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The Co-infection of

HIV/AIDS and Hepatitis B and C:

 The Socio-Economic Impact on the

State of Florida

http://www.theaidsinstitute.org/downloads/hepc.doc

Prepared For: The Florida Department Of Health

Bureau of HIV/AIDS

Prepared By: The Center for Public Policy Research and Ethics

The AIDS Institute

The AIDS Institute Administrative Center · P.O. Box 16705 · Tampa, Florida 33687-6705 Phone (813) 232-5886 · Toll Free In Florida (800) 779-4898 · Fax (813) 232-0857
theaidsinstitute.org

HIV/AIDS: The United States

*Assumes treatment for 900,000 individuals.               

*Calculations based on costs reported by (Kaiser Family Foundation, 2000 and Saag, 2002)

While this model was created for purely illustrative methods and remains simplistic, it encompasses a "blue sky" theory in assumptions.  The one very striking calculation, however, is the obvious difference in cost for a "healthier" population, as opposed to a "weaker" or at a more advanced disease state population.  These calculations argue for more early intervention and early treatment.  By providing that more individuals are kept healthy, almost 36% or $9,000,000,000 can be saved in expenditures.

Florida’s costs could be projected in a similar manner to the national figures, but would be based on a smaller subset of 95,000 infected individuals estimated by the Florida Department of Health.  Other costs not included in the calculations for both include the indirect costs discussed previously.  

HIV/AIDS: Florida

**Assumes treatment for 95,000 individuals.

*Calculations based on costs reported by (Kaiser Family Foundation, 2000 and Saag, 2002)

Based on the previous calculations related to HIV/AIDS mono-infection, the following tables represent the additional cost of treatment for HCV.  The CDC estimates a 25% co-infection rate between HIV/AIDS and HCV (CDC, 2002).  However, the model used previously can be repeated, adding the HCV treatment cost estimate of $15,000 into the cost per patient per year (PPPY) for HIV/AIDS along the disease state estimates to calculate the impact of HCV treatment costs on HIV/AIDS costs.  Again, this model is merely illustrative and must be considered a snapshot, especially when taking into consideration the inherent differences between the ongoing and eventually finite (until death) HIV/AIDS treatment and the HCV treatment (6 months to 12 months for one course).  It is for this reason that HCV treatments cannot be annualized. 

HIV/HCV Co-infection: The United States

*Assumes treatment for 225,000 individuals.

*Calculations based on costs reported by (Kaiser Family Foundation, 2000 and Saag, 2002)

Similarly, Florida’s costs could be projected using a smaller subset of the 95,000 infected individuals estimated by the Florida Department of Health, multiplied by 25% to obtain the estimated co-infection rate.  This total would then become 23,750 HIV/AIDS/HCV co-infected individuals.  Other costs not included in the calculations for both include the indirect costs discussed previously.  

HIV/HCV Co-infection: Florida

*Assumes treatment for 23,750 individuals.

*Calculations based on costs reported by (Kaiser Family Foundation, 2000 and Saag, 2002)

Assuming this co-infection rate and estimating the annual treatment costs for HCV at $15,000, then a base $3.375 billion can be added to the national HIV/AIDS subtotals to gain a general understanding of the impact of HCV treatment on HIV/AIDS costs, while $356.25 million can be added to the HIV/AIDS subtotals.  One major gap in this model is the lack of estimates for possible cost duplication of services, such as doctor visits and other services which may not be mutually exclusive between the two disease states.  The estimate of $15,000 for the treatment of HCV mono-infection from the New Jersey Correctional System and Florida's Medicaid system includes such visits, which may or may not be duplicative.  However, the disease state of HCV (i.e. well vs. advanced) of these distinct populations is unknown.  A higher proportion of individuals in advanced stage (i.e. liver failure up to and including liver transplantation), for example, can greatly inflate the estimate. 

The “take home” message of these illustrative models is the argument for early intervention.  Using a model purported by Wong involving a high degree (27.2%) of HCV clearance, 4.1% progression to moderate hepatic status, 7.3% progression to compensated cirrhosis (no signs of liver failure), and 1.5% progression to hepatocellular cirrhosis and decompensated cirrhosis (liver failure), 3.1% of patients with either compensated or decompensated cirrhosis would receive a liver transplant (Wong, 1999).  Calculating the impact of this cost could be shown as follows.  The average cost of a liver transplant, according to Walensky et.al., is $200,000.  If the previous population estimates (25% of HIV/AIDS estimated population) are used to create a co-infection population, and using Wong's 3.1% rate of liver transplantation, a model can be created to estimate the need-based cost of transplants nationally and in the State of Florida. 

*N=population                   *Calculations using (Walensky et.al., 2002 and Wong, 1999)

As with similar findings above, Wong concludes that, “economic savings derived from preventing future cases of cirrhosis and hepatocellular carcinoma more than offset the initial treatment cost” (Wong, 1999). 

However, the actual cost would be far less for liver transplants because of the reality of the low availability of transplant livers, coupled with the fact that HIV/HCV co-infected individuals are less likely to receive them due to their co-morbidity and low predicted long-term success rate. 

CURRENT SERVICES AVAILABLE-Co-infection

Primary Care:

            Primary care doctors for hepatitis B and C, attained through private insurance, can be located either by the consumer or by several local and national groups that attempt to pair consumers with providers to best suit their needs.  Two examples of such resources include the American Liver Foundation and Hep C-Alert.  Both organizations have information on doctors that either specialize in hepatitis treatment or have been known to treat people with hepatitis. 

            The route to treatment for people without health insurance or with public insurance is through a national database provided by the U.S. Department of Health and Human Services’ Bureau of Primary Health Care (BPHC) (http://bphc.hrsa.gov).

Via the Bureau, people can locate community health services or “look-alikes,” i.e. doctors with sliding fee scales or pharmaceutical programs, such as Roche’s “Peg-Assist” and Schering-Plough’s “Commitment to Care” or “Patient Assistance programs.”  All of the pharmaceutical programs offer people with both medical and financial need access to either free or reduced price medications, usually for a limited time if they meet eligibility criteria established by the program.  It should be noted that the pharmaceutical assistance programs are regarded as a “last resort” and do not ensure continuous treatment. 

            In a one year period in Florida alone, 4,503 individuals applied for Commitment to Care (Schering-Plough's patient assistance program).  Because they had no other means of reimbursement identified by either the State or Schering Plough, 1,392 individuals were approved and supplied with Schering Plough's product.  As part of the established program, Schering-Plough employs reimbursement staff to work with applying clients to identify eligibility possibilities such as the Veteran's Association or Medicare Part B for therapy.  

Additionally, the BPHC can locate Veteran’s Assistance (V.A.) treatment centers.  Groups such as Hep-C Alert also link uninsured persons with pharmaceutical representatives and/or their physicians for reduced cost medications.

            The only instance in which hepatitis will be treated at a hospital is in the case of an extremely acute case, and hospitals cannot serve as primary health care providers.  Once treated for an acute infection, patients will have to return to their primary health care providers, community health centers, or county health departments. 

Support Groups:        

            There are several support groups for people living with hepatitis in the state of Florida.  Support groups are located in Ft. Lauderdale, Tampa, St. Petersburg, Broward County, Miami, Boca Raton, Gainesville, Orlando, Palm and West Palm Beach and Plantation.  Many of these groups are led by local hospitals, hepatitis organizations, and national organizations such as the American Liver Foundation.  Locations of support groups are found on the Internet, through local hepatitis or liver foundations, or through hospitals.  It is important to note that the majority of the times listed for meetings are in the evening. 

Programs Specific to Florida:

            In 1999, Florida instituted its state-funded Florida Department of Health, Hepatitis and Liver Failure Prevention and Control Program, administered through county health departments.  Initial appropriations were $2.5 million for the first year and $3.5 million the subsequent year.  The program began by serving six counties (Broward, Collier, Miami-Dade, Monroe, Pinellas, and Polk) and their adult residents at an increased risk for hepatitis A, B or C.  Services include: a) enhanced surveillance;

b) education of public health providers; c) immunization against viruses A and B;

d) targeted intervention; e) screening and testing for chronic hepatitis B and C and;

f) epidemiologic investigations.  In 2001, the program was extended to include hepatitis A and B vaccine availability for the entire state, specifically for people at increased risk for infection.  The expansion also included chronicity testing for adults with hepatitis B and C.  Currently, the original six counties receive continued funding, with limited funding for three new counties, including Escambia, Lee and Seminole. 

Links and Additional Resources:

The Department of Health, through the My Florida (myflorida.com) website, offers a web-based clearinghouse containing 24 links to websites and phone numbers for information regarding most aspects of hepatitis.  These sites include information from the CDC concerning facts on the cause and spread of the disease and most common treatments; groups dedicated to advocacy work; information about HIV and hepatitis co-infection; information about screening, education and prevention; Medicaid referral services, and locations of support groups. In addition to the web resources, the Florida DOH also offers a toll-fee hepatitis C Hotline, 1-866-FLA-HEPC.  Additional resources, some of which assisted in the research development of this work, include www.all-about-hepatitisc.com, www.hepnet.com, www.who.int/inf-fs/en/fact164.html, www.hcop.org, and www.hepcassoc.org.

RESULTS – PROVIDER SURVEYS

To achieve a realistic perspective on hepatitis outreach, testing, and treatment, a survey was developed to target providers from both the public and private sector.  Developed in collaboration between Florida AIDS Action and the Florida Department of Health, Hepatitis and Liver Failure Prevention and Control Program, the survey included many data gathering methodologies.  These techniques included open and close-ended questions, Likert and ordinal scales, and ranking.  The surveys were mailed to a randomly selected number of private physicians, garnered from a BPHC list, who identified themselves as hepatitis treatment providers, as well as to all county health department hepatitis contacts identified by the Hepatitis and Liver Failure Prevention and Control Program.  In addition to an introductory letter and a copy of the survey, the Florida AIDS Action packet included a self-addressed, stamped envelope to help with return rates. In order to increase anonymity, no program specific or contact information was required.  Given a finite amount of time to complete the survey, respondents mailed them to Florida AIDS Action.  Research staff colored and numerically coded each survey, and then entered the quantitative data into a statistical computer package for analysis.  Qualitative data were entered into a coding system.  Each data set was then cleaned and analyzed.  The following results summarize the responses of the survey respondents. 

            The respondents consisted of a blend of community health department/public programs and private physicians, with a slightly larger percentage (10%) of community health departments reporting.  Despite not providing incentives, having a randomized listing of private providers, and some incorrect contact information gained from the hepatitis section within the Florida Bureau of HIV/AIDS for county health department hepatitis programs, the survey response rate was 24%.  This percentage is higher than what is routinely achieved when using written surveys.

            Respondents tested an average of 495 individuals for HBV ranging from 3-2,500 reported tests per provider.  A majority of respondents (60%) do not actively treat HBV. Of those that do provide treatment, they do so to an average of 10 individuals ranging from 1-12.  When asked why they believe individuals seek testing for hepatitis B, 54.2% of respondents indicated physician referral, 75% friend/spouse/partner/relative, 58.3% blood bank, and 41.7% other.  Interestingly, 100% and 70.8% indicated they believed individuals do not seek testing because of Internet research or public prevention education, respectively. 

            The majority (87%) of respondents who answered why they believe individuals do not seek testing for hepatitis B included either a lack of knowledge or education, while over 20% indicated fear of the unknown.  When asked why they believe individuals seek hepatitis vaccines, 30.4% indicated knowledge or education, 60.8% school, work, or travel requirements, and 26% indicated perceived risk, a prior exposure, or a hepatitis diagnosis. 

            Most respondents (60.8%) indicated a risk assessment tool when asked how they determine an individual should be tested for hepatitis B, while 73% indicated either a risk assessment tool or other risk categories when asked how they determine an individual should be vaccinated. 

Concerning HCV, respondents reportedly tested an average of 535 individuals ranging from no tests to over 2,500 individuals.  A very high percentage (68%) of providers reported that they do not treat HCV.  Of those that perform treatment, they do so to an average of 16 individuals ranging from 0-200. 

            When asked why they believe individuals seek testing for hepatitis C, 2/3 (66.7%) of respondents indicated physician referral, friend/spouse/partner/relative, and blood bank.  45.8% indicated public prevention education, 41.7% other, and only 4.2% because of Internet research. 

            The same majority (87%) of respondents who answered why they believe individuals do not seek testing for hepatitis C, as was the case with hepatitis B, included either a lack of knowledge or education, while over 20% indicated fear of the unknown.  When asked whom they consider to be “at risk” for contracting hepatitis C, nearly 70% of respondents cited IDU/drug use. 

            Most respondents (52%) indicated a risk assessment tool when asked how they determine that an individual should be tested for hepatitis C, while 65% indicated a risk assessment tool combined with other risk categories. 

            When asked how effective given modes of prevention education are, respondents rarely tended to indicate “slightly ineffective” or “highly ineffective.”  This indicated that the majority of responders marked positive rather than negative answers with regard to prevention outreach modes.  Therefore, it can be concluded that a non-answer may also be a negative answer.  The “unable to determine” percentage remained large for each response.  For television commercials, combined “slightly effective” and “highly effective” responses yielded 54.2%, with 37.5% “unable to determine.”  For radio commercials, 50% and 37.5%, respectively; materials and/or pamphlets 62.5% and 20.8%; peer educators 66.7% and 25%; and focus groups 54.2% and 33.3%. 

            Respondents were asked where they would prioritize hepatitis services for hepatitis C infected individuals or those at risk, given unlimited resources (e.g. funding, time, staff).   Ordinal response options were one (1) through nine (9), with (1) representing “most important” and (9) representing “least important.” 

Weighted tendencies were used to analyze the responses, where (1) through (3), (4) through (6), and (7) through (9) were grouped together.  Of the scales that weighed toward “most important,” testing totaled a combined 79.1%; prevention education 62.5%; 54.2% treatment; 49.9% vaccines; and 25% surveillance.  Of those that weighed toward  “least important,” other social services (e.g. transportation, housing, etc.) was given 87.5%; mental health 79.2%; substance abuse treatments 37.5%; and case management 29.1%. 

            When asked if they thought physicians and other medical staff require any additional training and/or education with regard to hepatitis C infection, testing, and treatment, an overwhelming majority of respondents (91%) indicated “yes.”  A follow-up question was then given, which asked what kind of training and/or education they would suggest.  The majority of common responses included updates regarding treatment, testing, and surveillance changes. 

            Regarding the treatment of HIV co-infected individuals, both past and present, 34.8% indicated a positive response.  For respondents who treat or have treated those who are co-infected, the final question asked was what they thought were special issues to be considered when treatment, prevention education, and the provision of social services occur.  Responses varied among prevention education, medication interactions, depression, holistic health strategies, and hope.  

            The survey and its results were found to be very useful in creating recommendations for current practices in viral hepatitis outreach, prevention, treatment, and other cost projection activities.  Florida AIDS Action views the answers of current employees dealing with related issues from both public and private sectors to be paramount to policy making and policy altering decisions.  

SERVICE COSTS

PROJECTIONS

            Following investigations into disease manifestations, their treatment theories, and how they are, in fact, impacting the community, it is most beneficial to investigate how this impact will be felt economically.  Given the uneasy reliance on surveillance projections and the complicated science of drug pricing, projecting costs remains a difficult endeavor. 

            Projection models for service costs are dependent on the interaction of two other projections: the estimated “burden” of disease (prevalence) and the future costs of treatment.  Further complicating the model are methodological data collection problems, changing treatment standards, differing response levels, recurrence, and unknown weights or factors that can significantly undermine the quality of the data. 

            The value of each model is dependent on the combination of epidemiological, demographic, and behavioral trends.  Different methods are used to determine differing

rates of interest.  It should be noted that HIV incidence, HIV infection prevalence, AIDS incidence, and AIDS prevalence and mortality are interrelated, yet separate concepts. Each are associated with time. 

            From a prevention perspective, HIV incidence is of particular interest.  The infection prevalence, or pool of those currently infected, represents the potential for future incidence and the effect of past incidence.  Although current rates of transmission can be calculated from prevalence rates, reflecting the experience with the disease among those that have already acquired it, future incidence is still dependent on personal behaviors. 

            AIDS incidence can also be used to calculate HIV prevalence by subtracting cumulative AIDS deaths from cumulative incidence.  Using a standard rate of progression from HIV to AIDS, the figures are worked backwards to estimate past HIV incidence.  The standard rate of progression has been 10 years, and is commonly employed for this type of analysis.  Adjustments that take into consideration the impact of HAART are constantly needing revision.   

Serologic surveys, such as NHANES, are used to find the status of participants.  Because the participants are selected at “random,” their status is extrapolated to others of the same category within the population.  Census numbers are used to determine the population figures.  The problems with this method are the issues of  “random” and representation. 

Many countries have employed active surveillance systems.  Instead of relying on individuals to come into the system, current levels of HIV infection are determined by testing samples of blood and other bodily fluids obtained for other routine screening purposes.  Since the specimens are anonymous, the tests capture specimens of those that refuse to be tested for HIV. 

IMPACT ANALYSIS:  Medicaid

According to the Florida Agency for Health Care Administration (AHCA), total spending for all hepatitis C patients enrolled in the MediPASS program for fiscal year 2000-2001 totaled $76,824,541.  This sum, divided by 62,174 total case months, yields a $1,236 per member per month (PMPM).  A person undergoing annual hepatitis C treatment will incur a cost of approximately $15,000, which is consistent with findings in the New Jersey prison system cited previously. 

Of those patients with AIDS who are treated for hepatitis C under the MediPASS program, overall costs amounted to $23,162,195, representing 30.1% of all patients treated for hepatitis C.  Divided by 10,319 case months, PMPM rises 81.6% to $2,245.  The cost for a person with AIDS undergoing annual hepatitis C treatment is approximately $26,940. 

IMPACT ANALYSIS:  The AIDS Drug Assistance Program (ADAP)

            Sixteen state ADAP programs have already been forced to cut back on HIV services due to budget problems, increased enrollment, longer duration periods, and rising healthcare costs, with more expected to follow.  Current reports on the status of ADAPs are maintained by the National Alliance of State and Territorial AIDS Directors (NASTAD) ADAP Funding Watch Report. 

Eligibility and drug formulary restrictions, as well as waiting lists, are commonly used to limit expenditures.  Effects include treatment gaps and patient migration.  Without consistent access to medications, which help to keep viral loads down, time becomes a very real threat.  While some patients are forced to wait-and-see, others will actively migrate to locations that can provide treatment, blurring the historical trend lines capturing geographic need and making them incongruous to “estimated” demand. 

            Even with these problems involving the treatment of HIV alone, there is a sustained need for those that are HCV co-infected.  New Jersey and Massachusetts were surveyed in order to assess the possible impact of HCV services on the Florida ADAP, which does not currently provide them.  In New Jersey, out of 3,000 ADAP clients, in one month, 29 clients accessed Ribavirin and 35 accessed Peg-Interferon.  This was at a cost of approximately $86,000 for the month to provide treatment to all of these clients (personal communication with Ronald Weinstein, New Jersey ADAP Director, April 23, 2003).  Using these figures, out of a total ADAP budget of $55 million per year, the projected cost, given a somewhat consistent need, would be $1 million spent on hepatitis C treatments.  This would account for less than 2% of their total budget. 

When the Massachusetts ADAP was surveyed, it was found that out of the 1,106 ADAP clients served in one month, five (5) clients accessed HCV medications.  A combined total of $2,635.26 was spent on Ribavirin and Peg-Interferon for the month of December 2002.  For the 2002 fiscal year, the total ADAP budget for the state of Massachusetts consisted of $14 million, $8 million of which was spent on pharmaceuticals and $6 million on insurance continuation and other programs (personal communication with Annette Rockwell, Massachusetts HDAP Coordinator, April 29, 2003).  If the December total for New Jersey is generalized to each month, without making exceptions for treatment failure and other confounding factors leading to shortened length of treatment, Massachusetts would spend around $32,000 a year for HCV treatments.  This sum would account for less than 1% (.2%) of the total ADAP budget and less than 1% (.4%) spent on pharmaceuticals. 

Using the HCV treatment costs and usage figures from New Jersey ($2,866 per person; one percent) and Massachusetts ($2,635; less than one percent), the approximately 13,000 ADAP clients in Florida would yield roughly $350,000 per month. 

This figure assumes that treatment usage for Florida will be similar to the experiences of New Jersey and Massachusetts, where a percentage (1%) from the ADAP total is multiplied by drug costs.   

If 25% of the 13,000 ADAP clients estimated to be co-infected with HCV would receive treatment, this figure increases to nearly $8.8 million.  Although much higher than the experience cost, using a co-infection estimate more accurately predicts budgeted possible need within the ADAP program.  This total, however, is less feasible than the experience cost, due to the more sporadic than consistent nature of HCV treatment. 

Finally, if all 23,750 (25% of 95,000) estimated HIV-infected individuals in Florida were to receive treatment, over $64 million per month ($768 million annually) would be spent for HCV treatment.  This figure provides a high-end estimate to illustrate a total approximate “need” for the state of Florida.   Based on the experience of both New Jersey and Massachusetts, this total greatly exceeds an actual usage approximation of 1%, multiplied by 23,750 and by drug costs, or nearly $641,000.  This, of course, is unrealistic due to the mere fact of the eligibility requirements for Florida ADAP, and the improbability that many of the co-infected individuals would not qualify. 

The approximate $2,700 per month figure used to calculate these totals makes the $1,250 ($15,000 annual) HCV treatment figure used to calculate the co-infection tables for Florida look like conservative estimates.

            Given current surveillance testing and treatment rates, we would estimate total impact to the Florida ADAP to be between the $350,000 and $8.8 million figures.  While the overall need is evidenced in the second calculation, variables such as lack of community health, professional education of hepatitis risks, testing, testing return rates, and availability/eligibility to treat force the “need” numbers lower and closer to the experience figures from New Jersey and Massachusetts.  The experience number would have to be augmented to approximate Florida’s already expressed hepatitis characteristics. 

SUMMARY

            Because of the unique nature of HIV/AIDS and hepatitis B and C, the community must be cognizant of the impact and implications they will have economically, socially, and ethically. 

            AIDS in the U.S. is not gone, and new problems arise as old ones continue to plague all people affected and infected by AIDS.  Every hurdle cleared is relative to those that lie ahead.  Continued stigmatization, complacency, antiretroviral therapy resistance, dwindling public funding, stagnant infection rates, and chronic co-infection issues all confound the advances in HIV/AIDS treatment and care that have been made over the past twenty years.  There is still no cure and no vaccine for HIV/AIDS.  Therefore, until cures and vaccines are found, we are relegated to focusing on prevention, care, and treatment. 

            The less studied and less glamorized viral hepatitis strains are on track to exponentially impact publicly and privately funded medical care.  These “silent killers” are causing large expenditures due to their chronicity, while acute stage expenditures may devastate the health infrastructure if left unattended.  There is hope in the form of vaccines for hepatitis B, which are now required by many schools, work places, and travel authorizations.  Daily, this increases the pool of individuals that are vaccinated pre-exposure.  Unfortunately, there is no vaccine for hepatitis C.  Additionally, of those that are infected, very few will be able to access and tolerate the current treatments.  This does not bode well for the community.  Because of the estimated infection rates discussed earlier, it is understood that knowledge remains one of the largest barriers to ending hepatitis infection.  Because testing rates seem to be inconsiderable compared to projected infection rates, one can surmise that there are millions of individuals that do not know that they are infected.  This, in turn, increases the likelihood that they will not take precautions to prevent the spread of infection.  This is coupled with the fact that much of the transmission of HCV is blamed on the use of unclean needles.  Whether past or present, injection drug users are not a readily identifiable subpopulation. 

            Adding these circumstances together and taking into consideration the unique and labyrinthine collection of confounding variables, it remains unfathomable to attempt to create clear and concise guidelines, regulations, and cost projections.  One aspect of this work is certain—it is in its infant stages.  Experts predict that the true HCV impact will occur in another 10-20 years with needs as extensive and expensive as liver transplants. 

From the hepatitis perspective, HIV is a very small problem.  HIV is a minute co-infector compared to many other confounding variables.  However, from the HIV perspective, HCV poses a much larger threat.  The HIV community can no longer ignore the impact that hepatitis will have on the community's members and resources.  To ignore HCV at this point is similar to taking ten steps backward by not considering the holistic nature of the human body and disease states.  The community would be remiss to not address HCV in prevention and treatment, especially given the large strides it has made in HIV/AIDS treatment and prevention.  The HIV can be treated and controlled, but this treatment is of no use if the co-infected individual dies from HCV related complications; HCV still kills.  The following recommendations hope to address several of the issues relevant to the health and well-being of Florida and its citizens, in the hope of creating a better system of prevention, education, and treatment.

RECOMMENDATIONS

Florida AIDS Action encourages the Florida Department of Health, Hepatitis and Liver Failure Prevention and Control Program to:

1.      Increase funding and attention paid to testing for HBV and HCV, with additional emphasis on HBV vaccination.  Hepatitis, which has the ability to slowly degrade the liver without producing obvious symptoms, can be prevented with a vaccination for hepatitis B and treated early in the case of hepatitis C.  The former is dependent on prevention awareness, while the latter is dependent on early detection.  The cost differentials for hepatitis B vaccination versus chronic treatment (and associated personal and societal costs) make for a strong argument for wide-spread vaccination programs. 

2.      Utilize more peer-to-peer education and primary prevention, modeled after HIV successes for HBV and HCV, which should include culturally sensitive and appropriate employees and materials. 

3.      Strongly encourage and provide incentives for HBV and HCV testing in both private and public sector sites, especially public health departments.  There is an opportunity to educate those who are seeking treatment for other STDs and make hepatitis testing standard.  While funding is available through the Department of Health, hepatitis testing is not required.  This is a lost opportunity.  There is a need for incentives to be designed for both private and public sector sites. 

4.      Create and provide training modules for HBV and HCV education for non-specialized physicians and other medical staff to include late breaking treatment options, guidelines, and other research related outcomes.  These modules can be created with both public and private partners, but should undoubtedly include hepatitis infected individuals.  From the provider surveys, education was shown as being a consistent item.  An overwhelming number of respondents indicated "yes" to whether they thought physicians and other medical staff require any additional training and/or education with regard to hepatitis C infection, testing and treatment.  Hepatitis B information can be easily incorporated. 

5.      Create and provide training modules for HBV and HCV education for HIV related staff.  This staff can be defined as state employees as well as community providers. These modules can be created with both public and private partners, but should undoubtedly include hepatitis infected individuals.

6.      Create and foster linkages with other programs to include, but not be limited to jails/prisons, substance abuse (long and short term facilities), domestic violence shelters, homeless shelters, and HIV related programs for testing, counseling and education. 

7.      Increase knowledge and awareness for our public officials concerning the impact of this disease, monetarily as well as socially. 

8.      Educate and encourage our elected officials to provide for the prevention, care, and treatment of the at-risk and those mono- and co-infected with hepatitis. 

9.      Encourage State of Florida-Department of Health, Bureau of HIV/AIDS to consider treating HIV/HCV co-infected individuals (given appropriate programmatic and monetary controls) with ADAP funds to assist in the overall coverage of hepatitis infected individuals.

REFERENCES

1.   AIDS.org.  Antiretroviral Therapy Guidelines.  Retrieved April 17, 2003, from

http://www.aids.org/factSheets/411-guidelines.html

2.   AIDS101.com.  Timeline 1984-1990.  Retrieved April 17, 2003, from

http://www.aids101.com/timeline2.html

3.   AIDS Treatment Data Network (ATDN) (2003).  HCV and HIV Co-Infection: A

Simple Factsheet. Retrieved January 1, 2003, from      

http://www.atdn.org/simple/coinf.html

4.   All About Hepatitis C (2002).  Hepatitis C Statistics. Retrieved September 1, 2002, from http://www.all-about-hepatitisc.com/about/statistics.jsp 

5.   American Civil Liberties Union (ACLU) (1999).  Commments on CDC Draft

Guidelines for National HIV Case Surveillance, Including Monitoring for HIV Infection and Acquired Immunodeficiency Syndrome (AIDS) 63 Fed. Reg. 237, 68289.  Retrieved April 21, 2003, from http://www.aclu.org/news/NewsPrint.cfm?ID=8868&c=90.

6.      American Correctional Association (2003).  Archived Webcast on Hepatitis. 

Retrieved November 10, 2003, from http://www.aca.org/media_20020805b_hepatitis.htm

7.   American Liver Foundation (2000). Hepatitis B [Pamphlet] New York: American

            Liver Foundation. 

8.   American Liver Foundation. (2001) Getting Hip to Hep: What You Should Know

            About Hepatitis A, B, and C. [Pamphlet] New York: American Liver Foundation. 

9.   Benhamou Y., Bochet M., Di Martino, V. et al. (1999).  Liver Fibrosis Progression in

            Human Immunodeficiency Virus and Hepatitis C Virus Co-infected Patients. 

Hepatology, 30, 1054-1058. 

10. Bica, I., McGovern, B., Dhar, R., Stone, D., McGowan, K., Scheib, R., & Syndman,

DR. (2001). Increasing Mortality Due to End Stage Liver Disease in Patients with

Human Immunodeficiency Virus Infection. Clinical Infectious Diseases, 32, 492-

497.

11. Bozzette, Samuel et al. (2001).  Expenditures for the Care of HIV-Infected Patients in

the Era of Highly Active Antiretroviral Therapy.  New England Journal of Medicine. 344(11), 817-823.  

12. Brinker, M., Wit, F.W.M. N., Wertheim-van Dillen, P., Jurrians, S. et al. (2000).

            Hepatitis B and C Virus Co-Infection and the Risk for Hepotoxicity of Highly

Active Antiretroviral Therapy in HIV-1 Infection. AIDS, 14, 2895-2902.

13. Centers for Disease Control and Prevention (CDC) (1999). Revised Guidelines for

HIV Counseling, Testing, and Referral.  MMWR 50(RR19), 1-58. Retrieved January 10, 2003, from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5019a1.htm

14. Centers for Disease Control and Prevention (CDC) (2002).  CDC Vaccine Price List. 

Retrieved April 22, 2003, from http://www.cdc.gov/nip/vfc/cdc_vac_price_list.htm

15. Centers for Disease Control and Prevention (CDC) (2002) Statistics and Trends,

HIV/AIDS. Retrieved November 11, 2002, from http://www.cdc.gov/hiv/stat- trends.htm

16. Chung, R.T., Kim, A.Y., Polsky, B. (2001) HIV/Hepatitis B and C Co-Infection:

Pathogenic Interactions, Natural History and Therapy. Antiviral Chemistry &

Chemotherapy, 12(Supp1), 73-91. 

17. Cohen, C. (1999).  The Boundaries of Blackness: AIDS and the Breakdown of Black

Politics.  Chicago: The University of Chicago Press. 

18. Dore, G.J., & Cooper D.A. (2001). The Impact of HIV Therapy on Co-Infection with

            Hepatitis B and Hepatitis C Viruses. Current Opinion in Infectious Disease, 14,

749-755.

19. Falvo, D.R. (1994).  Effective Patient Education: A Guide to Increased Compliance

            (2^nd Ed.) Gaithersburg, MD: Aspen Publishers. 

20. Fialaire, P., Payan, C., Vitour, D. et al. (1999). Sustained Disappearance of Hepatitis

C Viremia in Patients Receiving Protease Inhibitor Treatment for Human

Immunodeficiency Virus Infection. Journal of Infectious Disease, 180, 574-575.

21. Florida Department of Health: Bureau of HIV/AIDS (2002). The HIV/AIDS

Epidemic Among Homeless Persons: United States.  Florida Epidemiologic Profile for HIV Prevention Community Planning, 2000, 307-313.   

22. Florida Department of Health: Bureau of HIV/AIDS, HIV/AIDS Reporting System

            (2003).  HIV/AIDS AND Hepatitis Virus Co-Infection – Florida [Presentation]. 

Florida Community Planning Group (FCPG).  Tampa, FL. 

23. Florida Department of Health: Bureau of HIV/AIDS (2003).  Method for Deriving

            Plausible Ranges.  Florida, 2002.  Retrieved March 13, 2003, from

http://www.doh.state.fl.us/Disease_ctrl/aids/trends/prevalence/Range.pdf

24. Focusonhepc.com.  2.7M Americans May Have Hepatitis C.  Retrieved January 1,

            2003, from http://www.focusonhepc.com/hcvnews/42hcvnw.html

25. Goldman, Dana P., Bhattacharya, Jayanta, Leibowitz, Arleen A. et al. (2001). 

The Impact of State Policy on the Costs of HIV Infection.  Medical Care Research and Review 58(1), 31-53. 

26. Greub, G., Ledergerber, B., Battegay, M. et al. (2000).  Clinical Progression,

Survival, and Immune Recovery During Antiretroviral Therapy in Patients with HIV and Hepatitis C Co-Infection: the Swiss HIV Cohort Study. Lancet, 356, 1800-1805. 

27. Haney, Daniel Q. (2003).  Promising New AIDS Drugs on the Horizon.  The

Associated Press, February 11, 2003. 

28. Haydon, G.H., Flegg, P.J., Blair, C.S. et al. (1998). The Impact of Chronic Hepatitis

C Virus Infection on HIV Disease and Progression in Intravenous Drug Users.

European Journal of Gastroenterological Hepatology, 10, 485-489.

29. Health on the Net Foundation (2002).  HON: Hepatitis B V4.1 – Medical Tests and

Procedures.  Hepatitis B.  Retrieved August 12, 2003, from http://www.hon.ch/Library/Theme/HepB/tests.html

30. Health on the Net Foundation (2003).  HON – News: New Hope for Hepatitis B

Sufferers.  New Hope for Hepatitis B Sufferers.  Retrieved August 12, 2003, from http://www.hon.ch/News/HSN/511954.html

31. Herek, G. Capitanio, J., Widaman, K. (2002).  HIV-Related Stigma and Knowledge

in the United States: Prevalence and Trends, 1991-1999.  American Journal of

Public Health, 92, 371-377. 

32. Hivtest.org.  Frequently Asked Questions about HIV Testing.  Retrieved March 13,

            2003, from http://www.hivtest.org/faqs/testing.htm

33. Hubbard, M.J. (2001).  Evaluation and Management of the Patient Co-Infected with

Human Immunodeficiency Virus and Hepatitis C. Clin Excell Nurse Pract., 5(4), 205-210.

34. International Association of Physicians in AIDS Care (IAPAC) (2002).  More than

            80% of HIV-Positive Patients Display Symptoms of Depression or Anxiety.  40^th

Annual Meeting of the Infectious Diseases Society of America, October 25, 2002. 

35. JAMA Newsline (1998).  HIV/AIDS Care Calls for Reallocation of Resources. 

Medical News & Perspectives, 279(7), February 18, 1998.  Retrieved January 7, 2003, from http://www.ama-assn.org/

36. Kaiser Family Foundation (KFF) (2000).  Financing HIV/AIDS Care: A Quilt With

Many Holes.  Retrieved October 18, 2002, from  

http://www.kff.org/content/2000/1607/financingisbrf.pdf 

37. Lafeuillade, A., Hittinger, G. & Cahdapaud, S. (2001). Increased Mitochondrial

            Toxicity with Ribavirin in HIV/HCV Co-Infection. Lancet, 357, 280-281.

38. Landau A., Batisse D., Piketty C. et al. (2000) Lack of Interference Between

            Ribavirin and Nucleoside Analogues in HIV/HCV Co-Infected Individuals

Undergoing Concomitant Antiretroviral and Anti-HCV Combination Therapy.

Research Letters. AIDS, 14(12), 1857-1858.  

39. Martinez, E. Herrero (2001). Hepatitis B and Hepatitis C Co-Infection in Patients

with HIV.  Reviews in Medical Virology, 11, 253-270.

40. McHutchinson, J.G., Gordon, S.C., Schiff, E.R. et al. (1998) Interferon Alfa-2b Alone

or in Combination with Ribavirin as Initial Treatment for Chronic Hepatitis C. New England Journal of Medicine, 339, 1485-1492. 

41. McQuillan, Geraldine et al. (1999).  Prevalence of Hepatitis B Virus Infection in the

United States: The National Health and Nutrition Examination Surveys, 1976 Through 1994.  American Journal of Public Health, 89(1), 14.   

42. Melvin, D.C., Lee, J.K., Belsey, E. et al. (2000) The Impact of Co-Infection with

            Hepatitis C Virus and HIV in the Tolerability of Antiretroviral Therapy.

Correspondence. AIDS, 14(4), 463-465. 

43. Miller, L.G. & Hays, R.D. (2000).  Adherence to Combination Antiretroviral

            Therapy: Synthesis of the Literature and Clinical Implications.  The AIDS Reader, 

10(3), 177-185. 

44. National ADAP Monitoring Project.  Annual Report, 2002, 38.

45. National AIDS Treatment Advocacy Project (NATAP).  Hepatitis C and Hepatitis C-

            HIV Co-Infection Handbook, Version III.  Retrieved January 15, 2003, from 

http://www.natap.org/2002/pdf/hep5-21.pdf

46. National Conference of State Legislators (NCSL) (2003).  HIV/AIDS Drug

Treatment. Retrieved April 1, 2003, from http://www.ncsl.org/programs/health/hivdrugtr.htm

47. National Institutes of Health (NIH) (2002).  Management of Hepatitis C: Speaker

Abstracts. June 10-12, No. 1.  Retrieved January 15, 2003, from http://consensus.nih.gov/cons/116/116cdc_introl.htm

48. National Organization Responding to AIDS (NORA) (2002). Fiscal Year 2003

HIV/AIDS Appropriations Recommendations. Washington: AIDS Action. 

49. Patient Care Capsules.  Issue 2, September 16, 2002.  Retrieved February 20, 2003,

            from http://www.doh.state.fl.us/disease_ctrl/aids/news/pc.html

50.    Patlack, Margie (2003).  The Hepatitis B Story.  Beyond Discovery: The Path from

Research to Human Benefit.  Retrieved August 12, 2003, from http://www.beyonddiscovery.org/content/view.txt.asp?a=265

51. Perez, Olmeda M., Garcia-Samaniego, J. & Soriano V. Hepatitis C Viremia in HIV-

            HCV Co-Infected Patients Having Immune Restoration with Highly Active Anti-

Retroviral Therapy. AIDS, 14, 212. 

52. Piroth L., Grappin, M., Cuzin, L., Mouton, Y., Bouchard, O., Raffi, F. et al. (2000).

Hepatitis C Virus Co-Infection is a Negative Prognostic Factor for Clinical Evolution in Human Immunodeficiency Virus-Positive Patients. Journal of Viral Hepatitis, 7, 302-308.

53. Poynard, T., Marcellin P., Lee, S.S. et al. (1998). Randomized Trial of Interferon

Alfa-2b Plus Ribavirin for 48 weeks or for 24 Weeks Versus Interferon Alfa-2b

Plus Placebo for 48 Weeks for Treatment of Chronic Infection with Hepatitis C Virus. Lancet, 352, 1426-1432. 

54. Projinf.org (2001).  Drug Side Effects Chart.  Retrieved January 1, 2003, from

            http://www.projinf.org/fs/sideeffectschart.html 

55. Pratt, Chi Chi N., Undeagu, Denise, Paone, Rosalind, Carter, Marcelle C.

            Layton. (2002). Hepatitis C Screening and Management Practices: A Survey of

Drug Treatment and Syringe Exchange Programs in New York. American Journal of Public Health, 92(8), 1254-1256. 

56. Roberts, Rebecca, Rydman, Robert, Gorosh, Kathye, & Robert A. Weinstein

            (1999).  Actual Costs of HIV/AIDS Care.  Chicago, IL: Rush University and the

CORE Foundation.       

57. Rossi, S.J., Volberding, P.A., & Wright, T.L. (2002). Does Hepatitis C Virus

Infection Increase the Risk of HIV Disease Progression? Journal of the American Medical Association, 288(2), 241-243.

58. Rutschmann, O.T., Negro, F., Hirschel, B. et al. (1999). Impact of Treatment with

            Human Immunodeficiency Virus (HIV) Protease Inhibitors on Hepatitis C

Viremia in Patients Co-Infected with HIV. Journal of Infectious Disease, 177,

783-785.

59. Saag, Michael (2002).  UAB Announces Results of First HIV Patient Care Cost

            Analysis.  University of Alabama.  XIV International AIDS Conference. 

Barcelona, Spain.  July 3, 2002. 

60. Scharschmidt, B.F., Held, M.J., Hollander, H.H. et al. (1992) Hepatitis B in Patients

            with HIV Infection: Relationship to AIDS and Patient Survival. Annals of Internal

Medicine, 117, 837-838.

61. Schechter, M.T., Craib, K.J.P., Le, T.N. et al. (1989) Progression to AIDS and

            Predictors of AIDS in Seroprevalent and Seroincident Cohorts of Homosexual

            Men.  AIDS, 3, 347-353.

62. Smith, N., Yusuf, H., Averhoff, F. (1999).  Surveillance and Prevention of Hepatitis

B Virus Transmission. AJPH Editorials.  Retrieved November 1, 2002, from

http://www.apha.org/journal/editorials/edjan9.htm

63. Solomon, R.E., Van Raden, M., Kaslow, R.A. et al. (1990) Association of Hepatitis B

            Surface Antigen and Core Antibody with Acquisition and Manifestation of

Human Immunodeficiency Virus Type 1 (HIV-1) Infection. American Journal of

Public Health, 80, 1475-1478.

64. Southern State AIDS Directors Work Group (2003).  Southern States Manifesto. 

January 30, 2003.  

65. Stone, S.F., Lee, S., Keane, N., Price, P., French M.A. et al. (2002) Association of

            Increased Hepatitis C Virus (HCV)- Specific IgG and Soluble CD26 Dipeptidyl

            Peptidase IV Enzyme Activity with Hepotoxicity After Highly Active

Antiretroviral Therapy in Human Immunodeficiency Virus HCV Co-infected Patients. Journal of Infectious Disease, 186, 1498-502.

66. Sulkowski, M.S., Thomas, D.L.  Hepatitis C in the HIV Infected Patient.  Annals of

            Internal Medicine  (2002 in press).  

67. Vento, S., Garofano, T., Renzini, C. et al. (1998) Enhancement of Hepatitis C Virus

            Replication and Liver Damage in HIV Co-Infected Patients on Antiretroviral

Combination Therapy, AIDS, 12, 116-117. 

68. Virology-online.com (2003).  Hepatitis C Virus.  Retrieved August 12, 2003, from

http://virology-online.com/viruses/HepatitisC.htm

69. Walensky, Rochelle, Freedberg, Kenneth & David Paltiel (2002). AIDS Drug

            Asistance Programs: Highlighting Inequitites in Human immunodeficiency

Virus—Infection Health Care in the United States.  Clinical Infectious Diseases. 

35, 606-610.

70. Wong, John B. (1999).  Cost-Effectiveness of Treatments for Chronic Hepatitis C. 

            The American Journal of Medicine, 107 (6B), 74S-78S. 

71. World Health Organization (2000).  Hepatitis C.  WHO Information Fact Sheets. 

Retrieved August 12, 2003, from http://www.who.int/inf-fs/en/fact164.html

72. World Health Organization (2001).  Hepatitis C Assays: Operational Characteristics

(Phase I).  Blood Safety and Clinical Technology.  Retrieved August 12, 2003, from http--www.who.int-bct-Main_areas_of_work-BTS-HIV_Diagnostics-Evaluation_reports-Hepatatis-HCVRep1_Rev.pdf

73. World Health Organization (2002).  Serological Test Findings at Different Stages of

HBV Infection and in Convalescence.  Hepatitis B.  Retrieved August 12, 2003,

from http://www.who.int/emc-documents/hepatitis/docs/whocdscsrlyo20022/disease/serological_test_findings.html

74. Yawn, B.P., Wollan, P., Gassuola, L. et al. (2002).  Diagnosis and 10-Year Follow-

Up of a Community-Based Hepatitis C Cohort. Journal of Family Practice 51(2), 135–40.

75. Yokozaki, Takamatsu J., Nakano, I. et al. (2000). Immunologic Dynamics in

            Hemophiliac Patients Infected with Hepatitis C Virus and Human

Immunodeficiency Virus: Influence of Anti-Retroviral Therapy. Blood, 96, 4293-

4299.

76. Youle, Mike (2002).  Rising HCV Rates and Sexual Transmission.  Royal Free

Hospital, London, UK Excerpted from the 6^th Intl Congress on Drug Therapy in HIV in Glasgow, Nov 22-27

77. Zuckerman, A. J. Rx Options for Chronic Hepatitis B. BMJ1999, 319, 799-800 (25

            September). Retrieved January 26, 2003, from

http://archive.mail- list.com/hbv_research/msg00348.html

78. Zylberg, H., Nalpas, B., Pol, S. et al. (2000) Is There a Relationship Between

Hepatitis C Virus Infection and Anti-Retroviral Lipoatrophy? AIDS, 14, 2055-2065.