Hepatitis C Virus Care Continuum Research Articles

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.

Persistent Challenges in the Hepatitis C Virus Care Continuum for Patients in a Central Texas Public Health System.

BackgroundDirect-acting antiviral treatment regimens cure >95% of chronic hepatitis C virus (HCV) infections, but recent studies indicate that <25% of patients in the United States receive treatment. Patients need to overcome barriers on the steps of the care continuum in order to be prescribed treatment. We aimed to examine the steps of the HCV care continuum up to prescription of HCV therapy among patients receiving care within a large safety net health care system in Houston, Texas.MethodsWe used electronic medical records to identify patients with positive screening tests for HCV antibodies between July 1, 2017, and June 30, 2018, and abstracted data on their advancement through the care continuum for HCV. We used logistic regression to identify factors associated with patient navigation through the continuum.ResultsOf the 2450 patients screening positive for HCV antibodies, 2016 (82.3%) received quantitative RNA testing, of whom 1081 (53.6%) exhibited chronic infection. Providers referred 915 (84.6%) to specialty care for evaluation, 540 of these patients (50.0%) received their specialist evaluation, and 299 (27.7%) received a prescription for treatment. Patients with history of substance use were less likely to be prescribed treatment (adjusted odds ratio, 0.66; 95% CI, 0.49–0.88).ConclusionsWe found substantial attrition at each stage of the HCV care continuum. In particular, history of substance abuse was a predictor of nonprescription. Challenges in the care continuum motivate increased provider education as well as the adoption of recent innovations in patient care.

Co-Located hepatitis C virus infection treatment within an opioid treatment program promotes opioid agonist treatment retention

BackgroundCo-located treatment for hepatitis C virus (HCV) infection for patients with opioid use disorder (OUD) within an opioid treatment program (OTP) addresses gaps in the HCV care continuum. Few reports have analyzed outcomes related to OUD treatment, such as retention, associated with co-located HCV treatment. MethodsPatients (n = 89) treated for OUD and chronic HCV infection in a Northeast US OTP from January 2014 through July 2017 were compared to control patients (n = 199) being treated for OUD and diagnosed with but not treated for HCV during the same period. All patients received opioid agonist treatment (OAT). The outcome of interest is patient retention in the OTP from January 2014 through September 2018, analyzed using logistic regression and survival analysis based on OTP loss to follow-up dates. ResultsAfter adjusting for baseline covariates, patients who completed HCV treatment had 2.22 (95 % CI: 1.11, 4.45) increased likelihood of remaining in the OTP compared to patients in the control group. Survival analysis indicated the HCV treatment group had a significantly greater probability of being retained over the duration of the study compared with the control group. ConclusionResults indicate that a co-located model of care is associated with improved OTP treatment retention following HCV treatment, and suggest that co-locating HCV and OUD treatment has a secondary impact on keeping patients engaged in OAT.

4185 Assessing Barriers to Retention in Care Continuum Among HCV Positive Homeless Adults of New Orleans

OBJECTIVES/GOALS: This study has two primary aims: 1) evaluate points of success and failure in connecting hepatitis C virus (HCV) positive homeless patients to care following a preliminary positive rapid HCV test result, and 2) describe the barriers cited by patients who drop out at each step in the care continuum. METHODS/STUDY POPULATION: A retrospective longitudinal analysis of adult (18 years or older) homeless individuals accessing shelter at six homeless shelters in New Orleans, LA was conducted. Every patient who came through a testing site received a survey collecting information on demographics, barriers to healthcare, and recent utilization of health services. A retrospective chart review of hospital and homeless clinic medical records was used to track patient linkage to care and their progress through the HCV care continuum. We defined successful linkage to care as attendance at the first scheduled follow-up appointment for treatment with a primary care physician. RESULTS/ANTICIPATED RESULTS: A total of 1719 unique patients were identified from August 2016 through August 2019 which included 36% self-identified as African American/Black, 55% identified as White and 8% identified as mixed-race or other. A total of 24% of individuals reported no insurance coverage while 66% of patients reported having insurance. Overall, 85 patients reported they experienced no barriers to healthcare. Of those who reported barriers, 44% reported trouble with finances or insurance, 22% transportation, 18% personal drug use, 9% personal alcohol use, and 7% reported a distrust of healthcare providers or the system. Other barriers included long wait times, distance, and recent incarceration. DISCUSSION/SIGNIFICANCE OF IMPACT: Although screening for HCV is readily available, barriers exist which prevent diagnosis and treatment. We implemented a HCV testing and linkage-to-care program between local homeless shelters and health centers in New Orleans in an effort to reduce HCV-related morbidity and mortality.

Engagement in the Hepatitis C care continuum among people who use drugs

ABSTRACT Background: Despite high rates of Hepatitis C virus (HCV) infection among people who use drugs (PWUDs), access to the HCV care continuum combined with the receipt of medications for addiction treatment in primary care settings remains suboptimal. Methods: A qualitative study was conducted among adults admitted for inpatient detoxification for opioid use disorder (OUD) in New York City (n = 23) to assess barriers and facilitators with HCV prevention, screening, treatment, interactions with primary care providers, and experiences with integrated care approaches. Results: Study findings yielded six major themes related to HCV care. Major gaps persist in knowledge regarding HCV harm reduction strategies, voluntary HCV testing services, and eligibility for HCV treatment. Treatment coordination challenges reinforce the importance of enhancing linkages to HCV care in key access-points utilized by PWUDs (e.g., emergency rooms, specialty addiction treatment settings). Peer networks combined with frequent patient-physician communication were elicited as important factors in facilitating linkage to HCV care. Additional care coordination needs in primary care settings included access to integrated treatment of HCV and OUD, and administrative support for enrollment in Medicaid, subsidized housing, and access to transportation vouchers. Discussion: Strategies are needed to enhance access to harm reduction and treatment services for PWUDs, including improved clinical and administrative support in primary care, and patient education.

Nurse case management to improve the hepatitis C care continuum in HIV co-infection: Results of a randomized controlled trial.

The opportunity to eliminate hepatitis C virus (HCV) is at hand, but challenges remain that negatively influence progress through the care continuum, particularly for persons co-infected with HIV who are not well engaged in care. We conducted a randomized controlled trial to test the effect of nurse case management (NCM) on the HCV continuum among adults co-infected with HIV compared to usual care (UC). Primary outcomes included linkage to HCV care (attendance at an HCV practice appointment within 60days) and time to direct-acting antiviral (DAA) initiation (censored at 6months). Sixty-eight participants were enrolled (NCM n=35; UC n=33). Participants were 81% Black/African American, 85% received Medicaid, 46% reported illicit drug use, 41% alcohol use, and 43% had an undetectable HIV viral load. At day 60, 47% of NCM participants linked to HCV care compared to 25% of UC participants (P=.031; 95% confidence bound for difference, 3.2%-40.9%). Few participants initiated DAAs (12% NCM; 25% UC). There was no significant difference in mean time to treatment initiation (NCM=86days; UC=110days; P=.192). Engagement in HCV care across the continuum was associated with drinking alcohol, knowing someone who cured HCV and having a higher CD4 cell count (P<.05). Our results support provision of NCM as a successful strategy to link persons co-infected with HIV to HCV care, but interventions should persist beyond linkage to care. Capitalizing on social networks, treatment pathways for patients who drink alcohol, and integrated substance use services may help improve the HCV care continuum.

Decentralization, Integration, and Task-Shifting in Hepatitis C Virus Infection Testing and Treatment: A Global Systematic Review and Meta-Analysis

Background: Worldwide, a limited proportion of hepatitis C virus (HCV)-infected persons have been diagnosed and treated. Increasing access to HCV care and treatment will require simplified service delivery models. We conducted a systematic review and meta-analysis to examine the effectiveness of decentralization of care, integrated HCV testing and treatment with harm-reduction services, and task-shifting to non-specialists on outcomes across the HCV care continuum. Methods: We searched bibliographic databases and conference abstracts for studies published 01/01/2008-20/02/2018 that evaluated uptake of HCV testing, linkage to care, treatment, cure assessment, and sustained virologic response at 12 weeks (SVR12) in people who inject drugs (PWID), people in prisons, people living with HIV (PLHIV), and the general population. Decentralization was categorised as 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 were pooled using random-effects meta-analysis. Findings: We included 139 studies from 34 countries (20 from low- and middle-income countries). Among PWID and people in prisons, full compared to partial or no decentralization had higher testing uptake, linkage to care and treatment, and comparable high SVR rates. The general population results were more heterogenous. In all populations, task-shifting of care and treatment to non-specialists showed similar SVR12 rates as treatment delivered by specialists. Interpretation: Decentralization of care to primary-care or harm-reduction sites and task-shifting of care and treatment to non-specialists achieved high levels of treatment cure across a range of populations and settings. These findings provide strong support for the adoption of these approaches in national HCV programmes. Funding Statement: This project was funded through an enabler grant to the WHO Global Hepatitis Programme from UNITAID. WHO experts were involved in the technical and scientific discussions of this project. The writing of this paper was done solely by the authors. Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: PRISMA guidelines were followed.

298. Collocation of Hepatitis C Care Continuum with MAT for High-Prevalence, High-Risk Population

BackgroundThe hepatitis C virus (HCV) epidemic in the United States disproportionately impacts people who inject drugs (PWID) who account for 80% of new infections and have a high prevalence of chronic infection. Baltimore City has the highest case rate of HCV in the state of Maryland with over 25% of new cases statewide occurring in the city. Only 10% of PWID have access to directly acting antiviral (DAA) therapy and are cured of HCV. Medication-assisted treatment (MAT) is currently offered in isolated facilities with limited access to other specialty care. In this study, we collocated HCV care continuum in a MAT facility offering opioid agonist therapy and psychosocial interventionsMethodsCollocation of HCV care was initiated in an MAT (methadone and buprenorphine) clinic, the University of Maryland Drug Treatment Center (UMDTC) serving over 700 patients, for Opioid Use Disorder (OUD) in Baltimore City (Figure 1). Screening for HCV was expanded through health education of patients and staff and expanded testing. HCV antibody-positive patients were linked to care with an experienced HCV provider or referred to hepatologists (decompensated cirrhosis).ResultsMost of the attendees were African-American with an average age of 52 years. 354 out of 701 clients attending clinic for methadone/suboxone (50.5%) were screened for HCV. Of the 251 patients who were hepatitis C antibody positive (70% of tested), 54 had undetectable HCV RNA. 46 had no HCV RNA labs available. 151 of the remaining HCV Ab positive patients who had a detectable HCV RNA result were evaluated for treatment (Figure 2). At initial assessment, 45 (48%) with liver fibrosis staged greater than F3, including 25 (27%) with cirrhosis. Sixty-four patients initiated DAA therapy. Fifty-four patients completed treatment (84%). Forty patients achieved sustained virologic response (100%) and 14 patients who completed treatment await SVR labs.ConclusionCollocation of HCV care continuum in MAT setting is an effective way to achieve micro elimination of HCV. The follow-up of this marginalized population still remains challenging given the high rates of homelessness and incarceration. In this regard, coordinated care between MAT settings and prisons are likely to demonstrate successful elimination of hepatitis C. Disclosures All authors: No reported disclosures.

Hepatitis C Elimination in People With HIV Is Contingent on Closing Gaps in the HIV Continuum.

BackgroundBolstered by the high efficacy of hepatitis C virus (HCV) treatment, the World Health Organization has called for HCV elimination by 2030. People with HIV (PWH) have been identified as a population in which elimination should be prioritized.MethodsWe examined progress in HCV elimination through the HCV care continuum among patients infected with HIV/HCV receiving HIV care at Johns Hopkins Hospital in Baltimore, Maryland, United States. Patients with HIV care visits in at least 2 consecutive years were followed through December 15, 2018, for referral to HCV care, treatment initiation, and cure.ResultsAmong 593 HIV/HCV-coinfected individuals, 547 (92%) were referred for HCV care, 517 (87%) were evaluated for HCV treatment, 457 (77%) were prescribed HCV treatment, 426 (72%) initiated treatment, and 370 (62%) achieved HCV cure. In multivariable analysis, advanced liver disease (hazard ratio [HR], 1.48; 95% confidence interval [CI], 1.17–1.88) remained significantly positively associated with HCV treatment initiation. Conversely, being insured by state Medicaid (HR, 0.75; 95% CI, 0.61–0.92), having an HIV RNA >400 copies/mL (HR, 0.29; 95% CI, 0.18–0.49), and having missed 1%–24% (HR, 0.72; 95% CI, 0.54–0.97), 25%–49% (HR, 0.66; 95% CI, 0.49–0.89), and ≥50% of HIV care visits (HR, 0.39; 95% CI, 0.25–0.60) were significantly negatively associated with HCV treatment initiation.ConclusionsHCV infection can be eliminated in PWH. However, HCV elimination requires unrestricted access to HCV treatment and improved methods of retaining people in medical care.

The Hepatitis C Virus Care Continuum: Linkage to Hepatitis C Virus Care and Treatment Among Patients at an Urban Health Network, Philadelphia, PA.

Improving care and treatment for persons infected with hepatitis C virus (HCV) can reduce HCV-related morbidity and mortality. Our primary objective was to examine the HCV care continuum among patients receiving care at five federally qualified health centers (FQHCs) in Philadelphia, PA, where a testing and linkage to care program had been established. Among the five FQHCs, one served a homeless population, two served public housing residents, one served a majority Hispanic population, and the last, a "test and treat" site, also provided HCV treatment to patients. We analyzed data from electronic health records of patients tested for HCV antibody from 2012 to 2016 and calculated the percentage of patients across nine steps of the HCV care continuum ranging from diagnosis to cure. We further explored factors associated with successful patient navigation through two steps of the continuum using multivariable logistic regression. Of 885 chronically infected patients, 92.2% received their RNA-positive result, 82.7% were referred to an HCV provider, 69.4% were medically evaluated by the provider, 55.3% underwent liver disease staging, 15.0% initiated treatment, 12.0% completed treatment, 8.7% were assessed for sustained virologic response (SVR), and 8.0% achieved SVR. Regression results revealed that test and treat site patients were significantly more likely to be medically evaluated (adjusted odds ratio [aOR], 2.76; 95% confidence interval [CI], 1.82-4.17) and to undergo liver disease staging (aOR, 1.92; 95% CI, 1.02-2.86) than patients at the other FQHCs combined. Conclusion: In this US urban setting, over two thirds of HCV-infected patients were linked to care; although treatment uptake was low overall, it was highest at the test and treat site; scaling up treatment services in HCV testing settings will be vital to improve the HCV care continuum.

Integration of Hepatitis C Treatment in a Primary care Federally Qualified Health Center; Philadelphia, Pennsylvania, 2015-2017.

Hepatitis C virus (HCV) infection remains a pressing public health issue. Identification of long term infection in primary care settings and community health centers can facilitate patients’ access to appropriate care. Given the increase in HCV prevalence in the United States, improving the HCV care continuum and expanding medication access to disproportionately affected populations can help reduce disease burden, health care system costs, and transmission. Innovative treatment programs developed in the primary care setting are needed to deliver quality care to meet the demand of those engaging in treatment. This article describes an HCV treatment program developed within a primary care federally qualified health center (FQHC) using physician assistants (PAs) and nurse practitioners (NPs) to address the high number of HCV positive patients identified at the clinic. An interdisciplinary care team was established to optimize patient experience around HCV care and treatment, using on-site primary care behavioral health consultants, an HCV treatment coordinator, and a 340B contracted specialty pharmacy. From January 2015 to April 2017, the Public Health Management Corporation (PHMC) Care Clinic medical providers referred 189 patients for HCV treatment. Of those referred, 102 patients successfully obtained a sustained virologic response (SVR), representing a 53.7% success rate from referral to cure. This treatment program successfully integrated HCV treatment in a patient population heavily affected by substance use and mental illness. Support and adoption of similar programs in primary care community health centers testing for HCV can help meet the clinical/behavioral needs of these marginalized populations.

Expanding care for patients infected with Hepatitis C through community partnership in Delaware.

BackgroundHepatitis C virus (HCV) is the most common blood-borne pathogen in the U.S., and Delaware has one of the highest sero-prevalence rates in the country. As a cause of significant morbidity and mortality, it is a public health priority to identify and link individuals with HCV to care. The demand of patients with HCV far exceeds the current availability of providers in Delaware that offer HCV management. ObjectiveTo propose a framework for enabling non-specialist providers within Westside Family Healthcare to manage patients with HCV.MethodsAs a recipient of a Harrington Value Institute Community Partnership grant, the HIV Community Program of Christiana Care Health System (CCHS) started working together with the NE Wilmington pilot site of Westside in July 2018 to: 1) provide HCV education to Westside, 2) implement an HCV care model at Westside, and 3) conduct programmatic evaluation of this framework’s effectiveness. Our goal is to improve Westside rates of HCV knowledge amongst patients and staff, as well as to improve the HCV care continuum, starting with universal HCV screening.Results and ConclusionsResults from the first year of collaboration will be available in August 2019. Implementation of this partnership will enable future expansion and continuation of HCV management amongst Westside sites.

Race and Hepatitis C Care Continuum in an Underserved Birth Cohort.

Birth cohort screening is recommended for hepatitis C virus (HCV) and underserved populations are disproportionally affected by HCV. Little is known about the influence of race on the HCV care continuum in this population. To assess the cascade of HCV care in a large racially diverse and underserved birth cohort. Retrospective cohort study using electronic medical record data abstracted until August 31, 2017. 34,810 patients born between 1945 and 1965 engaged in primary care between October 1, 2014, and October 31, 2016, within the safety-net clinics of the San Francisco Health Network. Rate of hepatitis C testing, hepatitis C treatment, and response to therapy. Cohort characteristics were as follows: median age 59years, 57.6% male, 25.5% White (20.6% Black, 17.7% Latino, 33.0% Asian/Pacific Islander (API), 2% other), and 32.6% preferred a non-English language. 99.7% had an HCV test (95.4% HCV antibody, 4.3% HCVRNA alone). Among HCV antibody-positive patients (N = 4587), 22.9% were not tested for confirmatory HCVRNA. Among viremic patients (N = 3673), 20.8% initiated HCV therapy, 90.6% achieved sustained virologic response (SVR) and 8.1% did not have a SVR test. HCV screening and treatment were highest in APIs (98.7 and 34.7% respectively; p < 0.001). Blacks had the highest chronic HCV rate (22.2%; p < 0.001). Latinos had the lowest SVR rate (81.3%; p = 0.01). On multivariable analysis, API race (vs White, OR 1.20; p = 0.001), presence of HIV co-infection (OR 1.58; p = 0.02), presence of chronic kidney disease (OR 0.47; p < 0.001), English (vs non-English) as preferred language (OR 0.54; p = 0.002), ALT (OR 0.39 per doubling; p < 0.001), and HCVRNA (OR 0.83 per 10-fold increase; p < 0.001) were associated with HCV treatment. Despite near-universal screening, gaps in active HCV confirmation, treatment, and verification of cure were identified and influenced by race. Tailored interventions to engage and treat diverse and underserved populations with HCV infection are needed.

"Why Me?" Understanding the HCV Care Continuum Among People With Serious Mental Illness.

Despite possible cure rates of >90% with new treatment, people with serious mental illness are rarely screened for hepatitis C virus (HCV). A colocated approach may help patients navigate the care continuum. This study used a mixed-methods approach to increase understanding of the HCV care continuum for people with mental illness (N=170). Quantitative data included laboratory testing, risk assessments, and chart reviews. Qualitative interviews (N=9) were conducted to gain a broader understanding. Thirty-one (18%) patients tested positive for HCV; 13 were cured of HCV, and 10 are still receiving treatment. Qualitative interviews revealed that fear of the diagnosis may be an important treatment barrier. Those with serious mental illness who were diagnosed as having HCV and received the colocated prevention and treatment program were able to navigate the continuum of care for HCV treatment. Fear of diagnosis may be an important consideration for future efforts.

Care2Cure: A randomized controlled trial protocol for evaluating nurse case management to improve the hepatitis C care continuum within HIV primary care.

Co-infection with HIV and hepatitis C virus (HCV) results in a threefold increase in relative risk of progression to end stage liver disease and cirrhosis compared to HCV alone. Although curative treatments exist, less than one quarter of people with HCV are linked to care, and even fewer have received treatment. The Care2Cure study is a single-blinded, randomized controlled trial to improve the HCV care continuum among people co-infected with HIV. This ongoing study was designed to test whether a nurse case management intervention can (i) improve linkage to HCV care and (ii) decrease time to HCV treatment initiation among 70 adults co-infected with HIV who are not engaged in HCV care. The intervention is informed by the Andersen Behavioral Model of Health Services Use and consists of nurse-initiated referral, strengths-based education, patient navigation, appointment reminders, and care coordination for drug-drug interactions in the setting of HIV primary care. Validated instruments are used to measure participant characteristics including HCV knowledge, substance use, and depression. The primary outcome is linkage to HCV care (yes/no) within 60 days. In this protocol paper, we describe the first clinical trial to examine the effects of a nurse case management intervention to improve the HCV care continuum among people co-infected with HIV/HCV in the era of all-oral HCV treatment. We describe our work in progress, challenges encountered, and strategies to engage this hard-to-reach population.

‘Hep C’s like the common cold’: understanding barriers along the HCV care continuum among young people who inject drugs

BackgroundNew highly effective medications are available to treat the hepatitis C virus (HCV). However, little is known about HCV treatment knowledge and readiness among young people who inject drugs (PWID), or factors that may contribute to treatment uptake and adherence in this treatment era. PurposeUsing a framework for understanding healthcare utilization, we examined perspectives and experiences of young PWID tied to the HCV care continuum in Boston, Massachusetts, to inform future strategies. MethodsWe conducted 24 in-depth interviews with active and recent PWID aged 22–30 years living with HCV in Boston, February-August 2016. At the time of the interviews, no participants had been prescribed or had taken the new direct acting antivirals. We developed a codebook deductively from the interview guide and coded and analyzed the data into themes using a consensus-based process. ResultsThe following five themes emerged, which captured PWID’s knowledge of and experiences with HCV along the care continuum through social determinants of engagement in care, as well as illness level: (1) deservingness of HCV treatment and stigma, (2) dissatisfaction with provider interactions, (3) perceived lack of referral to treatment and care continuity, (4) disincentives around HCV treatment for PWID; and (5) perceived need for treatment. Young PWID living with HCV face unique barriers to HCV testing, counseling, and treatment. ConclusionBreakdowns in the HCV care continuum may have adverse effects on HCV-treatment readiness and willingness. Improved public health and practice approaches are needed to address these barriers to effectively engage young PWID in care.

Hepatitis C care continuum and associated barriers among people who inject drugs in Chennai, India

BackgroundLittle is known regarding barriers to hepatitis C virus (HCV) treatment among people who inject drugs (PWID) in low-resource settings, particularly in the era of direct-acting antiviral therapies. MethodsBetween March, 2015–August, 2016, a cross-sectional survey was administered to community-based PWID in Chennai, India to examine the HCV care continuum and associated barriers. Adjusted prevalence ratios (APR) were estimated by multivariable Poisson regression with robust variance. ResultsAll participants were male (n = 541); 152 participants had HCV mono-infection and 61 participants had HIV/HCV co-infection. Only one HCV mono-infected and one HIV/HCV co-infected participant was linked to HCV care. Overall, there was moderate knowledge of HCV disease but poor knowledge of HCV treatment. Higher total knowledge scores were negatively associated with HIV/HCV co-infection (vs. HCV mono-infection), though this was not statistically significant in adjusted analysis (APR = 0.71 [95%CI = 0.47–1.06]). Participants ≥45 years (APR = 0.73 [95%CI = 0.58–0.92]) and participants with HIV/HCV co-infection (APR = 0.64 [95%CI = 0.47–0.87]) were less willing to take weekly interferon injections for 12 weeks. Willingness to undergo HCV treatment improved with decreasing duration of therapy, higher perceived efficacy, and use of pills vs. interferon, though willingness to use interferon improved with decreasing duration of therapy. Most participants preferred daily visits to a clinic for HCV treatment versus receiving a month’s supply. Participants ≥45 years (vs. <45 years; APR = 0.70 [95%CI = 0.56–0.88]) and participants with HIV/HCV co-infection (APR = 0.75 [95%CI = 0.57–0.98]) were less likely to intend on seeking HCV care. Common reasons for not having already seen a provider for HCV treatment differed by HIV status, and included low perceived need for treatment (HCV-mono-infected), competing money/health priorities and costs/fears about treatment (HIV/HCV-co-infected). ConclusionResidual gaps in HCV knowledge and continuing negative perceptions related to interferon-based therapy highlight the need to scale-up educational initiatives. Readiness for HCV treatment was particularly low among HIV/HCV co-infected and older PWID, emphasizing the importance of tailored treatment strategies.

Hepatitis C Continuum of Care in a Treatment Center in Sub-Saharan Africa

Hepatitis C virus (HCV) infection is a major public health challenge in Cameroon with over three million people infected. Government efforts to improve care and treatment are unsatisfactory and need to be assessed. We aimed at studying the several steps along the HCV continuum of care in one of two hepatitis treatment centers in Cameroon. We undertook a retrospective chart review of anti-HCV positive individuals, who attended the Douala general hospital between 2008 and 2015. We defined the HCV treatment cascade as follows: step 1-HCV RNA testing, step 2-complete pre-therapeutic evaluation (genotyping and liver fibrosis markers), step 3-initiation of treatment, step 4-treatment completion, and step 5-sustained virological response (SRV). Each successive step in the HCV care continuum was dependent on passing through the previous step. The mean age of the 669 anti-HCV antibody positive individuals was 57 (sd: ±13) years. Females were 52.8% of the study population. 410 (61.3%) were tested for HCV RNA. Three hundred and sixty-six (54.7%) were confirmed to have viral replication (HCV RNA positive). One hundred and eighty (26.9%) did a complete pre-therapeutic evaluation (both HCV genotyping and liver fibrosis assessment included). Eighty-one (12.1%) initiated treatment with pegylated interferon/ribavirin. Seventy-two (10.8%) completed treatment and 44 (6.6%) had SVR. Sociodemographic characteristics including age, gender, marital status, having medical insurance, and profession were associated with attaining later steps in the care cascade. This study shows that HCV continuum of care and treatment is less optimal at the Douala general hospital and is highly impacted by socio-economic factors. Continued efforts are needed to improve HCV care.

Patterns and Gaps Identified in a Systematic Review of the Hepatitis C Virus Care Continuum in Studies among People Who Use Drugs.

Systematic reviews are useful for synthesizing data on various health conditions and for identifying gaps in available data. In the US, the main risk group for hepatitis C virus (HCV) infection is people who use drugs (PWUD); as a group, PWUD have the highest prevalence of chronic HCV. While the care continuum construct has been increasingly applied to studies of HCV care among PWUD, what constitutes the steps in an HCV care continuum is not standardized. We sought to examine the range of HCV care continuum outcomes that studies reported on, to identify gaps in the literature, and to develop strategies that allowed for valuable syntheses of care continuum data. We conducted searches of electronic databases for published literature. Reports were eligible if they provided original data from 1990 to 2016 from the US, presented data on one or more HCV care continuum outcomes, and provided outcome data on PWUD as a distinct group. A total of 313 full-text reports were assessed for eligibility. Of 212 potentially eligible reports, 32 (15.1%) did not present outcomes for PWUD separately from those who were non-PWUD. Among 101 eligible reports, a total of 166 care continuum outcomes were extracted; outcomes could be grouped into three categories that represent the HCV care continuum: testing (39.8%, n = 66/166); linkage to care (16.9%, n = 28/166); and treatment (43.4%, n = 72/166). Seventy-four reports (73.3%, n = 74/101) presented data on only one step. Linkage to care occurred variably after only antibody, or after antibody and viral load (VL) testing. Six (5.9%, n = 6/101) reports presented data on all three steps. Reports examined a variety of HCV care continuum outcomes that could be grouped into the three steps of testing, linkage to care, and treatment. The application of this care continuum model would facilitate subsequent data synthesis for program comparison and public health evaluation. Given the two-step nature of HCV testing, analyses also need to account for variation in whether linkage to care occurred after antibody testing or after sequential antibody and VL testing. Additional data are needed on the progression of PWUD through the entire care continuum.

HCV management in resource-constrained countries.

With the arrival of all-oral directly acting antiviral (DAA) therapy with high cure rates, the promise of hepatitis C virus (HCV) eradication is within closer reach. The availability of generic DAAs has improved access to countries with constrained resources. However, therapy is only one component of the HCV care continuum, which is the framework for HCV management from identifying patients to cure. The large number of undiagnosed HCV cases is the biggest concern, and strategies to address this are needed, as risk factor screening is suboptimal, detecting <20% of known cases. Improvements in HCV confirmation through either reflex HCV RNA screening or ideally a sensitive point of care test are needed. HCV notification (e.g., Australia) may improve diagnosis (proportion of HCV diagnosed is 75%) and may lead to benefits by increasing linkage to care, therapy and cure. Evaluations for cirrhosis using non-invasive markers are best done with a biological panel, but they are only moderately accurate. In resource-constrained settings, only generic HCV medications are available, and a combination of sofosbuvir, ribavirin, ledipasvir or daclatasvir provides sufficient efficacy for all genotypes, but this is likely to be replaced with pangenetypic regimens such as sofosbuvir/velpatasvir and glecaprevir/pibrentaasvir. In conclusion, HCV management in resource-constrained settings is challenging on multiple fronts because of the lack of infrastructure, facilities, trained manpower and equipment. However, it is still possible to make a significant impact towards HCV eradication through a concerted effort by individuals and national organisations with domain expertise in this area.