INTEGRATED HCV SCREENING AND TESTING IN SUBSTANCE ABUSE TREATMENT

INTEGRATED HCV SCREENING AND TESTING IN SUBSTANCE ABUSE TREATMENT

HEPATITIS Hepatitis is the name for a family of viral infections that affect the liver. The most common types are Hepatitis A, B, and C. Hepatitis C is a blood-borne infectious disease that is caused by the Hepatitis C Virus (HCV) and primarily affects the liver. The impact of Hepatitis C varies widely from a mild illness lasting only a few weeks to a serious, lifelong illness that attacks the liver. Most people do not know that they are infected, because they often do not look or feel sick until they have developed liver problems. Hepatitis C is considered to have two stages: Acute and Chronic.

DIFFERENCES BETWEEN HEPATITIS A, B, & C Hepatitis A, B, and C are diseases caused by three different viruses. Hepatitis A only appears as an acute infection and is usually spread through fecal matter. Hepatitis B can be acute or chronic and is spread through body fluids. While all three can cause similar symptoms, they all have different methods of transmission and can affect the liver differently. There is a vaccination for Hepatitis A and B, but there is none for Hepatitis C. If a person has one type of Hepatitis, it is still possible to get the other types.

WHO IS AT RISK FOR HCV Current or former injection drug users, including those who injected only once many years ago Recipients of clotting factor concentrates made before 1987, when more advanced methods for manufacturing those products were developed Recipients of blood transfusions or solid organ transplants before July 1992, when better testing of blood donors became available Chronic hemodialysis patients Persons with known exposures to HCV, such as health care workers after needlesticks involving HCV-positive blood recipients of blood or organs from a donor who tested HCV-positive Persons with HIV infection Children born to HCV-positive mothers

STATISTICS The CDC estimates that there are 3.5 million people currently infected with Hepatitis C, with 2.7-3.9 million people living with chronic HCV. However, studies estimate that 75% of those living with Hepatitis C have never been tested and are unaware of their diagnosis. These may be underestimates since incarcerated and homeless individuals are high prevalence populations but are rarely tested. CDC estimates that there were actually 33,900 new cases in 2015.

TRANSMISSION Hepatitis C is a blood-borne disease spread primarily through blood-to-blood contact. The most common methods of transmission are: Injection drug use Sharing drug paraphernalia Improperly sterilized medical equipment Blood transfusions Unsterilized tattoo and piercing equipment Being born to a mother with Hepatitis C Less method common methods of transmission include: Sexual contact with a person with Hepatitis C Sharing personal care items that may have come in contact with a person s blood such as razors or toothbrushes

TRANSMISSION Methods that Hepatitis C cannot be spread include: Food Water Sharing eating utensils Breastfeeding Hugging or kissing Holding hands Mosquitos and other bug bites

BLOOD SPILLS The Hepatitis C Virus can survive outside of the body at room temperature for up to three weeks. Even if the blood is dry, it can still be infectious. The best method for cleaning up any blood spills is to use a dilution of 1part bleach and 10 parts waters. Gloves should always be worn when cleaning up blood spills.

ACUTE INFECTION The initial stage of a Hepatitis C infection is an Acute Infection. An Acute Infection is a short-term illness that occurs within the first six months after someone is exposed to the Hepatitis C Virus. Only 20% - 30% of newly infected individuals will have symptoms. When symptoms do manifest at this stage, they are often varied. Most common symptoms of an acute infection are jaundice, abdominal pain, poor appetite or fatigue. Serious complications are very rare in this early stage. Acute infections are resolved without treatment in about 15% - 25% of cases.

CHRONIC INFECTION Approximately 75% - 85% individuals infected with HCV will develop a Chronic Infection. A Chronic Infection is a long-term illness that occurs when the virus remains in a person's body. Symptoms often do not develop until a person has been infected for many years and liver problems have developed. A Chronic Infection can last a lifetime and lead to serious liver problems including cirrhosis (scarring of the liver) or liver cancer.

LONG-TERM EFFECTS Of every 100 people infected with Hepatitis C, about: 75-85 will develop a chronic infection 60-70 will develop chronic liver disease 5-20 will develop cirrhosis 1-5 will die from liver cirrhosis or liver cancer More than 19,000 people die every year from Hepatitis C- related liver disease.

CIRRHOSIS Cirrhosis is a process in which damaged or dead liver cells are replaced with scar tissue, altering the structure of the liver. As a result, the liver's smooth texture becomes nodular and lumpy. The spread of the scar tissue impedes the proper functions of the liver by blocking the flow of blood through the liver. This slows the production of proteins and processing of nutrients, hormones, drugs, and naturally produced toxins. The rate of progression of cirrhosis is different in different people, but different factors such as alcohol consumption can accelerated progression. Symptoms are still rare in the early stages and vary significantly. The most common symptoms include tiredness and weakness, loss of appetite, nausea and vomiting, weight loss, easy bruising, itchiness, and jaundice

END STAGE LIVER DISEASE Cirrhosis is irreversible so the treatment focuses on keeping the condition from worsening. Compensated Cirrhosis means that the liver is heavily scarred but can still perform many important bodily functions. Decompensated Cirrhosis occurs when the liver is so extensively scarred that it is unable to function properly. At this stage, people often begin to develop symptoms and complications that can be life threatening. The goal at this stage is to try and manage complications due to deteriorating liver through treatment. When the liver breaks down and can no longer perform its job, it is called End-Stage Liver Disease. At this point, the only treatment available is a liver transplant.

TESTING GUIDELINES Persons for Whom HCV Testing is Recommended by the CDC: Adult born between 1945 to 1965 regardless of risk factors Current and former injection drug users Individuals treated for a blood clotting problem before 1987 Individuals that received a blood transfusion prior to July 1992 Individuals that were ever on long-term hemodialysis treatment Individuals with liver disease Health care and public safety workers exposed to blood through needle stick or other sharp object injury HIV-positive individuals Children born to HCV-positive women

TESTING GUIDELINES Persons for whom HCV testing is of uncertain need according to the CDC: Recipients of transplanted tissue Non-injection drug users Persons with a history of tattooing and body piercing Persons with a history of multiple sex partners or sexually transmitted diseases Long-term sex partners of HCV-positive persons Persons for whom HCV testing is not recommended according to the CDC: Health care, emergency medical, and public safety workers Pregnant women Household (nonsexual) contacts of HCV-positive persons General population

INFECTIONS OVER TIME 7,000 Reported New Cases of Hepatitis C in the United States by year 6,000 5,000 4,000 3,000 2,000 1,000-1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

NEW TRENDS For the first time in two decades, new Hepatitis C infections are on the rise. Between 2011 and 2015, new infections have increased 197% nationally. The new infection rate is fastest growing among America s youth, a group that was previously rarely exposed to Hepatitis C. This group is now twice as likely to be newly infected than the national average. Several early investigations of newly acquired HCV infections reveal that most occur among young, white persons who live in non-urban areas In their latest surveillance report, the CDC has labelled the increase in Hepatitis C an emerging epidemic.

CORRELATION BETWEEN HEPATITIS C AND HEROIN Most researchers attribute this startling increase in new HCV infections to the nation s Heroin Epidemic and associated high risk behavior. The rate of new Hepatitis C infections between 2003 and 2013 is closely correlated with the rate of heroin overdoses over the same period. 2,500 2,000 1,500 1,000 500 - Reported New HCV Infections 9,000 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 - Heroin Overdoses r = 0.97, r2 = 0.94

INJECTION DRUG USERS AND HEPATITIS While infection rates for HIV, another blood-borne virus, among injection drug users has declined significantly as a result of efforts such as needle exchange programs, Hepatitis C has not. This is because the Hepatitis C Virus is more infectious and can survive outside of the body for a longer time: The rate of IDUs with HIV is 2,147 per 100,000, or 2% The rate of IDUs with HCV is 43,126 per 100,000, or 43% HCV is also three times more prevalent than HIV, and there is a much lower awareness among the target population. Thus, many researchers are concluding that needle exchange programs while effective for HIV are not enough to contain the spread of HCV.

INJECTION DRUG USERS AND HEPATITIS CDC reports that recent surveys of active IDUs indicate that approximately one third of young (aged 18 30 years) IDUs are HCV-infected. Older and former IDUs typically have a much higher prevalence (approximately 70% 90%) of HCV infection, reflecting the increased risk of continued injection drug use

CHICAGO: HEPATITIS C AND HEROIN The dramatic resurgence of Hepatitis C has been particularly noticeable in Chicago. This is largely the result of Chicago being the epicenter of the nation s heroin epidemic: Chicago leads the nation in heroin-related emergency room visits with 24,627, more than doubling the number of New York City The percentage of substance abuse treatment admissions for heroin in Chicago (35.1%) is more than double the national average (18.6%). Chicago arrestees test positive for opioids at the highest rate in the nation (18.6%). Chicago is the number one destination for heroin shipments in the nation.

CHICAGO STATISTICS It is estimated that there are 70,000 individuals with Hepatitis C in Chicago, many of them current and former substance abusers. Fewer than 15% are aware of their status and less than 1% are engaged in medical care. This disparity is the result of several synergistic factors: Substance users rarely seeks out health care services due to their active drug and alcohol abuse Lack of insurance Insufficient knowledge of the disease and treatment availability An absence of symptoms A fear that treatment does more harm than good A distrust of the health care system.

HEPATITIS C AND SUBSTANCE ABUSE Today, nearly 90% of all new HCV infections are occurring among current substance abusers. Due to the increase in heroin use and associated high risk behaviors, there is a clear need to target and engage this population in HCV screening and care. However, efforts to test and engage substance abusers have had limited success. Any effort to accomplish this would face significant barriers. This population is often marginalized and medically underserved.

HEPATITIS C AND SUBSTANCE ABUSE One of the primary challenges Chicago faces in responding to Hepatitis C is that substance abusers are inadequately screened and tested, because they rarely access health care resources through traditional methods. For example, 78% of Haymarket s clients report never having received a comprehensive medical examination prior to admission. Substance abusers first point of entry into medical care is often through substance use disorder treatment. Unfortunately, only 15% of treatment agencies nationwide provide HCV antibody testing, and less than 2% provide quantitative and qualitative testing. This is because HCV testing, unlike HIV testing, has not been well funded and widely emphasized, and there are limited community-based testing locations.

INTEGRATED HCV SCREENING AND TESTING PROJECT As a result, Haymarket launched its Integrated HCV Screening and Testing Project in 2011. The project is designed to reduce HCV infection and transmission among substance users through: Expansion of screening and testing Increased knowledge and awareness of HCV Linkage to care and care coordination for HCV-positive individuals.

PROJECT HISTORY Between 2011 and 2015, the project offered group-level Hepatitis C education sessions, individual risk assessments, and rapid HCV testing to clients admitted Haymarket. Due to funding limitations, tests were only offered to clients that were screened to be at high risk for contracting and transmitting HCV. While the project identified a large number of HCV-positive individuals, we were only able to test a small fraction of our service population.

MEDICATION TREATMENT The launch of this program coincided with the release of a new, highly effective treatment for Hepatitis C. Previously, the only treatment for Hepatitis C was accompanied by painful side effects and was only effective half of the time. The new treatment therapy offered a cure nearly 100% of the time with minimal side effects. However, this new therapy is very expensive. Currently, one course of treatment can cost as much as $100,000 per patient, and some patients will need two courses of treatment.

ACCESS TO TREATMENT Illinois became of the few states to cover these new, very expensive treatment therapies through Medicaid. However, it introduced tough restrictions on who could receive the medication. For Medicaid to cover the costs of treatment, patients would have to pass a drug test and not have been diagnosed with a substance use disorder in the past year. Considering almost all new HCV infections are among substance users, this created a significant barrier to treatment sobriety. Thus, collocating testing and treatment at the same site became even more essential.

FOCUS PROJECT In 2016, Haymarket partnered with Gilead Science s FOCUS Program in order to redesign and expand our project. Through this partnership, Haymarket has implemented an opt-model testing model where all clients entering Haymarket could be tested. Tests would now be offered using a HCV antibody blood test at the time of their physical examination. The project also implemented a health navigation model that combined evidence-based linkage to care and recovery coaching practices.

MODEL DESIGN: LINKAGE TO CARE The linkage to care protocol is based on the evidence-based practice ARTAS (Anti-Retroviral Treatment and Access to Services). ARTAS uses strength-based case management and intensive motivational counseling that is designed to link clients to medical care and keep them engaged in medical care. Clients are linked to care within 14 days by health navigators who meet with the clients regularly to: Build a trusting relationship Identify their strengths, abilities, needs, and barriers to care Help clients overcome their fears

MODEL DESIGN: RECOVERY COACHING This is then combined with the evidence-based practice Manual for Recovery Coaching and Personal Recovery Plan Development. Recovery coaching is a manual-driven recovery management and health navigation program for people in substance use disorder treatment. Recovery coaches follow the client for up to a year providing intensive case management aimed at identifying their specific needs and developing step-by-step plans to address those needs. This model is designed to regularly follow-up with clients to ensure that they are still on the path to recovery, are still engaged in care, and adhering to their treatment. At the completion of services, the client will be a year sober and eligible for the most effective treatment of Hepatitis C within a year of diagnosis.

PROJECT OUTCOMES 2011 2012 2013 2014 2015 2016 2017* Number of HCV Tests 802 882 660 335 645 1025 477 New Positives Identified 40 58 45 44 50 97 80 Out-of-Care Positives Identified - - - 20 33 48 28 * Results through May 2017. Since 2011, Haymarket has tested and identified 414 new HCV-positive individuals. Since 2013, Haymarket has identified and reengaged 129 out-of-care HCV-positive individuals. Over 95% of our HCV-positive clients have been linked to medical care. The project s positivity rate is over 8%. According to the Illinois Department of Public Health, there are 2,615 HCV-positive individuals in Chicago. Given this number, Haymarket has identified 10% of Chicago s HCV-positive population.

SUCCESSES Linkage to care has been extremely successful. Support Group Peer support and education Services provide safety net for clients that would normally not receive support services. Passionate response from the clients encountered in the project.

CHALLENGES AND LESSONS LEARNED Haymarket is not a medical setting making the implementation of an opt-out testing model very difficult to coordinate. There is extremely limited funding available for Hepatitis C services. Despite being more prevalent, infectious, and deadly than HIV, HCV receives less than four cents for every dollar devoted to HIV services in the federal budget. There is a massive need for services among this population. Haymarket has only begun to graze the surface of this problem, and we have already found a massive underserved population. Access to treatment limited to our population. We still have yet to have a client meet criteria for treatment and be prescribed the cure. State policies continue to stigmatize substance use and impede access to treatment. Changes to ACA could limit access to health insurance, without which clients could not access specialty care.

NEXT STEPS Explore opportunities to implement laboratory-based testing and shift away from point of care testing. Explore 3 rd party billing. * Work with partners to increase testing and make it part of routine medical services provided to Haymarket Center clients.???? (What do you think we should do next?)

THANK YOU TO OUR FUNDERS We would like to thank the funders of our Integrated HCV Testing and Screening Project: Gilead Sciences U.S. Substance Abuse and Mental Health Service Administration Gibbs Family Foundation

CONTACT Jessica L Dubuar, LCPC Assistant Clinical Director Haymarket Center jdubuar@hcenter.org 312-226-7984 ext. 373