Friday, June 23, 2006

THMP Medication Advisory Committee to meet

Department of State Health Services
July 7, 2006 - 12:00 PM
Bldg 636, Rm 1102,
4110 Guadalupe
Austin

Texas HIV Medication Advisory Committee

The Advisory Committee will meet to discuss and possibly act on:
  • Call to Order
  • Approval of Minutes (November 18, 2005 and February 17, 2006)
  • Utilization Report Update on Medicare Part D Department of State Health Services
  • Advisory Committee Orientation
  • Gilead/BMS Combo Drug (STR)-Update/Approval Tibotec (TMC 114/Darunavir)-Review for Formulary addition
  • Expenditure Projections
  • Update on Physician Consultant
  • Schedule Next Meeting
  • Public Comments
  • Adjourn.

Additional Information Contact: 512/463-5561

Thursday, June 22, 2006

HPV vaccine news and speculation

This story from CDC Prevention News seems to cover most of the bases on the new vaccine against HPV:

"Cervical Cancer Vaccine: For Women Already Exposed to HPV, Shots May Not Be as Helpful" Los Angeles Times (06.19.06):: Shari Roan

On June 8, the Food and Drug Administration (FDA) approved Merck & Co.'s vaccine Gardasil, which protects against the two HPV strains responsible for 70 percent of all cervical cancers and two strains that cause genital warts. On June 29, the National Advisory Committee on Immunization Practices will meet and is expected to recommend routine vaccination for girls ages 11 and 12.

FDA approved the vaccine for use in females ages 9-26. Because around half of all US teens have sex before age 18 (6 percent before age 13), public health officials say the three-shot series should be administered at a young age. But for sexually active teens and young women who may have already been exposed to HPV, it is less clear whether Gardasil will be of benefit.

Gardasil does not cure HPV, but it may help people who have one strain of the infection from being infected by other strains. A test can determine whether women are infected with HPV, but it cannot specify which strains they have. Hence, HPV-infected women would not know whether Gardasil, which protects against strains 16 and 18, would still be useful.

Also, it is not known how effective Gardasil would be in conferring immunity in women older than 26, as trial data focused on younger women. Merck said it is currently studying the vaccine's efficacy in women up to age 45.

Women should continue to get routine Pap smears, which look for cell changes caused by HPV that can lead to cervical cancer. Even girls who receive Gardasil will likely need regular Pap examinations, said Dr. Mark Wakabayashi, director of gynecologic oncology at City of Hope. "There are still going to be one-third of the HPV strains out there that will cause cervical cancer" and are not blocked by Gardasil, he noted.

The next question is whether this vaccine will become mandatory for young women. There's a rumor that legislation on the subject will be introduced in the 80th session, come January.

Condoms work. Who knew?

Linda Johnson writes for the Associated Press and CBS reports: Condoms work. Who knew?

Actually the report is about new research that specifically targets the issue of preventing the transmission of HPV. Even better:
"This is about as ideal a study as you can get," said Dr. Tom Fitch, a San Antonio pediatrician and board chairman at the Medical Institute for Sexual Health, which stresses abstinence and monogamy as the only sure ways to prevent sexually transmitted infections.

So, can we end the War on Condoms now?

Update: The war isn't over (Kaiser Family Foundation has more), but reality is making progress.

Go, Team Shosholoza!

Not that I know diddly about the America's Cup races, but at least Team Shosholoza will be carrying our colors--a giant red ribbon on their spinnaker. I guess that gives me a horse, I mean boat, in this race.

Tuesday, June 20, 2006

Notes on changes

Again, nothing much for changes, but I've added a link to the "AIDS Clock" in the sidebar, updated the reading list, and at least tried to do something about that raggedy tag cloud.

The AIDS Clock link takes you to the United Nations Fund for Population Activities page. The "clock" is a number that gets updated every six-and-a-half seconds as yet another person becomes infected with HIV. The clock also tells us when someone dies from AIDS--every ten seconds.

I did try to post this as a graphic, since the site does provide a some graphic links, but that didn't work. The plain text will have to do for now.

The Additional Reading list in the sidebar comes from Google Reader. I've added a couple more source feeds to the reading list, so that should expand the pool of readings that will be coming through.

The tag cloud from Zoom Clouds sorta works like it's supposed to. It does seem to get updated now and then. It doesn't look anything like the cloud template that I created and just seems to fall off the edges of the sidebar. The "keyword" list is limited to 50, and it is supposed to show word count frequency. However, there seem to be some filters applied that I can't quite figure out.

This page of blog posts (everything posted prior to the current post for seven days) has 2,454 words. Of those, 1,108 are unique (not repeated). "AIDS" is the most frequent word, but it is used 65 times, not the 14 that showed up in the tag cloud prior to a manual update. "Shalala" now shows up in the cloud, but is listed as only 3 occurrences when the actual word count for her last name (again, prior to this post) was 9.

None of this, of course, gets at the need for real tags and category labels for the various blog posts. I'm still working on figuring out how to do that. In the meantime, I will just keep manually entering the tags that I think we will need for the cloud, and, if they are words that are actually used in a post, hope that they eventually show up.

The top 10 words on this page (prior to this post and not counting dates and my own name)?: AIDS, HIV, risk, prevention, Texas, health, she, will, links, funding. I guess that means that I talk about preventing HIV/AIDS, money, female persons, staying healthy, and the future. I can live with that.

Monday, June 19, 2006

Shalala and the needle exchange ban

Looking on my hard drive for something else, I found this picture.


While it's comforting to know that my memory isn't completely gone, the next question is: Is Shalala's memory gone? Or is she simply correcting the record now that she's no longer bound to take the hit for the President? Did Congress set the HHS Secretary up to be the fall guy on needle exchange after cutting some deal with President Clinton that he would not allow her to certify the safety of these programs?

So whose picture belongs here? Bill Clinton's? Jesse Helms'? Or Mike Leavitt's? We still don't have federal funding for needle exchange programs. The research is even clearer now than it was when Shalala was HHS Secretary.

The darling disease

Is Hollywood burned out? Or, is the media fickle?

I had a chance to visit with family this past weekend. Lots of girl talk, lots of old lady talk. One of the family members is the publisher of a daily newpaper in a small town in Texas. I didn't want to be a pest about HIV and Texas AIDS Network, but I was delighted when there was even a brief opportunity to talk about this work that I do. I took it as an opportunity to refine some thoughts that I've been having about HIV and the media. The conversation moved on before I got a chance to finish the refinement, but you're here, no? So let's think about this a bit.

Today's Contra Costa Times brings an article (Tina Daunt, LA Times) that exactly makes my point--in a roundabout way. Daunt writes about Hollywood stars and their many causes. She points out that AIDS was once, as Paul Michael Glaser says, "the darling disease," but now actors might be found working on other things, such as the environment. If they are working to call attention to AIDS, it's just as likely that, like Bono, they are focusing on AIDS in Africa. This has caused some problems for some Los Angeles AIDS organizations, reducing the funds that they are able to raise with the help of Hollywood. After 25 years, however, Daunt (and some of her interview subjects) allow that there is both burnout and complacency because of the available treatments in the U.S.

My thoughts, as I expressed them this weekend (or would have had I been a little pushier with the ladies), are that Hollywood is not necessarily the culprit here. After all, each of us is attracted to some issues more than to others. HIV seems to have claimed my heart, but it could just as easily have been diabetes or heart disease or cancer or hemophilia or substance abuse or urban planning or . . . something else. People have different interests, and, for all the glitter in Hollywood, actors turn out to be just folks.

What may be more critical here, even in terms of Daunt's article, is the media. Among the points I managed to squeeze in over Diet Coke and conversation is that there are really very few stories today about AIDS in the media. My publisher relative brought the subject up herself, intending to say, I think, that the number of news stories was really quite few. That in itself is true. Twenty years ago, there were dozens of stories about AIDS each day. The total number of U.S. media stories about AIDS might have been in the thousands in some years. Not so much these days.

What I tried to express, however, is that if you discount the repetitions of various stories, there are really only a few basic stories being told at all these days. There are variations, but the news story is the same.
  • A celebrity attends a fundraiser.
  • AIDS is a big problem in Africa.
  • Researchers have passed another step in development of a drug (usually in the business or scientific press).
  • It's World AIDS Day.
  • There's a management problem at an ASO (fortunately, not too many of these).
  • We're still trying to figure out where AIDS came from.
  • People are arguing over abstinence.

Are there others? This is just the riff that I can gave off the top of my head, but I think it's not a bad summary.

What I didn't get to say to the ladies, but what I thought when I read Daunt's article, is "it's the media, stupid!" It's the media that has burned out on the issue, that has gotten bored and moved on to other causes.

The result is that we are stuck in a time warp of information. People are left with the old stories and ideas--that HIV is a gay disease, that it's not an issue that the general public needs to be concerned about. At the same time, the paucity of story lines adds another distortion--AIDS is a concern in Africa, but not in the U.S.; we just really don't know the best way to promote prevention; we have drugs to deal with that now (so why worry?).

I recall a conversation with a businessperson, some time in the 1980's, when I mentioned a conference session being planned about AIDS. Her remark sticks in my memory: "AIDS is very vogue right now." Maybe that's Daunt's point--that AIDS is no longer "vogue" in Hollywood. Mine is that, vogue or not, the media isn't covering the epidemic in the U.S. Maybe they're too busy covering Hollywood.

Wednesday, June 14, 2006

Tidbits from "The Age of AIDS"

The PBS Frontline documentary, The Age of AIDS, can be viewed online in segments. A transcript is also available: Part One, Part Two.

Biggest surprise:

DONNA SHALALA: Forty percent of new AIDS infections came from IV drug use. I believed that we had an opportunity here for at least a narrow part of the campaign to eliminate new AIDS infections, to make a real contribution.

NARRATOR: But the Republicans who controlled Congress cast AIDS prevention in moral terms.

REP. DENNIS HASTERT (R), Illinois: If drugs are illegal in this country, and it's illegal to use cocaine or heroin or anything that's injectable, then you know, we shouldn't be handing out free utensils.

Pres. BILL CLINTON: The opposition to it was simply overwhelming.

Rep. MARK SOUDER (R), Indiana: -because you think the cause is right, to violate the law and enable people to violate the law-

Pres. BILL CLINTON: It was overwhelming in Congress and it was overwhelming within the drug control office of the administration, and it simply would have been reversed in the Congress if I'd done it. It just wasn't- politically, the country wasn't
ready for it.

DONNA SHALALA: I believe the president made the wrong decision. I said so at the time. No one tried to debate with me what the science said or what the right thing to do was, there was simply a straight political decision that was made.


I always thought that it was Shalala's hesitancy that blocked federal funding for needle exchange programs. It's interesting that she now lays it on Clinton, who lays it on Congress. The law at the time was that no funds could be spent unless the HHS Secretary (that would be Shalala) could certify that research showed that needle exchange programs did not contribute to increased drug use but did reduce HIV infections. She just never could be persuaded by the evidence. Of course Congress was the big stumbling block, but, if Shalala ever endorsed needle exchange as a means to reduce the spread of HIV, I don't recall that she ever did it where anyone could hear it.

Favorite line:
MECHAI VIRAVAIDYA: The religious institutions of this country have been extremely helpful. And luckily, we didn't have the church that kept on saying, "Don't use the condoms, don't use the condoms." That just shows you, with good leadership, real political commitment and financial commitment and great common sense, things can happen.

This is not an anti-church sentiment; Thailand is a Buddhist country, so the values of its people are different. Those values helped in the fight against HIV; Thailand's condom campaign reduced infections by 90 percent. The country is less tolerant of drug use. There has been no acceptance of needle exchange programs, so the epidemic continues to spread among drug users.

Made me angry:
Dr. MERVYN SILVERMAN: Due to Senator Jesse Helms, we could not fund anyone who would talk about homosexual sexual activities in their prevention activities. That's like saying we want to try and stop alcoholic-related deaths on the highway, but we can't talk about booze and we can't talk about cars. I mean, you can't do that. Without question, politics has been one of the driving forces in the spread of this disease.

Of course, we never learn, do we? For the time being, the restraints on PEPFAR have regarding "promoting prostitution" have been partially lifted, but there is every indication that new language in the Ryan White CARE Act will go further than Jesse Helms ever dreamed and ban any education that might "promote sex, whether heterosexual or homosexual."

Made me cry:
Dr. GLENDA GRAY: As HIV became more frequent and more commonplace in children, and as they needed more and more care, the ICUs in the country also made decisions not to admit children with HIV into their ICUs because it was terminal, and we needed to keep the beds open for children who had better prognosis. HIV became the new apartheid in South Africa. You know, we discriminated not on race anymore, but on HIV status.

The epidemic continues to be overwhelming in any number of ways, not the least of which is the continuing stigma of having HIV, the political nonsense that gets in the way of effective public health, and the perpetual frustration with lack of resources. At least we have hope.

If you missed "The Age of AIDS" when it was shown last week, make some time to watch it online or read the transcript.

Monday, June 12, 2006

Who's at risk for AIDS?

For several years, we had one of those static cling sticker things on the bathroom mirror at the office. It read: 'Who's at risk for AIDS?" You were supposed to look in the mirror and see the answer.

One of the 25th anniversary news articles (USA Today: "Profile: Generation AIDS") included this point [emphasis added]:

The lingering impression that AIDS is a gay disease helped promote its spread among blacks, says Pernessa Seele, founder of Balm in Gilead, a New York-based AIDS advocacy organization that works with 15,000 churches nationwide.

"The fundamental problem with the African-American community is that information about HIV came at us wrong," she says. "It came to us that this was a gay white disease, you don't have to worry about it. Then it was homosexuals and drug addicts. We're still suffering from the wrong information."

I don't disagree with these statements at all, but I highlighted the points about AIDS-as-gay-disease because that was the very first image of AIDS in the media, and we never seem to have gotten past that--even after 25 years. Right now, the demographics of HIV are indicating that it is turning into an epidemic threat to Black women. However, it would, I believe, be a mistake to once again try to characterize the epidemic by those who are infected by the virus.

The sense that "I am not at risk" comes from the tendency to characterize the epidemic in terms of population and not in terms of behavior. Individuals, regardless of sexual orientation, gender, race, age, ethnicity, or preferred pronunciation of "potato," who engage in high risk behavior that is not mitigated by one or more harm reduction strategies, can become infected with HIV if they engage in those unmitigated high risk behaviors in the presence of HIV.

This point matters in the context of determining an appropriate strategy for prevention in the broader community. Do you try to concentrate resources for those who are most affected by the epidemic (whack-a-mole)? Do you look at a broader strategy to address the fact that high risk behaviors are not necessarily concentrated in those groups (shock and awe)?

I don't have the answer. I tend to prefer the latter strategy, although I know that there are all sorts of arguments against it, not the least of which is the fact that we simply don't have enough prevention dollars to waste on the wrong strategy (abstinence-only, for example). However, "Wear a condom" has become so standard around our house, that the hubby once even told the grandson, "If you burn the house down, make sure you wear a condom." And I couldn't help but cringe when I read this blog entry about a young woman's affair. She only ended up pregnant, but I couldn't help thinking: "What educated woman in the 21st century would put herself and her husband at risk by not insisting on a condom?"

NYT on 25th: AIDS can (still) kill you

Reading through the many stories about HIV/AIDS that surround the 25th anniversary of the first documentation of the disease, Dr. Abigail Zuger's "AIDS, at 25, offers no easy answers" (in the New York Times) is strikingly different from the usual run of news stories. Writing, of course, from the physician's perspective, she tells of the difference between then ("AIDS will kill you") and now:

By now, those of us in the AIDS business long term have cared for thousands of patients. No one with that kind of personal experience can doubt for a moment the malignant potential of H.I.V. or the lifesaving capabilities of the drugs developed against it. But there are also now hundreds of footnotes and exceptions and modifications to those two facts that make the big picture ever murkier.

Dr. Zuger highlights some of the incongruities of our current situation, where someone who looks quite healthy may be failing his/her treatment, while someone who looks quite ill may be doing quite well on treatment (but not so well with the side effects). She also points to the frustrating level of complacency that new treatments have brought to both prevention and HIV diagnosis.
Twenty-five years ago, . . . [w]ith no possibility of saving our patients, life was sadder but far simpler. The big war was already lost, so we could concentrate on small victories instead.

Now, a complete rundown of all the news from the front would take hours. Risk of death from AIDS: way down. Risk of death from other things: going up. Risk of drug reaction: depends. Risk of fatal drug reaction: low but not zero. Risk of drug resistance: gets higher every year. The statistics change almost hourly as new treatments appear. It is all too cold, too mathematical, too scary to dump on the head of a sick, frightened person. So we simplify. "We have good treatments now," we say. "You should do fine."

Her article highlights 25 years of research and progress in treatment that still leaves us in the same place we were 25 years ago: we still only have one vaccine (prevention); we still only have one cure (prevention).

[Bloogered again. Eliminating duplicate post.]

Bloggered

Or Bloogered, as some have been calling it. Whatever term we might apply, Blogger has been intermittently down (more down than up) for much of the past week. As much as I love Google (they let me do so many things for free whereas some other major content providers keep asking for money we don't have), this kind of thing does make me look forward to the day when we can migrate the blog to Texas AIDS Net.

In the meantime, we'll try to get caught up.

Thursday, June 08, 2006

Stuff occurs

That would be one of my favorite sayings. I can say it in polite company--and it's fun to see the light dawn. And, lo, stuff has been occurring.

I managed to get an issue of Texas AIDS eNews out before hitting the road on Saturday, thinking that I would get to Houston for a couple of meetings in the early part of this week. One meeting was cancelled because of Houston's toxic effect on my colleague's lungs. The other didn't quite gel, since the person I would have met with was really in Dallas. Oh, well.

That didn't keep stuff from continuing to occur in my absence. The Commissioner of Health, Dr. Eduardo Sanchez, has resigned, effective October 6. Aside from the fact that Dr. Sanchez is a nice fellow and will be missed by many, there's the tiny little fact that once again the Department of State Health Services will go into a legislative session without a leader, or with such a new leader that effective advocacy for the department's programs and budgets will be difficult.

There's another tiny fact that Dr. Sanchez is hell on wheels when the subject is prevention. I recall my first meeting with him and being told in no uncertain terms that a health department's primary concern is prevention, not treatment. I did some fast tap dancing in that meeting to make the point that HIV treatment really is an important part of HIV prevention and was immensely gratified to hear Dr. Sanchez use that same argument later in support of HIV (treatment) funding when speaking to legislators. I was really counting on his support for a request for actual funding for HIV prevention funding this time around.

As if that weren't enough, the state's leadership has issued its instructions to state agencies--about four months late--on what to ask for in their legislative appropriations requests for the 2008-2009 biennium. Our dear leaders have outdone themselves this time. In the last budget cycle, they mandated a 5 percent reduction in budget requests. This time, they're going for a 10 percent reduction.

On the other hand, TWiT is coming back. (Sometimes good stuff occurs.)