Access to pain relief

There have been important recent developments in the Drug Enforcement Administration regarding their policies on opium-based prescription drugs such as OxyContin. Before September, strict regulation by the Drug Enforcement Administration required physicians to limit prescriptions to a 30-day supply. Physicians who exceeded the required amount have faced investigation, arrest, and persecution as "drug dealers". A new proposal, subject to 60 days of public comment starting in early September, would allow doctors to prescribe up to a 90-day supply without fear of prosecution. Doctors that exceed this new limit will be subject to prosecution. Their cases will be identified on the DEA's new webpage, "Cases Against Doctors".

Marc Kaufman of the Washington Post has been following this, along with many others. Useful links to his articles (available on the PRN website) and more below:

http://www.usdoj.gov/dea/pubs/pressrel/pr090606.html
http://www.usdoj.gov/dea/concern/oxycontin.html
http://www.painreliefnetwork.org/article_detail_T6_R214.html
http://www.painreliefnetwork.org/article_detail_T6_R288.html
http://www.mercurynews.com/mld/mercurynews/living/health/15453353.htm
http://www.stopthedrugwar.org/chronicle/452/dea_proposed_rules_to_ease_pain_prescribing_restrictions
http://a257.g.akamaitech.net/7/257/2422/01jan20061800/edocket.access.gpo.gov/2006/pdf/E6-14520.pdf

Questions from Civil Society to All Nominees for WHO Director General

These questions were proposed to all WHO Director Nominees. Stay tuned--we will post their responses as they come.


1. Global commitments have been made to universal access to HIV/AIDS prevention, care, treatment and support. For example, the African Union (AU) Common Position commits to doing everything possible to achieve 80% coverage of adults and children in need of antiretroviral treatment (ART) by 2010. Do you support the establishment of similar targets for other regions? How, specifically, will the World Health Organization (WHO) contribute to reaching these goals in Africa and in other regions?

2. The promotion of basic human rights is essential to the global response to HIV/AIDS. Medical and public health approaches to the epidemic must address basic human rights concerns at all levels, yet tension often exists between public health and human rights communities. In what specific ways do you see WHO responding to human rights concerns as a fundamental aspect of public health and medical approaches to prevention, treatment and care across the board?

3. How, specifically, will you ensure that the involvement of civil society--including people living with HIV/AIDS and vulnerable groups—is a priority at all levels of decision making, from the setting of funding, policy, and programmatic priorities through the design, implementation, monitoring and evaluation of prevention, care, treatment, and support programs? For example, a major concern for civil society right now is the development and dissemination of new guidelines by WHO for provider-initiated testing without adequate concern either for basic human rights principles and/or adequate transparency and accountability in the consultation process to develop these guidelines. How will you ensure adequate global consultation, comment, and critique on issues of voluntary counseling and testing versus provider-initiated testing and by what means will you include civil society actors in monitoring and accountability in these areas?

4. How will WHO tackle the challenges of TB/HIV co-infection, and move to help countries achieve universal access to the full WHO-recommended package of 12 collaborative TB/HIV activities in all health systems, particularly in countries with high HIV burden? How will WHO address the increasing epidemics of MDR- and XDR-TB?

5. The advancement and protection of sexual and reproductive rights are crucial in the response to HIV/AIDS. Gender inequality, gender-based violence and discrimination fuel the spread of HIV among women, girls, LGBT and other populations and are both cause and consequence of the spread of HIV infection and other urgent public health problems. How will WHO deal with these issues specifically as integral to all of the work of the organization and health systems under your tenure and as integral to the response at every level of law, policy, and health practice within member countries?

6. Specific populations are particularly vulnerable in the epidemic, including those already marginalized by social stigma and widespread discrimination and routinely denied their basic human rights. These groups include, among others, intravenous drug users (IDUs), commercial sex workers (CSWs), gay, lesbian and transgender persons, men who have sex with men (MSM), and undocumented migrants. Rather than promoting their basic human rights, governments often seek instead to criminalize and further marginalize these groups. How—specifically--will WHO work to protect the right to health for all these groups? How can WHO, for example, help advance the rights of IDUs, CSWs, MSM, and others as an integral part of an effective global response to the HIV/AIDS epidemic, especially in countries where these rights are not protected? By what means will WHO seek to ensure effective and adequate services are made available to those in prison settings? How will WHO work to advance rights-based public health approaches over efforts to further marginalize and/or criminalize vulnerable groups?

7. The world continues to fail in delivering on universal access to an essential package of AIDS commodities that includes: antiretroviral medicines (for both treatment and prevention of HIV infection); drugs to treat and prevent tuberculosis, hepatitis C, sexually transmitted infections (STIs) and other co-infections; HIV testing kits and other diagnostic technologies; home-based care kits and related essentials; breast milk substitutes; male and female condoms, substitution treatments; and clean injecting equipment. In what ways will WHO lead in filling these gaps?

8. All prevention interventions must include complete and accurate evidence-based information about HIV/AIDS prevention and treatment at the level of the individual. “Conscience clauses” and “opt-outs” can not trump the rights of individuals to fully informed choices and consent. How will you seek to bridge the increasing ideological divide undermining access to comprehensive prevention interventions worldwide? Prevention and treatment must also be linked in meaningful ways: Today, for example, only a small share of pregnant women living with HIV have access to services for the prevention of mother-to-child transmission, and few of those accessing PMTCT have sustained access to treatment for themselves. In what ways will WHO help to bridge these and other gaps?

9. How do you envision WHO’s work with generic producer countries and less developed country governments without manufacturing capacity to set precedents for the use of TRIPS flexibilities including compulsory licenses for export of first- and second-line anti-retrovirals?

10. UNAIDS estimates that the world needs to provide between $20 billion to $22 billion by 2008 to fund a comprehensive response to HIV/AIDS. How will WHO work with donors, multilaterals (GFATM, UNAIDS, World Bank), and countries around the world to assure the necessary resources are mobilized and deployed? How will you work to end the unnecessary institutional friction in Geneva between UNAIDS and WHO and to ensure that GTT recommendations on harmonization and alignment of multilaterals are implemented?

11. Finally, what is your vision of the role of WHO in promoting needed research and development on HIV, TB, malaria, and other global killer diseases to ensure that health-related Millenium Development Goals are met and that new generations of more effective diagnostics, treatments, and vaccines, including a vaccine and ultimate cure for HIV/AIDS, are developed?

Kennedy and Waxman urge U.S. to promote access to healthcare in its trade practices

In recent letters to Secretary Michael Leavitt (Health and Human Services) and Comptroller General David Walker (Government Accountability Office), Senator Kennedy and Representative Waxman remind the Administration of its obligations under the Trade Act of 2002. Under this act, the U.S. is obligated by law to respect the commitments made under the TRIPS and Public Health, commonly known as the 'Doha Declaration'.

Kennedy said:
“In this era of HIV epidemics, avian flu outbreaks, and other public health threats, it is essential that we promote good health and access to medicines in every country”.

Waxman chimed in, perhaps more pointedly:
“We have to recognize that the Bush Administration’s single-minded pursuit of intellectual property protections for drug companies can have potentially devastating consequences for the public health in developing countries”.

Kennedy and Waxman also asked the government to retract its demand for the World Health Organization to withdraw its 2005 report, "The Use of Flexibilities in TRIPS by Developing Countries: Can They Promote Access to Medicines?, that identifies barriers that trade agreements impose on public health policies. Waxman said, “We need more analysis of the implications of our policies, not less”. One point the WHO report made was:
“…the U.S. policy, by focusing exclusively on the interests of its export industries, may lead to very restrictive interpretations of the flexibilities contained in international agreements to the detriment of public health needs in developing countries”.


Links to:
Letter to the Honorable David M. Walker in the Government Accountability Office
Letter to the Honorable Michael O. Leavitt, Secretary of Health and Human Services

ONDCP: Misconstruing evidence on needle exchange programs.

The ONDCP (Office of National Drug Control Policy) has a blog called “Pushing Back” which recently featured an interview with Dr. David Murray, an ONDCP policy analyst and “expert” on needle exchange. The blog entry was entitled “What’s Wrong with Needle Exchange Programs?”

In the interview Dr. Murray claims that recent research about the programs’ effectiveness in lowering HIV infection has been inconclusive, and that their effect on continued drug use is unknown. These claims form the basis of the Federal Government’s refusal to fund needle-exchange programs. Dr. Murray says that endorsing needle exchange programs conflicts with the “primary burdens for any public health intervention” which are to:

“…produce the effect that they intended to produce, that they do not introduce harmful unintended consequences, and that they are demonstrably superior to other interventions that could produce better outcomes”

Ok, let’s look at these criteria:

1) produce the effect that they intend to produce –

Murray cites a recent Institute of Medicine report , and says that evidence concerning the effect of these programs on HIV infection is “limited and inconclusive”. However, the report specifically says:

“a large number of studies and review papers…show that participation in multicomponent HIV prevention programs that include NSE [needle and syringe exchange] is associated with a reduction in drug-related HIV risk behavior, including self-reported sharing of needles and syringes, unsafe injection and disposal practices, and frequency of injection.”

2) do not introduce harmful unintended consequences –

Dr. Murray also misrepresents the IOM report when discussing the effects of needle exchange on drug use itself. While Dr. Murray says that evidence on this is “inconclusive”, the IOM report says:

“the few studies that have examined the unintended consequences of programs that include NSE found no evidence that they lead to more new drug users, more frequent injection among established users, expanded networks of high-risk users, changes in crime trends, or more discarded needles in the community.”

3) are demonstrably superior to other interventions that could produce better outcomes –

Dr. Murray states: “The single most important point, however, is that there is a superior intervention that reduces the risk of disease transmission and that reduces the danger from the drugs themselves -- that intervention is drug treatment.”

Drug treatment is clearly essential, but why should it be only drug treatment, and what is ONCDP doing to make treatment more available worldwide? UNAIDS estimates that there are now 13 million injecting drug users worldwide. Where drug treatment is available at all, it is often ineffective or punitive. In Russia, with an estimated two million IDUs, “treatment” is often restricted to medically managed withdrawal. Prescription medication to reduce cravings for illegal opiates (substitution treatment) is illegal. Across Asia, many drug users are confined to centers that are more like prisons than health care facilities, and that offer little or no psychosocial or medical support.

It’s one thing for the Federal Government to decide not to fund needle exchange programs and leave it up to the states. It’s quite different for them to misconstrue the evidence of their important role in battling HIV-infection. The Institute of Medicine is not alone in its findings. In 2002 Surgeon General David Satcher issued a report to Congress that concluded:

“After reviewing all of the research to date, the senior scientists of the Department and I have unanimously agreed that there is conclusive scientific evidence that syringe exchange programs . . . are an effective public health intervention that reduces the transmission of HIV and does not encourage the use of illegal drugs.”

Additional organizations that support needle-exchange programs as effective tools for protecting the public health of communities include:

American Academy of Pediatrics
American Bar Association
American Foundation for AIDS Research
American Medical Association
American Public Health Association
Association of State and Territorial Health Officials
National Alliance of State and Territorial AIDS Directors
New York Academy of Medicine

Omololu Falobi: the loss of a great activist

Human Rights Watch mourns the death of its Nigerian colleague Omololu Falobi, 35, a multiple-awards winning journalist and human rights activist. Falobi died unexpectedly on October 5th, leaving behind his wife and two young children.

Human Rights Watch spoke with Falobi in July 2006 about his work and his hopes for the impact of journalism on the AIDS epidemic.

Falobi was the founder/executive director of Journalists Against AIDS (JAAIDS) Nigeria. At the 15th International AIDS conference in 2000, he won the International AIDS Society's Young Investigator Award. The same year, he was named the winner of the Highway Africa Award for Innovative Use of New Media, an award that recognizes outstanding and innovative use of the Internet in African journalism.

In 2001, he was appointed an Ashoka Fellow in recognition of his outstanding and innovative approaches to 're-engineering society'. In recognition of this advocacy on HIV/AIDS in Africa, he was selected as the African NGO representative on the board of the Joint United Nations Programme on HIV/AIDS (UNAIDS) for 2004 and 2005. More recently, he helped in convening the African Civil Society Coalition on HIV and AIDS, which serves as an umbrella movement for organizations involved in HIV and AIDS advocacy and campaigns on the continent.

“His individual leadership, his longtime commitment to pushing for Africa's own community leadership over its epidemic, his example of how journalists can be stronger social activists, his vision and championing of the Nigeria E-Forum (the only HIV/AIDS-focused listserve of its type and breadth in Africa), and his ability to draw other activists together for positive change have inspired and motivated people from around the globe into action - including me. His legacy speaks for itself...but his departure from us leaves a great void.” –Ron MacInnis, the Director of Health Journalism at Internews

More tributes to Omololu at: http://omololu-falobi.blogspot.com/

New report:Sterile injecting equipment and opiate substitution for IDUs

The Institute of Medicine recently published Preventing HIV Infection among Injecting Drug Users in High Risk Countries: An Assessment of the Evidence (2006), highlighting research that found that access to sterile injecting equipment and opiate substitution treatment effectively reduces the spread of HIV among injecting drug users (IDUs). Outside Africa, UNAIDS estimates that nearly one in three HIV infections is due to injecting drug use, yet HIV prevention services reach only 5 percent of the world's injection drug users. The report highlights this alarming fact by focusing on China, Thailand, and Russia and calls on governments to take immediate action to curb HIV among IDUs.

Unfortunately, there is a stark absence of a human rights framework. The article fails to hold governments accountable to adopting effective policies, saying for example "...HIV prevention interventions for IDUs should be tailored to local circumstances and implemented in a culturally appropriate manner". Too often "cultural norms" have been used as an excuse for horrendous rights abuses against individuals who use drugs. In order to effectively apply the research presented by IOM's scientists, a rights-based approach is necessary to overcome local stigma and discrimination.

Alert to CHAMP’s new monthly bulletin

The Community HIV/AIDS Mobilization Project has started a monthly bulletin focusing on AIDS in jails and prisons. Each issue will outline a case-study of an advocacy campaign. The first issue, published in June 2006, focuses on the movement around AB1677 which advocated for the distribution of condoms in California prisons (this bill was, unfortunately, vetoed over the weekend).

Check it out at: http://www.champnetwork.org/media/prisonissue1.pdf

AIDS adding to 'brain drain'

There are many factors contributing to the ‘brain drain’, or the loss of skilled professionals from developing countries. AIDS adds another layer to this: Lancet in August 2006 wrote that, alarmingly, “Death is depleting the ranks of health professionals more rapidly than recruitment abroad”.

Lancet cites studies from the Joint Learning Initiative and the WHO showing that the median age at death of HIV-positive professionals in Zambia is 38 years old. Over a decade, the deaths of nurses accounted for a 37 percent nurse vacancy rate.

The article promotes providing heightened access to HIV/AIDS care for civil servants in countries severely affected by AIDS. Granting them normal access creates delays and absenteeism, and does nothing to lessen stigma. Focusing on care for HIV-positive health professionals, the article argues, would do more to extend the survival of HIV-positive patients than banning recruitment abroad.

Uganda and Namibia are cited as nations that are taking steps to care specifically for civil servants with HIV.



Frank Feeley (2006) “Fight AIDS as well as the brain drain” The Lancet 368 (August):435.

Lancet on Maternal Mortality

From time to time we’ll include issues related to health and human rights that go beyond HIV/AIDS.

In an upcoming issue of the British medical journal Lancet are a couple of articles which advocate for increasingly focused approaches to the problem of maternal mortality.

In 2000, the Millennium Development Goals proposed to reduce maternal mortality by two-thirds by 2015. An article in this week’s Lancet says that this will best be done by adopting a “core strategy of intrapartum care based in health-centres”. The authors contend that not enough international attention has been directed towards maternal health and that the international donor community should “channel funds through sector-wide support”.

But in a related comment, researchers from University College London call the argument a “one-size-fits-all” strategy and suggest instead that maternal health policies be “context-specific” and community-based. Just strengthening the health services will have little effect on poor people who may not have access to the health centers, the Comment says.

Human Rights Watch recently reported on women turned away from care in Burundi, and imprisoned after giving birth for failing to pay their hospital fees. This report shows that clearly we must act both to strengthen the availability of appropriate, quality care, and the accessibility of it.

Kristof’s “The Deep Roots of AIDS”

Nicholas Kristof searches for the roots of HIV [Op-Ed, “The Deep Roots of AIDS”, September 19] and finds them in poverty and gender inequality. He tells the story of a man in Cameroon who falls ill and eventually dies of AIDS. The family, unable to gather the funds to pay for consistent treatment, is now destitute: the man’s wife is alone and disenfranchised, his daughters have dropped out of school and have few choices ahead of them.

Yet Kristof’s solution isn’t to address the root causes he identifies—poverty and gender inequality—but to promote routine HIV testing. Expanding testing programs alone will not ensure antiretroviral treatment for the lower-class. It will not end violence against women, which helps fuel the epidemic, nor will it diminish the lure of sugar-daddies to pay school fees or put food on the table.

In preaching abstinence until marriage and fidelity, the U.S. program on AIDS has turned a blind eye to these issues. We do need a more aggressive approach to the global AIDS crisis, but it must be built around protecting human rights, empowering women and girls, and expanding access to antiretroviral drugs. Only then will people seek HIV testing - and be able to do something about the result.

Report from New York City: the immigrant experience and HIV/AIDS

Over the last 3 decades, the growth and diversification of New York City’s immigrant population has mirrored the growth in the HIV epidemic.

Michele Shedlin and her colleagues in a recent study examined this concurrence, locating a gap in public health research. They state:

Because the HIV pandemic undergoes continual change in its locations and affected populations, it is crucial to study HIV risk behaviors among mobile and immigrant groups within and across borders.

Seeking to examine the impact of migration on health risks and disparities, the study focuses on Hispanic, West Indian, and South Asian immigrants to New York City. A complicating factor of great consequence is that since September 11th, 2001 data on immigrants in NYC have gotten scarce as the individuals have been more reluctant to identify themselves, fearing stigma or even deportation.

The study, published in the Journal of Urban Health as part of its “HIV perspectives after 25 years”, examined the three immigrant groups in different scenarios, involving in depth interviews and assessments. The contacts were made through hospitals, social workers, health officials, and outreach workers. The researchers found that, among an array of other hardships, immigrants are more than twice as likely as citizens to have no health insurance and knew less about HIV infection and protective measures.

The articles states boldly, “the success or failure of this city’s response to its HIV epidemic…will likely revolve around the adequacy of our responses to the challenges posed by our city’s vital and growing immigrant communities.” It calls for more studies of its kind, heightened communication, and more partnerships in order to achieve more informed HIV/AIDS prevention and care.

“Immigration and HIV/AIDS in the New York Metropolitan Area” Journal of Urban Health: Bulletin of the New York Academy of Medicine, Vol. 83, No. 1 (43-58)

Needle Exchange Debates

Progress in New Jersey

New Jersey has long prohibited the distribution of hypodermic needles in government-sanctioned programs and is the only state in the union still to do so. Now, 4 in 10 cases of HIV infections in New Jersey result from injecting drug use with contaminated needles. 14 years after the legislation was first introduced, lawmakers are reviewing a bill that finally appears to have enough support to win passage. The bill would allow needle-exchange programs and even Governor Jon Corzine has expressed support.

The New York Times reported on this story (September 25): http://www.nytimes.com/2006/09/25/nyregion/25needles.html


US AIDS policy: Still hostile to Evidence and Rights

On an international front, American officials withdrew their support for needle exchange programs at the WHO’s Asia-Pacific conference last week. They submitted last-minute proposals to a resolution calling for universal access to HIV/AIDS treatment that, in Peter Hodgson’s view, New Zealand’s Health Minister, would have watered down the resolution. He said “[the U.S.] position is that if they have needle exchanges then people will use needles more and use intravenous drugs more…I think it is demonstrably wrong”.

“Demonstrably wrong” pretty much says it all.

The Associated Press reported on this story in the IHT (September 25):
http://www.iht.com/articles/ap/2006/09/22/asia/AS_MED_WHO_Asia_AIDS.php

An urban structural intervention to fight AIDS

In the response to AIDS we need to keep reminding ourselves that it’s not all about individual behaviors.

For example, an AIDS and Behavior article from September 2005 targets housing as a promising structural intervention to reduce the spread of AIDS. The first study of its kind, it collaborated with a national, multi-site evaluation of HIV/AIDS service delivery projects that focused on providing services to low income HIV positive people. The projects were located all over the U.S. in primarily urban settings. Angela Aidala and colleagues then took the data and focused on the correlation between three variables: drug risk behavior and sex risk behavior (dependent variables), and housing status (independent variable). The researchers traced change in individuals’ risk behavior over time as housing status changed. They found that there is a strong association between housing status and HIV transmission; moreover, this association occurs on a gradation, with the homeless at greater risk than the marginally housed, and with both groups at greater risk than the stably housed.

The researchers outline a next step that is needed for action: “data must be produced to show that the provision of housing not only causes a profound reduction in HIV risk-taking but that the risk reductions are so substantial that this is a cost-effective strategy to fight the spread of AIDS in the United States.”

So what’s being done and why aren’t we doing more?
Here’s one model we should be looking at more closely:

Housing Works is a minority-controlled, community-based, not-for-profit corporation providing housing, health care, advocacy, job training, and vital supportive services to homeless New Yorkers living with HIV and AIDS: http://www.housingworks.org/aboutus/index_more.html

Aidala, Angela, J. Cross, R. Stall, D. Harre, and E. Sumartojo “Housing Status and HIV Risk Behaviors: Implications for Prevention and Policy”. AIDS and Behavior, Vol. 9, No. 3, September 2005 (251-265)