PNH AIDS care said to improve as investigations continue
CPG elects co-chair, moves forward with needs assessment
State presses TPAC on conflict of interest
AIDS deaths rising; blacks hardest hit
Gingrich criticizes Clinton, Magic Johnson no HIV in military
Highly-resistant TB strain spreads
Study: HMOs top-heavy with paperwork
Vaccine collaboration announced
PNH AIDS care said to improve as investigations continue
Medical and nursing care at the 16-bed AIDS unit of the city's Philadelphia Nursing Home is said to be improving steadily, while concern about the overall care at the home continues after years of poor evaluations from state and federal licensing authorities.
The AIDS unit at the home was created by Mayor Goode and Health Commissioner Maurice Clifford in 1986. Since its start, the quality of medical care provided by the Home's contract physicians, Eugene Newton, MD and Theodore Burton, MD, has been severely criticized by people with HIV/AIDS and their advocates. Newton and Burton -- who paid a $480,000 fine to settle a Medicare fraud complaint in 1993 -- are major political contributors to local Democratic candidates, including both Mayors Goode and Rendell.
PNH official Trina Wynne told the members of the AIDS Housing Task Force this week that new management at PNH, which was "privatized" by the city under a contract with Episcopal Hospital, has "much improved" care on the AIDS unit, which she said currently holds about eight patients. PNH can provide skilled and intermediate nursing care at the facility, but is currently unable to take patients on intravenous medications because of shortages of certified staff.
Wynne and Sherry Gifford, the new director of social work at PNH, told the Task Force that medical supervision on the AIDS unit has not been provided by Drs. Newton and Burton "for some time." They said that former Graduate Hospital physician Rosalie Pepe, MD, an infectious disease specialist, is responsible for managing medical care on the AIDS unit, along with an internist who was recently added to the PNH staff.
PNH Coalition member Jeanmarie Zippo, a nurse case manager with ActionAIDS who works with many of the home's AIDS residents, said that there is "definite improvement in the quality of care on the unit" and that the "'county home' atmosphere at PNH has slowly started to improve." She said that Mayor Rendell has been asked by her group to appoint an advisory board to help the home's management address quality of life issues at the home, and that they have requested that the panel include representation by people living with HIV/AIDS.
Gifford said that a daily activity program is also now operating on the unit, and healthier residents are permitted passes to engage in activities outside the home when possible.
The indications of improvement at AIDS care at the home come in the midst of increased attention by state and federal authorities to the years of complaints about poor management, patient abuse and neglect of residents. According to the Philadelphia Inquirer, new state and federal investigations of the home have been initiated after inspections last year by state health authorities indicated that the home's performance was not up to state licensing standards.
The state recently awarded a provisional license to the home after noting that improvements had been implemented since the last inspection.
However, Constance Peters, a nurse formerly with DePaul Health Care Co., which monitors care at the 500-bed home for the city health department, has told authorities that PNH is "staging a show" for the state inspectors and that "sexual abuse [and] mismanagement" continues at the home. Her charges are apparently being taken seriously by state and federal officials, who have requested the city to turn over monthly monitoring reports from DePaul for their investigation. City officials have said that Peters is a "disgruntled employee" who was upset at being assigned to PNH by DePaul, and left their employment rather than continuing to help to resolve the home's problems.
CPG elects co-chair, moves forward with needs assessment
At its Valentine's Day meeting, Philadelphia's HIV Prevention Community Planning Group (CPG) -- the CDC-mandated community group charged with doing planning and priorities for the spending of HIV prevention money allocated to Philadelphia by the CDC -- elected Joe Cronauer, WTP's Education Director, as its co-chair. Cronauer will serve with already-appointed co-chair Jesse Milan, who is the AACO Director and will represent the city throughout the process.
Cronauer, a person living with HIV disease, said after the meeting that he was excited to be given the opportunity to work with other members of the community to help bring real prevention and harm reduction strategies to people most at risk. He said his priorities would be to "...work with the committee to begin a real assessment of the prevention needs of communities most at risk, and then work to get real money to those communities so they can develop and implement their own strategies to help reduce the risk of people in their own neighborhoods."
Following the election, the meeting turned to doing just that, with Dr. Loretta Sweet-Jemmott, who has been contracted to work with the committee to begin a needs assessment, leading a discussion of what information is already available in Philadelphia and other places about communities at risk, and what information is most lacking.
The committee is looking into a variety of strategies to reach those most at risk of HIV infection or re-infection to learn from them what prevention and harm reduction methods work, and which do not. Focus groups, key informant interviews, surveys and community meetings will all be developed with the communities affected to ensure reaching these communities and getting information that is accurate. The needs assessment will be ongoing, targeting first communities who are highest at risk for which there is the least amount of accurate information, and then moving to other communities for which a little more information is already available.
Also at the meeting, representatives from the CDC who were present gave a report on their perceptions of the roles and status of CPGs generally and Philadelphia's CPG in specific, as well as reporting on the CDC resources available to the local CPG in order to assist them in their tasks. This year's CDC money award to the city of Philadelphia was one of 17 awards which were made provisionally, meaning that the city had to document that it was complying with CDC regulations about community planning and that the structure, functioning and composition of the CPG were acceptable to the CDC.
This step by the CDC was in reaction to severe difficulties last year which the CPG experienced in its relationship with AACO which brought planning and priorities setting to a near stand-still. Eventually, after then-AACO-director Richard Scott inadvertently disclosed the HIV status of CPG participants on a government report without the consent of those individuals, the city chose to dissolve the CPG and remove Scott from AACO responsibilities. The CPG was re-formed this past fall with new members and under a new planning structure located within the health department structure but with some level of autonomy.
The CDC officials at this latest meeting -- Philadelphia's project officer Wendy Lyon and her supervisor Sam Taveras -- said that they were very pleased with Philadelphia's improvements over this last year, and believed that Philadelphia was now meeting all of the necessary provisions in terms of community planning. They offered their hand in providing technical assistance to the group as the group thought was necessary, and promised to have a hands-on approach to working with the group throughout this process to help ensure that the process continued to be a positive and collaborative one.
State presses TPAC on conflict of interest
State AIDS program administrator Bonnie Jo Brautigan has again pressed officials of the Philadelphia AIDS Consortium to come up with a plan to assure that the groups allocations of state and federal funds are in compliance with prohibitions against conflict of interest included in the state's contract with the group.
TPAC is the regional planning council for the allocation of Ryan White CARE Act Title II funds awarded through the state health department, as well as for the state's own general funds for AIDS services. Its contract with the state prohibits grants to organizations or individuals represented on the planning council.
TPAC has been in violation of this provision for some time. Without consulting with the TPAC of directors, ousted TPA executive director Jim Littrell had requested an "exception" from the prohibition last spring, which Brautigan now admits was awarded by the state at the time.
Brautigan had previously announced that TPAC was in violation of the conflict of interest clause and that no exception had been requested.
It was unclear who authorized Littrell to request the exception. Most baord members at TPAC have said they were not aware of the prohibition until it was brought to light in Brautigan's letter in December to TPAC 'co-president" Rashidah Hassan.
Hassan had declined o release the letter to board members, but it was obtained by PWA board member Mark Davis who distributed it to board members on his own.
In a letter to Hassan dated January 2nd, Brautigan apologized for the "confusion" resulting from her statement that TPAC did not have an exception to the contract provision. However, she re-stated the state's direction that TPAC eliminate the conflict of interest which exists on its board, and that unless a plan to "come into compliance over a limited period of time" is not in place, she "will not be able to finalize the processing of the TPAC contract effective July 1, 1996."
Meanwhile, the embattled TPAC board of directors -- which has been boycotted by over half of its members for many months and often has difficulty getting a one-third quorum to conduct business -- is now faced with a state requirement to re-bid most of its funding allocations through a request for proposal process this spring. The state expects TPAC to review applications for millions of dollars in state and federal funds over the next four months, for allocations that would take effect on July 1st.
Many board members have expressed deep concern that the continued disarray and conflict within the board -- including at least two physical confrontations among board members in recent months -- have so paralyzed the group that no one will trust a funding allocation process developed in this atmosphere.
TPAC has never conducted an allocations process that has been in compliance with its contractual provisions regarding conflict of interest, and each process has resulted in political controversy that has hampered its planning efforts.
Hassan ignored a motion by several board members last month to revisit funding allocations made last fall, instead relying on a mail ballot to obtain approval for the allocations.
A motion to remove from TPAC the responsibility for planning priorities and allocating state and federal AIDS funds was not brought to the floor at the last TPAC board meeting, after complaints from its sponsors that TPAC staff had mis-stated the motion in writing in the board's meeting materials.
A coalition of city and county board members, as well as most members of the TPAC HIV+ caucus, have asked for a meeting with state officials to express their concern at the continued tension within the planning council and its impact on funding allocations and service delivery. No response had been made to the request at press time. A similar request by black gay board members, who were concerned that no AIDS education funds were allocated to their communities in last fall's funding process despite board direction that these efforts receive high priority, was also initially ignored by state officials, who have since said they may meet with the group sometime this spring.
AIDS deaths rising; blacks hardest hit
Deaths from AIDS rose 9 percent in a year and the disease was the leading cause of death among Americans aged 25 to 44 for a second year in a row, federal health officials have announced.
The Centers for Disease Control and Prevention (CDC) estimated that, among all ages, 55,000 to 60,000 people with AIDS died in 1994, the latest year for which figures were available.
The agency said the total number of AIDS deaths rose 9 percent from 1993 to 1994.
The CDC said AIDS accounted for 19 percent of all deaths among people aged 25 to 44 in 1994. Of all AIDS deaths in 1994, 72 percent were among people aged 25 to 44, 25 percent were among those age 45 or older, and 3 percent occurred in people under age 25.
Dr. John Ward, chief of the CDC's HIV/AIDS Surveillance Branch, said deaths from AIDS can only be estimated because death certificates sometimes list other causes.
"Based on death certificates we know of an estimated 42,000 persons who have died of HIV, and that number may be as high as 55,000 to 60,000," Ward said.
Among people aged 25 to 44, AIDS caused 32 percent of deaths among black men, 22 percent of deaths among black women, 20 percent among white men and 6 percent among white women. In this age bracket, the rate of AIDS-related deaths rose 30 percent among white women, 28 percent among black women, and 13 percent among black men. The rate among white men aged 25 to 44 changed little, the CDC said.
"It's sobering to me that almost one out of every three black men who die in this age group die of HIV, an illness that wasn't even recognized 15 to 16 years ago," Ward said. "These are very disturbing statistics."
The CDC said 1994 was the first year that AIDS was the leading cause of death among white men aged 25 to 44 and the second year it was the leading cause among black women in that age group.
AIDS has been the leading cause of death among black men aged 25 to 44 every year since 1991.
The rate of AIDS-related deaths among people age 25 to 44 was almost four times as high among black men than it was among white men, the CDC said, and the rate was nine times as high for black women as it was for white women.
In 1994, the death rate from AIDS was 177.9 per 100,000 among black men aged 25 to 44, and 51.2 per 100,000 among black women.
The CDC also warned that the estimated 80,000 HIV-infected women of childbearing age who were alive in 1992 will leave approximately 125,000 to 150,000 children when they die during the 1990s. Among people aged 25 to 44, the second-leading cause of death is unintentional injuries -- mostly motor vehicle accidents, Ward said.
Researchers have found that measuring the amount of genetic material from HIV may be a better way to gauge how fast the disease is progressing and whether a treatment is working.
Doctors have traditionally counted CD4+ lymphocytes to measure the progression of the disease.
But a team of scientists from several Veterans Administration Medical Centers concluded in a study published in the New England Journal of Medicine that measuring the level of RNA, the genetic blueprint for HIV, from a blood sample is a better technique.
The study of 270 infected patients found that when the RNA levels in the virus receded, patients became healthier.
Dr. William O'Brien of the West Los Angeles VA Medical Center, the chief author of the study, said if further research confirms the finding, "I expect faster approval of new drugs, since we won't need these five-year trials to establish drug efficacy."
Assessing new drugs to combat the disease can take years because AIDS usually takes time to appear once a person has been infected with HIV. Once AIDS has surfaced, it can then take a long time for the disease to progress.
"Patients will see this as a major advance because it will accelerate the process of new drug evaluations for the treatment of HIV infection," said Dr John Hamilton of the Durham VA Medical Center and a co-author of the study.
Gingrich criticizes Clinton, Magic Johnson no HIV in military
House Speaker Newt Gingrich has criticized President Clinton and basketball star Earvin "Magic" Johnson for trying to keep people with HIV in the military.
Although it is Pentagon policy not to send such soldiers into combat, or even overseas, Gingrich said it was totally irresponsible to risk putting soldiers infected with HIV into combat where battlefield blood transfusions could spread the virus.
He commented when asked about a letter the HIV-infected basketball star sent to him and Senate Republican Leader Bob Dole. Johnson, who retired in 1991 after disclosing he was HIV-positive but resumed National Basketball Association play last month, urged the two Republican leaders to support a bill proposed by Clinton and several members of Congress that would repeal a provision approved by Congress requiring dismissal of people with HIV from the military.
"What Magic Johnson doesn't understand is the nature of being in the military and the danger of being in combat," Gingrich said after a breakfast speech in his district.
"No one who has ever studied seriously how bad combat can get wants to have a person in your unit who's HIV-positive, because you have a very real danger of transferring blood," he said. "It is a totally irresponsible position for the administration to take. It's a sign of how little President Clinton understands combat and the difficulties of being able to deal with these kinds of dangers."
Johnson said in his letter that he is proof that "many of us who have it (HIV) are continuing to lead healthy and productive lives. I hope you will do right by 1,049 service members (with HIV) and stop ignorance, fear and prejudice from forcing them to 'retire' from the jobs they love and their important service to our country."
The provision in a $265 billion defense bill requiring discharge of service people with HIV was sponsored by Rep Robert Dornan, a California Republican and presidential candidate who said they should be dismissed because it is wasteful and unfair to other service people to keep them in the military when Pentagon policy prohibits their being sent overseas or into combat.
Highly-resistant TB strain spreads
Deadly drug-resistant strains of tuberculosis that were first identified in patients in New York City four years ago have spread to other U.S. and European cities, researchers have determined.
In an article in the Journal of the American Medical Association, researchers from the Public Health Research Institute in New York who tracked down the genetic fingerprints of the "W" strain of the disease said that new drugs may have to be developed to wipe out the strain.
A woman in Denver spread the lung-borne infection to housemates and some residents of a nursing home where she worked, they said. Carriers of the strain were also located in Miami, Atlanta and Paris.
The stubborn strain does not respond to treatment with between four and seven of the most effective commonly used anti-TB drugs, the researchers said.
"The spread of this difficult-to-treat bacteria beyond New York City, where aggressive containment has been implemented, will have major implications for public health well into the 21st Century," said the institute's Tuberculosis Center director Barry Dreiswirth.
Tuberculosis has made a comeback in developed nations in recent years, in part because of the spread of AIDS and the migration of infected people from developing countries.
While New York City reported a 21 percent decline in cases between 1992 and 1994, the drug-resistant strains could complicate efforts to eliminate the disease.
Study: HMOs top-heavy with paperwork
A significant portion of the money that Californians pay to for-profit health maintenance organizations goes for paperwork, advertising, salaries, dividends and profits - not medical care, according to a new report by the California Medical Association. Among the state's biggest plans, the amount spent on treating patients ranges from 84 percent for PacifiCare to 73 percent for CaliforniaCare, according to the report.
In contrast, the nonprofit HMO Kaiser Permanente spends 97 percent of its revenue on patient care, the report said.
The medical association said the report showed that for-profit HMOs, which bill themselves as being a more efficient provider of health care than traditional fee-for-service plans, actually were top-heavy with administration and intent on turning a profit. Many doctors and patient advocates oppose for-profit HMOs because the organizations limit patient care and fees to doctors.
Vaccine collaboration announced
Federal health officials have released a plan for more collaboration between the private and public sectors to facilitate the development of an HIV vaccine.
A major goal of the effort is to improve the poor market conditions that discourage biotechnology companies from pursuing an HIV vaccine.
The plan will call for specific steps that must be completed to move a vaccine toward licensing. One such criteria could be that patients in the vaccine trials could have to develop certain types of antibodies. More than 20 HIV vaccines have been tested in the first two stages of experiments, but none have reached the third stage.
Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases said it will be years before the first AIDS vaccine is licensed. Industry representatives want a partnership with the government because they say a clinical trial of an experimental HIV vaccine is a business risk. Under the plan, the government would do the basic research and industry would use the results to develop a vaccine.
(AIDS Treatment News (01/19/96) No.239)
There is mounting concern that the hormone DHEA, which is chemically related to testosterone and estrogen, may be banned in the United States because it might be misused by athletes to build muscle. The popular product has been available for at least the last seven years in some AIDS buyers' clubs.
Clinical trials have shown DHEA to have potential in the treatment of lupus and for improving the quality of life in healthy elderly people who had a natural decrease of the hormone. Almost no reports of harmful effects of DHEA were found in the medical literature.
People with AIDS have lower levels of DHEA, but that may increase with AZT use. Early studies have shown that abnormally low levels of DHEA in HIV-infected persons were associated with progression to AIDS and that DHEA itself may have some antiviral activity. One small clinical trial that tested DHEA as a potential HIV treatment found some benefit, including CD4 cell count increases of more than 25 percent. In studies with lupus, DHEA has been shown to improve the production of IL-2, which is otherwise reduced as a result of the disease. While IL-2 has increased CD4 levels in some AIDS patients, it also increases the growth of HIV. Currently, there is little evidence of particular benefit in HIV disease related to DHEA. However, DHEA replacement is a technique that should be considered in AIDS patients with extremely low DHEA levels, along with good antiviral therapy, to see if DHEA causes a CD4 increase.