WINCHESTER — Fatal overdoses are the most obvious local symptom of the national heroin epidemic, but it’s also having a less visible effect: high Hepatitis C rates.
The Hepatitis C virus is a blood-borne infectious disease that attacks the liver. HCV-related diseases killed nearly 20,000 people nationally in 2014, a record-high, according to the Centers for Disease Control and Prevention. HCV rates nearly tripled nationally between 2010-15, and the outbreak has been felt locally and statewide.
In Winchester, the rate for people between 18-30, the age range when people are most likely to become infected, was nearly seven times higher than the state rate in 2017, according to Dr. Colin M. Greene, Lord Fairfax Health District director. The 18-30 rate for the Northern Shenandoah Valley — defined as Winchester as well as Clarke, Frederick, Page, Shenandoah and Warren counties — is more than three times higher than the state rate.
The 53 new cases involving people between 18-30 in Winchester were among 185 new cases in the city. In Frederick County, the numbers were 37 and 144. The numbers are from the Virginia Department of Health. Statewide, new HCV diagnoses increased from 7,012 in 2014 to 10,353 last year, a 47% spike.
According to the CDC, the national increase in cases is related to increasing intravenous drug use. Like the national rate, area heroin use has skyrocketed in recent years, with about 200 people fatally overdosing since 2012.
“Not all of these cases of Hepatitis C are attributable to drug use and needle sharing, but it is likely that at least some are,” Greene said. “These are two things happening at the same time with a plausible connection between them.”
The virus can go undetected for decades, increasing liver damage, so local clinics and health departments urge people to get tested. AIDS Response Effort is one of the groups that does tests, which take about 30 minutes. Of the 492 tests the group did last year, 158 people tested positive, according to Laura Arellano, ARE education and outreach coordinator.
In addition to the ARE office at 124 W. Piccadilly St., testing is done during health fairs at the Handley Library, as well as at methadone clinics and the Northwestern Regional Adult Detention Center. The idea is to reach out to at-risk people who may be reluctant to visit ARE due to the stigma about HIV/AIDS and Hep C.
“They’re not going to want to come into our agency, so we go to where we can meet them at,” said Quintara Lane, an ARE testing specialist. “We want to meet the people where they’re at and be able to provide for the needs that they have.”
For those infected, there is good news. Chronic Hepatitis C can be cured with an anti-viral pill taken daily for two to four months. The bad news is that cured people can get re-infected and the medication is expensive, an average of about $90,000 for full treatment..
And there are only a handful of area doctors providing medication including those at the Sinclair Health Clinic and Winchester Gastroenterolgy Associates. Lane said she’s grateful to the doctors who provide treatment but more are needed because of the increasing need.
People get the virus from a variety of ways. Some were infected from a piercing or tattoo that wasn’t properly sterilized. Others may have gotten infected from a blood transfusion in the military before stricter protocols to prevent the virus took effect in 1999.
But many are addicts who became infected from re-using or sharing needles. Arellano and Lane said most doctors won’t treat users if they aren’t in recovery. Arellano said some clients promise to go to Sinclair for followup testing and treatment, but if they’re using or relapse, treatment “isn’t on their radar.”
While the expansion of Medicaid in Virginia in January has increased health coverage, infected clients face many obstacles. If an addict is in recovery, they often lack housing or transportation making it hard to get to doctor’s appointments and get their daily regimen of pills. “If a person is more concerned about where they are going to sleep, how are they going to take their medication?” Lane asked.
Clients who test positive for the virus are sent to the Sinclair Clinic for followup testing and treatment. People in the first six months of infection have acute Hepatitis C. Those infected more than six months have chronic HCV.
Many Sinclair patients have chronic HCV because they lack health insurance and can’t afford doctors visits. Many came to Sinclair for other ailments and learned they had HCV because the clinic tests all patients for the virus.
“By the time they get here, they haven’t had a primary care provider in years,” said Veronica Salazar Stickley, a Sinclair community health worker who works with HCV patients. “The majority of them don’t even know. They’ve had it for years and years and didn’t know.”
Most infected patients are under 40, said Dr. J. Leocadia Conlon, Sinclair director of clinical services. She said the clinic has seen a lot more infected patients since 2012 corresponding with the rise in heroin use. Patients are educated about risk factors, but not lectured.
“We do not judge them on how they got the infection,” Conlon said. “It’s just making sure they’re not currently doing behaviors that can get them infected or re-infected.”
Conlon said there have been advances in treating the virus since she worked on research and treatment while part of The Johns Hopkins Hospital’s liver transplant program in 2000-01. At the time, treatment involved shots and pills for a year and the success rate was only 30 to 40 percent. In 2012, clinical trials she worked on in Hawaii and Virginia increased the success rate to about 75 percent, but treatment involved injections and two different pills taken three time per day.
“They were very hard to take, very difficult to tolerate and patients had many side effects,” Conlon said. “Now, with the pill, there’s almost no side effects associated with it.”
Besides greater education, other proactive measures being explored in Winchester are starting a needle exchange/harm reduction program in which addicts bring in used needles for sterilized ones to a clinic or mobile clinic. Local drug treatment advocates said in March that discussions about starting a program were in the early stages and no decision had been made.
Needle exchange programs have been endorsed by the American Medical Association, the CDC and the National Institutes of Health as a way to reduce HIV/AIDS and the HCV. In one of the most comprehensive studies, Hepatitis C rates decreased significantly among heroin addicts who used a New York City needle exchange program between 1990 and 2001, according to the Harm Reduction Coalition which advocates for scientifically-based solutions to reducing drug addiction.
Conlon supports starting a needle exchange program to reduce the virus as well as creating more drug treatment and mental health programs. She said some patients have to be sent out of state to get treatment.
“We just don’t have the resources here that they need,” she said. “And I know that’s not unique to Winchester. I know that’s in [many] areas, but at some point we have to step up and put the funding in.”
Arellano and Lane said ARE, which has a staff of 17, is seeking grant money to hire a much-needed caseworker dedicated to working with Hep C clients to ensure they get treatment and take their medicine. They encourage people to not be ashamed to get tested and educate themselves about how to avoid infection.
Despite the lack of local resources, Lane said she’s hopeful the outbreak can be reduced. She said people must be willing to break the stigma about Hepatitis C and show compassion to those who are infected. “It’s possible for us to reduce these numbers as long as we come together as a community,” Lane said.