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Screening, Linkage to Care and Treatment of Hepatitis C Infection in Primary Care Setting in the South of Italy. Life (Basel) 2020; 10:life10120359. [PMID: 33352991 PMCID: PMC7766029 DOI: 10.3390/life10120359] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 12/09/2022] Open
Abstract
Hepatitis C virus (HCV) infection remains a pressing public health issue. Our aim is to assess the linkage to care of patients with HCV diagnosis and to support the proactive case-finding of new HCV-infected patients in an Italian primary care setting. This was a retrospective cohort study of 44 general practitioners (GPs) who managed 63,955 inhabitants in the Campania region. Adults with already known HCV diagnosis or those with HCV high-risk profile at June 2019 were identified and reviewed by GPs to identify newly diagnosed of HCV and to assess the linkage to care and treatment for the HCV patients. Overall, 698 HCV patients were identified, 596 with already known HCV diagnosis and 102 identified by testing the high-risk group (2614 subjects). The 38.8% were already treated with direct-acting antivirals, 18.9% were referred to the specialist center and 42.3% were not sent to specialist care for treatment. Similar proportions were found for patients with an already known HCV diagnosis and those newly diagnosed. Given that the HCV infection is often silent, case-finding needs to be proactive and based on risk information. Our findings suggested that there needs to be greater outreach, awareness and education among GPs in order to enhance HCV testing, linkage to care and treatment.
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Connolly SP, Avramovic G, Cullen W, McHugh T, O'Connor E, Mc Combe G, Crowley D, Naughton AM, Horan A, Lambert JS. HepCare Ireland-a service innovation project. Ir J Med Sci 2020; 190:587-595. [PMID: 32761548 DOI: 10.1007/s11845-020-02324-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 07/23/2020] [Indexed: 10/23/2022]
Abstract
Hepatitis C virus (HCV) remains a major cause of morbidity and death worldwide, with prevalence highest among people who inject drugs (PWID), homeless populations and prisoners. The World Health Organization has published targets to be achieved by 2030 as part of its global health sector strategy to eliminate viral hepatitis. Recent innovations in testing and treatment of HCV mean such goals are achievable with effective infrastructure, political will and funding. 'HepCare Europe' was a 3-year, EU-funded project involving four member states. It sought to develop, implement and evaluate interventions to improve HCV outcomes through multiple-level interventions, running between 2016 and 2019. This paper aims to summarize the methods and present the aggregate cascade of care figures for the Irish components of HepCare. 'HepCare Ireland' contained five integrated work packages: HepCheck, HepLink, HepFriend, HepEd and HepCost. Interventions included intensified screening, community-based assessment, linkage to specialist care, peer training and support, multidisciplinary educational resources and cost-effectiveness analysis. A total of 812 participants were recruited across the three clinical work packages in Ireland. Two hundred and fifty-seven (31.7%) of the tested participants had an HCV antibody-positive result, with 162 (63.0%) testing positive for HCV RNA. At the time of writing (6th of November 2019), 57 (54.8%) of participants put on treatment had achieved SVR12, with 44 (42.3%) still undergoing treatment. In HepCheck, HepLink. HepEd and HepFriend, we demonstrate a series of interventions to improve Irish HCV outcomes. Our findings highlight the benefits of multilevel interventions in HCV care.
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Affiliation(s)
- Stephen P Connolly
- Mater Misericordiae University Hospital, Dublin 7, Ireland. .,University College Dublin, Dublin, Ireland.
| | | | | | - Tina McHugh
- Mater Misericordiae University Hospital, Dublin 7, Ireland
| | | | | | - Des Crowley
- University College Dublin, Dublin, Ireland.,Irish Prison Service, Longford, Ireland
| | | | | | - John S Lambert
- Mater Misericordiae University Hospital, Dublin 7, Ireland.,University College Dublin, Dublin, Ireland
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3
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Williams J, Miners A, Harris R, Mandal S, Simmons R, Ireland G, Hickman M, Gore C, Vickerman P. Cost-Effectiveness of One-Time Birth Cohort Screening for Hepatitis C as Part of the National Health Service Health Check Program in England. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2019; 22:1248-1256. [PMID: 31708061 DOI: 10.1016/j.jval.2019.06.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/14/2019] [Accepted: 06/28/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND AND OBJECTIVES Birth cohort screening for the hepatitis C virus (HCV) has been implemented in the US, but there is little evidence of its cost-effectiveness in England. We aim to evaluate the cost-effectiveness of one-time HCV screening for individuals born between 1950 and 1979 as part of the National Health Service health check in England, a health check for adults aged 40 to 74 years in primary care. METHODS A Markov model was developed to analyze add-on HCV testing to the National Health Service health check for individuals in birth cohorts between 1950 and 1979, versus current background HCV testing only, over a lifetime horizon. The model used data from a back-calculation model of the burden of HCV in England, sentinel surveillance of HCV testing, and published literature. Results are presented from a health service perspective in pounds in 2017, as incremental cost-effectiveness ratios per quality-adjusted life years gained. RESULTS The base-case incremental cost-effectiveness ratios ranged from £7648 to £24 434, and £18 681 to £46 024, across birth cohorts when considering 2 sources of HCV transition probabilities. The intervention is most likely to be cost-effective for those born in the 1970s, and potentially cost-effective for those born from 1955 to 1969. The model results were most sensitive to the source of HCV transition probabilities, the probability of referral and receiving treatment, and the HCV prevalence among testers. The maximum value of future research across all birth cohorts was £11.3 million at £20 000 per quality-adjusted life years gained. CONCLUSION Birth cohort screening is likely to be cost-effective for younger birth cohorts, although considerable uncertainty exists for other birth cohorts. Further studies are warranted to reduce uncertainty in cost-effectiveness and consider the acceptability of the intervention.
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Affiliation(s)
- Jack Williams
- Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, England, UK; The National Institute for Health Research Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections at University College London, England, UK.
| | - Alec Miners
- Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, England, UK; The National Institute for Health Research Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections at University College London, England, UK
| | - Ross Harris
- National Infection Service, Public Health England, Colindale, England, UK
| | - Sema Mandal
- The National Institute for Health Research Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections at University College London, England, UK; National Infection Service, Public Health England, Colindale, England, UK
| | - Ruth Simmons
- The National Institute for Health Research Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections at University College London, England, UK; National Infection Service, Public Health England, Colindale, England, UK
| | - Georgina Ireland
- The National Institute for Health Research Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections at University College London, England, UK; National Infection Service, Public Health England, Colindale, England, UK
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, England, UK; The National Institute for Health Research Health Protection Research Unit in Evaluation of Interventions, England, UK
| | | | - Peter Vickerman
- The National Institute for Health Research Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections at University College London, England, UK; Population Health Sciences, Bristol Medical School, University of Bristol, England, UK; The National Institute for Health Research Health Protection Research Unit in Evaluation of Interventions, England, UK
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Harrison GI, Murray K, Gore R, Lee P, Sreedharan A, Richardson P, Hughes AJ, Wiselka M, Gelson W, Unitt E, Ratcliff K, Orton A, Trinder K, Simpson C, Ryder SD, Oelbaum S, Foster GR, Christian A, Smith S, Thomson BJ, Reynolds R, Harris M, Hickman M, Irving WL. The Hepatitis C Awareness Through to Treatment (HepCATT) study: improving the cascade of care for hepatitis C virus-infected people who inject drugs in England. Addiction 2019; 114:1113-1122. [PMID: 30694582 DOI: 10.1111/add.14569] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 09/17/2018] [Accepted: 01/24/2019] [Indexed: 01/23/2023]
Abstract
BACKGROUND AND AIMS Previous studies have shown low rates of diagnosis and treatment of hepatitis C virus (HCV) infection in people who inject drugs (PWID). Our aims were to test the effect of a complex intervention [Hepatitis C Awareness Through to Treatment (HepCATT)] in drug and alcohol clinics-primarily, on engagement of HCV-positive PWID with therapy and, secondarily, on testing for HCV, referral to hepatology services and start of HCV treatment. DESIGN AND SETTING A non-randomized pilot study in three specialist addiction clinics in England comparing an intervention year (starting between September 2015 and February 2016) with a baseline year (2014), together with three control clinics. PARTICIPANTS Analysis included all attendees at the intervention and control specialist addiction clinics identified as PWID. INTERVENTION The intervention comprised the placement of a half-time facilitator in each clinic for 12 months with the brief to increase diagnosis of HCV infection within clients at those services and the engagement of diagnosed individuals with an appropriate care pathway. The facilitator undertook various activities, which could include training of key workers, direct interaction with clients, streamlining and support for hepatology appointments and introduction of dried blood-spot testing. MEASUREMENTS For each clinic and period, we obtained the total number of clients and, as relevant, their status as PWID, tested for HCV, known HCV-positive, engaged with HCV therapy or treated. FINDINGS Compared with baseline, there was strong evidence that engagement with HCV therapy in the intervention year increased (P < 0.001) more in the HepCATT centres than controls, up + 31 percentage points [95% confidence interval (CI) = 19-43] versus -12 (CI = -31 to + 6) and odds ratio (OR) = 9.99 (CI = 4.42-22.6) versus 0.35 (CI = 0.08-1.56). HepCATT centres also had greater increases in HCV testing (OR = 3.06 versus 0.78, P < 0.001), referral to hepatology (OR = 9.60 versus 0.56, P < 0.001) and treatment initiation (OR = 9.5 versus 0.74, P < 0.001). CONCLUSIONS Introducing a half-time facilitator into drug and alcohol clinics in England increased engagement of HCV-positive people who inject drugs with hepatitis C virus care pathways, with increased uptake also of testing, referral to hepatology and initiation of treatment.
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Affiliation(s)
- Graham I Harrison
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - Karen Murray
- United Lincolnshire Hospitals Lincoln County Hospital, Lincoln, UK
| | - Roxanne Gore
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | | | | | - Paul Richardson
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | | | - Martin Wiselka
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Will Gelson
- Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Esther Unitt
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | | | | | | | | | | | | | | | | | | | - Rosy Reynolds
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Magdalena Harris
- Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Matthew Hickman
- Population Health Sciences, University of Bristol, Bristol, UK
| | - William L Irving
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
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Munang M, Smit E, Barnett T, Atherton C, Tahir M, Atabani SF. Outcomes and costs of single-step hepatitis C testing in primary care, Birmingham, United Kingdom. Public Health 2019; 166:40-44. [PMID: 30448691 DOI: 10.1016/j.puhe.2018.09.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 08/31/2018] [Accepted: 09/18/2018] [Indexed: 01/21/2023]
Abstract
OBJECTIVES In UK laboratories, the diagnostic algorithm for chronic hepatitis C (HCV) infection commonly requires two serological assays to confirm anti-HCV-antibody positivity in a serum sample followed by HCV RNA detection in a second whole-blood sample (two-step testing algorithm). A single-step algorithm (both anti-HCV antibodies and RNA tested on an initial serum specimen) has been advocated to reduce attrition rates from the care pathway. STUDY DESIGN To investigate the feasibility, clinical impact and relative costs of switching from a two-step to single-step testing algorithm in the laboratory, a pilot study on unselected primary care requests was undertaken. METHODS All primary care patients tested for HCV infection from December 2013 to April 2016 were included. The single-step testing algorithm was introduced in March 2015. Before this, the two-step algorithm was used. Patients were followed up until August 2016. RESULTS RNA quantitation in plasma was within one log of serum values for 21 paired samples. Although all patients in the single-step algorithm received an RNA test, only 70% completed the two-step testing algorithm; differences in referral rates to specialist care was due to 30% of HCV antibody-positive patients in the two-step algorithm not having follow-up whole-blood sampling for HCV RNA testing. Costs per new diagnosis and new diagnosis referred to specialist care were lower in single-step testing by £94.32 and £144.25, respectively. CONCLUSION This study provides further evidence that a single-step testing algorithm, as recommended in the UK Standards for Microbiology Investigation, works in practice and should be the standard of care for screening for chronic HCV.
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Affiliation(s)
- M Munang
- Department of Infection, Heart of England NHS Foundation Trust, Bordesley Green East, Birmingham B9 5SS, United Kingdom
| | - E Smit
- Public Health England Birmingham Laboratory, National Infection Service, University Hospitals Birmingham Foundation Trust, Bordesley Green East, Birmingham B9 5SS, United Kingdom
| | - T Barnett
- Public Health England Birmingham Laboratory, National Infection Service, University Hospitals Birmingham Foundation Trust, Bordesley Green East, Birmingham B9 5SS, United Kingdom
| | - C Atherton
- Public Health England Birmingham Laboratory, National Infection Service, University Hospitals Birmingham Foundation Trust, Bordesley Green East, Birmingham B9 5SS, United Kingdom
| | - M Tahir
- West Midlands East Health Protection Team, Public Health England, 5 St Philip's Place, Birmingham B3 2PW, United Kingdom
| | - S F Atabani
- Public Health England Birmingham Laboratory, National Infection Service, University Hospitals Birmingham Foundation Trust, Bordesley Green East, Birmingham B9 5SS, United Kingdom.
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Identifying and classifying indicators affected by performing clinical pathways in hospitals: a scoping review. INT J EVID-BASED HEA 2018; 16:3-24. [PMID: 29176429 DOI: 10.1097/xeb.0000000000000126] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
AIM To analyse the evidence regarding indicators affected by clinical pathways (CPW) in hospitals and offer suggestions for conducting comprehensive systematic reviews. METHODS We conducted a systematic scoping review and searched the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, Scopus, OVID, Science Direct, ProQuest, EMBASE and PubMed. We also reviewed the reference lists of included studies. The criteria for inclusion of studies included experimental and quasi-experimental studies, implementing CPW in secondary and tertiary hospitals and investigating at least one indicator. Quality of included studies was assessed by two authors independently using the Critical Appraisal Skills Program for clinical trials and cohort studies and the Joanna Briggs Institute Critical Appraisal Tool for Quasi-Experimental Studies. RESULTS Forty-seven out of 2191 studies met the eligibility and inclusion criteria. The majority of included studies had pretest-posttest quasi-experimental design and had been done in developed countries, especially the United States. The investigation of evidence resulted in identifying 62 indicators which were classified into three categories: input indicators, process and output indicators and outcome indicators. Outcome indicators were more frequent than other indicators. Complication rate, hospital costs and length of hospital stay were dominant in their own category. Indicators such as quality of life and adherence to guidelines have been considered in studies that were done in recent years. CONCLUSION Implementing CPW can affect different types of indicators such as input, process, output and outcome indicators, although outcome indicators capture more attention than other indicators. Patient-related indicators were dominant outcome indicators, whereas professional indicators and organizational factors were considered less extensively. WHAT IS KNOWN ABOUT THE TOPIC?: WHAT DOES THIS ARTICLE ADD?
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Simmons R, Ireland G, Irving W, Hickman M, Sabin C, Ijaz S, Ramsay M, Lattimore S, Mandal S. Establishing the cascade of care for hepatitis C in England-benchmarking to monitor impact of direct acting antivirals. J Viral Hepat 2018; 25:482-490. [PMID: 29239130 DOI: 10.1111/jvh.12844] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 10/31/2017] [Indexed: 01/01/2023]
Abstract
Little is known about engagement and retention in care of people diagnosed with chronic hepatitis C (HCV) in England. Establishing a cascade of care informs targeted interventions for improving case finding, referral, treatment uptake and retention in care. Using data from the sentinel surveillance of blood-borne virus (SSBBV) testing between 2005 and 2014, we investigate the continuum of care of those tested for HCV in England. Persons ≥1 year old with an anti-HCV test and subsequent RNA tests between 2005 and 2014 reported to SSBBV were collated. We describe the cascade of care, as the patient pathway from a diagnostic test, referral into care, treatment and patient outcomes. Between 2005 and 2014, 2 390 507 samples were tested for anti-HCV, corresponding to 1 766 515 persons. A total of 53 038 persons (35 190 men and 17 165 women) with anti-HCV positive were newly reported to SSBBV. An RNA test was conducted on 77.0% persons who were anti-HCV positive, 72.3% of whom were viraemic (RNA positive) during this time period, 21.4% had evidence of treatment and 3130 49.5% had evidence of a sustained virological response (SVR). In multivariable models, confirmation of viraemia by RNA test varied by age and region/test setting; evidence of treatment varied by age, year of test and region/test setting; and SVR varied by age, year of test and region/setting of test. In conclusion, our findings provide HCV cascade of care estimates prior to the introduction of direct acting antivirals. These findings provide important baseline cascade estimates to benchmark progress towards elimination of HCV as a major public health threat.
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Affiliation(s)
- R Simmons
- Immunisation, Hepatitis, and Blood Safety Department, Public Health England, London, UK.,The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections, University College London, London, UK
| | - G Ireland
- Immunisation, Hepatitis, and Blood Safety Department, Public Health England, London, UK.,The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections, University College London, London, UK
| | - W Irving
- Gastrointestinal and Liver Disorders Theme, NIHR Nottingham Biomedical Research Centre at the Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - M Hickman
- School of Social and Community Medicine, NIHR HPRU in Evaluation, University of Bristol, Bristol, UK
| | - C Sabin
- The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections, University College London, London, UK.,Infection & Population Health, Institute for Global Health, University College London, London, UK
| | - S Ijaz
- The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections, University College London, London, UK.,Blood Borne Virus Unit, Public Health England, London, UK
| | - M Ramsay
- Immunisation, Hepatitis, and Blood Safety Department, Public Health England, London, UK
| | - S Lattimore
- Immunisation, Hepatitis, and Blood Safety Department, Public Health England, London, UK.,The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections, University College London, London, UK
| | - S Mandal
- Immunisation, Hepatitis, and Blood Safety Department, Public Health England, London, UK.,The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections, University College London, London, UK
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Hashim A, O’Sullivan M, Williams H, Verma S. Developing a community HCV service: project ITTREAT (integrated community-based test - stage - TREAT) service for people who inject drugs. Prim Health Care Res Dev 2018; 19:110-120. [PMID: 29199921 PMCID: PMC6452958 DOI: 10.1017/s1463423617000731] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 09/05/2017] [Accepted: 10/08/2017] [Indexed: 12/19/2022] Open
Abstract
Background and aims Majority of the individuals with hepatitis C virus (HCV) infection in England are people who inject drugs, a vulnerable and disenfranchised cohort with poor engagement with secondary care. Our aim is to describe our experiences in setting up a successful nurse led HCV service at a substance misuse service (SMS). METHODS We justify the need for a community HCV service and review the different community based models. Our experiences in engaging with stakeholders, obtaining funding, service set up, challenges faced and key recommendations are discussed. Finally, a summary of interim clinical outcomes is presented. RESULTS A successful community based "one-stop" nurse led HCV service was set up in Dec 2013 at a large SMS. It provides all aspects of care (blood borne virus screening, non-invasive assessment of hepatic fibrosis, Hepatology input, HCV treatment, peer mentor, social and psychiatrist support, and opiod substitution) at one site. Interim clinical data indicate high service uptake with HCV treatment outcomes comparable to secondary care. CONCLUSIONS The advent of direct acting antivirals provides a unique opportunity for HCV elimination in England by 2030. Our "one-stop" integrated and multidisciplinary community HCV model suggests that HCV care can be successfully delivered outside of a hospital setting and warrants national adoption.
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Affiliation(s)
- Ahmed Hashim
- Department of Medicine, Brighton and Sussex Medical School, Brighton, UK
- Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospital, Brighton, UK
| | - Margaret O’Sullivan
- Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospital, Brighton, UK
- Pavilions Drug & Alcohol Services, Richmond House, Brighton, UK
| | - Hugh Williams
- Pavilions Drug & Alcohol Services, Richmond House, Brighton, UK
- Surrey and Borders Partnership NHS foundation trust
| | - Sumita Verma
- Department of Medicine, Brighton and Sussex Medical School, Brighton, UK
- Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospital, Brighton, UK
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Falla AM, Veldhuijzen IK, Ahmad AA, Levi M, Hendrik Richardus J. Limited access to hepatitis B/C treatment among vulnerable risk populations: an expert survey in six European countries. Eur J Public Health 2017; 27:302-306. [PMID: 27542982 PMCID: PMC5444238 DOI: 10.1093/eurpub/ckw100] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background To investigate access to treatment for chronic hepatitis B/C among six vulnerable patient/population groups at-risk of infection: undocumented migrants, asylum seekers, people without health insurance, people with state insurance, people who inject drugs (PWID) and people abusing alcohol. Methods An online survey among experts in gastroenterology, hepatology and infectious diseases in 2012 in six EU countries: Germany, Hungary, Italy, the Netherlands, Spain and the UK. A four-point ordinal scale measured access to treatment (no, some, significant or complete restriction). Results From 235 recipients, 64 responses were received (27%). Differences in access between and within countries were reported for all groups except people with state insurance. Most professionals, other than in Spain and Hungary, reported no or few restrictions for PWID. Significant/complete treatment restriction was reported for all groups by the majority in Hungary and Spain, while Italian respondents reported no/few restrictions. Significant/complete restriction was reported for undocumented migrants and people without health insurance in the UK and Spain. Opinion about undocumented migrants in Germany and the Netherlands was divergent. Conclusions Although effective chronic hepatitis B/C treatment exists, limited access among vulnerable patient populations was seen in all study countries. Discordance of opinion about restrictions within countries is seen, especially for groups for whom the health care system determines treatment access, such as undocumented migrants, asylum seekers and people without health insurance. This suggests low awareness, or lack, of entitlement guidance among clinicians. Expanding treatment access among risk groups will contribute to reducing chronic viral hepatitis-associated avoidable morbidity and mortality.
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Affiliation(s)
- Abby M Falla
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Division of Infectious Disease Control, Municipal Public Health Service Rotterdam-Rijnmond, Rotterdam, The Netherlands
| | - Irene K Veldhuijzen
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Division of Infectious Disease Control, Municipal Public Health Service Rotterdam-Rijnmond, Rotterdam, The Netherlands
| | - Amena A Ahmad
- Department of Health Sciences, Hamburg University of Applied Sciences, Faculty Life Sciences/Public Health Research, Hamburg, Germany
| | - Miriam Levi
- Department of Health Sciences, Division of Hygiene, Preventive Medicine and Public Health, University of Florence, Florence, Italy
| | - Jan Hendrik Richardus
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Division of Infectious Disease Control, Municipal Public Health Service Rotterdam-Rijnmond, Rotterdam, The Netherlands
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10
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Falla AM, Veldhuijzen IK, Ahmad AA, Levi M, Richardus JH. Language support for linguistic minority chronic hepatitis B/C patients: an exploratory study of availability and clinicians' perceptions of language barriers in six European countries. BMC Health Serv Res 2017; 17:150. [PMID: 28219385 PMCID: PMC5319068 DOI: 10.1186/s12913-017-2095-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 02/11/2017] [Indexed: 12/23/2022] Open
Abstract
Background Language support for linguistic minorities can improve patient safety, clinical outcomes and the quality of health care. Most chronic hepatitis B/C infections in Europe are detected among people born in endemic countries mostly in Africa, Asia and Central/Eastern Europe, groups that may experience language barriers when accessing health care services in their host countries. We investigated availability of interpreters and translated materials for linguistic minority hepatitis B/C patients. We also investigated clinicians’ agreement that language barriers are explanations of three scenarios: the low screening uptake of hepatitis B/C screening, the lack of screening in primary care, and why cases do not reach specialist care. Methods An online survey was developed, translated and sent to experts in five health care services involved in screening or treating viral hepatitis in six European countries: Germany, Hungary, Italy, the Netherlands, Spain and the United Kingdom (UK). The five areas of health care were: general practice/family medicine, antenatal care, health care for asylum seekers, sexual health and specialist secondary care. We measured availability using a three-point ordinal scale (‘very common’, ‘variable or not routine’ and ‘rarely or never’). We measured agreement using a five-point Likert scale. Results We received 238 responses (23% response rate, N = 1026) from representatives in each health care field in each country. Interpreters are common in the UK, the Netherlands and Spain but variable or rare in Germany, Hungary and Italy. Translated materials are rarely/never available in Hungary, Italy and Spain but commonly or variably available in the Netherlands, Germany and the UK. Differing levels of agreement that language barriers explain the three scenarios are seen across the countries. Professionals in countries with most infrequent availability (Hungary and Italy) disagree strongest that language barriers are explanations. Conclusions Our findings show pronounced differences between countries in availability of interpreters, differences that mirror socio-cultural value systems of ‘difference-sensitive’ and ‘difference-blindness’. Improved language support is needed given the complex natural history of hepatitis B/C, the recognised barriers to screening and care, and the large undiagnosed burden among (potentially) linguistic minority migrant groups. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2095-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Abby M Falla
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands. .,Division of Infectious Disease Control, Municipal Public Health Service Rotterdam-Rijnmond, Rotterdam, The Netherlands.
| | - Irene K Veldhuijzen
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Division of Infectious Disease Control, Municipal Public Health Service Rotterdam-Rijnmond, Rotterdam, The Netherlands
| | - Amena A Ahmad
- Department of Health Sciences, Faculty Life Sciences / Public Health Research, Hamburg University of Applied Sciences, Hamburg, Germany
| | - Miriam Levi
- Department of Health Sciences, Division of Hygiene, Preventive Medicine and Public Health, University of Florence, Florence, Italy
| | - Jan Hendrik Richardus
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Division of Infectious Disease Control, Municipal Public Health Service Rotterdam-Rijnmond, Rotterdam, The Netherlands
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Martin NK, Vickerman P, Brew IF, Williamson J, Miners A, Irving WL, Saksena S, Hutchinson SJ, Mandal S, O’Moore E, Hickman M. Is increased hepatitis C virus case-finding combined with current or 8-week to 12-week direct-acting antiviral therapy cost-effective in UK prisons? A prevention benefit analysis. Hepatology 2016; 63:1796-808. [PMID: 26864802 PMCID: PMC4920048 DOI: 10.1002/hep.28497] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 02/08/2016] [Indexed: 12/31/2022]
Abstract
UNLABELLED Prisoners have a high prevalence of hepatitis C virus (HCV), but case-finding may not have been cost-effective because treatment often exceeded average prison stay combined with a lack of continuity of care. We assessed the cost-effectiveness of increased HCV case-finding and treatment in UK prisons using short-course therapies. A dynamic HCV transmission model assesses the cost-effectiveness of doubling HCV case-finding (achieved through introducing opt-out HCV testing in UK pilot prisons) and increasing treatment in UK prisons compared to status quo voluntary risk-based testing (6% prison entrants/year), using currently recommended therapies (8-24 weeks) or interferon (IFN)-free direct-acting antivirals (DAAs; 8-12 weeks, 95% sustained virological response, £3300/week). Costs (British pounds, £) and health utilities (quality-adjusted life years) were used to calculate mean incremental cost-effectiveness ratios (ICERs). We assumed 56% referral and 2.5%/25% of referred people who inject drugs (PWID)/ex-PWID treated within 2 months of diagnosis in prison. PWID and ex-PWID or non-PWID are in prison an average 4 and 8 months, respectively. Doubling prison testing rates with existing treatments produces a mean ICER of £19,850/quality-adjusted life years gained compared to current testing/treatment and is 45% likely to be cost-effective under a £20,000 willingness-to-pay threshold. Switching to 8-week to 12-week IFN-free DAAs in prisons could increase cost-effectiveness (ICER £15,090/quality-adjusted life years gained). Excluding prevention benefit decreases cost-effectiveness. If >10% referred PWID are treated in prison (2.5% base case), either treatment could be highly cost-effective (ICER<£13,000). HCV case-finding and IFN-free DAAs could be highly cost-effective if DAA cost is 10% lower or with 8 weeks' duration. CONCLUSIONS Increased HCV testing in UK prisons (such as through opt-out testing) is borderline cost-effective compared to status quo voluntary risk-based testing under a £20,000 willingness to pay with current treatments but likely to be cost-effective if short-course IFN-free DAAs are used and could be highly cost-effective if PWID treatment rates were increased. (Hepatology 2016;63:1796-1808).
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Affiliation(s)
- Natasha K Martin
- Division of Global Public Health, University of California San Diego, USA
- School of Social and Community Medicine, University of Bristol, UK
| | - Peter Vickerman
- School of Social and Community Medicine, University of Bristol, UK
| | | | | | - Alec Miners
- London School of Hygiene and Tropical Medicine, UK
| | | | | | | | | | | | - Matthew Hickman
- School of Social and Community Medicine, University of Bristol, UK
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12
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Levi M, Falla A, Taddei C, Ahmad A, Veldhuijzen I, Niccolai G, Bechini A. Referral of newly diagnosed chronic hepatitis B and C patients in six EU countries: results of the HEPscreen Project. Eur J Public Health 2016; 26:561-9. [PMID: 27095794 DOI: 10.1093/eurpub/ckw054] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Effective linkage to specialist care following screening is crucial for secondary prevention of chronic viral hepatitis-related consequences. METHODS To explore the frequency of referral of patients to secondary care from the health services involved in screening and to gather information on the services responsible for the provision of post-test counselling and contact tracing, four online surveys were conducted among general practitioners (GP), and experts working in sexual health services (SHS), antenatal care (ANC) and specialist secondary care in Germany, Hungary, Italy, The Netherlands, Spain and the UK. RESULTS Overall, 60% of GPs report referring all patients to specialist care. Although 67% of specialists commonly receive patients referred by GPs, specialists in Germany rarely or never receive patients from ANC or from centres testing injecting drug users; and specialists in the Netherlands, Hungary and Germany rarely receive patients from SHS. Gastroenterologists/hepatologists are the professionals mainly responsible for the provision of counselling following a positive diagnosis of viral hepatitis according to two-thirds of specialists, 14% of SHS providers and 11% of ANC providers. Almost half of ANC providers (45%) stated that gynaecologists are the professionals responsible for the provision of counselling to positive pregnant women; among SHS providers, only 14% identified SHS as the services responsible. CONCLUSION Our findings suggest the existence of complex/ineffective referral practices or that opportunities to screen risk groups are missed. Recommendations clarifying the services responsible at each step of the referral pathway are needed in order to increase the success of screening programmes.
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Affiliation(s)
- Miriam Levi
- 1 Department of Health Sciences, University of Florence, Viale G. B. Morgagni 48, Florence, 50134, Italy
| | - Abby Falla
- 2 Department of Public Health, Erasmus MC, University Medical Center Rotterdam, The Netherlands 3 Division of Infectious Disease Control, Public Health Service Rotterdam-Rijnmond, Rotterdam, The Netherlands
| | - Cristina Taddei
- 1 Department of Health Sciences, University of Florence, Viale G. B. Morgagni 48, Florence, 50134, Italy
| | - Amena Ahmad
- 4 Department of Health Sciences, Hamburg University of Applied Sciences, Hamburg, Germany
| | - Irene Veldhuijzen
- 2 Department of Public Health, Erasmus MC, University Medical Center Rotterdam, The Netherlands 3 Division of Infectious Disease Control, Public Health Service Rotterdam-Rijnmond, Rotterdam, The Netherlands
| | - Giuditta Niccolai
- 1 Department of Health Sciences, University of Florence, Viale G. B. Morgagni 48, Florence, 50134, Italy
| | - Angela Bechini
- 1 Department of Health Sciences, University of Florence, Viale G. B. Morgagni 48, Florence, 50134, Italy
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Poll R, Allmark P, Tod AM. Reasons for missed appointments with a hepatitis C outreach clinic: A qualitative study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2016; 39:130-137. [PMID: 27939298 DOI: 10.1016/j.drugpo.2015.12.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 11/07/2015] [Accepted: 12/10/2015] [Indexed: 01/08/2023]
Abstract
BACKGROUND Non-attendance in drug service hepatitis C outreach clinics means clients miss the opportunity of being given lifestyle advice and referral to hospital for assessment and treatment. A similar problem is experienced in other services throughout the UK. A qualitative study was undertaken to investigate the problem. METHODS Clients with a history of not attending the outreach clinic were invited to participate during a routine drug clinic appointment. A contact details sheet with a preferred telephone number was completed by those agreeing to take part. Verbal consent was taken and a telephone interview took place. The participants were remunerated for taking part with a five pounds high street voucher. The 'framework method' was used to analyse the data with key themes identified. RESULTS Twenty-eight telephone interviews were undertaken from April to June 2012. All the clients gave 'prima-facie' reasons for non-attendance including 'not a priority' and 'forgot'. However, the study indicates these are insufficient to explain the various experiences and influences. Underlying reasons that impacted upon attendance were identified. These reasons relate to (i) client characteristics e.g. 'priority' to score drugs and the 'cost of travel' and (ii) clinic service e.g. 'difficult journey' to the clinic and timing of the 'appointment'. The reasons operated within a complex context where other factors had an impact including addiction, welfare policy, stigma and the nature of hepatitis C itself. CONCLUSION The study revealed that beneath apparently simple explanations for non-attendance, such as clients' chaotic lifestyle resulting in them forgetting or not being bothered to attend, there were far more complex and varied underlying reasons. This has important implications for drug policy including the need to better incorporate clients' perspectives. Policy that is based only on the simple, surface reasons is unlikely to be effective.
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Affiliation(s)
- Ray Poll
- Department of Infection and Tropical Medicine, The Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, England, United Kingdom.
| | - Peter Allmark
- Centre for Health and Social Care Research, Montgomery House, 32 Collegiate Crescent, Collegiate Campus, Sheffield S10 2BP, England, United Kingdom
| | - Angela M Tod
- Faculty of Human and Medical Sciences, Room 5.319, Jean McFarlane Building, Oxford Road, Manchester M13 9PL, England, United Kingdom
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Abstract
Persons who inject drugs (PWID) are at high risk for infection with and poor outcomes from HIV and hepatitis C virus (HCV). Well-established interventions for HIV/HCV prevention among PWID include syringe access, opioid agonist maintenance treatment, and supervised injection facilities, yet these interventions remain unavailable or inadequately resourced in much of the world. We review recent literature on biomedical and behavioral interventions to reduce the burden of HIV/HCV among PWID, with an emphasis on randomized controlled trials and quasi-experimental studies. Since 2013, there have been significant advancements in utilizing antiviral therapy and behavioral interventions for prevention among PWID, including approaches that address the unique needs of couples and sex workers. In addition, there have been significant developments in pharmacotherapies for substance use and the implementation of naloxone for opioid overdose prevention. Notwithstanding multiple ongoing structural challenges in delivering HIV/HCV prevention interventions to PWID, these emerging and rigorously evaluated interventions expand possibilities for prevention among PWID.
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15
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Howes N, Lattimore S, Irving WL, Thomson BJ. Clinical Care Pathways for Patients With Hepatitis C: Reducing Critical Barriers to Effective Treatment. Open Forum Infect Dis 2016; 3:ofv218. [PMID: 26900576 PMCID: PMC4759583 DOI: 10.1093/ofid/ofv218] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 12/28/2015] [Indexed: 12/17/2022] Open
Abstract
New therapies with the potential to eradicate HCV are available. Engagement of infected individuals with care is the major barrier to realising this vision. We describe an enhanced care pathway leading to a sustained increase in indices of engagement. Background. Engagement of individuals infected with hepatitis C virus (HCV) with care pathways remains a major barrier to realizing the benefits of new and more effective antiviral therapies. After an exploratory study, we have undertaken an evidence-based redesign of care pathways for HCV, including the following: (1) reflex testing of anti-HCV-positive samples for HCV RNA; (2) annotation of laboratory results to recommend referral of actively infected patients to specialist clinics; (3) educational programs for primary care physicians and nurses; and (4) the establishment of needs-driven community clinics in substance misuse services. Methods. In this study, we conducted a retrospective cohort study of progression through care pathways of individuals with a new diagnosis of HCV infection made between January 2010 and January 2012. We also analyzed patient flow through new care pathways and compared this with our baseline study of identical design. Results. A total of 28 980 samples were tested for anti-HCV antibody during the study period and yielded 273 unique patients with a new diagnosis of HCV infection. Of these, 38% were tested in general practice, 21% were tested in substance misuse services, 23% were tested in secondary care, and 18% were tested in local prisons. Overall, 80% of patients were referred to specialist clinics, 70% attended for assessment, and 38% commenced treatment, in comparison to 49%, 27%, and 10%, respectively, in the baseline study. Referral rates from all testing sources improved. Conclusions. This study provides timely evidence that progression through care pathways can be enhanced, and it demonstrates reduction of key barriers to eradication of HCV.
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Affiliation(s)
| | - Sam Lattimore
- National Health Service Blood and Transplant/Public Health England Joint Epidemiology Unit, Immunisation, Hepatitis and Blood Safety Department , National Centre for Infectious Disease Surveillance and Control , London , United Kingdom
| | - William Lucien Irving
- National Institute for Health Research, Nottingham Digestive Diseases Biomedical Research Unit , Nottingham University Hospitals
| | - Brian James Thomson
- National Institute for Health Research, Nottingham Digestive Diseases Biomedical Research Unit , Nottingham University Hospitals
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16
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Bechini A, Falla A, Ahmad A, Veldhuijzen I, Boccalini S, Porchia B, Levi M. Identification of hepatitis B and C screening and patient management guidelines and availability of training for chronic viral hepatitis among health professionals in six European countries: results of a semi-quantitative survey. BMC Infect Dis 2015; 15:353. [PMID: 26286525 PMCID: PMC4545377 DOI: 10.1186/s12879-015-1104-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 08/12/2015] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND As part of the EU funded project "HEPscreen", the aim of this study is to identify hepatitis B and C screening and patient management guidelines, to assess the awareness of these among health professionals (HPs) and to explore the availability of hepatitis B/C training programmes for HPs in Germany, Italy, the Netherlands, the UK, Spain and Hungary. METHODS A comprehensive literature search through the main scientific databases was performed to retrieve guidelines, following which an online survey was developed and sent to HPs in six areas of health care, including public health, to verify whether HPs are aware of these guidelines, to retrieve additional guidelines and to find out whether specific professional training is available. RESULTS Twelve national guidelines were identified through the literature search. Of the 268 respondents, 80 % were aware of hepatitis B guidelines and 73 % were aware of hepatitis C guidelines in their country. The national guidelines identified through the literature search were mentioned by 1/3 of HPs in the UK and Germany, 13 % of HPs in the Netherlands, 14 % in Italy and 4 % in Spain. An additional 41 hepatitis B/C related guidance documents were retrieved through the online survey: 15 in the UK, seven in Hungary, six in Italy, five in the Netherlands, four in Germany and four in Spain. Availability of training programmes to improve skills and knowledge in viral hepatitis was most often reported in the Netherlands, with 82 % indicating availability and just 10 % indicating no availability, and least commonly in Italy, with 42 % indicating yes but 40 % indicating no. Availability was also reported by the majority in the UK, Hungary and Spain, while in Germany the majority selected unsure. CONCLUSIONS Results suggest that the scientific databases are not the most important information source of best clinical practice for many HPs. Implementation of best practices requires that guidelines are specifically designed and actively promoted among those who are to follow them. Training can disseminate these best practice recommendations and raise awareness of guidelines. It is therefore encouraging that diverse training about hepatitis B/C is available to the different professional groups.
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Affiliation(s)
- Angela Bechini
- Department of Health Sciences, University of Florence, Florence, Italy.
| | - Abby Falla
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Amena Ahmad
- Department of Health Sciences, Hamburg University of Applied Sciences, Hamburg, Germany.
| | - Irene Veldhuijzen
- Division of Infectious Disease Control, Public Health Service Rotterdam-Rijnmond, Rotterdam, The Netherlands.
| | - Sara Boccalini
- Department of Health Sciences, University of Florence, Florence, Italy.
| | - Barbara Porchia
- Department of Health Sciences, University of Florence, Florence, Italy.
| | - Miriam Levi
- Department of Health Sciences, University of Florence, Florence, Italy.
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17
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Evidence-based interventions to enhance assessment, treatment, and adherence in the chronic Hepatitis C care continuum. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2015; 26:922-35. [PMID: 26077144 DOI: 10.1016/j.drugpo.2015.05.002] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 04/21/2015] [Accepted: 05/07/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND With the explosion of newly available direct acting antiviral (DAA) Hepatitis C virus (HCV) treatments that demonstrate 95% sustained virologic response (SVR) rates, evidence-based strategies are urgently needed to achieve real-world effectiveness in challenging patient populations. While HIV is incurable, lessons from over 30 years of experience overcoming obstacles to the HIV treatment cascade could be applied to the HCV context. METHODS Using Institute of Medicine guidelines, we conducted a systematic review of published interventions from PubMed, Medline, GoogleScholar, EmBASE, and PsychInfo bibliographic databases and citation indices. Abstracts were first screened by three independent reviewers and studies were included if they involved original research, described a specific intervention, were published in English in a peer-reviewed journal between 2001 and 2014, and had full text available. RESULTS Evidence-based interventions to enhance HCV assessment, treatment, and adherence generally fell into one of 4 categories, including those involving: (1) diagnosis or case-finding; (2) linkage to HCV care; (3) pre-therapeutic evaluation or treatment initiation; or (4) treatment adherence. While most available eligible studies described interventions using non-contemporary interferon-based HCV treatments, future research will need to address how these interventions apply to the context of well-tolerated, simple, oral treatment regimens. In some cases, we explored how HIV-specific interventions might be modified to fit the HCV spectrum of care engagement. CONCLUSIONS Evidence-based interventions should be strategically incorporated into HCV treatment implementation efforts to most effectively deliver treatment and maximize treatment outcomes.
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18
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Martin NK, Foster GR, Vilar J, Ryder S, E Cramp M, Gordon F, Dillon JF, Craine N, Busse H, Clements A, Hutchinson SJ, Ustianowski A, Ramsay M, Goldberg DJ, Irving W, Hope V, De Angelis D, Lyons M, Vickerman P, Hickman M. HCV treatment rates and sustained viral response among people who inject drugs in seven UK sites: real world results and modelling of treatment impact. J Viral Hepat 2015; 22:399-408. [PMID: 25288193 PMCID: PMC4409099 DOI: 10.1111/jvh.12338] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Hepatitis C virus (HCV) antiviral treatment for people who inject drugs (PWID) could prevent onwards transmission and reduce chronic prevalence. We assessed current PWID treatment rates in seven UK settings and projected the potential impact of current and scaled-up treatment on HCV chronic prevalence. Data on number of PWID treated and sustained viral response rates (SVR) were collected from seven UK settings: Bristol (37-48% HCV chronic prevalence among PWID), East London (37-48%), Manchester (48-56%), Nottingham (37-44%), Plymouth (30-37%), Dundee (20-27%) and North Wales (27-33%). A model of HCV transmission among PWID projected the 10-year impact of (i) current treatment rates and SVR (ii) scale-up with interferon-free direct acting antivirals (IFN-free DAAs) with 90% SVR. Treatment rates varied from <5 to over 25 per 1000 PWID. Pooled intention-to-treat SVR for PWID were 45% genotypes 1/4 [95%CI 33-57%] and 61% genotypes 2/3 [95%CI 47-76%]. Projections of chronic HCV prevalence among PWID after 10 years of current levels of treatment overlapped substantially with current HCV prevalence estimates. Scaling-up treatment to 26/1000 PWID annually (achieved already in two sites) with IFN-free DAAs could achieve an observable absolute reduction in HCV chronic prevalence of at least 15% among PWID in all sites and greater than a halving in chronic HCV in Plymouth, Dundee and North Wales within a decade. Current treatment rates among PWID are unlikely to achieve observable reductions in HCV chronic prevalence over the next 10 years. Achievable scale-up, however, could lead to substantial reductions in HCV chronic prevalence.
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Affiliation(s)
- N K Martin
- School of Social & Community Medicine, University of BristolBristol, UK,Social and Mathematical Epidemiology Group, London School of Hygiene and Tropical MedicineLondon, UK,
Correspondence: Natasha K. Martin, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK. E-mail:
| | - G R Foster
- Blizard Institute, Queen Mary's University of LondonLondon, UK
| | - J Vilar
- Pennine Acute Hospitals NHS TrustGreater Manchester, UK
| | - S Ryder
- Nottingham University Hospitals NHS TrustNottingham, UK
| | - M E Cramp
- Plymouth Hospital NHS TrustPlymouth, UK
| | - F Gordon
- University of Bristol Health TrustBristol, UK
| | | | - N Craine
- Health Protection WalesBangor, Wales, UK
| | - H Busse
- School of Social & Community Medicine, University of BristolBristol, UK
| | | | - S J Hutchinson
- Glasgow Caledonian UniversityGlasgow, UK,Health Protection ScotlandGlasgow, UK
| | - A Ustianowski
- Pennine Acute Hospitals NHS TrustGreater Manchester, UK
| | | | | | - W Irving
- University of NottinghamNottingham, UK
| | - V Hope
- Public Health EnglandLondon, UK
| | | | - M Lyons
- Health Protection WalesBangor, Wales, UK
| | - P Vickerman
- School of Social & Community Medicine, University of BristolBristol, UK,Social and Mathematical Epidemiology Group, London School of Hygiene and Tropical MedicineLondon, UK
| | - M Hickman
- School of Social & Community Medicine, University of BristolBristol, UK
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19
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Ford C, Bressan J. Ending the mass criminalisation of people who use drugs: a necessary component of the public health response to hepatitis C. BMC Infect Dis 2014; 14 Suppl 6:S4. [PMID: 25253223 PMCID: PMC4178555 DOI: 10.1186/1471-2334-14-s6-s4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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20
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Cramp ME, Rosenberg WM, Ryder SD, Blach S, Parkes J. Modelling the impact of improving screening and treatment of chronic hepatitis C virus infection on future hepatocellular carcinoma rates and liver-related mortality. BMC Gastroenterol 2014; 14:137. [PMID: 25100159 PMCID: PMC4128826 DOI: 10.1186/1471-230x-14-137] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 07/17/2014] [Indexed: 12/14/2022] Open
Abstract
Background The societal, clinical and economic burden imposed by the complications of chronic hepatitis C virus (HCV) infection - including cirrhosis and hepatocellular carcinoma (HCC) - is expected to increase over the coming decades. However, new therapies may improve sustained virological response (SVR) rates and shorten treatment duration. This study aimed to estimate the future burden of HCV-related disease in England if current management strategies remain the same and the impact of increasing diagnosis and treatment of HCV as new therapies become available. Methods A previously published model was adapted for England using published literature and government reports, and validated through an iterative process of three meetings of HCV experts. The impact of increasing diagnosis and treatment of HCV as new therapies become available was modelled and compared to the base-case scenario of continuing current management strategies. To assess the ‘best case’ clinical benefit of new therapies, the number of patients treated was increased by a total of 115% by 2018. Results In the base-case scenario, total viraemic (HCV RNA-positive) cases of HCV in England will decrease from 144,000 in 2013 to 76,300 in 2030. However, due to the slow progression of chronic HCV, the number of individuals with cirrhosis, decompensated cirrhosis and HCC will continue to increase over this period. The model suggests that the ‘best case’ substantially reduces HCV-related hepatic disease and HCV-related liver mortality by 2020 compared to the base-case scenario. The number of HCV-related HCC cases would decrease 50% by 2020 and the number progressing from infection to decompensated cirrhosis would decline by 65%. Therefore, compared to projections of current practices, increasing treatment numbers by 115% by 2018 would reduce HCV-related mortality by 50% by 2020. Conclusions This analysis suggests that with current treatment practices the number of patients developing HCV-related cirrhosis, decompensated cirrhosis and HCC will increase substantially, with HCV-related liver deaths likely to double by 2030. However, increasing diagnosis and treatment rates could optimise the reduction in the burden of disease produced by the new therapies, potentially halving HCV-related liver mortality and HCV-related HCC by 2020.
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Affiliation(s)
| | | | - Steven D Ryder
- NIHR Biomedical Research Unit in Gastrointestinal and Liver Diseases, Nottingham University Hospitals NHS Trust and The University of Nottingham, Nottingham NG7 2UH, UK.
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Abstract
The US faces at least two distinct epidemics of hepatitis C virus infection (HCV), and due largely to revised screening recommendations and novel therapeutic agents, corresponding opportunities. As only 49%-75% of HCV-infected persons in the US are aware of their infection, any chance of addressing HCV in the US is dependent upon screening to identify undiagnosed infections. Most HCV in the US consists of longstanding infections among persons born during 1945-1965 who are suffering escalating rates of liver-related morbidity and mortality. Mathematical modeling supports aggressive action to reach and treat these persons to minimize the subsequent burden of advanced liver disease on patients and the health care system. Incident infection is primarily among persons who inject drugs, less than 10% of whom have been treated for HCV. Expanded screening and treatment of active persons who inject drugs raises the prospect of utilizing "treatment as prevention" to stem the tide of incident HCV infections in this population. HIV-positive men who have sex with men (MSM) represent a population at risk for sexually transmitted HCV who may also benefit from adjusted screening guidelines to identify both acute and chronic infections. Prisoners also represent a critical population for aggressive screening and treatment. Finally, the two-stage testing algorithm for HCV diagnosis is problematic and difficult for patients and providers to navigate. While emerging therapeutics raise the prospect of reducing HCV-related morbidity and mortality, as well as eliminating new infections, major barriers remain with regard to identifying infections, improving access to treatment, and ensuring payer coverage of costly new therapeutic regimens.
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Affiliation(s)
- Phillip O Coffin
- San Francisco Department of Public Health, Substance Use Research Unit, San Francisco, CA, USA
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22
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Mu X, Zhang L, Chang S, Cui W, Zheng Z. Multiplex Microfluidic Paper-based Immunoassay for the Diagnosis of Hepatitis C Virus Infection. Anal Chem 2014; 86:5338-44. [DOI: 10.1021/ac500247f] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Xuan Mu
- Institute
of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, 5 Dongdan Santiao Beijing, 100005 P. R. China
| | - Lin Zhang
- Department
of Laboratory Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, and Peking Union Medical College, 1 Shuaifuyuan Beijing, 100730 P. R. China
| | - Shaoying Chang
- Institute
of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, 5 Dongdan Santiao Beijing, 100005 P. R. China
| | - Wei Cui
- Department
of Laboratory Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, and Peking Union Medical College, 1 Shuaifuyuan Beijing, 100730 P. R. China
| | - Zhi Zheng
- Institute
of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, 5 Dongdan Santiao Beijing, 100005 P. R. China
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McDonald SA, Hutchinson SJ, Innes HA, Allen S, Bramley P, Bhattacharyya D, Carman W, Dillon JF, Fox R, Fraser A, Goldberg DJ, Kennedy N, Mills PR, Morris J, Stanley AJ, Wilks D, Hayes PC. Attendance at specialist hepatitis clinics and initiation of antiviral treatment among persons chronically infected with hepatitis C: examining the early impact of Scotland's Hepatitis C Action Plan. J Viral Hepat 2014; 21:366-76. [PMID: 24716639 DOI: 10.1111/jvh.12153] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2013] [Accepted: 06/27/2013] [Indexed: 01/08/2023]
Abstract
Primary goals of the Hepatitis C Action Plan for Scotland Phase II (May 2008-March 2011) were to increase, among persons chronically infected with the hepatitis C (HCV) virus, attendance at specialist outpatient clinics and initiation on antiviral therapy. We evaluated progress towards these goals by comparing the odds, across time, of (a) first clinic attendance within 12 months of HCV diagnosis (n = 9747) and (b) initiation on antiviral treatment within 12 months of first attendance (n = 5736). Record linkage between the national HCV diagnosis (1996-2009) and HCV clinical (1996-2010) databases and logistic regression analyses were conducted for both outcomes. For outcome (a), 32% and 45% in the respective pre-Phase II (before 1 May 2008) and Phase II periods attended a specialist clinic within 12 months of diagnosis; the odds of attendance within 12 months increased over time (OR = 1.05 per year, 95% CI: 1.04-1.07), but was not significantly greater for persons diagnosed with HCV in the Phase II era, compared with the pre-Phase II era (OR = 1.1, 95% CI: 0.9-1.3), after adjustment for temporal trend. For outcome (b), 13% and 28% were initiated on treatment within 12 months of their first clinic attendance in the pre-Phase II and Phase II periods, respectively. Higher odds of treatment initiation were associated with first clinic attendance in the Phase II (OR = 1.9, 95% CI: 1.5-2.4), compared with the pre-Phase II era. Results were consistent with a positive impact of the Hepatitis C Action Plan on the treatment of chronically infected individuals, but further monitoring is required to confirm a sustained effect.
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Affiliation(s)
- S A McDonald
- Health Protection Scotland, Glasgow, UK; School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
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Lattimore S, Irving W, Collins S, Penman C, Ramsay M, on Behalf of the Collaboration for the Sentinel Surveillance of Blood-Borne Virus Testing. Using surveillance data to determine treatment rates and outcomes for patients with chronic hepatitis C virus infection. Hepatology 2014; 59:1343-50. [PMID: 24214920 PMCID: PMC4258076 DOI: 10.1002/hep.26926] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Accepted: 11/06/2013] [Indexed: 01/29/2023]
Abstract
UNLABELLED The aim of this work was to develop and validate an algorithm to monitor rates of, and response to, treatment of patients infected with hepatitis C virus (HCV) across England using routine laboratory HCV RNA testing data. HCV testing activity between January 2002 and December 2011 was extracted from the local laboratory information systems of a sentinel network of 23 laboratories across England. An algorithm based on frequency of HCV RNA testing within a defined time period was designed to identify treated patients. Validation of the algorithm was undertaken for one center by comparison with treatment data recorded in a clinical database managed by the Trent HCV Study Group. In total, 267,887 HCV RNA test results from 100,640 individuals were extracted. Of these, 78.9% (79,360) tested positive for viral RNA, indicating an active infection, 20.8% (16,538) of whom had a repeat pattern of HCV RNA testing suggestive of treatment monitoring. Annual numbers of individuals treated increased rapidly from 468 in 2002 to 3,295 in 2009, but decreased to 3,110 in 2010. Approximately two thirds (63.3%; 10,468) of those treated had results consistent with a sustained virological response, including 55.3% and 67.1% of those with a genotype 1 and non-1 virus, respectively. Validation against the Trent clinical database demonstrated that the algorithm was 95% sensitive and 93% specific in detecting treatment and 100% sensitive and 93% specific for detecting treatment outcome. CONCLUSIONS Laboratory testing activity, collected through a sentinel surveillance program, has enabled the first country-wide analysis of treatment and response among HCV-infected individuals. Our approach provides a sensitive, robust, and sustainable method for monitoring service provision across England.
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Affiliation(s)
- Sam Lattimore
- Immunization Hepatitis and Blood Safety Department, Public Health EnglandColindale, London, UK
| | - Will Irving
- NIHR Biomedical Research Unit in Gastrointestinal and Liver diseases at Nottingham University Hospitals NHS Trust and the University of NottinghamNottingham, UK
| | - Sarah Collins
- Immunization Hepatitis and Blood Safety Department, Public Health EnglandColindale, London, UK
| | - Celia Penman
- Immunization Hepatitis and Blood Safety Department, Public Health EnglandColindale, London, UK
| | - Mary Ramsay
- Immunization Hepatitis and Blood Safety Department, Public Health EnglandColindale, London, UK
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Hagan LM, Yang Z, Ehteshami M, Schinazi RF. All-oral, interferon-free treatment for chronic hepatitis C: cost-effectiveness analyses. J Viral Hepat 2013; 20:847-57. [PMID: 24304454 DOI: 10.1111/jvh.12111] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Accepted: 03/19/2013] [Indexed: 02/06/2023]
Abstract
Interferon-based standard of care treatments (SOC) for chronic hepatitis C are unable to provide high cure rates in certain subgroups of the infected population and can cause debilitating side effects. Clinical trials evaluating all-oral, interferon-free treatments have demonstrated high rates of sustained virologic response with no resistance or major adverse events in most populations. As these drug regimens move towards FDA approval, it will be important to assess their cost-effectiveness in addition to their clinical efficacy. A decision-analytic Markov model with a lifetime, societal perspective was used to evaluate the cost-effectiveness of a generalized all-oral drug regimen compared to SOC by modelling the progression of a 50-year-old, HCV-positive cohort through disease natural history and treatment. In base case analysis, all-oral treatment dominated SOC across a range of willingness-to-pay (WTP) thresholds with an incremental cost-effectiveness ratio (ICER) of US$44,514/quality-adjusted life year (QALY). In sensitivity analyses, the model was sensitive to all-oral drug costs as well as rates of SVR and treatment uptake among noncirrhotic subjects, but robust to variations in all other parameters. All-oral treatment was most cost-effective among genotype 1 subjects but remained cost-effective for genotypes 2 and 3 at WTP thresholds ≥$80,000/QALY. Quality-adjusted life years gained per dollar spent were maximized in younger treatment cohorts. Using this model, the degree of cost-effectiveness depended on the WTP threshold and the final cost set for approved drug combinations.
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Affiliation(s)
- L M Hagan
- Department of Pediatrics, Laboratory of Biochemical Pharmacology, Center for AIDS Research, Emory University School of Medicine, Atlanta, GA, USA; Emory University Rollins School of Public Health, Atlanta, GA, USA; Veterans Affairs Medical Center, Decatur, GA, USA
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Miners AH, Martin NK, Ghosh A, Hickman M, Vickerman P. Assessing the cost-effectiveness of finding cases of hepatitis C infection in UK migrant populations and the value of further research. J Viral Hepat 2013; 21:616-23. [PMID: 24215210 DOI: 10.1111/jvh.12190] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Accepted: 09/25/2013] [Indexed: 02/01/2023]
Abstract
Hepatitis C (HCV) infection can cause cirrhosis, liver cancer and death in the absence of treatment. Many people living in the UK but born overseas are believed to be infected with HCV although many are unlikely to know they are infected. The aim of this study is to assess the potential for a case-finding approach to be cost-effective and to estimate the value of further research. An economic evaluation and value of information analysis was undertaken by developing a model of HCV disease progression and by populating it with evidence from the published literature. They were performed from a UK National Health Services cost perspective, and outcomes were expressed in terms of quality-adjusted life-years (QALYs). The comparator intervention was defined as the background rate of testing (i.e. no intervention). The base case results generated an incremental cost-effectiveness ratio (ICER) of about £23,200 per additional QALY. However, the ICER was shown to be particularly sensitive to HCV seroprevalence, the intervention effect / cost and the probability of treatment uptake. The value of information analysis suggested that approximately £4 million should be spent on further research. This evaluation demonstrates that testing UK migrants for HCV could be cost-effective. However, further research, particularly to refine estimates of the probability of treatment uptake once identified, the utility associated with sustained virological response and the cost of the intervention, would help to increase the robustness of this conclusion.
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Affiliation(s)
- A H Miners
- Department Health Services Research & Policy, London School of Hygiene and Tropical Medicine (LSHTM), London, UK
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Martin NK, Hickman M, Miners A, Hutchinson SJ, Taylor A, Vickerman P. Cost-effectiveness of HCV case-finding for people who inject drugs via dried blood spot testing in specialist addiction services and prisons. BMJ Open 2013; 3:e003153. [PMID: 23943776 PMCID: PMC3752052 DOI: 10.1136/bmjopen-2013-003153] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2013] [Revised: 06/28/2013] [Accepted: 07/01/2013] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES People who inject drugs (PWID) are at high risk for acquiring hepatitis C virus (HCV), but many are unaware of their infection. HCV dried blood spot (DBS) testing increases case-finding in addiction services and prisons. We determine the cost-effectiveness of increasing HCV case-finding among PWID by offering DBS testing in specialist addiction services or prisons as compared to using venepuncture. DESIGN Cost-utility analysis using a dynamic HCV transmission model among PWID, including: disease progression, diagnosis, treatment, injecting status, incarceration and addition services contact. SETTING UK INTERVENTION DBS testing in specialist addiction services or prisons. Intervention impact was determined by a meta-analysis of primary data. PRIMARY AND SECONDARY OUTCOME MEASURES Costs (in UK £, £1=US$1.60) and utilities (quality-adjusted life years, QALYs) were attached to each state and the incremental cost effectiveness ratio (ICER) determined. Multivariate uncertainty and one-way sensitivity analyses were performed. RESULTS For a £20 000 per QALY gained willingness-to-pay threshold, DBS testing in addiction services is cost-effective (ICER of £14 600 per QALY gained). Under the base-case assumption of no continuity of treatment/care when exiting/entering prison, DBS testing in prisons is not cost-effective (ICER of £59 400 per QALY gained). Results are robust to changes in HCV prevalence; increasing PWID treatment rates to those for ex-PWID considerably reduces ICER (£4500 and £30 000 per QALY gained for addiction services and prison, respectively). If continuity of care is >40%, the prison DBS ICER falls below £20 000 per QALY gained. CONCLUSIONS Despite low PWID treatment rates, increasing case-finding can be cost-effective in specialist addiction services, and in prisons if continuity of treatment/care is ensured.
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Affiliation(s)
- Natasha K Martin
- School of Social and Community Medicine, University of Bristol, Bristol, UK
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Matthew Hickman
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Alec Miners
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Sharon J Hutchinson
- Health Protection Scotland, UK
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | | | - Peter Vickerman
- School of Social and Community Medicine, University of Bristol, Bristol, UK
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Elsharkawy AM, Miller C, Hearn A, Buerstedde G, Price A, McPherson S. Improving access to treatment for patients with chronic hepatitis C through outreach. Frontline Gastroenterol 2013; 4:125-129. [PMID: 28839713 PMCID: PMC5369807 DOI: 10.1136/flgastro-2012-100282] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Revised: 11/07/2012] [Accepted: 11/10/2012] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Chronic hepatitis C infection (HCV) is common in injecting drug users and is a major cause of liver disease. Antiviral treatment can 'cure' HCV, but is frequently associated with side effects and requires regular monitoring. Non-attendance at hospital appointments is frequent. To try and improve attendance and increase the number of current and previous injecting drug users treated we developed three outreach clinics. OBJECTIVE To review the outcome of patients referred to the outreach clinics. METHODS Retrospective service review of three clinics at drug treatment centres in Newcastle and Northumberland. Data was collected on attendance rates, patient demographics, treatment rates and outcomes. RESULTS 141 referrals were received across the three sites with an overall attendance rate of 75% (106 patients, 79% men and median age 36), which compared favourably with that at our hospital (50%). All patients were on methadone/subutex. 45% were infected with Genotype 1 HCV. 10% were cirrhotic. To date, 30% have started treatment and 21% are waiting to start or are still in workup. 13% elected to delay treatment due to early stage disease and 11% were not ready for treatment on psychological or social grounds. Only 12% failed to attend follow up after initial assessment. To date, 24 patients have completed full courses of treatment with sustained viral response in 13 patients. Results are awaited for seven patients. CONCLUSIONS The development of outreach clinics for HCV in drug treatment centres can substantially improve clinic attendance and increase access to treatment in this marginalised group.
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Affiliation(s)
| | | | - Andrea Hearn
- Plummer Court Addiction Service, Newcastle upon Tyne, UK
| | | | - Ashley Price
- Department of Infectious Diseases, Royal Victoria Infirmary, Newcastle Upon Tyne, UK,Institute of Cellular Medicine, Newcastle University, Newcastle Upon Tyne, UK
| | - Stuart McPherson
- Liver Unit, Freeman Hospital, Newcastle Upon Tyne, UK,Institute of Cellular Medicine, Newcastle University, Newcastle Upon Tyne, UK
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Abstract
Worldwide eradication of hepatitis C virus (HCV) is possible through a combination of prevention education, universal clinical and targeted community screening, effective linkage to care and treatment with promising new direct-acting antiviral drug regimens. Universal screening should be offered in all healthcare visits, and parallel community screening efforts should prioritize high-prevalence, high-transmission populations including injection drug users, prison inmates and those with HIV/HCV co-infection. Increasing awareness of HCV infection through screening, improving treatment uptake and cure rates by providing linkage to care and more effective treatment, and ultimately combining education efforts with vaccination campaigns to prevent transmission and reinfection can slow and eventually stop the 'silent epidemic'.
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Affiliation(s)
- Liesl M. Hagan
- Center for AIDS Research; Emory University School of Medicine and Veterans Affairs Medical Center; Decatur GA USA
| | - Raymond F. Schinazi
- Center for AIDS Research; Emory University School of Medicine and Veterans Affairs Medical Center; Decatur GA USA
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Marufu M, Williams H, Hill SL, Tibble J, Verma S. Gender differences in hepatitis C seroprevalence and suboptimal vaccination and hepatology services uptake amongst substance misusers. J Med Virol 2013; 84:1737-43. [PMID: 22997076 DOI: 10.1002/jmv.23389] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Injecting drug users are the principal at risk group for blood borne viruses. The aim was to assess the feasibility of screening substance misusers for blood borne viruses, and to offer appropriate vaccinations/referral to hepatology services. This was a nurse led prospective 6-month study based at a large Substance Misuse Service in south east England. Of the 196 consecutive individuals assessed, 81 were eligible for HBV immunization of whom only 33.3% completed a vaccination course. Prevalence of positive serological markers were: anti-HBc 14.4%, HBsAg 1.5%, and HCV antibody 37.9%. Compared to men, women were more likely to accept blood borne virus testing (83.3% vs. 62.3%), have ever injected (89.6% vs. 76.3%), overdose (54.2% vs. 23.6%), be anti-HBc positive (27.5% vs. 8.8%), drink alcohol above national recommended guidelines (41.7% vs. 25.7%), and have a positive HCV serology (55% vs. 30.4%) (P ≤ 0.05 for all). Of the 73 individuals identified with a positive HBsAg and or HCV antibody, only 14 (19.1%) were known to hepatology services and 8 (20%) of those eligible subsequently accepted a specialist referral. In conclusion, serological markers for blood borne viruses remain high in substance misusers (anti-HBc 14.4%, HCV antibody 37.9%), with women more likely to be positive. Overall, only 33.3% and 20%, respectively, complete HBV vaccination and accept a hepatology referral. A multidisciplinary approach is paramount to address both the blood borne viruses and the substance misuse and realignment of hepatitis services to Substance Misuse Services may offer such a strategy.
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Affiliation(s)
- Muchandidemba Marufu
- Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospital, Brighton, UK
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31
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Seidenberg A, Rosemann T, Senn O. Patients receiving opioid maintenance treatment in primary care: successful chronic hepatitis C care in a real world setting. BMC Infect Dis 2013; 13:9. [PMID: 23298178 PMCID: PMC3548742 DOI: 10.1186/1471-2334-13-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Accepted: 12/21/2012] [Indexed: 01/14/2023] Open
Abstract
Background Injection drug users (IDUs) represent a significant proportion of patients with chronic hepatitis C (CHC). The low treatment uptake among these patients results in a low treatment effectiveness and a limited public health impact. We hypothesised that a general practitioner (GP) providing an opioid maintenance treatment (OMT) for addicted patients can achieve CHC treatment and sustained virological response rates (SVR) comparable to patients without drug dependency. Methods Retrospective patient record analysis of 85 CHC patients who received OMT for more than 3 months in a single-handed general practice in Zurich from January 1, 2002 through May 31, 2008. CHC treatment was based on a combination with pegylated interferon and ribavirin. Treatment uptake and SVR (undetectable HCV RNA 6 months after end of treatment) were assessed. The association between treatment uptake and patient characteristics was investigated by multiple logistic regression. Results In 35 out of 85 CHC patients (52 males) with a median (IQR) age of 38.8 (35.0-44.4) years, antiviral therapy was started (41.2%). Median duration (IQR) of OMT in the treatment group was 55.0 (35.0-110.1) months compared to the group without therapy 24.0 (9.8-46.3) months (p<0.001). OMT duration remained a significant determinant for treatment uptake when controlled for potential confounding. SVR was achieved in 25 out of 35 patients (71%). Conclusion In addicted patients a high CHC treatment and viral eradication rate in a primary care setting in Switzerland is feasible. Opioid substitution seems a beneficial framework for CHC care in this “difficult to treat” population.
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Affiliation(s)
- André Seidenberg
- Institute of General Practice and Health Services Research, University of Zurich, Zurich, Switzerland
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32
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Coffin PO, Scott JD, Golden MR, Sullivan SD. Cost-effectiveness and population outcomes of general population screening for hepatitis C. Clin Infect Dis 2012; 54:1259-71. [PMID: 22412061 PMCID: PMC3404694 DOI: 10.1093/cid/cis011] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Accepted: 12/06/2011] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Current US guidelines recommend limiting hepatitis C virus (HCV) screening to high-risk individuals, and 50%-75% of infected persons remain unaware of their status. METHODS To estimate the cost-effectiveness and population-level impact of adding one-time HCV screening of US population aged 20-69 years to current guidelines, we developed a decision analytic model for the screening intervention and Markov model with annual transitions to estimate natural history. Subanalyses included protease inhibitor therapy and screening those at highest risk of infection (birth year 1945-1965). We relied on published literature and took a lifetime, societal perspective. RESULTS Compared to current guidelines, incremental cost per quality-adjusted life year gained (ICER) was $7900 for general population screening and $4200 for screening by birth year, which dominated general population screening if cost, clinician uptake, and median age of diagnoses were assumed equivalent. General population screening remained cost-effective in all one-way sensitivity analyses, 30 000 Monte Carlo simulations, and scenarios in which background mortality was doubled, all genotype 1 patients were treated with protease inhibitors, and most parameters were set unfavorable to increased screening. ICER was lowest if screening was applied to a population with liver fibrosis similar to 2010 estimates. Approximately 1% of liver-related deaths would be averted per 15% of the general population screened; the impact would be greater with improved referral, treatment uptake, and cure. CONCLUSIONS Broader screening for HCV would likely be cost-effective, but significantly reducing HCV-related morbidity and mortality would also require improved rates of referral, treatment, and cure.
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Affiliation(s)
- Phillip O Coffin
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA 98104, USA.
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Gonzalez SA, Davis GL. Demographics of hepatitis C virus today. Clin Liver Dis (Hoboken) 2012; 1:2-5. [PMID: 31186836 PMCID: PMC6490694 DOI: 10.1002/cld.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Stevan A. Gonzalez
- Division of Hepatology, Department of Medicine, Annette C. and Harold C. Simmons Transplant Institute, Baylor All Saints Medical Center, Fort Worth, TX
| | - Gary L. Davis
- Division of Hepatology, Department of Medicine, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
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Butt AA, McGinnis K, Skanderson M, Justice AC. A comparison of treatment eligibility for hepatitis C virus in HCV-monoinfected versus HCV/HIV-coinfected persons in electronically retrieved cohort of HCV-infected veterans. AIDS Res Hum Retroviruses 2011; 27:973-9. [PMID: 21338329 DOI: 10.1089/aid.2011.0004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Treatment rates for hepatitis C virus (HCV) are low in actual clinical settings. However, the proportion of patients eligible for treatment, especially among those coinfected with HIV, is not well known. Our aim was to determine and compare the rates for HCV treatment eligibility among HCV and HCV-HIV-coinfected persons. We assembled a national cohort of HCV-infected veterans in care from 1998-2003, using the VA National Patient Care Database for demographic/clinical information, the Pharmacy Benefits Management database for pharmacy records, and the Decision Support Systems database for laboratory data. We compared the HCV-monoinfected and HCV-HIV-coinfected subjects for treatment indications and eligibility using current treatment guidelines. Of the 27,452 subjects with HCV and 1225 with HCV-HIV coinfection, 74.0% and 84.6% had indications for therapy and among these, 43.9% of HCV-monoinfected and 28.4% of HCV-HIV-coinfected subjects were eligible for treatment. Anemia, decompensated liver disease (DLD), chronic obstructive pulmonary disease (COPD), recent alcohol abuse, and coronary artery disease were the most common contraindications in the HCV, and anemia, DLD, renal failure, recent drug abuse, and COPD in the HCV-HIV-coinfected group. Among those eligible for treatment, only 23% of the HCV-monoinfected and 15% of the HCV-HIV-coinfected subjects received any treatment for HCV. Most veterans with HCV are not eligible for treatment according to the current guidelines. Even for those who are eligible for treatment, only a minority is prescribed treatment. Several contraindications are modifiable and aggressive management of those may improve treatment prescription rates.
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Affiliation(s)
- Adeel A. Butt
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania
| | | | | | - Amy C. Justice
- VA Connecticut Healthcare System, West Haven, Connecticut
- Yale University School of Medicine, New Haven, Connecticut
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Hepatitis C management: the challenge of dropout associated with male sex and injection drug use. Eur J Gastroenterol Hepatol 2011; 23:32-40. [PMID: 21048503 DOI: 10.1097/meg.0b013e3283414122] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Anecdotal reports of poor patient compliance with hepatitis C disease management exist yet little data are available on the true rates of dropout. AIMS To examine all referrals made to an urban tertiary care liver centre for hepatitis C virus (HCV) management, track subsequent progress and identify dropout trends. METHODS A cross-sectional retrospective review was conducted to examine the HCV referrals received on 2000 through 2007. The demographic, clinical and treatment data were derived from medical charts and the hospital information system. RESULTS A total of 588 individuals were referred for HCV disease management. The repeated referrals yielded 742 cases for analysis. Of the 742 referrals received, 141 (19%) failed to attend their initial appointment, 180 dropped out from early outpatient management, 29 failed to attend liver biopsy and 81 defected from subsequent outpatient follow-up. In total, 451 (61%) dropouts occurred. In those treated, a sustained viral response rate of 74% was observed (18/30 genotype 1; 4/5 genotype 2; 40/49 genotype 3). Statistically significant associations between history of injection drug use and dropout immediately after the referral (P<0.001), dropout from early outpatient management (P<0.001) and dropout over entire span of disease management (P<0.001) were observed. Male sex was also associated with dropout from disease management (P<0.05). CONCLUSIONS An exceptionally high rate of dropout exists within the HCV disease management framework, particularly in the early stages of service delivery. Dropout was associated with sex and positive history of injection drug use. The study findings have led to the development of innovative approaches helping to optimize the disease management in this population. These developments are discussed.
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Jacobson IM, Davis GL, El-Serag H, Negro F, Trépo C. Prevalence and challenges of liver diseases in patients with chronic hepatitis C virus infection. Clin Gastroenterol Hepatol 2010; 8:924-33; quiz e117. [PMID: 20713178 DOI: 10.1016/j.cgh.2010.06.032] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2010] [Revised: 06/21/2010] [Accepted: 06/28/2010] [Indexed: 02/07/2023]
Abstract
Hepatitis C virus (HCV) infections pose a growing challenge to health care systems. Although chronic HCV infection begins as an asymptomatic condition with few short-term effects, it can progress to cirrhosis, hepatic decompensation, hepatocellular carcinoma (HCC), and death. The rate of new HCV infections is decreasing, yet the number of infected people with complications of the disease is increasing. In the United States, people born between 1945 and 1964 (baby boomers) are developing more complications of infection. Men and African Americans have a higher prevalence of HCV infection. Progression of fibrosis can be accelerated by factors such as older age, duration of HCV infection, sex, and alcohol intake. Furthermore, insulin resistance can cause hepatic steatosis and is associated with fibrosis progression and inflammation. If more effective therapies are not adopted for HCV, more than 1 million patients could develop HCV-related cirrhosis, hepatic decompensation, or HCC by 2020, which will impact the US health care system. It is important to recognize the impact of HCV on liver disease progression and apply new therapeutic strategies.
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Affiliation(s)
- Ira M Jacobson
- Division of Gastroenterology and Hepatology and Center for Study of Hepatitis C, Joan and Sanford I. Weill Medical College of Cornell University, New York, New York 10021, USA.
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Davis GL, Alter MJ, El-Serag H, Poynard T, Jennings LW. Aging of hepatitis C virus (HCV)-infected persons in the United States: a multiple cohort model of HCV prevalence and disease progression. Gastroenterology 2010; 138:513-21, 521.e1-6. [PMID: 19861128 DOI: 10.1053/j.gastro.2009.09.067] [Citation(s) in RCA: 652] [Impact Index Per Article: 46.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2009] [Revised: 08/12/2009] [Accepted: 09/28/2009] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS The prevalence of chronic hepatitis C (CH-C) remains high and the complications of infection are common. Our goal was to project the future prevalence of CH-C and its complications. METHODS We developed a multicohort natural history model to overcome limitations of previous models for predicting disease outcomes and benefits of therapy. RESULTS Prevalence of CH-C peaked in 2001 at 3.6 million. Fibrosis progression was inversely related to age at infection, so cirrhosis and its complications were most common after the age of 60 years, regardless of when infection occurred. The proportion of CH-C with cirrhosis is projected to reach 25% in 2010 and 45% in 2030, although the total number with cirrhosis will peak at 1.0 million (30.5% higher than the current level) in 2020 and then decline. Hepatic decompensation and liver cancer will continue to increase for another 10 to 13 years. Treatment of all infected patients in 2010 could reduce risk of cirrhosis, decompensation, cancer, and liver-related deaths by 16%, 42%, 31%, and 36% by 2020, given current response rates to antiviral therapy. CONCLUSIONS Prevalence of hepatitis C cirrhosis and its complications will continue to increase through the next decade and will mostly affect those older than 60 years of age. Current treatment patterns will have little effect on these complications, but wider application of antiviral treatment and better responses with new agents could significantly reduce the impact of this disease in coming years.
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Affiliation(s)
- Gary L Davis
- Division of Hepatology, Baylor University Medical Center and Baylor Regional Transplant Institute, Dallas, Texas, USA.
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38
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Putka B, Mullen K, Birdi S, Merheb M. The disposition of hepatitis C antibody-positive patients in an urban hospital. J Viral Hepat 2009; 16:814-21. [PMID: 19842281 DOI: 10.1111/j.1365-2893.2009.01137.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Previous studies have indicated that only 26-61% of hepatitis C virus (HCV) antibody-positive patients are referred to specialists who treat HCV. However, these studies were conducted in homogeneous populations and before pegylated interferon and ribavirin became the standard of care for chronic HCV infection. The aims of this study were: (i) to determine the percentage of HCV antibody-positive patients who were referred to specialists for further management in an urban, racially diverse population, (ii) to determine the percentage of referred patients who attend specialty clinics, and (iii) to identify factors that predict referral and follow-up. All patients with a positive HCV antibody test in 2005 were identified by an inquiry of Epic, our electronic medical record system. All medical records were reviewed for demographics, location where the test was ordered (inpatient vs outpatient), specialty ordering the test, referral, clinic attendance, detectability of HCV RNA and liver function tests. Univariate and multivariate logistic regression were used to evaluate each variable's effect on referral and clinic attendance. Overall, 251 of 375 (67%) antibody positive patients were referred to HCV specialists. Of the 251 referrals, 166 (66%) attended at least one specialty clinic appointment. Patients were more likely to be referred if their HCV antibody was ordered in the outpatient setting (77% outpatient vs 38% inpatient, P < 0.001) ordered by a family practitioner (79% FP vs 64% for internal medicine doctor vs 58% for all other specialties, P = 0.01) had detectable RNA (88% detectable vs 65% not detectable vs 23% RNA status not available, P < 0.001) or elevation of alanine aminotransferase (75% elevated vs 56% not elevated, P < 0.001). Location, HCV RNA status and ALT elevation remained significant in a multivariate logistic regression model. These data confirm that up to one-third of HCV antibody-positive patients are not referred to HCV specialists, despite the availability of improved treatment regimens. Additional patients are lost to follow-up after being referred. The reasons for suboptimal referral and specialty clinic attendance rates are probably multifactorial. Institution of reflexive RNA testing for positive antibody tests and additional education of those physicians who encounter HCV-positive individuals may improve both rates.
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Affiliation(s)
- B Putka
- MetroHealth Medical Center, Division of Gastroenterology, Cleveland, OH, USA.
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Jack K, Willott S, Manners J, Varnam MA, Thomson BJ. Clinical trial: a primary-care-based model for the delivery of anti-viral treatment to injecting drug users infected with hepatitis C. Aliment Pharmacol Ther 2009; 29:38-45. [PMID: 18945252 DOI: 10.1111/j.1365-2036.2008.03872.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Injecting drug use is the main risk factor for hepatitis C virus (HCV) infection. Secondary-care-based strategies for the management of HCV do not effectively target this vulnerable population. AIMS To evaluate the feasibility, safety and efficacy of a primary-care-based model for the delivery of HCV services including anti-viral therapy to injecting drug users. METHODS A partnership between a clinical nurse specialist employed by, and working under the supervision of, a secondary-care-based hepatitis service and drug workers and general practitioners. Three hundred and fifty-three clients attending opiate substitution clinics in primary care were evaluated. Outcomes were: number of new diagnoses of HCV infection, number of clients assessed as suitable for anti-viral treatment, and number of patients treated. RESULTS 174 HCV antibody positive clients were identified. Of these, 124 were chronically infected with HCV of whom only six had been previously identified. Of 118 new chronically-infected individuals, 86 entered the care pathway, 43 were assessed as suitable for anti-viral treatment and 30 have so far been treated. Outcomes of anti-viral treatment are comparable with those obtained in secondary care settings. CONCLUSION A primary-care-based model offers a new paradigm for the treatment of HCV in injecting drug users.
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Affiliation(s)
- K Jack
- Department of Infectious Diseases, Nottingham University Hospitals and Windmill Practice, Sneinton, Nottingham, UK
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Shutt JD, Robathan J, Vyas SK. Impact of a clinical nurse specialist on the treatment of chronic hepatitis C. ACTA ACUST UNITED AC 2008; 17:572-5. [DOI: 10.12968/bjon.2008.17.9.29242] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- James D Shutt
- Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth
| | - Julia Robathan
- Department of Gastroenterology, Salisbury District Hospital, Salisbury
| | - Samir K Vyas
- Department of Gastroenterology, Salisbury District Hospital, Salisbury
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Evaluation of the French national plan to promote screening and early management of viral hepatitis C, between 1997 and 2003: a comparative cross-sectional study in Poitou-Charentes region. Eur J Gastroenterol Hepatol 2008; 20:367-72. [PMID: 18403936 DOI: 10.1097/meg.0b013e3282f479ab] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND AIMS The aim of this repeated cross-sectional survey was to document trends in screening practices, to analyze the evolution of the epidemiological characteristics of patients with newly diagnosed hepatitis C virus (HCV) infection, and to evaluate the implementation of hepatitis C management guidelines. METHODS Medical laboratories in Poitou-Charentes region were surveyed on serological tests for HCV infection prescribed during two 2-month periods in 1997 and 2000, and a 4-month period in 2003. An epidemiological questionnaire and a 12-month follow-up questionnaire were addressed to physicians who prescribed tests that were positive. RESULTS The annual screening coverage rate increased by 40% during the study period, whereas the number of positive tests fell by 53%. The estimated detection rate of new cases decreased from 43 to 26 per 100 000 inhabitants between 1997 and 2003. In 2003, 56% of serological tests were prescribed to patients who already knew that they were HCV-seropositive. The frequencies of the two main risk factors (transfusion and intravenous drug use) slightly decreased. Management of newly diagnosed patients was inappropriate in 42% of cases in 1997, 33% in 2000, and 34% in 2003; 26% of the participants at the three periods declined follow-up. Among drug users, the proportion of treated patients remained stable (17%). One-third of the drug users were lost to follow-up by their family doctor. CONCLUSION Campaigns to encourage HCV screening have been effective, but the number of newly diagnosed cases has fallen markedly. National campaigns targeting the general public and healthcare professionals seem to have had no impact on patient management: in particular, drug users still do not receive adequate follow-up.
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Capacity enhancement of hepatitis C virus treatment through integrated, community-based care. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2008; 22:27-32. [PMID: 18209777 DOI: 10.1155/2008/369827] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND An estimated 250,000 Canadians are infected with the hepatitis C virus (HCV). The present study describes a cohort of individuals with HCV referred to community-based, integrated prevention and care projects developed in British Columbia. Treatment outcomes are reported for a subset of individuals undergoing antiviral therapy at four project sites. METHODS Four demonstration projects based on a public health nurse and physician partnership were established in rural and small urban centres in British Columbia. Comprehensive medical assessments determined whether individuals received treatment, or counselling and education. Outcomes of the treatment group were compared with published randomized controlled trials. Client demographics were mapped using geographical information systems applications. RESULTS A total of 1795 individuals were referred to the clinics for medical assessment between September 2001 and December 2005. After assessment, 26% were eligible for therapy, while 74% received counselling and education. Wait times decreased annually, with one-half of all referrals assessed within 30 days. Combination antiviral therapy was initiated in 363 clients with interferon plus ribavirin (n=36) or pegylated interferon plus ribavirin (n=327). Treatment outcomes were available for 205 individuals. The overall rate of sustained virological response was 61% (126 of 205 individuals). The number of individuals assessed at each site represented, on average, 20% of the total cumulative reported HCV cases in the catchment areas. DISCUSSION The study findings illustrate how a public health nurse and physician partnership can service a population with complex medical needs while simultaneously increasing local capacity. Treatment outcomes were comparable with published clinical trials.
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Manns MP, Foster GR, Rockstroh JK, Zeuzem S, Zoulim F, Houghton M. The way forward in HCV treatment--finding the right path. Nat Rev Drug Discov 2007; 6:991-1000. [PMID: 18049473 DOI: 10.1038/nrd2411] [Citation(s) in RCA: 245] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Infection with the hepatitis C virus (HCV) represents an important health-care problem worldwide. The prevalence of HCV-related disease is increasing, and no vaccine is yet available. Since the identification of HCV as the causative agent of non-A, non-B hepatitis, treatment has progressed rapidly, but morbidity and mortality rates are still predicted to rise. Novel, more efficacious and tolerable therapies are urgently needed, and a greater understanding of the viral life cycle has led to an increase in the number of possible targets for antiviral intervention. Here we review the specific challenges posed by HCV, and recent developments in the design of vaccines and novel antiviral agents.
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Affiliation(s)
- Michael P Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Medical School of Hannover, Hannover, Germany.
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Shafran SD. Early initiation of antiretroviral therapy: the current best way to reduce liver-related deaths in HIV/hepatitis C virus-coinfected patients. J Acquir Immune Defic Syndr 2007; 44:551-6. [PMID: 17224846 DOI: 10.1097/qai.0b013e31803151c7] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Approximately 25% to 35% of HIV-infected persons in developed countries are coinfected with hepatitis C virus (HCV). HCV liver disease is accelerated by HIV coinfection, especially at low CD4 cell counts. Highly active antiretroviral therapy (HAART) dramatically reduces HIV-related mortality, and liver disease has emerged as a major cause of death in HIV/HCV-coinfected persons. Anti-HCV therapy with pegylated interferon plus ribavirin can cure HCV infection in up to 40% of coinfected patients; however, only approximately 10% of coinfected patients are considered candidates. Hence, HCV therapy cures approximately 4% of coinfected patients. Eleven cohort studies have shown that HAART is associated with a reduced rate of progression of HCV liver disease, and 4 of these studies have demonstrated a reduction in liver-related mortality. Although offering HCV therapy to the few eligible HIV/HCV-coinfected patients is important, early initiation of HAART in coinfected patients has a greater public health impact in reducing liver-related mortality than in curing HCV infection in approximately 4% of these patients.
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Affiliation(s)
- Stephen D Shafran
- Division of Infectious Diseases, Department of Medicine, Walter C. Mackenzie Health Sciences Centre, University of Alberta, 8440-112 Street, Edmonton, Alberta, Canada.
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Souvignet C, Lejeune O, Trepo C. Interferon-based treatment of chronic hepatitis C. Biochimie 2007; 89:894-8. [PMID: 17570576 DOI: 10.1016/j.biochi.2007.04.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2007] [Accepted: 04/27/2007] [Indexed: 01/22/2023]
Abstract
The treatment of patients with chronic hepatitis C has rapidly evolved in the past 10 years centered on the use of interferon alpha 2 as an antiviral and immunomodulatory agent against hepatitis C virus. Firstly used as a monotherapy associated with a deceiving long-term efficacy, interferon alpha was then combined with ribavirin, a nucleoside analog with large antiviral properties. Combination of both drugs dramatically improved the efficacy of treatment with 50% of patients reaching a sustained viral response, characterized by the final eradication of the virus from the infected individual. Surprisingly, this synergistic effect remains greatly unexplained. The third step consisted in the use of pegylated interferon in order to adapt its pharmacokinetics and to allow a better efficacy with a more tolerable dosing schedule: once weekly subcutaneous injection instead of thrice weekly. Pegylated interferon combined with ribavirin during 24-48 weeks of treatment is the current standard of care with nearly 60% of sustained virologic response, overall. Development of new forms of interferon alpha are on the way with promising preliminary results.
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Affiliation(s)
- Claude Souvignet
- Hospices Civils de Lyon, Hôtel Dieu, Service d'Hépatologie et Gastroentérologie, 69002 Lyon, France
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Abstract
Antiviral therapy is approved by NICE but too few patients receive it
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Affiliation(s)
- Kosh Agarwal
- Institute of Liver Studies, King's College Hospital, London SE5 9RS
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