On Jan. 6, the Journal called for prudence in the treatment of patients with chronic Hepatitis C virus (HCV) infection, specifically in prisoners in New Mexico. We appreciate the attention brought to this important issue and want to highlight additional critical concerns that require a similar level of “prudence” in decision-making on both a state and national level.
We have at least 3 million people in the United States with HCV, and probably over 35,000 in New Mexico. As the Journal editors noted, the health impact of this chronic infection is significant for those who have it.
An investigative report released last month by the U.S. Senate Finance Committee found, to nobody’s surprise, that U.S. pricing of several new oral agents for HCV at $1,000 per pill was intended to “maximize revenue” for the drug company and that “fostering broad, affordable access was not a key consideration in the process of setting the wholesale prices.”
In contrast, the price in Egypt for a 12-week course (84 pills) of the same drugs made by the same manufacturer is less than the cost of a single pill in the United States.
Over 100,000 people in Egypt received treatment last year. Were the cost of treatment the same in New Mexico as Egypt, no one would be raising questions regarding the rationing of treatment.
An important recent study in Health Affairs concluded that early treatment of all Americans with chronic HCV infection is by far the most cost-effective strategy, given the much higher expense (when treatment has been delayed) of treating cirrhosis, liver failure and liver cancer many years later.
So, prudence would indicate that any move to treat more HCV-infected individuals would provide financial benefit for both the United States and New Mexico.
However, at $80,000 per treatment course, the United States would spend $250 billion to treat all Americans with HCV and $3.2 billion here in New Mexico. Neither government’s budget can afford that cost in a single year, nor do we have enough health professionals to treat everyone in one year’s time.
So, directors of state Medicaid and corrections programs, insurance company administrators, health professionals and many others must decide how to treat as many people as possible, as quickly as we can, at a cost we can afford.
This is where good evidence becomes critical to making prudent decisions that are neither based on opinions nor biases against those who may not have had the same advantages as others in our society.
Ironically, there seems to be an intense media focus on the cost of HCV treatment in prisoners and persons who inject drugs, but little attention to the baby boomers, who represent 55 percent of Americans with chronic HCV infection.
All those born between 1945 and 1965 should be tested once for HCV infection. Indeed, it would be prudent even if you believe you have no risk factors.
Research shows that the reinfection rate of HCV in active injection drug users is startlingly low: below 5 percent. So prudence would dictate that these individuals be treated as well. There is an additional public health benefit from reducing HCV transmission. It is also critical that these individuals have access to effective treatment for their addiction.
So, if we had to choose the most prudent public policy course to address the HCV epidemic, we would recommend:
1) Legislative changes to set drug prices at a cost that would allow for the affordable treatment of all persons in the United States with chronic HCV infection this year.
2) Prudent investment of New Mexico health care dollars by treating as many people with HCV as early as possible, with a goal of treating everyone within five years. It should be noted that Medicare currently covers HCV treatment for all its beneficiaries, which, by 2031, will include all of the baby boomers. The cost to treat this group is estimated at $140 billion.
3) Immediate screening for any individual at higher risk for HCV infection, including persons born between 1945 and 1965, who have ever used injection drugs or who have a non-professional tattoo.
We believe this is a more prudent approach than raising questions about who does and does not deserve treatment.