Hepatitis C Homeless

1
Hepatitis CHomeless

• Burdened
• and
• Ineligible

2
Davis, Liver Transpl 039(4)331-8
3
Wise, Hep 08471128-35
4
Disproportionately Affected
3.2 mill. RNA
mill.
0.34
0.43
Edlin, Hep0542(4)Supp1213A
5
Recommendations for HCV Testing(Alter
AnIM04141715-17, based on CDC, AASLD)

• High risk for infection or need for postexposure
  mgt.
• Ever injected illegal drugs
• Received clotting factors made before 1987
• Received blood or organs before July 1992
• Ever received long-term hemodialysis
• Unexplained abnormal ALT levels
• Health care, emergency medical, and public safety
  workers after needlestick or mucosal exposures to
  HCV-positive blood
• Children born to HCV-positive women
• Low risk for infection but may benefit from
  testing
• Long-term monogamous sex partners of HCV-positive
  persons (counseling and testing of partners may
  provide reassurance)

6
Wasley, MMWR Surveill Summ 0857(2)1-24
7
US homeless adults HCV prevalence
53
44
42
41
P A L O A L T O V A
M A S S. V E T S
32
S K I D R O W
31
30
M A N H A T T A N
22
E L R I O
U C L A
19
M I M H
U C L A
B A L T
198
418
597
636
139
134
114
884
N
168
8
Eligibility and Treatment Rates

• 50/100 clinic referrals a/p Healthy Liver
  Program (Hagedorn 07)
• 49/14 rxd colocated PCNS/existingMH (Knott 06)
• 46 elig w/shared care (Ewart 04)
• 38 eligibles initiate rx (Fr, Moirand 07)
• 37 rxd after liver bx (Narasimhan 06)
• 33 Cook County (25/39 /- HIV)
• 1/3 VA psych pts (Rifai 06)
• 33 HIV referrals b. rx (McClaren 08)
• 32 VAMCs elig (Bini 05)
• 32 Duke VAMC (Muir 02)
• 32 St. Louis VAMC (Cawthorne 02)
• 30 Houston VAMC (Rowan 04)
• 30 UPitt vets (Butt 05)
• 30 UnitedHealth (Shatin 04)
• 30 elig, 16 rx (Can, Witkos 06)
• 30 real-life France rxd (Cacoub 06)
• 29 SF HIV REACH elig (Thompson 05)
• 28 Case Western rxd (Falck-Ytter 02)
• 27 MGH CHC PCPs (Morrill 05)

• 16 IDUs rxd (Grebely 07)
• 15.7 St.Louis VA rxd (Kanwal 07)
• 15 HIV (Restrepo 05)
• 15 HIV elig (Fleming 03)
• 10.7-13.9 Medi-Cal rxd (Markowitz 05)
• 12.5 Swiss begin rx (Zinkernagel 06)
• 12 HIV/hx EtOH elig (Nunes 06)
• 11.8 VA NPCD rxd (Butt 06)
• 10 UK begin rx (Irving 06)
• 9.1 elig if keep 1st appt (Cheung 06)
• 7 VA NPCD HIV rxd (Butt 06)
• 7 Montefiore DUs rxd (Fishbein)
• 7 HIV or meth.clinics (Schackman 07)
• 6.6 if pos. at STD clinic rxd (Mark 07)
• 6 Baltimore IDUs rxd (Mehta 08)
• 3.8 SF HIV REACH rxd (Hall 04)
• 3.4 Hopkins HIV rxd (Mehta 06)
• 3 of HIV/HCV vets rxd (Fultz 03)

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obstacles to treatment

• no medical care
• not screened
• not referred
• referral delay, N/A
• alcohol/sub.abuse
• psych. comorbidity
• medical comorbidity

• no/minimal liver dz
• ESLD
• pt declines treatment
• pt nonadherence
• LFU
• social circumstances
• cost of Rx/monitoring

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AASLD Hep04391147-71
11
Homeless VIHNESViral Hepatitis the Need to
Expand Services
El Rio Community Health Center, Tucson, Az
12
(No Transcript)
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AST Platelet Ratio Index (APRI)

• ASTx100/ULNplatelets (Wai Hep0338518-26)
• 1.5/2.0 ppv 88/57 for BF/cirrhosis
• systematic review (Shaheen Hep0746912-21)
• evaluated in
• veterans (Cheung 08)
• dialysis pts (Schiavon 07)
• HIV pts (Al-Mohri 07)
• liver transplant pts (Toniutto 07)
• NALT pts (Fabris 06)
• in combination with Fibrotest (Sebastiani 06,
  Leroy 07)
• pts with RVR, SVR (GUCI, Westin 07)
• 6 mo after interferon (Yu 06)

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Prospective comparison of transient elastography,
Fibrotest, APRI, and liver biopsy (Castera
GE05128(2)343-50)
AUROC
15
Predicting cirrhosis, HALT-C cohort(Lok
Hep0542282-92)

16
Vaccine02201157-62
Connor J Trav Med 07149-15
17
88
80
7474
62
59
43
36
34
14
anti-HBs
0.5
1.0
18
IDUs receiving DOT in a multidisciplinary group
model (Genoway, Hep0746(4)Suppl370A)

• weekly peer-support group
• attendance 15 patients/wk (3-32)
• 129 referred in 108 weeks
• 30 under evaluation
• 26 have initiated or completed rx w/group
• 30 lost to follow-up
• 8 medically ineligible
• 6 initiated/completed rx before group
• LFU attended 2 meetings, 23 3 clinic visits
• Treated attended 34 meetings, 97 3 clinic
  visits
• GT1/2/3 40/100/67 ETR despite 72 ongoing DU

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Active Injection Drug Users

• majority willing to be treated
• treatment completion similar to others
• SVR rates similar to others
• keeping appointments predicts SVR
• SVR for occasional users freq. users
• 0-4.1/100 pers-yrs reinfection (Backmund,CID0439
  1540-3)
• recidivism no effect on LTx surv (Nickels, Exp
  Clin Transp 07)
• AASLD 2004 guidelines
• able and willing to maintain close monitoring
  and practice contraception
• considering the anticipated risks and benefits
  for the individual
• continued support from drug abuse and psyciatric
  counseling services

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program components

• CTR (counsel, test, refer)
• vaccination
• multidisciplinary
• social services (outreach, medicaid enrollment,
  pharmaceutical assistance programs)
• addiction, mental health services
• nursing
• primary care
• hepatitis treatment provider
• peer/group support
• DOT
• longitudinal, continuity of care

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DOT Health Promoters (Behforouz
CID0438S429-36)

• Accompaniment to medical appointments
• Adherence, harm reduction counseling
• Assist with social crises, homelessness, DV
• Education
• Political advocacy
• Peer support
• Street outreach
• virtuous social cycle improved disease
  outcomes, QOL, employment, activities, social
  networks

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Wesuggest that directly-observed therapy of
chronic infectious disease with multidrug
regimens can be highly effective in settings of
great privation as long as there is sustained
commitment to uninterrupted care that is free to
the patient. Farmer, Lancet01358404
23
Meanwhile

• education
• weight loss
• avoid EtOH, hepatotoxic meds
• vaccinate for hep A and B
• alternative therapies unproven
• monitor plts, PT, LFT
• discuss serial biopsy
• cirrhosis
• EGD q1-2 yrs (small, no varices)
• U/S q6-12mo (/- AFP)
• Transplant evaluation
• await better treatments