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Fighting hospital infections

By Denise Cardo

Preventing health care-associated infections is possible. Yet on any given day, these infections affect about 1 in 25 patients in U.S. hospitals. Furthermore, bacteria that defeat the drugs designed to kill them — a process known as antibiotic resistance — could return us to a time when even simple infections often proved fatal, and hospitals were a place to be avoided.

Today, antibiotic resistance causes more than 23,000 deaths and 2 million illnesses per year in the United States. Many cases begin while people are receiving health care.

The Centers for Disease Control and Prevention’s most current state-level report on health care-associated infections shows progress has been made preventing some life-threatening infections, and Georgia is heading in the right direction. However, much more work needs to be done.

For example, Georgia hospitals have cut in half the number of bloodstream infections among babies cared for in neonatal intensive care units. Surgical site infections from two common types of surgeries, colon surgery and abdominal hysterectomy, are now 17 percent and 14 percent lower than national levels. Georgia recently reported that bloodstream infections from central lines in intensive care units are 33 percent lower than the national level, but progress outside of ICUs is less marked.

Today in health care, six types of bacteria are about to defeat all drugs designed to treat them. If that happens, the risk of untreatable infection will make common surgical procedures, such as hip and knee replacements, far more dangerous. Dialysis patients could develop deadly bloodstream infections. Life-saving treatments that suppress the immune system, such as chemotherapy and organ transplants, could potentially cause more harm than good.

Better antibiotic prescribing practices, known as antibiotic stewardship, can protect today’s patients from infections caused by multi-drug-resistant superbugs, and can preserve lifesaving antibiotics for use by tomorrow’s patients. Our health care facilities are an important part of the solution to prevent growing drug resistance.

Last year, the Georgia Department of Public Health reached out to CDC to help it develop strategies for improving antibiotic prescribing practices. At first, about half of Georgia hospitals had committees addressing the issue, but few were taking specific actions. To rally hospital engagement, Georgia developed a recognition program that honors hospitals that meet its goals for antibiotic stewardship.

Georgia’s is now one of 10 state health departments within the CDC-funded Emerging Infections Program network of state health departments and academic medical centers. Georgia’s participation is important in answering critical questions about emerging health care-associated infection threats, including antibiotic resistance trends in the United States.

Georgia also is one of five locations in the U.S. implementing the federal Partnership for Patients initiative. Its Healthcare Engagement Networks engage hospitals across the country to improve patient safety and quality and achieve lower costs. As of April, 132 hospitals in Georgia were active members. These partners meet monthly, along with the Georgia Quality Improvement Organization (QIO), to ensure that partners coordinate activities and maximize benefits for patients. This team supports vigorous educational activities and other initiatives to help Georgia hospitals improve and maintain quality care and patient safety.

Additionally, a group of Georgia hospitals is participating in a nationwide project by the Agency for Healthcare Research and Quality to reduce catheter-associated urinary tract infections. The Georgia Hospital Association has recruited 52 units in 31 hospitals for the project. The units have put into practice a proven method to prevent such infections.

CDC depends on Georgia and all states to continue to work to eliminate health care-associated infections. As a Georgia patient, I am happy to see the Georgia Department of Public Health facilitating work to improve in-patient prescribing practices across the state and prevent these infections. This work is clearly paying off.

Dr. Denise Cardo is the director of the Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, at the Centers for Disease Control and Prevention.

Change HIV criminalization laws

By Wendy Armstrong

His name was Paul. I had cared for him for several years as he struggled to cope with his HIV infection. He had contracted HIV through unprotected sex. He’d been diagnosed a decade earlier when he first developed Pneumocystis pneumonia.

Paul hated taking pills. The sight of them made him retch, and it would take him hours to force down the pills that made up his treatment regimen. He would take them for months at a time but then tell me he needed a break. Once he could manage to think about swallowing pills again, he would restart his medications.

Then, suddenly, there he was in my office, crying. He had been indicted on charges, brought by a partner of several months, of having sex without disclosing his HIV status. Paul insisted he had disclosed the matter, and although the partner continued to test negative for HIV, the district attorney was determined to prosecute.

I was served with a subpoena requiring me to testify about Paul’s HIV status and his care. Surely, I thought, naively, our conversations were protected by patient-client privilege laws. Weren’t they? Wasn’t my office a place where patients could talk frankly and safely to me about their personal lives and sexual practices, their bodies and their symptoms? I called the attorneys at the health care system where I work and was told that, in criminal cases involving HIV, I would have to testify.

The criminal charges against Paul shattered the safety of my office and our confidences. His name was released to the media. Friends found out about his HIV status and the criminal charges, increasing his shame. He was depressed, withdrawn, and in disbelief, but felt hopeful because there was nothing to support the claim against him. The case boiled down to his ex-partner’s word against his.

On the day of the trial, I testified about his HIV infection and the details of our visits. Later, as I drove back to the hospital, I experienced a sense of betrayal to a patient that I’d never felt before. As I arrived at the hospital, the district attorney called me. Paul had been found guilty. The prosecutor congratulated me on my testimony and told me I should be proud that I had put a “scumbag” behind bars that day. I felt nauseated.

That was my first experience with a patient being prosecuted for having sex while having HIV, but it was not to be my last. Nearly 30 percent of my colleagues confirm that they too have had criminal prosecutions invade their patient relationships.

In the 15 years I have practiced HIV medicine, I have seen medical advances happen at an historic rate. Today, the life expectancy of a newly diagnosed patient with HIV is nearly indistinguishable from his uninfected neighbor. The risk of transmission of disease from a patient taking effective medical therapy is close to zero.

But while advances in treatment have turned HIV from a death sentence into a treatable, chronic condition, the HIV criminalization laws in effect in 32 states reflect the fear, stigma and misconceptions of the earliest days of AIDS. Most states, including Georgia, make a felony out of actions that have long since been shown to carry little to no measurable risk of transmitting HIV.

The most important interventions to combat the spread of this epidemic are those that encourage personal responsibility for sexual health, reduce stigma and encourage testing, linkage and retention in care. Criminalization laws do none of these things; they embrace blame and corrupt the physician-patient relationship, which I believe is a powerful tool to improve individual and public health outcomes.

A new report — “A Roadmap for Change: Federal Policy Recommendations for Addressing the Criminalization of LGBT People and People Living with HIV” — may get policymakers thinking about the consequences of this kind of over-criminalization. The report, published by Columbia University’s Center for Gender and Sexuality Law, recommends practical steps government agencies can take to dispel myths about HIV, remove barriers to testing and treatment, and help modernize current laws and practices that criminalize HIV exposure and transmission.

Medical science has made tremendous strides in the treatment of HIV. Public health policy and criminal law need to keep pace.

Wendy Armstrong is an infectious disease physician and associate professor of medicine at Emory University.

Get tested, again and again

By Patrick Sullivan

This week, the White House held a meeting focused on the HIV crisis in the South. In the fourth decade of the U.S. HIV epidemic, nearly half of new HIV diagnoses occur in this region. Many of the factors that perpetuate the Southern HIV epidemic — stigma, poor access to health care, and lack of recognition of risk — are complicated, and opinions about how to tackle them are varied. But there is one strategy that almost all agree on: scaling up HIV testing.

Today, nearly 200,000 Americans are living with HIV infection and don’t know it. One of every six Americans living with HIV is not aware that he or she is infected; that person is not receiving antiretroviral treatment that can control the infection, improve survival and decrease transmission to others. This is why next week’s National HIV Testing Week is so important: to raise awareness and send the message, “Talk HIV. Test HIV. Treat HIV.”

While HIV is a global problem, in Georgia, it is also a local problem. The state ranks fifth in the nation in the number of new HIV diagnoses. Nearly a third of Georgians diagnosed with HIV through 2012 were diagnosed so late that they had developed Stage 3 disease (AIDS) at diagnosis or within a year. CDC recommends everyone ages 13 to 64 be routinely screened for HIV; those at high risk should be tested at least once a year. Despite this, routine screening is not the norm.

AIDSVu.org is a partnership of Emory University and Gilead Sciences Inc. that can help people understand the HIV epidemic where they live. On AIDSVu, interactive maps detail HIV data by county in Georgia, and by ZIP code in the Atlanta metropolitan area. A look at the latest data, to be released June 27 at http://www.AIDSVU.org, will illustrate why we should make routine HIV testing a reality in the state. In Georgia, HIV is all too common and touches us all — urban and rural, rich and poor, black and white.

Getting an HIV test as the CDC recommends is easier than ever. Because of the Affordable Care Act and a new, strong recommendation for HIV screening from the U.S. Preventive Services Task Force, routine HIV testing is a covered preventive service; patients in a qualified health plan can receive tests at no charge. Those newly covered under expanded Medicaid, in the 27 states implementing expansion, can also receive HIV screening at no cost. Many state Medicaid programs already cover routine HIV screening.

One day, we will end the stigma that perpetuates HIV. One day, we will find a cure. Today, you can take an important step to protect your health and slow the spread of HIV by being tested for it. Ask your doctor, or find a testing location near you at http://www.aidsvu.org/testing.

Dr. Patrick Sullivan is a professor of epidemiology at the Rollins School of Public Health at Emory University, and the lead researcher for AIDSVu.