March 17, 2014
NEW YORK CITY — An innovative program that goes into at-risk neighborhoods to identify people infected with HIV and hepatitis C virus is proving to be very successful at finding and linking these people to care.
"We recognize that there are a multitude of barriers to care for individuals living with hepatitis C and HIV, and we know that 50% to 75% of people who have hepatitis C are unaware of their infection," said lead investigator Stacey Trooskin, MD, from the Drexel University College of Medicine in Philadelphia.
"Most at risk are people with a history of injection drug use, those who received a drug transfusion before 1992, and those who have had multiple sexual partners. Our concern is that many of these at-risk individuals may not have access to medical care or see their doctor regularly," Dr. Trooskin explained.
She described the campaign to test and link patients to care — called Do One Thing, Change Everything — here at the International Conference on Viral Hepatitis 2014.
Dr. Trooskin and her team went into a Philadelphia neighborhood known to have one of the highest prevalences of HIV and hepatitis C and the lowest number of medical resources.
"It's a guerrilla-based street and door-to-door campaign," she explained. We invite people who are walking on the street or who answer their doors to "come out to our van to be tested for hepatitis C and HIV."
Dr. Trooskin presented results from 1001 individuals who were tested for HIV and hepatitis C from December 2012 to October 2013.
It's a guerrilla-based street and door-to-door campaign.
The OraQuick rapid antibody test was used to identify hepatitis C infection. Immediately after a reactive test result, reflexive confirmatory testing with the hepatitis C nucleic acid test was done with a blood draw.
"Our hepatitis C testing uses a very unique algorithm," Dr. Trooskin said.
"We know that 15% to 25% of individuals who are exposed to hepatitis C clear it on their own, so they will have antibodies but do not have the virus. If they only get the antibody tested, it doesn't really tell them the true nature of their status," she explained. With our protocol, "not only are we out on the street pulling people into the van to get tested, when somebody has a reactive rapid antibody test for hepatitis C, we immediately draw their blood and automatically run a second test."
The program has been very successful, Dr. Trooskin said.
She reported that 42 individuals (4.2%) had a seroprevalence of anti-hepatitis C antibodies.
Of these 42 people, 37 (88%) underwent confirmatory testing and 31 (84%) turned out to be chronically infected. For 13 (42%) of these chronically infected people, the hepatitis C diagnosis was new.
None of the people who tested positive for hepatitis C were receiving subspecialty care at the time they were tested. In addition, 9 (29%) of the people who were chronically infected had no medical insurance.
Three uninsured patients were lost to care, but the other 6 were able to get insurance.
High Rates of Care
With aggressive case management, 18 (58%) of those chronically infected with hepatitis C were linked to subspecialty care, and all of the others are now actively engaged in the linkage process, Dr. Trooskin reported. However, 10 (35%) people said they had difficulty obtaining a referral for subspecialty care from their primary care physician.
"Many of these individuals we find have not been to a primary care provider in many years. We have had great success linking individuals to care who wouldn't otherwise have had access," she said.
"The bottom line here is that testing for hepatitis C in a nonclinical setting is a necessary and effective means of identifying new hepatitis C infections. It also re-engages individuals who sort of knew they had something wrong with them and might have been told along the way that they might have hepatitis C, but didn't know they needed to do anything about it," Dr. Trooskin said.
Such testing "facilitates linkage to myriad clinical and behavioral services," said José Zuniga, PhD, president of the International Association of Physicians in AIDS Care.
"If successful, this can mean a diagnosis and cure for countless undiagnosed individuals, as well as reduced risk behaviors and reduced transmission rates," he told Medscape Medical News.
"Going to where hepatitis C is establishing a foothold is an important means by which to use the epidemiology of an evolving epidemic to ensure that recent progress in hepatitis C clinical management benefits patients in rural and urban settings alike," Dr. Zuniga explained.
This study was funded by Gilead Sciences. Dr. Trooskin is on the Gilead Sciences board for hepatitis C. Dr. Zuniga has disclosed no relevant financial relationships.
International Conference on Viral Hepatitis (ICVH) 2014: Abstract 61. Presented March 17, 2014.