Hepatitis and HIV Care
Hepatitis and HIV Care
Hepatitis is widespread, deadly, and yet, largely preventable. In the United States, chronic viral hepatitis (hepatitis B and C) affects 3.4-5.3 million people. Most do not know they are infected. Hepatitis is the leading cause of liver transplants in the United States, and it accounts for 12,000-18,000 deaths annually. Worldwide, 130-150 million are infected with HCV, with 350,000 to 500,000 deaths each year.
For people living with HIV/AIDS, the impact of hepatitis is more severe. An estimated 33% of persons living with HIV are coinfected with the hepatitis B virus (HBV) or hepatitis C virus (HCV), while about one fourth are HCV/HIV coinfected (June 2016). According to CDC, "liver disease—much of which is related to HCV and HBV—has become the leading cause of non-AIDS-related deaths" among people living with HIV/AIDS.
Hepatitis management is increasingly within our grasp, given vaccinations, more widespread screening to identify infected individuals, and new treatments--in particular, a new generation of HCV treatments approved in 2013 that has a cure rate of around 90% (AIDS.gov blog). Yet, significant challenges exist, from mobilizing health systems to screen and vaccinate to the high cost of HCV medications. The framework for confronting hepatitis is outlined in the National Viral Hepatitis Action Plan 2017-2020, an update of 2014 and 2011 versions, with goals and priorities on testing to inform infected individuals of their status, care and treatment for infected persons, preventive work to reduce new cases, and elimination of mother-to-child transmission.
Around one-third of persons living with HIV are coinfected with hepatitis B or C.
Ryan White and Hepatitis
HRSA and Ryan White entities have been working on hepatitis initiatives for many years. Some of the earlier work is described in this 2013 AIDS.gov blog while more recent activities are described below. The outcome of projects to date, in terms of tools and resources for ready adoption by others, can be found on the Hepatitis Topic Page.
HCV Care Initiatives
Jurisdictional Approach to Curing Hepatitis C among HIV/HCV Coinfected People of Color is a new initiative funded in late 2016 to improve hepatitis C virus services among HIV/HCV co-infected people of color, funded under the FY 2016 Secretary’s Minority AIDS Initiative Fund.
Ryan White efforts to confront HCV/HIV coinfection coalesced under the SPNS research and demonstration project Hepatitis C Treatment Expansion Initiative, which focused on development of replicable HCV treatment models within HIV primary care programs. Early insights on the Initiative can be found in a 2011 issue of HRSA's What's Going on @ SPNS as well as subsequent research publications and other resources from the Initiative's website. Lessons learned have been turned into training materials and a curriculum under HRSA's IHIP, Integrating HIV Innovative Practices.
HCV Care and Treatment Protocols
Clinical guidance on hepatitis C management can be found in guidelines on testing, managing and treating hepatitis C, a web-based tool that is continuously being updated to reflect new treatments and developments in this rapidly changing field.
Guidance on how to conduct HCV care and treatment has also been produced in multiple HRSA documents, including the comprehensive Guide for HIV/AIDS Clinical Care's chapter covering hepatitis B and C, Guide for HIV/AIDS Clinical Care: Comorbidities, Coinfections, and Complications. The Hepatitis C in HIV/AIDS Pocket Guide, an outcome of the SPNS hepatitis initiative, operationalizes these protocols in a handy format designated for busy clinicians. (Additional protocols/pocket guides for clinicians can be found on the AETC NCRC Hepatitis page.)
Tools and Training
Materials to support Ryan White programs in operating hepatitis care/treatment programs include varied resources on the TARGET Center's Hepatitis Topic Page, especially the corresponding link to the AETC topic page on viral hepatitis and its extensive collection of clinician training tools, including the HCV Online Course. Also available on both the TARGET and AETC sites are tools such as Integrating Hepatitis C Treatment In Ryan White Clinics: Models and Steps, a 2011 guide to setting up an HCV care/treatment program in a Ryan White setting. This collection will expand with the addition of the above-mentioned IHIP Integrating HIV Innovative Practice hepatitis training materials and curriculum.
See IHIP training materials on hepatitis.
Data and Quality Monitoring
The HRSA HIV/AIDS Bureau has created a framework of resources to support Ryan White programs in monitoring the delivery of HIV care, inclusive of hepatitis. HAB's Performance Measures are comprised of multiple sets, with an adolescent/adult set of measures that include specific measures addressing hepatitis B screening and vaccination and hepatitis C screening. On the data end, HRSA's Ryan White Services Report, the RSR client-level data system, is used by grantees and funded providers to collect the same performance measure data, above, on hepatitis B screening and vaccination as well as hepatitis screening.