Veterans Affairs Aims at HCV Infection Cure

The US Department of Veterans Affairs (VA), the nation's largest care provider for hepatitis C virus (HCV) patients, has recently described its successful programs and indicated it is "poised to share" best practices with other organizations and healthcare providers to reduce the overall burden of HCV infection.

Pamela Belperio, PharmD (pictured), VA Office of Public Health/ Population Health, Los Angeles, CA, and lead author of the article on the VA approach to providing HCV treatment, described some key components to MD Magazine.

She cited the expansion of non-physician provider use, video telehealth, and teleconsultation as “critically important” to improving veteran access to HCV providers.

"The VA also has utilized care-delivery teams that personalize care where access is somehow more limited,” Belperio said.

While acknowledging that some aspects of the program are unique to the VA system, Belperio and colleagues wrote that many could be adapted by other systems, including “the importance of engaging organizational leadership to prioritize HCV treatment and support interventions, providing feedback on performance and outcomes; negotiating reduced drug prices or lower-priced preferred agents."

Success in negotiating lower drug costs may be easier to achieve because of elements such as the size of the VA and the involvement of Congress. However, the authors suggested that commercial insurers can respond to "consistent leveraging of drug prices and removal of restrictions to HCV treatment."

They also argued the importance of eliminating policies that are not based on evidence of improved outcomes, such as requiring a defined length of abstinence before paying for HCV treatment.

Belperio and colleagues described 5 pillars supporting the VA strategy: information, interventions, service delivery, financing, and research. The information processes utilized databases and analytics for population health management strategies to measure, monitor and identify trends in HCV care.

The interventions include continuously improving case identification, initiatives to increase HCV testing; and staffing multi-disciplinary "HCV Innovative Teams" (HITs) across VA facilities to strategize implementation of programs in their particular settings.

The area of service delivery encompasses expanding access to care through telemedicine and electronic technology, involvement of non-physician advanced practice providers, and addressing barriers to care such as substance use, homelessness and mental illness.

"The VA has reached out to veterans in multiple ways," Belperio said, "For example, lists were generated of all untreated HCV patients with their relevant clinical characteristics and each VA clinic used this to contact patients — usually by phone or letter — and invite them for screening and treatment."

Financing for the broadened programs has been attained through several initiatives, including funding priorities in proposed budgets, "steadfast negotiations" on the prices of direct-acting antivirals (DAAs), and removal of restrictions on payment for treatment based on liver disease stage.

Research is included among the principles of the comprehensive approach because of the utility of their large database and capacity of their faculty to contribute to advances in the field.

Belperio and colleagues reported that between January 2014 — when the DAAs were introduced — and June 2017, approximately 92,000 HCV-infected veterans received treatment, and over 90% achieved a sustained virologic response (SVR) corresponding to a cure.

Researchers contrasted this to the period before 2014, when 39,388 had received any HCV treatment of 174,889 patients who had a detectable HCV viral load (23%). Currently, there are approximately 51,000 veterans in VA care who remain potentially eligible for treatment.

"Although elimination seems attainable, the VA recognizes the reality of the HCV epidemic and population — namely, many of those in care who remain to be treated have complex substance use, mental health, and medical comorbidities," Belperio and colleagues wrote.

The researchers found that accomplishing HCV control in the VA includes a “long tail of persistence driven by system, patient and care delivery determinants."

The study, "Curing Hepatitis C Virus Infection: Best Practices From the U.S. Department of Veterans Affairs," was published online in Annals of Internal Medicine last month.

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