"Sex is an integral part of my life, and I don’t intend to stick on a piece of rubber that will rob me of its pleasure.” Over the past few years, I heard words to that effect, in one variation or another, from a good friend who holds a senior position in an investment house. He wanted to explain why he always has unprotected sex. “It bothered me in my twenties, but since then I have completely freed myself,” he says. He didn’t repress the possibility that he would become a victim of an STD − sexually transmitted disease − with AIDS looming particularly large. On the contrary: he had regular checkups, once every six months on average. A few months ago he tested positive; he is a carrier. But even now, as a carrier, he hasn’t changed his tune. Taking a daily pill is a tiny nuisance compared to the alternative of enslavement to condoms.
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Though one’s initial instinct is to accuse my friend of irresponsible behavior, more and more experts would say that he “handled the matter” in a mature way. Thanks to the frequent checkups, he was able to discover the virus within a relatively short time after being infected, and he immediately began treatment.
Medical treatment dramatically reduces the possibility that he will infect others. In fact, it turned out, in the course of his regular follow-ups, that his viral load − the level of HIV in the blood − is undetectable, thus diminishing the risk of transmission even further. Studies show that the likelihood of carriers transmitting the virus decreases by 96 percent if they are under medicinal treatment (even in cases of unprotected sex). The growing sophistication of the medicinal treatment, and its transformation into no more than a minor burden, has not only brought about a change in the carriers’ everyday life, it has generated a new approach to HIV throughout the Western world – both in the scientific community and also in the at-risk population (those prone to infection).
The relevant data: in 2012, 496 new cases of infection were discovered in Israel (an increase of 8 percent over 2011), of which 150 cases involved men having sexual relations with men (30 percent). These figures are similar to the rates that were reported at the end of the 1980s, not long after the disease appeared, when 38 percent of the carriers in Israel were homosexual. But afterward, the rate fell steadily, leveling off in the 1990s at just 5 percent. In recent years, though, the trend has reversed itself.
Let there be no confusion: No one says that condom use should stop, but in the spirit of the American “Treatment as Prevention” approach − part of a broader plan to cope with HIV that was articulated in the Bush administration and is continuing to be updated under President Barack Obama − the medical establishment is no longer ignoring the reality in the field. The assumption underlying Treatment as Prevention is that the more carriers there are who are under treatment, the fewer new cases of infection there will be. The rationale is that if a kind of “interim generation” can be created of carriers who get treatment and are not infectious, it will be possible to kill off the disease, or at least considerably reduce its rate among the population.
Sex toy for the rich
The way in which the medical establishment in Israel is adapting itself to this approach − or not − will be considered later. In the meantime, it is useful to look at another manifestation of the “pill revolution.” It rests on the assumption that Truvada, one of the medicines that make up the AIDS treatment cocktail, in addition to “suppressing” the virus and preventing the disease from breaking out, also makes it possible for healthy people to avoid becoming infected. One of the unplanned results is that people take the drug ahead of a wild and intensive weekend of passion parties followed by unprotected sex, thus ostensibly providing immunization against infection. How widespread this phenomenon is in Israel is not known. The people I spoke to thought it was fairly marginal, though a night person in the gay community admitted, not for attribution: “It has become a genuine trend. There are communities abroad that are far more permissive, if we can call it that, such as in Berlin, for example, where ‘condom’ is not part of the lexicon. So, before a holiday people stuff themselves with Truvada and allow themselves to run wild freely.” Legally, Truvada is available only to those who need it, but anyone who really wants to obtain it can do so. The simplest option is to ask a carrier friend to do you a favor and trust him to fill in what he needs somehow (though it’s a complicated procedure). Rumors of more sophisticated ploys are rife in the community. For example, you go to a hospital and fake a scenario of possible exposure to the virus − the condom tore, I got carried away, I didn’t notice − and request a post-exposure prophylaxis. But instead of taking the pills immediately, you store them for the right occasion.
Marginal or not, this phenomenon did not arise in a vacuum; it draws inspiration from a series of scientific publications and reports in the media. In November 2010, the prestigious periodical The New England Journal of Medicine published the results of an experiment which declared that treatment capable of reducing the likelihood of HIV infection by 90 percent existed. No vaccination for the disease has been found − that is still a long way off − and despite the dramatic results and the public stir the study generated, it did not offer any chemical news that the scientific community didn’t already know. All told, the research, which was funded by the National Institutes of Health in the United States, proved the effectiveness of Truvada as a preventive treatment.
The experiment encompassed 2,500 negative homosexuals − that is, healthy ones − half of whom received the medicine and were the experimental group, while the other half, the control group, received a placebo.
The researchers asked all of them to engage in protected sex and gave them ongoing advice about sexual diseases. At the end of two and a half years, the average monitoring time, the infection rate among those for whom Truvada was readily available was 44 percent lower than in those who did not take it. The most impressive finding was that, of those who took the medication consistently − as could be gleaned from its presence in their blood − 95 percent were not infected.
Dr. Robert Grant, the project’s chief researcher, maintained that those who never missed taking the pill and took it meticulously seven times a week, were “completely protected.” Time Magazine picked the treatment, which is known as PrEP (pre-exposure prophylaxis) as that year’s “top medical breakthrough.”
President Obama himself congratulated the research team in a phone call, and the American Centers for Disease Control put out new guidelines recommending Truvada’s usage for those at high risk of contracting HIV.
That was almost three years ago. Two months ago, The New Yorker published an article criticizing the excessively slow adoption of the drug. Quoting a CDC official, the author, Christopher Glazek, wrote that “at least half a million Americans are good candidates for PrEP − meaning that they are at high risk for contracting HIV through sexual activity − yet only a few thousand Americans are receiving the treatment.” The article also devoted extensive space to the viewpoint of the method’s critics. They question its effectiveness and maintain that it validates dangerous sexual behavior, is ineffective in preventing other sexual diseases and is liable to bring about the development of new species of the virus that will be immune to the cocktail.
The most acerbic of the opponents described PrEP as a “profit-driven sex toy for rich Westerners.” Some even claimed that the government was in cahoots with the manufacturer of the drug in promoting its use. The debate, as the article indicates, is emotional and at times bitter. Yet its very existence shows that the establishment is not taking a do-nothing approach, but is responsive to scientific developments. In Israel, however, the issue of pre-exposure treatment has not yet been raised for professional discussion in the Health Ministry or among the physicians who treat AIDS, still less has it become a routine element in preventive treatment.
Fed up with condoms
Dr. Gal Wagner Kolasko, who runs the LGBT clinic (of the Clalit HMO) in Tel Aviv’s Gan Meir public park, believes that we need to think out of the box. “I can’t say definitively that preventive treatment is the perfect solution and will save us from HIV, but I do think that to ignore the subject, as is the case in Israel, is wrong and that it needs to be discussed,” he says. “It has to be admitted that many in the community are fed up with condoms. Whereas in the past you could see ‘dead’ people walking in the street and fear of the disease led to a sweeping use of condoms, young people today don’t know anyone who is ill with AIDS. There are some among them who want to enjoy sex, and preaching or distributing condoms at the entrance to the bathroom in clubs won’t help. It is definitely possible that if we offer medicinal treatment to this population, their chance of becoming infected will decrease substantially.”
The implication is that people will take medicine every day and live as carriers even though they are HIV-negative. What about the drug’s long-term effects?
“It doesn’t have to be a lifelong solution. People can take the drug for five or ten years − in the period when they are sexually active at an intensive level − and stop when they have ‘calmed down.’ In the meantime, science might come up with more effective solutions, which will provide better protection. People who are concerned about their health and use condoms will keep on doing so, and will not rely on drugs that don’t offer full protection. This form of treatment is meant for those who don’t use condoms anyway, and they will have to take into account possible side effects.”
Isn’t it morally flawed for the authorities to grant medicinal treatment only because people don’t feel like using a condom?
“It is impossible to ignore the standstill policy of ‘use a condom’ as the only option. It’s not necessary to fund the medical treatment; it can be subsidized. Generally speaking, the fact is that this medical discovery exists out there, and the Health Ministry should give it consideration. For starters, they could decide to conduct an experiment, maybe harnessing one of the pharmaceutical companies, to examine the treatment as a possible goal that is part of a larger, fully worked out preventive plan.”
Wagner Kolasko’s approach cannot be said to reflect a consensus in the community. “We certainly support an open dialogue regarding all possibilities of prevention,” says Dr. Yuval Livnat, the director of Israel’s AIDS Task Force. “But there is a certain illogic in taking medicines by choice in an era in which infection would result in the taking of those same medicines.” Noting the arguments about developing immunity to the drug and the fact that the method does not protect against other sexual diseases, Livnat concludes, “Taking the overall view, the PrEP solution cannot be the high road, and the idea of an entire community living on pills is certainly not a desirable vision.”
Fertility clinics for carriers
Although the issue of prophylactic treatment in the gay community is understandably controversial, it is important to point out that a method of this kind can also be very effective for mixed couples − male carrier and healthy female − especially if the woman wants to conceive. In the United States and Britain, there are already clinics which, with establishment backing, recommend to such couples that they have sexual intercourse without a condom when the woman is ovulating, on condition that she take Truvada. At present, fertility treatments in Israel are centered in two venues: the In Vitro Fertilization Unit at Rambam Medical Center in Haifa, and the sperm-washing unit at Hadassah Medical Center in Ein Karem, Jerusalem. Both procedures were introduced about three years ago and have been beneficial to carriers, even though they are expensive and complicated. The Health Ministry has recently considered the possibility of opening additional “branches” for fertility treatments, though the question of preventive treatment has not yet been taken up.
“We are still somewhat conservative in Israel, but there is no doubt that the whole subject of sperm washing will become superfluous once the new method receives the legitimization of the medical establishment. We are following developments in Europe and the United States with interest,” says Dr. Margalit Lorber, the director of the Clinical Immunology Unit at Rambam, and the first in Israel to use the technique of sperm washing for carriers. (Sperm washing is the process in which individual sperm are separated from the seminal fluid. The sperm are then used in intrauterine insemination or in IVF.) “The medical community is definitely moving to PrEP usage. If a person is in the undetectable category, the likelihood that he will infect others is very low to begin with, and if the woman receives prophylactic treatment, the likelihood is reduced to the level of negligibility,” Lorber adds.
It needs to be said that preventive treatment, though as yet unexamined by the establishment in Israel, is actually far from being fully accepted elsewhere in the West as well. If Israel wants to close gaps, it might do better to focus first on another area related to childbirth, namely testing pregnant women for HIV. In contrast to the great majority of Western European countries, where pregnant women are routinely checked (in the United States, the recommendation is to do an additional test, close to the projected birth date, among women in at-risk populations), in Israel the test is not included in the recommended “basket of tests” and is certainly not classified as obligatory.
“The Health Ministry’s approach to date was that there are specific population groups in which the risk is significant and obliges a test. But other women have a low probability of becoming infected, so why should we worry them?” says Dr. Michal Chowers, director of the Infectious Diseases Unit and the AIDS Center at Meir Hospital, Kfar Sava. “However, the scientific literature recognizes the fact that when you survey only the at-risk populations, you unavoidably miss people, those who fall between the cracks.
“If a woman comes from a country where AIDS frequency is high,” Chowers says, “it’s clear that she belongs to a group at risk. But what about a woman whose partner used narcotics in the past? How is the nurse supposed to spot that on the basis of observation? Generally speaking, because no uniform procedure exists, this test [for HIV], though inexpensive and simple, is not in the medical staff’s consciousness.” But couples undergoing a fertility procedure are both required to be tested before the process begins.
The Israeli Association for AIDS Medicine, an organization of expert physicians in the field, and of which Dr. Chowers is chairman, recently singled out HIV tests for pregnant women as a primary goal. “This year, two babies were born to Israeli women who did not know they were carriers, and that is also the average across the past 10 years. In practice, there are eight mothers a year on average who were not identified, because there is a 25 percent chance of transmission,” Chowers says.
“We carried out a cost-effectiveness test of the Health Ministry’s current policy, vs. the policy we are proposing. The cost of doing a test on all the [pregnant] women in a calendar year and monitoring them is NIS 4 million annually. But given that the medical treatment for children who are born as carriers never ends, the present policy both fails to prevent infection and is ultimately costlier.”
Over the years, the Health Ministry has come under massive pressure to adopt a different policy. “The accepted approach in Israel today, of ‘surveying women at risk only’ is anachronistic and ineffective,” Yonatan Karni, the former executive director of the AIDS Task Force, wrote in a letter to the Health Ministry in 2009. “If we had chosen to follow the recommendations [to implement policies] which have existed in countries such as the United States, Canada and Holland for years, we would have prevented the infection of dozens of babies born in 21st-century Israel as HIV carriers. Treating those children, who will have to live with a chronic disease for their whole life, will cost the state more than NIS 1.3 billion. That amount would suffice to underwrite HIV tests for all the pregnant women in Israel for the next 44 years.”
The official who fiercely opposed such a change and blocked it for years is Dr. Daniel Shem-Tov, the head of the tuberculosis and AIDS department in the Health Ministry. He cited two main reasons for his opposition: the high cost of testing tens of thousands of women a year, despite the almost nonexistent probability that they were carrying the virus; and the fact that on many occasions the first test indicated that a woman was a carrier, but a repeat test found that this was not the case. Shem-Tov has apparently retreated from this approach recently.
“After the move to fourth-generation testing kits and a significant decline of the risk of obtaining mistaken results, there is today no fundamental
opposition to recommending that all pregnant women undergo tests for HIV,” a source in the Health Ministry says. The source adds that the ministry is currently examining the possibility of updating the recommendations. Furthermore, “every pregnant woman can be tested for HIV through her health maintenance organization with no economic hindrance, and there is a Health Ministry procedure to have women who are at risk tested.”
The fact Shem-Tov has dropped his opposition should have paved the way for HIV tests to enter the basket of recommended tests. However, setting the change in motion has now run into a budgetary obstacle: since July 1, the HMOs have been responsible for paying for the test. “Now the mission is to persuade the HMOs to look ahead a few years and not just at the here-and-now,” says Chowers.
The game of the name
The issue of tests for pregnant women brought out differences of approach between Dr. Shem-Tov and many physicians and others who are not part of the establishment. But this is not the only contentious issue. Many of those who were interviewed for this article − representatives of nonprofit associations, officials of organizations, physicians − said the dialogue with the Health Ministry’s tuberculosis and AIDS unit left them deeply frustrated. So much so that some of them have forged a “Shem-Tov bypass” and are in direct contact with Prof. Itamar Gruto, the head of the public health division in the Health Ministry, and with the ministry’s director general, Prof. Roni Gamzo.
The gist of the criticism leveled at Shem-Tov’s unit is that it sanctifies the status quo, clings to assumptions whose relevance needs to be reexamined from time to time, and in general is reluctant to take dramatic action. For example, Shem-Tov is considered to personify the conservative approach on the Advisory Committee for Blood Transfusion Medicine. This is a body that meets at the request of the health minister and examines the necessity of the clause in the form filled out by blood donors which prohibits men who have had sexual relations with other men after 1977 from donating blood. Shem-Tov sees no urgency in revising or amending this procedure, as has been done in a number of Western countries. Still, the various organizations involved point out that there are far more critical issues to deal with than the issue of the questionnaire. Mentioning Shem-Tov’s stance in this connection is mostly symbolic, they say.
According to a Health Ministry source, “The committee took up the issue in depth in order to examine the possibility of shortening the period in which blood donations from homosexuals are rejected. The Health Ministry is examining the policy followed by other countries in this matter and will formulate its position on the subject soon.”
The Health Ministry rejects the personal criticism leveled at Shem-Tov: “The tuberculosis and AIDS department has engaged in a dialogue of many years with a large number of [individuals and institutions]. Naturally, the approaches are not always identical and agreement is not always reached, as in every professional field. The ministry’s policy is based − in part, but not wholly − on recommendations from the tuberculosis and AIDS department. The fact that others in the ministry, such as the director general and the head of the public-health services, pursue an open-door policy and allow a variety of opinions to be voiced, does not necessarily attest to a special need to create ‘bypass routes,’ as intimated in the article.”
In any event, a significant dispute with Shem-Tov emerged on June 30, following the publication of a director general’s circular issued on behalf of Shem-Tov’s department, stating: “The preferred manner of testing for the HIV virus is by name and confidentially.” This “preference” turned out to have more general implications. “Anonymous tests will not be financed by the Health Ministry, other than those conducted in the ministry’s clinics for sexually transmitted diseases,” the circular stated. The organization that stood to be harmed most by the new guideline is the AIDS Task Force, which has been conducting anonymous tests for the past five years and sending the samples to Kaplan Hospital in Rehovot for analysis without paying for them. The new ministry edict could translate into a budget shortfall of some NIS 200,000 a year for the AIDS Task Force, which even now enjoys negligible support from the state at best.
A major reason for the surprise expressed in the light of the new directive is that it flies in the face of the prevailing trend internationally: to facilitate anonymous testing, especially among at-risk population groups. The U.S.-based Treatment as Prevention approach is based primarily on tests on as large a scale as possible, and which are accessible to the public. In the United States, for example, one can purchase home kits for HIV tests using saliva − nothing could be more anonymous.
According to Wagner Kolasko, “The Health Ministry needs to maximize in every way possible the number of people who are tested. If two of 10 people who I refer to an HIV test prefer to have the test done by the AIDS Task Force, because they will get a speedy answer and are concerned that the information is not sufficiently confidential in the HMO − maybe their aunt works there − why should we forgo that 20 percent? That the HIV stigma still exists, even among medical teams, is undeniable; so much so that people are afraid that an HIV-positive result will be forwarded directly to their family doctor [by the HMO].”
Indeed, the fact is that in Israel, for every person who identifies and tests HIV-positive, three anonymously taken tests turn out to be HIV-positive. To be more precise, one of 196 people who were tested in 2011-2012 under anonymous conditions by the AIDS Task Force were HIV-positive, whereas only one of 615 people who were tested by other organizations, most of which do not allow anonymity, tested positive.
The explanation for these results is almost intuitive and rests on a solid social rationale: even in a milieu which perceives itself as liberal, the disease is associated with a multitude of taboos. People who belong to the main groups at risk, such as homosexual men, and particularly those who hide their sexual proclivity, are not eager to volunteer personal information and have their name entered into state databases. Refugees and work migrants, who constitute another group at risk, fearing the authorities’ response, tend not to trust the hospitals and the HMOs, and almost always prefer to be tested anonymously (see below). The new policy advocated by Shem-Tov’s unit stems from a desire to supervise the statistics and ensure that no one will slip under the radar, avoid receiving medical treatment and thereby endanger others. This approach is not without logic, though in practice it turns out to be irrelevant.
“The fact is that, in the past year, we had no cases of people who disappeared after testing positive and who refused to provide their details,” the task force’s director, Yuval Livnat, says. “There is a trade-off here,” he continues. “If it’s decided that the tests will only be given to those who identify themselves, obviously no one who is tested will slip under the radar. On the other hand, it is more than likely that in this case we will not reach many potential cases for testing, some of whom would test positive. Furthermore, every rational person knows that even if the test is anonymous, if the result is positive the individual will have to identify himself in order to receive treatment. It follows that the advantage of the anonymous test far outweighs the possibility that someone will test positive in anonymous conditions and then disappear. It’s just worth it. Period.”
In the light of this, the issue of financing for the anonymous tests stirred a furor whose impact was clearly felt in the Health Ministry and threatened to spill over into the Knesset. The pressure paid off. In the wake of a request by MKs Karine Elharrar (Yesh Atid) and Erel Margalit (Labor), Health Minister Yael German this month ordered the procedure to be updated again and to provide financing for the anonymous tests. The AIDS Task Force welcomed the decision.
In the past, the tendency was to wait to give treatment until the CD4 cell count was below 300 − that is, until there was a real indication that the immune system had been weakened − based on the idea that it was better to defer using medicines for as long as possible. Today, however, the pendulum has swung sharply the other way, and the tendency is to take immediate action.
At the same time, the Western world is starting to retreat from the idea that a borderline needs to be demarcated. “The prevailing policy internationally is in the spirit of Treatment as Prevention − providing immediate medicinal treatment,” says Dr. Lorber. “That is also better at both the personal level, for the patient, and at the community level, because the more you reduce the viral load in a particular community, the less chance there is of infection. This approach is accepted today in many countries, with Canada in the lead. In the United States, the formal guideline is to begin treatment below 500, but the final decision is left up to the treating physician, in consultation with the patient, so this is not a rigid restriction.
“In Israel, though,” she adds, “the criterion is fixed and the physician has no discretion in the matter. Basically, even if the CD4 count is 501, the establishment does not permit medicinal treatment to begin. We plan to hold a discussion of this issue with the AIDS Task Force, with the intention of submitting recommendations on the subject ahead of the deliberations on the next ‘health basket.’ The below-500 approach will gradually disappear. The physicians in Israel are very aware and very much updated, and the aspiration is for the Health Ministry to overhaul the procedures, too.”
Not all doctors share this viewpoint. For example, Dr. Dan Turner, director of the AIDS Center at Sourasky Medical Center (Ichilov Hospital) in Tel Aviv, says bluntly, “I am not part of the trend.” According to Turner, “We do not yet have unequivocal proof of the effectiveness of Treatment as Prevention, and despite the feeling that this is the direction, it is mixed with response to social pressure and a demand for immediacy. I myself am taking part in an international study that is examining the basis for this assumption. We also have to take into account the possibility of immunity to drugs when they are taken in masses and year after year. In general, every case should be examined on its own merits. If there is a patient who has a high chance of becoming infected or who is in a relationship, I too would recommend early treatment − but not as a general policy.”
In any event, individuals close to Dr. Shem-Tov emphasize that they are keeping abreast of developments internationally and that they intend to examine whether new guidelines should be published. However, physicians do not intend to wait for the authorities to act. As the HMOs − which approve the drug prescriptions and underwrite them − lack access to hospital databases, the doctors can “play” with the data to ensure that a newly diagnosed carrier will receive treatment, even though the condition of his immune system is not “sufficiently deteriorated.”
Haaretz is in possession of testimonies about physicians who introduced deliberately mistaken information − lower than 500 − in their medical opinion, knowing that otherwise the HMOs would not allow treatment to begin. “If I write 400 or 450, the patient will start to receive medicines without any problem,” Dr. A. admits. “But we don’t want to work like that. We want to do things properly. You can call it ‘Israbluff,’ but in large measure it’s due to a rigid establishment. Our first consideration is for the good of our patients. There is no reason for them to suffer, just because the Health Ministry isn’t changing its procedures.”
No status, no treatment
One of the most delicate issues in connection with testing for and treating HIV concerns foreign workers, refugees and those with no status, particularly if they are from an African country. This population segment constituted 28 percent of the new carriers this year − the country’s second largest at-risk group.
Acrobatic improvisation by the voluntary sector is the best that people without status in Israel can hope for. The AIDS Task Force provides treatment for about 60 carriers, with drugs it manages to get from the pharmaceutical companies, though these are usually generic drugs of inferior quality. Periodic testing at a reduced price is provided by Physicians for Human Rights, in cooperation with the AIDS Center at Ichilov Hospital, though in the absence of state subsidies this is still very expensive. In practice, treatment is not accessible and is given selectively only to those whose condition is badly deteriorated.
“We have been trying for four years, without exaggeration, to find some sort of structured solution for those without status,” notes Dr. Zvi Bentwich, the senior AIDS physician in Israel and the chairman of PHR. “One reason, beyond budgetary constraints, that the State of Israel has refrained from setting a policy in this regard is the fear that when carriers discover that treatment is available here, they will flock to the country. That argument is no longer valid, because the global networks provide free treatment in all the countries from which refugees come − Ivory Coast, Ghana and, of course, Eritrea and Sudan.”
Recently, the Health Ministry seems to have grasped that in a long-term approach, it is both immoral and economically imprudent to neglect those who have no status. Under the plan that has been worked out, the Health Ministry will get the pharmaceutical companies to make generic drugs available, and the AIDS Center at Ichilov will concentrate the periodic testing and the medical monitoring of the patients. At the moment, however, implementation of the plan has been blocked and the understandings suspended because of what sources who are involved describe as “Health Ministry flaws in strategic planning.”
Haaretz has learned that one of the obstacles to implementation of the plan is the opposition of Ichilov Hospital’s director general, Prof. Gabi Barabash, to his hospital being the only participant. An effort is now underway to coopt additional medical centers. A spokesman for Ichilov stated, “The Tel Aviv medical center is bearing, to date without [external] financing, the lion’s share of the treatment of the African labor migrants, who lack medical insurance, and is according them equal, advanced medical care. Prof. Barabash believes that the volunteering quota required of one hospital for this humanitarian subject has been filled, and therefore refused to assume exclusivity for another problematic area that characterizes this population.”
A spokesman for the Health Ministry noted, “The details of this important initiative are still being worked out, and the appropriate ways to implement it are being examined. This is a complex, sensitive project.”