Alex Shirreffs, the HIV/HCV Project Coordinator at the Philadelphia Department of Public Health, presented on Hepatitis C and HIV co-infection at the April 2017 meeting of the Positive Committee.

1. The Beginning of
The End?
Alex Shirreffs
HIV/HCV Project Coordinator

2. Epidemiology of HCV
• More than 4 million people in the US expected to be
chronically infected with hepatitis C virus (HCV)
• Most people (~70%) are undiagnosed
• Most common reason for liver transplantation
• 50-75% of HCV(+) individuals are unaware of infection
• Worse liver-related outcomes
• Spread of disease

3. 0
200
400
600
800
1000
1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67 70 73 76 79 82 85 88 91 94
2007
1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67 70 73 76 79 82 85 88 91 94
2011
Age
NumberofIndividuals
Population of Young HCV Cases in
Philadelphia
0
200
400
600
800
1000
1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67 70 73 76 79 82 85 88 91
2013
0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60 63 66 69 72 75 78 81 84 87 90 93 96
2015
Baby-Boomers
Young Cases
(18-35 years)

4. Investigated HCV cases by age and risk factor:
Philadelphia, 2013-2014
• Behavioral risk factors (injection drug use and incarceration) account for most of HCV
*Medical includes
blood/organ
transplants, dialysis,
needlesticks,
work in medical/dental
field
20%
35%
21%
8%
16%
<=30 years
Medical
IDU
Incarcerated
Sexual
Tattoo
16%
32%
27%
11%
14%
31-44 years
26%
26%
26%
12%
10%
45-64 years
42%
22%
19%
13%
4%
>=65 years

5. Proportion of HCV-Infected Individuals Reaching Successive Stages
HCV Cascade of Care
0
10000
20000
30000
40000
50000
HCV infected
(estimate)
HCV Ab HCV RNA HCV in
medical care
HCV antiviral
treatment
NumberofIndividuals
47%
22%
6%
3%
HCV-Positive Individuals Are Being Lost At All Stages of Care:
1. HCV Testing Confirmation
2. Referral To Specialist’s Care
3. Treatment
Viner K et al. The Continuum of Hepatitis C Testing and Care. Hepatology. 61: 783-789, 2015.

6. HIV/HCV Coinfection FACTS
• Among HIV-infected individuals, HCV co-
infection
• Is estimated at 25% (CDC)
• Ranges from 10–30% in MSM1
• Up to 80–90% in PWID2
• HIV/HCV coinfection more than triples the risk
for liver disease, liver failure, and liver-related
death
• ART may slow the progression of liver disease by
preserving or restoring immune function and
reducing HIV-related immune activation and
inflammation
1) G.M. Lauer, B.D. Walker. Hepatitis C virus infection. N Engl J Med, 345 (2001), pp. 41–52
2) K.E. Sherman, S.D. Rouster, R.T. Chung, N. Rajicic. Hepatitis C Virus prevalence among patients infected with Human Immunodeficiency
Virus: a cross-sectional analysis of the US adult AIDS Clinical Trials Group. Clin Infect Dis, 34 (2002), pp. 831–837

7. HIV/HCV Coinfection - Philadelphia
• Prevalence
• EMA estimate of 6,200 PLWH coinfected with HCV (18.6%) as of
12/31/2015
• 17.5%* of PLWH in Philadelphia are HCV coinfected as of
12/31/15
• Screening
• Approximately 84% of PLWH screened for HCV in Philadelphia
residents in the Ryan White system
• Two types of HIV/HCV co-infected patients can be distinguished
• Those infected for decades (often have severe fibrosis and several
comorbidities)
• Those recently infected with HCV
• All HIV-infected patients should be screened for HCV
• Patients at high risk of HCV infection should be screened annually
and whenever HCV infection is suspected.
*Source: AACO 2015 Surveillance Report

8. I said that an AIDS-free generation is within reach,
and today, the global community is committed to
ending this epidemic by 2030.
- Former President Barack Obama

9. What does it take to end an epidemic?
Prevention
• Condoms
• PrEP and PEP
• Syringe
Exchange
• STD Testing &
Treatment
• Health
Campaigns
Testing &
Diagnosis
• CDC : Everyone
tested at least
one time, more
freq per risk
• Provider testing
• Walk-In Test
Sites
• STD Clinic
• Partner Services
Linkage to &
Retention in Care
• Case
Management
• SEPTA Tokens
• Co-Located
services
• START Care
• CoRECT
Treatment
• Lifelong
treatment
• Viral Load
Suppression
minimizes
transmission risk
Some Tools in Our Local HIV Infrastructure:

10. HIV: There is still work to be done
HIV Care Continuum, Philadelphia, 2015

11. We have the tools we need to end hepatitis C
in Philly (we just don’t have the $$)!
-Alex Shirreffs

12. What does it take to end an epidemic?
Prevention
• Condoms
• Syringe
Exchange (AND
clean works!)
Testing &
Diagnosis
• CDC: All Baby
Boomers; others
more freq per
risk
• Less than 5 walk
in test sites
• Not all have
confirmatory
• Provider Testing
Linkage to &
Retention in Care
• FOCUS grant
sites have some
linkage support
(ex: C A
Difference,
Prevention
Point)
Treatment
• A
CURE
• Medications
cure most ppl
of HCV in 12
wks or less w
minimal side
effects
Some Tools in Our Local Hep C Infrastructure:

13. Proportion of HCV-Infected Individuals Reaching
Successive Stages
Total HCV Ab+ estimate
Reported HCV Ab+ estimate
Surveillance findings
0
5000
10000
15000
20000
25000
30000
HCV infected
(estimate)
HCV Ab HCV RNA HCV in
medical care
HCV antiviral
treatment
NumberofIndividuals
47%
22%
6% 3%
2010 – 2013
Hep C: There is still a lot of work to be done

14. What if we combined our resources?
Could Philadelphia be the first city to eradicate
hepatitis C among HIV/HCV co-infected people?
Prevention
• Condoms
• Syringe
Exchange (AND
clean works!)
• Integrated
messaging
Testing &
Diagnosis
• Annual hep C
testing for
everyone with
HIV (more with
risk factors)
• Scale up HCV
testing in HIV
care settings
Linkage to &
Retention in Care
• Hep C Linkage
Coordinators
• Train case
managers &
frontline staff on
hepatitis C
Treatment
• A CURE
• Encourage hep
C treatment at
all HIV care
sites
A More Integrated HIV & Hepatitis C Infrastructure:

15. Project Aims:
• Increase Philadelphia’s capacity to provide
comprehensive screening, care and treatment of
hepatitis C among HIV/HCV co-infected people of
color
• Increase number of HIV/HCV co-infected people
of color who are diagnosed, treated and cured of
HCV infection

16. Working Towards Eradication
Data &
Evaluation
Training &
Capacity
Building
Linkage to
Care
Service
Integration

17. Data & Evaluation
• Match PDPH hepatitis C and HIV data sets to create a
baseline HCV Continuum for PLWH in Philadelphia
• Integrate additional hepatitis C measures into
CAREware
• Develop provider report card tool to measure
progress by HIV care site
• Provide technical assistance to help care sites use
data to track progress moving patients through the
HCV continuum
• Monitor impact of program on Philadelphia’s
HIV/HCV continuum

18. Training & Capacity Building
• Identify gaps in services along the HCV care continuum
using PDPH surveillance data and pre-Implementation
knowledge and needs assessments
• Build hepatitis C curricula into established models of
provider training and capacity building at Health
Federation’s Philadelphia performance site of the Mid-
Atlantic AETC
• Ex: Peer to Peer training, Preceptorships
• Explore other innovative service delivery models:
• Telemedicine
• Directly Observed Therapy

19. Linkage to Care
• Centralized care coordination support under AACO
• Use PDPH data to prioritize lost to care clients and re-
engage in care
• Provide centralized intake to offer sites additional
support with client linkage to hepatitis C services
• Identify opportunities to integrate hepatitis C into
existing patient support activities
• Training Medical Case Managers on hepatitis C
• Create targeted education and awareness materials
• Help publicize existing hepatitis C services offered in
Philadelphia

20. Service Integration
• Identify facilitators and barriers to integration of
hepatitis C into existing Ryan White activities
• What additional resources would be needed to
improve hepatitis C services within Ryan White
programs?
• How can local best practices be shared and replicated?
• Develop a sustainability plan to ensure that any
improvements to hepatitis C services through this
opportunity can be maintained
• Promote and leverage local successes to bring in
additional resources

21. NEXT STEP:
NEEDS ASSESSMENTS

22. Refining Philadelphia’s Plan
• Pre-Implementation Phase includes Knowledge
Assessments
• Does our strategy begin to meet the needs of
improving HCV services for HIV-infected people?
• How can we refine our strategy to be most useful to
providers and clients in the HIV service system?
• Patient and Provider Knowledge Assessments

23. Patient Focus Groups
• Anonymous and confidential
• Will you help us? Your insight will help us:
• Determine what resources can support clients
• Are there new educational materials that need to be
developed?
• What are barriers and facilitators to hep C treatment?
• If you are interested, provide your contact info and Amy
will follow up!