We’ve made great progress treating people who are infected with HIV, but if they get cancer they’re less likely to get the care they need, a recent study found.

Researchers examined treatment for a variety of cancers, including upper gastrointestinal tract, colorectal, prostate, lung, head and neck, cervix, breast, anal and two blood cancers. With the exception of anal cancer, treatment rates differed significantly between HIV-infected people and those who weren’t infected, according to the study published online Tuesday by the journal Cancer.

For example, a third of patients with HIV and lung cancer failed to receive any treatment for the cancer, compared with 14 percent of those who were HIV-negative. Similarly, 44 percent of people who were HIV-positive didn’t receive treatment for upper GI cancer versus 18 percent of those who weren’t infected with HIV. Twenty-four percent of men with prostate cancer who were HIV-positive didn’t get treatment, compared with 7 percent of men uninfected with HIV.

Cancer treatment was defined as radiation, chemotherapy and/or surgery.

“To have made such great strides with treating HIV only to have them succumb to cancer is devastating,” said Dr. Gita Suneja, a radiation oncologist at the University of Utah’s Huntsman Cancer Institute in Salt Lake City and the lead author of the study.

The study used the National Cancer Data Base to analyze treatment for adults younger than 65 who were diagnosed with any of the 10 most common cancers to affect HIV patients between 2003 and 2011. The study included 10,265 HIV-infected adults and 2.2 million without HIV.

The database, which is sponsored by the American Cancer Society and the American College of Surgeons, captures roughly 70 percent of newly diagnosed cancer cases in the United States.

The study noted that more than a third of the patients with HIV had stage 4 cancer — cancer that has metastasized — when they were diagnosed, while only 19 percent of those without HIV did.

Improvements in antiretroviral therapy to treat HIV have helped reduce the incidence of cancers such as Kaposi sarcoma that are closely linked to AIDS. But rates for other cancers often associated with normal aging have increased among HIV patients.

In addition, people with HIV have a higher incidence of some lifestyle-related cancers, such as lung cancer, which could be linked to higher rates of smoking. Cancer is now the second most common cause of death among HIV-infected people, behind AIDS-related causes.

HIV patients are more likely to be uninsured or underinsured, and lack of coverage can affect access to cancer care. But having insurance didn’t eliminate the problem: Privately insured people with HIV were significantly more likely to be untreated for many cancers than were privately insured people without HIV, the study found.

“We know that people with Medicaid or who are uninsured receive subpar cancer treatment, and that’s a big public health issue,” said Suneja. “But even factoring that in, HIV-infected people are still less likely to receive cancer treatment. That means there are other drivers that we couldn’t measure in the study.”

Disparities in cancer treatment could exist for several reasons. For one thing, for most cancers there are no national treatment guidelines for HIV-infected patients, Suneja said. One of the few exceptions is anal cancer, the only cancer for which the study found little discrepancy in treatment among HIV-infected and uninfected patients. According to the research, the difference among those not receiving treatment was 4.8 percent for HIV patients versus 3.1 percent for others.

For other cancers, “the oncologist may pause and ask, ‘Does the HIV infection mean they shouldn’t get standard cancer treatment?’ ” Suneja added.

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Michelle Andrews is on Twitter: @mandrews110.

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Amid a raging opioid epidemic, many doctors and families in the U.S. have been pleading for better treatment alternatives. One option now under consideration by the Food and Drug Administration is a system of implanted rods that offer controlled release of buprenorphine — a drug already used in other forms to treat opioid addiction.

Because it’s implanted in the skin, this version of the drug can’t easily be sold on the illegal market, proponents say — a key treatment advantage. The FDA is expected to decide whether to approve the device — called Probuphine — within a week.

The implant system includes four rods, each about the size of a match stick, explains Dave, a paramedic in a small town outside of Boston; he was one of the patients recruited to test the device last year. Dave’s worried about reprisal if co-workers find out he is addicted to opioid pain pills, so NPR agreed to use only his first name.

“My implants were placed in my left arm, just above my elbow on the inside,” he explains. He’s been in recovery for four years — previously with the help of daily buprenorphine pills. Last year, he agreed to be part of an experiment that delivered regular doses of the drug to him via an implant instead. He’s sold on the new approach.

“I felt completely normal all the time,” he says.

Probuphine implants, inserted under the skin by a trained doctor, are left in place for six months at a time. Dave says the rods are convenient, safe and discreet — they provided steady relief from his cravings.

When he takes the daily buprenorphine pills, he says, he has to be careful to hide them so that his 2-year-old granddaughter can’t get into them. And though he’s supposed to take the tablets at least 15 minutes before he eats or drinks anything, he sometimes forgets. Or he forgets to take the pills at all.

“With the implant, you didn’t have to worry about that,” he says. “It was just there, and you felt good all the time.”

The device doesn’t work for everyone. During the study, 12 percent of patients who had implants relapsed. But the relapse rate for the pill version of the drug was 28 percent.

And there’s a second reason implants can be better than pills, says Braeburn Pharmaceuticals CEO Behshad Sheldon: A lot of buprenorphine winds up being sold illegally on the street. Though the drug produces a less intense high than most opioids, it is still sometimes abused.

“Buprenorphine is the third most confiscated opioid by the DEA, so there’s certainly diversion going on,” Sheldon says.

But during the clinical trial, she says, there were no cases of anyone trying to remove their implant so they could to the drug inside and sell it.

An FDA advisory committee recommended approval of the implant in January, and a final decision from the agency is expected by May 27.

“Anything that might help people beat their opioid addiction is a good idea,” says Dr. Barbara Herbert, president of the Massachusetts Society of Addiction Medicine. But she says she also has reservations about this method of delivering treatment.

The main one is price. The company says it will price the implants to be competitive with other injectable treatments used to battle opioid addiction, including a shot that costs about $1,000 a month. Herbert says a high price may force providers to turn patients away — or cut back on other services.

“High profits in the middle of this epidemic are really unconscionable,” she says.

Sheldon, of Braeburn Pharmaceuticals, says the company will offer rebates to make sure appropriate patients can get access to the implant. She plans to negotiate with insurers and providers on a price that takes both their cost and savings into account, she says.

“And if they don’t realize those savings, we’re happy to rebate them even further,” Sheldon says.

If the implant is approved, demand for it is expected to be high even with the high price-tag, addiction specialists say.

Dave, the New England paramedic in recovery, says he’s thought about trying to wean himself off the treatment drugs altogether.

“But then, the more I think about it, it scares the hell out of me,” he says. “I’m scared of going backward. I honestly don’t know what would happen.”

That’s a fear voiced by many of the growing number of Americans who have come to see their addiction as a chronic disease, a condition they may have to live with — and need treatment for — for many years.

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

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While Congress fidgets over whether and how to pay for the fight against the Zika virus, state and local health departments are scrambling and slimming down.

That’s because these front-line public health agencies have already seen their budgets chopped because of the debate.

The Centers for Disease Control and Prevention in April cut $44 million from its fund that helps state and local governments prepare for public health emergencies. It was part of the $589 million the White House moved from other programs – mostly money allocated for domestic and international responses to the Ebola virus – to combat Zika as it awaited action on Capitol Hill.

New York City’s health department lost $1.1 million in the deal.

Marisa Raphael, the deputy commissioner in New York’s Office of Emergency Preparedness and Response, says she expects to have to cut jobs.

“We depend on this grant to create an infrastructure for our preparedness and our response,” Raphael tells Shots. “That’s everything from our lab staff to our surveillance staff, so when we have this cut, that does immediately impact our capabilities.”

New York isn’t unique. A survey of state and local health departments shows that many are struggling with the reduced funding. About a third of state health departments say they expect to lay people off, and the same number say they’ll likely eliminate training programs.

The cuts will affect the kinds of things these departments normally do.

“A new measles outbreak? That’s the job of the health department to discover and to control,” says Thomas Inglesby, the CEO of the Center for Health Safety at the University of Pittsburgh Medical Center. “Or a new mumps outbreak on a college campus, or a meningitis outbreak. That’s the day-in, day-out work of public health.”

He says public health department budgets have been slashed over the last 10 years and they just don’t have excess resources or people that can be cut.

“If you take funding from local health department preparedness that means people are fired or labs can’t run the same way or disease surveillance has to stop,” he says. “If we take people from those jobs to work on Zika, that will help with Zika, but that will hurt our other preparedness efforts.”

President Obama in February made an emergency request of $1.9 billion to combat the Zika virus. The money would be used for research into a new vaccine, treatments and tests for the disease as well as to study and track how it spreads and try to control the population of mosquitoes that carry the virus.

Scientists agree that the Zika virus is linked to microcephaly, a condition in which babies are born with undersized brains and skulls. It is also linked to several other types of birth defects, and to Guillain-Barre syndrome in adults.

The House of Representatives this week passed a bill allocating $622 million for Zika response, about a third of the president’s request. And all of the money comes from other programs.

House Appropriations Committee Chairman Hal Rogers, R-Kentucky, argued at a recent markup that the emergency money was a stopgap until Congress could allocate more money as part of the regular budget process.

The Senate is working on a separate bill that would provide $1.1 billion in new money for the disease.

Public health experts argue that three months is a long time to wait for what many say is an impending public health emergency.

And since Zika is just the latest in a string of infectious disease threats, many public health experts want to create a standing fund for public health emergencies.

Such a fund could operate like the one maintained by the Federal Emergency Management Agency. The agency can draw on it as needed in an emergency; it would be replenished in the regular government budgeting process.

Anthony Fauci, the director of the National Institute for Allergies and Infectious Diseases, part of the National Institutes of Health, and Thomas Frieden, the director of the CDC, advocated for such a fund in recent weeks.

“The whole idea is to have funding available urgently when it is needed urgently,” says Melinda Moore, associate director of the Population Health Program at the Rand Corporation.

She says FEMA money is “available as soon as it’s needed, right on the heels of a hurricane, a tornado, et cetera. Some of these outbreaks — and Zika is a good example — are nearly as urgent as that.”

Inglesby agrees that an emergency fund would eliminate these repeated budget fights.

But for Zika that debate is too late, he says. Congress should allocate emergency money for Zika now and then treat is as a regular part of our public health landscape.

“Zika is the new normal,” Inglesby says. “Zika is something we’re going to have to deal with not just this summer, but next summer and the summer after that.”

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NPR’s Ari Shapiro speaks with Republican Sen. Johnny Isakson of Georgia about the need for congressional funding to prevent the Zika virus from spreading in the U.S. The Florida delegation sees this as a national emergency.

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Renee Montagne talks to David Shulkin, under secretary for Health at the Department of Veterans Affairs, about the VA’s plans to fix Veterans Choice, which allows some veterans to see private doctors.

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A single question asked at an annual checkup — whether parents have trouble making ends meet — could help pediatricians identify children at risk for serious health problems associated with poverty and the chronic levels of stress that often accompany it.

The American Academy of Pediatrics urges members to ask if their patients’ families are struggling financially and then commit to helping them get the resources they need to thrive. And some communities are trying to make that happen.

Since almost half of young children in the United States live in poverty or near poverty, it’s no small challenge.

The Center for Youth Wellness, located in San Francisco’s low-income Bayview Hunters Point neighborhood, is working with the pediatricians’ organization on a national campaign, Children Can Thrive, to raise awareness about the impact of a range of childhood stressors, known as adverse childhood experiences, or ACEs. These experiences of abuse, neglect or household dysfunction can have grave implications for both child and adult health.

In screening children for ACEs, the Center recognizes a “high relationship” between low incomes and harmful stressors. Although children from any economic status can live with ACES, exposure is greater for children who live in poverty, says Mark Cloutier, executive director of the Center.

The ACE screening test is simple; 10 questions that an adult or child can answer in a few minutes. (You can take it below.) But doctors aren’t taught about ACE scores in medical school, and some are reluctant to give patients the test because they think it’s too invasive or brings up problems that can’t be treated. That’s not true, researchers say.

Knowing that a child lives in poverty “changes everything,” says Dr. Susan Briner, medical director at the Bayview Child Health Center. Briner knows to expect that there may be more emergency room visits in families with low incomes “because if parents miss a day of work for an office visit, that can be catastrophic to their housing or family budget.”

Earlier this year the AAP, which represents 64,000 pediatricians, published a policy statement and technical report on how poverty affects children’s health in the academy’s journal Pediatrics. Lead author James Duffee, a child psychiatrist in Columbus, Ohio, says the policy represents “a new emphasis on the health of children in communities, trying to get pediatricians to think broadly about the context in which a child is born.”

According to the report, poor children have higher rates of low birth weight, infant mortality and chronic illnesses such as asthma, Type 2 diabetes and obesity.

According to Duffee, toxic stress has also been proved to disrupt the architecture of the developing brain, damaging the prefrontal cortex, which is responsible for impulse control, planning and thinking about consequences.

But the effects of poverty can be mitigated, and that’s where early intervention can help. “There is a way that we can change toxic stress into tolerable stress,” says Duffee. He cites the developing science on resilience, which shows that growing up in a close, supportive relationship with an emotionally attached adult can help a child overcome adversity.

By promoting those early attachments, pediatricians and other adults can help young people develop protective factors and head off potentially serious health effects. “One of the changes in pediatric practice is looking for ways we can promote relational health and not just physical or medical health,” says Duffee.

Families aren’t as averse to talking about their economic situation as doctors may think.

“I think it’s a great question to ask,” says Lottie Titus, a San Francisco resident who shares parenting of her three grandchildren. Titus says talking about finances with a family doctor “can establish why there are so many illnesses, so many challenges, so much depression.”

Titus’ grandkids “have been exposed to a lot,” she says. “All their lives they’ve lived in public housing.” The children, ages 10 to 14, also have health problems, from Type 1 diabetes to asthma and emotional problems. All three children see a therapist.

They are also involved in community programs such as Big Brothers Big Sisters of the Bay Area and the youth development organization City of Dreams. Titus said it was the children’s pediatrician who ensured that Titus was connected with these services: “She referred me to many programs that have been beneficial to the children, pointing them in the direction of the services that they needed, that helped them to be well-rounded.” Titus has since become a community liaison with City of Dreams, providing information and resources to youth and families living in San Francisco public housing.

That’s the model of engaged pediatric practice the pediatricians hope to see replicated nationwide.

This story was produced by Youth Today, a national news source for youth-service professionals, including child welfare and juvenile justice, youth development and out-of-school-time programming.

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A study examined the economic effects of the Affordable Care Act. Researchers found states that opted to expand Medicaid through Obamacare had residents with fewer unpaid bills and less debt overall.

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Scientists and doctors say the case is clear: The best way to tackle the country’s opioid epidemic is to get more people on medications that have been proven in studies to reduce relapses and, ultimately, overdoses.

Yet, only a fraction of the more than 4 million people believed to abuse prescription painkillers or heroin in the U.S. are being given what’s called medication-assisted treatment.

One reason is the limited availability of the treatment. But it’s also the case that stigma around the addiction drugs has inhibited their use.

Methadone and buprenorphine, two of the drugs used for treatment, are themselves opioids. A phrase you often hear about medication-assisted treatment is that it’s merely replacing one drug with another. While doctors and scientists strongly disagree with that characterization, it’s a view that’s widespread in recovery circles.

Now, the White House is pushing to change the landscape for people seeking help. In his 2017 budget, President Obama has asked Congress for $1.1 billion in new funding to address the opioid epidemic, with almost all of it geared toward expanding access to medication-assisted treatment.

The White House is also highlighting success stories. At the National Prescription Drug Abuse and Heroin Summit held in Atlanta in March, President Obama appeared on stage with Crystal Oertle, a 35-year-old mother of two from Ohio. Oertle spoke of her spiral into addiction, which began with prescription painkillers and progressed to heroin. She tried unsuccessfully to quit on her own several times, before being prescribed buprenorphine a year ago. “I personally couldn’t get through the withdrawal symptoms,” Oertle said in Atlanta. “I couldn’t tough it out. I know some people can. I couldn’t do it. This last time has been the most successful recovery for me.”

Her experience isn’t unique.

“I’ve seen people with opioid-use disorders go through inpatient treatment without medications time and time and time again, without ever being offered alternatives,” says Michael Botticelli, director of National Drug Control Policy at the White House. “We wouldn’t do that with any other disease. If one treatment failed for you, we’d say, let’s look at other possible treatment options.”

Botticelli says patients should consider the evidence for medication-assisted treatment and together with their doctors make a decision about what’s best for them.

Methadone and buprenorphine have been tested in scores of clinical trials. Researchers have found that when combined with counseling, they significantly reduce opioid use and keep people in treatment longer.

“We have tons of experience with patients who remain in treatment for months and years, who do very well on relapse-prevention medicines,” says Dr. Marc Fishman, medical director at Maryland Treatment Centers in Baltimore. He says among his patients, primarily young people, about half remain with the program six months into treatment. Studies have shown far worse outcomes for patients who detox without follow-up medications, with relapse rates topping 90 percent.

Still, there are many people who stand by the so-called abstinence route — recovery without the use of medications. Their views are informed by personal experiences and deeply-held beliefs about what constitutes true recovery.

For years, Juan Ramirez, 56, led a high-risk lifestyle to support his use of prescription painkillers. “When you start robbing drug stores and drug dealers because of your drug habit, your life is not working right,” he says.

A friend told Ramirez about a doctor in Baltimore who prescribed Suboxone, a brand of buprenorphine. He liked the way Suboxone made him feel, so he would often exceed the dosage, buying pills from other patients so he wouldn’t run out. The good news was he stopped using other narcotics and, overall, he felt more functional. Still, after three years of seeing the doctor, he never felt like he’d achieved full recovery. “I was still an addict,” he says. “It was just legal.”

That line of thinking extends to some people whose mission is to help people in recovery, including David Lidz, a recovering alcoholic, who runs a group home in Hagerstown, Md. The home has 10 beds for men who are transitioning out of intensive drug treatment back into daily life. In addition to beds, Lidz offers the men work with his contracting business, refurbishing houses. The emphasis is on hard work, personal responsibility and purpose. It’s what worked for Lidz in his recovery, but even he knows it doesn’t work for everyone.

When he started his work as a recovery advocate, Lidz knew little about medication-assisted treatment and had yet to form an opinion about it. Soon, he started getting reports from the group home that someone’s Suboxone had been stolen, or someone looked high, or that people were trading, selling, and snorting Suboxone. “That to me just looks like heroin,” Lidz says.

So he made a decision: He wouldn’t accept anyone on it.

Today, that stance is threatening the group home and his business. “Now we’ve been told by clinical settings that we’re essentially blacklisted, that they can’t even mention our program if we won’t take people on opiates, on Suboxone,” Lidz says.

He worries it could lead to missed opportunities for people like Charles Testerman, who came to Lidz’s group home after several months in drug treatment. Testerman describes his years of drug use as “doing everything to excess.” He drank, smoked marijuana, and got hooked on prescription painkillers and later heroin. When he couldn’t afford heroin, he bought Suboxone on the street, hoping it would help him stop using other drugs. It didn’t work.

“I was doing Suboxone in the mornings, as well as Adderall to bring myself up. Then at night, I was taking Xanax, smoking weed and drinking, just to go to sleep every night,” Testerman says. “It was just a constant cycle.”

Today, he has an apprenticeship with a master woodworker at a place called The Stoner Farm, Anglicized from Steiner, the name of the family that built the place. Testerman is working to restore an early 19th century barn there. “I feel great, happy to be out here doing this,” he says. “It’s just nice to wake up in the morning and not have to do anything to feel normal.”

Fishman, the addiction doctor in Baltimore, knows there are people like Testerman who find the strength to have what he calls a life-changing conversion without medications. But, he cautions, not everyone can do it, and it’s not scalable. He wants to persuade the doubters that medication-assisted treatment is the best tool available at the moment, and, in making his case, he’s willing to acknowledge its limitations.

“This doesn’t change my claim that it should be the standard of care,” he says. “But we don’t have the penicillin for addiction. These are not curative medications. In having a nuanced, thoughtful discourse with people who might disagree with us, acknowledging those limitations I think would make us more credible.”

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When insurers pull out of the health law marketplaces, will customers buying plans outside those exchanges lose access, too? And do families have to meet two deductibles if each spouse has a separate insurance plan? Here are the answers.

I see story after story about insurance companies leaving some state health insurance exchanges, but does that mean they’ll stop selling health insurance on the individual market altogether? Will these companies’ policies still be an option for those of us who buy coverage off of the exchange since, for example, we don’t qualify for subsidies?

An insurer’s decision to stop selling plans on the marketplace doesn’t necessarily mean it will stop selling individual coverage in that state altogether. This year, for example, Aetna stopped selling individual plans on the marketplaces in Kansas, Utah and Washington, D.C. But the company continues to sell individual policies outside the marketplaces in Kansas and Utah, said T.J. Crawford, a spokesman for Aetna. However, it stopped selling off-exchange plans in the District, which requires insurers selling on the individual and small group markets to offer their products on the exchange. A handful of other states require insurers to sell similar plans on and off the exchange.

Aetna last week announced that it intends to continue selling policies on the exchanges in at least 15 states. UnitedHealthcare and Humana, on the other hand, have said they expect to withdraw from a number of state exchanges but have not specified which ones yet. A spokesperson for UnitedHealthcare said that no one was available to comment on its plans, and Humana didn’t respond to a request for comment.

Insurers have taken different approaches to date on offering individual coverage only on the exchange versus both on and off the exchange, said Paul Rooney, vice president for carrier relations at eHealth.com, which sells such plans outside the exchanges. No matter where they’re sold, all individual plans have to meet health law standards, including covering the 10 essential health benefits. Although the plans are similar in many ways, provider networks may be broader in some off-exchange plans, said Rooney.

Since the Affordable Care Act passed, my employer won’t allow me to cover my spouse because she has coverage through her employer. I have a family plan with a high deductible. Is there any provision in the law to link her policy and mine? We have met the family deductible and family out-of-pocket maximum on the plan that covers me and the kids. It doesn’t seem fair that we would have to meet her deductible also.

There’s no way to link your two policies under the health law. In order to pick the best coverage for your family between the plans offered by both employers, you need to consider several factors, including the premium, deductible and out-of-pocket maximum, and how those amounts change depending on which family members are covered under which policy.

In high-deductible plans, the kind that are typically linked to a health savings account, it’s particularly important to consider how that family deductible works, said Tracy Watts, a senior partner at benefits consultant Mercer. If the plan has a $6,000 deductible, for example, it may be that the entire deductible must be satisfied before the plan starts to pay claims for any family member other than for preventive care. In contrast, a traditional plan with a family deductible of say, $3,000, might “embed” individual deductibles of $1,000 per family member within that total and begin paying benefits sooner.

If one family member is likely to need expensive care, running the numbers can be especially important. “If they have someone who they know is going to need coverage, it’s important to make sure they’re in most advantageous plan,” Watts said.

Regardless of the amount of the family deductible, the maximum amount that any one person can be required to pay out-of-pocket is $6,850 in 2016.

It’s worth noting that a growing number of employers are discouraging workers from covering spouses who have insurance available through their own jobs. In 2016, 7 percent of employers didn’t offer coverage to workers’ spouses who had insurance available elsewhere, and 44 percent said they were considering it, according to a survey by benefits consultant Aon Hewitt. Another 17 percent charged spouses extra if they had other coverage available, and 47 percent said they were considering extra charges.

Why can’t consumers change health insurance every month if they want to, like they can with auto and homeowners insurance?

The issues for these types of insurance are not the same.

Most people buy or renew their health insurance during an annual open enrollment period and generally have to stick with that plan all year.

If people could switch health plans whenever they wished, there would be nothing to stop them from buying a plan with minimal coverage and a low premium, then trading up to a pricier, more generous plan if they got sick, said Penny Gusner, a consumer analyst at insure.com, a website that provides information about insurance and insurers, who may pay for placement or leads.

“It would destabilize the marketplace,” Gusner said, since some insurers would end up paying for a disproportionate number of sick people.

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Email questions for future columns: KHNHelp@KFF.org. You can also follow Michelle Andrews on Twitter: @mandrews110.

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With a vacancy, Supreme Court justices are looking for ways to avoid tie votes on key issues. On Monday, the justices sent an Obamacare case back to a lower court — saying compromise seemed feasible.

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