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Issue #194: September 11, 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 American Journal of Pathology, American Journal of Public Health, Bloomberg News, Business Wire, Journal of Infection, Reuters
Philadelphia gets $335K in new prevention funds
Whitman renews opposition to needle exchange
CVS confirms dropping HealthPartners
Bactrim said effective for toxo
FDA approves first "antisense" drug for AIDS
STDs, elevated hormone increase woman's HIV risk
HIV, tobacco are biggest killers worldwide, scientist says
"Homeless episodes" prevalent among US teens
"Stella" under attack for Haitian AIDS reference
AIDS Activities Coordinating Office (AACO) co-director Joe Cronauer has announced that Philadelphia's AIDS prevention efforts has received a $335,000 boost as a result of new funding awarded to the city by the U.S. Centers for Disease Control (CDC).
Philadelphia gets $335K in new prevention funds
The funding includes $107,000 restored by the CDC from a nation-wide funding reduction implemented in 1997, and $128,000 in new funding awarded through a competitive process involving 65 cities and communities throughout the nation.
Cronauer said that Philadelphia's application in the competitive process placed third among the 65 applicants.
"Our success in competing with other jurisdictions for these funds indicates that Philadelphia's community-based HIV prevention programs continue to be among the best in the nation," Cronauer told fastfax. In addition to the $335,000, which will be distributed to seven organizations in the city, AACO also received $100,000 to conduct an intensive evaluation of two prevention models utilized by Philadelphia AIDS education groups: prevention case management and using social activities to transmit HIV risk reduction information.
A proposal by AACO to dramatically expand "secondary" prevention activities – that is, HIV education directed to people already infected with HIV – ranked tenth in the national competition, but the CDC said it only had funds to support the top five ranked proposals.
The CDC had requested proposals in two primary categories, one open to all agencies and the second targeted to minority providers. The city will allocate $107,000 from the first category to support programs which had not succeeded in getting funded in a $5.5 million local competitive process held last spring, in which AACO received over $14 million in proposals. The new money will be distributed to the Philadelphia Health Management Corporation to conduct outreach programs directed to injection drug users, to the Family Planning Council to support its school-based health education and condom availability programs, and to The Colours Organization for programs targeting sexual minority people of color. This funding is included in the amount which the CDC is restoring from its 1997 cut of all HIV prevention funding.
The remaining $128,000 was won by the city in a highly competitive process limited to organizations run by minority providers and serving communities of color. This funding will be allocated to One Day At A Time, to support a neighborhood-based HIV prevention site in Southwest Philadelphia; a program working with Latino inmates in Philadelphia prisons, sponsored by Asociacion de Puertoriqquenos en Marcha; a "train the trainers" program, operated by the Community AIDS Resource Center (formerly Ecumenical Information AIDS Resource Center), which will help pastors and other church staff develop HIV risk reduction programs for their congregations, and a variety of outreach and education programs at Congreso De Latinos Unidos for Latinos and African Americans in North Philadelphia.
Most of these programs were ranked high in AACO's spring allocation process but could not be funded because there was not enough money available.
Cronauer said that the new funding will support the programs through December of 1999, and that the CDC expects to be able to continue the funding as part of its regular "cooperative agreement" with the city for future years.
Whitman renews opposition to needle exchange
New Jersey Gov. Christine Todd Whitman has issued her most forceful rejection yet of her Advisory Council on AIDS' recommendation in support of a needle exchange program for drug addicts.
Panel chair David Troast wouldn't say whether the panel would continue to defy Whitman's opposition to the program, or abandon an effort unlikely to change current laws while Whitman remains in office.
In an Aug. 5 letter to the council, Whitman wrote that she remained "resolute" in her opposition to the program she first rejected two years ago, against the council's recommendation. She renewed her objections in correspondence on September 9th.
Whitman stated that she opposes needle exchange programs "because they seem to condone illegal drug use and contradict our efforts to reduce" drug use. Instead, Whitman urged the council to focus on efforts to curb the spread of AIDS among minority women and teenagers. However, several members of the council contend that needle exchange programs remain the single most important initiative needed to slow the spread of HIV in New Jersey, particularly among women and children.
HIV transmitted through injection drug use has been the leading means of HIV transmission in the state since the early 1980s.
Council member Riki Jacobs emphasized that needle exchange programs target women and children, and three-fourths of the HIV infections among these groups are attributable to intravenous drug use. After the council's meeting on September 9th, Troast continued to emphasize the effectiveness of needle exchange to reduce HIV infection, citing studies "that show these programs slow the spread of AIDS without increasing drug use." Jacobs added that the council will pursue the issue.
"Even if [Whitman] is not open-minded, it's our responsibility to give her as much information as we can."
New Jersey legislators have sponsored legislation to implement needle exchange pilot programs, despite Whitman's long-standing opposition. Bill sponsor state Sen. Joseph Vitale (D) criticized Whitman for empowering a council to provide recommendations only to reject its proposals. "This is a matter of life and death," Vitale said.
Senate Health Committee chair Sen. Jack Sinagra (R) confirmed that the committee would hold hearings on the legislation -- one bill to create the pilot program and another to permit the sale of syringes. Sinagra opposes Whitman's position "given that half of all AIDS and HIV cases in New Jersey can be attributed to injection drug use." However, he admits that her staunch opposition ultimately means "these bills are dead on arrival."
CVS confirms dropping HealthPartners
CVS Corporation, one of the largest pharmacy chains in the Philadelphia area, has formally announced that it will no longer fill prescriptions for members of Health Partners.
The prescription benefit for Health Partners is managed by Eagle Managed Care, a subsidiary of the Rite Aid Corporation.
The contract covers more than 100,000 Medical Assistance recipients in the Philadelphia area. Consumers who wish to continue to fill prescriptions at CVS/pharmacy have the option of switching to Oxford Health Plan, the only remaining HealthChoices HMO which retains a contract with CVS.
"Philadelphia HMOs participating in the Department of Public Welfare's managed care initiative have been struggling financially. They indicate that the present level of reimbursement afforded to them by the state is insufficient to manage the needs of the patients," said Fred McGrail, CVS Director of Corporate Communications, in a statement released over Business Wire. "Unfortunately, we cannot accept a reimbursement decrease that would make it not viable economically for us to fill prescriptions."
"This is the third Medicaid program in Philadelphia that we have been forced to exit in recent months," said McGrail. "We are obviously concerned for the well being of our patients since our departure from the network will negatively affect their access and compromise their continuity of care, particularly those who have limited transportation alternatives available to them."
Bactrim said effective for toxo
Bactrim (trimethoprim-sulfamethoxazole, or TMP-SMZ), commonly used as prophylaxis for Pneumocystis carinii pneumonia (PCP) in HIV-positive patients, may also be an effective treatment for cerebral toxoplasmosis, according to Italian researchers.
The incidence of cerebral toxoplasmosis in AIDS patients is between 3% and 40%, Dr. D. Torre and colleagues at the Regional Hospital in Varese reported.
The standard treatment for cerebral toxoplasmosis, the most common cause of focal brain lesions in AIDS patients, is the combination of pyrimethamine and sulfadiazine. However, less toxic agents are needed.
In a retrospective study, published in the July issue of the Journal of Infection, Dr. Torre's group found TMP-SMZ to be effective for cerebral toxoplasmosis in about half of the people with AIDS who received the treatment.
Dr. Torre's group evaluated the records of 71 people with AIDS with cerebral toxoplasmosis who received intravenous TMP-SMZ for 4 weeks. Overall, 35 patients, or 49.2%, experienced a complete resolution of symptoms, and 41 patients, or 57.7%, had a complete resolution of brain lesions, as indicated by x-rays. Another 27 patients (38%) experienced some clinical improvement.
They also noted that 22 subjects (30.9%) had cutaneous reactions associated with the treatment. "However, a good outcome was noted in patients with adverse reactions to TMP-SMZ."
Based on these findings, Dr. Torre's group suggests that larger, prospective studies investigate the potential usefulness of TMP-SMZ for treating cerebral toxoplasmosis in people living with AIDS.
FDA approves first "antisense" drug for AIDS
Isis Pharmaceuticals Inc. has received approval from the U.S. Food and Drug Administration (FDA) to sell a drug to treat an AIDS-related eye condition based on a groundbreaking genetic technology.
The approval of Vitravene makes it the first available product based on a complex technology known as "antisense." The technology allows drugs to actually disable the genetic instructions for a disease.
"It's the first drug to take genetic information directly and convert it," said Stanley Crooke, chairman and chief executive of the company. "It is a seminal event."
The FDA approved the drug in just five months to treat the eye condition known as CMV retinitis which often strikes the ravaged immune systems of AIDS patients. The drug, which will be marketed by a unit of Switzerland's Novartis AG, won approval for patients who aren't helped by current treatments.
CMV, or cytomegalovirus, attacks many organs in the body but has its most dramatic effects on the eyes, and can cause loss of vision within weeks if left untreated.
CMV is one of the most common infections to ravage the weakened or destroyed immune systems of people with HIV/AIDS. Such opportunistic infections in AIDS patients are on the decline, though, because effective anti-HIV therapies have led to a sharp drop in full-blown AIDS cases.
Yet, there's now evidence that a growing number of patients are no longer helped by the powerful anti-HIV drugs, meaning more people with HIV/AIDS patients may come down with CMV retinitis.
Analysts said the FDA approval helps validate the antisense technology, which has been considered a risky¸ complex theory of drug design.
The strategy involves mapping out the genetic code responsible for a disease beforehand. Antisense technology allows Isis to reverse-print the virus gene codes, and home in on a precise section to block it. The reverse printed gene sequence binds to the gene section which would trigger disease activity, like filling the grooves of a key so it no longer works in a lock.
While the theory is attractive, critics have said results from the company's trials may be due to inactive ingredients in the injections. They maintain the genetic material contained in Vitravene, also known as fomivirsen, is more likely to be destroyed by the body than to reach the portions of the eye where CMV hides out.
The FDA approval does specify that the drug should be used in patients who aren't helped by other treatments. Though the company was originally angling for an approval that would specify the drug could be the first tried, Crooke said its commercial potential isn't significantly affected by the label.
STDs, elevated hormone increase woman's HIV risk
Women with sexually transmitted disease or elevated progesterone levels who have unprotected sex with an HIV-positive man significantly increase their risk for also contracting HIV, according to a study by Northwestern University Medical School scientists.
Northwestern AIDS researcher Bruce Patterson, M.D., and colleagues published results of the study in the August issue of the American Journal of Pathology.
The research group showed that sexually transmitted diseases, such as herpes, human papillomavirus, chlamydia and genital ulcer disease and elevated progesterone levels increase certain chemokine receptors for HIV in the female genital tract.
Chemokine receptors are protein molecules on the surface of host cells that play an integral role in mounting the body's immune response to infection. Two chemokine receptors, CCR5 and CXCR4, enable HIV to enter and infect cells involved in the immune response.
First, a cell surface protein on the HIV virus, gp120, attaches to a receptor known as CD4 on infection-fighting T cells. But for HIV to enter and infect T cells, a chemokine co-receptor is required. After binding to the CD4 receptor, HIV undergoes changes that allow it to bind to the chemokine receptor. The chemokine receptor then passes the gp120-CD4 complex through the T cell membrane, while part of the HIV envelope protein passes the HIV virus into the T cell.
Strains of HIV that use the chemokine receptor CCR5 are most often found early in the course of disease in an HIV-infected person. HIV strains that act later use CXCR4.
Male-to-female transmission of HIV, which is now the leading mode of transmission worldwide, involves exposure of virus in semen to cells in cervical and vaginal mucus membranes. Many studies have noted a gender imbalance for heterosexual HIV transmission that places women at greater risk for acquiring HIV from infected male partners. And related research has demonstrated an increased rate of HIV infection in women older than 45.
But aside from gender, other factors may increase susceptibility to HIV-1 infection, including co-infection with sexually transmitted diseases and genital ulcers, as well as hormonal influences, Patterson said.
Post-menopausal women have higher levels of progesterone relative to estrogen, compared with normal premenopausal women, in whom estrogen predominates in the first two weeks of the menstrual cycle. Hormone replacement therapy with progesterone alone also increases progesterone levels.
Additionally, laboratory studies have shown that progesterone enhances transmission of simian immunodeficiency virus, presumably by allowing more of the virus to move through the thinned vaginal tissues that occur in menopause.
Patterson and his research group wanted to determine the factors that influence the expression and regulation of HIV co-receptors in human tissue. Specifically, they looked at whether sexually transmitted disease and/or progesterone increase either the number of target cells present, the immune response or expression of cell type-specific chemokine receptors that are necessary for HIV-1 infection.
They used immunological and extremely sensitive molecular methods to determine expression levels of CCR5, CXCR4 and other chemokine receptors in circulating blood and cervical biopsy specimens of 12 women with and without sexually transmitted disease, genital ulcer disease and progesterone-predominant conditions.
Their results showed that CCR5 is the major HIV co-receptor expressed in cervical tissues and CXCR4 is the major co-receptor in the circulating blood in women with HIV and human papillomavirus or progesterone-dominant conditions.
Because CCR5 chemokine receptor expression is confined primarily to the cervicovaginal tract rather than the blood, therapy should be directed at decreasing sexual transmission by blocking chemokine receptors in genital tissues, Patterson said.
"Understanding the dynamics of male-to-female HIV sexual transmission is critical to designing effective prevention strategies," he said.
HIV, tobacco are biggest killers worldwide, scientist says
The best way to reduce death rates worldwide is to target the biggest killers -- HIV and tobacco, a British scientist has said.
Richard Peto, a professor of medical statistics and epidemiology at Oxford University, told a science conference that the only two causes of death that are increasing fast worldwide are HIV disease and tobacco.
"You can save far more lives by a moderate reduction in the big causes of death than by a large reduction in smaller causes," he said.
"Tobacco is still the biggest killer we've got," he told the British Association of Science, adding that 100 million people will die from smoking worldwide over the next 20 years.
While infant deaths have decreased at amazing rates in the last 100 years, with only about one percent of children worldwide dying before their fifth birthday, Peto said the emphasis has shifted to preventing deaths in middle age which is becoming a global priority.
In the United States tobacco causes one third of all deaths in people before the age of 70. Twelve percent of deaths among middle-aged American men in 1990 were caused by smoking, which was responsible for nearly a third of the deaths in women of the same age group.
Peto said that a decrease in mortality in Britain, however, "is being driven by a decrease in tobacco."
Smoking is also the cause of most of the differences in death rates between the rich and poor because the people from lower social classes and on smaller incomes are more likely to take up the habit.
But the news, he added, was not all bad and even heavy smokers still had a chance to beat the statistics.
"Half of all smokers are killed by tobacco, but stopping works amazingly well; even in middle age smokers who stop avoid most of their risk of death from tobacco and stopping before middle age avoids almost all the risk," he said.
Turning his attention to HIV, Peto said it will evolve differently in different populations. The newest drugs have prolonged the lives of many people with HIV/AIDS sufferers but they are expensive and unaffordable in developing countries where the virus is spreading at alarming rates. Experts at the World AIDS conference in Geneva earlier this summer agreed that a vaccine against the virus is still years away and prevention is the best way to deal with the disease, particularly in poor nations.
"Homeless episodes" prevalent among US teens
As many as 1 in 13 adolescents in the US is homeless for some period of time in the course of a year, researchers report in the September issue of the American Journal of Public Health.
In interviews with researchers, 7.6% of a nationwide sample of more than 6,000 adolescents said they had been homeless for at least one night during the preceding year.
"These findings suggest that youth homelessness is a national phenomenon that is much more common than is generally thought," write Dr. Christopher L. Ringwalt, of the Research Triangle Institute, in Research Triangle Park, North Carolina, and colleagues.
Previous studies have suggested that homeless adolescents run an increased risk of medical problems, including infection with the AIDS virus and other diseases, drug and alcohol abuse, depression, prostitution, suicide attempts, and trauma.
"Many homeless youths have difficulty meeting basic needs, in large part because of the scarcity or inappropriateness of existing services and their lack of access to housing education systems, medical and mental health services and social welfare programs," Ringwalt and colleagues write.
To plan such programs, public health workers need data on the size and needs of homeless youths, the researchers point out. To estimate the extent of homelessness among adolescents in the US, they interviewed 6,496 youths, aged 12 to 17, who had been included in an earlier nationwide survey.
The researchers asked the youths whether they had spent one or more nights in homeless shelters, various other places not intended as dwellings, or areas where "their safety would be compromised," during the previous year.
About 3.3% of the adolescents interviewed said they had spent at least one night in a youth or adult shelter. Because data from US youth shelters suggests that fewer adolescents stay in shelters, however, this may be an overestimate, the researchers write. Another 2.2% of those interviewed said they had spent one or more nights in a public place, and an equal number said they had spent at least one night outside. About 1.1% reported spending at least one night with a stranger. Roughly 1% said they had spent one or more nights in an abandoned building, and 0.4% reported spending at least one night underground, the researchers report. Although the shelter figure may have been an overestimate, these rates appear to be "reasonable," the researchers report.
In general, boys were more likely to report having been homeless during the previous year than girls. But girls were more likely to report having spent at least one night with a stranger, according to Ringwalt and colleagues.
"The prevalence of homelessness did not vary significantly by race, family poverty, family structure, or residence either in a metropolitan area or in a particular region of the country," the authors report.
"This study suggests that homelessness among adolescents is not simply an urban problem and that prevention programs targeting homeless youths should be implemented nationwide," they conclude.
"Stella" under attack for Haitian AIDS reference
A hit U.S. movie that links Haiti with AIDS has brought an angry response from government officials, who joined Haitian-Americans in rejecting what they called an unwarranted slur.
In the 20th Century Fox summer movie hit "How Stella Got Her Groove Back," about a 40-year-old American woman who falls for a 20-year-old Jamaican man, the character played by star Angela Bassett is asked by her sister if she feared getting AIDS in Jamaica.
But another sister interrupts, saying, ``No, that's Haiti, Miss Manners.''
"The people at Fox forget that the virus came from the United States. We deplore that this company would say such a thing," Dr. Michaele Amedee-Gedeon, general director of Haiti's Ministry of Health, told Reuters.
"We accuse them of ignorance and judgment without proof," Amedee-Gedeon said.
Officials at Haiti's Ministry of Tourism have also spoken out against the movie.
The reference has been an unwelcome reminder to Haitian-Americans of the stigma attached to their homeland in the 1980s, when the world became aware of AIDS.
Some scientists attempting to track the cause of the deadly disease incorrectly theorized that it was brought back to the United States by homosexual tourists who had visited Haiti.
That belief prompted the U.S. Centers for Disease Control in Atlanta to list Haitians as one of four high-risk groups for AIDS, with homosexuals, hemophiliacs and heroin users. Haitians were removed from the list in 1991.
According to international health organizations, about 5 percent of adults in Haiti are infected with HIV, compared with a U.S. rate of less than 1 percent.
Haitian-Americans have staged protests against the movie, saying it revives an old, unfair stereotype. They have called for a boycott and asked Fox to delete the exchange from the film.
"Stella's got the wrong groove," said a flier distributed outside movie theaters in the New York area.
"It affects Haitians everywhere. We're trying to get out of this darkness we've been in for so long, and then we're slapped again," said Jimmy Jacques, the producer of a Haitian television show in the Washington area.
A spokeswoman for 20th Century Fox in Los Angeles said the studio had no comment on or response to the Haitian protests.
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