Montefiore develops HIV/HCV best practice
Montefiore develops HIV/HCV best practice
Patients receive combined primary/HCV care
Montefiore Medical Center in the Bronx, NY, has developed a successful, multidisciplinary team for the treatment of HIV/hepatitis C (HCV) co-infection, new research suggests.
The philosophy has been to handle the HCV infection within the HIV clinic rather than referring to specialists, and with 30 months of results available, it appears to be a winning strategy, says Barry S. Zingman, MD, medical director of the AIDS Center and medical director of the HIV/HCV Co-Infection Program at Montefiore.
With 2.5 years of data, the Montefiore program appears to work well with co-infected patients who come from diverse backgrounds.
"We're finding that with adequate support and education for providers and for people living with HIV/HCV co-infection there is much more interest in treatment than we might have previously thought," Zingman says. "Many people are being referred for treatment or are self-referred for treatment once they learn about the opportunities.
"Also, we find that not only do you need a multidisciplinary team, it's preferable to have them be at the site of HIV primary care," Zingman says. "Instead of sending a patient out to another site where they don't know anybody, their treatment of co-infection is much more successful if it's incorporated into HIV primary care."
Zingman describes these aspects of the Montefiore co-infection program:
• Interdisciplinary team approach is crucial.
The co-infection program's team includes various disciplines working with an HIV primary care provider. These disciplines include a physician director (Zingman), an HIV- and HCV-expert nurse practitioner, a patient educator/ adherence counselor, a social worker, a psychiatrist, a registered dietitian, and a substance use counselor. Everyone on the team works at the Montefiore Center for Positive Living/Infectious Disease Clinic (CPL/ID Clinic), Zingman says.
For some of the more difficult co-infection cases, the patient will be referred to a liver specialist, who is not a part of the HIV clinic staff, but who works in an upstairs clinic, Zingman says.
This year, the AIDS Clinic will hire a second patient educator and a nurse, he adds.
The interdisciplinary team provides nutritional support, social work support, medical evaluation, medical treatment, directly-observed therapy for interferon injections, and other services to patients, he says.
• Provide specialty team in primary care setting.
Also, both Zingman and the nurse practitioner have received additional training in hepatitis C care and HIV/HCV co-infection. They work with HIV primary care physicians and, when needed, liver specialists.
"The hepatologist we use is consulted by referral only and will see only the most complicated patients or the ones who have end-stage liver disease," Zingman adds.
"This is a key difference with our program," he explains. "We approach this problem of co-infection from a primary care perspective."
In primary care, the general philosophy is that all medical problems are the primary care team's responsibility and need addressing, Zingman says.
"If you don't treat them now and they get worse, then they're on your hands, and you still have to take care of them," he says. "This is different from the referral model in which you refer patients to a specialist, who decides whether they are a good candidate for treatment, and if they are not, then the specialist sends them back."
In the CPL/ID Clinic, everyone is considered a candidate for HCV treatment, Zingman adds.
"We identify the needs of the patient at that moment in time and steadily work on each of those aspects and incorporate them into primary care, steadily working to prepare the patient for the hoped-for time when the hepatitis C can also be treated," Zingman says. "That's a different way of approaching this, and, in some ways, it's like what we did with HIV: we embraced it as an illness that could best be treated if in the context of primary care with an HIV specialist managing the whole care of the patient."
While many HIV specialists don't have the time, education, or experience to be hepatitis C specialists as well, the primary care physicians work with the co-infection team and its HCV experts to provide more comprehensive care.
• Tweak standard co-infection care models.
For co-infected patients whose HIV is well controlled, the major mortality risk is now hepatitis C-associated, end-stage liver disease, so a primary goal is to get patients' HCV infection under control, Zingman says.
Co-infected patients typically are treated for HCV with pegylated interferon and ribavirin for 12 weeks, during which time their virologic response is monitored closely. They visit the clinic each week and receive their interferon injection from a nurse or nurse practitioner.
Patients are staged at each visit as preparatory, pre-treatment evaluation, treatment, post-treatment, cirrhosis, or hepatoma.1
Typically the first 12 weeks of treatment for HCV will indicate whether the patient will have a long-term response to the medication, Zingman says.
"If patients have not had significant reduction in viral load at 12 weeks, then they're very unlikely to respond after that point," he says. "Our rate of successful treatment at 12 weeks is about 70%."
The treatment team identifies each patient's personal barriers to adherence and treatment success and will provide substance use counseling when IDU or alcoholism is factors.
"We tell them why it's more difficult for us or their doctor to treat them and why we want to reduce their substance use to more manageable levels," Zingman says. "We don't reject someone because of a specific level of substance use because sometimes it's more important that they're willing to follow through with treatment."
For those who don't succeed in virologic suppression at 12 weeks, the program will often continue treating them with a goal of providing some medical benefit, even if a cure can't be achieved, Zingman says.
"There seems to be accumulating evidence that treatment is a benefit even if they're not cured, and it may slow cirrhosis of the liver," Zingman says. "So we talk with patients about the risks and benefits of continuing treatment despite their not being able to reach a cure."
Many patients decide they are tolerating the treatment well enough that they'll continue in the hope it will delay cirrhosis, he adds.
For the patients who do indicate potential success at 12 weeks of treatment, their HCV medications are continued for 48 weeks, and they're offered a continuation of interferon injections at the clinic if they'd prefer that to doing it on their own, Zingman says.
The clinic's co-infection team continuously adjusts treatment protocols according to scientific evidence and experience, and so there is a possibility they will begin to extend therapy past 48 weeks, Zingman says.
"Forty-eight weeks may be good with mono-infection, but it may not be optimal with people with co-infection, who have a slower response and lower success rate with standard treatment duration," Zingman says. "In our hands there has been a one-to-two in 10 chance even after 48 weeks that a person's HCV will relapse months later, despite complete viral suppression at the end of treatment."
For hepatitis genotype 1 patients, African American patients, and patients who've had a slower response in the first few weeks, the clinic has begun to offer extended treatment past 48 weeks for another eight or 12 weeks, he says.
The program is also evaluating studies of experimental medications to improve response rates, but new medications are coming out slowly, Zingman adds.
• Expand program to include more patients.
The co-infection program's plans include two types of expansions: the first is offering the team's expertise to patients who are not Montefiore patients, and the second is to more actively promote the program's services among African American patients, Zingman says.
"We've been successful enough and have honed and are comfortable with the model for care, so this year we are hiring more staff and will open up the program to people outside of Montefiore," Zingman says.
"These patients might not receive their primary care here, but we feel like we are seeing so much success that it's our goal to open this up to other people."
The program also has targeted African Americans with co-infection because this is a group that clinicians and researchers have not had much success in treating for HCV in the past, he says.
"Genetically, there seems to be a barrier to treatment success, so there's a reluctance among primary care providers to treat them and they tend to refer fewer of these patients," Zingman explains.
So far the program's success with African American patients has equaled its success with Latino patients, but the team will see if these positive results continue once the patient base is expanded, Zingman adds.
The CPL/ID Clinic's patient demographics include 65% Latinos, 30% African-Americans, and 5% non-Hispanic Whites, Zingman says.
• Funding comes from a grant, Medicare, Medicaid.
The program is funded by a grant from the New York State Department of Health's (NYSDOH's) AIDS Institute, and it's the only co-infection program funded in the state by NYSDOH, Zingman says.
"We're funded as a model program for co-infection care," Zingman explains. "What we proposed to them is we thought we could be successful if we set up a care model in which multiple needs were addressed in one location by one team working in concert with primary care providers."
Visit revenues billed to Medicare, Medicaid, and private insurance also are a big part of the clinic's revenues, particularly as it grows in size, Zingman says.
Reference:
- Zingman BS, Ortiz-Morales H, Freeman K, et al. The Montefiore HIV/HCV co-infection program: 18 month results from an expert multidisciplinary team co-located at an urban HIV primary care clinic. Presented at the Treatment and Management of HIV Infection in the United States Conference, held Sept 15-18, 2005, in Atlanta, GA.
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