HCV Coinfection: Expanding Access through the RWCA

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HCV CoinfectionExpanding Access through the RWCA

• Laura W. Cheever, MD, ScM
• Chief Medical Officer, Deputy Associate
  Administrator
• U.S. Department of Health and Human Services
• Health Resources and Services Administration
• HIV/AIDS Bureau

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HIV/HCV Why is it important now?

• Co-infection common in US (15-30)1,2
• Liver disease is a major cause of death3,4
• Rates are increasing from 1996 to 2004
• At death
• 38 with CD4gt200 cells/mm32
• 37 with no detectable virus
• RWCA structured to respond to the changing
  epidemic through local planning

1Sherman, CID, 2002 2Sulkowski, Ann Intern Med
2003 3Palella, JAIDS 2006 (HOPS) 4Dominique,
42nd ICAAC, 2002, 1719
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Barriers to Care

• Provider
• Knowledge, skills (managing pts with
  contraindications), attitudes
• System
• Availability of multidisciplinary team, labs,
  meds, biopsies, patient support
• Referral out of HIV system (stigma)
• Patient
• Knowledge, fears (bx, tx), contraindications

Adapted Badem and Clanon, RWCA AGM, 2004
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HCV Care Room for Improvement

• Hepatitis A
• 57 screened
• 23 of eligibles vaccinated
• Hepatitis B
• 82 screened
• 32 of eligibles vaccinated

Source Tedaldi, CID, 2004
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Access to Treatment

• Urban Co-infection Clinic
• 30 of 149 pts eligible for HCV treated
• 56 gt 1 criterion
• 36 of eligible pts agreed to tx
• 53 if genotype 2,3

Fleming, CID, 2005
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Access to Treatment

• VA Multisite study
• 33 active alcohol users counseled to stop
• 18 patients eligible for treatment biopsied
• 3 eligible patients received interferon
  treatment
• Bottom line Funding is necessary but not
  sufficient- other barriers

Fultz, CID 2003
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Barriers to HCV Treatment
Title III survey 10/04, 40 response rate
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Ryan White CARE Act Role in HIV/HCV Care

• Funding medical services
• Visits, counseling, lab monitoring
• Medications, vaccination
• Building Capacity
• Training (AIDS Education and Training Centers)
• Technical assistance

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Funding Medical Services

• Costs
• Medical visits, counseling, labs (diagnostics and
  monitoring), biopsy, medication, vaccination
• AIDS Drug Assistance Program (ADAP)
• 17 states cover IF/RBV
• Total number of patients treated is small
• Claims are low
• Approx. 5000 patients txed per 2005 CADR

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ADAP HCV Treatment Claims (9/01)

• NY 0.2- 0.3 of costs
• California 0.0023
• Massachusetts 0.03
• New Jersey 0.07
• 2002 Mass and NJ Little increase in utilization
  since adding PEG

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Treatment in Title III Programs

• HCV antibody screening 99
• Treating HCV 70
• Treating in house 43
• Referral out 32
• Combination 24

Title III survey 10/04, 40 response rate
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Building Capacity

• AIDS Education and Training Centers Center of
  Excellence in HCV
• www.uchsc.edu/mpaetc/coe.htm
• Technical Assistance
• Individual
• New HCV document

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Overcoming Barriers

• Reauthorization of the RWCA
• Current legislation with authority to treat HCV
• Learning from other Federal agencies (VA)
• Technical assistance to grantees
• Highlighting importance of HCV in morbidity and
  mortality
• Assessing impact of adding IFV/RBV to ADAP costs
• Disseminating treatment guidelines and best
  practices
• Replicating models that work
• Education and support
• Clinicians, patients

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Laura W. Cheever, MD, ScMChief Medical
OfficerDeputy Associate Administrator, HIV/AIDS
BureauHealth Resources and Services
AdministrationLcheever_at_hrsa.gov301-443-3067