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The Long Goodbye: Leaving Humboldt

Of the 13 counties our ECHO project is targeting over 3 years, Humboldt County was the first I visited. The objective of the Project ECHO program is to build infrastructure to treat hepatitis C (HCV) by teaching primary care providers to treat, locally, rather than refer out to an academic medical center to see a hepatologist.

When I arrived in Eureka, in January of 2018, I didn't know how long I'd be there. I only knew that Humboldt had the highest rate of HCV in the entire state of California, and there were only 3 healthcare providers who knew how to treat. ​ I dove into the work, getting to know the local healthcare providers, the organizations they work for, and the culture of the community. I was most fortunate to be invited to join several ongoing task forces and committees and was impressed with the existing infrastructure and the community’s commitment to finding solutions to a myriad of problems related to illicit drug use and HCV.

Besides the recruiting of healthcare providers into the ECHO program, I wanted to find a project in the community where I could volunteer and while doing so, challenge the newly trained providers’ capacity to treat. I connected with Humboldt Area Center for Harm Reduction (HACHR), an organization that offers harm reduction services, including a widely used syringe exchange program serving people from all walks of life, but mostly the homeless and marginalized. Humboldt County has a very large and evident homeless population. Additionally, meth and heroin are readily available and consumed by people from all walks of life. HACHR is a place of great controversy for many people in Eureka, and there is considerable animus toward them from community members. The Executive Director receives threats on the regular, and there are groups actively seeking to take HACHR down. What a perfect place, I thought, to do an informal pilot project!

I was curious to see what might happen if once a week during syringe exchange hours, a nurse triage clinic be made available to the consumers. HACHR graciously gave me an office in the building, and placed a note on the announcement board, "The Nurse Is In". I do not have prescriptive privileges so my services were limited to triage, wound care, foot care, and education. Over the 6 months I was there, I saw an average of 7 people a day. Most of the visits centered around injection site complications such as abscesses. Each visit included presentation appropriate education, a mental health check-in, and an offer for a referral to a primary care provider. And, each visit ended with a talk about HCV and the importance of not sharing needles and good injection practices. While doing this work, I was able to connect a couple handfuls of people with a primary care doctor. And of those, one of them has been successfully treated for hepatitis C. This experience at HACHR, and my the experience of seeing this individual's commitment to being cured, serve as proof of concept that HCV care in a Harm Reduction Center is 100% feasible.

I loved my time at HACHR. It was a joy to be in service to the people there. HACHR is a place where the consumers can relax in an environment in which they are welcome, get a bite to eat, use a bathroom, get some clean syringes, engage in community projects and classes and when I was there, see a healthcare provider. While in the trenches at HACHR, I was educated about harm reduction by people who use drugs. One of their mottos is, “Nothing about us without us”. During this time, some of my own preconceptions were challenged, and I was schooled in the practice of empathy within boundaries. I had the opportunity to accept people right where they were. These invaluable lessons will go with me as I continue my HCV work. Surely, it will intersect with harm reduction many more times.

As I worked at HACHR, it became crystal clear that it was the perfect place to provide HCV testing for this hard to reach demographic. Any kind of testing requires a CLIA waiver at the state and federal level. My organization has a waiver, but we didn’t have any tests, so the waiver was useless. The application process for a waiver is lengthy and requires a physician to agree to be the lab director. One of the local physicians agreed to serve in this role, allowing us to move forward with the paperwork. We completed it, sent it in, and waited. It took about 6 months, but I recently learned that HACHR now has its waiver, so they are in the process of building up their HCV and HIV testing program. Collaboration with local HCV providers, the health department, and other entities is ongoing, and this vital service is now becoming a reality.

If HCV is to be eliminated in Humboldt County, HACHR is ground zero. The connection between HCV and injection drug use is part of what I call a tale of 2 epidemics. One cohort of the epidemic is composed of people born between 1945 and 1965; the baby boomers. And then there's the new cohort of people who inject drugs. This group is much younger, and the primary method of contracting HCV is through sharing needles during injection drug use. A robust harm reduction center with programs and services, like HACHR, is a gateway to HCV treatment, primary care, and other services. It is now possible, in California, for an individual who is actively injecting drugs, to receive treatment and be cured of HCV. No judgment. No stigmatization. During the treatment, the importance of not sharing needles is reviewed regularly, and interestingly, people who engage in one form of service tend to participate in others. It’s the ‘comin’ up club’, and it’s a joy to watch a disenfranchised individual step up and do something positive for themselves.

I finally left Eureka on September 18, the HepCarestream in tow behind my Ford F-350. Momentum had been built. When I left, over 20 primary care providers had signed up for ECHO and capacity to treat in this community was exponentially higher. People were coming into HACHR seeking out services.

With all the work going on in the community, the remarkable increase in the capacity to treat, a newly formed HCV task force, increase in medication assisted treatment (MAT) services, I’m feeling like ECHO made its mark on Humboldt County and they are well on their way to building an example of how a community can come together and accomplish micro-elimination. Keep your eye on Humboldt County. They have a mountain to climb, but they've got the right gear.

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