As Hepatitis C Goes Rural, Public Health and Medicine Strain to Adapt

Until several years ago, hepatitis C virus (HCV) infections were on the decline in the U.S. But between 2006 and 2012, rates more than tripled across Kentucky, Tennessee, West Virginia and Virginia, according to the U.S. Centers for Disease Control and Prevention (CDC). A surge in heroin and injectable opioid drug use across the country -- particularly in rural Appalachia, the Midwest and the Northeast -- has been associated with the increase in HCV cases.

HCV infection "is the most common chronic blood borne infection in the United States [and] approximately 3.2 million persons are chronically infected," according to the CDC. More Americans now die from HCV complications than HIV, according to a 2012 report from the CDC.

HCV infection can remain asymptomatic for years or even decades. Advanced stages can cause cirrhosis, liver cancer and ultimately lead to the need for a liver transplant. Injection drug use is the most common risk factor for infection. Until recently, HCV infections disproportionately impacted people of color, the incarcerated, urban residents and older populations.

HCV infections rose 364% during those six years in the four central Appalachian states, with nearly half of the new cases in people under 30 years old.

"Seventy three percent of the new infections cited injection drug use as the primary risk factor," the report noted. The cases were almost evenly split among men and women, but almost 80% of the new infections were among whites.

"We are probably just seeing the tip of the iceberg," said Daniel Raymond, policy director for the New York City-based Harm Reduction Coalition. "This also demonstrates weaknesses in our rural public health care infrastructure."

When nearly 150 new HIV infections were reported in a rural region in Scott County in Southern Indiana in a matter of months, a flurry of media stories shone a spotlight on rural injection drug use. Less reported was the reality that many were also coinfected with HCV.

HCV and HIV coinfection is a significant challenge among people living with HIV in the U.S. About 25% of the estimated 1.2 million people living with HIV in the U.S. are coinfected.

In fact, HIV prevalence remains relatively low among younger people who inject drugs in Appalachia. But the increase in HCV infection "raises concerns about the potential for an increase in HIV infections because [injection drug use] is a risk factor for both HCV and HIV infection," the CDC reported. Syringe exchange, which has been an important component of reducing HIV and HCV rates in some areas, is very rare or inaccessible in most rural areas, though it has now been initiated in Scott County.

Kentucky: Finding Solutions to High HCV Rates

Kentucky leads the nation with 4.1 HCV cases per 100,000 residents, according to the CDC. The national average is 0.6 people per 100,000. The epicenter of the state's epidemic is Northern Kentucky with 13 cases per 100,000 people, according to the Northern Kentucky Health Department. The region has become "the state's epicenter for heroin, straining legal and medical systems and bringing deadly consequences that are starting to spill out to the rest of the state," the Cincinnati Enquirer reported in March 2013.

"At the same time we are seeing an increase in [rural] hepatitis C infections we are also seeing an increase to admissions into substance abuse programs," said Kraig E. Humbaugh, M.D., M.P.H., the Kentucky Department of Public Health's director of epidemiology and public health. "That's why it's really important to bring people in for testing and linked to care and medical management. We can do that now because Kentucky has expanded Medicaid. We also have our own health benefit exchange so there are more options to choose from for an affordable and qualified health plan. There are more options than ever for people to get more [HCV] testing."

Kentucky is one of 30 states and the District of Columbia that has expanded Medicaid eligibility as a result of the Affordable Care Act (ACA). Of the four Appalachian states cited by the CDC for substantial HCV increases, only Kentucky and West Virginia have opted into the program. Tennessee and Virginia did not.

Kentucky has enrolled about 500,000 people in Medicaid and private health plans through the ACA. Health care reform has also been accompanied by an increase in substance abuse treatment centers and providers, community mental health centers, as well as local grants for hepatitis testing, surveillance and management, said Humbaugh.

Kentucky's expansion of Medicaid has been "critical in treating its HCV and injection drug use epidemics," said Raymond. "If you're finding people with HIV, hepatitis or in need of drug treatment, but can't link them to care and get reimbursed, you are still pushing the problem farther downstream."

The standard treatment for HCV infections usually lasted almost one year. The regimen included weekly injections of interferon. Many people could not tolerate the side effects and were forced to interrupt treatment, which allowed the infection to progress. A new class of antiviral medications has revolutionized treatment, but at substantial cost. Gilead's Sovaldi -- the brand name for sofosbuvir -- which was approved by the U.S. Food and Drug Administration in 2013, has demonstrated a higher cure rate, fewer side effects and a drastically reduced duration for therapy. The price for the 12-week course is about $84,000 or about $1,000 per pill. "The sudden huge increase in spending on Sovaldi has strained the budgets of health plans, state Medicaid programs and prison systems," The New York Times reported in February.

Kentucky spent about $50 million for Sovaldi in 2014, according to officials. That was for about 1,000 HCV cases.

"The economics are aligned against early detection and treatment for young people," said Raymond. "Many payers say they will only treat people with advanced liver disease. But what if you are one of these young people living in a rural area and just learned you have an HCV infection? You won't be eligible for the new treatment."

Telemedicine for Hepatitis C

People living with HCV infections in rural areas traditionally had to travel to larger communities for treatment. However, telemedicine has emerged as a low-cost and effective treatment strategy to manage rural HCV infections.

Treating rural HCV infections via videoconferencing technology began in New Mexico about a decade ago with Project ECHO. Rural primary care providers are trained in weekly videoconferences to manage HCV infections. The results have been impressive: A study reported in the New England Journal of Medicine in 2011 found that rural primary care clinicians -- who were not hepatitis specialists -- "achieved slightly better cure rates and their patients had fewer serious adverse events" than those treated by specialists.

The treatment strategy has been replicated in Arizona and Washington state. The University of Oklahoma Health Sciences Center was awarded almost $500,000 by the federal government last fall to help primary care physicians in 11 "remote rural communities treat patients with the hepatitis C virus and prevent future cases." Kentucky and West Virginia, among other states, are also investing in telemedicine to treat HCV.

"It's a very promising strategy," said Raymond. The increase in rural HCV cases means that "more people are looking to scale up outside urban settings."

Rod McCullom has written and produced for ABC News and NBC, Scientific American_,_ The Atlantic_,_ The Nation_,_ Ebony_,_ Poz and many others. He will become a Knight Science Journalism Fellow at the Massachusetts Institute of Technology later this summer.