1. Hepatitis C: Where are we? Where do we want to go?
Jessica Leston, MPH
Programs Manager

2. Background
Hepatitis C virus (HCV) infection is a substantial and largely unrecognized health problem.
An estimated 3.5 million persons in the US are currently living with HCV, most of whom are unaware of their infection.
¾ of persons living with HCV were born between
HCV is a major cause of liver disease, cirrhosis, hepatocellular carcinoma.
Hepatitis C Virus (HCV) infection is a substantial and largely unrecognized public health problem. An estimated 3 million persons in the United States are currently living with HCV, most of whom are unaware of their infection. (1) Persons born from (Birth Cohort) comprise 75% of all persons with chronic HCV infection. In addition to risk-based testing, the Centers for Disease Control and Prevention (CDC) and the US Preventive Services and Task Force (USPSTF) recommend one-time HCV testing of persons in the Birth Cohort. (1,2) Expanded HCV testing combined with curative direct acting antiviral drugs (DAAs) are provide an unprecedented opportunity to prevent HCV-related morbidity and mortality. (6-8)
HCV infection is disproportionately high in American Indian/Alaska Native (AI/AN) populations, with an estimated over 10% AI/AN currently living with HCV. (3,4) Death rates from chronic liver disease in AI/AN, which often has HCV-related etiology, are nearly 4 times that of Whites. (5 ) To provide the earliest possible diagnosis and treatment, IHS began implementing recommended HCV screening among the IHS enrollees in the Birth Cohort  in June 2012.
Expanded HCV testing combined with curative HCV therapy provide an unprecedented opportunity to prevent HCV-related morbidity, mortality, and potentially transmission. (REF)  

3. HCV Deaths and Deaths from Other Nationally Notifiable Infectious Diseases,* 2003- 2013
* TB, HIV, Hepatitis B and 57 other infectious conditions reported to CDC
Holmberg S, et al. “Continued Rising Mortality from Hepatitis C Virus in the United States, ”
Presented at ID Week 2015, October 10, 2015, San Diego, CA

4. Incidence of Acute Hepatitis C,
by Race/Ethnicity – United States,
The CDC generates estimates for the total number of new cases that occur each
year based on reporting data. For each new symptomatic acute HCV case that is reported, an
estimated 3.3 cases of symptomatic acute HCV actually occur. In addition, for each new HCV case
that is symptomatic and reported, the actual number of acute cases is approximately 13.4 times the
number of new HCV infections reported.
Source: National Notifiable Diseases Surveillance System (NNDSS)

5. A 300% Increase in Hepatitis C –related Hospitalization for AI/AN – 1995-2007
Byrd KK, et al Pub Hlth Rep 2011

6. HCV – Related Mortality by Race/Ethnicity 2007 compared to 2011
Byrd KK, et al Pub Hlth Rep 2011

7. Good and Bad News The good news The bad news Good news again
Hepatitis C can be cured
Curing HCV reduces mortality and morbidity
Curing HCV reduces the risk of transmission
The bad news
The HCV epidemic still remains invisible
Public/Medical providers/Policy makers
It is the infectious diseases with the highest mortality1
Access to treatment is complicated
Good news again
WE CAN CHANGE THIS
We are going to change it, today we are making this epidemic visible. Today we have all the stakeholders present
Expanded HCV testing combined with curative HCV therapy provide an unprecedented opportunity to prevent HCV-related morbidity, mortality, and potentially transmission.
Holmberg SD, et al ID Week 2015 San Diego

8. HCV Cascade Chronic HCV Infection 3.5 million in United States
Diagnosed and Aware
Access to Primary Care
Antibody Tested
RNA Confirmed
Case Management
Workup
Consultations
Prescribed HCV Treatment
Continued Consultation
Drug Access
Achieved SVR
Successfully Treated and Cured
Communication, Systems and Strategic Thinking,
Conflict and Change Management
2%-12% BC

9. Hepatitis C Screening Portland Area
IHS 37
Avg 16
Max 75
Min 0
The Portland Area Avg 14%
HIS

10. Hepatitis C Screening at CNHS

11. From Screening to Treating: Story from an FNP
“In my 4.5 year tenure with un-named Health clinic I have cured 85 patients of their hepatitis C. I have 20 patients in treatment and another 22 patients who have completed treatment and are waiting for their 12 week viral load to test for cure. I have only had 3 failures and we are working on developing a treatment plan for them. I have about 5 new hepatitis C patients a week. One of my patients came to me having failed previous treatments regimens for her hepatitis C. She was barely able to lift herself off the table. Her daughter was very concerned for her. She had cirrhosis and was worried that she was going to die from her liver disease. She is now cured form her hepatitis C, she looks beautiful, puts on make-up, walks in unassisted and joins our hepatitis C support group. She looks vibrant and energetic and is grateful for her renewed life. We are happy to have her as part of our Clinic life.”

12. Hepatitis C Paneling
Purpose: To provide sites with a list of current HCV+ patients and begin cascade of care
Started with 6 Federal Sites (open to all)
Remote access to iCare
Paneled patients according to ICD9/10 codes

14. HCV Panel Results
635 unique patients with an HCV diagnosis were identified
The median age was 53 (range 10-86)
The proportion that were boomers was 61% (387/635)
Of these, 3 charts could not be opened due to technical issues and were excluded from analysis.

16. Cross-site Breakdown: APRI
635 unique patients with an HCV diagnosis were identified
360 (57%) RNA test documented
43% need follow up
174 (48%) RNA+ (chronic HCV infection)
This implies a 52% clearance
138 (80%) had enough information to calculate APRI
28 (20%) had an acute APRI (stage 3 or 4 fibrosis)
20 (71%) were born between
Most common genotype GT1 (60%)

17. Consider HCV cirrhosis risk 20% over 20 years =
HCC risk in HCV cirrhosis 17% over 5 years
So, when you CURE 25 patients with HCV
(in 8-24 weeks of treatment) you will prevent:
5 cases of cirrhosis
1 case of HCC
Compare, if you treat 104 patients with statins, you will prevent 1 first time heart attack and ¾ of a stroke.
Review Dr. David Newman July 2015

18. Access to Medication
If patient has insurance – insurance will mostly cover
Assistance with co-pay
If patient is eligible for Medicaid – apply for Medicaid
WA, ID, OR will treat stages 3 or 4
For exact rules,
If patient is not eligible or denied – apply for patient assistance

19. Breaking down cost
One case manager = $50,000 salary 50 courses of 8 weeks of Harvoni obtained via patient assistance = 1.9 million dollars of meds into the system 50 patients treated = 10 cirrhosis cases avoided and 2 cases of liver cancer avoided $17,000 /year HCV no cirrhosis $23,000 /year HCV comp cirrhosis $60,000 / year HCV decomp cirrhosis
The economic cost of advanced liver disease,
The current economic burden of cirrhosis,

20. Simple, Effective, but out of Reach?

21. Where do we WANT to go?

22. Syringe Access: Partial Lift of Congressional Ban
A simple adjustment to congressional policy to help stop the spread of HIV and HCV and lower healthcare cost – without costing extra money.
What is it –
A syringe access program provides free syringes and ensures safe disposal of used syringes. Most programs also offer other services, such as HIV/HCV/HBV screenings, referrals, vaccinations and on-site medical care.
Public safety –
In Portland, OR, the number of improperly discarded syringes dropped by almost 2/3 after implementation of an access program.
Lifetime cost HIV – K, HCV – billions each year,
50% users infected with HCV within 3 years of first injection
In DC, syringe access programs have helped reduce drug-related transmission of HIV by more than 80%

23. Wide-spread support for Syringe Access
Syringe access policies are supported by
American Academy of Pediatrics
American Bar Association
American Medical Association
American Nurses Association
American Psychological Association
American Public Health Association
National Academy of Sciences
National Police Association
U.S. Conference of Mayors
U.S. Surgeon General
World Health Organization

25. Applications are due February 15, 2015!