Last month, a huge RV sat among health care provider booths at the annual Homeless Connect at the Spokane Convention Center.
The renovated vehicle serves a unique purpose: touring the country testing people for hepatitis C in an effort to quell the rising rates of the disease nationwide.
Inside, it feels like a living room with plush couches and homey decor, and in the back, nurses analyzing a finger-prick antibody detection test to see whether a person has been exposed to hepatitis C. If it is positive, a person needs a blood draw to confirm whether they have detectable virus.
In Spokane County, hepatitis C rates have been much higher than other metro areas in Washington in the last five years.
In 2020, Spokane County had a case rate of 86 chronic cases per 100,000 residents. King County had a rate of 38 cases per 100,000 that same year.
On March 1, about a third of the people who got tested for hepatitis C at Homeless Connect were positive and referred for treatment at local health providers.
And while this rate is not an accurate snapshot of the virus in the community, providers and public health workers agree that there is a need for more testing and treatment to stem the growing tide of cases in Spokane County.
Unlike hepatitis A and B, there is no vaccine for hepatitis C. Treatment, however, has become a lot more accessible in recent years.
Local providers are hoping to increase access to testing and treatment in the hopes that it can be eliminated.
Hepatitis C is a silent killer that can go undetected for years, all while inflaming the liver to the point of cancer or limited functioning that requires a transplant.
In 2020, there were 4,471 chronic cases of hepatitis C recorded in Washington residents and 453 deaths attributed to the virus.
Hepatitis C is spread through blood, and the majority of cases in the United States are associated with injection drug use. Beyond needles, the virus can be spread through shared water or cotton .
The opioid epidemic has driven an increase in hepatitis C in the community.
The epidemic, spurred by the prescription of highly addictive painkillers during the past decade, led many people to become addicted.
Once a person is addicted to opioids, that addiction can rewire their brain, prioritizing their need for the substance.
“We’ve had this massive increase in hepatitis C in the last 10 years due to the opioid crisis because people started taking pills, and those got expensive and then they started taking heroin,” said Mackenzie Driscoll, an epidemiologist at the Spokane Regional Health District.
Access to testing
Treating hepatitis C begins with diagnosing it, and the health district offers antibody testing on Tuesdays and Thursdays at the syringe services program.
The antibody test can determine if a person has been exposed. To confirm if a person has an active infection, they need to get their blood drawn and tested by a provider.
The health district is not offering this level of testing. Driscoll will sit with patients who have confirmed exposures and help them set up appointments at local federally qualified health clinics where they can get their test and begin treatment soon after.
Testing is vital because people often will have no symptoms or mild symptoms like fatigue or joint pain that they chalk up to other conditions, said Dr. Emily Colgate, an internal medicine physician who treats patients with the virus at CHAS.
Guidelines around testing shifted recently, and screening for hepatitis C is recommended for anyone 18 to 79 years old. Some people who’ve been exposed may not even know it, especially if it happened decades ago from an unclean needle or blood transfusion.
Bridging the gap between testing and treatment is largely left to the health district and community health clinics in Spokane County.
Colgate said she mainly treats CHAS patients as well as some referrals from emergency departments or the health district.
Driscoll hopes that the health district can expand its ability beyond just the antibody testing.
How treatment works
Treatment for hepatitis C has come a long way. Previously, diagnosis and treatment were more complex and often much less comfortable for patients.
Now, treatment is a daily three-pill regimen that can clear the virus in about two to three months.
Colgate said the most common medication, Mavyret, which Medicaid covers, is well tolerated by her patients.
After a patient completes treatment, providers wait another three months before checking their viral load again to make sure the virus is undetectable. About 95% of patients clear their infection, Colgate said.
Since Colgate joined CHAS six years ago, treatment options for hepatitis C at CHAS have expanded. Some clinical pharmacists are able to do intakes and treatment for some of the more straightforward cases, an option that could be used to expand the number of providers treating patients in the county.
“There’s a huge need for more clinicians and providers to treat (hepatitis C) given the high numbers of cases,” Colgate said.
There aren’t enough liver or infectious disease specialists, she added.
“This is in the wheelhouse of primary care, which is where I think it needs to be expanded on,” she said.
Getting people into treatment for hepatitis C not only helps prevent a person from having severe liver issues, cancer or death later in life but also helps slow the spread of the virus.
“If we treat people who have hepatitis C, they cannot spread it, and that’s really the only way we’re going to get this current hepatitis C epidemic under control,” Driscoll said.
‘We have to address everything’
Every weekday, the health district serves between 40 to 70 people in the syringe services program, offering not only needle exchange but also bandages, ointments, cotton and containers for people to safely dispose of and store used syringes .
The program is the largest east of the Cascades, said Katie Booher, who runs it.
The health district has made the program more of a one-stop shop for not only syringes but testing and treatment.
On a weekly basis, the district offers vaccines for Hepatitis A and B, wound care and testing for hepatitis C. Even if it’s not a testing day, Driscoll will make sure to connect with a client who needs it.
“When people are asking for help, you need to give it to them,” Driscoll said.
About 95% of needles distributed by the district are returned, according to health district data.
The demand for services has increased in the past five years.
In 2017, the district’s syringe services program served 1,854 unique clients. By 2021, it was serving 2,590 unique clients in a year.
Currently, Booher said their engagement is lower, likely because people are finding different ways to use opioids, specifically fentanyl.
Offering clean syringes to the community still is important for slowing the spread of hepatitis C.
“We can get people treated for hepatitis C, but once they’re treated, we have to make sure they don’t get it again – that’s why needle exchanges are important,” Driscoll said.
Driscoll and Booher said they need more partners, like nonprofits, and providers helping to test, treat and prevent the spread of the virus.
Driscoll said her clients who are housed routinely go through treatment more successfully than those who are homeless.
Some clients don’t have phones, which makes scheduling appointments for testing and treatment challenging.
“All of these social issues come together to create this big issue we have,” Driscoll said. “We can’t address the problem – we have to address everything.”
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