Original Research

Current State of Hepatitis C Care in the VA

Although the VA has been successful in screening, treating, and curing many veterans infected with hepatitis C virus, reaching young injection drug users and homeless persons remains a challenge.

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The following is a lightly edited transcript of a teleconference discussion of hepatitis C virus treatment in the Veterans Health Administration system.



VA Hepatitis C Treatment Progress

Lisa Backus, MD. For a long time the US Department of Veterans Affairs (VA) has approached hepatitis C virus (HCV) care in a comprehensive way. We have done extensive screening to look for people with HCV infection. Even before birth cohort testing was recommended by the Centers for Disease Control and Prevention (CDC), the VA had aggressive HCV screening programs.

From the VA Corporate Data Warehouse, we know that the VA has screened more than 80% of people who are in the 1945 to 1965 birth cohort in VA care. Over time, HCV prevalence has been dropping in screened veterans and by extension in those who remain to be screened. Based on internal modeling, the VA estimates that only 6,000 to 7,000 veterans in the 1945 to 1965 birth cohort remain to be found if we could somehow screen everyone in that group.

On the treatment side, the VA has provided an unparalleled amount of care. In data from the Clinical Case Registry: HCV, as of February 2018 the VA has started more than 104,000 veterans on direct-acting antiviral (DAA) treatment. When the DAAs first became available, we estimated that there were about 165,000 people who were HCV viremic and who needed to be treated. By the end of January 2018, that number was down to about 35,000 people. The VA has done an unbelievably good job of finding people, getting them into care, and treating them.

Samuel Ho, MD. I agree with Dr. Backus. The VA has done an excellent job over the past few years in treating a very significant proportion of our patients with HCV. In addition to the extensive screening efforts, I want to emphasize that going back to about the year 2000, the VA has been very active in supporting the establishment of HCV clinics within every VA medical center to identify and engage patients in treatment. At that time, of course, the treatment was with pegylated interferon and ribavirin, which was very challenging. The VA support consisted of funding 4 hepatitis C Resource Centers (HCRCs) nationwide, which were located in Minneapolis, Portland/Seattle, New Haven, and San Francisco.

The HCRCs reached out to every VA facility in the country, developed networks of health care providers (HCPs), trained them, and educated them regarding the HCV treatments and strategies to engage patients in care, especially the large numbers with comorbidities, such as psychiatric problems and substance use disorders. This highly engaged network of local HCV clinic providers was set up and running and was well poised to take advantage of the interferon-free DAAs when they became available in late 2013 and early 2014. With the continuing leadership of David Ross, MD, and many others at the national level, the VA then supported the development of HCV Innovation Teams in every VISN that continued the efforts to support local quality improvement initiatives related to HCV care.

That being said, the VA still has challenges. There are a significant number of people who have barriers to receiving treatment. For example, here at the VA San Diego Healthcare System, Dr. John Dever and our other colleagues looked at 481 patients who were high priority to get started on HCV treatment, because they were all believed to be a high risk for cirrhosis due to their Fibrosis-4 (FIB4) scores and other characteristics.1

We really worked hard on that group, and of the ones who were eligible for treatment, 30% were either unwilling or unable to engage in care over a yearlong follow-up with multiple attempts at outreach. In comparison with patients who became engaged or were engaged in care, these nonengaged patients were significantly more likely to be homeless, have other comorbidities, or active alcohol and/or drug use. Not surprisingly, they had obvious barriers to engaging in care.

Further efforts need to be made to focus on these patients, maybe with innovative ideas and strategies for outreach to get them into treatment or to bring treatment to them. I’m not sure exactly as to what the best approach would be. There is ongoing research in that regard, but it still is a challenge.

Erica Trimble, NP. Our experience at VA San Francisco Health Care System is similar. If we actively reach out to veterans already engaged in primary care, we can usually engage them in the liver clinic as well. However, there are quite a number of veterans who engage regularly with HUD-VASH (US Department of House and Urban Development-VA Supportive Housing program) and other homeless veteran services but have no primary or specialty care engagement. These veterans are very difficult to reach.


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