Addressing the High Burden of HCV in HIV-Positive MSM
The threat of Hepatitis C (HCV) co-infection casts a long shadow over the lives of men who have sex with men (MSM) living with HIV, demanding a swift and decisive response. Globally, 7% of this group also faces chronic HCV infection—a disproportionately high burden compared to the estimated 1% prevalence in the general population. A recent meta-analysis published in Health Sciences Reports, which synthesized data from 56 studies across various countries, also revealed a 9% global prevalence of hepatitis B virus (HBV) among MSM living with HIV, further highlighting their vulnerability to viral hepatitis co-infection.
While highly effective direct-acting antiviral (DAA) therapies offer a cure for HCV, access to these life-saving medications remains uneven, perpetuating health disparities and undermining global elimination efforts. This disparity is driven by a complex interplay of factors, including shared transmission routes for HIV and HCV, persistent stigma surrounding both viruses, and structural barriers such as poverty, homelessness, and lack of access to healthcare.
To dismantle these barriers and chart a path towards HCV elimination and health equity, we need a comprehensive strategy. This includes expanding ADAP coverage of DAA therapies, streamlining convoluted authorization processes, and implementing tailored interventions that address the unique needs and vulnerabilities of MSM living with HIV.
The Case for DAAs
The advent of direct-acting antiviral (DAA) therapies has revolutionized HCV treatment, offering a cure for a disease that was once considered a chronic, debilitating condition. DAAs are now the standard of care for HCV, providing a safe and effective cure for most people within a relatively short treatment duration, typically 8 to 12 weeks.
The benefits of DAA treatment extend beyond curing HCV. Studies have demonstrated a profound impact on long-term health outcomes, including a lower risk of both liver and non-liver complications. A large, real-world analysis published in JAMA Internal Medicine found that DAA therapy was associated with a remarkable 57% reduction in all-cause mortality among patients with chronic HCV. This underscores the life-saving potential of these medications and the importance of ensuring timely access for all who need them.
The Economics of DAAs
Despite the high initial cost of DAAs, concerns about affordability are countered by the substantial long-term cost savings they generate. A 2022 study in the Journal of Managed Care & Specialty Pharmacy demonstrated that treating HCV with DAAs in the Veterans Affairs (VA) system resulted in $7 billion in savings over a lifetime compared to pre-DAA treatments. These savings are achieved through reduced healthcare utilization, as fewer patients experience the costly complications of advanced liver disease. The study further highlighted that DAAs become less expensive than both pre-DAA treatments and no treatment within just five years, demonstrating a rapid return on investment.
The budgetary impact of expanded HCV treatment extends beyond individual payers like the VA. The Congressional Budget Office (CBO) has reported that increased HCV treatment leads to net budget savings for the federal government due to averted healthcare spending. Even a modest 10% increase in Medicaid treatment rates could save $700 million over 10 years, according to the CBO's estimates. This underscores the fiscal responsibility of investing in HCV elimination efforts, as treating the disease upfront prevents more costly interventions down the line.
Furthermore, the CBO highlights the importance of considering the long-term budgetary impact of HCV treatment, particularly the savings that accrue beyond the typical 10-year budget window. As HCV is a slow-progressing disease, the full economic benefits of treatment may not be realized within a decade. By taking a longer-term perspective, policymakers can better appreciate the true value of investing in HCV elimination and the potential for significant cost savings over time.
The Consequences of Limited Coverage
Despite the transformative potential of DAAs and the compelling evidence for their cost-effectiveness, access to these life-saving therapies remains uneven for people living with HIV (PLWH). A significant barrier is the limited coverage of HCV therapies by some state AIDS Drug Assistance Programs (ADAPs). CANN's HIV/HCV Co-Infection Watch for April 2024 reveals that only 47 out of 56 ADAPs in the United States offer some form of coverage for HCV treatment, meaning that a substantial number of PLWH, particularly those who rely on ADAPs as a safety net, face significant financial barriers to accessing the care they need.
This echoes the challenges faced within Medicaid programs, where restrictive policies driven by cost concerns have historically limited HCV treatment access. A 2024 study published in JAMA Health Forum analyzed data from 39 state Medicaid programs and found that easing restrictions related to liver disease severity, sobriety, or prescriber specialty led to a substantial increase in DAA utilization. Specifically, these policy changes were associated with an increase of 966 DAA treatment courses per 100,000 Medicaid beneficiaries each quarter. This evidence strongly suggests that similar policy shifts within ADAPs could significantly expand access to curative therapies for PLWH.
The consequences of limited ADAP coverage are far-reaching. Without access to DAAs, PLWH face a higher risk of progressing to advanced liver disease, experiencing debilitating complications, and ultimately succumbing to HCV-related mortality. This not only jeopardizes patient health outcomes but also undermines public health efforts to control and eliminate HCV. Furthermore, the financial burden imposed by limited coverage exacerbates existing health disparities. People of color, low-income persons, and those living in rural areas are more likely to rely on ADAPs and also experience higher rates of HCV infection. Denying them access to curative treatment perpetuates a cycle of inequity, further entrenching health disparities and undermining the goal of achieving health justice for all.
Policy Barriers and Provider Discouragement
The path to HCV treatment for MSM living with HIV is fraught with obstacles, a tangled web of restrictive policies and a healthcare system that often fails to prioritize their needs. Compounding the challenges of limited ADAP coverage are state-level restrictions that create a patchwork of barriers, disproportionately impacting vulnerable populations. Stringent eligibility criteria, complex authorization processes, sobriety requirements, and limited provider networks—often justified by cost concerns—prioritize short-term budget considerations over the long-term health and well-being of PLWH.
These policy barriers intersect with personal and systemic biases to create a system that perpetuates inequities in HCV care. A 2019 study published in the International Journal of STD & AIDS revealed that Medicare enrollees and patients with drug abuse diagnoses were significantly less likely to initiate DAA treatment, highlighting the impact of cost-sharing requirements and stigma. Stigma surrounding substance use can discourage patients from seeking treatment or disclosing their drug use history, while providers may harbor biases about the effectiveness of DAAs in this population.
This complex landscape also contributes to provider discouragement, further limiting access to HCV care. The administrative complexity of ADAPs, with their varying formularies, eligibility criteria, and authorization processes, creates a confusing and burdensome system for providers. Many providers also lack familiarity with newer DAA regimens and the latest treatment guidelines, particularly those who primarily focus on HIV care. Persistent stigma surrounding HCV and substance use can also lead to provider fatigue and bias, compounding these challenges.
Moving Towards Equitable HCV Care and Elimination
The evidence is clear: MSM living with HIV face significant and unjust barriers to accessing life-saving HCV treatment. We must act decisively to dismantle these barriers and create a healthcare system that prioritizes equity, accessibility, and the well-being of all PLWH.
Achieving this vision requires a bold policy agenda that addresses the systemic issues driving disparities in HCV care. We must demand action from policymakers and hold them accountable for creating a more just and equitable healthcare system.
Policy Changes are Needed:
Mandate DAA Coverage for All ADAPs: Every state ADAP must be required to cover all FDA-approved DAA regimens for HCV treatment, ensuring that no PLWH is denied access to a cure based solely on their geographic location.
Streamline Prior Authorization Processes: The administrative burden of navigating complex and inconsistent prior authorization processes within ADAPs discourages both providers and patients. We must demand a streamlined, standardized system, ideally with a single prior authorization form that can be used across all payers, including ADAPs and Medicaid, as recommended by NASTAD. Better yet, remove the need for prior authorizations all together.
Increase Funding Allocations for ADAPs: ADAPs are a lifeline for PLWH, yet these programs are chronically underfunded. We must advocate for increased federal and state funding allocations, ensuring they have the resources to provide comprehensive HCV care, including DAA treatment, without imposing undue restrictions.
Expand Financial Assistance Programs for Medicare Enrollees: Medicare's cost-sharing requirements create a significant financial barrier to DAA access for many PLWH. ADAPs must expand financial assistance programs to cover out-of-pocket costs for DAA treatment for Medicare enrollees with HIV/HCV co-infection.
These policy recommendations are concrete steps that can be taken to create a more just and equitable healthcare system for PLWH. By advocating for these changes, we can dismantle the barriers to HCV treatment, improve health outcomes, and move closer to eliminating HCV.
Tailored Interventions: Addressing the Unique Needs of MSM Living with HIV
While expanding ADAP coverage and addressing cost concerns are crucial, policy changes alone are insufficient to achieve equitable HCV care. We must also invest in tailored public health interventions that address the unique needs of MSM living with HIV.
This includes:
Targeted Testing and Linkage to Care: MSM living with HIV should be routinely screened for HCV, with a focus on re-engaging those who have fallen out of care or disengaged from traditional healthcare settings. Implementing targeted testing programs in community-based organizations, substance use treatment facilities, and MSM-centric settings, coupled with robust linkage to care services, is essential.
Peer Support Programs: Peer support programs, led by MSM living with HIV who have successfully navigated HCV treatment, can be powerful tools for addressing stigma, providing emotional support, and promoting adherence to DAA regimens.
Provider Training and Education: Provider training programs are necessary for addressing implicit bias, promoting harm reduction, and fostering patient-centered communication. These programs should equip providers with the knowledge, skills, and attitudes necessary to provide equitable and compassionate care to all PLWH, regardless of substance use history or other social challenges.
By investing in these tailored interventions, we can create a more responsive and equitable healthcare system that meets the unique needs of MSM living with HIV. Combining policy reform with targeted programmatic efforts will empower PLWH to access life-saving HCV treatment, improve health outcomes, and advance our shared goal of eliminating HCV.
A Shared Responsibility for Health Equity
The disproportionate burden of HCV among MSM living with HIV is a reminder of the persistent health disparities that plague our healthcare system. We have the tools to eliminate HCV, yet systemic barriers and inequities continue to impede access to life-saving treatment for many vulnerable populations.
Addressing HCV co-infection among MSM living with HIV is critical for improving patient health outcomes and essential for achieving broader public health goals, including the Ending the HIV Epidemic (EHE) initiative. Eliminating HCV among PLWH will reduce liver-related morbidity and mortality, improve overall health, and contribute to reducing HIV transmission.
Achieving HCV elimination and health equity for all PLWH is a shared responsibility. Policymakers must enact bold reforms that expand access to DAAs, simplify authorization processes, increase funding for ADAPs, and address systemic inequities. Healthcare providers must embrace patient-centered care, commit to ongoing education, and actively dismantle stigma and bias. Communities must mobilize to advocate for change, support peer-led initiatives, and create a culture of support and empowerment for PLWH.
The time for action is now. By working together, we can create a healthcare system that upholds the dignity and well-being of all PLWH, ensures equitable access to life-saving HCV treatment, and paves the way for a future free from the burden of this devastating disease.
Focus on Hepatitis B: WHO's New Guidelines and Their Global Implications
At the 2024 Asian Pacific Conference for the Study of Liver Disease in Kyoto, the World Health Organization (WHO) introduced transformative guidelines for the prevention, diagnosis, care, and treatment of chronic Hepatitis B virus (HBV) infection. HBV is a major global health challenge affecting approximately 296 million people worldwide. If left untreated, it results in nearly 900,000 deaths annually from complications like liver disease and cancer.
The new guidelines aim to increase testing access and expand treatment eligibility, particularly in sub-Saharan Africa which accounts for 70% of all new HBV infections. They provide evidence-based recommendations based on updated scientific data about antiviral effectiveness, diagnostic test performance, and service delivery models. By simplifying testing and extending treatment eligibility, these guidelines address longstanding access barriers. They represent a significant step towards achieving the 2030 goal of eliminating HBV as a major public health threat.
Key Changes in the New Guidelines
The WHO's new guidelines focus on making HBV testing and treatment more accessible for those who need it most. Key changes include:
Simplified Testing Recommendations
The WHO's revisions highlight the importance of streamlined testing methods such as dried blood spot sampling and point-of-care viral load assessments. The goal is to expand early diagnosis. Coupled with community-based testing, these methods aim to enhance accessibility, particularly in areas with limited resources. They facilitate early intervention and aim to reduce the stigma associated with traditional diagnostic procedures.
There is also an emphasis on expanding testing among pregnant women to prevent transmission of HBV from mother to child during birth or through breastfeeding, which is the primary way the virus is transmitted.
Previous recommendations advised pregnant women with active HBV infection to receive temporary treatment until their child was fully vaccinated against the disease. The new guidelines take into account that not every health facility has the tests to determine if a woman has an active infection. They suggest that health care providers consider administering prophylaxis to pregnant women with HBV, even if they cannot determine the status of their infection.
Expanded Treatment Eligibility and Access
Nearly 300 million people currently live with HBV, and the disease causes approximately 820,000 deaths each year. Prior guidelines typically limited treatment to those with advanced liver disease or significant fibrosis, which made it challenging for patients to access care until their conditions had substantially deteriorated. The new guidelines propose a more inclusive treatment approach, expanding eligibility for antiviral therapy to millions more people. This change should increase the portion of people living with HBV eligible for treatment from the current 8% to 15% to around 50%. The World Health Organization now strongly recommends treatment for all people aged 12 and older who have chronic HBV and exhibit early signs of liver damage or other indicators, including co-infections such as HIV. The previous guidelines often recommended treatment only at more advanced disease stages and for patients above 30 years old, a significant hardship considering that 25% of infections in the region occur in people under 20.
The updated guidelines provide a more comprehensive approach to the management of hepatitis B virus (HBV) infection. These guidelines notably broaden the recommended treatments. Previously, the guidelines strongly advocated for single-drug therapies as the preferred treatment option. However, in recognition of the ongoing shortage of these single-drug therapies in some low- and middle-income countries, the updated guidelines now also endorse two dual regimens as alternate treatment options when the preferred monotherapies are not readily accessible.
This shift in treatment recommendations is a direct response to the pressing need to ensure that effective therapies are available in all regions, irrespective of their economic status. The scarcity of the preferred monotherapies in some parts of the world has necessitated the inclusion of the dual regimens in the guidelines.
Furthermore, the expansion of the recommended treatments is grounded in a growing body of scientific evidence. This evidence increasingly suggests that initiating treatment at an earlier stage of the disease can have a significant positive impact on long-term health outcomes for people living with HBV infection. Early intervention also has the potential to markedly reduce transmission rates. By taking this approach, we can address the global HBV burden more effectively and ensure a healthier future for those affected by this disease.
Improving Patient Support
Improvements in patient support mechanisms, such as the introduction of peer support and digital adherence tools, show a thorough and empathetic understanding of the many challenges faced by people living with chronic Hepatitis B virus (HBV) infection. These patient-focused initiatives, an evolution of the regulations that governed HIV testing and treatment, are based on real-world experiences and insights. They are carefully designed with two critical objectives in mind.
First, they aim to significantly enhance treatment adherence. This is crucial, as consistent adherence to prescribed treatment regimens is a key factor in the success of long-term antiviral therapy. Without proper adherence, the effectiveness of the treatment is compromised, potentially leading to less than optimal health outcomes for the people affected.
Second, these initiatives also aim to reduce the risk of drug resistance. Drug resistance is a major concern in managing chronic diseases like HBV, as it can make first-line treatments less effective over time. This can complicate the disease management process and potentially lead to worse health outcomes.
By addressing the dual challenges of treatment adherence and drug resistance, these improved patient support mechanisms represent a significant step forward in the comprehensive and patient-centered management of chronic HBV.
Integrating HBV into Existing Services
The guidelines suggest integrating existing HIV, tuberculosis, and primary care programs to offer streamlined services for Hepatitis B Virus (HBV). This leverages the existing infrastructures, resources, and patient engagement strategies of these programs, potentially resulting in early detection and effective management of HBV.
By making use of these existing programs, healthcare systems can effectively expand HBV services. This method ensures patients receive coordinated care for their various health needs, fostering a more holistic patient care approach. Not only does this integration yield immediate patient benefits, but it also presents long-term advantages for the entire healthcare system, aiding healthcare providers in efficient resource allocation and reducing overall costs. Additionally, the improved patient outcomes resulting from this integration could decrease the long-term expenses associated with managing chronic conditions.
Potential Impact of the Guidelines
The global impact of these guidelines could be transformative. By simplifying the diagnostic process and expanding treatment access, the WHO aims to significantly increase the rate of early HBV diagnoses. This method aims to improve health outcomes for people living with HBV, reducing liver cancer, cirrhosis, and other disease-related complications. Additionally, preventing HBV progression to severe liver diseases could substantially lessen the economic burden on global healthcare systems. This aligns with the WHO's goal of eliminating HBV as a public health threat by 2030. Experts anticipate:
Increased Diagnosis and Treatment: Expanded eligibility and easier testing could lead to more HBV diagnoses and access to lifesaving antiviral therapy.
Improved Health Outcomes: Earlier intervention and broader treatment may reduce rates of liver cancer, cirrhosis, and HBV-related deaths.
Reduced Healthcare Costs: Preventing long-term HBV consequences could alleviate strains on healthcare systems and lower economic burdens.
Considerations for the United States
The WHO's new Hepatitis B guidelines could have significant implications for U.S. healthcare policy. Domestic adoption could improve HBV management in the U.S. and demonstrate the country's commitment to global health initiatives. While the WHO guidelines provide a global framework, their implementation in the U.S. requires policy-level action. Advocates could focus on:
Streamlining Screening Programs: Encouraging community-based testing and simplifying recommendations could raise diagnosis rates, particularly in underserved populations.
Expanding Access to Treatment: Prioritizing the removal of insurance-based barriers and addressing treatment access disparities.
Implementing Supportive Care Models: Exploring strategies like peer support programs to improve patient adherence and ensure everyone benefits from treatment.
Aligning with the WHO's Hepatitis B guidelines requires substantial shifts in U.S. public health policy. This includes integrating streamlined testing protocols into existing healthcare frameworks for more accessible diagnostic services. Expanding treatment eligibility may require revising healthcare policies to include a broader range of HBV-affected populations. This could mean changes in insurance coverage and healthcare provider guidelines to implement broader treatment protocols.
The U.S. can lead global efforts in adopting these guidelines through its role in global health initiatives. By advocating for and implementing these guidelines, the U.S. can demonstrate the effectiveness of simplified and accessible HBV care, encouraging other nations to follow. This leadership role can include providing technical support, sharing best practices, and offering financial assistance to resource-limited countries, thereby enhancing global health security and moving closer to eliminating HBV as a public health threat by 2030. Researchers have estimated that $6 billion annually is needed to meet the global hepatitis targets in 67 low- and middle-income countries alone.
The WHO's revised guidelines for Hepatitis B management represents a significant step towards addressing this global health challenge. They provide a plan for simple, accessible, and effective HBV care, with a focus on early diagnosis and expanded treatment eligibility to enhance patient outcomes and reduce transmission.
A Different Booster: HBV Vaccines among PLWHA
Because of the shared transmission vectors between HIV and Hepatitis B (HBV), the rate of co-infection is about 10% in the United States, according to the Centers for Disease Control and Prevention (CDC). As a result, people living with HIV (PLWHA) are more likely to experience adverse health impacts including cirrhosis and certain types of liver cancers. A small study conducted in Chile took a look at the recommended HBV vaccine schedule among adults living with HIV and HBV antibody uptake and potentially finding cause for a “high dose” fourth shot to be added into the series for PLWHA.
A giant asterisk belongs on the study’s findings, labeled “deserves further study consideration”. Despite being double-blinded, the study’s greatest weakness included participant pool size (right around 100 participants) and clinical selection criteria (which remains an issue in clinical trial work, generally speaking). In order to be considered for the study, participants generally had to present with an undetectable HIV viral load and no other comorbidities, ruling out application of the resulting data to most PLWHA and especially most long-term survivors or people experiencing barriers to care or medication adherence concerns – or those most likely to be impacted by HIV and HBV co-infection.
The study sought to examine the need for revaccination among PLWHA. Of note, the CDC’s “Pink Book” on HBV does not recommend “boosters” unless a particular “low” threshold of HBV antibodies is met, nor does the publication recommend for routinized serological testing among people who have previously received a vaccine. Therein lies a program and policy problem. We’ll get to that in a moment.
As a result of selection bias favoring those with more ideal circumstances, few participants dropped out of the trial. The study itself found that a fourth and “stronger” dose of vaccine improved antibody responses among people with “well controlled” HIV with an improved HBV antibody response from 50.9% in the low-dose arm of the study to 72% among the high-dose arm of the trial. After a one-year follow up, 80% of participants of the high-dose arm still had sufficient antibody titers, whereas only 39% of the standard-dose arm still had sufficient antibodies for protection.
While Ryan White and CDC funded clinical care programs for PLWHA require HBV monitoring and vaccination efforts as part of their grant funding, few entities necessarily do and almost no private providers do. Federally-funded providers may screen upon intake or initial labs but maintenance screening is not a priority in terms of clinical data collected on a given patient. Even on-site audits from these funders can sometimes look like reviewing particular case files and discussing details but the HBV conversation is not pressing. Rather, a review of intake data can suffice depending on the clinical auditor/consultant (site-visits and audits are often conducted under the supervision of the funding agency but only actually audited by consultants, including staff from other funded clinics).
Public funders aiming to end HBV and the unjust circumstances in which PLWHA are not educated by their providers on the other risks to their health should shift some focus to emphasize the need for preventative care – especially vaccines. Provider education for these publicly funded clinics should include the need to routinize HBV antibody monitoring not just as a concern on behavioral risk factors continuing in a client’s life but because HBV immunity is clearly not necessarily a given, regardless of prior vaccination history.
While the study suggests the need for investigating further, with regard to efficacy of HBV vaccines among PLWHA, the larger question - given the nation-wide rush for another vaccine (and boosters) - creating more robust standards of care among a population known to have immunological “memory-loss” due to the particular cells “attacked” by HIV seems to be in order. Part and parcel to that is tying this level of necessary education to funding and licensure could improve the quality of care PLWHA receive, especially those of low-income and otherwise marginalized identities.
Rising Morbidity: Viral Hepatitis Co-Infection with HIV and Age All Associated with Increased Rates of Liver Cancer
In February, researchers associated with numerous universities across Canada and the United States published one of the most comprehensive data reviews thus far conducted on the incidence rates of the most common type of liver cancer among people living with HIV/AIDS (PLWHA) and PLWHA co-infected with viral hepatitis. The study reviewed data collected as part of the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD), conducted between 1996 and 2015, with clinical data from 109,283 participants. Conclusions from the study were fairly straight-forward: the combination of HIV status (mono-infection), co-infection with viral hepatitis (HBV and/or HCV) and age all correlated with an increased chance of developing liver cancer (hepatocellular carcinoma [HCC]). The hope of researchers, as evidenced in the study’s introduction was to “inform expectations for other regions with a substantial burden of HIV and HBV-HCV coinfection but with delayed cART [combination antiretroviral therapy] scale-up and limited access to viral hepatitis treatment”.
While most research papers wait to include study limitations at the end, I prefer to open with them as prefacing allows for contextualizing data. The first and primary limitation on the review is clinical information reviewed was necessarily from those people linked to care and correlations provided by the data in the study cannot be applied to the diagnosed-but-not-in-care or undiagnosed population. Second, researchers note, information on relevant, individual health factors were missing from significant portions of participants data (example: smoking and drinking habits, natural clearance of HCV, fibrosis score, and HIV exposure risk). Additionally, data collection was not uniform across all participating entities at the time of linkage to care, though a quality analysis was used to help even things out and ensure the integrity of data comparisons. This lack of uniform protocol also included certain sites not administering or participants not receiving HCV or HBV screening. The last, though likely most significant limitation of the study is the data were collected prior to the advent of curative direct acting agents (DAAs) for HCV, and conclusions cannot be made on the potential positive impacts of readily available DAAs.
A limitation not mentioned and data unassessed is any reference between older ART regimens and newer ones, in which toxicity and tolerability is commonly known to be considerably improved with newer regimens. Liver health monitoring is fairly standard, among other relevant patient labs, for PLWHA because of a relationship between ART and liver health. While it’s understandable researchers who generally enjoy significant funding from manufacturers may wish to avoid broaching this topic, not mentioning the issue, even to say “we can’t make any conclusions on cART tolerability and toxicity as an indicator for adherence or risk of developing HCC” misses an incredibly important elephant in the room for researchers, providers, and patients alike.
Instead, researchers chose to focus on cART “eras” (1996-2000 [A], 2001-2005[B], and 2006-2015[C]), in which there’s a positive correlation between age and era; or those aging with HIV were more likely to be diagnosed with HCC. Highest rates of HCC diagnosis by cART area are as follows: A – between 50 and 60 years-old (HBV co-infection with HIV), B – lower end 70-80 (HCV co-infection with HIV), and C – upper end 70-80 (HCV and HBV co-infection with HIV). This data is particularly valuable on its own, however, as the associated risk cohort shift appears to be very closely related to age (ie. those in the upper end of the C “era” are also those to first receive effective cART and the 20-year age gap between the C and A cART eras).
Ultimately, PLWHA were more than 3 times as likely as the general population to develop HCC and more than 20 times more likely to develop HCC if co-infected with viral hepatitis. HCC incidence among study participants fell along rather predictable lines in terms of HIV related clinical monitoring metrics; those with higher viral loads and lower CD4 counts were more likely to develop HCC.
The study’s finding highlight the need for ensuring access to DAAs and HBV vaccines, ready ART uptake upon linkage to care, and strengthening the integrity of AIDS Drug Assistance Programs, Medicaid Programs, and care provided to incarcerated persons – specifically, ensuring the inclusion of coverage of DAAs in these.
Advocates, providers, and patients can review DAA coverage inclusion in ADAPs and Medicaid and harm reduction policies impacting HIV and HCV with Community Access National Network’s quarterly HIV-HCV Co-Infection Watch report.
Ongoing Viral Hepatitis Outbreaks: Systemic Interventions
Viral Hepatitis outbreaks, namely Hepatitis A and Hepatitis B, have been in the news quite a bit during the last year. Could COVID-19 have contributed to them?
Annual surveillance data for the state of Florida found the 2017 Hepatitis A outbreak has shifted location from primarily South Florida to the Pensacola area, in Escambia County. Florida isn’t alone with persistent Hepatitis A outbreaks. According to the CDC’s Hepatitis A outbreak dashboard, as of February 5, 2021, almost 40,000 cases of Hepatitis A have been confirmed related to the outbreak beginning in 2017, with more than 25 states still in an active outbreak status. Florida, Indiana, Kentucky, Ohio, Tennessee, and West Virginia top the list for the most cases reported since the outbreak began.
These outbreaks are primarily attributed to an increase in homeless populations and populations experiencing housing instability and lack of access to sanitary conditions. Hepatitis A is primarily transmitted in close-contact settings by way of ingesting blood or stool particles from a person carrying the disease. While the disease is not always deadly, it can be. Indeed, the 2017 multi-state outbreak has resulted in at least 354 deaths, according to the CDC.
Additionally, in late 2020, Vermont reported outbreaks of Hepatitis A and B, with Vermont Health Commissioner, Dr. Mark levin, said the state had been anticipating an eventual outbreak because of existing outbreaks in New Hampshire and Massachusetts. Hepatitis B, much like Hepatitis C, is often attributed to injection drug use, long-term health care settings, and contact with bodily fluids containing the virus, including blood and semen.
In response to these outbreaks, the CDC has encouraged states to engage in more active community education and vaccination programs. Both Hepatitis A and Hepatitis B are preventable and post-exposure vaccine administration may be appropriate in some situations. However, as the COVID-19 pandemic has reminded us, other interventions are necessary to address both risk factors to infectious diseases and reduce barriers to care. Addressing the nation’s housing and homelessness crisis could potentially provide one, extraordinarily significant structural intervention to address these and other public health crises.
President Joe Biden made campaign promises relating to need for more equitable housing policies and expanding affordable housing to address social justice needs as well as health-related needs and is already working to establish a fairer housing environment for the country. From extending the eviction moratorium to ensuring housing protections are extended to all Americans regardless of sexual identity or gender orientation (a reversal of the previous Administration’s policies), first steps are already being laid in order to meet well-known housing needs. And none too soon, as we don’t yet have a full picture of exactly how the COVID-19 caused economic recession will impact rates of homelessness, but one study issued a rather dire warning last month, saying this recession would likely cause double the rate of homelessness than the 2008 crisis.
From Hepatitis A and B to COVID-19 and the Opioid Crisis, housing has become (always was) a preeminent intervention that remains largely inadequately addressed. Federal funding and state programming must move to invest in housing as a prevention strategy in order to get ahead of these outbreaks and stop the chains of transmission. Housing is not just a human necessity; it is a public health necessity and must be embraced with the vigor the moment demands.
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