Treatment as Prevention: What Is the Evidence?

Walt Senterfit

Can we "treat our way out of the HIV epidemic," as some at the highest levels of government and science argue?

Since anti-retroviral therapy (ART) for
HIV can extend life by 50+ years, providing ART to all who need it worldwide
is an ethical imperative.  But is treatment also an effective prevention
strategy as well?  Can we "treat our way out of the epidemic"
as some at the highest levels of government and science argue? 
The efficiency of HIV transmission depends primarily on the concentration
of virus in an HIV+ person. Effective ART substantially reduces the
viral burden and thus would be expected to correspondingly reduce infectiousness.  

Observational studies in several places,
beginning with the famous Rakai study in Uganda, have shown that in
serodiscordant heterosexual couples the likelihood of the negative partner’s
becoming infected is very low when the positive person’s viral load
is very low.  However, preliminary conclusions from observational
studies do not always prove true in more rigorous study designs or in
real world experience. This underscores the importance of a large, multi-site
clinical trial (HPTN Protocol 052, Dr. Myron
Cohen, Protocol Chair
) of
1750 heterosexual serodiscordant couples in six countries to see whether
or not early vs. later initiation of ART will reduce transmission of
HIV to the uninfected partners. Results of the study, conducted by the
NIAID HIV Prevention Trials Network, will likely not be available until
sometime after 2013.  

Is the treatment effect significant
at a population or public health level?

It would be wise to remain skeptical.
As many as 50% of new HIV infections come from individuals who are in
the acute or very early stage of HIV infection when they are likely
to be highly infectious and unlikely to know of their infection. 
Drug resistant strains of HIV emerge and may be transmitted.  Many
individuals have difficulty tolerating ART indefinitely and others have
problems in adherence for a variety of reasons.  

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The strongest argument for skepticism
is the experience of much of the US and parts of Western Europe, where
treatment is relatively widely available and yet HIV incidence remains
stubbornly high and even rising.  At the very least, the relationship
of treatment to prevention is not simple or automatic, even under the
best current conditions. 

If this is the case in the wealthiest
countries, how much farther away then are we from being able to "treat
our way out of the epidemic" in developing nations, home to the majority
of people living with HIV and those at highest risk of contracting it? 
There were 3 new infections with HIV-1 for each person started on HAART
in 2006.  

Treatment is a basic human right. 
It may also contribute to lessening transmission and thus be an important
part of effective prevention strategies. Nonetheless, no magic bullet,
no universally effective prevention strategy exists, and none is likely
for the foreseeable future. Meanwhile, less than one in five persons
at substantial risk of infection with HIV has access to even basic prevention
services, let alone a broad evidenced-based package of prevention tools.   

We have work to do.

News Health Systems

Texas Anti-Choice Group Gets $1.6 Million Windfall From State

Teddy Wilson

“Healthy Texas Women funding should be going directly to medical providers who have experience providing family planning and preventive care services, not anti-abortion organizations that have never provided those services," Heather Busby, executive director of NARAL Pro-Choice Texas, said in a statement.

A Texas anti-choice organization will receive more than $1.6 million in state funds from a reproductive health-care program designed by legislators to exclude Planned Parenthood

The Heidi Group was awarded the second largest grant ever provided for services through the Healthy Texas Women program, according to the Associated Press.

Carol Everett, the founder and CEO of the group and a prominent anti-choice activist and speaker, told the AP her organization’s contract with the state “is about filling gaps, not about ideology.”

“I did not see quality health care offered to women in rural areas,” Everett said.

Heather Busby, executive director of NARAL Pro-Choice Texas, said in a statement that it was “inappropriate” for the state to award a contract to an organization for services that it has never performed.

“The Heidi Group is an anti-abortion organization, it is not a healthcare provider,” Busby said.

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State lawmakers in 2011 sought to exclude Planned Parenthood from the Texas Women’s Health Program, which was jointly funded through federal and state dollars. Texas launched a state-funded version in 2013, and this year lawmakers announced the Healthy Texas Women program.

Healthy Texas Women is designed help women between the ages of 18 and 44 with a household income at or below 200 percent of the federal poverty level, and includes $285 million in funding and 5,000 providers across the state.

Bubsy said the contract to the Heidi Group was “especially troubling” in light of claims made by Everett in response to a recent policy requiring abortion providers to cremate or bury fetal remains. Everett has argued that methods of disposal of fetal remains could contaminate the water supply.

“There’s several health concerns. What if the woman had HIV? What if she had a sexually transmitted disease? What if those germs went through and got into our water supply,” Everett told an Austin Fox News affiliate.

The transmission of HIV or other sexually transmitted infections through water systems or similar means is not supported by scientific evidence.

“The state has no business contracting with an entity, or an individual, that perpetuates such absurd, inaccurate claims,” Busby said. “Healthy Texas Women funding should be going directly to medical providers who have experience providing family planning and preventive care services, not anti-abortion organizations that have never provided those services.”

According to a previous iteration of the Heidi Group’s website, the organization worked to help “girls and women in unplanned pregnancies make positive, life-affirming choices.”

Texas Health and Human Services Commission spokesperson Bryan Black told the Texas Tribune that the Heidi Group had “changed its focus.”

The Heidi Group “will now be providing women’s health and family planning services required by Healthy Texas Women, including birth control, STI screening and treatment, plus cancer screenings to women across Texas,” Black said in an email to the Tribune.

Its current site reads: “The Heidi Group exists to ensure that all Texas women have access to quality health care by coordinating services in a statewide network of full-service medical providers.”

Everett told the American-Statesman the organization will distribute the state funds to 25 clinics and physicians across the state, but she has yet to disclose which clinics or physicians will receive the funds or what its selection process will entail.

She also disputed the criticism that her opposition to abortion would affect how her organization would distribute the state funds.

“As a woman, I am never going to tell another woman what to tell to do,” Everett said. “Our goal is to find out what she wants to do. We want her to have fully informed decision on what she wants to do.”

“I want to find health care for that woman who can’t afford it. She is the one in my thoughts,” she continued.

The address listed on the Heidi Group’s award is the same as an anti-choice clinic, commonly referred to as a crisis pregnancy center, in San Antonio, the Texas Observer reported.

Life Choices Medical Clinic offers services including pregnancy testing, ultrasounds, and well-woman exams. However, the clinic does not provide abortion referrals or any contraception, birth control, or family planning services.

The organization’s mission is to “save the lives of unborn children, minister to women and men facing decisions involving pregnancy and sexual health, and touch each life with the love of Christ.”

Analysis Politics

Experts: Trump’s Proposal on Child Care Is Not a ‘Solution That Deals With the Problem’

Ally Boguhn

“A simple tax deduction is not going to deal with the larger affordability problem in child care for low- and moderate-income individuals," Hunter Blair, a tax and budget analyst at the Economic Policy Institute told Rewire.

In a recent speech, GOP presidential nominee Donald Trump suggested he now supports policies to made child care more affordable, a policy position more regularly associated with the Democratic Party. The costs of child care, which have almost doubled in the last 25 years, are a growing burden on low- and middle-income families, and quality options are often scarce.

“No one will gain more from these proposals than low- and middle-income Americans,” claimed Trump in a speech outlining his economic platform before the Detroit Economic Club on Monday. He continued, “My plan will also help reduce the cost of childcare by allowing parents to fully deduct the average cost of childcare spending from their taxes.” But economic experts question whether Trump’s proposed solution would truly help alleviate the financial burdens faced by low- and middleincome earners.

Details of most of Trump’s plan are still unclear, but seemingly rest on addressing child care costs by allowing families to make a tax deduction based on the “average cost” of care. He failed to clarify further how this might work, simply asserting that his proposal would “reduce cost in child care” and offer “much-needed relief to American families,” vowing to tell the public more with time. “I will unveil my plan on this in the coming weeks that I have been working on with my daughter Ivanka … and an incredible team of experts,” promised Trump.

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An adviser to the Trump campaign noted during an interview with the Associated Press Monday that the candidate had yet to nail down the details of his proposal, such as what the income caps would be, but said that the deductions would only amount to the average cost of child care in the state a taxpayer resided in:

Stephen Moore, a conservative economist advising Trump, said the candidate is still working out specifics and hasn’t yet settled on the details of the plan. But he said households reporting between $30,000 and $100,000, or perhaps $150,000 a year in income, would qualify for the deduction.

“I don’t think that Britney Spears needs a child care credit,” Moore said. “What we want to do is to help financially stressed middle-class families have some relief from child-care expenses.”

The deduction would also likely apply to expensive care like live-in nannies. But exemptions would be limited to the average cost of child care in a taxpayer’s state, so parents wouldn’t be able to claim the full cost of such a high-price child care option.

Experts immediately pointed out that while the details of Trump’s plan are sparse, his promise to make average child care costs fully tax deductible wouldn’t do much for the people who need access to affordable child care most.

Trump’s plan “would actually be pretty poorly targeted for middle-class and low-income families,” Hunter Blair, a tax and budget analyst at the Economic Policy Institute (EPI), told Rewire on Monday.

That’s because his tax breaks would presumably not benefit those who don’t make enough money to owe the federal government income taxes—about 44 percent of households, according to Blair. “They won’t get any benefit from this.”

As the Associated Press further explained, for those who don’t owe taxes to the government, “No matter how much they reduce their income for tax purposes by deducting expenses, they still owe nothing.”

Many people still may not benefit from such a deduction because they file standard instead of itemized deductions—meaning they accept a fixed amount instead of listing out each qualifying deduction. “Most [lower-income households] don’t choose to file a tax return with itemized deductions,” Helen Blank, director of child care and early learning at the National Women’s Law Center (NWLC), told Rewire Tuesday. That means the deduction proposed by Trump “favors higher income families because it’s related to your tax bracket, so the higher your tax bracket the more you benefit from [it],” added Blank.

A 2014 analysis conducted by the Congressional Research Service confirms this. According to its study, just 32 percent of tax filers itemized their deductions instead of claiming the standard deduction in 2011. While 94 to 98 percent of those with incomes above $200,000 chose to itemize their deductions, just 6 percent of tax filers with an adjusted gross income below $20,000 per year did so.

“Trump’s plan is also not really a solution that deals with the problem,” said Blair. “A simple tax deduction is not going to deal with the larger affordability problem in child care for low- and moderate-income individuals.”

Those costs are increasingly an issue for many in the United States. A report released last year by Child Care Aware® of America, which advocates for “high quality, affordable child care,” found that child care for an infant can cost up to an average $17,062 annually, while care for a 4-year-old can cost up to an average of $12,781.

“The cost of child care is especially difficult for families living at or below the federal poverty level,” the organization explained in a press release announcing those findings. “For these families, full-time, center-based care for an infant ranges from 24 percent of family income in Mississippi, to 85 percent of family income in Massachusetts. For single parents the costs can be overwhelming—in every state annual costs of center-based infant care averaged over 40 percent of the state median income for single mothers.”

“Child care now costs more than college in most states in our nation, and it is an actual true national emergency,” Kristin Rowe-Finkbeiner, CEO and executive director of MomsRising, told Rewire in a Tuesday interview. “Donald Trump’s new proposed child care tax deduction plan falls far short of a solution because it’s great for the wealthy but it doesn’t fix the child care crisis for the majority of parents in America.”

Rowe-Finkbeiner, whose organization advocates for family economic security, said that in addition to the tax deduction being inaccessible to those who do not itemize their taxes and those with low incomes who may not pay federal income taxes, Trump’s proposal could also force those least able to afford it “to pay up-front child care costs beyond their family budget.”

“We have a crisis … and Donald Trump’s proposal doesn’t improve access, doesn’t improve quality, doesn’t lift child care workers, and only improves affordability for the wealthy,” she continued.

Trump’s campaign, however, further claimed in a statement to CNN Tuesday that “the plan also allows parents to exclude child care expenses from half of their payroll taxes—increasing their paycheck income each week.”

“The working poor do face payroll taxes for Social Security and Medicare, so a payroll tax break could help them out,” reported CNN. “But experts say it would be hard to administer.”

Meanwhile, Democratic presidential nominee Hillary Clinton released her own child care agenda in May, promising to use the federal government to cap child care costs at 10 percent of a family’s income. 

A cap like this, Blank said, “would provide more help to low- and middle-income families.” She continued, “For example, if you had a family with two children earning $70,000, if you capped child care at 10 percent they could probably save … $10,000 a year.”

Clinton’s plan includes a promise to implement a program to address the low wages many who work in the child care industry face, which she calls the “Respect And Increased Salaries for Early Childhood Educators” program, or the RAISE Initiative. The program would raise pay and provide training for child-care workers.

Such policies could make a major difference to child-care workers—the overwhelming majority of which are women and workers of color—who often make poverty-level wages. A 2015 study by the EPI found that the median wage for these workers is just $10.31 an hour, and few receive employer benefits. Those poor conditions make it difficult to attract and retain workers, and improve the quality of care for children around the country. 

Addressing the low wages of workers in the field may be expensive, but according to Rowe-Finkbeiner, it is an investment worth making. “Real investments in child care bring for an average child an eight-to-one return on investment,” she explained. “And that’s because when we invest in quality access and affordability, but particularly a focus on quality … which means paying child-care workers fairly and giving child-care workers professional development opportunities …. When that happens, then we have lower later grade repetition, we have less future interactions with the criminal justice system, and we also have a lower need for government programs in the future for those children and families.

Affordable child care has also been a component of other aspects of Clinton’s campaign platform. The “Military Families Agenda,” for example, released by the Clinton campaign in June to support military personnel and their families, also included a child care component. The former secretary of state’s plan proposed offering these services “both on- and off-base, including options for drop-in services, part-time child care, and the provision of extended-hours care, especially at Child Development Centers, while streamlining the process for re-registering children following a permanent change of station (PCS).” 

“Service members should be able to focus on critical jobs without worrying about the availability and cost of childcare,” said Clinton’s proposal.

Though it may be tempting to laud the simple fact that both major party candidates have proposed a child care plan at all, to Rowe-Finkbeiner, having both nominees take up the cause is a “no-brainer.”

“Any candidate who wants to win needs to take up family economic security policies, including child care,” she said. “Democrats and Republicans alike know that there is a child care crisis in America. Having a baby right now costs over $200,000 to raise from zero to age 18, not including college …. Parents of all political persuasions are talking about this.”

Coming up with the right way to address those issues, however, may take some work.

“We need a bold plan because child care is so important, because it helps families work, and it helps them support their children,” the NWLC’s Blank said. “We don’t have a safety net for families to fall back on anymore. It’s really critical to help families earn the income their children need and child care gives children a strong start.” She pointed to the need for programs that offer families aid “on a regular basis, not at the end of the year, because families don’t have the extra cash to pay for child care during the year,” as well as updates to the current child care tax credits offered by the government.

“There is absolutely a solution, but the comprehensive package needs to look at making sure that children have high-quality child care and early education, and that there’s also access to that high-quality care,” Rowe-Finkbeiner told Rewire. 

“It’s a complicated problem, but it’s not out of our grasp to fix,” she said. “It’s going to take an investment in order to make sure that our littlest learners can thrive and that parents can go to work.”

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