Barriers to hepatitis C treatment

Hepatitis C Care in the Greater New Orleans Area: Patient Perspectives on the Barriers and Facilitators to Care

Increasing engagement in hepatitis C virus (HCV) care and treatment will help mitigate HCV incidence, morbidity, and mortality in the United States. This study aimed to understand the multilevel factors affecting engagement in HCV care after implementation of a subscription-based payment model for HCV treatment. Semi-structured interviews were conducted with patients with chronic HCV from a federally qualified health center in New Orleans, Louisiana. We used a convenience sampling method to recruit patients for the study. The interviews conducted between May 2020 and February 2021 explored factors influencing linkage to and retention in HCV care, using the socio-ecological model as the guiding framework. An analysis of the interviews with 39 patients revealed multilevel barriers to care, including instability, provider attitudes, prior care experiences, and the corrections system. Facilitators identified included personal health journey, network HCV experiences, and HCV awareness. A multilevel approach to facilitate engagement in HCV care is imperative.

Results from a retrospective case finding and re-engagement exercise for people previously diagnosed with hepatitis C virus to increase uptake of directly acting antiviral treatment

BACKGROUND

Direct acting antivirals (DAAs) for the Hepatitis C virus (HCV) have shifted the World Health Organisation global strategic focus to the elimination of HCV by 2030. In England, the UK Health Security Agency (UKHSA) led a national 'patient re-engagement exercise', using routine surveillance data, which was delivered through the HCV Operational Delivery Networks (ODNs) with support from National Health Service England (NHSE), to help find and support people with a positive HCV PCR test result to access treatment. We report a quantitative evaluation of outcomes of this exercise.

METHODS

Individuals with a recorded positive HCV antibody or PCR result between 1996 and 2017 were identified using UKHSA's records of HCV laboratory diagnosis. Linkage with established health-care datasets helped to enhance patient identification and minimise attempts to contact deceased or previously treated individuals. From September to November 2018 each ODN was provided with a local list of diagnosed individuals. ODNs were asked to perform further data quality checks through local systems and then write to each individual's GP to inform them that the individual would be contacted by the ODN to offer confirmatory HCV PCR testing, assessment and treatment unless the GP advised otherwise. Outcomes of interest were receipt of treatment, a negative PCR result, and death. Data were collected in 2022.

RESULTS

Of 176,555 individuals with a positive HCV laboratory report, 55,329 individuals were included in the exercise following linkage to healthcare datasets and data reconciliation. Participants in the study had a median age of 51 years (IQR: 43, 59), 36,779 (66.5%) were males, 47,668 (86.2%) were diagnosed before 2016 and 11,148 (20.2%) lived in London. Of the study population, 7,442 (13.4%) had evidence of treatment after the re-engagement exercise commenced, 6,435 (11.6%) were reported as PCR negative (96% had no previous treatment records), 4,195 (7.6%) had prescription data indicating treatment before the exercise commenced or were reported to have been treated previously by their ODN, and 2,990 (5.4%) had died. The status of 32,802 (59.3%) people remains unknown.

CONCLUSIONS

A substantial number of those included had treatment recorded after the exercise commenced, however, many more remain unengaged. Evaluation of the exercise highlighted areas that could be streamlined to improve future exercises.

Micro-elimination of chronic hepatitis C virus in mental health settings: A prospective multicentre pragmatic trial

INTRODUCTION

Hepatitis C virus (HCV) prevalence is high in the mental health population. We sought to evaluate testing and treatment uptake for HCV following the implementation of a universal nurse led study in inpatient and outpatient mental health populations.

METHODS

From January 2018 to December 2020, we screened mental health inpatients (n = 322) and community mental health patients (n = 615) for HCV with either specialist hepatology nurses or mental health nurses (mental health nurse).

RESULTS

75.5% (464/615) of community patients and 100% (322/322) of inpatients consented to screening, with an HCV antibody-positive prevalence of 12.7% (59/464) in community patients and 19.6% (63/322) in inpatients. RNA detectable prevalence was 4.0% (22/464) and 7.5% (24/322), respectively. Community patients who were screened by specialist hepatology nurses were more likely to consent to screening (94.4% vs. 45.7%, p < 0.001) but had lower proportion of HCV antibody (10.5% vs. 20.3%, p < 0.001) and RNA detectable (4.0% vs. 7.5%, p = 0.018) when compared to mental health nurse screening. Engagement with treatment was 27.0% of community mental health patients and 45.8% of mental health inpatients undergoing treatment. All patients undergoing treatment and underwent sustained viral response (SVR) testing achieved SVR.

DISCUSSION AND CONCLUSIONS

Universal screening of HCV using a nurse-led model has high rates of success in mental health patients with high proportions undergoing screening, with no reduction in the rates of SVR achieved with DAA therapy compared to the general population. Further work is needed to bridge the gap between identification of HCV and treatment among mental health patients.

Barriers to accessing hepatitis B medication: a qualitative study from the USA and Canada

OBJECTIVES

To collect and document the numerous barriers that people living with hepatitis B (PLHB) encounter when trying to access their hepatitis B virus (HBV) medications.

DESIGN

Researchers collected qualitative data through 24 online interviews. The semistructured interview questions focused on the impact that HBV has on different aspects of daily life (physical, emotional and social), personal experiences managing their infection, HBV treatment experiences and interactions with healthcare providers.

SETTING

All interviews occurred over Zoom.

PARTICIPANTS

The participant cohort consisted of 12 males and 12 females. 63% of all participants represented communities of colour (37% white, 17% black/African/African American and 46% Asian/Asian American). Most of the participants were on antiviral treatment at the time of the study (62%). Participants were PLHB (self-reported), ≥18 years old, living in the USA or Canada and spoke English.

RESULTS

Participants reported several barriers to accessing medicine among PLHB including financial barriers, health insurance and pharmacy preauthorisation process and other intangible barriers like lack of access to reliable patient-friendly information and stigma. The identified barriers to accessing HBV medication impacted patients' continuity of care.

CONCLUSIONS

Access to medicine is essential to improving health outcomes. PLHB experience significant barriers to accessing HBV antivirals at different levels. Patient-related, physician-related and healthcare system barriers were identified as themes contributing to antiviral access challenges. More research is needed to identify strategies to improve access to HBV medications.

Tools Needed to Support Same-Day Diagnosis and Treatment of Current Hepatitis C Virus Infection

The current multiday diagnosis and treatment paradigm for hepatitis C virus (HCV) infection results in far fewer patients receiving treatment with direct-acting antiviral agents than those with diagnosed HCV infection. To achieve HCV elimination, a paradigm shift in access to HCV treatment is needed from multiday testing and treatment algorithms to same-day diagnosis and treatment. This shift will require new tools, such as point-of-care (POC) antigen tests or nucleic acid tests for HCV and hepatitis B virus (HBV) and nucleic acid tests for human immunodeficiency virus (HIV) that do not require venous blood. This shift will also require better use of existing resources, including expanded access to HCV treatment and available POC tests, novel monitoring approaches, and removal of barriers to approval. A same-day diagnosis and treatment paradigm will substantially contribute to HCV elimination by improving HCV treatment rates and expanding access to treatment in settings where patients have brief encounters with healthcare.

How to better improve the treatment and outcomes of HCV in psychiatric patients: review of a Belgian monocentric psychiatric center

Introduction

Hepatitis C (HCV) is one of the major worldwide infections with 58 million infected persons in the world. HCV can lead to chronic liver disease, cirrhosis, and cancer. These past few years, clinical progress allowed a curative rate of 95% of the patients. There are still populations in which, treating the disease is more difficult, especially psychiatric patients, when substance abuse, psychiatric disorders are important risks factors for getting HCV. With the WHO organization establishing goals for clinical management and treatment of HCV, it is important to target where the difficulties lie in getting a better treatment program for those populations.

Aim

Try to highlight the challenges of treating a certain group of patients compare to the general population.

Method

This is a cross sectional monocentric study. 79 patients from a mental facility were included between 2012 and 2022. Inclusion criteria were: >18 years old, an active viral HCV infection.

Results

34.7% of patients with a positive PCR were treated with a significant difference between the closed psychiatric unit and the open one (66.5 vs 22.6%, p<.05). There was an 82.4% eradication rate (Sustained Viral Response at 3 months). There were significantly more schizophrenic disorders in the closed unit and significantly more alcohol abuse in the open one.

Conclusion

Treatment of HCV in a psychiatric population is feasible with eradication rate equivalent at those in the general population. Patients with more severe mental illness are better treated in the configuration of a closed psychiatric unit.

Patients' experience of accessing hepatitis C treatment through the Myanmar national hepatitis C treatment program: a qualitative evaluation

BACKGROUND

Globally, 56.8 million people are living with hepatitis C and over three-quarters of those reside in low and middle-income countries (LMICs). Barriers and enablers to hepatitis C care among people who inject drugs in high-income countries are well documented. However, there is scant literature describing the patient experience in LMICs. Understanding the barriers and enablers to care from the patient perspective is important to inform service refinements to improve accessibility and acceptability of hepatitis C care.

METHODS

We conducted a qualitative evaluation of the patient experience of accessing the national hepatitis C program at eight hospital sites in Myanmar. Semi-structured interviews were conducted with four to five participants per site. Interview data were analysed thematically, with deductive codes from Levesque et al.'s (2013) Framework on patient-centred access to healthcare.

RESULTS

Across the eight sites, 38 participants who had completed treatment were interviewed. Barriers to accessing care were mostly related to attending for care and included travel time and costs, multiple appointments, and wait times. Some participants described how they did not receive adequate information on hepatitis C, particularly its transmission routes, and on the level of cirrhosis of their liver and what they were required to do after treatment (i.e. reduce alcohol consumption, liver cirrhosis monitoring). Many participants commented that they had few or no opportunities to ask questions. Provision of treatment at no cost was essential to accessibility, and gratitude for free treatment led to high acceptability of care, even when accessing care was inconvenient.

CONCLUSIONS

These findings highlight the importance of streamlining and decentralising health services, adequate human resourcing and training, and affordable treatment in maximising the accessibility and acceptability of hepatitis C care in LMICs. Findings from this work will inform future service delivery refinements for national program and other decentralised programs to improve accessibility and acceptability of hepatitis C care in Myanmar.

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

Background

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

Methods

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

Findings

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

Interpretation

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

Funding

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

[Prognostic factors in patients with hematological malignancies and concomitant chronic hepatitis C]

The study evaluated the impact of HCV infection on the prognosis in patients with hematological malignancies. A total of 96 patients with anti-HCV antibodies were enrolled, with the age of 37.8 (3.0-81.0) years old, 39.6% had non-Hodgkin's lymphoma. Chronic hepatitis C (CHC) was diagnosed in 46.9% patients prior to malignancy development, in 38.5% patients simultaneously with malignancy, and in 14.6% patients during malignancy treatment. Clinical and biochemical signs of HCH were mild in most of the patients, minimal liver fibrosis (F0-1 by METAVIR system) was discovered in 47.3% patients, severe fibrosis or cirrhosis (F3-4) was diagnosed in 40% of participants. Only 20 (20.8%) of patients received antiviral therapy against HCV prior to enrollment. Regression analysis demonstrated that age >55 years old, late onset of antiviral therapy, and poor nutritional status were significant predictors of death from hematological malignancy. Survey conducted among physicians of hematological oncology hospitals in Saint-Petersburg revealed gaps in knowledge on presentation and risks of HCV infection, as well as on opportunities of modern antiviral therapy.

The Incidence and Care Cascade of the Hepatitis C Virus in Korea

Background/Aims

The 2030 hepatitis C virus (HCV) elimination targets of the World Health Organization are an 80% reduction in incidence and 65% reduction in mortality compared to the 2015 rates. However, information on the nationwide incidence and treatment rates of HCV infection are limited. We aimed to investigate the nationwide incidence and status of the care cascade for HCV infection in Korea.

Methods

This study used data from the Korea Disease Control and Prevention Agency linked with the data of the Korea National Health Insurance Service. Linkage to care was defined as visiting hospitals twice or more due to HCV infection within 1.5 years of the index date. The treatment rate was the number who had been prescribed antiviral medication within 1.5 years from the index date out of patients newly diagnosed with HCV.

Results

The new HCV infection rate was 17.2 per 100,000 person-years (n=8,810) in 2019. The number of new HCV infections was the highest in patients aged 50 to 59 years (n=2,480), and the new HCV infection rate significantly increased with age (p<0.001). Among newly infected patients with HCV, the linkage to care rate was 78.2% (78.2% men, 78.2% women) and the treatment rate was 58.1% (56.8% men, 59.3% women) within 1.5 years.

Conclusions

The new HCV infection rate was 17.2 per 100,000 person-years in Korea. It is necessary to continuously monitor the incidence and care cascade of HCV to establish proper strategies to reach the goal of HCV elimination by 2030.

Leveraging telemedicine in gastroenterology and hepatology: a narrative review

BACKGROUND AND OBJECTIVE

Over the years, telemedicine has played a prominent role in delivering healthcare to patients. Due to its flexibility and many benefits, telemedicine confers physicians the ability to guide and promote medical care remotely. The advent of the coronavirus disease 2019 (COVID-19) pandemic has changed the landscape of medicine and has accelerated the usage of digital and remote healthcare systems for clinical care. Herein, we provide an overview of telemedicine, its applications in managing inflammatory bowel disease (IBD), celiac disease (CD), and liver diseases, its advantages and limitations, and its use in educating the next generation of gastroenterologists.

METHODS

We conducted a review of scientific articles published in PubMed and Google Scholar. Articles were selected based on the search terms included in the search strategy summary. The language of the articles was restricted to English only.

KEY CONTENT AND FINDINGS

We report that telemedicine has the potential to streamline and improve patient care in gastroenterology (GI) and hepatology while also limiting health care expenses. Additionally, we noted the importance of tele-education for training the next generation of physicians who intend on practicing in rural settings. Furthermore, we identified barriers to telemedicine care that exacerbate health inequities and potential solutions to achieving digital health equity. Lastly, we briefly discuss the role of artificial intelligence (AI) in remote patient monitoring.

CONCLUSIONS

Although telemedicine has existed for many decades, over the past decade there have been many advancements in telemedicine applications in GI and hepatology. Despite its broad benefits, further research needs to be done to alleviate barriers to telemedicine care.

Evaluation of and implications for a novel hepatitis C e-consult direct-to-treatment pilot program

A Hepatitis C (HCV) e-Consult Direct-To-Treatment (DTT) program managed by midlevel providers was developed at the Veteran Affairs Greater Los Angeles Healthcare System (VAGLAHS) which provided remote referral and, in some, remote management of HCV. DTT patients were more likely to be initiated on HCV treatment compared to standard of care (SOC), lending support for similar programs of remote engagement in HCV care.

Alpha-mangostin, piperine and beta-sitosterol as hepatitis C antivirus (HCV): In silico and in vitro studies

Hepatitis C is still a serious liver case of health. Up to now the development of anti-Hepatitis C Virus (HCV) drugs is challenging, especially the development of natural material compounds as anti-HCV. In the present study, we evaluated the probability of α-mangostin, piperine, and β-sitosterol as anti-HCV with the in silico and in vitro approaches. Molecular docking was performed between nonstructural protein 5B (NS5B, PDB ID 3FQL) with α-mangostin, piperine, and β-sitosterol by Autodock Tools® and BIOVIA Discovery Studio®. Subsequently, molecular dynamics simulations were conducted for 200 ns, evaluating the dynamic interaction between the ligands and the viral protein NS5B. Furthermore, compound characterization at the hepatocarcinoma cell line was employed. α-Mangostin with NS5B complex demonstrated the most negative binding free energy value based on MM-PBSA calculation with a value of -9.13 kcal/mol. In vitro test showed that IC50 of α -mangostin was 2.70 ± 0.92 μM, IC50 of piperine was 52.18 ± 3.21 μM, IC50 of β-sitosterol was >100 μM. α-Mangostin can serve as a valuable lead compound for further development of the anti-HCV.

Educational interventions to improve hepatitis C testing or treatment in South Asian communities: A systematic review

BACKGROUND: Hepatitis C (HCV) places a disproportionately higher burden on the South Asian community in comparison to the general population, despite the availability of effective antiviral therapies. This study seeks to characterize the effectiveness of health promotion initiatives aimed at South Asians to improve HCV prevention, education, screening, and treatment adherence. METHODS: A systematic review (PROSPERO: CRD42021253796) was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Ovid MEDLINE, CINAHL Plus, Web of Science, ERIC, Ovid Embase, Cochrane Library, and PsycINFO were searched from inception to 15 April 2022 for original studies that reported on any health promotion initiative directed at improving HCV outcomes in the South Asian community. Risk of bias was assessed via a quality score. RESULTS: A total of 15 studies (6 uncontrolled interventional, 3 before-after interventional, 3 randomized controlled, 2 prospective cohort, and 1 historically controlled interventional study designs) involving 69,958 participants were included. The most studied interventions were formal HCV teaching (n = 12), community outreach (n = 6), and coupling screening/testing with existing programs (n = 3). Ninety-two percent (14/15) of interventions were concluded to be successful, and 71% (10/14) of those were concluded to be feasible and/or cost-effective. CONCLUSIONS: Interventions that aim to improve HCV education and accessibility to screening/treatment can substantially reduce barriers to care in South Asian communities. Further research, of higher quality RCT evidence, is needed to study the long-term reduction in HCV prevalence from these proposed interventions, and their associated feasibility profiles.

Integrating Management of Hepatitis C Infection into Primary Care: the Key to Hepatitis C Elimination Efforts

Elimination of hepatitis C virus (HCV), a leading cause of liver disease in the USA and globally, has been made possible with the advent of highly efficacious direct acting antivirals (DAAs). DAA regimens offer cure of HCV with 8-12 weeks of a well-tolerated once daily therapy. With increasingly straightforward diagnostic and treatment algorithms, HCV infection can be managed not only by specialists, but also by primary care providers. Engaging primary care providers greatly increases capacity to diagnose and treat chronic HCV and ultimately make HCV elimination a reality. However, barriers remain at each step in the HCV cascade of care from screening to evaluation and treatment. Since primary care is at the forefront of patient contact, it represents the ideal place to concentrate efforts to identify barriers and implement solutions to achieve universal HCV screening and increase curative treatment.

HIV And HCV adherence and treatment outcomes among people who inject drugs receiving opioid agonist therapy

Among people who inject drugs (PWID), 60% have HCV and 50-90% of HIV-infected PWID are co-infected with HCV. Data comparing adherence to direct-acting antiviral (DAA) therapy among HCV mono-infected and HIV/HCV co-infected PWID is limited. The impact of HCV treatment initiation on HIV antiretroviral therapy (ART) adherence is also poorly understood. We assessed DAA adherence in HCV mono-infected and HIV/HCV co-infected PWID and examined changes in ART adherence and HIV outcomes following HCV treatment. Study was conducted in three Medication for Opioid use Disorder (MOUD) programs in Bronx, New York. HCV treatment adherence was measured using electronic blister packs. 2-week DAA adherence rates were compared and controlled for study arm, psychiatric illness and alcohol intoxication within the past 30 days. ART adherence was measured using participant self-report and dichotomized to "excellent" or "other". ART adherence, CD4 count, and HIV viral load were identified six months prior to, during, and six months after HCV treatment. Statistical significance was assessed with mixed-effects regression linear or logistic models. Overall DAA adherence rates among HCV mono-infected and HIV/HCV co-infected PWID were 74% (95% CI=71-78%) and 76% (95%CI=70-83%), respectively (p=.55). There were no significant changes in ART adherence, CD4 counts, or HIV viral loads prior to, during, or after HCV treatment. This is the first study assessing the impact of DAA therapy on ART adherence and HIV treatment outcomes among PWID. It is one of the first to compare DAA adherence among HCV and HIV/HCV co-infected PWID. Our data demonstrate no significant difference in DAA adherence and no significant impact of HCV treatment on ART adherence or HIV outcomes.

The British HIV Association national clinical audit 2021: Management of HIV and hepatitis C coinfection

OBJECTIVES

We aimed to describe clinical policies for the management of people with HIV/hepatitis C virus (HCV) coinfection and to audit routine monitoring and assessment of people with HIV/HCV coinfection attending UK HIV care.

METHODS

This was a clinic survey and retrospective case-note review. HIV clinics in the UK participated in the audit from May to July 2021 by completing an online questionnaire regarding their clinic's policies for the management of people with HIV/HCV coinfection, and by contributing to a case-note review of people living with HIV with detectable HCV RNA who were under the care of their service.

RESULTS

Ninety-five clinics participated in the clinic survey; of these, 15 (15.8%) were regional specialist centres, 19 (20.0%) were HIV services with their own coinfection clinics, 40 (42.1%) were HIV services that referred coinfected individuals to a local hepatology service and 20 (21.1%) were HIV services that referred to a regional specialist centre. Eighty-one clinics provided full caseload estimates; of the approximately 3951 people with a history of HIV/HCV coinfection accessing their clinics, only 4.9% were believed to have detectable HCV RNA, 3.15% of whom were already receiving or approved for direct-acting antiviral (DAA) treatment. In total, 29 (30.5%) of the clinics reported an impact of COVID-19 on coinfection care, including delays or reductions in the frequency of services, monitoring, treatment initiation and appointments, and changes to the way that treatment was dispensed. Case-note reviews were provided for 283 people with detectable HCV RNA from 74 clinics (median age 42 years, 74.6% male, 56.2% HCV genotype 1, 22.3% HCV genotype 3). Overall, 56% had not received treatment for HCV, primarily due to lack of engagement in care (54.7%) and/or being uncontactable (16.4%).

CONCLUSIONS

Our findings show that the small number of people with HIV with detectable HCV RNA in the UK should mean that it is possible to achieve HCV micro-elimination. However, more work is needed to improve engagement in care for those who are untreated for HCV.

Uptake and factors associated with direct-acting antiviral therapy for hepatitis C and treatment outcomes among Canadian immigrants: A retrospective cohort analysis

BACKGROUND

We sought to compare rates and factors associated with direct acting antiviral (DAA) treatment uptake and sustained virological response (SVR) between Canadian-born and foreign-born patients.

METHODS

The study was conducted utilizing a retrospective cohort of hepatitis C virus (HCV)-infected patients assessed at The Ottawa Hospital Viral Hepatitis Clinic between January 2015 and October 2021. Risk factors, income, and clinical characteristics of HCV infection associated with DAA therapy uptake and SVR were compared by immigration status using logistic regression.

RESULTS

Of 1,459 HCV-infected patients, 264 (18.1%) were born outside of the country. A median 17 years passed from immigration to first assessment at the clinic. The proportion of patients initiating DAA therapy was similar between groups (65.2% versus 69.5%, p = 0.17). Characteristics associated with DAA therapy uptake included age at first assessment (OR 1.02; 95% CI 1.01 to 1.03) and being cirrhotic (OR 3.19; 95% CI 1.99 to 2.13). Crude SVR rate was higher in immigrants than in Canadian-born patients (91.5% versus 83.7%, p = 0.01). After controlling for other variables, only advancing age was associated with the likelihood of achieving crude SVR (OR 1.04, 95% CI 1.02 to 1.05).

CONCLUSIONS

We found that DAA therapy uptake and HCV cure rates were high in both groups suggesting equity of opportunity in those referred to our program. The older age at presentation suggests missed opportunities to diagnose and engage immigrants in HCV care. These findings emphasize the importance of early large-scale screening and engagement in care for HCV infection of immigrant populations to prevent future complications.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Universal screening for hepatitis C - in for a penny, in for a pound

Infection with hepatitis C virus (HCV) is a major public health problem. In fact, chronic HCV is a leading cause of cirrhosis, hepatocellular carcinoma, and death from liver disease in most countries. The advent of highly effective oral direct-acting antiviral therapy is the most significant advance in the treatment of HCV in decades and now allows us to cure chronic HCV. However, a large number of infected patients have not been diagnosed since hepatitis C is a largely asymptomatic disease. Thus, it is fundamental to improve the screening system in order to identify individuals who are currently infected and to treat them. Risk-based hepatitis C testing and birth cohort screening have had limited success and many patients living with the infection are not aware of their status. Universal screening for HCV is a tremendous improvement compared with the previous strategies. Indeed, global screening leads to the appropriate identification and treatment of all individuals chronically infected with HCV and prevents the progression of liver disease and the associated morbidity and mortality. In addition, universal HCV testing appears to be cost-effective. In this article, we review the current barriers to HCV eradication and the different strategies for HCV infection screening.

Hepatitis C Virus Prevalence, Medical Status Awareness and Treatment Engagement among Homeless People Who use Drugs: Results of a Street Outreach Study

Background:

Hepatitis C virus (HCV) infection is a primary health concern among people who use drugs (PWUDs). Homeless PWUDs that constitute a key population for HCV transmission remain underrepresented in many surveys.

Objectives:

We performed a proactive street outreach to evaluate HCV infection prevalence among homeless PWUDs in Tel Aviv, identify risk factors associated with HCV infection, awareness of disease status and linkage to care rate.

Results:

Thirty-eight percent of approached PWUD were willing to participate in the study. Out of 53 subjects who got tested for anti HCV by rapid test, 29 (54.72%) had a positive result, 20 of 29 anti-HCV positive (69%) patients had positive HCV PCR. Risk factors were investigated using structured questionnaires. Heroin use was reported significantly more frequently in the HCV-positive group (P = .05, CI 95%), whereas other established risk factors did not reach significance in our cohort. While 21 of 29 (72%) HCV-positive participants were aware of their condition, only 4 of 21 (19%) received treatment in the past, and 2 of 4 (50%) failed to achieve treatment goals, as assessed by HCV PCR.

Conclusions:

Our data indicate a high prevalence of HCV infection among homeless PWUDs. Importantly, despite relatively high awareness of HCV status in this population, we found strikingly low access to care. These findings motivate novel interventional approaches targeted at improving patient access, and compliance among homeless PWUDs, in an effort to reduce HCV transmission.

Efficacy of an eConsult service to cure hepatitis C in primary care

In 2016, an eConsult service was developed within a safety net health system to expand access to hepatitis C (HCV) treatment in the primary care setting. The eConsult system provides individualized treatment recommendations from specially trained primary care pharmacists and primary care physicians to primary care providers with less experience in the rapidly changing treatment of HCV. Since its launch, this service has had a large impact in expanding care to a largely homeless and low-income urban population within our health system. We now aim to evaluate its efficacy in curing HCV. In this retrospective cohort study, we describe rates of sustained virologic response 12 weeks after treatment completion (SVR12) for those who received primary care-based HCV treatment through the eConsult system with those who were treated in primary care independent of an eConsult from 2017 to 2019. We found there was no significant difference in the proportion of patients who achieved SVR12 between the two groups. Overall, >90% of patients who received treatment achieved SVR12. Approximately 40% of patients treated for HCV received an eConsult, suggesting utility of the eConsult in expanding access and coordinating treatment for patients within our network.

The PRO-TEST Program: HIV and Hepatitis C Services at the Parole Office

This article describes an on-site program for HIV and hepatitis C (hep-C) services at a parole office in an impoverished U.S. state. Both officers and their supervisees participated in the program. The officers attended workshops on the biology of HIV, and hep-C, and workplace safety, and collaborated in development and implementation of the services. The supervisees received HIV and hep-C education, voluntary testing, and referral for treatment after a positive diagnosis. Test results showed that few supervisees were positive for HIV and 16% of White individuals were diagnosed with hep-C. These findings support the need for on-site services for supervisees in community corrections.

A Focused Review on Recent Advances in the Diagnosis and Treatment of Viral Hepatitis

The global burden of viral hepatitis remains substantial despite advances in antiviral therapy and effective vaccines. There are five hepatitis viruses (hepatitis A, B, C, D, and E). Mortality related to hepatitis B virus and hepatitis C virus infections is among the top four global infectious diseases, together with human immunodeficiency virus infection, malaria, and tuberculosis. Of those deaths, approximately 47% are attributable to hepatitis B virus, 48% to hepatitis C virus and the remainder to hepatitis A virus and hepatitis E virus. Ending hepatitis epidemics as a major public health threat is feasible with the tools and approaches currently available. Effective vaccines are available for preventing viral hepatitis A, B and E infections. New oral, well-tolerated treatment regimens for chronic hepatitis C patients can achieve cure rates of over 90%. Effective treatment is also available for people with chronic hepatitis B virus infection; although for most people such treatment needs to be long-term, and recent advanced aim at a "functional cure" of hepatitis B. In this review article, we discuss the most recent advances of the diagnosis and treatment of viral hepatitis.

"It's time!": A qualitative exploration of the acceptability of hepatitis C notification systems to help eliminate hepatitis C

BACKGROUND

In Australia, the unrestricted and subsidised availability of direct-acting antivirals for people living with hepatitis C has made the elimination of hepatitis C possible. Recent declining treatment uptake, however, may jeopardise the attainment of this goal. Notification data already exist in many jurisdictions but are presently under-utilised. Despite growing interest in the potential use of data to link people diagnosed with hepatitis C to treatment services, little evidence exists on the acceptability and feasibility of this approach. Our study aimed to address this gap and guide future strategies to enhance treatment uptake.

METHODS

Twenty-seven people with lived experience of injecting drug use and/or hepatitis C participated in two focus groups exploring views on implementing a system of hepatitis C notification follow-up in Australia, that would direct people to treatment and care. Additionally, qualitative interviews were conducted with 20 key informants to examine the ethical, logistical, and regulatory implications of implementation. Data were thematically analysed using the Theoretical Framework of Acceptability - which has been used to assess the acceptability of interventions from the perspectives of intervention deliverers and recipients.

RESULTS

While there were clear reservations, there was consensus that the potential benefits of using notification data to contact people with hepatitis C, outweigh harms. The method of contact (including by whom and how), whether follow-up should include recent versus historical diagnoses, and if record linkage should be used to enhance follow-up were important considerations. Ethical and logistical concerns were raised about the risk that such an approach could exacerbate stigma and discrimination.

CONCLUSION

Findings highlight potentially significant benefits of using notifications data to increase access to hepatitis C treatment, a novel approach that can contribute to hepatitis C elimination efforts and prevent hepatitis C-related morbidity and mortality.

Impact of Behavioral Health Consultation on Hepatitis C Treatment Outcomes at a Federally Qualified Health Center; Philadelphia, PA

Hepatitis C virus (HCV) infection is a public health issue that claims the lives of 350,000 individuals globally every year. Primary care providers are increasingly prescribing HCV medications with more modern, simplified administrations. Individuals with HCV are disproportionately affected by behavioral health challenges and substance use disorders. Integrated behavioral health providers can work in concert with their patients' primary care teams to provide innovative treatment programs to help support the needs of HCV care. We used simple and multivariable logistic regression to determine the association between receipt of behavioral health consultation and two outcomes on the care continuum: insurance approval for treatment and initiated HCV treatment regimen. These models were fitted using theoretically hypothesized variables and multivariable regression models included age, sex, and race/ethnicity as potential confounders. From January 2015 to May 2017, 189 patients at health centers were referred for onsite HCV primary care treatment. Of these, 142 were approved for participation, and 132 started treatment. Simple regression revealed a significant association between behavioral health consultation and treatment approval; however, behavioral health consultation was non-significant in the multivariable model for treatment approval. For initiating HCV treatment, onsite behavioral health consultation was significantly associated in both the unadjusted and adjusted regression models. Integrating behavioral health services for patients seeking HCV treatment may improve movement across the care continuum, optimizing patient's HCV health outcomes. Behavioral health consultation in primary care settings should be studied further to improve HCV treatment outcomes for patients with behavioral health and substance use disorders.

Reasons for Not Seeking Hepatitis C Treatment among People Who Inject Drugs

Despite increases in treatment uptake for hepatitis C viral infection (HCV) in Australia since the introduction of direct acting antiviral (DAA) therapy, a large proportion of HCV-infected people who inject drugs (PWID) have not sought treatment. Purpose/Objectives: To examine predictors of treatment uptake and reasons for not seeking treatment among PWID. Methods: PWID (n = 404) recruited through five needle and syringe programs in South East Queensland were interviewed about HCV testing, status and treatment, recent injecting drug use, mental health and reasons for not taking up treatment. Predictors of treatment uptake were examined using unadjusted and adjusted logistic regression analyses. Proportions were calculated for participants reporting each reason for not taking up treatment. Results: We recruited 404 PWID. Of those tested for HCV (94%), 55% were HCV antibody positive and 31% with active infection. Approximately 36% of eligible participants had begun or completed DAA treatment. In adjusted analyses, injecting drugs three or more times per day was associated with not taking up HCV treatment (p = 0.005). Common reasons for not seeking treatment ("applied a lot") included experiencing no HCV-related symptoms (25%), HCV treatment not being a priority (23%), fear of treatment side effects (18%), and no knowledge of DAA treatments (15%). Conclusions/Importance: HCV education efforts for PWID should target misperceptions and lack of awareness of DAA therapy, and highlight the likely benefits of treatment even when asymptomatic. The use of peer workers and increased investment in integrated treatment facilities will likely aid treatment uptake.

Risk Factors, Pathogenesis, and Strategies for Hepatocellular Carcinoma Prevention: Emphasis on Secondary Prevention and Its Translational Challenges

Hepatocellular carcinoma (HCC) is a leading cause of cancer-associated mortality globally. Given the limited therapeutic efficacy in advanced HCC, prevention of HCC carcinogenesis could serve as an effective strategy. Patients with chronic fibrosis due to viral or metabolic etiologies are at a high risk of developing HCC. Primary prevention seeks to eliminate cancer predisposing risk factors while tertiary prevention aims to prevent HCC recurrence. Secondary prevention targets patients with baseline chronic liver disease. Various epidemiological and experimental studies have identified candidates for secondary prevention-both etiology-specific and generic prevention strategies-including statins, aspirin, and anti-diabetic drugs. The introduction of multi-cell based omics analysis along with better characterization of the hepatic microenvironment will further facilitate the identification of targets for prevention. In this review, we will summarize HCC risk factors, pathogenesis, and discuss strategies of HCC prevention. We will focus on secondary prevention and also discuss current challenges in translating experimental work into clinical practice.

Geographically Focused Collocated Hepatitis C Screening and Treatment in Los Angeles's Skid Row

BACKGROUND

The inequitable prevalence of hepatitis C (HCV) in the homeless is a clinical and public health concern. Prior research estimates, at least one-quarter of homeless persons have been infected with HCV, yet linkage to care and treatment uptake remains marginal.

AIM

To evaluate the feasibility of treating HCV in a homeless population.

METHODS

Retrospective study of homeless individuals treated for HCV. Demographic information including risk factors was collected. Univariate analyses were performed. The proportion of patients linked to care and sustained viral response at 12 weeks post-treatment (SVR12) was measured.

RESULTS

During the study period, 6767 individuals were screened for HCV. A total of 769 (11.4%) were found to have detectable HCV antibodies. Of the individuals with detectable HCV antibodies, 443 (57.6%) were viremic. Of the 443 viremic patients, 375 (84.7%) were linked to care. Among them, 59 patients began antiviral treatment and 95% (56/59) completed the course of therapy. The ITT was 83.1% (49/59), and the per-protocol virologic cure rate was 100% (49/49).

CONCLUSION

The favorable linkage to care and cure outcomes in our study suggests that homeless persons may be more likely to engage in HCV screening and treatment when these services are located in the community for their use. Our study further lends support to the efficacy of care coordination programs to encourage movement through the HCV care continuum in vulnerable populations.

Health Department Efforts to Increase Hepatitis C RNA Testing Among People Appearing Out of Care: Comparison of Outreach Approaches, New York City, 2017

OBJECTIVES

Hepatitis C virus (HCV) infection is a serious health problem in New York City. Although curative treatments are available, many people are out of care. The New York City Department of Health and Mental Hygiene (DOHMH) used surveillance data and various outreach methods to attempt to link to care people diagnosed with HCV infection from 2010 through 2015.

METHODS

We randomly assigned people out of care (ie, no HCV test >6 months after first report) to 4 outreach groups: no outreach (control group); letter only; letter and telephone call; and letter, text message, and telephone call. Three months after outreach ended, we analyzed surveillance data to identify people with a subsequent HCV RNA or genotype test suggesting linkage to care.

RESULTS

Of 2626 selected people, 199 (7.6%) had a subsequent HCV test. People in all 3 outreach groups had higher odds of a subsequent test than people in the control group (letter only: adjusted odds ratio [aOR] = 1.81 [95% CI, 1.18-2.91]; letter and telephone: aOR = 3.11 [95% CI, 1.67-5.79]; letter, text, and telephone: aOR = 3.17 [95% CI, 1.48-6.51]). People in the letter and telephone group had higher odds of a subsequent test than people in the letter-only group (aOR = 1.72; 95% CI, 1.04-2.74). Most people in the letter and telephone (136/200, 68.0%) and the letter, text, and telephone (71/99, 71.7%) groups could not be reached, primarily because telephone numbers were incorrect or out of service.

CONCLUSION

Reaching out to people soon after first report or prioritizing groups in which more recent contact information can be found might improve outcomes of future outreach.

Prevalence and high risk behaviours associated with HCV testing among people who inject drugs: a systematic review and Meta-analysis

BACKGROUND

Hepatitis C diagnosis could be a gateway to behavioral change and subsequent decline in transmission among people who inject drugs (PWIDs). We assessed the association between the social determinants of PWID, their risk behaviors and hepatitis C testing.

METHODS

We searched for studies in English published before May 1, 2020, on PubMed, Scopus, Cochrane, and Web of Science to identify primary studies on the factors associated with hepatitis C virus (HCV) testing among PWID. After reviewing for study duplicates, the full-text of selected articles were assessed for eligibility using Population, Intervention, Comparator, Outcomes (PICO) criteria. i) population: individuals who report injecting drugs; ii) intervention: HCV testing in the past year; iii) comparator: PWIDs who did not have an HCV test; iv) outcome: HCV testing among PWIDs and v) study type: cross-sectional, cohort, and case-control studies. Two independent reviewers (author BA and AB) chose the references in a two-phased monitoring process. The authors gathered data from selected papers, including the surname of the first author, publication date, participant demographic data (age, sex, and level of education) and other characteristics like previous HCV testing, past treatment attempts, duration of injecting drug use and condomless sex. We used fixed and random-effects meta-analysis models to estimate the pooled prevalence, pooled odds ratio (OR), and 95% confidence intervals. The data were analyzed using Stata 12.0 software.

RESULTS

After a detailed assessment of over 12,000 articles, a total of 16 studies containing 38,952 participants met the eligibility criteria. Our findings showed a pooled prevalence rate of 61.01% (95% CI, 34.65-84.32%) for recent HCV testing among PWIDs. Being female (OR = 1.69, 95%CI = 1.13, 2.26), aged > 30 years, (OR = 2.61, 95%CI = 1.66-3.56) having past treatment attempt (OR = 2.24, 95%CI = 1.80-2.68), and reporting a previous test (OR = 2.03, 95%CI = 1.23-2.82). were significantly associated with having a recent HCV test.,,. Finding of present study was that unprotected sex had a negative association with HCV testing. Those PWIDs who had unprotected sex were 0.56 times less likely to have completed HCV testing during last year (OR = 0.56, 95%CI = 0.33-0.78).

CONCLUSION

Prevention programs that address age > 30 years, being female, past treatment attempt, previous testing of safe sexual practices, are strongly recommended to prioritize HCV risk reduction strategies.

Discovery of Hepatitis C Virus: 2020 Nobel Prize in Medicine

Hepatitis C virus (HCV) accounts for hepatitis, cirrhosis, hepatocellular carcinoma, and liver transplantation. Every year, millions of people develop chronic liver diseases. This article provides novel insights into the major breakthroughs in the discovery of hepatitis C virus. 2020 Nobel Prize in Medicine was awarded to Michael Houghton, Harvey Alter, and Charles Rice for their outstanding contribution in the discovery of HCV. Also, this article deals with current findings, challenges, and future prospects in the diagnosis of HCV infection. DAA, along with protease inhibitors, is found to have higher SVR and is a promising drug to treat HCV infection. However, with regard to the emergence of resistance to DAAs, CRISPR-Cas can be the future technique in preventing resistance. Although the current knowledge of molecular mechanisms associated with HCV infection is insufficient, the better understanding of it provides better hope in the treatment of HCV.

Lymphoma

A cancer causing infection on lymphocytes.

Fulminant hepatitis

A decrease in the size of the liver accompanied even by the death of liver parenchyma with the onset of infection with hepatitis virus.

Transfection

The process of introducing nucleic acids into eukaryotic cells without using viral methods.

Huh-7 cells

A type of liver cells grown in the laboratory for research purposes.

Immunoscreening

A biomedical method that helps to detect a protein produced from a cloned gene after it undergoes transcription, followed by the translation process within the cell.

cDNA library

A group of only the genes that are encoded into proteins by an organism.

Sustained virologic response

Absence of any evidence of the presence of HCV in the blood of patients with chronic HCV infection after undergoing antiviral treatment.

Pegylated interferon

A covalent conjugate of recombinant interferon and polyethylene glycol, used as an antiviral and antineoplastic agent.

Immunoelectron microscopy

A technique to localize ultrastructure antigens or antibodies in cells or tissues for the diagnosis of viral infections.

Stellate cells

A major type of liver cell involved in liver cirrhosis.

Hepatitis C virus (HCV) accounts for hepatitis, liver cirrhosis, hepatocellular carcinoma, and liver transplantation. This virus is a single-stranded RNA virus that belongs to the Flaviviridae family. According to the WHO, about 71 million people have chronic HCV infections around the globe in 2020, and hence, it is a plague of humankind. The credit of discovery of HCV goes to Michael Houghton, Harvey Alter, and Charles Rice for which they are awarded 2020 Nobel Prize in Medicine. Their contribution has given better hope to mankind to cure HCV for the first time in the history. With the use of pegylated interferon and ribavirin jointly, higher SVR has been found comparatively, even in patients with chronic liver diseases. However, due to excessive pain tolerated by patients, interferon (IFN)-based therapy is rapidly being replaced with IFN-free DAA regimens. With the onset of resistance to DAA drugs, CRISPR-Cas system can be used to modify the viral genome to impair their ability to develop resistance.

How to cite this article: Laugi H. Discovery of Hepatitis C Virus: 2020 Nobel Prize in Medicine. Euroasian J Hepato-Gastroenterol 2020;10(2): 105–108.

Network-based recruitment of people who inject drugs for hepatitis C testing and linkage to care

Although oral direct-acting agent (DAA) therapies have the potential to reduce the burden of hepatitis C virus (HCV) infection, treatment uptake remains low, particularly among people who inject drugs (PWID). This study examined the feasibility of an innovative peer-based recruitment strategy to engage PWID in HCV testing and treatment. We interviewed an initial set of HCV antibody-positive PWID as 'primary indexes' to gather demographic, drug use, health information and drug network characteristics. Primary indexes were then briefly educated on HCV and its treatment and encouraged to recruit their injection drug 'network members' for HCV testing and linkage to care. Eligible network members were enrolled as 'secondary indexes' and completed the same index study procedures. In sum, 17 of 36 primary indexes initiated the recruitment of 64 network members who were HCV antibody positive and eligible to become indexes. In multivariable analysis, successful recruitment of at least one network member was positively associated with prior HCV treatment (OR 2.80; CI [1.01, 7.72]), daily or more injection drug use (OR 2.38; CI [1.04, 5.47]), and a higher number of injection drug network members (OR 1.20; CI [1.01, 1.42]). Among the 69 participants with chronic HCV not previously linked to HCV care at enrolment, 91% (n = 63) completed a linkage to HCV care appointment, 45% (n = 31) scheduled an appointment with an HCV provider, and 20% (n = 14) initiated HCV therapy. These findings suggest a potential benefit for peer-driven, network-based interventions focused on HCV treatment-experienced PWID as a mechanism to increase HCV linkage to care.

Implementation of a unique hepatitis C care continuum model in Rwanda

BACKGROUND

There has been an evolution in the treatment of chronic hepatitis C (HCV) due to highly effective direct-acting antivirals, however, restriction of treatment to medical specialists hinders escalation of HCV treatment. This is particularly true in resource-limited settings (RLS), which disproportionately represent the burden of HCV worldwide. The ASCEND study in Washington, DC, demonstrated that complete task-shifting can safely and effectively overcome a low provider-to-patient ratio and expand HCV treatment. However, this model has not been applied internationally to RLS.

METHOD

The validated ASCEND model was translated to an international clinical program in Kigali, Rwanda, aimed at training general medicine providers on HCV management and obtaining HCV prevalence data.

RESULTS

The didactic training program administered to 11 new HCV providers in Rwanda increased provider's knowledge about HCV management. Through the training program, 26% of patients seen during the follow-up period were screened for HCV and a prevalence estimate of 2% was ascertained. Of these patients, 30% were co-infected with hepatitis B.

CONCLUSION

The ASCEND paradigm can be successfully implemented in RLS to escalate HCV care, in a self-sustaining fashion that educates more providers about HCV management, while increasing the public's awareness of HCV and access to treatment.

Impact of comprehensive care on health care use among a cohort of marginalized people living with hepatitis C in Toronto

Background

The majority of new hepatitis C (HCV) cases occur among people who inject drugs. In recent years, multidisciplinary models of HCV treatment have emerged that demonstrate successful treatment outcomes for this population, as well as broad positive individual- and system-level impacts. Our objective was to evaluate changes in health care use among a cohort of people living with HCV before and after engagement with one such program.

Methods

Program data were uniquely linked to provincial health administrative databases. Rates of emergency department (ED) visits and hospital admissions of clients from 2011 through 2015 (N = 103) were evaluated using linkages with administrative data for the 2 years before and after program initiation. Data were evaluated using negative binomial regression models with a covariance structure to account for within-individual correlations. Results: Of participants, 72.8% were men (mean age 47 years), and 38% experienced high rates of physical and mental health comorbidity (Aggregated Diagnosis Group score ≥10). Female clients had significantly fewer ED visits 2 years after program initiation (5.04 versus 3.12; risk ratio [RR] 0.61 [95% CI 0.44% to 0.86%]). ED visits for infectious diseases and soft tissue injury were significantly lower for the cohort overall (RRs 0.58 0.51 [95% CIs 0.35% to 0.95% and 0.29% to 0.90%], respectively).

Conclusion

Co-locating HCV treatment within comprehensive primary care and harm reduction services appears to have benefits beyond HCV, including a reduction in ED visits among women and a decrease in ED visits for soft tissue infections for all participants.

Telemedicine successfully engages marginalized rural hepatitis C patients in curative care

BACKGROUND

Rurally located individuals living with hepatitis C virus (HCV) face barriers to engagement and retention in care. Telemedicine technologies coupled with highly curative direct acting antiviral (DAA) treatments may increase accessibility to HCV care while achieving high sustained virologic response (SVR) rates. We compared clinical and socio-economic characteristics, SVR, and loss to follow-up among telemedicine (TM), mixed delivery (MD), and outpatient clinic (OPC) patients receiving care through The Ottawa Hospital Viral Hepatitis Program (TOHVHP).

METHODS

TOHVHP clinical database was used to evaluate patients engaging HCV care between January 1, 2012, and December 31, 2016. SVR rates by HCV care delivery method (TM versus OPC versus MD) were calculated.

RESULTS

Analysis included 1,454 patients who engaged with TOHVHP at least once. Patients were aged almost 50 years on average and were predominately male and Caucasian. A greater proportion of TM patients were rurally based, were Indigenous, had a history of substance use, and had previously been incarcerated. Per-protocol DAA SVR rates for TM, OPC, and MD patients were 100% (26/26), 93% (440/472), and 94% (44/47), respectively. Loss-to-follow-up rates for HCV-treated TM and MD patients were higher (27% [10/37], 95% CI 0.58 to 0.88, and 11% [7/62], 95% CI 0.81 to 0.97, respectively) than for those followed exclusively in the OPC (5% [39/800], 95% CI 0.94 to 0.97).

CONCLUSIONS

TM can successfully engage, retain, and cure rurally based HCV patients facing barriers to care. Strategies to improve TM retention of patients initiating HCV antiviral treatment are key to optimizing the impact of this model of care.

Impact of a digital medicine programme on hepatitis C treatment adherence and efficacy in adults at high risk for non-adherence

BACKGROUND

Direct-acting anti-virals (DAA) are highly effective for hepatitis C virus (HCV) treatment, but perceived risks of medication non-adherence may restrict access to care. Digital medicine programme (DMP) has improved adherence and outcomes for some conditions.

AIMS

To conduct a prospective, single-arm, open-label study across the United States to assess the impact of DMP on adherence and efficacy in adults with chronic HCV infection at high risk for non-adherence.

METHODS

Eligible participants were placed on the DMP to evaluate real-time adherence; primary outcome was sustained virological response (SVR) at ≥10 weeks post-treatment.

RESULTS

Between August 2017 and April 2019, 288 participants (Medicaid, 64.9%; psychiatric disorders, 61.1%; homeless, 9.4%) received DAAs for 8-12 weeks (sofosbuvir/velpatasvir or ledipasvir, 45%; glecaprevir/pibrentasvir, 55%). SVR was achieved in 99.1% of 218 participants who had HCV RNA assessed at ≥10 weeks post-treatment; of the 70 participants who did not have SVR assessed, 17 had SVR4 with HCV RNA assessed at a median (IQR; interquartile range) 5.6 weeks (4.1, 7.9) post-treatment; one completed treatment but did not have HCV RNA assessed, and 52 discontinued treatment early without assessment. Overall, the primary analysed participants (n = 218) actively used the DMP for median (range) 92.9% (12.5%, 100%) of their prescribed treatment time, and overall pill-taking adherence was 95.0% (57.1%, 100%). Participants reported the programme was useful and easy to use through satisfaction surveys.

CONCLUSIONS

HCV treatment with DMP was accepted by patients and clinicians and may support HCV treatment outcomes among patients at high risk for treatment non-adherence (Clinical trials.gov NCT03164902).

Animal Models of Hepatitis C Virus Infection

Hepatitis C virus (HCV) is an important and underreported infectious disease, causing chronic infection in ∼71 million people worldwide. The limited host range of HCV, which robustly infects only humans and chimpanzees, has made studying this virus in vivo challenging and hampered the development of a desperately needed vaccine. The restrictions and ethical concerns surrounding biomedical research in chimpanzees has made the search for an animal model all the more important. In this review, we discuss different approaches that are being pursued toward creating small animal models for HCV infection. Although efforts to use a nonhuman primate species besides chimpanzees have proven challenging, important advances have been achieved in a variety of humanized mouse models. However, such models still fall short of the overarching goal to have an immunocompetent, inheritably susceptible in vivo platform in which the immunopathology of HCV could be studied and putative vaccines development. Alternatives to overcome this include virus adaptation, such as murine-tropic HCV strains, or the use of related hepaciviruses, of which many have been recently identified. Of the latter, the rodent/rat hepacivirus from Rattus norvegicus species-1 (RHV-rn1) holds promise as a surrogate virus in fully immunocompetent rats that can inform our understanding of the interaction between the immune response and viral outcomes (i.e., clearance vs. persistence). However, further characterization of these animal models is necessary before their use for gaining new insights into the immunopathogenesis of HCV and for conceptualizing HCV vaccines.

The balancing perspective of hard-to-reach hepatitis C patients who were lost to follow-up: A qualitative study

Background

In the foreseeable future, patients with hepatitis C virus (HCV) with good healthcare access will all have been cured and the lost to follow-up (LFU) HCV-population will increasingly exist of hard-to-reach patients. Efforts to retrieve these individuals with HCV have been moderately successful so far. A deeper understanding of the reasons for loss to follow-up and the underlying processes is lacking.

Aims

To explore reasons for previous loss to follow-up in patients with HCV who have been brought back into care.

Methods

In 2017, fifteen patients with HCV who were evaluated at the University Medical Center Utrecht (UMCU) Infectious diseases outpatient clinic as part of the “REtrieval And cure of Chronic Hepatitis C” (REACH)-project were included in this study through convenience sampling. Face-to-face semi-structured in-depth interviews were conducted and a qualitative analysis based on the grounded theory was applied.

Results

A basic socio- psychological process named “maintaining the achieved balance” was uncovered in patients with HCV who were LFU. This “achieved balance” is the result of a transformative process following the initial HCV diagnosis. It is a steadfast stance in which participants keep HCV out of sight and in the margin of their lives in order to reestablish an optimal state of well-being. The balancing perspective is subsequently defended by repeated evasive behavioral patterns to avoid confrontation with the disease.

Conclusion

The balancing perspective gives insight into why individuals with HCV were not retained in care but also why they remained LFU thereafter. Physicians should realize that this mindset can be persistent and repeated efforts may be needed to finally trace and retrieve these patients.

Barriers to treatment of chronic hepatitis C with direct acting antivirals in an urban clinic

INTRODUCTION AND AIM

Direct-acting antiviral (DAA) agents are highly effective for treatment of chronic hepatitis C virus (HCV) yet access to treatment remains a serious challenge. The aim of this study was to identify barriers to treatment initiation with DAA-containing regimens in an urban clinic setting.

MATERIALS AND METHODS

A retrospective cohort of all chronic HCV patients seen in an urban academic practice in Jacksonville, FL, USA from 1/2014 to 1/2017 was analyzed. Baseline characteristics were recorded and a review of medical records was performed to identify barriers to treatment initiation and overall success rates.

RESULTS

Two-hundred and forty patients with chronic HCV were analyzed. Fifty-six percent of patients were African-American and 63% were insured through Medicaid/county programs or uninsured. Sixty-nine percent had barriers to initiating antiviral therapy categorized as psychosocial (n=112), provider (n=26), medical (n=20), and insurance-related factors (n=7). The most commonly encountered psychosocial barriers included failure to keep appointments (79/240, 33%), active substance abuse (18/240, 8%), and failure to obtain laboratory testing (11/240, 5%). Overall, only 27% of patients evaluated were initiated on DAA-containing regimens with 18% reaching SVR12 within the 36-month study period.

CONCLUSION

In conclusion, only 27% of patients who presented to an urban academic practice with chronic HCV received DAA-containing regimens over a 36-month period. Psychosocial issues were the major barriers to antiviral therapy. These findings illustrate the need for an integrated approach that addresses psychosocial factors as well as comorbidities and adherence to care in order to increase rates of HCV treatment in at risk patients.

Hepatitis C Care Continuum in a Human Immunodeficiency Virus (HIV) Positive Cohort: Data From the HIV Atlanta Veterans Affairs Cohort Study

Background

Human immunodeficiency virus (HIV) and hepatitis C virus (HCV) coinfection is associated with accelerated progression to cirrhosis, end-stage liver disease, and liver-associated death. It is fortunate that curative direct-acting antivirals for the treatment of HCV are widely available in the VA healthcare system. We attempted to identify, evaluate, and treat all HIV/HCV-coinfected persons at the Atlanta VA Healthcare System.

Methods

Human immunodeficiency virus/HCV-coinfected persons at Atlanta VA between 2015 and 2018 were identified using the HIV Atlanta Veterans Affairs Cohort Study and Hepatitis C VA Clinical Case Registry. Retrospective reviews of each electronic medical record were conducted by the hepatitis C clinical team for validation. The primary end point was achieving sustained virologic response.

Results

One hundred thirty-eight veterans with HIV and hepatitis C viremia were identified. One hundred twenty-five (90%) were evaluated for treatment and 113 (91%) were initiated on direct-acting antiviral therapy. Median age at initiation of treatment was 60 years and the majority were black race (90%). Genotype 1a was most common (70%) and 41% had compensated cirrhosis. One hundred eight completed treatment and 96% achieved sustained virologic response. Six veterans had virologic relapse; 4 had treatment-emergent resistance mutations in the NS5a gene. Mean CD4 was 580 cells/mm³ with HIV viral suppression in 82% of the cohort. In those not treated, unstable housing (25%), active substance use (31%), and psychiatric conditions (42%) were identified barriers to care.

Conclusions

Through a concerted, systematic effort, over 80% of HIV/hepatitis C persons in the Atlanta VA have been initiated on treatment for hepatitis C, 96% of which have been cured.

Individual and network factors associated with HCV treatment uptake among people who inject drugs

BACKGROUND

Hepatitis C virus (HCV) treatment uptake among people who inject drugs (PWID), a population with disproportionately high rates of HCV, remains low. Peers have been shown to positively impact a broad range of health outcomes for PWID. There is, however, limited data on the impact of PWID social network members on HCV treatment.

METHODS

HCV-infected PWID enrolled in an ongoing community-based cohort were recruited as "indexes" to complete an egocentric social network survey. The survey elicited from the index PWID a list of their network members and the index's perception of network member characteristics. Logistic regression analyses were conducted to compare individual and network factors associated with HCV treatment in the index PWID.

RESULTS

Among 540 HCV-infected PWID, the mean age was 55.7 years and the majority were black (87.2%) and male (69.8%). PWID reported a mean of 4.4 (standard deviation [SD] 3.2) network members, most of whom were relatives (mean 2.2 [SD 1.5]). In multivariable analysis, increasing index age and HIV infection were positively associated with HCV treatment, while drug use and homelessness in the preceding 6 months were negatively associated with HCV treatment. From a network perspective, having at least one network member who regularly talked with the index about seeing their doctor for HIV care was associated with HCV treatment (Adjusted Odds Ratio [AOR] 2.7; 95% Confidence Interval (CI) [1.3, 5.6]). Conversely, PWID who had at least one network member who helped them understand their HCV care were less likely to have been HCV treated (AOR 0.2; CI [0.1, 0.6).

CONCLUSION

HCV treatment uptake in this group of PWID appeared to be positively influenced by discussions with network members living with HIV who were in care and negatively influenced by HCV information sharing within PWID networks. These findings underscore the influence of peers on health seeking behaviors of their network members and emphasizes the importance of well-informed peers.

Framework for community-based models for treating hepatitis C virus

Objective Although community-based models for treating hepatitis C virus (HCV) are widely recognised for reaching more people who require treatment, little is known about their organisational and operational elements. This study aimed to address this gap and develop a framework for designing, implementing and evaluating community-based models for treating HCV. Methods This study was a systematic review in which 17 databases were searched for published and unpublished studies. The final search of databases was performed in September 2017. A qualitative inductive thematic approach was used to extract and categorise organisational and operational elements of community-based models for treating HCV. Results Data analysis yielded 13 organisational and operational elements that were categorised into three domains: support for patients, support for healthcare providers and service delivery facilitation. In the support for patients domain, support was categorised into four elements: peer support, psychological assessment and support, social assessment and support and adherence support. In the support for healthcare providers domain, the elements included the provision of educational opportunities for HCV care providers, specialist mentoring, decision making support and rewarding and recognition for HCV care providers. Finally, the service delivery facilitation domain included seven elements that target service-level enablers for community-based HCV treatment, including essential infrastructure, policy implementation and collocation and collaboration with other related services. Conclusion This framework for understanding the components of models of community-based HCV treatment may be used as a guide for designing, implementing and evaluating models of care in support of HCV elimination. HCV care providers and patients need to be supported to improve their engagement with the provision of community-based treatment. In addition, evidence-based strategies to facilitate service delivery need to be included. What is known about the topic? Community-based models for treating HCV are widely recognised as having the advantage of reaching more people who require treatment. These types of models aim to remove barriers related to accessibility and acceptability associated with tertiary centre-based HCV treatment. What does this paper add? Community-based models for treating HCV use various organisational and operational elements to improve the accessibility, effectiveness and acceptability of these services. The elements we identified target three main domains: support for patients with HCV, support for HCV care providers and service delivery facilitation. The importance of these organisational and operational elements designed to improve health and health services outcomes of community-based models for treating HCV is strongly influenced by context, and dependent on both the setting and target population. What are the implications for practitioners? Health policy makers and practitioners need to consider a patient’s psychosocial and economic status and provide support when needed. To successfully deliver HCV treatment in community settings, HCV care providers need to be trained and supported, and need to establish linkages, collaborations or colocations with other related services.

Case Management and Capacity Building to Enhance Hepatitis C Treatment Uptake at Community Health Centers in a Large Urban Setting

An estimated 4.1 million people in the United States are infected with hepatitis C virus (HCV). In 2014, the Hepatitis C Community Alliance to Test and Treat (HepCCATT) collaborative was formed to address hepatitis C in Chicago. From 2014 to 2017, the HepCCATT Case Management Program case managed 181 HCV-infected people and performed on-site capacity building at a 6-site community health center (CHC) that produced codified protocols, which were translated into a telehealth program to build capacity within CHCs to deliver hepatitis C care. HepCCATT's innovative approach to addressing multilevel barriers is a potential model for increasing access to hepatitis C care and treatment.

A cost-effectiveness analysis of primary versus hospital-based specialist care for direct acting antiviral hepatitis C treatment

BACKGROUND

Hepatitis C virus elimination may be possible by scaling up direct-acting antiviral (DAA) treatment. Due to the safety and simplicity of DAA treatment, primary care-based treatment delivery is now feasible, efficacious and may be cheaper than hospital-based specialist care. In this paper, we use Prime Study data - a randomised controlled trial comparing the uptake of DAA treatment between primary and hospital-based care settings amongst people who inject drugs (PWID) - to estimate the cost of initiating treatment for PWID diagnosed with hepatitis C in primary care compared to hospital-based care.

METHODS

The total economic costs associated with delivering DAA treatment (post hepatitis C diagnosis) within the Prime study - including health provider time/training, medical tests, equipment, logistics and pharmacy costs - were collected. Appointment data were used to estimate the number/type of appointments required to initiate treatment in each case, or the stage at which loss to follow up occurred.

RESULTS

Among the hepatitis C patients randomised to be treated within primary care, 43/57 (75%) commenced treatment at a mean cost of A$885 (95% CI: A$850-938) per patient initiating treatment. In hospital-based care, 18/53 hepatitis C patients (34%) commenced treatment at a mean cost of A$2078 (range: A$2052-2394) per patient initiating treatment - more than twice as high as primary care. The lower cost in the primary care arm was predominantly the result of increased retention in care compared to the hospital-based arm.

CONCLUSIONS

Compared to hospital-based care, providing hepatitis C services for PWID in primary care can improve treatment uptake and approximately halve the average cost of treatment initiation. To improve treatment uptake and cure, countries should consider primary care as the main model for hepatitis C treatment scale-up.

Hepatitis C treatment for difficult to access populations: can telementoring (as distinct from telemedicine) help?

BACKGROUND

Although hepatitis C virus (HCV) infection is curable, treatment of difficult to access populations (DTAP) presents unique challenges. Project ECHO (PE) (Extension for Community Healthcare Outcomes) is a telementoring programme adopted to support clinicians treating DTAP.

AIMS

To determine if the PE model supports primary care clinicians treating HCV and to compare cohort of PE patients with those in a tertiary liver clinic (TLC).

METHODS

Weekly PE group video conferences were conducted. Clinical information, laboratory indices, psychosocial elements and treatment outcomes, including sustained virological response (SVR) data were recorded in the first 100 consecutive cases and retrospectively compared to 100 consecutive patients seen at a TLC from July 2016 to April 2017.

RESULTS

Some patient characteristics were similar between PE and TLC: gender (72% vs 75% male; P = 0.23), median age (45 vs 50; P = 0.344) and the proportion of treatment naïve patients (95.0% vs 90.9%). Treatment for HCV was commenced in 78% of the PE patients and 81% of the TLC patients; 67/68 of the TLC patients and 60/61 PE patients with virological follow up who completed treatment and attended follow up have confirmed SVR. PE patients are more likely to have ongoing substance use (44% vs 17% P < 0.001), be active intravenous drug users (32% vs 17%; P < 0.001) and polysubstance abusers (26% vs 7%; P < 0.001) and were more likely to be taking opioid substitution therapy (74% vs 20%; P < 0.001). Indigenous patients were three times more greatly represented in PE (15% vs 5%; P = 0.018).

CONCLUSION

PE is an effective model to support primary healthcare providers treating HCV in DTAP with similar rates of treatment uptake and SVR compared to patients in TLC.

The population level care cascade for hepatitis C in British Columbia, Canada as of 2018: Impact of direct acting antivirals

BACKGROUND

Population-level monitoring of hepatitis C virus (HCV) infected people across cascades of care identifies gaps in access and engagement in care and treatment. We characterized the population-level care cascade for HCV in British Columbia (BC), Canada before and after introduction of Direct Acting Antiviral (DAA) treatment.

METHODS

BC Hepatitis Testers Cohort (BC-HTC) includes 1.7 million individuals tested for HCV, HIV, reported cases of hepatitis B, and active tuberculosis in BC from 1990 to 2018 linked to medical visits, hospitalizations, cancers, prescription drugs and mortality data. We defined six HCV care cascade stages: (a) antibody diagnosed; (b) RNA tested; (c) RNA positive; (d) genotyped; (e) initiated treatment; and (f) achieved sustained virologic response (SVR).

RESULTS

We estimated 61 127 people were HCV antibody positive in BC in 2018 (undiagnosed: 7686, 13%; diagnosed: 53 441, 87%). Of those diagnosed, 83% (44 507) had HCV RNA testing, and of those RNA positive, 90% (28 716) were genotyped. Of those genotyped, 61% (17 441) received therapy, with 90% (15 672) reaching SVR. Individuals from older birth cohorts had lower progression to HCV RNA testing. While people who currently inject drugs had the highest proportional progression to RNA testing, this group had the lowest proportional treatment uptake.

CONCLUSIONS

Although gaps in HCV RNA and genotype testing after antibody diagnosis exist, the largest gap in the care cascade is treatment initiation, despite introduction of DAA treatment and removal of treatment eligibility restrictions. Further interventions are required to ensure testing and treatment is equitably accessible in BC.

The challenges of hepatitis C management in Iran: A qualitative study with patients

BACKGROUND

The patient's perspective concerning the treatment process and the knowledge of the challenges and problems that they encounter can help to improve their treatment conditions.

AIM

The present study aimed at analyzing the experiences of hepatitis C virus (HCV) patients in Iran and the challenges encountered during the management and treatment process.

METHODS

Semi-structured in-depth and face-to-face interviews were conducted. The criteria for selecting patients were as follows: HCV-positive subjects, with confirmed diagnosis of HCV, and under treatment. Content analysis was used to analyze the data. MAXQDA Ver11 software was used to better manage data. This study is based on the "Consolidated Criteria for Reporting Qualitative Research" (COREQ) checklist.

RESULTS

Twenty-one HCV patients were interviewed. The mean age of participants was 36.14 ± 11.29 years. Seven themes with 20 subthemes emerged from the content analysis of the interviews, namely, (a) disease-related stigma, (b) lack of knowledge, (c) psychological problems, (d) financial problems, (e) complications of treatment, (f) lack of family and community support, and (g) health-care system.

CONCLUSION

The findings of this study showed that a range of economic, social, and cultural problems could affect the treatment of HCV patients. Health policy and decision makers should try to provide them with a better management.