the importance of developing an HIV monitoring system "...with strong and enforceable privacy protections to prevent discrimination against people who are HIV positive."
The agency maintains its opposition to mandatory government-run partner notification. "Our call for a new monitoring system should not become a vehicle for enacting punitive, ineffective or unrelated HIV policies," Johnson continued. GMHC also continues its support for free, publicly funded anonymous HIV testing.
Some features of the HIV monitoring system included in the GMHC position paper issued yesterday include: involvement of communities, strong privacy safeguards, evaluation of a "unique identifier" system and re-evaluation of the type of data collected by public health officials.
To date, 28 states have HIV infection reporting systems, according to an article in the January 13th edition of The New York Times. However, these states have only 24% of reported AIDS cases. New York currently has the most cases of HIV infection--69 cases per 100,000. Therefore, an HIV reporting system in New York would greatly increase the number of HIV infections in government registries.
Some believe that HIV case reporting in New York is inevitable, the Times article continued. "It will move to a system of HIV reporting and ultimately it will go to name reporting," predicts Lawrence O. Gostin of the Georgetown University-Johns Hopkins University Program on Law and Public Health. "New York is the most important state in the country in terms of the AIDS epidemic. It's a matter of time."
Study looks at improving protease drugs
The "bioavailability" of HIV-1 protease inhibitors may be increased by inhibition of the multidrug transporter P-glycoprotein, according to researchers at Vanderbilt University in Nashville, Tennessee.Protease inhibitor therapy is complicated by limited oral absorption and variable tissue distribution, Dr. Richard B. Kim and colleagues said in the January issue of the Journal of Clinical Investigation. The researchers "...hypothesized that the limited membrane permeability of HIV-1 protease inhibitors could be explained if they were substrates of P-glycoprotein and that the tissue expression of this transport may be a determinant of whether therapeutic drug levels are attained."
In the current study, they tested this hypothesis using indinavir, nelfinavir and saquinavir in an in vitro system and in a mouse model in which the mdr1a gene for P-glycoprotein was disrupted.
"All three compounds were found to be transported by P-glycoprotein in vitro." In the animal model, Dr. Kim's group observed that following "...oral administration, plasma concentrations were elevated 2-5-fold in mdr1a (-/-) mice and with intravenous administration, brain concentrations were elevated 7-36-fold."
Based on these findings, they conclude that "...P-glycoprotein limits the oral bioavailability and penetration of these agents into the brain...creating a potential sanctuary for viral replication." Therefore, it might be possible to achieve higher concentrations of HIV-1 protease inhibitors "...by targeted pharmacologic inhibition of P-glycoprotein transport activity."
In an accompanying editorial, Drs. Caroline Lee and Michael Gottesman of the National Cancer Institute in Bethesda, Maryland, discuss some of the possible implications of these findings. They point out that P-glycoprotein is also expressed in a percentage of CD4+ T cells, in monocytes and macrophages, which are primary targets for HIV-1 infection. They raise the
question of whether the "...expression of Pgp [P-glycoprotein] in these cells [could] explain the resistance of some patients to PI [protease inhibitors]."
The physicians also raise the question of whether or not P-glycoprotein inhibitors could alter the bioavailability and biodistribution of other antiretroviral drugs. Also, the addition of a second protease inhibitor drug to combination regimens could possibly alter the pharmacodynamics of P-glycoprotein, resulting in unanticipated effects.
"Whatever strategy is ultimately pursued, knowledge of the physiological role of the multidrug transporter will allow more rational approaches to the treatment of AIDS," they conclude.
State to require HIV testing for pro fighters
The Independent Regulatory Review Commission has granted the Pennsylvania State Athletic Commission permission to enforce a new regulation requiring professional boxers and kickboxers to be tested for HIV before fighting.Pennsylvania joins Nevada, Arizona, Maryland, Massachusetts, New Jersey, New York, and California in requiring testing for HIV. State Boxing Commissioner George Bochetto said the regulation was not as comprehensive as he had hoped for, but that it is a "step in the right direction."
Greg Sirb, of the State Athletic Commission, explained that athletes will have to pay for the testing themselves, but the Commission is working with public health officials to have testing offered for free. However, the free testing issue has drawn fire from Health Secretary Daniel Hoffman, who notes that the actual risk of contracting HIV during a bout is minimal and that the money used for free testing could be better used to educate athletes about the disease.
Acyclovir study questions survival benefit
In the January issue of Clinical Infectious Diseases, researchers report that -- contrary to previous research -- there appears to be no correlation between acyclovir therapy and prolonged survival in people with AIDS.Dr. Ramon A. Torres and colleagues evaluated data from the Community Program for Clinical Research on AIDS (CPCRA) observational cohort, analyzing the effects of acyclovir treatment on more than 2,300 AIDS patients over a 4-year period. The researchers found that intermittent and continuous acyclovir use actually seemed to increase the risk of death, but they warn that the results should be interpreted cautiously. The authors note that unlike randomized trials, it is not apparent why some patients received the drug therapy and others did not, and they suggest that selection bias could have affected the findings.
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