Jennifer Fiddner, MPH,CIC is the co-chair of Hep C Free Allegheny and is the Infectious Disease Epidemiology (IDE) Program Supervisor at the Allegheny County Health Department (ACHD) in Pennsylvania, which serves a region that includes the City of Pittsburgh. With a background in public health, epidemiology, and infection control, she oversees infectious disease surveillance and outbreak prevention and mitigation activities, including hepatitis C (HCV) testing, surveillance, and linkage to care efforts across the region. Fiddner works closely with community partners, healthcare providers, and harm reduction organizations to address the local impact of hepatitis C, particularly among people who inject drugs. Her program’s recent work includes a report describing barriers to HCV confirmatory testing and treatment in Allegheny County. Fiddner’s work focuses on using data-driven strategies and cross-sector collaboration to improve access to care and advance local HCV elimination.
One of the focuses of your work in Allegheny County is expanding hepatitis C prevention and treatment, and the health department recently released a report describing barriers to HCV confirmatory testing and treatment within the county. What were some of the most significant challenges identified, and how are they impacting linkage to care in Allegheny County?
The ACHD is committed to eliminating hepatitis C in Allegheny County. It is imperative that people have timely access to treatment in order to prevent the development of serious illness like liver cancer and reduce the chance of spreading the virus to others. In Allegheny County, the most commonly reported barriers to confirmatory testing and treatment were being unaware that additional testing was needed and being unaware that curative treatment was available. Implementing strategies like routine reflex testing and encouraging both behavioral and physical healthcare providers to provide testing and treatment services within their practices rather than relying on referrals will help to address these barriers.
Allegheny County has taken a proactive approach to understanding gaps in the hepatitis C care continuum, particularly around confirmatory testing and linkage to treatment. Can you share more about the unique approach your team has taken to identify barriers in this space?
Hepatitis C is a reportable condition. When disease surveillance staff receive a laboratory report in our electronic disease surveillance system, PA-NEDSS, they initiate a case investigation, just as they would for any other reportable condition. Case investigations involve calling people and asking about potential exposure sources, symptoms, and providing information about how the disease is transmitted and what steps people can take to prevent spreading the infection to others. In 2022, we implemented enhanced surveillance to better inform our local HCV elimination efforts. During HCV case investigations, staff ask people who had a reactive antibody test but no other testing about what barriers may be preventing them from accessing confirmatory testing and they ask people who had a positive RNA test about what barriers may be preventing them from initiating curative treatment. Additionally, the ACHD conducts an annual survey of agencies that serve clients at high risk of HCV infection to assess access to testing and treatment services.
How have your efforts informed ACHD’s strategies or partnerships to improve testing and treatment outcomes?
Our surveillance efforts have contributed to the development of educational materials for our department’s Family and Child Health home visiting programs, resources for our Overdose Prevention Program field staff, and the recent addition of HCV testing and treatment services in our STI Clinic, providing our disease investigation team the opportunity to help people schedule appointments while they are conducting case investigations and assessing barriers to care. Our IDE Program has partnered with the Allegheny County Department of Human Services and a behavioral health managed care organization to explore methods of incorporating HCV testing and treatment in behavioral healthcare settings, with the City of Pittsburgh Bureau of EMS to develop and implement hepatitis C testing and treatment referrals at mobile syringe service program sites and homeless shelters, and developed and implemented a peer testing program with a local syringe service provider.
The ACHD is also an active member of Hep C Free Allegheny (HCFA), our local elimination collaborative. HCV elimination requires interdisciplinary partnerships and dedication. Surveillance data are routinely shared with members of HCFA’s workgroups, providing structure for our Testing and Treatment as well as our Education, Prevention, and Advocacy team members as they develop and prioritize goals and objectives. We also share our findings and recommendations during regular infectious disease update meetings with representatives from Federally Qualified Health Centers, urgent care facilities, pediatric practices, health system laboratories, and other healthcare partners.
Data shows that despite advancements in Hepatitis C treatment; many people still don’t receive initial HCV testing. What are some of the most common barriers that prevent individuals from getting tested for HCV?
People, especially those at highest risk of infection, need consistent, low-barrier access to HCV testing. We launched our local HCV elimination initiative in 2018 after reviewing the results of our first survey of agencies that serve clients at high risk of HCV infection to assess access to testing and treatment services. The data revealed that people in Allegheny County who were at highest risk of infection did not have consistent access to testing services. We also held a listening session with members of a local syringe service provider’s Community Advisory Board. The CAB consisted of syringe service provider clients. Participants revealed that physical healthcare providers often did not offer HCV testing despite awareness of ongoing risk factors, and that they often felt judged by healthcare providers and their staff. Participants also shared that they were reluctant to make healthcare appointments solely for HCV testing and expressed a preference for testing and treatment service access at medication-assisted treatment clinics and correctional facilities, stressing the importance of providing these services at locations that they were more likely to visit.
How do stigma and systemic inequities play a role in preventing people from accessing HCV testing, particularly among people who use drugs or are involved in the criminal justice system? Did the ACHD report reveal any patterns in barriers among people who use drugs or those involved in the criminal justice system?
Hep C Free Allegheny believes in health justice, recognizing that discrimination and stigma have contributed to the current hepatitis C epidemic. The ACHD believes that all people deserve access to low-barrier testing and treatment. Injection drug use is the most commonly reported risk factor among people who have hepatitis C infections in Allegheny County. Our local elimination efforts are focused on people at highest risk of infection, including those who inject drugs and infants born to women who have active HCV infections. Our surveillance efforts revealed that people who use drugs often face stigma when accessing healthcare services and are not always offered the services that they need.
As the field moves toward hepatitis C elimination, what gives you hope? Additionally, given ongoing funding challenges, where do you think we need to focus more attention and resources to make meaningful progress?
The enduring compassion, commitment, and resourcefulness of public health colleagues and other partners despite existing and developing funding and healthcare service delivery challenges indicate that we will continue to make progress toward our shared goal of hepatitis C elimination. Thinking outside of the box, incorporating non-traditional partners like EMS personnel, and developing new ways of linking people to care within existing systems is crucial. To ensure meaningful progress, we must prioritize hepatitis C as a solvable public health problem, integrate physical and behavioral healthcare, implement evidence-based prevention and linkage to care strategies, and incorporate the perspective of those most affected by the hepatitis C epidemic in our elimination planning efforts. Local public health staff have a unique opportunity to assess barriers to care among people affected by HCV and their efforts to link people to care should be encouraged and supported.
