Public-Health Officials Go To Court To Stop Man With HIV

Public-Health Officials Go To Court To Stop Man With HIV

By Carol M. Ostrom, The Seattle Times

SEATTLE — In a very unusual step, King County, Wash., public-health officials have gone to court to try to stop a man with HIV who has infected eight partners in the past four years from infecting others.

“We’re not trying to criminalize sexual behavior here,” said Dr. Matthew Golden, director of Public Health-Seattle & King County’s HIV/STD Control Program. “We are trying to protect the public’s health. And we’re trying to make sure that everyone gets the care they need, including the person involved in this.”

The order, issued Sept. 4 by King County Superior Court Judge Julie Spector, requires the man, identified only as “AO,” to follow a “cease-and-desist” order issued in late July by the public-health department requiring him to attend counseling and all treatment appointments made by public-health officials.

If he defies the court order, the judge could order escalating fines or even jail time.

“AO” tested positive at the Public Health STD Clinic at Harborview Medical Center in June 2008, where he was counseled to disclose his status to sex partners and how he should practice safe sex, according to papers filed in the court case.

Since then, despite having received HIV counseling at least five more times, he is believed to have infected eight adult partners from 2010 through this June. Public-health officials said in the court documents that eight people newly diagnosed with HIV had named AO as a partner with whom they’d had unprotected sex.

The officials in July and August served “AO” with “cease-and-desist” orders, the first specifying he attend counseling and the second adding the requirement he seek HIV treatment.

In August, health officials repeatedly made appointments for him to see an HIV medical provider, but the man ignored them. Public-health officials delivered the notice of the last appointment, on Sept. 2, to the house he shares with his mother, who said she would place the notice under her son’s door.

“AO” did not show up for the appointment. The same day, the agency filed for court enforcement of its order, saying his conduct “continues to endanger the public health.”

According to the Centers for Disease Control and Prevention, about 1.1 million people in the United States are living with HIV, and nearly one in six are not aware they are infected.

About 50,000 people in the U.S. become newly infected each year with HIV, which, if untreated, typically progresses to AIDS, which kills more than 15,000 U.S. residents annually.

Golden said it’s not the department’s business to monitor decisions made by two consenting adults — even if it’s risky behavior.

“That is a decision you’re entitled to make in this society,” he said. “Public health doesn’t get involved in that.”

But, he added: “This is not an instance where two knowledgeable consenting adults took a risk.”

By law and inclination, the first option for the department is always “the least coercive,” Golden said. “We have business we need to get done: protect the public’s health. But we are not looking to criminalize people, not looking to routinely put people in jail.”

Only when there is danger to the public health, such as a person with infectious tuberculosis who avoids treatment, do health officials consider the next step.

In the case of someone with HIV, that next step might be more counseling, and eventually, if the problem continues, a cease-and-desist order.

If that is ignored, and the person is “repeatedly coming up as being named as a sex partner for people newly diagnosed with HIV,” Golden said, the public-health agency is empowered under state law, RCW 70.24.024, to seek court enforcement of its orders.

The agency’s cease-desist order requires AO to seek treatment, but does not compel him to comply. As Golden said, “He can go to the doctor and not take the pills.”

By law, the burden of proof in court is on the public-health officer to show why the order is needed, and that the conditions imposed “are no more restrictive than necessary to protect the public health.”

The public-health agency issues such cease-and-desist orders less than once a year, Golden said. It has sought legal enforcement of its orders only once before, in 1993, in the case of a sex worker. That was before effective antiretroviral therapy, Golden said, and the sex worker eventually left the jurisdiction.

Golden said he expects a better outcome this time.

Antiretroviral therapy has improved from a multi-pill, multi-dose-per day schedule to a one-pill, once-a-day dose, he said. Cost shouldn’t be an issue, with a federal grant from the Ryan White HIV/AIDS Program and Medicaid expansion, he said.

Golden, an HIV doctor for 20 years, has met “AO.”

“I think the patient is going to take his meds,” he said. “The goal here is not to send the patient to prison; the goal is to get him to adhere to the health order. I am very optimistic that we are going to make progress here.”

“We are trying to protect the public’s health. And we’re trying to make sure that everyone gets the care they need, including the person involved in this.”We are trying to protect the public’s health. And we’re trying to make sure that everyone gets the care they need, including the person involved in this.”

Dr. Matthew GoldenHIV/STD programStatement from Public HealthPublic Health – Seattle & King County’s primary goal is to ensure that all HIV-infected persons, including the person for whom we recently sought enforcement of a health order, know their HIV status and receive the medical care they need. HIV treatment helps protect both the health of infected persons and the health of the community as a whole. All of our work related to the case in question has been designed to ensure that an HIV infected person receives needed medical care and adopts behaviors that protect both him and his sex partners.

Photo: Daniel Schwen via Wikimedia Commons

Study: Mammograms Can Find Cancer At Earlier Stages In Older Women

Study: Mammograms Can Find Cancer At Earlier Stages In Older Women

By Carol M. Ostrom, The Seattle Times

SEATTLE — When a mammogram detects breast cancer in a woman age 75 or older, it’s more likely to be early stage disease that can be treated less aggressively, according to a study of thousands of patients in a Seattle cancer registry.

Dr. Henry Kaplan of the Swedish Cancer Institute and Judith Malmgren, an epidemiologist from the University of Washington’s School of Public Health and Community Medicine who has long worked with Kaplan, published the study in the journal Radiology on Tuesday.

“If you do mammograms in the older group, you will find a lot of cancer, the cancers will be early or lower stage, and the patients will therefore need less therapy,” Kaplan summarized.
Mammograms, compared to detection by patients or doctors, typically catch tumors at an earlier stage. That’s important, because older women often can’t withstand the chemotherapy treatment used in later-stage cancer, said Malmgren, the study’s lead author.

“For older women, who have fewer treatment options, you really do want to catch it early,” Malmgren said.

The paper adds a bit of fuel to raging debates in the United States and other countries over mammography screening — what age to begin and to stop, how often women should be screened, whether the risks of treatment outweigh benefits, and of course, the cost to the health care system overall. A recent paper put the cost of mammography screening in the United States in 2010 at $7.8 billion.

Although older women are at higher risk of breast cancer, with higher death rates from the disease, Malmgren noted, the U.S. Preventive Services Task Force, a panel of independent health experts convened by the federal government, does not recommend mammography screening in this age group, saying there is insufficient evidence to weigh risks and benefits.

Not only does most breast-cancer research not include older women, in some regions of the world — the United Kingdom, for example — women older than 70 are rarely treated for the disease, Kaplan noted.

In the United States, many women 75 and older simply don’t get mammograms, he said.

It’s a calculation that may have made sense when life spans were much shorter, Kaplan said. But now, at age 75, the average woman in the United States can be expected to live 13 years.

“It’s really pretty surprising if you’re healthy at 75 how much longer you’re expected to live. It’s very significant and very different than it was 20 years ago.”

Over the past 15 years, deaths from breast cancer have dropped by 30 percent, Kaplan noted. But it’s not clear whether the drop is a result of more widespread use of mammograms or better treatments.

As the population ages, the debate over mammograms becomes more critical, Kaplan said. “For all the debate about what’s appropriate for a 40-year-old, there is an analogous debate about what to do with a 70- or 80-year-old.”

Early diagnosis for invasive cancer is key, he said. “If they have advanced breast cancer, they do crappy, just like 24-year-olds. And if they have an extensive cancer, you can’t treat them, because they can’t tolerate the treatments as well.”

The American Cancer Society recommends that women continue mammography screening, the paper notes, as long as they have no serious chronic conditions or shortened life expectancy.

But at this point, there are no clear guidelines for mammography screening for women 75 and older, Kaplan said. “Even though our study is not a randomized trial, it’s indirect evidence that it’s probably a good thing to do.”

The research used Swedish’s breast-cancer patient registry, which has compiled records for more than 14,000 breast cancer patients since 1990. More than 1,000 patients age 75 and older were identified and tracked for the study, which was funded by the Kaplan Cancer Research Fund, supported by patients and families.

Dr. Constance Lehman, director of imaging at Seattle Cancer Care Alliance, who was not involved in the research, said she was pleased with the paper’s conclusions and focus on older women.

“It’s an important study, a good study,” she said. “A lot of research groups say, ‘Who cares when they’re 75 and older?’ Well, we care! Many older women live incredibly active, vital lives.”

She sees many patients confused by the constant barrage of conflicting information about mammograms, she said. As a result, some just stop having them.

The disagreements among researchers are about which age to begin, the intervals for screening, and which age to stop, she said.

“But there is so much we all agree on,” she said, including that mammography offers women the best chance for early detection. In older women, she said, the rate of false positives — which can lead to unnecessary diagnostic tests, including surgical biopsies — is very low.

But she noted that the study included women diagnosed with ductal carcinoma in situ, or DCIS, a noninvasive breast cancer. Over time, while the incidence of more advanced Stage II and Stage III cancers detected by mammography dropped, the incidence of DCIS detected increased by 15 percent.

She’s worried about overtreatment in that group, she said, particularly in older women, where the cancer likely won’t progress significantly. Overtreatment is a serious concern, she said, because all treatments have risks, and particularly in older women, may affect quality of life.

“We’re treating women a lot the same,” when the women — and the cancers — are different, she said. “We think patients with DCIS are an ideal population in which to reduce overtreatment. I think there are very safe alternatives for low-intensity intervention.”

It’s difficult to quantify how many cancers could be safely ignored, Kaplan said. Computer simulations produce wildly varying estimates.

In the end, Kaplan said, he hopes the debates will lead to specific recommendations that take into account older women’s health and breast cancer risk factors.

Photo: Paul Falardeau via Flickr

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Heart Muscle Successfully Regenerated In Monkeys From Stem Cells

Heart Muscle Successfully Regenerated In Monkeys From Stem Cells

By Carol M. Ostrom, The Seattle Times

SEATTLE — Since 1996, Dr. Chuck Murry, a University of Washington cardiovascular biology researcher, has been intent on transforming powerful human stem cells into heart-muscle cells that can repair damaged hearts.

Over the years, he and his colleagues have worked through myriad setbacks and complications in studies on mice, rats and guinea pigs, piling up successes as their animal models got larger and physiologically closer to humans.

Now, they have successfully regenerated heart muscle in monkeys, Murry and Dr. Michael Laflamme and other colleagues at the UW Institute for Stem Cell & Regenerative Medicine reported in the journal Nature on Wednesday.

As before, the researchers transformed the human stem cells into heart-muscle cells, this time injecting them into damaged monkey hearts. There, the cells assembled themselves into muscle fibers, began beating in the heart’s rhythm, and ultimately were nurtured by the monkey’s arteries and veins, which grew into the new heart tissue.

“This is 10 times more heart muscle than anybody else in the world has been able to generate,” said Murry, who predicted his lab would be ready for clinical trials in humans within four years.

Dr. Michael Simons, director of the Yale Cardiovascular Research Center, said the research is the first to show that human embryonic stem cells can fully integrate into normal heart tissue. The lab’s impressive “scale up” for production of sufficient newly programmed stem cells for a large-animal heart, which was done by Laflamme’s team, was likely unprecedented, as well.

The Murry team’s latest success, like the others, did not answer every question and had its own complications, but even so, cardiovascular research leaders not connected with the work hailed it as a significant step forward.

“It’s a very big deal,” said Dr. Richard Lee of the Harvard Stem Cell Institute and Brigham and Women’s Hospital in Boston. It’s very challenging to do such experiments, and being able to show benefit is a “real achievement,” he said.

Murry is “an extraordinarily careful and thoughtful investigator,” Lee added. “When work comes out of his lab it makes us all feel better because we know we can trust it.”

The most serious problem encountered in the research was a period of irregular heartbeats, known as arrhythmias. Although the monkeys’ arrhythmias disappeared after a few weeks, Murry and others said it was concerning.” That’s a very big deal, because that’s what kills,” Simons said. On the other hand, he said, the arrhythmias were not unexpected because of technical issues with larger hearts.

“The question is: How serious are they? How long do they last? Do they go away after several weeks after the tissue matures and the heart matures, or is it a lifelong problem?”

Murry said if his lab hadn’t been monitoring the monkeys 24-7, researchers might have missed the arrhythmias, which didn’t appear to have disturbed the monkeys.

“The monkey is in the cage eating a banana,” Murry said. Meanwhile, “the investigators are freaking out. We’re having the heart attack. But the monkey was OK.”

The six monkeys involved in the study were pigtail macaques, a type commonly used in research.

Heart muscle is inextricably linked to heart failure, which for Murry is Public Enemy No. 1, with worse average survival time than breast cancer, he said.

When a heart attack damages heart muscle, it forms scar tissue rather than growing back. If there is enough damage, the heart may not have enough muscle to pump out blood, leading to heart failure, which Murry calls “a burgeoning public-health problem.”

“It’s really bad now, and it’s going to get worse” as the baby boomer generation ages, he said.

For Murry, his lab’s latest success is bittersweet. His mother, Donna Murry — the inspiration and motivation for his focus on fixing damaged hearts, he said — died last week of multiple infarctions. Heart disease ran in her family, Murry said.” She is the kind of person we would like to have helped,” he said. “My mom would have been so proud.”

UC Irvine via Flickr