Laird Harrison

October 10, 2017

CHICAGO — In a single year, 230 people infected with hepatitis C virus were identified when a pioneering program offered screening wherever county services were available — such as community outreach locations, the lobby of the social services department, and the county jail — in Durham County, North Carolina.

"Our program was innovative in offering testing to people coming for social services," said Arlene Seña, MD, from the University of North Carolina at Chapel Hill.

Some of those screened were seeking services like food stamps or income support, not healthcare, she told Medscape Medical News.

Hepatitis C infection frequently occurs in populations that do not have regular contact with healthcare workers.

Most health departments have not yet initiated widespread screening services for a couple of reasons, Dr Seña said here at the International Conference on Viral Hepatitis (ICVH) 2017.

First, it was not until 2013 that the Centers for Disease Control and Prevention recommended screening for everyone born from 1945 to 1965. Second, direct-acting antiviral medications that can effectively cure hepatitis C have only become available in recent years, and initially cost as much as $80,000 a year.

As a result, many states have limited the number of Medicaid patients whose treatments will be reimbursed. In such situations, extensive screening programs might not be useful, Dr Seña explained.

But North Carolina does not impose such limitations and, like many Southern states, has a high prevalence of hepatitis C infection, she said.

Finding Infected Patients

In an effort to identify infected patients and link them to healthcare providers, Dr Seña and her colleagues targeted screening at baby boomers, people with a long-term partner infected with hepatitis C, people with tattoos or ear piercings done by unregulated providers, and people with a history of intravenous drug use, other illegal drug use, HIV infection, incarceration, or exchanging sex for drugs.

The screening was also targeted at people who had more than five sexual partners in the previous 12 months and at men who had sex with men in the previous 12 months.

Hepatitis C antibody and reflex RNA testing was incorporated into a program that already screened for HIV.

Of the 4558 people screened from March 2016 to April 2017, 230 (5.0%) were positive for both the antibody and RNA. Most of the positive tests — 41.7% — came from people in jail.

The majority of people identified as having chronic hepatitis C were male, nearly half were black, 39% were baby boomers, 55% were previous or current intravenous drug users, 23% were or had been incarcerated, and 4% were infected with HIV.

The prevalence of chronic infection was highest in the county jail population, where 96 of the 1246 (7.7%) people screened tested positive. It was least prevalent in women tested at maternal health clinics, where only two of the 489 (0.4%) people screened tested positive.

Linking to Healthcare

A bridge counselor, also known as a healthcare navigator, initiated contact with people whose results were positive and helped them organize transportation, health insurance, and appointments with healthcare providers.

Of the 230 people with positive tests, 147 (64%) were linked to healthcare through the program. Of these, 27% were seen in primary care, 41% by a specialist, and 16% by a healthcare provider in prison. Another 17% met only with a bridge counselor.

Of the 36% not linked to healthcare, 42% were lost to follow-up, 27% were homeless, 19% moved out of the area, and 12% could not be contacted for other reasons.

Dr Seña and her colleagues are in the process of determining which of the people seen by a healthcare provider received prescriptions to treat the virus or achieved a sustained viral response.

Working with inmates was particularly challenging, said Dr Seña, because they were so often transferred or released before they could meet with a bridge counselor.

"For the jail population, in addition to screening, we also have to have a bridge counselor meet with inmates before their release," she said. These people need someone to connect and engage with, because they probably have "a lot of other social issues, whether it's substance abuse, mental health, housing, or transportation," she explained.

After her presentation, Dr Seña was asked about programs in other detention centers.

Ours is one of the few jails that is actually screening in North Carolina.

"Ours is one of the few jails that is actually screening in North Carolina," explained. "This is a jail; at a prison, there are more services."

More work needs to be done to screen and treat people in jail, said Nancy Reau, MD, from the Rush University Medical Center in Chicago, who is the ICVH conference cochair.

"I think it's a very natural place to find individuals with hepatitis C. Concentration on this population is important," she told Medscape Medical News.

Other counties have tried to connect everyone released from a jail with a federally qualified health center, she added.

Dr Seña has disclosed no relevant financial relationships. Dr Reau reports relationships with AbbVie, Gilead, Merck, Bristol-Myers Squibb, Boehringer Ingelheim, and Janssen.

International Conference on Viral Hepatitis (ICVH) 2017: Abstract 17. Presented October 9, 2017.

Follow Medscape Gastroenterology on Twitter @MedscapeGastro and Laird Harrison @LairdH

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