Progress Curing HCV among People Living with HIV in the US

Cross-posted from the Department of Health and Human Services' Viral Hepatitis Blog 

On December 1, we join colleagues, healthcare providers, public health professionals, advocates, and people living with HIV in commemorating World AIDS Day. On this annual observance, we remember those we’ve lost to HIV and AIDS and recommit to improving the health of all people at risk for and living with HIV. For many of us who are also concerned about viral hepatitis, that includes improving hepatitis C (HCV) screening, care, and treatment for people living with HIV/HCV coinfection. On World AIDS Day we want to celebrate important progress being made here in the U.S. to improve health outcomes for people living with HIV who are coinfected with HCV.

In the era of highly effective antiretroviral treatment for HIV, an increasing number of individuals are on treatment and maintaining a suppressed viral load. As a result, fewer people living with HIV are progressing to AIDS or dying of HIV-related causes. However, since HIV and HCV share common routes of transmission, in the U.S. approximately 20% of people living with HIV are co-infected with HCV. Hepatitis C-related liver disease has become one of the leading causes of non-AIDS-related death among people living with HIV because viral hepatitis progresses faster and causes more liver-related health problems among people living with HIV than among those who do not have HIV. But with the advent of direct-acting antiviral (DAA) therapies that can cure HCV in the majority of people who take them–including people living with HIV–we now have the exciting opportunity to eliminate HCV, thereby preventing one of the main non-AIDS-related causes of death among people living with HIV.

HRSA’s Ryan White HIV/AIDS Program Innovates to Eliminate HCV Coinfection
Given the health threat posed by this relatively common coinfection, the Health Resources and Services Administration’s Ryan White HIV/AIDS Program (RWHAP), which reaches approximately 54% of all people living with diagnosed HIV in the United States, has undertaken several activities to increase HCV screening and treatment among its clients. Indeed, RWHAP has set elimination of coinfection as one of its goals: “The Ryan White HIV/AIDS Program provides the infrastructure to screen and treat people with HIV/HCV coinfection and is committed to eliminating HCV coinfection among all RWHAP clients,” observed Laura Cheever, MD, ScM, HRSA’s Associate Administrator for the HIV/AIDS Bureau, which administers the Program.

The Program provides a comprehensive system of care that includes HIV primary medical care, medication, and essential support services for people living with HIV who are uninsured or underserved. The Program funds grants to cities/counties, states, and local community-based organizations to provide HIV care and treatment services to more than half a million people each year.

For clients who are diagnosed with HCV coinfection, RWHAP supports medical services and treatment that cures HCV coinfection. More than two-thirds of the states (34) plus Washington, DC, and Puerto Rico, have DAAs on their RWHAP Part B AIDS Drug Assistance Program (ADAP) formularies, making the treatment accessible to many who need it. However, many states have reported that uptake is low. So HRSA/HAB has been supporting innovative work to expand provider, clinic, and jurisdictional capacity to provide comprehensive HCV screening, care, and treatment for people living with HIV.

• Under the “Jurisdictional Approach to Curing Hepatitis C among HIV/HCV Coinfected People of Color” initiative, HRSA/HAB is supporting the development of new HCV/HIV screening, care and treatment approaches. Five jurisdictions that receive RWHAP funding (Hartford, CT; New York, NY; and Philadelphia, PA; and the state health departments in North Carolina and Louisiana) were awarded supplemental funding to increase their capacity to provide comprehensive screening, care, and treatment of HCV among HIV/HCV coinfected people of color and increase the number of HIV/HCV coinfected people of color who are diagnosed, treated, and cured of HCV infection. They are supported in this four-year project by an Evaluation and Technical Assistance Center and a State Health Departments Coordinating Center, which will coordinate dissemination of best practices, lessons learned, and other findings from the initiative. The project is supported by resources from the Secretary’s Minority AIDS Initiative Fund (SMAIF). (Read more about this initiative.)
• To strengthen provider capacity across all RWHAP-supported clinical sites in the U.S., earlier this year, the RWHAP’s Part F AIDS Education and Training Centers National Coordinating Resource Center published a free, online curriculum that offers healthcare providers and health profession educators training on HIV/HCV co-infection, including prevention, screening, diagnosis, and treatment recommendations. The curriculum also examines barriers and other co-factors that may impede optimal treatment outcomes for co-infected people of color. This curriculum was developed as a component of the jurisdictional initiative and was also supported by SMAIF resources. (Read more about the National Curriculum on HIV/HCV Coinfection.)
• Under a new, multi-pronged initiative just getting underway, HRSA/HAB is supporting RWHAP recipients in Connecticut and San Antonio to develop and implement plans that coordinate multiple strategies aimed at improving the prevention, care, treatment, and cure of HCV among low-income, uninsured, and underserved racial and ethnic minority populations. The ultimate goal of this three-year initiative, also supported by the SMAIF, is to increase the number of people living with both HIV and HCV in each of the awardees’ service areas who are screened, diagnosed, linked to care, treated, and cured of HCV. Components of this initiative will include: expansion of HCV prevention, testing, care, and treatment capacity among RWHAP-funded clinics, HRSA and Medicare-certified Federally Qualified Health Centers, and SAMHSA-funded community-based substance use disorder (SUD) and behavioral health treatment providers that predominantly serve people of color living with both HIV and HCV; improved coordination of linkage to and retention in care and treatment for people who are co-infected with HIV and HCV; improved coordination with SAMHSA-funded SUD treatment providers to expand the delivery of behavioral health and substance use treatment support to achieve HCV treatment completion and to prevent HCV transmission and re-infection; and enhancement of health department surveillance systems to increase their capacity to monitor acute and chronic coinfections of HIV and HCV and to enable an HCV Data to Care capacity. A technical assistance and evaluation team will support the two performance sites in documenting outcomes and disseminate findings, best practices, and lessons learned to all RWHAP recipients and other stakeholders.

Other Federal Programs Tackle HIV/HCV Coinfection
In addition to the important work underway at HRSA, other federal activities are also supporting efforts to improve screening, diagnosis, linkage to care, and, HCV cure among people living with HIV/HCV coinfection:

• The HHS Office on Minority Health, with support from the SMAIF, recently partnered with 12 minority-serving organizations to raise awareness about and increase opportunities for HIV and HCV diagnosis and linkage to care among at risk racial/ethnic minority populations.
• An NIH-supported study conducted in 12 health centers evaluated the effectiveness of HCV management and treatment using DAAs by three types of providers – specialists, primary care physicians, and nurse practitioners. It concluded that nonspecialist providers can safely and effectively use DAA-based HCV therapy in real-world community health centers and that patients with HIV/HCV coinfection had similarly high cure rates as those with HCV mono-infection regardless of provider type.
• Since the Department of Veterans Affairs (VA) introduced DAAs in January 2014 through August 15, 2017, a total of 3,188 Veterans with HIV/HCV coinfection have completed treatment for their HCV with DAAs, which means that VA has treated over 65% of all veterans with diagnosed HIV/hepatitis C (HCV) coinfection in VA care for their HCV.

“Together, these efforts are helping thousands of individuals living with HIV/HCV coinfection,” noted Richard Wolitski, Ph.D., Director of the HHS Office of HIV/AIDS and Infectious Disease Policy. “They are also helping us achieve goals set forth in both the National HIV/AIDS Strategy and National Viral Hepatitis Action Plan, 2017–2020: increasing access to care and improving health outcomes for people living with HIV and reducing deaths and improving the health of people living with viral hepatitis. So we salute our colleagues for their efforts, celebrate their progress, and look forward to working with them and all stakeholders to eliminate HCV coinfection among people living with HIV in the U.S.”