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CME / ABIM MOC

Cure in the HCV Care Cascade: Critical Strategies for Practice to Eliminate HCV

  • Authors: Nancy S. Reau, MD; Kevin A. Ault, MD, FACOG, FIDSA; Philippe Zamor, MD
  • CME / ABIM MOC Released: 3/17/2022
  • Valid for credit through: 3/17/2023
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  • Credits Available

    Physicians - maximum of 0.50 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.50 ABIM MOC points

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for gastroenterologists, infectious disease/HIV specialists, primary care physicians, and obstetricians/gynecologists.

The goal of this activity is for learners to implement strategies to overcome barriers to hepatitis C virus (HCV) elimination.

Upon completion of this activity, participants will:

  • Have greater competence related to
    • Applying screening guideline recommendations for HCV elimination goals
  • Demonstrate improved performance associated with
    • Identifying barriers to HCV elimination in practice
    • Applying practical strategies that support HCV elimination goals


Disclosures

Medscape, LLC requires every individual in a position to control educational content to disclose all financial relationships with ineligible companies that have occurred within the past 24 months. Ineligible companies are organizations whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated according to Medscape policies. Others involved in the planning of this activity have no relevant financial relationships.


Faculty

  • Nancy S. Reau, MD

    The Richard B. Capps Chair of Hepatology
    Professor, Department of Internal Medicine, Division of Digestive Diseases & Nutrition
    Rush Medical College
    Section Chief, Hepatology
    Associate Director of Organ Transplantation
    Chicago, Illinois

    Disclosures

    Grants for clinical research from: Abbvie; Eiger; Gilead
    Advisor or consultant for: Abbvie; Arbutus; Gilead; Intercept; Salix

  • Kevin A. Ault, MD, FACOG, FIDSA

    Professor, Obstetrics & Gynecology
    The University of Kansas Health System
    Kansas City, Kansas

    Disclosures

    Advisor or consultant for: PathoVax

  • Philippe Zamor, MD

    Gastroenterology
    Hepatology & Liver Transplantation
    Atrium Health – Carolinas Medical Center
    Charlotte, North Carolina

    Disclosures

    Grants for clinical research from: Abbvie; Gilead Sciences
    Advisor or consultant for: Abbvie; Gilead Sciences
    Speaker or member of speakers bureau for: Abbvie; Gilead Sciences

Editors

  • Maria Uravich, BSc, ELS

    Sr Medical Education Director, Medscape, LLC

    Disclosures

    Disclosure: Maria Uravich, BSc, ELS, has no relevant financial relationships.

  • Frederick Stange, DO

    Scientific Content Manager, Medscape, LLC

    Disclosures

    Disclosure: Frederick Stange, DO, has no relevant financial relationships.

Compliance Reviewer

  • Susan L. Smith, MN, PhD

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Disclosure: Susan L. Smith, MN, PhD, has no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has no relevant financial relationships.


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    For Physicians

  • Medscape, LLC designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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CME / ABIM MOC

Cure in the HCV Care Cascade: Critical Strategies for Practice to Eliminate HCV

Authors: Nancy S. Reau, MD; Kevin A. Ault, MD, FACOG, FIDSA; Philippe Zamor, MDFaculty and Disclosures

CME / ABIM MOC Released: 3/17/2022

Valid for credit through: 3/17/2023

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Activity Transcript

Nancy S. Reau, MD : Hello. I'm Nancy Reau from Rush University Medical Center in Chicago. I want to welcome you to this program titled, Cure in the Hepatitis C Care Cascade: Critical Strategies for Practice to Eliminate Hepatitis C. Joining me today are Kevin Ault, professor of obstetrics and gynecology at University of Kansas health system in Kansas City, Kansas. And Philippe Zamor, hepatologist for Atrium Health Carolinas Medical Center in Charlotte, North Carolina. Welcome both of you.

Kevin A. Ault, MD, FACOG, FIDSA : Thank you.

Philippe Zamor, MD: Thank you.

Dr Reau: So I'm going to start a little bit by just setting the scene. I think we're all aware that acute hepatitis C is increasing. Now, that doesn't mean symptomatic, it means that there's a rise of new hepatitis C, and this has been consistently elevating since over the last 15 years, a strong parallel in the opioid use disorder, an injection drug use, and it has some pretty significant implications. Our population is now younger, more white, more rural and strongly again, linked to injection drug use. We see that this is easily supported by other demographics, such as paralleling maps that look at hepatitis C prevalence on top of opioid injection, overdose and opioid injection mortality. There are distinct demographic abnormalities or differences so that some places you feel you don't feel this at all, in other places you think, well, everyone in your community has a hepatitis C or injection drug use or opioid use disorder.

And that's why we have such a diverse panel. It's really important to recognize that this new group or this new demographic has not eliminated our old demographics. So although our previous guidelines for screening concentrated on the group of individuals that were the birth cohort or those born between 1945 and 1965, the newer demographic of these younger individuals is really going to change how we approach our patients, how we approach screening, how we approach linkage to care.

And that's what this program is, getting over, recognizing those barriers and then getting around those barriers as our population becomes more diverse. So, it's really important to recognize that hepatitis C screening guidelines have incredibly evolved. They went from risk based to emphasizing the birth cohort as well as risk-based screening. And now in 2020, the CDC released near universal screening for hepatitis C, and that included an emphasis on all pregnant women.

This does not replace the risk-based screening, so that if you have someone who's got risk factors for hepatitis C, that individual should still be screened. This was also supported by the United States Preventative Taskforce to a grade B. That means it will be paid for. And then shortly after that, the ACOG and Maternal-Fetal Medicine societies also supported the pregnancy screening recommendations. So, this is a big shift in hepatitis C screening recommendations.

I'm going to start with screening because you can't fix something until you can recognize it. I'm going to turn to our 2 consultants. Kevin, why don't you tell me a little bit about the roadblocks as an OB-GYN?

Dr Ault: Well, I think the roadblocks that we have when we're taking care of women for OB-GYNs or family physicians, is just force of habit. We are used to making sure women are up to date on their mammograms, on their Pap smears and that type of thing. And then when you incorporate new recommendations into clinical care routines, well-woman visits, it takes a little while to turn the ship. A lot of this conversation, a lot of this literature reminds me of where we were with HIV screening in the 1990s.

We had a sea change as far as how we approached women back then for HIV screening and eventually led to very widespread HIV screening recommendations for the general population.

Dr Reau: Kevin, I think that your hat is dual-fold, right? That's why your OB-GYN, so that we are going come to the screening guidelines and how those changed in an obstetric population. But as a gynecologist, a lot of women really don't have a "primary care provider." They use their gynecologist for primary care, and I think that that's challenging, at least in my mind, our gynecologist may not feel as proactive in some of those preventative measures as an internist or a family medicine physician.

Dr Ault: Well, I would argue in the United States that the reason we have a whole specialty of obstetrics and gynecology is because 80 years ago, Dr Papanicolaou invented the Pap smear. We do have a big stake in preventative care for women, it's just expanded in the past few decades to include other items, not just breast and cervical cancer screening, but other items that may not traditionally fall under OB-GYN. You're correct. But we need to do a better job. I think if there's any silver lining to electronic medical records [it’s that], in our system, on the lower left there's a screen.

If the patient is scheduled for a preventative health visit, including a well-woman visit with a gynecologist, [there is] a screen of a to-do list for you, and hepatitis C has been on that to do list since the recommendation's changed.

Dr Reau: So, Philippe, I'm going to turn to you now because your practice setting is very different. You're a hepatologist like me in a very large GI healthcare system. What are some of the barriers that you see?

Dr Zamor: Well, I think we see a reflection of what's happening in our world. Many patients have barriers to being able to come and see us. For example, I was reviewing my schedule yesterday for tomorrow, and there's 1 patient on my schedule who has hepatitis C and the person has missed 4 different appointments to come and see me. I reviewed the chart. There's no obvious drug or alcohol abuse or any other sort of social red flag or anything, but it just may be a reflection of access to care. This person does come from rather far away. So, I'm perhaps considering changing this to a virtual visit, where perhaps there may be a little bit easier access.

I think we all want to get back to a world where we can see patients in person and talk to them and examine them, but obviously the virtual world has helped bring down some barriers for some people. I think what I'm seeing still is patients that are coming to me from, let's say, a specialist, like a rheumatologist or a dermatologist that's diagnosed hepatitis C or a nephrologist that's picked up on the hepatitis C, and the person perhaps may have been diagnosed sooner in their primary care setting.

So, I think a big barrier that I'm seeing is that patients are still... I think what we're missing this diagnosis still quite a bit in a general medical community, and [some are] coming into us very late in the game, or they come to us with a very large unresectable hepatocellular carcinoma. And you say, "Boy, this was an opportunity missed." So, we hope we can try to get these folks sooner.

Dr Reau: So, I think that both Philippe and Kevin, I'm hearing a lot of emphasis on screening and lack of opportunity. Certainly, if an individual has no overlap with a healthcare system, screening is not going to occur. I think there are lots of grassroots, things like church screening and a lot of community health wellness screening that probably occurred pre-pandemic, and Philippe, as you pointed out, that really has come down significantly with the pandemic. I really want to emphasize our guidelines have become more inclusive. So, we are losing screening opportunities, but it's not because there aren't recommendations to screen.

And clinicians sometimes are not aware of those recommendations or the patient has like 62 more pressing problems, you just don't really get to hepatitis C screening. But the guidelines have evolved to essentially near-universal screening now. The CDC with support from the [US Preventive Services Task Force] have recommended screening for everyone at least once. And then I'm going to pull out for Kevin the additional recommendation of screening every pregnant woman during each pregnancy. So, that's not just once, that means with each pregnancy. And from what I understand, that went over very well with the OB-GYN societies. Is that correct?

Dr Ault: Well, there are a lot of things we do at the beginning of pregnancy. Everybody has a prenatal panel that they draw and they don't change much over the decades. So, adding 1 more thing to our prenatal panel was not going to be a big stretch. I mean, we do screen for anemia and some other non-infectious things, but we still screen for rubella and hepatitis B, syphilis, HIV, every pregnancy. So, it's not really a big sea change for what obstetricians do at the initiation of prenatal care.

Dr Reau: So, the CDC did give us a little wiggle room. They said that if you live someplace where hepatitis C is not particularly common, then you don't have to screen. But I think that there is no state that fits under that threshold. Is that correct?

Dr Ault: There are no states under that 1 in a 1000 threshold right now, and you alluded to this previously. Unfortunately, the guidelines came out near the beginning of the pandemic, and if you go back to that original NWR article, there are some data in that article about rates of hepatitis C in pregnancy, and basically no state jurisdiction is really under that rate, as you said.

Dr Reau: Philippe, do you have any experience with co-localized screening in injection drug use or needle exchange programs? Is that something that your area has investigated?

Dr Zamor: Well, unfortunately, in North Carolina, we don't have as vigorous treatment options for injection drug users as opposed to when I was in New York, where there were much more widely available centers for treating addiction. What I have seen here, though, that I've been very impressed with is that many of our community health centers, as well as many of our primary care family medicine clinics, have really taken a very proactive stance on screening.

And in fact, many of them are now actually treating. And we worked very closely with many of these primary care centers that treat a lot of the higher risk patients and they've felt very comfortable managing these patients. I think by us working with them, interactions back in the days when we could actually meet with folks, we actually sat down and met and had discussions about what the best way to help implement screening. And they've really taken off and have screened and captured a lot of patients that I feel otherwise may not have been captured.

Dr Ault: If you don't mind, I'll jump in here and expand maybe on what I said a little bit before. My experience would be that we do have pretty reasonable linkages to care for pregnant women who have risk factors. I think that the recommendations to screen people with risk factors are old enough. We do a reasonable job with that. I think OB-GYNs have to think about their linkages to care for both the pregnant woman and the newborn. It's a little beyond the scope of what we're talking about today, but that's probably going to be the biggest challenge for obstetricians and other specialties, nurses, midwives, and family doctors that do routine obstetrical care, is when you do find that 1 in a 1000 patient, what are you going to do with them as far is getting them into care and thinking about the newborn as well.

Dr Zamor: Well, I can tell you, Kevin, I've been pretty impressed because I can recall when those guidelines changed from ACOG, and we started to get a flood of referrals from the GYN service on first or second trimester pregnant women with hepatitis C. I think your society did a very good job of getting the word out, and others should follow suit.

Dr Ault: The follow-up to that is we're going to see them 8 or 10 or 12 more times after you've seen them for that first consult. Now they have a connection to you.

Dr Zamor: Absolutely.

Dr Ault: That's the way to go.

Dr Zamor: Absolutely.

Dr Reau: Well, so this is a perfect segue into a more focused discussion on diagnosis and linkage to care. First of all, I think it's really important that screening should automatically trigger diagnosis. So, most of our commercial labs will do a reflex. If your antibody is positive, it'll automatically trigger a hepatitis C PCR or a viral load, so that you do not have to pull the patient back. Now, you knowing they have Hep C is not the same thing as communicating to that patient that they have Hep C, but screen to diagnosis should really not be a barrier.

And linkage to care, I think you've heard some really important messages from both Kevin and Philippe that linkage to care can be done quite successfully, both from more unstable situations like federally qualified healthcare clinics, as well as that transition from OB-GYN to linkage to a provider that feels comfortable for treatment. But there are some pretty difficult places to link from. Philippe, do you have an ER screening program in your system?

Dr Zamor: The short answer is no, but we do have, like we talked about earlier, in our EMR embedded these pop-ups that prompt you. The problem is that these are not hard stops. They're soft stops that we can just click through them and get past them. The big discussion has been about how do they code and how do they do the appropriate billing for that screening test? I think there are many places out there that do this, and they do it well. Unfortunately our ER does not do it, but what the ER does pretty well here is they do link patients that are otherwise not attached to a primary care provider to a clinic.

And again, the clinics in turn have a very robust Hep C screening system.

Dr Reau: Rush does have a very nice ED screening program. EDs have consistently not linked as well as some other places, so I think our best linkages to care are in places like the VA or Kaiser where everything is very all-inclusive, or if you're screened by your very well established primary care physician, who will, like Kevin said, if you're seeing that patient 8, 10, 12 times, you have that reminder -- did you go get your Hep C taken care of? No, you didn't? Here's another referral.

So that they can nag them until that full cascade is completed. The ED doesn't do this as well as maybe those systems, but probably a lot better than we would think they could. So, it's a reminder if they can do it, we should probably be able to do it also. And there are some other pretty high-risk groups that I think that linkage could definitely improve. I don't know how much -- if either of you see incarcerated populations, but screening in our incarcerated populations is probably improving, but that linkage to care, not so.

Dr Ault: There's a whole body of literature about care of that population of women while they're pregnant. There certainly should be screening. A lot of those people have risk factors obviously, but again, I think maybe we knew that before these more universal guidelines came out.

Dr Zamor: You have different levels of the prison system. You have the local county jails and the state penitentiaries and so forth. Our local county jail, we do see a fair amount of those patients at our hospital. We serve -- we're the big public hospital here in town that serves the big part of the county, so we do see a fair number of those patients. The one barrier can be -- still is that if you prescribe them medication, they may not receive it when they're in a city/county jail. I think because they say, well, you'll get treated when you get sentenced in the state prisons or something.

So, I think there's some areas still there where we could do better, quite frankly. Of course, it's a shuffle of money, who's going to be paying for what? I'm assuming coming from the county funds or state funds or so forth, either way, I think the patients need to be treated. I don't believe they get hepatitis C screening per se in a local county facility, but I'm pretty sure they do in a state facility though here.

Dr Reau: Those rules definitely depend on the situation. And there are some of the prisons that are very good at treatment, but there are also really good examples of linkage to care at the exit from incarceration. So Philadelphia, I think, has a strong program in linking incarcerated individuals to the FQHC at the time of release. Like you said, Philippe, they don't want to start something that might be disrupted. And so, if you start something while they're incarcerated and 2 weeks later they're released, then that means that you may undertreat the patient, which is a nice segue right into therapy.

I think hopefully we have emphasized the importance of screening, how screening could trigger diagnosis. And that linkage is really not just linkage to assess your liver health, but linkage to curative treatment. I think that when we have been putting this into context, a lot of this is based on barriers, and so, what do you think are some barriers that you are seeing in the hurdle to get patients to linkage that results in cure?

Dr Zamor: I mean, certainly we see the wide variety from patient ill-conceived notions, oh, I knew my uncle 20 years ago, he took interferon and he told me, never take interferon, but this was 20 years ago. So, patients were still holding onto some of the older ideas about how we approached hepatitis C treatment, where it was basically, we used to hurt more people than we used to actually help. Obviously, things radically changed in 2014-2015 with the advent of newer medicines. So still holding onto that, patients have the idea they're going to come and see ‘the liver doctor,’ therefore, the first day I meet them I'm going to insert a liver biopsy needle into their right flank. Again, I have not done a liver biopsy for Hep C staging in years, so you have to realize that patients are coming to this with different ideas or different notions about what treatment may be or what it entails. And the cost obviously for us, is for the patients they have a big concern about cost. I tell them, yes, you may have read that in the newspaper or saw on a website that these medicines are very expensive, but oftentimes patients come out-of-pocket very little to nothing to pay for these medicines.

That's just some of my experience. Just one more thing I'd like to throw out there would be patients -- again, with the insurance -- our world revolves around insurance these days and navigating the insurance minefield has gotten a lot better these days, and our pharmacies have really streamlined these things. They work very well with the insurers and the payers, so they've made our lives incredibly much more simple.

Dr Reau: I definitely have heard from patients that their family doctor or their primary care provider did not think that they would get access to therapy because of some of our older rules, like active addiction precluded treatment -- that's changing state by state still, but many states now no longer have fibrosis restrictions, no longer have active drug use restrictions. And so, those things might have preconceived notions in a provider who has a linkage to care. Kevin, you are in a bit of a unique population because our OB-GYN individuals may have variable coverage insurance.

Dr Ault: Right. So, the American College of Obstetricians and Gynecologists, ACOG, has had on its radar for a long time to expand Medicaid benefits for the first 6-12 months postpartum, and when we were talking about making this change to screening every pregnant woman, that really struck me as an opportunity to get women treated postpartum. We've already said this, but if you can get them in and get them established with somebody who's going to treat them postpartum, that gets rid of one of those barriers to linkage.

But also, that financial barrier is also broken down as states expand their Medicaid coverage postpartum. I think one of the other things [is], this has become a fly-over country-type of epidemic in the United States, and when a family doctor screens people, or an obstetrician/gynecologist screens people, that may be the only screen they see for a few years. That's a significant barrier to care as well for these individuals that we screen. Rule #1 of a screening test is: what are you going to do with the positive results? And so, you have to have that available as you start to get into this area of screening pregnant women and everybody else.

Dr Reau: So, I think that the simplistic treatment now is sometimes, like Philippe said, that you have these historical views, that treatment is challenging, has a lot of side effects, has a lot of monitoring, and yet we have very, very great examples of the fact that we don't need a lot of monitoring on treatment; that cure rates are great; that medicines are well tolerated. Pre-existing groups that were felt to be poorly adherent actually really do take their drugs, so you don't have to have as many physical visits with the patients as you might have thought.

But how do we now impart this information, this message on the effectiveness and the ease and simplicity of treatment to the primary care providers or the OB/GYNs, the group that needs to either embrace treatment and become a provider or encourage that linkage. Philippe, what are you telling your community providers?

Dr Zamor: Well, obviously, we try to spend some time to educate our colleagues, let them know, look, this whole idea of treatment has been revolutionized, it's simple, it's easy. Anybody can get treated, everybody should be treated. There really are no reasons to not treat people or very few reasons to not treat people. So, we try to spend some time just educating our colleagues... We've given presentations, we've done some in-person networking with our primary care docs or just now quick Zoom meetings just to update them about what we have to offer.

And if I'm going out and meeting people, we're doing some satellite clinics far away from the center or doing some lectures elsewhere, I try to remind people, try to figure out or try to know the landscape in your area, who is treating in your area. Okay. Just be aware, for example, there's some GIs around me that don't treat. So, their primary cares oftentimes have those send to that GI doctor who don't treat them and then the GI will send to us. Again, try to reduce the barriers for the patients. So figure out who is treating in some areas, infectious disease treats, some areas, some general practitioners are treating, some areas family docs are treating. And also just to know that again, really emphasize that treatment is certainly feasible. It's quite easily approachable.

Dr Reau: So, Kevin, are there OB-GYNs treating hepatitis C?

Dr Ault: I would guess probably not, however, I would say that there's a lot going on with viral hepatitis in general for women's health. I was in the elevator with a medical student earlier this week, and she didn't know I was doing this today, but we were talking about infectious diseases that get the short shrift because of COVID. She had just finished adult inpatient medicine, and she said, ‘there's a lot of hepatitis A in our neighborhood.’ And so, I think the way to approach continuing medical education for my specialty is to mention some of the things that have changed about hepatitis A, B, and C.

We now encourage treatment with antivirals for hepatitis B during pregnancy. There was some new vaccine recommendations for pregnancy and hepatitis A vaccine, as well as expanded age range for hepatitis B. I know that's not what we're talking about today, but ACOG is working very hard and we need to keep up to date on this, even though this infectious disease has not been a pandemic in the purest sense, but that is going on in the background for the care of women that we take care of.

Dr Reau: Yeah. So, I think that viral hepatitis has lost a little bit in the pandemic because COVID has become the dominant virus of conversation, but there are some very great examples of alternative care models. So, whether it's a primary care provider that's treating hepatitis C or whether it's a nurse practitioner, or pharmacy-driven treatment model, these are just as successful as Philippe and myself, a hepatologist treating hepatitis C. There is plenty of literature showing that this is successful, so that if you have that elevator conversation with one of your colleagues and they are in an area where there are limited treaters and they're interested in treatment, they should be encouraged to reach out.

ECHO, which is a great program to help engage and mentor individuals who might be rural and don't have access to a subspecialist can now do that in a primary care setting or in an alternative setting. And these models have gone nicely in federally qualified healthcare clinics FQHCs, in addiction medicine... I think anywhere where there's a prevalence and an interested provider, you can pop up hepatitis C treatment. I know that we are coming to a close, so I wanted to make sure I gave each one of you an opportunity to provide some of your salient summary points. I can start with you, Kevin.

Dr Ault: Well, I think anytime we have a guideline change, it takes a few years to get things into practice. Obstetricians and other primary care physicians have had to deal with frequent Pap smear guideline changes every 5 years for the past couple of decades. And so, those are always hard to implement, but this is really an area we can make a difference. I think we've shown data that hepatitis C is rapidly increasing in reproductive age women. And that's the group that we deal with the most, especially during pregnancy. So, it's a real opportunity to improve the care of your patients, if you're practicing OB-GYN or you're another provider that takes care of women during those years of their life.

Dr Reau: Thank you. And Philippe.

Dr Zamor: Well, good. Thank you, Nancy. I just want to, again, emphasize a few points, is that, the age group for this disease has changed from, like you said earlier, a bit of an older middle aged population to now a much younger population. We don't have to go through the questions to ask them, have you ever been in jail? Have you ever done this or done that? Just offer the patient's screening. Universal screening is what's recommended. You should not even hesitate to offer the patient’s screening. Let your patients know this is a routine part of recommendations.

Again, I remember back in 2014 or so when Hep C was in the front page of the New York Times and LA Times in Chicago Sun Times, everything. It was very exciting. Everybody was excited about hepatitis C, this silent killer. Then I felt like it went away, and it wasn't on everyone's radar like it should have been. So, I think this disease should still be on everyone's radar, no matter what field of medicine you're in, it certainly can have an impact.

I think our treatment options now are amazing. They've been revolutionized. I think it's given the ability for us to treat and eradicate this disease in many more patients. So, I'm still very excited about it. And it's certainly something that we hope to keep spreading the word about. Thank you.

Dr Reau: Thank you. So, although, we have incredibly effective curative therapies, we have not screened and identified and cured all of our patients. I think that that excitement really came when we had all oral curative treatments and then everyone just assumed everyone got cured, and that is not true. So, every adult needs at least a one-time hepatitis C screen, and recognize that we lose patients with each transition in the cascade of care. They drop out from screening to diagnosis, from diagnosis to linkage, from linkage to actually taking your drug.

Now, if you can get the person to take their medication, which most patients are very adherent, the expectation for cure is nearly a hundred percent. All the more reason to get them through that entire care cascade. Philippe, Kevin, I really want to thank you for this amazing discussion. Hopefully, this has encouraged a lot of our colleagues to be more aggressive with screening and linkage. And I want to thank anyone in our audience for participating in this activity. You do want to please continue on to answer the questions that follow and complete the evaluation.

This transcript has been edited for style and clarity.

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