Whose Job is it? Hint: Look in the mirror.
By David A. Wohl, MD – September 19, 2014
The two most recent seismic developments in the management and prevention of HIV, respectively, are the advent of super-highly active, inferferon-free HCV therapy (SHAFT – you heard that acronym here first, folks) and pre-exposure prophylaxis (PrEP). But in North Carolina one would hardly know it by talking with infectious diseases clinicians. Both potent HCV treatment/cure and PrEP are radical advances that save lives – they are also not that hard to do, particularly for providers well accustomed to dealing with a fatal viral illness, challenging populations, and even, pharmaceutical support program paperwork. Yet, although many HIV providers complain that their work has lost its intensity and become staid, only a minority are embracing these new advances. Why are so few ID docs embracing HCV treatment or opening their clinic doors to people interested in PrEP?
The slow uptake of HCV treatment among the infectious diseases community is rooted in territoriality. HCV has been a province of the gastroenterologist. With liver biopsies, Child’s Pugh scores, and interferon toxicities, HCV treatment was messy business and ID clinicians were happy to leave all this to their no-fear-in-the-face-of-a-bilirubin-of-9 hepatology colleagues. In addition, most HIV-positive patients, by virtue of depression, on-going substance abuse, or lack of commitment to toxic and impotent therapy, were poor candidates for interferon-based regimens; so, demand was not high. Now, HCV is not just treated but in most cases cured with oral antivirals that target viral replication and carry little adverse-effect baggage – frequently with 12 weeks of therapy. Combinations of sofosbuvir and simepravir burden the patient with a whopping two pills a day and a bottle of sunscreen. Patients needing sofosbuvir and ribavirin have it a little rougher but do no more heavy lifting than those being treated for tuberculosis. The sofosbuvir and ledipasvir combo will even bring singe table regimen cache to HCV.
Further, traditional obstacles to HCV treatment have been obviated. With response rates pushing 90%, short courses, and great tolerability, liver biopsies are not needed in most cases and contraindications for substance abuse or mental illness are becoming as relevant or irrelevant for treatment of HCV as they are for treatment of HIV. Cost of therapy, does act to stay the prescribing hand. However, as fiscally conscious as I know we all are, we have had no difficulty ordering up treatment of HIV with medications that cost $30,000 to $50,000 a year for life.
We infectious diseases docs have to man- and woman-up and claim HCV for what it is: an infectious disease. We can do this – at least for those without decompensated cirrhosis. With over 3 million HCV-infected people in the US, there are more patients to be evaluated, counseled, and treated than gastroenterologists can or will handle. IAS-USA often offers half day workshops in HCV management in Atlanta and DC, and sometimes in North Carolina. Your ATEC would, at the drop of an email, organize a training or individual web-based support for HCV treatment.
The lower hanging fruit are those with HIV-HCV co-infection. These are our patients. We treat their dyslipidemia, hypertension and depression, let alone other infections, including hepatitis B (often without realizing it). These people love you and feel comfortable in your clinic. No one is in a better place to see them through the eradication of their HCV. Treatment of the mono-infected can follow and is incredibly rewarding as these are often very committed patients for whom you can actually say the words, “You are cured. No return appointment needed”.
PrEP presents a very different challenge for ID clinics. Foremost, many of us have to get accustomed to the concept of giving Truvada to someone not to suppress a virus but to prevent them from becoming infected with one. I too can become preachy when it comes to condoms but the fact is some people will not use an HIV/STI prevention method that reduces sexual pleasure. And, some of these folks are at risk for acquiring HIV. PrEP has been clearly demonstrated to reduce that risk substantially. Therefore, the first step in putting PrEP on the menu of services you offer is accepting that it plays a role in HIV prevention.
Next is developing a plan for how your clinic handles the integration of those seeking PrEP. Procedures for scheduling, the handling of insurance and support program applications, refill procedures, and appointments for regular HIV and STI testing need to be made, but are pretty straightforward. While many imagine a flood of humanity lapping at the clinic doors clawing for the blue-pill – mirroring the scene outside Walmart before the new X-Box goes on sale – chances are this will be a trickle. Again, training is available and we at the ATEC can help and share procedures developed at other clinics.
Equally important is understanding which patients are appropriate for PrEP. Some may desire PrEP but have little or no potential exposure to HIV. At this point, however, it is likely that those going to the trouble of seeking out a clinic to prescribe them Truvada to prevent HIV infection are motivated and have actual risk. If committed to adhering to daily PrEP, coming in for routine HIV/STI testing, and appreciative of potential risks such as renal and bone issues and the lack of protection against other STI, PrEP for such folks makes sense.
Of course, PrEP would be ideally provided by primary care clinics. However, most of these practitioners have not heard much of anything about PrEP. As an HIV treating community, we should change that and speak with our colleagues in internal and family medicine about PrEP and support their appropriate prescribing of this medication. Leading by example, is a good start.
HIV care providers have confronted and beat back an epidemic. We did this creatively and compassionately, embracing and caring for people who are marginalized, ostracized, and devalued. Artfully applying advances in HIV therapeutics we extend life in quantity and quality. Treatment of HCV and PrEP are extensions of this care – natural next steps that spring from our success. Some of our major academic HIV clinics are starting to offer both. You can too. In a time of a monotony of suppressed HIV RNAs and climbing CD4 cell counts it is easy to rest and reassure. Instead, lets continue to lead the way and make HCV treatment and PrEP available to people here in our state.