State policies that require abstinence before initiating hepatitis C virus (HCV) treatment and laws that cut back on harm reduction services perpetuate stigma and prevent people who use alcohol or drugs from pursuing hep C screening or care, according to a new report from the National Viral Hepatitis Roundtable (NVHR) and the Center for Health Law and Policy Innovation (CHLPI) at Harvard Law School presented at The Liver Meeting Digital Experience.

“Sobriety requirements and laws that limit harm reduction services restrict access to hepatitis C treatment and deny people who use substances their right to health care,” NVHR policy manager Adrienne Simmons, PharmD, said in a press release. “These discriminatory practices not only needlessly endanger patients’ health but also undermine public health efforts to end the HCV epidemic.”

In the United States, the number of hep C cases continues to increase, largely due to sharing needles and other drug injection equipment. While direct-acting antiviral therapies can now cure most people with hep C, obstacles to its elimination remain.

Phillip Waters, a staff attorney at CHLPI, and colleagues analyzed state Medicaid criteria for HCV treatment employed between 2017 and 2020. They were specifically looking to establish whether states required drug or alcohol screening or abstinence in order to acess treatment for hep C. Using a variety of materials available to the public on Medicaid websites, they categorized states into those that had no restrictions to seeking care and those that imposed a sobriety period prior to treatment.

Some states restrict access to hep C care through regulations regarding alcohol or substance use. Medicaid programs may require that people abstain from using alcohol or drugs for a period of time before beginning hep C treatment. They may also call for screening or require those receiving therapy to remain abstinent. Some programs ask that health providers administer counseling.

Fortunately, there has been some progress toward eliminating hepatitis C treatment restrictions over the last few years.

From 2017 to 2020, the number of states requiring proof of sobriety has fallen. In 2020, 74% of Medicaid programs did not enforce a minimum period of abstinence prior to starting treatment, compared with 41% of programs in 2017. Moreover, states that continue to require sobriety checkpoints no longer specify a full year—most states have requirements of at most six months.

A majority of the 12 states that do not provide community-based prevention programs including syringe services and 13 states that criminalize HCV transmission also require sobriety in order to receive hep C treatment through Medicaid.

Since people who use alcohol or drugs are no less likely to respond to treatment than people who do not, such policies serve only to perpetuate stigma and dissuade people from getting tested or seeking treatment.

“Limiting hepatitis C treatment access through sobriety requirements not only perpetuates stigma and goes against medical standards of care but may also violate the Americans with Disabilities Act, which prohibits discrimination against persons with disabilities in public services, including people with substance use disorders who are seeking health care,” said CHLPI faculty director Robert Greenwald. “Ending these discriminatory practices is both a health justice issue and a public health issue. In order to eliminate hepatitis C in the U.S., we need to make treatment available to all who need it and remove burdensome barriers to care.”

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