The Role of Primary Care in HCV
Primary care providers have held the responsibility for multiple roles in HCV care since the discovery of the virus—particularly for HCV risk factor assessment, screening, and diagnosis. HCV antiviral treatment, however, was largely placed in the hands of specialists, given the complexities of patient selection, frequent reliance on a liver biopsy for determining need for treatment, and the toxicities of peginterferon and ribavirin therapy.
There are discussions both inside and outside the VA about potentially expanding the role of PCPs in HCV care. First, primary care is the major setting where the CDC and USPSTF recommendations for birth cohort screening are being implemented, and thus PCPs will be identifying veterans previously undiagnosed with HCV. 1,2 Second, the ease and tolerability of the new all-oral combination regimens is causing a shift in the paradigm for HCV treatment, from a highly individualized approach, toward a more uniform approach.
Expanding the role of primary care would have multiple benefits to patients and the health care system as a whole. Only approximately 9% of HCV-infected veterans in VA care have been successfully treated at this time, largely due to low eligibility rates and the poor response rates, but other barriers have also contributed to the low success rate, one of which has been limited access to specialists. Furthermore, veterans who are referred to specialists are often noncompliant with the referral. 10 If seeing an HCV specialist is required for treatment, the time to treat the HCV population will be much greater, more costly, and less efficient. Therefore, if the prospect of delivering HCV treatment to the majority of HCV patients is to be accomplished, it is necessary to consider providing treatment in the primary care setting as well as the specialist setting.
Treatment provided by nonspecialists has been evaluated in patients receiving peginterferon and ribavirin regimens and has shown that with adequate education and support, SVR rates were equivalent in the specialist and nonspecialist setting. 11 To develop programs to provide primary care with such support, the VA has implemented the Specialty Care Access Network-Extension of Community Healthcare Outcomes program initiative, with casebased learning along with real-time consultation.
Currently, the majority of HCV-infected patients have never seen an HCV specialist, thus PCPs are already providing the majority of HCV care beyond HCV antiviral
treatment.12 Primary care providers are, therefore, key to addressing multiple important aspects of HCV care, including (1) counseling patients on transmission, prevention, lifestyle, and the role of substance use; (2) providing hepatitis A and B vaccination as well as appropriate general vaccinations for any patient with chronic liver disease; (3) modifying comorbidities that could accelerate fibrosis progression, such as diabetes mellitus, obesity and hyperlipidemia; (4) reducing risk from ongoing alcohol, drug, and tobacco use; (5) monitoring patients for fibrosis progression and identifying the presence of cirrhosis; and (6) providing general care for patients with cirrhosis, including HCC screening. These are critical aspects of HCV care, and many PCPs may still need additional education for these roles. The VA provides education and support for PCPs in their current role and is enhancing efforts to expand delivery of HCV treatment to the primary care setting as well.