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Issue #181: June 14, 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 articles in this issue include AIDS, AIDS Treatment News, New England Journal of Medicine, Philadelphia Inquirer, Reuters.TPAC cuts HIV testing funds in Bucks County
Needle exchange demo confronts Clinton at UN
Sustiva shows strong anti-HIV effect
Vaginal suppositories linked to HIV transmission
Study links homelessness to higher medical costs
TPAC cuts HIV testing funds in Bucks County
Bucks County advocates say that The Philadelphia AIDS Consortium (TPAC) has deeply limited access to HIV testing, especially for "high-risk" women, while at the same time increasing funding for programs that encourage it.Planned Parenthood of Bucks County has added its name to the growing list of advocates and organizations complaining at the way in which TPAC has allocated almost $2.7 million in AIDS service funding awarded by the state and federal governments. TPAC serves as the "planning coalition" for the state in distributing AIDS funds from the Pennsylvania Health Department and through Title II of the Ryan White CARE Act.
The Bucks County group's complaints follow an announcement that Latino PWAs intend to sue TPAC and the state because of a similar decision, which prohibits Latino PWAs from receiving state-funded primary medical care or case management services.
Planned Parenthood, which says it has offered HIV counseling and testing services to over 3000 people since it began the program with TPAC funds in 1995, charged that TPAC's emphasis on racial categories in determining who gets funded has resulted in an "irrational" distribution of resources in Bucks County, which has only a small population of people of color, and where the AIDS epidemic is overwhelmingly concentrated among white gay men.
Several weeks ago, TPAC withdrew an annual $32,000 grant to Planned Parenthood in favor of a $44,000 grant to Family Service Association of Bucks County to do AIDS education and outreach in the county's small African American community. A priority for the AIDS education effort is to encourage people to get an HIV test, at the same time as TPAC is eliminating the county's largest HIV testing program.
Planned Parenthood told the Philadelphia Inquirer that the county's HIV testing program would probably be closed by the end of the month. People seeking testing will still be able to get it at some state health clinics and through private doctors and hospitals, however.
Larry Hochendoner, executive director of TPAC, said that the allocations decisions were based on a priority set by the TPAC planning council to concentrate funding in the communities hardest hit by the AIDS epidemic. Overall in the Philadelphia region, over 70% of AIDS diagnosed cases are African American or Latino.
"The dollars follow the epidemic," Hochendoner told the Inquirer in an article published June 10th. "All we're attempting to do is make sure we're getting to the most-affected communities."
Linda Hahn, executive director of Bucks County Planned Parenthood, argued that such a strategy does not make sense in Bucks County, where more than 95 percent of the population is white and less than 3 percent is black, according to 1990 census figures. Her complaints echo concerns expressed by county AIDS advocates for many years that Philadelphia-based AIDS planning processes are not cognizant of the different realities of the epidemic in outlying areas.
Of the 520 people reported to have full-blown AIDS in the county since 1982, 82 percent have been white; 11 percent have been black, according to the Bucks County Health Department. Hochendoner did not comment on why the Bucks County allocations were based on the regional distribution of AIDS cases rather than on that of Bucks County itself.
People with AIDS who participated in TPAC's planning committees said they were never informed of the demographic breakdown of AIDS cases in the various counties when they were asked to set priorities for the state funding.
The dispute highlights growing complaints from a broad base of AIDS service organizations and people living with HIV/AIDS about what they call a lack of coordinated planning for the distribution of AIDS dollars in the region. Philadelphia Health Commissioner Estelle Richman has complained that TPAC has refused to work collaboratively with the city health department, which distributes over $18 million in city, state and federal AIDS funds, to assure that funding is awarded in ways which address existing service gaps and avoid creating new ones. TPAC's Hochendoner refused to meet with city officials when asked by the state health department, according to Richman.
In response to complaints that TPAC's decision will, in effect, reduce options for Bucks County residents seeking anonymous HIV testing, Hochendoner said that TPAC has not decided to exclude any group from testing services. He did not comment on where Bucks County residents can go for "anonymous" testing, however, since the few other testing sites all require that the client reveal their name and information about their risk behavior and sexual and drug use partners. Numerous studies have shown that those most at risk of HIV infection are much more likely to get tested if they can remain anonymous.
While Hochendoner said that TPAC did not intend to exclude testing options for people, Latino people living with HIV/AIDS in Philadelphia, along with several community organizations, are developing a federal lawsuit against TPAC for specifically excluding Latinos from access to case management and primary care services supported by state or Title II funds.
TPAC's decision to award funding only in certain service areas, and limit which racial group can get state-funded services, is the first time in the Philadelphia area's contentious AIDS allocations process that such distinctions have been made. Traditionally, while racial categories have been set in terms of target populations, TPAC's allocations represent the first attempt to enforce a policy which says that certain population groups can get some services and not others.
Alba Martinez, an attorney and director of Congreso de Latinos Unidos, has said that TPAC's policy is an "obvious" violation of federal civil rights protections that will be overturned once the courts get involved.
Hochendoner said that the funding priorities were developed after consultation with people living with HIV/AIDS, who, he said, set the specific priorities and amounts allocated to each service area. He noted that there were three public meetings with Latino people with HIV as well as one all-day meeting with African American PWAs to set the funding standards. The conduct of those meetings and the information provided have been severely criticized, however.
Those priorities resulted in few historically black or Latino AIDS organizations being funded through TPAC's process, including the elimination of TPAC's only programs for gay people of color and the closure of the only full-time AIDS service site in Southwest Philadelphia, which has the highest per-capita concentration of people with AIDS in the region.
Other cutbacks made by the city's AIDS Activities Coordinating Office (AACO), which also cites consumer input as its reason for re-allocating AIDS funds, have severely reduced AIDS case management services for Latinos and reduced the availability of primary medical care for uninsured people in the region. Critics of both TPAC and AACO said that most of the cuts could have been averted if there was better coordination of planning and allocations processes between the two groups. AACO and TPAC each blame the other for the collapse of a joint planning agreement they reached last year.
Advocates have also complained that TPAC is attempting to characterize the latest disputes as "sour grapes" from providers who lost funding in the process, rather than a debate on how the AIDS system is designed to serve those most in need of publicly-funded services. "This isn't about any specific grant or decision," said David Fair, a former TPAC treasurer and the founder of AACO. "It's about a process that has gotten so far removed from the realities of people with AIDS that it isn't working any more for the most needy PWAs, especially for those who don't spend their time playing downtown politics with the AIDS bureaucrats."
Others have criticized TPAC's planning process as superficial and manipulative of people with HIV/AIDS. Despite pledges to provide a year-long training program for those participating in its priority-setting process, TPAC instead held information sessions just prior to the deadline for the priority decisions, and asked consumers to make decisions on priorities immediately thereafter. Most PWAs who participated in the meetings, when contacted by fastfax, said they did not clearly understand that their opinions would be utilized to eliminate whole service categories for certain populations based on their race.
"TPAC says that the priorities set for Latinos are appropriate because 'Latino consumers made the decisions," Martinez told fastfax. "This is not fair to the consumers, because it implies that they have only themselves to blame if the decisions are bad. As the conduit of funds and the recipient of substantial administrative dollars to manage this process, TPAC is responsible and accountable for ensuring the consumers are well-informed, and that they have the necessary tools to make decisions."
Martinez said that the planned federal lawsuit will target TPAC and its staff for the decisions, not the consumers who TPAC convened to make decisions. "TPAC's argument that consumers set their own priorities cannot shield them from responsibility," she said, noting that many of those who participated in TPAC's process are being recruited to join the lawsuit. "TPAC cannot violate federal antidiscrimination laws whatever excuse it might have," she said. "TPAC cannot discriminate, and no group of individuals to whom they delegate decision-making power can do so either, especially if TPAC failed to inform them of the implications of their actions."
Martinez noted that she had been told by both AACO and TPAC representatives that Congreso should be satisfied because it still received "a lot of money" in the recent round of AIDS funding decisions. Congreso received the largest AIDS prevention grant in the city from AACO and an increase for its food programs from TPAC.
"We're apparently speaking a different language," Michael Hinson, executive director of The Colours Organization, which faces a major reduction in the TPAC's only AIDS programs for black gay men, told fastfax. "The bureaucrats talk about contracts and money, but what we're talking about is what PWAs need. This isn't about 'deals' among AIDS politicos. It's about creating an AIDS service system that makes sense for real people."
Needle exchange demo confronts Clinton at UN
Over a thousand demonstrators marched down 42nd Street to the United Nations in New York City last week to demand federal funding for needle exchange programs to prevent HIV among intravenous drug users.The marchers, who snarled the mid-town rush-hour traffic, charged that President Bill Clinton's refusal to lift the ban on federal funding for needle exchange programs would result in tens of thousands of new AIDS cases in the United States. Clinton was at the United Nations to speak at a conference on International Drug Control Policy, seeking international support for his "War on Drugs."
The protesters carried 33 coffins, some of them child-sized, to signify the number of HIV infections resulting every day from Clinton's policy. A giant puppet of President Clinton as the grim reaper complete with black robe and bloody hands, accompanied the marchers. Some demonstrators wore targets signs symbolizing that they are the "collateral damage" in the presidents "drug war."
Marvin Crawford, an HIV-positive veteran, who is also president of We The People, said he was infected from sharing syringes. Crawford compared the President's syringe ban to the infamous experiment conducted by the Tuskegee Institute, which allowed hundreds of African-Americans infected with syphilis to remain untreated.
"Needle exchange is Clinton's Tuskegee," Crawford charged. "The President knows what he has to do to save lives, but he won't do it. Because of him, thousands of people will be infected, most of them people of color. Clinton's 'War on Drugs' is really a war on poor and minority communities."
On April 20, Health and Human Services Secretary Donna Shalala informed Clinton that scientific research has proven that needle exchange programs effectively prevent the transmission of HIV and hepatitis, and do not lead to increased drug use. Her long-awaited action cleared the way for the President to lift the ban on federal funding for sterile syringe programs. Clinton accepted the findings, but stated that in spite of them he would continue to block the use of federal funds for needle exchange programs.
HIV prevention advocates charge that the President's decision is politically motivated and will cause tens of thousands of new and preventable HIV infections by the year 2000.
"Clinton says he is worried about sending the wrong message to kids," said Chris Lanier of the National Coalition to Save Lives Now, which advocates for access to clean needles for IV drug users. "But the message he's sending now is that it's okay to let people who use drugs get AIDS, it's okay to let their kids be orphaned, it's okay to let their communities be devastated by HIV. Well, we're here to say it's not okay. Clean needles save lives, and those lives are precious."
Sustiva shows strong anti-HIV effect
Six HIV-positive people taking the DuPont Merck's investigational non-nucleoside reverse transcriptase inhibitor (NNRTI), Sustiva (efavirenz), in dual and triple combinations, achieved HIV-RNA levels in plasma and cerebrospinal fluid (CSF) below the level of detection (less than 400 copies/mL).The results were presented by Dr. Karen Tashima and colleagues at The Miriam Hospital, Brown University, Massachusetts General Hospital, Harvard University and DuPont Merck at the eighth annual Neuroscience of HIV Infection, Basic Research and Clinical Frontiers meeting, sponsored by Northwestern University Medical School.
CSF drug levels and HIV-RNA were measured in these individuals who took Sustiva in a combination either with AZT and 3TC, or with Crixivan (indinavir), for a mean duration of 26 weeks.
"We are encouraged that these early results show Sustiva, in combination with other agents, suppresses HIV replication in the CSF," said Tashima, assistant professor of medicine at Brown University. "Since not all antiretrovirals cross the blood-brain barrier, the ability to control viral replication in the CSF will become increasingly critical when constructing durable combination treatment regimes."
Sustiva is currently in development as a once-daily treatment.
Sustiva is generally well tolerated; side effects include rash, nausea, dizziness, diarrhea, headache and insomnia. Severe rashes have been reported in fewer than one percent of patients. Pregnant women should not take this new medication, which is available through a clinical trial, unless the benefit to the mother clearly outweighs the potential risk to the fetus.
Meanwhile, treatment activist John S. James, who publishes the weekly AIDS Treatment News, has reported that people taking both efavirenz and saquinavir should know that the combination can reduce the plasma level of saquinavir by about 60% -- "which will likely result in under dosing of the protease inhibitor," James said.
DuPont Merck, the maker of efavirenz, "strongly urges patients taking Sustiva with Fortovase to talk to their physicians about changing their regimens."
Currently efavirenz is not marketed but is available through clinical trials or through an expanded access program. The company has sent detailed information to physicians in those programs.
Vaginal suppositories linked to HIV transmission
Policresulen vaginal suppositories, which are used to treat vaginitis, cause mucosal disruption that may facilitate HIV transmission, according to a report in the May 7th issue of the journal AIDS.There has been much concern recently about "...exogenous factors that may disrupt the genital mucosa and thereby facilitate sexual transmission of HIV," according to Dr. Peter H. Kilmarx of The HIV/AIDS Collaboration in Nonthaburi, Thailand, and colleagues at the Centers for Disease Control and Prevention in the US.
In the current study, Dr. Kilmarx's team surveyed 200 female commercial sex workers in Thailand. The researchers found that 32% of the women reported using policresulen vaginal suppositories in the past year, and 46.5% reported ever using them. "Many used them for reasons not listed on the package insert, such as improving their male partners' sexual pleasure, and most did not abstain from vaginal sex following use."
Dr. Kilmarx's team also evaluated the effects of a single self-administered policresulen vaginal suppository in six women. All of them experienced exfoliation of the vaginal and cervical mucosa after suppository use. In three who were HIV-positive, they also noted an increase in genital HIV-1 shedding after suppository use. However, they add that this shedding may have been the result of repeated examinations.
Despite the fact that no epidemiologic link between suppository use and HIV infection was found, "...policresulen vaginal suppository use did disrupt the genital mucosa and therefore may have the potential to facilitate HIV transmission."
The Thai Food and Drug Administration has suspended over-the-counter sales of these suppositories, and they can be obtained only by prescription from hospitals. Dr. Kilmarx's group suggests that drug licensing authorities re-evaluate the safety of this product, which is also available without prescription in the US.
"If the product continues to be distributed, steps should be taken to limit its use to the specific conditions for which it is indicated and to ensure that women abstain from vaginal sex following its use."
Study links homelessness to higher medical costs
A chronic shortage of affordable housing is leading to extended hospital stays and large medical expenditures for America's homeless ill, researchers report."Homelessness is associated with substantial excess costs per hospital stay," concludes a study led by researchers at the New York City Health and Hospitals Corporation. Their findings appear in the June 11th issue of The New England Journal of Medicine.
Experts believe changes in government policies toward both low-income housing and the care of the mentally ill, along with the rising incidence of substance abuse, are contributing to the growing population of homeless Americans, estimated at over 500,000 in 1987.
The New York City study evaluated the discharge records of nearly 19,000 homeless patients admitted to area hospitals during 1992-1993, comparing their stay periods and expenses to those of nearly 384,000 low-income patients who had homes.
"The homeless patients stayed an average of 4.1 days per hospital stay, or 36% longer, than the other patients," the researchers report. Overall, this extra length of stay cost the public health care system an average of $2,414 per homeless patient. Additional costs for homeless patients with certain conditions (such as psychiatric disorders or AIDS) were pegged at higher amounts ($4,094 and $3,370, respectively).
Why are the homeless discharged from hospitals later than other patients? The researchers explain that the courts now mandate that all homeless psychiatric patients suffering from mental illness be discharged into a supportive environment. "However, because of a shortage of supportive housing in the city and the continued downsizing of state psychiatric hospitals, this process can be delayed for months," the researchers contend.
The situation is just as bad for other homeless patients, largely due to severe overcrowding (especially in winter) in city shelters and the continuing decline in the number of inexpensive low-rent rooming houses.
"As a result," the authors say, "some homeless patients are kept in hospitals until beds in shelters become available."
They say efforts to trim state and city housing budgets are backfiring as health expenditures climb skyward. "Seventy days in a general-hospital psychiatric unit, even at a rate of $250 per day for subacute care, costs $17,500," the researchers point out, "whereas a unit of supportive housing with social services for an entire year costs $12,500 in New York City."
In his accompanying editorial, Dr. Paul Starr of Princeton University in Princeton, New Jersey, says the subsidization of existing housing for the homeless (and those at risk for homelessness) is only part of the solution.
He suggests an increase in the minimum wage, along with a relaxing of government regulations regarding the construction of cheaper housing, as two possible means of providing marginal populations with options away from a life on the street.
"In the case at hand," Starr writes, "we continue paying to put the homeless in hospital beds while not providing them with ordinary beds of their own."
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