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.
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
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.
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/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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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.