Members of the work group: Fasiha Kanwal, Bruce R. Bacon, Lauren A. Beste, Joel V. Brill, Allen L. Gifford, Stuart C. Gordon, Michael A. Horberg, Jacob G. Manthey, Nancy Reau, Vinod K. Rustgi and Zobair M. Younossi
Approximately 50 percent of Americans with chronic hepatitis C virus (HCV) are unaware of their infection status and far fewer have received curative antiviral therapy. New direct acting antiviral (DAA) treatments offer an unprecedented opportunity to cure the more than 2.7 million individuals in the U.S. affected with HCV. Once HCV infection is recognized, linkage-to-care interventions are important to ensure that patients are afforded access to antiviral treatment.
By implementing the AGA HCV Care Pathway in practice settings, clinicians and health care systems will be able to provide care that is consistent with evidence-based guidelines and performance measures, leading to value-based, efficient, safe and effective care. Given the diversity in health care delivery systems across the world, this pathway may not be generalizable to patients and clinicians outside the U.S.
Outreach and Screening
More needs to be done to reach a variety of populations infected with chronic HCV. [Figure 1] HCV screening is recommended for all persons born between 1945-1965, and for anyone with transmission risk factors (e.g., history of injection drug use, transfusion or organ transplant before 1992, received clotting factors before 1987, history of long-term dialysis, HIV infection, persistently elevated liver enzymes, health care and public safety workers after needle sticks, sharps, or mucosal exposure to HCV-positive blood, and children born to HCV positive women).
One-time screening for at-risk patients has been shown to be effective, so it’s important to screen patients where they are in both the outpatient and inpatient settings. As a covered service under the Affordable Care Act, HCV testing is available without financial responsibility to insured patients born between 1945-1965.
Once HCV has been detected, it’s important that all patients receive access to potentially curative treatment. Support services, such as patient navigators, the establishment or expansion of treatment referral networks and multidisciplinary teams, and primary-care-based HCV treatment may help increase the number of patients receiving access to care.
Organization of HCV Care Team
Integrated multidisciplinary care has proven effective in improving HCV treatment and sustained virologic response (SVR). Practices will vary in their HCV caseloads, and thus the capacities of individual practices to dedicate staff to each role will likely vary. The clinical team may include [Figure 2]:
- Care coordinator — main point of contact for the patient throughout all aspects of treatment and care; may be done by a nurse, social worker, health technician or another appropriate team member.
- Clinical pharmacist — administers pre-treatment assessment for drug interactions, monitors adherence, preventative waste and diversion of expensive medications.
- HCV specialist — provides pre-treatment evaluation and prescribes HCV treatment; may be trained in hepatology, gastroenterology or infectious diseases, but in some cases with appropriate training and support, could be a general internist, or other primary care provider.
- Mental/substance abuse provider — addresses high prevalence of behavioral and mental health problems in patients.
Initial Evaluation of Patients With HCV
The first visit is an opportunity to assess medical conditions that may contribute to progression, risk of complications or potential treatment regimens. Although HCV eradication is considered beneficial in virtually all infected persons, a patient must be physically and mentally ready for treatment.
Continued patient education and obtaining follow-up data for conditions identified at the first assessment should be the objectives for the second visit. This visit also offers an opportunity to initiate treatment or treatment planning.
Post-Treatment Monitoring and Follow-Up Care
Appropriate follow-up recommendations and ongoing linkage to liver-related care is important for excellent HCV care. Patients who do not achieve SVR after antiviral treatment should continue to receive ongoing monitoring for progressive liver fibrosis. At this point, patients may be referred to an experienced HCV provider, preferably one with access to clinical trials for patients who did not respond to the current DAAs.
More detailed information can be found in full HCV Clinical Pathway in Gastroenterology.