While potent new direct-acting antiviral (DAA) therapy has revolutionized treatment hepatitis C by shortening treatment and offering an actual cure, there has been one persistent roadblock in caring for more patients: not enough specialists who can prescribe the drugs and manage the progress.
But a lack of hepatitis specialists might no longer be an issue, according to one major study and a screening project in California.
The 600-patient ASCEND study, cosponsored by the NIH’s Clinical Center and National Institute of Allergy and Infectious Diseases (NIAID), explored how primary care providers compare with specialists in treating patients with DAAs.
Researchers targeted providers at community health centers in Washington, D.C., and distributed HCV patients randomly to receive treatment from a primary care physician, a nurse practitioner, or an infectious disease or hepatology specialist. All providers had three hours of training on HCV treatment guidelines.
Among the 409 patients who completed twelve weeks of therapy, 93.8 percent achieved SVR12, or sustained virological response, twelve weeks after completion of treatment with sofosbuvir/ledipasvir (the drugs in Harvoni).
Even more significant was the adherence rate. It was significantly higher among people treated by nurse practitioners (51.4 percent) or primary care physicians (49.0 percent) compared to specialists (19.2 percent).
Researchers concluded that DAAs delivered by nurse practitioners and primary care physicians was safe and effective, even for the most difficult-to-treat patients, and could potentially help increase the number of people receiving treatment.
“The ASCEND model could increase the availability of community-based, non-specialist providers to significantly expand the scale of HCV therapy, and bridge existing gaps in the hepatitis C care cascade,” the researchers said.
On the other side of the country, the Alameda Health Consortium in San Leandro, California, was planning to expand HCV testing in 2015. But management was concerned that there wouldn’t be enough doctors to treat all of the patients who might test positive.
So Alameda Health’s medical director, Dr. Sophy Wong, enlisted the help of Dr. Jan Diamond, a family physician, in developing a curriculum that would help non-specialists on their site understand how to treat patients with the hepatitis C virus (HCV).
They developed collaborative learning models, one for project staff and the other for primary care providers interested in treating HCV with the objective of facilitating peer-to-peer learning.
Project staff met quarterly to share best practices in optimizing staff support, workflows, data collection, and tracking tools. Providers were given a half-day of intensive training led by non-specialist providers, plus quarterly evening update meetings. The first training was conducted in the summer of 2015.
All patients were monitored through post-treatment labs. In addition, Dr. Wong and her staff collected data from each health center six months after the initial provider training to measure progress in increasing treatment capacity.
Over a sixteen-month measurement period, the number of providers actively treating HCV at Alameda Health’s four health centers increased 380 percent and the number of patients initiating treatment more than quintupled, increasing by 538 percent. Ninety-six percent of treated patients with confirmed labs post-treatment had achieved SVR12.
The majority of hepatitis patients at Alameda Health are on MediCal (the state version of Medicaid) or uninsured. As reported in HepTalk previously, drop-off in the cascade of care among this population is typically high. And getting patients to be tested for HCV is a challenge, especially if they consider the treatment to be extensive and confusing. Managing appointments with several different doctors is often enough to make a patient drop out of treatment.
An analysis of the evaluation data from Alameda health’s peer-to-peer training was presented at the annual conference of the American Association for the Study of Liver Diseases (AASLD) last November.
Alameda Health’s peer-to-peer training on hepatitis treatment benefits both patients and health centers, according to Megan Crowley, HIV project manager for the Alameda Health Consortium. Crowley says that, in a changing insurance landscape, efforts to streamline billing by making HCV treatment a one-stop affair, is a benefit for patients and health centers.
“Patients can stay with their medical home and sometimes with their primary care physicians and they don’t have to get lost in the abyss of the hospital system,” Crowley tells A&U. “That leads to a continuity of care. There is no chasing of records if a patient is not in the system.”
“Anecdotally we’re hearing that HCV treatment is now becoming an entry to better engagement for health care generally,” Crowley adds. “When patients see that something can be cured quickly and relatively easily, they’re not afraid to get tested for it and they’re willing to keep coming back when they need treatments for [other ailments].”
Larry Buhl is a radio news reporter, screenwriter, and novelist living in Los Angeles. Follow him on Twitter @LarryBuhl.