The disconnect in hepatitis screening: participation rates, awareness of infection status, and treatment-seeking behavior

Coproduction of Low-Barrier Hepatitis C Virus and HIV Care for People Who Use Drugs in a Rural Community: Brief Qualitative Report

BACKGROUND

People who inject drugs are experiencing syndemic conditions with increasing risk of infection with hepatitis C (HCV) and HIV. However, rates of accessing HCV and HIV testing and treatment among people who inject drugs are low for various reasons, including the criminalization of drug use, which leads to a focus on treating drug use rather than caring for drug users. For many people who inject drugs, health care becomes a form of structural violence, resulting in traumatic experiences, fear of police violence, unmet needs, and avoidance of medical care. There is a clear need for novel approaches to health care delivery for people who inject drugs.

OBJECTIVE

This study aimed to analyze the process of a multidisciplinary team-encompassing health care professionals, community representatives, researchers, and people with lived experience using drugs-that was formed to develop a deep understanding of the experiences of people who inject drugs and local ecosystem opportunities and constraints to inform the cocreation of low-barrier, innovative HCV or HIV care in a rural community. Given the need for innovative approaches to redesigning health care, we sought to identify challenges and tensions encountered in this process and strategies for overcoming these challenges.

METHODS

Analysis was based on an in-depth review of meeting notes from the project year, followed by member-checking with the project team to revise and expand upon the challenges encountered and strategies identified to navigate these challenges.

RESULTS

Challenges and tensions included: scoping the project, setting the pace and urgency of the work, adapting to web-based work, navigating ethics and practice of payment, defining success, and situating the project for sustainability. Strategies to navigate these challenges included: dedicated effort to building personal and meaningful connections, fostering mutual respect, identifying common ground to make shared decisions, and redefining successes.

CONCLUSIONS

While cocreated care presents challenges, the resulting program is strengthened by challenging assumptions and carefully considering various perspectives to think creatively and productively about solutions.

Global importance of new treatment strategies to efforts to control hepatitis B virus

INTRODUCTION

Hepatitis B Virus (HBV) infection can progress to chronic HBV (CHB) disease, thereby increasing the risk of severe forms of liver disease (i.e. liver cirrhosis and hepatocellular carcinoma) and resulting in a high global burden of morbidity, mortality, and health-care utilization.

AREAS COVERED

We discuss how future therapeutic strategies and treatment guidelines may address the large unmet medical needs among patients with CHB.

EXPERT OPINION

Complexity and a lack of consensus in current CHB treatment guidelines may limit their effective implementation. To minimize poor outcomes in patients not currently receiving treatment (including immune-tolerant and inactive carriers), a simplified harmonized treatment approach is needed across guidelines. Current treatment recommendations focus on nucleot(s)ide analogs (NAs) and pegylated interferon (Peg-IFN), both of which have limitations. NAs provide clinical benefits, but treatment is prolonged and has little impact on functional cure rates. Peg-IFN offers the potential for functional cure but has notable safety and tolerability issues. A shift toward finite treatments with acceptable safety and tolerability profiles is needed.

CONCLUSION

The key to achieving World Health Organization targets for the global eradication of HBV involves enhanced diagnosis with new treatments and/or combinations of existing treatments alongside globally aligned and simplified treatment guidelines for untreated/inadequately treated populations.

An adaptable platform for in-house hepatitis C serology

Serology-based diagnosis remains one of the major tools for diagnosis and surveillance of infectious diseases. However, for many neglected diseases no or only few commercial assays are available and often with prices prohibiting large scale testing in low and middle-income countries (LMICs). We developed an adaptable enzyme-linked immunoassay (ELISA) using hepatitis C virus (HCV) as a proof-of-concept application. By combining the maltose-binding-protein with a multiepitope HCV protein, we were able to obtain a high concentration of protein suitable for downstream applications. Following optimization, the assay was verified using previously tested human samples from Canada, Denmark and Gabon in parallel with the use of a commercial protein. Sensitivity and specificity were calculated to 98 % and 97 % respectively, after accounting for non-specific binding and assay optimization. This study provides a thorough description of the development, and validation of a multiepitope ELISA-based diagnostic assay against HCV, which could be implemented at low cost. The described methodology can be readily adapted to develop novel ELISA-based diagnostic assays for other infectious pathogens with well-described immunogenic epitopes. This method could improve the diagnosis of neglected diseases for which affordable diagnostic assays are lacking.

Exploring factors associated with hepatitis B screening in a multilingual and diverse population

BACKGROUND

Racial/ethnic minorities bear a disproportionate burden of hepatitis B virus (HBV) infection and disease. Disparities in HBV screening contribute to worse outcomes for communities of color. We examined the impact of race/ethnicity, language preference, and having a usual place of care on HBV screening in a multilingual, urban cohort.

METHODS

We used questions from the Health Information National Trends Survey and added validated questions about healthcare access and health literacy. We administered this survey in English, Spanish, and Chinese to a selected convenience sample of San Francisco city/county residents in 2017, with pre-specified targets for populations with known cancer disparities: 25% Spanish-speaking, 25% Chinese-speaking, and 25% Black Americans. Using weighted multivariable logistic regression analyses, we assessed how race/ethnicity, language preference, and having a usual place of care impacts self-report of HBV screening.

RESULTS

Overall, 1027 participants completed the survey (50% of surveys administered in English, 25% in Spanish, and 25% in Chinese). Only 50% of participants reported HBV screening. In multivariable analysis, Black (OR = 0.20, 95% CI 0.08-0.49), Latinx (OR = 0.33, 95% CI 0.13-0.85), Asian (OR = 0.31, 95% CI 0.10, 0.94), and 'Other' race/ethnicity (OR = 0.17, 95% CI 0.05-0.53) respondents had lower odds of HBV screening compared to non-Hispanic White respondents. Participants who had insurance had increased odds of HBV screening (OR = 2.70, 95% CI 1.48-4.93).

CONCLUSIONS

HBV screening disparities persist for Black Americans, Asian Americans, Latinx, and the uninsured. Future studies should explore reasons why current strategies have not been implemented or are not successful, particularly in addressing racial/ethnic and insurance disparities.

Development of an intervention system for linkage-to-care and follow-up for hepatitis B and C virus carriers

Background

Poor connections in the cascade of viral hepatitis care have been discussed around the world. In 2011 in Japan, 500,000 to 1.25 million hepatitis B and C virus carriers needed to consult with hepatologists, so linkage-to-care (LTC) needs to be promoted. Therefore, in this study, to improve LTC and care-seeking behaviors, we attempted to establish a community-based intervention system and evaluate its effectiveness by analyzing behavior modifications.

Methods

In a model city, Okazaki (population: 387,887 as of 2019), LTC was encouraged among HBV and HCV carriers by annually mailed brochures, and their care-seeking behaviors were followed up through questionnaires for 8 years (2012–2019). Their behavior modifications and demographic characteristics were analyzed anonymously in cooperation with community health workers, hepatologists, and researchers.

Results

Through regional HBsAg and anti-HCV screening, 333 HBV and 208 HCV carriers were identified. Before the intervention, only 34.7% (25/72) of HBV- and 34.3% (24/70) of HCV-positive individuals had consulted with hepatologists. However, in 2019, after the intervention, these proportions increased to 79.8% (91/114) and 91.2% (52/57), respectively. Access to outpatient care and treatment uptake also continuously improved. However, individuals over 70 years of age were significantly less likely to engage in care-seeking behaviors (p < 0.05), and significantly fewer HCV-positive females received treatment (p = 0.03).

Conclusions

A paper-based reiterative intervention encouraging LTC and follow-up successfully improved the care-seeking behaviors of hepatitis virus-positive individuals and enabled their behavior modifications to be monitored. Further trials are required to advance the system by age- and gender-specific interventions.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s12072-021-10269-5.

A Survey of the Knowledge of and Testing Rate for Hepatitis C in the General Population in South Korea

Background/Aims

To eliminate hepatitis C virus (HCV) infection, improving public knowledge of and access to HCV screening and treatment is essential. The aim of this study was to evaluate the knowledge of and testing rate for HCV and the opinions about the inclusion of the HCV test in the National Health Examination (NHE) among the general population in South Korea.

Methods

A telephone interview survey was conducted by an independent research company using a 16 item-questionnaire (demographics, knowledge of HCV, testing and results, need for screening) in May 2019. The sample population consisted of 1,003 adult Korean residents adjusted by age, sex, and area according to the standard Korean population in 2019.

Results

Among the 1,003 participants (505 women, mean age of 47.9 years), 56.4% recognized HCV; 44.4% understood that HCV is transmittable, and 56.8% thought that HCV is curable by medication. The recognition rate tended to increase with an increasing level of education. Testing for anti-HCV antibodies was reported by 91 people (9.1%); among them, 10 people (11.0%) reported a positive result, and eight people received treatment. The common reasons for HCV testing were a health check-up (58.5%), a physician's recommendation (11.0%) and elevated liver enzyme levels (10.7%). The majority of the population (75.1%) agreed with the integration of HCV into the NHE.

Conclusions

The level of knowledge of HCV is suboptimal, and the self-reported testing rate for HCV is less than 10%; however, once HCV infection is diagnosed, the treatment rate seems to be high in South Korea. More active campaigns and effective screening are needed.

High prevalence of unawareness of HCV infection status among both HCV-seronegative and seropositive people living with human immunodeficiency virus in Taiwan

Objectives

HCV infection status awareness is crucial in the HCV care continuum for both HCV-seropositive (HCV-positive status awareness) and seronegative (HCV-negative status awareness) populations. However, trends in the unawareness of HCV infection status (UoHCV) remain unknown in HIV-positive patients. This study investigated UoHCV prevalence, the associated factors of UoHCV, and its association with HCV-related knowledge in HIV-positive patients.

Methods

For this cross-sectional, multicenter, questionnaire-based study, 844 HIV-infected participants were recruited from three hospitals in Taiwan from June 2018 to March 2020. Participants were grouped by HCV serostatus (HCV-seronegative [n = 734] and HCV-seropositive [n = 110]) and categorized by their HIV diagnosis date (before 2008, 2008–2013, and 2014–2020). Exploratory factor analysis was used to categorize the 15 items of HCV-related knowledge into three domains: route of HCV transmission, HCV course and complications, and HCV treatment.

Results

The prevalence of UoHCV was 58.7%–62.6% and 15.1%–31.3% in the HCV-seronegative and HCV-seropositive groups, respectively, across 3 periods. More participants with UoHCV believed that HCV infection was only contracted by intravenous injection. In the HCV-seropositive group, participants with UoHCV were more likely to have HIV diagnosis before 2008 (vs. 2014–2020), be men who have sex with men (vs. people who inject drugs), and have hepatitis A virus seronegativity. In the HCV-seronegative group, participants with UoHCV were more likely to have a recent history of sexually transmitted diseases, but had a lower education level, had received less information on HCV infection from clinicians, and were less likely to have heard of HCV infection prior to the research. UoHCV was associated with lower scores for three domains of HCV-related knowledge in both groups.

Conclusions

The negative association of UoHCV with HCV-related knowledge suggests that strategies targeting patients according to their HCV serostatus should be implemented to reduce UoHCV and eradicate HCV infection among HIV-positive patients.

Promoting Hepatitis B Awareness: Evaluating an Educational Approach through Health Care Workers in Tanzania

Background:

Hepatitis B virus (HBV) infection disproportionally affects populations in sub-Saharan Africa. Lack of HBV awareness perpetuates disease burden in Africa.

Objective:

To promote HBV awareness in Tanzania using a systematic, measurable, and expandable approach to educating health care workers (HCW).

Methods:

We designed and implemented an HBV knowledge and teaching skills session in southern Tanzania to empower HCWs in leading education to promote disease awareness in their communities. Training was divided into two sessions: didactic and practical. A five-question anonymous survey was distributed in person immediately before and after the practical portion of the training to evaluate HBV knowledge as well as specific skills for teaching. Differences between responses before and after the sessions were evaluated by Chi-Square analysis. A sub-group of questions were further analyzed for differences based on HCW self-report of HBV serostatus awareness.

Findings:

130 HCWs participated in the didactic lecture and 30 HCWs participated in both portions. A pre-post training five-question survey showed an increase in correct answers for all questions, with two showing statistical significance: HBV is silent (7% pre vs. 87% post; p < 0.0001), and repetition as key to promote awareness (63% pre vs. 100% post; p = 0.0002).

Conclusions:

Our low-cost intervention is applicable to increase HBV awareness in low resource settings across Africa.

Challenges of transferring rural adults with chronic HCV infection for further HCV RNA confirmation and free DAAs treatment: a success story of the interdisciplinary collaboration approach

Background

Chronic hepatitis C virus (HCV), which is a concern in many countries, is the leading cause of liver cancer around the world. Since Taiwan launched its national health insurance system in 1995, it has managed to extend health coverage to 99% of the Taiwanese population, providing free but limited antiviral treatment each year since 2017. However, many people in rural areas are unaware that they have chronic HCV; nor do they realize that new drugs with high cure rates could drastically reduce their health burden. The aim of this study is to explore the implementation facilitators of and barriers to inviting potentially infected patients in rural areas to be transferred for HCV ribonucleic acid (RNA) confirmation and new drug treatment.

Methods

A descriptive and prospective study design with an interdisciplinary collaboration approach was implemented. After five elements of referral were developed, telephone counseling was conducted between August 2018 and May 2019 in Yunlin, Taiwan. The elements of referral developed by the research team were: (1) forming and coordinating physicians’ schedules, (2) recruiting and training volunteers, (3) training the nursing staff, (4) raising funds or resources, and (5) connecting with village leaders. Thereafter, we collaborated with two district health centers, a private local hospital, and health clinics. Based on the medical records provided by these agencies, community adults that were HCV antibody (anti-HCV) positive were invited to join the program.

Results

Of the 1795 adults who were serum anti-HCV positive, 1149 (64%) accepted transfer to a qualified hospital; of these, 623 (54.2%) had an HCV infection. 552 (88.6%) of those infected started receiving direct-acting antivirals (DAAs) treatment. The top four barriers to accepting transfer were: (1) they perceived themselves to be healthy (n = 98, 32.3%); (2) mistrust of treatment/healthcare (n = 60, 20.2%); (3) limited transportation to the hospital (n = 52, 17.5%); and (4) work conflict (n = 30, 10.1%).

Conclusion

An interdisciplinary collaboration approach significantly contributed to the invitation of CHC patients, as well as their acceptance of HCV RNA confirmation and free DAAs treatment. Using anti-HCV data from previous medical records for case-finding and collaborating with a hospital and health clinics proved to be an efficient strategy.

HCV infection status and care seeking among people living with HIV who use drugs in Vietnam

HCV co-infection is widespread among people living with HIV who use drugs (PLHWUD). However, HCV testing was inconsistently implemented among PLHWUD. The low infection awareness and mental health challenges together impede PLHWUD's treatment-seeking. The study used baseline data of a randomized controlled trial conducted in Vietnam. HCV infection status was collected through self-report and medical record review. A linear mixed-effects regression model was used to examine the relationships between PLHWUD's perceived barriers to seeking healthcare, their depressive symptoms, and the consistencies in HCV status reports. Among the 181 PLHWUD in the study, one-third (64; 35.4%) had inconsistent self-reports and medical records of HIV infection status. The agreement between the two records was fair (Kappa statistics = 0.43). PLHWUD with consistent HCV infection confirmed by both medical records and self-reports perceived lower levels of healthcare-seeking barriers than those with discrepant HCV reports (estimated difference = -1.59, SE = 0.71, P = 0.027). Depressive symptoms were significantly correlated with healthcare-seeking barriers among those with discrepant HCV results (estimate = 0.17, SE = 0.06, P = 0.007). There is an urgent need to extend HCV screening efforts and increase HCV awareness among PLHWUD. Explicit HCV result notification and integrated mental health support are recommended to facilitate patients' access to needed care.

An Investigation of the Side Effects, Patient Feedback, and Physiological Changes Associated with Direct-Acting Antiviral Therapy for Hepatitis C

Background: Hepatitis C virus (HCV) infection is one of the major causes of liver cirrhosis and hepatocellular carcinoma globally. The advent of direct-acting antivirals (DAAs) with high cure rates provides an opportunity to reduce the rising HCV disease burden. However, few studies have explored the side effects and physiological benefits of DAA therapy in rural areas. The aim of this study was to investigate the subjective reports of discomfort, patient feedback about the course of treatment, and physiological changes after DAA treatment in HCV patients. Methods: A descriptive, prospective, comparative cohort study was conducted from January to August 2019 in western coastal Yunlin County, Taiwan. Data regarding demographic characteristics, subjective discomfort levels, and physiological responses were collected through face to face interviews and from medical records by a cooperating hospital. Results: Six-hundred-and-twenty-three participants with an active HCV infection were identified; 555 (89.1%) had completed treatment, and sustained virologic response was achieved in 99.6% (n = 553). The mean age was 64.9 (standard deviation = 13.1) years, and 35% of patients experienced discomfort during DAA treatment, including fatigue, itching, and dizziness. After three months of treatment, physiological markers, including body weight (p < 0.001), waist circumference (p < 0.05), blood pressure (p < 0.001), alanine aminotransferase (p < 0.001), and aspartate aminotransferase (p < 0.001), had significantly improved. Almost all participants provided positive feedback about the treatment experience and reported manageable side effects. Conclusions: The findings showed that, in an endemic rural area, DAA treatment had a high cure rate and improved physiological markers with few discomforts. These results can be used to reduce the barriers HCV patients face in adopting new medications.

Liver Health Literacy and Health Status Among Adults With Hepatitis C: Implications for the Nursing Profession as Part of the 2030 Global Elimination Goal

PURPOSE

To explore the prevalence of hepatitis C virus (HCV) infection as well as the levels of liver health literacy and association with the health status of people with HCV through the nurse-led community health development goal of global elimination.

METHODS

A community-based, cross-sectional study was conducted between July 2018 and June 2019 in coastal Western Yunlin County, Taiwan. This study was conducted at five townships, and serum HCV antibody (anti-HCV) screening was used for the identification of potentially infected people by a collaborating local hospital.

RESULTS

Of the 1,963 adults from rural areas enrolled in this study, 321 (16.4%) were anti-HCV positive, 237 (73.8%) reported that they were unaware of their HCV positivity, and none of them were provided information on direct-acting antiviral agent therapy. The levels of anti-HCV positivity were higher among female patients (p < .05), elderly people (p < .001), those with a low education level (p < .001), and those from the Sihu Township within Yunlin County (p < .001). Participants with anti-HCV positivity tended to have lower intakes of vegetables (p < .01) and fruit (p < .05), a greater number of comorbidities (p < .05), as well as a greater incidence of abnormal liver (p < .001) and renal function (p < .001) compared to those with anti-HCV negativity. Multivariable linear regression analysis showed that the presence of HCV infection and a greater number of metabolic syndrome components were associated with poor liver and renal function.

CONCLUSIONS

These findings showed a high prevalence of HCV infection among adults living in rural areas, who had low literacy levels on hepatitis, unhealthy lifestyles, and abnormal liver and renal function.

CLINICAL RELEVANCE

Clinicians and primary healthcare providers should initiate efforts to increase the levels of liver health literacy by increasing the accessibility to infection confirmation tests and reducing the number of barriers to the reception of antiviral treatment.