Co-Infection: HIV & Hepatitis C Therapies Under State AIDS Drug Assistance Programs

By: Brandon M. Macsata, CEO, ADAP Advocacy Association

According to amfAR, The Foundation for AIDS Research, there are an estimated 1.2 million people living with HIV/AIDS in the United States, with as many as 150,000 unaware of their status.[1] The U.S. Centers for Disease Control & Prevention (CDC) estimates one percent of the adult population, or nearly 2.4 million Americans, are living with Hepatitis C (HCV).[2] The intersection between these dual epidemics continues to place significant strain on the nation's public health system. In 2009, approximately one in five of the HIV-infected adults who were tested for past or present HCV infection tested positive.[3] It is unknown how the ongoing Covid-19 pandemic is influencing HIV/HCV co-infection.

Photo Credit: iStock (rights purchased)

What we do know is people living with HIV-infection face a higher risk of long-term liver failure as a result of co-infection with HCV. In fact, HCV-related liver failure has become the leading non-AIDS-related cause of death among people living with HIV-infection in the United States – and as such, treating HCV is of paramount importance.[4]

HIV/HCV co-infection remains a growing and evolving epidemic. Advances in HIV medication since the introduction of highly-active anti-retroviral therapy in 1996 has increased a detection of sexually transmitted HCV infection. Dating back to 2011, sexual transmission of HCV is becoming a growing concern amongst men-who-have-sex-with-men (MSM).[5] 

The HIV/HCV Co-Infection Watch — a program of the Community Access National Network (CANN) — delivers relevant information from a “patient-centric” perspective on access to care and treatment. The three primary groups best suited for this information include patients, healthcare providers, and community-based AIDS Service Organizations.

Of particular importance to the ADAP Advocacy Association are the patients who frequently rely on coverage provided by state- and federally-funded programs – such as the AIDS Drugs Assistance Program (ADAP). According to the National Alliance of State & Territorial AIDS Directors (NASTAD), "While ARVs represent 95% of all CY2018 ADAP drug expenditures, 0.4% and 1% were expended on hepatitis B and C treatment, respectively."[6]

Dating back to the passage of the Affordable Care Act, NASTAD has detailed the availability of testing, care and treatment for individuals who are mono-infected with HCV and co-infected with HCV and HIV, in light of newly available curative treatments for HCV.[7]  NASTAD has also made available an interactive map highlighting the important work of health department HIV and viral hepatitis programs.

Additionally, CANN's HIV/HCV Co-Infection Watch includes detailed information on States whose ADAP drug formularies cover HCV therapies. Summarized Jen Laws, Project Director for the HIV/HCV Co-Infection Watch, “For purposes of our monitoring, coverage is broken down into ten categories - Basic Coverage, Sovaldi, Harvoni, Zepatier, Epclusa, Vosevi, Mavyret, Pegasys, Harvoni (generic), and Epclusa (generic). This will be expanded as newer treatment options become available."

Photo Source: HIV/HCV Co-Infection Watch

While 47 of the country's 56 state and territorial ADAPs provide some form of HCV coverage, only 44 provide coverage for direct acting agents matching with the standards of care provided for by American Association for the Study of Liver Diseases and the Infectious Diseases Society of America. The quarterly report monitors for changes in HCV medication coverage. Most recently published in April 2021, it notes several changes with regard to HCV treatment coverage among ADAPs, primarily as a result of budget impacts due to COVID-19. For example, Texas's program has ceased coverage of any HCV therapies except for Epclusa (brand only), and Georgia's ADAP has stopped paying for all HCV therapies, while maintaining them as drugs on the formulary.

Laws further reflected, "Program information can be challenging to navigate and the Watch is an invaluable as a tool to help patients navigate what's available to help them, when they need it." Laws added, "As far as HCV treatment coverage, given the significant rate of HCV coinfection with HIV, it's unfortunate to see some ADAPs treat access to and coverage of HCV medications as optional or fail to adopt medication coverage in alignment with standards of care because we know treating the medical needs of PLWH holistically leads to a higher rate of positive health outcomes."

The HIV/HCV Co-Infection Watch list-serve sign-up form is available online: https://www.tiicann.org/signup_listserv.php.

[1] amfAR, The Foundation for AIDS Research (June 2020). Statistics: United States. Retrieved online at https://www.amfar.org/about-hiv-and-aids/facts-and-stats/statistics--united-states/#:~:text=An%20estimated%201.1%20million%20people%20in%20the%20United,15%25%20of%20those%20don’t%20know%20they%20are%20infected.

[2] Centers for Disease Control & Prevention (2018, November 18). CDC Estimates Nearly 2.4 Million Americans Living with Hepatitis C. U.S. Department of Health & Human Services. Retrieved online at https://www.cdc.gov/nchhstp/newsroom/2018/hepatitis-c-prevalence-estimates-press-release.html. 

[3] Centers for Disease Control & Prevention (2020, September 21). People Coinfected with HIV and Viral Hepatitis. U.S. Department of Health & Human Services. Retrieved online at https://www.cdc.gov/hepatitis/populations/hiv.htm. 

[4] Community Access National Network (April 2021). HIV/HCV Co-Infection Watch – About. Retrieved online at https://www.hiv-hcv-watch.com/about.

[5] U.S. Centers for Disease Control & Prevention, MMWR Vol. 60 No.28, July 22, 2011.

[6] National Alliance of State & Territorial AIDS Directors (2020, August 10). NATIONAL RYAN WHITE HIV/AIDS PROGRAM (RWHAP) PART B AND ADAP MONITORING PROJECT: 2020 ANNUAL REPORT. Retrieved online at https://www.nastad.org/PartBADAPreport.

[7] National Alliance of State & Territorial AIDS Directors (2014, December 4). Access to Care and Treatment for HCV Mono-Infection and HIV/HCV Co-Infection. Retrieved online at https://www.nastad.org/sites/default/files/resources/docs/HCV-HIV-Care-Access-Webinar-December-2014.pdf.

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.