President-elect Trump on global health and HIV

Secretary of State John Kerry hosts a high-level meeting on global AIDS with PEPFAR partners at the United Nations General Assembly in 2013.

Today is World AIDS Day. A new Republican administration convenes in January. So it’s a good time to look at what the next four years means for American-led global-health programs, particularly efforts to combat the HIV crisis. The U.S. and the world are watching.

Will President-elect Trump make changes to PEPFAR, the President’s Emergency Plan for AIDS Relief? The U.S. initiative is a multilateral global commitment to saving lives and achieving an AIDS-free future. The prospect of Trump making cuts to the program has many health experts fearful.

In a November 9 Council on Foreign Relations online letter, Laurie Garrett, senior fellow for global health, noted that the British journal Lancet created a website tracking the U.S. elections and its impact on global health.

“Terrific detail can be found there,” said Garret, about the website. “Though in fairness to Republicans it is clear the Lancet folks were not enamored” with Trump.

The signs are worrisome, according to Mitchell Warren, executive director of the AIDS Vaccine Advocacy Coalition, a New York-based organization founded in 1995 by nine HIV treatment activists.

“During the U.S. election campaign, plenty was said about emails and sexual harassment,” said Warren, in a November 25 article on (DW), the German broadcaster Deutsche Welle’s website. “But there was little or no talk on global health or HIV.”

President George W. Bush signed PEPFAR into law in 2003, with strong bipartisan support from the U.S. Congress.

“HIV/AIDS is one of the greatest medical challenges of our time, said President Bush, when signing the PEPFAR bill. “The legislation launches an emergency effort that will provide $15 billion over the next five years to fight AIDS abroad.”

Thirteen years later and many experts consider PEPFAR a success. However, there have been challenges. A studypublished in the May 2016 issue of Health Affairs found that abstinence programs in Sub-Saharan Africa have failed.

Despite roadblocks, PEPFAR’s achievements since 2003 have been dramatic, with more than:

• 68.2 million people receiving HIV testing and counseling, including 14.7 million pregnant women,
• 1 million babies born HIV-free,
• 9.5 million men, women and children receiving life-saving antiretroviral treatment,
• 8.9 million men receiving voluntary medical circumcision, and
• 5.5 million orphans and vulnerable children receiving care and support.

Today, PEPFAR is a generous $57 billion global-health juggernaut. (Add the United States Leadership Against HIV/AIDS, Tuberculosis and Malaria Act, and total funding exceeds $72 billion.)

“Thanks to a spate of scientific advances, this decade could be the beginning of the end of the HIV/AIDS epidemic,” reported STAT News in July.

President Obama marks World AIDS Day in 2011 by announcing plans to boost U.S. efforts to fight AIDS at home and aboard.

President Obama continued to support PEPFAR, and, despite eight tough years of partisan wrangling on Capitol Hill, his administration pushed through many advances in global health and development. The Pentagon led an international military mobilization against Ebola, and the Obama administration strengthened the Global Health Security Initiative and launched the Global Health Security Agenda, which coordinates the global effort to standardize disease surveillance and response spelled out in the International Health Regulations.

For 2017, PEPFAR’s budget request is $5.2 billion. Will a President Trump, bolstered by renewed conservative GOP armor in both houses of Congress, maintain the initiative’s staggering momentum? It’s vital that he does, not only for the benefit of its recipients overseas, but for American workers as well.

Though estimates are scarce, PEPFAR employs–either directly or indirectly, in both the public and private sector–tens of thousands Americans.

The State Department implements the program. Key agency coordinators include the U.S. Agency for International Development, the Department of Health and Human Services, the Center for Disease Control and Prevention, the departments of defense, commerce, and labor, and the Peace Corps.

Add to that list the National Institutes of Health, the Health Resources and Services Administration, the Food and Drug Administration, and the Substance Abuse and Mental Health Services Administration–and decreases to PEPFAR’s labor requirements by Trump could impact scores of American workers.

However, some health experts choose to focus on small nuggets of hope in Trump and his Vice President-elect Mike Pence, the deeply conservative and devotedly religious Indiana governor.

“Politics is cyclical,” said Naomi Seiler, an associate research professor at George Washington University, at a World AIDS Day 2016 panel at GW’s Milken Institute School of Public Health.

Democrat or Republican, its normal for policies to be renegotiated, realigned and reaffirmed with every new presidential administration, said Seiler.

HIV/AIDS care delivery and awareness was an exception to the rule in the 1980s and early 90s, said panelist Dr. W. David Hardy, senior director at the Whitman Walker Clinic. But today, said Hardy, the American public is more accepting of the public health model championed by HIV/AIDS that’s shown that effective funding and resources can beget worthy results.

One panelist even finds optimism in Pence.

In 2015, when an HIV outbreak sprung seemingly out the blue among intravenous drug addicts in small, rural and poor Scott County, Indiana, Governor Pence, said Dr. Richard J. Wolitski, director of the Office of HIV/AIDS and Infectious Disease Policy, (eventually) responded admirably.

Pence’s first reaction to the endemic was to pray, according to an August 2016 article in the New York Times. But in short order, Pence approved a needle exchange program, along with drug therapy and aggressive outreach, slowing “the flood of new HIV cases to a trickle.”

But as the AIDS Vaccine Advocacy Coalition’s Warren indicated about the 2016 presidential campaign, there is little indication of what Trump will do about global health or HIV.

However, at an October 2015 press briefing in New Hampshire, when a college student asked Trump whether he would support PEPFAR, he seemed to suggest he wouldn’t make changes. The student, whose name was not revealed, began his question to Trump by saying how successful PEPFAR has been.

“Would you commit to doubling the number of people on treatment to 30 million by the year 2020?” asked the student.

Though candidate Trump did not particularly reference PEPFAR in his response, he mentioned AIDS and seemed to commit to PEPFAR in a general way. “Well, I like committing to all those things. Those are great things–Alzheimer and AIDS–but the answer is yes. I believe so strongly in that. And we are going to lead the way.

A clinic on the outskirts of Kampala, Uganda, that receives money from the United States through PEPFAR for AIDS prevention. (Photo: Rodney Muhumuza, Associated Press)

One year later, will President-elect Trump stick to his word?

Even as Trump’s views rotate toward conservative GOP ideology the closer we get to inauguration day, he has altered his positions on domestic healthcare a number of times, both pre- and post-election. In April, the Washington Postreported that Trump changed his position on abortion five times in just three days.

And what of the Affordable Care Act, or Obamacare, the health reform law that Republicans have demonized ever since it was enacted in 2010? Trump and his fellow 2016 GOP presidential candidates, together with Republicans in Congress, have made it clear that repealing the law will be one of their first initiatives in 2017. Now Trump is not so sure.

“Either Obamacare will be amended, or repealed and replaced,” he told CNNfour days after the November 8 election, acknowledging that it was Obama, who met with Trump in the Oval Office for 90 minutes, who encouraged him to reconsider. “I told him I will look at his suggestions, and out of respect, I will do that.”

If ACA is repealed, an estimated 22 million people, many of them poor and older, will lose their health insurance, according to a November 28 New York Times editorial. After his meeting with President Obama, Trump seems open to compromise. The key word is “seems.”

And if Trump so easily flips-flops on domestic healthcare policies like abortion and ACA, what can be expected on the global HIV crisis? Which brings us back to World AIDS Day.

Absent a crystal ball into Trump’s HIV/AIDS global plans, today is a day for action. Whether partnering with the ONE initiative to empower women to take action, or working with the International Medical Corps to relieve suffering, or volunteering with the CDC to rally a domestic response, World AIDS Day inspires small and large acts of hope every December 1, and throughout the year, for achieving an AIDS-free future.

 

8 Health Insurers in 7 States Allegedly Discriminate Against HIV Patients

HIV medications

Cambridge, MA – A Harvard University healthcare advocacy group recently filed complaints against seven health insurers in eight states, claiming that they discriminate against HIV patients by making vital medications they need either too expensive or by not covering the drugs at all, according to Kaiser Health News.

The complaint was filed in September by the Center for Health Law and Policy Innovation of Harvard Law School (CHLPI) with the Department of Health and Human Services’ Office of Civil Rights (OCR).

CHIPL argues that plans by Anthem Blue Cross Blue Shield, Cigna, Community Health Choice, Highmark, Humana, Independence Blue Cross, and UPMC Health Plan, in Alabama, Georgia, Illinois, Louisiana, Pennsylvania, Tennessee, Texas and Wisconsin, circumvent federal health care law, which profits insures from discriminating against people based on medical condition.

The result not only renders essential treatments unaffordable and unavailable for people living with HIV in those states, it’s alleged to violate both their health care rights guaranteed under the Affordable Health Care (ACA) and their civil rights protections under the Americans with Disabilities Act (ADA).

“What’s most important to us is that there’s a robust enforcement mechanism around the promises … in the ACA and its regulations, especially the anti-discrimination provisions,” said Kevin Costello, director of litigation at CHLPI.

The Harvard center, along with AIDS groups in seven states, examined silver-level–plans, where insurance companies pay 70%, and patients pay 30% and have lower out-of-pocket premiums–available on the Marketplace, to determine whether the plans cover six treatment regimens that are the current standards of care for treating HIV.

CHIPL says the insurers bypass the ACA and its regulations by refusing to cover single-tablet drug regimens that are often tied to better compliance because a number of effective medicines are combined in one pill.  Alternatively, the insurers place most or all of the drugs in the higher gold and premium cost tiers, with patients having to shell out higher monthly premiums, according to the complaint.

CHIPL found, for example, that Anthem silver plans in Wisconsin cover only four of the 16 drugs or combination products that are recommended to meet the current standard of care, and they fail to cover any single-tablet regimens.  In Illinois, the center charged that Humana’s silver plans place 16 of the 24 most commonly prescribed HIV drugs in the highest cost-sharing tier, which requires patients to pay 50 percent of the cost.

With estimated monthly costs ranging from $377 to $684 for different drug regimens, enrollees in the Illinois Humana plans would have to pony up between 8 and 14 percent of their average monthly income, according to the Harvard center.

Costello said although the complaints are addressing HIV drugs, the center hopes the complaint speaks to the larger issue of patients with chronic illnesses difficulty in accessing drugs.

Ben Stiller says an early PSA test (and surgery) saved his life

Actor Ben Stiller revealed last week that he is cancer-free after a controversial screening test diagnosed him with prostate cancer in June 2014. He credits his good health today on early detection and surgery to remove the tumor three months later.

Stiller, 50, made the announcement on Howard Stern’s Sirius XM radio and in an essay posted on the website Medium with the bold title “The Prostate Cancer Test That Saved My Life.”

“Taking the PSA test saved my life,” Stiller wrote in the essay.

The trouble is Stiller’s doctor tested his baseline prostate-specific antigen (PSA) levels when he was 46, and he choose to have surgery at 48, much too early according to many in the medical community.

The American Cancer Society recommends men begin PSA screening at age 50. And the U.S. Preventative Services Task Force (USPSTF), a group of independent medical experts that issue medical guidelines for doctors to follow, declared in 2012 that no man of any age should have the PSA test to screen for prostate cancer unless he has urologic symptoms.

PSA tests detect an enzyme that is released by prostate cells. Elevated levels of PSA could indicate cancer. In many cases, however, the cancers would progress so slowly that it would not threaten a man’s health or life.

Stiller said his doctor started monitoring his PSA levels after a year and a half of “rising PSA numbers.” He went for an MRI and biopsy and after learning he had a “mid-range aggressive cancer,” he elected to have his prostate removed.

But sometimes the surgery may not be worth taking.

“PSA tests find a whole lot of prostate cancers that will never kill people,” urological surgeon Dr. Peter Albertsen of the University of Connecticut Health Center told STAT  – a national publication focused on telling compelling stories about health, medicine, and scientific discovery – in 2015.

USPSTF’s 2012 recommendation was partly based on evidence that 90% of men with PSA-detected prostate tumors opt for treatment — biopsy, surgery and chemotherapy — but at least 20% of them will have adverse effects such as erectile dysfunction or incontinence.

Stiller wrote, “If he (his doctor) had followed the US Preventive Services Task Force guidelines, I would have never gotten tested at all, and not have known I had cancer until it was way too late to treat successfully.”

The good news is that prostate cancer diagnoses seem to have declined slightly. But a 2015 editorial in the Journal of the American Medical Association worried that fewer PSA tests would lead to more men dying from prostate cancer.

“I think men over the age of 40 should have the opportunity to discuss the test with their doctor and learn about it, so they can have the chance to be screened,” Stiller wrote. “After that an informed patient can make responsible choices as to how to proceed.