1. Innovative Strategies for Addressing Hepatitis C in Indian Country March 14, 2016

2. JESSICA LESTON, MPH PROGRAMS MANAGER JLESTON@NPAIHB.ORG JESSICA.LESTON@IHS.GOV 907-244-3888 Hepatitis C in Indian Country Overview – Focus – Need

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, 2003-2013” Presented at ID Week 2015, October 10, 2015, San Diego, CA

4. Source: National Notifiable Diseases Surveillance System (NNDSS) Incidence of Acute Hepatitis C, by Race/Ethnicity – United States, 2000-2013

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  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 mortality 1  Access to treatment is complicated Good news again  WE CAN CHANGE THIS Holmberg SD, et al ID Week 2015 San Diego Slide courtesy Dr. Jorge Mera, Cherokee Nation

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

9. HCV Screening persons born 1945- 1965, IHS ALL IHS highest SU: 72% 2012201320142015mid 2016 Total8%10%25%32%42%

10. Best Practices EHR reminders Quick-picks and automation Standing orders Clear delegation Formal policy and training Leadership Partnership Access innovations  PCC leads, pharmacy  Teleconsultation

11. Preliminary Epidemiology of HCV in IHS “Barbell” epi curve split between newly diagnosed baby boomers with longstanding infection and younger newly infected youth Younger HCV patients believed to be predominately among injection use as per wider US (prescription and opioids) Boomer seroprevalence range from 2%-12% in SUs > 50% screening

12. Simple, Effective, but out of Reach?

13. Where do we WANT to go?

14. REdesigned response to HCV is necessary Structural issues – policy, funding, legislation  Cost of drugs  PAP successful, but require dedicated staff  State Medicaid programs with ‘flat’ encounter rate Organizational issue – leadership, relationships Provider issues – training and education Patient issues – access, knowledge Innovation – rigor of development, adaptability Ethical implications – health equity and social responsibility

15. LINGERING QUESTIONS? CONTACT ME AT: JLESTON@NPAIHB.ORGJLESTON@NPAIHB.ORG OR JESSICA.LESTON@IHS.GOV OR 907-244-3888JESSICA.LESTON@IHS.GOV Thank you