Scientific Meeting Advances Efforts to Cure HCV Infection in the Ryan White HIV/AIDS Care Act Program

Earlier this year, I had the opportunity to join colleagues at the Health Resources and Services Administration's (HRSA) HIV/AIDS Bureau (HAB) and an invited group of clinical experts for a scientific consultation on expanding hepatitis C virus (HCV) treatment among people living with HIV. This issue is important because an estimated 1 in 5 of the 1.1 million people in the United States who are living with HIV are coinfected with HCV. People who are coinfected with HIV and HCV have worse health outcomes, including liver disease and increased risk of death.

The meeting was convened to identify successes, barriers, and costs associated with HCV care and treatment among people living with HIV (PLWH) as part of the "Study to Identify Barriers to HCV Treatment among People Living with HIV" being conducted by the George Washington University (GWU) Milken Institute School of Public Health.  The purpose of the study is to understand and inform communication with stakeholders on barriers to addressing HCV among PLWH in primary care settings and the development of a strategic plan for addressing HCV screening, care, and treatment among PLWH. HRSA administers the Ryan White HIV/AIDS Program (RWHAP), which serves over 500,000 PLWH in the United States, including at least 100,000 coinfected with HCV. Curing HCV among people in the RWHAP could have significant benefits for the individual clients who are cured and further expand the capacity of providers and clinics to diagnose and successfully treat HCV among all the patients they serve.

Improving viral hepatitis treatment among persons living with HIV is among the strategies prioritized in both the National HIV/AIDS Strategy and National Viral Hepatitis Action Plan, 2017-2020. The national goals of 1) increasing access to care and improving health outcomes for people living with HIV and 2) reducing deaths and improving the health of people living with viral hepatitis are supported by these efforts. The recent availability of highly-effective direct-acting antiviral (DAA) therapies that can cure HCV in the majority of people who take them -- including people living with HIV -- offers an important opportunity to substantially reduce this common coinfection and further efforts to achieve these national goals.

HCV screening and treatment are essential elements of HIV care. In comparison with HCV-monoinfected patients, persons coinfected with HIV have higher liver-related mortality as well as overall mortality. Treating and curing HCV in people with coinfection results in reductions in liver failure, liver cancer, and liver-related mortality. Previously available HCV treatments were much less effective in curing HCV, especially among people with HIV/HCV coinfection. The older treatments required almost a full year to complete, and many people experienced adverse events that were associated with these treatments. As a result, few people with coinfection sought treatment or were cured. Fortunately, the new DAA therapies that are now available are much more effective for all people, including those who are living with HIV, are safer, and usually require a shorter treatment length of 12 to 24 weeks. 

This study, along with another HAB initiative, "Jurisdictional Approaches to Curing Hepatitis C among HIV/HCV Coinfected People of Color" will help to develop sustainable systems of care that effectively screen, treat, and cure HCV in those with coinfection.  The findings will also inform future efforts to eliminate HCV coinfection among PLWH. Among the important insights that arose at the meeting were: 

• Many clients are familiar with the previously available treatment for HCV but unaware of the vastly improved DAAs. Education about the new DAAs is needed to alleviate their fears of side effects and treatment failure.
• The infrastructure of RWHAP addresses many of the non-medical needs of clients and could be better leveraged to expand HCV treatment among coinfected clients to improve quality of life and health outcomes.
• There are emerging clinical models and practices that are effective in curing patients with HIV/HCV coinfection.
• The success of curing coinfected patients has not been well described, from either patient or the provider perspectives. More stories from patients about their improved quality of life after successful HCV treatment and from healthcare providers about the ability to cure patients of a potentially life-threatening disease are needed.

The meeting reflected the optimism among many that we can now leverage new HCV treatments and our healthcare delivery system to help reach our national goals by reducing, and perhaps even eliminating, one of the most common coinfections that represents a significant threat to the health and survival of PLWH in the United States.

Author's note: This project is supported in part by the Secretary's Minority AIDS Initiative Fund (SMAIF) which supports a wide range of activities that are designed to reduce new HIV infections, improve HIV-related health outcomes, and reduce HIV-related health disparities in racial and ethnic minority communities.

Corinna Dan, R.N., M.P.H., is viral hepatitis policy advisor, Office of HIV/AIDS and Infectious Disease Policy, U.S. Department of Health and Human Services.