Out of Sight, Out of Out of Sight, Out of Time:Time:

Injection Drug Users,Injection Drug Users,Hepatitis C, and HIV Hepatitis C, and HIV

PolicyPolicyDaniel Raymond

Hepatitis C Policy AnalystHarm Reduction Coalition

raymond@harmreduction.orgwww.hepcproject.org

Hepatitis C Harm Reduction Project

Hepatitis C Shatters Hepatitis C Shatters Our Our Paradigms for Paradigms for

IDUs & HIVIDUs & HIV

Outreach?Outreach?PreventioPrevention?n?EducationEducation??TreatmentTreatment??

Hepatitis C Harm Reduction Project

HIV

Hepatitis C

Hepatitis C Harm Reduction Project

Looking at HIV andLooking at HIV andHepatitis C together…Hepatitis C together…

HIV

Hepatitis C

Hepatitis C Harm Reduction Project

……Brings IDUs into Brings IDUs into Focus…Focus…

IDUIDUss

Hepatitis C Harm Reduction Project

……and Brings other Systems and Brings other Systems

into Viewinto View

IDUIDUss

Needle

Exchang

e

Jails and PrisonsHousing

and

Shelter

Primary Care

Mental Health Care

Substance Use Treatment

Hepatitis C Harm Reduction Project

Envisioning IDU-centricEnvisioning IDU-centricPolicy ModelsPolicy Models

IDUsIDUs, ,

HIV, HIV, & &

Hep Hep CC

Needle Needle ExchangExchang

ee

Jails and Jails and PrisonsPrisons

Housing Housing and and

ShelterShelter

Primary Primary CareCare

Mental Mental Health Health CareCare

SubstancSubstance Use e Use

TreatmeTreatmentnt

Hepatitis Hepatitis CC

and IDUsand IDUsHIV:HIV:

PolicyPolicy

PreventiPreventionon

TreatmeTreatmentnt

Hepatitis C Harm Reduction Project

Hepatitis Hepatitis CC

and IDUsand IDUsHIV:HIV:

PolicyPolicy

PreventiPreventionon

TreatmeTreatmentnt

Hepatitis C Harm Reduction Project

Hepatitis C Harm Reduction Project

IDUs are the IDUs are the Blind SpotBlind Spotin HIV Policy & HCV in HIV Policy & HCV

AdvocacyAdvocacy

We don’t “see” IDUs in most discussions about Prevention, Access to Care & Treatment, funding for Support Services, Housing, Research, Global AIDS….

IDUs: Caught in the Political Crosshairs of the War on

Drugs

How can drug users organize How can drug users organize when drug use itself is when drug use itself is criminalized?criminalized?

Who will advocate for drug Who will advocate for drug users and against stigma and users and against stigma and moralizing?moralizing?

What are the political costs of What are the political costs of supporting an IDU health supporting an IDU health agenda?agenda?Hepatitis C Harm Reduction

Project

Hepatitis Hepatitis CC

and IDUsand IDUsHIV:HIV:

PolicyPolicy

PreventiPreventionon

TreatmeTreatmentnt

Hepatitis C Harm Reduction Project

HCV Transmission:HCV Transmission: It’s All About the It’s All About the BloodBlood

Hepatitis C Harm Reduction Project

Social Networks MatterSocial Networks Matter

So Why So Why

Aren’t We Aren’t We

Working Working

withwith and and

throughthrough

Social Social

Networks in Networks in

Prevention Prevention

for IDUs?for IDUs?

Hepatitis C Harm Reduction Project

Hepatitis Hepatitis CC

and IDUsand IDUsHIV:HIV:

PolicyPolicy

PreventiPreventionon

TreatmeTreatmentnt

Hepatitis C Harm Reduction Project

Hepatitis C Harm Reduction Project

Ryan White Planning Ryan White Planning Councils have largely not Councils have largely not assessed, planned for, or assessed, planned for, or allocated funds for the allocated funds for the special needs of active special needs of active substance users, including substance users, including for substance abuse for substance abuse treatment nor have they treatment nor have they addressed particular addressed particular barriers in receipt of HIV barriers in receipt of HIV care.care.

Finkelstein et al., appendix to the Finkelstein et al., appendix to the IOM report: Public Financing and IOM report: Public Financing and Delivery of HIV/AIDS Care: Securing Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White (2004)the Legacy of Ryan White (2004)

HIV+ IDUs fare HIV+ IDUs fare worse across a worse across a range of range of metrics:metrics:• Delayed receipt of Delayed receipt of HAARTHAART

• Poorer adherencePoorer adherence

• Less likelihood of Less likelihood of virologic, immunologic virologic, immunologic response to HAARTresponse to HAART

• Greater incidence of Greater incidence of AIDS-defining illnessesAIDS-defining illnesses

• Poorer survival due to Poorer survival due to increased AIDS- and increased AIDS- and non-AIDS-related non-AIDS-related mortalitymortality

Taking a Closer Look atTaking a Closer Look atHIV Care and Treatment for IDUsHIV Care and Treatment for IDUs

A Microeconomic Perspective on A Microeconomic Perspective on Hepatitis C TreatmentHepatitis C Treatment

Hepatitis C Harm Reduction Project

DemaDemandnd

SuppSupplyly• Low reimbursement for Low reimbursement for

providers (vs. procedures)providers (vs. procedures)

• Need for intensive patient Need for intensive patient management & support management & support (e.g. physician extender)(e.g. physician extender)

• Lack of on-site psychiatric Lack of on-site psychiatric carecare

• Little training in Little training in addictions medicine, HIVaddictions medicine, HIV

• Physicians may ration Physicians may ration expensive HCV treatment expensive HCV treatment to “ideal patients”to “ideal patients”

• Mixed messages about Mixed messages about need for treatmentneed for treatment

• Competing priorities – drug Competing priorities – drug use, housing, other health use, housing, other health issuesissues

• Distrust of medical systemDistrust of medical system

• Fear of biopsyFear of biopsy

• Concerns about treatment Concerns about treatment side effects – particularly side effects – particularly depressiondepression

• Limited knowledge from Limited knowledge from peer experiences with HCV peer experiences with HCV care and treatmentcare and treatment

Hepatitis C Harm Reduction Project

Bringing It All into Bringing It All into Focus:Focus:

Who Are the PlayersWho Are the Players??

HIV Policy:

• Federal

• State

• Local

Harm Reduction:

• Needle Exchange

• Drug Policy

• Researchers

HCV Advocacy:

• NHCAC

• HCAP

• Local/State

Planning Councils and Advisory Boards

CDC, HRSA, NIH, SAMHSA

Communities

Legislators

Substance Abuse Tx?

Poster from the Poster from the Hepatitis C Harm Hepatitis C Harm Reduction Project.Reduction Project.

raymond@harmredcutioraymond@harmredcution.orgn.orgwww.hepcproject.orgwww.hepcproject.org

Envisioning Envisioning IDU-centricIDU-centricPolicy Policy Models…Models…