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Issue #213: January 22, 1999
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 Associated Press, Journal of AIDS and Human Retrovirology, Journal of the American Medical Association (JAMA), Journal of Medical Virology, New York Times, Reuters.
Medicare plan may improve HMO AIDS care
Board of Health endorses code reporting
KS may improve with protease inhibitor therapy
Protease drugs are reducing overall care costs
Colo. schools may ban HIV+ players
GALAEI sponsors lesbian PWA support group
Prison guards acquitted of PWA beating
Medicare plan may improve HMO AIDS care
by Robert Pear, The New York Times
Medicare officials have announced that they would pay private health plans more for patients who were sick and less for patients who were healthy.
The new technique represents a major change in Federal health policy. It will penalize health maintenance organizations that avoid sick people and reward those that enroll such patients.
The change will be put into effect gradually over five years, starting Jan. 1, 2000. Medicare officials said they would make the change administratively, with authority they received from Congress in 1997.
The officials said many HMO's had fattened their profits by recruiting and enrolling healthy Medicare beneficiaries, a practice known as risk selection or cherry picking. Dr. Robert A. Berenson, director of the Center for Health Plans and Providers at Medicare, said the new method of payment "reduces the incentive for cherry picking."
Medicare finances health care for people who are elderly or disabled. Six million of its 39 million beneficiaries are in HMO's, and 60,000 to 70,000 more enroll every month.
In theory, HMO's could save money for Medicare. But many studies have found that the Government actually loses money because Medicare HMO patients have tended to be healthier than the average beneficiary for whom the standard Federal payment was calculated.
HMO's now receive a fixed payment for each beneficiary, adjusted only for a few factors, like the beneficiary's age, sex and county of residence -- but not for the patient's medical history.
Medicare pays an average of $5,800 a year for each beneficiary in an HMO Under the new payment system, HMO's will receive extra payments for beneficiaries who have been hospitalized in the prior year for specific conditions.
The bonus runs from $1,910 a year for a patient with breast cancer to $26,464 for a person with AIDS. The extra payment would be $4,666 for heart attack, $5,969 for colon cancer, $8,474 for stroke, $12,435 for lung cancer and $13,547 for ovarian cancer.
Payments for healthy Medicare beneficiaries could be reduced as much as 20 percent. Dr. Berenson said that at least 90 percent of Medicare HMO's would see their total payments cut, compared with what they would otherwise have received.
Medicare officials said the new method of payment would save $200 million next year and a total of $11.2 billion over five years.
HMO's denounced the changes, saying they would prompt more health plans to pull out of Medicare. In the last four months, HMO's dropped more than 400,000 Medicare patients because, they said, Federal payments were not keeping up with costs.
Karen M. Ignagni, president of the American Association of Health Plans, said, "The real losers in this fight will be Medicare beneficiaries." The Health Insurance Association of America said the decision to cut payments was "a slap in the face to seniors, and to Congressional leaders who see HMO's as the future of Medicare."
HMO executives deny that the organizations shun sick patients. But they have had immense financial incentives to do so because they can slash their costs if they avoid even a few of the sickest patients. Government data show that 5 percent of elderly beneficiaries account for more than 50 percent of all Medicare spending on the elderly.
Donna E. Shalala, the Secretary of Health and Human Services, said the new formula would make payments fairer and more accurate. Medicare officials said it might encourage some HMO's to specialize in caring for people with cancer or AIDS, because the Government would recognize the extra costs.
In the Balanced Budget Act of 1997, Congress cut $22 billion from the projected growth of Medicare payments to HMO's over five years. But none of those savings came from the changes announced today by Dr. Shalala. Ms. Ignagni said today's action would increase the total savings by 50 percent, beyond what Congress assumed.
Medicare officials said they would compute a "risk score" for each Medicare patient in an HMO Patients with serious illnesses will have high scores, indicating that they will need more services than the average patient.
In computing these scores, the Government will initially use data on hospital admissions. But for the first four years, it will not increase payments to HMO's to reflect the extra cost of services provided in doctors' offices, hospital clinics or patients' homes, by visiting nurses.
HMO executives said that this omission could create a perverse incentive for them to hospitalize patients to gain the extra payments. Medicare officials said they had included safeguards to discourage such abuse. HMO's have long prided themselves on treating patients outside hospitals whenever possible.
Board of Health endorses code reporting
The Philadelphia Board of Health, which holds legal responsibility for defining formal health policy for the city of Philadelphia, unanimously endorsed a policy supporting the use of unique identifiers in tracking cases of HIV infection in Philadelphia at its meeting on January 19th.
The board action followed a strong recommendation in favor of code reporting from city health commissioner Estelle Richman and the Philadelphia HIV Commission, which sets priorities for the region's AIDS care and prevention funds. Joe Cronauer, interim co-director of the city's AIDS Activities Coordinating Office, delivered to the board a copy of a report on two public hearings held by AACO early last year, at which all participants strongly endorse HIV reporting by unique identifier rather than by name.
The policy also applies to a newly-enforced requirement that area laboratories report instances where blood tests find that an individual's CD4 count is 200 or less, one of the most common AIDS indicators. Low CD4 counts, which account for over 66% of city AIDS cases reported over the past two years, is one of eighteen health conditions which define an AIDS diagnosis. The city will continue to collect the names of individuals who are reported as a result of a diagnosis of pneumocystis carinii pneumonia and other AIDS indicator conditions.
Some board members expressed concern that the city policy may differ from what is expected to be a state announcement in the next few months requiring that reporting of HIV infection, rather than just AIDS diagnoses, be mandated in Pennsylvania by the state health department, and that the new HIV reporting system will require the reporting of the names of those found to be HIV+. Richman said that she hoped that the Board of Health action, as well as the unanimous opinion of city AIDS service providers and AIDS activists, might influence the state to consider using unique identifiers or codes rather than names once it mandates HIV reporting in the state.
Richman said that she was deeply concerned that requiring HIV reporting by name would discourage individuals at risk of HIV infection from getting tested.
Federal guidelines issued by the U.S. Centers for Disease Control recommend that names be used in HIV reporting systems, but also suggest that communities continue anonymous HIV testing programs in order to accommodate those who might otherwise refuse to be tested.
Governor Tom Ridge, in his 1994 gubernatorial campaign, pledged not to institute HIV names reporting, but he refused to repeat that pledge during his successful campaign for re-election this year.
Since 1981, the state has only required that the names of those formally diagnosed with AIDS be reported to the health department. Most public health officials agree that to track today's epidemic, better systems for monitoring those diagnosed with HIV infection but not full-blown AIDS need to be in place.
Most AIDS advocates also support HIV reporting, but have strenuously objected to collecting names and other identifying information on those reported. They say that the risk of confidentiality violations and discrimination are too high, and that the same epidemiological goals can be reached through a coded reporting system.
Children exposed to zidovudine (ZDV, AZT) in utero and as newborns and who escaped acquiring HIV from their infected mothers show no cancers or other adverse health effects up through preschool age, according to a new study from the National Institutes of Health (NIH).
It is the first report to assess the late effects of AZT exposure in healthy HIV-uninfected children born to mothers who took the drug to prevent transmitting HIV to their offspring.
The study, sponsored by the Pediatric AIDS Clinical Trials Group (PACTG) and funded by the National Institute of Allergy and Infectious Diseases (NIAID) and the National Institute of Child Health and Human Development (NICHD), appears in the Jan. 13 issue of the Journal of the American Medical Association (JAMA).
"These data are critically important because the current recommendation is to treat HIV-infected pregnant women with regimens that include AZT to prevent perinatal HIV transmission," says NIAID Director Anthony S. Fauci, M.D. "Although these findings are reassuring," he adds, "we need to continue to monitor these children for long-term adverse effects of the drug." The investigators plan to follow these children until at least age 21.
The 234 HIV-uninfected children evaluated in this report are part of PACTG 219, a long-term follow-up study that includes more than 2,200 children who have been enrolled in PACTG prevention and treatment protocols. The 234 children were born to mothers who participated in PACTG 076. This landmark NIH study showed that AZT can reduce HIV transmission from an infected woman to her infant by approximately two-thirds. The children in PACTG 076 were exposed to AZT or a placebo in utero and during labor and delivery, and also as newborns for six weeks.
The randomized design of PACTG 076 and subsequent follow-up in this study makes it easier to clearly evaluate AZT's potential toxicity, the investigators note. The health of children who received AZT (122 children) can be compared with that of a similar number of children (112) who received a placebo.
For the current study, the investigators evaluated the children at regular intervals. The main measures of interest included physical growth, cognitive and development milestones, immunologic function, cardiac and ophthalmologic evaluations, the occurrence of malignancies, and mortality.
"The good news is that there are no differences in growth and cognitive development between the children exposed to AZT versus the children who were not," comments lead author Mary Culnane, M.S., C.R.N.P, of NIAID's pediatric medicine branch in the Division of AIDS. "It also is reassuring that none of the children have developed cancers or died."
The JAMA article reports on data collected through February 1997. The median age of the children was 4.2 years (range 3.2 to 5.6 years). They continue to be followed in the PACTG clinics.
The authors conclude that their findings complement the earlier findings of PACTG 076, which found no evidence of AZT toxicity in children up to 18 months of age, and are consistent with the limited other early safety data concerning perinatal exposure to AZT. Future evaluations of these and other children in PACTG 219 will help define the long-term safety of AZT use during the perinatal period. Pediatric HIV specialists also hope to establish a registry to track the health of all children exposed to antiretrovirals, a proposal that is being actively discussed within the medical community.
KS may improve with protease inhibitor therapy
Use of highly active antiretroviral therapy (HAART), which can decrease HIV RNA load and increase CD4 cell counts, may also improve or prevent symptoms of Kaposi's sarcoma in HIV-positive people, according to a European group.
Clearance of human herpes virus 8 (HHV-8), the pathogen implicated in KS, has been reported in HIV-positive patients following treatment with HAART, Dr. Angelo De Milito of the Karolinska Institute in Stockholm, Sweden, and colleagues in Italy report.
To further investigate this, they evaluated six coinfected patients over time, four with KS and two without KS, by measuring levels of plasma HIV RNA, HHV-8 DNA, and CD4 T cells. All of the subjects received a HAART regimen that contained a protease inhibitor. At baseline, four of the six patients had active KS.
"A specific anti-HHV-8 role for [protease inhibitors] was not consistently found, since fluctuation of HHV-8 viral load over time appeared to be independent of treatment," they report in the January issue of the Journal of Medical Virology.
However, in two of the patients with KS, Dr. De Milito's group observed a regression of lesions following the commencement of HAART. And a third KS patient developed no new lesions, which they believed was associated with indinavir treatment. The fourth patient, who had severe cutaneous KS lesions, experienced no improvements following saquinavir therapy.
Dr. De Milito's group observed decreased levels of plasma HIV RNA and increased levels of CD4 cells in the three KS patients who improved. This was not seen in the fourth patient, who was suspected of being noncompliant with therapy.
The clinicians also noted a "...temporal correlation between increasing CD4+ cell numbers and falling HHV-8 DNA levels" in four subjects, which supports the "...hypothesis that CD4+ lymphocytes play a role in controlling HHV-8 replication."
The researchers believe that KS probably results from a "...complex interaction of viral and immunological factors." Therefore, the effects of protease inhibitors on KS may be associated with decreases in HIV replication and restoration of immune function, as well as decreases in HHV-8 load.
Protease drugs are reducing overall care costs
Despite the high costs of protease inhibitors, HIV-positive people who are taking these drugs have fewer days in the hospital and lower overall healthcare costs, according to a report in the January 1st issue of the Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology.
Treatment with protease inhibitors has been associated with lower rates of opportunistic infections and increased survival, Dr. Philip Keiser of the University of Texas Southwestern Medical Center in Dallas and associates explained. "Statistical models predict that decreased complications will be associated with decreased hospitalization costs," they added.
To investigate the relationship between protease inhibitor use and HIV-related hospital usage and costs, Dr. Keiser's group evaluated patients at the Dallas Veteran Affairs Medical Center, a facility that provides comprehensive care to patients with HIV infection, between January 1995 and July 1997. Specifically, they examined the mean number of days in the hospital and outpatients visits, along with costs of these services.
Dr. Keiser's group observed a "...decrease in hospital use and overall costs by HIV-infected patients that was associated with increased [protease inhibitor] usage." The number of hospital admission days markedly decreased, and although smaller, there was also a decrease in the number of outpatient visits. There were slight increases in outpatient treatment costs, which were attributed to the cost acquiring protease inhibitor drugs.
They found that the reductions in total HIV costs were primarily due to decreases in hospital stays. During the time interval examined, Dr. Keiser's group reports that the monthly costs of HIV care per patient declined from an average of US$1,905 at the beginning to $1,122 at the end.
In addition, Dr. Keiser's group noted an "...inverse relation between [protease inhibitor] use and total HIV costs...but no relation between nucleoside use, stage of disease or financial class."
Although they point out that these findings may not be generalizable to all HIV healthcare facilities, they believe that further investigation of the impact of protease inhibitors on HIV costs is warranted.
Colo. schools may ban HIV+ players
In a move reminiscent of early policies discriminating against people with HIV/AIDS, a local Colorado school district has adopted a new policy that could bar students with HIV and AIDS from playing school sports.
The 22,000-student Poudre School District now requires a committee of parents, health professionals and school officials to decide whether an infected student may participate in sports.
The policy, approved unanimously by the district board and which says that an infected student "may be excluded from participation in school athletics," applies to all sports and all "serious communicable diseases," but only HIV and AIDS are specified.
Jerry Diehl of the National Federation of State High School Associations in Kansas City, Mo., said he knows of no other school districts that have enacted such a policy.
"We're not automatically excluding anybody," said Joe Hendrickson, the district's director of pupil services and the policy's lead author. "Our intention was to find a policy that did not discriminate, that would only consider exclusion if there were a medically sound recommendation."
But critics say the policy does discriminate and raises concerns about privacy rights.
"On the face of it, you're taking a group of people and, based on their health status, potentially excluding them," said Peter Brown of the Colorado AIDS Project.
The policy is triggered only when a student athlete reveals he or she has an infectious disease, which makes it difficult for the rule to be fairly enforced, said lawyers with the American Civil Liberties Union of Colorado. Students often don't know they are HIV-positive and, even if they do know, Colorado law does not compel them to disclose it.
The ACLU would consider challenging the policy if a student is kicked off a team, said Christine Cimini, an attorney for the organization.
Health experts say there is only a minute risk that an HIV-infected athlete could transmit the disease, even during contact sports.
"In day-to-day sport contact, it's really not an issue unless someone has an open cut," said Dr. Ken Greenberg, who works with AIDS patients at Denver Infectious Disease Consultants. "HIV can't be transmitted through sweat. It can't be transmitted through saliva."
Professional and amateur athletic groups have generally taken the opposite approach since 1991, the year that the basketball player Earvin (Magic) Johnson announced that he was infected with HIV. Instead of banning athletes with blood-borne diseases, like AIDS and hepatitis, athletic associations have almost universally adopted sanitary procedures for handling open wounds and spilled blood.
"National Hockey League players with active bleeding are taken off the ice until bleeding stops, the same thing for basketball players," said Benjamin Young, an infectious-disease specialist in Denver. Noting that Mr. Johnson played basketball after he announced his infection, Dr. Young said, "Professional sports elected not to make this a big issue."
"To my knowledge," he said, "there is no known case of HIV transmission through sports."
Researchers have ruled out sweat and saliva as agents of transmission, he added, and "in the millions of household contacts, there has been no transmission."
Monte Peterson, a Poudre Valley School District official, said the new policy, adopted on Monday, was "intended to be a cooperative policy, not a restrictive, exclusionary policy."
"If a parent chose to share with us that a student was infected with, say, HIV, how can we help?" he said from Fort Collins, the major metropolitan area in the district. "We are not dealing with a case. Our policy is a proactive policy."
Only 26 AIDS cases have been recorded among Coloradans of high school age since 1982, the state health department said. Last year the department reported no new AIDS cases and five new cases of HIV infection among state residents of high school age.
On the national level, there are not believed to be any school districts with policies intended to exclude HIV-infected athletes, said Jerry L. Diehl, assistant director of the National Federation of State High School Associations, a sport regulatory group in Kansas City, Mo.
"While risk of one athlete infecting another with HIV/AIDS during competition is close to nonexistent, there is a remote risk that other blood-borne infectious diseases can be transmitted," begins the association's policy, written in 1995.
Noting the threat of Hepatitis B transmission, it lists sanitary procedures for when open wounds are incurred on playing fields. Doctors say the main route for transmission would be from the open
wound of an infected player to the open wound of another player.
In Colorado, high school teams forfeit games if they refuse to play teams that have members who have HIV infection or hepatitis, said Bob Ottewill, commissioner of the Colorado High School Activities Association.
Dr. Young criticized the Poudre schools for not specifying whether the new policy applied to non-contact sports. He added that exclusionary programs were ineffective because the presence of HIV in the bloodstream could manifest itself up to one year after an infectious contact.
"We think this policy is uninformed, discriminatory and fraught with ignorance." said Lori Midson, a spokeswoman for the Colorado AIDS Project, an education and prevention group in Denver. "This means that students that are athletes and HIV positive will be discouraged from revealing their HIV status."
Cimini, the ACLU lawyer, said: "The danger of this policy is that you are going to discourage students from being tested. And the consequences of not being tested are incredibly severe."
GALAEI sponsors lesbian PWA support group
Thanks to a grant from the Philadelphia AIDS Consortium, the Gay and Lesbian Latino AIDS Education Initiative is sponsoring a new support group specifically designed for lesbians living with HIV/AIDS.
The next meeting of the group, for Latina and other lesbian women, is scheduled for Saturday, January 30th, from 10:00 a.m. to 11:00 a.m. at the offices of the Washington West Project, 1201 Locust Street.
"The establishment of a support group for lesbians living with HIV/AIDS has been on the forefront of GALAEI's agenda ever since we collaborated with PCHA and Dykes and Dames in a needs assessment of lesbians with HIV/AIDS sponsored by the AIDS Activities Coordinating Office," said David Acosta, GALAEI executive director. The report, titled "Health, Mental Health and Social Service Needs of HIV Positive Lesbians and Women Who Have Sex With Women (WSW) in Philadelphia," identified lack of support as one of the most important issues facing lesbian women with HIV/AIDS."
Acosta said that the issue of lesbians and AIDS is barely acknowledged by the federal government as well as community-based organizations because woman to woman transmission of HIV/AIDS is extremely rare, with only two cases reported. "This lack of data has created a false sense among the lesbian community as a community at low or no risk for HIV infection and prevents the establishment of safer sex practices among lesbian women despite the fact that other STDs such as HPV, Herpes, and Chlamydia can be transmitted between women, Acosta said.
One study in San Francisco found that 76 percent of lesbian and bisexual women reported sex with both men and women, with twenty percent reporting unprotected anal or vaginal intercourse with gay or bisexual men. A second study, in New York State, of 27,370 women being tested for HIV, found seroprevalence rates of 3.0% among women who were sexually active exclusively with women and a 4.8% infection rate among women sexually active with both women and men.
Women who use drugs are at an increased risk and lesbian who use drugs in particular are isolated due to the misconception that IV drug users are not lesbians and also that lesbians don't get AIDS.
Meanwhile, a report released last week by the Institute of Medicine indicates that lesbians face unique challenges in the medical community and that many health care professionals are ignorant of lesbian health needs.
Andrea Solarz, head of the committee that authored the report, "Lesbian Health, Current Assessment and Directions for the Future," said that most of the issues concern interaction and access as opposed to specific health risks. Some activists note that gay and lesbian health organizations have focused on HIV issues for the past two decades instead of on other health issues in the community.
According to some health activists, lesbians are sometimes overlooked for sexually transmitted diseases or Pap smears because they may not be having sex with men. However, researchers are still unsure if lesbians and heterosexual women have different risks, and few reliable studies on lesbian health exist.
Prison guards acquitted of PWA beating
Seven former prison guards have been acquitted in Florida of charges they covered up their beating of an HIV-positive inmate in the days before he committed suicide.
Jurors deliberated at least nine hours over two days before reaching a verdict clearing former Capt. Donald B. Abraham and six other former guards of conspiring to violate the federal civil rights of 28-year-old inmate John Edwards.
Prosecutors had alleged the guards beat Edwards at Charlotte Correctional Institution because he had bitten a guard at another prison, and that they then conspired to cover it up when the prisoner committed suicide in August 1997.
After the verdict, the courtroom erupted with cheers, shouts and tears as the defendants and their families hugged, slapped one another on the back, and cried. Some jurors also cried.
"Our lives have changed dramatically. All we want is our lives back," Abraham said afterward. "We were innocent when we were charged and when we walked out of that building today we were innocent."
All of the defendants had been charged with conspiring to violate Edwards' 8th Amendment right to be free of cruel and unusual punishment. If convicted they each could have received up to 10 years in prison and fines up to $250,000.
Edwards, who was serving two life sentences for the murder of his wife and a man in Tampa, was transferred to the Charlotte prison on Aug. 18, 1997, as punishment for biting a Zephyrhills correctional officer on the face.
Federal prosecutors alleged the Charlotte guards, along with two Zephyrhills transport officers, plotted to injure, threaten and intimidate Edwards in retaliation.
They allegedly kicked and beat Edwards, slamming him into walls while he was in restraints. After three days of being brutalized at the Charlotte prison, Edwards tried to kill himself by slashing his arm.
He then was moved to a psychiatric dorm and after another beating -- while chained naked to a metal bed -- he bled to death over a 12-hour period, prosecutors said.
In the days after Edwards' death, a number of officers and supervisors filed false reports, according to indictments. They claimed Edwards had been combative and had needed to be restrained.
One juror said the government's case was not strong enough to convict the former guards.
"It was lack of evidence," said juror Jill Palmer. "It was a very trying time for everyone. We were crying as the verdicts were read. It was heart-wrenching to watch the individuals on both sides of the case."
Doug Molloy, the managing assistant U.S. attorney who prosecuted the case, said the truth came out, despite the acquittals.
"Justice is done when the truth comes out," Molloy said. "John Edwards died after three days at Charlotte Correctional Institution. These are the men he was in contact with."
In closing arguments, defense attorneys said the prosecution's main witnesses -- three other former guards charged in the case who later agreed to testify against their colleagues for potentially lighter prison sentences -- could not be believed.
Last July, the 10 guards, supervisors and transport officers were indicted on federal charges in the case. Nine pleaded innocent. All later were removed from their jobs.
Besides Abraham, the other former guards from Charlotte on trial were Kevin Browning, Michael Carter, Paul Peck and Richard Wilks. Also charged with taking part in the beatings are the two guards who transported Edwards to Charlotte from Zephyrhills Correctional Institution -- Gary Owen and Joseph Delvechhio.
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