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

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

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

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

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

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

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

This interview has been edited for clarity and length.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Consumers, lawmakers and industry players all seem to agree that prescription drugs prices are too high. What they can’t always agree on is whom to blame.

On Tuesday, though, fingers are expected to point toward pharmacy benefit managers, the industry’s mysterious middlemen.

The Senate Finance Committee will hear from executives from the biggest pharmacy benefit managers, led by CVS Caremark and Cigna’s Express Scripts.

“They’re kind of a secret organization,” says Sen. Chuck Grassley, R-Iowa, of the pharmacy benefit managers. “I ask people to explain what they’re doing and nobody seems to give you the same answer twice.” Grassley is chairman of the Finance Committee and Tuesday’s hearing is its third on drug prices this year.

Pharmacy benefit managers, or PBMs, manage prescription drug benefits for insurance companies and employers. And because they control the medication purchases of millions of patients, they are tremendously powerful.

“They exist only because pharmaceutical prices got so high and they were a way to get some market power in there that was on the consumer side,” says Len Nichols, a health economist at George Mason University. “Now they’ve become so big and dominant that they are hurting pharma.”

How dominant? CVS Caremark negotiates drug prices, copayments and which drugs are preferred options for more than 92 million people in the U.S. Express Scripts covers another 83 million.

The companies are hired by insurance companies, or self-insured employers, to control spending on prescription drugs. The PBMs negotiate discounts with pharmaceutical manufacturers, but those discounts come in the form of confidential rebates that are paid to the PBMs after the drugs are purchased.

PBMs pass most of the rebates on to their clients, but they often keep a slice for themselves.

The PBMs dispute that they are withholding savings from their clients. “While drug manufacturers would have people believe that PBMs are retaining these discounts, virtually all rebates and discounts are passed on to clients,” said Tom Moriarty, executive vice president at CVS Health, in a February speech.

Some analyses show that PBMs actually do help reduce drugs prices.

“PBMs have saved money over the last decade by encouraging use of generics,” says Dr. Walid Gellad, director of the Center for Pharmaceutical Policy and Prescribing at the University of Pittsburgh.

A report from SSR Health, an investment research firm, says the net prices of brand-name prescription drugs fell 4.8 percent in the last quarter of 2018, even while list prices rose 4 percent. The declines came as pharmacy benefit managers refused to pay for some drugs altogether, opting for a competing brand that offered a better price.

Gellad says that evidence is murky, because the rebate system means that many drugs start at prices that are artificially high.

But critics say the system creates perverse incentives for drugmakers to set high prices for their products so they can offer larger percentage rebates. And they say sometimes PBMs benefit more when patients buy expensive drugs than when they buy cheaper ones.

Now the entire business model is under attack. Health and Human Services Secretary Alex Azar in February proposed eliminating the rebate system that underpins the work of companies like CVS Caremark and Express Scripts.

Instead, Azar proposed, the companies would use their market power to negotiate discounts from drugmakers upfront that would be passed on in full to patients.

In comments on HHS’ proposal to get rid of rebates, CVS said drugmakers — not PBMs — are to blame. “Our data show that it is not rebates that are causing drug prices to soar and, in fact, list price is increasing at a faster rate for many drugs with small rebates than for drugs with substantial rebates,” CVS wrote. “The elimination of rebates may not only lead to higher net drug prices, but will undoubtedly lead to higher premiums across the Medicare Part D program.”

Tuesday’s hearing comes six weeks after the leaders of seven pharmaceutical manufacturers appeared before the same committee to defend their pricing practices.

Those CEOs acknowledged that their prices are high for many patients, but they deflected blame onto pharmacy benefit managers.

“We want these rebates, which lower net prices, to benefit patients,” said Olivier Brandicourt, CEO of Sanofi, which makes Lantus, one of the highest priced brands of insulin. Its list price has risen from $244 to $431 since 2013, according to the committee.

“Unfortunately, under the current system, savings from rebates are not consistently passed through to patients in the form of lower deductibles, co-payments or coinsurance amounts,” Brandicourt said in testimony prepared for the hearing.

Sen. Ron Wyden, D-Oregon, who is the ranking member of the Finance Committee, had harsh words for the drug makers at the February hearing.

“I think you and others in the industry are stonewalling on the key issue, which is actually lowering list prices,” he said. “Lowering those list prices is the easiest way for consumers to pay less at the pharmacy counter.”

Grassley is also frustrated.

“The pharmaceutical companies pointed the finger at the PBMs. The PBMs point their finger at the pharmaceuticals. And then both of those are pointing their fingers at the at the health insurance companies,” Grassley said.

“I’m not announcing another hearing,” he continued. “But it might be that if we get this finger-pointing going on all the time, we may want to get those three groups all at the same table to stop the finger-pointing.”

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Across the U.S., many doctors, nurses and other health care workers have remained silent about what is being called an epidemic of violence against them.

The violent outbursts come from patients and patient’s families. And for years, it’s been considered part of the job.

When you visit the Cleveland Clinic emergency department, these days —whether as a patient, family member or friend — a large sign directs you toward a metal detector.

An officer inspects all bags and then instructs you to walk through the metal detector. In some cases, a metal wand is used — even on patients who come in on stretchers. Cleveland Clinic officials say they confiscate thousands of weapons like knives, pepper spray and guns each year. The metal detectors were installed in response to what CEO Tom Mihaljevic is calling an epidemic.

“There is a very fundamental problem in U.S. health care that very few people speak about,” he says, “and that’s the violence against health care workers. Daily — literally, daily — we are exposed to violent outbursts, in particular in emergency rooms.”

Many health care workers say the physical and verbal abuse comes primarily from patients, some of whom are disoriented because of illness or from medication. Sometimes nurses and doctors are abused by family members who are on edge because their loved-one is so ill.

Cleveland Clinic also has introduced other safety measures — such as wireless panic buttons incorporated into I.D. badges, and more safety cameras and plain clothes officers in ERs.

But these incidents aren’t limited to emergency rooms.

Allysha Shin works as a registered nurse in neuroscience intensive care at the University of Southern California’s Keck Hospital in Los Angeles. One of the most violent incidents she’s experienced happened when she was caring for a patient who was bleeding inside her brain.

The woman had already lashed out at other staff, so she’d been tied to the bed, Shin said.

The woman broke free of the restraints and then kicked and punched Shin in the chest — before throwing punch at her face.

“There was this one point where she swung, and she had just glanced off the side of my chin. If I hadn’t dodged that punch she could have knocked me out,” Shin says. And she very well could have killed me.”

The encounter left Shin shaken and anxious when she returned to work days later. She still has flashbacks.

She used to be afraid to speak about these types of attacks, she says because of what she calls a culture of accepting violence in most hospitals.

“It is expected that you are going to get beat up from time to time,” Shin says.

According to the Occupational Safety and Health Administration, incidents of serious workplace violence are four times more common in health care than in private industry.

And a poll conducted by the American College of Emergency Physicians in 2018 found nearly half of emergency physician respondents reported being physically assaulted. More than 60 percent of them said the assault occurred within the previous year.

Groups representing doctors and nurses say while the voluntary safety improvements that some hospitals have enacted are a good first step, more needs to be done.

There is still a code of silence in healthcare, says Michelle Mahon, a representative of the labor group National Nurses United.

“So what happens if they do report it?” Mahon says. “In some cases, unfortunately, they are treated as if they are the ones who don’t know how to do their job. Or that’ it’s their fault that this happened.”

“There’s a lot of focus on de-escalation techniques,” Mahon adds. “Those are helpful tools, but oftentimes they are used to blame workers.”

In California, the nurse’s labor union pushed for a law giving OSHA more authority to monitor hospital safety. The group is now backing a national effort to do the same thing.

“The standard that we are recommending federally holds the employer responsible,” Mahon says. “It mandates reporting of incidents and transparency.”

The Workplace Violence Prevention for Health Care and Social Service Workers Act, recently introduced in Congress, would require hospitals to implement plans to prevent violence. And any hospital could face fines for not reporting incidents to OSHA, Mahon adds.

The goal of the legislation — and of the union — is to hold administrators more accountable for acts of violence in their hospitals.

This story is part of NPR’s reporting partnership with Ideastream and Kaiser Health News.

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