New Mexico Corrections Department (NMCD) 2018 Hepatitis C Treatment Selection Criteria and Guidelines Hepatitis C virus (HCV) infects and damages the liver. HCV is primarily transmitted through blood to blood contact. In the prison system this is usually through sharing needles to inject drugs or through tattooing. HCV can also be transmitted through sexual contact or perinatally from mother to baby, but these modes of transmission are relatively inefficient and account for a small percentage of cases. According to the Centers for Disease Control and Prevention (CDC), 2.7-3.9 million Americans have chronic HCV infection. According to the New Mexico Department of Health, an estimated 53,000, or 2.5% of the New Mexico state population, are chronically infected. There are 6 genotypes of HCV (genotypes 1-6). Genotypes 1 and 3 are the most common genotypes in New Mexico, with genotype 1 comprising approximately 70% of infections. Some people who are infected will spontaneously clear the virus. However, between 70-85% of people infected with HCV will develop chronic infection. Not all state corrections departments conduct HCV screening of inmates at intake, which may explain why other states report lower rates of HCV positivity among their inmate populations. As of June 2018, NMCD incarcerates approximately 7,300 inmates, of which about 45% are HCV antibody positive during any given month. Upon intake, every inmate is tested for HCV antibodies. Since August of 2017, all HCV antibody positive inmates undergo reflex confirmatory testing with a nucleic acid amplification test (NAAT). NMCD and Centurion, NMCD’s inmate healthcare vendor, have partnered with Project ECHO at the University of New Mexico to evaluate and treat HCV infected inmates. NMCD has maintained a relationship with Project ECHO for this purpose since 2004. The goal of the ongoing project is to treat as many inmates as possible, given available resources, with the priority of identifying and treating the most advanced cases. Patients with advanced liver disease, cirrhosis, advanced fibrosis or serious extra-hepatic manifestations of HCV are prioritized for treatment during incarceration. To be considered for treatment, inmates must meet security criteria, be able to provide informed consent and demonstrate a willingness and ability to comply with daily medication dosing. Inmates must have at least 6 months remaining on their sentence so that treatment and a sustained viral response (SVR) test, or “test of cure,” can be completed prior to release. Courage Responsibility Ethics Dedication - CREDibly serving the public safety of New Mexico Inmates with a disciplinary history that includes major infractions are not eligible for treatment consideration until 12 months have elapsed without a major infraction. Multiple minor infractions do not necessarily prevent treatment consideration unless the history indicates a clear inability or unwillingness to comply with programming. Treatment is offered at every facility that has 24-hour medical coverage and offers directly observed therapy (DOT) for medication administration. DOT is required to assure that all medication doses are being taken as directed. Patient-inmate Selection Guidelines: Patients with confirmed HCV infection and ANY of the following should be presented to HCV Corrections teleECHO for treatment consideration: 1. Patients with confirmed HCV infection with cirrhosis or advanced fibrosis. Patients should be considered to have cirrhosis or advanced fibrosis if any of the following laboratory, radiographic or clinical findings are present: a. Presence or history of ascites or esophageal varices b. Platelet count <150,000 c. APRI score > 1.0 (utilize AST upper limit of normal of 40 for calculating APRI) d. FIB-4 > 3.25 e. Fibrosure > 0.72 f. Imaging with evidence of cirrhosis (nodular contour of the liver or presence of portal hypertension) g. Liver biopsy with F3 or F4 fibrosis h. Transient elastography consistent with advanced fibrosis/cirrhosis 2. Patients with confirmed HCV infection and any potential extra-hepatic complications of HCV, including: a. Type 2 or 3 essential mixed cryoglobulinemia with end-organ manifestation (e.g., vasculitis) b. Membranoproliferative glomerulonephritis c. Renal dysfunction d. Proteinuria e. Lymphoma f. Diabetes mellitus g. Peripheral neuropathy h. Chronic arthralgias i. Debilitating fatigue 3. Patients with confirmed HCV infection and the following co-infections or circumstances which are high-risk for accelerated progression of liver disease or other complications: Courage Responsibility Ethics Dedication - CREDibly serving the public safety of New Mexico a. Organ transplant recipients b. HIV coinfection c. Hepatitis B coinfection d. ALT > 10 time the upper limit of normal Patient-inmate Security Guidelines: 1. At least 6 months minimum remaining on incarceration 2. No major infractions in the past 12 months 3. A history of multiple minor infractions may prevent consideration for treatment if the infractions indicate an inability or unwillingness to comply with regular programming Priority Consideration for Case Presentation to ECHO of Patient-inmates with Confirmed HCV Infection: Priority 1  Patients with evidence of cirrhosis or advanced fibrosis  Liver transplant candidates or recipients  Patients with renal failure  Patients with lymphoma  Patients with cryoglobulinemic vasculitis  Patients who are organ transplant recipients  Patients with HBV or HIV co-infection  Patients receiving immunosuppressants  Patients on HCV medication upon arrival at NMCD Priority 2  Patients with APRI score of 1.0 or greater (greater likelihood of hepatic fibrosis or cirrhosis)  Patients with ALT> 200 (in chronic HCV infection)  Patients with co-morbid liver disease, i.e. steatohepatitis or hemochromatosis Priority 3  Patients with stage 2 Fibrosis  Patients with APRI score of >0.7 to <1.0  Patients with co-morbid diabetes mellitus Priority 4  Patients with stage 0-1 fibrosis  All other cases of HCV infection Courage Responsibility Ethics Dedication - CREDibly serving the public safety of New Mexico