Telemedicine successfully engages marginalized rural hepatitis C patients in curative care

Proper distance in the age of social distancing: Hepatitis C treatment, telehealth and questions of care and responsibility

During the COVID-19 pandemic, telehealth has played a prominent role in the treatment of hepatitis C. As part of a qualitative study on the accessibility and effectiveness of telehealth for hepatitis C treatment during this period in Australia, this article considers how health-care practitioners and patients experience and manage their proximity to each other in telehealth encounters of care. Comparisons between telehealth and in-person health-care tend to focus on measures of patient satisfaction rather than qualitative changes in treatment relationships. Media scholar Silverstone (Digital media revisited: Theoretical and conceptual innovations in digital domains, MIT Press, 2003) uses the term 'proper distance' to theorise how ethical relationships are mediated by technology. Drawing on this concept, we explore how patients and health-care practitioners understand telehealth as affecting distance and proximity. We find that both groups express some ambivalence about the impact of telehealth on relationships, on the one hand expecting and privileging simple, transactional relationships, and on the other hand, expressing concerns about the loss of more intimate relationships in health care and about 'missing something' while providing health care. Given that proximity is important to the development of ethical relationships in health care, we conclude with some considerations for establishing and sustaining attentive and responsive relationships in telehealth.

ECHO+: Improving access to hepatitis C care within Indigenous communities in Alberta, Canada

BACKGROUND

Indigenous populations experience higher rates of hepatitis C virus (HCV) infections in Canada. The Extension for Community Health Outcomes+ (ECHO+) telehealth model was implemented in Alberta to support HCV screening and treatment, using Zoom technology to support Indigenous patient access to specialist care closer to home. Our goal was to expand this program to more Indigenous communities in Alberta, using various Indigenous-led or co-designed methods.

METHODS

The ECHO+ team implemented a Two-Eyed Seeing framework, incorporating Indigenous wholistic approaches alongside Western treatment. This approach works with principles of respect, reciprocity, and relationality. The ECHO+ team identified Indigenous-specific challenges, including access to liver specialist care, HCV awareness, stigma, barriers to screening and lack of culturally relevant approaches.

RESULTS

Access to HCV care via this program significantly increased HCV antiviral use in the past 5 years. Key lessons learned include Indigenous-led relationship building and development of project outputs in response to community needs influences impact and increases relevant changes increasing access to HCV care. Implementation of ECHO+ was carried out through biweekly telehealth sessions, problem solving in partnership with Indigenous communities, increased HCV awareness, and flexibility resulting from the impacts of COVID-19.

CONCLUSION

Improving Indigenous patient lives and reducing inequity requires supporting local primary health care providers to create and sustain integrated HCV prevention, diagnosis, treatment, and support services within a culturally safe and reciprocal model. ECHO+ uses telehealth and culturally appropriate methodology and interventions alongside multiple stakeholder collaborations to improve health outcomes for HCV.

Interventions to increase linkage to care and adherence to treatment for hepatitis C among people who inject drugs: A systematic review and practical considerations from an expert panel consultation

BACKGROUND

Following advances in treatment for hepatitis C (HCV), optimizing linkage to care and adherence to treatment of people who inject drugs became of pivotal importance. An ECDC/EMCDDA stakeholders survey in 2018 indicated that two components of the cascade of care, linkage to care and adherence to treatment, were priority areas for inclusion in the updated guidance, planned for publication in 2022. This systematic review was commissioned with the aim to evaluate the effectiveness of interventions on HCV linkage to care and adherence to treatment among people who inject drugs.

METHODS

The full study protocol is available at PROSPERO (2020 CRD42020191116). We searched five databases to identify studies published between 2011 and 2020. Studies were included if they had a comparative study design and reported on the primary outcomes for linkage to care (visits, treatment initiation) and/or adherence to treatment (treatment adherence, treatment completion, SVR12) among people who inject drugs/people receiving opioid substitution therapy. Following the risk of bias (EPHPP) and quality of evidence assessment (GRADE), evidence to decision tables were produced and shared for critical review with an expert panel convened by ECDC and EMCDDA. The expert panel provided further considerations on the benefit, acceptability, and transferability of interventions.

RESULTS

Fourteen studies (using DAA therapy as well as DAA plus interferon-based therapy) met eligibility criteria and were included in the analysis. Integrated care with case management, peer support, psychological interventions, contingency management, and cooperation between health care providers improved engagement in and adherence to HCV care in most studies. However, the quality of evidence was predominantly low to moderate.

CONCLUSIONS

Available evidence suggests that integrated, people-centered approaches may improve engagement throughout the continuum of HCV care among people who inject drugs. For progressing HCV elimination efforts, interventions should be implemented in colocation with harm reduction and counselling activities and in combination with additional services, including opioid substitution treatment, directly observed therapy, peer support and/or contingency management.

Utilizing Telemedicine and Modified Fibrosis Staging Protocols to Maintain Treatment Initiation and Adherence Among Hepatitis C Patients During the COVID-19 Pandemic

The COVID-19 pandemic exacerbated the decline in Hepatitis C Virus (HCV) screening and treatment globally in part due to lockdowns and restrictions at healthcare centers. The goal of this retrospective cohort study was to assess the effectiveness of an updated workflow implemented at Boston Medical Center (BMC) HCV clinics. Revised workflow incorporated appointments via telemedicine, transitioning to blood test-based fibrosis scoring, and delivering medication by mail to mitigate the lack of in-person services. We compared 2 cohorts of patients who attended at least the initial intake appointment at BMCHCV clinics: 170 before the pandemic and 133 after the pandemic. Outcome variables included treatment starts, fibrosis lab tests completed, appointment attendance, and SVR achievement. Proportions for outcome variables were compared between groups by use of χ2 and 2-sample t-tests where appropriate. Our results showed a 14.43% decrease in completing fibrosis scoring tests (P-value: <.001) and a 15.21% decrease in medication initiation (P-value: <.001) among the patients who initiated care during the pandemic (modified workflow group). Furthermore, we found a 18.56% decrease in sustained virologic response (SVR) among the modified workflow group when compared to the controls. Overall, these results align with current trends of patients' decreasing engagement in HCV care but show higher retention than other published data. Furthermore, these figures support how appointments via telemedicine, transitioning to blood test-based fibrosis scoring, and medication delivery by mail can serve as tools to increase access to HCV care and successful HCV treatment completion even after COVID restrictions are lifted.

The hepatitis C epidemic in Canada: An overview of recent trends in surveillance, injection drug use, harm reduction and treatment

Hepatitis C continues to be a significant public health concern in Canada, with the hepatitis C virus (HCV) responsible for more life-years lost than all other infectious diseases in Canada. An increase in reported hepatitis C infections was observed between 2014 and 2018. Here, we present changing epidemiological trends and discuss risk factors for hepatitis C acquisition in Canada that may have contributed to this increase in reported hepatitis C infections, focusing on injection drug use. We describe a decrease in the use of borrowed needles or syringes coupled with an increase in using other used injection drug use equipment. Also, an increased prevalence of injection drug use and use of prescription opioid and methamphetamine injection by people who inject drugs (PWID) may be increasing the risk of HCV acquisition. At the same time, while harm reduction coverage appears to have increased in Canada in recent years, gaps in access and coverage remain. We also consider how direct-acting antiviral (DAA) eligibility expansion may have affected hepatitis C rates from 2014 to 2018. Finally, we present new surveillance trends observed in 2019 and discuss how the coronavirus disease 2019 (COVID-19) pandemic may affect hepatitis C case counts from 2020 onwards. Continual efforts to i) enhance hepatitis C surveillance and ii) strengthen the reach, effectiveness, and adoption of hepatitis C prevention and treatment services across Canada are vital to reducing HCV transmission among PWID and achieving Canada's HCV elimination targets by 2030.