Standing Subcommittee to Monitor the Issues Related to Infection with HIV
September 22, 1999, Richmond
The General Assembly's AIDS Study Committee has been in existence since 1988, evolving through various configurations and currently continued to monitor new and existing policy issues emerging as a result of more effective treatments for HIV and the costs of these drug therapies. Three meetings have been projected for the 1999 interim, with a focus on treatment, prevention, and testing issues, particularly access to treatment vis-à-vis the high costs and the modifications being made in the insurance industry, issues relating to treatment in the correctional system, and the prevention and treatment efforts of the AIDS services organizations.
Statistical TrendsThe Commissioner of Health provided the subcommittee with an update on Virginia's epidemic and its AIDS Drug Assistance Program. She noted that the rate of HIV infection, which is reportable in Virginia, has declined in recent years, thus indicating that education and prevention efforts are proving successful. Further, the incidence of reported AIDS cases has been declining since 1993, with an upsurge in cases reported in 1995. AIDS deaths are down sharply in Virginia since 1995--an 87 percent decrease.
TransmissionData on selected transmission modes for AIDS and HIV infection indicate that, although modes of transmission are changing, men having sex with men remains the most prevalent transmission mode. Injection drug use and heterosexual transmission now account for larger percentages of transmission than in the early years of the epidemic. In addition, transmission mode data indicate that the incidence of HIV infection through heterosexual transmission and injection drug use has grown in recent years. Further, the number of women with AIDS experienced small spikes in 1993 and 1995, with declining numbers in recent years. HIV infection cases among women increased in 1993, dropped in 1994, increased again in 1995, and then slowly declined.
RaceAIDS data by race and year indicate that the number of African-American AIDS cases in Virginia has exceeded the number of cases among whites and other races since 1993. Similarly, reported cases of HIV infection indicate that infection among African-Americans is higher than in other groups.
AgeThe age group with the largest population of AIDS patients remains the group between 20 and 39 years old; however, the numbers of AIDS patients and HIV-infected individuals who are young (0 to 19 years) and older (40 and over) did increase overall in the 1990s. Individuals 40 and over now represent a much higher proportion of AIDS patients--a statistic that possibly reflects improvements in treatments and longer life expectancies.
LocationThe regional data indicate that, although Northern Virginia experienced over 50 percent of the cases in the early 1980s, the epidemic has shifted, with Central Virginia and Eastern Virginia reporting a greater number of cases than Northern Virginia, and the number of cases in Southwest Virginia on the increase. Further, an examination of reported HIV-infection cases indicates that the epidemic continues to shift to Central and Eastern Virginia. The number of reported HIV-infection cases has declined somewhat in Northern Virginia, has remained stable in Northwest Virginia, and has increased in Southwest Virginia.
Pregnant WomenThe Department of Health's data on testing of pregnant women indicate that 100 percent of HIV-infected pregnant women are being tested prior to actually giving birth. Approximately 90 percent of these women are receiving AZT treatment during pregnancy. Thus, the number of perinatally exposed HIV pediatric cases has declined significantly in recent years, with eight women being identified this year and only one case of perinatal transmission confirmed. These data indicate a decline in perinatal transmission from 19 cases in 1992.
ADAPVirginia's AIDS Drug Assistance Program (ADAP) is administered by the Board of Health with the help of an expert advisory group in developing the formulary. The ADAP now covers approximately 30 drugs. The number of patients served by the ADAP in Virginia has continued to increase. To date in 1999, 884 clients have been served. The state has increased its funding by nearly three-quarters of a million dollars in recent years; however, in order to leverage the maximum federal dollars, state funding will need to increase by another $1 million next year. A shortfall of over a half-million dollars is still projected because of the projected increase in clients. Total Ryan White state matching funds may increase steadily in the next millennium.
Inmate InfectionThe Department of Corrections noted that 2,936 inmates were tested for HIV in fiscal year 1998-1999, with 42 testing positive for HIV. Twelve AIDS deaths occurred in the correctional system in calendar year 1998; six have occurred to date in 1999. The University of Virginia and the Medical College of Virginia serve various prisons through telemedicine; for example, the University of Virginia services inmates from Fluvanna to Augusta, and the Medical College of Virginia serves inmates at Powhatan. Other prisons receive medical care through contracted private services. The department spent $3,411,178 on AIDS drugs during the 12 months ending June 1999.
Treatment IssuesThe director of the Whitman-Walker Clinic of Northern Virginia told the subcommittee that "the face of AIDS has changed"; however, the issues relating to prevention and treatment have not changed. She noted that the death rates are down; however, not in all populations. Because of the shifts in the epidemic, many current clients have tremendous needs, such as mental illness, substance abuse, and poverty. Case management is needed more than ever, and many of today's clients have language barriers and cultural issues (e.g., women of color who may wait until they are sick to seek treatment).
The decrease in mortality and longer life expectancies are, in other words, coupled with complex cultural, societal, and care needs, drugs which work well to contain the illness for many do not work for everyone. Side effects, costs, and the demands of sticking to exacting protocols (timing, food and water requirements) are barriers for many clients. A test of drug protocol adherence was conducted in one health department, using color-coded jelly beans. This test resulted in success for only about 15 percent of the involved health professionals. Thus, ADAP revisions and increased funding as well as emergency drug assistance funding are essential.
Education and prevention in varied and multiple populations present challenges, such as reaching young people who believe they are impervious to risks. Prisoners, who have an HIV-infection rate of five times the general population, are desperately in need of discharge planning for the time when they are no longer incarcerated. Ryan White funds cannot currently be used to provide these services; therefore, other sources of funding are needed.
The staff attorney for Whitman-Walker Clinic also spoke to an increasingly difficult insurance issue: restrictive capitation of prescription drug coverage in individual policies. For many people with individual policies, prescription drug insurance coverage in Virginia ranges from one to three thousand dollars per year, and many individual policies do not have any prescription drug coverage. Kaiser-Permante, for example, adopted a $1,500 prescription drug coverage cap in November of 1998; previously Kaiser had no cap. For AIDS patients, prescription drugs are a lifeline. Combination therapies cost approximately $1,500 a month. Thus, the average coverage for prescription drugs under individual policies would only cover about one month's treatment. Options are very few for those people caught in this situation. Most people with private insurance do not qualify for the ADAP (the current maximum income level is $18,000 per year).
Some possible results from the restrictive prescription caps might be that ADAP could be increasingly strained as those who do qualify access this program after reaching their prescription cap. Some persons who are ineligible for ADAP will simply stop taking the medicine, with the possible consequence that the virus will become resistant to the medications and/or the patients' medical condition will decline rapidly.
A representative of Glaxo-Wellcome, Inc., presented estimates for the Virginia ADAP medications program--an econometric model. This model, based on mathematical and economic formulas and theories, demonstrates that ADAP's funding needs will increase with higher utilization; that is, additional clients (if eligibility is increased by raising the income threshold). However, the model demonstrates that ADAP increases are offset by health care savings, which will result from cost avoidance associated with the drug treatment, such as hospitalizations for opportunistic diseases. Life expectancies would also be expected to rise.
Future PlansThe subcommittee will continue to examine issues related to the AIDS Drug Assistance Program, telemedicine in the correctional system, and community services.
The Honorable Marian Van Landingham, Chair
Legislative Services contact: Norma E. Szakal