California’s ADAP Expanded Coverage for HCV

By: Marcus J. Hopkins, Blogger

Every two weeks, we here at HEAL Blog try to bring our readers something both timely and topical related to the treatment landscape for people living with HIV/AIDS and Hepatitis C (HCV). Keeping with tradition, this week’s blog will focus on what many advocates for HIV/HCV co-infection consider a net “win” for patients.

It was recently announced that the state of California’s new budget would include funds to expand that state’s AIDS Drug Assistance Program (ADAP) to cover more clients co-infected with HIV/HCV.

California’s ADAP coverage for HCV has always been something of a mystery, to me – a state known for its relatively vanguard approach to healthcare coverage (particularly in its public programs for low-income residents), ADAP in California has proven a bit arcane, in the past year, in not expanding to cover newer, more effective therapies, such as Sovaldi (Gilead), Harvoni (Gilead), Olysio (Janssen), or Viekira Pak (AbbVie).

Flag of California

Photo Credit: American Images

I suppose that, all things considered – those things being a gigantic population in a state with two of the nation’s biggest “gay” cities (Los Angeles and San Francisco) and a relatively high rate of injection drug abuse – it’s shouldn’t really surprise me that their formulary doesn’t extend to coverage for those more expensive options.

That said, the existing ADAP prerequisites for HCV coverage have been notoriously difficult to meet (clients must be in very advanced stages of the disease and demonstrate a specific level of liver scarring), so much so that only 13 clients will be treated for HCV infection in 2015 under the current guidelines. Next year, the ADAP guidelines will be updated to provide coverage to all clients, regardless of their stage in the disease, resulting in 199 clients being covered for treatment.

If that number seems a bit low, one must take into account that covering those 199 clients is likely to cost the CA ADAP program $6.5 million dollars. In a state whose total ADAP expenditures are estimated to be $389 million in the next fiscal year, HCV expenditures are literally 1.7% of the budget for the program.

This raises an interesting conundrum for both HIV and co-infection advocates – because Ryan White funds are intended to treat HIV-related health issues, does co-infection with HCV fall under those auspices? This is a question that continues to create controversy in the advocacy community.

The issue of HCV coverage, as well as coverage for other health issues, has widened an existing schism in the advocacy community, essentially creating two opposing camps – those who believe that Ryan White funds should not be used to treat HCV (HIV-only) and those who believe that they should (HCV-inclusive).

HIV-only advocates – long supporters of Ryan White Part B – argue that there are still a steady number of new infections, each year, and therefore, ADAP dollars should go to cover new clients, rather than be expanded to include HCV therapies for existing clients.

HCV-inclusive advocates – also long supporters of Ryan White Part B – argue that the same issue that has led people living with HIV/AIDS to require assistance from ADAP exists if they are co-infected, and therefore, funds should be used to treat all health-related issues for clients, up to and including HCV drug therapies, as HCV can create serious health issues in people living with HIV.

It is difficult to determine which side is “right,” especially in the current coverage environment of expanding coverage to all. Regardless of which side of the argument one stands, the primary issue is funding – from where will the funds come to cover these treatments?

Further muddying the waters is the suggestion by some HCV advocates (separate from the HCV-inclusive faction) that Ryan White be reopened and altered to include coverage for HCV, whether or not potential clients are mono- or co-infected, meaning that HCV patients could apply for ADAP coverage without actually being HIV-Positive.

This suggestion raises the specter of whether or not reopening Ryan White to adjust language and update the law to reflect the current state of treatment will result in “gutting” to law, altogether, given the current political climate in Congress as it relates to healthcare funding. Advocates on both sides of the HCV argument seem to agree that doing so would result in a net “loss” for people living with HIV/AIDS, and there seems to be little appetite to test those waters.

It has been reported that numerous agencies and organizations are working together to craft what they believe would serve as a good template for updating Ryan White, but there is nothing substantive to report on those suggestions, at this time.

As someone who’s relied on ADAP in the past to cover the cost of medications, it strike me as odd that, even as keyed into current events as I am, I don’t know what’s in those suggestions, who’s suggesting what changes, or how “regular” clients (read: the people whose needs are the ones being met by Ryan White) can provide input into the process.

To be perfectly frank, despite all of the “great work” done by many of the national HIV/AIDS organizations, my confidence in their priorities has taken a rather large hit due to the relative lack of inclusion of the Patient voice in these discussions. I’m not altogether certain that, given those circumstances, having these organizations craft a new Ryan White bill is going to result in something that’s a net “win” for clients.

Whatever the future for HCV coverage is going to be, the real question always will boil down to funding. So, at this point, “Yay!” for California taking a relatively big leap for them, but with some of the highest tax revenues in the country, can’t we do a bit better than 199 clients being served?

References:

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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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