Why It Matters

To stop HIV in Iowa, we must look at intersecting syndemics, including viral hepatitis and substance use. A syndemic is two or more epidemics that are happening at the same time. In a syndemic, the epidemics interact with one another and cause linked health problems.

 

Many states across the country have seen outbreaks of HIV and viral hepatitis (A, B, and C) among people who inject drugs (PWID). Drug user health and harm reduction strategies play an important role in addressing these epidemics.   

 

For people living with HIV (PLWH) to achieve their best health outcomes, co-occurring health conditions must be addressed, including viral hepatitis. This includes ensuring vaccinations for hepatitis A and B and increasing access to treatment for chronic hepatitis C. 

 

Collectively addressing these intersecting issues is vital to ending the HIV epidemic in Iowa.

 

Where We Stand Today

About Viral Hepatitis
 

The three most common types of viral hepatitis are A, B, and C.

Hepatitis A and B can both be prevented with a vaccine. Outbreaks of hepatitis A are happening across the United States among certain populations, including people who use drugs, people experiencing homelessness, and men who have sex with men. These populations are also at risk for HIV. Additionally, chronic hepatitis B disproportionately affects people born outside of the United States.

 

Limited data exists for people living with viral hepatitis A and B in Iowa. Currently, Iowa has no available data indicating the number of Iowans living with HIV who have been vaccinated for hepatitis A and/or B. 

There is no vaccine for hepatitis C (HCV), but it is curable. However, 45-85% of people living with HCV are unaware of their status and significant barriers to accessing treatment remain. In 2020, 70% of Iowans under 40 diagnosed with HCV reported injection drug use. People who inject drugs (PWID) are at an increased risk for hepatitis B and C through sharing injection drug equipment. The HCV epidemic has increasingly impacted young PWID (under age 40) in rural and suburban settings. Co-infection with HIV and hepatitis C is especially common among people who inject drugs.

Importantly, people living with HIV and viral hepatitis have a greater chance of  adverse health outcomes. 

Evidence Based Interventions
 

Evidence based interventions, including Syringe Services Programs (SSPs), reduce the transmission of HIV and viral hepatitis among people who inject drugs. SSPs are community-based prevention programs that provide a variety of services, including HIV and HCV testing and prevention counseling, linkage to substance use treatment, and medicines to prevent overdoses. Under current state law, SSPs are not allowed to legally operate in Iowa.

What We're Doing Now

Prevention/Diagnosis 
  • Iowa Adult Immunization Program works to improve immunization rates for adults through education and awareness efforts aimed at the public and medical providers.
     

  • Integrated Testing Services (ITS)—12 agencies across the state funded by the Iowa Department of Public Health (IDPH) provide outreach and clinic based testing services to prioritized populations. ITS sites also provide free hepatitis A and B vaccines.
     

    • Three ITS sites in areas in Iowa identified as vulnerable to an HIV/ outbreak are piloting expanded services to provide more holistic services for people who inject drugs (PWID). These expanded services include linkage to substance use treatment, hepatitis B testing, and assessment of and linkage to additional medical and social services. 
       

  • IDPH is working to expand HCV and HIV testing in substance use treatment facilities through internal and external partnerships. Additionally, IDPH has increased efforts to provide training and education about HCV, HIV, and harm reduction for staff working in substance use prevention and treatment settings. 

Treatment 
  • For Iowans living with HIV and HCV who qualify, the Ryan White Part B program can pay for HCV treatment.
     

  • Starting in 2022, IDPH will provide statewide patient navigation services to prioritize populations living with HCV. Patient navigation services include benefit counseling, linkage, and support to maintain treatment.

Gaps, Barriers, & Challenges

Lack of data on vaccinations for and treatment of viral hepatitis in Iowa

Currently, Iowa has no available data indicating the number of Iowans living with HIV who have been vaccinated for hepatitis A and/or B.

 

Lack of Syringe Services Programs (SSPs) in Iowa​

Syringe Services Programs (SSPs) are an evidence based tool for prevention and treatment of HIV and viral hepatitis by offering vaccines (hepatitis A and B), sterile injection equipment, and referrals to treatment.

 

SSPs have been linked to a 50% decrease in HIV transmission. However, Iowa does not currently allow SSPs to legally operate.​

 

Accessing HCV Treatment
 

The high cost of hepatitis C (HCV) treatment has been a barrier to making HCV treatment widely available, especially for vulnerable populations.

 

The prior authorization criteria to access HCV treatment through Iowa’s Medicaid restricts the number of people who can access treatment. These criteria include sobriety restrictions and prescriber restrictions.  Learn more about state Medicaid restrictions and how Iowa stacks up through the Hepatitis C: State of Medicaid Access project. 

Compounded stigma

Stigma is a barrier that can prevent people from accessing services that keep them healthy and safe. It manifests in public perception, policies, and self-stigma (shame). Compounded stigma happens when someone belongs to multiple groups that experience stigma (e.g. substance use, HIV, racial/ethnic minority). The multiple layers of stigma pose additional barriers to care for these individuals.

 
 
 

To stop HIV in Iowa by 2030, this focus area must:

  • Continue engaging with providers and systems, both medical and social, to integrate HIV and hepatitis C (HCV) education and testing into as many entry points as possible.
     

  • Expand upon evidence-based prevention strategies, such as Syringe Service Programs.
     

  • Increase access to treatment for HCV.
     

  • Ensure vaccinations for hepatitis A and B among people living with HIV (PLWH).
     

  • Prioritize drug user health and address stigma. 
     

  • Eliminate viral hepatitis among PLWH.

 

Process for Community Engagement 

Engagement Focus

This focus area will work with partners across the state to understand barriers related to addressing viral hepatitis, identify best practices and define potential improvement opportunities.

​What we learn will inform and support our work in the following areas:

Harm reduction services
Harm reduction services & supplies
Bandaid with heart
Knowledge of & attitudes toward hepatitis A/B vaccination
Hand holding medication bottle
Hepatitis treatment
Stigma icon
Stigma
Integration of services
Integration of services
Person with megaphone
Education & marketing messaging

Gathering Feedback

Focus Groups
  • Clinicians/providers

  • Integrated Testing Services (ITS) staff 

  • Ryan White Part B case managers/support staff

  • Harm reduction organizations

  • Iowa’s Health Initiative for People Who Use Drugs (HIPWUD) advisory body

 

Surveys
  • Federally Qualified Health Center (FQHC) staff 

Key Informant Interviews
  • ECHO hepatitis C (HCV) providers

  • Specialty pharmacies

  • Substance use prevention/treatment

  • Harm reduction organizations

  • People living with HIV (PLWH)

  • People who use drugs (PWUD)/people who inject drugs (PWID)

 

Resources

Iowa Department of Public Health | Bureau of HIV, STD, and Hepatitis

Iowa Department of Public Health | Bureau of HIV, STD, and Hepatitis

Iowa Department of Public Health | Bureau of HIV, STD, and Hepatitis

Centers for Disease Control and Prevention

Centers for Disease Control and Prevention

Woman showing the arm after the vaccine shot