SUD and the Growing Hepatitis C Virus Epidemic
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Welcome to the learning module about substance use disorder and the growing hepatitis C virus epidemic I'm Eve Andersen-Buescher and I'll be starting this presentation and I'll be followed by Kathy Davis (next) the objectives for this learning module are to learn about the hepatitis C past present and current trends and statistics review increases in HCV infections among the substance use disorder population review treatment of substance use disorder populations with hepatitis C and prevention of hepatitis C virus among the substance use disorder population and neither Kathy nor I have any disclosures so really what is hepatitis (next) hepatitis is an inflammation of the liver caused by the hepatitis C virus the virus can cause both acute and chronic hepatitis ranging in severity from a mild illness to a serious lifelong illness including liver cirrhosis and cancer the hepatitis C virus is a blood-borne virus and most infections occur through exposure to blood from unsafe injection practices unsafe health care unscreened blood transfusions injection drug use and sexual practices that lead to exposure to blood and there is currently no effective vaccine against hepatitis C (next) so although we are focusing on hepatitis C it's important to be aware of hepatitis A and B trends as well so for hepatitis A there has been a large increase in 2019 most notably among the homeless and persons who use drugs and for hepatitis B and hepatitis C it is estimated that 50 percent of infected persons are unaware globally an estimated 58 million people have chronic hepatitis C virus infection with about 1.5
million new infections occurring per year in 2019 approximately 290,000 people died from hepatitis C mostly from cirrhosis and hepatocellular carcinoma which is a primary liver cancer antiviral medicines can cure more than 95 percent of persons with hepatitis C infection but access to diagnosis and treatment is low (next) when we look at the history and the prevalence they seem to occur in waves the first wave occurred basically between 1960 and 2005 and mostly infected baby boomers which are individuals born between 1945 and 1965. it is believed that increases in blood transfusions contributed to the peak of infection rates in the 1970s and 1980s prior to 1992 the most prevalent cause of hepatitis C was transfusion of blood products that contained hepatitis C then in '92 a sensitive screening tool was developed to test blood donations thereby virtually eliminating hepatitis C transmissions through the blood supply the second wave goes from 2005 onward with a three-fold increase in new cases between 2005 and 2015 and this is because drug and alcohol use often leads to risky sexual behavior shared works and impaired judgment so therefore injection drug use remains the most common risk factor for requiring HCV in the United States accounting for more than 60 percent of all cases of HCV approximately 20 to 30 percent of persons who inject drugs become infected with HCV within the first two years of starting to inject drugs and 50 within five years transmission risk is greatest with direct sharing of needles and syringes but may also occur indirectly via sharing of injection paraphernalia such as water cookers and cotton filters the CDC Division of Viral Hepatitis 2025 strategic plan seeks to reduce new viral infections decrease viral hepatitis related morbidity and mortality decreased disparities in established national surveillance as part of their plan to prevent hepatitis C infections they have a National Viral Hepatitis Progress Report which you can find online as you can see here the goal of decreasing new cases has not been met (next slide) by age it is the 20 to 40 year olds really are Generation X that are most affected by this there are more males than females and ejection drug use is the highest risk and when you look at race and ethnicity the American Indian and Alaskan Natives have the highest percentage of infections followed by African Americans so when we look at viral hepatitis and the ethnic minority populations broken down we can see that the Asian American Pacific Islander is the most heavily affected by hepatitis B which we talked about a little bit before and they also are estimated to have 1 in 12 live with hepatitis B and estimates two of three hepatitis B infected people of this population do not know that they are infected because they have never been tested and when we look at African Americans they comprise 25 of the people in the United States with hepatitis C infections there are higher rates of infection and hepatitis C related death compared with the overall population from ages 60 and up are 10 times more likely in the African American population to be chronically infected with hepatitis C compared to other races when we look at the American Indian and the Alaskan Native they have the absolute highest rate of acute hepatitis C infection the highest rate of hepatitis C related deaths and hepatitis C related death is more than double the national rate this graph gives us a little more information or different perspective when we're looking at the viral hepatitis and ethnic minority populations you can see here again that the American Indian Alaska Native has significantly higher risk and prevalence of hepatitis C infections there have been various studies in rural areas all around and this kind of gives us an overall example of people who inject drugs and the rate of hepatitis C in a variety of different rural communities according to the CDC as well as statistics compiled by the National Notifiable Disease Surveillance System cases of acute hepatitis C increased 32 percent in rural areas between 2015 and 2019.
the U.S. counties most vulnerable to outbreaks of injection-related HIV or hepatitis C were overwhelmingly rural I think that can clearly be seen in the map of the U.S. here why why are there such barriers to detection and treatment in rural areas one there's a low number of providers in rural areas also there's a limited number of treatment facilities minimal public transportation or access to care options costs of financial roadblocks and stigma everyone knows everyone's concern I want to think when you think about perception perception on the parts of the patient can be that the treatment is very arduous because back before it was but there's also some perception problems on the part of the provider that they need special skills or there's only a certain type of healthcare provider that can provide the treatment which Kathy will be talking about shortly and educate you about that and in cost think about basic costs it may be too expensive to actually pay for the gas to get to and from the pharmacy there's very little public transportation and how much does it cost you to get to the pharmacy so there are a variety of different barriers in these rural areas that we really need to overcome (next) and overall when you look at engagement or lack thereof why in addition to the things I just talked about which are significant barriers in this population the people that are currently affected are also in a younger age group so they have less co-morbid medical issues they're much less likely to seek medical care they're also more likely to be isolated from society many of these people are homeless and in general have less access to health care many people have legal issues and are concerned that if they engage in treatment it will bring legal issues to life it also gives them a different perception of people who are taking care of them often there are occurring mental health disorders and due to this that affect their perception and their ability to engage in treatment and then there's provider bias which we all have to own and that is that providers sometimes can view these clients as poor candidates for therapy and just assuming that they'll be non-compliant and less likely to follow through with recommendations making the provider most likely to offer treatment next will be Kathy Davis who will talk with you more about specific treatment of hepatitis C Hi this is Kathy Davis I'm going to talk about the treatment of hepatitis C in the SUD population your first step in treating hepatitis C is to identify it as Eve mentioned that many people do not know that they are infected with hepatitis C so the World Health Organization and the AASLD the American Association for the Study of Liver Diseases is recommending they have it on HCVguidelines.org
that all individuals ages 18 through 75 get a one-time test at least a one-time test people younger than 18 can be tested as well if they have a history of risk factors such as any form of drug use so we start with a one-time HCV antibody test now most of the labs when you order an HCV test offer HCV antibody testing with reflex testing so initially if your antibody test comes back non-reactive that means there is no HCV antibody detected and there's no further treatment work up necessary the person does not have hepatitis C if the HCV antibody is reactive comes back positive reflex testing is done that is where the lab will then run a PCR test it takes about five days usually to get that back and the HCV RNA is evidence of the virus if it is detectable the individual has current HCV infection and needs to be linked to care if it's not detected that means the patient does not have a current HCV infection either they had a previous infection they didn't know it and they cleared it on their own we know approximately 25 percent of individuals infected with HCV will clear their virus on their own or it meant that they were previously treated so if the RNA is negative we don't do anything except re-screen again according to the risk factors or if they're in a program the program guidelines and if they do have the RNA present they need to be linked to care all persons with active HCV infection meaning they have a detectable amount of HCV RNA after six months post-infection equals chronic HCV now we normally aren't able to detect acute hepatitis C virus that's a rarity a person may have symptoms of jaundice vomiting nausea fatigue malaise low-grade fever and may go to the emergency room and it could be detected at that point but most people are never aware that they have had an exposure or an infection because it's asymptomatic that's what makes hepatitis C virus chronic hepatitis C very dangerous and a silent killer and why we should be screening all patients at least once whether they have used a substance or not for this virus so all persons with an active HCV infection and that means any amount of viral load there is no too low amount to treat should be linked to a healthcare provider who is knowledgeable and prepared to provide comprehensive management by completing this training that would qualify you as a knowledgeable health care provider we do not need to reserve treatment to only those practices that are a GI or hepatology primary care providers can in the era now of the direct acting antivirals can and should be treating their patients just as they treat hypertension diabetes management etc so your HCVguidelines.org
on the bottom you'll see the website that is going to be your place to go for all information related to treatment now when you go to hcvguidelines.org on the landing page if you are able to go there now in a separate window you'll see as you scroll to the bottom that they have a one page it says now available simplified HCV treatment for treatment naive patients without cirrhosis or with compensated cirrhosis so most of us will be treating our patients that don't have cirrhosis so there is a one page downloadable algorithm that has everything you need to know on it it's a busy page but it's amazing and everything that I say here is going to be on there so you don't have to take really vigorous notes you just need to know where to find the information so it's going to tell you everything you need to know it's going to go over all of this pre-treatment assessment labs history and physical exam counseling and education they'll touch on medication and monitoring (next slide) first of all you're going to need more information before you can treat somebody so they recommend that six months within a six-month time period before treatment that these labs are received so the pre-treatment laboratory testing you're going to want to get a CBC they recommend a hepatic function panel I usually just order a comprehensive metabolic profile because I do want to know what their glucose is as well an INR the INR is done because it's a good indication of liver health we want the INR to be one if it's out of range that may indicate that the individual has some liver disease and you want to also order a full hepatitis it comes as an A B C panel with reflex viral load genotype is not always necessary anymore but it's a good thing to have we know that certain genotypes may be more sometimes more associated with fibrosis but we do need the hepatitis B surface antigen before initiating antiviral therapy because of the black box warning with both of the drug combos can reinitiate a past infection with hepatitis B so that must be drawn an HIV test a serum pregnancy test because within your females because we do not want to treat females who are pregnant and the fibrosis blood test there is no longer a liver biopsy required that is very reassuring to patients as Eve mentioned the treatment fears still exist from horror stories from even 10 years ago when the DAAs were not widely available and can only be used on those individuals that did have evidence of fibrosis so the interferon the rib of vibrant and the the long side effects that were associated with that that's a complete thing of the past this is revolutionary this is what we've been waiting for and they are so you easy to use and so well tolerated so patients I try to show them a lot of excitement about being treated so they're not afraid and they look forward to treatment this is what you're going to see when you get your fibrosis test back this is just part of it as you can see you're going to have zero to four ideally you're going to want to see no fibrosis or mild fibrosis now in the patients that I've treated I have had all of these scores in my individuals who have had a stage 4 fibrosis I treated alongside a liver specialist who is available through telemedicine and every individual that we treated when we repeated the fibrosis testing everyone reversed once their hepatitis C was cured it was a wonderful thing that we were able to catch individuals one individual had a stage four score within only five years of being infected which is very very rare as a rule it usually takes 20 years or so before hepatitis C is going to cause problems with the liver what's not shown on the screen is you'll also get an inactivity score and usually the two of those scores will correspond together (next slide) factors that can affect fibrosis so these are all things that might affect why somebody might have fibrosis or scarring in the liver versus somebody that doesn't have any scarring in the liver and I have had individuals who have been positive for hepatitis C for 20 or more years have zero fibrosis the duration of the infection certainly the longer that they've had it the more likely that there's some scarring there older age at the time of infection being infected at age 40 45 is a little bit more worrisome than somebody that was infected in their early 20s males there's a slight increase that they may have increase in fibrosis people who consume alcohol on a regular basis obesity as it is an inflammatory condition G3 genotype has a slightly more potential to have more fibrosis co-infection with HIV or hepatitis B diabetes is that's also an inflammatory condition and individuals who also use tobacco mainly who smoke cigarettes may have accelerated fibrosis (next slide) so after you've got your lab work you've interpreted your fibrosis scoring you bring the patient in and you're going to be going through the blood work with them and do a history and physical you want to pay careful attention to evaluate for evidence of decompensated liver disease the history is important you want to know if there's any history of liver disease in the family if the individual ever had treatment in the past if you can get a history in their substance use background when they started using if they can remember being sick a little thing that we kind of have discovered is that people who know when they got sick and had symptoms of hep C are usually the ones that are more likely to clear the virus on their own and again that's only 25 percent of individuals so we take the history and then the physical exam you want to look at it's so it's focused it's mainly you know look for heart lungs they you should have them lay on the table feel for nodules in the liver enlargement of the spleen look for spider angioma looking at the palms look at asterixis and to see if they have any other signs of cognitive decline things that would raise your fur about maybe this person is a little more advanced than they show initially at that point you know you may want to also think about checking in with a liver specialist see we have to make sure that there is no decompensation if they do have cirrhosis you want to look for manifestations of hepatitis C virus these include vasculitis glomerulonephritis eye problems Sjogren's syndrome other skin problems Non-Hodgkin's lymphoma and other extra hepatic manifestations would include vasculitis and other conditions so once you've done your history and physical and most people I have to say all of the people that I've treated I've not found any evidence of liver disease and I think going in with treatment I would have been looking for it if I had seen some red flags in their blood work I would be a little bit more perked up and ready for finding something ascites, edema but I was lucky to to have pretty healthy patients so all patients starting direct acting antivirals the DAAs need a thorough medication reconciliation between their medications you have to go through not only the prescription but the over-the-counter and supplements and herbs everything that they put in their mouth that is potentially a dietary supplement or that they purchase over the counter as there is very there is a large amount of drug interactions with the medications and I'll go over some of those on one of the next slides so there also is availability to you if you have a pharmacist that you know well that can help you or you can go to this website you go to the liverpool hep interaction site drug.com
also has a nice thing you can type in the medications and see what the interactions are so we will go through that next and also there's the AIDS Education Treatment Center Program quick guide for clinicians there too your two medications that insurances will usually point you to are the combination drug Mavyret is the first one and that is a combination of glecaprevir and pibrentasvir and that is a duration of eight weeks the second medication is Epclusa the brand name and that's a combination of so sofosbuvir and velpatasvir and that one is a duration of 12 weeks now these medications when you reconcile the patient's drug list you're going to see that there are 160 drugs that are known to interact with Epclusa 40 are major 115 are moderate and there's five that are minor and with the moderate there's approximately 164 drugs that are known to interact and some of the common ones are the PPIs they're contraindicated while taking these medications however there are so many people on PPIs and antacids that some people just cannot come off that so the most important thing is that they do not take it anywhere near taking these medications so we usually say take these medications in the morning their hep C medications and then if they have to have the anti-acid they take it at night because it can decrease the absorption of the HCV medications and we really don't want to interrupt that and there are other medications like amiodarone and artemisinin carbamazepine you go on the list they'll all come up and then you can talk to the pharmacist and the patient and figure out how best to dose the other medications so that there is no interruption in the activity of the DAAs in eliminating the hepatitis C virus (next slide) side effects are really minimal if they're gonna occur they're going to occur within the first week most often reported are these four that are these three that are listed the first one is nausea and we always recommend that the individual take it with food not on an empty stomach and I have had to prescribe PRN Zofran for the first week or two in at least two patients headache can happen fatigue when we encourage people to rest or none of the above I would say out of the 13 patients that I treated only three or four actually had any side effects really what you're going to hopefully see is within two weeks or so when we did our initial study of treating HCV in combination with their methadone we reached recheck the viral load at two weeks and 12 out of the 13 were negative that's how quickly these drugs work we don't recommend that you do that there's no need for an early a virologic response check anymore counseling and education is very important you want to make sure that the individual knows how HCV is spread and that they use practice measures to prevent that spread to others meaning they do not share toothbrushes clippers razors etc that they practice good liver and general health habits if they're they have obesity encourage them to follow a healthy diet to go out and get some exercise smoking cessation is really hard but I do encourage them to do that and most importantly that they practice measures to prevent reinfection this is not a one and done you treat this infection you help this individual be cured of hepatitis C that is not to say they cannot get infected again I had two individuals become reinfected and they were with different genotypes so the person has to not share needles any drug use is not safe so at least you can do is encourage them with harm reduction that they never reuse needles and that they don't share any paraphernalia also individuals should have their immunizations updated particularly hep A and have B if they've not been vaccinated for them and you'll see that when you've done the have A B C panel they should get immunized for those as well monitoring we mentioned a I've mentioned a repeat visit or through a telemedicine or a phone call or a nursing visit and then you are going to make sure that 12 weeks after the last dose was taken at least 12 weeks or later that they get a repeat quantitative HCV RNA and usually a hepatic function panel is as good because you want to see mainly that their their numbers are good their ALT has gone down their liver is looking healthy and the main thing is the HCV RNA is undetectable if at 12 weeks after taking their medicine that HCV RNA is undetectable the person is cured of this present HCV infection that is a cure the HCV is not going to come back on its own if the individual had evidence of fibrosis you can repeat the fibrosis test six months to one year after completion of therapy and then you're going to repeat HCV RNA testing as needed based on the patient's risk factors HCV must continually infect new target cells to maintain even an established infection so as the DAAs render the virus incapable of reproducing the existing virus will quickly die off and we saw that within two weeks an individual is considered cured if the HCV RNA is negative 12 weeks after completion of DAA therapy SVR is achieved I have to tell you that's my favorite phone call to make is to let the individual know that they're cured I really love telling them that and I've been able to do that more than a dozen times and it never gets old (next slide) follow-up after treatment you're just going to follow them as you normally would follow your patients whether you bring them back on a yearly basis only test people if they have risk factors if the HCV RNA test is positive within 12 weeks after completion of the DAA therapy it is considered a relapse that's a rare event and more often represents a new exposure and reinfection and plan is going to be retreatment so in the individuals that I used the same medication because the insurance company told me I needed to I wanted to try the everybody we used Epclusa on I wanted to try Mavyret but they said it was not justified so we use the Epclusa and you're just going to start from scratch and genotyping is is probably a good idea you want to see if it's was it a different genotype and you're going to get your baseline blood work again now community-based prevention of HCV okay so this is the what takes a village you know we all have to work together through awareness education there's some you can get pamphlets from that link for HCV education in Spanish and English harm reduction address mental health and substance use disorders early on as support networks and reducing stigma people need to know that this is common it's commonly not found early and if it's not found we can't treat it and if it's not found the person could progress to severe liver disease that could result in death and this is life saving this medicine so that we have now and it is not hard to work with or to prescribe and primary care providers all of you can be treating HCV now here are some additional websites that you can go to the American Association for the Study of Liver Diseases that's where the hcvguidelines.org
the Centers for Disease Control and Prevention Hepatitis C Online there's this is a wonderful course the third one I've gone through it and I'm going to go through it again because I learned something new every time the HRSA website the US Department of Health and Human Services Office of Minority Health the Viral Hepatitis HCV toolkit another fabulous resource definitely get that download it and the World Health Organization fact sheets on hepatitis C and here is some contact information for you thank you
Eve Andersen-Buescher, MSN, PMHNP-BC & Kathleen Davis, NP
This session will provide insight into the growing hepatitis C virus (HCV) epidemic and its implications for rural communities. The module will also discuss the treatment options for individuals with HCV in the primary care setting, as well as prevention strategies for individuals who are currently using drugs.