Viral Hepatitis in Hawai‘i Differing Perspectives
IV. Perspectives of Administraors and Health Care Plans
A. Viral Hepatitis and the Hawai‘i State Departments of Health and Public Safety:
Kay Bauman MD and Heather Lusk
The primary challenges identified when working with hepatitis from the state-sponsored health department and department of public safety (prison system) perspectives include: lack of funding and cost of providing services; integration of services; and increasing capacity within private and public systems to meet the needs of persons at-risk for and living with viral hepatitis.
The annual budget for the Centers for Disease Control (CDC) Division of Viral Hepatitis for fiscal year 2010 is $18.3 million, with approximately $5 million allocated to various states for the Adult Hepatitis Prevention Coordinator Program. These funds are distributed to 51 jurisdictions with the goal of developing and implementing comprehensive viral hepatitis prevention and control programs at the state, county, and city levels by providing one full-time salary position and limited travel funds. At the Hawai‘i Department of Health (DOH), the hepatitis program has an Adult Viral Hepatitis Prevention Coordinator who is functionally located within the STD/AIDS Prevention Branch of the Communicable Disease Division. Because the CDC funding only allows for salary, there are very little additional funds available for viral hepatitis activities and general program support. Despite these challenges, creative solutions have been successful in circumventing limited funding resources. Because training and education are relatively inexpensive, these areas have been heavily utilized, with over 1,000 people trained annually in recent years through presentations conducted as part of larger conferences, workshops, and integration of information on viral hepatitis into existing trainings for different agencies. In 2007, four “Training the Trainers” programs were conducted statewide to increase the cadre of persons who can authoritatively educate about viral hepatitis in settings such as high school workshops, prisons and jails, and drug and alcohol treatment centers.
In addition to education programs, in kind staff and funds from the HIV prevention program have been used to provide free hepatitis C testing and counseling at all DOH HIV/STD sites and some community-based organizations with approval from the HIV Community Planning Group as allowed by the CDC. Since 2004, over 2,000 tests have been conducted with an approximately 16% positivity rate. Free hepatitis A and B immunizations for adults at-risk as identified by the Advisory Committee on Immunization Practices (ACIP) have been provided by the DOH Immunization Program at all HIV/STD sites for those who can’t afford them, with on-site vaccinations made available at the Pride Festival and injection drug user events. As a result of these group efforts, infrastructure has been established with the standardization of policies and procedures, forms, and data tracking systems in place for future funding and improvements. Collaborations with organizations such as the Hepatitis Support Network of Hawai‘i have also been vital tools in coordinating a statewide viral hepatitis program with little in the way of funding or resources. Given the lack of federal funds dedicated to combating the viral hepatitis epidemics, it is essential to leverage existing resources. By being creative and thinking outside the box, state-sponsored programs can make a difference in affecting the hepatitis community with limited resources.
Hepatitis C is an increasing challenge for health care providers working in correctional facilities. In the US prison system, which houses approximately 2 million adults, 16% to 41% of inmates are positive for antibody to HCV, and 12% to 31% have chronic infection.11-12 The California state correctional system found the prevalence of HCV infection among incoming inmates to be 34.3% overall.13 These statistics are not surprising given the fact that a primary source of HCV infection is from current and former illegal injection drug users, with drug offenders comprising 20% of state and 55% of federal prison populations.14 Within the Hawai‘i prison system, there are a significant number of inmates who are HCV positive, averaging 24% in targeted testing done from 1999-2007 (Table 1). Of additional concern is a rise in the number of prisoners with recognized liver disease and a 27% death rate from liver failure within the Hawai‘i prison system that exceeds all other diagnostic categories.
Since the beginning of 2007, all inmates upon entry into prisons or jails in Hawai‘i are offered HIV testing, and testing for hepatitis C is available on request and encouraged if there is a history of HIV or HBV, injection drug use, transfusions before 1992, liver disease, tattoos acquired in prison, hemodialysis, or treatment with isoniazid or agents that lower cholesterol. Patients with HCV who are candidates for treatment are treated with pegylated interferon and ribavirin. In order to qualify for treatment, sobriety and completion of a substance abuse treatment program are encouraged, but not required, and patients sign a permission form that allows for random urine drug testing with the understanding that any positive urine test is a reason for discontinuation of treatment. Treatment is initiated if more than 12 to 18 months of incarceration are anticipated and approval has been obtained by a psychiatrist. Therapy is considered if the ALT is >1.5 times the upper limit of normal on a single test, or any abnormal elevation at two separate occasions for African-Americans. If a liver biopsy is done, therapy is offered if there is evidence of fibrosis (grade 2-3 by Knodell Scale). When fibrosis is advanced (grade 4), therapy is done at the physician’s discretion. The course for treating genotype 1 is 48 weeks, and 24 weeks for genotypes 2 and 3. Therapy is discontinued for any genotype if there is no response after 12 weeks of treatment, where response is defined as a negative viral load or a two-log drop from initial viral load.
The cost of providing care within the prison system as compared to the community is shown in Table 2, where cost estimates were based on the 2007 charge data for the institution with additional data provided by local pharmacies and laboratories. The combined cost of interferon and ribavirin alone for a treatment course of 48 weeks through the Hawai‘i prison system was approximately $25,578 compared with $41,354 in the community in 2007. These expenses do not cover laboratory studies, provider services, staffing, administration, or other overhead charges.
In the United States, direct medical expenditures related to chronic hepatitis C are predicted to total $10.7 billion from 2010 to 2019.15 The cost-effectiveness of treating hepatitis C in prisons has been a matter of public debate, with proponents arguing ethical duty to provide contemporary medical care to inmates, while opponents note that therapy is often interrupted by transfers or release, and that relapse into high-risk behavior is likely upon release from the system. However, Tan et al.16 found that from a pharmaco-economic standpoint, treatment within correctional facilities was cost-effective and improved the quality of life in prisoners of all age ranges and genotypes.
The costs of hepatitis management, which includes liver biopsy, transportation for specialty care, and medications, vary among correctional systems. While the cost of providing hepatitis C treatment is still substantial, recent data indicates that in Hawai‘i it is considerably cheaper to treat hepatitis C infections in prisons than in the community. Correctional systems are often able to negotiate cost-effective contracts for pharmaceutical and laboratory expenses, which are often 40% of the retail cost, although cost of physician and nurse time is likely comparable.17 Because the data shows excellent response rates compared to treatment in the community, treating eligible inmates makes both economic and public health sense. Prisons hold high risk populations, some of whom are likely to resume risky behaviors upon release and become infection risks to current or future drug users if the hepatitis C goes untreated. With the availability of interferon and ribavirin, it is possible to cure the infection, although adverse effects, prolonged courses of therapy, cost, and success rates are significant limiting factors when considering treatment. Despite the challenges to treatment, correctional facilities offer an opportunity to screen and treat this infection in a controlled environment, and prevent its spread within the facilities and to others in the community upon release.
Integration of Services
Integrating viral hepatitis into existing community services that may already be accessed by people at-risk for and living with viral hepatitis is a functional method of merging resources and talents, although it is not always practical or accessible due to legal barriers, existing case loads, contractual obligations, funding issues, and problems with general infrastructure. However, settings such as correctional facilities, drug and alcohol programs, schools and educational programs, HIV/STD programs, churches and faith-based agencies, community health centers, homeless services, veterans services, family planning, cultural programs, mental health programs, and complementary and traditional medical are all practical targets for integration of hepatitis services. This can be accomplished by: providing training to staff; educational materials; examples of language; client intake and assessment forms; and by sharing data, evidence, and federal recommendations that support integration. Respectfully building relationships and finding individuals within organizations that are interested in viral hepatitis leads to successful outcomes when coordinating the integration of services.
In 2003, more than 6,000 people in Hawai‘i were thought to be homeless with over 155,000 at risk of becoming homeless. A high proportion of the homeless have a history of drug abuse, incarceration, and prostitution.18 Common tools of hygiene such as razors and toothbrushes may be unavailable or become a vehicle of transmission if shared. Hepatitis C virus has been found in up to one-third of tooth brushes and 38% of razors used by those infected.19-20 A recent study suggests that the homeless people of Hawai‘i are more likely to have viral hepatitis than the general population, as expected and reported by others and that they appear to be lacking in awareness of possible therapy for their infections as well as prevention of secondary infections through hepatitis vaccination.21 Interventions through health care programs designed for homeless shelters offer a good opportunity to educate, test and offer treatment and safety kits to stem the spread of these infections within and outside the homeless communities. Taking advantage of the healthcare programs already in place within the state prison system is an effective way to share resources and support state-wide hepatitis efforts, however, there are unique challenges to treating an incarcerated population. There are significant legal and moral questions associated with providing hepatitis treatments in prisons, including whether inmates can be required to stay within the prison system for the length of treatment necessary regardless of their judicial sentence, whether incarcerated patients should be required to complete substance abuse programs prior to HCV treatment to improve compliance, or if inmates should be eligible for organ transplantation in the event of end stage liver disease as a result of HCV infection. As such, centers of care in the community including government institutions and correctional facilities must balance treatment recommendations with the threat of legal recourse.
Similar in scope to improving integration of services, services and awareness for persons with hepatitis C can be greatly improved by identifying existing resources and collaborating with various agencies. Hepatitis is often not addressed because it se
ems overwhelming for organizations that are already supporting other, even related, causes. By providing tangible steps and support, and by utilizing everyone’s strengths, these issues can be overcome. Although there are a variety of challenges to providing a comprehensive state hepatitis program, by working together we can effectively strategize and maximize the resources that are available to raise hepatitis awareness and provide essential services within the community.
Despite the challenges in working within the prison population, the state of Hawai‘i has maintained a successful HCV treatment program with data that matches or is superior to published data. Successful components to the system are close monitoring of inmate patients, including well-trained nurses, which ensures excellent adherence to required testing and monitoring. An HBV treatment program within the prison system is currently in the planning stages.