Addressing the Barriers: National Academies of Medicine (NAM) Hepatitis Elimination Feasibility Report

Transcription

1 Addressing the Barriers: National Academies of Medicine (NAM) Hepatitis Elimination Feasibility Report Mariah Johnson Senior Manager Hepatitis, Policy & Legislative Affairs Erin M. Bascom, MPH Senior Associate Prevention

2 NASTAD MISSION & VISION NASTAD s mission is to end the intersecting epidemics of HIV, viral hepatitis, and related conditions by strengthening domestic and global governmental public health through advocacy, capacity building, and social justice. NASTAD s vision is a world free of HIV and viral hepatitis. READY TO END THE EPIDEMICS #NASTAD25

3 NASTAD Domestic Programs Health Care Access Prevention and Surveillance Health Equity Hepatitis Health Systems Integration Policy & Legislative Affairs Global Program READY TO END THE EPIDEMICS #NASTAD25

4 NASTAD & HCV Three Major Components: Technical Assistance Public Policy Coalition Engagement Health Department Capacity and Expertise Support Technical Assistance Access to Prevention Services HCV Screening SSPs Mental Health Substance Use Treatment READY TO END THE EPIDEMICS #NASTAD25

5 NASTAD & HCV Health Equity Approach Native Americans African Americans Hispanics and Latinos Asian and Pacific Islanders Policy & Legislative Affairs Congress Federal Agencies Administration States Health of People Who Use Drugs Prevention Services Treatment Services READY TO END THE EPIDEMICS #NASTAD25

6 HEPATITIS OVERVIEW Hepatitis Overview 5.3 million people are living with hepatitis B (HBV) and/or hepatitis C (HCV) in the U.S. Up to 75% of chronic hepatitis cases are undiagnosed Baby boomers have the highest rates of HCV-related morbidity and mortality Increases in acute HCV infection among young persons who use drugs who began by using prescription opioids and transitioned to injection 2015 outbreak among people who inject drugs in Scott County, Indiana: 95%+ of HIV cases co-infected with HCV READY TO END THE EPIDEMICS #NASTAD25

7 HEPATITIS OVERVIEW Holmberg S, et al, NEJM, 2013 READY TO END THE EPIDEMICS #NASTAD25

8 HEPATITIS OVERVIEW FY2016 Prevention, Surveillance, Linkage to Care Division of Viral Hepatitis: $34 million 52 jurisdictions funded, VHPCs ~$90,000* avg. 7 Enhanced Surveillance Sites ~4-500,000* avg. No service provision, including treatment Health Resources and Services Administration: $XX Insert information when available Treatment Department of Veterans Affairs: $1.5 billion Persons co-infected with HIV and hepatitis may receive treatment through ADAPs No treatment program or funding for mono-infected people living with hepatitis READY TO END THE EPIDEMICS #NASTAD25

9 HEPATITIS OVERVIEW FY2017 OUTLOOK President s Request Division of Viral Hepatitis: $39 million Surveillance Integration HCV Epidemic Among Young People at Risk Mother-to-Child Transmission Implementation of USPSTF Recommendations Ryan White SPNS: $9 million HIV/HCV co-infection screening Linkage to Care Department of Veterans Affairs: $1.5 billion Congress Bipartisan Budget Act 2015 established budget caps Budget resolution possible, unlikely Appropriations process underway READY TO END THE EPIDEMICS #NASTAD25

10 HCV Incidence in 2014 and the Healthy People 2020 National Goal Source: National Notifiable Diseases Surveillance System (NNDSS) READY TO END THE EPIDEMICS #NASTAD25

11 Changes in Rates of New Hepatitis C Virus Cases Reported by State, United States, Washington, D.C. (no data) Rate decreased Rate unchanged Rate increased Did not report data READY TO END THE EPIDEMICS #NASTAD25

12 HCV-Related Deaths, READY TO END THE EPIDEMICS #NASTAD25

13 Status Quo Insufficient READY TO END THE EPIDEMICS #NASTAD25

14 Contact Information Mariah Johnson (202) Erin M. Bascom, MPH (202) READY TO END THE EPIDEMICS #NASTAD25

15 Eliminating the Public Health Problem of Hepatitis B and C in the United States Randy Mayer Iowa Department of Public Health National Academy Committee Member

16 Background on The National Academy of Medicine Established by Congress in 1970 as the Institute of Medicine of the National Academies Part of the National Academies of Sciences (1863) and Engineering (1964) Now called National Academies of Sciences, Engineering, and Medicine 2

17 National Academy of Medicine Private, non-profit society of distinguished scholars engaged in research Serve as advisers to the federal government and act independently on critical issues in health, medicine, and related policy Goal of spurring public action 3

18 A National Strategy for the Elimination of Hepatitis B and C Sponsors: Division of Viral Hepatitis HHS Office of Minority Health 4

19 Statement of Task PHASE I The IOM will determine whether HBV and HCV elimination goals for the United States are feasible; and Identify possible critical success factors. Tools: Literature review and two in-person meetings. Time frame: Approximately 60 days from first meeting to report. 5

20 Overall Key Findings of Committee The elimination of hepatitis B and C poses challenges, both in defining what qualifies as elimination and in monitoring progress toward those goals. It is feasible in the relatively short term to control hepatitis B and C meaning to reduce their incidence and prevalence (and their sequelae). Eliminating the public health problem of hepatitis B and C meaning that the diseases may remain but transmission will stop and the most undesirable manifestations will be prevented completely is also feasible, but considerable barriers face any elimination program. 6

21 Overall Consensus Conclusion After analyzing the problems of hepatitis B and hepatitis C in the United States, the committee concluded that control is feasible in the relatively short term. Eliminating the public health problems of hepatitis B and C will take more time and will require considerable public will, resources, and attention to the barriers discussed in the report. 7

22 HBV Framework Goal 1: End transmission Perinatal Children Adults Goal 2: Reduce morbidity and mortality Slow progression to cirrhosis Reduce deaths 8

23 HCV Framework Goal 1: End transmission Focus on PWID Goal 2: Eliminate chronic infection Focus on treatment and adherence Goal 3: Reduce morbidity and mortality Slow progression to cirrhosis Reduce deaths 9

24 Clinical barriers to HBV elimination No curative treatment for hepatitis B. Treatment is not recommended for all people living with chronic HBV infection and often not for those with high viral load. Risk of developing liver cancer is still present for those with liver damage even if undergoing HBV treatment. Suppressed HBV can be reactivated my medications or immune suppression. 10

25 Policy and other barriers to HBV elimination HBV disease surveillance is inconsistent across jurisdictions and under-funded. Impacts accuracy of prevalence and incidence estimates. Enhanced surveillance could support identification of highrisk contacts for testing and vaccination. Consistent disease surveillance in all jurisdictions will be needed to evaluate elimination efforts. Tracking vaccination across jurisdictions is not currently possible through Immunization Registries. Chronic HBV infection carries a social stigma for some populations that could undermine elimination efforts. 11

26 Policy and other barriers to HBV elimination (2) Increased screening of chronic HBV cases is needed to reduce morbidity and mortality Current screening recommendations are poorly understood and implemented Screening should be accompanied by a method to enroll and retain patients in care. Only limited funding is available for expanded adult HBV immunization programs. Research on reactivation, better vaccines, and a curative treatments would facilitate HBV elimination. 12

27 Clinical barriers to HCV elimination No preventative vaccine is available. HCV is highly infectious in blood, making prevention of HCV among people who inject drugs more complex. Acute and chronic infections are often asymptomatic Curing HCV after development of fibrosis and cirrhosis does not eliminate the risk of hepatocellular carcinoma. 13

28 Policy and Other Barriers to Hepatitis C Elimination Surveillance for HCV infection is sporadic and underfunded in the US, which limits our ability to know true prevalence and incidence and to evaluate People who inject drugs drive most transmission in US, but are less likely to be tested or included in surveillance. Limited access to comprehensive prevention services; role of treatment as prevention untested Half of all chronically infected people are estimated to be undiagnosed. Many insurers and three-quarters of states Medicaid programs have responded to the cost of DAAs by restricting access. Only about one in ten people with chronic hepatitis C receives curative treatment. Stigma can undermine any elimination effort 14

29 Further Barriers to Hepatitis C Elimination Even at the current prices, these drugs are cost-effective. The benefits of treatment outweigh the costs. Eliminating Hepatitis C would require near universal access to treatment, something that appears unfeasible given the current pricing, clinical workforce, and policy environment. Though HCV is more than twice as common as HIV and causes more deaths, it is less of a public priority, far fewer resources are allocated to its prevention, testing, treatment, and research. Almost a third of the United States chronic hepatitis C cases are found in prisons, but managing the infection is not usually within the capacity of a prison health system. 15

30 What is Next? Phase II: Consensus Report Elimination and control goals and a plan of action to achieve the goals Lay out a National Strategy Make recommendations to address barriers Assign stakeholders and their responsibilities Three meetings will be held: the first is an open meeting on June 8-9, 2016, in Washington, DC, focusing on testing and access to care Final report to be issued in

31 Some of the questions that will need to be addressed in Phase II What is the time frame for control and elimination of HBV and HCV? What specific programs, services, and policies will be needed to address the barriers? What additional research would support elimination efforts? Who are the stakeholders for each goal/strategy? 17

32 Brian L. Strom, M.D., M.P.H Chancellor Rutgers Biomedical & Health Sciences Rutgers University, The State University of New Jersey Jon Kim Andrus, M.D. Executive Vice President and Director Vaccine Advocacy and Education Sabin Vaccine Institute Andrew Aronsohn, M.D. Assistant Professor of Medicine Gastroenterology University of Chicago Daniel Church, M.P.H. Epidemiologist and Viral Hepatitis Prevention Coordinator Massachusetts Department of Public Health Seymour Cohen, Ph.D. Instructor Emeritus Marine Biological Laboratory Alison Evans, Sc. D. Associate Professor Dornsife School of Public Health Drexel University Paul Kuehnert, DNP, RN Assistant Vice President, Program Robert Wood Johnson Foundation Vincent Lo Re III, M.D., M.S.C.E. Assistant Professor of Medicine and Epidemiology Perelman School of Medicine, University of Pennsylvania Kathleen Maurer, M.D., M.P.H., M.B.A. Director, Health and Addiction Services Connecticut Department of Correction Randy Mayer, M.S., M.P.H. Interim Director, Division of Behavioral Health Iowa Department of Public Health Shruti Mehta, Ph.D., M.P.H. Professor of Epidemiology Bloomberg School of Public Health, Johns Hopkins University Stuart C. Ray, M.D. Professor of Medicine Center for Viral Hepatitis Research, Johns Hopkins University Arthur Reingold, M.D. Edward Penhoet Distinguished Professor Global Health and Infectious Diseases School of Public Health, University of California, Berkley Samuel So, M.B. Lui Hac Minh Professor School of Medicine, Stanford University Neeraj Sood, Ph. D. Associate Professor and Vice Dean for Research Sol Price School of Public Policy University of Southern California Grace Wang, M.D. Family Physician International Community Health Services Lucy Wilson, M.D., Sc.M. Chief, Center for Surveillance, Infection Prevention, and Outbreak Response Maryland Department of Health and Mental Hygiene 18

33 Discussion Questions What do you need to address hepatitis B and C better in your jurisdiction? Do you have programs or projects to suggest as models or know of evidence that we could use? Did the committee miss barriers or opportunities in the report? 19