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HCV in HIV-Coinfection: ADAP, Access, Treatment Costs
Reported by Jules Levin
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In Clinical Infectious Diseases (Aug 2002; 35: 606-610) Walensky, Freedberg and Paltiel discuss the shortcomings and problems associated with our ADAPs (AIDS Drug Assistance Programs). As part of this article the authors discuss HCV and the implications of care and treatment as it relates to ADAP and finding a way to make treatment accessible to coinfected patients without medicaid or private insurance. The full text of the article is available right here for download in pdf.
Emerging infections: hepatitis C. A new public health crisis threatens to send the (health care for HIV) system into further disarray. The story of the emergence of hepatitis C virus infection in many ways mirrors the HIV story, albeit 15 years later. First, there is a large and growing hepatitis C prevalence. Hepatitis C is already the most common chronic bloodborne infection in the United States, affecting at least 2.7 million people and accounting for 25,000 deaths annually. Second, a substantial number of people with hepatitis C infection remain unaware they are infected and continue to transmit the virus to others. Third, hepatitis C infection has a long, clinically silent period followed by considerable morbidity, mortality, and cost. Unlike HIV infection, however, liver transplantation further increases the cost of care for advanced hepatitis C infection. Hepatitis C infection is now the leading reason for liver transplantation nationally, accounting for 30% of all transplantation procedures (1000 patients per year).
In 1997, the estimated total costs of medical treatment and lost work in the United States attributable to hepatitis C infection, including costs attributable to transplantation, primary liver cancer, and chronic liver disease, exceeded $5 billion. Finally, new and effective hepatitis C therapy carries substantial costs that cannot possibly be borne by uninsured patients. The hepatitis C nucleoside analogue, ribavirin, for example, has an average wholesale cost of $1100 per month, which is 3 times greater than the cost of the most expensive HIV nucleoside analogue. Treatment with IFN- also costs $500$1000 per month. Thus, combination medical therapy for hepatitis C infection carries a higher annual cost than does HIV therapy, even if the transplantation costs of >$200,000 per patient are ignored.
As treatment for hepatitis C infection increasingly becomes standard, a need will emerge either for ADAP-like programs for hepatitis C infection to be instituted or for existing ADAPs to expand coverage for hepatitis C therapy. The challenge for infectious diseases physicians and public policy makers is to tackle the current inequalities, limitations, and budget constraints of ADAPs before they are further exacerbated by the hepatitis C epidemic.
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