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Expanding Access to Hepatitis C Screening and Treatment in the IHS Portland Area

by David Stephens, BSN, RN and Jessica Leston, DrPH, MPH, Portland Area Indian Health Board

Hepatitis C virus (HCV) is a chronic infection and a deadly disease. If HCV is left untreated, the virus slowly destroys the liver. The American Indian/Alaska Native population is disproportionately affected by hepatitis C virus (HCV). The most recent national data show American Indian/Alaska Native people with both the highest rate of acute HCV infection and the highest HCV-related mortality rate of any U.S. racial/ethnic group. In the Northwest from 2006-2012, the American Indian/Alaska Native HCV-related mortality rate was over three times that of non-Hispanic whites. This disparity has persisted over time, demonstrating the need for access to treatment for American Indians and Alaska Natives in the Northwest.

HCV has historically been difficult to treat, with highly toxic drug treatments and low cure rates. In recent years, however, medical options have vastly improved. These new medications have high rates of achieving sustained response with few adverse effects. These advances represent a major shift in treatment options for HCV and have the ability to reduce HCV-related deaths.

Unlike those infected with hepatitis A and hepatitis B, most people infected with HCV, approximately 80%, have chronic disease. Chronic hepatitis C is a lifelong infection that's characterized by the presence of the virus in the blood, and most importantly by a slowly progressive inflammatory condition in the liver that eventually leads to fibrosis, and possibly liver cancer. Curing a patient of HCV greatly reduces the risk of liver cancer and liver failure. New drug regimens have made early detection and treatment of HCV critical.

As a result, IHS created an updated sample policy Exit Disclaimer: You Are Leaving  for I/T/U facilities to provide a range of HCV services at the primary care level. Facilities are able to adapt this template as needed to reflect their local conditions and priorities.

In the Portland IHS Area, it is understood by all that by treating at the primary care level, we can begin to eradicate this disease. In 2017, the Secretary's Minority AIDS Initiative Fund awarded IHS and the Portland Area a grant to increase the HCV public health and clinical infrastructure for the 43 Tribes of Idaho, Oregon and Washington using the teleECHO model of care.

Project ECHO (Extensions of Community Health Outcomes) was designed to build primary care clinicians', pharmacists' and other staffs' capacity to treat chronic, common, and complex diseases through weekly teleECHO clinics called "Knowledge Networks." Clinicians present their cases through videoconferencing to specialists who provide advice and clinical mentoring. Working together and supplemented with short educational presentations (e.g., on HCV diagnosis and management) by interdisciplinary experts, the community-based providers and specialists manage patients following evidence-based protocols.

The Portland Area HCV ECHO was launched in January 2017 following a clinical training with providers from the Northwest and beyond. From January to July of 2017, the Portland Area’s ECHO, hosted in collaboration with the Northwest Portland Area Indian Health Board, has reviewed 63 patient cases from clinics in the Portland, Billings and Great Plains Areas. The Lummi Tribal Health Center is one of those clinics, who has developed a HCV program.

Primary care clinics note that a main barrier to implementing such a program is provider knowledge, comfort in prescribing the new medications and cost. A second opportunity to attend a free clinical training for national I/T/U facilities to provide a range of HCV services at the primary care level and address such barriers will take place this fall.

Related Content:
Hepatitis C Virus in Indian Country

David Stephens, BSN, RN and Jessica Leston, DrPH, MPH, Portland Area Indian Health Board

David Stephens is a RN Case Manager for the Northwest Portland Area Indian Health Board. He was born and raised in the Pacific Northwest and began serving the 43 NW federally recognized Tribes in 2008 working on the design and implementation of multimedia health resources.

Jessica Leston, DrPH, MPH (Tsimshian) is the HCV/HIV/STI Clinical Programs Director for the Northwest Portland Area Indian Health Board. She has been working in Indian Country for 13 years in various HCV, HIV, STI, adolescent health and quality improvement initiatives.