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Pharmacist collaboration in HCV, HIV extends the reach of care

As direct-acting antivirals become more affordable, they also become accessible to more patients with hepatitis C, without treatment delays. These powerful drugs, which were once provided only to the sickest of HCV patients, are now a treatment option for HCV cases at all stages.

In 2016, the Department of Veteran’s Affairs (VA) received funding from Congress that would enable them to provide care for all veterans affected with HCV, regardless of stage.

“The VA felt compelled to treat every veteran with hepatitis C,” Macy Ho, PharmD, of the VA Long Beach Healthcare System told HCV Next. “Before, the only veterans who got these agents were people with advanced liver disease, cirrhosis. Since 2016, we are now able to treat everyone with [hepatitis] C regardless of stage of liver disease.”

To address this additional caseload, VA Long Beach Healthcare System enlisted the help of Ho, an infectious disease pharmacist and liver specialist, in handling some of the less advanced cases. The pharmacists also are involved in the treatment of HIV.

Ho spoke with HCV Next about how this approach functions within the VA system, and discussed how other facilities might incorporate such a model in the future.

HCV Next: How did pharmacists first get involved in HCV/HIV treatment at your hospital?

Ho: We have a lot of HCV patients among the vets. The new direct acting agents are so easy to take, but they were expensive, and their use was limited prior to 2016. In 2016, the VA was given funds specifically to purchase these agents for HCV treatment.

At that point, we wanted to avoid any delays. If a veteran said yes to being screened for HCV, we wanted to get them in, get all their labs done, evaluate them and get started on treatment. We didn’t want to say our clinics were full, although they were getting very full. We didn’t want to have to tell patients, “We won’t be able to do this until a month from now, 2 months from now.” A lot of these patients were avoiding it to begin with, saying things like, “I feel fine. My liver’s okay. Why should I do it now?”

The moment these patients said yes, we wanted to be able to say “Okay, come on in. I’m going to schedule you an appointment and we’ll get you started.”

To do that, our process is that they all have to see the liver pharmacist first. They may see the hepatologist if they have complications and they need to be cleared, or something’s going on. If the patient’s numbers are good and they have no signs of advanced liver disease, they come straight to us. I actually triage all the consults. I have my own system.

We handle HIV cases too; this is how the ID pharmacists got involved in HCV. It was just such an easy transition.

HCV Next: Has there been any pushback against implementing pharmacist management of HCV or HIV?

Ho: None at all, not at our hospital. We’ve had clinical pharmacy for decades; I’ve been here a long time. I was the second ID pharmacist to become involved. I started the HIV clinic, along with the HIV doctor. Then we added HCV. The agents are just so well tolerated. Our process is that they do see a liver specialist, either the doctor or a PharmD. We do the initial counseling, the workup, and determine the treatment, if it’s an uncomplicated case. We wouldn’t handle a case where they need ribavirin, which has lots of side effects and does require experience. If all they needed was a single agent, such as Harvoni (ledipasvir/sofosbuvir, Gilead Sciences) alone or Zepatier (elbasvir/grazoprevir, Merck) alone, I would refer the patient to their Patient Aligned Care Team (PACT) clinic. All our patients are assigned to a PACT team, which includes their primary care doctor, their nurse case manager, and pharmacists.

Patients return to this PACT team for all subsequent follow-up. The patient is familiar with going back to the PACT clinic. Some of them will have dealt with a pharmacist, if they’re on anticoagulants, but patients don’t always see the PACT pharmacist. Just if they’re on anticoagulation, or lipid management; some of the disease states where patients need more fine tuning and follow-up.

HCV Next: What are some of the benefits of involving pharmacists in HCV and HIV treatment?

Ho: The greatest advantage is that there are not enough doctors to really monitor these patients. We all know that in GI and liver, they are so busy with transplant patients, or those with cirrhosis. They handle the really sick ones, where there’s a lot more medical intervention. Because HCV is curable, the treatment’s only 3 months long, and the drugs are so well tolerated, we can treat a lot of patients by expanding the number of providers to include pharmacists. The goal of the VA is to treat everyone with HCV in 2 years. We’re now getting down to our last couple hundred patients.

We’ve been working collectively on this. We’ve met as part of these hepatitis C innovation teams, both locally within our region and on a national level. It’s great; we’re sharing best practices.

HCV Next: How might other systems or practices implement a program like yours?

Ho: I would say that even though primary care pharmacists can do this, you still need access to liver specialists. With our primary care pharmacists here, communication is important. I tell them to call us, email us, instant message us if you have any questions. I think that gives them confidence also.

Our chief of hepatology was also totally supportive of this. He’s totally supportive of the liver pharmacists.

For pharmacy, you really need at least one pharmacy liver specialist and champion who can bring everyone else on board, to be the liaison between the liver specialist and other providers. Our hepatologist is comfortable with this, because we already have a relationship and he trusted me. When it’s a tough case, he trusts that I will let him know about it, because we can’t have the hepatologist be on call to 10 primary care pharmacists. You need one specialist, one champion, to bridge it all.

HCV Next: What advice would you give to other institutions who are looking to initiate this type of system?

Ho: First, I would say that pharmacy can’t act in a vacuum. I think a multidisciplinary approach has to happen. I work closely with our hepatology section; it’s very collegial and collaborative. We’re all on the same wavelength. The chief of hepatology does dictate the philosophy, so it’s not as though pharmacy is just going to do its own thing. It’s good for pharmacists to keep learning. It’s easy for us to feel comfortable, but it’s nice to branch out. Hepatitis C treatment is not so broad that you can’t learn it. At the VA, within our system, we’re lucky, because HCV is such a priority. There are so many webinars, so that during the workday we have SharePoint sites where people can look up information. There are even monthly liver lectures people can “attend.” If you’re in a health care group and can provide these avenues while a pharmacist is on the clock, without them having to go to a $300 weekend seminar, it’s beneficial to everyone.

HCV Next: So , collaboration and mutual trust seem to be essential to make this work.

Ho: Yes, and support. It’s nice, because our hepatologist’s goal is to treat as many patients as possible, and because he’s had experience with us liver specialists, he knew this could be done. I imagine in some areas, it’s all handled within the liver doctors; I’m sure there are turf wars. I think the bottom line is, if everyone believes in this, if the goal is to treat as many patients as possible right now and not delay treatment, this is the way to go. – by Jennifer Byrne

Reference: Sanders AR. Scientific Reports. 2017; doi:10.1038/s41598-017-15736-4.

Disclosure: Ho reports no relevant disclosures.

For More Information: Macy Ho, PharmD, can be reached at 5901 7th Street, Long Beach, Calif. 90222; email: macy.ho@va.gov.