1. BPHC Enrichment Series for Grantees: Stopping a Silent Epidemic: Policy and Practice Innovations to Treat and Prevent Viral Hepatitis Thursday, January 26, 2012 2:00 PM – 3:30 PM ET 1

2. Learning Objectives Learn about viral hepatitis through a brief clinical review Learn about the HHS Viral Hepatitis Action Plan Describe several state and local health department hepatitis treatment partnerships with health centers Gain perspective and strategies from two current BPHC health center grantees who will discuss their approach to the treatment of Hepatitis B and C Learn about an innovative program, Project ECHO, that utilizes telehealth in the treatment of viral hepatitis. 2

3. Agenda in Brief Welcome Jim Macrae, BPHC Clinical Overview and HHS Viral Hepatitis Action Plan John Ward, CDC State Support of Viral Hepatitis Action Plan Chris Taylor, NASTAD Perspectives from the Field Hepatitis B: Caring for Asian & Pacific Islanders Su Wang, MD Charles B. Wang Community Center, NY Hepatitis C: Caring for Homeless Individuals Danielle Robertshaw, MD, Baltimore Health Center for the Homeless, MD Innovative Program Presentation: Project ECHO Dr Saverio Sava, Chief Medical Officer and Primary Care Physician First Choice Community Healthcare, Albuquerque, NM 3

4. Clinical Overview and HHS Viral Hepatitis Action Plan Dr. John Ward Director, Division of Viral Hepatitis, NCHHSTP Centers for Disease Control and Prevention Atlanta, GA 4

5. Learning Objectives Describe HBV and HCV epidemiology Review HHS prevention priorities Describe opportunities for community health centers ( CHC) to improve viral hepatitis prevention care and treatment Highlight new opportunities for public health-CHC collaborations 5

6. 6 Continued Transmission of HBV and HCV –New infections continue to occur, 2009 Hepatitis B: 36,000 Hepatitis C: ~20,000 –Hepatitis B vaccine-based interventions do not reach all at risk populations ~ 800 newborns infected with HBV/yr Adults with risks represent 95% of new HBV infections –HCV infection rates have plateaued since 2004 Among young IDUs, annual incidence is > 10% Increases in case reporting among young persons Recent HCV sexual transmission among HIV+ MSM –Healthcare-related outbreaks persist In 2009; 115 infections; ~13,000 exposed patients Settings: outpatient (HCV) and residential care (HBV)

7. Persons Living With Viral Hepatitis Over 150,000 deaths due to Hepatitis B and Hepatitis C are projected to occur in the next 10 years

8. Future Burden of Hepatitis C Related Morbidity and Mortality in the US – Markov model of health outcomes - – Of 2.7 M HCV infected persons in primary care 1.47 M will develop cirrhosis 350,000 will develop liver cancer 897,000 will die from HCV-related complications 1 Rein et al Dig Liver Dis 2010

9. Viral Hepatitis and HIV/AIDS

10. HHS Viral Hepatitis Action Plan EDUCATING PROVIDERS AND COMMUNITIES TO REDUCE HEALTH DISPARITIES IMPROVING TESTING, CARE, AND TREATMENT TO PREVENT LIVER DISEASE AND CANCER STRENGTHENING SURVEILLANCE TO DETECT VIRAL HEPATITIS TRANSMISSION AND DISEASE ELIMINATING TRANSMISSION OF VACCINE- PREVENTABLE VIRAL HEPATITIS REDUCING VIRAL HEPATITIS CASES CAUSED BY DRUG-USE BEHAVIORS PROTECTING PATIENTS AND WORKERS FROM HEALTH-CARE-ASSOCIATED VIRAL HEPATITIS

11. HHS Viral Hepatitis Action Plan Health Goals Increase in the proportion of persons who are aware of their hepatitis B virus infection, from 33% to 66% Increase in the proportion of persons who are aware of their hepatitis C virus infection, from 45% to 66% A 25% reduction in incidence of HCV infection Elimination of mother-to-child transmission of HBV

12. Educate Providers and Communities to Reduce Health Disparities Build a U.S. health-care workforce prepared to prevent, diagnose and treat viral hepatitis Educate communities experiencing health disparities –Culturally appropriate –Community based Recognize health events –World Hepatitis Day – July 28 –National Hepatitis Testing Day- May 19, 2012

13. Improving Viral Hepatitis Testing, Care, and Treatment – Update HHS guidelines; mandate coverage as health benefits CDC recommends HBV testing for persons born in Asia, Africa and other pops. > 2% prev CDC recommends HCV testing for persons with hx of IDU, elev ALT; considering one time testing for all persons born 1945-1965 – Include viral hepatitis testing and care coordination as standards for: Health exchanges Expanded Medicaid programs Community health centers Pre-existing condition insurance programs – Implement performance measures in electronic medical records – Develop and implement care models – Build public health capacity for testing and care referral 13

14. Strengthen Surveillance to Detect Viral Hepatitis Transmission and Disease Build state and local surveillance systems –Automate case detection from electronic medical records – Gather data from non-traditional sources (e.g., clinical data sets) Monitor provision of preventive and care services –Collect data to evaluate quality of prevention and care –Create data –sharing agreements across federal agencies –Provide data to support state/local case registries

15. Reduce Viral Hepatitis Caused by Drug Use Behaviors –Ensure IDUs have access to viral hepatitis preventive services Integrate viral hepatitis prevention within drug treatment and HIV prevention programs –Provide persons who inject drugs access to care and substance abuse treatment Build network of primary care providers trained to provide prevention and care services for IDUs Promote continuity of care for releases inmates Strengthen partnerships between community re-entry programs and CHCs

16. Community Health Centers Programs to Improve Viral Hepatitis Prevention, Care, and Treatment – NACHC HCV Initiative- Keeping HCV Treatment at Home increased HCV treatment 178% in 18 CHCs* – Project ECHO- telemedicine-based knowledge networks linking public health-CHC- tertiary care** improved care in underserved communities – Possible opportunity in FY 12 Prevention Public Health Fund available to support HCV and HBV testing and linkage to care Funding announcement in development Public health-CHC partnerships will be a priority * http://www.iom.edu; ’**N Engl J Med. 2011 Jun 9;364(23):2199-207 16

17. Viral hepatitis “cause(s) substantial morbidity and mortality despite being preventable and treatable.” Institute of Medicine, 2010

18. State Support of Viral Hepatitis Action Plan: Health Center and Public Health Collaborations Chris Taylor Associate Director, Viral Hepatitis National Alliance of State and Territorial AIDS Directors (NASTAD) 18

19. Who is NASTAD? NASTAD is a non-profit national association of state health department HIV/AIDS program directors who administer HIV/AIDS and viral hepatitis prevention, care and treatment programs funded by state and federal governments. –Domestic Programs o Health Care Access o Prevention and Surveillance o Health Equity o Viral Hepatitis –Policy and Legislative Affairs –Global Program

20. NASTAD Mission and Vision Mission NASTAD strengthens state and territory-based leadership, expertise and advocacy and brings them to bear on reducing the incidence of HIV and viral hepatitis infections and on providing care and support to all who live with HIV/AIDS and viral hepatitis. Vision NASTAD’s vision is a world free of HIV/AIDS and viral hepatitis.

21. NASTAD and Viral Hepatitis Since 2000, NASTAD has been providing viral hepatitis support and technical assistance to health departments. –Due to the similarities in populations at risk, an emphasis on integration of HIV, STD, VH and Immunization activities at the client level NASTAD’s viral hepatitis program has three major components –Technical assistance –Public policy –Coalition engagement 2010 Viral Hepatitis incorporated into Mission and Vision

22. Adult Viral Hepatitis Prevention Coordinator Perinatal HBV Coordinator Adult Immunization Coordinator Vaccines for Children (VFC) Coordinator HIV/AIDS Program Connecting with Public Health Department

23. Staff In-service Brochures & Posters in Clinic/Agency Referral Guide Integrated Risk Assessments –Hepatitis Risk –Previous Testing –Vaccination History Prevention Interventions Integrated Presentations/Trainings Short Term Strategies

24. Hepatitis Workgroup/Committee Fee for Services –HBV/HCV Testing –HAV/HBV Vaccination Partner Services Support Group Include Hepatitis in Organization Mission Public Service Announcements Medium Term Strategies

25. Free Testing and Vaccination Medical Monitoring and Management Hepatitis Case Management Hepatitis Prevention Research Clinical Trials/Vaccine Development Successful Treatment! (Cure!) Long Term Strategies

26. NASTAD report 26 http://www.NASTAD.org/care_and_treatment

27. Chris Taylor Associate Director, Viral Hepatitis ctaylor@NASTAD.org 202.434.8041 Follow NASTAD Online: Contact Information

28. Hepatitis B: Caring for Asian & Pacific Islanders Su Wang, MD MPH Assistant Director of Medical Affairs Charles B Wang Community Health Center, NY 28

29. Background on Hepatitis B Virus (HBV) HBV is transmitted perinatally(childbirth), blood and sex –Not transmitted by saliva, food, casual contact Hepatitis B Infection can be acute or chronic –Acute infections resolve and individual becomes immune (90% of adult infections) –Chronic infections are usually lifelong (90% of childhood infections) o Medications control disease but rarely “cure” it National Health Disparity –1 out of 10 Asians has chronic HBV (5-15% in screening programs), general population HBV rate is 0.3% –2/3 of those infected in are unaware More than ½ of those with HBV in the US are Asians –Other areas of HBV infected origin o 22% from Latin America, 13% from Africa, 7.5% from Europe

30. HBV: The Good, The Bad An effective vaccine prevents transmission (universal childhood vaccine in US since ‘91). HBV affects more people globally than HIV (350 vs 30 million) but gets less attention, less funding Most are asymptomatic, but 1 out of 4 may develop cirrhosis or liver cancer –Early intervention can prevent complications and is cost effective –Liver cancer rates are increasing in the US, largely due to chronic HBV and HCV infection Post SE, Sodhi NK, Peng CH, Wan K, Pollack HJ. A simulation shows that early treatment of chronic hepatitis B infection can cut deaths and be cost-effective. Health Aff. 2011 Feb;30(2):340-8.

31. Served 39,000 patients in 2010 89% served in language other than English –Mandarin, Cantonese, Fujianese, Korean, Vietnamese 90% earn <200% of poverty 22% Uninsured, 72% Medicaid/Medicare, 6% Commercial insurance Hepatitis B Infection –12.8% prevalence rate –5,020 HBV+ patients in registry –2800 are active within 18 mos Charles B. Wang Community Health Center

32. Community screening programs point to a large burden of disease CBWCHC Community Screening PartnersYears # Screened% HBV+ Community-based screening CAMS, CAIPA, Oxford, GSK, NYC DOHMH 2000-2003 2100 11- 16% Asian-American Hepatitis B Program (AAHBP) NYC City Council, NYU, NYC DOHMH, HHC 2004-2008 300024% Hepatitis B family (Household contacts of HBV+ individuals) Robin Hood Foundation, NYC DOHMH 2006-2008 120020% Perinatal household contacts NYC DOHMH2008-current 170 25% B Free NYC Gilead, BMS, NYU 2009-10 70013% Total6670

33. Developing our HBV Program Incorporated screening/vaccination into primary care. –Reminders built into EMR. –Case management strategy for vaccine completion –Collaborate w/ NYC DOHMH for perinatal household contact screening Developed HBV care model for a primary are setting (many patients without access to specialist care and HBV very prevalent) –Train physicians: o Screening/vaccination, interpretation of tests o Evaluate HBV disease o Monitor for disease progression o Treat with antivirals –Support staff o Nurses educate, assist patient to apply for Patient Assistance Programs for no cost antiviral medication. –Implement collaborative care model to improve patient engagement and health care delivery

34. Collaborative Care Model

35. Health System Improvements for HBV

36. Provider Education: AASLD summary in exam rooms

37. Registry Form and HBV Flowsheet

38. Reminders of Overdue Tests Protocols utilize ICD9 code and last test date

39. Standardizing Patient Education

40. Hepatitis B Patient Tracker: Portable Medical Record & Education Tool

41. Take Home Messages FQHCs serve many populations at risk for HBV infection (i.e., foreign-born, HIV infected, MSM, IVDA) Screening needs to be increased Screening is simple –Hepatitis B surface Ag, Hepatitis B surface Ab, Hepatitis B core Ab –Identifies who is immune, infected and needs vaccine Early diagnosis and care of chronic hepatitis B infection can prevent complications of cirrhosis and cancer The Collaborative Care Model provides a thorough approach to improve delivery of care 41 IOM (Institute of Medicine). 2010. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C. Washington, DC: The National Academies Press http://www.iom.edu/Reports/2010/Hepatitis-and-Liver-Cancer-A-National-Strategy-for- Prevention-and-Control-of-Hepatitis-B-and-C.aspxhttp://www.iom.edu/Reports/2010/Hepatitis-and-Liver-Cancer-A-National-Strategy-for- Prevention-and-Control-of-Hepatitis-B-and-C.aspx

42. Questions? Su Wang, MD MPH Assistant Director of Medical Affairs Charles B Wang Community Health Center 268 Canal St. NY NY 10013 swang1@cbwchc.org 212-379-6999, ext 2507 swang1@cbwchc.org 42

43. Danielle Robertshaw, MD Medical Officer Family Physician Health Care for the Homeless, Inc. Baltimore, MD Hepatitis C Virus (HCV) Caring for Homeless Individuals

44. Hepatitis C Virus (HCV) in the U.S. Most common blood borne infection in U.S. New infections annually: 16,000-19,000 –Approximately 80% become chronic –Estimated that more than half are unaware CDC/NHANES: Chronic HCV estimated 1.3%-1.9% of general population (2.7-3.9 million) *Other estimates that include homeless, incarcerated – increase to 5.2 million persons

45. HCV- Natural history Long-term –Nonspecific symptoms: fatigue, nausea, anorexia, chronic pain, depression –Chronic liver disease: 20-30% develop liver fibrosis, cirrhosis and liver failure over 20 years –Cancer: 2-5% advance to Hepatocellular Carcinoma (HCC) –In the United States: o HCV most common cause of liver transplant o Principal cause of death from liver disease – Est. 12,000 annually o All-cause mortality >2x higher for HCV infected patients

46. Health Care for the Homeless (HCH) Baltimore Health Care for the Homeless –Chronic HCV affects 21% of adults E Chak, AH Talal, KE Sherman, et al. Hepatitis C virus infection in USA: an estimate of true prevalence. Liver International31(8): 1090-1101. September 2011 Prevalence in the general U.S. population 1.3-1.9%

47. Health Care for the Homeless Patient demographics Baltimore: Race/Ethnicity – 77% African American, 18% Caucasian, 3% Hispanic Gender – 64% male, 36% female Age – 93% between 25-64 years Uninsured - 75% (19% Medicaid, 6% Medicare) Nationally: Average 8 chronic, active medical problems HIV - 3.4% of adults Approximately 1/3 have Mental Health (MH) diagnoses Estimated 2/3 meet criteria for Substance Abuse (SA) –Co-occurring: 50% of mentally ill have a substance abuse disorder

48. Treatment of HCV – AASLD Characteristics of persons for whom therapy Is widely accepted: –Willing to be treated and adhere to treatment requirements Is currently contraindicated: –Major uncontrolled depressive illness –Severe concurrent medical disease Should be individualized –Current users of illicit drugs or alcohol –Coinfection with HIV

49. Barriers to HCV treatment Lack of insurance –Lack of primary medical care –Not screened/tested –Lack of specialty care –Lack of SA and MH treatment –Medication access Substance abuse Psychiatric co-morbidity Medical co-morbidity Medication –Non-adherence –Side effects Systemic and Individual Social circumstances –Housing, food, transportation –Support system

50. Quality Improvement at HCH 2010 - Focus on primary care indicators 1. Internal ‘adapted’ clinical guidelines 2.Expand local partnerships 2011 – Focus on process 3. Strengthen internal processes for patient “care team” 4.Utilization of EMR for indicator tracking, communication and care reminders Courtesy of Kathleen Becker, DNP, CRNP

51. HCV in a Primary Care setting Screen/test for Hepatitis C Educate –Hep C pos: diagnosis, transmission and prevention, treatment options –Hep C neg: prevention Counsel on –safe sex –good nutrition, weight control –avoid hepatotoxins and –avoid sharing of razors/toothbrushes Test for HIV, Hepatitis A and B Vaccinate: Hep A &B, flu and pneumonia Monitor for signs of liver disease Co-manage disease symptoms and treatment side effects Utilize peer/group support Screen, counsel and treat for substance abuse, depression/other psychiatric Refer for evaluation/treatment

52. Data from first phase – 16 weeks Characteristic Baseline % Post-implementation % Diagnostic testing Viremia33 92 Hep A & B90 100 Liver function 87 96 HIV67 71 Vaccination Flu33 54 Hep A & B46 57 Currently working on improving and tracking (2011-2012) - Education and counseling – provision, standardization and documentation - Enhanced utilization of EMR - decision support and information sharing - Compliance – appointment and medication - Referral for specialty care - Treatment access and outcomes

53. Health Care for the Homeless – Lessons learned Multidisciplinary team approach Medical (PCP, Nursing) Medication Adherence * Substance Abuse treatment * Mental Health treatment * Mobile and Street Outreach * Respite Care program * Social Work/Case Management o Benefits assistance o Housing assistance (obtaining and maintaining) o Patient Assistance Programs for medications Considerations for Medications –Access –Side effects (ex: diarrhea) –Instructions (3x/day with food) Partner with local service providers e.g., in Baltimore o Health Dept for vaccines o Specialists/Hospital to access evaluation and treatment o Specialists to assist in designing protocol to improve quality of care in resource limited setting Harm reduction – ex: safe injecting, access to sterile injecting equipment Provide hygiene products –Toothbrushes –Razors Use of technology –EMR –Future ?text, email in improving compliance and quality of care