May 2020 CCSS S04: Hepatitis C for Primary Care: From Diagnosis to Cure and Beyond

QuestionAnswer
What is the difference between hepatitis C virus (HCV) vs A&B?Dr. Rife: In addition to the response I gave during the Q&A, I would additionally refer to the Centers for Disease Control and Prevention (CDC) website for additional details on hepatitis A & B. These are 3 distinct viruses that just have the common nomenclature of causing inflammation of the liver.
If your patient has antibodies to hepatitis C and no viral load, is there a time period you should obtain a follow-up viral load? If both viral loads are non-detectable, are they considered hepatitis C free or cured? Or do they always have a risk of relapse? I have had patient state they cannot donate organs because once diagnosed with the infection they were considered always infected.If your patient has antibodies to hepatitis C and no viral load, is there a time period you should obtain a follow-up viral load? If both viral loads are non-detectable, are they considered hepatitis C free or cured? Or do they always have a risk of relapse? I have had patient state they cannot donate organs because once diagnosed with the infection they were considered always infected.
Dr. Rife: If a patient has a positive hepatitis C virus (HCV) antibody and negative viral load in the absence of treatment, it is presumed that the patient spontaneously cleared. It takes 2-3 weeks after exposure for the viral load to become detected, but it takes 4-10 weeks for the antibody to become positive.
A patient is considered “cured” if their viral load remains undetectable 12-weeks post-treatment, or what is referred to as having achieved a sustained virologic response-12 (SVR12). Some providers may also choose to additionally recheck the viral load 24-weeks post-treatment or what is referred to as SVR24. If a patient achieves SVR, no additional monitoring of their HCV viral load or risk of relapse is warranted unless a suspicion arises due to a rising aspartate aminotransferase (AST) & alanine transaminase (ALT) and/or new risk factor exposure. Patients who achieve SVR from treatment are not protected from reinfection. However, patients without risk factors for reinfection have a very rare/low risk of relapse and should not be routinely monitored for unless the patient has a rise in their AST and ALT.
This is in contrast to hepatitis B virus (HBV). Patients ever exposed to HBV indicated by a positive HBV core antibody-total may indefinitely carry a risk of reactivation. The American Gastroenterological Association (AGA) has HBV reactivation prophylaxis guidelines that outline who is at risk of HBV reactivation and when prophylaxis is warranted or should be considered.
Patients ever exposed to (HCV) will indefinitely have a positive HCV antibody and are at this time indefinitely disqualified from donating blood. However, it is becoming more common to allow HCV patients to donate organs and to just have the recipient undergo HCV treatment after organ donation.
Any ideas on the physiologic basis between HCV and diabetes mellitus (DM)?Dr. Rife: Please see our attached manuscript that discusses some of the proposed physiologic bases for HCV increasing rates of DM. It is likely multifactorial, with a key role being the effects of the increased inflammatory cytokines of patients with HCV.
Is there a specific threshold for viral load to withheld HCV treatment?Dr. Rife: No, there is not a viral load threshold for withholding HCV treatment. Per the American Association for the Study of Liver Disease (AASLD) guidelines, all patients with chronic HCV should be evaluated for HCV treatment.

 

May 2020 CCSS S06: Cardiovascular Health and Transgender Patients: Considerations for Primary Care Practitioners

QuestionAnswer
This is more than about gender. What about the ambiguously sexed persons?Dr. Hashemi: Yes, this presentation is about gender identity. The main goal here was to be able to differentiate between “sex” and “gender”. In everyday living, even in medical practice, we use these two words interchangeably but they are not the same thing. Institute of Medicine defines sex as “the classification of living things, generally as male and female according to their reproductive organs and function assigned by chromosomal complement,” while gender is defined as “ a person’s self-identification as male or female”. While sex differences are caused by biological factors as consequences of genetic, molecular, cellular interaction, gender difference is due to environmental factors like social and cultural role of an individual. Sexual ambiguity is due to faulty pathways when reproductive organs are made. This was not the topic of interest today.
Could you please repeat where to find the paper you composed?Dr. Hashemi: In the list of references at the end of the talk, there is a paper written by myself and my colleagues about the “Transgender Care in Primary Care Setting: A Review of Guidelines and Literatures.”
What are the possible outcomes if a patient abruptly or repeatedly stops the hormone treatments?Dr. Hashemi: The main concern is mood problem. Transgender individuals usually take hormone replacement to decrease their anxiety due to gender dysphoria, which could be problematic. Some of the desired changes like hair pattern, etc. that have been achieved by taking hormone could go away if not going back on hormone.
Are there policy determinations as to the age of a person (child) when treatments can proceed? Especially in light of cardiovascular issues?Dr. Hashemi: Yes, they are. WPATH has a section about the care of transgender kids. I am not aware of any data about cardiovascular health and gender-affirming hormone treatment in kids, but that doesn’t mean data does not exist. It means I do not know.
What additional resources are you aware of that will assist health care providers with adopting a more respectful treatment approach and environment for transgender patients?Dr. Hashemi: There are national and international conferences. Also University of California- San Francisco (UCSF) has a website that people can do consult and ask questions. (https://transcare.ucsf.edu/guidelines). I love USCF transgender guidelines. Very well organized and easy to follow.
In light of the legislation that has passed, are there ongoing initiatives from the Veterans Affairs (VA) that address the discrimination and health care disparities experienced by individuals within the transgender community?Dr. Hashemi: Yes, the transgender health research is an HSR&D priority research. VA also has a national LGBTQ center. They work very hard to establish guidelines. Drs. Jillian Shipherd and Michael Kauth are in charge of the program. They can be reached out at VALGBTProgram@va.gov, website: Transgender SharePoint: http://go.va.gov/Transgender
Treatment options for transgender patients are still very new. Do you know of any evidence-based training opportunities for health care teams supporting a transgender patient that can be attended by health care providers, either sponsored by the VA, DoD or some other reputable source?Dr. Hashemi: Unfortunately I do not know of any program at VA but there is E-consult available nationally that any questions the providers have regarding Transgender care are answered.
Do you have any recommendations to the primary health care providers working with Active Duty transgender patients to prepare them for VA health care prior to discharge?Dr. Hashemi: They can enroll at VA upon discharge like any other veteran. Non-discriminatory care is the VA’s goal. They also can reach out to the national LGBTQ center for more information.
Has the spread of COVID-19 impacted the care for transgender patients in any way?Dr. Hashemi: I am sure they are as affected as others. I am not aware of any hard evidence or data about how affected they are. VA Greater Los Angeles continues to offer virtual care during the COVID pandemic in non-urgent cases and face to face visits for urgent cases. I am not an expert in COVID-19 and not able to comment further.
As a primary care physician, how often do you recommend meeting with an endocrinologist or other care providers associated with the transgender patients that you care for?Dr. Hashemi: It really depends on how comfortable one is with providing care, even if the patients are not able to meet with endocrine specialist in person, E-consult is available to the primary care physicians at VA. The primary care practitioner (PCP) is able to get recommendations via E-consult.
As a primary care provider working for the VA, can you discuss any recommendations within your health care system that you believe will improve the provision of care for a transgender patient?Dr. Hashemi: I wish VA would change the face-sheet to include sex at birth and gender.
How long does a transgender person need to take hormone therapy?Dr. Hashemi: It depends on the patient really, the reason for taking hormone is gender dysphoria. The hormone replacement treatment decreases the person’s anxiety, improves the quality of life. Some patients do not experience gender dysphoria, so they do not need hormone treatment. While some have severe dysphoria and need to take the hormone to the full extent to have secondary sex characteristics of the opposite sex and in addition to that have surgical interventions. Gender dysphoria has a wide spectrum.