Tuesday, October 19, 2004
One other problem is that the article is based on a study that was published in "the Journal of Acquired Immune Disorders." When I find a news story like this, I like to link to the original study, if possible. In this case, I spent quite a bit of time looking for the journal cited in the article to no avail. Either the name of the journal is misidentified, or the journal is not available on the web, or my search skills need some improvement.
To make matters worse, I couldn't find any other news stories about this research that weren't a repetition of the HealthDayNews article.
All of that being said, the article does report some interesting research:
Convincing HIV-positive young adults to avoid infecting others is one of the biggest challenges in the fight against AIDS.It almost makes you wish that news stories had footnotes, doesn't it. ;)
But in a new study, American researchers contend the solution may lie in one-on-one counseling that encourages people to make better decisions by understanding their own personal values.
The rates of one kind of unprotected sex dropped by more than 30 percent among HIV-positive drug users who underwent an intensive counseling program. "You shore up a person's ability to control their life and change their behavior," said Lee Klosinski, director of programs at AIDS Project Los Angeles, which hopes to replicate the study's findings. The counseling "equips them to make healthy choices in their life."
An estimated 110,000 Americans under the age of 23 are infected with the AIDS virus. Studies suggest that many of them aren't aware they're sick; those who know they're infected don't always take the expensive drugs that have revolutionized the treatment of AIDS over the past eight years.
Researchers offered a choice of three infection-prevention programs to 175 HIV-positive young people in Los Angeles, San Francisco, and New York City. The subjects, aged 16 to 29, were regular users of methamphetamine or intravenous drugs; more than two-thirds were gay men.
The participants, for the most part, had been very sexually active before the study: They reported a median of 50 sexual partners over their lifetime, and 21 said they'd had sex with 1,000 or more people. The risk is that they will continue to have unprotected sex and infect others.
Some of the subjects had as many as 18 sessions with a counselor over the phone. Another group attended one-on-one sessions, while a third group was assigned to get counseling at a later date. All participants received $20 to $25 for attending each of four meetings with counselors to measure their progress.
The goal of the counseling was to bring out an inner sense of responsibility in the participants, said study co-author Mary Jane Rotheram, director of the Center for Community Health at the University of California at Los Angeles. "Most people want to be good people," she said. "Our program helps people remember what's joyful and happy in their lives, and helps them figure out how to maintain that on a daily basis."
The findings appear in the October issue of the Journal of Acquired Immune Disorders.
The study suggested the one-on-one counseling convinced more than a third of participants to cut down on unprotected sex with partners whose HIV status -- positive or negative -- was unknown. "They had the same amount of sex, but it was either protected or they went to HIV-positive people," Rotheram said.
The telephone counseling wasn't as successful.
The findings are encouraging because they show that the federal emphasis on counseling is a good idea, said Steve Morin, director of the AIDS Policy Research Center at the University of California at San Francisco. "What this study illustrates is that it works."
Previous research has suggested that the counseling approach works in groups. But counseling several young people at once isn't feasible in many parts of the country, such as rural areas, Rotheram said. "This showed that you could also work with kids individually."
The next step is to expand the counseling program, Rotheram said. "We're being funded by the CDC [U.S. Centers for Disease Control and Prevention] to train providers so we can make this a routine part of medical care."
Monday, October 18, 2004
Thursday, October 14, 2004
Talking from a 20-page handout that detailed the FY2006-2007 HHSC LAR for baseline budget needs and exceptional items, Suehs pointed out that, of the $3.6 billion in new state funds requested, $2.7 billion would maintain current services. He also pointed out that the combined budget would be requesting about $6 billion total in new general revenue. This, he agreed, would be a substantial request, but he expected that the exceptional item requests would place the focus on specific policy issues that need to be discussed by legislators, and, it seems, it was just the right thing to do. [Note: We really haven't heard that "right thing to do" justification for budget requests very much from bureaucrats in the past few years.]
- October 18--HHSC presentation to Senate Finance Committee
- October 20--HHSC public hearing before Legislative Budget Board
- November 1--Consolidated budget available
Points of Interest:
- HHSC is proposing an actual plan to eliminate waiting lists for state services across all component agencies over the next 10 years.
- There are no funds for the expansion of STAR+PLUS in the current LAR.
- TIERS is (finally) expected to begin in mid to late 2005.
- The state will begin paying premiums to Medicare in 2006 to cover the cost of prescription drug coverage for dual eligibles (who formerly received medications through Medicaid). [My crystal ball says this debate ain't over.]
- The Medicaid VendorDrug Program, despite some significant changes that were supposed to save money, is expected to grow by about 25%. [That's a rough estimate, not an exact calculation.] The $1.8 billion increase is, however, hard to find in the exceptional item requests, and it's even harder to figure out how much of that amount is general revenue (state dollars) versus federal Medicaid matching funds. Exceptional Item 3, Maintain Medicaid Cost and Utilization Trends, appears the most likely place for this issue, but other costs are combined in the item.
Wednesday, October 13, 2004
What's Next? Treatment Options When the First Antiretroviral Regimen Fails Virologically or Is Not Tolerated, Part 1
Peter J. Ruane, MB, MRCP; Eric S. Daar, MD
There are many choices for the initial treatment of HIV infection. However, a change may be required if drug resistance or intolerance occurs. Thus, the selection of an initial regimen is important not only because of its immediate effects but also because of its potential influence on subsequent treatment options. HIV clinicians should be aware of the resistance and safety profiles of the regimens they prescribe as initial therapy and be ready with a strategy for subsequent treatment in the event of virologic failure or drug toxicity. This article suggests treatment algorithms for those experiencing adverse events or the emergence of drug resistance with commonly used antiretroviral regimens.
Monday, October 11, 2004
The Texas Health and Human Services Commission will conduct a briefing on Oct. 14 to provide information about the agency's legislative appropriations request for fiscal years 2006-2007. The briefing will provide consumers, advocates, providers and others with an opportunity to learn more about the HHSC budget request. No public comment will be taken during the meeting. However, there will be an opportunity for public comment on HHSC's legislative appropriations request during a joint meeting of the Legislative Budget Board and the Governor's Office of Budget, Planning and Policy. [Hearing schedule]
What: Briefing on HHSC's legislative appropriations request
When: 10 a.m. Oct. 14, 2004
Where: Public Hearing Room at HHSC headquarters, 4900 N. Lamar in Austin
Contact for special accommodations: Sandra Conzemius at 512-424-6648 or Sandra.firstname.lastname@example.org
Thursday, October 07, 2004
AIDS groups and activists tell Advocate.com they are disappointed the candidates avoided talking about domestic AIDS issues, particularly the Bush administration's flat-funding of Ryan White spending, the financial crisis faced by the nation's AIDS Drug Assistance Programs, and President Bush's push for abstinence-only sex and HIV prevention education programs.
AIDSVote.org says "Democrats and Republicans still need AIDS 101 education":
AIDSVote.org urges the audience participants and moderators of the two final presidential debates to demand specific and detailed answers from the candidates about their HIV/AIDS policies. The group's model presidential platform contains a detailed plan on effective strategies to combat HIV/AIDSin the U.S. and abroad. Hundreds of organizations and thousands of individuals have endorsed this platform, generating emails to the candidates encouraging them to do more in the fight against HIV/AIDS.
Note: Texas AIDS Network has endorsed the AIDSVote platform.
The CAEAR Coalition issued a call for national action in response the failure of the candidates to answer Gwen Ifill's question adequately:
It is time for a wake-up call to all of our leaders. It is time to increase funds for the Ryan White CARE Act with an additional $425 million. Congress has the appropriations legislation before it now, it should act now, and the administration should call for this action immediately.
At the same time, we will redouble our efforts to educate the nations leaders and decision makers about the appalling statistics regarding the prevalence of HIV/AIDS among African American women and other severely impacted communities, and the need to support the CARE Act, which is the foundation of the nation's ability to meet the needs of these communities.
Developing, as they say.
A long-used AIDS drug appears to be the first effective, long-term treatment for hepatitis B in those with advanced liver disease caused by the virus.
The drug lamivudine, also known as 3TC, has been available for the treatment of
hepatitis B since 1998, but the consequences of using it for years in those with serious liver disease or cirrhosis were unknown.
Researchers tested the drug for almost three years in 651 people, mostly Asians, and found it cut in half the risk of liver failure and the chances that the disease would develop into liver cancer.
About 8 percent of those who got lamivudine saw their liver disease get worse, compared with 18 percent of those who were given a dummy pill. The study was ended early because of the difference in the groups, and everyone was offered lamivudine.
Wednesday, October 06, 2004
Contact: Mark Del Monte of the AIDS Alliance for Children, Youth & Families . . .
WASHINGTON, Oct. 5 /U.S. Newswire/ -- Tonight, Vice President Cheney and Senator John Edwards were asked about the domestic AIDS epidemic. Gwenn Ifill, cited a statistic on the HIV infection rates of African-American women with HIV/AIDS. Vice President Cheney stated he was unaware of the statistic.
The following facts are background information:
-- According to the CDC, African American women represent a grossly disproportionate percentage of new HIV infections among women. In 2002, African American women made up 64 percent of reported new HIV infections, Hispanic women made up about 17 percent, and white women made up 17 percent.
-- According to the Centers for Disease Control and Prevention young women account for 58 percent of new HIV cases among people ages 13 to 19. Furthermore, these young women are largely racial and ethnic minorities. Young African American and Hispanic women account for 75 percent of HIV infections among women ages 13 to 24.
-- While the Bush Administration has increased funding for global AIDS programs to $2.8 billion this year, the Administration has proposed no increases in domestic HIV/AIDS prevention programs. These programs have remained level funded over the past 4 years at $700 million per year.
-- The Bush Administration has requested no new funding for the HIV/AIDS care programs in the Ryan White CARE Act the past 4 years while funding minimal and inadequate increases for AIDS drugs. One program that targets African American women and their families, Title IV of the CARE Act, has remained level funded at $73.5 million despite double digit increases in patients served each year.
Tuesday, October 05, 2004
Here's her question:
IFILL: I will talk to you about health care, Mr. Vice President. You have two minutes. But in particular, I want to talk to you about AIDS, and not about AIDS in China or Africa, but AIDS right here in this country, where black women between the ages of 25 and 44 are 13 times more likely to die of the disease than their counterparts.
What should the government's role be in helping to end the growth of this epidemic?
Here's Vice President Cheney's response:
CHENEY: Well, this is a great tragedy, Gwen, when you think about the enormous cost here in the United States and around the world of the AIDS epidemic--pandemic, really. Millions of lives lost, millions more infected and facing a very bleak future.
In some parts of the world, we've got the entire, sort of, productive generation has been eliminated as a result of AIDS, all except for old folks and kids--nobody to do the basic work that runs an economy.
The president has been deeply concerned about it. He has moved and proposed and gotten through the Congress authorization for $15 billion to help in the international effort, to be targeted in those places where we need to do everything we can, through a combination of education as well as providing the kinds of medicines that will help people control the infection.
Here in the United States, we've made significant progress. I have not heard those numbers with respect to African- American women. I was not aware that it was--that they're in epidemic there, because we have made progress in terms of the overall rate of AIDS infection, and I think primarily through a combination of education and public awareness as well as the development, as a result of research, of drugs that allow people to live longer lives even though they are infected--obviously we need to do more of that.
Here's Senator Edwards' response:
EDWARDS: Well, first, with respect to what's happening in Africa and Russia and in other places around the world, the vice president spoke about the $15 billion for AIDS. John Kerry and I believe that needs to be doubled.
And I might add, on the first year of their commitment, they came up significantly short of what they had promised.
And we probably won't get a chance to talk about Africa. Let me just say a couple of things.
The AIDS epidemic in Africa, which is killing millions and millions of people and is a frightening thing not just for the people of Africa but also for the rest of the world, that, combined with the genocide that we're now seeing in Sudan, are two huge moral issues for the United States of America, which John Kerry spoke about eloquently last Thursday night.
Here at home we need to do much more. And the vice president spoke about doing research, making sure we have the drugs available, making sure that we do everything possible to have prevention. But it's a bigger question than that.
You know, we have 5 million Americans who've lost their health care coverage in the last four years; 45 million Americans without health care coverage. We have children who don't have health care coverage.
If kids and adults don't have access to preventative care, if they're not getting the health care that they need day after day after day, the possibility of not only developing AIDS and having a problem--having a problem--a life-threatening problem, but the problem of developing other life-threatening diseases is there every day of their lives.
Here's some reactions from the (corporate) blogosphere. First, Paul Begala, at CNN:
How many African-American women with AIDS?
Posted: 10:27 p.m.
Gwen Ifill just asked Cheney to talk about AIDS in America.
She specifically asked Cheney not to talk about AIDS overseas. But all Cheney's talking about is AIDS overseas. He hasn't been programmed on it, and candidly told Gwen he didn't know about how African-American women have been hurt by the disease.
One of the downsides of the Bush-Cheney record is the sense that they care more about the rest of the world than America.
But Edwards is responding in terms of Africa -- first AIDS, and now genocide. Come on, guys, bring it home.
Jessi Klein, also blogging for CNN:
AIDS is infecting who?
10:19 p.m. ET
Did Cheney just admit that he was not aware of an AIDS statistic that Gwen brought up? I think for Cheney to say he doesn't know about something in this forum, he has to truly, truly not know about it.
That's pretty disturbing, no matter how you slice it. Wonder if he did the same thing with the AIDS statistics memo that Condi did with that silly "Al Qaeda Plans On Attacking US Inside the Country Using Airplanes" memo in August 2001?
Keith Olberman at MSNBC blogs the debate as a boxing match (which explains the "score" at the end of his post:
Round sixteen: Cheney receives about AIDS affecting women in America.
Cheney flinches, talks globally, cites $15B for international aid. Minus one point to Cheney. Says he had not heard numbers about African-American women. Startling admission. Minus one point to Cheney. Cheney wounded badly. Edwards misses easy opening on Cheney's unfamiliarity, goes back to Africa. Minus one point to Edwards. Opens up towards Sudan, says "here, we need to do much more." Broadens out ineffectively to American health care coverage. Subject completely avoided. Minus one point to Edwards. Round -- Draw, -2 to -2.
I couldn't find any blogs or mention of the AIDS question and responses at FOX, CBS, or ABC. It is gratifying, however, that two major media outlets, albeit cable rather than network, did pick up on the question and respond. I know that the issue is cropping up on some of the political blogs that are not funded by the corporate media--and that will be quite helpful now in raising some awareness of the issue. The importance of the corporate media, however, is that these are the outlets that will reach the broadest audience. How--and whether--this question is covered in these media outlets will help increase awareness and understanding of the issue.
The only way this is likely to happen is for folks in the HIV/AIDS community to follow up on the opening that Ifill has given us to provide the answers that neither candidate provided:
- The Senate needs to increase the proposed appropriation for AIDS Drug Assistance Program from $35 million to $217 million.
- The CDC needs to rescind its requirement to provide confusing information about the effectiveness of condoms in preventing the spread of HIV so that prevention workers can do a more effective job in outreach.
- The Administration must make sure that the changes in Medicare that provide for a prescription benefit does not decrease access to HIV medications.
Monday, October 04, 2004
I will, however, post as much as possible during this time. This would really be a good time to have a co-moderator, hunh?
Together, Medicaid and Medicare represent nearly three quarters of all federal spending on HIV/AIDS care in the U.S., and provide health insurance coverage to an estimated half of all people living with HIV/AIDS who are receiving care. These programs are likely to play an even greater role as people live longer with HIV/AIDS and continue to rely on these programs for care and treatment, including access to prescription drugs.
As part of the Kaiser Family Foundation's ongoing effort to provide information on the key programs that provide care and services to people living with HIV/AIDS, we are releasing two new fact sheets on the role of Medicaid and Medicare. Most people with HIV/AIDS who qualify for Medicaid are Supplemental Security Income (SSI) beneficiaries, meaning they are both disabled and low income. The majority of Medicare beneficiaries with HIV/AIDS are under the age of 65 and disabled, and most also rely on Medicaid.
These fact sheets provide an overview of the role of these programs for people with HIV/AIDS including federal funding estimates, eligibility criteria and services, profile of beneficiaries, and future outlook. The fact sheets are available at http://www.kff.org/hivaids/hiv100104pkg.cfm.
The Amarillo Globe-News has published three articles on the case over the past week or so. The first, published on September 25 and written by Greg Cunningham, is headlined "City sues prostitute to get HIV treatment; issue pits public safety against civil rights." The second, published on September 28, was also written by Cunningham and is headlined "Prostitute may agree to treatment; Officials won't go through with lawsuit if woman cooperates." The third, published on October 2, was written by Jim McBride. The headline: "HIV-infected woman denies suits claims."
This case is important because it appears to be the first time that the Texas Department of State Health Service's rules on recalcitrant transmission have been applied. How they are applied should be of great concern to all in the HIV/AIDS community. And a big caveat to this is the question of whether those rules have been followed in the case at all, since the news reports only cite the statutory authority for the city to sue and not the DSHS rules.
The statutory authority to bring this suit derives from Chapter 81 of the Health and Safety Code (The Communicable Disease Prevention andControl Act). The specific section in operation appears to be 81.083, Application of Control Measures to Individual, which gives the local health authority the power to issue a written order regarding control measures and to back it up with a court order if necessary:
If the department or a health authority has reasonable cause to believe that an individual is ill with, has been exposed to, or is the carrier of a communicable disease, the department or health authority may order the individual, or the individual's parent, legal guardian, or managing conservator if the individual is a minor, to implement control measures that are reasonable and necessary to prevent the introduction, transmission, and spread of the disease in this state.The rules are departmental policy, not formal rules that have been promulgated as part of the Texas Administrative Code. This particular policy (HIV/STD Policy No. 410.003) is called the "Accelerated HIV Intervention Program, Addressing the Potential for Recalcitrant Transmission of HIV in Texas." It begins by saying:
This policy establishes the Accelerated HIV Intervention Program, a program developed by the Bureau of HIV and STD Prevention (Bureau) to address the public health concerns of potential HIV transmission to unsuspecting persons by an individual who is known to have HIV. Any HIV positive individual found to be practicing recurrent behaviors which are known to transmit the virus and who engages in those behaviors with limited regard for the health of another person is considered a threat to public health.
When this policy was under review in 2001, Texas AIDS Network expressed a number of concerns about its wording, its purpose, and its eventual implementation. We were concerned, among other things, about the possibility of community witch hunts to label persons living with HIV "recalcitrant." The need to apply the rules would ordinarily come up in the course of contact tracing and partner notification, a standard part of disease prevention practices, when a single contact might be identified as the partner allegedly "responsible" for one or more other cases. An overzealous or biased investigator, we thought, might be able to use the rules to harass or penalize an HIV-positive person for any sexual activity. (There was some reason to worry about this in some parts of Texas at the time.)
In the Amarillo case, the HIV-positive woman, identified only as "T.T.," was indeed identified in the course of contact tracing and partner notification related to a recently reported case of HIV. T.T. was allegedly the source of that infection. Further investigation appears to have revealed that T.T. knew her status, had been informed of methods to prevent the spread of HIV, and allegedly engaged in prostitution while knowing that unprotected sexual intercourse could spread the virus. As it happens, these are key protections for the accused person: knowing their status and having received counseling about HIV prevention. If either of these things did not obtain, then the person would not need to be hauled through the courts but simply educated about prevention.
What is remarkable about the Amarillo case is that no criminal charges for prostitution or drug use are being brought against T.T. The concern stated by all appears to be getting T.T. into treatment coupled with the belief that all other means for gaining T.T.'s cooperation in preventing the spread of HIV have failed. And it does appear that the case is following the guidelines of the recalcitrant transmission policy, since T.T. received additional counseling about high risk behaviors and allegedly refused to avoid them, due, it would seem, to possible addiction to cocaine. The court case is being used as a "last resort."
Another concern that Texas AIDS Network had with the recalcitrant transmission policy was the potential for this policy to become the springboard for criminalization of HIV transmission. That very issue was raised by Cunningham in his second article. There is some comfort that both public health officials and the legal authorities are treating the case as a public health issue and not a criminal case, but the possibility that criminalization will be introduced in the Texas Legislature now looms large. Texas legislators are well known for legislation by headline, and this story has generated a lot of headlines in Texas.
We should all keep a weather eye out for developments in this case. How it is handled can have important consequences for others besides T.T.
Friday, October 01, 2004
Commissioner Eduardo Sanchez laid out the department's budget request by talking about the state of health in Texas, emphasizing that it includes concern for both a sound mind and sound body. Two points of concern to the Texas HIV/AIDS community came in his discussion of exceptional items. The first was a request to restore the 5% reduction in general revenue. The second was a request for $5.7 million in new funding for the Texas HIV Medication Program (THMP).
In regard to the first, Dr. Sanchez was responding to the mandate that all state agencies have been instructed to follow in making their budget requests for the coming biennium: Make the budget request for 5 percent less that was appropriated for FY 2003 and make any additional funding requests as an exceptional item. Dr. Sanchez requested that the 5% funding cut be restored for the sake of the health of the people of Texas. He pointed out that, if the 5% was not restored, 400 people would have to be cut from the Texas HIV Medication Program's current client load.
In regard to the second, Dr. Sanchez discussed the exceptional item request for the Texas HIV Medication Program, pointing to a $5.7 million shortfall projected for FY 2007. He told the LBB that access to medications was important because the medications prolonged lives, reduced transmission, and allowed people to live productive lives.
Rep. Davis asked Dr. Sanchez whether there were any waiting lists for THMP. Dr. Sanchez pointed out that there were no waiting lists and that the Department had rules in place to move to cost containment procedures if the program ever began to run out of money. Waiting lists, he said, would be the last step in that process.
When it came time for public testimony, I spoke on behalf of Texas AIDS Network. I pointed out that a new actuarial report showed that THMP would experience an $8.3 million shortfall in FY 2007. The Network, therefore, supported both the restoration of the 5% funding cut and an increase in the exceptional item request from $5.7 million to $8.3 million. I emphasized the importance of THMP as our "safety net for the safety net."
Rep. Davis asked me about Fuzeon and its presence on the THMP formulary. I responded that Fuzeon was on the formulary but limited to 50 clients. An expensive drug, Fuzeon is partially responsible for the increased funding need for FY 2007. Rep. Davis asked about criteria for eligibility for the drug, and I agreed to provide additional information.
The next hearing on the budget will be on October 6 when the LBB hears the combined budget request for the Commission on Health and Human Services.