‘Light bulb moment’: New approach to treating Hep C postpartum a success in St. Louis
A new “meds to beds” program at Barnes-Jewish Hospital dispenses Hepatitis C medication to women before they are discharged after giving birth (Getty Images).
Until recently, it was not uncommon for Dr. Jeannie Kelly, a high risk obstetrician at Washington University School of Medicine in St. Louis, to diagnose a pregnant patient with Hepatitis C, then refer her to a specialist for what is typically a simple medication treatment.
But when those patients returned to her office with another pregnancy down the road, it was often with bad news.
“I will see them again for their subsequent pregnancy, and they still have hepatitis C, and their first baby may be infected with hepatitis C, and their second baby is born with that risk as well,” said Kelly, an associate professor of obstetrics and gynecology and director of the division of maternal-fetal medicine and ultrasound. “It’s this problem that just keeps propagating.”
A number of legislative solutions, as well as the increased use of telemedicine during the pandemic, paved the way to broader access to medication, but the process of referring pregnant and postpartum patients out to other offices continued to be a “failing strategy,” Kelly said.
That’s where the new “meds to beds” program at Barnes-Jewish Hospital came in, dispensing medication to women before they are discharged after giving birth.
“There is a cure for hepatitis C that not only would protect the mom and the family and future children from infection,” Kelly said, ”but also prevent more conditions for mom down the road, including things like cancer and liver failure, a really huge big deal, both on the family and on the health care system.”
A study of this new clinical program developed by Washington University researchers found that when an infectious disease specialist visited a patient in labor and delivery, and then sent them home with the prescribed antiviral medication, women were twice as likely to be cured of Hepatitis C than women who were referred to an outpatient appointment to obtain their medication.
“They’ve got a virus. I’ve got antiviral,” said Dr. Laura Marks, an assistant professor of medicine in the division of infectious diseases at Washington University School of Medicine and an author on the study. “We’re a match made in heaven.”
What is Hepatitis C?
Hepatitis C is a virus that can cause extensive liver damage, including cancer, if left untreated. It’s transmitted through blood. In rare cases, it can also be transmitted to the baby.
Between 2010 and 2021, the number of Americans of reproductive age infected with Hepatitis C more than tripled, according to one CDC study. As a result, the number of infections discovered during pregnancy increased tenfold from 2000 to 2019.
About 5% of babies exposed to Hepatitis C during delivery become infected, according to the CDC, which began recommending Hepatitis C screenings for pregnant women beginning in 2020.
Treatment options are available for both the mother and baby, but getting treatment to postpartum mothers proved difficult despite increased attention on testing and access to medication.
In 2021, Missouri became one of several states to allow Medicaid to cover Hepatitis C treatment without a prior authorization, letting doctors prescribe patients all of their medication at once so they don’t have to navigate getting a refill halfway through. The medication is usually taken over the course of two to three months.
Until recently, Missouri only required medical providers to test women for Hepatitis C at their first prenatal appointment. Driven in part by rising STD rates in pregnant patients, a bill signed into law earlier this year added testing in the third trimester and immediately after birth.
The new screening recommendations are helpful in identifying infections earlier, but that alone isn’t enough, Marks said.
Unlike other infections, like syphilis, treatment can only begin after the woman has given birth because the antiviral can harm the pregnancy.
Up until recently, once a woman with a known Hepatitis C infection delivered a baby, she would receive a referral to a clinic to see an infectious disease specialist, like Marks, soon after being discharged from the hospital.
“But that usually meant sometime during the postpartum period, or often even further away,” Marks said. “That’s sometimes a really big lift for women to be doing all of these extra appointments during what could be a really chaotic time.”
Women of childbearing age make up about one-fifth of people with chronic hepatitis C globally. Accessing a cure can be even more difficult when the woman is navigating life with a newborn, Kelly said.
In 2021, Marks sent out a survey to obstetricians asking how the infectious diseases department could better help. She received half a dozen responses saying while the increased use of telehealth appointments was great for connecting their patients with specialists, they still needed help getting medication in the hands of their patients.
“It was that light bulb moment,” Marks said.
Her team began testing out prescribing antivirals to women before they were discharged from labor and delivery.
Marks and Dr. Madeline McCrary, also an assistant professor of medicine in the division of infectious diseases at Washington University School of Medicine, analyzed medical records of 149 mothers who tested positive for Hepatitis C and who delivered babies at Barnes-Jewish Hospital between January 2020 and September 2023.
Some were discharged with a referral, and others were discharged with medication, depending on whether an infectious disease specialist was available to visit them on the labor and delivery floor at the time.
They found that two-thirds of patients who received medication at the hospital took their full prescription of antiviral medication and were cured. Only about one-third of those who received referrals finished their medication.
‘Meds to beds’
While the “meds to beds” solution may sound obvious to those not practicing medicine, the reason it took years to implement is complex.
First, there can be a reluctance among non-obstetricians to treat obstetric patients, Kelly said.
“They’re not used to taking care of pregnant women,” she said. “A lot of other specialists have anxiety about prescribing medications that they’re not sure about the effects during pregnancy.”
And American health care remains very siloed. This is especially pronounced for OB patients faced with navigating several steps to get treatment. And at every additional step, more patients fall off course, Kelly said.
It’s why she’s been grateful for the eagerness specialists like Marks have shown to meet pregnant women where they are, especially because for many of her patients, who typically are younger and overall healthy, pregnancy is the first time they’ve seen a doctor in years.
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Kelly said the results have been encouraging and empowering to her patients, many of whom have a history of substance use or sex work, and who often carry some amount of distrust in the medical system.
“It’s a huge strategy to engage with patients who have had horrible experiences with the medical system in the past,” Kelly said. “Multiple patients have told me ‘this is so powerful. I know that I’m not just doing this for myself, but for my family and my future kids as well.’ So it’s been more than just a cure of Hepatitis C. It’s a lifeline for patients to find trust and a relationship with the healthcare system.”
In 2023, because of the project’s success in the obstetrics department, the doctors expanded the program to other parts of the hospital. Whether someone comes in for chest pain or because they were in a car crash, for example, they are tested for Hepatitis C and handed the medication on the spot.
So far they’ve treated 250 more patients through the expanded effort, and they’ve started hearing from other hospitals around the country hoping to implement the same changes.
Every time another one of Kelly’s patients is cured, Marks’ team emails her to tell her the good news. Lately the emails are coming more and more frequently.
“It’s life changing for mom and family right, to have this disease eradicated,” Kelly said. “ … This is why we come to work in the morning, no matter how hard it gets.”
