Practical Implementation of HCV Care


The panelists offer practical tips on implementing HCV care into your clinical practice.


Anthony Martinez, MD: I want to kind of just go around the table, andwhen we think about implementation of a program, …could each of you give me just some practical concepts that you feel are essential to implementing a program?

Jordan Mayberry, MPAS, PA-C: I think much like Dr Khan was saying, it's really about empowering your APPs [advanced practice provider] as someone who can treat hepatitis C and not just in our GI and hepatology clinics. We should be empowering APPs in primary care and other specialties to feel confident treating hepatitis C with some of these simple regimens.

Anthony Martinez, MD: Yeahes, definitely a key aspect. In my own clinic, we have three APPs and they're trained in addiction and hepatitis C. This is who's doing the work. I mean, this is one of the essential treater groups. Mark?

Mark Sulkowski, MD: Well, [if I] think about it and sayprobably …[just] one word, it's partnerships.What we have found is that… I work at an academic medical center. If I sit in the office and wait for patients to come to me, it's going to be a long [wait], it's going to be a slow clinic. No one's going to walk in that door. But if we partner with organizations, county health departments, for example, we have a partnership around Baltimore [, Maryland,] from with the qualified health centers. We say, look, we're going to work with you to get people treated. That could be in some cases training,; we call that “sharing the cure” where they [the health centers]become independent. [They] don't need us anymore, but we're there tocall off those…[answer] questions. [Another option is] telehealth in the county health department, : bBring the person [patient] in front of the computer. And iIf you guys are too busy and don't have a band with the the bandwidth to treat, we'll do it. And we'll do it via telehealth. And wWe've been able to spread the hepatitis C cure around Maryland, which is a kind of a long state, to Wwestern Maryland, to the eastern shore across the bay. And it's through partnerships.

Anthony Martinez, MD: Yeah, I think tThose partnerships, that's[are] obviously essential. We've long known where these patients are at. We know exactly where they access care, how to find them. And it's building those relationships with our community partners to help us to facilitate that linkage. Also, though, probably important to point out, we've discussed meeting patients where they are. You've also got to meet providers where they are. If you want them to do this work, to do the screening and to facilitate that link, you've also got to make it as easy for the providers as we hopefully will for the patients.

Mark Sulkowski, MD: Yeahes, and that was kind of the point in some of the programs, is to say, it's really simple, look at the guidelines. All you got to do is this,

this, and this. But [if] you look at their day and look at what they're being asked to do., Iit's not that easy, and there is no room to add hep[atitis][hepatitis] C. So different layers of partnerships that we have found can work. And yYou have to really get to know who you're working with.

Anthony Martinez, MD: Nancy?

Nancy Reau, MD: Well, I'm going to use a word that probably is a little bit blended, but policy. And I think that when we talk about this, some of the biggest limitations to expanding our provider pool are things like prior [authorizations]., Tthe need for a genotype. Wwhen you really don't need a genotype. , there'sThere are a lot of things that hold over that are barriers and they're inconsistent. Like one insurer might require some things, another insurer might require something else. Even in Illinois, public aid got rid of prior [authorization], which is amazing. Thank you, public aid. But some of our public aid affiliates don't follow that rule. And so that'sIt’s really hard when you're trying to take a primary care provider or someone in addiction medicine who does have a narrow bandwidth and you've told them everything is simple and then they can't even get the paperwork done for access to the medication. And tThat's why they get frustrated and why you start to get your referrals back.

Anthony Martinez, MD: Yeah, I think that's essential. The policy is a key component. And I would add to that, advocacy. Hepatitis C, we haven't had a lot of great advocacy. It's very, very different than the HIV world. And that's something I think we need more of. Tipu, how about you?

Tipu V. Khan, MD: Yeah, wWearing two 2 hats is as a primary care doctor and as an addiction specialist, I see it from two 2 different angles. From the primary care standpoint, like we've all touched on, is it's tough, right? You've got a busy day. You've got 12, 13 patients in a half day, everything from a heart failure to a dialysis patient that has no other doctor to see. So yYou're managing all these things, especially in an underserved setting, you're managing all these problems. So, tThen all of a sudden say[someone says], “Hey, why don't you just go ahead and cure hep[atitis][hepatitis] C as welltoo?” It's not as easy as it sounds sometimes in a busy practice. So wWhat I focus on with our residents, we train as well as our community doctors is really helping them understand they're supported. There's a lot of national organizations out there that provide both local support and partnerships like echo ECHO [Einstein Community Health Outreach] clinics in your region [New York, New York] to also national phone numbers you can call to get support on starting a treatment program. And so I like to make sure people feel supported, [as if someone said], that, “Hey, you can start this.” This is easier than [treating] everyone else you're going to see in your day. Treating hep[atitis][hepatitis] C is going to be easier than your diabetes appointment that you have next, than in your heart failure follow-up from the hospital. This is going to be the easiest treatment of your day.

Anthony Martinez, MD:And the visit may even be quicker.

Tipu V. Khan, MD: It's going to be quicker, exactly, and more satisfying to some extent, right? But when you need support, this is who you reach out to at home. So sSetting that algorithm up so they know where to go when they need that help on that next step [is important.]. And then fFrom the addiction medicine standpoint, I think it's really normalizing the importance that this is a co-occurring disease and a co-epidemic really, right? We talked about the opiate use disorder epidemic. Hep[atitis][Hepatitis] C goes right along with that, right? Upwards of 20% to 40%, depending on the data you're looking at and the clusters of community, have hep[atitis][hepatitis] C as well. So I think we, as academic addiction doctors, are really focused on training our learners that these problems go hand in hand. And so wWhen you are treating as an addiction specialist, hep[atitis][hepatitis] C is in your wheelhouse,. iIt's your bread and butter as well.

Anthony Martinez, MD: I think it's really empowering for all types of providers from all types of disciplines. A lot of times in medicine, we don't get a win. We manage a lot, but there's very few things we actually cure. And tThis is something that we can tangibly eliminate, cure, and it really goes a long way not only to empower patients, but also providers. Nancy, as we see more of these sort of emerging providers from different disciplines, what is the role of the hepatologist in supporting them.?

Nancy Reau, MD: I think we're a little bit like a parent, right? The most important thing is to is to help them through that first hurdle of understanding, that this is really very easy. You are unlikely to mess it up. [It’s about] holding their hand and then being the backup to catch them if they need tertiary-level assistance. Once you've treated a couple of patients, all the fear goes away. You're like, “oOh look, they did fine. They felt great, they're cured now. Now I can do this.” They don't need you anymoreanymore, [and] you really don't need me. Then you'll have the person that comes in that has a seizure disorder that you can't find a way to get rid of the drug-drug interactions or they have more advanced disease,. oOr you did that liver cancer screening, [and,] lo and behold, they actually have something that could be a liver cancer and you have to be that backup phone number. I am still here for you. I know you. You didn't need me for six 6 years, but I am still here for you, and—that's our role. I mean, I think aAs a hepatologist, I love hep[atitis][hepatitis] C. I like hep[atitis][hepatitis] C more than pretty much anything else I see in my clinic, but I have to let it go. This is not what I this is not what you need me to do. I went to school a long time to be an academic hepatologist, I should let someone else win this battle.

Anthony Martinez, MD: Again, it goes back to what we talked about a little bit before, relationship building, knowing that you're there, you're available for that support if and when they need it.

Transcript was AI-generated and edited for clarity.

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