August 25 2016
Thinking Big: Personal Reflections on Adopting the Goal of Hepatitis C Elimination*
On July 28th, 2016, San Francisco Department of Public Health (SFDPH) Director Barbara Garcia stood at a podium on the steps of San Francisco City Hall in front of news cameras, reporters, and a large crowd of hepatitis advocates and declared that San Francisco is the first city in the U.S. to set the goal of hepatitis C elimination. Dr. Annie Luetkemeyer, an infectious disease physician and researcher who actively treats hepatitis C, later stood at that same podium and emphasized this rare opportunity to eliminate an infectious disease – hepatitis C is a virus that can be tackled by highly effective medications that cure most people, putting hepatitis C elimination within our reach. We don’t have to debate anymore about whether or not everyone living with hepatitis C would benefit from treatment, Annie explained—we have data demonstrating that all people who are cured can benefit, regardless of how much liver damage they may have. However, we can’t simply treat our way out of the hepatitis C epidemic. Widespread treatment must be paired with testing so all San Franciscans know their status and get education about how to prevent infection and reinfection after cure. Our job is to figure out how to put these tools to work and to make this potential for elimination a reality.
I think it’s fair to say it was a proud moment for all of the 70+ participants of End Hep C SF. We were making a bold statement and celebrating our leadership, vision, and commitment to do more to end hepatitis C in San Francisco.
In reflecting on the year of planning that got us to this point, I admit that when Annie first approached me about a hepatitis C initiative, I was hesitant to take on the goal of elimination. I reasoned that it’s one thing for a clinician to imagine the elimination of hepatitis C —you’d have a good start if you could treat everyone in your clinic population and get the other doctors in San Francisco to do the same. Researchers, too, can envision hepatitis C elimination in a specific way. They offer thought exercises and models that predict reductions in prevalence relative to the scale up of treatment and other prevention methods. This is vital and fascinating work, but on my more cynical days it can feel distant from what we see happening on the ground for people living with hepatitis C who are disenfranchised or underserved.
As a Viral Hepatitis Coordinator, I hold a different perspective in thinking about hepatitis C elimination as it relates to program administration. Like Annie, I am intimately acquainted with the enormity of the problem and the way it interplays with seemingly intractable social issues like homelessness, drug use, and stigma. My programmatic-specific perspective can get overwhelmed by the relative lack of resources we have nationally to address hepatitis C across the continuum of care. In the US, there is woefully inadequate funding for hepatitis C prevention, testing, care, and treatment. The National Alliance of State & Territorial AIDS Directors (NASTAD) argues that we need at least $170 million dollars in federal funding to adequately address viral hepatitis in the US. The current budget for the Division of Viral Hepatitis at the Centers for Disease Control & Prevention is $34 million. I was concerned that by setting such an ambitious agenda we could appear out of touch with these realities.
But in talking more with Annie and colleagues, I couldn’t help but ask myself some questions. What would it look like if we had an army of providers treating hepatitis C in San Francisco? And they could all work under a shared vision to develop creative and aggressive interventions to get the most complex patients treated on the patients’ terms. What if both the public and private medical sectors shared best practices with each other to develop primary care capacity to treat hepatitis C, partnering with behavioral health services, and creating quality improvement measures? What happens when every methadone counselor, syringe access and homeless shelter staff in San Francisco embrace their respective roles as encompassing hepatitis C prevention, testing, and linkage-to-care interventions? And what possibilities lie in combining the brainpower of our brilliant epidemiologists and researchers so that we could understand the burden of hepatitis C in more nuanced ways and develop better interventions to reach those living with the virus who remain undiagnosed or untreated?
I don’t think any city or health department can answer the questions above, because none of us have scaled up services to this extent. We’ve been hindered by lack of funding, the fractured nature of our national health care system, and silos in behavioral health and prevention services. I now believe that in the process of trying to answer the questions above, of making incremental changes that continually increase the scope of our hepatitis C interventions, we will be well on our way to eliminating HCV in San Francisco.
People have asked me how we got buy-in from all the End Hep C SF partners, but that part actually wasn’t that difficult. Annie, and I, along with Dr. Kelly Eagen, the SFDPH’s clinical lead on primary-care based hepatitis C treatment, did a little outreach and made some calls. It turns out epidemiologists, clinicians, and harm reduction and substance use treatment program staff across the city wanted to answer those questions too. No arm twisting was required—they were more than willing to show up with no incentives beyond their desire to see a San Francisco without hepatitis C. As a collective impact initiative, the job of End Hep C SF is to provide the space and structure for the brainstorming, planning, fundraising, and harnessing of our collective wisdom and resources to continually move us closer to our vision.
It’s been about a year since the initial conversations that led to the creation of End Hep C SF. In that time, we have developed a multi-disciplinary steering committee and four functioning working groups. We have, as I mentioned, more than 70 people participating in various ways, including people affected by hepatitis C. At the time of writing, we have commitments from 26 community-based organizations, patient advocacy groups, public health clinics, private medical practices, pharmacies, and health plans to be partners in this effort. We are close to producing our strategic plan.
And we’ve still got a lot to do—we need to figure out how to disrupt San Francisco’s high hepatitis C incidence rate, to cure all San Franciscans living with hepatitis C, to scale up prevention, testing, and linkage services, and to raise funds to carry out all these plans. But I no longer doubt that it’s possible to do everything we’re envisioning—a multi-disciplinary and growing collaborative of 70 passionate, committed hepatitis C experts also believe we can #EndHepCSF!
*This is a personal reflection piece. The views expressed herein do not necessarily reflect the official policies of the City and County of San Francisco; nor does mention of the San Francisco Department of Public Health imply its endorsement.
Katie Burk is the Viral Hepatitis Coordinator at the San Francisco Department of Public Health and is on the Steering Committee of End Hep C SF.