AIDS TREATMENT NEWS Issue #388, February 7, 2003
phone 800-TREAT-1-2, or 215-546-3776

CONTENTS

** Antibiotic-Resistant Skin Infections Spreading among Gay Men,
Also in Prisons
An outbreak of staphylococcus skin infection, causing large
boils that are difficult to treat because these bacteria are
resistant to many antibiotics, has spread recently among gay men
in some cities, and also in certain prisons. In the past this
infection occurred mainly in hospitals.

** Retroviruses Conference, Feb. 10-14; Sites to Watch for News
AIDS TREATMENT NEWS will cover the important 10th Conference on
Retroviruses and Opportunistic Infections starting in our next
issue. Here are some Web sites to check for other reports,
especially during the next few weeks.

** Building Grassroots Support for AIDS
Citizen-action campaigns (like getting people to call Congress
or their state representatives to support Medicaid, ADAP, or
other program for access to medical care) could get much more
response if they were made accessible to the millions of people
who are already supportive but not already involved. We suggest
several ways to make action alerts and other citizen organizing
work better.

** Bush Proposes Near Tripling of U.S. Commitment on Global HIV
Epidemic
The presidential initiative to increase funding for global AIDS
prevention and treatment is widely seen as a groundbreaking
advance. But critical time will be lost if the U.S. focuses so
heavily on building its own new system, instead of using
multinational organizations like the Global Fund that are ready
now.

** African-Americans and AIDS, Conference Feb. 24 and 25, New
York
This national meeting brings leading experts and professionals
together for lectures and networking. It offers continuing
education credit for doctors and nurses, but is open to all.


***** Antibiotic-Resistant Skin Infections Spreading among Gay
Men, Also in Prisons

by John S. James

In the last few months doctors have seen a large increase in
aggressive, antibiotic-resistant "staph" (Staphylococcus aureus)
skin infections in gay men in some areas -- and a separate
epidemic in certain prisons. Symptoms include boils or blisters;
treatment can be difficult, and sometimes requires
hospitalization. One HIV doctor in Los Angeles who used to see
about one case a year is now seeing two a week. In the past this
infection occurred mainly in hospitals.

Physicians should note a February 1, 2003 review in the BRITISH
MEDICAL JOURNAL ("Old Drugs for New Bugs," BMJ 2003; volume 326,
pages 235-236) on evidence for the value of older antimicrobials
for resistant bacteria, including staph. It suggests using co-
trimoxazole (Bactrim(R) or other brand names) as an alternative
to vancomycin for resistant S aureus (also called MRSA). In one
case co-trimoxazole was used successfully after a patient had
failed the new and very expensive antibiotic linezolid
(Zyvox(R)). The article is at:
http://bmj.com:80/cgi/content/full/326/7383/235?maxtoshow=?eaf

Below is a fact sheet published by the Los Angeles County
Department of Human Services on how to avoid the infection (or
avoid spreading it if you have it). Also, a fact sheet by the
U.S. CDC, revised February 7, 2003, is at:
http://www.cdc.gov/ncidod/hip/aresist/mrsafaq.htm

For a recent overview, see "Skin Infection Spreads Among Gay Men
in L.A.," LOS ANGELES TIMES, January 27, 2003.

Fact Sheet Published by Los Angeles County Department of Human
Services"
Antibiotic-resistant "Staph" Skin Infections

"Recently, doctors in Los Angeles have been seeing an increasing
number of patients with skin infections caused by Staphylococcus
aureus ("Staph") bacteria that are resistant to many antibiotics
(drugs that kill bacteria). The Los Angeles County Department of
Health Services is working with doctors and other healthcare
providers to better understand why this is happening and how to
prevent antibiotic (drug) resistant Staph infections from
spreading.

"What is a Staph infection? Staph is a bacteria commonly found
on human skin. Sometimes it does not cause any problems;
sometimes it causes minor infections, such as pimples or boils.
Staph skin infections often begin with an injury to the skin.
Staph enters the skin weakened by the injury and develops into
an infection. Symptoms of a Staph infection include redness,
warmth, swelling, tenderness of the skin, and boils or blisters.

"How do Staph skin infections spread? The cleanest person can
get a Staph infection. Staph can rub off the skin of an infected
person onto the skin of another person during prolonged (skin to
skin) contact between them. Or, the Staph can come off of the
infected skin of a person onto commonly shared objects and
surfaces, and get onto the skin of the person who uses it next.
Examples of commonly shared objects include personal hygiene
objects (i.e. towels, soap, clothes), benches in saunas or hot
tubs, and athletic equipment -- in other words, anything that
could have touched the skin of a Staph infected person can carry
the bacteria to the skin of another person.

"How can I prevent myself from getting infected? Avoid prolonged
skin to skin contact with anyone you suspect could have a Staph
skin infection. Do not share personal items with other persons.
Clean objects and surfaces that you share with other persons,
such as athletic equipment, before you use it. Always wash your
skin, clothes, and towels that might be carrying Staph.

"What should I do if I think I have a Staph skin infection? If
you suspect that you might have a Staph skin infection, consult
your doctor or healthcare provider as soon as possible. Early
treatment can help prevent the infection from getting worse. Be
sure to follow each direction from your doctor or healthcare
provider closely, even when you start to feel better. Weak or
incomplete treatments of Staph infections lead to stronger,
antibiotic-resistant bacteria.

"If my health care provider has told me that I have an
antibiotic-resistant Staph infection, what can I do to keep
others from getting infected? You can prevent spreading an
antibiotic-resistant Staph skin infection to those you live with
or others by following these steps:

"1. Keep the infected area covered with clean, dry bandages. Pus
from infected wounds is very infectious.

"2. Wash your hands frequently with soap and warm water,
especially after changing your bandages or touching the infected
skin.

"3. Regularly clean your bathroom and personal items. Wash
linens and clothes that become soiled with hot water and bleach,
when possible. Drying clothes in a hot dryer, rather than air-
drying, also helps kill bacteria in clothes.

"4. Tell any healthcare providers who treat you that you have an
antibiotic-resistant Staph skin infection.


***** Retroviruses Conference, Feb. 10-14; Sites to Watch for
News

The important 10th Conference on Retroviruses and Opportunistic
Infections is February 10-14, 2003, in Boston. We will report
some of the developments beginning in our next issue, #389.

Meanwhile, here are some Web sites that are likely to publish
reports during or shortly after the meeting:

* Official Retroviruses site,
http://www.retroconference.org/2003/

* The Body,
http://www.thebody.com/confs/retro2003/retro2003.html

* Clinical Care Options, http://www.clinicaloptions.com (new
site from experienced team, plans extensive reviews, CME)

* HIVandHepatitis.com, http://www.hivandhepatitis.com

* Medscape, http://www.medscape.com/viewprogram/2221

* HIV Insite, http://hivinsite.ucsf.edu/InSite.jsp?page=md-02-04

* Aegis, http://www.aegis.org

* National AIDS Treatment Activist Project, http://www.natap.org


***** Building Grassroots Support for AIDS

by John S. James

Today in the U.S. we are facing one of the worst climates ever
for access to medical care and social services for AIDS and
other needs. Government budget problems, combined with the
dysfunctional financing of medical care, are threatening
Medicaid, ADAP, and the long-standing agreement that most people
with HIV in the U.S. can get treatment.

For years the AIDS community has done well in the media and in
building public consensus on what needs to be done. But we have
been much less effective in grassroots organizing -- in giving
those who agree with us effective, satisfying actions for making
their values and priorities known. Perhaps 1% of U.S. citizens
who care about AIDS have *ever* let any of their political
representatives know it. So Congress, the White House, and state
and local governments seldom hear from their constituents back
home. And that hurts everything that happens in AIDS.

After watching this happen for years, I have become convinced
that we could do *much* better in mobilizing popular support, by
slightly refocusing some of what we are already doing. AIDS
organizations and activists already have the skills and
resources required.

Improving Action Alerts

As an example of what is needed, consider what must be changed
to improve Internet action alerts so that they are truly
accessible to everyone who cares, not only to experts or
insiders.

A year ago, it was clear that we were being hurt in Washington
because members of Congress were hearing about AIDS (especially
international issues) mainly from media and a few activists and
professionals, but not from the voters in their districts. Since
then important progress has been made. Now there are usually
several action alerts and sign-on letters circulating at any one
time. As a result, more people are contacting their
representatives, and AIDS is treated more seriously in political
circles.

These action alerts vary in quality and credibility. Some
include errors that could easily be fixed, such as misspellings
or obsolete information. More important are judgment issues that
are harder to detect -- such as whether the alert is based on a
thought-out, workable strategy, or only on somebody being upset
one day and wanting to do something. And many alerts try to get
people to act by hammering on how bad the problem is -- while
those most likely to respond already know this, but need help
with other obstacles.

The main problem is that unless people recognize a sponsoring
organization or already know the issue very well, they have no
way of knowing which action alerts they truly want to support.
Therefore many alerts that may look accessible (because they
correctly avoid jargon, abbreviations, or insider code meanings)
are still effectively available only to those already involved.
The general public, even those who completely agree on the
issues, cannot use them intelligently.

Even very experienced activists have sometimes had to retract
their endorsement of a campaign that turned out not to be what
it seemed. How can we expect people to speak out on our issue if
we do not negotiate the necessary credibility up front?

The Right Target Audience: Those Who Care But Are Not Already
Connected

Action alerts should be credible, feasible, and rewarding to all
who agree on the issue -- not just AIDS specialists. Here are
some pointers:

* Any action request or other grassroots campaign should be
designed for a target audience -- not for no one in particular.

For most alerts, we suggest addressing someone who already
agrees on that issue, but may live miles away from the nearest
AIDS organization or activist, and not personally know anyone
involved. Imagine also that this person wants to bring the alert
to his or her church group, civic or political club, or other
social circle -- also non-experts. An action alert package must
provide exactly what is needed to do so. Probably it will
include a one-page explanation, plus a background document (or
Web link, preferably to a page designed for that campaign) for
anyone who wants more information.

People usually join causes not as individuals, but as members of
social circles. Therefore, campaigns should facilitate group
involvement, as well as helping individuals who want to act on
their own.

* The action alert should be based on human values and not
assume special knowledge of facts, or of their special
significance. If it does include facts, these should be
separated from the action item, so that people are not asked to
sign someone else's research. Otherwise the alert will lose
supporters unnecessarily, because many will feel that they do
not have enough background to publicly endorse the factual
statement. For example, everyone would agree that children
should not die, but not everyone would sign a statement saying
that 610,000 children under 15 died of AIDS in 2002.

* The way to make an action alert credible to the general public
is to negotiate it in advance among different organizations
and/or public figures, including some that are widely known and
respected by the general public (such as Doctors Without
Borders, which recently won a Nobel prize), or major churches,
or popular celebrities. This may seem like a lot of work, but in
fact it is already being done. For years AIDS organizations have
developed sign-on letters, often endorsed by over a hundred
well-known organizations, including both AIDS and non-AIDS
health, political, religious, and other groups.

These sign-on letters do help. But unfortunately they waste most
of their potential, because once they are released they are
finished. They do not involve the public because they give
people no chance to act. Usually the letter and signatures are
delivered to some office, and perhaps a press release goes out.
Then it is all forgotten, because there is no follow-through.

On the other hand, most action alerts do have the follow-through
in public involvement -- but did not bother with consensus
development. Generally they are sent out by one organization
that is all but unknown outside the AIDS field. No wonder they
cannot generate many letters, phone calls, or other actions
requested, since only AIDS specialist can be confident that the
action request is credible.

Imagine what could be done by combining consensus development
with actions that any supporter could take. These action alerts
could break out of AIDS circles and reach many more people.

* One way to make it much easier for someone to bring an action
alert to his or her church group (for example) is to get a
national office of that church to endorse it. Then all the
members of the national group have an occasion to bring the
matter up if they want to.

The way to get organizations to work together on a citizen-
action campaign is to reach a meeting of the minds first. This
requires ongoing dialog to discover areas for working together.
Instead of bringing a finished product or preconceived plan, see
what can be developed mutually. The AIDS catastrophe affects so
many people and organizations that the opportunities for working
together are endless.

* Once this groundwork is done, one still must tell people about
their opportunity to help. Reaching the public is a separate
challenge. But there are self-starters who can pick up an issue
from a friend's email or a newspaper, without needing an
organization to provide someone to hold their hand. And we can
publicize campaigns by coordinating them with major news
stories.

* We should pay attention to developing actions that fit
gracefully into peoples' lives. We need to understand and
address their real reluctances to act. Contacting state or
federal political representatives, civic or political
organizations, corporate offices, etc. should not be a high-
anxiety chore.

Perhaps citizen action could become a practice worth doing for
its own sake -- designed to guide us through effective styles of
everyday living. Imagine a discipline like Tai Chi, only built
on interpersonal moves instead of physical ones. (This writer
started a Web site to explore the possibility,
http://www.communicationpractices.org.)

The bottom line is that by properly targeting our action
campaigns, and negotiating the right consensus and sign-on in
advance, we can involve many more people than before -- without
necessarily building a major national grassroots organization,
something the AIDS community has not yet been able to do. Better
use of the skills we already have could increase public response
many times over. We are addressing people who already agree with
us on the issues. The critical need now is to provide specific
actions that truly work for them.


***** Bush Proposes Near Tripling of U.S. Commitment on Global
HIV Epidemic

by John S. James

In what is widely seen as a groundbreaking advance, President
Bush proposed additional U.S. funding of almost $10,000,000,000
over the next five years for fighting the global HIV epidemic.
The president made this unexpectedly major announcement in the
State of the Union speech on January 29, 2003. If appropriated
by Congress, the money would bring the total spending over five
years to about to about $15,000,000,000. The measure will have
strong bipartisan support, but passage is not assured.

The proposed U.S. initiative is for 14 countries, 12 of them in
Africa, that together have about half of the HIV-infected people
in the world. Over five years, it aims to prevent 7,000,000 new
HIV infections (60% of the number projected for those
countries), treat 2,000,000 people with HIV, and care for
10,000,000 HIV-infected individuals and AIDS orphans. (The
countries are Botswana, Cote d'Ivoire, Ethiopia, Guyana, Haiti,
Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa,
Tanzania, Uganda, and Zambia; for initial ideas on how the
program may work within these countries, see the January 29,
"Fact Sheet; the President's Emergency Plan for AIDS Relief" at
http://www.whitehouse.gov/news/releases/2003/01/20030129-1.html
-- check later information if available). The program will start in
fiscal year 2004 (the U.S. government fiscal year 2004 begins
October 1, 2003), with funding expected to begin slowly and ramp
up in later years. This proposal is not finished, and much is
being worked out now in discussions among the White House,
Congress, and global AIDS and health organizations.

The announcement came as a surprise even to members of Congress,
and European and other governments -- apparently because
President Bush and his administration were weighing many factors
and were not sure what HIV program (if any) would be announced
until shortly before the speech. It was known that
administration officials and AIDS experts had been working
quietly for months to develop an initiative to address the
global epidemic. We have heard that President Bush was given
several proposals, and chose one (the one, incidentally, with
the largest total funding). This plan includes a comprehensive
prevention program (including abstinence and condoms), and an
equal emphasis on prevention and treatment, including
antiretrovirals.

This high-profile announcement is already changing the tone of
the discussion, with talk in Washington shifting from whether
there should be a larger U.S. program to how to make it work. A
key issue is getting European and other donor nations to also
increase their commitment to fighting an epidemic that could
kill a third of the entire population of many countries, and is
spreading rapidly today in huge populations in Asia and Eastern
Europe.

Some Widespread Criticisms

While the announcement was universally welcomed and the plan is
considered credible, there have also been some widespread
concerns:

* Even if Congress acts favorably, this plan will not formally
start until October, and then will build slowly as the U.S.
negotiates and develops new management and oversight structures
in the 14 countries instead of using what is already available.
Meanwhile, the Global Fund to Fight AIDS, Tuberculosis, and
Malaria, started by United Nations Secretary-General Kofi Annan
(and now to be headed by U.S. Secretary of Health and Human
Services Tommy Thompson), is running today and has excellent
proposals ready to go, delayed only by lack of money. But the
president's initiative de-emphasizes the Global Fund, and we
have heard that administration officials are lobbying Congress
not to provide more money. Either they want to see a track
record first, with statistical proof of results like number of
infections prevented, or they want to control the geopolitical
impact of the funding. In either case the result is more delay.
Yet in an epidemic, the best time to act is now.

Activists have, however, noted one advantage of the president's
initiative over the Global Fund. The new U.S. program is likely
to provide antiretroviral treatment to more people than the
Global Fund, which developed earlier when treatment was more
controversial. Today it is more widely recognized that treatment
must be included to make prevention work, since otherwise people
have no incentive to come forward for testing, or to help
organize prevention and care programs in their communities.

* Health and development experts are concerned that the
president's proposal is heavily weighted toward bilateral
agreements between the U.S. and each of the 14 countries,
instead of multilateral institutions like the Global Fund.
Multilateral approaches can better leverage contributions from
other donor countries, and coordinate the worldwide fight.
Separate donor programs could increase bureaucracy (including
multiple application and reporting requirements for the
recipient countries) and reduce effectiveness.

Instead of using the Global Fund or other international
agencies, the president's initiative calls for oversight by a
Special Coordinator for International HIV/AIDS Assistance, to be
confirmed by the Senate with a rank of ambassador, and report
directly to the Secretary of State. It includes some support for
the Global Fund, but only about ten percent of the total.
Development experts hope that this small support for
multilateral programs can be increased.

* The president's initiative proposed $10,000,000,000 in new
money and $5,000,000,000 being spent already, both over five
years. Where will the billion dollars a year in "old" money come
from? "Mr. Bush in his State of the Union speech proposed new
spending to fight AIDS and HIV in Africa and the Caribbean. But
his budget for 2004 would reduce by about the same amount the
funding that aides had said would be sought for a separate
development-aid initiative for poor nations," ("Budget for Hard
Times Offers New Plans but Many Cutbacks, by John D. McKinnon
and Greg Hitt, THE WALL STREET JOURNAL, February 4.)

The president's budget request, released February 3, includes
major cuts in child health and survival programs, which include
routine vaccination, according to the BOSTON GLOBE ("U.S. Seeks
Cuts in Health Programs Abroad," by John Donnelly, Feb. 5). "The
bottom line is with 10.5 million children dying around the world
each year from easily preventable causes -- things that could be
stopped at very low costs -- this is an area where the world
community has really dropped the ball over the last decade. When
you recognize that you have dropped the ball, you don't drop it
even further." (Nils Daulaire, Global Health Council, quoted in
the BOSTON GLOBE, February 5.)

Civil society and the public will have to watch these and other
issues closely. Certainly funding for AIDS must not come at the
cost of programs like child survival.

Community Support Needed

The president's proposal will need public support to make sure
that it is implemented and works as well as possible:

* Congress must decide whether or not to spend the money.
Members of Congress must hear from their constituents back home
that they care about the global epidemic. AIDS and health
organizations have generally been effective in working with
experts and the media, educating the public on the seriousness
of the epidemic and building consensus that this country must
help in the solution. They can and must do better in giving non-
experts practical ways to express their values and concerns --
to their political representatives, in their social circles, and
otherwise. (See "Building Grassroots Support for AIDS" in this
issue.)

* How can people get involved in helping? So far, much of the
non-government work in pushing government to make sure that
President Bush would have well-developed options if he decided
to have an AIDS initiative was done by the Advocacy Network for
Africa (ADNA), a group of 231 member organizations (as of
January 19, 2003; the list is at
http://www.africaaction.org/adna/adnalist.htm). Readers can look
over this list to find organizations they might like to work
with, and see if there is a program where they could help.

Also important is that evangelical Christians are becoming more
interested in AIDS in Africa, especially in the last year, and
more inclined to see the epidemic there as a health problem
instead of a moral one (see "Unlikely Allies Influenced Bush to
Shift Course on AIDS Relief," by Mike Allen and Paul Blustein,
WASHINGTON POST, Jan. 30). It is likely this change is happening
now because conservative Christianity is spreading rapidly in
Africa, and religious organizations see their members die --
often for reasons beyond their control, as when a faithful wife
is infected by her husband. Also, in February 2002, arch-
conservative Senator Jesse Helms told conservative Christians
that "I have been too lax too long in doing something really
significant about AIDS," and was going to keep AIDS in Africa on
his agenda for his remaining months in office. This new
involvement of evangelical Christians may have been key to a
national consensus that made the Bush proposal possible.

Comment: Is the Cup Half Full or Half Empty?

After the State of the Union speech, most AIDS experts and
activists saw the president's initiative as a major
breakthrough. Two weeks later they still see it that way,
although concerns like those above are widely stated. We see
this proposal as a big step forward, but one that needs public
involvement to help make it work.

One of the problems facing national leaders who want to work on
AIDS is their fear that they will be attacked no matter what
they do. This fear is realistic, because in fact most
governments and their leaders around the world have done
appallingly badly on AIDS. But if this is going to change, we
must have workable paths forward.

For these reasons we have chosen to emphasize the positive --
without denying that, as with any major new proposal, problems
exist and changes will be needed as the work goes forward.


***** African-Americans and AIDS, Conference, Feb. 24 and 25,
New York

The 2003 National Conference on African-Americans and AIDS will
take place Feb. 24-25 at the New York Marriott Marquis in New
York City. This conference will focus mainly on treatment and
care, but include other topics as well. It offers continuing
education credit for physicians and nurses. Admission is $90 in
advance, $120 on site; some scholarships are available. This
conference is sponsored by The Foundation for Better Health
Care.

Speakers and panelists include:
Jean Anderson, M.D.
Guthrie Birkhead, M.D.
Victoria Cargill, M.D., M.S.C.E.
Charles E. Clifton
Keith Cylar
Elaine M. Daniels, M.D.,, Ph.D.
Thomas E. Douglas
Henry "Skip" Francis, M.D.
Debra Fraser-Howze
Robert Fullilove, Ed. D.
Donna Futterman, M.D.
Danny Glover
Barney S. Graham, M.D., Ph.D.
Wilbert Jordan, M.D.
Jake Liang, M.D.
Cleo Manago
Marsha A. Martin D.S.W.
Celia Maxwell, M.D.
Sandra McDonald
Bill Peters
Beny J. Primm, M.D.
Rep. Charles Rangel
George W. Roberts, Ph.D.
Pernessa Seale
Cheryl Smith, M.D.
Valerie Stone
Glenn Treisman, M.D., Ph.D.
Darrell Wheeler, Ph.D.
Phill Wilson
Jonathan Zenilman, M.D.

For more information visit http://www.ncaaa.net, or contact:
The National Conference on African Americans and AIDS
c/o ExpoTrac
PO Box 1280
Woonsocket, RI 02895
phone 410-766-4142, fax 401-765-6677.


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