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Helping the Hard to Reach

Shruti Mehta works to deliver HIV and Hep C care to people who inject drugs.

Interview By Jackie Powder • Photography by Chris Hartlove

Shruti Mehta, PhD ’02, MPH ’98, has seen HIV/AIDS evolve from death sentence, to chronic disease, to the promise of an AIDS-free generation, thanks largely to lifesaving advances in treatment.

Now hepatitis C appears to be on a similar trajectory, following the approval in 2014 of a new 12-week drug regimen that’s 90 percent effective.

For Mehta, an Epidemiology professor who studies obstacles to HIV and hepatitis C care among people who inject drugs (PWID) in India and Baltimore, the talk of eliminating these diseases is exciting—but much work remains.

“There are still a lot of barriers to deal with if we want to change the overall picture,” says Mehta, who leads the long-running AIDS Linked to the IntraVenous Experience (ALIVE) study, which tracks thousands of past and current PWID in Baltimore.

What are the challenges in your research?

The recent mantra for HIV has been seek, test, treat and retain. The paradigm is easily extendable to hepatitis C except it’s a shorter path: seek, test, cure and prevent. But PWID can be more challenging to reach, get tested and into care and on treatment.

For HIV, our big problem today is retention. PWID can get into care but they just don’t stay there and tend to fall off the radar. For HCV, the biggest challenge is getting people tested.

The challenge for both is to first understand what the barriers are and then design interventions to strategically address them.

How was the HCV treatment trajectory different from that of HIV?

The path was slower with hepatitis C, and the game-changing drug came only very recently in 2013. We’re in a place where the drugs are there, but they’re expensive and there are a lot of restrictions in terms of insurance coverage relative to active drug use and disease stage. 

Even with the dramatic improvements in access to antiretroviral therapy (ART), only a third of those who need the treatment for HIV receive it. For hepatitis C, the picture is more stark: Up to 80 percent of the PWID population is infected with hepatitis C and just between 5 and 10 percent are on treatment.

"We know that if people access one service they’re more likely to use other services, but few people have access to multiple services. They might go to a clinic that offers needle exchange or opioid substitution therapy but not HIV services. There’s a lot of missed opportunity."

In India your focus is on the exploding HIV epidemic among PWID.

It’s estimated that 84 percent of HIV infection in India is related to heterosexual transmission, and previous prevention and intervention efforts were targeted to female sex workers and their clients, people who attend STD clinics and the general population.

As a result, we’ve seen prevalence and incidence go down among heterosexuals, but it’s going up in PWID and men who have sex with men (MSM). It hasn’t been until now that the government has focused on them.

There are emerging HIV epidemics in north and central India, which are thought to be related to new drug trafficking routes. In some cities, the HIV prevalence among PWID is as high as 30 to 40 percent.

What’s your strategy for surmounting traditional barriers to care?

We know that if people access one service they’re more likely to use other services, but few people have access to multiple services. They might go to a clinic that offers needle exchange or opioid substitution therapy but not HIV services. There’s a lot of missed opportunity.

As part of a large trial in 22 cities in India, we’ve set up integrated care clinics (ICCs) in 11 cities. These are one-stop shops for all services, tailored to each population—MSM and PWID—providing HIV, TB and STD testing and treatment, drug treatment, needle exchange and counseling. The 11 control clinics offer these services, but they’re all separate.

By putting everything in one place in an environment sensitized to the population, we hope we can improve uptake of testing and get people into HIV care.

What kind of results are you seeing?

To date we’ve registered more than 6,000 people across these ICCs. More than half have had HIV tests, and 5 percent are newly diagnosed as HIV positive. Despite the fact that we’re seeing a lot of clients and doing a lot of testing, engagement in HIV care and treatment is less than what we had expected. We thought we would build these ICCs and see a lot of people getting onto ART and that’s not the case.

We’ve created safe spaces for care, but we’re still asking people to come to us. We need to figure out how we can reach the hardest of the hard to reach.

Lost wages can be a barrier if someone has to take time off [work] to go to a clinic. If we offered a very modest payment or voucher, it might help to compensate for lost wages or provide something for their home like rice or lentils. Another option might be taking services to them.

Why did you title your recent Dean’s Lecture “HIV and HCV: The Beginning of the End?”?

There’s a lot to be hopeful about. I think we’re at a different place than we have ever been. We know what we need to do; now it’s about how to do it. It’s clear that a lot of the story has yet to be written and much work needs to be done. 

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B. Frank Polk
THE MACS HIV STUDY
In 1984, B. Frank Polk received NIH funding for Johns Hopkins-Baltimore to be one of four original sites in the Multicenter AIDS Cohort Study (MACS), among the world’s most influential AIDS studies. The prospective study of the natural history of HIV-1 infection in homosexual men has produced landmark discoveries regarding the pathogenesis, treatment and prevention of HIV. In 1988, the Department of Epidemiology launched the AIDS Linked to the IntraVenous Experience (ALIVE) Study to expand knowledge of injection drug users at risk of acquiring HIV.
 
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