Lack of health insurance limits the benefits of hepatitis C virus screening: insights from the National Health and Nutrition Examination Hepatitis C follow-up study

Implementation of a mobile health clinic framework for Hepatitis C virus screening and treatment: a descriptive study

Background

Although treatment for Hepatitis C Virus (HCV) is effective, individuals face access barriers. The utility of mobile health clinics (MHC), effective mechanisms for providing healthcare to underserved populations, is understudied for HCV-related interventions. We aimed to describe implementation of, and factors associated with, screening and treatment via MHCs.

Methods

Clemson Rural Health implemented a novel MHC program to reach and treat populations at-risk for HCV with a focus on care for uninsured individuals. We examined HCV screening and treatment initiation/completion indicators between May 2021 and January 2023.

Findings

Among 607 individuals screened across 31 locations, 94 (15.5%) tested positive via antibody and viral load testing. Treatment initiation and completion rates were 49.6% and 86.0%, respectively. Among those screened, the majority were male (57.5%), White (61.3%; Black/Hispanic: 28.2%/7.7%), and without personal vehicle as primary transportation mode (54.4%). Injection drug use (IDU) was 27.2% and uninsured rate was 42.8%. Compared to HCV-negative, those infected included more individuals aged 30-44 (52.1% vs. 36.4%, p = 0.023), male (70.2% vs. 55.2%, p = 0.009), White (78.5% vs. 60.2%, p < 0.0001), without personal vehicle (58.5% vs. 43.5%, p = 0.028), IDU (83.7% vs. 21.0%, p < 0.0001), and uninsured (61.2% vs. 48.8%, p = 0.050). Uninsured rates were higher among those initiating compared to not initiating treatment (74.5% vs. 45.3%, p = 0.004).

Interpretation

The MHC framework successfully reaching its target population: at-risk individuals with access barriers to healthcare. The high HCV screening and treatment initiation/completion rates demonstrate the utility of MHCs as effective and acceptable intervention settings among historically difficult-to-treat populations.

Funding

Gilead Sciences, Inc., and SC Center for Rural and Primary Healthcare.

Hepatitis C care cascade in a large academic healthcare system, 2012 to 2018

To determine the hepatitis C virus (HCV) care cascade among persons who were born during 1945 to 1965 and received outpatient care on or after January 2014 at a large academic healthcare system. Deidentified electronic health record data in an existing research database were analyzed for this study. Laboratory test results for HCV antibody and HCV ribonucleic acid (RNA) indicated seropositivity and confirmatory testing. HCV genotyping was used as a proxy for linkage to care. A direct-acting antiviral (DAA) prescription indicated treatment initiation, an undetectable HCV RNA at least 20 weeks after initiation of antiviral treatment indicated a sustained virologic response. Of the 121,807 patients in the 1945 to 1965 birth cohort who received outpatient care between January 1, 2014 and June 30, 2017, 3399 (3%) patients were screened for HCV; 540 (16%) were seropositive. Among the seropositive, 442 (82%) had detectable HCV RNA, 68 (13%) had undetectable HCV RNA, and 30 (6%) lacked HCV RNA testing. Of the 442 viremic patients, 237 (54%) were linked to care, 65 (15%) initiated DAA treatment, and 32 (7%) achieved sustained virologic response. While only 3% were screened for HCV, the seroprevalence was high in the screened sample. Despite the established safety and efficacy of DAAs, only 15% initiated treatment during the study period. To achieve HCV elimination, improved HCV screening and linkage to HCV care and DAA treatment are needed.

Insurance Status, Comorbidity Diagnosis, and Hepatitis C Diagnosis Among Antibody-Positive Patients: A Retrospective Cohort Study

Background

In California, laboratories report all hepatitis C (HCV)-positive antibody tests to the state; however, that does not accurately reflect active infection among those patients without a viral load test confirming a patient's HCV diagnosis. These public health surveillance disease incident records do not include patient details such as comorbidities or insurance status found in electronic medical records (EMRs).

Objective

This research seeks to understand how insurance type, insurance status, patient comorbidities, and other sociodemographic factors related to HCV diagnosis as defined by a positive viral load test among HCV antibody-positive persons from January 1, 2010 to March 1, 2020.

Methods

HCV antibody-positive individuals reported to the California Reportable Disease Information Exchange (CalREDIE), with a medical record number associated with the University of California, Irvine Medical Center, and an unrestricted EMR (n = 521) were extracted using manual chart review.

Main Outcomes and measures

HCV diagnosis as indicated in a patient's EMR in the problem list or disease registry.

Results

Less than a quarter of patients in this sample were diagnosed as having HCV in their EMR, with 0.4% of those diagnosed (5/116) patients with indicated HCV treatment in the medication field of their charts. After adjusting for multiple comorbidities, a multinomial logistic regression found that the relative risk ratios (RRRs) of HCV diagnosis found that patients with insurance were more likely to be diagnosed compared to those without insurance. When comparing uninsured patients to those with government insurance at the P < .05 level (RRR = 10.61 (95% confidence interval (CI): 4.14-27.22)) and those uninsured to private insurance (RRR = 6.79 (95% CI: 2.31-19.92).

Conclusions

These low frequencies of HCV diagnosis among the study population, particularly among the uninsured, indicate a need for increased viral load testing and linkage to care. Reflex testing on existing samples and improving HCV screening and diagnosis can help increase linkage to care and work towards eliminating this disease.

Shelter-Based Integrated Model Is Effective in Scaling Up Hepatitis C Testing and Treatment in Persons Experiencing Homelessness

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.

Predictors of progression through the cascade of care to a cure for hepatitis C patients using decision trees and random forests

BACKGROUND

This study uses machine learning techniques to identify sociodemographic and clinical predictors of progression through the hepatitis C (HCV) cascade of care for patients in the 1945-1965 birth cohort in the Southern United States.

METHODS

We compared sociodemographic and clinical variables between groups of patients for three care outcomes: linkage to care, initiation of antiviral treatment, and virologic cure. A decision tree model and random forest model were built for each outcome.

RESULTS

Patients were primarily male, African American/Black or Caucasian/White, non-Hispanic or Latino, and insured. The average age at first HCV screening was 60 years old, and common medical diagnoses included chronic kidney disease, fibrosis and/or cirrhosis, transplanted liver, diabetes mellitus, and liver cell carcinoma. Variables used in predicting linkage to care included age at first HCV screening, insurance at first HCV screening, race, fibrosis and/or cirrhosis, other liver disease, ascites, and transplanted liver. Variables used in predicting initiation of antiviral treatment included insurance at first HCV screening, gender, other liver cancer, steatosis, and liver cell carcinoma. Variables used in predicting virologic cure included insurance at first HCV screening, transplanted liver, and ethnicity.

CONCLUSION

These patients have a high hepatic health burden, likely reflecting complications of untreated HCV and highlighting the urgency to cure HCV in this birth cohort. We found differences in HCV care outcomes based on sociodemographic and clinical variables. More work is needed to understand the mechanisms of these differences in care outcomes and to improve HCV care.

Measuring Hazards of Undetectable Viral Load among Hepatitis C Antibody Positive Residents of a Large Southern California County

Background Hepatitis C virus (HCV) infection is the most common bloodborne infection in the U.S. However, only a small proportion of persons are treated and cured. Previous research has not characterized sociodemographic characteristics of who receives treatment. We examined predictors of undetectable for HCV in Orange County, the sixth largest county in the United States, where HCV is the most commonly reported infection.

METHODS

From 2014 to 2020, we acquired public health surveillance data from 91,165 HCV antibody-positive care encounters from the California Reportable Disease Information Exchange (CalREDIE). We used a time-to-event proportional hazards framework to estimate individual and area-level correlates of time-to-HCV undetectable viral load among HCV + individuals.

RESULTS

Older adults (>65 years) showed an increased hazard of undetectable viral load relative to younger adults (HR = 2.00). In addition, residents of census tracts with greater enrollment in health insurance showed a greater likelihood of undetectable viral load (HR = 1.36). The moderating effect of higher tract median household income and higher tract levels of health insurance were more likely to have undetectable viral load and was statistically significant.

CONCLUSION

In a large urban county, HCV antibody-positive older adults appear much more likely to show undetectable viral load compared to younger adults. Residents in areas with higher quartiles of health insurance enrollment have an increased likelihood of undetectable viral load. The extent to which constraints impede HCV care requires further investigation, including follow-up studies on health insurance type to test the relationship of health insurance type to undetectable viral load.

Clients' perceptions of barriers and facilitators to implementing hepatitis C virus care in homeless shelters

Background

Hepatitis C virus (HCV) is highly prevalent among homeless persons, yet barriers continue to impede HCV testing and treatment in this population. We studied the experiences of homeless individuals related to accessing HCV care to inform the design of a shelter-based HCV prevention and treatment program.

Methods

Homeless shelter clients (10 women and 10 men) of a large shelter in San Francisco participated in gender segregated focus groups. Focus groups followed a semi-structured interview format, which assessed individual, program/system, and societal-level barriers and facilitators to universal HCV testing and linkage to HCV care. Focus group interviews were transcribed, coded, and analyzed using thematic analysis.

Results

We identified key barriers to HCV testing and treatment at the individual level (limited knowledge and misconceptions about HCV infection, mistrust of health care providers, co-morbid conditions of substance use, psychiatric and chronic medical conditions), system level (limited advocacy for HCV services by shelter staff), and social level (stigma of homelessness). Individual, system, and social facilitators to HCV care described by participants included internal motivation, financial incentives, prior experiences with rapid HCV testing, and availability of affordable direct acting antiviral (DAA) treatment, respectively.

Conclusions

Interrelated individual- and social-level factors were the predominant barriers affecting homeless persons’ decisions to engage in HCV prevention and treatment. Integrated models of care for homeless persons at risk for or living with HCV address many of these factors, and should include interventions to improve patient knowledge of HCV and the availability of effective treatments.

Factors influencing treatment outcome in hepatitis C virus minority patients at an inner-city hospital: A STROBE-complaint article

Chronic hepatitis C virus (HCV) infection disproportionately affects African-Americans (AAs) and is a major contributor to liver failure and mortality. Genetic factors may not be the only cause in outcome disparity. We retrospectively investigated whether genetic host factors, viral genotypes, and treatment compliance in AA patients impacted the efficacy and the sustained virological response (SVR) rate of the interferon (IFN)-based treatment regimen. The medical chart review included 76 African-American patients (age ranging from 26 to 76) with varying levels of hepatitis condition. Fifty-seven (75%) of them had a clinically verifiable HCV infection and were followed by a hepatologist for 2 years at Howard University Hospital in Washington, DC. Both comprehensive metabolic profile and complete blood count analyses were performed. Among the 57 patients whose viral and IL28B genotypes were determined, sixty-eight percent (68%) were infected with viral genotype 1 and 71% harbored the CT allele of the IL28B gene. Among the 12 patients who completed treatment with IFN-based dual or triple therapy, 58% had achieved SVR 12 weeks following completion of treatment; 33% had a partial response with under 6000 viral count after 16 weeks of treatment; and there was one patient with viral genotype 1a and CT allele who did not respond to the medications. The results of this study prove that the PEG IFN-based regimen was effective in treating HCV-infected AA patients despite the current availability of new direct-acting antivirals. The major obstacles contributing to a low reduction in HCV infection and outcome in the AA community were avoidance or lack of treatment or compliance; contraindications, medication side effects, non-adherence, and payer eligibility restrictions.

Cascade of care for migrants tested Hepatitis C antibodies positive in France through a systematic screening programme: The PRECAVIR study

Migration of people from HCV endemic countries is a public health issue for the French healthcare system. The PRECAVIR study focused on migrant patients and provides a multidisciplinary, patient-centred approach to treat chronic HCV-infected migrants through a systematic screening programme. Between 2007 and 2017, 101 (2.98%) out of 3386 consecutive adult migrants attending two primary healthcare settings in Créteil, France, tested positive for HCV. The median age was 44.5 years old, and 55% were women. Patients were mainly from sub-Saharan Africa, Eastern Europe and Asia. Seventy-four patients were undocumented migrants, and 25 were asylum seekers. Eighty-four (83%) patients were unaware of their serological status. All patients were offered referral to a specialist in the same setting. HCV RNA testing was performed in 88 (87%) of the patients who tested anti-HCV positive. Forty-nine (57%) were chronically infected, while 39 (43%) had an undetectable viral load. All patients were treatment-naïve. More than half of patients had access to treatment. Before 2014, thirteen patients were treated with pegylated interferon and ribavirin, and an SVR was achieved in 8 (61.5%) of them. By 2017, 17 patients had begun oral, direct-acting antiviral treatment. An SVR was achieved in 16 of 17 patients (93%). However, all patients not initially eligible for treatment were lost to follow-up. This study showed the effectiveness of a coordinated care network when anti-HCV testing, linkage to care and treatment are organized for a migrant population in the same setting as long as universal treatment makes a test and treat policy possible.

A Descriptive Analysis of a Community Clinic Providing Hepatitis C Treatment to Poor and Uninsured Patients

This study describes clinical characteristics of poor and uninsured patients living with hepatitis C virus (HCV) who received care from a multidisciplinary HCV clinic, reports treatment completion and cure rates, and estimates the cost of HCV medications provided at no cost to uninsured patients. A retrospective chart review was performed and identified 69 uninsured HCV patients who received medical care at Mercy Health Center, a small non-profit community clinic, between January 2008 and March 2015. Three-fourths of the patients were unemployed, a third had multiple HCV exposures, nearly half acquired HCV due to illicit drug use, and more than half had active psychiatric disorders. Of those who received HCV treatment, 81% completed treatment and 85% were achieved virological cure. The multidisciplinary community clinic provided > $1.4 million of HCV antivirals at no cost to uninsured patients. Findings suggest a multidisciplinary community clinic comprised of a social worker, pharmacist, gastroenterologist, nurse, nurse practitioner, psychologist, and dietitian can help patients achieve HCV treatment completion and cure rates comparable to traditional physician-led clinics, and successfully manage uninsured and underserved HCV patients-who are often regarded as "difficult-to-treat" patients. Public health social workers and other health professionals are encouraged to advocate for treatment and care of poor and uninsured patients living with HCV in health agencies and health systems, otherwise population-wide reductions in HCV morbidity and mortality will not be realized.

Hepatitis C Virus Infection in the Dallas County Jail: Implications for Screening, Prevention, and Linkage to Care

OBJECTIVES

Screening for hepatitis C virus (HCV) infection in jail provides an opportunity to educate and offer care to a high-risk population. We aimed to (1) estimate the prevalence of HCV infection in jail; (2) describe the demographic characteristics, risk factors, and pre-incarceration health insurance status associated with HCV infection; and (3) examine the implementation of HCV screening in jail.

METHODS

We conducted a retrospective analysis of an opt-out HCV screening program with HCV RNA confirmation and patient education at the Dallas County Jail from April 1 through November 2, 2017. We extracted data on test results, demographic characteristics, and release destination from electronic medical records. A nurse navigator recorded data on patient self-reported risk factors and pre-incarceration health insurance status.

RESULTS

Of 4089 incarcerated persons screened, 708 (17.3%) had a positive HCV antibody result. Of these, 641 (90.5%) had an HCV RNA test ordered; 576 (89.9%) had RNA tests completed, of whom 413 (71.7%) had a positive HCV RNA result. Of these 413, 352 (85.2%) received patient education. Half of HCV RNA-positive incarcerated persons (n = 207, 50.1%) were born outside the birth cohort (1945-1965). Among those with HCV infection, commonly reported risk factors were injection drug use (168 of 352; 47.8%) and tattoos (82 of 352; 23.4%). Most incarcerated persons with HCV infection (284 of 350; 81.1%) did not have health insurance. HCV antibody prevalence was higher among incarcerated persons released to prison (232 of 961; 24.1%) than to outside agencies (38 of 403; 9.4%) or the community (178 of 1026; 17.4%).

CONCLUSIONS

Screening for HCV with RNA confirmation in jail provides an opportunity for disease education, transmission prevention, and navigation to HCV treatment. Future efforts should examine post-incarceration linkage to care.

Impact of geographic origin on access to therapy and therapy outcomes in the Swiss Hepatitis C Cohort Study

Late diagnosis and treatment may increase morbidity and mortality among persons with hepatitis C virus (HCV) infection. We included all participants of the Swiss Hepatitis C Cohort Study (SCCS). We used unadjusted and adjusted logistic and Cox regressions to determine the association between the geographic origin of the participants and the following outcomes: antiviral treatment status; sustained virologic response; cirrhosis at enrolment; incident cirrhosis; loss to follow-up (LTFU); and mortality. The analyses were adjusted for sex, baseline age, education, source of income, alcohol consumption, injection drug use (IDU), HCV genotype, HIV or HBV coinfection, duration of HCV infection, time since enrolment, cirrhosis, (type of) HCV treatment, and centre at enrolment. Among 5,356 persons, 1,752 (32.7%) were foreign-born. IDU was more common among Swiss- (64.1%) than foreign-born (36.6%) persons. Cirrhosis at enrolment was more frequent among foreign- than Swiss-born persons, reflecting the high frequency of cirrhosis among Italian-born persons who acquired HCV between 1950 and 1970 in Italian healthcare settings. Although antiviral treatment coverage was similar, the sustained viral response rate was increased and the mortality was lower among foreign-vs. Swiss-born persons, with the lowest mortality in persons from Asia/Oceania. LTFU was more frequent in persons from Germany, Eastern and Southern Europe, and the Americas. In conclusion, in Switzerland, a country with universal healthcare, geographic origin had no influence on hepatitis C treatment access, and the better treatment outcomes among foreign-born persons were likely explained by their lower prevalence of IDU and alcohol consumption than among Swiss-born persons.

Hepatitis C care cascade in HIV patients at an urban clinic in the early direct-acting antiviral era

Guidelines advocate universal, prompt treatment of hepatitis C (HCV) infection in HIV/HCV co-infected patients, but barriers to uptake of HCV direct-acting antivirals (DAAs) remain unclear in this population. This retrospective study investigated the care cascade from HCV diagnosis to sustained virologic response (SVR) at an urban infectious disease clinic in Saint Louis, Missouri during the first 18 months of interferon-free DAA availability in the United States. Of 1949 HIV patients seen in clinic, 91.9% were screened for HCV and 5.4% (n = 106) had chronic HCV infection with follow-up. Of these 106 co-infected patients, 100 underwent fibrosis testing, 55 were offered DAAs, 38 completed treatment, and 37 achieved SVR. Delayed DAA treatment was associated with no insurance, substance abuse, poor HIV control, and younger age. Providers delayed DAA treatment most commonly for substance abuse, psychiatric disease, and uncontrolled HIV. Mean time to insurance decision from initial prescription was 20.9 ± 29.6 days and mean time to final decision was 29.9 ± 40.1 days. DAAs are highly successful in co-infected patients in this early period but insurance delays and misconceptions from the interferon era can ultimately limit uptake. Addressing these factors in a comprehensive treatment model may bridge disparities and improve real-world SVRs.

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

BACKGROUND

Hepatitis C virus (HCV) infection is a major public health challenge in Cameroon with over three million people infected. Government efforts to improve care and treatment are unsatisfactory and need to be assessed. We aimed at studying the several steps along the HCV continuum of care in one of two hepatitis treatment centers in Cameroon.

METHODS

We undertook a retrospective chart review of anti-HCV positive individuals, who attended the Douala general hospital between 2008 and 2015. We defined the HCV treatment cascade as follows: step 1-HCV RNA testing, step 2-complete pre-therapeutic evaluation (genotyping and liver fibrosis markers), step 3-initiation of treatment, step 4-treatment completion, and step 5-sustained virological response (SRV). Each successive step in the HCV care continuum was dependent on passing through the previous step.

RESULTS

The mean age of the 669 anti-HCV antibody positive individuals was 57 (sd: ±13) years. Females were 52.8% of the study population. 410 (61.3%) were tested for HCV RNA. Three hundred and sixty-six (54.7%) were confirmed to have viral replication (HCV RNA positive). One hundred and eighty (26.9%) did a complete pre-therapeutic evaluation (both HCV genotyping and liver fibrosis assessment included). Eighty-one (12.1%) initiated treatment with pegylated interferon/ribavirin. Seventy-two (10.8%) completed treatment and 44 (6.6%) had SVR. Sociodemographic characteristics including age, gender, marital status, having medical insurance, and profession were associated with attaining later steps in the care cascade.

CONCLUSION

This study shows that HCV continuum of care and treatment is less optimal at the Douala general hospital and is highly impacted by socio-economic factors. Continued efforts are needed to improve HCV care.

Barriers to Hepatitis C Screening in a Minority Population: A Comparison of Hepatitis C and Human Immunodeficiency Virus Screening Rates at a Community STD Clinic in Miami, Florida

METHODS

357 patients at a free STD clinic in Miami, FL were screened for HCV. Surveys were administered assessing risk factors for infectious disease transmission, and HCV and HIV screening history.

RESULTS

15.1% of participants had been screened for HCV before whereas 83.8% had been screened for HIV (n = 356). Of the patients previously screened for HCV (n = 54), 98.2% of these patients had previously been screened for HIV as well.

CONCLUSION

This data shows the low prevalence of prior HCV screenings in a high-risk population in Miami, FL. Participants who had previously received an HIV screening test were more likely to report receiving a prior HCV screening. Despite the high prevalence of HCV, most HCV infections are undiagnosed. Mortality from HIV has been declining in the United States while mortality from HCV is increasing. To decrease HCV related mortality, we recommend offering HCV screening in conjunction with HIV screening.

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

BACKGROUND

New highly effective medications are available to treat the hepatitis C virus (HCV). However, little is known about HCV treatment knowledge and readiness among young people who inject drugs (PWID), or factors that may contribute to treatment uptake and adherence in this treatment era.

PURPOSE

Using a framework for understanding healthcare utilization, we examined perspectives and experiences of young PWID tied to the HCV care continuum in Boston, Massachusetts, to inform future strategies.

METHODS

We conducted 24 in-depth interviews with active and recent PWID aged 22-30 years living with HCV in Boston, February-August 2016. At the time of the interviews, no participants had been prescribed or had taken the new direct acting antivirals. We developed a codebook deductively from the interview guide and coded and analyzed the data into themes using a consensus-based process.

RESULTS

The following five themes emerged, which captured PWID's knowledge of and experiences with HCV along the care continuum through social determinants of engagement in care, as well as illness level: (1) deservingness of HCV treatment and stigma, (2) dissatisfaction with provider interactions, (3) perceived lack of referral to treatment and care continuity, (4) disincentives around HCV treatment for PWID; and (5) perceived need for treatment. Young PWID living with HCV face unique barriers to HCV testing, counseling, and treatment.

CONCLUSION

Breakdowns in the HCV care continuum may have adverse effects on HCV-treatment readiness and willingness. Improved public health and practice approaches are needed to address these barriers to effectively engage young PWID in care.

Obstacles to successful treatment of hepatitis C in uninsured patients from a minority population

BACKGROUND

Hepatitis C virus (HCV) treatment regimens (DAAs) are well tolerated, efficacious but costly. Their high cost and restricted availability, raises concerns about the outcome of treatment in uninsured patients. This study investigated sustained virologic response (SVR) outcomes in a predominately uninsured patient population and completion of four steps along the HCV treatment cascade.

METHODS

A retrospective chart review was conducted to characterize the patient population and analyze covariates to determine association with insurance status, attainment of SVR and progression through the HCV treatment cascade.

RESULTS

Out of a total of 216 patients, 154 (71%) were uninsured. Approximately 50% of patients (109 of 216 patients) were male and 57% were Hispanic (123 of 216 patients). Sex, race, ethnicity, treatment compliance, and rates of complications were not associated with insurance status. Insured patients were older (median 60 years vs 57 years, p-value < 0.001) and had higher rates of cirrhosis: 32 out of 62 patients (52%) vs 48 out of 154 patients (31%) (p-value = 0.005). Insured patients were tested for SVR at similar rates as uninsured patients: 84% (52 of 62 patients) vs 81% (125 of 154 patients), respectively. Of those tested for SVR, the cure rate for insured patients was 98% (51 out of 52 patients) compared to 97% (121 out of 125 patients) in the uninsured. Out of those who completed treatment, 177 of 189 (94%) were tested for attainment of SVR. Compliance rates were significantly different between tested and untested patients: 88% (156 of 177 patients) vs 0% (0 of 12 patients), respectively (p-value < 0.001). However, insurance status, race ethnicity, cirrhosis, and complications were not associated with being tested for SVR.

CONCLUSIONS

These results demonstrate that insured and uninsured patients with chronic HCV infection, with access to patient assistance programs, can be treated and have comparable clinical outcomes. In addition, testing for SVR remains an important obstacle in completion of the HCV treatment cascade. Nevertheless, patient assistance programs remove a significant barrier for treatment access in real-world HCV infected populations.

Barriers in Hepatitis C Treatment in Somali Patients in the Direct Acting Antiviral Therapy Era

BACKGROUND AND AIMS

Hepatitis C virus (HCV) treatment has changed dramatically in the last few years. Our observations suggest that a minority of HCV infected Somalis are treated. In this study, we aimed to evaluate for treatment and health outcome disparities between Somali and non-Somali patients during the direct acting antiviral (DAA) era.

METHODS

Patients with HCV seen in the gastroenterology clinic in 2015 were included in the study. Patients were identified using ICD9 and 10 codes. Electronic medical records were analyzed to evaluate for treatment candidacy, acceptance and reasons for refusal of treatment.

RESULTS

Genotype 4 followed by 3 were the most common genotypes in the Somalis while genotype 1 was the most common in the non-Somalis. Majority of patients were offered treatment, active alcohol and substance abuse was a common reason for not offering treatment in non-Somalis while the presence of hepatocellular carcinoma was the most common reason in Somalis. Somalis had higher rates of declining treatment given the asymptomatic nature of their disease and the feeling that treatment is not needed. Sustained virologic response rates were comparable in both groups.

CONCLUSIONS

Disparities in acceptance of HCV treatment persist in the DAA era. The asymptomatic nature of the infection and potential cultural mistrust makes patients hesitant to undergo treatment. Healthcare providers must find interventions aimed at reducing barriers to treatment and increasing acceptance of HCV treatment.

Global Cancer in Women: Burden and Trends

This review is an abbreviated version of a report prepared for the American Cancer Society Global Health department and EMD Serono, Inc., a subsidiary of Merck KGaA, Darmstadt, Germany, which was released at the Union for International Cancer Control World Cancer Congress in Paris in November 2016. The original report can be found at https://www.cancer.org/health-care-professionals/our-global-health-work/global-cancer-burden/global-burden-of-cancer-in-women.html. Staff in the Intramural Research Department of the American Cancer Society designed and conducted the study, including analysis, interpretation, and presentation of the review. The funding sources had no involvement in the study design, data analysis and interpretation, or preparation of the reviewThere are striking disparities in the global cancer burden in women, yet few publications highlight cancer occurrence in this population, particularly for cancers that are not sex specific. This article, the first in a series of two, summarizes the current burden, trends, risk factors, prevention, early detection, and survivorship of all cancers combined and seven sites (breast, cervix, uterine corpus, ovary, colorectum, lung, and liver) that account for about 60% of the cancer burden among women worldwide, using data from the International Agency for Research on Cancer. Estimated 2012 overall cancer death rates in general are higher among women in low- and middle-income countries (LMICs) than high-income countries (HICs), despite their lower overall incidence rates, largely due to inadequate access to early detection and treatment. For example, the top mortality rates are in Zimbabwe (147 deaths per 100,000) and Malawi (138). Furthermore, incidence rates of cancers associated with economic development (e.g., lung, breast, colorectum) are rising in several LMICs. The burden of cancer among women could be substantially reduced in both HICs and LMICs through broad and equitable implementation of effective interventions, including tobacco control, HPV and HBV vaccination, and screening (breast, cervix, and colorectum). Cancer Epidemiol Biomarkers Prev; 26(4); 444-57. ©2017 AACRSee related article by Islami et al. in this CEBP Focus section, "Global Cancer in Women."

Racial/ethnic disparities in hepatocellular carcinoma treatment and survival in California, 1988-2012

AIM

To describe racial/ethnic differences in treatment and survival among liver cancer patients in a population-based cancer registry.

METHODS

Invasive cases of primary hepatocellular carcinoma, n = 33270, diagnosed between January 1, 1988-December 31, 2012 and reported to the California Cancer Registry were analyzed by race/ethnicity, age, gender, geographical region, socio-economic status, time period of diagnosis, stage, surgical treatment, and survival. Patients were classified into 15 racial/ethnic groups: non-Hispanic White (White, n = 12710), Hispanic (n = 8500), Chinese (n = 2723), non-Hispanic Black (Black, n = 2609), Vietnamese (n = 2063), Filipino (n = 1479), Korean (n = 1099), Japanese (n = 658), American Indian/Alaskan Native (AIAN, n = 281), Laotian/Hmong (n = 244), Cambodian (n = 233), South Asian (n = 190), Hawai`ian/Pacific Islander (n = 172), Thai (n = 95), and Other Asian (n = 214). The main outcome measures were receipt of surgical treatment, and cause-specific and all-cause mortality.

RESULTS

After adjustment for socio-demographic characteristics, time period, and stage of disease, compared to Whites, Laotian/Hmong [odds ratio (OR) = 0.30, 95%CI: 0.17-0.53], Cambodian (OR = 0.65, 95%CI: 0.45-0.96), AIAN (OR = 0.66, 95%CI: 0.46-0.93), Black (OR = 0.76, 95%CI: 0.67-0.86), and Hispanic (OR = 0.78, 95%CI: 0.72-0.84) patients were less likely, whereas Chinese (OR = 1.58, 95%CI: 1.42-1.77), Koreans (OR = 1.45, 95%CI: 1.24-1.70), Japanese (OR = 1.41, 95%CI: 1.15-1.72), and Vietnamese (OR = 1.26, 95%CI: 1.12-1.42) were more likely to receive surgical treatment. After adjustment for the same covariates and treatment, cause-specific mortality was higher for Laotian/Hmong [(hazard ratio (HR) = 1.50, 95%CI: 1.29-1.73)], Cambodians (HR = 1.35, 95%CI: 1.16-1.58), and Blacks (HR = 1.07, 95%CI: 1.01-1.13), and lower for Chinese (HR = 0.82, 95%CI: 0.77-0.86), Filipinos (HR = 0.84, 95%CI: 0.78-0.90), Vietnamese (HR = 0.85, 95%CI: 0.80-0.90), Koreans (HR = 0.90, 95%CI: 0.83-0.97), and Hispanics (HR = 0.91, 95%CI: 0.88-0.94); results were similar for all-cause mortality.

CONCLUSION

Disaggregated data revealed substantial racial/ethnic differences in liver cancer treatment and survival, demonstrating the need for development of targeted interventions to mitigate disparities.

Simple Predictive Model for Identifying Patients with Chronic Hepatitis C and Hepatitis C Virus Genotype 4 Infection with a High Probability of Sustained Virologic Response with Peginterferon Alfa-2a/Ribavirin: Pooled Analysis of Data from Two Large, International Cohort Studies

INTRODUCTION

Wherever access to direct-acting antiviral agents is restricted, dual peginterferon/ribavirin (PegIFN/RBV) therapy remains an option for treatment of hepatitis C virus (HCV) genotype 4 (GT4) infection, which predominates in the Middle East and Sub-Saharan Africa. Our goal was to develop a baseline scoring system to identify GT4-infected patients with a low or high probability of achieving a sustained virologic response (SVR) with PegIFN alfa-2a/RBV using data from two large cohort studies.

METHODS

Associations between baseline characteristics and SVR were explored by generalized additive models and multiple logistic regression analysis to develop a predictive model, which was then checked by bootstrapping. The score comprised four factors with points assigned thus: age ≤40, 3 points; >40 but ≤55, 2 points; alanine aminotransferase ≤1 or >3× the upper limit of normal, 1 point; no cirrhosis, 1 point; HCV RNA <50,000 IU/mL, 2 points; 50,000 to <400,000 IU/mL, 1 point. The values for a given patient are summed to produce a score from 0 to 7 where higher scores indicate higher chances of SVR.

RESULTS

Among the 459 patients, 28 (6%), 50 (11%), 92 (20%), 121 (26%), 103 (22%), and 65 (14%) patients had scores of 0-1, 2, 3, 4, 5, and 6-7, respectively, with respective SVR rates of 11%, 28%, 50%, 57%, 63%, and 83%. Relapse rates decreased with increasing prediction score (80%, 39%, 15%, 19%, 5%, and 7%, respectively). SVR rates were consistently higher in Caucasian than Black patients and in patients with a rapid virologic response HCV RNA <50 IU/mL at week 4); however, the trend toward higher SVR rates with increasing score remained apparent in each subgroup.

CONCLUSION

In conclusion, a simple scoring system can be used to identify GT4-infected patients with a high probability of achieving an SVR with PegIFN alfa-2a/RBV.

FUNDING

F. Hoffmann-La Roche Ltd.

Racial Disparities in Treatment Rates for Chronic Hepatitis C: Analysis of a Population-Based Cohort of 73,665 Patients in the United States

Chronic hepatitis C (CHC) disproportionately affects racial minorities in the United States (US). Although prior studies have reported lower treatment rates in Blacks than in Caucasians, the rates of other minorities remain understudied. We aimed to examine antiviral treatment rates by race and to evaluate the effect of other demographic, medical, and psychiatric factors on treatment rates. We performed a population-based study of adult CHC patients identified via ICD-9CM query from OptumInsight's Data Mart from January 2009 to December 2013. Antiviral treatment was defined by pharmaceutical claims for interferon and/or pegylated-interferon. A total of 73,665 insured patients were included: 51,282 Caucasians, 10,493 Blacks, 8679 Hispanics, and 3211 Asians. Caucasians had the highest treatment rate (10.7%) followed by Blacks (8.8%), Hispanics (8.8%), and Asians (7.9%, P < .001). Hispanics had the highest cirrhosis rates compared with Caucasians, Blacks, and Asians (20.7% vs 18.3%, 17.1%, and 14.3%, respectively). Caucasians were the most likely to have a psychiatric comorbidity (20.1%) and Blacks the most likely to have a medical comorbidity (44%). Asians were the least likely to have a psychiatric (6.4%) or medical comorbidity (26.9%). On multivariate analysis, racial minority was a significant predictor of nontreatment with odds ratios of 0.82 [confidence interval (CI): 0.74-0.90] for Blacks, 0.87 (CI: 0.78-0.96) for Hispanics, and 0.73 (CI: 0.62-0.86) for Asians versus Caucasians. Racial minorities had lower treatment rates than Caucasians. Despite fewer medical and psychiatric comorbidities and higher incomes and educational levels, Asians had the lowest treatment rates. Hispanics also had lower treatment rates than Caucasians despite having higher rates of cirrhosis. Future studies should aim to identify underlying racial-related barriers to hepatitis C virus treatment besides socioeconomic status and medical or psychiatric comorbidities.

Directly acting antivirals for hepatitis C virus arrive in HIV/hepatitis C virus co-infected patients: from 'mind the gap' to 'where's the gap?'

In patients living with HIV infection with hepatitis C (HCV) is common. HIV/HCV co-infection results in more rapid liver fibrosis progression than HCV alone and end-stage liver disease is a major cause of morbidity and mortality in co-infected patients. Historically, treatment outcomes with interferon based therapy in this group have been poor but with the advent of directly acting antiviral (DAA) drugs for HCV, rates of cure have improved dramatically. This article reviews recent evidence on the treatment of HCV in co-infected patients including the efficacy of new regimens and information on drug-drug interactions between DAAs and antiretroviral therapy. We also discuss the relationship between the pathogenesis of HIV and HCV infections, the treatment of acute hepatitis C and the current debate regarding the cost-effectiveness and affordability of DAAs.

Primary liver cancer deaths and related years of life lost attributable to hepatitis B and C viruses in India

BACKGROUND AND AIMS

More than 25,000 people die of liver cancer annually in India. There is little information about the contribution of hepatitis B virus (HBV) and hepatitis C virus (HCV) to these deaths. We conducted a systematic review of published studies on HBV or HCV infection and liver cancer in India and estimated the population attributable fraction (PAF) of liver cancer deaths caused by these infections and the corresponding annual number of deaths and years of life lost (YLL) in the country.

METHODS

We searched the PubMed and Scopus databases, as well as the reference list of relevant articles in the systematic review. For calculation of the number of liver cancer deaths attributable to HBV and HCV, we used two sources of outcome data and two relative risks for the association between HCV and liver cancer.

RESULTS

The PAF was 67% for HBV, 17-19% for HCV, and 71-72% for HBV and/or HCV. The annual attributable number of liver cancer deaths was approximately 17,000 for HBV; 4500 for HCV; and 18,500 for HBV and/or HCV, corresponding to approximately 297,000, 75,000, and 315,000 YLL, respectively. There was little difference in these numbers using the two sources of outcome data or the two risk estimates for HCV.

CONCLUSIONS

Our findings underscore the importance of primary prevention of HBV and HCV by appropriate measures, including vaccination (HBV only), prevention of transfusion-related infections, and increased awareness of the routes of transmission and long-term health outcomes.

The Impact of Enhanced Screening and Treatment on Hepatitis C in the United States

BACKGROUND

The effectiveness of interferon-free direct-acting antivirals (DAA) in treating chronic hepatitis C virus (HCV) is limited by low screening and treatment rates, particularly among people who inject drugs (PWIDs).

METHODS

To evaluate the levels of screening and treatment with interferon-free DAAs that are required to control HCV incidence and HCV-associated morbidity and mortality, we developed a transmission model, stratified by age and by injection drug use, and calibrated it to epidemiological data in the United States from 1992 to 2014. We quantified the impact of administration of DAAs at current and at enhanced screening and treatment rates, focusing on outcomes of HCV incidence, prevalence, compensated and decompensated cirrhosis, hepatocellular carcinoma, liver transplants, and mortality from 2015 to 2040.

RESULTS

Increasing annual treatment of patients 4-fold-from the approximately 100 000 treated historically to 400 000-is predicted to prevent 526 084 (95% confidence interval, 466 615-593 347) cases of cirrhosis and 256 315 (201 589-316 114) HCV-associated deaths. By simultaneously increasing treatment capacity and increasing the number of HCV infections diagnosed, total HCV prevalence could fall to as low as 305 599 (222 955-422 110) infections by 2040. Complete elimination of HCV transmission in the United States through treatment with DAAs would require nearly universal screening of PWIDs, with an annual treatment rate of at least 30%.

CONCLUSIONS

Interferon-free DAAs are projected to achieve marked reductions in HCV-associated morbidity and mortality. Aggressive expansion in HCV screening and treatment, particularly among PWIDs, would be required to eliminate HCV in the United States.

HCV Screening Behaviors and Infection Status among Vietnamese Americans

OBJECTIVES

The aim of this study was to identify socio-economic and acculturation factors associated with hepatitis C (HCV) screening and infection among US Vietnamese Americans.

METHODS

Participants were recruited from 7 Vietnamese community-based organizations in Pennsylvania and New Jersey. The analysis ultimately included 309 participants who participated in a HCV education intervention program.

RESULTS

Overall, 82.5% (255 of 309) intervention participants completed HCV screening over the 6 months prior to the post-intervention assessment. In multivariate-adjusted analysis, participants who lived in Vietnam for 40 years versus 20 years were more likely to receive HCV screening; unemployed individuals were less likely to receive HCV screening than employed people. Among screened participants, 7.5% had HCV infection.

CONCLUSIONS

These findings will guide future culturally and linguistically appropriate interventions to reduce HCV infection and HCV-related liver cancer.

Drug Authorization for Sofosbuvir/Ledipasvir (Harvoni) for Chronic HCV Infection in a Real-World Cohort: A New Barrier in the HCV Care Cascade

BACKGROUND

New treatments for hepatitis C (HCV) infection hold great promise for cure, but numerous challenges to diagnosing, establishing care, and receiving therapy exist. There are limited data on insurance authorization for these medications.

MATERIALS AND METHODS

We performed a retrospective chart review of patients receiving sofosbuvir/ledipasvir (SOF/LED) from October 11-December 31, 2014 to determine rates and timing of drug authorization. We also determined predictors of approval, and those factors associated with faster decision and approval times.

RESULTS

Of 174 patients prescribed HCV therapy during this period, 129 requests were made for SOF/LED, of whom 100 (77.5%) received initial approval, and an additional 17 patients (13.9%) ultimately received approval through the appeals process. Faster approval times were seen in patients with Child-Pugh Class B disease (14.4 vs. 24.7 days, p = 0.048). A higher proportion of patients were initially approved in those with Medicare/Medicaid coverage (92.2% vs. 71.4%, p = 0.002) and those with baseline viral load ≥ 6 million IU/mL (84.1% vs. 62.5%, p = 0.040). Linear regression modeling identified advanced fibrosis, high Model of End Stage Liver Disease (MELD) score, and female gender as significant predictors of shorter decision and approval times. On logistic regression, Medicare/Medicaid coverage (OR 5.96, 95% CI 1.66-21.48) and high viral load (OR 4.52, 95% CI 1.08-19.08) were significant predictors for initial approval.

CONCLUSIONS

Early analysis of real-world drug authorization outcomes between October-December 2014 reveals that nearly one in four patients are initially denied access to SOF/LED upon initial prescription, although most patients are eventually approved through appeal, which delays treatment initiation. Having Medicare/Medicaid and advanced liver disease resulted in a higher likelihood of approval as well as earlier decision and approval times. More studies are needed to determine factors resulting in higher likelihood of denial and to evaluate approval rates and times after implementation of restrictive prior authorization guidelines.