HCV Care Cascade Research Articles

Financial incentives to increase engagement across the hepatitis C care cascade among people at risk of or diagnosed with hepatitis C: A systematic review

BackgroundReversing declining rates of people initiating and completing hepatitis C (HCV) treatment, observed in many countries, is needed to achieve global HCV elimination goals. Providing financial incentives to increase HCV testing and treatment uptake among people at-risk of or living with HCV infection could be an effective intervention. We conducted a systematic review to assess evidence regarding the effectiveness of financial incentives to improve engagement and progression through the HCV care cascade. MethodsWe searched MEDLINE, PubMed and EMBASE for studies published from January 2013 to January 2023 that evaluated financial incentives offered to people living with and at-risk of HCV to increase HCV antibody and or RNA testing, linkage to care, treatment initiation, treatment adherence, treatment completion, and sustained viral load (SVR) testing. Open-label randomised controlled trials (RCTs), controlled non-randomised studies, cohort or observation studies and mixed-methods studies were included, whereas literature reviews, case series and studies which did not report data were excluded. ResultsWe identified 1,278 studies, with 21 included after full-text screening (14,913 participants); three randomised controlled trials and 18 non-randomised studies. Studies evaluated incentives aimed at improving test uptake (n = 11), engagement in care (n = 13), treatment initiation (n = 8), adherence (n = 3), completion (n = 3) and attainment of SVR (n = 5). Findings provided inconclusive evidence for the effectiveness of incentives in improving engagement in the HCV cascade of care. Determining incentive effectiveness to improve care cascade engagement was limited by low quality study designs, heterogeneity in type (cash or voucher), value (US$5 to $600) and cascade stage being incentivised. No randomised controlled trials assessed the effectiveness of incentives to promote HCV testing, and none showed an impact on treatment uptake. In non-randomised studies (observational comparative), some evidence suggested that incentives promoted HCV testing, but evidence of their role in promoting linkage to care, HCV treatment adherence and treatment completion were mixed. ConclusionCurrently, there lacks high-quality evidence evaluating whether financial incentives improve HCV testing and treatment outcomes. Future research should seek to standardise methodologies, compare incentive types and values to enhance engagement in HCV care, and determine factors that support incentives effectiveness.

'I just never wanted them to feel uncomfortable': Barriers to pharmacy-based identification and treatment of hepatitis C in Victoria, Canada.

Canada is currently on target to reach the 2030 WHO goal of HCV elimination. Continued high rates of treatment are required to meet this goal. Novel models such as Tayside, Scotland pharmacy-based HCV screening and treatment have proven successful to engage people who use drugs (PWUD) in HCV therapy with a simplified, task-shifted cascade of care. This study seeks to determine whether these successes can be replicated at community pharmacies in Victoria BC. Four pharmacies who work with PWUD and provide opioid agonist therapy were trained to provide consent and perform point-of-care HCV antibody screening. They were supported by study nurse to link to HCV RNA testing when antibody positive patients were identified, with HCV treatment offered to RNA positive participants. Qualitative interviews were conducted with five pharmacy staff to explore experiences and feasibility of pharmacists in HCV care cascade. Pharmacy staff completed 200 HCV OraQuick tests between October 2020 and June 2022: 65 HCV antibody positive, 29 HCV RNA negative (25 previously treated and 4 self-cleared). Of the 26 RNA positive participants, one is awaiting treatment, 25 people have started treatment, 22 achieving SVR. Although the onset of the COVID-19 pandemic was a fundamental barrier incorporating HCV testing at pharmacies, stigma related to HCV and illicit drug use continues to impact this process. This innovative pharmacy-based approach found people with limited connection to primary health care to test and treat HCV but requires more training and support to be more widely feasible.

Engagement with the HCV care cascade among high-risk groups: A population-based study.

HCV elimination requires a thorough understanding of the care cascade. A direct-acting antiviral (DAA)-era description of the care cascade has not been undertaken in Ontario, Canada's most populous jurisdiction. Our primary objective was to describe the current population-level care cascade in the general Ontario population and among key risk groups ─ baby boomers, immigrants, and individuals experiencing residential instability. The secondary objective was to identify predictors of engagement. We conducted a population-based cohort study of Ontario residents undergoing HCV testing between January 1, 1999, and December 31, 2018, and mapped the care cascade [antibody-diagnosed, RNA tested, RNA positive, genotyped, treated, achieved sustained virologic response, reinfected/relapsed] as of December 31, 2018. The cascade was stratified by risk groups. Cause-specific hazard modeling was used to identify demographic, and socioeconomic predictors of engagement with key steps of the cascade. Among 108,428 Ontario residents living with an HCV antibody diagnosis, 88% received confirmatory RNA testing; of these, 62% tested positive and 94% of positive tests were genotyped. Of those with confirmed viremia, 53% initiated treatment and 76% of treated individuals achieved sustained virologic response, while ~1% experienced reinfection or relapse. Males, older birth cohorts, long-term residents, those with a history of substance use disorder and social marginalization (eg, material deprivation, residential instability), and those initially diagnosed in the pre-DAA era exhibited lower rates of engagement with almost every step of HCV care. Despite DAA era improvements, treatment initiation remains a major gap. HCV screening and linkage-to-treatment, particularly for those with a history of substance use disorder and social marginalization, will be needed to equitably close gaps in HCV care in the province.

Identifying barriers and facilitators along the hepatitis C care cascade to inform human-centered design of contextualized treatment protocols for vulnerable populations in Austin, Texas: a qualitative study

BackgroundHepatitis C virus (HCV) is a leading cause of liver-related mortality and morbidity. Despite effective direct acting antivirals and a simplified treatment algorithm, limited access to HCV treatment in vulnerable populations, including people experiencing homelessness (PEH) and people who inject drugs (PWID), hinders global elimination. Adapting the evidence-based, simplified HCV treatment algorithm to the organizational and contextual realities of non-traditional clinic settings serving vulnerable populations can help overcome specific barriers to HCV care. The first phase of the Erase Hep C study aimed to identify barriers and facilitators specific to these vulnerable populations to design the site-specific, simplified treatment protocols.MethodsForty-two semi-structured qualitative interviews, guided by the Practical, Robust Implementation and Sustainability Model (PRISM) framework, were conducted with clinic staff, community-based organizations providing screening and linkage to care, and patients diagnosed with HCV, to identify contextual barriers and facilitators to treatment at a local community health center’s Health Care for the Homeless program in Austin, Texas. Audio-recorded interviews were systematically analyzed using thematic analysis informed by the PRISM framework and design thinking, to anchor barriers and facilitators along the HCV care cascade. Findings were fed into human-centered design workshops to co-design, with clinic staff, site-specific, simplified HCV treatment protocols.ResultsThe specific needs of PEH and PWID patient populations informed barriers and facilitators of HCV care. Barriers included tracking patients who miss critical appointments or labs, medication access and adherence, and patient HCV knowledge. Clinical teams leveraged existing facilitators and incorporated solutions to barriers into clinic workflows to improve care coordination and medication access. Actionable solutions included augmenting existing staff roles, employing HCV care navigation throughout the cascade, and standardizing medication adherence counseling.ConclusionsClinic staff identified HCV care facilitators to leverage, and designed actionable solutions to address barriers, to incorporate into site-specific treatment protocols to improve patient HCV outcomes. Methods used to incorporate staff and patient experiential knowledge into the design of contextualized treatment protocols in non-traditional clinic settings could serve as a model for future implementation research. The next phase of the study is protocol implementation and patient enrollment into a single-arm trial to achieve HCV cure.

Non-disclosure of drug injection practices as a barrier to HCV testing: results from the PrebupIV community-based research study

BackgroundHepatitis C virus (HCV) infection prevalence is particularly high in people who inject drugs (PWID), a population that faces many barriers to HCV testing and care. A better understanding of the determinants of access to HCV testing is needed to improve their engagement in the HCV care cascade. We used data from a cross-sectional survey of people who inject drugs, mainly opioids, to identify factors associated with recent HCV testing.MethodsSelf-reported data on HCV antibody testing were analyzed for 550 of the 557 PWID enrolled in PrebupIV, a French cross-sectional community-based survey which assessed PWID acceptability of injectable buprenorphine as a treatment. Factors associated with recent (i.e., in the previous six months) HCV antibody testing were identified performing multivariable logistic regression.ResultsAmong the study sample, 79% were men and 31% reported recent HCV antibody testing. Multivariable analysis found that PWID who did not disclose their injection practices to anyone (aOR [95% CI] 0.31 [0.12,0.82], p = 0.018), older PWID (aOR [95% CI] 0.97 [0.95,1.00], p = 0.030) and employed respondents (aOR [95% CI] 0.58 [0.37,0.92], p = 0.019) were all less likely to report recent HCV testing. No association was found between opioid agonist therapy and HCV testing.ConclusionsOur findings suggest that non-disclosure of injection practices, employment and age were all barriers to HCV antibody testing. Preventing stigma around injection practices, developing the HCV testing offer in primary care and addiction care services, and training healthcare providers in HCV care management could improve HCV testing and therefore, the HCV care cascade in PWID.

Integrated supervised consumption services and hepatitis C testing and treatment among people who inject drugs in Toronto, Canada: A cross-sectional analysis.

Despite the availability of publicly funded hepatitis C (HCV) treatment in Canada, treatment gaps persist, particularly among people who inject drugs. We estimate correlates of HCV care cascade engagement (testing, diagnosis, and treatment) among people who inject drugs in Toronto, Canada and examine the effect of accessing differing supervised consumption service (SCS) models on self-reported HCV testing and treatment. This is a cross-sectional baseline analysis of 701 people who inject drugs surveyed in the Toronto, Ontario integrated Supervised Injection Services (OiSIS-Toronto) study between November 2018 and March 2020. We examine correlates of self-reported HCV care cascade outcomes including SCS model, demographic, socio-structural, drug use, and harm reduction characteristics. Overall, 647 participants (92%) reported ever receiving HCV testing, of whom 336 (52%) had been diagnosed with HCV. Among participants who reported ever being diagnosed with HCV, 281 (84%) reported chronic HCV, of whom 130 (46%) reported HCV treatment uptake and 151 (54%) remained untreated. Compared to those with no SCS use, participants who had ever injected at an integrated SCS model with co-located HCV care had greater prevalence of both ever receiving HCV testing (adjusted prevalence ratio [aPR]: 1.12, 95% confidence interval [CI]: 1.02-1.24) and ever receiving HCV treatment (aPR: 1.67, 95% CI: 1.04-2.69). Over half of participants diagnosed with chronic HCV reported remaining untreated. Our findings suggest that integrated SCS models with co-located HCV care represent key strategies for linkage to HCV care, but that more is needed to support scale-up.

1536. Hepatitis C Care Cascade Before and After Lifted Insurance Restrictions In Birth Cohort and Non-Birth Cohort Patients

Abstract Background In 2016, the MetroHealth System implemented a system-wide hepatitis C (HCV) screening initiative in novel settings. We previously showed that those born 1945–1965 (birth cohort, BC) had higher rates of linkage to care (LTC) and sustained virologic response (SVR) rates compared to non-BC (not born 1945–1965). Since 2019, restrictions on fibrosis, sobriety and prescriber have been loosened. We hypothesized that gaps in care cascade between BC and non-BC patients (including LTC rates) would lessen in those diagnosed after 2019. Methods We compared the HCV LTC rates and care cascade in patients diagnosed from Jan 1, 2016 to June 30 2017 (early group) to those diagnosed July 1, 2019 to Dec 31, 2020 (late group) as well between BC and non-BC patients. We performed logistic regression to evaluate the impact of race, gender, known prior HCV positivity, site of HCV diagnosis, HIV, insurance, active injection drug use (IDU), remote IDU, psychiatric disorder, BC status and early/late diagnosis on LTC. Results The study population comprised 2103 HCV+ patients (1349 non-BC, 754 BC). There were 1026 patients in the early group and 1077 patients in the late group. 1353 patients were HCV RNA+. Of those, 914 (67.6%) were white, 306 (22.6%) African American; 872 (64.4%) male; 990 (74.5%) Medicaid; 822 (60.7%) outpatient diagnosis. On multivariable analysis, factors affecting. LTC were: BC (aOR 1.71, 95%CI 1.19–2.45, p=0.003); diagnosed inpatient (aOR 0.45 (0.32–0.66), p< 0.0001), emergency department (aOR 0.55, (0.35–0.89), p=0.0142) or jail (aOR 0.23, (0.13–0.4), p=0.23); active IDU (aOR 0.22, (0.14–0.35),p< 0.0001); remote IDU (aOR 0.60, (0.4–0.89)p=0.01); and diagnosis in the late group (aOR 0.67, (0.51–0.8), p=0.005). The care cascade improved in the late group, but gaps remained in non-BC vs BC (Table). Conclusion The non-BC continued to have lower rates of LTC compared to BC in the late group.Overall LTC was decreased in the late group for both non-BC and BC likely due to COVID-19. However, improvement in medication approval was shown in the late group, and most patients who were prescribed treatment completed it. Active IDU remained a barrier to non-LTC, but did not fully explain the differences between BC and non-BC patients. Disclosures Melissa O. Jenkins, Meliisa Jenkins, Gilead Sciences: Grant/Research Support.

OS051 - The HCV care cascade for children and young people in British Columbia, Canada: a large, linked administrative population-based cohort study

OS051 - The HCV care cascade for children and young people in British Columbia, Canada: a large, linked administrative population-based cohort study

Psychiatrist-led treatment of hepatitis C (HCV) at an opioid agonist treatment (OAT) clinic in Stockholm - enhancing the HCV treatment care cascade

IntroductionPeople who inject drugs (PWID) and opioid agonist treatment (OAT) patients have an increased hepatitis C (HCV) prevalence. Studies among these populations show promising HCV treatment results, which is essential to reach the WHO goal of eliminating HCV as a major public health threat by 2030.ObjectivesTo introduce psychiatrist-led HCV treatment at an OAT clinic and to investigate HCV treatment results, i.e. sustained virological response at 12 weeks post treatment (SVR12) and numbers of reinfections.MethodsPrima Maria OAT clinic in Stockholm, provides OAT for 450 patients. The majority have a history of injection drug use. Baseline HCV prevalence (January 2018) was retrospectively investigated through medical charts. In January 2018, psychiatrist-led HCV treatment (with consultation support from infectious diseases specialists) was introduced at the clinic. Prospective treatment results, numbers of reinfections and incidence rates between January 2018 and April 2021 were further investigated.ResultsBaseline data (n=418), showed that 46% were not tested for HCV. Of those tested (n=225), 64% had a chronic HCV infection. By January 2021, 104 HCV treatments were initiated. 97/97 (100%) were HCV RNA negative at end-of-treatment. 78/88 (89%) reached SVR12. Overall, 2 reinfections were noted after SVR12 corresponding to a reinfection rate of 3.5/100 PY. Numbers of HCV treatment did not decrease during the COVID-19 pandemic.ConclusionsTo enhance the HCV treatment cascade, targeted HCV diagnosis efforts are needed. Bringing HCV treatment to OAT clinics enhance the HCV care cascade. HCV treatment education for psychiatrists/addiction specialists makes HCV treatment more sustainable, as specifically noted during the COVID-19 pandemic.DisclosureThis study was partly funded by Gilead Nordic Fellowship 2020. The funders had no role in study design, data collection and analysis, decision to publish or preparation of the poster/manuscript.

904. Improving Infectious Disease Screening and Hepatitis C Care Cascade Outcomes Among Adults Receiving Medication Assisted Treatment

Abstract Background This initiative increased infectious disease (ID) screening in an adult medication assisted treatment (MAT) population at a Federally Qualified Health Center (FQHC) by implementing opt-out screening for HIV, viral hepatitis, and sexually transmitted infections (STIs), and assessed the success of a co-located hepatitis C (HCV) treatment program. Methods ID providers maintained a standing lab order for HIV, hepatitis A, hepatitis B, HCV, syphilis, chlamydia/gonorrhea (GC/CT), and trichomoniasis (trich), with reflex to confirmatory for HIV/HCV/syphilis. For all existing and new adult MAT patients, a MAT RN provided education, ensured lab draw on the day of MAT induction, and scheduled an ID follow-up visit. The patient then had an in-person or telemedicine visit with the ID provider to review results, discuss risk reduction, and initiate treatment (HIV PrEP or treatment for STI, HCV, or HIV) as indicated. Data was compiled and monitored by a Prevention RN. Plan, Do, Study, Act (PDSA) Model PDSA model demonstrating implementation approach Results The rate of testing among MAT patients increased over a one-year period. HCV treatment uptake in this setting exceeded that documented in published data for people who inject drugs (PWID). HCV Care Cascade Outcomes HCV screening and treatment outcomes within HCV Care Cascade model Screening Outcomes Screening rates among adult MAT population over a one-year measurement period Conclusion This study documents the successful implementation of an opt-out screening program among an adult substance use disorder (SUD) treatment population across urban, mixed, and designated rural environments. HCV treatment uptake in this setting exceeded that documented in published data for people who inject drugs (PWID). Barriers to implementation included acceptance among patients with long-term MAT participation, acceptance/adoption by behavioral health nursing and provider staff, and functional workflow development – establishment of protocol, lab availability, scheduling, and “tough sticks.” Modifications that increased effectiveness included an interdisciplinary approach and dedicated staff for monitoring results completion and patient outreach. Run chart: HIV screening rates over a one-year period HIV screening change among adult MAT patients over a one-year period Run chart: HCV screening rates over a one-year period HCV screening change among adult MAT patients over a one-year period HCV Care Cascade: HCV screening and treatment outcomes HCV screening and treatment outcomes presented in HCV Care Cascade for adult MAT population Disclosures All Authors: No reported disclosures

831. Hepatitis C Virus Micro-elimination Within a Human Immunodeficiency Virus Clinic: Challenges in the Home Stretch

BackgroundHepatitis c virus (HCV) eradication among persons with HIV (PWH) is alluring since DAAs efficacy is high regardless of HIV status and PWH in care are usually screened for HCV. Despite the potential, barriers to care have prevented many from achieving sustained virologic response (SVR). We performed a pharmacist-led campaign to reduce the proportion of PWH with active HCV and describe the barriers to care. MethodsThis retrospective review evaluated patients receiving care at a Ryan White-funded clinic from 07/2018 to 12/2020. Patients were eligible if HCV diagnosed ≥1 year and receiving HIV care. The primary endpoint was to compare the prevalence HCV before and after a pharmacy initiative to target the remaining patients at the clinic not treated during first 3 ½ year period of oral DAA therapy availability. Secondary analysis was to identify barriers to care, measure the proportion of patients in each step of the HCV care cascade, and determine predictors of SVR. Among barriers to care, inconsistent engagement was defined as patients with habitual missed appointments. Logistic regression and Chi-square tests were performed.Results46 of 1,100 PWH had active HCV for ≥1 year. Median age, years since HIV and HCV diagnoses were 58.5 years of age, 17 years, and 11.5 years, respectively. Most patients were male (70%), Black (61%), Latinx (28%), HCV genotype 1 (90%), had an HIV RNA < 200 copies/mL (72%), & had Medicaid (87%). 32/46 patients agreed to therapy, with all getting insurance approval and DAAs delivered. Glecaprevir/pibrentasvir (73%) was the preferred by payors, followed by sofosbuvir/velpatasvir (15%). Eight remained with active HCV and 19 achieved SVR. The prevalence rate dropped from 4.2% to 0.7% (P < 0.0001). Active drug use, inconsistent engagement, mental health disorder and nonadherence were initial barriers to care. After multivariate analysis, patients with inconsistent engagement continued to be less likely achieve SVR compared to those we remained consistently in care (aOR: 0.062, 95 CI: 0.009-0.421).HCV care cascade in PWH within a Ryan White-funded clinic Active HCV includes 46 patients with chronic HCV infection receiving HIV in care at clinic, DAA approval process describes patients agreeing to HCV treatment along a continuum of pending laboratory results or pending prior authorization requests, DAA procurement depicts patients that have received approval and delivery of medications, DAA initiation describes patients who started treatment (27 patients), and SVR documented defines patients with an undetectable HCV RNA 12 weeks after therapy (19 patients).ConclusionPharmacists can impact the burden of HCV among PWH receiving care. The HCV care cascade remains tied to the HIV continuum of care, with disengagement from care remaining an important rate-limiting step impeding micro-elimination.Disclosures All Authors: No reported disclosures

Impact of COVID-19-related public health measures on HCV testing in British Columbia, Canada: An interrupted time series analysis.

Background & AimsPublic health measures introduced to limit transmission of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), which causes coronavirus disease 2019 (COVID‐19), also disrupted various healthcare services in many regions worldwide, including British Columbia (BC), Canada. We assessed the impact of these measures, first introduced in BC in March 2020, on hepatitis C (HCV) testing and first‐time HCV‐positive diagnoses within the province.MethodsDe‐identified HCV testing data for BC residents were obtained from the provincial Public Health Laboratory. Weekly changes in anti‐HCV, HCV RNA and genotype testing episodes and first‐time HCV‐positive (anti‐HCV/RNA/genotype) diagnoses from January 2018 to December 2020 were assessed and associations were determined using segmented regression models examining rates before vs after calendar week 12 of 2020, when measures were introduced.ResultsAverage weekly HCV testing and first‐time HCV‐positive diagnosis rates fell immediately following the imposition of public health measures by 62.3 per 100 000 population and 2.9 episodes per 1 000 000 population, respectively (P < .0001 for both), and recovered in subsequent weeks to near pre‐March 2020 levels. Average weekly anti‐HCV positivity rates decreased steadily pre‐restrictions and this trend remained unchanged afterwards.ConclusionsReductions in HCV testing and first‐time HCV‐positive diagnosis rates, key drivers of progression along the HCV care cascade, occurred following the introduction of COVID‐19‐related public health measures. Further assessment will be required to better understand the full impact of these service disruptions on the HCV care cascade and to inform strategies for the re‐engagement of people who may have been lost to care because of these measures.

A hepatitis C elimination model in healthcare for the homeless organization: A novel reflexive laboratory algorithm and equity assessment.

Reaching World Health Organization hepatitis C (HCV) elimination targets requires diagnosis and treatment of people who use drugs (PWUD) with direct acting antivirals (DAAs). PWUD experience challenges engaging in HCV treatment, including needing multiple provider and laboratory appointments. Women, minoritized racial communities, and homeless individuals are less likely to complete treatment. We implemented a streamlined opt-out HCV screening and linkage-to-care program in two healthcare for the homeless clinics and a medically supported withdrawal center. Front-line staff initiated a single-order reflex laboratory bundle combining screening, confirmation, and pre-treatment laboratory evaluation from a single blood draw. Multinomial logistic regression models identified characteristics influencing movement through each stage of the HCV treatment cascade. Multiple logistic regression models identified patient characteristics associated with HCV care cascade progression and Cox proportional hazards models assessed time to initiation of DAAs. Of 11,035 clients engaged in services between May 2017 and March 2020, 3,607 (32.7%) were screened. Of those screened, 1,020 (28.3%) were HCV PCR positive. Of those with detectable RNA, 712 (69.8%) initiated treatment and 670 (94.1%) completed treatment. Of those initiating treatment, 407 (57.2%) achieved SVR12. There were eight treatment failures and six reinfections. In the unadjusted model, the bundle intervention was associated with increased care cascade progression, and in the survival analysis, decreased time to initiation; these differences were attenuated in the adjusted model. Women were less likely to complete treatment and SVR12 labs than men. Homelessness increased likelihood of screening and diagnosis but was negatively associated with completing SVR12 labs. Presence of opioid and stimulant use disorder diagnoses predicted increased care cascade progression. The laboratory bundle and referral pathways improved treatment initiation, time to initiation, and movement across the cascade. Despite overall population improvements, women and homeless individuals experienced important gaps across the HCV care cascade.

S1232 Electronic Health Engagement Improves Hepatitis C Care Cascade in PWID

Introduction: There are multiple challenges in the hepatitis C [HCV] care cascade. Electronic health engagement could emerge as a tool in linking patients to the HCV care cascade. There is an emerging epidemic of HCV among people who inject drugs (PWID). Our aim is to link PWID that are HCV RNA positive to care and utilize our online patient database management system (PDMS) with Substance Abuse Treatment Centers to fulfill the linkage portion. Methods: Longitudinal prospective cohort study with HCV screening and linkage to care through utilization of a HIPPA compliant PDMS (www.linkagetocare.com). A centrally located Linkage to Care Specialist (LTCS) is notified immediately when an individual’s information is entered in the system by the treatment center or self-referred. The LTCS educates the individual and proceeds to link them to care. Results: January 2017 – 2020, 1867 patients were referred to LTC; 52% self-referred and 48% referred from 40 facilities in 29 states; 51% were uninsured; and 60% were between the ages of 21-40. 1012 (54%) of patients were from sober living homes and 470 (25%) from treatment facilities. 1034 HCV RNA positive patients; 888 (86%) patients were contacted by LTCS; 470 (53%) referred to a medical provider; 16% patients awaiting lab results; 4.5% lost contact. 210 (37%) patients made it to their first appointment; 122 initiated therapy; 49% were completing evaluation; 51% finished therapy or achieved SVR12; and 3 patients relapsed to drug use. Conclusion: Targeting PWID is an effective way of reducing the prevalence of HCV infection and ultimately eliminating HCV. Our study demonstrates a promising role for patient engagement in electronic health portals as a tool in linking patients to the hepatitis C care cascade. With the LTC program, there is an increase in patient compliance with linkage to care as compared to current care models.

Outcomes of the CT2 study: A 'one-stop-shop' for community-based hepatitis C testing and treatment in Yangon, Myanmar.

BackgroundWith the advent of low‐cost generic direct‐acting antivirals (DAA), hepatitis C (HCV) elimination is now achievable even in low‐/middle‐income settings. We assessed the feasibility and effectiveness of a simplified clinical pathway using point‐of‐care diagnostic testing and non‐specialist‐led care in a decentralized, community‐based setting.MethodsThis feasibility study was conducted at two sites in Yangon, Myanmar: one for people who inject drugs (PWID), and the other for people with liver disease. Participants underwent on‐site rapid anti‐HCV testing and HCV RNA testing using GeneXpert(R). General practitioners determined whether participants started DAA therapy immediately or required specialist evaluation. Primary outcome measures were progression through the HCV care cascade, including uptake of RNA testing and treatment, and treatment outcomes.FindingsAll 633 participants underwent anti‐HCV testing; 606 (96%) were anti‐HCV positive and had HCV RNA testing. Of 606 tested, 535 (88%) were RNA positive and had pre‐treatment assessments; 30 (6%) completed specialist evaluation. Of 535 RNA positive participants, 489 (91%) were eligible to initiate DAAs, 477 (98%) completed DAA therapy and 421 achieved SVR12 (92%; 421/456). Outcomes were similar by site: PWID site: 91% [146/161], and liver disease site: 93% [275/295]). Compensated cirrhotic patients were treated in the community; they achieved an SVR12 of 83% (19/23). Median time from RNA test to DAA initiation was 3 days (IQR 2‐5).ConclusionsDelivering a simplified, non‐specialist‐led HCV treatment pathway in a decentralized community setting was feasible in Yangon, Myanmar; retention in care and treatment success rates were very high. This care model could be integral in scaling up HCV services in Myanmar and other low‐ and middle‐income settings.

Need for universal hepatitis C screening in incarcerated populations

Hepatitis C carries a large burden of disease in Canada. Barriers to care, especially in the incarcerated population, may impede effective treatment and the achievement of targets for disease eradication. Access to universal screening in incarcerated populations could support engagement in the care cascade, and local studies around prevalence and screening efficacy could be used to justify and inform screening programs. A focus on incarcerated populations is an important step toward HCV eradication and ensuring equitable healthcare for all. This article will discuss the HCV care cascade, the unique burden of HCV in correctional facilities, and provide an argument in support of universal screening in incarcerated populations.

A population-based US study of hepatitis C diagnosis rate.

Underdiagnosis of HCV infection may hinder the obtainment of 2030 elimination goal. To estimate the pre-DAA HCV diagnosis rate to inform future public health effort. Data were obtained from three nationwide databases (Truven Health MarketScan Research Database 2007-2014, US Census Bureau 2012-2016 and NHANES 2007-2014). HCV diagnosis was defined with either one inpatient or two outpatient HCV International Classification of Disease 9 codes, providing the number of patients with diagnosed HCV (Truven). US Census Bureau data were used for age- and sex-standardization. We derived the total (diagnosed and undiagnosed) HCV infection using the NHANES database. To determine the rate and number of undiagnosed HCV, we subtracted diagnosed HCV burden (Truven) from the total HCV burden (NHANES). Of the 198 073 302 privately insured Americans, 1.49% (2 951 490 persons) had HCV infection. However, only 362 672 (12.29%) persons were diagnosed with HCV, leaving 2 588 818 (87.71%) undiagnosed. About two-third (68.04%) and one-third (33.04%) of diagnosed HCV patients had HCV RNA or genotype tests overall, with even lower rates for the ≥65 age group, respectively. In the pre-DAA era, only 12% of insured Americans with HCV were diagnosed. While this grim statistic is expected to rise, much more effort is needed to enhance the HCV care cascade.

1065. Hepatitis C Virus Care Cascade Assessment–One Step Closer to Micro-Elimination

BackgroundHepatitis C virus (HCV) is a leading cause of advanced liver disease and death. In the United States about 3.5 million people are living with HCV, but only 50% are aware of the infection, 16% are prescribed treatment, and only 9% achieve sustained viral response. The World Health Organization published an HCV elimination goal for 2030 that strives to achieve a 65% reduction in HCV-related deaths and 90% reduction in transmission. An important step toward this goal is micro-elimination at local hospitals by addressing care gaps in the HCV care cascade.Figure 1 MethodsWe created a retrospective cohort of patients who tested positive for HCV antibody (HCV Ab+) between 2016 and 2018 at Tufts Medical Center in Boston, Massachusetts. We assessed achievement of care cascade steps including HCV viral load (VL) testing, linkage to care, treatment initiation, and sustained viral response (SVR). We also assessed patient demographics, clinical factors and HCV risk factors. We used STATA/IC 14.1 to conduct bivariate analysis to identify factors associated with loss to follow-up across each care cascade step.ResultsA total of 24,308 HCV antibody tests were done during this timeframe, of which 5% (n=1,222) were HCV Ab+. After excluding duplicate tests, 1,041 unique patients with HCV Ab+ were included. This cohort had a mean age of 47 years and were 61% male, 66% white, 72% on public insurance, 12% HIV-positive, 13% HCV treatment-experienced. The most frequent HCV risk factor was injection drug use, occurring in 64% of patients. Of patients with HCV Ab+, 76% (n=791) were tested for an HCV VL, of which 50% (n=393) had detectable VL and 50% (n=398) had undetectable VL. Of the patients with a detectable VL, 58% (n=226) were linked with care. Following care linkage, 69% (n=155) initiated treatment, of which 90% (n=139) completed treatment, of which 97% (n=135) achieved SVR (Figure 1). Factors that were significantly associated with getting a VL test and linking to care included private insurance, HIV co-infection, absence of intravenous drug use and cirrhosis; however, these factors were not significantly associated with achieving subsequent steps.ConclusionAssessment of the HCV care cascade at our hospital allowed us to identify clear care gaps and areas needing improvement towards a local micro-elimination.Disclosures All Authors: No reported disclosures

933. Cured vs. Not Yet Treated: Population Differences for HIV/HCV Co-infected Patients Navigating the HCV Care Cascade in 11 Connecticut Clinics

BackgroundHepatitis C (HCV) care cascades for persons with HIV/HCV co-infection are hampered by incomplete HCV surveillance data, lack of standardized matching algorithms, and incomplete ability to determine HCV treatment status from surveillance alone. However, client-level data from individual clinics can be combined into multi-site cascades to assess progress toward micro-elimination goals. To achieve these goals, characterization of treatment gaps is crucial. Looking at trends in 11 HIV clinics, we examine correlates of not entering/initiating HCV therapy.MethodsWe established a partnership with CT Dept. of Public Health and 11 HIV clinics through a HRSA SPNS grant (047). Lists of HIV/HCV co-infected individuals obtaining care from these clinics from 1/2009-9/2018 were created using data from HIV (eHARS) and HCV (CTEDSS) surveillance, individual clinic rosters and a validated matching algorithm. Clinic personnel reviewed these lists to determine who were treatment eligible (TE) and their current HCV treatment status (e.g. treatment initiated, SVR documented, untreated but in clinical care). Clinic lists were updated regularly to reflect changes in overall patient status (e.g. deceased, relocated, transferred care). We performed bivariate analysis to identify correlates of treatment initiation including odds ratios with 95% confidence intervals.ResultsOf 7265 patients receiving HIV-related services, 2117 matched to HCV surveillance, representing 1496 unique patients. As of 6/1/2020, 821 patients were TE, 727 (89% of TE) were in active care, 630 (77%) initiated treatment, 620 (76%) completed treatment, 584 (71%) achieved SVR. Of the TE group, 77 (9%) had not yet initiated treatment. Compared to initiators of HCV therapy, patients not yet initiating treatment are more likely to be women (OR 1.7 95% CI 1.1-2.8), and black (OR 1.9 95% CI 1.1-3.1), with unsupressed HIV viral loads (OR 2.5, 95% CI 1.5-4.0).ConclusionThis work capitalizes on the feasibility of creating a care cascade for HIV/HCV by Data to Care methods. Patients in partner clinics who had not yet initiated treatment were more likely to be women, black, and have poorly controlled HIV. Further efforts are needed to determine the barriers to treatment initiation among these groups.Disclosures All Authors: No reported disclosures

The hepatitis C care cascade among people who inject drugs accessing harm reduction services in Catalonia: Major gaps for migrants

BackgroundThis study aimed to describe the HCV cascade of care among people who inject drugs (PWID) in Catalonia, as well as to compare the observed gaps in care between Spanish-born and migrant PWID. MethodsA cross-sectional study of PWID (N = 410) attending four harm reduction services (HRS) was performed in 2016–17 (HepCdetect II Study). Participants were tested for both HCV antibodies (rapid testing) and RNA (from dried blood spot samples). The HCV care cascade was estimated from HCV testing results combined with self-reported data on previous testing, diagnosis and treatment collected through a questionnaire. Logistic regressions were used to test for an association between migration status and the proportions observed in each step of the HCV care cascade adjusting for age, sex, years of injection, homelessness, and treatment for drug dependence. ResultsOverall, 85.4% were men and 28.0% were migrants. Among Spanish-born (n = 295) and migrant (n = 115) PWID participants in the study, 96.6% vs. 88.6% had previously been HCV screened (AOR=3.11; 95% CI: 1.11–8.65), 79.3% vs. 80.9% were antibody positive, and 70.7% vs. 67.6% were HCV-RNA positive or cured with treatment; among the latter, 36.6% vs. 18.2% had started treatment (AOR=2.41; 95% CI: 1.09–5.34), and 20.6% vs. 9.1% had been cured by treatment, respectively. Unawareness of having hepatitis C was more common among migrants than Spanish-born PWID (46.0% and 31.5%, respectively; p<0.05). ConclusionThis study estimates the HCV care cascade among Spanish-born and migrant PWID in Catalonia for the very first time, and highlights a higher attrition of migrant PWID in all HCV care cascade stages. The observed limited linkage to care and treatment by PWID that attend the HRS network warrants future implementation of decentralized diagnosis and antiviral treatment. Strategies focusing on migrants by increasing HCV screening coverage and treatment access will be especially relevant in our setting.