San Francisco Department of Public Health Targets People Who Inject Drugs in HCV Treatment Access Interventions

People who inject drugs (PWIDs) are highly impacted by hepatitis C virus (HCV) infection; estimates range from 50-90% HCV prevalence in this population. Recent broadening of Medi-Cal (California’s Medicaid program) criteria for HCV treatment includes PWIDs as a priority population for HCV treatment. However, limited access to specialty care and treatment continues to be a significant barrier for many PWIDs and other vulnerable populations. 

The San Francisco Health Network Primary Care Clinics

The San Francisco Health Network’s (SFHN) primary care clinics within the San Francisco Department of Public Health provide care to an urban, largely poor population with public or no health insurance. It is estimated that there are at least 2,400 patients in the SFHN who are chronically infected with HCV (estimated at 2.9% of the active SFHN patient population).  Patients living with HCV are disproportionately African-American (n=1018/42.3%), relative to 5-6% of African-Americans in San Francisco’s general population.

SFHN providers have significant expertise engaging PWIDs across the continuum of primary care, prevention, and drug treatment-related services. Having learned many important lessons about harm reduction and client-centered care during the worst years of the HIV crisis, SFHN supports broad syringe access and low-barrier access to methadone and buprenorphine through primary care and centralized methadone clinics. SFHN also employs skilled clinicians who work to retain PWIDs in primary care with impressive results.

The San Francisco Health Department’s Hepatitis C Treatment Initiative

With new curative treatments available for HCV, San Francisco’s Health Department has made great strides to expand access to HCV prevention, testing, and treatment interventions. In early 2016, the California Department of Public Health (CDPH) awarded SFDPH a 3-year, $1.37 million award for community and clinic-based HCV testing, linkage, and treatment projects. The CDPH grant provides support for a nurse at Zuckerberg San Francisco General’s Opiate Treatment Outpatient Program (OTOP) to support an onsite HCV treatment project, a data analyst to track HCV metrics, and a capacity-building program for primary care-based HCV treatment.

The primary care initiative achieves dual goals of (1) expanding access to HCV treatment for patients in the SFHN network and (2) improving primary care physician (PCP) capacity to treat HCV.  The Health Department’s innovative model for expanding primary care-based HCV treatment includes HCV training for clinicians, the development of a primary care-driven web-based referral system (eReferral), and partnerships between the Health Department and community–based organizations.

Since the launch of the Hepatitis C Treatment Initiative on February 1, 2016 and through October 26, 2016, approximately 130 SFHN clinical staff have participated in multi-hour Continuing Medical Education in-person trainings to learn to treat HCV within primary care. The eReferral, an electronic consultation service where primary care physicians can ask treatment questions (to whom) about individual patients through a secure messaging system, also launched on February 1 2016. A primary care provider (PCP) and two clinical pharmacists experienced in HCV treatment staff the service. During this time period, 30 PCPs have utilized the HCV eReferral service to treat 73 patients. Approximately 55% of patients treated using eReferral consultation are African-American, and the majority have co-occurring past or present substance use disorders. Based on the current average treatment rates of 24 patients per month, it is projected that approximately 288 patients will be treated in the SFHN Primary Care system in 2017, constituting 11.9% of the SFHN patient population living with HCV. The primary care-driven HCV treatment model is essential to making treatment accessible for PWIDs and other vulnerable populations.