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August 2001

Articles in the Newsline section were abstracted by the National Prevention Information Network (NPIN) of the U.S. Centers for Disease Control and Prevention (CDC).

NYS Senator: Bills Give Inaccurate Picture of HIV Transmission

New York's only acknowledged HIV-positive and openly gay state lawmaker is opposing two bills designed to expand AIDS-related health benefits, claiming the measures inaccurately portray how the disease is transmitted. Sen. Thomas Duane (D-Manhattan) said that the bills, which would provide enhanced benefits for some employees who contract HIV, suggest that it is far easier to be exposed to the virus on the job than it really is.

One of the bills Duane opposes, sponsored by Sen. John Marchi (R-Staten Island), provides that New York City parking control specialists, limousine commission inspectors, campus police officers and some other employees should be entitled to receive 75 percent disability pensions if they contract HIV. The measure stipulates that it should be presumed that the workers' HIV infection was contracted on the job unless it can be proven otherwise. The second bill, sponsored by Sen. Mary Lou Rath (R-Erie County), provides the same protections for paramedics in the town of Tonawanda. And both bills include presumptions that if workers get TB or hepatitis, those illnesses were contracted on the job as well.

Duane said both bills provide a distorted notion of what the state Health Department and other agencies have recognized as the ways the vast majority of people with HIV were exposed to the virus. "It is not easy to contract HIV," Duane said. "It is close to impossible to receive HIV during the normal course of action during employment." That is especially true of such job titles as limousine commission inspector or parking control officer, Duane said. "I am by no means advocating for the denial of disability pension benefits to those who do contract HIV on the job through no fault of their own" such as when receiving a tainted transfusion following an on-the-job accident, Duane. "However, to presume HIV infection is contracted on the job is ignorant." (Associated Press (04.30.01) Joel Stashenko)


Hepatitis C Poses New Threat to Many with AIDS

When the Food and Drug Administration (FDA) approved the first protease inhibitors for HIV/AIDS in 1996, many people believed they had been granted a reprieve from death. Yet thousands are now learning that their longevity has left them with a second disease, hepatitis C, which can lead to liver cancer, cirrhosis and, in some cases, death. Up to 40 percent of Americans with HIV -- or 300,000 to 400,000 people -- may be infected with the hepatitis C virus (HCV). Among those who have used intravenous drugs, the rate may be 90 percent. Among hemophiliacs, rates are high due to past contaminated blood supplies.

"This is emerging as a really huge problem," said Alan Franciscus, publisher of HCV Advocate newsletter and director of the Hepatitis C Support Project in San Francisco. "Before protease inhibitors, most people died too quickly from HIV-related causes to even know they were infected with HCV," which can take 20 years to become symptomatic. As the death rate from AIDS declined, liver disease from hepatitis C became the number one cause of death of those with HIV.

The hepatitis C virus is the deadliest of the three major varieties of hepatitis. Almost four million Americans have been infected and 8,000-10,000 die annually from complications of the disease, according to the CDC. Ten to 20 percent of those with the disease progress to cirrhosis or some other fatal liver disease. The treatment outlook has improved markedly, and the FDA has recently approved a new form of interferon that is performing well in clinical trials. Yet despite treatment advances, many do not benefit because of the complications of medicating two different diseases. The antiretroviral drugs used to treat HIV/AIDS place a great strain on the liver. Many doctors do not know how to treat the co-infection, and only a handful of physicians specialize in both diseases. It is easier to educate HIV doctors about HCV than to tax HCV doctors with the new burdens of HIV knowledge.

Transplants have not been an option for people with HIV. Transplant centers have routinely rejected individuals with HIV as organ recipients because their life expectancies were so short. But now a handful of programs are looking at the candidacy of individuals with HIV as liver transplant patients. However, according to Dr. Douglas Dieterich, chief of gastroenterology and hepatology at Cabrini Medical Center in New York, "It will be years before we see what the long term result of these studies are." (New York Times (05.01.01) David Tuller)

Contraceptives Do Not Protect Against Pelvic Inflammatory Disease

US researchers reported recently that no barrier or hormonal contraceptive method protects women against pelvic inflammatory disease (PID). Roberta Ness of the University of Pittsburgh and her team evaluated the contraceptive use of 563 women with symptoms in the PID Evaluation and Clinical Health (PEACH) study. Most of the participants were black and age 24 years or younger. They were interviewed about recent contraceptive use and had endometrial biopsy and upper genital tract isolate evaluation. The researchers found that condoms were the most common contraceptive method used, followed by oral contraceptives, medroxyprogesterone and other barrier methods. Inconsistent condom use in the four weeks before enrollment was associated with a greater than two-fold increased risk of upper genital tract infection compared with no condom use; infection rates were not affected by medroxyprogesterone or oral contraceptives. "Women whose partners are using condoms may be the group of women who are engaged in more risky sexual behavior to start with," Ness said.

Endometriosis without upper genital tract infection was related to the use of contraceptive injections in women with symptoms of PID. A slight decrease in risk was conferred by consistent (100 percent) condom use, whereas oral contraceptive use was associated with less severe PID symptoms. Since the study results suggest that consistent condom use may decrease PID risk, physicians should emphasize "correct and consistent use," urged Ness. The full report appeared in Epidemiology (2001; 12: 307-12). (Lancet (04.21.01) Vol 357; No 9264: P 1269. Marilynn Larkin)

New Therapy Promising for Genital Herpes

Researchers at the 11th European Congress of Clinical Microbiology and Infectious Diseases reported that "an experimental immunity-enhancing drug administered as a topical gel shows promise in substantially delaying onset of recurrent genital herpes lesions." Spotswood Spruance, M.D., of the University of Utah School of Medicine, explained the potential treatment at a symposium sponsored by 3M Pharmaceuticals, saying, "One episodic treatment seems to act like a vaccination and prolong the time to the next recurrence." If the findings are confirmed in large-scale studies, the new agent, resiquimod, "would provide an alternative to current suppressive therapy for genital herpes," said Spruance. The currently approved trio of systemic antiviral medications for recurrent genital herpes -- the nucleoside analogs acyclovir, famciclovir and valacyclovir -- "can decrease the duration of viral shedding and time to healing of lesions when patients take them at onset of symptoms. But episodic treatment -- taking the drugs only during an outbreak -- has no effect on the frequency of recurrences," said Richard Whitley, M.D., of the University of Alabama at Birmingham. But resiquimod, Spruance said, appears to induce the production of certain cytokines. The effect is an altered immune response, particularly enhanced cell-mediated immunity, said Richard Miller, Ph.D., of 3M Pharmaceuticals, which is developing the drug.

Some genital herpes patients do not have recurrent outbreaks, "presumably because their immune system has succeeded in containing the virus. The rationale for treating patients with recurrent disease with immune response modifiers is that these drugs appear to have effects that can shift the ineffective immune response seen in people who have recurrences to the kind of response seen in outbreak-free individuals," said Spruance. "I believe that treating people [with the drug] at the time of an active herpes recurrence is equivalent to an autologous therapeutic vaccination with adjuvant," he said. During the outbreak, the patient's own herpes simplex virus acts as the "vaccine" by exposing the immune system to viral antigens, and resiquimod acts as an adjuvant to raise the immune response. Phase 3 clinical trials involving about 2,000 patients with recurrent genital herpes infection are now under way in the United States and Europe, results for which are expected in 2004. (Journal of the American Medical Association (05.02.01) Vol 285; No 17: P 2182-2183. Joan Stephenson, Ph.D.)

UC San Francisco Study: Gay/Bisexual Men Who Were Sexually Abused as Children More Likely to Engage in Unsafe Sex

According to a study in the April issue of Child Abuse & Neglect, men who have sex with men (MSM) are more likely to engage in risky sexual behaviors if they were sexually abused as children. The researchers from the University of California San Francisco's Center for AIDS Prevention (CAPS) found that 20.6 percent of all MSM experienced childhood sexual abuse -- a rate higher than prevalence estimates for the general population. The researchers found that greater severity of childhood abuse (more incidents) was associated with higher rates of risky sexual behavior. Two definitions of risky sexual behavior were used: unprotected anal intercourse with a non-primary partner, and unprotected anal intercourse with a male whose HIV status was different from their own.

The telephone sample of MSM in San Francisco, New York, Chicago and Los Angeles found that men reporting childhood sexual abuse were more likely (24 percent vs. 14 percent) to be HIV-positive. The study also found that men who were sexual abuse survivors had higher rates of sex under the influence of alcohol/drugs, more "one-night stands" and more intimate partner violence.

"These findings clearly indicate that there is a need to consider childhood sexual abuse in developing and delivering HIV prevention interventions," said lead author Jay Paul, Ph.D. "Messages that emphasize the avoidance of 'sex under the influence' may not be effective for those men whose use of substances may be a form of coping with the disturbing aftermath of early sexual traumatization." Paul said the findings indicate that community services should be reviewed to ensure they offer appropriate referrals to mental health, substance abuse, social and medical services. "The multiple health-related negative consequences of childhood sexual abuse emphasize the need to give this issue appropriate attention," Paul said. (Associated Press (05.03.01))

Judge Urged to Rap City on AIDS Housing

Advocates for the homeless in New York City urged a state judge to hold the city in contempt for ignoring a 1999 order to provide emergency housing for people with AIDS.

According to affidavits filed in Manhattan Supreme Court by Housing Works, a non-profit agency providing resources for homeless people with AIDS, the Human Resources Administration (HRA) routinely circumvents the law. Documents indicate that strategies used by the HRA include routing homeless individuals with AIDS to hotels where HRA bills have not been paid, non-existent addresses, shelters deemed medically unfit for those with the disease, and closing referral centers on weekends and at 5 PM weekdays.

Armen Merjian, a lawyer for Housing Works, described the daily struggle of people with AIDS to find housing as "life-threatening." She admonished the HRA for its callous treatment of people with AIDS. The HRA spokeswoman declined to comment on the court charges because she had not seen the affidavits." ((New York) Daily News (05.03.01) Helen Peterson)

More Patients Seek Drugs Through ADAPs, Creating $50 Million Deficit

Recent increases in drug expenditures and the number of clients seeking help from AIDS Drug Assistance Programs (ADAP) have created the potential for a crisis this summer, according to ADAP Working Group Chair Bill Arnold. "We've already written to President Bush, saying, 'We've got a crisis and need emergency supplemental appropriation in this year of $50 million,'" Arnold said. Some 600 people join the ADAP rolls each month and, thanks to the effectiveness of drug therapies, attrition is not as significant as it once was. ADAP now serves about 70,000 people nationwide, and state programs reported a 22 percent increase in expenditures in June 2000 compared to June 1999, according to a report released in March. Arnold predicted some states will feel the crunch as early as next month.

Large states, including Texas, California and Florida, are expected to experience the effects of the budget shortfall first. Small states that have historically had ADAP waiting lists, like South Carolina, Alabama and West Virginia, will also likely be in trouble. In Alabama, 340 people are already awaiting enrollment, while 59 are on the list in South Carolina. This year, Florida is receiving a $5.8 million increase in ADAP funds, yet this amounts to less than a 10 percent increase at a time when enrollment is up 13 percent. Colorado's program has no waiting list and is adequately funded but that may change this year when it revises its income eligibility requirement (at 185 percent of the federal poverty level, currently one of the nation's strictest).

New York, with one of the nation's most generous ADAP formularies and one of the largest HIV-positive populations, has not had to add restrictions or put clients on a waiting list. The state's comprehensive Medicaid program provides medical and pharmaceutical coverage to HIV-infected persons whether or not they have AIDS symptoms. But if the national ADAP program does not get the $50 million emergency increase, New York may have to transfer money from other AIDS programs. State directors also hope to see Congress pass a Medicare pharmacy benefit, which would take some people out of the ADAP system. (AIDS Alert (05.01))

HPV Strain Linked to Increased Mortality from Cervical Cancer

A strain of the human papilloma virus (HPV) that causes 20 percent to 30 percent of all cervical cancers doubles the mortality rate when compared with cervical cancers caused by the most common version of the virus, according to a paper in the April issue of Journal of Clinical Oncology (Vol 19; No 7: 1906-15). The population-based study confirmed that mortality rates from cervical cancers caused by HPV-18, which is the second most common cause of the disease, could be four times as high as those caused by other HPV variants, including HPV-16, which causes the majority of cervical cancers.

"What is needed now is a trial to see if measuring the presence of HPV-18 in the tumors of cervical cancer patients makes a difference in clinical outcome in terms of treatment decisions," said Stephen Schwartz, Ph.D., primary author of the study and an associate member of the Fred Hutchinson Cancer Research Center in Seattle. "What we need to do now is figure out what we can do with this information to help women with cervical cancer live longer."

But cervical cancer experts said that the latest study should earmark those with HPV-18 for more intense treatment. The disease is now treated with varying combinations of surgery, radiation and chemotherapy, but not always all three. HPV type testing is not a standard of care and is primarily used as a research tool. The Food and Drug Administration has approved a test for HPV as an adjunct screen to the Pap smear, but a test that determines the type of HPV has not yet been approved. Such a test is expected to be most useful as a diagnostic and to determine treatment strategies for cervical cancer patients. Researchers said the study would also aid the search for vaccines. There are nearly 100 varieties of HPV, but the most dangerous strains could be prioritized for vaccine development. (American Medical News (04.23.01) Vol 44; No 16: P 29, 33. Victoria Stagg Elliott)

Effect of Highly Active Antiretroviral Therapy on Frequency of Oral Warts

The introduction of highly active antiretroviral therapy (HAART) has been accompanied by a reduction of the frequency of many of the secondary events caused by HIV infection, including some oral lesions. This study sought to investigate the changing pattern of oral lesions associated with HIV infection and HAART among patients in the authors' referral clinic.

The researchers retrospectively studied 1,280 patients seen between July 1990 and June 1999, relating oral findings to medication use, immune function and viral load. They focused on three key oral lesions -- oral candidiasis, hairy leukoplakia and oral warts -- and studied their relation with antiretroviral therapy, with or without the use of protease inhibitors, adjusting for CD4 count and viral load. Treatment that included one or more antiretroviral agents including non-nucleosides but excluding protease inhibitors was defined as antiretroviral therapy (ART), while treatment that included one or more antiretroviral agents plus protease inhibitors was defined as HAART.

During the 9 12-month periods, oral candidosis, hairy leukoplakia and Kaposi's sarcoma decreased substantially, whereas the frequency of aphthous ulcers did not change. There was an increase in the occurrence of salivary gland disease and a "striking increase" in the rate of warts: three-fold for patients on ART and six-fold for patients on HAART. The researchers said that "the increase in the occurrence of oral warts, and its apparent association with both ART and protease inhibitors, is somewhat unexpected, although a link has been suggested previously. Some other opportunistic infections, most notably TB and cytomegalovirus retinitis, can also recur among patients receiving HAART as HIV viral loads fall and CD4 cell counts improve. (Lancet (05.05.01) Vol 357; No 9266: P 1411-1412. Deborah Greenspan; Alison J. Canchola; Laurie A. MacPhail; Behnaz Cheikh; John S. Greenspan)

Justices Set Back Use of Marijuana to Treat Illness

The Supreme Court ruled yesterday that federal law allows no "medical necessity" exception to its prohibition of the distribution of marijuana. The 8-0 decision was seen as a setback, though not a definitive blow, to the medical marijuana movement, which has succeeded in passing ballot initiatives in eight states. The ruling neither overturns those initiatives nor addresses any question of state law. Rather, it affirms that marijuana's listing as a Schedule I drug under the Controlled Substances Act means that it "has no currently accepted medical use in treatment in the United States." Advocates say the drug helps combat the nausea of chemotherapy and AIDS wasting syndrome.

The question before the court in United States v. Oakland Cannabis Buyers' Cooperative was a relatively narrow one. Nearly three-quarters of Oakland's voters supported California's Proposition 215, the 1996 initiative that enacted the Compassionate Use Act permitting the medical use of marijuana. The Oakland Cannabis Buyers' Cooperative was set up with the blessing of the city's government and police department. The US Court of Appeals for the Ninth Circuit ordered Federal District Court Judge Charles Breyer to tailor an injunction permitting access to marijuana for those whose serious medical conditions could be alleviated by it. The Clinton administration, asserting that the Ninth Circuit had committed a serious error that could undermine federal drug laws, persuaded the Supreme Court to grant a stay of Breyer's ruling last August. Justice Stephen G. Breyer did not participate in any phase of the case because Judge Charles Breyer is his younger brother.

In the opinion by Justice Clarence Thomas, the court said the Ninth Circuit had misread Federal law when it ruled that the Oakland cooperative could raise medical necessity as a defense against the federal government's attempts to close it down. But the broad language of Thomas' opinion suggested there could be no acceptable medical use of marijuana in any setting, not just in the context of distribution by large organizations. For that reason, Justices John Paul Stevens, David H. Souter and Ruth Bader Ginsburg refused to sign it, instead filing a separate concurring opinion. Stevens said that Thomas' opinion showed inadequate "respect for the sovereign states that comprise our federal union." (New York Times (05.15.01) Linda Greenhouse)

First Combo Vaccine for Hepatitis Gets OK

The Food and Drug Administration has approved the first combination vaccine that prevents hepatitis A and B. The combination vaccine uses two existing vaccines and will reduce the number of shots needed for those at risk for the diseases, according to manufacturer GlaxoSmithKline. Each year, 125,000 to 200,000 Americans are infected with hepatitis A, and 140,000 to 320,000 are infected with hepatitis B. (USA Today (05.15.01) Michelle Healy)

Human Immunodeficiency Virus Infection in Elderly Patients

Thanks to improved drug therapies, more patients with HIV are surviving into older age. The researchers performed a retrospective case-control study of 58 patients who were more than 60 years old at the time of HIV diagnosis and compared them with 232 controls, who were matched by CD4+ lymphocyte count. The clinical and demographic data were obtained from the Adult Spectrum of Diseases (ASD) database at the Medical Center of Louisiana. The mean age was 32.8 years for the younger group and 64.05 years for the older group. Homosexual contact and intravenous drug use were the most common risk factors in both groups. The use of antiretroviral therapy, including protease inhibitors, was similar in both groups during the course of the study (Jan. 1, 1989 - Feb. 28, 1998).

The researcher's report does not support previous findings that older patients have lower CD4+ lymphocyte and are more likely than younger patients to die in the same month they receive an HIV-positive diagnosis. The researchers found older patients to have CD4+ lymphocyte counts similar to those of their younger counterparts, and they did not observe a significant difference in the incidence of opportunistic infections in the two groups. But the report noted that although they are "remaining sexually active well into the sixth and seventh decades of life, older patients are perceived by themselves and their physicians to be at lower risk for HIV infection." Doctors are less likely to test older patients for HIV or to talk to them about safer sex practices.

"In conclusion, elderly patients are a growing population of persons infected with HIV. Persons in this age group need to be specifically targeted for primary prevention because of a self-perceived lower risk for HIV infection and the lower likelihood of being tested for such infection by their physicians. We found that elderly patients are not having HIV infection diagnosed at a later stage, but they still have a shorter survival, possibly because of the effect of co-morbid conditions," the authors wrote. (Southern Medical Journal (04.01) Vol 94; No 4: P 397-400. Adeel A. Butt, M.D., et al.)

US Government Unveils Guidelines for the Care of HIV-Infected Women

The US government last Tuesday unveiled the first edition of a guide intended to help physicians better understand the unique problems of women infected with HIV. The 508-page document ("A Guide to the Clinical Care of Women With HIV: 2001 -- First Edition") details how HIV infection affects women differently than men, focusing on gynecologic conditions and reproductive concerns as well as social issues such as domestic violence. The manual is intended to help primary care physicians and providers recognize that treating women with HIV is not the same as treating men with the disease, according to the guide's editor, Dr. Jean Anderson of Johns Hopkins School of Medicine in Baltimore.

"It became very clear that there were a lot of gaps in people's understanding," Anderson said in an interview. "So people who did a lot of HIV care didn't necessarily know what were the special issues for women. And providers who did a lot of health care for women didn't know much about HIV."

According to the introduction to the volume, "In most industrialized countries, women tended to have lower income, be un- or under-insured for health care, know less about HIV, are more likely to be Black or Hispanic, and to have a personal or partner history of injection drug or cocaine use. Women also appear to have more rapid progression of illness than men and to present with a different constellation of opportunistic conditions than men."

Women make up 50 percent of adults living with HIV/AIDS and are a dominant feature of the evolving epidemic. Because they are often diagnosed later and generally have less access to care and medications, women tend to have higher viral loads and lower CD4 counts. Women living with HIV/AIDS must contend with issues related to reproduction and to domestic violence. Finally, women living with HIV/AIDS are usually relied upon to meet the care needs of children and other family members, many of whom are also HIV-positive. The report is available through the HIV/AIDS Bureau of the Health Resources and Services Administration, an agency of the Department of Health and Human Services. (Reuters (05.16.01)

Back to the August 2001 Issue of Body Positive Magazine.

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This article was provided by Body Positive. It is a part of the publication Body Positive.
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