Expanding Treatment Access for Chronic Hepatitis C with Task-shifting in the Era of Direct-acting Antivirals

Abstract

In the United States, the fight to eradicate hepatitis C virus (HCV) infection has been ongoing for many years, but the results have been less than ideal. Historically, patients with chronic hepatitis C (CHC) were treated with interferon-based regimens, which were associated with frequent adverse effects, suboptimal response rates, and long durations of treatment – of up to 48 weeks. Expertise from specialist-physicians, such as hepatologists and gastroenterologists, was needed to closely follow patients on these medications so as to monitor laboratory values and manage adverse effects. However, the emergence of direct-acting antiviral (DAA) agents against HCV infection have heralded outstanding progress in terms of safety, tolerability, lack of adverse effects, efficacy, and truncated duration of therapy – 12 weeks or less – thereby making the need for close monitoring by specialist-physicians obsolete. With the recent approval of DAA agents by the Food and Drug Administration, the treatment model for CHC no longer relies on the limited number of specialist-physicians, which represented a major barrier to treatment access in the past, especially in underserved areas of the United States. We propose and share our experiences in adapting a task-shifting treatment model, one that utilizes a relatively larger pool of non-specialist healthcare providers, such as nursing staff (medical assistants, vocational licensed nurses, registered nurses, etc.) and advanced practice providers (nurse practitioners and physician assistants), to perform a variety of important clinical functions in an effort to make DAA-based antiviral therapy widely available against HCV infection. Most recently, task-shifting was implemented by the United States and World Health Organization in the fight against the human immunodeficiency virus and showed encouraging results. Based on our experiences in implementing this model at our outreach clinics, the majority of HCV-infected patients treated with DAA agents can be easily monitored by non-specialist healthcare providers and physician extenders. Task-shifting can effectively address one of the major rate-limiting factors in expanding treatment access for HCV infection.

We know DAAs work, so now what? Simplifying models of care to enhance the hepatitis C cascade

“…With proper training, anyone can undertake assessment and prescribe DAAs competently, either as a delegated prescriber or a nonmedical prescriber – which again facilitates scale‐up. Evidence has shown good results from the prescribing of DAAs by primary care providers, drug and alcohol service providers, nurse practitioners, nurses, including nurse prescribers, and pharmacists . Delegated prescribing may be a good option where prescribing is limited by statute.…”

Successful Implementation of a Shared Medical Appointment Model for Hepatitis C Treatment at a Community Health Center

“…Diversification of providers overseeing HCV treatment is necessary to end the HCV epidemic [6]. HCV-infected adults undergoing community-based treatment through a shared appointment model showed excellent clinical response consistent with contemporary efforts in a similar patient population [7, 8].…”

Strategies for the Elimination of Hepatitis C Virus Infection as a Public Health Threat in the United States

“…In the interferon era, HCV treatment was primarily coordinated by hepatologists and infectious diseases specialists in office settings with established resources for administering complicated treatment regimens and managing the side effects of antiviral therapy. However, the ease of administering new DAA regimens that are all-oral, well-tolerated, and require short treatment duration has made HCV treatment feasible by non-specialist providers in a variety of settings [26–29]. In particular, strategies to offer HCV care in the primary care setting may mitigate the drop-offs in linkage to care that occur with subspecialty referral [18].…”

“…As an additional example, the New York City Department of Health and Mental Hygiene has developed networks to provide educational resources, access to HCV treatment guidelines, and mentoring and consultations for providers managing patients with chronic HCV [28]. Finally, in California, a task-shifting treatment model for HCV was implemented that enabled a trained licensed practical nurse, under the guidance of hepatologists, to treat over 100 HCV-infected patients between 2014 and 2015 [29]. A secure web-based electronic health record enabled the nurse to communicate with hepatologists for medical advice as needed.…”