Assessing Your Patients for HCV and HIV

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ExchangeCME.com/ HCVHIVRESOURCES19 This activity is jointly provided by the Postgraduate Institute for Medicine (PIM) and Integritas Communications.

This activity is supported by an educational grant from Gilead Sciences, Inc. This event is neither sponsored nor endorsed by The American College of Obstetricians and Gynecologists (ACOG).

MEDICAL COMMUNICATIONS INQUIRIES info@integritasgrp.com integritasgrp.com

GREGG ALLEYNE, MD

FACULTY

FACULTY

Associate Professor Director of HIV and Women’s Health Director of Global Women’s Health Initiatives Department of Obstetrics and Gynecology Associate Professor Department of Family, Community and Preventive Health Drexel University College of Medicine Philadelphia, Pennsylvania Dr. Gregg Alleyne is a clinician and patient advocate who specializes in women’s health and HIV. He currently is Director of HIV and Women’s Health and Director of Global Health Initiatives in Obstetrics and Gynecology (OB/GYN) in the Department of OB/GYN at Drexel University College of Medicine, where he holds joint faculty appointments in the Departments of Obstetrics and Gynecology and the Department of Family, Community and Preventive Medicine. Dr. Alleyne led the development of a successful model of care for pregnant adult and adolescent women living with HIV and AIDS, and is currently Director of The Partnership Plus Prenatal Clinic, which uses a multidisciplinary model to provide care and delivery services for 30 to 40 pregnant adult and adolescent women living with HIV/AIDS each year. He also helped successfully implement testing for hepatitis C (HCV) in pregnancy and now manages pregnant patients with HCV in his clinic, which has become a large referral source for this novel model in obstetric/ gynecologic care.

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CHRISTIAN B. RAMERS, MD, MPH FACULTY

Assistant Medical Director, Research/Special Populations Director, Graduate Medical Education Family Health Centers of San Diego Clinical Associate Professor UC San Diego School of Medicine San Diego, California

Dr. Christian Ramers is a specialist in infectious diseases and oversees clinical programs in HIV and hepatitis B and C at Family Health Centers of San Diego (FHCSD), an urban, underserved, Federally Qualified Health Center clinic network. He serves as FHCSD’s Assistant Medical Director for Research and Special Populations, and the Director of Graduate Medical Education, serves on several speakers bureaus, providing HIV and HCV education throughout the Western United States, and has consulted for the California Department of Public Health, WebMD, Medscape, and the Centers for Disease Control and Prevention. He chairs the California chapter of the American Academy of HIV Medicine and has advocated for HIV/HCV care at the state legislative level. Dr. Ramers serves as a coinvestigator on several National Institutes of Health–sponsored projects in collaboration with other San Diego State University investigators.

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TARGET AUDIENCE

The educational design of this activity addresses the needs of OB/ GYN physicians, nurse practitioners, nurse midwives, and physician assistants.

Both human immunodeficiency virus (HIV) and hepatitis C virus (HCV) affect women, and both infections can be screened for in the women’s health setting of obstetric and gynecologic care. Once a woman with either or both of these infections is linked to care, she has a better chance of preventing transmission to others, including her unborn child.

The proportion of HIV cases in women tripled from 1985 to 2013 (7% to 24%).1 In 2017, adult and adolescent women represented 19% (7401) of the 38,739 new HIV diagnoses.2 Today, one quarter of people living with HIV are women; 64% were infected via heterosexual transmission and 32% through injection drug use. HIV disproportionately affects black women, who represent only 15% of the female population in United States, yet 59% of cases of HIV in women.2 One in eight individuals living with HIV are unaware of their infection3; 91.5% of new HIV infections were transmitted from people who were not in medical care.4 Furthermore, approximately 25% of all individuals infected with HIV are coinfected with HCV.5 Importantly, HIV increases the rate of progression of HCV-related hepatic fibrosis, and HCV is associated with a 3-fold increase in HIV antiretroviral therapy–induced liver toxicity.5 In addition to the problem of HIV, HCV infections are increasing in the United States, with an increase from 850 cases in 2010 to 2436 cases in 2015.6 The most rapid increase is among 20- to 29-year-olds who inject drugs, and many of these cases are women.6 Whereas HIV infection is now effectively manageable, chronic HCV infection is curable. Yet, despite new, highly effective direct-acting antiviral treatment regimens for HCV, their broad-scale use and associated therapeutic successes remain stymied by barriers at the patient, clinician, and healthcare system levels.7 OB/GYN clinicians are uniquely positioned to screen for these infections and, importantly, to link patients who test positive for HIV, HCV, or both, to appropriate specialist care. Linking patients to care has significant benefits, not only for the patient, but for others, by minimizing transmission, including mother-to-child transmission to an unborn child.

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PREAMBLE

STATEMENT OF NEED

REFERENCES 1.

Centers for Disease Control and Prevention. HIV Surveillance Report. www.cdc.gov/hiv/ library/reports/surveillance. Accessed March 19, 2018.

2. Centers for Disease Control and Prevention. HIV Among Women. www.cdc.gov/hiv/ group/gender/women/index.html. Accessed March 20, 2019.

3. Centers for Disease Control and Prevention. HIV in the United States and Dependent Areas. www.cdc.gov/hiv/statistics/overview/ataglance.html. Accessed March 19, 2019.

4. Skarbinski J, Rosenberg E, Paz-Bailey G, et al. Human immunodeficiency virus transmission at each step of the care continuum in the United States. JAMA Intern Med. 2015;175(4):588-596.

PREAMBLE

5. Sulkowski MS, Benhamou Y. Therapeutic issues in HIV/HCV-coinfected patients. J Viral Hepat. 2007;14(6):371-386.

6. New hepatitis C infections nearly tripled over five years [press release]. Atlanta, GA: Centers for Disease Control and Prevention. May 11, 2017. https://www.cdc.gov/nchhstp/ newsroom/2017/Hepatitis-Surveillance-Press-Release.html. Accessed March 19, 2019.

7. National Viral Hepatitis Roundtable. Hepatitis C: The State of Medicaid Access. October 23, 2017. https://stateofhepc.org/wp-content/uploads/2017/10/State-of-HepC_2017_ FINAL.pdf. Accessed March 19, 2019.

EDUCATIONAL OBJECTIVES

After completing this activity, the participant should be better able to: •• Identify patients who have risk factors for HCV and HIV and obtain appropriate screening tests •• Discuss principles of linkage of care for patients who have confirmed HCV and/or HIV infection •• Counsel patients on the implications of HCV and/or HIV infection, including measures to prevent transmission

PROGRAM AGENDA 6:15 pm–6:45 pm

Registration and Dinner

6:50 pm–7:00 pm

Why HIV and HCV Matter in OB/GYN Practice in 2019

7:10 pm–7:25 pm

HCV Screening and Treatment

6:45 pm–6:50 pm Introductions and Preactivity Assessment 7:00 pm–7:10 pm

The Epidemiology of HCV in Women

7:25 pm–7:35 pm

The OB/GYN’s Role in HCV and Pregnancy

7:40 pm–7:55 pm

HIV Treatment and Prevention

8:05 pm–8:10 pm

HIV/HCV Coinfection

7:35 pm–7:40 pm

7:55 pm–8:05 pm

The Epidemiology of HIV in Women

The OB/GYN’s Role in HIV and Pregnancy

8:10 pm–8:15 pm Postactivity Assessment and Question & Answer Session

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JOINT ACCREDITATION STATEMENT

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and Integritas Communications.

Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

PHYSICIAN CONTINUING MEDICAL EDUCATION

PREAMBLE

The Postgraduate Institute for Medicine designates this live activity for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

CONTINUING NURSING EDUCATION

The maximum number of hours awarded for this Continuing Nursing Education activity is 1.5 contact hours. Pharmacotherapy contact hours for Advance Practice Registered Nurses to be determined.

DISCLOSURE OF CONFLICTS OF INTEREST

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers, and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity.

All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high-quality activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty

Gregg Alleyne, MD

Nothing to disclose

Christian B. Ramers, MD, MPH

Consulting: Abbvie Inc., Gilead Sciences, Inc.; Contracted Research: Gilead Sciences, Inc.; Speakers Bureaus: Abbvie Inc., Gilead Sciences, Inc., Merck & Co., Inc., ViiV Healthcare.

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Planners and Managers

The PIM planners and managers have nothing to disclose. The Integritas Communications planners and managers, Julia Muino and Jim Kappler, PhD, have nothing to disclose.

PREAMBLE

DISCLOSURE OF UNLABELED USE

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the US Food and Drug Administration. PIM and Integritas Communications do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of any organization associated with this activity. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

DISCLAIMER

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed in this activity should not be used by clinicians without evaluation of patient conditions and possible contraindications on dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

INSTRUCTIONS TO RECEIVE CREDIT

In order to receive credit for this activity, the participant must attend the program and complete the program evaluation.

PIM CONTACT INFORMATION

For information about the accreditation of this program, please contact PIM via email at inquiries@pimed.com.

FEE INFORMATION & REFUND/ CANCELLATION POLICY There is no fee for this educational activity.

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HCV CLINICAL PRACTICE GUIDELINES »» HCV Guidance: Recommendations for Testing, Managing, and Treating Hepatitis C. American Association for the Study of Liver Diseases/Infectious Diseases Society of America, 2017. https://www.hcvguidelines.org/

»» Testing Recommendations for Hepatitis C Virus Infection.

Centers for Disease Control and Prevention.

https://www.cdc.gov/hepatitis/hcv/guidelinesc.htm

»» A Guide to Comprehensive Hepatitis C Counseling and Testing.

Centers for Disease Control and Prevention.

https://www.cdc.gov/hepatitis/resources/professionals/pdfs/ counselingandtestingpc.pdf

»» Hepatitis C in Pregnancy: Screening, Treatment, and Management.

Society for Maternal-Fetal Medicine.

https://www.ajog.org/article/S0002-9378(17)30930-4/fulltext

»» Hepatitis B and Hepatitis C in Pregnancy.

The American College of Obstetricians and Gynecologists.

https://www.acog.org/Patients/FAQs/Hepatitis-B-and-Hepatitis-C-inPregnancy

»» Viral Hepatitis Surveillance — United States, 2016.

RESOURCE CENTER

Centers for Disease Control and Prevention, 2016.

https://www.cdc.gov/hepatitis/statistics/2016surveillance/ pdfs/2016HepSurveillanceRpt.pdf

HIV CLINICAL PRACTICE GUIDELINES »» Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents With HIV. US Department of Health and Human Services, 2017 (last updated October 2018). https://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-arv/0

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»» Guidelines for Managing Advanced HIV Disease and Rapid Initiation of Antiretroviral Therapy.

World Health Organization. Geneva, 2017.

http://www.who.int/hiv/pub/guidelines/advanced-HIV-disease/en/

»» Patients With HIV/HCV Coinfection.

American Association for the Study of Liver Diseases/Infectious Diseases Society of America, 2018 Update. https://www.hcvguidelines.org/unique-populations/hiv-hcv

»» Preexposure Prophylaxis for the Prevention of HIV Infection in the United States—2017 Update.

Centers for Disease Control and Prevention/United States Public Health Service.

https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2017.pdf

PROVIDER RESOURCES »» Harm Reduction Coalition. http://harmreduction.org/

»» American Academy of HIV Medicine, 2018. https://aahivm.org/provider-resources/

PATIENT RESOURCES »» HCV Patient Education Resources.

Centers for Disease Control and Prevention. Fact Sheets for Patients. https://www.cdc.gov/hepatitis/hcv/patienteduhcv.htm

RESOURCE CENTER

»» Hepatitis C and Injection Drug Use.

This webpage provides concise information regarding HCV risk, transmission, and prevention in people who inject drugs. https://www.cdc.gov/hepatitis/hcv/pdfs/factsheet-pwid.pdf

HIV Patient Resources »» Centers for Disease Control and Prevention.

Resources for Persons Living With HIV.

https://www.cdc.gov/hiv/basics/livingwithhiv/resources.html

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SUGGESTED READINGS »» Vertical transmission of hepatitis C: towards universal antenatal screening in the era of new direct acting antivirals (DAAs)? Short review and analysis of the situation in Switzerland.

Aebi-Popp K, et al. J Virus Erad. 2016;2(1):52-54.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4946698/

»» Premature ovarian senescence and a high miscarriage rate impair fertility in women with HCV. Karampatou A, et al. J Hepatol. 2018;68(1):33-41.

https://www.journal-of-hepatology.eu/article/S0168-8278(17)32259-6/fulltext

»» Medical and behavioral approaches to engage people who inject drugs into care for hepatitis C virus infection.

Gonzalez SA, et al. Addict Disord Their Treat. 2017;16(2 suppl 1):S1-S23. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5491232/

»» National Viral Hepatitis Action Plan 2017–2020.

US Department of Health and Human Services, 2017.

https://www.hhs.gov/hepatitis/viral-hepatitis-action-plan/index.html

»» The HCV care continuum does not end with cure: a call to arms for the prevention of reinfection.

Falade-Nwulia O, Sulkowski M. J Hepatol. 2017;66(2):267-269.

RESOURCE CENTER

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5472097/

»» Treatment of HCV in persons who inject drugs: treatment as prevention.

Grebely J, Dore GJ. Clin Liver Dis. 2017;9(4):77-80.

https://aasldpubs.onlinelibrary.wiley.com/doi/full/10.1002/cld.626

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