Friday, January 25, 2013

A Two-Front Battle Facing ADAP: HIV/HCV Co-Infection

Despite very little news coverage, there is a storm brewing that will have a serious impact on the nation's already-strained public health system.

People living with HIV infection are disproportionately affected by viral hepatitis; about one-third of HIV-infected people are co-infected with Hepatitis C, which can cause long-term (chronic) illness and death. Hepatitis C progresses faster among people living with HIV infection and people who are infected with both viruses experience greater liver-related health problems than those who do not have HIV infection. Although antiretroviral therapy has extended the life expectancy of people living with HIV infection, liver disease—much of which is related to Hepatitis C has become the leading cause of non-AIDS-related deaths among this population.
Map of the United States showing ADAP Coverage of Hepatitis C Treatment
ADAP Coverage of Hepatitis C Treatment, June 2011
Here are some sobering important facts about HIV/HCV co-infection:

  • About 25% of people infected with HIV in the U.S. are also infected with HCV.
  • About 80% of injection drug users (IDUs) with HIV infection also have HCV.
  • HIV/HCV co-infection more than triples the risk for liver disease, liver failure, and liver-related death from HCV.
  • Compared with other age groups, a greater proportion (about 1 in 33) of people aged 46–64 years are infected with HCV.
  • Chronic HCV is often "silent," and many people can have the infection for 20 to 30 years without having symptoms or feeling sick.
  • In the U.S., HCV is twice as prevalent among blacks as among whites.
  • New data suggest that sexual transmission of HCV between MSM living with HIV occurs more commonly than previously believed and that sexual transmission can occur undetected between HIV-infected MSM in the absence of injection drug use. [1]
Undoubtably, public health systems are facing a grim reality as more people are co-infected with HIV/HCV.  Currently, there are twenty-eight (28) states that have Hepatitis C treatment as part of their drug formulary under the AIDS Drug Assistance Program (ADAP).[2]  It is therefore important to examine relevant cross-section between HIV/HCV with respect to ADAPs.

HIV/HCV co-infection remains a growing and evolving epidemic. Advances in HIV medication since the introduction of HAART in 1996 has increased a detection of sexually transmitted HCV infection. Sexual transmission of HCV is becoming a growing concern amongst MSM as discussed in an MMWR report released July 22, 2011.[3]

ADAPs provide HIV-related prescription drugs to low-income people with HIV/AIDS who have limited or no prescription drug coverage. With nearly 200,000 enrollees, ADAPs reach approximately one-third of people with HIV estimated to be receiving care nationally. In June 2008 alone, ADAPs provided medications to about 110,000 clients and insurance coverage to thousands more. 

HCV is a common co-infection in people living with HIV/AIDS. An estimated 200,000-300,000 people in the United States are co-infected with both HIV and HCV infections. Experts believe that about 25% - 30% of Americans living with HIV are also co-infected with HCV; conversely some 10% of people with HCV are thought to also have HIV infection.  Currently specific ADAP funding does not exist to support treatment for Hepatitis C. However, some states with robust ADAP budgets use Part B money to pay for HCV treatment for co-infected clients.

The Community Access National Network (CANN) has recognized this emerging public health concern, and recently announced the formation of its new hepatitis initiative.  The “HEPATITIS: Education, Advocacy & Leadership” Project also known as HEAL, will participate in various hepatitis stakeholder groups to map out strategies on prevention, education, treatment and access to care, with a particular focus on HIV and Hepatitis C (HCV) co-infection.

“CANN has long been recognized for its commitment to promoting patient access to timely care and treatment, and the HEAL project will educate consumers, community partners, as well as congressional staff here in Washington, D.C. about the fastest growing public health epidemic since AIDS: HCV infection,” summarized Bill Arnold, President & CEO of the Community Access National Network.  “We have learned many valuable lessons from the HIV/AIDS advocacy community over the last three decades, and CANN will now apply those lessons to ensuring access to effective HCV treatments.” 

To that end, HEAL will be collaborating with the ADAP Advocacy Association in April to host an HIV/HCV Co-Infection ADAP Summit in Las Vegas, NV.  The purpose of the HIV/HCV Co-Infection ADAP Summit is to provide the latest information to appropriate ADAP stakeholders on Hepatitis C drug development, patient assistance programs, and other updates about HIV/HCV co-infection; identify funding shortfalls within ADAP, and bring to the forefront dialogue and a strategy to attain more funding for ADAP to treat co-infected clients; identify potential HCV rebate dollars available using ADAP rebate methodology; and facilitate ongoing dialogue between ADAP stakeholders, pharmaceutical industry and other applicable entities in order to collectively identify practical strategies to improve access to care for people co-infected with HIV/HCV. 

Interested parties should inquire at

[1] Centers for Disease Control & Prevention, HIV and Viral Hepatitis Fact Sheet, November 2011.
[2] National Alliance for State and Territorial AIDS Directors (NASTAD), National ADAP Monitoring Project Annual Report, 2011.
[3] U.S. Centers for Disease Control & Prevention, MMWR Vol. 60 No.28, July 22, 2011.