How CROI 2015 Restored My Hope

Michael C. Webb, Jr. serves as a Prevention Supervisor for Legacy Community Health Services’ Public Health Department. As prevention supervisor, Michael oversees daily operations of HIV/STD prevention and empowerment outreach activities for Legacy’s mPowerment program, a program that focuses on empowering young gay/bi men of color.

Michael is one of the participants in a pilot program for community delegates at CROI. In addition to the CROI Community Educator Scholarship Program, AVAC and the Black AIDS Institute—with support from the CROI Community Liaison Subcommittee—supported a pilot program providing an opportunity for additional community reps to attend the meeting. For more such updates from CROI, visit here.

When I applied to be a Community Educator Scholar for CROI 2015 I was starting to lose hope that we could ever defeat HIV/AIDS within Black MSM communities and I was desperately seeking help and inspiration. As prevention supervisor at Legacy Community Health Services, I am still relatively new in this field but during my tenure I am witnessing the alarming increase in HIV infections within Black MSM in Houston, Texas. This reality combined with my own HIV positive journey paints a picture of courageous resilience within our most underserved communities but also highlights the necessity of immediate action. CROI 2015 has given me invaluable hope that HIV/AIDS within Black MSM communities can be defeated if we are courageous and strategically take advantage of all the tools we now have at our disposal.

As commonly agreed upon, we now have the tools that could accomplish and AIDS free generation and get us to zero (zero new infections, zero discrimination, and zero HIV/AIDS related deaths). PrEP, or Pre-Exposure Prophylaxis in the form of Truvada, has received an extensive amount of attention by researchers attending CROI 2015 and the universal conclusions were that our fears on how PrEP works in the real world were unfounded. Based off the research presented, PrEP does not encourage a change in sexual behavior practices or increase “risky behavior,” PrEP adherence has not been a major issue, and there has been minimal Truvada resistance for participants who seroconverts to an HIV positive status.

This game changing research now puts the responsibility of preventing new HIV infections in our hands. It can be argued that with these facts, it is our moral obligation as public health advocates to make this new weapon against HIV/AIDs widely available to communities in the most need. This means making PrEP accessible within our community health centers, advocating for policy developments that increase funding for PrEP access for the economically disadvantaged, and creating coalitions that actively feeds the community and policy makers with accurate information on PrEP. When we comprehensively integrate PrEP into our HIV/AIDS prevention toolkit the possibility of getting to zero new infections can become a much needed reality.

CROI 2015 also highlights the lack of research within our transgender communities even though there is common speculation that transgender women are the hardest hit by HIV/AIDS, with some projecting a positivity rate above 40 percent. If we sincerely want to progress social justice for transgender communities then we must be willing to evolve our social structures, which include intentional research within transgender communities.

I have never left a conference more inspired to tackle this epidemic, prepared with plans derived from the research and facts. Nevertheless, we must ensure that we are not leaving our transgender brothers and sisters behind in this fight. I now confidently believe that if we utilize this approach and information effectively across the nation, our dream of an AIDS free generation can become our reality.

Essential Power(ful) Points from CROI: Community Delegates’ Blogs

Don’t miss the rich, varied, thoughtful and opinionated blogs that have been written by advocates and activists working on the frontline of the AIDS epidemic in the US and globally. These blogs were written by delegates participating in a pilot program that launched at this year’s CROI conference and is in addition to the addition to the CROI Community Educator Scholarship Program.

For this program, AVAC and the Black AIDS Institute—with support from the CROI Community Liaison Subcommittee—provided an opportunity for additional community representatives to attend the meeting. Delegates were mentored and supported with supplemental programming to help translate big science into accessible language for our communities.

Links to the blogs posted so far are below—and more will be posted in the coming days!

Cardiovascular Disease in HIV Patients: An Emerging Paradigm and Call to Action

Jeffrey Pope is an advocate, community educator, and pro bono consultant for MAACA, Inc. living in Tallahassee, Florida and attended CROI in association with the AVAC/Black AIDS Institute initiative.

At CROI 2015 we heard a lot about intermittent use of PrEP, PrEP on demand and vaginal microbicides. However, there is still the issue of HIV and cardiovascular disease which has been with us for decades and still the need for research.

It should be noted that there was an early association of antiretroviral therapy with cardiovascular disease. However, in a presentation by Steven Grinspoon, Cardiovascular Disease in HIV Patients: An Emerging Paradigm and Call to Action, he argued that perhaps there are beneficial aspects on cardiovascular disease related to antiretroviral therapy that must be comingled and adjusted according to the end effects.

The researcher presented current challenges in preventing, treating and identifying patients with HIV related CVD:

Understanding and timing of the use of antiretroviral therapies to maximize effects on immune function and minimize metabolic effects.

Developing safe and effective strategies for primary prevention of cardiovascular disease while still at subclinical levels.

Developing interventions that address both traditional and immune related risk.

Developing successful strategies for lower income countries with burgeoning and intersection in epidemics of HIV and cardiovascular disease.

Do Communities Have to Concern Themselves with Basic Science?

This post was written by Morenike Folayan, Coordinator of the New HIV Vaccine and Microbicide Advocacy Society and member of the CROI Community Liaison Subcommittee.

Once again, I sat intrigued by the science discussed at the CROI conference. I wonder at the ‘magic’ of unraveling gene sequences and other molecular research and how the scientists find these things out. But I also see that by listening to them each year, I kind of get the gist of what they say.

On the 23rd of February 2015, I listened to Guido Silvestri who spoke about animal models and HIV prevention cure research. I learned about the types of animals used for HIV prevention studies.

As many of us may know, animal studies are required prior to testing of study products in humans. This is known as the pre-clinical trials. Many times, the pre-clinical trials are conduct in both small (rodents) and big (non-rodents) animal models.

For HIV research, the big animal model—non-human primates—had always been used for studying HIV infection. These include the Macaque monkey and the Rhesus Monkey. They are highly genetically similar to humans. They are also able to acquire SIV, which is similar to HIV infection in some ways but not in all ways.

(Editor’s Note: For as long as non-human primates have been used in HIV research, there have been discussions about what the model can and cannot do. Efficacy in monkeys doesn’t predict protection in humans; lack of efficacy may or may not signal that product isn’t worth moving forward—for any given “go/no go” decision on moving a product from animals to clinical trials in humans, there may be strong opinions on all sides.)

More recently, rodents are now been used for HIV research. These are humanised mice. They carry functioning human genes, cells, tissue and or organs. It is therefore possible to study the how HIV interacts with human tissues using mice.

These humanised mice could be BLT humanised mice (they have the most functional immune system) or PMBC-humanised mice (which allows for short term studies of human T cells without having to wait for maturation of the T cells).

Interestingly however are the small animal models that are used for HIV research are humanised mice. For one, there is a lot to learn about curing HIV infection through the use of humanised mice.

Do communities have to concern themselves with animal studies? I think we do. Some of us may need to learn about these basic research issues, learn about the animal models used for HIV research and question their appropriateness and the interpretation of the results generated from these studies. Doing this may further stretch our work as community monitors of HIV prevention research. I think this stretch is in the right direction.

Does Sex Have Impact on HIV Prevention Research?

This post was written by Morenike Folayan, Coordinator of the New HIV Vaccine and Microbicide Advocacy Society and member of the CROI Community Liaison Subcommittee.

At the CROI meeting, I seem to be getting signals that sex significantly impacts HIV research design, data interpretation and data use.

First, I learned that availability of tenofovir, the drug used for pre-exposure prophylaxis (PrEP), is 10 to 100 times lower in the vagina tissues than the rectal tissues when taken orally. This therefore implies that the results of PrEP studies conducted to assess HIV transmission through anal sex cannot be automatically translated to imply the results would be pan out the same way when considering vaginal sex. Hmmmm.

Second, I also learned, through informal conversation with those who work in the field for ARV studies, that the reasons many HIV positive men decide to commence ARV use for HIV prevention (treatment as prevention, or TasP) differ from the reasons why women do commence TasP. More men commence TasP out of a sense of protection of their sexual partner—they have a higher sense of responsibility to protect their sexual partner from getting infected. Women on the other hand, commence the use of TasP simply because they are eligible to use the product. I found that very interesting. I think there may be cultural differences in this observation. I doubt if this is the case in Africa. However, like the lessons we learn from CROI, we need evidence. I would like to see a formal study evaluate this social context of TasP use by men and women in different cultural setting.

Third, the iPrEx OLE study showed increase uptake of, and adherence to, PrEP by MSM who were at high risk for HIV infection. In the VOICE study, we see less uptake and adherence by women who were at high risk of HIV infection. Hmmm. Are we starting to see differences in cultural perception of risk or is this truly a sex difference in risk perception?

(Editor’s note: In iPrEx OLE, participants knew that they were being offered an effective prevention tool—it was an open label study; in VOICE, women were counseled that they might be receiving a placebo and that none of the strategies were proven. Understanding how context—research site, clinic, public health program or community center—affects uptake and risk perception is also key.)

Reason for more studies on sex differences in PrEP and TasP use. Maybe conducting studies with transgenders may help address this question. Maybe.

CROI Through a Pharmacist’s Perspective

William Larson is an HIV medication adherence pharmacist working in Minneapolis, MN as part of the Ryan White program. He strives to increase HIV treatment literacy in disproportionately impacted communities. He is a graduate of the Black AIDS Institute’s Community Mobilization College in 2013.

Last week I attended CROI 2015 as a community educator scholarship recipient from CROI, in association with the Black AIDS institute and AVAC. It has been a rare opportunity to hear first-hand live presentations of new research by leading HIV researchers.

I got to meet several of the researchers at breakfast updates for scholarship recipients. What an opportunity! I was impressed by the researchers’ approachability and willingness to answer questions.

I was also impressed by the committed and knowledgeable scholarship recipients, all of whom are eager to better understand the new research so that they could bring the information back to their home communities.

As a pharmacist working in HIV medication adherence, I am interested in new therapeutic agents for the treatment of HIV. Information was presented on a new compound, tenofovir alafenamide or TAF as part of single tablet regimen also containing elvitegravir, cobicistat and emtricitabine. This was compared to the currently available single tablet medication, Stribild, which contains elvitegravir, cobicistat, emtricitabine and tenofovir disaproxil fumarate (TDF).

TDF (Viread) is a frequently used medication and part of most HIV treatment regimens. It is found in the combination product Truvada and the single tablet regimens Atripla, Complera and Stribild. Although considered safe for most patients, there are concerns about bone and kidney changes which can occur in some patients with long-term use.

In research presented by Dr. David Wohl, TAF was found “non-inferior” to TDF in achieving viral suppression irrespective of age, sex, race, viral load or CD4 count. In simpler terms, TAF is at least as effective as TDF. Both drugs had low rates of viral resistance and both were well tolerated.

Dr. Paul Sax presented data on renal and bone safety of TAF compared to TDF. This research demonstrated that TAF has less effect on the kidney (serum creatinine and urinary protein) and bone (bone mineral density) compared to TDF, with slightly higher lipid levels from TAF.

In the clinic where I work, we are discontinuing or replacing TDF weekly in select patients with elevated creatinine levels. Although we are discontinuing TDF less often for bone changes, it is possible that is a problem which might be detected or develop later in patients on life-long therapy.

Why does TAF appear to be safer than TDF, with fewer kidney and bone changes? Compared to TDF 300 mg, TAF 25 mg produces 90 percent lower level of tenofovir in the plasma. Tenofovir is responsible for the bone and kidney changes. TAF, like tenofovir, is converted to tenofovir diphosphate intracellularly and this is the compound with antiviral properties.

Tenofovir alafenaide or TAF is a safer and equally effective alternative to TDF, and will likely become the preferred alternative for individuals now receiving a TDF-containing product.

My sincere thanks to CROI, AVAC and the Black AIDS Institute for allowing me and others to attend CROI and their commitment to disseminating the latest research to our most heavily-impacted communities in the United States and around the globe.

Learning about Africa, Looking for Answers for Mississippi: One Advocate’s CROI perspective

Cedric Sturdevant is the co-chair for BTAN Jackson in Jackson, Miss. and has worked in the field of HIV prevention for seven years. Over the past five years, Cedric has worked at My Brother’s Keeper, Inc. and gained a wealth of knowledge and experience in HIV/AIDS, STDs and health-related matters.

In addition to the CROI Community Educator Scholarship Program, AVAC and the Black AIDS Institute—with support from the CROI Community Liaison Subcommittee—are supporting a pilot program that provides an opportunity for additional community reps to attend the meeting. Delegates are mentored and supported with supplemental programming to help translate big science into accessible language for our communities. Cedric Sturdevant is a participant in this program.

My feeling at CROI so far has been mixed. There is great information being giving, at such a fast pace that it makes me dizzy. I know we will have access to the information afterward but most of the studies being talked about are all in Africa. I know HIV infection is heavy there but I’m interested in knowing what we can do to get more people living in the US get more involved in these trials.

In my state, Mississippi, more education is desperately needed about the advancements being made around the epidemic. I know we are 30-plus years into the epidemic but Mississippians are still behind on the science of HIV. That could be a result of other issues we have within our state like housing, lack of access to health care and retention in care. When I return to Mississippi from CROI I’m going to meet with My Brother’s Keeper’s (MBK) HIV Prevention Programs Manager and BTAN member to come up with a plan to get this information out to the community and professional people working in the field.

My goal is to use the information I’ve gathered, especially around PrEP, PEP and TasP, and incorporate it into the already planned BTAN training, find some funding and travel across the state doing workshop. Personally, my goal is to do a learning session with MBK’s Empowerment Support Group, MBK’s staff, Open Arms Healthcare Center and BTAN Mississippi members. Getting this information out is not something I cannot do alone; it will take all of us working together to make a change in Mississippi.

The biggest thing thus far for me is learning the different ways PrEP can be used. I plan to read more about some of the trials they have on PrEP especially the on-demand PrEP.

FACTS 001 and Me

This post was written by Morenike Folayan, Coordinator with the New HIV Vaccine and Microbicide Advocacy Society and member of the CROI Community Liaison Subcommittee. This is the third in a series of community voice posts from CROI 2015. Read the others here and here.

I sat in the meeting room today listening to the results of the FACTS 001 study. I am sure a number of you must have received mails about what the FACTS study was and what the result of the study is.

AVAC states that: FACTS 001 was a trial of a tenofovir-based vaginal microbicide gel to be used before and after sex among young women in South Africa. The study found no effect for vaginal tenofovir gel overall in the trial. While it appeared that most of the participants used the product at some point, there was not enough correct and consistent use in the trial to provide significant levels of protection. There was a trend of modest protection among the small proportion of women in the trial who appeared to have used the product consistently. This was similar to trends seen in previous studies of tenofovir gel among women, but not enough to change the overall outcome of the trial.

I felt extremely disappointed with the results. I ask myself, where do we go from here? How come the FACTS study has no similitude of efficacy? Why does the result of this study not show any complimentary to the CAPRISA 004 study? How can the IRR be 1.0? How can that be if the women used it even some of the time?

I still remain very unclear about the answers to these questions. I think the answers may come as we move into the future. I know some answers may never come also. I hear that repeatedly during this meeting that FACTS, VOICE and Fem-PrEP studies seem to tell us something. I no longer hear that CAPRISA 004 told us something.

As the researchers meet and think about the interpretation of the results, I have one question for them as someone concerned about ethics? Why were study participants recruited from only (that is what it seems to me) from the low socio-economic strata? The PI seem to imply that the study participants were majorly unemployed (she noted this in a response to a question doing the session) and live in shacks and so may have had challenges with using the gel discretely. Microbicides would be used by women from all socioeconomic strata if found effective. Why is it that the livelihood of the young girls recruited from the study a reason to explain poor adherence. Why are studies not designed to fit into the lives of people; rather we expect the lives of people to fit into our research? Why does the recruitment of study participants into these trials not respect the principle of justice?

More questions I guess. I hope to look for answers as I move forward today. I hope my search does not generate more questions also as I face FACTS.

More confirmation for PrEP in gay men—now what about the ladies?

Nichole Little is the Founder and Executive Director at Sexual Health Education Research & Outreach (SHERO) and an AVAC PxROAR member. She is also part of the first cohort of the CROI Community Delegate Program, which provides an opportunity for additional community representatives to attend the meeting. She writes about how despite the new PrEP trial results, there needs to be more focus on women’s health and prevention needs.

On Tuesday, during the 2015 Conference on Retroviruses and Opportunistic Infections (CROI), findings from the iPERGAY PrEP trial were released. The results were exciting and determined that “on demand” or intermittent use of TDF/FTC (Truvada) led to an 86 percent reduction in HIV risk in the trial participants—all of whom are gay men. Absolutely awesome news.

Now… How do I go home and proudly deliver this information to a room full of women who have been waiting for the trial that tells them that their lives and sexual health matter. Us advocates, activists, educators and researchers know the nuances of who and how to fill a clinical trial. We know that women in sero-discordant relationships have done very well in PrEP studies. But, at the end of the day, good news is only good news if it directly impacts your life. These women are waiting for a piece of good news to come out of one of these conferences that will directly impact their lives. They want to hear the words, PrEP WORKS IN WOMEN, especially young women not in serodisordant couples. And since we’ve done such a good job, as community advocates in educating folks about the clinical trials process, they want us to prove women in the US will use PrEP and it will protect them.

During CROI’s opening plenary, Dr. Susan Buchbinder, UCSF, presented a talk titled HIV Prevention 2.0: What’s Next? Dr. Buchbinder discussed the challenges of incorporating the new biomedical prevention interventions with what she called “old interventions,” defined as public health campaigns, testing and condoms. She discussed the data that show post-HIV screening counseling may be a deterrent to those individuals testing negative for HIV. Is it the information we are delivering to them not effective? This concerned me because a number of the women I talk to understand the need for a female initiated HIV prevention strategy but they are no longer interested in being treated like little men or after thoughts. PrEP is indicated for men and women. But honestly, I cannot point them to the pudding where the proof is showing the type of information these iPERGAY results show.

The data around PrEP and women have not always been the most promising—think VOICE and FEM PrEP. The trials showed many women underestimated their HIV risk, which is partly the reason they didn’t use PrEP or gel. During the U.S. Women and PrEP pre-CROI conference face-to-face meeting, advocates from across the country convened to review the current biomedical prevention agenda with the goal to ensure that women are properly included in the work toward the end game. One point that threaded its way into every discussion we had during the day-long meeting was how do we determine what a high-risk woman is.

It was pointed out by Marsha Jones, from The Afiya Center, that we often don’t know that something is a risk until it is happening. The idea that the complexities of the lives of women put us in the position where it is difficult to place a target where we can then deliver effective advocacy. The idea that to identify a person as MSM is probably not offensive if you are gay or a man who has sex with other men. It makes moving into that population with a little more ease of motion because you know who you are looking for and have effective ways to reach them. With a woman, her husband may be her risk. For another woman, the stress of single-handedly having to financially provide for family may be her risk. Hell, for a great number of women… walking down the street with breasts puts us at a level of risk that men just cannot understand.

So where I am super excited that the IPERGAY results were so promising… I am challenged with how I take this information back into the community I serve. I can hear the question “What about us?” I’ve heard it year after year. All women want to know is that they are going to be able to have an HIV prevention option that is not going to interfere with the reproductive process, make them gain weight and WILL REALLY PROTECT THEM. I guess, where biomedical interventions are concerned, that is too much to ask at least at this current moment in time. But what I can tell them is that I’m a member of an army of women and men who place women in high priority. I can tell them that we are at the table and we are bringing their concerns back to the folks who control the dollars as well as those who control the science and we are letting them know that women matter.

And one day we will be sitting in a huge conference room and hear the good news that women across the globe have been waiting to hear. The kind of good news that men have been getting for the last few years. I will also reassure the women in my community that microbicides are going to change the game for us—maybe not gels but there is a lot of promise in the work that is currently being done to develop numerous other delivery methods. Now that’s AWESOME news. And until then, my sisters and I will continue to attend conferences, continue to occupy a seat at the table and continue to keep women’s health high on the list of prevention priorities.

ACT UP, Eat Hors d’oeuvres?: Strange days, missing histories at CROI 2015

Cassie provides client-centered, low-threshold, sex-positive, gender affirming care at the Broadway Youth Center. The BYC is a one-stop shop for LGBTQIA youth experiencing housing instability (drop-in, GED, health clinic, talking support, and programming). Cassie’s approach to their work is two-fold: to provide young people with health literacy, support navigating the medical industrial complex, enrollment in health insurance, and know your medical rights information to young people. He also supports provider trainings on how to work with and support young people, be gender affirming, and provide trauma informed care in clinical settings. She also supports AfterHours, an all ages, trans and gender-non-conforming drop-in night (clinical, legal, social support) at Howard Brown Health Center, and is a member of AVAC’s PxROAR program.

Warren is one of the participants in a pilot program for community delegates at CROI. In addition to the CROI Community Educator Scholarship Program, AVAC and the Black AIDS Institute—with support from the CROI Community Liaison Subcommittee—are supporting a pilot program that provides an opportunity for additional community reps to attend the meeting. Delegates are mentored and supported with supplemental programming to help translate big science into accessible language for our communities. Expect regular updates from the meeting.

How’d we go from ACT UP to Nordstrom? No, it wasn’t a protest against capitalism, consumerism or classism. It was the Conference on Retroviruses and Opportunistic Infections’ 2015 reception. Against my best gut reaction, I went for the free champagne and “food” (aka: tiny trays of deviled eggs, mini chicken salad sandwiches, and truffle popcorn—if I hadn’t moved from Kentucky 6 years ago, I wouldn’t even know what a truffle was). Champagne in hand, I stiffly shuffled around without direction. Afraid I’d spill it on a dress that cost more than three of my paychecks combined, I decided to down it quickly. Unsure where to walk, where to sit or what I was even doing there. I felt strange, yet looking around that didn’t seem to be the sentiment reflected by anyone else.

Anxiety, and anger—which I do a good job of turning into sadness, started rising up my throat. I might cry in front of all these people I thought to myself. Cry for a movement that feels separated from people’s experiences. For the 23 year old girl with a CD4 count less than 200 and her three beautiful children, for the 22 year old who was almost murdered by a date but who’s only need at the moment was trying to replace her ID, for the 19 year old boy who told me he didn’t need to start PrEP because soon his parents would accept him, invite him back home, and stop withholding his health insurance, and for the man I encountered three hours earlier who was roughly rejected by asking for spare change. I had to stop myself. All their stories were running through my head. You’re close to the entrance, I told myself. All you have to do is walk down the escalator, past the Jimmy Choo’s and then you’ll be out.

Out front I took a deep breath. Exhaled my roots into the ground and called love into my heart. A man walked up to the entrance. “This is a private party, you can’t come in” Nordstrom’s security stated. Man walks 200 yards away. The security follows him. “This is private property. You have to leave. Go on now, get out of here.” The streets are private property. I threw up in my mouth. Swallowed it. But I did nothing else. I was/am ashamed.

Is this what the movement looks like from cutting edge science and biomedical interventions? Fancy meals on pharma money while we drop comments in our speeches about “social determinants” and “resource poor areas” and “racial disparities”. Erasing queertories with comments like, “CROI has always been a place that accepts community.” Forgetting that folks busted through the conference doors in DC in the early 1990s, demanding to be included. I asked one presenter why they didn’t include transgender populations in their data and they said there isn’t any data, and we have very limited slides. They added that we need that data because transgender populations are at the highest risk. Don’t tell me in the same breath that they are the most vulnerable population and that you couldn’t include one bullet point in one slide about it.

For the record, the data says that the HIV infection rate in the trans community is 30 percent. That’s 1 in 4 people who are HIV positive. Trans people are 49 times more likely to be HIV+ than their cis counterparts. The seropositivty rate in trans people experiencing homelessness is 22%. If we look at other “social determinants” we see that trans people are 1,000 times more likely to be murdered than cis people. That half of the trans population are victims of rape, and a quarter are victims of assault.

There is so much momentum, and it seems we could be so close to ending the epidemic. We certainly have the tools for it. PrEP works if you take it, and you don’t even have to take it everyday. We literally have a pill you can take to prevent HIV, and in the city of Chicago if you’re low income or undocumented, it’s completely free. I was easily swept away by Galit Alter’s engaging and very well articulated presentation on the path to a vaccine (I recommend you watch it), and we have proof of concept for a cure. But if trans folks are the most vulnerable population, and we don’t have trans competent doctors then what does it matter? If we arrest or institutionalize poor, Black young people for attempting to access care at ERs, then what does it matter if we have the best treatment in the world?

If I’ve learned anything this week it’s that science is hard, and humans are even more complicated. This week there has been no shortage of passion, knowledge and energy to end the epidemic, but there are some very clear ways that we are failing. If we want the “most vulnerable” and “most risky” populations to take PrEP, to care about a cure, to get engaged in primary care, to get on treatment then we have to provide gender affirming services, we have to get rid of security guards and police in our health care clinics. We need to affirm people’s consensual pleasures. We need more youth centered healthcare spaces, and insurance companies need to survive on something other than capitalism.