I think there is another issue that Dr. Dickson pointed out. Although it is small and really only occurs in some regions, there is a young population of people with HCV. Some of the models of care that we have used may not work with this population, and we have to recognize that this will be an ongoing issue. Care for these patients will look different. For example, clinics may need to provide child care for this younger population.
Cancer is another important issue. Many of these people have cirrhosis, and even if we cure their HCV, we have to remain cognizant that they still have cirrhosis and potentially need screening for hepatocellular carcinoma. They also may need care for their cirrhosis or counseling about ongoing alcohol use, because even though their HCV was cured, continued alcohol use is not good for their cirrhosis.
Those 3 issues are still in the immediate future of HCV care in the VA. The World Health Organization has a goal for eliminating HCV. One could hope that maybe we could get there; it may be possible through screening, treatment, and prevention strategies. If we are lucky, we could put ourselves out of a job. I don’t see that happening, but it’s a hope.
Ms. Trimble. Are we seeing the same trend in new infections in young injection drug using veterans that are being seen in the nonveteran population nationally?
Dr. Backus. We have looked at this quite closely. The CDC came out with a report recently that showed a substantial increase in HCV cases in people aged 20 to 39 years. At the VA, we have not seen that uptick. The VA rates of new infections or new diagnosis of infections in peopled aged 20 to 39 years are pretty stable. The VA screening rates in people who were born after 1965 is in the high 70% range—nearly as high as in the cohort of people born between 1945 and 1965. As a result, the VA has excellent internal data about the incidence of infections in younger populations. In the VA, we are not seeing this sort of massive increase in incidence in younger populations. Definitely, there are new young injection drug users in the VA who are contracting HCV but not what the CDC is reporting in other parts of the country.4
Ms. Trimble. That’s really interesting.
Dr. Ho. Part of that has been the fact that if you’re a VA patient, you had to have been engaged at some point with the VA with access to its extensive psychiatric mental health and substance use disorder treatment infrastructure. I wonder if the availability of these services is a factor that can be protecting our patients from this recent upsurge in injection drug use.
Dr. Dickson. For our VISN, we do have smaller sites with a number of their remaining viremic veterans in this young cohort who are indeed proving to be a challenge to link to care in the HCV clinics. We continue to brainstorm ideas to determine and overcome their barriers to treatment. The VA is excellent at connecting all of us nationwide, so we look forward to hearing from other sites in a similar situation on how they are overcoming this challenge. Because when you look outside the VA, many are wondering what to do and how to engage these patients.
Dr. Backus. One of the amazing things about HCV treatment is how effective it has been. Traditionally the real-world effectiveness for medications is not nearly as good as the clinical trial efficacy. Clinical trials have extra resources, specially trained doctors and nurses, and tend to recruit engaged and cooperative patients. Often, there has been a stepdown between the clinical efficacy from the trials and what we see in the real world. A pleasant surprise about DAA treatment at the VA is that the clinical effectiveness we see in the real world almost matches the amazing results seen in clinical trials. That also has been critical to the success that we are seeing. The medications are powerful, and even outside the settings of a clinical trial, they work incredibly well.
Dr. Ho. I agree. You, Dr. Backus, along with Pam Belperio, PharmD, George Ioannou MD, MS, and other VA researchers have done excellent work in documenting the real-world effectiveness of these medications in the VA system. It was surprising but not unexpected.5-7 It is due to the VA’s excellent clinical infrastructure and that it provides an integrated system for caring for these patients. It is a measure of that success.
Dr. Dickson. The multidisciplinary teams are a major part of that. I don’t think we could care and support the veterans that we have, especially the challenging ones, the ones who are resistant, without having nursing, social work, mental health, and pharmacy involved. It’s just a huge team effort. That is what I love about caring for patients at the VA—it’s always been supportive of the multidisciplinary aspect of looking at this disease.