Hepatitis C has been a silent public health crisis.

Transcription

1 WELCOME to October 3, 2012 Hepatitis C has been a silent public health crisis. 1

2 3.2 million to 5.2 million people in the US are chronically infected with hepatitis C Up to 75% of chronically infected individuals are unaware of their infection Chak E. Liver Internat. 2011, 2: Smith BD. AASLD poster #394, 2011 Armstrong GL. Annals of Int Med, ; % of Baby Boomers have been exposed to hepatitis C* 6.31% of African American Baby Boomers have been exposed to hepatitis C *This includes anyone born between

3 More people are now dying of hepatitis C than HIV. Ly et al. Ann Intern Med. 2012;156: Funding for hepatitis C does not match the need for resources. Edlin BR. Nature, , s18-s19. 3

4 Incident Cases of Consequences of Chronic HCV Infection Left ignored, over 150,000 of DCC and HCC Americans will die from DEATHS DCC HCC TRANSPLANTS hepatitis C related illness in the next decade Number 0 Year Rein, DB et al. J of Dig Liver Dis Investing in hepatitis C now will prevent expensive long term costs Pyenson B. New York: Milliman (2009). McAdam-Marx C, J Manag Care Pharm (7):

5 Medical costs for hepatitis C patients will double in the next 20 years $30 billion Pyenson B. New York: Milliman (2009). McAdam-Marx C, J Manag Care Pharm (7): $85 billion NOW is the time for CHANGE: New CDC Recommendations New Testing Modalities New Therapies, Improved Cure Rates 5

6 HepCAP will end the silence in Philadelphia. is COMMUNITY 6

7 GALAEI PA DOH University of the Sciences Lax Center Kensington Hospital Action AIDS Burman s AFAHO Drug Policy Alliance Vertex Jefferson Action AIDS Abbott PHMC Prevention Point PDPH: Division of Disease Control American Liver Foundation Hepatitis B Foundation DBHIDS: Office of Addiction Services HepTREC MANNA Gilead Philadelphia Hepatitis Outreach Project GlaxoSmithKline Temple PDPH: AACO Women s Christian Alliance Office of HIV Planning BEBASHI Penn OraSure St. Chris Consortium Health Federation Merck Presby Drexel Mazzoni Center Project Safe GPHA Gaudenzia DRC is COMMUNITY IDEAS 7

8 Training programs for variety of providers Telemedicine Partner with school district Build clinical capacity Mobile apps Linkage to care model De-stigmatize PREVENTION Testing & Counseling Protocol Safe injection kits Disseminate best practices RESOURCE DEVELOPMENT CARE & TREATMENT ADVOCACY AWARENESS Harm Reduction resources Support system for patients Awareness Campaign Resource Guide Targeted educational materials Culturally competent resources Partner with recovery agencies Have a presence in the community Target youth Promote testing Flexible clinical availibility Patient navigation is COMMUNITY IDEAS ACTION 8

9 Where do you fit in? 9

10 Structural Barriers to Hepatitis C Care Amy B. Jessop, Ph.D., MPH Director, HepTREC Assistant Professor of Public Health University of the Sciences in Philadelphia Reducing the Impact of Viral Hepatitis HepTREC is a nonprofit organization established in 2002 to reduce the impact of viral hepatitis in the Delaware Valley HepTREC was incorporated into University of the Sciences in 2009 HepTREC services include: Education and training to the public, patients, social service and healthcare providers Support services, website, toll free number Immunization and screening programs Health Service Research 10

11 Patient Provider Systems Barriers to appropriate care exist at all levels Potential to reduce barriers if we work together and change perspective Is a patient problem really a system problem? Is a provider problem a systems problem? Is system problem a training problem? 11

12 Can small changes reduce barriers? Time Hepatitis C is not just health problem for individuals it is a population health problem. Reduction of barriers will come through community-level approaches. We can leverage resources (including ideas!) to improve prevention, diagnosis, and care. We need a systematic approach in the region to increase: Awareness Perspective Coordination We need leadership and commitment from all stakeholder groups to achieve this. 12

13 Hepatitis C Prevention Among Injection Drug Users José Benitez, MSW Prevention Point Philadelphia (PPP) Prevention Point Philadelphia PPP is a non-profit, public health organization committed to protecting the health and welfare of drug users and sex workers. PPP works to reduce the harm associated with substance use and sex Industry work by offering a safe and humane alternative to the war on drugs. 13

14 What is Harm Reduction? A set of practical, public health strategies designed to reduce the negative consequences of drug use and promote healthy individuals and communities without necessarily reducing drug use. Harm Reduction in Philly % of new HIV infections attributed to unsafe injection drug use*: 1980 s: nearly 50% PPP legalized in : 30.5% 2006: 19.8% 2008: 17.0% 2010: 11.0% *All values cited from the AIDS Activities Coordinating Office for the City of Philadelphia 14

15 Cost of prevention Average cost of lifetime treatment for a person with HIV using ART: $618,900 * Estimated lifetime costs for Hepatitis C care: $300,000 * Average price of a box of 100 sterile syringes: $40 Number of HIV/AIDS cases one box of 100 sterile syringes could prevent: 100 * Medical Care, November The lifetime costs of current HIV care in the United States. Service Delivery Methods Drug Treatment REFERRALS Primary Health Care AUXILARY Legal Representation Mental Health Services SSHP CORE SEP Legal Clinic Outreach/Education HIV Case Mgmt. Case Management Social Service Support Housing SSI BHSI: Behavioral Health Special Initiative 15

16 PPP Programs, Services & Integrated Support to Syringe Exchange Varied locations and times of SEP sites with in-building emergency distribution Street side and in-building medical clinics serving different populations Overdose prevention and response training SCOPE (syringe and biohazard collection) Harm Reduction counseling and case management services Pilot Buprenorphine program Group Harm Reduction education around HIV, HCV Street-based outreach and social network outreach Common Health Issues at the Street-side Health Project HIV & Hepatitis C Endocarditis Depression Abscesses & Cellulitis Wounds Upper respiratory infections Overdose Malnutrition Sexually Transmitted Diseases Chronic pain/pain management 16

17 Insurance Status Unreported insurance status W/insurance W/O insurance # of patients Areas for Programmatic Development: Increase opportunities for HCV testing which are low threshold Increase care outreach programs for HCV Navigators project Development of education programs Care Providers Public Coordinate services 17

18 Treatment Barriers to Hepatitis C Care Jay Kostman, M.D. Presbyterian Medical Center University of Pennsylvania Medicine Evolution of Hepatitis C Treatment SVR (%) Standard interferon (6 mos) [1] 8-12 Standard interferon (12-18 mos) [2,3] Interferon/ ribavirin (6-12 mos) [3,4] PegIFN monotherapy (6-12 mos) [5,6] PegIFN/ribavirin (6-12 mos) [6,7] PI + PegIFN/RBV (6-12 mos) [8-10] Carithers RL Jr., et al. Hepatology. 1997;26(3 suppl 1):83S-88S. 2. Zeuzem S, et al. N Engl J Med. 2000;343: Poynard T, et al. Lancet. 1998;352: McHutchison JG, et al. N Engl J Med. 1998;339: Lindsay KL, et al. Hepatology. 2001;34: Fried MW, et al. N Engl J Med. 2002;347: Manns MP, et al. Lancet. 2001;358: Poordad F, et al. N Engl J Med. 2011;364: Jacobson IM, et al. N Engl J Med. 2011;364: Sherman KE, et al. N Engl J Med. 2011;365:

19 Consequences of Untreated Chronic HCV Chronic HCV is often asymptomatic ~75% chance of developing chronic infection Progression of liver disease 20% develop cirrhosis after ~20 years Patients may become to sick to be treated 36% of people on liver transplant waiting list have HCV 50% of people with HCC are HCV infected Liver cancer is the fastest growing cause of cancer-related death in the US CDC. MMWR RecommenRep. 2012; 61: Kim WR, et al. Gastroenterology. 2009; 137: Kanwal F, et al.gastroenterology. 2011; 140: Economic Burden of Untreated HCV Cost of caring for a patient with chronic HCV: ~$24,000 a year Without cirrhosis: $17,277/yr Compensated cirrhosis: $22,752/yr End stage live disease: Up to $59,995 a year Liver transplant: ~$150,000 to ~$250,000 Gordon SC, et al. AASLD Abstract US Dept of Veteran s Affairs. 19

20 Why are so many people undiagnosed? Providers are not screening patients for HCV HCV is often asymptomatic HCV is not in providers forefront of thought HCV screening tools have not been used Failure to screen and diagnose results in failure to treat HCV Treatment Misperceptions Among IDU Unaware response rates are higher with new therapies Especially in Black and Hispanic people Cannot differentiate flu-like symptoms associated with Interferon from symptoms of methadone withdrawal Misinformation from peers Canfield KM, et al. Subst Use Misuse. 2010; 45:

21 Barriers to Treatment for IDU Lack of training and expertise in treatment of HCV by opioid treatment providers Providers unwilling to treat HCV Failure to establish and coordinate a multidisciplinary team Frustration with patients Active IDU Missed appointments Non-adherence to treatment Telal SH, et al. J Subst Abuse Treat. 2012; [Epub ahead of print] Other Reasons People are Not Being Treated Patients Do not think they need treatment Clinicians Do not believe patients need treatment Do not understand who may benefit from treatment Biased against treatment for IDUs and inmates, who account for large proportion of disease prevalence System Difficult to navigate Lack of access to specialists Treatment requires travel Patients cannot or will not travel for specialist care Referral process is not effective Stoove MA, et al. Drug Alcohol Depend. 2005; 77: Hagan H, et al. Clin Infect Dis. 2006; 42: Myles A, et al. Can J Gastroenterol. 2011; 25: Brunsden A. UCLA L Rev. 2000; 54: McGovern B, et al. Clin Infect Dis. 2005; 41: S Tan J, et al. Hepatology. 2008; 46:

22 Complexities of Current HCV Therapy Co-morbidities Drug-Drug Interactions Management of Drug Toxicities When to Treat Decisions Overcoming Complexities Leads to Better Outcomes Establish multidisciplinary management team Provide support and education Treat psychiatric disorders / substance abuse Administer CES-D and AUDIT Vaccinate against hepatitis A and/or B Avoidance of hepatotoxins Provide anti-hcv therapy Offer weekly adherence visits, monitoring Lo Re V et al. Clin Liver Dis 2008; 12:

23 Priorities Treat underserved populations Educate providers and patients Increase awareness of treatment efficacy and consequences of untreated chronic HCV Prevent new HCV infections Taylor LE, et al. Drug Alcohol Depend. 2011; 116: Neukam K, et al. Eur J Microbiol Infect Dis. 2012; 31: Moving Forward What we have been doing is not working Screening is not happening; people are not being referred for treatment and evaluation An HCV bottleneck is created resulting in year long delays for linkage to care We now have a new model of care for screening Birth cohort screening will lead to early identification of individuals unaware of their diagnosis If we don t have an effective system for linkage, management, and communication enhanced screening efforts will not result in improved outcomes 23

24 You ve heard about the problem Will you join us in building solutions? Join a workgroup! Share skills that can help improve HepCAP projects from education to grantwriting! 24

25 Current HepCAP Workgroups Clinician Education Workgroup Speaker s Bureau Quarterly Case Conferences Public Awareness Workgroup Telling Philadelphia s hepatitis story Creating local campaign Developing outreach strategies Think big with us 25

26 Model of HCV Education and Testing in Philadelphia Community Based Organizations Primary Care Providers Emergency Rooms/ Hospitals Community Awareness Campaign Confirmatory Testing Provider Educational Campaign Patient Navigators LINKAGE Coordination Social Workers Private Practice Academic Subspecialty Care Community Based Providers HCV awareness, testing and linkage to care should be a political priority HCV awareness, testing and linkage to care should be a budgetary priority Through HepCAP we can collaborate to maximize our City s existing resources 26

27 Next Meeting: Wed, November 7th 5:30pm 7pm 500 S. Broad Street 27