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This Week in HIV/AIDS News

Mar 27th, 2009 | no responsesPosted by OIA Staff in Health & Lifestyle

Reps. Introduce Bill To Expand Medicaid Coverage to Some HIV-Positive People

Reps. Eliot Engel (D-N.Y.), Ileana Ros-Lehtinen (R-Fla.) and House Speaker Nancy Pelosi (D-Calif.) have introduced a bill (H.R. 1616) to allow states to expand Medicaid coverage to low-income HIV-positive people, CQ HealthBeat reports. The bill would permit states to change their Medicaid eligibility policies to increase access to early and cost-effective HIV treatment before the virus progresses to AIDS, Engel said in a statement. According to Engel, this approach would be “more cost effective for the federal government since it’s much more expensive to treat patients with AIDS than HIV.”

Under current Social Security regulations, HIV-positive people must be disabled by the virus before they can receive Medicaid coverage, according to Engel’s statement. The bill would allow participating states to receive higher federal rates for providing treatment to people living with HIV and is similar to other initiatives, such as the Children’s Health Insurance Program and a program providing early Medicaid access to low-income women with cancer. “It makes no sense that a person must develop … AIDS before Medicaid can treat them,” Ros-Lehtinen said in the statement. She added, “This legislation would remedy this by giving states the option to extend Medicaid coverage to low-income persons so that they can confront their HIV before it becomes AIDS and thus help them from becoming terminally ill and a burden on their families and the public health system” (Feldman, CQ HealthBeat, 3/26).

“Reprinted with permission from kaisernetwork.org. You can view the entire Kaiser Daily HIV/AIDS Report , search the archives, and sign up for email delivery at www.kaisernetwork.org/dailyreports/hiv. The Kaiser Daily HIV/AIDS Report is published for kaisernetwork.org, a free service of The Henry J. Kaiser Family Foundation. © 2009 Advisory Board Company and Kaiser Family Foundation. All rights reserved.”

About 25% of TB Deaths Occur Among HIV-Positive People, WHO Global TB Control Report Says

About one-quarter of tuberculosis-related deaths involve an HIV-positive person, twice as high as previous estimates, according to the Global Tuberculosis Control Report 2009, which the World Health Organization released Tuesday to coincide with World TB Day, the Wall Street Journal reports.

The report found a total of 9.3 million new TB cases in 2007, 1.4 million of which occurred in people living with HIV/AIDS (Goldstein, Wall Street Journal, 3/25). These new estimates from WHO do not reflect an increase HIV/TB coinfections or in TB deaths among HIV patients, rather “better analyses, better data and better methodology,” Kevin De Cock, HIV/AIDS director at WHO, said (MacInnis, Reuters, 3/24). In addition, “stepped-up HIV testing among TB patients has revealed cases of HIV that previously went undetected,” the Journal reports. In previous reports, WHO used data on HIV/TB coinfection from 15 countries; however, the new report includes data from 64 countries, several of which are in sub-Saharan Africa, the Journal reports. The report noted that improved data are needed to “increase the reliability of these estimates” (Wall Street Journal, 3/25).

TB incidence decreased from 142 new cases in 2004 to 139 cases in 2007 (Brown, Washington Post, 3/25). According to the report, 55% of recorded TB cases occurred in Asia in 2007, while 31% occurred in Africa. India had the highest number of recorded cases at two million, followed by China with 1.3 million and Indonesia with 530,000 (Brooks, AP/Google.com, 3/24).

There were about 1.3 million TB deaths among HIV-negative people and about 456,000 among HIV-positive people in 2007, the report said. TB was the No. 1 cause of death among people living with HIV/AIDS in 2007 (Washington Post, 3/25). Health officials noted that HIV-positive people are about 20 times more likely to develop TB than HIV-negative people in countries with high HIV prevalence and are between 26 and 37 times more likely to develop TB in countries with lower HIV prevalence (AP/Google.com, 3/24).

The report found a “sharp increase” in the number of HIV tests that are administered to people with TB, particularly in Africa. About 4% of TB patients in Africa were tested for HIV in 2004, compared with 37% in 2007. In several countries, more than 75% of TB patients received an HIV test, according to the report (WHO release, 3/24). Although efforts to address HIV/TB coinfection have improved, the report noted that such efforts are inadequate in many developing countries. De Cock noted that only one in seven HIV-positive people receive preventive treatment for TB. In addition, more than one-third of TB cases worldwide are undiagnosed, increasing the risk of transmission, the report said (AFP/Google.com, 3/24). The report recommended that HIV-positive people receive TB screenings and medications to reduce their risk of developing the disease.

The report also found an increase in drug-resistant strains of TB in recent years. According to the report, more than 500,000 people worldwide have been diagnosed with multi-drug resistant TB (Reuters, 3/24). Fewer than 1% of people with MDR-TB were receiving WHO-recommended treatment in 2007 (WHO release, 3/24). In addition, at least one case of extensively drug-resistant TB has been reported in 55 countries and territories worldwide, the report said. XDR-TB is resistant to two of the most potent first-line treatments and at least two of the classes of second-line drugs. Mario Raviglione, director of WHO’s Stop TB Department, added that the actual prevalence of XDR-TB likely is higher because many developing countries do not conduct tests to determine the extent of drug-resistance in TB patients (Reuters, 3/24).

The report also documented concern over funding in the current economic downturn, noting that 94 countries that account for 93% of all TB cases worldwide have a funding shortfall of $1.5 billion to meet the targets in the Global Plan To Stop TB 2006-2015 (WHO release, 3/24). Michel Kazatchkine — executive director of the Global Fund To Fight AIDS, TB and Malaria — estimated that the shortfall will increase to at least $4 billion by 2010. “The [economic] crisis is severely affecting developing nations, but countries should realize health costs are an investment for development and not just a strain on budgets,” Kazatchkine said (AP/Google.com, 3/24). United Nations Secretary-General Ban Ki-moon welcomed funding commitments made by governments, nongovernmental organizations, foundations, the private sector, academia and researchers to meet the United Nations Millennium Development Goals‘ target of reversing the spread of the disease by 2015. “In this time of economic crisis, we must protect investments in global health, particularly to protect the most vulnerable,” Ban said (U.N. News Service, 3/24).

Health officials from the 27 countries that account for 85% of MDR-TB cases worldwide — including Bangladesh, China, India, Russia and South Africa — are expected to meet next week in Beijing to discuss efforts to address drug-resistant TB, AFP/Google.com reports (AFP/Google.com, 3/24).

Reaction
The report’s findings “point to an urgent need to find, prevent and treat TB in people living with HIV and to test for HIV in all patients with TB in order to provide prevention, treatment and care,” WHO Director-General Margaret Chan said, adding, “Countries can only do that through stronger collaborative programs and stronger health systems that address both diseases.” Michel Sidibe, executive director of UNAIDS, said, “We have to stop people living with HIV from dying of TB.” He added, “Universal access to HIV prevention, treatment, care and support must include TB prevention, diagnosis and treatment” (WHO release, 3/24). Wafaa El-Sadr, a professor of medicine and epidemiology at Columbia University, said the report’s findings “demonstrat[e] that one cannot think of tackling or controlling the TB epidemic globally without thinking of how we’re going to do it in HIV-infected populations” (Wall Street Journal, 3/25).

Ban said the “rate of decline” in TB incidence is “far too slow,” adding that unless the global health community “accelerate[s] action, the numbers of those falling ill will continue to grow” (U.N. News Service, 3/24). In addition, the “scale-up of interventions to deal with MDR-TB is not at the pace we would like to see and is far from the targets that have been established,” Raviglione said. He added that TB incidence is decreasing by “less than 1% per year, which will get us to potentially eliminate TB in a very distant future: we are talking centuries if not a millennia in a way” (AFP/Google.com, 3/24).

The report is available online.

Lancet Opinion Piece Examines Progress Made Against HIV/AIDS

“Nearly 30 years into the AIDS epidemic, we are able to access our progress in tackling the disease with both increased knowledge and the benefit of hindsight,” former UNAIDS Executive Director Peter Piot of Imperial College London, who also serves as an adviser on global health strategy to the Bill & Melinda Gates Foundation; Michel Kazatchkine, executive director of the Global Fund To Fight AIDS, Tuberculosis and Malaria; Mark Dybul of the O’Neill Institute for National and Global Health Law at Georgetown University and former U.S. Global AIDS Coordinator; and Julian Lob-Levyt of the GAVI Alliance write in a Lancet opinion piece. They add that the piece aims to examine “what we — the international community — got right, what we got wrong, and why we need to urgently dispel several emerging myths about the epidemic and the global response to it.”

According to the authors, when “HIV was emerging in the early 1980s, we clearly underestimated the global effect that the disease would have, and that in only a few decades, tens of millions of people worldwide would become infected.” They add, “The epidemic nowadays is the result of what 30 years ago was an unpredictable — but tremendously potent — combination of intimate personal behaviors … and socioeconomic factors … that have affected nearly every country worldwide.” In addition, the international community underestimated “the extent to which stigma and discrimination — against people living with HIV/AIDS and those most vulnerable to it — would remain formidable obstacles to tackling AIDS,” the authors write, adding that the “sense of urgency and solidarity that would eventually develop in the global AIDS epidemic, leading to an unusual convergence of political will, money and science” also was underestimated.

Other aspects of the HIV/AIDS pandemic were overestimated, the authors write. They add that despite innovations and successes regarding antiretroviral treatment, “we have also overestimated our capacity to devise technological solutions to prevent HIV,” and “continued investments in new prevention technology remain a crucial part of the AIDS research agenda.”

The author’s point to the common myth that HIV prevention has not been successful overall — which they say is contradicted by evidence it has been effective in several countries, adding that prevention is about behavior in addition to technology. They add that sustaining changes in sexual behavior “remains a major challenge,” citing the possible “complacency about AIDS and the sense that a treatable disease is somehow less threatening than are other diseases.”

There is also a “recurrent” myth that there is one “silver-bullet” solution to HIV prevention; however, “no approach will be enough on its own, and the promotion of one solution is … irresponsible,” the authors write. They continue that another “prevailing” myth is that there is little heterosexual transmission of HIV outside Africa and note that HIV transmission among women is rising worldwide, with “[m]ethods of transmission and affected groups” being “many and varied.”

The authors write, “Alarmingly, a myth has begun to emerge that too much money is spent on AIDS,” as countries face new financial difficulties while “competing for the attention of political leaders and donors.” The myth that investments in AIDS efforts have been at the expense of underfunded health systems also needs to be dispelled, the authors write, adding that funds for HIV/AIDS efforts “are making a major contribution to the strengthening of health systems.” The authors also address the myth that HIV/AIDS “has somehow been solved, writing, “We need to recognize that AIDS is a long-term event. Tackling it is complex, but our successes so far indicate what is possible.” Increased efforts to examine epidemiological trends, “develop long lasting links with broader efforts to strengthen health systems and health workforces,” continue investment in research, and make a “serious, concerted effort” to address stigma and discrimination are needed to “be anywhere close to the point at which we can truthfully say the fight against AIDS is being won” (Piot et. al, Lancet, 3/20).

Christian Science Monitor Examines Effect of Economy on U.S. Foreign Aid Targets

The Christian Science Monitor on Monday examined how the Obama administration is “hinting that the economic downturn means the president is unlikely to reach his goal of doubling foreign aid by the end of his four-year term.” Doubling foreign aid to $50 billion annually by 2012 and a pledge to reform the way the U.S. works with the rest of the world were key elements of Obama’s presidential campaign, the Monitor reports. The situation is raising concerns about the possible effects on development and global health efforts, as well as the perception of the U.S. oversees, according to the Monitor. The U.S. in recent years has increased funding for efforts to address HIV/AIDS, tuberculosis, malaria and other diseases, but some “worry that the upward trend may now be reversed,” the Monitor reports.

Some development experts point out that President Obama’s fiscal year 2010 budget includes an almost 10% increase in foreign aid. However, the White House Office of Management and Budget has been discussing “extending out” the target of doubling foreign aid, likely into what some hope will be Obama’s second term. Steve Radelet of the Center for Global Development said that although the development community reacted “pretty positively” to Obama’s budget, there is “still a wait-and-see attitude.”

In addition, some in the development community have said that the current economic crisis is the time to reform the U.S. foreign aid system to make it more current and efficient. However, “questions remain about whether Congress will go for what the president is proposing and where any additional money will be spent,” according to the Monitor.

Congress recently approved $900 million for the Global Fund To Fight AIDS, Tuberculosis and Malaria — the highest annual U.S. contribution since the Global Fund launched. Global Fund officials still say that they plan to monitor the 2010 U.S. contribution for any signals about donations. “We are all aware of the severity of the global economic crisis and the strain it is putting on budgets and economies,” Christoph Benn of the Global Fund said. He added that he remains hopeful because when Obama, Vice President Biden and Secretary of State Hillary Rodham Clinton were senators, they all signed letters supporting increases to the Global Fund (LaFranchi, Christian Science Monitor, 3/23).

Release Paper On The Aids Drug Assistance Program
Propose Policy Changes to Secure HIV/AIDS Drugs for the Nations Poor and Uninsured

Washington, DC – The AIDS Institute and AIDS Action announce the release of a new policy paper titled, “The AIDS Drug Assistance Program: Securing HIV/AIDS Drugs for the Nations Poor and Uninsured.” The two organizations examined the AIDS Drug Assistance Program (ADAP) of the Ryan White HIV/AIDS Program and how well it ensures access to HIV/AIDS drugs for people living with HIV in the U.S. ADAPs provide medications and other services to over 158,000 low-income and underinsured people, or about 1 in 4 people receiving HIV/AIDS treatment in the U.S. It is the largest component of the Ryan White Program. Despite a budget of $1.4 billion in federal and state funds, the authors found that ADAP is not fully meeting the needs of people living with HIV/AIDS with 45 percent of people needing medications not receiving them. Furthermore, there are great disparities between the states in their ADAP coverage.

With increased healthcare costs and increased caseloads due to new infections, new diagnoses, and people losing their health insurance due to job loss, the program is constantly growing and there is an annual need for increased federal and state funds. With the deepening state and federal fiscal crisis the future health of ADAPs are uncertain. Without added funding people will not have access to lifesaving medications, people will be on waiting lists and additional program restrictions will be put in place by individual states.

The paper recommends 25 policy options relating to ADAP and surrounding HIV/AIDS service programs on how they can be improved to better meet the growing needs for medications.

“Without question the number one recommendation we heard from all the people we interviewed for the paper is the need for increased funding,” commented Carl Schmid of The AIDS Institute and one of the paper’s authors. “Unfortunately, increases for ADAP are falling far short of what is needed.” This year the program required $135 million in additional federal funds, but Congress only provided $21 million. Due to this shortfall, the need now for FY10 is $270 million.

In order to strengthen ADAPs this paper proposes Presidential and Congressional action and a number of other policy changes. These changes include, allowing ADAP expenditures to count towards the calculation of true out of pocket (TrOOP) expenses in Medicare Part D, to a larger proposal such as enactment of the Early Treatment for HIV Act (ETHA). This would allow low-income people with HIV access to Medicaid at the option of the state. Both these recommendations would relieve pressure on ADAP programs.

“We hope the policy options we have laid will be utilized by decision makers as they draft budgets, work on healthcare reform, the development of a National AIDS Strategy,” added William McColl of AIDS Action, who also authored the paper.

As a federal-state program, the paper also identified a number of options that individual states can do to improve the program, such as increasing state contributions, reviewing state match requirements, expanding the use of ADAP funds to purchase health insurance and fully wrap around the Medicare Part D drug benefit.

The full report can be accessed at:
www.theaidsinstitute.org/downloads/ADAPReportMarch2009TheAIDSInstitute.pdf
www.aidsaction.org/images/pdf/aids_drug_assistance_program.pdf