An Update of a Hepatitis C Strategic Plan for Action Hepatitis Prevention, Education, Treatment & Support Network H

1. Hepatitis and the Homeless:The Coming Storm An Update of a Hepatitis C Strategic Plan for Action Hepatitis Prevention, Education, Treatment & Support Network Honolulu, HI (808) 221-6204 Fax (808) 738-5797 KenAkinaka@aol.com

2. Hepatitis B & C - The “Silent Epidemics” of the Homeless even in a Paradise

3. Clouds gathering… • “Despite over 20 years of knowledge, millions of dollars thrown into prevention and the distribution of countless condoms, many people in the U.S. are contracting HIV and Hepatitis at an alarming rate.” • WHY? Slide modified from Countny East, APRN, 12/2004

4. Estimated US HCV Prevalence including Select Populations: 5 MillionUnited States (Gish et al, J Clin Gastro Hep, 2005) Incarcerated, ~310,000 (15%)1;Ever incarcerated, ~1,400,000 Injection drug users~300,000 (80-90%)2,3 HIV-infected ~300,000 (30%)4 Alcoholics~240,000 (11-36%)5 Living below poverty level ~940,000 (2.4%)6 Homeless ~175,000 (22%)7 Veterans ~280,000 (8%)8 Children (6-19 years) ~100,000 (0.1%)9 1MMWR Recomm Rep. 2003;52(RR-1):1-36. 2Edlin. Hepatology. 2002;36(5 Suppl 1):210-9. 3NHSDA Report. 2003. 4Khalili and Behm. Clin Inf Dis. 2000;31:154-61. 5Labreque and Sandt. In Hepatitic C: Choices. 2002. 6Alter et al. N Engl J Med. 1999;341(8):556-562. 7Nyamathi et al. J Gen Intern Med. 2002;17(2):134-43. 8Bräu et al. Am J Gastroenterol. 2002;97(8):2071-8. 9Jonas. Hepatology. 2002;36(5 Suppl 1):S173-8.

5. Sirens to Wail 60 Second Hepatitis C PSA from New Orleans

6. Adults who are at the most risk for infection with Hepatitis C • Homeless substance abusers • Injection Drug Users • Prisoners sharing injection drug using equipment or tattooing needles or ink • People who snort drugs may be at risk • Those with multiple sex partners and a history of sexually transmitted diseases • Hemophiliacs • Healthcare workers including EMT and others • Military and others in other parts of the world who may exposed to blood Slide by Ken Akinaka, MRA 10/2005

7. Risk Factor HBV HCV HIV Injection drug use 14% 60% 31% MSM 15% 1% 47% Heterosexual partners 40% 20% 10% Transfusion rare Past 7- 20% Past 2% Occupational 5-7% (past) <<1% <<1% No Identified Risk 30% 10% 9% Risk Factors for Transmission of Hepatitis Viruses and HIV in the USA Proportion of Infections Slide by Countny East, APRN, 12/2004

8. Research indicates HCV 25% 30% 30% Residential SA Tx (Day Top, NY) >2 xs Nat. Avg. Homeless with Mental Illness & Substance Abuse (St. Louis, MI) Co-infected with HIV (CDC, USA) Veterans (UW-SPH, USA) Higher with Vietnam era Veterans LOCAL RESEARCH IS NEEDED WITH THESE HIGH RISK GROUPS TO TARGET PREVENTION, TESTING, & TREATMENT EFFORTS! Groups of High Rates Transmission of Hepatitis C Virus in the USA Proportion of Infections Slide by Ken Akinaka, MRA, Jan. 2005

9. In USA HCV Inmates 25 - 30% On Methadone Maintenance Treatment 85 to 95% Other Groups with High Rates Transmission of Hepatitis C Virus in the USA Proportion of Infections Slide by Ken Akinaka, MRA, Jan. 2005

10. The number of homeless is growing because of the exploding real estate market, the high costs of rent, and in Hawai`i because of the consistent pleasant weather and environment. • In fiscal year 2004, emergency shelters in Chicago served 13,108 unduplicated clients, up from 11,050 in fiscal year 20031. 1. http://www.chicagohomeless.org/factsfigures/causesandfacts.htm#shelter

11. Each day at least 800,000 persons are homeless in the USA. That includes 200,000 children. On any given night, almost 300,000 veterans experience homelessness nationwide, a number far greater than the roughly 58,000 U.S. soldiers who died during the Vietnam War.  • As many as 18,000 veterans are estimated to experience homelessness every night in the six counties of the Chicago metropolitan area. • Over the course of a year, between 2.3 and 3.5 million people experience homelessness nationwide and approximately 166,000 people experience homelessness in the Chicago Metropolitan area.

12. Hepatitis B, Hepatitis C, Human Immunodeficiency Viral Infections and Tuberculosis In A Homeless Veteran Population RAMSEY CHI-MAN CHEUNG, M.D. Chief of Hepatology Veterans Affairs, Palo Alto, CA Cheung et al, J Clin Gastroenterol, 2002

13. Domiciliary for the Homeless • Rehabilitation program • Homelessness of any duration • Ability for self-care • Monthly income < $1,200 • Willingness and ability to return to work Cheung et al, J Clin Gastroenterol, 2002

14. Cheung et al, J Clin Gastroenterol, 2002

15. Cheung et al, J Clin Gastroenterol, 2002

16. Cheung et al, J Clin Gastroenterol, 2002

17. Cheung et al, J Clin Gastroenterol, 2002

18. Cheung et al, J Clin Gastroenterol, 2002

19. What most people still do not know: The delay in signs and symptoms of HIV or chronic Hep infections can result in people who don’t feel sick and who disregard that possibility of spreading HIV or Hep infection. Slide by Countny East, APRN, & Ken Akinaka, MRA 12/2004

20. The face of the Hepatitis C (HCV) epidemic is also changing! • The new infections are estimated at 25,000 (CDC) to 40,000 (HRSA) per year. • Injection drug use and experimental injection drug use appear to be the greatest source of the spread of new infections. • 44% of the Homeless with mental illness and substance abuse may have already been infected with hepatitis B and/or C. Slide by Ken Akinaka, MRA 10/2005

21. Other High risk groups that may continue to be a “Reservoir” of HCV infection unless they are tested, become aware of their infection, and are treated: • 5.4% to 8% of Veterans appear to have been infected. • Prisoners and people who have been incarcerated in the past appears to be about 15%. In many prisons it is 25% to 30%. • It has been estimated that over 300,000 people may have HCV that had a blood transfusion before our blood supply was required to be tested for HCV in July 1992. • Many of them still do not know it yet! Slide by Ken Akinaka, MRA 10/2005

22. The face of the HIV pandemic is changing, and it is younger. • 25% of persons living with HIV in the world are 15 -24 years old. • ½ of all new infections of HIV occur in 15 to 24 year olds. • 51% of the new infections occur in women and girls. Slide by Countny East, APRN, 12/2004

23. What youth are the most at the most risk for HIV infection? • Street youth (40% of homeless youth identify themselves as being gay or lesbian.) • Runaways • Teens having “survival sex” • Those with a history of sexual abuse • Teens with psychiatric diagnoses, such as mood disorder, substance abuse, and depression. • Teens lacking resources – housing, safety • Teens with older partners Slide by Countny East, APRN, 12/2004

24. Contributing factors to risk: What is it about teens and young adults that makes them so vulnerable to contract HIV or Hep B or C? Slide by Countny East, APRN, 12/2004

25. Early teens (10 – 13) Sex drive begins Peer pressure, separation from parents Poor future orientation. Sexual interest usually exceeds activity Mid Teens (14 – 16) Sex drive surges Peak conflict with parents Peer group sets standards. Increasing sexual behavior and experimentation. Developmental stages in adolescence Slide by Countny East, APRN, 12/2004

26. Some quick numbers… • 17% of 7th and 8th grade students report that they have had sexual intercourse. • By the time teens turn 18, 56% of girls and 73% of boys report having had intercourse. Slide by Countny East, APRN, 12/2004

27. Late adolescence developmental stage (17 – 21+) • Maturation complete • Close friendships formed. • Intimacy. • Focus on role in society. • Future oriented. • Refinement of values. • Sexual orientation consolidates. Slide by Countny East, APRN, 12/2004

28. Teen behavior and their risks to acquire HIV or Hepatitis B or C: • Have multiple sex partners. • Relationships are short-lived. • Teens fall “in-and-out of love” and it can be dangerous. • Teens tend to be “serially monogamous”…for a very short period of time! • Some experiment with using Injectable drugs • Some have Tattoos (or in Hawai`i Tatau or Polynesian Tattoos) or body piecing that is not done with new Needles or that uses shared ink. Slide by Countny East, APRN, 12/2004

29. Challenges that predispose teens & adults to disregard HIV or Hepatitis risk • The fear of HIV or Hepatitis has been lost. • HIV & Hepatitis command less urgency that it once did, feeding the perception that HIV is no longer a threat. • Infallibility, “HIV or Hep can’t happen to me.” • A belief by teens and others that HIV can be cured. • HIV medications are portrayed as being easy to take. • Sexual risky behavior is back in vogue. Slide by Countny East, APRN, 12/2004

30. Almost 50% of Students Have HadSex Before Leaving High School1 • 54% of HBV infections in U.S. attributed to sexual contact2 • Like HIV, HBV is spread by infected blood and body fluids, but can be 100 times more infectious than HIV3 1. CDC. MMWR 2002;51(SS04):1–64., 2. CDC. Epidemiology and Prevention of Vaccine-Preventable Diseases. 8th ed. 2004., 3. CDC. MMWR 2003;52(RR-01).

31. Why is it so important to get teens’ attention? Every hour 2 adolescents in the United States are infected with HIV, and most never know they are at risk. ExposureSero-conversionAsymptomaticSymptomatic AIDS Death 0 - 3 mos 3 - 6 mos 8 - 10 years 2-3 years 8 mos – 2 years The Natural History of HIV infection Slide by Countny East, APRN, 12/2004

32. STDs and Teens • It is believed that at least 25% of sexually active American teens have contracted an STD. That’s 3 million teens a year. • Bottom line, if teens are getting STDs, they either aren’t consistently using condoms or they aren’t using them right! Slide by Countny East, APRN, 12/2004

33. A word on gay teens • There are nearly 1 million gay teens in the U.S. • There is a lack of information about safe-sex practices for gay teens. • Sex education ignores gay youth…it renders them “invisible”. • Experience emotional isolation. • Experience widespread harassment. • High suicide and dropout rates. Slide by Countny East, APRN, 12/2004

34. Traces of Blood – A Hepatitis C Video Training Video for Staff and Injection Drug Users

35. E Ho'omalu Kakoa I Ka Po'e Nele A Hune"Lets Shelter & Protect Those Who Are In Need" Save-A-Life Free Safety Kits Campaign • Razors & Shaving Cream • Tooth Brushes & Tooth Paste • Nail Clippers • Toe Nail Clippers • Nail Files • Band-Aids • Antiseptic or Alcohol Wipes • Soap &/or Anti-Bacterial Hand Gel • Condoms

36. Free Save-A-Life Safety Kit Campaign • In May 2006, we informed a person with Hep B & a person with Hep C at the new 300 people Kakoa`ako Homeless Shelter that they were positive. • They both stated that they had been sharing razors. • In June 2006, we started our new free Save-A-Life Safety Kit Campaign!

37. Can Razor Blades Transmit Hepatitis B? • “Determination of Hepatitis B Virus at Used Razor Blade by PCR” • 78 used razor blades were purchased from different barber’s shops in Turkey. • HBV DNA was detected in 6 (7.7%) razor blade samples. CONCULSION: Reuse of razor blade that carry HBV will infect other people. Hence any HBV control & prevention program should educate barbers (and others) about the importance of contagious diseases, proper sterilization tech., and avoiding reuse and sharing of contaminated equipment and supplies like razor blade. • ICAAC, Reported by Jules Levin, Sept. 27-30, 2006, San Francisco, CA.

38. Hepatitis C – contamination of toothbrushes: myth or reality? • 30 patients with chronic hepatitis C had their saliva and rinsing water tested. • 40% of the toothbrush rinsing water specimens tested HCV-RNA-positive. • CONCULSION: Study demonstrates a contamination with HCV-RNA of considerable portion toothbrushes used by hepatitis C patients • Journal of Viral Hepatitis, Volume 13, No. 9, Sept. 2006, pp. 571-573(3)

39. HCV may survive on environmental surfaces at room temp. at least 16 hrs. up to 4 days! This re-emphsizes the importance of: • Cleaning and disinfection procedures, • Safe therapeutic injection practices, and • Harm reduction counseling and services for injection drug users.

40. Get The Facts Video by Diana Slyvestre, MD, and Patients who have Hepatitis C at Oasis Clinic in Oakland, CA

41. Hawai`i has the highest rate of Liver Cancer in the USA because of our high rates Hep B & C. Immigration from Pacific Island and Asian countries, which have extremely high rates of chronic hepatitis B is why we have the second highest rate of Hep B in the USA.

42. Population HBsAg+ % Infected with Hepatitis B American Samoa 50,923 3,565 7% China 1,299,180,000 155,901,600 12% Fiji 883,000 97,130 11% Kiribati 72,000 22,320 31% S. Korea 46,403,000 5,568,360 12% Marshall Islands 190,000 22,800 12% Micronesia, FSM 190,000 22,800 12% to 15% New Zealand 3,662,000 29,296 0.8% (10% of Maori) Palau 16,386 1,966 12% to 15% Papua New Guinea 4,845,000 969,000 20% to 25% Philippines 77,473,000 7,747,300 10% Samoa (Western) 190,000 15,200 8% to 10% Tonga 92,000 18,400 20% Vietnam 82,427,000 9,891,240 12% Here are the rates of hepatitis B in these other Pacific Island countries as reported by the World Health Organization.

43. The homeless are one of the highest at-risk groups that will continue spreading chronic viral hepatitis B and/or C unless we can start to effectively test & treat them for these hidden epidemics and vaccinate them for Hepatitis B. • Most states do not have any special case management program to help the homeless populations that are infected with chronic hepatitis and that are at risk of spreading these infections to others.

44. Many Homeless want to receive treatment for their Hepatitis C! Hepatitis C treatment study in 2005 by Alan D. Tice, MD, 32 of 150 methadone patients that thought they had active hepatitis C volunteered to be treated with pegylated interferon and ribavirin. An important new finding was that of those who were interested in treatment for their hepatitis C, 40% were homeless!

45. These efforts will save lives, limit the spread of disease, and in the long run be cost-effective! • Earlier testing and more housing, medical benefits, support, and case management are needed for effective treatment. • Medical Costs of Cirrhosis or End Stage Liver Disease related complications (even before a Liver Transplants is needed) is very costly to our Healthcare Systems. • Liver Transplants cost $250,000 to $350,000 apiece with about $10,000 of anti-rejection medications per year.

46. Chronic liver disease due to hepatitis C causes between 10,000 and 12,000 deaths per year! • It is the leading indication for liver transplantation each year in the United States. • By the year 2010, the number of deaths from hepatitis C is expected to rise to 38,000 each year. • It is also now the primary reason for death from HIV.

47. A number of Homeless drink Alcohol.Should they be treated for their HCV?“Alcohol use and treatment of hepatitis C virus: results of a national multicenter study” • A total of 4061 subjects were enrolled. • The aim of study was to determine the impact of alcohol use on HCV tx outcomes. • Recent alcohol use was associated with increased higher HCV tx discontinuation and lower SVR. • However, patients who use alcohol and completed HCV tx had a response comparable to that of nondrinkers. CONCULSIONS: Patients with a history of alcohol use should not be excluded from HCV tx. Instead, additional support should be provided to ensure their ability to complete HCV tx. • Gastroenterology. 2006 May;130(6):1912-4. Dept. of Medicine, Michael E. DeBakey VA Medical Center, Houston, Texas. PMID: 16697724 [PubMed – in process]

48. Free Hepatitis B or C Tests for the Homeless & other at risk Groups We now give a Free T-Shirt to those who test at: • Health Fairs • Community & Organizational Talks • Free for Homeless or people with risk factors who cannot afford special low cost tests • $15 for HBV • $25 for HCV • $35 for Both Tests

49. Where can they be tested for HCV if you do not have Health Insurance? • Very limited resources in the USA • Home Access Hepatitis C test Kits for $59.95 at http://www.homeaccess.com/02/ • Through the State Department of Health in Hawai`i if you have been an injection drug user • Check with your local Health Dept. if you do not have Health Insurance or cannot be tested by your physician or a local Community Health Clinic Slide by Ken Akinaka, MRA 10/2005

50. Another Important Health Concern!The Homeless as well as many otherwise Healthy People Need to Be Protected from Hepatitis A & B and need to be vaccinated!