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Identification and Clinical Management of Persons with Chronic Hepatitis C Virus Infection - Cherokee Nation,
Insights
Cherokee Nation Health Services increased hepatitis C virus (HCV) testing and treatment by implementing a tribal policy. This initiative successfully raised screening rates and achieved high cure rates with new antiviral drugs.
Area of Science:
- Hepatology
- Public Health
- Infectious Diseases
Background:
- Hepatitis C virus (HCV) infection affects 3.5 million in the U.S., causing significant mortality from cirrhosis and liver cancer.
- American Indian/Alaska Native (AI/AN) populations face disproportionately high HCV incidence and mortality rates.
- Recent advancements include highly effective 8-12 week antiviral treatments with >90% sustained virologic response (SVR) rates, and expanded CDC/USPSTF testing guidelines.
Purpose of the Study:
- To evaluate the impact of a tribal HCV testing policy implemented by Cherokee Nation Health Services (CNHS).
- To assess the effectiveness of electronic health record (EHR) reminders and clinician education in increasing HCV screening.
- To determine HCV testing, diagnosis, and treatment rates within the Cherokee Nation population.
Main Methods:
- CNHS implemented a tribal HCV testing policy in October 2012, incorporating EHR clinical decision support reminders and primary care clinician education.
- Data were collected from October 2012 to July 2015, analyzing HCV screening, antibody testing, RNA confirmation, and treatment initiation and completion.
- Screening rates were tracked among 92,012 CNHS clinic patients, with a focus on the 1945-1965 birth cohort.
Main Results:
- First-time HCV screening increased from 3.6% to 18.2% among CNHS patients during the study period.
- The highest screening percentages were observed in the 1945-1965 birth cohort.
- Of 388 individuals with confirmed chronic HCV infection, 57.5% initiated treatment, 90.1% completed it, and 89.6% achieved SVR.
Conclusions:
- CNHS successfully enhanced HCV testing and treatment through its tribal policy and integrated clinical support.
- The program demonstrates a successful model for increasing HCV diagnosis and care, particularly in AI/AN populations.
- CNHS is collaborating with the CDC to develop an HCV elimination program, potentially serving as a replicable model for other tribal nations.
Abstract:
An estimated 3.5 million persons in the United States are living with hepatitis C virus (HCV) infection, resulting in approximately 20,000 deaths each year, primarily from cirrhosis or hepatocellular carcinoma (1,2). American Indian/Alaska Native (AI/AN) populations have the highest incidence of acute HCV infection among all U.S. racial/ethnic groups and are at greater risk for HCV-related mortality compared with the general population (3). In 2013, new antiviral drugs became available that make possible 8-12 week treatment regimens with fewer adverse events and are able to achieve sustained virologic response (SVR) in >90% of treated patients (4), equivalent to a cure of HCV infection. Also of note, HCV testing recommendations were expanded in 2012 by CDC and in 2013 by the U.S. Preventive Services Task Force to include one-time testing of persons born during 1945-1965 (the "baby boomer" cohort) in addition to anyone at increased risk for HCV infection (5,6). Given the availability of new HCV drugs, expanded testing recommendations, and high incidence of HCV infection in AI/AN populations, in October 2012, Cherokee Nation Health Services (CNHS) implemented a tribal HCV testing policy.* As part of the policy, CNHS added a reminder in the electronic health record (EHR) for clinical decision support and provided HCV education to primary care clinicians. From October 2012 to July 2015, among 92,012 persons with at least one CNHS clinic encounter, the cumulative number who received HCV screening for the first time increased from 3,337 (3.6%) to 16,772 (18.2%). The largest percentage of HCV screening was among persons born during 1945-1965. Of 715 persons who tested positive for HCV antibodies, 488 (68.3%) were tested for HCV RNA; among those 488 persons, 388 (79.5%) were RNA positive and were thus confirmed to have chronic HCV infection. Treatment was initiated for 223 (57.5%) of the 388 with chronic infection; 201 (90.1%) completed treatment, of whom 180 (89.6%) achieved SVR. CNHS has successfully increased HCV testing and treatment and is now collaborating with CDC and other external partners to develop an HCV elimination program for the Cherokee Nation that might serve as a model for similar settings.
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