Italians are ashamed of Andrew Cuomo's failure to see that BCG is as easily available in NY as condoms, clean needs, automatic weapons, ammunition, and betting at Nassau OTB 365 days of the year.
See pubmed.org ristori + bcg and faustmanlab.org and pubmed.org faustman dl
You would think that Andrew Cuomo would be able to discern good work?
What can you expect of lawyers and politicians?
Got MS get BCG in NY or go to Italy? Don't vote for Andrew Cuomo!
Ristori
G, Romano S, Cannoni S, Visconti A, Tinelli E, Mendozzi L, Cecconi P,
Lanzillo R, Quarantelli M, Buttinelli C, Gasperini C, Frontoni M,
Coarelli G, Caputo D, Bresciamorra V, Vanacore N, Pozzilli C, Salvetti
M.
Neurology. 2014 Jan 7;82(1):41-8. doi: 10.1212/01.wnl.0000438216.93319.ab. Epub 2013 Dec 4.
On Sunday, Gov. Andrew Cuomo announced an ambitious goal: Ending the AIDS epidemic in New York State by 2020.
Governor
Cuomo does not mean he expects the state to find a cure; he wants to
cut new infections so drastically that the number of New Yorkers living
with H.I.V. goes into decline. He has set a goal of 750 new infections
in 2020, down from about 3,000 in 2013 and 14,000 at the epidemic’s peak
in 1993.
To
that end, he has embraced a new and controversial treatment for people
at risk of contracting H.I.V. He wants to put more H.I.V.-negative
people on Truvada, a drug originally developed to treat those who
already have the virus, and which the F.D.A. approved in 2012 as
protection against new infections.
This
strategy, known as pre-exposure prophylaxis (PrEP), is one of three
planks in Governor Cuomo’s broad plan to cut H.I.V. infections, and the
most novel one. The other two (testing more people and getting those who
test positive to see doctors; getting H.I.V.-positive people to stay in
treatment and on medication) are strategies that New York and other
states have pursued for decades with varying degrees of success.
The
timing of the announcement, on gay pride weekend, reflects Governor
Cuomo’s desire to shore up gay votes at a time when his relations with
other core Democratic Party constituencies are uneasy. But it also
reflects a certain political boldness: While health agencies at the
local, state and federal levels have been embracing PrEP, H.I.V.
professionals I spoke with could not recall another example of a
governor or similarly high-level elected official personally advocating
its use.
Studies
provide increasing evidence that PrEP is highly effective at stopping
H.I.V. infection when people take the medication daily as prescribed,
and the Centers for Disease Control and Prevention have recommended its
use by up to half a million Americans. In New York, Medicaid covers
PrEP, as do most private insurers.
Yet uptake has been slow, in part because calls to use PrEP have been muted, and because in certain parts of the gay male community, users have been stigmatized as “Truvada whores” who could end up spreading infection if they stop using condoms and don’t take the drug rigorously as prescribed.
A 2013 study found that 75 percent of infectious disease physicians supported the use of PrEP, but only 9 percent had actually prescribed it.
Before Mr. Cuomo’s announcement, pro-PrEP guidance from the government
has generally come through bureaucratic news releases. The C.D.C. did
not hold a news conference when it endorsed PrEP in May. Even Truvada’s
manufacturer, Gilead Sciences, is not actively marketing the drug for
PrEP.
As Donald G. McNeil Jr. wrote for the Times
in May, “For now, Truvada has no Andromeda or Margaret Sanger,”
referring to early ads for birth control pills that used the
mythological figure as a symbol of sexual liberation and to one of birth
control’s most outspoken champions. But now Governor Cuomo is stepping
into the role of Sanger, along with the health departments of New York
State and New York City. The city’s health department is running a public education campaign
urging the use of both PrEP and post-exposure prophylaxis (PEP), a
similar emergency treatment that people can start immediately after an
exposure to H.I.V.
When
I asked why the governor had made PrEP a key part of his anti-H.I.V.
strategy, a top administration official involved in developing the plan
who spoke on condition of anonymity gave me a remarkably frank answer.
“Some people use condoms, some people don’t,” the official said. “You
can’t offer condoms to people who don’t want them.”
Condoms
have long been the main risk-reduction tool the state promotes for gay
men, and in recent years, New York has had great success in reducing
H.I.V. infection among most major risk groups – but not as much among
gay men. From 2007 to 2012, new infections fell 28 percent in New York,
despite being close to flat nationally. New York infections fell 41
percent among women, and 63 percent among injection drug users;
transmission through sex between men declined just 8 percent.
New
York officials are not abandoning condoms; city and state guidelines
say that people on PrEP should still use them. But many people,
including many gay men, will continue to ignore that guidance. For that
group, PrEP may be the harm-reduction tool that can bring down new
infection rates, much as policies to make clean syringes available have
drastically reduced new infections among injection drug users.
In
addition to PrEP, Governor Cuomo hopes to cut new infections by
improving the state’s performance at getting H.I.V.-positive people
tested, into treatment and virally suppressed. When people with H.I.V.
take antiviral medication consistently, the virus becomes undetectable
in their blood. That doesn’t just make those people healthier; it also
makes it virtually impossible for them to transmit the virus to others.
Jurisdictions like Massachusetts and San Francisco that have sharply
increased the share of people with H.I.V. who have undetectable viral
loads have seen related reductions in new H.I.V. infections.
New
York is already better than average at this. Forty-four percent of
people living with H.I.V. have undetectable levels of the virus,
according to state data from 2012. The Cuomo administration official
expects the state to soon revise that number to closer to 50 percent
because of improvements in data collection; some people currently
counted as having fallen out of treatment have actually left the state,
and a change to state law in April making it easier for medical
providers to share information with health departments is helping the
state to identify those people. (Federal data from the C.D.C. show just
25 percent of people with H.I.V. are in care and virally suppressed, but
the true number may be higher, because of the same data issue with
patients who have moved or changed medical providers being incorrectly
reported as out of care.)
Even
the revised figure leaves about half of New Yorkers with H.I.V. not
virally suppressed, about 15 percent because they haven’t been diagnosed
and the remainder because they are not in effective treatment. Mark
Harrington, executive director of the Treatment Action Group, an AIDS
policy think tank, expects the state to create a task force to flesh out
strategies for getting those numbers down, and the Cuomo administration
is already promoting a few initial actions toward that goal.
The
state recently repealed a law requiring written patient consent to
perform H.I.V. tests, and the state will start enforcing a 2010 law
requiring doctors to routinely offer H.I.V. testing to all patients aged
between 13 and 65, according to the Cuomo administration official. The
idea is to overcome the shame and stigma around the virus that
discourages some people from getting tested; if testing is routine,
patients need not feel they are admitting to anything by getting a test.
The
law allowing greater information-sharing about H.I.V.-positive patients
isn’t just helping the state improve its statistical reporting; it’s
also helping doctors and health departments re-engage patients who fall
out of care. And the state has strengthened housing support, capping
rents for people with H.I.V. who live in public or subsidized housing at
30 percent of income, reasoning that stable housing is a driver of
adherence to H.I.V. care.
Other
novel ideas to keep people in treatment are currently in testing. Dr.
Wafaa El-Sadr, director of the International Center for AIDS Care and
Treatment Programs at Columbia, is running a trial of a program that
makes cash payments to patients with H.I.V. in exchange for quarterly
tests showing undetectable viral loads.
What
all these approaches have in common, including PrEP, is that they don’t
involve pharmaceutical breakthroughs. They are structured around using
already existing resources and already developed medications more
effectively.
Governor
Cuomo’s administration even expects the state to save money with this
approach. The state will buy more medication in the short term, for
Medicaid recipients on PrEP and for H.I.V.-positive people using
Medicaid or the state’s AIDS Drug Assistance Program. But the state
estimates that every prevented H.I.V. infection saves $400,000 in
medical costs, for net savings over $300 million through 2020 if the
state hits its goal of a three-quarters decline in new infections.
Of
course, that’s a big “if.” Over time, we will see if the state’s new
initiatives, including PrEP, succeed in achieving such a sharp drop.
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