By SOMA SEN
I keep hearing the voices of colleagues and friends that have been part of the AIDS epidemic compare it to the current COVID-19 pandemic. In fact Dr. Kathy Creticos, Director of Infectious Disease at Howard Brown Health spoke about the politicization of both the pandemics.
“Here we are in 2020 with this disease that kills people, that we don’t have any treatments for, that we really don’t understand the full manifestation and presentation biology of the virus,” Creticos said In the final segment of an interview with Contagion during International AIDS Society (IAS) AIDS 2020 Virtual Sessions. “We’re really dealing in the same situation as in the HIV epidemic.”
Her words make me reflect on the levity with which the Raegan administration treated the AIDS epidemic and it’s parallel to the Trump administration’s treatment of the current pandemic. However, she makes an important distinction between the two when she says, “I think a lot of it has to do with the fact that COVID affects everybody, but HIV was certainly perceived as not affecting everybody.”
As an Asian American researcher with more than 15 years of experience in this area, whenever, I bring up the issue of the scourge of HIV/AIDS in our community, the common response both from inside and outside the community is “It’s not a problem in this community.”
“The night I found out, I slept one and a half hours,” recalls D, a 29-year-old black gay man.
He’s talking about being diagnosed with HIV, the virus that causes AIDS.
“Even though I work in public health and tell people daily that HIV is not a death sentence, that first night that’s all I could think of,” says D. “This has to be wrong, I thought. I work in public health. This can’t happen to me.”
D, who requested anonymity, says he contracted the virus when a condom broke during sex. Two weeks later, he was tested for two sexually transmitted infections (STIs) – chlamydia and gonorrhea – but not for HIV. Shortly afterward, he went back for an HIV test and found out that he had the virus.
Soon after his diagnosis, D moved to Atlanta, which also happens to be the epicenter of a re-emerging national HIV crisis.
As you might expect from a blog, we’re big fans of HBO’s VICE, the cable giant’s slickly-produced answer to staid network news magazine shows like Sixty Minutes. Over it’s first two seasons, the show has established a small cult following with fast-paced, drop-you-down-in-the-center-of-the-action investigations of stories that are usually owned by the major television news organizations.
The recipe works and works surprisingly well as entertainment. It’s also pretty damn good journalism, much to the dismay of traditionalists.
VICE generally avoids slower-moving health care stories in favor of edgy, faster-paced, occasionally subversive pieces that send correspondents to far flung locations around the globe and put their lives in jeopardy as they go places the other guys generally won’t go.
The show’s first two seasons have seen correspondents sent to Afghanistan to report on teen suicide bombers, to Bangladesh to report on the illegal organ trade and to North Korea to a report on a basketball game attended by Dennis Rodman and North Korean Dictator Kim Jong Un.
Killing Cancer, Season Three’s season opening special report, an optimistic hour long episode that airs before the season premiere, is an encouraging exception to the no-healthcare rule that demonstrates that the show may be capable of much more than critics give it credit for.
In 1985, during the height of the AIDS crisis in New York City, I was elected to the New York City Council. Time and again, I felt heartbroken as my friends and constituents lost their lives to a deadly disease without a cure. Too frequently, they suffered the effects of ignorance, fear and hate.
Now, nearly 30 years later, advances in biomedical treatment have been stunning in their power to achieve an AIDS-free future. But the truth is that prejudice and fear are as persistent as HIV. Medicine alone cannot deliver the future we seek. Even as we celebrate the scientific discoveries and treatments that dramatically reduce HIV transmission and death, we should not delude ourselves into thinking that a biomedical solution can overcome the devastating effects of bigotry. If, as the United Nations agency UNAIDS urges, we wish to get to zero—zero discrimination, zero new infections, and zero deaths—we must take an integrated approach that combines biomedical treatment and an enduring commitment to human rights.
Without a doubt, medicine is working. As of September 30, 2013, the United States’ program, PEPFAR, is currently supporting life-saving antiretroviral treatment for 6.7 million men, women, and children worldwide. This exceeds President Obama’s 2011 World AIDS Day goal of 6 million people on treatment—a four-fold increase (from 1.7 million in 2008) since he took office. But, unfortunately, the World Health Organization predicts that 50 million people will need treatment for HIV by 2030. This means we face a tremendous uphill climb and must somehow identify between $22 and $24 billion—a truly ambitious financial target.
When CMS approved Solvadi, Gilead’s $84,000 drug for hepatitis C, the stakes were raised in drug price wars. Two opposing forces, one, a financial push toward lower costs came up against an opposing force of public sentiment. The FDA’s goal of getting 90% of patients moved from costly branded prescriptions to generics met with an an large outcry in social and traditional media for providing the best available care, rallying around the story of a patient. The wave of sentiment seems to have won over CMS.
Granted, CMS was likely considering the reversal in its policy on Solvadi, but it was the May 12th coverage by the Kaiser Family Foundation and NPR of the patient who was denied treatment, and the amplification across social media that turned the tide toward coverage.
Solvadi had not been approved by the patient’s prescription drug carrier, so physicians lobbied CMS for coverage of Solvadi and the life of the patient. Solvadi appears to cure liver cancer in 90% of the patients who take it as recommended. CMS agreed. As a single payer, they have the incentive to balance drug costs and benefits with other costs and benefits, and new therapies often win the fight for coverage.
Getting Covered: The decision to pay for drug combinations is often quicker than FDA approval of the drug combinations
Objective health policy observers such as KFF note that in the early days of successful antiviral drug treatment for HIV, payers allowed doctors to “mix and match” medications in “off-label” or unapproved combinations as they thought best. Medicare is often slow to approve the physician-driven cocktails, so getting CMS to adopt the strategy was a win for many very sick people in this country, as it sets a precedent for “exceptions.”
One doctor at Beth Israel Health System in Boston has a trial that has shown that combining Solvadi with another high-cost treatment, Olysio (by Janssen, cost $66,000 for a course of treatment) resulted in 90-100% cure rate.
The CMS statement in this case noted that that “the new policy will apply broadly to hepatitis C patients whose doctors prescribe the combined use of the two drugs because they meet certain criteria laid out in January by the Infectious Diseases Society of America and the American Association for the Study of Liver Diseases.” Those guidelines recommend the combined use of the two drugs in patients with advanced liver disease who have failed to be cured by earlier drug regimens – even though the FDA has not yet approved the combination—because Medicare guidelines say a patient must have access to a therapy if his or her condition warrants it.
On election night voters in Maryland, Maine and Washington state voted in favor of same-sex marriage, the first time marriage equality has been approved by popular vote. Although same-sex unions have been legalized in six states and the District of Columbia by lawmakers, the voting public have consistently rejected passing approval for same-sex unions. This is clearly a tipping point in the national discourse over the rights of gays and lesbians to marry.
However, although recent estimates suggest that more than half of the American population approves of same-sex marriage, there is still much to be done before equality is achieved. Even with all the good news, more than 30 states have approved constitutional bans on same-sex marriage. To date the debate over same-sex marriage has centered on equality – that my right to marry should be equal to the right of a Kardashian to marry anyone from the NBA. But is this more than a question of equity? Marriage provides legal protections, affords access to services and provides a source of social support – all of which may be protective of health. There is strong evidence that providing everyone with the right to marry is not only a question of equity, it is a pathway to improving the nation’s health.
Data from a range of studies confirm that marriage is good for you: in virtually every category, ranging from violent deaths to cancer, the unmarried are at far higher risk than the married. Marriage provides companionship, a social support system, someone to make you go to the doctor. “Marriage is sort of like a seat belt when it comes to improving your wellbeing,” says Dr. Linda Waite, Professor of Sociology at the University of Chicago and author of The Case for Marriage.