Over at Time to Deliver, a group blog by HIV activists and advocates attending the International AIDS Conference in Toronto, Brad Biggers (who also blogs at AIDS Combat Zone) writes:
HCV is on many people’s minds here at the 2006 IAC for two important reasons. First of all, because HCV and HIV are spread in many of the same ways, a large number of people are co-infected with the two viruses at once. Second, because HCV causes liver failure, it magnifies the hepatoxicity of antiretroviral drugs.
I had the opportunity to attend a session on HCV yesterday, which covered several HCV-related studies. These studies ranged from HCV prevalence in Zanzibar to HCV risk factors among incarcerated Canadian youths. The information covered was all fascinating, but it was a comment from a member of the audience that really caught my attention. The young man was involved with the Committee of 10,000, an HCV advocacy organization from California. I regret not having a voice recorder, but his question as I remember it was this:
We know that the people at risk for HCV are the same as those at risk for HIV. We also know that HCV kills almost as many people as HIV, and infects more than three times as many. With those things in mind, why are we not using our thousands of HIV testing sites to also offer screening and testing for HCV?
What do you think?
I responded in the comment section, and I'm cross-posting here -- after the jump.
Good question, complicated answers -- I'll speak from a United States perspective; I'd be very interested in hearing views and experiences from other countries.
Here's several angles:
1. The majority of funding for HIV testing comes from the U.S.
Centers for Disease Control & Prevention. The CDC allows community-based organizations to offer hepatitis C
testing using CDC HIV prevention funds; however, my impression is that very few
community groups offer hepatitis C testing through their CDC-funded programs.
2. The CDC also has a Division of Viral Hepatitis,
responsible for hepatitis C activities. The current internal restructuring at the CDC will move this division
into the same center as the CDC's HIV division, and will hopefully result in greater
collaboration and integration. However,
the Division of Viral Hepatitis receives very little funding -- only $16.7
million for hepatitis C in fiscal year 2006 (down from a peak of $19.4 million
in FY 2003). Advocates have been
requesting (so far unsuccessfully) that Congress increase the division's budget
to $50 million.
3. The CDC's Division of Viral Hepatitis funds hepatitis C
coordinators in nearly all 50 states, plus a few cities and the Indian Health
Service. States only get enough funding
to cover the cost of the coordinator's salary, so most coordinators have little
or no budget for programs and services such as hepatitis C testing. By necessity, the coordinators and the CDC
have worked hard to promote integrating hepatitis C into other programs and
settings -- particularly STD clinics, HIV programs, jails and prisons,
substance abuse treatment, AIDS service organizations. The CDC has funded a number of successful
demonstration projects and training initiatives on integrating viral hepatitis
into existing services and structures -- including a pilot study in California
found that offering hepatitis C testing to injection drug users alongside HIV
testing actually increased the number of people getting an HIV test (showing
that adding hepatitis C testing creates an incentive for more HIV
testing). Unfortunately, there's just no
money to replicate and sustain this work.
4. SAMHSA (the Substance Abuse & Mental Health Services
Administration, part of the federal Department of Health & Human Services)
also funds hepatitis C testing in substance abuse treatment programs. However, most of this funding is bundled with
HIV testing, and it's not clear to me how much directly supports hepatitis C
testing, and how many tests are administered annually through these funds.
5. The main overlap in risk factors between hepatitis C
& HIV comes from injection drug use, and this is where it makes the most
sense to offer testing for both viruses at the same time & place. A 2001 survey of U.S. substance abuse treatment
facilities found that nearly all methadone programs offered some hepatitis C
testing, and 2/3rds of drug-free treatment programs offered testing. However, not all of these programs offered
testing to all of their patients, and only 60% of patients offered testing
provided a blood sample -- meaning that roughly 30% of substance abuse
treatment patients actually got tested. A 2002 survey of syringe exchange
programs found that 43% provided hepatitis C testing; that number has likely
risen in the past four years. Among
surveys of syringe exchange participants in New York City conducted by my organization, the overwhelming majority of injection drug users
indicate that they've been tested for hepatitis C, though needle exchange
programs in New York and elsewhere reach only a fraction of injectors. Jails and prisons are also (unfortunately)
logical places to test for hepatitis C; various surveys find prevalence rates
ranging from 15% to 40% among incarcerated persons. Yet most correctional facilities have not
implemented hepatitis C testing -- and have resisted taking on responsibility
for medical care and treatment.
6. In general, sexual
transmission of hepatitis C is considered rare, especially between monogamous
heterosexual partners. Several reports
from Europe, with some anecdotal support in the U.S., describe clusters of
hepatitis C transmission among HIV+ men who have sex with men. Some U.S. surveys of people attending
STD clinics have found a higher rate of hepatitis C (say, 4-10%) among gay men
as well as sex workers. However, many of
these cases may have resulted from injection drug use rather than sexual
transmission, and much of the epidemiological data on hepatitis C (particularly
in the U.S.)
is likely confounded by underreporting of injection drug use due to stigma --
hence overstating the role of sexual transmission. Indeed, a recent report of a large cohort of
HIV-negative gay men in Canada found no cases of new hepatitis C infections. For these reasons, hepatitis C is not typically classified as a sexually
transmitted disease; sexual transmission can and does happen, but much more
rarely and less efficiently than with "classic" sexually transmitted
infections.
7. The U.S.
Preventive Services Task Force, an independent panel with a great deal of
influence on medical guidelines and reimbursement, reviewed evidence on
hepatitis C testing in 2004 and recommended against screening for the
"general population". They
"found insufficient evidence to recommend for or against routine screening
for HCV infection in adults at high risk for infection." However, other professional associations
(infectious disease and liver specialists) and health officials -- along with
community groups and advocates -- repudiated that assessment and recommend
testing for adults at high risk. 'High
risk' is defined in various ways - people who have ever injected drugs are
always considered at high risk, but people with a potential sexual exposure
(e.g. categories such as multiple sex partners, men who have sex with men or
sex workers) are usually not considered at high risk and hepatitis C testing is
not recommended (with some flexibility around sex partners of people with
hepatitis C, where testing is typically framed around relieving anxiety than
any actual/substantial risk of transmission).
8. U.S. guidelines on care and management of people living with HIV recommend that all
PWHIV (regardless of mode of transmission) be tested for hepatitis C. Of course, guidelines don't always get
translated into clinical practice. I've heard that (according to chart reviews
conducted under the auspices of the state health department), over 90% of PWHIV
in medical care in New York have been tested for hepatitis C. But
I've also heard that hepatitis C testing is unevenly/inconsistently implemented
in HIV care in many parts of the U.S. Also, there are no clear guidelines for
repeat testing of people initially testing negative for hepatitis C who remain
at risk -- though virtually all HIV+ injection drug users likely acquired
hepatitis C before HIV.
9. The shift to oral
HIV testing, and more recently rapid HIV testing, poses challenges for adding
hepatitis C testing. Ideally, you could
go to a testing site and provide one sample (whether it's a blood draw or oral
swab) that would be tested for both viruses, and receive the results at the
same time. Right now, hepatitis C
testing requires a blood sample, and results take 1-2 weeks -- while in many
places, you can take an HIV test with an oral swab and get the results in 20
minutes. OraSure Technologies (makers of
the oral, rapid HIV test) is developing a rapid oral hepatitis C test, which
may reach the market in 2007.
10. Diagnosing
hepatitis C infection poses a distinct set of challenges in comparison to
HIV. For both viruses, the initial test
looks for virus-specific antibodies. With HIV testing, the presence of antibodies clearly and invariably
indicates infection (setting aside recent concerns about false positives among
people with 'preliminary positive' results on the rapid oral HIV test). With hepatitis C testing, the presence of
antibodies only indicates that a person has been infected at some point -- 25%
of people infected with hepatitis C clear the virus within a few months after exposure. Therefore, people receiving
positive hepatitis C antibody results need a second test (qualitative viral
load) to determine whether they're still (chronically) infected with hepatitis
C. These hepatitis C quantitative viral
load tests are only available from doctors; even health department-run HIV/STD
testing sites offering hepatitis C testing don't offer anything beyond the antibody test. Moreover, people receiving positive results
on hepatitis C tests (whether the initial antibody test, or the viral load test
to diagnose current/chronic infection) often receive confusing or inadequate
information about hepatitis C -- many report uncertainty about whether they'd
been diagnosed with hepatitis C vs. hepatitis A and B, whether it's a past
(resolved) or active infection, and the implications to their health and
whether they need medical care or treatment.
In short -- it's a complicated issue, but ripe for
advocacy: we can push for more federal
funding, and advocate on the local level for more integration in HIV testing
and prevention programs. And on all
levels, place testing in a broader framework of hepatitis C education, support,
medical care, and treatment.
Daniel Raymond
Harm Reduction Coalition
Very well written and reasoned response. You close with: In short -- it's a complicated issue, but ripe for advocacy: we can push for more federal funding, and advocate on the local level for more integration in HIV testing and prevention programs. And on all levels, place testing in a broader framework of hepatitis C education, support, medical care, and treatment.
I'd like to challenge everyone reading this blog to contact their congressman (or woman) and ask them to co-sponsor either H.R. 1290 or S. 521 (Hepatitis C Epidemic Control and Prevention Act). If they are already co-sponsors then ask if they would encourage their fellow members of Congress to join with them. More co-sponsors means we can move this legislation forward. Begin locally advocating for services to HCV+ individuals. Screening is an important first step, but it is still only just that, a first step. Surprisingly, most of the folks I see at our exchange assume that they are HCV+ when in fact only about 20% are antibody +. Could it be the fact that we've had NEX here in rural Oregon (Douglas County) for the past 6 years. Funded mostly through HIV prevention. Unfortunately, because we do a very good job of prevention we have seen our funding cut by 25,000 this year and another 20,000 next year. That is what happens when HCV prevention gets integrated into HIV prevention and there isn't enough money. Our county is committed to continuing HCV screening although we are left to fend for ourselves when it comes to maintaining our NEX. Anyone interested can read more about our present funding woes by downloading the past few issues of our newsletter at our website www.hivroseburg.org Click on the newsletter tab and you can view them online or download them.
Thanks to you Daniel and the HRC for the tremendous work you do.
Peace,
Mike
Posted by: Mike Bunyard | September 26, 2006 at 02:45 PM
Hi, My name Is Ricky and I,ve had Hep C for about six years now. I started on interfuron and rebital when i first found out about it. But i have'nt taken anything for about 5 years now. The doctor actually told me that my Hep C was inactive about four years ago, but I had my blood tested recently and the doctor told me It's really out of control now, very high. I think he said my numbers were in the millions. I guess thats because I had relapsed and started using drugs again. I Really need some help now, Because the job and Insurance I had covered the Hep c meds the last time now I'm out of work, I have no Insurance, and I'm having a really hard time holding any job because Of my addiction. Oh yeah i also have some type of sores that I believe contain parasites, But the doctors tell me I'm crazy, and halusinating. I know what i have even when I'm not getting high I can notice the parasites under my skin. They actually surface when i shoot heroin and coke. I mean they come right out of my skin, but they are practically impossible to catch or hold on to, I really dig the hell out of my skin too. I have scabs all over my body mostly face arms and legs, belly. I can't reach my back but I'm sure there there also. I really need some help with all of these problems. So, If anyone could help me out and point me in the right direction I would GREATLY appreciate it!!!! You can contact me at crzydawgs@aol.com or crzydawgs@yahoo.com. Please Help me!!!!!
Ricky"D"
Posted by: Ricky "D" | October 07, 2006 at 05:32 AM