Covid-19’s Impact on HIV, HCV, and Substance Use-Disorder
“New Year, new you!” Or so the saying goes.
Every effort moving forward must evaluate past and current circumstances in order to be successful. A year ago, states and local jurisdictions were moving through planning processes for updates to the Viral Hepatitis National Strategic Plan and working toward finalizing their Ending the HIV Epidemic plans. Many advocates were cautiously excited to move forward with innovative and integrated planning. Even the CDC’s February, 2020 EHE funding announcement allowed entities to use up to 10% of their EHE funds for integrated viral Hepatitis and STI activities. Few involved in state-level work were listening intently for news of the novel pneumonia we would come to call a pandemic merely 2 months later.
As of this writing, the data collection site Worldometers is reporting almost 20 million confirmed COVID-19 cases and 345,000 COVID-19 related deaths…in the United States alone. A slew of federal agencies introduced extraordinary flexibilities across the health care landscape; from cross-state licensing recognition to expanded telehealth allowances for most providers to flexibilities in programmatic spending and supplemental RWHAP in the CARES Act passed in March. In many ways, these changes ushered in an “uncontrolled”—yet welcome—“test atmosphere” for policies and programmatic flexibilities advocates have historically championed.
Ryan White clients across the country were able to recertify via phone or video conference for the first time. A Kaiser Family Foundation report evaluating Ryan White providers in the age of COVID-19 found an increase in providers offering telehealth services (22%-99%) and 89% are offering multiple month ARV fills (more than half attributing to COVID related policy changes).
However, not all changes have been positive. Despite the CDC’s guidance encouraging programs to offer HIV self-tests in lieu of offering on-site or mobile rapid testing, many Ryan White providers and STI clinics have had to shutter programs or reduce testing availability and disrupt PrEP services. Telehealth access, while wonderful in overcoming transportation barriers to care, does not address the need for actual testing. A study published in the Journal of Primary Care and Community Health found community hospitals and primary providers saw a significant drop in HCV testing from January 24 through August 17, 2020. Another study found instituting HIV testing as a standard of care and elimination protocol for COVID-19 screenings in hospitals saw an increase in new and acute HIV diagnoses for certain hospitals in the Chicago area. While it’s almost certain this is indicative of a certain transference of where clients are receiving services, we don’t yet know how many of these community members would have sought these testing services outside of a hospital or emergency setting.
COVID-19 has also clearly highlighted the impact of social determinants of health and health disparities of which HIV and HCV advocates have long been aware. One of the most unfortunate examples is lack of care and lack of policy and program attention to the incarcerated population. A report from the Hepatitis Education Project and National Hepatitis Corrections Network found incarcerated populations have a 12-35% Hepatitis C prevalence, with less than 1% of prisoners having received treatment. Similarly, COVID-19 has ravaged prison populations in the United States and, as of yet, FDA recommendations for vaccine distribution do not include prisoners as a “priority population”.
At the intersection of COVID-19 impacts on HIV and HCV policy and programs is the looming issue of humanity – the very thing that increases our risks of contracting a deadly respiratory illness: a need to connect. KFF reported significant increases in depression, anxiety, and substance and alcohol use due to job loss, income insecurity, and other stresses related to COVID-19 and COIVD-19 related restrictions. As Tuyishime Claire Gasamagera so aptly put, The COVID-19 Pandemic Is a Perfect Storm for People With Substance Use Disorders and Addiction. While traditional recovery programs and medication-assisted treatment have had similar disruptions to services, reduced outreach, and a need to shift to virtual platforms as HIV and HCV programs, some local health departments are using their syringe services programs to overcome these barriers by distributing larger quantities of supplies and delivering supplies to clients. Still, some officials have already reported an increase in overdose related deaths during the pandemic.
The incoming Biden administration has high hopes to tackle some of the most pressing immediate and long-standing health issues facing the nation. While the Biden transition team has already named a COVID-19 task force, promised to re-establish the Office of National AIDS Policy, and named Rochelle Walensky as his pick to lead the CDC, there’s also a number of executive actions the incoming administration could take to re-shape the health care landscape and work to fill these gaps.
We need to focus on these “wins” and unintended consequences in order to ensure our federal representation and local implementation are equally as mindful of the gaps created by well-meaning policies.
Hindsight and 2020 and all that.
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Disclaimer: HIV-HCV Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HIV-HCV Blogs might be graphic due to the nature of the issues being addressed in it.
Advocacy in 2021…and Beyond
The last four years seem to have passed in bit of blur. The events in public health and the related healthcare advocacy world have been driven by the fall-out from dysfunctional political chaos. The growing political divisions that prevented compromise, and thereby any progress on resolving overarching problems in our national life, have forced the Community Access National Network (like most national nonprofit organizations) to re-evaluate its approach to patient advocacy. In fact, democracy itself seems to look rather beaten up, even perhaps slightly damaged.
The advocacy priority landscape has changed in the last three decades that CANN has been a part of it, not to mention the almost four decades that I have spent in this field, personally. The mission of access to care and treatment in the HIV and viral hepatitis space for all regardless of their socio-economic capabilities clearly remain, but the world that started with no tools and no policies has expanded into a veritable constellation of potential policy changes, treatment improvements, and technological tools with which to work. The possibilities for improvement are a far cry from what was available in 1985.
Clearly, some advocacy priorities and tactics have evolved over time. HIV/AIDS is mainstreamed and routine even, close to “normal” if measured by expected life expectancy. Daily advocacy commitments for many individuals have been superseded by the ability to live a normal life. Remaining holes in the HIV/AIDS “safety net” are often local issues, which require local advocacy actions to correct.
As recent polling has shown us, crystal balls do not guarantee accurate predictions, but I think some areas bear watching. They include:
The Biden-Harris Administration shows signs of serious policy work. Most are likely to be issues we would support, such as improvements in the Affordable Care Act to cover a bigger piece of the currently uninsured U.S. population. It will be quite the contrast from what we have witnessed since January 2017.
Issues around changes in the 340B drug discount program, which might impact access to care for the HIV-positive (and other) demographics.
Changes in various state Medicaid eligibility levels, which can be a major factor in access to care and treatment for the uninsured.
Ongoing work will continue to be needed on issues like HIV-criminalization, health-related stigma, and the myriad phobias and bigotries circulating about drug additions, nontraditional sexual identity, racial and ethnic communities.
Importation safety for prescription drugs not now part of our FDA oversight and supply chain distribution safety oversights.
The costs of prescription drugs, most importantly to our HIV populations, in terms of insuring that out-of-pocket costs, deductibles, tier pricing and similar marketing ploys do not result in exceeding the ability of the patient to pay – regardless of their income level – thus leaving the medication on the pharmacy shelf.
All of the above points (and many others) will be in play in the background (and likely foreground) circulation as an incoming President-Elect Biden, Vice-President-Elect Harris, and a new Congress take office in January 2021. All in the context of damage from COVID-19 to the body politic and renewed human rights focus especially in the context of further defining the rights of racial, ethnic, cultural, religious, geographic, gender, sexual identity, religious desires for inclusion, diversity, economic equality. Our hope is we can collectively achieve a better state of fairness, equality and liberty. In short – the promise of “the American Dream”, our founders tried their best to articulate.
The ongoing need for civil discourse, actually policy changes and improvement is likely to be quite strong, which might actually predict substantive policy changes, political compromise, and a desire to rectify past errors that can no longer be ignored.
The goals of advocacy and education will be as important as ever in educating our political leaders at levels from local towns all the up through our national leadership in Washington, where there will be many new faces and new staffs. Firstly, to ensure that the folks we endeavor to speak for do not lose the hard-won gains of the last three decades, but also that their voices are heard in the debates and discussions that we hope will result in productive changes in policies at all levels of government.
As with every organization, change is inevitable. CANN has already started to make some changes in preparation for January 20th, when our country can collectively turn the page. As evidenced by the launch of our new microsite as the repository of information for our acclaimed HIV/HCV Co-Infection Watch, we will be building upon the good work done in this area over the last five years under the stewardship of our policy consultant, Marcus J. Hopkins. And Marcus, thank you for all of your hard work!
In anticipation of the issues surrounding the 340B drug discount program resurfacing in the next Congress, CANN welcomes its new policy consultant, Jen Laws. Jen’s community level knowledge about 340B’s impact on Ryan White providers and engaging patients on strategic communications and data analysis will play a central role in our work on HIV/HCV co-infection moving forward. And Jen, welcome aboard!
As we have since 1996, CANN hopes to continue as a constructive voice in the multiple process we’ll face in the next four years. Advocacy and education activities in person, by organizations, in multiple coalitions will be as important as they have been for the last three decades – perhaps even MORE important – as the cheeseboard of political life now has more movable pieces than ever and specific policy changes affect many different stakeholders.
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Disclaimer: HIV-HCV Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HIV-HCV Blogs might be graphic due to the nature of the issues being addressed in it.