2023 Hepatitis Awareness Month: A Conversation with Dr. Ada Stewart, MD, FAAFP

In observance of Hepatitis Awareness Month, Dr. Isabel Lechuga, MD, MPH, Associate Director on NASTAD’s Hepatitis team, and Zakiya Grubbs, MPH, Manager on NASTAD’s Hepatitis team, interviewed Dr. Ada Stewart, MD, FAAFP. They discussed Dr. Stewart’s experience as a leader in promoting primary care provider-led hepatitis C treatment and eliminating treatment disparities in communities that have been historically marginalized. They also talked about the online hepatitis C treatment and prevention course she developed with the Black Health Learning Academy. The eight-unit course provides a comprehensive overview of screening, diagnosis, and treatment, while acknowledging stigma, health disparities, and access to care as barriers to hepatitis elimination. Although geared towards primary care providers, the course can benefit a wide range of clinicians and support staff. 

Dr. Ada Stewart, MD, FAAFP is a family physician at Cooperative Health in Columbia, South Carolina. She is a past Board Chair of the American Academy of Family Physicians and past President. Dr. Stewart was the first African American Female President of the American Academy of Family Physicians. Dr. Stewart continues to advocate on behalf of family physicians and patients to inspire positive change in the U.S. health care system. Dr. Stewart has been a practicing family physician with Cooperative Health, also known as Eau Claire Cooperative Health Centers, since 2012 and currently serves as lead provider and HIV specialist. She has held many leadership positions on the local, state, and national levels. She has been a staunch advocate for marginalized populations, individuals living with HIV/AIDS, and those of trans experience. 

Q1: When we saw your course online, we were very excited, because again and again health departments raise or flag for us that there is so much more to be done in terms of provider awareness and education, and incentivizing providers to treat hepatitis C. Can you tell us a little bit about yourself and your career, and what led you to hepatitis C?  

A1: Of course. I'm Dr. Ada Stewart. I am a board-certified family physician. I have worked within the community health center space since residency, and I completed residency in 2003. Since then, I have been working with marginalized individuals. We were seeing individuals who were living with HIV, and that began my journey down the path of also, including individuals who are living with hepatitis C. And so, I started with individuals who are living with HIV, and found that as things progressed with treatment improvements for hepatitis C about 2012, when the direct-acting antiviral treatments kind of were on the forefront, [we] recognized the importance of primary care within the treatment space and how we were able to provide care to individuals who were oftentimes ignored, and those were people of color. Initially, our focus was on individuals who were baby boomers. And then, as that recommendation changed, as we saw the increase of folks with hepatitis C who were younger, in their twenties and thirties, and then most recently seeing the change to individuals who were, higher in prevalence, with hepatitis C due to the opioid epidemic. Recognizing again the importance of primary care because we are many times the first individuals who see patients and screen them. And so, why can't we also provide treatment, especially with the newer agents that are available right now.  

I have been part of the American Academy of Family Physicians, and initially, I served on the Commission on Health of the Public and Science. I was asked to attend a meeting where the new antiviral agents were discussed, and who was able to provide them. I was able to really lend the voice of primary care, and how many times we were diagnosing patients. There are so many times we forget, and we miss opportunities to be able to treat people because we send them off to specialists. Those were some of the reasons why I really found a profound interest in the hepatitis C space. I recognized that Black communities and people who inject drugs are the individuals who need us the most and who need us to eliminate hepatitis C, which we recently found out is possible with these medications. I strive to have a profound impact on the lives of patients who have for so long been neglected. In conclusion, that kind of sheds light on my story and how I ended up doing what I do.  

Q2: Absolutely. I appreciate that. You took us on the journey with you, and how you got to where you are, and the consideration of the GI specialists were making that distinction between they're not the first necessary point of contact. Right? 

A2: Yes, yes, for patients who couldn't even get to a specialist, and they have no insurance. 

Q3: So then, what led you to develop the Hep C course with the National Black Leadership Commission on Health?  

A3: Recognizing the huge disparity among people of color who were really, number one, becoming aware that hepatitis C is something that is out there that they should be aware of; and two that there are treatments that are available to cure hepatitis C. Additionally, recognizing that primary care physicians can really make a profound impact in getting individuals diagnosed and getting them treated, and especially for people of color. We saw that early on Black communities weren’t even being screened. And then, of course, treatment opportunities were not even being offered. Within communities where there are high incidence rates of HCV, there were many questions about the driving factors towards the high HCV incidence rates. Such as were they from an increase in incarceration rates, increased trauma, and/or drug use? We were seeing higher numbers within people of color, and at this point, we're seeing more individuals who are injecting drugs who have added to that equation. So of course, it's getting at those populations, people who are so many times neglected, not really being recognized as needing treatment, and them (not)being able to access treatment has been one of the main drivers for why I do what I do, and why I was honored to be asked to come up with that program and present it.   

Q4: Along the same lines, can you speak to the impact and initial successes of your course?  

A4: So, thus far we are seeing more and more patients, and we are recognizing that hepatitis C can be eliminated. There’s a goal of really eliminating hepatitis C by 2030. For many years, we had no idea that this is something that can happen and actually be treated and cured. The old treatments were really not successful. Having the opportunity to cure hepatitis C is very remarkable. We're seeing especially, I’m in South Carolina, a great number of individuals who are now treated and cured of hepatitis C. So, on the public health side it's had a profound impact. We continue to make some more changes, including individuals who now we see have an increased risk of hepatitis C, those with opioid use disorders, and IV drug users. So, it's been successful. We also recognize how important it is for primary care to be aware that this is something that they can do within their offices.  

There are some limitations, and those things have been highlighted and unveiled. We have seen insurance issues, such as issues where some insurers are requiring individuals to be seen by a specialist. Also, there have been situations where we see that you don't have to be abstinent to get treatment. So, there's been some great progress, but we still have a way to go. And, just seeing patients, I can tell you the many patients that I have cured of hepatitis C are so thankful and grateful, because many times we can't just cure something. Things like diabetes and hypertension. They continue to have these. We can say that your hepatitis C has been cured, their eyes light up, they are just so happy and so pleased. And it's a life changer. 

Q5: Absolutely. Yeah, that must be very gratifying. And I appreciate how in Unit 7, you are explicit in naming that most of these issues are related to greater health inequities and social determinants that disproportionately affect Black communities, that they need to be addressed at different levels. Can you speak more about how providers can address these inequities? And there is an intentionality with this question, considering how powerful providers are in the U.S.  

A5: Yes, yes, so number one is you can't address them unless you recognize it. And so, many times it's really important to be able to identify the social determinants of health and identify the inequities that exist, and you have to name it in order to be able to address it. And so, for providers, and I'm going to kind of change the terminology, we now like to use clinicians or health care professionals and not necessarily just providers, because we just don't provide care, which tends to be more monetary. We are professionals who are working to change the healthcare landscape.  

Also, if you talk about it, you know that people of color are more disproportionately impacted by hepatitis. When you see populations, such as Black and Latine/Hispanic communities, you address these issues and ensure that you screen for hepatitis C. If you don't screen and diagnose, you can't treat. Again, recognizing the social determinants and recognizing the inequities that exist. We all saw these things highlighted through COVID-19, such as not having access to transportation or even having access to seeing a clinician. The bottom line is being able to help other clinicians recognize the inequalities and recognize the groups who are disproportionately impacted by hepatitis C.  

Q6: Yes, absolutely. And I very much appreciate you naming the distinction between provider and clinician. Because you're right. “Provider” is basically more transactional. Which clinicians would benefit the most from your course?  

A6: Everybody has a role, from the front to the back. I always tell my staff that we must make sure that prevention and recognizing populations and individuals who are disproportionately cared for within our communities are all recognized from the front to the back. This includes nurses, physicians, social workers, and front desk. This goes more towards our healthcare clinicians who provide actual care, but everyone has a role. Everyone has a role.  

I talk about our nurse practitioners and our pharmacists. I was a pharmacist for 13 years prior to going to medical school. They have a role by being able to recognize individuals and groups, to help assist in providing medications and treatment plans, and ensuring that patients know what they need to do and recognize their risks. If one doesn't recognize the risk, then many times they don't know that they need to be screened. I would say that we're geared towards those who provide care, but everyone has a role in all of this. 

Q7: Thank you. You're right. It's true. Everyone does have a role, from front to back. This brought up a question to me about some of the reasons why folks don't necessarily access care. As you mentioned, you can treat folks with hepatitis C, whether they're using drugs, whether they're abstinent, or in recovery but a lot of folks still don't access care for a lot of reasons due to stigma. I was wondering how clinicians, nurses, front desk folks, and everyone involved can ensure that there is a welcoming environment for folks and to really welcome them into care?  

A7: Stigma is big, and until we really address that we're not going to get where we need to get as far as the elimination of many of these public health issues, such as hepatitis C; we must always normalize care. I tell people we screen everyone for hepatitis C. We screen everyone for HIV, we screen every day; and we talk about this for everyone. It's not like we're looking at a particular group of individuals, and saying that this person looks like they, may be an IV drug user, because you don't know. When you normalize it, you remove that stigma. That's the most important thing that you can do.  

Q8: Oh, yes, thank you so much, and that's one of the reasons why the CDC has recommended universal screening for hepatitis C. We are interested in knowing a little bit more about some of the barriers or challenges that you faced when you initially began treating for hepatitis C using DAAs and how ECHO programs, like the Southeast Viral Hepatitis Interactive Case Conference series, have helped new providers in implementing hepatitis C treatment?  

A8: It was very difficult. The biggest barrier was being a primary care clinician. They felt that - and this is the insurance companies, Medicaid, and other private insurers - primary care really could not do this. And of course, they were wrong. And so, what happened was, they would say that you need to refer your patient to a specialist, a GI or infectious disease individual, or we will not pay for this very expensive medication, which, of course, the cost has decreased tremendously, but that was the biggest barrier. Project ECHO allowed us to say that if we presented at this conference, or at this telehealth meeting, because we will present these cases, then that will suffice for us.  

We do not want to have to send our patients out who couldn’t go anywhere else. Which ties into social determinants of health and barriers to patients. And so, these programs really provided a means for us to be able to get our patients a “one-stop shop”, come to see us, get diagnosed and get treated within the space that they're familiar with as their medical home. These programs have been a tremendous asset. They helped clinicians who may have been afraid to even treat patients that previously thought that it was going to be difficult.  It just really gave everyone equal footing as far as learning what they could do as primary care clinicians, and in every practice setting, individuals not only at community health centers, but within the prison and jail systems. It just gave us that opportunity to treat and to meet patients where they are. That was the most important thing.  

Q9: And that leads to my next question, because at NASTAD, one of our priorities is addressing health as a syndemic, not just addressing hepatitis, or HIV or STDs, but holistically. Can you offer some advice for other clinicians about how they can ensure that they're addressing the whole person and social determinants of health when treating people for hepatitis C?  

A9: The biggest thing is having that conversation with the patient, and finding out what their needs are, what their social situation is. And again, normalizing things, so that patients don't feel that they're being singled out. I always tell my patients this is a conversation I have with everyone. Where do you live? What's your social situation? Who's your support system, if you have one? I also ask funny questions like, do you have any pets? Do you have any kids? All of those things help you to see that person for who they are. And then we get into the medical, such as diabetes, hypertension, kidney, and liver health, and making sure that prevention is number one. Have you had your mammogram, your colonoscopy, your pap smear?  I also do gender-affirming care and having that conversation with our patients. Are you seeing someone for your gender dysphoria? If not, I'm here for you, and so that really helps patients to feel that this is a home. This is somewhere where they can come and talk to me about anything that's going on. And I tell my patients, we are in this together, I'm going to be your biggest advocate. Everything that we do is what we call shared decision-making. I can make recommendations, can't make you do anything, but I can help you, and make sure that you have all the things that you need. I'm lucky that I provide care for individuals living with HIV, hepatitis C, those of trans experience, diabetes, and hypertension. Whatever you got, I can take care of it. And so that really makes a difference.

Q10: Dr. Stewart, what I’m hearing is your approach to your practice is based on, I’m getting the impression of trauma-informed principles. Was that part of your medical school training?  

A10: No, this is something that we are now starting to talk about more now, that was not a part of the training and that is something that we need to address and make sure that we look at. I just was talking about this with someone just yesterday; I said, we don't know what patients are dealing with, and what traumas they have seen, especially with the population in which I serve. And, not only just working, we talk about safe housing, such as you may have a house, but if you can't walk outside or if you can't even peep out the window for fear of being shot, you're going to bring all of that with you as part of your visits and it impacts your care, and it impacts your health. This is something that really has come to the forefront, I would say in the last couple of years. But, we really need to talk more about trauma-informed care, and actually put that within the medical school curriculums moving forward definitely.

NASTAD admires and appreciates Dr. Stewart’s passion for providing quality health care to communities that have been medically underserved.   

For more information on the Black Health Learning Academy Hepatitis C treatment and prevention course by Dr. Stewart, please click here. To learn more about Dr. Stewart and her journey to becoming a doctor, please view this video as part of the Department of Health and Human Services Women’s History Month celebration.   

Please note, this interview has been condensed and edited for clarity.