A health care team at Oregon Health & Science University is trying a different approach to caring for patients who have, or are at risk for, Hepatitis C, helping overcome barriers that can otherwise make receiving testing and treatment seem impossible.
The team is halfway through a year-long pilot project that helps already hospitalized patients get tested and receive care for liver injury that is caused by the Hepatitis C virus — a condition for which there is no vaccine, but can be cured with consistent treatment. OHSU's pilot, called Hepatitis C Transition-to-Treatment, seeks to end the cycle of delayed care for some of its most vulnerable patients, who struggle with substance use disorder, unstable housing and other challenges.
"A number of patients have become tearful when we're discussing treatment," said Jane Babiarz, M.D., an associate professor of medicine (general internal medicine and geriatrics) in the OHSU School of Medicine and one of the pilot project's organizers. "Patients have said, 'I never thought I was going to get treated for Hepatitis C. No one has ever treated me like a person before or acted like this matters.'"
In the first seven months of the pilot, 19 patients have been enrolled and six have completed treatment. The clinical team hopes post-treatment testing will soon confirm participants who completed treatment are free of Hepatitis C.
Prioritizing Hep C treatment
An estimated 2.4 million people in the United States have Hepatitis C, and more than half don't know they have it. The condition is more common in people who use injectable drugs because it's often spread by sharing needles. There is no Hepatitis C vaccine, making treatment a vital part of preventing transmission. Antiviral medications can cure someone from the Hepatitis C virus, but these pills typically need to be taken consistently for two to three months.
Keeping up with a treatment program can be particularly daunting for patients who are also struggling with substance use disorder; are experiencing homelessness or unstable housing; have limited access to transportation; or face other stigmatizing issues. Patients with Hepatitis C are more frequently hospitalized for other health issues, but hospital staff typically focus on treating their more urgent issues and defer Hepatitis C treatment for later. For many vulnerable patients, that can mean delays of years, if not decades. If Hepatitis C isn't treated, it can be spread to others, and can lead to liver cancer, cirrhosis or end-stage liver disease years later.
OHSU's pilot seeks to end this cycle of delayed care by offering treatment to patients while they're admitted to OHSU Hospital for another health issue. The project specifically seeks to help hospitalized patients who are unhoused, use drugs or have mental health conditions that can prevent them from receiving treatment. If a patient tests positive for Hepatitis C, OHSU Clinical Outreach Social Worker Carissa Williams, LCSW, M.P.H., stops by the patient's hospital room to discuss the program and assess a patient's readiness for treatment.
Patients who enroll then have virtual visits with Babiarz through video or phone calls from their hospital rooms. Babiarz partners with infectious disease pharmacists HaYoung Ryu, Pharm.D., and YoungYoon Ham, Pharm.D., to identify potential patients for treatment and expedite approval.
Most of those who are prescribed antivirals begin treatment while they're still hospitalized. After patients are discharged, Babiarz and Williams continue to meet with them and ensure they have the support they need. Williams also meets with patients in the community to provide support, link to resources and address barriers to completing treatment. Three months after completing treatment, a follow-up blood test is conducted to confirm the virus is gone.
"This is a real opportunity for ingenuity in medicine," Babiarz said. "We're using a human-focused approach to eradicate Hepatitis C, without making vulnerable patients jump through unnecessary, ineffective hoops."
OHSU identifies need
The approach used for this pilot is supported by OHSU research. The Centers for Disease Control and Prevention recommend that all adults be screened for Hepatitis C at least once in their lifetime — and that those with substance use disorder be screened more often. However, an OHSU-led study recently published in Therapeutic Advances in Infectious Disease found testing for this and other infections, such as syphilis or Human Immunodeficiency Virus, or HIV, varies in patients who have substance use disorder and are hospitalized for bacterial infections. Only 80% of studied patients who didn't have a prior Hepatitis C diagnosis were screened for the virus.
While primary care clinics are designed to help patients prevent and manage chronic health conditions, the study noted only about 24% of the patients it tracked had a primary care provider.
"Many who experience unstable housing or have substance use disorder have had negative health care experiences, and may not trust health systems enough to become a patient at a primary care clinic," said Cara Varley, M.D., M.P.H., an assistant professor of medicine (infectious diseases) in the OHSU School of Medicine and the OHSU-PSU School of Public Health, and a lead author of the study. "As a result, many only seek care when something is urgent enough that they need to go to an emergency room. Hospitalization offers a unique opportunity to address potentially life-threating conditions like Hepatitis C and also help decrease the spread of infectious diseases in our community."
Varley's findings reinforce patients' experiences documented in an earlier qualitative study led by Ximena Levander, M.D., M.C.R., assistant professor of medicine (general internal medicine and geriatrics) in the OHSU School of Medicine. The study concluded that, with varying needs among people who use drugs, hospitalization is a key opportunity to address Hepatitis C care, including treatment eligibility, consolidation of care and facilitation of referrals. The pilot's intervention design is based on these findings.
The pilot project began enrolling participants in July 2022 and aims to enroll, and hopefully cure, 25 patients through June 2023. It's currently supported by a grant from OHSU Health Integrated Delivery System, a network that focuses on meeting the needs of OHSU patients who are covered by Medicaid. Babiarz and colleagues plan to share their results with OHSU leaders and nonprofit organizations with the hope of continuing their efforts beyond this summer.
