May 20, 2013

Fewer Kids Die While Waiting for New Organs

By Kathleen Struck, Senior Editor, MedPage Today

Published: May 20, 2013

Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner

Action Points

  • Fewer children died waiting for organ transplants in the past decade after policy changes to the national organ allocation system.
  • Note that recipients of pediatic organ donation after circulatory determination of death increased, while recipients of pediatric donation after neurologic determination of death decreased over the study period.

Fewer children died waiting for organ transplants in the past decade after policy changes to the national organ allocation system, researchers stated.

The number of children dying before they could receive a transplant dramatically decreased from 262 to 110 as pediatric transplants increased from 2001 to 2010, stated Jennifer Workman, MD, of the University of Utah School of Medicine in Salt Lake City and colleagues, in Pediatrics.

The authors attributed major policy shifts for liver and kidney transplant protocols to the increase in transplants to children 17 and younger. Those organs compose the greatest percentage of solid-organ transplants in children, they noted.

Changes under the United Network for Organ Sharing (UNOS) allowed for increased transplantation from circulatory death donors while transplants from brain death donors decreased. UNOS is the private, non-profit organization that manages the nation's organ transplant system under the federal government, according to it website.

In fact, recipients of pediatric donation after circulatory determination of death (DCDD) increased by 174% (50 to 137), while recipients of pediatric donation after neurologic determination of death (DNDD) decreased by 13% (2,992 to 2,614), Workman and colleagues stated.

"The increased use of DCDD kidneys and livers for transplantation into children may be one method to increase the number of pediatric transplants," wrote Heung Bae Kim, MD, and Craig Lillehei, MD, of Harvard Medical School and Boston Children's Hospital in an accompanying commentary.

However, "efforts to pursue living donation as the primary option for kidney transplantation in children" should not be ignored, Kim and Killehei wrote.

Other changes included policies affecting pediatric liver transplants, a liver disease end-stage scoring system, and, regional sharing of pediatric liver donors.

"Our analysis suggests that these liver allocation changes improved access to transplantation for children with liver failure and support earlier reports which investigated the effect of the model for end-stage liver disease/pediatric end-stage liver disease scoring systems on pediatric liver transplantation," they wrote.

The authors obtained data from the Organ Procurement and Transplantation Network for U.S. organ recipients and donors from 2001 to 2010. Data were stratified by age, organ, and DCDD, and transplant wait-list removals due to death.

The criteria for donors for pediatric kidney transplants was expanded, giving pediatric recipients priority to kidney donors younger than 35. Pediatric kidney transplants increased an average 61 per year, the authors wrote.

"The kidney shortage remains an enormous problem for the transplant community, and allocation strategy changes to maximize donor kidney utilization are currently being assessed," they wrote.

The authors noted that adult recipients far outnumber child recipients, while adult donors are more numerous than child donors.

The innovative techniques of split, live donor, and reduced liver grafts have increased the number of donations to transplants and decreased waiting times, the authors wrote, although data are conflicting about outcomes.

Interestingly, when a liver is split for size and first offered to a child, the other half typically goes to an adult recipient. However, if a liver is first offered to an adult, no regulations require that the adult be asked to split the liver with a child.

"To increase the availability of split livers from organs offered primarily to adults, adult transplant teams need to place greater importance on this option," the authors said.

In the time period the authors assessed, 14,221 children received organ transplants from deceased donors. The transplant universe was broken down as:

  • Pediatric organ transplants increased from 1,170 to 1,475, peaking at 1,628 in 2009
  • Pediatric recipients increased 799 to 971
  • Pediatric donor organs used for transplantation decreased from 3,042 to 2,751
  • Pediatric donors decreased from 987 to 841
  • Pediatric transplant donors to adult recipients decreased 2,243 to 1,780

The majority of pediatric donor organs are still transplanted into adults, specially DCDD organs that are used almost exclusively for adult recipients.

"Although it is true that pediatric donation (both DCDD and DNDD) does not always directly benefit other children, improving the overall process of donation and increasing organ recovery allows for more pediatric transplants and fewer pediatric wait-list deaths," the authors wrote.

The study had some limitations. The data were not indexed for population growth and some of the increased rates of donation and transplantation seen in the study years could be attributed to an increase in the overall population. Also, the database identifies donor organs allocated, not individual donors. Organs from a single donor can be used in up to eight individuals, the authors pointed out.

Finally, "during the study period, advances in the medical management of patients have evolved, allowing some of these children to improve and either delay or not require transplantation," they said.

Workman reported no conflicts of interest. Co-authors reported relationships with the Organ Donation and Transplantation Alliance and Up To Date. The authors reported no external funding.

Kim and Lillehei have served on the Board of the New England Organ Bank and several committees within UNOS. They reported no external funding.

Primary source: Pediatrics
Source reference:
Workman J, et al "Pediatric Organ Donation and Transplantation" Pediatrics 2013; DOI: 10.1542/peds.2012-3992.

Additional source: Pediatrics
Source reference:
Kim H, Lillehei C "Organ Donation for Children: The Road Ahead" Pediatrics 2013; DOI: 10.1542/peds.2013-1005.

Source

Clinical Pointers on Rapid Home-Use HIV Testing

CDC Expert Commentary

Philip J. Peters, MD

May 20, 2013

On July 3, 2012, the US Food and Drug Administration approved the OraQuick® In-Home HIV Test, a rapid home-use HIV test kit that can be purchased over the counter and online. The kit provides a test result in 20-40 minutes and allows patients to conduct a self-test in their own home. The kit, which tests a sample of fluid from the mouth, is approved for sale in stores and online to anyone age 17 years and older.

Given the availability of a home-use HIV test, should primary care clinicians advise their patients to use this test, and in what situations is it expected to be most useful?

The Centers for Disease Control and Prevention (CDC) recommends HIV screening for all persons aged 13-64 years, regardless of risk, in healthcare settings where the prevalence of undiagnosed HIV is ≥ 0.1% or the yield of screening is at least 1 new HIV infection identified per 1000 persons screened.[1]

Annual HIV testing is recommended for those at high risk for HIV infection. The best approach for patients is to go to a physician and get tested as part of regular medical care, which is what the CDC recommends. Home-use self-testing is not a substitute for getting tested by a healthcare provider. Primary care clinicians should continue to encourage their patients to get tested for HIV.

Some patients might be reluctant or reticent to test for HIV with their provider or prefer the convenience of HIV testing at home.[2] Having access to a home-use, over-the-counter HIV test could lead to increased HIV testing and earlier HIV diagnoses among people who are not currently getting tested for HIV. If so, it will be an important advance.

Some patients at high risk for HIV infection may benefit from frequent (every 3-6 months) HIV testing. For these patients, home-use self-testing might be convenient.

How should physicians counsel patients who use the home-use HIV test?

It is important for patients to read and follow the test instructions carefully. Performing the test incorrectly can result in an invalid (uninterpretable) test result. In a clinical study, 1% of people who took the test did not get an interpretable test result.[3] A 24/7 support center toll-free number is provided with the test instructions in case there are any questions about how to perform the test correctly. Patients should be aware that in a clinical study, the home-use HIV test did not detect every HIV infection. Among people determined to have HIV infection, approximately 1 in 12 had a negative home-use HIV test result (8% rate of false negative results),[3] so patients should be counseled that a negative home-use HIV test result does not completely rule out HIV infection. Compared with a blood test performed by a healthcare provider, there is a trade-off for the convenience of self-testing oral fluid at home.

Patients should also be aware that this test does not detect recent HIV infection. This test detects antibodies against HIV approximately 3 months after infection occurred. Patients who are concerned about very recent HIV exposure should discuss this with their healthcare provider to determine whether medication to prevent HIV infection (eg, antiretroviral postexposure prophylaxis for HIV exposures within 72 hours) or diagnostic tests for early HIV infection (eg, a fourth-generation combination HIV antigen/antibody test or an HIV RNA test) are indicated.

Is additional HIV testing recommended for patients who report a positive home-use HIV test result?

Like any rapid test, a positive or reactive home-use, over-the-counter HIV test is a preliminary positive result that needs to be confirmed with additional testing. HIV testing always involves at least 2 tests. Patients who report a positive home-use HIV test should be counseled that they have a preliminary positive test result and must have blood drawn and sent to a laboratory for HIV testing to determine whether HIV infection is truly present or whether the test result is a false positive. (In clinical studies, only 1 false positive result occurred in 4903 tests on HIV-negative people.[3]) Patients with a confirmed positive HIV test result should be immediately referred for HIV medical care.

Given the high rate of false negative results, when should a clinician consider retesting a patient who reports a negative home-use HIV test result?

Self-testing for HIV at home is not intended as a substitute for going to a healthcare provider and getting tested. Patients who are concerned that they might have been exposed to HIV should be offered an HIV test even if they report a negative home-use test result. The clinical trials showed that the home-use HIV test was positive in 92% of persons who were infected. This is not as accurate as a blood test performed by a healthcare provider. Also, the home-use HIV test does not detect recent HIV infection (less than 3 months after exposure). Some laboratory tests (fourth-generation combination antigen/antibody tests or HIV RNA tests) can detect HIV as soon as 10-14 days after infection. Patients who might have been exposed to HIV very recently (that is, within 72 hours) also should be evaluated for possible use of postexposure prophylaxis with antiretroviral drugs. In addition, patients with ongoing potential exposures to HIV infection should be retested at least annually. Some patients, such as sexually active men who have sex with men, might benefit from testing as often as every 3-6 months. Therefore, the decision to repeat HIV testing should be based on the patient's specific circumstances.

How should clinicians advise partners of high-risk individuals about taking the home-use HIV test?

Partners of people at high risk for HIV infection are an important group to test for HIV infection. Clinicians with patients at high risk for HIV infection should encourage them to discuss HIV testing with their partners and urge their partners to be tested for HIV infection as well. Ideally, these partners could come to your office and receive HIV testing as part of their medical care. Further information on finding an HIV testing site is also available online. Some partners, however, may be reluctant or reticent to test for HIV because of perceived stigma or other reasons. In addition, some couples may prefer to test together, and HIV testing at home offers a convenient way to do that. Patients should be reminded that self-testing for HIV at home does not detect recent HIV infection (less than 3 months after exposure). Because individuals with recent HIV infection are at especially high risk for transmitting HIV infection to their partners, a negative home-use HIV test should not be used to make decisions about behaviors, such as having unprotected sex, that might place them at risk for HIV.

Web Resources

For information on CDC's HIV screening recommendations in healthcare settings: http://www.cdc.gov/actagainstaids/hssc/index.html

For general information on HIV testing: http://www.hivtest.org/

For general information on HIV infection: http://www.cdc.gov/hiv/default.htm

Philip J. Peters, MD, DTM&H, is a Medical Officer with the Division of HIV/AIDS Prevention, US Centers for Disease Control and Prevention, in Atlanta, Georgia. Dr. Peters is the activity leader for HIV testing in the Division of HIV/AIDS Prevention's Epidemiology Branch. He is responsible for conducting epidemiologic and biomedical research activities to evaluate acute HIV infection and important HIV-related coinfections such as Staphylococcus aureus, influenza, and hepatitis B virus. Dr. Peters received his medical degree from Cornell University Medical College. He completed his clinical training in internal medicine at Massachusetts General Hospital and his clinical training in infectious diseases at Emory University. He began his career at the CDC in 2006 when he joined as an Epidemic Intelligence Service Officer. His professional interests include improving HIV diagnosis in the clinical setting.

References

Source

Journal of Viral Hepatitis

What About Us?

Recent Advances in the Treatment of Chronic Hepatitis C Threaten to Leave Some Parts of the World Behind

F. Ahmed

J Viral Hepat. 2013;20(5):367-368.

Directly acting antiviral (DAA) agents are currently revolutionizing the treatment of chronic hepatitis C infection. The first generation of these agents have significant limitations including cost issues that are of particular concern in the developing world and a lack of efficacy in genotype 3 patients. Both of these concerns are of particular relevance in Pakistan.

One cannot attend any major international liver conference over the past 1 year and not be struck by the vast array of new directly acting antiviral (DAA) agents currently in the pipeline. Telaprevir and boceprevir have already been licensed for use in Western countries. Although these and other agents will revolutionize the treatment of chronic hepatitis C, these advances threaten to leave some parts of the world, the developing world in particular, and a large proportion of the world's hepatitis C burden, behind.

Pakistan is a case in point. Recent epidemiological data suggest that 4.9% of the Pakistani populace is chronically infected with hepatitis C.[1] With an overall population estimated at 180 million, this translates into approximately 9 million hepatitis C patients. On a positive note, >65% of these infections are genotype 3. But many patients struggle to pay for the 6-month course of standard interferon-based therapy; some having to sell their jewellery, homes and livestock to do so. The fivefold price difference between standard and pegylated interferon is an insurmountable hurdle for many patients here, where health insurance does not exist and where the average person makes $650 per year. Owing to cost considerations and comparable efficacy, the Pakistan Society of Gastroenterology recommends that the first-line therapy for these genotype 3 patients be standard interferon and ribavirin. A genotype 3 predominance, however, may also have a downside given that recent studies have suggested the genotype 3 is associated with accelerated fibrosis progression.[2] This is particularly consequential in a developing country, like Pakistan, where no liver transplantation program exists and where most cirrhotics lack the resources to travel abroad for liver transplant.

Where will these new DAA agents fit into the picture here? The minority of patients who have genotype 1 and those with genotype 3 who do not respond to conventional therapy could be considered candidates for newer therapies. However, given that patients here often struggle to pay for interferon-based therapy, the ability to pay for a third additional agent seems unlikely at best. Even if money was not an issue, in Pakistan, at least, the applicability of the first generation of direct-acting antiviral agents that have hit the market would be limited at best. In contrast to their spectacular results in hepatitis genotype 1 patients, telaprevir and boceprivir have limited activity against genotype 3.[3] It is still unclear whether other agents in development will have the same genotype barriers seen with telaprevir and boceprevir. Preliminary data suggest good activity against genotype 3 of nucleoside polymerase inhibitors and cyclophilin inhibitors, but not non-nucleoside polymerase inhibitors.[4]

Are there lessons to be learnt here? First of all, it highlights the need in Pakistan and other parts of the developing world to focus on prevention. If we cannot afford to treat these infections, perhaps the wiser approach is to try and prevent them from occurring in the first place. The vast majority of hepatitis C infections in Pakistan occur because of unsafe injections.[5] This phenomenon has also been recognized in other parts of the developing world.[6] We need to do a better job in maximizing the outcomes from the existing interferon and ribavirin regimen. Finally, hepatologists in developing countries need to do a better job of leveraging their hepatitis C patient volumes into clinical trials and perhaps drug development that is more relevant to their unique clinical scenarios.

A scenario may develop where hepatitis C is largely eradicated from the developing world but exits in large pockets in developing countries. Given current patterns of human migration, however, increasing numbers of these hepatitis C patients could be projected to arrive on the shores of Europe and North America.[7] Chronic hepatitis C is a truly global problem and needs to be addressed as such. Furthermore, if the treatment of hepatitis C evolves into a multidrug antiviral combination[8] similar to that for HIV, it is not difficult to foresee struggles over patents and intellectual property rights analogous to those that occurred in Sub-Saharan Africa in the 1990s and the early part of this decade over HIV drugs.

From my perspective, sitting in my office in Karachi, Pakistan, the new directly acting antiviral agents represent an exciting leap forward in the field of hepatitis C virology but are not obviously clinically relevant to my practice. Issues relating to cost, access and applicability will affect hepatologists in the developing world, in particular, in the coming years. Further advances in this field need to take into account the global hepatitis C burden. Perhaps most importantly, a greater emphasis on prevention is needed. My colleagues and I need to do a better job of marketing our 9 million Pakistani hepatitis C patients to make them more attractive to drug companies involved in new drug development and international aid donors, as do hepatologists in other parts of the developing world. For now, I will have to be content with marvelling at the science behind these new discoveries and envy those hepatologists who have access to new tools in the fight against this global menace.

References
  1. Mohsin M, Qureshi H. The first prevalence report on hepatitis B and C in Pakistan. Pak J Gasroenterol 2011; 25(1): 5–7.

  2. Bochud PY, Cai T, Overbeck K et al. Genotype 3 is associated with accelerated fibrosis progression in chronic hepatitis C. J Hepatol 2009; 51: 655– 666.

  3. Foster GR, Hézode C, Bronowicki JP et al. Telaprevir alone or with peginterferon and ribavirin reduces HCV RNA in patients with chronic genotype 2 but not 3 infections. Gastroenterology 2011; 141(3): 881–889.

  4. Soriano V, Peters MG, Zeuzem S. New therapies for hepatitis C virus infection. Clin Infect Dis 2009; 48: 313–320.

  5. Jafri W, Subhan A. Hepatitis C in Pakistan: magnitude, genotype, disease characteristics and therapeutic response. Trop Gastroenterol 2008; 29(4): 194–201.

  6. Saleh DA, Shedl FM, AL-Kamary SS et al. Incidence and risk factors for community acquired hepatitis C infection from birth to 5 years of age in rural Egyptian children. Trans R Soc Trop Med Hyg 2010; 104: 357–363.

  7. Ahmed F, Foster GR. Global hepatitis, migration and its impact on western healthcare. Gut 2010; 59(8): 1009–1011.

  8. Gane EJ, Roberts SK, Stedman CAM et al. Oral combination therapy with a nucleoside polymerase inhibitor (RG7128) and danoprevir for chronic hepatitis C genotype 1 infection (INFORM-1): a randomized, double-blind, placebo-controlled, dose-escalation trial. Lancet 2010; 376: 1467–1475.

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Pharmaceutical advances offer new options for health outcomes

Public release date: 20-May-2013

Contact: Aimee Frank
newsroom@gastro.org
407-685-4030
Digestive Disease Week

Research presented at DDW® 2013 feature new drugs for IBS, hepatitis C

Orlando, FL (May 20, 2013) — Research presented at Digestive Disease Week® (DDW) explores pharmaceutical advances for treating irritable bowel syndrome with diarrhea (IBS-D) and hepatitis C.

An international study holds promising results for patients suffering from IBS-D. In the phase II study, researchers found that the drug ibodutant significantly improved symptoms in more than 50 percent of the individuals treated.

"While there's been a lot of progress in medicines for IBS with constipation, we haven't seen the same in IBS with diarrhea," said Jan Tack, MD, professor and director of the division of gastroenterology and internal medicine at Leuven University in Belgium. "Up to this point, we haven't been able to provide a pharmaceutical option for this patient group that successfully manages the pain associated with the condition."

IBS is an extremely common condition, affecting an estimated 10 percent of adults. Funded by Menarini, the double-blind, multinational study recruited 559 patients with IBS-D who were randomized and treated with 1, 3 or 10 mg of ibodutant or a placebo. Patients took an oral tablet once daily for eight consecutive weeks. Researchers found that 10 mg was the most effective dose and that it worked best for females.

"These are exciting findings that could bring a lot of relief to many patients," said Dr. Tack said. "We're looking forward to moving into phase III to confirm our findings with a much larger sample of patients."

New therapy for patients with hepatitis C examined

New research suggests that an investigational therapy for patients with hepatitis C can achieve high response rates in a wide range of patients, even those who respond poorly to current treatments. The study examined the safety and efficacy of interferon-free regimens, including three direct-acting antiviral drugs with and without ribavirin, for 12 or 24 weeks, in patients with chronic hepatitis C who were either treatment-naïve or had previously failed standard treatment with peginterferon and ribavirin.

In the phase II study, researchers found that the treatment regimens achieved high sustained virologic response (SVR) rates, an efficacy measure of a hepatitis C treatment, in non-cirrhotic patients with HCV genotype-1 (GT 1). SVR was achieved by 98.7 percent of treatment-naïve patients and 93.3 percent of prior nonresponders after 12 weeks of treatment with three direct-acting agents with ribavirin.

"Hepatitis C genotype 1 is the most common type of hepatitis in the U.S., and many of these patients are still quite difficult to treat with current interferon-based therapies," said Frederick Nunes, MD, clinical associate professor of medicine at Penn Medicine. "This includes specific populations such as African Americans and patients with high body mass or pre-diabetes. These results suggest that highly effective regimens like this one may overcome that difficulty, without the need for interferon."

###

Assigning 247 patients to 12- or 24-week regimens, researchers found that four weeks after treatment, SVR rates were high regardless of patient characteristics previously associated with poorer response to interferon therapy. Funded by AbbVie (formerly Abbott), the study's results hold particular significance for patients who are older, black, Hispanic or have a higher body mass index.

Dr. Tack will present data from the study "Efficacy of ibodutant, a selective antagonist of neurokinin 2 receptors, in irritable bowel syndrome with diarrhoea (IBS-D): the results of a double-blind, randomised, placebo-controlled, parallel-group phase II study (The IRIS-2)," abstract 520, on Monday, May 20, at 8 a.m. ET in Room 300 of the Orange County Convention Center.

Dr. Nunes will present data from the study "Interferon-free Regimens of ABT-450/r, ABT-267, ABT-333, and Ribavirin Achieve High Sustained Virologic Response 4 Weeks Post-Treatment (SVR4 ) Rates in Patients With Chronic HCV Genotype 1 Regardless of Race, Ethnicity, or Other Baseline Characteristics" abstract 514, on Monday, May 20, at 8 a.m. ET in Room 203AB of the Orange County Convention Center.

Digestive Disease Week® (DDW) is the largest international gathering of physicians, researchers and academics in the fields of gastroenterology, hepatology, endoscopy and gastrointestinal surgery. Jointly sponsored by the American Association for the Study of Liver Diseases (AASLD), the American Gastroenterological Association (AGA) Institute, the American Society for Gastrointestinal Endoscopy (ASGE) and the Society for Surgery of the Alimentary Tract (SSAT), DDW takes place May 18 to 21, 2013, at the Orange County Convention Center, Orlando, FL. The meeting showcases more than 5,000 abstracts and hundreds of lectures on the latest advances in GI research, medicine and technology. More information can be found at http://www.ddw.org.

Follow us on Twitter @DDWMeeting; hashtag #DDW13. Become a fan of DDW on Facebook.

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Help on Wheels for Philly's Public Health 'Time Bomb,' Hepatitis C

Provided by Philadelphia City Paper

20130516_news_lead_hepc_rgb

Neal Santos

TEST DRIVES: At a recent free mobile screening, (from left) Ta-Wanda Preston and Gladys Thomas tend to Danielle Parks.

Posted: Thu, May. 16, 2013, 12:00 AM

An innovative mobile lab brings testing to highest risk neighborhoods.

Samantha Melamed

City Paper

Stepping out of the high-tech medical lab on wheels and into a sunny afternoon in the projects, McHale Colman, 28, doesn’t seem to notice that he has experienced something revolutionary.

“Anytime I see these buses, I try to come get tested and get it out of the way,” he says with a shrug. “I jump on it: It’s private, I don’t got to go nowhere, I’m in the ’hood.”

After all, free mobile screening programs have become common sights in neighborhoods like this one — Bartram’s Village in Southwest Philly — as public-health organizations try to capture poor residents who tend not to access regular primary care.

But the lab that Colman visited is unique: It’s the first in Philadelphia — and possibly the first in the nation — to pair rapid HIV testing with rapid hepatitis C testing, follow-up confirmatory testing and immediate connections to care. The program, called Do One Thing, is spearheaded by Amy Nunn, a medical researcher at Brown University. It rolled out with HIV tests last summer and added hepatitis C in December, targeting hot spots in Southwest Philly zip codes where the rates of HIV infection are among the highest in Philly — in fact, higher than in some countries in Africa. (Risk is increased due to factors like intravenous drug use or unregulated tattooing, such as in prison or at “tattoo parties.”) The van is out three days a week, sending outreach workers knocking on doors, handing out flyers and explaining those alarming statistics, working toward a goal of testing 12,000 area residents.

It’s an aggressive approach to a disease that Philly Health Commissioner Donald Schwarz recently called a “time bomb” — particularly if Gov. Tom Corbett doesn’t agree to Medicaid expansion in Pennsylvania. “There will be a very large number of people in Philadelphia who will require diagnosis and treatment for hepatitis C. We have been trying to do something about this epidemic that is invisible for the moment,” Schwarz told City Council recently. Hepatitis C is about five times more prevalent than HIV nationwide, but infected people can remain asymptomatic for years, often to be diagnosed only after severe liver damage, including cancer or cirrhosis, has occurred.

Now, with an aging baby boomer population expected to manifest hepatitis C in record numbers over the coming decade, public-health officials are worried. “This could be really costly to the health-care system, in terms of liver transplants, or you’ll have a lot of people potentially dying,” says Philly viral hepatitis prevention coordinator Alex Shirreffs. “There’s definitely a concern that if we don’t start paying attention to hepatitis C, we’re going to be catching people too late.”

But experts are also hopeful. The past few years have been a time of extraordinary progress in the diagnosis and treatment of hepatitis C, bringing the creation of a rapid test, new Centers for Disease Control (CDC) screening guidelines and radically improved treatment regimens that have doubled cure rates among the hardest-to-treat patients. Here in Philly, Do One Thing is just one of several public-health innovations around hepatitis C, including an unprecedented viral-surveillance initiative, a planned public-awareness campaign and a behind-the-scenes effort to educate doctors about new standards of care.

As of now, though, there’s still very little money to go around — not for treatment and not even for screenings. So, for example, while the rapid test was hailed as a major advancement when it was released in 2011, “unfortunately, because the [federal] government didn’t provide a lot of funding for governments to deliver rapid tests, it didn’t … get many done,” says Shirreffs.

In Philly, at least, all that could change, says Drexel professor Dr. Stacey Trooskin, who leads the hepatitis-C component of Do One Thing and, with Shirreffs, co-chairs the year-old, so-far-unfunded coalition Hepatitis C Allies of Philadelphia (HEP CAP). “We’re really focused on trying to put Philadelphia on the map as a city that is facing hepatitis C head on, and trying to address it as the public-health issue that it is.”

To that end, Do One Thing isn’t the only program pushing hep-C screenings: Philadelphia Health Management Corp., for one, is running a pilot effort funded by the CDC. But there’s hope that Do One Thing’s model — which brings testing to the most affected neighborhoods — just might launch a national movement.

Still, to get a program like this up and running means facing numerous regulatory and technical hurdles. In Nunn’s case, those included identifying a lab that could process confirmatory blood tests — a challenge because blood has to be analyzed within six hours of being drawn, and the van keeps late-night and Saturday hours. But the tests are necessary because one in five people who initially test positive do not have chronic infections.

Then there was the problem of connecting those who test positive to care — which can be hard when phone numbers are disconnected or housing is unstable. That’s why the same-day tests results are so important, Nunn says: Otherwise, “You lose a lot of patients to follow-up.” And, finally, there’s what Nunn calls “the real bugaboo”: paying for treatment. Hepatitis C is increasingly curable, but a 12-week course of Incivek, one of the newer drugs, is priced at a jaw-dropping $49,200.

So far, most of the people who’ve been diagnosed on the Do One Thing van have either had insurance or been Medicaid eligible — linkage-to-care coordinators can help them apply — and they’ve all been connected to care. Some people who know they’re positive come in for testing anyway, Nunn says, and get linked to care again. Up to now, Do One Thing has administered 3,000 HIV tests (about 1.3 percent positive) and 550 hepatitis C tests (5.5 percent positive).

The CDC has shown interest in the Do One Thing approach, Nunn says. The federal public-health agency is now two years into its own hepatitis C action plan, which among other things designated age-based screening guidelines. The CDC suggests people aged 47 to 67 get tested; previously, tests were based on risk factors alone.

Epidemiologists considered that change a victory — but in some cases an empty one. Today, Trooskin says, “Primary-care providers are just not testing.” Even the city’s own health centers, which offer risk-based screening, don’t routinely follow the CDC guidelines.

“There’s a lot of misconceptions among primary-care providers about what treatment is available and who’s eligible for it. A lot of primary-care providers aren’t aware that hepatitis C is curable, and they certainly aren’t aware of the rapidly evolving treatment paradigm,” Trooskin says, noting that several experimental treatments offer hope for a 90 percent cure rate. “To get that message out to primary-care providers is really important. Even if [patients are] not treatment candidates today, they may be in a year or two.”

HEP CAP has been getting experts to visit primary-care practices beginning this month and provide education on the guidelines, treatment and referral options.

But more targeted efforts remain elusive, since, as Trooskin puts it, “What we know about the epidemiology of hepatitis C is really the tip of the iceberg.” That could soon change, since Philly was one of seven cities nationwide to receive a federal viral-hepatitis-surveillance grant to study the city’s epidemic. “This idea of a neighborhood-based approach, going out into the community and linking individuals to care, is really going to be the next frontier when it comes to finding individuals that are [hepatitis C] positive but are not currently in care or are unaware of their infection,” Trooskin says. “I don’t think we can just wait for folks to come into the doctor’s office. We need to be out in the community.”

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