HCV/HIV Treatment Guidelines

AAHIVM Treatment Guidelines and Recommendations for treating HCV in people with HIV

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Current AASLD Guidelines for Simplified Treatment of HCV are available and emphasize that HCV treatment is relatively simple and can be done by a wide range of prescribers. However, it is worth noting that these guidelines state that HIV positivity is a contraindication for Simplified Treatment. Nonetheless, people with HIV (PWH) can be safely and effectively treated for HCV taking into account special considerations which we delineate below.
OVERARCHING PRINCIPLES
  • Treat everyone for HCV as soon as possible. Rationale: (i) PWH and HCV progress to fibrosis faster. (ii) Reduce the community hepatitis viral load for public health
  • Current DAAs are 95% effective in treatment-naïve individuals and are equally effective in PWH
  • States and insurance companies should remove barriers to treatment such sobriety restrictions and prescriber restrictions but each state has varying practices (see www.StateofHepC.org))
  • Adherence counseling is important to reinforce both HCV treatment success and promoting HIV viral suppression
  • Counsel all PWH on risk-reduction efforts to prevent HCV infection and re-infection (if successfully cured)
  • Consider annual rescreening of PWH who have ongoing risk factors such as active injection drug use and sexually active MSM
  • Rely on existing resources such as www.hcvguidelines.org for specific HCV treatment guidelines
RECOMMENDED BEST PRACTICES
ADOPT A TEAM APPROACH
Build a team to facilitate your ability to treat HCV; team members to include:
  • A CLINIC CHAMPION: clinician who is trained to be a HCV treatment prescriber
  • PHARMACY CONTACT: Community Pharmacist, Specialty Pharmacist, Mail Order Provider who can communicate with the clinic and patients during treatment and can help navigate insurance issues
  • ADMINISTRATIVE SUPPORT: clinic staff person who is responsible for monitoring clinic progress on persons undergoing treatment (e.g. contact patients for lab monitoring, tracking treatment success via a dedicated registry, communicating with pharmacist)
  • Identify a treatment network of hepatologists, gastroenterologists to co-manage complicated cases (e.g. decompensated cirrhosis)
  • Identify network of Substance Abuse providers (e.g., providers of medication assisted treatment) for co-management of persons with concomitant substance use issues
  • Consider an outreach specialist/community health worker/peer navigator to support patients.
ENGAGE INSURANCE/THIRD PARTY PAYER OPTIONS
  • Utilize www.StateofHepC.org as a resource to understand state policies regarding treatment
  • Advocate for the removal of limitations on the ability of all medical providers to prescribe HCV treatments
  • Prior to prescribing, call a pharmacist or an experienced HCV provider to identify which medications are covered by a patient’s medical insurance or third-party payer
  • If a preferred drug is declined or requires a pre-authorization that is declined, consider alternatives; this can be done in concert with Pharmacist
  • Advocate for the removal of sobriety restrictions to treat patients with active substance or alcohol use
CONSIDER SPECIAL POPULATIONS
PEOPLE WHO INJECT DRUGS (PWID)
  • Active Substance use is NOT a contraindication for treatment, but may represent a state level barrier
  • Use a substance use disorder screening mechanism that looks at active versus historic dependency such as the Substance Abuse Subtle Screening Inventory, 3rd Edition (SASSI-3)
  • Patients with active substance use may be re-infected so annual rescreening for HCV is important
  • Incorporate harm reduction education: use of clean needles/works, emphasize self-injection as a foray into drug treatment
  • For Medication Assisted Treatment (MAT) providers—incorporate routine screening for HIV and HCV and create programs to provide HCV treatment on site or refer to HIV clinical partners
  • Consider drug interactions with drug of choice/Methadone/Suboxone/Vivitrol
PERSONS WITH ALCOHOL USE DISORDERS
  • Use an alcohol use screening disorder tool to determine active versus historic dependency such as the Alcohol Use Disorders Identification Test (AUDIT) or CAGE Assessment
  • If a patent has problem drinking, consider their adherence to other factors – do they come to appointments? Are they adherent to HIV medications? If so, treatment for HCV should be considered
  • Be aware of state sobriety requirements for third party payments.
  • Incorporate liver disease progression education and harm reduction education with resources for alcohol use reduction/cessation
  • Consider Naltrexone/Vivitrol/Antibuse medication option for alcohol use reduction
WOMEN OF CHILDBEARING POTENTIAL/PREGNANT WOMEN
  • All pregnant women should be tested for HCV as part of routine pre-natal care
  • In general, HCV treatment should be offered before considering pregnancy
  • If a woman is pregnant, defer HCV treatment but treat HCV as soon as possible post-partum
  • Offer breast feeding counseling: breastfeeding is currently contraindicated in developed countries for prevention of HIV transmission
  • Consider HCV screening of sexual partners
  • Women of child-bearing potential should be offered birth control options while treating HCV and counsel women about delaying pregnancy until treatment is complete.
  • Consider birth-control and drug-drug interactions with HCV treatment options
PATIENTS WITH CIRRHOSIS
  • Patients should have assessment for cirrhosis as part of pre-treatment assessment; this includes non-invasive scoring (laboratory tests, imaging, transient elastography) and invasive in some cases (e.g. liver biopsy) as well as clinical evaluation
  • PWH with compensated cirrhosis can be treated with simplified regimens (REF: AASLD guidelines)
  • PWH with current or prior decomensated cirrhosis should be managed with a specialist (e.g. hepatologist)
  • Consider referral to a hepatologist for PWH with advanced liver disease (e.g. FIB-4 >3.25) as these patients need additional follow-up for liver related health (e.g. screening for HCC)
RENAL INSUFFICIENCY/CKD/END STAGE RENAL DISEASE
  • Chronic HCV is independently associated with development of CKD
  • PWH with renal insufficiency can and should be treated for HCV
  • Available DAA options for this group include: glecaprevir/pibrentasvir and elbasvir/grazoprevir (genotype 1)
  • Consult sources (e.g. HCVguidelines.org) for potential drug interactions with HIV medications
  • For patients on dialysis, discuss HCV treatment with their nephrologist.
  • Potential transplant may be impacted by the timing of HCV treatment so consult transplant nephrologist
HOMELESS/UNSTABLE HOUSED
  • Homeless/unstably housed patents require support services including mobile treatment/transportation assistance and third-party payment assistance
  • Utilize your treatment team – outreach workers/community health workers, and pharmacists to enable directly observed treatment or other support services (e.g. dispense a week’s worth of medication at a time to ensure adherence/ongoing access to medications).
  • Identify where the person normally stays or can be found or a contact with a phone who can reach him or her
  • Consider repackaging of medications/pill boxing to avoid disclosure concerns
FORMERLY INCARCERATED/HIGH RECIDIVISM
  • Formerly incarcerated/high recidivism populations require additional support services. Utilize the team with medical case management/outreach identifying the patient support network to assist with patient location.
  • Inquire if the patient is currently on probation or parole and if they have bench warrants or pending court dates. Timing factors may indicate a treatment delay.
  • Inform the patent If they are arrested/incarcerated to inform the civic justice team they are on HCV treatment. Help them to self-advocate with civic justice network to complete treatment.
  • Treatment prescribers should be contacted when patients are incarcerated in order to streamline completion of HCV treatment.

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About

The American Academy of HIV Medicine is a professional organization that supports the HIV practitioner and promotes accessible, quality care for all Americans living with HIV disease. Our membership of HIV practitioners and credentialed HIV Specialists™, HIV Experts™, and HIV Pharmacists™ provide direct care to the majority of HIV patients in the US.