2018 NYC. Viral Hepatitis Research Symposium

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2 Implementation and Evaluation of a Care Coordination Intervention for Patients with HCV Following Release from the New York City Jails Matthew Akiyama, MD, MSc Montefiore Medical Center / Albert Einstein College of Medicine

3 Disclosures Gilead Investigator Sponsored Research Grant

4 Outline Introduction HCV in correctional settings Linkage to HCV care following release from jail Conclusions/Future directions

5 HCV in Corrections Detainees bear disproportionate burden of HCV Interrelationship between high risk behaviors and incarceration National prevalence 17% Varan AK et al Public Health Rep.

6 HCV in Jail Short lengths of stay High volumes of detainees pass through US jails 1/3 of incarcerated adults 731,000 at any given time 12 million admissions per year 19 times the number in state and federal prisons Opportunity to provide HCV screening and linkage to care Kaeble et al. Bureau of Justice Statistics

7 Linkage to HCV Care Few existing data Rhode Island, 1 North Carolina/South Carolina 2 Variety of components have been used Informational video, posttest counseling, referral to community care, appointment scheduling 17%-56% linked to HCV care after release 1. Beckwith CG et al Schoenbachler BT et al. 2016

8 Objectives To assess the impact of a transitional care coordination intervention on linkage to HCV care To determine barriers to and facilitators of linkage to HCV care

9 New York City Jail System 10 facilities on Rikers Island 4 borough facilities Average daily population of ~10,000 More than 60,000 admissions per year Existing HIV transitional care coordination program No specific program for HCV

10 Methods One armed clinical trial Enrolment 5/2015-4/2017 Inclusion criteria: 18 years old Chronic HCV infection Anticipated release date permitting follow up within study period Exclusion criteria: Unable or unwilling to sign consent Anticipated transfer to prison HIV-infection

11 Methods Care Coordination Intervention Needs assessment HCV education D/c planning by jail-based transitional care coordinator Appointment scheduling (target within 2 weeks of release) Study coordinator contact number Jail Reminder calls Appointment accompaniment Community

12 Methods Primary outcome: Linkage to HCV care within 180 days of release Secondary outcomes: HCV treatment initiation HCV treatment completion SVR

13 Methods Predictors of linkage using the Addiction Severity Index at enrolment Employment, drug/alcohol use, legal status, family/social support, mental health Statistical significance was determined using Chi-square / Fisher s exact tests (p<0.05) EventFlow - visually inspect data and identify relevant temporal event sequences

14 Study Flow Chart 185 Approached for Eligibility 21 Ineligible 13 Pending transfer or sentence > 1 yr 5 Already on HCV Tx 2 Unable to give consent 1 HCV RNA negative 105 Enrolled 100 Followed 5 Excluded (HIV+) 8 Transferred to prison or other jurisdiction 4 Remained in jail 2 HCV Tx pre-release 1 HCV VL cleared 1 Died pre-release 59 Refused 24 Interested in HCV Tx, not in study (alternative provider specified) 8 Interested in HCV Tx, not in study (no alternative provider specified) 5 Not currently interested in HCV Tx 4 Time constraint 1 Will be treated in jail 17 Did not specify 84 Released from index incarceration

15 Results Mean duration of time between enrollment and release was 71 days (SD=101) Participant contacts attempted 3.8 (SD=4.4) 42 (50%) participants successfully contacted Participant NOK contacts attempted 2.7 (SD=2.1) 53 (63%) participants NOK successfully contacted

16 Results Primary Outcome: 26/84 (31%) participants linked to HCV care (median of 20 days) 17 (20%) initiated HCV treatment 15 (18%) completed treatment 7 (8%) out of 9 (78%) w/ 12 week follow-up had SVR

17 Correctional-community continuum of care 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 100% 84% 33% 31% 20% 18% *78% w/ 12 wk f/u * 8% Total Released Reincarcerated Linked Tx Initiation Tx Complete SVR

18 Correctional-community continuum of care 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 100% 84% Intervention? 33% 31% 20% 18% *78% w/ 12 wk f/u * 8% Total Released Reincarcerated Linked Tx Initiation Tx Complete SVR

19 Correctional-community continuum of care 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 100% 84% Intervention? 33% 31% Retention? 20% 18% *78% w/ 12 wk f/u * 8% Total Released Reincarcerated Linked Tx Initiation Tx Complete SVR

20 Participant # Event Flow Plot 33% were reincarcerated within 180 days Reincarceration and linkage equally common initial event (23 participants) 3 participants were linked to care following reincarceration No association between reincarceration within 180 days and linkage to care (p = 0.86) Days

21 Cohort Characteristics Total N = 84 (%) Linked to care N=26 (%) Unlinked to care N=58 (%) Age, mean (SD) 44 (13) 47 (11) 44 (12) 0.29 Female Male Race/ethnicity Hispanic NH Black NH White Other 36 (43) 48 (57) 46 (54) 15 (18) 19 (23) 4 (5) 9 (35) 17 (65) 15 (58) 5 (19) 5 (19) 1 (4) 27 (47) 31 (53) 31 (53) 10 (18) 14 (25) 3 (5) Homeless 22 (27) 5 (19) 17 (30) 0.11 Graduated high school 48 (57) 14 (54) 34 (59) 0.62 Mental illness 53 (63) 13 (50) 40 (69) 0.10 Ever injected 51 (61) 16 (62) 35 (60) 0.92 On methadone 53 (64) 20 (77) 33 (58) 0.03 Feel supported socially 69 (83) 25 (96) 44 (77) 0.03 Alcohol to intoxication 31 (37) 5 (19) 26 (45) 0.02 Primary care provider 19 (23) 9 (38) 10 (18) 0.06 Based on self-report regarding the pre-incarceration period P value

22 Cohort Characteristics Total N = 84 (%) Linked to care N=26 (%) Unlinked to care N=58 (%) Age, mean (SD) 44 (13) 47 (11) 44 (12) 0.29 Female Male Race/ethnicity Hispanic NH Black NH White Other 36 (43) 48 (57) 46 (54) 15 (18) 19 (23) 4 (5) 9 (35) 17 (65) 15 (58) 5 (19) 5 (19) 1 (4) 27 (47) 31 (53) 31 (53) 10 (18) 14 (25) 3 (5) Homeless 22 (27) 5 (19) 17 (30) 0.11 Graduated high school 48 (57) 14 (54) 34 (59) 0.62 Mental illness 53 (63) 13 (50) 40 (69) 0.10 Ever injected 51 (61) 16 (62) 35 (60) 0.92 On methadone 53 (64) 20 (77) 33 (58) 0.03 Feel supported socially 69 (83) 25 (96) 45 (78) 0.02 Alcohol to intoxication 31 (37) 5 (19) 26 (45) 0.02 Primary care provider 19 (23) 9 (38) 10 (18) 0.06 Based on self-report regarding the pre-incarceration period P value

23 Conclusions Integrated jail and community-based care coordination program may be effective in improving timely linkage to HCV care Significant barriers remain Multicomponent intervention aimed increasing social support, linkage to substance use treatment (OAT / alcohol), and primary care Reincarceration - opportunity to reengage individuals who have not yet linked to HCV care

24 Future Directions: HCV-ACCELERATE The HCV-ACCELERATE Trial Advanced Care Coordination and Enhanced Linkage and Retention Among Transitional re-entrants Aim 1: To assess barriers & facilitators of linkage to HCV care Qualitative study Aim 2: To tailor the existing intervention to create an enhanced care coordination intervention Address the barriers & facilitators identified Use peer mentors Aim 3: To pilot test the feasibility and effectiveness of HCV-ACCELERATE in an RCT

25 Acknowledgments Primary Mentors Alain Litwin, MD, MPH, MS Chinazo Cunningham, MD, MS Other Mentors and Collaborators Ross MacDonald, MD Alison Jordan, LCSW Jody Rich, MD, MPH Julia Arnsten, MD, MPH Moonseong Heo, PhD Alison Karasz, PhD Participants HCV Linkage Study Co-authors Jessie Schwartz, MPH Devin Columbus, MA Ellie Carmody, MD, MPH Ben Eckhardt, MD Funding NIDA (K99DA043011) NIDDK (P30DK41296) Gilead Sciences - Investigator Sponsored Research

26 Questions/Contact:

27 References Beckwith CG, Kurth AE, Bazerman LB et ai. J Public Health (Oxf) Mar;38(1): Hennessey KA et al. Prevalence of infection with hepatitis B and C viruses and co-infection with HIV in three jails: a case for viral hepatitis prevention in jails in the United States. J Urban Health.2009 Jan;86(1): Hochstatter KR, Stockman LJ, Holzmacher R et al. The continuum of hepatitis C care for criminal justice involved adults in the DAA era: a retrospective cohort study demonstrating limited treatment uptake and inconsistent linkage to community-based care. Health Justice Oct 30;5(1):10. Jordan AO, Cohen LR, Harriman G et al. Transitional care coordination in New York City jails: facilitating linkages to care for people with HIV returning home from Rikers Island. AIDS Behav Oct;17 Suppl 2:S Kaeble D, Glaze L. Correctional populations in the United States, Bureau of Justice Statistics NCJ Available at: Schoenbachler BT, Smith BD, Seña AC et al. Hepatitis C Virus Testing and Linkage to Care in North Carolina and South Carolina Jails, Public Health Rep May-Jun;131 Suppl 2: Varan AK et al. Hepatitis C seroprevalence among prison incarcerated patients since 2001: still high but declining. Public Health Rep. 2014; 129(2): Wenger PJ, Rottnek F, Parker T, Crippin JS. Assessment of hepatitis C risk factors and infection prevalence in a jail population. Am J Public Health Sep;104(9):