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Webcast 2.4 Targeted Outreach & Other Strategies for Increasing HCV Testing Working in Settings that Serve High-Risk Populations Presented By: Denise Stinson, MN, RN Tacoma-Pierce County Health Department Communicable Disease Control Program Manager

Targeted Outreach & Other Strategies for Increasing HCV ... · Testing & Linkage to Care 3. Hepatitis C Disparities 1. HCV Health Disparities ... 0-19 yrs 20-29 yrs 30-39 yrs 40-49

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Page 1: Targeted Outreach & Other Strategies for Increasing HCV ... · Testing & Linkage to Care 3. Hepatitis C Disparities 1. HCV Health Disparities ... 0-19 yrs 20-29 yrs 30-39 yrs 40-49

Webcast 2.4

Targeted Outreach & Other Strategies for Increasing HCV Testing Working in Settings that Serve High-Risk Populations

Presented By:Denise Stinson, MN, RN

Tacoma-Pierce County Health Department Communicable Disease Control Program Manager

Page 2: Targeted Outreach & Other Strategies for Increasing HCV ... · Testing & Linkage to Care 3. Hepatitis C Disparities 1. HCV Health Disparities ... 0-19 yrs 20-29 yrs 30-39 yrs 40-49

Webcast Overview

Hepatitis C

Disparities

1

Working with

High-Risk Groups

2

Tools to Increase

Testing & Linkage

to Care

3

Page 3: Targeted Outreach & Other Strategies for Increasing HCV ... · Testing & Linkage to Care 3. Hepatitis C Disparities 1. HCV Health Disparities ... 0-19 yrs 20-29 yrs 30-39 yrs 40-49

Hepatitis C Disparities

1

Page 4: Targeted Outreach & Other Strategies for Increasing HCV ... · Testing & Linkage to Care 3. Hepatitis C Disparities 1. HCV Health Disparities ... 0-19 yrs 20-29 yrs 30-39 yrs 40-49

HCV Health Disparities

• African Americans are 2 times more likely to be infected with HCV compared to the general US population

• African American are 2 times more likely to die from HCV than white Americans

• 1 in 7 African American men born 1950-1955 have HCV

• American Indians and Alaska Natives are 1.5 times more likely to be infected with HCV compared to white Americans

• American Indians/Alaska Natives are 2.8 times more likely to die from HCV than white Americans

• 25% of HIV-positive individuals are co-infected with HCV

• 60-90% of people who inject drugs (PWID) acquire HCV within 5 years

1. Centers for Disease Control and Prevention: Surveillance for Viral Hepatitis – United States, 2014.

2. Grebely, J. and Dore, G. J. (2011). Prevention of hepatitis C virus in injecting drug users: A narrow window of opportunity. J Infect

Dis, 203(5): 571-4.

Page 5: Targeted Outreach & Other Strategies for Increasing HCV ... · Testing & Linkage to Care 3. Hepatitis C Disparities 1. HCV Health Disparities ... 0-19 yrs 20-29 yrs 30-39 yrs 40-49

Incidence of Acute HCV by Race/Ethnicity – U.S., 2000-2014

0

0.5

1

1.5

2

2.5

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

American Indian/Alaska Native Asian/Pacific Islander Black, Non-Hispanic White, Non-Hispanic Hispanic

CDC: National Notifiable Disease Surveillance System (NNDSS).

Page 6: Targeted Outreach & Other Strategies for Increasing HCV ... · Testing & Linkage to Care 3. Hepatitis C Disparities 1. HCV Health Disparities ... 0-19 yrs 20-29 yrs 30-39 yrs 40-49

Incidence of Acute HCV by Age –U.S., 2000-2013

0

0.5

1

1.5

2

2.5

3

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

0-19 yrs

20-29 yrs

30-39 yrs

40-49 yrs

50-59 yrs

> 60 yrs

CDC: National Notifiable Disease Surveillance System (NNDSS).

Page 7: Targeted Outreach & Other Strategies for Increasing HCV ... · Testing & Linkage to Care 3. Hepatitis C Disparities 1. HCV Health Disparities ... 0-19 yrs 20-29 yrs 30-39 yrs 40-49

Increase in Acute HCV Cases in Young Non-Urban Persons – 2006-2012

Suryaprasad, A. (2014). Emerging epidemic of hepatitis C virus infections among young nonurban persons who inject drugs in the

United States, 2006-2012. Clinical Infectious Diseases, 59(10): 1411-9.

Page 8: Targeted Outreach & Other Strategies for Increasing HCV ... · Testing & Linkage to Care 3. Hepatitis C Disparities 1. HCV Health Disparities ... 0-19 yrs 20-29 yrs 30-39 yrs 40-49

Working with High-Risk Groups

2

Page 9: Targeted Outreach & Other Strategies for Increasing HCV ... · Testing & Linkage to Care 3. Hepatitis C Disparities 1. HCV Health Disparities ... 0-19 yrs 20-29 yrs 30-39 yrs 40-49

Barriers to Accessing HCV Services• Lack of health insurance

• Lack of financial resources

• Lack of primary care provider

• Structural barriers

• Transportation challenges

• Stigma and lack of culturally competent and nonjudgmental providers

• Legal barriers

• Medicaid and insurance treatment restrictions

• Incarceration

Page 10: Targeted Outreach & Other Strategies for Increasing HCV ... · Testing & Linkage to Care 3. Hepatitis C Disparities 1. HCV Health Disparities ... 0-19 yrs 20-29 yrs 30-39 yrs 40-49

Syringe Services Programs (SSPs)

• Core services:

• Sterile needles/syringes

• Other drug preparation equipment (cookers, cottons, etc.)

• Used syringe disposal

• Wrap-around services:

• Comprehensive sexual and injection risk reduction counseling

• Provision of naloxone to reverse opioid overdoses

• HIV and viral hepatitis testing, plus referral and linkage to treatment services

• STD testing and treatment, or referral to treatment

• Referral and linkage to hepatitis A and hepatitis B vaccination

• Referral to integrated and coordinated treatment of substance use disorder, mental health services, physical health care, social services, and recovery support services

Page 11: Targeted Outreach & Other Strategies for Increasing HCV ... · Testing & Linkage to Care 3. Hepatitis C Disparities 1. HCV Health Disparities ... 0-19 yrs 20-29 yrs 30-39 yrs 40-49

SSPs in the U.S. – 2014

https://nasen.org/site_media/files/amfar-sep-map/amfar-sep-map-2014.pdf

Page 12: Targeted Outreach & Other Strategies for Increasing HCV ... · Testing & Linkage to Care 3. Hepatitis C Disparities 1. HCV Health Disparities ... 0-19 yrs 20-29 yrs 30-39 yrs 40-49

HCV and HIV Services Provided at SSPs

9%

76%

87%

87%

6%

68%

80%

88%

4%

62%

81%

85%

7%

67%

87%

91%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Hepatitis C Treatment

Hepatitis C Testing

HIV Counseling and testing

Hepatitis C Education and Counseling

Percent of SSPs

2010

2011

2012

2013

Yearof

Operation

Des Jarlais, D. C., et al. The Dave Purchase Memorial 2014 National Survey of Syringe Exchange Programs [PowerPoint slides].

Retrieved from: https://www.nasen.org/site_media/files/bis2013/2013-survey-results-presentation-final.pptx

Page 13: Targeted Outreach & Other Strategies for Increasing HCV ... · Testing & Linkage to Care 3. Hepatitis C Disparities 1. HCV Health Disparities ... 0-19 yrs 20-29 yrs 30-39 yrs 40-49

Substance Abuse Treatment Programs• Serve key populations at risk for HCV

• Link to care and community resources

• Opportunities for LHD to:

• Educate clients and program staff

• Train counselors on HCV, HIV, and STD prevention

• Provide technical assistance

• Provide or refer for screening, immunizations, and treatment information

Zeremski, M., et al. (2014). Hepatitis C virus-related knowledge and willingness to receive treatment among patients on methadone

maintenance. J Addict Med, 00(00): 1-9.

Page 14: Targeted Outreach & Other Strategies for Increasing HCV ... · Testing & Linkage to Care 3. Hepatitis C Disparities 1. HCV Health Disparities ... 0-19 yrs 20-29 yrs 30-39 yrs 40-49

Reaching Other At-Risk Populations

• Behavioral and mental health

• People with mental health conditions are at greater risk for HCV and have been excluded from HCV treatment in the past

• Health departments can educate behavioral health partners and patients about new treatments, and provide field-based screening at behavioral health centers

• Homeless

• Prevalence 22% - 52%1

• Health departments can reach out to:

• Service providers including shelters, food kitchens, prevention programs, and community agencies serving the homeless

• Faith-based services

• Emergency departments

1. Chak, E., et al. (2011). Hepatitis C virus infection in USA: An estimate of true prevalence. Liver Int, 31(8): 1090-101.

Page 15: Targeted Outreach & Other Strategies for Increasing HCV ... · Testing & Linkage to Care 3. Hepatitis C Disparities 1. HCV Health Disparities ... 0-19 yrs 20-29 yrs 30-39 yrs 40-49

• Pregnant Women

• 5% risk of vertical transmission

• Cases of HCV-positive newborns increasing because of the opioid epidemic

• HCV-positive women should be counseled to have child tested

• RNA at 1-2 months, repeated subsequently; or antibody test at 18 months

• Health departments can educate primary providers on screening guidelines and changing epidemiology of HCV

• Health Alert from the Philadelphia Department of Public Health: https://hip.phila.gov/Portals/_default/HIP/HealthAlerts/2015/PDPH-HAN_Advisory_1_PerinatalHepatitisC_01052015.pdf

White, D. A. E., et al. (2016). Results of a rapid hepatitis C virus screening and diagnostic testing program in an urban emergency

department. Annals of Emergency Medicine, 67(1): 119-28.

Reaching Other At-Risk Populations

Page 16: Targeted Outreach & Other Strategies for Increasing HCV ... · Testing & Linkage to Care 3. Hepatitis C Disparities 1. HCV Health Disparities ... 0-19 yrs 20-29 yrs 30-39 yrs 40-49

Tools to Increase Testing & Linkage to Care

3

Page 17: Targeted Outreach & Other Strategies for Increasing HCV ... · Testing & Linkage to Care 3. Hepatitis C Disparities 1. HCV Health Disparities ... 0-19 yrs 20-29 yrs 30-39 yrs 40-49

Tools and Resources

• Field-based testing

• Rapid, finger-stick or whole blood test

• CLIA-waived

• Can be used in outreach, mobile, and nontraditional settings:

• Alongside SSPs

• At methadone clinics and at detox or recovery centers

• At job fairs, job training programs, or local government offices

• Strong referral network

• Health departments can develop and distribute information on culturally competent providers willing to accept HCV patients, including PWID and homeless persons

• Initial referrals should be to providers who can do confirmatory testing

• Refer to FQHCs or community health centers for uninsured persons

• Initial referral experience can impact follow-up and health outcomes

Page 18: Targeted Outreach & Other Strategies for Increasing HCV ... · Testing & Linkage to Care 3. Hepatitis C Disparities 1. HCV Health Disparities ... 0-19 yrs 20-29 yrs 30-39 yrs 40-49

Education

• Field-based testing is important opportunity for education

• Information on results

• Importance of confirmatory testing and where confirmatory testing is available locally

• How to stay healthy and prevent transmission

• Key messages:

• Using own injection equipment, including syringes, cookers, cottons, spoons, and other supplies

• Using new equipment whenever possible

• Liver health topics: reducing alcohol and acetaminophen use, maintaining healthy body weight, exercise and nutrition information, and vaccination of hepatitis A and B

• Improved treatment options with shorter treatment periods and fewer side effects

• For HCV-negative persons: importance of retesting every 3-6 months, depending on continuing risk

Page 19: Targeted Outreach & Other Strategies for Increasing HCV ... · Testing & Linkage to Care 3. Hepatitis C Disparities 1. HCV Health Disparities ... 0-19 yrs 20-29 yrs 30-39 yrs 40-49

NACCHO’s Educational Series on HCV & Local Health Departments: Module 2

2.1: Planning for Action at the Local Level

2.2: Creating a Local HCV Epidemiologic Profile

2.3: HCV Testing Challenges and Systems-based Solutions

2.4: Targeted Outreach and Other Strategies for Increasing HCV Testing: Working in Settings that Serve High-risk Populations

2.5: Building and Supporting Local Capacity for HCV Care, Treatment, and Cure

2.6: Advocating for Sensible Policies in the Age of HCV Cure