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Article American Academy of Nursing on Policy| Volume 62, ISSUE 5, P371-373, September 2014

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American Academy of Nursing: Hepatitis C testing in the birth cohort 1945-1965: Have you been tested?

  • American Academy of Nursing, Washington, DC

      Executive Summary

      In July 2012, the American Academy of Nursing endorsed the recommendations of the Expert Panel on Emerging Infectious Diseases to accelerate efforts to remove barriers for hepatitis C screening and testing (
      • Zucker D.M.
      Hepatitis C screening and testing: A call for a national response.
      ). One month later, the Centers for Disease Control and Prevention announced its “Recommendations for the Identification of Chronic Hepatitis C Virus Infection Among Persons Born During 1945–1965.” These baby boomers account for 76.5% of HCV cases in the United States (

      MMWR. (2012). Recommendations for the identification of chronic hepatitis C virus infection among persons born during 1945–1965. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6104a1.htm.

      ). Unfortunately, the stigma of injection drug use has been a major factor that has limited the success of current risk-based testing strategies (
      • Treloar C.
      • Rhodes R.
      The lived experience of hepatitis C and its treatment among injecting drug users: Qualitative synthesis.
      . Of the estimated 2.7 to 3.9 million persons living with HCV infection in the United States, one study found that 72% of persons with a history of injection drug use who are infected with HCV remain unaware of their infection status (
      • Hagan H.
      • Campbell J.
      • Thiede H.
      • Strathdee S.
      • Ouellet L.
      • Kapadia F.
      • Garfein R.S.
      • et al.
      Self-reported hepatitis C virus antibody status and risk behavior in young injectors.
      ). Barriers to testing include inadequate health insurance coverage and limited access to regular health care, despite having insurance coverage.
      • Zucker D.M.
      Hepatitis C screening and testing: A call for a national response.
      previously identified the following barriers to care for patients with viral hepatitis: (a) unclear definition of “acute” HCV and how this impacts surveillance; (b) limited federal support for surveillance services and different systems for monitoring; (c) lack of a universal immunization registry; and (d) limited resources to support hepatitis A and B vaccination. Additional barriers to care have been the treatment ineligibility of patients with significant comorbidity, treatment that was ineffective in large numbers of patients who experience great morbidity, and the challenges of getting African Americans into treatment.

      Background and Problem Identification

      Although these barriers continue to pose problems, the lack of education for patients with hepatitis is a significant barrier that inhibits adequate care and subsequent cure (
      • Zeremski M.
      • Zibbell J.E.
      • Martinez A.D.
      • Kritz S.
      • Smith B.D.
      • Talal A.H.
      Hepatitis C virus control among persons who inject drugs requires overcoming barriers to care.
      ). Because the disease may be silent for a number of years, individuals are often unaware that they have HCV. Disease progression is slow, and the first signs of disease may be joint pain, jaundice, ascites, end-stage liver disease or hepatocellular carcinoma; in the latter two conditions, the prognosis is poor. To address this barrier, the U.S. Preventive Services Task Force released their recommendations to screen for HCV infection in persons at high risk for infection and also to offer one-time screening for HCV infection to adults born between 1945 and 1965 (

      U.S. Preventive Services Task Force. (2013). Screening for hepatitis C virus infection, topic page. Retrieved from http://www.uspreventiveservicestaskforce.org/uspstf/uspshepc.htm.

      ). The question now is, “How are we doing?”
      The answer is that depends. Although we have made little progress on addressing barriers to care, we know that recent developments in the pharmaceutical treatment of HCV with all-oral regimens will soon be a reality. Once Food and Drug Administration approval of these new regimens is obtained, they will soon replace the existing combination therapy of interferon and ribavirin. Results from clinical trials confirm excellent cure rates in patients with genotypes 1, 2, and 3, and commercially developed drugs are now available (
      • Afdhal N.H.
      • Zeuzem S.
      • Schooley R.T.
      • Thomas D.L.
      • Ward J.W.
      • Litwin A.H.
      • Jacobson I.M.
      • et al.
      New Paradigm of HCV Therapy Meeting Participants
      The new paradigm of hepatitis therapy: Integration of oral therapies into best practices.
      ). We anticipate that this year patients with significant comorbidities will now be treated because these new drug regimens will have a lower side effect profile. However, the combination of efficient drugs for most patients and heightened government recommendations will put increased responsibility on primary care providers. Currently, nurse practitioners and physician assistants manage a large proportion of HCV patients; the number of such patients will likely increase as the demand for new therapies increases and additional patients who need treatment are identified. With this revolution in treatment for persons with HCV come added responsibilities for nurses and other health care providers, consumers, and insurers.

      Policy Position

      Strategic goals for success in meeting these recommendations include the following:
      • 1.
        Increase access to primary health care and prevention services in rural and urban settings.
        • Barocas J.A.
        • Brennan M.B.
        • Hull S.J.
        • Stokes S.
        • Fangman J.J.
        • Westergaard R.P.
        Barriers and facilitators of hepatitis C screening among people who inject drugs: A multi-city, mixed-methods study.
        examined barriers and facilitators to HCV screening in a large, multi-city study. Participants living in metropolitan areas and those with a primary care provider reported screening rates of 74% in the past year. Individuals living in non-urban settings without a primary care provider may experience significant barriers to screening. A successful model in Boston is using the electronic health record (EHR) to track and trigger if birth cohort patients have been tested. Surveillance data gathering and reporting varies state by state and is often inaccurate. In Massachusetts, all HCV test results from clinical laboratories are reported electronically to the Department of Public Health; however, the ordering clinician has the responsibility to report positive results to the DPH.
      • 2.
        Endorse patient-centered approaches that build relationships between patients and providers, thus reducing stigma. People with HCV experience stigma that can adversely affect treatment seeking and the patient-provider relationship. Building trust during the clinical encounter is an important first step in reducing stigma and increasing the use of health care services for people with HCV (
        • Treloar C.
        • Rance J.
        • Backmund M.
        Understanding barriers to hepatitis C virus care and stigmatization from a social perspective.
        ).
      • 3.
        Engage local, state, and national leaders who are influential in hepatitis policy, including members of Congress and the Administration using advocacy, outreach, and education. A Massachusetts example has used key stakeholders in clinical practice and health policy to engage in lobbying activities to inform and educate members of the legislature, CMS, and advocacy groups (C. Graham, personal communication, December 16, 2013).
      • 4.
        Increase the visibility and awareness of hepatitis in the United States by distribution of information through a variety of professional societies, advocacy groups, and other relevant organizations. Social media e-mail and professional websites are important tools that all health care professionals can use to promote the Centers for Disease Control and Prevention and U.S. Preventive Services Task Force recommendations. Such activities are consistent with the strategic priorities of the National Viral Hepatitis Roundtable (

        National Viral Hepatitis Roundtable. (2013). Strategic plan. Retrieved from http://nvhr.org/content/nvhr-strategic-plan-2.

        ).

      Role of Nurses

      The role of the nurse is crucial in optimizing success in HCV screening. In a redesigned health care delivery system, nursing case management not only provides continuity of care but also fosters patient advocacy (
      • Smith P.A.
      Case management in the GI clinic.
      ). Communication of the current U.S. government recommendations and conveying accurate and up-to-date information about hepatitis legislation, screening, testing, and treatment are vital. A recent report describes how emergency department nurses used the EHR to identify all patients born during 1945 to 1965 and administered a brief prescreening questionnaire; eligible patients were then screened for HCV (

      Galbraith, J. W., Franco, R., Rodgers, J., Donnelly, J. P., Morgan, J., Overton, E. T. , … Wang, H. E. (2013). Screening in the emergency department identifies a large cohort of unrecognized chronic HCV infection among baby boomers. Presented at the 64rd Annual Meeting of the American Association for the Study of Liver Diseases. Washington, DC, November 1-5, 2013. Retrieved from http://www.natap.org/2013/AASLD/AASLD_77.htm.

      ). Second is the critical role nurses play in successfully helping patients adhere to new treatment regimen.
      • Asher A.
      • Lum P.J.
      • Page K.
      Assessing candidacy for acute hepatitis C treatment among active young injection drug users: A case-series report.
      have concluded that a comprehensive, multidisciplinary program should include primary care, drug treatment, mental health services, HCV treatment and education, and risk reduction counseling. Data show that nursing case management that includes education, tracking, and incentives supports the highest rates of patient adherence to complex treatment regimens (
      • Nyamathi A.
      • Liu Y.
      • Marfisee M.
      • Shoptaw S.
      • Gregerson P.
      • Saab S.
      • Gelberg L.
      • et al.
      Effects of a nurse-managed program on hepatitis A and B vaccine completion among homeless adults.
      ). Proven strategies for success also require an investment in resources and management systems that are implemented to increase quality of care coordination and are focused on a relational work space (
      • Mc Evoy P.
      • Escott D.
      • Bee P.
      Case management for high-intensity service users: Toward a relational approach to care coordination.
      ). In addition, nursing surveillance has been shown to target high prevalence health problems and shortcut efforts at care management (
      • Schoneman D.
      Surveillance as a nursing intervention: Use in a community nursing center.
      ). A third role for nurses is to help patients manage the effects of a stigmatizing disease. The trusting relationship between nurse and patient allows patients to share their concerns and the nurse to intervene and support patient well-being (
      • Bova C.
      • Route P.S.
      • Fennie K.
      • Ettinger W.
      • Manchester G.W.
      • Weinstein B.
      Measuring patient- provider trust in a primary care population: Refinement of the health care relationship trust scale.
      ).
      Critical Next Steps
      • 1.
        Continue to support efforts to increase access to a broad range of primary care providers, including advanced practice registered nurses.
      • 2.
        Partner with other nursing organizations to disseminate educational materials and practice guidelines.
      • 3.
        Exploit the EHR to help identify individuals born between 1945 and 1965 and encourage screening.
      • 4.
        Identify frameworks that support the importance of the patient-provider relationship as critical to patient screening and treatment and disseminate these into practice.
      • 5.
        Create linkages with the National Viral Hepatitis Roundtable and primary care provider groups to promote patient education and care.
      • 6.
        Advertise World Hepatitis Day and National Hepatitis Awareness Month activities on the American Academy of Nursing website.
      • 7.
        Identify key stakeholders at the local, state, and national levels and work with these individuals to promote education of their constituents.
      • 8.
        Emphasize to our students, employees, and interdisciplinary team members the critical role of nurses in HCV screening, referral, and treatment. This includes case management, relationship building, and taking a lead role in the follow through of care recommendations.

      Acknowledgments

      Prepared by Donna M. Zucker, PhD, RN, FAAN, and Donald E. Bailey Jr, PhD, RN, FAAN. We gratefully acknowledge the assistance provided by Dr. Andrew Muir and the Academy’s Emerging Infectious Diseases Expert Panel in preparing this manuscript.

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