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NVHR, HRC, and Center for HIV Law & Policy Come Out Against Hepatitis Criminalization

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 National Viral Hepatitis Roundtable (NVHR), Harm Reduction Coalition (HRC),  Center for HIV Law & Policy (CHLP) have released a comprehensive new fact sheet regarding the criminalization of Hepatitis (NVHR, 2018). This issue is one that HEAL Blog has covered a number of times in the nearly five years since we’ve been in publication, and one that is vitally important to those who are living with Viral Hepatitis (VH).

According to the fact sheet, 13 states have laws that specifically target people living with VH by criminalizing the transmission of Hepatitis A, B, and C (HAV, HBV, and HCV, respectively), even in cases where the risk of transmission is so infinitesimal that almost no risk exists. These laws generally adhere to the equally unscientific panic associated with HIV criminalization and are intended to reduce the number of transmissions by way of penalizing people, rather than getting to the root of the issues.

Inmate looking out window with bars on it

Photo Source: thedenverchannel.com

For example – the primary manner in which HCV has been transmitted in the U.S. for much of the past decade is via Injection Drug Use (IDU). According to the Centers for Disease Control and Prevention (CDC), the prevalence of HCV among People Who Inject Drugs (PWID) is estimated to be 53.1%. Rather than focus on preventing the spread of disease among PWID by funding options that are much cheaper than incarceration – Syringe Services Programs (SSPs), increasing drug treatment facilities and funding, and placing limits on opioid prescription amounts and dosages (to reduce initial addiction) – these states instead decide to focus their efforts on criminalizing behaviors, resulting in higher rates of incarceration – the most expensive option the ensures that the state will have to be exponentially more to house, feed, and inadequately treat PWID.

Some of the scientifically unfounded “infection risks” include spitting, “allowing” someone to come into contact with blood, semen, urine, feces, or other bodily substances (NVHR). The state of Ohio, for example, makes exposure via these methods a Class 3 felony. In January of this year (2018), a man living with HCV was charged with four felonies for spitting at first responders during the course of an arrest (Jankowski, 2018). HEAL Blog covered this specific arrest in the final post of January (Hopkins, 2018). As we noted in January, neighboring Indiana classifies “Spitting While HCV” as Class 5 and/or Class 6 felony battery, depending on the circumstances and, if you can believe it, the disposition of the “offender” (e.g. – if they are rude, angry, or insolent while exposing someone to a bodily fluid).

These criminalization efforts extend beyond the general population, reaching into state and Federal prisons, resulting in far harsher punishment for inmates living with VH. For current inmates charged under HCV criminalization laws, the punishments can extend sentences for any number of years for violations that can stem from simply spitting at a guard – an action that has virtually no chance of spreading HCV.

It is time for more national organizations to stand up to states’ unscientific criminalization of both HIV, and VH. If that means going to court, then, so be it.

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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Three HCV Drugs Quietly Pulled From Market

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

Johnson & Johnson’s hepatitis C virus (HCV) drug Olysio (simeprevir) reached blockbuster status during the second quarter, clocking about $1.2 billion in sales for the first six months of the year (Sheridan, 2014). 

This article from 2014, ominously entitled, “In evolving HCV market, Johnson & Johnson’s Olysio is a blockbuster, for the moment,” a staff writer for BioWorld – a site that provides “actionable intelligence on the most innovative drug development science…” – essentially foretold Olysio’s doom.

The groundbreaking drug first approved by the U.S. Food and Drug Administration (FDA) in 2013 was meant to serve as a companion drug to Gilead’s Sovaldi (sofosbuvir) for the treatment of HCV, Olysio was quickly became the odd man out, in terms of treatment regimens. With a Wholesale Acquisition Cost (WAC) of $66,360 for twelve weeks of treatment, Olysio’s use in combination with Sovaldi (WAC – $84,000) had patients and payors looking at a combined cost of $150,360 to cure HCV in 12 twelve weeks. Unsurprisingly, payors balked at this price point, and instead recommended Sovaldi in combination with the much cheaper ribavirin, with a WAC of between $550-$850 for twelve weeks of treatment. It may not have been as easily tolerated as Olysio, but damn it – it was exponentially cheaper.

Olysio

Photo Source: stoprod.se

By the end of 2014, Gilead had gone the extra step to push Olysio into obsolescence by releasing their breakthrough combination therapy, Harvoni (ledipasvir-sofosbuvir) at a WAC of $94,500. This single-pill regimen could be used in most patients without a ribavirin booster, and proved much easier to swallow, despite the high price point.

And then, came Viekira Pak…

And then, came Daklinza…

And then, came Technivie, Zepatier, Epclusa, Viekira XR, Vosevi, and Mavyret…

In just a few years, Janssen might as well have not even entered into the HCV market. In 2017, the company announced that it was exiting the market. And then, in May of this year (2018), Janssen pulled the plug on Olysio, altogether. Effective May 25th, 2018, Olysio became unavailable in all markets. Janssen reasoned that the availability of [cheaper] pangenotpyic drugs to treat and cure HCV had made Olysio’s presence on the market untenable.

Then, in June 2018, AbbVie – makers of Viekira Pak, Technivie, Viekira XR, and Mavyret – quietly pulled the plugs on both Technivie and Viekira XR. Neither of these drugs really got off the ground and were essentially rendered obsolete within a year or two by Mavyret, which is far cheaper and a better product. Both of these drugs will become unavailable on January 01, 2019.

These won’t be the last casualties of the HCV, either. Some Medicaid programs are playing an interesting game, at the moment, when it comes to contracted drugs for treatment. Hawaii’s Medicaid program, Med-QUEST, operates using five different Managed Care Organizations (MCOs) – AlohaCare, HMSA, Kaiser Permanente, ‘Ohana Health Plan, and United Healthcare Community Plan. AlohoCare, from June to August pared their Preferred Drug coverage for HCV treatment to only Harvoni, Zepatier, and Epclusa – a strange move considering all three drugs are more expensive than AbbVie’s Mavyret.

I say “strange,” because nearly every other Medicaid program in the U.S. has shifted to Mavyret as their preferred drug, with Epclusa and Zepatier straggling along behind. In fact, the other four MCOs that service Med-QUEST have all reduced their coverage to include only Mavyret. AlohaCare is unique amongst the other MCOs in that it is a non-profit organization wholly local to Hawaii, whereas the other MCOs are backed by large national insurers – BlueCross/BlueShield, Kaiser Permanente, WellCare, and United Healthcare. That a local non-profit would reduce its coverage of HCV to exclude the cheapest drug on the market is, again, strange.

While I cannot definitively say that there’s anything nefarious afoot, my guess is that Gilead has cut a deal with AlohaCare to offer Harvoni and Epclusa at much lower prices than Mavyret. How low? Well, we aren’t legally allowed to see those prices, because of existing trade secrets laws.

I anticipate that Daklinza will be the next drug on the chopping block, but that’s just speculation.

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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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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