1. Co-occurring Challenges: Leveraging ADAP and ACA to Address Hepatitis C and Substance Use Disorders Daniel Raymond Policy Director Harm Reduction Coalition raymond@harmreduction.org

2. Challenges Hepatitis C co-infection is a leading cause of mortality in people living with HIV/AIDS Substance use disorders magnify gaps in the HIV Care Continuum ARV access is necessary but not sufficient

3. Hepatitis C Co-infection Roughly 25% of HIV+ in United States co- infected with chronic HCV HIV co-infection worsens HCV outcomes, and HCV-related liver disease is a leading cause of non-AIDS-related death in PLWHA New HCV treatments are increasingly effective and well-tolerated

4. Substance Use Disorders Substance use disorders are highly prevalent among PLWHA Untreated SUDs impede linkage & retention in care, receipt of ARV, and adherence An estimated 25% of PLWHA are in need of treatment for an alcohol or substance use disorder

5. Medications of Interest Current HCV regimens: Genotype 1: Sovaldi/PEG/RBV, Olysio/PEG/RBV, Sovaldi/Olysio +/- RBV, Sovaldi/RBV Genotype 2/3: Sovaldi/RBV Medication-assisted treatment for opioid use disorders: methadone, buprenorphine, naltrexone

6. Role of ADAP: Direct Purchase Limited coverage of HCV direct-acting antivirals: in 2012, only 8 states covered telaprevir and/or boceprevir (roughly half covered pegylated interferon) Extremely limited coverage of methadone and/or buprenorphine

7. Role of ADAP: Insurance Support (premiums/cost-sharing) HCV direct-acting antivirals: dynamic environment as new regimens enter market Payer resistance re: cost of new drugs, volume of potential patient population HCV drugs typically under PA requirements, higher specialty tiers Concerns re: clinical criteria, fail first/step therapy

8. Role of ADAP: Insurance Support (premiums/cost-sharing) 2013 ASAM report on MAT coverage Medicaid: incomplete coverage (17 states don’t cover methadone; majority require PA for buprenorphine; lifetime/dosage limits) Commercial plans: methadone typically not covered; buprenorphine subject to PA, dosage limits, specialty tier, other restrictions

9. ADAP/ACA Interaction How to guarantee access & affordability for HCV treatment & MAT for opioid use disorders? Monitor plan design (formulary & network) for care & coverage Track utilization & barriers to access Understand protections (discrimination; Mental Health Parity & Addiction Equity Act)

10. Additional resources NASTAD ADAP Monitoring Project https://www.nastad.org/resources.aspx?category=National%20ADAP%20Monitoring%20 Project%20Annual%20Report AASLD/IDSA Hepatitis C Treatment Guidance http://www.hcvguidelines.org/ ASAM Advancing Access to Addiction Medications http://www.asam.org/advocacy/aaam