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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”

    

http://www.house.gov/reform/ns/web_resources/news_release_june_7.htm

 

                                                           

June 7, 2001                                                   

 

Congressman Christopher Shays to Hold June 14 Oversight Hearing

On “Hepatitis C: Screening in the VA Health Care System”   

 

                    (Washington, DC) -- Congressman Christopher Shays (R-CT), Chairman of the Subcommittee on National Security, Veterans Affairs, and International Relations, will hold an oversight hearing June 14 to assess efforts by the Department of Veterans Affairs (VA) to screen and test veterans for Hepatitis C (Hepatitis C Virus) infection.  The hearing was announced today by Congressman Dan Burton (R-IN), Chairman of the Committee on Government Reform.

        "Hepatitis C is a serious national health crisis with an estimated four million Americans infected, many of whom are veterans and many of whom are not even aware they are at-risk," said Chairman Shays.  "But after two years, the laudable promise of the VA initiative to screen and treat Hepatitis C Virus-infected veterans remains unfulfilled.  The decentralized VA health system seems incapable of carrying out the Hepatitis C Virus program aggressively or consistently."  

The Thursday, June 14, 2001 hearing will convene at 10:00 a.m. in Room 2247, Rayburn Building in Washington, D.C.  Witnesses will include representatives from the General Accounting Office (GAO), and the VA.   

With an estimated four million Americans infected, and 30,000 new infections occurring annually, veterans are five to six times more likely to carry the Hepatitis C virus than the general U.S. population.  Termed the "silent epidemic," the blood-borne disease of the liver was not officially recognized until 1989, and reliable tests to detect the Hepatitis C virus were not available until 1992.  It is believed many veterans of the Vietnam War, for example, may have received blood transfusions contaminated by Hepatitis C Virus.

Hepatitis C can lead to serious and permanent liver damage.  It is the leading cause of cirrhosis and liver cancer and accounts for 40% of all chronic liver disease, about 20% to 30% of all liver transplants, and more than 8,000 deaths annually.  In 1998, the number of persons needing liver transplants was twice the available number of organs.  According to the Congressional Research Service, annual deaths from chronic liver disease caused by Hepatitis C could triple in the next 20 to 30 years if effective therapies are not found.

Surveys were conducted in 1998 among patients at two VA Medical Centers (VAMCs) to determine how many were infected with Hepatitis C.  At the Washington DC VAMC, 20% of the veterans seeking care in the facility tested positive for HVC; and at the San Francisco VAMC, 18% were infected.

In January 1999, the VA announced a new policy on Hepatitis C, a "major initiative to respond to the Hepatitis C epidemic in a comprehensive and consistent manner across its nationwide health care system.”  VA's goal is to screen all veterans who have not been screened during routine clinic visits to VAMCs, and provide treatment when appropriate.  In FY2001, VA received $340 million to reach this goal; however, VA believes it will spend only $151 million of that amount on Hepatitis C Virus related care.  The VA has requested $171 million in FY2002 for the Hepatitis C Virus initiative. 

        "In each of  the two hearings we’ve held since 1999 on this subject," Shays said,  “VA officials said the program was improving, and that every facility would soon be screening every veteran.  In fact, barely twenty percent of veterans using VA health care have been reached by the Hepatitis C Virus initiative.  Hepatitis C Virus-infected veterans are walking out of VA clinics and hospitals every day, unaware they may be ill, unaware of options available to prolong their lives, unaware they may be infecting friends and family." 

The Subcommittee requested that the General Accounting Office (GAO) assess the reach and consistency of the Hepatitis C program by visiting a number of VA health care facilities.  GAO testimony at the hearing is expected to state several reasons why screening has been limited and inconsistent.  According to GAO, local VA managers have adopted restrictive Hepatitis C Virus program efforts because they were not aware funding was available to screen and test patients.  GAO found instances in which screening for Hepatitis C Virus risk factors was limited to certain clinics on certain days of the week.  In some cases, the decision to test for Hepatitis C Virus infection was not clearly stated as a matter of VA policy, but left to the judgment of each physician. 

“This is not a matter of dollars, but of determination,” Shays said.  “The VA has not been able to spend the money Congress provided for Hepatitis C Virus screening and treatment because the message got lost somewhere between headquarters and the local clinics that this was a priority.  This important public health initiative has to be implemented more aggressively and more consistently.”

The Subcommittee on National Security, Veterans Affairs, and International Relations has oversight of those departments and agencies of government managing programs and activities related to national security, including the VA.

 

 

 

Witness List

 

PANEL ONE

 

Ms. Cynthia Bascetta

Director, Health Care - Veterans' Health and Benefits Issues

General Accounting Office

 

accompanied by:

 

Mr. Paul Reynolds

Assistant Director - Veterans' Health Care Issues

General Accounting Office

 

PANEL TWO

 

Dr. Frances Murphy

Deputy Under Secretary for Health

Department of Veterans Affairs

 

accompanied by:

 

Dr. Lawrence Deyton

Chief Consultant for Public Health

Department of Veterans Affairs

 

Dr. Robert Lynch

Director

Veterans Integrated Service Network 16

Department of Veterans Affairs

 

Ms. Mary Dowling

Director

VA Medical Center, Northport, New York

Department of Veterans Affairs

 

Mr. James Cody

Director

VA Medical Center, Syracuse New York

Department of Veterans Affairs  

 

Statement from the American Legion

Statement of VATA

 

SUBCOMMITTEE ON NATIONAL SECURITY, VETERANS AFFAIRS,
AND INTERNATIONAL RELATIONS

Christopher Shays, Connecticut
Chairman
Room B-372 Rayburn Building
Washington, D.C.  20515
Tel: 202 225-2548
Fax: 202 225-2382

June 8, 2001

 MEMORANDUM

 To:      Members of the Subcommittee on National Security, Veterans Affairs, and
                        International Relations

 From:  Kristine K. McElroy, Professional Staff Member

 Subject:           Briefing memorandum for the hearing Hepatitis C: Screening in the VA Health                             Care System, scheduled for Thursday, June 14, 2001,at10:00a.m. in  room 2247
Rayburn House Office Building in Washington D.C.

  

PURPOSE OF THE HEARING:

The purpose of the hearing is to assess the Department of Veterans Affairs’ efforts to screen and test veterans for the Hepatitis C Virus (Hepatitis C Virus).

 

    

 

HEARING ISSUES:

 

1.         Why has screening and testing for the Hepatitis C Virus (Hepatitis C Virus) been limited and inconsistent?

 

2.         Why weren’t VA personnel made aware of the funding available for screening and testing veterans for the Hepatitis C Virus?

 

 

 

BACKGROUND

 

The Hepatitis C Virus (Hepatitis C Virus) represents a serious national health crisis with an estimated 4 million Americans infected, and 30,000 new infection occurring annually.  The disease is of great concern because of the possible long-term health consequences and the current lack of vaccine or curative therapy.  It is a blood-borne infectious disease of the liver.  Some persons exposed to the virus never develop identifiable symptoms, although a large percentage eventually experience liver disease.  The latency period between exposure and manifestation of symptoms can be as much as 30 years.   It is a disease that is seen in increasing numbers among high-risk groups and effects veterans at a rate five times higher than the general U.S. population.

 

This disease can lead to serious and permanent liver damage.  It is a leading cause of cirrhosis and liver cancer and accounts for 40% of all chronic liver disease, 20% to 30% of all liver transplants and more than 8,000 deaths annually.  However, a major barrier to transplant surgery is liver transplants are both costly and unavailable to many due to the insufficient supply of organs.  In 1998, the number of persons needing liver transplants was twice the number of available organs.  The cost of a liver transplant is at least $200,000 and approximately $25,000 annually thereafter for required medications.  According to the Congressional Research Service (CRS), annual deaths from chronic liver disease caused by Hepatitis C could triple in the next 10 to 20 years if effective therapies are not found.  (Web Resources 1)

 

The virus was first recognized in the 1970s when the majority of transfusion-associated infections were found to be unrelated to Hepatitis A and B, the two Hepatitis viruses known at the time.  Research resulted in sequencing of the genome in 1989, and the term Hepatitis C was subsequently applied to this infection. 

 

In 1992, reliable and accurate tests to detect the Hepatitis C Virus antibody became available and have been used to screen donated blood.  Hepatitis C Virus blood screening technology has continued to improve, contributing to a decline in new Hepatitis C Virus cases.

 

There is no effective vaccine to prevent, or immune globulin to treat Hepatitis C infection.  Hepatitis C is spread primarily by contact with blood and blood products.  Prior to 1990, and the advent of any Hepatitis C Virus testing, many individuals contracted Hepatitis C through tainted blood or blood-derived products.  Contraction of the disease through the blood supply has been reduced due to both a change in the donor population, and the use of screening tests for donated blood products.

 

Risk factors for Hepatitis C Virus include receipt of blood or blood products prior to 1992, injection drug use, nasal cocaine, needle-stick accidents, and possibly tattooing.  Persons with multiple sexual partners are at higher risk of becoming infected.  The source of some Hepatitis C Virus infection is unknown. 

 

Treatment for Hepatitis C is expensive and limited.  It consists primarily of administration of interferon alpha, with or without the addition of ribavirin over the course of six to 12 months.  Interferon alfa was approved by the Food and Drug Administration (FDA) for treatment of chronic Hepatitis C and the National Institutes of Health (NIH) Consensus Conference recommended initial therapy for 12 months.  The treatment benefits some patients and appears to interfere with the natural progression of the disease, although “evidence is lacking that it will translate into improvements in the quality of life or reduction in the risk of hepatic failure.” (Web Resources 1)  

 

The VA and Hepatitis C

 

Hepatitis C is of particular interest to the Department of Veterans Affairs (VA) because of the high incidence of the disease among veterans.  Studies of Hepatitis C Virus prevalence among veterans/patients within the VA health care system have “confirmed seropositive rates of 8%-10%, or nearly five times higher than that (1.8%) of the general U. S. population,” according to the American Liver Foundation.

 

In 1991, the VA began tracking the number of persons examined in VA facilities who tested positive for Hepatitis C Virus.  While the availability of an antibody test was limited in 1991, about 6,600 persons in the VA system were identified with Hepatitis C Virus.  This number increased to 18,800 in 1994, to about 21,400 in 1996.  The VA states it is not clear whether the initial increase was due to an increase in the number of persons with Hepatitis C Virus or the trend was a reflection of improved testing technology.

 

According to the VA, a 1998 six-week survey at the VA Medical Center in Washington, D.C. found a prevalence of 20% positive antibody in veterans seeking care in the facility.  A similar survey in the San Francisco VA Medical Center found 18% of their patients to be infected.  In addition, the VA's transplant program data reveals that 52% of all liver transplants in VA facilities showed Hepatitis C infection.  In 1998, the VA reported that a 10-month electronic survey of 125 VA Medical Centers identified 14,958 patients who tested positive for Hepatitis C.  (Attachment 1, p.1)

 

During 1999 and 2000, VA screened 20% of all system users for Hepatitis C Virus.  In the first half of FY 1999, VA reported 198,000 patients were tested for Hepatitis C Virus.  Of that number, close to 40,000 VA patients tested positive.  The VA reported 478,000 veterans were screened and 77,886 veterans were treated for Hepatitis C- related conditions in fiscal year 2000 at a cost of $100 million.  In FY 2000, there were 39,426 unique hepatitis C positive patients. According to VA, 333,782 blood tests for hepatitis C were given, and 107,509 tests were Hepatitis C Virus positive.  It is important to note tests may be given more than once to the same patient in order to verify results.  (Attachment 2, p. 5)

 

On January 27, 1999 the VA, “announced major initiatives to respond to the Hepatitis C virus (Hepatitis C Virus) epidemic in a comprehensive and consistent manner across its (VA’s) nationwide health-care system.”  The VA’s 5-point strategic initiative to respond to Hepatitis C Virus included: patient education; health care provider education; epidemiologic assessment; treatment; and research.  The plan in part called for “Two new ‘Hepatitis C centers of excellence,’ to be located at VA medical centers in Miami and San Francisco to coordinate treatment and research efforts, as well as develop education for patients and their families, health-care providers, and counselors who will advise patients prior to and following testing.” (Attachment 3, p. 1)

 

To follow up on its initiative, the Veterans Health Administration (VHA) issued directive 2000-019 on July 19, 2000, mandating the installation and use of software on clinical reminders to support the Hepatitis C reporting process.  (Attachment 4, p. 1)

 

On February 27, 2001, the VHA issued directive 2001-009 entitled “National Hepatitis C Program.”  The purpose of the directive was to compile all VHA policies and programs on Hepatitis C and to outline specific requirements for implementing the program.  The directive also states “each VA medical center Director must designate a Hepatitis C Lead Clinician to be the point of contact for all clinical Hepatitis C communication and reporting between the facility, the Hepatitis C Program office and other program offices.”  (Attachment 5, p. 1-3)

 

The VA’s Emerging Pathogens Index (EPI) registry is used to track the incidence of Hepatitis C Virus in the VA system. VA claims it is now able to track veterans who tested positive for Hepatitis C Virus in each of the 22 Veterans Integrated Service Networks (VISNs) on a quarterly and annual basis. (Attachment 2, p. 7)  However, VA admits, “the true prevalence of Hepatitis C Virus in veterans who utilize medical care services is unknown.”  (Attachment 2, p. 12)  VA attributes this to “deficiencies in data (due to both gaps in our [VA] knowledge about the epidemiology of hepatitis C in the VA population as well as limitation in available data collection systems).”  (Attachment 2, p. 11)

 

Screening and Testing Procedures

 

VA has posted on the Internet guidelines for both public and private health care providers to follow in handling patients, including guidelines for counseling, risk assessment, screening, and treatment.  (Web Resources 2)

 

Screening for risk factors involves asking a variety of questions.  Current VHA policy enables veterans to be tested for Hepatitis C Virus infection if they desire to be tested, or if they have one or more of the following risk factors: 1.Vietnam-era veterans (as defined by dates of service or in the age range of 40-55 years), 2. received a blood transfusion before 1992, 3. past or present intravenous drug use, 4. unequivocal blood exposure of skin or mucous membrane, 5. history of multiple sexual partners (defined as more than 10 lifetime partners), 6. history of hemodialysis, 7. tattoo or repeated body piercing, 8. history of intranasal cocaine use, 9. unexplained liver disease, 10. unexplained/abnormal ALT, 11. intemperate or immoderate use of alcohol (defined as more than 50 g of alcohol per day for ten or more years.  (Attachment 6, p. 1)

 

Should a patient have one or more risk factors, VA recommends providers test the patient for the Hepatitis C Virus antibody.  This initial test is called the Enzyme immunoassays (EIA).  Since this test has a high rate of false positives, VA guidelines recommend all patients who test positive initially be given a confirmatory test called a recombinant immunoblot assay (RIBA).  This test confirms a patient is antibody positive.  If no risk factors are present in the initial screening, testing is not recommended unless at a patient’s request. (Attachment 7)

 

Funding for Hepatitis C

 

VA received $195 million for screening and treating patients with Hepatitis C Virus for FY 2000.  On June 28, 2000, Dr. Thomas Garthwaite, the Under Secretary for Health, granted an additional $20 million to be distributed to the 22 Veterans Integrated Service Networks (VISNs) in order to “ recognize the geographic differences in the prevalence of hepatitis C and to provide incentive to VA health care facilities to aggressively outreach, screen, diagnose and treat hepatitis C.”  The letter stated:

 

“In order to recognize the geographic differences in the prevalence of Hepatitis C and to provide incentive to VA health care facilities to aggressively outreach, screen, diagnose, and treat Hepatitis C, I have made the decision to provide $20 million from the National Reserve Fund to the Veterans Integrated Service Networks (VISNs) based on each network’s Hepatitis C costs during the first two quarters of FY 2000.  It is important to note that funds allocated under the Veterans Equitable Resource Allocation (VERA) will continue to be expended by each VISN to support the costs of veterans with Hepatitis C. This $ 20 million simply supplements those funds.”  (Attachment 8)

    

 

In recognition of the high cost of treating Hepatitis C Virus infection, VA decided Hepatitis C patients on drug therapy would be funded at the complex care level, starting in FY 2001.  This new classification will help medical centers offset the costs of treating Hepatitis C patients on drug therapy.

 

VA’s goal is to screen all veterans who have not been screened during routine clinic visits to VA medical centers, and provide treatment when it is appropriate.  In fiscal year 2001, VA received $340 million to accomplish this goal, however VA does not believe it will spend the full $340 million, but instead will spend closer to $151 million.  Since VA does not expect to spend $189 million of its FY 2001 budget allocations on Hepatitis C Virus costs, it has lowered the request for fiscal year 2002 budget to $171 million to treat veterans who have Hepatitis C Virus.  (Attachment 9 p. 1)

 

Based on testimony at previous Subcommittee hearings, and persistent reports the VA Hepatitis C Virus initiative was not being aggressively or consistently implemented across the regional VISN structure, the Subcommittee requested that the General Accounting Office assess program implementation at several VA health facilities.

 

 

 

 

 

 

DISCUSSION OF HEARING ISSUES

 

1.         Why has screening and testing for Hepatitis C been limited and inconsistent?

 

Many are concerned that over two full years VA has only managed to screen and test 20% of all health system users, despite setting far higher goals and projections.  Since veterans tend to have a higher rate of infection than the general public, the wide availability of screening and testing is seen as the central element of the VA initiative.  Until Hepatitis C Virus-positive veterans are diagnosed, they may continue to engage in behaviors which can speed the progression of the disease or spread it to others.  Undiagnosed veterans are not being provided access to vaccinations (against other forms of hepatitis) and viral drug therapies which can be vital to sustaining their health.

 

GAO found several reasons why screening has been limited and inconsistent.  According to GAO, local managers have adopted restrictive Hepatitis C screening policies because they were not aware specific funding was available to screen and test patients.  GAO found instances where Hepatitis C Virus screenings for risk factors were limited to a few clinics, on certain days of the week.  In other instances, GAO found patient access to screening and testing was viewed as solely a matter of the individual physician’s judgment, not a matter of VA policy.  In some cases providers were concerned about the costs of laboratory tests.  As a result, they screened in primary care clinics on a rotating basis, one clinic per day.

 

While visiting the Northport VA Medical Center (VAMC), in Long Island, NY, GAO found the director was concerned about pharmacy costs relating to Hepatitis C Virus treatment and the increased patient load the facility might incur because of the closure of the Health Maintenance Organizations (HMO) in the area.  The Northport VAMC had limited Hepatitis C Virus screening in one clinic, and no screening in specialty care clinics prior to FY 2001, but has since expanded Hepatitis C Virus screening.

 

GAO’s visit to the Syracuse, New York VAMC found similar concerns about expenses.  Syracuse providers expressed concerns about the cost of lab tests for Hepatitis C Virus.  As a result of these concerns, Syracuse patients were screened for Hepatitis C Virus in primary clinics on a rotating basis, one clinic per day.

 

A second reason for the low rate of screening and testing veterans for Hepatitis C Virus is attributed to weaknesses in facilities’ risk assessment procedures.  GAO is concerned the screening process may discourage veterans from being candid about risky behaviors.  Veterans are asked a series of questions relating to their sexual practices and drug and alcohol history which some may find invasive and embarrassing.  If a patient admits to a risk factor, the provider will order testing.  However, if a patient is not forthcoming about risk factors, providers will not test the patient unless the patient requests to be tested.  GAO also found instances of screening for risk factors being conducted near public areas where a veteran’s answers might be overheard.   Too-quick, routine administration of the Hepatitis C Virus questionnaire amidst other screening procedures may also result in veterans not understanding the risk factors.

 

A third factor why many veterans remain undiagnosed, according to GAO, is weakness in  testing procedures.  GAO found instances of blood tests never ordered, or never completed, for veterans with risk factors. 

 

In order to improve screening performance, GAO is expected to recommend VA set performance targets to convince providers Hepatitis C Virus screening and testing is a high priority, and that VA provide definitive implementation guidelines regarding who should be screened and how screenings should be conducted.

 

Hearing witnesses from the VA will be asked what incentives are in place to encourage providers to increase the number of patients screened for Hepatitis C Virus risk factors.  VA is anticipated to testify the installation of the clinical reminder software will encourage providers to screen patients for Hepatitis C Virus risk factors.  However, while VA mandated clinical reminder software be installed by July 30, 2000, GAO found many instances where facilities were slow to turn on the software.

 

 

2.         Why weren’t VA personnel made aware of the funding available for screening and testing veterans for Hepatitis C?

 

The cost of testing and treating patients for Hepatitis C Virus is high.  The Washington Post (1/27/99) quoted Dr. Kenneth Kizer, then the VA’s top doctor, as saying the new testing and treatment program will be a controversial “big ticket item” costing $12,000 to $15,000 per year per patient, or $250 million to $300 million in FY 1999 alone, and as much as $500 million in FY2000.  “There is a huge cost that is involved,” Kizer was quoted as saying.  “We acknowledge it, but I don’t know what choice we have.”

(Attachment 3, p. 3)

 

Some believe providers are reluctant to test patients for fear the resources and funding for treatment will not be available.  These concerns were raised by Mr. James J. Farsetta, Director of Veterans Integrated Service Network (VISN) Region III in a Subcommittee hearing on June 9, 1999 entitled,  “VA Outreach to Veterans at Risk for Hepatitis C Infection.”  Mr. Farsetta stated his treating clinicians for Hepatitis C were “troubled not by today, but by the uncertainty about tomorrow, that when you engage in screening and make a diagnosis and treatment, then you are really ethically committed to provide that treatment.  And do we want to engage a population that we are not quite certain that we are going to have the wherewithal to treat 6 months from today when we know the treatment is 48 weeks.  So it is really problematic.”   (Web Resource 3)

 

The Congress responded to concerns about the cost of testing and treating VA patients for Hepatitis C Virus by appropriating $195 million in FY 2000 and $340 million for Hepatitis C Virus expenses in FY 2001.  For FY 2000, the Veterans Health Administration (VHA) included Hepatitis C funds in the general medical care resource distributions process, without distinguishing how much was specifically allocated for screening and treatment for Hepatitis C Virus.  As a result of this, GAO found network budget officers, medical managers and clinical staff were not aware VA had allocated $21 million in funding for Hepatitis C Virus screening and testing for FY 2000.  Those VA employees who thought funds were available did not know how much funding was available.  (Attachment 9, p. 3-4)

 

It was not until June 2000 when VA released $20 million from the National Reserve Fund to the Veterans Integrated Service Networks (VISNs) based on each network’s Hepatitis C costs during the first two quarters of FY 2000, that managers and providers became aware of funding for Hepatitis C Virus costs.  It is for this reason some believe funding for Hepatitis C Virus expenses should be earmarked and separate from the general medical care resource distribution process.

 

VA spent $14 million of the $21 million budgeted for Hepatitis C Virus screening and testing in FY 2000.  VA believes the shortfall may be attributable to the use of “untested assumptions” in budget estimates regarding the number of veterans who would need to be screened for Hepatitis C.  Or, the number screened may be underreported due to inadequate data systems.  (Attachment 9 p. 3)  However, these reasons do not explain why VA has still not been able to test more than 20% of patients using VA health facilities.

 

There are also concerns as to why VA did not make it a point to notify networks of the funds available to screen and test patients for Hepatitis C Virus, since VA was aware network directors and providers were concerned about costs.  VA has acknowledged concerns for Hepatitis C Virus costs may effect the screening of patients.  This was noted in VA’s White Paper to Inform Congress on Decisions for Hepatitis C Funding in which VA stated, “we cannot be certain that local choices regarding allocation of available resources amongst a number of critical patient care areas have not created potential disincentives to the diagnosis and treatment of hepatitis C infection.”  (Attachment 2, p. 3)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ATTACHMENTS

 

 

1.      VA Information Letter, “Hepatitis C: Standards for Provider Evaluation & Testing   

      (6/11/98).

 

2.      Department of Veterans Affairs, “White Paper to Inform Congress on Decision for Hepatitis C Funding” 2001.

 

3.      VA Press Release, “VA launches Broad Attack on Hepatitis C Epidemic,” and Washington Post article, “VA Offers New Hepatitis C Drugs” (1/27/99).

 

4.      VHA Directive 2000-019, “Installation of Clinical Reminders 1.5 Software” (7/19/00).

 

5.      VHA Directive 2001-009, “National Hepatitis C Program” (2/27/01).

 

6.      “Screening Veterans for Hepatitis C Virus Infection” and “Hepatitis C Virus Risk Factor Assessment (Sample).”

 

7.      “Hepatitis C Virus Antibody Screening Flow Chart for the Veteran Population”

 

8.      Letter to Chairman Shays from Dr. Garthwaite on additional funding for selected VISNs to supplement approved budgets for the Hepatitis C testing and treatment programs (6/28/00).

 

9.      GAO testimony before the Subcommittee on VA, HUD, and Independent Agencies, Committee on Appropriations.  “Veterans’ Health Care: Observations on VA’s Assessment of Hepatitis C Budgeting and Funding” GAO-01-661T

 

 

 

WEB RESOURCES

 

1.      “Hepatitis C: A Challenge To Public Health.”

 

2.       VA’s Centers of Excellence in  Hepatitis C Research and Development website .

 

3.      http://www.gpo.gov/congress/house/house07.html  Subcommittee on National Security, Veterans Affairs and International Relations hearing transcript. “VA Outreach to Veterans At Risk For Hepatitis C Infection” June 9, 1999. Serial No. 106-30.