My first job in public health was as a health educator and HIV test counselor at a Federally Qualified Health Center (FQHC) in San Diego. There, I taught classes on HIV, STI, Viral Hepatitis, and TB prevention to individuals in alcohol and drug treatment programs and offered field-based rapid HIV testing following the class. After training to become a test counselor, I was ready to talk to my clients about reducing their risk for HIV and, if they tested positive, educate them on what this result meant while linking them to care as quickly as possible. In my first test counseling session, I realized that my job would be a little different than I imagined.
Although HIV was a concern, hepatitis C is what worried my clients most. Between 60-90% of people who inject drugs become infected with hepatitis C within 5 years .The majority of the people I worked with had received a positive antibody test at some point in their lives – sometimes the diagnosis had come decades before and other times the news was just a week old. But regardless of how long they had known their status, one common tie across my clients was that many had not received any follow-up such as a confirmatory RNA test or seeing a doctor. I quickly learned that very few resources were available in the county: a confirmatory test was nearly impossible to get without insurance, which none of my clients had; the standard of care for treatment at the time, Interferon and Ribavirin, had terrible side effects and very low success rates; and the issue was not getting the attention it deserved outside of the small community of providers, patients, and advocates.
Fast-forward five years and there is now a highly effective cure and the landscape has changed dramatically. In 2014, the World Health Assembly (WHA) adopted WHA Resolution 67.6, which urged member states and the World Health Organization (WHO) Director-General to enhance surveillance, prevention, disease control, and treatment access for viral hepatitis. This year, WHO released a draft of the Global Health Sector Strategy on Viral Hepatitis, 2016-2021 and countries such as Egypt, the Republic of Georgia, and the Cherokee Nation in the United States now have an elimination strategy. It is still hard for me to believe, but the global conversation has actually shifted to how we can eliminate viral hepatitis as a public health threat. This would mean reducing new infections and deaths from the disease; WHO has set their provisional targets at a 90 percent reduction in incidence and a 65 percent reduction in mortality by 2030.
In response to the WHA’s resolution, the Centers for Disease Control and Prevention (CDC) and the Office of Minority Health commissioned the Committee on a National Strategy for the Elimination of Hepatitis B and C to explore the feasibility of eliminating hepatitis B and C in the United States. In its Phase One Report released in April, the committee states that although elimination is feasible, a number of challenges, including limited resources and lack of political will, make prevention and control more realistic. As the committee begins Phase Two, the focus will be on establishing goals for a national strategy and identifying what is needed to overcome those challenges and implement the goals.
The committee kicked off Phase Two at its third meeting, which I attended from June 8-9. A multitude of barriers were identified during the meeting such as the high cost of medication, the number of treatment restrictions set in place by private and public payers to ration medication, limited provider infrastructure, limited access to SSPs especially in rural areas, inconsistent and limited surveillance, lack of national resources to coordinate and support this work, unequal Medicaid expansion, and structural barriers for clients in need including homelessness, unstable housing, lack of transportation, cost of healthcare for those who have insurance (co-pays, co-insurance), and stigma. One theme that emerged very quickly was the need to develop partnerships to address these barriers. There is a lot of work to be done and a variety of obstacles to overcome, so collaborative partnerships will be critical to progress. Further, a multi-pronged approach was identified with the need to treat people who currently inject drugs as a key strategy to prevent future infection, make drug treatment available to those in need, and support harm reduction.
Despite the many challenges identified, there was a lot of excitement about how Phase 2 will contribute to the committee’s primary charge. Having a national strategy and goals to work towards will give public health and its partners a tool to raise the urgency of addressing hepatitis C locally. Local health departments play an important role in the prevention and control of viral hepatitis C and will be vital to implementing a national strategy. Many operate Syringe Services Programs in their jurisdiction, conduct surveillance and contract tracing when outbreaks occur, screen in their clinics and outreach settings, link to care, and in rare cases offer treatment. Increasingly, public health is needed to help move people through the complex system of care and the need for increased case management and patient navigation was discussed.
Most local health departments are doing this work without any designated funding and are leveraging other program areas such as HIV because the need is too great not to do anything. Hopefully the release of these reports will support local health departments’ efforts, providing the momentum to effectively and meaningfully address the goals of a national strategy to eliminate hepatitis C in their jurisdiction. Stay tuned for the Phase 2 report, which will be released in early 2017, and be sure to check out NACCHO’s educational series on hepatitis C.
- 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.