Mark Sulkowski, MD

Expert hepatologists discuss future developments in HCV.

The Future and Resources in HCV Care

 Mark, are you looking into the future? Are you excited about anything in whether treatment of hep[atitis][hepatitis] C or management of hep[atitis][hepatitis] C? Is there anything down the line that's got you excited?

Certainly, it's a very exciting time. I mean, we've got opportunity in front of us to really for the first time eliminate hep[atitis][hepatitis] C's[in] public health. We can't lose sight of that. I think it's easy to lose sight of that as we struggle with some of the barriers that we've talked about today. So, what do we need to do? Some of you've heard here, we need to increase access to medications. And although tThese medications are highly cost effective, if not [a form of] cost savings, in a relatively short period of time, meaning society will spend less money over a brief period, say five 5 years, if we treat everyone. Despite that, there's there are still barriers to accessing medication. So, tThe first thing we're excited about is removing those barriers. Nancy mentioned and prior authorization forms. I'm working on one now that's 37 patient pages long. Six months we've been back and forth. I'll leave that where it is because there’s not much more I can say. But [the important point is] ensuring we have access. And tThen to pick up on people'sTipu’s point, it's bringing the medications to the patient. And tThere we really need point-of-care testing. So, the second thing I'm excited about is point-of-care PCR [polymerase chain reaction] testing, or antigen testing is another possibility. We mentioned the antibody shows that your immune system has seen hep[atitis][hepatitis] C, but when you cure someone, they remain antibody-positive. So, it [the testing] becomes less effective as we cure more people.. So gGo into a community,[and do] a point-of-care test, a rapid result that shows they're actively affected. Then you've got access. So, yYou reach into the backpack, pull out the medication, hand them a medication, follow that minimal mileage to actually get their phone number, although I'll make another plug for using social media like WhatsApp because they can lose their phone, but they’ll still have the same access. So tThat's the second thing, is point of care. And you say, well, what about people with bad livers? Well, bBring a mobile elastography or fiber scan machine. And iIf your their score is low, you they don't have liver failure. So, point of care. The third thing I'm excited about is actually the potential to develop long-acting therapies. And iIn the HIV space that I've alluded to a couple of times, they now have medications that can be given at that last eight 8weeks. Huh, eight 8 weeks. Well, iIf we had a hep[atitis][hepatitis] C medication that sustained in the liver for eight 8 weeks after a single injection, that would be a one-shot cure. And tThat is being worked on as we speak., Sso, it's not without the realm of possibility. And give me one more.: It's vaccine. And wWe've talked a lot about trying to treat our way out of the hep[atitis][hepatitis] C epidemic, but this is an incredibly transmissible pathogen. We saw that with healthcare–worker needle sticks. We see that with populations and networks of people who inject drugs,. [It’s]incredibly transmissible. So yYes, we should be treating everybody and taking the path of treatment prevention, but vaccine is essential. And tThere's now a lot of excitement around vaccine development and what's called human challenge studies. That's where you take a volunteer with the appropriate informed consent, you intentionally give them hepatitis C, and vaccinate some and see if the vaccine can clear the infection. And then oOf course, you've got treatment to rescuethem,…those who don't clear. It sounds a bit crazy, but they do this with malaria, they do this with dengue, they do this with shigella, diarrhea, and they did this with COVID-19, intentionally affecting [infecting] people. And wWhy would you do that? Because it allows you to test vaccine candidates very quickly. If they don't work, move on. So tThose are the things I'm excited about as we work our way to 2030. It's only seven 7years away, so we've got a lot of work to do.

 So sSome exciting things [are] on the horizon potentially. For some of our viewers who might not be aware, iIt's really an exciting time around Hep[atitis][hepatitis] C. We have a relatively newly announced federal elimination plan that has been brought forward. This is something that's obviously very fluid and dynamic, but it's in development. . [There are] [It has] the three 3 key components,: iIt would fast track point-of-care tests like Mark has described. It would open access to medications, hopefully eliminating a lot of the barriers that we've discussed. And it would also provide funding for the infrastructure needed to actually carry this work out. So sStay tuned for all of this, there is a lot that'’s happening. We'’ve covered a lot of ground. Nancy, if providers, if viewers [patients] are looking for more information, do you have any go-to sites that they can access to get more infoit?

Well, aAbsolutely. There are tons of them. So I think that Hep[atitis][Hepatitis] CP Live actually has great tools, the American Liver Foundation, [and] you cannot go wrong with things like the CDC or the World Health Organization. Also, I wouldn't discount your industry partners, especially once you [patients] know the agent that you're[they’re] being started on. There are really great resources on those websites when [they] you know what you're[they’re] going to be taking. But I think that misinformation is also prevalent. So yYou want to make sure that you're talking to your patients about what their fears are. There still are websites out there that say that Hep[atitis][hepatitis] C treatment is intolerable, that you're going to end up with depression or some of the interferon-related side [adverse] effects, [or] that you won't be able to work through things, or that these are still experimental. I mean, tThese are not experimental therapies anymore. And so, yYou want to make sure that you're using a tool that's vetted and up-to -date, not archaic.

 YeahYes, hcv.com is also another great resource.— A alot of information there, practical information about implementation, and tons of great educational content. Thanks to all of you for this rich and informative discussion. And thank you, our viewers, for joining us during this HCP Live Peer Exchange. If you enjoyed today's content, please subscribe to our e-news letters to receive information regarding upcoming peer exchanges and other great content right to your inbox. Thank you very much.

Transcript was AI-generated and edited for clarity.

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Expert hepatologists discuss future developments in HCV that they are excited about and provide resources for new providers to get started on delivering HCV care.

The panelists discuss challenges faced in HCV care, especially in addiction medicine and strategies to overcome them.

Challenges in HCV Care

 We’ve talked about implementing this into our practice. Sometimes it can be a difficult patient group because of certain aspects of patients’ lives that are simply their reality., [for example,] And things I'm thinking about specifically whether its active substance use or unstable housing. Tipu, how do you manage this in your in your practice. Does this impact anything? dDo you do anything differently? tTalk to us a little bit about that.

Yeah, so sSpecifically, those that suffer from unstable housing,—it's a tough population. We have a lot of it. I run our county's backpack medicine group, so we do a lot of on-the-ground outreach and treatment of patients. And, you know,tThe bottom line is that it all comes down again to meeting patients where they're at. And aAs we've heard from all of our panelists today, policy, advocacy, these are all things we need to improve treatment retention. And tThe best thing we could do for these patients is to give them all their medications up front, especially if they're in a shelter or a stable housing transitional area where they can store those medications, but also understanding there'sthere are some that patients who can't carry eight 8 weeks or 12 weeks’ worth of medications on them. And sSo maybe [in that scenario we] being able to dispense two 2weeks at a time with close follow-up. One of the things that we're implementing in our program is a community navigator who will store their medications for them [patients] for a couple weeks at a time.We'll go to them. … And there'sthere are different studiesthat have been out there …that look at ways you can do this. One of them includes having them carry a GPS [global positioning system] unit so you know where they're at.: Meet themin the river bottom or …downtown, wherever they're staying. Deliver those next two 2weeks and catch up with them again afterwards. So, [There are] a lot of different models on how that can be done. But I think the important point is we need to adjust this to the patient in front of you. And sSometimes that means that we may need to store medicationss and dispense them more frequently for a patient suffering from homelessness, so they don't lose their medications. But if they're in a transitional housing program, it might benefit them from getting their entire eight8-week or 12-week regimen upfront that they can keep with them.

 I think yYou bring up an important point. For a long time in the field of hepatitis C, we've worked on this sort of patient readiness model. Is the patient ready for treatment? And iIt's really held us back in terms of elimination. I think iIf we went around and we asked each other, what does readiness mean? What does stability mean? We'd get a bunch of different answers. We really, in my opinion, need to move to a provider-readiness model. These are variables that have affected patients forever., Aand they may never change. They may never reach a level of stability that a provider is necessarily comfortable with it. But the things that affect the patients, it's all about access, just getting them the treatment that they need.

Transcript was AI-generated and edited for clarity. 

The panelists offer practical tips on implementing HCV care into your clinical practice.

Practical Implementation of HCV Care

 I want to kind of just go around the table, andwhen we think about implementation of a program, …could each of you give me just some practical concepts that you feel are essential to implementing a program?

I think much like Dr Khan was saying, it's really about empowering your APPs [advanced practice provider] as someone who can treat hepatitis C and not just in our GI and hepatology clinics. We should be empowering APPs in primary care and other specialties to feel confident treating hepatitis C with some of these simple regimens.

 Yeahes, definitely a key aspect. In my own clinic, we have three APPs and they're trained in addiction and hepatitis C. This is who's doing the work. I mean, this is one of the essential treater groups. Mark?

Well, [if I] think about it and sayprobably …[just] one word, it's partnerships.What we have found is that… I work at an academic medical center. If I sit in the office and wait for patients to come to me, it's going to be a long [wait], it's going to be a slow clinic. No one's going to walk in that door. But if we partner with organizations, county health departments, for example, we have a partnership around Baltimore [, Maryland,] from with the qualified health centers. We say, look, we're going to work with you to get people treated. That could be in some cases training,; we call that “sharing the cure” where they [the health centers]become independent. [They] don't need us anymore, but we're there tocall off those…[answer] questions. [Another option is] telehealth in the county health department, : bBring the person [patient] in front of the computer. And iIf you guys are too busy and don't have a band with the the bandwidth to treat, we'll do it. And we'll do it via telehealth. And wWe've been able to spread the hepatitis C cure around Maryland, which is a kind of a long state, to Wwestern Maryland, to the eastern shore across the bay. And it's through partnerships.

 Yeah, I think tThose partnerships, that's[are] obviously essential. We've long known where these patients are at. We know exactly where they access care, how to find them. And it's building those relationships with our community partners to help us to facilitate that linkage. Also, though, probably important to point out, we've discussed meeting patients where they are. You've also got to meet providers where they are. If you want them to do this work, to do the screening and to facilitate that link, you've also got to make it as easy for the providers as we hopefully will for the patients.

Yeahes, and that was kind of the point in some of the programs, is to say, it's really simple, look at the guidelines. All you got to do is this,

this, and this. But [if] you look at their day and look at what they're being asked to do., Iit's not that easy, and there is no room to add hep[atitis][hepatitis] C. So different layers of partnerships that we have found can work. And yYou have to really get to know who you're working with.

Well, I'm going to use a word that probably is a little bit blended, but policy. And I think that when we talk about this, some of the biggest limitations to expanding our provider pool are things like prior [authorizations]., Tthe need for a genotype. Wwhen you really don't need a genotype. , there'sThere are a lot of things that hold over that are barriers and they're inconsistent. Like one insurer might require some things, another insurer might require something else. Even in Illinois, public aid got rid of prior [authorization], which is amazing. Thank you, public aid. But some of our public aid affiliates don't follow that rule. And so that'sIt’s really hard when you're trying to take a primary care provider or someone in addiction medicine who does have a narrow bandwidth and you've told them everything is simple and then they can't even get the paperwork done for access to the medication. And tThat's why they get frustrated and why you start to get your referrals back.

 Yeah, I think that's essential. The policy is a key component. And I would add to that, advocacy. Hepatitis C, we haven't had a lot of great advocacy. It's very, very different than the HIV world. And that's something I think we need more of. Tipu, how about you?

Yeah, wWearing two 2 hats is as a primary care doctor and as an addiction specialist, I see it from two 2 different angles. From the primary care standpoint, like we've all touched on, is it's tough, right? You've got a busy day. You've got 12, 13 patients in a half day, everything from a heart failure to a dialysis patient that has no other doctor to see. So yYou're managing all these things, especially in an underserved setting, you're managing all these problems. So, tThen all of a sudden say[someone says], “Hey, why don't you just go ahead and cure hep[atitis][hepatitis] C as welltoo?” It's not as easy as it sounds sometimes in a busy practice. So wWhat I focus on with our residents, we train as well as our community doctors is really helping them understand they're supported. There's a lot of national organizations out there that provide both local support and partnerships like echo ECHO [Einstein Community Health Outreach] clinics in your region [New York, New York] to also national phone numbers you can call to get support on starting a treatment program. And so I like to make sure people feel supported, [as if someone said], that, “Hey, you can start this.” This is easier than [treating] everyone else you're going to see in your day. Treating hep[atitis][hepatitis] C is going to be easier than your diabetes appointment that you have next, than in your heart failure follow-up from the hospital. This is going to be the easiest treatment of your day.

It's going to be quicker, exactly, and more satisfying to some extent, right? But when you need support, this is who you reach out to at home. So sSetting that algorithm up so they know where to go when they need that help on that next step [is important.]. And then fFrom the addiction medicine standpoint, I think it's really normalizing the importance that this is a co-occurring disease and a co-epidemic really, right? We talked about the opiate use disorder epidemic. Hep[atitis][Hepatitis] C goes right along with that, right? Upwards of 20% to 40%, depending on the data you're looking at and the clusters of community, have hep[atitis][hepatitis] C as well. So I think we, as academic addiction doctors, are really focused on training our learners that these problems go hand in hand. And so wWhen you are treating as an addiction specialist, hep[atitis][hepatitis] C is in your wheelhouse,. iIt's your bread and butter as well.

 I think it's really empowering for all types of providers from all types of disciplines. A lot of times in medicine, we don't get a win. We manage a lot, but there's very few things we actually cure. And tThis is something that we can tangibly eliminate, cure, and it really goes a long way not only to empower patients, but also providers. Nancy, as we see more of these sort of emerging providers from different disciplines, what is the role of the hepatologist in supporting them.?

I think we're a little bit like a parent, right? The most important thing is to is to help them through that first hurdle of understanding, that this is really very easy. You are unlikely to mess it up. [It’s about] holding their hand and then being the backup to catch them if they need tertiary-level assistance. Once you've treated a couple of patients, all the fear goes away. You're like, “oOh look, they did fine. They felt great, they're cured now. Now I can do this.” They don't need you anymoreanymore, [and] you really don't need me. Then you'll have the person that comes in that has a seizure disorder that you can't find a way to get rid of the drug-drug interactions or they have more advanced disease,. oOr you did that liver cancer screening, [and,] lo and behold, they actually have something that could be a liver cancer and you have to be that backup phone number. I am still here for you. I know you. You didn't need me for six 6 years, but I am still here for you, and—that's our role. I mean, I think aAs a hepatologist, I love hep[atitis][hepatitis] C. I like hep[atitis][hepatitis] C more than pretty much anything else I see in my clinic, but I have to let it go. This is not what I this is not what you need me to do. I went to school a long time to be an academic hepatologist, I should let someone else win this battle.

 Again, it goes back to what we talked about a little bit before, relationship building, knowing that you're there, you're available for that support if and when they need it.

Dr. Tipu Kahn gives an overview of various care models for HCV treatment.

Models of HCV Care

 Tipu, we've talked a lot about now screening, baseline workup, diagnosis, some of the medication regimens. We're going to move to implementing this into our clinical practice. Can you just give us an overview of what some of the basic models of care look like?

 YeahYes,. so there'sThere are a couple of different models out there on how to get meds medications to patients to get them treated. And I think the bottom line is, you want to meet patients where they're at. That's the most important part. So, Aa couple of ways you can do that.: One is co-localization, which is what I love doing, because it gives them multiple services under one roof. And tThat could be something as simple as your primary care doctor who also treats hep[atitis][hepatitis] C and MOUD [opioid use disorder]and gives them [patients]their OPU [opioid use] disorder medications. Something as sophisticated as a method on methadone treatment program that also has a physician or an APP [advanced practice provider] that comes in and screens and treats as well. So [we are] trying to bring as many of these services as you can [possible] under one roof. And again, aAs we talked earlier, I think what's important is, you do all of that in the same place along with harm reduction modality, treatment for the substance use disorder, and then all the other social determinants of health that are going to affect their ability to stay engaged in care, [for example,]access to food, access to housing, et cetera. So, [That is] trying to co-localize as many of those services as you can under one roof. The other option that, of course, has changed a lot with COVID is tele-med[telemedicine]. The ability to really check in with someone over the phone, do that screening visit,. yYou've got the labs done.,so Yyou can go ahead and [authorize the] start [of] those medications over the phone. There's no reason they [the patients] have to be there in person. And we do a lot of tele-med [telemedicine]in our program where we'll see patients, they'll have labs done by one of our satellite clinics, and we'll see them on the phone or on a video platform, whatever we're using., [We will] assess them, write the prescription and follow up with them once or twice via phone,. and wWe never see them in person., Bbut they're cured, because [and] we've got the labs to show it. So, I think that's been a huge expander of our ability to get access to care out there for those patients. Of course, there's a conventional referral where they can refer into a subspecialty access point, like hepatology, infectious disease, GI [gastrointestinal], or primary care that treats hep[atitis][hepatitis] C. Now again, tThat's another barrier though.: That's another appointment, another car ride, another bus ticket for them to get somewhere. And oftentimes the wait times are long for those. In our community, getting into a GI or a hepatologist is a six 6 months to a year [wait], at minimum. So tThose can really hinder the access to care for those patients, which is why I think it really dials down to integration. And the best way we can do this is truly integrating it into primary care.—Cchanging the scope of Hep[atitis][hepatitis] C being a subspecialty disease to really a primary care disease with support from subspecialists for complicated patients. But the majority of patients fall into simplified algorithms that we can all do within our primary care or addition addiction medicine setting.

 So aAgain, [we have] that concept of task shifting and maybe moving into different disciplines, different types of specialties. I consider primary care a specialty. It's hard to do. I can't do it.

Mark Sulkowski, MD

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