HIV Is Coming to An Unprepared Rural America

Williamson, West Virginia.

Rural America has many problems facing it ranging from economic decline to scarce access to medical facilities to a mindset that in some that embraces ignorance and bigotry.  Now, as a column in the New York Times makes clear, some parts of rural America, including much of neighboring West Virginia is about to face an HIV crisis that it is ill prepared to deal with largely due to closed mindedness, the stigma attached to being gay and/or HIV positive and lack of access to progressive testing and medical treatment. Much of the increase in HIV positive residents come from drug use and shared needles yet, rather adopting policies that might reverse the trend, many localities are shuttering programs that might stem increased infections. Here are highlights from a very troubling column:

While there are still about a million people living with H.I.V. in the United States, in some of America’s largest cities, the news about H.I.V. and AIDS is surprisingly positive.

“New H.I.V. Diagnoses Fall to Historic Lows,” the New York City Department of Health announced on Nov. 22, reporting that the largest city in the United States had fewer new diagnoses of H.I.V. in 2018 than during any year since statistics were first kept in 2001. This was just a few weeks after Philadelphia’s Department of Public Health reported a 14 percent drop in the number of newly diagnosed H.I.V. infections overall, and a drop of more than one-third among black men who have sex with men — an especially vulnerable population.

San Francisco and Chicago have also seen their rates of new H.I.V. infections falling.

[I]n much of rural America, an opposite trend is emerging. There have of course always been cases of H.I.V. in sparsely populated parts of the country, but in these places far from cities, the conditions that lead to H.I.V. transmission are now intensifying — and rural America is not ready for the coming crisis.

Indeed, in Appalachian West Virginia, the crisis has already arrived. A cluster of 80 new H.I.V. infections has been diagnosed since early last year in Cabell County.

Unlike large urban areas that have dealt with similar health and substance crises in the past, and that have networks of service providers and consumers in place, small rural health jurisdictions often lack the infrastructure to confront the crisis and have little history of dealing with comparable health issues, she explained.

[W]hen prescription highs can’t be sustained, people often turn to using — and sharing — needles to inject heroin and then fentanyl, leading to hepatitis C and H.I.V. This avoidable crisis has been exacerbated by unemployment, declining coal mining production and economic pressures on regional press to act as effectively as a watchdog.

At the same time, health care is relatively inaccessible. “It’s not so easy to get to the nearest town to see a doctor,” Dr. Judith Feinberg, professor of medicine at West Virginia University, explained, pointing to a lack of transportation and stigma as the biggest barriers to testing and care. People living with H.I.V. are stigmatized everywhere, but those who live in large cities can get tested while feeling relatively anonymous in a clinic in ways rural dwellers cannot.

[T]he C.D.C. released a list of 220 counties similarly vulnerable to such outbreaks among people who use intravenous drugs. The densest concentration of those counties is along the Appalachian Trail, with 28 of them in West Virginia — more than half of the state’s 55 counties.

“There is no way that doesn’t wind up as an H.I.V. outbreak in the state,” Ms. Young says. Yet unlike in places like New York — with its comprehensive sex education; efforts at queer- and trans-specific public health; embrace of public syringe exchanges; and what its health commissioner, Oxiris Barbot, describes as a “sex positive approach” — when it comes to confronting its H.I.V. epidemic, rural America is ill-prepared at best and antagonistic at worst.

[D]espite research showing that syringe programs are effective at limiting transmission of H.I.V. and encouraging people to enter drug treatment, two cities in West Virginia — Clarksburg and Charleston — have recently moved to close or limit their needle-exchange programs. Negative press, business worries and conservative approaches are among the reasons the programs have been reduced when they urgently need to be expanded (along with statewide testing and education about preventive H.I.V. medication).

While it’s true that people who are black, queer, transgender, homeless, incarcerated or poor, or who use injection drugs, are disproportionately affected by H.I.V. and AIDS, the misguided impression that members of these groups are the only ones affected has unfortunately contributed to the media’s choice to deprioritize coverage of H.I.V. and AIDS in recent years.

Meanwhile, the rural, heterosexual white Americans who have been the subject of countless national profiles because they’re imagined —  incorrectly — to represent all of President Trump’s supporters, are more at risk all the time. But while we’re bombarded by analyses of many aspects of their plight, we don’t hear about this crisis facing them.

[T]he new major terrain of the crisis right now is in rural America, and it can’t be ignored any longer.

Pharmaceutical Giant Makes Billions from HIV Treatment Funded by Taxpayers

I have touched on this topic before, but it bears addressing again since Donald Trump, a/k/a Der Trumpenführer, has again declared war on the Affordable Health Care Act and seeks to throw the general public at the mercy of greedy insurance carriers and even greedier pharmaceutical companies.  The preferred Trump/GOP health care system is one that maximizes profits to insurance companies, for profit health care providers and greed driven pharmaceutical companies and says to hell with average Americans and taxpayers other than the very wealthy.  A piece in the Washington Post looks at the obscene profits - $3 billion last ear - being raked in by Gilead Sciences on a drug that was developed at taxpayer expense and patented by the federal government  Something is seriously wrong with this picture even before one considers the fact that the high prices charged by Gilead makes the drug unobtainable for many who need it.  While the drug that is the subject of the article is HIV related, the same ridiculous screwing over of American taxpayers/consumers applies to many other drugs as well.  Here are article highlights (Note: (i) Gilead has made $36.2 billion off a government funded drug; and (ii) the same drug which cost $3,000/month in the USA costs $200 in the United Kingdom):

Thomas Folks spent years in his U.S. Centers for Disease Control and Prevention lab developing a treatment to block deadly HIV in monkeys. Then San Francisco AIDS researcher Robert Grant, using $50 million in federal grants, proved the treatment worked in people who engaged in risky sex.

Their work — almost fully funded by U.S. taxpayers — created a new use for an older prescription drug called Truvada: preventing HIV infection. But the U.S. government, which patented the treatment in 2015, is not receiving a penny for that use of the drug from Gilead Sciences, ­Truvada’s maker, which earned $3 billion in Truvada sales last year.

Gilead argues that the government’s patents for Truvada for PrEP, as the prevention treatment is called, are invalid. And the government has failed to reach a deal for royalties or other concessions from the company — benefits that could be used to distribute the drug more widely.

The extraordinary standoff between the CDC and a drug company over patent rights raises a big question for the Trump administration: How aggressively should the government attempt to enforce its patents against an industry partner?

The Department of Health and Human Services, which includes the CDC and the National Institutes of Health, has patented more than 2,500 inventions created with taxpayer dollars since 1976, according to the U.S. Patent and Trademark Office.

It routinely licenses new pharmaceutical compounds to private companies that take those publicly financed discoveries into the marketplace.

Gilead, which enjoys a U.S. monopoly on Truvada, charges between $1,600 and $2,000 for a month’s supply of a pill that can be manufactured for a fraction of that amount [actually about $0.6 per pill]. The number of new HIV infections in the United States has barely budged, meanwhile, and is stuck around 40,000 a year, according to CDC estimates.

Activists want the government to take a more aggressive stance against Gilead. Their complaints are part of a broader wave of anger over drug companies reaping hefty financial rewards by capitalizing on taxpayer-funded research.

“The CDC has all these patents, and is allowing Gilead to rip off the American people at the expense of public health,’’ said James Krellenstein, an HIV/AIDS activist and co-founder of the PrEP4All Collaboration, who has spent months digging into the government patents. Instead of enforcing its patent, Krellenstein said, the CDC is “twiddling their thumbs.’’

NIH and CDC officials see their role as encouraging the commercialization of government-financed discoveries, not placing curbs on them, Sukhatme said. That tends to take patent infringement lawsuits off the table. . . . But that stance increasingly is challenged by political anger over high drug prices. Consumer advocates and members of Congress have stepped up demands that the government exercise its rights under existing law to license generic competition or imports during shortages or unwarranted price spikes; several billswould enhance such “compulsory licensing’’ provisions.

The case of Gilead and Truvada for PrEP adds a new twist to these debates, with demands that the government be more aggressive in exercising its own patent to ease the cost effects of a monopoly.

After Truvada was shown to work as a prophylactic in primates, the CDC applied for its patents. That began a nine-year effort, using two outside law firms retained by the CDC, which made their case to U.S. Patent and Trademark Office examiners.

In addition to $50 million in government money, $17 million for the study came from the Bill & Melinda Gates Foundation, Grant said.

Federal officials estimated in 2016 that less than 10 percent of the 1.1 million people who should be on PrEP treatment are receiving the drug. Gilead says that has now improved to about 20 percent. The problem is particularly acute in Southern states, where cultural barriers and lack of education programs are holding back its use.

The CDC waged a successful defense of its patent in Europe, adding strength to its case that its patents are legitimate, Morten said.

“I have no reason to believe that these patents are not valid and enforceable, and moreover, they seem to be infringed [by Gilead] by the use of Truvada for PrEP,’’ Morten said in an interview. “These are public assets that were generated with public money that effectively are going to waste here.’’

In response to complaints about its price, Gilead said it offers discount coupons that reduce the cost to less than $5 for a monthly supply for patients who lack insurance. It says it has spent $138 million since 2012 on community grant programs to raise awareness and educate at-risk people. Gilead has earned $36.2 billion on Truvada since 2004, according to its annual reports.

Obtaining Gilead’s coupons for Truvada for PrEP is a cumbersome process, they said. If the CDC leveraged its patents to get money for Truvada, it could help cash-strapped state Medicaid programs undertake aggressive education and distribution programs. Virginia Medicaid said it pays $54.04 per pill, or $1,621.20 for a monthly course of treatment.

“What we’re seeing is that because city and local governments are spending so much on getting PrEP,’’ said HIV/AIDS activist Christian Urrutia, “they don’t have a lot of money left over to do these kinds of programs.’’ 

For the record, I have what is deemed "excellent" healthcare coverage and when I inquired about PrEP given the current controversy, I was advised that I would have to incur $3,600.00 in out of pocket expense before the coverage would reduce the cost.  Obviously, thousands of individuals do not have $3,600 lying around - and that assumes they have "excellent coverage", something most do not have.

PrEP Use Increasing, But Too Low Due to Extreme Cost

The United States' health care system remains one of the most inefficient of any developed nation and medications that cost little in Europe and Canada are exorbitantly expensive and out of financial reach of many.  A prime example is so-called PrEP which prevents HIV/AIDS infections.  At a cost of $2,000 -$3,000 per month, even good insurance coverage leaves one with thousands of dollars in out of pocket costs. A generic version sells for $200.00 a year and, as this blog has noted before, the actual production costs is about 6 cents per pill.  Making matters even more outrageous, government programs and charities funded the development research, not Gilead which markets the drug making obscene profits.   As long as insurance companies and pharmaceutical company greed control America's health care, quality health care remain out of the reach of millions. Meanwhile, the rest of us pay the price through astronomical hospital and drug costs.  A piece at NBC News looks at the under usage of PrEP.  Here are excerpts:

Thirty-five percent of gay and bisexual men at high risk of HIV infection were using PrEP, or pre-exposure prophylaxis, the daily pill that prevents HIV infection, in 2017, according to data released Thursday by the Centers for Disease Control and Prevention. In 2014, just 6 percent of these men used PrEP.

However, despite the nearly 500 percent jump in PrEP use among men who have sex with men, the CDC notes “PrEP use remains too low, especially among gay and bisexual men of color.”

The study was presented Thursday in Seattle at the 2019 Conference on Retroviruses and Opportunistic Infections, a major annual HIV/AIDS conference, and was based on more than 8,000 interviews in 20 American cities.

More than 40 percent of white gay and bisexual men at high risk of HIV used PrEP in 2017, while only 30 percent of their Latino counterparts and 26 percent of their African-American counterparts did so. The updated data highlights the fact that minorities access PrEP at lower rates than whites, despite being at higher risk of HIV infection.

The data also found high awareness of PrEP, which is also known by its brand name, Truvada, among all gay and bi men: Eighty-six percent of African-Americans know about it, as do 87 percent of Latinos and 95 percent of whites.

“The study’s findings suggest that efforts to increase PrEP awareness and use among populations at risk is working, but it remains underutilized,” according to a press memo distributed by the CDC.

Many people struggle to access PrEP because of its high cost — a roughly $2,000 per month list price — and complex insurance procedures.

“Of the estimated one million Americans at substantial risk for HIV and who could benefit from PrEP, fewer than 10 percent are actually using this medication,” the CDC noted, referring to low uptake overall among heterosexual and injection-drug-using populations that are also at high risk of HIV infection.

The CDC said it is funding government and private health organizations’ efforts to spread awareness of PrEP, and “developing new ways to connect gay and bisexual men of color and transgender people to PrEP."

Break Gilead's strangle hold on PrEP and allow generic forms and I suspect you would see usage surge.  But that would mean members of Congress would have to vote against their financial overlords. 

Mike Pence Is Not a "Decent Guy"

Joe Biden has a knack for making verbal gaffes.  Last week he made a major gaffe when he called Mike Pence a "decent guy."  Pence is anything but a "decent guy" and has a long track record of viscous homophobia that has cost lives and fueled bigotry and hatred. Being familiar with Pence's record, better descriptions of him might include, cold, cruel, hypocrite, dangerous or, as actress/activist Cynthia Nixon noted, insidious.   In an op-ed Nixon demonstrates why Pence is not a "decent guy" and, in my view, should be shunned by truly decent people.  Anyone who cares about LGBT family members or friends or who supports freedom of religion for all, not just Christofascists, should view Pence with horror. Many conjecture that Pence and his long time allies among anti-gay hate groups may in fact be behind much of the Trump/Pence regime's war on LGBT rights.  Here are op-ed excerpts:

Speaking at a forum in Omaha on Thursday, Joe Biden called Vice President Pence “a decent guy.”

When a chorus of progressives and LGBTQ activists, including myself, pointed out that a man who has built his career on homophobia and misogyny cannot possibly be considered “decent,” some dismissed it as just outrage Twitter. While Biden later walked back his comments and acknowledged that “there is nothing decent about being anti-LGBTQ rights,” I think it’s important to explain why calling Pence “a decent guy” is an affront to the real meaning of the word.

While I like and admire much about Biden personally and politically, especially his championing of the Violence Against Women Act, when he talks about Pence being “a decent guy,” he is putting politeness over policy. In effect, he is saying that Pence’s record doesn’t matter. So let’s talk about that record. As governor of Indiana, Pence signed a “religious freedom” bill that would have allowed LGBTQ discrimination. He refused to lift a ban on needle exchange programs until a preventable HIV outbreak reached epidemic levels. On the website for his 2000 congressional campaign, Pence suggested support for so-called conversion therapy, which is associated with higher suicide risk for LGBTQ youth. During Pence’s tenure as head of the Indiana Policy Review Foundation, it ran an article that suggested that women should have to be married to obtain birth control. He published an article urging businesses not to hire gay people, and his congressional website said that "homosexuality is incompatible with military service.”

Pence played a leading role in the Trump administration’s efforts to ban transgender people from military service, and he serves in an administration that seeks to define transgender Americans out of existence by stripping federal recognition of their gender identity. This is a man whose abhorrence of queer people is so notorious that even President Trump reportedly once joked that Pence “wants to hang them all.” (The White House later denied it.)

Pence has also made it his mission to take down Planned Parenthood, leading the GOP’s war on one of the nation’s largest providers of reproductive and transgender health care.
These are not the actions of a decent man. The fact that Pence does vile, hateful things while well-coiffed and calm doesn’t make him decent; it makes him insidious and dangerous.

It’s easy to say nice things about Pence when you’re not personally threatened by his agenda. If Biden were being directly attacked in the same way that our community is, I think he would see Pence from a very different vantage point.

When politicians of a certain age reminisce about the “civility” that used to define Washington, it’s telling that the old guard conveniently forgets that this decorum has never been extended to all.

[T]he problem isn’t getting along with Republicans. The problem is legitimizing an agenda of hateful discrimination. It’s about the fear that someone who would give Pence the benefit of the doubt in the name of civility might also be willing to bargain away our rights in the name of bipartisanship.

There is a sense among genteel Washington that partisanship is rude and boorish. But when you’re fighting for the rights of marginalized communities who are under attack, it’s okay to stop being polite. This is not a time for hollow civility. This is a time to fight.

If Democrats are too wedded to the collegiality of the Senate dining room to call out the Republicans who espouse homophobia, how are we ever going to stop them?

Mike Pence Hires New Homophobic Chief of Staff

Homophobe Marc Short.

While writers at the Washington Post were manufacturing attacks on the First Lady of Virginia, Vice President Mike Pence was hiring a new chief of staff who has a history of outspoken homophobia.  A piece in LGBTQ Nation looks at the past bigotry of Marc Short, Pence's new chief of staff as well as Pence's own long history of homophobia, attacks on LGBT citizens, and obstruction of efforts to curb HIV/AIDS which is increasingly a heterosexual problem in the black (of, course, Pence is anti-black as well).  The take away is that Short and Pence would happily see LGBT citizens simply die and disappear. Here are article highlights:

Mike Pence’s incoming chief of staff Marc Short has come under fire for a homophobic column he wrote about a man living with HIV.

Writing in his college newspaper at Washington & Lee University in Virginia, Short denounced, “the propaganda campaign ignited by gay activists and carelessly perpetuated by journalists whose intent is to scare all heterosexuals into believing they are prime targets for” HIV and AIDS.

“The campaign’s purpose is both to lobby Congress for more federal funding of AIDS research and to destigmatize the perverted lifestyles homosexuals pursue.”

The column, entitled “AIDS & The Heterosexual,” appeared in The Spectator, a student newspaper that Short co-founded and edited.

His column was ostensibly a response to an interview that appeared in the main student newspaper with Edwin Wright, a Washington & Lee alum who talked about watching several of his friends die from complications from AIDS and his own pending death.

Short said that he had “sympathy” for Wright, but “that does not mean that we glorify homosexuals’ repugnant practices of frequent anal intercourse nor should we consider them brave for coming out of the closet.”

“Homosexuals who pursue unhealthy lifestyles and engage in high risk sexual behavior, specifically anal intercourse, may very well end up like Mr. Wright.”

“Rhetoric like that killed us,” said Peter Staley, an ACT-UP activist who appeared in the documentary How to Survive a Plague. “Guys like him wanted us to die. And they had an effect.”

Pence has yet to comment on Short’s column. Pence himself has a long history of opposing LGBTQ rights both in the U.S. House and as governor of Indiana, even supporting federal funding for conversion therapy in 2000 as a means to fight HIV.

“His boss [Mike Pence] is responsible for enabling the single worst outbreak of HIV and AIDS in the history of Indiana due to his irresponsible and universally-criticized effort to end funding for needle exchange programs and HIV and AIDS testing centers. Mike Pence has spent his career attacking LGBTQ people and building a record of undermining HIV awareness and prevention initiatives.”

“After all this and being in the inner circle of Mike Pence for the past decade, the hiring of Marc Short is not surprising.”

Exposing The “Real” Mike Pence

In many ways, I believe Mike Pence embodies many of the worse elements of the Christofascist extremists who have a stranglehold on the Republican Party base.  Pence engages in false piety while doing violence to the Gospel message, he claims to be "pro-life" even though his party's policies are  anything but pro-life once a child - especially a poor minority child - is born, and he is fanatically anti-LGBT (I suspect because of his own sexual orientation issues).  On the latter point, the president of the Human Rights Campaign recently stated: “Mike Pence has made a career out of attacking the rights and equal dignity of LGBTQ people, women and other marginalized communities. Now as vice president, he poses one of the greatest threats to equality in the history of our movement. With the world distracted by Donald Trump’s scandal-ridden White House, Mike Pence’s nefarious agenda has been allowed to fly under the radar for too long.  . . ."  HRC and others in the LGBT and progressive community are seeking to expose Pence for what he really is and, hopefully expose the extremism of the GOP agenda in the process.  A piece in Politico looks at the effort.  Here are highlights (please take the time to check out the HRC website):

A leading progressive group is launching a campaign-style effort to [correctly] paint Vice President Mike Pence as an extremist who wields unprecedented power in the White House — an early sign that as the vice president takes a lead role in midterm campaigning, he also risks making himself a target.

The Human Rights Campaign, a leading LGBT rights organization, is launching a sustained attack against Pence, with a website, videos and a lengthy report to be released on Thursday. The materials were shown to POLITICO early.

And as President Donald Trump’s legal troubles expand, from the special counsel probe to a federal investigation of his personal attorney, some Democrats are beginning to train their fire on Pence in case the president doesn’t run for reelection in 2020 or gets removed from office. The broadside comes as Pence has taken on an outsize role in the Republicans’ work to prevent a Democratic wave in 2018. In the next week and a half, Pence will be making campaign stops in North Carolina, Wisconsin, Indiana and California. Those trips come after Pence has already crisscrossed the country stumping and fundraising for Republicans. The HRC effort highlights what it describes as Pence’s “extremist ideology”: his opposition while in Congress to Employment Non-Discrimination Act protections for sexual orientation; his opposition to ending “Don’t Ask, Don’t Tell,” which barred openly gay people from serving in the military; his opposition to hate crime protections for transgender individuals; and a statement on his 2000 campaign website that appeared to endorse federal funding for the controversial practice of “conversion therapy.”

The report, which highlights these positions, also hits Pence for his handling of an HIV/AIDS outbreak in Indiana during his governorship and for signing the Religious Freedom Restoration Act, which critics said would legalize discrimination against LGBT people and which nearly derailed his governorship.

Along with the report, HRC produced a series of videos, including one in which Pence decries the use of condoms and another in which he lobbies against hate-crime legislation. . . . . Clips of Pence speaking on the floor of the House — including one in which he says, “Abstinence and marital faithfulness before condom distribution are the cure for what ails the families of Africa” — are spliced in. “We’ve seen Mike Pence fly underneath the radar,” said Chris Sgro, HRC’s communications director. “The unfortunate reality is that Mike Pence has tried to hold himself out there as the moderate, grown-up voice in the room. But we know, and this report exposes, that he’s anything but. He is a dangerous extremist.” [GOP strategist, Rick] Tyler said even if HRC and other groups beat up on Pence as November approaches, he believes voters are more likely to make ballot-box decisions based on their views of Trump.

“When [House Speaker Paul] Ryan announced he wasn’t running for reelection, that was in many ways the end of the Republican Party the way I knew it and the way Ryan knew it,” Tyler said. “The cord is severed, this is now Trump’s party, for better or worse, for good or bad, and 2018 is now a referendum on his party.”