AIDS Treatment News
February 4, 2000

Retroviruses Conference: Overview, Information Available

No one major story came out of the 7th Conference on Retroviruses and Opportunistic Infections, January 30 - February 2, 2000, in San Francisco. What most caught our attention was found less in the official sessions than in private conversations: the possibility of preventing or treating many of the side effects of antiretroviral treatment, possibly including some body-shape changes, by simple nutritional strategies to protect or support the mitochondria of the body's cells -- an approach which has shown partial but important success in other areas of medicine. [This potential treatment often includes L-carnitine, coenzyme Q10, and/or riboflavin (vitamin B-2); we are researching this possibility and will report on it in future issues. The emerging theory that mitochondrial toxicity from nucleoside analogs, such as d4T, AZT, and ddI, may cause or contribute to many problems, probably including some but not all of those first attributed to protease inhibitors alone, was very much discussed in the official Retroviruses conference presentations; but this conference has a strong hard-science focus, which somehow has come to imply a general lack of interest in nutritional therapies.]

In both drug toxicities and strategic treatment interruption there were many presentations, but they often seemed to contradict each other, leaving people as confused as before. The different results did not necessarily mean that some were wrong; instead, there were many differences in how the studies were done, so the results could not be closely compared. (It is easy to call for standardization of definitions and research approaches -- too easy, in our view, as we do not believe that is the best way forward for this research. For another approach, see "2000 Outlook," AIDS Treatment News #334, January 7, 2000.)

The abstracts, lectures, summaries, and other information that did come out of the Retroviruses conference provide an encyclopedia of current work in most aspects of mainstream HIV/AIDS treatment. Here is a short guide to finding the information you need.

Official Conference Site

• Searching the abstracts. A way to learn about new developments involving a particular drug, illness, symptom, or other specific topic is to search the abstracts of the conference presentations. Click on "Conference Abstracts." Type in either one or two search terms (if two, use "and" or "or"), and click "Search." (For example, a search for "ddI or didanosine" returns 40 abstracts, from the total of about 900 which are on the site.) Note that these abstracts were submitted months ahead of the conference, and have not been updated to reflect changes in the information.

• Lectures and symposia. If you are not looking for specific keywords, but instead want an overview of a larger area, choose either "Hear the Lectures" or "Hear the Symposia" (the difference is that the lectures are by one person, while symposia have several speakers on different aspects of the topic). There are nine lectures, including "The State of HIV Vaccine Research," "Management of the HIV-Infected Pregnant Woman," "HIV Entry and Its Inhibition," and "Critical Issues in Antiretroviral Therapy." There are also nine symposia, with topics including integrase inhibitors, vaccines, hepatitis C, preventing mother-to-infant transmission, entry inhibitors, metabolic complications of antiretrovirals, epidemiology and prevention, and antiretroviral treatment failure. Some of the topics overlap; check both the lectures and the symposia to avoid missing relevant talks.

  Once you select a talk and click the control to start, you hear the speaker's voice and see the slides as they are being discussed (unless slides have been withheld pending publication). You can move to a different part of the talk whenever you want. We have had no problem with a 56K modem connection, although there is a delay of a few seconds at the beginning, or if you skip to a different part of the talk. The system works on newer computers, at least Windows and Macintosh; the lectures will not be available on some computers, especially older ones. The slides are probably more legible on the screen than to most of the people in the audience at the conference itself (one reason being that on the computer screen, they are always in focus).

• The posters. This year the conference has asked presenters to provide their posters on disk, if they want to do so; these posters will be made available on the site, probably starting in March. The posters are much more extensive than the abstracts, and will often include more recent information. No one knows how many will be submitted; presenters may either be afraid that journals will not publish their work if they make too much data available on the conference site, or they may be willing to publish the poster there, but not get around to preparing the disk.

• What will not be on the site, or otherwise available except to those in the room at the time, are the "Slide" sessions; only their abstracts are available, and some information from conference summaries (see below). These talks (along with the posters) are where most of the new data is presented (while the lectures and symposia tend to be summaries and overviews). The slide sessions are often quite technical, and non-specialists would seldom find them useful.

Retroviruses Conference Overview by Telephone

The panelists are David Cooper, M.D. (Sydney, Australia), Michael Saag, M.D., (University of Alabama, Birmingham), Steven Deeks, M.D., (University of California, San Francisco), Karen Beckerman, M.D. (Bay Area Perinatal AIDS Center), and Steven Becker, M.D. (Pacific Horizon Medical Group).

This teleconference is supported by an educational grant from Roche Laboratories.

Online Conference Summaries and Commentaries

• The Body, http://www.thebody.com, has over 100 brief, easily readable summaries of conference presentations. These are listed in a table of contents on the Web page, organized by date and session. It's worth glancing through all the major conference topics in the list of contents -- about seven pages of text when printed single spaced -- because important subjects, like drug toxicity, were often covered in more than one session on different days.

  Most but not all of the conference sessions are included; the ones covered tend to be those most important for clinical practice.

• Medscape HIV/AIDS, http://hiv.medscape.com, has in-depth reports -- and optionally includes an online test for one hour of CME (Continuing Medical Education) credit for each of the four days of the conference, for "physicians, pharmacists, and other health care community members providing frontline clinical care for persons with HIV/AIDS."

  Anyone can use this information, or take the test if they want to. Medscape requires registration to access most of its material, but registration is free and can be done quickly online.

  There is also a search function for locating particular information anywhere in the conference coverage on this site. (But be sure to use the correct search engine; it is under "Conference Search" on the bottom of the contents page of the Retroviruses conference online summaries. The search at the upper left of the Medscape pages does not limit itself to the coverage of this conference.)

  Topics include:

  • Day 1: Complications of antiretrovirals; drug interactions; lipodystrophy; adherence; vaccines; and epidemiology/prevention.

  • Day 2: HIV resistance; immune reconstitution; management of pregnant women; hepatitis B and C; metabolic complications; preventing transmission in developing countries; and opportunistic infections and malignancies.

  • Day 3: Treating drug-naive patients; antiretroviral failure; pathogenesis and immune response; AIDS mortality trends; neurology; HIV transmission (role of viral load, oral sex, and STDs); immunotherapy (with IL-2, interferon, and Remune); and primary HIV infection.

  • Day 4: Late-breaker sessions; cellular immunity; vaccines; resistance and resistance testing; fusion inhibitors; other experimental antiretrovirals; HIV-infected women; observational studies; maternal and pediatric issues; and CMV.

• HIVandHepatitis.com, http://www.hivandhepatitis.com, has over 25 reports, including: adherence and directly observed antiretroviral therapy in prison; osteopenia and osteoporosis (low bone mineral density); metabolic complications of antiretroviral therapy; vaccine advances; interaction of cholesterol-lowering drugs with protease inhibitors; and many other topics. One-paragraph summaries are listed, so readers can decide what they want to read in greater depth.

• NATAP, http://www.natap.org, has over 20 reports, focusing mainly on protease inhibitors and other drugs. These articles are often quite technical, with more percentages, tables, and other data than explanation. It may take some looking around on the site to find the list of reports from the Retroviruses conference.

San Francisco: Retroviruses Conference Community Forum, Feb. 17

A review of the 7th Conference on Retroviruses and Opportunistic Infections will be held Thursday, February 17, 6:00 p.m. to 8:30 p.m., at the Sheraton Palace Hotel, 2 New Montgomery Street (at the Montgomery Street BART stop), in San Francisco. Admission is free but persons are asked to RSVP to 415-597-UCSF, or ari@psg.ucsf.edu, to help with planning for light refreshments.

Topics and presenters are:

• Pathogenesis -- Warner Greene, M.D., Ph.D.;

• Treatment update, and a focus on issues for women -- Ruth M Greenblatt, M.D.;

• Lipodystrophy and related issues -- Carl Grunfeld, M.D., Ph.D.;

• Resistance testing -- Robert M. Grant, M.D., M.P.H.; and

• Hepatitis C/HIV co-infection -- Ben Cheng, of Project Inform.

The moderators are Thomas J. Coates, Ph.D., and Marcus A. Conant, M.D.

This forum is co-sponsored by the Conant Foundation and the University of California San Francisco AIDS Research Institute, with unrestricted educational grants from Agouron, DuPont, Merck, Roche, Unimed, and ViroLogic.

Testosterone, Other Injectable Drug Access Problems in San Francisco Area: Call for Information

Some patients in the San Francisco area have stopped receiving testosterone, and perhaps other injectable drugs, for which payment had already been approved. It appeared there was a business dispute between Coram Prescription Services, a home-care service which delivers and injects the drugs, and Brown & Toland Medical Group, an IPA (independent physician association) which currently pays for these drugs (and therefore decides which patients are eligible to receive them). It seems that Coram believed that Brown & Toland would no longer pay for home delivery of these drugs after the first of the year.

We called Coram in mid January, and were told that they were in negotiation with Brown & Toland, and therefore could not speak about the issue.

On February 7, after hearing that another patient was not getting his medication, we talked to Stephen Becker, M.D., Medical Director for the HIV Intervention Program at Brown & Toland. He said there has been no change at Brown & Toland, which still "has the risk," meaning that it is currently paying for these drugs as it always has -- and that Brown & Toland had not known about the problem until we brought it to his attention. He suspects there is confusion at Coram, because of efforts by Brown & Toland to shift "the risk" to HMOs in the future. But no such change has happened yet.

We called back to Coram on February 7, but were unable to reach a person after 15 minutes on the voicemail.

Anyone covered by Brown & Toland who still has problems getting home delivery of drugs which have been approved for payment should let Brown & Toland know, by writing to:

Brown & Toland Physician Services Organization
1388 Sutter St.
San Francisco, CA 94109

Also send a copy to:

Stephen L. Becker, M.D.
2351 Clay St.
San Francisco, CA 94115

Dr. Becker is not the one who decides who receives the medications, but he can make sure that Brown & Toland knows when drugs they agreed to pay for are not being delivered -- which is apparently due to a misunderstanding of Brown & Toland's current payment policy.

AIDS Treatment News would also like to hear of any further problems which are not quickly resolved.

Large Cuts in Public Hospital, Clinic HIV Services, San Francisco and National -- Why?

by Bruce Mirken

Threatened cutbacks to the HIV/AIDS outpatient clinic at San Francisco General Hospital appear to have been averted after activists and the press focused sufficient attention on the crisis that local elected officials located a source of stopgap funding, but the hospital -- and many others across the nation -- face a continuing financial crisis. The situation stems largely from changes to the federal Medicare and Medicaid programs included in the Balanced Budget Act (BBA) of 1997.

Even though San Francisco has had a booming local economy and a generally strong commitment to health care, the budget problems at San Francisco General have produced staffing shortages, longer waits for appointments, and cutbacks in pharmacy services, resulting in longer waits for prescriptions and some low-income patients (who had previously gotten their medicine at no cost) being charged an up-front copayment. San Francisco's generally favorable political and economic climate has thus far helped avert far worse cutbacks -- including a cut-off of access to viral load testing and closure of the evening HIV/AIDS clinic -- that may be harder to avoid in other parts of the country if recent trends continue.

Adjustments to the BBA passed late last year will provide some relief, but still leave most of the 1997 cuts intact. While the federal cutbacks are not disease-specific, they appear to be having a particularly severe impact on public hospitals and teaching hospitals, which traditionally have handled a large proportion of HIV/AIDS care in the U.S. So far the situation has received no attention in the 2000 presidential campaign and little notice from AIDS lobbyists.

The Balanced Budget Act, signed into law by President Clinton in August, 1997, sought to bring about a balanced federal budget by this year, and included big cuts in the projected growth of Medicare and Medicaid (known as Medi-Cal in California) as part of the plan to achieve that goal. The act was projected to cut growth in Medicare spending by $115 billion and Medicaid spending by $13.6 billion for the five years from 1997-2002, largely by cutting payments to hospitals and other health care providers. Though the Medicaid cuts are smaller than the cuts to Medicare, San Francisco officials say it is the Medicaid changes that have most impacted San Francisco General, as the hospital serves large numbers of Medi-Cal patients.

The complex and highly technical changes to Medicaid and Medicare cut payments to hospitals and other health care providers through a number of mechanisms. These included expansion and modification of Medicare's "Prospective Payment System," which pays providers on a flat-rate basis for various types of medical services -- with annual cost-of-living updates intentionally pegged below the actual change in the "market basket" of medical costs used to measure inflation. Also cut were subsidies to teaching hospitals and to "Disproportionate Share Hospitals" (DSH), the (mostly public) institutions which care for the bulk of the poor and uninsured.

These changes have cost San Francisco's Department of Public Health about $6 million a year, according to Chief Financial Officer Monique Zmuda. Compounding the problem has been a growing proportion of patients with no coverage at all, public or private, as well as more aggressive federal auditing of Medicare and Medicaid billings from previous years. "It's not a fraud and abuse thing, it's more of an accounting thing, and what are the feds disallowing," Zmuda says of the audits. And while not specifically required in the Balanced Budget Act, Zmuda believes the measure's spending reduction targets have stimulated new aggressiveness by federal auditors. As a result, San Francisco has had to return up to $12 million received from the federal government in prior fiscal years.

The combined effect of these fiscal blows has been "almost unmanageable," Zmuda says. "This experience is being shared by all the public hospitals. It's hitting everybody severely."

Some of the changes were needed, argues Bill Vaughn, Democratic staff assistant to the House Ways and Means Committee. "We were being gouged" on some items, such as therapy services in nursing homes, Vaughn says. "We would pay whatever they billed... In 1997 we all agreed that we needed to cut some of the inflation" and "curb some pretty suspicious growth" in the cost of the programs.

The cuts produced howls from hospital industry trade groups such as the American Hospital Association and the California Healthcare Association. The AHA released a study indicating that hospitals would lose large amounts of money on Medicare patients, and AHA President Dick Davidson said the BBA changes "will wreak havoc on the majority of the nation's hospitals, pressuring them to cut some services which are valuable to their patients." This appears to have been precisely what has happened in San Francisco, where even those who question the adequacy of the city's response to San Francisco General's budget problems acknowledge that the federal cutbacks were a major cause of the crisis.

Vaughn thinks the AHA and CHA, which represent both public and private institutions, are exaggerating the impact of the cuts, and notes that overall "hospital profits were higher in 1998." But, he acknowledges, "The public hospitals received some DSH payment cuts and teaching hospitals got some cuts, and those are not the hospitals you'd want to cut. The public hospitals are hurting. They need help."

Public and private hospitals did get a little assistance in the form of adjustments to the Balanced Budget Act passed by Congress in late 1999. The changes give back about $16 billion to health care providers over five years by scaling back or slowing the phase-in of some of the BBA cuts. The hospital lobbying groups, though pleased to get some relief, consider the recent adjustments inadequate. Barbara Jones, senior vice president of finance for the CHA, notes that because "the largest portion of the [BBA] cuts were coming in the latter years, 2001 and 2002," most of the adjustments won't actually put more money in hospitals' pockets, but will merely reduce cuts that haven't kicked in yet.

Zmuda agrees, saying, "Nothing [in the 1999 adjustments] gives us any more money, but it stops us from losing more."

Bob Prentice, former director of the Public Health Division of San Francisco's Department of Public Health, characterizes the BBA cuts as "part of the general attack on the public sector, the general attack on poor people" that has been coming out of Washington for some time, often supported by both Republicans and Democrats. So far in this election year there has been little political pressure to reverse the trend.

The major presidential candidates have all made some mention of the need to extend health coverage to the roughly 43 million Americans who are now uninsured, with most relying on a patchwork of tax breaks and subsidies, rather than fundamental changes to the current system. But none has dealt in any significant way with the harm being done to hospitals by the BBA. Democrat Bill Bradley's plan might offer some indirect relief by partly replacing the current Medicaid structure with government-subsidized private insurance, but its overall impact is a subject of some debate. Tim Bertholt, director of public policy for Health Access, a California-based health care lobbying group, calls all of the presidential candidates' health proposals "disappointing."

The 1999 changes came largely as a result of aggressive lobbying by the hospital trade groups. AIDS organizations in particular seem to have given the issue little attention. For example, the "Election 2000 Presidential Candidate Report" released last summer by AIDS Action Council, the Washington, DC-based AIDS lobby, focused only on AIDS-specific issues and proposals and did not address either the ramifications of the BBA or the candidates' proposals for reforming the health care system. The lengthy health care/treatment access discussion paper posted on AIDS Action's web site, while urging such Medicaid reforms as broadened eligibility requirements, also does not address the 1997 cuts or their impact.

Grassroots, patient-oriented lobbying on health care access and funding issues has never been as strong as lobbying by the health care and insurance industries. National groups addressing these issues are:

• Families USA, 1334 G St. NW, Washington, DC 20005, 1-202-628-3030, http://www.familiesusa.org, info@familiesusa.org.

• Physicians for a National Health Program, 332 S. Michigan Ave., Suite 500, Chicago, IL 60604, 1-312-554-0382, pnhp@aol.com, http://www.pnhp.org.

• UHCAN -- Universal Health Care Action Network -- is a nationwide coalition of groups and individuals supporting universal access to health care. Their web site has extensive listings of national and local organizations working on health access issues, as well as resources and information for people interested in doing grassroots organizing around health care. UHCAN, 2800 Euclid Ave., Suite 520, Cleveland, OH 44115-2418, 1-216-241-8422 or 1-800-634-4442, http://www.uhcan.org.

ISSN # 1052-4207

Copyright 2000 by John S. James. Permission granted for noncommercial reproduction, provided that our address and phone number are included if more than short quotations are used.