HCV Disease Burden in the US

CDC HCV Surveillance Report 2022: Reported Cases and Estimated Infections of Acute HCV

Dr Howard Lee (Baylor College of Medicine): So the CDC, just in their Annual Report in 2022, that it's actually the first year that we've seen the case of the reported acute cases. As you can see from the slide, this in year 2022 is actually the first year that the acute cases has decreased, despite we all know that the direct antiviral therapy has started, you know, available around the year of 2014-2015.

So I think it's a good thing to see that we finally see the going down of the estimated acute infections and actual reported acute cases.

[00:11:40]

CDC HCV Surveillance Report 2022: Documented Risk Behaviors or Exposures in HCV Acute Cases

However, if we look at the detail in the CDC report about the documented risks and behaviors or exposures in this acute hepatitis C cases, of course, we know that injection drug use has been, you know, still on the top of the reported risk. However, I also want to direct your attention to other risk behaviors and exposures, such as multiple sexual partners and men who have sex with men and some other sexual contacts also very top on the reported risk behaviors and exposures.

[00:12:22]

          HCV Prevalence Among Men Who Have Sex With Men

So this slide is – we're going to talk a little bit about what the actual hepatitis C prevalence among men who have sex with men. There is a study published in 2019—it's a meta-analysis—look at the global data and including 194 studies who have men who have sex with men between year 2000 and 2019.

And the pooled hepatitis C prevalence is 3.4%, with 95% confidence interval 2.8% to 4%. And I also want to discuss a little bit detail about the study, but it did show that in men who have sex with men that had living with HIV, their hepatitis C prevalence is even higher, up to 6.3% compared to those does not live with HIV.

Also, the other important finding, according to this study, is that people using HIV PrEP—sorry, the men who have sex with men who are using HIV PrEP—also have a much higher HCV incidence according to this study compared to those that do not use HIV PrEP.

Next, I'm going to have Tatyana going to talk us about the hep C prevalence among pregnant people in the US.

[00:13:52]

HCV Prevalence Among Pregnant People in the US

Dr Tatyana Kushner (Weill Cornell Medicine): Thank you, Howard, and thank you everyone for joining. So we also have had an increasing amount of data specifically about hepatitis C prevalence and incidence in pregnant people. And there now have been a number of studies done in the US and different regions in the US.

And what we see here on the left is a study that was published a few years ago and looked at hepatitis C, specifically among pregnant people over time. And what you see clearly here is that from 2009 to 2019, there's a significant increase of hepatitis C cases diagnosed in pregnant people. And specifically, we're seeing that the increase is seen in particular in nonHispanic White individuals. That's the graph on the right there.

And overall, per this study, hepatitis C and pregnancy went up from 1.8 to 5.1 per 1000 live births. Now, of course, this can and hopefully does reflect increased screening or testing for hepatitis C in the context of pregnancy, but also reflects a true increase in prevalence that we're seeing.

On the right is a study that was published earlier this year that looked just at a single tertiary clinic in Appalachia, and this is a region in the country with high hepatitis C prevalence, largely related to the opioid epidemic in that region. And in this particular study, they found that hepatitis C positivity among pregnant people was 12%, which is quite high. So over one in 10 people in this study had evidence of hepatitis C, suggesting that the pregnant patient population is a key population to be thinking about when we're talking about screening and intervention and, of course, linkage to care.

[00:16:00]

HCV Screening

So let's talk about hepatitis C screening and what are the current recommendations and practices around hepatitis C screening overall.

[00:16:12]

          Poll 4

So I'll start with a polling question. This is a free text question. You'll see a pop up on your screen. And the question is, at your practice site, wherever you practice, what barriers to implementing hepatitis C screening do you experience. And please enter just a free text response about any barriers that you have encountered in terms of actually implementing testing for hepatitis C?

Zachary Schwartz: And I think while people are moving on, you're free to move on to the next slide.

[00:16:54]

AASLD/IDSA HCV Guidance: Screening Recommendations

Dr Kushner: Great. Perfect. So these—I was too excited to move on. Let me go back one. Okay. So these are the current recommendations from the AASLD/IDSA. So this is the liver society and infectious disease society. And this is the hepatitis C guidance regarding screening.

So the clear recommendation is that universal hepatitis C screening is now recommended for all individuals at age 18 and over. And all individuals less than 18 with increased hepatitis C infection risk, which of course includes the adolescent subgroups of the adolescent patient population.

In addition, prenatal testing is recommended for hepatitis C for each pregnancy, so each pregnant individual should be tested for hepatitis C with each pregnancy.

Furthermore, periodic annual testing is recommended in individuals at increased hepatitis C infection risk. So annual hepatitis C testing is recommended for risk groups listed here. So that includes all persons who inject drugs. It includes HIV infected men who have sex with men, and it includes men who have sex with men while taking PrEP, which Howard was discussing in the beginning.

So I'll turn it over back to Howard to share a case.

[00:18:24]

Patient Case 1: Cisgender Man on HIV PrEP

Dr Lee: Thank you, Tatyana. All right, so that's back on our patient case one. So this is a cisgender man who is on HIV PrEP. He's a 32-year-old cisgender man who has sex with men, who has no known liver or other disease, returned to clinic for a PrEP refill.

So you asked a little bit more about the social history, and then the patient reported that being in an open relationship with his partner. He has engaged in unprotected anal intercourse with several men in the past years, and deny any IV drug use. He is on FTC and TAF for HIV PrEP.

[00:19:04]

          Posttest 1

So our question is, how often should you screen – sorry. Again, I'm also too excited. How often should you screen for hepatitis C in this case – in this patient? Again we talk about, you know, we as – so we want to ask your post-test one, according to the information that Tatyana was mentioning.

[00:19:33]

          Posttest 1: Rationale

So the – the correct answer is B, at least annual testing. So the patient that we mentioned should be screened for hepatitis C at least annually, because of the sexual behavior. And it is also important to discuss risk factors for hepatitis C infection. For example this case will be the unprotected anal intercourse. But we need to be mindful that we need to use a culturally sensitive approach when we discuss this with our patients.

[00:20:02]

AASLD/IDSA HCV Guidance: Activities and Other Conditions and Circumstances for HCV High Risk

Okay. So let's go back to the AASLD and IDSA hepatitis C guideline that Tatyana mentioned earlier. What other activities and other conditions and circumstances that can – was associated with higher risk of hepatitis C infection?

So the risk activities are: current or past injection drug use or intranasal illicit drug use, such as using nasal cocaine and/or use of glass crack pipes that can also increase the risk. And also, as we discussed, a man engaging in sex with other men that can also have been—has been identified as increased risk behavior as well.

And then chem sex, which is in some certain MSM population and also some straight population as well, that's also has been identified as an increased risk of hepatitis C infection.

There are other conditions and circumstances like also associated with higher risk of hepatitis C infection, such as HIV or hepatitis B infection, or as discussed in our case, the person that about to start HIV PrEP, again, some other chronic hepatitis and/or chronic liver disease, including unexplained ALT elevations, and our solid organ transplant recipients and donors. That can also have – that can also in the condition that's increased risk of hepatitis C infection.

[00:21:40]

Risk Factors for Sexual HCV Transmission

Okay. So this is another just to emphasize about especially in some of the MSM population, there are some risk factors and also including non-MSM population as well about the risk factor for sexual hepatitis C transmission. So I think oftentimes we forget about the possibility of sexual transmission for hepatitis C.

So they are several categories to kind of risk factor that we need to think about. First is the sex practices that can cause trauma to rectal mucosal tissue and rectal bleeding, such – such as receptive anal intercourse without a condom or receptive fisting.

Also sexualized drug use like we talked about earlier, chemsex or party and play or use substances such as crystal methamphetamine, mephedrone, gamma-hydroxybutyrate, or phosphodiesterase type 5 inhibitor before or during sex are also has been associated with increased risk.

Last but not least, if the person had presence of ulcerative and rectal sexual transmitted infections such as syphilis, lymphogranuloma venereum, and genital herpes. Those are also have increased as – has been identified as having increased risk for sexually hepatitis C transmission as well.

[00:23:10]

AASLD/IDSA HCV Guidance: HCV Testing and Prevention in Men Who Have Sex With Men

Now that's back to the AASLD/IDSA hepatitis C guidance again about hepatitis C testing and prevention in men who have sex with men. First of all, as we mentioned earlier in by Tatyana, that, you know, this group has been identified as high risk of hepatitis C infection. So the current guidance does recommend that test for hepatitis C annually for men who have sex with men. It's regardless of their HIV infection status.

We also do need to provide a patient counseling as well about the risk of sexual hepatitis C transmission, including their sexual and drug use practice, as we outlined in the previous slide.

Lastly, it's really important to educate our patients about hepatitis C infection or transmission and talk about prevention measures. But again, I want to remind everyone when we approach our patient, please, we do need to be aware of the implicit bias. And we need to have a very culturally sensitive approach as well.

Next I'm going to have – Tatyana is going to talk about hep C screening in pregnancy.

[00:24:20]

HCV Screening in Pregnancy

Dr Kushner: Great. Thank you, Howard. So we'll move on to specific recommendations around hepatitis C screening in the context of pregnancy and prenatal care.

[00:24:39]

          Patient Case 2: Pregnant Person Seeking Prenatal Care

Okay. So we will start with a patient case 2. So this is a case of a pregnant person who is seeking prenatal care. She's a 29-year-old female with a prior history of injection drug use. And she presents for prenatal care. And on presentation and testing, she's noted to have a hepatitis C antibody positive result on her prenatal panel.

In regards to her social history, she does report prior history of injection drug use and same sexual partner for the past few years. In regards to our medication, she's currently on a stable dose of methadone and albuterol inhaler as needed for asthma.

On the right, you see her bloodwork results and notably, her liver tests are normal, which is important to recognize that one of the key aspects of hepatitis C screening is there may not actually be symptoms or signs, such as elevated liver tests in people with hepatitis C, and this was an example of this.

And then in regards to her other testing, her hepatitis B panel is negative, meaning she does not have hepatitis B, and she's also not immune to hepatitis B, but she is immune to hepatitis A.

[00:26:00]

HCV During Pregnancy: Mother-to-Children Transmission (MTCT) and Other Adverse Outcomes

So why do we care about hepatitis C during pregnancy? Why is this a key population to have dedicated counseling and approach to management?

Well, there are a few different aspects that are specific to pregnancy, where hepatitis C is quite relevant. And among them are the issue of mother to child transmission of hepatitis C, but also the question of whether having hepatitis C in pregnancy can actually influence the health and outcomes of your pregnancy. So we're showing some data here about both of these aspects.

On the left is results from a meta-analysis published this year, which focused specifically on hepatitis C and pregnant people. And this was a global study that pooled data from a number of studies from around the world addressing hepatitis C in pregnancy. Overall, they did find quite a high prevalence of hepatitis C. There may be some bias there in terms of studies included. But when they looked specifically at the risk of mother to child transmission, they found that there's a risk of around 9% when they pull the data from all of these studies.

So to my knowledge, this is the most updated estimate of the risk of transmission from mother to child. And when we speak with patients, oftentimes the biggest concern in people who are pregnant is the health of their baby. And the risk of mother to child transmission is important to share in order for the patient to be informed about risk and consideration for possible interventions to decrease that risk, which we'll discuss later.

And then in regards to adverse pregnancy outcomes, there have been a number of studies that have looked at the association of having hepatitis C during pregnancy with pregnancy outcomes.

And on the right is a table from a study that we conducted using a large database in Canada, where actually what we looked at is specifically individuals who had active hepatitis C viremia during pregnancy, compared to those who may be hepatitis C antibody positive but were cured in the past, so were not actively viremic during pregnancy, to really try to get at what is the influence of having the virus present during pregnancy on pregnancy outcomes.

And what we found is that there was a significantly increased risk in those people with active hepatitis C during pregnancy of preterm pregnancy delivery, almost a 5-fold increase in the risk of a condition called intrahepatic cholestasis of pregnancy, which in turn is associated with negative outcome, potentially adverse outcomes in the fetus.

Also, we noted an increased risk of postpartum bleeding and intrauterine growth restriction. So this study, among others, suggests that having hepatitis C during pregnancy can be associated with worse pregnancy and neonatal outcomes.

[00:29:27]

          Importance of Identifying HCV in Pregnant People

So those are 2 of the reasons. And here are a few other reasons listed here about the importance of identifying hepatitis C in pregnant people. It's important to note that oftentimes the pregnancy encounter or prenatal care is the initial or the only encounter with the healthcare system in individuals who are otherwise – of childbearing age, who are otherwise healthy and may not seek care or have a regular primary care follow up, for example.

So this is a reason where – for that, it's really important to screen in this context and then link to care because you may not see them again encountering the healthcare system after the pregnancy care period.

In addition, it's important to counsel individuals who screen positive for hepatitis C in pregnancy or are known to have hepatitis C prior to pregnancy, about the risk of the adverse pregnancy outcomes and risk of mother to child transmission that I mentioned in the prior slide.

In addition, identifying hepatitis C in pregnant people can help to diagnose children early, so if there is transmission to the infant, then it is imperative to test the child—to test the infant, to determine if transmission occurred and then subsequently, if it did, link those children to treatment for hepatitis C.

And quite important is the idea of linkage to care. So if we are screening during pregnancy and identifying hepatitis C, we need to have systems in place to make sure that we link individuals to treatment of their hepatitis C, whether it is during pregnancy, as we'll discuss later, or more commonly, postpartum.

[00:31:24]

          Timeline of HCV Screening Recommendations During Pregnancy in US

So as a result of all of these considerations, there has been consensus, really, among all the major societies over the years about the importance of universal screening in pregnancy. Previously, the recommendation had been for risk-based screening, meaning only screened pregnant individuals if they have reported known risk behaviors.

But over the years, as you see here, guidelines have been updated to recommend universal screening. Back in 2018, the AASLD/IDSA initially made the recommendation, but after that there really was not too much uptake because really, most of the care of individuals who are pregnant occurs in the obstetric care setting. And so really it took a few years after that for the American College of Obstetricians and Gynecologists and the Society for Maternal Fetal Medicine to also make these recommendations, which also were endorsed by the CDC and USPSTF.

And now there's a clear consensus that there should be universal screening for hepatitis C during each pregnancy, regardless of risk factors.

[00:32:37]

          HCV Screening in Pregnant People: How Are We Doing?

And it's one thing to make a recommendation for screening, in particular in populations such as the pregnancy population. But it's quite another to implement, and I think we'll get to this in the discussion when we talk about potential barriers to implementation.

And this is data that now is published in, you know, a few years ago in 2022, but it looked at actual implementation of hepatitis C screening in the prenatal care setting. And this was a study that looked at Quest laboratory data. National look on – in terms – to evaluate who incorporated hepatitis C testing in their prenatal care panels.

And what you see here is that there has been an increase in hepatitis C screening in pregnancy, especially around 2020, 2021, when guidance began to be updated. But still, as of 2021, it was really less than half who were screening for hepatitis C in pregnancy.

I do think that probably by now and I hope the rates are higher. But clearly the study showed that there was still room to go. And the authors concluded that despite progression in pregnant persons screened for hepatitis C, current testing rates fall short of universal recommendations.

[00:34:12]

HCV Screening: How To

So now I'll turn it back to Howie to discuss how do we actually screen and what are best practices for hepatitis C screening.

[00:34:20]

CDC: HCV Testing Algorithm

Thank you, Tatyana. Now we're going to talk about a hepatitis C test algorithm. And some of you may be very familiar with this. So, you know, now currently our first step is checking for hepatitis C antibody. If it's negative, it's nonreactive, then no further test is needed. But if the person has hepatitis C—positive hepatitis C antibody, then we'll do a hepatitis C RNA. And ideally it should be a reflexive testing.

If there's no hepatitis C RNA detected, then that meaning that the person does not have current hepatitis C infection and the person had prior hepatitis C infection. However, if the person has a positive hepatitis C RNA, that meaning the person has currently hepatitis C infection. And then, then we need to link this person to hep C care.

[00:35:13]

The Long Journey to an HCV Diagnosis . . .

However, we all know that from diagnosis to treatment there has been a – it could be a long journey for some of our patients. So, you know, this is a – this is a cartoon about a more like a traditional hep C care pathway. So, you know, the patient comes in, visit 1 to see a provider that found to have anti – hep C antibody, and then they need to go get the lab test. So it will be a visit to with the phlebotomist and get the testing.

And the antibody test may take a while to come back. You know, up to 1 to 2 weeks sometimes in different places. And then the – the – the provider will receive the diagnosis at visit 3. And then they need to order more testing to confirm the RNA as we talked about, so the patient needs to have another visit with phlebotomist. And then we need to wait for the result of RNA coming back. And then finally get the diagnosis and make the treatment plan.

So as you can see, there's a lot of, you know, steps in this traditional pathway in terms of hep C diagnosis and treatment. So this was considered one of the major barriers to hep C elimination is loss to follow up because patient – if patient loss follow-up any of this step, the patient will not receive the hep C treatment.

So now there's, you know, a lot of discussion. Now we have really good treatment for hepatitis C now. So a lot of discussion, you know, gearing towards to the potential role of reflux nucleic acid testing and point-of-care testing. And we're going to have some discussion in our talk today as well.

[00:37:07]

          POC HCV RNA Testing

The – now the point of care hep C RNA testing. I'm going to talk a little bit more about that. It's – it does allow for diagnosis and treatment in one visit. It's – it has been – in some pilot study has been implemented successfully in various settings, such as correctional facilities such as prisons, mobile clinics, community clinics, needle syringe programs and overdose prevention sites.

And compared to the standard of care testing that we show on the last slide, this point of care is testing associated with first reduced time to treatment initiation, and second, increased treatment uptake, and third, reduce loss to follow up.

And then this as a potential very powerful tool, especially when we think about our marginalized communities, such as men who have sex men – with men that we talk about today. So a very exciting update is in June 2024, just several months ago, the point of care hep C RNA testing is approved.

And again, it's automated finger stick PCR test. The turnaround time is within an hour. So we think this will become a very powerful tool moving forward for hep C elimination, especially in MSM and a lot of marginalized communities as well.

[00:38:39]

          HCV Testing in Nontraditional Sites

So there has been studies looking at the hep C testing in the non-traditional sites. So for example, this study was done in also in the South Appalachian region of the US recently between 2017 and 2019 look at non-targeted hepatitis C screening and linkage to care programs developed in ten different institutions in that area, such as emergency room, medical clinics, health department clinics, syringe exchange programs, correction facilities, and FQHCs.

As you can see, there's still a very high positive rate of hepatitis C positive screening in all – in all these facilities. And the linkage of care can also be—a lot of—the linkage the rate of linkage of care is also can be pretty high in a lot of the settings.

So that kind of, you know, gives us confirm us that we – you know, in order to achieve the hep C elimination goal, I think it's really important to go outside of the traditional sites. And I think there's a lot of outreach need to be done, as shown by this study.

[00:39:58]

Testing for HCV Reinfection in Men Who Have Sex With Men

Now we're going to talk about testing for hepatitis C reinfection, especially in men who have sex with men. Why this is important in this population? Because study has shown that there's high hepatitis C infection rates reported after hep C treatment and cure among HIV infected men who have sex with men. It's around 7.3 to 15.2 per 100 person years.

And then for sexually active men who have sex with men after successful treatment or spontaneous clearance of hep C infection, we do still recommend test for hep C at least annually and risk based if indicated, if your patients have very active, unprotected sex as we talk about and/or other substance use, then this can also – this frequency might need to be increased as well.

If the patient – of course, if the patient already got treatment, then hepatitis C antibody is no longer a test that we can use for test for reinfection, then we need to use hep C RNA testing in – in – in this scenario.

[00:41:17]

HCV Prevention for Men Who Have Sex With Men

Now I'm going to have Andrew. He's going to talk us about hep C prevention for men who have sex with men.

Andrew Reynolds ( San Francisco AIDS Foundation): All right. Thanks, Howard and Tatyana. That was a great summary of hepatitis C screening and options for MSM and pregnant folks.

So just really quickly, one of the roles that we – I play as a health educator, patient advocate, whatever – whatever we want to call is around the education around hepatitis C prevention, especially for men who have sex with men.

I think there's a really key role that health educators, peer navigators, allied health professionals, whatever you want to call us can play in educating folks around all the stuff that we've been talking about thus far.

So I think really kind of elevating awareness around the things that make us more vulnerable to hepatitis C. So condomless anal sex. You know, we – we know that hepatitis C can be transmitted from blood-to-blood contact. And so during anal sex, there could be tearing and bleeding. And that also applies to anything that could like lead to “rectal trauma”, fisting, vigorous sex toy play, long periods of sex, sometimes with drugs or without drugs that could lead to more friction and more tearing and more bleeding.

And so talking to people about harm reduction techniques and sexual practices, staying hydrated, increasing condom use, wearing gloves for fisting, switching out condoms on sex toys and that type of play. All of those things would create a barrier that would prevent hepatitis C infected blood from getting into a person during sex.

I think it's also important to highlight the work of Dan Fierer. We don't have a slide on that, but Dan and his team found infectious levels of hepatitis C in some men who have sex with men who are living with HIV and their semen and in their nonbloody rectal fluids. So making sure we educate folks around that as well. This is especially important for PrEP, right? Like we have PrEP to prevent HIV. We don't have a PrEP for hepatitis C, we don't have a PrEP – a PEP for – for hepatitis C. So educating folks around that.

And then I think, you know, an understanding about the relationship of – of sexualized drug use, knowing how to refer people. SBIRT, the brief screening referral and treatment is a really nice way to kind of address substance use quickly and effectively.

And then knowing your harm reduction services in the area, your syringe service programs, are there places that distribute crack pipes or crystal meth pipes and that type of thing, as well as linkage to drug treatment programs, both inpatient and outpatient.

[00:44:28]

Faculty Discussion

So next up, we'll have a little discussion with the faculty. And we have a few questions, some of which we've asked you.

[00:44:35]

          Discussion

I'll give a quick summary of the first one. If I can get my – so I thought we – an easy way to kind of get – get rolling on this is to talk about some of the barriers to hepatitis C screening. A selection of answers from our audience. Not enough staff time, limited appointment availability, competing priorities. I definitely feel that one.

Stigma and privacy concerns. Stigma around hepatitis C is an absolute barrier for people to talk about testing. Lack of knowledge from providers and patients. That's definitely something that comes up. Costs, lack of insurance, limited availability of the rapid test. And then this one's a big one too, an inability to refer to treatment. You test somebody, they're positive, how do I – how do I hook somebody up to primary care?

So what do you – Tatyana and Howard, what do you guys think about some of these barriers and how your clinics have overcome them?

Dr Kushner: I think that it's a great summary, actually. Those really do seem the – like the key barriers. I think in the obstetric care settings – I mean, all of them do apply, but one important one especially I think is the idea of referral to treatment. So, you know, if we diagnose someone with hepatitis C during pregnancy, what are the options for treatment? Does it have to wait until after pregnancy? Can we consider it during pregnancy? And more importantly, who will be doing the treatment?

So if – we are screening. There has to be a very clear pathway within the healthcare system or whatever other setting to make sure that we know what the next steps are. Otherwise it, you know, puts kind of this responsibility on the person who's screened and puts them in a position where they don't know what to do next.

I think that's really a key one to make sure that if – once you implement screening to have a clear pathway in place to link to care.

Dr Kushner: I do – yeah, I – I agree with Tatyana. And I think in the MSM kind of settings that I think one of the key factors that I identified is actually some of the, you know, more LGBTQ focused primary care providers, there are probably some of them might not be familiar with the – the repeat testing annually that guidance from the IDSA. And so as we discussed because, you know, that's kind of connected historically, hepatitis C was not considered a sexually acquired infection.

So you know – and sometimes when we kind of forget about it that we need to test for that, especially like Andrew nicely described, you know, in certain MSM population with their sexual practice that does have a higher risk. So I think from the MSM settings, I think the education for both providers and patients are very important to.

Andrew Reynolds: Excellent, excellent. How about we move to the last one, the potential role and barriers to point of care testing in HCV RNA testing?

Dr Kushner: So I think that that's a really exciting field. As Howard mentioned, just this year, it was officially – this point of care testing was officially approved in the US by the FDA, which is a big step towards actually implementing. And I think similarly to what we said about screening, also, specifically with point of care testing, one thing is the approval and the next thing is where and how will you implement it effectively to actually help you work towards the goal of hepatitis C elimination?

I think that internationally, for example, in Australia this has been done very well, but in the US it's – it's new. And so I think this year we'll be learning a lot about different practices and their experiences of implementing it. And there are specific settings that I think that this will be a game changer. And then there are other settings where it may not make such a big difference, such as, for example, in the obstetric care setting, typically there are frequent touchpoints with the healthcare system anyway, so there may be less of a role for just a one-time touchpoint for hepatitis C diagnosis. But perhaps in some settings there will be.

Dr Lee: Yeah, I do think for – in terms of MSM population, I think this is an amazing tool and going to be a very powerful tool that I can foresee. As you – a lot of you guys probably are aware that in MSM populations, there has been HIV point of care testing and has been used, and that's actually accepted by a lot of MSM populations, and in some of them even have the kit in their home.

So, you know, I think adding this hep C point of care testing, I think it's – since a lot of them – a lot of our MSM group already have experience doing point of care testing, and so I think this will help, you know, the providers and patients testing more for hepatitis C and then that will – you know, I'm also very excited about this. And I can see that will improve the hep C elimination, especially in this subgroup of people.

Andrew Reynolds: Yes. I'll add. I do hep C testing and treatment at a syringe program and a sexual health clinic here in San Francisco. And I have dreams of rapid testing somebody, antibody positive, running a point of care RNA test, during that hour doing health education, collecting, locating information, health insurance information, and then eliminating that 1- to 2-week period waiting time to get that RNA test, so we can move faster on linkage to care.

Dr Kushner: And there's actually 1 question in the Q&A which is directly touching on this. Actually, 1 person asked, do you see insurance providers denying typical screening through point of care testing for hepatitis C? So maybe, Andrew, do you see that this may be a problem in the foreseeable future about denying the point of care testing?

Andrew Reynolds: I hope not, and I know there's a lot of people like National Viral Hepatitis Roundtable and other advocacy organizations who are working really hard to make sure that that doesn't happen. And if we are going to be committed to eliminating viral hepatitis, I think this is going to be an essential tool. And there seems to be a significant amount of buy in federally to – to support this. And I think that will trickle down to the rest of us.

Dr Kushner: I hope so as well. And I see other questions in the Q&A, but maybe we'll save them then for that to the end and address them and get back to our presentation.

[00:51:46]

          Key Take-home Points: Screening

Yeah. Let's – and let me wrap up with some key take-home points for everyone. So, you know, in the first part of our seminar today, we talk about screening. So that some – I just want to highlight some key take home points.

First of all, sexual and reproductive clinics should provide hep C screening and linkage of care. We should test for hepatitis C in all adults at least one time. For people who use drugs, HIV infected men who have sex with men and men who have sex with men receiving PrEP will recommendation – our recommendation is at least annually testing. For pregnant people, we should test for each pregnancy. For individuals at increased risk, we should also consider testing periodically.

And to improve our hep C screening, we should consider screening at non-traditional sites, including the reproductive health clinic and pregnancy clinic, as we talk about. Also use of reflex RNA or point of care hep C RNA testing as discussed in the last session. Also addition of hep C testing to prenatal screening panel has been shown to be an effective intervention as well.

Lastly, after SVR, sustained viral remission is achieved, screen at least annually for reinfection – reinfection, especially in those with ongoing risk, is also important, as we discussed earlier.

[00:53:13]

          Posttest 2

Now we're having posttest 2. Going forward for sexually active men who have sex with men who have been successfully treated for hepatitis C, I will test for hep C reinfection at least annually. And please tell us your answer. Okay.

Zachary Schwartz: Let's leave the poll open a little bit longer. I want to make sure we get lots of votes here.

Dr Lee: Yeah. Please tell us what you think.

Zachary Schwartz: Okay. I think we have enough here. We have well over 100 so we can close the poll and show the results.

Dr Lee: Sounds good. So our results show 63% strongly agree and 23% agree. So that's a total of 86% agree. We do have 10% of the patients that strongly disagree. And we can certainly talk about that if you have any special concern or questions, please welcome to put in the chat and we'll try to address in the last Q&A session as well.

[00:54:25]

HCV Treatment

All right. So now we're going to talk about hepatitis C treatment.

[00:54:29]

          Poll 5

We have another question poll here. At your practice site, what barriers to hep C treatment do you experience? And this is an open ended question, so please type a short answer in the chat box that appear on your screen.

Zachary Schwartz: And while people are typing this in, I think we can move on to the next slide.

Dr Lee: Sounds good, Zachary.

[00:54:54]

          HCV Goals of Treatment

So we're going to talk about hep C goals of treatment here. As we know, that goal of hep C treatment is sustained virologic response or virologic cure you may – you may say, which is continued lack of detectable hep C RNA for more than 12 – equal or greater to 12 weeks after therapy completion.

Fortunately, and now we have really, really good treatment or enrichments associated with up to 99% of SVR rates after 8 to 12 weeks of treatment, which is similar rates among people who use drugs.

Based on the USPSTF evidence review, sustained viral response associated with decreased risk of liver-related mortality, hepatocellular carcinoma, liver cancer, and all-cause mortality. So this is a really important outcome we're trying to achieve with our treatment – with treatment of hepatitis C.

[00:55:55]

AASLD/IDSA HCV Guidance: Simplified Treatment for Treatment-Naive Adults Without Cirrhosis

All right. So now I'm going to just briefly go over the AASLD/IDSA hep C guidance – guidance for simplified treatment for treatment naive adults without cirrhosis. So the eligible patients including adults with chronic hep C, any genotype and no cirrhosis and no prior hepatitis C treatment, and a patient – but patient who have any of the following characters will not be eligible, including prior hep C treatment, cirrhosis, hepatitis B surface antigen positive, current pregnancy, non or suspected HCC, liver cancer and prior liver transplantation.

So if the patient was – is eligible for this simplified treatment, the recommend regimen including glecaprevir/pibrentasvir, they need to be taken with the food and the duration is 8 weeks. The other option you can have is sofosbuvir and velpatasvir. The duration is 12 weeks.

[00:57:02]

AASLD/IDSA HCV Guidance: Simplified Treatment for Treatment-Naive Adults With Compensated Cirrhosis

For people that with compensated cirrhosis, if they have no prior hep C treatment, they are also eligible for a simplified treatment if they are treatment naive. So – but we need to notice that there's – if they have any of the following, they will not be eligible for this simplified treatment pathway.

If they have present or past decompensation from their cirrhosis or they have, you know, end stage renal – end stage renal disease, they have surface – hep B surface antigen positive, current pregnancy, known or suspected liver cancer or prior liver transplantations, as we discussed earlier, those people are not eligible.

So the recommend regimen if there are genotype 1 to 6 are glecaprevir/pibrentasvir, need to take in with the food with duration of 8 weeks the same duration, if they are genotype anything but genotype 3. So if they have genotype 1, 2, 4, 5 or 6, the – you can also use sofosbuvir and velpatasvir. Duration will be 12 weeks.

If the patient with genotype 3, you need to do baseline NS5A RAS testing, if required – it's required. If without Y93H can receive this treatment as well.

[00:58:26]

Back to Patient Case 1: Cisgender Man on HIV PrEP

So that's back to our patient case 1, our cisgender man who is on HIV PrEP. So the patient was found to be hepatitis C antibody positive and the hep C RNA reflexive test returned. The patient have a positive RNA, with a viral load of 5 million international units per milliliter. Other hepatitis testing, including a hep B surface antigen and hepatitis A IgM or negative. Other serology for autoimmune liver disease were negative. The patient's AST, ALT are both elevated at AST 220 and ALT 350.

The total bilirubin is normal and the CBC is normal.

[00:59:11]

          Poll 6

So here comes our questions. For this patient, should you recommend starting hepatitis C treatment? And our option including:

1. No, you should order hepatitis C genotype testing before starting treatment;
2. No, you should order RS testing before starting treatment;
3. No, you should recheck hep C RNA again in 2 months to allow for spontaneous clearance; and
4. Yes, you should start DAA treatment now.

So please select your answer on the box that pop up on your screen. We'll give – we’ll allot a little bit more time.

All right. Do we have enough?

Zachary Schwartz: Yeah, I think we do. Yeah.

Dr Lee: That's great. Okay. Let's see what people think. So almost half of people say they want yes. They both – yes, and start DAA treatment now. The second most popular vote is option A, no, we should order HCV genotype testing before starting treatment. They are around the same amount of people vote for B or C.

[01:00:42]

AASLD/IDSA HCV Guidance: Treatment Among Men Who Have Sex With Men and HIV/HCV Coinfection

All right. So the correct answer we’ll – we'll talk about it in a little bit. But I want to mention about the – what is said in the guidance, the AASLD/IDSA HCV guidance.

So why is it important to treat for hepatitis C for – in the men who have sex with men. It's not just for individual benefit. It's actually also to prevent hep C transmission in this group of people. Men who have sex with men and who have HIV hepatitis C co-infection are an important population for hep C elimination through treatment as prevention.

So efficacy of hep C treatment as prevention in this population is supported both by modeling studies and real world data.

[01:01:29]

AASLD/IDSA HCV Guidance: Treatment Among Men Who Have Sex With Men and HIV/HCV Coinfection

And the next slide, I'm going to – well, before we move on next slide, I do want to mention to everyone that simplify hep C treatment is effective in people with HIV on antiretroviral therapy, as we show earlier slide, having HIV in – even people with HIV, they're still qualified for simplified approach for treatment for hepatitis C. But we need to require awareness of potential drug-drug interactions.

There's a very helpful resources I usually share with my colleagues and patients, too. It's a Liverpool HEP Interactions, and you can access this database through this link shown here.

So, you know, before you start treatment, that's something that, you know, I would recommend everybody look it up.

[01:02:17]

          HCV Treatment as Prevention Among Men Who Have Sex With Men: Real-world Analysis

All right. So let's go back to the treatment of acute hepatitis C in the MSM population. What are the real world data showing. So this is one of the more well-known study regarding this. It's – in – by – they did show, according to this study, the 50% decrease in acute hepatitis C infection – incidence actually was noticed from your – compare to, you know, the one that without treatment.

So as you can see, acute hep C in 2014, there is – the incidence rate is 1.1% per year. And then after the universal DAA access and screening in this population, that decreased to 0.55% per year. So this real world study did show that, you know, treatment as prevention in the – especially in the MSM population for hepatitis C.

[01:03:27]

          HCV Care Continuum: Interventions to Preserve Benefits of HCV Cure

Lastly, I'm going to do a quick summary about the HCV care continuum. The intervention to preserve benefit of hep C cure. So first of all, we talk about diagnosis extensively in the first part of our talk. And we also talk about linkage of care. And then during this period as a provider, I think we do need to talk about – we need to consult our patient on transmission and infection risk. We need to linkage to not just for hep C care. Also need to link it to harm reduction according to each risk profile of the patients, especially for men who have sex with men, drug use screening, brief intervention, refer to treatment as needed, talk about condoms, as Andrew mentioned, behavior intervention as well.

And once the patient in treatment receive and cure. Post cure, care is also important because we talk about there's a higher risk of infection in this group. Also linkage to harm reduction as we mentioned earlier and linkage to hepatology care. I do want to mention especially for people that have F3 or F4 fibrosis, the HCC surveillance, the liver cancer surveillance will need to be continued in this group of patients.

In all men who have sex with men, as we discussed earlier, the reinfection surveillance annually at least is also recommended.

[01:04:55]

HCV Treatment in Pregnancy    

All right. Now I'm going to give – have doctor – have Tatyana talk us about hep C treatment in pregnancy.

Dr Kushner: Great. Thanks so much, Howie. So I think the guidance for hepatitis C treatment and pregnancy is a little bit less clear cut. But I'll show you where we are currently in the field and really what are the considerations for hepatitis C treatment in pregnant people.

[01:05:23]

          Poll 7

So we'll start with a poll question. How likely are you to recommend hepatitis C treatment in a pregnant person? Are you:

1. Extremely unlikely;
2. Unlikely;
3. Neutral;
4. Likely; or
5. Extremely likely to recommend hepatitis C treatment in a pregnant person.

So please vote.

Zachary Schwartz: And people voted really fast. I think we can close the poll. Okay.

Dr Kushner: Okay, great. So I think this spread really reflects our unclear guidance really regarding treatment. But if you look there are 21% and 27% who are likely or extremely likely to recommend hepatitis C treatment, and then 12% and 18% who are extremely unlikely or unlikely, and then 22%, about a fifth who are really neutral in regards to thinking about offering treatment of hepatitis C in pregnant people.

[01:06:28]

HCV Recommendations for Pregnant Persons

So what are the current recommendations from the official guidance panels? So these are the recommendations listed here. On the left, you see the text from the AASLD/IDSA guidance. And what it says is that despite the lack of a recommendation, treatment can be considered during pregnancy on an individual basis after a patient physician discussion about the potential risks and benefits.

So this guidance really points to the importance of joint decision making in this setting in order to determine whether to proceed with DAA treatment during pregnancy. Furthermore, women who become pregnant while on DAA therapy should discuss the risks versus benefits of continuing treatment.

So in this context, there may be a discussion which is probably the only context where we have the discussion of potentially not continuing treatment once someone becomes pregnant, if they are already on treatment.

What does the society for Maternal Fetal Medicine say? They say that we recommend that DAA regimens only be initiated in the setting of a clinical trial during pregnancy, and that people who become pregnant while taking a DAA should be counseled in a shared decision making framework about risks and benefits of continuation.

So I would say this guidance is a little bit less supportive of treatment, stating that really, if you are to consider treatment, it should be in the setting of a research trial where perhaps there's closer monitoring and follow up of patients on these medications.

[01:08:08]

          Back to Patient Case 2: Pregnant Person Seeking Prenatal Care

So back to patient case 2. This was our pregnant person who was seeking prenatal care. Confirmatory hepatitis C RNA testing did return positive, and because the patient was not immune based on the hepatitis B serology, hepatitis B vaccine series was initiated. And now she asked about recommendations on managing hepatitis C during pregnancy.

[01:08:38]

          DAA Treatment During Pregnancy: Pros and Cons

So when we think about the idea of offering DAA treatment during pregnancy, in the absence of clear guidance, as we just saw, we really need to consider the potential benefits and – and maybe potential downsides of offering hepatitis C treatment during pregnancy. The potential benefits on the left here is that we can offer maternal cure while the individual is actively engaged in pregnancy care and healthcare. So use this opportunity to actually cure the individual of their hepatitis C.

Furthermore, there is a potential that if we cure the hepatitis C, we can decrease the risk of mother to child transmission and potentially improve pregnancy outcomes, if – what we've seen earlier shows that having hepatitis C actually may increase the risk of pregnancy related complications.

Furthermore, you can offer treatment while there is insurance coverage. Pregnant people have insurance coverage and may lose insurance coverage after pregnancy delivery. So this is a time where they have coverage and you can treat. And of course, from a public health perspective, treat the person in front of you in order to decrease community transmission.

However, there are individuals that are not in favor of treatment and pregnancy. And that's because if we are to treat in pregnancy, we want to make sure that human safety and pregnancy is clearly established and also safety during breastfeeding is established.

Furthermore, we do have availability of DAA treatment for children starting at age 3. So some would say why offer treatment during pregnancy? Even if there is mother to child transmission, you could just treat the child later. And also, the question of cost effectiveness always comes up when we're thinking about implementing new interventions or treatments.

[01:10:33]

          HCV Treatment in Pregnancy: Patient and Provider Perspectives

In addition, it's important, especially if we're incorporating joint decision making in deciding about DAA treatment and pregnancy to understand the patient and provider perspective. And we do have some data on patient and provider perspective on hepatitis C treatment and pregnancy.

A few years ago, back in 2018, we conducted a survey of women with hepatitis C, and they were women who were being seen at UCSF and also women enrolled in the Women's Interagency HIV study.

And we asked them whether they would be willing to take DAA treatment in pregnancy. And this was really before we had any data on DAAs in the context of pregnancy. And actually even back then, 60% said that they would take DAA treatment if it lowered the risk of mother to child transmission. So again, the priority here was to optimize the child's health and to decrease the risk of child – transmission.

A lower number said they would take DAA treatment if it provided self-cure, but did not offer benefit in the way of decreasing vertical transmission.

And then more recently, there was a study done by Ravi Jhaveri and – and colleagues actually performing a qualitative investigation of obstetricians and patients to understand the themes in – in regards to their considerations for hepatitis C treatment in pregnancy.

And as what you – as you can see here, obstetricians and people living with hepatitis C had different considerations, but there was some overlap in their thought process about treatment in pregnancy, which included cost and access of DAAs in pregnancy, insufficient obstetrician knowledge regarding hepatitis C treatment during pregnancy, and always the priority here is the question about safety. Whenever we offer any medication during pregnancy, we want to make sure that it is safe.

[01:12:35]

HCV Treatment in Pregnancy: Available and Anticipated Data

And what is the data that we currently have? So I mentioned back in 2018 when we did that initial survey, we really didn't have any data. But fortunately since that time we have had accumulation of data specifically of DAA use in the context of pregnancy. And this is actually quite rare because there are not many conditions where we specifically study medications in the context of pregnancy.

Oftentimes we just extrapolate and view – use medications in pregnancy that may have never been studied specifically in the context of pregnancy. But this is the data that we currently have. We have 2 phase I studies that have been completed, one using sofosbuvir/velpatasvir and one using sofosbuvir/ledipasvir.

And both of these studies have shown that all of the individuals who were treated in pregnancy and second and third trimester of pregnancy, who completed follow up, had SVR12. So they had cure. And really no signal towards adverse outcomes in the infants.

And now there's a huge effort that is currently underway, which is the STORC trial. And this is a phase IV study which evaluates the use of sofosbuvir/velpatasvir in pregnant people, with the goal to recruit 100 individuals for treatment in pregnancy in this study, and really to accumulate the level of data that would allow both patients and providers to feel comfortable with the use of these medications in pregnancy in regards to safety and, of course, efficacy.

In addition, there's a study that will be starting soon that is also looking at the other main regimen, glecaprevir/pibrentasvir during pregnancy. So really at this point, we are accumulating data on both of the main regimens in the context of pregnancy in order to inform guidance.

Furthermore, there is a registry that is currently online, which is called the Treatment and Pregnancy for Hepatitis C registry, TiP-HepC. It was started by the Coalition for Global Hepatitis Elimination. And the goal of this registry is actually to accumulate real world data on DAA exposure in pregnancy so that we can accumulate data both from clinical trials as well as the real world.

[01:14:57]

          HCV Treatment in Pregnant People: Colocated Approach

In addition, some practices have implemented hepatitis C treatment in pregnancy. This is data from our own practice where we have been offering hepatitis C treatment in pregnant people with joint decision making, as recommended by the AASLD/IDSA guidance.

And it shows our early results where we ended up treating 7 individuals during pregnancy. And we found that 6 of 7 who came to SVR12 visit did achieve SVR.

However, really a big learning point here was that there was a huge drop off in the postpartum period in terms of engagement and care. So many people did not show up for their SVR12 visit because they were lost to follow up, really emphasizing the importance of the protocols in place to make sure that people are engaged in care not just during pregnancy, but also in the postpartum period.

[01:15:58]

          HCV Management Postpartum: Strategies to Improve Linkage to Care

And there are different strategies that have been looked at in order to improve this engagement in the postpartum setting. There's some data that suggests that among pregnant people with hepatitis C receiving medication for opioid use disorder. So the high risk population only, one third start on hepatitis C treatment and less than 10% are linked to care in the 6 months post delivery. And a few programs that are shown here have really tried to improve these rates of linkage.

The study on top was a retrospective study of over 300 pregnant people with hepatitis C, and they provided mother-infant linkage to care and co-located care, and found that they had a significantly increased likelihood of linkage to care and hepatitis C treatment initiation in this collocated care model.

In addition, patient navigation programs can be very helpful in this setting, where a navigator can have frequent touchpoints with the patient to make sure that they're linked to care, particularly in this postpartum period.

[01:17:03]

          Strategies to Improve Medication Adherence

So now I'll turn it over to Andrew. Of course, it's great that we are recommending a treatment, but how do we really optimize adherence to hepatitis C treatment?

Andrew Reynolds: Thanks, Tatyana. Yeah. Pills don't work if we don't take them. And the better we take our pills, the better the treatment and cure outcomes are. And, you know, these hepatitis C meds are actually a little bit forgiving for a missed dose here and there. But we want to encourage our folks to get as close to 100% adherence as they can. Very complicated, very few people – you know, we forget these things happen.

So I think working with folks and again, this is another key role that a health educator or a peer can – can play in your practice. Checking in with somebody about their routines. Every morning I brush my teeth, I'll keep my pill bottle next to my toothbrush or those med assets, pill boxes, those types of things are really, really good. So that I know, okay, it's Monday. Here's my pills. Tuesday, pills. Wednesday, wait a minute. I didn't take Tuesday. That way you can kind of see if you missed a dose and keep going.

Keeping your meds visible, if that's an option for you, is a really key and a good thing to do. Again, it's kind of that routine. Every morning I make my coffee, put the pill bottle next to the coffee maker. For folks who have access to technology, cell phones, smartwatches, what have you, using apps, using reminders, that's also a really nice way to kind of keep you going.

Side effects for these meds tend to be, you know, mild and much easier than certainly the earlier treatments for hep C, but still preparing somebody for this. Like there might be a little bit of nausea. There might be a little bit of gas and stomach upset. Letting a person know about that so they're aware of it and how they can kind of mitigate some of those side effects will help – help them get through that little stretch.

Following up, you don't have to check in regularly. We have some folks who come to our place and take a pill daily. We have medication lockers really helpful for our unhoused folks. But having, you know, a nurse follow up within the first week or so. Hey, how's it going on your first week taking these meds, that type of thing.

And then I think being mindful of pill burden and maybe treatment length. Maybe I'm freaking out about too many pills. So one pill for 12 weeks. I'm good with that. Or maybe 12 weeks freaks me out. Three pills for 8 weeks will be something that I feel like I can do.

You know, if you can tailor the treatment regimen to the person's needs that too will help improve adherence.

[01:20:02]

Faculty Discussion

All right. Well, we're on to the discussion session.

[01:20:04]

          Discussion

And I think very similar to our previous, I'll give a little summary of some of the barriers for treatment. Sufficed to say, cost, insurance coverage, challenges with receiving hepatitis C medications through specialty pharmacies came up. Social barriers, this is big for the population that I work with. Transportation, being unhoused. So you can't like send medications to – to a participant. People might have competing priorities. Once again, stigma, patient reluctance to start. I don't know if you all have heard – I'm not going to do that hepatitis C treatment. Interferon will kill you. The social memory of interferon is still out there for – for some folks.

What are some other barriers that you all find in your medical practice?

Dr Kushner: I mean, when we talk specifically about pregnancy, again, it's still – there's still a little bit of a gray zone there. So the stigma is still a part of it. So, you know, the recognition of hepatitis C in pregnancy and taking medications for it during pregnancy, for sure, as well as really there's not that much data. So – so really having that joint decision making is crucial in order to help the patient decide what – what they hope to do.

Dr Lee: Yeah. And then in my practice, I think and I saw on the chat there's a lot of, you know, our participants mentioned about the insurance restriction. I – I do still feel like, you know, that's – a lot of times that could be a barrier, you know, some of them still require genotype testing, although the – you know, the patient made this simplified criteria. So, you know, stuff like that. I think – I think, you know, there's probably a lot more work to do on the our stakeholder side as well, to see if we can simplify the preauthorization for hep c treatment.

Dr Kushner: Actually, to that point, there is one question in the Q&A that asks, will insurance pay for simultaneous HCV antibody and HCV RNA in a previously HCV negative individual, or do they want an HCV antibody positive before they will pay for an HCV RNA?

Dr Lee: I personally have not had any issue, especially if the patient you suspect about reinfection. If you document that, you know, the patient had been treated before, and then now you have – because of patient missed some risk factors and then you're worried about, you know, reinfection. I do not see – I personally have not had, you know, insurance company refuse to pay for – directly pay for hep C RNA.

Dr Kushner: Same. I agree. I've never had an issue with insurance coverage. Obviously, the most typical test that we send is the hepatitis C antibody with reflex to the RNA. So the RNA does come after the antibody. But again, in those with a history of hepatitis C in the past, you do want to start with the RNA.

And also I think since you mentioned risk factors, there was one question about risk factor. And maybe Andrew you can address it. It says can you please clarify why using glass pipes is considered a risk factor in people who inject drugs?

Andrew Reynolds: Yeah. So, you know, hep C is transmitted from blood to blood contact. So we know sharing of syringes, sharing of injection equipment, that's the potential of HCV infected blood from getting into me. For pipes, there could still be some blood to blood contact. It's not going to be as efficient as a syringe, but if I have bleeding lips, bleeding gums, and I hit a pipe and I have hepatitis C, some of my blood gets on the tip of that pipe, and I give it to my partner, who also has bleeding lips or bleeding gums, and some of my hep C blood can get into them and then infection can occur.

Hep C is a real tough virus. It lives outside the body for long stretches of time. One study found it infectious 16 days outside of the bodies. A couple of others, maybe a little bit longer. Heat doesn't kill it very efficiently, so pipes through bleeding gums, herpes outbreaks, burns can provide a point of transmission for hepatitis C.

So in San Francisco, we actually do hand out bubble pipes and straight pipes, bubble pipes for crystal meth, straight pipes for crack. And then we have little pipe covers. So if a person doesn't have access to a new pipe, they can switch out a pipe cover. So that way there's no blood to blood contact from lip to lip – lip to pipe to lip.

Dr Lee: Yeah, I agree with Andrew. There's actually a – the data is not as robust for nasal or, you know, or crack transmissions. But there is some study like there's one in CID[?] in 2008 that notice that hep C RNA can – they detect the hep C RNA in the pipes that, you know, that that being used. So there's definitely potential risk of transmission, most likely through the blood, as Andrew mentioned about during your – because a lot of people using nasal cocaine will have mucosal damage on their nose. So they're easily to have like blood along with the secretions. So that's definitely a possible transmission route.

Dr Kushner: Great.

Andrew Reynolds: Cool.

Dr Kushner: Actually there's another question related to just hepatitis C prevalence that maybe we can address quickly now. It said, did the studies that looked at hepatitis C prevalence among MSM control for the fact that men on HIV care or PrEP might have a higher prevalence just because they are screened more? So my question is really, are men in HIV or PrEP care really at higher risk than other MSM, or are they just more likely to be diagnosed with hepatitis C screen – hepatitis C due to screening practices? Great. Great question.

Dr Lee: Yeah, I think that's a great question. And you know, I didn't – that study is actually very well done. They collect data from all over the world. I do not – I do not think they mention about how frequent that each group has been testing. I think it depends on – because this is a meta-analysis. So it's a little bit harder to, you know, look that data, depends on not - probably not all the study they included a report that type of data.

I mean there's a possibility that increased testing frequency did increase your diagnosis rate. But I do think the – as we – you know, as we can see, the prevalence and incidence has been a lot higher. So I do think, you know, even – even adjusted for that – again, I don't think it's a just industry, but even just for that, I do think there is still a potential higher risk in the MSM population.

So I think that's why all the guidance now that has some special address to that population as well. But I think that's a good question. And, you know, that's something we can consider in the future study that see if we can control that factor.

Dr Kushner: Okay. Thanks.

[01:27:18]

Focus on Patients Needs

Andrew Reynolds: I think if this webinar were 8 hours, we would still have a lot of things to talk about. So with our remaining 7 minutes, we'll plow through.

[01:27:28]

Addressing Misconceptions on HCV Management

So quickly, you know, one of the other things about hepatitis C, we're much better about hep C education now in the DAA era than we – than we've ever been. But there are still sort of misconceptions on hepatitis C prevention, testing and treatment.

And so, you know, we've addressed many of these. You can't get hepatitis C from sex as we've seen it kind of, you know, there are certain individuals in certain sexual health groups that have more vulnerability to sexual transmission of hep C than some others. So being able to talk to folks about that, I think is really important.

You know, you can't get hep C from blood transfusions. We've been screening blood since July of 1992. So blood transfusions in the United States are safe. This one comes up – that Tatyana mentioned this one. Folks think the trans – vertical transmission of hepatitis C is – is a much higher rate than it actually is. You know, it's, you know, probably roughly around 4% or 5%, give or take. Co-infection with HIV raises it up a little bit.

But I think letting a person know that the – the – the transmission of hepatitis C from the pregnant person to the baby isn't that high. And then I would add like, you know, really supporting the person along the way to kind of cope with the stress of potentially transmitting the virus and waiting to see if the baby has it, that type of thing.

I won't touch upon all of these, but the last one let's get into for sure. Oh, Andrew, I don't need to worry about hepatitis C. I've been vaccinated. You know, let a person know, hey, you've probably been vaccinated against hepatitis A or hepatitis B. We've yet to come up with a successful vaccine for hepatitis C, so come on in. Let's test it. If you test positive, we'll treat and cure you.

Just letting folks know that interferon is out the door. And a lot of cases, ribavirin is out the door. Letting folks know that there is absolutely a cure for hepatitis C. Again, they might mix up hep C with hep B and that that type of thing.

And then making sure a person knows that, oh, I don't need to test for hep C because I don't have any symptoms for hep C. Let them know that hep C is often asymptomatic. It's the same with when we're living with hepatitis C. You might not necessarily know it because a lack of symptoms or the symptoms are so vague, you might think it's something else.

Let a person know that. Treatment and cure with or without symptoms, is really, really important. And for a lot of folks, treatment and cure will improve their quality of life because some symptoms that they have that they think they just have because they're old or other things are related to hepatitis C, and they're like, oh, Andrew, I – I don't feel the fatigue. I don't feel the joint aches that I used to have after they've been cured. So that's a big piece as well.

[01:30:32]

          HCV Among Transgender Individuals

We did want to touch quickly upon hepatitis C amongst transgender individuals. We don't have as great data for this population as we need. And there are actually a lot of people who are very interested in this subject and are doing a lot of really great work. So I think the next time we do this webinar, we'll have more robust data and information.

But, you know, studies that have looked at hepatitis C have found rates ranging anywhere from a little less than 2% to nearly 16%. And again, in the general population, it's 1%. So I think this is a great, you know, the same population – the same recommendations we have for screening MSM, we should have for transgender folks, once a year, ongoing risk factors – once lifetime ongoing risk factors once per year.

One of the things that definitely we should touch upon with transgender folks is when we talk about sharing of syringes, making sure we don't just focus on sharing of syringes around drug use, making sure that we also talk about sharing syringes for gender affirming hormones, fillers, that type of thing and knowing our resources around that.

UCSF's center for excellence has some really great care and treatment guidelines, and then looking up potential drug to drug interactions with hepatitis C treatments and gender affirming hormones that transgender folks might take is also really, really important to do.

[01:32:05]

Stigmatizing Language: Commonly Used Terminology to Avoid and Suggested Alternatives

This is something you can look at. One of – we talked about stigma. Making sure that, you know, the language that we use is open and we practice cultural humility with our folks. So using person first language, making sure we have the preferred terminology on race, sexual orientation, gender identity, not just in the way that we talk to folks, but also in – in with our forms, with the posters we have in our waiting rooms and our fact sheets and that type of thing, representing the diversity of our patient population.

[01:32:40]

          Use the Right Pronouns

And then last but not least, using the right pronouns. The easiest way to do that is when you introduce yourself. Introduce your pronouns. Hi, my name is Andrew and I go by he, him, his pronouns. What pronouns do you use? And then you got that.

And then if you misgender somebody, the best practice is apologize, correct yourself, and then just continue with your engagement with the individual.

[01:33:08]

Faculty Discussion

All right. Well, we have 2 minutes.

[01:33:14]

          Discussion

What are some common misperceptions you all hear and you want to talk about?

Dr Kushner: Yeah. I mean, I could just quickly say, because this is also relevant to one question, the hepatitis C treatment in pregnancy. Misconception that it's never been done or that you can't do it. I think, although the guidance does leave some room for joint decision making for sure, we do now have some data and you can treat on a case by case basis, or you can treat postpartum or you can make the decision to treat after breastfeeding is complete.

So I think that it's still joint decision making. But there's not an absolute contraindication to treatment in pregnancy.