Integration of HCV Treatment within an HIV Clinic

The University of California San Francisco, San Francisco General Hospital HIV Clinic developed a care model to enhance access to hepatitis C virus (HCV) treatment among people with HIV by co-locating care and creating a multidisciplinary team. Developed as part of the Ryan White HIV/AIDS Program (RWHAP) Part F Special Projects of National Significance (SPNS) Hepatitis C Treatment Expansion Initiative, this model of care led to a considerable decrease in the number of people with HIV who were coinfected with HCV among the patients served by San Francisco General Hospital during the 2010 and 2011 demonstration years.

San Francisco, CA

Emerging Intervention
Clinical service delivery model
Linkage to HIV medical care
Treat
People with HCV
RWHAP SPNS
Hospital or hospital-based clinic
Need Addressed

HCV is a common co-morbidity among people with HIV. HCV can cause liver damage and a coinfection of HIV can accelerate HCV progression. Medications for HCV change frequently and HCV treatment can be complicated by individuals having more than one health condition. Establishing co-located, coordinated services and a multidisciplinary approach for treating HIV and HCV can lessen many of these challenges and support better care and outcomes for individuals with both HIV and HCV.

Core Elements
Co-location

This intervention model shifted HCV care from primary care providers to a dedicated multi-disciplinary team co-located within the San Francisco General Hospital HIV Clinic. This co-location of services enhanced treatment initiation of individuals with HCV identified through screening at the HIV clinic. It also allowed the team to be nimble in response to the changing landscape of HCV treatment and to enhance the coordination and efficiency of care.

Multidisciplinary team

The multidisciplinary team included an infectious disease specialist, two medical fellows, a dedicated hepatitis nurse, a pharmacist, a pharmacy intern, and a social worker. The multidisciplinary approach allowed each member of the team to focus on their unique expertise, from treatment plans developed based on a patient’s co-morbidities, to medication adherence, and to the linkage to essential social supports to facilitate overall well-being and ability to engage in treatment.

Medication adherence support

Taking prescribed medication on schedule and as directed (adherence) is essential for the success of HCV treatment. The hepatitis nurse and/or pharmacist supported medication adherence with counseling and check-ins with patients. Due to the high cost of HCV treatment, San Francisco General Hospital also counseled patients on safe storage of HCV medication.

Outcomes

The clinical care model implemented by San Francisco General Hospital resulted in increased capacity of the clinic to treat individuals with HCV, and improved treatment outcomes and HCV cure rates among individuals coinfected with HIV and HCV.

Category Information
Evaluation data Patient panel information, electronic health records
Measures Number of patients under care of HCV clinic, HCV status
Results
  • Increased clinical capacity for HCV treatment by 45%
  • HCV coinfection rate decreased from 30-35% to 20%
  • 98% of patients are clear of HCV infection

“With only 300 HCV-infected clients left to treat, San Francisco General Hospital could eradicate HCV in its clinic altogether.”  

Planning & Implementation

The San Francisco General Hospital team took the following steps to implement this intervention:

  • Determined the capacity of the clinic environment to support co-location of HIV and HCV care. This included the ability to screen for HCV, staffing expertise and capacity, and connections to community resources.

  • Implemented a HCV screening process to identify individuals who need HCV treatment and to monitor the status of those receiving HCV treatment.

  • Built a multidisciplinary team that included:

    • A physician lead who reviews health records and prescriptions to determine treatment plans, stays current on the latest standards of care, and monitors complex cases

    • A hepatitis nurse who supports lab work and monitoring, provides treatment adherence education, and coordinates with other providers

    • A pharmacist who establishes each patient’s health coverage and supports prior authorization, monitors medication management including drug interactions, and supports medication adherence education

    • A social worker who assists with health care coverage and connection to additional supports such as housing, substance use disorder treatment, and behavioral health services.

  • Developed treatment protocols based on up-to-date standards of care and ensured the multidisciplinary team is familiar with the current protocol.

  • Ensured all staff shared a commitment to treating individuals coinfected with HCV and HIV, staying current on changes within the field of HCV and HIV, with a particular focus on cultural responsiveness.

Sustainability

Although developed with funding from the SPNS Hepatitis Treatment Expansion initiative, the San Francisco General Hospital model is sustained through health care coverage reimbursement, pharmaceutical assistance programs, and the overall efficacy of the HCV intervention model. Medicaid served as the primary health care coverage for many of San Francisco General Hospital’s patients. Clinics interested in replicating this model should explore reimbursement rates for HCV medication and care under Medicaid and private health care coverage.  

Lessons Learned
  • Identify an intervention champion. Champions are providers who can pave the way for changes needed to support implementation of a co-located, multidisciplinary team model to identify and treat HCV within an HIV clinic setting. Provider champions also play a key role in staying up-to-date on the latest standards of care for HCV.

  • Promote buy-in through education to partner groups that include primary care clinics, methadone clinics, and other stakeholders. Education efforts should focus on highlighting the unique role HIV clinics and community partners can play in supporting access to screening for and treatment of HCV.

  • Establish protocols for care for both standard and complex HCV. Patients with complex cases can then be triaged to include additional resources dedicated to treatment oversight and monitoring.

  • Emphasize the role of the pharmacist on the multidisciplinary team. The pharmacist plays a critical role related to ensuring patient access to HCV treatment by becoming knowledgeable of health care coverage requirements and pharmaceutical assistance programs. Pharmacists can also play a key role in medication adherence through education and monitoring.

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