Monthly Archives: January 2014

Omnibus Appropriations: The power of the purse

By: Marcus Hopkins, HEAL blogger

Once again, the U.S. government was on the verge of being shut down over disagreements on federal funding levels.  “Nothin’ new,” one might say – we haven’t had a functional legislative branch with much in the way of bipartisanship for close to five years (or some might argue even longer), outside of major legislation that is often passed out of the fear of voter retribution that rarely comes as a result of gerrymandered districting on both sides of the aisle.  In an act of self-preservation, the Republican-led Congress passed a three-day spending bill so that the details could be hammered out on the $1.012-trillion Omnibus spending bill.

For those of you unfamiliar with the term, an Omnibus bill is a large bill that covers a variety of diverse or entirely unrelated topics.  This current bill covers the entire discretionary budget and is comprised of no fewer than 1,582 pages, and largely follows the same conservative trend in government spending that has, in the past, spelled trouble for healthcare and public health initiatives.

Sign from Congressional Appropriations Committee,

Appropriations

The fifteen-day government shutdown that ended on October 16th, 2013, was largely the result of the Tea Party elements within the Congressional Republican Caucus attempting to defund or repeal the Affordable Care Act (better known as “Obamacare”).  When the inaction of our elected officials came to a head and the voters responded with both exasperation and outrage, legislators on both sides of the aisle brought their toys back to the playground and began playing with them, again, in their own separate corners.

Republican appropriators touted their “win” of no new funding for the ACA, and made certain to note that $1 billion was cut from the Independent Payment Advisory Board (once famously referred to by ½-term Alaskan Governor Sarah Palin as the “Death Panel”).  The latter was done to prevent the Secretary of Health and Human Services (currently Kathleen Sebelius) from “raiding” these funds to for the Health Care Insurance Exchanges.

Additional cuts include $10 million from Title X Family Planning funding, which funds many women’s health clinics that provide vital testing services for STDs/STIs, including HIV and HCV.  These clinics primarily serve people with no or low income, two of the highest non-race-related risk groups in the country for contracting both HIV and HCV.

Democratic representatives will be quick to point out that we saw an increase in funding for Alzheimer’s research, as well as a $1 billion increase in funding for the National Institutes for Health (NIH), both of which are fantastic.  But, with every quid, there comes a pro quo, and the cost, in this case, may be higher than we should be expected to pay.

A couple of things should be noted about the current omnibus:

1.)   There are no real serious attacks against programs that are a priority for access to care, and by “real,” I mean, “No funding has been substantially cut that will negatively impact more than a handful of people.”

2.)   While we avoided additional sequestration with this bill, and in fact it was slightly scaled back, it must be noted that this could prove to be problematic, still, for the Ryan White Care Act and the AIDS Drugs Assistance Program (ADAP) – programs upon which co-infected HIV/HCV patients are very likely to depend.

As I’ve noted in previous blogs, RWCA and ADAP are already problematic, as they are not nationally implemented with any consistency from state to state.  The popular saying in the HIV/AIDS community is, “When you’ve seen one ADAP, you’ve seen one ADAP.”

One of the primary issues I have with ADAP is that the money is allocated at the Federal level, is disbursed at the state level, and it’s basically a free-for-all from there.  Each state then has virtual carte blanche to appropriate those funds however they see fit, resulting in a hodgepodge of programs that may meet certain needs, but not others. Fortunately for patients seeking HCV treatment, about ½ of the ADAPs cover some level of access to care and treatment for the disease.

That said, with funding levels largely stagnant and the patient base increasing, it’s difficult to say whether or not state ADAPs will be able to cope, should an influx of new patients occur, particularly states that have not opted in to the Medicaid expansion (most notably in the American South).  The staff at HEAL Blog (myself included) don’t foresee the return of ADAP waiting lists, at the present time, but with every state healthcare agency working overtime to ensure that new regulations are met and coverage is provided under the ACA, we likely won’t know for certain until someone realizes (often too late) that there’s a problem.

The continuing funding issue with Ryan White and ADAP is something that will very likely lead to a lot of vociferous infighting within the HIV/AIDS policy community, as reauthorization of the Ryan White Act is due at any time…which may or may not even be necessary, as there is no sunset provision attached to the law (meaning that no new legislation is required to keep the funding active through the annual congressional appropriations process.  At this time, it’s fair to say that not many people can provide definitive answers about the fate of the RWAC/ADAP programs under the ACA, myself included.

So, where does this leave us as health educators and healthcare providers?  In the same position we’ve been in for several years, now – being asked to provide more services to a growing number of patients with fewer resources.

There are many within the healthcare community who take a look at these numbers and attempt to figure out how we can fit all that we need to accomplish into the ever tightening noose that is the funding game – the Pollyannas of the group who insist that, when handed fewer lemons, we make more watery lemonade.

I am not one of those people.   I am a realist, and the reality is that, if the current trend funding trends continue, as they are likely to do if Congressional seats do not flip one way or the other, we will eventually be asked to do with so little that any efforts will be both negligible and fruitless.

There comes a point when we must begin advocating not only for ourselves, but for those whose voices cannot reach the ears of Congressional leaders more concerned about retaining their seats than they are about doing what is best for everyone in the country.  If we intend to increase awareness and testing within the HCV community, it would behoove us to better leverage ourselves in a manner that will influence the Congressional purse strings.

Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates.

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Standard Operating Procedure

By: Marcus Hopkins, HEAL blogger

As an HIV, STD/STI, and reproductive health educator, one of my primary goals is to provide people with as much current and scientifically accurate information as possible.  In that regard, I feel that I am successful; that success can be measured by the responses I receive whenever I am asked to provide guest lectures at colleges and universities, both from the professors and the students who attend these lectures.

I know that I have achieved my goal when at least one of these people come up to me to tell me how my lecture has altered the way in which they view HIV and the afflicted population – even more so when they tell me that they are going to go get tested after hearing the information with which they’ve been provided.  One professor in whose classes I delivered numerous guest lectures even went so far as to incentivize her students by offering extra credit for any student who went to go get tested after those sessions.

But, how do we, as educators, further our reach into the greater medical community?  Here at HEAL Blog, we are tasked with providing up to date and current information about Hepatitis C and HIV co-infection, particularly as it relates to treatment.  But, how can we ensure that patients will be treated if the medical community isn’t consistently screening for HCV during routine checkups?  This is a problem we have been facing for at least the last decade, as the number of new HCV infections rises within the HIV+ community.

When I first tested positive for HIV, I did so at AID Atlanta, a non-profit organization that offers free HIV testing in downtown Atlanta.  At the time, however, I was not aware of, nor even concerned about, testing for other STDs/STIs.  When I finally decided to take control of my disease in 2007, a full 2.5 years after my initial diagnosis, I had progressed into AIDS, and was referred to an Infectious Disease specialist, Margaret Gorensek, MD, former chairman at the Cleveland Clinic in Weston, FL.

It was under her care that I really learned to take control not only of my HIV, but of my general sexual health.  During my first visit, she relayed to me the following bit of wisdom: “Generally, when someone tests Positive for HIV, they have an accompanying infection.  Where there’s one, there are likely others.”  This bit of logic and sage advice has stayed with me, to this day, and I frequently impart that wisdom on to the students and patients whom I counsel.

With that in mind, I wonder if other doctors in the field of Infectious Disease are also doing their due diligence when it comes to their patients.  In the world of treatment, knowledge is power – the more information you have about your illness, along with any other co-infections, the better equipped you are to be proactive in treating those diseases.

Image of patient having his blood drawn by his physician

The rates of HIV/HCV co-infection are staggering – the CDC estimates that roughly 25% of people infected with HIV are also infected with HCV; the rate of co-infection amongst injection drug users with HIV falls between 50-80%.  Beyond co-infection, the long-term ramifications of HCV infection are equally staggering – HIV/HCV co-infection more than triples the risk of liver disease, liver failure, and liver-related death from HCV, which has risen to the leading cause of non-HIV-related death within the HIV+ population.

To be fair, almost every single clinic in which I’ve been a patient has treated HCV screening as one of its first priorities – Ft. Lauderdale, Johnson City, TN, AHF San Fernando Valley, and Positive Health Clinic in Morgantown, WV – each of these clinics have been rigorous in testing for Hepatitis A-C.

The only experience I’ve had where this was not the case was at Harbor UCLA Medical Center in Los Angeles.  This was the first clinic to which I was sent in CA, and was both understaffed and underfunded, as are most of the state-run hospitals in Southern CA.  The clinic was situated in an annex to the full hospital, and patients were treated more like objects on a conveyor belt, rather than human beings.  The HIV-specific staff, however, were quite adept at their jobs, and did their best to attend to every need of their patients.

The reality, however, is that they simply didn’t have the resources to spend on educating their patients about HCV, simply because doing so would require more time than was feasible for them to spend during their very limited clinic hours.  Perhaps other clinics have this kind of staffing issue, as well.  Is it simply a lack of resources that leads to not screening for HCV?

Perhaps.  Every experience of mine has led me to believe that staffing and funding are two of the primary issues that face our HIV clinics, today.  These two problems are, of course, inextricably linked, and given the way Congressionally approved government funding has gone over the past few years, things don’t look to be getting much brighter.

So, the question stands – why is HCV screening not de rigueur along with other STDs/STIs?  With the statistics so stacked against the HIV+ community, would it not make sense for HCV screening to be standard operating procedure during the course of regular checkups?

For the sake of public safety, that answer should be, “Yes.”  If we fail to take this simple precautionary step, we are doing a grave disservice to patients who might otherwise never know the risks they may face.

Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates.

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