DOT-C: A cluster randomised feasibility trial evaluating d irectly o bserved an t i-H C V therapy in a population receiving opioid substitute therapy from community pharmacy

Cost-Effectiveness of Treating Hepatitis C in Clients on Opioid Agonist Therapy in Community Pharmacies Compared to Primary Healthcare in Australia

Meeting the World Health Organisation 2030 target of treating 80% of people with hepatitis C virus (HCV) in Australia requires accessible testing and treatment services for at-risk populations. Previous clinical trials, including those in Australia, have demonstrated the efficacy of outreach programmes to community pharmacies offering opioid agonist therapy (OAT). This analysis evaluates the potential cost-effectiveness of introducing an outreach programme in community pharmacies. Using a decision analytic model, we estimated the impact of adding a temporary hepatitis C outreach and treatment programme in community pharmacies to the standard treatment pathway available through general practice. We compared the expected number of tests, diagnoses, cures and costs occurring through the addition of this outreach and treatment programme to those expected through general practice alone over a 12-month time horizon. We examined costs from the perspective of the health system and conducted one-way and probabilistic sensitivity analyses to assess uncertainty in model parameters and test key assumptions. In the model adding the outreach programme pathway increased the number of tests from 4178 to 8737, the number of diagnoses from 615 to 1285 and the number of cures from 223 to 777 among people on OAT over a 12-month period. Each additional cure achieved through the addition of the outreach programme was estimated to incur $48,964 (AUD 2023) to the health system, with > 85% of these costs attributable to medication and dispensing expenses. The average cost per cure was estimated to be $49,152 through routine care and $49,018 in the outreach programme. Although outreach models of care incur large upfront costs, they can capture otherwise unreached populations and result in comparable or favourable cost per cure, due to higher levels of engagement and lower rates of loss to follow-up.

The implementation of a hepatitis C testing service in community pharmacies: I-COPTIC consensus statement

OBJECTIVES

This aimed to develop a blueprint for an effective community pharmacy Hepatitis C virus (HCV) testing service by producing a consensus statement.

STUDY DESIGN

This was a modified Delphi process.

METHODS

We recruited a heterogenous panel of experts (who had been involved in the setup or delivery of a community pharmacy HCV testing service) by purposive and chain referral methods. We had three rounds of a modified Delphi process. The first was a series of questions with free text responses and was analysed using thematic analysis, and the second and third were statements for the respondents to rate using a 7-point Likert scale. Consensus was predefined in a published protocol, and the results were reviewed by a public and patient involvement panel before the statement was finalised.

RESULTS

We had 24 participants, including community and hospital-based pharmacists, local pharmaceutical committee members, charity representatives (Hepatitis C Trust), local clinical service lead, nurse specialists and doctors. The response rate of the first, second and third rounds were 100%, 96% and 88%, respectively. After the third round, we had 60 statements that reached consensus. We discussed the accepted statements with a patient and public involvement group. We used these statements to produce the I-COPTIC statement and a graphical summary.

CONCLUSIONS

We developed a blueprint for the design of a gold standard community pharmacy HCV testing service. We believe this will support the successful implementation of community pharmacy testing for HCV. Community pharmacy testing is an important service to help achieve and maintain HCV elimination.

Viral hepatitis testing and treatment in community pharmacies: a systematic review and meta-analysis

Background

The World Health Organization seeks to eliminate viral hepatitis as a public health threat by 2030. This review and meta-analysis aims to evaluate the effectiveness of programs for hepatitis B and C testing and treatment in community pharmacies.

Methods

Medline, Embase, Cochrane CENTRAL, and Global Health were searched from database inception until 12 November 2023. Comparative and single arm intervention studies were eligible for inclusion if they assessed delivery of any of the following interventions for hepatitis B or C in pharmacies: (1) pre-testing risk assessment, (2) testing, (3) pre-treatment assessment or (4) treatment. Primary outcomes were proportions testing positive and reaching each stage in the cascade. Random effects meta-analysis was used to estimate pooled proportions stratified by recruitment strategy and setting where possible; other results were synthesised narratively. This study was pre-registered (PROSPERO: CRD42022324218).

Findings

Twenty-seven studies (4 comparative, 23 single arm) were included, of which 26 reported hepatitis C outcomes and four reported hepatitis B outcomes. History of injecting drug use was the most identified risk factor from pre-testing risk assessments. The pooled proportion hepatitis C antibody positive from of 19 studies testing 5096 participants was 16.6% (95% CI 11.0%-23.0%; heterogeneity I2 = 96.6%). The pooled proportion antibody positive was significantly higher when testing targeted people with specified risk factors (32.5%, 95% CI 24.8%-40.6%; heterogeneity I2 = 82.4%) compared with non-targeted or other recruitment methods 4.0% (95% CI 2.1%-6.5%; heterogeneity I2 = 83.5%). Meta-analysis of 14 studies with 813 participants eligible for pre-treatment assessment showed pooled attendance rates were significantly higher in pharmacies (92.7%, 95% CI 79.1%-99.9%; heterogeneity I2 = 72.4%) compared with referral to non-pharmacy settings (53.5%, 95% CI 36.5%-70.1%; heterogeneity I2 = 92.3%). The pooled proportion initiating treatment was 85.6% (95% CI 74.8%-94.3%; heterogeneity I2 = 75.1%). This did not differ significantly between pharmacy and non-pharmacy settings.

Interpretation

These findings add pharmacies to the growing evidence supporting community-based testing and treatment for hepatitis C. Few comparative studies and high degrees of statistical heterogeneity were important limitations. Hepatitis B care in pharmacies presents an opportunity for future research.

Funding

None.

Laying the foundations for hepatitis C elimination: evaluating the development and contribution of community care pathways to diagnostic efforts

BACKGROUND

Hepatitis C Virus (HCV) is a public health threat which contributes substantially to the global burden of liver disease. There is much debate about effective approaches to scaling up diagnosis of HCV among risk groups. Tayside, a region in the East of Scotland, developed low-threshold community pathways for HCV to lay the foundations of an elimination strategy. In this retrospective study, we sought to: quantify the contribution of community pathways to increasing HCV diagnosis; understand if shifting diagnosis to community settings led to a higher proportion of individuals tested for HCV being actively infected; and describe functional characteristics of the care pathways.

METHODS

Descriptive statistics were used to for analysis of routinely-collected HCV testing data from 1999 to 2017, and a review of the development of the care pathways was undertaken. Community-based testing was offered through general practices (GP); nurse outreach clinics; prisons; drug treatment services; needle and syringe provision (NSP) sites; community pharmacies; and mosques.

RESULTS

Anti-HCV screening was undertaken on 109,430 samples, of which 5176 (4.7%) were reactive. Of all samples, 77,885 (71.2%) were taken in secondary care; 25,044 (22.9%) in GPs; 2970 (2.7%) in prisons; 2415 (2.2%) in drug services; 753 (0.7%) in NSPs; 193 (0.2%) pharmacies; and 170 (0.1%) in mosques. The highest prevalence of HCV infection among those tested was in NSP sites (26%), prisons (14%), and drug treatment centres (12%).

CONCLUSIONS

Decentralised care pathways, particularly in harm reduction and other drug service settings, were key to increasing diagnosis of HCV in the region, but primary and secondary care remain central to elimination efforts.

Barriers and facilitators to implementing a Pharmacist, Physician, and Patient Navigator-Collaborative Care Model (PPP-CCM) to treat hepatitis C among people who inject drugs

BACKGROUND

Direct-acting antivirals (DAAs) offer an unprecedented opportunity to eliminate hepatitis C virus (HCV) infection, yet barriers among people who inject drugs (PWID) remain. Having pharmacists provide care through collaborative drug therapy agreements (CDTAs) offers a promising solution. We developed and piloted a Pharmacist, Physician, and Patient Navigator-Collaborative Care Model (PPP-CCM) which utilized pharmacists to directly deliver HCV care at community organizations serving PWID. We conducted formative evaluation of the PPP-CCM pilot to characterize implementation experiences.

METHODS

The PPP-CCM was implemented from November of 2020 through July of 2022. Formative evaluation team members observed implementation-related meetings and conducted multiple site visits, taking detailed fieldnotes. Fieldnotes were iteratively reviewed to identify barriers and facilitators to implementation and used to inform 7 key informant interviews conducted with programmatic staff at the end of the pilot. All data were analyzed using a Rapid Assessment Process (RAP) guided by the Consolidated Framework for Implementation Research (CFIR). The formative evaluation team shared results with program stakeholders (pharmacists, physicians, and other site staff) to verify and expand on learnings.

RESULTS

Evaluation of PPP-CCM revealed 5 themes, encompassing all CFIR domains: 1) PPP-CCM was feasible but challenging to deliver efficiently; 2) the pharmacist role and characteristics (e.g., being flexible, available, and patient-centered) were key to PPP-CCM successes; 3) the PPP-CCM team met challenges engaging patients over time, but some team-based strategies helped; 4) community site characteristics (e.g., existing trusting relationships with PWID and physical space that enabled program visibility) were important contributors; and 5) financial barriers may limit PPP-CCM scale-up and sustainability.

CONCLUSION

PPP-CCM is a novel and promising approach to HCV care delivery for PWID who may previously lack engagement in traditional care models, but careful attention needs to be paid to financial barriers to ensure scalability and sustainability.

I-COPTIC: Implementation of community pharmacy-based testing for hepatitis C: Delphi consensus protocol

OBJECTIVE

The World Health Organisation aims to eliminate Hepatitis C (HCV) by 2030. To achieve this, targeted testing needs to be widely available. Studies have demonstrated that community pharmacies can deliver effective targeted testing for HCV and the National Health Service in England has commissioned a national service. However, a recent survey of HCV operational delivery networks has shown limited uptake of this service. The objective of this protocol is to guide the formation of a consensus statement to facilitate the widespread implementation of community pharmacy-based targeted testing for HCV.

METHOD

We will use a modified Delphi method. A purposive selection of panel participants will be identified and recruited from a national survey and via chain-referral sampling. The main inclusion criteria for selection is direct involvement in the implementation of an HCV testing service in pharmacies. We aim for a heterogenous group, encompassing all aspects of the testing service. We will conduct a three round Delphi. The first round will consist of open questions which will be qualitatively analysed using thematic analysis with a framework method based on the WHO Health Systems Framework. This analysis will generate statements, that will be sent to the participants in the second round. A third round will be used where consensus is not reached.

CONCLUSIONS

The findings from this Delphi consensus study will facilitate the widespread implementation of targeted testing for HCV in community pharmacies.

Cost-effectiveness of pharmacy-led versus conventionally delivered antiviral treatment for hepatitis C in patients receiving opioid substitution therapy: An economic evaluation alongside a pragmatic cluster randomised trial

BACKGROUND

Elimination targets for hepatitis C have been set across the world. In the UK almost 90% of infections are in people who inject drugs. Evidence shows community case-finding is effective at identifying and treating undiagnosed patients. The aim of this analysis was to assess, from a healthcare provider perspective, the cost-effectiveness of a new pharmacist-led test and treat pathway for hepatitis C in opioid agonist treatment (OAT) patients attending community pharmacies compared to conventional care.

METHODS

In a cluster randomised controlled trial, pharmacies were randomised to the pharmacist-led or conventional care pathway. Mean cost per OAT patient and per patient initiating treatment was identified for each pathway. A Markov model tracking disease progression was developed, with a 50-year time horizon and 3·5% time discount rate, to estimate the incremental cost-effectiveness ratio (ICER) per quality-adjusted life-year (QALY) gained and the probability of being cost-effective at a £30,000 per QALY willingness-to-pay threshold. Probabilistic sensitivity analysis was performed for a range of drug discounts, re-infection rates, and model assumptions.

FINDINGS

Mean cost per OAT patient (£3,674 vs £1,965) and per patient initiating treatment (£863 vs £404) was higher in the pharmacist-led pathway, due to higher uptake of testing and pharmacist time requirements. Over a 50-year time horizon the ICER per QALY gained was £31,612 at NHS indicative price for treatment (£38,979 for 12 weeks) and 12·1/100 person-years re-infection rate, reducing to £21,027/£10,220/-£501 per QALY gained with 30%/60%/90% drug price discounts and £25,373/£21,738/£14,912 per QALY gained at re-infection rates of 8/5/2 per 100 person-years. At 30%/60%/90% drug discount rates, the pharmacist-led pathway has an 80%/98%/100% probability of being cost-effective.

INTERPRETATION

The pharmacist-led pathway is effective at increasing testing and treatment uptake, with cost-effectiveness being highly dependent on drug price discounts.

FUNDING

Trial funding provided by the Scottish Government, Gilead Sciences, and Bristol-Myers Squibb.

Randomized clinical trial: Direct-acting antivirals as treatment for hepatitis C in people who inject drugs: Delivered in needle and syringe programs via directly observed therapy versus fortnightly collection

Hepatitis C virus (HCV) treatment in people who inject drugs (PWID) is delivered within settings frequented by PWID, such as needle and syringe programs (NSP). The optimal direct-acting antiviral (DAA) dispensing regimen among NSP clients is unknown. This study compared cures (Sustained virologic response 12 weeks post-treatment, [SVR₁₂ ]) across three dispensing schedules to establish non-inferiority of fortnightly dispensing versus directly observed therapy. The ADVANCE HCV study was a randomized, unblinded trial, recruiting PWID attending NSP in Tayside, Scotland, between January 2018 and November 2019. HCV-positive participants were randomized to receive DAAs via directly observed therapy, fortnightly provision or fortnightly provision with psychological intervention. A modified intention to treat analysis was used to identify differences in cures between the three treatment regimes. The study was registered with clinicaltrials.gov; NCT03236506. A total of 110 participants completed the study. 33 participants received directly observed therapy, with 90.91% SVR₁₂ ; 37 received fortnightly provision, with 86.49% SVR₁₂ and 40 received fortnightly provision and psychological intervention at treatment initiation, with 92.50% SVR₁₂ . Analysis showed no significant difference in SVR₁₂ (p = 0.67). This study did not demonstrate a statistically significant difference in cure rate between groups. This provides evidence of the non-inferiority of fortnightly dispensing of direct-acting antivirals (DAAs) compared to directly observed therapy among PWID. It suggests that tight control of adherence through directly observed therapy dispensing of DAAs among this population offers no therapeutic advantage. Therefore, less restrictive dispensing patterns can be used, tailored to patient convenience.

Reaching people receiving opioid agonist therapy at community pharmacies with hepatitis C virus: an international randomised controlled trial

BACKGROUND

Conventional healthcare models struggle to engage those at risk of hepatitis C virus (HCV) infection. This international study evaluated point-of-care (PoC) HCV RNA diagnostic outreach and direct-acting antiviral (DAA) treatment for individuals receiving opioid agonist therapy (OAT) in community pharmacies.

AIMS

We assessed the effectiveness of a roving nurse-led pathway offering PoC HCV RNA testing to OAT clients in community pharmacies relative to conventional care.

METHODS

Pharmacies in Scotland, Wales, and Australia were randomised to provide PoC HCV RNA testing or conventional referral. Pharmacists directed OAT clients to on-site nurses (intervention) or local clinics (control). Infected participants were treated with DAAs, alongside OAT. Primary outcome was the number of participants with sustained virologic response at 12 weeks (SVR) and analysed using mixed effects logistic regression in the intention-to-treat (ITT) population.

RESULTS

Forty pharmacies were randomised. The ITT population contained 1410 OAT clients. In the conventional arm (n = 648), 62 (10%) agreed to testing, 17 (27%) were tested, 6 (35%) were positive and 5 (83%) initiated treatment. In the intervention arm (n = 762), 148 (19%) agreed to testing, 144 (97%) were tested, 23 (16%) were positive and 22 (96%) initiated treatment. SVR was obtained by 2 (40%; conventional) and 18 (82%; intervention). Intervention arm participants had higher odds of testing, OR 16.95 (7.07-40.64, p < 0.001); treatment, OR 4.29 (1.43-12.92, p = 0.010); and SVR, OR 8.64 (1.82-40.91, p = 0.007).

CONCLUSIONS

Nurse-led PoC diagnosis in pharmacies made HCV care more accessible for OAT clients relative to conventional care. However, strategies to improve testing uptake are required.

TRIAL REGISTRATION

NCT03935906.

'Not just one box that you tick off' - Deconstructing the hepatitis C care cascade in the interferon-free direct acting antiviral era from the client perspective

BACKGROUND

To achieve hepatitis C viral (HCV) elimination targets set by the World Health Organisation, pillars of the HCV care cascade are often referenced to track progress. The aim of this qualitative study was to explore the limitations of the care cascade framework through the real-world accounts of 'HCV journeys' among people who inject drugs (PWID), with particular attention to the intersection of PWID agency and structural determinants in the healthcare system.

METHODS

An in-depth analysis was conducted on five case studies to better understand participant experiences 'behind the cascade pillars'. The five case studies were drawn from the ETHOS Engage cohort as exemplars of the real-world complexities of people's HCV cascade journeys. Inclusion criteria for the qualitative study were participant has voluntarily signed the informed consent form, aged ≥18 years, HCV antibody positive by self-report, clients of selected sites participating in the ETHOS Engage cohort, and sufficiently proficient in English to participate in an interview. Thirty-four semi-structured interviews were conducted with participants who had received or had not received HCV treatment to identify barriers and facilitators to HCV care.

RESULTS

Participants 'housed' at the 'HCV RNA diagnosed pillar' (n = 2; Will; Julie) reported withholding their HCV serostatus in certain healthcare settings for fear that disclosure would lead to discriminatory decision-making from their treating physician. among participants who had completed treatment (n = 3; Corey; John; Nora) two reported still being unsure of their HCV status >6 months post-treatment. Ongoing feelings of frustration and shame were expressed in this 'post-cure care pillar' due to a perceived lack of quality care from clinic services and continued uneasiness when discussing drug use and reinfection while receiving opioid agonist treatment (OAT). Both case 'categories' described often tenuous therapeutic relationships with their physicians and recommended task-shifting to nurses and trusted case workers for ongoing care.

CONCLUSION

The care cascade provides a linear, two dimensional snapshot of clinical targets. Our findings illuminate structural barriers not visible behind its 'static' pillars, presenting insights into experiences among PWID otherwise dismissed as 'disengaged' or 'lost to follow-up'.

Reduction in the population prevalence of hepatitis C virus viraemia among people who inject drugs associated with scale-up of direct-acting anti-viral therapy in community drug services: real-world data

BACKGROUND AND AIMS

There has been little empirical evidence to show the 'real-world' impact of scaling-up direct-acting anti-viral (DAA) treatment among people who inject drugs (PWID) on hepatitis C virus (HCV) viraemia at a population level. We aimed to assess the population impact of rapid DAA scale-up to PWID delivered through community services-including drug treatment, pharmacies, needle exchanges and prisons-in the Tayside region of Scotland, compared with Greater Glasgow and Clyde (GGC) and the Rest of Scotland (RoS).

DESIGN, SETTING AND PARTICIPANTS

Natural experiment, evaluated using data from national biennial surveys of PWID and national clinical data. Services providing injecting equipment (2010-18) and HCV treatment clinics (2017-18) across Scotland. A total of 12 492 PWID who completed a questionnaire and provided a blood spot (tested for HCV-antibodies and RNA); 4105 individuals who initiated HCV treatment.

INTERVENTION AND COMPARATOR, MEASUREMENTS

The intervention was rapid DAA scale-up among PWID, which occurred in Tayside. The comparator was GGC/RoS. Trends in HCV viraemia and uptake of HCV therapy over time; sustained viral response (SVR) rates to therapy by region and treatment setting.

FINDINGS

Uptake of HCV therapy (last year) among PWID between 2013-14 and 2017-18 increased from 15 to 43% in Tayside, 6 to 16% in GGC and 11 to 23% in RoS. Between 2010 and 2017-18, the prevalence of HCV viraemia (among antibody-positives) declined from 73 to 44% in Tayside, 67 to 58% in GGC and 64 to 55% in RoS. The decline in viraemia was greater in Tayside [2017-18 adjusted odds ratio (aOR) = 0.47, 95% confidence interval (CI) = 0.30-0.75, P = 0.001] than elsewhere in Scotland (2017-18 aOR = 0.89, 95% CI = 0.74-1.07, P = 0.220) relative to the baseline of 2013-14 in RoS (including GGC). Per-protocol SVR rates among PWID treated in community sites did not differ from those treated in hospital sites in Tayside (97.4 versus 100.0%, P = 0.099).

CONCLUSIONS

Scale-up of direct-acting anti-viral treatment among people who inject drugs can be achieved through hepatitis C virus (HCV) testing and treatment in community drug services while maintaining high sustained viral response rates and, in the Tayside region of Scotland, has led to a substantial reduction in chronic HCV in the population.

Utilising an access to care integrated framework to explore the perceptions of hepatitis C treatment of hospital-based interventions among people who use drugs

BACKGROUND

Gaps remain in the hepatitis C virus (HCV) care cascade for people who use drugs (PWUD). Acute medical or surgical illnesses requiring hospitalisation are an opportunity to address addiction, but how inpatient strategies could affect HCV care accessibility for PWUD remains unknown. We explored patient perspectives of hospital-based interventions using an integrated framework of access to HCV care.

METHODS

We conducted a qualitative study of hospitalised adults (n=27) with HCV and addiction admitted to an urban academic medical centre in the United States between June and November 2019. Individual interviews were audio-recorded, transcribed, and dual-coded. We analysed data with coding specific for hospital-based interventions including screening, conducting HCV-related laboratory work-up, starting treatment, connecting with peers, and coordinating outpatient care. We analysed coded data at the semantic level for emergent themes using a framework approach based off an integrated framework of access to HCV care.

RESULTS

The majority of participants primarily used opioids (78%), were white (85%) and men (67%). Participants frequently reported HCV screening during previous hospitalisation with rare inpatient connection to HCV-related services. Participants expressed willingness to discuss HCV treatment candidacy during hospitalisation; however, lack of inpatient conversations led to perception that "nothing could be done" during admission. Participants expressed interest in completing inpatient HCV work-up to "get the ball rollin'" - consolidating care would enhance outpatient service permeability by reducing barriers. Others resisted HCV care coordination, preferring to focus on "immediate" issues including health conditions and addiction treatment. Participants also expressed openness to engaging with peers about HCV, noting shared drug use experience as critical to a peer relationship when discussing HCV.

CONCLUSION

Hospitalised PWUD have varied priorities, necessitating adaptable interventions for addressing HCV. Hospitalisation can be an opportunity to address HCV access to care including identification of treatment eligibility, consolidation of care, and facilitation of HCV-related referrals.

Patient Centeredness in Hepatitis C Direct-Acting Antiviral Treatment Delivery to People Who Inject Drugs: A Scoping Review

BACKGROUND AND OBJECTIVE

Patient-centered care (PCC) is crucial for value-based care. We aimed to assess PCC dimensions addressed in hepatitis C virus direct-acting antiviral treatment delivery to people who inject drugs.

METHODS

We conducted a scoping review to identify the studies that described hepatitis C virus treatment delivery to people who inject drugs in the direct-acting antiviral treatment era. We analyzed the included studies against eight PCC dimensions: (1) access to care; (2) coordination and integration of care; (3) continuity and translation; (4) physical comfort; (5) information, education, and communication; (6) emotional support; (7) involvement of family and friends; and (8) respect for individual patient preferences, perceived needs, and values. Additionally, we assessed the use of patient-centered terminology and the recognition of PCC importance and its relevance to treatment outcomes.

RESULTS

None of the identified 36 studies addressed all PCC dimensions (highest seven, lowest two). Our findings revealed that PCC dimensions are prioritized differently and addressed using different approaches and strategies. Studies that used PCC terminology referred to personalized activities, which does not imply comprehensive PCC. About one-third of the studies acknowledged the importance of patient centeredness and two-thirds recognized its relevance to treatment outcomes.

CONCLUSIONS

Our findings suggest more engagement of people who inject drugs and comprehensive involvement of their families and friends in hepatitis C virus treatment journey, decisions, and outcomes. The recognition of PCC importance and its relevance to treatment outcomes in the analyzed studies emphasizes the need for more patient-centered hepatitis C virus treatment for people who inject drugs.

Effect of strategic purchasing of antiviral drugs and the clinical pathway for the treatment of Chronic Hepatitis C in Colombia (hepC-STRATEGY): study protocol for a quasi-experimental study

Objective

Describe a study protocol to establish the effect of DAA's strategic purchase and the clinical pathway in the clinical outcomes, general costs, and quality of healthcare of patients with CHC in Colombia.

Methods

A quasi-experimental study will be carried out to compare clinical outcomes (treatment effectiveness), healthcare quality (access to treatment, time to treatment, patient's satisfaction and barriers/facilitators perceived) and direct costs before/after the implementation of the mentioned strategies. Patients ≥18 years old initiating DAA treatment between January 2015 and December 2019 in an outpatient pharmacist-led center in Colombia will be included. In order to reduce selection bias, the propensity score method will be used. In the bivariate analysis, χ 2 tests and t student will be used to analyse the study outcomes. A regression analysis will be used to explain the association of multiple variables with access to treatment, time to treatment and effectiveness. Descriptive statistics will be used to analyse the patient's satisfaction and barriers/facilitators perceived.

Key findings

Implementing local government policies is necessary to improve access to medicines and decrease disease burden. The strategies adopted by the Colombian Ministry of Health to manage CHC needs to be evaluated. Therefore, studies are required to establish their effects on clinical outcomes, overall costs, and quality of care.

Conclusions

This study will provide evidence on the effect of Colombian strategies to address the problem of HCC. It will provide information to policymakers in low- and middle-income countries that could reduce disease burden.

Hepatitis C standards of care: A review of good practices since the advent of direct-acting antiviral therapy

Significant steps must be taken to reduce the global incidence and prevalence of hepatitis C virus (HCV) and mortality from HCV infection to achieve the WHO goal of eliminating viral hepatitis as a public health threat by 2030. Proper epidemiological surveillance of the full continuum of care is essential for monitoring progress and identifying gaps that need to be addressed. The tools required for elimination have largely been established, and the issue at hand is more how they should best be implemented in different settings around the world. Documenting good practices allows for knowledge exchange to prevent transmission and improve health outcomes for people with HCV. This review found 13 well documented HCV good practices that have become the standard of care or that should become the standard of care as soon as possible. In 2013, highly effective direct-acting antiviral therapy became available, which has cure rates of over 95%. Together with this new therapy, evidence-based good practices can help countries eliminate viral hepatitis C.

What do primary care staff know and do about blood borne virus testing and care for migrant patients? A national survey

BACKGROUND

UK migrants born in intermediate to high prevalence areas for blood borne viruses (BBV) including hepatitis B, hepatitis C and HIV are at increased risk of these infections. National guidance from Public Health England (PHE) and National Institute for Health and Care Excellence (NICE) recommends primary care test this population to increase diagnoses and treatment. We aimed to investigate primary care professionals' knowledge of entitlements, and perceptions of barriers, for migrants accessing healthcare, and their policies, and reported practices and influences on provision of BBV testing in migrants.

METHODS

A pre-piloted questionnaire was distributed between October 2017 and January 2018 to primary care professionals attending the Royal College of General Practitioners and Best Practice in Primary Care conferences, via a link in PHE Vaccine Updates and through professional networks. Survey results were analysed to give descriptive statistics, and responses by respondent characteristics: profession, region, practice size, and frequency of seeing migrant patients. Responses were considered on a per question basis with response rates for each question presented with the results.

RESULTS

Four hundred fourteen questionnaires were returned with responses varying by question, representing an estimated 5.7% of English GP practices overall. Only 14% of respondents' practices systematically identified migrant patients for testing. Universal opt-out testing was offered to newly registering migrant patients by 18% of respondents for hepatitis B, 17% for hepatitis C and 21% for HIV. Knowledge of healthcare entitlements varied; fewer clinical staff knew that general practice consultations were free to all migrants (76%) than for urgent care (88%). Performance payment structure (76%) had the greatest reported influence on testing, followed by PHE and Clinical Commissioning Group recommendations (73% each). Language and culture were perceived to be the biggest barriers to accessing care.

CONCLUSIONS

BBV testing for migrant patients in primary care is usually ad hoc, which is likely to lead to testing opportunities being missed. Knowledge of migrants' entitlements to healthcare varies and could affect access to care. Interventions to improve professional awareness and identification of migrant patients requiring BBV testing are needed to reduce the undiagnosed and untreated burden of BBVs in this vulnerable population.

Identifying the Hidden Population: Former Intravenous Drug Users Who Are No Longer in Contact with Services. "Ask a Friend"

People who, after a period of drug use, have changed their lifestyle and left substance use behind them are a hidden population within our communities. Lack of contact with drug services may mean that they are not tested for hepatitis C (HCV) infection through service-led initiatives and, therefore, may be exposed to the chronic morbidity and risk of death inherent with a legacy of HCV infection. This study utilized respondent-driven sampling (RDS) in a novel fashion to find those at historical risk of HCV. The social networks of people with a history of drug use were mapped, and individuals not currently in contact with services were invited to come forward for testing by members of their social network. The study used a reference group to inform study methodology and communication methods to reach out to this hidden population. One hundred and nine individuals received dry blood spot tests for HCV, 17.4% were antibody positive. Fifty one individuals met the inclusion criteria for this study. One hundred and twenty three invite-to-test coupons were issued; however, only one wave of recruitment consisting of one participant resulted from this method. Using RDS in historical social networks was not effective in this study and did not reach this hidden population and increase testing for HCV. This study is registered with clinicaltrials.gov (Ref NCT03697135).

Hepatitis C Virus Treatment: Simplifying the Simple and Optimizing the Difficult

The availability of safe, efficacious, oral direct-acting antivirals (DAAs) have ushered in a new era of hepatitis C treatment with potential to eliminate hepatitis C as a public health threat. To achieve population-level effectiveness of these oral DAAs, hepatitis C treatment by a wide range of providers in different settings will be essential to increase the number of persons treated. We provide a clinical review of hepatitis C treatment with a focus on practical tools for management of hepatitis C in majority of currently infected individuals who can be easily cured and optimization of treatment for those in whom treatment may not be as simple.

The Copenhagen test and treat hepatitis C in a mobile clinic study: a protocol for an intervention study to enhance the HCV cascade of care for people who inject drugs (T'N'T HepC)

INTRODUCTION

Injecting drug use is the primary driver of hepatitis C virus (HCV) infection in Europe. Despite the need for more engagement with care, people who inject drugs (PWID) are hard to reach with HCV testing and treatment. We initiated a study to evaluate the efficacy for testing and linkage to care among PWID consulting peer-based testing at a mobile clinic in Copenhagen, Denmark.

METHODS AND ANALYSIS

In this intervention study, we will recruit participants at a single community-based, peer-run mobile clinic. In a single visit, we will first offer participants a point-of-care HCV antibody test, and if they test positive, then they will receive an HCV RNA test. If they are HCV-RNA+, we will administer facilitated referrals to designated 'fast-track' clinics at a hospital or an addiction centre for treatment. The primary outcomes for this study are the number of tested and treated individuals. Secondary outcomes include individuals lost at each step in the care cascade.

ETHICS AND DISSEMINATION

The results of this study could provide a model for targeting PWID for HCV testing and treatment in Demark and other settings, which could help achieve WHO HCV elimination targets. The Health Research Ethics Committee of Denmark and the Danish Data Protection Agency confirmed (December 2018/January 2019) that this study did not require their approval. Study findings will be disseminated through peer-reviewed publications, conference presentations and social media.

Applying a diffusion of innovations framework to the scale-up of direct-acting antiviral therapies for hepatitis C virus infection: Identified challenges for widespread implementation

BACKGROUND AND AIMS

Interferon-free, direct-acting antivirals (DAAs) for hepatitis C virus (HCV) offer much promise to achieve World Health Organization targets by 2030. However, impediments at the practitioner and health-system level will continue to obstruct the scale-up of DAAs worldwide unless identified and acted upon. Applying a diffusion of innovations framework, the aim of this study was to identify structural factors impacting practitioner experiences of managing HCV treatment.

METHODS

In-depth, semi-structured, telephone interviews took place between September 2018 and April 2019 to investigate barriers and facilitators for engaging in HCV management and DAA therapy amongst general practitioners (GPs) who prescribe opioid agonist therapy and drug and alcohol specialists in Australia. Interviews were transcribed verbatim, de-identified, and coded, and data were analysed with iterative categorisation and thematic analysis using Everett Rogers's diffusion of innovation framework.

RESULTS

amongst 30 participants (12 GPs, 18 drug and alcohol specialists), several structural factors were reported to impede practitioner efforts to deliver optimal HCV care. Two primary themes were explored: contextual factors for the diffusion of DAA therapies, including attempts by participants to shift clinic culture and respond to siloed health structures, and adopter factors. Some participants chose to 'rock the boat' by circumventing clinic protocol and HCV guidelines to treat more clients, effectively shifting adopter categories to become greater advocates in HCV care. Also, while a role for GPs as the 'new adopters' in HCV management was discussed, many participants expressed uncertainty as to how much GPs should become involved in the diffusion of DAA therapies more widely.

CONCLUSIONS

Reducing the global burden of HCV infection will not be possible without the widespread delivery of HCV treatment amongst practitioners. Practitioners and health workers require leadership and resources from health authorities so that the individual and population-level benefits of DAA therapy are realised.

HEPCARE EUROPE- A case study of a service innovation project aiming at improving the elimination of HCV in vulnerable populations in four European cities

OBJECTIVES

Hepatitis C Virus (HCV) is a significant cause of chronic liver disease. Among at-risk populations, access to diagnosis and treatment is challenging. We describe an integrated model of care, Hepcare Europe, developed to address this challenge.

METHODS

Using a case-study approach, we describe the cascade of care outcomes at all sites. Cost analyses estimated the cost per person screened and linked to care.

RESULTS

A total of 2608 participants were recruited across 218 clinical sites. HCV antibody test results were obtained for 2568(98•5%); 1074(41•8%) were antibody-positive, 687(60•5%) tested positive for HCV-RNA, 650(60•5%) were linked to care, and 319(43•5%) started treatment. 196(61•4%) of treatment initiates achieved a Sustained Viral Response (SVR) at dataset closure, 108(33•9%) were still on treatment, eight (2•7%) defaulted from treatment, and seven (2•6%) had virologic failure or died. The cost per person screened varied from €194 to €635, while the cost per person linked to care varied from €364 to €2035.

CONCLUSIONS

Hepcare enhanced access to HCV treatment and cure, and costs were affordable in all settings, offering a framework for scale-up and reproducibility.

Reaching mEthadone users Attending Community pHarmacies with HCV: an international cluster randomised controlled trial protocol (REACH HCV)

INTRODUCTION

Hepatitis C virus (HCV) is a global public health threat, and novel models of care are required to treat those currently or previously at highest risk of infection, particularly persons who inject drugs (PWID; ever injected), as conventional healthcare models do not have the reach to deliver cure of HCV to disadvantaged, disproportionately affected communities. In Western Europe and Australasia, it is estimated that HCV affects between 0.4% and 1.0% of the regions' populations, accordingly, it affects between 0.4% and 0.7% of the populations of countries in this study (Scotland, Wales and Australia). Reaching mEthadone users Attending Community pHarmacies with HCV (REACH HCV) will evaluate community pharmacy-based diagnostic outreach and HCV treatment against conventional HCV testing and treatment pathways for clients receiving opioid substitution therapy (OST) in community pharmacies.

METHODS AND ANALYSIS

REACH HCV is an international multicentre cluster randomised controlled trial with sites in Scotland, Wales and Australia. The sites are community pharmacies which are randomised equally to one of two pathways: the pharmacy intervention pathway or the education-only (control) pathway. Participants are recruited from OST clients in these pharmacies.In the pharmacy intervention pathway, participants receive a rapid point-of-care HCV PCR test in their pharmacy by a study outreach nurse. If positive, direct-acting antivirals (DAAs) are delivered to participants via their pharmacist in line with their OST schedule.In the education-only pathway, pharmacists counsel OST clients on HCV and refer them to the nearest nurse-led clinic or general practitioner offering HCV testing according to standard care protocols. If positive, DAAs are delivered as in the intervention pathway.The primary endpoint for both pathways is sustained viral response at 12 weeks post-treatment . Secondary outcomes are: cost-efficacy by pathway; participants tested by pathway; adherence to therapy by pathway and impact of blood test results on treatment decisions.A statistical analysis plan will be finalised prior to data lock. Analysis will be by intention to treat (ITT) to show superiority. Modified ITT analysis will also be undertaken to explore the steps in the pathways.

ETHICS AND DISSEMINATION

The trial received ethical favourable opinion from the East of Scotland Research Ethics Committee 2 (19/ES/0025) for UK sites and approval from the Alfred Hospital Ethics Committee (148/19) for Australian sites and complies with principles of Good Clinical Practice. Final results will be presented in peer-reviewed journals and at relevant conferences.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry NCT03935906.

PROTOCOL VERSION

V.4.0-19 March 2020.

Frequent loss to follow-up after diagnosis of hepatitis C virus infection: A barrier towards the elimination of hepatitis C virus

BACKGROUND

Previous studies on hepatitis C cascade of care have been mainly focused on diagnosis and treatment rate, while less attention has been given to patients lost to follow-up (LTFU) after diagnosis. Analyses of this latter issue on population level are missing.

AIMS

In this nationwide study of people with HCV, we aimed to estimate the proportion LTFU after HCV diagnosis, characterize them, and analyze their other healthcare contacts.

METHODS

Patients diagnosed with chronic HCV in the Swedish National Patient Register during 2001-2011 and still alive December 31, 2013, were included. The number of cured patients without need of follow-up was estimated. Visits to HCV specialist care during 2012-2013 were analysed. For those LTFU, other specialist care contacts were studied.

RESULTS

In total 29 217 patients were included, with 24 733 with need of HCV care. 61% (n = 15 007) of them were LTFU from HCV care in 2012-2013 and 58% did not attend HCV care during the second year after HCV diagnosis. The departments of surgery/orthopaedic or psychiatry/dependency were the most common other non-primary healthcare contacts. Predictors for LTFU were young age, male sex, low education, presence of psychiatric/dependency diagnosis, unmarried and longer duration since diagnosis of HCV.

CONCLUSIONS

This study showed that almost two-thirds of patients were LTFU after HCV diagnosis, with frequent occurrence early after diagnosis. Efforts to link patients back to HCV care, in combination with early and easy access to HCV treatment and harm reduction, are necessary to reach the HCV elimination goal.

Clinical effectiveness of pharmacist-led versus conventionally delivered antiviral treatment for hepatitis C virus in patients receiving opioid substitution therapy: a pragmatic, cluster-randomised trial

BACKGROUND

Highly effective direct-acting antiviral drugs provide the opportunity to eliminate hepatitis C virus (HCV) infection, but established pathways can be ineffective. We aimed to examine whether a community pharmacy care pathway increased treatment uptake, treatment completion, and cure rates for people receiving opioid substitution therapy, compared with conventional care.

METHODS

This cluster-randomised trial was done in Scottish community pharmacies. Before participants were recruited, pharmacies were randomly assigned (1:1) to refer patients with evidence of HCV antibodies to conventional care or offered them care in the pharmacy (pharmacist-led care). Pharmacies were stratified by location. All pharmacies were trained to offer dried blood spot testing. All eligible participants had received opioid substitution therapy for approximately 3 months, and those eligible to receive treatment in the pharmacist-led care pathway were HCV PCR positive, were infected with HCV genotype 1 or 3, and were willing to have a pharmacist supervise their antiviral drug administration. Neither pharmacists nor patients were masked to treatment allocation. In both groups, assessment blood samples were taken, infection with HCV was confirmed, and daily oral ledipasvir-sofosbuvir (90 mg ledipasivir plus 400 mg sofosbuvir) for 8 weeks for genotype 1 or daily oral sofosbuvir (400 mg) plus oral daclatasvir (60 mg) for 12 weeks for genotype 3 was prescribed by a nurse (conventional care group) or pharmacist (pharmacist-led care group). In the conventional care group, the patient received care at a treatment centre. Once prescribed, medication in both groups was delivered as daily modified directly observed therapy alongside opioid substitution therapy in the participants' pharmacy where treatment was observed on 6 days per week. The primary outcome was the number of patients with sustained virological response 12 weeks after completion of treatment (SVR12) as a proportion of the number of people receiving opioid substitution therapy at participating pharmacies. Participants were monitored at each visit for nausea and fatigue; other adverse events were recorded as free text. Secondary outcomes compared key points on treatment pathway between the two groups. These key points were the proportion of patients having dry blood spot testing, the proportion of patients initiating HCV treatment, the proportion of patients completing the 8 or 12 week HCV course of treatment, and the proportion of patients with sustained virological response at 12 months. This study is registered with ClinicalTrials.gov, NCT02706223.

FINDINGS

56 pharmacies were randomly assigned (28 to each group; one pharmacy withdrew from the conventional care group). The 55 participating pharmacies included 2718 patients receiving opioid substitution therapy (1365 in the pharmacist-led care group and 1353 in the conventional care group). More patients met the primary endpoint of SVR12 in the pharmacist-led care group (98 [7%] of 1365) than in the conventional care group (43 [3%] of 1353; odds ratio 2·375, 95% CI 1·555-3·628, p<0·0001). More users of opioid substitution therapy in the pharmacist-led care group versus the conventional care group agreed to dry blood spot testing (245 [18%] of 1365 vs 145 [11%] of 1353, 2·292, 0·968-5·427, p=0·059); initiated treatment (112 [8%] of 1365 vs 61 [4%] of 1353, 1·889, 1·276-2·789, p=0·0015) and completed treatment (108 [8%] of 1365 vs 58 [4%] of 1353, 1·928, 1·321-2·813, p=0·0007). The data for sustained virological response at 12 months are not reported in this study: patients remain in follow-up for this outcome. No serious adverse events were recorded.

INTERPRETATION

Using pharmacists to deliver an HCV care pathway made testing and treatment more accessible for patients, improved engagement, and maintained high treatment success rates. The use of this pathway could be a key part of an integrated and effective approach to HCV elimination at a community level.

FUNDING

Partnership between the Scottish Government, Gilead Sciences, and Bristol-Myers Squib.

High prevalence of hepatitis C virus infection and low level of awareness among people who recently started injecting drugs in a cross-sectional study in Germany, 2011-2014: missed opportunities for hepatitis C testing

BACKGROUND

In Germany, risk of hepatitis C virus (HCV) infection is highest among people who inject drugs (PWID). New injectors (NI) are particularly vulnerable for HCV-acquisition, but little is known about health seeking behaviour and opportunities for intervention in this group. We describe characteristics, HCV prevalence, estimated HCV incidence and awareness of HCV-status among NIs and missed opportunities for hepatitis C testing.

METHODS

People who had injected drugs in the last 12 months were recruited into a cross-sectional serobehavioural study using respondent-driven sampling in 8 German cities, 2011-2014. Data on sociodemographic characteristics, previous HCV testing and access to care were collected through questionnaire-based interviews. Capillary blood was tested for HCV. People injecting drugs < 5 years were considered NI.

RESULTS

Of 2059 participants with available information on duration of injection drug use, 232 (11% were NI. Estimated HCV incidence among NI was 19.6 infections/100 person years at risk (95% CI 16-24). Thirty-six percent of NI were HCV-positive (thereof 76% with detectable RNA) and 41% of those HCV-positive were unaware of their HCV-status. Overall, 27% of NI reported never having been HCV-tested. Of NI with available information, more than 80% had attended low-threshold drug services in the last 30 days, 24% were released from prison in the last 12 months and medical care was most commonly accessed in hospitals, opioid substitution therapy (OST)-practices, practices without OST and prison hospitals.

CONCLUSION

We found high HCV-positivity and low HCV-status awareness among NI, often with missed opportunities for HCV-testing. To increase early diagnosis and facilitate treatment, HCV-testing should be offered in all facilities, where NI can be reached, especially low-threshold drug services and addiction therapy, but also prisons, hospitals and practices without OST.

The testing of people with any risk factor for hepatitis C in community pharmacies is cost-effective

New antiviral drugs with high efficacy mean the hepatitis C virus (HCV) can now be eliminated. To achieve this, it is necessary to identify undiagnosed cases of HCV. However, the costs of testing should be considered when judging the overall cost-effectiveness of treatment. This study describes the cost-effectiveness of a community pharmacy testing service in a population of people at risk of HCV living on the Isle of Wight (United Kingdom). Dry blood spot testing was conducted in anyone with a known risk factor for HCV in 20 community pharmacies. The outcomes and costs were entered into a Markov model. Cost and health utilities from the model were used to calculate an incremental cost-effectiveness ratio (ICER). In 24 months, 186 tests were conducted, 13 were positive for HCV RNA and six of these (46%) received treatment during the follow-up period. All achieved a sustained virological response at 3 months. The overall cost of the testing and treatment intervention was £242 183, and the ICER for the service was £3689 per quality-adjusted life year (QALY) gained. If screening had been restricted to just people with a history of injecting drug use (PWID) the ICER would have been £4865 per QALY gained. The service was effective at identifying people with HCV infection, and despite the additional cost of targeted testing, its cost-effectiveness was below the commonly accepted thresholds. In this setting, restricting targeted testing to PWID would not improve the cost-effectiveness.

Hepatitis B and C testing strategies in healthcare and community settings in the EU/EEA: A systematic review

An estimated 9 million individuals are chronically infected with hepatitis B virus (HBV) and hepatitis C virus (HCV) across the European Union/European Economic Area (EU/EEA), many of which are yet to be diagnosed. We performed a systematic review to identify interventions effective at improving testing offer and uptake in the EU/EEA. Original research articles published between 1 January 2008 and 1 September 2017 were retrieved from PubMed and EMBASE. Search strings combined terms for HBV/HCV, intervention, testing and geographic terms (EU/EEA). Out of 8331 records retrieved, 93 studies were selected. Included studies reported on testing initiatives in primary health care (9), hospital (12), other healthcare settings (31) and community settings (41). Testing initiatives targeted population groups such as migrants, drug users, prisoners, pregnant women and the general population. Testing targeted to populations at higher risk yielded high coverage rates in many settings. Implementation of novel testing approaches, including dried blood spot (DBS) testing, was associated with increased coverage in several settings including drug services, pharmacies and STI clinics. Community-based testing services were effective in reaching populations at higher risk for infection, vulnerable and hard-to-reach populations. In conclusion, our review identified several successful testing approaches implemented in healthcare and community settings, including testing approaches targeting groups at higher risk, community-based testing services and DBS testing. Combining a diverse set of testing opportunities within national testing strategies may lead to higher impact both in terms of testing coverage and in terms of reduction, on the undiagnosed fraction.

We know DAAs work, so now what? Simplifying models of care to enhance the hepatitis C cascade

Globally, some 71 million people are chronically infected with hepatitis C virus (HCV). Marginalized populations, particularly people who inject drugs (PWID), have low testing, linkage to care and treatment rates for HCV. Several models of care (MoCs) and service delivery interventions have the potential to improve outcomes across the HCV cascade of care, but much of the relevant research was carried out when interferon-based treatment was the standard of care. Often it was not practical to scale-up these earlier models and interventions because the clinical care needs of patients taking interferon-based regimens imposed too much of a financial and human resource burden on health systems. Despite the adoption of highly effective, all-oral direct-acting antiviral (DAA) therapies in recent years, approaches to HCV testing and treatment have evolved slowly and often remain rooted in earlier paradigms. The effectiveness of DAAs allows for simpler approaches and has encouraged countries where the drugs are widely available to set their sights on the ambitious World Health Organization (WHO) HCV elimination targets. Since a large proportion of chronically HCV-infected people are not currently accessing treatment, there is an urgent need to identify and implement existing simplified MoCs that speak to specific populations' needs. This article aims to: (i) review the evidence on MoCs for HCV; and (ii) distil the findings into recommendations for how stakeholders can simplify the path taken by chronically HCV-infected individuals from testing to cure and subsequent care and monitoring.

A systematic review and meta-analysis of community and primary-care-based hepatitis C testing and treatment services that employ direct acting antiviral drug treatments

Background

Direct Acting Antiviral (DAAs) drugs have a much lower burden of treatment and monitoring requirements than regimens containing interferon and ribavirin, and a much higher efficacy in treating hepatitis C (HCV). These characteristics mean that initiating treatment and obtaining a virological cure (Sustained Viral response, SVR) on completion of treatment, in non-specialist environments should be feasible. We investigated the English-language literature evaluating community and primary care-based pathways using DAAs to treat HCV infection.

Methods

Databases (Cinahl; Embase; Medline; PsycINFO; PubMed) were searched for studies of treatment with DAAs in non-specialist settings to achieve SVR. Relevant studies were identified including those containing a comparison between a community and specialist services where available. A narrative synthesis and linked meta-analysis were performed on suitable studies with a strength of evidence assessment (GRADE).

Results

Seventeen studies fulfilled the inclusion criteria: five from Australia; two from Canada; two from UK and eight from USA. Seven studies demonstrated use of DAAs in primary care environments; four studies evaluated integrated systems linking specialists with primary care providers; three studies evaluated services in locations providing care to people who inject drugs; two studies evaluated delivery in pharmacies; and one evaluated delivery through telemedicine. Sixteen studies recorded treatment uptake. Patient numbers varied from around 60 participants with pathway studies to several thousand in two large database studies. Most studies recruited less than 500 patients. Five studies reported reduced SVR rates from an intention-to-treat analysis perspective because of loss to follow-up before the final confirmatory SVR test. GRADE assessments were made for uptake of HCV treatment (medium); completion of HCV treatment (low) and achievement of SVR at 12 weeks (medium).

Conclusion

Services sited in community settings are feasible and can deliver increased uptake of treatment. Such clinics are able to demonstrate similar SVR rates to published studies and real-world clinics in secondary care. Stronger study designs are needed to confirm the precision of effect size seen in current studies. Prospero: CRD42017069873.

Research gaps in viral hepatitis

Introduction

The World Health Organization has aimed for global elimination of both hepatitis B virus (HBV) and hepatitis C virus (HCV) by 2030. Treatments available to cure HCV and control HBV, as well as vaccination to prevent HBV infection, have certainly allowed for such bold goals, yet the final steps to usher in elimination require further evidence.

Discussion

We broadly discuss the needs for three major public health approaches. First, an effective vaccine exists for HBV and mass‐vaccination campaigns have resulted in decreases in hepatitis B surface antigen seroprevalence and overall rates of liver‐related morality. Still, HBV vaccination coverage is poor in certain regions of the world, while the reasons for such low coverage require further study. A prophylactic vaccine is probably needed to eliminate HCV, but is not being readily developed. Second, identifying HBV/HCV infected individuals remains a priority to increase awareness of disease status, particularly for key populations. Research evaluating large‐scale implementation of novel, rapid and mobile point‐of‐care tests would be helpful to determine whether increased awareness is achievable in these settings. Third, antiviral therapy allows for strong HBV suppression and HCV cure, while its access depends on financial factors among many others. Although there is strong evidence to treat key populations and specific groups with progressed disease, as stated in current guidelines, the advantages of extending treatment eligibility to decrease onward spread of HBV/HCV infection and prevent further burden of disease are lacking “real world” evidence. Novel anti‐HBV treatments are being developed to target intrahepatocellular HBV replication, but are still in the early phases of clinical development. Each of the strategies mentioned above has specific implications for HIV infection.

Conclusions

There are certainly effective tools to combat the spread of viral hepatitis and treat infected individuals – yet how they are able to reach key populations, and the infrastructure required to do so, continue to represent the largest research gap when evaluating the progress towards elimination. Continuously adapted and informed research is required to establish the priorities in achieving elimination goals.

Treatment access is only the first step to hepatitis C elimination: experience of universal anti-viral treatment access in Australia

BACKGROUND

Global targets to eliminate hepatitis C (HCV) might be met by sustained treatment uptake.

AIM

To describe factors facilitating HCV treatment uptake and potential challenges to sustaining treatment levels after universal access to direct-acting anti-virals (DAA) across Australia.

METHODS

We analysed national Pharmaceutical Benefits Scheme data to determine the number of DAA prescriptions commenced before and after universal access from March 2016 to June 2017. We inferred facilitators and barriers to treatment uptake, and challenges that will prevent local and global jurisdictions reaching elimination targets.

RESULTS

In 2016, 32 877 individuals (14% of people living with HCV in Australia) commenced HCV DAA treatment, and 34 952 (15%) individuals commenced treatment in the first year of universal access. Treatment uptake peaked at 13 109 DAA commencements per quarter immediately after universal access, but more than halved (to 5320 in 2017 Q2) within 12 months. General practitioners have written 24% of all prescriptions but with a significantly increased proportion over time (9% in 2016 Q1 to 37% in 2017 Q2). In contrast, hepatology or infectious diseases specialists have written a declining share from 74% to 38% during the same period. General practitioners provided a greater proportion (47%) of care in regional/remote areas than major cities.

CONCLUSIONS

Broad treatment access led to rapid initial increases in treatment uptake, but this uptake has not been sustained. Our results suggest achieving global elimination targets requires more than treatment availability: people with HCV need easy access to testing and linkage to care in community settings employing a diverse prescriber base.

Directly observed hepatitis C treatment with opioid substitution therapy in community pharmacies: A qualitative study

BACKGROUND

The hepatitis C virus (HCV) will only be eliminated through successful engagement with people who inject drugs (PWID), however some of this population experience socioeconomic and individual issues that can lead to poor HCV treatment adherence. A key sub-group of (PWID) are those who receive opioid substitution therapy (OST). In Australia, OST is most often delivered under direct supervision by a community pharmacist every day or multiple times a week. This regular interaction could be an ideal opportunity to enhance direct-acting antiviral (DAA) treatment adherence under directly observed therapy (DOT) by the pharmacist.

AIM

The aim of this study was to explore the perspectives of OST patients with a lived experience of HCV to understand whether or not dispensing DAAs in the same way as, or simultaneously with OST would benefit HCV treatment.

METHODS

Data collection occurred from June to August 2017. Semi-structured interviews were conducted with a sample of PWID living with HCV and on OST programs (n = 12) in Melbourne, Australia. Interviews were voice recorded and transcribed in verbatim. Interpretive phenomenology guided analysis of the data.

RESULTS

Themes reported by participants that provide insight into the suitability of DOT of DAAs include: Adherence and non-adherence to DAA treatment; Mixed views towards DOT of DAAs; Experiences and perceptions of OST providers; and Perceived stigma in the pharmacy.

CONCLUSIONS

Community pharmacies offering OST may be an effective place for DOT of HCV treatment, but is likely only to benefit people who face significant challenges to adherence. We suggest that a positive pharmacist-patient relationship, high OST adherence, and commitment to reducing stigma in the pharmacy would be necessary for the intervention to be effective. Further research is needed to evaluate the expanded-role of community pharmacies in improving DAA adherence and eliminating HCV.

Clinical effectiveness of pharmacy-led versus conventionally delivered antiviral treatment for hepatitis C in patients receiving opioid substitution therapy: a study protocol for a pragmatic cluster randomised trial

INTRODUCTION

Hepatitis C virus (HCV) infection affects 0.7% of the general population, and up to 40% of people prescribed opioid substitution therapy (OST) in Scotland. In conventional care, less than 10% of OST users are tested for HCV and less than 25% of these initiate treatment. Community pharmacists see this group frequently to provide OST supervision. This study examines whether a pharmacist-led 'test & treat' pathway increases cure rates for HCV.

METHODS AND ANALYSIS

This protocol describes a cluster-randomised trial where 60 community pharmacies provide either conventional or pharmacy-led care. All pharmacies offer dried blood spot testing (DBST) for HCV. Participants have attended the pharmacy for OST for 3 months; are positive for HCV genotype 1 or 3; are not co-infected with HIV and/or hepatitis B; have no decompensated liver disease; are not pregnant. For conventional care, pharmacists refer HCV-positive participants to a local centre for assessment. In the pharmacy-led arm, pharmacists assess participants themselves in the pharmacy. Drug prescribing is by nurse prescribers (conventional arm) or pharmacist prescribers (pharmacy-led arm). Treatment in both arms is delivered as daily modified directly observed therapy in a pharmacy. Primary trial outcome is number of sustained virological responses at 12 weeks after treatment completion. Secondary trial outcomes are number of tests taken; treatment uptake; completion; adherence; re-infection. An economic evaluation will assess potential cost-effectiveness. Qualitative research interviews with clients and health professionals assess acceptability of a pharmacist-led pathway.

ETHICS AND DISSEMINATION

This protocol has been ethically approved by the East of Scotland Research Ethics Committee 2 (15/ES/0086) and complies with the Declaration of Helsinki and principles of Good Clinical Practice. Caldicott guardian approval was given on 16 December 2016 to allow NHS Tayside to pass information to the cluster community pharmacies about the HCV test status of patients that they are seeing to provide OST supervision. NHS R&D approvals have been obtained from each health board taking part in the study. Informed consent is obtained before study enrolment and only anonymised data are stored in a secured database, enabling an audit trail. Results will be submitted to international peer-reviewed journals and presented at international conferences.

TRIAL REGISTRATION NUMBER

NCT02706223; Pre-results.

Caring and curing: Considering the effects of hepatitis C pharmaceuticalisation in relation to non-clinical treatment outcomes

BACKGROUND

The development of simplified and effective hepatitis C (HCV) pharmaceuticals enables treatment scale up among the most marginalised. This potentiates a promise of viral elimination at the population level but also individual level clinical and non-clinical benefits. Reports of transformative non-clinical outcomes, such as changes in self-worth and substance use, are primarily associated with arduous interferon-based treatments that necessitate intensive care relationships. We consider the implications of simplified treatment provision in the era of direct acting antivirals (DAAs) for the realisation of non-clinical benefits.

METHODS

We draw on qualitative data from ethnographic observations and longitudinal interviews with people receiving (n = 22) and providing (n = 10) HCV treatment in London during a transition in HCV biomedicine. First generation DAAs in conjunction with interferon were standard of care for most of this time, with the promise of simplified treatment provision on the horizon.

FINDINGS

Patient accounts of care accentuate the transformative value of interferon-based HCV treatment derived through non-clinical benefits linked to identity and lifestyle change. Such care is constituted as extending beyond the virus and its biomedical effects, with nurse specialists positioned as vital to this care being realised. Provider accounts emphasise the increased pharmaceuticalisation of HCV treatment; whereby care shifts from the facilitation of therapeutic relationships to pharmaceutical access.

CONCLUSION

HCV care in the interferon-era affords identity transformations for those receiving and providing treatment. Biomedical promise linked to the increasing pharmaceuticalisation of HCV treatment has disruptive potential, shifting how care is practised and potentially the realisation of non-clinical treatment outcomes.

Integrating hepatitis C and addiction care for people who inject drugs in the era of direct-acting antiviral therapy

As new, more tolerable and effective hepatitis C virus (HCV) treatments are available, there is a global need to consider how to maximize treatment access for groups who are most affected by HCV. A substantial number of people who inject drugs (PWID) are living with HCV, yet only a minority have received treatment. HCV treatment programs that are integrated into community-based addiction care may be a successful way to overcome barriers and increase access and uptake of HCV treatment for this population. Examples of successful HCV and addiction care integration in the community have been documented. However, potential challenges to integration exist and include changing healthcare provider roles, lack of stimulant use research and restrictive drug policies. Successful engagement of PWID in HCV care is critical step towards the elimination of HCV infection. Further research and efforts are needed in order to reach this goal.

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

BACKGROUND

Little 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.

METHODS

Between 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.

RESULTS

All 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).

CONCLUSION

Residual 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.

Hepcare Europe - bridging the gap in the treatment of hepatitis C: study protocol

BACKGROUND

Hepatitis C (HCV) infection is highly prevalent among people who inject drugs (PWID). Many PWID are unaware of their infection and few have received HCV treatment. Recent developments in treatment offer cure rates >90%. However, the potential of these treatments will only be realised if HCV identification among PWID with linkage to treatment is optimised. This paper describes the Hepcare Europe project, a collaboration between five institutions across four member states (Ireland, UK, Spain, Romania), to develop, implement and evaluate interventions to improve the identification, evaluation and treatment of HCV among PWID.

METHODS

A service innovation project and a mixed-methods, pre-post intervention study, Hepcare will design and deliver interventions in Dublin, London, Seville and Bucharest to enhance PWID engagement and retention in the cascade of HCV care.

RESULTS

The feasibility, acceptability, potential efficacy and cost-effectiveness of these interventions to improve care processes and outcomes among PWID will be evaluated.

CONCLUSION

Hepcare has the potential to make an important impact on patient care for marginalised populations who might otherwise go undiagnosed and untreated. Lessons learned from the study can be incorporated into national and European guidelines and strategies for HCV.