Strategies for the elimination of hepatitis C virus infection as a public health threat in the United States

Implementing a Surveillance-Based Approach to Create a Statewide Viral Clearance Cascade for Hepatitis C Among People With HIV and HCV Coinfection in Connecticut

OBJECTIVES

Highly effective direct-acting antiviral medications have made it feasible to achieve elimination of hepatis C virus (HCV), including for people with HIV and HCV coinfection. The Centers for Disease Control and Prevention offers guidance for a laboratory surveillance-based HCV viral clearance cascade, which allows public health departments to track the outcomes of people with HCV based on the following steps: ever infected, virally tested, initial infection, and cured or cleared. We examined the feasibility of this approach among people with HIV and HCV coinfection in Connecticut.

METHODS

We matched an HIV surveillance database, which included cases from the enhanced HIV/AIDS Reporting System as of December 31, 2019, and the HCV surveillance database, the Connecticut Electronic Disease Surveillance System, to define a cohort of coinfected people. We used HCV laboratory results obtained from January 1, 2016, through August 3, 2020, to determine HCV status.

RESULTS

Of 1361 people who were ever infected with HCV as of December 31, 2019, 1256 (92.3%) received HCV viral testing, 865 of 1256 people tested (68.9%) were HCV infected, and 336 of 865 infected people (38.8%) were cleared or cured. People who had undetectable HIV viral loads at most recent HIV test (<200 copies/mL) were more likely than those with detectable HIV viral loads to achieve HCV cure (P = .02).

CONCLUSIONS

A surveillance-based approach that includes data based on the Centers for Disease Control and Prevention HCV viral clearance cascade is feasible to implement, can help track population-level outcomes longitudinally, and can help identify gaps to inform HCV elimination strategies.

Association between Direct-Acting Agents Adherence and Health-Related Quality of Life of Patients with Hepatitis C

This observational study included all patients undergoing HCV treatment with direct-acting antiviral (DAA)-based therapy between May 2020 and September 2023 at the Dolj County Hospital, Romania. The aim was to investigate adherence to DAAs among HCV patients and the effect of this treatment on their health-related quality of life (HRQoL). Chronic HCV-infected patients were prospectively evaluated at baseline (T0), before the beginning of treatment, and 12 weeks after completing DAAs treatment (T1). The HCV-AD10 questionnaire was used to measure DAAs adherence, and HRQoL was assessed with the 15D instrument. The 15D questionnaire was administered at two time points: T0 and T1, during which the Sustained Virologic Response (SVR) was also measured. The primary outcome was DAAs adherence, with secondary outcomes including quality of life (QoL), and sustained virologic response (SVR). DAAs based therapy was initiated for 368 patients, all of whom were health insured. HRQoL and psychological state of HCV patients clinically improved. The DAAs adherence was very good (mean±SD, 91.51±8.34), being influenced by age (younger patients were much adherent, rho=-0.112, p-value=0.031) and the severity of the disease (patients with more severe hepatitis were less adherent, rho=-0.167, p-value=0.001). DAAs had a significant effect on improving HRQoL of HCV patients, but did not influence medication adherence.

Estimated Number of People Who Inject Drugs in the United States

BACKGROUND

Public health data signal increases in the number of people who inject drugs (PWID) in the United States during the past decade. An updated PWID population size estimate is critical for informing interventions and policies aiming to reduce injection-associated infections and overdose, as well as to provide a baseline for assessments of pandemic-related changes in injection drug use.

METHODS

We used a modified multiplier approach to estimate the number of adults who injected drugs in the United States in 2018. We deduced the estimated number of nonfatal overdose events among PWID from 2 of our previously published estimates: the number of injection-involved overdose deaths and the meta-analyzed ratio of nonfatal to fatal overdose. The number of nonfatal overdose events was divided by prevalence of nonfatal overdose among current PWID for a population size estimate.

RESULTS

There were an estimated 3 694 500 (95% confidence interval [CI], 1 872 700-7 273 300) PWID in the United States in 2018, representing 1.46% (95% CI, .74-2.87) of the adult population. The estimated prevalence of injection drug use was highest among males (2.1%; 95% CI, 1.1-4.2), non-Hispanic Whites (1.8%; 95% CI, .9-3.6), and adults aged 18-39 years (1.8%; 95% CI, .9-3.6).

CONCLUSIONS

Using transparent, replicable methods and largely publicly available data, we provide the first update to the number of people who inject drugs in the United States in nearly 10 years. Findings suggest the population size of PWID has substantially grown in the past decade and that prevention services for PWID should be proportionally increased.

A qualitative investigation of organizational challenges and facilitators to screening individuals experiencing homelessness for hepatitis C virus (HCV) in Houston, Texas

Background

Individuals experiencing homelessness may be at a disproportionately high risk for hepatitis C (HCV) because they may be more likely to engage in HCV risk behaviors. Community organizations that provide services to these vulnerable individuals can effectively screen, diagnose, and navigate them into HCV care. However, screening people experiencing homelessness for HCV at such organizations is limited by various challenges that remain understudied, including budgetary considerations and strategies to improve teamwork and communication. Accordingly, this study investigated the organizational challenges and facilitators to HCV screening of individuals experiencing homelessness as reported by homeless services providers.

Methods

Staff (N = 21) at two community organizations in Houston, Texas, completed an interviewer-administered survey and a semi-structured interview in August 2020 to assess the challenges and facilitators to screening people experiencing homelessness for HCV. Interviews were coded, and a thematic analysis was conducted to identify challenges as well as facilitators to HCV screening among individuals experiencing homelessness.

Results

Almost half of participants were employed in social services (42.86%; n = 9), while the remainder were employed in management/administration and health services. Barriers to HCV screening included funding, logistics, and resource-related challenges; and limited communication and collaboration around HCV screening. Facilitators to HCV screening included providing HCV education and training for all staff; and incentivizing, formalizing, and funding HCV screening.

Conclusions

Community organizations can help minimize barriers to HCV screening among individuals experiencing homelessness by providing staff with training specific to HCV, client education around HCV and the screening process, and providing clients with incentives for participation, as well as by maximizing community and clinic partnerships to provide linkage to care and services to this high-risk population.

Development and Validation of a Model for Prediction of End-Stage Liver Disease in People With HIV

BACKGROUND

End-stage liver disease (ESLD) is a leading cause of non-AIDS-related death among people with HIV (PWH). Factors that increase the progression of liver disease include comorbidities and HIV-specific factors, but we currently lack a tool to apply this evidence into clinical practice.

METHODS

We developed and validated a risk prediction model for ESLD among PWH who received care in 12 cohorts of the North American AIDS Cohort Collaboration on Research and Design between 2000 and 2016 and had fibrosis-4 index > 1.45. The first occurrence of ascites, variceal bleed, spontaneous bacterial peritonitis, or hepatic encephalopathy was verified by standardized medical record review. The Bayesian model averaging was used to select predictors among biomarkers and diagnoses and the Harrell C statistic to assess model discrimination.

RESULTS

Among 13,787 PWH in the training set, 82% were men and 54% were Black with a mean age of 48 years. Three hundred ninety ESLD events occurred over a mean 5.4 years. Among the ESLD cases, 52% had hepatitis C virus, 15% hepatitis B virus, and 31% alcohol use disorder. Twelve factors together predicted ESLD risk moderately well (C statistic 0.79, 95% confidence interval: 0.76 to 0.81): age, sex, race/ethnicity, chronic hepatitis B or C, and routinely collected laboratory values reflecting hepatic impairment (serum albumin, aspartate aminotransferase, total bilirubin, and platelets) and lipid metabolism (triglycerides, high-density lipoprotein, and total cholesterol). Our model performed well in the test set (C statistic 0.81, 95% confidence interval: 0.76 to 0.86).

CONCLUSION

This model of readily accessible clinical parameters predicted ESLD in a large diverse population of PWH.

Hepatitis C and hepatitis C-related advanced liver disease hospitalisation trends before and after the Strategic Plan for Tackling Hepatitis C in the National Health System

INTRODUCTION

This work evaluates the burden and trends of hepatitis C virus (HCV)-associated hospitalisations in Spain before and after the implementation of the Strategic Plan for Tackling Hepatitis C in the National Health System in 2015.

METHODS

HCV-related hospitalisation discharges from 2005 to 2017 were obtained from the National Registry of Hospitalisations. A descriptive analysis of the hospitalisations was performed.

RESULTS

From 2005 to 2017, there were 674 067 HCV-related hospitalisations: 1.2%, 29.9%, 63.9% and 5% of them due to acute, carriers, chronic and unspecified hepatitis C. Average age of the patients was 57.7 years (SD: 16.4), average hospital stay was 9.1 days (SD: 12.2) and intra-hospital case-fatality rate was 6.5%. Hospitalisation rates decreased notably (P < 0.05) in 2016-2017 compared to 2005-2015 for all [hospitalisation rate ratio (HRR): 0.77], males (HRR: 0.80), females (HRR: 0.74), chronic hepatitis C (HRR: 0.84), non-advanced liver disease (N-AdLD) (HRR: 0.80) and AdLD (HRR: 0.73). Acute HCV (HRR: 0.54) and carriers (HRR: 0.49) show decreases in 2016-2017 vs. 2005-2015, although their rates started to decrease in 2008/2009. Unspecified HCV hospitalisation rates increased (P < 0.05) in 2016-2017 (HRR: 2.02) vs. 2005-2015. From 2015 to 2017, cost per patient increased from 5981 euros to 6349 euros, but overall cost decreased, as hospitalisations rates decreased from 302 to 264 million euros.

DISCUSSION

HCV-related hospitalisation rates decreased notably in 2016 and 2017 after the strategic plan for tackling hepatitis C was launched. Although cost per AdLD patient increased in 2016 and 2017, globally costs were reduced around 35 million euros per year.

Reduction in hepatitis C-related hospitalizations after the implementation of the Strategic Plan for Tackling Hepatitis C in the Spanish National Health System: regional level differences

This work evaluates the potential impact at territorial level of the Strategic Plan for Tackling Hepatitis C in the Spanish National Health System on hepatitis C virus (HCV)-associated hospitalizations. Chronic HCV-related hospitalization discharges from 2014 to 2018 were obtained from the National Registry of Hospitalisations. A descriptive analysis of the hospitalizations was performed for all chronic, advanced liver disease and non-advanced liver disease. Hospitalization rates were calculated at national and regional level. Year 2015 and period 2016-2018 hospitalization rates were compared to 2014 hospitalization rates using a Poisson model. Municipal standardized hospitalization rates ratios adjusted by age-group were calculated for 2016-2018 period (2014 hospitalization rates as reference). From 2014 to 2018, there were 22,352 chronic HCV-related hospitalizations. In-hospital fatality rate was 4.3% for non-advanced liver disease and 11.7% for advanced liver disease patients. National hospitalization rate decreased 22% (95% CI: 21%-22%), 16% (95% CI: 15%-17%) and 34% (95% CI: 33%-35%) in 2016-2018 compared to 2014 for all chronic, non-advanced and advanced liver disease, respectively. During 2016-2018 period, 11/19 Spanish regions achieved >20% decrease in the hospitalization rates (p < .001) for non-advanced liver disease and 19/19 (except Melilla, the rest with p < .001) for advanced liver disease. At municipal level, 84.8% and 90.2% municipalities had <20% of chronic HCV-related hospitalization need compared to 2014 adjusted by age-group. Based on the data analysed, a high impact on reducing chronic HCV-associated hospitalizations have been achieved after the implementation of the Strategic Plan for Tackling Hepatitis C in the Spanish National Health System. However, small differences between regions and rural/urban areas were noticed.

A Telementoring Program and Hepatitis C Virus Care in Rural Patients

Background: Rural patients with chronic hepatitis C virus (HCV) infection may be less likely to access HCV care than those in urban areas. A telementoring, task-shifting model has been implemented to address the unmet needs of HCV care. Evidence is needed on whether this intervention improves HCV care in rural HCV patients. Methods: We compared three key HCV care indicators among Medicare patients with chronic hepatitis C in 2014-2016 by urban-rural status between New Mexico with a telementoring program and Pennsylvania without such a program. We classified each patient's urban-rural status based on his or her ZIP code of residence. We used multivariable log-binomial regressions to examine the relative probability of receiving HCV care by urban and rural status in two states. Results: In New Mexico, 41.3% of HCV patients resided in rural areas (N = 1155). In Pennsylvania, rural patients accounted for 13.2% (N = 1775). The unadjusted overall rates of receiving HCV RNA or genotype testing within 12 months before HCV treatment were 76.1% in "rural-New Mexico" versus 73.3% in "rural-Pennsylvania," 66.2% in "urban-New Mexico," and 70.2% in "urban-Pennsylvania." Post-treatment HCV RNA testing rate was also high in "rural-New Mexico" (83.0%). After adjusting for demographic and clinical characteristics, "rural-New Mexico" HCV patients who received HCV treatment still had the highest probability of taking HCV RNA or genotype testing before HCV treatment, compared with other groups (relative risk [95% confidence interval]: 0.91 [0.84-1.00] in "rural-Pennsylvania," 0.85 [0.78-0.93] in "urban-New Mexico," and 0.93 [0.87-1.00] in "urban-Pennsylvania"). Conclusions: The telementoring program may help improve HCV care in rural patients.

Changing Urban-Rural Disparities in the Utilization of Direct-Acting Antiviral Agents for Hepatitis C in U.S. Medicare Patients, 2014-2017

INTRODUCTION

The advent of direct-acting antiviral agents for treating hepatitis C virus infection has made hepatitis C virus elimination possible. Rural patients with hepatitis C virus infection may be less likely to access direct-acting antiviral agents, but the real-world evidence is scarce on urban-rural disparities in direct-acting antiviral agent utilization.

METHODS

This retrospective cohort study was conducted in 2019-2020 using Medicare data to examine urban-rural disparities in direct-acting antiviral agent utilization among newly diagnosed patients with hepatitis C virus infection in 2014-2016. Direct-acting antiviral agent use was defined as filling ≥1 prescription for direct-acting antiviral agents during 2014-2017, and patient's urban-rural status was classified on the basis of their ZIP code of residence. This study evaluated the associations between multilevel factors and direct-acting antiviral agent use with a focus on urban-rural disparities. It also assessed changes over time in urban-rural disparities in direct-acting antiviral agent utilization using multivariable cause-specific Cox regression analyses with time-varying hazard ratios.

RESULTS

Among 204,018 new patients with hepatitis C virus infection, about 30% received direct-acting antiviral agents during 2014-2017. Cumulative direct-acting antiviral agent use gradually increased over time in both urban and rural patients. However, the increase was greater in urban patients than in rural patients. In the first year of follow-up, rural patients had a similar rate of receiving direct-acting antiviral agents (adjusted hazard ratio=1.03, 95% CI=1.00, 1.07), but they were less likely to use direct-acting antiviral agents in later years than urban patients (adjusted hazard ratio=0.85, 95% CI=0.81, 0.90 in the second year, adjusted hazard ratio=0.82, 95% CI=0.76, 0.89 in the third year, and adjusted hazard ratio=0.76, 95% CI=0.64, 0.90 in the fourth year of follow-up).

CONCLUSIONS

This study reveals important gaps in hepatitis C virus treatment and suggests increasing urban-rural disparities in direct-acting antiviral agent utilization. Enhancing direct-acting antiviral agent uptake in rural populations with hepatitis C virus infection will help reduce hepatitis C virus‒related health disparities and reach the national goal of eliminating hepatitis C virus infection.

Can Telementoring Reduce Urban-Rural Disparities in Utilization of Direct-Acting Antiviral Agents?

Background: Expanding access to direct-acting antiviral agents (DAAs) for treating hepatitis C virus (HCV) infection is the national goal for HCV elimination, but important urban-rural disparities exist in DAA use. Evidence is needed to evaluate intervention efforts to reduce urban-rural disparities in DAA utilization. Methods: We used Medicare data to compare DAA use between urban HCV patients and rural HCV patients in two states: State A with a telementoring approach to train rural providers to treat HCV patients and State B without such an intervention. We focused on DAA utilization among newly diagnosed HCV patients in 2014-2016 and defined DAA use as filling at least one prescription of DAAs during 2014-2017. We classified patient's urban-rural status based on their ZIP code of residence. We assessed overtime changes in urban-rural disparities in DAA utilization for each state using multivariable cause-specific Cox regression analyses with time-varying hazard ratios. Results: Among 1,872 new HCV patients in State A, 135 (17.00%) rural patients and 243 (22.54%) urban patients received DAAs in 2014-2017. Although there was noticeable urban-rural disparities in DAA use during the first 24 months of follow-up (hazard ratios [HRs] = 0.73 [0.51 to 1.03] for 0-12 months and 0.61 [0.39 to 0.95] for 13-24 months), the disparities became nonsignificant afterward (HR = 1.06 [0.58 to 1.93] after 24 months). Most DAA users in rural areas (94, 70%) in State A received DAAs prescribed by primary care providers (PCPs). In State B, among 8,928 new HCV patients, 227 (18.22%) rural patients and 1,600 (20.83%) urban patients received DAAs in 2014-2017. Rural patients were less likely to receive DAAs over time (HR = 1.12 [0.93 to 1.36] in the first 12 months and HR = 0.62 [0.40 to 0.96] after 24 months). Only 81 (36%) DAA users in rural areas in State B were treated by PCPs. Conclusions: Our study suggests that the telementoring approach may help reduce urban-rural disparities in DAA utilization.

Translation and validation study of the Polish version of the Brief Hepatitis C Knowledge Scale

INTRODUCTION

Chronic hepatitis C (HCV), considered by the World Health Organization as one of the greatest epidemiological health hazards, often with asymptomatic clinical course and one which, due to scanty knowledge, remains a crucial risk factor of serious chronic HCV infection complications. The purpose of this study is to validate the psychometric properties of the Polish version of the validated Brief Hepatitis C Knowledge Scale (BHCKS_PL), developed by Balfour in 2009.

METHODS

The study, conducted from May to July 2018, included 246 persons (68,69% females), divided into four subgroups: patients (n = 86), nursing students (n = 74), medical students (n = 28), healthcare workers (nurses and doctors; n = 58). The 19-items questionnaire contained questions designed to assess general knowledge regarding hepatitis C and the transmission risk factors.

RESULTS

An evaluation by means of multiple comparisons in pairs showed that there were significant differences in the knowledge level between the group of patients and the group of nursing students (Mdn: 14.0 vs 11.0, z = 7.713, P<0.001), and between students of medicine (Mdn: 16.0 vs 11.0, z = 0.339, P<0.001) and healthcare workers (17.0 vs 11.0, z = 11.447, P<0.001). Moreover, significant differences were observed between the groups of students of nursing and medicine (Mdn: 14.0 vs 16.0, z = 3.646, P = 0.002) and healthcare workers (Mdn: 14.0 vs 17.0, z = 4.117, P<0.001). No significant differences in the knowledge level between the students of medicine and healthcare workers were observed (z = 0.377, P = 1.000).

CONCLUSIONS

The completed validation suggests good BHCKS_P psychometric characteristics with the internal consistency convergent and known-groups validity. The questionnaire can be used in educational practice. The obtained results of the measurement provide information about the studied person based on the total score.

Hepatitis C Virus Prevalence in 50 U.S. States and D.C. by Sex, Birth Cohort, and Race: 2013-2016

Hepatitis C virus (HCV) infection is a leading cause of liver-related morbidity and mortality, and more than 2 million adults in the United States are estimated to be currently infected. Reducing HCV burden will require an understanding of demographic disparities and targeted efforts to reduce prevalence in populations with disproportionate disease rates. We modeled state-level estimates of hepatitis C prevalence among U.S. adults by sex, birth cohort, and race during 2013-2016. National Health and Nutrition Examination Survey data were used in combination with state-level HCV-related and narcotic overdose-related mortality data from the National Vital Statistics System and estimates from external literature review on populations not sampled in the National Health and Nutrition Examination Survey. Nationally, estimated hepatitis C prevalence was 1.3% among males and 0.6% among females (prevalence ratio [PR] = 2.3). Among persons born during 1945 to 1969, prevalence was 1.6% compared with 0.5% among persons born after 1969 (PR = 3.2). Among persons born during 1945 to 1969, prevalence ranged from 0.7% in North Dakota to 3.6% in Oklahoma and 6.8% in the District of Columbia. Among persons born after 1969, prevalence was more than twice as high in Kentucky, New Mexico, Oklahoma, and West Virginia compared with the national average. Hepatitis C prevalence was 1.8% among non-Hispanic black persons and 0.8% among persons of other races (PR = 2.2), and the magnitude of this disparity varied widely across jurisdictions (PR range: 1.3-7.8). Overall, 23% of prevalent HCV infections occurred among non-Hispanic black persons, whereas 12% of the population was represented by this racial group. These estimates provide information on prevalent HCV infections that jurisdictions can use for understanding and monitoring local disease patterns and racial disparities in burden of disease.