New analysis has confirmed that LGBT youth are far more likely to attempt suicide than other adolescents their age.
A report in JAMA Pediatrics collated data from 35 other studies. The studies included responses from 2.4 million heterosexual adolescents and 113,468 non-straight students aged between 12 and 20 from 10 countries.
Researchers told Thomson Reuters Foundation that LGBT youth struggle to come to terms with sexual and/or gender identity because of social stigma.
‘Adolescents facing “non-conventional” sexual identity are at risk of higher self-threatening behaviors, independent of bullying and other risk factors,’ said the study’s lead author, Dr. Ester di Giacomo from the University of Milano-Bicocca.
‘I think that a difficulty in self-acceptance and social stigmatization might be keys for understanding such elevation in the risk of self-threatening behaviors.’
Suicide was the second leading cause of death for all adolescents with the risks increased for LGBTI people.
This analysis helps get the ‘best estimates of the disparity of suicide risk due to sexual orientation’, according to Brian Mustanski.
He is the director of the Institute for Sexual and Gender Health and Well Being at Northwestern University’s Feinberg School of Medicine in Chicago.
Mutanski and his team researched LGBT youth for more than 10 years and welcomed the latest analysis.
‘We already knew (LGBT) teens were at risk, but this study gives a more precise estimate of that risk,’ he said.
But Mutanski stressed the importance of remembering not all LGBT youth are suicidal.
‘We read about this community being at risk, but there are plenty of LGBT teens who are happy and thriving and doing great,’ he said.
The National LGBT Cancer Network is the newest recipient of a $2.5 million five year award from Centers for Disease Control and Prevention to expand resources for their grantees serving LGBTQ people at risk for tobacco-related cancers.
“The LGBTQ communities smoke at rates significantly higher than other populations. That alone increases our cancer risks dramatically,” said Liz Margolies, the Executive Director of the National LGBT Cancer Network.
The Cancer Network’s new award will expand their NYC presence to Providence, RI, the base for their Principal Investigator, Dr. Scout. For more than a decade, Dr. Scout has led this CDC health priority at other agencies. He emphasizes that the next five years will bring a new vision for this work: “We are really looking to expand the online knowledgebase and toolbox for LGBTQ community members at risk for cancer, living with cancer, and policymakers serving us. Watch our website at www.cancer-network.org; each month we will be adding new resources, building a robust library of information and tools everyone can access.”
The CDC award leverages a trusted network of organizational members who specialize in tobacco-related cancers and/or serving LGBTQ people. The Cancer Network reports early membership commitments from a wide range of LGBTQ serving national organizations, including the Human Rights Campaign, the National LGBTQ Task Force, the Gay & Lesbian Medical Association, the Equality Federation, and more. Likewise, many states health departments and national health organizations have already signed on as members: American Cancer Society, The Truth Initiative, Association of State and Territorial Health Officers, and more. “The American Cancer Society has a longstanding commitment to addressing cancer in the LGBTQ communities. We are very excited about this new award and look forward to helping further reduce the cancer impact for this population,” said Tawana Thomas-Johnson, Vice President, Diversity and Inclusion at ACS.
Ms. Margolies added, “We are particularly excited to have members work with the state health departments, who collectively are the second largest health funder in the United States.”
The National LGBT Cancer Network works to improve the lives of LGBT cancer survivors and those at risk, through education, training, and advocacy. They recently created the most comprehensive LGBTQ cultural competency training program available, which has been used to train thousands people across the country to date. Learn more at www.cancer-network.org.
We don’t talk much about chlamydia, gonorrhea, or syphilis, in part because it can seem like they’re not big health issues anymore. But it turns out more and more Americans may be quietly suffering from these once nearly eliminated STDs.
According to a new report from the Centers for Disease Control and Prevention, there were nearly 2.3 million cases of chlamydia, gonorrhea, and syphilis reported in the United States in 2017 — the highest cumulative number ever recorded, and one that surpassed a 2016 record high.
The leap in cases over the last few years are truly eye-popping. Between 2013 and 2017, the rate of:
Gonorrhea increased by 67 percent to 555,608 cases
Syphilis increased by 76 percent to 30,644 cases
Chlamydia increased by 22 percent to 1.7 million cases
To appreciate just how astonishing the trends are, consider that as recently as a decade ago, these STDs were at historic lows or near elimination, with more and better screening and diagnostics to help identify cases and get people into treatment.
Syphilis can show up on the body in sores and rashes. Gonorrhea and chlamydia can lurk with no symptoms. They’re all generally easy to cure with a timely antibiotics prescription, but when left untreated, they can lead to infertility or life-threatening health complications. That’s what makes screening and access to health care so important.
The increase in cases between across all three diseases was significant, and represents changing disease dynamics.“We are sliding backward,” said Jonathan Mermin, director of CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, in a statement. “It is evident the systems that identify, treat, and ultimately prevent STDs are strained to near-breaking point.”
African Americans and men who have sex with men have traditionally been the populations most plagued by gonorrhea and syphilis (and they’re still disproportionately affected). But other groups are now catching up too, especially women and babies in contracting syphilis.
So what’s behind the spread of these diseases here? There’s no single explanation. Like most health trends, it’s complicated. But here are a few ideas, according to experts:
1) There’s been a rise in condomless sex among men who have sex with men: Gay, bisexual, and other men who have sex with men are generally more at risk for STDs than women and men who have sex with women only. (The majority of new syphilis and gonorrhea cases occurred among men, and in particular, men who have sex with men.) And there’s been some concern about a shift toward riskier sexual behaviors in this group — like not wearing condoms — that may be contributing to the rise in STDs.
The reason for this shift has been explained by everything from the success in treating HIV (and therefore making sex less scary) to the advent of PrEP (pills that can prevent HIV). A systematic review published in the journal Clinical Infectious Diseases found that some PrEP users are having more risky sex — and are being diagnosed with more sexually transmitted infections.
HIV and syphilis are also interlinked: Some half of men diagnosed with a new syphilis infection also have HIV. And as these diseases spread in particular populations, like men who have sex with men, there’s a greater risk of them moving even further.
“The fear, which I share, is that we won’t contain syphilis among men who have sex with men,” Matthew Golden, director of the Public Health for the Seattle and King County HIV/STD control program, told Vox in 2017. “And if the epidemic in men who have sex with men gets big enough, which is what is happening, there are enough people who have sex with both men and women that it won’t be possible to contain it.”
2) STDs are spreading more broadly and into populations that weren’t traditionally affected — like babies: A 2017 CDC report on STDs in America showed that more women are getting syphilis these days, and they’re passing it to their babies. When an expectant mother is infected with the disease, and goes undiagnosed and untreated, the bacteria can get into her bloodstream and move through her placenta to her baby. Congenital syphilis is associated with serious health consequences, like stillbirths and neonatal deaths.
In 2016, there were 628 cases of congenital syphilis, an increase of 27.6 percent from 2015 — and that number includes 41 related deaths. According to the CDC, much of the rise was driven by increases in cases in the Western US. Between 2012 and 2016, Western states saw an astounding 366 percent rise in congenital syphilis.
The large increase has to do, in part, with the fact that many Western states have recently had few syphilis cases in women. “We were starting from almost nothing [in Washington],” said Golden. But that’s changing, and with more women getting the disease, their babies are at risk too.
3) With the rise of dating apps, sex is more readily available and more anonymous — and that makes it harder for health investigators to track outbreaks: Health experts increasingly view apps and sites such as Tinder, Grindr, and OkCupid as enablers of high-risk sex, helping people meet and hook up more efficiently than ever before. The impact of these sites is so profound they are also transforming the way health officials track and prevent outbreaks.
“We used to think about what we can do with bathhouses and sex clubs to make sure people’s risk was reduced,” said Dan Wohlfeiler, director of Building Healthy Online Communities, a public health group that works with apps to support STI prevention, told Vox in 2017. These places, after all, had become important meeting points for men who have sex with men — the group most affected by the HIV epidemic.
Today, the public health focus has shifted to “digital bathhouses.” Wohlfeiler said, “Now that dating sites and apps have become so common, we know we need to work with them.”
But many of the major dating networks don’t want to be involved in STD prevention, nor have they acknowledged the impact they’re having on public health, health experts told Vox.
4) The numbers may be higher because we may be better at detecting cases in some groups: The rise in chlamydia — which overwhelmingly causes no symptoms but can lead to infertility in women — may be an artifact of better detection and screening. The CDC keeps finding that rates of chlamydia are highest among young women, the group that’s been targeted for routine chlamydia screening. So an increase could just mean more testing.
5) Cuts to public health funding mean fewer STD clinics: Public health in the US — which includes operating STD clinics where people can get tested and into treatment — is historically underfunded. (As of 2012, only 3 percent of the health budget went to public health measures; the rest went mostly to personal health care.) And since the global financial crisis, public health funding has really taken a battering. There are 50,000 fewer public health jobs since 2008, and many STD clinics have had to reduce their hours or shut down.
STD clinics were a traditional safety net for people with these diseases. If those clinics continue to be harder to reach or vanish, finding and treating STDs will become even more difficult — and the diseases will continue to spread.
So in some ways, the STD increases across the country may have less to do with a changing sexual landscape, and more to do with more limited access to sexual health care. With Trump’s proposed public health budget cuts, the problem may be poised to get worse.
“It’s not a coincidence STDs are skyrocketing — state and local STD programs are working with effectively half the budget they had in the early 2000s,” said David Harvey, executive director of the National Coalition of STD Directors, in a statement today. “If our representatives are serious about protecting American lives, they will provide adequate funding to address this crisis. Right now, our STD prevention engine is running on fumes.”
The LGBT Foundation said there has been a recent rise in cases of shigella among men who have sex with men.
Shigellosis, or shigella, is an intestinal infection caused when bacteria found in poo gets into your mouth.
Last month, health officials in San Diego issued an advisory over the sexual transmitted infection. It said that gay and bisexual men, homeless individuals, and people with compromised immune systems could be at an increased risk for the intestinal disease.
In 2017, San Diego recorded the highest number of cases in 20 years, including a disproportional increase in the gay and bisexual community and among the homeless population.
How do you get it?
Shigella can be caught from rimming, oral sex, or putting your fingers in your mouth after handling used condoms, douches or sex toys, the LGBT Foundation says.
Signs of infection include having an upset stomach, fever, stomach ache, and diarrhoea which might have blood in it.
These symptoms can last for around a week. Shigella is closely related to the E.coli bacteria.
Disease and infections magazine outbreaknewstoday.com reported that the number of cases typically increases in the late summer and fall.
How to lower risk of shigella infection
The LGBT Foundation says you can lower your risk of infection by washing your hands, bum and genitals after sex.
You could also use dental dams, condoms, and fisting gloves to protect you when having oral sex, fisting, and fingering.
It is also recommended that you change condoms between partners, and between anal and oral sex, whether they’re on a penis, hands, or sex toys.
Hygiene as prevention: Wash often and don’t re-use condoms. Photo: Mark Johnson
Shigella is treated with a course of antibiotics, the Foundation says. However, the US Centers for Disease Control and Prevention warned last month of an increasing number of antibiotic-resistant shigella infections.
If you think you have shigella, go to a sexual health (GUM) clinic or your GP and explain your symptoms. You may also want to say that you think you may have picked up an infection from sex.
A new report by Human Rights Watch (HRW) has revealed the state of accessing healthcare for LGBT people in the United States.
The research indicates that queer and trans populations encounter significant barriers, including facing discrimination from insurers or providers and long waiting lists for specialist services.
Additionally, the report found that LGBT people have restricted options when facing prejudice as there isn’t federal legislation which prohibits healthcare discrimination based on sexual orientation or gender identity.The majority of the 81 interviewees told HRW that they had little or no access to LGBT-friendly healthcare providers in their area.
The head of one community center in rural Michigan said: “I do not know of any trans-affirming healthcare providers in the area. And I’ve talked to many trans people in the area.”
Some interviewees described driving two hours to attend a support group for gender-expansive youth, and others travelling two hours to attend therapy or meet with a trans-affirming doctor.
Other findings revealed some interviewees knew of very few providers in their areas who would prescribe PrEP, a medication that significantly lowers the risk of HIV infection by preventing HIV from taking hold in the body.
A psychologist in Knoxville, Tennessee, explained: “There are only two providers who’ll prescribe it—in a community this large. And the doctor we like, we overload him—we’re like, you have one option, and if you don’t have insurance, you’re pooched, because he’s expensive.”
While in Memphis, Tennessee, a healthcare provider similarly said that, in a city of a million people, the hospital they worked with was aware of three doctors who would handle PrEP referrals.
The report also highlighted struggles for same-sex couples looking for reproductive health providers.
A lesbian woman in Mississippi recalled that, when she and her wife sought a fertility doctor in 2012, they were unable to find options in their area and contacted a clinic in Alabama. When that clinic informed the couple that they only treated heterosexual, married couples, they did not find an LGBT-friendly provider for a year.
The report primarily focused on LGBT people living in Mississippi and Tennessee, two of the states where statewide antidiscrimination protections do not prohibit discrimination based on sexual orientation and gender identity and where lawmakers have recently enacted exemptions permitting some providers to refuse service to LGBT people because of their religious or moral beliefs.
A new study has suggested that the legalisation of same-sex marriage in the US has improved the health of gay men.
The latest research – by professors at Vanderbilt University – found that equal marriage had led to increased health insurance coverage and better access to health care for men living in same-sex households.
The study revealed that gay marriage “increased the probability” of a man in a same-sex household having health insurance by 4 percent.
These men, it found, since equal marriage became law in the US, were 4 percent more likely to have a “usual source” of healthcare, and 7 percent more likely to have had a health check-up in the past year.The new research, distributed by the National Bureau of Economic Research, did not ask respondents about their sexual orientation – but instead researchers calculated an estimate for number the number of gay or bisexual men and women living in same-sex households with one other adult.
They found that one in ten women and four in 10 men in these same-sex households were not likely to be heterosexual.
The academics then looked at the changes in health insurance and and healthcare for these people, following the legalisation of equal marriage in the US in June 2015.
Still, the results did not find that the impact of gay marriage was notable for women. Researchers pointed to deficiencies in their statistics as an explanation for this.
They said that women were more likely than men to have children from previous relationships – making them more likely to travel to another state where same-sex marriage was legal, before it became law in all the US states.
The researchers said their data did not record this prior residences or the location of same-sex marriages.
However, researchers pointed to previous studies that concluded that the legalisation of equal marriage had had a positive impact on the health of lesbian and bisexual women.
For both men and women in same-sex households, the new study revealed that gay marriage did not affect the rates of substance use and preventative health care.
The findings support the the results from previous research into the impact of equal marriage on gay couples.
In 2012, another study in Massachusetts, focusing on gay and bisexual men in same-sex marriages, revealed that same-sex marriage decreased their need to visit the doctor, and resulted in lower health-care costs.
Pierre-Cédric Crouch, nursing director of the sexual health clinic Magnet at San Francisco AIDS Foundation, said that this method “has some promise,” but that it’s definitely not a perfect solution and that more research is needed on the effectiveness of STI prophylaxis before it can be recommended.
Pierre-Cédric Crouch, PhD, ANP-BC
“Syphilis can cause a lot of harm and anything to help reduce the increasing rates would be helpful,” he said. “We don’t know the impact this would have on drug resistance and I would be concerned people would get complacent and not get tested for STIs as often. Gonorrhea is not covered by this strategy so it’s definitely not perfect. If someone came in to the clinic asking for it, I would counsel that this is still being studied and we would need more data before STI PEP [post-exposure prophylaxis] can be recommended.”
Jared Baeten, MD, PhD, director of the Center for AIDS Research at the University of Washington shared a similar view. “I absolutely would at least consider prescribing now, but I’d love to see some strong science to help me know if I should set aside my reasons to give pause. There isn’t a perfectly right answer right now.”
Keith Henry, MD, from Hennepin County Medical Center shared a more conservative view. “I don’t think prophylactic doxycycline is ready for prime time. Regularly testing for all STDs every three months and treatment for STDs diagnosed is my recommendation for sexually active men [who do not use condoms].”
Jeffrey Klausner, MD, MPH, who has conducted research on STI prevention with doxycycline, views this strategy as appropriate on a case-by-case basis.
Jeffrey Klausner, MD, MPH
“I have a few patients who are using doxycycline in addition to PrEP,” he said. “On an individual level, this method of STI prevention might be right for someone, for instance, who has had syphilis twice, and doesn’t want to get it again,” said Klausner.
For people interested in this method of STI prevention, Klausner said he encourages people to talk to their health care providers. “I’ve talked about this with other providers in urban areas,” said Klausner. “Doctors understand there is a role for this, and see it as an opportunity for select patients.”
What are the pros and cons?
Baeten counted four reasons to consider prescribing doxycycline to someone at high risk of STIs (e.g., a person with a history of STIs and frequent condomless sex). Namely, that STI rates are on the rise among men who have sex with men in the U.S. (with rates as high as 25-50% each year among people taking PrEP in research studies); evidence that doxycycline prophylaxis works to prevent chlamydia and syphilis; the opportunity to synergistically deliver STI prevention with PrEP; and, the fact that—other than condoms—there are not many effective ways to prevent STIs.
“If you’re a sexually active—if you have multiple partners in a given week, if you’re in a situation where you enjoy group sex, if you visit sex clubs, this could be a real solution for you,” said Klausner. “Obviously, it should be used in addition to condoms, but condoms don’t work for some people for various reasons.”
Baeten also counted four “reasons to pause” in using antibiotics to try to prevent STIs. First, he said that “it isn’t totally clear if prophylaxis is that much more beneficial than frequent screening and treatment.” It would be a waste of resources to prophylactically treat everyone for STIs, if increased screening and treatment are as effective in curbing new infections. Pill fatigue is another concern, as is drug resistance.
Jared Baeten, MD (Photo: Liz Highleyman)
“There’s legitimate concern that regular use of an antibiotic can result in resistance developing to that antibiotic—in this case, resistance to doxycycline and related antibiotics, for STI organisms and potentially for other bacteria that live naturally in our bodies and occasionally cause disease. The type of bacteria that causes gonorrhea already is often resistant to many antibiotics, including doxycycline, when it once was not, for example,” said Baeten.
“Everyone raises concerns about drug resistance,” said Klausner. “In some ways it’s a non-conversation when you talk about gonorrhea because we haven’t used tetracycline or doxycycline to treat gonorrhea since the mid-1980s, and it’s already resistant. The amount of tetracyclines that would be introduced by the increasing use of this practice and into the whole population—who already exposed to massive amounts of tetracyclines in the food industry, human health, acne treatments, malaria prophylaxis—is actually miniscule. I don’t think it would have a substantial impact.”
The research on STI chemoprophylaxis
Two studies with men who have sex with men have evaluated the efficacy of doxycycline to prevent sexually transmitted infections.
The first study, published in Sexually Transmitted Diseases by R. K. Bolan and colleagues, found that HIV-positive men who have sex with men who took 100 mg of doxycycline daily reduced the risk of contracting syphilis, chlamydia or gonorrhea during the study by 70%.
A total of 30 men were randomized to either take the antibiotic for 36 weeks or not. At each study visit (at baseline, 12-, 24-, 36- and 48-weeks post-baseline) participants received rectal and urine gonorrhea and chlamydia tests, a pharyngeal (throat) gonorrhea test, and a syphilis blood test.
During the study, there were 15 cases of any STI (gonorrhea, chlamydia and syphilis) among men not taking the antibiotic, compared to six cases of STIs among men taking doxycycline. This translated into a risk reduction of 70%.
The second study, published in Lancet Infectious Diseases, tested whether doxycycline prevented STIs in HIV-negative MSM taking PrEP. In this study, 232 participants were randomized to take 200 mg of doxycycline “on demand” (within 72 hours of having sex), or to not take an antibiotic.
A total of 73 participants presented with a new STI during the study period, 45 in the no-antibiotic group and 28 who were taking doxycycline. This translated into a risk reduction of 47%, with the antibiotic significantly reducing the number of chlamydia and syphilis infections (but having no effect on the number of gonorrhea infections).
Overall, the clinicians who shared their thoughts with BETA recognized the potential benefits—to individuals and on a population level—of allowing people to take doxycycline preventatively to treat STIs, but were acutely aware of the issues raised by this approach as well.
Although STI prophylaxis is not (and may not ever be) a strategy that health care providers recommend for people to reduce their risk of STIs, there are a number of things you can do if you’re concerned about STIs.
What comes to mind when you hear the term “harm reduction”? Many people in public health or in the community may think of needle exchanges or safer sex practices. PrEP can be a form of harm reduction, since it can allow you to enjoy the sex you want to have while at the same time reducing the harms that can come from condomless sex.
I probably don’t have to tell you that smoking tobacco causes many kinds of cancers and health problems. Interestingly, it’s the tobacco—and not nicotine—that is the source of those health concerns. Which means that other forms of nicotine-delivery agents, like vaping products and e-cigarettes, can be better for your health (harm reduction!) if they’re used instead of cigarettes.
What do e-cigarettes have to do with public health?
E-cigarettes are battery-operated devices that deliver nicotine to users in heated liquid vapors instead of smoke. After hitting the market in 2006, they became quite popular among consumers because they satisfy nicotine cravings without delivering the toxic carcinogens and combustibles found in tobacco that are known to cause so much damage. Although e-cigarettes are not completely harmless (there have been cases of burns and poisonings), there is no tobacco in vaping products.
We can think of vaping as a form of harm reduction—a practical public health philosophy that, at its heart, empowers people to reduce potential harms from sex, drugs or other substances without requiring abstinence. Vaping gives people the drug—nicotine—without the carcinogens and tobacco found in cigarettes.
For the same reasons that we encourage people who inject drugs to use sterile needles and other clean injection equipment—and provide people with those supplies freely—we can recognize that people may want the option to use vaping products to quit or reduce harm from nicotine addiction.
The problem I have with San Francisco’s Proposition E
On June 5, 2018, voters in San Francisco will vote on Proposition E which stands to ban the sale of flavored tobacco products, including products like menthol cigarettes and cigarillos, as a strategy to prevent “Big Tobacco” from appealing to children and hooking new users.
To be clear, I’m not against policy changes that may prevent people from starting to smoke or help people reduce the amount they smoke. I’m well aware of the devastating impact that tobacco is having on my community. But there’s a stunning flaw in this proposed ordinance that compels me to speak out against it: The ordinance lumps in e-cigarettes as a flavored tobacco product that would be forbidden from sale.
Proponents of the ordinance argue that tobacco companies have unfairly targeted LGBTQ adults, communities of color and children with flavored products. They say that children must be protected from the dangers of smoking. They want to stop new people from starting to smoke. Yes, I agree! But are there ways to do this without blocking a method of harm reduction from people who already smoke?
I take issue with denying adults, who already consume nicotine, the opportunity to use harm-reduction tools to do so.
Let’s be real. Quitting smoking cigarettes is DIFFICULT. Only about 6% of adults can successfully quit smoking, although about 70% report wanting to quit. The drug in cigarettes, nicotine, is highly addictive. For those people who are using electronic cigarettes as an alternative to smoking—what happens if the product is taken off the shelf?
San Francisco can proudly call itself a leader in providing harm reduction tools for its communities. Volunteer groups in the late 1980s were one of the nation’s first to successfully use needle exchange programs to prevent HIV. More recently, the city’s Getting to Zero consortium has committed to being the first to reach zero new HIV infections, with PrEP and treatment as prevention being critical strategies to reach this goal. These groundbreaking approaches share the common approach of harm reduction—meeting adults where they are to offer interventions that improve health and quality of life. The proposed ordinance runs counter to these harm reduction approaches.
E-cigarettes do need to be regulated and prevented from getting into the hands of children, but banning all flavored vaping products for adults just doesn’t make sense. It is quite possible to prevent nicotine addiction in children and help adults stay alive at the same time. I ask people to use science, logic, and compassion when going to the polls on June 5th.
The opinions expressed in this article are those of the author alone. They do not reflect the opinions or positions of BETA or of San Francisco AIDS Foundation. BETA serves as a resource on new developments in HIV prevention and treatment, strategies for living well with HIV, and gay men’s health issues. Our goal is to inform, empower, and inspire conversation.
“We recently expanded our hepatitis C treatment program to the 6th Street Harm Reduction Center, which primarily serve people who are homeless or marginally housed, and who use substances including injection drugs,” said Pierre-Cedric Crouch, PhD, ANP-BC, nursing director of San Francisco AIDS Foundation.
“We are one of the only centers in the U.S. who are prioritizing people who use substances in hepatitis C treatment work. We’re proving that this approach works and that it’s helping the right people who need access to hepatitis C medications.”
“If we want to make a dent in this epidemic, you have to treat people who are actively injecting drugs,” said Annie Luetkemeyer, MD, from University of California San Francisco, at a recent HIV grand rounds at San Francisco General Hospital. “If you want to avoid new cases, you’re going to double the reduction in hepatitis C cases averted if you treat PWID [people who inject drugs] as opposed to just focusing on non-PWID.”
With these comments, Luetkemeyer addressed the resistance that some providers may have about treating people who are at risk for re-infection (through injection drug use) or who have difficult lives that may stand in the way of adherence (for instance, because they are homeless).
Erica*, a 22-year old from San Francisco, is one person who has been cured of hepatitis C through the San Francisco AIDS Foundation program at the 6th Street Harm Reduction Center.
“It was like I had the whole healthcare system behind me—all I had to do was show up to my appointments. Nobody judged me when I relapsed. I was still able to take the meds. Sometimes you relapse, but you still want to be cured of hep C. I think that’s very important that you can still be using and still get the meds,” she said.
There are likely three to four million people in the U.S. living with chronic hepatitis C, with about 34,000 new hepatitis C infections occurring every year. Hepatitis C kills more people in the U.S. than any other infectious disease that is reported to the CDC (including HIV). In 2015, nearly 20,000 people dying from hepatitis C-related causes. Most people living with hepatitis C have been infected through injection drug use (this blood-borne virus can live in needles and syringes but also on other equipment like drug cookers and filters).
In San Francisco, the End Hep C SF initiative estimates that there are 12,000 people with active hepatitis C virus in their bodies. These are people who are able to transmit hepatitis C to other people and who would benefit from treatment.
End Hep C SF recommends that you talk to your medical provider about testing for hepatitis C (HCV) if you have ever injected drugs, are a man who has sex with men, are a trans woman, or were born between 1945 – 1965.
What keeps people who use drugs from getting cured of hepatitis C?
Katie Burk, MPH, viral hepatitis coordinator for the San Francisco Department of Public Health, said that there are a variety of factors that can stand in the way of people accessing hepatitis C treatment.
People who have unstable lives—because of substance use but also from things like homelessness—can make accessing any kind of medical care seem out of reach.
“If you don’t have the basic necessities of life secured, it’s hard to take on any new goal or health intervention,” said Burk. “If you’re homeless, it’s difficult to make appointments or hold on to medications. It’s difficult to work on any goal besides your immediate survival, because you’re just figuring out where to eat and a place to sleep.”
On top of that, health systems barriers may prevent people who want to access treatment from actually being able to do so.
“Our systems aren’t really designed to accommodate the needs of people who need our services the most,” said Burk. “There are all these bureaucratic and logistical barriers inherent in traditional medical care. Maybe somebody is ready to see a doctor, but they can’t get an appointment for a couple of weeks. If folks are actually ready to take medication, they might have to go through a lot of time-consuming hoops in order to get them. Re-establishing insurance in a particular setting can be difficult for people who may be homeless and moving frequently from county to county.”
Burk also said that people who use substances oftentimes have “tenuous relationships” with the medical system. If people have been mistreated, stigmatized or dismissed by medical providers it he past, they may be less willing to seek treatment for hepatitis C even if it is available to them.
How can we make hepatitis C treatment accessible to people who use drugs?
Innovative programs in San Francisco are finding ways to bridge the gap between people who use substance and hepatitis C treatment—making cure regimens more accessible than ever before. Meeting people where they already are is one strategy being used to reach more people with medications and care.
“There are so many people who we would love to go to primary care, but it’s just not going to happen right now,” said Burk. “They won’t or can’t go consistently. But there are places in our system where they may be meaningfully engaged. It might not be where hepatitis C treatment has traditionally been offered, but if we can bring treatment to those places, then we have opportunities to treat folks where they’re already showing up. In San Francisco we’re developing treatment models in drug treatment programs, syringe access programs, sexual health clinics, and homeless shelters to meet these needs.”
With the right support, people living with hepatitis C who still use substances and who may also be experiencing homelessness do well in hepatitis C cure programs.
Although re-infection is a risk for people who use IV drugs, the rate of reinfection is relatively low (between 1 – 2%), and worry over re-infection shouldn’t prevent people from being able to access hepatitis C medications, said Luetkemeyer.
At San Francisco AIDS Foundation, 24 people have started hepatitis C medication through the Hepatitis C Wellness Program, with 11 people who have completed treatment. The program, which began in July 2017, enrolls clients at the 6th Street Harm Reduction Center, which serves high-needs clients accessing harm reduction and safer drug use supplies.
“Everyone who has reached week four has been fully suppressed, which shows that the program is working well,” said Crouch. “Many people we see are homeless and out of medical care. We’re treating people who would never get treated for hepatitis C otherwise. There are a very small number of people doing hepatitis C cure programs at syringe access sites, but this is absolutely the right place to meet people who need access to treatment.”
In addition to access to hepatitis C medications, people enrolled in the program meet once a week with Pauli Gray, hepatitis C program coordinator for San Francisco AIDS Foundation, to share breakfast and health and wellness information. On-site lockers are available to hold people’s medications, to eliminate the risk that people’s medications get stolen or lost.
Gray said that in addition to being cured of hepatitis C, clients have used the meetings to work on other goals related to health and well-being.
“I set a goal with each client early in the process, and stay in constant touch with them. Almost everyone makes a goal and meets it. We’ve seen people who have already been able to do things like find housing, stop or reduce their substance use, and re-connect with their children. Getting cured changes the trajectories of people’s lives. The efficacy of it is amazing. It shows them that life can be different. They feel so much better—usually very quickly—and get excited at being able to do things they couldn’t before,” said Gray.
“Pauli told me that he would help me do everything,” said Erica. “He made appointments for me, he told me when to show up. He made it so easy for me. At the beginning, I was in [drug] treatment, so it was really easy for me to get to my appointments. At the end, I started relapsing, but Pauli went out of his way to make sure I was still taking my meds.”
Erica found out she had hepatitis C when she was 18, and undergoing chemotherapy for uterine cancer. She contracted HCV from IV drug use with her then-boyfriend, who didn’t reveal to Erica that he had HCV.
“I was living in Sacramento at the time, and tried to get into treatment. But I wasn’t ready,” she said.
So Erica moved back to San Francisco, and spent two years without housing—living in a tent under an overpass. She quit heroin to finish chemotherapy, and then relapsed when her cancer treatment ended.
She connected with Gray at the 6th Street Harm Reduction Center when she was accessing safer drug use supplies, and sought help for an abusive relationship.
“He didn’t pressure me with the hepatitis C treatment right away,” she said. “He was just like, ‘let’s get you safe and stable, and then we’ll go from there.’ Pauli helped me reconnect with my mom, and he also helped get me into [drug] treatment.”
About a year ago, Erica decided she was ready to pursue hepatitis C treatment.
Gray set up the medical appointments, helped her access the three-month course of treatment for free, and checked in on Erica daily. When Erica started using again, Gray continued to check in on her and make sure she continued to take her medication. Erica attended the weekly support groups at the 6th Street Harm Reduction Center, and received individual counseling and support as well.
In July, Erica finished the course of medication, and found out that she was cured of HCV.
“I noticed that I have way more energy now. For [the medication] to be free, that was huge. I’m so young. I was so worried that this would affect my long-term health. So for me to have it treated so quickly was amazing.”
The 6th Street Harm Reduction Center offers syringe access and disposal, overdose prevention and naloxone, counseling, suboxone treatment, walk-in medical care, hepatitis C treatment. Visit Monday – Friday, 9 am – 5 pm, and Saturdays 7 pm – 11 pm at 117 6th Street at Mission Street in San Francisco.