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Volume 6, No. 1, January 2008
From Your Colleagues
David Gahn, Tahlequah
You can make a big difference in women’s and children’s lives
Colleagues,
Here are some unique opportunities that are available for Indian Health staff
1) The Office of Global Health Affairs (OGHA), within the Department of Health and Human Services (HHS), has invested in improving the level of care at Rabia Balkhi Hospital (RBH), one of four maternity hospitals in Kabul, Afghanistan. HHS/OGHA has also contracted with a few non-governmental organizations (NGOs) to provide expertise in certain aspects of the program, run with the permission of and under the supervision of the Afghanistan Ministry of Public Health (MoPH). HHS partners include the Centers for Disease Control and Prevention (CDC) , the Health Resources and Services Administration (HRSA), the Agency for Health-Care Research and Quality (AHRQ) and the Indian Health Service (IHS).
2) RBH provides care to women, mostly in obstetrics. There is also a small component of general surgeons, internists, and dermatologists. 40 to 60 women a day deliver at RBH. One of the other four hospitals in Kabul, Malalai, is also this busy. Because of the U.S. presence at RBH, it has become the main referral hospital in Kabul, and receives the sickest women for delivery. RBH also houses an residency program in obstetrics and gynecology, with about 50 residents and 14 faculty.
3) The current focus of the HHS project is a Cesarean section quality-assurance (QA) program. The project is starting at RBH, but will branch out to collaborate with the other hospitals in Kabul. Over the last several years, HHS/CDC has developed a system within the MoPH for collecting data on maternal and child health in Kabul. The current data show an increase in the Cesarean section rate from 4% to 10%, which the Ministry and our partners thought would decrease maternal and perinatal morbidity and mortality. However, the data also show a concurrent increase in mortality.
4) HHS/OGHA is looking for obstetricians/gynecologists and pediatricians to go to RBH to work as advisors to the local physicians, to improve their skills, and to work on the QA programs as well the Cesarean section quality-assurance collaborative. The primary role for HHS/IHS staff would be to serve as advisors, by working at the bedside with the Afghan doctors and residents to improve the level of care.
5) The role of IHS CNM's has not been completely clarified, but deployment in 2008 is highly likely. I encourage CNM's who are interested to contact me.
6) The length of the tour would be 1-3 months, and could start as early as January 6, 2008. This is a TDY assignment. Candidates must be Federal employees (civil service or Commissioned Corps). HHS/OGHA will pay travel and per diem and will also reimburse service units for the salary. The interagency agreement between HHS/IHS and HHS/OGHA is under negotiation, and should be complete in the next two weeks.
7) Security in Afghanistan is always an issue. HHS personnel in Kabul will stay on the U.S Embassy compound. Trained security personnel in armored SUVs will accompany HHS staff to RBH. Leisurely travel about town is absolutely forbidden, but HHS staff may go to the army base, the International Security Assistance Force (ISAF) base, and the MoPH.
8)The U.S. Embassy itself is self-sufficient, and has two post exchanges (PXs), two dining halls, a gym, a swimming pool, etc. The rooms in which HHS staff will stay are converted shipping containers called "hooches." The rooms are relatively small, but include all the amenities: fridge, microwave, TV with cable, DVD player, bed and linens, desk, Internet access, phone, shower, toilet, sink, and hot-water heater.
9) My role in all of this is to coordinate recruitment and scheduling within HHS/IHS, and to participate in the operational aspects of the project. I will be going to Kabul in January with a pediatrician, a pharmacist, and a scrub tech. If you are interested in going to Kabul, please send me a CV, and we can discuss things over the phone. Afghanistan is an exciting place, and I can promise you a life-changing experience, as well as provide an opportunity to improve some of the highest maternal-mortality rates ever recorded. This is also a chance to contribute meaningfully to international efforts to stabilize Afghanistan.
Regards,
Dave Gahn
David R. Gahn, MD, FACOG
Hastings Indian Medical Center
Tahlequah , OK
Scott Giberson, HQE
Second annual Native HIV/AIDS Awareness Day coming March 20, 2008
Saturday December 1, 2007 was the 19th anniversary of World AIDS Day
This day gave us an opportunity to remind people the HIV/AIDS pandemic continues to be a threat and reality. It was very important to raise awareness, encourage education, and continue to make a difference. (www.worldaidscampaign.info/).
Recently UNAIDS reduced its estimates of how many people are infected with HIV/AIDS worldwide from nearly 40 million to 33 million. However, these numbers don’t tell the whole story. A large portion of this reduction was due in part to an overestimate of prevalence in one country, India. HIV impacts all countries and incidence rates are actually increasing in a number of areas. Officials said evidence showed the epidemic was creeping back into developed countries - where many people with AIDS have access to drugs that can extend their lives. "We are seeing a return of the epidemic," Paul De Lay of UNAIDS told reporters. "We are seeing that in the U.S., we are seeing that in the UK, we are seeing that in Germany and we are seeing that in the developing world also." This demonstrates, given the huge impact of HIV/AIDS worldwide, that we must continue the fight. This is a virus with explosive potential that (barring a vaccine or cure) will be with us for generations.
HIV/AIDS is a disease that goes beyond traditional prevention and treatment paradigms. Through 2005, AI/AN are ranked third in the US (among all ethnicities) in rates of HIV/AIDS cases. According to this CDC report, incidence of HIV/AIDS has remained relatively stable among AI/AN over the previous 6 years, however a steady rise in prevalence has been observed. Health disparities and disproportionate co-risk factors (such as STDs, substance use and domestic violence) among the AI/AN can contribute both directly and indirectly to the risk of HIV transmission. Therefore, HIV/AIDS poses a significant and ongoing risk to the American Indian / Alaska Native population.
World AIDS Day raised our awareness of the issues and also set the stage for the second annual Native HIV/AIDS Awareness Day to be observed on March 20, 2008. I look forward to working with you on our program initiatives and improving and protecting the health of the American Indian/Alaska Native population.
For more information and resources, please visit our IHS HIV website at: www.ihs.gov/medicalprograms/hivaids/
The UNAIDS report, discussing the revised worldwide HIV/AIDS estimates, can be found at: http://data.unaids.org/pub/EPISlides/2007/071119_epi_pressrelease_en.pdf
Updated U.S. DHHS Guidelines for Treatment of Adults and Adolescents with HIV
See below for some very pertinent changes to the DHHS Guidelines on the Treatment of those with HIV. Of particular interest may be that the guidelines now recommend (after much consideration and the most recent findings at the International AIDS Conference) that HAART be initiated in patients with history of an AIDS-defining illness or with a CD4 T-cell count < 350 cells/mm 3. This means initiation of therapy in a much less immunocompromised state. In addition, the new guidelines address the new classes of HAART including integrase inhibitors and CCR5 antagonists. For more detailed information, see below and/or the actual .pdf attached of the full and updated guidelines.
Updated U.S. DHHS Guidelines for Treatment of Adults and Adolescents with HIV
An updated version of the U.S. Department of Health and Human Services (DHHS) Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents has been released.
The latest revision, dated December 1, 2007, includes new information on:
- Lab tests during the initial clinic visit for newly diagnosed patients;
- Updated recommendations on when to start antiretroviral treatment;
- Management of treatment-experienced patients, including suggestions on use of the recently FDA-approved entry inhibitor (CCR5 antagonist) maraviroc ( Selzentry/Celsentri) and integrase inhibitor raltegravir ( Isentress).
Changes to the guidelines are summarized in the "What's New in the Document?" section located at the front of the guidelines. The changes are also highlighted in yellow throughout the text and tables. Following are the specific changes to this latest edition of the guidelines, made since the previous revision dated October 10, 2006. Additional revisions to other sections of the guidelines will be released in 2008.
The strength of the recommendations is included in parentheses, with “A” indicating the strongest recommendation, “C” indicating optional, and “E” indicating never recommended; the quality of scientific evidence supporting the recommendations is ranked from I (at least 1 randomized clinical trial) to III (expert opinion).
Laboratory Assessment
- Drug-resistance Testing -- The DHHS Panel on Antiretroviral Guidelines for Adults and Adolescents recommends genotypic drug resistance testing for all treatment-naive patients entering clinical care, regardless of whether they will immediately start antiretroviral therapy (AIII). This recommendation is based on the fact that transmitted drug-resistance mutations may be detected soon after infection. Repeat testing may be considered when therapy is to be initiated (CIII).
- Viral Tropism Assay -- The panel recommends tropism testing prior to the initiation of a CCR5 antagonist, such as maraviroc(AII), to determine which co-receptors a person’s HIV is using; these drugs should only be used by patients with exclusively CCR5-tropic virus. Co-receptor tropism testing might also be considered for patients exhibiting virological failure while taking maraviroc or another CCR5 antagonist (BIII).
- HLA-B*5701 Testing -- The panel recommends HLA-B*5701 testing prior to initiating abacavir ( Ziagen) to reduce the risk of hypersensitivity reactions (AI). HLA-B*5701 positive patients should not be given abacavir(AI), and the positive status should be recorded as an abacavir allergy in the patient’s medical record (AII).
When HLA-B*5701 screening is not readily available, it remains reasonable to initiate abacavir with appropriate clinical counseling and monitoring for any signs of abacavir-associated hypersensitivity reactions (CIII).
When to Start Antiretroviral Therapy
- The panel now recommends that antiretroviral therapy should be initiated in patients with history of an AIDS-defining illness or with a CD4 T-cell count < 350 cells/mm 3. The data supporting this recommendation are stronger for patients with a CD4 count < 200 cells/mm 3 and with a history of AIDS (AI) than for those with CD4 counts between 200 and 350 cells/mm 3(AII). This recommendation is consistent with the latest revision of the European AIDS Clinical Society (EACS) guidelines , presented this past October.
- The panel also recommends treatment for the following groups regardless of CD4 -cell count:
- Pregnant women (AI);
- Patients with HIV-associated nephropathy (kidney disease) (AI);
- Patients coinfected with hepatitis B virus (HBV) when anti-HBV treatment is indicated (BIII).
- The optimal time to initiate therapy in asymptomatic patients with a CD4 cell count > 350 cells/mm 3 is not well defined. The decision about whether or to start treatment in these patients should take into account the potential benefits and risks associated with therapy, co-morbidities, and patient readiness and willingness to adhere to long-term treatment.
Management of Treatment-Experienced Patients
This section was revised to include a review of the newer classes of antiretroviral agents (CCR5 antagonists and integrase inhibitors) and their roles in the management of treatment-experienced patients with virological failure; and a discussion of immunological failure (lack of adequate CD4 cell recovery).
Updated Tables
Various tables in the guidelines have been updated to reflect new recommendations and new information on specific antiretroviral drugs.
Source:
DHHS Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents. December 1, 2007).
Funding opportunity for HIV Prevention programs through CDC
(federally recognized tribes are eligible)
Fund Number: 3470
Fund Title: 2008 USCM HIV/AIDS Prevention Grants Program
Fund Category:
HIV/AIDS
Description:
Total Grant Amounts: Approximately $420,000.
The United States Conference of Mayors (USCM), in cooperation with the U.S. Centers for Disease Control and Prevention, National Center for HIV, STD and TB Prevention, is issuing this Request for Proposals (RFP) for the HIV/AIDS Prevention Grants Program to strengthen local capacities to carry out effective HIV/AIDS prevention activities.
Proposals will be accepted for the following funding priority: Implementation of HIV/AIDS Prevention Services Targeting Women of Color at High Risk of HIV Infection.
The purpose of these grants is to reduce risk behaviors associated with HIV/AIDS among women of color at high risk of HIV infection, and to strengthen the ability of organizations - in particular organizations with direct ties to the target populations - to respond to future needs for HIV prevention services among these groups.
Programs selected for funding will be required to:
(1) Implement activities that respond to HIV/AIDS prevention needs identified in a previous needs assessment, with specific reference to priorities determined in a community planning process (i.e., the HIV Prevention Community Planning Initiative, which began in 1994, to establish plans for the use of HIV prevention resources awarded under program announcement #300 to CDC's state and local health department HIV Prevention Cooperative Agreement grantees), or
(2) Demonstrate clearly how previous needs assessment and community planning activities have not adequately identified the needs of women of color at high risk of HIV infection and propose to carry out some very limited, specific assessment activities (e.g., focus groups, small surveys) to guide the implementation of the proposed intervention.
Sponsor(s):
US Conference of Mayors
Health Programs
HIV/AIDS Prevention Program
Funder's Fund ID:
Web Page:usmayors.org/hivprevention/rfp08.pdf
Application Due Date: 02/25/2008
Fund Duration: Grants are for a 12-month period and are non-renewable (though no-cost extensions may be granted upon request).
Application Process:
To request a copy of the USCM's new Technical Assistance Report "Writing Proposals for HIV/AIDS Prevention Grants," write to HIV/AIDS Program Publications, HIV/AIDS Prevention Grants Program, The United States Conference of Mayors, 1620 Eye St, NW, Washington, DC 20006; fax (202) 429-0422/(202) 293-2352; or e-mail: lbrown@usmayors.org.
Number of Awards: 6 grants
Total Award: $420,000.00
Award Notes:
USCM plans to award grants totaling approximately $420,000 to local health departments, non-profit
community-based organizations and Native American tribes for implementation of HIV/AIDS prevention
projects for high-risk women of color. Funding will be divided into six grants of approximately $70,000
each. (Note: in some years extra funds have become available, and additional grants have been made
from the same pool of applicants. Prospects for this year are unknown.)
Eligible Locations:
- National
Technical Contact Name:
Lillie Brown
Technical Contact Address:
HIV/AIDS Program Publications
HIV/AIDS Prev Grants Program
The US Conference of Mayors
1620 Eye St, NW
Washington, DC 20006
United States
Email:lbrown@usmayors.org
Phone: 202-293-7330
Fax: 202-429-0422
Support Types:
- Technical Assistance
Subject Areas:
- Community Health Education
- Community Health Services
- High Risk Behaviors
- HIV/AIDS Prevention
- Risk Reduction
Audiences:
- African Americans/Blacks
- At Risk Persons
- Women
Eligibility:
- City Agencies
- Community Based Organizations
- Consortia
- County Agencies
- IRS 501 (c)(3) Organizations
Eligibility Notes:
Eligible applicants include: Local health departments (LHDs); Community-based organizations (CBOs); Federally recognized Indian tribes; Existing agencies/consortia which have formed collaborative efforts between multiple groups or agencies.
Any CBO applying under this program must have been certified by the Federal Internal Revenue Service as a 501 (c)(3) organization prior to February 25, 2008, or certified by the state as a nonprofit agency. (State certification will be considered a temporary measure; if USCM funding is granted, CBOs must obtain certification by the IRS under 501(c)(3) before contracts with USCM are signed.) A copy of either the IRS or state certificate of non-profit status must be included with the application.
Steve Holve, Tuba City
Update on Pedvax Hib
CDC has sent out to state immunization programs regarding the current PedvaxHIB® (PRP-OMP [Merck]) supply. CDC is controlling the release of PedvaxHIB® so that states can continue to receive the same amount of PedvaxHIB® This means that providers SHOULD NOT have to change current Hib vaccination practices – e.g. if you have been using PedvaxHIB® to vaccinate children, you can continue to do so. If your site has been using PedvaxHIB® and you are told by the state that there is not sufficient supply to continue using PedvaxHIB® for all doses, PLEASE CONTACT AMY GROOM, Phone: (505) 248 – 4374 , amy.groom@ihs.gov
There are provisions to target stockpiled supplies of Pedvaxhib to AI/AN children if the shortage persists beyond early 2008.
Mary Wachacha, HQE
Seeking 2 Physicians for national IHS Patient Education Protocols and Codes Committee
The IHS has a national committee (IHS Patient Education Protocols and Code Committee – PEPC) which writes up all patient education protocols that are used by all I/T/Us in the documentation and coding of patient education. This national committee has a long-standing partnership with OIT ensuring that all issues concerning RPMS, PCC, PCC+, and EHR are addressed.
We are a long standing committee of 12-14 IHS staff that meets once a year to update the IHS Patient Education Protocols and Codes found at www.ihs.gov under Nationwide Programs and Initiatives: Look in the upper right corner of the webpage and you will see the Patient Education Protocols and Codes. The committee is made-up of 2 physicians, 2 RDs, 2 Pharmacists, one Health Educator, one Clinical Psychologist, one representative from the DM program and one HPDP representative, 1PHN and 3 RNs and an OIT Tech Writer. Four of these committee members are CDEs. It is a very dedicated group. It is a very hard working group. We meet face-to-face once every year with occasional conference calls if we are faced with the need for a quick decision by the Committee – otherwise, any revisions or changes to the protocols have to wait until the next face-to-face committee meeting. The committee works with a wide range of clinical experts within IHS – obviously, if we need expertise on nephrology education – we contact an IHS Nephrologist. We work extensively with the Diabetes, Nutrition program and MCH, etc. All travel to the single committee meeting is paid for by the IHS Health Education program.
The dilemma is that our two physicians are a husband and wife team (CCOs from Alaska; Family Practice and Peds) that has been with the committee for at least 8 years now. We could go on with these two physicians forever but each year it becomes harder and harder for them to get permission from Southcentral Foundation for them to travel to our meetings (even though prior to accepting employment with SCF, they originally obtained permission from SCF to attend the annual meetings.) Therefore, I would prefer that their replacements not come from the Alaska Area since it is totally compacted.
These two dedicated physicians have indicated that perhaps it is time they stepped down as the Co-Chairs of this Committee - their names are Dr. Michale Ratzlaff and Dr. Kelton Oliver. While I would hate to lose them, I feel that the inevitable is looming over me…..I need to find physician replacements to serve on this committee. I am seeking two physicians that might like to serve on this national committee?
The physicians that I am looking for would most definitely have to have a keen interest in educating our AI/AN clients….but you do not need any special background in education – (Health Education ensures that all aspects of education are met) you only need to be committed to the importance of educating our clients..,…your clinical expertise will be your greatest asset. If any of you are aware of any such physicians that might be interested, please forward this letter and have them contact me with any additional questions. Our next FY2008 meeting is scheduled for March 10-14 th in Tucson, AZ.
We would ask any physician that accepts this challenge to commit at least 3 years to this project.
Thank you for your time and I appreciate any assistance.
Mary Wachacha, Lead Consultant
IHS Health Education Program
828-292-1175 mary.wachacha@ihs.gov
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OB/GYN
Dr. Neil Murphy is the Obstetrics and Gynecology Chief Clinical Consultant (OB/GYN C.C.C.). Dr. Murphy is very interested in establishing a dialogue and/or networking with anyone involved in women's health or maternal child health, especially as it applies to Native or indigenous peoples around the world. Please don't hesitate to contact him by e-mail or phone at 907-729-3154.
