Advancing care for people with HIV and hepatitis C

A team of researchers across Yale School of Medicine (YSM) and the University of Texas Health Science Center at San Antonio (UTHSCSA) has published a set of papers on innovations in patient care for those diagnosed with hepatitis C (HCV), who are also living with human immunodeficiency virus (HIV).

The papers were published as part of a special edition titled, "Innovations in HIV/HCV Care," in the journal Health Promotion Practice on September 6, 2023.

The idea for the special edition series came about when the YSM and UTHSCSA teams were debriefing after the completion of a nearly five-year grant project that ended in March 2022. The grant was funded by the Health Resources and Services Administration (HRSA) Special Projects of National Significance and titled, "Curing Hepatitis C among People of Color Living with HIV."

The multi-pronged initiative sought to address racial disparities in access to HIV/HCV treatment for co-infected individuals. Overall project goals were to cure hepatitis C in persons with HIV, particularly persons of color through improvements in the HCV cascade of care; improve partnerships with key stakeholders; and improve surveillance mechanisms statewide for HIV/HCV co-infection.

"We put our heads together about what we learned through the project and our project officer suggested we compile our collective experiences and publish together," said Merceditas Villanueva, MD, associate professor of medicine (infectious diseases), and director of the HIV/AIDS Program at YSM.

Villanueva is a co-grantee, along with Waridibo Allison, MD, Ph.D., vice president of health policy and executive director of the Center for Health Policy at the University of North Texas Health Science Center at Fort Worth.

"The papers showcase practical approaches about what we learned to improve hepatitis C care for people who have coexisting HIV, which is a very special group," Villanueva explains.

"HCV and HIV exist as a syndemic and if we are to eliminate HCV and end the HIV epidemic in the U.S., the kind of work presented in this collection of papers is vital," adds Allison.

In the U.S., a quarter of people who have HIV are also infected with hepatitis C. Villanueva explains that this is a disease of underserved individuals, particularly those who have a history of injection drug use and how the proverbial saying "it takes a village" applies to this group.

The research team reports on experiences and findings on the barriers found by the care teams in the clinical delivery system. The four treatment barriers identified are socio-ecological, interpersonal, institutional, and structural. Each paper showcases the findings and provides suggestions and methodologies for providers on addressing these specific barriers and how to improve access to care.

"The biggest takeaway from this work is addressing multiple barriers instead of just one at a time. We discovered that people who need care usually have more than one reason why. Although it seems oversimplified, in actuality it's a really complex issue because you have to address multiple barriers for a patient, instead of just one," said Maximilian Wegener, MPH, epidemiologist in the HIV/AIDS Program.

Since there are a multitude of reasons people may not be receiving treatment, the two teams from YSM and UTSA developed various approaches that reflect where patients are treated. For example, the challenges providers and patients face are different in Connecticut than in Texas. This is in part due to the size difference of the two states, demographic variations in the affected populations, and how the health systems are set up.

"What we've seen with this project is that one size doesn't fit all. One plan doesn't fit every patient who still needs to be treated. An approach to improvement of testing practices at one clinic or a treatment program may not work across all locations," added Ralph Brooks, MS, research associate and data manager for the project.

The approaches in the collection address the issues from multiple vantage points, but ultimately should lead to more individualized personalized plans for patients, the team says. "There has been a big attempt for standardization, but once you hit a certain point, you really have to take a personalized look," said Brooks.

"Instead of saying, 'Hey, you missed your appointment, let's make you another one,' we need to figure out why. For example, one of the things that can be done within a clinic setting is to do a deep dive with folks with HIV and hepatitis C who are not cured. It's not just getting them a bus pass, but figuring out what issues are impeding them," said Villanueva.