Closing the Hepatitis C Treatment Gap: United States Strategies to Improve Retention in Care

Austin T. Jones; Christopher Briones; Torrence Tran; Lisa Moreno-Walton; Patricia J. Kissinger


J Viral Hepat. 2022;29(8):588-595. 

In This Article

Decentralization of Care to Non-specialist Healthcare Providers

A barrier to HCV care is decreased access to providers who are trained to treat HCV. The expanded 2013 and 2020 United States Centers for Disease Control and Prevention (CDC) screening guidelines have increased the pool of diagnosed HCV+ patients in the US, a number that cannot be sustained by current HCV specialists for treatment and management. Management of HCV therapy was traditionally limited to hepatologists who were most comfortable performing liver biopsies and managing complications of end-stage liver disease.[25] A specialty that numbers 1000–2000 physicians in the US, there are as few as 1 hepatologist for every 330,000 Americans.[26] This equates to 4.2 hepatologists per 10,000 Americans chronically infected. Issues with access to HCV specialists are not limited to the US. A study of 25 European countries found that patient groups in only 20% of European countries could access DAA treatment in the non-hospital setting, while another study found 94% of European countries restrict DAA administration to specialists only.[27,28]

As less invasive alternatives to fibrosis measurement have replaced the need for liver biopsies, infectious disease (ID) physicians have begun filling the gap; however, the demand still exceeds the supply of these two specialties. By decentralizing HCV treatment away from the limited number of hepatologists and ID specialists, HCV patients can more easily access DAA therapy. People living with HCV may more readily begin therapy as services are expanded from the limited number of hepatologists and ID physicians to an increasing number of non-specialist providers. A meta-analysis of HCV care in the community demonstrated primary care clinics as a feasible treatment delivery system with increased rates of HCV treatment uptake (67.4% vs. 34.5%) and similar rates of SVR (94.9% vs. 96.8%) compared with specialty care clinics.[29]

Advanced Practice Providers

Advanced practice providers (non-physician healthcare providers including nurse practitioners and physician assistants) can be leveraged to expand the pool of healthcare providers serving HCV patients. Shifting the responsibility of the pre-treatment evaluation—including RNA quantification, liver fibrosis and genotype testing—to advanced practice providers reserves physician appointments for the provision and management of HCV therapy. Nurse practitioners and physician assistants have been successfully utilized in this model to address the high demand for HCV services in outpatient clinic settings.[30] A non-randomized clinical trial demonstrated that advanced practice providers, primary care doctors and specialty physicians produce equivalent rates of SVR among HCV+ patients.[31] Expanding the role of advanced practice providers in HCV care will address the shortage in physicians managing HCV treatment while ensuring equivalent quality of patient care.

Telementoring for Primary Care Physicians

Project Expanding Capacity for Healthcare Outcomes (ECHO), a telementoring programme initiated by the University of New Mexico in 2003, serves as a successful example of HCV provision by primary care physicians in rural communities without access to HCV specialists.[32] With the goal of expanding hepatitis C services for underserved populations in the state, ECHO uses telementoring to connect primary care physicians with specialists in a 'hub and spoke' model via weekly videoconferencing.[32] The hub consists of a single facility with a hepatologist, pharmacist, clinical nurse and social worker, while the spokes are a number of community practitioners aiming to prescribe HCV therapy.[32] The spoke reports deidentified cases to the hub; expert consensus from the hub then teaches the spokes through navigating care management and with case-based learning.[32] Since the US Congress passed the ECHO Act in 2016, similar programmes have expanded nationally to increase US physicians' capacity to treat HCV.[33] Outside of the US, telementoring programmes have been replicated in the Patagonia region of Argentina, improving rural primary care physicians' ability to stage fibrosis, identify candidates for treatment and select optimal HCV therapies.[34]

Expanding care to these generalist providers has not diminished patient care.[31] ECHO has been demonstrated to promote equal HCV care outcomes by ECHO-telementored primary care physicians as university-based HCV specialists.[21] These models enable primary care providers to provide best-practice care to rural and underserved populations.