Meeting patients where they are is an essential part of reaching hepatitis C elimination. Traditionally, healthcare has been based on having a setting where people attend to receive treatment, however, due to a host of barriers, many will not attempt to access these types of healthcare services.
This case study will explore how the Cherokee Nation Health Service has used point of care (POC) testing to overcome this challenge. It will also explore how Dr Mera, the Director of the Infectious Disease Department at Cherokee Health Services and his team implemented a community centred integrated care model for hepatitis C elimination, particularly among marginalised and underserved communities.
In 2023, the Cherokee Nation Health Services decided to use a mobile unit to carry out POC testing in the community after a high number of people failed to return for the results of their lab-based tests and treatment initiation had fallen to around 40%. Using approved POC HCV RNA diagnostic tests enabled the team to make immediate, evidence-based treatment decisions directly in community settings. Initially, testing uptake was low but improved after adding incentives, which encouraged those who were tested to stay for their results.
During this outreach, 405 participants (both Native and non-Native) were offered POC HCV RNA testing with an 85.9% acceptance rate. 9.5% of tests were HCV RNA positive, and 34% of those who tested RNA positive initiated treatment.
This experience highlighted the high feasibility and community acceptance of POC testing, with successful same day treatment initiation.
‘Breaking silos is what [we] need to do’
Studies have shown that hepatitis C and substance use disorders are closely linked together, accompanied by mental health conditions such as depression, anxiety and PTSD. However, often healthcare services are split into many different departments and people are required to travel to multiple locations. This model creates a barrier for people living with hepatitis C as they are also often managing other issues such as mental health conditions, substance use disorders and homelessness, increasing drop off rates.
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The Cherokee National Syndemic Care Model prioritises face to face assessments and dedicates time to understanding the needs of the person they are helping. This ensures that the care provided goes beyond just physical health and addresses mental health also.
Factors such as stigma and discrimination also deter individuals from seeking testing and treatment. Dr Mera shares how Cherokee Nation addresses stigma during Harm Reduction Outreach Programmes. He explains that their priority is to treat each person with respect, acknowledging them and where they come from. He emphasises the importance of listening despite limited time and space. To further destigmatise hepatitis C testing, the programme is moving towards a more holistic approach, offering a ‘wellness visit’ where patients will be offered a broader health check which will include blood pressure measurement, body weight measurement, POC diabetes and lipid screening and testing for HIV, hepatitis C and syphilis. This approach presents as general health care rather than disease specific, with POC testing facilitating better linkage to care.
‘You first need to build trust’
Trust is a key part of initiating testing and continuity of care and it takes time and consistency. When the Cherokee Nation team first set up in the harm reduction site, most people did not want to be tested. However, when patients started to engage with the team members, getting to know them and seeing some of their friends get tested, it encouraged them also get tested. Dr Mera emphasises that this process cannot be rushed and requires persistence and presence. Patients like to know the services they are accessing are reliable and consistent. Being on site on the same days and at the same hours each week help to build trust and confidence. Dr Mera adds that the use of incentives, though valuable, are not effective on their own.
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‘The more partners you have, the more stakeholders you have, the more likely your programme is going to be successful’
Partnerships are vital for expanding access. Dr Mera explains that the Cherokee Nation Health Services collaborates with all key players involved in service delivery including the Cherokee Nation Behavioural Health department and Cherokee National Public Health department. Highlighting that internal partnerships are just as important as external partnerships.
Dr Mera and his team attribute the success of the Cherokee Nation Health Services to their leadership, namely Principal Chief Chuck Hoskin Jr and Deputy Chief Bryan Warner, who have ensured that the programmes they run have the resources that they need. The programme was started with an initial donor grant and when that grant finished on learning of the programmes impact the leadership of the Cherokee Nation Health Services found the funding to continue. Through sources like the Public Health and Wellness Fund Act, the programme has received the appropriate amount of funding as well as continuing to expand programmes and implement innovations such as POC testing.
In the midst of funding cuts across the globe, the leaderships clear understanding of community needs and their willingness to respond has enabled programmes to continue.
The Cherokee Nation Health Services approach to hepatitis C Elimination shows how integrated care, innovative testing strategies, strong partnerships – both internally and externally, community based and culturally appropriate outreach and unwavering leadership commitment can help improve patient outcomes for marginalised communities.
Through his work Dr Mera has exemplified the four pillars of a NOhep Medical Visionary – he has gathered allies, educated peers, been a vocal ambassador and advocated for increased investment.
If you would like to learn more about the Cherokee Nations work, please visit https://www.cherokee.org/
