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

2. 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

3. 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

4. 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

5. 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

6. 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

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

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

9. 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

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

11. Goal # 2: Expand Screening Program
Expand age targeted screening to 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

12. HCV “Lab Triggered” Screening WW Hastings Hospital

13. 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

14. 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

15. 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

16. 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

17. 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