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Hepatitis C Patients Who Abuse Alcohol Suffer Worse Health Outcomes

HEAL Blog is the recipient of the ADAP Advocacy Association’s 2015-2016 ADAP Social Media Campaign of the Year Award
By: Marcus J. Hopkins, Blogger

Patients living with Hepatitis C (HCV) have been shown to suffer worse health outcomes if they also abuse alcohol, according to a new study published in Clinical Epidemiology (Specialty Pharmacy Times, 2018)

In addition to the common deleterious effects of excessive alcohol consumption, patients living with HCV who drink excessively also face worse rates of liver-related mortality.  Additionally, between 10-20% of those who abuse alcohol regularly develop liver disease, and 20% of patients with alcoholic hepatitis – an inflammation of the liver that occurs as a result of alcohol consumption – have HCV.

Man holding alcoholic beverage

Photo Source: everydayhealth.com

There are some basic limitations to the study – a lack of data on changes in alcohol consumption over time, as well as a lack of data on the severity of some patients’ alcohol consumption in comparison with others. These limitations make generalizing the results slightly more difficult. That said, researched pointed to previous research findings that indicate up to 30% of people living with HCV may abuse alcohol.

While these limitations exist, it is definitely worth concern, particularly in patients who have not been, or are unlikely to be tested for the virus. This concern is exacerbated in areas of the U.S. with limited access to comprehensive medical treatment, but less limited access to alcoholic beverages. When combined with other factors – endemic poverty, unemployment, and other socioeconomic woes that are shown to lead to an increase in high-risk consumption behaviors – the risk to patients living with HCV who are undiagnosed grows exponentially.

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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AbbVie, American Legion Team Up For Veterans

HEAL Blog is the recipient of the ADAP Advocacy Association’s 2015-2016 ADAP Social Media Campaign of the Year Award
By: Marcus J. Hopkins, Blogger

Drug maker AbbVie (Viekira Pak and Mavyret) has teamed up with the American Legion in an effort to extend their Hepatitis C (HCV) outreach efforts to Veterans across the U.S. Their new nationwide campaign, “Take on Hep C,” launched on August 4th, 2018, and will work to provide free HCV antibody testing to Veterans and their communities, beginning with the Sturgis Motorcycle Rally in South Dakota (Bennett, 2018).

AbbVie

Photo Source: dddmag.com

The U.S. Veterans Administration (V.A.) first opened treatment access to all eligible Veterans in 2016 (Kine, 2016), quickly proving to be one of the most successful HCV treatment efforts in the U.S. Because the V.A. receives what is called “Best-Pricing” on pharmaceuticals, they have been able to keep costs contained where other government healthcare payors have been less successful (particularly Departments of Corrections). In fact, the V.A. is on track to eliminate HCV in all Veterans by the end of 2018, curing 59,200 Veterans at a cost of roughly $25,300/soldier (LaMattina, 2018).

Curing U.S. Veterans will no doubt serve as a great first step toward stemming the spread of disease, but there are concerns that still exist. When U.S. healthcare authorities speak of “elimination,” there are always communities who will be left behind – the homeless, the very poor, sexual, racial, and ethnic minorities. These populations are often left out of these treatment opportunities because they may feel ostracized by policies previously held by the military. Of particular concern are those Veterans who received dishonorable or other-than-honorable discharges from the military for being lesbian, gay, bisexual, or transgender either under the Don’t Ask, Don’t Tell (DADT) or prior policies that prohibited open service. These discharges may impact their ability to obtain services through the V.A. With the repeal of DADT, it is possible for LGBT Veterans to receive upgrades to their discharge paperwork (OutServe-SLDN, n.d.).

Ensuring that all U.S. Veterans are cured of HCV is vitally important, and this new effort by AbbVie and the American Legion will go a long way toward achieve that goal.

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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South Carolina Has a Liver Problem

HEAL Blog is the recipient of the ADAP Advocacy Association’s 2015-2016 ADAP Social Media Campaign of the Year Award
By: Marcus J. Hopkins, Blogger

It is the conventional wisdom that the Southern United States play host to health epidemics of several sorts – obesity, premature deaths, diabetes, heart disease, higher risks of cancer… To say that health issues in the South are prevalent is to say that the Great Pyramid of Giza is a small rock formation. With all those troubles, South Carolina has a growing problem: liver cancer deaths.

In just six years (2010-2016 – the best available information) liver cancer deaths rose 43% in adults aged 25 and older. When you focus on age groups, adults aged 55-64 saw a staggering 109% increase (National Center for Health Statistics, 2018). The rate of death in South Carolina falls in the range of 10.0-11.9 (per 100,000 – the NCHS report doesn’t list the specific rates), putting it above the national average, and sadly, three other Southern states – Texas, Louisiana, and Mississippi – all have higher death rates from liver cancer.

South Carolina

Photo Source: aventalearning.com

This rise in liver cancer deaths conveniently (for lack of a better word) coincides with a sharp increase in the number of Hepatitis C (HCV) infections. HCV is a disease that specifically impacts hepatic (liver) health and function, and the NCHS report indicates that HCV is likely the greatest factor in this increase (Osby, 2018).

Essentially, part of why HCV incidence reporting is so finicky is that testing and screening protocols are not standardized across the U.S. Each state essentially establishes its own screening guidelines, and the vast majority have failed to update said guidelines to reflect the growing face of the epidemic at hand – Injection Drug Use (IDU). Certainly, the U.S. Centers for Disease Control & Prevention (CDC) recommends testing for anyone who is or has participated in IDU, but the reality is that few people are willing to come forward about those actions on a voluntary basis; how can a physician proactively test patients for HCV if they don’t disclose current or previous IDU?

One step to help identify HCV infections, for which HEAL Blog has advocated, is using emergency care settings as mandatory HCV screening locations. The thinking behind this is that, rather than attempting to ferret out potential IDU among patients, HCV testing should be offered to all Emergency Room (ER) patients, regardless of apparent risk factors. Heck, even a half measure of testing every overdose victim in emergent care situations (on 911 calls and ER arrivals, for example, using rapid testing and immediate linkage to care) would be better than the system we currently have in place.

More than just advocacy, research is bearing out this measure. In a study published in Academic Emergency Medicine, HCV tests were performed at Boston Medical Center on 3,808 patients at least 13 years old undergoing phlebotomy (blood work) for clinical purpose (Schechter-Perkins, et al., 2018). The tests were performed in a nontargeted, opt-out method, meaning that patients had to provide informed refusal of the test. The results of this three-month effort resulted in 292 confirmed positive HCV patients (7.7% of all patients tested).

While this number may sound low, the breakdown of those results is telling: 155 of those 292 (53%) fell outside the Birth Cohort (1945-1965) for whom the CDC recommends one-time HCV testing, 46 of whom reported no IDU as a risk for infection. The breakdown, post-testing, occurred (as it usually does) with attempted linkage to care: linkage attempts were documented on 223 76.4% of those identified as testing positive for HCV, and follow-up appointments were scheduled for 102 (38% of attempted linkages). Only 66 out of 292 attended that follow-up appointment (22.5% of all RNA-positive patients).

So…is it the best solution? Potentially, given the abject failure of state and national politicians to grasp the severity of this epidemic and respond to it with even adequate increases in funding. A few states – California, for example – have responded for those on their Medicaid rosters, but only in terms of affording treatment. How do we treat people who haven’t been tested, particularly if there’s insufficient funding for testing? It’s all going to take money, and if we don’t pony up the costs ahead of time, it’s going to cost all of us exponentially more – in both financial, and human terms – further down the line.

References:

  • National Center for Health Statistics. (2018, July). Trends in Liver Cancer Mortality Among Adults Aged 25 and Over in the United States, 2000–2016, NCHS Data Brief, No. 314. Atlanta, GA: United States Department of Health and Human Services: Centers for Disease Control and Prevention: National Center for Health Statistics. Retrieved from: https://www.cdc.gov/nchs/data/databriefs/db314.pdf
  • Osby, L. (2018, July 23). Liver cancer deaths soar in South Carolina, across the US. Greenville, SC: The Greenville News. Retrieved from: https://www.greenvilleonline.com/story/news/2018/07/23/liver-cancer-deaths-soar-sc-nation/806045002/
  • Schechter-Perkins, E.M., Miller, N.S., Hall, J., Hartman, J.J., Dorfman, D.H., Andry, C., & Linas, B.P. (2018, May 31). Implementation and Preliminary Results of an Emergency Department Nontargeted, Opt‐out Hepatitis C Virus Screening Program. Academic Emergency Medicine. https://doi.org/10.1111/acem.13484

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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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Three States Expand Access to Hepatitis C Treatment

HEAL Blog is the recipient of the ADAP Advocacy Association’s 2015-2016 ADAP Social Media Campaign of the Year Award
By: Marcus J. Hopkins, Blogger

In the past two months, three states – California, New Jersey (Hester, 2018), and Rhode Island (Miller, 2018) – have moved or plan to move to drastically reduce the number of prerequisites to gain access to Direct-Acting Agents (DAAs)to treat and cure Hepatitis C (HCV). Here, at HEAL Blog, we have been advocating for such a change since our inception, though it would be hubristic to suggest that a single blog post could account for any change to state Medicaid policies.

As discussed in the previous blog linked above, California’s efforts to expand access likely relate to a couple of Class-Action lawsuits they’ve been facing over the past few years, both from Medicaid clients and incarcerated citizens. Rather than wait to end up paying exponentially more by way of settling or outright losing in court, the state wisely chose to expand access by providing more money through the budgeting process. This additional $176 million will allow the state to open treatment to more lower-income Medi-Cal recipients, as well as those incarcerated.

New Jersey has also broadened coverage for HCV DAAs to cover all Medicaid enrollees in the state once someone is diagnosed with the virus. This policy change was also facilitated by increased funding in the FY2019 budget to the tune of $10m. (Stainton, 2018).

New Jersey’s Medicaid program, however, is run a bit differently. Since 1995, the state’s Medicaid program has been administered by way of Managed Care Organizations (MCOs) – private companies who are contracted to provide and disburse benefits and payments to Medicaid recipients in exchange for a per member per month capitation payment. Currently, there are five private insurers who offer these services: Aetna, Amerigroup NJ, Horizon NJ Health, UnitedHealthcare Community Plan NJ, and WellCare. MCOs are designed to save state’s money by outsourcing the work to private companies for cheaper than the state itself would spend on salaries, pensions, and benefits to administer the program. Of the five MCOs in New Jersey, all but oneplan (Amerigroup NJ) provide drug coverage only for Mavyret (AbbVie), the newest pangenotpyic DAA drug on the market (which is conveniently also the cheapest). Amerigroup alone provides coverage to virtually every other DAA still on the market.

The problem with MCOs is that, because they are private companies providing this service, they are not always quick to adapt to new rules and regulations. There are several states which employ MCOs alongside traditional Fee-For-Service (FFS) Medicaid programs. The rub is that MCOs are required by law to provide the same coverage for clients as the FFS program, meaning that, if the FFS Program covers all available DAA drugs, the MCOs must also offer the same drug coverage. This is rarely the case, and few people, either from the state governments, or individuals who enroll in these plans, ever really push the point hard enough to ensure that MCOs are meeting this requirement. In the case of New Jersey, there is no FFS Medicaid programs; it’s entirely operated via MCOs, which essentially means that it will be difficult for New Jersey’s government to ensure that clients in all five MCOs are receiving access to this expanded treatment.

Finally, Rhode Island has also broadened coverage for HCV treatments. This was accomplished as a result of persistent lobbying by the Rhode Island Center for Justice, the Center for Health Law and Policy Innovation of Harvard Law School, and community activists and lawyers (Miller).

The ball got rolling on this change when a state resident receiving legal representation after being denied treatment by the state’s Medicaid program. The Center for Health Law and Policy Innovation has been tireless in its efforts to expand access to treatment of chronic illnesses both by government-funded programs, and by private insurers. Over the past three years, the Center has repeatedly stepped in on behalf of Medicaid recipients and privately insured individuals to use public pressure and threat of legal action to ensure that patients receive the coverage to which they are entitled, either by Federal law, or by state mandate. They have worked with several states to create HCV medication pilot programs that allow state AIDS Drug Assistance Programs (ADAPs) to offer coverage for HCV drugs that they might otherwise never receive.

All three of these states are moving in the right direction. Hopefully, we will see more forward momentum from other states in the coming months.

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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Kentucky Moves to Prevent Vertical Hepatitis C Transmission

HEAL Blog is the recipient of the ADAP Advocacy Association’s 2015-2016 ADAP Social Media Campaign of the Year Award
By: Marcus J. Hopkins, Blogger

The Commonwealth (state) of Kentucky has become the first state in the U.S. to require pregnant women to be tested for the Hepatitis C virus (HCV). This comes as the state is in the grasp of a crippling opioid addiction epidemic that has led to an increased number of new Acute HCV infections in the Appalachian Mountain region (Smith, 2018). This may, in fact, be the first piece of U.S. legislation that makes mandatory the testing of any specific demographic who are not incarcerated, as I have yet to see another law that requires testing, rather than simply mandate that a certain demographic – usually the Birth Cohort (people born between 1945-1965 – be offeredtesting.

The article cited above makes a curious claim:

“The disease can easily spread from mother to child, so starting this month, pregnant women in Kentucky must be screened.”

This asertion is questionable, at best, as the most recent data I’ve seen from the Centers for Disease Control and Prevention (CDC) indicates that vertical transmission occurs in only 5.8% of infants born to mothers monoinfected with only HCV, and 10.8% of infants born to mothers co-infected with HIV and HCV (Koneru, 2016). While vertical transmission is certainly a concern, the data available do not support the claim being made, nor do they necessitate the passage of mandatory testing protocol. In fact, CDC recommendations, which admittedly have not been revised since 2015, list pregnant women under “Persons for Whom Routine HCV Testing Is Not Recommended (unless they have risk factors for infection)” (CDC, 2015).

HCV Screening

Photo Source: Passport Health

I am certainly in favor of universal screening protocols, as evidenced by myriad HEAL Blog posts calling for expanding testing protocols to make testing mandatory in all healthcare settings. That said, it is curious to me that Kentucky has chosen pregnant women as the target of mandatory testing. The cynic in me wonders if this is truly a forward-thinking approach to reducing incidence of HCV transmission, or if it serves another, less altruistic purpose: using test results to infer opioid abuse.

Much of the HCV epidemic in Kentucky can be traced back to Injection Drug Use (IDU) of prescription or illicit opioid drugs (and occasionally stimulants such as methamphetamine). As of June 2018, in 22 states and the District of Columbia, substance use during pregnancy constitutes child abuse, and in three states ((MO, SD, and WI) can result in civil commitment (Guttmacher Institute, 2018). The state of Kentucky has not, yet, criminalized substance use during pregnancy, but given the current political temperament in the state, it isn’t outside the realm of possibility that state legislators will do so in the future. I fear, though there is no current evidence that this is the case, that legislators may use any findings of increased vertical transmission of HCV – HCV infection that may be attributed to IDU – as cause to join those 22 states and DC.

My secondary concern relates to the affordability of HCV testing. The costs of pregnancy are consistently increasing, while wages have remained relatively stagnant. Kentucky’s poverty rate hovers around 19.0%, which makes the various costs associated with being pregnant already burdensome; adding an additional testing requirement that may increase the amount of out-of-pocket spending for pregnant families is a concern.

Those concerns aside, it is always a good thing when HCV testing protocols are expanded. It will be interesting to see if this change in protocol will result in a higher incidence of new Acute HCV infections, or if it will have the desired impact of reducing vertical transmission.

References:

  • Centers for Disease Control and Prevention. (2015, October 15). Testing Recommendations for Hepatitis C Virus Infection. Atlanta, GA: United States Department of Health and Human Services: Centers for Disease Control and Prevention: National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention: Division of Viral Hepatitis: Hepatitis C Information: Testing Recommendations. Retrieved from: https://www.cdc.gov/hepatitis/hcv/guidelinesc.htm
  • Guttmacher Institute. (2018, June). Substance Use During Pregnancy. New York, NY: Guttmacher Institute: State Laws and Policies. Retrieved from: https://www.guttmacher.org/state-policy/explore/substance-use-during-pregnancy

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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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French Study Finds Universal HCV Screening Cost Effective

HEAL Blog is the recipient of the ADAP Advocacy Association’s 2015-2016 ADAP Social Media Campaign of the Year Award
By: Marcus J. Hopkins, Blogger

In May 2016, the World Health Organization (WHO) adopted a goal of eliminating Hepatitis B (HBV) and C (HCV) by 2030.  Some major nations are on the way to achieving that goal (Australia, for instance); others, like the U.S., are not. One reason why the U.S. is falling so far behind others is that we frequently fail to identify patients who are infected with HCV because the screening guidelines are woefully outdated, focusing primarily on “one-time testing” for patients in the Birth Cohort (those born between 1945-1965) and patients whose doctors knowthey use or have used injection drugs.

Journal of Hepatology

Photo Source: EASL

A new study out of France, however, has found that a combination of universal screening for and immediate treatment of HCV was the most cost-effective way to combat the virus. The study, published in the Journal of Hepatology, found that, using their model which did away with “highest risk” screening models like the one used in the U.S., reduced the incidence of hepatic events (i.e. – cirrhosis, decompensated cirrhosis, and liver-related mortality) in undiagnosed adults over the age of 18. The model also considered treatment initiation for all patients with fibrosis scores of 2 or higher, which resulted in reduced Chronic HCV prevalence in one year’s time; treatment initiation regardless of fibrosis score decreased prevalence significantly. A Healio article on this study has a much better explanation of the findings than the Journal of Hepatologysummary, and it can be found at this link:

https://www.healio.com/hepatology/hepatitis-c/news/online/%7B7c00ba17-af2b-4ddb-b0b2-26c8d6fed926%7D/universal-hcv-screening-in-adults-cost-effective-decreases-prevalence

While universal screening and treatment likely would be cost-effective in France (as well as other countries that offer Universal Healthcare), I predict that it would be incredibly difficult to replicate that finding here, in the U.S., primarily because of the way our for-profit healthcare system is structured. Between being constantly (and increasingly) bilked by private insurers and pharmaceutical companies, and the resultant exorbitant costs of testing and treatment, the U.S. is not currently positioned to adopt this strategy. In order for this strategy to be successful, the U.S. would have to fundamentally overthrow the existing healthcare payor model and adopt an intelligent policy of universal provision – an unlikely occurrence given the current legislative and executive political makeup.

That said, there is little stopping better prepared and positioned nations from adopting this strategy, and ensuring that their nations are able to eliminate HCV by 2030.

References:

  • Deuffic-Burban, S., Huneau, A., Verleene, A., Brouard, C., Pillonel, J., Le Strat, Y., Cossais, S., et. al. (2018, July 01). Assessing the cost-effectiveness of hepatitis C screening strategies in France. Journal of Hepatology. https://doi.org/10.1016/j.jhep.2018.05.027

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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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California Plans to Allocate $176 Million to Hepatitis C

HEAL Blog is the recipient of the ADAP Advocacy Association’s 2015-2016 ADAP Social Media Campaign of the Year Award
By: Marcus J. Hopkins, Blogger

The state of California has revised its 2018-2019 state budget to include $176 million to expand Hepatitis C (HCV) treatment to low-income citizens (Bartolone, 2018).

For low-income recipients of Medi-Cal (California’s version of Medicaid) and inmates in state prisons, access to the Direct-Acting Antivirals (DAAs) that cure HCV by allowing a patient to achieve Sustained Virologic Response – SVR – has been extremely limited. For recipients of Medi-Cal, there were several prior authorization requirements that served as barriers to treatment (Department of Health Care Services, 2015). For patients incarcerated in California state prisons, access has been so difficult that inmates have had to file a Class-Action lawsuit in an effort to force the state to provide the Constitutionally guaranteed access to treatment they should be receiving (Bayse, et al. v. California Department of Corrections and Rehabilitation, et al.).

Medi-Cal

Photo Source: Kaiser Health News

The newly allocated funds – $106m – will primarily go to the correctional system, as the rate of HCV infection is much higher in correctional settings than in the general population (Holzer, 2018). In speaking with colleagues at the National Viral Hepatitis Roundtable, the scuttlebutt around California is that this revision to increase HCV funding is a preemptive step to resolve the pending Class-Action suit against the state. The thinking seems to be that it will be cheaper to pony up the money to treat inmates, now, rather than to wind up paying a potentially much higher amount to accomplish the same goal, as well as potential damages awarded for failing to provide access to treatment.

While these funds are a fantastic development, history has shown that, even when the money is there, changing course is often difficult to implement with any immediacy. We’ve seen, before, that there will always be bugs in the system. Though Medi-Cal hasn’t yet moved to alter the existing prior authorization restrictions, it is highly anticipated that the agency will do so within the coming months (Bartolone). The $70m in additional funds designated to pay for treatment of approximately 2,090 patients. Let’s see if that comes to fruition.

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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