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While Hep C infections climb dramatically, a downtown Hep C clinic struggles to find funding

The Metropolitan Health District estimates there are 20,000 cases of Hepatitis C in San Antonio, yet less than 25 percent know they're infected, and a clinic that could treat thousands of patients is understaffed and underfunded.

Hep C is a bloodborne virus that attacks the liver and, untreated, can cause liver disease, cancer, and failure. In Bexar County, about 4,000 new cases are reported annually.

The caseload overwhelmed gasteroenterology clinics at the University Health Center, prompting the need for a clinic devoted solely to treating Hep C. In 2000, it opened the Hepatitis Clinic, one of the few clinics that treats exclusively Hep C in South Texas, and the only one that treats low-income people and people without health insurance.

Prior to 1992, the most common way to contract Hep C was through blood transfusions. Today, that risk has virtually been eliminated with blood screening. Today people can contract Hep C through intravenous drug use and tattoos received with unsterile needles. People living with a Hep C-infected individuals should avoid sharing items such as razors, toothbrushes, and nail clippers to reduce the risk of exposure to infected blood.

Each month, the Hepatitis Clinic, staffed with two doctors - one full and one part-time - two physician assistants, and a clinic coordinator, sees 500-600 Medicare, Medicaid, and CareLink patients from all over the state (CareLink is Bexar County's insurance program for people who don't have health insurance and aren't eligible for Medicare or Medicaid).

Hep C treatments are expensive and intense, sometimes requiring patients to visit the clinic weekly, which is difficult, says Anastacio Hoyumpa, director of the Hepatitis Clinic, because the clinic is chronically underfunded and understaffed. In order to provide care for the high volume of patients it sees, the clinic relies on the tenuous goodwill of pharmaceutical companies and annual grants.

The clinic is working on outreach to get people at risk for Hep C to come in for testing. This year the clinic participated in National AIDS testing day, providing free Hep C rapid tests in conjunction with the San Antonio AIDS Foundation. "We don't talk about who has Hepatitis C, but who should be screened," says Hoyumpa. "In most cases, Hep C is discovered incidentally, when a patient comes in for some other procedure, such as a blood test."

The hard facts about Hepatitis C

More than 4 million people are infected with the disease, 2.7 million of them chronically
10,000 people die annually from complications of Hep C
CDC projects the death rate will triple to 38,000 over the next 10 to 20 years

300,000 people are infected in Texas
20,000 are infected in San Antonio
3,000 new infections reported annually
Hep C causes 80 deaths a year

Hep C is detectable in antibody tests within 3 months of exposure. Who should be tested?
Those who:
Received a blood transfusion or organ transplant prior to 1992
Used intravenous drugs
Received long-term hemodialysis
Received clotting factor prior to 1987
Are health-care workers exposed to needles or sharps
Were born to a Hep C-infected mother
Have unprotected sex with multiple partners
Received tattoos or body piercings with unsterile needles
Have household exposure such as sharing a razor or toothbrushes with an infected person
NOTE: Hep C can only be contracted through exposure to blood. It can't be passed through saliva.

What does the liver do?
Stores iron, vitamins, and minerals
Produces bile to digest food
Detoxifies air-born and ingested poisons (such as alcohol)
Stores energy
Manufactures proteins
Regulates blood clotting
Helps regulate the immune system

The American Liver Foundation 1-800-GO-LIVER
The Hepatitis Clinic, University Health Center 358-5832

Source: American Liver Foundation and the Center for Disease Control

According to the National Liver Foundation, at-risk groups for Hep C are diverse: from health-care workers exposed to Hep C-positive blood to people who received tattoos with unsterile needles to anyone who ever used intravenous drugs, even once. "It's a big mistake to think that this is a disease of drug users or a fringe element," says Bob Madison, a spokesman for the National Liver Association. "Soccer moms and CEOs are just as likely to have it as a rock 'n' roll freako with a tongue piercing and multiple tattoos."

Prior to 1996, it was common practice to vaccinate a group of soldiers using a jetgun without sterilizing it between patients. "The medics would move through a whole line of guys - by the time they got to guy 10, he was getting injected with the blood of nine guys," says Madison.

Once exposed, 85 percent of people infected will develop chronic Hep C. Untreated, a Hep C-infected person may take 10-40 years to develop cirrhosis depending on their general health and lifestyle. Cirrhosis, scarring or fibrosis of the liver, decreases liver function and increases the chance of liver failure and liver cancer. Yet, Hoyumpa says, "Even with cirrhosis, it's still not too late for treatment, as long as the person is not in liver failure."

The most successful treatment is a mixture of two drugs, pegylated interferon, an injection administered weekly, and ribavirin pills, which is generally prescribed for six months to a year. According to the National Liver Foundation, combination therapy costs $6,000-8,000 per patient, per year. While CareLink covers office visits and lab work, it does not pay for prescriptions; the Hepatitis Clinic works with three pharmaceutical companies that donate drugs. "The minute the drug companies say, We have given enough to the clinic," says Hoyumpa, "that will be the day that we close the clinic, because we can't treat any of those patients."

Follow-up visits comprise the bulk of the clinic's patient load. Patients are seen in the clinic once a week during the first two months of treatment. Even those who respond well experience difficult side effects: flu-like symptoms, fatigue, depression, and bouts of intense emotion. More severe side effects, which Hoyumpa says are "less common, but still our biggest fear, and something we have to monitor very closely," include suicidal thoughts and optic neuritis, inflammation of the optic nerve that causes vision loss and sometimes blindness.

Post-treatment patients must also be seen regularly to monitor liver function and cirrhosis, as must those who don't respond to or aren't qualified for treatment.

Patients with depression, diabetes, or heart and kidney disease, which can all be exacerbated by Hep C therapies, don't qualify for treatment. Similarly, people who use drugs, are obese, or drink alcohol - all of which contribute to liver disease - will not respond well to treatment. "I tell patients that drinking alcohol when you have Hep C is like pouring gasoline on a fire," says Hoyumpa, but he emphasizes that it's important for physicians to follow these patients. "In fact, greater effort should be exerted to make them a suitable patient."

The Hepatitis Clinic also offers a monthly support group, which provides yoga classes and emotional support, as well as lectures on issues such as social services and labor rights. "There are a lot of stigmas associated with Hep C," says Kashi. "Some people have lost their jobs jobs; they are fired because they are too sick to work during treatment. Some of our patients are shunned by their family members."

Today, the Hepatitis Clinic is funded through the University Physicians Group, which provides for the current staff level. Anything above that is funded through grants. According to Hoyumpa, who also works half-time at a similar clinic at the Veterans Administration Hospital, the clinic should have at least three physician assistants, but it recently lost one when a grant ended, which could result in patients waiting longer for appointments; at times the wait has been as long as six months. "We are looking for more grants," he says, "but the clinic sees so many patients that to be able to plan our programming and provide good care, we need stable salaries not dependent on grant money."

Hoyumpa has appealed to the city's elected officials for more funding. "We have approached the City Council and the county commissioners, but we haven't gotten anywhere. We have already saved the City millions in prevention, but the City would rather fund a soccer team."

Yet, if Hoyumpa is cynical about the future funding of the clinic, he is optimistic where the disease is concerned. "Ten to 15 years ago there were no treatments. Patients came to us with the feeling they were going to die," he says. "Today Hepatitis C is not a death sentence. There are effective treatments, and new drugs are coming on board. `Hep C treatments` are the subject of intense study. There is reason to hope."

By Susan Pagani

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