The HIV clinic at Washington University integrated comprehensive hepatitis C virus (HCV) screening and treatment into its care model, as part of the Ryan White HIV/AIDS Program (RWHAP) Part F Special Projects of National Significance (SPNS) Hepatitis C Treatment Expansion Initiative (2010–2011). Chronic HCV is a “silent” infection as it damages the liver over time, often without symptoms. Early treatment of HCV is particularly important among people with HIV, as HIV accelerates HCV’s progression. Of the 1,711 clients served at the clinic each year, 174 had a detectable HCV viral load. These clients received integrated clinical and support services to reduce barriers to ongoing HCV care engagement.
St. Louis, MO
An estimated 25% of individuals with HIV also have been diagnosed with HCV.1 Without treatment, HCV can potentially reduce the gains in health and longevity that individuals with HIV can expect while being treated with antiretroviral therapy (ART).2,3 For example, end-stage liver disease and liver cancer from HCV are leading causes of death among people with HIV, even when taking ART. 4,5,6 Increasing access to HCV care and treatment can improve health outcomes for people with HIV.
“Washington University sought to demonstrate the potential of a multidisciplinary HCV team and a specific coinfection clinic session to improve evaluation, treatment, and monitoring of coinfected clients.”
The HIV clinic at Washington University wanted to integrate HCV screening and treatment into its care model without making all HIV clinicians responsible for HCV care. This required a dedicated team of staff who specialized in HCV care, including a lead HCV physician, lead HCV nurse, and a specialty pharmacist. The lead physician oversaw the intervention and served as the primary investigator for the demonstration project. The lead HCV nurse managed day-to-day responsibilities of the intervention, including monitoring, client education, appointment scheduling, referrals, and coordination with clients’ multidisciplinary providers. The specialty pharmacist supported the navigation of HCV treatment coverage with different health care coverage and patient assistance programs.
Designing and implementing consistent screening protocols across all populations was critical to identifying individuals with HCV among the clinic’s population. After the Washington University HIV clinic recognized it was uniquely suited to becoming a “health home” for people with HIV and HCV, it ensured that all individuals with HCV were identified, and HCV screening was integrated into the clinic’s care model. Opt-out screenings were conducted during client initiation into HIV primary care and at least annually thereafter.
Once diagnosed with HCV, many individuals in the demonstration project needed support services to make sure they stayed engaged with HIV and HCV care. In addition to the services already offered at the HIV clinic, such as mental health counseling and transportation services, the intervention helped navigate treatment coverage and patient assistance programs to cover costly HCV medications, scheduled liver biopsies at partnering hospitals, and provided education. The clinic also provided an additional support group for people with HIV and HCV. The HCV specialty staff were key in providing these essential support services.
During the 2010 and 2011 demonstration years, 174 people with a detectable HCV viral load were identified from among the existing client population. All of the people treated for HCV were cured, thanks to advances in HCV treatment and care engagement strategies.
Client medical data
- Washington University developed partnerships with hospitals to formalize referral pathways for people with HCV in its clinic. This ensured that clients could be referred for liver biopsies and treatment that could not be provided within the HIV clinic.
- Hiring HCV specialty staff was critical to the success of the intervention. This included a lead HCV physician, lead HCV nurse, and a specialty pharmacist. Each was trained in HCV care and had a genuine interest in supporting clients with HIV and HCV.
- HCV screening can be integrated into existing clinic procedures. However, consensus should be reached on what data should be collected from clients, and how that data should be tracked and updated. Washington University reviewed data for clients with HIV and HCV quarterly to identify barriers and what treatment plans needed to be updated.
- Cultural responsiveness was important for all staff supporting the intervention. Supporting clients in a culturally responsive way was critical for overcoming barriers in their perception of HCV and willingness to engage in HCV treatment.
- Washington University secured buy-in from their staff and provided ongoing professional development during multidisciplinary staff meetings. For example, Washington University’s HIV clinic nurses met with the university’s hepatology clinic staff to discuss the difficulties of HCV treatment in individuals with HIV and other coinfections. These and similar meetings improved morale, clarified priorities, and provided opportunities for ongoing education.
- Funding for necessary staff, including a lead HCV physician, lead HCV nurse, and specialty pharmacist, is essential. The Hepatitis Treatment Expansion SPNS initiative funded Washington University for the two-year demonstration project.
- The sustainability of an HCV program in HIV clinics also depends on securing funding for clients to access costly HCV treatment, which was one of the most substantial challenges experienced by Washington University. They were able to sustain the program through RWHAP Part C and other grant sources. The State AIDS Drug Assistance Program (ADAP) was used to cover the cost of HCV medication and health care coverage for clients.
- Overcoming treatment cost barriers for clients involved identifying health care coverage options or securing funding from patient assistance programs. The specialty pharmacist hired for the intervention was critical in securing this funding.
- Implement HCV screening for all new clients. HCV screening at the initiation of HIV care prevents HCV from progressing undetected, and it ensures the client is connected to HIV treatment that does not include potential drug-drug interactions with HCV treatment.
- Create standardized protocols. Clinic processes should be standardized to include HCV screening, and, if necessary, treatment. If clinics are already screening for alcohol use, drug treatment, and psychiatric disorders, HCV status and liver fibrosis, if applicable, can be included.
- Create procedures for tracking client data. Organizations should decide what information they want to track across the client population and develop effective methods for tracking and collecting that information. Tracking data makes sure there is an accurate picture of all clients with HCV. The HIV clinic at Washington University updated this information quarterly.
- Be prepared to support clients. While HCV treatment has become easier, it is important to talk to clients about the importance of treatment adherence and help them to remain engaged. Offering a support group for clients with HIV and HCV may help with this.
- Sulkowski MS. Current management of hepatitis C virus infection in patients with HIV co-infection. J Infect Dis. 2013;207 Suppl 1(Suppl 1):S26–S32. doi:10.1093/infdis/jis764.
- U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau, Special Projects of National Significance. Hepatitis C Treatment Expansion Initiative: Evaluation and Technical Assistance Center. FOA: HRSA-10-216. 2010.
- Reiberger T, Ferlitsch A, Sieghart W, et al. HIV-HCV co-infected patients with low CD4+ cell nadirs are at risk for faster fibrosis progression and portal hypertension. J Viral Hepat. 2010;17(6):400–409. doi:10.1111/j.1365-2893.2009.01197.x.
- de Lédinghen V, Barreiro P, Foucher J, et al. Liver fibrosis on account of chronic hepatitis C is more severe in HIV-positive than HIV-negative patients despite antiretroviral therapy. J Viral Hepat. 2008;15(6):427–433. doi:10.1111/j.1365-2893.2007.00962.x
- Salmon-Ceron D, Rosenthal E, Lewden C, et al. Emerging role of hepatocellular carcinoma among liver-related causes of deaths in HIV-infected patients: The French national Mortalité 2005 study. J Hepatol. 2009;50(4):736–745. doi:10.1016/j.jhep.2008.11.018
- Weber R, Sabin CA, Friis-Møller N, et al. Liver-related deaths in persons infected with the human immunodeficiency virus: the D:A:D study. Arch Intern Med. 2006;166(15):1632-1641. doi:10.1001/archinte.166.15.1632