1. Wisconsin D.O.C. Approach to Hepatitis C Treatment Edward Wall Secretary Jim Greer Bureau Director Health Services Wisconsin Department of Corrections

2. USA TODAY, March 2014 Should prisoners get expensive hepatitis C drugs? Michael Ollove, Pew/Stateline Staff Writer

3. The Issue At Hand The new treatment regimens for Hepatitis are tantamount to a cure for the disease The new treatment regimens present minimal side effects and are very well tolerated The cost of the new treatment per inmate is $84000-$160,000. Available financial resources result in the prioritization of patients for treatment

4. The Wisconsin Approach Try to mirror the treatment practices applied to other prison populations and the community ▫University of Wisconsin ▫Federal Bureau of Prisons ▫American Association for the Study of Liver Diseases (AASLD) ▫Infectious Diseases Society of America (IDSA)

5. The Wisconsin Approach Identify the patients with advanced disease ▫These patients have a higher risk of complications from Hepatitis C if not treated  Cirrhosis  Liver cancer ▫Patients are selected based on:  Degree of liver fibrosis (Metavir F3 or F4)  Other complicating factors: liver transplant, hepatitis induced kidney disease or vasculitis  Evidence of liver failure

6. The Wisconsin Approach Our screening will lead to a possible referral to the University of Wisconsin Hepatology experts. UW Hepatology will help determine who ultimately needs the treatment now. All patients will be treated with the new medications (≈ $1000 per day). Those who do not need the treatment now will be monitored closely using the same screening criteria and referred for treatment when indicated.

7. Percentage of Patients with Hep C

8. Some Wisconsin Data Prior to July 2014 ▫Patients with genotype 2 (because of their typically good response to treatment) and those with lesser degrees of fibrosis received treatment if they could tolerate the side effects ▫Treatment consisted of combinations of Pegylated Interferon, Ribavirin and Telaprevir depending on their genotype ▫Averaged 100 treatments per year ▫Significant drop out rate because of side effects

9. Previous Cost of Treatment

10. Estimates Going Forward Wisconsin DOC population is around 22,000 inmates 16 % estimated to have Hepatitis C ≈ 3520 inmates Estimated number with advanced (Metavir F3) disease ≈ 1056 (30%) Cost if all with advanced disease are treated…

11. $92-173 Million Dollars

12. Since Money Doesn’t Grow on Trees.. On average over the past few years we treated 100 patients per year. Estimate to treat about 30 per year (those with advanced fibrosis) using the new treatments. Estimated cost of $3-4 million per year using the new treatments. The current budget did not account for this rise in pharmacy costs.

13. Questions Going Forward Will the cost of the treatments increase before competition lowers them? ▫When will costs go down? Will the courts determine the standard of care and treatment going forward? ▫Will they mandate everyone receives treatment with the new drugs? How will we find the resources to address the above questions?

14. Thank You