PCP deaths dropping, CDC report says
AIDS drug works against hepatitis B
Clinton releases money for heating program
GOP: discharge service members with AIDS
Deficit may force ActionAIDS service cut
Governors can't work out Medicaid
HMOs limit what doctors tell patients
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PCP deaths dropping, CDC report says
Pneumocystis carinii (PCP) pneumonia -- once the most common cause of death among people with HIV -- has decreased dramatically in the United States, according to a new report from researchers at the Centers for Disease Control and Prevention in Atlanta.
However, pneumonia caused by unspecified organisms has become the second-leading cause of death among people with HIV infection, the researchers reported in the Annals of Internal Medicine.
The dramatic drop in HIV-related deaths associated with PCP pneumonia is due to a number of factors, including better drugs for both prevention and treatment, and improved methods of diagnosing the disorder early, the CDC said.
From 1987 to 1992, the percentage of HIV-related deaths associated with PCP pneumonia decreased from 32.5 percent to 13.8 percent, the report said.
On the rise are HIV-related deaths due to non-Hodgkin's lymphoma, bacterial pneumonia, cytomegalovirus disease and septicemia -- an infection that spreads throughout the entire body, the CDC added.
There were no significant changes in the percentages of deaths associated with Kaposi's sarcoma, toxoplasmosis or pneumonia caused by unspecified organisms, the report stated.
"Because drugs for many of these infections are available, HIV-infected people should learn of their infection and obtain appropriate medical care as soon as possible," the researchers wrote.
AIDS drug works against hepatitis B
A new infection-fighting drug used to treat HIV also appears to work against the highly contagious hepatitis B virus, Boston researchers report.
In a study of 32 people with chronic hepatitis B, the drug lamivudine stopped the virus from reproducing in those who took 100- or 300-milligram doses each day for 12 weeks.
Viral activity resumed in all but six of the 32 people after treatment was stopped. But a longer course of the drug could suppress the virus indefinitely and prevent subsequent liver disease, said Dr. Raymond Koff, chairman of medicine at MetroWest Hospital in Framingham, Mass.
The findings are "an exciting new observation, and in a small number of people we can start thinking about the notion of a cure," Koff said.
More contagious than the AIDS virus, hepatitis B causes inflammation of the liver, and can lead to an increased risk of liver cancer. About 300,000 people in the United States are infected with the virus each year, and more than one million Americans are thought to be carriers of hepatitis B, according to the Centers for Disease Control and Prevention in Atlanta. The majority of cases are spread through sexual intercourse, intravenous drug use and blood transfusions.
In the new study, published in The New England Journal of Medicine, hepatitis B patients took 25, 100 or 300 milligrams of lamivudine each day for 12 weeks.
Viral replication - a sign that the virus is active in the body - was stopped in 70 percent of the people who took 25-milligram doses of the drug, and in 100 percent of those who took either of the two higher doses, according to the report, led by Dr. Jules Dienstag of Harvard Medical School.
"It may be premature to get extraordinarily excited," Koff said. "But if longer term follow-up studies are done, we may really be talking about a cure."
Lamivudine, part of a new class of drugs called nucleoside analogues, works by interfering with the replication of DNA - the material in a cell's nucleus that gives instructions for a person's genetic makeup.
The drug, also known as 3TC, recently was approved by the U.S. Food and Drug Administration to treat HIV infection.
A vaccine to prevent hepatitis B infection is widely available. But the only other drug used to treat the infection - interferon - is ineffective in about 60 percent of people.
Katherine Liu, a hepatitis B expert with the American Social Health Association, said the new drug may work on a larger number of people than interferon does. But she stressed that vaccinations are even more important, because they can prevent infection altogether.
"Health-care professionals are always looking for a cure, rather than at available and effective prevention measures," she said.
While there were no severe side effects from the drug among people in the new study, everyone experienced a rise in a substance found in liver tissue - alanine aminotransferase - that has been shown to increase in people with liver damage.
"Although this substance does have a toxic effect on the liver, in most cases it is usually a mild [effect]," said Dr. Alfred Prince, director of virology at the New York Blood Center in New York City.
Clinton releases money for heating program
Defying a House plan to kill the program, the Clinton administration has released $578 million to help low-income families pay their heating bills.
The Low Income Home Energy Assistance Program, or LIHEAP, is one of the points of contention that have held up congressional action on a $250 billion bill to fund the departments of Labor, Health and Human Services and Education in 1996.
The House version of the Labor-HHS bill does not fund the program. The Senate has proposed $900 million - $100 million less than current spending set in the 1995 budget for 1996 programs.
House Republicans say that LIHEAP is a relic of the oil crisis in the 1970s when sharply rising heating costs caused widespread hardships in northern states. But their claims that the program has outlived its usefulness have been resisted by Democrats and many northern state Republicans.
Rep. Bernard Sanders, an independent from Vermont, praised the White House for releasing the funding in preparation for a freezing winter. The heating assistance program includes $3.2 million for Vermont.
"What we didn't want to see happening was that in the midst of all the squabbling in Congress, people going cold and finally this money being released in July," Sanders said. "I'm really delighted that the president has responded as quickly as he has."
Pennsylvania governor Tom Ridge announced earlier this month that state funding for LIHEAP would be released even though the federal portion was not yet available.
GOP: discharge service members with AIDS
The defense bill passed by the House of Representatives would require automatic discharge of thousands of service members with HIV.
Under the provision, put forward by Rep. Robert K. Dornan, R-Calif., service members who test positive on two separate tests would be discharged within six months. The bill makes an exception for those within two years of retirement; they would be able to serve out their military careers. In any case, the discharge papers of the service member would not mention HIV.
Senators won inclusion of a new provision that would enable those discharged to continue receiving military health care services.
Sen. Sam Nunn, D-Ga., said he will oppose the bill because of a number of "fundamental flaws" including the AIDS provision and a measure banning abortions at overseas military hospitals. The measures, Nunn said, "needlessly inject domestic political issues into military manpower policies."
A GOP rebuttal notes that the service member will receive an honorable discharge. It repeats an argument used by Dornan that service members with HIV are barred from being deployed overseas. The result, Dornan contends, is what amounts to preferential treatment of service members with the virus and an extra burden on the rest of the military.
In addition to the Clinton administration, the military services oppose the measure, saying they are able to manage the HIV problem internally without direction from Congress. Last spring the Army's personnel chief wrote to Dornan saying that "HIV-infected soldiers who are physically fit for duty should be allowed to continue on active duty."
Opponents of the provision say there is little chance of reversing an HIV discharge policy through court action because the military is exempt from the Americans with Disabilities Act.
"It clearly stems from Robert Dornan's anti-gay hysteria," said David Smith of the Human Rights Campaign Fund. "It's part of his obsessive dislike for gay people."
Deficit may force ActionAIDS service cut
ActionAIDS executive director Ennes Littrell has announced that a $125,000 deficit in the organization's $6 million annual budget may result in "cutbacks in service" beginning with the new year.
"Unless we see a substantial increase in our revenues in the next 30 days, we could start the year with cutbacks in service," Littrell said, in a letter to donors.
"As a result of losses in revenue from our donors and friends, many of whom have died, ActionAIDS now faces a deficit of nearly $125,000," she wrote.
The letter, directed to a "handful of ActionAIDS' most loyal supporters," is one of several which are part of the group's annual holiday fundraising appeal. More than half of ActionAIDS' funding is provided from city, state and federal government contracts, with the remainder from fundraising, corporate and foundation grants, and contracts for services to health maintenance organizations and others.
Governors can't work out Medicaid
Negotiations between Democratic and Republican governors on the future of Medicaid boiled down into a meeting among Govs. Lawton Chiles (D-Fla.), John Engler (R-Mich.), Mike Leavitt (R-Utah), and Roy Romer (D-Colo.).
Gov. Engler pronounced the negotations "encouraging" but they broke down shortly afterwards. Gov. Chiles probably summed it up best, as quoted in the Washington Post:
"Maybe we talked past each other for a while. They thought we were going to help them make a block grant work better for us and we were talking about how to make a per capita entitlement work better for them."
The one thing the four governors appeared ready to agree on, although this did not lead to a larger agreement, was that they didn't like getting sued. Gov. Engler was paraphrased as saying that "retention of an entitlement was anathema to the [Republican] governors because it would lead inevitably to an explosion [!] of Medicaid lawsuits." (Remember that governors have been dealing with Medicaid lawsuits, explosive or otherwise, for more than a quarter-century.)
Gov. Romer said that Democratic governors were sympathetic. "Any time anybody is denied anything, they run right down to federal court," he told the Washington Post. (Of course, one recent run to Colorado federal court, the Miller v. Ibarra case, corrected a serious inequity under which seniors with no realistic way to pay for nursing home care were being denied coverage by Colorado Medicaid. The judicial solution was so reasonable that in OBRA '93 Congress decided that it should be applied nationwide.)
According to the Post's paraphrase, Gov. Romer suggested that "lawsuit frenzy" could be avoided by "having a state administrative procedure to handle complaints." (Note: current law provides this.) The unsatisfied complainant could appeal to state court, and only state court decisions could be taken to federal court, "presumably" (the Post's word) "reducing the number of lawsuits." (And presumably doubling the amount of time and effort that would be spent on any single lawsuit.)
Gov. Engler observed (incorrectly) that this two-forum procedure was "provided in the vetoed legislation," that is, the budget reconciliation bill which the President vetoed on December 6. (In fact, the reconciliation bill would have ruled out any lawsuits, state or federal, based on a violation of federal conditions under which states received their block grants.)
At any rate, this meeting of the gubenatorial minds with respect to lawsuit frenzy, such as it was, did not produce a larger agreement on the structure of Medicaid.
HMOs limit what doctors tell patients
Doctors across the country say that health maintenance organizations routinely limit their ability to talk freely with patients about treatment options and HMO payment policies, including financial bonuses for doctors who save money by withholding care, according to a report in The New York Times.
HMOs may limit access to certain tests and treatments and require doctors to obtain permission from the HMO to offer them. Doctors may receive bonuses or other financial rewards from the HMO if they control costs and help restrain the use of health care -- especially for patients with advanced illnesses likely to be fatal.
But patients are often unaware of these financial arrangements because many contracts between doctors and HMOs prohibit the doctors from disclosing them. Increasingly, doctors are objecting to these confidentiality clauses, which they call "gag clauses," and they say that patients are entitled to such information.
A typical clause is found in the contract of Choice Care in Cincinnati, which says, "Physician shall take no action nor make any communication which undermines or could undermine the confidence of enrollees, potential enrollees, their employers, plan sponsors or the public in Choice Care, or in the quality of care which Choice Care enrollees receive."
A recent notice to doctors working for the Kaiser Permanente HMO in Ohio says, "Do not discuss proposed treatment with Kaiser Permanente members prior to receiving authorization" from an outside company that sets guidelines for the treatment of patients. In addition, it says that doctors should not discuss the procedure by which they get such authorization.
Asked about this instruction, Jenny Hovinen, a spokeswoman for Kaiser Permanente of Ohio, said, "It's a very unfortunate statement, isn't it?" But she said it was part of an elaborate effort to guarantee high-quality care by making sure doctors were aware of the best treatments before discussing them with patients.
Doctors in New York and the League of Physicians and Surgeons have filed a lawsuit challenging a confidentiality clause, on the ground that it "stifles discussion of quality of care issues and HMO practices that are harmful to patients." The case was argued last week before a state judge, who has yet to issue a decision.
Other contracts say that doctors may not make "disparaging remarks" or "derogatory remarks" about HMOs. Some contracts say that if doctors are dropped from a particular health plan for any reason, they may not contact their patients to inform them of that fact. The HMOs apparently fear that such doctors will encourage patients to leave one health plan and follow the doctors to another.
The doctors' complaints illustrate the tension between them and HMOs as health plans try tomonitor and regulate the doctors' behavior.
Dr. Daniel Gregorie, president of Choice Care in Cincinnati, defended the confidentiality clause as a way to prevent doctors from sharing their frustrations with patients.
"Physicians are angry, frustrated and, to some extent, depressed because the world as they've known it is changing rapidly and radically," Gregorie said. "But physicians should not take out that frustration in a nonconstructive way by sharing it with patients. That does not help the patients. It just makes them more anxious about the care they are receiving."
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