Let’s Tell The Truth About Entitlements

“We have a welfare system that's trapping people in poverty and effectively paying people not to work,”House Speaker Paul D. Ryan (R-Wis.). Speaker Ryan continues to perpetuate the myth of the “welfare queen,” the lazy, mostly likely black or brown woman, popping out babies and gobbling up our hard earned tax dollars. Nothing could be farther from the truth. That is not to say that there are no lazy people collecting means tested benefits. But the poor do not have a monopoly on lazy people. Poverty in the U.S. is a complex phenomenon that has been orchestrated by a variety of policies that segregated large masses of immigrants as well as black and brown people and limited their access to opportunities that might otherwise help lift them out of poverty, such as quality schools, well-paying jobs, affordable housing and blatant discrimination. But the greatest determinant has to do with where you live. If you are born and raised in a high poverty area, you are more likely to remain in poverty, than not. So, contrary to Speaker Ryan’s demagoguery, welfare is not a permanent prison, but more of a temporary safety net to help low income people endure difficult periods of their lives. Moreover, the average participant, almost 40%, is a child.

Former presidential candidate, Mit Romney stated that 47% of Americans paid no federal income tax, implying a parasitic lifestyle, sucking away again, at our hard earned tax dollars. But he never mentioned that three quarters of those individuals simply benefited from tax provisions that benefit senior citizens and low-income working families with children.

Only 21.3 percent of the U.S. population participates in government assistance programs on any given month. Over 90% of these benefits go to the elderly, disabled or working class families. Another key fact that those, scheming to cut taxes to benefit the wealthy, won’t tell you is that for many participants, it’s a temporary visit.

According to the U.S. Census:

• Of people enrolled in Medicaid, 35.6 percent participated between one and 12 months and 35.3 percent participated between 37 and 48 months.

• At 38.6 percent, the largest share of SNAP (Food Stamps) recipients participated between 37 and 48 months.

• At 49.4 percent, the largest share of people receiving housing assistance benefits participated between 37 and 48 months.

• Of people enrolled in the Supplemental Security Income (SSI) program, 35.6 percent participated between one and 12 months, while 38.2 percent participated between 37 and 48 months.

• At 62.9 percent, the largest share of people participating in Temporary Assistance for Needy Families (TANF) participated between one and 12 months.

Cutting these vital programs won’t solve the poverty. Rather, it will deepen the struggle of the disabled and elderly. Moreover, if working class people don’t receive that extra help when they need it the most, they may be more likely to end up in poverty, with fewer options to help them escape it.

They still don't get it! Lessons not learned for the Indiana HIV/AIDS Outbreak

In early 2015, news began to spread about an outbreak of HIV infections in rural Scott County in Indiana, eventually becoming an international story. Dozens of intravenous drug users in the county's tiny city of Austin (population 2,500) became infected with HIV, primarily from sharing and reusing dirty needles to inject opiates. Since the start of the outbreak, over 210 in the county have been diagnosed with HIV, most in Austin. Moreover, almost 95 percent of those infected with HIV were also infected with Hepatitis C. Prior to the outbreak, Scott County had fewer than five new cases of HIV each year. The IV drug use did not come as a surprise to public health officials. Hep C rates had been on the rise in Scott County for years and it was widely assumed that it was linked to IV drugs.

The outbreak was fanned by the flames of ignorance. Former Governor (now Vice President) Mike Pence's policies helped degrade the public health capacity to prevent and respond to this growing epidemic through limited funding and an actual shutdown of Planned Parenthood offices that offered HIV and Hep C testing. Eventually, with more than a little nudging from the Indiana Health Commissioner (and now US Surgeon General) Dr. Jerome Adams, and a lot of pressure from the CDC, Pence grudgingly declared a public health emergency and authorized a short-term needle exchange program as a part of a multi-pronged approach to contain the outbreak.

Now, just two years later and despite demonstrated progress in reducing new HIV and Hep C infection, some of the Indiana counties are closing their needle exchange programs. Some of the politicians voting to close the programs defined it as a "moral" issue. Other complained that not enough users actually entered treatment programs. Bottom line: the programs worked. But now, despite lower rates of HIV and Hep C, it’s easy to declare victory and close the programs.

There is an important lesson to be learned from this situation. It seems clear that this was never about addressing a public health crisis as much as it was about saving face. Having HIV infection rates in a predominately white, rural town in a predominately white state that mirrored and, in some cases exceeded, some areas of Sub Saharan Africa just looked bad! Rather than merely being reactive, it was an opportunity to learn more about the intersections of opioid addiction, poverty and HIV/Hep C infection. It was also an opportunity to develop an infrastructure of prevention and treatment programs that would, over time, lesson the economic burden and human toll extracted by these twin epidemics. Without that infrastructure (which should also include safe injection sites) we will see more of these outbreaks, and not just in small rust belt towns.

A Tale of two States and their struggle with HIV

On the surface, Indiana and Florida could not be more different. Be it size (Florida is the 3rd most populous state, while Indiana is the 38th); location (Midwest vs Deep South) or diversity of the population (Indiana is 84.3% white while Florida is over 46% minority), one might assume their challenges to be very different. However, each state's struggle with their own outbreaks of HIV only serves to reminds us of power of one of the virus' closest allies; poverty.  

Most HIV activists agree that poverty plays a major role in the intransigence of the epidemic. According to the International Labor Office of UNAIDS: "HIV/AIDS is both a manifestation of poverty conditions that exist…, and the result of the unmitigated impact of the epidemic on social and economic conditions. HIV/AIDS is at the same time a cause and an outcome of poverty, and poverty is both a cause and an outcome of HIV/AIDS." So there is no coincidence that as each state struggles with growing poverty, so too has HIV increased. 

Much has been written about Indiana's HIV outbreak-largely because it seemed to come out of nowhere. Starting in February 2015 through April 2016, 190 cases have been documented. Long known as a religiously and socially conservative state, it seemed ill suited to generate headlines for one town, Austin (population 4,200) now has a higher incidence of HIV than "any country in Sub Saharan Africa." says CDC Director Tom Frieden. "They've had more people infected through IV drug use than all of New York City last year." Indiana's poverty rate of almost 21% is also above both the national average (15.9%) and for that of Midwestern states (14.1%) 

Florida too, has both soaring rates of poverty and HIV. Roughly 1 in 6 Floridians live in poverty and, according to the Business Insider, has three of the top 15 cities where poverty is increasing the fastest. Florida also has the highest number of new HIV diagnoses in the nation, with a 23% increase in 2015 alone. 

Despite the largely different primary modes of infection in Austin, Indiana and Florida (IV drug use vs MSM), both states' increases in HIV can be linked to a lack of sustained effort to promote safer sex. In Florida, prevention funding has been flat or cut, and still has prohibitions on talking explicitly about sexuality in sex education classes. Austin IN, like much of rural America, has few medical providers. There is only one doctor and the Planned Parenthood clinic in the county that used to provide HIV testing and referrals closed in 2013, as government funding declined. There is a great fear among HIV surveillance experts of a growing prevalence of HIV in many other rural counties- especially in the south- but also in areas such as Idaho, which had two rural outbreaks in 2008. 

The ongoing debates about income equality and jobs carry a much greater importance that just determining the type of housing in which one lives or the schools our children attend: it has a direct impact on our health. Poverty is the ultimate social determinant and until we have the will to aggressively address it, we will continue to have these pervasive health disparities, like HIV disease. In the meantime, we know what works against HIV. Access to HIV testing and treatment; condoms; needle exchange programs and prevention education can make a real impact on preventing or halting the outbreaks. When the Indiana state health department aggressively moved in and offered HIV testing and treatment as well as setting up a needle exchange in Austin, it effectively stopped its outbreak. Sadly however, "the horse was already out of the barn' and reactive policies are just that, often too little too late. 

State governments and health departments, such as those in Indiana and Florida need to shelve their conservative rhetoric and provide a real plan to prevent HIV infection and to address their burgeoning IV drug use epidemics. Otherwise, we will continue to see a resurgence of this eminently manageable disease, all over the country. 

35 Years of HIV/AIDS

June 5, 2016 represented a solemn birthday as HIV/AIDS turned 35. On July 3, 1981, the New York Times published a groundbreaking article about a rare and often fatal cancer called Karposi’s Sarcoma, which was found in 41 cases of homosexual men in California and New York; eight of the sufferers died less than 24 months after the diagnosis was made. Due to the rarity of the cancer, it was believed at that time that earlier cases might not have been detected. An astounding 71 million infections later, and with over 34 million deaths, the HIV/AIDS epidemic is second in lethalness to the Bubonic Plague of the 14th century, which is estimated to have killed 75 to 200 million people. I began working in the field of HIV/AIDS in 1987, six years after its coming out party. During that time, an HIV diagnosis seemed akin to a death sentence. There was so much that we did know about HIV, and there was only one medication available to specifically treat HIV/AIDS. The medication, called AZT, was prescribed in such toxic doses that many felt more ill from the AZT treatments than they did from AIDS. People were so desperate for something to extend their lives that they would have taken almost anything. Needless to say, a fair number of individuals and "clinics" began to pop up with "cures" for AIDS. While a cure has continued to elude us to this day, we have dozens of medications that have extended the lives of millions of people throughout the world. The challenge now is to provide access to these life preserving medications for all who need them, and to ensure (or facilitate) people taking them. Several years ago I had an opportunity to meet with a group of female HIV activists from South Africa. When I informed them that not everyone in the US with HIV were taking anti-retrovirals, they were stunned. It was their understanding that HIV medication was widely available, and that everyone who needed them were taking them. I explained that health insurance plans in some states provided limited coverage for certain medications, and that some people (as many as 19%) living with HIV were unaware of their infection. While they understood this, they could not understand how so many who were aware of their diagnosis and had access to medications were not on medication. Various studies have shown that as few as 30% of people living with HIV in the US have suppressed viral loads, the gold standard for HIV care. While viral load suppression has risen in HIV+ individuals in care, there remains an alarming number of individuals not receiving consistent HIV disease management (ex. in and out of care, or not in care at all). While we cannot cure HIV, we have built a better toolbox that can help keep people alive for a long time, and there are even more tools in the pipeline. In spite of the tools at hand, however, issues of poverty, homelessness, substance abuse, and mental illness continue to disproportionately impact those most at risk for HIV. Thus, our goal at year 35 of the HIV/AIDS epidemic is to get people into care, and to help them stay there.

Know what you are talking about

I was recently asked if I felt that we, in the black community, could now decelerate our efforts to fight HIV due to so much progress with treatment. My answer, quite to the questioner’s surprise, was a resounding NO! Her question was predicated on the belief that the black community had previously issued a 'call to arms' and had mobilized, much like the LGBT community had in the 80's and 90's, to educate our community and advocate for more funding. It is downright depressing to think that the black community might be breathing a collective sigh of relief and backing off on whatever feeble efforts we are able to marshal, believing that we have won something. Has progress been made? Absolutely. Are we out of the woods yet? Absolutely not. Two recent reports have demonstrated that we still have a long way to go. While HIV has continued to wreak havoc on the black community (representing 44% of new HIV cases), the landscape is even bleaker for black gay and bisexual men in the United States. According to the Centers for Disease Control (CDC), one half of black MSM (men who have sex with men) “will be diagnosed with HIV in their lifetime” if current trends continue. To put this another way, if America’s black gay and bisexual men comprised a nation unto themselves, that nation would soon have the world’s highest rate of infection — twice as high as its closest rivals in Sub-Saharan Africa (CDC). If this isn't dire enough, the average survival time for African-Americans with AIDS is lower than for other racial or ethnic groups despite dozens of effective medications including a HIV prevention pill (PrEP). The main reason for this seems to be inconsistent treatment. From 2011 to 2013, only 38 percent of black HIV patients received consistent treatment, whereas about 50 percent of whites and Hispanics with the virus had continuous care (CDC's Feb. 4th Morbidity and Mortality Weekly Report). This disparity is consistent with the statistics regarding viral suppression, which is the gold standard for HIV care. In general, it is understood that the lower the amount of HIV virus in one’s blood, the lower the risk of opportunistic infections and the greater the life expectancy. Only about 25 percent of people living with HIV in the United States have achieved viral suppression, with African Americans being the least likely to do so at a rate of 21% compared to 26% among Hispanics and 30% of whites. Additionally, the 25-34 age group (one of the hardest hit among black MSM) is the least likely to have achieved viral suppression compared to other age groups, with only 15 percent of individuals 25-34 reaching this goal. The causes for this include the usual suspects of poverty, substance abuse, lack of access to health care, homophobia, stigma, etc. But, and back to my original premise, I have NEVER seen a true sense of urgency in the black community about HIV/AIDS. Oh sure, the Congressional Black Caucus has successfully fought for more money to address HIV in black and brown communities. Many black churches, civic and fraternal organizations have stepped up, and even a few celebrities have raised their voices (as well as money) for and about this epidemic. Our President has even released comprehensive HIV strategies, with specific objectives and time-frames. Nevertheless, we continue to get caught up in stereotyping and conspiracy theories that undermine the severity and urgency of this issue. I cringe when I read statistics about the terrible impact in black gay and bisexual men, because I know that gives our community more 'cover,' enabling us to bask in the warm waves of the delusion that HIV/AIDS is someone else's problem. We can no more stop HIV infection by building imaginary walls between ourselves and people who, well, are not 'like us' (gays and bisexuals), as we can stop terrorism and immigration by building brick and mortar walls. There is no simple solution to this. But, for starters, I suggest that we take the time to learn more about it. Something I hear over and over in my conversations about HIV/AIDS is that people don’t realize ‘how bad it is,’ despite the wealth of information available. I can't help but think about the words of two truly different, yet wise, black men. Chris Rock tells us (and I paraphrase) that books are like Kryptonite to black folks, and if you want to hide something from us, put it in a book. On a more serious note, President Obama, speaking to the 2016 graduating class at Rutgers University, said that “ignorance is not a virtue…It's not cool to not know what you are talking about. That's not keeping it real or telling it like it is. That's not challenging political correctness. That's just not knowing what you are talking about." Before we start dismissing HIV as only a “gay disease” or believing that there’s this secret cure for rich people, open a book or a suitable internet page (try the CDC.gov for starters) and begin to know what you are talking about.

"Kick and Kill"

The International AIDS Conference, this year in Melbourne, Australia, is one of the very few times that we can expect to read or hear about HIV in the regular media. For many years, the news was dominated by rising infections and mortality rates. However, the last few conferences have been dominated by new, promising results from studies that seem to confirm more and more that HIV is a manageable, chronic disease. Moreover, the "cure" word is also being tossed around quite often. For example, one recent study of six patients by Danish researchers seems to have taken a step towards addressing one of the more frustrating barriers towards curing HIV: the reservoirs of HIV that linger even after a person has an undetectable viral load. The researchers used the anti-cancer drug Romidepsin to activate the virus and bring it out of hiding. This potentially exposes the virus to the “killer” T-cells, which are responsible for attacking and eliminating pathogens in the blood stream but can’t detect the virus hidden in the CD4 cells. Unfortunately, in this study, even though the immune system detected the virus, it did not attack it. Nevertheless, the researchers are optimistic that in the next phase they can teach the immune system to recognize and clear these HIV cells. In closing, this study is indicative of the complexity of developing new therapies to combat or cure HIV. Yet, as we learn more about HIV, we get closer to that word, which decades ago seemed unrealistic, a cure.

Thank you Mr. Sterling

Strange title, eh? After all, why would I thank someone attributed to insensitive racial comments about African Americans in 2014? With an African American president, thousands of African Americans now listed among the elite, but elusive, top 1% (over a dozen of whom, by the way, who actually work for Mr Sterling) don't we now live in, as many idealistic pundits and scholars call it, a 'post racial' society? Well, this blog is not intended to thank him for reminding us that racism is alive and well. I am thanking Donald Sterling for getting HIV back in the news. Now, one would think that the greatest epidemic in modern history alone, would remain in the headlines by virtue of well, it being the greatest epidemic in modern history. Its amazing to think that 75 million total infections, over 36 million deaths and over 2.3 million new infections annually rarely makes the news. Nor is it the fundraising leadership of 'twinBill" of Bill Clinton and Bill Gates; or the dramatic breakthroughs in HIV treatment that have enabled millions to live longer, more productive lives; or even the tenacity of the advocates who have fought for access for these treatments. No, it takes the uniformed comments of an 80 year old man about one of the most iconic figures in the history of this epidemic, Magic Johnson, to justify front page news. So thank you, Mr Sterling for reminding us that HIV infection is not the same thing as AIDS and that people can LIVE with HIV. Thank you for reminding us that many people still blame the victim ( 32%- according a 2012 survey by the Kaiser Family Foundation). And last, but not least, thank you for reminding us that we still have a long way to go to reduce the crushing stigma still associated with HIV. The attention that you brought to this issue, misguided as it may have been, has produced the rare public 'teachable moment" that we HIV advocates and educators so often yearn for. Now, I guess we will just have to wait for the next major, public faux pas to get in the headlines again.