Tag Archives: Hepatitis

HCV Prescribing Lags While Prices Soar

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

An article in Newsweek in March 2017 talked about a “…crowded and confusing” landscape for treating Hepatitis C (HCV) that prevents many Primary Care Physicians (PCPs) from prescribing the new Direct Acting Agents (DAAs) to treat the disease (Wapner 2017). The argument posed is that, physicians are “…still too unfamiliar with the regimens to speak with confidence about them,” according to Ira Jacobson, a hepatologist who leads the department of medicine at Mount Sinai Beth Israel Hospital in New York. He posits that this discomfort leads them to send patients to liver specialists, or to delay treatment until more severe symptoms arise, the latter of which is a regular pre-requisite on virtually every Prior Authorization (PA) request form.

This argument caught my eye, as someone who writes about and researches coverage for these DAA drugs, as has done so since 2013. One of the most frequent conversations I heard when Sovaldi (Gilead) and Olysio (Janssen) were first released on the market was that there was confusion over which doctors could prescribe them. Unlike HIV, treatments for HCV largely lagged in the ‘completely intolerable’ realm, with patients dropping out of treatment like flies and a success rate of only around 50%. Things, however, have radically changed; the question, then, becomes, “Have doctors?”

Prescription Pad

Realistically, we have a considerable problem, in the United States, with aspiring doctors choosing to specialize, rather than going into general practice, in no small part because it guarantees them higher incomes. Higher incomes for them, however, means higher costs to consumers, in the same way that higher-priced drugs to treat chronic conditions get shunted into the highest pricing tiers. This gets passed along to consumers in the form of higher co-pays for visits ($25 for PCPs; $75 for Specialists), and higher co-pays for medications ($3 for blood pressure medication; $250 for HIV).

This problem extends, also, to prisons and jails – the high cost of treatment serves as a significant barrier to providing inmates with treatment, which presents a larger issue, because inmates have an exponentially higher incidence and prevalence of HCV than the general population (Gloucester Times, 2017). Testing prisoners is expensive, as well, as inmate populations swell, while prison healthcare budgets remain relatively stagnant. Once those prisoners are released back into the general population, if they’re unaware of being infected with HCV or whose infections have gone untreated, they can go on to infect those who are not part of the prison system, are also unlikely to be tested and treated.

Beyond just the cost of co-pays are the long-term costs of PCPs being reticent to screen or prescribe for HCV: failing to address HCV will lead to liver decompensation, liver cancer, kidney diseases and failure, higher HCV viral loads that make spreading the disease easier, jaundice, digestive illnesses, and thyroid issues, none of which are particularly cheap to treat. The host of accompanying side effects of leaving the disease untreated far outweigh the admittedly outlandish prices set by HCV drug manufacturers.

The reality is that any medical doctor who has prescribing privileges can prescribe these new treatment regimens. The vast majority of these doctors also have access to smartphones, all of which have any number of apps designed to compare new drug regimens with existing prescriptions to ferret out counter-indications; there is, in fact, an entire website specifically aimed at finding counter-indications (http://www.hep-druginteractions.org/) that also offers mobile apps. The argument that doctors are unsure of the counter-indications is really rendered moot by the existence of these easy-to-use tools.

With that, the biggest hurdle to overcome, for virtually every party involved, is the cost of treatment, and with the current administration’s funding priorities being…questionable, at best…it’s unapparent if even the existing treatment coverage landscape will exist. We’re hoping for more stable conditions, and less erratic proposals. Until then, we’ll just keep plugging to try and find a solution.

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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New River Valley Region Reports Sharp Rise in 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 New River is 360 miles long that spans three states – North Carolina, Virginia, and West Virginia – flowing from south to north (one of only a handful of rivers in the world to do so) and serves as one of the most scenic rivers in the eastern United States. It’s known for hosting some of the best white water rafting and kayaking in the U.S., and for having the third-longest single-arch bridge in the world. Nestled along some of the most rural parts of the three states in spans, the New River Valley (NRV) region is also home to a growing Hepatitis C (HCV) epidemic.

HEAL Blog has covered the exploding rates of HCV in West Virginia many times since our inception in 2013, as well as having covered those rates in the rest of the Appalachian Mountain Region (AMR). What frustrates many advocates and healthcare workers who live and work in the NRV is that the sharp increase in new HCV infections is largely a product of pharmaceutical companies’ – and healthcare providers’ – making.

Map showing the New River Valley area

Photo Source: Snipview

During the early-1990s, Perdue Pharma using rural towns and counties in the NRV as testing grounds for OxyContin, one of the most widely prescribed opioid drugs of the late-90s and early-00s. HEAL Blog has previously reported on this issue (Cassandra in the Coal Mines), and I stand by the assessment that this region and its population have been systematically targeted by the manufacturers and wholesalers of prescription opioid drugs; wholesalers have, in fact, spent several tens-of-millions of dollars settling cases in West Virginia related to oversupplying the drugs and creating “pill mills” in the state.

There is a direct link between the opioid and heroin epidemics in this region and the vast increase in new HCV infections. In December 2016, Dr. Marissa Levine warned during a meeting of the Virginia Board of Health that the state should expect a “tidal wave” of HCV and HIV primarily related to Injection Drug Use (IDU). The state saw a 21.212% increase in new HCV infections in 2015, from 6,600 in 2014 to 8,000 in 2015 (Demeria, 2016). Dr. Levine also argued that the lack of a dedicated funding stream greatly hinders the ability of the Health Department to accurately capture and track the data accurately, an argument shared by virtually every state in the U.S.

Beyond just opioid drug injection, New River Health District Health Director, Noelle Bissell, M.D., has seen a spike in acute HCV infections (as opposed to chronic conditions) linked to tattoo parlors, the use of homemade tattoo guns at parties, and in people who report more than 10 sexual partners, as well as a trend in cases associated with IDU involving methamphetamine, and in pregnant women and women of childbearing age (SWVA Today, 2017). It should be noted, however, that the Centers for Disease Control and Prevention (CDC) specifically states that the transmission of HCV via sexual activity is “not common” (CDC, 2015). The virus is inefficiently transmitted in this manner, and while it is possible in the manner Dr. Bissell describes, much of the data provided during screening is self-reported by patients – self-reporting may lead patients to purposely omit or skew their answers in an effort to avoid embarrassment or mask other behavioral risk factors.

The rural areas along the NRV are very likely to be hit with a greater explosion of HCV and HIV, and HEAL Blog will be monitoring the situation 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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2016 Year in Review

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 last post of 2016, we at HEAL Blog will take a look at the stories that presented the greatest issues of the year. While there are still new stories to cover, December presents an interesting challenge, as much of the news and events get swallowed up in the year-end hustle and bustle, as well as the excitement of the various holidays. As such, it serves as an excellent opportunity for reflection upon the year we leave behind, as well as aspirations we may have for the year to come.

In 2016, three main issues have garnered repeated coverage: nominal coverage versus actual access, the financial burden posed by newer Direct Acting Agents (DDAs) to treat Hepatitis C (HCV), and opioid and heroin abuse and overdose. The latter topic was featured or mentioned in no fewer than nineteen post, over the course of 2016, and if mortality and emergent care reports are indicative of any trend, that number is likely to increase in the coming year.

Perhaps the biggest frustration faced by patients is the lack of access to effective, easily tolerated HCV treatments. While most Medicaid, Medicare, AIDS Drug Assistance Programs (ADAPs), and private insurance plans indicate on their formularies and Preferred Drug Lists (PDLs) that they offer coverage for newer DAA HCV drugs, actually gaining access to these drugs is often an exercise in patience, abstinence, and enraging hurdle jumping that leaves many patients in the lurch. Whether it’s waiting for one’s liver to degrade to the right fibrosis score, abstaining from drug and/or alcohol use for a predetermined period, or simply fighting through the various appeals and denials, most patients, regardless of their payer, face an uphill battle to being approved for treatment. Many of these trends were also covered throughout the year in the HIV/HCV Co-Infection Watch.

This type of nominal coverage – indicating that coverage is offered, but approving relative few prescriptions – is largely related to the second major issue of 2016: financial burden. Treating and curing HCV is expensive, though few payers have the flexibility to openly disclose exactly how expensive due to existing trade secrets laws that prevent them from publicly revealing the exact price they pay per drug. Regardless of the various discounts and rebates offered by drug manufacturers, every player has indicated that the price is still too high to remove the draconian Prior Authorization (PA) standards they’ve put in place to open coverage to everyone, regardless of liver degradation or whichever other bullet point they’ve managed to fail. Regardless of how many reports, studies, and analyses are put forth indicating that the short-term high cost of a cure is far less expensive than the longer-term repercussions and various related ailments and costs associated with untreated Chronic HCV, there is little indication from payers that these roadblocks to care will be removed.

Perhaps the most personally onerous barrier amongst these myriad prerequisites is the abstinence measure. With an estimated 60% of new HCV infection being related to Injection Drug Use (IDU), People Who Inject Drugs (PWIDs) are often the most stigmatized and marginalized patients infected with HCV. In fact, the stigma related to IDU HCV infection has been listed as one of the primary social barriers to screening for HCV; the threat of being perceived as a drug abuser by friends, relatives, healthcare professionals, and society at large leaves many people hesitant to be screened for HCV, and that fear is exacerbated by the growing number of opioid-related arrests, overdoses, and deaths reported in the media.

Opioid and heroin abuse and overdoses were, again, mentioned in at least nineteen HEAL Blog entries, underscoring the immensity of the threat that’s facing rural and suburban America. While emergent care and law enforcement agencies are attempting various approaches to making headway in dealing with these issues, many state legislative and executive branches are instead taking a hard line on the issue, relying on outdated and troublesome research, as well as outmoded prejudices and preconceived notions about who is to blame, who is at fault, and how hard to come down upon them.

It doesn’t help that, despite solid research and scientific evidence, current public opinion about how to deal with the crisis has seen a troubling resurgence of blunt force solutions, over nuanced, evidence-based approaches. The prevailing sentiment seen in many of the rural and suburban areas is, “It’s their problem, and if they can’t deal with it, it’s still their problem.” While this line of thinking may provide feelings of moral superiority and indignity, they do not help craft real world solutions, especially when those sentiments become campaign talking points.

2017 pushing 2016 down

Photo Source: Fotolia by Adobe

Overall, 2016 has been something of a rough year, with less than glowing reports coming from virtually every sector of the HCV advocacy arena. And, if we’re being honest, we face uncertain times in 2017, with many of us watching and waiting for signs that we’re moving in either direction. This is the most frustrating part for virtually all parties involved: we just don’t know what’s next, nor do we know how or for what to prepare. And with that, we bid 2016 adieu.
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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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The 2016 Election, and What This May Mean for Healthcare

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 passage of the Affordable Care Act (ACA), also known as Obamacare, included a provision that gave states the option to expand Medicaid coverage in order to cover citizens whose incomes were above the Federal Poverty Level (FPL), but whose incomes still present a significant barrier to purchasing health insurance. Of the 50 United States and the District of Columbia, 32 states (including DC) have opted to expand their Medicaid programs. Nineteen states have opted not to expand access.

Expanding access to Medicaid is an essential piece of the ACA, as it was designed to help increase the number of people with access to affordable healthcare. Because the ACA envisioned low-income people receiving coverage through Medicaid, it does not provide financial assistance to people below poverty for other coverage options. As a result, in states that do not expand Medicaid, many adults fall into a ”coverage gap” of having incomes above Medicaid eligibility limits, but below the lower limit for Marketplace premium tax credits (Garfield & Damico, 2016). Since the expansion of Medicaid under the ACA, 73,137,154 Americans were enrolled in Medicaid/CHIP as of August 2016 (Henry J. Kaiser Family Foundation, 2016).

There are an estimated 2.6 million Americans who currently fall into that coverage gap, and of the states that did not expand Medicaid, four states represent 64% of those people (TX – 26%, FL – 18%, GA – 12%, NC – 8%). When looking at the geographic distribution of those 2.6 million Americans, 91% are in the American South (Garfield & Damico, 2016). Demographically, 46% are White non-Hispanics, 18% are Hispanic, and 31% are Black, and over half are middle-aged (age 35-54) or near elderly (55 to 64). Additionally, the majority of people in the coverage gap are in poor working families.

Donald J. Trump

Photo Source: NBC News

President-elect, Donald J. Trump, as well as the incoming Republican-led Congress and Senate, have openly stated that their first priority, at the beginning of the next legislative session, is the repeal of the ACA. There are very few comprehensive plans being proffered to replace the ACA, and healthcare professionals, providers, payers, patients, and advocates, alike, are currently unsure about the future of the expansion, and whether or not that aspect of the ACA will be retained in the forthcoming repeal.

It bodes poorly for those existing people infected with viral hepatitis, especially Hepatitis C (HCV), who stand to lose coverage if the Medicaid expansion does not survive the repeal, even with the existence of drug manufacturer and private Patient Assistance Programs (PAPs). In order for those PAPs to be accessed, however, people must first know about them; without the aid of social workers, healthcare aides, and advocates, people living with HCV are unlikely to find out about these PAPs, unless this information is provided to them by a doctor or nurse.

An additional concern exists for those recipients of the Ryan White Program. Over the past eight years, HIV/AIDS advocates and policy wonks have been in a near-constant debate about whether to reopen the Ryan White Care Act for reauthorization to address some of the ways in which the current law has not necessarily aged well, in terms of keeping up with newer treatments, costs, and funding paradigms. The concern over the past five years has been that the Republican-controlled Congress would “gut” the bill, cutting out many of the provisions upon which organizations and patients have come to rely. With repealing the ACA having played such a large role in this year’s election, concerns about reopening the act are likely to deepen, rather than abate. It is important to note that many states include HCV therapies under their AIDS Drug Assistance Program’s drug formularies.

The HEAL Blog  will pay close attention to both programs, as well as other HIV and HCV-related issues throughout 2017.

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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Do Black Boxes Mean Red Ink for Drug Companies?

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 U.S. Food & Drug Administration (FDA) has recently concluded that new Direct Acting Agents (DAAs) to treat Hepatitis C (HCV) require a boxed warning for the drugs advising clinicians and physicians to screen patients for evidence of a past or current Hepatitis B (HBV) infection before undergoing treatment for HCV. This warning, indicated by black box on the labels of all nine current DAAs, has many investors worried that, along with consistent questions about the Wholesale Acquisition Costs (WACs) of newer HCV drugs, stock prices may face volatility in the coming years.

The new DAAs for HCV have been on the market for roughly three years, beginning with the release of Sovaldi (Gilead) and the companion drug, Olysio (Janssen), in 2013. Since that time, there has been a tremendous outcry from virtually every stakeholder involved in the issue of pricing, save for the pharmaceutical companies, themselves. Additional concerns have been raised that the modules used by companies to determine initial WAC prices is neither transparent, nor representative of the will of consumers. Arguments that pricing structures take into account “what the market will bear” have served as little comfort to advocacy groups, state agencies, and Congressional panels, all of whom are becoming less tolerant of high drug prices.

Drug prices for specialty products – those that are designed to treat very specific conditions – continue to rise at meteoric rates, and regardless of what drug companies believe the markets can bear, state and Federal budgets are largely unequipped to handle the short-term costs to treat HCV without quadrupling their annual budgets, so vast is the pool of infected patients. Beyond just the traditional patient pool, the growing HCV infection crisis in prison populations, which is largely ignored in state reporting and which faces vast issues in screening, prison budgets may soon face extreme funding issues if Federal lawsuits go against them, and require them to provide treatment to all inmates infected with the disease.

These new concerns raised by the FDA represent just the latest hurdle for pharmaceutical companies whose HCV fortunes may turn in the coming years. HBV, an as-yet incurable form of the illness, is much more easily transmittable through sexual intercourse, which may pose an additional risk for HIV/HCV co-infected patients whose HBV infection flares up as a result of using DAAs for HCV. Whether or not the reactivation of HBV in HCV treated patients is widespread is unknown, as the FDA has only identified 24 cases at the time of their ruling.
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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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Many State Prisoners Can’t Access Hepatitis C Therapies

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

Here, at HEAL Blog, we frequently speak about issues related to the cost of newer Direct Acting Agents (DAAs) to treat Hepatitis C (HCV). We’ve also covered issues related to HCV treatment in America’s prison system. Our verdict, then, as now, stands – the only U.S. citizens who are Constitutionally guaranteed healthcare are the least likely to receive treatment for HCV.

Image of the red cross behind bars

Photo Source: Solidarity Watch

A recent study published in Health Affairs confirms our observations from earlier this year: inmates who are infected with HCV are not receiving proper treatment, largely because the cost of medications puts the drugs far out of reach. For co-infected patients, the HCV is likelier to kill them, before the HIV ever will.

The finding that is most troubling is that, of the 106,266 inmates known to have HCV (reported by 41 states), only 949 inmates were receiving any form of HCV treatment by January 01, 2015 – 0.89% of reported inmates. This means that fewer than 1% of reported inmates are receiving their Constitutionally guaranteed treatment.

Another finding that’s equally appalling is that numerous state departments of corrections were receiving much smaller discounts than other state agencies. The US Senate Committee of Finance’s 2015 report on the pricing of Sovaldi and Harvoni noted that the Federal Bureau of Prisons, Department of Defense, and Department of Veterans Affairs receive at least a 24% discount on those drugs, Medicaid receives at least a 23% discount, and that the V.A. and Medicaid programs that accepted the conditions of offered rebates may receive more than a 50% discount. In contrast, ten of eighteen state departments of corrections received less than a 10% discount on Sovaldi as of September 30, 2015, with Michigan paying the full $84,000; five of nineteen states received less than a 10% discount on Harvoni.

While this study does not claim to claim to represent an estimate of HCV prevalence in US prison populations, it does admit that this limitation means that there is likely a far greater prevalence of HCV than the 106,266 inmates listed in the report. This has been suspected for some time, and was specifically alleged in a Tennessee inmate’s case against the state for withholding treatment from prisoner. A May 2016 report by the Tennessean also found that many prisons in the state simply do not test incoming prisoners, because doing so might result in a positive HCV result; admitting that the inmates have HCV would require them to treat the inmates.

While Gilead Sciences (makers of Sovaldi, Harvoni, and Epclusa) justifies the price of their medications by comparing the cost of one course of treatment to the cost of multi-year treatment costs for other diseases, state budgets are not made in such a way that accommodates that pricing philosophy, particularly if patients/inmates become re-infected. With prison budgets already strained beyond the breaking point to provide for the basic needs of their inmates, having them pay price much higher than those paid by either Medicaid or the V.A. is simply a recipe for disaster.
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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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Veteran’s Administration $1.5 Billion for HCV to Expand Coverage

By: Marcus J. Hopkins, Blogger

Veterans Administration logo

Photo Source: VA

The Veteran’s Administration (VA) has requested $1.5 billion in the Fiscal Year 2017 (FY2017) budget in order to treat more veterans for Hepatitis C (HCV). This move comes after the announcement in March that the VA would be expanding treatment protocols to include all veterans in its health system with the virus, regardless of age or progression into liver cirrhosis (Kime, 2016). This coverage expansion was covered in the HIV/HCV Co-Infection Watch Report in April, and was recently reported in the Journal of the American Medical Association (JAMA) in the September edition.

With more than $2 billion appropriated for new HCV drugs during the past two years, the VA has treated 65,000 veterans for the virus (Wentling, 2016). One of the primary concerns expressed by veterans’ groups – Disabled Veterans (dot) Org, in particular – has been the rationing of care to only those whose liver fibrosis scores met what they feel are arbitrary measures that focus more on saving money, rather than saving lives. Tom Berge, head of the Vietnam Veterans of America (VVA) health care panel, went so far as to say the following: “When I found out that they were prioritizing the treatments, that’s when I said they were death panels (Krause, 2016).” The “death panels” claim is reminiscent of political arguments against single-payer or Universal healthcare coverage, wherein bureaucrats essentially decide which people would live or die, based on a set of predetermined markers.

The rationing of treatment to the sickest or most financially able to pay is nothing new – public and private insurers and payers, alike, have utilized these formulae and markers in an effort to reduce costs while still maintaining the visage that they “cover” drugs, even if actual utilization on the part of patients is low. With HCV drugs, in particular, many Medicaid and ADAP programs have indicated in their respective Preferred Drug Lists (PDLs) and formularies that they cover the new Direct Acting Agents (DAAs) that are currently considered to be the Standard of Care (SOC) for HCV, only to have the Centers for Medicare and Medicaid Services (CMS) release a guidance in November 2015 reminding Medicaid programs that “cost” was not an acceptable reason to deny coverage. Certain states – Arizona, for example – openly stated that they would not be following said guidance.

The VA currently estimates that 107,000 vets have undiagnosed or untreated HCV (Wentling, 2016), with Vietnam War-era veterans born between 1945 and 1965 being one of the demographics most likely to have been infected, as this generation (generally referred to as “Baby Boomers”) may have been the recipients of blood transfusions and organ transplants prior to the discovery and screening of blood for HCV. It wasn’t until 1992 that widespread screening of the blood supply began in the United States.

While this demographic is a target for HCV screening, most new HCV infections occur as a result of sharing syringes or other equipment to inject drugs (Centers for Disease Control and Prevention, 2016). Veterans are particularly susceptible to prescription opioid and heroin addiction. According to VA officials, roughly 60% of those returning from deployments from current engagements in the Middle East and 50% of older veterans suffer from chronic pain. That’s compared to about 30% of Americans, nationwide. Additionally, veterans are twice as likely to die of accidental opioid overdoses than non-veterans. Prescriptions for opioid drugs rose by 270% over a twelve-year period by 2013 (Childress, 2016). This places veterans at particular risk of contracting HCV as a result of Injection Drug Use (IDU).

Though the cost of treating HCV are currently astronomical, on a national scale, the VA does benefit from a requirement that drug manufacturers provide the system with the “best price,” though those discounts are currently shielded by Trade Secrets laws that specifically forbid programs from publicizing any deals, discounted prices, or pricing arrangements struck between pharmaceutical companies and payer programs. But, we have asked of our veterans that they make sacrifices to ensure our continued freedom and safety; is any price too high to ensure their continued health and wellbeing if and when they return from battle? I think not.
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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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