MDCH fails to set state nPEP policy

LANSING — The Michigan Department of Community Health has failed to fulfill a promise of a new policy addressing the use of anti-retroviral medications to prevent new infections of HIV.

“This is something that takes diligence,” said MDCH spokesperson James McCurtis. “Sometimes it takes time to get things done in state government.”

Michigan Messenger first reported on the issue — referred to as non-occupational Post-exposure Prophylaxis or n-PEP — for World AIDS Day, Dec. 1, 2009, noting that the lack of policy was putting people’s lives in jeopardy. Studies have found that the use of the powerful medications within 72 hours of a probable or known exposure to HIV is effective in preventing the virus from taking hold and causing an infection.

The World Health Organization and the Centers for Disease Control and Prevention in Atlanta have had guidelines on the use of the medications for exposures not related to job risks since 2005.

In July, the Obama administration released the nation’s first ever National HIV/AIDS Strategy to bring the various parts of the federal government together to target the on-going epidemic. It was the first time such a strategy had been developed since the disease was identified in 1981.

That document identifies n-PEP as an important prevention tool:

“We must also move away from thinking that one approach to HIV prevention will work, whether it is condoms, pills, or information. Instead, we need to develop, evaluate, and implement effective prevention strategies and combinations of approaches including efforts such as expanded HIV testing (since people who know their status are less likely to transmit HIV), education and support to encourage people to reduce risky behaviors, the strategic use of medications and biomedical interventions (which have allowed us, for example, to nearly eliminate HIV transmission to newborns), the development of vaccines and microbicides, and the expansion of evidence-based mental health and substance abuse prevention and treatment programs. It is essential that all Americans have access to a shared base of factual information about HIV. The Strategy also provides an opportunity for working together to advance a public health approach to sexual health that includes HIV prevention as one component.”

MDCH reported that it did not have policy “set in stone” regarding the use of medications to prevent infections.

Following the Messenger report, Amna Osman, director of the MDCH’s Division of Health, Wellness and Disease Control, said the department would have a policy in “early” 2010.

The delay does not mean that the policy plan had been abandoned, McCurtis said.

“We have a priority on getting it done and approved,” he said.

The policy was still being written in August, McCurtis said at the time. Monday he said the draft had been completed in late September and was currently being reviewed by the department’s legal staff.

The revelation the policy was stalled in bureaucratic red tape resulted in a harsh rebuke by Equality Michigan, a group working for policy and legal issues for the lesbian, gay, bisexual and transgender community.

“We appreciate the commitment the MDCH made to have a policy in place by early 2010, but that deadline has long since passed. For just 2009, the MDCH reported 820 new HIV diagnoses in Michigan. Equality Michigan calls on the MDCH to cut through the red tape,” said Emily Dievendorf, the group’s director of policy. “Equality Michigan can find no rationale or justification for the lack of a uniform protocol regarding the availability and distribution of n-PEP existing in our state.”

Dievendorf noted the state has had access to guidelines for n-PEP from both WHO and the CDC since 2005.

“While Equality Michigan understood that creating and releasing a policy tailored to Michigan would not happen over night, bureaucracy within the Michigan Department of Community Health could not have been so tangled as to excuse a five year delay in educating Michigan health facilities about their role in using n-PEP for HIV prevention,” she said. “This lack of communication translates to a lack of application that could have shielded countless individuals from HIV, ultimately saving lives.”

In addition to the condemnation from Equality Michigan, experts in HIV treatments are also speaking out.

Dr. Peter Gulick, who treats HIV patients throughout Michigan and is an associate professor of hematology, oncology and infectious disease at Michigan State University School of Medicine, says he baffled by the long delay in developing the policy.

“I don’t know why it has taken this long,” Gulick said.

He says he has already used the CDC protocols in his own practice.

“It’s another way to cut down on the risks,” he said. The doctor also said he spends a great deal of time reaching out to community groups, medical groups and others to discuss n-PEP and its importance in prevention.

Renee Canady, deputy health director of the Ingham County Health Department, said she understands how policies can be trapped in bureaucratic limbo, particularly when they get into the legal review, which she said was extremely detailed.

Regardless, Canady and the ICHD have begun convening a quarterly meeting of those involved in HIV and sexual health issues in the county. She calls the group “The Community Partners,” and the goal is to share ideas and push for development of policies to benefit the sexual health of the community.

“This is definitely on our priority list,” she said of n-PEP. She says the county is working to develop its own set of policies and will be relying on the CDC guidelines from 2005.

James Krellenstein, director of PEPnow.org, is not as forgiving of MDCH as Canady. He says the state has taken entirely too long. He noted that states do not need their own protocols.

“Human biology does not change when one crosses a border, and thus different protocols in different states are not necessary,” he said. “It seems to me that this whole exercise is just a excuse to delay the implementation of n-PEP.”

“Formulating nPEP guidelines should not take a long time to do, the scientific literature is unequivocal that in certain situations, n-PEP must be prescribed,” said Krellenstein. “The state has numerous ways it could do this [make n-PEP available], but the fact that n-PEP is not widely available in the state five years after the CDC released it’s guidelines is inexcusable.”