Outbreaking News

Reported hepatitis C cases on the rise in homeless community.

by Doron Taussig

"The liver is a filter, it filters out your blood. If it's not working, you poison yourself to death." Mark B. does not flinch when describing the possible circumstances of his own demise.

Though Mark is only 43 years old, his doctor tells him he may have only 10 or 15 years left. He spent 30 years drinking and drugging, and somewhere along the way, one of the toxins he put in his bloodstream stayed there. Yet Mark describes his condition as matter-of-factly as a mechanic describes an exhaust problem.

"Still now it's almost like I don't feel the full effect of somebody telling me, "You're gonna die,'" he says. "I don't feel sick."

Mark is one of a growing number of homeless and formerly homeless people who have learned in the past year that they are infected with hepatitis C. At the Mary Howard Health Center, a Center City clinic for the homeless operated by the Philadelphia Health Management Corp., the percentage of clients diagnosed with hep-C rose from 1 percent in 2000 to 11 percent in 2004 — and center clinician Lester Cohen says he continues to break the bad news to one or two people a week.

A reliable estimate of how many Philadelphians have been diagnosed with hep-C is not available because the city Health Department has not made it mandatory for physicians to report cases. But most experts agree that the rise in cases is not indicative of a rash of new infections; rather, they say, the government initiated an education campaign about the disease (which it labeled "the silent epidemic") a few years ago, and now tests are being conducted consistently enough for society to finally get a sense of how extensive the problem really is. The results are as bad as expected.

"Hep-C is astronomical," particularly among the homeless population, says Cohen. And to make matters worse, "a lot of [my patients] refuse treatment for it."

Hep-C is a complicated disease. Like HIV, it is a blood-borne virus and is often transmitted through intravenous drug use and sex. (Unlike HIV, however, it can live outside the body for nearly a month — so it can also be transmitted by shared toothbrushes or razors.) The disease first drew attention four or five years ago, when states conducting screenings reported that about a quarter of their prisoners were infected. (Pennsylvania spends nearly $10 million a year treating hep-C in prisons.)

At its worst, hep-C attacks the liver, causing cirrhosis or liver failure. But only about 20 percent of infected people reach that point. About a third clear the virus on their own. The rest experience very few symptoms. Even those who eventually suffer severe consequences can carry the virus for 20 or 30 years without feeling any significant effects. Unless they get treated.

The treatment for hep-C, a combination of interferon and ribavirin, often has very harsh side effects, including aching, depression and nausea. At the very least, it brings on exhaustion. "It's like chemo," says Cohen.

Additionally, the program only works about half the time, so for many people, beginning hep-C treatment means going from feeling fine to feeling much less than fine — to prevent something that has only a 20 percent chance of happening. That's a difficult choice for anyone to make, but it's particularly hard for a homeless person without caregivers or a good place to rest.

"If you're living in a shelter and you go back to your bed throwing up and they say the beds don't open until 7," explains Cohen, you might decide the treatment isn't worth it.

For a lot of patients, this means considerable agony down the road. It also means additional expense for taxpayers — the cost of knocking down hep-C with treatment is between $6,000 and $12,000, whereas the cost of treating liver failure is between $50,000 and $250,000 — and the unnecessary use of very valuable livers.

"There are more people who need liver transplants than get livers," says Dr. Steven Herrine, a hepatologist at Jefferson University.

Mark B. found out he had hep-C about a year ago. He probably contracted it through intravenous drug use, which he says he hasn't done in about 10 years.

"Sometimes it makes me feel like a walking germ," he says. "I have to watch what I do. Can't just lay toothbrushes around. Sex, I have to tell people. Right away if I cut myself, I have to wipe it with bleach. It could be something as simple as me picking my fingernail, going a little too deep, then somebody else picking it up and picking a bump on their face with it."

Mark has chosen to get treatment. He participates in a selective program for transitioning adults called Ready, Willing & Able that provides him with the necessary support, and thus far, he's been lucky: The only side effect he's feeling is exhaustion. But he understands that he is an exception. He knows for a fact, for example, that at least two other people in his program have hep-C but keep it much quieter than he does. And he imagines that people outside of the program have an even harder time taking the disease seriously.

"If I was still homeless, and if I was out there in the street, I would not be seeking the treatment that I'm doing now," he says.

During the next two decades, hep-C is expected to become a much bigger public-health problem, as more patients who are currently asymptomatic begin to deteriorate.

According to www.hepatitis-central.com, "Predictions in the USA indicate that [among the general population] there will be a 60 percent increase in the incidence of cirrhosis, a 68 percent increase in hepatoma incidence, a 279 percent increment in incidence of hepatic decompensation, a 528 percent increase in the need for transplantation, and a 223 percent increase in liver death rate."

Hep-C co-infection with HIV is another rising concern, as is continued substance abuse by infected people, which can aggravate the condition. Genevieve Burns, practice director at Mary Howard, says the key to convincing patients to get treatment is evaluation and explanation.

"The first step is to convince them to go to a [gastroenterologist] and have more of an evaluation," because not everyone needs treatment, she says. Then, you explain what it means, and try to keep the lines of communication open. "When people decide not to get treatment, it doesn't close the door."

But for the ones who need treatment, says Cohen, clinics need to find a better way to persuade them, because "it's a nasty way to die."