Back HIV Policy & Advocacy 9. HIV and Hepatitis C Treatment Cost and Barriers to Access

9. HIV and Hepatitis C Treatment Cost and Barriers to Access

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Lack of access to HIV and hepatitis C treatment were key issues this year, as studies showed that type of health insurance affects the likelihood of successful treatment. HIV now has the potential to be a chronic manageable illness and hepatitis C can usually be cured, but major barriers and disparities continue to keep many people from accessing treatment.

A large number of people living with HIV or hepatitis C in the U.S. are not covered by traditional private health insurance and rely on alternatives such as Medicaid (for low-income people), Medicare (for seniors), Veterans Administration care, or AIDS Drug Assistance Programs (ADAPs) and other care funded by the Ryan White program. But more than a third of states have not expanded their Medicaid programs under the Affordable Care Act (ACA) and many have not fully funded their ADAPs to cover everyone needing assistance.

At ID Week in October Kathleen McManus from the University of Virginia School of Medicine reported that enrolling low-income and under-insured people with HIV in an Affordable Care Act health plan improves their odds of staying on antiretroviral therapy (ART) and achieving sustained undetectable viral load.

A study published in JAMA Internal Medicine found that people who received care through Ryan White funded and non-funded clinics were about equally likely to be prescribed ART, but patients under the poverty level who attended Ryan White clinics had a better chance of achieving viral suppression.

Turning to hepatitis C, expert guidelines now recommend that everyone should be considered for interferon-free therapy. But due to the high cost of the new drugs many payers have imposed restrictions such as requiring that patients have advanced liver damage, be treated by certain specialists, or have a period of abstinence from alcohol and drugs.

A study presented at the AASLD Liver Meeting in November found that 16% of people in 4 states had their prescriptions for hepatitis C treatment rejected by private insurers, while almost half of Medicaid recipients were denied reimbursement for treatment in 2014 and early 2015.

Shortly before that conference, the Centers for Medicare & Medicaid Services issued a letter to state Medicaid programs stressing that they are expected to cover new interferon-free antiviral therapies without undue restrictions, as well as a letter to the pharmaceutical companies asking about purchasing arrangements to ensure wider access to their drugs.

Evidence continues to accumulate showing that hepatitis C treatment is likely to be cost-effective in terms of savings on later care for advanced liver disease. While the initial outlay will be very large, it may be temporary. At the Liver Meeting Jagpreet Chhatwal of Massachusetts General Hospital presented findings from a mathematical model showing that the cost of treating hepatitis C is likely to decline over the next decade as a majority of patients will already have been treated.

A growing body of research also underlines the importance of timely treatment, showing that the benefits of curing hepatitis C are greater if done before the development of advanced liver disease. A study of U.S. veterans presented at the EASL International Liver Congress showed that deferring treatment until a person progresses to advanced disease results in lower treatment effectiveness and an increased risk of clinical events and death. Similarly, researchers reported at the Conference on Retroviruses and Opportunistic Infections that HIV/HCV coinfected people who delay hepatitis C treatment remain at risk for liver failure, hepatocellular carcinoma, and liver-related death even after being cured -- with outcomes worsening the longer it is put off.

NEXT: 10. Shorter Tuberculosis Prevention and Treatment