[dropcap]W[/dropcap]ith new, game-changing hepatitis C meds available or in the pipeline, an emerging issue is how to find at-risk patients, get them screened and link those with the hepatitis C virus (HCV) with care. It’s something that many believe is too difficult. The belief is that many at-risk populations are poor and unreachable, unfamiliar with health care settings, lack insurance, and won’t follow-up and stay on treatment regimens even if they’re diagnosed with HCV.
One study published in the February, 2015 issue of the Journal of General Internal Medicine shows that outreach to medically underserved areas can overcome these barriers, if done right.
The study documented the largest non-clinical hepatitis C screening campaign in history, according to the study’s senior co-author Dr. Amy Nunn, Director of the Rhode Island Public Health Institute and assistant professor of behavioral and social sciences in the Brown University School of Public Health.
The campaign, “Do One Thing, Change Everything” campaign (http://1nething.com/) was a collaboration between Drexel University College of Medicine and Brown University School of Medicine to encourage HCV testing in communities with high rates of infection, by simply going door-to-door and asking people to get tested.
Working with a team including lead author Dr. Stacey Trooskin of the Drexel University College of Medicine, Nunn started with an HIV and hepatitis C screening and linkage-to-care campaign across several Philadelphia neighborhoods.
“We chose the neighborhoods based on the rate of HIV, which we already knew, in certain zip codes,” Nunn says. “We found that a three-percent rate of HIV in those zip codes, which are on par with sub-Saharan Africa.”
Because HCV and HIV often travel together, Nunn and her colleagues knew they were likely to find many people at risk of hepatitis.
The Do One Thing program’s team included physicians, phlebotomists, “patient navigators,” social workers and volunteers. Starting in December 2012, team members went door-to-door to offer screening at either a full-service mobile unit four days a week, or at the nearby health annex six days a week. At both facilities they performed rapid screening tests, through mouth swabs or finger sticks. For any positive results, phlebotomists drew blood for confirmation of HCV.
When blood work confirmed HCV, the next step was linkage to care. The team got almost everyone signed up with Medicaid and made sure they made appointments with PCPs and specialists if they were referred. Getting a referral to a hepatitis C subspecialist was the most difficult hurdle, researchers said in the paper, and required an extra primary care physician visit, which created “an opportunity for disengagement, particularly for vulnerable populations with low health literacy.”
“Basically the patient navigators hold their hands through the whole process of linkage to care, including following up to see that they actually went to the doctors,” Nunn says.
As of February 2014, the Do One Thing team had tested 1,301 people and found that four percent had anti-HCV antibodies. That’s higher than the rate for Philadelphia citywide, and about four times the national average.
And the effort continues. Patient navigators will continue to hold the patients’ hands all the way through SVR with a follow-up one year later.
Linking a troubled population to care
Residents who agreed to be screened filled out a demographic questionnaire, and the data from those surveys showed a highly troubled population. A third of the people (433 of 1,301) had been incarcerated, many had histories of drug use or mental health conditions, and more than half earned less than $15,000 a year. A large percentage showed signs of heavy alcohol use, which is devastating for the liver, with or without the addition of HCV.
Over the sixteen months of the study:
• Nine out of the twelve participants (seventy-five percent) who did not have health insurance obtained it after their hepatitis C diagnosis (sixty-six percent already had insurance at the time of diagnosis).
• Twenty-nine out of thirty-two participants (ninety percent) who obtained or already had health insurance found a primary care provider.
• Twenty-three out of twenty-nine (seventy-nine percent) participants with a primary care provider were referred to hepatitis C specialist care.
• Twenty-one out of twenty-three (ninety-one percent) participants with a referral to a hepatitis C specialist attended their appointment.
The community-based outreach model used by Do One Thing works, Nunn says, and she hopes that it can be replicated throughout the country in similarly troubled neighborhoods, but admits that most state health departments have been unwilling to earmark money for extensive community intervention and treatment for all.
The study’s other authors are Joanna Poceta, Caitlin Towey, Annajane Yolken, Jennifer Rose, Naija Luqman, Ta-Wanda Preston, Dr. Philip Chan, Dr. Curt Beckwith, Sophie Feller, and Hwajin Lee. Funding for the research came from an HIV FOCUS grant of Gilead Sciences, the National Institutes of Health and the Brown University Alcohol Research Center on HIV.
Larry Buhl is a radio news reporter, screenwriter, and novelist living in Los Angeles. His podcast on employment issues, “Labor Pains,” can be found at www.laborpainspodcast.com.