The Arizona Department of Health Services (AZDHS) partnered with three clinics to identify people with a dual diagnosis of HIV and hepatitis C virus (HCV), determine their care needs, and link them to HCV treatment. The project involved collaboration among state HIV and HCV surveillance units, the Arizona Ryan White HIV/AIDS Program (RWHAP) Part B, and RWHAP-funded clinics. Data from HIV and HCV surveillance systems and CAREWare (the networked RWHAP health and social services information system used by the state) were used to create initial lists of people with a dual diagnosis of HIV and HCV. Clinics then updated these lists based on information in electronic health record (EHR) systems and conducted intensive outreach with those eligible for treatment. The project was funded through Leveraging a Data to Care Approach to Cure HCV Within the RWHAP, a RWHAP Part F Special Projects of National Significance (SPNS) initiative implemented from 2020–2023. Yale School of Medicine served as the Technical Assistance Provider (TAP), providing support to seven participating jurisdictions.
AZ
Approximately 21% of people with HIV in the United States also have a diagnosis of HCV.1 Among people with HIV who inject drugs, the prevalence of HCV diagnosis is as high as three in four people. Dual diagnosis of HIV and HCV dramatically increases the risk for serious liver complications and decreases life expectancy, even among people on antiretroviral therapy (ART). Despite major advancements in HCV treatment, recent data from the Centers for Disease Control and Prevention (CDC) show that among all people with HCV, only one-third had evidence of viral clearance.2 HCV treatment rates remain suboptimal in part due to poverty, substance use, stigma, and lack of professional consensus about screening and treatment.3,4
AZDHS partnered with clinics within three healthcare systems covering different geographic areas of the state. El Rio Health, one of the largest health center networks in Arizona, provides the bulk of HIV care in the southern part of the state. North Country Healthcare primarily serves the northern region of Arizona, and the Valleywise Community Health Center – McDowell clinic centers on the Phoenix metro area. All three systems provide HCV treatment in at least one clinic site.
AZDHS worked with each clinic to create a list of people with HIV and HCV. For each clinic, AZDHS extracted data from the clinic domain in its centralized CAREWare system. This networked system contains demographic, service, and health outcome data on all people enrolled in RWHAP in the state. AZDHS then matched each clinic’s list to HIV and HCV surveillance data and appended information related to HCV status. These lists of people with HIV and HCV were then sent to each clinic.
Clinic staff then compared the lists provided by AZDHS to information in local EHR systems. Yale developed an Excel-based “case conferencing tool” to facilitate this process. Staff reviewed individual client records and populated the tool with updated HCV status. For example, if the state list indicated that the client had HCV, but more recent EHR data indicated the client had been treated, staff updated the client’s HCV status. This updated information was shared back with AZDHS.
Through this process, staff identified people who needed some type of HCV care, such as a follow-up PCR test after a positive antibody test, HCV treatment, or a follow-up test after HCV treatment to determine if the individual was cured. While each clinic had a different process to contact people, they typically relied on a combination of phone calls, letters, and home visits. Case managers would often huddle to discuss and address client barriers to care. Once clients were brought into the clinics for treatment, clinicians played a key role in discussing long-term impacts of HCV and the importance of cure. Pharmacists were also crucial for securing treatment coverage given its high cost, and case managers helped clients stay adherent to medications through daily calls and medication reminder apps as needed.
“We started doing outreach, utilizing our team of medical case managers, MAs, and providers…We are very fortunate to have our advanced pharmacist help us with any prior authorizations that were needed to access medication.”
Yale collected aggregate data from AZDHS and participating clinics through the case conferencing tool. Clinics input data into the tool at the client level, and the tool generated tables and graphs based on these data, summarizing steps on the HIV/HCV treatment cascade. Clinics submitted these aggregate data to AZDHS on a quarterly basis. The table below presents data from one participating clinic, El Rio, which compared measures from baseline (March 2022) to the final quarter of data (October 2022).
| Category | Information |
|---|---|
| Evaluation data | HIV and HCV surveillance data on clients’ dual diagnosis status and data tracked through the case conferencing tool, which included updates on treatment and outcomes. |
| Measures | Measures represent steps on the HIV/HCV coinfection treatment cascade.
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| Results |
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Source: Innovative HIV Care Strategies for HIV/HCV Co-infection webinar 2023
“We had a heavy focus on specialized outreach once the patients received treatment; we did several phone calls, home visits if the phone calls weren't working, we would do medication deliveries, and determine whether there were any other social determinants of health that affected their ability to follow through with treatment.”
Case conferencing tool development. Yale developed the Excel-based case conferencing tool with three main sections. The first section was populated by AZDHS with CAREWare and surveillance data for clients with a dual diagnosis of HIV and HCV, including race, ethnicity, gender, and most recent HCV testing information. Clinics then used their EHR systems to complete the second section of the tool with clients’ most recent HCV testing and treatment status. The final section was only populated for clients who needed a follow-up PCR test or HCV medications. For each of these clients, clinics input information on outreach and linkage activities, including barriers to treatment, helping clinics develop individualized treatment plans.
Technical assistance. Yale provided technical assistance to AZDHS through monthly calls and “office hours,” which AZDHS could join on an ad hoc basis if they had specific questions. Quarterly Learning Collaborative meetings, facilitated by Yale, provided an opportunity for AZDHS to troubleshoot issues with the jurisdictions participating in the project. In addition, AZDHS met with clinics monthly to share project updates and discuss strategies for updating the conferencing tool and conducting outreach to clients.
Data sharing. Data sharing across AZDHS and clinics was relatively straightforward given the state provided information on a clinic’s existing clients and data access was covered under long-standing RWHAP agreements. However, one clinic needed Institutional Review Board approval to participate in the project. This clinic also needed to obtain client consent for the Release of Information to share data back with the state.
SPNS funding covered the cost of jurisdiction activities to create the coinfection lists; clinics were not funded through SPNS. Clinics' RWHAP case management funds covered the cost of outreach and linkage to care activities and serve as an ongoing source for supporting people with a dual diagnosis of HIV and HCV in the long term.
- Clinics found that information in their EHR systems was more up to date than information in the HCV surveillance system. For example, the list contained people who had been out of care at the clinic for years or who had already been cured of HCV. Clinics spent considerable time cleaning the list by removing people who were deceased, had left the area, were incarcerated, or who had already been treated. Some clinics indicated that they may have saved time if they created the coinfection lists directly from their EHR systems instead of relying on HCV surveillance data.
- Clinics reported that staff familiar with EHR structure, HCV care, and client status should be responsible for updating the dual diagnosis lists. In some cases, clinicians updated information for their client panel, and case managers conducted outreach. They then worked together to document outcomes.
- Clinic leadership worked to get clinician buy-in, which was somewhat challenging given clinicians’ busy schedules and the range of client conditions they treat. Staff discussed the importance of HCV treatment during team meetings, which helped clinicians re-prioritize HCV care in the context of the client’s existing treatment needs.
- Intensive outreach is often necessary for this client population because a disproportionate number of people with HIV and HCV are dealing with substance use disorders and/or homelessness. Facilitating linkage to care often requires multiple forms of outreach, including messages through patient portals, phone calls, home visits, and street outreach.
Training Resources
Implementation Resources
Additional Resources
- Resources and Tools from the Leveraging a Data to Care Approach to Cure Hepatitis C within the RWHAP (including the case conferencing and the clearance cascade tools)
- Yale Team Hep C: Leveraging a Data to Care Approach to Cure HCV
- Innovative HIV Care Strategies for HIV/HCV Co-Infection. 2023
- Leveraging a Data to Care Approach to Cure HCV: Jurisdiction Perspectives. 2023
- CDC. People Coinfected with HIV and Viral Hepatitis, 2020.
- Wester C. Hepatitis C Virus Clearance Cascade — United States, 2013–2022. MMWR Morb Mortal Wkly Rep. 2023;72. doi:10.15585/mmwr.mm7226a3
- Taylor LE, Swan T, Matthews GV. Management of Hepatitis C Virus/HIV coinfection among people who use drugs in the era of direct-acting antiviral–based therapy. Clin Infect Dis. 2013;57(Suppl 2):S118-S124. doi:10.1093/cid/cit326
- Sacks-Davis R, Doyle JS, Rauch A, et al. Linkage and retention in HCV care for HIV-infected populations: early data from the DAA era. J Int AIDS Soc. 2018;21 Suppl 2:e25051. doi:10.1002/jia2.25051
