Day Two: Harm Reduction Conference

Heather Lusk
Alan Franciscus

Session: Counseling and Case Management for People with Hepatitis C

Presenter(s):Karen Schlanger, New York City Hepatitis Coordinator
Alison Goldstein, Hepatitis C Social Worker, Multnomah County Health Dept., Portland, OR
Marrisa Axelrod, Clean Needles Now, Los Angeles, CA

The objective of this session:

• Describe concerns of people living with HCV and strategies used to educate and care for themselves, reduce the likelihood of disease progression and prevent transmitting the disease to others
• Within a harm reduction framework, describe key components of educational and counseling messages for people recently diagnosed with hepatitis C
• Video “Living with Hepatitis C” by the New York Department of Health and Mental Hygiene

An objective of the Multnomah County Health Viral Hepatitis Integration Program (VHIP) was to develop core public health messages for people living with hepatitis C

The main points to cover were:

• Reduce/abstain from alcohol (and other liver toxic drugs)
• Be vaccinated against HAV and HBV
• Find and see a health care provider routinely

There are more specific health messages for people who inject drugs or have unprotected sex:

• Use new or clean syringes and all injection equipment (use needle exchange)
• If you can’t use new needles, use 3 minute water-bleach-water solution to clean equipment. It was noted that this hasn’t be proven to kill HCV, but may reduce risk of transmission of HCV and other diseases
• Have an overdose prevention plan
• Get tested for HIV, HCV, HBV and STDs
• Use barriers when blood may be involved in sexual activities

The process of prevention/education is meet people at their level and needs with clearly defined messages. The “Don’t Share Your S**T” was developed to convey the message that nothing should be shared

This presentation ended with a discussion of the importance of meeting clients where they are at by assessing their readiness, willingness, and ability to change behaviors and some techniques for working with some people who are not ready, unsure or ready to change behaviors.

Following this presentation a view of a video on hepatitis C titled "Living with Hepatitis C was shown. This is a short film (17 min) that was developed by the New York City Department of Health for people recently diagnosed with HCV was shown and responses to and uses of the film was discussed. The film interviews people living with HCV and their providers (hepatologist, social worker, harm reduction educator), and describes basic information about HCV, medical treatments, coping strategies within a harm reduction framework that addresses ways to reduce the likelihood of disease progression and how to prevent infecting others. This educational film is intended to document people's experiences while providing hope and information related to HCV disease.

Marrisa Axelrod talked about doing hepatitis C and harm reduction within the context of a needle exchange program. Clean Needles Now (CNN) provides health education including hepatitis C transmission information that is specific to IDUs and other drug users. Information about the liver, testing options, and self-care for living with hepatitis C is given. They provide “positive packets”, which contains information about living with hepatitis C by incorporating specific wellness strategies such as drinking water, stress reduction techniques, diet, and exercise. Information is provided to inform drug users about the effect of their drug use on their liver.

The session concluded with a discussion of street specific self-care including ways to access water and healthy food. One example is standing outside of a store and instead of asking for money is to ask for a bottle of water.

Session: HCV in Prisons

Presenter(s): Judy Greenspan, HIV in Prison/CPF, San Francisco, CA
Brenda Goldhammer, California STD/HIV Prevention, Berkeley, CA
Sue Currie, University of California, San Francisco, CA

The objectives of this session:

• How to fight for education and to provide support to prisoners with hepatitis C
• Describe efforts to educate HCV positive prisoners in California
• Describe the prevalence and risk behaviors of prisoners with hepatitis C in a sample of California prisoners

Topic: Fighting for Hepatitis C Treatment in Prison

Presenter: Judy Greenspan, HIV in Prison of California Prison Focus

Judy Greenspan discussed HIV in Prison’s advocacy efforts with hepatitis C positive prisoners. It was noted that the estimates of the number of hepatitis C positive prisoners vary but it is generally agreed that it is at least 1/3 of the general prison population. In addition, the majority of prisoners are incarcerated because of drug related crimes and this population is particularly susceptible to infection with hepatitis C. Greenspan noted that the vast majority of prisons and jails do not offer testing or diagnostic monitoring. More importantly very few prisons offer any type of education on prevention or living with HCV much less medications to treat hepatitis C. In fact, Greenspan commented that prisoners are discouraged from finding out their medical status and many prisoners are just discovering that they tested positive for HCV ten and fifteen years ago. It was noted that this lack of care has led to many instances to serious liver damage leading to cirrhosis and that many prisoners with end stage liver failure cannot access adequate care. It was felt that in general the prison system refuses to acknowledge the seriousness of this epidemic for many reasons such as costs associated with care and support.

In summary, the demand for Hepatitis C care for the incarcerated, including education, free and confidential HCV testing, care, monitoring and treatment must be a part of the overall campaign for harm reduction for people who use drugs. In order to make this process a success prisoners living with HCV must be part of this education, support and advocacy campaign to bring attention to this serious epidemic.

Session: “I Got It From the Air”: Innovative Attempts at HCV Education in California State Prisons

Presenter: Brenda Goldhammer, MPH, California STD/HIV Prevention Training,
Berkeley, CA and Derek Silva Community, San Francisco, CA

The objective of this session was to examine characteristics associated with HCV infection among inmates entering California prisons that may provide the basis for HCV education and prevention.

The title of this session was taken form a comment from a prisoner that she interviewed when she first started to work in prisons and asked a prisoner how he thought he got hepatitis C The prisoner replied that “I got it from the air”. This inspired Goldhammer to focus her efforts on education in the prison system.

This study recruited 472 prisoners entering 3 California Prisons. All participants were tested for HCV and surveyed using an in-depth questionnaire for risk behaviors, characteristics and exposures.

It was noted that natural obstacles exist within prisons that prevent self-reporting such as the lack of confidentiality which can result in many repercussions for prisoners.

The programs focus was to provide appropriate education that can be integrated into other trainings that currently exist in prison settings. The harms prevalent in prison settings and the skills building to improve competence in prevention counseling was explored in this session and it was noted that the difficulty in providing harm reduction in prisons is that the tools used for harm reduction such as condoms, clean needles and tools, tattooing and piercing equipment is considered contraband by the prison officials.

Informal focus groups with recently released parolees and a needs assessment study of community-based providers to determine the training needs were conducted. Hepatitis training and skills-based models based on harm reduction principles were created for prisoners, parolees and community-based providers working with the prison populations.

The training included information on hepatitis A, hepatitis B, and hepatitis C, the functions of the liver, transmission/prevention and testing. Education on living with chronic hepatitis B and/or hepatitis C was also included in the training. One of the most important goals of these trainings was to provide the means to promote peer education within the prisons.

The results of this study:

• A successful hepatitis training and skills-based models based on harm reduction principles was developed
• Preliminary analysis of evaluations indicate that there was a knowledge improvement and prevention skills enhancement
• Decreased self-efficacy in preventing hepatitis
• Decreased anxiety about living with chronic hepatitis

Goldhammer concluded that hepatitis education is needed, appropriate and can be adequately integrated into other training or educational programs, including harm reduction, drug recovery, STD/HIV, and other health related concerns.

Session: High Prevalence of HCV in Prisons: Opportunities for Education and Prevention.

Presenter: Sue Currie, Project Director, Hepatitis C in the California Prison Project (HEPCAP), University of California, San Francisco, CA

Investigators: Page-Shafer, Currie, Evan, Moss, Hernandez, Fox, Wright, Tobler, Dailey, Phelps, Busch

Drug and drug-related crime have been associated with a significant increase in the prison population within California. The estimated amount of prisoners in California varies but is believed to be between 30-60%. There have not been any extensive studies that examined the risk factors associated with HCV in prisons. Significant public health resources may be required to address HCV education and prevention among the prison populations and in the communities in which the return to upon release.

The objective of this study was to determine prevalence and independent correlates of HCV education and prevention among prisons entering California correctional facilities.

A cross-sectional sample of 615 prisoners entering 3 California prisons were contacted and 469 consented to be interviewed (76.2% response rate). Blood samples were tested and confirmed for HCV antibody. The negative samples were tested for HCV RNA to detect viremic infections.

Selected characteristics and demographics (number = 469)

Characteristics	Median	IQR (interquartile range)
Age	35	27-42
Years in Prison	5.5	3-11

Ever been tested for*:	Number	(%)
HIV	352	(75)
HCV	169	(36)
HAV	164	(35)
HBV	169	(36)

Note: * Lost opportunities – people that were tested for other conditions could have been tested for other conditions which would make education and testing more effective.

HBV Vaccinations	47	(10)
HAV Vaccinations	42	(9)

Parole Violations	76%
Drug Related	8%
Violent Crime	6%
Other Crimes	10%

Prevalence of HCV infection by selected demographic and behavioral characteristics

Characteristics	N = 469 (% of sample)	HCV positive (%)
Sex
Male	341 (73)	111 (33)
Female	128 (27)	48 (38)
Age
< =30	169 (36)	27 (16)
31-40	172 (37)	61 (36)
41-50	107 (23)	58 (54)
> =51	19 (4)	12 (63)
Race/Ethnicity
Black	104 (22)	20 (17)
White	123 (26)	60 (48)
Latino	174 (37)	53 (37)
Other/Mixed	67 (14)	32 (27)
Incarcerated for parole violation
No	117 (25)	30 (26)
Yes	350 (75)	129 (37)
Ever IDU
No	265 (57)	27 (10)
Yes	201 (43)	132 (66)
Ever snorted drugs with used equipment
No	159 (34)	39 (25)
Yes	307 (66)	120 (39)
Ever cut or assaulted
No	239 (52)	73 (31)
Yes	224 (48)	86 (38)
Ever tattooed or pierced
No	72 (15)	18 (25)
Yes	393 (85)	141 (36)

Summary findings:

• 34% prevalence of HCV antibody
• HCV infection inmates is associated with:
  • With gender (38% female vs. 33% male)
  • With race (60% White, 53% Latino, 20% African Americans
  • IDU (65% vs. 10%)
• Among those with no history of IDU, HCV was associated with total time incarcerated
• Parole violators almost twice as likely to have HCV
• No associations with tattooing, snorting or assaults
• Only 32% had ever tested for HCV but 73% had tested for HIV
• 77% HS Education or below
• 7% English as a second language
• 77% volunteered to participate without incentive
• Women get tested more than men

The authors of this study concluded:

• A high prevalence of HCV was detected in persons entering prison, the majority of whom were not aware of infection status
• Almost all HCV infections represent established rather than incident infection. Only 1 incident infection identified
• Majority of HCV in correctional institutions is attributable to history of IDU. Younger age of first incarceration associated with HCV
• Tattooing, piercing, snorting drugs, and being cut or assaulted were not independently associated with HCV
• Among those with no history of IDU, HCV infection was associated with a longer history of incarceration and history of blood transfusion or receipt of blood products during surgery or organ transplantation.

The implications of this study:

• Health education programs provided to prison populations should include HCV prevention education and specifically target juveniles, first-time offenders, and/or first-time drug offenders
• Prevention programs should focus on risk reduction both within correctional institutions and to community members upon release
• History of incarceration should be considered as an indication of HCV screening
• Screening and management of HCV may need to be addressed during incarceration

Editor’s Note: There was the potential for bias in this study because of the small sample size, participants were volunteers and for fear of disclosure in a prison setting by participating in the study.