VA Redesigns Approach to Treating All HCV-infected Veterans

With the assistance of funds granted by Congress, the Department of Veteran Affairs (VA) will extend new hepatitis C (HCV) treatment to all infected veterans within their healthcare system, of all stages of illness and regardless of whether or not the infection had been acquired during military service.

The VA’s integrated healthcare system, the largest in the nation, is comprised of more than 1,700 hospitals, clinics, counseling centers, and other facilities that aim to offer quality care for all who have served for America. This decision is paramount when it comes to improved identification and treatment of what an article published in JAMA calls, “the nation’s deadliest infectious disease.” According to the Centers for Disease Control and Prevention (CDC), HCV-related deaths have reached an all-time high of 19,659 in 2014, and according to John W. Ward, MD, director of CDC’s Division of Viral Hepatitis, “Because hepatitis C often has few noticeable symptoms, the number of new cases is likely much higher than what is reported.”

The VA is doubling the number of patients who will be treated with HCV antiviral therapy since last year, as it begins to treat 1,100 patients a week. The VA aims to almost double this number as well by the end of the year to treating 2,000 patients per week, David Ross, MD, director of the VA’s HIV, hepatitis, and public health pathogens programs, reported. In addition to increased treatment, another primary focus of the VA is to screen veterans born 1945 and 1965 for the virus, due to the fact that people who were born within that time frame account for more than 75% of HCV infections, according to the JAMA article.

Five medical centers in San Francisco; Richmond, Virginia; Ann Arbor, Michigan; West Haven, Connecticut; and Portland, Oregon are at the forefront of the initiative as they focus on providing expert HCV advice as well as training throughout the healthcare system. The overall end goal is to “eradicate as much of the disease as we can,” according to Chester Good, MD, chair of the VA’s medical advisory panel for pharmacy benefits management and an internist at the VA Pittsburgh Healthcare System.

VA Faces Insuffient Funds

Lack of funds has been an ongoing obstacle for the VA when it comes to effectively treating veterans infected with HCV. Last year, the government agency started restricting treatment access to veterans who had advanced liver disease due to high demands for new HCV therapies, an elevated cost of medicine, and a budget that could not cover all of the needed expenses. These medications were effective in curing HCV; where previous therapies cured only half of the patients and took twice as long, these results showed that after a 12- or 24-week course of therapy, 95% of HCV cases had been eradicated with minimal adverse effects.

According to the article, 89,000 veterans have been diagnosed with HCV but have not yet received treatment. About 40,000 more may be infected with the virus but have not yet received the diagnosis. Taking those numbers into account, authors of the article estimate that the price of HCV drugs would come to around $12.9 billion, and even with a 46% discount, the total still comes to about $7 billion for treatment. However, due to a bigger budget provided by the Congress, the VA will be provided with $1.5 billion; $1 billion of which will be used to pay for treatment medications, allowing for more veterans to be treated. In order to treat 35,000 cases of veterans diagnosed with HCV, the VA will ask for a $1.5 billion budget for next year as well.

Need for Specialists in Smaller Facilities/Less Populated Areas

In addition to the cost concerns, the fact that specialists are in short supply, remains a problem, according to the article, which makes improving access to primary care for veterans harder to implement. VA medical centers are using telehealth consults to address staffing issues in rural areas as well as less populated cities. Alexander Monto, MD, director of the liver clinic at the San Francisco VA Medical Center explains, “We can treat patients from San Francisco, but they don’t have to come to San Francisco.”

In addition, through its Specialty Care Access Network-Extension for Community Healthcare Outcomes (SCAN-ECHO), the VA will provide smaller facilities with HCV training that will entail videoconferencing. The training will consist of a weekly or biweekly lecture on HCV where physicians, clinical pharmacists, and nurses can share patient information as well as receive feedback from other experts in the field. Research from the JAMA article showed that through this training, physicians were able to significantly cut the time from treatment to diagnosis, (2 years for those without training and only 6 months for those who had it).

Increased Screening Needed

Another priority is increasing screening of veterans for HCV. The VA has been focusing on screening all veterans who had been born within the baby boomer generation, due to the recommendations provided by the CDC. Electronic health records assist in checking if veterans born within that time frame have been screened for the virus and if it finds that they have not, it issues a reminder to be tested. A quarterly performance list will be published by each VA region to see if they have effectively met their individual goals. According to the JAMA article, 70% of veterans born within that time frame had been screened by the end of last year, showing 7,400 new identified infections nationwide.

Another tool being utilized by the VA is a hepatitis C dashboard, updated daily, which has data from electronic medical records of patients. “The tool allows [Timothy Morgan, MD, chief of hepatology at VA Long Beach (California) Health System] and colleagues to sort through patients by hepatitis C genotype, extent of liver disease, treatment status, and other factors.” With this information, they were able to invite HCV-infected veterans with advanced liver disease who had not previously been treated to come in for treatment.

Continuing Education & Monitoring of HCV

The management of ongoing monitoring and additional education on HCV poses another challenge. In order to continually monitor diagnosed cases, the San Francisco VA Medical Center holds monthly group visits where 4 to 8 veterans each get their blood drawn, receive a 30-day supply of medication, and discuss test results in a supportive environment amongst their peers. In addition, they will have the opportunity to voice any emotional issues that they are experiencing to a psychologist as well.

Veterans who have a history of substance abuse are not excluded from treatment at the VA. In fact, the VA has experience in addressing the needs of these individuals through addressing various issues that can negatively impact medical treatment. An important factor that needs to be addressed is the stigma that is associated with HCV, that people who have it must have been “drug addicts” or “lazy good-for-nothings,” a common misconception of Vietnam veterans when they returned home from war. Due to this stigma, some people avoid being tested. Through continued education and addressing these issues, more people can get the treatment that they need.