HIV Specialist - March 2021 - 51

In Connecticut, effective advocacy has been led to the projection
that our state will become the first in the U.S. to meet the WHO
goal of micro-elimination of HCV, meeting that goal by 2028.4 It
is the work of advocates that has helped to make this possible.
Like every other state in the U.S., in 2015 the Connecticut
Medicaid program enacted a restrictive prior authorization process which would only approve direct-acting
agents to treat HCV by board certified Hepatologists,
Gastroenterologists, and Infectious Disease physicians,
and then only to patients with significant F3 or F4
fibrosis. These restrictions, while in line with every
other Medicaid program in the U.S., and nearly
every commercial insurance plan at the time,
undermined our ability to treat patients infected
with HCV. With the mortality rate from hepatitis
C already surpassing mortality from HIV, and cases
of HCV rising dramatically due to the opioid epidemic,
Connecticut advocates began strategizing on how to loosen the
restrictions on HCV treatment.5
Our group included legal aid attorneys, public health researchers,
faculty from Yale University School of Medicine and clinicians from
community health centers. A joint letter signed by many of us, to the
Social Services Commissioner, supported in tandem by a letter from
the Academy, underscored the importance of treating our patients with
the new curative therapies. A group of three clinicians met with the
medical director of the Medicaid program to implore expansion of access for HIV specialists and others to be able to be able to treat all of our
patients, and not only those with severe liver disease. We argued that
treating patients with HCV earlier would improve patient health, was
cost effective, and would ultimately reduce the future cost of treating
complications of cirrhosis and hepatocellular carcinoma. The result
of our advocacy was the elimination of all significant restrictions on
who can treat patients with HCV (all licensed prescribers) and which
patients can be treated (all except known terminally ill patients).

The Need to Get Involved

In this time of heightened awareness of the pervasive racism in
our society, taking an active advocacy stance is more important for
healthcare providers. Bias in healthcare persists today, whether it
is racial, gender, or sexual identity. Bias can be implicit, and even in
those who see themselves as providing equitable care can unknowingly be treating certain patients differently.6 Bias can lead to longer wait
times, less thorough workups, offering different treatment options,
or taking patient complaints less seriously.7 Racial bias can impact
healthcare regardless of the level of education or socioeconomic
status of the patient. Recent media attention was paid to the Black
Internal Medicine physician hospitalized with Covid-19 who posted
on her social media page her belief that had she been white, her treatment of COVID-19 would have been different.8 Many HIV specialists
work in academic medical settings, and are in a position to advocate
for changes in medical education to help eliminate implicit bias in the
next generation of healthcare providers.

Advocacy to local, state and federal policy
makers for changes in systemic and institutional policies that keep black and brown
people on an unequal footing with whites is
even more important. Taking a stand against
systemic racism, that impacts wealth inequality, racially-segregated housing, disparities in
employment, or access to healthcare are all
ways that the privileged status of healthcare
providers can be a voice for change.
Becoming a voice that speaks for equal
access to healthcare, or access to therapeutic medications that our patients need in
their HIV treatment has never been more
important.
The field of HIV medicine has a long and
proud history of public advocacy that has
moved policy makers to take action that
would not have occurred without the voices
of patients and clinicians speaking out for
policy change. Today, the need for those voices has never been greater. HIV
GARY SPINNER, PA, MPH,
AAHIVS, is Medical Director of the Ryan
White HIV/AIDS Program at the
Southwest Community Health Center in
Bridgeport, CT, and a member of the
Academy National Board of Directors.

REFERENCES
1.	 Stockdill, B.C. (2013). ACT UP (AIDS Coalition to Unleash
Power). In The Wiley-Blackwell Encyclopedia of Social
and Political Movements. Editors D.A. Snow, D. Della Porta,
B. Klandermans and D McAdam. doi.
org/10.1002/9780470674871.wbespm223
2.	 WHO. Global Health Sector Strategy on Viral Hepatitis
2016-2021. Towards Ending Viral Hepatitis: World Health
Organization, 2016.
3.	 Razavi H, Sanchez Gonzalez Y, Yuen C, Cornberg M. Global
timing of hepatitis C virus elimination in high-income
countries. Liver Int. 2020;40(3):522-529. doi:10.1111/
liv.14324
4.	 Sulkowski M, Cheng WH, Marx S, Sanchez Gonzalez Y,
Strezewski J, Reau N. Estimating the Year Each State in the
United States Will Achieve the World Health
Organization's Elimination Targets for Hepatitis C. Adv
Ther. 2020; Nov 3:1-18. doi: 10.1007/s12325-020-01535-3
5.	 Centers for Disease Control and Prevention. Surveillance
for Viral Hepatitis - United States, 2014. https://www.cdc.
gov/hepatitis/statistics/2014surveillance/commentary.
htm. Accessed February 2, 2021.
6.	 Hall WJ, Chapman MV ,Implicit Racial/Ethnic Bias
Among Health Care Professionals and Its Influence on
Health Care Outcomes: A Systematic Review. Am J Public
Health. 2015 December; 105(12): e60-e76.​
7.	 Hoffman KM, Trawalter S. Racial Bias in Assessment and
Treatment Recommendations. PNAS. April, 2016.
8.	 Eligon,J. Black Doctor Dies of Covid-19 After Complaining
of Racist Treatment. New York Times. December 24, 2020.

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https://doi.org/10.1002/9780470674871.wbespm223 https://doi.org/10.1002/9780470674871.wbespm223 https://www.cdc.gov/hepatitis/statistics/2014surveillance/commentary.htm https://www.cdc.gov/hepatitis/statistics/2014surveillance/commentary.htm https://www.cdc.gov/hepatitis/statistics/2014surveillance/commentary.htm http://WWW.AAHIVM.ORG

HIV Specialist - March 2021

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