1. Lesson 3: The HCV Care Continuum
Core Competency 1: Epidemiologic Background of HIV/HCV Co-infection in the United States
Lesson 3: The HCV Care Continuum
July 2017

2. Authors and Funders
This presentation was prepared by Stacey Trooskin, MD, PhD, (MidAtlantic AETC) and Susan Thompson, (MidAtlantic AETC) for the AETC National Coordinating Resource Center in July 2017.
This presentation is part of a curriculum developed by the AETC Program for the project: Jurisdictional Approach to Curing Hepatitis C among HIV/HCV Co- infected People of Color (HRSA ), funded by the Secretary's Minority AIDS Initiative through the Health Resources and Services Administration HIV/AIDS Bureau.  

3. Lesson Objectives Know the number of PLWH in the United States
Be familiar with research related to the incidence and prevalence of chronic HCV infection among PLWH
Be familiar with estimates of co-infected PLWH who:
are linked to HCV care
are prescribed HCV treatment
have achieved a sustained HCV virologic response 

4. PLWH in the United States
At the end of 2013, an estimated 1.2 million persons aged 13 and older were living with HIV infection1
Approximately 13% (161,200) of PLWH have not been diagnosed1
Approximately 25% of PLWH are co-infected with HCV2
Much of what we know about HCV among PLWH comes from the CDC, yet the data are limited. We know that 1.2 million persons 13 and older are living with HIV, and 13% have not been diagnosed. 25% of PLWH are co-infected with HCV.

5. Rates of HCV Testing among PLWH
In a large diverse cohort of HIV clinics nationwide at the end of 2011, 85% of PLWH received HCV antibody screening within 3 months of enrolling in care3
Among 17,090 patients registered at Center for AIDS Research Network of Integrated Clinical Systems (CNICS) sites between 2000 and 2011, (85%) received HCV antibody screening within 3 months of enrolling in care.

6. HCV Cascade in PLWH following HCV Diagnosis, UCSD Owen Clinic4
Total number of patients with access to HIV care with HCV antibody positive (n=748)
Chronic active HCV infection with access to HIV care 100% (n=562)
Referred for HCV treatment 54% (n=303)
Attended at least 1 clinic visit for HCV treatment evaluation 50% (n=283)
Final decision made regarding HCV therapy initiation 44% (n=250)
Initiated HCV treatment 16% (n=88)
HCV cure 7% (n=41)
The figure depicts the hepatitis C cascade of care among HIV-infected patients who attended the University of California, San Diego Owen Clinic between 1 January 2008 and 31 December 2012.
The timeframe referenced here reflects the use of interferon therapy, which is not reflective of current treatment options. We know the information presented in the next three slides will greatly improve with the advent of one pill per day treatment, with fewer side effects and drug interactions but this information is what we currently know based upon published literature.
There is very little published around the HCV care cascade among PLWH, and even less data available providing national estimates. There are two excellent examples of work that has been done in large HIV primary care clinics: UCSD Owen Clinic and the CORE Clinic in Chicago. Much of what we know about the HCV cascade of care among PLWH must be extrapolated from this work. These two cascades outline the barriers to care among PLWH. Between 2008 and 2012, 4725 HIV-infected patients received care at the UCSD Owen clinic. Most patients [4534 (96%)] were screened for HCV,
At the top of the inverted Pyramid 748 (16%) patients had reactive serum HCV antibodies
At the next level 542 patients had active chronic HCV infection and access to care.
At the next step down we see that of those 542 coinfected patients, 303 patients or 54% of the coinfected patients were referred for HCV treatment
At the fourth step of the cascade 283 patients or the vast majority of those individuals attended their initial evaluation or at least 1 clinic visit
In 250 cases or 44% the provider made a decision regarding initiation of treatment
At the sixth step 16% or 88 of the patients initiated treatment
Finally 41 patients or 7% were cured.
Cachay, et al. Plos ONE 2014.

7. HCV Cascade in PLWH following HCV Diagnosis, CORE Center5
CORE Center, Chicago,
94% of the 4,870 HIV positive patients who had >=1 primary care visit at CORE Center in 2013 had HCV antibody test results available. The authors of the study focused on the active cohort of patients in the clinic defining that as having a primary care visit between 1/2011 and 12/2013, which was 1,112 HCV antibody positive patients. 76% of those individuals had confirmatory testing or a genotype done and 40% of patients were seen in the hepatitis clinic. 27% had a liver biopsy and 13.5% were treated with a total of 4.4% achieving cure.
As noted, this study was conducted before DAA therapy, therefore diagnosis and treatment standards as well as treatment rates have since improved. For more information on current HCV diagnosis and HCV treatment, see competencies 3 and 4.
100%
76%
67%
57%
40%
27%
13.5%
4.4%
Oluwatoyin A, et al. CROI 2014

8. Treatment Cascade for Chronic HCV6
This review by, Yehia et al, identifies large gaps between current practice and treatment goals for people with mono infected chronic HCV infection. It also highlights multiple opportunities for improving engagement along the HCV treatment cascade, particularly in the diagnosis and awareness of infection, prescription of antiviral therapy, and achievement of SVR. 
Yehia, et al. Plos ONE. 2014

9. Disclaimer and Permissions
Users are cautioned that because of the rapidly changing medical field, information could become out of date quickly.
You may use or present this slide set and other material in its entirely or incorporate into another presentation if you credit the author and/or source of the materials.
The complete HIV/HCV Co-infection: An AETC National Curriculum is available at:

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