AIDS Action Committee’s Blog

Those who argue its time to “mainstream” AIDS should take a closer look at President Bush’s health care proposals. Bush’s proposal is premised on the odd notion that insurance obscures the true costs of health care and if people knew how much things cost they would opt for less or no care. And, this is a good thing?

In furtherance of this goal, the President would reform the tax code to drive people to buy insurance with less coverage by taxing those whose policy premium is more than $7,5000.00 for an individual plan or more than $15,000.00 for a family plan. Not surprisingly, the premiums of people with chronic illness tend to be higher than the standard deduction. So, under the President’s plan, people with HIV could look forward to not only dealing with a chronic, episodically critical illness, but paying more for the pleasure.

Modern medicine has been able to work miracles and miracles are expensive. Perhaps instead of trying to make the miracle harder to access, we should look to ways to reduce administrative costs. It was estimated in the ‘90s that 25 cents of every health care dollar was spent on administrative costs. No one thinks this has lessened. But of course, that would entail restructuring profitable business entities. Instead, the ongoing focus of health care reform has been to restrict access to care for the consumer. Bush proposes to upend a system that works, albeit expensively, for most people for the benefit of the uninsured, one-sixth of the population.

Perhaps instead of shoehorning everyone into a seriously broken health care system we should make AIDS exceptionalism the standard for health care for all and look for ways to restructure the industry. Of all the players in the health care system probably only those who actually need medical care would support this. But shouldn’t they count for something?

The Food and Drug Administration (FDA) recently approved the injectable filler Radiesse for the treatment of HIV-related facial wasting. Facial wasting is a major concern for many people living with HIV. It is basically a loss of fat under the skin of the face. Facial wasting can cause changes in appearance such as sunken cheeks, hollow eyes, indentations, or a generally gaunt look. Facial wasting and other forms of abnormal fat loss (lipoatrophy) have been associated with HIV treatment involving the drugs d4T and AZT.

Radiesse is the second substance that FDA has approved specifically for HIV-related facial wasting.  (The first, Sculptra, was approved in 2004.) FDA describes Radiesse as “a sterile, semi-solid implant consisting of synthetic calcium hydroxylapatite suspended in a gel carrier.”  Radiesse is injected beneath the skin to fill in areas where fat has been lost. People receive an initial treatment, followed by “touch-up” injections as needed. Most people require two or three treatments. Radiesse is designed both to fill in areas of fat loss and to stimulate the body to produce new collagen. As a result, the benefits of the treatment are expected to last an average of one year or more. The most common side effects of Radiesse injections are temporary swelling, bruising, reddening, or discomfort at the injection sites.

Check out www.facialwasting.org  or e-mail me at health@aac.org  if you’d like to learn more about facial wasting and lipoatrophy.

In President Bush’s 2007 State of the Union Address last night, he mentioned the HIV/AIDS epidemic, as in previous years.  This is good news given widespread apathy towards and lack of urgency about the still-raging epidemic in the United States.  The disappointing, shocking news is that the President was silent on the domestic HIV/AIDS epidemic, missing an invaluable opportunity to counter apathy and foster solutions to end the epidemic.  Especially missing were proposals to address and meet the needs of the most vulnerable and marginalized populations affected by HIV/AIDS.

Certainly HIV/AIDS is a worldwide pandemic that demands a United States response.  President Bush noted the President’s Emergency Plan for AIDS Relief’s (PEPFAR) work and called for Congress to continue its funding, without requesting increased funding.  The HIV/AIDS pandemic, however, does not exclude the U.S.

Today in the U.S., approximately 40,000 new cases of HIV infection occur each year, overwhelmingly among people of color.  A 2006 study by the Centers for Disease Control and Prevention (CDC) suggests that nearly 50% of urban black gay men are HIV positive and that over 60% of those men did not know that they were infected.  Background materials released by the White House before the President’s speech noted the high prevalence of HIV infection among intravenous drug users.

Why was there no acknowledgment of these or other realities of HIV/AIDS in the U.S. in the President’s address?  Why were there no bold, new proposals for stopping the epidemic here in the U.S., for example, calling on Congress to lift the ban on federal funding for syringe exchange?

Through PEPFAR, the U.S. expects other countries to have a national strategy to combat HIV/AIDS.  The American people, after over 25 years, deserve no less.  What we do not deserve is shameful silence from the President on HIV in the United States.

With its latest guidelines for HIV testing which do away with pre-test counseling the CDC has moved further away from successful prevention strategies.

Pre-test counseling has always been an opportunity to educate people about HIV risks.  The availability of this information in the course of routine health care has been especially important for certain populations not likely to tap into established HIV/AIDS networks, especially young people of either sexual orientation and closeted gay men. Counseling has also been critical for people who test negative as it might be their only chance to get this information.  The CDC, however, has decided that counseling is a barrier to testing.

It’s unclear when health education became a barrier to health care but it probably started around the same time that the federal government started discouraging frank discussions about sex, particularly gay sex, and drug use.

Sadly, like so much else in the federal government these days, public policy is driven by ideology, not fact (for example, the 2003 controversy over National Park Service’s  sale of A Different View, a creationist book arguing that the Grand Canyon was formed by approximately 5000 years ago by Noah’s flood, as opposed to 5 or 6 million years ago as agreed to by scientists).

Instead of encouraging proven prevention interventions like frank messages targeted to discrete populations, the CDC argues for an unproven strategy of test ‘em,  medicate ‘em and track ‘em.  Although this might be comforting to authoritarian federal bureaucrats, it leaves many of the rest of us deeply troubled.

Headlines
The recent headlines about the potential role of male circumcision in stopping the HIV epidemic have been dramatic. “Circumcision ‘helps to halt HIV” (BBC, July 26, 2006); “Study Says Circumcision Reduces AIDS Risk by 70%” (Wall Street Journal, July, 2006); “AIDS Conference to Debate HIV, Circumcision Link” (NPR August 17., 2006); and most recently, “Male Circumcision is ‘Real-World Equivalent’ to AIDS Vaccine, Opinion Piece Says” (New York Times, Jan 16, 2007).

Geographic Differences
Yet few of these pronouncements have really clarified that while male circumcision may indeed play a vital role in reducing HIV transmission in the developing world, its potential to stem the relentless tide of HIV infections in the US is, at best, limited.

It is critical to understand how different the HIV epidemic in the US continues to be from the epidemic in the rest of the world. Heterosexual transmission and commercial sex worker transmission makes up a much more significant proportion of how men become infected with HIV outside of the US. Only 15% of men infected with HIV in the US report high-risk heterosexual sex as their likely route of infection. And, most men in the US are already circumcised — somewhere around 60% of newborn baby boys in the US are circumcised. The studies cited in the articles above that showed the most dramatic results in circumcision reducing HIV transmission for men were discovered where male circumcision is, to a large part, previously nonexistent. It’s possible that any protective factor male circumcision offers is already at work here in the US.

More Questions
Not enough is yet known or studied about the role of circumcision in male-to-male HIV transmission to determine if increasing circumcision among American men would make a difference. And, all the studies on circumcision continue to point to the role in reducing infection for the men themselves – no evidence is given about potential protective effects for their female partners. Given that 80% of women infected with HIV in the US cite heterosexual sex as the likely route of their infection, this is critical question that remain to date unanswered. Navigating critical differences in the HIV/AIDS epidemic across the world remains one of our greatest challenges in 2007.

This article, from The New England Journal of Medicine draws attention to an important gap in U.S. HIV prevention efforts: the lack of effective harm reduction practices in our prison systems. This includes making condoms available, providing clean needles or access to bleach for injection drug users, and offering drug treatment and methadone maintenance programs.

Although public health advocates favor harm reduction, U.S. prison officials have rarely adopted it. Some argue that making condoms or clean needles available would send a “mixed message” to inmates condoning sex and drug use. A few even hold the punitive view that HIV and other infections are “just deserts” for breaking prison rules.

Whatever the rationale, policies that block harm reduction in prisons carry a heavy human cost – increased rates of HIV, viral hepatitis, and other infectious diseases both within prisons and in the communities outside.

Here are some sobering facts: The HIV infection rate among the 2 million prison inmates nationwide is more than four times that of the general population. In addition, about one out of every four HIV-infected persons passes through the correctional system in any given year. See this recent report on health disparities for more.

At the end of “Sex, Drug, Prisons, and HIV,” Columbia University’s Robert Fullilove observed:

Any reservoir of infection that is as large as a prison would warrant, by simple public health logic, that we do our best…to reduce the risk of transmission… The issue has never been, Do we understand what has to happen to reduce the risks?… It’s always been, Do we have the political will necessary to put what we know is effective into operation?

For more information, this audio interview with Theodore Hammett discusses HIV in prisons and the barriers to adopting harm reduction measures there.

• a world with no Internet, iPods or cell phones.
• a generation filled with ambition and optimism.
• a deadly virus with no known cure that will decimate a generation in its prime.

The year is 1981. Fear abounds, but there is hope that a cure will soon be found.

No one imagined that 25 years later, the epidemic would rage on in the United States and become a pandemic with more than one half million deaths in this country and over 30 million worldwide. (Read on …)