Cherokee Nation Health Services Makes Strides Toward HCV Elimination

The Cherokee Nation Health Services program to eliminate hepatitis C has made progress, but more work is needed to eliminate barriers to care.

In its first five years—between Nov. 1, 2015, and Oct. 31, 2020—the program identified 1,423 people with diagnosed HCV infection, according to a recent evaluation highlighted in the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report. Among them, 86% were linked to care, but only 61% initiated treatment and 56% completed treatment. Treatment was highly effective, with 99% of those who completed treatment being cured.

“The biggest take away is that the Cherokee Nation is on the right path for HCV elimination, but to achieve our final goal we need to address the cause of why some patients are not engaging in HCV care and the barriers to start HCV treatment immediately in those who are being engaged in care,” Jorge Mera, MD, director of infectious diseases for Cherokee Nation Health Services, told Contagion.

HCV affects about 2.4 million people in the United States, and American Indian or Alaska Native people are disproportionately affected by the disease.

“Many patients do not know that they are infected with HCV,” Mera said.

More than 450,000 registered Cherokee citizens live in 14 counties in Oklahoma, and Cherokee Nation Health Services operates 11 health care facilities in the Cherokee Nation reservation. An evaluation of electronic health records found that 1423 people were diagnosed with HCV infection during the five-year study period, including 870 (61.1%) male patients. A total of 189 had advanced liver disease. A total of 1227 of those diagnosed with HCV were linked to care with direct-acting antivirals. Overall, 698 achieved sustained virologic response 12 weeks after treatment, amounting to 99.4% of those who completed care but only 49.1% of those diagnosed with HCV.

“All health care providers need to be involved in some way for HCV elimination to occur,” Mera said. “For example, primary care providers need to be in the front line for screening, evaluating and treating HCV. The majority of the 1227 patients that were evaluated for HCV in the Cherokee Nation were seen by physician assistants, nurse practitioners, pharmacists and primary care physicians.”

Some possible barriers to initiating treatment included that Oklahoma Medicaid didn’t cover HCV treatment for patients with fibrosis scores of F0 or F1 until 2018 and payor requirements for prior authorization and evaluation by a specialist created delays and disconnection from care.

Study limitations include that the results may not be generalizable due to it being limited to one tribal health system, patients may have received care outside of the Tribal health system, and the COVID-19 pandemic may have affected participation in care visits.

“The next steps is to close the gaps that we have in our HCV cascade of care,” Mera said. “The major gap is starting treatment the same day that the patient with known HCV is being evaluated, and for this we need to have HCV medications on site. We need to eliminate prior authorizations for these medications and make them accessible to everyone.”