Perspective from Payers

2nd International Hepatitis Cure & Eradication

Meeting Nov 12, 2015

Bonnie Henry MD, MPH, FRCPC Deputy Provincial Heath Officer,

Ministry of Health, BC Associate Professor, SPPH, UBC

Mel Krajden MD, FRCPC

Acting Medical Director, Provincial Laboratory, Medical Head, Hepatitis

BC Centre for Disease Control Professor, Path & Lab Med, UBC

• How to test/screen those affected?

• Who/when to treat? • Cost-effectiveness! • Would TasP work? • Treatment prioritization to

avert health system costs? • Provider edu/capacity?

Questions Facing Policy Makers

As of October 12, 2015: 1,501,079 individuals

tested for anti-HCV since 1992

78,468 anti-HCV +ve

includes 8,837 seroconverters 4,505 within 24m

HCV testing in British Columbia highly centralized

BC Hepatitis Testers Cohort

All medical visits

All hospitalizations

All prescribed drugs

Some risk data

Cancer treatments

All death data

• De-identified health information for 1.5 million British Columbians tested for HCV, HBV and HIV

• Most lab tests/results & all: medical visits, hospitalizations, prescriptions, cancer outcomes, and mortality outcomes

• 25-years of information • Cost of services • Health outcomes by different

groups & adjust for confounders

Lab tests

1 yr lagging: 1,028,227 HCV tested people • 64,876 (6.3%) were HCV positive

Overall mortality • HCV negative: 6.4% (61,623/963,351) • HCV positive: 16.3% (10,572/64,876)

Mortality & health costs result from both acquisition risks and viral sequelae!

Analysis of BC- HTC (1992-2012)

Q5 (most deprived)

Q5 (most deprived)

Q5 (most deprived)

Q4 Q4

Q4

Q3 Q3

Q3

Q2 Q2

Q2

Q1 (most privileged)

Q1 (most privileged) Q1 (most

privileged)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

HCV +ve SERO HCV -ve

Material Deprivation Quintile

Q5 (most deprived)

Q5 (most deprived)

Q5 (most deprived)

Q4

Q4

Q4

Q3

Q3

Q3

Q2

Q2

Q2

Q1 (most privileged)

Q1 (most privileged)

Q1 (most privileged)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

HCV +ve SERO HCV -ve

Social Deprivation Quintile

2011 census

Globally HCV is a disease of vulnerable populations Solutions require a Syndemics Approach!

Policy and programs need to reflect the social and contextual factors that foster disease in certain populations

Current treatment-based rhetoric detracts from creating solutions that address the real needs of vulnerable populations!

Treatment Curability

Prevention

Cost-Effectiveness Analyses

Treatment is cost-effective! • Highly aggregated populations • “Treatment focused” • Markov models • Re-infection is not addressed • HIV/HCV co-infection is not addressed • Resource utilization/cost data is unreliable • HrQol data is of poor quality • Focus on liver dis. > F2+

• To have a population impact many people need to be treated with effective Rx

• Davis et al. Gastroenterology 2010

• High treatment costs beg for an opportunity cost discussion!

• Treatment rhetoric overshadows a proper dialogue on the prevention needs of vulnerable populations!

Treatment Cost-Effectiveness ≠ Population Impact

As for HIV: Patent rejection

Mass generic production in non-

TRIPS countries (non-trade-related aspects

of intellectual property rights) Health tourism Buyers clubs

van de Ven et al. Hepatology 2015

Developed world • Boomers basically

don’t transmit – Rx reduces M&M

• For PWID – comprehensive harm reduction (NEP, OST, ETOH) is also imp. to decreasing M&M

• TasP? • Stigmatized

Developing world • Globally most

infections result from unsafe injection practices

• PWID are important – overlay of greater poverty - stigmatized

• Design/deploy non reusable needles/syringes?

Why has the Prevention as Prevention (PasP) Dialogue been so Difficult?

Injection Use and Reuse by Wealth: Pakistan Demographic and Health Survey 2006-07

0102030405060708090

100

Poorest Poorer Middle Richer Richest

Per

cent

age

Wealth index

Injection use Injection with new syringe

Janjua NZ et. al. 2014 doi: 10.1016/j.jiph.2014.04.001.

Vulnerable populations access poorer quality care! Greatest risk of unsafe injection practices!

When infected have limited Rx access!

Social Determinants of Health

• Life expectancy ranges form 34 yrs in Sierra Leone (pre-Ebola) to 81.9 yrs in Japan (Marmot 2005; The WHO Health Report 2004)

• There is a 20 yr gap in life expectancy between the most and least advantaged Americans

(Murray et al. 1998)

• Inequities in health between and within countries are avoidable – policies that harm human health need to identified and where possible changed!

Marmot & Allan, Am J Public Health 2014

Goal: Disease elimination and a real population level health impact – a health equity lens & a

balanced prevention, care & treatment approach is needed!

Treatment Curability

Prevention

Prevention cheaper than cure?

Cost of single HCV treatment = ~200,000 single non-reusable needle/syringes

Farrer et al. Advocacy for Health Equity: A Synthesis Review Milbank Quarterly 2015

• Dominant school of thought influencing the culture of a particular period in time

• Contemporary economic approach favours privatization, deregulation, economic liberalization, private public partnerships (PPPs), with the general prioritization of economic over all other spheres of policymaking

• “Taking personal responsibility” • Terms: “market fundamentalism,” “neoclassical

economics,” or “neoliberalism”

Current Zeitgeist

• Results in countries competing to cut spending - hesitant to invest in improving the Social Determinants of Health lest they lose investment and jobs to other countries

• Limits the ability of individual countries to protect the health and well-being of their populations

• Specific human rights are relevant to improving the SDH • right to health, children’s rights, the right to food, economic and

social rights, the right to social protection • the right to health of marginalized individuals and

populations

Neoliberalism

Health impacts • HIV, HCV, HBV • STDs/STIs • Bacterial

infections • Tuberculosis • Overdoses

Societal impacts • Economic costs • Health care • Law enforcement • Lost productivity • Crime • Lost potential

1. Kinds of evidence needed to advocate for health equity - transfer of this knowledge to policy?

2. Who advocates for health equity – targets? 3. Messages? 4. Arguments tailored to different political

standpoints? 5. Understanding barriers/enablers of effective

advocacy? 6. Applying practices and activities that increase

advocacy effectiveness

Health Equity Advocacy Dimensions

Farrer et al. Advocacy for Health Equity: A Synthesis Review Milbank Quarterly 2015

Eliminate HCV burden & impact global M&M 1) Well-designed programs

• Address prevention, screening, engagement into care, treatment and follow up

• Education and training • Treatment standardization, simplified

delivery – primary care services

Conclusions

Ford et al. Int J Drug Policy 2015; Suthar et al PLoS 2015

2) Widespread stakeholder involvement, civil society, donors, and policymakers to generate the political will to:

• Improve treatment and diagnostic affordability and access

• Convert to non-reusable needles/syringes as global standard

• Not undermine the harm reduction PasP gains!

Conclusions

Ford et al. Int J Drug Policy 2015; Suthar et al PLoS 2015

3) Mobilize domestic & international funding to implement comprehensive programing:

• Integrate HCV with other programs e.g., HIV for financial, infrastructure and health workforce efficiencies – consistent with the need for a syndemic approach

• Apply a health equity lens to challenge the contemporary zeitgeist by tackling decriminalization of drugs, stigma and SDH

Conclusions

Ford et al. Int J Drug Policy 2015; Suthar et al PLoS 2015