A few of the recent pieces I’ve found worth bookmarking about the Supreme Court’s Hobby Lobby decision:
Dahlia Lithwick and Sonja West at Slate: Quick Change Justice: While you were sleeping, Hobby Lobby just got so much worse
“To prove that the Affordable Care Act’s contraceptive mandate was not the “least restrictive alternative,” the court pointed to a workaround in the law for nonprofits: If there are religious objections to a medical treatment, third parties will provide coverage to the employees. Yet in an unsigned emergency order granted Thursday evening, the very same court said that this very same workaround it had just praised was also unconstitutional, that this workaround also burdened the religious freedom of religious employers. Overnight, the cure has become the disease. Having explicitly promised that Hobby Lobby would go no further than Hobby Lobby, the court went back on its word, then skipped town for the summer.”
Emily Badger at Wonkblog: The 49-page Supreme Court Hobby Lobby ruling mentioned women just 13 times
“The 49-page majority opinion mentions “women” or “woman” a mere 13 times (I’ve excluded footnotes and URLs here). It does not mention women’s well-being once. Ginsburg’s dissent, at 35 pages, mentions women (singular or plural) 43 times, their well-being four times.”
Ann Friedman at New York’s The Cut: What a Woman’s Choice Means to the Supreme Court and Social Conservatives
“This idea — that women can always find another way to get the coverage or care they need — underpins just about every recent restriction on women’s health. What’s another 24-hour mandatory abortion waiting period? To a woman who lives 25 miles from the nearest provider, it’s everything. What’s one more tweak to a law about the width of clinic doors? To a clinic that can’t afford to remodel, it’s everything. What’s a minor policy change that means you have to pay full price for that IUD? To a woman who makes $14 an hour, it’s everything.
Micah Schwartzman, Richard Schragger, and Nelson Tebbe at Slate: The New Law of Religion: Hobby Lobby rewrites religious-freedom law in ways that ignore everything that came before
“Monday’s decision in Hobby Lobby was unprecedented. Much of the commentary has focused on the Supreme Court’s decision to extend rights of religious free exercise to for-profit corporations. Hobby Lobby is for religion what Citizens United was for free speech—the corporatization of our basic liberties. But Hobby Lobby is also unprecedented in another, equally important way. For the first time, the court has interpreted a federal statute, the Religious Freedom Restoration Act (or RFRA), as affording more protection for religion than has ever been provided under the First Amendment. While some have read Hobby Lobby as a narrow statutory ruling, it is much more than that. The court has eviscerated decades of case law and, having done that, invites a new generation of challenges to federal laws, including those designed to protect civil rights.”
Irin Carmon for MSNBC: 5 myths about the Hobby Lobby case, debunked
“[Myth] #4: But the government can just pay.” This one comes right from the majority, which said the Obama administration had failed the test of finding the least restrictive means to accomplish its goal. Justice Samuel Alito, writing the majority opinion, suggested “the most straightforward way” of filling the gaps would be for “the government to assume the cost.” He doesn’t have to care that this is, under current political realities, laughable. Senate Democrats have said they’ll introduce a legislative fix to the gaps left by the Hobby Lobby decision, but no one seriously thinks such a bill would become law. There is an existing family-planning funding program for low-income women, Title X, and nearly all House Republicans have already voted to gut it. In the 2012 campaign, Mitt Romney promised he would kill the program altogether.”
Alex Wayne for Bloomberg News: High court worsens pain of Obamacare birth-control compromise
“The U.S. Supreme Court’s suggested work-around to provide and pay for employees’ birth-control coverage at businesses whose owners have religious objections hasn’t worked in practice, say the companies administering it.”
Crystalline silica, hydrofluoric acid and formaldehyde. Those are just three of the dozens of air toxic chemicals that oil companies have used thousands of times in southern California in just the past year.
The data has come to light thanks to new reporting rules adopted in 2013 by the South Coast Air Quality Management District, which now requires oil and gas well operators to disclose the chemicals they use in oil and gas operations. According to a recently released analysis of the first year’s worth of reported data, oil companies used 44 different air toxic chemicals more than 5,000 times in Los Angeles and Orange counties during the past 12 months. Crystalline silica, hydrofluoric acid and formaldehyde — all of which are considered harmful to human health — were among the most frequently used. Since reporting began in June 2013, companies have reported the use of more than 45 million pounds of air toxics at almost 500 fracking, acidizing and gravel packing operations in the two California counties. (Acidizing is the process of injecting a combination of acids and chemicals underground to clean a well or dissolve rock; gravel packing is a process of placing chemical-filled gravel into the well hole to act as a filter.)
“We understand the terrible health impacts caused by the chemicals being used to extract oil in Los Angeles and Orange counties,” said Angela Johnson Meszaros, general counsel at Physicians for Social Responsibility-Los Angeles, in a news release. “Given the massive volume of chemicals being used so close to where people live, work and go to school, there is significant likelihood that people will be harmed by these chemicals. We routinely see reports of leaks, accidents and injury associated with oil extraction.”
Physicians for Social Responsibility-Los Angeles, along with the Center for Biological Diversity, Communities for a Better Environment and the Center on Race, Poverty and the Environment, conducted the chemical data analysis. Here are just a few of the unsettling findings as well as some of the health risks associated with the chemicals.
According to the analysis, oil and gas well operators used:
• more than 25 million pounds of crystalline silica, which is known to be harmful to skin, eyes, respiratory system, immune system and kidneys;
• more than 166,000 pounds of methanol, an endocrine disruptor and developmental inhibitor;
• more than 32,000 pounds of formaldehyde, which is harmful to skin, eyes, sensory organs, brain and nervous systems, and reproductive system;
• more than 69,000 pounds of 2-butoxy ethanol, which is harmful to a number of organs and systems, and is linked to liver cancer and adrenal tumors; and
• more than 5 million pounds of hydrofluoric acid, which is harmful to the reproductive and cardiovascular systems and can cause genetic mutations.
Moreover, the analysis reported that about 265 fracking, acidizing and gravel packing events happened within 1,500 feet of at least one hospital, preschool or residence. Children and the elderly may be particularly susceptible to air toxics. The analysis states:
These air toxics, which can be emitted before, during and after well stimulation, are endangering the health of nearby residents. In Los Angeles, the AllenCo oil facility has been cited for multiple air emission violations. The pollution has been linked to nosebleeds, headaches, breathing trouble and nausea suffered by nearby residents, leading to hundreds of complaints to (the South Coast Air Quality Management District). After AllenCo was forced to halt operations, the Los Angeles Times revealed that reports of illnesses had diminished significantly. Whether or not well stimulation is used, oil and gas operations are responsible for emitting air toxics throughout the process.
While the numbers in the analysis are worrisome on their own, they probably don’t account for all the chemicals being released. The analysis reported that operators withheld information in 5,050 instances. In claiming that some of the disclosures would jeopardize trade secrets, the companies only submitted vague descriptions to the air quality agency, such as “lubricant” or “mixture.”
“The pervasive and persistent use of these chemicals threatens to contaminate local air quality and put communities’ health and safety at risk,” the analysis concluded. “The reporting requirements have proven the need for immediate action to protect the public.”
Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for more than a decade.
They wanted to keep these words secret:
“two” ….. “two miner operators” …….”worn by the miners. Both” …….“right miner” …….“left miner”
They are the phrases the Labor Department’s Mine Safety and Health Administration (MSHA) initially redacted from a document requested by Mine Safety and Health News (MSHNews). (You can see the before and after versions here.) It’s not only redaction overkill, but it’s made worse coming from the Administration that “pledged to make this the most transparent Administration in history.”
The document with the redacted terms is a citation issued in January 2014 to Armstrong Coal company for violations at its Parkway mine. The underground coal mine was the subject of a story written last month by HuffPost’s Dave Jamieson. Jamieson reported on the experience of two whistleblowers who alerted federal inspectors that their company was cheating when it collected air samples to measure respirable coal dust. Rather than assigning miners to wear the dust pumps, the company put the devices in a part of the mine far away from coal dust.
The cheating by coal operators on respirable dust sampling is nothing new. Back in the early 1990′s Republican Labor Secretary Lynn Martin said the coal mining industry was “addicted to cheating.” Ouch. But it’s not so easy to catch mine operators in the act. This time MSHA inspectors did and the Parkway mine got a citation for it.
Jamieson’s story piqued the interest of the Ellen Smith, the editor of MSHNews. She had a simple request: a copy of the citation related to the cheating. Smith could share with her readers the details of the mine operator’s deception. Getting those details from MSHA was not as easy as it should have been.
In the current edition of MSHNews, Smith reports on their effort to obtain an unredacted version of the citation.
“MSHNews‘ correspondent Kathy Snyder, along with Emily Grannis, an attorney with the Reporters’ Committee for Freedom of the Press, went to MSHA headquarters to demand an unredacted copy of the citation.”
“Under the 1977 Mine Act’s Section 104(h) ‘all records, information, reports, findings, citations, notices, orders, or decisions required or issued pursuant to or under this Act may be published from time to time, may be released to any interested person, and shall be made available for public inspection.”
Section 109 (b)(2) of the Mine Act also addresses disclosure of records:
Any “notice, order, citation, or decision shall be available for public inspection.”
In this case, MSHA ultimately agreed to provide an unredacted version of the citation. But it had to be pushed. In other words, they admitted their error.
This should mean that in future requests for citations, phrases like “two miner operators,” “right miner,” and “left miner” are not hidden under the ink of a black marker. It should mean that MSHA will follow the plain language of the Mine Act’s Sections 104(h) and 109 (b)(2).
But will it?
My hope is that the before and after versions of the Parkway mine citations cross the desks of Labor Secretary Tom Perez and Solicitor of Labor Patricia Smith, or at least the desk of MSHA chief Joe Main. They’ll surely see the redactions on the document as ridiculous. As the officials ultimately responsible for implementing President Obama’s policies, including his pledge to be “the most transparent Administration in history,” I hope they will take steps to fix the cause of their Department’s redaction overkill.
I doubt the Parkway mine citation example is an isolated incident. It’s just the one that appeared in print courtesy of MSHNews.
The U.S. Supreme Court released two big decisions yesterday. The first, which you’ve probably heard about, ruled that for-profit companies can deny female employees insurance coverage for birth control if it conflicts with their religious beliefs. (For more on the potential consequences of this outrageous and offensive decision, read this great piece in Slate. Also, since this is the Occupational Health News Roundup, it bears mentioning that in her dissent, Justice Ginsburg noted that the cost of an IUD is about a month’s full-time pay for a worker earning minimum wage.) But in addition to the Hobby Lobby decision, the court also ruled in Harris v. Quinn, which delivered a pretty significant blow to labor unions’ rights to collect fees from all workers who benefit from collective bargaining.
In a 5-4 decision, the court ruled that a group of Illinois home health care workers — the plaintiffs in the case — can’t be forced to pay fees to a union they didn’t wish to join, even if they benefit from the outcomes of collective bargaining negotiations. Also known as fair-share fees or agency fees, the fees are used to support the expensive process of negotiating on behalf hundreds or thousands of workers for better working conditions.
Basically, agency fees mean no one gets a free ride: If a majority of a workforce votes to unionize, non-union workers still reap the rewards of union representation and should bear their fair share of the costs that go along with collective bargaining. Illinois is among a number of states that requires public-sector workers, whether they decide to join the union or not, to pay fair-share fees. The workers who brought the case are a small group of home health aides who care for Medicaid patients and are part of a larger workforce that voted to unionize. As Ian Millhiser at Think Progress wrote, the workers did indeed benefit from the union’s efforts:
By any reasonable objective measure, the union struck a very good deal for Illinois’ home health aides. Before the union negotiated a collective bargaining agreement, the aides’ wages were just $7.00 an hour. Now they are $11.65 an hour, and they are scheduled to increase to $13.00 per hour in December. Nevertheless, the National Right to Work Legal Defense Foundation (NRWLDF), an anti-union litigation shop, found a handful of home health aides who object to this arrangement.
In describing why unions were holding their breath while awaiting the decision, Millhiser wrote:
If the Supreme Court complies with NRWLDF’s request to halt the non-union members’ fair-share payments, there will be little incentive for most workers to reimburse the union for the costs of collective bargaining — after all, why pay for higher wages when you can get them for free? Indeed, such a decision could set off a death spiral endangering the unions themselves. If non-members can suddenly stop paying agency fees, then unions will have to raise dues on their members in order to cover these losses. But, if unions raise their dues, more members will decide to drop out rather than pay the increased fees. Which will force even higher dues. Which will cause more members to drop out. Which will force even higher dues. The loss of agency fees potentially presents an existential threat to the union in Harris and to public sector unions across the country.
The majority of the court ruled that the workers in question weren’t full-blown government employees, but partial public employees and shouldn’t be subject to the same fair-share rules as other public workers, such as teachers or police. The health workers are paid by the state, but employed by the patients. It’s an unfortunate decision, but the one silver lining, observers say, is that the court didn’t completely overturn a previous decision from 1977 upholding fair-share fees for government employees. Still, Justice Kagan wrote in the dissent that the worker classification distinction is a bit far-fetched. She wrote:
A joint employer remains an employer, and here, as I have noted, Illinois kept authority over all workforce-wide terms of employment — the very issues most likely to be the subject of collective bargaining. The State thus should also retain the prerogative — as part of its effort to “ensure efficient and effective delivery of personal care services” — to require all employees to contribute fairly to their bargaining agent.
To read more about the court’s decision, read Millhiser’s article at Think Progress; Steven Greenhouse’s article in The New York Times; or this one from Michael Hiltzik in the Los Angeles Times. For a reaction from SEIU, the union that represents home health aides in Illinois, click here. And Mother Jones has a piece by Andy Kroll on four lawsuits that may be even worse for unions than Harris v. Quinn.
In other news:
Boston Globe: Last week, Massachusetts officially raised its minimum wage from $8 per hour to $11 by 2017, which means it’ll have the highest minimum wage of any state in the nation. Hourly wages for tipped workers will also go up from $2.63 to $3.75. The Massachusetts Coalition for Occupational Safety and Health noted that the legislation also “strengthens safety protections for workers, increases funeral benefits for families and makes permanent the multi-agency task force charged with combating the underground economy.” Here’s a handy chart from the Washington Post on nationwide minimum wage trends.
The Nation: Reporter Zoë Carpenter writes that low-wage workers might have a new ally in David Weil, who recently took over as the director of the Department of Labor’s Wage and Hour Division. Carpenter writes that “Weill is directing the bulk of his resources to targeted investigations in industries and sectors where labor exploitation is endemic.”
Houston Chronicle: Texas Republicans are pushing back against proposed legislation drafted in response to the West, Texas, fertilizer plant explosion, which killed 15 people. According to reporter Paul Weber, the lawmakers are complaining that the proposed regulations, such as requiring that ammonium nitrate be stored in noncombustible containers, are an economic burden for business owners.
News of recent worker deaths: Just a small handful of recent worker deaths that made the news include Jose Felix Obando, a construction worker who died after falling down a 12-foot hole in Sweetwater, Florida (Sun-Sentinel); Macario Santiago-Cruz, a Kentucky construction worker who died after falling 30 feet (Lexington Herald-Leader); and Sarmad Iskander, a Toronto construction worker who died after falling from the 28th floor of a condominium project (Toronto Star).
Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for more than a decade.
Last week’s White House Summit on Working Families – hosted by the White House Council on Women and Girls, the Department of Labor, and the Center for American Progress – served both as a pitch to employers to adopt more family-friendly policies, and as a push for policies that require all employers to evolve for 21st-century realities. Wages, paid leave, flexibility, and caregiving were major topics in the day-long event, and speaker after speaker returned to the same themes. I was honored to attend the event, and left it feeling hopeful that we’ll keep seeing improvements in workplace policies – perhaps first at the level of individual employers, cities and states (where we’ve already seen progress), and eventually at the federal level.
“No one in this country should work a full-time job and have to live in poverty,” said Secretary of Labor Thomas E. Perez, who has been pushing for an increase in the federal minimum wage. As for why more workers need access to paid sick, medical, and family leave, he told the crowd, “No one should have to choose between the job they need and the family they love.”
Neera Tanden, President of the Center for American Progress, described the way her boss’s flexibility helped her to balance work and family when her children were young – but, she noted, many US workers don’t have access to paid leave or flexible schedules. “I won the boss lottery, but you shouldn’t have to,” she told the audience.
Vice President Joe Biden picked up on that theme. He described how he struggled to balance his job as a US Senator with raising his sons after his wife and daughter were killed in a car crash. He told the crowd that he made 8,000 round trips between Washington, DC and Delaware so he could be home before his children went to bed, and that he skipped procedural votes to make it to parent-teacher conferences and his kids’ games and debates. It was hard for him and challenging for others like him – but, he noted “we’re the lucky ones,” with good salaries and some schedule flexibility. It’s even harder for those whose struggle to make their paychecks cover expenses and don’t have flexible schedules or paid leave.
Another theme that speakers echoed was the idea that the US economy has changed, but workplace policies have failed to keep up with the changes. Where it used to be the norm for households to have one breadwinner and one parent who stayed home and cared for children, that’s not a workable option for most US households today. (And, I’d add, many low-income households didn’t have that option even in the Leave it To Beaver days.) As the average lifespan increases, many households are also faced with responsibilities to care for aging parents and young children simultaneously.
In his remarks, President Obama also shared his family’s story of challenges in balancing jobs and family, and repeated that they still found it hard even though they were among the more fortunate workers. And then he said this, to cheers and thunderous applause:
And every day, I hear from parents all across the country. They are doing everything right — they are working hard, they are living responsibly, they are taking care of their children, they’re participating in their community — and these letters can be heartbreaking, because at the end of the day it doesn’t feel like they’re getting ahead. And all too often, it feels like they’re slipping behind. And a lot of the time, they end up blaming themselves thinking, if I just work a little harder — if I plan a little better, if I sleep a little bit less, if I stretch every dollar a little bit farther — maybe I can do it. And that thought may have crossed the minds of some of the folks here from time to time.
Part of the purpose of this summit is to make clear you’re not alone. Because here’s the thing: These problems are not typically the result of poor planning or too little diligence on the parts of moms or dads, and they cannot just be fixed by working harder or being an even better parent. All too often, they are the results of outdated policies and old ways of thinking. Family leave, childcare, workplace flexibility, a decent wage — these are not frills, they are basic needs. They shouldn’t be bonuses. They should be part of our bottom line as a society. That’s what we’re striving for.
The President noted that there are countries that have figured out how to do childcare well and affordably, suggesting we could follow their lead and make it so decent childcare doesn’t cost more than in-state college tuition (something that’s currently the case in 31 states). And, he noted, “Many women can’t even get a paid day off to give birth. Now, that’s a pretty low bar. You would think [that’s something] that we should be able to take care of.”
In her speech, Jill Biden – who is a community-college professor as well as wife of Vice President Biden – pointed out that employees can be more productive if they’re not worried about childcare or their aging parents. Several small-business owners or members of upper management at large corporations, described the productivity and loyalty they experienced from employees as a result of offering higher wages, paid leave, and flexible scheduling.
I was also delighted that Makini Howell, owner of Seattle’s Plum Bistro described the public-health motivation behind her decision to support the city’s paid-sick-leave law: “I don’t want to serve you a cheap contagious flu with your sweet potato fries.” She and other business representatives also noted that demonstrating trust in employees not to abuse sick-leave policies tends to inspire trustworthy behavior.
Speakers also addressed the ways that family-unfriendly workplaces can hurt the economy as a whole, as well as individual businesses. Senator Amy Klobuchar (D-MN) pointed out that 70% of the US economy is consumer-driven, and low wages hurt consumer spending. Betsey Stevenson, a member of President Obama’s Council of Economic Advisors, noted that when trained, educated workers drop out of the workforce because they can’t meet their families needs otherwise, that’s a big loss to our economy.
The workers who drop out of the workforce for caregiving purposes are most often women, but several speakers stressed that family-friendly policies help men, too, and that this is not a zero-sum game. Earlier in the month, a White House Summit on Working Fathers addressed this sometimes-overlooked topic; Scott Behson collected some of the memorable quotes from the event at his Fathers, Work and Family blog.
The event showcased large and small employers that have chosen to go above and beyond what the law requires (which, in the case of federal law, isn’t much), and offer their workers higher wages, paid leave, and the flexibility they need to balance job and family responsibilities. They spoke about “the business case” for family-friendly policies –or, what I imagine much of the rest of the world considers to be commonsense policies. Another route to higher wages and better leave policies is unionization; House Minority Leader Nancy Pelosi (D-CA) said in her panel discussion that no one has done more for equal pay than organized labor.
Even as speakers encouraged other businesses to adopt these high-road practices, there was also a recognition that we can’t just wait for all employers to follow suit, or for workplaces to become unionized – this is an urgent problem that needs policy solutions. Workers should have access to livable wages, paid leave, and flexibility even if they don’t “win the boss lottery.”
In addition to Secretary Perez’s call for a higher minimum wage, President Obama urged Congress to pass the Pregnant Workers Fairness Act, which would require employers to make reasonable accommodations for women with pregnancy-related medical needs, and the Paycheck Fairness Act, aimed at reducing the gender wage gap. In a session on caregiving, Nancy Duff Campbell of the National Women’s Law Center added a call for the Strong Start for America’s Children Act to increase access to affordable, high-quality childcare, preschool, and pre-kindergarten.
Two bills that I was surprised not to hear mentioned (although it’s possible they came up in breakout sessions) were the Healthy Families Act and the Family and Medical Leave Insurance Act (FAMILY Act). The Healthy Families Act would allow workers in businesses with 15 or more employees to earn up to seven days a year of paid sick time, while the FAMILY Act would set up a social-insurance system to enable workers, regardless of employer size or job tenure, to get a portion of their pay while taking medical or family leave for serious health conditions.
The Washington Post’s Zachary Goldfarb suggests a disturbing reason why President Obama isn’t endorsing the FAMILY Act: The proposed social-insurance system relies on an additional payroll tax of 0.2 percent to fund replacements of a portion of workers’ salaries when they’re taking medical or family leave. According to the National Partnership for Women and Families, a worker earning the US median wage would pay an extra $65 per year into the system; the figure would be higher for higher-income workers, but in any case it would be a very modest contribution in exchange for access to benefits that could mean the difference between paying the rent and getting evicted for those who need to take time off to address a serious health condition or care for a new child.
Goldfarb notes, though, that President Obama made a 2008 campaign pledge to not raise taxes on families earning less than $250,000, and the FAMILY Acy would entail a tax increase on all workers. It seems that it would be worth violating a campaign promise in order to pass a law that would do so much good for so many people – especially those living paycheck to paycheck. Maybe President Obama would have more to say on the subject if the law were to pick up more support in Congress.
With Congressional gridlock as the current norm, the real hope for change seems to be at the state and local levels – and perhaps national action will eventually follow. Cities and states across the country are considering, or have already passed, laws and ballot measure to raise wages and require employers to offer paid sick leave; Rhode Island recently became the third state (following California and New Jersey) to establish a social-insurance system for paid caregiver leave. A Center for American Progress poll conducted earlier this month found that 71% of respondents, including 62% of Republican respondents, support paid family leave for workers with a sick child or immediate family member.
In a conversation with Robin Roberts, First Lady Michelle Obama told the summit audience, “The numbers are on our side – more and more people are realizing that this is an issue for everybody.” Later, she said, “We have to help elected officials understand just how important these issues are.”
Ideally, everyone should be tested for HIV and in fact, federal guidelines introduced in 2006 recommend routine HIV screening for all patients. In reality, however, only about half of U.S. adults have ever been tested for HIV and about half of the 50,000 new infections that happen every year in the U.S. are transmitted by people who are unaware of their HIV status. Such statistics recently led a group of researchers to ask if there’s a more efficient way to go about curbing the HIV epidemic.
“We strongly support the concept of universal testing and treatment to limit or control the spread of HIV,” Susan Little, faculty in the Antiviral Research Center at the University of California-San Diego, told me. “The problem with that approach is that here in the U.S., despite having the greatest health care dollar resources available, we’re not universally testing or treating. …So if we have limited prevention dollars to spend, where might we focus our resources to have a much greater impact than if we used the same resources to try to reach everyone?”
Basically, Little and her colleagues asked this question: Instead of casting such a huge prevention net and hoping that people will fall in, could they shrink the net, attach a GPS unit to it and let it lead them to hotspots of high risk and greater preventive potential? They found that they could — and moreover, all the data they needed to do it was already available. Using the unique genetic HIV sequence from individual patients as a proverbial GPS device, the researchers were able to generate maps that pinpointed high-risk transmission networks that they hope can eventually direct prevention resources where they’ll have the greatest impact. Here’s how they did it.
Little and her fellow researchers, who published their methods and findings in the June issue of PLOS ONE, analyzed HIV sequence data among nearly 500 people recently infected with HIV as well as 170 of their sexual and social contacts in San Diego between 1996 and 2011. The sequencing data was already available and centralized as a result of testing HIV patients for antiretroviral drug resistance, which has become standard protocol in HIV care. Using the sequencing data, they pinpointed viruses from different individuals with a high degree of genetic similarity, which could suggest a transmission link. And from those links, they could map a network of HIV transmission and then model the likelihood of new HIV transmissions. (Little did caution, however, that viral similarity does not alone prove that a transmission occurred, only that the individuals are both part of a closely connected transmission network.)
“Not everyone who is HIV-infected is equally likely to transmit the infection to others,” Little said in a news release about the study. “There are clusters of more active disease transmission. We can use this information to target treatment interventions to those most likely to transmit the virus to others and markedly reduce the number of new infections.”
In mapping the networks, researchers were also able to map, in many cases, the direction of infection. When putting all the components together, researchers could measure the rate at which a network and sub-networks were growing and zero in on areas in the population in which HIV is spreading at a faster rate. Within a network, researchers then calculated a transmission network score that estimated the risk of transmission from a patient who is newly diagnosed to a new partner.
According to the study findings, high scores identified a group of patients who had significantly greater predicted risks of HIV transmission within their first year of living with the virus than patients with low scores. If put into clinical practice, the concept means clinicians could more precisely direct treatment and prevention education to patients at highest risk of transmission. Little and study co-authors Sergei Kosakovsky Pond, Christy Anderson, Jason Young, Joel Wertheim, Sanjay Mehta, Susanne May and Davey Smith write:
When adequately sampled, HIV-1 sequence analysis can help characterize local HIV epidemics. This network based study in San Diego, California, corroborated previous findings that higher (viral load) was associated with transmission risk and that early (antiretroviral treatment) decreased this risk. This study went further to identify that network connections at baseline also predicted future transmission risk, and prevention efforts targeted to these individuals may be a better use of prevention resources than random implementation or targeting individuals with higher number of sexual partners or recently diagnosed with a (sexually transmitted infection).
But wouldn’t genetically linking newly infected patients to other patients violate medical privacy? No, Little told me. Clinicians would only get back a transmission network score. It works like this: When a patient’s sample is sent to the lab to test for drug resistance, the lab could automatically search for sequencing similarities within its existing database, generate a score and relay only that score to the physician, who could then more precisely act to prevent further HIV infections. The doctor wouldn’t know how many similarities were found or whom their patient might have had sexual contact with — they’d just get a score.
That score would ideally be much more telling than the kind of information that a doctor would normally collect during a patient encounter. For example, Little told me, a patient who identifies only one sexual partner may be at low risk for transmission. However, sequencing data could reveal that the one partner has dozens of potential partners, which offers unique insight into an underlying transmission network of which even the initial patient is unaware. Little admitted that while labs may be nervous about linking sequencing similarities at the moment, the scoring technique is a strategy that wouldn’t first require a revision of medical privacy laws.
“These data are already available and we could start using it tomorrow,” she said. “But we do need to figure out answers to some important questions.”
In addition to ensuring that no one’s medical privacy is breached, Little and her colleagues also want to know how much of an impact the new information would really make. Finding patients at high risk of transmission is only one part of the prevention puzzle; getting high-risk patients to adhere to a treatment regimen and modify their risk behaviors is another. Little noted that while newly infected patients do tend to engage in immediate behavior changes, risky behaviors tend to resurface over time. Still, the mapping method is a promising approach to help clinicians as well as public health practitioners maximize their prevention resources.
“Some people might read the study and think ‘why are you targeting interventions when everyone should be treated’ and I completely agree with that,” Little told me. “This isn’t meant to say that we should be targeting certain individuals because that’s a better approach. It’s that the approach of universal testing and treatment has well-documented failures. …Until we develop better methods to endorse and get people to accept testing and treatment, we’re saying that if we really want to control the HIV epidemic, we may have the data we need to do that right now.”
According to the Centers for Disease Control and Prevention, about 1.1 million people in the U.S. were living with HIV as of 2010, and about 16 percent don’t know they’re infected.
To read the full HIV network study, visit PLOS ONE.
Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for more than a decade.