Hepatitis C Initiative in Ryan White Clinics—Findings from a Special Program of National Significance

The Health Resources and Services Administration (HRSA) presentedExit Disclaimer findings and lessons from a four-year demonstration project that supported 29 organizations implementing focused interventions designed to increase access to and completion of hepatitis C (HCV) treatment for people also living with HIV at ID Week, a leading forum for sharing infectious disease research and practice. The Hepatitis C Treatment Expansion Initiative was supported by the Ryan White HIV/AIDS Program’s Special Projects of National Significance (SPNS).

Hepatitis C: A Common Coinfection among People Living with HIV

Among the estimated 1.2 million people living with HIV in the United States, approximately 25% – that’s about 300,000 people – are also coinfected with chronic hepatitis C. Unlike the situation with HIV, where advances in treatment with combination antiretroviral therapy have resulted in reductions in HIV-related morbidity and mortality, treatment of persons infected with hepatitis C has lagged behind. National estimates suggest that as of 2013, only 16% of people living with hepatitis C (mono-infection) have been treated and only 9% have achieved a sustained virologic response (SVR).¹ Until 2013, the standard of care treatment for hepatitis C included a combination of pegylated interferon and ribavirin which achieved a relatively low rate of SVR, required up to 48 weeks of treatment, had multiple contraindications, and caused side effects for many patients. Since 2013 however, several direct-acting antiviral medications have been approved that have greater than 90% cure rates with few side effects.^{2, 3} (Learn more about HIV and viral hepatitis coinfection. )

The SPNS Treatment Expansion Initiative

The Ryan White HIV/AIDS Program (RWHAP) funds a comprehensive system of care for people living with HIV (PLWH) in the United States, particularly those who are poor and/or come from vulnerable populations. RWHAP-funded clinical care sites typically offer coordinated medical care and support services, similar to patient-centered medical homes. These investments in infrastructure and coordination, along with the high rates of HIV/hepatitis C co-infection, make RWHAP-funded clinical care sites optimal places to test the standardization and integration of hepatitis C care and treatment into HIV care. Recognizing this opportunity gave rise to the RWHAP-funded Special Projects of National Significance (SPNS) Hepatitis C Treatment Expansion initiative. Participating sites were given the choice to implement one of four models of hepatitis C treatment:

1. Integrated care with Hepatitis C virus (HCV) management by providers (without designated HCV clinic)
2. Integrated care with designated HCV clinic at different dedicated time
3. Primary care management with HCV expert backup
4. Co-located care with specialist who manages HCV treatment at Ryan White HIV/AIDS Program clinical site

The SPNS Hepatitis C Treatment Expansion Initiative enrolled PLWH coinfected with hepatitis C at 29 demonstration sites between 2011 and 2014. A total of 5,131 HCV-positive patients were enrolled across all sites. By the end of the project, 239 patients had started HCV treatment. This relatively low treatment initiation rate is likely a result of the limitations of the available direct acting antiviral medications for hepatitis C which required interferon before 2013; the expectation that new, interferon-free therapies were being developed; and the concerns about managing HIV and hepatitis C drug-drug interactions. The relatively high number of eligible patients indicated a need for expanded hepatitis C treatment in these settings. The proportion treated within each care model did have statistically significant differences when compared to other models. Of those treated, 100 (41.8%) completed treatment and achieved SVR; 94 (39.3%) discontinued treatment early and 5 (2%) completed treatment but relapsed.⁴

Lessons Learned

Valuable lessons were learned from the project, including:

1. Multidisciplinary teams were needed to ensure that all aspects of care and treatment were adequately and appropriately addressed.
2. A monthly telehealth-based community of practice for clinical providers was well-attended, highly valued by participants, and a key component to helping providers feel comfortable with initiating hepatitis C treatment for PLWH.
3. This SPNS initiative prepared RWHAP-funded clinical care sites to develop standardized systems for diagnosis, care and treatment of PLWH coinfected with hepatitis C. This preparation will be extremely valuable in the era of highly effective treatments with direct-acting antivirals.
4. Now that we have interferon-free direct acting antiviral therapies, we can anticipate a greater uptake of treatment for hepatitis C among RWHAP-funded clinical providers and their patients.

To improve health outcomes for people living with HIV, the recently updated National HIV/AIDS Strategy calls for more comprehensive, coordinated care that addresses treatment of co-occurring conditions, including hepatitis C. The Hepatitis C Treatment Expansion Initiative offers lessons and tools that can help build system capacity and expand client access to curative hepatitis C treatment in RWHAP-funded programs.

References

1. Yehia BR, Schranz AJ, Umscheid CA, Lo Re V, 3rd. The treatment cascade for chronic hepatitis C virus infection in the United States: a systematic review and meta-analysis. PloS one. 2014;9(7):e101554.
2. Bichoupan K, Dieterich DT. Hepatitis C in HIV-infected patients: impact of direct-acting antivirals. Drugs. 2014;74(9):951-961.
3. Bichoupan K, Dieterich DT, Martel-Laferriere V. HIV-hepatitis C virus co-infection in the era of direct-acting antivirals. Current HIV/AIDS reports. 2014;11(3):241-249.
4. Wills T, Friedrich M, Beal J. Implementing Hepatitis C treatment programs in comprehensive clinics: The Health Resources and Services Administration (HRSA) Special Projects of National Significance Hepatitis C treatment expansion initiative. Paper presented at: IDWeek2014; Philadelphia.