Value of viral load testing "unequivocal": study
Minority MDs more likely to serve minorities: study
Ohio: state paying too much for Medicaid HMOs
Clinton signs Ryan White CARE Act reauthorization bill
After two months of struggling over a late March reduction of $1.8 million in federal Ryan White CARE Act supplemental funding for Philadelphia region AIDS services, people with AIDS and AIDS service providers were stunned this week to learn that the newly-reauthorized Ryan White CARE Act will result in a restoration of most of those funds -- and even a little more.
According to a statement issued by AIDS Activities Coordinating Office director Jesse Milan on Wednesday, a revised "formula" award for the Philadelphia area increases the Delaware Valley's allocation in that category to almost $6 million, a $1.9 million increase over the previous allocation. "Formula" funds are awarded according to a system which takes into account numbers of diagnosed AIDS cases, rates of increase, population demographics and other factors.
In addition to the formula funding, the region also competes with other municipalities for what is called "supplemental" funding. A $1.8 million reduction in the supplemental category led to a round of meetings over the past two months, at which almost $1.5 million in "indirect" AIDS services and planning and administrative activities were ordered by the Philadelphia HIV Commission, which is mandated to set priorities and policy for the distribution of Ryan White funds in the five-county southeastern Pennsylvania area and four counties in southern New Jersey.
According to Milan, the city health department is projecting that total Title I funding for the Philadelphia region -- that is, the combined total from both formula and supplemental funds -- will reach $10.3 million once all federal allocations are revised in light of the recent passage of legislation reauthorizing the Ryan White program.
"This amount is likely to be $455,697 above" last year's award, Milan wrote.
Milan cautioned that formal written notification from the federal Health Resources and Services Administration on the funding increase had not yet been received by his office.
PWA members of the HIV Commission contacted by We The People said that they were "extremely relieved" that some of the funding cuts authorized by the HIV Commission would not have to be implemented. Some said, however, that some of the cuts were based on "real fat in terms of administration and planning functions and generally useless services" and should not be restored.
Concern has also been raised that because the funding is awarded under the "formula" category -- which runs from February until next January -- AACO may have difficulty actually allocating all of the funds in the period available and will be left with another "underspending" problem at the end of the year.
Over the past two years, AACO and the Philadelphia AIDS Consortium have underspent over $1 million in federal AIDS funds, and has been forced into last-minute reallocations to make sure that the funding was not lost.
Meanwhile, AIDS advocates are hailing as a victory President Clinton's signing of the CARE Act reauthorization, which keeps the program going through the year 2000.
The CARE Act, which provides emergency financial relief to cities, states and local community-based programs affected by the AIDS epidemic, was originally enacted in 1990. It expired in September 1995. Aside from reauthorizing the program for an additional five years, the bill makes a number of significant changes, championed by national AIDS advocacy organizations such as the Washington, D.C.-based AIDS Action Council, that are intended to better reflect the effects of AIDS on contemporary America.
"The signing into law of this vital piece of AIDS care legislation is definitely cause for celebration. AIDS Action and our other national partners have labored for more than two years to reauthorize a Ryan White CARE Act that meets the critical needs of all Americans living with HIV disease at this stage of the epidemic," said Fred Miller, interim executive director of AIDS Action Council. "The legislation overwhelmingly approved by first the House and now the Senate is a testament to our efforts, and represents bipartisan support for the concept of caring fairly and comprehensively for the hundreds of thousands of people who are HIV-infected in this country."
The original Ryan White CARE Act was made up four titles which both worked independently of each other and complemented each other in a number of ways to provide a wide range of comprehensive services. These original four titles include:
* Title I. This title provides emergency formula and supplemental grants to those eligible metropolitan areas (EMAs) disproportionately affected by the HIV/AIDS epidemic to develop and deliver comprehensive HIV/AIDS health care services. There are currently 49 EMAs, among them New York City, San Francisco, Los Angeles and Miami.
* Title II. This title provides formula grants to states to improve the quality, availability and organization of health care and support services, to fund health insurance continuation, home-based care services, and the AIDS Drug Assistance Program (ADAP), which provides life-sustaining drugs to low income individuals who would otherwise go without.
* Title III(b). This title provides grants to existing community-based clinics and public health providers serving traditionally undeserved populations to deliver early and ongoing comprehensive HIV/AIDS primary health care services.
* Title IV. This title provides grants for pediatric AIDS research with family-centered health and support services to meet the HIV/AIDS care needs of adolescents, children and their mothers.
While the reauthorization bill signed into law maintains the fundamental structure of the Ryan White CARE Act, it does make several significant changes, among these changes are:
* The establishment of a fifth title to the Ryan White CARE Act. Title V includes the AIDS Dental Reimbursement Program, the Special Projects of National Significance (SPNS), and the AIDS Education and Training Centers (AETC) program. The SPNS program addresses the needs of underserved populations and model programs of national significance. The AETC program, transferred from federal health professions education legislation, provides critical up-to-date HIV clinical training for physicians, nurses, social workers and other allied health professionals across the country.
* The modification of Title I and Title II funding formulas so that the distribution of these funds more accurately reflects the service needs of people living with AIDS in states and cities. The Title II formula, specifically, is modified to better distribute funds to states that do not contain Title I EMAs.
* The requirement that Title I and II grantees prioritize a portion of their funds for the provision of services for women, infants, and children. These services may include but are not limited to the provision of treatments to prevent the perinatal transmission of HIV.
* A modification to the way that supplemental grants to Title I EMAs are awarded. Supplemental grants will now be awarded based on, among other current criteria, the degree of severe need in a given EMA as demonstrated by rates of co-morbidity factors. These factors include homelessness, poverty, substance abuse, severe mental illness and tuberculosis. These factors are an indication of the complexity and costs facing EMAs in providing services to their HIV-infected population.
AIDS advocates are expressing concern about other more troubling provisions included in the reauthorization bill, including ones dealing with spousal notification of HIV infection and mandatory HIV testing.
* The reauthorization bill includes Sen. Jesse Helms's (R-N.C.) original spousal notification amendment with minor revisions. This provision prohibits the Secretary of Health and Human Services from making Title II grants to any state that does not make a good faith effort to notify the spouse of a known HIV-infected person that he or she may have been exposed to HIV and should seek testing. The definition of "spouse" in this provision is any current marriage partner or former marriage partner at any time within the 10 years prior to the diagnosis of HIV infection.
* The reauthorization bill also includes provisions regarding counseling and testing of pregnant women and newborns that AIDS advocates fear may lead to state legislators implementing mandatory testing programs. This provision differs from the one originally championed by Reps. Tom Coburn (R-Okla.) and Gary Ackerman (D-N.Y.) in that it does not mandate HIV testing of newborns or pregnant women but instead emphasizes the importance of voluntary counseling and testing. However, because the language is confusing and does imply a threat to states's Title II funding unless a series of measures are met, AIDS advocates fear state legislatures will implement mandatory testing programs to protect themselves against the loss of critical Title II funds.
Value of viral load testing "unequivocal": study
New tests that measure viral load in people infected with the HIV can accurately show how fast someone will become sick and die of AIDS, scientists said.
In research appearing in the journal Science, Dr John Mellors and colleagues at the University of Pittsburgh Medical Center built on the landmark research they presented in January at an AIDS conference in Washington.
In the past, doctors and scientists counted CD4 and T cell counts -- immune system disease fighters in the bloodstream -- to try to estimate a patient's health status and prospects. But that gave only a rough idea of how sick someone was.
But the viral load tests, which directly quantify the HIV genetic material in plasma, accurately predict the risk of AIDS and death.
"The data also indicate we can predict disease progression as far as 10 years into the future," Mellors said.
Mellors said the tests give doctors a new diagnostic tool, similar to "staging" tumors to figure out how advanced the cancer is, to help devise the best course of therapy for an individual.
Less than 8 percent of the patients with low viral measurements developed AIDS within five years, while 62 percent of those above a threshhold defined as 36,270 copies of RNA per milliliter got sick within five years.
The bDNA assay was developed by Chiron Diagnostics . Known as the Quantiplex HIV RNA assay, it is under review by the Food and Drug Administration. Doctors can get access to viral load testing in the meantime through the Chiron Reference Testing Laboratory.
When Mellors presented his initial findings at the Washington conference, it was widely greeted as an important diagnostic breakthrough. Such measurements will become even more important as new drugs become available, and doctors can figure out when to intervene, and with which drugs.
It will also help researchers trying to develop new drugs better determine how effectively the compounds fight the virus.
David Ho, one of the nation's top AIDS researchers at Rockefeller University, wrote in an accompanying essay in Science that the Mellors results were "truly striking."
"The prognostic utility of measuring plasma viral load in HIV-1 infection is now unequivocal," he said.
Ride sponsors to include MAPP
In an agreement brokered through the mediation of Philadelphia health commissioner Estelle Richman, the sponsors of the Philadelphia-DC AIDS Ride have agreed to allow the Minority AIDS Project of Philadelphia to be among the beneficiaries of the Ride's proceeds.
In several meetings of the past two weeks, the three organizations which originally developed the Ride event -- ActionAIDS, the AIDS Information Network, and Philadelphia Community Health Alternatives -- agreed that an equal portion of the proceeds would be given to the board of directors of the Greater Philadelphia Urban Affairs Coalition (GPUAC), MAPP's parent organization. GPUAC will be responsible for developing a process for the allocation of the proceeds to minority-led AIDS service organizations in the Philadelphia area.
The Ride is expected to raise over $200,000 for each of the beneficiary organizations. A small percentage of the proceeds may also be set aside for other AIDS organizations, according to sources.
The Ride had been severely criticized in recent weeks by minority community leaders for failing to include minority-led organizations among the beneficiaries, even though they had requested participation last year. Over 80% of Philadelphia's recent AIDS cases have been diagnosed among people of color, according to city records.
Meanwhile, criticism continued to be leveled against the Ride event because of its high cost. Advocates have expressed concern that the $2 million cost of the event -- which also benefits two organizations in Washington, D.C. -- unfairly diverts desperately-needed funds to pay high-priced promoters of the event, including the Ride's national organizer, Daniel Pallotta, who admitted last week that he will personally make $360,000 for his work on the Ride.
Advocates have noted that the overhead costs of the Ride, according to published figures released by Ride officials, indicate that over 50% of the proceeds of the Ride will go to Ride staff and other Ride-related expenses. The beneficiary organizations will have their own overhead costs associated with the fundraiser, they note, even further reducing the actual amount of money which will ultimately go directly to AIDS services.
Minority MDs more likely to serve minorities: study
A study in the New England Journal of Medicine examines the role of black and Hispanic physicians in providing health care for underserved populations and the impact that the roll-back of affirmative action educational policies may have on this care. Researchers lead by Dr. Miriam Komaromy of the University of California-San Francisco surveyed 718 primary care physicians from 51 California communities in 1993 and analyzed data on physician practice locations and the racial, ethnic and socioeconomic makeup of communities in 1990.
Researchers determined that both black and Hispanic doctors in California not only care for "higher proportions of patients of their own race or ethnicity," but also "patients who are uninsured or are covered by Medicaid."
Urban communities with high proportions of black and Hispanic residents were four times as likely as other communities to have a shortage of physicians. Poor urban areas that did not have a high percentage of black or Hispanic residents had almost three times as many primary care physicians per capita. According to the authors, the findings suggest that "the residents of communities with high percentages of minority- group members may be in particular need of health care services and the physicians who choose to practice in these areas fill a critical need." They found that "physicians generally practiced in areas with relatively high proportions of residents of their own race or ethnic group." Accordingly, black physicians cared for almost six times as many black patients as did other physicians, while Hispanic physicians cared for nearly three times as many Hispanics as did other physicians.
The researchers said that physicians who choose to practice in poor urban areas "fill a critical need." They concluded that current moves to roll-back affirmative-action policies in education may have a major impact on the care of underserved populations.
"Minority physicians, particularly black and Hispanic, serve minority populations to a greater degree than white physicians ... [s]o training members of minority groups for medical careers is going to be extremely important to get care to under-served populations."
Despite the need for minority physicians, the authors write that minority groups are "markedly under-represented" in the medical field. In 1990, blacks comprised four percent of physicians, while Hispanics made up five percent of physicians. However, they write that the "implementation of affirmative-action programs coincided with the dramatic changes in the enrollment of students from minority groups in U.S. medical schools." Recent figures show that minority groups currently make up 12% of all medical students.
The researchers write that it is "impossible" to predict what would happen to underserved populations if affirmative action programs at schools were scaled back. However, they conclude that "the strong temporal relation between affirmative action programs and the number of minority medical students suggests that the medical schools' enrollment of blacks, Hispanics, and others has been responsive to changes in affirmative action programs." They write that "dismantling" affirmative action programs is "likely to result in poorer access to health care and may ultimately result in reduced health and well-being for a substantial proportion of the population."
Ohio: state paying too much for Medicaid HMOs
As Pennsylvania's poor gear up for being forced into Medicaid managed care plans, Ohio State House Insurance Committee Chair Robert Netzley (R) and House Speaker William atchelder (R) released a study which shows that the state may be paying too much for Medicaid atients enrolled in managed care plans, according to the Columbus Dispatch.
The study concluded "that the industry is making sizable profits" while at the same time "paying large salaries to its director, chief executive officers and key staff members."
The study found that "two nonprofit HMOs that exclusively served the Medicaid population reported a higher net profit margin than the for-profit HMOs." According to Batchelder, "We're looking at a situation where apparently ... the premiums that are being charged may be excessive."
As a result of the findings, Batchelder said, "It may be possible to provide Medicaid at less cost than originally anticipated." Netzley and Batchelder said that several conclusions can be drawn from the study's findings, including: "significant differences" exist in the operating practices of HMOs; the state can enter into a cheaper managed care program for Medicaid recipients than the current system; and the state Department of Insurance needs strengthening in order to obtain more data on Ohio's HMOs.
Netzley has proposed legislation that would privatize the state's Medicaid program and guarantee health coverage for state residents with incomes of up to 150% of the poverty level. The bill is currently being reviewed by the House Insurance Committee.
Despite the concerns raised by Netzley and Batchelder, Department of Human Services Director Arnold Tompkins said that Gov. George Voinovich's (R) administration hopes to have 55% of the state's Medicaid population enrolled in managed care plans by next July. Tompkins said that the department is currently "rebidding" its contracts with managed care plans "to try and pick up a 6 percent savings while maintaining high quality health care."