Insights in Public Health

Introduction

Hepatitis C has a wide reach.

Besides interventions such as education, screening, and medical management, public health programming for hepatitis C also typically addresses homelessness, opioid addiction, overdose prevention, drug policy, incarceration, pharmacy access, and many other cross-cutting issues. With such broad implications across multiple public health sectors, addressing hepatitis C in Hawai‘i could be an insurmountable challenge for small programs like the Department of Health's (DOH) Adult Viral Hepatitis Prevention Program (AVHPP). However, this breadth of impact is also an opportunity to identify novel ways to leverage relationship capital, reduce disease “silos,” and utilize intersecting frameworks for public health. By meaningfully framing hepatitis C in different contexts, AVHPP has effectively integrated services into multiple settings. Specifically, this article will explore how positioning hepatitis C as a touchpoint for other health and non-health issues allowed the AVHPP to enhance the network of support for hepatitis C in Hawai‘i.

Hepatitis C in Hawai‘i

Chronic hepatitis C is caused by a contagious, blood-borne virus that primarily affects the liver. Only 20% of individuals infected with the hepatitis C virus (HCV) will clear the infection on their own; 80% will go on to have chronic infection.¹ Hawai‘i is estimated to have at least 23,000 cases of chronic HCV infection, but there are not currently any available surveillance data for Hawai‘i.² The true prevalence of chronic HCV in Hawai‘i is likely higher since this estimate does not account for persons who are incarcerated, institutionalized, homeless, or within the Veterans Administration system.³

Undiagnosed and untreated, chronic HCV infection can lead to cirrhosis, hepatic fibrosis, and even hepatocellular carcinoma (liver cancer).⁴ Viral hepatitis is a leading risk factor for liver cancer, accounting for more than 75% of all liver cancer cases in Hawai‘i.⁵ Currently, Hawai‘i has one of the highest rates of liver cancer death in the United States, and the second highest rate of liver cancer overall.⁶

Fortunately, HCV can now be cured. Following years of treatments that were difficult to administer and tolerate and had low cure rates, new drugs are easy to take, have little to no side-effects, and almost always lead to a cure.⁷ Additionally, the costs for treatments have dropped from more than $80,000 to $20,000.⁸ In comparison, the lifetime medical cost for diabetes can be up to $211,400, depending on age of diagnosis.⁹ Since current therapies for HCV infection are curative and increasingly accessible, improved testing and treatment of people infected with HCV can lead to markedly improved individual and population health outcomes, especially within at-risk populations.

Impact on Populations

Due to the high prevalence of HCV among baby boomers (born during 1945 to 1965), the Centers for Disease Control and Prevention (CDC) recommends HCV screening for all persons in this age cohort, regardless of known risk exposure.¹⁰ HCV testing programs in community-based settings in Hawai‘i found baby boomers to have the highest HCV antibody prevalence (8.4%) compared with all other age groups.¹¹ Among the approximately 1.4 million people living in Hawai‘i, approximately 250,000 people were born between 1945 and 1965 and should be tested for HCV at least once.¹²

Another priority population is among persons who inject drugs. Injection drug use is one of the most efficient transmission routes for HCV, making it the most important risk factor for HCV infection, especially if needles or other drug equipment are shared. The Community Health Outreach Workers Project (CHOW)—Hawaii's state-funded syringe exchange program since 1993—found an HCV antibody positivity of 67% among a representative sample of its participants, who are all persons who inject drugs (PWID).¹³ CHOW found a difference in HCV antibody positivity between younger (under age 30 years) and older PWID, with rates of 31.6% and 90.9%, respectively. The lower HCV antibody positivity among the younger cohort at CHOW suggests that HCV prevention efforts are still possible among newer PWID. This is especially important as CHOW and other organizations are observing increases of young PWID in Hawai‘i.

Recently, about 1 in 10 lesbian, gay, and bisexual (LGB) public high school students in Hawai‘i reported injecting drugs at least once before graduating; 1 in 4 of these LGB youth also reported using prescription drugs without a prescription.¹⁴ Increase in injection drug use has been closely linked with opioid misuse and its sequelae, especially HCV infection and drug overdose.¹⁵ Currently, overdose is the leading cause of accidental deaths in Hawai‘i.¹⁶ As the misuse of prescription drugs, especially opioids, increasingly affects communities in Hawai‘i, addressing HCV has become relevant to issues like drug overdose and other drug-related harms.

With increases in opioid misuse and injection drug use, particularly among youth, it is likely that some people who use or inject drugs will enter the correctional system for drug-related offenses. Persons incarcerated within Hawaii's correctional system are disproportionately impacted by HCV. A seroprevalance study from 1999–2007 estimates HCV prevalence in Hawaii's prisons at 24%.¹⁷ This estimate is likely to increase, as the US prison population continues to age with more baby boomers entering the correctional system.¹⁸

Relationship Capital

Despite the demonstrable impact of HCV on many communities, few resources and little funding are available to address hepatitis on a local and national level. To overcome the lack of resource capital, AVHPP actively engages a wide breadth of public and private partners, effectively building and leveraging relationship capital. Primarily originating in business and organizational theory, the concept of relationship capital consists of “the socio-psychological aspects of the alliance that are positive and beneficial to the alliance. Two important areas of relationship capital are mutual trust and commitment.”¹⁹ As applied to public health in Hawai‘i, relationship capital may be considered as the common practice by which many organizations or programs foster ongoing partnerships by finding intersecting goals, ideals, and/or practices.

To leverage partnerships meaningfully and sustainably, AVHPP uses a programmatic framework that looks beyond just HCV to determine impact and opportunities for intersecting health and social areas. AVHPP addresses not only hepatitis prevention and access, but also overlapping issues such as the opioid epidemic, overdose prevention, immigrant/migrant health, homelessness, specialty drug pricing, drug policy, and incarceration. By expanding to a broader health and social context, AVHPP has successfully used relationship capital to assure mutual benefit for all stakeholders.

Intersecting Framework for Health

AVHPP has always identified and leveraged partnership opportunities to maximize limited resources in Hawai‘i. Over time, the program increased relationship capital even further by applying an intersecting framework of engagement that provided mutual benefit for all stakeholders. Although the framework originated with a focus on viral hepatitis, the same axioms can be applied to other health and social areas.

1. Look (and listen) broadly

Programs must be willing to frame their issues in the context of larger health and social issues. For resource- and funding-limited programs like AVHPP, meaningful improvements in care rely on integration and collaboration with other programs and partner agencies. To maximize the breadth of programs and opportunities, AVHPP continually seeks intersections between HCV and other health and social issues. Not only does this require ongoing study of research findings and healthcare delivery models, but also necessitates a dedication to looking beyond funding streams and disease-state silos.

Once an intersection is identified (eg, HCV and increased prevalence of severe mental illness²⁰), AVHPP then engages with possible partners (eg, community and DOH mental health clinics, Hawai‘i State Hospital, Law Enforcement Assisted Diversion) by establishing a continued presence in the particular community. The AVHPP can then determine the priorities of the partner (which is not likely to be hepatitis) in order to appropriately offer a specific and needed service, whether it be educational trainings, grant-writing assistance, or raising the partner's media profile.

2. Build relationships

Once a relationship has been established, AVHPP fosters and builds relationship capital to ensure mutual benefit. As mentioned above, one way AVHPP provides value for a partner is to provide grant-writing support. Recently, AVHPP co-wrote a grant for the CHOW Project, Hawaii's statewide syringe exchange, to establish an HCV registry. By helping this partner to scale up HCV services, AVHPP was also able to help it to secure funding for an on-staff Hepatitis Care Coordinator position.

Another opportunity to build relationship capital is through earned media engagement (as opposed to paid media engagement). Recognizing earned media's low cost and high-impact potential, AVHPP has developed skills and experience in utilizing broadcast, print, and social media to both increase general awareness for HCV and to leverage increased funding and partnerships. For example, AVHPP partners closely with the Hep Free Hawai‘i (HFH) coalition to align public messaging through its website (www.hepfreehawaii.org) and social media (@hepfreehawaii).

3. Identify opportunities

Every challenge can be considered an opportunity for engagement. With little resources dedicated to HCV in Hawai‘i, AVHPP prioritizes collaboration and integration of services to maximize effectiveness. For example, a major concern for healthcare providers is reimbursement for services. Given increased insurance coverage for preventive services under the Affordable Care Act, AVHPP increased access to billable hepatitis services by updating and disseminating billing coding and referral resources. AVHPP also engaged insurance payers, hospitals, and other health systems to explore billing possibilities for care coordination and access to HCV treatment.

4. Determine Impact

With little to no funding for active viral hepatitis surveillance in Hawai‘i, AVHPP identifies and utilizes alternative, relevant data sources to appropriately guide program efforts and to demonstrate the burden of disease for funding and media opportunities. These alternative data sources include: EvaluationWeb HIV/HCV testing databases, the Hawai‘i Immunization Registry, the Veteran Affairs Pacific Health System, electronic medical records (from community health centers), insurance payer billing, laboratory testing information, liver transplant/cancer registries, HFH partner agency reports, the Behavioral Risk Factor Surveillance System (BRFSS), the Youth Risk Behavior Survey (YRBS), and more. Although these collaborative efforts provide a general picture of hepatitis in Hawai‘i, truly meaningful surveillance data would require ongoing and dedicated funding.

Successes in Collaboration

Community Coalitions

Since 2011, AVHPP has implemented and maintained programs to enhance HCV management and prevention efforts through coordination and collaboration with Hep Free Hawai‘i (HFH). HFH is a community-based coalition dedicated to increasing awareness of and access to hepatitis services in Hawai‘i, and it is made up of over 1800 individual stakeholders and over 80 local, national, and global partner agencies representing DOH, medical providers, cultural groups, community health centers, hospitals, cancer coalitions, and correctional systems, among others. As HFH Co-Director since its inception in 2011, the Viral Hepatitis Prevention Coordinator at AVHPP ensures that HFH aligns its extensive resources and priorities with DOH activities and objectives, and vice versa.

Over the past 6 years, AVHPP's public-private partnership with HFH has led to many successful programs more expediently and effectively than if it had been implemented solely through DOH. By collaborating with HFH's extensive network of partners, the AVHPP promoted opportunities for community agencies to provide hepatitis services while also gaining some benefit for themselves. Examples of previous and current programs include: providing “talk story” sessions with local Marshallese and Chuukese communities; integrating testing and care coordination into Federally Qualified Health Centers; establishing client HCV registries at syringe exchange sites; supporting on-site education and testing at substance treatment centers; creating social media campaigns/contests. Additional projects and programs are described below.

Corrections Facilities

In 2016, AVHPP learned about small-scale HCV testing and education efforts within jails on Maui. A challenge for the providers in the jail setting was ensuring appropriate transitions to community care once a patient was released. To address this issue, AVHPP spearheaded a multi-agency effort—including DOH, Hawai‘i Department of Public Safety, the Maui Community Correctional Center (MCCC), Maui AIDS Foundation (MAF), and MedQuest—to write and submit a grant to scale up current efforts at MCCC. The proposed grant would provide universal, opt-out HCV (and HIV) testing for all incoming and current residents at MCCC, and it would also establish infrastructure to coordinate post-release linkage to care and treatment. For MCCC, the benefit of collaboration would be increasing quality transitions to post-release medical care, including HCV treatment. The grant also included a data sharing and evaluation component, which could be used to justify additional funding and/or expansion to other correctional settings in Hawai‘i. As of summer 2017, grant funds had been awarded to MAF, an HFH partner agency, who will begin the program in late 2017.

Pharmacies

Since 2014, AVHPP has partnered with local pharmacists and pharmacy groups to increase their capacity to provide hepatitis education, assessments, and eventually, testing. Given their increasing role in providing basic healthcare services, especially in hard-to-reach rural communities, pharmacies represent an important non-traditional setting in which to integrate HCV point-of-care (POC) testing. For pharmacies, providing on-site POC testing could mean additional revenue and customer engagement. In 2017, AVHPP partnered with the Hawai‘i Pharmacists Association (HPhA), the National Association of Chain Drug Stores, University of Hawaii's Daniel K. Inouye College of Pharmacy (DKICOP), and Orasure Technologies to provide the Community Pharmacy-based Point-of-care Testing Certificate course on O‘ahu and Hawai‘i Island. The course provided techniques for POC testing (including HCV testing) and also shared resources on making such testing a sustainable business model.

Syringe Exchanges

As Hawaii's statewide syringe exchange and primary harm reduction organization since 1993, the CHOW Project²¹ is an essential and ongoing partner in preventing and reducing the impact of HCV on people who inject drugs (PWID) in Hawai‘i. Since many CHOW participants do not know their current HCV status (even if they have been tested before), most do not take action to either prevent or treat it. To increase knowledge and action around HCV among this high-risk population, AVHPP worked with CHOW to write and submit a grant to the National Viral Hepatitis Roundtable in early 2017. The grant proposed to fund a Hepatitis Care Coordinator to specifically address HCV among CHOW participants. The proposal would use a registry database to determine the current HCV status of all CHOW participants on O‘ahu, thereby identifying appropriate care coordination follow-up (ie, prevention or treatment) for each participant. For CHOW, the grant could also increase substance treatment engagement for participants, since awareness of HCV infection can significantly reduce injection drug use.²² By July 2017, grant funds were awarded, and implementation had begun.

Looking to the Future

Given the current healthcare landscape, many public health initiatives, especially those for viral hepatitis, will have to cope with dwindling resources and funding. Although a robust public health infrastructure requires ongoing investment of financial capital, there are opportunities for many programs to leverage relationship capital. By applying an intersecting, collaborative, and mutually beneficial framework to address HCV in Hawai‘i, AVHPP has made demonstrable strides in enhancing the network of care statewide. Hopefully, some of the lessons learned can be applied to other programs that encounter limited resources for significant public health issues.