Current State of Hepatitis C Care in the VA
The following is a lightly edited transcript of a teleconference discussion of hepatitis C virus treatment in the Veterans Health Administration system.
Dr. Dickson. Our catchment area includes West Virginia, and we do telehealth for one of the sites, which has a number of 20-year-old and 30-year-old patients. In this slightly different population it is again a challenge getting and keeping them engaged as they go through the pretreatment evaluation. Some say that there may be a benefit to getting them on treatment as quickly as possible so that they don’t have time to disengage. The age difference brings about different barriers. We have to think outside the box on how to reach out to these patients. They work, they have kids, and they don’t feel ill right now. And many are active injection drug users. Trying to get them engaged in health care in general and on HCV treatment is the next big challenge.
Health Care Provider Education
Dr. Dickson. When we reach out to viremic veterans who’ve never been to our clinic, we will sometimes find comments such as, “patient not interested” or “patient still drinking” or no comment at all in the electronic health record primary care notes. So we began to focus our HCV education not only on veterans but also the providers. Some HCPs don’t consider the benefits of referring patients to the clinic for at least the opportunity to receive education on HCV, learning if there is any scarring on their liver, and learning about their options for treatment should they choose to proceed. We are continuing to meet with HCPs in all areas to let them know what’s offered in the HCV clinics. In addition, we have found that direct contact from our HCV clinic to veterans who were not interested is very successful. We get a chance to show that the VA cares and explain what our clinic offers and find that they are more than willing to arrange an appointment with us.
Ms. Trimble. I agree. We have successfully treated many veterans who are still using alcohol or drugs, and the VA supports considering any patient for treatment regardless of substance use; however, not all providers are aware of this. One of the other main education points for patients and providers is that they need not have severe liver disease to be considered for treatment. In the past, typically only patients with moderate to advanced liver fibrosis were considered for treatment, but this approach has changed in the past couple years.
Dr. Ho. I would agree that there still is a need to educate HCPs who may have had a presentation or read something on HCV a year or 2 ago. It’s now possible to treat almost all patients with HCV. It really has been fantastic, but not everyone is aware of it right now. That means we need to continue to be active with our colleagues and get them on the team. It is very helpful to increase enthusiasm if we can publicize new data and information coming out about the success in the VA of these DAA regimens.
Dr. Backus. There was a time when the DAAs first came out and the prices were higher and there was concern about the funding. At that time, we were treating only people with more advanced liver disease. Now we are treating everyone regardless of how advanced their liver disease is, but occasionally at VA Palo Alto I’ve run into providers who say, “The patient didn’t have cirrhosis, so I didn’t refer.” Education still needs to happen. It can be a little confusing because there was a time when we were not treating everyone. Now we are, and we have to make sure to get out this message.
Dr. Dickson. For patients with unstable comorbidities, HCPs may make the choice against HCV treatment. In the Baltimore clinic, we have case managers who will work with such patients and get to know them very well. Many times we do more than just cure their HCV. We also help them with their other conditions because we see them so often, such as helping with their pill boxes and encouraging them since they can see their liver enzymes getting better. There is a lot to be said for case management, the hands-on contact, and the concern that we can show these veterans. It helps not just the HCV but also their blood pressure and cholesterol are now controlled. We hear so many thanks from the veterans that come through our program. It might have taken a lot of work to get them to treatment, but in the end, they’re better overall.
Next Steps in HCV Care
Dr. Backus. The most pressing next step is becoming really creative and integrative about how to reach the more difficult-to-treat patients with comorbidities and reach the less-engaged populations. It is probably going to take some change in the models of care. For example, we are going to have to set up a clinic that is colocated in an opioid replacement therapy clinic or in the rehabilitation program. HCV care is going to have to evolve.
