Abby Prescott, Brenna Daly, Hallelujah Anteneh, Julia Dolak

Hepatitis C in Athens, Georgia: Needs Assessment

HPRB 3710

December 7, 2021
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Part A: Health and Culture

Health

General Information

Hepatitis C is a liver infection that makes its own proteins replicate, which causes

inflammation (U.S. Department of Health & Human Services, 2021). This infection is caused by

the hepatitis C virus (HCV) (U.S. Department of Health & Human Services, 2021). This virus is

spread by having contact with the blood of an infected person (U.S. Department of Health &

Human Services, 2021). For some people diagnosed with hepatitis C, this is a short term illness.

For others, this virus can cause long-term chronic infection where medical treatment is needed. I

(U.S. Department of Health & Human Services, 2021). In the United States, 50,300 new cases of

HCV were reported in 2018 (U.S. Department of Health & Human Services, 2021). There is a

high rate of new infections in the United States, with the number of acute HCV infections that

developed quadrupling (U.S. Department of Health & Human Services, 2021). These rates

greatly increased for the age groups of 20-29 years and 30-39 years, specifically (U.S.

Department of Health & Human Services, 2021). Around 80% of people with Hepatitis C

experience no symptoms (U.S. Department of Health & Human Services, 2021). Those who do

develop symptoms may experience joint pain, dark urine, fever, fatigue, nausea, vomiting,

abdominal pain, pale feces, lessened appetite, and jaundice (yellowing of skin and whites of

eyes) (U.S. Department of Health & Human Services, 2021).

Testing

About 40% of those with chronic Hepatitis C are unaware of their condition (Yale

Medicine, 2019). Testing is done using a blood test, known as the HCV antibody test, which is

sometimes referred to as the anti-HCV test (Yale Medicine, 2019) The test is looking for these
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antibodies, which are chemicals that enter one’s bloodstream once they are infected (Yale

Medicine, 2019). Standard HCV antibody test results can take between a few days to a few

weeks to come back. There are some health clinics and doctor’s offices that perform rapid

anti-HCV tests, where results come back in less than an hour (Yale Medicine, 2019)

The results of the test will either be: reactive or non-reactive. A non-reactive HCV antibody test

result means that one does not currently have a Hepatitis C infection (Centers for Disease

Control and Prevention, 2020). Even with this result, if one believes that they have been exposed

to Hepatitis C within the last 6 months, they will need another test. A reactive HCV test means

that an individual has had the viral Hepatitis C infection at some point in time (Centers for

Disease Control and Prevention, 2020). This does not explicitly mean that one is currently

infected (Centers for Disease Control and Prevention, 2020). Once an individual has been

infected, antibodies will always be present in their blood, even if the person has been cured or

still has the virus (Centers for Disease Control and Prevention, 2020). If an individual receives

reactive results, further testing will need to be done to determine if one currently has the HCV

infection. This test is referred to as a nucleic acid test (NAT) for HCV RNA, also known as a

PCR test (Centers for Disease Control and Prevention, 2020). If this PCR test is negative, the

individual was infected with HCV at some point in time, but they are not currently infected (the

virus has been cleared) (Centers for Disease Control and Prevention, 2020). If one has a positive

PCR result, they are currently infected with the virus and need to speak with a doctor about

treatment (Centers for Disease Control and Prevention, 2020).

Transmission

In the United States,the main cause of hepatitis C spread is by sharing needles or

equipment that is utilized to inject drugs (National Health Society, 2018). People who inject
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drugs are at a higher risk of Hepatitis C infection (National Health Society, 2018). Injecting

oneself with even just one needle contaminated with Hepatitis C is enough to become infected.

Other equipment used in order to prepare and take drugs, such as filters, pipes, spoons, or straws

that have been contaminated with infected blood can also transmit the infection (National Health

Society, 2018). This association of hepatitis C with drug use has led to some stigmatization that

can affect quality of life, lead to isolation, depression, housing insecurity, and loss of income

(National Health Society, 2018). This stigma can also frequently occur in healthcare settings,

where lack of primary care, testing, and treatment increases disease burden (British Columbia

Centre for Disease Control, 2015).

There are also some less common methods of transmission. Body piercing or tattoo

equipment that has not been sterilised properly can transmit hepatitis C (National Health Society,

2018). This risk is low as most places must follow health regulations to prevent disease spread

National Health Society, 2018). Another possible transmission method is via sharing items such

as toothbrushes, razors, or scissors that have been contaminated with infected blood (National

Health Society, 2018).

In order to address the health issue of hepatitis C, it is important to address the root cause

of exposure that creates high transmission rates in developing countries: contaminated needles

and medical equipment in medical settings (Mohapatra & Prabhakar, 2017). Transmission can be

prevented by utilizing single-use needles and fully submerging equipment in a disinfectant

solution before manually cleaning the device, and ensuring the concentration of the solution is

high enough to kill microbes (Mohapatra & Prabhakar, 2017). Unsafe injection practices and

reusing needles, syringes, and fingerstick devices increase transmission risk (Mohapatra &

Prabhakar, 2017). About 40% of Hepatitis C cases originate from the Western Pacific Region
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(World Health Organization, 2019). Laos has a particularly high number of cases, with about

548,000 persons infected in the country (World Health Organization, 2019). Around 8% of Laos’

population is living with chronic Hepatitis B and around 0.7% of the population is living with

chronic hepatitis C infection (World Health Organization, 2019). Medical or dental equipment

(especially needles, syringes, other sharp equipment) that has not been properly sanitized and is

then used for injection, medical procedures, and blood work can cause infection (World Health

Organization, 2019). Currently, there is no vaccine available for hepatitis C, so medical

professionals are focusing on treatment and care management options (World Health

Organization, 2019). In Laos, the World Health Organization is promoting vaccination to prevent

hepatitis A and B and promoting better sterilization and methods to prevent overall hepatitis

transmission (Sharma et al., 2015).

Reducing Transmission in Laos

Addressing the issue of unsafe removal of contaminated needles and medical equipment

in medical settings in Laos is difficult for various reasons. Firstly, a majority of healthcare

facilities are located in the country’s urban areas, which means they are likely densely populated

and underfunded (World Health Organization, 2018; ). Communicable diseases are the leading

cause of death. In 1975, a large number of Loas physicians departed the country, creating a gap

in the local healthcare system of qualified medical professionals (World Health Organization,

2018). The government responded by building more local village infirmaries and dispensaries in

provinces (World Health Organization, 2018). These rural medical workers provide much of the

primary health care in Laos. They often only use traditional medicinal herbs for treatment and

stray from Western practices. The structure of the healthcare system in Laos makes it difficult to

implement large scale sanitation education programs. Laos has this weak healthcare
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infrastructure, shortage of qualified health professionals, limited ability to have outbreak and

disease surveillance, and overworked health employees (USAID, 2021). The lack of qualified

health professionals increases the risk of an unsafe medical injection from occurring. Overall, the

hepatitis C epidemic in Laos can only be addressed once the medical infrastructure is improved

and there are more qualified health professionals available.

Hepatitis B Testing

It is also relatively common for those diagnosed with Hepatitis C to also be infected with

Hepatitis B (Sharma et al., 2015). This is because these viruses are spread by similar

transmission methods (Sharma et al., 2015). Unlike Hepatitis C, Hepatitis B can be prevented

with vaccination consisting of three shots (Sharma et al., 2015). Hepatitis B can be diagnosed via

a multitude of blood tests. Any person that is born in a country that has a medium to high

Hepatitis B prevalence rate (>2%), should be tested for chronic Hepatitis B infection (Sharma et

al., 2015). This includes any country in the Pacific Islands, Asia, and most African countries

(Centers for Disease Control and Prevention, 2020). These tests will either indicate: a

current/past infection or Hepatitis B antibodies (Lab Tests Online, 2021). The test is looking for

any Hepatitis B genetic material: antigens or antibodies (Lab Tests Online, 2021). If infection is

detected, then further testing is done to determine virus levels in the bloodstream (Lab Tests

Online, 2021). This further testing can guide treatment options, assess if one can spread Hepatitis

B to others, and to examine current infection levels (Lab Tests Online, 2021). This type of testing

is typically ordered by a doctor and can be done in labs, hospitals, or other healthcare settings

once a blood sample is acquired (Lab Tests Online, 2021). There is an at-home testing option

where an individual can collect their own blood sample, usually from a small needle finger prick,
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following the test kit instructions. This sample can then be mailed to a lab for testing (Lab Tests

Online, 2021).

Liver Cancer and Liver Cirrhosis

A person with HCV infection is at an increased risk of developing liver cancer or

cirrhosis (Centers for Disease Control and Prevention, 2020). Liver cancer is when cells in the

liver grow at an abnormally high rate (Centers for Disease Control and Prevention, 2021). Liver

cirrhosis is severe scarring of the liver tissue (Mayo Clinic, 2021). For every 100 people

currently infected with HCV, about 5 to 25 people will develop liver cirrhosis within 10 to 20

years (Centers for Disease Control and Prevention, 2020). There are factors that increase the risk

of developing cirrhosis once being infected: being aged 50+ years, being on immunosuppressive

therapy, consuming alcohol, male gender, or also having HIV, hepatitis B, or fatty liver disease

(Centers for Disease Control and Prevention, 2020). For those that develop liver cirrhosis,

“1%–4% annual risk of developing hepatocellular carcinoma and a 3%–6% annual risk of

hepatic decompensation” (Centers for Disease Control and Prevention, 2020). For those that do

develop this carcinoma or decompensation, there is a 15-20% chance of death within the next

year (Centers for Disease Control and Prevention, 2020). These conditions are common reasons

for liver transplants (Centers for Disease Control and Prevention, 2020).

Testing for Liver Damage

If liver damage caused by hepatitis C is detected, further testing will need to be

conducted to assess the extent of the damage (Hepatitis C Trust, 2021). There are a multitude of

ways to assess the severity of liver damage. Firstly, a blood test measuring the levels of liver

enzymes alanine aminotransferase and aspartate aminotransferase in the blood can be performed

(Hepatitis C Trust, 2021). There are also blood tests utilized that look for markers of liver
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damage: Fibrosure, Fibrotest, and Actitest (Hepatitis C Trust, 2021). These tests are not very

reliable for detecting liver damage or cirrhosis, as results of these liver function tests often

fluctuate for cases of chronic hepatitis C (Hepatitis C Trust, 2021). This test is non-invasive,

quick, and easily accessible for most individuals (Hepatitis C Trust, 2021). Another

non-invasive, fast way to test for liver damage is a Fibroscan (Hepatitis C Trust, 2021). A

fibroscan uses a sound wave to check liver elasticity (Hepatitis C Trust, 2021). This scan

measures the different degrees of cirrhosis. Overall, the most accurate way to assess liver

damage is a liver biopsy (Hepatitis C Trust, 2021). This method is rarely used if less invasive

tests are accessible (Hepatitis C Trust, 2021). Small pieces of liver tissue are extracted via a long

needle placed between the 8th and 9th ribs under the right arm (Hepatitis C Trust, 2021). This

tissue is then assessed on inflammation, scarring, and abnormalities (Hepatitis C Trust, 2021).

The testing is highly accurate, but painful and invasive (Hepatitis C Trust, 2021).

Re-Infection

There are seven different genotypes of HCV and 67 subtypes (Centers for Disease

Control and Prevention, 2020). 1a, 1b, 2, and 3 are the genotypes most frequently found in the

United States (Centers for Disease Control and Prevention, 2020). If an individual is already

infected with one genotype, it is possible to become infected with a different one if risk

behaviors or exposures continue (Centers for Disease Control and Prevention, 2020). If a person

has already cleared one genotype and is not currently infected, it is still possible to become

infected with a different strain (Centers for Disease Control and Prevention, 2020). An

individual’s immune system is not able to fight off the infection, due to virus mutations (Centers

for Disease Control and Prevention, 2020).

Treatment
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There are many treatment options for hepatitis C depending upon the extent of the

infection. With a new HCV infection, the immune system can sometimes fight the infection and

treatment will not be necessary (World Health Organization, 2021). If the infection becomes

chronic, the World Health Organization recommends treatment with pan-genotypic direct-acting

antivirals (DAAs) for persons over the age of 12 (World Health Organization, 2021). These

DAAs stop these proteins from being able to function, preventing the virus from finishing its life

cycle and growing (World Health Organization, 2021). There are four main types of these

antivirals that target one or more of the virus proteins and these antivirals are often taken in

combination with one another (World Health Organization, 2021).

There are some possible side effects of this treatment: headache, insomnia, runny nose,

fatigue, nausea, abdominal pain, diarrhea, irritability, and sore throat (Editorial Team, 2017).

Side effects can differ depending upon the specific DAA drug one is taking. Although many

people undergo DAA therapy with no significant side effects, these drugs increase one’s risk of

hepatitis B virus reactivation due to an increased immune response (Editorial Team, 2017).

The standard antiviral treatment for HCV was previously an interferon-based DAA drug,

but now interferon-free DAA medications are the standard (Rong, 2010). Interferons are

proteins that can trigger immune cells to attack the HCV virus (Rong, 2010). The shift towards

using interferon-free drugs created more sustainable virological response rates, safe drug use,

drug tolerability, and overall lessened the length of treatments (Rong, 2010). Conventional

interferon-based treatment for HCV had an effectiveness of around 40-50%, now with improved

interferon-free treatment there is up to 80% effectiveness (Rong, 2010). Overall, interferon-free

medications cause less symptoms and are more effective in treating chronic HCV (Rong, 2010).

Since interferons help the body produce immune responses to viruses, it is unknown why
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interferon-free medications are more effective (Rong, 2010). Scientists theorize interferon-free

treatment is more effective because it stops the virus from copying itself, along with preventing

drug resistance (Rong, 2010).

Determining the disease genotype of an infected person is also important for determining

treatments and choosing the most effective protease inhibitor (Zeuzem, 2017). Protease inhibitors

are chemical compounds that prevent specific enzymes from breaking down proteins (National

Cancer Institute, 2021). Genotype 1 is the most common variant in the US and is typically

treated with NS3/4A protease inhibitors (Zeuzem, 2017). The NS3/4A protease inhibitors also

treat genotype 4 by blocking the proteins that HCV needs to replicate itself and survive (Rong,

2010). However, all the genotypes of HCV can be treated with NS5A and NS5B protease

inhibitors (Rong, 2010). These inhibitors are selected by genotype depending on the condition’s

severity and are prescribed at different doses (Rong, 2010). In some cases, these inhibitors are

combined with other drugs to stop the virus from replicating (Zeuzem, 2017).

Treatment Costs

These direct-acting interactive drugs are highly expensive. There are a variety of drugs

and drug combinations that can be utilized depending on one’s virus genotype, liver damage

extent, past treatments, and a patient’s medical conditions (Watson, 2019). Some of these drugs

include ribavirin (Copegus, Rebetol, Ribasphere), elbasvir/grazoprevir (Zepatier),

ombitasvir/paritaprevir/ritonavir (Technivie), ledipasvir/sofosbuvir (Harvoni), and

glecaprevir/pibrentasvir (Mavyret) (Watson, 2019). While these antiviral drugs are highly

effective, there are multiple factors contributing to the high costs of these medications (Watson,

2019). For a twelve week treatment of these drugs, Harvoni costs $94,500, Mavyret costs

$39,600, Zepatier costs $54,600, and Technivie costs $76,653 (Watson, 2019). The large demand
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for these drugs, the high costs of developing the drug, running clinical trials, marketing the

product, and bringing it to market affect the pricing (Watson, 2019). In the United States, the

lack of a national health care system that can negotiate medication costs allows pharmaceutical

companies to price the drugs at any amount they desire (Watson, 2019). There is also little

competition from other drug manufacturers to create competitive pricing in the market (Watson,

2019). These extremely high costs of treatment prescriptions makes it difficult for both insured

and uninsured individuals to be able to afford treatment.

Another important consideration while treating someone with HCV is the influence of

their behaviors on their health. Maintaining a healthy weight through diet and exercise is

important in controlling HCV, as being overweight increases risk for liver damage (Zeuzem,

2017). The liver metabolizes the nutrients that one consumes, so it is important to have a diet full

of nutrient dense foods for someone suffering from HCV (Zeuzem, 2017). This aids in reducing

the severity of symptoms, such as fatigue (Zeuzem, 2017). Avoiding alcohol is also essential in

the treatment process of HCV, as it accelerates cirrhosis and end-stage liver disease (Zeuzem,

2017). Thus, lessening alcohol consumption can reduce the need for a liver transplant (Zeuzem,

2017).

Overall, every disease stage of HCV can be treated and sustained eradication can be

achieved when the person infected has the right combination of drugs (Zeuzem, 2017). This

viral eradication is important for people living with HCV because it provides better quality of

life, lower morbidity, and lower mortality (Zeuzem, 2017). Treatment schemes for HCV depend

on a patient's overall health, genotype, and hepatic/renal function (Zeuzem, 2017). While 15 to

25% of people clear the virus without treatment, many others infected need specialized plans to

reduce their viral load or eliminate it (Zeuzem, 2017).

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Pregnancy and Hepatitis C

Hepatitis C (HCV) can impact women who are pregnant before, during, and after

pregnancy (Karampatou et al., 2018). Women who have contracted Hepatitis C can become

pregnant and have safe pregnancies (Karampatou et al., 2018). However, women with Hepatitis

C do have a higher rate of miscarriage, gestational diabetes and have fewer live births

(Karampatou et al., 2018). Women have a small chance of spreading HCV to their children

during birth and treatment options should begin after breastfeeding is over (Hepatitis B and

Hepatitis C in Pregnancy, 2021).

Treatment options for women with Hepatitis C depend on whether they are currently

pregnant or are trying to get pregnant (HCV in pregnancy, 2020). If women tested positive for

Hepatitis C before becoming pregnant, antiviral medication should be started to reduce the risk

of HCV transmission to offspring in the future (HCV in pregnancy, 2020). There are no approved

treatments of Hepatitis C for women who are currently pregnant (Hepatitis B and Hepatitis C in

Pregnancy, 2021). The risk of birth defects from the typical treatment course for HCV is high

(Hepatitis B and Hepatitis C in Pregnancy, 2021). This is because traces of medications

commonly used to help combat this virus (such as ribavirin) can be in both semen and ova, and

are known for causing defects (Hepatitis B and Hepatitis C in Pregnancy, 2021). These methods

discussed describe the most effective ways preventative medicine can be used within an infected

person's household (Kushner et al., 2019). Women with HCV should take extra care to stay

healthy during pregnancy, even though there is no HCV-specific treatment for pregnant women

(Hepatitis B and Hepatitis C in Pregnancy, 2021).

Transmission of Hepatitis C from Mother to Baby

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Vertical transmission is the transmission of an infectious disease from mother to baby

during or after pregnancy (Arora et al., 2017). The vertical transmission of hepatitis C occurs

during birth when the baby comes in contact with the mother’s blood (Hepatitis B and Hepatitis

C in Pregnancy, 2021). The vertical transmission of HCV to a baby during birth increases when

the mother has a viral load higher than copies of HCV RNA (Yeung et al., 2014). While a

woman is pregnant viral load levels may change (Yeung et al., 2014). Viral load levels should be

measured in the third trimester to measure hepatitis C vertical transmission risk to the infant

(Yeung et al., 2014). Viral load is the amount of virus in an individual’s blood and HCV RNA

tests can measure this amount (Hepatitis C viral load/HCV RNA quantitative testing, 2021).

Around 4 in 100 women will pass hepatitis C onto their children during birth (Hepatitis B and

Hepatitis C in Pregnancy, 2021). The mode of delivery, whether vaginal or cesarean section,

does not increase or decrease the risk of HCV vertical transmission (Yeung et al., 2014). Women

who are co-infected with human immunodeficiency virus (HIV) and Hepatitis C are

recommended to have a cesarean section (Coll et al., 2002). HIV is a viral infection that impacts

the body’s immune system and can lead to Acquired Immunodeficiency Virus (AIDS) if not

treated ​(Centers for Disease Control and Prevention, 2021). Breastfeeding is not a mode of

transmission and women can safely breastfeed with Hepatitis C (Bhola & McGuire, 2007).

Hepatitis C RNA has been found in breast milk and colostrum; however, this will not infect the

infant with Hepatitis C (Centers for Disease Control and Prevention, 2021).

The children of women who are HCV positive will be tested for Hepatitis C around 18

months and will need ongoing medical care for infancy to ensure proper development (Hepatitis

B and Hepatitis C in Pregnancy, 2021). Approximately 1 in 4 children with Hepatitis C will

clear the virus from their system on their own, though others may become carriers for the virus
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(Hepatitis B and Hepatitis C in Pregnancy, 2021). HCV will stay in the liver of the children who

become carriers; however, most stay healthy with frequent doctor visits and blood tests to check

liver function (Hepatitis B and Hepatitis C in Pregnancy, 2021). Most children do not need

medicine, however, some benefit from antiviral medication that prevents severe liver damage

and liver cancer ("Hepatitis C in pregnancy," 2008).

Hepatitis C is not passed on genetically from mother to child (Hepatitis C Questions and

Answers for the Public, 2020). However, partners and family members of people infected with

HCV are at higher risk of infection (Hepatitis C Questions and Answers for the Public, 2020).

This is because HCV is spread through blood, even a small amount of blood and can transmit

hepatitis C to another person (Hepatitis C Questions and Answers for the Public, 2020). Sexual

partners of hepatitis C infected individuals are at higher risk for HCV compared to the average

person (Sexual Contact, 2021). There are risk factor behaviors that increase risk of Hepatitis C

transmission through sexual contact, such as unprotected sex (Sexual Contact, 2021).

Fertility with Hepatitis C

Hepatitis C can impact the fertility of men and women (Karampatou et al., 2018).

Hepatitis C infection of males impacts male fertility including sperm count, sperm mobility, and

abnormal development of sperm (Levy et al., 2002). Studies have shown that mitochondrial

membrane, chromatin compaction, and DNA fragmentation of sperm are impacted by chronic

HCV infection and affects male fertility (La Vignera et al., 2012). Thirty percent of males

infected with HCV had an alteration in semen before antiviral treatment for high viral serum load

(Levy et al., 2002). Female fertility is also impacted by HCV. The fertility rate for women with

HCV is 0.7 with the general population having a fertility rate of 1.37 (Karampatou et al., 2018).

Women infected with HCV have a higher rate of miscarriage, this could be due to decreased
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ovarian function and a decrease of anti-Mullerian hormone causing premature ovarian

senescence in HCV-positive women (Karampatou et al., 2018).

Culture

Influences of culture on views on diet and healthcare

A little over half of the population, 64.7% of 7.1 million people in Laos are Buddhists,

specifically Theravada Buddhists (Laos - United States Department of State, 2017; Khamvongsa,

2009). This tradition of Buddhism is based on Buddha’s earliest teachings and revolves around

the Four Noble Truths, “suffering is universal, the cause of suffering is attachment, suffering can

cease, and there is a way to end suffering,” (Khamvongsa, 2009). There are also a number of

precepts that Buddhists must follow depending on their position in the Buddhist community, but

for those who are non-ordained, also known as lay people, there are five precepts to follow

(British Broadcasting Company, 2002). These precepts are “to refrain from: taking life, taking

what is not given, sexual misconduct, false speech, and intoxicants causing heedlessness,”

(British Broadcasting Company, 2002). Most Buddhists are either vegetarian or vegan due to the

first precept (National Health Society, 2020). Some also only eat a single meal a day before

midday, some Buddhists also fast on the new and full moon days, as well as on specific festival

days throughout the year like Buddha’s birthday, his day of death, his day of enlightenment, and

his first sermon to name a few (National Health Society, 2020). This may interfere with an

individual's treatment plan when ill, as most medication requires food to be taken with it in order

to prevent further illness or damage to organs (National Health Society, 2020).

The majority of Buddhists also do not have any issues with taking medicine that will help

them heal or recover, but some prefer to know the effects of the drug before taking it due to the

fifth precept (National Health Society, 2020). Since the medicine is controlled and eliminates the
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individual's ability to perform harmful acts while intoxicated, most Buddists are usually open to

medicine. But some may be more comfortable with alternative medicinal practices due to its

nature (National Health Society, 2020).

Buddhist customs in sickness

Studies suggest that this religious-based healing through indegenous healers and helpers

is an important part of Buddhists’ healing process ( Ketchell et al., 2013). A belief shared

amongst most Laotians is that modern medicine can be helpful in fighting illnesses of the body

but are useless when it comes to spiritual/soul illnesses (Earls, 2020). An example of an

alternative practice conducted by indigenous healers and helpers is a ceremony for an individual

when they are ill (Earls, 2020). They call for as many of their friends and family to come for a

“soul-calling” ceremony where their loved ones care for them and help heal by “calling the

spirits back to their body to protect them” (Earls, 2020). The ceremony is called baci/su khuan

and it is a derivative of Theravada Buddhism, Brahmanism, as well as animism (Earls, 2020). It

is rooted in the belief that there are multiple souls/khuan in an individual's body, and that they all

need to be kept inside in order for someone to feel healthy (Earls, 2020). How many souls an

individual has is dependent on which ethnic group in Laos the person is a part of but the majority

believe there are roughly 32 (Earls, 2020). It is believed that illness is brought on when an

individual is frightened or experiences trauma because it allows for one of the many souls an

individual has to escape their body (Earls, 2020). The souls leaving one's body are believed to

manifest through physical symptoms like fatigue or loss of appetite (Earls, 2020). The ritual can

also be used as a preventative act as well as a response and is usually performed by a village

elder in the home of the person who is ill (Earls, 2020). They are placed in the middle of the

room and surrounded with a flower shrine made of banana leaves and French marigolds with
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white cotton strings attached to the shrine on one end and to their loved ones’ wrists on the other,

as they wish the person well (Earls, 2020). They tie the cotton strings on their wrists to

symbolize keeping the newly returned souls within the sick person’s body and it represents the

bond between the person who is ill and the person wishing them well, hence it must be worn for

three days for the connection to be sealed (Earls, 2020). As the ceremony occurs, the elders call

back the souls that have escaped by chanting and wishing good upon the sick (Earls, 2020).

Family Support and Treatments with Hepatitis C

Families often need counseling and support to determine the best way to avoid

transmission of the HCV in the household. Even though the risk is low, it is important to try and

not to share personal items that may have blood on them that could infect someone who doesn't

yet have the virus. These items include toothbrush, dental tools, razors, nail clippers, and glucose

meters (Information for healthcare personnel potentially exposed, 2017). It is also important to

cover cuts and sores of an infected person so the infectious blood is not spread (Information for

healthcare personnel potentially exposed, 2017). An important resource that is important for

individuals and families affected by hepatitis C are support groups. Specifically, ones that help

people know how to talk to loved ones about diagnosis, support caregivers, find information on

financial aid, and address specific challenges faced by those living with HCV (Information for

healthcare personnel potentially exposed, 2017).

It is also very important to consider how HCV infection impacts fertility for couples

trying to conceive. Counseling on artificial insemination may be needed since viral drugs need to

be preemptively stopped before conceiving in order to prevent birth defects (Karampatou et al.,

2018). Women can have premature ovarian senescence (a type of menopause) which can reduce

the number of viable ovarian follicles (Karampatou et al., 2018). Therefore, it's important for
 17

couples to talk about the timing of conceiving a biological child. Those infected with HCV have

a fertility rate of 1.37 versus the general population of women which is 0.7 (Karampatou et al.,

2018). It is also important to take into account that people with HCV that become pregnant are at

higher risk for gestational diabetes and miscarriage (Karampatou et al., 2018). Therefore,

specialists in fertility and comorbidities of HCV should be consulted in order to ensure a safe

pregnancy. Since HCV miscarriage rate is signifigantly reduced by treatment of HCV, it is

important to have a group of multidisciplinary specialists consider if there is enough time for an

individual to be treated before possibly conceiving (Karampatou et al., 2018). As for the future

baby, it is important to understand that antiviral medications have a strong effect on the body and

could cause birth defects in a child (Karampatou et al., 2018). Although stopping an antiviral

could negatively impact a current HCV infection, it may be considered, but only under the direct

supervision of a medical professional (Karampatou et al., 2018).

Health Insurance with Hepatitis C

The impact of HCV is highly contingent on the ability of an individual to pay for

treatment. The affordable care act (ACA) states that people can not be denied coverage because

of their HCV status (Edwards, 2015). However, the amount of insurance coverage people living

with HCV recieve is an influential factor in their outcomes from the disease. More effective drug

treatments are more expensive and there is a lack of access for some people because the basic

insurance provided by the government is not sufficient enough in covering costs (Edwards,

2015). Furthermore, testing isn't covered by all insurers and early detection is key to slowing or

stopping the disease progression. Those who are on Medicaid tend to have increased mortality

risk compared to those with private insurance (Bush et al., 2019). Policy makers must prioritize

funding of HCV treatment in order to support the differences seen in the HCV-positive
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population, as the disease is expensive to effectively treat (Bush et al., 2019). Life saving

medication is being withheld from many people with public and private insurance (Penn

Medicine News, 2018). Direct acting antivirals are up to 95% more effective than previous

interferon based medicines (Penn Medicine News, 2018). Since the most effective medicine is so

costly (between ~ $40,000 - $100,000), many public and private insurers have restricted

coverage to only HCV patients with evidence of advanced liver damage (Penn Medicine News,

2018).

Insurance in Georgia

The Affordable Care Act that was passed in 2010 and fully enacted by 2014, expanded

the scope of Medicaid to offer assistance to more individuals; however, states had the choice

whether or not to adopt the expansion (Hepatitis C: State of Medicaid Access Report Card,

2017). Medicaid provides insurance coverage for eligible low-income adults, pregnant women,

children, elderly persons and people with disabilities (Hepatitis C: State of Medicaid Access

Report Card, 2017). Georgia chose not to expand Medicaid after the Affordable Care Act was

passed (Hepatitis C: State of Medicaid Access Report Card, 2017). In 2020, 726,000 Georgians

were covered under Medicaid if it was expanded, however, 240,000 Georgians would still have

no access to health insurance without the expansion of Medicaid to the ACA expansion

guidelines (Norris, 2020)​​. A partial expansion of Medicaid in Georgia went into effect on July 1,

2021, however, it does not expand fully to the guidelines from the Affordable Care Act (Norris,

2020).

Georgia residents diagnosed with hepatitis C that are covered by Medicaid have more

access to treatment and medication than those without health insurance. However, Georgia does

have hepatitis C treatment restrictions that limit access, even when an individual is insured.
 19

Georgia has a fee-for-service (FFS) program and Medical Care Organizations (MCOs) including

AmeriGroup Community Care, WellCare of Georgia, CareSource, and Peach State Health Plan

(Hepatitis C: State of Medicaid Access Report Card, 2017). A Medical Care Organization is a

health insurance plan or company that focuses on limiting healthcare costs but keeping quality

high (What is managed care, 2021). The FFS does not require liver damage for treatment, but

does require diagnosis of hepatitis C ( Hepatitis C: State of Medicaid Access Report Card, 2017).

The MCO, AmeriGroup, requires a diagnosis of chronic hepatitis C and a baseline quantitative

hepatitis C RNA test (Hepatitis C: State of Medicaid Access Report Card, 2017). WellCare

requires severe liver damage to qualify for hepatitis C treatment, the damage must have a liver

fibrosis score of F3 or greater (Hepatitis C: State of Medicaid Access Report Card, 2017)​​. A F3

score means that the liver fibrosis is spreading and forming bridges with other fibrotic areas of

the liver (Pavlov CS et al., 2015). The F3 qualification would limit treatment to individuals that

are already extremely sick. WellCare does not have specific qualifications, however, they

consider liver fibrosis score and previous diagnosis of hepatitis C. Peach State Health and

CareSource do not ask about previous diagnosis of hepatitis C (Hepatitis C: State of Medicaid

Access Report Card, 2017). Not only do FFS and MCOs have diagnosis requirements, but many

of them also have sobriety requirements for treatment (Hepatitis C: State of Medicaid Access

Report Card, 2017). The sobriety requirement perpetuates a stigma that limits treatment for

hepatitis C patients and discourages treatment for hepatitis C. The Fee-for-Service program

requires a patient to enroll in a substance program if the patient with hepatitis C currently uses

alcohol or intravenous drugs (Hepatitis C: State of Medicaid Access Report Card, 2017).

AmeriGroup also requires patients to be enrolled in a substance use program if they are currently

using substances. If a patient isn’t currently using substances, such as alcohol or intravenous
 20

drugs, AmeriGroup requests that a physician check whether an adherence assessment has been

completed and assure successful treatment completion (Hepatitis C: State of Medicaid Access

Report Card, 2017). An adherence assessment would require patients to verify that they are not

using substances. WellCare has a prior authorization form that states that patients with prior

history of substance abuse will be admitted for treatment of hepatitis C on a case-by-case basis

and if accepted, will work in conjunction with a substance treatment specialist (Hepatitis C:

State of Medicaid Access Report Card, 2017). Peach State Health Plan and CareSource do not

have any sobriety requirements or the information is not available (Hepatitis C: State of

Medicaid Access Report Card, 2017). These restrictions make it difficult for privately or publicly

insured individuals with hepatitis C to receive insurance coverage for their medications and

treatment. When requirements include a certain extent of liver damage for coverage, this means

that people may not be able to access necessary care until their condition has worsened.

Immigration and Healthcare Services

Immigration status impacts every aspect of an immigrant’s life, including healthcare and

healthcare affordability. 21.3 million non-citizens were in the United States in 2019, including

lawfully present immigrants and undocumented immigrants (Health Coverage of Immigrants,

2021). This makes up 7% of the total population of the United States (Health Coverage of

Immigrants, 2021). Non-citizens are more likely to not have health insurance compared to

citizens, with 25% of lawfully present noncitizens and 46% of undocumented noncitizens being

uninsured (Health Coverage of Immigrants, 2021). A majority of the time non-citizens are not

eligible for public health insurance because they are not citizens and documented immigrants

may have a five year waiting period to qualify for public health insurance (Coverage for lawfully
 21

present immigrants, 2021). Non-citizens are likely to have at least one family member that is

employed full-time, however, many of the full-time workers are employed by low-wage jobs that

make private health insurance unaffordable (Coverage for lawfully present immigrants, 2021).

Low-wage employers are also unlikely to offer employer-sponsored health insurance due to the

high cost of private health insurance for employers (Health Coverage of Immigrants, 2021).

Immigrants that are documented and in the United States lawfully may be eligible for Medicaid

and Children’s Health Insurance Program (CHIP), however, there could be restrictions to their

coverage (Health Coverage of Immigrants, 2021). Medicaid coverage varies based on the state,

however, there is federal mandatory service coverage, including inpatient and outpatient hospital

services, physician services, laboratory and x-ray services, and home health services (Benefits,

2021). Most lawful permanent residents must wait five years after obtaining lawful status before

they can enroll in Medicaid or CHIP (Benefits, 2021). Twenty-nine states have chosen to waive

the five-year waiting period of children and/or pregnant women (Health Coverage of

Immigrants, 2021). Immigrants that are lawfully present in the United States can purchase

coverage through the Affordable Care Act Marketplaces and can receive subsidies for coverage.

The subsidies are available for noncitizens between 100% and 400% of the federal poverty line,

the federal poverty line varying based on the number of individuals in a household, who cannot

receive other health insurance coverage (Health Coverage of Immigrants, 2021). Lawfully

present immigrants that are below 100% of the federal poverty line can receive subsidies if they

are unable to receive Medicaid because of immigrant status (Health Coverage of Immigrants,

2021).

Not only do immigrants face challenges to be eligible for health insurance, but the

eligible non-citizens also face enrollment barriers for health insurance. Many lawful immigrants
 22

that are eligible for health insurance do not enroll because of fear in government programs,

confusing policies, difficulty in the enrollment process, and language barriers (Health Coverage

of Immigrants, 2021). The political climate of the United States impacts the enrollment of

immigrants in health insurance because of fear and confusion of government programs (Health

Coverage of Immigrants, 2021).

Stigma of Immigrants Having Diseases in the United States

There are multiple examples in history where social stigma of a disease has kept those

who are ill from speaking out and seeking help (i.e. leprosy, cholera, yellow fever, SARS,

HIV/AIDS, tuberculosis) (Perry et al., 2010). Stigma creates fear of those who have the disease,

and can cause prejudices against groups of people simply out of misplaced fears (Perry et al.,

2010). This forces individuals to feel isolated and alone on top of their illness, making their path

to recovery or getting treatment more difficult (Perry et al., 2010).

Part B: Scenario and What is Needed

Lori has just been diagnosed with Hepatitis C through testing. She has extended family

from Laos, however, her current immingration status is unknown. She is employed as an

engineer. She is married and her husband is a middle school teacher. She is 35 years old and still

plans on having children. Lori and her husband are now faced with finding out how Hepatitis C

affects Lori’s health, her husband’s risk, the risk of pregnancy and fertility, and how treatment

can be accessed.

Lori needs resources that will give her Hepatitis C treatment options and provide

guidance on fertility issues if she decides to pursue having children. It is also recommended that

Lori gets tested for hepatitis B because these viruses are spread by similar transmission methods.
 23

She should consider getting vaccinated for hepatitis B to prevent future infection. Depending on

the severity of her condition, she may need to get tested for liver damage and diseases. Athens

has a variety of resources including treatment centers, testing centers, women’s medical center,

and facilities offering vaccination services for Hepatitis A and B. The resources in Athens will

help Lori learn about her diagnosis, how it impacts her ability to have children, and how to

maintain a healthy lifestyle with Hepatitis C. These resources include centers that offer services

for the insured and uninsured. Lori should use these resources moving forward to receive proper

treatment, guidance on lifestyle changes that need to happen, and fertility changes, as well as

guidance on how her diagnosis impacts her husband.

Part C: Community Agencies that can provide assistance

Athens has many testing and treatment centers including Athens Neighborhood Health

Center, Athens Gastroenterology Center, Gastroenterology Associates of Athens, Digestive

Disease Clinic, Northeast GA Gastroenterology Associates, Athens Nurses Clinic, Mercy Health

Center, Women’s Healthcare Associates, Children’s Healthcare of Atlanta Gastroenterology

Clinic, and GI Care for Kids. Athens has community agencies that provide treatment and testing

for hepatitis C. This is important for Lori to receive proper treatment and medication as soon as

possible to decrease the effects of Hepatitis C in the future. While facing a hepatitis C condition,

it can be helpful to work with fertility specialists if one is trying to conceive. There are also

centers that provide treatment for hepatitis C in children, if Lori does pass on the virus in the

future.

Athens Neighborhood Health Center

Athens Neighborhood Health Center provides hepatitis testing and treatment for anyone

in Athens and surrounding areas. They accept Medicare, Medicaid, and most insurance plans. If
 24

a patient is uninsured, they offer sliding scale payments depending on income-level. The center

also has a pharmacy that offers reduced price medications for qualifying patients. The health

center is a non-profit that has received grants from TJX, Georgia Department of Public Health,

Athens-Clarke County, and United Way. These community partners have allowed the center to

continue to provide services for patients who cannot afford it. Their website does not list specific

pricing for testing and treatments of Hepatitis C nor specifies the cost for uninsured patients. As

for the pharmacy, because they are a federally qualified health center they strive to meet the

needs of Athens, since it is considered to be an “underserved” community. As access to

affordable medication is considered a burden of living in Athens, this center offers a pharmacy

on site at their east location and tries to offer more affordable options. Since the Athens

Neighborhood Health Center meets the federal requirements to be considered a community

health center, they receive funding from the Health Resources and Services Administration.

Under the Public Service Act, the center is a part of the Federal 340B Medication Program. This

federal government program requires pharmaceutical companies that participate in Medicaid to

provide outpatient medications to health care organizations at reduced prices. These discounted

medication prices increase accessibility for both insured and uninsured patients alike. These

costly medications are available at a much lower cost at this center. This means hepatitis C

medication at this pharmacy is based on a sliding scale and available at lower prices to ensure

affordability regardless of insurance status. This sliding scale can be a great help for people who

are insured also because of the extremely marked up treatment cost of effective medications that

are not usually covered. This also enables some people who are insured to use multiple

treatments (not often covered by insurance) in order to completely reduce their viral load until it
 25

is undetectable and they are considered “cured”. This resource may allow Lori to access her

hepatitis C medications at an affordable rate as anyone is eligible.

Athens Gastroenterology Center

Athens Gastroenterology Center is a digestive system specialist center that offers the

hepatitis B vaccine, hepatitis C treatment (alpha interferon & ribavirin), liver biopsies, and blood

testing for elevated liver enzymes. This center has a variety of payment options to help cover

costs: CareCredit accepts most major insurances, and a Cash Patient Fee Schedule that has

discounted prices for full prepayment. This resource is helpful for Lori to get any treatment she

may need and have testing done to assess her liver health. She will likely have insurance

coverage eligibility at this center.

Gastroenterology Associates of Athens

The Gastroenterology Associates of Athens facility provides hepatitis testing through

liver enzyme blood work and a follow-up confirmation test or a liver biopsy. They also provide

hepatitis C treatment (alpha interferon & ribavirin) and offer hepatitis A and B vaccinations.

They accept most major insurance plans, as well as offer discounted prices for those who are

uninsured or don’t want to report. Here, Lori can access treatment, vaccinations, and testing. Lori

will likely have insurance coverage eligibility at this center.

Digestive Disease Clinic

Digestive Disease Clinic has an internist that can help manage hepatitis C infections. This

clinic is a very good resource for Lori if she has other health concerns that arise from hepatitis C

since internal medicine doctors have a broad knowledge of many diseases. Lori could use this

resource as a preventative measure to detect any health issues that can arise from being infected

with hepatitis C, such as liver cancer or fatty liver. This clinic is also associated with both St.
 26

Mary's healthcare and Athens Regional systems, which are both highly reputable organizations.

The Digestive Disease Clinic accepts all major insurance plans which also includes Medicare.

Lori will likely have insurance coverage eligibility at this center.

Northeast GA Gastroenterology Associates

Northeast GA Gastroenterology Associates website has extensive educational resource

links for people living with hepatitis C that could be utilized in Lori’s case. Also, the health

center specializes in chronic liver diseases. Therefore, this office can both help Lori maintain

regular checkups for her hepatitis C and screen for hepatitis C risk factors at the same time.

Northeast GA Gastroenterology Associates accepts all major insurance plans, all major credit

card companies, and requires appointments to be made in advance. Lori will likely have

insurance coverage eligibility at this center.

Women’s Healthcare Associates

Women’s Healthcare Associates offers comprehensive gynecologic and obstetric care to

women of all ages. This facility offers fertility evaluations and infertility treatment options:

artificial insemination, intrauterine insemination, and fertility drugs. They provide financing

options such as CareCredit through the financial office and will include applicable fees and

inform a patient of all costs before treatment is administered. This resource is provided for Lori

because she hopes to have children eventually and having an HCV infection can cause potential

complications conceiving, in utero, and during/at birth. It is assumed Lori has medical insurance

and this center accepts most major medical insurance companies. Therefore, it is believed she

qualifies. However, if she was using Medicare or Medicare Advantage it would not be accepted.

Regardless of status, insurance may only partially cover some services and different centers'
 27

pricing may vary. Thus, a second resource is also provided to get a second opinion and other

price options.

Women’s Center of Athens

The Women’s Center of Athens offers gynecological and obstetric care to women of all

ages. Fertility evaluation, bloodwork, and fertility treatment is provided at this center. This

facility accepts most major insurances and expects a copay at the time of service for each visit.

This center can be used if Lori decides to start trying to have a baby to ensure a safe pregnancy

and birth. If certain treatments are given, the center may ask for partial payment until insurance

covers costs. In this case, the coverage cost one’s insurance provides will be refunded to the .

This is a helpful option for Lori because it has very little restrictions on patient eligibility and is

designed for people with insurance.

Children’s Healthcare of Atlanta - Gastroenterology, Hepatology, and Nutrition

Children’s Healthcare of Atlanta has a pediatric clinic in Athens that specializes in

gastroenterology and has hepatitis treatment for pediatric patients. This would be a valuable

resource for Lori and her husband if they do have children and their child contracts Hepatitis C

from Lori. The clinic accepts Medicaid and other private insurance plans. They have financial

counselors that can discuss ways to afford medical care. Even though the clinic is not currently

accepting patients because of the COVID-19 pandemic, it is a valuable resource for the future.

This resource would be helpful if Lori has a child that is diagnosed with hepatitis C.

GI Care for Kids

GI Care for Kids would be useful for Lori if she does indeed have a child and her

hepatitis C infection transmits. The health center accepts all major health insurances and also has

special programs designed for children. Peachcare for Kids is a special program that offers very
 28

low-priced medical coverage to Georgia residents under the age of 18. Discounted prices are also

applied based on insurance statuses. The website for the health center is a tool in itself because it

explains conditions, treatments, and procedures a child may endure at the facility. In this case,

the website could be used by Lori to see what her future child's quality of life may look like.

There are also certain resources on the site geared towards children and could be used to explain

a condition to a child.

Athens Nurses Clinic

Athens Nurses Clinic is a privately and publicly funded non-profit healthcare clinic that

offers free services if an individual meets the following qualifications: their household must be

below 150% of Federal Poverty Guidelines for each individual household size, be uninsured, and

fall within the scope of care provided at the clinic. This clinic offers hepatitis C treatment and a

hepatitis testing panel. The service listed is not recommended for Lori since she is assumed to be

insured and making enough money to not be considered impoverished.

Mercy Health Center

Mercy Health Center is a non-profit that provides clinical services for the underserved

community of Athens. These services include Hepatitis testing and treatment and are free of

charge for those who meet eligibility requirements of the center (uninsured, at or below 150%

the Federal poverty level, and a resident of one of the counties listed). This service is also most

likely not applicable to Lori either. However, others suffering from HCV could potentially

benefit from this service.

Lack of Support Resources

In Athens specifically, there is a lack of support resources for people affected by HCV.

Due to the stress that can come with this diagnosis, having support groups and resources in one’s
 29

community is important. These groups are helpful for gaining knowledge about liver health and

liver disease, evaluation of treatment options, decreasing feelings of isolation, learning about

behavioral risk factors, local resources, a place to express emotions, finding out more about

hepatitis, and emphasizing self-care (U.S. Department of Veteran Affairs, 2004). By providing

this support in proximity to or readily available in the facilities where individuals affected by

HCV get treatment and care, it increases the chances of the treatment clearing the virus. This can

prevent one from having to have multiple rounds of treatment or more invasive procedures due

to progression of the disease. These facilities in Athens offering hepatitis C treatment such as

Athens Neighborhood Health Center, Athens Gastroenterology Center, Gastroenterology

Associates of Athens, Digestive Disease Clinic, Northeast GA Gastroenterology Associates,

Athens Nurses Clinic, Mercy Health Center, Women’s Healthcare Associates, Children’s

Healthcare of Atlanta Gastroenterology Clinic, and GI Care for Kids, should consider having

support groups. The support resources should include providing easy-to-read information packets

on HCV at facilities when a person tests positive, so one can do further research with the right

tools and instead of following possible misinformation. All these facilities can also aim to

include more financial assistance programs, such as sliding scale fees or discounts. Also, if the

organization can’t provide assistance, they could provide resource information about

organizations that can offer financial help (Rauf et al., 2021).

Part D: Community Resource Handout

For these resources in Athens that offer services at a cost, there are limitations accessing

pricing information for testing and treatment centers. There is also limited availability on the

specificity of the services offered and how individuals can qualify for certain resources. This is

due to the great variance in cost that can occur for hepatitis C treatment that depends on the
 30

treatment plan recommended by an individual’s doctor and their insurance status or type of

insurance. This can create major barriers for Lori when trying to access treatment.

Insured Resource
ATHENS NEIGHBORHOOD HEALTH CENTER
402 McKinley Drive Athens, Ga 30601
Phone: 706-543-1145
Fax: 706-549-0056
Email: cstephens@aneighbor.org

675 College Avenue Athens, Georgia 30601

Phone: 706-546-5526
Fax: 706-546-5687
Email: tpass@aneighbor.org

870 Gaines School Road Athens, Georgia 30605

Phone: 706-546-7463
Fax: 706-549-0973
Email: lhopkins@aneighbor.org

Services: Hepatitis C testing through blood work, ultrasounds, liver biopsy, and Hepatitis C
treatment through prescription of medication

Athens Neighborhood Health Center has three locations throughout Athens. The health
center is open Monday, Wednesday, Friday from 8am to 5pm, Tuesday from 8am to 7pm, Friday
from 8am to 2pm, and Saturday from 8am to 12pm. The center is closed on Sundays. They
provide chronic and acute care of Hepatitis, including testing through blood work, ultrasounds,
liver biopsy, and treatment through prescription of medication. The center offers a pharmacy
where patients can receive medications (if they qualify) at a reduced cost due to the support of
federal programs. New patients can make an appointment over the phone and they offer services
in English and Spanish. The center accepts all insurance programs except for Kaiser, Medicare
for Cigna (Cigna Health Springs), and Wellcare. If a patient is uninsured, the center provides an
option for paying for services on a sliding-scale payment plan based on the individual’s income
level. This is open to residents of Athens-Clarke County and surrounding counties. The baseline
uninsured cost of an office visit is $25 and for blood work, including liver enzyme testing the
cost is $2.77. The center is a part of the Federal 340B Medication Program under the Public
Service Act. This federal government program requires Medicaid participating pharmaceutical
companies to provide outpatient medications to health care organizations at discounted prices.
This includes community health centers, such as Athens Neighborhood Health Center which is
federally qualified. These reduced medication prices increase accessibility for both insured and
uninsured patients alike. For Lori, who is likely insured, this would be a helpful resource for her
to afford her hepatitis C prescriptions. These costly medications are available at a much lower
cost at this center. At the McKinley Drive location, the center has its own pharmacy. This makes
 31

prescription pick up convenient for patients. This pharmacy also offers mail and same-day home
delivery for eligible prescription orders.
Although it was difficult to find the specific services offered by this center, as well as the
exact pricing, this is the top resource recommendation for Lori due to the general services they
offer. The acute and chronic care offered is valuable because it is unknown whether Lori will
recover from HCV with minor treatment or if this will be a lifelong illness for her. This resource
is especially valuable due to the sliding-scale payment plan that the center offers based on an
individual’s income. So regardless of whether her insurance is accepted at this center she will
have the option of paying for her services based on her yearly income.

Treatment Center Resources

ATHENS GASTROENTEROLOGY CENTER
21 Jefferson Place, Athens, GA 30601
Phone: 706-548-0058
Fax: 706-548-0555
Email: N/A
Services: Hepatitis C testing through blood work for liver enzyme levels and liver biopsies,
Hepatitis C treatment through prescription of alpha interferon & ribavirin, Hepatitis B vaccine

Athens Gastroenterology Center is a digestive system specialized center that accepts most
major insurances. The center is located at 21 Jefferson Place, Athens, GA 30601. There are also
other payment options if one does not currently have funds or insurance. Qualifying persons can
apply for CareCredit, which is medical credit, in order to get the desired procedure or make an
appointment. It allows an individual to get immediate service and pay later but it is not clear how
an individual qualifies). If the individual does not qualify for this credit, Athens
Gastroenterology Center also offers pre-payment plans so they can have their appointment or
procedure paid off before the date that it occurs. There is also an option for those who do not
have insurance called the Cash Patient Fee Schedule that has discount prices with discounted
prices for full pre-payments. If an individual has qualifying insurance or is able to commit to one
of these programs, they are eligible to receive services, The center offers Hepatitis C testing
through blood work for liver enzyme testing and liver biopsies. The Hepatitis B vaccine is also
offered here. Hepatitis C treatment is offered through the prescription of alpha interferon and
ribavirin. If an individual is actively sick, they are able to get a “same-day” appointment with a
mid-level provider. Some of these procedures may be conducted at outside locations: Athens
Endoscopy, LLC, Athens Regional Medical Center, St. Mary’s Hospital, Landmark Hospital.
This center and all associated surgical locations are located in Athens. Their hours are Monday
through Friday 9am-5pm. They also have telehealth appointments available, which are accessible
through their website.
This is another valuable resource for Lori to get tested and get treatment even if her
insurance is not accepted. The Athens Gastroenterology Center offers CareCredit which would
allow her to get immediate treatment and then pay later. But because it is not clear what
qualifications she needs to meet in order to get the credit, they also offer an option for people
 32

who might not qualify. This would allow her to pay for her procedure or appointment beforehand
and then later attend the service.

GASTROENTEROLOGY ASSOCIATES OF ATHENS

340 N. Milledge Avenue, Athens, Georgia 30677
Phone: 706.548.0008;
Fax: 706.369.9673
Email: N/A
Services: Hepatitis C testing through liver enzyme blood work and a follow-up confirmation test
or a liver biopsy, Hepatitis C drug treatment through prescription of alpha interferon & ribavirin,
Hepatitis A and B vaccinations

The Gastroenterology Associates of Athens offers services for adult and pediatric patients
who range from having minor GI problems to chronic digestive conditions. The center is located
at 340 N. Milledge Avenue, Athens, Georgia 30677. Their hours are Monday through Friday
from 8am to 5pm. They accept most health insurance plans like: Aetna, Beech Street,
Bluecross/Blueshield, Cigna, Coventry, First Health, Health Plan Select, Kaiser Permanente,
Private Healthcare Systems, and United Healthcare. They also accept Medicare and Medicaid,
and offer financial assistance by making discounted rates available for those who don’t have
health insurance or simply wish to pay without filing for coverage. The facility offers Hepatitis C
testing through liver enzyme blood work and a follow-up confirmation test or liver biopsy for
$500 at the self-pay rate. The drug treatment options include alpha interferon and ribavirin for
minor cases but the facility recommends considering transplant options in patients with liver
failure (severe cases). They also offer Hepatitis A and B vaccinations (Twinrix) together for $160
at the self-pay rate, separately the Hepatitis A vaccine (HAVRIX) is $120 and the Hepatitis B
vaccine (ENGERIX-B) is $130 at the self-pay rate. There are over 50 locations all over Georgia
(and one in North Carolina), and there is a medical office and endoscopy center in Athens,
Georgia.
This is also a valuable resource for Lori to get tested and get treatment even if her
insurance is not accepted. The Gastroenterology Associates of Athens offers discounted prices
for those who don’t have insurance but also for those who might not want to or can’t use their
insurance. This would allow her to pay for her procedure or appointment at a decent price and
get the services she needs.

DIGESTIVE DISEASE CLINIC

170 Hawthorne Park Athens, GA 30606
Phone: (706) 549-1222
Fax: 706-549-9975
Email: N/A
 33

Services: hepatitis C testing through blood work, liver enzyme testing, liver biopsies, treatment
plans through prescription for hepatitis C medication and pain management, vaccinations for
hepatitis A and B, and treatment of interconnected diseases

Dr. Ranjit runs and owns the digestive disease clinic in Athens, GA. He specializes in
gastroenterology and is considered an internist. This clinic is associated with the accredited St
Mary’s Health Care system and Piedmont Athens Regional system. It is open Monday through
Friday, 9:00 am to 5:00 pm. As of right now, Dr. Ranjit is accepting new patients and also is
accepting of most insurances as well as Medicare. There are 23 insurance plans listed that he
covers, with some of the more well known ones being Anthem, Blue Cross Blue Shield,
MultiPlan, Aetna, Alliant Health Plan, CIGNA, and Kaiser permanente. This private
organization accepts both mastercard and visa as acceptable forms of payment. One of Dr.
Ranjit’s many listed speciality expertise is in hepatitis C. Although the exact prices of tests and
procedures vary this private organization is still considered to be average to inexpensive.
Services offered in this office are hepatitis C testing through blood work, liver enzyme testing,
and liver biopsies. They offer treatment plans that include prescribing medication for hepatitis C
and pain management. They also offer vaccinations for hep A and B and additional treatment of
interconnected diseases of hepatitis C.
Although there is limited pricing information with this resource, if Lori’s insurance
qualifies, this could be a useful resource for testing and treatment. It is especially helpful if Lori’s
illness becomes chronic and her symptoms are more severe because the Digestive Disease Clinic
could provide her with pain management services as well as additional treatment for any
comorbidities that may arise due to her hepatitis C.

NORTHEAST GA GASTROENTEROLOGY ASSOCIATES

700 Sunset Dr Ste 501, Athens, GA 30606
Phone: (706) 208-0065
Fax: (706) 549-8693
Email: N/A
Services: hepatitis C testing, endoscopic retrograde cholangiopancreatography (ERCP),
treatment plans for hepatitis C through prescription medication, and treatment of hepatitis C
comorbidities

Dr. Swindle is the one practicing physician at this location in Athens, GA. Her
specialities include gastroenterology and chronic liver disease. Her practice is associated with
Gastroenterology Associates Of Gainesville and can treat conditions often associated with
hepatitis C, such as cirrhosis and fatty liver. This office can diagnose hepatitis C and offers
treatment plans through prescriptions, as well as complete regular work-ups for liver cancer. It is
open Monday through Friday 9:00 am to 5:00 pm. There is no exact cost listed for this office's
work, but hepatitis C treatment uninsured is very high. The office will not directly disclose
pricing information and do not have a website available but other sources state it varies based on
the patient's insurance status and case. Some accepted insurance plans are: Anthem, Blue Cross
Blue Shield, MultiPlan, Aetna, Alliant Health Plan, CIGNA, and Kaiser permanente. Therefore,
it's important to note that this office claims to accept most insurance plans but it's important to
double check while making the appointment. Payment methods used by this office include
Mastercard,American Express, Discover, and visa. Medicare is accepted. They also provide
 34

chronic hepatitis C education and injection training experience, and offer information about the
International Foundation for Functional Gastrointestinal Disorders, American liver foundation,
and American Gastroenterological Association. A referral to this office is not needed but
appointments are not meant to be immediate so it's important to plan in advance.
This resource was very difficult to find information on, as the center does not provide an
official website. But if Lori’s insurance qualifies, this could be a useful resource to get treatment.
It would be most helpful for comorbidity treatment because of the connection to the
Gastroenterology Associates of Gainesville. But the vagueness of how testing is conducted and
the types of medication provided for treatment as well as unknown pricing might not make this
the best resource for testing and drug treatment.

Fertility Centers
WOMEN’S HEALTHCARE ASSOCIATES
355 Hawthorne Lane, Athens GA 30606
Phone: 706-369-0019
Fax: 706-369-1819
Email: wwebsite@awhg.org
Hours: Monday-Thursday: 8am-5pm, Friday 8am-12:30pm
Services: fertility evaluation ($164-$250 for appointment, $250+ for further testing), infertility
treatment (artificial insemination, intrauterine insemination, & fertility drugs)

Women’s Healthcare Associates offers comprehensive gynecologic care to women of all ages.
The facility is located at 355 Hawthorne Lane, Athens GA 30606. There are physicians, certified
nurse midwives, a physician’s assistant, and a nurse practitioner specializing in obstetrics and
gynecology at this center. Relevant services offered are fertility evaluations and infertility
treatment options: artificial insemination, intrauterine insemination, and fertility drugs. Without
insurance, the out-of-pocket costs for a fertility evaluation appointment ranges between $164 to
$250 for an appointment. For further testing after the evaluation, the cost is $250+. The fertility
evaluation begins with an initial consultation with any of the facility’s providers. Depending on
how this consultation goes, further evaluation will be done. This could consist of bloodwork
(sometimes these labs are needed during a specific time in a woman’s cycle), partner’s semen
analysis, ultrasounds looking for tube blockages, fibroids, polyps, and at-home ovulation kits to
monitor the cycle. For certain cases, such as the patient having a chronic disease, they coordinate
care with Dr. Richard Roseman, a Maternal-Fetal Medicine Specialist. The infertility treatment
options, artificial insemination, intrauterine insemination, and fertility drugs vary greatly in price
depending upon which options are recommended by doctors and which options the patient
decides to pursue. Women’s Healthcare Associates does not accept Medicare or Medicare
Advantage insurance. They can also estimate coverage, but cannot guarantee that an
appointment/procedure will be covered by one’s insurance. There are financing options such as
CareCredit through the financial office. This can help someone cover upfront costs, and pay later.
Once an individual has a treatment plan, this will include applicable fees and inform this person
of all costs before treatment is administered.
 35

WOMEN’S CENTER OF ATHENS

1181 Langford Drive, Building 300 Suite 101 Watkinsville, Georgia 30677
Phone: 706-227-8999
Fax: 706-227-6118
Hours: 8:30am-5pm Monday-Friday
Services: bloodwork, high risk pregnancy care, infertility evaluation

The Women's Center of Athens provides Obstetric and Gynecology care to women of all ages.
The center is located at 1181 Langford Drive, Building 300 Suite 101 Watkinsville, Georgia
30677. This center provides infertility evaluation and treatment and can provide options for
addressing infertility. After examining a patient’s medical history, the center can provide more
information about medications, ultrasounds, and procedures to address infertility. Some surgical
procedures can be done directly at the center, while more invasive procedures may require a
referral. There is also an on-site phlebotomist that draws, preps, and processes blood work at
LapCorp. This prevents patients from having to schedule a separate appointment for blood work.
The lab hours are 8:30am to 5pm, with a lunch break from 12pm-1pm. If insurance directs a
patient to a different lab, LabCorp will send the sample to that location. The center has three
obstetricians that are able to provide care during pregnancy. The Women’s Center of Athens
accepts most insurance plans at their office: Aetna, Beech Street, Bluecross/Blueshield, Cigna,
Coventry, First Health, Health Plan Select, Kaiser Permanente, Private Healthcare Systems, and
United Healthcare. For services at the center one may be asked to pay a portion of their bill the
same day and a copay is expected at the time of service for each visit. The center will directly
bill one’s insurance. If insurance pays for a service that an individual has already paid for, the
center can reimburse this cost or keep a credit on file.

Child Treatment Centers

CHILDREN’S HEALTHCARE OF ATLANTA – GI, HEPATOLOGY, NUTRITION
1230 Baxter Street Athens, Georgia 30606
404-785-5437

Children’s Healthcare of Atlanta (CHOA) provides services for pediatric care of hepatitis A, B,
and C. They provide treatment and vaccinations for hepatitis. CHOA provides treatment to
pediatric patients from birth to age 21. CHOA accepts most major healthcare providers and
offers financial assistance that may fully or partially cover services. Patients with a household
income that is at or below 340% of the Federal poverty level have a sliding scale to determine
assistance and percentage off. They accept Medicaid and PeachCare for Kids. Specific costs for
pediatric testing and treatment were not listed or available to find. The gastroenterology clinic is
temporarily closed due to the COVID-19 pandemic with no listed prospective re-opening date.
 36

GI CARE FOR KIDS

1360 Caduceus Way Building 300, Suite 101 Watkinsville, GA 30677
Phone: (404) 257-0799
Email: billing@gicareforkids.com
Fax: (404) 256-5475
Hours: Monday - Thursday 8 am - 5 pm, Friday 8 am - 4:30 pm
Services: pediatric (up to 18 years of age) hepatitis C services include: blood test over several
days or weeks to determine the exact cause of liver inflammation, ultrasound of liver (to
determine how much damage there is), liver biopsy, hepatitis diagnosis/medications, counseling
for hepatitis, physiatric services, dietary counseling, and vaccinations for both hepatitis A and B.

GI care for kids accepts most major insurance plans, as well as Medicaid and Peachcare for Kids
programs. This office takes both in-network and out-of-network patients and out-of-pocket
expenses are dependent on where the patient is financially situated (out-of-pocket being higher).
For those uninsured, a 30% discount is offered on all charges. A standard visit for a new patient
would be ranging from $131 to $435 with a follow-up appointment typically being anywhere
from $89 to $294 (this also qualifies for the discount). Prices for lab work and procedures are
highly contingent on deductibles and coinsurance and all patients are expected to pay 50% of the
estimated cost before procedures take place. GI Care for Kids emphasizes the importance of
using registered psychologists and dieticians in treatment plans. They also provide explanations
of conditions and procedures on their website, and compile a list of other resources for education
and support on the condition. Although a referral to GI Care for Kids is needed before making an
appointment, they are typically always accepting new patients.

Uninsured Resources
ATHENS NURSES CLINIC
240 North Avenue, Athens GA 30601
Phone: 706-613-6976
Fax: 706-613-1055
Email: clinic@athensnursesclinic.org; paige.athensnursesclinic@gmail.com
Services: hepatitis C testing through blood work, ultrasounds and liver biopsies, further testing
through fibroscans, hepatitis C treatment through hepatitis panel patient assistance program
including prescription medication
The Athens Nurses Clinic is a non-profit healthcare clinic that is both privately and
publicly funded and offers free services if one qualifies. Relevant services offered at this clinic
are hepatitis C Treatment and a hepatitis panel. The requirements to be a patient at Athens
Nurses Clinic include not having any health insurance including Medicare, Medicaid, or Veterans
benefits. If an individual is uninsured or low-income, this non-profit clinic offers free education,
evaluation, and treatment for chronic and acute medical and dental conditions, such as hepatitis
C. They specifically have a program, “Free From C” sponsored by the Jackson EMC Foundation,
which focuses on hepatitis C testing through blood work, ultrasounds and liver biopsies and
treatment through medication (Jackson EMC, 2020). Due to the clinic’s limited hours it may be
difficult to make an appointment or walk-in during operation hours. Those who have tested
 37

positive for hepatitis C, further tests are conducted: such as a fibroscan to examine liver fibrosis
levels. Patients will then meet with a multi-focal group of counselors and be placed on the
appropriate antiviral medications. hepatitis C treatment will not start immediately, as patients
must go through the proper appointments and testing. The clinic utilizes their prescription
assistance program to find the best option for each patient. Patients will stay on these
medications for a minimum of a six month period and have follow-up laboratory testing. The
Athens Nurses Clinic is very clear that in order to qualify for services one’s household income
must be below 150% of Federal Poverty Guidelines for each individual household size, be
uninsured, and fall within the scope of care provided at the clinic. Individuals must provide
acceptable proof of household income, such as previous years filed federal tax forms. This center
is located in Athens. Their hours are Monday through Wednesday 8:45am-2:00pm for
appointments.

Due to the assumption that Lori is insured because she has a job, and that she is above the
federal poverty level she would not qualify for service at the Athens Nurses Clinic. But if her
circumstances did change and she no longer had insurance and her yearly household income fell
below the 150% Federal Poverty line this could be a useful resource.

Number in 150% of Federal Poverty

Household Level (annual income)

1 $18,216

2 $24,696

3 $31,176

4 $37,656

MERCY HEALTH CENTER

700 Oglethorpe Avenue Suite C7, Athens, Georgia 30606
Phone: 706.425.9445
Email: info@mercyhealthcenter.net
Services: hepatitis C testing through blood work, ultrasounds and liver biopsies, hepatitis A and
B vaccinations

The Mercy Health Center offers clinical services for the underserved community of
Athens. The center is located 700 Oglethorpe Avenue Suite C7, Athens, Georgia 30606. These
services include primary care, dental, gynecology, gastroenterology, physical therapy, neurology,
vision care, orthopedics, rheumatology, pulmonology, urology and more. They also offer
wellness resources, behavioral health services and have an onsite pharmacy but it is unclear
whether they offer prescriptions specific to hepatitis C. Their hours are Monday through Friday,
8:30am to 4:40pm, hours are extended until 8pm on Tuesday, Wednesday and Thursday. New
 38

patients must call between the hours of 4-5pm on Tuesdays to schedule new patient
appointments. For patients who suspect or are at risk of hepatitis C there are evaluations
available to assess needs using blood work, ultrasounds and liver biopsies. They also provide
hepatitis A and B vaccinations. The staff that provides services are volunteer doctors, physician
assistants, nurse practitioners and registered nurses. The eligibility requirements for Mercy
Health Center patients are to be completely uninsured, at or below 150% the Federal poverty
level, and a resident of either Clarke, Barrow, Jackson, Madison, Oglethorpe and Oconee. The
services are free of charge. The center is located in Athens, Georgia.
Due to the assumption that Lori is insured because she has a job, and that she is above the
federal poverty level she would not qualify for service at the Mercy Health Center. They require
individuals to meet at least one of the two qualifications. But if her circumstances did change and
she no longer had insurance or her yearly household income fell below the 150% Federal
Poverty line this could be a useful resource.

Part E: Sustainable Solutions

Affordable Prescriptions for Treatment

Hepatitis C treatment has notoriously involved a lack of affordable prescriptions because

of pharmaceutical giants placing patents on vital medications (Iyengar et al., 2016). Hepatitis C

is curable, but without proper direct acting antivirals (DAA), it can be fatal (Iyengar et al., 2016).

In the United States, the two main pharmaceutical companies responsible for the control of

pricing for hepatitis C are Roche and Merck & Co. (World Health Organization, 2015). Many

Americans living with hepatitis C need treatments these companies produce, but have a difficult

time accessing the treatment because both companies are focused more on profit margins, rather

than making the product more low cost and accessible to people living with hepatitis C. Thus,

these companies have successfully monopolized the market. Currently, market segmentation is

being implemented through government intervention and large discounting is taking place in

order to increase the volume of drugs circulating and to lower the cost (Edward, 2015). Market

segmentation is diversifying pricing policies within a country to improve access (Edward, 2015).

For example, if a policy that aided in creating licenses for generic versions of drugs would allow
 39

patent-holders the right to retain a monopoly over higher income segments, then it would allow

more drug brands to circulate (Edward, 2015). Thus, more high-volume/low-cost drugs would

become more readily available and affordable (Edward, 2015).

As for pricing, hepatitis C drugs typically average around US $84,000 per treatment

course (Edward, 2015). The monopolization can be seen when looking at the production cost

which only ranges from US $68 to US $136 per treatment course (World Health Organization,

2015). Most people need at least one 8-12 week treatment (~1 course), but some need multiple

treatments in order to clear the infection (World Health Organization, 2015). It is clear the

pricing of hepatitis C medications is controversial, due to the conflicting interests between the

public and pharmaceutical companies. A call to action is needed by companies, governments,

and people in order to make a substantial impact on the supply of affordable treatments (Iyengar

et al., 2016).

Social movement lessons for hepatitis C are also being taken from the HIV/Aids

pharmaceutical history (Edward, 2015). This is because, similarly, the high quality medicine

needed to treat HIV/Aids had unnecessarily inflated prices. Through activism, advocates were

able to push pharmaceutical companies to not place restrictions on life saving medicines and

propose more inclusive solutions (Edward, 2015). These solutions involved less restrictions and

more broad range ways to supply medications, making these drugs more affordable (Edward,

2015). Since many people that are living with HIV/Aids also have hepatitis C, many people have

been able to see how hepatitis C medication supply has had similar issues (World Health

Organization, 2015). Similarly to HIV/Aids, hepatitis C is underdiagnosed and can cause

life-long illness/death (Edward, 2015). In both diseases, there are new effective products on the

market that can help prevent the spread, but these lack affordability (Edward, 2015). Lessons can
 40

be learned from the unnecessary inflation of HIV/Aids medications, which proves that high

quality generic products can be achieved with some regulatory requirements (Edward, 2015)

In Athens, access to hepatitis C medications and services vary based on the center. Some

available options here include Gastroenterology Associates of Athens, Children's Healthcare of

Atlanta, Digestive Disease Clinic, GI care for kids, Northeast Ga Gastroenterology Associates,

and Mercy Health Center (Georgia Department of Public Health, 2015). Mercy Health Center

has free hepatitis C services contingent on meeting eligibility requirements. The requirements for

eligibility include being completely uninsured, at or below 150% of the poverty line, living in

Clarke county, and having documentation (Mercy Health Center). Both Medicare and Medicaid

offer treatment service for people with hepatitis C. Medicare offers Hepatitis C preventative

screening with often no cost and at least covers one treatment according to Medicare part D.

Medicaid is less likely to cover treatment because of drug and alcohol screenings not being

performed, therefore in these situations it's important to be one's own advocate. Gastroenterology

Associates of Athens accepts Medicare plans and Children's Healthcare of Atlanta accepts

Medicaid plans (Georgia Department of Public health, 2015). Putting Medicare and Medicaid

aside, all other centers listed besides Mercy Health Center (which is free) accept most major

insurance plans (Georgia Department of Public health, 2015). Levels of insurance given can vary

based on the insurance holder's policies and overall health. However, some insurance providers

make people get tested for drug and alcohol usage before authorizing treatments. Typically, even

with insurance hefty out-of pocket fees can still exist. However, every place listed (again, besides

Mercy Health Center) also has financial assistance or sliding scale fees available (Georgia

Department of Public health, 2015) . This means that affordable options for hepatitis C
 41

medications are available. However, the right initiatives need to be taken to find the center that is

best best suited to the person.

The high cost of treatment creates a barrier for insured and uninsured people. Many

health insurance companies restrict approval of coverage for treatment because of the high cost.

The treatment is limited to people with advanced liver fibrosis and abstinence for alcohol or drug

use (Penn Medicine News, 2018). Guidelines from the Infectious Diseases Society of America

and the American Association for the Study of Liver Disease recommends that anyone diagnosed

with hepatitis C be treated with a direct-acting antiviral treatment course (2021). However, large

pharmaceutical companies make it hard for health insurance companies to cover the treatment

and furthermore for people to receive treatment that is affordable. Governmental legislation that

lowers the cost of hepatitis C treatment is vital to reducing the spread of hepatitis C and

increasing the quality of life for those diagnosed with hepatitis C. A national healthcare system

within the United States would allow all people to receive the treatment required for hepatitis C

because it would lessen the ability for large pharmaceutical companies to price treatments

extremely high and cause health insurance companies to restrict coverage.

Access to Medicaid in Georgia

Medicaid is an essential service that provides health insurance to many Americans that

could not afford it otherwise. Medicaid allows hepatitis C treatment to help many Americans that

are in need. However in Georgia, citizens lack access to Medicaid and access to affordable

hepatitis C treatment through Medicaid.

As previously mentioned in the health section, additional requirements create barriers for

individuals that need Medicaid to cover hepatitis C treatment because of the fee-for-service and

the Medical Care Organization has additional restrictions on who can qualify for the treatment.
 42

The liver damage or diagnosis requirements and sobriety requirements create a barrier for

patients that are covered under Medicaid and limit access to hepatitis C treatment under

Medicaid. Medicaid coverage in Georgia should be expanded to cover the primary and secondary

prevention of HCV so that severe liver damage does not occur. Many MCOs require chronic and

severe liver damage before treatment is authorized, however, this causes HCV to continue to

spread and does not preserve the quality of life for those living with hepatitis C. The expansion

of Medicaid coverage for hepatitis C requires public policy through the state government to

require set guidelines for FFS and MCOs. Having consistent guidelines across all MCOs and

FFS programs will allow for Medicaid eligible patients to further understand the requirements. If

sobriety requirements are necessary for treatment, Medicaid must provide treatment programs

that are covered under FFS or MCOs to give the patients affordable options for substance use

treatment programs and hepatitis C treatment programs. Medicaid expansion is determined by

the federal government and must be passed by the states. The expansion and uniformity of

treatment coverage for hepatitis C under Medicaid would allow for more Georgians to receive

treatment and the overall health of Georgia’s population living with hepatitis C would increase.

Access to Insurance for Immigrants

Health insurance is difficult to obtain for immigrants that are documented and

undocumented citizens of the United States. Each state has different guidelines for health

insurance qualifications. The Health Insurance Marketplace is a resource that provides guidance

for individuals wanting to purchase health insurance in the United States (Coverage for lawfully

present immigrants 2021). Lawfully present immigrants are eligible to use this resource.

Lawfully present immigrants include immigrants that have a “qualified non-citizen” immigration

status without a waiting period, humanitarian statuses, valid non-immigrant visas, and legal
 43

status confirmed by other laws. Lawfully present immigrants can buy private health insurance

and may qualify for coverage through Medicaid or Children’s Health Insurance Program (CHIP)

if they meet the state requirements (Coverage for lawfully present immigrants 2021). Unlawfully

present immigrants are not eligible to purchase health insurance through a private health

insurance company or Medicaid.

A major barrier for lawful immigrants that see health insurance coverage through

Medicaid is the 5-year waiting period that must be completed after receiving their immigration

status (Rosenbaum et al., 2021). While there are exceptions to the 5-year waiting period, the

period reduces the number of immigrants that are able to receive Medicaid and could have

negative effects on their health status. States can choose to remove the waiting period to cover

lawfully present children and pregnant women through Medicaid or CHIP (Rosenbaum et al.,

2021). By 2017, only 31 states waived the waiting period for children and only 23 states have

waived the waiting period for pregnant women (Rosenbaum et al., 2021). Georgia has a five year

waiting period for immigrants to receive Medicaid health insurance, this includes pregnant

women and children (Harker, 2019).

The five year waiting period is a major barrier for lawfully present immigrants to receive

necessary medical care (Harker, 2019). Without Medicaid, many immigrant families go without

health insurance and do not visit the doctor because of the cost. This causes many immigrants to

have health decline during this time because primary prevention cannot occur often without a

visit to the physician. Primary prevention screens to health risks prior to health risks becoming

detrimental to health, this may include screening and vaccinations. The United States and

Georgia should eliminate the five year waiting period of lawfully present immigrants to receive

health insurance quickly. This solution requires national and state legislation from the Georgia
 44

General Assembly to change the waiting period and the requirements for being classified as a

lawfully present citizen.

Transmission in Healthcare Setting

The main mode of hepatitis C transmission through contaminated needles in healthcare

facilities means that reducing the transmission within these facilities will significantly lower

hepatitis C rates. The Centers for Disease Control recommends a variety of practices that can be

implemented to prevent HCV infection and aid those that have been infected. Firstly, public

safety workers, emergency medical workers, and healthcare providers need to be educated on

risk factors and prevention methods regarding bloodborne infections (Centers for Disease

Control, 1998). This includes vaccination against hepatitis B. There needs to be standardized sets

of precautions utilized to prevent exposure. The US Department of Health & Human Services

reports that improved education, enhanced infection control practices, oversight, and

enforcement can reduce the viral transmission of hepatitis in healthcare settings (U.S.

Department of Health & Human Services, 2016). Furthermore, protocols are needed once a

patient has been exposed to blood or bodily fluids containing blood. These protocols could

include: washing open wounds with soap and water, determining type of exposure, determining

associated risk, counsel exposed persons regarding risk, test source and exposed individuals for

hepatitis C antibodies, vaccinated against hepatitis B, and test for liver enzymes (New York State

Department of Health, 2005). These protocols should occur as soon as possible after exposure,

whether exposure occurs in a healthcare setting or elsewhere. At all times health professionals

should be following strict sanitizing techniques: thorough handwashing, sanitization of medical

equipment, protective barriers, requiring glove use when touching bodily fluids or contaminated

materials, employee training, protective clothing, and care when disposing needles and other
 45

sharp instruments (New York State Department of Health, 2005). These precautions are

especially important when working with a patient known to have HCV or that has possibly been

exposed. Furthermore, there needs to be a reduction in unnecessary injections, blood and blood

products must be universally screened, and facilities need to have infection control measures

(Suthar & Harries, 2015). Communities should focus on training programs for their health

workers to prevent HCV transmission and promote practices that emphasize safe removal of

medical waste.

Local Cultural Support

Research shows that the most common frequent form of transmission of HCV is through

injection drug use or blood transfusions (National Health Society, 2018). Due to the association

of criminal behavior with the transmission of the disease, hepatitis C has been stigmatized

(British Columbia Centre for Disease Control, 2015). It is a blood disease and associated with

illegal drug use, so healthcare practitioners may make stereotypical assumptions and moral

judgments about patients diagnosed with HCV (British Columbia Centre for Disease Control,

2015). When individuals are discriminated against and marginalized for their medical conditions,

they are less likely to have any support networks, or even if they did ,they may not participate

due to chance of discrimination (British Columbia Centre for Disease Control, 2015). In Athens

there is a lack of support groups for HCV specifically, much less support groups specific to those

of South-Asian descent. Despite the lack of HCV support, there are open meetings hosted by the

National Alliance on Mental Illness (NAMI) Georgia sector over Zoom every Monday and

Wednesday at 6:15pm and 6:30pm (National Alliance on Mental Illness, 2021). This link can be

accessed by emailing programs@namiga.org (National Alliance on Mental Illness, 2021). This

could be a helpful resource because fear of stigma and discrimination can take a toll on an
 46

individual’s health on top of the disease they are fighting, and this support group can be a

potential outlet to help process what they are currently going through in their lives (National

Alliance on Mental Illness, 2021). Previous research has shown that the best way to reduce the

stigma around hepatitis C is to work with the system rather than against it by working with

healthcare professionals to establish trust between them and their patient (Schambler, 2006). In a

study of HIV- HCV coinfected drug users, those who reported having a trusted relationship with

their physicians were less likely to share used needles with their peers (Jauffret-Roustide et al,

2012). The increase of trust between physicians and patients shows to improve the health of

patients and their overall health outcome, so this calls for physicians to continue their education

on how to promote trust between them and their patients.

Communication Barriers

When English is not the patient’s first, or even second language, there can be a language

barrier between the healthcare practitioner and the patient (Al Shamsi et. al, 2020). This can lead

to miscommunication between parties and can result in the patient misunderstanding the

guidance from the healthcare professional and/or the healthcare professional misunderstanding

the needs of the patient (Al Shamsi et. al, 2020). There is significant evidence that this results in

lower satisfaction and reduces the quality of care of the healthcare facility (Al Shamsi et. al,

2020). Interpreter services for patients come at a higher cost for the hospital because increased

patient understanding leads to more treatment (the hospital spends more money)(Al Shamsi et.

al, 2020). Hospitals want to spend the minimal amount of money on each patient which leads to

cutting corners (Al Shamsi et. al, 2020). Despite a dramatic increase in satisfaction rates in

hospitals which do implement online interpreter services (i.e. Google Translate, MediBabble),

some hospitals prefer to avoid the minor initial financial burden and carry the cost of unsatisfied
 47

patients and workforce (Al Shamsi et. al, 2020). An increased number of translators with a

diverse set of languages and cultures within a healthcare system is important to the access to

healthcare being consistent for all individuals. A nationalized healthcare system would allow for

consistent access to translators across all languages in the United States and eliminate

communication barriers between healthcare professionals and patients.

 48

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