Half of Heart Attacks in U.S. HIV Group Are Rare Type 2

By Mark Mascolini

From TheBodyPRO.com

 

January 27, 2017

____________________________________________________________________________________ 

Half of all myocardial infarctions (MIs) in a large U.S. HIV cohort were type 2 MIs, which are rare in the general population. Sepsis, bacteremia and recent illicit drug use explained most type 2 MIs, and the type 2 group differed from the type 1 group in cardiovascular risk and certain demographics.

Much research indicates that MI rates are higher with than without HIV infection. But these studies usually rely on unadjudicated MI outcomes and do not distinguish between the two MI types. Type 1 MIs result from atherosclerotic plaque instability, while the much rarer type 2 MIs reflect a mismatch between oxygen demand and supply, for example, with severe hypotension.

CNICS Cohort investigators conducted this study to measure rates of type 1 and 2 MIs in this HIV population, to compare patients with type 1 and type 2 MIs and to identify causes of type 2 MIs. The analysis included CNICS members from six sites who had an MI between January 1996 and March 2014. Researchers retrospectively identified MIs by searching the CNICS data repository for clinical diagnoses or indicative coronary interventions. Two expert physician adjudicators reviewed relevant data to verify MI diagnosis, to assign MI type and to identify causes of type 2 MIs.

 Among 26,909 cohort members evaluated, 571 had an adjudicated MI (65% definite and 35% probable). The reviewers rated 283 MIs (49.6%) type 1 and 288 (50.4%) type 2. An additional 79 events did not meet MI criteria but represented severe atherosclerotic disease requiring a coronary intervention. Among patients with an adjudicated MI or intervention, 77% were men and median age stood at 49 years (interquartile range 43 to 55).

Compared with patients who had a type 1 MI, those with a type 2 MI included a higher proportion who were younger than 40 (16.3% versus 8.8%), women (28.1% versus 19.1%), African American (70.1% versus 43.1%), not receiving antiretroviral therapy (46.5% versus 25.1%) and with drug injecting as their HIV transmission risk (37.2% versus 21.5%). A higher proportion of type 2 patients had a latest CD4 count below 200 cells/mm3 (44.4% versus 26.0%), and a lower proportion had a viral load below 400 copies/mL (44.1% versus 59.9%). Mean total cholesterol was lower in the type 2 group (167 versus 190 mg/dL), as was mean low-density lipoprotein cholesterol (87 versus 108 mg/dL). The type 2 group was less likely to use a statin (19.4% versus 32.6%) or to smoke (40.3% versus 50.0%). Average 10-year Framingham risk score was lower among type 2 patients (8 versus 10). All of these differences were statistically significant.

The most frequent causes of type 2 MI were sepsis or bacteremia (34.7%), vasospasm due to use of cocaine or other illicit drugs (13.5%) and hypertensive emergencies (9.7%).

The researchers concluded that HIV-positive people with type 2 MIs had fewer traditional cardiovascular risk factors than those with type 1 MIs. But the type 2 group was younger and had more advanced HIV infection than the type 1 group. The investigators believe their results suggest that, in people with HIV infection, type 1 and 2 MIs "may represent distinct clinical entities that require different approaches to prevention and treatment, as noted in the general population." The 50% type 2 incidence in this HIV population far exceeds the 2% to 26% rate reported in the general population.

Mark Mascolini writes about HIV infection.


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Lessons Learned: Surviving the Holocaust as a Gay Man

Rudolf Brazda, who died six years ago, recounted his experiences surviving Buchenwald. Watch him tell his story as we honor International Holocaust Remembrance Day.

By Neal Broverman

 

January 27 2017 

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On January 27, the world honors the millions of victims of the Holocaust — the systematic murdering of Jews, disabled people, gypsies, Jehovah's Witnesses, and gays at the hands of Germany's Nazi regime during World War II.

German-born Rudolf Brazda was one of the gay men imprisoned in a Nazi concentration camp. After being arrested for homosexual behavior — illegal in Germany at the time, thanks to the infamous Paragraph 175 — he was sent to the Buchenwald camp, where he was regularly subjected to abuse. Brazda was able to survive thanks to his ability to adapt and the aid of a possibly gay SS officer who became "infatuated" with him. Brazda recounted his experiences at Buchenwald in a video made shortly before his death in 2011; watch it below. 

Read more here about Brazda, who eventually settled in France with his partner and outlived nearly all his Nazi captors.

Rudolf Brazda, last of the Pink Triangles... by EugeneOcie

Read more articles from the Advocate, here. 
 

Misconceptions About Nicotine Among People Living with HIV

Leah Mangini, 2017 PharmD candidate, 

the University of Connecticut School of Pharmacy

 

 JANUARY 26, 2017

 

 

____________________________________________________________________________________ 

 

 

Limiting nicotine content in tobacco products can reduce dependence and overall tobacco use, and may subsequently reduce morbidity and mortality. However, the success of such measures is limited by the public’s misperceptions about nicotine's safety. Researchers at Johns Hopkins University investigated knowledge of smoking and nicotine among HIV-positive smokers in a study published online in Addictive Behaviors.

Current smokers living with HIV completed an online survey regarding demographics, tobacco use, and knowledge about smoking and nicotine. Of those surveyed, the majority were light smokers—defined as those who do not smoke daily—and nicotine dependence was low.

A majority correctly identified the chemicals in cigarette smoke, and also recognized nicotine as the addictive component. The authors noted that public health efforts to educate consumers about the dangers of smoking are working, as evidenced by the number of correct responses to their survey.

However, most participants incorrectly identified nicotine as the cause of smoking-related cancers and other morbidities. Lack of differentiation between nicotine's effects and tobacco smoke in public health campaigns may be to blame for this confusion.

The belief that nicotine is the harmful component may have repercussions. It may lead smokers to perceive that products with reduced nicotine levels are safe, create a reduced urge to quit among smokers, or even encourage former smokers to resume smoking.  This misconception may even limit the success of nicotine reduction policies.

Income, education level, and cigarettes per day did not consistently correlate with knowledge the way the authors expected. For example, neither greater education nor higher income positively correlated with knowledge. The researchers concluded that additional research is needed to elucidate these associations.

Because most people living with HIV have regular contact with the medical system, ample opportunity for screening and education about smoking cessation exists. The authors called for clarification on tobacco product labels and in educational materials about the relative harm of nicotine replacement and nicotine reduction.

Reference

Pacek LR, Rass O, Johnson MW. Knowledge about nicotine among HIV-positive
smokers: Implications for tobacco regulatory science policy. Addict Behav. 2017; doi: 10.1016/j.addbeh.2016.10.008. PubMed PMID: 27792909; PubMed
Central PMCID: PMC5140741.

 

Read more articles from Pharmacy Times, here.

Flawed herpes testing leads to many false positives — and needless suffering

CDC - Various viruses from the herpes family seen using an electron microscope.

By Lindzi Wessel

January 26, 2017

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Herpes is a lifelong infection, but Lauren had it only for six tumultuous months. Or rather, she believed she did, after a request for sexually transmitted disease testing returned a positive result. But after weeks of Googling, chatting with members of online herpes forums, and reading scientific papers, she asked for a different test, which eventually confirmed her suspicion — her herpes diagnosis was wrong.

In the six months that passed between the tests, the mistake led her to keep a romance at bay and left her anxiously patrolling her health.“Every tingle I would get in my leg or any kind of itch down there would just set me off,” sending her into a new flurry of research, she said. “And that was just to try to calm my own anxiety, but it would only really make it worse.”

Genital herpes, predominantly caused by herpes simplex virus type 2, is a sexually transmitted disease that’s very common — 1 in 6 people aged 14 to 49 in the United States have HSV-2, and this number goes up with age. Most of these people, however, don’t have obvious symptoms and wouldn’t know they were carriers without blood tests.

But blood tests can be highly unreliable. The kind of test used to diagnose Lauren, an IgM test, has long been rejected by the Centers for Disease Control and Prevention but is still used by some clinicians. Meanwhile, the CDC and the US Preventive Services Task Force concur that the most widely available herpes test, called HerpeSelect, should not be used to screen asymptomatic people because of its high risk of false positives: Up to 1 in 2 positive tests could be false, according to the USPSTF’s most recent guidelines.

That high failure rate isn’t, however, always communicated to patients. Online forums abound with stories like Lauren’s, of people who request herpes tests alongside those of other STDs and are shellshocked by the results. Some doctors discourage the testing or simply don’t include it in a standard STD panel without having the conversation. But no data exists on herpes screening rates, according to Kimberly Workowski, lead author of the CDC’s STD treatment guidelines — so it’s difficult to say how many people could be living with the misdiagnosis.

CDC - A micrograph of herpes simplex virus in a Tzanck test specimen.

Testing pitfalls

Next to the meandering waterways connecting Puget Sound to Seattle’s Lake Washington is the only laboratory in the world that offers to the public the Western blot, the gold standard test for herpes. The University of Washington Clinical Virology Laboratory provides the test to patients across the country, a practice it began over a decade ago when it realized the more common tests were prone to false positives.

The problem, said Christine Johnston, a physician and researcher at the lab, is “low-positive” results of antibodies to HSV-2. The cutoff for a positive result on the HerpeSelect test, manufactured by Quest Diagnostics, is 1.1. A 2005 study published in the journal BioMed Central Infectious Disease found that index values above 3.5 yielded over 90 percent accuracy — but scores between 1.1 and 3.5 had around a 50 percent chance of being wrong.

What’s more, scores falling just above the 1.1 cutoff had an almost 90 percent chance of being wrong.

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When tests fall between 1.1 and 3.5, more testing is necessary, said Johnston. This recommendation is also noted in the 2015 CDC Sexually Transmitted Diseases Treatment Guidelines. But some patients will never be referred for a second test.

“I think most clinicians are unaware and perhaps labs don’t have this available and/or it is not straightforward to order,” Johnston said of second-step tests.

But while her facility’s Western blot is considered highly accurate, it is expensive and cumbersome to perform. Each test costs over $200 and the University of Washington is the only lab that provides it.

Other confirmatory tests also exist, for instance Biokit’s HSV-2 Rapid Test and Quest’s own HSV-2 IgG Inhibition assay. The latter, which adds only $4 to the price of the HerpeSelect test, performed well in a study conducted over a decade ago. Rick Pesano, the medical director for infectious disease at Quest, believes that with more awareness, the test could stand in for the Western blot. But the test was not mentioned in the USPSTF guidelines because it still has not been evaluated in asymptomatic individuals, according to Cindy Feltner, associate director of the RTI-UNC Evidence-based Practice Center, who helped prepare the science review for USPSTF.
“We need better diagnostic testing. That is where we are stuck at this point,” said Johnston. “We don’t have a good test that’s inexpensive, high throughput, and reliable.”

Finding out the hard way

No good data exist on how often patients with questionable positive results are actually re-tested. Until the 2015 update, CDC herpes testing guidelines had no mention of confirmatory testing for low-positive results, said Johnston. So patients often discovered the option not through their doctors, but through searching the web and reading online herpes forums.

That was the experience of Bryan, a 40-year-old man who lives in Indiana, who wrongly believed he had herpes for about two months in 2011. The misunderstanding actually put him at higher risk, he said: During those months he considered joining the hundreds of thousands of Americans on dating sites for herpes-positive people. Exclusively dating people with herpes would have increased his likelihood of contracting the virus.

The experience of YT, a 33-year-old mom who has suffered from frequent herpes symptoms over the last year, shows another side of the testing breakdown. She believes she was given HSV by a partner who didn’t realize herpes wasn’t included in his previous STD tests, she told STAT.

Having herpes has caused her significant emotional trauma, and has driven her to permanently swear off dating. Had her partner known his true status, she wonders if her story would have been different.

These kinds of stories come out in anguished postings on internet forums and in dozens of confused calls to the UW lab each week, where research coordinator Matt Seymour says some desperate patients call over and over again, unable to get the answers they need from their doctors.

“People call and say, ‘I just don’t know what’s going on,’” he said. “We’ve almost become de facto counselors.”

CDC - Transmission electron microscope scan of cytomegalovirus particles.

In the absence of answers

Herpes tests aren’t the only ones with a risk of false positive results. False positives can occur for any test that diagnoses viral infection based on antibodies, i.e., your body’s immune reaction, rather than direct detection of the virus. For similar diagnostics like HIV and hepatitis C testing, protocols automatically call for a second test that directly detects the virus whenever an antibody test comes back positive, said Paul Swenson, laboratory director in the department of public health of King County, Washington. Herpes, however, is a particularly challenging infection to directly test for, because the virus spends most of its time hiding in nerves. Swab tests can sometimes detect the virus during outbreaks, but this isn’t an option for people without symptoms. Thus even the Western blot relies on antibodies, and may give indeterminate results to a small number of people.

But two steps of antibody testing are still more reliable than one step; today’s diagnostics for Lyme disease and syphilis are a two-step antibody testing approach, said Dr. Edward Hook, a medical epidemiologist specializing in STI screening and prevention at the University of Alabama, Birmingham, who questioned why such a standardized two-step approach hasn’t taken firm hold for herpes.

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“Some research has shown that two-step testing … might improve the specificity — that is avoid false positive results for the blood test — which would be a great thing because these diagnoses create great anxiety and concern for people,” he said. In a commentary accompanying the USPSTF guidelines, Hook expressed disappointment that herpes testing had barely improved over the past decade.

“There is no perfect test but there are ways to reduce the inaccuracies and reduce the number of equivocal results and those are actively used in other diseases,” he said in an interview with STAT. “But they haven’t been used very aggressively for the purpose of herpes.”

In the absence of sure-fire test advances, education and a lessening stigma surrounding herpes might help, not only by reducing test-related confusion, but potentially by bringing discussion of the virus out into the mainstream, said Hook.

“There’s no major herpes advocacy group,” he said. “People call attention to diseases that they suffer from, but people with herpes don’t feel they can call attention to it. And that creates a lot of suffering.”

 Read more articles from STAT, here.

Waiter Says Customer Called Him A 'Faggot' Instead Of Leaving A Tip

Instinct Staff | January 27, 2017

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Just awful!

A Louisville man who works as a waiter at a local sports bar says that a recent customer left him a nasty, hateful message, in lieu of a tip. 

Kyle Griffith, who works at Buffalo Wild Wings, prides himself upon giving quality service to all of his customers. 

Which is why it came of a shock to him to encounter two surly young women.

"I ended up cashing them out, gave them boxes, told them if they needed anything else before they headed out to let me know,” Griffith said to WDRB

Griffith did not observe anything out of the ordinary until he picked up their check. 

"And it said 'Sorry I don't tip f*****s,' and then said '#UNeedJesus,' and it just crushed me that someone could say something like that.”

Distraught, the young man explained:

"I depend on those tips to be able to pay my bills and everything else ... to live, to eat, everything,” 

Griffith shared a photo of the receipt to his Facebook page, but obscured the customer's name, indicating that he wanted to call attention to her message, not her identity. 

"I woke up the next day and saw that it was being shared a whole lot more than I ever thought it would.”

He added: 

"I want to be able to tell everyone that this is not a lie, that this is truth, this is an everyday happening,” he said. ”It's an occurrence that ... can't happen any longer. It's got to stop. The hate has to stop. There's no reason for it." 

In response to the incident, Buffalo Wild Wings issued the following statement:

“We’re disappointed to learn about the comment left on a receipt by a Guest at one of our independently owned franchise locations in Louisville recently. Because Buffalo Wild Wings is about creating a great guest experience, we feel strongly that our restaurant environment needs to be respectful in order to provide the experience that our Guests and Team Members expect and deserve.“

Griffith said that he did eventually get an apology from the rude customer.

"She did apologize and said that it was a joke and that it shouldn't have been a joke and that she felt bad for it,” he said. "It's not something you should joke about. My sexual preference at all shouldn't be something someone should joke about."

 

WDRB 41 Louisville News

Read more articles from Instinct, here.

‘Not Turning Back’: California Governor Vows To Protect State’s Health Care

By Pauline Bartolone January 25, 2017

Michelle Sherman

January 26, 2017

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In an unusually impassioned speech, Gov. Jerry Brown vowed Tuesday to protect California’s health care gains under Obamacare against Republican attempts in Washington, D.C., to roll them back.

“More than any other state, California has embraced the Affordable Care Act,” Brown told state legislators and appointees in his annual State of the State address at California’s Capitol. “I intend to join with other Governors and Senators, and with you, to do everything we can to protect the health care of our people.”

Brown said California would not “turn back” on advances it’s made in health coverage under pressure from the new Republican administration in Washington. Under the new federal leadership, he said, the “future is uncertain and dangers abound.”

Health coverage for Californians under the Affordable Care Act “has come with tens of billions of dollars from the federal government,” said Brown. “Were any of that were to be taken away, our state budget would be directly affected, possibly even devastated.”

Leveraging an estimated nearly $20 billion federal money, health coverage has been extended to five million Californians under Obamacare, which includes federally subsidized private health plans and an expansion of eligibility for Medicaid, the program for low-income people — known in this state as Medi-Cal.

Brown received cheers and several standing ovations from legislators during his speech, an address intended to set the state’s policy-making tone for the year. The 78-year old governor was visibly energized during his 16-minute speech, often speaking in an emphatic, defiant tone. While also emphasizing renewable energy initiatives and an inclusive immigration policy, Brown veered off script to voice support for women’s reproductive health care.

“We’re going to fight for Planned Parenthood, which has been unfairly attacked in too many places in this country,” he said.

Health care advocates quickly piped up on Twitter and in press releases to support the governor, saying he is rightly alarmed at the threat of losing billions of federal dollars not just from the repeal of the Affordable Care Act, but also under Congressional proposals to change Medicaid into a state block grant program.

“We look forward to working with [Governor Brown] to fight for our health in Congress,” Anthony Wright, executive director of Health Access, said in a statement.

Kieryn Darkwater, a young transgender person of color, praised the speech on Twitter, saying it provided reassurance that California is a safe place for immigrants and others who are “marginalized.”

“I deeply appreciated that he spent so much time talking about the issues of health care and protections for our communities,” Darkwater, an Oakland-based activist, artist and programmer said via email to California Healthline.

Darkwater is enrolled in Medi-Cal, which covers much-needed mental health medications and gender transition hormone treatments.

“Medi-Cal is currently keeping me both alive and able to stay afloat financially,” Darkwater said.

Assemblymember Rob Bonta, D-Oakland, the former chairman of the Assembly Health Committee, tweeted that he was proud Brown “came out swinging in strong defense of health, immigrants, [and] science.”

Even some state Republicans responded favorably to Brown’s call for bipartisanship.

Senate Republican Leader Jean Fuller, R-Bakersfield, said reaching across party lines is especially important to build bridges with national policymakers.

“Working with Washington should emulate the bipartisan successes we have had in our state,” Fuller wrote in a statement.

Covered California, the state’s Obamacare insurance exchange, reported strong enrollment numbers today despite uncertainty surrounding a possible repeal of the health reform law. 

Officials said 320,000 Californians have signed up in the subsidized marketplace since November, roughly on par with last year’s enrollment over the same time period.

Read more articles from HIVTHRIVE, here.

 

Tackling Patients’ Social Problems Can Cut Health Costs

By Sarah Varney January 23, 2017

Michelle Sherman

January 24, 2017

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HOUSTON — Donning a protective gown, rubber gloves and a face mask, Dayna Gurley looks like she’s heading into surgery. But Gurley is a medical social worker charged with figuring out why her client, a man who uses more health care services than almost anyone else in Houston, has been in three different hospitals in the last month.

The patient, who asked not to be identified, has chronic massive ulcers, AIDS and auditory hallucinations. He rents a cot in another person’s home but is more often homeless, with no family to help him.

“It’s almost like self-sabotage,” Gurley said about her many attempts to steady her client’s life. “We get really close to an important doctor’s appointment or getting him connected with stable housing, and his impulsiveness gets in the way of that.”

Patients like the Houston man are health care’s so-called “super-utilizers”— people with complex problems who frequent emergency rooms for ailments more aptly handled by primary care doctors and social workers. They cost public and private insurers dearly — making up just five percent of the U.S. population, but accounting for 50 percent of health care spending.

As health care costs continue to rise, hospitals and doctors are trying to figure out how to find these patients and get to the root of their problems. 

An effort to do just that started in New Jersey’s poorest city, Camden, more than a decade ago. Inspired by the way police departments mapped crime data to detect “hot spots,” family physician Dr. Jeffrey Brenner dug into ambulance records and emergency department data to show how high-cost patients were shuttling between city hospitals.
 
“In America, we’re medicalizing social problems and we’re criminalizing social problems, and we’re wasting huge amounts of public resources,” Brenner said. “We have the wrong tools to solve the wrong problem.”

To steer patients away from expensive emergency care and push health systems to change the way they do business, the Affordable Care Act funds programs called Accountable Care Organizations. These are networks of hospitals, physicians and others who team up to improve care, lower costs and reap the savings.

Jeffrey Brenner has sought to change the way the

health care industry treats people with complex problems.

(Sarah Varney/KHN/PBS Newshour)

Brenner’s team at the Camden Coalition includes Latonya Oliver and Bill Nice, social workers who seek out patients like Peter Bowser in local neighborhoods. Bowser was once homeless and went to the emergency department nearly 30 times in one year.
 

But after Oliver and Nice helped get a permanent roof over his head, Bowser’s trips to the ER all but stopped.

“I think you’d prefer to spend your time here than in the hospital any day of the week,” Nice said to Bowser on a recent afternoon, gathered at the kitchen table in his tidy apartment.

This high touch, data-driven approach has yielded big savings. ER visits for the first group of patients dropped by 40 percent, cutting monthly hospital bills from $1.2 million dollars to $500,000.
Since then, Brenner has sought to spread the model around the country. One example is the Patient Care Intervention Center in Houston, a sprawling city desperate to aid its sickest and most isolated patients.

While the more than 100 hospitals here typically know their own super-utilizers, they had no way of knowing the top users across the entire city.

This story also ran on PBS NewsHour. It can be republished for free (details). 

 Tackling that problem took unprecedented planning among typically disjointed city and county agencies, hospitals and nonprofits. Now, many of the hospitals in Houston and the fire department pool their data and send it to Kallol Mahata, a former oil industry IT engineer with the patient care intervention center who combines it into one database.

Mahata and Dr. David Buck, the group’s founder, help to identify patients at the top of the list—the outliers of the outliers.

Teams are dispatched to parks and neighborhoods to find the patients.

Firefighters and paramedics like Thomas Pierrel often know these residents from 911 calls. But this time, their mission is different: to encourage them to enroll in the volunteer program.

Inside one super-utilizer’s threadbare home, Pierrel makes his pitch. “We go with you to your doctors, we make appointments, we find specialists. We try to maximize the resources that you have,” he tells the prospective client.

The results of these intensive interventions can be stunning.

Timmy Williams was dying when Dayna Gurley found him.

He was holed up at home and reeling from untreated HIV that had progressed to AIDS. He couldn’t take care of his young son and cycled through Houston’s hospitals.

“When we first met Timmy, he was very hard to engage,” Gurley recalled. “We knew that he probably was not taking any of his medication, and he was very skinny.”

Timmy Williams says his illness no longer gets in

 the way of being the father he wants to be.

 (Sarah Varney/KHN/PBS Newshour)

She arranged for a home aide to care for Williams seven days a week, got his apartment cleaned and the lights turned back on.

Now, Williams’ HIV is undetectable and his health — and life — have been steadied.


In the two years since Houston’s Patient Care Intervention Center has been up and running, costs for those in the program have gone down 83 percent and hospital visits by 70 percent.

But it can be difficult to keep these programs moving. Often insurance companies and government payers reap those savings, rather than hospitals. Buck and Dayna Gurley were once banned from a Houston hospital whose executives feared losing money if their high-cost patients stopped showing up.

“Nobody wants to take ownership of any of it,” said Buck, his voice bristling with frustration. “The people just want ownership of what they have authority over, and that’s really the issue: each of these areas are little fiefdoms.”

Back in Camden, even Brenner is less optimistic than he once was. His office now overflows with pillows and kitchenware for clients the Camden Coalition is trying to place in housing. And he thinks homelessness and entrenched financial interests in health care are the biggest barriers.

“I think this is going to take a lot longer than I ever imagined,” he said. “I think we’re in a 20-year arc of recalibrating and rethinking what is health and what’s health care? What’s the purpose of our health care system? What are we trying to accomplish?”

But Brenner still believes these intensive efforts are the best way to help patients like Timmy Williams. He’s now healthy enough to make his way around the city on his own, says Gurley, and her super-utilizer team did more than rescue him from his darkest days.

“I had to put it in my head that no one is going do it for me,” he said. “I have to do it for myself. I have to step out and do it myself.”

At home now with his son, his illness no longer gets in the way of being the father he wants to be.

But it’s unclear how these efforts will be affected by a Trump administration, which along with congressional Republicans wants to repeal the health law.

PBS NewsHour producer Jason Kane contributed to this report.

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

Read more articles from HIVTHRIVE, here.