So what was all the shouting about? Who won, who lost, and why will NAPWA be honoring President Obama and others with a Positive Leadership Award at AIDSWatch? NAPWA's Matt LeSieur has prepared a wonderfully thorough summary of what the bill does and what the President and our friends in Congress had to do to get it passed . . . .There will be immediate impacts for those living with HIV and AIDS.

· Within 90 days, the federal government will create a temporary high-risk insurance pool for people who have been uninsured for  six months and have a pre-existing health condition. Premiums will be offered at a subsidized rate.

· Within six months, plans will be prohibited from placing lifetime limits on the dollar value of coverage and insurance can not be cancelled except in cases of fraud.

· People with HIV and AIDS enrolled in Medicare's Part D drug benefit  will get some small, but immediate help filling the coveragegap, otherwise known as the donut hole. A $250 check will be sentall Medicare Part D enrollees this year. Drug discounts begin in 2011 and the gap will gradually close.

· By far the biggest benefit starts in 2014. That's when Medicaid willbe expanded to all low-income individuals, including those who are HIV-positive, whose income is below 133 percent of the federal poverty level. No longer will an AIDS diagnosis be required.

 

Read more about these benefits and the story of how it all happened here.

 

We are delighted to welcome Dr. Bruce Rashbaum to our Positive Voice to answer your practical HIV treatment questions. Send your questions to PositiveVoice@NAPWA.Org, and we'll select one question per issue for Dr. Rashbaum to answer. (And let us know if you want us to say, Jeff in Seattle asks . . . . )

 

Here is how Dr. R introduces himself: "i have been hiv + since 1979 being part of the old hepatitis b trials and having actually seroconverted in 1979, which we know from banked blood from the trial. i have been practicing since 1987 and have been a primary investigator for every pivotal trial with antiretrovirals. my web site is www.dcdocs.com." That's what he says for himself, but there's lots more we can add. A graduate of Boston University Medical School, he now teaches at George Washington University School of Medicine. He is one of the Washington, DC area's leading physicians working with HIV+ patients, he's been knee-deep in the design of many of the clinical trials so many of us know and love, and he has a long and distinguished record of volunteer work with DC's Whitman Walker Clinic, DC AIDS Ride, The Names Project, and Food and Friends. We're proud to have him on board.

 

This issue's question: "I know now that I'm HIV+. When should I start treatment with anti-retroviral (ART) drugs?"

Dr. Rashbaum writes (in the style of a busy man):

the decision to start ART can be tough, emotional and a very individualized one. it starts with acceptance of having HIV and the understanding that HIV is a progressive disease and will harm you if you let it. and it takes motivation and discipline to accept the responsibility of taking a medical regimen everyday, probably for the rest of your life. there are guidelines that on review and debate of scientific data by a group of our medical and community peers from the department of health and human services instruct a clinician and their patient how to decide if therapy with ART is appropriate at a particular time.. these guidelines have evolved over the past decade from hit hard and hit early to waiting till the cd4 counts fell below 200 cells/mm3, then waiting till they fall below 350 cells/mm3 and now, in 2010, essentially treating all comers. the decisions to recommend treatment were based on reviews of large cohort trials that showed benefits of starting therapy at earlier and earlier stages of infection. not only was there improvement in HIV related morbidity and mortality but also non-AIDS related diseases: malignancies, cardiovascular disease, liver and kidney diseases. even though the panel concluded with recommending that people be treated with cd4 counts over 500 cells/mm3, they were split nearly 50/50 on the strength of this recommendation. use the guidelines but one should use their clinical judgment over all else to determine if treatment is best. the goal of therapy is to control the inflammation caused by the virus and to preserve immune function as much as possible. now that we have medications that are much less harmful, it is easier to recommend therapy to my patients. i believe that everyone living with HIV should be on medications today in 2010. ask your docs if they were infected, what would they do? i think we would be surprised by the answers.

i am not so sure there are the same challenges today that confronted people living with HIV in the first decade of this epidemic. then, it was a death sentence and the medications were difficult and toxic. i lost 200 patients per year for the first decade. now, maybe lose one. so where we were and where we are is a compelling story., and the opportunities abound for the individual living with HIV in 2010 and the choices are myriad and daunting for some. we have 6 classes of drugs from which to concoct a regimen. there are now 4 preferred regimens for a naive patient although a multitude of alternatives from which to devise a cocktail from. one of the problems is whether to trust the advances of science and choose a newer cocktail over one that is tried and true such as atripla. there are known short and long term side effects of the older drugs yet we have little knowledge of the toxicities of the newer agents, especially long term, they appear to be far better tolerated . . . . it is all about tolerability and toxicity, but who can beat one pill once a day. so maybe one big problem confronting a person living today is how to integrate the knowledge that this medical condition will live with you for a very long time, hoping that you will always have the means or access to healthcare and how to use your health to enrich your life's experiences . . . . good health is achievable and it is key to a long and fuller life.