Kaisernetwork.org (Washington, DC)
1 August 2008
Global Challenges
Washington Post Examines HIV Epidemic in Tijuana, Mexico
[Aug 01, 2008]
The Washington Post on Friday examined the HIV/AIDS epidemic in the border town of Tijuana, Mexico, where HIV prevalence is about three times that of the national average, with about one in 125 adults living with HIV. Mexico has one of the lowest HIV prevalences in the Americas, and according to UNAIDS, the percentage of people living with HIV/AIDS in Mexico is about half that of the U.S. and one-third that of El Salvador, Guatemala and Panama, the Post reports.
According to a survey by researchers at the University of California's Division of International Health and Cross-Cultural Medicine, 64% of 116 HIV-positive Tijuana residents came into the U.S. at least once monthly. About half of men who have sex with men living in Tijuana and 75% of MSM living in San Diego reported having sex partners across the border, the survey found. In addition, of 1,000 commercial sex workers interviewed in Tijuana, 69% reported having U.S. clients who crossed the border for sex. Steffanie Strathdee, a HIV/AIDS researcher at IHCCM, said HIV is the "uninvited hitchhiker."
According to the Post, HIV advocacy groups have implemented needle-exchange programs and condom distribution campaigns in Tijuana to curb the spread of HIV. The government has "quietly" supported such programs, the Post reports. Although the country is traditionally conservative, health leaders persuaded the government to support such programs and discuss issues such as condom use in a scientific, rather than moral, context. "Before, it was taboo to even talk openly about condoms," Jorge Saavedra -- director of Censida, the National Center for the Control of HIV/AIDS in Mexico -- said, adding, "Groups still oppose condom use, but at least we can mention the word." According to Saavedra, needle-exchange programs also are sound public health strategies. "We are not giving needles to people who are not drug users," he said, adding, "We're giving needles to people who are already using those drugs. This is a way to avoid HIV infections." The article also profiles Angel Cabrera, who conducts HIV/AIDS outreach in Tijuana (Connolly, Washington Post, 8/1). The article was supported by a Kaiser Family Foundation mini reporting fellowship.
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Mexican Officials Promote Sex Education Among Young People
[Aug 01, 2008]
Mexican officials on Wednesday announced their intention to promote sex education among young people in the country in an effort to reduce the spread of HIV, Xinhuanet reports.
Speaking at a youth presentation in advance of next week's XVII International AIDS Conference in Mexico City, Ricardo Baruch, International AIDS Society youth program coordinator, said that sex education is a "right" and "should be promoted by all means available." Baruch added that sex education has a wide reach but is inexpensive and therefore cost efficient, Xinhuanet reports. Jorge Saavedra -- director of Censida, the National Center for the Control of HIV/AIDS in Mexico -- said that improving sex education among teenagers is a challenge. According to Saavedra, sex education should cover the proper use of condoms and safer-sex relations among young people. Priscila Vera, director of the Mexican Youth Institute, said that condoms will be handed out at no cost to young people in the coming months (Xinhuanet, 7/31).
Kaisernetwork.org is the official webcaster of the XVII International AIDS Conference in Mexico City. Click here to sign up for your Daily Update e-mail during the conference.
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Reuters Examines How Laws, Conservative Attitudes Are Hampering Efforts To Fight HIV/AIDS in Malaysia
[Aug 01, 2008]
Reuters on Thursday examined how some laws and widespread conservative attitudes are hindering efforts to fight the spread of HIV/AIDS in Malaysia, a predominantly Muslim country where high-risk groups are driven "deeper underground" because of the situation. Soliciting sex work and sodomy are illegal in Malaysia, and the country has heavy punishments for illegal drug use, according to Reuters. In addition, although efforts from some advocates have garnered government support for HIV/AIDS programs and the distribution of condoms and clean needles, "implementation is far from easy," Reuters reports.
Celine Ng, who runs a needle-exchange program, said that her biggest challenge is the police. "Even my staff encounter problems with them. We have the endorsement of the narcotics (authorities) and we give needles, not drugs," she said, adding, "So if they catch our clients with drugs, we can't stop them, but you can't catch those with just needles." Laws make it difficult to distribute condoms to sex workers and men who have sex with men. In addition, oral and anal sex is illegal in all circumstances and is punishable by up to 20 years in prison. Although sex work is not illegal, solicitation is punishable by up to 10 years in prison. Drug trafficking carries a mandatory death sentence, according to Reuters.
People in high-risk groups are "driven underground, so you can't reach them," Adeeba Kamarulzaman, president of the government-supported Malaysian AIDS Council, said. He added, "We have (our) outreach workers getting arrested. They (authorities) raid and catch everyone, we are forever trying to bail out our outreach workers from the lockup, which is a major headache on a day-to-day basis." Injection drug users comprise the largest risk group for HIV in Malaysia and accounted for 65% of the 4,549 new cases recorded in 2007. Malaysia recorded a total of 80,938 people living with HIV at the end of 2007, but many sources say that the actual number of cases could be much higher. "Infections are going up, but surveillance is very poor in Malaysia," Raymond Tai of the Pink Triangle Foundation said, adding, "Many young [MSM] only know of their illness for the first time when they are warded with AIDS. How long have they been positive, how long have they been infectious? It is critical."
There also are concerns that HIV/AIDS is spreading from high-risk groups to women in the general population in the country. High-risk groups do not "exist in isolation," Kamarulzaman said, adding that IDUs "have wives, drug users patronize sex workers, they buy sex, they sell sex." Some groups are attempting to promote HIV/AIDS prevention messages, which can be difficult because advertisements are under government control, according to Reuters. Ads for condoms are not permitted on national television, except in certain circumstances such as promoting use for married couples. Advocates also are stressing that increased action should be taken and that the government should acknowledge the situation and cooperate with nongovernment organizations (Lyn, Reuters, 7/31).
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Politics and Policy
Federal Health Plan, Medicare Do Not Cover Routine HIV Screening as Recommended by CDC, Bloomberg Reports
[Aug 01, 2008]
Medicare and federal health care plans that provide coverage under the Federal Employees Health Benefit Plan do not offer payment for routine HIV screening of people ages 13 to 64 -- a practice that was recommended by CDC in 2006 -- Bloomberg reports. According to Bloomberg, FEHBP provides coverage for 8.5 million employees, and Medicare provides coverage for 7.1 million disabled people under age 65. CDC revised its recommendations because risk-based HIV screening often was not covered by insurance, and doctors often did not know which of their patients were considered high risk. In addition, more people outside high-risk groups -- including women, minority groups and people living outside cities -- were contracting the virus.
FEHBP, which costs $35 billion annually, pays 230 regional health plans nationwide to provide care for federal workers, including those employed by CDC, elected officials and their family members. FEHBP does not follow the CDC HIV screening guidelines but instead adheres to an alternative protocol adopted by the U.S. Preventive Services Task Force, which only covers high-risk individuals. In order to support screening recommendations, the task force requires that studies already have demonstrated the testing provides benefits, Ned Calonge, chair of the task force's advisory panel, said. He added that although the CDC guidelines aim to identify more undiagnosed HIV cases, the agency has not proved yet that the guidelines will be successful. "I don't think they have evidence that a universal testing strategy is going to lead to lower infection rates and less HIV," Calonge said, adding, "There are some indications to be optimistic, but optimism and promise aren't proof."
Bernard Branson of CDC said that meeting the task force's requirements could take years. CDC recommended universal testing for pregnant women in 1995, and the task force did not adopt the guidelines for 10 years, Branson said, adding that during those 10 years, studies showed the routine screening prevented thousands of cases of mother-to-child HIV transmission. In addition, another reason to support the CDC testing recommendations is that agency research has found as many as 70% of new HIV cases are transmitted by people who are unaware of their status, Branson said.
Medicare also does not cover routine HIV screening, according to a spokesperson. Although most Medicare beneficiaries are older than age 65 -- the cut-off age under the CDC testing recommendations -- about seven million younger disabled beneficiaries should be screened under the recommendations, Bloomberg reports.
Cornelius Baker, a policy adviser at the National Black Gay Men's Advocacy Coalition, said that risk-based testing particularly endangers blacks in the U.S., about 2% of whom are living with HIV. Many physicians do not ask patients about their sexual behavior and make assumptions about who is at risk of HIV, Baker said, adding that blacks who do not consider themselves at risk will not be tested unless offered routine screening. "Some doctors are still making irrational decisions about HIV testing, deciding whether to screen someone based on what he or she looks like,' Baker said, adding, "I can't imagine any African-American not being screened for sickle-cell disease; why not for HIV, which is higher in prevalence?'
According to Branson, not following the CDC guidelines allows HIV to spread and prevents HIV-positive people from early diagnosis and treatment. "It's a real paradox when one big federal agency makes a recommendation that another big federal agency won't support,' John Bartlett, a Johns Hopkins University physician, said. He added, "I think they've got to catch up. It's a disease that's lethal, and one of the major problems with HIV today is late entry into care."
Some private insurers -- including UnitedHealth Group, Aetna and Cigna -- began covering routine HIV screening soon after the CDC guidelines were released, according to Bloomberg (Lauerman/Goldstein, Bloomberg, 7/31).
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In The Courts
Abbott Agrees To Settle Lawsuit Over Price of Antiretroviral Norvir
[Aug 01, 2008]
Abbott Laboratories on Wednesday agreed to pay between $10 million and $27.5 million to settle an antitrust lawsuit filed by HIV/AIDS advocates and other drug companies over an increase in the price of the company's antiretroviral drug Norvir, the AP/International Herald Tribune reports (AP/International Herald Tribune, 7/31).
Abbott in December 2003 quadrupled the per-patient wholesale price of Norvir, which is known generically as ritonavir. Norvir primarily is used as a booster for other protease inhibitors. Abbott exempted Medicaid, Medicare and state AIDS Drug Assistance Programs from the price increase and announced it would expand its patient assistance program. The cost of Norvir increased from $51.30 for 30 100-milligram capsules to $257.10 for 30 100-mg capsules, or by $5,000 more annually. In a suit filed in October 2007, GlaxoSmithKline and several pharmacy chains -- Safeway, Walgreen, Kroger, Supervalu's New Albertson's and American Sales -- also alleged that Abbott "unlawfully extended its monopoly position as the sole provider of Norvir" by increasing the drug's price (Kaiser Daily HIV/AIDS Report, 11/12/07).
The settlement will need to be approved by a federal judge in Oakland, Calif., where the suit was scheduled to go to trial next month, the AP/Herald Tribune reports. In addition, the final amount of the payout depends on an appeals court ruling of three legal questions, Abbott spokesperson Melissa Brotz said. Attorneys for the plaintiffs did not return calls for comment.
Abbott is facing six other antitrust lawsuits filed by 16 companies, the AP/Herald Tribune reports. Two other lawsuits filed in Illinois have been dismissed (AP/International Herald Tribune, 7/31). "The price adjustment of Norvir was a legitimate response to advances that Abbott scientists made in treating HIV and captured the fair value of its new use as a bolster" in combination therapies," Abbott spokesperson Scott Stoffel said. He added that Abbott sees the settlement as being "in the best interests of both parties." According to Stoffel, the agreement calls for the settlement funds to primarily go to HIV/AIDS-related charities (Graybow, Reuters UK, 7/31).
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Opinion
Editorials Respond to PEPFAR Reauthorization
[Aug 01, 2008]
President Bush on Wednesday signed into law legislation (HR 5501) that reauthorizes the President's Emergency Plan for AIDS Relief at $48 billion through 2013. Two newspapers have published editorials in response to the bill. Summaries appear below.
New York Times: Bush can be "justifiably proud of his administration's leadership in ramping up its commitments to the global efforts to control AIDS over the past five years and in proposing to do more in the next five." The "only hitch is whether the money will actually materialize in the form of appropriations," the editorial says, adding, "The signs in Congress are not good." The $48 billion called for in the PEPFAR reauthorization bill "implies appropriations of roughly $9 billion to $10 billion a year," the editorial says, adding, "But advocacy groups say the amounts emerging from Congressional appropriations committees for fiscal year 2009 will be little more than half of that." In addition, a report released this week by the Black AIDS Institute has "come up with a startling insight into the AIDS epidemic in this country by contrasting it with the global epidemic," according to the editorial. The Bush administration has not "shown the same zeal to control this domestic tragedy that it has shown in the global campaign," the editorial says, concluding, "Surely we should be doing as much to prevent the spread of the AIDS virus in our own communities as we are trying to do abroad" (New York Times, 8/1).
San Diego Union-Tribune: Bush "cemented his own legacy" by signing the bill, a Union-Tribune editorial says, adding that PEPFAR is "saving literally millions of lives, and it will stand as [Bush's] greatest bipartisan foreign policy achievement." With "less than six months remaining in the Bush presidency, the rest of his legacy remains, at best, cloudy," the editorial says, concluding, "But the impressive results of his battle against the scourge of AIDS cannot be denied. Its impact, in real lives saved, will be felt for many years to come" (San Diego Union-Tribune, 8/1).
In related news, the AP/Google.com on Thursday examined how the PEPFAR reauthorization bill "sets a goal of treating more than the two million patient target set in 2003, but how much more isn't clear." When signing the bill, Bush said, "With this funding, we will support treatment for at least three million people." However, the "bill itself doesn't set a specific target," according to the AP/Google.com. Early versions of the bill that passed the House included a specific target of treating at least three million people by 2013, but the target was removed in the final version. The bill now says that U.S. policy is to increase the number of people receiving treatment beyond the original goal of two million. According to the U.S. State Department, 1.7 million people received treatment as of March 31, and the original bill's target of reaching two million with treatment will be met by December (Euphrat, AP/Google.com, 7/31).
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Eliminating Funds for HIV/AIDS Vaccine Research, Shifting Funds to Treatment 'Dangerous Sentiment,' Opinion Piece Says
[Aug 01, 2008]
The call to eliminate all funding for HIV/AIDS vaccine research and prevention programs and "shifting" those funds to the expansion of HIV/AIDS treatment is a "dangerous sentiment" that is "sweeping over the AIDS establishment," Laurie Garrett, a senior fellow for global health at the Council on Foreign Relations, writes in an International Herald Tribune opinion piece.
There is "genuine joy" among HIV/AIDS advocates that millions of HIV-positive people are living longer because of antiretroviral treatment, and Congress is to be "congratulated" for the passage of a bill to reauthorize the President's Emergency Plan for AIDS Relief through 2013, Garrett writes. However, she adds that it is "troubling" that some HIV/AIDS advocates "fail to see AIDS treatment for what it is: A stop-gap measure to tide humanity over until we can collectively reach what ought to be our real goal -- stopping HIV's spread entirely." Garrett notes that on an "individual basis, living with AIDS is a proper goal; on a population basis, it is catastrophic."
If the current HIV/AIDS treatment model is "viewed as an interim step ... its funding and expansion make sense not only morally, but also as a practical matter of economics and foreign policy," Garrett writes, adding, "[B]ut only if a massive commitment to finding searches for both a vaccine and cure for HIV are sustained for years to come." The recent news concerning HIV/AIDS vaccine trials is "demoralizing," but the "multibillion-dollar HIV research enterprise" that focuses on improving treatment options "will inexorably increase," Garrett writes. HIV/AIDS "ought to be eliminated entirely from the pantheon of threats to humanity," but that requires a "dose of realism," Garrett adds (Garrett, International Herald Tribune, 7/31).
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