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In this issue:
Gay men of color surpass whites in US AIDS cases
HAART adherence lower in 'inner cities'
HIV+ drug users less likely to receive HAART
Reasons for HIV treatment failure complex
Single-pill treatment in the works
Court allows AIDS insurance limits
United Nations debates AIDS impact
Working Group issues HealthChoices complaint form
African-American and Latino gay men with AIDS now outnumber white gay men with the disease, according to a new report released by officials at the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia.
Men of color represent more than half of all AIDS cases among men who have sex with men in the US, according to the study, published in the January 14th issue of the CDC's Morbidity and Mortality Weekly Report.
Gay men of color have, since the 1980s, outnumbered white gay men in Philadelphia AIDS diagnoses since 1993. This is the first time that that trend has occurred nationally.
Between January 1989 and December 1998, the proportion of AIDS cases among gay and bisexual men of color rose from 31% to 52%, while over the same period AIDS cases declined from 69% to 48% among gay and bisexual men who are white, CDC officials report. One third of these cases were in African-American men and 18% were in Latino men.
These findings demonstrate "a dramatic impact of the epidemic among Latino and African-American men who have sex with men," Dr. Helene Gayle, director of the CDC's National Center for HIV, STD and TB Prevention, commented at a press conference.
"The rate of AIDS cases among African-American men who have sex with men is now almost five times higher than that among their white counterparts and the rate among Latino men is twice as high as among white men," Gayle continued.
Furthermore, the results of a survey of 8,780 HIV-infected men who have sex with men indicate that "a significant number of African-American and Latino men who have sex with men identified themselves as heterosexual, rather than gay or bisexual," CDC officials report.
"One in four black men and one in six Latino men actually identified themselves as heterosexual despite the fact that they have sex with men and are HIV-positive," Gayle told reporters. "This compares with 1 in 17 white men."
"The tendency to equate gay with white has persisted, despite the fact that gay and bisexual men have always represented the greatest proportion of AIDS cases among minority men," Gayle pointed out.
These CDC findings also illustrate how the "stigma of homosexuality has had an impact," she said. "Homosexuality is stigmatized across all cultures, but it may be even greater in African-American and Latino communities."
"It is important to point out that this epidemic is by no means over in white gay men," she continued, "but we are starting to see a reversal in the trends."
"We've also examined the data geographically to determine the areas hardest hit and found that the vast majority, 85%, of AIDS cases among gay and bisexual men of color are occurring in cities with populations over 500,000," the researcher noted. "The five cities with the highest number of AIDS cases among these men were New York, Los Angeles, Miami, Washington, DC, and Chicago."
Looking at HIV data collected between 1996 and 1998 from the 25 states with HIV reporting systems, it also appears that men of color who have sex with men "are being infected at younger ages than white men," Gayle continued.
"Among gay and bisexual men diagnosed with HIV during this period, 16% of African-American and 13% of Latinos were age 13 to 24, compared with 9% of white men," CDC officials report.
"Men of color must be reached early with comprehensive HIV prevention programs especially in high-risk communities," according to Dr. Janet Blair, CDC study author.
"Community leadership will be critical," Gayle added. "AIDS has always raised difficult, uncomfortable issues. The silence about homosexuality and homophobia in communities of color remains a major obstacle." Gayle hopes this report will raise the visibility of this issue and help to break the silence.
In Philadelphia, African Americans have always constituted the largest segment of men who acquire AIDS by having sex with other men. About 54 percent of the AIDS cases in that group are among gay or bisexual African American men.
AIDS experts pointed to a number of factors to explain the changing demographics among men who become infected with HIV by having sex with other men.
Among them are prevention efforts and treatment advances among gay white men that have reduced the number of new HIV infections and dramatically slowed their progression to fully developed AIDS.
There have not been commensurate gains among minority gays or bisexual men, giving them a higher proportion of all AIDS cases stemming from sex with other men.
Besides homophobia in the black and Hispanic communities, AIDS experts also pointed to high rates of poverty among gay or bisexual men of color, unemployment, and lack of access to health care.
"Until we embrace all members of the community . . . we will not succeed in defeating the AIDS epidemic," said Dr. Rafael Campo, who treats a large number of Hispanic AIDS patients at Boston's Beth Israel Deaconess Medical Center.
Phill Wilson, director of the African-American AIDS Policy and Training Institute at the University of Southern California, called on every institution in the black community, from churches to schools to families, to "come to the plate" and address AIDS among sexual minorities.
"Black churches really have to embrace the teaching of Jesus around this issue," Wilson said. He said Jesus stood for loving all people, no matter what their sexual orientation or health status.
The AIDS experts joined CDC officials during an hour-long news conference to release the data.
In Philadelphia, the city Health Department commended the CDC's effort to highlight an issue that city officials say they have already begun to attack through stepped-up funding and community-outreach programs.
Of the $5 million the city will spend this year to prevent the spread of HIV, about $810,000 - the largest single grant - will go to prevent the disease among African American men who have sex with other men, Joseph Cronauer, codirector of the city's AIDS Activities Coordinating Office (AACO), told the Philadelphia Inquirer.
Cronauer said about $280,000 would go to prevent HIV among Hispanic men who have sex with other men, and $192,000 will be targeted at the more traditional community - gay or bisexual white men.
In addition, the city is setting up three storefront centers aimed, in part, at reaching minority men at high risk of HIV and AIDS. A center was recently opened by We The People at 4016 Lancaster Ave., in West Philadelphia, and two others are planned, in Kensington and in Germantown.
The centers will provide a variety of services including HIV education, prevention, links to primary medical care, and legal advice.
Michael Hinson, executive director of Colours Inc., a city-financed nonprofit group that works to prevent AIDS among gay and bisexual African Americans, told the Inquirer that he commended the stepped-up effort but said it needed to target new minority groups that are emerging in Philadelphia, such as gay or bisexual men in the West African and Indian communities.
He said many gay or bisexual black men hide their sexual orientation because they need the sanctuary of the black community to combat racism.
David Acosta, an AACO education coordinator and former head of the Gay and Lesbian Latino AIDS Education Initiative, which offered HIV prevention programs among sexual minorities in the city's Hispanic community, noted the same phenomenon among gay and bisexual Hispanic men.
"In societies where homosexuality is taboo, the society creates ways for same-sex behavior to happen without it being defined as such," he said.
He called for increased dialogue about homosexuality, particularly in poor, minority communities.
While more affluent gay men in those communities have the option of moving up and out to the larger and wealthier gay white community, poor men don't have that choice. They are forced to stay in their own communities, hiding their sexual orientation for fear of rejection, Acosta said.
"Economics has a great part to do with it," he said. (Reuters/Philadelphia Inquirer)
Up to 39% of HIV-infected patients in an inner-city population do not adhere to their antiretroviral regimens, according to members of a multicenter team.
Dr Paul J. Weidel of the Centers for Disease Control and Prevention and associates used a confidential interview and a self-administered anonymous questionnaire to estimate the degree of adherence among 173 HIV-infected patients on antiretroviral therapy.
The study participants were receiving care for HIV infection at the Bronx-Lebanon Hospital Center, which serves an impoverished community in the South Bronx. All of the subjects participated in the interview and 101 completed the questionnaire.
The results of the confidential interview indicated that 6% of the patients were nonadherent to any drug in their treatment regimen on the previous day, whereas the results of the anonymous questionnaire indicated that 28% were nonadherent on the previous day.
Similarly, the results of the confidential interview indicated an 11% rate of nonadherence during the previous month, while responses on the anonymous questionnaire indicated a 39% rate.
"The most common reasons for nonadherence in both methods were forgetfulness, inaccessibility of medications, and perceived or actual toxicity," the investigators report in the December 15th 1999 issue of the Journal of Acquired Immune Deficiency Syndromes.
In addition, for 12% of the patients who completed the anonymous questionnaire, "perceived or actual lack of drug efficacy" was the reason for nonadherence. However, "this reason was not given in any of the confidential interviews."
These findings suggest that reasons for nonadherence may vary when different methods are used to obtain data, Dr Weidel's group points out. In any case, they urge that "interventions to improve adherence should focus on making dosages easier to remember, ensuring a continued supply of medications, and circumventing toxicities." (Reuters)
Intravenous drug users who are HIV-positive appear to be significantly less likely to receive highly active antiretroviral therapy (HAART) compared with individuals in other HIV exposure groups. However, their response to treatment is comparable to that of other patients, according to members of the EuroSIDA Study Group.
Dr Amanda Mocroft of the Royal Free and University College Medical School in London, and colleagues prospectively evaluated a cohort of 6645 HIV-infected patients. Specifically, they looked at factors associated with the use of HAART, response to therapy and survival.
The results of multivariate analysis revealed that "intravenous drug users were significantly less likely to be receiving HAART at recruitment to EuroSIDA...when compared with homosexual men."
Intravenous drug users continued to be less likely to receive HAART during follow-up. After adjusting for other factors, they found that "intravenous drug users were at a 27% reduced risk of starting HAART."
In contrast, Dr. Mocroft's team observed no differences in the likelihood of receiving HAART between homosexual and heterosexual subjects.
"Among those patients who started HAART, there were no significant differences between exposure groups in CD4 lymphocyte count response to HAART or virologic response to HAART," the researchers report in the December 1st 1999 issue of the Journal of Acquired Immune Deficiency Syndromes.
If intravenous drug users continue to receive HAART less frequently than other exposure groups, Dr Mocroft's team suggests, these individuals may have a "poorer prognosis, a different spectrum of AIDS-defining illnesses, and differential long-term clinical results."
But another study reported that while injection drug users and individuals with low educational levels tend to receive HAART later in the course of HIV infection compared with other patients, this delay does not appear to influence the rate of clinical disease progression.
These findings, reported by Dr Matthias Egger of the University of Bristol in the United Kingdom and other members of the Swiss HIV Cohort Study, are published in the December 24th 1999 issue of AIDS.
Dr Egger's group looked at 3342 subjects in this national prospective multicenter study, which included 1007 women. A total of 1155 subjects had acquired the virus through injection drug use and 1172 men became HIV-infected through homosexual contact.
The researchers examined the use of HAART in these subjects, as well as the effect that the timing of treatment had on clinical disease progression. At baseline, the majority of patients (87%) did not have AIDS. The subjects' median CD4 count was 269 cells/L and their median viral load was 4.3 log10 copies/mL.
After controlling for confounding factors, Dr Eggers' group found that ""the probability of starting HAART was lower in injection drug users compared with men who have sex with men...and in patients with minimum schooling compared with those with vocational training."
However, the researchers found the risk of clinical disease progression to be "similar among men and women, patients with a history of injection drug use, and patients with lower educational attainment in both univariable and multivariable analysis."
Overall, these "apparently contradictory findings" suggest to the researchers that "deferring HAART may not be detrimental." However, they stress that confirmation of these data with long-term clinical trials is still needed to determine when HAART should be started. (Reuters)
HIV treatment may fail because patients are not taking their medications as instructed or because the drugs are not potent enough, results of two new studies suggest. The findings could have an impact on treatment for HIV-infected individuals, experts say.
Powerful combinations of medications can reduce HIV to undetectable levels. If levels of the virus begin to rebound, it is often thought that such treatment failure is due to mutant strains of the virus resistant to the medications.
However, the problem may be even more complex, according to research published in the January 12th issue of the Journal of the American Medical Association.
In one study, Dr. Diane Descamps, of the Bichat-Claude Bernard Hospital in Paris, and colleagues compared 58 patients who experienced an increase in HIV levels to 58 patients who still had undetectable levels of HIV. Based on the results of tests that detect resistant strains of HIV, Descamps and her colleagues conclude that growing resistance to medications was not the main reason for the rebound of HIV. Instead, patients who experienced a rebound were less likely to have taken all the doses of the medication as prescribed. In another group of patients whose HIV levels rebounded, however, the problem may have been insufficient drug potency, since this group appeared to be taking their medications as recommended. The findings may have important implications for the treatment of HIV, according to the report. Instead of switching all medications when drug therapy begins to fail, it is important to identify which drugs a person might be having a hard time taking and to find an alternative medicine, they report. In the second study, Dr. Diane V. Havlir, of the University of California at San Diego and colleagues compared 26 patients whose HIV levels began to rise to 10 patients whose levels remained undetectable.
In an interview with Reuters Health, Havlir said that when HIV treatment fails, it's often thought that the virus has become resistant to all of the drugs used. However, this may not be necessary.
"When their virus rebounded, it was resistant to one of the drugs, but not the protease inhibitor," Havlir said.
Based on the findings, Havlir said it might make more sense to change only the medication to which HIV has become resistant. The findings "provide a rationale for trying new therapeutic options," Havlir said. The results highlight the importance of periodic testing to see if HIV has developed resistance, she said.
In an editorial that accompanies the studies, Dr. Martin Markowitz, of the Aaron Diamond AIDS Research Center in New York, agrees on the importance of testing for HIV resistance. He also states that no single factor -- resistance, adherence to therapy or drug dosage -- is to blame for the failure of HIV treatment.
Developing drug regimens that are simpler and that have fewer side effects will be helpful for patients, but the results of these studies show that it is important not to do so at the expense of the proper strength of medication, according to Markowitz. (Reuters)
In the field of HIV drug treatment, any successful attempt to simplify the drug regimens of patients taking combination therapy is a welcome event.
One such simplification came in the form of Combivir, a single pill combining both AZT and 3TC that was approved in Canada on December 4, 1998.
Now the same companies that brought us Combivir, namely Glaxo Wellcome and BioChem Pharma, are seeking approval for Trizivir, a product that combines AZT, 3TC and abacavir in a single tablet. Each of these products belongs to the class of drugs called nucleoside analogues (nukes).
One advantage that this product offers is convenience. If doctors choose to prescribe Trizivir, patients will simply have to take one pill twice daily, with or without food. Another possible advantage is that using a triple nuke combination allows patients to reserve drugs such as protease inhibitors for future use in the event that Trizivir stops working.
Trizivir may, however, present some disadvantages. For example, according to the journal SCRIP, some doctors are concerned that Trizivir may not be strong enough to suppress production of HIV in people with relatively high viral loads. The product may therefore not be suitable on its own for every patient. As well, patients taking Trizivir may risk having a hypersensitivity reaction to the product because of its abacavir content.
About three to five per cent of abacavir users have had such a reaction, manifesting symptoms such as nausea, rash, fever and fatigue. When a hypersensitivity reaction to abacavir occurs, treatment must be stopped immediately.
Glaxo Wellcome submitted its data on Trizivir for approval in Canada, the European Union and the United States in December 1999. (Community AIDS Treatment Information Exchange. For more information visit CATIE's Information Network at http://www.catie.ca)
The Supreme Court, rejecting allegations of illegal bias, has let an insurance company provide less health care coverage for AIDS-related illnesses than for other conditions under the same policy.
The court, without comment, turned down an appeal in which two HIV-positive men argued that the limit on AIDS coverage violates a federal ban on discrimination against the disabled.
The two Chicago-area men, whose names were not given in court papers, bought health care policies from Mutual of Omaha.
One policy, purchased in 1992, set a $25,000 lifetime coverage limit for AIDS-related illnesses but a $1 million maximum for other conditions. The other policy, purchased in 1997, had a $100,000 limit for AIDS-related illnesses and a $1 million limit for other aliments.
The men sued, saying the limits on AIDS coverage violated the federal Americans With Disabilities Act. The law protects the disabled against discrimination in many areas, including jobs and public accommodations.
The Supreme Court ruled in 1998 that people who carry the HIV virus that causes AIDS are covered by the disabilities law even if they have no visible symptoms of acquired immunity deficiency syndrome. A federal judge in Chicago ruled for the two men in 1998, but the 7th U.S. Circuit Court of Appeals reversed that ruling.
Mutual of Omaha did not refuse to sell insurance to people infected with HIV, the appeals court said, but instead made a coverage decision similar to a furniture store deciding not to sell wheelchairs.
The appeals court said most health insurance policies contain coverage caps. Ruling for the two men would ban coverage caps for diseases classified as disabilities but allow limits on coverage for other illnesses, such as heart disease, it added.
Lawyers for the two men told the justices that the limit on AIDS coverage "presents a classic case of disability-based discrimination." The policy would limit coverage for diseases, such as pneumonia, when they are AIDS-related but would not limit coverage for the same disease when it is not AIDS-related, the appeal said.
Mutual of Omaha's lawyers urged the justices to reject the appeal. They said the insurance firm had not discriminated because it offered them the same coverage given to other customers. Mutual's policies limit coverage for other conditions such as alcoholism, drug addiction and mental illness, the company's lawyers said.
The case is Doe vs. Mutual of Omaha Insurance Co., 99-772. (Associated Press)
U.S. Vice President Al Gore, presiding over his first U.N. Security Council session on January 10th, announced $150 million in stepped-up U.S. contributions in the worldwide battle against AIDS, particularly in Africa where whole villages are being wiped out by the disease.
Gore, addressing the council's first-ever meeting on AIDS, said the Clinton administration was seeking another $100 million from Congress in the 2001 budget to combat the virus abroad by reducing mother-to-child transmission, providing care for AIDS orphans and increasing prevention programs.
Most of the new funding had been announced previously by the Clinton Administration, according to advocates.
Gore also said next month's budget proposals would include $50 million to help fund vaccine research and distribution for a variety of diseases, including AIDS.
The new funds, in addition to those pledged earlier, amounted to a budget proposal of $325 million to combat AIDS and other diseases in the developing world, Gore said.
U.N. AIDS officials estimate Africa annually needs at least $1 billion to combat the disease but currently receives only $160 million a year in official assistance.
"It's doable but we can't continue with business as usual as we have been doing in many years," said Peter Piot, head of UNAIDS. He hoped other nations would follow the U.S. lead and triple their contributions. In his opening comments, Gore said the council had to consider the epidemic as a threat to peace and therefore as a proper subject for the council to discuss.
"When 10 people in sub-Saharan Africa are infected every minute; when 11 million children have already become orphans, and many must be raised by other children; when a single disease threatens everything from economic strength to peacekeeping -- we clearly face a security threat of the greatest magnitude," Gore said.
China and Russia, apparently apprehensive that human rights would become the next council issue if health matters were allowed, refused to address the session that included speeches from the health ministers of Namibia, Uganda and Zimbabwe.
Some 33.6 million people have HIV around the world, 70 percent of them in Africa, thereby robbing countries of their most productive members. About 13 million of the 16 million people who have died of AIDS are in Africa.
Gore sat in the chair of the Security Council for some 40 minutes of the all-day meeting. The United States holds the rotating presidency of the 15-member council for January, which its U.N. ambassador, Richard Holbrooke, has turned into a "Month of Africa," with plans for a series of public meetings. British Ambassador Sir Jeremy Greenstock, whose country has pledged some $160 million to combat AIDS over three years, said the council's debate would "stop with words produced today" without a proper follow-up.
France called for similar action.
Greenstock said the world needed political will, coordination and research because "we've got to have a vaccine." He also said every rich country, like the United States, "should say publicly what money it is putting into an AIDS program and then we might be getting somewhere."
Eastern and southern Africa have been particularly hard hit by AIDS, with 50 percent of the world's HIV positive cases but less than 5 percent of the global population.
Zimbabwe, which loses nearly 1,000 people a week to HIV-AIDS, said the virus had peaked in 1995 because of numerous government programs but that it could not do it alone.
Its health minister, Dr. Timothy Stamps, castigated the West for spending some $600 billion on the Y2K computer threat. He called it a "largely irrelevant threat ... whilst the world at large has laconically observed the exponential growth of the HIV epidemic in areas not materially linked to the growth of the international economy."
Wars, a lack of resources for health care, the high costs of drugs and a lack of public discussion on prevention often contribute to the spread of the disease.
In India, for example, World Bank President James Wolfensohn said some bank funds had not been spent because of a fear that discussions of AIDS would promote promiscuity.
"We're losing judges, lawyers, government officials, persons in the military. It is being more effective than war in terms of destabilizing countries," Wolfensohn said.
Secretary-General Kofi Annan said high AIDS death rates among Africa's elite threatened the ability of some countries to govern properly. "In already unstable societies, this cocktail of disasters is a sure receipt for more conflict. And conflict in turn provides fertile ground for further infections," he said. Piot and other U.N. officials said the "bottom line" for the future was the development of safe and affordable vaccines and drugs required to prevent and treat HIV.
Pressed by drug makers, the United States had objected to a South African law to allow local manufacturers to make cheaper, generic copies of AIDS drugs or import medicines from a third party. But in September, Washington agreed to support Pretoria's efforts to obtain cheaper AIDS medicines in exchange for promises patent rights would not be violated.
Meanwhile, ACT UP reacted to the events at the UN with a reminder that official US policy continues to effectively block access to AIDS medications in Africa.
Activists contend that, without continued pressure, the Clinton Administration's statements that it will back away from obstructing access to AIDS drug in developing countries will not result in substantial change.
"Collaboration between USTR and public health officials is a welcome-if overdue-change," said John Bell of ACT UP. "But this dubious process misses the point: US trade pressure on poor countries must end immediately."
More than 40 countries remain on USTR's 301 "Watch List" or are otherwise involved in bilateral trade disputes with the US regarding pharmaceuticals access. Tunisia and Egypt are among the African nations currently targeted by USTR for their efforts to increase essential drug access.
After confrontations with Gore on the campaign trail, including mass protests in DC and Philadelphia, the Clinton administration reversed its position on the South African law authorizing trade measures such as compulsory licensing (generic production of patented drugs) and parallel importing (drug purchasing through third party country).
These measures are legal according to international trade agreements on intellectual property can reduce medication prices by as much as 90%.
However, the South Africa agreement will not be applied to other struggling nations, according to Clinton's top AIDS advisor Sandy Thurman; activists are demanding that this agreement be extended to all poor countries in need of essential medications.
"We forced Gore to do the right thing on access to essential drugs in South Africa, but US trade policy on medication access is still deadly despite reform," said Joyce Hamilton, ACT UP member. "Poor countries remain vulnerable at the hands of big business and USTR."
ACT UP also criticized Gore's announcement of US funding for AIDS efforts in Africa.
"At the behest of the multi-billion dollar drug industry, and on the taxpayer's dime, the Clinton Administration has spent years bullying poor nations who were simply trying to provide medications for its citizens. Gore's call for a drop in the funding bucket -- with no certain fate in Congress -- rings hollow," said Del Guilfoy, an ACT UP member. "Right now, our government is keeping African nations from saving the lives of millions of people with AIDS. An end to these US pressure campaigns would cost taxpayers nothing."
The Working Group on HealthChoices and HIV has revised the form it uses to collect complaints from people living with HIV/AIDS in southeastern Pennsylvania regarding HealthChoices, the state's Medicaid managed care program.
Since its implementation over three years ago, the requirement that all Medicaid recipients in the Delaware Valley obtain their health care through Medicaid HMOs has led to problems for some PWAs in getting access to AIDS specialists and obtaining HIV-related prescriptions.
The new forms are attached as Microsoft Word documents with the email edition of this issue of fastfax, and are printed on the last two pages of the print edition. The forms will also be available through We The People's website at http://peoplewithaids.org/healthchoices, beginning on January 15th.