Hepatitis C is the deadliest infectious disease in the US. The VA has a strategy to defeat it among veterans.
Homelessness, mental health disorders, and substance use can be barriers to care for patients with hepatitis C. Many state Medicaid programs, including Rhode Island’s, restrict treatment to healthy, sober individuals. But those clinical challenges aren’t stopping Veterans Administration providers in their quest to cure as many veterans with the virus as possible.
“We’ve had a veteran who came in every day to get directly observed therapy, which is something we do for tuberculosis, but we’ve never really done that for hepatitis C,” says Amanda Noska, MD, MPH, F’15, an infectious disease physician at the Providence VA Medical Center.
“That worked really well for him, and he has been cured of hepatitis C,” Noska says. “He otherwise never would have gotten treatment.”
In 2014 the VA declared war on hep C. It had 168,000 veterans in the system with the virus, and those numbers were on the rise, due not only to baby boomers who may have lived, asymptomatically, with the disease for decades, but also to injection drug use, fueled by the opioid crisis.
The agency negotiated lower prices for new, highly effective, but notoriously expensive direct-acting antivirals and has allocated more than $1 billion annually to buy them. By August 2017, the VA reports, it had treated more than 96,000 patients. The cure rate of the new drugs is about 95 percent.
“I really think we’re going to be able to wipe out hepatitis C from the VA system in the next couple of years,” says Kittichai Promrat, MD, a hepatologist at the Providence VA who heads the local arm of the nationwide initiative to treat all veterans with the virus. “They prioritize hepatitis C as an important issue that they need to address. That’s the first step. And then they allocate enough resources for us to do this type of work.”
Promrat, an associate professor of medicine, says there’s been a “paradigm shift” in the VA’s approach to hep C. Rather than wait for veterans to come to them already suffering from serious liver complications, the VA seeks them out before they get sick—with screening reminders that pop up in the electronic medical records of at-risk patients, calls and letters inviting them to come in for testing, and other outreach. As of July 2017 the VA says it had tested 79.5 percent of patients born between 1945 and 1965 and nearly 90 percent of its homeless population, two groups with the highest prevalence of hep C.
They expanded treatment capacity by allowing primary care physicians, clinical pharmacists, nurse practitioners, and physician assistants to provide care, and using telemedicine to reach more patients. “Many patients may not want to come in all the way to Providence,” Promrat says. “By having that option, it’s really helped improve treatment uptake.”
The VA’s hep C teams also collaborate with specialists in its mental health, substance use, and homeless clinics. “Many [veterans]do have issues—drug and alcohol use, mental health, homelessness—that need to be addressed at the same time,” Promrat says. “We just can’t tackle this alone.”
BOOTS ON THE GROUND
Noska, an assistant professor of medicine, sports a button on her white coat that reads, “Born 1945-1965? Ask me about Hep C!” (“I have a T-shirt too,” she says.) She sees veterans in the homeless clinic every Friday. “We’ve done a bunch of innovative things,” she says, like directly observed therapy. “It’s really very patient centered. … Just developing a really strong rapport with the patient is actually paramount to getting some of our veterans into care.”
From left, pharmacist Marlene Callahan, infectious disease physician Amanda Noska, nurse practitioner Yetunde Shittu, hepatologist Kittichai Promrat, linkage-to-care nurse Christina Furtado, and nurse practitioner Shelagh Wood-Gouveia. Photo by David DelPoio
Integrated, comprehensive treatment is easier when everything is under one roof—starting with the test. “In the conventional civilian population, you’d refer somebody to Rhode Island Hospital to get a liver elastography,” Noska says. “If they no-show that appointment, you’re dead in the water.” At the VA, she simply sends her patients downstairs. Similarly, she or Promrat might get a call from a primary care provider or social worker in another part of the hospital, and they’ll swing by to see the patient. “The VA makes it easier to coordinate and expedite care,” Noska says.
Experts who have been sounding the alarm about hep C, some for many years, say new approaches like the VA’s are the only way to defeat the disease, which kills more than 19,000 people in the US annually. “The world has the tools to prevent these deaths,” the National Academies of Sciences, Engineering, and Medicine noted in a press release last year, as it laid out a plan to get rid of viral hepatitis by 2030. But doing so requires a bold financial commitment in testing and treatment, as well as prevention measures like needle exchange—“a significant departure from the status quo.”
“We’re all supposed to be scaling up, revving up, moving faster,” says Lynn Taylor, MD RES’00 F’05, director of Rhode Island Defeats Hep C. “The VA is a bright spot in the state.”
Taylor helped establish colocated, integrated care—“one-stop shopping”—at The Miriam Hospital, where until recently she directed the HIV/Viral Hepatitis Coinfection Program; and at CODAC Behavioral Healthcare, a nonprofit treatment and recovery program in Rhode Island, where she’s now director of HIV and Viral Hepatitis Services.
But she says she can only do so much under the restrictions placed by the state’s Medicaid program. Rhode Island limits treatment to people who have reached a certain stage of advanced liver disease and who don’t use illicit drugs, and generally allows only certain specialists (usually GI and infectious disease docs) to prescribe treatment. “The evidence does not support withholding treatment,” Taylor says. “We need to identify [hepatitis C]early. … We need to get people treated and cured soon after diagnosis so they don’t get sicker … and so they aren’t spreading hep C.”
And then there are the “benefits beyond cure,” including decreased recidivism and substance use, she adds: “Patients tell us they think, ‘I’m worth it, they’re investing in me, they want my hep C cured,’ and they are motivated to work on other issues.”
Many challenges remain for the VA. Its success depends on continued Congressional allocations, identifying everyone who has the virus, and addressing the remaining barriers for those veterans who can’t get or don’t want treatment. The Providence hep C team is in regular contact with their counterparts at other VA hospitals, so they can share what’s worked and what hasn’t, and brainstorm new ideas. They’re also preparing for a certain proportion of patients who, after they’re cured of hep C, will develop fatty liver disease, Promrat says: “There’s still more work. That’s for sure.”
But for so many veterans, the VA is preventing liver cancer and liver failure and saving lives. “It’s a unique situation because I can’t think of a chronic viral disease that we can cure,” Promrat says. “This thing doesn’t come up probably again in my lifetime.”
