Data Gaps Exist for Transgender Patients Living with HIV, Despite Need
The current unequal representation and inadequate amounts of data on transgender people in terms of HIV poorly represents this subpopulation group in the LGBTQ+ community in the US. Diana Tordoff writes about this issue in an article published in STAT, where she writes that the scarce amount of data concerning trans people affects how policy is shaped in the country.
Per a study published by the National Institute of Health, several barriers hindering participation from trans people were things like logistical concerns, mistrust, lack of awareness, and psychosocial/emotional concerns related to being “outed”. This separate study provides probable insight on why there may be less amounts of data on transgender people in terms of HIV.
The Centers for Disease Control (CDC) recently published data about HIV prevalence among trans people based on public health surveillance data, however gender identity data is not collected consistently across local jurisdictions. As a result, mathematical models can’t be built effectively to help policymakers if there are poor amounts of data regarding trans people and their experience with HIV.
Tordoff writes that there are likely hundreds of mathematical models focused on HIV. Only seven of these models include trans people at all. There are two key problems that Tordoff and her co-authors note in models that do include trans people. The first problem is that there are models only including trans women and not trans men or nonbinary people. Tordoff notes that there seems to be regurgitated information across such models and this first problem may be a reason why.
In a separate study published by the National Institute of Health, researchers state that by acknowledging less visible identities, transgender individuals may be better represented by research studies. The study also refers to recent research highlighting the experience that transgender people have had in completing questionnaires for research studies. Questionnaires will often only include the choices “male” or “female”, and even if there are options like “transgender male” or “transgender female”, researchers are at risk of ignoring nonbinary identities.
The second problem is that such models assume trans women exclusively partnering with cisgender men, however there are other choices that trans women make when choosing who to partner with.
There’s evidence that access to gender-affirming care (e.g., hormones) can increase adherence to other types of disease prevention among trans people (PrEP and getting STI-tested). In general, researchers and advocates have long called for the inclusion of SOGIE data (sexual orientation, gender identity expression) to get a better understanding of these sidelined populations.
Tordoff notes a separate study where Minalga looked at 41 milestone HIV trials between 1991-2023 and this study found that out of more than 170,000 total participants, less than 1% were identified as part of the trans community and 94% of those were trans women.
Minalga notes that when data from such studies gets analyzed and published, that data does not make it back to trans people.
The analysis notes that lack of data on trans people is harmful to trans people and policies, but it is also harmful to other areas of health that aren’t publicly tied to LGBTQ+ populations. An example of this is clinicians not having enough data on how interventions or treatment may work for trans patients. A lack of this data often leads clinicians to extrapolate data from cisgender people despite some physicians not being comfortable with that.
The Centers for Medicare and Medicaid Services (CMS) introduced optional questions on SOGIE data for state Medicaid programs to collect from applicants. CMS recommended collecting information on sex assigned at birth, gender identity and sexual orientation.
Although this data would not be nationally representative, self-reported SOGIE data has never been collected on such a large scale according to Nathaniel Tran at the University of Illinois at Chicago School of Public Health in JAMA. This is good because only a few states collect this type of data.
Legislation continues to restrict gender-affirming care across the country, preventing the collection of additional meaningful data on queer populations.
Queer people living in states that restrict access to gender-affirming care don’t trust the state to protect their personal data. On the other hand, most clinicians simply don’t know much about LGBTQ+ populations in the first place. Trans people are often frustrated by the way they are considered in the research they participate in. Despite the need, data gaps will continue to hamper policy changes designed to improve access to care and services for this already underserved population.
HCV Prevalence Burden Higher Among HIV-Positive MSM
In a study published in the Oxford Academic, researchers established the New York Acute C Surveillance Network to study potential risk behaviors leading to primary Hepatitis C Virus (HCV) infection and reinfection among men who have sex with men (MSM) with HIV. The study was performed over the span of two decades from 2000-2018 to determine both incidence factors and risk factors for HCV reinfection among MSM with HIV in New York City.
The World Health Organization published a systematic review outlining that there is an elevated HCV prevalence among HIV-positive MSM and that this burden is higher among this community compared to the general population. The study found that primary HCV infection rates among MSM with HIV were lower than among individuals who inject drugs but that reinfection rates are higher for MSM and higher compared to individuals who inject drugs. Researchers define HCV clearance as an undetectable HCV viral load at or greater than 12 weeks after the end of treatment.
The study asked participants about behavioral risk factors for primary HCV infection. First, the study asked about receipt of semen ejaculated into the rectum with condomless receptive anal intercourse (CRAI). Second, the study asked about methamphetamine use during sex and if the route of use was by injection.
Besides risk factors for primary infection, the study also assessed MSM with HIV for reinfection beginning on January 1, 2000. Researchers defined HCV reinfection as the detection of new HCV viremia after clearance of a previous infection. The date of onset of reinfection was recorded in two ways–either by detection of new HCV viremia or of alanine aminotransferase (ALT) elevation. A study published by the National Library of Medicine (NLM) defines ALT as a surrogate marker and predictor of liver disease and liver-related mortality.
Data collected and considered as risk factors for reinfection were:
Date of birth
Race
Ethnicity
Health insurance type (public or private)
HCV genotype
Interferon (IFN) λ3
Haplotype
Calendar year of clearance of primary HCV
Mode of clearance of primary HCV
Timing of HCV clearance
CD4 cell count
HIV VL suppression: defines as <50 copies/mL
The study determined the incidence rates of first reinfection, second reinfection and overall reinfection.
Researchers observed 304 MSM with HIV with clearance of a primary HCV infection for reinfection. At the time of clearance, the median age of participants was recorded to be 45 years of age. About 18% were black and 21% were hispanic. Public health coverage funded for 160 participants and private health coverage funded for 140 participants.
About 10% of participants were spontaneously cleared for HCV and 90% were cleared by treatment either with an IFN-based regimen or a direct-acting antiviral (DAA) regimen. The study recorded that 37% of participants were cleared with an IFN-based regimen and 61% were cleared with a DAA regimen.
Researchers found that for recurrent events with reinfection as an outcome, receiving semen in the rectum was associated with HCV reinfection but that sexualized methamphetamine use was not associated with reinfection. Reinfection therefore was associated with sexual behaviors but not with drug use behaviors.
The study further discussed that MSM that participated in sexualized methamphetamine use belonged to sexual networks that had a high HCV prevalence enough to result in onward HCV transmission. On the other hand, those not participating in sexualized methamphetamine use were part of sexual networks in which HCV prevalence was low enough to result in fewer transmissions of HCV. Researchers noted that semen transmits most HCV infections among MSM with HIV and that those who participate in sexualized methamphetamine use are more likely to receive HCV-containing semen in their rectums.
The study notes additional issues that likely result in an increased transmission of HCV among MSM with HIV.
First, delays in insurance companies prescribing DAA treatments are likely a factor in the increased transmission of HCV. Second, MSM have not accepted condom use as a means to prevent HCV infection. Third, DAA treatments can’t help individuals who do not attend care. Individuals who have untreated HCV are less likely to engage in HIV care, further perpetuating these high-prevalence sexual networks.
With the findings that researchers gathered, they note that there is a need for novel interventions to prevent sexual transmission of HCV among MSM.
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.
Considerations for Hepatitis C Vaccine in HIV-HCV Co-Infected Populations
The interplay between groundbreaking research and its real-world application can shape the trajectory of entire communities. Once of the most evident place we see this is in the realm of HIV-HCV co-infection. As we stand on the precipice of breakthroughs in Hepatitis C Virus (HCV) vaccine development, the unique challenges posed by HIV-HCV coinfection come into sharp focus, reminding us of the urgency and significance of our endeavors.
Understanding the Landscape of HIV-HCV Coinfection:
HIV and HCV coinfection represents both a medical challenge and a reflection of broader societal issues searching for policy solutions. These viruses mainly impact marginalized communities, highlighting deeper socio-economic disparities. The combination of HIV, which taxes the immune system, even when well-controlled, and HCV intensifies health risks, such as liver diseases, emphasizes the need for effective interventions like a preventive HCV vaccine. Beyond the medical perspective, societal barriers like stigma, payer barriers, and limited healthcare access further complicate the issue. Recent vaccination studies, including those for COVID-19 and Hepatitis B Virus (HBV) among people living with HIV (PLWH), underscore these challenges and the necessity for tailored strategies. To comprehensively address HIV-HCV co-infection, a holistic approach that considers both medical and societal aspects is essential.
Drawing Parallels: Vaccination Lessons for HIV Patients:
The vaccination experiences of PLWH, especially during the COVID-19 pandemic, highlight the need for tailored strategies. While HIV patients were prioritized due to potential severe COVID-19 risks, vaccine efficacy varied based on individual immune responses, suggesting the potential need for boosters. Similarly, the Hepatitis B vaccination journey revealed that many PLWH had suboptimal responses to the standard vaccine. However, alternative, additional, or re-administration dosing regimens emerged as a promising solution. As we approach HCV vaccine development for people with co-occurring conditions, these experiences and the data-driven developments originating from them provide invaluable insights to anticipate challenges and innovate solutions.
Special Considerations for Vulnerable Populations:
Equitable policy and programmatic design in public health ensures everyone has access to optimal healthcare, yet societal barriers often sideline certain groups. Incarcerated people face challenges like close-quartered living and limited healthcare access, amplifying the transmission of illnesses like HIV and HCV. Tailored strategies, informed by COVID-19 vaccination efforts in prisons, such as on-site clinics, can improve vaccine uptake. People experiencing homelessness, battling issues like unstable housing and societal stigma, benefit from strategies like mobile clinics and community collaborations, as seen with HBV vaccinations. Building community trust, especially for populations with historical mistrust, is vital. Addressing HIV-HCV coinfection requires an inclusive, trust-centric approach, ensuring no one is overlooked.
Parallels with Mpox Vaccine: Addressing Vulnerable Populations
The U.S. Mpox outbreak in 2022 highlighted health disparities, especially among people experiencing homelessness, LGBTQ+ persons, and people of color. Mpox's transmission and significant impact on gay, bi sexual, and same gender loving men (GBSGLM), including those living with HIV, mirrors challenges with HIV-HCV co-infection.
The outbreak revealed health inequity issues, such as stigma and misinformation, exacerbated by the disease's former name "monkeypox." The Centers for Disease Control and Prevention’s (CDC) Mpox Vaccine Equity Pilot Program and Chicago Health Department's community-centric strategies provided insights for HIV-HCV coinfection management. Key takeaways included:
Community Engagement: Engage with affected communities, fostering trust through tailored programs and partnerships. Ready availability and responsiveness were critical to earned trust among affected communities.
Combatting Stigma: Deliver clear messages to dispel myths, ensuring vaccine uptake.
Vaccine Accessibility: Emphasize genuine accessibility, especially for marginalized groups, inspired by the Mpox Vaccine Equity Pilot Program.
Addressing HIV-HCV Co-infection in Vulnerable Groups:
Equity is vital in managing HIV-HCV co-infection, with incarcerated persons and populations experiencing homelessness and housing instability demanding special focus.
Incarcerated Populations: Prisons, due to their close confines and shared activities, are hotspots for disease transmission. While confinement offers some healthcare delivery opportunities, many lack comprehensive or personalized care, and most-notably, provide a microcosm of healthcare failures affecting surrounding communities. Identifying cost-effective program designs which address these disparate would prove beneficial for communities writ-large. Similarly, ensuring post-release care continuity is essential.
Homeless Populations: The transient nature of homelessness poses healthcare consistency challenges. Drawing from smallpox vaccine strategies, mobile clinics and community partnerships are effective. Building trust through tailored campaigns and community collaborations is crucial.
General Considerations: Skilled staff, robust data management, and inter-agency collaborations are essential for effective vaccination campaigns. Sufficient appropriations are required in order to build and maintain the missions of public health departments.
By addressing these populations' unique challenges, we can create an inclusive HIV-HCV coinfection strategy.
Future Medical Considerations:
The evolving nature of medical science presents new challenges and questions. The relationship between HIV and HCV may necessitate a tailored vaccine approach. Given experiences with COVID-19 and HBV vaccinations, how can we optimize the HCV vaccine for PLWH? Are there specific strategies to enhance its efficacy?
Public trust in health institutions remains fragile and highly politcized. How can we effectively communicate an HCV vaccine's importance and safety? How can we rebuild community trust?
Globally, ensuring the HCV vaccine's equitable access, especially in vulnerable populations with significant HIV-HCV co-infection risk, is a challenge. Can we learn from other vaccine distribution programs to strategize for HCV?
Urgent Considerations for HIV-HCV Coinfection's Future:
As we navigate the complexities of HIV-HCV coinfection, several pivotal questions arise, guiding researchers, policymakers, and healthcare professionals:
Vaccine Efficacy: Given varied vaccine responses in HIV patients, such as with COVID-19 and HBV, how can we optimize the HCV vaccine's effectiveness?
Access and Trust: How can we promote equal access, especially for vulnerable groups, and rebuild public trust?
Global Collaboration: How can we ensure global HCV vaccine access and which partnerships are essential?
Learning from History: Using insights from the U.S. Mpox outbreak, how can we better anticipate and manage health crises?
Policy Evolution: How can we swiftly incorporate evidence-based discoveries into health policies?
Actionable Recommendations for HIV-HCV Management:
To effectively combat HIV-HCV coinfection, we should consider:
Vaccination Strategies: Given varied responses among PLWH, explore frequent dosing, boosters, or double-dosing for the HCV vaccine, as seen with HBV and COVID-19.
Monitoring: Implement regular health assessments post-vaccination and periodic antibody and viral load tests.
Policy and Awareness: Prioritize coinfected individuals in vaccine rollouts, ensure accessibility, and launch awareness campaigns.
Collaborative Efforts: Foster interdisciplinary and global collaborations to holistically address HIV-HCV coinfection.
Addressing Current Deficiencies in Access: Despite curative therapies for HCV being readily accessible for more than decade, HCV remains a pressing public health concern in the United States. Effective vaccine distribution will hinge on addressing the challenges identified by these findings.
By strategically planning with these considerations in mind, we can create a comprehensive plan, prioritizing the well-being of those impacted by HIV-HCV co-infection.
Streamlining Vaccine Delivery and Building Trust in Healthcare
Efficient Vaccine Delivery: Successfully delivering vaccines for HIV-HCV co-infection requires more than just the vaccine. It's about a blend of skilled staff, efficient processes, and the right infrastructure:
Continuous Training: Ensure healthcare professionals are updated on the latest in vaccine administration for coinfections.
Resource Allocation: Balance routine healthcare with specialized vaccine campaigns, especially in resource-limited settings.
Infrastructure Upgrades: Enhance facilities, considering temperature-controlled storage and patient comfort, especially in remote areas.
Addressing Staffing Issues: Bridge the gap in healthcare professional shortages to ensure comprehensive care.
Workflow Efficiency: Use technology and process improvements for a seamless patient experience.
Community Health Worker Integration: Utilize their insights and community rapport to enhance healthcare delivery.
Feedback-Driven Improvements: Create a feedback-rich environment for continuous workflow enhancements.
Rebuilding Trust in Public Health: Trust is the bedrock of public health success, especially in the context of HIV-HCV coinfection:
Recognize Historical Mistrust: Address and make amends for past skepticism, especially among marginalized groups.
Combat Misinformation: Proactively counter myths about vaccines and transmission in the digital age.
Cultural Outreach: Use tailored messages and collaborate with community leaders for effective health drives.
Prioritize Transparency: Regularly update and demystify vaccine processes to foster trust.
Empathetic Engagement: Address vaccine hesitancy with understanding and compassion.
Collaborative Efforts: Partner with trusted community figures to amplify public health messages.
Feedback and Accountability: Implement public feedback mechanisms and act on them to reinforce trust.
In addressing HIV-HCV co-infection, both operational efficiency and trust-building are paramount. Together, they form the pillars of a comprehensive approach to public health challenges.
Conclusion:
Exploring the complexities of HIV-HCV coinfection reveals the depth of challenges and potential of modern healthcare. Each revelation, whether from studies on COVID-19, HBV, or HCV, not only highlight the gaps in our current understanding but also illuminates potential pathways forward. These insights should serve as guiding lights, directing our strategic development and interventions in the context of HIV-HCV co-infection.
However, our journey through this complex landscape is not solely guided by scientific discoveries. Central to our mission is a profound commitment to humanity and equity. It's a pledge to ensure that every individual, regardless of their background or circumstances, receives optimal care. From vulnerable groups, such as people experiencing homelessness or incarcerated persons, informed by lessons from the U.S. Mpox outbreak, to those in remote areas with limited healthcare access, our overarching goal remains steadfast: no one should be left behind.
By fostering collaboration across sectors, continuously updating our knowledge, ensuring investment in public health, and placing community engagement and trust at the forefront of our efforts, we can carve out a promising path. A trajectory that not only addresses the immediate challenges of HIV-HCV coinfection but also sets the stage for a healthier, more inclusive future for all affected individuals.
National Monitoring Report Highlights Disruptions and Opportunities
In September, Community Access National network (CANN) and Health HIV, Health HCV, and the National Coalition for LGBT Health partnered for the 7th Annual National Monitoring report on HIV/HCV Co-Infection as a “pre-Sync” session, warming up public health advocates and professionals for SYNChronicity 2022, which will be held virtually December 6-8. Presented by Marissa Tonelli, Director of Health Systems Capacity Building for Health HIV, and yours truly. Attendees represented a variety of stakeholders including funders, patients, advocates, providers, and public health professionals. The National Monitoring Report was generously supported by ADAP Advocacy Association, Gilead Sciences, Janssen Pharmaceutical Companies of Johnson & Johnsons, Merck & Co, and ViiV Healthcare.
The annual report presented information highlighting coverage of hepatitis C (HCV) curative direct acting agents (DAAs) in public health programs, including AIDS Drug Assistance Programs (ADAP), Medicaid, and Veterans Affairs as public payers. Additional information was presented on areas of intersectional focus, including harm reduction policy and programs across different states and at the national level.
Particular note was made on disparities of HCV diagnoses along racial identity, age, and geography, emphasizing where public health programs and advocates have room to improve in outreach, education, screening, linkage to care, and coverage. Highlighting data from the Centers for Disease Control and Prevention (CDC) on HCV diagnoses in 2020 and data presented earlier this year from the CDC on HCV screening and linkage to care based on payer type, both presenters discussed a failure of providers to screen for HCV. The failure of providers, particularly hospitals, to effectively enact opt-out screening has impact of furthering health outcome disparities and not taking opportunities to stop chains of transmission. While some of these missed opportunities may be attributed to disruptions to care due to the crisis phase of the COVID-19 pandemic, many of these failures are related to a lack of incentive to screen. Both presenters insinuated an expectation of HCV diagnoses to increase in the coming years as a result of these disruptions and failures.
Barriers to care from providers include failure to adopt the 2019 recommendations for universal screening, utilization management practices from payers which may limit the ability for providers to ensure patients are receiving DAAs (including extraordinary prior authorization requirements), lack of infrastructure to implement HCV programming, and a lack of consensus in the care guidelines. Patient barriers to care include lack of knowledge, social barriers (like homelessness), cost of insurance and restrictions from payers, and substance use-associated comorbid conditions. The commonality of payer roles as barriers to care is worthy of particular attention as advocates engage public health program administrators and seek to leverage public programs for better practices. Advocating for integrating HCV screening as a standard of care and ensuring states adopt HCV screening and linkage to care as part of state level “Essential Health Benefit” benchmarks is one approach which would tie provider reimbursements with screening and linkage to care activities.
While no debate occurred, discussion was had around the issue of “co-located” and telehealth models as a means of extending care and support for affected communities. The model of providing comprehensive care in a single site proves an opportunity for patients to access providers and support services is effective for certain communities. But if this model consolidates access sites, it may also prove to be a barrier for patients not closely located to these “one stop shops”.
Despite these tools and a generally supportive statutory environment, the nature of health care access is not necessarily getting easier for service providers or patients but more complicated. Advocates should be mindful of unintended consequences and how to leverage broader health care reform as they approach solution finding.
An archive of the event is available here.