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On the fight against HIV and AIDS—and on the people who really started the conversation

38-13-2016 Yesterday, at Nancy Reagan’s funeral, I said something inaccurate when speaking about the Reagans’ record on HIV and AIDS. Since then, I’ve heard from countless people who were devastated by the loss of friends and loved ones, and hurt and disappointed by what I said. As someone who has also lost friends and loved ones to AIDS, I understand why. I made a mistake, plain and simple.

I want to use this opportunity to talk not only about where we’ve come from, but where we must go in the fight against HIV and AIDS.

To be clear, the Reagans did not start a national conversation about HIV and AIDS. That distinction belongs to generations of brave lesbian, gay, bisexual, and transgender people, along with straight allies, who started not just a conversation but a movement that continues to this day.

The AIDS crisis in America began as a quiet, deadly epidemic. Because of discrimination and disregard, it remained that way for far too long. When many in positions of power turned a blind eye, it was groups like ACT UP, Gay Men’s Health Crisis and others that came forward to shatter the silence — because as they reminded us again and again, Silence = Death.

They organized and marched, held die-ins on the steps of city halls and vigils in the streets. They fought alongside a few courageous voices in Washington, like U.S. Representative Henry Waxman, who spoke out from the floor of Congress.

Then there were all the people whose names we don’t often hear today — the unsung heroes who fought on the front lines of the crisis, from hospital wards and bedsides, some with their last breath. Slowly, too slowly, ignorance was crowded out by information. People who had once closed their eyes opened their hearts.

If not for those advocates, activists, and ordinary, heroic people, we would not be where we are in preventing and treating HIV and AIDS. Their courage — and their refusal to accept silence as the status quo — saved lives. We’ve come a long way. But we still have work to do to eradicate this disease for good and to erase the stigma that is an echo of a shameful and painful period in our country’s history.

This issue matters to me deeply. And I’ve always tried to do my part in the fight against this disease, and the stigma and pain that accompanies it. At the 1992 Democratic National Convention, when my husband accepted the nomination for president, we marked a break with the past by having two HIV-positive speakers — the first time that ever happened at a national convention.

As First Lady, I brought together world leaders to strategize and coordinate efforts to take on HIV and AIDS around the world. In the Senate, I put forward legislation to expand global AIDS research and assistance and to increase prevention and education, and I proudly voted for the creation of PEPFAR and to defend and protect the Ryan White Act. And as secretary of state, I launched a campaign to usher in an AIDS-free generation through prevention and treatment, targeting the populations at greatest risk of contracting HIV.

The AIDS crisis looks very different today. There are more options for treatment and prevention than ever before. More people with HIV are leading full and happy lives. But HIV and AIDS are still with us. They continue to disproportionately impact communities of color, transgender people, young people and gay and bisexual men.

There are still 1.2 million people living with HIV in the United States today, with about 50,000 people newly diagnosed each year. In Sub-Saharan Africa, almost 60 percent of people with HIV are women and girls. Even though the tools exist to end this epidemic once and for all, there are still far too many people dying today.

That is absolutely inexcusable.

I believe there’s even more we can — and must — do together. For starters, let’s continue to increase HIV and AIDS research and invest in the promising innovations that research is producing. Medications like PrEP are proving effective in preventing HIV infection; we should expand access to that drug for everyone, including at-risk populations. We should call on Republican governors to put people’s health and well-being ahead of politics and extend Medicaid, which would provide health care to those with HIV and AIDS.

We should call on states to reform outdated and stigmatizing HIV criminalization laws. We should increase global funding for HIV and AIDS prevention and treatment. And we should cap out-of-pocket expenses and drug costs—and hold companies like Turing and Valeant accountable when they attempt to gouge patients by jacking up the price of lifesaving medications. We’re still surrounded by memories of loved ones lost and lives cut short.

But we’re also surrounded by survivors who are fighting harder than ever. We owe it to them and to future generations to continue that fight together. For the first time, an AIDS-free generation is in sight. As president, I promise you that I will not let up until we reach that goal. We will not leave anyone behind.

 

Needle exchange is not enough: lessons from the Vancouver injecting drug use study.
FAST TRACK

AIDS. 11(8):F59-F65, July 11, 1997.
Strathdee, Steffanie A. 1,3,7; Patrick, David M. 2,4; Currie, Sue L. 1; Cornelisse, Peter G.A. 1; Rekart, Michael L. 2,4; Montaner, Julio S.G. 1,4,5; Schechter, Martin T. 1,3; O'Shaughnessy, Michael V. 1,5,6
Abstract:
Objective: To describe prevalence and incidence of HIV-1, hepatitis C virus (HCV) and risk behaviours in a prospective cohort of injecting drug users (IDU).
Setting: Vancouver, which introduced a needle exchange programme (NEP) in 1988, and currently exchanges over 2 million needles per year.

Design: IDU who had injected illicit drugs within the previous month were recruited through street outreach. At baseline and semi-annually, subjects underwent serology for HIV-1 and HCV, and questionnaires on demographics, behaviours and NEP attendance were completed. Logistic regression analysis was used to identify determinants of HIV prevalence.
Results: Of 1006 IDU, 65% were men, and either white (65%) or Native (27%). Prevalence rates of HIV-1 and HCV were 23 and 88%, respectively. The majority (92%) had attended Vancouver's NEP, which was the most important syringe source for 78%. Identical proportions of known HIV-positive and HIV-negative IDU reported lending used syringes (40%). Of HIV-negative IDU, 39% borrowed used needles within the previous 6 months. Relative to HIV-negative IDU, HIV-positive IDU were more likely to frequently inject cocaine (72 versus 62%; P < 0.001). Independent predictors of HIV-positive serostatus were low education, unstable housing, commercial sex, borrowing needles, being an established IDU, injecting with others, and frequent NEP attendance. Based on 24 seroconversions among 257 follow-up visits, estimated HIV incidence was 18.6 per 100 person-years (95% confidence interval, 11.1-26.0).

Conclusions: Despite having the largest NEP in North America, Vancouver has been experiencing an ongoing HIV epidemic. Whereas NEP are crucial for sterile syringe provision, they should be considered one component of a comprehensive programme including counselling, support and education.

 

Who Does AIDS Affect the Most 8-25-2006

Black Women are 68% of the Entire US AIDS Infected People Currently

Why are these people the most vulnerable of society? When their ancestors came to the US in boats as slaves they were at the hands of their masters of the plantations. Their treatment was something that many were ashamed of. Their own families didn't even talk about it when they knew that they were being abused sexually. Why, because it was a shame on them and their families. Not all families were treated in that manner. Those who were, were also threatened with death, and the banishment of their brothers or fathers or entire families if they were known to tell someone.

Why are these people the most vulnerable of society? When their ancestors came to the US in boats as slaves' they were at the hands of their masters of the plantations. Their treatment was something that many were ashamed of.

Their own families didn't even talk about it when they knew that they were being abused sexually. Why, because it was a shame on them and their families. Not all families were treated in that manner. Those who were were also threatened with death, and the banishment of their brothers or fathers or entire families if they were known to tell someone.
Many of the women gave birth to children who were then raised on the farms as more slaves and worked the plantations.

In todays’ world, with the recognition of sexual diversity, there are many black homosexual men. However, having said that because their society does not accept them, they lead double lives. One as a straight man and the other as a gay man. Many times they don’t tell their women that they are having sex with men, so if they have the AIDS virus or HIV, they don’t tell. This type of behavior spreads the disease even more to unsuspecting women.

Who's to blame for this double standard you ask me? Well, most of the blame goes to the individual men, however, there is much blame to go around. If you look at the individual families where shame is an arm band, they do not use good communication skills to begin with. If you look harder you will see a community which has been marginalized since the first days that they were born. When you have such a marginalization, people end up in desperate situations, using drugs, being abused by family members, fighting each other and depression, and societies other ills as well.

Good people will tell you that the black communities are strong church people. Yes, that is true, however, there is much more blame there, in the pulpits, because their ministers have not prepared, nor taught them anything about this type of sexual behavior, or problem. It is simply put a “Silent Problem” which is costing thousands of lives everyday.

I can hear some of those Baptist Ministers, and Pentecostal Ministers shouting at the sky about Jesus, while they are handling snakes during their services, yet no mentions have been made about that personal beast the AIDS virus as a result of promiscuous sexual behavior. In the past I have never heard of one black minister who actually addressed the days important issues. All they seem to do is shout how good the Lord is, but not how to take care of one another. The black male has long been considered a good sexual partner, although not a long term one.

Jails are filled with black men whose penchant for trouble has overshadowed their good sensibilities. Many of the men in jails are having sexual relations with one another, yet the American Federal Justice system would rather not give them preventive measures against sexual diseases, rather let them kill themselves slowly, then take it home to their girlfriends who wait for them and then they are both killed by the disease in the end.

There are needle exchange programs that work in places like Baltimore, Maryland and Seattle Washington for drug users. currently there are 83 cities that provide these programs. They do help, but the programs are not enough, there also needs to be psychological, and job programs.

How much does needle exchange cost?

According to King County in Seattle Washington,
Combined total cost for needle exchange programs in Seattle-King County in 2001 is $775,000. This compares with $120,000 to $150,000 in medical costs to care for just one person with AIDS from the time of infection to death. By preventing infections in just five people per year, the needle exchange more than pays for itself. By preventing HIV infections in just 1% of the injection drug users in King County, the program saves over $18 million in AIDS-related medical costs. In this light, the exchange provides both a public health and an economic benefit to the residents of Seattle and King County.

How much misery and wrongful deaths do we have to watch because the current president of the US, and his administration just doesn’t care about people. What George Bush doesn’t think about is the misery a person has to go through when they have AIDS in the end. I wish he would be taken on a forced vacation to a hospital where people are in the last stages of the disease, just so he could see what happens. “The Term Dereliction of Duty”comes to mind when I think about President George Bush, in many ways.

Youth and HIV/AIDS

Young people and HIV: the evidence is clear - act now!
Study identifies prevention interventions.
16 AUGUST 2006 | TORONTO -- For the first time, the effectiveness of different types of HIV interventions in schools, health services, media, communities, and for young people most at risk of HIV have been reviewed and graded for their usefulness. The review Steady, Ready, GO!, launched at the XVI International AIDS Conference, identifies what should be done now to reduce HIV infection in young people, and achieve the global targets set by world leaders.

The 2001 UN General Assembly Special Session on AIDS adopted universal access goals for young people: by 2010, 95% of young people to have access to the information, skills and services that they need to decrease their vulnerability to HIV.

However, despite these commitments, young people (15-24 years) remain at the centre of the AIDS pandemic in terms of transmission, vulnerability and impact, with an estimated 4-5,000 people in this age group acquiring HIV every day.

Over 80 studies were reviewed, from different developing countries and settings. The interventions have been classified in a way that makes the evidence easy for policy makers and programme managers to understand and use.

From the mass of evidence available, the effectiveness of different types of interventions have been graded as:
• GO! (stop asking for more evidence and get on and do it!)
• Ready (implement widely but evaluate carefully)
• Steady (not ready yet for implementation because more research and development is required).

The review makes recommendations for policy makers, programme managers and researchers.
"Steady, Ready, GO! provides a clear Agenda for Action for governments around the world if they want to prevent HIV among young people," says Joy Phumaphi, Assistant Director-General, Family and Community Health at WHO. "In light of the available evidence, governments will need to have a very good reason for not acting. We know what works and we should be doing it. We should not confuse lack of implementation with lack of evidence."

This publication will be as important for NGOs as it is for governments. NGOs frequently have very limited resources and are often working in a politically charged environment. Steady, Ready, GO! will help advocates move beyond opinions and moral judgements to scientific fact, and provide much needed information to young people themselves.

“With 40% of all new adult HIV infections occurring among young people aged 15-24, more investment in comprehensive HIV prevention efforts for young people is absolutely critical. We need youth-specific HIV prevention programmes to be based on what has been proven to work and tailored to countries' individual epidemics and realities,” said Purnima Mane, UNAIDS Director of Policy, Evidence and Partnerships.

Among the interventions that should be widely implemented because they have been classified as GO! or Ready are:
• In schools: curriculum-based interventions, led by adults, that are based on defined quality criteria, can have an impact on knowledge, skills and behaviours
• In health services: interventions can increase young people's use of services provided that service providers are trained and changes are made in health facilities to ensure that they are "adolescent-friendly".
• In the mass media: interventions can have an impact on knowledge and behaviours if they involve a range of media, for example TV and radio supported by print, and are explicit about sensitive topics but in line with cultural sensitivities
• In communities: increased knowledge and skills can be achieved through interventions that are explicitly directed to young people and are delivered through existing organizations and structures
• For young people most at-risk: interventions that provide information and services through static and outreach facilities can help achieve the global goals for young people most at risk of HIV, such as young sex workers, young injecting drug users or young men who have sex with men.

The review was carried out under the auspices of the UNAIDS Inter-agency Task Team on Young People, in which WHO has been working with the London School of Hygiene and Tropical Medicine, UNAIDS Secretariat and key UNAIDS co-sponsors, notably UNFPA and UNICEF.

Update 5-23-2016

World AIDS Day

December 1, Every Year

GENEVA, 1 December 2011—The Joint United Nations Programme on HIV/AIDS (UNAIDS) congratulates President Barack Obama on his bold commitment to provide AIDS treatment to 6 million people by 2013 and reach 1.5 million pregnant women living with HIV to protect their children from becoming infected with HIV. This reinforces the collaboration between UNAIDS and the United States on the global plan towards elimination of new HIV infections among children by 2015—the foundation for an AIDS free generation.

“The commitments made by President Obama today will save lives and help move us towards an AIDS free generation,” said Michel Sidibé, Executive Director of UNAIDS. “Getting to zero and ending AIDS is a shared responsibility.”

UNAIDS also welcomes the United States’ strong bipartisan commitment to the global AIDS response. This unprecedented solidarity has made the United States the largest global AIDS donor, providing more than half (54.2%) of all international AIDS assistance available to low- and middle-income countries in 2010. The PEPFAR programme, initiated under the leadership of President George W. Bush and expanded by President Obama, currently provides lifesaving HIV prevention, treatment, care and support services to millions of people, especially in sub-Saharan Africa, the region most affected by the epidemic.

World leaders have pledged to invest between US$ 22-24 billion by 2015 for the AIDS response. In recent years, international assistance has begun to decline, jeopardizing the ability of countries to sustain and scale up access to prevention and treatment services. UNAIDS urges members of the G8 and G20 to expand their investments in AIDS—domestic and international.

President Obama’s call to step up HIV prevention efforts using high-impact combination tools, such as treatment as prevention, male circumcision, antiretrovirals to stop new HIV infections among children and consistent condom use, has the potential to avert millions of new HIV infections. This approach, endorsed by UNAIDS, uses the best of new science and will save both money and lives.

World Aids Day 2010

“Failure to protect the rights of sex workers, women, young people, people who use drugs or those in same sex relations significantly hampers our efforts to meet public health goals,” says Marcel van Soest, Executive Director of the World AIDS Campaign. “Where human rights are officially recognised as a priority and protected, people living with HIV and key populations are accessing necessary treatment, prevention, support and care services”.

Human Rights Watch:World AIDS Day: Punitive Laws Threaten HIV Progress

According to the World Aids Campaign:12-1-2009 (New York) - HIV prevention efforts - and the promise of antiretroviral therapy as prevention - are being undermined by punitive laws targeting those infected with and at risk of HIV, Human Rights Watch said today on the eve of World AIDS Day. More than two million AIDS related deaths reported globally in 2008 - two million children under the age of 15 now live with HIV.

New figures released by the World Health Organization and UNAIDS estimate the number of new HIV infections have declined each year by about 17% from 2001 to 2008, but for every five people infected, only two start treatment.

Monitoring AIDS Treatment by Physical Symptoms is Effective

Result is almost as good as therapies based on advanced laboratory tests, a new study finds
25 APRIL 2008 | GENEVA --

When millions of HIV-infected people in poor countries began receiving advanced drug therapies, critics worried that patient care would suffer because few high-tech laboratories were available to guide treatments. But according to a study being published today in The Lancet, these concerns are as yet unfounded. In fact, the study indicates that when clinicians use simple physical signs of deteriorating health -- such as weight loss or fever -- these doctors can provide therapies almost as effective as those relying on the most advanced laboratory analysis.

"The results of this study should reassure clinicians in Africa and Asia, who are treating literally millions of people without these laboratory tests, that they are not compromising patient safety," said a coauthor of the paper, Dr Charles Gilks, who is the Coordinator of Antiretroviral Treatment (ART) and HIV Care at WHO in Geneva. "In fact, the outcome of their treatment is almost as good as of those patients in the USA and Europe where laboratory-guided treatment is the norm."

The aim of the study was to look at the medium and long-term consequences of different approaches to monitoring antiretroviral therapy in a resource-limited setting: using clinical signs and symptoms alone as recommended in WHO guidelines; or more sophisticated and costly but far less accessible immunological and virological load tests. The scientists used a model that had been tried and tested in London, and shown accurately to predict the course of the epidemic in the UK over 20 years, but with various changes to reflect realities on the ground.

According to the study authors, survival rates for individuals assessed for clinical symptoms alone were almost identical to survival rates for those who underwent laboratory monitoring. The 5-year survival rate was 83% for individuals monitored for viral load, 82% for CD4 (a critical immune component) monitoring, and 82% for clinical monitoring alone. Corresponding values over a 24-year period were 67%, 64% and 64% respectively.

Although the survival rate was slightly higher with viral load monitoring, study authors pointed out it was not the most cost-effective strategy in the poorest countries. The study also examined whether clinical observation alone was effective in determining when to switch patients from WHO-recommended first-line treatments to more costly second-line medicines. Again, diagnosis based on an assessment of clinical symptoms was almost as effective as those relying on expensive laboratory tests.

Study authors concluded that for patients on the WHO first-line regimen of stavudine, lamivudine and nevirapine, the benefits of CD4 count or viral load monitoring were only modest at best.

The study, conducted by a prominent group in the United Kingdom working with WHO scientists, employed mathematical models which were designed to identify emerging problems and problems that might appear after long-term use of ART. But more work must be done. The study is based on mathematical projections and not on real-world patients. While there is little real-world data yet available because these drugs have been used for such a short time in these countries, the little existing information does support the findings. Other studies are ongoing and more results should be available soon.

Latino AIDS Commission to Honor Dr. Mathilde Krim May 13,2008

On May 13, the Latino AIDS Commission will honor leaders in the fight against HIV/AIDS at their annual gala, Cielo Latino. amfAR Founding Chairman Dr. Mathilde Krim will accept the Fuerza Award for her commitment to stopping the spread of HIV/AIDS.

Cielo Latino is the largest annual national fundraiser for the Latino community in its fight against HIV/AIDS. In its 13th year, Cielo Latino is a prominent and highly visible platform for leaders in business, government, entertainment and the media to showcase their philanthropy for AIDS.

Thursday, May 13th, 2008
Cipriani Wall Street
55 Wall Street
New York, NY 10005

Inaugural Dubai Event Raises $3 Million to Support amfAR's AIDS Research Programs and Raise Awareness about HIV/AIDS

Gala Event Presented by the Dubai International Film Festival and Sponsored by Dubai Pearl; Hewlett-Packard Company and Alfiya Kuanysheva Were Grand Patrons.

Dubai, UAE, December 11, 2007 - Sharon Stone, Michelle Yeoh, Kenneth Cole, Hayden Christensen, Rachel Bilson, Paulo Coelho, Gloria Estefan, Dana Fuchs, Christian Louboutin, and Dita Von Teese came out to raise awareness about HIV/AIDS last night at amfAR's inaugural Cinema Against AIDS gala in Dubai. The event, which was presented by the Dubai International Film Festival, raised $3 million for amfAR, The Foundation for AIDS Research. Dubai Pearl was the event’s sponsor, and the grand patrons were Hewlett-Packard Company and Alfiya Kuanysheva.

Among other guests who attended the gala at the Jumeirah Bab Al Shams Desert Resort and Spa were Abdul Majid al Fahim (chairman of Dubai Pearl), Abdulhamid M. Juma (chairman of the Dubai International Film Festival), Pooja Batra, Kabir Bedi, Akbar Khan, and Sarah Shahi.
The evening opened with remarks by amfAR CEO Kevin Frost. Thanking those in attendance, Frost said, “no action that you take has greater potential to bring an end to the global AIDS pandemic than what you do tonight in support of AIDS research.” Frost then introduced amfAR Ambassador Michelle Yeoh, who spoke about amfAR’s Treat Asia Initiative and the power of cinema to engender cross-cultural understanding. Both Abdul Majid al Fahim and Abdulhamid M. Juma spoke about the importance of funding research to find a cure for HIV/AIDS.

Later in the program, amfAR Chairman Kenneth Cole recognized the vision of the Dubai International Film Festival and thanked the organizers for joining amfAR as a partner in the fight against HIV/AIDS. He then introduced amfAR Global Fundraising Chairman Sharon Stone, who spoke about the importance of remembering that HIV/AIDS affects everyone. Stone began the live auction by raising bids to $55,000 for a custom Louis Vuitton Vanity Case that she designed.

Five-time Grammy Award-winning Cuban-American singer and songwriter Gloria Estefan provided a surprise performance, singing her hit “Cuts Both Ways.” During a break in the auction, Across the Universe star Dana Fuchs performed “The Rose.” Celebrity portraitist Brian Olsen then created a one-of-a-kind Marilyn Monroe portrait during the event, which was later auctioned off for $200,000.

Estefan closed the evening’s festivities by joining Dana Fuchs and Sharon Stone to sing the Beatles’s “Let It Be”. A fireworks display and an after-party featuring DJ Mateo ended the evening.

Other highlights of the auction:
Sharon Stone’s vintage 1961 Lincoln Continental, refurbished to mint condition, sold for $400,000.
Sharon Stone auctioned a private screening in Beverly Hills, followed by a private dinner with her at Spago Beverly Hills, courtesy of ce¬lebrity chef Wolfgang Puck, for $110,000.
The Dior Christal Unique Timepiece by Dior Watches sold for $200,000.

The Trench of Stars by Ottavio Fabbri, a fabulous limited edition crystal-encrusted silk trench coat, sold for $10,000.
The Voodoo Omen Gold-Edition Hewlett-Packard’s Custom-Built Gold-Plated Personal Gaming Computer sold for $45,000.
The Jumeirah/Emirates Vacation for Two–which included five nights in a suite in any Jumeirah hotel in New York, London, Dubai, or the soon-to-open Shanghai property, as well as round-trip business class airfare–sold for $30,000.
amfAR's annual Cinema Against AIDS galas have been important and successful fund-raising events for the Foundation since 1993, generating more than $33 million for essential AIDS research. Past events have been hosted by Dame Elizabeth Taylor, Sharon Stone, Demi Moore, and Sir Elton John.

amfAR, The Foundation for AIDS Research, is one of the world’s leading nonprofit organizations dedicated to the support of AIDS research, HIV prevention, treatment education, and the advocacy of sound AIDS-related public policy. Since 1985, amfAR has invested $260 million in its programs and has awarded grants to more than 2,000 research teams worldwide.

Senator Hillary Clinton on World AIDS Day 2007

"Today, on World AIDS Day we are reminded that AIDS is not just an African problem, an Asian problem, or an American problem. It's not someone else's problem. It's a problem of our common humanity, and we are called to respond, with love, with mercy, and with urgency. And though we have made progress on many fronts, there are still 33 million people living with HIV/AIDS around the world, and here in America, HIV infection rates are rising among gay men and African Americans. The disease is taking a disproportionate toll on other communities of color, and it is an outrage that HIV/AIDS is the leading cause of death of black women between the ages of 25 and 34. The time for action and leadership is now.


"That is why I have called for a doubling in funding for research for new treatments and a vaccine as well as investments in prevention, education, and access to treatment and other services. I have also proposed to increase funding for the global HIV/AIDS fight to at least $50 billion by 2013.
"But neither money nor government alone will solve this problem. We must all work together to care for those who are infected and their families, remove the stigma by showing it's not a sin to be sick, and encourage prevention and promote healthy behaviors. Then and only then will we be able to declare victory for this pandemic."

Scaling up HIV Prevention

Global HIV incidence may have peaked, but calls for scaling up prevention have not diminished. The number of new infections worldwide remains high (4.1 million in 2005) with some regions previously unscathed experiencing rising incidences of HIV.

2 The number of patients presenting late at health facilities with advanced HIV/AIDS is also a cause of concern. In general, there is a growing sense of frustration that global efforts to prevent HIV/AIDS are being outpaced by the spread of the pandemic.

3 Consequently, calls have been made for a more pragmatic approach to containing the disease, with routine and mandatory testing gaining increasing attention. The US Centers for Disease Control and Prevention (CDC) recently proposed a new approach for HIV testing in adults, adolescents and pregnant women under which testing will be routinely offered in all health-care settings. No signed consent from patients would be required under this new proposal; the general consent for medical care would be considered sufficient to encompass consent for HIV testing

.4,5 Former US President Bill Clinton has also lent support for mandatory HIV testing in countries where the prevalence rate is 5% or higher

.6 Political support for mandatory testing has been seen in countries like India, where the state government of Goa has proposed mandatory premarital testing, and in China, which plans to test all workers in the tourism industry.

HIV Medicine Association

HIV Medical Provider Medicare Part D Survey
April 2007

The American Academy of HIV Medicine (AAHIVM) and the HIV Medicine Association (HIVMA) recently conducted a survey of their HIV medical provider members to obtain information on how Medicare’s new prescription drug benefit, also known as Part D, has affected HIV care today. Medicare has historically been an important source of health insurance coverage for people with HIV/AIDS, and stands to play an even greater role as a result of the new prescription drug benefit. As of January 1, 2006, all people on Medicare were given access to the new Part D benefit and people with Medicaid and Medicare coverage were automatically enrolled in the new program.

INTRODUCTION
Through the passage of the Medicare Modernization Act of 2003, Medicare now offers prescription drug coverage to its elderly and disabled beneficiaries, including approximately 100,000 Medicare beneficiaries with HIV/AIDS. Even before the prescription drug benefit, Medicare was the second largest source of federal funding for HIV care and treatment behind Medicaid. Through the extension of drug coverage, Medicare plays an even more important role in the disease management of people living with HIV/AIDS in America.

By now most Americans are familiar with the dramatic improvements in the treatment of HIV infection that have reduced mortality due to the disease by nearly 80 percent. What was once almost always considered a fatal diagnosis; HIV disease can now be managed with consistent and reliable access to a combination of medications known as highly-active antiretroviral therapy (HAART) medications.

These medications are critical to the health and well-being of patients infected with HIV/AIDS; however, successful viral suppression demands strict adherence to a complex drug regimen that requires multiple doses of three or more highly expensive medications daily. In addition, antiretroviral medications are simply not interchangeable with one another due to individual physiological factors and differences in toxicity, efficacy, drug interactions, and potential drug resistance. As a result, it is critical that people with HIV/AIDS maintain unhindered access to all of the FDA-approved medications available to treat the disease and its complications. Beyond viral suppression, people with HIV disease often must contend with opportunistic complications and serious co-occurring conditions such as hepatitis C and mental illness.

The Centers for Medicare & Medicaid Services (CMS) has recognized that these concerns make the HIV-infected population particularly vulnerable and has included antiretrovirals as one of six protected drug classes for which Part D plans are required to cover “all or substantially all drugs” available. Specifically, the formulary guidance in effect during our survey period required drug plans to cover all drugs available in the antiretroviral class available on January 1, 2006 and prohibited plans from applying utilization management techniques such as prior authorization to these drugs with the exception of enfuvirtide (Fuzeon).
Prescription drug coverage through Medicare Part D is complicated for Medicare beneficiaries with HIV/AIDS by the fact that a majority of them are also enrolled in other safety-net programs. An estimated 80,000 are dually eligible for both Medicaid and Medicare and were automatically enrolled in Medicare Part D. Many also received assistance from the Ryan White CARE Act’s AIDS Drug Assistance Program (ADAP) prior to the availability of Medicare Part D. Beginning in January 2006, ADAPs were required to enroll all eligible ADAP beneficiaries into Medicare Part D. Some state ADAPs were able to supplement the Medicare Part D coverage by paying co-pays, deductibles, premiums, and/or coverage for beneficiaries in the doughnut hole. However, since payments made by ADAPs on behalf of Medicare beneficiaries do not count toward the true out of pocket cost limit known as “TrOOP” many states could not afford to help Medicare beneficiaries with these expenses.

Given these complex interactions among payors, patients, plans, and providers, the HIVMA and AAHIVM conducted a joint survey of their memberships to ascertain how the Medicare Part D program is working for HIV medical providers and their patients living with HIV/AIDS. Included below is a summary of the survey findings as well as recommendations for improving the Medicare drug benefit to help alleviate ongoing implementation issues.
_____________

SURVEY METHODOLOGY
The survey was administered online through a web-based survey engine. The sample for the survey was created through a de-duplication of the membership lists of HIVMA and AAHIVM and totaled 3378 HIV medical providers. The preliminary findings are based on the 561 responses received as of November 27, 2006 to the 44-question online survey and represent a 17% response rate. Ninety-one percent of respondents were HIVMA or AAHIVM members and the remainder were their proxies.

Due to the design limitations of the survey, the results and conclusions (while highly illustrative) cannot be generalized to the entire population of our memberships or to all HIV medical providers.
_____________
KEY FINDINGS
Clinic/Practice Characteristics
• 64% of respondents worked at clinics that treat more than 400 patients (HIV and non-HIV).
• 39% worked at clinics with more than 400 patients with HIV/AIDS.
• 54% worked at clinics that received Ryan White CARE Act funding.
• 81% reported having at least “some” patients with Medicare Part D coverage.
• 88% of the respondents that have patients with Medicare Part D coverage reported having at least “some” patients who were enrolled in Medicaid and Medicare.
In addition:
• 26% worked in private practice
• 24% worked in a hospital-affiliated clinic
• 21% worked in a university academic medical center
Respondent Characteristics
• 66% identified as male
• 78% identified as white
• 82% identified as physicians

The following data are based on the 452 respondents that indicated that they see HIV patients with Medicare Part D coverage.
Medicare Part D Drug Plans are not meeting the needs of beneficiaries with HIV/AIDS.
• 83% of respondents reported that their patients had experienced problems getting their prescriptions since joining a Medicare drug plan. Of those reporting problems for their patients with HIV/AIDS:
o 80% reported one or more of a patient’s drugs were subject to prior authorization.
o 76% reported one or more of a patient’s drugs were not covered by their plan’s formulary.
o 73% reported that patients could not afford the co-payments/cost-sharing requirements.
o 46% had patients that had problems getting enrollment cards or letters.
o 44% reported that a patient’s drugs were subject to quantity limits.

Graph # 1: Percentage of Survey Respondents Reporting Problems Filling Part D prescriptionsPriorAuthorizationNot onformulary Unaffordablecost-sharingEnrollmentproblemsQuantitylimits on Rx377 participants (86% of surveyrespondents) reported that their Medicare patients had problem sfilling prescriptions under Part D.This chart indicates the percentageof those 377 who reported thesespecific problems.

People with HIV/AIDS experienced lapses in medications due to Part D problems.
• Of those reporting problems with Part D, 75% reported that patients with HIV/AIDS went without medications due to Part D problems. Of those that reported on specific medication lapses:
o 65% reported patients with HIV/AIDS going without antiretrovirals as well as other medications.
o 11% reported patients with HIV/AIDS going without only antiretrovirals
o 24% respondents reported patients with HIV/AIDS going without only non-antiretroviral medications.
Problems with Part D coverage led to unscheduled medical visits and other adverse health consequences for some patients.
• 60% of respondents that reported problems indicated that patients with HIV/AIDS came in for unscheduled or extra medical visits due to Part D problems.
• 28% of respondents that reported problems indicated that patients with HIV/AIDS experienced other adverse health consequences due to Part D problems.
• For those that reported problems, the percentage of respondents reporting that patients with HIV/AIDS had trouble accessing medications included: antiretroviral medications (54%); mental health medications (55%); cholesterol medications (55%); pain medications (46%); medications for HIV-related opportunistic infections (36%); hypertensive medications (35%) and hepatitis medications (22%).
Graph # 2: Problems with Medicare Part D Prescriptions: By Drug Type
0%10%20%30%40%50%60%70%80%90%100%ARVsMental HealthmedsCholesterolmedsPain medsHIV-related OImedsHypertensivemedsHepatitis medsBy each type of drug, percentage of the377 (86% of all surveyed) respondentswho reported problems their Medicarepatients had filling their Rx.

Some drug plans are requiring prior authorization for antiretrovirals.
• 45% of respondents reported that they had requested prior authorization for an antiretroviral medication.
HIV medical providers find the administrative burden associated with Part D is greater than it is for other insurance plans.
• 69% of respondents indicated that the administrative burden under Part D is “worse” than that required for other insurance plans, including Medicaid.
• 79% of respondents indicated that the amount of time spent ensuring Medicare patients get access to drugs has increased – 36% reported that the time increased substantially.
Many dual eligibles are worse off under Medicare Part D and now pay more for their prescription drugs.
• 48% of respondents reported that their dual eligible patients with HIV/AIDS were worse off under Medicare Part D; 40% reported drug coverage for their dual eligible patients stayed the same; and 9% reported drug coverage improved for their dual eligible patients.
• 58% of respondents reported that out-of-pocket costs increased for their dual eligible patients with HIV/AIDS; 34% reported that costs stayed the same; and 5% reported that costs decreased.
Overall Impressions
• 57% of respondents indicate that they understand Part D “very well” or “somewhat well.”
• 63% of respondents indicated an “unfavorable” impression of Medicare Part D; 24% reported a “neutral” impression of Medicare Part D and 12% reported a “favorable” impression.
____________
CONCLUSIONS and RECOMMENDATIONS
HIV medical providers reported challenges obtaining antiretroviral and non-antiretroviral medications for their Medicare patients with HIV/AIDS. Many of the problems appear to stem from complex and in some cases inappropriate prior authorization processes; high prescription drug co-payments; and inadequate formulary coverage of non-antiretroviral medications – particularly for cholesterol medications, pain medications, medications for HIV-related opportunistic infections and hypertensive medications. These problems occurred despite the protections for antiretrovirals and the five other drug classes included in the Centers for Medicare and Medicaid (CMS) 2006 and 2007 formulary guidance.
Of particular concern is the high percentage of HIV medical providers that reported that their patients that are dually eligible for Medicare and Medicaid are worse off under Medicare Part D. Dual eligibles with HIV/AIDS by virtue of qualifying for both programs live on very low monthly incomes and have been disabled for more than two years. With Medicaid drug coverage, this population had access to an open drug formulary and in many states were not subject to cost-sharing. (If they were subject to cost sharing, Medicaid law ensures that beneficiaries are not denied access to drugs or other services due to an inability to pay cost-sharing.) Better monitoring of the dual eligible population is needed along with stronger protections to ensure that they maintain reliable access to lifesaving drug therapies.

While our findings are limited by the relatively small pool of respondents, the numerous challenges and negative outcomes raised warrant further attention. Some issues such as the burdensome prior authorization processes should be addressed administratively by CMS; while others such as formulary inadequacies and prohibitive cost sharing require the U.S. Congress to intervene legislatively.

Nearly 100,000 Medicare beneficiaries have HIV/AIDS. Their lives depend on consistent and affordable access to these medications. We must do everything we can to ensure the health and well-being of this most-vulnerable population.
____________
ACKNOWLEDGEMENTS
Jennifer Kates and Alicia Carbaugh with the Kaiser Family Foundation provided input on this project. AAHIVM and HIVMA greatly appreciate their insights and contributions.

FOR MORE INFORMATION
Together the American Academy of HIV Medicine and the HIV Medicine Association represent nearly every experienced HIV medical provider in the United States. For more information or to see the original survey design, please contact Andrea Weddle with HIVMA at (703) 299-1215 or Greg Smiley with AAHIVM at (202) 659-0699 or visit either website at www.hivma.org or www.aahvim.org

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"AIDS is more than a health issue" according to new UNAIDS chief Michel Sidibe and should be seen as a political opportunity to spark changes in society to talk more about issues like human rights, homophobia and sex education.

AIDS Quilt photography by diane knaus copyrighted

The AIDS Quilt Opened in 1992 in WAshington, D.C.

Photo by Diane Knaus

 

Sharing Needles Makes the AIDS Virus Numbers of Infected People Go Up

According to Dr. Jeffrey Laurence is amfAR's senior scientific consultant for programs,A substantial portion of the AIDS epidemic in the U.S., much of Eastern Europe, and Asia is driven by injection drug use—specifically by users sharing contaminated equipment. Contaminated syringes account for 17 percent of new HIV infections in the U.S. and 10 percent of new cases worldwide.

However, the Centers for Disease Control and Prevention (CDC) estimates that two out of three such infections could be prevented if drug users had access to clean needles and “works,” the paraphernalia injection drug users use he claims.

December 1 is World AIDS Dayphoto taken in Landsing,Mi by photographer diane knaus copyrighted

Graphics Supplied by the U.N.

DS Keep The Promise

photo in Landsing,Mi by diane knaus photographerSupporting AIDS Campaigning Globally

The AIDS epidemic is a global emergency that affects people in every country on earth. UNAIDS estimates that, by the end of 2005, a total of 25 million people had died of AIDS since it was first recognised in 1981. In 2005 alone, some 38.6 million people were living with HIV, 4.1 million people were newly infected and 2.8 million people lost their lives.

Treatment of HIV-1 infection

Formulation Marks The First One Capsule, Once Daily Protease Inhibitor Dosing Option for Use With Ritonavir In Appropriate Patients -

PRINCETON, N.J., Oct. 20 /PRNewswire-FirstCall/ -- Bristol-Myers Squibb Company (NYSE: BMY) today announced that the U.S. Food and Drug Administration (FDA) has granted approval of a new 300 mg single capsule formulation of REYATAZ® (atazanavir sulfate) for the treatment of HIV-1 infection in adults as part of combination therapy. Taken once daily along with ritonavir and food as part of a anti-HIV drug regimen, the REYATAZ 300 mg single capsule formulation can replace two REYATAZ 150 mg capsules for: patients who have previously received anti-HIV medicines, patients who will be receiving tenofovir disoproxil fumarate, and patients who have never taken anti-HIV medicines that require SUSTIVA® (efavirenz) as part of their anti-HIV drug regimen. The REYATAZ single capsule formulation will be available in the United States within seven business days.REYATAZ is an anti-HIV drug that blocks the action of the HIV protease enzyme, which is needed for the virus to multiply. REYATAZ is a prescription medicine used in combination with other medicines to treat people who are infected with HIV. REYATAZ has been studied in 48-week trials in both patients who have taken or have never taken anti-HIV medicines. REYATAZ does not cure HIV, a serious disease, or help prevent passing of HIV to others. Since REYATAZ was initially approved by the FDA in 2003, approximately 129,000 patients in the United States have been treated with the drug. Bristol-Myers Squibb will continue to produce the currently available REYATAZ 200 mg, 150 mg, and 100 mg once-daily capsules.
Important Safety Information About REYATAZ® (atazanavir sulfate) 300 mg Capsules:

REYATAZ does not cure HIV or help prevent passing HIV to others.

REYATAZ should not be taken with the following medicines: ergot medicines, Versed®, Halcion®, Orap®, Propulsid®, Camptosar®, Crixivan®, Mevacor®, Zocor®, rifampin, St. John's wort, AcipHex®, Nexium®, Prevacid®, Prilosec® or Protonix®. Viagra®, Levitra®, Cialis®, Vfend®, Advair®, Flonase®, or Flovent® should not be used while taking REYATAZ without first speaking with a healthcare provider. This list of medicines is not complete. The use of all prescriptions and non-prescription medicines, vitamins, herbal supplements, or other health preparations should be discussed with a healthcare provider.

Prevention Takes Center Stage at International AIDS Conference

August 29, 2006 - The theme was “Time to Deliver,” but the message at the XVI International AIDS Conference was as much about preventing new infections as it was about treating people already living with HIV/AIDS. The week-long conference, in Toronto August 13-18, was the largest ever held, bringing together close to 30,000 delegates from around the world.

“Just as no government organization can win the fight against AIDS alone, prevention, care, and treatment are intertwined,” said former U.S. President Bill Clinton. “And we cannot realize universal treatment, let alone stop AIDS, unless we also see prevention as a part of a mutually dependent strategy.”

Putting Prevention in the Hands of Women
Close to half of all new HIV infections worldwide are now occurring in women. Standard prevention messages, which teach women either to abstain from sex or to use condoms within a mutually monogamous relationship, are not realistic in societies and cultures in which women cannot dictate their own sexuality or their partner’s sexual behavior.

“Gender inequality is driving the pandemic, and we will never subdue the gruesome force of AIDS until the rights of women become paramount in the struggle,” said Stephen Lewis, U.N. Special Envoy for HIV/AIDS in Africa.

For this reason, HIV prevention technologies that women could control, such as microbicides, have emerged as critical components of the fight against this epidemic. Five different microbicides are currently being tested in late-phase trials on thousands of women in Africa. Results of those clinical trials will be announced in 2008. In other news, researchers also conducted a small safety trial of a vaginal ring that surrounds the cervix and slowly releases an antiretroviral compound while it is in place. Dr Joe Romano, of the International Partnership for Microbicides, reported that the ring is safe and releases the drug so that it covers the cervix, vagina, and introitus, all of which bodes well for further development of this technology.

Treatment as Prevention
Dr. Leigh Peterson of Family Health International presented results of the world’s first completed trial of pre-exposure prophylaxis, using antiretroviral drugs to prevent HIV infection. He reported that 936 uninfected women were randomized to receive either the anti-HIV drug tenofovir or placebo. The study was designed primarily to test the safety of giving healthy people a daily dose of tenofovir, but researchers also hoped to retrieve some preliminary indication of its efficacy in reducing HIV transmission. There were no serious adverse effects among the group who took the study drug, but in terms of preventing HIV infection, not enough women became infected to know whether tenofovir conferred any protective effect.

Dr. Julio Montaner, director of the British Columbia Centre for Excellence in HIV/AIDS, gave a presentation demonstrating how highly active antiretroviral therapy (HAART) could be used to reduce transmission of HIV.

“This is not HAART instead of prevention,” he said. “This is HAART to enhance prevention.”
In sero-discordant couples, in which one person is infected and the other is not, the negative partner is much more likely to acquire HIV if the positive partner has a high level of virus in his or her blood. There is a strong possibility that because HAART lowers viral load, it may also reduce the risk of transmission, he said.

Data from British Columbia showed that after highly active antiretroviral therapy became widely used in 1996, new HIV infections dropped while syphilis rates—also a sexually transmitted infection—continued to rise.

“We cannot afford to ignore the prevention value of HAART, or how it can synergize with traditional prevention methods and some of the newer methods that have been explored,” Montaner said.

Debating the Merits of Male Circumcision

Male circumcision has also emerged as a potentially promising HIV prevention method ever since a South African study last year showed that the procedure might reduce the risk of HIV acquisition in heterosexual men by as much as 60 percent. Two major trials of male circumcision are currently under way in Kenya and Uganda, with results expected in 2007 and 2008. The World Health Organization and UNAIDS are awaiting the results of these trials before deciding on any broad-scale implementation of the procedure.

But these trials do not test for variables of cultural and ethical values, say some experts. In public health, there are many interventions—such as quarantine for infectious diseases—that are effective but are not implemented because of human rights concerns, said Gary D. Dowsett, of La Trobe University in Melbourne, Australia, during an amfAR-sponsored presentation on HIV among men who have sex with men.

On the Road to Mexico City in 2008

The next International AIDS Conference will take place in Mexico City, in a part of the world that is grappling with not just the health repercussions of HIV, but also the socio-political dimensions of the epidemic.

“Latin America is faced with many challenges in its response to HIV—an urgent need for prevention” and “a lack of infrastructure to ensure access to antiretrovirals,” said Luis Soto Ramirez, regional International AIDS Society representative in Mexico. “We will talk at AIDS 2008 about human beings, each of whose life has equal value: whether you are gay or straight, sex trade worker or stay-at-home mom, black or white, mestizo or native, rich or poor, young or not so young.”

UN AIDS Actions

On 2 June 2006, Governments injected new momentum into the fight against AIDS.  At a High-Level Meeting of the United Nations General Assembly, they adopted a Political Declaration, in which they committed themselves to a range of actions vital to our struggle.  They pledged to tackle the causes and forces that propel this epidemic, most especially by promoting gender equality, the empowerment of women and the protection of girls.

 They also stressed the need to respect the full rights of people living with HIV.  They called for strengthened protection for all vulnerable groups -- whether young people, sex workers, injecting drug users or men who have sex with men.  They called for provision of the full range of HIV prevention measures, including male and female condoms and sterile injection equipment.  And they called for the full engagement of the private sector and civil society, including people living with HIV.

It is my hope that with the Declaration, world leaders have finally placed on record the personal commitment and leadership needed to win the fight against AIDS -- the greatest challenge of our generation, and of the next.  Only if we meet this challenge can we succeed in our other efforts to build a humane, healthy and equitable world.  Only if we win this fight can we reach the Millennium Development Goals, agreed by all the world’s Governments as a blueprint for building a better world in the twenty-first century.

Johns Hopkins Hospital New Report on AIDS drug

Early results from a large study of HIV-infected people in rural Uganda show that seven out of 10 who got free, emergency access to antiretroviral drugs successfully suppressed the AIDS virus in their blood to nearly undetectable levels.  The findings are being presented by researchers at Johns Hopkins and the Rakai Health Sciences Program who are leading the study.

Access to the drugs, provided at a reduced cost of less than $400 per year to Ugandan aid organizations, comes from the President’s Emergency Plan for AIDS Relief (PEPFAR), inaugurated in January 2003.  PEPFAR currently provides free access to drug therapy for approximately 400,000 people in sub-Saharan Africa infected with HIV, treatments that can cost upwards of $12,000 per year in the United States. See Health Page for additional info

According to the Henry J. Kaiser Foundation

Since the first cases of what would later become know as AIDS were reported in the United States in June 1981, approximately 1.5 million people in the U.S. have been infected with HIV, including more than 500,000 who have already died. This updated fact sheet presents an overview of the HIV/AIDS epidemic in the U.S., including a snapshot of the epidemic, key trends and current cases, and the U.S. government response.

The Top Ten Cities Having the Largest Numbers of AIDs cases in 2003 are:New York,California,Florida,Texas,New Jersey,Illinois,Pennsylvania,Puerto Rico,Gerogia, and Maryland.

Women account for the top rising AIDS diagnoses rising from 8% in 1985 to 27% in 2003.


Data Resistant

2001 (SACRAMENTO, Calif.) -- In a blow to critics of syringe-exchange programs, a new UC Davis study shows that the controversial programs do reduce injection drug users' HIV risk. The study appears in the July 27 issue of AIDS.

"Our review of the literature should blunt the claims of opponents of syringe exchange, but I'm not optimistic that it will," said lead author David R. Gibson, associate professor of infectious diseases at UC Davis and a senior scientist at UC San Francisco's Center for AIDS Prevention Studies. "Opponents of syringe-exchange programs can be quite data-resistant."

UC Davis researchers scoured the medical literature from 1989 to 1999 for studies examining the impact of exchange programs on HIV risk. The search turned up 42 published studies, most of them conducted in the United States, Canada, the United Kingdom and the Netherlands. Twenty-eight of the studies concluded that syringe-exchanges reduce HIV risk among injection drug users.

Of the remaining 14 studies, two found that the programs increase HIV risk, and 12 concluded the programs either have no effect or a mixture of both positive and negative effects.
Gibson and his co-authors found that the 14 negative and equivocal studies all looked at syringe-exchange programs in settings -- primarily in Canada, the United Kingdom and the Netherlands-- where injection drug users can legally purchase low-cost syringes at pharmacies. In contrast, only five of the 28 positive studies were conducted in such communities.

"If you exclude the studies that took place in communities where clean syringes are also available from pharmacies, 28 out of the 29 studies remaining show that syringe exchange is protective against either HIV risk behavior and/or HIV seroconversion," Gibson said.

Syringe-exchange programs in communities where clean needles can be obtained from other sources can be expected to appear less effective than programs that constitute a community's only source of clean syringes, Gibson argues.

Researchers call this effect "dilution bias." A program to provide free fluoride supplements to children who already drink fluoridated water, for example, might have no impact on tooth decay rates. But the same program, implemented in a population with no alternate source of fluoride, would decrease those rates.
Besides dilution bias, another factor complicates the evaluation of syringe-exchange programs in areas where clean needles are available from other sources. Researchers have found that in areas where drug users have a choice, the higher-risk drug users tend to gravitate to the syringe-exchange programs. This, too, can make syringe-exchange programs appear less effective.

Another possible explanation for the negative and equivocal study findings is that syringe-exchange programs, while helpful, may not be sufficient to prevent spread of HIV among injection drug users in all communities.

Among the 28 positive studies, beneficial effects were often substantial. Studies of syringe exchanges in San Francisco; Portland, Ore.; Tacoma, Wash.; and Baltimore all concluded that the programs decreased needle sharing among injection drug users ranging from 16 percent to 72 percent. In a different type of study, researchers compared overall HIV seroconversion rates among injection drug users in cities with and without syringe exchanges. Seroconversion rates decreased 5.8 percent a year in the cities with the programs, but increased by 5.9 percent a year in the cities without them.

Perhaps the most direct evidence supporting needle exchange comes from studies in the early 1990s of an exchange program in New Haven, Conn. When injection drug users exchanged used syringes for new ones in that program, researchers tested the returned syringes for HIV. They found that as the volume of syringes exchanged grew, the time it took for the syringes to return to the exchange fell substantially--meaning used, potentially infectious syringes spent less time in the community. As a result, in the first three months of the program's operation, the percentage of HIV-infected syringes dropped by about a third, from 67 percent to 44 percent.

Injection drug use now accounts for nearly one-third of new AIDS cases in this country. When drug users' sexual partners are included, injection drug use accounts for up to three-quarters of new HIV infections. The infection spreads via shared use of injection equipment and other drug paraphernalia, as well as through unprotected vaginal and anal intercourse.

The world's first needle exchange program was established in Amsterdam in 1984 by the local Junky Union and was soon taken over by the Amsterdam Municipal Health Service. Other European countries, Great Britain and Australia soon followed suit.
In the United States, more than 100 syringe-exchange programs now operate in 30 states and 80 cities. The programs have been growing at a rate of about 20 percent per year. In 1997 alone, more than 17 million needles or syringes were exchanged through these programs.

Yet the programs have remained controversial. In the 1980s, recipients of grants from the National Institute on Drug Abuse were banned from conducting research into needle exchange. Such research may be awarded federal grants today, but a congressional funding ban still prevents any federal support of exchange programs themselves.

In recent years, critics of syringe exchange have seized on the two negative studies to bolster their opposition. Both studies were conducted in Canada, in settings where pharmacies also dispensed syringes.
One of the negative studies, published in 1997, followed a group of IV drug users in Montreal for about two years. The drug users who participated in a syringe-exchange program were 1.7 times more likely to become HIV positive during the study compared with those who did not participate.

However, the Montreal researchers reported last year at a San Francisco AIDS meeting that more recent data show no relationship between syringe exchange participation and HIV seroconversion.
The second negative study, also published in 1997, found that IV drug users who visited an exchange program in Vancouver, British Columbia, more than once a week were 10 percent more likely than non participants to be HIV positive.
But a later study, conducted in the same setting, found that when additional factors were controlled for, this association disappeared.

Both the Montreal and Vancouver studies were conducted at sites where drug users had legal access to syringes both from pharmacies as well as syringe exchange, making it difficult to assess the impact of syringe exchange in the two cities.
In their review, Gibson and his co-authors did not attempt a formal meta-analysis of the 42 studies; the studies' methods and outcome measures differed too markedly. Instead, they appraised the strengths and limitations of the studies in such areas as adequacy of statistical controls, statistical power and other factors.

To settle the still-simmering debate over syringe-exchange programs, Gibson says future studies should more rigorously deal with confounding factors, including dilution bias.
Neil Flynn, professor of clinical medicine at UC Davis, and Daniel Perales, associate professor of public health at San Jose State University, are co-authors of the study.

The research was funded with grants from the National Institute on Drug Abuse, the National Institute of Mental Health, and the United States Public Health Service.
Copies of all news releases from UC Davis Health System are available on the Web at http://news.ucdmc.ucdavis.edu

WHO

The world health report: Working together for health
Related links2006: A review of major health issues In 2006, both The world health report and World Health Day focused on health workers. The creation by WHO and other partners of the Global Health Workforce Alliance and the adoption by the World Health Assembly of resolutions calling for a response to this crisis have paved the way towards better recognition for the vital role health workers play within health systems. There are currently 57 countries with critical shortages of health workers which prevent them from delivering vital interventions such as vaccination of children, ante-natal and obstetric care and treatment of HIV/AIDS, malaria and tuberculosis. Today, the figures speak for themselves. There is a shortage of more than four million physicians, nurses, midwives, support staff and public health workers to meet the needs of these countries, 36 of which are in sub-Saharan Africa.

Treating people with HIV/AIDS

In December 2003, WHO and UNAIDS launched the "3 by 5" initiative. Three years later, access to HIV treatment has increased three-fold, but major challenges still remain. In June, 2006, 1.65 million people were receiving treatment in low- and middle-income countries, in comparison with 400 000 in December 2003. Sub-Saharan Africa was the first to benefit from the expansion of treatment. Several lessons learnt from the effort to expand treatment have provided us with valuable guidance for the continuation of efforts towards universal access to treatment. In August 2006, the Sixteenth International AIDS Conference put the accent on the balance between prevention, treatment and care.

In the words of Dr Anders Nordström, WHO Acting Director-General, on World AIDS Day, "The AIDS epidemic provides us with clear evidence that even some of the most complex health and development problems can be successfully addressed. To see this positive pattern repeated everywhere will take greater political will and more resources. …We do not just need more. We need to commit to clear sightedness about what is working and what is not - and quickly apply that knowledge."

This year, WHO welcomed the launch of UNITAID, the International Drug Purchase Facility established by Brazil, Chile, France, Norway and the United Kingdom. UNITAID is an innovative funding and resource-mobilization mechanism. Its purpose is to guarantee reliable and sustainable supplies of drugs and diagnostics for the most common diseases.

Does male circumcision reduce the risk of HIV infection? Several trials under way in Kenya, South Africa and Uganda appear to show that circumcision does reduce risk. In the light of these findings, WHO and UNAIDS will shortly be organizing a broad consultation to examine the results of the trials and their implications for countries and for AIDS control.

All children worldwide have the potential to grow the same

New international Child Growth Standards for infants and young children were published by WHO. They provide guidance for the first time about how every child in the world should grow. The new standards prove that differences in children's growth to age five are more influenced by nutrition, feeding practices, environment and health care than by genetics or ethnicity. It took WHO almost 10 years to develop the new standards, the previous ones having been in existence since the 1970s. 1970s.

The World AIDS Programm Says

Keep The Promise

The fight against AIDS is over twenty five years old. Throughout this struggle, campaigners have galvanized action and protested against inaction. In the current era, national leadership on AIDS is being supported as never before. AIDS organisations are proliferating. Campaigners still speak out on a multitude of issues – yet one overarching campaign, the World AIDS Campaign, links their concerns at the global level.

The World AIDS Campaign fights to ensure that campaigning voices, north and south, continue to be heard. The World AIDS Campaign works to create solidarity and collaboration between campaigners, ensuring impact at the local and international level. The AIDS sector is now huge, spending billions of dollars a year. Yet this effort can not afford to lose the energy, innovation or public awareness campaigners bring.

The World AIDS Campaign will protect and support the voices of campaigners worldwide.

The most visible aspect of the work undertaken by the World AIDS Campaign is World AIDS Day, a day of global shared action and awareness on AIDS. However, our work does not stop here. Throughout the year the World AIDS Campaign works to connect and strengthen campaigning voices across the globe.
In all our work, we start with the premise that civil society is central in meeting the challenges of the AIDS epidemic. We recognize that professional non-government agencies represent only one small part of civil society. Faith communities, labour and youth organisations and other large scale, grass-roots movements are integral to our efforts. We work through a range of partnerships to ensure our campaigning voice captures the aspirations of these different constituencies.

The primary campaigning objective of the World AIDS Campaign, from 2005 to 2010 is to make sure policymakers keep their promises on AIDS. Accountability is also the specific theme we are promoting for World AIDS Day 2006. The theme for World AIDS Day next year may change. It will once again be selected through consultations with partners. Yet for the World AIDS Campaign our underlying objective will remain centred on accountability, and the slogan, Stop AIDS. Keep the Promise. will continue to guide our work.

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