The U.S. HIV care system is being swamped by a rising tide of new patients, an Institute of Medicine (IOM) report warns.

As HIV treatment continues to improve, people with HIV are living much longer. Meanwhile, the CDC’s universal HIV screening program is bearing fruit, identifying more people who are infected with the AIDS virus.

The result is a widening gap between the number of Americans with HIV and the resources available to treat them.

“Our system is getting stretched,” IOM panel chair Paul D. Cleary, PhD, dean of the Yale School of Public Health, tells WebMD. “There is going to be a dramatic change in the number of people with HIV detected and cared for. When we start treating this many more people … we find there are barriers to getting them into available treatment facilities.”

Over 20% of the 1.1 million Americans with HIV don’t know they are infected. Learning they have HIV is good for the individual, as earlier treatment means better health. It’s also good for society, as people who know they carry HIV are less likely to infect others — and treatment actually makes a person less infectious.

“There is a moral imperative that if we do testing, we have to get people who test positive into care,” Michael Saag, MD, tells WebMD.

But there’s a raft of problems with actually providing this care, notes Saag, director of AIDS research at the University of Alabama, Birmingham and immediate past president of the HIV Medicine Association.

Saag’s state-of-the-art AIDS clinic is a prime example. In 2000, the clinic was caring for 750 patients. Now the same clinic, with pretty much the same funding and same staff level, is caring for 1,800 patients.

“We are at capacity now,” Saag says.

But more patients soon will be knocking at the door. Saag points to a graph in the IOM report showing that while U.S. funding for HIV care under the Ryan White Act has remained stable at about $200 million per year, the number of patients who qualify for benefits has increased from about 150,000 to 250,000.

That difference reflects the U.S. HIV treatment gap.

“We call it the triangle of misery,” Saag says. “But in this day and age of budget crisis in every state across the country, asking Congress for more money is not going to cut it.”

The IOM notes that states are slashing, not increasing, their HIV/AIDS programs. In 2009, states cut $170 million from these programs:

-22 states cut HIV care and treatment programs
-17 states cut their contributions to AIDS Drug Assistance Programs
-25 states cut HIV prevention programs
The cuts mean more red tape and more waiting lists for people who need HIV care. It sometimes means that people must interrupt their HIV treatment — an extremely dangerous situation, as such interruptions mean an increase in drug-resistant HIV.

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Moreover, the old generation of health-care professionals caring for people with HIV is, well, getting older. And there’s only a trickle of young doctors in the pipeline.

One solution is “task shifting” — allowing trained nurse practitioners, physician assistants, psychologists, dentists, and others to perform tasks previously relegated only to doctors. Saag says this strategy has worked at his clinic, allowing it to double the number of patients treated.

But stretching current resources can only go so far. “It is worrisome. That is why the IOM report is so timely,” Saag says.

But Cleary says he and the other experts on the IOM committee are optimistic. He points to the National HIV/AIDS strategy as an important road map. And he says the committee was relieved at the passage of the Affordable Care Act, as an estimated 529,000 Americans with HIV are uninsured or underinsured.

A big step forward, Cleary says, would be coordination of state regulations to give health care providers flexibility in treating people with HIV. Also important is to find incentives for young doctors to choose primary care as a profession.

“We are a clever and caring nation. The amount of caring and concern on everyone’s part is just amazing,” he says. “HIV care providers aren’t in this for the money. But we should make it less of a burden on the providers and on the system to do this kind of work.”

According to an investigation by the CDC and New York city and state health officials, a kidney transplant recipient contracted the virus from a donor in an unnamed New York City hospital in 2009. The male donor acknowledged that he had engaged in unprotected sex with another man after he was screened for HIV, but before he donated the organ. The New York hospital tested the donor 79 days before transplant, when he showed no evidence of infection, but did not re-test him closer to the surgery that removed the organ.

The centers’ 1994 guidelines for organ-donor screening, which are being revised, did not address the timing of screening tests.

The CDC is also recommending the use of a test that detects the virus within eight to 10 days of infection.

Of the three major transplant centers serving the city, Mount Sinai Medical Center said the event did not occur there; a spokesman for another, New York-Presbyterian Hospital/Weill Cornell Medical Center, said, “We don’t have any information about this.” New York University Langone Medical Center said that it would be “inappropriate” to comment.

Thanks to screening of organ donors for HIV, the chance of contracting the virus from a transplant is remote. The CDC estimates the risk of HIV transmission from deceased donors is about one in 25,000 donors, or about one every three years. “This may be happening more frequently than we recognize and we are likely missing cases,” said Matthew J. Kuehnert, director of the CDC’s Office of Blood, Organ, and other Tissue Safety.

The Organ Procurement and Transplantation Network, a public-private partnership that sets nationalpolicies for organ allocation and screening, and the United Network for Organ Sharing, which operates the system, are formulating a policy for living-donor screening that would keep patients safe without compromising organ availability, said Connie L. Davis, who chairs the panel working on the policy. “People don’t realize how complicated the scheduling and logistics can be for donors who are stepping forward out of the true goodness of their heart.” Dr. Davis said.

Sander Florman, director of the transplant program at Mount Sinai, said the hospital will test its donors as close to transplant as possible in accordance with the new recommendations, and educate donors “to be very careful about any risky behaviors and report them to us confidentially” before donating an organ.

The investigation began after the Wisconsin Division of Public Health noted a 144% increase in reported HIV diagnoses in Milwaukee County from 2000 to 2008 among black men ages 15 to 29 who have sex with men.

The resulting investigation – which involved the state, Milwaukee Health Department and U.S. Centers for Disease Control and Prevention – found the increase likely wasn’t due to intensified testing efforts, but to increased transmission of HIV through high risk behavior and nondisclosure of HIV status.

If the spike in HIV diagnoses among young black men isn’t reversed, the entire metro area could see increased rates, Milwaukee Health Commissioner Bevan Baker warned Thursday.

A higher percentage of young black males than nonblack males have male sex partners at least five years older, according to the investigation, which involved a sampling of Milwaukee County men with HIV or syphilis diagnoses. Older men are more likely to be infected with HIV.

The Milwaukee Health Department last summer announced a multifaceted strategy to boost HIV testing, reduce stigma in the community and teach men to protect themselves.

The city partnered with Diverse & Resilient, an organization that works to improve the public health of lesbian, gay, transgender and bisexual individuals. That group networked with multiple other community groups and the medical community. It has trained 60 men to help provide information to the targeted population.

Root causes
Young black men are less likely to see a doctor, are at greater risk of being homeless, are more likely to have a lower economic status, and lack access to health care and health information, said Gary Hollander, executive director of Diverse & Resilient.

Internalized homophobia makes them more likely to occasionally have unprotected sex, and being shunned by family and church teachings because of their sexuality increases their chances of being homeless, Hollander said.

“If they are couch hopping to find housing, they’re at greater risk for not adhering to the best health practices, and are more vulnerable to predators exchanging sex for housing, and sex for food,” he said.

The broader questions that need to be addressed, according to Hollander, include services and housing available to this group, whether they have safe venues to remain drug-free and how churches can support them.

“It’s one thing to be 17 and poor,” he said. “Add to that housing that’s vulnerable, being preached against at church and being bullied at school.”

About $4 million in funding from national sources recently has been granted for prevention efforts. On Thursday, Mayor Tom Barrett called on the CDC to reconsider its funding formula so Milwaukee can be eligible to receive “critical resources that will enable us to more efficiently address our city’s high HIV rates.”

Larger cities, whose overall HIV and AIDS infection rates are higher, are getting the lion’s share of federal money for prevention, Baker said.

“The CDC needs to be more agile and nimble to change their formula,” he said.

In 2009, CDC funding to Wisconsin for HIV prevention totaled $3.4 million, according to a CDC spokeswoman.

Black men ages 15 to 29 who have sex with men form the group most affected by HIV, according to Thursday’s report. That age group in 2008 accounted for 71% of new diagnoses among Milwaukee County black men who have sex with men. Nationwide in 2006, black men ages 13 to 29 who have sex with men accounted for an estimated 52% of all new HIV infections among black men who have sex with men – nearly as many infections as Hispanic and white men in this age group combined.

Free testing
The Milwaukee Health Department will provide free, confidential HIV and STD testing from 3 to 7 p.m. Monday at Heartlove Place, 3229 N. King Drive. Call (414) 286-3521.

Michigan and Connecticut are the latest two states which reported their first deaths on Wednesday.

The Michigan Department of Community Health has confirmed that the state’s first death of A/H1N1 flu involved a 53-year-old woman, who died on Tuesday in a hospital in Macomb County after being sick for more than two weeks.

“This is sad and unfortunate. But, at the same time, we do expect a number of deaths (nationally) following the infection from this virus,” James McCurtis, a spokesman for the department, said on Wednesday.

As of Wednesday, Michigan reported 298 confirmed cases of A/H1N1 flu statewide, comparing to 287 cases released by the U.S. Centers for Disease Control and Prevention (CDC) on its website.

Meanwhile, the Connecticut Department of Public Health on Wednesday announced that a resident aged over 50 has become the first person in the state to die from the A/H1N1 flu.

Confirmed cases of the A/H1N1 flu in the state has jumped to 397, almost double the figure of 197 released by the CDC on its website, the department said.

Officials said the actual number might be much higher because many people with mild symptoms do not go to a doctor or hospital.

New York and Illinois are the two states which reported on Wednesday more deaths from the A/H1N1 flu virus. The New York health department said that two more New Yorkers have been killed by the virus, bringing the state’s death toll to seven.

In Chicago, Illinois Department of Public Health spokeswoman Melaney Arnold declared that a 22-year-old Chicago woman has died from complications of the A/H1N1 flu one day after she gave birth, bringing the number of Illinois deaths related to the virus to four.

The state health department has reported 1,268 confirmed cases of the A/H1N1 flu statewide, comparing to 1,151 cases released by the CDC on its website on Wednesday.

Nationwide, the CDC has reported 17 deaths from the A/H1N1 virus in seven states, not including four deaths reported by local health officials on Tuesday — the first two deaths in California, the first death in Virginia and the fifth death in New York.

On Wednesday, the CDC also reported 11,054 confirmed cases of the A/H1N1 flu in all 51 states.

The agency anticipates more cases, hospitalizations and deaths associated with this new virus in the coming days and weeks.

BiPar’s BSI-201 has emerged as one of the most promising new products at this year’s ASCO cancer conference in Orlando, Florida, with positive mid-stage trial results helping lift Sanofi shares by more than 3 percent on Monday.

But there is a fly in the ointment. A Sanofi spokesman said on Monday that the main U.S. composition patent on the medicine was valid only until 2013, though this could be extended by five years.

In Europe, the patent runs to 2014 and Sanofi will have 10 years data exclusivity after approval.

“These facts probably explain the relatively modest agreed price for the BiPar deal,” analysts at Morgan Stanley said in a research note.

They estimate BSI-201 could sell between $1 billion and $4 billion a year to Sanofi’s 2016 revenues, with a U.S. launch as possible by late 2010.

On the face of it, that makes the price Sanofi’s new chief executive, Chris Viehbacher, paid for BiPar seem a bargain. The problem is the medicine could face generic competition in the world’s biggest pharmaceuticals market from 2018.

BSI-201 belongs to a new class of drugs that block a cell repair enzyme known as PARP.

It impressed doctors at the annual meeting of the American Society of Clinical Oncology (ASCO) on Sunday by improving survival by 60 percent compared with chemotherapy alone for women with tough-to-treat “triple negative breast cancer.”

Patients with triple negative metastatic breast cancer have tumors that do not express the hormones oestrogen or progesterone, as well as the protein HER-2.

These women, who account for 15 to 20 percent of breast cancer patients, have a very aggressive form of disease and there are currently no treatments other than chemotherapy.

Citigroup analyst Mark Dainty said the data for BSI-201 was significantly better than the results with Roche’s Avastin in triple negative patients and the new drug could put 20 to 25 percent of Avastin sales forecasts at risk.

Citi currently forecasts 2011 Avastin breast cancer sales at 1.7 billion Swiss francs ($1.6 billion) and losing 20 percent of this would slice some 2 percent off Roche’s 2011 earnings per shares.

AstraZeneca also has an experimental PARP inhibitor called olaparib that is further behind in development.

Most people who develop mesothelioma have worked on jobs where they inhaled asbestos particles, or they have been exposed to asbestos dust and fiber in other ways. Washing the clothes of a family member who worked with asbestos can also put a person at risk for developing mesothelioma.[2] Unlike lung cancer, there is no association between mesothelioma and smoking, but smoking greatly increases risk of other asbestos-induced cancer.[3] Compensation via asbestos funds or lawsuits is an important issue in mesothelioma (see asbestos and the law).

The symptoms of mesothelioma include shortness of breath due to pleural effusion (fluid between the lung and the chest wall) or chest wall pain, and general symptoms such as weight loss. The diagnosis may be suspected with chest X-ray and CT scan, and is confirmed with a biopsy (tissue sample) and microscopic examination. A thoracoscopy (inserting a tube with a camera into the chest) can be used to take biopsies. It allows the introduction of substances such as talc to obliterate the pleural space (called pleurodesis), which prevents more fluid from accumulating and pressing on the lung. Despite treatment with chemotherapy, radiation therapy or sometimes surgery, the disease carries a poor prognosis. Research about screening tests for the early detection of mesothelioma is ongoing.

Signs and symptoms
Symptoms of mesothelioma may not appear until 20 to 50 years after exposure to asbestos. Shortness of breath, cough, and pain in the chest due to an accumulation of fluid in the pleural space are often symptoms of pleural mesothelioma.

Symptoms of peritoneal mesothelioma include weight loss and cachexia, abdominal swelling and pain due to ascites (a buildup of fluid in the abdominal cavity). Other symptoms of peritoneal mesothelioma may include bowel obstruction, blood clotting abnormalities, anemia, and fever. If the cancer has spread beyond the mesothelium to other parts of the body, symptoms may include pain, trouble swallowing, or swelling of the neck or face.

These symptoms may be caused by mesothelioma or by other, less serious conditions.

Mesothelioma that affects the pleura can cause these signs and symptoms:

chest wall pain
pleural effusion, or fluid surrounding the lung
shortness of breath
fatigue or anemia
wheezing, hoarseness, or cough
blood in the sputum (fluid) coughed up (hemoptysis)
In severe cases, the person may have many tumor masses. The individual may develop a pneumothorax, or collapse of the lung. The disease may metastasize, or spread, to other parts of the body.

Tumors that affect the abdominal cavity often do not cause symptoms until they are at a late stage. Symptoms include:

abdominal pain
ascites, or an abnormal buildup of fluid in the abdomen
a mass in the abdomen
problems with bowel function
weight loss
In severe cases of the disease, the following signs and symptoms may be present:

blood clots in the veins, which may cause thrombophlebitis
disseminated intravascular coagulation, a disorder causing severe bleeding in many body organs
jaundice, or yellowing of the eyes and skin
low blood sugar level
pleural effusion
pulmonary emboli, or blood clots in the arteries of the lungs
severe ascites
A mesothelioma does not usually spread to the bone, brain, or adrenal glands. Pleural tumors are usually found only on one side of the lungs.