Modern medicine can cure a hepatitis C infection with three doctor’s appointments and two prescription refills. For most, it is not a big ask to rid oneself of a deadly disease.

But for those without homes, keeping up with the required 12-week treatment regimen can be an overwhelming commitment.

Sitting on a metal folding chair at the edge of an empty parking lot in Balboa Park on a recent morning, Holly, a resident of San Diego’s nearby O Lot safe sleeping site, explained that visiting a doctor’s office miles away comes with significant risk.

A tent can never be fully secured, so leaving one’s possessions inside to go to the doctor’s office all but guarantees returning to find possessions missing.

“There is nobody that holds themselves accountable for your stuff, so it’s just hard for me to leave, knowing that,” she said. “Everything I have left in the world is in that campsite, and it’s easy for people to just walk right in.”

And yet Holly just completed her full hepatitis C treatment, not missing a dose over three straight months after a screening test detected her infection. Her friend, Chris, just started his second week. Like his companion, he said that because his infection had not yet progressed far enough in damaging his liver to start causing symptoms, there is pretty much no way he would have traveled to the clinic for treatment.

“You know, you just sort of put it on the back burner if it’s not causing any signs,” he said.

Finding and keeping housing trumps following up on test results. And that is the particular problem with hepatitis C, which may take decades to cause its first symptom. Often, by the time signs and signals such as easy bruising, fatigue, yellowing of the skin and weight loss appear, a person’s liver is significantly damaged, making life-altering consequences such as liver cancer much more likely.

In recognition of the disease’s slow and deadly burn, the county health department, several local medical providers and the Liver Coalition of San Diego County launched a hepatitis C elimination plan in 2021 with the goal of preventing new cases while simultaneously working to discover and treat so-called “chronic” cases that have gone undetected.

Though recent results are skewed slightly due to a change in how hepatitis C cases are counted, the overall case trend has been downward since 2019 when 4,249 chronic cases were confirmed or suspected compared with 2,298 in 2023.

A big part of driving that number down, said Dr. Christian Ramers, medical director for research and special populations at Family Health Centers of San Diego, has been more aggressive outreach to those at increased risk of hepatitis C infection. Because the virus transmits in human blood, injection drug users are at an increased risk as are those with HIV.

The crusade to eliminate hepatitis C started with increasing screening to detect chronic cases and with the region’s first needle exchange programs, helping drug users avoid re-using and sharing needles. Many have recently begun to realize that those techniques, while effective, are not enough.

Chris and Holly’s recent experience in a Balboa Park parking lot involved a physician assistant with Family Health Centers whose job is to take many services, including the checkups and medication delivery necessary to cure the disease, out of doctor’s offices and into the places where people with reduced mobility live.

“Really, the only way is to bring the care to this population,” Ramers said. “They’re not going to come in and meet us at the clinic, so we have to find a way to go to them.”

And, simply showing up in tent encampments for checkups and to fill prescriptions is not enough. Family Health Centers workers have learned that the usual practice of delivering one month’s worth of medication at a time does not work. Such a large supply is likely to be stolen before it can be consumed.

Instead, workers deliver seven pills at a time, making weekly visits and using those encounters to discuss other health matters that a person might also be experiencing.

But eliminating the disease will not be accomplished only by embracing street medicine for those experiencing homelessness. Scott Suckow, executive director of the Liver Coalition of San Diego County, said recent modeling by researchers at UC San Diego found that reaching intravenous drug users in many different types of venues will be key to winning this fight.

More work could be done, he said, in organizations that treat substance use disorder, often combined with mental health care, to screen for hepatitis C and to make sure that those who test positive are referred to medical providers for treatment.

The state, through the ongoing reform of its Medi-Cal health insurance system for needy residents, has recently approved paying substance use treatment and behavioral health providers for “enhanced care management” when treating patients with substance use disorder. This additional benefit allows for a more holistic set of services that can go beyond drug and alcohol treatment.

Driving hepatitis C infections lower, getting more people screened and treated, Suckow said, is likely to see a significant benefit from the enhanced care management benefit if the disease is included in the host of additional health problems that doctors look for when care management is engaged.

“The position we’re taking is that it’s the behavioral health and substance use disorder treatment community’s responsibility if they’re providing whole-person care, to make these linkages, especially if they know that a client has hepatitis C or they’re at risk for it,” Suckow said.

Why couldn’t this simply be a mandate of the county health department, which spends millions per year contracting with substance use treatment programs serving patients whose care is covered by Medi-Cal? Why couldn’t a mandate to test all substance use treatment patients for hepatitis C infection just be written into county contracts?

Dr. Nicole Esposito, chief population health officer for the county’s behavioral health department, said that contracting is not seen as the right solution for promoting better coordination between different types of medical providers serving Medi-Cal beneficiaries.

Better coordination of care is not, she noted, about only one disease.

“The goal of care coordination is to really assess all of the needs of the whole person, rather than programmatically calling out specific diseases in contracts,” Esposito said. “Then it becomes like a patchwork where we have the hepatitis C expectations and the HIV expectations and we have some that get missed.

“I think the goal is to put the person at the center and work across all of the various factors, whether it’s all of the illnesses they might have or housing needs or social needs or school needs, rather than trying to do it with line item contract language.”

Medi-Cal changes, she added, will make it easier for different types of providers to securely share patient information electronically, making it easier for referrals to be made across organizations that are engaged in different missions.

“I think the big hope for significant progress lies in the fact that, in the future, we’re going to have a lot more data sharing so that there will be more visibility of whether tests were done, what were the results, was treatment started, was treatment completed,” Esposito said.

Originally Published: August 1, 2024 at 11:40 a.m.