Treat first! Shade says… Establishing Access to Hepatitis C Treatment in a Nurse Practitioner-led Community-Based Syringe Access Center in San Francisco Pauli Gray (He/Him/His) Sr SAS HCV Wellness Coordinator Pierre-Cédric Crouch, PhD, ANP-BC, ACRN Director of Nursing Magnet @Strut

Disclosures We have no disclosures San Francisco and California have privilege which makes this work easier than other places San Francisco AIDS Foudation

1 2 Objectives Why we do this Walk through Hep C Health Program San Francisco AIDS Foudation

TREAT FIRST! 5 PRONGS: TREAT at Syringe Access sites SHADE SAYS... TREAT FIRST! 5 PRONGS: TREAT at Syringe Access sites NO HOOPS to jump through OFFER HCV MED STORAGE SUPPORT/WRAP-AROUND SERVICES SECONDARY GOALS

TAKEAWAYS Each time we partner to cure a single case of PWID Hep C, we are helping prevent 25 others from being infected We have the unique opportunity of curing the deadliest communicable disease and the honor of facilitating a huge change and providing hope in people’s lives.

San Francisco AIDS Foundation Harm Reduction Center Mobile Testing Unit Magnet at Strut Main Downtown Office SAN FRANCISCO AIDS FOUNDATION

Hepatitis C Program End Hep C SF Hep C Treatment Priority Communities Out of care Expanded Magnet HCV Testing Priority Communities IDU, Gay/MSM, Kink/Blood, HIV Positive Hep C Navigation and Treatment Support Tx Breakfast Medication Storage End Hep C SF San Francisco AIDS Foundation

Harm Reduction Center Visit Schedule Screening H&P: Focus on Cirrhosis Labs: CBC, LFTs, PT- INR, HCV RNA, HCV GT HCV Counseling Prior Authorization Initiation Within 1-2 weeks of screening Adherence Counseling Week 4 HCV Counseling CBC, LFTs, HCV RNA Week 8, 12 HCV Reinfection Counseling SVR12 HCV Reinfection Counseling Labs: HCV RNA Ongoing treatment breakfast, medication storage, & HCV counseling by navigators San Francisco AIDS Foundation

Hep C Treatment Program Eligibility Generally Healthy over age 18 Exclude decompensated cirrhosis Prefer monoinfected Hep C May work with HIV coinfected with PCP Do not bill professional fees Allows us to accept most insurance for labs and meds No need to change medical home Unable to treat Kaiser or VA clients Able to treat uninsured and undocumented clients Abbvie and Gilead Patient Assistance San Francisco AIDS Foundation

Outcomes Age 26-69 (43.8) Gender Cis-male 34 Cis-female 8 Transfemme 1 Clients Screened 86 Clients Initiating treatment 61 Clients Completing Treatment 44 (14 active) Clients Achieving SVR12 21/23 (91%) Clients not initiating 6-Cleared Hep C 2-Medically complex 1-Enrolled in Research 3-Did not return to initiate 3-other Clients with Incomplete Treatment 3 Clients Not Achieving SVR12 1 Reinfected 1 Adherence Cross-sectional data from November 9, 2018 San Francisco AIDS Foundation Table 1 Demographics Age 26-69 (43.8) Gender Cis-male 34 Cis-female 8 Transfemme 1 Transmasculine Gender Non-conforming 2 Race/Ethnicity Latinx White 30 AA/Black 9 Asian/API Multiple 4 Table 1 Demographics Age 26-69 (43.8) Gender Cis-male 34 Cis-female 8 Transfemme 1 Transmasculine Gender Non-conforming 2 Race/Ethnicity Latinx White 30 AA/Black 9 Asian/API Multiple 4

Demographics Age Range Mean 26-69 (43.8) Gender Cis-male 34 (76%) 24-69 (42.3) Gender Cis-male 67 (78%) Cis-female 15 (17%) Transfemme 1 (1%) Transmasculine 0 (0%) Gender Non-Conforming 2 (2%) Race/Ethnicity Latinx/o/a 6 (7%) White 58 (67%) AA/Black 17 (20%) Asian/PI Native American Multiple 3 (4%) Table 1 Demographics Age Range Mean 26-69 (43.8) Gender Cis-male 34 (76%) Cis-female 8 (18%) Transfemme 1 (2%) Transmasculine 0 (0%) Gender Non-conforming 2 (4%) Race/Ethnicity Latinx White 30 (68%) AA/Black 9 (20%) Asian/API Native American Multiple 4 (9%) Table 1 Demographics Age Range Mean 26-69 (43.8) Gender Cis-male 34 (76%) Cis-female 8 (18%) Transfemme 1 (2%) Transmasculine 0 (0%) Gender Non-conforming 2 (4%) Race/Ethnicity Latinx White 30 (68%) AA/Black 9 (20%) Asian/API Native American Multiple 4 (9%) Table 1 Demographics Age Range Mean 26-69 (43.8) Gender Cis-male 34 (76%) Cis-female 8 (18%) Transfemme 1 (2%) Transmasculine 0 (0%) Gender Non-conforming 2 (4%) Race/Ethnicity Latinx White 30 (68%) AA/Black 9 (20%) Asian/API Native American Multiple 4 (9%) San Francisco AIDS Foundation

Demographics Primary Care Provider Barrier No provider in last year 58 (67%) Provider with Cultural Barrier (problem with their provider) 10 (12%) Clinic with Structural Barrier (problem with how clinic is set up) 5 (6%) Prefer treatment at SFAF despite easy access elsewhere 13 (15%) Housing Marginally housed (SRO) 11 (13%) Homeless 44 (51%) Stable Housing 31 (36%) Substance Use Current Use 77 (90%) Prior Use 6 (7%) Never used 3 (4%) San Francisco AIDS Foundation

Demographics AST to Platelet Ratio >1 (potential liver damage) 14 (18%) <1 (less likely to have liver damage) 62 (82%) Weeks of Treatment 8 weeks 58 (78%) 12 weeks 15 (22%) San Francisco AIDS Foundation

Discussion People living with active substance use can successfully be cured of Hepatitis C. Differentiated Service Delivery of Hepatitis C treatment in a Syringe Access Service can reach communities who traditional healthcare settings have struggled to reach. San Francisco AIDS Foundation

Facilitators Facilitators A ”treat first” approach allows for clients to focus on Hepatitis C treatment Newer 8 week treatments facilitate cures Expanded Nursing Scopes of Practice No billing of professional fees Reduced barriers for Medi-Cal/Medicaid coverage San Francisco AIDS Foundation

Barriers Barriers Lack of Nurse Practitioner Autonomy in California Blood Specimen Collection Microtainers, Newer technologies use capillary sticks Funding to expand program San Francisco AIDS Foundation

Thank You! To all the clients who put their trust in our team. All SFAF staff and volunteers and the San Francisco community who support our work. Protocols: https://tinyurl.com/hepcSFAF San Francisco AIDS Foundation

TREAT FIRST, SAVE LIVES SPREAD THE WORD

Contact Info Pauli Gray pgray@sfaf.org Pierre-Cedric Crouch pcrouch@sfaf.org Janessa Broussard jbroussard@sfaf.org San Francisco AIDS Foundation