Hepatitis C testing and status among opioid substitution treatment clients in New South Wales

Investigating hepatitis C screening among people receiving opioid agonist treatment: A retrospective audit study

Background

Estimates of the prevalence of hepatitis C virus (HCV) amongst people who inject drugs are in the range of 50%. Opioid Agonist Treatment (OAT) clinics have a large proportion of people who inject drugs. These clinics, therefore, present an excellent opportunity to identify and treat patients with HCV. Despite this, it remains unclear as to how well these clinics screen patients for HCV.

Aim

This study aims to quantify the rate of HCV screening of patients that enrolled into treatment at an OAT clinic attached to a large teaching hospital in NSW.

Methods

A retrospective audit of the electronic medical record of patients commencing OAT at the clinic was performed to determine the rate of HCV screening.

Findings

During the audit period, there were 99 episodes of care that involved the commencement of OAT at the clinic, for patients who had a history of injecting drugs. Successful screening for HCV occurred in 56% (55/99) of these episodes. Of those screened, 26% were ribonucleic acid positive. Analysis of demographics did not reveal a statistically significant difference between those that were screened and those that were not.

Discussion

This study revealed a suboptimal rate of HCV screening at the OAT clinic. To improve the screening rate, the clinic could consider providing dried blood spot testing at the initial nurse assessment or having a clinician capable of venepuncture at the clinic.

Point-of-care Hepatitis C virus testing and linkage to treatment in an Australian inner-city emergency department

BACKGROUND

In Australia, Hepatitis C Virus (HCV) treatment is declining, despite broad access to direct-acting antiviral medication. People who inject drugs are proportionally over-represented in emergency department presentations. Emergency department assessment of people who have injected drugs for HCV presents an opportunity to engage this marginalised population with treatment. We describe the outcomes of risk-based screening and point-of-care anti-HCV testing for emergency department patients, and linkage to outpatient antiviral treatment.

METHODS

During the three-month study period, consecutive adult patients who presented to the emergency department during the study times were screened for risk factors and offered the OraQuick oral HCV antibody test. Those with reactive results were offered venepuncture in the emergency department for confirmatory testing and direct-acting antiviral treatment in clinic. The main outcome measures were the number and proportion of viremic participants that were linked to the hepatitis clinic, commenced treatment and achieved a sustained viral response. Secondary outcome measures were the proportion (%) of presentations screened that were oral antibody reactive, and the prevalence and type of HCV risk factors.

RESULTS

During the study period, 2408 of the 3931 (61%) presentations to the emergency department were eligible for screening. Of these 2408 patients, 1122 (47%) participated, 307 (13%) declined participation and 977 (41%) could not be approached during their time in the emergency department. Among the 1122 participants, 378 (34%) reported at least one risk factor. Subsequently, 368 (97%) of the 378 participants underwent OraQuick anti-HCV test, and 50 (14%) had a reactive result. A risk factor of ever having injected drugs was present in 44 (88%) of participants who were sero-positive. Of the 45 that had blood tested, 30 (67%) were HCV ribonucleic acid (RNA) positive. Three participants died. Of the 27 remaining participants, 10 (37%) commenced treatment and 7 of these 10 (70%) obtained a cure. There was a high rate of homelessness (24%) among anti-HCV positive participants.

CONCLUSION

Among emergency department participants with a risk factor for HCV, positive serology was common using a rapid point-of-care test. A history of injecting drug use was identified as the risk factor with highest yield for positive HCV serology, and is suitable as a single screening question. However, linkage to care post ED presentation was low in this marginalised population. There is a need for new pathways to improve the care cascade for marginalised individuals living with HCV infection.

Accelerating the elimination of viral hepatitis: a Lancet Gastroenterology & Hepatology Commission

Viral hepatitis is a major public health threat and a leading cause of death worldwide. Annual mortality from viral hepatitis is similar to that of other major infectious diseases such as HIV and tuberculosis. Highly effective prevention measures and treatments have made the global elimination of viral hepatitis a realistic goal, endorsed by all WHO member states. Ambitious targets call for a global reduction in hepatitis-related mortality of 65% and a 90% reduction in new infections by 2030. This Commission draws together a wide range of expertise to appraise the current global situation and to identify priorities globally, regionally, and nationally needed to accelerate progress. We identify 20 heavily burdened countries that account for over 75% of the global burden of viral hepatitis. Key recommendations include a greater focus on national progress towards elimination with support given, if necessary, through innovative financing measures to ensure elimination programmes are fully funded by 2020. In addition to further measures to improve access to vaccination and treatment, greater attention needs to be paid to access to affordable, high-quality diagnostics if testing is to reach the levels needed to achieve elimination goals. Simplified, decentralised models of care removing requirements for specialised prescribing will be required to reach those in need, together with sustained efforts to tackle stigma and discrimination. We identify key examples of the progress that has already been made in many countries throughout the world, demonstrating that sustained and coordinated efforts can be successful in achieving the WHO elimination goals.

Aiming for the elimination of viral hepatitis in Australia, New Zealand, and the Pacific Islands and Territories: Where are we now and barriers to meeting World Health Organization targets by 2030

Viral hepatitis affects more than 320 million people globally, leading to significant morbidity and mortality due to liver failure and hepatocellular carcinoma (HCC). More than 248 million people (3.2% globally) are chronically infected with hepatitis B virus (HBV), and an estimated 80 million people (1.1% globally) are chronically infected with hepatitis C virus (HCV). In 2015, more than 700 000 deaths were directly attributable to HBV, and nearly 500 000 deaths were attributable to HCV infection; 2-5% of HBV-infected people develop HCC per annum irrespective of the presence of cirrhosis, whereas 1-5% HCV-infected people with advanced fibrosis develop HCC per annum. The rapidly escalating global mortality related to HBV and HCV related viral hepatitis to be the 7th leading cause of death worldwide in 2013, from 10th leading cause in 1990. Australia, New Zealand, and Pacific Island Countries and Territories fall within the World Health Organization Western Pacific Region, which has a high prevalence of viral hepatitis and related morbidity, particularly HBV. Remarkably, in this region, HBV-related mortality is greater than for tuberculosis, HIV infection, and malaria combined. The region provides a unique contrast in viral hepatitis prevalence, health system resources, and approaches taken to achieve World Health Organization global elimination targets for HBV and HCV infection. This review highlights the latest evidence in viral hepatitis epidemiology and explores the health resources available to combat viral hepatitis, focusing on the major challenges and critical needs to achieve elimination in Australia, New Zealand, and Pacific Island Countries and Territories.

Uptake of direct acting antiviral therapies for the treatment of hepatitis C virus among people who inject drugs in a universal health-care system

INTRODUCTION AND AIMS

Direct acting antiviral (DAA) treatment can reduce hepatitis C virus (HCV) infection incidence and mortality, although large scale uptake of these treatments is necessary to achieve those reductions. Targeting people who inject drugs (PWID) will be crucial to achieve the necessary reductions. Previously, treatment uptake has been very low (1-2%) among PWID, but these new DAAs have been subsidised in Australia since March 2016. This study describes treatment uptake among a sample of PWID in Australia and examines sociodemographic and drug use variables associated with treatment uptake.

DESIGN AND METHODS

An Australian national cross-sectional sample (n = 817) of regular PWID drawn from a convenience sentinel sample aged ≥18 years. Information on demographics, drug use, HCV antibody testing, RNA testing, recent DAA treatment initiation and DAA prescriber settings was collected via an interviewer-administered survey.

RESULTS

There were 291 HCV RNA positive participants, of who one-third reported initiating DAA treatment since the introduction of subsidised DAA medications. Current opioid substitution treatment was significantly associated with increased treatment uptake (adjusted odds ratio 2.20, 95% confidence interval 1.31, 3.68) while those with unstable housing were less likely to initiate treatment (adjusted odds ratio 0.42, 95% confidence interval 0.22, 0.82).

DISCUSSION AND CONCLUSIONS

This study found that DAA treatment uptake has increased among current PWID, a priority population for treatment. Efforts to maintain this uptake through linking current PWID with treatment providers through harm reduction services such as opioid substitution therapy, needle and syringe programs, and outreach services are required to meet incidence and mortality reduction targets.

Opioid substitution therapy is associated with increased detection of hepatitis C virus infection: a 15-year observational cohort study

BACKGROUND

Strategies are needed to enhance screening of hepatitis C virus (HCV) infection among people who inject drugs to improve engagement in HCV treatment, and stem the growing burden of HCV-related morbidity and mortality.

METHODS

We linked routinely collected data on enrolment in opioid substitution therapy (OST) and HCV notifications. We calculated rates of incident HCV notifications, and compared rates in and out of OST.

RESULTS

Following adjustment for sex, age and calendar period, rates of incident HCV notification were significantly higher during periods of OST, compared to periods out of OST (adjusted incident rate ratio: 1.91; 95% confidence interval: 1.86, 1.97). This effect was seen across multiple treatment periods.

CONCLUSIONS

HCV screening in OST settings increases detection of HCV infection among people who inject drugs.