May 20, 2013

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

Provided by Philadelphia City Paper


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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