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Issue #229: May 14, 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 AIDS, Bay Area Reporter, Journal of AIDS, Las Vegas Sun-Times, Los Angeles Times, Reuters
In This Issue:
AIDS housing subsidies suspended in LA
Nevada will allow forced HIV testing by police
Study: Hodgkin's disease an AIDS-defining illness
FDA fast tracks another Trimeris drug
Many Asian American men unaware of HIV risk
Decline in NY AIDS deaths slowing
Treatment guidelines, drug scheduler now on Internet
Confronted with conflicting claims about the management of money intended to help poor people with AIDS obtain housing, Los Angeles City Council members recently voted to halt disbursement of the grants while they studied the results of a city audit.
The result: Hundreds of poor people with AIDS and in desperate straits have temporarily lost rental subsidies of $100 a month, although the city has the money to pay them.
"Here I am, a person with AIDS," said Ken Murray, who went to AIDS Project Los Angeles to apply for his check, only to be told that it was not available. "There's supposed to be money put aside to help me. I've worked and paid taxes when I can, and this money is supposed to help me. Now, I'm told I can't get it."
Some people with AIDS and their advocates are outraged by what they say is a case of City Hall neglect -- of a council that voted without regard for the effects of its actions and of city bureaucrats unwilling to provide assistance to those most in need.
"They're squeezing the people who can least afford it," said Ged Kenslea, community relations director for AIDS Health Care Foundation.
Scott Figenshow, executive director of Project New Hope, agreed.
"We warned them that this would happen and they went ahead and did it," he said.
It is not clear how long the money will be held up or precisely how many people the suspension will affect. On May 6th, providers of the money were notified by fax that the program was temporarily on hold.
The delay was caused because the council elected not to award 12-month contracts to organizations recommended by a city committee created to consider how to distribute federal grants under a program called Housing Opportunities for Persons With AIDS (HOPWA).
That program's administration and management was criticized in a city audit, and the council decided that rather than go ahead with another set of year-long grants, it instead would approve three-month extensions and then revisit the issue. The problem with that, observers said, was that it required bureaucrats to rewrite all the existing contracts, a time-consuming process.
For those agencies receiving money to build housing or other long-term projects, the effect is small. But for those individuals who count on the program's money to make ends meet, the impact was quick and hurtful.
Adding to that is the uncertainty about just when the money will begin flowing again.
"I don't know," said Terry Goddard, operations director for Aid for AIDS.
At Beyond Shelter, which receives the money from the city and distributes it to organizations across the city, officials said they are asking assistance groups to have clients fill out all the necessary paperwork so that once the logjam is cleared, money can be doled out immediately--something they hope happens within a few days.
Several people who receive money through the program praised the private groups for their efforts, but blamed the city for adding to the hardship already endured by people who are suffering from the disease and struggling to make ends meet.
"When you're living hand-to-mouth, this hurts," said Richard W. Eastman. "I'm getting sick and tired of having to fight for everything."
Eastman, who has battled AIDS since 1995, added that he wants an investigation into the delay. "Enough is enough," he said.
The AIDS Healthcare Foundation, meanwhile, has filed a suit against Los Angeles Mayor Richard Riordan alleging that the city of Los Angeles has mismanaged the federal HOPWA money.
According to the lawsuit, the city's Housing Department has applied for and received HOPWA money every year since 1992. Year after year, however, local authorities have been slow in passing it along to those who need it, critics say, resulting in a pool of unspent money that has reached more than $17 million.
"Defendants have failed to spend the money received in the manner and in the time in which they promised," the lawsuit alleges. "Because of defendants' repeated and continual breaches of their agreement and violations of rules of the ... program, defendants are in jeopardy of losing the funds currently allocated and future funding, to the detriment of the citizens of Los Angeles city and Los Angeles County with AIDS and their families."
The lawsuit caps more than a year of mounting frustration over the city's handling of the AIDS money. Activists have staged news conferences outside Mayor Richard Riordan's office and protests outside his official residence.
Riordan has generally downplayed the issue's seriousness, but the city audit completed late last month amplified some of the critics' complaints.
That report, released April 29th by Los Angeles City Controller Rick Tuttle, documented what activists have called "widespread mismanagement" of the HOPWA. The report confirmed that Los Angeles has been hoarding at least $17 million in unspent or "only recently programmed" funding, some of which it received from the federal government as long ago as 1994, while homelessness continues to disproportionately affect people with AIDS and HIV.
"This report confirms what we've being saying all along about the city's gross mismanagement of L.A.'s AIDS housing program," said Michael Weinstein, president of the AHF. But Weinstein and other activists who were outraged at the confirmation of their fears also took some comfort in knowing the city will now have to change policies if it is to remain in compliance with federal guidelines.
"Rather than look seriously at our allegations and interpretations of earlier financial reports, city officials instead chose to 'shoot the messenger' by attacking or ignoring us," Weinstein said.
Meanwhile, he said, "An untold number or Angelenos with AIDS lived and died on the streets as money to house them went unspent."
A preliminary report from an AIDS housing study commissioned by the city of Los Angeles revealed in July 1998 that two-thirds of local PWAs reported homelessness. In January 1999, without fanfare, the city released the final copy of the study, with the statistics unchanged. Local activists have held two earlier news conferences at the mayor's office to protest HOPWA funds going unspent while PWAs were homeless, and held a press conference in September, as well as a 34-hour vigil for homeless people with HIV in October, at Riordan's official mayoral residence. In both instances they pointed out the irony that homelessness continues to be a concern for PWAs, but Riordan lives elsewhere and the mayoral residence is vacant.
At the October vigil, activists pointed out the potential fatal effect of homelessness on people who depend on complex prescription drug schedules, but who can't maintain life-saving treatment while homeless.
At that time, Los Angeles responded by estimating that "only" between $5.5 million and $6.8 million AIDS housing dollars went unspent.
Tuttle's report confirmed the figure is at least $17 million. It also concluded, in his words:
--"Federal HOPWA program funds administered by the city for county residents have not been committed or used timely;"
--"Approximately $17 million of the current and prior years funding has only recently been programmed;"
-- "Significant unspent funds remaining in contracts from program years as early as 1994;"
--"There is inadequate long-term program planning;"
--"The recent study did not quantify the unmet needs of the entire affected community;"
--"The LAHD [L.A. Housing Department] needs to break the cycle of being a year or two behind the funding cycle and plan proactively for the future;"
--"[There are] inadequate goals or measures to effectively gauge performance, and no plan to continually identify and address the primary needs of the affected community and measure results of the program;"
-- "[There is] no comprehensive outreach program"; and
--"HOPWA brochures are outdated and only available in English."
He had several suggestions for improving the situation:
-- Evaluate the needs of HIV/AIDS patients countywide and prioritize the areas where HOPWA program funds are most needed;
-- Quantify the amount of unspent HOPWA funds from current and prior year grants;
-- Develop a strategic plan to match unspent available funds to prioritized needs;
-- Work to speed up the process of identifying providers and reprogramming moneys to ensure needs are met, including increasing outreach efforts; and
-- Provide adequate management oversight of the program, including the addition or reassignment of senior level staff.
Cesar Portillo, AHF's government affairs director, has an additional suggestion. "We've demanded an emergency plan of action since October," he said. "Since the housing bureaucrats are still denying serious problems with HOPWA, we are now also demanding that the mayor fire the bureaucrats responsible or turn the program over to the county."
"I truly hope that this scathing report finally serves as catalyst for the long-overdue overhaul of the city's handling of HOPWA," Weinstein said, "but I won't put away my protest signs just yet."
(This article was prepared from reports in the Los Angeles Times and the Bay Area Reporter.)
Nevada will allow forced HIV testing by police
The Nevada Assembly voted unanimously on May 6th for a bill letting Nevada firefighters and police force anyone who splashes blood or other bodily fluids on them to be tested for communicable diseases.
Assembly Bill 483 would let firefighters, police, prison guards, emergency medical technicians or "any other person who is employed by an agency of criminal justice" petition a court to force anyone who voluntarily or involuntarily exposes emergency workers to blood, feces or urine to be tested for HIV or Hepatitis B immediately.
Although the bill passed without comment in the Assembly, law enforcement officials lobbied heavily for the bill in the Judiciary Committee.
Supporters say if emergency workers are exposed to a significant amount of bodily fluids, they should know as soon as possible if that exposure could lead to serious health problems.
To force a test on someone who has exposed them, emergency workers would have to get a public health officer to convince a judge that they have indeed been exposed.
There is no known incidence of HIV infection of police officials through the methods the bill describes. While infection by splashing with infected blood is theoretically possible, it is not believed that HIV can be transmitted through contact with urine or feces.
Supporters say that getting faster test results would help officers avoid the stress of not knowing whether they've been exposed and would also allow them to seek treatment immediately if test results are positive. This is especially important in cases of HIV, supporters say. After exposure, emergency workers can seek a certain type of treatment, called prophylaxis, which significantly reduces the chance of contracting HIV.
Study: Hodgkin's disease an AIDS-defining illness
An increased incidence of Hodgkin's disease occurring in HIV-infected people around the time of progression to AIDS suggests that this cancer should be added to the list of AIDS-defining conditions.
This is one of the conclusions reported by Australian investigators who conducted a retrospective review of 3,616 registered AIDS cases in New South Wales.
Dr. Andrew E. Grulich, of the National Center in HIV Epidemiology and Clinical Research in Darlinghurst, and associates calculated the adjusted standardized incidence ratios for individual cancers that occurred between 1980 and 1993.
They identified 716 cases of AIDS-defining cancer and 62 cases of other cancers over the study period. Among the 62 non-AIDS cancers, they observed a significantly increased incidence of Hodgkin's disease, multiple myeloma, leukemia, lip cancer and lung cancer.
"The incidence of Hodgkin's disease increased significantly around the time of AIDS diagnosis...suggesting an association with immunodeficiency," according to the team's report in the May 7th issue of AIDS.
These findings and other reported data "indicate that Hodgkin's disease is associated with immunodeficiency in people with HIV infection and that it should probably qualify as an AIDS-defining illness," the authors write.
As more effective antiretroviral therapy regimens prolong the lives of people with AIDS, Dr. Grulich's group suspects that "other cancers occurring at increased rates will be identified."
FDA fast tracks another Trimeris drug
Less than a month after receiving the application, the US Food and Drug Administration has granted a fast-track designation to T-1249, the second HIV fusion inhibitor developed by Trimeris Inc., according to a statement from the company.
The peptide, designed to block the entry of HIV into host cells, "has demonstrated potent HIV suppression in animal models," Trimeris officials said. T-1249 is also said to be "highly active against a wide range of HIV strains in culture."
Trimeris is currently finishing phase II trials of T-20, its first HIV fusion inhibitor, which also has fast-track status. The company hopes to begin phase III trials of T-20 by the end of this year.
Many Asian American men unaware of HIV risk
Most Asian American men do not believe they are at risk of HIV or other sexually transmitted diseases (STD), and almost half report that they do not always use condoms during sexual intercourse, according to the results of a survey conducted by the National Asian Women's Health Organization.
The majority of the 802 respondents, 87%, reported having at least one sexual partner in the previous 12 months, according to a NAWHO press release. However, more than 83% of all respondents indicated that they do not feel that they are at risk for STDs, and 49% of the sexually active respondents reported that they do not always use condoms.
Of the respondents who reported ever using condoms, 82% cited contraception as the main reason and only 18% cited prevention of HIV or other STDs.
The survey also found a low rate of HIV screening among Asian men. Thirty-nine percent of the survey respondents had been tested for HIV compared with 59% of men in the general US population.
The data were obtained from English-speaking Asian men between the ages of 18 and 65 years of age who resided in Los Angeles, San Francisco or New York City. The overall response rate was 52%.
"This behavior has an immediate impact on the health of their Asian American women partners and families and puts them at great risk," Mary Chung, NAWHO president, commented. "Public health policies and programs need to target and educate Asian American men about STD and HIV awareness."
Chung added that "Asian American men have been noticeably absent from health studies and it's important to pay attention to the impact of gender roles on health behaviors."
The study found that Asian American men want to be responsible decision- makers in sexual relations. However, the extremely high sense of responsibility is limited by the under estimation of personal risk for STDs or HIV.
Other findings include an overwhelming majority of Asian American men support public funding for family planning programs as well as a woman's right to access abortion services. Their primary source for reproductive health information is the mass media.
Decline in NY AIDS deaths slowing
Between 1995 and the end of 1997, the number of AIDS deaths in New York City fell by 63%, according to researchers at the New York City Department of Health. But by 1998, this rate of decline began to slow down.
The increased availability of new antiretroviral therapies played a role in the "precipitous" decline in HIV/AIDS deaths, Dr. Mary Ann Chiasson and colleagues report in the Journal of Acquired Immune Deficiency Syndromes. But the slowing declines in HIV/AIDS deaths observed in 1998 suggest that "not all HIV-infected individuals are receiving adequate treatment or benefitting from it and that deaths due to HIV/AIDS will continue."
From the beginning of the epidemic, New York City has had one of the highest concentrations of HIV infections in the US, the investigators point out. The city, which accounts for 3% of the US population, has close to 16% of all reported US AIDS cases.
The researchers note that the annual number of HIV/AIDS deaths rose steadily from 1983 until 1995, when it stabilized at 7,046. AIDS deaths declined by 29% in 1996 and by 47% in 1997.
"Comparing data from 1997 with those from 1995, declines occurred in all demographic groups and in all major HIV transmission categories," Chiasson and colleagues report.
However, from 1995 through June 1998, "declines were smaller than they had been in previous 6-month intervals in all demographic groups except Hispanic males and those between 35 and 44 years of age," the investigators report. In addition, the number of New Yorkers living with AIDS increased by 22% between 1995 and July 1998.
"The challenge for the future will be to ensure adequate medical and social services for the increasing number of people living with HIV and AIDS," the research team concludes.
Treatment guidelines, drug scheduler now on Internet
Updated HIV treatment guidelines are now available on the World Wide Web at the AIDS Treatment Information Service (ATIS) website, http://www.hivatis.org. The guidelines are published by the Panel on Clinical Practices for the Treatment of HIV Infection, convened by the US Department of Health and Human Services with the help of the nonprofit Henry J. Kaiser Family Foundation.
In a statement from the National Institute of Allergy and Infectious Diseases (NIAID), panel co-chair and NIAID Director Dr. Anthony S. Fauci called the guidelines ``an invaluable resource to all healthcare providers who care for HIV-infected individuals.''
NIAID officials describe the web-posted version of the ''Guidelines for the Use of Antiretroviral Agents in HIV-Infected Adults and Adolescents'' as a ``living document,'' updated frequently as therapeutic recommendations change.
The online service also includes resources for those with HIV. For example, viewers can use a hypertext link to jump to a discussion of the use of the controversial drug hydroxyurea in the treatment of HIV infection. Recommendations for the use of abacavir (Ziagen), a medication recently approved for use against HIV by the US Food and Drug Administration, are also included in the guidelines. NIAID officials say an update on the use of the newly approved protease inhibitor amprenavir (Agenerase) will be added in the near future.
Also under review by the panel are new data suggesting that women have more rapid disease progression than men with the same viral load. At this time, the panel does not recommend that HIV-infected women start antiretroviral therapy earlier than men.
The guidelines were first published in the print versions of Morbidity and Mortality Weekly Report (a journal of the Centers for Disease Control and Prevention), and the journal Annals of Internal Medicine.
Meanwhile, an interactive HIV/AIDS program that can help clinicians quickly devise a daily dosing schedule for multidrug HIV regimens is also now available on the Internet.
The "Drug-Drug Interactions and Medication Daily Scheduler" is available exclusively at the Medscape website, http://medscape.com. When the user enters the desired regimen, the program returns a detailed and printable dosing schedule designed to help clinicians avoid drug interactions, simplify complex multidrug schedules and improve patient adherence.
The program first identifies any potential drug-drug interactions from a list of medications commonly prescribed for HIV-infected patients. The dosing recommendations can be tailored to patient preferences about sleep and mealtime schedules.
The HIV/AIDS drug scheduler was developed by Dr. Stephen C. Piscitelli, of the National Institutes of Health in Bethesda, Maryland, and Dr. Charles Flexner, of the Johns Hopkins University School of Medicine in Baltimore, Maryland. It is part of a continuing medical education program on HIV drug scheduling that is jointly sponsored by Medscape and the Medical Education Collaborative.
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