HEP Spring 2019

A SMART+STRONG PUBLICATION SPRING 2019 HEPMAG.COM

Hoosier Strong

Overcoming addiction and curing hep C

Matt Heskett

Got Ink? An estimated 3–5 million Americans are living with hepatitis C. Most don’t know it.

Get tested today.

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FROM THE EDITOR

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CONTENTS 3 FROM THE EDITOR Addressing the impact of the opioid crisis on the hepatitis C epidemic

att Heskett has a lot to be thankful for—in addition to overcoming his opioid addiction, he is cured of hepatitis C virus (HCV).

After breaking a finger in high school, Heskett became addicted to painkillers, which over time escalated to heroin use. Heskett believes he contracted hep C when he switched from snorting heroin to injecting the drug.

Now sober and free of hep C, Heskett is paying his good fortune forward through activism and education. The Indiana native (aka Hoosier) is helping others recovering from opioid use as an employer services coordinator for Fairbanks, an addiction treatment center.

He is the liaison between addiction patients and their jobs.

Although the 32-year-old advocate had shared his addiction story with the media previously, this is the first time Heskett has discussed his HCV journey with the press. We at Hep magazine are honored to have earned his trust to share his complete personal story. Go to page 8 for more.

A new analysis estimates that 2.4 million U.S. residents are living with HCV. The opioid crisis has fueled the spread of hep C nationwide. Increased focus on the connections between both epidemics is leading researchers to new conclusions.

A new meta-analysis argues that people who inject drugs should not be restricted from receiving HCV treatment given the evidence that they have a high cure rate on such medications.

Another study concludes that health care providers across the country are missing the opportunity to screen for HCV among youth with opioid use disorder.

The focus on this demographic is a result of the surge in nonprescription use of opioids among young people in particular.

Go to page 7 for more on all these studies.

To address screening drug users for hep C, some public health advocates are calling for the development of an entire system of HCV care just for this group.

This conclusion is in response to the failure of drug treatment centers, which are well positioned to initiate hep C testing, to do so for both opioid and meth users.

To improve targeting by medical providers of young people living with HCV, some experts are looking at a blueprint designed by Australia. That nation aims to eliminate hep C in the next decade or so by implementing a universal HCV screening policy, regardless of age. Go to page 4 to read more about all these efforts.

For the latest updates on hep C, as well as other types of viral and nonviral hepatitis, go to HepMag.com.

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4 NEWS Treating youth living with hepatitis C • Screening drug users for hepatitis C • The quest for a hepatitis B cure • Hepatitis A cases tripled in 2018

6 TREATMENT NEWS Hep C treatment is heart healthy • 2.4 million Americans have hep C • Don’t bar people who inject drugs from hep C meds • Opioid crisis raises need for youth hep C tests

8 PROFILE Indianapolis native Matt Heskett beat both opioid addiction and hep C. Now he’s paying his good fortune forward with activism and education.

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NEWS

Treating Youth Living With Hep C As access to hepatitis C virus (HCV) treatment expands across the country, young people are still being left out when it comes to diagnosis and care, and doctors are trying to figure out how to better combat the crisis, MDMag reports.

According to a study presented at IDWeek 2018, from a pool of nearly 269,000 teenage and young-adult patients across 19 states, just 2.5 percent were tested for hep C. Among those with a history of drug use, just 8.9 percent were tested. Among those officially diagnosed with an opioid-use disorder, 35 percent were tested—despite the fact that Americans who use opioids are nearly nine times more likely to have HCV than the general population.

What’s more, an additional study on hep C prevalence in young drug users ages 22 to 30 found that even when diagnosed, these patients face a number of barriers in accessing treatment, including, in some states, minimum liver damage requirements before medication may be

given and stigmatization by health care providers.

So how can medical providers better target young people?

A lot of experts are looking at a blueprint designed by Australia. That nation aims to eliminate HCV in the next 10 to 15 years by implementing a universal hep C screening policy—regardless of age—to help track down hard-to-reach cases and reduce stigma surrounding the disease.

Expanding access to new direct-acting antivirals with a fixed payment method that would ensure all Medicaid and uninsured patients have access to care when diagnosed would also help significantly.

In the midst of the opioid crisis, health workers are not only seeing firsthand the effects of addiction, abuse and accidental overdose— but they’re also on the front lines of America’s hepatitis C virus (HCV) epidemic. So why are so few drug treatment centers testing opioid and meth users for the virus? NPR’s Shots dived into the topic.

The report lists all the ways in which health care facilities that serve people who use drugs are well-positioned to initiate hep C testing: They’re often the first point of health care for opioid or meth users; they are experienced in working with hard-to-reach populations; and they often offer harm reduction

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services, like syringe exchanges, to help reduce new infections. However, studies show that drug users often go untested for HCV, which represents an enormous missed opportunity for finding and curing new infections.

Public health advocates say lack of money, staff and other resources stand in the way of testing and point out as well that potential clients are not necessarily interested in getting tested or treated.

Plus, if people test positive, they need to be linked to treatment and other care services, and financial support for staffing such services is often limited. Then there’s the matter of insurance. Many people who enroll in drug treatment

programs are uninsured and cannot access expanded Medicaid under the Affordable Care Act where they live.

The result? In 2017, just 27.5 percent of 12,166 centers specializing in substance use disorders offered testing for hep C. Among federally certified methadone and other drug treatment clinics, the HCV testing rate, though higher, was just over 63 percent. When it comes to primary care settings, those between ages 13 and 21 diagnosed with opioid use disorder at federally qualified health centers were screened for hep C at a rate of only 36 percent, which is especially alarming given that HCV rates are growing fastest among this population.

Advocates call for the development of an entire system of hep C care just for drug users.

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Screening Drug Users for Hep C

Hep A Cases Tripled in 2018

For 2018, 15 states declared outbreaks of hepatitis A virus (HAV), which affects the liver and is spread via contaminated food, oral-anal sex, close personal contact with someone with the virus, using contaminated water for intravenous drug use and unsanitary conditions. The virus has largely affected homeless populations across the country.

The crisis reveals much about America’s failing public health system, suggests an article on the Huffington Post. Cases of hep A more than tripled in the United States in 2018, and more than 10,500 people have been affected. Some of the most notable HAV outbreaks have occurred in California, Kentucky, Ohio, West Virginia, Colorado, Indiana and Missouri—states where the opioid epidemic continues to take its toll and homelessness is on the rise.

States, counties and cities have spent millions trying to fight their local outbreaks. But the spending has revealed a dark secret about the nation’s public health system—namely, that it’s collapsing as a result of funding cuts and can’t meet the demands of a growing at-risk and notoriously hard-to-reach population.

For example, officials report that more than 56,000 local health department jobs have been eliminated since 2008. Meanwhile, the costs of battling hep A have been astronomical for cities caught in the crisis.

The Quest for a Hep B Cure As liver disease treatment improves around the world, researchers continue to diligently search for a cure for hepatitis B virus (HBV). The journal Science overviewed nearly 50 new potential treatments currently in development and suggested we could soon be one step closer to a cure for HBV. The shape-shifting nature of hep B has long perplexed researchers. In some cases, the virus simply waits inside liver cells, barely signaling its presence. In other cases, it can establish a chronic infection, churning out lots of new virus but doing little harm. In yet other cases, the virus can trigger liver damage that can turn into cirrhosis or cancer, which kills nearly 900,000 people around the world every year.

Currently, HBV can be controlled with drugs and prevented with a vaccine.

However, HBV drugs must be taken for a lifetime, and

vaccine coverage around the world remains spotty.

Two major types of hep B cures are under development— those that directly attack different phases of the viral life cycle and those that boost immunity against the virus. Researchers are also looking into a latent form of viral DNA produced by HBV called covalently closed circular DNA (cccDNA), which forms a mini-chromosome inside the nucleus of infected cells that likely needs to be fully eliminated before a cure can be achieved.

Thus far, no drugs specifically target cccDNA. For now, researchers are looking to develop “functional cures” that lower the amount of virus to the point that the body’s own immune system can keep the infection in check, allowing for people to stop treatment. Experts in the field estimate that it will take five to 10 years to clear cccDNA.

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TREATMENT NEWS

BY BENJAMIN RYAN

Hep C Treatment Is Heart Healthy People with hepatitis C virus (HCV) have a lower risk of cardiovascular disease (CVD) if they receive treatment for the virus, in particular if they take direct-acting antivirals (DAAs) rather than the older, now largely obsolete class of interferon-based regimens.

Researchers reviewed Veterans Affairs data and identified 242,700 vets with hep C. Among them, 4,440 were treated with interferon and ribavirin while 12,670 received DAA regimens. The study authors drew upon the wider cohort of people with HCV to create an untreated control group, matching the treated individuals according to age, race, sex and other baseline characteristics.

No one in the overall cohort used for the study’s analysis had been diagnosed with a CVD health event upon entry into the electronic database.

A total of 1,240 (7.2 percent) of those in the treated group were subsequently diagnosed with a CVD health event, as were 2,360 (13.8 percent) of those in the control group. This translated to a diagnosis rate per 1,000 cumulative years of follow-up of about 20 diagnoses in the treated group and 31 diagnoses in the control group.

Compared with not receiving treatment, being treated with interferon plus ribavirin was associated with a 22 percent reduction in the CVD health event diagnosis rate, while being treated with DAAs was linked to a 43 percent reduction. The diagnosis rates per 1,000 cumulative years of follow-up were about 24, 16 and 30 diagnoses in the interferon group, DAA group and control group, respectively.

The study authors wrote that their findings demonstrate “clear evidence of a benefit of successful treatment” of hep C. They continued: “With cure rates of greater than 90 percent with DAAs and a clear survival benefit with treatment, more HCV-infected persons will live longer. Reducing CVD risk will be increasingly important in these patients.”

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As the opioid epidemic rages, fueling a rise in hepatitis C virus (HCV) transmission through the sharing of injection drug equipment, a new analysis estimates that 2.4 million U.S. residents are living with HCV. Researchers analyzed 2013 to 2016 data on all adults from a Centers for Disease Control and Prevention (CDC) national survey on health and nutrition. They also relied on scientific literature reviews and estimates of population sizes to estimate the prevalence of HCV among incarcerated people, homeless individuals, active-duty military personnel and nursing home residents.

An estimated 1.7 percent of all adults in the United States, or 4.1 million people, had HCV antibodies (which indicates a past or current infection) during the study period.

(Note that hep C can spontaneously clear without treatment during the first months after infection.) And about 1 percent of adults, or 2.4 million people, had both HCV antibodies and a positive HCV RNA test, indicating a current infection.

“Hundreds of thousands of Americans have been cured, but many people infected with hepatitis C have not benefited from direct-acting antiviral [treatment for the virus] because they don’t know they are infected or cannot access treatment,” said the study’s first author, Megan Hofmeister, MD, MPH, a medical officer in the CDC’s Division of Viral Hepatitis. “Until hepatitis C testing and treatment are expanded to more Americans, we will be in a losing battle against this disease.”

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2.4 Million Americans Have Hep C

Don’t Bar People Who Inject Drugs From Hep C Meds Given the considerable evidence that people who inject drugs have a high success rate on hepatitis C virus (HCV) treatment, they should not be restricted from receiving such medications. That’s according to researchers behind a new meta-analysis of 38 hep C treatment studies including some 3,635 PWID as participants.

Twenty-one of these studies, which had a cumulative 1,400 participants, included those with recent injection or noninjection drug use. Ninety-eight percent of these individuals completed hep C treatment, and 87.7 percent were cured.

Thirty-six studies with just under 3,000 participants included those receiving opioid medication treatment, also known as opioid agonist therapy, to treat opioid use disorder. Of these, 97 percent received HCV treatment and 91 percent were cured.

Eight studies with 670 participants included those with recent injection drug use. Of these, 97 percent received HCV treatment and 87 percent were cured.

“Data from this review clearly demon-

strate that people receiving opioid agonist therapy and people with recent injection drug use respond favorably to direct-acting antiviral therapy for hepatitis C,” says study author Jason Grebely, PhD, a professor at The Kirby Institute at UNSW Sydney in Australia.

“These data reinforce international clinical guidelines recommending that there should be no restrictions for treatment of hepatitis C based on recent or ongoing drug use.”

Opioid Crisis Raises Need for Youth Hep C Tests

As the nonprescription use of opioids has surged among young people in particular, health care providers are missing the opportunity to screen for hepatitis C virus (HCV) among youth with opioid use disorder.

Researchers analyzed the electronic medical records of

nearly 270,000 U.S. residents between 13 and 21 years old who attended one of 57 federally qualified health centers in 19 states between 2012 and 2017.

A total of 875 of these young people were diagnosed with opioid use disorder; of these, just 36 percent were tested for hep C. Of those who were screened, 11 percent tested positive for HCV antibodies and 6.8 percent tested positive for antibodies and the presence of the virus, indicating a chronic infection.

A total of 6,812 (2.5 percent) of all the young people included in the analysis were tested for HCV. Of this group, 122 (1.8 percent) tested positive for the virus.

“It is critical that pediatricians and other physicians seeing adolescents and young adults first take time to screen for

opioid and other substance use and risk factors that may lead to substance use disorders,” says study author Rachel Epstein, MD, MA, a pediatrician at Boston Medical Center.

“Second, once substance use is recognized, clinicians must appropriately screen for both hepatitis C virus and HIV and link diagnosed individuals to [medical] care. Third, treating opioid and other substance use disorders is essential to curb all three epidemics.”

“Additionally,” Epstein says, “expanded HCV screening recommendations that do not rely on identification or disclosure of risk factors could also expand HCV testing significantly, as multiple studies note no identified risk factor in over half of individuals newly diagnosed with HCV.”

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PROFILE

Matt Heskett helps other recovering opioid users.

Hoosier Strong Indianapolis native Matt Heskett beat both opioid addiction and hep C. Now he’s paying his good fortune forward with activism and education.

By Tim Murphy Photography by Harold Lee Miller

L

ife is good today for Matt Heskett, 32, of Indianapolis.

He’s finally sober. He’s rebuilding his credit and working toward buying a house. He’s playing guitar and recently ran his first half-marathon, raising $1,200 for Fairbanks, the drug and alcohol addiction treatment center where he now works helping others find their way out of addiction. “I get to see that light come back into people’s eyes as they turn their lives around,” he says.

On top of all that, in 2017, he was cured of hepatitis C virus (HCV). But according to the laid-back, affable Heskett—a fan of both the Indiana Pacers and singer Ed Sheeran—things got real bad, then worse, before they got better.

He grew up a middle child, loving sports and the outdoors, and graduated from Indiana University with a public affairs degree and a desire to work in the nonprofit sector.

But he wound up selling retirement and insurance funds

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and then put in nearly five years at a distributor for industrial and safety products.

Heskett’s problems trace back to his senior year in high school, when he drunkenly smashed his hand against a concrete slab and broke a finger. He was given the painkiller Percocet—but went through all three refills quickly and experienced physical withdrawal. “You feel achy, like you have a cold,” he says, “sweating one moment, freezing the next, no appetite, no energy.”

Like so many Americans in the past decade, Heskett became addicted to opioids. A childhood friend introduced him to OxyContin, which fed his habit for a while. “But they were hard to find and expensive,” he says. So one day when he was experiencing particularly bad withdrawal symptoms, a friend offered him something stronger, cheaper and more available: heroin, which he started snorting.

“By that point,” he says, “both my parents and brother had kicked me out.” What’s worse, his job, sensing he was addicted, offered help but only if he was up front with them about his substance abuse. “But I denied it,” he says. They let him resign and gave him a severance package.

He’s certain he contracted hep C when he switched from snorting heroin to injecting. “I’d always said that I’d never do that because there would be no going back,” he says. But once, when friends who were also using had an extra needle, he did it. Going forward, he wasn’t always careful to use clean syringes and paraphernalia.

By late 2015, he was sleeping in his car or various trailer homes. “Every minute revolved around finding money for drugs,” he says. His moment of clarity arrived when the trailer home he was staying in was busted for drugs; mercifully, the cops just told him to scram.

“I left with nowhere to go, no money, no gas in my car,” says Heskett. “I’d run out of options and didn’t know what else to do. So I called my parents.” They told him he could come home for two days while he made other arrangements. That’s how he ended up at Fairbanks, where he’d gone before, urged by family and friends. “But this time I wanted to be there.” Thankfully, after a day’s wait, the state’s Healthy Indiana health insurance plan agreed to cover his stay.

After a week of inpatient detox, he

Eight weeks later, he tested clear for hep C but remained on the drug for another four weeks. He’s been hep C–free ever since.

“Reach out to your primary doctor or someone to try to walk you through the process,” is his advice for anyone newly diagnosed with HCV. “I didn’t know where to start at all.

But there is a cure, and you don’t have to be stuck with hep C the rest of your life.”

At first, he says, he was ashamed of his diagnosis.

(In fact, when he talked to a local paper about his recovery a while back, he withheld his hep C diagnosis.) But then he heard that the Indiana Addiction Issues Coalition was looking for someone to speak publicly about his or her HCV journey. “I realized that maybe somebody out there needs to hear my story to give them that boost to get the treatment they need,” he says. So he stepped up.

Thus began his new side career as a hep C activist.

Not only does he continue to speak publicly for the coalition, but he also volunteers for the organization Overdose Lifeline, which does overdose education and prevention, particularly by promoting training in the use of the overdose reversal drug Narcan to first responders, police and drug users.

Life has treated him well the past year, he says—except for one heartbreak. In recovery, he began dating another recovering opioid user. But she started using again and fatally overdosed. Heskett got the news after attending a 12step meeting.

“I couldn’t have handled that if I hadn’t been sober,” he says. “I reached out and had about 100 people calling me, checking on me, giving me a ride to work, to meetings, bringing me food. A friend said, ‘I’m coming to get you,’ and I said, ‘No,’ and he said, ‘Screw you, I’m coming.’ Sometimes it’s hard to let people help me.” He also went to a grief and trauma therapist.

Since then, he’s been Fairbanks’s employer services coordinator, meaning that he is the liaison between addiction patients and their jobs. “I get to advocate for the patient to have more treatment after detox, instead of just going straight back to work,” he says. “That’s very cool because I lost a job where they wanted to help me. I see people come in broken, and I get to try to keep their spirits up, share my own story and keep them hopeful and motivated.”

Running races and playing guitar are not the only new pastimes in his life. Before his girlfriend died, the couple went skydiving together. Recently, Heskett went again— with her dad. “That was bittersweet,” he says. “I feel she sends me little reminders that I’m on the right path. I’ll be driving home and notice a big sunbeam breaking through the clouds—and I know that’s her.” ■

“I realized that maybe somebody out there needs to hear my story.”

moved across the street to Fairbanks’s supportive living 12-step-based program and ended up staying there for 10 months. This time, he says, “I was willing to do whatever they told me to. The biggest breakthrough for me was understanding the power of the drug. I’d thought I was weak and lacked willpower.”

Yet while in recovery, he also received a diagnosis that didn’t surprise him: He tested positive for HCV. “There were so many times I was sick from withdrawal and used somebody else’s syringe,” he says. “The addiction overrides every thought.” Although Indianapolis had needle exchanges at the time, Heskett says he was unaware of them.

His primary care doctor referred him to a local hepatologist at Franciscan Health who found that his liver already had quite a bit of scarring—but also that his hep C viral load was low. Over time, though, it shot up into the millions, and Heskett lost weight, energy and appetite.

“I thought I was just depressed, but the doctor said she could see the jaundice in my eyes,” he says. By this point, he was working at Fairbanks rehab as a peer coach for adolescent groups, so he had new health insurance, which initially refused his treatment. “But Franciscan kept fighting for me, and one day they said, ‘Congrats, we got the approval.’”

Heskett started taking the HCV drug Harvoni in December 2017. “I had no side effects except for a three-day span where I got a bad migraine around midnight,” he says.

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