Hepatitis C Virus Care Continuum Research Articles

2490. Improving Hepatitis C Continuum of Care in an Outpatient Internal Medicine Population

Abstract Background According to the WHO, approximately 71 million people are infected with Hepatitis C virus (HCV), and more than 400,000 people die each year due to HCV-related liver diseases. Since the advent of safe and highly effective direct-acting antivirals (DAA) in 2014, treatment for HCV has been revolutionized with cure rates exceeding 90%. Although the detection of undiagnosed HCV infection itself likely has some inherent benefit, the impact of screening is greatly reduced if it does not lead to treatment and cure. Studies on the HCV continuum of care have concluded many patients are lost at each stage, highlighting the need to raise awareness among healthcare professionals and at-risk populations about hepatitis testing, referral, support, and care. A practical model to help fill care gaps in urban internal medicine clinics and improved treatment enrollment and adherence is necessary, which in turn will improve public health outcomes. Methods The objective of the study is to improve the continuum of care of HCV, from diagnosis to treatment of the disease at the outpatient Faculty Medical Center (FMC) Internal Medicine Clinic, and identify hurdles to treatment. We enrolled 31 patients who screened positive for hepatitis C antibody into a pooled cohort, where biweekly telephone encounters were initiated for 3 months to facilitate close follow-up, including scheduling labs and office visits and facilitating subspecialty referrals. (Table 1). Hepatitis C Continuum of Care Workflow HCV labs include HCV viral load and genotype, Fibroscan, Hepatitis B surface antigen, and antibody, Hepatitis A antibody, and HIV 1/2 antibody test. Results Six months post-study, 7 out of 31 (22%) patients enrolled in our intensive follow-up completed treatment. Among the patients who were lost to follow-up, the most common issue encountered was following up with specialists (58%). The most common communication barrier was patients having inactive phone numbers. Results Conclusion Our next step is to establish an HCV clinic within our FMC Internal Medicine Center to expand access to care for HCV-affected patients. The HCV clinic will include coordination with the Infectious Diseases specialist through E-Consult and TriHealth Specialty Pharmacy. The impact will be early treatment of HCV-affected patients, improved treatment success which ultimately reduces the risk of transmission and progression of the disease, and improved quality of life. Disclosures All Authors: No reported disclosures

Using the Diabetes Care System for a County-Wide Hepatitis C Elimination: An Integrated Community-Based Shared Care Model in Taiwan.

Despite the serious risks of diabetes with hepatitis C virus (HCV) infection, this preventable comorbidity is rarely a priority for HCV elimination. We aim to examine how a shared care model could eliminate HCV in patients with diabetes (PwD) in primary care. There were 27 community-based Diabetes Health Promotion Institutes in each township/city of Changhua, Taiwan. PwD from these institutes from January 2018 to December 2020 were enrolled. HCV screening and treatment were integrated into diabetes structured care through collaboration between diabetes care and HCV care teams. Outcome measures included HCV care continuum indicators. Township/city variation in HCV infection prevalence and care cascades were also examined. Of the 10,684 eligible PwD, 9,984 (93.4%) underwent HCV screening, revealing a 6.18% (n = 617) anti-HCV seroprevalence. Among the 597 eligible seropositive individuals, 507 (84.9%) completed the RNA test, obtaining 71.8% positives. Treatment was initiated by 327 (89.8%) of 364 viremic patients, and 315 (86.5%) completed it, resulting in a final cure rate of 79.4% (n = 289). Overall, with the introduction of antivirals in this cohort, the prevalence of viremic HCV infection dropped from 4.44% to 1.34%, yielding a 69.70% (95% credible interval 63.64%-77.03%) absolute reduction. Although HCV prevalence varied, the care cascades achieved consistent results across townships/cities. We have further successfully implemented the model in county-wide hospital-based diabetes clinics, eventually treating 89.6% of the total PwD. A collaborative effort between diabetes care and HCV elimination enhanced the testing and treatment in PwD through an innovative shared care model.

Telemonitoring of the Continuum of Care of Hepatitis C During the COVID-19 Pandemic in Brazil.

Introduction: To accomplish elimination of hepatitis C virus (HCV) by 2030, as proposed by the World Health Organization, the Brazilian Ministry of Health outlined the Hepatitis C Elimination Plan, which provides coverage of all critical steps in the continuum of care (CoC) of hepatitis C. As expected, the advent of COVID-19 pandemic has disrupted the CoC of hepatitis C worldwide. The Brazilian Liver Institute launched a remote patient monitoring (RPM) program to assist the general population at risk in HCV testing and to provide linkage and retention to care for HCV-positive subjects. The RPM program was also designed to relink HCV-positive patients lost to follow-up during the COVID-19 pandemic due to their limited access to the health care system. Methods: The HCV telemonitoring number was highly advertised in Brazilian media. The RPM program was conducted by dedicated health care personnel trained to follow a predefined script designed to provide awareness, ensure consistent information for educational purposes, and recruit eligible participants to be tested for HCV. Results: From August 2020 to December 2021, 3,738 subjects entered in contact with RPM. There were 26,884 interactions (mean 7.2 interactions per participant), mostly by WhatsApp (78%). Twenty out of those 221 subjects (9%) who tested were HCV positive. Those subjects altogether with 128 other patients with HCV, tested elsewhere, were followed in the HCV CoC. Up to now, 94% of them were linked to care, 24% are undergoing treatment and 8% achieved sustained virological response (SVR). Conclusions: Our preliminary results showed that HCV CoC telemonitoring was a feasible and useful strategy to follow HCV at-risk subjects through all cascade of care until SVR during the COVID-19 health care disruption. It could be used beyond the defervescence of SARS-CoV-2 pandemic to ensure linkage to care of those HCV-positive patients.

The role of community pharmacies in the HIV and HCV care continuum

IntroductionIn 2019, there were over 1.1 million people living with human immunodeficiency virus (HIV) and 2.4 million people living with hepatitis C virus (HCV) in the United States. One in seven (14%) are unaware of their HIV infection and almost half of all HCV infections are undiagnosed. People with unstable housing are disproportionately affected by HIV and HCV. The present study will evaluate interventions by community pharmacists that may reduce HIV and HCV transmission and promote linkage to care. MethodsThis study was conducted in an independent community pharmacy in Spokane, Washington. Eligible study participants were walk-in patients of the pharmacy, over the age of 18, and experiencing homelessness. Pharmacy patients were excluded if they had a history of HIV or HCV diagnosis, received a screening for HIV or HCV in the last six months or were unable to give informed consent. The intervention included administration of HIV and HCV point-of-care testing (POCT) using a blood sample, risk determination interview, comprehensive HIV and HCV education, and personalized post-test and risk mitigation counseling followed by referral to partnering health clinics. ResultsFifty participants were included in the final data analysis. Twenty-two participants (44%) had a reactive HCV POCT, and one participant had a reactive HIV POCT. Of the 94% of participants who reported illicit drug use, 74% reported injection drug use. Seventy-six percent (n = 38) qualified for PrEP. Pharmacist referrals were made for 28 participants and 71% were confirmed to have established care. ConclusionIndividuals experiencing homelessness are at an increased risk for acquiring HIV and HCV due to risky sexual behaviors and substance misuse. PrEP is underutilized in the U.S. and pharmacist involvement in the HIV and HCV care continuum may have a significant impact in improving linkage and retention in care of difficult to treat populations.

Evaluation of a pilot emergency department linkage to care program for patients previously diagnosed with Hepatitis C.

There is a significant number of Emergency Department (ED) patients with known chronic hepatitis C virus (HCV) infection who have not been treated with directly acting antivirals. We implemented a pilot ED-based linkage-to-care program to address this need and evaluated the impact of the program using the HCV Care Continuum metrics. Between March 2015 and May 2016, dedicated patient care navigators identified HCV RNA-positive patients in an urban ED and offered expedited appointments with the on-site viral hepatitis clinic. Patient demographics and care continuum outcomes were abstracted from the EMR and analysed to determine significant factors influencing linkage-to-care (LTC) and treatment initiation rates. The ED linkage-to-care program achieved a 43% linkage-to-care rate (165/384), 22% treatment rate (84/384) and 16% sustained virologic response rate (63/384). Significant associations were found between linkage-to-care and increasing age (OR=1.03), Medicare insurance (OR=2.21) and having a primary care physician (PCP) (OR=4.03). For patients who were linked, the odds of initiating treatment were also positively significantly associated with increasing age (OR=1.04) and having a PCP (OR=2.77). For patients who initiated treatment, the odds of sustained virologic response were marginally associated with having a PCP (OR=4.92).Our ED linkage-to-care program utilized care coordination to successfully link nearly half of approached HCV RNA-positive patients to care. This design can be feasibly replicated by other EDs given limited non-clinical training required for linkage-to-care staff. Adoption of similar programs in other EDs may improve the rates of LTC and treatment initiation for previously diagnosed HCV patients.

A qualitative investigation of the barriers and facilitators to Hepatitis C virus (HCV) screening among individuals experiencing homelessness in Houston, Texas.

Individuals experiencing homelessness may be at a higher risk for hepatitis C infection because many are vulnerable to risk factors related to HCV. Screening is the very first step in the HCV care continuum, but it remains unclear how to improve HCV screening among this hard-to-reach population. Thus, the present study investigated the barriers and facilitators to HCV screening from the perspective of individuals experiencing homelessness within a non-residential social service setting. Individuals experiencing homelessness (aged 18+) were approached while they were seeking services at two community-based organizations in Houston, Texas, during August 2020. Participants (N = 31) completed an interviewer-administered demographic survey and a semi-structured interview about their experiences with healthcare, homelessness, and HCV screening. Following transcript coding and content analysis, a thematic analysis was conducted to identify HCV screening barriers and facilitators discussed by participants. Participants were predominantly male (n = 25, 80.6%), and almost 40% of participants had no form of medical insurance. Participants identified the following as barriers to HCV screening: mistrust of the healthcare system and professionals and lack of knowledge of HCV prevention, harm reduction, and complications. Participants identified the following as facilitators to HCV screening: providing incentives and increasing access and convenience to HCV screening. Community-based HCV screening programs may wish to account for the lived experiences of individuals experiencing homelessness in order to minimize barriers to screening. Client-centered strategies that reduce wait times and incentivize participation should be considered to eliminate barriers and increase convenience for this high-risk population.

Closing the hepatitis C treatment gap: United States strategies to improve retention in care.

The hepatitis C virus (HCV) treatment landscape is shifting given the advent of direct-acting antivirals and a global call to action by the World Health Organization. Eliminating HCV is now an issue of healthcare delivery. Treatment is limited by the complexity of the HCV care continuum, expensive therapy and competing health burdens experienced by an underserved HCV population. The objective of this literature review was to assess strategies to improve retention in HCV care, with particular focus on those implemented in the United States. We identified barriers in HCV care retention and propose solutions to increase HCV treatment delivery. The following recommendations are herein described: improving the cohesion of health services through localized care and integrated case management, expanding the supply of non-specialist HCV treatment providers, leveraging patient navigators and care coordinators, improving adherence through directly observed therapy and reducing cost barriers through value-based payment and pharmaceutical subscription models.

Impact of a Targeted Intervention on Hepatitis C Care Among African Americans With Serious Mental Illness.

This study aimed to update findings on the continuum of care for hepatitis C virus (HCV) infection with follow-up data for individuals with serious mental illness and to identify predictors of decisions to decline vaccination. The screening, testing, immunization, risk reduction, and referral (STIRR) intervention has been shown to increase testing and immunization rates. Prevalence of HCV diagnoses, HCV continuum of care, and hepatitis A (HAV) and B (HBV) vaccination were evaluated with laboratory results and chart review. The prevalence of HCV was 15% (N=40 of 270 African Americans receiving the STIRR intervention). Of the 40 individuals identified as having HCV, 75% (N=30) accepted referral to treatment, of whom 47% (N=14) achieved sustained virologic response. Nearly 68% (N=155) of those eligible received at least partial HAV/HBV vaccination. The STIRR intervention facilitated access to treatment for HCV and high acceptance of hepatitis vaccination. Avoidance proved to be a significant factor in decisions to decline vaccination.

907. The HCV Care Continuum Among Hospitalized Persons Who Inject Opiates: Missed Opportunities for Screening and Referral to Treatment

Abstract Background Despite an effective cure, hepatitis C virus (HCV) remains a major public health problem for persons who inject opiates. Hospitalization provides an opportunity to identify chronic HCV infection and provide referral and linkage to outpatient care upon discharge. We examined the HCV care continuum among hospitalized persons who inject drugs and have opiate use disorder (OUD). Methods The CHOICE Study is a retrospective chart review of adults hospitalized with infectious complications of OUD and injection drug use at four academic medical centers (University of Maryland, George Washington University, University of Alabama, and Emory University). The sample included patients hospitalized between 1/1/2018-12/31/2018, had ICD9/10 diagnosis codes consistent with OUD and acute bacterial/fungal infection, and chart review verification of active infection associated with OUD. Data on HCV antibody (Ab) and RNA testing and referral to HCV treatment within the medical system were abstracted from medical records. Results Of 287 patients, median age was 40 (IQR: 32-52), 59% were male, and 63% were white and 34% black. Overall, 38% (n=108) had known HCV infection at hospitalization; of those with unknown status, only 41% (n=73) were screened for HCV. Among those, 67% were HCV Ab+. Of patients who were HCV Ab+ or had known HCV infection (n=157), only 52% were tested for HCV RNA, of whom 61% had detectable RNA. Only 40% of those with detectable RNA received a treatment referral prior to discharge (Fig. 1). The length of stay of the admission was not associated with treatment referral, but a shorter length of stay was significantly associated with not being screened for HCV Ab or RNA tested (p< 0.05). Of five patients who were referred to care within the medical system, four initiated HCV treatment, and two achieved known sustained viral response. Figure 1. HCV Continuum of care for hospitalized patients who inject drugs with opioid use disorder (OUD) at four academic medical centers in the United States, January 2018-December 2018 Conclusion Hospitalization is a missed opportunity for HCV screening and linkage. Despite opportunities to address HCV infection among this highly impacted population, there were sizeable gaps in the HCV continuum of care among hospitalized persons who inject opiates. Structural reasons such as length of stay may be a factor in implementing HCV testing. Disclosures Sarah Kattakuzhy, MD, Gilead Sciences (Scientific Research Study Investigator, Research Grant or Support) Ellen Eaton, MD , Gilead (Grant/Research Support) Ellen Eaton, MD , Gilead (Individual(s) Involved: Self): Research Grant or Support Greer A. Burkholder, MD, MSPH, Eli Lilly (Grant/Research Support) Elana S. Rosenthal, MD, Gilead Sciences (Research Grant or Support)Merck (Research Grant or Support)

Exploring how hospitalization can alter hepatitis c virus treatment prioritization and trajectories in people who use drugs: A qualitative analysis

Background: People who use drugs (PWUD) have high rates of hepatitis C virus (HCV) infection. Hospitalization can be a time for PWUD to engage in addiction treatment, but little is known about how hospitalization shapes HCV treatment readiness. We aimed to describe how hospitalization and addiction medicine consult service (AMCS) can alter HCV prioritization of inpatient PWUD with HCV. Methods: We conducted a qualitative study consisting of semi-structured interviews (n = 27) of hospitalized adults with addiction and HCV infection seen by an AMCS at a single, urban, academic center. Interviews were audio-recorded, transcribed, and coded iteratively at the semantic level, and analyzed for themes. Results: Of the 27 participants, most identified as Caucasian (85%), male gender (67%), and they primarily used opioids (78%); approximately half (48%) reported HCV diagnosis over 5 years ago. We identified three main themes around hospitalization altering the prioritizations and HCV treatment preferences for PWUD: (1) HCV treatment non-engaged (2) HCV treatment urgency, and (3) HCV treatment in the future. Those wanting to treat HCV—whether urgently or in the future—shared the overlapping theme of hospitalization as a reachable moment for their addiction and HCV. These participants recognized the long-term benefits of addressing HCV and connected their hospitalization to substance use. Conclusion: In our study, PWUD with HCV expressed varying and competing priorities and life circumstances contributing to three main HCV treatment trajectories. Our results suggest ways hospitalization can serve as an HCV touchpoint for PWUD, especially in the context of addressing substance use, and could be used when designing and implementing targeted interventions to improve the HCV care continuum for PWUD.

Hepatitis C treatment uptake among patients who have received methadone substitution treatment in the Republic of Georgia

ObjectivesThere is a dearth of research on hepatitis C virus (HCV) treatment uptake among people who inject drugs (PWIDs) and receive methadone substitution treatment (MST) in Eastern Europe and Central Asia countries. This study contributed to addressing that gap. We examined and identified factors that may affect HCV treatment uptake among PWID who received MST in the Republic of Georgia. Study designThe design of the study is retrospective cohort study. MethodsWe conducted HCV care cascade analysis by matching the data from the web-based national hepatitis C program registry (ELIM C) and the MST treatment database between January 1, 2015, and December 31, 2018. Using the World Health Organization's (WHO) Consensus HCV cascade of care (CoC) global instrument, we assessed the progress made toward the country's 2020 and WHO's 2030 hepatitis C elimination targets for the subpopulation of MST patients. ResultsOverall, 10,498 individuals have been dispensed methadone during the study period. A total of 6828 MST beneficiaries had HCV screening, of whom 5843 (85.6%) tested positive; 5476 (93.7%) were tested for HCV viremia, and 5275 (96.3%) were confirmed with chronic HCV infection. More than 75% (n = 4000) of HCV-infected MST patients initiated HCV treatment, and 3772 (94.3%) completed the treatment. Of those eligible for sustained virologic response assessment, 71.0% (2641/3715) were evaluated, and the reported cure rate was 96.1% (2537). The study found the odds of patients starting HCV treatment differed by the type of facility they were screened at and whether they were registered as PWID at the screening sites. The patients screened at centers with integrated HCV treatment services had higher treatment uptake rates than those screened at other centers. ConclusionsAs the cumulative HCV treatment uptake and cure rates among MST patients with HCV infection are high (75.8% and 96.1%, respectively), the MST patients might become the first microelimination target population in which hepatitis C elimination will be achieved in Georgia. The study found the type of screening facility and whether MST patients registered themselves as PWID or not had significant effects on MST patients starting HCV treatment. At the same time, the study did not find gender and age to be significant predictors of MST patients starting HCV treatment. MST patients used different types of health facilities to get screened for HIV. Many of them did not register themselves as PWID when screened for HIV. The existence of only a few harm reduction sites with integrated HCV treatment services, a high level of stigma, and the criminalization of drug use might have incentivized MST patients to self-navigate across the HCV care continuum with the rest of the population. The implementation of focused, harm reduction, integrated HCV treatment with good peer and professional adherence support at treatment sites could help reach the hepatitis C elimination goals among MST patients.

The Hepatitis C Continuum of Care Among HIV-Positive Persons with Heavy Alcohol Use in St. Petersburg, Russia.

This study describes the self-reported prevalence of hepatitis C virus (HCV) coinfection and the HCV care continuum among persons enrolled in the St PETER HIV Study, a randomized controlled trial of medications for smoking and alcohol cessation in HIV-positive heavy drinkers and smokers in St. Petersburg, Russia. Baseline health questionnaire data were used to calculate proportions and 95% confidence intervals for self-reported steps along the HCV continuum of care. The cohort included 399 HIV-positive persons, of whom 387 [97.0% (95% CI 95.3-98.7%)] reported a prior HCV test and 315 [78.9% (95% CI 74.9-82.9%)] reported a prior diagnosis of HCV. Among those reporting a diagnosis of HCV, 43 [13.7% (95% CI 9.9-17.4%)] had received treatment for HCV, and 31 [9.8% (95% CI 6.6-13.1%)] had been cured. Despite frequent HCV testing in this HIV-positive Russian cohort, the proportion reporting prior effective HCV treatment was strikingly low. Increased efforts are needed to scale-up HCV treatment among HIV-positive Russians in St. Petersburg.

Decentralisation, integration, and task-shifting in hepatitis C virus infection testing and treatment: a global systematic review and meta-analysis

SummaryBackgroundIncreasing access to hepatitis C virus (HCV) care and treatment will require simplified service delivery models. We aimed to evaluate the effects of decentralisation and integration of testing, care, and treatment with harm-reduction and other services, and task-shifting to non-specialists on outcomes across the HCV care continuum.MethodsFor this systematic review and meta-analysis, we searched PubMed, Embase, WHO Global Index Medicus, and conference abstracts for studies published between Jan 1, 2008, and Feb 20, 2018, that evaluated uptake of HCV testing, linkage to care, treatment, cure assessment, and sustained virological response at 12 weeks (SVR12) in people who inject drugs, people in prisons, people living with HIV, and the general population. Randomised controlled trials, non-randomised studies, and observational studies were eligible for inclusion. Studies with a sample size of ten or less for the largest denominator were excluded. Studies were categorised according to the level of decentralisation: full (testing and treatment at same site), partial (testing at decentralised site and referral elsewhere for treatment), or none. Task-shifting was categorised as treatment by specialists or non-specialists. Data on outcomes across the HCV care continuum (linkage to care, treatment uptake, and SVR12) were pooled using random-effects meta-analysis.FindingsOur search identified 8050 reports, of which 132 met the eligibility criteria, and an additional ten reports were identified from reference citations and grey literature. Therefore, the final synthesis included 142 studies from 34 countries (20 [14%] studies from low-income and middle-income countries) and a total of 489 996 patients (239 446 [49%] from low-income and middle-income countries). Rates of linkage to care were higher with full decentralisation compared with partial or no decentralisation among people who inject drugs (full 72% [95% CI 57–85] vs partial 53% [38–67] vs none 47% [11–84]) and among people in prisons (full 94% [79–100] vs partial 50% [29–71]), although the CIs overlap for people who inject drugs. Similarly, treatment uptake was higher with full decentralisation compared with partial or no decentralisation (people who inject drugs: full 73% [65–80] vs partial 66% [55–77] vs none 35% [23–48]; people in prisons: full 72% [48–91] vs partial 39% [17–63]), although CIs overlap for full versus partial decentralisation. The results in the general population studies were more heterogeneous. SVR12 rates were high (≥90%) across different levels of decentralisation in all populations. Task-shifting of care and treatment to a non-specialist was associated with similar SVR12 rates to treatment delivered by specialists. There was a severe or critical risk of bias for 46% of studies, and heterogeneity across studies tended to be very high (I2>90%).InterpretationDecentralisation and integration of HCV care to harm-reduction sites or primary care showed some evidence of improved access to testing, linkage to care, and treatment, and task-shifting of care and treatment to non-specialists was associated with similarly high cure rates to care delivered by specialists, across a range of populations and settings. These findings provide support for the adoption of decentralisation and task-shifting to non-specialists in national HCV programmes.FundingUnitaid.

Effect of an mHealth Intervention on Hepatitis C Testing Uptake Among People With Opioid Use Disorder: Randomized Controlled Trial.

BackgroundThe growing epidemic of opioid use disorder (OUD) and associated injection drug use has resulted in a surge of new hepatitis C virus (HCV) infections. Approximately half of the people with HCV infection are unaware of their HCV status. Improving HCV awareness and increasing screening among people with OUD are critical. Addiction-Comprehensive Health Enhancement Support System (A-CHESS) is an evidence-based, smartphone-delivered relapse prevention system that has been implemented among people with OUD who are receiving medications for addiction treatment (MAT) to improve long-term recovery.ObjectiveWe incorporated HCV-related content and functionality into A-CHESS to characterize the HCV care continuum among people in early remission and receiving MAT for OUD and to determine whether incorporating such content and functionality into A-CHESS increases HCV testing.MethodsHCV intervention content, including dissemination of educational information, private messages tailored to individuals’ stage of HCV care, and a public discussion forum, was implemented into the A-CHESS platform. Between April 2016 and April 2020, 416 participants with OUD were enrolled in this study. Participants were randomly assigned to receive MAT alone (control arm) or MAT+A-CHESS (experimental arm). Quarterly telephone interviews were conducted from baseline to month 24 to assess risk behaviors and HCV testing history. Cox proportional hazards regression was used to assess whether participants who used A-CHESS were tested for HCV (either antibody [Ab] or RNA testing) at a higher rate than those in the control arm. To assess the effect of A-CHESS on subsets of participants at the highest risk for HCV, additional analyses were performed to examine the effect of the intervention among participants who injected drugs and shared injection equipment.ResultsOverall, 44.2% (184/416) of the study participants were HCV Ab positive, 30.3% (126/416) were HCV Ab negative, and 25.5% (106/416) were considered untested at baseline. At month 24, there was no overall difference in HCV testing uptake between the intervention and control participants. However, among the subset of 109 participants who engaged in injection drug use, there was a slight trend toward increased HCV testing uptake among those who used A-CHESS (89% vs 85%; hazard ratio: 1.34; 95% CI 0.87-2.05; P=.18), and a stronger trend was observed when focusing on the subset of 32 participants who reported sharing injection equipment (87% vs 56%; hazard ratio: 2.92; 95% CI 0.959-8.86; P=.06).ConclusionsIncorporating HCV prevention and care information into A-CHESS may increase the uptake of HCV testing while preventing opioid relapse when implemented among populations who engage in high-risk behaviors such as sharing contaminated injection equipment. However, more studies that are powered to detect differences in HCV testing among high-risk groups are needed.Trial RegistrationClinicalTrials.gov NCT02712034; https://clinicaltrials.gov/ct2/show/NCT02712034International Registered Report Identifier (IRRID)RR2-10.2196/12620

Age and gender-specific hepatitis C continuum of care and predictors of direct acting antiviral treatment among persons who inject drugs in Seattle, Washington

BackgroundDirect acting antivirals (DAAs) have revolutionized management of hepatitis C virus (HCV), but treatment uptake remains low among persons who inject drugs (PWID). We report the continuum of care for HCV and describe predictors of treatment with DAAs among PWID in Seattle. MethodsWe analyzed data from the 2018 Seattle area National HIV Behavioral Surveillance (NHBS) survey of PWID. Persons ≥18 years of age who injected drugs in the past year and completed the core NHBS survey, a local survey supplement, and rapid HCV antibody testing were included. Among those who screened HCV antibody positive, we calculated proportions and 95 % confidence intervals for self-reported steps along the HCV care continuum. Multivariable logistic regression was used to calculate the adjusted odds (AOR) of having received DAA therapy. ResultsThe sample included 533 PWID, 376 (71 %) of whom tested positive for antibodies to HCV. Among those who were HCV antibody positive, 94 % reported any prior HCV test, 81 % reported a prior confirmatory test, and 68 % reported a prior HCV diagnosis. Of those diagnosed, 26 % had undergone treatment and 18 % had been cured. In a multivariate model, being one year older (AOR 1.05 per year, 1.01−1.08) was predictive of DAA treatment, while homelessness (AOR 0.39, 0.19−0.80) and female gender (AOR 0.36, 0.16−0.78) were associated with a lower odds of DAA therapy. ConclusionsDespite widespread HCV testing among PWID in Seattle, treatment uptake remains low in the DAA era. In particular, treatment of women, younger adults and persons living homeless is lagging behind.

The civil society monitoring of hepatitis C response related to the WHO 2030 elimination goals in 35 European countries

BackgroundPeople who inject drugs (PWID) account for the majority of new cases of hepatitis C virus (HCV) infection in Europe; however, HCV testing, and treatment for PWID remain suboptimal. With the advent of direct acting antivirals (DAAs) the World Health Organization (WHO) adopted a strategy to eliminate HCV as public health threat by 2030. To achieve this, key policies for PWID must be implemented and HCV continuum of care needs to be monitored. This study presents results of the first monitoring led by civil society that provide harm reduction services for PWID.MethodsIn 2019, harm reduction civil society organizations representing focal points of Correlation-European Harm Reduction Network in 36 European countries were invited to complete a 27-item online survey on four strategic fields: use/impact of guidelines on HCV testing and treatment for PWID, availability/functioning of continuum of care, changes compared to the previous year and, the role of harm reduction services and non-governmental organizations (NGOs) of PWID. A descriptive analysis of the responses was undertaken.ResultsThe response rate was 97.2%. Six countries reported having no guidelines on HCV treatment (17.1%). Twenty-three (65.7%) reported having treatment guidelines with specific measures for PWID; guidelines that impact on accessibility to HCV testing/treatment and improve access to harm reduction services in 95.6% and 86.3% of them, respectively. DAAs were available in 97.1% of countries; in 26.4% of them they were contraindicated for active drug users. HCV screening/confirmatory tests performed at harm reduction services/community centers, prisons and drug dependence clinics were reported from 80.0%/25.7%, 60.0%/48.6%, and 62.9%/34.3% of countries, respectively. Provision of DAAs at drug dependence clinics and prisons was reported from 34.3 to 42.9% of countries, respectively. Compared to the previous year, HCV awareness campaigns, testing and treatment on service providers’ own locations were reported to increase in 42.9%, 51.4% and 42.9% of countries, respectively. NGOs of PWID conducted awareness campaigns on HCV interventions in 68.9% of countries, and 25.7% of countries had no such support.ConclusionFurther improvements in continuum-of-care interventions for PWID are needed, which could be achieved by including harm reduction and PWID organizations in strategic planning of testing and treatment and in efforts to monitor progress toward WHO 2030 elimination goal.

Linkage to specialty care in the hepatitis C care cascade

Quality gaps exist in the hepatitis C virus (HCV) care process from diagnosis to cure. To better understand current gaps and to identify targets for quality improvement, we constructed an...

Hepatitis C treatment uptake among people who inject drugs in the oral direct-acting antiviral era.

Increased uptake of hepatitis C virus (HCV) treatment among people who inject drugs (PWID) will be critical to achieve HCV elimination goals. There are limited data on HCV treatment uptake among PWID recruited from community-based settings in the HCV direct-acting antiviral (DAA) era. We analysed data from PWID with HCV newly recruited into the Baltimore, Maryland-based AIDS Linked to the IntraVenous Experience (ALIVE) cohort between 2015 and 2018. We characterized the HCV care continuum and evaluated factors associated with HCV treatment uptake. Of the 418 PWID with HCV, the median age was 49 years and most (88%) reported recent injection drug use (IDU). Overall, 23% had ever been evaluated by a provider for HCV treatment, 17% ever initiated DAA treatment and 13% were cured of HCV infection. Treatment uptake approximately doubled between 2015 and 2018 (13% to 26%, P = .01). In multivariable analyses, HIV infection (adjusted Odds Ratio [aOR] 2.5 [95% Confidence Interval (CI) 1.3, 4.8]), current employment (aOR 4.1 [CI 1.2, 14.4]), having a primary care provider (aOR 4.3 [CI 1.2, 14.9) and longer duration of IDU (aOR 1.3 [CI 1.1, 1.6]) were positively associated with HCV treatment. PWID with a lower annual income (≤$5000) were less likely to have initiated HCV treatment (aOR 0.5 [CI 0.3, 0.98]). Although HCV treatment uptake among PWID in this community-based setting in the DAA era remains suboptimal, it is encouraging that treatment uptake has increased in recent years. Innovative strategies are needed to reach all PWID infected with HCV.

Hepatitis C Virus (HCV) Care Continuum Outcomes and HCV Community Viral Loads Among Patients in an Opioid Treatment Program.

Hepatitis C virus (HCV) remains endemic among people who use drugs (PWUD). Measures of HCV community viral load (CVL) and HCV care continuum outcomes may be valuable for ascertaining unmet treatment need and for HCV surveillance and control. Data from patients in an opioid treatment program during 2013-2016 were used to (1) identify proportions of antibody and viral load (VL) tested, linked-to-care, and treated, in 2013-2014 and 2015-2016, and pre- and postimplementation of qualitative reflex VL testing; (2) calculate engaged-in-care HCV CVL and "documented" and "estimated" unmet treatment need; and (3) examine factors associated with linkage-to-HCV-care. Among 11 267 patients, proportions of HCV antibody tested (52.5% in 2013-2014 vs 73.3% in 2015-2016), linked-to-HCV-care (15.7% vs 51.8%), and treated (12.0% vs 44.7%) all increased significantly. Hispanic ethnicity was associated with less linkage-to-care, and Manhattan residence was associated with improved linkage-to-care. The overall engaged-in-care HCV CVL was 4 351 079 copies/mL (standard deviation = 7 149 888); local HCV CVLs varied by subgroup and geography. Documented and estimated unmet treatment need decreased but remained high. After qualitative reflex VL testing was implemented, care continuum outcomes improved, but gaps remained. High rates of unmet treatment need suggest that control of the HCV epidemic among PWUD will require expansion of HCV treatment coverage.

Epidemiology of Hepatitis C in Delaware.

Infection with hepatitis C virus (HCV) is pervasive throughout the United States of America as we fight the ongoing urban and rural opioid epidemics and rising rates of fatal and non-fatal overdoses. While risk factors for incident HCV abound, our country and the State of Delaware have increasing access to highly effective, short-course, curative HCV treatments. Despite unprecedented medical advances for HCV, as well as expanded HCV screening guidelines calling for universal adult HCV screening and screening during every pregnancy, the epidemiology of HCV at the national and statewide levels continues to be lacking. In attempting to gather, interpret, and present the highest quality available data, we conclude that HCV remains a pressing public and individual health concern for Delawareans, and our nation at large. We urge stakeholders in Delaware to make concerted efforts to fill in the many remaining gaps of HCV epidemiology in order to better inform public health resource allocation, educate the public and healthcare professionals regarding viral hepatitis, and ultimately improve the HCV care continuum, spanning from increasing rates of universal HCV screening and diagnosis to linkage to care to treatment initiation all the way to cure and beyond.