SF working on ambitious plan to eliminate hepatitis C
By Erin Allday, San Francisco Chronicle February 19, 2017
Photo: Santiago Mejia, The Chronicle
Dr. Andrew Desruisseau checks the eyes of Sonia Hernandez at Tenderloin Health Services in San Francisco. Hernandez is a hep\atitis C patient.
San Francisco is trying to become the first city in the nation to eliminate hepatitis C, rolling out an ambitious plan that would involve curing everyone who already has it and stopping further spread of the infectious disease, which can cause severe liver damage.
Just two or three years ago, the plan, called End Hep C SF, would have been impossible. But a new cure that is effective and relatively easy to take, combined with growing enthusiasm for programs to increase access to health care, has doctors and public health officials convinced that they can wipe out the virus over the next decade.
“Ten years ago, I wouldn’t have thought we’d be at a point where we were talking about elimination — where you could say that without someone laughing,” said Emalie Huriaux, who directs federal and state affairs for Project Inform, an advocacy organization in San Francisco, and chairs the California Hepatitis Alliance. “It’s going to be a heavy lift. But it’s really exciting. I hope this will become a model for other parts of the country.”
The key is going to be identifying everyone who’s infected while persuading insurers to pay for the notoriously expensive treatment, which can cost tens of thousands of dollars for a 12-week regimen.
A decade ago, California began requiring that public health authorities report every new case of hepatitis C. But that leaves thousands of unknown cases, including anyone diagnosed before 2007 and people who haven’t been tested because they don’t believe they’re infected.
Public health officials estimate that 15,000 to 20,000 people in San Francisco have the virus, including many from the Baby Boomer generation, who may have been infected decades ago before the virus was screened out of the blood supply.
Hepatitis C is part of a family of viruses that cause inflammation in the liver and other, less obvious, systemic problems throughout the body. The virus is transmitted through blood, much like HIV, though it’s more infectious than the AIDS-causing virus. It’s often spread through needles shared by intravenous drug users.
The body is able to naturally fend off the virus in about 20 percent of cases. In the rest, hepatitis C becomes a chronic infection, and over decades it can attack the liver and cause cirrhosis, possibly leading to liver cancer or liver failure that requires a transplant.
Some people go decades, even their entire lives, without experiencing problems with their liver. But doctors are realizing that chronic infection may cause more widespread damage, potentially leaving patients at increased risk of heart disease, diabetes or non-liver cancers.
That knowledge has prompted broad support among health care providers for treating everyone who’s infected, even if they don’t seem to be suffering ill effects.
The virus also is a lot easier to cure now than it was just a few years ago. Previously, treating hepatitis C involved almost a full year of medications — including a form of chemotherapy — that could cause disabling side effects such as extreme fatigue, nausea and body aches. Half the time, the treatment didn’t work. The new therapy lasts three months, often has no side effects, and is curative 95 percent of the time.
Aside from being humane, treating everyone who has hepatitis C is the only way to eliminate it, or else people who are infected will keep passing it to others, said Dr. Annie Luetkemeyer, a UCSF infectious disease expert who treats people with HIV and hepatitis C at San Francisco General Hospital. If the amount of virus circulating in the community is lowered dramatically, new cases will slow down and, ideally, stop altogether.
“If you just treat Baby Boomers, you’re not going to treat the forward motion of the epidemic. You’re just going to treat the individual,” Luetkemeyer said. “That’s good. But by treating a small number of active injection drug users, you make an active dent in the epidemic.”
But there is opposition to plans to treat everyone, including from insurers who would rather limit care because the treatment is so expensive. When the first widely successful cure for hepatitis C came out — a drug called Sovaldi, made by Gilead Sciences in Foster City — it carried a shocking $1,000-a-pill price tag. A full course of treatment cost $84,000, and the drug became one of a handful cited as an example of pharmaceutical greed.
The cost has come down dramatically, doctors and public health experts say, though it varies widely among providers. And treatment is still expensive. It’s thought that the Veterans Administration pays the lowest amount, about $17,000 for a 12-week treatment.
Another concern is reinfection. Some studies have suggested that 1 in 4 people in especially high-risk groups who are treated for hepatitis C, largely intravenous drug users, ends up getting it again within two years. San Francisco health care providers said they’re not seeing reinfection rates nearly that high, but they acknowledge their reports are largely anecdotal.
Stigma clearly plays a role in reluctance to offer hepatitis C treatment to everyone, said Huriaux of Project Inform. Though Baby Boomers of all demographics are considered an at-risk group, the illness dominates marginalized communities.
For example, African Americans make up less than 6 percent of San Francisco residents, but nearly a third of hepatitis C cases. The disease is prevalent among people who are homeless or who have recently been in jail. Among injection drug users, more than half are thought to be infected. People who are already HIV-positive are at increased risk of contracting hepatitis C, too — about 1 in 3 have both viruses.
“If there was a cure for diabetes or Alzheimer’s, rationing care would never be a conversation,” Huriaux said. “But a large part of the issue around hep C treatment is the perception of who is infected and whether they’re worth being cured.”
While public health advocates work to persuade insurers and others to expand care, health care providers in at-risk communities are developing plans to make the treatment as easy as possible for their patients.
For someone without stable access to health care — or a safe place to sleep or regular meals — complying with a 12-week drug therapy can be a challenge. But there are ways to make it easier, experts say. It may make sense to offer hepatitis C treatment while people are in long-term homeless shelters or county jails, for example, or as part of their daily methadone treatment.
Dr. Andrew Desruisseau, an HIV and hepatitis C expert with Healthright 360, a clinic in San Francisco, would like to speed up the test-and-treatment process so that clients who enter his organization’s 90-day residential treatment programs can do the 84-day hepatitis C regimen at the same time.
That would mean pulling together varied and complicated resources in just six days, but he and his colleagues believe it’s doable — and necessary.
“To be able to say to someone, ‘I’m going to take care of this problem,’ that is awesome,” Desruisseau said. “All the problems we see at the clinic every day — we can’t cure most things. But we can do this.”
To learn more
A draft of the plan to end hepatitis C in San Francisco is available for public comment until Wednesday at http://endhepcsf.org. A final plan is expected within a couple of months.