Slide Presentation for Summit on Opportunities for Improving HIV Diagnosis, Prevention & Access to Care in the U.S., Nov. 29-30, 2006, by Michael Horberg, MD, MAS, FACP, Director, HIV/AIDS Policy, Quality Improvement, and Research, Kaiser Permanente. Kaiser Permanente, the second largest provider of HIV care in the U.S., ombines a health plan, hospitals and medical groups located in multiple communities throughout California, Colorado, Georgia, Hawaii, Washington, DC, Maryland, Virginia, Ohio, Oregon, and Washington State, and has over 16,000 active HIV positive patients in care.
KPÂ?s philosophy is that HIV testing is a process that includes an antibody test with pre- and post-test counseling, patient education, and procedures to handle newly identified cases, convey test results, and discuss risk behavior, sexuality, and STD testing; counseling and the frequency of testing are determined individually. Ninety percent of KPÂ?s HIV patients are in care within 120 days of diagnosis, and their mortality rate is lower than the national average
Slide Presentation for Summit on Opportunities for Improving HIV Diagnosis, Prevention, & Access to Care in the U.S., Nov. 29-30, 2006; addressed areas of potential legal liability raised by implementation of September, 2006 CDC Guidelines on HIV testing.
With widespread use of antiretroviral therapy, Kaiser Permanente researchers suggest that HIV-positive patients can safely undergo a wide range of surgical procedures. While the risk of some post-operative complications is higher than seen in HIV-negative patients, that appears to occur mostly in patients with moderately high viral loads and very low CD4 cell counts. In short, most HIV+ surgical patients have no increased risk of surgical complications compared to their HIV-negative counterparts; HIV should not be a reason for avoiding surgery.
This is Tim Horn's synopsis of the Horberg/KP study on the impact of HIV infection on the surgical safety. Thanks to the widespread availability and use of antiretroviral therapy, Kaiser Permanente researchers suggest that HIV-positive patients can safely undergo a wide range of surgical procedures. The new study, published in the December 18 issue of Archives of Surgery, indicates that the risk of some post-operative complications is higher than that seen in HIV-negative patients, but mostly in HIV-positive patients with moderately high viral loads and very low CD4 (T4) cell counts.
There is no uniform policy on minors rights to consent to HIV testing and treatment. The process of obtaining consent is complex and depends on several factors, including individual state laws related to HIV testing and to a minors capacity to consent to general, and to sexual-health related, medical care. This article reviews the laws of informed consent and confidentiality related to HIV disease in adolescents, of particular important for pediatric and adolescent clinicians.
This Reuters summary of a report featured in Clinical Infectious Disease supports the view that a substantial focus on universal opt-out HIV testing as an answer to the problem of HIV positive individuals receiving care late in the course of their disease may be missing the boat.
Dr. Laura A. Cheever states that "in the US, it is estimated that only half of those eligible for antiretroviral therapy actually receive it."
And Dr. Cheever, of the Health Resources and Services Administration, Rockville, Maryland, states: "If we are to improve our response to the HIV epidemic in this country and lessen mortality, we need to place a greater emphasis on engaging and retaining patients in care.
In this article from the Journal of Urban Health: Bulletin of the New York Academy of Medicine (provided by Abt Associates,Inc.), Ted Hammett, a long-time expert on HIV in corrections and a vice-president at Abt Associates, elaborates on what he considers the three essential points to effective advocacy for health care services in prisons and jails: that correctional facilities are important settings for health care interventions because there populations typically bear a disproportionately heavy disease burden; that successful health interventions are possible among inmate populations; and that successful interventions benefit not only inmates, their families and partners, but the public at large, particularly the urban communities from which most inmates come.
A list and synopsis of key federal cases on access to, and quality of, medical care in correctional settings. The list is organized by federal circuit.
Citations and cases synopses for five useful federal court decisions on the refusal to provide appropriate care to transgender prisoners as a violation of prison officials 8th Amendment obligation to attend to the serious medical needs of those in their custody.
This report, prepared by the Center on Budget and Policy Priorities, examines the February, 2006 provision requiring all Medicaid applicants and recipients to provide a birth certificate or passport to become eligible for the program. While the provision was passed as an effort to prevent illegal immigrants from being covered by Medicaid, it is more likely to create unnecessary challenges to a significant number of low-income U.S. citizens.
The federal government's new requirement is this: people claiming to be citizens must provide documentation of citizenship to the Medicaid program. In other words - eligibility has not changed, but there is a new documentation requirement. This is only required of citizens; there is no new Medicaid documentation required from people who are green card holders, or PRUCOL (Permanently Residing Under Color of Law).
You do not need to be a US citizen in order to be allowed to use the Medicaid program. Using Medicaid does not have negative immigration consequences.
Most naturalized US citizens are in a good position to provide this documentation. The documentation is more likely to be a challenge for US-born citizens who don't have their birth certificates. Citizenship documentation is not required for lawful permanent residents or other non-citizens who are eligible for the Medicaid program - the new requirement applies only to citizens.
This chart summarizes the guidelines and policies currently in place regarding HIV-positive health care workers (HCW) in all 50 states, as well as some U.S. territories. To our knowledge, it is the most comprehensive compilation of this information available. For each state, the chart includes any relevant guidelines, statutes, or regulations, as well as definitions of 'HCW' and 'invasive procedure' adopted by the state. It also includes information on the state's policy related to testing HCWs for HIV, notification of patients, and implementation of restrictions on the practice of HIV-positive HCWs.
The guidelines, statutes, and regulations referenced in this document were adopted between 1991 and 1993 in response to a CDC directive that was eventually codified. In the 15 years since these policies were put in place, the limited ways in which HIV transmission is a genuine risk, and the absence of such risk to health care patients, has been solidly confirmed . In 2000, Professor Larry Gostin called for a revision of the national policy restricting the practices of HIV-positive HCWs, concluding that such a policy is not necessary because of the negligible risk of HIV transmission from HCW to patient. Gostin also asserted that, because the policy unnecessarily stigmatizes HIV-positive HCWs, some HCWs might avoid or delay testing, or leave the medical profession altogether. (See Lawrence O. Gostin, A Proposed National Policy on Health Care Workers Living with HIV/AIDS and Other Blood-Borne Pathogens, 284 JAMA 1965 (Oct. 18, 2000)).
The CDC’s public acknowledgement of, and efforts to reduce, HIV-related stigma run counter to the CDC’s own policy on HIV-positive HCWs. The CDC has stated that “the stigmatization of persons infected with HIV and the groups most affected by HIV… is a barrier to testing.” (See 49 MMWR 1062 (Dec. 1, 2000). At the same time, the CDC has issued, and maintained for more than 15 years, a policy that overtly stigmatizes HIV-positive HCWs, sometimes even at the expense of testing. Perhaps now is the time to revisit the issue and call on the CDC to amend its recommendations related to HIV-positive HCWs.
Prepared by Jay Dobkin, M.D., Arnold P. Gold Foundation Associate Professor of Clinical Medicine, Columbia College of Physicians and Surgeons, these slides 1)establish, based on data from the NYC Department of Health, that thousands of individuals who have been diagnosed with HIV receive little or no outpatient care to control the progression of their disease, despite the availability of health services; and 2) posit queries and potential solutions addressing possible causes of this significant public health problem.
It is not unusual to encounter women battling both HIV disease and breast cancer. But can an undocumented immigrant get prescribed chemotherapy or radiation therapy to treat cancer as an emergency medical service? The NY Department of Health, Office of Health Insurance Programs, issued this directive to local district commissioners, Medicaid directors, and Temporary Assistance directors to clarify that, until told differently, local social services must continue to treat chemotherapy and radiation as emergency medical services payable under Emergency Medicaid, on behalf of immigrants without status (undocumented immigrants).
This settlement agreement resolving Smiths complaint in response to emergency medical services personnels refusal to touch or lift him because of his HIV status illustrates possible non-monetary remedies for such conduct, and also how one persons lawsuit can change the way a public institution behaves towards people living with HIV. In addition to monetary compensation, the agreement requires the city to implement a mandatory paramedic/EMT training program on HIV and infectious diseases on a periodic, on-going basis.
A thorough consumer guide to New York law, and sample forms, addressing the right to make treatment decisions, and ensuring that an individual's wishes for end-of-life-care are understood and respected by care givers, family and friends. Includes an explanation of different types of advance directives (e.g., health care proxy, living will); guidance on how to prepare, make known,or cancel these directives; and issues such as pain management, hospice care, and organ donation. The guide also incorporates a list of resources (organizations that can provide additional forms and information) and a list of citations to relevant case law and statutes. test
The purpose of this study was to explore patient perspectives on rapid and routine HIV testing in an urgent care center at an urban public hospital. Participants supported routinely-offered testing, but there were concerns about privacy and cost. Fear and stigma were common reasons for refusing testing and not returning for results. Distrust and misconceptions about HIV, particularly regarding the importance of testing, were very common. Fear was the greatest single reason given for not accepting an HIV test when offered. Those who refused testing also had more concerns about anonymity than the groups that accepted testing. In the female group that refused testing, fear of becoming infected with HIV during testing was mentioned by several of the participants who discussed the need to see them [the phlebotomist] take out a new [sterilized] needle. Although this study addresses the acceptability of rapid HIV testing in urban ERs, the authors discussion suggests that identifying and addressing factors that affect individual testing and care decisions are more complex than can be characterized by a yes or no on types of testing technology. Its also apparent that what may be "rapid" for a health care provider may require hours of waiting for a patient, even with rapid testing, and that this is a deterrent. Additionally, if one accepts HIV testing as a gateway to care, and patient health literacy and engagement in treatment as central to that care, then this study also suggests that counseling and communication that breaks down mistrust and misunderstanding at the time of HIV testing is important.
This five-count complaint brought in state court under the Rehabilitation Act of 1973, the Americans with Disabilities Act of 1990 and various Wisconsin state law claims alleges that defendants refused medical treatment to plaintiff because of his HIV-positive status. Defendants are an orthopedic practice and an orthopedist who refused to perform plaintiffs spinal fusion surgery. Plaintiff was asked and agreed to be tested for HIV, an independent group of surgeons approved him as appropriate for the surgery and the surgery itself was prompted by the fact that plaintiff was in constant and excruciating pain. Plaintiff, who did not know he was HIV-positive until defendants cancelled his surgery, also sued them under state law for the indignity they caused him for the callous manner in which he was informed of his status and their refusal to counsel or refer him for further medical services.
An HIV-positive man sued his dentist under the New Jersey Law Against Discrimination (LAD) and the AIDS Assistance Act, for the dentists illegal and discriminatory refusal to provide routine dental care because of his HIV status. The dentist also disclosed, for reasons unrelated to his medical care, the plaintiffs HIV-status to a person outside the office. As an excuse for denying plaintiff treatment, the dentist claimed that his staff felt unsafe and that he believed that, in order to treat an HIV-positive person, the dentist would need to have special equipment and cleaning practices. The complaint highlights the fallacy of the dentists arguments by reiterating the American Dental Associations position that standard practices are completely adequate to protect dentists and dental workers from risk of HIV infection by patient contact, and that it is medically and scientifically unwarranted and unethical for dentists to refuse to treat individuals solely because of HIV status.
Amended class action complaint, filed in New Jersey, seeking monetary and injunctive relief for all state prisoners with Hepatitis C who were denied diagnostic and treatment sercies for their medical condition. The complaint, filed in 2003, provides a good outline of potential claims under the Americans with Disabilities Act, and the U.S. constitution, for failure to provide adequate protection and medical care for prisoners with or at risk of hepatitis or HIV.
The following synopsis is condensed from NY Law School Professor Art Leonards excellent discussion on Leonard Link, http://newyorklawschool.typepad.com/leonardlink/:
A unanimous panel of the California 2nd District Court of Appeal has revived a lawsuit against a pharmacist who is charged with discriminating against a person with AIDS in a dispute over filling a prescription.
The plaintiff had just been discharged from the hospital, with instructions to get certain prescriptions filled immediately. He and his wife went to a Walgreen pharmacy, and he gave the prescriptions to the pharmacist. One was for an AIDS med. Plaintiff alleges that "without giving any reason or justification," the pharmacist "refused to fill the prescription," and when plaintiff insisted it had to be filled right away, the pharmacist again refused and asked in a loud and hostile tone (and in the presence of other customers) whether plaintiff had AIDS or cancer, a question plaintiff declined to answer because he felt "embarrassed and shocked" by having this question loudly asked in the presence of other customers. Eventually, convinced it was the only way he would get service, plaintiff responded that he had AIDS "and needed the antibiotics to live." Plaintiff claims that the pharmacist made no similar inquiries of other customers before filling their prescriptions. Plaintiff is an African-American man.
The pharmacist claims that the prescription in question was for a medication whose coverage under the Medi-Cal insurance program is restricted to those with a diagnosis of cancer or AIDS, and that he was asking the questions to be sure that plaintiff, who was using Medi-Cal for payment, was eligible for the medication. This requires documentation, not just the patient's say-so, in the form of information in writing from the prescribing doctor confirming the diagnosis; a simple prescription form won't do.
According to the pharmacist, the plaintiff returned later that evening when other customers were not around, and the pharmacist explained the documentation requirements under Medi-Cal. Pharmacist denies raising his voice either time. Ultimately plaintiff "cancelled" his order and took his prescription elsewhere, subsequently filing suit.
Plaintiff's complaint alleged violation of civil rights under the Unruh Act (California's public accommodations law), alleging race, disability and (perceived) sexual orientation discrimination. He also alleged infliction of emotional distress, violation of medical confidentiality law, fraud and negligence. The trial judge, Melvin Sandvig of LA County Superior Court, had dismissed all claims on motion by the defendant.
On appeal, the court disagreed, finding that plaintiff's factual allegations were sufficient to bring the Unruh Act into play. The court pointed out that the relatively simple pleading requirements were met by stating that plaintiff was an African-American man living with AIDS, had been denied services at a time when they were provided to others, and was entitled to the service. However, the appellate court agreed with the trial court that the factual allegations did not state a violation of the medical confidentiality law, or support tort claims of negligence or fraud.
In a 6 to 3 decision of potential impact for people with HIV, the U.S. Supreme Court ruled that courts must examine benefit denials by insurance companies carefully when circumstances indicate that the company’s financial considerations may have affected a benefits decision. The ruling recognizes that the apparent conflict of interest created when an insurance company is both the reviewer and payer of claims is one of many factors to consider, and offers guidance to federal judges reviewing medical disability and health insurance determinations in group policies. Although the plaintiff in this case was not HIV-positive, she suffered from severe fatigue, a condition that many people with advanced HIV disease frequently experience.
The plaintiff had applied for and was granted long-term disability benefits through her employer when she became disabled with a heart condition that caused severe fatigue and prevented her from doing any kind of work. MetLife, as administrator of the employer’s ERISA-governed long-term disability insurance plan, had the authority to make disability determinations and was also responsible for making payments to beneficiaries. When MetLife terminated the employee’s disability benefits based on a determination that she was able to do sedentary work, she brought a claim under ERISA alleging a conflict of interest on the part of MetLife. The court found that MetLife, as reviewer and payer, did have a conflict of interest in this situation. The court further found that the conflict could be considered as a factor in determining whether or not the administrator abused its discretion, and that the significance of the factor would be determined by the circumstances of the case.
The Kaiser Family Foundation commissioned a racially diverse group study of lower-income women with HIV/AIDS in Philadelphia, Los Angeles, Miami and Savannah to hear directly from them about their lives and the challenges they face in obtaining a full-range of health care services. The specific issues addressed were barriers to receiving care, interactions with the health care system, relationships with providers, challenges unique to women, knowledge level about their illness, effects of HIV/AIDS on other aspects of their lives and the information they need and sources they trust.
Ideas for improving access to quality health care were distilled from the womens insights. First, time of diagnosis is a critical moment to inform, support and connect women with HIV/AIDS services. How women were told about their status affected when and if they sought treatment. Second, gender specific services should be available to women such as mental health support, child care assistance, transportation and access to female providers. Third, women who were connected to local AIDS services organizations, services and networks of information had better health care experiences. Fourth, making Medicaid available to more women with HIV/AIDS and continuing to support ADAP. Fifth, use providers, peers, internet, TV/radio to inform women about HIV/AIDS and especially to reach out to Latinas with HIV/AIDS.
Although not mentioned in the conclusions, a persistent problem for women with HIV is the stigma and prejudice they face from health care professionals who are not HIV specialists. Women still experience denial of services from dentists, gynecologists and general practitioners after disclosing their status. Stigma, and perception of social risk, affects when and whether women disclose their status or pursue and receive care for a multitude of health issues. This study highlights the imperative that all health care professionals be trained and educated about HIV/AIDS issues.
This fact sheet prepared by the Kaiser Family Foundation, www.kff.org, provides new statistics on health coverage and describes the major sources of health insurance for non-elderly adult women ages 18-64, including employer-sponsored coverage, Medicaid, individually purchased insurance, and Medicare. It also summarizes the major policy challenges facing women in obtaining health coverage, and provides data on the more than 17 million women who are uninsured In the United States, nearly 1 in 5 women under the age of 65 do not have health insurance.
The Convention on the Elimination of All Forms of Discrimination Against Women (“CEDAW”), addresses women’s rights within the political, social, economic, cultural, and family life. It calls for state parties to overcome barriers of discrimination against women in areas of legal rights, education, employment, health care, politics, and finance, and sets benchmarks. Particularly relevant to HIV/AIDS issues are: the definition of discrimination against women (Article 1); a mandate that states condemn discrimination in all its forms and ensure a legal framework that provides protection and embodies the principle of equality (Article 2); mandate of the end of discrimination in employment, including the right to work, employment opportunities, equal renumeration, free choice of profession and employment, social security, and protection of health, including maternal health (Article 11); requirement of steps to eliminate discrimination in health care, including family planning access (Article 12); a focus on the unique problems that rural woman face in access to health care and adequate living conditions (Article 14); requirment of steps to ensure equality in marriage and family relations, including the right to freely determine the number and spacing of children (Article 16).
The Convention on the Elimination of All Forms of Racial Discrimination (“CERD”) is an international treaty designed to protect individuals from discrimination based on race that is both intentional or the result of neutral policies. Particularly relevant to HIV/AIDS issues are: the requirement that state parties take concrete measures in social, economic, cultural, and other fields to ensure the adequate development and protection of certain racial groups or individuals belonging to them for the purpose of guaranteeing them the full and equal enjoyment of human rights and fundamental freedoms (Article 2); and the requirement that state parties undertake to prohibit and eliminate racial discrimination in all its forms and to guarantee the right of everyone to equality before the law in the enjoyment of rights including the right to work and to free choice of employment, the right to housing, the right to public health, medical care, social security, and social services, and the right to education and training (Article 5).
As a treaty, CERD is binding on all parties that ratify it; those who sign but do not ratify it are obligated not to act contrary to the purpose of the convention under Article 18 of the Vienna Convention. State parties must submit periodic reports to the Committee on the Elimination of Racial Discrimination detailing how they are giving effect to CERD. Moreover, under Articles 11-13, if a state party is not giving effect to the provisions of CERD, another state party may bring this to the attention of the Committee, which will collect information from the relevant state parties and, if the dispute cannot be reconciled, will form an ad hoc commission to investigate and issue recommendations. Under Article 14, a state party has the option of allowing the Committee to receive and consider complaints from individuals claiming that the state party has violated their rights under CERD, and the Committee will issue recommendations to the state party accordingly.
The United States has ratified CERD, but has not exercised the option set forth in Article 14.
The Convention on the Rights of the Child (“CRC”) is an international treaty that discusses many of the rights children, some of which are in addition to those also enjoyed by adults. Particularly relevant to HIV/AIDS issues are: the right to life and corresponding obligation of the state to ensure to the maximum extent possible the survival and development of the child (Article 6); the right to seek, receive, and impart information (Articles 13, 17); the right to education (Article 28); the right to the highest attainable standard of health, including preventative health care, guidance for parents, and family planning education and services (Article 24); rights of disabled children to special care and to conditions that ensure dignity and facilitate active participation in the community (Article 23);the right to a standard of living adequate for physical, mental, spiritual, moral, and social development (Article 27); and the right to be actors in their own development and to express their opinions in all matters affecting the child (Article 12). States are also obligated to respect and ensure the rights in the CRC without discrimination of any kind, irrespective of the child’s or his or her parent’s disability (Article 2). The best interests of the child must be a primary consideration in all actions concerning children (Article 3). Moreover, states are obligated to ensure that the child as such protection and care as is necessary for his or her well-being, and to ensure that institutions, services, and facilities responsible for the care or protection of the child conform with the standards established by competent authorities, particularly in the area of safety and health (Article 3).
As a treaty, the CRC is binding on all parties that ratify it; those who sign but do not ratify it are obligated not to act contrary to the purpose of the convention under Article 18 of the Vienna Convention. State parties must submit periodic reports to the Committee on the Rights of the Child detailing their progress on upholding the treaty’s provisions.
General Comment No. 3 of the Committee on the Rights of the Child, available separately in the Resource Bank, analyzes the obligations of the CRC in the context of HIV/AIDS.
The United States has signed, but not ratified, the CRC.
A revised and consolidated version of the original guidelines published in 1996, the purpose of the Guidelines is “to assist States in creating a positive, rights-based response to HIV that is effective in reducing the transmission and impact of HIV and AIDS and is consistent with human rights and fundamental freedoms.” The Guidelines are a joint project of the United Nations Office of the High Commissioner for Human Rights and UNAIDS. The consolidated guidelines include the revised Guideline 6, which reflects the human rights dimensions of access to HIV prevention, treatment, care, and support. The document consists of three parts: 1) twelve guidelines for state action; 2) recommendations for dissemination and implementation of the Guidelines; and 3) a description of the human rights principles underlying a positive response to HIV. The primary users are intended to be states, but it is also meant to inform intergovernmental organizations, non-governmental organizations, networks of people living with HIV, community-based organizations, networks on ethics, law, human rights, and HIV, and AIDS service organizations. It is also useful for any person looking for interested in a rights-based approach to HIV/AIDS and specific steps needed to implement such an approach.
The International Covenant on Economic, Social and Cultural Rights (the “ICESCR”) represents one-third of what is informally referred to as the “International Bill of Rights.” The other two thirds consist of the International Covenant on Civil and Political Rights (“ICCPR”), and the Universal Declaration of Human Rights. The ICESCR outlines universal economic, social and cultural rights; particularly relevant to HIV/AIDS issues are: the right to the highest attainable standard of health (Article 12); the right to education (Article 13); the right to work (Article 7); the right to enjoy the benefits of scientific progress and its applications (Article 15); the right to social security (Article 9); the right to an adequate standard of living, including adequate food, clothing, and housing (Article 11); and the right to participate in cultural life (Article 15).
As a convention, the ICESCR is binding on all parties that ratify it; those who sign but do not ratify it are obligated not to act contrary to the purpose of the convention under Article 18 of the Vienna Convention. Like the ICCPR, parties to the ICESCR are obligated to make periodic reports on their compliance with the convention to the Committee on Economic, Social and Cultural Rights. The Committee also prepares “General Comments” interpreting the ICESCR and exchanges general views on the rights of the ICESCR.
However, unlike the ICCPR, the ICESCR has no optional protocol that would allow victims of violations of ICESCR to present complaints before the Committee on ESCR against a state that has ratified the convention and violates its obligations; however, in April 2008, a UN working group approved a draft of such an optional protocol, and sent it to the UN Human Rights.
The United States has signed, but not ratified, the ICESCR.
