Charging Migrants for HIV Treatment

posted: 04/04/2011

The government has said it will soon change the rules about charging people from abroad for most treatment at NHS hospitals in England. At the moment the rules do not affect many people in North West England with HIV but that is likely to change. New Rules will probably appear in June.

The government has also announced another, bigger review of NHS charges. This will look at anything and everything and is intended to save the NHS a lot of money.

The next step is the department of health will publish the new rules for NHS hospital and clinic charges and guidance quickly – probably before June.

They have just published their response to a public consultation so now we know something about what the new rules from June will probably say. George House Trust gave evidence and comments to this consultation.

The Department of Health's plans for the June rules are 

• They won’t change which treatments will be charged for yet – but may do so later.
• The rules will be changed to make it clear that refused asylum seekers who get Section 4 and Section 95 payments do not pay for NHS treatment
• Unaccompanied children will no longer have to pay, but children with parents here can be charged
• They will make clear in the new rules that anyone who has begun HIV treatment that is free of charge (e.g. because they have an asylum claim which has not been finally decided) will continue to receive free HIV treatment
• They will keep putting up posters about charging for treatment in hospitals and clinics, even though they know this frightens some people that need treatment away and can lead to discrimination by hospitals
• They will change the guidance that tells doctors to think about the cost of treatment, because this encourages discrimination
• They will start a new system of telling the UK Borders Agency about the people who owe the NHS money. This will mean people will be refused permission to stay longer, applications for citizenship may be refused and people will be refused a visa to return to the UK if they leave
• They will consider introducing a rule that will force visitors from overseas to have health insurance
• They will look at charging people for primary care (treatment by family doctors)

Free HIV treatment for all?
The Government still has not decided whether to make HIV treatment free for everyone who needs this on public health grounds, like for all other sexually transmitted infections. They say they are still considering this and will report “in due course”.

Next, an even tougher review
They have also announced another major review which is designed to save the NHS a lot of money. This will look at

• Changing the residence rules, including the definition of ordinary residence
• Changing some or all of all the types of treatment and types of people who do not have to pay for NHS treatment
• Making people pay for primary care (that is treatment by family doctors and dentists)
• Changing which bit of the NHS has to pay when people cannot pay
• Making the procedures for checking who should pay tougher before treatment begins
  Making the procedures for collecting charges tougher
• Using new ways to collect charges 
• Requiring migrants to have health insurance 
• They will consider anything and everything else.

They try to soften this tough new cost-saving review by saying “the NHS is, and must remain, ultimately a humanitarian organisation. In undertaking the review, we will be mindful of the NHS’s core values, in particular its obligations to provide urgent treatment to any person irrespective of their status or ability to pay, to protect the vulnerable and respect our obligations on healthcare provision under international treaties . There is no intention to consider policies that would deny access to any group, only whether an individual should be charged. It will consider the full benefits and costs of introducing new charges including risks of deterred or delayed treatment and any other societal costs. In addition, we will ensure that public health considerations are fully factored into proposed rules and processes (ensuring in particular that access policies do not compromise the identification and control of infectious diseases).”

A comprehensive package of confirmed proposals will be put to full public consultation on completion of the review work, in 2012. We may consult separately at an earlier stage on some options, such as primary care charging.
 

You can read the details of the government's proposals for the June regulations and this new review here. The new review details begin on page 24. 

Proposals and Review report

Hepatitis C Twice for HIV+ Gay Men

posted: 16/03/2011

Just over one-quarter of gay men with HIV cured of early stage hepatitis C in Amsterdam got it again within two years. The men got hepatitis C from different people the second time.
 

10 times more reinfection – better prevention needed
The hepatitis C reinfection rate among these Amsterdam HIV positive men is ten times higher than the rate they of first hepatitis C infection among men with HIV.
 

It is clear that much better health promotion work is needed if men are to avoid reinfection with hepatitis C.
 

Sexually transmission of hepatitis C among gay and bisexual men happens widely especially in cities like Manchester, Brighton, London, Amsterdam, Berlin, as well as in North America and Australia.
 

Sex risks and networks
Various explanations have been offered for the greater vulnerability of men with HIV infection, including chosing sexual partners who also have HIV (called sero-sorting), and networks of sexual partners where many of the men have HIV. However it is the sexual and drug-using practices which affects who gets hepatitis C.
 

Heptatitis C reinfection
Researchers from Amsterdam Academic Medical Centre and the Amsterdam Public Health Service reported HIV+ men reinfected after being successfully treated for hepatitis C.
Twenty-eight men were successfully treated. Two men relapsed and hepatitis C reappeared within two months of the end of their hepatitis C treatment. Of the remaining 26 men, 7 were reinfected within two years, an incidence of 19.6 per 100 person years of follow-up. The time to reinfection was typically one year but could be much sooner.
 

Different type of hepatitis C
In every man reinfected they had a different genetic version of hepatitis C - three who first had genotype 4 then got genotype 1, while two men who started with genotype 1 get genotype 4 the second time. One man got genotype 1 again but even this was from a different clade, a different subtype.
 

Better prevention
The researchers say that discussion about prevention measures needs to take place not only at the time of diagnosis, but during and after treatment.
In particular men need to understand all the possible sexual and drug sharing transmission routes, and must to feel free to have frank discussions with doctors about sexual practices, drug-using behaviour and other risk factors. Too many HIV positive men with hepatitis C feel unable to talk freely because they feel judged, shamed and blamed by their HIV clinic.
 

Keep testing
Regular HCV testing in previously-treated individuals is also essential. We reported recently that while around 8% of gay and bi men with HIV in the UK have hepatitis C, one quarter of positive gay men were not checked for this in 2008, when every person with HIV should be checked at least once a year.

A German study showed similar reinfection among HIV-positive men. 22% became reinfected within six years, despite the number of first hepatitis C infections in Germany falling. 

Treatment of acute hepatitis C infection with pegylated interferon and ribavirin prevents early HIV infection progressing to chronic infection, which is harder to treat in HIV-positive people.
European guidelines on treatment of acute hepatitis C infection note that HIV-positive patients have a good response rate to treatment begun within a year of infection.

Source  with reference

Jane Takes a HIV Lead

posted: 16/03/2011

The discovery of HIV in 1981 sparked widespread panic and a media frenzy. But 30 years on, one of London’s leading London HIV doctors, Professor Jane Anderson, knows that keeping HIV in the public eye is now much harder.
 

Jane is the director of Homerton Hospital’s Centre for Sexual Health and HIV – she happens to be married to TV wit Clive Anderson – has watched the HIV changes over the years.

New Chair for BHIVA

She takes over as Chair of the British HIV Association this spring.
 

“I qualified as a doctor just at the beginning of the AIDS epidemic,” she said. “We didn’t know about HIV. We just knew about the [gay] men who were dying. When I first started, we were giving people huge quantities of drugs to take home – like shoe boxes full of the most revolting potions. If you told me then that we would have one pill to be taken once a day in the course of my career – not even my lifetime – I would have said absolutely not.”
 

She began working at the Homerton in 1990 after setting up the HIV unit at Barts hospital in London.

The Homerton had just 35 HIV positive patients back then. Now the Homerton hospital HIV team care for 820 people. Survival rates have hugely improved with the development of combination treatment of antiretroviral drugs in the mid 1990s, which has transformed HIV into a lifelong, but manageable, condition. People can have a good and long life now with HIV.
 

Treatment success
Patients aged 35 when infected can expect a further 35 years of normal life, and the team at the Homerton ensure the babies women with HIV may have are HIV-negative.
 

Stigma still a testing barrier
But despite the medical advances, one barrier still remains. “There’s a frustration with the stigma and the fact that people are still reluctant to get tested,” said Jane. “It is one of those things –you know that you have got the solution in your hands but people are too afraid to come and take it. To have come this far and to still find people won’t talk about it – this is where medicine meets reality.”
 

Undiagnosed means treated late

The number of people living with HIV nationally reached an estimated 86,500 in 2009. But more than a quarter – almost 22,500 – were still unaware of their infection, according to the Health Protection Agency. In many HIV clinics around one quarter of all HIV diagnoses are at a late stage of infection, when permanent damage has already been done to the immune system. Most deaths from HIV in the UK are among the people who were late coming for medical help.
 

The Homerton hospital has some celebrity supporters - actor and comedian Stephen Fry, who filmed part of a HIV documentary at the hospital, as well as Jane’s husband, the former barrister and television presenter Clive Anderson, who are not afraid to take a public stand.
 

Jane and Clive met in 1979 and will be celebrating their 30th anniversary this year.
“He is incredibly supportive. He has always been up for helping,” said Jane. “I’m always coming along with another request and he always says yes.”
 

Source

HIV Migrants Detained and Denied

posted: 14/03/2011

UPDATED  4 April 2011

In their new report Detained and Denied: The clinical care of immigration detainees living with HIV, the charity Medical Justice produce evidence showing that their experience is that most HIV+ immigration detainees are denied HIV medication and care.

This study is the first ever comprehensive analysis of the UK's treatment of 35 HIV+ immigration detainees who were supported by Medical Justice. Eight independent expert clinicians assessed the detainees's health and needs, and there are also legal documents and testimonies from detainees.

Is HIV detention illegal? - Appeal Court will decide

The evidence in this report will be heard in the Court of Appeal in April when three HIV-positive migrants seek to have their detention ruled unlawful because of the centres' failure to treat them properly.

The key findings in Detained and Denied are :

• The British government treats HIV+ detainees’ health beneath contempt : 60% had breaks in their HIV treatment due to their detention, and many developed drug resistance. 77% were deported with little or no medication.
• The government may well have shortened detainees’ lives and prematurely orphaned children
• The process of detaining people who are HIV+ inherently puts them at risk
• The denial of medication has in some cases meant that detainees developed drug resistance, necessitating more complex drug combinations, which are rarely available in many countries
• The government is willing to deport people who may die within a few years as a consequence of that drug resistance.

Detained and Denied - Medical Justice report 

Chronic Indifference is a similar study, about the experience of HIV+ migrants who were detained and denied in the USA.

NAT (National AIDS Trust) points out that the Government has a special duty of care to people it detains. All detainees and prisioners are entitled to the same level of healthcare as is available to everyone else, particularly for a serious life-threatening condition like HIV.

Instead the report shows people with HIV are continuing to face unacceptable neglect. NAT worked with the British HIV Association (BHIVA - the professional association for HIV clinicians) to produce best practice advice on HIV treatment at Immigration Removal Centres precisely to prevent these problems. It is a disgrace that the advice is being ignored in so many cases.

Deborah Jack, Chief Executive of NAT (National AIDS Trust), said:

'NAT welcomes the important report from Medical Justice, 'Detained and Denied', on the treatment of people with HIV in immigration detention, and deplores the continuing failures in care. The NAT/BHIVA best practice advice is there to assist those responsible to provide equivalent high quality care to that available in the community - not to do so is inexcusable.

‘NAT has asked the UK Border Agency to work with us on a 12-month audit of every person with HIV who goes through the immigration detention process, to assess the quality of their care. We are still waiting for a response. The Medical Justice report underlines how urgent it is for such an audit to take place and concerted action to be implemented to address problems identified. We urge the Government to agree to the HIV audit as soon as possible.'

NAT call on the Government:
 

• To investigate the breaches of care outlined in the Medical Justice report 'Detained and Denied’
• In particular, to investigate the failures at Yarl's Wood and in advance of this and any resulting action, to immediately stop using Yrarl's Wood for detaining anyone with HIV
• To commission centrally healthcare in Immigration Removal Centres through the planned NHS Commissioning Board
• To agree to a 12-month collaborative audit with NAT of all those with HIV detained at any Immigration Removal Centre

Treating to Prevent HIV

posted: 03/03/2011

Could people who do not have HIV use HIV treatment drugs (PrEP) to stop themselves from getting HIV? The detailed results just out for gay and bi men are better than the early findings. This means PrEP could be approved for use in the USA by the end of the 2011.

Last year, the first results from a study of gay and bisexual men appeared. Taking PrEP cuts gay and bi men’s risk of getting HIV. But there were worries because many of the men did not take all the tablets. Some men got HIV.

HIV infection
Much better updated results were announced at the CROI conference in Boston, USA, that has just ended.

In the different places where the trial took place, including South Africa, the taking of PrEP (HIV drugs to prevent HIV infection) varied a lot.

Gay and bi men in the two USA cities (Boston and San Francisco) of the international iPrEx study of tenofovir/FTC (Truvada) had near-perfect HIV-prevention drug taking, compared with 50% tablet taking at the other sites.
 

And the men taking the greatest sexual risks for HIV, by having unprotected receptive anal sex, were taking the prevention treatment better than men taking less HIV risks – which is good to know.
 

USA approval within a year?
Lead investigator Bob Grant announced that the US Food and Drug Administration (FDA) had agreed that the trial results were good enough for the FDA to consider allowing the use of Truvada to prevent HIV. PrEP, as a result, might be approved in the USA by the end of this year.
 

First USA Guidelines for gay men published

Interim Guidance: Pre-exposure Prophylaxis for the Prevention of HIV Infection in Men Who Have Sex with Men from USA Centers for Disease Control and Prevention. 

2500 men and the results

There were almost 2500 men in this trial and 130 of them got HIV by the end. Like most drug trials men were randomly split into two groups and told they would either get Truvada, or a dummy pill, but no-one would know who was taking what, until the end. The men were therefore warned they should still use condoms, because half were using the dummy pill.
 

48 of the men who got HIV took the Truvada and 82 of the men who were taking the dummy pills, a HIV infection rate of 2.6% a year. Another 10 other men have HIV, but they already had the symptoms of HIV infection when they joined the study.
 

This means that the final ‘how well does it work’ rate in the ‘modified intent to treat’ analysis, (this leaves out the 10 men who started the study with HIV, and ignores things like different rates of tablet-taking and the men’s level of sexual risk-taking), was 42%.
 

PrEP worked better when men were over 25 (56%), among men who took more than 9 out of 10 of the tablets (68%), and among the men who were circumcised (76%).
 

Would PrEP be cost effective? 

Other new studies have now looked at the value for money of treating people to prevent HIV in South Africa. The answer is mixed. 

It is usually cheaper to treat the person with HIV than treating one or more HIV negative people with PrEP. Treating the person with HIV should reduce their viral load so it becomes undetectable and their chance of passing on HIV then becomes very small. In mixed status couples, that may be enough protection for many. But PrEP would help protect negative partners who have unsafe sex outside the main relationship and who don't use condoms.  

Source and more details