of various treatments for chronic HBV infection (for example, interferon, pegylated interferon, lamivudine, and adefovir) and found them to be cost-effective (Kanwal et al., 2005; Rajendra and Wong, 2007). Treatments for HCV infection with interferon or pegylated interferon plus ribavirin have also been shown to be cost-effective (Campos et al., 2007; Lidgren et al., 2007; Rajendra and Wong, 2007; Salomon et al., 2003).

There is evidence that people’s ability to pay affects whether they seek and receive appropriate medical care for chronic hepatitis B and hepatitis C. For example, among people who tested positive for HCV antibody at public STD clinics in San Diego and an HIV test-site screening program, the presence or absence of health insurance was strongly associated with whether later medical care was received for HCV (Mark et al., 2007).

MAJOR GAPS IN SERVICES

The lack of comprehensive case management (that is, initial clinical evaluation and laboratory testing, regularly scheduled clinical and laboratory monitoring, appropriate referral and treatment, and monitoring for HCC) for people who have chronic hepatitis B or hepatitis C and who do not have access to private health insurance and care is an important gap in control of chronic viral hepatitis. The committee believes that people who are living with chronic HBV or HCV infection should receive the health-care services outlined in Box 5-3. The Ryan White Care program for people who are living with HIV/AIDS is a federal approach that could be replicated to fill the void in health-care services for patients who have HBV or HCV infection. The committee recognizes that uncertainties in funding and health-care reform may make implementation of such a program challenging.

General Population

Various factors can lead to difficulties in accessing screening, prevention, testing, and care related to viral hepatitis. Obstacles to obtaining such services may be limitations in private or public insurance coverage and cost-sharing, lack of access to public health insurance, lack of public funding to support implementation of state viral hepatitis plans, lack of hepatitis awareness and health literacy, inadequacy of sites or practice settings where health-care services are received, transportation needs, social stigmas, fear of legal prosecution related to drug use and immigration, and such cultural factors as religious beliefs, beliefs about biologic products, health perceptions, and language. Among those, however, the most important barriers to receipt of existing services are inadequacy of health-insurance coverage and lack of money to pay for services.



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