Stacey Trooskin, MD, PhD, has disclosed that she has received funds for
research support from Gilead Sciences.
Outline
HCV Elimination Among PWID
Models of Linkage to HCV Care for PWID
Models of HCV Treatment and Cure
‒ Supporting Providers
‒ Supporting Patients
HCV Elimination Among PWID
Global Call for HCV Elimination
WHO vision[1]: “Eliminate viral US HBV/HCV Elimination Strategy
hepatitis as a major global public (National Academies of Sciences,
health threat by 2030” Engineering, and Medicine)[2]
‒ “Elimination” = 90% reduction in
2030 Targets incidence by 2030
90% Diagnosed HCV elimination in US not feasible
80% Treated without engaging, treating PWID
65% Reduced mortality ‒ 30.5% of all HCV infections in
North America are among people
with recent IDU[3]
1. WHO. Global Health Sector Strategy on Viral Hepatitis, 2016-2021. 2. NASEM. A national strategy for the elimination of
hepatitis B and C. Washington, DC: The National Academies Press; 2017. 3. Grebely. Addiction. 2019;114:150. Slide credit: clinicaloptions.com
The Challenge: HCV Care Cascade Among PWID
100
90
Number of People (Thousands)
80
70
60
50
40
30
20
10
0
PWID Screened HCV Confirmatory HCV Treated Cured (SVR)
for HCV Antibody HCV RNA or Specialist
Antibody Positive GT Test Assessment
Grebely. Nat Rev Gastroenterol Hepatol. 2017;14:641. Iversen. Int J Drug Policy. 2017;47:77. Slide credit: clinicaloptions.com
The Barriers
50 48 48
42
Participants, n
40 36 35
32 58%
30 29
23 21
20 17
12
10
0
Anti-HCV Accepted HCV RNA HCV RNA Received Had or Had or Obtained Linked to Retained in Initiated
positive HCV RNA test positive HCV RNA obtained obtained referral to sub- sub- HCV
test performed test results insurance PCP sub- specialty specialty therapy
specialist care care
Trooskin. J Gen Intern Med. 2015;30:950. Slide credit: clinicaloptions.com
Linkage to Care at Philadelphia FIGHT
Patient Navigation Model
‒ Obtain detailed contact information
‒ Cross disciplinary and multicenter weekly “HCV Huddle”
‒ Open scheduling/walk-in hours
‒ Mobile FibroScan
‒ FQHC: no insurance or referral required
‒ Free transportation, food, blankets, shoes
‒ Modified DOT model, nurse-led but patient-driven
‒ Blood draws in the community
Slide credit: clinicaloptions.com
Philadelphia FIGHT: The C a Difference Testing and
Linkage to Care Program
600
371
400
219
200
65
0
HCV Ab+ HCV RNA test HCV RNA+ Linked to Care Initiated Documented
performed Treatment SVR
Courtesy of Stacey Trooskin. Slide credit: clinicaloptions.com
Facilitated Linkage to Care Model in North Carolina
Durham County Department of Public Health federally funded HCV testing and
linkage to care program in Durham, North Carolina
HCV antibody testing with reflex HCV RNA offered through STI clinic, county jail,
community testing sites (including residential substance abuse recovery program),
homeless clinic
Linkage to care facilitated by HCV bridge counselor: education, incentives,
transportation, appointment scheduling with HCV specialists at nearby academic
centers and on-site clinics
Dec 2012 – Feb 2014: 2004 HCV tests; 326 (16.3%) HCV Ab+; 241 (12.0%) HCV RNA+
‒ Rate of linkage to care: 51% (123/241)
Odds of treatment initiation higher for participants receiving on-site clinical care vs
participants linked to off-site care in bivariate analysis: 46% vs 25% (P < .0001)
No restrictions
By or in consultation with a specialist
Specialist must prescribe
Restrictions unknown
CHLPI and NVHR at https://stateofhepc.org/. Slide credit: clinicaloptions.com
Strategies to Address Barrier of Payer Restrictions on
Type of Provider
Utilize models that involve close collaboration between PCPs and
subspecialists
‒ Telemedicine
‒ Knowledge networks
Also overcomes geographic distances to specialist access
Good option for drug treatment and correctional settings
Arora. N Engl J Med. 2011;364:2199. Rossaro. Dig Dis Sci. 2013;58:3620. Miller. J Natl Med Assoc. 2012;104:244. Slide credit: clinicaloptions.com
Project ECHO: Extension for Community Healthcare
Outcomes
Addresses critical gap in availability of specialty care for patients with complex
health conditions in rural and underserved settings
41
40 34
P < .05
30
21 22
20
9 9
10 6
0
Referred for Evaluated for Offered HCV Initiated HCV
HCV Care HCV Care Treatment Treatment
Norton. J Subst Abuse Treat. 2017;75:38. Slide credit: clinicaloptions.com
HCV Services at Syringe Service Program (SSP):
Contingency Management
New York Harm Reduction Educators
39 clients positive for HCV antibody by rapid testing
‒ 19 enrolled in contingency management arm
‒ 20 enrolled in control arm
Contingency management:
‒ $20/visit for 2 evaluation visits and Wk 4, 8, and 12 visits
‒ $50 if HCV RNA undetectable at Wk 4
10 9 9
6
5 4
3
1
0
Enrolled Attended Chronic Initiated SVR12
Baseline Visit HCV Treatment
Norton. Int J Drug Policy. 2019;69:1. Slide credit: clinicaloptions.com
PREVAIL: Intensive Models of HCV Care for PWID With
GT1 HCV Infection
Randomized, controlled trial conducted Oct 2013 - Apr 2017 in Bronx, NY
Individual Treatment: self-administer all HCV medications
(n = 53)
Patients with GT1 HCV
infection willing to receive Group Treatment: attend weekly treatment group
HCV therapy on site at 3 (n = 52)
OAT programs
(N = 158) DOT: receive observed oral doses by nursing staff
at same time as receiving methadone or buprenorphine
(n = 53)
Individual Group
DOT
Outcome, % Treatment Treatment P Value
(n = 51)
(n = 51) (n = 48)
Overall adherence
Electronic blister pack 74.4 77.5 82.8 .007 (DOT vs individual)
Self report 94.2 95.5 94.8 .85
Completed HCV
96.1* 95.8* 98.0 .81
treatment
SVR12 90 94 98 .24
*1 patient in each of these groups died during study.
clinicaloptions.com/hepatitis
Partnership Information