Hepatitis C Virus Care Cascade Research Articles

Road to Hepatitis C Elimination in Israel: Improvements in Linkage to Care (2009-2020).

Disrupted linkage to care is a major barrier to hepatitis C virus (HCV) elimination leading to high attrition rates. This study aimed to describe (1) flow through the HCV care-cascade (2009-2020), and (2) monthly patterns in HCV care during the coronavirus disease 2019 (COVID-19) pandemic (2020) in Israel. Data were obtained from Maccabi Healthcare Services, a 2.6-million-member healthcare provider in Israel. Flow through the HCV care-cascade in 2009-2020 was described from individuals' first positive HCV antibody (Ab+) test to sustained virological response (SVR), and monthly data were obtained on individuals newly attaining a given stage in the HCV care-cascade in 2020. Among 2809 new patients who were Ab+, 2651 (94.4%) had an HCV polymerase chain reaction (PCR) test, and 1417 (50.4%) were PCR+ during the study. Median time from Ab+ to PCR+ was 3.9 years, with 39.7% PCR+ within 12 months. Median time from PCR+ to HCV treatment was 3.3 years, with 639 (55.5%) of patients who were PCR+ purchasing direct-acting anti-viral agents (DAAs), and 413/416 patients attained SVR. A significant reduction was observed in the time from first HCV detection (Ab+) to HCV confirmation (PCR+) and from PCR+ test to HCV treatment purchase in the pre-DAA era compared to the post-DAA. Monthly data during 2020 (Part B) indicates a decline in the numbers of patients receiving HCV care during the first pandemic-related closure. Real-world data from a nationally representative healthcare provider database suggest that HCV linkage to care improved over time alongside increased access to DAAs, despite observed declines in access to care in 2020.

P-2197. Pharmacist-Led Hepatitis C Virus Model of Care Effectively CURES Simplified Cases

Abstract Background Despite the existence of curative direct acting antiviral therapy, hepatitis C Virus (HCV) prevalence and mortality has increased in many regions of the United States. Existing models of care have failed to yield treatment rates needed for HCV elimination by 2030. In June 2023, we implemented UK-CURES (University of Kentucky - Cascade Utilizing Routinized screening through treatment to Eliminate Syndemics), a novel model of HCV care (Figure 1). This pharmacist-led model utilizes collaborative care agreements to carry out AASLD/IDSA best practices at the point-of-care in an effort to eliminate variation and waste along the HCV cascade.Figure 1.UK-CURES Simplified Treatment Algorithm Methods This study is a retrospective descriptive analysis including patients evaluated by the UK-CURES team between 6/1/2023 and 5/1/2024. Patients were excluded from this analysis if they were not eligible for the UK-CURES HCV simplified treatment algorithm. Patient demographics, clinical and operational data were collected from electronic medical record modifications. Patients were considered lost to follow-up if they had not engaged with treatment 120 days and had not completed sustained virologic response (SVR12) laboratory results. Results are summarized with descriptive statistics. Results 1,428 patients were evaluated by the UK-CURES team, of whom 1,105 were excluded from the treatment algorithm. The primary reason for exclusion was a negative confirmatory HCVRNA laboratory test (n = 579, 52.5%). Of 323 patients treated, demographics and baseline status are displayed in Table 1. Median time from first UK-CURES encounter to treatment order was 2 days, while the median time to first treatment dispense was 12 days (Table 2). Less than half of treated patients were lost to follow-up prior to obtaining SVR12 results (n = 147; 45.5%), and remaining patients are currently engaged in therapy (n = 141; 43.7%) or have completed SVR12 results (n = 35; 10.8%) (Figure 2). 32 patients (91%) were undetectable at SVR12.Figure 2.UK-CURES current patient status and attrition diagram Conclusion Our novel pharmacist-led model of care, UK- CURES, improved key performance indicators along the HCV care cascade for simplified cases while maintaining best practices surrounding HCV guidelines. The success of this model has significant implications for future HCV elimination efforts. Disclosures Maribeth P. Wright, RPh, CSP, Gilead FOCUS Program: Gilead FOCUS grant support Christian Rhudy, PharmD, MBA, Amgen, Inc.: Grant/Research Support Daniel Moore, MD, MBA, FACEP, Gilead FOCUS: Grant/Research Support

Opioid agonist treatment programs and hepatitis C virus elimination in Taiwan: Ways of expanding the care cascade in screening and treatment

BackgroundOne key population related to achieving the global goal of hepatitis C virus (HCV) elimination is people who inject drugs (PWID). By surveying opioid agonist treatment (OAT) programs nationwide in Taiwan, this study aimed to examine (1) the current status of HCV care cascade provision by OAT programs and (2) the opinions of the programs’ directors on integrating the HCV care cascade into OAT programs. MethodsFrom September to November 2022, questionnaires were sent via administrative networks to case managers for information on daily operation and routine booking and to directors for information on the HCV care cascade of 185 OAT programs. The responses of the 125 OAT programs that provided information from both case managers and directors were included for subsequent analyses. ResultsAmong the 125 OAT programs, 91 (73 %) offered HCV antibody testing, and 69 (55 %) offered HCV treatment services. The provision of HCV antibody testing was associated with being general hospital- or psychiatric hospital-based and having more care team personnel, whereas the provision of HCV treatment was associated with being general hospital-based. However, on-site HCV treatment was found to be rarely offered, and the future willingness to do so remained low. ConclusionOur survey revealed that the provision of HCV screening and treatment in OAT programs in Taiwan has substantial room for improvement. Increasing the number of care personnel for satellite-dispensing OAT programs is key to expanding the service for HCV screening, as more issues related to multidisciplinary medical resources are involved in the provision of HCV treatment. Our results point to some options that might help accomplish these goals.

Effects and Costs of Hepatitis C Virus Elimination for the Whole Population in China: A Modelling Study.

China has the highest number of hepatitis C virus (HCV) infections in the world. However, it is unclear what levels of screening and treatment are needed to achieve the WHO 2030 hepatitis C elimination targets. We aimed to evaluate the impact of scaling up interventions on the hepatitis C epidemic and determine how and at what cost these elimination targets could be achieved for the whole population in China. We developed a compartmental model incorporating HCV transmission, disease progression, and care cascade for the whole population in China, calibrated with data on demographics, injecting drug use, HCV prevalence, and treatments. Five different scenarios were evaluated for effects and costs for 2022-2030. All costs were converted to 2021 US dollar (USD) and discounted at an annual rate of 5%. One-way sensitivity analyses were conducted to assess the robustness of the model. Under the status quo scenario, the incidence of hepatitis C is projected to increase from 60.39 (57.60-63.45) per 100,000 person-years in 2022 to 68.72 (65.3-73.97) per 100,000 person-years in 2030, and 2.52 million (1.94-3.07 million) infected patients are projected to die between 2022 and 2030, of which 0.76 (0.61-1.08) million will die due to hepatitis C. By increasing primary screening to 10%, conducting regular rescreening (annually for PWID and every 5 years for the general population) and treating 90% of patients diagnosed, the incidence would be reduced by 88.15% (86.61-89.45%) and hepatitis C-related mortality by 60.5% (52.62-65.54%) by 2030, compared with 2015 levels. This strategy would cost USD 52.78 (USD 43.93-58.53) billion. Without changes in HCV prevention and control policy, the disease burden of HCV in China will increase dramatically. To achieve the hepatitis C elimination targets, China needs to sufficiently scale up screening and treatment.

Pilot model of hepatitis C virus micro-elimination in high-risk populations in Hong Kong: Barriers and facilitators

BackgroundAlthough the general seroprevalence of hepatitis C virus (HCV) infection in Hong Kong is <0.5 %, Hong Kong is still striving for HCV elimination owing to barriers in care cascade encompassing linkage-to-care (LTC), treatment initiation and adherence. We aimed to evaluate the feasibility of a pilot model of micro-elimination to strengthen the HCV care cascade for high-risk groups in Hong Kong. MethodsWe initiated the pilot Conquering Hepatitis vIa Micro-Elimination (CHIME) program which adopts an integrated care approach involving outreach visits to halfway house or drug rehabilitation centers run by non-governmental organizations. Participants with history of injection drug use (PWID), recreational drug use, or imprisonment were included. We performed point-of-care test for anti-HCV with reflex HCV RNA testing. LTC with government-subsidized direct acting antiviral was provided to viremic participants. We compared the impact on the care cascade with a cohort of HCV patients (17.8 % PWID) under usual care. Results396 participants (62.9 % PWID) were screened and 187 (47.2 %) were viremic, of which 29.8 % had cirrhosis. Proportion with LTC, treatment initiation and adherence were 76.5 % and 63.7 %, 90.9 % and 85.8 %, and 90.0 % and 92.2 %, for the CHIME program and usual care, respectively. The CHIME program was significantly associated with higher odds of LTC (OR 1.797, 95 % CI 1.221–2.644). Non-engagement in care (affecting 37.9 % participants with HCV viremia) was associated with unemployment (OR 2.165, 95 % CI 1.118–4.190). ConclusionThe pilot CHIME program demonstrated feasibility of an integrated approach to consolidate the HCV care cascade in high-risk populations in Hong Kong.

Population-level cascade of care for hepatitis C in Newfoundland and Labrador

Background: Global elimination of hepatitis C virus (HCV) is feasible using existent tools. Reporting the provincial HCV care cascade will contribute to national and global HCV elimination efforts. Methods: This observational study was a secondary use of population-level medical record data, including laboratory results for HCV testing and prescription data for HCV treatment in the province of Newfoundland and Labrador (NL). All patients with HCV antibody testing performed between Jan 1, 2017 and Jan 1, 2022 were included. All prescriptions dispensed from a community pharmacy in NL for any HCV treatment during the same period were included. Results: There were 84,252 antibody tests included. Of these, 3,626 (4.3%) tests were positive for HCV antibodies. Seventy eight percent (1,377/1,766) of the individuals with positive antibody tests were tested for HCV RNA. Only 377/1,061 (35.5%) individuals with a positive RNA test were treated, and 257/395 (65.1%) achieved sustained virological response at 12 weeks. Conclusions: NL has successfully identified and treated HCV, but treatment access is low. Targets for improvement include increased screening, reflex testing of positive antibody with RNA, increased linkage to care, change in treatment funding policy, and quicker treatment funding decision.

Best practices for hepatitis C linkage to care in pregnant and postpartum women: perspectives from the Treatment In Pregnancy for Hepatitis C Community of Practice

There is an increasing burden of hepatitis C virus among persons of reproductive age, including pregnant and breastfeeding women, in many regions worldwide. Routine health services during pregnancy present a critical window of opportunity to diagnose and link women with hepatitis C virus infection for care and treatment to decrease hepatitis C virus-related morbidity and early mortality. Effective treatment of hepatitis C virus infection in women diagnosed during pregnancy also prevents hepatitis C virus-related adverse events in pregnancy and hepatitis C virus vertical transmission in future pregnancies. However, linkage to care and treatment for women diagnosed in pregnancy remains insufficient. Currently, there are no best practice recommendations from professional societies to ensure appropriate peripartum linkage to hepatitis C virus care and treatment. We convened a virtual Community of Practice to understand key challenges to the hepatitis C virus care cascade for women diagnosed with hepatitis C virus in pregnancy, highlight published models of integrated hepatitis C virus services for pregnant and postpartum women, and preview upcoming research and programmatic initiatives to improve linkage to hepatitis C virus care for this population. Four-hundred seventy-three participants from 43 countries participated in the Community of Practice, including a diverse range of practitioners from public health, primary care, and clinical specialties. The Community of Practice included panel sessions with representatives from major professional societies in obstetrics/gynecology, maternal fetal medicine, addiction medicine, hepatology, and infectious diseases. From this Community of Practice, we provide a series of best practices to improve linkage to hepatitis C virus treatment for pregnant and postpartum women, including specific interventions to enhance colocation of services, treatment by nonspecialist providers, active engagement and patient navigation, and decreasing time to hepatitis C virus treatment initiation. The Community of Practice aims to further support antenatal providers in improving linkage to care by producing and disseminating detailed operational guidance and recommendations and supporting operational research on models for linkage and treatment. Additionally, the Community of Practice may be leveraged to build training materials and toolkits for antenatal providers, convene experts to formalize operational recommendations, and conduct surveys to understand needs of antenatal providers. Such actions are required to ensure equitable access to hepatitis C virus treatment for women diagnosed with hepatitis C virus in pregnancy and urgently needed to achieve the ambitious targets for hepatitis C virus elimination by2030.

Hepatitis C Virus Care Cascade by Race/Ethnicity in a Statewide Correctional Population, 2019-2023.

Hepatitis C virus (HCV) care cascade data by race/ethnicity for US correctional populations are sparse. To evaluate the HCV care cascade by race/ethnicity for a state correctional population. This retrospective cohort study used Connecticut Department of Correction data for incarcerated individuals tested, diagnosed, and treated for chronic HCV infection with direct-acting antivirals (DAAs) from 2019 to 2023. HCV care cascade outcomes, including testing, treatment, and cure rates, were compared by race/ethnicity. Poisson regression was used to estimate prevalence ratios (PRs), with adjustment for demographic and legal status factors. A total of 24,867 patients tested for HCV (88.9% men, mean (SD) age 35.6 (11.8), 32.7% White, 37.9% Black, 28.4% Hispanic, 0.6% Asian, 0.4% American Indian/Alaska Native (AIAN), 34.7% sentenced ≥ 1year). Both HCV exposure and chronic HCV were highest for White (27.1% and 15.2%) and lowest for Black individuals (4.6% and 2.6%) (P < 0.01, for both outcomes). While incarcerated, 63.2% of chronic HCV patients started DAAs, and treatment rates did not significantly differ by race/ethnicity (P > 0.05). For those treated and having post-treatment lab data available, cure rates were 98.8% or better for all racial/ethnic groups (P > 0.05). In the adjusted regression analyses, HCV treatment initiation was lower for those sentenced < 1year (PR, 0.76; 95% CI, 0.67-0.87) and unsentenced (PR, 0.85; 95% CI, 0.80-0.91) than those sentenced ≥ 1year. The adjusted prevalence of advanced fibrosis stage/activity grade was not significantly associated with race/ethnicity. In this cohort study, less than two-thirds of chronic HCV patients initiated DAA treatment during their incarceration, and for those with available data, nearly all were cured. While there were disparities in HCV exposure and chronic HCV infection, significant racial/ethnic differences were not observed for treatment initiation or cure rates. Further efforts are needed to increase HCV treatment, especially for patients with shorter incarceration periods.

Impact of simplified HCV diagnostic strategies on the HCV epidemic among men who have sex with men in the era of HIV oral pre-exposure prophylaxis in Taiwan: a modelling study.

Simplified hepatitis C virus (HCV) diagnostic strategies have the potential to improve HCV diagnoses and treatment. We aimed to investigate the impact of simplified HCV diagnostic strategies on HCV incidence and its effect on HCV diagnosis and treatment among men who have sex with men (MSM) regardless of HIV status and use of HIV pre-exposure prophylaxis (PrEP) in Taiwan. A compartmental deterministic model was developed to describe the natural history of HCV disease progression, the HCV care cascade and the HIV status and PrEP using among MSM. The model was calibrated to available data for HCV and HIV epidemiology and population demographics in Taiwan. We simulated the epidemic from 2004 and projected the impact of simplified testing strategies on the HCV epidemic among MSM over 2022-2030. Under the current testing approach in Taiwan, total HCV incidence would increase to 12.6 per 1000 person-years among MSM by 2030. Single-visit point-of-care RNA testing had the largest impact on reducing the number of new HCV infections over 2022-2030, with a 31.1% reduction (interquartile range: 24.9%-32.8%). By 2030, single-visit point-of-care HCV testing improved HCV diagnosis to 90.9%, HCV treatment to 87.7% and HCV cure to 81.5% among MSM living with HCV. Compared to status quo, prioritized simplified HCV testing for PrEP users and MSM living with diagnosed HIV had considerable impact on the broader HCV epidemic among MSM. A sensitivity analysis suggests that reinfection risk would have a large impact on the effectiveness of each point-of-care testing scenario. Simplified HCV diagnostic strategies could control the ongoing HCV epidemic and improve HCV testing and treatment among Taiwanese MSM. Single-visit point-of-care RNA testing would result in large reductions in HCV incidence and prevalence among MSM. Efficient risk-reduction strategies will need to be implemented alongside point-of-care testing to achieve HCV elimination among MSM in Taiwan.

An Analysis of Social Determinants of Health and Their Implications for Hepatitis C Virus Treatment in People Who Inject Drugs: The Case of Baltimore.

Sixty-eight percent of the nearly 3.5 million people living with hepatitis C virus (HCV) in the United States are people who inject drugs (PWID). Despite effective treatments, uptake remains low in PWID. We examined the social determinants of health (SDoH) that affect the HCV care cascade. We conducted a secondary analysis of data from 720 PWID in a cluster-randomized trial. We recruited PWID from 12 drug-affected areas in Baltimore. Inclusion criteria were injection in the prior month or needle sharing in the past 6 months. Intake data consisted of a survey and HCV testing. Focusing on SDoH, we analyzed self-report of (1) awareness of HCV infection (in those with active or previously cured HCV) and (2) prior HCV treatment (in the aware subgroup). We used descriptive statistics and logistic regression for statistical analyses. The 342 participants were majority male and Black with a median age of 52 years. Women were more likely to be aware of their status but less likely to be treated. Having a primary care provider and HIV-positive status were associated with increased awareness and treatment. Unhoused people had 51% lower odds of HCV treatment. People who reported that other PWID had shared their HCV status with them had 2.3-fold higher odds of awareness of their own status. Further study of gender disparities in HCV treatment access is needed. Increased social support was associated with higher odds of HCV treatment, suggesting an area for future interventions. Strategies to identify and address SDoH are needed to end HCV.

Ongoing Gaps in the Hepatitis C Care Cascade during the Direct-Acting Antiviral Era in a Large Retrospective Cohort in Canada: A Population-Based Study.

To achieve hepatitis C virus (HCV) elimination, high uptake along the care cascade steps for all will be necessary. We mapped engagement with the care cascade overall and among priority groups in the post-direct-acting antivirals (DAAs) period and assessed if this changed relative to pre-DAAs. We created a population-based cohort of all reported HCV diagnoses in Quebec (1990-2018) and constructed the care cascade [antibody diagnosed, RNA tested, RNA positive, genotyped, treated, sustained virologic response (SVR)] in 2013 and 2018. Characteristics associated with RNA testing and treatment initiation were investigated using marginal logistic models via generalized estimating equations. Of the 31,439 individuals HCV-diagnosed in Quebec since 1990 and alive as of 2018, there was significant progress in engagement with the care cascade post- vs. pre-DAAs; 86% vs. 77% were RNA-tested, and 64% vs. 40% initiated treatment. As of 2018, a higher risk of not being RNA-tested or treated was observed among individuals born <1945 vs. >1965 [hazard ratio (HR); 95% CI; 1.35 (1.16-1.57)], those with material and social deprivation [1.21 (1.06-1.38)], and those with alcohol use disorder [1.21 (1.08-1.360]. Overall, non-immigrants had lower rates of RNA testing [0.76 (0.67-0.85)] and treatment initiation [0.63 (0.57-0.70)] than immigrants. As of 2018, PWID had a lower risk of not being RNA tested [0.67 (0.61-0.85)] but a similar risk of not being treated, compared to non-PWID. Engagement in the HCV care cascade have improved in the post-DAA era, but inequities remain. Vulnerable subgroups, including certain older immigrants, were less likely to have received RNA testing or treatment as of 2018 and would benefit from focused interventions to strengthen these steps.

Does a simplified algorithm and integrated HCV care model improve linkage to care, retention, and cure among people who inject drugs? A pragmatic quality improvement randomized controlled trial protocol

BackgroundAs many as 2.4 million Americans are affected by chronic Hepatitis C Virus (HCV) in the United States.In 2018, the estimated number of adults with a history of HCV infection in San Diego County was 55,354 (95% CI: 25,411–93,329). This corresponded to a seroprevalence of 2.1% (95% CI: 2.1–3.4%). One-third of infections were among PWID. Published research has demonstrated that direct-acting antivirals (DAAs) have high efficacy and can now be used by primary care providers to treat HCV. In addition, limited evidence exists to support the effectiveness of simplified algorithms in clinical trial and real-world settings. Even with expanded access to HCV treatment in primary care settings, there are still groups, especially people who inject drugs (PWID) and people experiencing homelessness, who experience treatment disparities due to access and treatment barriers. The current study extends the simplified algorithm with a streetside ‘one-stop-shop’ approach with integrated care (including the offer of buprenorphine prescriptions and abscess care) using a mobile clinic situated adjacent to a syringe service program serving many homeless populations. Rates of HCV treatment initiation and retention will be compared between patients offered HCV care in a mobile clinic adjacent to a syringe services program (SSP) and homeless encampment versus those who are linked to a community clinic’s current practice of usual care, which includes comprehensive patient navigation.MethodsA quasi-experimental, prospective, interventional, comparative effectiveness trial with allocation of approximately 200 patients who inject drugs and have chronic HCV to the "simplified care" pathway (intervention group) or the "usual care" pathway (control group). Block randomization will be performed with a 1:1 randomization.DiscussionPrevious research has demonstrated acceptable outcomes for patients treated using simplified algorithms for DAAs and point-of-care testing in mobile medical clinics; however, there are opportunities to explore how these new, innovative systems of care impact treatment initiation rates or other HCV care cascade outcomes among PWID.Trial registrationWe have registered our study with ClinicalTrials.gov, a resource of the United States National Library of Medicine. This database contains research studies from United States and other countries around the world. Our study has not been previously published. The ClinicalTrials.gov registration identifier is NCT04741750.

Hepatitis C virus micro-elimination in people who inject drugs: Challenges and chance in Taiwan and worldwide.

With the introduction of direct-acting antivirals, elimination of hepatitis C virus (HCV) infection is becoming possible. People who inject drugs (PWID) represent a population with a high risk for HCV infection, which has been reported as high as 90% in Taiwanese PWID. To reach the goal of HCV elimination, PWID is a key population deserving special attention. Barriers in HCV care cascade still exist in PWID, and interventions to promote access to HCV diagnosis, link-to-care, treatment, and prevention for PWID are warranted. Although HCV micro-elimination can be achieved in some prisons and opioid substitution therapy (OST) centers by a multidisciplinary team and integrated care in Taiwan, there are still several unmet needs for HCV elimination in PWID. Continuous efforts, such as the participation of OST specialists and the continuum of care for HCV among PWID, are needed to achieve HCV elimination in Taiwan. In addition, the combination of harm reduction services, treatment as prevention and regular posttreatment HCV surveillance is critical to substantially reduce HCV transmission and prevalence in PWID.

Real-world treatment outcome of direct-acting antivirals and patient survival rates in chronic hepatitis C virus infection in Eritrea

Reliable real-world data on direct acting anti-retroviral (DAA) uptake and treatment outcomes are lacking for patients with hepatitis C virus (HCV) in sub-Saharan Africa. This study provides data on HCV DAA-based treatment outcomes, mortality, loss-to-follow up, and associated factors among patients in Eritrea. A multicenter retrospective observational cohort study was conducted in two tertiary hospitals in Asmara, Eritrea. A structured checklist was used to collect data from patient’s cards. Descriptive and inferential statistics used included means (± Standard deviation (SD), medians (Interquartile range (IQR), chi-squire (χ2), Kaplan–Meier estimates, and multivariate Cox proportional hazard models. A total of 238 patients with median age of 59 years (IQR 50–69 years) were enrolled in the study. Out of the 227 patients initiated on treatment, 125 patients had viral load measurements at 12 weeks after end of treatment (EOT) whereas 102 patients had no viral load measurements at 12 weeks EOT. Among the patients with HCV RNA data post-EOT 12, 116 (92.8%) had sustained viral response (SVR). The prevalence of death and loss-to-follow up (LTFU) were (7.5%, 95% CI 1.7–4.1) and 67 (28.1%, 95% CI 22.3–33.9) translating into an incidence of 1.1 (95% CI 0.8–1.5) per 10,000 person days. Independent predictors of LTFU included the enrollment year (2020: aHR = 2.2, 95% CI 1–4.7; p value = 0.04); Hospital (Hospital B: aHR = 2.2, 95% CI 1–4.7; p value = 0.03) and the FIB-4 score (FIB-Score < 1.45: aHR = 3.7, 95% CI 1.2–11.5; p value = 0.02). The SVR rates achieved in this cohort were high. However, high LTFU and high mortality driven largely by late presentation and suboptimal population screening/case finding, were uncovered. These challenges can be addressed by test-and-treat programs that simultaneously prioritize programmatic screening, decentralization of care, and better patient tracking in the HCV care cascade.

2502. Best Practice Alert for Hepatitis C Virus Screening Demonstrates Importance of Reminders during Disruptive Times (COVID-19)

Abstract Background In 2015, a Best Practice Alert (BPA) was implemented into our electronic health record that prompts ordering of Hepatitis C Virus (HCV) antibody (Ab) screens for unscreened patients born between 1945-1965 (baby boomers: BB). The BPA begins the first step of the three-step care cascade, after which follow-up is needed for RNA testing if Ab-positive and HCV clinic visit if RNA-positive (figure 1). Prior studies found a 3.5-fold increase in HCV Ab screening after BPA implementation. We sought to understand the BPA’s role in cascade navigation during the COVID-19 pandemic. Initial BPA is triggered, which leads to subsequent steps including HCV antibody testing, HCV RNA testing, and ending with a clinic visit for treatment initiation. Methods This retrospective study included BB receiving their first BPA between 7/1/18-12/31/19 (pre-pandemic: PP) and 1/1/20-7/1/21, (intra-pandemic: IP), excluding patients with a death date ≤ 180 days after their BPA. Patients were followed for 180 days for each step and were marked unsuccessful if it was not completed. Successful navigation (SN) was defined as completing all steps or testing negative at any step. Hazard ratios for completion of each step were calculated via Cox Proportional Model. Clinical and demographic predictors of SN were examined via multivariable logistic regression in each cohort. Results Overall, 14,236 unscreened BB had a BPA (8,090 PP, 6,146 IP) fire during the study periods. The cohorts were similar, except for an increase in share with county financial assistance and those cared for by advanced practice providers in the IP cohort (table 1). An increase in HCV Ab screening (aHR 1.31 [95% CI: 1.25, 1.38]) and decreases in HCV RNA testing (aHR 0.79 [0.65, 0.96]) and clinic visits (aHR 0.43 [0.28, 0.66]) were seen in the IP cohort (figures 2A, B, and C). Hispanic patients had increased odds (aOR: 1.25 [1.02, 1.54]) of SN in the IP cohort (figures 3A and B). Compared to family medicine, those cared for in geriatric clinics had lower odds (aOR 0.75 [0.62, 0.91]) of SN in the IP cohort. Lower odds were also seen for those with Charlson Index ≥ 2 (aOR 0.85 [0.74, 0.98]) compared to 0.Table 1.Cohort Demographics.Baseline demographic, comorbidity, and provider factors for the pre-pandemic and intra-pandemic cohorts. Figure 2. Survival-Time Analysis of the HCV Care Cascade. Kaplan-Meier curves with 95% confidence intervals depicting time to completion by day after step initiation in each cohort. Data for the HCV antibody screening (A), HCV RNA testing (B), and liver clinic visit (C) steps are each shown separately. Log-rank test p-values are shown. Figure 3. Logistic Regression Forest Plots Forest plots showing the adjusted odds ratios and 95% confidence intervals for successful cascade navigation in the pre-pandemic (A) and intra-pandemic (B) cohorts. Odds ratio less than 1 indicates lower odds of successful navigation during that period. Odds ratio greater than 1 indicates higher odds of successful navigation. Conclusion The BPA increased the durability of HCV Ab screening rates during the pandemic compared to other steps in the cascade. Disparities in completing all steps of the cascade persisted and likely worsened in some groups during the pandemic. Overall, electronic reminders lessen impacts of disruptions in healthcare services. Disclosures Mamta K. Jain, MD, MPH, Gilead Sciences: Grant/Research Support|Laurent: Grant/Research Support

Planning, implementing, and evaluating Hepatitis C virus elimination via collaborative community-based care cascade: age–period–cohort model for estimating demand from antecedent anti-HCV survey

BackgroundEstimating the demand for HCV care cascade plays an important role in planning, monitoring, and assessing the performance of introducing a new community-based hepatitis C virus (HCV) elimination program but such an analytic and systematic approach has been barley addressed.MethodsA new collaborative care program for HCV elimination in the Changhua Community of Taiwan has been offered to a total of 895,353 residents since 2018. To grasp the variation of demand for HCV care cascade across demographic and geographic features in the planning stage, we applied the age–period–cohort spatial model to the antecedent anti-HCV survey enrolling 123,617 participants aged 30 years or older between 2005 and 2018. Based on this precise denominator, we then employed a “before-and-after” study design to routinely evaluate whether the WHO criteria of 90% RNA positive diagnosis and 80% successful treatments could be reached.ResultsThe overall demand for HCV care cascade was 4.28% (HCV infection) of the underlying population but a declining trend was noted. The early cohort had a higher demand, whereas the demand of the young cohort decreased with each passing year. The demand also differed by township. The demand, allowing for these variations, for antiviral treatment was 22,362, yielding the WHO target of 12,880 for achieving HCV elimination. With 11,844 successful treatments, the effectiveness of elimination has already reached 92% (11,844/12,880) by the end of 2022.ConclusionsThe demand for HCV care cascade allows health care decision-makers to timely and properly assess the performance of a novel community-based collaborative care program in achieving HCV elimination.

Reflex Hepatitis C Virus Viral Load Testing Following an Initial Positive Hepatitis C Virus Antibody Test: A Global Systematic Review and Meta-analysis.

Many people who have a positive hepatitis C virus (HCV) antibody (Ab) test never receive a confirmatory HCV RNA viral load (VL) test. Reflex VL testing may help address this problem. We undertook a systematic review to evaluate the effectiveness of reflex VL testing compared with standard nonreflex approaches on outcomes across the HCV care cascade. We searched 4 databases for studies that examined laboratory-based reflex or clinic-based reflex VL testing approaches, with or without a nonreflex comparator, and had data on the uptake of HCV RNA VL test and treatment initiation and turnaround time between Ab and VL testing. Both laboratory- and clinic-based reflex VL testing involve only a single clinic visit. Summary estimates were calculated using random-effects meta-analyses. Fifty-one studies were included (32 laboratory-based and 19 clinic-based reflex VL testing). Laboratory-based reflex VL testing increased HCV VL test uptake versus nonreflex testing (RR: 1.35; 95% CI: 1.16-1.58) and may improve linkage to care among people with a positive HCV RNA test (RR: 1.47; 95% CI: .81-2.67) and HCV treatment initiation (RR: 1.03; 95% CI: .46-2.32). The median time between Ab and VL test was <1 day for all laboratory-based reflex studies and 0-5 days for 13 clinic-based reflex testing. Laboratory-based and clinic-based HCV reflex VL testing increased uptake and reduced time to HCV VL testing and may increase HCV linkage to care. The World Health Organization now recommends reflex VL testing as an additional strategy to promote access to HCV VL testing and treatment. PROSPERO CRD42021283822.

Creating a Longitudinal HCV Care Cascade for Persons With HIV/HCV Coinfection in Selected HIV Clinics Using Data to Care Methods.

Highly effective direct-acting antiviral (DAA) treatments for hepatitis C have led to strategic goals promoting hepatitis C virus (HCV) cure particularly in focus populations including persons with HIV/HCV coinfection. Implementing treatment more broadly requires both clinic-level and public health approaches such as those inherent in Data to Care (D2C) originally developed to improve the treatment cascade for persons with HIV (PWH). We used D2C methods to characterize and improve HCV treatment for persons with HIV/HCV coinfection among 11 HIV clinics in Connecticut cities with high PWH prevalence. Providers who were local champions in HCV treatment were recruited to participate along with clinic data staff and were key to quality improvement via practice transformation. We developed a methodology whereby clinic-generated lists of PWH receiving care from 2009 to 2018 were matched by CT Department of Public Health (DPH) against the state-wide HCV surveillance system. The resultant coinfection list was reviewed by clinical staff who designated HCV treatment status, enabling creation of individual clinic-level HCV treatment cascades. Data from DPH, especially current residency and deaths, enabled better characterization and allowed for refinement of longitudinal cascades. There were 1,496 patients with HIV/HCV coinfection. Sustained virologic response (SVR) rates varied by clinic (range, 44%-100%) with an aggregate SVR rate of 71% in September 2020. SVR rates improved during the project through a combination of increased treatment initiation/completion as well as data clean-up including serial updates of patient treatment status. Lack of treatment initiation was associated with being female (odds ratio [OR] = 2.18) and not having HIV viral suppression (OR = 3.24).

Hepatitis C virus care cascade among people who inject drugs in Puerto Rico: Minimal HCV treatment and substantial barriers to HCV care

BackgroundPeople who inject drugs (PWID) in Puerto Rico are disproportionately affected by the hepatitis C virus (HCV) epidemic. However, there is a scarcity of data on the HCV care cascade among PWID in Puerto Rico. This study aims to describe the HCV cascade of care among PWID in Puerto Rico, identify gaps, and explore barriers to HCV care. MethodsParticipants were recruited using respondent-driven sampling and tested for both HCV antibodies (Ab) and RNA (ribonucleic acid) using rapid testing and dried blood spot samples (DBS). The cascade of care was estimated based on the DBS HCV Ab and RNA results, as well as self-reported data on HCV screening, linkage to care, treatment uptake and sustained virologic response collected through a questionnaire. The cascade was constructed sequentially, with each step using the number of people from the preceding step as the base denominator. The survey also assessed participants' perceived barriers to HCV care. ResultsOut of 150 participants, 126 (84%) had previously been HCV screened, 87% (109/126) were HCV Ab positive, 72% (79/109) were RNA positive,48% (38/79) were linked to care, 32% (12/38) initiated treatment, 58% (7/12) finished treatment, and 71% (5/7) achieved SVR. Barriers to HCV care included concerns about drug abstinence requirements, access to transportation, stigma in healthcare settings, and lack of knowledge about HCV treatment sites. ConclusionThis study provides insights into the HCV cascade of care among PWID in Puerto Rico for the first time and highlights limited diagnosis, treatment uptake, and barriers to care.

Trends in hepatitis C virus coinfection and its cascade of care among adults living with HIV in Asia between 2010 and 2020.

Chronic hepatitis C virus (HCV) infection contributes to substantial morbidity and mortality among adults living with HIV. Cascades of HCV care support monitoring of program performance, but data from Asia are limited. We assessed regional HCV coinfection and cascade outcomes among adults living with HIV in care from 2010-2020. Patients ≥18 years old with confirmed HIV infection on antiretroviral therapy (ART) at 11 clinical sites in Cambodia, China, India, Indonesia, South Korea, Thailand and Vietnam were included. HCV- and HIV-related treatment and laboratory data were collected from those with a positive HCV antibody (anti-HCV) test after January 2010. An HCV cascade was evaluated, including proportions positive for anti-HCV, tested for HCV RNA or HCV core antigen (HCVcAg), initiated on HCV treatment, and achieved sustained virologic response (SVR). Factors associated with screening uptake, treatment initiation, and treatment response were analyzed using Fine and Gray's competing risk regression model. Of 24,421 patients, 9169 (38%) had an anti-HCV test, and 971 (11%) had a positive result. The proportion with positive anti-HCV was 12.1% in 2010-2014, 3.9% in 2015-2017, and 3.8% in 2018-2020. From 2010 to 2014, 34% with positive anti-HCV had subsequent HCV RNA or HCVcAg testing, 66% initiated HCV treatment, and 83% achieved SVR. From 2015 to 2017, 69% with positive anti-HCV had subsequent HCV RNA or HCVcAg testing, 59% initiated HCV treatment, and 88% achieved SVR. From 2018 to 2020, 80% had subsequent HCV RNA or HCVcAg testing, 61% initiated HCV treatment, and 96% achieved SVR. Having chronic HCV in later calendar years and in high-income countries were associated with increased screening, treatment initiation or achieving SVR. Older age, injecting drug use HIV exposure, lower CD4 and higher HIV RNA were associated with reduced HCV screening or treatment initiation. Our analysis identified persistent gaps in the HCV cascade of care, highlighting the need for focused efforts to strengthen chronic HCV screening, treatment initiation, and monitoring among adult PLHIV in the Asia region.