Feds Tell States to Cover Hep C Medications, Regardless of Substance Use

By: Ranier Simons, ADAP Blog Guest Contributor

The right to health is a human right recognized in many international human rights documents, such as the 1966 International Covenant on Economic, Social, and Cultural Rights and the World Health Organization’s (WHO) Constitution.[1,2] According to the WHO, “Countries have a legal obligation to develop and implement legislation and policies that guarantee universal access to quality health services and address the root causes of health disparities, including poverty, stigma and discrimination.”[1] To that end, in recent history, the United States Departments of Justice (DOJ) and Health and Human Services (HHS) have found it necessary to intervene in order to protect citizens’ right to health. 

Photo Source: U.S. Department of Justice

The DOJ Civil Rights Division issued a letter to state Medicaid administrators on January 24, 2024, reminding them of their obligation to ensure that their programs allow people who have both Substance Use Disorder (SUD) and Hepatitis C (HCV) to access direct-acting antivirals (DAAs).[3] In the letter, the DOJ and HHS reiterate Medicaid agencies are required to grant this access under the Americans with Disabilities Act (ADA). Under the Act, states cannot discriminate against people with disabilities, which includes SUD. SUD qualifies as a disability because it “substantially limits one or more major life activities and interferes with the operation of key bodily functions.”[5]

In 2022, the DOJ reached a settlement agreement with Alabama Medicaid after an investigation of its Medicaid policy. It was denying access to DAAs for people who had consumed drugs or alcohol six months prior to starting treatment and denying payment if they used any drugs during their treatment. The DOJ accused Alabama Medicaid of “imposing non-medically indicated sobriety restrictions for HCV treatment, in violation of the Americans with Disabilities Act (ADA).”[4] There was no scientifically evidence-based reasoning for the restriction. 

Alabama Medicaid agreed to multiple stipulations and reporting requirements as part of the settlement. They were required to reverse their sobriety policy for HCV treatment and agree not to create any further restrictions, such as requirements for drug or alcohol counseling.[4] Additionally, Alabama Medicaid had to notify Medicaid providers of the change and inform the  Alabama Board of Medical Examiners and the Alabama Department of Public Health.[4] One notable requirement was notification of all Medicaid recipients of the change, thus informing them of their rights. Interestingly, in the settlement, Alabama Medicaid denied any acknowledgment of any violation of the ADA but framed their cooperation as an amicable negotiated resolution to the matter.[4]

Photo Source: Arkansas Medical Society

The DOJ utilized the ADA in 2020 to reach a settlement with Massachusetts General Hospital.[6] Massachusetts General Hospital denied a cystic fibrosis patient access to be listed on the lung transplant list because he was taking suboxone, a drug used to treat dependence on opioids. The cystic fibrosis damaged his lungs so severely that he needed a lung transplant to live. As part of the settlement, Massachusetts General Hospital paid $170,000 to the patient and $80,000 to his mother.[6] The hospital additionally agreed to give ADA training to its staff and end its discriminatory policy. The patient ended up receiving a lung transplant at the University of Pennsylvania.[6] Selma Medical, Charwell Operating Nursing Facility, Athena Health Care Systems, Alliance Health, New England Orthopedic Surgeons, and King’s Daughters Medical Center are other providers that reached settlements with the DOJ after violating the ADA by denying healthcare to patients taking medication for SUD.[6] 

Utilizing the ADA to ensure health protections for people with SUD is a robust tool. However, under the ADA, protections against discrimination only extend to “a person in recovery who is no longer engaging in the current illegal use of drugs.”[7] Protections from being denied healthcare services is an exception or ‘carve-out’: “A person who is currently engaging in the illegal use of drugs can’t be denied healthcare or rehabilitation services because of their current use if they would otherwise qualify for these services.”[7] 

That is why the letter issued by the DOJ and HHS is important. Amplifying attention to the matter is a way to prevent harm before it happens since widespread understanding of the exception is lacking policy-wise and programmatically. Although people with SUD have rights, having to fight for their rights when denied care results in treatment delays and poor health outcomes. It is better to address and change policy before issues occur. The letter is guidance and an indication to entities that the DOJ can and will actively seek remedy against infractions. Optimistically, the threat of litigation is enough of a deterrent for entities to examine and modify their policies.

[1] World Health Organization. (2023, December 1). Human rights. Retrieved from https://www.who.int/news-room/fact-sheets/detail/human-rights-and-health#:~:text=The%20right%20to%20health%20and,of%20physical%20and%20mental%20health.

[2] Office of the United Nations High Commissioner for Human Rights. n.b. The Right to Health. Retrieved from https://www.ohchr.org/sites/default/files/Documents/Publications/Factsheet31.pdf

[3] Department of Justice. (2024, January). Letter to State Medicaid Administrators. Retrieved from https://www.justice.gov/d9/2024-01/dear_colleague_letter-state_medicaid_coverage_for_people_with_hcv_and_sud.pdf

[4] Settlement Agreement between the United States of America and the State of Alabama's Medicaid Agency. (2022, December 5). Retrieved from https://www.justice.gov/opa/press-release/file/1555501/download

[5] U.S. Department of Justice Civil Rights Divison. (2022, April 5). The ADA and Opioid Use Disorder: Combating Discrimination Against People in Treatment or Recovery. Retrieved from https://www.ada.gov/resources/opioid-use-disorder/#2-does-an-individual-in-treatment-or-recovery-from-opioid-use-disorder-have-a-disability-under-the-ada

[6] Rahim, H. (2023, Decemeber 26). Does the ADA protect people with substance use disorder from health care discrimination? Retrieved from https://blog.petrieflom.law.harvard.edu/2023/12/26/the-ada-as-protection-from-health-care-discrimination-towards-persons-with-substance-use-disorder/

[7] ADA National Network. (2020). The Americans With Disabilities Act, Addiction, and Recovery for State and Local Governments. Retrieved from https://adata.org/factsheet/ada-addiction-and-recovery-and-government

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. 

HRSA Offers Guidance on Buprenorphine

By: Ranier Simons, ADAP Blog Guest Contributor

There is a higher prevalence of substance use disorder (SUD) among people living with HIV/AIDS (PLWHA) compared to the population at large.[1] Among PLWHA, nearly 50 percent report a current or past history of substance use disorders (SUD).[2] As such, in May 2023, the HIV/AIDS Bureau of the Health Resources and Services Administration (HRSA) sent a letter to all Ryan White HIV/AIDS Program (RWHAP) Part B Aids Drug Assistance Program (ADAP) recipients encouraging them to include medications used to treat SUD in their formularies. HRSA additionally emphasized adding buprenorphine and naloxone.[3] 

Photo Source: HRSA

Buprenorphine is used to treat opioid addiction as an agonist treatment. It is a long-acting drug compared to the short-acting opioids to which people have addictions, such as heroin and oxycodone. Buprenorphine stays in the blood for 24-36 hours, in contrast to shorter-acting drugs people abuse that require consumption multiple times a day to prevent withdrawal symptoms.[4] Proper dosage of buprenorphine does not cause a euphoric high, and it allows substance abusers to stabilize their lives and gain control. Any drug can be abused and overdosed. However, an overdose of buprenorphine is less likely than an overdose of methadone, another medication used for agonist treatment. Naloxone is a drug that can temporarily reverse the effects of an opioid overdose giving a person time to allow medical assistance to arrive.

Roughly 40 percent of ADAPs do not have buprenorphine or naloxone on their formularies.[3] While most health insurance plans cover medications to treat SUD, 37.4 percent of ADAP patients have no health coverage.[3] Each ADAP determines the composition of its formulary. They use advisory boards of professionals to examine their populations and determine the cost/benefit analysis of including certain medications. ADAP clients without health insurance who also have SUD are left without the means to obtain SUD drugs that could drastically improve their lives.

PLWHA dealing with substance use addictions have poorer health outcomes than those without addictions. Drug abuse causes inconsistent antiretroviral adherence resulting in lower rates of viral suppression. SUD causes people to not engage in behaviors necessary for a productive, stable existence. Additionally, substance abuse can result in dangerous drug interactions between therapeutic medications and the drugs being abused, in addition to excessive wear on organs such as the liver and kidneys. To effectively fight the HIV/AIDS epidemic, it is vital to treat PLWHA wholistically. This means dealing with their mental and physical co-morbidities in addition to their HIV.

Photo Source: Baton Rouge Behavioral Hospital

The World Health Organization (WHO) also recognizes the importance of buprenorphine and naloxone. Both are listed on the 2021 22nd WHO model list of essential medicines, which is updated every two years. The essential medicine list are medicines: “that satisfy the priority health care needs of a population…selected with due regard to disease prevalence and public health relevance, evidence of efficacy and safety and comparative cost-effectiveness…intended to be available in functioning health systems at all times, in appropriate dosage forms, of assured quality and at prices individuals and health systems can afford…“[5] 

RWHAP's ADAP manual states that ADAPs may include medications used to treat chronic medical and mental health conditions in addition to some of the mandatory requirements, such as including at least one drug from each class of HIV antiretroviral medications.[6] If more ADAPs heed the suggestion of the HRSA letter, more PLWHA with substance addictions can get treatment and relief. Many ADAPs are facing funding challenges. However, including buprenorphine and naloxone would be worthwhile formulary additions as their usage is evidence-based.

[1] Shiau, S., Arpadi, S. M., Yin, M. T., & Martins, S. S. (2017). Patterns of drug use and HIV infection among adults in a nationally representative sample. Addictive behaviors, 68, 39–44. https://doi.org/10.1016/j.addbeh.2017.01.015

[2] Durvasula, R., & Miller, T. R. (2014). Substance abuse treatment in persons with HIV/AIDS: challenges in managing triple diagnosis. Behavioral medicine (Washington, D.C.), 40(2), 43–52. https://doi.org/10.1080/08964289.2013.866540

[3] HRSA. (2023, May 11). Ryan White Letter. Retrieved from https://ryanwhite.hrsa.gov/sites/default/files/ryanwhite/grants/rwhap-partb-aids-drug-assistance.pdf

[4] Centre for Addiction and Mental Health. (2023). Buprenorphine. Retrieved from https://www.camh.ca/en/health-info/mental-illness-and-addiction-index/buprenorphine#:~:text=Overview,pain%20relief%20for%20seven%20days

[5] World Health Organization. (2023). WHO model list of essential medicines - 22nd list, 2021. Retrieved from https://www.who.int/publications/i/item/WHO-MHP-HPS-EML-2021.02

[6] HRSA. (2016). AIDS Drug Assistance Program Manual. Retrieved from https://ryanwhite.hrsa.gov/sites/default/files/ryanwhite/resources/adap-manual.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.  

Intersection between Substance Use Disorder & HIV

By: Ranier Simons, ADAP Blog Guest Contributor

Drug use and drug abuse intersect many aspects of the health journey of substance users and those with substance use disorders. This includes HIV. The complex intersection of HIV and drug use affects HIV acquisition, treatment, and spread. To create solutions with the goal of better health outcomes for those dealing with HIV and substance abuse issues, it is necessary to research and understand how drug use affects the HIV trajectory. It is equally important to understand the barriers in place that hinder effective outreach and care.

Photo Source: Recovery Research Institute

Past and present research indicates a higher level of drug use and drug abuse in the population of those living with HIV than to those who are not infected.[1] The drugs include alcohol, crack cocaine, methamphetamines, prescription opioids, and heroin.[2] There is a distinction between drug use and drug abuse. Drug use is more episodic, whereas drug abuse or substance use disorder is consistent and chronic. Regardless of the level of use or addiction, drug use results in suboptimal HIV outcomes.

Substance abuse affects the entire continuum of the HIV care cycle, starting with acquiring infection. Drug use and abuse have been shown to increase the odds of engaging in risky behaviors that lead to infection.[2,3,4] Research shows that being under the influence lowers inhibitions, can result in a higher prevalence of multiple sex partners, and poor judgment resulting in unprotected sex.[2,4] Moreover, injectable drug usage can be a direct path to infection when needle sharing is involved.

A good deal of research has been focused on HIV in MSM (men who have sex with men), given that the rate of HIV infection is higher in this group than in the general population. It is observed that the usage of amyl nitrites, methamphetamine, and club drugs is higher in this group as well.[4] Thus, it is imperative to target this group to curb the transmission of HIV within. Intervention would also benefit the general population since there are MSM who have sex with women. 

Recreational or episodic drug use can lead to substance disorders or drug abuse. HIV-positive people dealing with substance disorders have additional challenges. One substance abuse group research has focused on is injection drug abusers. Injectable drug users tend to inject opiates, like heroin, alone or in combination with other drugs, even stimulants such as cocaine.[4] Not only are injectable drug users at a higher risk of contracting and spreading HIV, but they are also more likely to contract other infections.

Photo Source: CDC

Regardless of the drug, drug use and abuse exacerbate poor HIV outcomes because it causes additional damage to the body. The drugs are taxing on organs such as the liver, heart, and kidneys. Illicit drug use has also been shown to suppress the immune system.[6] Having a decreased immune response is detrimental to drug users living with HIV. This can lead to a faster progression to adverse HIV outcomes, especially for HIV-positive addicts not on antiretroviral therapy.

Treatment adherence is another intersection of HIV and drug abuse. Research shows that substance abusers on ART have lower treatment adherence. A study from 2007 showed that drug use resulted in a fourfold greater risk of medication adherence failure.[5] Drug use affects cognitive functioning and psychosocial conditioning. Drug addiction makes it difficult to focus on the importance of consistent and timely taking of medication, especially when multiple pills and times are involved. Poor medication adherence can result in subpar treatment response or complete drug resistance.

To improve the outcomes of HIV-positive people with substance abuse issues, it is paramount to remove the stigma of drug use. It should be treated just as any other chronic medical condition. Encouraging a cultural change to remove stigma would result in treating substance abusers with dignity, which could result in self-motivated behavior modification. Stigma against drug abusers sometimes results in medical professionals not dealing with the addiction with compassion and prohibiting infected individuals from seeking consistent care. Stigma also creates policy that hinders people from getting the help they need.

Photo Source: Wellthy

Anecdotal and evidence-based research shows that it is best to reach drug-addicted HIV-positive individuals where they are in their journey. They should be treated without the expectation of stopping drug use. Ongoing drug use is not a contraindication for antiretroviral therapy.[3] Educating drug users to understand they can still be on ART while still being on drugs could increase adherence. Reducing stigma could also affect policy change. For example, many politicians are against needle exchange programs. However, needle exchange programs are places that drug-addicted people living with HIV are more likely to visit regularly. They are places where additional services can be provided, including treatment. Handing out clean needles, cookers, and pipes would lower the risk of transmission while also creating a space to meet other needs.

Navigating the intersection of HIV and drug use starts by acknowledging they do not exist in separate vacuums. Drug treatment programs should include HIV testing, and HIV treatment should involve screening for substance abuse.

[1] Shiau, S., Arpadi, S. M., Yin, M. T., & Martins, S. S. (2017). Patterns of drug use and HIV infection among adults in a nationally representative sample. Addictive behaviors, 68, 39–44. https://doi.org/10.1016/j.addbeh.2017.01.015

[2] CDC. (2021, April). HIV and substance abuse. Retrieved from https://www.cdc.gov/hiv/basics/hiv-transmission/substance-use.html

[3] HIV.GOV. (2021, June 3) Considerations for antiretroviral use in special patient populations. Retrieved from https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-arv/substance-use-disorders-and-hiv

[4] Strathdee, S., Patterson, T. (2006) Behavioral interventions for HIV-Positive and HCV-Positive drug users. AIDS and Behavior, 10(2), 115-130

[5] Hinkin, C. et al. (2007) Drug use and medication adherence among HIV-1 infected individuals. AIDS and Behavior, 11(2), 185-194

[6] Nnorom-Dike, O., Ekwebelem, O., Ofielu, E., Attah, M., Ekwe, D. (2020, December 9). Long term immunologic consequences of illicit drug abuse. Retrieved from https://www.heraldopenaccess.us/openaccess/long-term-immunologic-consequences-of-illicit-drug-abuse

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.  

Veterans Linkage to Care: Perspectives on HIV, Viral Hep, Opioids & Mental Health

By: Jonathan J. Pena, MSW, Licensed Clinical Social Work Associate (LCSWA)

*** Reprinted with permission from the Community Access National Network (CANN) ***

Approximately 8 percent of the U.S. population are Veterans, numbering over 18 million Americans with most of them being males and older than nonveterans. But those demographics will change in the coming years, with significant increases in ranks among women and minorities (Schultz, 2017). As a society, we tend to view these men and women formerly in uniform as larger than life figures capable of overcoming almost any odds. The reality, however, is there are numerous ongoing public health challenges faced by Veterans in this country once discharged from the military – among them HIV, Hepatitis C, opioid dependence, and mental health conditions. As a society, don't we owe it to them to provide the most timely, appropriate linkages to care and treatment?

To view the full opinion piece, infographic and video, go to: https://www.hiv-hcv-watch.com/blog/veterans-linkage-to-care.

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.