Marguerite Beiser ANPBC AAHIVS Boston Health Care for the Homeless Program Regis College 111418 I have no disclosures Outline Hepatitis C HCV Pathophysiology Epidemiology Screening ID: 1047957
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1. Confronting Hepatitis C and HIV Among the HomelessMarguerite Beiser, ANP-BC, AAHIVSBoston Health Care for the Homeless ProgramRegis College 11/14/18
2. I have no disclosures
3. OutlineHepatitis C (HCV)PathophysiologyEpidemiologyScreening TreatmentHIV PathophysiologyEpidemiologyScreening TreatmentDelivering effective care for HIV and HCV among homeless populations
4. Single-stranded RNA virus in the Flaviviridae familyReplication does NOT require entry into nucleus or integration with host DNA= able to be cleared/cured
5. HCV Basics Most common blood borne infection in the USAcute infectionSubjective: usually asymptomatic, but possibly n/v/d, fatigue, jaundiceObjective: possibly transaminitis (ALT>AST)Testing: HCV Ab/reflex VL, HCV genotype (1-6)Assess for coinfection with HIV, Hep A/B(vaccinate as needed)No vaccine Viremic > 6 months post infection = chronic HCV
6. Without intervention, HCV deaths may reach total of 897,000 in the United StatesRein et al. Dig Dis Sci 2011 John Ward, Topics in Antiviral Medicine 2013DCC: decompensated cirrhosis; HCC: hepatocellular carcinoma
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8. Source: Dan Church, MA DPH
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10. HCV treatmentDirect-Acting Antiviral (DAA) TherapyIDSA/AASLD guidelineswww.hcvguidelines.org1-3 pills once daily8-12 week regimens Pangenotypic >95% SVR rates SEs: fatigue, HA Special considerations in advanced cirrhosis, ESRD, drug-drug interactions
11. HCV treatment considerationsTreating at minimal stage fibrosis has better mortality benefit and fibrosis regression Treating active users can reduce incidence of new infectionsTREATMENT AS PREVENTION Treating women of child-bearing age before future pregnancy prevents mother-child transmissionTreating PWIDs is just as effective as treating others and rates of reinfection are low there are low
12. 10-year Cumulative Incidence Rate530 patients with advanced fibrosis, treated with interferon-based therapy, and followed for 8.4 (IQR 6.4-1.4) years Van der Meer et al. JAMA 2012; 308:25848.9265.121.82.129.9SVR (Cure) Associated with Decreased All-Cause Mortality
13. HCV Care Cascade, United States 2014Yehia BR, Schranz AJ, Umscheid CA, Lo Re V III (2014) The Treatment Cascade for Chronic Hepatitis C Virus Infection in the United States: A Systematic Review and Meta-Analysis. PLoS ONE 9(7): e101554. https://doi.org/10.1371/journal.pone.0101554
14. Double-stranded RNA retrovirus in the Retroviridae family, Lentivirus genusReplication requires integration into host DNA= Not able to be cured (yet)
15. Natural history of HIV infectionLevels (Separate Scales)CD4+ T cellHIV viral loadCD8+ T cellNeutralizing AntibodiesYearsAIDS and DeathAcuteAsymptomatic (clinical latency)4 – 8 weeksPrimary infection
16. 16HIV.gov (https://www.hiv.gov/blog/new-hiv-infections-drop-18-percent-in-six-years)
17. HIV Screening
18. HIV Treatment Goals of treatment:HIV viral load suppressionPreservation of CD4 cells/immune functionPrevention of transmission to othersRecommended: All, regardless of CD4 count, to reduce morbidity and mortality
19. HCV deaths exceed those from 60 infectious conditions (including HIV, pneumococcus)Ly et al. CID 2016
20. Housing status matters:Stark disparities in prevalence of HCV and HIV between housed and homelessHCV Epidemiology Population studiedPrevalence Citation Household phone survey1%(Hofmeister et al, 2018)Homeless at 7 HCH sites31%(Strehlow et al, 2012)Homeless in Boston23%(Bharel et al, 2013) HIV EpidemiologyPopulation studiedPrevalenceCitationNational estimate0.3%(CDC, 2015)Homeless meta-analysis world-wide0.3%-21%(Beijer et al, 2012)Homeless in the US estimate3.4%(National Alliance to End Homelessness, 2006)Homeless in Boston2.7%(BHCHP internal data)
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22. Impact of HCV and HIV among Boston homelessGreater morbidity/mortalityShifting HIV mortality among Boston homeless- HIV-attributable mortality 18% (1988-1993) 5.8% (2003-2008) Homeless men at BHCHP suffered excess mortality burden from liver cancer than the general MA male population Increased cost and health care utilization Patients at BHCHP with HCV had significantly increased health care utilization compared to BHCHP patients without HCV(Baggett et al, 2015); Bharel et al, 2013)
23. How does being homeless impact an individuals ability to achieve good health related to HIV and HCV? PovertyInsurance coverage (premiums, copays)Masshealth and HDAP are exemplary in addressing these, but not the case in other states or other plansPractical issuesMed storageRefrigerationTransportation to appointments Competing prioritiesHigher priority survival needsShelterFoodSafety Child care WorkOften medical issues are not addressed until they are unavoidableIncreased utilization of ED Delayed diagnosis/Diagnosis at advanced stages of illness High rates of comorbid complex medical, mental health and addiction disorders Stigma, particularly related to substance use
24. Strategies to improve care for people living with HIV or HCV and are homeless HOUSING AS HEALTHCAREHIV care outcomes: housing associated with improved linkage and retention in care, reduced hospitalizations, improved adherence, higher rates of viral suppressionProvide comprehensive services at convenient sitesShelter-based clinics, street outreach, locations at sites of greatest needIntegrated primary and specialty care (PCPs are HIV and HCV specialists, Ryan White Program, co-located pharmacy, dental, etc)Expand capacity for non-billable services such as outreach, adherence support, housing servicesCase management associated with improved HIV care outcomesCare coordination fundamental to HCV programming at BHCHP(Buchanan et al, 2009; Aidala et al, 2016); Kushel et al, 2006)
25. HIV Outcomes at BHCHP~300 patients with HIV Housing intervention by case management24 individuals housed in 18 months 2017-2018BHCHP Quality GoalsGY 2016GY 2017GY 2018 HRSA Measures HIV Viral Load Suppression94%84%87%Prescription of HIV Antiretroviral Medications93%89%92%HIV Medical Visit Frequency88%87%88%
26. HCV Treatment OutcomesFirst 300 BHCHP Patients Linked to HCV Tx Evaluation510Initiated Tx300Deferred210Completed Tx285SVR Achieved254Did Not Complete Tx15Lost to F/U11Stopped due to SEs2Incarcerated2SVR Achieved1SVR Not Achieved17Missing SVR Data14Total SVR Achieved 255(85%)
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