Alex Shirreffs of the Philadelphia Department of Public Health provided this overview of the Philadelphia area's plan to end HIV and Hepatitis C coinfections to the HIV Integrated Planning Council on May 10, 2018.
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C-YA! Philadelphia EMA's Plan to Connect our Co-infected Community to a Cure for Hep C
1. C-YA!
Alex Shirreffs, MPH
May 10, 2018
Philadelphia EMA’s Plan to Connect our
Co-infected Community to a Cure for Hep C
2.
3. Before C YA…
• Philadelphia was a leader in viral hepatitis…
• HepCAP coalition
• Hepatitis Surveillance infrastructure
• Ryan White providers some of our biggest hep C champions
• But there was room for improvement…
• What does co-infection look like in the Philly area?
• How is hep C being addressed in the RW system?
• Where are opportunities to integrate hep C sustainably in HIV
infrastructure?
• What will it take to eliminate hep C among PLWH?
3
4. C YA PROJECT AIMS:
• Identify systems-level
opportunities to increase
capacity to provide hep C
screening, care & treatment in
HIV infrastructure
• Increase the number of co-
infected people who have
their hepatitis C diagnosed,
treated and cured
• Eliminate hepatitis C among
people living with HIV
CAPACITY
CURE
ELIMINATON
5. C YA TARGET AREAS
• C Who is Co-Infected
Data & Evaluation
• Cross train staff to address
hep C
Training &
Capacity Building
• Connecting PLWH to HCV
Cure
Re-Engagement
in Care
• Continuity & SustainabilityService
Integration
E
L
I
M
I
N
A
T
I
O
N
6. DATA & SURVEILLANCE
A strong HIV and Hep C surveillance infrastructure is
a critical component of our project.
7. Data Sources
QUANTITATIVE
Illustrate progress and gaps along
the HCV Continuum
QUALITATIVE
Describes why gaps exist and where
project might have impact
Surveillance Databases:
• Hepatitis Registry
• EHARS
• CAREWare
Data Activities:
• Routine Monthly Matches
• Data-To-Care Integration
(CoRECT)
• CAREWare Measures and
Feedback Reports
• Clinical Site Visits
• HepCAP & Community
Meetings
• Focus Groups
• Training Feedback
• CoRECT Case
Conferences
• Cross-Program Meetings
8. Our Cascade is Improving!
8
82%
70%
56%
28%
100%
0
20
40
60
80
100
HCV Ab-Positive Confirmatory RNA
Received
Confirmatory RNA
Positive
In HCV Care Resolved Infection
Percentage%
Baseline: HIV 2015 - HCV 2016 Updated: HIV 2015 - HCV 2017
3,086 2,537 2,171 1,736 8592,929 2,454 2,083 1,784 1,053
82% 86% 80%
Source: Philadelphia Department of Public Health, AIDS Activities Coordinating Office & Viral Hepatitis Program
50%
9. Our Cascade is Improving!
9
82%
70%
56%
28%
100%
84%
71%
61%
36%
0
20
40
60
80
100
HCV Ab-Positive Confirmatory RNA
Received
Confirmatory RNA
Positive
In HCV Care Resolved Infection
Percentage%
Baseline: HIV 2015 - HCV 2016 Updated: HIV 2015 - HCV 2017
3,086 2,537 2,171 1,736 8592,929 2,454 2,083 1,784 1,053
84% 85% 86%
Source: Philadelphia Department of Public Health, AIDS Activities Coordinating Office & Viral Hepatitis Program
59%
50% of HCV RNA+
Patients Have Resolved
Their HCV Infection!
10. New Co-infection Trends in Philadelphia
0
20
40
60
80
100
Male
Female
NHBlack
NhWhite
Hispanic
0-29
30-39
40-49
50+
MSM
PWID
Heterosexual
MSM/PWID
Gender Race/Ethnicity Current Age HIV Transmission Risk
Percentage%
Historic HCV Infection <2012 Recent HCV Infection >= 2012
13. STRENGTHS
• Ability to create and
update a HCV continuum
• Buy-in from AACO
leadership to adapt
CAREWare measures
• Provider flexibility
adapting to new HCV
measures
• QI process allows us to
monitor HCV services and
provide feedback
CHALLENGES &
OPPORTUNITIES
• Surveillance limitations in
PA and NJ
• Tracking outcomes for
clients getting care from
non-RW providers
• Creating a feedback loop
with community partners
to share data in timely
way (ex: new infections)
14. QUESTIONS:
Is there any hepatitis C data or analyses that
you would find interesting or useful?
• Ex: Geographic data and maps? Demographic or risk populations?
Are there useful ways we can share data
with community partners?
• Ex: Slides or handout showing local co-infection data you can use
in your presentations or share?
14
15. TRAINING & CAPACITY BUILDING
Incorporating hep C into local AETC infrastructure at
the Mid-Atlantic AETC, housed at Health Federation
16. Moving System Towards Change
Encourage full integration of hep C clinical services from
testing through cure at HIV care sites
• Reflex Testing Available:
• Out of 19 care sites: 8 in 2016; 15 in 2018
• Onsite Treatment Available:
• Out of 22 care sites: 14 in 2016; 18 in 2018
“Hep C should be
treated by a
specialist…”
“I don’t have
time for prior
auths, the
drugs cost too
much…”
“I treat but would
like to know how to
better reach my
‘hard to engage’
patients…”
“I’m ready to start
with 1 patient…”
17. STRENGTHS
• With coordination by Mid-
Atlantic AETC
• 17 HIV practice site visits
• 5 providers from 4 sites
trained
• 2 new treatment sites
• “We’ve started treatment on our
first co-infected patient, got the
medication approved, he is
starting this week. He thanks
you for your help!!”
• Showcasing local providers
and their best practices
• Variety of models to share
• Empowering clinicians to be
leaders
CHALLENGES &
OPPORTUNITIES
• Ongoing support for new
treaters
• Outdated information about
cost, access, etc prevents
some providers from
treating hep C
• Invite non-RW clinicians to
participate in trainings
• Training topics to consider:
• Monitoring liver health after
cure
• Harm reduction & drug user
health
18. QUESTIONS:
Are there training topics related to hep C
that you would find interesting or useful?
• Ex: Integrating hep C treatment; supporting patients through
treatment; harm reduction strategies
Are there other materials or resources you
need and for what audience?
• Ex: Talking points for case managers, list of online resources,
posters, multi-lingual or visual materials
18
20. CoRECT Care Re-Engagement
• Prioritizing HCV co-infected patient re-engagement
through CoRECT process
• CoRECT works with 7 sites to use data, provider
feedback, and DIS staff to re-engage clients
• C Ya team has:
• Learned CoRECT process (ex: attending case conferences)
• Adapted forms and procedures to include HCV
• Cross-trained DIS who do patient outreach
• Developed a HCV data matching and monitoring
• Will track care retention, HCV treatment outcomes
• Once clients are re-engaged in HIV care, will they stay in
care long enough to start hep C treatment?
21. Re-Engagement in Care
Data
• Monthly data uploads and matches btw care sites and AACO
• Routine matching to generate reports and identify high priority
patients
Discussion
• Monthly case conferences with care sites (in-person, by phone)
• Valuable insight into complexity of cases
• Opportunity to engage and build relationships with care sites
DIS
• STD DIS have been cross-trained on hepatitis C
• Limitation: DIS can get folks back in the door, but keeping clients
engaged falls on other pieces of HIV system
22. STRENGTHS
• Integrated hep C into
CoRECT protocols and
procedures
• Piloted hep C in CoRECT
at 1 site, 16 LTC clients
identified as needing DIS
outreach
• 3-4 more sites in June/July
• Cross-trained 4 CoRECT
DIS
• Built hep C fluency among
other AACO staff
CHALLENGES &
OPPORTUNITIES
• CoRECT is time and
resource intensive process
• Clearly defining
expectations of role case
managers re: hep C
• Referring clients back into a
“broken system”
• Reaching clients who are
NOT engaged at all in HIV
care or services
23. Next Steps
Data & Surveillance:
• Assess new/re-infections; consider prevention strategies
• Integration of hep C data-to-care activities at additional CoRECT sites
• Annual hep C Screening Measure added into CAREWare
Training & Capacity Building:
• Outreach to case managers and clients
• How can hep C be meaningfully but manageably incorporated into
case managers’ role
• Co-infection prioritized for intensive case management in new model
• Certificate program to ensure subset of MCM have hep C fluency?
Service Integration
• Identify strategies for AACO and providers to address drug user health
• Collaborate with other program areas: HEP, STD, Opioids, etc
25. THANK YOU!
PDPH Team: Hep and AACO
AETC Team at Health Fed
HepCAP
HIV Service Providers
And the people we serve…
those living with HIV and hep C
26. Alex Shirreffs
HIV/HCV Project Coordinator
Philadelphia Dept. of Public Health
Alexandra.shirreffs@phila.gov
215-685-5381
www.hepCAP.org
www.phillyhepatitis.org
Notes de l'éditeur
2 states, 3 Regions under Philadelphia EMA
Philadelphia, Southeast PA, Southern NJ
HepCAP coalition advocated for treatment access for all
PDPH houses one of the best hep surveillance programs in the US
Many Ryan White providers had already integrated hep C services
AACO and Hepatitis siloed
Best practices to share between treating and non-treating providers
AACO and Hepatitis siloed
3-year cooperative agreement: Sept 2016 – Sept 2019
Special Projects of National Significance (SPNS)
Funded Sites:
Cities: Hartford, New York City, Philadelphia
States: Louisiana, North Carolina
TA Center: RAND
HRSA project outcomes: comprehensive, but these goals can be accomplished through overlapping activities
Local categorization of the project addresses all of the required components, but organizes them in a way that makes it manageable and easier to conceptualize – both for us and our partners
I think it is also important to recognize that systems level work sounds impersonal but succeeding in changing systems is reliant on the people who interact with that system
Our team brings intent and values to our work so that the impact of this project is meaningful and sustainable
We look at the systems we are proposing to change and try to anticipate impact as best as we can; Any success we can boast is in part due to the values that drive the work – both among our health dept team but also our partners in the community – these values come through in the project areas we are going to highlight today
From 2015 – 2017, 157 Individuals are deceased (approximately 1/3 of all hiv positive decedents
From 2015 – 2017, 157 Individuals are deceased (approximately 1/3 of all hiv positive decedents were co-infected with hcv)
Nationally & Internationally:
Sexual transmission of HCV higher in HIV+ MSM1
Reports in MSM in Boston, San Francisco, and NYC2,3,4
Cluster of sexual transmission of HCV in HIV+ MSM identified molecularly in Michigan5
In Philadelphia: UPDATE MY NUMBERS
A recent analysis identified 70 HCV seroconvesions in PWLH
Majority MSM (49%) and Heterosexuals (27%)
Among seroconverted MSM & Heterosexuals, reports of IDU low
Also editing hepatitis B measures
Also editing hepatitis B measures
Cascade/continuum essential to monitoring progress towards elimination
Use qualitative data to understand clinical practices
CW, surveillance: Quality Improvement reports
Also interviews with sites inform us of best practices, possible training/capacity building needs are also an opportunity to update/correct outdated information
Use interviews to make recommendations too like reflex testing
Identify resources sites are willing to share and pass along to other care providers
Caveats with progress:
Reflex testing available via major reference labs; more hospital labs offering reflex option
Challenge is simplifying lab ordering process in EMRs so that ordering is universal
Have not heard of billing/reimbursement issues
Treatment available at more sites BUT NOT ALL PROVIDERS are treating at these sites!
Hep C built into existing AETC modalities
Peer to peer learning via didactic lessons and preceptorship
Plans for follow up and ongoing support
Hep C built into existing AETC modalities
Peer to peer learning via didactic lessons and preceptorship
Plans for follow up and ongoing support
Two primary pools of clinicians to train:
Novice Sites: Scaling new sites up to treat
Start Small! 1 site, 1 provider, 1 patient
Experienced Sites: Treatment onsite already, adding providers
Addressing turnover, building practice capacity
(ex: Ana Lapp, David Koren…)
Pro: Building linkage/re-engagement of lost to care into an existing project
Challenge: Very complex protocol to build into; but forced us to be very intentional with what we want to accomplish
Pros: Information about complexity of cases; opportunity to engage and build relationships with care sites
Cons: Time consuming and resource heavy