New Philadelphia Study Highlights Need for HCV Community-Based Screening ($200 million needed)
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$200 million in Federal Funding for HCV Community-Based Screening Needed....Liver Cancer Rates Tripled, HCV healthcare Costs Skyrocket / Yet HCV HCV could be eradicated & eliminated & a "rare Disease within 10-15 years IF the Federal Government made a commitment http://www.natap.org/2014/HCV/080614_01.htm.......new HCV treatment is arguably the biggest breakthrough in medicine in 50 years - we can for the 1st time cure a virus - is that we can now cure (SVR - sustained viral response) up to 100% of HCV+ individuals with short-term 12 weeks therapy with a regimen of antiviral drugs that is easy to take, convenient, few if any side effects. It is not well known that HCV is "curable" and that HCV is not just a silent disease but can cause numerous other illnesses & diseases commonly referred to as extra-hepatic manifestations including heart disease, cancers, diabetes and a cure results can result in the elimination of many of these risks: HCV Extrahepatic Mortality-kidney/heart/cancers - (06/01/14)
- HCV Increased death risk: HCV+ died 20 years earlier compared to HCV-neg individuals & HCV/HIV coinfected died 26 years earlier in a study by the NYC Dept of Health: http://www.natap.org/2014/HCV/051214_02.htm......
- HIV/HCV coinfection rates among MSM in NYC has tripled from 2000 to 2010 http://www.natap.org/2013/IDSA/IDSA_35.htm
- A CDC study reported the mortality rate in 12 times higher for HCV+ vs the general US population & HCV die 15 years earlier: http://www.natap.org/2013/IDSA/IDSA_31.htm
- The costs of not treating HCV are high: liver cancer rates have tripled: http://www.natap.org/2009/HCV/060309_01.htm.....once a patient develops liver cancer the costs for that patient is $40-50,000 per year
- patients who achieved SVR incurred approximately half the HCV-related costs per month incurred by those who did not achieve SVR ($717 vs. $1436; P<0.0001).".......http://www.natap.org/2013/HCV/040513_01.htm
- The Overall Economic Burden of HCV to the US Healthcare System is enormous: http://www.natap.org/2012/HCV/040412_02.htm
The NIH reported $2.8 billion per year in costs in 2004 with costs increasing as the HCV+ population ages towards advanced & costly disease, patients annual costs are $6000- $26,000, with direct costs to the economy based on work loss http://www.natap.org/2013/EASL/EASL_68.htm
- The future Medicare Burden is enormous: http://www.natap.org/2014/AASLD/AASLD_60.htm
Consequences of Hepatitis C Virus (HCV): Costs of a Baby Boomer Epidemic of Liver Disease http://www.natap.org/2009/HCV/051809_01.htm
Community-Based Screening studies recently reported results. Here is study that took place in Wash DC:
High Hepatitis C Infection Rate in Birth Cohort Testing of an Urban, Primary Care Clinic Population: HCV Cascade, 8.2% Prevalence - (03/24/14)
This study was in inner city DC clinic, 1412 tested, 90% HCV+ were African-American, HCV+ rate was 8.2%, 65% were women, 80% attended first appointment
Here are additional screening projects recently reported, in 2014:
Optimization of the HCV Testing and Care Continuum in an Urban Federally Qualified Health Center in Denver....http://www.natap.org/2014/IDSA/IDSA_20.htm
Impact of Rapid Hepatitis C testing on Receipt of Hepatitis C Results in a Public STD Clinic - (03/24/14)
Implementation of a Hepatitis C testing program in a network of Federally Qualified Health Centers: initial results of an Academic-Community partnership - (03/24/14)
Results from a Geographically Focused, Community-Based HCV Screening, Linkage-to-Care and Patient Navigation Program - (02/17/15)
Community-Based HCV Screening Program/Philadelphia [full text below].....door-to-door to offer screening......rapid screening tests....immediate blood draws for confirmatory lab work.....full suite of services to guide patients through the process of gaining health insurance, access to medical specialists, and ultimately, to a hepatitis C cure....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.
Published on February 15, 2015
.....on the streets in medically underserved Philadelphia neighborhoods......when expert advocates made a focused effort in a medically underserved area, they were able to help vulnerable patients leap each of the many hurdles that often keep people out of care....few models exist for scaling screening and treatment, particularly for patients who may not have regular access to medical services....."New testing technologies, coupled with new medications that can cure HCV, provide overwhelming opportunity to cure millions of Americans living with HCV, many of whom don't even know they are infected," Nunn said. "Our paper proves that scaling screening and treatment, even in neighborhoods with the highest rates of infection, is possible. We overcame all the commonly cited obstacles in this high-risk population."
"This study demonstrates the importance of community-based testing for HCV in identifying previously undiagnosed individuals and re-engaging those aware of their diagnosis but not currently in care," Trooskin said in the release. "We learned that a comprehensive approach to nonclinical testing is critical and must integrate immediate access to confirmatory testing as well as intensive patient navigation to effectively link patients to care."
Because many health maintenance organizations (HMOs) require a PCP referral before seeing an HCV specialist, we included PCP referrals. The last three endpoints highlight whether patients were linked and retained in subspecialty care, and whether they initiated treatment......Notably, lack of insurance was not the greatest barrier to linking HCV patients to care; we were able to insure nearly all participants. Our biggest drop-off in the care
continuum occurred at the subspecialty referral stage, which has not commonly been acknowledged as a barrier to care,21,24,31 perhaps because many patients never progress to requesting referrals. Most HCV providers are sub specialists, and Health Maintenance Organizations often mandate referrals from PCPs for every visit as requirements for reimbursements. Referrals often necessitate an extra PCP visit and create an opportunity for disengagement, particularly for vulnerable populations with low health literacy. However, we note that care continuum "drop-offs", presented in Fig. 2, do not always represent disengagement from care; many patients are in care but have not fully progressed through the care continuum. We note that progression through this continuum, and ultimately to treatment and cure, is an ongoing process. Repeated referral requirements and rigid preauthorization requirements associated with direct-acting antiviral therapy (DAAs) slow progression through the care continuum.
Door-to-door campaigning encourages people to get tested for hepatitis C and to get linked to care
In Philadelphia, as in many cities, neighborhoods with high rates of hepatitis C virus (HCV) often also have limited access to screening and treatment. A new study in the Journal of General Internal Medicine shows that when expert advocates made a focused effort in a medically underserved area, they were able to help vulnerable patients leap each of the many hurdles that often keep people out of care.
The U.S. Food and Drug Administration recently approved several medications that can cure hepatitis C, the most common blood-borne illness, affecting 3 to 5 million Americans. Since 2013, the Centers for Disease Control and Prevention has endorsed routine screening for HCV in medical settings for baby boomers and high-risk individuals. However, few models exist for scaling screening and treatment, particularly for patients who may not have regular access to medical services, said study senior co-author Amy Nunn, assistant professor of behavioral and social sciences in the Brown University School of Public Health.
"New testing technologies, coupled with new medications that can cure HCV, provide overwhelming opportunity to cure millions of Americans living with HCV, many of whom don't even know they are infected," Nunn said. "Our paper proves that scaling screening and treatment, even in neighborhoods with the highest rates of infection, is possible. We overcame all the commonly cited obstacles in this high-risk population."
Working with a team including lead author Dr. Stacey Trooskin of the Drexel University College of Medicine, Nunn has been operating a sweeping HIV and hepatitis C screening and linkage-to-care campaign in several Philadelphia neighborhoods. Since December 2012, the Do One Thing program's volunteers and workers, including physicians, phlebotomists, patient advocates ("navigators"), and social workers have been going door-to-door to offer screening. They have performed rapid screening tests and, for any positive results, immediate blood draws for confirmatory lab work. For those with confirmed chronic hepatitis C infections, the team provides a full suite of services to guide patients through the process of gaining health insurance, access to medical specialists, and ultimately, to a hepatitis C cure.
"This study demonstrates the importance of community-based testing for HCV in identifying previously undiagnosed individuals and re-engaging those aware of their diagnosis but not currently in care," Trooskin said. "We learned that a comprehensive approach to nonclinical testing is critical and must integrate immediate access to confirmatory testing as well as intensive patient navigation to effectively link patients to care. Although hepatitis C is now a curable disease, we identified new barriers to care such as the need for a referral to subspecialty care and challenges obtaining medication approval for patients, particularly those covered under Medicaid."
Nunn said the key is having the caring staff in place to help.
"The secret is the dedicated physician, the patient navigator, and the clinical social worker. One unanticipated challenge is the staff time associated with haggling with payers about coverage for the drug," Nunn said. "With the advent of new medications that can cure hepatitis C, we have created a culture of urgency about staying in care and cure. This model works because the very same person that delivers your confirmatory test is the person that holds your hand all the way to cure."
Many hurdles to care
As of February 2014, the Do One Thing team had tested 1,301 people and found that 4 percent had anti-HCV antibodies (higher than Philadelphia's citywide rates).
When area residents consented to screening, they filled out demographic questionnaires while awaiting results. The data paint a portrait of a distressed 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.
Of the 52 people positive for antibodies on the initial screening, only four were already engaged in HCV care. Research has shown that the first critical barrier to treatment is lack of testing to confirm preliminary test results. In Do One Thing, immediate confirmatory testing helped ensure that patients remained in care. Nunn and Trooskin's team achieved more than double the rate of confirmatory testing previously reported in the literature, the study reports.
Of the 42 who received confirmatory testing, 36 proved to be chronically infected. Those were the people who needed care and weren not getting it even though 21 of them were already aware of their infection. Most worrisome, since hepatitis C attacks the liver, was a finding that more than half of the chronically infected people met criteria for an alcohol use disorder. The chronically infected people were more likely than uninfected people to have been in prison, to drink heavily, and to have used drugs.
The team of navigators and social workers helped everyone who had an infection but no care to become linked to care. Twelve of the chronically infected didn't yet have insurance. The team helped nine of them get coverage, and another, a man, joined his spouse's plan. They helped connect people, insured or not, who didn't have primary care doctors to get one.
Getting a referral to a hepatitis C subspecialist has proven to be the hardest hurdle to overcome, the researchers found. "Referrals often necessitate an extra primary care physician visit and create an opportunity for disengagement, particularly for vulnerable populations with low health literacy," the authors wrote.
The team's efforts to get referrals, subspecialty care, and medicines are still underway. But as of February 2014 the team had twice the rate of other studies in getting patients subspecialty care and had already been able to guide 12 patients all the way through the process to receiving the potentially life-saving medicines.
"At the beginning, many naysayers said this wasn't worth doing because these patients will be uninsured or have problems with addiction; many people thought we wouldn't be able to get them insured, linked, and retained, much less ever get them drugs to cure their hepatitis," Nunn said. "But we've been able to overcome all the of the commonly perceived barriers to not screening and treating people. This model works. That's the bottom line."