CROI 2020 Abstract eBook

Abstract eBook

Poster Abstracts

567 MEDICAID HCV TREATMENT RESTRICTIONS: SPILLOVER TO THE PRIVATE- PAYER HCV CARE CASCADE? Rachel Epstein 1 , Jianing Wang 2 , Jake R. Morgan 2 , Shashi Kapadia 3 , Yuhua Bao 3 , Laura F. White 2 , Benjamin P. Linas 2 1 Boston Medical Center, Boston, MA, USA, 2 Boston University, Boston, MA, USA, 3 Cornell University, Ithaca, NY, USA Background: Medicaid HCV treatment restrictions limit access to HCV cure. There is evidence that public insurance policies influence care more broadly, even among commercially insured patients. Further, if states limit HCV treatment access, screening may lag due to decreased provider motivation. This study investigates whether Medicaid HCV treatment restrictions ‘spillover’ to affect HCV testing among patients with commercial insurance. Methods: We linked the Marketscan commercial claims database to the National Viral Hepatitis Roundtable state-by-state categorization of Medicaid HCV treatment policies. We considered any requirement for negative drug testing prior to HCV treatment to be a restrictive abstinence-based policy and any requirement that a patient have evidence of Metavir fibrosis stage F2 or greater to be a restrictive fibrosis-based policy. We categorized states into four groups: 1) maintained low fibrosis or abstinence restrictions over the study period (2014-2017), 2) relaxed both fibrosis and abstinence restrictions, 3) relaxed only one restriction type, and 4) maintained high restrictions in both domains. We analyzed HCV testing rates across these groups in 18-64-year- olds. We used negative binomial regression adjusted for calendar time and for whether policy change occurred, to estimate testing rate ratios between groups. Results: From 2014-2017, 2,134,569 HCV tests occurred over 876,444,123 eligible person-months (29.2 tests/1000 person-years). Testing rates increased over time in all groups. States that maintained unrestrictive policies had the highest HCV testing rates, followed by states that reduced both fibrosis and abstinence restrictions. States maintaining high restrictions for one or both policies had similar rates (Figure). In regression analysis, states maintaining low restrictions had an adjusted rate ratio of 1.74 (95% CI 1.61-1.89) compared with states maintaining high restrictions. In states that relaxed restrictions, we observed a rate ratio of 1.07 (95% CI 1.00-1.14) post- vs. pre-policy change. Conclusion: Restrictive state Medicaid HCV treatment policies are associated with decreased HCV screening rates among commercially insured individuals in the same state. Unmeasured state-level variables such as Medicaid expansion may contribute to observed differences, and we will conduct further analysis. These data suggest, however, that Medicaid HCV treatment restrictions may have spillover effects that hinder HCV elimination progress across all payers.

effective, but has remained out of reach for many patients due to high cost. We evaluated the relationship between health insurance status, a key factor for the mitigation of financial barriers to medical care, and DAA initiation in an observational cohort of women living with HIV in the United States (US). Methods: Women’s Interagency HIV Study participants coinfected with HIV and HCV (RNA+) without history of DAA use were followed for DAA initiation (2015-2018). We estimated risk ratios (RRs) of the relationship between time- varying health insurance and DAA initiation, adjusting for confounders with stabilized inverse-probability-of-treatment weights. Baseline covariates were age, race, and education, and time-varying predictors in the weight models were US region of residence, annual household income, alcohol use, injection/ non-injection drug use, AIDS Drug Assistance Program participation, HIV viral load, CD4 count, and advanced liver fibrosis (APRI ≥1.5 or FIB-4 ≥3.25). We also estimated unweighted and weighted cumulative incidences of DAA initiation by health insurance status. Results: 137 women (74% Black) were followed; at baseline, median age was 55 years (interquartile range, 50-59) and 87%were insured. The majority of women (79%) lived in Northern states and had annual household incomes ≤$18,000 (85%). Advanced liver fibrosis (30%) and use of alcohol (45%) and drugs (34%) were common. At 368 subsequent biannual visits, 74 women (54%) reported DAA initiation. The weights had a mean of 0.99 and ranged from 0.12 to 8.06. Compared to no insurance, health insurance increased the likelihood of reporting DAA initiation at a given visit (RR 4.99, 95% confidence interval [CI] 1.56-16.0), an estimate markedly stronger (but less precise) than the unadjusted (RR 2.02, 95% CI 0.76-5.34). When weighted, the cumulative incidence of DAA initiation was lower (8% vs. 30%) at two years among the uninsured (Figure). Conclusion: In an analysis accounting for financial, clinical, behavioral, and sociodemographic factors over time, health insurance had a substantial positive effect on DAA initiation. Interventions to improve insurance coverage, such as Medicaid expansion or subsidies for private plans, should be prioritized in order to increase uptake of HCV curative therapy for persons with HIV. 569 MOBILE HCV SCREENING IN AN AT-RISK URBAN POPULATION IDENTIFIES SIGNIFICANT FIBROSIS Jennifer C. Price 1 , Rachel Kanner 1 , Emily Valadao 1 , Yesenia S. Laguardia 1 , Maria Duarte 1 , Norah A. Terrault 2 1 University of California San Francisco, San Francisco, CA, USA, 2 University of Southern California, Los Angeles, CA, USA Background: Most people living with hepatitis C virus (HCV) remain undiagnosed, impacting HCV elimination efforts. We designed a mobile unit to bring HCV screening and liver fibrosis staging to at-risk communities in San Francisco. Methods: A university shuttle bus was furnished with a phlebotomy station, Fibroscan®430 Mini+ and clinical exam table. Screening with the OraQuick® HCV Rapid Antibody (Ab) test was performed at: 1) community events 2) street outreach and 3) outside methadone programs. HCV Ab+ clients were offered venipuncture for confirmatory HCV RNA, liver stiffness measurement (LSM) and linkage to care. Significant fibrosis and advanced fibrosis were defined as LSM ≥7.0 kPa and ≥9.5, respectively. Results: From 1/17/2019-9/13/2019, 428 people underwent HCV Ab screening at community events (12%), street outreach (72%) and methadone programs (15%). Median age was 53 (IQR 43-62), 67%were male, 49% reported living outdoors or in a vehicle in the past year, and 5%were HIV-positive. Overall, 156 were HCV Ab+ (36%), and prevalence varied by screening location: 17% at community events, 34% at street outreach sites, and 66% outside methadone programs (p<0.001). HCV Ab+ individuals were more likely than HCV Ab- to be white (44% vs 32%, p=0.003), have Medi-Cal insurance (80% vs 61%, p<0.001), and report ever injection drug use (IDU) (86% vs 29%, p<0.001), ever smoking

Poster Abstracts

568 HEALTH INSURANCE AND DIRECT-ACTING HCV ANTIVIRAL INITIATION IN US WOMEN WITH HIV Andrew Edmonds 1 , Danielle Haley 2 , Jessie K. Edwards 1 , Catalina Ramirez 1 , Audrey French 3 , Phyllis Tien 4 , Michael Plankey 5 , Mardge H. Cohen 3 , Anjali Sharma 6 , Michael Augenbraun 7 , Eric C. Seaberg 8 , Kimberly Workowski 9 , Hector Bolivar 10 , Svenja Albrecht 11 , Adaora Adimora 1 1 University of North Carolina at Chapel Hill, Chapel Hill, NC, USA, 2 Northeastern University, Boston, MA, USA, 3 Stroger Hospital of Cook County, Chicago, IL, USA, 4 University of California San Francisco, San Francisco, CA, USA, 5 Georgetown University, Washington, DC, USA, 6 Albert Einstein College of Medicine, Bronx, NY, USA, 7 SUNY Downstate Medical Center, Brooklyn, NY, USA, 8 Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA, 9 Emory University, Atlanta, GA, USA, 10 University of Miami, Miami, FL, USA, 11 University of Mississippi Medical Center, Jackson, MS, USA Background: Direct-acting antiviral (DAA) therapy for Hepatitis C virus (HCV) is well tolerated, yields high sustained virologic response rates, and is cost-

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