By Melissa Patrick
Kentucky Health News
Kentucky leads the nation in new infections of hepatitis C, a liver disease now mainly driven by intravenous drug use. It could be virtually eliminated, but that would require a committed strategy to increase syringe exchanges, medication-assisted therapies, and policies that remove all restrictions to treatment, such as a ban on treating active intravenous drug users.
That was the overarching message to almost 300 people who attended the fourth annual Viral Hepatitis Conference in Lexington July 27. They also heard that Kentucky is working on all three fronts, but not going as far as some experts want when it comes to treating drug users.
"Hepatitis can be eliminated," Homie Razavi, director of the Center for Disease Analysis, an independent research group based in Lafayette, Colo. "The key is to increase harm-reduction programs and basically remove all restrictions, and the final catch is we have to expand it to treat everyone, whether they are 15 or 74."
Razavi said studies show if you only have a syringe-exchange program, it reduces new hepatitis C infections by 15 percent; if you only offer medication-assisted therapies, they reduce the rate by 50 percent; but if you have both, that cuts it 75 percent.
"These programs are very, very effective. They are very cost-effective," Razavi said. But he added, "At the end of the day harm-reduction programs can only go so far.”
More than 38,000 Kentuckians are estimated to be chronically infected with the disease, and many don't know they are, because it can take decades for symptoms to appear. If left untreated, hepatitis C can cause liver damage from cirrhosis or fibrosis, liver cancer, and even death.
Kentucky has the potential to get a lot more hep-C cases, quickly. The federal Centers for Disease Control and Prevention has identified 54 Kentucky counties among the 220 most vulnerable in the nation to a rapid spread of HIV and hepatitis C infection among persons who inject drugs. Sixteen of the state's counties ranked in the nation's top 25.
In 2015, the Kentucky legislature authorized syringe-exchange programs that let drug users swap dirty needles for clean ones to thwart the spread of HIV and hepatitis. But if they want special state funding, the administration of Gov. Matt Bevin requires them to have a one-for-one exchange policy, which experts discourage.
"I cannot underscore enough, one-for-one exchange is not an effective public health intervention," Wayne Crabtree, who oversees the syringe exchange in Louisville, told the group.
"Exchange is not about syringes, it's about the relationship"
As of July 25, Kentucky had 26 operating syringe exchanges and eight that have been approved but not operational, according to the state Cabinet for Health and Family Services.
Crabtree called the Louisville program a "sad success," since it has had more than 11,000 participants since it opened in 2015, with 4,790 returning. He said that in addition to reducing infection rates and offering other important harm reduction services, syringe exchanges can lead people who inject drugs to testing, counseling and treatment.
“Studies show that program participants were five times more likely to enter drug treatment than IV drug users who did not participate in syringe exchange programs. That's amazing!” he said. “Syringe exchange is not about syringes, it's about the relationship. And if you are in relationship with someone and they know you care, you have the makings of change."
State infectious-disease specialist Dr. Ardis Hoven, one of the moderators, said she appreciated Wayne's efforts as "we continue to push and pull and shove and make our voices heard in public health around this very, very important issue."
Eliminating barriers to treatment has its own barriers
Razavi said a successful strategy to eliminate hepatitis C must also allow IV drug users and people who are in the early stages of the disease to be treated. Those restrictions have been in reduced in some commercial and veterans' insurance policies, but are remain in Kentucky's Medicaid program – which provides care to about one-third of the state's people, generally those with incomes up to 138 percent of the federal poverty line.
Dr. Gil Liu, the state medical director for Medicaid, said 10,500 Kentuckians on the program had been diagnosed with hepatitis C, costing the federal and state governments an average of $83,735 for each case. "In the last full fiscal year, Kentucky’s Medicaid program spent $69.7 million on pharmacy claims to treat 833 beneficiaries," according the cabinet, the Lexington Herald-Leader reported in May.
State Medicaid rules allow hepatitis C treatment only during advanced stages of the disease, which Liu called "very restricted." He said, "We want everybody to have access. We are moving toward relaxing those requirements."
But one restriction, which requires a person being treated to not inject an illicit drug for six months prior to treatment, doesn't seem as likely to be relaxed. Liu said the rule was "under discussion" but there is concern that if it is relaxed, people who use IV drugs won't seek "the full continuum of care" needed to overcome their addictions.
However, Jon Zibbell, senior public-health analyst for the Behavioral and Urban Health Program at RTI International, an independent nonprofit research institute, said that if active injectors can be treated, fewer people would be infected, and therefore fewer to transmit the disease.
“Let me make it clear, we will never control the epidemic unless we treat people who are actively using,” Zibbell said. “Scientific fact.”
Liu eventually got to the crux of the matter: money.
He said it will soon be "financially unsustainable" to support the state's "heroic expansion of eligibility of Medicaid," and he wasn't sure how the state would or could pay to treat everyone for hepatitis C if all restrictions on treatment were removed.
"It very quickly becomes a question of what are you going to ration; that is a zero-sum-game at some point in time," Liu said.
Razavi researched has proven that "the cost of inaction is actually more costly than elimination" of hepatitis C. He said the cost of new, life-saving pills that have a 100 percent cure rate have dropped from $80,000 to $35,000 and lower.
"From a health-care perspective, the state of Kentucky is going to pay for these people. So whether you treat them or don't treat them, they are going to cost you – in fact more if you don't treat them."
The World Health Organization defines the elimination of hepatitis C as reducing the number of new infections by 90 percent and reducing the number of liver-related deaths associated with it by 65 percent before 2030.
Kentucky Health News
Kentucky leads the nation in new infections of hepatitis C, a liver disease now mainly driven by intravenous drug use. It could be virtually eliminated, but that would require a committed strategy to increase syringe exchanges, medication-assisted therapies, and policies that remove all restrictions to treatment, such as a ban on treating active intravenous drug users.
That was the overarching message to almost 300 people who attended the fourth annual Viral Hepatitis Conference in Lexington July 27. They also heard that Kentucky is working on all three fronts, but not going as far as some experts want when it comes to treating drug users.
"Hepatitis can be eliminated," Homie Razavi, director of the Center for Disease Analysis, an independent research group based in Lafayette, Colo. "The key is to increase harm-reduction programs and basically remove all restrictions, and the final catch is we have to expand it to treat everyone, whether they are 15 or 74."
Razavi said studies show if you only have a syringe-exchange program, it reduces new hepatitis C infections by 15 percent; if you only offer medication-assisted therapies, they reduce the rate by 50 percent; but if you have both, that cuts it 75 percent.
"These programs are very, very effective. They are very cost-effective," Razavi said. But he added, "At the end of the day harm-reduction programs can only go so far.”
Kentucky has the potential to get a lot more hep-C cases, quickly. The federal Centers for Disease Control and Prevention has identified 54 Kentucky counties among the 220 most vulnerable in the nation to a rapid spread of HIV and hepatitis C infection among persons who inject drugs. Sixteen of the state's counties ranked in the nation's top 25.
In 2015, the Kentucky legislature authorized syringe-exchange programs that let drug users swap dirty needles for clean ones to thwart the spread of HIV and hepatitis. But if they want special state funding, the administration of Gov. Matt Bevin requires them to have a one-for-one exchange policy, which experts discourage.
"I cannot underscore enough, one-for-one exchange is not an effective public health intervention," Wayne Crabtree, who oversees the syringe exchange in Louisville, told the group.
"Exchange is not about syringes, it's about the relationship"
As of July 25, Kentucky had 26 operating syringe exchanges and eight that have been approved but not operational, according to the state Cabinet for Health and Family Services.
Crabtree called the Louisville program a "sad success," since it has had more than 11,000 participants since it opened in 2015, with 4,790 returning. He said that in addition to reducing infection rates and offering other important harm reduction services, syringe exchanges can lead people who inject drugs to testing, counseling and treatment.
“Studies show that program participants were five times more likely to enter drug treatment than IV drug users who did not participate in syringe exchange programs. That's amazing!” he said. “Syringe exchange is not about syringes, it's about the relationship. And if you are in relationship with someone and they know you care, you have the makings of change."
State infectious-disease specialist Dr. Ardis Hoven, one of the moderators, said she appreciated Wayne's efforts as "we continue to push and pull and shove and make our voices heard in public health around this very, very important issue."
Eliminating barriers to treatment has its own barriers
Razavi said a successful strategy to eliminate hepatitis C must also allow IV drug users and people who are in the early stages of the disease to be treated. Those restrictions have been in reduced in some commercial and veterans' insurance policies, but are remain in Kentucky's Medicaid program – which provides care to about one-third of the state's people, generally those with incomes up to 138 percent of the federal poverty line.
Dr. Gil Liu, the state medical director for Medicaid, said 10,500 Kentuckians on the program had been diagnosed with hepatitis C, costing the federal and state governments an average of $83,735 for each case. "In the last full fiscal year, Kentucky’s Medicaid program spent $69.7 million on pharmacy claims to treat 833 beneficiaries," according the cabinet, the Lexington Herald-Leader reported in May.
State Medicaid rules allow hepatitis C treatment only during advanced stages of the disease, which Liu called "very restricted." He said, "We want everybody to have access. We are moving toward relaxing those requirements."
But one restriction, which requires a person being treated to not inject an illicit drug for six months prior to treatment, doesn't seem as likely to be relaxed. Liu said the rule was "under discussion" but there is concern that if it is relaxed, people who use IV drugs won't seek "the full continuum of care" needed to overcome their addictions.
However, Jon Zibbell, senior public-health analyst for the Behavioral and Urban Health Program at RTI International, an independent nonprofit research institute, said that if active injectors can be treated, fewer people would be infected, and therefore fewer to transmit the disease.
“Let me make it clear, we will never control the epidemic unless we treat people who are actively using,” Zibbell said. “Scientific fact.”
Liu eventually got to the crux of the matter: money.
He said it will soon be "financially unsustainable" to support the state's "heroic expansion of eligibility of Medicaid," and he wasn't sure how the state would or could pay to treat everyone for hepatitis C if all restrictions on treatment were removed.
"It very quickly becomes a question of what are you going to ration; that is a zero-sum-game at some point in time," Liu said.
Razavi researched has proven that "the cost of inaction is actually more costly than elimination" of hepatitis C. He said the cost of new, life-saving pills that have a 100 percent cure rate have dropped from $80,000 to $35,000 and lower.
"From a health-care perspective, the state of Kentucky is going to pay for these people. So whether you treat them or don't treat them, they are going to cost you – in fact more if you don't treat them."
The World Health Organization defines the elimination of hepatitis C as reducing the number of new infections by 90 percent and reducing the number of liver-related deaths associated with it by 65 percent before 2030.
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