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Re:Re HIV and Disability
Jun 3, 2008

Hey Dr. Bob, no need to thank me for the last post! I'm always happy to do my part. By my calculations, you've given me way more minutes of smiles and laughter reading your columns than I've spent on the response to SSI-guy (and often there's some real humor in the questions themselves. The kid whose father told him that masturbation caused elephantiasis? Classic! Just when you thought that you'd heard every masturbation myth that had ever been dreamed up! I guess in your line of service, you've never really heard it all. There's always another chicken-bone-marrow boy to surprise you!). After I sent the reply to 'HIV and Disability', I went looking for a list of providers of free legal services for pozitoids in California so I could send a link. All the lists I found seemed a little short, so I figured I'd try to put together a more complete one when I got a minute. Anyway, yesterday was Memorial Day, I finally had a day off and finally remembered to compile it, so it's attached below for the original poster (or for others who need help applying for benefits in the Golden State; most of the resources should be good for other legal needs too).

Crystal blue eyes, six-pack abs, and killer pecs? That description of me was so dead-on I would've sworn you were a protege of Sybil Trelawney! Actually, it's green eyes, a kind-of visible-if-I-flex 4-pack, and a 34C (to those readers who are desperate to see symptoms where none exist, that probably sounds like an impressive case of gynecomastia! hint: it's not). I'm still more-than-willing to accept any man who has been Dr. Bob tested, approved, and pleasure-guaranteed. Just do me the additional favor of making sure he swings both ways (in the sense of being an honest-to-god bisexual, not a closeted gay man who wants a sexless marriage as political cover for his wide stance and fondness for glory holes). Ten years from now, I don't want to be Mrs. Larry Craig writing to Dr. Bob wondering about whether the frat boy in the basement and the unauthorized credit card charges to twinks.com might "mean something". I don't think it should be a problem: so many straight guys on this forum have fallen head-over-heels for Dr. Hottie-pants over the years; this clearly indicates to me that you're a magnet for hunks of all orientations.

You're available for free advice whenever I'm in need? Careful what you offer, Doctor! I have a stack of files containing hundreds of pages of medical records with all sorts of anomalies that BEG for the interpretation of an HIV-experienced MD! (I'm already spending a decent part of my own doctor appts asking about other peoples' problems). Not to mention about a zillion immunology questions (there were never enough office hours to get all my questions out back when I was taking immunology). But most of these would be way outside of the scope of your forums. I only have a couple questions on the topics addressed by your forums, and neither is actually urgent, so if it'll take more than a minute or two to answer, please don't feel obligated. Your worried-wells need you a lot more than I do! They make me, and just about every poz friend I have, look healthy by comparison! On the other hand, now that one of your dear WWs has educated me about the classic ARS symptom of longer, thicker eyelashes, I'm starting to wonder if perhaps I got the short end of the HIV stick... Oh, I guess I really can't complain. After all, I missed out on the spattergroit.

Seriously, not a huge deal if you don't have time or there are more pressing questions (I doubt that mine are really of general applicability) - I'll be seeing my own MD next month and can ask him then. On my end, if you get any other questions where the assistance of a mere law student with little experience and no accreditations of any kind will come in handy, you know where to find me (out scanning every bathtub jacuzzi in town for my soon-to-be lover with the great pecs and six-pack - mmmmmmm, nice!)

Question 1: I have a client with a normocytic, normochromic anemia (most recent hgb 9.8) since his dx about 16 months ago. Was on Bactrim at prophylactic dosages for about 8 months. Other than that, no drugs that commonly cause myelosuppression or hemolysis (current meds: EFV, TDF, 3TC [I have NO idea why he hasn't just tried Atripla]). Other lab tests look OK to me (slightly elevated ALP, but transaminases were fine. MD hasn't run liver function tests beyond the CMP, so the only thing I can guess is that the ALP is being chocked up to the Viread or probably it just isn't high enough to warrant concern. He has no known liver disease. He had a relatively mild thrombocytopenia when his CD4 counts were around 150, but it has resolved without specific intervention a couple months after VL was suppressed]), but I'm obviously not a doctor! No known cause of blood loss (but they haven't done a fecal smear), no known history of infections that infiltrate bone marrow. VL has been suppressed for almost 15 months. Last CD4+ count was 412. Iron tests were run about a year ago (never repeated): serum Fe 35 (ref range 45-175); transferrin saturation 12% (20-50); ferritin 2632 (24-336), iron binding capacity 292. They never did a Coombs test (but serum bilirubin was normal) or tested his serum testosterone, EPO level, or looked at his bone marrow. No reticulocyte count or peripheral smear either. The diagnosis was iron deficient anemia and he was prescribed iron and folic acid supplements (serum folate was never actually tested. Neither was B12 for that matter). He's been on the supplements for almost a year, and his hemoglobin hasn't improved. I know better than to play doctor (I don't think I could hack 7+ years of that kind of sleep deprivation in order to be qualified to do so; plus, my inane teenage attempts to forego antifungals and cure my thrush with a macrobiotic diet suggest that I would probably suck at it!), but from the bit I know about anemia, this seems more similar to anemia of chronic disease than iron deficiency (but I'll repeat, I'm not a doctor!). For my purposes (a disability application), is it reasonable to characterize this as anemia of chronic disease (which, for whatever reason, works better on these things than anemias caused by vitamin deficiency, perhaps because the examiners don't know shit about HIV and don't realize that anemia of chronic disease is actually treatable!)? More importantly, for the client's well-being and health, should I suggest that he seek out a second opinion and a more complete work-up, or is there a reasonably good chance that the vitamin-deficiency diagnosis was correct and that the treatment is just taking a long time to work? If a second opinion IS necessary, should it be with another HIV doc (maybe a more experienced one) or is a hematologist actually necessary?

Question 2: Another client is a MTF transsexual who was trying to get some of her body and facial hair permanently removed through electrolysis (already had laser, apparently didn't get all of it). The electrolysist who she saw gave her some sort of medical history form that asked if she had been HIV-tested, and if so, what the results were. She didn't know that she wasn't obligated to answer this, responded honestly, and the electrolysist refused to serve her. She is now electrolysing her hair herself with some gadget from the internet. I'm pretty upset about this one because the lady was nasty, and the client is emotionally vulnerable (she has felt, and quite sadly, been treated, like an outcast her entire life, and the ignorance and rejections that most of us would spit, she appears to swallow and be deeply wounded by). I'm no expert on these matters (hence I turn to you), but the risk here seems negligible, or at best, minimal. The best I can tell from "the google", the needles they use are solid-bore and very tiny (way smaller than a Fuzeon needle. I mean, it's supposed to be small enough to fit in a hair follicle!). According to the client, there's no blood visible on the skin or the needle afterward, at least with the home unit. The client's VL has been below the level of detection for many years. I figured that this situation was analogous to a suture-needle stick (if it's interpreted in the riskiest possible light - from the pictures I've seen, a suture needle is bigger and can go much deeper, and if somethings being sutured, there's often blood from the wound. Not to mention that an electrolysist's office is a much more controlled atmosphere than a chaotic OR, which should make a stick less likely to begin with). With zero cases of HIV transmission from suture needle sticks, despite thousands upon thousands of such sticks every year (many of which must have been from HIV+ patients in the pre-PEP era), how should I characterize the risk to an electrolysist from a patient with a suppressed VL? "purely theoretical"? "so unlikely that it can't even be roughly quantified"? "less likely than being struck by lightening"? Or would that be understating the risk? Be forewarned: given your credentials, if you answer this one, I will almost definitely be quoting it! I'm hoping that resolution and getting the right people to take the proper actions won't hinge on this point, but it does go to this being discrimination and not just a legitimate health and safety concern (as far as I can tell, electrolysists have discretion in whether they use precautions like gloves).

I'm thrilled about the California ruling. Even though all sane people already considered you and Steve (as well as every other committed gay couple) to be married, I'm glad that your state will finally recognize your union as equally meaningful and worthy of protection. Long overdue! I'm counting on Obama to change federal law so that you and Steve will truly be afforded the same rights as hetero citizens, but the California ruling is a good start. If it wouldn't be too much of an intrusion into your personal life, you should post a wedding picture on this site or concertedeffort. I think a lot of your longtime readers would like to share in your happiness from afar (not to mention drool over the picture of the two of you in tuxes...).

"Most of my lawyer friends charge by the word or fraction of a second" So, Dr. Bob, you know what its like to be charged in split-second increments? Now I finally understand why all the WWs with penchants for lapdances and ladies-of-the-night feel that you can relate to them! Personally, I feel you get better bang for the buck with the type of prostitutes who don't have JDs.

yours truly, professional-whore-in-training

p.s. Any idea where my punctuation disappeared to in that last post? Is there some hot commodities market in dashes, semicolons quotation marks, and apostrophes that I haven't heard about? Guess I better be more frugal with those contractions and subordinate clauses so my poor little sentences don't get stripped down and sold for parts. Here, take these:;/'[]---():"""\''',,,,,

PLACES IN CALIFORNIA WHERE THE HIV+ MAY BE ABLE TO GET FREE LEGAL HELP/BENEFITS ASSISTANCE: - HIV & AIDS Legal Services Alliance, Inc. (associated w/ UCLA Law School; free legal services for low-income HIV+ individuals in L.A. County): 213-637-1690, http://www.halsaservices.org/ - AIDS Legal Referral Panel (free legal services + referrals to pro bono/reduced-fee attorneys for HIV+ individuals in the SF Bay Area) - 415-701-1100 www.alrp.org - East Bay Community Law Center (associated with U.C. Berkeley Law School, a program that provides free legal services for low-income HIV+ individuals who live in Alameda County): 510-548-4040 www.ebclc.org - Positive Resource Center (San Francisco, attorney assistance and benefits counseling for HIV+ individuals) 415-777-0333, http://www.positiveresource.org/benefits/default.asp - AIDS Legal Services (San Jose; direct legal services to the HIV positive, which presumably means benefits cases, according to a description I found elsewhere) 408-293-3135; no website; - San Diego Volunteer Lawyer Program AIDS/HIV Legal Services Project (free legal services to the HIV+ on a variety of issues stemming from HIV; there are a whole bunch of numbers you call to make an appointment, depending on which of their clinic sites you want your appointment at see the webpage for info): http://www.sdvlp.org/service_aids.htm - Ventura County Rainbow Alliance (case management, benefits advocacy, and legal services for HIV+ in Ventura County; services provided to all HIV+ regardless of sexual orientation) - 805-339-6340 info@lgbtventura.org; http://www.lgbtventura.org/programs.php?subPage=services - Legal Services of Northern California (Sacramento; not HIV-Specific, but they do all sorts of benefits cases for free for the low-income) - 916.551.2150 ; www.lsnc.net - Stanford Community Law Clinic (run by Stanford Law School; no program specific to helping HIV+ individuals, but they provide free legal services to residents of East Palo Alto, including benefits cases): 650-475-0560 - North Coast AIDS Project (Humboldt County; services for people living with HIV includes professional services program where professionals volunteer their services to low-income people living with HIV who would be otherwise unable to afford them; Includes legal services); 707-268-2132; http://co.humboldt.ca.us/HHS/PHB/NorCAP.asp - Santa Cruz AIDS Project (free case manager and extensive help w/ getting benefits; not sure if they have lawyers [the ALRP website said they have an AIDS Legal Panel, but their website said no such thing; in any case, it looks like theyre experienced in such matters], they can also probably provide a referral [not that a lawyer is necessary! Ive long said that community advocates could do most of the work we do with a bit of training. The major benefit to having a lawyer isnt that theyll necessarily do a better job, but rather that the folks at SSA are significantly more accommodating to people who could realistically drag their asses into court!]) 831-427-3900, www.scapsite.org - Marin AIDS Project (same as the last one free counseling/help obtaining benefits, but no mention of lawyers; also some last-resort financial assistance) 415-457-2487, www.marinaidsproject.org - Face To Face Sonoma County AIDS Network (same, free benefits counseling/case management, assistance with applications), 707-544-1581: http://www.f2f.org/careservices.html - Desert AIDS Project (Palm Springs and surrounding areas; free benefits counseling, legal counseling) 866-331-3344, http://www.desertaidsproject.org/clientservices/index.html - AIDS Project Central Coast (listed on ALRPs webpage; couldnt find much on them, except a google description saying benefits help that didnt open. Cant hurt to call...) 805-643-0446 - Loyola Law School has a Disability Rights Legal Clinic (from their website, it looks like they mostly do impact litigation [class action suits + civil rights litigation that could result in widespread changes], but they may be able to provide a referral to an experienced, perhaps pro bono, attorney in Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego or Ventura county): 213-736-1334 For anyone HIV+ in other locations looking for free legal assistance, I would start by asking your case manager/social worker (if you have one) and/or by calling local ASOs. If that doesnt pan out, GLBT community organizations are also an excellent place to start (theyll often know which lawyers in your area are HIV-friendly and/or have experience in handling the legal needs of HIV+ folks. You dont have to be G/L/B/T in order to call). Yellow pages for the GLBT community often list gay-friendly attorneys (whom I would trust more than some random national law firm with television commercials or full-page ads in the yellow pages). In my experience, non-profits that provide free legal services are very good, so I wouldnt go to a law firm without making sure that I couldnt get help from a non-profit first. I wouldnt use this as my first resort (it would actually be pretty close to my last), but the California Bar Association has a lawyer referral service: 866-442-2529. A local ASO or GLBT center will likely be more sensitive and knowledgeable about the legal needs of HIV+ people.

Response from Dr. Frascino Hello Future Esq.,

Thank you for taking the time and effort to address this all-too-common issue. You have provided some very valuable information that I plan to pass on to the many folks caught in the SSA quagmire. Gosh, for such a detailed and erudite dissertation, I feel I should offer you some remuneration. Most of my lawyer friends charge by the word or fraction of a second of their time. So unfortunately I guess I can't afford to pay you in dollars, euros or even Monopoly money. Instead I'll offer you my free and unfettered advice and wise-assed comments whenever you are in need, OK? And just because I'm such a nice guy, I'll start interviewing future husbands for you. OK readers, who wants to marry an extremely smart, very sex, soon-to-be lawyer with dreamy crystal blue eyes, rock-hard six-pack abs and a chiseled chest with pecs so well defined they belong in Merriam-Webster's unabridged dictionary?!? I'll personally interview and test drive all likely candidate-studs and promise you'll have a spunky-hunky to join you and your rubber ducky in your bathtub Jacuzzi (Did I mention Future-Lawyer Guy has a killer bathtub Jacuzzi???) before Memorial Day, OK?

Thanks again. I really do appreciate your effort. I'm also quite confident your Mr. Right is indeed out there!

Response from Dr. Frascino

Hello Professional Whore-In-Training,

Hmm . . . it seems Sybil Trelawney's crystal ball is as cloudy as ever. Sorry about the gender-bending confusion. I'm still recovering from a recent Crumble-Horned Snorkack bite and it may have affected my judgment to discern X and Y chromosomes. I promise to rescreen all candidates who check "bi," "bi-curious" and "doesn't matter as long as it's naked" to assure the Kinsey rating is in the proper zone before passing them on to you. After all, bisexuality immediately doubles your chances for a date on Saturday night, right?

Regarding your two questions, I'll just make a few quick comments:

Question 1:

Without reviewing the entire medical record and all the laboratory tests, it's always difficult to comment on specific cases. Was the ferritin level really 2632? That's really high. (It's an indication of iron stores.) In anemia of chronic disease, ferritin can be elevated (produced as an acute-phase reactant), but usually not that high!

Anemia of chronic disease is generally caused by immune activation and is sometimes referred to as "anemia of inflammation." It is immune driven. Cytokines and cells of the reticuloendothelial system induce changes in iron homeostasis, the proliferation of erythroid progenitor cells, the production of erythropoietin and the lifespan of red cells, all of which contribute to the anemia. Hepcidin, an acute-phase protein that affects iron metabolism, may play a crucial role in the pathophysiology of anemia of chronic disease. That's still being worked out.

Perhaps the best way to approach this case would be to state that anemia in the setting of HIV/AIDS is often multifactorial in nature. Certainly anemia of chronic disease may well be a contributing factor in light of the laboratory studies obtained to date coupled with the lack of response to iron therapy.

Question 2:

I would characterize the HIV-transmission risk from electrolysis as negligible at best. (Chance of contracting HIV similar to the chance Dick Cheney will record a public service announcement for PFLAG). For all medical procedures where bloodborne pathogens are a potential risk, universal precautions are recommended. If the electrolysis technician feels a questionnaire is all she/he needs to protect him/her from exposure to HIV, he/she is incredibly nave. It's estimated 25% of the over-1,000,000 HIV-positive Americans have no idea they are infected with the virus. This is a case of discrimination pure and simple. There is no medical justification for denial of these services.

As for the recent California ruling on same-sex marriage, there is indeed a chance wedding photos could be uploaded onto the foundation's Web site. Although there is a ballot initiative in the works to try to amend the state constitution to outlaw same-sex marriage. So we will have to see if Californians want to write discrimination into the state's constitution or not.

Finally, the disappearance of your (and everyone else's, including my) punctuation remains a mystery. It's a technical problem with the site. I'll have the tech geeks try to solve that issue ASAP.

Thanks for the extensive research. It's very much appreciated! I've even printed out a copy for our office to have on hand.

Ciao for now, Future Esq.

Dr. Bob



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