Hepatitis C Treatment Initiation Among US Medicaid Enrollees

Racial disparities in cancer risk among MSM with HIV in the United States

BACKGROUND

Greater immunosuppression is associated with an elevated risk of virus-associated cancers among people with HIV. We investigated racial and ethnic disparities in cancer risk among MSM with HIV (MSMWH).

METHODS

Among MSMWH from 2001 to 2019 in the HIV/AIDS Cancer Match Study, we examined Kaposi sarcoma, non-Hodgkin lymphoma (NHL), liver cancer, anal cancer, and Hodgkin lymphoma. Within racial/ethnic groups, we estimated cancer rates relative to the general population with standardized incidence ratios (SIRs). We calculated incidence rate ratios (IRRs) comparing cancer risk between racial/ethnic groups among MSMWH using Poisson regression. We stratified these calculations according to prior AIDS diagnosis to assess whether differences persisted after accounting for AIDS.

RESULTS

We evaluated 358 023 MSMWH followed for 3.2 million person-years. The SIRs for KS for Hispanic/Latino MSMWH [887; 95% confidence interval (95% CI) = 833-943] and Black MSMWH (772; 95% CI = 727-819) were higher than White MSMWH (417; 95% CI = 392-443). Among MSMWH, risk of Kaposi sarcoma was higher for Hispanic/Latino and Black MSMWH compared to White MSMWH (IRR = 1.40 and 1.24, respectively). We did not detect differences in IRRs when stratified by AIDS diagnosis. While the SIR for anal cancer was lower among Black MSMWH (24.1; 95% CI = 22.3-26.0) compared to White MSMWH (38.4; 95% CI = 36.3-40.6), incidence was not statistically different (IRR = 0.98; 95% CI = 0.89-1.08).

CONCLUSION

Incidence rates and relative risks for several virus-related cancers were greater for Hispanic/Latino and Black MSMWH than White MSMWH, even when examined exclusively among those with or without AIDS. These disparities in cancer risk point to inequities in access to HIV care and disease burden.

County socioeconomic status and premature mortality from cancer in the United States

INTRODUCTION

There are consistent data demonstrating socioeconomic status (SES) is associated with cancer survivorship among older adults, but research on the relationship between area-level SES and risk of premature mortality from cancer remains not well understood. This study investigated the association between county-level SES and premature mortality from cancer.

METHODS

Demographic characteristics and causes of death were ascertained from the national death certificate data for years 2016-2020. Premature cancer death was defined as cancer mortality between ages 25-64. County SES was calculated using the Yost Index and categorized into distribution-based quintiles (1 =lowest SES, 5=highest SES). To calculate the mortality-adjusted rate ratios (aRR) and corresponding 95 % confidence intervals (95 %CI) for the associations between county SES and cancer, we performed multivariable linear mixed models, adjusting for confounders.

RESULTS

A total of 3143 counties were included. The age-adjusted mortality rates of all cancers combined were 107.6, 98.4, 88.6, 81.1, and 66.7 per 100,000 population for the 5 SES quintiles, respectively. Compared with high SES counties, low SES counties had a 58 % greater premature cancer mortality rate (aRRquintile 1 vs.5 =1.58, 95 %CI: 1.55-1.60). Similar associations were observed when stratified by sex, though risk was greatest among men ([aRRwomen=1.48, 95 %CI: 1.45-1.52]; [aRRmen=1.66, 95 %CI: 1.62-1.70]). Among leading cancer types, the association was greatest for lung cancer mortality for the lowest SES counties (aRR=2.03; 95 %CI: 1.98-2.08).

CONCLUSION

Our findings demonstrate that lower SES counties are at greater risk of premature mortality from cancer. Place-based interventions should target the socioeconomic environment across the cancer control continuum.

Burden of disease and risk factors for primary liver cancer by etiology in the United States, 1990-2021: Results from the Global Burden of Disease study, 2021

INTRODUCTION AND OBJECTIVES

The distribution of major causes of liver cancer (LC) in the United States (US) has changed significantly over time. This study analyzes recent temporal trends in the causes of LC in the US from 1990 to 2021 and predicts future trends.

MATERIALS AND METHODS

We obtained detailed data on LC in the US from the Global Burden of Disease (GBD) 2021 study. Estimated annual percentage change (EAPC) values for LC in the US were then calculated using linear regression models. An exponential smoothing (ES) projection model and Bayesian Age-Period-Cohort (BAPC) projection model were then used to predict the future disease burden of LC. Risk factors for LC were also assessed.

RESULTS

In 2021, the disease burden of LC in the US was significantly higher than in 1990. Hepatitis C virus (HCV)-associated LC resulted in the greatest burden of disease. The fastest growing burden of disease was attributed to metabolic dysfunction-associated steatotic liver disease (MASLD)-associated LC. Higher burdens of disease were seen in older and male populations.

CONCLUSIONS

In the US, the disease burden of LC from different etiologies continues to rise. As such, targeted prevention and control strategies should be developed to address these unique disease characteristics.

Project HCV Connect: Using a County Surveillance Registry to Link Hepatitis C Virus-Infected Residents to Cure-Los Angeles County, April 2023 to March 2024

Los Angeles County has a high prevalence of chronic hepatitis C virus (HCV) infection, but resources and infrastructure to notify and increase treatment uptake among county residents are absent. Through an innovative academic-public partnership, we developed a linkage-to-cure program utilizing the Department of Public Health's HCV surveillance registry. Case workers contacted reported cases via phone, to offer education, and treatment referral. Three months after the initial communication, individuals that reported that they were untreated were recontacted to evaluate treatment status. Between April 2023 and March 2024, a total of 639 individuals with HCV were interviewed; 84% of them were aware of their infection status, and 70% were untreated. Among those interviewed three months after initial communication (n = 260), 22% started or completed treatment and 30% were under evaluation for treatment. Leveraging existing resources and new partnerships Public Health Departments could mobilize individuals to seek medical care and lead the effort towards elimination of HCV.

Liver Cancer Etiology in Asian Subgroups and American Indian, Black, Latino, and White Populations

Importance

Hepatocellular carcinoma (HCC) is a major public health issue in the US, linked to hepatitis C virus (HCV), hepatitis B virus (HBV), alcohol-related liver disease (ALD), and metabolic dysfunction-associated steatotic liver disease (MASLD). Monitoring HCC high-risk populations and trends across increasingly diverse groups is crucial for targeted prevention and intervention strategies.

Objective

To evaluate incidence patterns and temporal trends in HCC incidence by etiology across sex, race and ethnicity, and detailed Asian subgroups in California, highlighting emerging metabolic risks and declining viral influences, to guide targeted prevention strategies.

Design, Setting, and Participants

This population-based, retrospective cohort study used data from the California Cancer Registry linked to statewide hospital diagnostic records for etiology classification. All HCC cases diagnosed between 2010 and 2018 in California were included. Data were analyzed from March 28 to November 3, 2024.

Exposure

Etiology of HCC, categorized as HCV, HBV, ALD, MASLD, or other causes.

Main Outcomes and Measures

Age-adjusted incidence rates (AAIRs) of HCC, stratified by sex, race and ethnicity, and etiology. Trends were analyzed using Joinpoint regression.

Results

From 2010 to 2018, 31 671 patients (23 558 [74.4%] male; median [IQR] age, 64 [15] years) were newly diagnosed with HCC in California, with 14 664 (46.3%) due to HCV, 7457 (23.5%) due to MASLD, 3941 (12.4%) due to ALD, and 3271 (10.3%) due to HBV. By 2017 to 2018, MASLD accounted for 27.4% of HCCs, surpassing HCV among women. HCV-related HCC rates per 100 000 population were highest among American Indian (men: 12.8; women: 3.6), Black (men: 10.8; women: 3.0), and US-born Latino (men: 15.7; women: 3.5) populations and specific Asian groups (particularly Cambodian [men: 15.5; women: 6.3] and Vietnamese [men: 13.7; women: 4.8]). Rates of MASLD-related HCC per 100 000 population were highest among American Indian (men: 4.2; women: 2.7), Asian and Pacific Islander (men: 3.9; women: 1.8), and Latino (men: 4.4; women: 2.9) populations. Rates of HBV-related HCC per 100 000 population remained high throughout the study period in some Asian and Pacific Islander subgroups (Cambodian [men: 18.3; women: 3.4], Chinese [men: 10.1; women: 2.6], Korean [men: 11.5; women: 2.8], Laotian [men: 25.0; women: 5.4], and Vietnamese [men: 16.6; women: 3.5]), but not all subgroups, and HBV-related HCC declined overall. During 2014 to 2018, the overall HCC incidence changed annually by -3.1% (95% CI -4.8% to -1.4%) in men and -3.2% (95% CI, -10.9% to -0.9%) in women, largely due to declines in HCV-related HCC. However, MASLD- and ALD-related HCC rates increased throughout 2010 to 2018 (MASLD: 1.9% [95% CI, 0.8% to 3.0%]; ALD: 1.9% [95% CI, 0.6% to 3.1%]).

Conclusions and Relevance

This retrospective cohort study found that etiology of HCC was associated with detailed racial and ethnic groups, with notable variation across disaggregated Asian groups. Rates of MASLD-related and ALD-related HCC were increasing, posing new challenges for prevention. American Indian, Asian and Pacific Islander, and Latino populations were disproportionately affected by HCC, beyond viral causes. Targeted public health interventions addressing alcohol, viral, and metabolic risk factors are needed.

Significant Disparities in Hepatocellular Carcinoma Outcomes by Race/Ethnicity and Sociodemographic Factors

BACKGROUND

Hepatocellular carcinoma (HCC) disproportionately affects racial/ethnic minorities. We evaluated the impact of income and geography on racial/ethnic disparities across the HCC care cascade in the United States.

METHODS

Using NCI registry data spanning 2000 to 2020, adults with HCC were evaluated to determine race/ethnicity-specific differences in tumor stage at diagnosis, delays and gaps in treatment, and survival. Adjusted regression models evaluated predictors of HCC outcomes.

RESULTS

Among 112,389 adults with HCC, cohort characteristics were as follows: 49.8% non-Hispanic White (NHW), 12.0% African American(AA), 20.5% Hispanic, 16.5% Asian/Pacific Islander, and 1.1% American Indian/Alaska Native. Compared with NHW patients, AA patients had lower odds of localized-stage HCC at diagnosis [adjusted odds ratio (aOR), 0.84], lower odds of HCC treatment receipt (aOR, 0.77), greater odds of treatment delays (aOR, 1.12), and significantly greater risk of death [adjusted hazards ratio (aHR), 1.10]. Compared with NHW patients from large metro areas, AA patients from large metro areas had 8% higher mortality risk (aHR, 1.08), whereas AA patients from small-medium metro areas had 17% higher mortality risk (aHR, 1.17; all P < 0.05).

CONCLUSIONS

Among a population-based cohort of US adults with HCC, significant race/ethnicity-specific disparities across the HCC care continuum were observed. Lower household income and more rural geography among racial/ethnic minorities are also associated with disparities in HCC outcomes, particularly among AA patients.

IMPACT

Our study shows that lower income and less urban/more rural geography among racial/ethnic minorities are also associated with disparities in HCC outcomes, particularly among AA patients with HCC. This contextualizes the complex relationship between sociodemographic factors and HCC outcomes through an intersectional lens.

Hepatitis C Treatment in Kentucky Medicaid Recipients with Concurrent Opioid Use Disorder: A Cross-Sectional Study

BACKGROUND

Hepatitis C virus (HCV) infections and injection drug use have concurrently increased in the last decade. Evidence supports simultaneously treating chronic HCV and opioid use disorder (OUD) with medication. Kentucky is a hard-hit state for both conditions that has undertaken policy and practice efforts to increase access to both types of medications.

OBJECTIVE

To examine receipt of direct-acting antivirals (DAAs) for patients living with HCV-OUD and received any vs. no medications for opioid use disorder (MOUD).

DESIGN

We conducted a cross-sectional study using a proprietary dataset from HealthVerity of health claims between 1/1/2020 and 12/31/2021.

PATIENTS

Kentucky Medicaid beneficiaries aged ≥ 18 with concurrent chronic HCV-OUD diagnoses.

MAIN MEASURES

Multivariable logistic regression models were used to calculate adjusted proportions of HCV DAA receipt based on receipt of MOUD, adjusting for patient characteristics and region.

KEY RESULTS

Of 2149 patients, 36% (n = 780) received HCV DAAs; 84% (n = 1804) received any MOUD during the study period. Buprenorphine was the most common MOUD type used (n = 1414, 66%). Adjusting for covariates, HCV DAA receipt was lower among people who received any vs. no MOUD (33% vs. 46%, p < 0.0001). Methadone (vs. no MOUD, 29% vs. 46%, p = 0.0002) had the greatest difference in odds of HCV DAA receipt.

CONCLUSIONS

Gaps in HCV treatment among Kentucky Medicaid recipients with OUD were pervasive. Despite evidence supporting HCV-OUD co-treatment, patients receiving MOUD were significantly less likely to receive curative HCV treatment.

A National Survey of Pharmacist Involvement in Hepatitis C Virus Management in the United States

Models estimate that the United States will not meet its 2030 hepatitis C virus (HCV) elimination goal. Engagement of healthcare providers including pharmacists is critical for HCV elimination efforts. We aimed to characterise the involvement of pharmacists in HCV management. The study design was a cross-sectional survey. Investigators sent the questionnaire to pharmacy and HCV organisations' listservs and limited responses to licensed pharmacists with direct patient care. Questions assessed setting, HCV screening, prescribing, and management; and opinions, and perceived barriers and facilitators to pharmacists' HCV management. Two hundred and nine survey respondents across 45 states reported managing 24 patients/month, with 5.3 (±4.4) years' experience in HCV, and identified pharmacist-managed HCV at their site since 2013 (±5.8 years). Most practice at academic medical centres (29%, 58/203) under collaborative practice agreements (67%, 127/189), as ambulatory care pharmacists (70%, 131/187), in primary care (50%, 65/131). Many pharmacists provide screening, linkage to care, and/or referral (81%, 157/194); 99.5% (190/191) perform treatment evaluation and selection; 98% (180/183) provide treatment education, 93% (171/183) initiate treatment, and 90% (162/180) provide on- and/or post-treatment monitoring. Respondents indicated collaboration with prescribers as most helpful in their role in HCV management, whereas lack of reimbursement was a main barrier. Satisfying components include HCV cure, care and education provision; frustrations include socioeconomic factors impeding patients' follow-up and prior authorisations/insurance barriers. Survey results show the variety of pharmacists' roles in direct HCV patient care and may be used to increase other providers' awareness of pharmacists' services and contributions to HCV elimination efforts.

The State of Hepatitis C Elimination from the Front Lines: A Qualitative Study of Provider-Perceived Gaps to Treatment Initiation

BACKGROUND

Hepatitis C (HCV) is a curable chronic infection, but lack of treatment uptake contributes to ongoing morbidity and mortality. State and national strategies for HCV elimination emphasize the pressing need for people with HCV to receive treatment.

OBJECTIVE

To identify provider-perceived barriers that hinder the initiation of curative HCV treatment and elimination of HCV in the USA.

APPROACH

Qualitative semi-structured interviews with 36 healthcare providers who have evaluated patients with HCV in New York City, Western/Central New York, and Alabama. Interviews, conducted between 9/2021 and 9/2022, explored providers' experiences, perceptions, and approaches to HCV treatment initiation. Transcripts were analyzed using hybrid inductive and deductive thematic analysis informed by established health services and implementation frameworks.

KEY RESULTS

We revealed four major themes: (1) Providers encounter professional challenges with treatment provision, including limited experience with treatment and perceptions that it is beyond their scope, but are also motivated to learn to provide treatment; (2) providers work toward building streamlined and inclusive practice settings-leveraging partnerships with experts, optimizing efficiency through increased access, adopting inclusive cultures, and advocating for integrated care; (3) although at times overwhelmed by patients facing socioeconomic adversity, increases in public awareness and improvements in treatment policies create a favorable context for providers to treat; and (4) providers are familiar with the relative advantages of improved HCV treatments, but the reputation of past treatments continues to deter elimination.

CONCLUSIONS

To address the remaining barriers and facilitators providers experience in initiating HCV treatment, strategies will need to expand educational initiatives for primary care providers, further support local infrastructures and integrated care systems, promote public awareness campaigns, remove prior authorization requirements and treatment limitations, and address the negative reputation of outdated HCV treatments. Addressing these issues should be considered priorities for HCV elimination approaches at the state and national levels.

Association between claims-based setting of diagnosis and treatment initiation among Medicare patients with hepatitis C

OBJECTIVE

To develop a claims-based algorithm to determine the setting of a disease diagnosis.

DATA SOURCES AND STUDY SETTING

Medicare enrollment and claims data from 2014 to 2019.

STUDY DESIGN

We developed a claims-based algorithm using facility indicators, revenue center codes, and place of service codes to identify settings where HCV diagnosis first appeared. When the first appearance was in a laboratory, we attempted to associate HCV diagnoses with subsequent clinical visits. Face validity was assessed by examining association of claims-based diagnostic settings with treatment initiation.

DATA COLLECTION/EXTRACTION METHODS

Patients newly diagnosed with HCV and continuously enrolled in traditional Medicare Parts A, B, and D (12 months before and 6 months after index diagnosis) were included.

PRINCIPAL FINDINGS

Among 104,454 patients aged 18-64 and 66,726 aged ≥65, 70.1% and 69%, respectively, were diagnosed in outpatient settings, and 20.2% and 22.7%, respectively in laboratory or unknown settings. Logistic regression revealed significantly lower odds of treatment initiation after diagnosis in emergency departments/urgent cares, hospitals, laboratories, or unclassified settings, than in outpatient visits.

CONCLUSIONS

The algorithm identified the setting of HCV diagnosis in most cases, and found significant associations with treatment initiation, suggesting an approach that can be adapted for future claims-based studies.

Hepatitis C Virus Care Cascade by Race/Ethnicity in a Statewide Correctional Population, 2019-2023

IMPORTANCE

Hepatitis C virus (HCV) care cascade data by race/ethnicity for US correctional populations are sparse.

OBJECTIVE

To evaluate the HCV care cascade by race/ethnicity for a state correctional population.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used Connecticut Department of Correction data for incarcerated individuals tested, diagnosed, and treated for chronic HCV infection with direct-acting antivirals (DAAs) from 2019 to 2023.

MAIN OUTCOMES AND MEASURES

HCV care cascade outcomes, including testing, treatment, and cure rates, were compared by race/ethnicity. Poisson regression was used to estimate prevalence ratios (PRs), with adjustment for demographic and legal status factors.

RESULTS

A total of 24,867 patients tested for HCV (88.9% men, mean (SD) age 35.6 (11.8), 32.7% White, 37.9% Black, 28.4% Hispanic, 0.6% Asian, 0.4% American Indian/Alaska Native (AIAN), 34.7% sentenced ≥ 1 year). Both HCV exposure and chronic HCV were highest for White (27.1% and 15.2%) and lowest for Black individuals (4.6% and 2.6%) (P < 0.01, for both outcomes). While incarcerated, 63.2% of chronic HCV patients started DAAs, and treatment rates did not significantly differ by race/ethnicity (P > 0.05). For those treated and having post-treatment lab data available, cure rates were 98.8% or better for all racial/ethnic groups (P > 0.05). In the adjusted regression analyses, HCV treatment initiation was lower for those sentenced < 1 year (PR, 0.76; 95% CI, 0.67-0.87) and unsentenced (PR, 0.85; 95% CI, 0.80-0.91) than those sentenced ≥ 1 year. The adjusted prevalence of advanced fibrosis stage/activity grade was not significantly associated with race/ethnicity.

CONCLUSIONS

In this cohort study, less than two-thirds of chronic HCV patients initiated DAA treatment during their incarceration, and for those with available data, nearly all were cured. While there were disparities in HCV exposure and chronic HCV infection, significant racial/ethnic differences were not observed for treatment initiation or cure rates. Further efforts are needed to increase HCV treatment, especially for patients with shorter incarceration periods.