By Dani Fitzgerald | Beaver County Times | April 7, 2022

Pennsylvania received mediocre grades for its hepatitis elimination and prevention in a recent study, and advocates say limited access to harm reduction programs and outdated policies are large contributors to the state’s poor grade. 

The COVID-19 pandemic, which many health and addiction experts say increased overall drug use, heightened the need for better education and resources surrounding substance use and hepatitis, experts say. 

Hepatitis C is a virus that affects the liver. It’s the leading cause of liver cancer and liver transplants, and is transmitted through blood, predominantly spread through sharing needles and syringes. Hepatitis C has a 90% cure rate, with most new treatments including 8-12 weeks of oral antiretroviral therapy. 

While individuals who inject drugs are the most at risk of developing hepatitis C, those who do not use drugs can also be infected, as the virus is spread through microscopic blood. 

The stigma that the virus only affects those sharing needles means few people get tested, and some die. Additionally, community advocates believe prejudice against individuals with substance use disorder is another reason potentially life-changing harm reduction initiatives like syringe service programs are not prioritized.

Pennsylvania’s C grade is connected to legal barriers to syringe service programs 

The O’Neill Institute for National and Global Health Law at Georgetown University Law Center, the National Viral Hepatitis Roundtable (NVHR), and the Center for Health Law and Policy Innovation at Harvard Law School (CHLPI) in January launched Hep ElimiNATION, a partnership to study viral hepatitis elimination efforts across the country. 

Hep ElimiNATION is the country’s first comprehensive analysis of the policies and strategies aimed at viral hepatitis elimination in the U.S. Hep ElimiNATION assigned letter grades to 52 jurisdictions based on the state’s current capacity to eliminate viral hepatitis by 2030 and in alignment with the Department of Health and Human Services Viral Hepatitis National Strategic Plan. 

States were graded on their viral hepatitis elimination plan development; harm reduction laws and policies; budget allocations; improving viral hepatitis prevention, treatment and outcomes; reducing viral hepatitis-related disparities and health inequities; improving viral hepatitis surveillance and data usage; and achieving integrated, coordinated efforts that address the viral hepatitis epidemics among all partners and stakeholders. 

Out of the 8.5 possible points, Pennsylvania only received 1.5, receiving a C grade.

“The primary reason is that syringe service programs aren’t legal in Pennsylvania,” said Adrienne Simmons, director of programs for NVHR. “Possessing substance-use or drug-use equipment is illegal in the state. There are vast disparities in access to harm reduction services.”

Syringe service programs (SSPs) are currently authorized in the cities of Philadelphia and Pittsburgh, but are not legal statewide. 

SSPs are community-based prevention programs where individuals who use drugs can receive substance use disorder treatment, access to and disposal of sterile syringes and injection equipment, and vaccinations, testing and other treatment for infectious diseases. 

According to the CDC, SSPs are associated with a reduction in approximately 50% of incidents of HIV and hepatitis C transmission. New users of SSPs are five times more likely to enter drug treatment and three times more likely to stop using drugs when compared to individuals who do not use those programs. 

“We rank support for harm reduction policies in Hep ElimiNATION framework because we know most of the new hepatitis infections are linked to injection drug use,” said Daniel Raymond, director of policy for NVHR. “(SSPs) are a great place to screen people who inject drugs to find out if they have Hep B and C, and to give care also for substance abuse and hepatitis.”

Although Pennsylvania isn’t the only state where SSPs are illegal, in bordering states like Ohio, West Virginia, New York and Maryland, SSPs are authorized.

“Pennsylvania is not unique here,” Raymond said, noting that syringes are categorized as drug paraphernalia in the state, which many hepatitis, HIV and addiction advocates say is a 1970s legal barrier that became a stronghold during the ‘War on Drugs’ era. 

“It made it illegal to buy or use anything considered paraphernalia,” Raymond said. “States like Ohio and West Virginia and a lot of other states in the broader region have authorized and legalized syringe services in the last years. Pennsylvania has lagged behind the curve.”

To legalize SSPs statewide, Maggie Barton, deputy press secretary for the Pennsylvania Department of Health, said legislation must be passed.

Gov. Tom Wolf’s administration is in support of legalizing SSPs and met with the Pennsylvania Harm Reduction Network (PAHRN) last October to find ways to mobilize that effort. 

“We believe syringe service programs are a critically needed tool to add to our toolbox statewide to provide a bridge to treatment and social services and ultimately help to reduce the number of drug overdose deaths,” Barton said. “Syringe services programs also increase public safety and protect law enforcement and first responders by properly disposing of used syringes.”

In January, state Reps. Sara Innamorato, D-Allegheny County, and Jim Struzzi, R-Indiana County, introduced bipartisan legislation to expand SSPs to local service providers throughout the state.

“The federal government is allocating funding to states that offer SSPs, but Pennsylvania can’t access this money until SSPs can operate in every corner of the commonwealth,” Innamorato said in a release. 

Until legislation is passed to legalize SSPs statewide, Struzzi said Pennsylvania is missing out on potentially millions of dollars.

“In these times of extreme mental, social and physical stress, it is imperative that we do all that we can to treat addiction and provide these harm reduction services,” Struzzi said in the release. “In addition, by having this legislation written into law, it will open the door to millions in federal dollars that we can use to truly impact the lives of Pennsylvania residents and families struggling with addiction.”

‘More than a needle exchange’

While illicit drug use isn’t safe, Alex Tatangelo, a nurse practitioner with Central Outreach Wellness Center in Aliquippa, said it’s important to educate people and provide harm reduction opportunities for those who are going to use drugs anyway. Countless studies show SSPs are an invaluable way to do that.

“What we want to do is engage people in prevention, engage people in getting clean needles and part of the engagement we want to talk about is safe drug use,” Tatangelo said. “Is any drug safe? No. But can we make it slightly more safe? Yes.”

SSPs can prevent overdose deaths, according to the CDC, by “teaching people who inject drugs how to prevent overdose and how to recognize, respond to and reverse a drug overdose by providing training on how to use naloxone.”

These community centers offer a more holistic approach to substance abuse treatment by providing education, resources, medical assistance and a safe space for people who inject drugs.

Suzanna Masartis, chief executive officer of Community Liver Alliance, said SSPs are “more than a needle exchange.”

“It’s about helping to refer to mental health and other health services, vaccination for Hep A and B, and also Hep C and HIV testing and linkage to care services,” Masartis said. “It’s about meeting people where they are.”

Access to those services also can “prevent a barrier to infectious disease outbreaks, including outbreaks with Hep C,” said Jennifer Fiddner, epidemiology research associate supervisor with the Allegheny County Health Department. 

More than 2,500 new HIV infections occur each year among those who inject drugs. Hepatitis C and HIV transmissions can be reduced by two-thirds when combined with medications that treat opioid dependence, the CDC reports.

“In my experience, these programs work best when supported by the community, but they also often confront misunderstanding and stigma,” Raymond said. “If the average person took some time to learn about these programs and think about the programs with an open mind, I think we would end up with a lot more buy-in for this missing piece of the puzzle.”

More than 2.4 million people nationwide were living with hepatitis C in 2016, and 250,000 have chronic hepatitis in Pennsylvania. Now, infections could be closer to 3 million.

In 2019, approximately 7.2% of Beaver County residents between the ages of 15-39 with substance use disorder were also diagnosed with hepatitis C, according to state data.

Simmons believes the number of hepatitis C infections is “only the tip of the iceberg.”

“We don’t have the surveillance and testing infrastructure in place to test all the cases. And that was exacerbated by the pandemic. It’s multifactorial,” she said.

Simmons also mentioned the disparity in federal funding between HIV/AIDS and hepatitis C. The Biden administration allocated $39 million this year for hepatitis prevention and treatment, compared to $167 million for HIV/AIDS.

“It’s part funding, it’s part poor public health infrastructure, and it’s also stigma around the disease,” Simmons said. “There is a universal recommendation that all adults be tested at least once in their life. We haven’t seen that since COVID.”

Raymond said hepatitis C infections appear to be “linked to the relative lack of harm reduction services and engagement in treatment. That’s why we feel urgency in calling this out before we end up with another generation with a chronic infection that can be ultimately life-threatening.”

The pandemic and substance use in Beaver County

Tatangelo said few options are available in Beaver County for hepatitis risk reduction other than Central Outreach.

The primary care center is open to every one, but creates an especially inclusive environment for marginalized groups, including the LGBTQIA community, people of color and those with substance use disorder. The physicians specialize in HIV and hepatitis C care. 

For many folks with substance use disorder, lock-down, quarantines and working from home was a trigger. At Central Outreach, Tatangelo saw relapse rates increase during that time. 

“The pandemic has been a huge struggle for those people,” Tatangelo said. “People that went through rehab and are engaged in Suboxone or Methadone for MAT (Medication-Assisted Treatment) were relying on meeting at churches and meetings at other locations who are hosting drug and alcohol, AA, NA, and dual recovery anonymous… but they haven’t been happening.”

Much of the recovery community had to go virtual for meetings because of COVID-19, which meant people were staying at home and were less likely to socialize with their communities.

“People who were pretty stable relied heavily on those meetings to maintain sobriety, and then they didn’t have that available to them. Relapse rates are definitely higher,” Tatangelo said.

Between April 2020 and April 2021, deaths related to substance abuse reached 100,306 nationwide, an increase of 28.5% from the previous year, the CDC reported. In 2020, Pennsylvania had a 42.4% overdose death rate, ranking in the top 10 states nationwide.

According to the University of Pittsburgh’s Overdose Free PA database, between 2020 and 2021, Beaver County saw 117 reported overdose deaths, a slight increase from the 102 between 2018 and 2019.

“We saw overdose rates continue to go up (during the pandemic). People lost their connection to support programs and some tragically relapsed or overdosed,” said Raymond. “So many of the solutions to viral hepatitis are about connection. Connecting people to harm reduction, connecting to health care… we have a lot of catching up to do.”

Mobilizing hepatitis C screenings 

Central Outreach has a Hepatitis C & HIV Rapid Testing and Linkage to Care mobile program that services communities around the region, including Ohio, and offering education and screenings for hepatitis C, HIV and STDs. 

“If positive for Hep C, we offer to draw labs right then and there. We send them off to be tested. If someone needs lifesaving medication, we need about 14 days to get medication in their hand,” said Kathi Scholz, nurse practitioner and outreach director for Central Outreach.

The mobile program travels to the Beaver County Jail, Gateway Rehab, alternative incarceration facilities, transitional houses, and more. 

“Beaver County is an untapped area for screening for Hep C. High number of cases and low number of facilities offering treatment. We were essentially exclusive partners with 19 different facilities to screen for Hep C,” Tatangelo said. 

In 2021, Central Outreach cured 1,600 people of hepatitis C throughout the region. Since 2017, the center has cured approximately 4,200 people.

In Beaver County, 274 residents have been tested for hepatitis C at Central Outreach, with 75 people testing positive, and 73 who already knew they had hepatitis C when arriving at the facility for care.

In neighboring Allegheny County, there were 2,230 cases of hepatitis C in 2019, 1,289 of which were confirmed chronic cases and 941 probably chronic cases, according to the Allegheny County Health Department.

The American Association for the Study of Liver Diseases and the CDC recommend every person be tested at least once in their lifetime for hepatitis C, and high-risk individuals should be screened yearly. 

While hepatitis C is largely contracted through intravenous drug use, Tatangelo said there’s a misconception that that’s the only way to be infected.

“People think, ‘I never used IV drugs so I’m not at risk,'” Tatangelo said. “Have you had sex with someone who uses? Have you snorted cocaine with someone?”

Approximately 45% of people infected with hepatitis C do not recall or report having specific risk factors, the CDC reports. Many people who have hepatitis do not show symptoms and may not know they are infected. Sometimes symptoms arise weeks or even months after exposure. Common symptoms include fever, fatigue, nausea, vomiting, abdominal pain, joint pain, dark urine and jaundice. 

Baby boomers — those born between 1945 and 1965 — are at high risk for hepatitis C infection, according to the CDC, as many could have been infected during medical procedures in the years after World War II when blood transfusions and other technologies were not as safe as today. 

Other ways people can contract hepatitis C is by getting tattooed or pierced with an unclean needle, or using a dirty or shared razor or toothbrush, Scholz said.

“There are so many avenues you can contract this,” Tatangelo added.

In Beaver County, residents interested in testing can visit Central Outreach’s office 2360 Hospital Drive in Aliquippa, visit one of their hepatitis C screening locations, or call 724-707-1155.

“Even if they don’t have health insurance, there may be avenues we can take to still get them treated for hepatitis C,” said Tatangelo. “Health insurance in our country isn’t a right, and it should be. The more people we see the more we can connect to health insurance and get screened for diabetes, colon cancers, HIV, and be on a better road to general wellness.”

For more information about hepatitis C treatments, call  866-WE-CURE-HEP-C. To see statewide treatment and screening facilities visit the Department of Health website.