Advancing Hepatitis C Elimination through Opt-Out Universal Screening and Treatment in Carceral Settings, United States

Rural-Urban Disparities in Hepatocellular Carcinoma Deaths Are Driven by Hepatitis C-Related Hepatocellular Carcinoma

INTRODUCTION

Recent data suggest emerging rural-urban disparities in hepatocellular carcinoma (HCC) burden in the United States. We aimed to assess (i) trends in rural vs urban HCC-related mortality and (ii) differences in underlying chronic liver disease etiologies contributing to HCC-related deaths.

METHODS

We used the National Vital Statistics System to examine crude and age-adjusted HCC death rates overall and by etiology for rural and urban residents from 2005 to 2023. Using the National Cancer Institute Joinpoint Trend Analysis Software, we identified statistically significant changes in annual percentage change (APC) in HCC mortality rates.

RESULTS

Examining mortality rates over time, average APC in HCC deaths was significantly higher in rural residents (crude average annual percentage change [AAPC] 4.64, 95% confidence interval [CI] 4.10, 5.34; age-adjusted AAPC 3.53, 95% CI 3.09, 4.07) compared with urban residents (crude AAPC 2.72, 95% CI 2.43, 3.01; age-adjusted AAPC 1.68, 95% CI 1.28, 2.13). Differences in HCC death rate changes were driven by a significantly greater recent decline in HCC cases from hepatitis C virus (HCV) in urban residents (crude APC -6.69, 95% CI -8.85, -5.30 from 2017 to 2023) compared with rural residents (crude APC -3.31, 95% CI -8.05, 0.73 from 2016 to 2023).

DISCUSSION

Annual increases in HCC deaths have been more pronounced in rural compared with urban populations. Deaths from HCV-related HCC have declined with a geographical disparity that favors urban populations, possibly driven by decreased access to HCV screening or availability of highly effective direct-acting antiviral therapies for rural residents. These findings underscore the need for targeted HCV screening and treatment strategies in rural populations in addition to ongoing strategies to combat alcohol use and metabolic diseases.

Feasibility of implementing viral hepatitis services into a correctional service facility in Cape Town, South Africa

BACKGROUND

Hepatitis B virus (HBV) and hepatitis C virus (HCV) are estimated to be of the most prevalent infectious diseases in correctional settings worldwide. However, viral hepatitis services have not been routinely integrated into South African correctional facilities. We aimed to assess prevalence of HBV infection and HCV infection among people accessing HIV services and assess the feasibility of viral hepatitis service integration in a South African correctional centre.

METHODS

Voluntarily participating people in a correctional services facility were offered free hepatitis B surface antigen (HBsAg) and anti-HCV point-of-care testing in addition to routine HIV testing and treatment services on a first-come, first-served basis during June 2021-March 2022. Off-site laboratory testing (HBV and HCV molecular testing and non-invasive liver fibrosis staging) and screening for hepatocellular carcinoma informed further management. A general practitioner at the facility managed participants, with virtual support from hepatologists. Data on age and history of injecting was collected and point-of-care and laboratory results were recorded. Data were analysed using descriptive statistics.

RESULTS

The median age of the 765 people who participated was 32.5 years (IQR 27.5 - 38.2), with 2.2% (17/765) reporting having ever injected a drug. The sample prevalence was 3.9% (30/765) for HBV infection, 0.5% (3/665) for HCV infection, and 1.2% (9/765) for HIV-HBV coinfection. Thirty people had reactive HBsAg point-of-care tests. Among those with reactive HBsAg point-of-care tests 90.0% (27/30) received work-up, among whom 48.1% (13/27) were monitored, 44.4% (12/27) were placed on treatment and two people were released before a management plan could be finalised. Of those treated 33.3% (4/12) started tenofovir/emtricitabine and 66.7% (8/12) antiretroviral therapy. Of the eligible participants, 27.3% (201/735) received at least one hepatitis B vaccine dose and 26.9% (54/201) received three doses. All three participants who had confirmed HCV infection were started on direct-acting antivirals. Of the two completing treatment one achieved sustained virological response at 12 weeks (SVR12), one person was released before SVR12 was done. One person was lost to follow-up. No clinical adverse events were reported.

CONCLUSION

There was a notable viral hepatitis burden among people in this correctional centre and integration of viral hepatitis services into the existing HIV services was acceptable and feasible. Further efforts to sustain and expand access to viral hepatitis services in South African correctional centres could catalyse national viral hepatitis elimination efforts.

Building a Low-Threshold Model for HCV Diagnosis and Treatment Among Formerly Incarcerated Patients in Alabama

BACKGROUND

Millions of Americans remain infected with hepatitis C (HCV). Innovation in care delivery is required to achieve the goal of national elimination.

AIM

Develop a low-threshold HCV treatment program.

SETTING

Free clinic with mobile unit providing transitional care to people leaving jails and prisons across Alabama.

PARTICIPANTS

Formerly incarcerated persons, many of whom are uninsured and live in rural areas.

PROGRAM DESCRIPTION

We utilized point-of-care diagnostics to condense the HCV screening and pre-treatment evaluation into a single encounter. Patient assistance programs were used to obtain medications for uninsured patients. Clinical support was provided through in-person and telehealth care.

PROGRAM EVALUATION

From January 2023 to December 2024, 369 patients were screened for HCV; 104 (28.1%) were HCV antibody positive, and 71 (19.2%) were viremic. Of these patients, 70 completed pre-treatment diagnostics, 54 started treatment, 41 confirmed completion, 20 had SVR12 collected, with 19 achieving cure (94% cure rate). The median time from diagnosis to treatment initiation was 27 days.

DISCUSSION

It is possible to both diagnose HCV and complete the entire pre-treatment evaluation in a single encounter and initiate treatment within 1 month, even for predominantly uninsured populations in rural areas.