C-YA! Philadelphia EMA's Plan to Connect our Co-infected Community to a Cure for Hep C
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Alex Shirreffs of the Philadelphia Department of Public Health provided this overview of the Philadelphia area's plan to end HIV and Hepatitis C coinfections to the HIV Integrated Planning Council on May 10, 2018.
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C-YA! Philadelphia EMA's Plan to Connect our Co-infected Community to a Cure for Hep C
- 1. C-YA! Alex Shirreffs, MPH May 10, 2018 Philadelphia EMA’s Plan to Connect our Co-infected Community to a Cure for Hep C
- 3. Before C YA… • Philadelphia was a leader in viral hepatitis… • HepCAP coalition • Hepatitis Surveillance infrastructure • Ryan White providers some of our biggest hep C champions • But there was room for improvement… • What does co-infection look like in the Philly area? • How is hep C being addressed in the RW system? • Where are opportunities to integrate hep C sustainably in HIV infrastructure? • What will it take to eliminate hep C among PLWH? 3
- 4. C YA PROJECT AIMS: • Identify systems-level opportunities to increase capacity to provide hep C screening, care & treatment in HIV infrastructure • Increase the number of co- infected people who have their hepatitis C diagnosed, treated and cured • Eliminate hepatitis C among people living with HIV CAPACITY CURE ELIMINATON
- 5. C YA TARGET AREAS • C Who is Co-Infected Data & Evaluation • Cross train staff to address hep C Training & Capacity Building • Connecting PLWH to HCV Cure Re-Engagement in Care • Continuity & SustainabilityService Integration E L I M I N A T I O N
- 6. DATA & SURVEILLANCE A strong HIV and Hep C surveillance infrastructure is a critical component of our project.
- 7. Data Sources QUANTITATIVE Illustrate progress and gaps along the HCV Continuum QUALITATIVE Describes why gaps exist and where project might have impact Surveillance Databases: • Hepatitis Registry • EHARS • CAREWare Data Activities: • Routine Monthly Matches • Data-To-Care Integration (CoRECT) • CAREWare Measures and Feedback Reports • Clinical Site Visits • HepCAP & Community Meetings • Focus Groups • Training Feedback • CoRECT Case Conferences • Cross-Program Meetings
- 8. Our Cascade is Improving! 8 82% 70% 56% 28% 100% 0 20 40 60 80 100 HCV Ab-Positive Confirmatory RNA Received Confirmatory RNA Positive In HCV Care Resolved Infection Percentage% Baseline: HIV 2015 - HCV 2016 Updated: HIV 2015 - HCV 2017 3,086 2,537 2,171 1,736 8592,929 2,454 2,083 1,784 1,053 82% 86% 80% Source: Philadelphia Department of Public Health, AIDS Activities Coordinating Office & Viral Hepatitis Program 50%
- 9. Our Cascade is Improving! 9 82% 70% 56% 28% 100% 84% 71% 61% 36% 0 20 40 60 80 100 HCV Ab-Positive Confirmatory RNA Received Confirmatory RNA Positive In HCV Care Resolved Infection Percentage% Baseline: HIV 2015 - HCV 2016 Updated: HIV 2015 - HCV 2017 3,086 2,537 2,171 1,736 8592,929 2,454 2,083 1,784 1,053 84% 85% 86% Source: Philadelphia Department of Public Health, AIDS Activities Coordinating Office & Viral Hepatitis Program 59% 50% of HCV RNA+ Patients Have Resolved Their HCV Infection!
- 10. New Co-infection Trends in Philadelphia 0 20 40 60 80 100 Male Female NHBlack NhWhite Hispanic 0-29 30-39 40-49 50+ MSM PWID Heterosexual MSM/PWID Gender Race/Ethnicity Current Age HIV Transmission Risk Percentage% Historic HCV Infection <2012 Recent HCV Infection >= 2012
- 11. HCV Measures in CAREWare
- 12. HCV Measures in CAREWare
- 13. STRENGTHS • Ability to create and update a HCV continuum • Buy-in from AACO leadership to adapt CAREWare measures • Provider flexibility adapting to new HCV measures • QI process allows us to monitor HCV services and provide feedback CHALLENGES & OPPORTUNITIES • Surveillance limitations in PA and NJ • Tracking outcomes for clients getting care from non-RW providers • Creating a feedback loop with community partners to share data in timely way (ex: new infections)
- 14. QUESTIONS: Is there any hepatitis C data or analyses that you would find interesting or useful? • Ex: Geographic data and maps? Demographic or risk populations? Are there useful ways we can share data with community partners? • Ex: Slides or handout showing local co-infection data you can use in your presentations or share? 14
- 15. TRAINING & CAPACITY BUILDING Incorporating hep C into local AETC infrastructure at the Mid-Atlantic AETC, housed at Health Federation
- 16. Moving System Towards Change Encourage full integration of hep C clinical services from testing through cure at HIV care sites • Reflex Testing Available: • Out of 19 care sites: 8 in 2016; 15 in 2018 • Onsite Treatment Available: • Out of 22 care sites: 14 in 2016; 18 in 2018 “Hep C should be treated by a specialist…” “I don’t have time for prior auths, the drugs cost too much…” “I treat but would like to know how to better reach my ‘hard to engage’ patients…” “I’m ready to start with 1 patient…”
- 17. STRENGTHS • With coordination by Mid- Atlantic AETC • 17 HIV practice site visits • 5 providers from 4 sites trained • 2 new treatment sites • “We’ve started treatment on our first co-infected patient, got the medication approved, he is starting this week. He thanks you for your help!!” • Showcasing local providers and their best practices • Variety of models to share • Empowering clinicians to be leaders CHALLENGES & OPPORTUNITIES • Ongoing support for new treaters • Outdated information about cost, access, etc prevents some providers from treating hep C • Invite non-RW clinicians to participate in trainings • Training topics to consider: • Monitoring liver health after cure • Harm reduction & drug user health
- 18. QUESTIONS: Are there training topics related to hep C that you would find interesting or useful? • Ex: Integrating hep C treatment; supporting patients through treatment; harm reduction strategies Are there other materials or resources you need and for what audience? • Ex: Talking points for case managers, list of online resources, posters, multi-lingual or visual materials 18
- 19. LINKAGE TO CARE Integrating hep C into existing HIV service delivery models.
- 20. CoRECT Care Re-Engagement • Prioritizing HCV co-infected patient re-engagement through CoRECT process • CoRECT works with 7 sites to use data, provider feedback, and DIS staff to re-engage clients • C Ya team has: • Learned CoRECT process (ex: attending case conferences) • Adapted forms and procedures to include HCV • Cross-trained DIS who do patient outreach • Developed a HCV data matching and monitoring • Will track care retention, HCV treatment outcomes • Once clients are re-engaged in HIV care, will they stay in care long enough to start hep C treatment?
- 21. Re-Engagement in Care Data • Monthly data uploads and matches btw care sites and AACO • Routine matching to generate reports and identify high priority patients Discussion • Monthly case conferences with care sites (in-person, by phone) • Valuable insight into complexity of cases • Opportunity to engage and build relationships with care sites DIS • STD DIS have been cross-trained on hepatitis C • Limitation: DIS can get folks back in the door, but keeping clients engaged falls on other pieces of HIV system
- 22. STRENGTHS • Integrated hep C into CoRECT protocols and procedures • Piloted hep C in CoRECT at 1 site, 16 LTC clients identified as needing DIS outreach • 3-4 more sites in June/July • Cross-trained 4 CoRECT DIS • Built hep C fluency among other AACO staff CHALLENGES & OPPORTUNITIES • CoRECT is time and resource intensive process • Clearly defining expectations of role case managers re: hep C • Referring clients back into a “broken system” • Reaching clients who are NOT engaged at all in HIV care or services
- 23. Next Steps Data & Surveillance: • Assess new/re-infections; consider prevention strategies • Integration of hep C data-to-care activities at additional CoRECT sites • Annual hep C Screening Measure added into CAREWare Training & Capacity Building: • Outreach to case managers and clients • How can hep C be meaningfully but manageably incorporated into case managers’ role • Co-infection prioritized for intensive case management in new model • Certificate program to ensure subset of MCM have hep C fluency? Service Integration • Identify strategies for AACO and providers to address drug user health • Collaborate with other program areas: HEP, STD, Opioids, etc
- 24. Picture courtesy of Clinical Care Options PHILLY CAN END HEPATITIS C!
- 25. THANK YOU! PDPH Team: Hep and AACO AETC Team at Health Fed HepCAP HIV Service Providers And the people we serve… those living with HIV and hep C
- 26. Alex Shirreffs HIV/HCV Project Coordinator Philadelphia Dept. of Public Health Alexandra.shirreffs@phila.gov 215-685-5381 www.hepCAP.org www.phillyhepatitis.org
Editor's Notes
- 2 states, 3 Regions under Philadelphia EMA Philadelphia, Southeast PA, Southern NJ
- HepCAP coalition advocated for treatment access for all PDPH houses one of the best hep surveillance programs in the US Many Ryan White providers had already integrated hep C services AACO and Hepatitis siloed Best practices to share between treating and non-treating providers AACO and Hepatitis siloed
- 3-year cooperative agreement: Sept 2016 – Sept 2019 Special Projects of National Significance (SPNS) Funded Sites: Cities: Hartford, New York City, Philadelphia States: Louisiana, North Carolina TA Center: RAND
- HRSA project outcomes: comprehensive, but these goals can be accomplished through overlapping activities Local categorization of the project addresses all of the required components, but organizes them in a way that makes it manageable and easier to conceptualize – both for us and our partners I think it is also important to recognize that systems level work sounds impersonal but succeeding in changing systems is reliant on the people who interact with that system Our team brings intent and values to our work so that the impact of this project is meaningful and sustainable We look at the systems we are proposing to change and try to anticipate impact as best as we can; Any success we can boast is in part due to the values that drive the work – both among our health dept team but also our partners in the community – these values come through in the project areas we are going to highlight today
- From 2015 – 2017, 157 Individuals are deceased (approximately 1/3 of all hiv positive decedents
- From 2015 – 2017, 157 Individuals are deceased (approximately 1/3 of all hiv positive decedents were co-infected with hcv)
- Nationally & Internationally: Sexual transmission of HCV higher in HIV+ MSM1 Reports in MSM in Boston, San Francisco, and NYC2,3,4 Cluster of sexual transmission of HCV in HIV+ MSM identified molecularly in Michigan5 In Philadelphia: UPDATE MY NUMBERS A recent analysis identified 70 HCV seroconvesions in PWLH Majority MSM (49%) and Heterosexuals (27%) Among seroconverted MSM & Heterosexuals, reports of IDU low
- Also editing hepatitis B measures
- Also editing hepatitis B measures
- Cascade/continuum essential to monitoring progress towards elimination
- Use qualitative data to understand clinical practices CW, surveillance: Quality Improvement reports Also interviews with sites inform us of best practices, possible training/capacity building needs are also an opportunity to update/correct outdated information Use interviews to make recommendations too like reflex testing Identify resources sites are willing to share and pass along to other care providers Caveats with progress: Reflex testing available via major reference labs; more hospital labs offering reflex option Challenge is simplifying lab ordering process in EMRs so that ordering is universal Have not heard of billing/reimbursement issues Treatment available at more sites BUT NOT ALL PROVIDERS are treating at these sites! Hep C built into existing AETC modalities Peer to peer learning via didactic lessons and preceptorship Plans for follow up and ongoing support
- Hep C built into existing AETC modalities Peer to peer learning via didactic lessons and preceptorship Plans for follow up and ongoing support Two primary pools of clinicians to train: Novice Sites: Scaling new sites up to treat Start Small! 1 site, 1 provider, 1 patient Experienced Sites: Treatment onsite already, adding providers Addressing turnover, building practice capacity (ex: Ana Lapp, David Koren…)
- Pro: Building linkage/re-engagement of lost to care into an existing project Challenge: Very complex protocol to build into; but forced us to be very intentional with what we want to accomplish
- Pros: Information about complexity of cases; opportunity to engage and build relationships with care sites Cons: Time consuming and resource heavy