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The Beginning of the End? (Hepatitis C and HIV Presentation)

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Alex Shirreffs, the HIV/HCV Project Coordinator at the Philadelphia Department of Public Health, presented on Hepatitis C and HIV co-infection at the April 2017 meeting of the Positive Committee.

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The Beginning of the End? (Hepatitis C and HIV Presentation)

  1. 1. The Beginning of The End? Alex Shirreffs HIV/HCV Project Coordinator
  2. 2. Epidemiology of HCV • More than 4 million people in the US expected to be chronically infected with hepatitis C virus (HCV) • Most people (~70%) are undiagnosed • Most common reason for liver transplantation • 50-75% of HCV(+) individuals are unaware of infection • Worse liver-related outcomes • Spread of disease
  3. 3. 0 200 400 600 800 1000 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67 70 73 76 79 82 85 88 91 94 2007 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67 70 73 76 79 82 85 88 91 94 2011 Age NumberofIndividuals Population of Young HCV Cases in Philadelphia 0 200 400 600 800 1000 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67 70 73 76 79 82 85 88 91 2013 0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60 63 66 69 72 75 78 81 84 87 90 93 96 2015 Baby-Boomers Young Cases (18-35 years)
  4. 4. Investigated HCV cases by age and risk factor: Philadelphia, 2013-2014 • Behavioral risk factors (injection drug use and incarceration) account for most of HCV *Medical includes blood/organ transplants, dialysis, needlesticks, work in medical/dental field 20% 35% 21% 8% 16% <=30 years Medical IDU Incarcerated Sexual Tattoo 16% 32% 27% 11% 14% 31-44 years 26% 26% 26% 12% 10% 45-64 years 42% 22% 19% 13% 4% >=65 years
  5. 5. Proportion of HCV-Infected Individuals Reaching Successive Stages HCV Cascade of Care 0 10000 20000 30000 40000 50000 HCV infected (estimate) HCV Ab HCV RNA HCV in medical care HCV antiviral treatment NumberofIndividuals 47% 22% 6% 3% HCV-Positive Individuals Are Being Lost At All Stages of Care: 1. HCV Testing Confirmation 2. Referral To Specialist’s Care 3. Treatment Viner K et al. The Continuum of Hepatitis C Testing and Care. Hepatology. 61: 783-789, 2015.
  6. 6. HIV/HCV Coinfection FACTS • Among HIV-infected individuals, HCV co- infection • Is estimated at 25% (CDC) • Ranges from 10–30% in MSM1 • Up to 80–90% in PWID2 • HIV/HCV coinfection more than triples the risk for liver disease, liver failure, and liver-related death • ART may slow the progression of liver disease by preserving or restoring immune function and reducing HIV-related immune activation and inflammation 1) G.M. Lauer, B.D. Walker. Hepatitis C virus infection. N Engl J Med, 345 (2001), pp. 41–52 2) K.E. Sherman, S.D. Rouster, R.T. Chung, N. Rajicic. Hepatitis C Virus prevalence among patients infected with Human Immunodeficiency Virus: a cross-sectional analysis of the US adult AIDS Clinical Trials Group. Clin Infect Dis, 34 (2002), pp. 831–837
  7. 7. HIV/HCV Coinfection - Philadelphia • Prevalence • EMA estimate of 6,200 PLWH coinfected with HCV (18.6%) as of 12/31/2015 • 17.5%* of PLWH in Philadelphia are HCV coinfected as of 12/31/15 • Screening • Approximately 84% of PLWH screened for HCV in Philadelphia residents in the Ryan White system • Two types of HIV/HCV co-infected patients can be distinguished • Those infected for decades (often have severe fibrosis and several comorbidities) • Those recently infected with HCV • All HIV-infected patients should be screened for HCV • Patients at high risk of HCV infection should be screened annually and whenever HCV infection is suspected. *Source: AACO 2015 Surveillance Report
  8. 8. I said that an AIDS-free generation is within reach, and today, the global community is committed to ending this epidemic by 2030. - Former President Barack Obama
  9. 9. What does it take to end an epidemic? Prevention • Condoms • PrEP and PEP • Syringe Exchange • STD Testing & Treatment • Health Campaigns Testing & Diagnosis • CDC : Everyone tested at least one time, more freq per risk • Provider testing • Walk-In Test Sites • STD Clinic • Partner Services Linkage to & Retention in Care • Case Management • SEPTA Tokens • Co-Located services • START Care • CoRECT Treatment • Lifelong treatment • Viral Load Suppression minimizes transmission risk Some Tools in Our Local HIV Infrastructure:
  10. 10. HIV: There is still work to be done HIV Care Continuum, Philadelphia, 2015
  11. 11. We have the tools we need to end hepatitis C in Philly (we just don’t have the $$)! -Alex Shirreffs
  12. 12. What does it take to end an epidemic? Prevention • Condoms • Syringe Exchange (AND clean works!) Testing & Diagnosis • CDC: All Baby Boomers; others more freq per risk • Less than 5 walk in test sites • Not all have confirmatory • Provider Testing Linkage to & Retention in Care • FOCUS grant sites have some linkage support (ex: C A Difference, Prevention Point) Treatment • A CURE • Medications cure most ppl of HCV in 12 wks or less w minimal side effects Some Tools in Our Local Hep C Infrastructure:
  13. 13. Proportion of HCV-Infected Individuals Reaching Successive Stages Total HCV Ab+ estimate Reported HCV Ab+ estimate Surveillance findings 0 5000 10000 15000 20000 25000 30000 HCV infected (estimate) HCV Ab HCV RNA HCV in medical care HCV antiviral treatment NumberofIndividuals 47% 22% 6% 3% 2010 – 2013 Hep C: There is still a lot of work to be done
  14. 14. What if we combined our resources? Could Philadelphia be the first city to eradicate hepatitis C among HIV/HCV co-infected people? Prevention • Condoms • Syringe Exchange (AND clean works!) • Integrated messaging Testing & Diagnosis • Annual hep C testing for everyone with HIV (more with risk factors) • Scale up HCV testing in HIV care settings Linkage to & Retention in Care • Hep C Linkage Coordinators • Train case managers & frontline staff on hepatitis C Treatment • A CURE • Encourage hep C treatment at all HIV care sites A More Integrated HIV & Hepatitis C Infrastructure:
  15. 15. Project Aims: • Increase Philadelphia’s capacity to provide comprehensive screening, care and treatment of hepatitis C among HIV/HCV co-infected people of color • Increase number of HIV/HCV co-infected people of color who are diagnosed, treated and cured of HCV infection
  16. 16. Working Towards Eradication Data & Evaluation Training & Capacity Building Linkage to Care Service Integration
  17. 17. Data & Evaluation • Match PDPH hepatitis C and HIV data sets to create a baseline HCV Continuum for PLWH in Philadelphia • Integrate additional hepatitis C measures into CAREware • Develop provider report card tool to measure progress by HIV care site • Provide technical assistance to help care sites use data to track progress moving patients through the HCV continuum • Monitor impact of program on Philadelphia’s HIV/HCV continuum
  18. 18. Training & Capacity Building • Identify gaps in services along the HCV care continuum using PDPH surveillance data and pre-Implementation knowledge and needs assessments • Build hepatitis C curricula into established models of provider training and capacity building at Health Federation’s Philadelphia performance site of the Mid- Atlantic AETC • Ex: Peer to Peer training, Preceptorships • Explore other innovative service delivery models: • Telemedicine • Directly Observed Therapy
  19. 19. Linkage to Care • Centralized care coordination support under AACO • Use PDPH data to prioritize lost to care clients and re- engage in care • Provide centralized intake to offer sites additional support with client linkage to hepatitis C services • Identify opportunities to integrate hepatitis C into existing patient support activities • Training Medical Case Managers on hepatitis C • Create targeted education and awareness materials • Help publicize existing hepatitis C services offered in Philadelphia
  20. 20. Service Integration • Identify facilitators and barriers to integration of hepatitis C into existing Ryan White activities • What additional resources would be needed to improve hepatitis C services within Ryan White programs? • How can local best practices be shared and replicated? • Develop a sustainability plan to ensure that any improvements to hepatitis C services through this opportunity can be maintained • Promote and leverage local successes to bring in additional resources
  21. 21. NEXT STEP: NEEDS ASSESSMENTS
  22. 22. Refining Philadelphia’s Plan • Pre-Implementation Phase includes Knowledge Assessments • Does our strategy begin to meet the needs of improving HCV services for HIV-infected people? • How can we refine our strategy to be most useful to providers and clients in the HIV service system? • Patient and Provider Knowledge Assessments
  23. 23. Patient Focus Groups • Anonymous and confidential • Will you help us? Your insight will help us: • Determine what resources can support clients • Are there new educational materials that need to be developed? • What are barriers and facilitators to hep C treatment? • If you are interested, provide your contact info and Amy will follow up!

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