First for hiv and now for hepatitis that you see in australia that you see in chicago new york, san francisco and our goal over the last 10 years has been to try to catch up and to see. If we can make washington d.c a model for good practices rather than what our history was before 2007. and i have to say a lot of what i’m going to talk about the strategy for the clinical studies, we’re really led by sean codlill who’s on the organizing Committee of this and some of the younger people that he attracted to washington to work on this, so that a lot of this, of what i’m going to say, really reflects what they have done. One of the issues i’d like to bring up is how we use some of the lessons from hiv to attack hcv and our city. Hepatitis c, as best we can tell, is more prevalent than hiv, and yet obviously it gets a lot less attention and a lot less funding. As we will see, the question is: how do we really move forward with hepatitis c because, certainly being a federal city, we would like to do the things that andy has outlined in his national strategy, because i think that clearly would be a model for other people. Uh to to follow one of the interesting aspects, also, our approach is the nih has traditionally not done this kind of implementation, research or implementation work.
We have a 30 year history, starting back from when mitch matsuya was a young man at nih, developing new drugs. In doing basic research and doing translational research and it wasn’t really until 2007, when we realized how bad things were with hiv in washington dc, that we decided that from an intramural perspective, we need to do more in terms of looking at implementation and how we can Improve washington dc so that our nation’s capital wasn’t lagging behind the rest of the country. So the question is: what lessons did we learn with from hiv? Again in 2007, we were embarrassed to recognize that while we knew the hiv in dc was bad. We had not collected any data, or i should say we collected data. The d.c government had not put together the data or published the data as to what the incident was. So when the gw school of public health probably eventually got their hands on the data and published a report with the d.c government, it was clear that d.c had a huge problem and one of the problems that we’ll get into that i see is we really don’t Know what the prevalence of hepatitis c is in washington dc, because we don’t have the funding to do the the kind of studies that need to be done. We launched this project on hiv as a partnership between the city, government and the federal government. I think what andy alluded to before is clearly.
We need the partnership of various components of the federal government to work with state and local governments, because the amount of money that we need, as well as the coordination we need, i think, is only possible with the federal government. So this is in dc how we launched our problem in our project in 2007, with tony fauci there on the left and then mayor fenty on the right. So what did we do for hiv? That needs to be again a strategy for what we do for hcv. One of the things that we did not have is a good sense of who the patients were who had hiv. So we built a citywide cohort that was modeled after some of the cdc cohorts, and this now has over 10 000 patients that we follow in real time so that we can see what’s happening in terms of testing and treatment for for hiv. And this has been a huge advance in terms of our ability to make sure that patients are under care or listed to initiatives to enhance the likelihood of their undercare and being effectively treated. There had been no hiv prevention, research in washington dc. This was launched in washington is now one of the leaders nationally in terms of uh of uh hiv prevention, research, uh, uh, patient uh, recruitment and retention. We did a test and treatment initiative and we started clinical research and again under sean kotliel’s uh leadership. One of the issues that the providers in washington said was a big issue was not getting patients and retroviral drugs.
It was comorbidities, especially liver disease, main event. To tackle hiv. We needed to get a patient cohort, so we could follow our patients. We needed to initiate prevention, research, we needed to do more, widespread testing and we needed to start looking in terms of research at what were the major causes of morbidity and mortality. Unlike some of the cities that many of you have been working in, our city did not have good interaction between community providers, academic centers and the department of health and nih was sitting up in bethesda with no real role in terms of this into 2007.. One of the first issues we had to address was how to get these groups to see that they had a common interest in terms of working together so that they could tackle this problem and that took a fair amount of work to get these groups to work Together, but i think 10 years later, we do have have a cohesive group, and that gives us real advantage for how we’re going to attack hepatitis c, because we are all talking together. The citywide database has been a great success for hiv. We have 10 000 of the 14 000 people in our d.c cohort. We would like to have the same for hepatitis c for mono infected people, but we don’t have the funding so again. Funding for some of these tools will help us understand our population and monitor how they’re treated whether getting reinfected requires money that we simply don’t have because nih is an important part of this project.
Nih, i think all of you have grants, will recognize, and i understand only one thing, and that is publications so that if you’re putting a nice money into projects and you don’t publish you’re not going to get funded again so again, one of the things that sean Made sure we did is that, as we looked at comorbidities as we looked at other aspects of clinical care, that we publish our results and again if the city was going to have credibility and we’re going to get funding from nih as well as other agencies, we Needed to make it clear that the science behind all this was sound so, ultimately, in terms of hiv, we were able to get these groups together and getting these groups together had a number of major advantages. One is in getting the department of health, the the relatively new george washington school of public health and nih and academic partners together. This led to a synergy that brought many talented, younger people into the effort into the city. Some of them are are sitting in this room today, and this led to may more knr grants this led to more people coming into the city and ultimately led to the city being able to attract people like alan greenberg, who really started this effort coming from cdc And doug nixon who was getting, who was able to get one of the martin delaney grants and those these really put nih on the map in term i’m? Sorry, these really put washington d.
c on the map as a city that could do important research and try to understand the hiv epidemic. This is the same thing we need to do for a for hcv. We are proud of the fact that these efforts for hiv had dramatic results, not all of which were due to these interventions, but many were, and, for instance, if you look at the number of patients who are living with hiv, it increases over the years as fewer Patients are dying as we’re recognizing more patients, but, most importantly, is the orange line, which shows that the number of new cases has gone down from about 1100 a year to 325 and that’s something we’re proud of accomplishing. The question is: can we do the same with hepatitis c? How is this challenge different? First of all, if you look at federal funding, it’s very hard to actually get an accurate assessment of what federal funding is for a given locality. So i took the easiest route, which was to call the deputy commissioner of health for hiv in dc and said how much federal funding do you get for hiv compared to hepatitis c and again, to some extent, these are distorted by whether or not the funding includes Funding for for drugs, but our city gets about 180 000 a year from the federal government for surveillance, another several million for hepatitis c treatment and that’s compared to 70 million dollars a year for hiv. So the disproportionate funding really makes a huge effort in terms of what we can do in terms of understanding the prevalence of hepatitis c and in terms of initiating therapy again, whether that is an appropriate allocation.
I think remains to be seen but clearly limits what the city can do. I think everybody is aware, as andy alluded to that, if you look at the continuum of care, we know what this continuum of care is for. Hiv again in 2017 is probably a little bit better than these data that come off the cdc website which were as of 2014. But if you look at the continuum of care for hepatitis c, whether you look nationally or you look at the most recent data that we have for washington, d.c, the number of people who have been prescribed, hcv treatment or the number of people who have achieved cure Is disturbingly low again, andy alluded to the reasons why this is the case: some economic, some health care awareness, some community awareness, but clearly we need to do better. If you look at where the epidemic is in our city on the left, there you see the cases with hepatitis c on the right. You see the cases of hiv and the density of the color relates to the prevalence of the disease. There are some similarities in the epidemics in terms of where they occur and in our poorest wards words, seven and eight. You can see that there is a lot of both diseases, but there is a difference in distribution which reflects the fact that, as our previous two speakers alluded, all epidemics are local, so in our city, hepatitis, c and hiv do overlap in many areas, but they also Involve some distinct populations, as you can see at least geographically that’s, something that we have to understand better so in terms of managing persons with hiv.
One of the things i think we all recognize is that actually the center should be hcb that if you look at patients, persons with hcv, if we’re really going to improve their health care, many of the issues that raymond has brought into this conference today, we have To deal with, we have to deal with not just the liver disease, but their opioid substance, abuse, their fatty, liver, their diet and obesity, their co infection with hiv, the fact that they have accelerated aging. All these are issues that we have to deal with. If we’re not only going to decrease hepatitis c, but if we’re also going to increase their longevity and decrease their long term morbidity – and this is something that we’re trying to deal with in terms of having more one – stop shopping in terms of where patients get their Care, but the real problem is in terms of what do we know about how much hepatitis c there is in the city and how many people are getting treated. The estimate of 2.7 is something the health department has come up with, but if you ask the director of medicaid in dc, if you ask some of the academics, the percent of patients, the prevalence of potassium varies widely. We really do not have good data, so i was easy to put this kind of slide together and says 2.7 for hepatitis c. We think that the 2.0 is a good uh is an accurate reflection of how much hiv there is in the city.
We really don’t know how much hepatitis c there is and again the dc medicaid director thinks that she has treated a large percentage of the patients in dc, who have hepatitis c. Most other people think that certainly isn’t the case, but without data we really don’t know. So we really don’t know how many people in the district have hepatitis c. The next question is how many people, who we know have hepatitis c get treated and the everybody in the in in the room recognizes that, as you heard from margaret, as you heard from andy, there are many different opportunities to get treated for hepatitis c, depending on What kind of insurance you have, but everybody has the experience if you have private insurance, if you have medicare, it is relatively hassle, free and i say relatively, but if you have medicaid depending on our city on what kind of medicaid you have the barriers in terms Of alcohol, drugs, fibrosis and paperwork can be daunting, so our three medicaid providers have very different standards and again this makes it very complicated for providers. I think we can all understand why the providers are reluctant to get involved in hepatitis c treatment, because while they clearly want to do what’s best for the patient, this is a time consuming onerous approach. I think, probably also in every city. You recognize that, depending on who you are and what kind of insurance you have, the likelihood of your getting offered treatment varies uh dramatically.
So, for instance, if you looked at the va system, i think we all admire what the va system has done in terms of recognizing and treating hepatitis c and each time i talked to eleanor wilson who what she’s done in maryland. I talked to amy weintraub in d.c it’s, amazing, that they’ve treated 70 80 or even more percent of the patients who are recognized with hepatitis c. If you talk to michael horberg for kaiser dc they’ve, also treated 65 to 70 percent of their patients with either hcv mono infection or hcv co infection. The problem, of course, is that if you look at medicaid depending on what you think the medicaid population is – and we estimate this at least 10 000 patients – the number of patients been treated with medicaid is very slim, and now in our city we treat 200 to 500 patients per year on medicaid, so this is a tiny fraction of the patients that we estimate need to be treated so again, there’s great inequity, depending on what your insurance is. This is obvious to all of us again, something that we have to deal with. Why are more practitioners not treating hepatitis c? I think i indicated to you that the big issue is what kind of insurance you have and how much of a hassle, but again as andy alluded to the issue, is not so much what kind of pro how many providers you have. Studies have been done, such as the study, the ascendant study that we did in the district, which have shown that nurse practitioners and primary care physicians can do a great job at treating most patients of hepatitis c in the study that we showed and that we did.
If you look at nurse practitioners, you look at general practitioners. If you look at specialists, their likelihood of achieving svr was equal. Our studies are done in almost entirely minority populations. They have many problems with substance, abuse and alcohol, and, while some of the reviewers of the study were not impressed that 85 to eighty nine percent of the patients were treated, we were very impressed considering the trouble these patients have uh in terms of the challenges of Daily life, but again, the problem is not that a nurse practitioner or a general practitioner can treat every patient with complicated liver disease, but they’re plenty that they can do a great job with. Given the simplicity of current regimens and again, the adherence of patients in picking up their prescriptions was much higher than the number of visits they made, suggesting that it’s important to them that they get their drugs and take it and again, we were very pleased with the Outcome, but what really is going to change hepatitis c in our city or in the country? Again andy alluded to the fact that we need people to speak up. We need more advocacy. I think some of us have forgotten how effective the hiv advocacy groups were in making sure that the federal government and state and local agencies responded to the urgency of hiv and came up with money and resources. We need more of that with hepatitis c. We need to support the great groups that are currently doing that again in terms of funding.
The ryan white care act was tremendous in terms of expanding hiv coverage in this country. We need the same kind of congressional action for hepatitis c. I think the national plan is a good initial step in terms of getting there so will dc eliminate hiv. The plan that you show that andy showed for the nation, i think, is something that we would like to generate. The district of columbia. Department of health has a great strategic plan for limiting hiv. They do not have a plan for eliminating hepatitis c. I think we need the attention of our political leaders. We need funding, we need advocacy and at least in washington dc, while we’re hoping at this meeting, to learn some of the best practices from the from the rest of you. Unless we have advocacy, unless we have more funding less, we have more buy in for our political leadership, we’re uh.