Professor of Medicine, Epidemiology, and Public Health
Section of Infectious Diseases
Department of Internal Medicine
Director of Clinical and Community Research
Director of HIV in Prisons Program
Director of the Community Health Care Van
Yale School of Medicine/Yale School of Public Health
New Haven, Connecticut
Frederick L. Altice, MD, has disclosed that he has received consulting fees from Gilead Sciences, LSU, Melinta, and Merck; fees for non-CME/CE services from Bristol-Myers Squibb and Gilead Sciences; and funds for research support from Gilead Sciences.
Eliminating HCV infection in persons who inject drugs (PWID) is a daunting task whether tackling it from a patient care perspective, one patient at time, through practice transformation, or by influencing policies that improve access to treatment.
I have the luxury of seeing patients in multiple clinical care settings—an infectious diseases specialty clinic, an addiction treatment setting, a mobile medical clinic that also provides syringe services programs, and in prisons and jails. As a clinician, I try to consider for each of these settings how to best influence the HCV continuum of care. The first step, HCV diagnosis, has been the most challenging to overcome. Certain settings, such as our mobile medical clinic that tailors services for PWID, the addiction treatment center, and our county jail, are uniquely poised to improve detection of disease. Although it is seductive to consider risk-based screening in such settings, the prevalence of HCV and overall high risk for new infections suggest that HCV screening should be routine, meaning everyone is tested unless they purposefully opt out. Despite excellent data from demonstration projects confirming the feasibility of routine HCV (and HIV) testing in these settings, the incremental costs resultant from extra staffing and laboratory fees make universal adoption challenging. For instance, addiction treatment reimbursement is capitated, meaning that the cost of any additional testing must be absorbed by the agency. For incarcerated populations, medical staff and testing cost limitations are further exacerbated by the fact that identification of a person living with HCV opens up the potential for further costs related to additional testing and mandated treatment either for the jail or, if the patient is sentenced, for the prison. Although criminal justice agencies may deem HCV screening and treatment cost-prohibitive, it is short-sighted to avoid testing, as the eventual costs for society may be substantially greater if HCV progresses to end-stage liver disease or hepatocellular carcinoma, either of which may require costly liver transplantation.
Increasingly in these settings, I have worked to streamline HCV diagnosis and treatment. When point-of-care testing is not performed, reflex testing of blood to confirm chronic infection and identify genotype (which is increasingly less important with the availability of pangenotypic HCV regimens) and use of laboratory markers to assess fibrosis can consolidate several steps in the cascade. Such practice transformations can be further realized in settings where integration of comprehensive HCV programming is practical (eg, primary care in mobile medical clinics, HCV care by addiction treatment and jail clinicians). Having clear, evidence-based treatment protocols and associated training for nonspecialists is crucial, as is gaining experience and learning within collaborative learning environments, for example Project ECHO-like strategies. Cell phone technologies also allow HCV experts to communicate with patients and nonspecialists, and to answer questions, inspiring confidence and ensuring that nuanced care is provided.
Finally, the incorporation of harm reduction services into clinical care can be easily achieved as a strategy for reaching toward HCV elimination. Substance use disorders are chronic relapsing conditions where many patients continue to inject, yet still achieve SVR. For treated patients who still inject, it is simple to eliminate the hassles of going elsewhere for syringe services programs when a clinician can legally prescribe sterile injection equipment for HIV/HCV prevention (similar to prescription for self-treatment with insulin for diabetes). Additionally, to simplify the care of recently released prisoners using opioids, or even those in primary care or infectious diseases specialty clinics, buprenorphine can be prescribed for administration sublingually each day, subcutaneously each month, or as a 6-month maintenance implant. This one-stop shopping greatly improves patient access and reduces complex delivery of care, a key element for HCV elimination in PWID.
What is your greatest obstacle in reaching HCV elimination goals among PWID in your clinical practice? What steps are you currently taking or do you plan to take to make progress toward these goals? I invite you to join the conversation by leaving your thoughts and anecdotes in the comments box below or by participating in the interactive poll at right.