The Population Level Cascade of Care for Hepatitis C in British Columbia, Canada: The BC Hepatitis Testers Cohort (BC-HTC)

Perceived barriers related to testing, management and treatment of HCV infection among physicians prescribing opioid agonist therapy: The C-SCOPE Study

The aim of this analysis was to evaluate perceived barriers related to HCV testing, management and treatment among physicians practicing in clinics offering opioid agonist treatment (OAT). C-SCOPE was a study consisting of a self-administered survey among physicians practicing at clinics providing OAT in Australia, Canada, Europe and the United States between April and May 2017. A 5-point Likert scale (1 = not a barrier, 3 = moderate barrier, 5 = extreme barrier) was used to measure responses to perceived barriers for HCV testing, evaluation and treatment across the domains of the health system, clinic and patient. Among the 203 physicians enrolled (40% USA, 45% Europe, 14% Australia/Canada), 21% were addiction medicine specialists, 29% psychiatrists and 69% were metro/urban. OAT physicians in this study reported poor access to on-site venepuncture (35%), point-of-care HCV testing (16%), and noninvasive liver disease assessment (25%). Only 30% of OAT physicians reported personally treating HCV infection. Major perceived health system barriers to HCV management included the lack of funding for noninvasive liver disease testing, long wait times to see an HCV specialist, lack of funding for new HCV therapies, and reimbursement restrictions based on drug/alcohol use. Major perceived clinic barriers included the lack of peer support programmes and/or HCV case managers to facilitate linkage to care, the need to refer people off-site for noninvasive liver disease staging, the lack of support for on-site phlebotomy and the lack of on-site delivery of HCV therapy. This study highlights several important modifiable barriers to enhance HCV testing, evaluation and treatment among PWID attending OAT clinics.

The syndemic effect of HIV/HCV co-infection and mental health disorders on acute care hospitalization rate among people living with HIV/AIDS: a population-based retrospective cohort study

OBJECTIVE

Our primary objective was to examine the syndemic effect of HIV/HCV co-infection and mental health disorders (MHD) on the acute care hospitalization rate among people living with HIV (PLW-HIV) in British Columbia, Canada. Secondarily, we aimed to characterize the longitudinal trends in the aforementioned rate, while controlling for the effect of several factors.

METHODS

In this retrospective cohort study, individuals were antiretroviral therapy-naïve, ≥ 18 years old, initiated treatment between 1 January 2000 and 31 December 2014, and were followed for at least 6 months until 31 December 2015 or last contact. The outcome was acute care hospitalization rate (every 6-month interval) per individual. The exposure was the interaction between HIV/HCV co-infection and MHD. Generalized non-linear mixed-effects models were built.

RESULTS

Of the 4046 individuals in the final analytical sample, 1597 (39%) were PLW-HIV without MHD, 606 (15%) were people living with HIV and HCV (PLW-HIV/HCV) without MHD, 988 (24%) were PLW-HIV with MHD, and 855 (21%) were PLW-HIV/HCV with MHD. The adjusted rate ratios for acute care hospitalizations were 1.31 (95% [confidence interval] 1.13-1.52), 2.01 (95% CI 1.71-2.36), and 2.53 (95% CI 2.20-2.92) for PLW-HIV with MHD, PLW-HIV/HCV without MHD, and PLW-HIV/HCV with MHD, respectively, relative to PLW-HIV without MHD.

CONCLUSION

The HIV/HCV co-infection and MHD interaction demonstrated a significant effect on the rate of acute care hospitalization, particularly for PLW-HIV/HCV with MHD. Implementing widely accessible integrative care model best practices may address this public health challenge.

The change in the nationwide seroprevalence of hepatitis C virus and the status of linkage to care in South Korea from 2009 to 2015

BACKGROUND

Hepatitis C virus (HCV) requires epidemiological monitoring to estimate its disease burden and to develop countermeasures. This study aimed to investigate the difference between the 2015 and 2009 nationwide anti-HCV seroprevalence and to determine linkage to care estimates in South Korea.

METHODS

A total 268,422 examinees ≥ 20 years old were included in 2015 from 33 medical institutions nationwide. Electronically extracted data were retrospectively analyzed to calculate the age-, sex-, and area-adjusted anti-HCV prevalence. Seroprevalence in 2015 was measured using the same method as that in 2009. For anti-HCV-positive subjects, medical records were reviewed to see whether HCV RNA testing or antiviral treatment was performed.

RESULTS

Adjusted anti-HCV prevalence was 0.60% (95% confidence interval, 0.57-0.63) based on general Korean population in 2015. It showed an increasing trend according to age; 0.23% in thirties, 0.38% in forties, 0.63% in fifties, 1.08% in sixties, and 1.65% in those aged ≥ 70 years. From 2009 to 2015, the adjusted anti-HCV prevalence decreased by 30%, with odds ratio of 0.70 (95% CI 0.70-0.71). There was significant intranational regional variation and changing pattern of seroprevalence. Among 1359 anti-HCV-positive subjects, HCV RNA test was performed in 60% and 25.4% had positivity. Treatment-initiated and cured rates in 2015 were 18.5% and 10.9%, respectively.

CONCLUSIONS

Anti-HCV prevalence in South Korea was 0.6% in 2015, showing a 30% decrease from that in 2009. Although the HCV RNA testing rate was increased since 2009, this remains suboptimal. Moreover, the treatment uptake rate should be improved in South Korea.

Streamlining the screening cascade for active Hepatitis C in Russia: A cost-effectiveness analysis

OBJECTIVE

Screening for hepatitis C in Russia is a complex process that involves several visits and stepwise testing, limiting adherence and substantially reducing the yield in the identification of active infections. We aimed to evaluate the cost-effectiveness of different screening algorithms from a health system perspective.

METHODS

A decision analytic model was applied to a hypothetical adult population eligible to participate in a general screening program for hepatitis C in Russia. The standard pathway (I: Screen for anti-HCV antibodies followed by a nucleic acid test for HCV RNA on antibody positives) was compared to three alternatives (II: Screen for antibodies, a reflexed test for HCV antigen on antibody positives, and RNA on antigen negatives; III: Screen for antibodies, a reflexed test for HCV antigen on antibody positives; IV: Screen for antigen). Each strategy considered a cascade of events (referral, adherence, testing, diagnosis) that must occur for screening to be effective. The primary measure of effectiveness was the number of diagnosed active infections. Calculations followed a health system perspective with costs derived from 2017 reimbursement rates and a willingness-to-pay of 2,000RUB ($82) per diagnosed active infection. Model was tested with deterministic and probabilistic sensitivity analyses.

RESULTS

Non-adherence to screening stages reduced the capture rate of active infections in Strategy I from 79.0% to 40.6%. Strategies II, III, and IV were less affected and identified 69%, 67%, and 104% more infections. Average costs per diagnosed infection were decreased by 41% from 89,599RUB ($3,681) for I to 53,072RUB ($2,180), 53,004RUB ($2,177), and 59,633RUB ($2,450) for II, III, and IV, respectively. With a probability of 97%, Strategy III was most cost-effective with an incremental cost-effectiveness ratio vs. I of -1,373RUB (CI: -5,011RUB to -2,033RUB; $-56; CI: -$206 to -$84). Below a willingness-to-pay of 91,000RUB ($3,738), Strategy IV was not cost-effective. Sensitivity analyses confirmed the robustness of results.

CONCLUSIONS

Testing strategies for hepatitis C with HCV antigen on HCV antibody positive cases offer a streamlining opportunity for population screening programs. Those shall increase the chances for detecting active infections and are cost-effective over current practice in Russia.

Achievement of hepatitis C cascade of care milestones: a population-level analysis in Alberta, Canada

OBJECTIVES

Despite highly effective directly acting antiviral (DAA) therapy for hepatitis C virus (HCV), many patients do not receive treatment. We characterized the achievement of cascade of care milestones within 2 years of diagnosis among the Alberta population and evaluated variables associated with engagement at each stage.

METHODS

All Albertans with a first-time positive HCV antibody between 2009 and 2014 were included in this retrospective study. We determined which patients received follow-up testing (HCV RNA and HCV genotype), referral to hepatitis specialty care, and antiviral prescription, and achieved SVR within 2 years of diagnosis. Factors associated with achieving cascade milestones were identified by multivariable logistic regression analysis.

RESULTS

Of 6154 patients with HCV antibody and complete follow-up, 4238 (68.9%) had HCV RNA testing, 2360 (38.3%) had HCV genotyping, 2096 (34.1%) were assessed by a specialist, 711 (11.6%) were prescribed treatment and 207 (3.4%) achieved SVR within 2 years of diagnosis. Independent variables associated with reduced likelihood of achieving cascade milestones were Indigenous heritage (adjusted odds ratio (AOR) 0.53 (0.41-0.68) for HCV RNA testing), unstable housing (AOR 0.50 (0.32-0.79) for specialist assessment) and alcohol misuse (AOR 0.61 (0.38-0.99) for antiviral prescription). Men, older patients, patients with a higher income and patients with more advanced liver disease were more likely to achieve cascade of care milestones.

CONCLUSION

At each stage of patient engagement, opportunities for improvement were identified. Understanding the local cascade of care and factors associated with achieving cascade milestones will help prioritize initiatives to facilitate access to DAA therapy in Alberta.

Point-of-care hepatitis C testing from needle and syringe programs: An Australian feasibility study

BACKGROUND

Achieving hepatitis C elimination requires novel approaches to engage people at highest risk of infection into care pathways. Point-of-care-tests may help to overcome some of the barriers preventing people who inject drugs (PWID) accessing testing and progressing to treatment for hepatitis C virus (HCV). We assessed the feasibility and acceptability of HCV point-of-care testing at needle and syringe exchange programs (NSPs) co-located in three community health clinics in Melbourne, Australia.

METHODS

NSP clients were offered an oral fluid point-of-care test for HCV antibody by NSP staff. Positive HCV antibody tests were followed by a point-of-care test for HCV RNA alongside standard-of-care laboratory testing for hepatitis C treatment work-up. Participants were offered same-day point-of-care results on site, via phone or text message, or upon return to the service. Participants were scheduled for follow-up review with the study nurse for assessment and linkage to treatment.

RESULTS

A total of 174 participants completed HCV antibody point-of-care test; 150 (86%) had a reactive result. Of these, 140 (93%) underwent a HCV RNA point-of-care test and 76 (54%) tested positive; few participants (5%) waited on site for results delivery, but the majority of RNA positive (63%) attended a follow-up visit for treatment work-up (median time to follow-up visit = 11 days; IQR = 7-20 days). The majority of participants reported a preference for point-of-care tests (66%) and supported NSP staff involvement in testing (90%).

CONCLUSION

Provision of HCV point-of-care tests, follow-up and linkage to treatment services through NSPs was feasible and acceptable to PWID. Despite few participants waiting to receive same-day results, there was effective linkage to care, suggesting value in further evaluation of this approach.

Conceptualising access in the direct-acting antiviral era: An integrated framework to inform research and practice in HCV care for people who inject drugs

As direct-acting antiviral (DAA) therapy costs fall and eligibility criteria are relaxed, people who inject drugs (PWID) will increasingly become eligible for HCV treatment. Yet eligibility does not necessarily equate to access. Amidst efforts to expand treatment uptake in this population, we seek to synthesise and clarify the conceptual underpinnings of access to health care for PWID, with a view to informing research and practice. Integrating dominant frameworks of health service utilisation, care seeking processes, and ecological perspectives on health promotion, we present a comprehensive theoretical framework to understand, investigate and intervene upon barriers and facilitators to HCV care for PWID. Built upon the concept of Candidacy, the framework describes access to care as a continually negotiated product of the alignment between individuals, health professionals, and health systems. Individuals must identify themselves as candidates for services and then work to stake this claim; health professionals serve as gatekeepers, adjudicating asserted candidacies within the context of localised operating conditions; and repeated interactions build experiential knowledge and patient-practitioner relationships, influencing identification and assertion of candidacy over time. These processes occur within a complex social ecology of interdependent individual, service, system, and policy factors, on which other established theories provide guidance. There is a pressing need for a deliberate and nuanced theory of health care access to complement efforts to document the HCV 'cascade of care' among PWID. We offer this framework as an organising device for observational research, intervention, and implementation science to expand access to HCV care in this vulnerable population. Using practical examples from the HCV literature, we demonstrate its utility for specifying research questions and intervention targets across multiple levels of influence; describing and testing plausible effect mechanisms; and identifying potential threats to validity or barriers to research translation.

"Towards eliminating viral hepatitis": Examining the productive capacity and constitutive effects of global policy on hepatitis C elimination

In 2016 the World Health Organization published the first global health strategy to address viral hepatitis, setting a goal of eliminating viral hepatitis as a major public health threat by 2030. While the field has been motivated by this goal, to date there has been little critical attention paid to the productive capacity and constitutive effects of this policy. How is governing taking place through the mechanism of this global strategy, and how are its goals and targets shaping what is made thinkable (indeed, what is made as the real) about hepatitis C and its elimination? And with what effects? Taking the Global Health Sector Strategy on Viral Hepatitis, 2016-2021 as a text for analysis, we draw on poststructural thinking on problematisation and governmental technologies to examine how 'elimination' - as a proposal - constitutes the problem of hepatitis C. We critically consider the conceptual logics underpinning the elimination goal and targets, and the multiple material-discursive effects of this policy. We examine how governing takes place through numbers, by analysing 'target-setting' (and its accompanying practices of management, quantification and surveillance) as governmental technologies. We consider how the goal of elimination makes viral hepatitis visible and amenable to structuring, action and global management. Central to making viral hepatitis visible and manageable is quantification. Viral hepatitis is made as a problem requiring urgent global health management not through the representation of its effects on bodies or situated communities but rather through centralising inscription practices and comparison of estimated rates. It is important to remain alert to the multiple makings of hepatitis C and draw attention to effects which might be obscured due to a primary focus on quantification and management. To do so is to recognise the ontopolitical effects of governmental technologies, especially for communities 'targeted' by these strategies (including people who inject drugs).

Effectiveness of Ledipasvir/Sofosbuvir and Sofosbuvir/Velpatasvir in People Who Inject Drugs and/or Those in Opioid Agonist Therapy

We evaluated the effectiveness of ledipasvir/sofosbuvir (LDV/SOF) in treating hepatitis C virus (HCV) genotype 1 and SOF/velpatasvir (SOF/VEL) for all genotypes among people who inject drugs (PWID) and those not injecting drugs and who were on or off opioid agonist therapy (OAT). Study participants comprised a population-based cohort in British Columbia, Canada. The British Columbia Hepatitis Testers Cohort includes data on individuals tested for HCV from 1990 to 2016 that are integrated with medical visits, hospitalization, and prescription drug data. We classified study participants as off OAT/recent injection drug use (off-OAT/RIDU), off OAT/past IDU (off-OAT/PIDU), off OAT/no IDU (off-OAT/NIDU), on OAT/IDU (on-OAT/IDU), and on OAT/no IDU (on-OAT/NIDU). We assessed sustained virologic response (SVR) 10 weeks after HCV treatment among study groups treated with LDV/SOF or SOF/VEL until January 13, 2018. Analysis included 5,283 eligible participants: 390 off-OAT/RIDU, 598 off-OAT/PIDU, 3,515 off-OAT/NIDU, 609 on-OAT/IDU, and 171 on-OAT/NIDU. The majority were male patients (64%-74%) and aged ≥50 years (58%-85%). The SVRs for off-OAT/RIDU, off-OAT/PIDU, off-OAT/NIDU, on-OAT/IDU, and on-OAT/NIDU were 91% (355/390), 95% (570/598), 96% (3,360/3,515), 93% (567/609), and 95% (163/171), respectively. Among those with no SVR, 14 individuals died while on treatment or before SVR assessment, including 4 from illicit drug overdose. In the overall multivariable model, off-OAT/RIDU, on-OAT/IDU, male sex, cirrhosis, treatment duration <8 weeks, treatment duration 8 weeks, and treatment with SOF/VEL were associated with not achieving SVR. Conclusion: In this large real-world cohort, PWID and/or those on OAT achieved high SVRs, although slightly lower than people not injecting drugs. This finding also highlights the need for additional measures to prevent loss to follow-up and overdose-related deaths among PWID.

Test uptake and hepatitis C prevalence in 5483 Danish people in drug use treatment from 1996 to 2015: a registry-based cohort study

BACKGROUND AND AIMS

The aims of this study were, in people in treatment for drug use in Funen, Denmark, to: (1) assess prevalence of hepatitis C virus (HCV) test uptake and prevalence of HCV; (2) identify predictors of test update and HCV infection; and (3) characterize changes between 1996 and 2015 in test uptake, HCV prevalence and drug use.

DESIGN

Cohort study linking the Danish National Registry on Drug Users in Treatment to the regional hepatitis test registry and the Danish Death Certificate Registry, thus combining longitudinal data on drug use with data on HCV testing and results.

SETTING AND PARTICIPANTS

People recorded as having received treatment for drug use between 1996 and 2015 (n = 5483) in Funen, Denmark. In the cohort, 24.8% were female, median age 23 years [interquartile range (IQR) = 20-32] at entry and 50% had self-reported injecting or had received opiate substitution therapy (OST).

MEASUREMENTS

The main outcomes were the test for HCV ever and latest HCV-RNA being positive. The main predictors were for test and infection investigated; ever receiving OST, self-reported injecting, age at entry and connection to treatment centre offering outreach hepatitis care.

FINDINGS

HCV test uptake was 52% and prevalence of current HCV-RNA+ was 21% in people alive at the end of follow-up. Positive predictors of having undergone HCV testing were: receiving OST [odds ratio (OR) = 3.7; 95% confidence interval (CI) = 3.2-4.5], self-reported injecting (OR = 2.3; 95% CI = 2.0-2.7), female gender (OR = 1.7; 95% CI = 1.4-1.9) and having been connected to centres with outreach hepatitis care (OR = 1.4; 95% CI = 1.2-1.7). In people alive, HCV-RNA+ prevalence was 31% if ever on OST or self-reported injecting. Among HCV-infected people, 69% were in drug use treatment at end of follow-up. For participants entering the cohort after 2010, only 5% reported opiates as main drug of use and 17% had experience of injecting.

CONCLUSION

Among Danish people in treatment for drug use from 1996 to 2015, receiving opiate substitution therapy had the largest associating to being tested for hepatitis C virus. As opiate use is declining, adapting test strategies will be necessary.

The Road to Hepatitis C Virus Cure: Practical Considerations from a Health System's Perspective

Hepatitis C virus infection remains a significant global health problem. Many individuals are unaware of their infection or disease stage. Innovations in care that promote rapid and easy identification of at-risk populations for screening, comprehensive diagnostic screening, and triage to curative direct-acting antiviral medications will accelerate efforts to eradicate hepatitis C.

Estimating the impact of early hepatitis C virus clearance on hepatocellular carcinoma risk

Although achieving sustained virological response (SVR) through antiviral therapy could reduce the risk of hepatocellular carcinoma (HCC) attributable to hepatitis C virus (HCV) infection, the impact of early viral clearance on HCC is not well defined. In this study, we compared the risk of HCC among individuals who spontaneously cleared HCV (SC), the referent population, with the risk in untreated chronic HCV (UCHC), those achieved SVR, and those who failed interferon-based treatment (TF). The BC Hepatitis Testers Cohort (BC-HTC) includes individuals tested for HCV between 1990-2013, integrated with medical visits, hospitalizations, cancers, prescription drugs and mortality data. This analysis included all HCV-positive patients with at least one valid HCV RNA by PCR on or after HCV diagnosis. Of 46 666 HCV-infected individuals, there were 12 527 (26.8%) SC; 24 794 (53.1%) UCHC; 5355 (11.5%) SVR and 3990 (8.5%) TF. HCC incidence was lowest (0.3/1000 person-years (PY)) in the SC group and highest in the TF group (7.7/1000 PY). In a multivariable model, compared to SC, TF had the highest HCC risk (hazard ratio (HR):14.52, 95% confidence interval (CI): 9.83-21.47), followed by UCHC (HR: 5.85; 95% CI: 4.07-8.41). Earlier treatment-based viral clearance similar to SC could decrease HCC incidence by 69.4% (95% CI: 57.5-78.0), 30% (95% CI: 10.8-45.1) and 77.5% (95% CI: 69.4-83.5) among UCHC, SVR and TF patients, respectively. In conclusion, using SC as a real-world comparator group, it showed that substantial reduction in HCC risk could be achieved with earlier treatment initiation. These analyses should be replicated in patients who have been treated with direct acting antiviral therapies.

The removal of DAA restrictions in Europe - One step closer to eliminating HCV as a major public health threat

Of ∼10.2 million people with chronic HCV infection in Europe, 6.7 million live in Eastern Europe, 2.3 million in Western Europe and 1.2 million in Central Europe. HCV transmission continues to occur in parallel with an increasing HCV-related liver disease burden, the result of an ageing population infected during peak HCV epidemics decades earlier. In 2016, the World Health Organization set targets to eliminate HCV infection as a major public health threat by 2030. Across Europe, an estimated 36% of those living with chronic HCV infection have been diagnosed and ∼5% have been treated. A major barrier to enhancing HCV treatment uptake has been restrictions set by payers, including national governments and others, in response to the initially high list prices of direct-acting antiviral (DAA) therapies. The aims of this article are to discuss DAA restrictions in Europe, why DAA restrictions are still in place, what has facilitated the removal of DAA restrictions, and what challenges remain as we attempt to eliminate HCV as a major public health threat in the region by 2030.

Hepatitis C virus reinfection after successful treatment with direct-acting antiviral therapy in a large population-based cohort

BACKGROUND & AIMS

Direct-acting antiviral therapies (DAA) are an important tool for hepatitis C virus (HCV) elimination. However, reinfection among people who inject drugs (PWID) may hamper elimination targets. Therefore, we estimated HCV reinfection rates among DAA-treated individuals, including PWID.

METHODS

We analyzed data from the British Columbia Hepatitis Testers Cohort which included ∼1.7 million individuals screened for HCV in British Columbia, Canada. We followed HCV-infected individuals treated with DAAs who achieved a sustained virologic response (SVR) and had ≥1 subsequent HCV RNA measurement to April 22nd, 2018. Reinfection was defined as a positive RNA measurement after SVR. PWID were identified using a validated algorithm and classified based on recent (<3 years) or former (≥3 years before SVR) use. Crude reinfection rates per 100 person-years (PYs) were calculated. Poisson regression was used to model adjusted incidence rate ratios (IRRs) and 95% CIs.

RESULTS

Of 4,114 individuals who met the inclusion criteria, most were male (n = 2,692, 65%), born before 1965 (n = 3,411, 83%) and were either recent (n = 875, 21%) or former PWID (n = 1,793, 44%). Opioid-agonist therapy (OAT) was received by 19% of PWID. We identified 40 reinfections during 2,767 PYs. Reinfection rates were higher among recent (3.1/100 PYs; IRR 6.7; 95% CI 1.9-23.5) and former PWID (1.4/100 PYs; IRR 3.7; 95% CI 1.1-12.9) than non-PWID (0.3/100 PYs). Among recent PWID, reinfection rates were higher among individuals born after 1975 (10.2/100 PYs) and those co-infected with HIV (5.7/100 PYs). Only one PWID receiving daily OAT developed reinfection.

CONCLUSIONS

Population-level reinfection rates remain elevated after DAA therapy among PWID because of ongoing exposure risk. Engagement of PWID in harm-reduction and support services is needed to prevent reinfections.

LAY SUMMARY

Direct-acting antivirals are an effective tool for the treatment of hepatitis C virus, enabling the elimination of the virus. However, some patients who have been successfully treated with direct-acting antivirals are at risk of reinfection. Our findings showed that the risk of reinfection was highest among people with recent injection drug use. Among people who inject drugs, daily use of opioid-agonist therapy was associated with a lower risk of reinfection.

Hepatitis C cascade of care among people who inject drugs in Vancouver, Canada

BACKGROUND

People who inject drugs (PWID) have high rates of hepatitis C virus (HCV) infection. Little is known about the rates of diagnosis and treatment for HCV among PWID. Therefore, this study aims to characterize the cascade of care in Vancouver, Canada, to improve HCV treatment access and delivery for PWID.

METHODS

Data were derived from 3 prospective cohort studies of PWID in Vancouver, Canada, between December 2005 and May 2015. The progression of participants was identified through 5 steps in the cascade of care: (1) chronic HCV; (2) linkage to HCV care; (3) liver disease assessment; (4) initiation of treatment; and (5) completion of treatment. Predictors of undergoing liver disease assessment for HCV treatment were identified using a multivariable extended Cox regression model.

RESULTS

Among 1571 participants with chronic HCV, 1359 (86.5%) had ever been linked to care, 1257 (80.0%) had undergone liver disease assessment, 163 (10.4%) had ever started HCV treatment, and 71 (4.5%) had ever completed treatment. In multivariable analyses, human immunodeficiency virus (HIV) seropositivity, use of methadone maintenance therapy, and hospitalization in the past 6 months were independently and positively associated with undergoing liver disease assessment (all P < .001), whereas daily heroin injection was independently and negatively associated with undergoing liver disease assessment (P < .001).

CONCLUSIONS

Among this cohort of PWID, few had been started on or completed treatment for HCV. These findings highlight the need to improve the prescribing of HCV treatment among PWID with active substance use.

Descriptive epidemiology of hepatitis C in individuals referred for specialized HCV care in Newfoundland and Labrador, 1996–2014

BACKGROUND: Despite growing awareness of the significant burden of disease caused by hepatitis C virus (HCV) infection worldwide, understanding of the epidemiology and demographic distribution of HCV infection in Canada, specifically in Atlantic Canada, is limited. Currently, data on the demographic and clinical profile of HCV-infected individuals in Newfoundland and Labrador is limited. The aim of this study is to address this knowledge gap. Methods: A retrospective cohort study of HCV-positive individuals referred for specialized care in St. John’s, Newfoundland, between 1996 and 2014, was conducted. Descriptive data were obtained through chart review and access to a database consisting of individuals referred for specialized HCV care in St. John’s. Results: During the study period, 767 individuals were referred for specialized HCV care, of whom 714 were included in our analysis. These individuals represent 57.5% of HCV-positive cases identified by the province’s public health department during the same time frame. HCV infection was more common among men (68.2%) and urban dwellers (74.8%). The majority of cases were HCV genotype 1 (52.1%). Intravenous and intranasal drug use were the most common self-reported risk factors for HCV transmission. High loss-to-follow-up rates were found among those referred from the province’s correctional system. Conclusions: This study provides important insights into the demographic and clinical profile of individuals referred for HCV-related care in Newfoundland and Labrador and fills a gap in the current understanding of HCV-positive individuals in this Atlantic province. These findings can help inform future directions for HCV-related health policy, resource allocation, and clinical care initiatives in Newfoundland and Labrador and across Canada.

Beyond cure: patient reported outcomes of hepatitis C treatment among people who inject drugs in Australia

Background

Recent advances in the treatment of hepatitis C virus (HCV) infection provide the possibility of eliminating HCV as a public health threat. This focus on HCV elimination through treatment, however, is also driving a concomitant focus on ‘achieving cure’ as the primary outcome of treatment. The aim of this paper is to explore what people who inject drugs consider to be important in relation to outcomes of HCV treatment, and whether there are outcomes ‘beyond cure’ that might be important to understand as part of improving engagement in treatment.

Methods

A peer researcher with experience of both HCV treatment and injecting drug use conducted interviews with 24 people in the following groups in Melbourne, Australia: (1) people who had refused or deferred HCV treatment; (2) people who were actively thinking about, planning and/or about to commence HCV treatment; (3) people currently undertaking HCV treatment and (4) people who had recently completed HCV treatment.

Results

The findings show that people who inject drugs are seeking outcomes ‘beyond cure’ including improved physical and mental health, positive changes in identity and social relationships and managing future health and risk. Participants indicated that these other outcomes had not been addressed within their experience of HCV treatment.

Conclusion

While cure is an obvious outcome of HCV treatment, patients are seeking change in other areas of their lives. This study also provides valuable insights for the development of patient-reported measures in this context, which would be an important step towards more patient-centred approaches to HCV treatment.

The role of prevention strategies in achieving HCV elimination in Canada: what are the remaining challenges?

Background

The worldwide economic, health, and social consequences of drug use disorders are devastating. Injection drug use is now a major factor contributing to hepatitis C virus (HCV) transmission globally, and it is an important public health concern.

Methods

This article presents a narrative review of scientific evidence on public health strategies for HCV prevention among people who inject drugs (PWID) in Canada.

Results

A combination of public health strategies including timely HCV detection and harm reduction (mostly needle and syringe programmes and opioid substitution therapy) have helped to reduce HCV transmission among PWID. The rising prevalence of pharmaceutical opioid and methamphetamine use and associated HCV risk in several Canadian settings has prompted further innovation in harm reduction, including supervised injection facilities and low-threshold opioid substitution therapies. Further significant decreases in HCV incidence and prevalence, and in corresponding disease burden, can only be accomplished by reducing transmission among high-risk persons and enhancing access to HCV treatment for those at the greatest risk of disease progression or viral transmission. Highly effective and tolerable direct-acting antiviral therapies have transformed the landscape for HCV-infected patients and are a valuable addition to the prevention toolkit. Curing HCV-infected persons, and thus eliminating new infections, is now a real possibility.

Conclusions

Prevention strategies have not yet ended HCV transmission, and sharing of injecting equipment among PWID continues to challenge the World Health Organization goal of eliminating HCV as a global public health threat by 2030. Future needs for research, intervention implementation, and uptake in Canada are discussed.

Addressing hepatitis C in the foreign-born population: A key to hepatitis C virus elimination in Canada

Hepatitis C virus (HCV) is the leading cause of death from infectious disease in Canada. Immigrants are an important group who are at increased risk for HCV; they account for a disproportionate number of all HCV cases in Canada (~30%) and have approximately a twofold higher prevalence of HCV (~2%) than those born in Canada. HCV-infected immigrants are more likely to develop cirrhosis and hepatocellular carcinoma and are more likely to have a liver-related death during a hospitalization than HCV-infected non-immigrants. Several factors, including lack of routine HCV screening programs in Canada for immigrants before or after arrival, lack of awareness on the part of health practitioners that immigrants are at increased risk of HCV and could benefit from screening, and several patient- and health system-level barriers that affect access to health care and treatment likely contribute to delayed diagnosis and treatment uptake. HCV screening and engagement in care among immigrants can be improved through reminders in electronic medical records that prompt practitioners to screen for HCV during clinical visits and implementation of decentralized community-based screening strategies that address cultural and language barriers. In conclusion, early screening and linkage to care for immigrants from countries with an intermediate or high prevalence of HCV would not only improve the health of this population but will be key to achieving HCV elimination in Canada. This article describes the unique barriers encountered by the foreign-born population in accessing HCV care and approaches to overcoming these barriers.

A Surveillance-Based Hepatitis C Care Cascade, New York City, 2017

OBJECTIVES

The care cascade, a method for tracking population-level progression from diagnosis to cure, is an important tool in addressing and monitoring the hepatitis C virus (HCV) epidemic. However, little agreement exists on appropriate care cascade steps or how best to measure them. The New York City (NYC) Department of Health and Mental Hygiene (DOHMH) sought to construct a care cascade by using laboratory surveillance data with clinically relevant categories that can be readily updated over time.

METHODS

We identified all NYC residents ever reported to the DOHMH surveillance registry with HCV through June 30, 2017 (n = 175 896). To account for outmigration, death, or treatment before negative RNA results became reportable to the health department, we limited the population to people with any test reported since July 1, 2014. Of these residents, we identified the proportion with a reported positive RNA test and estimated the proportion treated and cured since July 2014 by using DOHMH-developed surveillance-based algorithms.

RESULTS

Of 78 886 NYC residents ever receiving a diagnosis of HCV and tested since July 1, 2014, a total of 70 397 (89.2%) had ever been reported as RNA positive through June 30, 2017; 36 875 (46.7%) had initiated treatment since July 1, 2014, and 23 766 (30.1%) appeared cured during the same period.

CONCLUSION

A substantial gap exists between confirming HCV infection and initiating treatment, even in the era of direct-acting antivirals. Using this cascade, we will monitor progress in improved treatment and cure of HCV in NYC.

Hepatitis C Virus Elimination in the Human Immunodeficiency Virus-Coinfected Population: Leveraging the Existing Human Immunodeficiency Virus Infrastructure

The objective of this review is to consider how existing human immunodeficiency virus (HIV) infrastructure may be leveraged to inform and improve hepatitis C virus (HCV) treatment efforts in the HIV-HCV coinfected population. Current gaps in HCV care relevant to the care continuum are reviewed. Successes in HIV treatment are then applied to the HCV treatment model for coinfected patients. Finally, the authors give examples of HCV treatment strategies for coinfected patients in both domestic and international settings.

Reducing patient and provider knowledge gaps: An evaluation of a community informed hepatitis C online course

OBJECTIVES

Hepatitis C (HCV) knowledge gaps are associated with lower levels of engagement in (HCV) care which contributes to HCV-related morbidity and mortality. Knowledge gaps may be exacerbated by rapid changes in HCV care/treatment. Cost-effective, timely and easy-to-implement education is needed to address knowledge gaps and foster HCV engagement.

METHODS

We developed a free, one-hour, online course for patients and providers. Online and facilitated course events were evaluated. Outcome measures included: pre/post-scores, perceived knowledge gains and increased capacity to educate/encourage engagement in HCV care.

RESULTS

Total pre-post-test gains were significant (p < .001) across groups. Over 50% of participants reported: perceived knowledge gains of "A lot" or higher; the course increased their capacity to educate and encourage client engagement in care by "A lot" or higher.

CONCLUSIONS

The evaluation confirmed ongoing patient and provider HCV knowledge gaps, significantly reduced those gaps, and increased provider's capacity to educate and encourage client engagement in HCV care.

PRACTICE IMPLICATIONS

The course is an effective tool to address knowledge gaps that might lower engagement in care. It is available to patients to use in the privacy of their own home or for providers for their personal use, to use with individuals or patient groups.

Eliminating HIV/HCV co-infection in gay and bisexual men: is it achievable through scaling up treatment?

INTRODUCTION

Broad availability of direct-acting antiviral therapy for hepatitis C virus (HCV) raises the possibility that HCV prevalence and incidence can be reduced through scaling-up treatment, leading to the elimination of HCV. High rates of linkage to HIV care among HIV-infected gay and bisexual men may facilitate high uptake of HCV treatment, possibly making HCV elimination more achievable in this group. Areas covered: This review covers HCV elimination in HIV-infected gay and bisexual men, including epidemiology, spontaneous clearance and long term sequelae in the absence of direct-acting antiviral therapy; direct-acting antiviral therapy uptake and effectiveness in this group; HCV reinfection following successful treatment; and areas for further research. Expert commentary: Early data from the direct-acting antiviral era suggest that treatment uptake is increasing among HIV infected GBM, and SVR rates are very promising. However, in order to sustain current treatment rates, additional interventions at the behavioral, physician, and structural levels may be required to increase HCV diagnosis, including prompt detection of HCV reinfection. Timely consideration of these issues is required to maximize the population-level impact of HCV direct-acting antiviral therapy. Potential HCV transmissions from HIV-uninfected GBM, across international borders, and from those who are not GBM also warrant consideration.

The impact of HIV prevalence, conflict, corruption, and GDP/capita on treatment cascades: data from 137 countries

OBJECTIVE

In 2014, UNAIDS and partners set the 90-90-90 targets for the HIV treatment cascade. Multiple social, political and structural factors might influence progress towards these targets. We assessed how close countries and regions are to reaching these targets, and compared cascade outcomes with HIV prevalence, gross domestic product (GDP)/capita, conflict and corruption.

METHODS

Country-level HIV cascade data on diagnosis, ART coverage and viral suppression, from 2010 to 2016 were extracted from national reports, published papers and the www.AIDSinfoOnline database, and analysed. Weighted least-squares regression was used to assess predictors of cascade achievement: region, HIV prevalence, GDP/capita, the 2016 Corruption Perceptions Index (CPI), which is an international ranking system, and the 2016 Global Peace Index (GPI), which ranks all countries based on three main categories: societal safety, militarisation and conflict.

RESULTS

Data were available for diagnosis for 84 countries, ART coverage for 137 countries, and viral suppression for 94 countries. Regions with the lowest ART coverage were South-east Asia and Pacific (36%), Eastern Europe and Central Asia (17%), and Middle East and North Africa (13%). Lower HIV prevalence was associated with poorer cascade results. Countries with higher GDP/capita achieved higher ART coverage (P<0.001). Furthermore, countries with lower levels of peace and higher corruption had lower ART coverage (P<0.001). Countries with a GPI >2.5 all had ART coverage of <40%.

CONCLUSION

Only one country has reached the UNAIDS 90-90-90 targets. International comparison remains difficult due to heterogeneous data reporting. Difficulty meeting UNAIDS targets is associated with lower GDP/capita, lower HIV prevalence, higher corruption and conflict levels.

Disparities in direct acting antivirals uptake in HIV-hepatitis C co-infected populations in Canada

Background

Direct acting antivirals (DAAs) have revolutionized hepatitis C (HCV) treatment with >90% cure rates even in real‐world studies, giving hope that HCV can be eliminated. However, for DAAs to have a population‐level impact on the burden of HCV disease, treatment uptake needs to be expanded. We investigated temporal trends in HCV treatment uptake and evaluated factors associated with second‐generation DAA initiation and efficacy among key HIV‐HCV co‐infected populations in Canada.

Methods

The Canadian HIV‐HCV Co‐Infection Cohort Study prospectively follows 1699 participants from 18 centres. Among HCV RNA+ participants, we determined the incidence of HCV treatment initiation per year overall and by key populations between 2007 and 2015. Key populations were based on World Health Organization (WHO) guidelines including: people who actively inject drugs (PWID) (reporting injection drug use, last 6 months); Indigenous people; women and men who have sex with men (MSM). Multivariate Cox models were used to estimate adjusted hazard ratios (aHR) and 2‐year probability of initiating second‐generation DAAs for each of the key populations.

Results

Overall, HCV treatment initiation rates increased from 8 (95% CI, 6–11) /100 person‐years in 2013 to 28 (95% CI, 23–33) /100 person‐years in 2015. Among 911 HCV RNA + participants, there were 202 second‐generation DAA initiations (93% with interferon‐free regimens). After adjustment (aHR, 95% CI), active PWID (0.60, 0.38–0.94 compared to people not injecting drugs) and more generally, people with lower income (<$18 000 CAD/year) (0.50, 0.35, 0.71) were less likely to initiate treatment. Conversely, MSM were more likely to initiate 1.95 (1.33, 2.86) compared to heterosexual men. In our cohort, the population profile with the lowest 2‐year probability of initiating DAAs was Indigenous, women who inject drugs (5%, 95% CI 3–8%). Not having any of these risk factors resulted in a 35% (95% CI 32–38%) probability of initiating DAA treatment. Sustained virologic response (SVR) rates were >82% in all key populations.

Conclusion

While treatment uptake has increased with the availability of second‐generation DAAs, marginalized populations, already engaged in care, are still failing to access treatment. Targeted strategies to address barriers are needed to avoid further health inequities and to maximize the public health impact of DAAs.

Late hepatitis B and C diagnosis in relation to disease decompensation and hepatocellular carcinoma development

BACKGROUND & AIMS

We measured the timing of hepatitis B virus (HBV) and hepatitis C virus (HCV) diagnoses relative to the detection of decompensated cirrhosis (DC) and hepatocellular carcinoma (HCC) as an indicator of late hepatitis diagnosis.

METHODS

HBV and HCV diagnoses were defined relative to the diagnosis of DC or HCC such that HBV/HCV diagnoses within two years prior, at the time of or after HCC or DC diagnosis were considered late. We performed multivariable logistic regression to assess factors associated with late HBV/HCV diagnoses among those with DC or HCC.

RESULTS

From 1990 to 2012, 778/32,664 HBV cases (2.4%) and 3,925/57,866 HCV cases (6.8%) developed DC while 628/32,644 HBV cases (1.9%) and 902/57,866 HCV cases (1.6%) developed HCC. Among HBV and HCV cases with DC, 49% and 40% respectively were late diagnoses, as were 46% and 31% of HBV and HCV cases with HCC, respectively. HBV late diagnosis declined from 100% in 1992 to 11% and 26% in 2011, while HCV late diagnosis declined from 100% in 1992 to 16% and 14% in 2011 for DC and HCC respectively. In multivariable modelling, late HBV diagnosis was associated with mental illness and a fewer number of physician visits in the five years prior to HBV diagnosis. Late HCV diagnosis was also associated with fewer physician visits, while those with illicit drug use were less likely to be diagnosed late.

CONCLUSIONS

The proportion of late diagnoses has declined over time. People with better engagement with the healthcare system and with risk activities were diagnosed earlier. Lay summary: Late diagnosis of HBV and HCV represents a missed opportunity to reduce the risk of serious liver disease. Our results identify successes in earlier diagnosis over time using risk-based testing as well as groups that are being missed for screening such as those who do not see a physician regularly and those with serious mental illness.

A syndemic approach to assess the effect of substance use and social disparities on the evolution of HIV/HCV infections in British Columbia

BACKGROUND

Co-occurrence of social conditions and infections may affect HIV/HCV disease risk and progression. We examined the changes in relationship of these social conditions and infections on HIV and hepatitis C virus (HCV) infections over time in British Columbia during 1990-2013.

METHODS

The BC Hepatitis Testers Cohort (BC-HTC) includes ~1.5 million individuals tested for HIV or HCV, or reported as a case of HCV, HIV, HBV, or tuberculosis linked to administrative healthcare databases. We classified HCV and HIV infection status into five combinations: HIV-/HCV-, HIV+monoinfected, HIV-/HCV+seroconverters, HIV-/HCV+prevalent, and HIV+/HCV+.

RESULTS

Of 1.37 million eligible individuals, 4.1% were HIV-/HCV+prevalent, 0.5% HIV+monoinfected, 0.3% HIV+/HCV+ co-infected and 0.5% HIV-/HCV+seroconverters. Overall, HIV+monoinfected individuals lived in urban areas (92%), had low injection drug use (IDU) (4%), problematic alcohol use (4%) and were materially more privileged than other groups. HIV+/HCV+ co-infected and HIV-/HCV+seroconverters were materially most deprived (37%, 32%), had higher IDU (28%, 49%), problematic alcohol use (14%, 17%) and major mental illnesses (12%, 21%). IDU, opioid substitution therapy, and material deprivation increased in HIV-/HCV+seroconverters over time. In multivariable multinomial regression models, over time, the odds of IDU declined among HIV-/HCV+prevalent and HIV+monoinfected individuals but not in HIV-/HCV+seroconverters. Declines in odds of problematic alcohol use were observed in HIV-/HCV+seroconverters and coinfected individuals over time.

CONCLUSIONS

These results highlight need for designing prevention, care and support services for HIV and HCV infected populations based on the evolving syndemics of infections and social conditions which vary across groups.

Shift in disparities in hepatitis C treatment from interferon to DAA era: A population-based cohort study

We evaluated the shift in the characteristics of people who received interferon-based hepatitis C virus (HCV) treatments and those who received recently introduced direct-acting antivirals (DAAs) in British Columbia (BC), Canada. The BC Hepatitis Testers Cohort includes 1.5 million individuals tested for HCV or HIV, or reported cases of hepatitis B and active tuberculosis in BC from 1990 to 2013 linked to medical visits, hospitalization, cancer, prescription drugs and mortality data. This analysis included all patients who filled at least one prescription for HCV treatment until 31 July 2015. HCV treatments were classified as older interferon-based treatments including pegylated interferon/ribavirin (PegIFN/RBV) with/without boceprevir or telaprevir, DAAs with RBV or PegIFN/RBV, and newer interferon-free DAAs. Of 11 886 people treated for HCV between 2000 and 2015, 1164 (9.8%) received interferon-free DAAs (ledipasvir/sofosbuvir: n=1075; 92.4%), while 452 (3.8%) received a combination of DAAs and RBV or PegIFN/RBV. Compared to those receiving interferon-based treatment, people with HIV co-infection (adjusted odds ratio [aOR]: 2.96, 95% CI: 2.31-3.81), cirrhosis (aOR: 1.77, 95% CI: 1.45-2.15), decompensated cirrhosis (aOR: 1.72, 95% CI: 1.31-2.28), diabetes (aOR: 1.30, 95% CI: 1.10-1.54), a history of injection drug use (aOR: 1.34, 95% CI: 1.09-1.65) and opioid substitution therapy (aOR: 1.30, 95% CI: 1.01-1.67) were more likely to receive interferon-free DAAs. Socio-economically marginalized individuals were significantly less likely (most deprived vs most privileged: aOR: 0.71, 95% CI: 0.58-0.87) to receive DAAs. In conclusion, there is a shift in prescription of new HCV treatments to previously excluded groups (eg HIV-co-infected), although gaps remain for the socio-economically marginalized populations.

Long-term effect of sustained virological response on hepatocellular carcinoma in patients with hepatitis C in Canada

BACKGROUND & AIMS

Evidence is limited on hepatocellular carcinoma (HCC) risk after sustained virological response (SVR) to interferon-based treatment of hepatitis C virus (HCV) infection. We evaluated the effect of SVR on the risk of HCC and estimated its incidence in post-SVR HCV patients from a large population-based Canadian cohort.

METHODS

The British Columbia Hepatitis Testers Cohort includes individuals tested for HCV between 1990-2013 linked with data on their medical visits, hospitalizations, cancers, prescription drugs and mortality. Patients receiving interferon-based HCV treatments were followed from the end of treatment to HCC diagnosis, death or December 31, 2012. We examined HCC risk among those who did and did not achieve SVR using multivariable proportional hazard models with the Fine and Gray modification for competing risks.

RESULTS

Of 8147 individuals who received HCV treatment and were eligible for analysis, 4663 (57%) achieved SVR and 3484 (43%) did not. Each group was followed for a median of 5.6years (range: 0.5-12.9) for an HCC incidence rate of 1.1/1000 person-years (PY) among the SVR and 7.2/1000 PY among the no SVR group. The HCC incidence rate was higher among those with cirrhosis (SVR: 6.4, no SVR: 21.0/1000 PY). In the multivariable model, SVR was associated with a lower HCC risk (subdistribution hazard ratio [SHR]=0.20, 95% CI: 0.13-0.3), while cirrhosis (SHR=2.61, 95% CI: 1.68-4.04), age ⩾50years, being male and genotype 3 infection were associated with a higher HCC risk. Among those who achieved SVR, cirrhosis, age ⩾50years and being male were associated with a higher HCC risk.

CONCLUSION

SVR after interferon-based treatment substantially reduces but does not eliminate HCC risk, which is markedly higher among those with cirrhosis and age ⩾50years at treatment initiation. Treatment of patients at an advanced fibrosis stage with new highly effective drugs will warrant continued surveillance for HCC post-SVR.

LAY SUMMARY

We assessed the effect of successful hepatitis C treatment with older interferon-based treatment on the occurrence of liver cancer (hepatocellular carcinoma) and found that successful treatment prevents liver cancer. However, more people with cirrhosis and older age continued to develop liver cancer after successful treatment. Thus, treatment with new drugs among those with cirrhosis will require continued monitoring for liver cancer.