February 10, 2006

This Week in Washington
1. President Releases FY 2007 Budget, Requests Increases for HIV Funding

In the News
1. Study Finds Health Outcomes Better with Early Treatment
2. The New York Times: Supportive of Changing Laws to Broaden HIV Testing and Treatment

Announcements
1. Medicare Part D Beneficiaries Encouraged to Share Experience Using the New Benefit

This Week in Washington
1. President Releases FY 2007 Budget, Requests Increases for HIV Funding
On Monday, February 6, the White House released the President’s budget request for fiscal year 2007. The President’s budget request kicks off the annual budget process, during which Congress sets spending limits that then guide the appropriations process (when Congress actually allocates money to programs). Through his budget request, which is prepared in consultation with the agency heads and the Office of Management and Budget (OMB), the President provides Members of Congress with a suggestion of how they should set spending limits. It is not a legally binding document.

Every year on the same day that the budget is released, the Department of Health and Human Services (HHS) holds a press conference to announce the President’s requested allocations for HHS programs. Since nearly all domestic HIV programs fall within the HHS portfolio (Housing Opportunities for Persons with AIDS is the one exception), AIDS Action staff attends this annual press conference, where the Secretary of the Department unveils the HHS portion of the budget request and responds to questions from members of the media.

At this year’s press conference, Secretary Mike Leavitt described the FY 2007 budget as laying out a “hopeful agenda [that]…heeds the call of compassion.” He also said that the nearly $700 billion budget request is 9.1% higher overall than the fiscal year 2006 budget. However, in many cases, the President requested funding reductions for specific programs or their elimination. Explaining the rationale used to make these funding cuts, the Secretary said that the agency needed to prioritize the “areas with the highest payoff.” Those deemed not to have a high enough “payoff” received requests for less funding or no funding.

While HIV research was subject to such a cut, HIV prevention and treatment programs were among those receiving high priority, and thus more funding. Overall, the President’s budget requests an increase of $188 million for HIV programs at HHS: $95 million for the Ryan White CARE Act and $93 million for HIV prevention.

According to the HHS budget, this increase in funding is for a new “domestic HIV/AIDS initiative focused on HIV testing, outreach, and treatment.” Secretary Leavitt praised the new initiative which aims to test three million people for HIV and buy drugs for people waiting for HIV medicines on AIDS Drug Assistance Program (ADAP) waiting lists.

In a press release issued by AIDS Action, Craig Thompson, AIDS Action Council Board chair and executive director of AIDS Project Los Angeles, commented on the President’s requests for HIV programs. “Against the backdrop of four years of funding cuts, President Bush’s pledge of new funding is a very welcome and necessary start.” He cautioned, however, that additional funding is needed.

Below is a more thorough breakdown of how HIV programs and other health programs providing services to HIV positive people fared in the President’s budget request.

HIV specific programs at HHS

• Ryan White CARE Act
  The budget proposes an overall increase of $95 million for the CARE Act (nearly $2.2 billion), administered by the Health Resources and Services Administration (HRSA). Of this new money, the budget proposes that $70 million go to “address the on-going problem of State waiting lists and provide care and life-saving medications to those newly diagnosed as a result of increased testing efforts.” The remaining $25 million will be awarded through “HIV community action grants.” These grants will be awarded to “intermediaries including faith-based and community based organizations” and will “provide technical assistance and sub-awards to grassroots organizations.”
  
• HIV Prevention
  The budget proposes an increase of $93 million ($740 million total) for expanding “rapid testing to communities and populations hardest hit with HIV/AIDS to identify individuals who are infected with the HIV virus, but do not know it.”
  
• HIV Research
  The budget proposes a decrease of $15 million ($2.88 billion total) for HIV research, coordinated by the Office of AIDS Research at the National Institutes of Health.
  
• Abstinence-Only Education
  The budget proposes a $28 million increase ($204.5 million total) for abstinence-only funding.

Non-specific HIV programs at HHS

• Family Planning
  The budget proposes level funding ($283 million) for family planning programs administered by HRSA.
  
• Minority AIDS Initiative (HHS General Departmental Management)
  The President’s budget requests $52 million for the Minority AIDS Initiative (MAI) portion of the Secretary’s fund, the same as last year’s appropriation. (The rest of the MAI money is distributed throughout many different agencies, and that breakdown is not yet available.)

HIV specific program at Department of Housing and Urban Development

• Housing Opportunities for Persons with AIDS
  The budget recommends a $14 million increase for the Housing Opportunities for Person with AIDS Program (HOPWA), totaling $300 million.

Non-HIV specific programs

• Medicaid
  The President’s budget contains several legislative and administrative recommendations for decreasing Medicaid spending, including lowering reimbursement for targeted case management services, allowing states to use managed formularies (using “private sector management techniques to leverage greater discounts through negotiations with drug manufacturers”), and capping payments to government providers. By the Administration’s calculations, these proposals result in a net “savings” of $14.02 billion over the next five years (FY 2007- FY 2011).

In the News
1. Study Finds Health Outcomes Better with Early Treatment
Findings from a new study are calling into question guidelines that recommend that people living with HIV delay taking anti-retrovirals in order to reduce the risk of treatment-related complications, The Washington Post reported on February 7. The study found that the side effects of treatment as well as the number of deaths and the rate of opportunistic infections were lowest in patients who started treatment early.

"If you stayed on treatment and started earlier, you had the best outcomes," the lead researcher, Dr. Kenneth Lichtenstein of the University of Colorado Health Sciences Center, reported in a February 7 article by Reuters.

How the Study Was Conducted
A research team reviewed the medical records of 2,304 people living with HIV from eight U.S. cities, The Washington Post noted. Then, they divided the participants into five groups, based on their CD4 count (a lab test that measures the number of CD4 T-cells, which fight infection in the body).

According to Reuters, HIV positive individuals are generally advised to start a drug regimen of three or four anti-retrovirals (a treatment often referred to as highly active anti-retroviral therapy) once their CD4 cell count is 200 or lower. However all the study participants were receiving this treatment—even those with CD4 counts of 350, 500, or higher.

In their review of the medical records, the researchers looked for three common treatment-related toxicities: kidney insufficiency; peripheral neuropathy, a type of nerve damage which can cause either pain or numbness in the hands and feet; and a form of wasting known as lipoatrophy, Reuters reported. They did not however attempt to separate out the effects of individual drugs, according to The Washington Post.

The Results
Presenting their findings earlier this week at the Conference on Retroviruses and Opportunistic Infections in Denver, CO, the researchers revealed that individuals who started treatment with CD4 counts above 350 were at least 60% less likely to develop kidney insufficiency, 30% less likely to have peripheral neuropathy, and 60% less likely to develop lipoatrophy than patients who started at a CD4 count of 200 cells or below, Reuters added.
One member of the research team, Dr. John T. Brooks of the Centers for Disease Control and Prevention, remarked in The Washington Post that the study’s findings argue for early HIV testing and treatment, but he added, "I don't think anyone is ready to recommend changing the guidelines based on a single report."

To read the articles on which this news brief is based, link to The Washington Post at http://www.washingtonpost.com/wp-dyn/content/article/2006/02/07/AR2006020701099_pf.html and Reuters at http://today.reuters.com/news/newsArticleSearch.aspx?storyID=260244+07-Feb-2006+RTRS&srch=%22Early+treatment+always+better+for+HIV%2c+study+finds%22+

2. The New York Times: Supportive of Changing Laws to Broaden HIV Testing and Treatment
A New York Times editorial, published on February 6, supports the desire of New York City’s health commissioner, Dr. Thomas R. Friedan, to change state laws so that more people are able to receive HIV testing and treatment. Dr. Friedan has proposed making “two major changes” to New York State legislation.

First, he proposes to ease legal requirements which call for obtaining written consent before testing and providing individuals with information on the “downsides of testing.” Dr. Friedan advocates instead for obtaining oral consent. In addition, he would make testing a routine part of medical care. The Times notes that such changes might lead to some patients being “hoodwinked” into being tested. However, the newspaper then affirms, “[I]t seems reasonable to treat AIDS more like any other infectious or sexually transmitted disease. Wider testing might save some lives and alert people not to spread the virus.”

Second, Dr. Friedan seeks to establish a greater capacity for outreach to HIV positive individuals. Currently, New York State law allows health authorities to keep confidential records of the names of people who have tested positive for HIV, but they cannot use this information to look into who is—and is not—being treated.

Dr. Friedan wants to have the authority to contact people living with HIV or their doctors to ensure that they are connected to proper care, the Times reports.

The Times further reports that some people, skeptical about this approach, worry that individuals will be harassed or that the government will “second-guess decisions best made by the doctor.” The newspaper then counters: “But surely most patients would rather get life-extending treatments than languish in neglect.”

In addition, the Times points out that New York’s laws on this issue were passed almost twenty years ago before there were effective treatments for HIV, which limited the value of testing. Further, it notes, there was widespread discrimination against HIV positive people. Whereas today, there are effective drugs that can extend lives, and “health authorities have shown that they can be trusted to keep sensitive information confidential,” which may alleviate some fears about discrimination.

To read the editorial on which this news brief is based, link to The New York Times at http://www.nytimes.com/2006/02/06/opinion/06mon4.html?_r=1&oref=login&pagewanted=print

Announcements
1. Medicare Part D Beneficiaries Encouraged to Share Experience Using the New Benefit
Since the Medicare Part D prescription drug benefit took effect on January 1, there have been an overwhelming number of reported problems with the benefit. A high concentration of these reports come from “dual eligible beneficiaries”—individuals who receive benefits from both Medicare and Medicaid. Most of the people living with HIV who are receiving drugs through Part D—approximately 70,000 people—are dual eligibles.

HIV advocates encourage clients who have had trouble filling one or more prescriptions under the new Medicare Part D drug program to inform the Centers for Medicare and Medicaid Services (CMS) of the problems so that the agency can work to fix it.
Reports can be sent electronically to lorraine.zicha@cms.hhs.gov, Ekegler@cms.hhs.gov and hivma@idsociety.org.

Parties who wish to submit reports do not have to include personal identifying information. Information to consider sharing with the CMS includes:

• A description of what happened
• The names of the medication(s) being used, especially if it is an HIV drug
• Pharmacy name and general location (city and state, at a minimum)
• Name of the prescription drug plan being used
• Possible causes of the problem experienced

For parties who do not wish to reveal their e-mail addresses, there is another way to get a report to CMS. E-mails may be sent anonymously to the HIV Medicine Association (HIVMA) at hivma@idsociety.org. HIVMA will collect reports, remove all personal identifying information and then forward the remaining information on to CMS.

The AIDS Action Weekly Update
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