Cherokee Nation Health Services HCV Elimination Program Jorge Mera, MD, FACP Director, Infectious Diseases Cherokee Nation Health Services

Outline Overview of Cherokee Nation Health Services (CNHS) Chronology of events leading to the HCV elimination program HCV elimination program Goals Progress to date Challenges

Cherokee Nation Jurisdiction Sovereign Nation within a Nation Oklahoma Second largest Indian Nation 322,855 Registered citizens) Medically serves 131,000 AI/AN 14 county area (over 9,200 sq mi.) Capital located in Tahlequah, OK AI/AN: American Indians/ Alaskan Natives

CNHS HCV Program: Chronology 2012 263 patients HCV seropositive CDC recommends Birth Cohort screening 2013 232 patients evaluated (29 treated) Partnered with IHS Birth Cohort HCV electronic health record (EHR) implemented Partnered with UNM ECHO HCV Clinic ECHO: Extended Community Health Outcomes. IHS: Indian Health Services. UNM: Univ. of New Mexico

CNHS HCV Program: Chronology 2014 761 HCV (+) patients (92 treated) Partnered with OUHSC, OSHD, Yale University Estimated 5.8 % HCV prevalence 2015 945 HCV (+) patients (274 treated) 4 CN HCV ECHO clinics Partnered with CDC Elimination Program started (10/2015) HCV Clinic OSHD: Oklahoma State Health Dep. OUHSC: Oklahoma Univ. Health Sciences Center

Birth Cohort HCV Screening in CNHS Percentage of patients in the birth cohort screened who accessed the CN primary care clinics without a previous HCV screen Birth Cohort defined as those patieets born between 1945 and 1965

Birth Cohort HCV Screening CNHS HCV Screening Policy and EHR Reminder HCV Screening Education EHR: Electronoc Health Record

HCV: Age Distribution n=263 Patients who were evaluated for treatment at CNHS (2012) CNHS: Cherokee Nation Healht Services

Linkage to HCV Care and Treatment New DAAs Engagement of PCPs and Pharmacists ECHO DAAs DAA: Direct Antiviral Agents PCP: Primary Care Providers, ECHO: Extended Community Health Outcomes

October 30th CN HCV Awareness Day Goal # 1 Political Commitment October 30th CN HCV Awareness Day

Goal # 2: Expand Screening Program Expand age targeted screening to 20-69 years old Screen 85 % of targeted age group who access the CNHS Serotest 84,000 patients in 3 years HCV screening will be triggered by EHR reminder Lab triggered HCV screening Dental Screening May capture a different population Potentially easier to engage in care

HCV “Lab Triggered” Screening WW Hastings Hospital

Goal #3: Establish Robust Program to link to care, treat and cure patients with HCV Linkage to care, evaluation and treatment Centralized screening reporting and linkage to care Expand use of HCV rapid screening tests Expand local ECHO 20 primary care providers and 8 pharmacists recruited Expand case manager workforce Goals Treat 85% (2,486) of patients with active HCV infection in 3 years (based on an estimated prevalence of 3.7 %) Cure 85% (2,113) of treated patients defined by SVR12

Goal #4: Reduce the incidence of new HCV infections in CNHS Develop and conduct culturally-competent public awareness of risk factors for transmission Treatment as Prevention Contact tracing Nested case control study of acute hepatitis C cases approved by IRB Opioid Substitution programs Naltrexone program in development Needle Exchange programs Discussions ongoing with legislature

Goal #5: Model Elimination of HCV infection in the CNHS Model of HCV transmission dynamics specific to the CN Nested case-control study data , cross-sectional study data and clinical data will be used to model HCV transmission dynamics in CN An advisory committee was established and will assist in development and ongoing review of short and long term goals towards HCV elimination in the CNHS

Challenges Screening EHR reminders are not” pop ups” they require a “reminder for the reminder” Not all patients access the system where screening is offered People who do not access the care system don’t get screened Engangement in care and followup are still a problem Treatment Antivirals procurement is complex Treatment failures are more frequent in the real world Difficult to reach/treat populations PWID/incarcerated people/Homeless/People with alcohol abuse Political Needle exchange prorgrams Funding

Challenges Screening Most EHR reminders are not” pop ups” they may still require a “reminder for the reminder” Not all patients access the system where screening is offered ((Pharmacy, optometry, etc.) Duplicate screening occurs when EHR’s don’t comumicate People who do not access the care system don’t get screened Engangement in care and followup are still a problem Treatment Antivirals procurement is complex Treatment failures are more frequent in the real world Difficult to reach/treat populations PWID/incarcerated people/Homeless/People with alcohol abuse Political Needle exchange prorgrams Funding