Approximately 3.5 million Americans are currently living with hepatitis C virus (HCV), yet only around half are aware of their infection. In 2013, hepatitis C-related mortality surpassed the total number of combined deaths from 60 other infectious diseases, including HIV and tuberculosis, reported to CDC. Fortunately, direct-acting antivirals have transformed the treatment landscape and now give us the ability to cure HCV. Behind the leadership of the World Health Organization (WHO), countries around the world, states within the U.S., and now cities such as San Francisco have started to develop elimination strategies that are moving us closer to eliminating HCV as a public health threat.
In this interview, Katie Burk, MPH, Viral Hepatitis Coordinator at San Francisco Department of Public Health (SFDPH), describes End Hep C SF and how this initiative is working to eliminate HCV in San Francisco.
End Hep C SF describes itself as a multi-sectoral collective impact initiative that utilizes evidence-based practices, community wisdom, and the creative leveraging of resources to work toward hepatitis C elimination in San Francisco. Can you tell me a little bit more about this initiative and describe how you got to this point? Collective impact is a framework I continue to learn more about, but its basic premise – that we need to bring people together in a structured way to address complex social problems – is quite simple and logical. There are several examples of collective impact initiatives in San Francisco, but End Hep C SF probably learned the most from people involved in Getting to Zero, which is the collective impact initiative that aims to get to zero new HIV infections, zero HIV-related deaths, and zero HIV-related stigma. We were inspired by the Getting to Zero initiative and thought it made sense to approach HCV in a similar way, especially since we now have curative treatments for HCV.
As the San Francisco Department of Public Health (SFDPH) Viral Hepatitis Coordinator, my work touches many different aspects of HCV prevention, testing, and treatment interventions. My role is really about bringing together doctors, population-level prevention experts, researchers, administrators, San Franciscans personally impacted by HCV, and others – those on the front lines as well as decision makers. We all hold different pieces of the puzzle and believe it’s time to have serious conversations about what HCV elimination in San Francisco would look like and how to plan for it. If we all work together to align our efforts and appropriately scale them up, elimination will be within reach.
End Hep C SF started as a conversation between SFDPH Population Health Division and two HCV clinician champions providing care to SFDPH patients. Dr. Annie Luetkemeyer, Dr. Kelly Eagen, and I spent some time talking and thinking about creating the initiative, how to engage SFDPH leadership in the process, and how to address any concerns that might arise, such as cost of treatment. With support from the Health Director, we created a Steering Committee with broad representation from clinicians, frontline workers, advocates, and affected community members. The Steering Committee decided to form four work groups: (1) Research and Surveillance; (2) Prevention and Education; (3) Testing and Linkage; and, (4) Treatment Access. End Hep C SF has been growing for about a year now; over 100 people have attended at least one meeting and 28 San Francisco-based public and private organizations have signed on as partners.
You mentioned that you learned from San Francisco’s Getting to Zero initiative. Can you describe how you leveraged this work? The Getting to Zero initiative has been really instructive and supportive, especially when we were initially getting off the ground. A few End Hep C SF Steering Committee members met with Getting to Zero co-founder Dr. Susan Buchbinder of SFDPH early on for guidance on how to get support for the initiative and where to start. Jeff Sheehy, who is a Getting to Zero Steering Committee member and works for UCSF, also met with the early End Hep C SF leadership several times to provide support as we got started. A few of us on End Hep C SF attended the Getting to Zero community meetings as well. Dana Van Gorder of Project Inform, another Getting to Zero Steering Committee member, gave us advice on fundraising strategies. It’s been so helpful to look to Getting to Zero as we progress because that initiative is a little further along in its process than we are with End Hep C SF, and we are appreciative of their perspective.
What partners have been important in this work?
We have a great wealth of expertise around HCV in San Francisco, and every partner represents an essential component that helps us better understand our HCV burden and our successful strategies in addressing it. Each partner has been important in very different ways. The epidemiologists are getting a handle on how to triangulate our data sources to develop an HCV prevalence estimate in San Francisco, which is something we have never had. The people on the ground who are doing data-driven, community-based HCV testing and linkage work are helping some of the most vulnerable San Franciscans get tested and treated (cured!) for hepatitis C. The clinicians are not only trying to cure as many patients as they can, but they are helping to develop capacity and enthusiasm in other medical providers to do the same. The advocates are fighting for supportive policies and funding to make all this work possible. It has also been essential to have community members who have lived experience with HCV and injection drug use at the table, so they can help ensure that the interventions we develop will actually increase access for the folks we are trying to reach. Importantly, the SFDPH leadership is solidly behind the initiative and has demonstrated its support both by allowing me to spend considerable time on the initiative, as well as by carving out the clinician time needed to treat its nearly 3,000 patients living with HCV in the coming years. This is the embodiment of the collective impact principle of mutually reinforcing activities, which is the idea that all the work each of us does in our own roles supports that of the other.
Do you have advice for other local health departments looking to develop an elimination strategy?
Think broadly about what HCV expertise is. Sometimes folks may not have been working on HCV specifically, but they’ve been working with impacted communities in ways that can prove really instrumental to what you are trying to accomplish. It’s helpful to be clear about what you are asking people to do, like commit to a monthly meeting or share data from their programs. Make the meetings purposeful, inclusive, and efficient. And keep outreaching to potential partners and new members! It’s a lot of work to get and keep people engaged, but it’s worth it!
Learn more about End Hep C SF and be sure to check out NACCHO’s Hepatitis C and Local Health Departments Educational Series for resources to help your local health department.