Getting by (with a little help from our friends) Marjorie Hurie, RN, MS Wisconsin Hepatitis C Coordinator 608-266-5819 huriemb@dhfs.state.wi.us Good afternoon. As many of you know, I recently transferred from being the hepatitis B coordinator to the hepatitis C coordinator. While I loved my hepatitis B job, I decided to take the opportunity to work on a disease that seemed to be begging for attention. I came into the job thinking I knew a fair amount about hepatitis C. During the past three months I’ve learned much more and I am very pleased to be here today to share a some of it - but not all of it, don’t worry. To that end, you have two handouts today. One is of the slides I will use and the other is a draft of Hepatitis C Guidelines for Local Health Departments that I have been developing. If you don’t see the specifics of the information I’m covering today in the slides, you’ll find it in the Guidelines.

Organization Chart & Authority Division of Public Health Bureau of Communicable Diseases AIDS/HIV STD General Epi Immunization TB This organization chart will give you a picture of where hepatitis C is located in the Wisconsin Department of Health and Family Services. The Bureau of Communicable Diseases is one of 6 Bureaus in the Division of Public Health. There are 5 sections in the Bureau: AIDS, STD, General Epi, Immunization and TB. Hepatitis C is a program within the AIDS/HIV Section. This is a good place for a hepatitis C program to be, not only because of the similarities between the two diseases, Hepatitis C is reportable by state statute and administrative rule to the local health department that has jurisdiction over where the patient lives. When patient follow-up is complete, LHDs forward the case reports they have received from providers and hospitals to the Hepatitis C Program. Hep C

Hepatitis C Coordinator Responsibilities Developing HCV testing capacity Identifying sources of vaccine Integrating HCV testing in high risk settings Identifying medical resources Educating providers and the public This is an overview of what we are going to be discussing today: Wisconsin’s hepatitis C morbidity - as much as we know of it - ; serological patterns showing what happens when the patient does and does not clear the virus; an algorithm showing the natural history of hepatitis C, some characteristics of the hepatitis C virus such as infectivity and viability, the state role and the local role in the prevention, detection and management of hepatitis C; and resources for HCV care and treatment.

Approaches Rely on relationships Know and use the infrastructure Obtain additional funding Win, or be blessed by, support from administrators

Rely on relationships: Vaccine Collaboration with the State Immunization Program LHDs and CHCs can order hepatitis A and B vaccine for persons with HCV infection who are un-or under-insured for vaccine Number of doses of adult Hep A vaccine shipped in 2002: 763 You are probably all familiar with the persons who should be screened for hepatitis C - for example, persons who have a history of injecting drug use, even if it was a few times many years ago, persons who had a transfusion before 1992, sex partners of hepatitis C positive persons and so forth. A complete list of persons who should be screened for hepatitis C is in the Guidelines. Local health departments can screen people for hepatitis C if they have one or more risk factors and are uninsured or have insurance that will not cover the cost of screening. LHDs that do not provide venipuncture should consider developing a relationship with a local provider to draw the blood. The specimen can be submitted to the state lab for hepatitis C testing under the LHD’s fee-exempt number. To maximize case-finding, LHDs should work with local substance abuse service providers that treat injecting drug users to develop anti-HCV testing services for their clients. For example, the Madison City health department offers hepatitis C screening to clients of a methadone maintenance facility. Positive EIA test results should be supplemented with a RIBA or confirmed with a PCR, as the following algorithm will show. The State lab offers PCR but not the RIBA test.

Know and use the infrastructure: Testing Capacity WSLH performs hepatitis C EIA and qualitative PCR tests Established system to pay for public health testing with state funds through an agreement between the Division of Public Health and the Wisconsin State Lab of Hygiene (SLH) LHDs can test persons with HCV risk factors who could not otherwise access testing LHDs can use MOUs to permit other health care providers, e.g., CHCs, to access testing thru SLH

Know and use the infrastructure: Testing in Corrections History of collaboration on communicable disease issues with BCD and SLH Regular quarterly meetings All inmates screened for anti-HBc since 1980s 1999 serosurvey of incoming inmates identified selective HCV screening criteria

Current testing volume: 7/1/02-12/31/02 Dept of Corrections EIA: N=988, +=315 (32%) PCR: N=425, +=320 (75%) LHDs and CHCs EIA: N=260, +=48 (18%) PCR: N=43, +=26 (60%)

Obtain additional funding: Hepatitis Plan Wrote a successful proposal to CSTE Identified and met with 32 external and internal experts 3 times Drafted the plan Implementation sections for hepatitis A, B and C Overarching activities: surveillance, vaccination, provider education Revising plan based on comments received Distribution plans: printing, mailing, internet posting, state hepatitis conference

Support from Administration AIDS/HIV Medical Director Jim Vergeront supportive and invested in success Supervisors encourage collaboration among staff Culture of collaboration is formalized by including collaboration with Hep C activities in AIDS/HIV staff PPDs (performance planning and development tool)

Support from Administration: Identifying medical resources [Adding HCV medications to AIDS Drug Assistance Program (ADAP)] Estimated number of co-infected persons eligible for ADAP (a few) Obtained drug cost information from MA($$$) Calculated costs ($200,000) Determined what other states had done Obtained opinions from ADAP’s external medical advisors Received permission, announced availability

Support from Administration: Integrating HCV Testing into HIV CTR sites Preplanning integration with AIDS/HIV CTR staff HIV anonymity limited extent of integration (forms, reports) Developed model procedures for HCV testing counseling and referral Presented integration overview at regional CTR meetings

Support from Administration: Educational Materials Developed by Knupp and Watson (graphic design company) Intended audience: public and private clinics, local health departments Purpose: inform about prevention, risk factors and encourage testing Funding: One time use of discretionary state funds for HIV

Poster

Brochure

Caveats If relationships are not good, If you don’t know the infrastructure, If you don’t get extra funding, If management is not inclined or able to be supportive, Getting stuff done will be more difficult

But there are limits to largesse…. Milwaukee STD program did not continue HCV testing after completion of pilot because following up + test results took too much staff time Some LHDs and HIV CTR sites are unwilling to integrate HCV testing without a per capita payment for clients tested

Approximate value of contributed goods and services: 2002 Vaccine (Hep A) $20,000 Vaccine (Hep B) $28,000 Testing $100,000 Education materials Development $5,000 Printing $2,000 $155,000

Poster and brochure instructions Printer Disc Cannot be read with regular software Printer can change text Handout includes printer specifications To customize Mark up paper copy with desired changes Ask printer to make changes and give back proofs