Doctors Urge the Government to Keep Up With Medical Progress
HIV Policy and Funding Left in the Dust of Treatment Success
What an era. Tolerable and easy-to-take medications can stop HIV in its tracks. This prevents AIDS. It prevents new infections. It saves mega-bucks.
And so, say a group of medical providers, it's time for this country to catch up with the reality of medical progress. It's time for Medicaid and Medicare, as well as private insurers, to pay for HIV testing and thereby catch infections early. It's time for earlier treatment, which is much less expensive than later treatment. This could not only save money and protect health, but also avoid spreading of the virus by those who don't know they're infected.
Instead, what doctors see to this day is large numbers of patients come in suffering from advanced infection when that could have been easily prevented. At this stage treatment is not only more expensive, but also less successful.
Without coverage for HIV testing, poor people, and anyone else with financial difficulties, will not be able to afford the $60 or more it costs to pay for the test, and doctors can't order it knowing that their clinic won't be reimbursed.
"Can the Red Ribbon survive red tape?" the doctors asked.
And, they added, it's time for the federal government to pay for proven prevention strategies like needle exchange, and stop wasting it on abstinence-only education, which has been proven to be ineffective.
Following are remarks made during a media teleconference by representatives of the two groups that issued the policy statement, the American College of Physicians (ACP) and the HIV Medicine Association (HIVMA), which is part of the Infectious Diseases Society of America (IDSA).
Michael S. Saag, M.D.
"The background of [our policy statement] is that there's been incredible progress in the care of HIV patients. It was a disease that wasn't known in 1980, first described in 1981, had no therapies available at all until 1987, and was virtually a universal death sentence for almost everyone who was infected with HIV through the 1980s.
"It emerged in the 1990s with a revolution in therapies, now up to 32 individual medications that are available and on the market for use and that, especially when used in combination, are able to halt the virus in its tracks -- stop its replication.
"What that translates into is an ability for people who are HIV-positive today to live near-normal lifespans based on these interventions, and that type of progress was really unimaginable when most of us started working in this field in the 1980s.
Early identification is only going to come about through routine screening.
"So what's happened is that this progress has moved forward very rapidly, but a lot of the public policy that we're using today to manage this epidemic in the United States were policies that were established in the late 1980s and early 1990s, and have not really been re-visited in a serious way since that time.
"We know this virus is transmitted person-to-person, either through sexual activity, through sharing of blood through needles, or through pregnancy from mother to child. We basically stopped transmission from mother to child simply by doing prenatal screening of the mom to see if she's HIV-positive while she's being followed by her obstetrician. If she's found to be HIV-positive through this universal opt-out testing, she gets treated, her virus goes to undetectable levels, and when she delivers, under those circumstances, there is no transmission of HIV from mother to child, whereas untreated that transmission rate would be about 25%, or one in four.
"The problem today, though, is that that same concept needs to be applied to the entire population. The reason I say that is because we are pretty much finding most of our patients when they've been infected for 10 to 12 years and they start getting sick due to the impact of the virus, and then they show up in our emergency room sick. We get them into care at that point, but the success of the therapy is diminished when people show up late.
"And during that entire time while the virus was replicating in them, if they are having contact with somebody and exposing someone to the virus, it's possible that that virus can be transmitted. Whereas if that person is on therapy, and their virus is reduced to undetectable levels, the risk of transmission from person to person is markedly reduced.
"Briefly, some data that can support this whole concept can be found at our clinic, where we follow, annually, the median of what's called the CD4 count of people when they show up to clinic. CD4 count normally in an uninfected person is 500 to 1,500. When somebody has advanced HIV it's below 200.
"The median CD4 count of people showing up at our clinic over the last decade is around 200, so that means half of our patients are showing up late.
"The one exception to that is a group of patients who show up with a CD4 count of around 400 or so, and those are pregnant women. Why? Because of opt-out testing, being found when they have less advanced disease. They get on treatment, they can live to a near-normal lifespan, take care of their child, not have a child who's infected, everything's better.
"So what we need to do is implement a policy of opt-out testing that was recommended by the CDC two years ago, but to really make that happen, not just talk about it but implement it, so that the public health improves and the health of the individual improves."
Michael S. Saag, M.D., is a professor of medicine at the University of Alabama and chair of Infectious Diseases at UAB. He is the HIVMA chair elect.
Jeffrey Harris, M.D.
"Last December the ACP and the HIVMA issued a guidance statement recommending that routine screening should begin. The CDC issued a similar recommendation, in September 2006. But federal funding and reimbursement lagged far behind.
"It's our understanding that the Centers for Medicaid and Medicare Services, the CMS, is now considering covering HIV testing, but limiting it to high-risk patients. What we would recommend to the CMS is that they expand this policy for routine screening to cover all Medicare beneficiaries, that they also encourage the coverage and screening of the Medicaid population, and that they provide adequate funding. The screening could take place in community health centers, Federal Bureau of Prisons, and the Department of Veteran Affairs.
"We also believe that part of this evolving health reform debate should address the issue of expanding routine screening for HIV. This proposal is driven by the reality of funding. The cost of routine screening plus the cost of treating those who are detected earlier is simply less than the cost of treating those who present at a more advanced stage when they are immune-compromised.
"Currently, it was suggested that about 40% of those people who are turning out to be HIV-positive arrive at a time when they are already immune-compromised and thus much more ill. There are data to suggest that when the CD4 cell count is greater than 350 when diagnosed, the cost of treating that individual is demonstrated to be $13,885.
"In contrast, when a CD4 count is less than 50, the cost of treating that patient at that juncture is $36,533 annually.
"Thus early identification is only going to come about through routine screening. And this is only going to be possible if we can persuade federal programs and private insurers to embark upon a much broader screening program."
Jeffrey Harris, M.D., is president of the ACP.
Kathleen E. Squires, M.D.
"The ACP and the HIVMA has taken the position that it's really time to support evidence-based prevention. We really do know what transmits HIV. So we do have evidence-based prevention strategies for the two major transmission factors, which are sexual activity as well as the use of intravenous drugs and things like exchanging needles and so forth.
The federal government really doesn't support needle exchange programs despite numerous studies that demonstrate that these programs are very highly effective.
"Over the past several years, a major emphasis on the part of the federal government in terms of looking at prevention strategies is to fund abstinence-only education instead of supporting comprehensive sex education. This is despite the fact that there have been now numerous studies that really document that abstinence-only education is not effective.
"If you look at federal spending on this issue since 1996, the federal government has spent more than 1.5 billion dollars on abstinence-only education. In the year 2009, Congress continues to spend about $99 million on abstinence-only education efforts. [In the latest budget from President Obama, this $99 million has been cut from abstinence-only programs.]
"In terms of looking at the issue of intravenous drug use, the federal government really doesn't support needle exchange programs despite numerous studies that demonstrate that these programs are very highly effective at reducing HIV and hepatitis C transmission, and do not increase drug use in the people who are participating in these exchange programs.
"The other thing that we need to think about at the global level is that we are exporting ideological prevention strategies like the use of abstinence-only efforts to other countries where it's really important for us to employ all of the tools that have been proven to be effective at reducing transmission of HIV.
"Now, this year and just last week [week of April 13th], the White House and the CDC announced a very important campaign, $45 million and a five-year new communication campaign to raise awareness about the domestic HIV epidemic and specifically addressing the impact of HIV in African American people in this country. This campaign is one component of a broader HIV prevention strategy, but it's really critical to increase funding across the range of tools that have been shown to be effective."
Kathleen E. Squires, M.D., is HIVMA vice-chair and director of infectious disease at Jefferson Medical College and associate professor of medicine at University Hospital in Philadelphia.
"HIV Policy: The Path Forward" was published in the April 17 Clinical Infectious Diseases. Read the text and list of recommendations at www.hivma.org.
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