Okay, good afternoon, everybody. Welcome to the beginning of our spring webinar series sponsored by AOA and the Opioid Response Network. Today's webinar is Peer-Assisted Telemedicine for Hepatitis C, or PATHS. This is the first of our lecture series. We're going to have five more after today. My name is Julie Kmick, and I'm your moderator for this session. Today, our presenter is Dr. Hunter Spencer. Dr. Spencer is an assistant professor of medicine at Oregon Health and Science University and practices general internal medicine, HIV medicine, and addiction medicine. He's a clinician scientist focused on improving access to HIV prevention and hepatitis C treatment for rural people who use drugs. He co-authored the most recent U.S. Preventative Service Task Force Evidence Review of HIV Prevention and leads hepatitis C elimination work throughout Oregon as director of Peer-Assisted Telemedicine for Hepatitis C and syphilis. And I'm going to turn it over to Dr. Spencer. Great. Thank you so much, Julie. It's a pleasure to be here today, and I really appreciate the invitation. Today, we'll be talking about our Peer-Assisted Telemedicine program for hepatitis C treatment specifically, which focuses on rural people who use drugs in Oregon. And it's situated within our whole sort of peer-based research and implementation system, which we call the Oregon Model. So I'm going to just give you that context as well. I'm supported through NIH, through the National Center for Advancing Translational Sciences on an institutional KL2 award, and several of my co-authors have NIH funding, and the main study I'll present was NIH funded. I have a co-author who has investigator-initiated funding from private foundations, or from pharmaceutical companies, but it wasn't related to our work. So our learning objectives are to describe the substance use disorder and hepatitis C epidemic and how they are co-occurring and amplifying one another, to describe the findings of a randomized trial of peer-assisted telemedicine for hepatitis C treatment, which we completed in Oregon in 2024, and to describe implementation of a peer-assisted telemedicine hepatitis C elimination model, which we're doing in the PATHS program. So I'm going to start by contextualizing this in Oregon. Oregon is like a lot of the country in how it has had an overlapping and amplifying hepatitis C and opioid epidemic, but it's a little bit unique as well. So one of the things that's really prominent in Oregon is that we are very strongly seeing the fourth wave of the opioid epidemic, which by that I mean combined opioid and methamphetamine use with combined morbidity and mortality related to that. In Oregon, actually, it was sort of always like this. There's always been a very high prevalence of methamphetamine use, and so there's always been a high prevalence of people who use opioids and methamphetamines. But what really changed with the fourth wave epidemic in Oregon is the arrival of fentanyl. This was delayed compared to much of the eastern part of the country and of the continent here in North America, delayed but came very profoundly. And you can see this in our overdose epidemic, which is national data here, but we mirrored really closely in Oregon, this sort of exponential explosive growth in our opioid overdoses, which was attributable to fentanyl. We were really sort of struck with fentanyl in 2020 to 2021. At the same time, Oregon has a very prevalent hepatitis C problem. This is from the good folks at hepview.org. Their most recent prevalence maps are based off the 2013 to 2016 data. You can see that every state is color-coded, and the darker the color, the more prevalent hepatitis C is. And out of the west part of the country, Oregon really stands out. We've got far more hepatitis C prevalence than either of our neighbors. And actually, on a numeric level, we're generally between third and fourth, depending on the prevalence rates, year to year, any time really, from 2013 to 2022. Our sort of closest peer states are New Mexico and Oklahoma and Washington, DC. So highly prevalent hepatitis C problem. This is mirrored by a highly more prevalent problem of hepatitis C. We have one of the highest hepatitis C mortality rates out of any state, the third highest in 2021, where these data come from. And you can see here, once again, the darker the state is, the worse off things are. And when you look at the bar on the bottom, you can see that the darkest color, purple, starts at 7.6. Oregon is almost off the scale, in a sense. Oregon's mortality rate per 100,000 is over 10. And this is, again, comparable, most comparable to New Mexico and Oklahoma. So we have a lot of people dying from overdose, a great many people dying from hepatitis C as well. It's striking that this is not at all an urban problem. It's a urban and a rural problem. So this is our hepatitis C mortality data by county across the country. So if you look at in Oregon on the left, to orient you, Portland, where I live, is right on the Washington border, sort of just off the edge of the coast. So it's sort of in the left upper quadrant. Many other parts of the state are very, very rural. And in our southeastern corner that borders Idaho, for example, it's designated as a sort of very, very rural or frontier rural level of rurality, where very few people live per square mile. So that's true in many spots all over Oregon, including this big dark purple swatch that you see in the southwest. Those are all counties that are very rural and have very high hepatitis C mortality rates. I think Oregon is a great example of a place with high hepatitis C mortality and a rural hepatitis C epidemic because it maps to a lot of other states. So you can see big swaths of rural areas in Oklahoma and Texas and New Mexico, and then into the Appalachian region, there's similar patterns where there's really highly concentrated hepatitis C mortality in these very rural places. So back in 2018 to 2019, we were struck by this kind of confluence of problems. We had at the time a kind of pre-fentanyl opioid epidemic, which was still quite morbid. And we had this very explosive hepatitis C epidemic. And we gathered as a group of researchers and community members and also state government officials to try to solve this problem. And we ultimately came up with what we call the Oregon model. So this is our attempt to do a lot of things at once in a very integrated way. We both design and implement health services interventions, and we research them and implement them at the same time. And the defining feature of our work is that we do it with peers. Now, peers are people with lived experience of substance use. And we partner with these folks who know what it's like to walk in the shoes of somebody who's currently using drugs. And all of our work is, of course, centered on improving the lives of people who use drugs all over Oregon. So the way we function is that we've got our team of researchers and community-based organizations and government officials who are seated within the Oregon Health Authority in both the public health and the behavioral health branches of Oregon Health Authority. And we sort of try to do everything we can as that group to surround peers and their clients and give them easy access to everything they would need to do to complete implementation projects and also to participate in research projects at the community level. So that looks like peers and clients being sort of centered in the model in the yellow part there. And then the peers help navigate the clients to whole bunches of different services. So things like navigating social services, like housing or food services, and providing harm reduction, like syringe exchange and mobile syringe exchange and naloxone training and distribution. But peers also help clients access health care, like getting tested for the types of infectious diseases that are prevalent amongst people who inject drugs, for example. Peers also help folks access providers through telemedicine or through physical providers as they're kind of partnering with folks throughout the state. And then we've also created systems so that the peers can help with data collection and tracking of all of their implementation work. And also we've created a role for peer research assistants where peers can function as research assistants with special training to directly conduct research with the rest of the team. We've done a lot as a group with regard to the Oregon model, and it's changed quite a bit. And I wanted to just give you the timeline to help orient you to what we'll be talking about today. So starting in 2017, we first came up with a project which was kind of our first foyer into peer-based work, and that was called the Oregon HOPE Engagement Project. The general thrust of this project was to put peers in rural communities, actually in that southwestern corner of Oregon predominantly, put peers into those rural communities and just see what happened. Would people engage with them? Would people interact with them? Could they actually do harm reduction, et cetera? That evolved into a pilot program where the peers, after having initial success, the peers model was expanded throughout the state through a different program called Prime Plus, which provided funding for many peers in different counties throughout the state from 2019 to 2020. And then in 2020, we started to pivot and expand a little bit more. So in 2020, we started the Oregon HOPE Telehepatitis C trial, which we'll be talking about today. And at the same time, Prime Plus received additional funding to expand even further. So we now have a sort of statewide network of peers. And after that statewide network of peers was founded, and after the Oregon HOPE Telehepatitis C trial showed such positive results, we were able to implement the same intervention inside of our Hepatitis C program paths. And starting in 2023 until the present, we've been adding clinical trials and replicating this model where we do community-based research followed by rapid implementation of the stuff that works. So today, we'll touch on the Oregon HOPE engagement trial in a bit more detail. We'll talk about the Oregon HOPE Telehepatitis C trial in a lot of detail. That'll be the majority of the talk, talking about the main findings and the secondary findings. And then we'll also talk about paths and a brief touch on sort of some future directions. So thinking about the Oregon HOPE engagement study, this was the first time where we tried to put peers into rural Oregon communities and see what had happened. And really the goal was just to count how much engagement there was, how many rural people who use drugs would come in for syringe exchange or follow up with referrals or set goals with their peers. And everything we did in this initial model was foundational for us in that we really stuck to a harm reduction approach and we used a strengths-based and client-oriented goal setting to be like our north star. Everything the peers did was really rooted in those two frameworks. We did it in some very rural places in southern Oregon, Douglas County and rural Lane County, and then some other even smaller places, including on south coastal Oregon, which is really beautiful and very remote, and a couple other counties as well. And similar, as I was describing with that sort of wraparound nature of our model, where we have researchers and the Oregon Health Authority and the community based organizations, we had that same type of partnership with Oregon Health and Science University and a consulting firm Comagine Health supplying the researchers, OHA representing the government's interests, and then two key partners are community-based organizations, which are peer run in southern Oregon, the HIV Alliance and Bay Area First Step. So, this study found that peers were quite readily accepted in these rural communities, and there was a lot of engagement. We enrolled 178 folks, 70% of them engaged with peer services. So, we were quite pleased with ourselves. And then we found out that of everybody who had been engaging with peer services, many of them, almost all of them, got hepatitis C screening as part of those peer services with a point-of-care hepatitis C antibody test. 50% of them had a hepatitis C antibody, and yet only 5% of them had ever received treatment. So, of course, it's possible to spontaneously clear hepatitis C. So, some people who have a hep C antibody don't currently have hep C, but that is not the most common thing to have happen. So, we knew that a huge amount of the folks that we were engaging with had hepatitis C, had never been treated, and were still actively infected. And not only that, we were hearing from the peers that this is awful. Like, we're telling people they have hep C, and then they try to get to a doctor, and there's so many barriers, and they don't have insurance, or they can't get to a specialist, or their doctors will just be stigmatizing and just flat refuse to treat them for hep C. So, it was this huge burden for the peers and for the clients to kind of have this knowledge about hepatitis C status, and yet have no feasible options for treatment. And that need and gap led us to the new project idea, which was phase two of this study, which was the OrganHope telehepatitis C study. And this is where we thought we should randomize people to hepatitis C treatment versus, sorry, hepatitis C treatment using a peer-assisted telemedicine model versus hepatitis C treatment with referral to local hepatitis C providers, either generalists or specialists in those rural communities. So, what was really the unique things about the peer-assisted telehepatitis C model compared to the enhanced usual care model were really important. So, in both arms of this study, there was peers. So, there was peer-assisted telemedicine versus what we called enhanced usual care. And it was enhanced because there was a peer helping somebody navigate insurance and navigate setting up appointments and navigate transportation to clinics and all of that stuff. So, it was really a high-level care in the control arm. But the peer-assisted telemedicine arm had a lot of unique elements. One of them was reduced delays. So, we had really rapid access to peer- assisted telemedicine by design. We had providers available for sort of same-day walk-in virtual visits for five days a week from noon to seven. And we also had some time-saving lab forms and other procedures that were really trying to streamline everything so that we could draw all the blood we needed with a single blood draw. The peers could take the clients to the lab before the doctor ordered those tests. We kind of ordered standing tests because we knew that we would need the same labs over and over. In addition to reduced delays, we also cut down on the barriers that people who were sort of unhoused or otherwise marginalized were facing. So, what we did was provide peers with the technology to facilitate the telemedicine visits. And this was really key because actually like 40 percent of rural Oregon doesn't have broadband internet. And many of those folks also don't have phones. So, to serve this population, we knew that just if we gave phones and devices out to people, it wasn't really going to help. So, instead, we provided the peers with technology to help facilitate those telemedicine visits. We also did some work to ensure that if a person was homeless, for example, and they were unable to store their medications securely, we arranged to have medication storage lockers available at these harm reduction agencies where the peers were housed. And this was a really key innovation for us because it allowed folks who otherwise kept their things in a backpack or a tent where she was, you know, prone to getting stolen or prone to getting wet, we were able to provide an option for folks to receive medications and keep them secure. And that was a protocol that we sort of co-developed with our Board of Pharmacy in Oregon. And then finally, the peer-assisted telemedicine arm of this trial had really proactive in the community support from the peers. So, there was peers assisting on both sides, but the peer-assisted telemedicine arm had a little bit more direct interaction because the doctors were communicating with the peers and the patients, and so the peers were more involved in the healthcare navigation components in the peer-assisted telemedicine arm. They were doing things like helping with medication pickup and adherence support. They were really active in going out to find people. That was true in both sides of the study. The peers were really active in going out to find people and maintaining contact. And then they also, in both arms, peers were providing harm reduction tools. So, when we conceptualized how it looked, it was a lot like what we thought of as the Oregon model in general. We still had the peers and the clients sort of centered in the model. The peers were still helping the clients access resources. We gave the peers some even enhanced protocols to make access to testing really easy with those standing order sets that I was mentioning. We gave the peers very ready access to these walk-in telemedicine visits. And then we also helped navigate these very difficult specialty pharmacies, which are frequently located out of state and really not connected to the needs of our patient population, which is rural people using drugs. And so, we really worked to help the peers navigate these specialty pharmacy systems as well. So, this is the study who we recruited for the Oregon HOPE telehepatitis C study. You can see that folks were on average 41 years. We recruited a similar population as the underlying race and ethnicity characteristics of the underlying populations of the counties that we were sampling from. We had a slight male predominance at 62% male. And this number on the bottom is really shocking to me. We had 70% of our participants were homeless. That was a sort of inclusive definition of homelessness or housing insecurity over the previous six months, but still 70% houseless was really remarkable to even be able to recruit that many people who were homeless into this study was surprising to me. And then I was always mentioning methamphetamine and opiates really go hand in hand in Oregon. We had 88% of people were using amphetamines and 58% of people were using heroin initially and then sort of fully transitioned to fentanyl by the sort of second and third and fourth year of the study. We had also more than half of people who were intentionally using opiates, opioids and amphetamines at the same time. So overall, we referred to 203 folks. And this is what our outcomes were. They were quite shocking and robust as you can see. So we had 85% of people in the telemedicine group initiated hepatitis C treatment versus only 13% in the community referral group. So we had a really profound difference in this secondary outcome of hepatitis C treatment initiation. And then in our main outcome of hepatitis C cure, we had a huge difference as well with 63% of people attaining hepatitis C cure in the telemedicine arm versus only 16% of people attaining cure in the community referral arm. And you might wonder why more people got cured than in the community referral arm or the enhanced usual care arm. More people got cured than actually started treatment. That is just a reflection of the fact that sometimes people spontaneously clear hepatitis C. So the spontaneous clearance was actually the only kind of beneficial effect in the community referral group it appeared. So really huge differences between the groups here and this is what caught our attention and obviously was quite a pleasing result. So we had a couple of follow-up questions. One of the things that the peers identified is that folks would get cured for hep C and then they'd stop wanting to use drugs which I think made sense but also was a little bit hard to prove. So we were able to demonstrate this in a paper we published in viruses and the percentage of participants who were injecting drugs was similar at baseline. So you can see in blue, we have the tele-hep C group and in orange, we have the community referral group and the baseline characteristics are represented in the top bar of those two colors and the follow-up characteristics, follow-up injection, follow-up percentage of people injecting drugs are represented in the lower bar. So the number of people who injected drugs was similar at baseline between groups and decreased more in the telemedicine hep C group but it did decrease in both. When we looked at this, it did attain statistical significance that the decrease was larger in the tele-hep C group and when we also looked at the number of peer encounters, so like a measure of how engaged was a person with the peer in both arms, the more engaged a person was with the peer, the less likely they were to be injecting drugs. Similarly, we looked at injection equipment sharing and we made a similar comparison. So you can see the tele-hep C group in the blue and the community referral group in the orange, there was a bigger increase in, both groups increased their injection equipment sharing over time but that happened more so in the community referral group. And once again, when we looked at the association with peer encounters, the more peer engagement a person had, the less likely they were to share injection equipment. So we found this very positive suggestion that peer-assisted telemedicine is a model that maybe gives you more bang for your buck. Not only can you cure hep C but you can also make harm-reductive, and you can make positive influences in folks' harm-reduction behaviors. Next thing we wanted to think about was telemedicine for homeless folks. So we had this very prominent population of homeless people in our study. And we know from pre-existing literature that unstable housing is a risk factor for hepatitis C or there's a higher prevalence of hepatitis C in people who are unstably housed. And yet there's lower rates of treatment and cure amongst unstably housed people. So we knew this was a really big need was models that could respond to homeless folks' needs. And so what we found is that in our study across both arms, hepatitis C cure was less likely amongst people who are unstably housed. So that lined up with the pre-existing literature. However, among the people who were unstably housed, those who were assigned to the tele-hep C arm were more than six times likely to achieve hep C cure compared to those who were assigned to community referral. So the effect of the intervention was even bigger in people who are homeless than in the general population. And also the more peer engagement somebody had, amongst homeless people, the more peer engagement that a person had, the likelier it was that their hepatitis C would be treated and cured. So we took this to suggest that the hepatitis tele-hep C works really well, and it maybe even works better if you're taking care of a lot of patients with unstable housing. Here's our statistics from that study. You can see the rate ratio is comparing unstable housing to the stable housing, and the rate ratio is over six there. So in addition to all of this quantitative analysis, we had a really thorough qualitative component to this study, from which we learned really interesting stuff. So what we found was three main themes from participants and how they described the hep C treatment experience. So the three main themes were the role of peer facilitation, the importance of the clinician, and the structural elements of the peer tele-hep C model. These were three things that helped people through hep C treatment. We'll talk about each. So to summarize the peer facilitation qualitative data, folks described that peers lived experience and the ways of engaging that the peers possessed. It really moved to create an alliance between the participants and the peers. And that was really an alliance characterized by trust. The peers were really able to generate trust amongst those clients. Peers were really appreciated by clients for conducting this proactive outreach that they were doing to mitigate these losses to contact that might have been expected in a trial that enrolled a lot of folks who were houseless and using substances in rural areas. And yet the peers really mitigated that loss to follow up by doing proactive outreach in the community, in parks and shelters and out in the woods and in dispersed camping sites really far away from town. It was quite an in-depth type of outreach. Peers also served as a communication bridge with the healthcare system. So some participants described that there was a sort of translation effect where the peer would co-attend telemedicine visits most frequently and the participants would want to say something and the peer would help them say it to the doctor in the way that the participant wanted to say. And then the doctor would want to say something to the participant and the peer would help kind of translate that into words that the participant could understand better. So the peers were a communication bridge. The effect that peers had on addressing other life needs and just basic needs like food and shelter was really important to the participants. And many participants sort of left with the takeaway that although they did successfully get hep C treatment and cure, they would not have if it wasn't for the peer. Here's a quote that we found representative. She would always find me one way or another. If she couldn't reach me by phone, she would come to my mom and dad's house. No matter what it took for her to track me down, she always did. She didn't just stop at one spot because she wasn't able to get ahold of me. She never gave up. I love this quote because it really to me highlights what we've said about the intervention from the beginning is that the peers are the secret sauce. Like the peers are what makes peer assisted telemedicine work and it's because they were like this. They were able to find people who were otherwise not going to be found by the healthcare system. In addition to the peers, the characteristics of the clinicians were also really important. The participants described clinicians as providing nonjudgmental and non-stigmatizing care that was really valuable to the participants. Clinicians were seen as informative and patient and attentive. And a key feature was that participants felt as if they received hope from the clinicians. A representative quote is here. I was treated just like another human being. Usually in like a hospital situation or in most doctor's situations, it feels like a judgmental situation. Since they know that you're an addict, they start to look down on you or talk down to you. It's like a judgmental thing. I didn't feel any of that with this telemedicine at all. They talked to me like I was an equal. So in addition to the features of the peers and the particular characteristics of the clinicians, there were some elements of the model that were really important as well. Some kind of structures of the model that made it work for participants. So one of those is that it was mobile and in the community and that things were very flexible. The support from the peers kind of facilitated all of these features. Peers driving around, meeting participants. Peers giving participants rides to labs, for example. And also peers just being flexible. Hey, I thought we were gonna meet today. Didn't work out. See you tomorrow. And just trying again, just having a really flexible attitude. The other element that was successful was the rapid access to telemedicine. And it was rapid and flexible in that it could be wherever the participant wanted to make the call from. That was really essential. So we had a lot of telemedicine visits in the vans, in campsites kind of on the side of the road or in the, there's a particular dog park in Douglas County, Oregon, which has probably been the site of more hepatitis C cures than any dog park in the world. So that's where we were able to flexibly meet people literally where they were at. And then the final element of the model was the role that peers had in helping with adherence, whether it was adherence to taking medications or adherence to maintaining appointments. So a representative quote here is, I didn't have to not go to work or make another appointment because of it. They came and I sat in the van, then they punched it on the computer for me and I talked to the doctor that way. It was real easy. It would be like a walk-in almost. I just scheduled it and did it real fast. I didn't have to wait. So these features, the peers, the clinician characteristics and the structural features of the model were really valuable to the participants in our qualitative data. Some sort of like a super theme or a larger theme that emerged from the qualitative data as well is that participants viewed engaging in hepatitis C treatment and making harm reduction changes and making other life changes as sort of steps that occurred along a path, which was really beautiful to see, frankly. We had a lot of people, we were intentionally recruiting people who currently use drugs and were not seeking substance use treatment, but they were willing to get hep C treatment. And then once they got engaged with hep C treatment, there was more motivation to start engaging in harm reduction treatment. And they were with the peer more and they trusted the peer more. So they were more interested in harm reduction changes. And then after that, many other folks made really remarkable life changes. Many of our participants stopped using substances altogether. Some of our participants became peers themselves and currently work with us in that capacity. And many others went on to do great things, get jobs for the first time in a long time and get into healthy relationships and get into stable housing. And it was just really a honor to see the way that people could make successive changes along this path. Some quotes that sum that up. Well, I intend to change my whole life and I just figured it was a good way to start it. It being getting hep C treatment. If you're gonna start changing your whole life, you might as well get the hep C taken care of first. I think that's a great answer. And then another one is I was afraid. I was never gonna be able to quit drugs. Things are looking up since they told me that I've gotten rid of the hep C and stuff. I'm starting to pull a little bit more strength out of things looking up like that. So people found that hep C treatment was a thing that they could do and succeed in when they had the peer assisted telemedicine model. They could succeed in hep C treatment and that predisposed them to succeed in other things. So that brings us to implementation. So we had this model that's sort of wildly effective. We had a, you know, in the general population, we had an effect size over four for the primary outcome of hepatitis C or a risk ratio of cure of over four for these sort of sub ad hoc subpopulations of homeless folks, it was even better. We knew that the model worked really well and it probably caused some other beneficial harm reduction changes. So how did we get it out? You know, we did the study in only five rural counties. How do we expand it out to the whole state where we know that similar problems are persistent all through the state, not just in these five counties that we're working on? And our answer to that was peer assisted telemedicine for hepatitis C and syphilis or PADS. I'm not gonna talk much about syphilis today, but just focusing on the work as it relates to hepatitis C. So we expanded PADS really rapidly. After the preliminary results of the Oregon HOPE telehepsy trial were available internally, because the Oregon model was constituted with members of Oregon Health Authority there at the table from the get-go, we sort of immediately disseminated those results. We would look at preliminary results in our weekly meetings and there's someone from OHA sitting in that meeting with us. So it was almost in real time how we were able to disseminate these results. And that led to really rapid uptake. So initially we started offering peer assisted telemedicine for hepatitis C treatment in a non-randomized way to people who had been through the study and failed to get cured, which is people mostly in the usual care arm, just because we wanted to ethically provide hepatitis C treatment to people in the study. But we were able to expand that really rapidly starting with some state opioid response funding in 2020. And then we could expand to about two more counties in 2020. And then with additional state opioid response funding in 2022, we started expanding much more rapidly. So currently we have 17 sites across 20 of Oregon's 36 counties. And those are folks that we've at least trained, 20 out of 36 counties. And then of the people that we've trained and they've started to do it, like they've already got a hep C treatment initiation done in their county, we've got 14 sites across 16 counties. So we've got really broad reach. And if you remember that map of counties, you can see that of all these super rural areas where there's a ton of hep C mortality, PADS is in almost all of them. So it's really encouraging that we're able to go to these areas with the sort of most robust need. This is our results from PADS. We are using the same model. We're using peers. They're mostly funded by that same Prime Plus program that I mentioned briefly in the beginning. And the peers and the clients help navigate participants through the telemedicine hepatitis C treatment process. You can see that we've engaged a lot of people. This is data since 2021, predominantly since the end of 2022. And this is showing that we've got over 900 folks, almost 950 folks for whom we've collected pre-treatment labs. You see that our hepatitis C positivity rate is still insane. So we have like a hep C RNA positivity. So current active infection out of everybody who goes to get labs, current active infection is almost 30%. So that's really high. It really speaks to that organ, that high level of prevalence of hepatitis C in organ. And then out of those 303 people who we have found hepatitis C infection, we're linking the vast majority of them to treatment with a telemedicine visit. And almost everybody who gets linked to a telemedicine visit is able to initiate treatment. And then the way we count our numbers is just kind of continuous. So we've got 192 people who've initiated treatment, a hundred of them approximately have completed treatment. Many of those 94 folks who have not completed treatment are just taking treatment still. The treatment takes two months or three months and they're just not done yet. But of everybody who's completed treatment, we've proven cure in 95% of people. So we're really proud of these numbers. It's a large program with reach all through the state. So perhaps you could say maybe we should be curing more people. However, these are 95 folks that are very similar to that population of people that we initially recruited in the Organ Hope Study. So we have a really high rate of homelessness amongst our population, almost universal rate of ongoing substance use. These are folks who don't engage with the medical system and they frequently specifically avoid medical care as it stands. So the fact that we were able to get these 95 folks cured, to me, they really represent people who would not have been cured for hep C otherwise. And eventually they would have contributed to those mortality data that were so startling in the beginning. We are working through some dissemination efforts. A first thing that we've done is organize our website, peerpathstohealth.org. This is a great spot to find more about resources. We've collated all of the evidence that we've been publishing from the Organ Hope Study and also directly about paths. Sort of collated that here as a reference. We have some example forms, for example, our lab form, which can be used in that standardized way that I was alluding to. So we've got some resources and also contact if you're looking for technical assistance or further questions. And we'll talk in the next couple minutes before we have some time for discussion. We'll talk about what occurs next or what we're doing sort of going forward. So one thing I'd like to talk about is an ongoing trial here at OHSU and through the various PATH sites called dried blood spot test and treat. So what we found in Oregon Hope is actually the biggest barrier in the in the randomized controlled trial where we had you know pretty tight data and survey and follow-up on everyone. The biggest drop-off in our study actually occurred before the study. So remarkably in the Oregon Hope study we had an 84% retention rate which is really great for a study that's on purpose recruited folks with homelessness and substance use. So we got a really high retention rate but what we had a really high dropout rate was when people were offered to be in the study and they knew they had hep C or they knew they had a hep C antibody and they were offered incentives to go get labs and be in the study and they declined. And the biggest reason people declined was because they didn't want to get a blood draw. So we know that phlebotomy is hard for folks especially with a history of intravenous substance use. We also know that phlebotomy is really stigmatizing so it's a really hard procedure to undergo for folks who are currently using drugs. In our area of Oregon in the PATH program we've really worked to kind of identify the phlebotomists that the locations for phlebotomy the labs that are the best and even individual phlebotomists we've got sort of a list of preferred phlebotomists around rural areas in the state. But even with that it's really hard to get phlebotomy done and it's a barrier or a bottleneck to prevent people from even starting to engage with PATH. So one ideal we have is to replace phlebotomy with dried blood spot. So dried blood spot can do a lot of things but not everything so the dried blood spot cards that we have access to are covered by participants insurance. They test for hepatitis C antibody and hepatitis C RNA. They also test for hepatitis B antigen. They also test for HIV and they also with a fourth-generation antibody antigen and then they test for syphilis with a TPA. So we can do that on two cards in the cartoon here. Those are the cards with the circles so just to make sure you get enough blood we ask people to complete two cards of the circles and that tests for all all those things I just said. And then we also ask people to complete two other cards which are slightly different they're called serum separator cards and these tests for hepatitis B core antibody because of course whenever you're starting hepatitis C treatment for someone if they have active hepatitis B you could treat the hep C and unmask their hep B and they could get acutely sick from hep B. There's a very very small chance that that could also happen if they don't have a hep C antigen or a hep B antigen but they happen to have a hep B core there is a chance that a hep B core could convert to active hep C and so we try to take that chance off the table by proving that they don't have an isolated hep B core. So those are the ways we can do the testing and what we're looking at is can we replace the phlebotomy step of the pretreatment workup for peer-assisted telemedicine for hepatitis C replace phlebotomy with dry blood spot testing. I'm running right now a cluster randomized trial at 18 of our PATH sites throughout the state excuse me and we will see we've just started recruitment and we'll see how it's going. So far there's difficulties training peers to collect dry blood spot certainly can be done I'm very impressed with how willing the peers are to take it on but it is kind of hard so I would recommend some thoughtfulness if you're thinking about expanding that in your area and the uptake by the peers or the enthusiasm by the peers is actually pretty strong I think the desire to help folks avoid going to the lab runs pretty strong in a lot of these harm reduction communities and also just the practicality of having to pick somebody up and take them to the lab and take them back that type of transportation work often falls on peers and so to cut that out is a big lift of a burden for the peers. So I'm looking forward to recruiting the rest of this trial and hopefully reporting this results soon. The other thing we're really working on is disseminating paths so we've had some great success in Oregon I'm really proud of what we've been able to do in Oregon but I would love to be able to expand our model to other other states because many states are like Oregon where there's an academic center here and there's tons of hep C doctors there and tons of people who are willing to help and then there's all this landmass and there's no providers in between it feels like sometimes. So telemedicine seems to be the fix for that and peer-assisted telemedicine seems to be the thing that fixes all the problems that telemedicine can't fix on its own like you don't have a phone or you don't have cell service or whatever or you just don't trust doctors. The peers help with all of those things so the peer-assisted telemedicine I think is a model that could really expand to other states. We are intending and have not yet gotten sufficient funding to package up our sort of training and technical assistance materials so that we have a bit more of a like a deliverable that we can give out to people and we would love to partner with folks to develop that if there's interest. I think in general I think it sounds kind of simple it's like just doctors doing telemedicine but at the same time the beauty of the intervention is really in the details. I think the way peers are trained, the way peers are sort of acculturated into this type of health healthcare specific work is really important and so we have a lot of experience with that a lot of lessons that we could share so if you're interested in this type of model we would we would love to talk. So far we've been looking to our our northerly neighbor and talking to some folks in Washington. They have a very exciting telebuprenorphine program and so the idea of combining telebuprenorphine and telehepatitis c is almost too good to be true but that's a great example where they've got a huge infrastructure in place for telebuprenorphine already but they don't have the same type of peer infrastructure that we have in Oregon so it would require some really thoughtful kind of startup I think to do properly. I think we've got plenty of time for questions and any discussion and I'm hopeful we can have a nice chat. I do just want to mostly acknowledge our participants. Imagine being a rural person who's currently using methamphetamines in rural Oregon and being approached by OHSU researchers that was a big thing for them to put their faith in us and I'm really really appreciate them doing that. I really appreciate the peers we meet with the peers every week for a PATHS operations call and it's definitely the coolest people I hang out with in a week at work and they're really fun so I really appreciate working with them. They're really dedicated to turning around the health of their communities in rural Oregon. My main mentor is Todd Horthis who I sort of owe my entire career to so I always like to thank him and our collaborators collaborators and funders of course have been really foundational. Thank you so much that was very interesting and very hopeful presentation to help reach these people that you know have difficulty with getting to doctors either because of the rural or not having the technology to do telemedicine so this is great. We did have a couple of questions that already came in. One was about the peers themselves. Are they certified peer specialists or peers that had specific training through your program? Yeah in Oregon peers are certified by OHA by the Oregon Health Authority. They are situated or certified through the traditional health worker pathway so they receive licensure in that sense. They have basically the basic requirements are some training in recovery principles and practices and then two years of sobriety which this agency that licenses them considers two years without using illicit substances so like abstinence-based or like so there are clearly people who have a lived experience of substance use in Oregon. Okay we also had a question about how you facilitated telehealth and patients with unstable housing since they tend to struggle with internet access. Yeah that was really a foundational thing for us. I mentioned that the rate of un-interneted people in Oregon is really high so we did that by relying on the peers. We had provided the peers with hardware and to complete telemedicine visits laptops and cell phones then we used the academic medical center OHSU's resources for secure communications and because the peers and the clients were already in such a sort of trusting healthcare navigation type relationship peers would anyway be coming to the telemedicine visits on for almost all the participants anyway and so we just asked the participants to do the visit from the peers technology and mostly they wanted to do that visit sort of physically right next to each other anyway. So we like I was saying we I've done telemedicine visits while people were in you know cars in really rural Oregon and usually there's not enough cell there's there's frequently not a sufficient internet but there's almost always enough cell so we could get at a minimum we could do over the phone visits but almost everybody else was able to get sufficient cell to do a choppy video visit even in a really remote areas. There was one question is there are there any issues with insurance coverage if patients are still actively using? I've previously heard from my ID colleagues that sometimes it's not covered if somebody's actively using. Yeah so one of the reasons why Oregon has such a terrible hepatitis C epidemic is because of this type of law that was in place or these types of restrictions. In Oregon Medicaid is expanded we have really good access to medications but up until 2019 there was very strict basically the same requirements that it took to get a liver you would have to meet those requirements you have to be really sick with liver disease you had to not use drugs and you had to not even drink alcohol which doesn't even pharmacokinetically make sense. So those were the restrictions up until 2019 which laid the groundwork for our uncontrolled hepatitis C epidemic. However after 2019 in Oregon Medicaid covers hep C drugs and in January 2024 until now there's not even a prior authorization so we've been able to move from sort of the worst type of state for hep C drug coverage to actually in the kind of top performers of states in a short amount of time. On hepview.org you can check in your state what the Medicaid insurance requirements are and it will give your state a score whether it's like as bad as Oregon in 2019 or as good as Oregon now you'll have something in that range. Private insurers are sort of different and sometimes make up restrictions. It is both unethical and not evidence-based to risk to prevent people who use drugs from getting hepatitis C treatment. The cure rate in active substance using people is almost identical and over 95 percent. The reinfection rate is small and it's quite easy to treat people once again so I would really push back and do frequently push back against insurers that put up those types of barriers. Here's another question. Can you speak to clinical experience if telehealth arm patients were found to have advanced decompensated liver disease how that changed or didn't change the management? Yeah great so this has been a really fun thing for me to sort of learn how to do is make fibrosis assessments virtually. So frequently we just relied on the labs to sort of choose whether or not somebody had hepatic fibrosis or not and obviously the exam is a little bit more limited in telemedicine. We had very few people who had decompensated cirrhosis but when we did we would just make tailored individual decisions about their hep C treatment. So many people with decompensated cirrhosis can still be treated for hepatitis C but of course it's a different treatment regimen that's a little bit more complicated and a lot more likely to cause side effects unfortunately. So we would we'll do that over telemedicine and actually sometimes we have physical clinics will kind of start hep C workups in cellular Oregon for example and then if it's they're decompensated they'll call us and we'll do it. And the reason for that is just because we're the five providers that we have available for hep C treatment. They're all experts in hepatitis C treatments and so we're able to do it but of course if people are quite decompensated and have for example a meld that's high enough for transplant or hepatocellular carcinoma we refer them to hepatology which is a still a big gap because there's not really hepatology outside of the couple of metropolitan areas in Oregon. So once you get people cured what does the treatment plan look like or the involvement what the peers look like once they're achieving SVR? Yeah that's I think really fun about hep C treatment is once you're cured you're done. So for hep C there's no kind of follow-up actually we structure our visits so that the providers typically will see the participant one time give them the medicine and then there's a pharmacy kind of protocolized follow-up but but there's not another clinician visit. What we find is that after people get cured they frequently stay in contact with their peers and they'll continue doing harm reduction frequently continue or start doing substance use disorder treatment or other sort of recovery support services because the peers are not because the peers are funded separately. I think of I think of pads more as a thing that peers have access to rather than the peers working for us like I work for the peers more more than the other way around and so because of that it's just like a thing that the peers and the clients did and then they go on to do the other stuff they just meet other goals that they have and you know a lot of that's housing a lot of it is finding jobs a lot of it is recovery. Were there any patients that had enough medical issues that required in-person evaluation or could not be treated remotely? In the study we did we excluded people with decompensated cirrhosis but I think that was only one person or maybe two people if I'm remembering right. In our implementation work we will frequently see pretty much everybody the exception is if we're worried about very severe liver disease like a MELD over 16 to 18 is kind of where people start thinking about transplanted organ so a really high MELD or they all already have HCC hepatocellular carcinoma when that happens we refer them to hepatology which is sometimes virtual or in person depending on the peculiarities. We have some wonderful compliments somebody had just mentioned they were totally impressed with the impact you've made on the health of this population how you've circumvented barriers to care in this population is truly amazing and we had some somebody echo that so thank you. And let's see anybody doing similar work on the east coast? I'm in rural Virginia and he also agreed with the comments about the talk. Oh thank you yeah you know I don't know of anybody doing something similar in Virginia certainly but it could be you it could be you and us so feel free to reach out to us if you're if you're interested. I'm wondering if you have a date on what percentage of patients are on MLUD or data? Oh increased pre or post program? Yes I we did not see a statistically significant pre post change in that I think those numbers are published in the main findings which was authored by Andrew Seaman in clinical infectious diseases in December 2024. So I would check that citation I think it's in table one there. It was not very many because we recruited for organ hope we recruited people who were using illicit opiates in the last 30 days or were injecting drugs so it was kind of by purpose on purpose we were recruiting non-treatment engaged people. Okay and somebody did answer about the east coast and said southern tier AIDS program and reach medical Ithaca New York. Look us up. Right on. Okay and I think that's it for all the questions just some more appreciation for your talk and the work that you've been doing. Yeah somebody's saying that they're going to reach out to you there in South Carolina so. Right. Okay well I guess it's 5.58 as far as like CME you've got to go back to the website where you registered and fill out the course evaluation and then you can get the CME credits for this. We're looking forward to five more presentations the next five weeks. Next week we have Dr Peck who's going to be talking about PTSD treatment for people who are in treatment for opioid use disorder with either buprenorphine or methadone so I hope that you'll join us again next Wednesday at 5 p.m. and again I'd like to thank Dr Spencer for the opportunity to learn from his experiences with treating hepatitis C in rural communities using the PATH model and thank you again for attending and have a good night. Thanks so much.

Peer-Assisted Telemedicine

Hepatitis C

Opioid Response Network

Oregon Health and Science University

Telemedicine

Substance Use

Rural Healthcare

Peer Support

Barriers to Treatment