Just a few years after the introduction of a reliable cure for hepatitis C, San Francisco has launched a campaign built on shoe leather and shrewd epidemiology to eliminate the virus. Health workers are expanding testing and searching the streets for homeless patients who don't pick up their medication. Clinicians are training more doctors to treat infections. Patients can store their medications at a syringe exchange.
It's all to combat a pressing and growing problem: In the U.S., more deaths are tied to hepatitis C, which can eventually cause liver cancer and failure, than the 60 other top communicable diseases combined, HIV and tuberculosis among them.
Before the development of the latest hepatitis C drugs, which are remarkably effective at curing the disease, the notion of eradication would have been implausible. That is no longer the case. But the virus is now being fueled by drug use, hitting patients who are the hardest to reach and have the least access to care and the pricey medications. Many are homeless, mentally ill, or incarcerated.
"Taking the medication is one thing, and it's not hard on their bodies," said Katie Burk, the viral hepatitis coordinator at the city's public health department. "But getting them there, and through the hoops they need to get through, that takes a lot of work."
"People are still getting infected with hepatitis C," she added. "But what we need to do is outpace infection rates with treatments. If we start every year curing more people than are getting infected, then you can turn that curve around."
San Francisco's campaign — called End Hep C SF — is the result of an alliance among health officials, hospitals, advocates, and clinicians to cobble together funding, coordinate care, and combat the stigma of a disease associated with prison, drug use, and unsafe sex. Organizers acknowledge that even if they somehow eradicated hepatitis C in the city, the virus would reappear. But the campaign still aims to dramatically reduce the city's disease burden — and to become a model for what elimination would require elsewhere.
The effort starts with patients like Bill, whose case reflects both the potential of End Hep C SF and the challenges.
A homeless man who said he sometimes injects drugs, Bill was sick with hepatitis C for years but never got treated. That changed earlier this year, when his methadone clinic, which previously didn't treat hepatitis C, found a way to get him the therapy.
And yet Bill, who did not give his last name, said his backpack was stolen with a week's worth of pills during the 12-week course of treatment. Twice.
"People are always stealing my stuff," said Bill, 50, who was using a golf iron as a cane and wore a dark green ball cap with a bedazzled skull.
The bulk of hepatitis C patients are baby boomers, many of whom were infected before the blood supply was screened for the virus. But infection rates, driven by the country's opioid epidemic, are rising fastest among young people, contributing to more than 19,000 annual hepatitis C-related deaths in the U.S. in recent years. (The virus can remain asymptomatic for years, so health officials believe documented cases and deaths are just a portion of the toll of the virus.)
From 2007 to 2015 in California, infection rates increased by 55 percent among men in their 20s and by 37 percent among women in their 20s. In San Francisco, it's estimated that about two-thirds of the more than 12,000 patients inject drugs. "We have the tools to fix it, but hep C numbers are going up," Dr. Annie Luetkemeyer, an infectious disease doctor at University of California, San Francisco, who is involved with the campaign here. "That is really unacceptable."
One reason, experts say, is because the disease is not a priority. A National Academies panel that recently looked at the feasibility of eliminating hepatitis C held congressional briefings when it released its reports, and almost no one showed up, said Dr. Brian Strom, who chaired the panel. "Congress cares little enough about this disease that they didn't even send their staffs," said Strom, the chancellor of biomedical and health sciences at Rutgers.
Some places are making treatment and prevention a priority. States including New York and Rhode Island have developed strategic plans, and the Department of Veterans Affairs, with a funding boost from Congress, has moved to treat all veterans, curing tens of thousands already.
In San Francisco, the funding for the campaign has been patched together from state grants and local sources; Burk estimated the budget is about $700,000 a year.
The money has funded work by community organizations like Glide, which runs a harm reduction center — including a syringe exchange — in the city's Tenderloin neighborhood. New patient navigators facilitate testing in homeless encampments and single-room-occupancy hotels and help link people who test positive to doctors. So far, they have tripled the number of hepatitis C tests Glide is able to conduct each month.
"The hardest thing is when people are not housed," said Janelle Silvis, one of the navigators. Many homeless people have no problems taking medication, but for others, she said, "that lack of stability makes it really hard to remember to take a pill every day. And like, 'Where's my stuff? Can I even hold onto my stuff?'"
Health workers also have to convince young, otherwise healthy people with the virus to pursue treatment to begin with. They don't always recognize the damage the virus is slowly doing to their livers — what Paul Harkin, who helps run harm reduction at Glide, called "the ticking time bomb of hep C."
Doctors who treat hepatitis C said some patients report feeling less fatigued after being cured of the virus, though they acknowledge that might be placebo effect. By getting cured, many people also seem more willing to address other issues, whether it's starting treatment for a substance use disorder or finding housing.
David Matisi, 62, was cured earlier this year after contracting the virus decades ago while in prison, either from injecting drugs or getting a tattoo with a dirty needle, he said. He hasn't used drugs for almost a year, and he said that being rid of the virus will help him stay clean. He's now turned into an advocate to support others getting treated.
"I want to help others having a hard time or who need help — I can do that," Matisi said.
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