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Carmody MD, Wagner K, Bizstray B, Thornton K, Fiuty P, Rosario AD, Teshale E, Page K. Cascade of Care for Hepatitis C Virus Infection Among Young Adults Who Inject Drugs in a Rural County in New Mexico. Public Health Rep 2023; 138:936-943. [PMID: 36633367 PMCID: PMC10576476 DOI: 10.1177/00333549221143086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE Treatment for hepatitis C virus (HCV) infection is highly effective; however, people who inject drugs (PWID), the population most affected by HCV, may encounter barriers to treatment. We examined the cascade of care for HCV infection among young adult PWID in northern New Mexico, to help identify gaps and opportunities for HCV treatment intervention. METHODS Young adults (aged 18-29 y) who self-reported injection drug use in the past 90 days were tested for HCV antibodies (anti-HCV) and HCV RNA. We asked participants with detectable RNA to participate in an HCV education session, prior to a referral to a local health care provider for treatment follow-up, and to return for follow-up HCV testing quarterly for 1 year. We measured the cascade of care milestones ranging from the start of screening to achievement of sustained virologic response (SVR). RESULTS Among 238 participants, the median age was 26 years and 133 (55.9%) were men. Most (90.3%) identified as Hispanic. Of 109 RNA-positive participants included in the cascade of care assessment, 84 (77.1%) received their results, 82 (75.2%) participated in the HCV education session, 61 (56.0%) were linked to care through a medical appointment, 27 (24.8%) attended the HCV treatment appointment, 13 (11.9%) attended their follow-up appointment, 6 (5.5%) initiated treatment, 3 (2.8%) completed treatment, and 1 (0.9%) achieved SVR. CONCLUSIONS We observed a steeply declining level of engagement at each milestone step of the cascade of care after detection of HCV infection, resulting in a suboptimal level of HCV treatment and cure. Programs that can streamline testing and expand access to treatment from trusted health care providers are needed to improve the engagement of PWID in HCV treatment.
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Affiliation(s)
- Mary D. Carmody
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Katherine Wagner
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Birgitta Bizstray
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Karla Thornton
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | | | - Aubrey Del Rosario
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Eyasu Teshale
- Epidemiology and Surveillance Branch, Division of Viral Hepatitis, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Kimberly Page
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
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DiDomizio E, Chandra DK, Nichols L, Villanueva M, Altice FL. Challenges to Achieving HCV Micro-Elimination in People With HIV in the United States: Provider Perspectives and the Role of Implicit Bias. Health Promot Pract 2023; 24:998-1008. [PMID: 37440258 DOI: 10.1177/15248399231169928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
The prevalence of HIV/HCV (hepatitis C virus) co-infection is high particularly in persons who inject drugs (PWID) and is increasing because of the evolving opioid epidemic in the United States. The introduction of effective antiviral medications for HCV has raised the strategic goal of HCV micro-elimination, and efforts to understand the barriers to treatment are critical. In this study, we explored the provider perspective of factors that inhibit HCV micro-elimination efforts in people with HIV (PWH), including the role of implicit bias and related stigma in providers' health care decision making. We used the mixed-methods approach of nominal group technique (NGT) with 14 participants from 11 different clinics engaged in two virtual focus group sessions (n = 5 and n = 9). Responses from the NGTs were rank ordered during the sessions to identify providers' perspectives of major barriers and facilitators, then identified possible implicit bias after the NGTs concluded. There were 12 responses given for micro-elimination barriers with the three most prioritized being housing instability, medication nonadherence concerns, and inability to motivate patients. Of these, eight were categorized as potential implicit biases. Among the 14 responses given for facilitators of treatment, the three major solutions included distributive models of care, improved provider knowledge, and increased patient engagement. Although the solutions offered were insightful, there was consensus that the individual lives of patients were the root cause of most barriers to care. We recommend further research on behavioral design interventions that promote patients' involvement in decision making and focus on patients' eligibility criteria for HCV treatment as opposed to providers' perceived barriers to treatment.
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Affiliation(s)
| | - Divya K Chandra
- University of Connecticut School of Medicine, Farmington, CT, USA
| | - Lisa Nichols
- Yale University School of Medicine, New Haven, CT, USA
| | | | - Frederick L Altice
- Yale University School of Medicine, New Haven, CT, USA
- Yale School of Public Health, New Haven, CT, USA
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Taylor SN, Munson D. Health Care of People Experiencing Homelessness: Part I. NEJM EVIDENCE 2023; 2:EVIDra2300123. [PMID: 38320148 DOI: 10.1056/evidra2300123] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Homelessness and Health CarePeople who experience homelessness have high rates of medical illness. They struggle with conditions associated with living in crowded shelters, trauma, and exposure to extreme weather. Here, Taylor and Munson review the care of this vulnerable population.
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Affiliation(s)
| | - David Munson
- Massachusetts General Hospital, Boston
- Boston Health Care for the Homeless Program, Boston
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4
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Desai A, O'Neal L, Reinis K, Chang P, Brown C, Stefanowicz M, Kuang A, Agrawal D, Bhavnani D, Mercer T. Development, implementation, and feasibility of site-specific hepatitis C virus treatment workflows for treating vulnerable, high-risk populations: protocol of the Erase Hep C study - a prospective single-arm intervention trial. Pilot Feasibility Stud 2023; 9:78. [PMID: 37158965 PMCID: PMC10165844 DOI: 10.1186/s40814-023-01311-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 04/26/2023] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND Hepatitis C virus (HCV) is the leading indication for liver transplantation and liver-related mortality. The development of direct-acting antivirals (DAA) and a simplified treatment algorithm with a > 97% cure rate should make global elimination of HCV an achievable goal. Yet, vulnerable populations with high rates of HCV still have limited access to treatment. By designing locally contextualized site-specific HCV treatment workflows, we aim to cure HCV in vulnerable, high-risk populations, including people experiencing homelessness (PEH) and people who inject drugs (PWID), in Austin, TX, USA. METHODS Our implementation science study will utilize a qualitative and design thinking approach to characterize patient and systemic barriers and facilitators to HCV treatment in vulnerable, high-risk populations seeking care across seven diverse primary care clinics serving PEHs and PWIDs. Qualitative interviews guided by the Practical, Robust Implementation and Sustainability Model (PRISM) framework will identify barriers and facilitators by leveraging knowledge and experience from both clinic staff and patients. Data synthesized using thematic analysis and design thinking will feed into workshops with clinic stakeholders for idea generation to design site-specific HCV treatment workflows. Providers will be trained on the use of a simplified HCV treatment algorithm with DAAs and clinic staff on the new site-specific HCV treatment workflows. These workflows will be implemented by the seven diverse primary care clinics serving vulnerable, high-risk populations. Implementation and clinical outcomes will be measured using data collected through interviews with staff as well as through medical chart review. DISCUSSION Our study provides a model of how to contextualize and implement site-specific HCV treatment workflows targeting vulnerable, high-risk populations in other geographic locations. This model can be adopted for future implementation research programs aiming to develop and implement site-specific treatment workflows for vulnerable, high-risk populations and in primary care clinical settings for other disease states beyond just HCV. TRIAL REGISTRATION Registered on ClinicalTrials.gov on July, 14, 2022. Identifier: NCT05460130 .
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Affiliation(s)
- Anmol Desai
- Department of Population Health, The University of Texas at Austin Dell Medical School, Austin, USA
| | - Lauren O'Neal
- The University of Texas at Austin Dell Medical School, Austin, USA
| | - Kia Reinis
- Department of Population Health, The University of Texas at Austin Dell Medical School, Austin, USA
| | - Patrick Chang
- Department of Population Health, The University of Texas at Austin Dell Medical School, Austin, USA
| | - Cristal Brown
- Department of Internal Medicine, The University of Texas at Austin Dell Medical School, Austin, USA
- CommUnityCare Health Centers, Austin, USA
| | - Michael Stefanowicz
- Department of Population Health, The University of Texas at Austin Dell Medical School, Austin, USA
- CommUnityCare Health Centers, Austin, USA
| | - Audrey Kuang
- Department of Population Health, The University of Texas at Austin Dell Medical School, Austin, USA
- Department of Internal Medicine, The University of Texas at Austin Dell Medical School, Austin, USA
- CommUnityCare Health Centers, Austin, USA
| | - Deepak Agrawal
- Department of Internal Medicine, The University of Texas at Austin Dell Medical School, Austin, USA
| | - Darlene Bhavnani
- Department of Population Health, The University of Texas at Austin Dell Medical School, Austin, USA
| | - Tim Mercer
- Department of Population Health, The University of Texas at Austin Dell Medical School, Austin, USA.
- Department of Internal Medicine, The University of Texas at Austin Dell Medical School, Austin, USA.
- CommUnityCare Health Centers, Austin, USA.
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Kherghehpoush S, McKeirnan KC. The role of community pharmacies in the HIV and HCV care continuum. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2023; 9:100215. [PMID: 36938123 PMCID: PMC10017415 DOI: 10.1016/j.rcsop.2022.100215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 12/10/2022] [Accepted: 12/13/2022] [Indexed: 01/13/2023] Open
Abstract
Introduction In 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. Methods This 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. Results Fifty 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. Conclusion Individuals 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.
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Conti J, Dryden E, Fincke BG, Dunlap S, McInnes DK. Innovative Approaches to Engaging Homeless and Marginally Housed Patients in Care: a Case Study of Hepatitis C. J Gen Intern Med 2023; 38:156-164. [PMID: 35879538 PMCID: PMC9849487 DOI: 10.1007/s11606-022-07708-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 06/16/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Homeless and marginally housed (HAMH) individuals experience significant health disparities compared to housed counterparts, including higher hepatitis C virus (HCV) rates. New direct-acting antiviral (DAA) medications dramatically increased screening and treatment rates for HCV overall, but inequities persist for HAMH populations. OBJECTIVE This study examines the range of policies, practices, adaptations, and innovations implemented by Veteran Affairs Medical Centers (VAMCs) in response to Veterans Health Administration (VHA)'s 2016 HCV funding allocation to expand provision of HCV care. DESIGN Ethnographic site visits to six US VAMCs varying in size, location, and availability of Homeless Patient-Aligned Care Teams. Semi-structured qualitative interviews informed by the HCV care continuum were conducted with providers, staff, and HAMH patients to elicit experiences providing and receiving HCV care. Semi-structured field note templates captured clinical care observations. Interview and observation data were analyzed to identify cross-cutting themes and strategies supporting tailored HCV care for HAMH patients. PARTICIPANTS Fifty-six providers and staff working in HCV and/or homelessness care (e.g., infectious disease providers, primary care providers, social workers). Twenty-five patients with varying homeless experiences, including currently, formerly, or at risk of homelessness (n=20) and stably housed (n=5). KEY RESULTS All sites experienced challenges with continued engagement of HAMH individuals in HCV care, which led to the implementation of targeted care strategies to better meet their needs. Across sites, we identified 35 unique strategies used to find, engage, and retain HAMH individuals in HCV care. CONCLUSIONS Despite highly effective, widely available HCV treatments, HAMH individuals continue to experience challenges accessing HCV care. VHA's 2016 HCV funding allocation resulted in rapid adoption of strategies to engage and retain vulnerable patients in HCV treatment. The strategies identified here can help healthcare institutions tailor and target approaches to provide sustainable, high-quality, equitable care to HAMH individuals living with HCV and other chronic illnesses.
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Affiliation(s)
- Jennifer Conti
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA.
| | - Eileen Dryden
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - B Graeme Fincke
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, USA
| | - Shawn Dunlap
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - D Keith McInnes
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, USA
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Moore MS, Bocour A. Association Between Time to First RNA-Negative Test Result Among People With Hepatitis C Virus Infection and Homelessness or Testing at a Correctional or Substance Use Treatment Facility, New York City. Public Health Rep 2022; 137:1126-1135. [PMID: 34694921 PMCID: PMC9574298 DOI: 10.1177/00333549211049263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Curative treatments for hepatitis C virus (HCV) infection are available, but access and barriers to treatment can delay initiation. We investigated the time to first negative RNA test result among people with HCV infection and examined differences by homeless status and whether people were tested at a correctional facility or substance use treatment facility. METHODS We used surveillance data to identify New York City residents first reported with HCV infection during January 1, 2015-December 31, 2018, with ≥1 positive RNA test result during January 1, 2015-November 1, 2019. We used Kaplan-Meier survival analysis to determine the time from the first positive RNA test result to the first negative RNA test result, with right-censoring at date of death or November 1, 2019. We determined substance use treatment, incarceration, or homelessness by ordering facility name and address or from patient residential address. RESULTS Of 13 952 people with an HCV RNA-positive test result first reported during 2015-2018, 6947 (49.8%) subsequently received an RNA-negative test result. Overall, 25% received an RNA-negative test result within 208 (95% CI, 200-216) days and 50% within 902 (95% CI, 841-966) days. Homelessness, incarceration, or substance use treatment was indicated for 4304 (30.9%) people, among whom 25% received an RNA-negative test result within 469 (95% CI, 427-520) days and <50% received an RNA-negative test result during the study period. CONCLUSIONS Efforts to connect people to treatment should occur soon after diagnosis, especially for people who could benefit from hepatitis C care coordination.
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Affiliation(s)
- Miranda S. Moore
- Viral Hepatitis Program, Bureau of Communicable Disease, New York City Department of Health and Mental Hygiene, Queens, NY, USA
| | - Angelica Bocour
- Viral Hepatitis Program, Bureau of Communicable Disease, New York City Department of Health and Mental Hygiene, Queens, NY, USA
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8
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Del Rosario A, Eldredge JD, Doorley S, Mishra SI, Kesler D, Page K. Hepatitis C virus care cascade in persons experiencing homelessness in the United States in the era of direct-acting antiviral agents: A scoping review. J Viral Hepat 2021; 28:1506-1514. [PMID: 34314081 PMCID: PMC9829430 DOI: 10.1111/jvh.13583] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 05/26/2021] [Accepted: 07/12/2021] [Indexed: 01/12/2023]
Abstract
The hepatitis C virus (HCV) care cascade has been well characterized in the general United States population and other subpopulations since curative medications have been available. However, information is limited on care cascade outcomes in persons experiencing homelessness. The main objective of this study was to map the available evidence on HCV care cascade outcomes in people experiencing homelessness in the U.S. in the era of direct-acting antiviral agents (DAAs). Primary and secondary outcomes included linkage to care (evaluation by a provider that can treat HCV) and sustained virologic response (SVR) or cure. Exploratory outcomes included other cascade data, like treatment initiation, which precedes SVR. PubMed was the primary database accessed for this scoping review. We characterized the HCV care cascade in people experiencing homelessness using sources of evidence published in 2014 onwards that reported the proportions of persons who were linked to care, achieved SVR, and completed other cascade steps. We synthesized our results into a scoping review. The proportion of persons linked to care among chronically infected cohorts with unstable housing ranged from 29.3% to 88.7%. Among those chronically infected, 5%-58.8% were started on DAAs and 5%-50% achieved SVR. In conclusion, these results show that persons experiencing homelessness achieve high rates of linkage to care in non-specialist community-based settings compared to the general U.S. population pre-DAAs. However, DAA initiation was found to be a rate-limiting step along the care cascade, resulting in commensurate low rates of cure.
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Affiliation(s)
- Aubrey Del Rosario
- University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Jonathan D Eldredge
- University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Sara Doorley
- University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Shiraz I Mishra
- University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Denece Kesler
- University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Kimberly Page
- University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
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Khalili M, Powell J, Park HH, Bush D, Naugle J, Ricco M, Magee C, Braimoh G, Zevin B, Fokuo JK, Masson CL. Shelter-Based Integrated Model Is Effective in Scaling Up Hepatitis C Testing and Treatment in Persons Experiencing Homelessness. Hepatol Commun 2021; 6:50-64. [PMID: 34628726 PMCID: PMC8710795 DOI: 10.1002/hep4.1791] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 06/14/2021] [Accepted: 06/27/2021] [Indexed: 12/26/2022] Open
Abstract
Hepatitis C virus (HCV) prevalence is high among people experiencing homelessness, but barriers to scaling up HCV testing and treatment persist. We aimed to implement onsite HCV testing and education and evaluate the effectiveness of low‐barrier linkage to HCV therapy among individuals accessing homeless shelters. HCV rapid testing was performed at four large shelters in San Francisco (SF) and Minneapolis (MN). Sociodemographic status, HCV risk, barriers to testing, and interest in therapy were captured. Participants received information about HCV. Those testing positive underwent formal HCV education and onsite therapy. Multivariable modeling assessed predictors of receipt of HCV therapy and sustained virologic response (SVR). A total of 766 clients were tested. Median age was 53.7 years, 68.2% were male participants, 46.3% were Black, 27.5% were White, 13.2% were Hispanic, and 57.7% had high school education or less; 162 (21.1%) were HCV antibody positive, 107 (66.0%) had detectable HCV RNA (82.1% with active drug use, 53.8% history of psychiatric illness), 66 (61.7%) received HCV therapy, and 81.8% achieved SVR. On multivariate analysis, shelter location (MN vs. SF, odds ratio [OR], 0.3; P = 0.01) and having a health care provider (OR, 4.1; P = 0.02) were associated with receipt of therapy. On intention to treat analysis, the only predictor of SVR when adjusted for age, sex, and race was HCV medication adherence (OR, 14.5; P = 0.01). Conclusion: Leveraging existing homeless shelter infrastructure was successful in enhancing HCV testing and treatment uptake. Despite high rates of active substance use, psychiatric illness, and suboptimal adherence, over 80% achieved HCV cure. This highlights the critical importance of integrated models in HCV elimination efforts in people experiencing homelessness that can be applied to other shelter settings.
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Affiliation(s)
- Mandana Khalili
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA.,Division of Gastroenterology and Hepatology, Department of Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA.,University of California San Francisco Liver Center, San Francisco, CA, USA
| | | | - Helen H Park
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA.,Division of Gastroenterology and Hepatology, Department of Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA.,School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Dylan Bush
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA.,Division of Gastroenterology and Hepatology, Department of Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Jessica Naugle
- San Francisco Department of Public Health, Street Medicine and Shelter Health, San Francisco, CA, USA
| | | | - Catherine Magee
- Division of Gastroenterology and Hepatology, Department of Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | | | - Barry Zevin
- San Francisco Department of Public Health, Street Medicine and Shelter Health, San Francisco, CA, USA
| | - J Konadu Fokuo
- Department of Psychiatry, University of California San Francisco, San Francisco, CA, USA
| | - Carmen L Masson
- Department of Psychiatry, University of California San Francisco, San Francisco, CA, USA
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10
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Alfranca R, Salvans M, López C, Giralt C, Ramírez M, Calvo F. Hepatitis C in homeless people: reaching a hard-to-reach population. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2021; 113:529-532. [PMID: 33494612 DOI: 10.17235/reed.2021.7737/2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE the aim of this study was to analyze the process of detection and treatment of hepatitis C in individuals experiencing homelessness (IEH). METHODS an analytical cross-sectional study was performed in a Primary Care center. The center screened and registered patients with a positive hepatitis C antibody test and referred them to the Digestive Service. RESULTS finally, 8.3 % presented with a positive HCV antibody test, of which six were patients who had already received treatment. Of those who had not received treatment, one patient was successfully treated; 30.8 % of the total could not be located or did not wish to participate. CONCLUSION community coordination and the use of rapid tests would improve detection.
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Affiliation(s)
- Rebeca Alfranca
- Centro de Atención Primaria Santa Clara. Institut Català de la Salut
| | - Mercè Salvans
- Centro de Atención Primaria Santa Clara. Institut Català de la Salut
| | - Carmen López
- Unidad de Hepatitis, Hospital Universitari de Girona Doctor Josep Trueta
| | - Cristina Giralt
- Centro de Atención Primaria Blanes. Institut Català de la Salut
| | - Marissa Ramírez
- Centro de Atención y Seguimiento a las Drogodependencias de Girona. Institut d'Assistència Sanitària
| | - Fran Calvo
- Pedagogia, Institut de Recerca sobre Qualitat de Vida. Universitat de Girona, España
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11
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Benitez TM, Fernando SM, Amini C, Saab S. Geographically Focused Collocated Hepatitis C Screening and Treatment in Los Angeles's Skid Row. Dig Dis Sci 2020; 65:3023-3031. [PMID: 31974916 DOI: 10.1007/s10620-020-06073-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 01/12/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND The inequitable prevalence of hepatitis C (HCV) in the homeless is a clinical and public health concern. Prior research estimates, at least one-quarter of homeless persons have been infected with HCV, yet linkage to care and treatment uptake remains marginal. AIM To evaluate the feasibility of treating HCV in a homeless population. METHODS Retrospective study of homeless individuals treated for HCV. Demographic information including risk factors was collected. Univariate analyses were performed. The proportion of patients linked to care and sustained viral response at 12 weeks post-treatment (SVR12) was measured. RESULTS During the study period, 6767 individuals were screened for HCV. A total of 769 (11.4%) were found to have detectable HCV antibodies. Of the individuals with detectable HCV antibodies, 443 (57.6%) were viremic. Of the 443 viremic patients, 375 (84.7%) were linked to care. Among them, 59 patients began antiviral treatment and 95% (56/59) completed the course of therapy. The ITT was 83.1% (49/59), and the per-protocol virologic cure rate was 100% (49/49). CONCLUSION The favorable linkage to care and cure outcomes in our study suggests that homeless persons may be more likely to engage in HCV screening and treatment when these services are located in the community for their use. Our study further lends support to the efficacy of care coordination programs to encourage movement through the HCV care continuum in vulnerable populations.
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Affiliation(s)
| | | | | | - Sammy Saab
- Departments of Medicine, Nursing, and Surgery, University of California at Los Angeles, Los Angeles, CA, USA. .,Pfleger Liver Institute, UCLA Medical Center, 200 Medical Plaza, Suite 214, Los Angeles, CA, 90095, USA.
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12
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Johnson L, Lewer D, Aldridge RW, Hayward AC, Story A. Protocol for a systematic review of treatment adherence for HIV, hepatitis C and tuberculosis among homeless populations. Syst Rev 2020; 9:211. [PMID: 32921306 PMCID: PMC7488663 DOI: 10.1186/s13643-020-01470-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 08/28/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Homelessness is a global issue and HIV, hepatitis C and tuberculosis are known to be prevalent in this group. Homeless populations face significant barriers to care. We aim to summarise evidence of treatment initiation and completion for homeless populations with these infections, and their associated factors, through a systematic review and meta-analysis. METHODS We will search MEDLINE, Embase and CINAHL for all study types and conference abstracts looking at either (1) treatment initiation in a cohort experiencing homelessness with at least one of HIV, hepatitis C, active tuberculosis and/or latent tuberculosis infection (LTBI); (2) treatment completion for those who initiated treatment. We will perform a meta-analysis of the proportion of those with each infection who initiate and complete treatment, as well as analysis of individual and health system factors that may affect adherence levels. We will evaluate the quality of research papers using the Newcastle-Ottawa scale. DISCUSSION Given the political emphasis on global elimination of these diseases, and the current lack of understanding of effective and equitable treatment adherence strategies in homeless populations, this review will provide insight to policy-makers and service providers aiming to improve homeless healthcare. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42019153150.
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Affiliation(s)
- Luke Johnson
- Collaborative Centre for Inclusion Health, Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London, WC1E 7HT UK
- Department of Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, SO17 1BJ UK
| | - Dan Lewer
- Collaborative Centre for Inclusion Health, Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London, WC1E 7HT UK
| | - Robert W. Aldridge
- The Farr Institute of Health Informatics Research, University College London, London, NW1 2DA UK
| | - Andrew C. Hayward
- Collaborative Centre for Inclusion Health, Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London, WC1E 7HT UK
| | - Alistair Story
- Collaborative Centre for Inclusion Health, Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London, WC1E 7HT UK
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13
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Springer SA, Barocas JA, Wurcel A, Nijhawan A, Thakarar K, Lynfield R, Hurley H, Snowden J, Thornton A, del Rio C. Federal and State Action Needed to End the Infectious Complications of Illicit Drug Use in the United States: IDSA and HIVMA's Advocacy Agenda. J Infect Dis 2020; 222:S230-S238. [PMID: 32877568 PMCID: PMC7467230 DOI: 10.1093/infdis/jiz673] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
In response to the opioid crisis, IDSA and HIVMA established a working group to drive an evidence- and human rights-based response to illicit drug use and associated infectious diseases. Infectious diseases and HIV physicians have an opportunity to intervene, addressing both conditions. IDSA and HIVMA have developed a policy agenda highlighting evidence-based practices that need further dissemination. This paper reviews (1) programs most relevant to infectious diseases in the 2018 SUPPORT Act; (2) opportunities offered by the "End the HIV Epidemic" initiative; and (3) policy changes necessary to affect the trajectory of the opioid epidemic and associated infections. Issues addressed include leveraging harm reduction tools and improving integrated prevention and treatment services for the infectious diseases and substance use disorder care continuum. By strengthening collaborations between infectious diseases and addiction specialists, including increasing training in substance use disorder treatment among infectious diseases and addiction specialists, we can decrease morbidity and mortality associated with these overlapping epidemics.
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Affiliation(s)
| | | | | | - Ank Nijhawan
- UT Southwestern Medical Center, Dallas, Texas, USA
| | - Kinna Thakarar
- Maine Medical Center, Portland, ME, USA
- Tufts University School Of Medicine, Boston, Massachusetts, USA
| | - Ruth Lynfield
- Minnesota Department of Health, St. Paul, Minnesota, USA
| | | | - Jessica Snowden
- University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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14
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Successful Implementation of a Shared Medical Appointment Model for Hepatitis C Treatment at a Community Health Center. J Community Health 2020; 44:169-171. [PMID: 30132236 DOI: 10.1007/s10900-018-0568-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Highly efficacious direct acting antiviral (DAA) therapy for treatment of Hepatitis C Virus (HCV) infection is largely inaccessible to communities facing a shortage of available specialist providers. Though less demanding than previous interferon regimens, DAA therapy requires patients to adhere to 8-12 weeks of daily treatment, which can be challenging for some patient populations. Duffy Health Center, located on Cape Cod, Massachusetts, provides integrated medical, mental health and case management services to people who are homeless or at risk for homelessness. The goal of this manuscript is to evaluate the outcomes of treatment of HCV infection with a shared medical appointment (SMA) model. The primary outcome was sustained virologic response (SVR-12), or HCV RNA ≤ 15 IU/mL at 12 weeks post-treatment. There were 102 patients recruited, with a total of 104 treatments administered. Over three-fourths of patients who attended one SMA visit (78 of 102) continued in SMA for the duration of treatment. Of these patients opting for SMA, 99% (77 of 78) completed the full treatment course, and 91% (71 of 78) of SMA patients achieved SVR-12. DAA therapy provided by non-specialist providers using the SMA model yielded comparable response rates to those achieved by specialist providers, and has the potential to substantially increase access to HCV treatment for patient populations within high-risk communities.
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15
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Bakr O, Gelberg L, Seragaki S, Youn S, Kawamoto J, Hoppe M, Altman L, Kopelson K, May FP, Cowan B, Bhattacharya D. Treating Hepatitis C in Homeless Veterans at the Greater Los Angeles Veterans' Affairs Medical Center. Hepatology 2019; 70:1071-1073. [PMID: 30945758 DOI: 10.1002/hep.30643] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 04/01/2019] [Indexed: 12/07/2022]
Affiliation(s)
- Omar Bakr
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA.,Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Lillian Gelberg
- Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA.,Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Shinobu Seragaki
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Sarah Youn
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Jenna Kawamoto
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Marcie Hoppe
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Lisa Altman
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Kristin Kopelson
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Folasade P May
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA.,Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA.,Vatche & Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Brianna Cowan
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA.,Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Debika Bhattacharya
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA.,Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, CA.,Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA
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16
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Beiser ME, Smith K, Ingemi M, Mulligan E, Baggett TP. Hepatitis C treatment outcomes among homeless-experienced individuals at a community health centre in Boston. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 72:129-137. [PMID: 30962036 DOI: 10.1016/j.drugpo.2019.03.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 03/13/2019] [Accepted: 03/15/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Hepatitis C virus (HCV) infection prevalence is high among adults who experience homelessness but data on HCV treatment outcomes are limited in this population. We examined HCV treatment engagement and outcomes in a cohort of homeless-experienced adults treated through an innovative community-based primary care program in Boston, Massachusetts, USA. METHODS We conducted a retrospective chart review of individuals referred for HCV treatment at Boston Health Care for the Homeless Program (BHCHP) from January 2014 to March 2017. We assessed HCV treatment initiation, treatment completion, sustained virologic response (SVR), and reinfection rates. We conducted univariate and multivariable logistic regression analyses to examine the predictors of these outcomes. RESULTS Of 510 referred for HCV treatment, 210 (41.1%) did not initiate treatment, principally because of being lost to follow-up (N = 93) or having superseding social issues (N = 49). Of 300 who initiated treatment, 80% were male, 52.3% were non-white, and 29% were homeless. Over half (58.6%) had a history of opioid use disorder (OUD). Twenty percent had cirrhosis. Treatment was completed by 285 (95.0%) individuals, and 255 (85.0%) achieved SVR. In multivariable analyses, individuals with bipolar disorder (OR 0.38, 95% CI 0.15-0.99), treated (OR 0.36, 95% CI 0.14-0.96) or untreated (OR 0.18, 95% CI 0.05-0.57) OUD, or on-treatment insurance change (OR 0.16, 95% CI 0.04-0.67) were less likely to achieve SVR, while individuals living with HIV (OR 10.43, 95% CI 1.33-81.96) were more likely to achieve SVR. Among 126 individuals with post-SVR follow-up data, 27 reinfections were identified during 206 person-years of follow up (rate 13.1 per 100 person-years). CONCLUSION Homeless-experienced individuals initiating HCV treatment in a community-based program achieved high rates of treatment completion and SVR, but a large proportion did not initiate treatment. Individuals with OUD experienced lower but still substantial rates of cure. Treatment strategies targeting homeless-experienced people should focus on improving initial engagement and minimizing reinfection risk following treatment.
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Affiliation(s)
- Marguerite E Beiser
- Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, 780 Albany St., Boston, MA 02118, USA.
| | - Kamala Smith
- Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, 780 Albany St., Boston, MA 02118, USA.
| | - Molly Ingemi
- Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, 780 Albany St., Boston, MA 02118, USA.
| | - Emma Mulligan
- Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, 780 Albany St., Boston, MA 02118, USA.
| | - Travis P Baggett
- Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, 780 Albany St., Boston, MA 02118, USA; Division of General Internal Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, USA; Department of Medicine, Harvard Medical School, 25 Shattuck St., Boston, MA 02115, USA.
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17
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Lambert JS, Murtagh R, Menezes D, O’Carroll A, Murphy C, Cullen W, McHugh T, Avramovic G, Tinago W, Van Hout MC. 'HepCheck Dublin': an intensified hepatitis C screening programme in a homeless population demonstrates the need for alternative models of care. BMC Infect Dis 2019; 19:128. [PMID: 30732573 PMCID: PMC6367728 DOI: 10.1186/s12879-019-3748-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 01/28/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Hepatitis C virus (HCV) is one of the main causes of chronic liver disease worldwide. Prevalence of HCV in homeless populations ranges from 3.9 to 36.2%. The HepCheck study sought to investigate and establish the characterisation of HCV burden among individuals who attended an intensified screening programme for HCV in homeless services in Dublin, Ireland. METHODS The HepCheck study was conducted as part of a larger European wide initiative called HepCare Europe. The study consisted of three phases; 1) all subjects completed a short survey and were offered a rapid oral HCV test; 2) a convenience sample of HCV positive participants from phase 1 were selected to complete a survey on health and social risk factors and 3) subjects were tracked along the referral pathway to identify whether they were referred to a specialist clinic, attended the specialist clinic, were assessed for cirrhosis by transient elastography (Fibroscan) and were treated for HCV. RESULTS Five hundred ninety-seven individuals were offered HCV screening, 73% were male and 63% reported having had a previous HCV screening. We screened 538 (90%) of those offered screening, with 37% testing positive. Among those who tested positive, 112 (56%) were 'new positives' and 44% were 'known positives'. Undiagnosed HCV was prevalent in 19% of the study sample. Active past 30-day drug use was common, along with attendance for drug treatment. Unstable accommodation was the most common barrier to attending specialist appointments and accessing treatment. Depression and anxiety, dental problems and respiratory conditions were common reported health problems. Forty-six subjects were referred to specialised services and two subjects completed HCV treatment. CONCLUSIONS This study demonstrates that the current hospital-based model of care is inadequate in addressing the specific needs of a homeless population and emphasises the need for a community-based treatment approach. Findings are intended to inform HepCare Europe in their development of a community-based model of care in order to engage with homeless individuals with multiple co-morbidities including substance abuse, who are affected by or infected with HCV.
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Affiliation(s)
- John S. Lambert
- Infectious Diseases Department, Mater Misericordiae University Hospital, Dublin, Ireland
- UCD School of Medicine, University College Dublin, Dublin, Ireland
- Department of Infectious Diseases, Catherine McAuley Centre, 21 Nelson Street, Phibsborough, Dublin 7, Dublin Ireland
| | - Ross Murtagh
- UCD School of Medicine, University College Dublin, Dublin, Ireland
| | | | | | - Carol Murphy
- Mater Misericordiae University Hospital, Dublin, Ireland
| | - Walter Cullen
- UCD School of Medicine, University College Dublin, Dublin, Ireland
| | - Tina McHugh
- Mater Misericordiae University Hospital, Dublin, Ireland
| | | | - Willard Tinago
- UCD School of Medicine, University College Dublin, Dublin, Ireland
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18
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Hepatitis C Management Simplification From Test to Cure: A Framework for Primary Care Providers. Clin Ther 2018; 40:1234-1245. [PMID: 29983266 DOI: 10.1016/j.clinthera.2018.05.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 05/09/2018] [Accepted: 05/09/2018] [Indexed: 12/23/2022]
Abstract
This article proposes a strategy for primary care providers to begin treating patients with hepatitis C virus (HCV). We are motivated by the need to expand HCV treatment and by developments that have simplified treatment for most patients. This article presents 5 steps to achieving quality HCV treatment in the primary care setting: (1) accurate diagnosis via reflex testing; (2) risk stratification and identifying comorbidities via pretreatment evaluation; (3) simple, once-daily, pan-genotypic HCV treatment regimens; (4) minimized on-treatment monitoring: and (5) posttreatment monitoring and high-quality care for comorbidities such as cirrhosis and injection drug use. We provide indications for referral to specialists: notably children, patients with genotype 3 and cirrhosis, advanced liver or kidney disease, previous treatment failures, drug interactions with recommended regimens, and hepatitis B co-infection. Finally, potential barriers for providers are discussed, as well as further research findings and policy interventions that can promote HCV treatment in the primary care setting. We believe that a substantial portion of patients with HCV can be treated safely and effectively by nonspecialists and that the engagement of primary care providers is critical to efforts to end the HCV epidemic.
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19
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Yek C, de la Flor C, Marshall J, Zoellner C, Thompson G, Quirk L, Mayorga C, Turner BJ, Singal AG, Jain MK. Effectiveness of direct-acting antiviral therapy for hepatitis C in difficult-to-treat patients in a safety-net health system: a retrospective cohort study. BMC Med 2017; 15:204. [PMID: 29151365 PMCID: PMC5694912 DOI: 10.1186/s12916-017-0969-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 10/31/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Direct-acting antivirals (DAAs) have revolutionized chronic hepatitis C (HCV) treatment, but real-world effectiveness among vulnerable populations, including uninsured patients, is lacking. This study was conducted to characterize the effectiveness of DAAs in a socioeconomically disadvantaged and underinsured patient cohort. METHODS This retrospective observational study included all patients undergoing HCV treatment with DAA-based therapy between April 2014 and June 2016 at a large urban safety-net health system (Parkland Health and Hospital System, Dallas, TX, USA). The primary outcome was sustained virologic response (SVR), with secondary outcomes including treatment discontinuation, treatment relapse, and loss to follow-up. RESULTS DAA-based therapy was initiated in 512 patients. The cohort was socioeconomically disadvantaged (56% uninsured and 13% Medicaid), with high historic rates of alcohol (41%) and substance (50%) use, and mental health disorders (38%). SVR was achieved in 90% of patients (n = 459); 26 patients (5%) were lost to follow-up. SVR was significantly lower in patients with decompensated cirrhosis (82% SVR; OR 0.37, 95% CI 0.16-0.85) but did not differ by insurance status (P = 0.98) or alcohol/substance use (P = 0.34). Reasons for treatment failure included loss to follow-up (n = 26, 5%), viral relapse (n = 16, 3%), non-treatment-related death (n = 7, 1%), and treatment discontinuation (n = 4, 1%). Of patients with viral relapse, 6 reported non-compliance and have not been retreated, 5 have been retreated and achieved SVR, 4 have undergone resistance testing but not yet initiated retreatment, and 1 was lost to follow-up. CONCLUSIONS Effective outcomes with DAA-based therapy can be achieved in difficult-to-treat underinsured populations followed in resource-constrained safety-net health systems.
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Affiliation(s)
- Christina Yek
- Parkland Health and Hospital System, Dallas, Texas, USA.,University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Carolina de la Flor
- Parkland Health and Hospital System, Dallas, Texas, USA.,University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - John Marshall
- Parkland Health and Hospital System, Dallas, Texas, USA.,University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | | | - Lisa Quirk
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Christian Mayorga
- Parkland Health and Hospital System, Dallas, Texas, USA.,University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Barbara J Turner
- University of Texas Health Science Center, San Antonio, Texas, USA
| | - Amit G Singal
- Parkland Health and Hospital System, Dallas, Texas, USA.,University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Mamta K Jain
- Parkland Health and Hospital System, Dallas, Texas, USA. .,University of Texas Southwestern Medical Center, Dallas, Texas, USA.
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