Girl’s ‘promising’ AIDS remission after stopping anti-HIV drugs encourages scientists


A South African girl born with the AIDS virus has kept her infection suppressed for more than eight years after stopping anti-HIV medicines — more evidence that early treatment can occasionally cause a long remission that, if it lasts, would be a form of cure.

Her case was revealed Monday at an AIDS conference in Paris, where researchers also gave encouraging results from tests of shots every month or two instead of daily pills to treat HIV.

“That’s very promising” to help people stay on treatment, the U.S.’s top AIDS scientist, Dr. Anthony Fauci, said of the prospects for long-acting drugs.

Current treatments keep HIV under control but must be taken lifelong. Only one person is thought to be cured — the so-called Berlin patient, a man who had a bone marrow transplant in 2007 from a donor with natural resistance to HIV.

But transplants are risky and impractical to try to cure the millions already infected. So some researchers have been aiming for the next best thing — long-term remission, when the immune system can control HIV without drugs even if signs of the virus remain.

Aggressive treatment soon after infection might enable that in some cases, and the South African girl is the third child who achieved a long remission after that approach.

She was in a study sponsored by the agency Fauci heads, the National Institute of Allergy and Infectious Diseases, that previously found that early versus delayed treatment helped babies survive.

The girl, who researchers did not identify, started on HIV drugs when she was 2 months old and stopped 40 weeks later. Tests when she was 9 1/2 years old found signs of virus in a small number of immune system cells, but none capable of reproducing. The girl does not have a gene mutation that gives natural resistance to HIV infection, Fauci said, so her remission seems likely due to the early treatment.

The previous cases:

— A French teen who was born with HIV and is now around 20 has had her infection under control despite no HIV medicines since she was roughly 6 years old.

— A Mississippi baby born with HIV in 2010 suppressed her infection for 27 months after stopping treatment before it reappeared in her blood. She was able to get the virus under control again after treatment resumed.

At least a dozen adults also have had remissions lasting for years after stopping HIV medicines.

A study underway now is testing whether treating HIV-infected newborns within two days of birth can control the virus later after treatment stops. It started in 2014 in South America, Haiti, Africa and the United States, and some of the earliest participants might be able to try stopping treatment later this year.

Treatment might get easier if two large studies underway now confirm results reported Monday from a study testing a long-acting combo of two HIV drugs — Janssen’s rilpivirine and ViiV Healthcare’s cabotegravir.

Cabotegravir is experimental; rilpivirine is sold now as Edurant and used in combination with other drugs for treating certain types of HIV patients.

After initial treatment to get their virus under control, about 300 study participants were given either daily combination therapy pills or a shot every four or eight weeks of the long-acting drug duo to maintain control.

After nearly two years, 94 percent on eight-week shots, 87 percent on four-week shots and 84 percent on daily pills had their infections suppressed, with similar rates of side effects.

“The results were good regardless of whether people came monthly or every two months for their treatment. This has important policy implications,” said Dr. Linda-Gail Bekker, deputy director of the Desmond Tutu HIV Centre at the University of Cape Town in South Africa, and a co-leader of the conference.

The study was sponsored by the drugmakers. Results were published in the British medical journal Lancet.

Two large studies aimed at winning approval to sell the treatment are testing the monthly shots. Janssen said in a statement that good results from eight-week shots warrant reconsidering the longer approach.

If it works, “this will have a huge impact on how we manage that very important group of people who are not able to access and take drugs on a day-to-day basis,” such as those with mental health or drug abuse problems, said Dr. Steven Deeks, an AIDS specialist at the University of California, San Francisco.

Everest Metro police log includes hit-and-run crash, drunken driving causing injury


On July 15, an 18-year-old man was arrested on charges of first-offense drunken driving causing injury and possession of a prescription medication without a prescription after a traffic crash on Moreland Avenue at Grand Avenue, Schofield.

On July 16, a 34-year-old man was arrested and cited on charges of first-offense drunken driving and hit-and-run after a report of a hit-and-run crash at Grand Avenue and Business 51, Schofield.

On July 17, a 29-year-old man was arrested on a warrant on Candy Lane, Weston.

On July 18, a 34-year-old man was taken into custody on a warrant in the 5000 block of Schofield Avenue, Weston.

20 arrested in undercover prostitution investigation


OSHKOSH – Twenty people, including a woman with a 3-month-old child, were arrested in undercover prostitution investigations within the last week in Oshkosh.

The Oshkosh Police Department Vice and Narcotics Unit conducted multiple investigations for prostitution during a three-day period, according to a media release from the department.
Six females and one male were arrested for prostitution. One of the females arrested had taken her 3-month-old child to the location where she was arrested. Child Protective Services was contacted and as a result, the child was turned over to a relative. Those arrested for prostitution were from Milwaukee. One of the females also was arrested for possession of an electric weapon.

Thirteen male “johns” were arrested for solicitation of sex. They are from Oshkosh, Appleton, Larsen, Eldorado, Milwaukee, Kaukauna, Rubicon, Bear Creek and Neenah. One male from San Bruno, California, also was arrested in the investigation.
In addition, one of the males was arrested for being a felon in possession of a firearm, and several drug arrests were made as a result of the investigation. Two of the males were taken to jail and the remainder had referral arrests made on them to the Winnebago County District Attorney’s Office.
The Vice and Narcotics Unit plans to conduct these investigations in the future. If you see, hear or suspect illegal activity occurring in your neighborhood, please contact the Oshkosh Police Department at 920-236-5700 and report it.
If you have information but want to remain anonymous, contact Winnebago County Crime Stoppers at 920-231-8477; or Text IGOTYA and your tip to 274637; or send a web tip by going to If an arrest is made from your tip, you may be eligible for a cash reward.

Judge rejects dismissal request by ‘pharma bro’ Shkreli’s lawyers


Get your seat cushions ready.

Lawyers for Martin Shkreli lost a long-shot bid on Wednesday to get criminal charges against the ‘pharma bro’ dismissed in Brooklyn, New York, federal court, after prosecutors and defense lawyers rested their cases.

The rejection sets the stage for a very long, full day of closing arguments in the case by prosecutors and Shkreli’s lawyers Thursday, with those arguments only expected to wrap up Friday morning.

Jurors could then begin deliberations later Friday, exactly one month after opening arguments were made in the trial.

When they do, they will do so without the benefit of having heard any testimony from Shkreli, who declined to take the witness stand.

Nor will they have heard from any other witnesses or evidence from the defense, which rested without putting on a case of their own.

Shkreli, however, commented, in acerbic fashion, on his case on Facebook.

“Have a nice day, and I’ll see you at 9,” Judge Kiyo Matsumoto told Shkreli as she excused him Wednesday from having to remain in court and listen to her, his lawyers and prosecutors huddle over how she will instruct jurors on the law for their deliberations after closing arguments.

Earlier, Shkreli had told Matsumoto that he was waiving his right to a separate trial by the same jury on the question of how much he should be required to forfeit in assets if he is convicted of the criminal charges.

Shkreli earlier had said he wanted jurors to decide that question in the event he is convicted. He did not explain his decision Wednesday.

Jurors were not in court Wednesday, having been given the day off.

Shkreli, 34, is accused of defrauding a group of investors in two hedge funds he ran by lying to them about his past performance managing investments, and by lying to them about how well he was doing with their money.

He also is charged with defrauding the drug company he subsequently founded, Retrophin, by using company stocks and cash to pay back the investors he allegedly ripped off at his funds.

Shkreli has pleaded not guilty to eight criminal counts, including securities fraud, and conspiracy to commit securities fraud and to commit wire fraud.

The charges are unrelated to Shkreli having raised the price of the anti-parasite drug Daraprim by more than 5,000 percent while serving as CEO of another company, Turing Pharmaceuticals, in 2015.

That action made Shkreli the subject of widespread negative media attention. A number of would-be jurors mentioned the Daraprim price increase when they were considered and then excused from serving on the jury for his trial.

On Wednesday morning, Shkreli’s lawyer Marc Agnifilo asked Matsumoto to dismiss the entire eight-count indictment against him.

“There’s legally insufficient evidence to substantiate each of the eight charges,” Agnifilo told Matsumoto.

Agnifilo argued that the decisions by investors to put their money into Shkreli’s funds were not based on the allegedly false statements he told them before they invested. Those statements included claims that the MSMB Capital and MSMB Healthcare hedge funds had an independent auditor, were “transparent” investment vehicles and had enough liquidity to satisfy monthly redemption requests.

Matsumoto brushed aside that argument. She noted that multiple investors have testified that “they did pay attention to the monthly [financial] performance reports” that Shkreli sent them about their purported investment returns.

Those investors “in fact did rely on those reports and felt like they were making money,” Matsumoto said.

Prosecutors have introduced evidence that indicates that while Shkreli was issuing glowing financial reports, he was actually losing most, if not all, of the investors’ money, or using it without their knowledge to capitalize his new drug company Retrophin.

Agnifilo at one point in his argument said that the eighth criminal count, conspiracy to commit securities fraud on Retrophin, “reminded” him “of the old Wendy’s commercial, ‘Where’s the Beef?’ “

Matsumoto interjected, teasing Agnifilo that he was dating himself with the reference to that 1980s-era ad.

“It’s not ‘Where’s the Beef? It’s ‘A nothing burger,’ ” the judge cracked, referring to the dismissive term used by some in the Trump administration when commenting on disclosures that Donald Trump Jr. had met with a Russian lawyer during the presidential campaign.

Another humorous moment occurred when Matsumoto mentioned an employee of a third hedge fund run by Shkreli.

“He was with MSMB Consumer, which was the strip-club hedge fund,” Matsumoto said.

That was in reference to the employee having testified that at one point MSMB Consumer’s funds were so low that it began focusing on a position in just a single stock, Rick’s Cabaret, which operates strip clubs.

Shkreli smiled broadly at reporters when Matsumoto made the “strip club” remark.

Agnifilo also argued there was evidence that Retrophin’s board of directors had known of and approved of consulting agreements that were used to pay off investors in Shkreli’s hedge funds.

That evidence, the lawyer said, undercuts the prosecution’s claim that Shkreli was defrauding the company.

Prosecutors have said the consulting agreements were shams and served as seemingly legitimate vehicles to siphon off Retrophin assets to pay back investors for money that Shkreli told them falsely remained in his fund.

Assistant U.S. Attorney Jacquelyn Kasulis argued to Matsumoto that Retrophin’s board was “not provided with full and complete information”‘ about the nature of the agreements that it was asked to approve. Kasulis also said “the money was already paid” at the time the approval was sought.

Matsumoto wasted little time rejecting Agnifilo’s request to dismiss the indictment.

“Respectfully, I’m going to dismiss the motion,” the judge said.

Police arrest dozens, seize thousands in Wednesday north side operation


Local and federal officers arrested more than a dozen people — including those believed responsible for a shooting that injured two children — and seized thousands in cash, several firearms and drugs Wednesday during an all-day, north side warrant sweep.

Milwaukee Police Chief Edward Flynn announced the seizures and arrests in a press conference that took place in front of an FBI command center truck outside MPD’s fifth district offices. Wednesday’s actions occurred in the Center Street area and were executed alongside federal law enforcement officers from the FBI, ATF and U.S. Marshals Service.

So far, police have arrested 16 people and seized five guns, $4,000 in cash and small quantities of marijuana and cocaine across the Center Street area, Flynn said. Police made arrests for offenses that included felon in possession of a firearm and narcotics-related charges.

Also, three arrests were made in connection to a July 18 quadruple shooting that injured children. Flynn noted that police also arrested a 22-year-old male suspect in connection to a rash of north side pharmacy burglaries.

The operation, called the Center Street Corridor Operation, started in the morning and is ongoing.

Sgt. Tim Gauerke said the operation was not in response to recent shootings and killings in the area and it was tied to separate investigations. Police did not make any arrests in the shooting death of 16-year-old Emani Robinson’s, which occurred on June 25 in the area.

Flynn said more than 100 officers participated and executed search warrants in the Center Street Corridor area, about 2.3 miles. MPD deployed about 40 officers, the FBI sent some 30 agents and the ATF and U.S. Marshals made up the rest.

Milwaukee police worked with federal law enforcement because the department has an ongoing partnership, the Public Safety Partnership, with the U.S. Department of Justice since 2016. The program focuses on providing federal resources and officers to focus on local law enforcement goals, Flynn said.

Flynn said that police have conducted similar sweeps before and have more planned for Center Street. Police said they were not targeting a specific crime network.

“Periodically, we do major warrant sweeps and search warrant sweeps in the targeted area based on the input of our policing districts,” Flynn said.

Flynn described the targeted area of Wednesday’s operation as “the main street of crime.”

“Even though it represents a very small part of this community, it has an outsized impact on violent crime afflicting the north side of Milwaukee,” he said.

Flynn added that the warrant sweeps are just a part of their efforts to improve the area through community policing, foot patrols and other community engagement methods.

“We’re trying to, if you will, liberate the neighborhood, not conquer it,” Flynn said.

Stray cats find respite at new pet shelter


MARSHFIELD — The city’s first animal shelter is now housing stray cats, but more money is needed for it to become fully operational, shelter officials say.

“We’re still getting organized,” said Karen Rau, president of the nonprofit Marshfield Area Pet Shelter.

For months, Rau and others affiliated with the shelter have been working to convert the city’s former airport terminal at Marshfield Municipal Airport, 210 W. 29th St., into a facility to house stray animals. The pet group has not had a physical headquarters, but instead has relied on volunteers to care for stray animals in their homes.

Animal shelter may not open until fall

That changed last month, when the shelter’s airport facility began taking in stray cats found by police ordinance officers. The building is intended to be a temporary site until a permanent structure can be built.

The shelter now holds the sole contract with the city to care for stray cats, which had previously been with the Park View Pet Motel for about 40 years. The motel, 11115 S. Lincoln Ave., is a private animal boarding business.

Under the new contract, the city will pay the shelter $7 per cat for up to seven days, which is the window of time owners have to claim a cat. That amount is more than the $4.50 that was paid to the pet motel — an increase due in large part because the shelter is providing more services.

The city’s arrangement with the pet motel had covered just food, water and shelter; if medical treatment was required, ordinance officers had to administer medication themselves or take the animal to a veterinarian, pet motel owner Ray Poeppel said.

But under the MAPS contract, the shelter will be responsible for providing medical care, and all stray cats brought to the shelter will receive health assessments and treatments in addition to food, shelter and water. If unclaimed, the cats also will be spayed or neutered, vaccinated and affixed with microchips for identification purposes.

“The big difference is that we’re providing a higher quality of care,” Rau said.

The shelter is currently housing about 18 cats at the airport facility, with about 30 more being held at volunteers’ homes.

To house dogs and operate at full capacity, the shelter needs more money for additional dog kennels, more cat housing, fencing and computers, Rau said.

And to do that, the shelter has launched an online crowdfunding campaign aimed at raising about $8,000 by the end of the November.

DMAA is back: DOD names 39 workout supplements to avoid


DMAA, an ingredient found in some workout supplements and banned by federal regulators in 2013,remains widely available online, according to the Defense Department’s Human Performance Resource Center.

Nearly 40 supplements containing 1,3 dimethlyamylamine, sometimes called “geranium extract,” can be purchased through online retailers, according to the center.

“Many [products with DMAA] are still being produced (or produced again), and some are even new,” HPRC officials stated in a news release. “That means it’s very important to read dietary supplement product labels carefully to make sure yours doesn’t contain this potentially dangerous ingredient.”

Originally developed and sold as a nasal decongestant, DMAA is advertised as a fat-burner or body-sculpting product. It is known to elevate blood pressure and can cause health problems ranging from heart attacks to shortness of breath, the FDA says.

Before it sent warning letters requiring manufacturers to remove DMAA products from the market, the FDA had received 86 reports of illnesses or death associated with the substance.

The Defense Department removed DMAA products from military exchanges and on-base GNC stores out of concern it may have contributed to the deaths of at least two soldiers who suffered heart attacks during physical training.

After the deaths and several other incidents involving DMAA, defense officials launched a two-year review of the ingredient that concluded there was insufficient evidence to prove it caused the service members’ deaths.

But the authors of the review also agreed that the ingredient posed enough of a health risk to keep it off the shelves of military stores.

However, these “adverse event reports” indicate only that a patient either developed symptoms or died after or while using the product — and does not necessarily mean the ingredient was responsible for the illness or injury.

According to the HRPC website, the FDA’s declaration of DMAA as illegal for use as a dietary supplement ingredient specifically means “service members should not use dietary supplement products that contain it.”

The families of the two troops who died, Pvt. Michael Sparling and Sgt. Demekia Cola, filed lawsuits against GNC and USPLabs, the manufacturer of Jack3d, OxyElite Pro and other products containing DMAA. A jury trial has been postponed in the Sparling case until 2016; the mother of Demekia Cola reached a settlement with USPLabs on July 13.

Muhammed Islam, CEO of Total Body Nutrition, marketers for 1,3 D Bomb, a product that hails itself as the “most potent 1,3 dimethylamylamine available,” said he is breaking no laws by selling a pure DMAA powder online, because “it is pure and not actually ‘adulterating’ any product.”

He said that as with any substance that is ingested, it should be consumed with caution.

“If you consume a lot of anything, you can get sick. If you eat too much chicken, you would be sick,” Islam said. “I can see people in the military thinking, ‘I’m in the military, I can handle it.’ But it must be taken carefully.”

Roughly a quarter of the 40 products containing the ingredient are made by Georgia-based Hi-Tech Pharmaceuticals, which has filed a lawsuit against the Food and Drug Administration, alleging it illegally seized products containing DMAA in 2013 and failed to take the legal steps required to restrict the substance.

The government contends that DMAA is an unapproved food additive, and because the FDA considers it unsafe, the agency acted legally in banning it and confiscating products containing the ingredient, since those products are considered “adulterated.”

While the suit makes its way through the judicial system — a judge in April denied the government’s motion to dismiss — some DMAA products remain available online.

“Not only could it be dangerous to your health, it could also be dangerous to your military career,” HPRC officials wrote on their website. “Keep in mind, though, that pre-workout, weight-loss or other performance dietary supplements without DMAA also may not be safe for your health.”

Carolyn Hax: My boyfriend’s pot use has turned me into a nag

Carolyn Hax

Adapted from a recent online discussion:

Carolyn: I’ve been in a relationship with a man for the past year and a half. He’s a wonderful guy and I love him very much. We live together, and he puts up with all my faults and foibles.

Yet I’ve become what I despise — a nag. And I don’t know how to stop being so disapproving.

My boyfriend works hard, pays his bills and treats me and my dog with love and respect. He has had a history of alcohol use, culminating in a trip to a psychiatric hospital after a near-fatal binge and suicidal inclinations. He does suffer from depression and anxiety, and his alcohol use was interfering with the efficacy of his antidepressants.

He has since stopped drinking, except for an occasional beer. But now he’s moved onto pot. He uses it several times a day. I hate it. It stinks on him and in our apartment, and I highly disapprove of it (it’s illegal here). Plus I think he’s replacing one chemical with another.

I feel like I fuss at him all the time about it. He’s a grown man, and he’s going to do what he’s going to do. Sometimes I feel like I’m behaving like his Mom — if I’m not sniffing him for pot, I’m constantly on alert for him to start drinking again. Do you have any advice on how to stop trying to micromanage things?

—I’ve Become a Monster

Monster: Leave?

You don’t need “good” reasons to leave (though yours seem stellar to me); you don’t need to stop loving him; you don’t even need to examine your own co-dependency — though I strongly suggest you do.

You also don’t need to defend or rethink your disapproval. Let’s say, for the sake of argument, that pot is now legal where you live and that it’s a more effective antidepressant/anti-anxiety than the medication he’s taking. You’re still fully entitled to dislike the smoke and smell in your home and the frustration of having a partner who spends the bulk of his waking hours high.

In other words, you don’t have to figure out a position on the principles of the thing; you can make decisions based solely on not liking the reality you live with.

Clearly you’re unhappy with your relationship and home life right now, and that unhappiness manifests in your nagging and fussing and suspense as you await the next calamity. Leaving is a reasonable response to systemic, not-just-a-bump-in-the-road unhappiness.

Nagging, by the way, is not. To nag is to accept the status quo while you verbally, annoyingly, kid yourself that you’re changing it.

If you have really good reasons not to leave — even if it’s just that you don’t feel you’ve tried everything yet — then please make some sort of reputable counseling, for you alone, your next move. You don’t have to sort all of this out on your own, nor is it a good idea to when you’re at the point of confusion and frustration you seem to have reached.

To: Monster: Al-Anon. You may leave this person but are at risk to go on to another addict.


Anon: Yes. Even if it’s ultimately not the right place for someone, it’s a free and accessible first step, thanks.

Supermarket killer outlined plan before attack


Before a 24-year-old fired 59 shots inside a Pennsylvania supermarket — killing three fellow employees and himself — he documented his planand motives in chilling and painstaking detail online.

Police say Randy Stair, of Dallas, Pa., blocked the entrances and exits to the Weis store where he worked in Tunkhannock shortly before 1 a.m. Thursday after the store had closed. He opened fire with two-pistol-grip shotguns he carried into the store in a duffel bag.

Killed were Terry Sterling, 63, of South Montrose; Victoria Brong, 26, of Factoryville; and Brian Hayes, 47, of Springville. One witness escaped unharmed and called Wyoming County 911 dispatchers.

Stair detailed his plans in a video online — part of a massive, highly disturbing series of uploads that included videos, photographs, audio and journal entries posted just before the killings.

In that video, Stair said a co-worker goes on break every night and “when he goes out, I’m going to block the emergency exits. I’m going to get palettes and I’m going to put them in front of the doors.”

Stair talked to the camera and described his plan in detail, even naming employees who would be in the store. He appeared lucid, articulate and organized in his plan, wearing a gray American Eagle T-shirt and taking occasional swigs from a beer bottle.

But this young man was waving two shotguns — he named them and scratched the names into each stock — trying the barrel of each in his mouth to see which would be a better fit in the end.

At the end of the 37-minute video, created May 11, he paused and was reflective.

“What’s going to happen in the future after this to prevent this from happening again?” he asks.

“And the answer is you can’t prevent it. You can only endure it,” he answers.

Part of the night crew each night takes a break at about 1 a.m., and Stair described where everyone would be, what they would be doing and how he would work his way through the market. “I want this to be on the surveillance camera so you can see it,” he said.

He talked about always having a back-up weapon in case the other breaks. The worst situation, he said, would be wanting to kill himself after the shootings and not have a working weapon.

Throughout the video, he details how he would use palettes to block exits. One door gave him a particular problem, but he said he seized on an idea while sitting in his car in the parking lot one night during break. He said the answer hit him like a train: Park his car on the door so it would not open. “That is the greatest idea I’ve ever had. … That idea just changed everything.”

“It’s May 11th, counting down the days. Can’t come fast enough. Every day I get more and more confident. I get more and more inspired,” he said.

Stair disclosed his seven-year anniversary of working in the market would be in June. Working night shift was the “icing on the cake,” he said. He got keys, he got alarm codes, he studied how the place worked.

In a written document online, Stair says he had been planning to die for more than four years and had been plotting the attack for three to four months. Stair cited a spiral of depression that began in 2013.

In an iPhone video for his family posted on June 3, Stair apologized for the iPhone quality because he couldn’t get his Canon camera working.

I know you might be thinking, he said, “you could have gotten help.”

“That wouldn’t be me,” he said in his family message. Getting medication, sitting in therapy: “That’s not me, never would be.”

The killing shook residents of the small Pennsylvania borough of about 1,800 people, half an hour northwest of Wilkes-Barre.

This is a day to remember how fragile life is and each day should be lived to the fullest, said Bryan McDonald, 34, of Montrose. For the past year, he has been store manager at Auto Zone, next door to the Weis where the shooting happened.

Being so close, he said, you get to know some of the employees and frequent faces. He called Sterling a friend.

“He was always very sociable, very easy to talk to,” McDonald said outside his store Thursday. “That man (Sterling) couldn’t have an enemy in the world. I knew him well enough to know that he just treated everybody like gold.”

By early Thursday afternoon, a few local residents pulled into the Weis shopping area parking lot only to be greeted by yellow bands of crime scene tape.

A few passers-by said they frequently shop at this Weis, nestled along a busy thoroughfare leading a short distance into Tunkhannock’s historic downtown.

“You hear about these kinds of horrific tragedies on the news, but this is a small town where no one expects it to happen, said 20-year-old Dan Kosty. The Tunkhannock resident stopped in at the pizza shop adjoining Weis for lunch when he learned about the shooting.

“I wonder what was going through his head,” Kosty said of the shooter. “You wish you could’ve talked to him, you wish you could’ve stopped it before things like this happen.”

Contributing: Anthony Borrelli, Neill Borowski, Maggie Gilroy, Kevin Hogan, Jeff Platsky and Kristen Cox Roby of the Press & Sun Bulletin; the Associated Press

Powell: Best ways to save money with a health savings account


Most Americans who have a health savings account or HSA use them as specialized checking accounts for current health care costs such as such as deductibles, co-insurance and co-payments rather than as investment vehicles for medical expenses in retirement, according to new research from the Employee Benefit Research Institute (EBRI). In fact, 96% of HSA owners invest their money in cash, according to EBRI.

That’s not necessarily a bad thing. HSAs can be used either as a spending or investment vehicle.

But HSA owners — given nearly 24 million accounts with $37 billion in assets in 2016 — should at least know how and where to invest their money. And that’s especially so since, according to Morningstar’s 2017 Health Savings Account Landscape report, investors have few resources available to help them navigate the hundreds of plan providers that exist.

By way of background, HSAs are a tax-exempt trust or custodial account that is funded with contributions and assets that a individual workers can use to pay for health care expenses, according to EBRI’s report. “Individuals can contribute to an HSA only if they are enrolled in an HSA-eligible health plan,” according to the EBRI report. “HSAs benefit from a triple tax advantage: employee contributions to the account are deductible from taxable income, any interest or other capital earnings on assets in the account build up tax free, and distributions for qualified medical expenses from the HSA are excluded from taxable income to the employee.”

For 2017, if you have self-only high-deductible health plan (HDHP) coverage, you can contribute up to $3,400, according to the IRS. If you have family HDHP coverage, you can contribute up to $6,750. Additional catch-up contribution of up to $1,000 may be made by persons over age 55, as set out by the IRS.

On average, total contributions to HSA accounts — combined individual and employer contributions — were $2,922 in 2016, according to EBRI.

Of note, the Senate Republican’s health care plan, the Better Care Reconciliation Act of 2017, would increase the annual tax-free contribution limit to equal the limit on out-of-pocket cost sharing under qualified high deductible health plans ($6,550 for self-only coverage, $13,100 for family coverage in 2017, indexed for inflation).

So how might you go about deciding where and how to invest your HSA?

Plan to use for current health-care expenses

If you’re using your HSA for current health-care costs, you have a lot of flexibility, says Paul Fronstin, director of EBRI’s Health Research and Education Program and author of the report, Trends in Health Savings Account Balances, Contributions, Distributions, and Investments, 2011‒2016: Estimates from the EBRI HSA Database.

“You can fund the account as you incur medical expenses,” he says. “Or you can wait — as you can with a traditional IRA — until April 15 of the following calendar year to fund the account for past year and take an immediate distribution.”

In general, Fronstin and others recommend investing money in an HSA that will be used for current or near-term health-care expenses in safe rather than risky assets. “Investments carry risk and the account balance may fall and not be sufficient to cover current medical expenses,” he says.

Fronstin also recommends making personal HSA contributions via payroll deduction. “That allows you to save FICA taxes on the contribution,” he says. “For these people, contributions are more about the tax break than about account build up, assuming all they want to do is fund current expenses.”

In the Morningstar report, Alliant Credit Union, SelectAccount, and The HSA Authority are the most compelling plans for account holders using their HSA to cover current medical costs. The three plans offer checking accounts without monthly maintenance fees, according to Morningstar.

According to Leo Acheson, co-author of Morningstar’s HSA report, account maintenance fees represent the most important consideration for account holders intending to use their HSAs as a spending vehicle. “In some cases, it can be challenging to know what fees are being levied,” Acheson says. “But it’s important to know because it can definitely erode away your savings.”

Plan to use for long-term expenses

For those selecting an HSA plan to use as an investment vehicle to save for future medical expenses, Acheson says there are three important considerations: The breadth of investment options offered, the attractiveness of those investments, and the total cost of investing in those options, including fund fees, maintenance fees, and investment fees.

For his part, Fronstin says those using HSAs for future health-care expenses should consider maxing out their contributions if possible, as well as make contributions via payroll deduction to get the FICA tax break.

According to Acheson, using HSAs for future medical expenses makes sense, especially given cost projections. A 65-year-old couple retiring in 2016 would need an average of $260,000 — in today’s dollars — to cover medical expenses throughout retirement, not including long-term care costs such as a nursing home, according to Fidelity Benefits Consulting. “It definitely makes sense to think about an HSA as a supplement to retirement savings,” Acheson says.

Acheson also noted that it would be “optimal, if you can afford it” to avoid using money in your HSA for current medical expenses and pay out of pocket instead. “But it also depends on how much you have saved already,” he says.

If you’ve saved enough to cover your future health care expenses in a 401(k), Acheson says paying for current medical expenses with your HSA makes sense though it makes sense to use both — a 401(k) and an HSA when saving retirement.

A word of caution to those who plan to use their HSA as an investment vehicle. Morningstar gave only four plans — Bank of America, HealthEquity, Optum, and The HSA Authority — positive overall assessments for their investment programs. And only one plan — HealthEquity — offers a well-designed investment menu, strong underlying managers, and attractive fees.

Also of note, only HSA Authority earned positive scores as both a spending and investment vehicle in the Morningstar report.

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