Eliminating HCV in San Francisco

Transcription

1 Eliminating HCV in San Francisco Interventions for PWIDs KATIE BURK, MPH VIRAL HEPATITIS COORDINATOR SAN FRANCISCO DEPARTMENT OF PUBLIC HEALTH 1

2 Presentation Outline 1. The case for HCV Elimination 2. The San Francisco Context 3. Situating drug users in the center of HCV elimination strategies 2

3 Hepatitis C Elimination: Why Now? 3

4 HCV Deaths Exceed Deaths from 60 Other Infectious Diseases Combined Other notifiable infectious conditions include HIV, tuberculosis, and hepatitis B Ly CID

5 Global and U.S. Conversations about HCV Elimination - Why Now? The clock is ticking as HCV-related mortality rises. Almost all people with HCV can be cured with a short-course, well-tolerated, all-oral treatment. All people with HCV can benefit from a cure. HCV Cure as HCV Prevention: Scaled up HCV treatment paired with prevention of reinfection can lead to HCV elimination. 5

6 What will it take to eradicate HCV in the US? Base Case: - Risk based & Baby boomer screening - Treatment ramps up Ideal - Universal Screening - Treatment capacity unlimited Kabiri AIM 2014 Aug 5;161(3):170-80

7 Martin Hepatology2013, Martin 2013 Treating PWID More effective when paired with Opiate substitution and needle exchange

8 Active Substance Users Critical target population for HCV elimination Is treatment of active users feasible? % of Patients with Positive Urine Drug Screen Any drug use of 8 classes* Any drug use of 7 classes (excl. cannabinoids) Cannabinoids Benzodiazepines Opiates Cocaine 0 Despite substantial Time Point drug use during treatment, 96.5% of patients missed 3 doses during 12 weeks Amphetamines Dore AASLD 2015, AIM 2016 REINFECTION 6 reinfections through week reinfections/100py

9 HCV in San Francisco 9

10 San Francisco by the numbers SF with > 16,000 unduplicated past or present cases of HCV since data collection started 22,500 active PWID (Chen 2015 AIDS & Behavior) NHBS data suggest 60% are living with HCV 16,000 HIV+ individuals in SF end of 2015* 3-4% prevalence of HCV among San Francisco Health Network population 6,866 homeless individuals per One Night Count 2015 Highest rate of liver cancer in the US *HIV Count and Survey. Accessed at Epidemiology Annual Report The San Francisco Department of Public Health. Population Health Division, HIV Epidemiology Section. Available at

11 The Feasibility Issue: What makes HCV elimination possible in SF? Compact size (7x7 miles) HIV program infrastructure Getting to Zero initiative Drug user health service infrastructure Committed medical providers willing to treat HCV Medi-Cal (state Medicaid program) policy makes it possible to treat the majority of Medi-Cal beneficiaries UCSF s UFO Study (longitudinal study of HCV among young people who inject drugs) CDC-funded hepatitis surveillance program 11

12 Big Picture Barriers to HCV Elimination in SF Homelessness and displacement High incidence of HCV among young PWIDs ( 21-25%) Racial disparities in HCV case reporting Donut hole of Medi-Cal coverage People living w/ HCV in Medi-Cal who aren t eligible for HCV treatment Limited federal investment in viral hepatitis surveillance, prevention, testing, and treatment interventions 12

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14 Draft Vision, Mission, Values, and Strategies VISION End Hep C SF envisions a San Francisco where hepatitis C is no longer a public health threat. MISSION To support all San Franciscans living with and at risk for hepatitis C to maximize their health and wellness. We achieve this through prevention, education, testing, treatment, and linkage to reduce incidence, morbidity, and mortality related to hepatitis C. All people living with hepatitis C deserve access to a cure Everyone living with or at risk for hepatitis C should have equal access to prevention and care Draw on the wisdom of those most impacted by HCV Engage populations that have been characterized as difficult to engage Address health disparities 14

15 ENGAGING PWIDS IN OUR HCV ELIMINATION WORK 15

16 Strategies: Representation of Impacted Communities End Hep C SF Steering Committee Katie Burk, MPH SFDPH Kelly Eagen, MD Tom Waddell Urban Health Mandana Khalili, MD Annie UCSF Luetkemeyer, MD UCSF Rena Fox, MD UCSF/VA Rachel McLean, MPH CDPH Theresa Hughes Hughes Health Care Disparities Alfredta Nesbitt Bayview Hunters Point Foundation Emalie Huriaux, MPH Project Inform Isaac Jackson Urban Survivors Union Kyriell Noon Glide Foundation Robin Roth SF Hep C Task Force Janetta Johnson Transgender Intersex Justice Project Norah Terrault, MD UCSF 16

17 Prevention Strategies: Drug User Health Engagement Early adoption of syringe access National model of overdose prevention programming Sobering center Outpatient buprenorphine induction clinic Robust methadone access 17

18 Prevention Strategies: Education Messaging for and by drug users 18

19 Prevention, Testing, Linkage Strategies: Agency Outreach Drug Court City Clinic (STD Clinic) Cole St. Clinic (queer youth clinic) BAART Clinic (methadone program) Bayview Hunters Point Foundation (methadone program) Treatment Access Program Scientific Working Group (DPH) Fox Plaza (SRO) HIV Community Planning Council Shelters Larkin Street Youth Services (planned) Westside Clinic (methadone program) 19

20 Testing and Linkage Strategies: Go where drug users are San Francisco AIDS Foundation Syringe Access Services (city-wide) Homeless Youth Alliance ZSFG Ward 93/OTOP methadone program Glide Programs St. James Infirmary UFO/VIP studies Drug Users Union Project Homeless Connect SF County Jail SROs Martin de Porres Drop-in Center Outcomes 4/1/16-9/30/16: ü 961 tested, community based settings ü 22% Antibody prevalence ü 177 linked to care 20

21 Prevention Strategies: Treatment Access CA State Medi-Cal HCV Treatment Eligibility Guidelines Evidence of Stage 2 or greater hepatic fibrosis/cirrhosis Evidence of extra-hepatic manifestation of hepatitis C virus Persons with hepatocellular carcinoma with a life expectancy of >12 months Pre- and post-liver transplant, or other solid organ transplant HIV-1 co-infection Hepatitis B co-infection Other coexistent liver disease Type 2 diabetes mellitus (insulin resistant) Porphyria cutanea tarda Debilitating fatigue Men who have sex with men with high-risk sexual practices Active injection drug users Persons on long-term hemodialysis Women of childbearing age who wish to get pregnant. HCV-infected health care workers who perform exposure-prone procedures 21

22 Treatment Access Strategies: Bring HCV Treatment into Primary Care Program Development Patient-centered Feasible & safe Efficient Satisfying (to staff and patients alike) Increases access for vulnerable populations SFHN and HR 360 HCV Treatment Outcomes (1/1/16-10/31/16) ü 166 providers trained ü 35 providers used ereferral ü 395 patients completed treatment ü 84 on treatment currently Trainings ereferral Technical assistance for individual clinics

23 Treatment Access Strategies: Take Treatment out of Primary Care What s next? Get outside the 4-wall clinic! Shelters Methadone programs (OTOP!) Street Medicine Syringe exchange Mental health clinics Supportive housing Residential treatment programs OTOP Outcomes ü 18 completed treatment since 7/1/15 ü 26 currently on treatment since 7/1/2016

24 Treatment Access Strategy: Reach populations hardest hit by HCV in SF Trans women African- Americans Homeless Drug users Interventions: ü Nurse for homeless and TG clinics ü Rapid initiation of treatment at residential drug treatment ü DOT at methadone programs in predominantly African- American neighborhood ü HCV testing integration in Trans*National study 24

25 For More Information: Katie Burk, MPH Viral Hepatitis Coordinator SFDPH Thanks to: Annie Luetkemeyer Kelly Eagen Aaron Smith Shelley Facente End Hep C SF Steering Committee End Hep C SF Community Partners SFDPH 25