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Issue #190: August 16, 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, American Journal of Public Health, Congressional Record, Disability Law Compliance Bulletin, HIV Update, Journal of the American Medical Association, Physician's News Digest, Reuters.Half of IDUS don't get HIV treatment: study
Study says 5-drug combo better
Judge allows ADA insurance claim
House gets federal HIV reporting bill
House approves mandatory prison testing
More prison AIDS programs needed: U.S.
Study notes dangers of anal sex for women
GALAEI launches transgender safer sex kit
Half of IDUS don't get HIV treatment: study
Two studies by researchers at the Johns Hopkins School of Public Health and the University of British Columbia in Canada have shown that roughly half the HIV-infected injection drug users studied who were eligible for lifesaving antiretroviral therapy were not receiving it.Both reports appear the Journal of the American Medical Association.
One of the studies, conducted by researchers at the Johns Hopkins School of Public Health, has shown that only half of HIV-positive injection drug users in Baltimore were receiving proven HIV therapies, even though many were no longer using illicit drugs.
A companion study by researchers at the University of British Columbia and Center for Excellence in HIV/AIDS found that 60 percent of HIV-positive injection drug users were not receiving any antiretroviral therapy, despite universal health care and the availability of free HIV therapies in Canada. On average, the HIV-positive drug users in Vancouver had been eligible to receive free HIV therapies for over a year.
Correct use of double or triple combinations of proven antiretroviral therapies can prolong life and reduce levels of HIV in the bloodstream. However, some doctors believe that these costly medications should not be prescribed to HIV-infected persons who may not be able to adhere to their complex treatment regimens.
"What this shows is that universal health care does not necessarily mean universal access to HIV antiretroviral therapy," said lead author of the Vancouver study, Steffanie Strathdee, Ph.D., who has since joined the Johns Hopkins School of Public Health as associate professor of epidemiology. "Ninety percent of all HIV-infected persons live in developing countries, where there is often no access to these therapies. "Our studies show that even in North America, the best HIV treatments are not reaching those who need them the most."
"The trouble is, former addicts in stable living situations are also being denied this therapy," said lead author of the Baltimore study, David Celentano, ScD, professor of epidemiology, Johns Hopkins School of Public Health. "Clinicians may be thinking, 'Once an IDU, always an IDU' and therefore they withhold proper therapy to these patients."
According to the authors of the Baltimore study, investigations have shown that prior drug users, once they are in recovery and have stopped injecting illicit drugs, can comply with complex medication regimens just as faithfully as those who have never touched illicit drugs.
The Baltimore study involved a total of 404 HIV-infected active and former injection drug users. Half reported no recent antiretroviral therapy, with most former addicts reporting no use of triple combination therapies that include a potent protease inhibitor. In contrast, the majority of drug users studied in Vancouver who were receiving HIV therapy were receiving double or triple combination therapies that are in agreement with current international guidelines.
In the Vancouver study, female drug users were half as likely to receive HIV therapy as males, while drug users not enrolled in drug or alcohol treatment programs were three times less likely to receive HIV treatment. Most striking was the fact that drug users who had physicians with the least experience treating HIV infection were five times less likely to receive therapy.
The authors recommended that delivery of HIV therapies be expanded to all HIV-infected persons who meet recognized international guidelines. They called for increased supports from drug abuse treatment programs, economic assistance programs and prisons to help HIV-infected persons access and adhere to complex HIV regimens. Since continued injection drug use complicates access to HIV treatments and adherence, the investigators believed it crucial that HIV infection and substance abuse are treated simultaneously. They also urged for enhanced education oriented towards physicians and drug users to improve utilization of these lifesaving treatments.
Study says 5-drug combo better
HIV-1 RNA load can be suppressed to below detectable levels (50 copies per milliliter) more rapidly using a five-drug combination regimen than using a three-drug antiretroviral regimen, which is considered the standard of care, according to Dutch researchers.In a preliminary report, Dr. Joep M.A. Lange of the University of Amsterdam and colleagues evaluated the efficacy of a three-drug regimen in 15 subjects with the efficacy of a five-drug regimen in 9 subjects. All participants had 10,000 or more HIV-1 RNA copies per milliliter at baseline.
Dr. Lange's findings, which include data at 12 weeks, appear in the July 30th issue of AIDS.
Patients on the three-drug regimen received two nucleoside analogues (zidovudine and lamivudine) and a protease inhibitor (ritonavir). Patients on the five-drug regimen, eight of whom were antiretroviral naive, received zidovudine, 3TC, abacavir, indinavir and nevirapine. The ninth subject received a comparable five-drug combination, but instead of zidovudine and 3TC, stavudine and ddI were administered.
Dr. Lange's team found that viral suppression to less than 50 copies per milliliter was reached by a median of 4 weeks among patients on the five-drug regimen, while those on the three-drug regimen took a median of 12 weeks to reach this level.
They suggest that this more rapid decline in viral load "...will translate into more durable suppression of viral replication." And this may also be "....of particular relevance to patients with a very high plasma viral load who initiate antiretroviral therapy."
Whether or not this five-drug regimen can eradicate the virus is still unknown, they point out. However, they believe "...it makes sense to hit the virus as hard as possible in eradication attempts."
The investigators suspect that the findings would also be applicable in protocols involving induction therapy followed by maintenance therapy. "One would not like to conclude wrongly that a maintenance therapy will not work because a suboptimal viral regimen was used in the induction phase," they explain.
In any case, Dr. Lange's group concludes that triple-drug treatment does not "...represent the zenith of anti-HIV activity."
Judge allows ADA insurance claim
A federal district judge in Illinois refused to dismiss an ADA claim against an insurer whose health insurance policies provide significantly lower lifetime benefits caps for the treatment of AIDS and its related conditions, according to the Disability Compliance Bulletin. At issue was whether Title III of the Americans with Disabilities Act, which prohibits discrimination, reaches the contents of insurance policies. The Bulletin reports that the court looked at the statute's plain language, its applications in other cases, and the legislative history and determined that a broader interpretation of its scope was intended by Congress. In its ruling, the court found that the content of insurance policies issued by insurers constitutes "goods or services" to which all persons are entitled "full and equal enjoyment."The two HIV-positive plaintiffs in the case, Doe v. Mutual of Omaha Ins. Co., claim they were denied equal opportunity coverage by being assigned lower lifetime maximum benefits than policyholders with non-AIDS related medical conditions. Mutual of Omaha's policies set significantly lower coverage limits for AIDS and AIDS-related conditions than it does for other illnesses. In response, Mutual of Omaha presented a "tertiary" defense. First, it claimed it was protected under ADA's "safe harbor" provision. Second, it claimed that ADA interfered with a state's 10th Amendment right to "regulate the insurance industry." Third, it contended that different types of disabilities warrant different levels of lifetime coverage. The court rejected all three claims.
House gets federal HIV reporting bill
U.S. Reps. Gary Ackerman (D-NY) and Tom Coburn (R-OK) have introduced the "HIV Partner Protection Act of 1998," which may see committee action as early as September.The legislation mirrors a recently enacted New York notification law, and requires states to track the names of those who test positive for HIV and to notify individuals whose past or current partners tested positive for HIV.
The bill comes as AIDS activist groups have criticized the U.S. Centers for Disease Control for attempting to "force" states which do not require HIV name reporting to implement such programs as a condition of continuing t get federal AIDS education funds. While most activists are not opposed in concept to HIV reporting, they object to recording the names of those reported, since federal funds are not generally available to assure that those identified are able to get quality medical care.
Many activists have proposed testing various models for reporting that assign a "unique identifier" to the person with HIV, which they say will meet the CDC's epidemiological goals while protecting the anonymity of those who test HIV+.
Pennsylvania's health department is expected to require HIV name reporting in the state soon. New Jersey has required HIV name reporting for several years without major protest or incident.
Sponsors of the bill, H.R. 4431, say it is intended to help medical epidemiologists track the spread of the virus. In a statement, Coburn said, "While every state is required to have a procedure to notify those who may have been exposed, only 30 states have enacted HIV notification laws, and most do not mandate a duty to notify."
The legislation "essentially requires two steps," he said. "The first is to counsel all infected individuals about the importance of notifying their partner or partners that they may have been exposed. The second is for their doctor to forward the names of any partners named by the infected person to the Department of Health where public health staff complete the notification." Coburn said he believed that partner notification programs have proven "highly effective" and did not lead to less voluntary testing.
Coburn noted that partner notification programs have been in place "for over fifty years" for other contagious diseases, and the shroud of secrecy surrounding HIV/AIDS has contributed to the "unnecessary" deaths of "nearly 400,000 Americans." Coburn said, "We do, however, know enough about the virus to prevent its spread, but the response of the federal government and the public health community has contributed to the growth of the epidemic. ... Due to the unfair stigmas associated with the populations most at risk, it was decided that HIV would be treated as a civil rights issue instead of a public health crisis. As a result, our response has been based almost exclusively on the rights of those infected to the detriment of the uninfected."
Coburn said that the legislation has already received the support from groups such as Beyond AIDS, Women Against Violence, the Medical Institute of Sexual Health, the Independent Women's Forum and the Children's AIDS Fund, which are mostly conservative health groups.
House approves mandatory testing of prisoners
The U.S. House of Representatives has approved by voice vote the "Correction Officers Health and Safety Act of 1998," which requires mandatory HIV testing of all federal prison inmates incarcerated for six months.The bill, HR 2070, also allows federal prison workers to request that an inmate be tested for HIV if there was an incident where the prisoner could have spread the virus to a worker. If a prisoner tests positive, the government is required to provide "appropriate access for counseling, health care, and support services to the affected" parties.
Speaking on the House floor in support of the bill, Judiciary Committee Chair Henry Hyde (R-IL) said the bill would "give an added measure of protection to those federal employees who work with or near prison inmates." Hyde said, "The need for this legislation is simple: Drugs have now been developed which can prevent the transmission of the HIV virus after exposure to someone who carries the virus. The drugs are effective in preventing transmission approximately 80% of the time" if they are "administered within 2 to 24 hours after exposure." Sponsored by Rep. Gerald Solomon (R-NY), the legislation requires the attorney general to "develop model guidelines for states to follow to prevent, detect, and treat all types of infectious diseases that are commonly found in prison populations." Hyde said there was a great need for the legislation: "The job of a law enforcement officer or corrections officer is a dangerous one. We owe it to these citizens to make the government take whatever steps it can to minimize the risks they encounter on the job. This bill will help identify the risk of HIV infection to those who serve in these jobs so that appropriate precautions can be taken to prevent its transmission." The bill has the support of the American Federation of State, County, and Municipal Employees, the Federal Law Enforcement Officers Association, the Corrections and Criminal Justice Coalition and the Fraternal Order of Police, Hyde noted.
More prison AIDS programs needed: U.S.
Meanwhile, according to a U.S. government report, more effort is needed to prevent and treat HIV/AIDS and other sexually transmitted diseases in the prison population.Such an effort helps not just the inmates but protects the public, the report said.
The report, developed jointly by the Department of Justice and the Centers for Disease Control and Prevention, revealed that AIDS is almost six times more prevalent among inmates than in the total U.S. population. "Because there is a strong likelihood that inmates will return to the community, collaborations between public health and correctional agencies may help fill gaps in programs for the prevention and treatment of these diseases," the report states. While finding that in 1997, almost all correctional systems had some degree of collaboration with public health agencies, these joint efforts by and large did not extend to discharge planning and transitional services for those being released. The study's key recommendations for improvement in this area are:
--Public health agency collection and dissemination of data on the burden of infectious disease in inmate populations;
--Correctional representation on all HIV prevention planning groups;
--Public health agency initiation or expansion of funding for services and staff in correctional facilities and other criminal justice settings;
--Public health and correctional agency recognition of the importance and potential benefits of interventions in correctional settings of the health for the larger community.
Study notes dangers of anal sex for women
Although researchers have long known that receptive anal sex among homosexual men is a substantial independent risk factor for contracting HIV, until recently a parallel study had never been conducted on women.Researchers from the Centre for Epidemiological Research in Southern Africa conducted interviews with 145 sex workers recruited between August 1996 and March 1997 from truck stops along South Africa's main national road between Durban and Johannesburg. According to a research letter published in this month's issue of the American Journal of Public Health, the South African study found that 61.3% of the women who had anal sex with their clients contracted HIV.
On the other hand, only 42.7% of the women who did not have anal sex with their clients contracted the virus. After controlling for age, condom use, number of clients per week and duration of sex work, the researchers determined that anal sex was "consistently associated with a higher risk" -- ranging from a 1.4-fold to 5.1-fold increased risk for the women contracting HIV. The researchers theorize that "abrasions in and bruising of the rectum and anus," in conjunction with "the collagenase and spermine in semen" may be responsible for the increased risk of infection.
The authors write, "The potential of anal application of microbicidal gels to protect against HIV infection associated with anal sex needs further exploration." They say their findings have "important implications for interventions aimed at sex workers; discouraging anal sex and insisting on condom use during anal sex need to be entrenched in health promotion programs targeted at this group."
City doctors form union
Over 90 percent of Philadelphia-area orthopedic surgeons, ENTs and urologists have joined a physician union in order to fight dramatic cuts in reimbursement from Independence Blue Cross (IBC), according to a story in this month's Physician's News Digest.This massive recruitment effort by the Florida-based Federation of Physicians and Dentists (FPD), which is affiliated with the National Union of Hospital and Health Care Employees, AFSCME and the AFL-CIO, promises to bring a major confrontation between surgeons and IBC, with possible Justice Department scrutiny for antitrust violations, if events follow similar situations in Delaware and Connecticut.
The FPD uses the third-party messenger model developed by the Federal Trade Commission to represent independent physicians who are prohibited from collective bargaining. The union consults with each individual physician or group practice on insurance contracts, publishes data on customary charges for key medical procedures and reimbursement rates of other insurers in the area, and helps draft counter-proposals and delivers them to insurers.
In Delaware, nearly all of the state's orthopedic surgeons joined the FPD to fight rate cuts from Blue Cross Blue Shield of Delaware (BCBS). The Delaware Blues refused to deal with the FPD as a third-party messenger and none of the orthopedic surgeons accepted the Blue's contract terms.
Orthopedic surgeons put up signs in their practices indicating that they were no longer taking BCBS, but gave those patients a receipt for their out-of-pocket payment -- at rates prior to the BCBS cuts.
The patients could then go back to BCBS requesting reimbursement.
Joining FPD "is the only response we have left that's still legal," other than early retirement or leaving the state says E. Michael Okin, M.D., past president of the Pennsylvania Orthopedic Society. Okin's two-physician orthopedic practice has told IBC that it cannot accept its new rates. "I've been in practice 26 years and have to go into my savings in order to pay my bills," says Okin.
Charles Hummer, Jr., M.D., expects his eight-doctor orthopedic surgery practice at Crozer-Chester Medical Center to suffer a 20 percent to 30 percent overall drop in revenue under the IBC rate cuts. He notes that the cuts are across the board for surgical procedures, and especially target the higher-risk, high-liability procedures. Common procedures, such as arthroscopy, are cut by 40 percent, says Hummer. Hummer's eight-physician orthopedic practice also rejected the IBC rate changes and joined FPD. He believes that most doctors who follow suit, will continue to treat IBC patients and would bill them directly, leaving their insurance company to work out the rest.
GALAEI launches transgender safer sex kit
GALAEI's Midnight Cowboy Project has launched a safer sex kit specifically designed to meet the needs of Philadelphia's transgender community.The kit called "Trans Protection" was developed by the GALAEI Project in consultation with Ben Singer of the Transgender Health Action Coalition, and with the input of other members of Philadelphia's transgender community including the San Francisco based Transgender Community Health Project.
David Acosta, executive director of the GALAEI Project says, "The development of a safer sex kit specifically designed to address the informational needs of transgender communities, fills a current void in services targeting this community in Philadelphia, and seeks to address the informational needs of a complex community around safer sex and safer injection use."
The kit consists of a small informational insert which discusses safer sex issues for male to female and female to male individuals. The latter is oftentimes ignored by programs seeking to work with transgender populations. The brochure discusses safer sex issues for both pre-operation and post-operation individuals as well as guidelines for safely injecting hormones and/or injection drug use. The information included was compiled largely in response to requests GALAEI was receiving while doing street outreach. Other information included came from trans resource guides from New York and San Francisco.
For more information, contact the Midnight Cowboy project at 215-985-3382.
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