The NEW ENGLA ND JOURNAL of MEDICINE

Perspective August 31, 2017

A Tale of Two Epidemics — HCV Treatment

among Native Americans and Veterans
Brigg Reilley, M.P.H., and Jessica Leston, M.P.H.​​

I
n light of ongoing debates about health care
HCV Treatment among Native Americans and Veterans

active role in the elimination of

budgets and rising drug prices, a current public HCV infection. Now the biggest
barrier is cost: the retail price of
health crisis can provide useful insights. For each pill is more than $1,000.
patients who get their health care through two Even when federal discounts
are factored in, cost is a formi-
separate federal agencies, the hep- they are infected, since HCV often dable hurdle to treating large
atitis C virus (HCV) epidemic is remains asymptomatic for many numbers of patients. Yet the VA
unfolding in vastly different ways. years as it silently damages the is on track to complete treatment
In recent years, the Department liver. Risk factors for HCV infec- of all its HCV-infected patients
of Veterans Affairs (VA) health tion include injection-drug use — nearly 200,000 people — with-
care system has mounted a re- and historical medical exposures in the next few years.2 In contrast,
sponse to HCV that should be (such as through blood transfu- the IHS, which covers roughly
the envy of any health system, sion prior to 1996). The virus is the 40% fewer patients with HCV
public or private. On the other driving force behind increasing than the VA does,3 will need dec-
hand, the Indian Health Service rates of liver cancer in the United ades to treat all of them. This
(IHS), an agency that serves Amer- States, and it kills more Ameri- disparity has taken a measurable
ican Indians and Alaska Natives, cans than 60 other notifiable in- toll: American Indians and Alaska
is struggling to meet the needs of fectious diseases, including HIV, Natives have the highest HCV-
its patients with HCV. combined.1 In recent years, break- related mortality of any race (in
Hepatitis C is a chronic viral throughs have resulted in medica- 2015, a total of 12.95 per 100,000,
infection that affects an estimated tions that can reliably cure HCV, as compared with 4.91 per
3.5 million Americans. The major- often by means of a single pill 100,000 in the U.S. population as
ity of these people were exposed taken once a day for just 12 weeks. a whole).4 How has one popula-
to the virus decades ago, and These new medications allow tion fared so well, while the other
many of them still don’t know primary care providers to take an has been left so far behind?

n engl j med 377;9  nejm.org  August 31, 2017 801

The New England Journal of Medicine
Downloaded from nejm.org on August 31, 2017. For personal use only. No other uses without permission.
Copyright © 2017 Massachusetts Medical Society. All rights reserved.
PERS PE C T IV E
2.5
American Indian or Alaska Native
Reported Cases of Acute Hepatitis C
White, non-Hispanic
2.0 Hispanic
(per 100,000 population)
Black, non-Hispanic
Asian or Pacific Islander
1.5
1.0
0.5
0.0
2000 2003 2006
Incidence of Acute Hepatitis C in the United States by Race and Ethnicity, 2000–2015.
The graph shows new HCV infections, and only a fraction of patients with HCV present with acute
symptoms. Data are from the Centers for Disease Control and Prevention.
One answer would be resources.
The VA cares for about 4 times as
many patients as the IHS, but its
budget is more than 10 times as
large (the VA budget is $59 bil-
lion, which has been supplement-
ed by more than $2 billion ear-
marked for HCV; the IHS budget
is $5.7 billion, inclusive of collec-
tions from public and private in-
surers). The IHS spends $3,688
per capita on health care — less
than half the average for the
United States as a whole ($9,523).5
Once the VA received supplemen-
tal funding for expensive new
HCV medications, it placed the
drugs on its National Core For-
mulary and lifted all nonclinical
restrictions on treatment. As a
result, treatment rates increased
more than 20-fold.2 HCV drugs
aren’t on the IHS formulary, how-
ever, so clinicians must spend
considerable time mounting often
unsuccessful attempts to get third-
party payers such as private in-
surers, Medicaid, and patient-
assistance programs to pay for
them. Such payers have strict cri-
teria regarding HCV treatment,
since they must try to shield
their own budgets from the costs
of an expensive cure for a com-
802
The New England Journal of Medicine
Downloaded from nejm.org on August 31, 2017. For personal use only. No other uses without permission.
Copyright © 2017 Massachusetts Medical Society. All rights reserved.
HCV Treatment among Native Americans and Veterans
2009 2012 2015
mon disease. The end result is
that VA clinicians can provide
treatment for all their patients
with HCV, whereas their IHS
counterparts cannot.
The slow progress toward elim-
inating HCV isn’t the result of a
lack of dedication on the part of
IHS and tribal clinicians. The
agency makes use of telehealth
and teleconsultation services with
external HCV specialists and has
many facilities that are success-
fully treating small numbers of
patients at the primary care level.
The IHS participates in multiple
telehealth programs on HCV each
month, using the ECHO (Exten-
sion for Community Healthcare
Outcomes) platform. Dozens of
IHS clinicians have attended in-
person immersion training on
HCV treatment through partner-
ships with the University of New
Mexico and the University of Cal-
ifornia, San Francisco. Regional
HCV telehealth clinics have been
replicated by tribal entities in the
Midwest and Northwest. The IHS
has offered national guidance on
HCV screening and facility-level
policy and has conducted multi-
ple Web-based HCV grand rounds
and training sessions.
n engl j med 377;9  nejm.org  August 31, 2017
These efforts are laudable in a
network of mainly rural health
care facilities with very few spe-
cialists, but they aren’t enough to
meet clinical demand. Conversa-
tions with IHS providers reveal
frustrations that have a common
theme: if newer HCV drugs were
on the IHS formulary, providers
could treat many more patients.
Telehealth clinics and capacity
building are essential, but they
aren’t sufficient to respond to the
needs of all IHS patients with
HCV; lack of drug access is the
single most important barrier to a
wider scale-up of HCV treatment
within the IHS.
Discussions about federally
funded health care for American
Indians tend to evoke certain
stock responses. One is that Amer-
ican Indians have widespread
wealth from casinos to supple-
ment federal funding. In reality,
only a small proportion of casinos
earn substantial profits for tribes.
The vast majority of American
Indian Nations, by virtue of hav-
ing been pushed onto the most
remote and undesirable land,
must depend on federal dollars
for the operating budgets of the
health facilities that serve their
communities.
A second response is that the
IHS falls short in certain aspects
of its delivery of health care. Al-
though the agency’s shortcom-
ings have recently been covered
by the media, the VA faces simi-
lar problems but has shown that
federal health care can deliver
strong results in HCV elimination
if it is properly resourced.
The U.S. government has a
special responsibility to both
American Indians and veterans.
Veterans have served their coun-
try. Indian Nations, after a long
struggle, have treaties ratified
PE R S PE C T IV E
by the government that dictate
sovereign nation-to-nation rela-
tionships and a federal trust re-
sponsibility to uphold treaty agree-
ments. The current disparities in
HCV resources and mortality give
the appearance of neglect at best
— and institutional racism at
worst. American In-
An audio interview
with Mr. Reilley is
dian nations deserve
available at NEJM.org the same quality of
care and the same
level of resources as the VA. The
IHS serves the population with
the highest HCV-related mortal-
Interprofessional Education
Interprofessional Education — A Foundation
for a New Approach to Health Care
Alan Dow, M.D., M.S.H.A., and George Thibault, M.D.​​
“This might have been the
most important thing I did
in medical school,” the fourth-
year student said. “It felt like we
had an impact.”
The student was reflecting on
a program during his final semes-
ter of medical school in which he
collaborated with a team of stu-
dents from nursing, pharmacy,
social work, and anthropology.
The team worked with three pa-
tients who were identified by their
primary care physician as having
uncontrolled health problems. The
students sought to identify under-
lying barriers to improving the
patients’ health by visiting them
in their homes and accompany-
ing them to health care visits.
Then they leveraged the expertise
of each of their disciplines to de-
velop solutions to overcome those
barriers.
For example, one patient’s
medical conditions had recently
become uncontrolled. None of
n engl j med 377;9  nejm.org  August 31, 2017
The New England Journal of Medicine
Downloaded from nejm.org on August 31, 2017. For personal use only. No other uses without permission.
Copyright © 2017 Massachusetts Medical Society. All rights reserved.
HCV Treatment among Native Americans and Veterans
ity and highest incidence of acute
HCV in the country (see graph).
Providing supplemental funding to
add new HCV medications to its
National Core Formulary would
be a huge step toward ensuring
equitable access to treatment.
Disclosure forms provided by the authors
are available at NEJM.org.
From the Northwest Portland Area Indian
Health Board, Portland, OR.
1. Ly KN, Hughes EM, Jiles RB, Holmberg
SD. Rising mortality associated with hepati-
tis C virus in the United States, 2003-2013.
Clin Infect Dis 2016;​62:​1287-8.
2. Moon AM, Green PK, Berry K, Ioannou
her health care practitioners had
identified the underlying cause
— grief over the recent death of
her husband. But by spending
time with her in her home, the
students came to recognize the
effects of loss and mourning.
The social work and nursing stu-
dents got the patient’s daughter
involved in helping to support her
mother, while the medical and
pharmacy students developed a
more streamlined approach to
managing her medications. By the
end of the semester, the patient’s
medical conditions had stabilized,
and the students, the patient, and
her daughter were working to-
gether to enhance the woman’s
health — for instance, by read-
ing nutrition labels together and
developing strategies for healthier
eating. Through this experience,
the students gained firsthand
knowledge of the potential of in-
terprofessional teams to adapt to
— and better meet — the needs
GN. Transformation of hepatitis C antiviral
treatment in a national healthcare system
following the introduction of direct antiviral
agents. Aliment Pharmacol Ther 2017;​ 45:​
1201-12.
3. Edlin BR, Eckhardt BJ, Shu MA, Holm-
berg SD, Swan T. Toward a more accurate
estimate of the prevalence of hepatitis C in the
United States. Hepatology 2015;​62:​1353-63.
4. Viral hepatitis surveillance:​United
States, 2015. Atlanta:​Centers for Disease
Control and Prevention, May 2017 (https:/​/​
www​.cdc​.gov/​hepatitis/​statistics/​2015surveil
lance/​pdfs/​2015HepSurveillanceRpt​.pdf).
5. Indian Health Service. IHS 2016 profile
(https:/​/​w ww​.ihs​.gov/​newsroom/​factsheets/​
ihsprofile/​).
DOI: 10.1056/NEJMp1705991
Copyright © 2017 Massachusetts Medical Society.
HCV Treatment among Native Americans and Veterans
of patients and society. That is
the promise of interprofessional
education (IPE).
As the World Health Organiza-
tion defines it, “Interprofessional
education occurs when two or
more professions learn about,
from and with each other to en-
able effective collaboration and
improve health outcomes.”1 The
recent surge in interest in IPE
grew out of the patient-safety
movement2: failures of teamwork
and interprofessional communi-
cation were, and continue to be,
frequent causes of harmful medi-
cal errors. Training practitioners
with better skills in teamwork
and communication is thought to
be essential for preventing these
errors.
In addition, IPE has been pro-
moted as part of the solution to
other problems facing society’s
health. Training health care pro-
fessionals who know how to adapt
within a team to the needs of a
803