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STD Control Branch

HCV Testing and Linkage to Care in California

RachelMcLean,MPHCaliforniaDepartmentofPublicHealth(CDPH)

NASTADTAMeeting,Washington,D.C.November29,2017

DRAFT

STD Control Branch

The Problem: Most People with Hepatitis C are Not Diagnosed,

Linked to Care, Treated or Cured

0%

20%

40%

60%

80%

100%

AllHCVchronicallyinfected

HadHCVdetected

Werereferredto

care

Hadinfectionevaluated

Weretreated

Werecured

Source:Holmbergetal.,NEnglJMed2013

STD Control Branch

Sources of New HCV Infection, 1995-2000

*Inamedicalsetting;healthcarework,perinatal

Previously Acquired ( <1990s )

Transfusion10%

Sexual18%Other *

Unknown9%

Injection Drug Use68%

Unknown10% Other *

1%

Sexual15%

Injection Drug Use60%

OccupationalOccupational

4%

Newly Acquired ( 1995-2000 )Previously Acquired ( <1990s )

Transfusion10%

Sexual18%Other *

Unknown9%

Injection Drug Use68%

Unknown10% Other *

1%

Sexual15%

Injection Drug Use60%

OccupationalOccupational

4%

Newly Acquired ( 1995-2000 )

1%4%

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People with Hepatitis C Who Inject Drugs Face Barriers to Care

Transportation

HealthCoverage/Literacy

Stigma/Shame

Homelessness

LackofID

Hunger

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• $2.2M/yearfor3yrs.• 3Goals:

1) UsingsurveillancetoimproveHCVoutcomes2) HCVtestingandlinkagestocare3) HCVcarecoordination

• 5Sites:1) ButteCountyDPH(Goal1)2) AccessSupportNetwork(Goal2)3) SanFranciscoDPH(Goal2andGoal3)4) FamilyHealthCentersofSanDiego(Goal2and

Goal3)5) St.John’sWellChildCenter(LA)(Goal3)

Hepatitis C Testing and Linkage to Care Demonstration Projects

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Goal 2: Community-Based HCV Testing and Linkages to Care

(RuralAIDSServiceOrganization)

(Urbanmulti-servicecenter,syringeexchangeprogram,SanFrancisco’sTenderloinDistrict)

(UrbanFederallyQualifiedHealthCenter,syringeexchange

program,HIV/HCVclinic)

STD Control Branch

What Does HCV Testing & Linkage to Care Mean, Really?

*MediacampaignsdesignedbypeoplelivingwithhepatitisCandpilottestedwithpeoplewhoinjectdrugs(PWID)*Outreach onthestreets,underbridges,alongriverbanks,inshelters,drugtreatment,atsyringeexchange,atfoodpantries,etc.

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What Does HCV Testing & Linkage to Care Mean, Really?

* HCVrapidtestingatsyringeexchanges,onmobilevans,atdrugtreatmentprograms

* PhlebotomytodosamedayHCVRNAtesting,includinggettingHCVtestcounselorscertifiedasaphlebotomist;CLIAcertificateofwaiver

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What Does HCV Testing & Linkage to Care Mean, Really?

* Collectingextensivecontactinformation

* Keepingtrackofclientswhentheyarearrested,hospitalized,deported,injail

* Maintaininganopendoorpolicyincasepeopleshowuplater

Source:UCSFVIPStudy

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What Does HCV Testing & Linkage to Care Mean, Really?

* Patientnavigation,includinghelpgettingID,benefitsenrollment,reminders,transportationto—andincentivesforattending—keyappts.

* Patienceandpersistence;kindnessandnon-judgment

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What Does HCV Testing & Linkage to Care Mean, Really?

* Paidstaff/peers:HCV-specificnavigatorsforoutreach,HCVtesting,navigation,phlebotomy;projectmanager;dataanalyst!

* CulturalcompetencewithPWIDandco-locationofservices—bringingtestingtowherePWIDhangout

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HCV Testing Outcomes in Community-Based Settings, Goal 2 Sites, March 2016 – September 2017

Non-IDU44%IDU

56%

ClientsScreenedforHCVantibodybyInjectionDrugUse(IDU)Status

Total:3,693

STD Control Branch

HCV Testing Outcomes in Community-Based Settings, Goal 2 Sites, March 2016 – September 2017

0

100

200

300

400

500

600

700

800

900

1000

Anti-HCVpositive

ReferredtoRNAtesting

CompleteHCVRNAtesting

HCVRNApositive

ReceivedHCVRNAresult

Referredtomedicalcare

Attendedfirstappointment

IDU Non-IDU

87%

76%

74%

76% 93%

58%

*Percentagesshownarecalculatedasaproportionofthepreviousbar.

STD Control Branch

HCV Testing and Linkage to Care Project Outcomes, California, Goal 2 & 3 Sites, March 2016 – September 2017

1 KnownIDU:IDUstatusisunderestimatedforbecausetwoclinicalsiteswereunabletoconsistentlycollectinjectiondrugusestatus.2 Linkedtocare:DefinedasattendingfirstHCVmedicalappointmentforGoal2sitesandasstartingtreatmentforGoal3sites.3 CompletedTreatment:Thisnumberisanunderestimate,asGoal2sitesdonotcurrentlyreportthisdatatoCDPH.4 ReceivedSVRTestingandAchievedSVR:Thisnumberisanunderestimate,asGoal2sitesdonotcurrentlyreportthisdatatoCDPHandbecauseGoal3sitesreportthatclientscompletemedicationbutmaynotreceivetestingtoconfirmthattheyhaveachievedSVR.

AllClients(Goal2andGoal3)

Known toHaveEverInjectedDrugs1

%Among ThoseServedWhoReportedEverInjectionDrugs

TotalScreenedforHCVAntibody 28,417 2,895 10%HCVAntibodyPositive 2,154 1,147 53%TotalTestedforRNA 1,914 943 49%RNAPositive 1,554 737 47%LinkedtoCare/ReceivingClinicalCareManagement2 623 443 71%CompletedTreatment3 344 211 61%ReceivedSustainedVirologicResponse(SVR)TestingandAchievedSVR4 208 129 62%

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What Does It Take to Support Local HCV Demo Projects?

* Dedicatedfunding!* $1.7Mgrants;$400Kstate-levelpersonnel

* Programmanager(me)* StafftodoTA(2)* KnowledgeofHCV,drugtreatment,harmreductionlandscape

* Evaluatortododatacollection,QA(had1butneeded2!)

ChristineRodriguez,MPHProgramAdvisor

SusanaTat,MPHProgramAdvisor

PatriciaZialcita,MPHProgramEvaluator

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Awesome Grantees!

• FamilyHealthCentersofSanDiego– ElizabethEstrada,ShannonHansen,ChristianRamers,SandraReal,LettyReyes

• LosAngelesCommunityHealthProject– MichaelMarquesen,ShoshannaScholar,AimeZuniga

• SanFranciscoDepartmentofPublicHealth– KatieBurk,ColleenLynch,AaronSmith,PauletteWalton

• St.John’sWellChild&FamilyCenter,LosAngeles– VictorConstantino,VictorMartinez,PaolaRamirez,JoseRodriguez,PattiWagonhurst

• TarzanaTreatmentCenters,LosAngeles– YolandaCeballos,InnaLemeshko,JimSorg,KimberlyWard

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How Does this Relate to the Hepatitis Care Cascades Grant?• Interventionpartnerships– “Leveraging”existingresources• HCVdemonstrationprojectsitesubcontractor• HCVtestkitspurchasedwithone-timestatefunds• StateMATexpansiongrantsrequireHIV/HCVtesting

– Policyintervention/performancemeasure• ProportionofPWIDscreenedforHCVannually

– Providereducation• TrainingHCVtestingandlinkagetocarebestpracticesforHCVtestkitandSAMHSAMATexpansionsites

Key:MAT=medicationassistedtreatment

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Resources* EndHepCSFAwarenessCampaignMaterialshttp://www.endhepcsf.org/campaigns/* CaliforniaHepatitisAlliance,HCVlinkageresourceshttps://calhep.org* DHCSMedicationAssistedTreatmentExpansionGrantshttp://www.dhcs.ca.gov/individuals/Pages/State-Targeted-Response-to-Opioid-Crisis-Grant.aspx* DHCSDrugMedi-CalOrganizedDeliverySystemhttp://www.dhcs.ca.gov/provgovpart/Pages/Drug-Medi-Cal-Organized-Delivery-System.aspx* HepatitisCOnlinehttp://hepatitisc.uw.edu* DHCSHCVTreatmentPolicy– prioritizesPWIDhttp://www.dhcs.ca.gov/Pages/HepatitisC.aspx

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Contact Information

RachelMcLean,MPHChief,OfficeofViralHepatitisPreventionSTDControlBranchCaliforniaDepartmentofPublicHealthP:(510)620-3403Rachel.McLean@cdph.ca.govhttps://cdph.ca.gov/ovhp