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Wednesday, November 30, 2011

RED RIBBONS NOT ENOUGH: BEYOND AIDS STATEMENT ON WORLD AIDS DAY, 12/1/11

PRESS RELEASE: December 1, 2011 (World AIDS Day)

CONTACT:                                                                                                                               
Beyond AIDS, Inc., Inland California Region
1554 Barton Road #401, Redlands, CA 92373   
www.beyondaids.org

WHEN RED RIBBONS ARE NOT ENOUGH:
ONE ORGANIZATION, BEYOND AIDS, INSISTS THAT POLITICS HAS OBSTRUCTED AN ADEQUATE PUBLIC HEALTH RESPONSE TO HIV
Redlands and San Bernardino, CA:
World AIDS Day has been observed every December 1st since 1988, but the leaders of Beyond AIDS say there is too little to celebrate. Thirty years into the AIDS epidemic, the number of new infections is not decreasing.overall, and in some populations it has been rising. Over 2.5 million new cases occur each year, including over 40,000 in the U.S.  The number of persons living with the virus exceeds 30  million worldwide, with an estimated 1.2 million in the U.S. Worldwide, well over one and a half million deaths still occurring each year. Over 16 million children have been left as AIDS orphans. (Statistics from Centers for Disease Control and Prevention and World Health Organization)

If we wish to reverse these trends and see a steady reduction in cases and a decrease in the severity of the epidemic, the organization maintains, we will have to do some things differently.

The problem, says Dr. Ronald Hattis, President of Beyond AIDS and a physician in Redlands, California, is that the public health response HIV/AIDS has been partially obstructed by politics. For example, he points out, "until 2006, HIV infections that had not progressed to the late stage of AIDS were not even reportable to public health in California and some other states in the same manner as other communicable diseases. And even now, although the information about new cases is reported by laboratories and physicians, it is still not routinely utilized by health departments to find and test persons who may have been exposed and to stop further transmission, as is done with tuberculosis and syphilis. Until 2008, HIV testing in California required special written consent and could not be easily combined with panels of other lab tests, and that is still the case in some other states. And even now, California law includes special informing requirements that do not apply to any other medical lab testing."

  
Dr. Ron Hattis

"Every year, on World AIDS Day, red ribbons are displayed, but they do not prevent the spread of HIV," continues Hattis. "It is time that we treat HIV/AIDS as the infectious disease that it is, and that we change our policies and laws so that we can apply the most effective techniques that work with other infections.  It spreads in ways very similar to a number of other diseases, by blood and sexual fluids. It is not the only disease that takes years until it causes symptoms, or that is incurable (for example, hepatitis C shares these qualities). However, what is truly unique about HIV/AIDS is how we have treated it politically, and how we have tied the hands of our physicians and public health workers to reduce their ability to control it."  

So how could HIV/AIDS be more effectively controlled? Hattis says that the disease epidemic could be stopped in its tracks, if everyone with HIV were identified by testing, then referred for immediate treatment, and meanwhile the persons they had exposed were identified, testing, and also treated if infected.

Published studies have shown that the infectiousness of people on effective treatment decreases by 96%. Treatment combined with consistent condom use and avoidance of needle sharing could reduce the number of new cases to a negligible number. But this would require changes in both public policy and in treatment guidelines. Testing would need to be more widespread and routine, as would notification of exposed partners. Currently, most patients are unaware for a long time that they have the virus, and then have to wait for years after infection, until the number of their CD4 white blood cells drops in half, before treatment is started. In the meantime, they may have unknowingly infected other people.

Earlier treatment would protect public health, but studies are showing that it would also be good for patients’ health. Already, guidelines are beginning to change, and more patients are being treated at CD4 counts of under 500 per milliliter of blood, rather than under 350 as in the past. However, Hattis notes, it can still take years for those counts to drop from initial normal values of 800-1000, and that can translate to both a weaker immune system that never fully recovers, and the potential for more people exposed to each infected person to contract the infection. Beyond AIDS urges further research that could lead to a standard of universal testing and immediate treatment.

Dr. Cary Savitch

"HIV remains a public health emergency, but it has unfortunately been managed as a public health exception," agrees Dr. Cary Savitch, an infectious disease physician from Ventura, California.who wrote a book on this issue in 1997 ("The Nutcracker is Already Dancing"). Savitch  first convened the group that founded Beyond AIDS in 1998, and served as its first president. Beyond AIDS was founded to combat "AIDS exceptionalism." Savitch explains. The organization has been in the leadership of nationwide efforts to improve the public health response to HIV/AIDS ever since, he continues, including the long, ultimately successful struggle to achieve name-based HIV reporting, and the more recent fight to eliminate the written consent requirement. The ultimate grand mission of Beyond AIDS, according to its Web site, is "to reverse the course of the global HIV epidemic through sound public health policy."  Beyond AIDS also operates a tax-deductible foundation dedicated to education and research on HIV/AIDS prevention, including an internship program. 

Web references:
http://articles.latimes.com/2011/may/13/health/la-he-aids-prevention-20110513
http://www.cdc.gov/hiv/topics/surveillance/basic.htm#incidence 

Saturday, September 10, 2011

SEX AND SAFETY: BEYOND AIDS WEIGHS IN ON CONDOMS FOR PORN FILM ACTORS

NOTE: SEE UPDATE AT END OF THIS ARTICLE, CURRENT TO 12/1/16

Since HIV/AIDS is transmitted by sex, it was inevitable that Beyond AIDS would be drawn into rather hot issues involving sex, including an industry in which sex is performed for profit. Since 2010, Beyond AIDS has been actively involved in the controversy about whether porn film actors should be required to use condoms.

Beyond AIDS has had policy in place to support legislation to require condom use in the industry, but in spite of a California legislative hearing in 2004, no such legislation has been introduced. Instead, regulations are now being considered pursuant to current federal law on worker safety, and Beyond AIDS has seized that opportunity to become involved.

Most of the film production has been centered in Los Angeles County, where it is a multi-billion dollar a year industry. As a result, that area and the state of California have become the crucibles of what has become both a political and economic fight of major proportions. Though many conservatives may prefer that the entire industry be banned, its legality, at least in California, is not in question, having been confirmed by the California Supreme Court in 1987, with denial of reconsideration by Justice Sandra Day O'Connor of the U.S. Supreme Court.

The issue of preventing HIV and other infections in the porn film industry probably first came to largescale public attention when an HIV outbreak occurred among porn workers in the 1980s, ultimately causing a number of deaths. That outbreak led to the creation of the Adult Industry Medical (AIM) Healthcare Foundation, which set up a program of testing porn actors in Southern California every 30 days for HIV and several other STDs, with exclusion of infected workers. Nevertheless, positive tests among actors in 1998, 2004, 2009, and 2010 showed that risk had not been eliminated (the L.A. Times claimed in June 2009 that 22 workers had been infected since 2004). The AIM testing program operated until the clinic was shut down in late 2010 for licensing deficiencies. Compounding that setback was an unauthorized disclosure of actor testing results by Porn Wikileaks in 2010, leading to a class action lawsuit against AIM. The foundation was dissolved entirely in May 2011; Porn Wikileaks itself was closed down soon afterward, in July 2011.

The issue continued to simmer until the AIDS Healthcare Foundation (AHF) brought it to the fore in 2009, first by filing a lawsuit against the Los Angeles County Department of Public Health, to take vigorous enforcement action against the industry. AHF accused the department of paying insufficient attention to increased numbers of both HIV and other STD cases among adult-film performers, but the department denied that it had authority to take enforcement action. By June 2011, an appeals court reaffirmed a lower court ruling that declined to overrule the discretion of L.A. county health officer Jonathan Fielding. (An appeal to the California Supreme Court is planned.)

At the end of 2009, AHF tried another approach, proposing that the California Occupational Safety Administration (Cal/OSHA) expand its regulations for the health care industry that require barriers (e.g., gloves) to protect workers against bloodborne pathogens, so as to require condoms as protective barriers for worker safety in the adult film industry. The theory is that the porn industry is similar to the healthcare industry in that workers are unavoidably exposed to certain pathogens (disease-causing agents) unless barriers and other precautions are used. Beyond AIDS has participated since 2010 in the advisory committee set up by Cal/OSHA to advise that agency regarding the development of possible regulations. The Los Angeles Department of Public Health is also supporting a condom regulation, contending that the issue must be addressed at the state level (thus making the county a "strange bedfellow" with the organization that has been suing it).

A consultation group to the industry called the Free Speech Coalition, and AIM (until its dissolution), have countered that the testing program has been relatively effective, keeping sexually transmitted diseases to rates comparable to those of sexually active people with demographics similar to the actors. Irate producers and some vocal actors have also spoken up at meetings and hearings to oppose mandatory condoms, citing economic concerns. They fear that films and videos using condoms will attract fewer customers than those without, causing closure of businesses, loss of jobs, and driving off the business to unregulated countries or underground filmmakers who do not do testing and have fewer protections for workers. Interestingly, though, condom use has become the standard for the production of gay films (which continue to sell well), but not for those depicting heterosexual activity (for which the few films that do show condoms tend to sell poorly).
 
Not all porn actors oppose mandatory condoms, however. Notable is their advocacy by former actor Derrick Burts, who has emphasized that he contracted HIV despite the testing program. A number of former actresses have testified before Cal/OSHA of abusive conditions, especially for women in the industry, and of contracting multiple infections. One such actress has founded the Pink Cross Foundation to reach out to workers who wish to leave the industry.

Derrick Burts, former porn actor infected with HIV in October 2010, who supports a condom requirement

Denise Bleak, an experienced infection control nurse, has been the lead representative of Beyond AIDS in the advisory meetings, assisted by Ron Hattis, MD, the organization's president. A series of meetings has been attended in Oakland and Los Angeles, and the organization issued a position paper in October 2010. The approach of Beyond AIDS has been to attempt to assure a reasoned, science-based approach in an often emotional debate. Dr. Ron Hattis has emphasized the value for prevention of both screening through tests for HIV infection (which has kept the rates of HIV and other bloodborne infections from blood transfusions extremely low) and utilizing condoms (which is a mainstay of HIV and STD prevention worldwide). He cites protocols used by the legal brothels of Nevada, which have almost totally eliminated HIV and other STD transmission. Those protocols require both condom use and frequent testing of the prostitutes.

One of the reasons that Beyond AIDS would like to see condoms used in porn film production, over and above worker safety, is that millions of sexually active people view these films every year, and the unsafe sex that is protrayed produces a bad role model for prevention. Unlike the actors, the customers are not being tested for HIV and other STDs every month. Beyond AIDS supports both the reestablishment of a screening program for the actors and the addition of a requirement for condom use. Protocols for how to manage actors infected with a variety of STDs, including specific restrictions and precautions, have also been suggested.


 Denise Bleak, Beyond AIDS lead representative on Cal/OSHA advisory committee 

Denise Bleak has openly challenged the actors and producers with provocative appeals at the Cal/OSHA-sponsored meeting. "I ask again, what is the performers' definition of the perfect storm, as far as transmission of infectious diseases, in this venue? It is safer to use what our (infection control) colleagues envision for you, as we watch you (perform)" she has stated. She suggests that condom use and other safety precautions can be utilized in a sexually enticing way. "Think. Imagine, also. Clear condom? Vivid red condoms? Even fake (semen)? In colors? Can there be refinement in the performance for more teasing and less 'pounding and grinding' as one seasoned individual put it?" She noted that condoms could be omitted if both partners were confirmed to have the same diseases, however "the public will likely not enjoy HIV on HIV sex to view." In a reference to the statements in film credits that no animals were harmed in the creation of a movie, she asked that porn films be produced in a manner that could permit a similar statement for humans. "The parallel is for film industry to begin protecting all warm blooded creatures on film, not just the four legged kind. So get it together folks," she said.

Ms. Bleak reflects on the work so far as she continues to appeal to the industry: "Despite my trying to avoid double entendre, some of the work we did at the hearings was unavoidably fun and fulfilling, with the higher purpose in mind, to protect you all and love you a little bit." She has enjoyed being "an equal partner at the table" as a representative of Beyond AIDS.

UPDATE ON THE ADULT FILM REGULATION ISSUE, DECEMBER 1, 2016:

As of World AIDS Day, 2016, the problem of unprotected commercial sex has still not been resolved. Since the original posting of this article on September 10, 2011, Beyond AIDS has continued to support the efforts of the AIDS Healthcare Foundation (AHF) on this issue. There have been several recent areas of developments.

Renewed State Legislation: In the 2013 California legislative year, Assembly Member Isadore Hall introduced Assembly Bill 332 on behalf of AHF, to do on a state level what Measure B intended to do in Los Angeles County. Beyond AIDS was in strong support, and the AIDS Healthcare Foundation was the official sponsor. The bill got suspended in the Assembly Appropriations Committee, theoretically because it required Cal-OSHA to issue long-delayed regulations, which would cost money. This is somewhat ironic, considering that Cal-OSHA continues to claim that it still plans to ultimately issue regulations anyway, regardless of state legislation.

However, in the 2014 legislature, Mr. Hall has introduced a new bill with the same intent, AB 1576, again with the AIDS Healthcare Foundation as the sponsor and Beyond AIDS as a supporter. The new bill required both condoms for performers, and a testing program to include various sexually transmitted diseases. Unfortunately, that bill, too, failed to pass.

Local County Ordinances, Passed but Weakened by Litigation: On November 6, 2012, the voters of Los Angeles County approved a ballot initiative (Measure B), requiring condom use in adult film production, and providing for county regulation of worker safety standards. The AIDS Healthcare Foundation sponsored this initiative, and Beyond AIDS supported the measure, which achieved 57% support in spite of the opposition of major newspapers. No mechanism was put in place for implementation and enforcement, and the county seemed reluctant to take on this new task. Some producers threatened to simply move production to neighboring counties, particularly Ventura County, so that county's Board of Supervisors passed a similar ordinance.

Meanwhile, the future of county enforcement is likely to be made more difficult, because of a court challenge filed in January 2013 by Vivid Entertainment and two performers. On August 17, 2013, U.S. District Court Judge Dean Pregerson issued what has been called a split decision in that case. On the one hand, the judge upheld the requirements that adult film productions receive permits from the county, that performers must use condoms, and that criminal charges could be brought against violators. On the other hand, he threw out other provisions that he determined would permit too much discretion to the county Department of Public Health in denying permits, and in inspecting film production for enforcement purposes.

“The department is given no guidance as to what types of diseases or what types of transmission methods applies,” the ruling stated. “Indeed (it) would seem to authorize revoking a permit if a cameraman were working with a cold.” Judge Pregerson also restricted the power of the county to enter and inspect any location where filming is taking place, but permitted the county to obtain warrants to enforce Measure B. In summary, the key requirements of the measure are still in place, but enforcement will be difficult. AHF considers the decision a victory, but the Department of Public Health does not appear certain of how to proceed.

The most recent attempt to resolve the issue was a statewide ballot initiative, Proposition 60, on the general election ballot on November 8, 2016. Again the AIDS Healthcare Foundation was the sponsor, with Beyond AIDS a strong supporter mentioned in the voter booklet as well as in some TV ads. This initiative would have applied statewide, requiring condom use for filming of sexual intercourse, and requiring producers to pay for vaccinations, medical examinations, and HIV/STD testing of actors. One controversial provision would have allowed citizens to sue if non-compliance were discovered. This arose from frustration about the failure of Los Angeles authorities to enforce the ballot initiative that had passed there. Both political parties and the California Medical Association opposed the initiative, partly because of that litigation wording. It failed to pass, garnering only 46% of the vote (about 6 million in favor, vs. 7 million against).

Cal-OSHA's Moribund Regulatory Efforts: As of December 1, 2016, Cal/OSHA has not yet issued final regulations over 6 years after a series of hearings. A new draft state standard was developed in 2013, but was not considered as an official rulemaking proposal and not sent out for public comment. The draft regulations developed so far focus heavily on condoms and other infection control protection (including immunization), but ignore the issue of periodic screening tests. Testing would only be required as part of post-exposure evaluation. The agency has explained at hearings that its mandate is limited to the types of protection originally authorized by federal OSHA for health care workers and delegated within the state of California to Cal/OSHA, such as barrier protection, personal protective equipment, engineering controls, and immunization. In fall 2016, Cal/OSHA, after another three years of delay, was planning another hearing, but it was cancelled pending the results of Proposition 60 in the November 8 election. Cal/OSHA claims to have authority to issue regulations and/or to issue citations for unsafe practices, based on the existing state and federal bloodborne pathogen standards. With the failure of the ballot proposition, the ball would appear to be  in Cal/OSHA's court.

Saturday, September 03, 2011

LEGISLATIVE VICTORY IN CALIFORNIA: HELP WITH HIV PARTNER NOTIFICATION

A bill to help physicians obtain public health assistance with HIV contact tracing and partner notification has passed the California legislature. Governor Brown signed  Senate Bill 422 into law on August 1, 2011. The bill was sponsored by Beyond AIDS, and introduced by Senator Roderick Wright.  It will take effect in January 2012.
Roderick Wright (center), holding Beyond AIDS award for previous HIV legislation, with Presdient Ron Hattis (left) and Past-President Cary Savitch (right)

The new law will allow a physician, with the patient's consent, to inform local public health staff that the patient may have exposed other persons to HIV. The public health staff can then interview the patient, elicit information on partners and details on how they can be reached, and can help assure that these exposed persons are notified, counseled, and referred for testing and follow-up. The local public health agency will be able to retain information about the partners until those services are complete. Both the physician and the local public health staff will be protected from liability.

Up to now, it has been illegal for a California physician to identify a patient, who may have exposed others to HIV, to local public health agency staff. As a result, physicians have not been able to request that the patient be interviewed to identify possible exposed partners by trained public health staff. A physician who has wished partners to be notified of their exposure has had to perform the interview him or herself. The physician could name the identified partners to the local health officer (it was unclear whether other public health staff were covered under that term), but could not pass on information about who the infected patient was and how that person could be reached.

Partner services include coaxing infected patients to reveal their sexual and needle-sharing partners, eliciting information on how to reach those persons, and performing the actual notification, counseling, and referrals. Most physicians do not have the time or the special training and experience to perform partner services, and any such services are not compensated by insurance or any other funding source. As a result, partner services, including the actual notification and referral of the exposed partners, are greatly under-utilized as a prevention tool.  Local public health agencies do have trained staff assigned to this function, but due to the limitations of the law, in many counties few partners are notified. Most of the patients whose partners have been notified by public health staff have been those who are being treated in clinics operated of the local public health agency itself.

When public health staff notify a partner, the name of the infected source is not revealed. Because of this,  patients may often be willing to reveal to public health staff the identity of partners and how to reach them, even though they would be unwilling to tell the partners themselves. Some patients also would be embarrassed to reveal all their partners to their physicians, but would do so to neutral public health workers pledged to confidentiality.

While some patients notify their own partners and refer them for testing, studies have shown that this does not happen most of the time. There may be well-founded fears of rejection by the partner, or even fears of physical abuse. Frequently, partners have been anonymous or have moved on and been lost to follow-up, so that a patient cannot reach them even if he or she wants to; but with enough information on where the partners "hang out" and their descriptions, public health staff may be able to locate and notify them.

If performed effectively, partner services can help stop HIV transmission. If an exposed partner tests negative for HIV and is lucky enough not to have already been infected, precautions can be taken to avoid infection. If the partner tests positive, he or she can be promptly directed to medical care and follow-up, and assisted in not infecting anyone further. Thus, the chain of infections can be interrupted.

SB 422 is expected to be a step toward better communication between physicians and local public health staff about HIV exposures, and an advance in efforts to stop HIV transmission. This is part of the mission of Beyond AIDS.

The bill as passed was somewhat of a compromise. Several additional provisions proposed by Beyond AIDS were opposed by the American Civil Liberties Union and could have resulted in the bill's defeat, so they were not included. Among these were expanding the bill to include nurse practitioners and physician assistants as well as physicians, and to permit the bill to also deal with exposures to blood or other infectious substances of infected persons other than needle sharing, as in trauma situations or surgical accidents. Beyond AIDS also wished to eliminate the need for written consent by the patient for referrals to public health, since all cases should have already been reported to public health and thus should not be new disclosures of the patient's infected status. Beyond AIDS will evaluate whether there is sufficient political support for an expanded bill in 2012.

Beyond AIDS President Ron Hattis has expressed the organization's appreciation and recognition to Stan DiOrio, Senator Wright's tireless Legislative Director, without whom the new law could never have become a reality. This is the fourth bill related to HIV prevention that Roderick Wright has introduced for Beyond AIDS (earlier as an Assembly Member, and now as a Senator), and the second one signed into law. The California Academy of Preventive Medicine, Infectious Disease Association of California, AIDS Healthcare Foundation, and California Medical Association provided supporting letters and testimony.