to thank all of you for being here today. My name is Lisa Catelli and I'm a nurse practitioner in the Department of Medicine and Division of GI Hepatology at the UCSF Medical Center, and I'm thrilled to join a group of stellar speakers who have led novel collaborative programs to improve the HCV care cascade. So we're going to be beginning the webinar with Dr. John Scott, who will highlight how digital health and telemedicine can deliver effective HCV care and amplify specialty expertise to reach more patients. Then in the next section, Dr. Price will discuss an urban community-based model of care and will show how her mobile deliver van brings HCV care to marginalized communities where they are. Then in the final section, Dr. Hodder will discuss the burden of HCV in rural America and adapting telehealth for local community solutions to amplify shared specialty expertise. So by way of introduction to our first section, it's my pleasure to introduce Dr. John Scott, who is a physician leader in creating and implementing digital health strategies. He has received CDC-funded initiatives in HCV care and his research is focused on telehealth technologies. He's a professor in the Department of Medicine in the Division of Allergy and Infectious Diseases, as well as the Medical Director of Digital Health at the University of Washington. He also chairs the Washington State Telehealth Collaborative and serves on the Telehealth Committee for the Infectious Disease Society of America. He was also one of the first pioneers of Project ECHO, launching his program at UW in 2009 to expand access to HCV care in both urban and rural settings. Dr. Scott? All right. Thanks, Lisa. So these are my disclosures here. So just to give you an outline of what I want to talk about in the next 10 to 15 minutes, I'll start out with just some definitions and some brief overviews of the models in telehealth. And we'll talk about the directive patient telemedicine model, and then the Project ECHO, or also known as the telementoring model, and then finally finish up with the asynchronous, or sometimes called the e-consult model. So let's start off with some definitions, because I think a lot of these terms get kind of run around and are for the most part used interchangeably, but strictly speaking, telemedicine is the narrowest definition of care, and that's the provision of clinical care for the diagnosis and treatment of conditions through video teleconferencing. And telehealth is a little bit more expansive, so it encompasses telemedicine, but also can include things like the long-distance clinical healthcare, education, public health, and health administration. And then finally, digital health is the most expansive term and includes both telemedicine and telehealth, but also can kind of get into things like mHealth, mobile health, wearables, and some of these more novel forms of technology. So for the purpose of this talk, we will use those interchangeably, but just know that if you're being strict in definitions, there are some subtle differences. So let's start with some pictures, because sometimes that tells a lot more of what we're talking about. So when people hear the term telemedicine and telehealth, they often think of this picture here, where you have a provider often in a more urban area on a video screen with audio and video and talking to a patient often in a more remote part of their region. And this is probably the most popular way of conducting telemedicine with telepsychiatry in particular being a very popular way to deliver that. Next is something called store and forward, also known as asynchronous. And this is where a provider or a patient sends some information to a clinician to review. In this picture here, there's a dermatologist who's reviewing a skin lesion. But there's lots of other ways you can digitize information and then send it to the doctor for review. Next is remote monitoring. And this is a hot area, lots of growth. And so you'll expect to see a lot more in this in the coming years. The idea here is that the patient is in their home, and they are taking measurements of things like their blood pressure, their weight, even their pulse, pulse oximetry, and then they're able to transmit that to their care team who then review that asynchronous asynchronously and get back to the patient for any kind of adjustments. And then finally, case-based teleconferencing is how I kind of got into telemedicine over 10 years ago. And this is the Project ECHO model, where you're talking about cases, a lot of times the patient's not there. But it's a very efficient way of delivering telemedicine. So let's start talking about live synchronous video telemedicine. And let's start off with some what happened back in March with COVID-19. So Medicare made some very wide sweeping changes in policies. So before this, if you were a Medicare patient, you wanted to use telemedicine, you had to be in either a rural area or a medically underserved area. And you also could not be in your own home. So they did away with those geographic restrictions, and that really opened up who could access telemedicine. So in my own state, in Washington, that opened up about 80% of the state. Previously, only 20% of our Medicare recipients could access telemedicine. It also allowed providers to be at home, because some of our providers were at risk for getting COVID-19, or they had child care issues, and they needed to be at their home. So that was great flexibility. They also finally allowed for reimbursement rates that were on parity with in-person care, and also allowed for audio reimbursement rates that were on par with in-person. So on the state level, many of the states were quick to update their telemedicine laws, including some that have something called payment parity. That's basically saying you're going to get paid the same for telemedicine as you would in person. My state passed that in February, and that was a great advance. So just to say that these policies were made under the Public Health Emergency Declaration, and that ends on October 24th. So we're kind of in a little bit of uncertainty here, and the future of these waivers is unknown. There are a couple of laws or bills being proposed that would make these changes permanent. The last issue is interstate licensure. I get this question quite a bit in Washington, because we have folks from all over the Northwest who come to Seattle for the care, and I would just say that before COVID, all states pretty much required that you need to be licensed in the state where the patient was at the time of the consultation. There have been some states that have temporarily relaxed this requirement, and if you want more information, I suggest you visit this website, the Federation for State Medical Boards. So there have been some studies looking at this type of telemedicine for HCV care. This came from Andrew Talal and colleagues in New York State and was published last year in Clinical Infectious Diseases, and the way that they worked this is they collaborated between the Academic Medical Center at Dr. Talal's institution and a methadone clinic, and they started off with some education and some testing. So they had to be RNA positive, and then Dr. Talal and his colleagues would evaluate the patient, interview them, and would talk with an advanced practitioner on site at the methadone clinic. He would document everything. He would submit a bill and then would write a prescription, and that prescription would then go to the methadone treatment facility, and you can see this gentleman here who's taking his medications, both his methadone and his HCV therapy at the same time, so it's almost like DOT. So they had 62 patients that were in the program. A high number of them had HIV, so almost a quarter, and almost a third of them had advanced fibrosis, were F3, F4, and over 60% were African American. So they were able to get 45 of those patients on therapy and 93%, very high rate, achieved a sustained viral response. So then they looked at those roughly 17 patients who were not able to get treated, and the most common reason why they were not able to be treated were insurance issues. I think at the time insurance in New York State was a little bit more restrictive on fibrosis levels. So I get a lot of questions about how do you document and do you need to get consent? So just be aware that there are certain states that require written consent before a telemedicine visit, so please review your own state laws on that. My state of Washington does not, but this is what we recommend. And first of all, did you start off the visit by documenting that this is different? You need to tell them this is, I'm not going to be able to touch you, I can't do as detailed an exam. So there's a possibility that as a result of what we talked about today, I may need you to come in for further evaluation. I also do talk about the technology and it doesn't matter what platform you're using, there's no such thing as 100% hack-proof technology, but I do spend some time talking about our own platforms and how we take that very seriously. And also that it is dependent on an internet connection. And then finally, we give them option that if they are not comfortable with this, that they could come in to be evaluated in person. So we are on Epic and we use a dot phrase that is included on all of our telemedicine visits. This is at the end of our visit saying that we encounter, we did this encounter via live face-to-face video conference. And we document where we are. And if you're at home, we just say my home. And then we document where the patient was. And if there was anyone else, say a family member, or in some cases, there might be a nurse who was maybe helping you out in the physical exam. And then we talk just about the verbal consent being obtained before that visit. So in terms of your note, it's going to look a lot like your normal clinic note. I do recommend putting somewhere your start and stop times, just because you might be documenting by time. And if they have taken their temperature, blood pressure, things like that ahead of time, you can put that in and just say that it was patient recorded. And then there's quite a bit you can do to document the physical exam. This is an example from an AGA webinar this summer of what you could say. There's quite a bit you can do on visual inspection. And sometimes you can have the patient also participate in the physical exam by palpating their lymph nodes. You can have them palpate their right upper quadrant, have them jump up and down, make sure there's no signs of acute abdomen, things like that. So you can do quite a bit there. So then how do you bill? So like any other kind of billing, you can bill on time or by complexity. The one little wrinkle that is pertinent for Medicare is that you can now bill on total time. So that would include review of outside records, the actual time of the patient, and any time you spent with coordination and care and documentation. So this is an example of something I said on a recent visit. I spent 32 visits on this visit today, including chart review prior to the visit, face-to-face time with the patient, and then documentation coordinate care. So that maps out to over 25 minutes, and I would go in 99214 for that. Like I said, you can bill based on medical decision making, just have to document the features of the complexity of the visit. And then the other thing is, at least in my institution, we recommend using a GT modifier. Some payers want different things like a POS2 or a 95, but the GT modifier is probably the most common modifier to document that this was a telemedicine visit. So some folks have questions about the facility fee code, and this is changing quite a bit. I would really recommend that you check with your compliance department about charging that, because with this new total time, that has added some complexity. So lastly, if you're doing phone visits, you can use the 99441-3 codes, and it's based on total time. And during the public health emergency, they will pay at the same rate, although the latest physician fee schedule that's being proposed is they're going to wind some of that back. So next, I want to talk about Project ECHO. So this is a form of telementoring that we started at the University of Washington in 2009, and we do it the same time every week. So I'm going to be doing it later today over the noon hour here on the West Coast, and we usually kick it off with a 10 to 15 minute didactic. So one of my colleagues is going to be giving a talk on HCC surveillance, kind of a basic talk. And then we have folks from all over the Northwest who have sent de-identified cases in advance. We have like a two-page form that they send, and these folks are a combination of primary care providers, pharmacists, mid-level providers, medical students. A couple of these folks are infectious disease providers as well. And on our end, we have a multi-specialty panel. So I'm infectious diseases. I have a colleague who's a board-certified transplant hepatologist. I have a mid-level who specializes in liver care, an addiction medicine specialist, and sometimes we'll have a psychiatrist. And so we give a very comprehensive opinion and write back to them so they have a written documentation of that visit. One of the exciting things is that over time, this becomes a learning community, and some of the best education actually comes from folks out in the rural areas and how they've kind of adapted to take care of HCV patients. So we learn as much as they do. So the four pillars of Project ECHO, as originally outlined by Dr. Vora at the University of Mexico, was that we're using technology to leverage scarce health resources, removing knowledge, not people. It's case-based learning, which is how we learn as adults. There's a lot of very collaborative care. We use best practices and have a protocol as we're using ASLD guidelines for the most part, and then we monitor and evaluate outcomes. So one of the exciting aspects of Project ECHO is you're really increasing capacity. We call this a force multiplier. So some of these folks in these rural communities have become mini experts, and then they're able to take more responsibility for the care in their communities. So we can just take care of many more people in our state and in our region. So Dr. Vora studied the safety and efficacy of Project ECHO. This was back in the interferon ribavirin era. And so he had patients who were being cared for through ECHO and then also at the academic medical center in Albuquerque. And the bottom line is that the cure rates were the same at both locations. So all gene types had a 58% SVR in ECHO and 57.5 in Albuquerque. Some really interesting findings, however, is first of all, there were more minorities, way more minorities treated in ECHO. And also about half the rate of SAEs are seriously adverse events on the ECHO sites as compared to Albuquerque. And there are many other studies have since found very similar results in the DAA era. So lastly, I want to talk about the asynchronous model. And this is something that we launched in 2016. It's called E-Consult. And this was a collaboration with AAMC and UCSF. And this is where we're leveraging the EMR to transmit information from primary care providers to specialists. And this is really meant for kind of lower acuity specialist questions in which there's a very clear clinical question. So more complicated patients probably should be seen in person. And so they can either put in a regular consult or an E-Consult. If they do an E-Consult, there's a specialist pool that kind of check the medical record once a day. And when they see them, a lot of the pertinent labs have been slaved in. They can look at those labs, look at anything in the chart, and then they write back to them. So we started this at the University of Washington for three specialties where we had poor access, like dermatology, endocrinology, and hematology. But it was so successful, we expanded to most of the Department of Medicine specialties, including GI and hepatology. We've now done over 16,000 E-Consults and has really helped us with our access. So the patients that we're seeing in person are a little bit more complex and a little bit more appropriate for that kind of in-person visitation. So this is what it looks like. It's something that Epic makes available, pretty easy to put in. And some exciting things about E-Consult is that Medicare now pays for this, both for the requesting provider and for the specialist. It's a 99451 or 99452, pays a 0.7 RVU. And like I said, has improved our wait times and access overall. Patients like it because they don't have to travel. And we have an open chart so they can see what the specialist is writing. And one of the really exciting things is it's empowering primary care to work at the top of their training and really saving those in-person visits for a higher level of acuity. So with that, I'll turn it over back to Lisa and happy to answer any questions either in the chat box or the Q&A. Thank you. Great, great presentation. I'd like to move on because for the purpose of time, to introduce Dr. Jennifer Price, who is an Associate Professor in the Department of Medicine and Division of GI Hepatology at UCSF Medical Center. She's the Director of the UCSF Viral Hepatitis Center and HCV Project ECHO and is also the Vice Chair of our HCV Special Interest Group. Her research interests are in viral hepatitis, HIV, and liver fibrosis progression. She leads efforts to eliminate HCV in San Francisco through a collaborative community-based program and all over Northern California through Project ECHO. She's also the founding director of a novel Deliver Care ban to provide high quality care to vulnerable populations. Dr. Price. So thank you, Lisa. Over the next 15 minutes, I'll be reviewing the San Francisco experience in improving the hep C care continuum. Here are my disclosures. And first to give you a brief overview of the hep C epidemic in San Francisco, an estimated 2.5% of the population in San Francisco is hep C antibody positive, and an estimated 12,000 are actively viremic. And the majority of these active cases, about 70% are among people who inject drugs, whereas people who inject drugs are only about 3% of the total San Francisco population. So in 2015, around when the DAAs became increasingly available, the San Francisco Department of Public Health created a hep C elimination strategy, recognizing these five key programmatic goals, which really paralleled the care continuum from prevention to diagnosis, linkage, care, and cure. And to achieve these goals, in 2016, San Francisco became the first US city to launch a hep C elimination initiative, which we call NHEPC San Francisco. And while the San Francisco Department of Public Health is very heavily invested in NHEPC SF, it's really a community-owned collective impact initiative that's comprised of partners from more than 32 community-based organizations and clinic, all of whom have a shared vision of a San Francisco where hepatitis C is no longer a public health threat and hep C related health inequities have been eliminated. And our mission is to support all San Franciscans living with and at risk for hepatitis C to maximize their health and wellness. And the shared values of the group are that all people living with hep C deserve access to a cure. Everyone living with or at risk for hep C should have equal access to prevention and care. We draw on the wisdom of those who are most impacted by hep C and engage populations that have been characterized as quote unquote difficult to engage and address health disparities. So to address the first programmatic goal of the Department of Public Health to increase hep C awareness, the initiative launched this educational campaign targeting affected populations. So I think we're all aware that there's a lot of stigma around hep C and a lot of misinformation. And for example, people who inject drugs may have been told that they aren't eligible for treatment or they don't have a mechanism to obtain treatment. So the initiative launched this really robust public awareness campaign to target people who inject drugs and other communities most affected by hep C by using these simple but powerful catchphrases like new treatments have changed the game. There's new hope for people with hep C and everyone deserves to be cured of hep C. And in 2019, we created a short video series which you can view on the website and hepcsf.org where people tell their stories of being cured of hep C, clinicians tell their stories of curing hep C, people tell their stories of being a peer navigator and of being part of the elimination effort. To address the second programmatic goal of increasing hep C screening, the Department of Public Health has supported a really vast network of community-based screening programs. So now in San Francisco, HIV and hep C counselors have been providing screening in a real array of settings, including at homeless shelters, at single room occupancy hotels, which we call SROs, at syringe exchange sites, methadone programs and other harm reduction centers. And as a result of these efforts, as you can see on this slide, there was a 339% increase in community-based hep C testing from 2016 to 2019, which has been followed by a steep drop in 2020 due to COVID-19. So the third goal was to develop linkage to care programs. And there are many ways that this has been done in the city. We do know that social support that's really operating at multiple different levels can be a key facilitator to overcoming barriers to hep C care. So three community-based organizations in San Francisco launched a peer navigation pilot program. And this is a picture from the training day, which was pre-COVID, during which these 24 peer navigators were trained on hep C education, cultural competency, working with drug users and motivational interviewing. And they're now working alongside test counselors and linkage coordinators in the city to help people access care. So now moving from diagnosis to care, the fourth strategic goal was to increase primary care provider capacity to treat hep C. And one example of this was in the San Francisco Health Network, which is a network of 12 primary care clinics that's run by the San Francisco Department of Public Health. These are all considered safety net clinics that treat high prevalence populations. And in 2016, the San Francisco Health Network undertook this primary care-based treatment initiative to improve treatment capacity to deliver hep C treatment. So the components involved in this capacity building initiative included in-person training, e-referral consultation services, and individualized in-clinic technical assistance. And when we did an analysis of the impact of this, what was a relatively low cost initiative, we found a 112% increase in the total patients who were treated post-intervention as compared to pre-intervention. And seven additional clinics started providing hep C treatment onsite post-intervention. So the fifth and final goal is to increase access to treatment. And the San Francisco Health Plan is the major managed medical plan in San Francisco and really has been a tremendous partner in our hep C elimination efforts. So in July of 2015, the California Department of Healthcare Services liberalized restrictions on DAAs such that there was no longer a fibrosis requirement for patients with significant comorbidities, including those with high risk for ongoing transmission. So you can see that after the restrictions were liberalized and that's the second green bar on this slide, the number of treatment starts significantly increased because we were able to obtain prior authorizations for most of our patients. So in July of 2018, that's the second green bar here, those treatment restrictions were liberalized even further such that there were essentially no restrictions. So we don't really have any restrictions anymore. So now about 37% of our San Francisco Health Plan members with known hep C have been treated. But I wanted to draw your attention to the right side of this graph because you can see that there's been a drop-off in treatment starts since mid-2019. And of course, part of the recent drop-off is due to COVID-19, but there was really a decline in treatment starts even before the pandemic. And much of this was because the so-called warehouse patients who were already engaged in care had largely been treated. So this really begs the question of what to do about the people who are not engaged in primary care. And in San Francisco to reach these patients, we really had to think outside of the box and come up with innovative methods to meet people where they are. And in particular in San Francisco, the priority populations are people living with HIV and hep C, criminal justice involved individuals, people who inject drugs and people experiencing homelessness. So there are many examples of hep C treatment being offered in San Francisco outside of the primary or specialty clinics to really reach these priority patients, including embedding hep C treatment within methadone clinics, offering treatment at harm reduction centers and at homeless shelters, for example. And while each of these programs are slightly different, there are some similar themes in terms of what the key facilitators of success for the programs are. And those include co-localization of services to really make hep C treatment convenient for clients, reducing barriers to treatment so we can truly offer a low threshold treatment, making sure that we have skilled phlebotomists, which is really important for this population, especially among people who inject drugs, gift card incentives to help people remain on treatment and to motivate them, and then supportive clinical leadership, partnerships with pharmacies for prior authorization support and assistance for safe medication storage, like providing lockers, for example, have been very successful. So as an example of a community-based treatment program, in 2019, we launched a mobile hep C screening, fibrosis staging, and treatment van called the Deliver Care Van. And in our first year, among over 600 clients who were screened, 36% were hep C antibody positive, but the prevalence of reactive hep C antibody really varied depending on where the van was situated. So when we were on street outreach shifts, like outside of syringe access service stations, for example, the prevalence of hep C antibody reactivity was 32%. At community events like health fairs, it was lower at 10%. And when we parked the van outside of methadone programs, the prevalence was as high as 64%. And most of our clients who screened positive had a history of injection drug use with about two thirds reporting current use of injection or non-injection drugs. And most were unstably housed with over half living outdoors or in a vehicle. And we are fortunate to have an extensive safety net healthcare coverage in San Francisco. So interestingly, the vast majority of our clients screened on the van who were antibody positive had health insurance. And in fact, only 6% reported being uninsured. So we also on the van have a portable mini fiber scan, and this actually demonstrated a high burden of fibrosis among those who were antibody positive. 51% of the antibody positive clients had F2 or greater fibrosis, and 27% had advanced fibrosis. And while the van was initially intended to provide free hep C screening, fibrosis staging, and then linkage to care among high risk populations, several clients expressed their desire to be treated on the van. And it actually ended up being a very common request. So we therefore just started offering onsite standard of care treatment. And the way this works is we draw the pretreatment labs on the van and then bring the blood back to UCSF for processing. And then after this, we arrange a telehealth visit with a hep C clinician. So the van staff will set up the telehealth encounter on the van using a laptop and a hotspot. And then the clinician can zoom in from wherever their location may be. And then after that visit is complete, the clinician orders hep C treatment, which is picked up by the van team and then brought back to the patient on the van. And then all subsequent visits, labs, medication pickups are all completed on the van. So it's basically like a mobile hep C clinic. And this is just one example of how we're trying to reach that so-called difficult to engage population with hep C in San Francisco. So finally, while our work in San Francisco is still ongoing, we are making significant progress. And so that's why I wanted to include this figure, which is from an analysis, which is not yet published of the National HIV Behavioral Surveillance Surveys of people who inject drugs, which was conducted in San Francisco in 2015 and 2018. And it showed a near tripling of hep C treatment receipt among people who injected drugs between that 2015 and 2018 survey administration rounds. So just to note here, this is the SVR data was not measured in 2015. And in 2018, the SVR data were obtained only by self-report similar to the treatment receipt and diagnosis of hep C, this was self-report. But we do know from other studies that people who inject drugs can successfully be treated with high SVR rates. And indeed Mandana Khalili and colleagues will be presenting data at the liver meeting next month that showed that among 66 clients treated in homeless shelters in San Francisco, as well as Minneapolis, 84% achieved SVR. So to summarize, hep C elimination requires thinking beyond a one size fits all approach. In San Francisco, we prioritize the inclusion of people most impacted by hep C and we've gotten creative about how to involve them and how to deliver care and have created multiple thresholds for participation. Our experience has been that community-based hep C treatment, sorry, hep C screening and treatment reduces numerous barriers to care. It really allows us to meet people where they are on their own schedule. And it really helps us provide patient-centered care and reduce stigma and also allows for the co-localization of other services. But I think one thing we have realized in San Francisco in particular is that we really need to help optimize our patient's ability to complete treatment once it's been initiated. So patients with housing instability have multiple competing and pressing priorities. And we found that incentives for visits and patient navigation services can really help them remain in care and complete their hep C treatment. And safe medication storage is still a big challenge for many patients. So trying to help them overcome this barrier is also really important. So I'd like to end by thanking all of my colleagues in the end hep C San Francisco initiative, especially Katie Burke, who provided several of these slides as well as the funders of the Deliver Care Van and our community partners. And I would be happy to answer any questions in the chat or the Q and A. Great, thank you so much, fantastic. Now I'm going to, we're gonna move on to the next part of the webinar with Dr. Sally Hodder. She is a professor of medicine, associate vice president for the clinical and translational research at the West Virginia University and director and PI of the West Virginia Clinical and Translational Science Institute. She has been at the front lines of HIV care for decades including international experience in Africa, building programs in high HIV prevalence areas of the US serving as protocol chair for NIH funded HIV prevention study among 2000 women and recruited to West Virginia in 2014. She is building programs through the NIH funded center to address emergent epidemics in hep C, hep B and HIV and more recently programs addressing SARS-CoV-2 testing. Dr. Hodder. Thank you very much for that kind introduction. For the next couple of minutes, I'm going to talk a little bit about rural America and some strategies to enhance hepatitis C treatment, testing and prevention. These are my disclosures. As you can see in this first slide, the states with the highest prevalence of hepatitis C RNA are shown in orange and many of those states have large rural areas. So hepatitis C is a problem in rural America. And this also shows that it's not just hepatitis C but we have syndemics. You can see on the left panel, those areas with the highest overdose death rates are very similar to what you just saw for hepatitis C prevalence. And on the right areas with highest rates of poverty also are similar and overlap with those areas highly impacted by hepatitis C. Going to West Virginia, a rural state that I know best, you can see on the panel on the left, and these are acute cases, the incidence of acute hepatitis B is going up. And on the right, you see the increased incidence rate of hepatitis C. I wanna just digress for hepatitis B. Hepatitis B is a vaccine preventable illness and it has been for decades. And yet we're seeing an increase. And when we looked at, not shown on the slide, but when we looked at a sub sample, it really appeared that those folks who were in their 30s and 40s, most of whom were folks who used injection drugs and had missed hepatitis B had obviously missed opportunities to get vaccinated. So, it was really sort of a reminder about the importance of when we're thinking about hepatitis C, also making sure that folks are immunized for other forms of hepatitis. As shown in this slide in the blue and red lines, more than 70% of cases of acute hepatitis C, which we all know is just the tip of the iceberg, were related to drug use. And sort of reprising what you saw on the first couple of slides, in West Virginia, you see those states with the highest rate of chronic hepatitis C are in the South. And those are just the states that are shown on the right, have the highest drug overdose mortality rates. And also in the blue, have the highest rates of poverty. Many of the areas with the highest rates of hepatitis C have more than a third of their population living in poverty. And this other part of West Virginia was that area of West Virginia early on in the opioid epidemic, where large millions of doses of opioids were literally dumped in those areas. And this has really continued, with subsequently, initially heroin and more recently other synthetic opioids. Age distribution, I think, is important to remember. As you can see on the panel on the left, the most common ages are young individuals, 20 to 40. And on the right, the implication of that as well is, this is just when women are in their reproductive years, and it's not as appropriate to say that they're in their early 20s. They're in their reproductive years. And it's not a surprise that West Virginia, closely followed by Kentucky, has the highest proportion of pregnant women who are hepatitis C infected. I wanna sort of just take a point here that I think universal screening for hepatitis C among pregnant women is extremely important. It is endorsed by multiple organizations. And I think that it's important because pregnancy is a time when women, particularly perhaps rural women, access healthcare when they might not at other times in their life. It's easily, hepatitis C testing is easily packaged with other prenatal assessments that are done. And I think that it is, if you do risk-based screening, you'll miss many, many cases of hepatitis C. Moving to barriers, there are many in rural America. Of course, lack of insurance is a problem in some places. Fortunately, West Virginia has had Medicaid expansion. There are many places that have not. But even with Medicaid, there exists today, and I'll address this in a minute, restrictions to access to hepatitis C treatment. Transportation is an enormous problem in rural America. There's by and large no public transportation. Windy mountain roads are difficult in the best of weather and impossible in poor weather. And having access to a car and money to buy gasoline, particularly, as I showed you, the populations most affected are those in high poverty areas is problematic. Also travel times, it can be hours to get to a specialist as well. I think stigma is enormous. Others have alluded to this. I think that it's no surprise individuals would not want to go to a place where they felt they were being judged really in a negative fashion. And I think that that remains a significant barrier. Lack of specialty providers in rural areas is problematic. There is a Medicaid restriction in West Virginia that requires a specialist ID or GI to write the prescription and evaluate the patient. And at a time, and I'll talk about some of the solutions to that, but at a time before we had solutions, there were individuals who were waiting months to get in to see a specialist and have their hepatitis evaluated. Substance use disorder in and of itself, I think can be problematic, often sort of really contributing to very chaotic lifestyle and difficulty with places to keep medication as mentioned earlier. Moving to solutions, Dr. Scott addressed telemedicine earlier. And I think one of the rare silver linings perhaps of the COVID epidemic has been the fact that telemedicine, particularly given the ease restrictions and enhanced reimbursement as Dr. Scott detailed, has really increased use in rural West Virginia and other places. Shown in the panel on the right lower corner, and this is from the Medication for Opioid Use Disorder Treatment Program, a large program at West Virginia University. You can see that as the number of virtual visits went up, the number of in-person visits went down, though the appointment adherence was assessed and found not to change. Not shown on the slide, but I think extremely important is that in the Hepatitis C Clinic in Morgantown with the advent of telemedicine, the appointment adherence more than doubled, and that was both for new and existing patients. So I think that this is really an important advance. I think though for rural America, and perhaps sort of for populations with substance use and people who inject drugs, I think really the role of integration of services as described in a report from the National Academy of Medicine last winter is critically important. In West Virginia, there are among the most dedicated men and women providing primary care in rural West Virginia. And through the funding from the National Institutes of Health to build infrastructure to improve outcomes and study those outcomes, we've developed a network of primarily primary care practices shown on this map. They are 80% FQHCs. And about a third of these programs, interestingly enough, have not only implemented Hepatitis C, but also medications for opioid use disorder programs. And these are really ideal venues for service integration. And as with any sort of successful initiative, the grassroots sort of requirement for that is what makes it successful. And in fact, as our rural providers are seeing more and more Hepatitis C patients, and the more they saw, the more they looked for it, and the more they saw. At that time, there was an extremely stringent fibrosis requirement. There was a six-month sobriety requirement. And I think really at a source of frustration, they actually came to us and they said, we have got to start an ECHO program. And we found funding to do it. And so the ECHO program as described by Dr. Scott was started in 2016. And I'm not gonna belabor. It's really very much as he described, so with the really sort of time constraints of rural providers, taking care of everything in West Virginia, we actually have these sessions twice a month, not every week. I wanna just sort of draw your attention to three points that I think that are important. Number one, the sessions are recorded and uploaded to our WP Project ECHO YouTube page, which can then be reviewed at a convenient time by our providers. Number two, and just this year, we've developed a non-demand case systems. Sometimes there's a large queue of cases to be presented, or sometimes somebody has an urgent need and wants to get information. And so we've developed an on-demand case review systems that our multidisciplinary hub members can review and get back to the provider in very, very short order. And that has been very, very popular. Third, the ECHO program in West Virginia, West Virginia Medicaid looked at the program and said, we will consider that if a case is presented at WV, the ECHO program, that that will satisfy the requirement for a specialist. This became particularly important when about a year ago, the fibrosis requirements were eased and we have had now a lot of folks. The one caveat is there remains a three-month sobriety requirement. And that is why I think it's so important to have integration of, you know, medication-assisted treatment for opioid use disorder as well. This just shows the ECHO folks, and there are just two points I wanted to make. And that's number one, that hepatitis C is not the only issue in rural America, particularly among persons with substance use. Very quickly, we had requests to start ECHOs to address medications for opioid use disorder, chronic pain management, general psychiatry, and then the primary care providers said, well, it's not only hepatitis, you know how long it takes to get specialty consultation for thyroid disease. So we have now general endocrinology, heart failure. There are out-of-state folks that are not complete there. We have 11 states in addition to West Virginia, including the furthest West is Wyoming. I want to just end with a couple of slides on prevention. Going back to the theme of the importance of integration of services, persons who are actively in medication for opioid use disorder programs have a significantly decreased risk of hepatitis C acquisition as shown there. And the second important program are syringe service programs. The CDC website and many others advise that syringe service programs reduce HIV and hepatitis C infections. It's interesting, and I just wanted to point out that I didn't think this was controversial, but in fact, there are reviews that conclude that needle exchange programs alone in the U.S. have not been demonstrated to decrease hepatitis C. They have in Europe. I would just suggest that number one, you know, particularly for hepatitis C, it needs to be more than clean needles. It needs to be, you know, cottons and cookers that need to be cleaned along with the needles. And number two, it all depends how you sort of look at a syringe service programs. In West Virginia, for example, there's been some restriction about requirements for ID and residence and so forth. That, as you might imagine, might sort of preclude the success that you would expect to see. With the outbreak of the HIV epidemic in Scott County, Indiana, a rural area, most of those individuals, by the way, were infected with hepatitis C. The CDC looked at counties and generated the 220 counties felt vulnerable to HIV or hepatitis C outbreaks shown in blue and concentrated in central Appalachia. A needle exchange programs are shown in green. And as you can see, the proximity where you have both shown with gold are few and far between. Nonetheless, in recent years, Kentucky has been a model rural state that has increased syringe service programs. West Virginia has as well, though I would not be so sanguine about this slide. Within the past year, there have been several syringe service programs closed in West Virginia, including one in the state capital, Charleston, serving thousands of clients. Today, there is an HIV outbreak in Charleston, West Virginia, and just down the road in Cabell County. And many, many of those folks are also hepatitis C infected. So in conclusion, rural America has among the most highest of the highest rates of hepatitis C in the country. There are multiple barriers that exist. And I think comprehensive wraparound services are really required and they must include testing and treatment for hepatitis C, as well as for substance use disorder. Rural clinics near patients' homes are ideal to provide these wraparound services. And I think telemedicine and echo are effective strategies to further amplify expertise. Thank you. Fantastic. Thank you so much, Dr. Hodder. These were really brilliant talks. Now we're going to move on to some questions that I see in the chat box. First of all, there was one question posed to Dr. Price asking if peer navigators are actually paid and also where can one get a mini FibroScan in the United States? So the programs will vary with the peer navigations, but usually peer navigators are paid. And regarding the FibroScan, you could buy one from Echosense. That's where we got our portable FibroScan. We happened to purchase it right when the portable version was available in the United States. It had been available in Europe previously. Okay. And then there's also a question in the Q&A. Is there any movement toward the removal of the sobriety requirement? This is for Dr. Hodder. This seems to be such a barrier for active drug users. Oh, I absolutely agree. I would say that there has been a move in West Virginia and other places to start easing these requirements. The actual requirement was six months and was decreased to three months a year ago. There used to be a very high fibrosis requirement. It was decreased to F2 and that was removed about a year ago. And as I described, the state is now sort of certifying that the ECHO programs serve as that specialty, meet that specialty requirement, which I think is really enormous. And it's, we have, as I said, the on-demand system. We're getting so many cases, particularly with removal of the fibrosis requirement. And we have lots of young patients who want to treat those. So we're really sort of meeting that. The sobriety requirement per se, I would say just given the tempo of the decrease in requirements and the understanding about the need to treat individuals who have hepatitis C. And I think as more data emerged that folks that continue to use drugs can be successfully treated. I think, I mean, I don't have a crystal ball, but I think that is where we are going in this world. I gotta tell you, the COVID pandemic though has like put a screech on everything. I think the state health department services have been focused on the pandemic, which really I think has kind of stopped progress on treating more people and so forth. So yeah, there was an also, there are also things in the chat about, the Medicaid system to remove all restrictions to Medicaid, using policy makers to use the guidelines to say that sobriety is not required. So yeah, thank you for responding Dr. Scott to that. I have a question for Dr. Scott in particular, what are some barriers that you have seen for patients actually doing telehealth visits? Have you actually seen people having problems getting connected or a reluctance because they're not tech savvy? And how do you overcome those kinds of barriers for direct patient care? Yeah, so I work at the large public hospital in Seattle Harborview. And so we have seen it. Fortunately, it's not that frequent. And so there's a variety of barriers. One is just not speaking English. So there are ways to incorporate a video interpreter. And I actually think having a video interpreter is better. Privacy is another one. So a lot of people are kind of crowding in home. I mean, they're working from home or the kids are doing school from home. So I've had a couple of video visits from patient's bathrooms. So you kind of have to prep them for that and make sure they have a private place. But then there's this real, very real issue of the digital divide. People not having access to broadband, not having the devices. And sometimes even they'll have those two things but they don't know how to work it. They don't know how to do an email or they don't know how to work Zoom. So those are all gonna require different solutions. Some ideas are like using a kiosk model, maybe going to like a methadone treatment and having a little private area that's set up with internet and someone can help them or working with community centers, things like that. So I think we're learning a lot but don't be overwhelmed by some of these barriers. And do you have a telehealth team that helps them? Actually, I'm sorry, interrupted. Do you have a telehealth team that actually helps people get connected? We have a very small but mighty team. So we have 3000 clinicians and a team of eight. So we really had to do a self-service model. So a lot of the support actually is from the medical assistants and the clinical staff that are troubleshooting. We're trying to make it as easy as possible though. Okay, Dr. Price, did you have a comment? Oh, I was just gonna comment that I love the kiosk idea. I just love that, I think that's a great idea. Our experience, we were doing the telehealth on the van before COVID because at UCSF we were also like you all early adopters of telemedicine and it's been working really, really well, better than I could have expected because there's staff members right there to set up the encounter and there's a hotspot and they can troubleshoot and it really has worked beautifully so something like that in other community-based centers I think would be amazing. Yeah, and I was wondering, Dr. Hodder, do you think Dr. Price's Deliver Care Van, something like a model like that would be helpful in rural America? Absolutely, there are programs that utilize vans for syringe services in West Virginia. There are a couple of drawbacks. Some of these communities are very, very small and so a van is really a marker, particularly if that van is only, for example, for hepatitis or for syringe exchange, which is one problem because all your neighbors, you know, there's just one main street there and everybody sees it. Number two, you know, I was shocked coming from New Jersey that there could be roads as windy and as steep as there are here with potholes. So, I mean, you've got to have a robust van. It's, you know, that is sort of a second thing. Nonetheless, I think that it will be used more and I think that it's important. There are other, we have a mobile, it's not a van, it's an RV that does mammogram screening from the Cancer Institute that's been quite effective and they have sort of really broadened out to offer other services because they have a schedule and go into very, very remote areas and obviously would not have a stigma if you're going to that van of drug use and so forth. Great. There's a comment in the Q&A from a person from Zimbabwe saying that it would be interesting to look at the outcomes of telemedicine in low-income countries. Sure, I'll take that. So, we did establish a Project ECHO in Namibia for HIV in 2015 and just published our outcomes from that. It was very, very successful and surprisingly, the bandwidth was pretty good. We capitalized, they were laying fiber optic for their national lab medicine system. So, it worked really well and people were really hungry for that knowledge. So, I think we definitely need to study, but so far it's looking really good. Yeah, and I know that Project ECHO in particular is international now too. There is another question. What steps did you take to link with methadone clinics and shelters for HCV therapy? So, this could probably be for Dr. Price. Yeah, so there was a lot involved in getting hep C treatment into methadone clinics and into shelters and it was all part of the Antep C San Francisco initiative. And it really varies depending on the methadone clinic and the shelter. Some of the methadone clinics in San Francisco started offering treatment within the clinic and it was, for the most part, directly observed therapy and that was really successful. And others don't have the bandwidth or the capacity or don't have the ability to do some primary care within the clinic. So, in those clinics, it's been more challenging, but they can utilize the navigation assistance to the linkage navigators, start a link to a clinician at one of the FQHCs or another provider. And then at the shelters, Vandana Kallili led a group to really first do a lot of investigation into the facilitators and barriers of treatment within the shelters and then piloted a study where linkage and treatment was offered within the shelters. But it did require a lot of groundwork for a while to figure out how this could be successful. And we have a really great shelter health and street medicine team in San Francisco that is really on the ground screening folks and drawing labs and providing the treatment. And they're able to actually go into shelters and provide treatment. This is a real collaborative effort, I would say. And some of our nurses from the School of Nursing at UCSF are doing street medicine as well, street nursing. So it's very cool. So I think we have answered all the questions and we're at the end of our webinar. Thank you so much, all of you. This was a fantastic program. Thank you.

HCV care

telehealth

telemedicine

digital health technologies

San Francisco Hep C elimination initiative

peer navigation programs

rural America

access to care

barriers

disparities