new addition to the HEART is our
On behalf of the American Liver
Foundation, we applaud the continued leadership of this Committee to
bring appropriate focus and attention to hepatitis C and
liver disease problems that exist among the veteran population. With
your leadership, we believe that much progress has been made. We also
applaud the efforts of the Department of Veterans Affairs as we believe
both nationally and at the VISN's across the country a commitment to
this problem is evident. We would note, however, that the Department of
Veterans Affairs has consistently under-spent its budget that has been
made available by Congress. For example, in FY 1999 $46 million was made
available for hepatitis C funding, but only $27 million
was spent. In FY 2000, $195 million has been made available, but only $
100 million has been spent. The House Appropriations Committee has
recommended and the full House has supported spending $340 million in FY
We applaud your leadership, but believe
much remains to be done. We would encourage the Committee to focus it's
attention to the continued under-spending by the Department of Veteran's
Affairs on the hepatitis C crisis that exists among the
ALF's Veterans Hepatitis C
Liver Disease Council
Since testifying before this Subcommittee
last year, ALF has formed the Veteran Hepatitis C Liver
Disease Council to address the issue of hepatitis C and
liver disease in the Veteran population. This council brings together
representation from Veteran Service Organizations, Veteran Health
Administration officials, the nation's leading medical authorities on
hepatitis C, and ALF leadership to identify and implement the
most expeditious means to increase the rate of testing and treatment for
hepatitis C for at risk veterans. This Council stands
unified in its firm commitment to help meet the needs of veterans
affected by the hepatitis C virus.
The Council has identified four major
goals of this campaign:- Raise awareness of
hepatitis C infection risk factors/prevalence among veterans-
Motivate veterans who may be infected with hepatitis C
virus to seek testing and as appropriate, seek treatment- Provide
credible, up-to-date hepatitis C information and education
to at-risk veterans and those receiving treatment- To achieve the above
goals through education and advocacy.
Following the Council's first inaugural
meeting on June 15, 2000, two major campaigns are currently underway to
help raise awareness of hepatitis infection
risk factors. First, during the celebration of Independence Day last
week (July 3-9), the Council's first initiative helped over 1,500
at-risk veterans get tested free of charge for hepatitis C
through a nationwide promotion using an FDA approved home testing and
counseling service (manufactured by Home Access Health Corporation).
Secondly, ALF has developed a veteran
hepatitis C information brochure that is to be accompanied
with a letter signed by the VA's Deputy Undersecretary for Health, Dr.
Thomas Garthwaite and sent out to the 3.6 million veterans that use the
VA health system. This letter with the ALF brochure is being printed and
will be mailed to veterans in the near future.
The Prevalence and Impact of
Hepatitis C in the United States and Among Veterans
Hepatitis C, designated by the CDC, as an "emerging infectious
disease" is one of the most serious public health problems that the
United States will face as we enter the 21" century:
- Four million Americans have been
infected with hepatitis C and most don't know it.- Ten
thousand people die every year from Hepatitis C, and this
amount is projected to triple in the next 10- 1 5 years.-
Hepatitis C is the leading cause of liver transplantation.
C is a democratic disease that affects everyone - all races, men, women
and children. It mirrors mainstream America ... doctors, lawyers,
teachers and even soccer moms, not just those who received blood
transfusions prior to 1992 and illegal injection drug users. However, it
is important to recognize that some populations are more vulnerable to
chronic hepatitis C than others. For example:
-1.8% Overall U.S. population-8-10%
Veterans-3.5% Overall population between the ages of 35-55-1.5%
White-3.2% African-American-2.1% Mexican-American.
Clearly, hepatitis C is a
well-documented major health challenge for U.S. Because hepatitis
C is a "quiet" virus, the vast majority of veterans with hepatitis
C do not have symptoms, and thus, are unaware that they are affected.
This combined with the prevalence of hepatitis C, and the
fact that it is a serious, potentially life-threatening condition,
underscores the importance of identifying those veterans who are
infected. And further, new studies show that treatment succeeds in about
40% of patientswho are suited for treatment. And even for those who do
not respond to treatment, it is important that they become aware,
because there are interventions that can significantly slow down the
progression of hepatitis C damage to the liver - for
example, by abstaining from drinking alcohol, and making sure they are
immunized to protect them from hepatitis A and B.
Veterans Health Administration Response
As stated in the Department's budget
documents, hepatitis C has particular importance because
of its prevalence in the VA's service population. The Administration's
Fiscal Year (FY) 2001 budget proposal requests $340 million to support
efforts to test and treat veterans with Hepatitis C. This
is $145 million more than the $195 million made available in FY 2000 for
this purpose. As noted earlier, while the budget requests and
expenditure levels have increased, there has been a significant spending
shortfall below amounts made available.
To address needs of hepatitis
C positive veterans, VA designated medical centers in Miami, Florida and
San Francisco, California as "Centers of Excellence" to serve as
research and education lynchpins in VA's 5-point strategic initiative to
respond to hepatitis C. The 5-point strategic initiative
includes: 1) patient education; 2) health care provider education; 3)
epiderniologic assessment; 4) treatment; and 5) research.
new addition to the HEART is our
The Centers of Excellence have also
developed risk factor and counseling recommendations for all VHAs, as
well as treatment guidelines for the care of veterans with
hepatitis C. These treatment guidelines will be updated
periodically, and as there is a greater experience of clinical care,
they can be broadened to be more inclusive. Management guidelines, such
as the need of vaccination against hepatitis A and B, have
also been distributed throughout the VHA system.
In collaboration with the Centers of
Excellence, ALF has developed ten fact sheets on hepatitis
and live disease for veterans. These educational materials have been
widely distributed throughout the VA system.
Significant progress has been made, but
more needs to be done. The recommendations of the ALF follow.
Challenges for the VA Hepatitis
C Testing, Diagnosis & Treatment Program While it is clear that the
commitment and significant budgeted support is in place to launch a
public health campaign directed at hepatitis C among U.S.
veterans, many challenges lie ahead. If these challenges are not
addressed, it will not be possible to spend anywhere near the $340
million that has been budgeted. Some of the challenges facing this major
public health undertaking are identified below along with the
identification of some public and private sector partnership
Challenge #1 - Infrastructure Development
In order to meet the increased demand for
hepatitis C services, additional medical, psychological
and managerial personnel will be needed at the VA's VISNNAMC Network.
- Public Sector Efforts Needed:
Additional funding support needs to be identified and dedicated to
support the additional personnel that will be needed over the next 4-6
years to meet the demand for hepatitis C treatment.
- Private Sector Efforts Needed: Methods
for training primary care personnel to manage hepatitis C
patients in consultation with specialists need to be explored. One such
model being developed at ALF involves a program to increase the
"Quantityand Quality of Health Care Services Provided in the Management
of Chronic Hepatitis C Through the Expanded Use of Nurse
Personnel." This plan has the potential for developing a training module
coupled with a recruitment strategy to bolster the supply of
hepatitis C certified nursing personnel available for employment
within the VHA Network or through some external contract mechanism
should the expansion of FTEs not be feasible. Developing and
implementing this recruitment and training initiativecould be done for
$1.5 million over two years.
Challenge #2 - Health Provider Education
- Public Sector Efforts Needed: The
designation of "VA Hepatitis C Centers of Excellence" and
the National Hepatitis C Symposium (June 3-4, 1999) are
excellent examples of how VHA is seeking to educate its personnel. It
appears that VHA is seeking to make sure information on hepatitis
C is communicated to its health personnel on an ongoing basis.
- Private Sector Efforts Needed: ALF has
been running an ad "Combating a Crisis" in numerous primary care
journals. It is also using this ad in conjunction with mailings to
primary care physicians through health departments. This ad, which
provides succinct information for primary care practitioners about
hepatitis C, can be easily adapted to be specific for VA
primary care practitioners. ALF would be pleased to do this in
consultation with VA hepatitis C leadership and have it
distributed throughout the VA system.
ALF is currently exploring ways in which
it could assist in training primary care practitioners through its
nationwide network of chapters and their medical leaders, many of whom
are involved in their local VISNNAMCs. There are numerous ways in which
public and/or private resources can be used for this purpose.
Challenge #3 - Veteran Education and
Educational materials and outreach
strategies must be employed to stimulate the vast reservoir of unmet
needs among undiagnosed veterans with hepatitis C.
- Public Sector Efforts Needed: Ongoing
communications between VHA and VSOs. Development of educational
materials through the VA Hepatitis C Centers of
- Private Sector Efforts Needed:
ALF is currently working with its
chapters to develop these programs targeted to veterans:
- Meet the Researchers - ALF's
educational series featuring leading liver specialists. Working with
local VISNNAMCs, ALF plans to hold up to 36 symposiums the first year
throughout the U.S. focusing on issues specific to veterans. These half
or full dayconferences will be sponsored by both ALF's local chapters
and National Office. The symposiums will provide veterans with access to
current information on treatment and disease issues that might not
otherwise be readily available.
- Support Groups - ALF chapters will be
forming support groups targeted to veterans. Support groups provide a
forum to share concerns about diagnosis and treatment, discuss coping
issues and provide support from other veterans. These support groups
also provide another opportunity for education as local health care
providers are invited to participate by speaking at these meetings. Over
the next year, ALF expects to form 30 support groups meeting monthly
through local chapters. A health care professional will be hired to
coordinate and facilitate each group.
- Outreach - ALF has developed cultural
"blueprints" targeted to different racial and ethnic populations for
hepatitisawareness. These efforts and materials need to be
developed and implemented in culturally appropriate ways.
For all the challenges listed above, it
is important that accountability mechanisms be established by the VA
that include the following:
- performance measures for testing,
diagnosis and treatment- performance measures for outreach and
education- establishing a database to measure performance- annual
reporting of results.
The hepatitis C liver
disease problem facing veterans is not a one-year campaign. Instead, it
will require a long-term commitment from the public sector and the
private sector. It will also require a comprehensive use of different
medical, psychosocial, and economic supports if it is to be successful
in the long term. The ALF Veterans Hepatitis C Liver
Disease Council represents the long-term commitment and unification of
government and advocacy groups to face this epidemic.
ALF stand ready to work in collaboration
with the VA and other in any public and private models to accomplish
these goals. Again, we thank you for your leadership on these important
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