How HHS Secretary Reconciles Proposed Medicaid Cuts, Stopping The Spread Of HIV | KUER 90.1

How HHS Secretary Reconciles Proposed Medicaid Cuts, Stopping The Spread Of HIV

Apr 8, 2019
Originally published on April 9, 2019 7:35 am

In his State of the Union address this year, President Trump announced an initiative "to eliminate the HIV epidemic in the United States within 10 years."

The man who pitched the president on this idea is Alex Azar, the Secretary of the Department of Health and Human Services.

"We have the data that tells us where we have to focus, we have the tools, we have the leadership — this is an historic opportunity," Azar told NPR's Ari Shapiro Monday. "I told the president about this, and he immediately grabbed onto this and saw the potential to alleviate suffering for hundreds of thousands of individuals in this country and is deeply passionate about making that happen."

Trump's push to end HIV in the U.S. has inspired a mix of enthusiasm and skepticism from public health officials and patient advocates. Enthusiasm, because the plan seems to be rooted in data and is led by officials who have strong credentials in regards to HIV/AIDS. Skepticism, because of the administration's history of rolling back protections for LGBTQ people, many of whom the program will need to reach to be successful.

For instance, transgender people are three times more likely to contract HIV than the national average, according to the Centers for Disease Control and Prevention. Trump has banned transgender people from serving in the military and undone rules that allow transgender students access to bathrooms that fit their gender presentation.

Azar himself has strong Republican credentials — as a young man, he clerked for Justice Antonin Scalia. And yet he's now touring the country promoting this plan to end HIV, which includes supporting needle exchange programs to reduce HIV infection among intravenous drug users.

"Syringe services programs aren't necessarily the first thing that comes to mind when you think about a Republican health secretary," Azar acknowledged at an HIV conference last month. "But we're in a battle between sickness and health — between life and death."

This interview has been edited for clarity and length.

This morning you toured facilities in East Boston, a neighborhood in one of 48 counties targeted in Trump's plan. What did you learn there?

I was able to be at the East Boston Neighborhood Health Center and they have a remarkable program called Project Shine. What I was able to do is meet with the entire team that provides this type of holistic approach. It is very much what we're going to try to do in the most impacted areas.

You find the individuals who may have HIV — get them diagnosed. Get those who are diagnosed on the HIV antiretroviral treatment — so that they have an undetectable viral load and can't spread the disease to others, as well as live a long healthy life themselves. Get those who are most at risk of contracting HIV on a medicine called PrEP so that they dramatically reduce their chance of getting HIV. And then, finally, respond when you have clusters of outbreaks. So, just getting to see the the holistic approach there was extremely helpful for me.

Given that Medicaid is the single largest payer for medical care for people with HIV, do Republican efforts to block Medicaid expansion in high-infection states like Mississippi and Alabama undermine your efforts to get more people treatment?

The program that we have is based on the assumption that Medicaid remains as it is. .... And even were we to change Medicaid, along the lines of what the president has proposed in the budget ...

Meaning the major reductions to Medicaid that are in the president's budget?

Well, there are there are some reductions. But what it would do is actually give states tremendous flexibility. One of the challenges in the Affordable Care Act was that it prejudiced the Medicaid system very much in favor of able-bodied adults, away from the more traditional Medicaid populations of the aged, the disabled, pregnant women and children.

What we would do is restore a lot of flexibility of the states so that they could put those resources really where they're needed. We would expect that those suffering from HIV/AIDS infection would be in the core demographic of people that you would want to make sure were covered. What we will do here, by stopping the epidemic of HIV, is have a dramatic reduction in cost for the Medicaid and Medicare programs in the future.

So one big part of your plan is expanding access to PrEP, the HIV prevention drug. Without insurance it can cost around $1,600 a month in the U.S. A generic version available overseas costs roughly $6 a month. AIDS activists say your department could 'march in' and break the patent that Gilead holds in order to make a generic version available to Americans. Is your agency going to pursue that?

I don't know what you're saying by breaking the patent. There's no such thing as a legal right to break patents in the United States ...

The Centers for Disease Control and Prevention also has a patent for PrEP, which Gilead disputes ...

Well, that's very different than breaking a patent. That would be asserting patent rights held by the CDC. So the CDC has a patent on the product and Gilead has a patent on the product. We are actually in active negotiations and discussion with Gilead right now on how we can make PrEP more available and more cost effective for individuals as part of this ending the HIV epidemic program.

I recently went to Jackson, Miss., which has one of the highest rates of HIV infection in the country. I talked to Shawn Esco, a black gay man, who told me that stigma, homophobia, and racism prevent people from seeking care, and he has very little hope. What would you say to him?

That is exactly what the president and I want to solve. I want to give him that hope. So many of the infections are happening in areas of our country where there's intense stigma against individuals — males who have sex with men; the African-American community, Latino community, American Indian, Alaska Native communities. What's really made this is a historic opportunity right now is we have data that show us that 50 percent of new infections are happening in 48 counties as well as the District of Columbia and Puerto Rico, and so we can focus those efforts.

We want to learn from people on the ground, as I did this morning here in East Boston. How do we reduce stigma? How do we provide a holistic approach for Shawn and others? We can get them diagnosed and get them on treatment in ways that they find acceptable — or, as one of the individuals said to me this morning, meet people where they are.

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ARI SHAPIRO, HOST:

Every year, about 40,000 Americans contract HIV, and that number has not changed for years. President Trump wants to end this. Here's what he promised in this year's State of the Union address.

(SOUNDBITE OF 2019 STATE OF THE UNION ADDRESS)

PRESIDENT DONALD TRUMP: To eliminate the HIV epidemic in the United States within 10 years.

SHAPIRO: The man leading this effort is Health and Human Services Secretary Alex Azar. This morning, he toured a health center in East Boston. This is in 1 of 48 counties targeted in the new initiative. Secretary Azar, welcome to ALL THINGS CONSIDERED.

ALEX AZAR: Glad to be with you, Ari. Thank you.

SHAPIRO: Tell us the story of one of the people you met this morning and your hope for how this program would change the course of their life.

AZAR: Absolutely. So I was able to be at the East Boston Neighborhood Health Center, and they have got a remarkable program called Project Shine. And what I was able to do is meet with the entire team that provides this type of holistic approach where you find the individuals who may have HIV, get them diagnosed, get those who are diagnosed on antiretroviral treatment so that they have an undetectable viral load and can't spread the disease to others, as well as live a long healthy life themselves.

Get those who are most at risk of contracting HIV on a medicine called PrEP so that they dramatically reduce their chance of getting HIV. And then finally, respond when you have clusters of outbreaks. So just getting to see the holistic approach there was extremely helpful for me.

SHAPIRO: So as you point out. There is a drug to prevent HIV infection. There are drugs to treat HIV infection. And the big challenge is getting people access to care. especially in southern states, where infection rates are highest. Republican leaders have fought Medicaid expansion in states like Mississippi, Alabama, Tennessee. Does that undermine your efforts to give more people treatment? Medicaid is the single largest payer for care for people with HIV.

AZAR: Not at all. So the program that we have is based on the assumption that Medicaid remains as it is, that Congress doesn't take action to change that. And even were we to to change Medicaid along the lines of what, say, the president has proposed in the budget, really what we would be doing is...

SHAPIRO: Meaning major reductions.

AZAR: Well, there are some reductions, but what it would do is actually give states tremendous flexibility. One of the challenges in the Affordable Care Act was that it prejudiced the Medicaid system very much in favor of able-bodied adults away from the more traditional Medicaid populations of the aged, the disabled, pregnant women and children.

And what we would do is restore a lot of flexibility to the states so that they could put those resources really where they're needed. And absolutely we would expect that those suffering from HIV/AIDS infection would be in the core demographic of people that you would want to make sure were covered. So - but in any event, we've based ours - our program off of Medicaid being as it is now. And what we will do here by stopping the epidemic of HIV would have a dramatic reduction in cost for Medicaid and Medicare program in the future.

SHAPIRO: So one big part of your plan is this daily pill known as PrEP - pre-exposure prophylaxis. Without insurance, that pill can cost up to $1,600 a month in the U.S. And there is a generic version available overseas for roughly $6 a month.

AIDS activists say HHS, your department, could march in and break the patents that Gilead holds in order to make a generic version available to Americans. Is your agency going to pursue that route to make a generic version of the medicine available to people in the U.S.?

AZAR: Well, so the good news is for those individuals who have HIV, we have very cost-effective antiretroviral treatments.

SHAPIRO: But I'm talking about PrEP, the pre-exposure prophylaxis. Yeah.

AZAR: I know. I just want to make sure your listeners know of the different medicines that we're dealing with. So on antiretroviral treatment, we have many different therapies available. And we have a federal program called the Adapt (ph) program that makes those available.

For PrEP, that is available at a very significant discount through what's called the 340B program so that providers, including our community health centers, that individuals would be able to get that medicine at a dramatically reduced price. Including at our Ryan White HIV/AIDS Programs. Where over 50 percent of individuals who have HIV receive their care.

SHAPIRO: So it sounds like you're not talking about breaking the patent. I also want to let listeners know you were a drug executive yourself with Eli Lilly. You're not thinking of breaking the patent then?

AZAR: Well, I don't know what you're saying by breaking the patent. We actually - there's no such thing as any legal right to break patents in the United States. That's - we have a...

SHAPIRO: Well, without getting too deeply in the weeds, the Centers for Disease Control and Prevention do have a patent which Gilead disputes. I mean, there could be action here on behalf of the government. Is that action...

AZAR: Well, that's very different than breaking a patent. That would be asserting patent rights held by the CDC. So the CDC has a patent on the product, and Gilead has a patent on the product. And we are actually in active negotiations and discussion with Gilead right now on how we can make PrEP more available and more cost-effective for individuals as part of ending the HIV epidemic program.

SHAPIRO: After President Trump delivered the State of the Union address, I went to Mississippi, which has one of the highest rates of HIV infection in the country. And I spoke to gay African-American men about the disease, some of the people at highest risk of infection. At current rates, about half of all black gay and bisexual men in the U.S. are forecast to get HIV. And the thing I heard again and again is that stigma, homophobia and racism prevent people from seeking care.

I asked a man named Shawn Esco how hopeful he is that a decade or a generation from now, black gay men living in the South would not see friends die of AIDS the way he did. And here's what he told me.

(SOUNDBITE OF ARCHIVED BROADCAST)

SHAWN ESCO: There's not even a glimmer of a silver lining when it comes to that. You still have people that are not going to go to a doctor until it's time to go, until they're forced to go, until they pass out somewhere and people take them to a hospital. It's like that.

SHAPIRO: Secretary Azar, what do you say to him?

AZAR: I say that is exactly what the president and I want to solve. And I want to give him that silver lining. And I want to give him that hope. And you're absolutely right that so many of the infections are happening in areas of our country where there is intense stigma against individuals, males who have sex with men, the African-American community, Latino community, American Indian, Alaska Native communities.

What's really made this is a historic opportunity right now is we have data that show us that 50 percent of the new infections are happening in 48 counties in America, 48 counties as well as the District of Columbia and San Juan, Puerto Rico. And so we can focus those efforts. And we want to learn from people on the ground, as I did this morning here in East Boston, how do we reduce stigma? How do we provide a holistic approach that, for Shawn and others, we can get them diagnosed and get them on treatment in ways that that they find acceptable or, as one of the individuals said to me this morning, meet people where they are?

SHAPIRO: If I could just end with a slightly more personal question, you have strong Republican credentials. And you're traveling the country talking about the importance of needle exchanges, sex education for LGBT people, things that are not part of traditional Republican doctrine. How did you reach this place?

AZAR: You know, for me, it's all about public health and about evidence. And I was presented by our incredible CDC director, Dr. Bob Redfield, and Tony Fauci, who runs our National Institute of Allergy and Infectious Disease, and other top leaders at the department saying, you know what, Mr. Secretary, we have the data that tells us where we have to focus. We have the tools. We have the leadership now. This is a historic opportunity.

And I was immediately captivated that we could solve one of the greatest public health challenges of our time. I told the president about this, and he immediately, immediately grabbed onto this and saw the potential to alleviate suffering for tens of thousands, hundreds of thousands of individuals in this country and is deeply passionate about making that happen.

SHAPIRO: Alex Azar, secretary of the Department of Health and Human Services. Thank you for speaking with us today.

AZAR: Thank you, Ari. Transcript provided by NPR, Copyright NPR.