[I]nitiating HCV treatment is almost never an emergency; there’s no reason for clinics to exceed what they feel they can safely handle at any given time. A clinic thinking about beginning an HCV treatment program should assess its resources, start slowly, and build capacity as [staff] gain experience.145 —Michael Rigsby, MD Director, VA HIV and Hepatitis C Program Office

Conclusion

In the United States, HCV coinfection is a major contributor to morbidity and mortality among PLWHA. Many coinfected people are from traditionally underserved, uninsured, and hard-to-reach communities. HIV/HCV coinfection is linked with psychiatric disorders, drug and alcohol dependence, poverty, homelessness, incarceration, and race.168,169,170 Those barriers are amplified by limited access to HCV diagnostic testing and treatment and restrictive eligibility criteria for treatment. The side effects and limited efficacy of drug therapy in people with HIV/HCV coinfection create additional obstacles for coinfected patients and their clinicians. Despite these challenges, HCV can be successfully treated in PLWHA.

CARE Act providers have already developed innovative models for delivering HCV care and treatment.56,68,171 The CARE Act community has a wealth of experience in providing culturally competent care and treatment to underserved individuals and diverse communities. Providers have demonstrated the capacity to respond to changes in care and treatment paradigms, patient demographics and, most significantly, decreasing resources in the face of increasing need. Thus, the CARE Act community is ideally suited to tackle HCV/HIV coinfection.

Addressing coinfection seems daunting, but that is not the reality. Not all coinfected patients require HCV treatment, and not every clinic will—or should—provide comprehensive treatment services for coinfected patients. All HIV treatment providers, however, should develop a supportive structure for coinfected patients, whether or not they plan to deliver HCV drug treatment onsite. Specifically, providers should provide screening, education, and support—services that can be coordinated and delivered by clinic staff, case managers, and peers.56,57,67,68 Those services create the foundation for referrals when onsite care is not feasible.

Referring patients to off-site providers may seem like the best option for many HIV/AIDS services providers. Many liver specialists, however, are not comfortable treating HIV-positive people and do not have experience treating patients with multiple psychosocial needs. Fortunately, experienced HIV care providers have many tools at their disposal with which to increase their capacity to deliver HCV care and treatment, including collaboration with culturally competent liver specialists, miniresidency programs, journal clubs, consultation, and co-locating care.

In the coming years, we are likely to see significant progress in HCV treatment, echoing the advent of HAART in HIV disease. Several therapies have entered clinical trials, and early data are promising. Novel, potent oral agents may significantly shorten the course of treatment and increase SVR rates. Yet, coinfected patients will not benefit from upcoming improvements in HCV treatment unless care and treatment are delivered in a supportive, multidisciplinary context. Coinfected patients require education and integrated medical, mental health, and addiction treatment services.

As CARE Act providers have learned during more than 15 years of experience with HIV disease, a strong infrastructure is crucial for successful delivery of care and treatment, particularly for people with multiple diagnoses. Models for delivering HCV care must be developed now—to meet current needs, anticipate therapeutic improvements, and accommodate corresponding increases in HCV treatment uptake among people with HIV/HCV coinfection. The CARE Act community has successfully reached underserved PLWHA and increased the length and quality of their lives, and it has the skill and expertise to do the same for coinfected persons.