Jeffrey Zients

March 18, 2015
The Honorable Thad Cochran
Chairman
Committee on Appropriations
United States Senate
Washington, DC 20510
The Honorable Barbara Mikulski
Ranking Member
Committee on Appropriations
United States Senate
Washington, DC 20510
The Honorable Harold Rogers
Chairman
Committee on Appropriations
United States House of Representatives
Washington, DC 20515
The Honorable Nita Lowey
Ranking Member
Committee on Appropriations
United States House of Representatives
Washington, DC 20515
Dear Chairman Cochran, Ranking Member Mikulski, Chairman Rogers, and Ranking Member Lowey:
As you begin work on the Fiscal Year (FY) 2016 Labor, Health and Human Services, Education, and Related
Agencies Appropriations bill, the Hepatitis Appropriations Partnership (HAP) respectfully requests an increase in
appropriations for the Division of Viral Hepatitis (DVH) at the Centers for Disease Control and Prevention (CDC)
by $31.5 million over FY2015 to total $62.8 million, consistent with the President’s budget request.
The viral hepatitis community understands the challenge of budgeting additional resources in the current fiscal
climate, yet the need for these programs continues to grow.
In the United States, more than 5.3 million people live with chronic hepatitis B and/or hepatitis C, and at least
15,000 deaths annually are attributed to hepatitis-related liver disease or liver cancer. These figures are based on
National Health and Nutrition Examination Survey (NHANES) data, which does not include homeless and unstably
housed individuals, those living in nursing homes, the incarcerated, the military, or many immigrant and migrant
populations – populations disproportionately affected by viral hepatitis. Worse, of the estimated 2.2 million people
living with chronic HBV and 3.9 million people living with chronic HCV, 65-75% do not know their diagnosis and
are not receiving the appropriate care and treatment. Without a confirmed diagnosis and linkage to and retention in
care, 15-40% of those living with viral hepatitis will eventually develop liver cirrhosis and/or liver cancer. In 2012
alone, 40,599 cases of HBV and 145,762 cases of HCV were reported to the CDC. Unfortunately, due to the lack
of adequate comprehensive and coordinated surveillance activities, these estimates are likely only the tip of the
iceberg.
Viral hepatitis disproportionately impacts several communities, particularly people who inject drugs (PWID), men
who have sex with men, persons living with HIV, African immigrants and African Americans, Asian immigrants
and Asian Americans, Pacific Islanders, Latinos, tribal communities, veterans, and residents of rural and remote
areas with limited access to medical treatment or culturally and linguistically-appropriate services. “Baby
Boomers,” persons born between 1945 through 1965 have the greatest risk for HCV-related morbidity and
mortality – 1 in 33 people born in this time period are hepatitis C positive. Both CDC and the U.S. Preventive Task
Force (USPSTF) recently released HBV and HCV screening guidelines recommending that providers offer a onetime screening of HCV to anyone in this birth cohort, and that anyone at high-risk for HBV should be screened.
Additionally, recent alarming epidemiologic reports indicate a burgeoning epidemic of HCV infection among
young people throughout the country. Some jurisdictions have even noted that the number of people ages 15 to 29
being diagnosed with HCV infection now exceeds the number of people diagnosed in all other age groups
combined, representing 75 percent of new HCV cases. Alarmingly, 35 out of 41 responding states reported
increases in persons newly infected with HCV from 2010-2012.
Even with these challenges, the availability of effective new curative treatments for HCV, and an effective vaccine
and good treatments to control HBV, brings the elimination of HCV and HBV in the United States within our
reach, setting the stage for an enormous new public health victory. The elimination of HCV and HBV in the United
States is possible – but not without increased investments in comprehensive, national viral hepatitis prevention,
screening, linkage to care, education and surveillance programs.
In FY2012, Congress demonstrated a commitment to increasing the federal response to the viral hepatitis epidemics
with the creation of the first-ever viral hepatitis screening initiative through the Prevention and Public Health Fund
(PPHF). This brought the total funding at DVH to an unprecedented $29.7 million in FY2012. The viral hepatitis
community is appreciative that Congress recognized the importance of the identification and linkage to care of
people living with viral hepatitis who are unaware of their status. While past increases have been helpful, these
have only been small steps toward building a more comprehensive response to viral hepatitis. The CDC’s 2010
professional judgment (PJ) budget recommended $90.8 million each year from FY2011-FY2013, $170.3 million
annually from FY2014-FY2017, and $306.3 million annually from FY2018-FY2020 for DVH in order to
comprehensively address the hepatitis B and hepatitis C epidemics. HAP’s requested increase of $31.5 million is in
line with the needs determined by that PJ and the goals of the Action Plan for the Prevention, Care, & Treatment of
Viral Hepatitis (Viral Hepatitis Action Plan). HAP recommends that these funds be used on the following priority
areas, allocated in proportion to HBV and HCV burden, using available epidemiological data.
Screening and Linkage to Care
At present, only 25-35 percent of people living with chronic viral hepatitis are aware of their infection. The Viral
Hepatitis Action Plan established a goal of increasing the proportion of persons who are aware of their hepatitis
infection to 66 percent for both HBV and HCV. In addition to identifying youth who are living with hepatitis C
who are unaware of their status, DVH must also increase the percentage of Baby Boomers who are aware of their
HCV status, and foreign-born and 2nd generation immigrants from Asian or African countries that have HBV
infection rates of 10% or higher. These numbers continue to grow with an estimated 40,000 infected people
entering the U.S. each year. This is why full implementation of the CDC and USPSTF recommendations for HBV
and HCV testing and linkage to care by state Medicaid programs, Medicare, and private health systems and
providers are so necessary. In the absence of a federal commitment to a nationwide awareness, testing and linkage
to care initiative, we remain concerned about the ability of the federal government to meet the goals of the Viral
Hepatitis Action Plan.
Surveillance
As testing and linkage to care activities increase and improve, strengthening local and state capacity to execute viral
hepatitis monitoring and surveillance activities takes on an even greater importance. The CDC currently funds only
5 state health departments and 2 local health departments to conduct minimal surveillance in their jurisdictions.
CDC also provides funds to state and local health departments, the cornerstone implementers of national public
health policies, to coordinate prevention and surveillance efforts via the Viral Hepatitis Prevention Coordinator
Program (VHPC). The VHPC program is the only national program dedicated to the prevention and control of the
viral hepatitis epidemics. This program provides funding to support a coordinator position in each jurisdiction, but
leaves little to no money for the provision of public health services, such as surveillance, public education and
access to prevention services like testing and hepatitis A and B vaccinations, which must be cobbled together from
other sources year-to-year. With increased investments in nationally coordinated surveillance activities, key
stakeholders (states, health departments, policy makers, and providers) would be equipped with information that is
critical to understanding the burden and impact of the hepatitis epidemics, identify and averts outbreaks, and that
will allow for improved targeting of resources to the most impacted communities.
Addressing the Emerging Hepatitis C Epidemic Among Young Persons at Risk
HCV prevalence among PWIDs is as high as 70%, and between 20-30% of uninfected people who inject drugs
acquires HCV each year. In recent years, state health departments have reported an alarming increase in new HCV
cases among people under the age of 30 in many states, including but not limited to: Alabama, Colorado,
Connecticut, Georgia, Indiana, Kentucky, Maine, Maryland, Massachusetts, Montana, New Mexico, North
Carolina, Oregon, Tennessee, Washington and West Virginia. Unlike historical trends of HCV infections (i.e.,
concentration in larger, urban city centers), new HCV infections are increasingly found in suburban and rural
settings, especially in Appalachia. This trend is largely due to the prescription opiate epidemic and the transition
many young people have made from using opiate pills to injecting heroin. This increase makes the need to enhance
and expand these prevention efforts all the more urgent and underscore the need to prioritize immediate support in
the field, strengthening health department and community responses that target youth and young adults, specifically
persons who injection drugs, persons under 30 years old, and persons living in rural areas.
Elimination of Mother-to-Child Transmission of Hepatitis B
Although we have made great strides in reducing the burden of HBV among newborns and young people, due in
part to the success of the Perinatal Hepatitis B Coordinator program at CDC’s National Center for Immunization
and Respiratory Diseases (NCIRD), between 800 to 1000 perinatal HBV transmissions occur each year. Further,
one of the greatest remaining challenges for hepatitis A and B prevention is the vaccination of high-risk adults.
Additional funding at NCIRD for an Adult HBV Vaccination Initiative is necessary to prevent the transmission of
HBV, and especially perinatal HBV. High-risk adults account for more than 75 percent of all new cases of HBV
infection each year and annually result in an estimated $658 million in medical costs and lost wages, despite the
fact that HBV is preventable.
Additional Hepatitis Related Priorities
In addition to the above-recommended HHS funding priorities, the President’s FY2016 budget must also include
robust funding for viral hepatitis activities within the Department of Veterans Affairs’ Veterans Health
Administration. Approximately 175,000 veterans are diagnosed with HCV, at least 30,000 of whom have liver
cirrhosis; and as many as 40,000 veterans may be infected with HCV and not know it. Hepatitis B testing and
treatment rates are low among US veterans with only15% of US veterans having been tested for HBV infection,
and among those who tested positive just 25% having received antiviral treatment. Therefore, HAP supports the
President’s request for $690 million for the Veterans Health Administration to provide lifesaving treatment for
veterans suffering from hepatitis B and hepatitis C, and requests the Committee appropriate this sum.
Finally, we urge the Committee to end the ban on the use of federal funds for syringe services programs and to
maintain language allowing the use of local funds for syringe services programs in the District of Columbia.
Syringe exchange programs are one of the most effective ways to prevent transmission of blood borne pathogens,
including HIV, hepatitis B, and hepatitis C, among people who inject drugs. Given the prescription opiate epidemic
and the well-known trend in people transitioning from the use of pills to injecting heroin, it is critical that syringe
exchange programs have appropriate support to provide life-saving services and to link participants to much-needed
additional support, such as drug treatment, mental health services, and housing.
The viral hepatitis community welcomes the opportunity to work with you and your staff on these very important
and timely issues. HAP is a national coalition based in Washington, DC and includes community-based
organizations, public health and provider associations, national hepatitis and HIV organizations, and diagnostic,
pharmaceutical and biotechnology companies. HAP works with policy makers and public health officials to
increase federal support for hepatitis prevention, testing, education, research and treatment. Should any questions
arise or if you need additional information, please contact Mariah Johnson at (202) 434-8042 or
[email protected]. We thank you for your leadership and look forward to your assistance in the fight
against these silent epidemics.
Sincerely,
The Hepatitis Appropriations Partnership