HIV at 30: Epidemic continues to try resources and government policy

By Todd A. Heywood

LANSING -

The HIV epidemic reached its 30th anniversary earlier this year, but in Michigan the battle against the crisis continues to be hampered by misguided and out of date policies and funding cuts.

BY THE NUMBERS

According to the October 2011 statewide analysis, Michigan has an estimated 19,500 cases of HIV, but only 15,000 have been identified. Of these, 49 percent are men who have sex with men, with another four percent not only MSM but also intravenous drug users. Heterosexuals account for 18 percent of the cases, intravenous drug users account for 10 percent, while a whopping 18 percent have an undetermined transmission route.

The epidemic is concentrated on the lower end of the age spectrum. Thirty-four percent of the cases were diagnosed in people 30-39, while 13-19 year olds account for five percent, 20-24 year olds account for 14 percent and 24-29 year olds account for 17 percent. In short, 36 percent of those living with HIV in Michigan are under the age of 30, and 70 percent are under 40.

The epidemic is centered in Detroit - with 65 percent of the identified cases. And the epidemic is crushing in some areas of the city, with prevalence rates of three, four and five percent in over half of the city's zip codes, while one zip code has a prevalence of six percent.

Of the identified cases, 54 percent are African American men and 39 percent are white men. Women are heavily weighted to African Americans with 78 percent of the cases, while white women represent 19 percent.

There is some good news when looking at the long-term review of HIV cases in Michigan. The number of newly diagnosed cases has dropped since peaking in 1992, but it has held relatively steady in the decade since. The number of AIDS deaths has also dropped dramatically since the 1996 advent of anti-retroviral medication treatments.

Many of the people with HIV have their drugs - which can cost $15,000 or more a year - paid for by the AIDS Drug Assistance Program. ADAP is a federally funded program which combines drug discount prices, some state cash and federal money to provide the life saving medication. The program costs millions of dollars a year to provide medications to just fewer than 2,000 residents.

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UNCERTAIN FUNDING FUTURE

Funding for Michigan's financial programs is under assault due to both federal and state budget challenges. With an exceptionally anti-gay and hostile Republican legislature, Michigan has seen an attempt by Rep. Dave Agema (R-Grandville) to defund the Healthy Michigan Fund Initiative. This fund provides the entire cash match the state has to provide for HIV funding programs. Agema introduced legislation in January that would have transferred the funds to airport upkeep. The bill has gone nowhere, but continues to float in the legislature.

On a federal level, a new formula to determine HIV funding priorities will result in a 33 percent cut to Michigan's share of federal prevention cash.

On top of this, the Centers for Disease Control and Prevention in Atlanta announced earlier this year that if would shift funding priorities for HIV prevention away from traditional programming that targets HIV-negative persons or persons who do not know their status to funding prevention for positives programming.

Prevention for positives focuses cash and prevention messaging on those who know their HIV-positive status, but critics have raised concerns the programming contributes to stigma and could contribute to increased HIV infections.

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A SHIFT IN POLICY

While the funding picture for HIV appears muddied at best, the state department of health has made moves to bring Michigan HIV policies in line with current science.

After over a year of delay, the Michigan Department of Community Health launched protocols for administration of non-occupational post-exposure prophylaxis (n-PEP). This is the use of powerful anti-retroviral medications for 28 days following a sexual or needle sharing exposure to HIV. The medications have to be administered within 72 hours of exposure or the medicine does not work.

The CDC and the World Health Organization issued guidance for n-PEP administration in 2005 and 2006, respectively. But the state did not adopt a policy until after a 2009 investigation by Michigan Messenger found access to the life saving medication was dependent on where one was in the state.

While the state has an official policy, access to the medications is limited. The MDCH has announced that there is not a program to assist in paying the $1,000 price tag for the medications, and the federal programs for medical access to medication is limited to those who have already tested positive for the virus.

Ingham County, home to the state's capitol, has the highest prevalence rate of HIV outside of Detroit. The health department announced in 2010 that it would offer n-PEP and the drugs are now covered by the county's health plan for low income residents, says Renee Canady, interim health officer for the county.

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DISCLOSURE AND STIGMA

Access to prevention medications is not the only issue the state has faced in terms of policy in the last year. A multi-year investigation by Michigan Messenger and Between The Lines found that many counties were having persons who tested positive for the virus sign documents which outlined supposed legal obligations for the HIV-positive person. Many of these documents were legally inaccurate, resulting in the MDCH directing local health departments to review their documents.

"The Michigan Department of Community Health (MDCH) does not endorse or encourage the use of 'Client Acknowledgment Forms,'" wrote Amna Osman, director of the Division of Health, Wellness and Disease Control. "We do not support or endorse any practice or policy which may contribute to stigmatizing HIV or associated risk behaviors as this may serve as a deterrent to individuals seeking testing to learn their HIV status, or from seeking care, if they know they are HIV-infected."

Osman also indicated in the letter that such forms are not required under Michigan law.

"We strongly encourage LHDs - local health departments - that are currently using Client Acknowledgment forms to review this practice immediately," Osman wrote.

But even as the state was directing counties to stop using the legally inaccurate documents, it was continuing to use an obscure section of the public health act to track and challenge those living with the disease. The Health Threat To Others program is a civil procedure to force those with HIV to disclose their status and to engage in safer sex behaviors. The program follows a strict process of warning, followed by a list of sanctions. Failing to fulfill the obligations of a warning and sanctions can result in civil confinement for up to six months. In addition, those under observation under the program are listed in a statewide database of HTTO orders.

Trevor Hoppe, a doctoral student at the University of Michigan studying the application of Michigan's disclosure statute by public officials, reported at the CDC's National HIV Prevention Conference this summer in Atlanta that he had documented health officials using sensitive health information to assist in their health threat investigations. Interviews with health officials showed that some were actively cross-referencing the state's name-based database of known HIV-infected persons with partner services referrals to identify potential HTTO cases. In addition, Hoppe reported that some officials said they would identify as a health threat any HIV-positive woman in their jurisdiction who became pregnant - something advocates say impinges on the sexual and reproductive rights of those living with HIV.

While the HTTO program appears to be the preferred tool of Michigan's health officials, a felony law remains hanging over the heads of any HIV-positive person. That law requires an HIV-positive person to disclose his or her status prior to sexual penetration, "however slight." However, it does not require disclosure prior to sharing needles. Failing to disclose is a felony punishable by up to four years in prison in Michigan.

Criminalization has become a major issue for advocates who note that research shows the law has no impact on the behavior of HIV-positive people, and may in fact be hampering prevention and testing initiatives. Advocates say more and more people who are engaged in high-risk behavior are unwilling to get tested in order to prevent being held criminally liable for their behavior.

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TESTING ISSUES

People who refuse to get tested hampers efforts to slow the progress of the disease. Strong scientific evidence has shown that those on successful medication treatment are extremely unlikely to transmit the virus. This has lead to high impact drives to increase testing and access to care in a program federal authorities call test and treat.

Part of the test and treat strategy is a requirement from the federal government that state governments track viral loads of persons living with HIV. The goal is to reduce the community viral load and in the process reduce the new incidence rate of infections.

In some jurisdictions, health officials are beginning to use viral load testing to find people who are not on treatment and to confront them about it.

Michigan tracks viral loads, but MDCH says those results are not used for anything.

"Currently MDCH collects HIV viral load, western blot and CD4 results for epidemiological surveillance of HIV disease in Michigan," says Angela Minicuci, spokesperson for the MDCH. "Physicians will follow up with their patients on any positive HIV test results (such as a detectable viral load and reactive western blot) and will then report that case to the MDCH for the epidemiological surveillance. Additionally, viral load (detectable and undetectable) and CD4 results are aggregated and used to identify areas of the state where there may be gaps in service for persons living with HIV. This helps us to make well-informed funding decisions."

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