Uptake Of Hepatitis C Virus Testing Research Articles

One stop shopping – Bringing services to drug users

Many developed countries are facing a major challenge to improve identification of individuals acutely and chronically infected with hepatitis C virus (HCV) infection. We explored the views and experiences of people who inject drugs (PWID) in relation to HCV testing, and diagnosis through a review and synthesis of qualitative research.Based on the thematic synthesis of qualitative research. Searches were conducted in 14 databases and supplemented by reference checking, hand searching of selected journals, and searches of relevant websites. Studies of any qualitative design that examined the views and experiences of, and attitudes towards, HCV testing and diagnosis among PWID or practitioners involved in their care were included. Key themes and sub-themes were systematically coded according to the meaning and content of the findings of each study which proceeded to the preparation of a narrative account of the synthesis.28 qualitative studies were identified. We identified a number of overarching descriptive themes in the literature, finding overall that PWID hold complex and differing views and experiences of testing and diagnosis. Three major themes emerged: missed opportunities for the provision of information and knowledge; shifting priorities between HCV testing and other needs; and testing as unexpected and routine. Evidence of missed opportunities for the provision of knowledge and information about HCV were clear, contributing to delays in seeking testing and providing a context to poor experiences of diagnosis. Influenced by the nature of their personal circumstances, perceptions of the risk associated with HCV and the prioritisation of other needs acted both to encourage and discourage the uptake of HCV testing. Undergoing HCV testing as part of routine health assessment, and an unawareness of being testing was common. An unexpected positive diagnosis exacerbated anxiety and confusion.This review has identified that there are modifiable factors that affect the uptake of HCV testing and experiences of HCV diagnosis among PWID. Intervention development should focus on addressing these factors. There is a need for further research that engages PWID from a diverse range of populations to identify interventions, strategies and approaches that they consider valuable.

Uptake of hepatitis C antibody testing in patients with end‐stage liver disease in Glasgow, 1993–2007

Individuals infected with hepatitis C virus (HCV) need to be diagnosed well before developing end-stage liver disease to benefit from treatment. We aimed to ascertain what proportion of cases had been tested for HCV to inform on the effectiveness of current guidelines. Record linkage between national databases of HCV tests, hospital discharges and deaths identified 10,645 persons who were hospitalized or had died with mention of end-stage liver disease in Glasgow, Scotland, between 1993 and 2007. We estimated HCV test uptake and prevalence of HCV infection within the study population. The associations between both HCV test uptake and HCV-antibody status and sex, age group and deprivation quintile were estimated using logistic regression. We found that 43% of those hospitalized (n = 9153) and 23% of those who otherwise died (n = 1492) with first-time mention of end-stage liver disease had been tested for HCV during this period. Test uptake in those hospitalized increased from 13 (95% CI: 12-14%) in 1993-1997 to 58% (56-59%) in 2003-2007. The adjusted odds of being tested for HCV were significantly higher for men (OR=1.3, 95% CI: 1.2-1.5), for ages 25-54 (25-34 years: 2.7, 95% CI: 2.1-3.4; 35-44 years: 2.3, 95% CI: 2.0-2.6; 45-54 years: 1.5, 95% CI: 1.4-1.7) compared with 55+ years, and for those residing in the two most deprived quintiles (1.1, 95% CI: 1.0-1.2). Twenty-eight per cent of the HCV testees aged 25-44 years were HCV infected. These results highlight the continuing need for raising awareness among medical professionals for comprehensive HCV testing in patients with liver disease.

Targets for Hepatitis C virus test uptake and case-finding among injecting drug users: In prisons and general practice

We re-analyse data on new diagnoses of Hepatitis C virus (HCV) for injectors in prison or attending general practices which were relied on for the cost-effectiveness of HCV testing in injectors. We use these revised estimates to suggest readily achievable targets in Scottish general practices on HCV diagnoses for injectors born in 1956–1975. Using audit data from general practices around Edinburgh, we confirm that, with effort, the suggested targets are achievable. On re-analysis, we found that over 20% of HCV-undiagnosed injectors in English prisons accepted HCV testing, and half the injectors aged 30–54 years who attended a Glasgow general practice. On the basis of 30% HCV test uptake and 80% of ever-injectors having self-identified, a target of 2500 HCV diagnoses within a year in known ever-injectors born in 1956–1975 attending Scottish general practices is feasible. Its target of five new HCV diagnoses was achieved during an HCV testing intervention by Muirhouse Practice, Edinburgh. During a 2-year audit period, 86 other general practices around Edinburgh providing enhanced services for drug users increased HCV test uptake by known ever-injectors from 43% (314/727) to 62% (655/1062) in the 1956–1975 birth-cohort. Their new HCV diagnoses in ever-injectors were 171 over two years against a target of 166 within 1 year.

Evaluation of a General Practice Based Hepatitis C Virus Screening Intervention

In 2003 an estimated 37,500 of Scotland's population was chronically infected with HCV; 44% were undiagnosed former injecting drug users (IDU)--a priority group for antiviral therapy. To evaluate a hepatitis C virus (HCV) screening intervention. Outcome measures among two similar General Practice populations in an area of high HCV and drug use prevalence, one of which was exposed to an HCV screening intervention, were compared. Thirty to fifty four year old attendees of the intervention practice were opportunistically offered testing and counselling, where clinically appropriate, (November 2003-April 2004). HCV test uptake, case detection, referral and treatment administration rates. Of 584 eligible attendees, 421 (72%) were offered and 117 (28%) accepted testing in the intervention practice; no testing was undertaken in the comparison practice. Prevalences of HCV antibody were 13% (15/117), 75% (3/4) and 91% (10/11) among all tested persons, current IDUs and former IDUs respectively. For 4/15 (27%) evidence of binge drinking following the receipt of their positive result, was available. Of the 11 referred to specialist care because they were HCV RNA positive, nine attended at least one appointment. Two received treatment: one had achieved a sustained viral response as of February 2008. While non targeted HCV screening in the general practice setting can detect infected former IDU, the low diagnostic yield among non IDUs limited the effectiveness of the intervention. A more targeted approach for identifying former IDUs is recommended. Additionally, the low uptake of treatment among chronically infected persons four years after diagnosis demonstrates the difficulties in clinically managing such individuals. Strategies, including support for those with a history of problem alcohol use, to improve treatment uptake are required.

Prevalence of hepatitis C in an ethnically diverse HIV‐1‐infected cohort in south London

There is limited information on the prevalence of and risk factors for hepatitis C virus (HCV) infection among HIV-1-infected patients in the UK. Our objective was to determine the prevalence of HCV infection among an ethnically diverse cohort of HIV-infected patients in south London, and to extrapolate from these data the number of co-infected patients in the UK. A total of 1017 HIV-1-infected patients who had attended King's College Hospital HIV clinic between September 2000 and August 2002 were screened for HCV antibody using a commercial enzyme-linked immunosorbent assay (ELISA). Positive results were confirmed by polymerase chain reaction (PCR) or recombinant immunoblot assay. Demographic, clinical and laboratory data were obtained from the local computerized database and medical records. We applied our HCV prevalence rates in the different HIV transmission groups to the estimated number of HIV-infected persons in these groups in the UK, to obtain a national estimate of the level of HIV-HCV co-infection. Of the 1017 HIV-1-infected patients, 407 (40%) were white men, 158 (15.5%) were black African men, 268 (26.3%) were black African women, and 61 (6%) and 26 (2.6%) were black Caribbean men and women, respectively. Heterosexual exposure was the most common route of HIV acquisition (53.5%), followed by men having sex with men (36.9%), and current or previous injecting drug use (IDU) (7.2%). The overall prevalence of HCV co-infection was 90/1017 (8.9%), but this varied substantially according to route of transmission, from 82.2% among those with a history of IDU (which accounted for 67% of all HCV infections), to 31.8% in those who had received blood products, to 3.5% and 1.8% in those with homosexually and heterosexually acquired infection, respectively. Multivariate logistic regression analysis identified several independent risk factors for HCV infection: a history of IDU [odds ratio (OR) = 107.2; 95% confidence interval (CI) = 38.5-298.4], having received blood products (OR = 16.5; 95% CI = 5.1-53.7), and either being from a white ethnic group (OR = 4.3; 95% CI = 1.5-12.0) or being born in Southern Europe (OR = 6.7; 95% CI = 1.5-30.7). Based on the 35,473 known HIV-1-infected persons in the UK and the 10 997 estimated to be unaware of their status, we projected that there are at least 4136 HIV-HCV co-infected individuals in the UK and 979 who are unaware of their status. Overall, 9% of our cohort was HIV-HCV co-infected. The prevalence was highest among intravenous drug users (82%), who accounted for most of our HCV cases, and lowest among heterosexual men and women from sub-Saharan Africa and the Caribbean [< 2%]. Our estimate that a significant number of co-infected persons may be unaware of their HIV and HCV status, highlights an urgent need to increase the uptake of HCV and HIV testing, particularly among injecting drug users, to reduce the risk of onward transmission.

Projecting severe sequelae of injection-related hepatitis C virus epidemic in the UK - Part 1

Hepatitis C is transmitted by transfusion of unscreened blood, through injecting drugs, from mother-to-child and, on occasion, sexually. Transmission generally requires that the infector is hepatitis C virus (HCV) RNA positive, a 'carrier'. About three-quarters of injectors who are hepatitis C antibody positive are HCV-RNA positive and so infectious to others. Incubation periods from HCV infection to cirrhosis and hepatocellular carcinoma are even longer than from HIV infection to AIDS, being counted in decades; they depend on age, gender, alcohol consumption and co-infection with other viruses. We identify 25 data sources that are available, or required, for projecting the severe sequelae of the injection-related hepatitis C epidemic. Three data sources relate to hepatitis C diagnosis: register of confirmed HCV infections (with initial of first name + soundex of surname + date of birth + gender = master index, exposure category, year of starting to inject, and region); surveys of HCV test-uptake by injectors and others; documentation of pregnancy and its outcome in HCV-infected women (injectors and others). Four data sources relate to HCV prevalence and incidence among injectors and others: anonymous testing for HCV antibodies in blood or saliva (for sentinel groups ranging from new blood donors, pregnant women, patients awaiting kidney transplantation, non-injector prisoners, health-care workers, non-injector heterosexuals attending genitourinary medicine clinics; to injectors in the community, at drug treatment centres or in prison); historical data on HCV prevalence in injectors; HCV incidence studies in injectors; and uptake of harm reduction measures--frequency of sharing and methadone substitution--by injectors. Key reporting problems in HCV incidence studies, which inhibit checks on the convenient exponential assumption for time from start of injecting to hepatitis C infection, are discussed. Nine critical data sources are identified for monitoring the late sequelae of hepatitis C carriage, its investigation and treatment: linkage surveillance, for example by master index, to identify deaths, hospitalisations or cancer registrations among confirmed HCV infections; surveys of HCV status among patients who undergo liver biopsy, are newly diagnosed with cirrhosis or are newly diagnosed with liver cancer; surveys of liver-biopsy rate in HCV-infected injectors and others; uptake and outcome of interferon + ribavirin in the treatment of hepatitis C carriers; cohort studies of HCV progression; sample surveys of genotype in HCV-infected injectors, and others; acute hepatitis B infections and uptake of hepatitis B immunisation by injectors; liver transplantation in HCV-infected patients; and hepatitis C-status and other risk factors in deaths from cirrhosis or liver cancer, to determine whether they are HCV and injector-related. Finally, nine critical data sources are identified for quantitative understanding of the underlying injector epidemic: drug misuse databases plus capture-recapture methods to assess number of injectors, drug-related deaths by region to assess injector numbers; number of HIV-infected injectors; HIV progression in injectors; overdose and other causes of death in injectors; expert opinion on injector incidence historically, plus survey information on age-distribution at initiation and duration of injector careers; injector incidence historically inferred from hepatitis C infected blood donors; age-distribution of current injectors and at initiation, as a check on the assumptions made in stochastic simulation about injector incidence and 'outcidence' from injecting historically; mortality of former injectors; and general population or other survey ratios of surviving ever-injectors to injectors in the last 5 years, last year and currently, as a check on simulations. We recommend a common HCV diagnosis report form to improve ascertainment of risk-factor information, especially year of starting to inject--which is a key date epidemiologically. We also recommend updated surveys of current and former injectors' HCV-test uptake, or a denominator study that registers master index and risk factor information for all HCV testees. We recommend that injector surveys ask about typical frequency of needle sharing per 4 weeks in three distinct periods this year, last year and in the first year of injecting. We also recommend the location of stored historical samples from injectors to be tested retrospectively and anonymously for HCV antibodies. We recommend immediate attention to the uptake of, and response to, combination treatment by hepatitis C carriers who are former or recovering injectors. We rec

Projecting severe sequelae of injection-related hepatitis C virus epidemic in the UK - Part 2

In Part 2, we illustrate how available data can be used to obtain preliminary estimates for Scotland of prevalent injection-related hepatitis C carriers and of maternally hepatitis C virus (HCV)-infected infants. Novel approaches to reducing uncertainty about the number of Scotland's HCV infected children of injector parents are discussed in brief. Three approaches, one direct and two indirect, to estimating the number of current and ever-injectors are presented for England and Wales. Diagnosed HCV infections in injectors and HCV test uptake by current injectors are combined with survey estimates for the ratio of ever-injectors to current injectors to estimate prevalent injection-related hepatitis C carriers. Household surveys give direct but potentially biased estimates of the number of current and ever-injectors. Indirect estimates make use of hepatitis C diagnoses in injectors, HCV prevalence and test-uptake by injectors, or exploit international comparisons. We comment on key reporting problems that inhibit synthesis of HCV progression studies; and suggest how to derive preliminary gender-and-age specific progression rates to liver cirrhosis for use in projections. Preliminary estimates for Scotland of prevalent injection-related hepatitis C carriers are: central estimate 39,000, inner uncertainty 16,000-59,000; of maternally hepatitis C virus (HCV)-infected infants central estimate 260, uncertainty 110-1100; and for England and Wales estimates of the number of prevalent ever-injectors are central estimate 360,000, uncertainty 240,000-835,000. Both hepatitis C prevalence in injectors and estimated numbers of current injectors are similar in Australia, and England and Wales (but not so for Scotland), Australian work on projections of severe HCV sequelae from hepatitis C infections may therefore be a suitable starting point for projections for England and Wales. Australia anticipates a doubling in the number of persons living with hepatitis C cirrhosis from 8500 in 1997 to over 17,000 in 2010. Australian projections of severe HCV sequelae used progression rates that, for simplicity, were independent of gender and of age at HCV infection. Faster HCV progression for males, and their higher injector prevalence, means that the impact of HCV infection on, for example, liver cancer may be evident to a greater extent and earlier in males.