Swiss HIV Study Confirmed in Canada: Treatment Eliminates Transmission

 A few years ago, we reported on this blog a Swiss Study that concluded that when HIV-positive individuals receive treatment that reduces their viral loads to "undetectable" levels (less than 40 copies per ml blood at the time), the transmission of the virus to negative partners was virtually impossible.  The study was so certain in its results that it lead to changes in Swiss law concerning criminalizing HIV+ individuals having sex.

That news was received with mix results, as the 30 year old "wear a condom!" message, long losing steam but still a cornerstone of government-funded HIV programs, began to be replaced with a common sense message of universally treating the virus as a better prevention approach. The move to "attacking the virus" rather than "restraining the individual" has not been met without resistance, especially by HIV agencies used to receiving government funding merely by placing baskets of condoms around town and telling people to 'wrap up.'

Now, a more comprehensive study validating the Swiss findings was released in Canada this past month.


According to this review of multiple studies, released by National AIDS Treatment Advocacy Policy (NATAP),  heterosexual serodiscordant couples have an almost non-existent risk of HIV transmission if the HIV-positive partner has an undetectable viral load as a consequence of successful antiretroviral (ARV) therapy,  Presenting their findings at the Third International Workshop on HIV and Women in Toronto, researchers pooled data from six different studies of serodiscordant heterosexual couples, including the famous HPTN 052, which found a 96 percent risk reduction due to ARV therapy.

Three of the studies provided data on HIV transmission rates, ARV history and viral load of the HIV-positive partner. These studies included a combined 991 couples with 2,064 person-years of follow-up. The researchers found a transmission rate of 0.0 per 100 person years.

Three additional studies, including HPTN 052, had information on just rates of transmission and treatment history, covering 5,233 couples. Factoring in these studies with the other three, the researchers found a pooled transmission risk of 0.14 per 100 person years. In other words, if 1,000 serodiscordant couples in which the HIV-positive partner is on ARV therapy with an undetectable viral load had sex for one year, about one or two of the HIV-negative partners would become infected with the virus.

All four of the transmissions in the six studies took place before six months had passed since the HIV-positive partner began ARVs and therefore may not have yet reached an undetectable viral load. Taking this into account, the researchers conducted another analysis excluding the data from these transmissions. In this case, the risk of transmission was also 0.0 per 100 person years.

To read the conference abstract, click here.

Demand FDA Approve Rapid Over-the-Counter HIV Test

[Action Alert! We have ONE WEEK to submit comments to the FDA - instructions below]


According to the Center for Disease Control in Atlanta, (the "CDC"):

- 1.2 million people in the United States (U.S.) are living with HIV infection.

- One in five (20%) of those people – or about one-quarter million people are unaware of their infection. That’s the equivalent of the entire population of Jersey City, New Jersey; Orlando, Florida; or Buffalo New York living with an infectious disease and not knowing it.

- 50,000 new cases of HIV infection every year in the United States since the epidemic began.

- An estimated 17,774 people with AIDS died in 2009, and nearly 619,400 people with AIDS in the U.S. have died since the epidemic began.

The scientific and medical communities are united in their belief that one of the most effective ways to control the spread of HIV is through early detection (testing) and early treatment (Anti retroviral drugs that reduce the viral load to undetectable levels).
And so, the fact that a rapid-test to detect HIV has been available for over a decade, but is still illegal to sell over-the-counter in drug stores, is nothing short of criminal.

On November 3, 2005, (six and a half years ago) the Blood Products Advisory Committee of the FDA wrote:

Over the past four years, FDA has approved a number of rapid HIV tests of low complexity, which are simple to use, require no special storage conditions and provide a highly accurate test result within 20 minutes for the detection of antibodies to HIV. Two of these tests were found to be simple enough to perform that they received a CLIA waiver, expanding the availability of testing.

But here’s the kicker. The FDA continued:

Since 2002, all rapid HIV tests were approved as restricted devices, with sales and use restrictions in place. Sale is restricted to clinical laboratories …and [t]he test is approved for use only by an agent of a clinical laboratory...[The] FDA has discussed HIV home-use test kits and home-use collection kits over the past 10 years in various forums…In the course of these discussions, appropriate regulatory criteria were identified for home-use specimen collection kits for HIV testing, but not for home-use HIV test kits. With improved test kit technology (ease of use, freedom from biohazards, and excellent performance characteristics), we believe it may be feasible to identify regulatory criteria for home-use HIV test kit.


Yesterday, while walking through my local pharmacy, I saw at-home pregnancy tests; tests to detect cocaine, marijuana, and a list of other drugs in one’s system; and of course, the blood glucose tests that many diabetics use on a daily basis. But in spite of the available technology, no home tests for HIV…even though the FDA itself concluded in 2005:

“Benefits of HIV home-use test kits include anonymous testing potentially leading to more people knowing their HIV status, empowerment of consumers in healthcare decisions, earlier diagnosis of HIV infection and therefore earlier intervention.”

And yet, in the decade that has passed since the rapid tests were denied for private home use, 500,000 new HIV cases have occurred. Of those, 100,000 people do not even realize they are infected.

Why does this continue?

The FDA is concerned that “Risks of HIV home-use test kits include inappropriate use of the test or test result, including misinterpretation,” “obtaining a test result without live counseling,” and “and use by minors.”

Yeah? And so what? Aren’t those the possibilities with any of the above mentioned at-home tests sold in a drug store? Would we rather that minors who are uncomfortable in a clinic simply walk around with HIV and infect others as their own health deteriorates for unknown reasons? Are they suggesting that pregnancy is a condition that does not require a support system?

Thousands of individuals would use a test at home rather than go to a clinic. People in rural communities who are reluctant to show their faces in a clinic where everybody-knows-everybody; men or women who have cheated on a partner; young people still ill-at-ease with discussing their activities; those for whom English is not a first language and for whom clinical translations are not readily available; those who are high-profile members of their communities; and those who were raised with a fear or stigma of HIV and AIDs - would all be more likely to test at home than walk into a clinic.

The reasons for denying the public access to these tests are entirely unacceptable.

In a perverse reversal of roles, it is the HIV clinics themselves who have been partly responsible for the delay in releasing these tests to the public. The very clinics and “AIDS Service Organizations” or “ASOs” who exist to help HIV positive persons navigate complex legal and medical support systems have a vested interest in keeping these tests out of public hands. Annually these agencies report the number of people to whom they provided services to private donors, government agencies who fund them on a ‘per-person-served’ basis, and to United Way Charities, which requires a “Number Served” figure as part of their funding formula. Thus, some of those agencies that are most vocal about “supporting” the HIV community are actually the very agencies that have given life to the idea that the FDA should prohibit private, at-home testing because it wouldn't be accompanied by “live counseling.”

A recent survey of over 1,500 people by "Who's Positive" revealed the gap in support between persons living with HIV and those with a clinic-based livelihood or agency role. The survey found:

"The survey gathered responses from 1,569 participants, 74% of which said that they would support an OTC rapid, oral swab HIV test that could be purchased in a retail store, if approved by the FDA. Other key findings include:

66% of the respondents who identify as a HIV-positive consumer support an OTC HIV test
80% of those aged to 30 support an OTC HIV test"

But then went on to show lower support by those with a vested interest in maintaining clinic control"

"A majority or nearly 52% of those who identified as a paid member of an HIV/AIDS organization support an OTC HIV test
47% of those who identify as one who performs HIV testing support an HIV OTC test"

It is hypocritical, self-serving, and dangerous.

On the other hand, the public often views medical technology companies with a critical eye…but in this case, it has been just such a company – OraSure Technologies – which has been fighting for a decade to obtain FDA approval to market it’s 20-minute, at-home anonymous test kit.

And once again, the issue is scheduled to be discussed before the FDA Blood Products Advisory Committee. OraSure has applied – again - for the approval of its OraQuick(R) Rapid HIV-1/2 test for sale in the U.S. consumer or over-the-counter market at a meeting scheduled for May 15, 2012.

The Company will be presenting its findings from a study of 5,800 subjects who believed they were HIV negative. When enrolled in a test-phase using their at-home testing product across 20 sites nationwide, more than 100 of them tested HIV positive.

The FDA has issued the following public notice, permitting public comment in person or in writing. You know what to do:

On May 15, 2012, the FDA Blood Products Advisory Committee will meet from 8:30 a.m. to approximately 5:00 p.m. to discuss the evaluation of the safety and effectiveness of the OraQuick In-Home HIV Test.

The meeting will take place at the Hilton Washington DC/North, 620 Perry Pkwy., Gaithersburg, MD, Tel: 1-301-977-8900.
Interested persons may present data, information, or views, orally or in writing, on issues pending before the committee.

Written submissions may be made on or before May 8, 2012 by submitting them to:

Bryan Emery or Rosanna Harvey
1401 Rockville Pike, HFM-71, Rockville, MD 20852
301-827-1277
FAX: 301-827-0294
or via e-mail: Bryan.Emery@fda.hhs.gov or email: Rosanna.Harvey@fda.hhs.gov

Oral presentations at the meeting from the public will be scheduled between approximately 1:30 p.m. and 3:15 p.m. Those individuals interested in making formal oral presentations should notify Bryan Emery or Rosanna Harvey on or before April 30, 2012, and submit a brief statement of the general nature of the evidence or arguments they wish to present, the names and addresses of proposed participants, and an indication of the approximate time requested to make their presentation.
Time allotted for each presentation may be limited. If the number of registrants requesting to speak is greater than can be reasonably accommodated during the scheduled open public hearing session, FDA may conduct a lottery to determine the speakers for the scheduled open public hearing session. Those making a request to speak will be notified regarding their request by May 1, 2012.
The notice and complete description of the May 15 and May 16 meetings (as well as the link to the webcast for the hearings) is available on the FDA Website

[pictures: thanks to Tom Donohue of "Who's Positive"]

Year in Review: The Top 10 News Stories of 2011

From this Blogger's perspective, here are the top 10 news stories of 2011. Each was chosen based on their potential on-going long-term effects on humanity. In no particular order, they are:

1) The Arab Spring: Erupting in Tunisia and spreading across the Arab world, the entire year was characterized by protests and political changes in Northern Africa and the Middle East. Regime changes in Tunisia, Egypt, and Libya, as well as on-going protests in a dozen nations (currently (most serious in Syria and Yemen) represent serious winds of change throughout the geo-political sphere. A timeline of protests throughout the Arab world can be found at The Guardian

2) Weather Extremes and Global Warming: Once a matter of debate, the vast majority of the world’s climatologists agree that global warming is happening at an even faster rate than expected, with significant changes in the ocean temperatures and subsequent weather patterns. According to the National Oceanic and Atmospheric Administration, there were an all-time record of twelve weather disasters costing more than $1 billion each in 2011 (for a total of 45 billion dollars in damage). The previous record was nine such disasters in 2008. Weather events included a blizzard across much of North America on February 2, record wilfires in the US west, a tornado outbreak that levelled Joplin, Missouri, Hurricane Irene (which uncharacteristically inundated and devastated inland communities in Vermont and Upstate New York), and a foot-and-half snowfall at Halloween in the northeast US. Elsewhere, record high temperatures were recorded in Iraq and Kuwait, an all-time record low volume of Arctic sea was recorded, record floods inundated Australia and Asia, and the worst droughts in three decades affected Africa.

3) Osama bin Laden Killed: A decade after he masterminded the 9/11 attacks on New York City’s World Trade Center, Osama bin Laden was killed in a surgical strike on his hideout in Pakistan. This represented the most visible and significant victory in the global fight against terrorism and the al Qaeda organization.

4) New York State Enacts Marriage Equality: Four days after its scheduled adjournment for the season, the New York State Senate gave its approval to Marriage Equality by a larger-than expected margin of 33-29 when four Republicans broke rank and joined the majority of Democrats, making New York the seventh and largest jurisdiction in the US to permit same-sex marriage. Full story at Tully's Page

5) Occupy Wall Street and Police Brutality: Beginning on September 17 in New York City, the “Occupy Wall Street” movement in many ways inaugurated an American version of the Arab Spring. Spreading to other cities across the nation, thousands of Americans from all walks of life took to the streets to protest persistent unemployment, indebtedness, foreclosures and economic injustice in raw juxtaposition to the trillions of bailouts received by Wall Street financial houses and executives. The movement elicited a brutal response by police forces, and the use of pepper spray against peaceful protesters, young women, and veterans became a national outrage. The movement propelled Time magazine to name “The Protester” as it’s Person of the Year.

6) Federal Reserve Bailouts Revealed: For almost 100 years, the Federal Reserve System, which serves as the nations Central Bank, operated without an audit or significant political oversight. In the aftermath of the bank bailouts commencing in 2008, Congress began looking into the Fed’s activities using taxpayer dollars. In all, it was revealed that over 16 trillion in secret unpaid loans were made to both American and foreign banks. Sen. Bernie Sanders

7) Earthquake, Tsunami, and Nuclear Meltdown in Japan: On March 11, an 8.9 Magnitude earthquake rocked Japan, the worst earthquake in modern history. Over 16,000 people died from the quake and the tsunami that followed. When the Fukushima Daiichi power plant site in Fukushima was inundated by a 49-foot high tsunami wave, the nuclear reactors could not be cooled, began to overheat, and meltdowns began at three of the reactors. What followed was a release of radioactive cesium, evacuation of the surrounding area, and subsequent government and industry cover-ups of the extent of radiation. Fukushima Radiation

8) John Wheeler Murdered: On New Year’s Eve, after the death of 100,000 fish and 5,000 blackbirds in Arkansas, John P. Wheeler, a decades-long government expert in toxic chemicals, was found murdered in a dump as he was en route to Washington DC. The kills and murder came in the wake of the US Government’s Pine Bluffs Arsenal "disposal” of mustard and nerve gas in the area, as well as active “fracking” by energy companies. The incidences awakened a national concern for the environmental effects of these activities, and was the single most visited and cited webpage on this site: John Wheeler

9) Milton Hershey Rejects HIV Positive Student: In an almost incomprehensible burst of ignorance, prejudice, and chutzpah, the highly-vaunted Milton Hershey School (a private, tuition-free boarding school), issued a statement coinciding with World AIDs Day explaining their refusal to admit a student due to his HIV positive status, in direct violation of the federal Americans with Disabilities Act (ADA). Outrage was swift, and brought additional publicity to continuing ignorance about HIV transmission. Milton Hershey

10) European Debt Crisis: Beginning in Greece, the ability of some Eurozone member nations to repay their government debts created continental – and global – concern. Ireland, once seen as the “Celtic Tiger” for its explosive, high-tech-driven growth found itself enacting austerity measures and slashing government spending; Italy, Portugal, and Spain found themselves in a similar condition. The downgrading of these nations bonds began a record weakening of the Euro against the US Dollar that continued throughout the year. A weakened Euro makes it more difficult for the Eurozone members to purchase American goods, endangering the US recovery.

Milton Hershey rejects HIV-positive Student: Official Statement & Reaction

In an almost incomprehensible burst of ignorance, prejudice, and chutzpah, the highly-vaunted Milton Hershey School (a private, tuition-free boarding school), issued a statement coinciding with World AIDs Day explaining their refusal to admit a student due to his HIV positive status.

What follows is the official statement by the school (in italics), with my commentary following in boldface type.

HERSHEY, Pa., Dec. 1, 2011 -- /PRNewswire/ -- The following statement was issued today by Connie McNamara, Vice President, Communications at Milton Hershey School:

Milton Hershey School had planned to file a request in federal court asking the court to review our decision to deny enrollment to a child who is HIV positive because of concerns for the health and safety of our current students.

Nonsense. There ARE NO significant health or safety concerns. HIV is not transmitted by saliva, sneezing, sweat or tears; it is not transmitted by sharing toilets or bathrooms, drinking glasses, laundry facilities, towels, beds, dorm rooms, or eating utensils. In addition, the student in question is on antiretroviral medications, reducing the ability to transmit the virus, even in the most conducive of circumstances through specific kinds of sexual acts or blood interaction, to a fraction of 1%. It is not surprising that a Hershey spokeswoman, appearing on Anderson Cooper 360 tonight, was unable to name the doctor or medical personnel that advised the school of any such “concern.”

We had been in discussions with the AIDS Law Project of Pennsylvania, which is representing this 13-year-old boy. Recognizing the complex legal issues, the School was preparing to ask the court to weigh in on this matter…

There are no “complex legal issues.” Persons with HIV are covered by the Americans With Disabilities Act. Under the ADA, all people, including those with disabilities, are given equal opportunity to use or enjoy a public accommodation’s goods, services, and facilities. Public accommodations include restaurants, hotels, theaters, doctors’ offices, dentists’ offices, hospitals, retail stores, health clubs, museums, libraries, private schools, and day care centers.

… Unfortunately, attorneys for the young man took the adversarial action of filing a lawsuit against the School.

The first resort of bullies when victims push back is to call the victims names; they attempt to characterize those who insist on their rights as crybabies, divisive or ‘adversarial.’ The young man’s legal suit is not out of place or adversarial; the fact is, Milton Hershey has no basis in medicine or law for denying the student admission, and the students suit against the School is an entirely appropriate avenue for redress. Hershey’s statement is the standard “blame-the victim” defense.

The decision to deny enrollment was a challenging one for us to make. Like all our enrollment decisions, we need to balance our desire to serve the needs of an individual child seeking admission with our obligation to protect the health and safety of all 1,850 children already in our care…

Again, the school takes the odd position that their school is somehow ‘unique,’ a phrase used later in this press release and used multiple times in media interviews. The ADA covers private schools; there is nothing about Hershey that would exempt them. There are hundreds of boarding schools in the United States, a number of which house over 1,000 students. There are schools designated as Military Academies, Therapeutic Schools, schools for Students in Recovery, Experiential, Learning Disabled, Religious, Fine-Arts based, Math & Science-based, and Performing Arts based. In spite of Hershey’s assertions, their duty to care for their residential students is no different than any other of these schools…and all are covered by the ADA.

Attorneys for this young man and his mother have suggested that this case is comparable to the Ryan White case. But this case is actually nothing like the Ryan White case.

Actually, it is precisely like the Ryan White case, which, ironically, we referenced in a blogpost yesterday [see below]. This is a decision to exclude a student based on ignorance of medicine and in violation of federal statute. It is based on the unreasonable fear & loathing of HIV, and nothing more.

Milton Hershey School is not a day school, where students go home to their family at the end of the day. Instead, this is a unique home-like environment, a pre-K -12 residential school where children live in homes with 10-12 other students on our campus 24 hours a day, 7 days a week.

Again, Hershey is by no means unique in this, as hundreds of boarding schools do likewise. Hershey is making the entirely illogical arguement that students with HIV should not live at their school because it is "home-like," "residential," and where "children live," (their words)...but should instead live at home - which is the ultimate 'residential setting.'

In order to protect our children in this unique environment, we cannot accommodate the needs of students …

Yes, Milton Hershey, you can, and you must. You must accommodate the daily medical needs of students with insulin-dependent Diabetes. Epilepsy. Asthmatics. It is part of running a boarding school. If you can not ensure that a resident takes a pill, you need to reconsider your ability to operate a boarding school.

…with chronic communicable diseases that pose a direct threat to the health and safety of others.

This is not an argument against admitting a student; this is evidence of your own medical ignorance. No health or safety threat is present.

The reason is simple. We are serving children, and no child can be assumed to always make responsible decisions that protect the well being of others.

This is a well-crafted innuendo concerning the prospective students sexual activities, implying that the student might attempt sexual activity with another student. Well guess what, Milton Hershey…if that is your concern, you have a much bigger problem than this one student: EVERY one of your hormone-exploding students might be tempted to engage in sexual relations with other students, and pass along not only HIV, but syphilis, gonorrhea, chlamydia, herpes, genital warts, scabies, hepatitis, and HPV. Your reasoning suggests that you should reject ALL students who might be tempted to engage in sexual activity; In that case, you might want to consider closing down entirely, because all teenage students present that risk.

That is why, after careful review and analysis, we determined we could not put our children at risk.

No, this was not after “careful review and analysis.” There is no analysis of the medical or legal issues; there is only an unwise, illegal, and cruel response based on hysteria that tarnishes the reputation of a once-respected institution.



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Fiscal Conservatives: Ending DOMA is a responsible step

Robert and Carl* are a gay couple who have been together for several years. They live in a state that permits same-sex marriage, and recently tied the knot in a Church ceremony. Like many other married couples, they have established a stable home and are active members of their community. Carl is healthy but lives with a manageable medical condition. Like approximately 1.1 million other Americans, Carl is HIV positive.

Today, HIV positive people are living long, normal, healthy lives…as long as they receive proper medical care. Highly Active Anti-Retroviral Therapy (HAART), a combination of three medications, is now the standard treatment to battle HIV. While quite effective one of the major downsides of treatment is cost. Carl’s three medications run about $2,200 per month…a figure that is quite typical. This, of course, does not include approximately six blood tests and physicians appointments per year, bringing his treatment costs to about $3,000 per month.

The US Congress recognized the steep cost of treatment when they reauthorized the Ryan White Care Act in 2009 by a vote of 408-9. This Act authorizes the expenditure of over $2 billion annually to assist with HIV outreach and treatment. It is the ‘payer of last resort,’ and income guidelines are applied towards recipients, but still it is estimated that some 30% of HIV positive individuals receive some assistance through this program.

More comprehensive coverage, of course, is available through private insurance. More than 25% of Americans work for an employer that offers domestic partner benefits; 51% percent of Fortune 500 companies offer domestic partner health benefits; and 37% of all Americans live in states where some legal protection of same-sex partner arrangements exist (marriage, civil unions, or domestic partner benefits.)

Back to Robert and Carl.

Robert has a full-time, secure job, and both he and his employer contribute towards Roberts’ health insurance. When Robert married Carl, they looked forward to Carl’s being added to Roberts policy as a spouse, thus providing not only coverage for Carl’s HIV medicine, but for the entire range of normal health care for which the typical American might visit the doctor or the hospital. Robert, who had been married before, had already had his children (and formerly, an ex-wife), on his family policy.

Enter the federal Defense of Marriage Act (“DOMA”).

Under DOMA, the federal government agencies are prohibited from recognizing the validity of same-sex unions of any kind, even when they are authorized under state law. This is a significant change to federal-state relationships, since Family Law issues have always been decided at the state level. As a result, in Rhode Island, Alabama, and Alaska first cousins may legally marry, while in Louisiana, New Hampshire, and Pennsylvania such marriages are illegal. The Federal government dos not take a stand on this issue: they accept first-cousin marriages from Alaska as legal, but would reject the validity of first-cousin marriages illegally performed in Pennsylvania. In other words, the federal government normally accepts the states’ definition of marriage as authoritative in the matter of marriage.

Under DOMA, however, the federal government will not consider a same-sex marriage, validly performed under state law, as a valid marriage under federal law. And that has serious federal income tax implications.

When Robert added Carl, his lawful spouse, to his family health insurance, his HR office informed him that since Carl was not a spouse under federal law, Robert would have to pay taxes on “imputed income” to Carl. “Imputed Income is the addition of the value of cash/non-cash compensation to an employees’ taxable wages,” and both federal income taxes and FICA (Social Security) taxes are assessed against the value of this imputed income.

Robert was shocked when he saw his next paycheck. In order to cover the imputed value of providing health insurance to his spouse – an action that is never applied to an opposite-sex spouse – his employer had withheld an additional $450/month from his paycheck.

As a middle-class income-earner, the loss of an additional $5,400 annually was too much to absorb. Robert removed Carl from his health insurance policy, and Carl applied for – and received – HIV coverage under the Ryan White Act.

The sad reality is that without DOMA, Carl could have been added to a private insurance policy just as any other spouse could be, without the punishing effect of federal taxes associated with imputed income.

Because of DOMA, American taxpayers will now pay a minimum of $36,000 annually for Carl. And this is just a single instance of a pattern that is replicated across the nation.

There are over 1.1 million HIV positive Americans. 30% receive assistance through the Two Billion dollar plus Ryan White Care Act. Close to half might currently or eventually be eligible for private insurance coverage through spouses, civil unions, domestic partnership arrangements, or company policies.

Fiscal Conservatives, take note: one of the single most significant actions you could take to reduce spending and taxpayer burden, while improving health care provisions for hundreds of thousands of Americans, is to repeal the provision of DOMA that prohibits federal recognition of valid state marriages.

The only real question is whether you believe that punishing homosexual couples is a more important public policy goal.

*Robert and Carl are not their real names, but they are real people and the dollar figures and story are entirely accurate.
--------------------------

SOURCES:

CDC 'HIV Prevalence Estimates -- United States, 2006' MMWR 57(39), 3 October 2008
http://health.msn.com/health-topics/articlepage.aspx?cp-documentid=100057404
http://aids.about.com/od/hivmedicationfactsheets/a/drugcost.htm
AIDS Drug Assistance Programs (ADAPs) - Henry J. Kaiser Family Foundation Fact Sheet
U.S. Census Bureau. “County Business Patterns: 2000.”
Human Rights Campaign, “State of the Workplace: 2006.”
http://www.haasjr.org/index.php
http://definitions.uslegal.com/i/imputed-income/