Sharing the cure: Building primary care and public health infrastructure to improve the hepatitis C care continuum in Maryland

Abstract

In 2014, trained healthcare provider capacity was insufficient to deliver care to an estimated 70 000 persons in Maryland with chronic hepatitis C virus (HCV) infection. The goal of Maryland Community Based Programs to Test and Cure Hepatitis C, a public health implementation project, was to improve HCV treatment access by expanding the workforce. Sharing the Cure (STC) was a package of services deployed 10/1/14-9/30/18 that included enhanced information technology and public health infrastructure, primary care provider training and practice transformation. Nine primary care sites enrolled. HCV clinical outcomes were documented among individuals who presented for care at sites and met criteria for HCV testing including risk factor or birth cohort (born between 1945 and 1965) based testing. Fifty-three providers completed the STC training. STC providers identified 3237 HCV antibodypositive patients of which 2624 (81%) were RNA+. Of those HCV RNA+, 1739 (66%) were staged, 932 (36%) were prescribed treatment, 838 (32%) started treatment, 721 (27%) completed treatment and 543 (21%) achieved cure. Among 1739 patients staged, 693 (40%) patients had a liver fibrosis assessment score < F2, rendering them ineligible for treatment under Maryland Medicaid guidelines. HCV RNA testing among HCV antibody-positive people increased from 40% (baseline) to 95% among STC providers. Of 554 patients with virologic data reported, 543 (98%) achieved cure. Primary care practices can effectively serve as HCV treatment centers to expand treatment access. However, criteria by insurance providers in Maryland were a major barrier to treatment.

Geographic variation in HCV treatment penetration among people who inject drugs in Baltimore, MD

“…This finding is consistent with several changes that have occurred since 2014. For example, efforts were made to expand HCV treatment into primary care, which increased the number of providers that could treat HCV and expanded awareness of DAAs 46 . Additionally, there were changes in Maryland's Medicaid restrictions over time.…”

“…For example, efforts were made to expand HCV treatment into primary care, which increased the number of providers that could treat HCV and expanded awareness of DAAs. 46 Additionally, there were changes in Maryland's Medicaid restrictions over time. When DAAs first became available, Maryland's Medicaid program required documentation of 6-month sobriety from any substance use, treatment could only be prescribed through a specialist, and patients had to have documentation of at least moderate fibrosis.…”

Hepatitis C in Black Individuals in the US

“…Simple treatment algorithms, such as those recommended by the American Association for the Study of Liver Diseases/Infectious Diseases Society of America (IDSA) HCV treatment guidelines, and similarly high rates of HCV cure by physicians, nurse practitioners, or physician assistants in community settings can improve access to HCV care in community-based, nonspecialist settings . In an observational clinical trial including 12 community health centers in the District of Columbia, clinicians (6 specialists, 5 primary care physicians, and 5 nurse practitioners) completed a 3-hour HCV training course.…”

“…Among 600 patients, 578 (96%) were Black with equally high rates of HCV cure reported among nurse practitioners (134/150, 89.3% [95% CI, 83.3%-93.8%]), primary care physicians (139/160, 86.9% [95% CI, 80.6%-91.7%), and specialist practitioners (243/290, 83.8% [95% CI, 79.0%-87.8%]) . Collaborative educational models in which HCV care specialists support clinicians in a collaborative model of HCV medical education and care management have been associated with increased HCV care access for racial and ethnic minority populations . One such model implemented in Baltimore, Maryland, is the Sharing the Cure program, which consisted of group sessions with clinicians in community-based settings including a 1-day conference and 20 weekly 1-hour video conferences to train 53 primary care clinicians in HCV care over 4 years.…”

“…One such model implemented in Baltimore, Maryland, is the Sharing the Cure program, which consisted of group sessions with clinicians in community-based settings including a 1-day conference and 20 weekly 1-hour video conferences to train 53 primary care clinicians in HCV care over 4 years. In this time, 3250 patients (75.2% Black) were evaluated for HCV treatment . Of 3237 patients with data, 2624 (81.1%) were HCV RNA positive, 838 of 2624 (31.9%) started treatment, 721 of 838 (86.0%) completed treatment, and 543 of 721 (75.3%) achieved cure.…”