Primary care takes on HIV and its co-infections

Human immunodeficiency virus (HIV) isn’t the only disease moving out of specialty care and into the primary care office. Primary care physicians are now taking on more areas of co-infection, such as hepatitis C (HCV), out of necessity.

With limited access to specialists a problem for many patients, researchers at the University of Maryland conducted a study to determine whether primary care providers could fill the gap.

HCV treatment led by PCPs and nurse practitioners was equally effective and safe as care by experienced specialists. In fact, the study showed that composite adherence to a 12-week treatment regimen was significantly higher in primary practices, with 50% adherence with nurse practitioner practices, 41% in PCP practices, and 19% in specialty practices.

Additional details about the study will be presented under the title, “HCV Cure: Moving the Needle from the Patient to the Population,” at the CROI Foundation’s conference in Seattle in February 2017.

Sarah M. Kattakuzhy, MD, assistant professor at the University of Maryland School of Medicine will lead the presentation, and spoke with Medical Economics about the role of PCPs in managing HIV and its co-infections.

Medical Economics: What is the role of PCPs in treating HIV patients co-infected with HCV?

Kattakuzhy: In the era of direct-acting antiviral therapy, HIV co-infection no longer impacts treatment efficacy. As such, similar to patients with HCV mono-infection, co-infected patients with stable HIV disease can be treated safely and successfully by primary care providers. One important factor in treating HIV/HCV co-infected patients is recognition of drug-drug interactions, but outside of this, treatment is generally the same as patients with HCV mono-infection. Patients with decompensated cirrhosis, including both HCV-mono or HIV/HCV co-infected patients, should be evaluated by specialist providers with experience in advanced liver disease and transplantation. 

Next: Comorbidities and complications

Medical Economics: Do HIV patients with comorbidities like HCV require more specialized care than PCPs can offer?

Kattakuzhy: Persons living with HIV/AIDS (PLWHA) require lifelong chronic care, both for HIV as well as its associated comorbidities, and many primary care providers offer HIV services as a part of their longitudinal care. PLWHA who are virally suppressed, on stable medications, without hepatic decompensation are ideal candidates for PCP-based HCV treatment. 

Medical Economics: What are some of the complications PCPs can expect from these two diseases working together and what should they watch for?

Kattakuzhy: People with HIV have a disproportionately higher prevalence of HCV infection. In the U.S., approximately 1 in 4 people with HIV are co-infected with HCV. Health outcomes for people with HIV/HCV co-infection are significantly worse than in people with HCV alone. HIV co-infection results in more rapid progression of liver fibrosis and a 2.92 relative risk of cirrhosis or decompensated liver disease compared to HCV mono-infected patients.

Medical Economics: What new modalities in medicine are leading to the drive to shift management of these types of patients out of specialty care and back into primary care?

Kattakuzhy: The development of direct-acting antivirals which are tolerable, short duration and highly efficacious has revolutionized HCV care. Interferon-based HCV treatment was highly toxic, with long administration times; as such, treatment was often outside the capacity of a typical primary care practice. Now, most patients can be cured with as little as one pill per day for 3 months. As such, this advancement can facilitate a decentralized shift towards primary care management for most patients with hepatitis C. In addition, the development of national consensus guidelines by the AASLD-IDSA have made hepatitis C workup and treatment easily accessible to all kinds of providers. 

Unfortunately, many payers still have provider-based restrictions around hepatitis C treatment, limiting access to specialist providers. {Our investigation] and work around the U.S. has demonstrated that these policies are not evidence based, and stand as significant impediments to the HCV care continuum.