Understanding Hepatitis C Among Young Adults: Training for Outreach Workers

1. Understanding Hepatitis C Among Young Adults

2. Staff Casey Rudd Edward E. Rudd John Olson Founder/Director Outreach Supervisor Outreach worker Connections 1195 Stone Ridge Dr. #3 Bozeman, MT 59718 (406) 556 – 1139 www.mtconnections.org

3. Who We Are • Non Profit 501c3 • Prisoner Advocates • Harm Reduction Specialists • Hepatitis C Educators • Street Outreach Workers (ORW)

4. This Training • Why this population, what are the issues in this population, and how can we intervene. • What are the benefits and barriers to reaching high risk youth. • Program in MT called Taking It To The System that promotes collaboration. • Talk about outreach program in MT and how it works.

5. Learning Objectives • Describe the scope of HCV infection in young adult IDU • Identify the specific issues and risks related to HCV infection in young adult IDU • List types of interventions that can address HCV prevention and care among young adult IDU

6. Background on HCV and IDUs • HCV infection is a serious and common blood borne viral infection for which there are no current vaccines and limited prevention. • HCV is highly infectious and easily transmitted • HCV infection occurs mostly among active IDU • HCV is the leading cause of liver transplants in the United States

7. Epidemiology • Globally - 130 -170 million HCV- infected - 10 million due to IDU - 350,000 deaths per year from HCV-related liver disease

8. Epidemiology • United States - 4 million estimated by the National Institute of Health but many researchers believe the true number is higher than 5 million HCV-infected - Most due to IDU - 12,000 deaths per year from HCV-related liver disease

9. Injection Drug Use and HCV • Highly efficient 1.) Can be spread through drug paraphernalia, not just needles and syringes but cottons, cookers, water, straws and glass pipes 2.) 37% of HCV infections among young injectors are due to sharing drug preparation equipment • Highly infectious For every one person with HIV there are four with Hep C in this country.

10. Why Young Adult IDUs? • Narrow window of opportunity for prevention Ages 17-24 within 6 months of first injection 50 to 80% are HCV infected (NIDA) National Institute of Drug Abuse - Community Bulletin • Increased reports of HCV among young IDU • Prescription drug misuse • Internet

11. Young Adult IDU HCV Risk Factors • Age - Younger age is an important risk factor for HCV, young IDU report frequent needle sharing and a lot of sexual risk behaviors including unprotected sex, and multiple sex partners • Social and Economic Risk - Often homeless runaways, frequently involved in the illegal street economy: • Prostitution Drug sales • Theft and selling stolen property Panhandling

12. Young Adult IDU and HCV Risk • Trauma - Street youth sometimes experience a large number of negative and traumatic events prior to leaving home • Intergenerational drug abuse • Forced institutionalization • Sexual abuse

13. Young Adult IDU and HCV Risk • Victimization Many are physically or sexually victimized after leaving home, contributing further to common psychiatric disorders such as: Depression Post-traumatic stress disorder (PTSD)

14. Young Adult IDU and HCV Risk • Lack of opportunity - Limited education - High levels of unemployment - Incarceration adds to these already complicated circumstances

15. Young Adult IDU and HCV Risk • Disenfranchisement - Fear and mistrust of public authorities keeps them from accessing services - Results in very high risk of blood borne viral infections and other drug related harms

16. Barriers to Prevention and Care • Lack of knowledge • Highly mobile population • Mental illness • Risk in relationships • Substance use

17. Overcoming Lack of Knowledge • Individual and group education • HCV trainings for provider and front line workers at agencies • HIV and Hep C testing and Counseling

18. Overcoming Highly Mobile Population • Consistency - Open all year round • Web presence - Maintain a web presence through email and social networking • Provide interstate referrals

19. Overcoming Mental Illness • Emergency support • Referrals • Staff education and training • Staff safety • Post-day/week staff meeting for decompression - Not administrative stuff

20. Overcoming substance Use • Provide drug preparation equipment • Risk behavior education • Overdose prevention • Individual counseling • HIV and Hep C Testing and Counseling • Referrals

21. What is in the “Tool Box” forHCV Prevention for IDU • Before exposure - Risk behavior education - Drug treatment - Reducing transmission from positive partners (HIV and HCV) - Preventive vaccines - Counseling and testing

22. What is in the “Tool Box” for HCV Prevention for IDU • Point of transmission - Change in injecting behavior (not sharing) - Clean injecting equipment • Clean needles - Safe injecting rooms • EDUCATION, EDUCATION EDUCATION

23. What is in the “Tool Box” forHCV Prevention for IDU • After exposure - Counseling and testing - Reducing risk behaviors 1.) Treatment 2.) Alternative medicine and options

24. Harm Reduction 101 Principles of HR Harm reduction is a set of practical actions that reduce negative consequences of drug use, to incorporating strategies from safer use, to managed use to abstinence. Any Positive Change • Meets drug users “where they are at” addressing conditions of use along with the use itself • Non-coercive; Non-judgmental • Presents risk reduction options • Participant chooses what is best for him/herself

25. Taking It To The System • Educate agencies on drug lifestyle and drugs in MT • Harm reduction 101 • Risk behaviors for Hepatitis C • Testing and counseling for clients • The goal ???? 1.) Lower stigma 2.) Find user friendly staff within agencies

26. Street Outreach In Montana. • Target population ?? Where ? • Peer educators • Educate Outreach Workers • Harm reduction approach • Supplies, referrals • Testing and counseling

27. Hepatitis C Stats For Montana

28. Hepatitis C In 2008, there were 943 cases of hepatitis C(chronic and acute) reported in Montana. The reported rate for American Indians was nearly 6 times higher than that for Whites (Figure 21). As was the case with other STDs, the number of cases reported with no race was substantial (30%) and may lead to underestimates of the disease burden for other races. • Hepatitis C Cases by Race, 2008 • The most common age group for newly reported hepatitis C cases was 45-54, which also represented the highest case rate (Figure 22). Of importance is the number of persons under 24 newly reported with hepatitis C as it indicates transmission occurring at a young age, most likely from injection drug use. • Hepatitis C Rates by Age Group, 2008 • Hepatitis C Rates by County, 2008 • Reported rates were higher for Glacier and Roosevelt counties than in other counties in 2008 (Figure 23). The overall rate for Montana was 97 cases/100,000 population in 2008. April 12

29. Risk Assessment • Lifestyle • Tattoo • Multiple body piercings • Shared razor, toothbrushes, nail clippers, scissors • Multiple sex partners • Inhaled drugs using rolled up bill or straw • Sharing glass pipes • Were in prison or jail • Unprotected sex with anyone who fits any of the above • Medical History • Blood transfusion prior to 1992 • Unexplained chronic fatigue • Diagnosis of HIV or Hep C • Hemodialysis • Family member with any of above Work History Military duty Health Care - doctors, nurses, dental workers, hospital cleaning services Emergency Services- police, firefighters, paramedics Prison Services- corrections officers, prisoners, prison cleaning services Institution Workers- nursing homes, elderly care, psychiatric hospitals, substance abuse centers, hospice Tattooists Beauticians, Barbers

30. IOM Recommendations The Institute of Medicine notes that multi-component, comprehensive risk reduction programs are likely to be the most successful, including: - Access to sterile syringes and drug preparation equipment through syringe exchange services - Expanded harm reduction programs directed toward young drug users - Entry to drug treatment for young IDU - Access to comprehensive services that include HCV testing and linkage to care -Institute of Medicine 2010