Offering HIV patients a new look

Cosmetic surgeon Anthony Caglia specializes in working with patients to reduce the effects of wasting syndrome

DAVID TAFFET  |  Staff Writer
taffet@dallasvoice.com

An ever-evolving array of HIV/AIDS medications has transformed what was once a terminal illness that claimed its victims quickly into a chronic ailment that has to be managed long term — allowing people with HIV/AIDS to live much longer, much healthier lives.

But those medications come with a price. For many HIV/AIDS patients, that price is AIDS Wasting Syndrome, the involuntary loss of more than 10 percent of body weight accompanied by more than 30 days of either diarrhea or weakness and fever.

The syndrome also includes lipoatrophy, the gradual loss of fatty tissue and collagen in the face that results in sunken cheeks and deep lines in the face. As collagen production slows, the cheekbones slowly begin to protrude.

For some, that may seem a small price to pay. But for many others, lipoatrophy can have a significant impact on self-esteem, and that, in turn, can seriously impact a patient’s overall health.

But medical science has found ways to address the issue, and Richardson cosmetic surgeon Anthony Caglia is one of those that specializes in fighting the effects of lipoatrophy.

Caglia works with facial fillers and serves on the HIV Advisory Board of Suneva Medical Inc., a company that manufactures the filler Artefill.

Artefill is approved to correct wrinkles around the smile lines but may have applications for other parts of the face such as the cheeks, Caglia said. In fact, Caglia pioneered the use of facial fillers such as Artefill on persons with AIDS Wasting Syndrome.

Caglia said that he usually uses a filler to create thicker skin to replace the lost fat. Then he uses a product to stimulate the body to produce its own natural collagen.

“Artefill has microspheres in it and it doesn’t biodegrade,” Caglia said. That makes the product a longterm solution.

Caglia said that in contrast, Sculptura, a similar product, is a biostimulator. The particles biodegrade over two years, but it stimulates the body to create its own new collagen.

He said that using facial fillers like Artefill gives some quick results but “takes from five to eight months” to get back to their previous appearance.

“And they might need touch-ups” — or “maintenance” — “in 12 to 16 months,” the doctor added.
Caglia said most people he sees with HIV have undetectable viral loads but he said that people with low T-cell counts do just as well.

Costs

The treatment is expensive. Artefill, for example, costs $1,200 per syringe. The number needed varies per person.

“One patient had 13 syringes and two more since then,” Caglia said.

But he said there are patient assistance programs underwritten by the manufacturers of the products.

Generally, people with income under $40,000 can get on an assistance program and treatment is prorated with incomes up to $100,000.

Caglia suggested that even those who never considered cosmetic treatment because of the cost may qualify.

Medicaid is beginning to look at these treatments as more than cosmetic and is looking at covering the procedure for some persons with HIV, he said. And as government programs begin to cover it, private insurance carriers find it harder to deny coverage.

For others, payment plans are available.

The benefits

As people with HIV live longer with better medications and return to work, Caglia said, the facial filler treatments serve more than vanity. They may help someone get a job.

Caglia talked about one of his patients who was leading an OK life, but not looking good. But then at Parkland, the man heard someone say something that spurred him to inquire about treatment: “Oh, there’s one of those gay guys.”

He knew it was because of his gaunt, sunken cheeks.

Another patient slipped him Caglia’s card and said, “Someone takes care of this.”

Most people just get used to that look until someone else points it out to them.

Complications from treatment with fillers may include bumps and nodules, Caglia said, but added, “It’s about technique.”

Treatment takes about an hour and Caglia said he is very methodical, massaging the product evenly through the skin and agitating the cells to produce new collagen and avoid the bumps that occur when the product is not administered properly.

“There’s an artistry in reshaping the face,” the doctor said.

Dr. Anthony Caglia, Derm Aesthetics and Laser Center, 670 W. Campbell Road, Suite 150, Richardson. www.dermlasercenter.net. 972-690-7070.

This article appeared in the Dallas Voice print edition Jan. 14, 2011.

—  John Wright

Local ASOs respond to disability proposals

New guidelines are more specific but would require qualifying for benefits every three years

DAVID TAFFET  |  Staff Writer taffet@dallasvoice.com

Bret Camp
Bret Camp

The Institute of Medicine has published recommendations that would change guidelines for people living with HIV to apply for Social Security disability.

Bret Camp, Resource Center Dallas’ associate executive director for health and medical services, said the recommendations are a starting point for discussions about changing those qualifications.

To qualify, the institute recommended that a person’s T-cell count would have to be less than 50. Currently, a count of 200 or lower is generally needed to qualify.

The other major change is that persons qualifying after new rules take effect would have to requalify every three years. Currently, disability payments are for life.

Certain AIDS-related illnesses would qualify someone for disability payments no matter what the CD4-cell count is. Wasting syndrome, for example, would impair a person’s ability to function, the Institute of Medicine report said. Dementia, AIDS-related cancers, heart disease or hepatitis are other conditions they list that would qualify a person for disability payments.

“These seem fairly reasonable to me,” said AIDS Arms Executive Director Raeline Nobles. “Perhaps I would consider a CD4 of 100 rather than 50 — 50 does seem very low and indicates rather extreme health vulnerability.”

She said that by the time someone has a CD4 cell count of 50, chances are they have already experienced an opportunistic infection.

“However, current treatment, if ongoing and proactive and of high quality, does do miraculous things these days even for people with CD4s who drop well below 50,” she said.

“The Social Security Administration is beginning to revise the listing criteria for every condition starting with HIV,” Camp said. “Reevaluation has always been a goal for SSA.”

He said that because of strides in treatment of HIV over the last 15 years, this was a good place to start.

Current guidelines are not as specific, he said. Camp said he likes the specific enumeration of certain AIDS-related cancers and other infections.

He said he has worked with people who have been denied benefits with a CD4 cell count of 200 and seen people with a higher count receive them.

Nobles worried about compromising access to treatment because disability status impacts Medicare eligibility.

“That would be disastrous,” she said. “Sure, HIV treatment has come a long way — for those who have ongoing access to that treatment administered by specialists in the field. And therein lies the problem.”

Nobles is also worried about unforeseen problems with the changes.

“Often governmental entities seem to forget that a change in one area ripples throughout the entire system of care and support and has ramifications they should have thought about, but didn’t until it’s too late and significant issues/problems emerge,” she said.

Steve Dutton, executive director of Samaritan House in Fort Worth, said the proposed changes don’t surprise him.

“It’s going to be tough,” he said.

Dutton said he likes the addition of certain specific categories that qualify people for disability but worries about those who don’t quite fit into those categories.

“I hope there are still some gray areas,” he said.

Dutton also wondered about the motive.

“They’ll look for every opportunity to minimize the number of people covered,” he said.

He agreed that those who manage their disease well can go back to work without further need for disability payments.

But he worries about those who became ill and are too sick toward the end of the three-year period to go through the bureaucratic paperwork to qualify again.

For more on the report go online to iom.edu/Reports/2010/HIV-and-Disability-Updating-the-Social-Security-Listings.aspx

This article appeared in the Dallas Voice print edition October 08, 2010.

—  Kevin Thomas

Institute of Medicine recommends changes for people with HIV/AIDS to qualify for disability

Raeline Nobles

The Institute of Medicine is recommending new guidelines to determine whether someone with HIV qualifies for Social Security.

The new recommendations reflect new treatments for the virus but in the wrong hands could be used to discriminate against those who need disability payments to survive.

These are the changes that would qualify someone as eligible for Social Security disability payments:

  • A CD4 (white blood cell) count at or below 50 cells per microliter of blood, a threshold that indicates an advanced stage of illness
  • One of a few rare but fatal or severely disabling HIV-associated conditions, such as dementia or certain types of AIDS-related cancers. The committee advises that benefits for these diseases should be permanent.
  • An HIV-associated condition, such as heart disease or hepatitis, that is already covered by another section of SSA’s full Listing of Impairments
  • An HIV-associated condition, such as wasting syndrome, that is not already included in another section but that significantly impairs a person’s ability to function.

The biggest change to the regulations would be that people with HIV would qualify for disability for three years and would have to re-apply. That change would apply only to new applications, not to those already receiving disability.

AIDS Arms Executive Directors Raeline Nobles said current regulations allow disability for people with a CD4 count of 200. She said that she sees many people now who can get along OK with a CD4 count of 100.

“But politically, it might be a way to cut some expensive corners,” she said.

She said reassessing over time might be reasonable.

“Over time some do get better,” she said. “But 50 seems awfully low to me.”

Rafael McDonnell, a spokesman for Resource Center Dallas who alerted us to the changes, said the center likely will release a statement about them next week.

—  David Taffet