Tag Archives: North Carolina

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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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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Carolina on My Mind

By: Marcus J. Hopkins, Blogger

Every year, legislatures around the United States pass legislation that is a mixture of good and bad, and this year, North Carolina’s bill, H972, is no exception.

First and foremost, H972’s primary function is to codify into law that recordings made by law enforcement agencies are not public record, and therefore are not subject to Freedom of Information Act (FOIA) or public records requests. This portion of the bill – which makes up two-thirds of the document, itself – is the likeliest portion of the bill to head immediately to court. It is not, however, within the context of the purposes of HEAL Blog to comment either on the legality or constitutionality of this section, and we will therefore move on to the next.

For our purposes, the final two pages of the bill authorize the establishment of state-sanctioned needle exchange programs in the state of North Carolina. This is a fantastic step forward in a state hard hit by the ravages of opioid prescription drug and heroin abuse. Injection drug users (IDUs) represent an ever-increasing percentage of new HIV and Hepatitis C (HCV) infections in the United State, and syringe exchange programs as a measure of harm reduction have largely shown to be effective in preventing the spread of disease by reducing the likelihood that IDUs will share needles.

Image promoting needle exchange for IDUs

According to the Centers for Disease Control and Prevention (CDC), injection drug use accounted for a full 6% of new HIV infection in adults and adolescents in 2014. That number is likely to rise considerably for the year 2015, with the recent spate of widespread infection in rural and suburban areas in Indiana, Kentucky, Ohio, West Virginia, and Massachusetts.

Indiana’s well-publicized example of the risk of HIV and HCV exposure via injection drug use was so vast, it inspired a usually vehemently opposed conservative legislature to agree to pass emergency permission to establish state-sanctioned syringe exchange programs in the hardest hit areas of the state. Similar circumstances prompted certain areas in Kentucky and West Virginia – areas where syringe exchanges have been long needed, but never funded – to establish localized syringe exchange programs in some of the most impacted areas.

While North Carolina’s legislature should be lauded for their passage of Needle Exchange provisions, there is some concern that its inclusion in a bill designed to make secret the recordings of law enforcements agencies and the constitutional concerns that raises may prompt the governor to veto the bill. If that occurs, it is hoped that the tireless advocacy efforts of NC State Senator Stan Bingham and State Representative John Faircloth – both Republicans – will find their way back into another bill, as this issue is vitally important to preventing the further spread of HIV and HCV in North Carolina and beyond.
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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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When the Standard of Care Isn’t Standard Procedure

By: Marcus J. Hopkins, Blogger

This past week, I has the privilege of attending the ADAP Advocacy Association’s AIDS Drugs Assistance Program (ADAP) Regional Summit in Birmingham, AL. This was the sixth such meeting since 2011, with the previous year’s meeting having been held last year in Atlanta, GA. These summits are designed to discuss issues involving state-administered ADAPs that face specific regions, and three times now, this meeting has focused on the South.

This Southern focus is no accident: of the top ten states with the highest incidence of new HIV infections in 2014, Southern states fill five of those spots — including Florida, Georgia, Louisiana, North Carolina, and Texas (Kaiser Family Foundation, 2015). In addition, these states face significant barriers – endemic poverty, geographic barriers to care, inadequate Federal and state funding for assistance programs, and endemic distrust of authority and medical professionals – that largely prevent them from providing low- or no-cost HIV treatment and medications for low-income patients.

Map of the United States, with the southern states highlighted in red

Photo Source: Dialect Blog

In addition to leading the nation in regional HIV infections, the South also leads the nation in opioid prescribing. Of the top ten states for opioid prescriptions per 100 people, nine of those spots are occupied by Southern states (Centers for Disease Control, 2014). Alabama, host of this year’s Regional ADAP Summit, currently boasts the highest rate – 142.9 opioid prescriptions per 100 people. States with higher opioid prescribing rates inevitably have more Injection Drug Users (IDUs), which bodes poorly for the burgeoning rate of new HCV infections in these states. In 2015, the CDC released a report linking the increase in new HCV infections to IDUs under the age of 30 (CDC, 2015). The prescribing data, IDU rates, and HCV infection rates combine to create a bleak omen for the South’s burgeoning co-infection crisis.

ADAPs were created to serve the healthcare needs of people living with HIV for whom primary insurance coverage was essentially impossible to find. Combine a lack of access to adequate coverage with the high cost of HIV Direct Acting Agents (DAAs), and lower-income people living with HIV faced (and continue to face) seemingly insurmountable costs of care.

ADAPs are Federally-funded through a grant process; once those funds are allocated to each state (using a formula to determine the amount of ADAP funds each state is awarded), each state is then responsible for operating their own ADAP on the state-level, resulting in a sad-but-true adage: “When you’ve seen one ADAP, you’ve seen one ADAP.” This state-level administration of the program creates a massively uneven landscape, with no one state offering the same services or formulary coverage – what’s true in Tennessee may not be true in Alabama, or Georgia, or North Carolina.

Southern ADAPs almost all fail to provide coverage for the current standard of care for HCV (Infectious Diseases Society of America, 2016), which includes only newer Direct Acting Agents (DAAs) – Sovaldi, Harvoni, Olysio, Viekira Pak, Daklinza, Technivie, and Zepatier – for treatment, as opposed to the poorly tolerate ribavirin- and Pegylated interferon-based treatment regimens. Of the seventeen states that make up the American South, only three offer coverage for one or more HCV DAAs (AR, VA, & TN), while five states – all of which have very high HCV infection rates – offer no coverage, whatsoever (FL, GA, KY, LA, & TX). The remaining states provide coverage only for last decade’s poorly tolerated treatment regimens.

These older regimens often have very high failure rates for curing HCV – achieving a Sustained Virologic Response (SVR) – largely because they are so poorly tolerated that many patients simply cannot complete the regimen before they abandon treatment. In addition to being more easily tolerate, the newer DAAs have much higher success rates in achiever SVRs. This means that patients are more likely to successfully complete their treatments in a single go, rather than repeatedly failing using older regimens. With so few Southern ADAPs providing coverage for these DAAs, clients are much more likely to remain co-infected and continue to drain precious financial resources through repeated unsuccessful treatments.

There are, however, significant costs associated with these DAAs. Each of these drugs boast some of the highest Wholesale Acquisition Costs (WACs) in the pharmaceutical industry. Zepatier, the newest DAA on the market, currently sports the lowest WAC of the pack at the comparatively low price of only $54,000 for twelve weeks of treatment. Even with negotiated pricing and rebate deals between ADAPs and drug manufacturers that may lower those costs by up to 80% off the WAC, many ADAPs, Southern or otherwise, find themselves unable to afford the cost of coverage, leaving ADAP recipients to fend for themselves in an attempt to pay for treatment.

Under the Affordable Care Act (ACA), states were asked to voluntarily expand their Medicaid programs, which would have allowed Ryan White Part B ADAP programs to shift a significant number of their clients off of their rosters and onto their states’ Medicaid programs. However, this voluntary expansion plan ended up working out exactly as expected: the states that most needed the Medicaid expansion to address their healthcare needs ended up being the states that opted not to expand their programs. Of the seventeen Southern states, only seven states have expanded their programs, only three of which (AR, KY, & LA) fall in the area commonly referred to as the “Deep South.”

In these non-expansion states, ADAPs and their clients continue to face barriers related to coverage of the HCV DAA drugs. Of the nineteen states whose legislatures (or governors, via executive order) have opted not to expand Medicaid, only five (ME, OK, SD, TN, & VA) off expanded DAA coverage, while seven (FL, GA, KY, LA, NE, TX, & UT) offer no coverage, whatsoever. The remaining seven states (AL, MS, MO, NC, SC, WI, & WY) provide the outdated, ribavirin- and Pegylated Interferon-based treatments.

Further complicating issues of coverage is that many ADAPs (including Alabama’s and Louisiana’s) have decided to pay for their clients to enroll in private insurance plans through the ACA, rather than pay directly for their care. This can be considerably problematic, because it essentially ties drug coverage to whatever plans are available and their respective formulary coverage. These formularies vary from payer to payer, and in many Southern states, options can be limited to only a handful of insurance providers; in some states, those options are essentially monopolies.

What makes these insurance formularies problematic for ADAP clients is that many plans categorically shunt many of the HIV and HCV DAA and combination therapy drugs into higher tiers that require patients to pay exponentially higher co-pays to fill prescriptions; and, again, each state’s respective ADAP determines whether or not those co-pays are paid for by ADAP funds or left up to the patient.

Anecdotally, my personal Highmark West Virginia Blue Cross/Blue Shield provider currently has an HIV formulary that does not reflect the current standard of care for HIV, covering only a single single-pill regimen (Atripla), which is no longer being actively prescribed. When I contacted Highmark to inform them that their formulary is outdated and needs to come into compliance with ACA non-discrimination requirements, I was told that I was welcome to seek coverage with another insurer. As of April 15th, 2016, I filed a complaint with the Department of Health and Human Services Office of Civil Rights to begin an investigation into the provider.

While ADAPs go a long way toward helping lower-income HIV patients afford the cost of care and treatment, co-infected clients still face significant hurdles when trying to address their HCV-related care. This situation is slowly being ameliorated, as more state ADAPs add DAAs to their respective formularies. That said, there are still myriad obstacles to overcome in order to ensure that all lower-income HIV and HIV/HCV co-infected patients receive the care they need in order to live a happy, healthy, and productive life.

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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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