Tag Archives: Indiana

Increase in HCV Cases Calls for Updated Screening Protocols

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

We, here at HEAL Blog, attempt to provide coverage of local outbreaks of Viral Hepatitis (VH), as well as to investigate and report them using evidence-based data to accurately characterize the issues at play. What consistently comes to the forefront of Hepatitis C (HCV) infection is the issue of Injection Drug Use (IDU) and the People Who Inject Drugs (PWID). More than any other risk factor, IDU in consistent across Hepatitis A (HAV), Hepatitis B (HBV), and HCV. According to the Centers for Disease Control and Prevention (CDC), in 2015, IDU was reported as a risk factor in 36.1% of all Acute HAV cases, ~34.3% of all Acute HBV cases, and 64.2% of all Acute HCV cases (CDC, 2017).

Hepatitis Screening

Photo Source: JAMA

In the five of the states with the highest rates of HCV – Massachusetts (MA), West Virginia (WV), Kentucky (KY), Tennessee (TN), Maine (ME), and Indiana (IN) – these data are undeniable:

And yet, none of these states have amended their HCV screening protocols to include compulsory “Opt-Out” screening in every healthcare setting. This is folly, at best, and dereliction of duty, at worst. If a state’s responsibility is to ensure the health and welfare of its citizens, it is incumbent upon them to take non-extraordinary steps to expand screening protocols. Moreover, they must begin regularly surveilling and reporting, including detailed risk-factor reporting.

If this sounds “revolutionary,” it’s simply not. Given the high rates of infection, mortality, co-morbidities, and the fact that there is a functional cure for the disease, there is simply no excuse for failing to expand testing to include compulsory “Opt-Out” screening for HCV, particularly in states where IDU is high. Is it expensive? Yes. But, again, when it comes to the health and welfare of people, sometimes short-term expenditures outweigh long-term costs of care. This is why there are grants; this is why people pay taxes.

Some of the most successful screening efforts are being conducted not in traditional healthcare settings, but at Syringe Services Programs (SSPs), which remain controversial among those who say that they promote and encourage drug use. These services are, however, vital to stemming the spread of disease. Perhaps the least successful screening efforts are conducted in incarceration settings, despite having essentially a captive demographic. These efforts are hampered, again, by cost concerns, as, if the results come back “Positive,” they are required by law to treat.

While expanding screening may be initially costly, it is the best way for us to go about eliminating HCV in the U.S.

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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Scott County and Indiana’s Steep Learning Curve on HIV and 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

In early 2015, Scott County, Indiana was thrust into the global spotlight for an HIV outbreak among injection drug users abusing opioid prescription drugs and heroin (Hopkins, 2015). In a county that averaged a total of 5 new HIV infections each year, even doubling that number would’ve been a statistical anomaly. By the end of 2016, the county had 216 new HIV infections in the span of just two years, and of those, 95% were co-infected with Hepatitis C (HCV). So rare was the disease that county health department officials had never handled HIV cases, instead sending them all to the regional Sexually Transmitted Diseases Department in Clark County (May, 2016).

The outbreak in Scott County was, and still is, both instructive and reflective of several concurrent health crises faced by most of rural America. In one county, virtually every major health risk met in the middle: a prescription opioid addiction problem, the resultant heroin usage problem, and an access to comprehensive healthcare problem all walked into a bar, and out came one of the worst concentrated HIV epidemics in the U.S. in the past decade. Throw in a paucity of drug addiction, recovery, and Syringe Services Programs (SSPs), and you had the perfect case study for how outbreaks occur.

To be fair to Indiana’s legislature and then-Governor Mike Pence, the state responded intelligently to the crisis by legalizing for the first time SSPs…under certain previsions. Counties had to apply for approval, had to show that they had funding, and had to be located in a high-risk zone. Since Mike Pence’s departure from the state to swampier D.C. pastures, his replacement has actively attempted to ease those restrictions. Earlier this year, the Indiana General Assembly passed a bill allowing local governments to establish syringe or needle exchange programs without having to receive state approval (Rudavsky, 2017). His efforts have not, however, managed to convince everyone.

Map showing states with syringe exchange programs.

Source: HIV/HCV Co-Infection Watch

Madison County, for example, recently voted to remove all funding from their SSP, run by the county’s health department, and prohibited appropriations of funds for paying for both supplies and labor (Fentem, 2017). The ordinance, approved by five of the seven-person council, immediately shuttered the only operating SSP in the county, and was largely driven by stigma-based fears: discarded syringes were going to litter front lawns and public parks; drug addicts were going to wander over from neighboring counties, bringing their drug problems with them; “What about the innocent children?!” These well-worn excuses and arguments against the establishment and funding of SSPs have plagued the proven Harm Reduction measure since its inception. The fears are also unsupported by anything other than anecdotal evidence and hearsay, few assertions of which are backed up by any credible research or quantifiable proof.

Worse, still, is that the council members did nothing on their part to allay these fears. Council member Fred Reese is quoted as saying the following:

Some say if you don’t do the needle exchange, you’re going to have a spread of HIV, you’re going to have a spread of hepatitis C, but my concern is the innocents. I don’t want these needles out (Fentem).

This kind of statement on the part of an elected officials shows cowardice, rather than leadership. Part of the job of county councils is to do what’s in the best interests for everyone, rather than kowtowing to fear-based arguments that bear little resemblance to reality.

Clark County – where Scott County once sent its HIV cases for management – recently renewed their SSP for one year, after which it will be up for renewal in August 2018. About half of the program’s 150 participants have HCV, many of whom were diagnosed through the program (Beilman, 2017). Their hopes for the program include seeing a more balanced rate of return on needle collection. Of the nearly 16,000 needles distributed, the exchange collected almost 8,000 (Beilman).

In Boone County, where no SSP currently exists, Prosecutor Todd Meyer sent the following communique to county leaders:

A needle exchange program does not help in fighting the demand side, in fact, it will do the exact opposite by providing the users/addicts with the tools they need to continue to abuse illicit drugs…(Davis, 2017).

That this opinion was issued by a prosecutor should shock no one. Meyer’s position, however, is reflective of those espoused by [mostly Conservative] voters, legislators, and law enforcement officials, but again, bear little resemblance to reality. Instead, they rely upon fear and stigmatization, along with two terrifyingly short-sighted sentiments: “Not in my back yard!” and “It can’t happen here!” While Meyer contends that Boone County doesn’t have an HIV problem, now, let’s see if it has one in two years.

Back in Scott County, the SSP, run by the Scott County Health Department (SCHD), has another issue: it doesn’t keep track of HCV cases (de la Bastide & Filchak, 2017). For some reason, SCHD officials are only worried about their HIV problem. If that seems counterintuitive, that’s because it is. It was, in fact, a spike in new HCV cases that led to the discovery of the HIV epidemic. Additionally, with a 95% co-infection rate in the 216 HIV cases identified in the initial outbreak, as well as the more aggressive spread of HCV in the U.S. compared to HIV, it makes no sense, whatsoever, for the SCHD to fail to keep track of HCV.

The concurrent HIV and HCV outbreaks in Scott County, Indiana were just the beginning. Already, rural states and counties are beginning to see an uptick in new infections of both diseases as a result of Injection Drug Use (IDU). More concerning is the fact that most of those counties are deeply Conservative, which creates significant challenges for those hoping for proactive healthcare policies, rather than reactive cleanup measures. As for Scott County, there are several families with multiple generations infected with HIV, and very likely with HCV, as a result of prescription opioid and heroin abuse. Unfortunately for them, their county’s health department doesn’t see fit to track their issues.

Download the latest edition of the HIV/HCV Co-Infection Watch.

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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Viral Hepatitis Funding Lowest in States Most at Risk

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 Centers for Disease Control and Prevention (CDC) recently released the data related to Viral Hepatitis (VH) surveillance in the U.S. for 2015, and the picture is…grim. While many states saw relatively stable rates of new Acute Hepatitis C (HCV) infections, two states – AL and PA – experienced 100% increases from 2014 (CDC, 2017). CDC funding for states’ respective Viral Hepatitis programs, however, tends to fall short in states where rates of infection are high relative to the population (The AIDS Institute, 2017).

Infection rates are generally calculated by taking the number of total infections, dividing that by a state’s total population, and multiplying that result by 100,000 to calculate how many people, on average, will be infected for every 100,000 residents. For example:

The state of West Virginia reported 63 new cases in 2015; the state has a population of 1,844,000, so 63/1,844,000 = 0.00003416 x 100,000 = 3.416 rate of infection.

West Virginia, despite being the 14th least populous state (including the District of Columbia), has the second highest rate of new HCV infections in the U.S., second only to Massachusetts, which has a rate of 3.7. The following chart lists the top ten states in order of highest infection rate, their respective populations, and the amount of funding in those states for VH:

Chart showing 10 states with highest viral hepatitis infections also having lowest state budgets to combat the disease, including MA, WV, KY, TN, ME, IN, NM, MT, NJ, NC

The above chart seems to be indicative of two things irrespective of a state’s population: (1.) certain states make VH funding a priority, while others do not; (2.) states are simply not receiving enough funding from the Federal government and the CDC to bring their VH programs up to funding levels adequate enough to effectively combat VH.

Each of these states has a number of factors contributing to their respective rates of infection: (1.) Aging populations (Baby Boomers born between 1945-1965); (2.) High rate of Injection Drug Use related to opioid drugs, heroin, or stimulants; (3.) Sharp increase in the number of tests administered, resulting in higher rates of positive results.

What is clear is that funding for VH is woefully inadequate if the U.S. intends to eradicate HCV from the U.S. by 2030.

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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Heroin and Hepatitis Go Hand in Hand

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

Over the past year, HEAL Blog has paid a lot of attention to heroin, particularly in relation to the massive increase in heroin and prescription opioid overdoses in Appalachia, the Midwest, and the Northeast. While the purpose of HEAL – “HEAL” standing for “Hepatitis: Education, Advocacy, and Leadership” – is to specifically address issues related to Viral Hepatitis, and particularly Hepatitis C (HCV), when we cover issues related to prescription opioid abuse and heroin, we sometimes fail to connect the dots between the two topics. There is, in fact, a very high correlation between Injection Drug Use (IDU), People Who Inject Drugs (PWIDs), and the transmission of HCV: most new HCV infections in the three previously listed regions are related to IDU.

Sources of Infection for Persons with Hepatitis C

Photo Source: Pinterest

HCV and HCV-related co-morbidities (e.g. – Cirrhosis, Advanced Liver Disease) kill more Americans each year than any other infectious disease (Centers for Disease Control and Prevention, 2016). It is also one of the most expensive diseases to treat, with Direct Acting Agent (DAA) drug Wholesale Acquisition Costs (WACs) ranging between $50,000 and $100,000 for twelve weeks of treatment. This makes preventing the spread of HCV not only a matter of physical health, but one of fiscal health.

Despite pharmaceutical manufacturers’ arguments that the one-time cost of a regimen to achieve a Sustained Virologic Response (SVR – “cure”) is far cheaper than the long-term costs of other diseases, not to mention the long-term costs that arise if HCV goes untreated, state and Federal healthcare budget departments remain unconvinced. Budgeting processes generally focus on a single year, rather than accounting for multi-year spending, so arguing that long-term expenditures “cost” more hasn’t been an effective argument. Even with the clandestine pricing agreements and rebates – clandestine, because they are not made public due to “trade secrets” laws – states have yet to begin treating every HCV-infected client on their government-funded rosters. To do so would blow through entire pharmacy budgets several times over, in many states.

With PWIDs representing the highest number of new HCV infections between the ages of 18-35, state legislatures are starting to come around to the realization that the best way to avoid spending that money on expensive treatments is to put into place Harm Reduction measures that are shown to prevent the spread of blood borne illnesses. As it is very difficult and unfeasible to stop IDU, syringe exchanges can be put into place that allow PWIDs to inject using clean needles, rather than sharing them.

Syringe exchanges have, for much of the past forty years, been largely reviled by politically conservative politicians and states; many Republican politicians have repeatedly argued that state-sponsored syringe exchanges will only encourage bad behavior, serving as a tacit endorsement of IDU. Now that prescription opioid and heroin abuse has moved outside of the urban areas and into the suburban and rural areas that serve as bastions of the Conservative ideal, suddenly, these politicians are coming around to the idea.

Medical technician counting needles.

Photo Source: Daily Beast

In the past two years, several considerably conservative states have passed laws allowing syringe exchanges to be established – Indiana, North Carolina, Ohio, and Virginia, to name a few – largely in response to a relative explosion of new HIV and HCV infections related to IDU. The problems that politicians and their constituents once relegated to the big cities have come to their quiet towns, and have done so right under their noses. The lessons out of Scott County, Indiana, where nearly 200 people tested positive for HIV near the end of 2015 and into 2016, are still reverberating throughout the region, and people are starting to look at ways to prevent the spread of disease, rather than punish the behavior.

It is clear that the opioid and heroin abuse epidemic is not going away, anytime soon. Since we aren’t likely to stop currently addicted people from injecting drugs, the smartest path forward is to at least make certain they can do so safely.

References:

  • Centers for Disease Control and Prevention (CDC). (2016, May 04). Hepatitis C Kills More Americans than Any Other Infectious Disease. Atlanta, GA: Centers for Disease Control and Prevention: Newsroom Home: Press Materials: CDC Newsroom Releases. Retrieved from: https://www.cdc.gov/media/releases/2016/p0504-hepc-mortality.html

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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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A Case of Northern Overexposure

By: Marcus J. Hopkins, Blogger

The face of Hepatitis C (HCV) continues to change, as the State of Alaska Section of Epidemiology is reporting – nay, warning – of yet another example of rapid increase in HCV rates among people aged 18-29 (State of Alaska, 2016). Of the 1,486 cases of HCV reported in 2015, the aforementioned age group represented 459 of those cases – roughly 31% – putting them on par with people aged 30-49 (461, roughly 31%). The remaining cases in 2015 were seen in people aged 50 or older.

This data conforms to national trends in HCV. While the majority of cases tend to occur within the 50+ age range, the fastest rate of increase continues to exist amongst the young, largely driven by opioid prescription drug and heroin abuse. Injection Drug Use (IDU) is consistently pegged as the largest driver of new infections, and the problem continues to grow and more people are being prescribed addictive prescription opioid drugs for pain management for injuries that may not necessitate them.

While opioid and heroin IDU is a growing problem, Alaska has long been utilizing Harm Reductions methods to attempt to mitigate the harm to IDUs. Four Syringe Exchange Programs (SEPs) are currently operating in Alaska in four cities: Anchorage, Fairbanks, Homer, and Juneau. Only once of these cities – Juneau – is present in the hardest hit region of the state, where the rate of infection for 18-29-year-olds saw a 490% increase from 2011-2015. Of further concern is that no SEP programs are operative in other parts of the state, which means that people in those areas are least likely to receive IDU support services.

The State of Alaska is quick to state that these data should not be considered the final word on HCV infections for 2015; many people who are infected with HCV are not diagnosed until years after the initial infection (Juneau Empire, 2016).

In similar news, Clark County in Indiana has become the sixth county in the state to qualify for permission to open an SEP under a 2015 emergency law that allows states to open an approved exchange if the state’s health commissioner declares a public health emergency in the county (. This was in response to a massive outbreak of HIV and HCV in southern Scott County in late-2014/early-2015 related to IDU.

While Clark County has received approval for the opening of an SEP, it spent a full eight months attempting to work out issues with its initial application. The primary issue, according to County Health Commissioner Kevin Burke, was that state officials didn’t support how the SEP would have been funded. Funding for the program was and will be provided by the Los Angeles-based AIDS Healthcare Foundation (AHF), which has garnered both high praise and sharp criticism in its approach to negotiating contracts with states and counties. After the problematic funding models were hammered out, a second application was submitted and approved.
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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.

 

References

 

 

 

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