FY 2017 Federal budget proposal addresses Hepatitis C epidemic, but misses opportunity to reach many at highest risk for infection

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Yesterday the White House released the proposed budget for fiscal year 2017. It includes a $5 million funding increase to the CDC and a $9 million increase to HRSA to support viral hepatitis prevention and treatment initiatives, with an emphasis on addressing the Hepatitis C epidemic. The $5 million at CDC will fund increased efforts to stop the spread of Hepatitis C in young people, reduce viral hepatitis deaths, and reduce mother-to-child transmission of Hepatitis B and C. The $9 million in increased funding for the Ryan White HIV/AIDS Program at HRSA will support a new initiative to treat those co-infected with both Hepatitis C (HCV) and HIV.

The budget also includes a proposal for $1.1 billion to pay for drug treatment for people addicted to opioid medications or heroin. This is in response to the exponential increase in opioid addiction rates and heroin overdose deaths seen in the last decade. The plan seeks to support expanding treatment capacity for opioid abuse, and increase access to these services to more people by making the services more affordable. It also includes $500 million for the Department of Justice and HHS to improve prescription-drug overdose prevention strategies, which includes increasing access to the overdose-reversal drug naloxone.

Prescription opioid drug abuse has become a significant health problem in this country over the past 10 years. The government has addressed the liberal prescribing of these drugs by enacting stricter limitations and accountability to providers. However, these restrictions had the unfortunate side effect of causing many of those addicted to painkillers to start abusing heroin, because it provides a similar effect and was easier to obtain following the government crackdown.

At first glance, these budget requests do not seem to have a direct link to one another. However, there is a significant correlation between the Hepatitis C and opioid abuse epidemics that has been overlooked in these budget proposals, and indicates a missed opportunity by the government to concurrently provide funding to address both of these public health concerns.

The current rise in Hepatitis C cases in the U.S. can be largely attributed to infections among people who share needles during injection drug abuse of drugs such as heroin. The CDC estimates that between 2.5 and 4.7 million Americans are infected with HCV. The broad range of uncertainty in that number is due to the asymptomatic nature of the infection, whereby many people are not aware of their status and unknowingly pass on the infection when engaging in risk behaviors such as injection drug use. This correlation between higher HCV infection rates and injection drug abuse is also a significant contributor to the rise in HCV cases among young people, which is an issue the CDC’s budget proposal specifically seeks to address.

A review of the essential components of the President’s opioid abuse plan indicates no provisions to ensure comprehensive testing or educational interventions for high risk infections from injection drug use such as HIV and HCV as part of the widespread outreach and treatment strategy outlined in the proposal. Such ready access to a large number of people who are at particularly high risk for these infections would be an ideal opportunity for the government to integrate interventions that both address opioid abuse prevention and treatment and the need for improved Hepatitis C testing, treatment and prevention.

Standing alone, the CDC's $5 million budget increase to address viral hepatitis is likely insufficient to have the desired impact on reducing new incidence of infection and promoting prevention measures. However, if these funds were included as part of a comprehensive strategy like the opioid abuse initiative, the CDC could avoid incurring expenses on outreach and identifying high-risk persons, and focus the funds on providing direct services such as testing and education.

The government should consider more holistic health intervention strategies that effectively address correlated public health concerns, allow for more efficient uses of federal dollars, and maximize desired outcomes. It is also essential that the level of funding the government provides for such initiatives is adequate to effectively respond to the scope of these public health challenges.

Posted in National Healthcare, Uncategorized; Tagged: , .


President’s Budget Proposes $20 Million Pilot Program to Increase Access to PrEP

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635906109641174425-AFP-548698797-79533506In his final State of the Union Address, President Obama told Congress, “Right now, we are on track to end the scourge of HIV/AIDS, and we have the capacity to accomplish the same thing with malaria — something I’ll be pushing this Congress to fund this year.” HIV experts applauded the President’s elevation of HIV/AIDS in the month preceding his annual budget request but had to wait to learn what exactly the President would propose to Congress. On February 9, 2016, President Obama released his Fiscal Year (FY) 2017 budget, proposing a record $4.1 trillion spending plan, including new funding for HIV prevention.

The FY 2017 budget provides $20 million for a new innovative pilot program to increase access to pre-exposure prophylaxis (PrEP) and allows health departments to use up to 30 percent of these available funds to pay for PrEP medication as the payer of last resort. I have previously written about the need for federal programs to provide financial assistance for PrEP. This pilot program is a significant step toward improving PrEP access in the United States.

PrEP, a pill taken daily to prevent HIV infection in people who do not have HIV, offers an unprecedented chance to end the HIV epidemic. When taken as prescribed, PrEP has been shown to reduce the risk of HIV infection in people who are at high risk by more than 90 percent. One concern that many advocates have is that PrEP may not be accessible to the most vulnerable and high-risk populations who may be particularly disenfranchised from getting PrEP because of its financial cost. A 30-day supply of Truvada, the only medication FDA-approved for PrEP, has a retail cost of approximately $1,160 with no insurance. Individuals with insurance can still have co-payments required by some insurance plans ranging as high as $1,300 per year. Without an expansion of financial assistance programs, many people who stand to benefit from PrEP cannot cover these costs.

Public programs, insurance programs, and other initiatives providing PrEP medication assistance are essential to reducing new HIV infections in the United States. Recent estimates of new HIV infections demonstrate that HIV continues to be a severe problem in the United States. Although new cases of HIV infection have dropped by 19 percent in the last decade due to declines among several populations, including heterosexuals, people who inject drugs, and African Americans, among whom African American women had the steepest decline, the statistics among gay and bisexual men and transgender women have not improved the same degree. New HIV infections significantly increased in the last decade among Black and Latino gay and bisexual men before leveling off in 2010. Young Black gay and bisexual men had the steepest increase in HIV diagnoses but have had a 2 percent decline since 2010.

The recent five-year trends coincide with the launch of the first National HIV/AIDS Strategy (NHAS) in 2010. The President’s budget offers promise for further progress through continued implementation of the NHAS, which was updated last year to guide the Nation’s efforts through 2020. This is an exciting time for the national response to HIV/AIDS, and investment in PrEP and other highly effective prevention approaches could accelerate progress toward the NHAS’s goals. Investment in PrEP is just one piece in a boarder budget that HIV experts will analyze more closely in the coming weeks. For now, it is important to recognize that expanding access to PrEP is key to ending the HIV epidemic in the United States.

Posted in National Healthcare; Tagged: , , , , .


Beyond cost-effectiveness: Why we need a human rights approach to universal health coverage

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This blog was jointly prepared by Eric A. Friedman and Lawrence O. Gostin.

The world having agreed to universal health coverage as a key target of the Sustainable Development Goals, a basic question becomes: Coverage of what?

A traditional approach to answering this question is to focus on cost-effectiveness. Start with a given resource envelope. Then choose the set of health interventions that will buy the most health for the population. Under this approach, health is typically measured by disability-adjusted life years (DALYs). Run the numbers – the cost of different interventions, the expected benefits in DALYs – and include the most cost-effective interventions within the funds available. There is your universal health coverage benefit package.

A human rights approach differs dramatically. The first difference is the question we ask. It is no longer a straightforward matter of determining how to get the greatest health gain for the dollar based on straightforward formulas. "Coverage of what?” is only one question of many. The questions extend to the very process of answering this question, and include such questions as how are the benefits distributed across the population, how health systems can deliver on the chosen priorities, what are the resources available, and more.

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Posted in Global Health, Human Rights, National Healthcare; Tagged: , , , , , .


Enforceability of Economic, Social and Cultural Rights: Historical Background, Legal Basis and Misleading Assumptions

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441159619_fb8e8fcfc7_oThis blog post was written by Daniel Cerqueira, Senior Program Officer at DPLF and originally appeared on the DPL Foundation blog. The original posting can be found here.

After World War II, a paradigm of States’ promotion of social welfare was predominant in several western governments, including those that lead the peace conferences that galvanized the constitutive instruments of the United Nations. This environment influenced the drafting of the Universal Declaration of Human Rights and regional human rights declarations in Europe and the Americas. The Universal Declaration of Human Rights of 1948 enshrines several civil and political rights (CPR) along with economical, social and cultural rights (ESCR). This trend was followed in the American continent, where a Declaration of the Rights and Duties of Man combined CPR and ESCR provisions with no distinction.

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Three Challenges for Mental Health and the Syrian Refugee Crisis

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This post was written by Nicholas J. Diamond, JD, MBE.  Nicholas is trained in both law and bioethics, and frequently speaks and writes on various issues in public health law. He is also a LL.M. candidate in global health law at Georgetown Law. Any questions should be directed to njd9@georgetown.edu.

Source: Vox

Source: Vox

I was struck by a recent blog post in the Canadian edition of The Huffington Post, which offered a compassionate perspective on the mental health challenges confronting the growing number of Syrian refugees that the Canadian government has wholeheartedly welcomed into the country. I have written elsewhere about the need to focus greater attention on the public health crisis that attends the forced migration of approximately 4 million Syrians and the internal displacement of an additional over 7 million Syrians. Mental health must be a major component of any public health response to the refugee crisis.

Reports from multiple international organizations providing mental health services to Syrian refugees have noted the prevalence of a wide spectrum of mental health disorders. For example, using a 6,000-person caseload of refugees in Syria and along its border, the International Medical Corps found that 31 percent suffered from severe emotional disorders, such as biopolar disorders, and 10 percent suffered from schizophrenia. As a further example, a 2015 study focusing on approximately 300,000 Syrian refugees in Germany concluded that as many as half could be suffering from post-traumatic stress disorder. Read More

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The WHO Must Include Access to Birth Control and Abortion in its Temporary Recommendations for Zika-Associated Public Health Emergency of International Concern

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Mosquito sucking blood

This post was written by Lawrence O. Gostin, Faculty Director of the O’Neill Institute for National and Global Health Law and University Professor, Georgetown and Alexandra Phelan, an Adjunct Professor in Global Health Law at Georgetown University Law Center and Doctoral Researcher with the O’Neill Institute for National and Global Health Law. Any questions about this post should be directed to alexandra.phelan@gmail.com.

On Monday 1 February 2016, the World Health Organization (WHO) Director-General Margaret Chan declared the recent cluster of microcephaly and other neurological abnormalities (including Guillain-Barré Syndrome) in Latin America a Public Health Emergency of International Concern (PHEIC) under article 12 of the International Health Regulations (2005). While Zika Virus is strongly associated with these cases, the WHO Director-General and the Emergency Committee advising her did not expressly include Zika Virus in the PHEIC, with further research necessary to establish a causative link between Zika infections and the disease clusters.

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4 Challenges to Mitigating the Impact of Zika Virus Infection

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Image courtesy of PAHO

Image courtesy of PAHO

Yesterday, the World Health Organization announced that the Zika virus was “spreading explosively” in the Americas and that as many as three to four million people in the region could be infected in the next year23 countries and territories in the region have already reported cases of infection with the virus. Zika is transmitted by the Aedes mosquito, which also transmits dengue and Chikungunya viruses. One in four people with Zika infection develops symptoms, which can include mild fever, conjunctivitis, headache and joint pain, and skin rash.

Although Zika virus infection typically causes only mild symptoms, outbreaks in Brazil have coincided with a notable increase in microcephaly in newborns. Brazil has reported over 4,000 cases of microcephaly since October, compared to only about 150 cases each year before the epidemic. Microcephaly is an uncommon condition in which infants are born with abnormally small heads. It can present as an isolated condition or may be associated with other conditions, such as convulsions, developmental delays, or feeding difficulties, of varying degrees of severity. In many cases, microcephaly is life-threatening.

Various factors have made it particularly difficult to prevent the spread of the Zika virus and reduce its impact. Here are just a few:

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Posted in Global Health, Human Rights, WHO; Tagged: , , , , , , , , , , , , , .


Ending childhood obesity: the role of laws and regulations

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Obesity can have serious effects on children’s health, educational achievements, and overall quality of life. In 2014, a UNICEF-WHO-World Bank joint report estimated that 41 million children under 5 were overweight or obese. Globalization and urbanization mean that many children are growing up in obesogenic environments and that the prevalence of childhood obesity is increasing, particularly in low- and middle-income countries.

This week, the World Health Organization (WHOCommission on Ending Childhood Obesity (ECHO) released its final report: Ending Childhood Obesity. The ECHO report stresses the importance of a comprehensive and integrated approach to addressing childhood obesity, which includes medical interventions, public education campaigns, and laws and regulations. Today, I’ll consider the role that laws and regulations can play in reversing the shift towards obesogenic environments and addressing the alarming levels of childhood obesity facing communities all over the world.

School lunch photoThe Commission on Ending Childhood Obesity

The final report is the culmination of a 2 year process during which 15 commissioners reached a consensus on the interventions most likely to effectively tackle childhood overweight and obesity in different contexts across the globe. The commission was supported by two working groups focused on the science and evidence and implementation, monitoring, and accountability. Read More

Posted in Non-communicable diseases;


Preliminary Opinion Validates the Legality of Large Pictorial Warnings and Plain Packaging Measures in the European Union

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This post was written by Céline Brassart Olsen. Any questions or comments can be directed to celine.brassart.olsen@jur.ku.dk.

On December 23, 2015, Advocate General Kokott of the European Court of Justice (ECJ) gave a preliminary opinion in which she validated the legality of the European Union’s (EU) Tobacco Products Directive 2014/40 (the Directive). In particular, the opinion upheld the validity of mandatory large pictorial warnings and optional plain packaging. Although the opinion of the Advocate General is not binding on the ECJ, it is quite influential and is a good indicator of what the ECJ could decide in the coming months.

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Posted in Tobacco;



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This post was written by Lawrence O. Gostin, Fernanda Alonso and Oscar Cabrera. Questions about this post can be directed to fa265@law.georgetown.edu.

o-mature-marijuana-facebook_720Whether or not you agree with legalizing marijuana, it is happening. So far, at least nine countries have legalized cannabis for medical purposes. Uruguay has also made it legal for recreational use, and Canada is expected to follow suit. In the USA, cannabis products remain illegal under federal law. But at least 23 states and D.C. have legalized medical cannabis under their laws, with four states and D.C. also legalizing recreational use. The legislatures of additional states and countries are considering legalization, and other legalization proposals will be on the ballots in the coming U.S. elections.

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The views reflected in this blog are those of the individual authors and do not necessarily represent those of the O’Neill Institute for National and Global Health Law or Georgetown University. This blog is solely informational in nature, and not intended as a substitute for competent legal advice from a licensed and retained attorney in your state or country.

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