1. Out of Sight, Out of Time: Injection Drug Users, Hepatitis C, and HIV Policy Daniel Raymond Hepatitis C Policy Analyst Harm Reduction Coalition raymond@harmreduction.org www.hepcproject.org Hepatitis C Harm Reduction Project

2. Hepatitis C Shatters Our Paradigms for IDUs & HIV Outreach?Prevention?Education?Treatment? Hepatitis C Harm Reduction Project

3. HIV Hepatitis C Hepatitis C Harm Reduction Project Looking at HIV and Hepatitis C together…

4. HIV Hepatitis C Hepatitis C Harm Reduction Project …Brings IDUs into Focus… IDUs

5. Hepatitis C Harm Reduction Project …and Brings other Systems into View IDUs Needle Exchange Jails and Prisons Housing and Shelter Primary Care Mental Health Care Substance Use Treatment

6. Hepatitis C Harm Reduction Project Envisioning IDU-centric Policy Models IDUs, HIV, & Hep C Needle Exchange Jails and Prisons Housing and Shelter Primary Care Mental Health Care Substance Use Treatment

7. Hepatitis C and IDUs HIV:PolicyPreventionTreatment Hepatitis C Harm Reduction Project

8. Hepatitis C and IDUs HIV:PolicyPreventionTreatment Hepatitis C Harm Reduction Project

9. IDUs are the Blind Spot in HIV Policy & HCV Advocacy We don’t “see” IDUs in most discussions about Prevention, Access to Care & Treatment, funding for Support Services, Housing, Research, Global AIDS….

10. IDUs: Caught in the Political Crosshairs of the War on Drugs How can drug users organize when drug use itself is criminalized? Who will advocate for drug users and against stigma and moralizing? What are the political costs of supporting an IDU health agenda? Hepatitis C Harm Reduction Project

11. Hepatitis C and IDUs HIV:PolicyPreventionTreatment Hepatitis C Harm Reduction Project

12. HCV Transmission: It’s All About the Blood Hepatitis C Harm Reduction Project

13. Social Networks Matter So Why Aren’t We Working with and through Social Networks in Prevention for IDUs? Hepatitis C Harm Reduction Project

14. Hepatitis C and IDUs HIV:PolicyPreventionTreatment Hepatitis C Harm Reduction Project

15. Ryan White Planning Councils have largely not assessed, planned for, or allocated funds for the special needs of active substance users, including for substance abuse treatment nor have they addressed particular barriers in receipt of HIV care. Finkelstein et al., appendix to the IOM report: Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White (2004) HIV+ IDUs fare worse across a range of metrics: Delayed receipt of HAART Delayed receipt of HAART Poorer adherence Poorer adherence Less likelihood of virologic, immunologic response to HAART Less likelihood of virologic, immunologic response to HAART Greater incidence of AIDS-defining illnesses Greater incidence of AIDS-defining illnesses Poorer survival due to increased AIDS- and non- AIDS-related mortality Poorer survival due to increased AIDS- and non- AIDS-related mortality Taking a Closer Look at HIV Care and Treatment for IDUs

16. A Microeconomic Perspective on Hepatitis C Treatment Hepatitis C Harm Reduction ProjectDemandSupply Low reimbursement for providers (vs. procedures) Need for intensive patient management & support (e.g. physician extender) Need for intensive patient management & support (e.g. physician extender) Lack of on-site psychiatric care Lack of on-site psychiatric care Little training in addictions medicine, HIV Little training in addictions medicine, HIV Physicians may ration expensive HCV treatment to “ideal patients” Physicians may ration expensive HCV treatment to “ideal patients” Mixed messages about need for treatment Mixed messages about need for treatment Competing priorities – drug use, housing, other health issues Competing priorities – drug use, housing, other health issues Distrust of medical system Distrust of medical system Fear of biopsy Fear of biopsy Concerns about treatment side effects – particularly depression Concerns about treatment side effects – particularly depression Limited knowledge from peer experiences with HCV care and treatment Limited knowledge from peer experiences with HCV care and treatment

17. Hepatitis C Harm Reduction Project Bringing It All into Focus: Who 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?

18. Poster from the Hepatitis C Harm Reduction Project. raymond@harmredcution.orgwww.hepcproject.org Envisioning IDU-centric Policy Models…