CDC to research coverage gaps for gay people of color

The Centers for Disease Control and Prevention wants to research whether gay and transgender people of color could receive better access to care and experience reduced HIV infection rates if they discuss insurance coverage with their providers earlier.

The agency is seeking approval from the White House’s Office of Management and Budget to launch the study in Chicago, focusing on black and Hispanic males who have sex with men and transgender persons. The CDC will work with community partners to help people connect to coverage.

Gay men accounted for 81% of new HIV infections among males and 65% of all new HIV infections, according to the CDC. Researchers have also found HIV rates among black and Hispanic transgender women to be 56% and 16%, respectively.

The CDC wants to evaluate whether these individuals will experience better health outcomes if providers talk with them about coverage options during sexually transmitted disease testing. Currently, these conversations tend to take place after patients receive their test results.

The agency wants to determine whether the change will lead to more participants obtaining health insurance, experiencing better health by achieving viral suppression or remaining HIV-free and improve retention rates for HIV care including using medications known as pre-exposure prophylaxis, or PrEP, and other HIV-associated health services like mental health counseling and substance use treatment.

Research has shown that individuals who start antiretroviral therapy on the same day that they are diagnosed with HIV are more likely to be engaged in their care over the long term, according to Jeffrey Crowley, who served under President Barack Obama as director of the Office of National AIDS policy and now oversees infectious disease initiatives at Georgetown University.

However, there are too many barriers to same-day starts to treatment, Crowley said. A primary hurdle is lack of health insurance.

“If this study is able to demonstrate that getting people who test for HIV enrolled in coverage when they test, it could improve their health generally no matter their HIV test result,” Crowley said.

Others agreed the study could be an important step to making sure marginalized individuals are getting the coverage they need.

“People who are HIV-negative are great candidates for PrEP, and we have seen very low uptake among populations most vulnerable to HIV in Chicago and nationally,” said John Peller, CEO of the AIDS Foundation of Chicago. “The opportunity to sign these most vulnerable populations up for health insurance and connect them to primary care could address a major gap in the system.”

A third of gay young men who take PrEP medication discontinue it within six months, according to a May 2018 study published in the AIDS and Behavior Journal.

Common reasons for stopping included being unable to get an doctor appointment and problems with insurance coverage.

The CDC’s proposed study could affect the practice of medicine by engaging individuals in care earlier and thus improving the support these populations receive, according to Ethan Morgan, a research fellow at Northwestern University who co-authored the May 2018 study.

In addition to improving access to coverage, there is hope that promising findings from the CDC study will lead to an increase in federal funding for coverage navigators, according to Erin Loubier, senior director for health and legal integration and payment innovation at Whitman-Walker Health, a community health center in Washington, D.C., that specializes in caring for LGBTQ patients.

Federal funding for navigators that help people search the individual market or Medicaid programs for coverage dropped 41% or by $62.5 million between 2016 and 2017.

“If the CDC finds it makes a difference to have these conversations it begs the question if it will help drive more funding for insurance enrollment assistance,” Loubier said.

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Narrow Focus on Opioid Crisis Leads to More Law Enforcement & Lack of Funding

Over the past few months, many members of Congress who find themselves in tight Congressional races have spent a great deal of time and effort rallying behind their legislative response to the opioid crisis in an attempt to influence voters in the Fall elections. Unfortunately, the zeal with which these vulnerable members of Congress have been promoting a recently passed House bill and the likely impact of the contents of the bill itself are not in sync, as it avoids addressing the glaring funding needs that must be met if any substantial progress is to be made on the issue.

Last week, the House of Representatives passed the bipartisan SUPPORT for Patients and Communities Act (H.R. 6), which collects the chamber’s meek opioid response to send to the Senate in one comprehensive package. As reported earlier this month, the legislative aims are narrowly focused on limiting the supply of opioids through prescription monitoring, expansion of SUD treatment, innovations on non-addictive pain treatments, and harsher criminalization of illicit drugs like fentanyl.

Following the passage of the bill, Politico reporter Adam Cancryn wrote a piece looking at a small collection of health care and pharmaceutical companies that spent millions lobbying Congress this year and who would bring in a windfall if H.R. 6 becomes law. Drug companies who sell medications for SUDs or chronic pain have spent hundreds of thousands, if not millions of dollars, aiming to get their slice of the pie since Congress passed the Bipartisan Budget Deal in late March, which authorized $6 billion over two years toward fighting the opioid crisis.

At present, only one in ten patients who need treatment receive it, and a reportfrom the Administration’s opioid commission identified a lack of willing providers as one the main barriers. Congress needs to do more to influence providers to treat people who use drugs – coming from criminalized communities means they face stigma, discrimination, and denial of services in health care and beyond. Even after the Comprehensive Addiction and Recovery Act of 2016 (S. 524 (114)) expanded the limits on buprenorphine-prescribing, only a fraction of the workforce got on board.

Meanwhile, ease of access to opioid crisis-related data by law enforcement is leading to increased prosecutions and harsher criminal sentencing among people who use drugs and health care providers. Prescription monitoring programs have been touted for their role in detecting pill mills, which is a subsiding problem, but they are being over-used by investigators in some states.Calibri;mso-hansi-font-family:Calibri;mso-bidi-font-family: Calibri”> In Oklahoma – where authorities searched the state’s database 10 times more often than investigators in Texas – the queries result in criminal charges against 7 to 10 providers a year, and investigations of 50 to 100 patients suspected of doctor shopping, forging prescriptions, or street sales. Worse, when someone dies of an overdose, police are increasingly arresting their friends and families on charges relating to murder.

As neither chamber of Congress has committed itself to addressing the opioid crisis as the public health emergency that it is, criminalization of drug use will continue to mire the response.

Posted By: AIDS United, Policy Department – Friday, June 29, 2018

Pneumocystis Pneumonia -“The first five”reported/documented

In the period October 1980-May 1981, 5 young men, all active homosexuals, were treated for biopsy-confirmed Pneumocystis cariniipneumonia at 3 different hospitals in Los Angeles, California. Two of the patients died. All 5 patients had laboratory-confirmed previous or current cytomegalovirus (CMV) infection and candidal mucosal infection. Case reports of these patients follow.

Patient 1: A previously healthy 33-year-old man developed P. carinii pneumonia and oral mucosal candidiasis in March 1981 after a 2-month history of fever associated with elevated liver enzymes, leukopenia, and CMV viruria. The serum complement-fixation CMV titer in October 1980 was 256; in may 1981 it was 32.* The patient’s condition deteriorated despite courses of treatment with trimethoprim-sulfamethoxazole (TMP/SMX), pentamidine, and acyclovir. He died May 3, and postmortem examination showed residual P. carinii and CMV pneumonia, but no evidence of neoplasia.

Patient 2: A previously healthy 30-year-old man developed p. carinii pneumonia in April 1981 after a 5-month history of fever each day and of elevated liver-function tests, CMV viruria, and documented seroconversion to CMV, i.e., an acute-phase titer of 16 and a convalescent-phase titer of 28* in anticomplement immunofluorescence tests. Other features of his illness included leukopenia and mucosal candidiasis. His pneumonia responded to a course of intravenous TMP/.SMX, but, as of the latest reports, he continues to have a fever each day.

Patient 3: A 30-year-old man was well until January 1981 when he developed esophageal and oral candidiasis that responded to Amphotericin B treatment. He was hospitalized in February 1981 for P. carinii pneumonia that responded to TMP/SMX. His esophageal candidiasis recurred after the pneumonia was diagnosed, and he was again given Amphotericin B. The CMV complement-fixation titer in March 1981 was 8. Material from an esophageal biopsy was positive for CMV.

Patient 4: A 29-year-old man developed P. carinii pneumonia in February 1981. He had had Hodgkins disease 3 years earlier, but had been successfully treated with radiation therapy alone. He did not improve after being given intravenous TMP/SMX and corticosteroids and died in March. Postmortem examination showed no evidence of Hodgkins disease, but P. carinii and CMV were found in lung tissue.

Patient 5: A previously healthy 36-year-old man with clinically diagnosed CMV infection in September 1980 was seen in April 1981 because of a 4-month history of fever, dyspnea, and cough. On admission he was found to have P. carinii pneumonia, oral candidiasis, and CMV retinitis. A complement-fixation CMV titer in April 1981 was 128. The patient has been treated with 2 short courses of TMP/SMX that have been limited because of a sulfa-induced neutropenia. He is being treated for candidiasis with topical nystatin.

The diagnosis of Pneumocystis pneumonia was confirmed for all 5 patients antemortem by closed or open lung biopsy. The patients did not know each other and had no known common contacts or knowledge of sexual partners who had had similar illnesses. Two of the 5 reported having frequent homosexual contacts with various partners. All 5 reported using inhalant drugs, and 1 reported parenteral drug abuse. Three patients had profoundly depressed in vitro proliferative responses to mitogens and antigens. Lymphocyte studies were not performed on the other 2 patients.

Reported by MS Gottlieb, MD, HM Schanker, MD, PT Fan, MD, A Saxon, MD, JD Weisman, DO, Div of Clinical Immunology-Allergy; Dept of Medicine, UCLA School of Medicine; I Pozalski, MD, Cedars-Mt. Siani Hospital, Los Angeles; Field services Div, Epidemiology Program Office, CDC.

Editorial Note: Pneumocystis pneumonia in the United States is almost exclusively limited to severely immunosuppressed patients (1). The occurrence of pneumocystosis in these 5 previously healthy individuals without a clinically apparent underlying immunodeficiency is unusual. The fact that these patients were all homosexuals suggests an association between some aspect of a homosexual lifestyle or disease acquired through sexual contact and Pneumocystis pneumonia in this population. All 5 patients described in this report had laboratory-confirmed CMV disease or virus shedding within 5 months of the diagnosis of Pneumocystis pneumonia. CMV infection has been shown to induce transient abnormalities of in vitro cellular-immune function in otherwise healthy human hosts (2,3). Although all 3 patients tested had abnormal cellular-immune function, no definitive conclusion regarding the role of CMV infection in these 5 cases can be reached because of the lack of published data on cellular-immune function in healthy homosexual males with and without CMV antibody. In 1 report, 7 (3.6%) of 194 patients with pneumocystosis also had CMV infection’ 40 (21%) of the same group had at least 1 other major concurrent infection (1). A high prevalence of CMV infections among homosexual males was recently reported: 179 (94%) had CMV viruria; rates for 101 controls of similar age who were reported to be exclusively heterosexual were 54% for seropositivity and zero fro viruria (4). In another study of 64 males, 4 (6.3%) had positive tests for CMV in semen, but none had CMV recovered from urine. Two of the 4 reported recent homosexual contacts. These findings suggest not only that virus shedding may be more readily detected in seminal fluid than urine, but also that seminal fluid may be an important vehicle of CMV transmission (5).

All the above observations suggest the possibility of a cellular-immune dysfunction related to a common exposure that predisposes individuals to opportunistic infections such as pneumocystosis and candidiasis. Although the role of CMV infection in the pathogenesis of pneumocystosis remains unknown, the possibility of P. carinii infection must be carefully considered in a differential diagnosis for previously healthy homosexual males with dyspnea and pneumonia.

The Whitewashed History of HIV: A Black Teen Died of AIDS in 1969

WHITEWASHED

Fifty years ago, a frightened 15-year-old black youth checked into St. Louis’s City Hospital with unusual symptoms that puzzled doctors. His legs were swollen, and soon so was his entire body. Nothing seemed to work, not even seven weeks of antibiotics. Doctors suspected he may have acquired chlamydia from a same-sex partner, but the youth never said he had. For six months he continued to deteriorate, until in May of 1969 this sweet, shy teen lost his life to the disease that baffled medical personnel. His name was Robert Rayford, and he is the first known person to die of HIV in the United States. He died just one month before the Stonewall riots of June 1969, led by queer people of color, and which we honor each year with our annual June Pride celebrations.

At the time, no one knew what HIV was. It would be another 12 years before the Centers for Disease Control and Prevention reported a mysterious pneumonia and immune deficiency that had afflicted “5 young men, all active homosexuals.” Deaths started mounting in 1981, but HIV would not be identified by scientists until 1984, and it wouldn’t be until 1987 that HIV would be found in Rayford’s tissue samples. When it finally was, few noticed his story.

The CDC’s campaign Start Talking. Stop HIV rightly states the obvious, that we must talk about this virus with one another to stop it spreading and tell our collective stories to fight stigma. But, if we are really going to stop HIV, then we need to talk about how HIV continues to have a disparate impact on communities of color. We must tell the story of Rayford and so many more.

By the time Rayford’s case was identified, a different narrative about who was perishing from HIV had already begun –– focused on white gay men. But, that narrative ignores all others and is a narrative deeply rooted in racial insensitivity and injustice played out again and again in our LGBTQ community’s history.

In 1981 the CDC reported five young gay men had come down with pneumonia, the report didn’t indicate their race, which at the time meant they were all white. Two additional cases of black men, one a gay African-American, the other a heterosexual Haitian, were not mentioned at all. The doctor who wrote the report, Michael Gottlieb, told The New York Times, “Until recently, I wouldn’t have thought it mattered.”

The face of HIV became a French-Canadian flight attendant, Gaëtan Dugas. This man was vilified in journalist Randy Shilts’s book on the initial outbreak, And The Band Played On.Shilts portrayed Dugas as a promiscuous “sociopath” who spread the virus across the country. Media dubbed him Patient Zero, and the New York Post even ran a headline in 1987 calling Dugas “The Man Who Gave Us AIDS.”

The claim that Dugas was the first person to bring HIV into the U.S. was disproved by researchers in November 2016 through genetic testing, but during the 1980s the narrative was set. In pop culture, films that tackled the history of HIV, from Philadelphia to even the more recent adaptation of The Normal Heart, look at HIV through a predominantly white, gay, and male lens. Even a recent art exhibition on HIV perpetuated an almost exclusively white perspective by selecting an overwhelming number of white artists –– 88 –– compared to just nine Latinx and four black artists.

This white history of HIV neglects Rayford’s tragic experience and the fact that he is not the last black person –– or even queer person of color –– to lose their life to HIV. He was the first victim of what would become a scandalous trend in the emerging HIV epidemic: HIV’s devastating and wildly disproportionate impact on black communities, especially black gay and bisexual men.

Since the virus was discovered, black people have made up 43 percent of all HIV deaths in the United States, yet African-Americans are only about 13 percent of the U.S. population.

Black gay and bisexual men accounted for 26 percent of all new HIV infections in 2016, despite representing less than 2 percent of America’s total population. Of the 1.1 million Americans living with HIV today, almost 475,000 of them — more than any other racial group — are black. Almost 150,000 of them are black gay and bisexual men.

Rayford’s death marked the beginning of our national HIV crisis. And like so many other stories of black and brown experiences, their stories of living with HIV rarely get told. One example of our collective erasure of black and brown people living with HIV was seen in 2015, when multiple celebrities took to Twitter to congratulate Lester Holt for being the “first black news anchor” on broadcast news — forgetting former ABC World News Tonight  anchor Max Robinson, who died from complications of HIV in 1988.

Silence equals death. And too many black and brown gay, bisexual, and transgender people have died and continue to die from HIV, but their stories are not being heard. More deaths from AIDS occur today in the South than in any other region, and those deaths are overwhelmingly of black and brown people, and many are part of the LGBTQ community.

Queer people of color’s experiences with HIV matter, and when we push their stories out of view, we put these communities at even greater risk. Their stories of today must be told, or we will never get to the end of the HIV epidemic. Black men make up 38 percent of all new diagnoses among gay and bisexual men, and the CDC predicts that if trends continue as they exist today, one out of every two gay and bisexual black men can expect to acquire HIV during their lifetime. For Latinx gay and bisexual men, that figure is one of every four. And perhaps the most disturbing finding by the CDC is their recent estimate that 56 percent of black transgender women may already be living with the virus.

This Pride Month, remember and consider this: The whitewashing of queer experiences isn’t just in the narratives we see in HIV but all across media, our Pride celebrations, and in our organizations. We owe it to everyone who has faced living with and dying from HIV to take part in the struggle to stop the virus, and to do that we need to start talking, get tested, and uplift the stories of LGBTQ people of color. If we don’t, who will?

REA CAREY is the executive director of the National LGBTQ Task Force, and JESSE MILAN JR. is the president and CEO of AIDS United.

Suicide rates rise sharply across the United States, new report shows

Suicide rates rise sharply across the United States, new report shows

  •  Health Blog •

This article was originally published by The Washington Post.

This post has been updated.

Suicide rates rose in all but one state between 1999 and 2016, with increases seen across age, gender, race and ethnicity, according to a reportreleased Thursday by the Centers for Disease Control and Prevention. In more than half of all deaths in 27 states, the people had no known mental health condition when they ended their lives.

In North Dakota, the rate jumped more than 57 percent. In the most recent period studied (2014 to 2016), the rate was highest in Montana, at 29.2 per 100,000 residents, compared with the national average of 13.4 per 100,000.

Only Nevada recorded a decline — of 1 percent — for the overall period, although its rate remained higher than the national average.

Increasingly, suicide is being viewed not only as a mental health problem but a public health one. Nearly 45,000 suicides occurred in the United States in 2016 — more than twice the number of homicides — making it the 10th-leading cause of death. Among people ages 15 to 34, suicide is the second-leading cause of death.

The most common method used across all groups was firearms.

“The data are disturbing,” said Anne Schuchat, the CDC’s principal deputy director. “The widespread nature of the increase, in every state but one, really suggests that this is a national problem hitting most communities.”

It is hitting many places especially hard. In half of the states, suicide among people age 10 and older increased more than 30 percent.

Percent change in annual suicide rate* by state, from 1999-2001 to 2014-2016 (Centers for Disease Control and Prevention)

“At what point is it a crisis?” asked Nadine Kaslow, a past president of the American Psychological Association. “Suicide is a public health crisis when you look at the numbers, and they keep going up. It’s up everywhere. And we know that the rates are actually higher than what’s reported. But homicides still get more attention.”

One factor in the rising rate, say mental health professionals as well as economists, sociologists and epidemiologists, is the Great Recession that hit 10 years ago. A 2017 study in the journal Social Science and Medicine showed evidence that a rise in the foreclosure rate during that concussive downturn was associated with an overall, though marginal, increase in suicide rates. The increase was higher for white males than any other race or gender group, however.

“Research for many years and across social and health science fields has demonstrated a strong relationship between economic downturns and an increase in deaths due to suicide,” Sarah Burgard an associate professor of sociology at the University of Michigan, explained in an email on Thursday.

The dramatic rise in opioid addiction also can’t be overlooked, experts say, though untangling accidental from intentional deaths by overdose can be difficult. The CDC has calculated that suicides from opioid overdoses nearly doubled between 1999 and 2014, and data from a 2014 national survey showed that individuals addicted to prescription opioids had a 40 percent to 60 percent higher risk of suicidal ideation. Habitual users of opioids were twice as likely to attempt suicide as people who did not use them.

High suicide numbers in the United States are not a new phenomenon. In 1999, then-Surgeon General David Satcher issued a report on the state of mental health in the country and called suicide “a significant public health problem.” The latest data at that time showed about 30,000 suicides a year.

Kaslow is particularly concerned about what has emerged with suicide among women. The report’s findings came just two days after 55-year-old fashion designer Kate Spade took her own life in New York — action her husband attributed to the severe depression she had been battling.

“Historically, men had higher death rates than women,” Kaslow noted. “That’s equalizing not because men are [committing suicide] less but women are doing it more. That is very, very troublesome.”

Among the stark numbers in the CDC report was the one signaling a high number of suicides among people with no diagnosed  mental health condition. In the 27 states that use the National Violent Death Reporting System, 54 percent of suicides fell into this category.

But Joshua Gordon, director of the National Institute of Mental Health, said that statistic must be viewed in context.

“When you do a psychological autopsy and go and look carefully at medical records and talk to family members of the victims,” he said, “90 percent will have evidence of a mental health condition.” That indicates a large portion weren’t diagnosed, “which suggests to me that they’re not getting the help they need,” he said.

Cultural attitudes may play a part. Those without a known mental health condition, according to the report, were more likely to be male and belong to a racial or ethnic minority.

“The data supports what we know about that notion,” Gordon said. “Men and Hispanics especially are less likely to seek help.”

The problems most frequently associated with suicide, according to the study, are strained relationships; life stressors, often involving work or finances; substance use problems; physical health conditions; and recent or impending crises. The most important takeaway, mental health professionals say, is that suicide is an issue not only for the mentally ill but for anyone struggling with serious lifestyle problems.

“I think this gets back to what do we need to be teaching people — how to manage breakups, job stresses,” said Christine Moutier, medical director of the American Foundation for Suicide Prevention. “What are we doing as a nation to help people to manage these things? Because anybody can experience those stresses. Anybody.”

The rates of suicide for all states and the District of Columbia were calculated using data from the National Vital Statistics System. Information about contributing circumstances for those who died by suicide was obtained via the National Violent Death Reporting System, which is relatively new and in place in only 27 states.

“If you think of [suicide] as other leading causes of death, like AIDS and cancer, with the public health approach, mortality rates decline,” Moutier said. “We know that same approach can work with suicide.”

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Get to Know the In It Together Health Literacy Project

 

Event Date: Thursday, June 14, 2018 – 2:00pm to 3:00pm EDT

Event Type: Webinar / Teleconference

ACE TA Center

Register for the Webinar

Better health starts with health literacy!

Register and join(link is external) this webinar to learn about:

  • How limited health literacy impacts the health of people living with HIV
  • How to identify when a client is struggling with health literacy
  • Approaches and resources you can use to promote health literacy for your clients
  • The cultural, social, and environmental factors that can impact the health literacy of racially, ethnically, culturally, and linguistically diverse people
  • How In It Togetherresources could benefit your organization or community

In this webinar, two In It Together trainers will also share their experience providing the community health literacy training in their own communities. Join the webinar to learn how you or someone at your organization can to become a health literacy community trainer.

Intended Audience954627 954627

This training webinar will be especially useful to program managers, clinical staff, health educators, case managers, staff that conduct outreach, as well as other staff that provide HIV care or supportive services.

 

IHAP Webinars Upcoming Webinars

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