Five Questions

Brad Biggers over at AIDS Combat Zone took the five question challenge and then tossed it to his readers. I offered to take up the challenge, and he has sent me my five questions.

1. What do you see as today's biggest barrier to helping people living with HIV/AIDS in Texas?
2. What degree do you hold and what other jobs have you held before your job with Texas AIDS Network?
3. Imagine you're given $1,000,000 and told you can only use it to increase funding of one AIDS-related service in Texas, what would it be? (e.g. expanding free testing, outreach to a specific group, ADAP, etc.)
4. To steal a question from Terrance, If you weren’t doing what you’re doing now in regards to work, what else would you choose if there were no limitations on your choices?
5. Do you have any advice for young people like me who are embarking on careers in Public Health?

These are some pretty tough questions, so I'll be taking my time in answering them. After all, if I offer that advice, someone might take it--so it had better be good!

Thanks to Brad for offering this challenge. It's already provoking some serious thought.

Texas HIV Appropriations

At this point, the appropriations bill is in Conference Committee. Even though both the House and the Senate have recommended that $15 million in new funding be appropriated for HIV, there is still the odd chance that the committee might decide to take that money to pay for something else. We (Texas AIDS Network and allies) have been keeping a close watch on the situation, just in case we needed to take some sort of additional action.

For the time being, we're thinking that it's best to let sleeping dogs lie.

Why? First, we know that there are some strong allies for HIV on the committee. Senator Zaffirini is practically a one-woman army, and she has a lot of help in unexpected quarters. Second, we spent some time at the capitol on Monday "taking pulses" and checking for indicators that there might be any trouble on the horizon for HIV. What we found was pretty much comforting--no indicators of trouble.

This doesn't mean that we don't have to maintain vigilance, but it does mean that, as the session moves into its final month, there is more reason to be cautiously optimistic that the Texas HIV Medication Program will have the funding that it needs to operate in the coming biennium without cutting services.

I'm back (again)

This is starting to get a little old, I think. We have lost four family members since Christmas (five if you count the cat), and I've just returned from the funeral for a beloved uncle. Let's all hope that this is the last one.

I will be playing catch up yet again. There is, however, much in the Good News Department, so stay tuned.

Barriers to Care

Bob LaMendola writes for the South Florida Sun-Sentinel regarding barriers to care for HIV-positive black women in the region. The list of barriers pretty much fits everyone else everywhere else, no?

The stigma: Many women avoided doctors, public clinics and programs because they didn't want family or friends to know they were infected.

Red tape: HIV/AIDS programs often require long and intrusive forms, and send women from office to office to get services. Many women had no idea where, in a jumble of agencies, to find help.

. . .

Putting family first: Some women reported having no time for medical care because they were too busy earning money and taking care of their families.

Denial: Some women insisted they were misdiagnosed or felt fine.

Misconceptions and mistrust: Some thought that being infected meant they were only carriers, not sick. Others, including many Caribbean immigrants, rely solely on folk remedies or religion.

Inadequate access: Hurdles to health care include a scarcity of local doctors, long waits at clinics and a lack of public transportation and day care.

Lax followup: Doctors, clinics and emergency rooms struggle to make sure patients keep taking medicine. No agency takes charge.

Giving up: Some infected drug users and prostitutes don't bother seeking treatment because they are ashamed about their history. Others assume HIV equals death.

. . .

Other obstacles found by the study: Some programs do not provide care unless patients are drug free, some patients suffer debilitating side effects from meds and some report disrespectful treatment by assistants at clinics and doctors'
offices.

Some of these barriers can be torn down with more intensive education of both clients and providers. Building some trust would help out a bit, too. But the red tape and the clear evidence of lack of funding needs more attention at the higher levels of planning and policy. We could stand some of that in Texas, too, I'd say.

Crystal Meth-->Hypersexuality-->HIV

Uh huh.

HIV and Viacom

Viacom is in the midst of a three-year program in partnership with the Kaiser Family Foundation to increase HIV awareness through Viacom's various media outlets, including: CBS and UPN; cable networks MTV, BET, VH1, CMT: Country Music Television, TV Land, Nick at Nite, Showtime, Spike TV and Comedy Central; and 183 Infinity Broadcasting radio stations in the top 50 markets. An Associated Press report published on ABCnews (a Disney outlet), says:

. . . Kelli Lawson, executive vice president of corporate marketing for BET, says Viacom's outreach efforts are effecting change.

In a survey of blacks conducted by Kaiser last August, among 18-to-24-year-olds exposed to Viacom's campaign, half said they had discussed safe sex practices with their partner because of the Viacom campaign.

And nearly 77 percent of that group who were sexually active said they were more likely to use a condom because of the campaign.

Maybe Disney will now take up the challenge?

Spongeworthy

Contraceptive Sponge to Return to Market

Linda A. Johnson, writing for the Associated Press, reports that the contraceptive sponge is about to return to the U.S. market after a ten-year hiatus. The sponge is one of the older forms of birth control used by women and, while not as effective as some other means now available, preferred by many because of comfort and convenience.

While this would be good news for many women, a word of caution applies: This device will not prevent the transmission of sexually transmitted diseases.

Waiting Lists for ADAPs

Perhaps I spoke too soon when I complained about the trickle of "new news" regarding HIV and AIDS in the U.S. Reuters has a story out today about the waiting lists for some state ADAP programs thanks to a new study (PDF) released by the Kaiser Family Foundation. The Reuters report is, however, much truncated from the much more informative press release issued by the Foundation about the study.

Texas is shown in the report as providing "all approved ARV's in all four drug classes, NRTIs, NNRTIs, PIs, and Fuseon Inhibitor" but "[less than] 10 'AI' drugs recommended for the prevention of OIs." The PowerPoint presentation for the report does not show that Texas has a waiting list for the Fuseon Inhibitor, and that number (now about 36) is not apparently included in the total number of persons counted as being on waiting lists for ADAPs. Texas is listed as one of the states with cost containment measures in place and anticipation of additional measures needed in FY 2005.

KFF also provides a brief fact sheet (PDF) on the issue (with some clue about all those acronyms I threw out above).

Catching up on some links

Blogger is giving me fits today, but I will make a stab at getting another post out. [crossing fingers]

Here are some links that may be helpful in getting a broader perspective on HIV/AIDS issues:

Texas AIDS Health Fraud Information Network--This is a task force that Texas AIDS Network has participated in since 1982. Indeed, Texas AIDS Network helped found it. The task force provides information for consumers and providers regarding fraudulent treatments, devices, and information related to HIV/AIDS. The web site includes news, fact sheets, downloadable brochures, and tips on what to look for when considering alternative and complementary therapies. There's no agenda to discourage CAM, just some help for the cautious consumer, because there are some products that are harmful to people living with HIV and, of course, some outright fraud. There are, by the way, similar task forces in other states.

AIDS Combat Zone--Brad Biggers left a nice comment and then linked to Texas AIDS Blog. After visiting his site, I see that there is a nice round up of news stories there, many of which we don't cover here, e.g., international news, since our focus is pretty much limited to Texas and things that matter to Texans living with HIV (at least, we hope so!). Brad's done a lot of work on his site to gather useful reference links.

Respectful of Otters--This one is an old favorite. When someone gives their tagline as--"I'm a psychologist working in HIV research and treatment in the inner city. Don't talk to me about 'compassionate conservatism'"--I have to look twice. Ms. "Otter," who has just given birth to a new "Otter pup" named Alexandra (congratulations!), writes on an eclectic mix of health issues and Canadian and U.S. politics. There are occasional HIV-related stories on her site, but you do have to hunt for them. The title, by the way, comes from a student typo: "Psychologists have a duty to be fair and respectful of otters." Somehow I think we all share that duty. ;)

Oy!

Expensive drugs, sick patients, bribery--not a good mix. Even worse that it comes along at the same time that there are investigations of embezzlement at a Florida ASO.

I hope that's the end of it.

Scanning the news for stories about AIDS brings mostly stories about the epidemic overseas. There are occasional stories that pop up about a large fundraiser somewhere. Sometimes there's a press story about the allocation of Ryan White funds in a particular area. Of course, there is a slow but steady stream of reports about this or that stage in the progress of drug research.

AIDS is, however, mostly old news in the U.S. It takes a scandal of some sort to really get press attention. The Florida story has been showing up for several days now in various news reports. Then along comes the Serono story. All we need is for enterprising reporters to start looking for more dirt to lose what little focus there is on the needs of people living with HIV and AIDS in this country.

If that sounds like I'm missing the point that both of these stories are about criminal behavior, I'm not. But I'm just as upset about the fact that these folks had to practice their criminal behavior on AIDS. If they had been bribing docs to prescribe some cancer medication or embezzling funds from a diabetes organization, the impact on patients would be less hurtful.

HIV is already a "scandalous" disease. Anytime we go to the Texas Legislature to ask for more funds for HIV, there's always some legislator who wants to bring up "responsibility." There was a bit of a struggle in the Senate Finance Committee that included a hint of that issue. We have made it (so far so good) through both the House and the Senate now with our request for $15 million in new funds for HIV--and only have to watch out for the Conference Committee and the Governor's line item veto. We don't need any additional stories to feed the "scandal beast" and give anyone any ideas about cutting that funding.

So, I'm just saying, I hope that's the end of it.

HPV Vaccine

Via Atrios and The Light of Reason.

I am apparently a bit behind on this news: GlaxoSmithKline and Merck have both developed new vaccines to prevent human papilloma virus, a cause of cervical cancer, which in turn is a significant risk for women with HIV. Earlier reports on these vaccines were available last November. Current reports are now addressing some of the difficulties of getting social acceptance of the vaccines and of licensure for production in other countries.

Tell me again why a parent would put a child in a car without a seatbelt?

Nonoxynol-9 Warning Labels--Not Yet

The Government Accountability Office (GAO) has released a new report about nonoxynol-9 (N-9) and the prevention of HIV: HHS: Efforts to Research and Inform the Public about Nonoxynol-9 and HIV (March 2005). The report's Concluding Observations are:

CDC’s and NIH’s efforts to research N-9’s potential use as a microbicide ended in 2000, when the preliminary results of a major clinical trial indicated that N-9 may actually increase the risk of contracting HIV. CDC has warned that N-9 may increase the risk of HIV transmission when used frequently, and some manufacturers of N-9 condoms have taken steps to either add their own warning labels or remove their N-9 condoms from the market, while other manufacturers have not taken such steps. FDA has proposed requiring new warning labels that indicate that N-9 vaginal contraceptive products do not protect against HIV or other STDs and that frequent use, such as more than once a day, may increase the risk of contracting HIV. FDA is also developing proposed warning labels for N-9 condoms. While FDA expects to issue the final rule for the new warning labels for vaginal contraceptive products by September 2005, it has not yet issued proposed warning labels for N-9 condoms, and it has not indicated a target date to issue the final warning labels for N-9 condoms. Since FDA is still in the process of completing warning label changes for N-9 vaginal contraceptive products and condoms, the public may be left in doubt about the appropriate uses of these products until FDA finalizes these warnings. Further, the public may be at risk if the products are used inappropriately.

There are any number of snarky comments that come to mind in response to this report, but I will forego them in order to point out that there needs to be a tad more haste in the slow progress of government processes when it comes to warning labels. My recollection is that repeated use of N-9 irritates mucous membranes and makes it easier for the virus to enter the bloodstream. Even if my recollection is off in terms of the exact problem, I'm still thinking we heard all of this several years ago. If folks are using out of date information for prevention messages ("Use latex condoms with N-9" used to be the recommendation), the delay in providing warning labels is inexcusable.

Disinformation.gov

The American Prospect's online article is captioned "Misleading.gov," but there may be a more proactive element to the inaccuracy of information that is now being published on the new website being promoted by the U.S. Department of Health and Human Services--www.4parents.gov--which is why I'm going with disinformation. TAP does a nice job of pointing out some of the inaccuracies and gaps in information regarding condoms that are published on the site as well as pointing out some of the consequences of those inaccuracies.

So here's a thought. Seatbelts neither promote nor prevent accidents. They just protect you when you have one. Why wouldn't you tell your kids to wear their seatbelts when they get in a car?

The War on Condoms continues apace.

I'm Back

My father-in-law passed away last week, and we spent most of the week making arrangements and traveling to the funeral. I will be catching up on blog posts as rapidly as I can.

Licensing Canadian Pharmacies in Texas

HB 173, by Rep. Scott Hochberg (and the companion SB 518 by Sen. Rodney Ellis) has been on my list of "troubling" bills for some time. The bill is captioned as: "relating to the licensing and regulation of Canadian pharmacies for the dispensing of prescription drugs in this state." When I first saw the caption, I immediately thought that this was a reimportation bill. The original press release that accompanied its filing didn't do much to change my thinking (the press release for SB 518 is a little clearer) .

Still, the bill is one that we would ordinarily watch as it goes through the process and not do anything about. However, that changed when Rep. Hochberg's office called Texas AIDS Network and asked for an endorsement. We had to "get down" and do some serious discussions about the bill's intent and what it might do for people with HIV/AIDS in Texas.

So here's the deal.

Prescription medications are expensive, even if you're only dealing with allergies. If you have a chronic disease or multiply diagnoses and need a combination of medications to treat your illness (gee, just like HIV), the cost can get out of hand pretty rapidly. If you do not have insurance and do not qualify for any of the pitifully few public safety net programs, you have to dig into your own pocket for $12-15,000 worth of medications each year. Or wait until you get sick enough to lose your job and then qualify for the public safety net.

One of the alternatives to waiting out the disease and/or going broke paying for medications in the U.S. is to look across our national borders for cheaper alternatives. This has not always been a good idea. There's your questionable manufacturing practices. There's your shady pharmacies. There's your outright fraud and substitution of fake ingredients for the real thing.

Still, the possibility of getting cheaper medications from Canada specifically has gotten a lot of attention in the last few years. (Canada has a single payer system of health care and has negotiated lower prices for medications used throughout their system.) Now the idea has come to Texas.

Texas AIDS Network bases it advocacy on a set of policy principles. A couple of those principles come into play on this bill:

• 13: Persons with HIV infection should have access to FDA-approved, effective drug treatments.
• 14: Persons with HIV infection should have accurate information about quality medical and health treatments available to combat HIV-related illnesses. Fraudulent treatments should be aggressively pursued by legal authorities.

The Network was a founding member of the Texas AIDS Health Fraud Information Network. Since the FDA has been a sponsor of that group, we have long been exposed to (and shared) the FDA's concerns about fraudulent treatments, the risks of reimportation, and the gaps in FDA's resources to deal with either of these.

Rep. Hochberg's office is now looking at the bill, not as an invitation for consumers to buy their medications from Canada, but as a means to protect consumers who choose to do so from potential fraud. The bill allows real "brick and mortar" Canadian pharmacies to apply to the Texas Board of Pharmacy for licensure in Texas. These pharmacies would have to meet all Canadian licensure requirements before applying for Texas licensure; they would be subject to inspection by the Texas Board. (This would eliminate some of the risks associated with internet pharmacy orders and the apparent abundance of fake Canadian pharmacies now advertising via spam.)

The bill says that the pharmacies would apply to dispense specific medications, meaning that they would have to name the medication and its price for the Texas Board. The medications would have to be "equivalent" to U.S. FDA approved medication. The Texas Board would then maintain a website that provides information about approved pharmacies, their prices, and how to order.

As a bill designed to protect the public safety, we have endorsed the bill. As a matter of public policy regarding patient access to medications, we prefer a stronger public safety net.

Worth following up

[Reminding self to do so]

As I may have mentioned, I'm using a new service called GovTrack to feed me information about Congressional actions. It's not terribly timely; there's usually some delay between action and notice of an action--and even more delay before the details are accessible on the web. Still, it's been pretty much of an eye-opener, as in the case of S. 288, State High Risk Pool Funding Extension Act of 2005. This bill was reported out (passed) by the Senate Committee on Health, Education, Labor, and Pensions on February 10, 2005 (well, I did say there was some delay in getting information!).

According to the committee summary:

S. 288 would amend the Public Health Service Act to extend the funding for the creation andoperation of a state high-risk health insurance pool. The high-risk pools offer health insurance to individuals who cannot obtain coverage in the marketplace. Under an authorization that expired in 2004, the Department of Health and Human Services (HHS) provided seed grants to states to create a high-risk health insurance pool and operational grants for the losses incurred in connection with the operation of a pool. S. 288 would extend the funding for the seed grants through 2006 and would increase and extend the funding for the operational grants through 2009. In addition, the bill would alter how grants are allotted to states.

The summary provides a few more details about the changes in how grants are allotted to states:

S. 288 would eliminate both the original requirement that each state match the amount of the federal grant to defray the cost of operating a high-risk pool and the corresponding limit on the federal contribution to no more than half of the operating loss of the pool. The bill would require that a portion of the funds for operational grants be used for grants to provide supplemental benefits, such as premium subsidies for low-income individuals, a reduction in premiums or other cost-sharing requirements, an expansion or broadening of the pool of individuals eligible for coverage, or increased benefits to enrollees or potential enrollees in a qualified high-risk pool. However, on June 30 of each fiscal year, unspent funds allocated to grants for supplemental benefits would be distributed to the states receiving operational grants that cover incurred losses. [emphasis added]

The bill also would modify the formula for allocating funds to states to give half of the funds to eligible states equally and apportion the other half based on the number of uninsured individuals in each state and the number of enrollees in the state's qualified high-risk pool. Previously, all funds were allotted based solely on the number of uninsured individuals in the state. Based on the operating losses of the existing pools (in 31 states), CBO expects that all of the appropriated funds would be spent, with direct spending of $14 million in 2005 and $355 million over the 2005-2010 period.

I'm not quite sure how this plays out for Texas. The Texas High Risk Pool has been operational for several years and is quite expensive, more so as individual risks are calculated. The program was not intended to help low income individuals. If, however, Texas is eligible for these grants--and our high rate of uninsured residents should put us in the ballpark--it would be interesting to know whether any accommodation will be made for low income persons as a result of the grants.

Sex and the Course of HIV Infection in the Pre- and Highly Active Antiretroviral Therapy Eras

Medscape reprints an article by Maria Prins, Laurence Meyer, and Nancy A. Hessol, which was first published in the March 4 issue of AIDS. Here's the abstract:

We reviewed the available literature on the potential effects of sex on the course of HIV infection and found that there is little evidence for sex differences in the rate of disease progression in the pre-highly active antiretroviral therapy (HAART) and HAART era. Compared to men, women appeared to have lower HIV RNA levels and higher CD4 cell counts shortly after infection with HIV, but studies were inconclusive regarding whether these differences diminish over time. Differences in viral load or CD4+ cell count might cause women to delay initiation of HAART. Nonetheless, we found no substantial sex difference in the benefit of antiretroviral therapy. The studies we reviewed failed to find any harmful effect of pregnancy on HIV disease progression. With the availability of effective antiretroviral agents, HIV-infected women have increasingly decided to have children. Conflicting results exist on the effect of HAART on regression of cervical intra-epithelial neoplasia (CIN). Unlike CIN, invasive cervical cancer has not been found to be much higher in HIV-infected women than in HIV-uninfected women. Although publication bias cannot be ruled out, published studies suggest higher rates of adverse events among HIV-infected women on therapy as compared to men. As more pharmacological agents are developed, it is especially important that potential sex differences in pharmacodynamics are assessed. The relationship between metabolic abnormalities, changes in body habitus, and endocrine perturbations has not been extensively studied. Whether sex differences are due to unalterable genetic factors or social and environmental conditions, it is imperative that all HIV-infected individuals have equal access to interventions that can slow disease progression.

So far so good in the House

The House Appropriations Committee has voted unanimously to substitute its version of the appropriations bill (HB 1) for the Senate version of the appropriations bill (SB 1). Now SB 1 will go to the full House of Representatives for discussion and vote.

The good news is that the House version of the appropriations bill is exactly the same as the Senate version when it comes to funding for HIV. The $15 million exceptional item request made by the Texas Department of State Health Services has been approved--so far.

The next step is the House vote. Then comes a conference committee to iron out the differences between the House version and the Senate version. This is where the bad news comes in. Even if both houses say that the $15 million should be appropriated, the conference committee can still take it away to pay for something else.

Texas AIDS Network is gearing up for a campaign to help the conference committee do the right thing. If you want to be part of that, drop us an email: tan AT texasaids DOT net. To participate, you'll have to commit to getting at least 19 other folks to send postcards to all 10 conference committee members. We'll provide the postcards, but you and your posse will have to pay your postage.

Update: The House is expected to start considering SB 1 on Wednesday, April 6.

Updated Pediatric Guidelines

The Office of Special Health Services for the FDA sends the following information:

The Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection have been updated, March 24, 2005. Please note that the Appendix, Characteristics of Available Antiretroviral Drugs, has been extensively modified to include up-to-date drug information, including updated information about pediatric dosing and new drug formulations. The updated Appendix also includes a matrix based on Table 18 in the Adult Guidelines (adverse drug reactions) and three matrices based on Tables 19-21 in the Adult Guidelines (drug interactions between antiretrovirals and other drugs).

The Pediatric Guidelines are developed by the Working Group on Antiretroviral Therapy and Medical Management of HIV-Infected Children, which reviews new data on an ongoing basis and provides regular updates to the guidelines.

The updated guidelines document is available in the Pediatric Guidelines section of the Guidelines page on the AIDSinfo Web site.

The AIDSinfo website is also a valuable source of other information related to HIV/AIDS, including other treatment and prevention guidelines, downloadable databases for PDAs (Personal Digital Assistants), and HIV/AIDS-related clinical trials information.

Legislature at Half-way Point

We have passed the 70th day of the 79th regular session, marking the end the first half of the session. So far:

• 3484 bills and 1072 resolutions were filed in the House. Because of the 60 day rule, relatively few additional bills would be expected for the remainder of the session.
• Of the House bills filed in the first half, 192 received favorable committee votes and 27 of those were then passed by the House.
• 1787 bills and 500 resolutions were filed in the Senate in the first half.
• Of the Senate bills, 152 received favorable committee votes and 45 of those were passed by the Senate.
• Only 1 joint resolution was approved by its originating chamber during the first half.
• No bills or joint resolutions have yet been approved by both houses. 43 concurrent resolutions, all ceremonial in nature, passed both houses in the first half and 35 of those were signed by the governor.

Bills passed by the Senate must also be passed by the House (and vice versa) before they are sent to the Governor for his signature or veto. We're half-way through it all, but there is still a long way to go.

Medicaid Estate Recovery

The Texas Health and Human Services Commission has sent the following notice"

In compliance with federal law, Texas has implemented the Medicaid Estate Recovery Program. With this program, the state may file a claim against the estate of a deceased Medicaid recipient, age 55 or older, who applied for certain long-term care services on or after the program's effective date, March 1, 2005.

Officials with the Department of Aging and Disability Services, which manages the program in Texas, say claims will not be filed when:

• There is a surviving spouse.
• There is a surviving child or children under 21 years of age.
• There is a surviving child or children of any age who are blind or
  permanently and totally disabled under Social Security requirements.
• There is an unmarried adult child residing continuously in the Medicaid recipient's homestead for at least one year before the time of the Medicaid recipient's death.
  

[Website information]

HB 43 Hearing

The hearing broadcast begins at 1:31:25 on the first session archived for March 22. It continues for about 15 minutes at the beginning of the second session archived for the day.

SB 127 -- Disease Control Programs

Disease control, harm reduction, needle exchange--we've seen this issue every session since I've been working for Texas AIDS Network. Some really fine folks have carried these bills in both the House and the Senate. Very often, the bills have died in committee, especially in the House. The Senate has been a little more collegial, allowing bills to be voted out of committee, but then they mysteriously never seem to get to the floor for debate and vote.

SB 127 was heard in the Senate Health and Human Services Committee yesterday afternoon. Several folks testified in support of the bill. No one spoke against it. Senator Jane Nelson chaired the hearing and was quite engaged in the issue. She asked several pertinent questions and seemed to have an honest interest in trying to figure out a way to support the bill. Her biggest concern was not the "moral" issue of needle exchange but the "message" issue, i.e., her concern that supporting needle exchange would send the wrong message to our youth with the apparent implication being that drug use is okay because we are giving needles to addicts and allowing them to continue to break the law by using illegal drugs. Or something like that.

Chairman Nelson was about to leave the bill pending in committee, since a quorum was not present, when several Senators began trickling in through various doors of the chamber. Senator Lindsay had marshalled his votes--and the bill passed.

The next challenge is to get the bill to the Senate floor for a vote.

HB 43 - Mandatory HIV Testing in Texas Prisons

Rep. Yvonne Davis' bill requiring HIV tests for all Texas inmates just prior to release will be heard this morning in the House Committee on Corrections. Texas AIDS Network will testify on the bill.

It took some doing, but we finally got a chance to talk to an aide in Davis' office about the bill and share our concerns. Our understanding is that Rep. Davis will introduce a committee substitute, but the only addition is to clarify reporting requirements for test results.

The bill is deceptively simple, as we discussed earlier. It simply changes "may" to "shall" or "must," applies to both state prisons and state jails, and applies to prisoners about to be released from the institutions. The fiscal note for the bill says that it won't impact the state's budget.

On one hand, the Network would like to support the bill.

• The incidence of HIV is about 7 times higher in the Texas criminal justice system than it is in the general population. The state releases a little more than 100 HIV-positive prisoners each month, according to the Texas State Epidemiologic Profile, 2005. The actual number of HIV-positive prisoners may be higher.
• Upon release, ex-prisoners often seek to do those things that they were not allowed to do while in prison. This may include behaviors that can lead to the transmission of HIV or other infectious diseases.
• The over-representation of African Americans in the Texas prison system, coupled with their over-representation in current HIV surveillance reports, suggests that there might be some net benefit to prevention, especially for that community, if some policy like what is being proposed in HB 43 is implemented.

On the other hand, we have some concerns about the bill.

• The Network bases its advocacy on a set of policy principles that provide a framework for progressive public policy for HIV/AIDS education, prevention, and treatment. Principle 9 says:

"There are no scientifically valid grounds for the mandatory HIV testing of specific groups of persons. Public health policy regarding HIV testing should be firmly grounded in current scientific evidence regarding risk of HIV transmission and should take into account the social and economic impact of HIV testing."

• The Network would rather see the testing protocol be "routine" rather than "mandatory." This would allow a prisoner to opt out of the test if he/she really objected to being tested. Our justification for this is simply a matter of human rights, allowing the individual to make an informed decision regarding his/her own health.
• That matter of "informed decision" is also a concern. Any HIV test administered in the state of Texas is supposed to be accompanied by pre-test counseling which allows the individual to have the information needed to make a decision regarding testing. If testing becomes mandatory in Texas prisons, there appears to be no concomitant requirement that any sort of counseling or education precede the test.
• In the case of a positive test result, Texas law also requires post-test counseling regarding prevention and treatment. This law is often disregarded, so we think it would be worthwhile to reference the relevant part of the statute to make sure that this counseling occurs.
• When this counseling occurs is also important. A positive test result is not like saying, "Beef! It's what's for dinner!" This is a life-altering moment. This is news that pretty much shuts out the world and all that it might have to say while the individual processes the fact that he/she has a life-threatening disease that is more than a little socially unacceptable. (Not only are you going to die, people won't like you anymore!) HB 43 makes no provision for timing of the test--and therefore does not allow time for an individual to adjust to a positive test result or make arrangements for living with HIV after release. Just as important from the perspective of the bill as a prevention bill, there needs to be some time allowed for the individual to be able to receive and understand the prevention information that he/she now needs in order to protect future sexual partners.
• The bill makes no reference to after care. There is some indication that after care is now a concern at the Texas Department of Criminal Justice, but there is also anecdotal evidence that what is said to happen doesn't always happen. The Network would prefer an explicit reference in the bill to TDCJ's responsibility to provide referrals and assistance in making connection with local community HIV services and, when appropriate, the Texas HIV Medication Program. For community services, this might include introduction to a case manager, even if only by telephone, and setting up an appointment to begin services, preferably within 30 days of release.

We'll see how it goes.

[Edited to correct embarrassing error in the number of prisoners released each month.]

US under fire over needle exchanges for AIDS prevention

The controversy regarding the current administration's stand on needle exchange is expanding. In a letter coordinated with 300 organizations from 56 countries, Human Rights Watch laid out concerns about the US' pressure on the UN not to support needle exchange programs. While the "mainstream" view is that needle exchange is a public health solution to a public health problem, the US is taking the position that needle exchange contributes to drug use and is, therefore, part of the public health problem. The US, not surprisingly, is advocating abstinence.

The result:

"We must not deny these addicts any genuine opportunities to remain HIV negative," Antonio Maria Costa, head of the UN Office on Drugs and Crime (UNODC) told in Vienna on Monday the 48th session of the UN Commission on Narcotic Drugs (CND).


Costa said that contaminated syringes were a major source of transmission of the HIV virus and other diseases including hepatitis, especially among drug users whose capacity for rational thought was diminished.


"We reject the false dichotomy that either drug control prevails, with no consideration for HIV, or that HIV prevention prevails with no consideration for drug abuse," he added.

. . .

Costa had said in a letter sent in November to the US State Department that the controversy over US objections to needle exchanges "continue to place... (Costa's office) in a difficult position," according to a copy of the letter obtained by AFP.


Costa said the United Nations does not "endorse needle exchanges as a solution for drug abuse nor support public statements advocating such practices" and feels such "prophylactic measures to prevent the spread of HIV/AIDS should be undertaken only within the overall effort to reduce druge abuse," the letter said. (sic)

Progress on state HIV appropriations

Items from Article II that were pended from the March 3 meeting of the Senate Finance Committee were sent to a workgroup, chaired by Sen. Judith Zaffirini (D-Laredo). The workgroup reported back on March 8 with its recommendations for items to be included in the final appropriations bill. The recommendation included $15 million for HIV and did pass.

The background of passage is a bit more interesting. You can listen to the archived broadcast of the March 8 meeting by scrolling down on the linked page to March 8, Finance Committee (part II). The relevant section occurs at about 2:19:00 in the broadcast.

The committee minutes are fairly cut and dried on this portion of the meeting:

The chair recognized Senator Zaffirini to lay out the workgroup recommendations and riders for Article II.

Senator Zaffirini moved to adopt the workgroup recommendations for Article II. There was a roll call vote. The motion carried with a record vote of 11 ayes, 3 nays, and 1 absent. Senator Averitt, Senator Barrientos, and Senator Staples requested unanimous consent to be shown voting aye, and Senator West and Senator Shapleigh requested unanimous consent to be shown voting nay; without objection, it was so ordered.

When Sen. Zaffirini reported that the workgroup recommended $15 million for HIV, she was challenged by Sen. Nelson. Sen. Zaffirini then reported that the item had initially been defeated in the workgroup on a 1-3 vote. A second vote had the same results. The third vote ended in a tie (2-2). Sen. Nelson questioned why the amount was brought forth as a recommendation. Sen. Zaffirini made reference to Chairman Ogden's support, there was laughter in the chamber, and the matter was dropped. Sen. Ogden was heard to make the comment: "That's my compassionate side showing."

All of these bits and pieces make for several important points:

1. The possibility of getting an appropriation of $15 million for HIV is one step closer. The Senate Finance Committee's recommendation must be approved by the full Senate. Now would be a good time to make sure that one's own Senator will support the Finance Committee's recommendation for $15 million for HIV.
2. Senators Shapleigh and West would ordinarily have been supportive of the request for funding for HIV. Since the vote on HIV funding came in the same package as several other issues, one or more of those other issues may have determined their need to vote "no" on the entire package, including, unfortunately, HIV. Since their late vote didn't affect the outcome (and Sen. Nelson was the only "nay" during the live vote), there is every likelihood that there was some other driver for their votes. Indeed, Sen. Shapleigh spoke up in support of HIV funding during the discussion. However, it would be good to know why Senators Shapleigh and West voted "no" and to encourage them to support HIV funding in the future. This would, of course, come best from people who live in their districts and should be done with great politeness.
3. It is worth noting that this vote is perhaps the single most critical vote in the entire process that leads to a final appropriations bill. There are still several points at which funding for HIV can be defeated, but this was the point at which HIV funding had to be added to the bill. Sen. Zaffirini's strong stand in the face of opposition--and Sen. Ogden's decisive support--were clearly heroic. They deserve our thanks.

Drugs, Lies, and Needle Exchange

Kevin Drum's blog has a post about an editorial in the Washington Post (registration required)that started a lively discussion about the effectiveness of needle exchange and the degree to which the current administration in Washington adheres to the truth. The central focus of the WP editorial is an interview with an anonymous Washington official regarding needle exchange and the anonymous source's assertion that at least three scientific studies showed that needle exchange was ineffective. The WP reporter then called the researchers responsible for all of those studies and asked what their conclusions were. In all three cases, their conclusions were that needle exchange programs were indeed effective rather than ineffective, as the anonymous source had asserted.

In the past, the tactics used to oppose needle exchange programs at the federal level centered on the quality of science in the research about needle exchange. As that has improved, apparently the new tactic is just to invert the outcome of the research and to assert that it says what NEP opponents wish it would say.

The context for the WP editorial is actually international. Most of its discussion centers on the need for needle exchange programs in other countries (e.g., Russia) and pressure being applied to the United Nations to abandon those programs. However, there is also relevance for the issue here at home.

• There is a current ban on spending federal funds for needle exchange programs.
• Texas paraphernalia laws make it difficult for needle exchange programs to operate out in the open in Texas.
• Of course, no state funds are being provided to support needle exchange programs either.
• Injecting drug use is a significant driver for the HIV epidemic in Texas.

Senator Jon Lindsay has introduced SB 127, to allow for the legalization of needle exchange programs in Texas. The bill was also introduced in the last legislative session, received a favorable vote from the Senate Health and Human Services Committee, but failed to receive a second reading in the Senate (i.e., someone blocked it). Senator Lindsay's stature is such that the bill is likely to get a hearing this session and may well be voted out of committee. The problem will be to get it to the Senate floor (and then, of course, through the House).

One thing that will help, I think, is for there to be an accurate representation of the science that considers needle exchange. The possibility that the same tactics being used in Washington will be used in Austin exist. It's our job to counter that with the truth.

HIV Advocacy Day, 2005

It's in the history books now. Seventy-five advocates, 2 training sessions, 181 visits to legislative offices, 181 green folders. HIV Advocacy Day was, by all accounts, a grand success. Not the least of our success were the meeting reports that advocates completed to let us know what happened during their meetings. Good stuff in there!

Thanks to all the organizers in Houston, Dallas, San Antonio, and Fort Worth for bringing all these wonderful folks together. It was nice to see old friends and make new ones. Ham that I am, I thoroughly enjoyed providing the briefing sessions for such a receptive audience.

Now, as always, the paperwork still has to be completed. I hear that folks are getting their thank you letters written. (This is excellent!) I have already entered the registration forms into a database and the certificates are being printed out as I type this. Getting them mailed will take a bit of work (I've stuffed more than enough envelopes for one lifetime, thank you very much), but they will get to you pretty soon, I think. There are still a couple of steps to go before I actually start stuffing those dreaded envelopes. Hang in there!

HIV Infection Rate Among Blacks Doubles

Jeff Donn reports for the Associated Press on research presented in Boston at the 12th Annual Retrovirus Conference that:

The HIV infection rate has doubled among blacks in the United States over a decade while holding steady among whites — stark evidence of a widening racial gap in the epidemic, government scientists said Friday.

The study on which Donn's report is based excluded the homeless, soldiers, and prisoners, making it likely that the infection rate in the African-American community may be higher. Adding insult to injury, the study shows that as much as 44 percent of those who need to be in treatment in this country are not.

FDA Approves First Ever Treatment for Hepatitis C in Patients with HIV

A press release by Roche pharmaceutical company talks about its new FDA approval and what it means for people living with HIV and Hepatitis C:

Roche announced today that the U.S. Food and Drug Administration (FDA) has approved the first and only hepatitis C treatment, Pegasys(R) (peginterferon alfa-2a) in combination with Copegus(R) (ribavirin, USP) for patients coinfected with HIV.

Hepatitis C and HIV are the two most prevalent blood-borne infections in the United States. It is estimated that approximately 30 percent of Americans with HIV are believed to be infected with the even more common blood-borne virus hepatitis C. Chronic hepatitis C affects approximately 2.7 million Americans and HIV, almost one million. Research has shown that hepatitis C is more resistant to treatment in people with HIV.

The approval of Pegasys combination therapy for the treatment of hepatitis C in HIV patients was based on results from the largest study of its kind conducted to date. The results showed that 40 percent of the 860 patients treated had the levels of their virus become and stay undetectable for at least 24 weeks after finishing a course of treatment.

In Texas, this sort of treatment would be available through private insurance and Medicaid (both are listed on the Medicaid formulary as preferred drugs that do not require prior authorization). The Texas HIV Medication Program does not provide treatment for co-infection with either Hepatitis C or tuberculosis.

Happy Valentine's Day

Watch this video. (Watch it all the way to the end. It can get loud, so close the door or adjust your sound.)

It's more fun if I don't give away the surprise, but this link tells you why this video seems appropriate for Valentine's Day.

Senator Lautenberg Introduces Legislation to Provide Comprehensive Sex Education in Schools

In a refreshing change, bills have been introduced in Congress to fund reality-based sexuality education in the schools. Neither text nor numbers are available on Thomas yet, but here is Sentator Lautenberg's press release on his bill.

WASHINGTON, D.C. -- At a press conference today, United States Senator Frank R.
Lautenberg and Rep. Barbara Lee announced the introduction of the "Responsible Education About Life (REAL) Act"; legislation that will bring a comprehensive
approach to teaching young people about the risks of sex, and the steps necessary to prevent unwanted pregnancies and Sexually Transmitted Diseases (STDs).

The measure will create a grant program administered by the Department of Health and Human Services (HHS) that would award $206 million per year to states for comprehensive sexuality education programs that would include medically accurate information about both abstinence and contraception. While $206 million in federal funding currently exists for "abstinence only before marriage education", there is no funding dedicated to comprehensive sex education.

"Abstinence only education only tells young people half the story, and they need the full picture," said Senator Lautenberg. "The abstinence-only programs funded by the federal government are not getting the job done."

Even the Heritage Foundation finds that "Some 75 percent of parents want teens to be taught about both abstinence and contraception." A Hickman-Brown 1999 poll reports that 93 percent of Americans support teaching comprehensive sex education in high schools.

"The REAL Act is a step in a more effective direction. It brings sex education up-to-date in a way that will reflect the serious issues and real life situations millions of children find themselves in every year," said Lautenberg.

I'm guessing that this won't pass, but it could open the dialogue, and dialogue is sorely needed. While abstinence is a good strategy for some people at certain points in their lives, unless one is making a lifelong vow of abstinence, there will come a point when some information about sex is going to be needed. That's the point at which reality-based information about contraception, disease prevention, and sexual health would come in mighty handy.

Routine HIV testing urged

Linda Johnson writes for the Associated Press that two major studies are advocating routine HIV testing. Such testing would be cost effective since the savings in detection and early intervention would outweigh the cost of testing, except for the celibate and monogamous. The VA participated in one of the studies and appears likely to go ahead with routine testing.

Testing is now routine for pregnant women in Texas. Women can opt out of the test, but the overwhelming majority consent to be tested. This has reduced the rate of perinatal transmission in Texas dramatically.

Texas budget hearings

The House Appropriations Subcommittee on Health and Human Services held its hearing on the Department of State Health Services legislative appropriations request yesterday. (The Senate Finance Committee hearing is today.) For most of the hearing, Commissioner Eduardo Sanchez held the hot seat, while he was grilled by committee members about various aspects of the budget.

The major good news related to HIV appropriations is that the 5 percent reduction originally mandated as an across-the-board cut for all state agencies has been eliminated for HIV. The Legislative Budget Board recommended restoring $4.1 million to HIV, keeping funding at 2005 levels.

However, new actuarial studies of the projected needs of the Texas HIV Medication Program show that the shortfall for FY 2006-2007 is higher than previously projected. The actual need is a little over $15 million (up from $11.7 million). Again, there is good news in that the Department of State Health Services has amended its legislative appropriations request to seek this higher amount of funding. (Historically, getting the Department to do that has been almost impossible.)

During the hearing, the subcommittee members asked several questions about HIV and STDs. All of them showed concern about the direction of the epidemic and the effectiveness of prevention.

• Rep. Isett (R-Lubbock) expressed concern about the apparent disparity between the low amount of funds being spent on abstinence education and the high amount of funds being spent on the treatment of HIV and STDs. He asked for more information about what other prevention programs were being provided. He also requested more information about funds being spent on HIV in other programs.
• Rep. Dukes (D-Austin) and others entered into a dialogue about the Texas A & M study of abstinence education in Texas.
• Rep. Luna (D-Corpus Christi), Vice-Chair of the Appropriations Committee, sat in on most of the hearing. She asked whether there was unmet need for HIV services. Are people who are not getting services from the Department going elsewhere for care, and does this involve cost-shifting to local communities?
• Rep. Davis (R-Houston), Chair of the Subcommittee, asked about the epidemiological trends for HIV and STDs and reasons for recent increases in new cases.

The Department will be providing additional information to committee members in response to their questions.

Thanks to Rep. Dukes, the hearing also included a lively discussion of Hepatitis C programming in the state. It appears that rumors that most Hep C programming would be abandoned are now not true. (We'll see.)

Texas AIDS Network testified in support of the the exceptional item request for $15 million for HIV medications, thanked the Legislative Budget Board for restoring the 5 percent reduction, and requested that Rider 29 (relating to abstinence education) not be amended.

AARP blogs Social Security

If you are trying to keep up with the debate on Social Security, AARP now has a blog which covers some of the basics and the ongoing dialogue. There is a very real concern that changes in Social Security will negatively affect support for disabled persons.

. . . via TPM.

FDA warns about home test kits

The FDA has issued the following warning:

The Food and Drug Administration (FDA) is warning consumers not to use unapproved home-use diagnostic test kits that have been marketed nationwide via the Internet by Globus Media, Montreal, Canada. In fact, no home-use test kits intended for diagnosing HIV*, syphilis and dengue fever are approved for sale in the U.S. The use of these products could result in false results (though there is no confirmed evidence of false positives) that could lead to significant adverse health consequences. The illegal kits are labeled as:

• Rapid HIV Test Kit
• Rapid Syphilis Test Kit
• One Step Cassette Style Cocaine Test
• One Step Cassette Style Marijuana (THC) Test
• One Step Cassette Style Amphetamine Test
• Rapid Dengue Fever Test
• One Step Midstream Style HCG Urine (Home) Pregnancy Test

FDA has not approved or evaluated the performance of any of Globus Media's products. As a result, consumers cannot know with any degree of certainty that test results are correct. For example, a person testing positive for HIV (human immunodeficiency virus, or the AIDS virus) using one of these tests may not be infected with HIV, or, worse, someone infected with HIV may test negative and not seek medical treatment, or spread the virus to others.

The tests were sold through websites and distributed throughout the U.S., usually by overnight delivery services. They have been made available for sale on several websites, including www.htkit.com and www.hstkits.com. The kits usually are contained in a paper envelope with instructions inside the packaging. The envelope, instructions and packaging may not accurately identify the manufacturer, packer or distributor. The name of the kit appears on the instructions. Consumers who have these products should not use them. Anyone who has used one of these test kits should be retested using valid test methods. The FDA has issued an import alert which alerts FDA field personnel to the possible importation of these devices, provides guidance as to their detention and refusal of admission into the U.S., and also advises U.S. Customs officials about these products. Other unapproved tests may also be available through the Internet. You can find a list of FDA approved / licensed tests for HIV and Hepatitis on the FDA website at http://www.fda.gov/cber/products/testkits.htm. [emphasis added]

*Please note that one licensed/approved diagnostic home collection kit for HIV, which is mailed to a laboratory for testing and confirmation, is commercially available in the United States.

Congressional Schedule

Congress' schedule for 2005 in now available.

• The HTML version lists the dates of various recesses and when Congress will reconvene.
• The PDF version is in calendar format, showing days in session in blue.

You can, for example, use these resources to plan visits to your congressional representatives' district offices.

Bush Budget May Harm PWAs

The response to the President's budget is starting to trickle in. The consensus is likely to be that this budget will cause some real problems for people living with HIV/AIDS. Not only is the proposed increase ($10 million) too small to fit the need (NASTAD recommended an increase of $197 million for AIDS drug assistance programs), cuts in other places will negate any potential benefit.

"This budget does not reflect the concern President Bush showed during his State of the Union for HIV and AIDS care and prevention," said HRC Vice President of Policy David M. Smith. "Unfortunately, the President's actions do not match his words."

. . .

In addition, the Centers for Disease Control saw a $4 million cut to its budget for HIV/AIDS prevention and surveillance. At the same time, unproven non-science-based abstinence-only programs, which do not include education about how HIV/AIDS is transmitted, received $38 million in additional funding. A recent study at Texas A&M University showed that teenagers taking abstinence-only sex education programs endorsed by the President became increasingly sexually active, which is the exact opposite effect that the program is designed to have. "Programs which focus on abstinence as the sole means of preventing HIV/AIDS put our young people at tremendous risk," said Smith. "The President has repeatedly stated his commitment to combating the spread of HIV. We have to question that commitment when his ideology consistently outweighs sound scientific facts."

. . .

Despite the President's recognition that HIV/AIDS is a growing problem in communities of color, the Minority AIDS initiative was flat-funded. Also, $14 million was cut from the Housing for Persons Living With AIDS program, which helps people living with HIV/AIDS afford housing. Having stable living conditions increases the chances of strict adherence to drug regimens, which is necessary for fighting HIV/AIDS and also prevents the development of medication-resistant strains of the virus.

President Bush's budget also includes Medicaid cuts of at least $45 billion over the next 10 years. These cuts would greatly affect a program that is responsible for providing health care to 55 percent of all adults living with AIDS and 90 percent of all children the HRC said.

The good news is that Congress still has something to say about all of this. Letting your congressional representatives know what impact this budget would have on you and your community would be a good place to start. See Texas AIDS Network's "Who Represents Me?" to find out how to contact your representatives.

The President's Budget (part 2)

Well, if I read this correctly(see page 429 [or 3 of 49 in this file]), the President is recommending only a $10 million increase for the Ryan White CARE Act with slightly more than half of that being earmarked for the AIDS drug assistance programs.

This amount will not be adequate to help Texas maintain current services for its clients in the Texas HIV Medication Program. It will effectively constitute another cut for other services provided under the CARE Act.

Ouch!

The President's Budget & HIV/AIDS

According to the federal Office of Management and Budget, President Bush has addressed HIV/AIDS thusly in his proposed budget for federal FY 2006:

Battling HIV/AIDS:
o The Budget devotes almost $18 billion for domestic AIDS prevention, treatment, and research, including almost $2.1 billion for the Ryan White CARE Act program (and its comprehensive approach to address the health needs of persons living with HIV/AIDS.)
o Under the President’s five-year, $15 billion Emergency Plan for AIDS Relief, the Administration has moved quickly and efficiently to mobilize the scientific and programmatic expertise,leadership, and resources of HHS and other Federal government agencies and their partners both here and abroad.

Without specific numbers, this sounds like so much smoke screen. The Ryan White CARE Act numbers don't sound like an increase, but, at this level of rounding, it would be hard to tell.

House Appropriations on Dual Eligibles

Clicking on the title for this post will bring up the broadcast for the House Appropriations Committee meeting held this morning. (RealAudio is required to view the broadcast.) The second item on the agenda was a presentation regarding the state's "give back" requirement under Medicare Part D. The discussion occurs about 17:55 (minutes:seconds) into the broadcast and ends at about 58:00.

Melitta Bustamante, an analyst for the Legislative Budget Board, laid out the basics on the state's role in financing prescription drug coverage for Medicaid/Medicare dual eligibles beginning January 1, 2006.

At that time, dual eligibles will no longer be able to receive medications through Medicaid. Instead, they will receive them through Medicare. The medications themselves will come from private providers (HMOs, insurance companies) that choose to participate in providing this pharmacy benefit. Persons who are dual eligible will be able to choose (in most cases) among two or more programs. A premium and co-pays will be charged. Each provider will determine its own formulary.

The state will be required to "give back" to the federal government's Medicare program 90 percent of the amount that it would otherwise have spent on providing medications for this group of people. (The estimate is that there are 316,000 dual eligibles in Texas.) The amount of the "give back" will decline over a period of years until it reaches 75 percent, so that the state will eventually "save" 25 percent of the cost of providing medications to this population.

Questions from Representatives Vilma Luna, Dawnna Dukes, and Graig Eiland zeroed in on several elements still at issue on this program. Dukes spent a fair amount of time questioning what would happen when a needed drug is not on the formulary of the provider selected by a client. She also pointed out the heavy burden of co-pays on the low income population. Representative Luna discussed the problem of clients being targeted by aggressive marketing campaigns with the result that naive clients may end up signed up for (and financially obligated to) more than one program. Representative Eiland asked some pointed numbers questions about losses to Medicaid from drug rebates (suggesting that the cost savings of Medicare Part D are less than 10 percent).

If you're at all wonky, this is a good session to listen to. I just hope that your feed is better than mine. The whole committee looked like smurfs.

Leavitt Sees $60 Billion in Medicaid Savings

(registration required to read entire article)

Ceci Connolly, writes in the Washington Post, that the new Health and Human Services Secretary Mike Leavitt

said yesterday that $60 billion can be saved over the next decade in the Medicaid health program for the poor by closing loopholes, prohibiting "accounting gimmicks" by states and eliminating wasteful spending on items such as overpriced prescription drugs.

Leavitt assured his audience that there would be no cap on mandatory benefits under Medicaid, but that left in limbo the question of what the administration might do about such optional services as prescription drugs.

Diane Rowland, executive vice president of the nonpartisan Henry J. Kaiser Family Foundation, said that because children are the largest group of mandatory beneficiaries, Leavitt's comments seemed to indicate "the potential goal here is to reduce spending on the aged and people with disabilities, who tend to be classified as optional and are the most expensive."

Unfortunately, details of that $60 billion in savings are elusive.

He promised aides would provide details on the $60 billion in savings. But a staff e-mail later said only: "The estimated savings numbers used in the speech are formal HHS estimates and can be attributed as such."

The Texas Health and Human Services Commission publishes an annual report on Medicaid in Texas, the most recent called Medicaid in Perspective 2004. In Chapter 5 (p. 16), a pie chart shows the federal budget expenditures for FY 2003. Medicaid and CHIP combined comprise 8 percent of spending. (Interestingly, interest on the national debt comes in at 7 percent, which is almost as much as Medicaid.) According to the Texas Fact Book 60.5 per cent of the federal funds that Texas received in FY 2004-2005 were for health and human services ($23,729.4 million).

Senate Health and Human Services Committee

The committee held its organizational meeting today and adopted rules. The committee's regular meeting time during the session will be Tuesday mornings at 9:00 a.m. in the Senate Chamber. The committee will meet more often if the workload necessitates it.

Governor's Budget Recommendations

The governor has made his recommendations for the appropriations for the coming biennium. While his budget document does not show allocations as specifically as the Legislative Budget Board recommendations do, the budget does show that the Governor is recommending more than $100 million less for the Department of State Health Services than the Department is requesting.

The Governor's priorities for increased funding include:

• Reform child and adultprotective services
• Create emerging technology fund
• Add offices of inspectors general
• Increase skills development fund
• Expand mentoring initiatives
• Improve student financial aid
• Etc.

National Condom Week . . .

occurs every year February 14-21. (This is not to be confused with the British Condom Week, which occurs in May. Canada has apparently switch from "National Condom Week" to "National Sexual Health Awareness Week.")

Some light-hearted, but perhaps out-of-date, information is available at Condomania. Here's a Planned Parenthood press release from last year's Condom Week.

National Black HIV/AIDS Awareness Day . . .

will occur on February 7 this year. For more information, go to http://www.blackaidsday.org/NBHAAD_info_home.htm.

Texas Senate committees, too

Lt. Governor David Dewhurst has announced the appointment of Senate standing committees for the 79th Texas legislature. A list of committees with links to members is available on the capitol website. The Texas Senate website also has a list of committees with useful links. However, the Senate website has not yet been updated to reflect today's appointments.

Members of the Texas HIV/AIDS community will be most interested in the work of the Senate Committees on Finance and Health & Human Services. However, other legislation of interest will be referred to other committees, so it will be helpful to bookmark the entire lists of committees as well.

Texas House committees appointed

Speaker Tom Craddick has announced the appointment of House committees for the 79th Texas legislature. The capitol website provides a list of committees with links to membership lists. In addition, the House website provides a similar list of committees with a slightly different set of links. However, the House page has not yet been updated to reflect the new appointments.

Here is the speaker's press release on the committee appointments. Printable PDF documents with committee appointments can be found here.

The Texas HIV/AIDS community will be interested in the House Committees on Appropriations (especially the subcommittee on health and human services) and Public Health. Bills of interest will, however, be referred to other committees, so it is worthwhile to bookmark the links for the whole list of committees for easy access to useful information.

H.R. 308: To amend title II of the Social Security Act to eliminate the 5-month waiting period

Congressman Mike McIntyre (D-NC) has introduced H.R. 308, "To amend title II of the Social Security Act to eliminate the 5-month waiting period for entitlement to disability benefits and to eliminate reconsideration as an intervening step between initial benefit entitlement decisions and subsequent hearings on the record on such decisions." The bill has been referred to the House Committee on Ways and Means.

The text of the bill is not yet available on Thomas. It should be available in a couple of days.

U.S. Women at Greatest Risk of Sexual Disease: Study

Why does this not surprise me?

LONDON (Reuters) - Americans, and especially women, are three times more likely to suffer premature death and adverse health due to sexual activity than people in other rich nations, scientists said on Thursday.

Researchers from the U.S. Centers for Disease Control (CDC) found some 20 million cases of adverse health conditions and 29,745 deaths in the United States in 1998 were related to sexually transmitted diseases.

"The research showed the sexual behavior attributable health burden is about three fold higher in the U.S. than other developed countries," Dr. Shahul Ebrahim, one of the authors of the CDC study, told Reuters.

"All of it is totally preventable and that's the message."

Ebrahim said the health burden included conditions such as infertility, abortions and infections such as gonorrhea.

Women accounted for 62 percent of all adverse health cases, with most female deaths attributable to cervical cancer and HIV.

Deaths from curable sexually transmitted diseases were, however, rare among both men and women.

The paper, published in the journal Sexually Transmitted Infections, was the first attempt to generate comprehensive findings on the health burden related to sexual
behavior in the United States.

Citation: Sexual Behavior- Related Adverse Health Burden in the United States. H. Ebrahim, M. T. McKenna, and J. Marks Sex Transm Infect 81: 38-40 (February 2005).

More information is available in this HealthDay-reported article.

Making a district visit

Well, I just lost this post somehow. Fumble fingers on the keyboard, I guess.

Anyway, as I was trying to say: Your elected representatives have offices both at the capital (Austin or Washington) and in their home district. Making a visit to the district office is a good way for advocates to have an impact on legislation without the added expense of traveling to the capital.

Texas AIDS Network has developed a brief PowerPoint presentation to give you some tips about finding your representatives' district offices as well as how to get the most out of your visit. The presentation is called, originally enough, "The District Visit."

Right now the Texas legislature is in session, but, in these early days of the session, legislators frequently leave Austin on Thursday evening and return on Monday. Their district staff members are, of course, available all week long.

Congress is in session, too, but Congress takes a lot of breaks for "district work periods." The district staff members are also available even when Congress is in session.

Who represents me?

Texas AIDS Network has provided a new PowerPoint presentation called "Who Represents Me?" to assist advocates in identifying their elected representatives. In 17 slides, the presentation explains the system for representation and points to web sites where advocates can enter their home addresses to find their state representative and senator as well as their U.S. representative. Full contact information for statewide representatives (including the President and Vice President) is also provided.

Food for thought

From the Boston Globe

WASHINGTON -- Disability benefits may not be safe from the across-the-board cuts that are likely in President Bush's proposal to allow personal investment accounts in the Social Security program.

Retirement and disability benefits are calculated using the same formula, so if future promised retirement benefits are cut, then disability benefits also would be reduced -- unless the program is somehow separated.

This raises big questions about how investment accounts would be structured for the disabled, especially if they are injured at a young age or are dependent on a parent. Disabled beneficiaries typically work less and need benefits sooner, so the accounts would not provide enough income to them.

. . .

Currently, disabled workers move seamlessly through the Social Security system, often unaware they draw their benefits from the disability program until they reach retirement age and shift to the retirement program. That would change with investment accounts, advocates say, with people falling through holes in a new system.

About 16 percent of the 47 million people receiving Social Security benefits are disabled workers and their dependents. The impact of accounts on beneficiaries who aren't retirees has not been publicly discussed by the Bush administration.

. . .

Help save Medicaid for people with HIV

Below is an organizational sign-on letter written by the HIV Medicaid/Medicare Working Group. As you have likely heard, there is great concern that there will be efforts this year to cut funding and/or make harmful changes to Medicaid. This letter urges the President not to make such changes/cuts and explains the importance of Medicaid for people with HIV/AIDS.

The letter will be sent to the President and key Administrativeofficials, and will be distributed to Members of Congress during legislative visits in early February. Please help with this effort by signing your organization to the letter and encouraging others to do the same.

To sign this letter (organizations only), email Lei Chou at theaccessproject-at-aol.com

Please provide the following information:

• Organization Name:
• Address:
• City/State/Zip:
• Phone:
• Contact person/Title:
• email:

Deadline: 5 pm EST, Friday January 21st.

If you have any questions, contact Ryan Clary at rclary-at-projectinform.org . To sign-on, email theaccessproject-at-aol.com.

The President
The White House
Washington, DC 20500
Date

Dear Mr. President:

The undersigned organizations that serve and advocate for people living with and at risk for HIV/AIDS are writing to strongly urge you not to propose cuts in Medicaid funding and/or any changes in the program's structure that would alter the open-ended financing for states. We also urge you not to weaken the individual entitlement or other key consumer protections that have helped Medicaid to serve the national interest so effectively for nearly four decades.

Medicaid is the largest source of federal financing for HIV/AIDS care in the United States. The program provides access to healthcare for 55% of all people living with HIV/AIDS, and 90% of all children living withAIDS. It plays a critical role in providing access to anti-HIV drugs that forestall illness and disability, and allow people to live longer, more productive lives. While Medicare and the Ryan White CARE Act are vital components of the national system of health care for people withHIV/AIDS, they do not have the resources and are not appropriately designed to respond to unmet needs if structure changes were made to Medicaid that would result in either fewer people qualifying for coverage or if states were forced to restrict services. Thus, any cuts or changes in Medicaid's financing structure will seriously jeopardize access to HIV/AIDS care in the United States.

Furthermore, we are firmly opposed to changes in the current structure of the Medicaid program that would turn the program into a block grant or cap federal funding. The individual entitlement provided underMedicaid is essential. The reliable and consistent federal funding stream allows the program to respond to increases in demand as more people with AIDS are identified - an important goal of the Centers forDisease Control and Prevention's Advancing HIV Prevention initiative, and supports access to more effective, less toxic anti-HIV therapies as they are developed.

The health of our country's most vulnerable residents must be viewed as a priority. We ask that you create a budget proposal for FY 2006 that ensures adequate Medicaid funding and maintains the program's current structure so that it can continue to meet the needs of people with HIV/AIDS and others who rely on this lifesaving program.

Sincerely,

Texas AIDS Network has signed on to the letter and urges other organizations to do the same.

Who is my representative?

There are several places to go to find out who your representatives in the Texas Legislature are. (Everybody has one each in the Texas House of Representatives and the Texas Senate, by the way).

The Texas Legislature provides a locating service at http://www.capitol.state.tx.us/fyi/fyi.htm (the "fyi" used to stand for "Find Your Incumbent," but the page is now simply called "Who represents me?"). You can search for your personal representative by entering your home address. Representatives can also be searched by city and county, which can be useful if your city or county is represented by more than one person and you want to visit/contact all of them. Be sure to note that senators and representatives usually have an office in Austin at the capitol and one or more offices in their home district.

If you already know who your representatives are, you can find listings for their district offices in the blue pages of your local telephone directory.

If you don't like web searches, you can also call the voter registrar for your county to ask who represents you. However, you will still probably have to consult those blue pages for contact information.

What to do right now about appropriations

The 79th Texas Legislature convenes at noon tomorrow (January 11). For the following 140 days, legislators will consider 5000 or so bills and pass a budget for the next biennium--2006-2007. Most of the bills will die somewhere in the legislative pipeline, and a lot of attention will be given, both in the press and on the floor of both houses, to critical state issues relating to school finance and reform of child and adult protective services. Even so, at the end of 140 days, the legislature must pass an appropriations bill.

We can expect to have several opportunities to influence the decisions to be made regarding the appropriations bill. Indeed, Texas AIDS Network has already been active in testifying at hearings during the past several months to advocate for increased funding for HIV. There are, however, a number of things that individuals and organizations can do right now to help legislators to focus on HIV and its funding needs in Texas.

• Make sure that concerned persons in your community are aware of the impending shortfall in HIV funds in the next biennium. Tell them that the Texas HIV Medication Program needs $15.9 million in new state funds in order to maintain services at the current level. Concerned persons would include:
• People living with HIV/AIDS
• Their family members and caregivers
• Health professionals
• City Council members
• County Commissioners
• Hospital district
• Local AIDS service organizations
• Ryan White planning groups
• Faith-based organizations
• Allied organizations (e.g., Red Cross, PFLAG, etc.)
• Gather a group (4 or 5 at most) of people from diverse backgrounds (so you can share different perspectives on the issue) and visit the local district office of your state legislators. Meet with the staff who support the legislator in the district to talk about how HIV/AIDS affects the district (or local area/city/county) and how important the Texas HIV Medication Program is to clients in the area. Request the legislator's support for $15.9 million in new state funds for HIV.
• Note that legislators usually stay in Austin Monday-Thursday during the early weeks of a legislative session, so that it may be possible to meet with your legislator in the district on a Friday. However, staff members are critically important in helping legislators understand the importance of some issues. You should not hesitate to meet with staff members if the legislator is not available.
• Try to leave something in writing so that your facts and figures don't get forgotten. Providing contact information for follow up questions is also a good idea.

These are two activities that would be most helpful in the next two or three weeks. If you take any of these actions, be sure to let us know by email or in the comments.

THMP MAC meets

The Texas HIV Medication Program (THMP) Medication Advisory Committee (MAC) met today in Austin to discuss the formulary and budgetary issues.

Two new additions to staff were introduced: Felipe Rocha, MSSW, is now manager of the HIV/STD Comprehensive Services Branch (what used to be the HIV Bureau), and Janna Zumbrun, MSSW, is now manager of the Health Promotion Unit (the next organizational level above the HIV Services Branch).

Robert Kaspar, MD, provided an update on Fuzeon: THMP is currently providing Fuzeon to 50 clients, the maximum possible with current funding. There are 12 clients on the waiting list for Fuzeon. Dr. Kaspar also reported on ongoing discussions regarding the use of ritonavir as a fifth drug in combination therapies; for the time being each request for a five-drug combination will be reviewed on a case-by-case basis.

Regarding appropriations for the coming biennium, Dwayne Haught, MSN, ACRN, reported that the Legislative Appropriations Request for the medication program had been revised to reflect new data. The request is now $11,701,085 for FY 2006-2007. In addition, the Department of State Health Services is requesting the restoration a 5 percent cut imposed by state leadership. THMP's share of that 5 percent cut is $4,171,240. Therefore, the total amount in new state funds needed for the coming biennium will be $15,872,325.

Texas AIDS Network will be sending out action alerts and other advisories to members and interested members of the community. To sign up to receive these alerts, send an email to tan-at-texasaids-dot-net (using the proper email address format, of course).

Unfortunate juxtaposition

USA Today ran a series of op/eds on Monday (January 3) that explored both the divergence of opinion about values in our country and the desire (in most cases) to find some common ground. An especially interesting op/ed came from a minister in Texas.

Congregation's values are broad and inclusive

I lead a predominantly white evangelical congregation of about 800. Each election, I urge our folks to vote their convictions. In November, most of them decided that the incumbent Republican best represented their values. Yet, for decades, these same folks have consistently voted for a Democratic congressman for the same reason.

Who doesn't vote their values? My first vote was cast for George McGovern because I wanted legalized marijuana. My values have changed, but I still vote my values. But my values and those of my brethren are much broader than those attributed to us.

Yes, we detest abortion, but our church collects furniture for young single moms. We also adopt children and serve as foster parents.

Yes, we believe that marriage is for one man and one woman, but we also have loved and cared for victims of AIDS.

A wonderful black man serves on our church board, and I cry against racial discrimination from the pulpit because we detest racism.

We are stewards of the Earth. I collect used copy paper from the office, bind the pages and reuse them as notepads to save a tree.

We care for the poor and therefore help to provide housing for homeless families.

In November, we chose the man who seemed to best resonate with our values, but please don't paint us with a Republican brush. If Sen. John Kerry had been running against McGovern, most of us would have given our vote to Kerry.

Jim Johnson, White Oak, Texas [emphasis added]

My personal values lead me to think that Jim Johnson must be a very fine person; I know a lot of people who seem to feel and act the way he portrays his congregation. My professional concern, however, is that Jim Johnson sets opposition to same-sex marriage right next to care for persons with AIDS as if the latter mitigates the other. Mitigation can only occur if the two are equivalent or nearly so. In this case, there is no equivalence, since the underlying assumption appears to be that AIDS is a gay disease, such that opposing equal rights for healthy gay persons is mitigated by caring for gay people who are ill or dying.

HIV in Texas is increasingly black or brown and increasingly heterosexual. In 2003, 35 percent of the HIV cases reported were identified as white. However, 41 percent were African-American and 22 percent were Hispanic. Of all the new cases of HIV reported in 2003, 26 percent were female. Of those cases where mode of transmission was known, more than 24 percent were due to heterosexual transmission. This rate of transmission is higher than that which can be attributed to IDU (18 percent).

While these numbers leave plenty of room to recognize that HIV infection is still a major concern to the gay community, those who are at risk for infection are increasingly people of color and women (who are often both). We increase their risk when we imply or allow others to imply that HIV is limited to the gay community.

The fine folks in Jim Johnson's congregation should be applauded for their compassion. There is great need of it in White Oak, which is located in Gregg County. Gregg County reported 21 new cases of HIV and 9 new cases of AIDS in 2003. There were 229 people living with HIV and AIDS in Gregg County on December 31, 2003. Many of them are undoubtedly gay, but there is every likelihood that some are women.

Alcohol May Boost HIV Risk from Oral Sex

ABS News carried a story that I missed a couple of weeks ago regarding the role of alcohol in HIV transmission. As timely as the story was during the holiday-partying-drinking season, it's still timely as we approach any given weekend or happy hour of the year. The story is based on a Reuter's report about a research study published in the Journal of Acquired Immune Deficiency Syndromes (December 1, 2004).

The study itself reports that "Lab experiments show that cells that line the mouth become more susceptible to infection with HIV when they're exposed to alcohol." Specifically, "oral epithelial cells exposed to 4% ethanol for 10 minutes showed three- to six-fold greater susceptibility to infection with HIV strain." That's the level of alcohol in a beer, by the way.

Hiatus

Aside from the activities of the holiday season, I have not been able to post due to a family illness. Regular posting should be back on track now.