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Issue #163: February 8, 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 Cox News Service, Mayo Clinic Proceedings, Medical Tribune News, New England Journal of Medicine, Reuters, United Press InternationalCity allocates case management funds
AIDS deaths drop in city -- except for Latinos
Herpes risk tied to protease drugs
Researcher calls for 5-drug combo
Drug names said to risk errors
Rare lung condition worse for PWAs
ActionAIDS sets February wellness series
City allocates case management funds
Philadelphia's AIDS Activities Coordinating Office (AACO) has announced the distribution of over $3 million to support AIDS case management services in nine counties in southeastern Pennsylvania and southern New Jersey.About ten percent of the funding, $330,000 supports the AIDS Coalition of Southern New Jersey, which provides services in four South Jersey counties. A slightly larger amount, $347,000, was provided to five agencies serving people living with HIV/AIDS in Bucks, Chester, Delaware and Montgomery Counties.
Most of the funding was distributed in Philadelphia, with ActionAIDS receiving almost 40% of the funding available for the city, over $900,000. Other big grants include that to Blacks Educating Blacks About Sexual Health Issues ($490,000), the Philadelphia Regional Services Consortium ($208,000), Congreso de Latinos Unidos ($201,000), and North Philadelphia Health Systems ($170,000).
BEBASHI appears to be the biggest winner in the competition for funds, increasing its allocation by almost $200,000.
The Philadelphia Regional Services Consortium is a coalition of minority organizations that formerly received their funding through the Minority AIDS Project of Philadelphia. The new grant supports existing projects at the Chester AIDS Coalition, Unity, Inc., and the Southwest Philadelphia FACT Center, as well as new services at the Committee for a Better North Philadelphia. The Consortium grant also supports strengthened supervision and coordination of case management services at the agencies.
The total allocation for AIDS case management made by the city was less than in previous years, as the city has diverted several hundred thousand dollars to support a new centralized intake system for case management services, and the percentage of federal dollars available for these services was reduced by the HIV Commission. For the first time, some organizations lost all of their funding for AIDS case management services, while others faced significant reductions.
Congreso received slightly less funding than last year, and NPHS lost about 30% of its previous allocation. While exact figures were not available as fastfax went to press, it is also believed that the grant for ActionAIDS, while the largest, is still significantly less than it has received previously.
Hospital and clinic-based AIDS case management services fared most poorly in the competition for funds, with significant reductions in funding for case managers in North Philadelphia Health System's St. Joseph's Hospital and at Allegheny University's Partnership for the People program.
None of the organizations which had not previously received case management funding, but who applied for support in the city's bidding process, were approved for funding. Among those who were denied were the Jonathan Lax Immune Disorders Treatment Center and the HOPE Clinic, a North Philadelphia clinic.
Some hospital and clinic-based case managers and their clients have expressed concerns at the funding reductions in their programs, noting that it appears to contradict the consensus among people living with HIV/AIDS that integrated programs which provide both clinical and social services are the preference of most consumers of case management services. Others have criticized the hospital programs, however, claiming that most case managers in that system act primarily as discharge planners rather than provide ongoing case management services.
City officials had noted in the "Request for Proposals" issued when the funding was made available that organizations which had contracts with health maintenance organizations and other insurers would be expected to maximize reimbursement from those sources rather than relying on AACO funds.
City officials had sought to increase support for minority AIDS organizations through this allocation, following guidelines adopted by the Philadelphia HIV Commission. About 40% of the total funding supports organizations defined as "minority community organizations" by the city's definition.
As the epidemic has spread to an increasingly low-income and minority clientele, most AIDS case management services in both the city and the suburbs now have a high percentage of clients of color.
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AIDS death rates decline in city -- except for Latinos
Philadelphia's AIDS Activities Coordinating Office has reported that the rate of death from AIDS has dropped in the city, declining 24% in 1997 as compared to 1996.The decline is significantly slower in Philadelphia than nationally, where death rates for the same period dropped 44% in the first six months of last year, according to the U.S. Centers for Disease Control.
In Philadelphia, death rates among African Americans dropped the fastest, declining 27%. Among whites, the rate was 23%, and among Latinos, only 1.6%. Latino AIDS advocates say that access to new AIDS treatments is much more difficult among Puerto Ricans and Latinos, because of the lack of expertise of many doctors serving their communities and language obstacles, which delays the benefits of AIDS treatment advances for their communities.
''The very favorable trends we are seeing appear to us to be very much the result of improved treatment,'' said Dr. Harold Jaffe, director of AIDS laboratory research at CDC. ''We have very little evidence that it is due to improved prevention.''
Terry Hammond, an HIV prevention specialist at the Centers for Disease Control and Prevention (CDC) in Atlanta, said that "the numbers of deaths from AIDS are decreasing, the number of new cases of AIDS are decreasing, but about 40,000 new HIV infections occur each year."
In a report to the 5th Conference on Retrovirus and Opportunistic Infections in Chicago, Dr. Kevin De Cock said that nationally, deaths from AIDS fell from 21,460 in the first six months of 1996 to 12,040 deaths in the first half of 1997 -- a 44 percent drop.
"We are at a very special moment in the epidemic of AIDS in the industrialized world," De Cock said. "A new era in the AIDS epidemic has become apparent." However, he says, the epidemic still remains rampant in the developing world where 90 percent of AIDS cases exist.
Dr. Mary Ann Chiasson of New York City's Department of Health reported that 7,000 people died of AIDS in 1995; that dropped to 5,000 in 1996 and has tumbled to 2,600 in 1997.
In New York City, the survival time after an AIDS diagnosis has increased from 14 months in 1989 to 29 months in 1994, bracketing the time when protease inhibitors became available, Chiasson said. And across the country, those who were receiving triple-drug therapies with protease inhibitors had an 86 percent lower risk of death from AIDS than those who had not received any drugs, according to Dr A.D. McNaughten of the CDC.
Despite the excitement due to the 64 percent decrease in AIDS deaths in the two-year period, the number of people living with AIDS in New York City has increased from 32,000 to 36,000 and an estimated 10,000 new HIV infections occur each year in the city.
De Cock says the decreases in mortality are almost exclusively the result of better treatments, and urges more work in preventing infections, especially targeting young men and minorities when AIDS continues to exist at disproportionate levels.
Meanwhile, CDC officials are using the new numbers to renew the agency's call for national tracking of HIV infections, saying that surveillance is about to lose sight of trends in the 17-year epidemic.
The CDC said that deaths from AIDS have always been the chief statistical yardstick to track the epidemic, because the percentage of those infected who developed AIDS, and the percentage who died, were relatively constant. With infected persons holding off symptoms for longer periods and those with AIDS living longer lives, the yardstick has warped, the CDC says. They say a new measure -- a direct count of new HIV infections -- is needed instead.
''Our ability to monitor this epidemic is remarkably weak compared to what it was a few years ago, because of these encouraging developments,'' De Cock said. ''I see real urgency about getting HIV reporting organized at the national level. And because the U.S. is closely watched by other countries, what happens over the next 12 months in this area will have international implications as well.''
Whether to move to uniform HIV reporting is a nationally contentious issue. More than half the states now report infections in some form, but states with the biggest HIV-positive infections - including New York, California and Georgia - do not. Activists have expressed fears that confidentiality breaches will imperil a reporting system based on names of people with HIV, while the CDC has claimed that alternate systems, using ''unique identifiers,'' are not reliable. CDC has not specified how reporting should be done.
Philadelphia's AIDS Activities Coordinating Office will hold two public meetings in March to hear views on whether or not to require that doctors, laboratories and hospitals report individuals who test positive for HIV.
Pennsylvania health department officials are still weighing the pros and cons of requiring HIV reports, as well as whether the reports would be made with the names of those infected or a code to protect their identities. Harrisburg's decision on these issues will be applicable to all local health departments in the state, including Philadelphia's.
Herpes risk tied to protease drugs
Spanish physicians alerted colleagues to a high incidence of herpes zoster in HIV-positive patients after they begin protease inhibitor therapy, in a poster shown at the 5th Conference on Retroviruses and Opportunistic Infections.Dr. E. Martinez and others at the Hospital Clinic in Barcelona noticed this apparent effect and collected prospective data to see if it held true. They followed 193 patients with AIDS after a protease inhibitor was added to their antiretroviral regimen. After a median follow-up of about 8 months, 13 patients (7%) had an episode of herpes zoster. This occurred in 11 of these patients within the first 8 weeks of protease inhibitor therapy.
The clinicians noted that the manifestations were usually milder than might be expected in patients with AIDS. Nonetheless, in their display they suggested "...it could be clinically useful to consider transient prophylaxis for these patients at high risk."
Researcher calls for 5-drug combo
The rate of HIV elimination can be improved with the use of 5-drug antiretroviral combinations, Dutch researchers said at the 5th Conference on Retroviruses and Opportunistic Infections.Dr. Frank de Wolf of the University of Amsterdam and colleagues assessed serum HIV RNA levels in 59 treatment-naive patients over the 2 weeks following initiation of therapy. Of these patients, 15 were given zidovudine, lamivudine and ritonavir; 35 received stavudine, lamivudine, nelfinavir and saquinavir; 9 took zidovudine, lamivudine, abacavir, indinavir and nevirapine. Standing by his poster exhibit, Dr. de Wolf said that compliance in all groups was good.
The mean slope in the decline of HIV RNA in the first week was -0.44 in the 3-drug group, -0.37 in the 4-drug group, and -0.60 in the 5-drug group. The decline was significantly more rapid with 5-drug treatment. The asymptomatic level reached at 12 weeks was similar in all groups and depended on initial viral load.
"Whether a multidrug regimen is more effective than the standard 3-drug combination depends on what you mean by effective," Dr. de Wolf commented. Clinical outcomes were not assessed in the study, which covered just 12 weeks of treatment. "The initial decline in RNA is probably important, because slower elimination can lead to sanctuaries in which virus is more or less persistent or more or less crippled."
The detection limit in the study was 50 copies/mL. "What we should do now is look at levels below 50 copies," Dr. de Wolf said, and he hopes to present that data in Geneva at the 12th International AIDS Conference.
Drug names said to risk errors
Physicians from Cook County Hospital in Chicago say that the similarity in both the generic and trade names of two antiretroviral drugs for HIV infection create a substantial potential for drug-dispensing errors.The two drugs, nevirapine (Viramune) and nelfinavir (Viracept), are also available in similar tablet strengths, 200 mg and 250 mg, respectively.
In a letter published in the February 5th issue of the New England Journal of Medicine, Drs. Blake Max and Nike Mourikes describe two HIV-positive patients seen at their hospital within a 2-week period who encountered this problem.
The first patient, who had a prescription for nelfinavir, a protease inhibitor manufactured by Agouron Pharmaceuticals, noted a discrepancy in the name of the medication between the dispensed bottle and the label. The pharmacy had mislabeled a bottle of nevirapine as nelfinavir. The error was detected before the patient took the drug.
However, the error in the second patient, who had been prescribed stavudine, lamivudine and nelfinavir, was not detected until she developed severe fatigue, hypersomnia and nausea. The symptoms stopped when the drugs were discontinued. It was subsequently discovered that she was given nevirapine, a non-nucleoside inhibitor manufactured Roxane Laboratories, instead of nelfinavir.
The authors caution physicians and pharmacists to be "...particularly careful when prescribing, transcribing prescriptions for, and dispensing nevirapine and nelfinavir in order to prevent potentially serious adverse drug reactions or subtherapeutic dosing."
These two medication errors were unfortunate, Dr. Kirk V. Shepard of Roxane Laboratories replied in a comment to the editor. However, while the names may be confused, he points out, there are distinctive differences in the product labels, the appearance of the tablets and the packaging.
"Regardless of the steps taken to reduce medication errors, dispensing mistakes...do occur," he said. In the meantime, Roxane plans to continue its participation in programs to reduce medication errors. Although offered the opportunity, Agouron Pharmaceuticals declined to reply to the Journal letter.
Rare lung condition worse for PWAs
A condition marked by high blood pressure in the lungs can take a particularly harsh toll on people infected with HIV, according to a new report.This kind of high blood pressure, commonly associated with liver disease, is caused by a narrowing of major blood vessels in the lungs. In people not infected with HIV, the condition leads to death within a year about a third of the time.
But a review of 88 cases of HIV-infected people with pulmonary hypertension found that a much higher proportion of the patients in this population, almost half, died within a year of developing the condition.
Of the cases assessed by researchers at the Mayo Clinic in Rochester, Minn., 83 percent were directly linked to HIV infection and not to other chronic diseases of the lung or liver, or intravenous drug use - all risk factors for the condition.
And three-fourths of the 38 fatal cases included in the analysis died directly from complications arising from pulmonary hypertension, according to the study. The researchers concluded that when the condition is associated with HIV infection, it seems to follow a much more damaging course.
"If blood pressure rises in the lungs," said Dr. Dava Klirsfeld, director of the AIDS program at Bellevue Hospital in New York, "the weaker, right side of the heart has to pump much harder to work against the resistance. The blood vessels to the lungs get congested and fluid and blood get backed up so that oxygen-rich blood doesn't get pumped out to the rest of the body as well as it should."
The researchers warn in their report, published in the January issue of the journal Mayo Clinic Proceedings, that as new treatments prolong the lives of HIV-infected people, pulmonary hypertension, which is typically rare, will become increasingly common in such patients.
Its manifestation in the absence of AIDS, according to Klirsfeld, is more common in women than in men. A wide and seemingly unrelated range of diseases can lead to high blood pressure in the lungs, but the exact mechanism of the disease remains a mystery.
This kind of high blood pressure is usually diagnosed when patients visit the doctor with lung infections, said Klirsfeld.
"HIV-infected people should tell their physicians when they start having a persistent shortness of breath or a reduction in their exercise capacity, or if they develop a...swelling in their legs," she suggested. "But remember, it is a very rare occurrence, not something we expect to see very much of and it's not an under-diagnosed condition."
While the prognosis of the disease is dismal, there are some drug treatments that seem to work some of the time. "There are some people who seem to improve with calcium channel blockers, and others who respond well to treatment with blood-thinning drugs like warfarin and heparin," she said. "More recently, it's been found that a natural substance produced by the body, prostacyclin," which widens arteries and blocks clotting, "may also help," she added.
ActionAIDS sets February wellness series
ActionAIDS has announced its February series of workshops and classes which are part of its "Maintaining Wellness Series."This month's offerings include:
"Qi Gong Series" - "Qi Gong: any training or study dealing with Qi (energy) which takes time and effort to develop." How can you have more energy, shake off depression, and decrease some of those aches and pains? Qi Gong! This class is powerful! Try it out! Then tell us how you feel. Daily practice gives the best results.
Monday, February 2, 9, 16, 23*, @ 6:00 -- 8:00 P.M. ( * = see front desk for location)
Reiki Sharing: Come experience a Reiki Treatment! Reiki is a form of healing energy used to promote wellness. This "laying on of hands" technique will cause deep relaxation, decrease anxiety, pain, and stress.
Thursday, 12, 19, 1998 @ 6:00 p.m.- 7:30 p.m.
Meditation Practice: You can have more peace of mind, enhance your immune system, and nurture your creative self. Regular daily time outs of meditation and stretching have been proven to provide the above mentioned results.
Tuesday, 3, 10, 17, 1998 @ 5:30 - 7:30 p.m.
"Unlimited Power -- Tapes #13-17
How much does the way you think impact your life experience? A whole lot! This $200.00 tape series is available for your listening education free of charge. Relax, Listen and learn. Anthony Robbins is the best selling author of "Unlimited Power," and other success focused technology.
These educational forums are for anyone living with HIV or AIDS, and participants do not have to be an ActionAIDS client. All workshops are participatory with pre-registration required. For more information or to pre-register call Kevin D. Greene, ACT Program Coordinator, at (215)981-3330, 1216 Arch Street, 6th Floor, Philadelphia, PA 19107.
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