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Marshall AD, Willing AR, Kairouz A, Cunningham EB, Wheeler A, O'Brien N, Perera V, Ward JW, Hiebert L, Degenhardt L, Hajarizadeh B, Colledge S, Hickman M, Jawad D, Lazarus JV, Matthews GV, Scheibe A, Vickerman P, Dore GJ, Grebely J. Direct-acting antiviral therapies for hepatitis C infection: global registration, reimbursement, and restrictions. Lancet Gastroenterol Hepatol 2024; 9:366-382. [PMID: 38367631 DOI: 10.1016/s2468-1253(23)00335-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 09/25/2023] [Accepted: 10/02/2023] [Indexed: 02/19/2024]
Abstract
Direct-acting antivirals (DAAs) for hepatitis C virus (HCV) infection have delivered high response rates (>95%) and simplified the management of HCV treatment, permitting non-specialists to manage patients without advanced liver disease. We collected and reviewed global data on the registration and reimbursement (government subsidised) of HCV therapies, including restrictions on reimbursement. Primary data collection occurred between Nov 15, 2021, and July 24, 2023, through the assistance of a global network of 166 HCV experts. We retrieved data for 160 (77%) of 209 countries and juristrictions. By mid-2023, 145 (91%) countries had registered at least one of the following DAA therapies: sofosbuvir-velpatasvir, sofosbuvir-velpatasvir-voxilaprevir, glecaprevir-pibrentasvir, sofosbuvir-daclatasvir, or sofosbuvir. 109 (68%) countries reimbursed at least one DAA therapy. Among 102 low-income and middle-income countries (LMICs), 89 (87%) had registered at least one HCV DAA therapy and 53 (52%) reimbursed at least one DAA therapy. Among all countries with DAA therapy reimbursement (n=109), 66 (61%) required specialist prescribing, eight (7%) had retreatment restrictions, seven (6%) had an illicit drug use restriction, five (5%) had an alcohol use restriction, and three (3%) had liver disease restrictions. Global access to DAA reimbursement remains uneven, with LMICs having comparatively low reimbursement compared with high-income countries. To meet WHO goals for HCV elimination, efforts should be made to assist countries, particularly LMICs, to increase access to DAA reimbursement and remove reimbursement restrictions-especially prescriber-type restrictions-to ensure universal access.
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Affiliation(s)
- Alison D Marshall
- Viral Hepatitis Clinical Research Program, The Kirby Institute, University of New South Wales, Sydney, NSW, Australia; Centre for Social Research in Health, University of New South Wales, Sydney, NSW, Australia.
| | - Alex R Willing
- Viral Hepatitis Clinical Research Program, The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Abe Kairouz
- Viral Hepatitis Clinical Research Program, The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Evan B Cunningham
- Viral Hepatitis Clinical Research Program, The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Alice Wheeler
- Viral Hepatitis Clinical Research Program, The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | | | | | - John W Ward
- Coalition for Global Hepatitis Elimination, Task Force for Global Health, Decatur, GA, USA
| | - Lindsey Hiebert
- Coalition for Global Hepatitis Elimination, Task Force for Global Health, Decatur, GA, USA
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Behzad Hajarizadeh
- Viral Hepatitis Clinical Research Program, The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Samantha Colledge
- National Drug Research Institute, Curtin University, Perth, WA, Australia
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Danielle Jawad
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Jeffrey V Lazarus
- Barcelona Institute for Global Health (IS Global), Hospital Clinic, University of Barcelona, Barcelona, Spain; CUNY Graduate School of Public Health and Health Policy, New York, NY, USA
| | - Gail V Matthews
- Therapeutic and Vaccine Research Program, The Kirby Institute, University of New South Wales, Sydney, NSW, Australia; St Vincent's Hospital, Darlinghurst, Sydney, NSW, Australia
| | - Andrew Scheibe
- TB HIV Care, Cape Town, South Africa; Community Orientated, Primary Care Research Unit, Department of Family Medicine, University of Pretoria, Pretoria, South Africa
| | - Peter Vickerman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Gregory J Dore
- Viral Hepatitis Clinical Research Program, The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Jason Grebely
- Viral Hepatitis Clinical Research Program, The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
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Snow K, MacLachlan JH, Rowe S, Higgins N, Cowie BC. The cascade of care for hepatitis C in Victoria, Australia: a data linkage cohort study. Intern Med J 2024. [PMID: 38504432 DOI: 10.1111/imj.16361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 02/01/2024] [Indexed: 03/21/2024]
Abstract
BACKGROUND Highly effective hepatitis C therapies are available in Australia. However, people living with hepatitis C face various barriers to accessing care and treatment. AIMS To identify gaps in the cascade of care for hepatitis C and generate estimates of the number living with untreated infection according to population group, using a representative longitudinal study population. METHODS We linked hepatitis C notification data from Victoria to national pathology, prescribing and death registry data. We assessed receipt of key clinical services in a large cohort who tested positive for hepatitis C from 1 January 2000 to 31 December 2016, with follow-up to 30 June 2018. We estimated the number still living with hepatitis C, adjusting for spontaneous clearance and mortality. RESULTS The cohort comprised 45 391 people positive for hepatitis C. Of these, 13 346 (29%) received treatment and an estimated 28% (95% confidence interval (CI): 26-30%) were still living with chronic infection at 30 June 2018, with the remainder still living following spontaneous clearance (30%, 95% CI: 29-32%) or having died (12%, 95% CI: 12-12%). Half (50%) of those still living with hepatitis C were born from 1965 to 1980, and 74% first tested positive before 2011. CONCLUSIONS Despite an enabling policy environment and subsidised therapy, many people in this cohort were not treated. Increased measures may be needed to engage people in care, including those who acquired hepatitis C more than 10 years ago.
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Affiliation(s)
- Kathryn Snow
- WHO Collaborating Centre for Viral Hepatitis, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Jennifer H MacLachlan
- WHO Collaborating Centre for Viral Hepatitis, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Department of Infectious Diseases, University of Melbourne, Melbourne, Victoria, Australia
| | - Stacey Rowe
- Victorian Government Department of Health, Melbourne, Victoria, Australia
- School of Population Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Nasra Higgins
- Victorian Government Department of Health, Melbourne, Victoria, Australia
| | - Benjamin C Cowie
- WHO Collaborating Centre for Viral Hepatitis, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Department of Infectious Diseases, University of Melbourne, Melbourne, Victoria, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Barbati S, Strasser J, Allemann SS, Arnet I. Initiation of oral hepatitis C virus treatment: Which barriers are pertinent for ambulatory individuals with a history of illicit substance use? A qualitative interview study. Health Sci Rep 2024; 7:e1814. [PMID: 38260184 PMCID: PMC10802086 DOI: 10.1002/hsr2.1814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/01/2023] [Accepted: 12/21/2023] [Indexed: 01/24/2024] Open
Abstract
Background and Aims The World Health Organization has set a goal to eradicate hepatitis C virus (HCV) by the year 2030. Nonadherence to HCV treatment has substantial economic implications due to high treatment costs, among others. Barriers to start HCV treatment may be critical. The aim of this study was to assess pertinent barriers to HCV treatment in ambulatory patients with a history of illicit substance use and to compare them to the literature. Methods Barriers to HCV treatment mentioned by the key risk group (i.e., people who inject drugs) were retrieved from literature through a pragmatic literature search. From 34 published articles, we identified 80 modifiable barriers that were bundled in 23 items within the four topics "Personal difficulties and barriers to treatment," "Personal motivation to be treated," "Knowledge about the disease," and "Received information about the medicine." In-depth semistructured interviews were performed face-to-face with ambulatory patients from the University Psychiatric Clinics in Basel, Switzerland. Transcripts were coded inductively. Results Interviews were performed with seven individuals (mean age: 48.3 years; range: 38-63 years; one woman) treated with oral direct-acting antivirals between 2014 and 2022. Thirteen barriers to start HCV treatment were mentioned that corresponded to the five categories: information, attitudes, swallowing difficulties, social environment, and unfavorable lifestyle. The barrier "swallowing difficulties" emerged exclusively from the statements provided by the interviewees. Conclusion Barriers to the initiation of HCV treatment indicated by our interviewees clearly differed from the literature. Notably, the challenge of swallowing medicines may be particularly relevant for physicians prescribing and pharmacists dispensing HCV medication.
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Affiliation(s)
- Selina Barbati
- Pharmaceutical Care Research Group, Department of Pharmaceutical SciencesUniversity of BaselBaselSwitzerland
| | | | - Samuel S. Allemann
- Pharmaceutical Care Research Group, Department of Pharmaceutical SciencesUniversity of BaselBaselSwitzerland
| | - Isabelle Arnet
- Pharmaceutical Care Research Group, Department of Pharmaceutical SciencesUniversity of BaselBaselSwitzerland
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Ho N, Vandyk A, Horvath C, Magboo Cahill T, O'Byrne P. The experiences of people who use injection drugs with accessing hepatitis c testing and diagnosis in western countries: A scoping review. Public Health Nurs 2024; 41:37-56. [PMID: 37712447 DOI: 10.1111/phn.13254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 07/28/2023] [Accepted: 08/29/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND The purpose of this scoping review was to summarize the literature that reported on the experiences of people who use injection drugs' access to hepatitis C testing and diagnosis in Western countries. METHODS The initial search was conducted in 2020 and an updated review was completed in 2022. Seven electronic databases were searched using a peer-reviewed search strategy and included: full-text, peer-reviewed studies with people who inject(ed) drugs, hepatitis C testing or diagnosis, conducted in Western countries. Excluded were studies published prior to 2014 and intervention studies. Two-step screening was conducted in duplicate. Conventional content analysis was used. RESULTS Six studies were found from the search. The studies were published between 2014 and 2021 in Australia, United Kingdom, and United States. A total of 19 participant characteristics were extracted to contextualize their experiences, demonstrating a lack of demographic data. Four themes were found: Awareness and Knowledge, Stigma, Healthcare Service, and Psychological Responses. There were 58 occurrences of client quotes where participants described their experiences, 29 occurrences of quotes describing client-identified barriers, and 14 occurrences of quotes describing client-identified facilitators. CONCLUSION A scoping review was conducted to present the experiences, barriers, and facilitators of people who use injection drugs to hepatitis C testing. The lack of demographic data and connection to client quotes further exacerbates the inequities among the population by overlooking their intragroup identities. Understanding their experiences of accessing hepatitis C testing and collecting demographic data will help advance health policies and interventions targeting people who use injection drugs.
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Affiliation(s)
- Nikki Ho
- Faculty of Health Sciences, School of Nursing, University of Ottawa, Ottawa, Ontario, Canada
| | - Amanda Vandyk
- Faculty of Health Sciences, School of Nursing, University of Ottawa, Ottawa, Ontario, Canada
| | - Cynthia Horvath
- Ottawa Public Health, Health Protection Service, Ottawa, Ontario, Canada
| | - Taliesin Magboo Cahill
- Faculty of Health Sciences, School of Nursing, University of Ottawa, Ottawa, Ontario, Canada
| | - Patrick O'Byrne
- Faculty of Health Sciences, School of Nursing, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Public Health, Health Protection Service, Ottawa, Ontario, Canada
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Horváth I, Mårdh O, Schwarz T. Models of good practice to enhance infectious disease care cascades among people who inject drugs: a qualitative study of interventions implemented in European settings. BMC Health Serv Res 2023; 23:1352. [PMID: 38049823 PMCID: PMC10696743 DOI: 10.1186/s12913-023-10412-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 11/30/2023] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND People who inject drugs (PWID) in Europe are at an increased risk of HIV/AIDS, chronic viral hepatitis B (HBV) and C (HCV), and tuberculosis (TB). We aimed to complement the evidence base on interventions optimising their care cascade with evidence from models of good practice (MoGPs) implemented in the EU/EEA and countries from the Eastern European region. METHODS A model of good practice (MoGP) was defined as (a package of) interventions with proven effectiveness in certain settings that are likely to be replicable and sustainable in other settings or countries. Fifteen MoGPs, identified by the European Centre for Disease Prevention and Control (ECDC) and the European Monitoring Centre on Drugs and Drug Addiction (EMCDDA) following a call launched in 2020, have been analysed. For the 15 MoGPs, a qualitative content analysis was conducted of (i) intervention characteristics and (ii) enabling factors. Information was extracted and summarised for community-based testing, linkage to care and adherence to treatment. RESULTS MoGPs emerged from projects implemented in Belarus, Norway, Portugal, the Republic of Moldova, Spain, and the UK alongside the multi-country HepCare project (Ireland, Romania, Spain, the UK) targeting either HCV (6/15) or HIV/AIDS (4/15), alone or combined with HBV, and/or TB (5/15). All MoGPs used packages of interventions, with decentralisation of services (15/15), cooperation among service providers (14/15), integrated services (10/15), peer interventions (12/15), and case management (4/15) reported across all stages of the care cascade. The synthesis of enablers shows that when replicating interventions in other settings, consideration should be given to national (legal) frameworks, characteristics of and proximity between healthcare and service providers, and establishing relations of trust with PWID. CONCLUSION To improve the cascade of care for PWID in European settings, care structures and pathways should be simplified, based on cooperation and multidisciplinary. MoGPs can provide implementation-based evidence on interventions alongside evidence from peer-reviewed literature to optimise the care cascade among PWID.
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Affiliation(s)
- Ilonka Horváth
- Austrian National Public Health Institute (Gesundheit Österreich GmbH, GOEG), Vienna, Austria.
| | - Otilia Mårdh
- European Centre for Disease Prevention and Control (ECDC), Solna, Sweden
| | - Tanja Schwarz
- Austrian National Public Health Institute (Gesundheit Österreich GmbH, GOEG), Vienna, Austria
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Hernandez-Con P, Wilson DL, Tang H, Unigwe I, Riaz M, Ourhaan N, Jiang X, Song HJ, Joseph A, Henry L, Cook R, Jayaweera D, Park H. Hepatitis C Cascade of Care in the Direct-Acting Antivirals Era: A Meta-Analysis. Am J Prev Med 2023; 65:1153-1162. [PMID: 37380088 PMCID: PMC10749988 DOI: 10.1016/j.amepre.2023.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 06/30/2023]
Abstract
INTRODUCTION The hepatitis C virus (HCV) epidemic remains a public health problem worldwide. A systematic review and meta-analysis were conducted to provide evidence of outcomes attained across the HCV care cascade in the era of direct-acting antivirals. METHODS Studies from North America, Europe, and Australia (January 2014 through March 2021) reporting on HCV care cascade outcomes (screening to cure) were included. When calculating the proportions of individuals completing each step, the numerator for Steps 1-8 was the number of individuals completing each step; the denominator was the number of individuals completing the previous step for Steps 1-3 and Step 3 for Steps 4-8. In 2022, random effects meta-analyses were conducted to estimate pooled proportions with 95% CIs. RESULTS Sixty-five studies comprising 7,402,185 individuals were identified. Among individuals with positive HCV ribonucleic acid test results, 62% (95% CI=55%, 70%) attended their first care appointment, 41% (95% CI=37%, 45%) initiated treatment, 38% (95% CI=29%, 48%) completed treatment, and 29% (95% CI=25%, 33%) achieved cure. HCV screening rates were 43% (95% CI=22%, 66%) in prisons or jails and 20% (95% CI=11%, 31%) in emergency departments. Linkage to care rates were 62% (95% CI=46%, 75%) for homeless individuals and 26% (95% CI=22%, 31%) for individuals diagnosed in emergency departments. Cure rates were 51% (95% CI=30%, 73%) in individuals with substance use disorder and 17% (95% CI=17%, 17%) in homeless individuals. Cure rates were lowest in the U.S. DISCUSSION Despite the availability of effective all-oral direct-acting antiviral therapies, persistent gaps remain across the HCV care cascade, especially among traditionally marginalized populations. Public health interventions targeting identified priority areas (e.g., emergency departments) may improve screening and healthcare retention of vulnerable populations with HCV infection (e.g., substance use disorder populations).
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Affiliation(s)
- Pilar Hernandez-Con
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Debbie L Wilson
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Huilin Tang
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Ikenna Unigwe
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Munaza Riaz
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida; Institute of Pharmacy, Lahore College for Women University, Lahore, Pakistan
| | - Natalie Ourhaan
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Xinyi Jiang
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Hyun Jin Song
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Amanda Joseph
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Linda Henry
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Robert Cook
- Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida
| | - Dushyantha Jayaweera
- Department of Medicine, Miller School of Medicine, University of Miami, Miami, Florida
| | - Haesuk Park
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, Florida.
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Dawe J, Hughes M, Christensen S, Walsh L, Richmond JA, Pedrana A, Wilkinson AL, Owen L, Doyle JS. Evaluation of a person-centred, nurse-led model of care delivering hepatitis C testing and treatment in priority settings: a mixed-methods evaluation of the Tasmanian Eliminate Hepatitis C Australia Outreach Project, 2020-2022. BMC Public Health 2023; 23:2289. [PMID: 37985979 PMCID: PMC10662700 DOI: 10.1186/s12889-023-17066-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 10/25/2023] [Indexed: 11/22/2023] Open
Abstract
INTRODUCTION Australia has experienced sustained reductions in hepatitis C testing and treatment and may miss its 2030 elimination targets. Addressing gaps in community-based hepatitis C prescribing in priority settings that did not have, or did not prioritise, hepatitis C testing and treatment care pathways is critical. METHODS The Tasmanian Eliminate Hepatitis C Australia Outreach Project delivered a nurse-led outreach model of care servicing hepatitis C priority populations in the community through the Tasmanian Statewide Sexual Health Service, supported by the Eliminating Hepatitis C Australia partnership. Settings included alcohol and other drug services, needle and syringe programs and mental health services. The project provided clients with clinical care across the hepatitis C cascade of care, including testing, treatment, and post-treatment support and hepatitis C education for staff. RESULTS Between July 2020 and July 2022, a total of 43 sites were visited by one Clinical Nurse Consultant. There was a total of 695 interactions with clients across 219 days of service delivery by the Clinical Nurse Consultant. A total of 383 clients were tested for hepatitis C (antibody, RNA, or both). A total of 75 clients were diagnosed with hepatitis C RNA, of which 95% (71/75) commenced treatment, 83% (62/75) completed treatment and 52% (39/75) received a negative hepatitis C RNA test at least 12 weeks after treatment completion. CONCLUSIONS Providing outreach hepatitis C services in community-based services was effective in engaging people living with and at-risk of hepatitis C, in education, testing, and care. Nurse-led, person-centred care was critical to the success of the project. Our evaluation underscores the importance of employing a partnership approach when delivering hepatitis C models of care in community settings, and incorporating workforce education and capacity-building activities when working with non-specialist healthcare professionals.
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Affiliation(s)
- Joshua Dawe
- Disease Elimination, Burnet Institute, Melbourne, Australia.
| | - Megan Hughes
- Sexual Health Service Tasmania, Hobart, Australia
| | | | - Louisa Walsh
- Disease Elimination, Burnet Institute, Melbourne, Australia
- Centre for Health Communication and Participation, La Trobe University, Melbourne, Australia
| | | | - Alisa Pedrana
- Disease Elimination, Burnet Institute, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Anna L Wilkinson
- Disease Elimination, Burnet Institute, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Louise Owen
- Sexual Health Service Tasmania, Hobart, Australia
| | - Joseph S Doyle
- Disease Elimination, Burnet Institute, Melbourne, Australia
- Department of Infectious Diseases, Alfred Health and Monash University, Melbourne, Australia
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Snell G, Marshall AD, van Gennip J, Bonn M, Butler-McPhee J, Cooper CL, Kronfli N, Williams S, Bruneau J, Feld JJ, Janjua NZ, Klein M, Cunningham N, Grebely J, Bartlett SR. Public reimbursement policies in Canada for direct-acting antiviral treatment of hepatitis C virus infection: A descriptive study. CANADIAN LIVER JOURNAL 2023; 6:190-200. [PMID: 37503523 PMCID: PMC10370724 DOI: 10.3138/canlivj-2022-0040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 01/28/2023] [Indexed: 07/29/2023]
Abstract
Background Direct-acting antiviral (DAA) therapies have simplified HCV treatment, and publicly funded Canadian drug plans have eliminated disease-stage restrictions for reimbursement of DAA therapies. However other policies which complicate, delay, or prevent treatment initiation still persist. We aim to describe these plans' existing reimbursement criteria and appraise whether they hinder treatment access. Methods We reviewed DAA reimbursement policies of 16 publicly funded drug plans published online and provided by contacts with in-depth knowledge of prescribing criteria. Data were collected from May to July 2022. Primary outcomes were: (1) if plans have arranged to accept point-of-care HCV RNA testing for diagnosis; testing requirements for (2) HCV genotype, (3) fibrosis stage, and (4) chronic infection; (5) time taken and method used to approve reimbursement requests; (6) providers eligible to prescribe DAAs; and (7) restrictions on re-treatment. Results Fifteen (94%) plans have at least one policy in place which limits simplified HCV treatment. Many plans continue to require results of genotype or fibrosis staging, limit eligible prescribers, and take longer than 1 day to approve coverage requests. One plan discourages treatment for re-infection. Conclusion Reimbursement criteria set by publicly funded Canadian drug plans continue to limit timely, equitable access to HCV treatment. Eliminating clinically irrelevant pre-authorization testing, expanding eligible prescribers, expediting claims processing, and broadening coverage of treatment for reinfection will improve access to DAAs. The federal government could further enhance efforts by introducing a federal HCV elimination strategy or federal high-cost drug PharmaCare program.
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Affiliation(s)
- Gaelen Snell
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alison D Marshall
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
- The Centre for Social Research in Health, UNSW Sydney, Sydney, New South Wales, Australia
| | | | - Matthew Bonn
- Canadian Association of People Who Use Drugs, Dartmouth, Nova Scotia, Canada
| | | | - Curtis L Cooper
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Nadine Kronfli
- Division of Infectious Diseases and Chronic Viral Illness Service, Department of Medicine, McGill University Health Centre, Montréal, Quebec, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montréal, Quebec, Canada
| | - Sarah Williams
- Calgary Liver Unit, Alberta Health Services, Calgary, Alberta, Canada
| | - Julie Bruneau
- Centre Hospitalier de l’Université de Montréal Research Center, Quebec, Canada
| | - Jordan J Feld
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Naveed Z Janjua
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Marina Klein
- Division of Infectious Diseases and Chronic Viral Illness Service, Department of Medicine, McGill University Health Centre, Montréal, Quebec, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montréal, Quebec, Canada
| | - Nance Cunningham
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Jason Grebely
- The Centre for Social Research in Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Sofia R Bartlett
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
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Park H, Brown C, Wilson DL, Huang PL, Hernández-Con P, Horne P, Goodin A, Joseph A, Segal R, Cabrera R, Cook RL. Clinician barriers, perceptions, and practices in treating patients with hepatitis C virus and substance use disorder in the United States. Prev Med Rep 2023; 32:102138. [PMID: 36865395 PMCID: PMC9971512 DOI: 10.1016/j.pmedr.2023.102138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 12/19/2022] [Accepted: 02/10/2023] [Indexed: 02/16/2023] Open
Abstract
The likelihood of clinicians prescribing direct-acting antiviral (DAA) therapy for patients with chronic hepatitis C virus (HCV) and substance use disorder (SUD) was assessed via a survey emailed throughout the United States to clinicians (physicians and advanced practice providers) in gastroenterology, hepatology, and infectious disease specialties. Clinicians' perceived barriers and preparedness and actions associated with current and future DAA prescribing practices of HCV-infected patients with SUD were assessed. Of 846 clinicians presumably receiving the survey, 96 completed and returned it. Exploratory factor analyses of perceived barriers indicated a highly reliable (Cronbach alpha = 0.89) model with five factors: HCV stigma and knowledge, prior authorization requirements, and patient- clinician-, and system-related barriers. In multivariable analyses, after controlling for covariates, patient-related barriers (P < 0.01) and prior authorization requirements (P < 0.01) were negatively associated with the likelihood of prescribing DAAs. Exploratory factor analyses of clinician preparedness and actions indicated a highly reliable (Cronbach alpha = 0.75) model with three factors: beliefs and comfort level; action; and perceived limitations. Clinician beliefs and comfort levels were negatively associated with the likelihood of prescribing DAAs (P = 0.01). Composite scores of barriers (P < 0.01) and clinician preparedness and actions (P < 0.05) were also negatively associated with the intent to prescribe DAAs. Conclusion These findings underscore the importance of addressing patient-related barriers and prior authorization requirements-significant problematic barriers-and improving clinicians' beliefs (e.g., medication-assisted therapy should be prescribed before DAAs) and comfort levels for treating patients with HCV and SUD to enhance treatment access for patients with both HCV and SUD.
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Affiliation(s)
- Haesuk Park
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Carolyn Brown
- Health Outcomes, College of Pharmacy, University of Texas, Austin, TX, United States
| | - Debbie L Wilson
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Pei-Lin Huang
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Pilar Hernández-Con
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Patrick Horne
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Amie Goodin
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Amanda Joseph
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Rich Segal
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Roniel Cabrera
- Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Robert L Cook
- Department of Epidemiology, College of Health and Health Professions and College of Medicine, University of Florida, Gainesville, FL, United States
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10
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Walters SM, Frank D, Felsher M, Jaiswal J, Fletcher S, Bennett AS, Friedman SR, Ouellet LJ, Ompad DC, Jenkins W, Pho MT. How the rural risk environment underpins hepatitis C risk: Qualitative findings from rural southern Illinois, United States. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 112:103930. [PMID: 36641816 PMCID: PMC9974910 DOI: 10.1016/j.drugpo.2022.103930] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 12/01/2022] [Accepted: 12/05/2022] [Indexed: 01/15/2023]
Abstract
BACKGROUND Hepatitis C virus (HCV) infection has increased among persons who inject drugs (PWID) in the United States with disproportionate burden in rural areas. We use the Risk Environment framework to explore potential economic, physical, social, and political determinants of hepatitis C in rural southern Illinois. METHODS Nineteen in-depth semi-structured interviews were conducted with PWID from August 2019 through February 2020 (i.e., pre-COVID-19 pandemic) and four with key informants who professionally worked with PWID. Interviews were recorded, professionally transcribed, and coded using qualitative software. We followed a grounded theory approach for coding and analyses. RESULTS We identify economic, physical, policy, and social factors that may influence HCV transmission risk and serve as barriers to HCV care. Economic instability and lack of economic opportunities, a lack of physically available HCV prevention and treatment services, structural stigma such as policies that criminalize drug use, and social stigma emerged in interviews as potential risks for transmission and barriers to care. CONCLUSION The rural risk environment framework acknowledges the importance of community and structural factors that influence HCV infection and other disease transmission and care. We find that larger structural factors produce vulnerabilities and reduce access to resources, which negatively impact hepatitis C disease outcomes.
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Affiliation(s)
- Suzan M Walters
- Department of Epidemiology, New York University School of Global Public Health, New York, NY, United States; Center for Drug Use and HIV/HCV Research, New York, NY, United States.
| | - David Frank
- Department of Epidemiology, New York University School of Global Public Health, New York, NY, United States; Center for Drug Use and HIV/HCV Research, New York, NY, United States
| | - Marisa Felsher
- College of Population Health, Thomas Jefferson University, United States
| | - Jessica Jaiswal
- Department of Health Science, University of Alabama, Tuscaloosa, AL, United States
| | - Scott Fletcher
- Department of Epidemiology, New York University School of Global Public Health, New York, NY, United States; Center for Drug Use and HIV/HCV Research, New York, NY, United States; College of Population Health, Thomas Jefferson University, United States; Department of Health Science, University of Alabama, Tuscaloosa, AL, United States; Department of Social and Behavioral Sciences, New York University School of Global Public Health, New York, NY, United States; Department of Population Health, New York University Grossman School of Medicine, United States; Division of Epidemiology & Biostatistics, School of Public Health, University of Illinois Chicago, Chicago, IL, United States; Department of Population Science and Policy, SIU School of Medicine, Springfield, IL, United States; Department of Medicine, University of Chicago, Chicago, IL, United States; The Community Action Place, Murphysboro, IL, United States
| | - Alex S Bennett
- Center for Drug Use and HIV/HCV Research, New York, NY, United States; Department of Social and Behavioral Sciences, New York University School of Global Public Health, New York, NY, United States
| | - Samuel R Friedman
- Center for Drug Use and HIV/HCV Research, New York, NY, United States; Department of Population Health, New York University Grossman School of Medicine, United States
| | - Lawrence J Ouellet
- Division of Epidemiology & Biostatistics, School of Public Health, University of Illinois Chicago, Chicago, IL, United States
| | - Danielle C Ompad
- Department of Epidemiology, New York University School of Global Public Health, New York, NY, United States; Center for Drug Use and HIV/HCV Research, New York, NY, United States
| | - Wiley Jenkins
- Department of Population Science and Policy, SIU School of Medicine, Springfield, IL, United States
| | - Mai T Pho
- Department of Medicine, University of Chicago, Chicago, IL, United States
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11
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Cunningham EB, Wheeler A, Hajarizadeh B, French CE, Roche R, Marshall AD, Fontaine G, Conway A, Bajis S, Valencia BM, Presseau J, Ward JW, Degenhardt L, Dore GJ, Hickman M, Vickerman P, Grebely J. Interventions to enhance testing and linkage to treatment for hepatitis C infection for people who inject drugs: A systematic review and meta-analysis. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 111:103917. [PMID: 36542883 DOI: 10.1016/j.drugpo.2022.103917] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 11/10/2022] [Accepted: 11/12/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND With the advent of direct acting antiviral (DAA) therapies for the treatment of hepatitis C virus (HCV), the World Health Organization recommended a goal to eliminate HCV as a public health threat globally by 2030. With the majority of new and existing infections in high income countries occurring among people who inject drugs, achieving this goal will require the design and implementation of interventions which address the unique barriers to HCV care faced by this population. METHODS In this systematic review and meta-analysis, we searched bibliographic databases and conference abstracts to July 21, 2020 for studies assessing interventions to improve the following study outcomes: HCV antibody testing, HCV RNA testing, linkage to care, and treatment initiation. We included both randomised and non-randomised studies which included a comparator arm. We excluded studies which enrolled only paediatric populations (<18 years old) and studies where the intervention was conducted in a different healthcare setting than the control or comparator. This analysis was restricted to studies conducted among people who inject drugs. Data were extracted from the identified records and meta-analysis was used to pool the effect of interventions on study outcomes. This study was registered in PROSPERO (CRD42020178035). FINDINGS Of 15,342 unique records, 45 studies described the implementation of an intervention to improve HCV testing, linkage to care and treatment initiation among people who inject drugs. These included 27 randomised trials and 18 non-randomised studies with the risk of bias rated as "critical" for most non-randomised studies. Patient education and patient navigation to address patient-level barriers to HCV care were shown to improve antibody testing uptake and linkage to HCV care respectively although patient education did not improve antibody testing when restricted to randomised studies. Provider care coordination to address provider level barriers to HCV care was effective at improving antibody testing uptake. Three different interventions to address systems-level barriers to HCV care were effective across different stages of HCV care: point-of-care antibody testing (linkage to care); dried blood-spot testing (antibody testing uptake); and integrated care (linkage to care and treatment initiation). INTERPRETATION Multiple interventions are available that can address the barriers to HCV care for people who inject drugs at the patient-, provider-, and systems-level. The design of models of care to improve HCV testing and treatment among people who inject drugs must consider the unique barriers to care that this population faces. Further research, including high-quality randomised controlled trials, are needed to robustly assess the impact these interventions can have in varied populations and settings.
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Affiliation(s)
| | - Alice Wheeler
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | | | - Clare E French
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 1UD, UK; NIHR Health Protection Research Unit (HPRU) in Behavioural Science and Evaluation, University of Bristol, Bristol, UK
| | - Rachel Roche
- Blood Safety, Hepatitis, Sexually Transmitted Infections (STI) and HIV Division, National Infection Service, Public Health England Colindale, London, UK; The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections at UCL, NIHR, London, UK
| | - Alison D Marshall
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia; Centre for Social Research in Health, UNSW Sydney, Sydney, NSW, Australia
| | - Guillaume Fontaine
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada; Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Anna Conway
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia; Centre for Social Research in Health, UNSW Sydney, Sydney, NSW, Australia
| | - Sahar Bajis
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | | | - Justin Presseau
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - John W Ward
- Coalition for Global Hepatitis Elimination, The Task Force for Global Health, Decatur GA, USA
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia
| | - Gregory J Dore
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 1UD, UK; NIHR Health Protection Research Unit (HPRU) in Behavioural Science and Evaluation, University of Bristol, Bristol, UK
| | - Peter Vickerman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 1UD, UK; NIHR Health Protection Research Unit (HPRU) in Behavioural Science and Evaluation, University of Bristol, Bristol, UK
| | - Jason Grebely
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
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12
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Krekulová L, Damajka T, Krumphanslová Z, Řehák V. Pilot Outreach Program in Remedis-The Promising Step toward HCV Elimination among People Who Inject Drugs. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:501. [PMID: 36612821 PMCID: PMC9819867 DOI: 10.3390/ijerph20010501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/20/2022] [Accepted: 12/21/2022] [Indexed: 06/17/2023]
Abstract
The global effort to eliminate HCV infection requires new approaches to accessing and testing the affected population in a setting with as low of a threshold as possible. The focus should be on socially marginalized people who inject drugs (PWIDs) and who are not willing or able to visit standard medical services. With this vision, we established an outreach service-a testing point in an ambulance in the park in front of the Main Railway Station of the capital city of Prague-to provide bloodborne disease testing and treatment. The service was available every week on Wednesday afternoon. Over the initial two years of our experience, 168 unique people were tested. Of them, 82 (49%) were diagnosed with chronic HCV infection and were eligible for treatment with antivirals. Of these, 24 (29%) initiated antiviral treatment over the study period, and 17 (71%) of these individuals achieved a documented sustained virological response. Offering medical services in PWIDs' neighborhoods helps overcome barriers and increase the chances that they will become patients and begin HCV treatment. The described outcomes appear promising for reaching the vision of linkage to the care of such a hard-to-reach population and can serve as a feasible model of care for further expansion.
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Affiliation(s)
- Laura Krekulová
- Remedis, s.r.o., Vladimírova 10, 140 00 Prague 4, Czech Republic
- 4th Department of Internal Medicine, First Faculty of Medicine, Charles University in Prague, Kateřinská 32, 128 00 Prague 2, Czech Republic
| | - Tomáš Damajka
- Remedis, s.r.o., Vladimírova 10, 140 00 Prague 4, Czech Republic
| | | | - Vratislav Řehák
- Remedis, s.r.o., Vladimírova 10, 140 00 Prague 4, Czech Republic
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13
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Armoon B, Bayani A, Mohammadi R, Ahounbar E, Higgs P. Drug type and high risk behaviors associated with health-care utilization among people who inject drugs: a systematic review and meta-analysis. JOURNAL OF SUBSTANCE USE 2022. [DOI: 10.1080/14659891.2022.2120429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Affiliation(s)
- Bahram Armoon
- Social Determinants of Health Research Center, Saveh University of Medical Sciences, Saveh, Iran
| | - Azadeh Bayani
- Student Research Committee, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Rasool Mohammadi
- Department of Biostatistics and Epidemiology, School of Public Health and Nutrition, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Elaheh Ahounbar
- Orygen, The National Center of Excellence in Youth Mental Health, University of Melbourne, Parkville, Australia
- Center for Youth Mental Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Australia
| | - Peter Higgs
- Department of Public Health, La Trobe University, Melbourne, Australia
- Burnet Institute, Melbourne, Australia
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14
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A Testing Campaign Intervention Consisting of Peer-Facilitated Engagement, Point-of-Care HCV RNA Testing, and Linkage to Nursing Support to Enhance Hepatitis C Treatment Uptake among People Who Inject Drugs: The ETHOS Engage Study. Viruses 2022; 14:v14071555. [PMID: 35891535 PMCID: PMC9316739 DOI: 10.3390/v14071555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/08/2022] [Accepted: 07/14/2022] [Indexed: 11/17/2022] Open
Abstract
This study evaluated HCV treatment initiation among people who inject drugs (PWID) following an intervention of campaign days involving peer connection, point-of-care HCV RNA testing, and linkage to nursing support. ETHOS Engage is an observational cohort study of PWID attending 25 drug treatment clinics and needle and syringe programs in Australia (May 2018–September 2019). Point-of-care results were provided to the nurse, facilitating confirmatory testing and treatment. The study aimed to evaluate treatment uptake and factors associated with treatment at 24 months post-enrolment. There were 317 people with current HCV infection and eligible for treatment (median age 43, 65% male, 15% homeless, 69% receiving opioid agonist treatment, 70% injected in last month). Overall, 15% (47/317), 27% (85/317), 38% (120/317), and 49% (155/317) of people with current HCV infection had initiated treatment at 3-, 6-, 12-, and 24-months following testing, respectively. Homelessness (adjusted hazard ratio (aHR): 0.40; 95% confidence interval: 0.23, 0.71) and incarceration in the past 12 months (vs. never, aHR:0.46; 0.28, 0.76) were associated with decreased treatment initiation in the 24 months post-enrolment. This testing campaign intervention facilitated HCV treatment uptake among PWID. Further interventions are needed to achieve HCV elimination among people experiencing homelessness or incarceration.
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15
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Declining prevalence of current HCV infection and increased treatment uptake among people who inject drugs: The ETHOS Engage study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 105:103706. [DOI: 10.1016/j.drugpo.2022.103706] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 04/05/2022] [Accepted: 04/13/2022] [Indexed: 12/11/2022]
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16
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Evon DM, Hurt CB, Carpenter DM, Rhea SK, Hennessy CM, Zule WA. Substance Use Disorder Treatment Providers' Knowledge and Opinions Toward Testing and Treatment of Chronic Hepatitis C in Rural North Carolina. RURAL MENTAL HEALTH 2022; 46:162-173. [PMID: 35967261 PMCID: PMC9371459 DOI: 10.1037/rmh0000200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Poor access to care has made western North Carolina vulnerable to an outbreak of hepatitis C viral infection (HCV), particularly among persons who inject drugs (PWID). As substance use disorder (SUD) treatment providers could potentially improve linkage to HCV testing and treatment, we sought to understand SUD providers, clinic and client characteristics; referral patterns; HCV knowledge; willingness to participate in additional trainings; and local linkage-to-care pathways for treatment of substance use and HCV. Online survey data were collected from 78 SUD providers serving PWID in eight western rural North Carolina counties. Providers' attitudes toward working with HCV+ clients were very positive. One-third of providers reported a low fund of knowledge regarding HCV, HCV treatment, and financial assistance opportunities. Non-prescribing providers rarely initiated discussions about HCV testing/treatment, but were receptive to training. Respondents indicated that HCV testing and treatment were best delivered at local health departments or primary care clinics but were open to other venues where PWID access care. The vast majority of prescribing and non-prescribing providers expressed interest in obtaining training in HCV treatments, how to obtain HCV medications and topics on advanced liver disease. Data from prescribing and non-prescribing SUD providers suggest opportunities to develop or expand integrated care models for HCV testing/treatment in PWID in rural Appalachian North Carolina.
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Affiliation(s)
- Donna M. Evon
- Division of Gastroenterology & Hepatology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Christopher B. Hurt
- Institute for Global Health & Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Delesha M. Carpenter
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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17
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Dawe J, Wilkinson AL, Asselin J, Carter A, Pedrana A, Traeger MW, Thomas AJ, Curtis M, Cooper M, Howell J, Doyle JS, Hellard ME, Stoové M. Hepatitis C antibody testing among opioid agonist therapy recipients, Victoria, Australia, 2012 to 2020. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 104:103696. [DOI: 10.1016/j.drugpo.2022.103696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 04/01/2022] [Accepted: 04/07/2022] [Indexed: 10/18/2022]
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18
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Carson JM, Hajarizadeh B, Hanson J, O'Beirne J, Iser D, Read P, Balcomb A, Davies J, Doyle JS, Yee J, Martinello M, Marks P, Matthews GV, Dore GJ. Retreatment for hepatitis C virus direct acting antiviral therapy virological failure in primary and tertiary settings: the REACH-C cohort. J Viral Hepat 2022; 29:661-676. [PMID: 35583922 PMCID: PMC9542502 DOI: 10.1111/jvh.13705] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 04/29/2022] [Accepted: 05/04/2022] [Indexed: 12/12/2022]
Abstract
Virological failure occurs in a small proportion of people treated for hepatitis C virus (HCV) with direct-acting antiviral (DAA) therapies. This study assessed retreatment for virological failure in a large real-world cohort. REACH-C is an Australian observational study (n=10843) evaluating treatment outcomes of sequential DAA initiations across 33 health services between March 2016 to June 2019. Virological failure retreatment data were collected until October 2020. Of 408 people with virological failure (81% male; median age 53; 38% cirrhosis; 56% genotype 3), 213 (54%) were retreated once; 15 were retreated twice. A range of genotype specific and pangenotypic DAAs were used to retreat virological failure in primary (n=56) and tertiary (n=157) settings. Following sofosbuvir/velpatasvir/voxilaprevir availability in 2019, the proportion retreated in primary care increased from 21% to 40% and median time to retreatment initiation declined from 294 to 152 days. Per-protocol (PP) sustained virological response (SVR12) was similar for people retreated in primary and tertiary settings (80% vs 81%; p=1.000). In regression analysis, sofosbuvir/velpatasvir/voxilaprevir (vs. other regimens) significantly decreased likelihood of second virological failure (PP SVR12 88% vs. 77%; adjusted odds ratio [AOR] 0.29; 95%CI 0.11-0.81); cirrhosis increased likelihood (PP SVR12 69% vs. 91%; AOR 4.26; 95%CI 1.64-11.09). Indigenous Australians had lower likelihood of retreatment initiation (AOR 0.36; 95%CI 0.15-0.81). Treatment setting and prescriber type were not associated with retreatment initiation or outcome. Virological failure can be effectively retreated in primary care. Expanded access to simplified retreatment regimens through decentralised models may increase retreatment uptake and reduce HCV-related mortality.
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Affiliation(s)
| | | | - Josh Hanson
- The Kirby InstituteUNSW SydneySydneyNew South WalesAustralia
- Cairns and Hinterland Hospital and Health ServiceCairnsQueenslandAustralia
| | - James O'Beirne
- Sunshine Coast Hospital and Health ServiceSunshine CoastQueenslandAustralia
- University of the Sunshine CoastSunshine CoastQueenslandAustralia
| | - David Iser
- Scope GastroenterologyMelbourneVictoriaAustralia
| | - Phillip Read
- Kirketon Road CentreSydneyNew South WalesAustralia
| | - Anne Balcomb
- Prince Street MedicalOrangeNew South WalesAustralia
| | - Jane Davies
- Menzies School of Health ResearchDarwinNorthern TerritoryAustralia
- Royal Darwin HospitalDarwinNorthern TerritoryAustralia
| | - Joseph S. Doyle
- Burnet InstituteMelbourneVictoriaAustralia
- Department of Infectious DiseasesThe Alfred and Monash UniversityMelbourneVictoriaAustralia
| | - Jasmine Yee
- The Kirby InstituteUNSW SydneySydneyNew South WalesAustralia
| | | | - Philippa Marks
- The Kirby InstituteUNSW SydneySydneyNew South WalesAustralia
| | - Gail V. Matthews
- The Kirby InstituteUNSW SydneySydneyNew South WalesAustralia
- St Vincent's HospitalSydneyNew South WalesAustralia
| | - Gregory J. Dore
- The Kirby InstituteUNSW SydneySydneyNew South WalesAustralia
- St Vincent's HospitalSydneyNew South WalesAustralia
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19
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Cunningham EB, Wheeler A, Hajarizadeh B, French CE, Roche R, Marshall AD, Fontaine G, Conway A, Valencia BM, Bajis S, Presseau J, Ward JW, Degenhardt L, Dore GJ, Hickman M, Vickerman P, Grebely J. Interventions to enhance testing, linkage to care, and treatment initiation for hepatitis C virus infection: a systematic review and meta-analysis. Lancet Gastroenterol Hepatol 2022; 7:426-445. [PMID: 35303490 DOI: 10.1016/s2468-1253(21)00471-4] [Citation(s) in RCA: 51] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 12/08/2021] [Accepted: 12/08/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Despite the goal set by WHO to eliminate hepatitis C virus (HCV) as a public health threat, uptake of HCV testing and treatment remains low. To achieve this target, evidence-based interventions are needed to address the barriers to care for people with, or at risk of, HCV infection. We aimed to assess the efficacy of interventions to improve HCV antibody testing, HCV RNA testing, linkage to HCV care, and treatment initiation. METHODS In this systematic review and meta-analysis, we searched MEDLINE (PubMed), Scopus, Web of Science, the Cochrane Central Register of Controlled Trials, and PsycINFO without language restrictions for reports published between database inception and July 21, 2020, assessing the following primary outcomes: HCV antibody testing; HCV RNA testing; linkage to HCV care; and direct-acting antiviral treatment initiation. We also searched key conference abstracts. We included randomised and non-randomised studies assessing non-pharmaceutical interventions that included a comparator or control group. Studies were excluded if they enrolled only paediatric populations (aged <18 years) or if they conducted the intervention in a different health-care setting to that of the control or comparator. Authors were contacted to clarify study details and to obtain additional population-level data. Data were extracted from the records identified into a pre-piloted and standardised data extraction form and a random-effects meta-analysis was used to pool the effects of the interventions on study outcomes. This study is registered in PROSPERO, CRD42020178035. FINDINGS Of 15 342 unique records identified, 142 were included, which reported on 148 unique studies (47 randomised controlled trials and 101 non-randomised studies). Medical chart reminders, provider education, and point-of-care antibody testing significantly improved at least three study outcomes compared with a comparator or control. Interventions that simplified HCV testing, including dried blood spot testing, point-of-care antibody testing, reflex RNA testing, and opt-out screening, significantly improved testing outcomes compared with a comparator or control. Enhanced patient and provider support through patient education, provider care coordination, and provider education also significantly improved testing outcomes compared with a comparator or control. Integrated care and patient navigation or care coordination significantly improved linkage to care and the uptake of direct-acting antiviral treatment compared with a comparator or control. INTERPRETATION Several interventions to improve HCV care that address several key barriers to HCV care were identified. New models of HCV care must be designed and implemented to address the barriers faced by the population of interest. Further high-quality research, including rigorously designed randomised studies, is still needed in key populations. FUNDING None.
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Affiliation(s)
| | - Alice Wheeler
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | | | - Clare E French
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; National Institute for Health Research Health Protection Research Unit in Behavioural Science and Evaluation, University of Bristol, Bristol, UK
| | - Rachel Roche
- Blood Safety, Hepatitis, Sexually Transmitted Infections and HIV Division, National Infection Service, Public Health England Colindale, London, UK; National Institute for Health Research Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections at UCL, National Institute for Health Research, London, UK
| | - Alison D Marshall
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia; Centre for Social Research in Health, UNSW Sydney, Sydney, NSW, Australia
| | - Guillaume Fontaine
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Anna Conway
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia; Centre for Social Research in Health, UNSW Sydney, Sydney, NSW, Australia
| | | | - Sahar Bajis
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Justin Presseau
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - John W Ward
- Coalition for Global Hepatitis Elimination, The Task Force for Global Health, Decatur, GA, USA
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia
| | - Gregory J Dore
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Peter Vickerman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jason Grebely
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
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20
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Whiteley D, Speakman EM, Elliott L, Jarvis H, Davidson K, Quinn M, Flowers P. Developing a primary care-initiated hepatitis C treatment pathway in Scotland: a qualitative study. Br J Gen Pract 2022; 72:BJGP.2022.0044. [PMID: 35606160 PMCID: PMC9423057 DOI: 10.3399/bjgp.2022.0044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/10/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The ease of contemporary hepatitis C virus (HCV) therapy has prompted a global drive towards simplified and decentralised treatment pathways. In some countries, primary care has become an integral component of community-based HCV treatment provision. In the UK, however, the role of primary care providers remains largely focused on testing and diagnosis alone. AIM To develop a primary care-initiated HCV treatment pathway for people who use drugs, and recommend theory-informed interventions to help embed that pathway into practice. DESIGN AND SETTING A qualitative study informed by behaviour change theory. Semi-structured interviews were undertaken with key stakeholders (n = 38) primarily from two large conurbations in Scotland. METHOD Analysis was three-stage. First, a broad pathway structure was outlined and then sequential pathway steps were specified; second, thematic data were aligned to pathway steps, and significant barriers and enablers were identified; and, third, the Theoretical Domains Framework and Behaviour Change Wheel were employed to systematically develop ideas to enhance pathway implementation, which stakeholders then appraised. RESULTS The proposed pathway structure spans broad, overarching challenges to primary care-initiated HCV treatment. The theory-informed recommendations align with influences on different behaviours at key pathway steps, and focus on relationship building, routinisation, education, combating stigmas, publicising the pathway, and treatment protocol development. CONCLUSION This study provides the first practicable pathway for primary care-initiated HCV treatment in Scotland, and provides recommendations for wider implementation in the UK. It positions primary care providers as an integral part of community-based HCV treatment, providing workable solutions to ingrained barriers to care.
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Affiliation(s)
- David Whiteley
- Department of Nursing and Community Health, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow
| | | | - Lawrie Elliott
- Department of Nursing and Community Health, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow
| | - Helen Jarvis
- Newcastle University, Newcastle; GP partner, the Bellingham Practice, Northumberland
| | | | | | - Paul Flowers
- School of Psychological Sciences and Health, University of Strathclyde, Glasgow
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21
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Harney BL, Whitton B, Paige E, Brereton R, Weiss R, Membrey D, Wade AJ, Iser D, Kemp W, Roberts SK, Spelman T, Sacks-Davis R, Hellard ME, Doyle JS. A multi-site, nurse-coordinated hepatitis C model of care in primary care and community services in Melbourne, Australia. Liver Int 2022; 42:522-531. [PMID: 34821021 DOI: 10.1111/liv.15107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 11/10/2021] [Accepted: 11/18/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Hepatitis C virus (HCV) treatment through primary care and community-based services will be a critical component of HCV elimination. We evaluated a nurse-coordinated programme providing care across eight sites and analysed progression through the HCV care cascade. METHODS People-accessing services from six primary care clinics, a homeless crisis accommodation provider and a mental health service were directly referred to nurses or engaged by nurses during regular clinic visits. Nurses supported HCV testing, treatment and follow-up. The prescription was provided by affiliated clinicians. Logistic regression was used to examine factors associated with treatment commencement and sustained virological response (SVR) testing. RESULTS Of 640 people referred to and/or engaged by the nurses from January 2017 to July 2019, 518 had an HCV RNA test of whom 381 (74%) were HCV RNA positive. Treatment was commenced by 281 (74%) people of whom 161 had an SVR test, 157 (97.5%) were cured. Opioid agonist therapy was associated with treatment commencement (aOR 2.68, 95% CI 1.48-4.88). People who were homeless/unstably housed were less likely to commence treatment (aOR 0.45, 95% CI 0.23-0.87). Treatment prescription from a specialist (aOR 2.39, 95% CI 1.20-4.74) and recent injection drug use (<6 months) (aOR 2.15, 95% CI 1.07-4.31) was associated with SVR testing. CONCLUSION A nurse-coordinated model of care led to high levels of HCV treatment uptake and cure amongst people attending primary care and community services. More tailored models of care may be beneficial for people who are homeless or have unstable housing. These results support primary care and community-based hepatitis C treatment.
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Affiliation(s)
- Brendan L Harney
- Department of Infectious Diseases, Alfred Health & Monash University, Melbourne, Australia.,Disease Elimination Program, Burnet Institute, Melbourne, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Bradley Whitton
- Department of Infectious Diseases, Alfred Health & Monash University, Melbourne, Australia
| | - Emma Paige
- Department of Infectious Diseases, Alfred Health & Monash University, Melbourne, Australia
| | - Rebecca Brereton
- St Kilda Road Clinic & South City Clinic, Alfred Community Mental & Addiction Health, Melbourne, Australia
| | | | | | - Amanda J Wade
- Disease Elimination Program, Burnet Institute, Melbourne, Australia.,Department of Infectious Diseases, Barwon Health, Geelong, Australia
| | - David Iser
- Department of Infectious Diseases, Alfred Health & Monash University, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
| | - William Kemp
- Department of Gastroenterology, Alfred Health, Melbourne, Australia.,Department of Medicine, Monash University, Melbourne, Australia
| | - Stuart K Roberts
- Department of Gastroenterology, Alfred Health, Melbourne, Australia.,Department of Medicine, Monash University, Melbourne, Australia
| | - Tim Spelman
- Disease Elimination Program, Burnet Institute, Melbourne, Australia
| | - Rachel Sacks-Davis
- Disease Elimination Program, Burnet Institute, Melbourne, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Margaret E Hellard
- Department of Infectious Diseases, Alfred Health & Monash University, Melbourne, Australia.,Disease Elimination Program, Burnet Institute, Melbourne, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Doherty Institute and School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Joseph S Doyle
- Department of Infectious Diseases, Alfred Health & Monash University, Melbourne, Australia.,Disease Elimination Program, Burnet Institute, Melbourne, Australia
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22
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Yee J, Carson JM, Hajarizadeh B, Hanson J, O'Beirne J, Iser D, Read P, Balcomb A, Doyle JS, Davies J, Martinello M, Marks P, Dore GJ, Matthews GV. High Effectiveness of Broad Access Direct-Acting Antiviral Therapy for Hepatitis C in an Australian Real-World Cohort: The REACH-C Study. Hepatol Commun 2022; 6:496-512. [PMID: 34729957 PMCID: PMC8870316 DOI: 10.1002/hep4.1826] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 07/29/2021] [Accepted: 08/24/2021] [Indexed: 12/15/2022] Open
Abstract
Australia was one of the first countries with unrestricted access to government subsidized direct-acting antiviral (DAA) therapy for adults with chronic hepatitis C virus. This study assessed real-world DAA treatment outcomes across a diverse range of Australian clinical services and evaluated factors associated with successful treatment and loss to follow-up. Real-world Effectiveness of Antiviral therapy in Chronic Hepatitis C (REACH-C) consisted a national observational cohort of 96 clinical services including specialist clinics and less traditional settings such as general practice. Data were obtained on consecutive individuals who commenced DAAs from March 2016 to June 2019. Effectiveness was assessed by sustained virological response ≥12 weeks following treatment (SVR) using intention-to-treat (ITT) and per-protocol (PP) analyses. Within REACH-C, 10,843 individuals initiated DAAs (male 69%; ≥50 years 52%; cirrhosis 22%). SVR data were available in 85% (9,174 of 10,843). SVR was 81% (8,750 of 10,843) by ITT and 95% (8,750 of 9,174) by PP. High SVR (≥92%) was observed across all service types and participant characteristics. Male gender (adjusted odds ratio [aOR] 0.56, 95% confidence interval [CI] 0.43-0.72), cirrhosis (aOR 0.52, 95% CI 0.41-0.64), recent injecting drug use (IDU; aOR 0.64, 95% CI 0.46-0.91) and previous DAA treatment (aOR 0.50, 95% CI 0.28-0.90) decreased the likelihood of achieving SVR. Multiple factors modified the likelihood of loss to follow-up including IDU ± opioid agonist therapy (OAT; IDU only: aOR 1.75, 95% CI 1.44-2.11; IDU + OAT: aOR 1.39, 95% CI 1.11-1.74; OAT only, aOR 1.36; 95% CI 1.13-1.68) and age (aOR 0.97, 95% CI 0.97-0.98). Conclusion: Treatment response was high in a diverse population and through a broad range of services following universal access to DAA therapy. Loss to follow-up presents a real-world challenge. Younger people who inject drugs were more likely to disengage from care, requiring innovative strategies to retain them in follow-up.
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Affiliation(s)
- Jasmine Yee
- The Kirby InstituteUNSW AustraliaSydneyNSWAustralia
| | | | | | - Joshua Hanson
- The Kirby InstituteUNSW AustraliaSydneyNSWAustralia.,Cairns HospitalCairnsQLDAustralia
| | - James O'Beirne
- Sunshine Coast University HospitalSunshine CoastQLDAustralia
| | - David Iser
- Scope GastroenterologyMelbourneVICAustralia
| | | | | | - Joseph S Doyle
- Burnet InstituteMelbourneVICAustralia.,The Alfred and Monash UniversityDepartment of Infectious DiseasesMelbourneVICAustralia
| | - Jane Davies
- Royal Darwin HospitalDarwinAustralia.,Menzies School of Health ResearchDarwinAustralia
| | - Marianne Martinello
- The Kirby InstituteUNSW AustraliaSydneyNSWAustralia.,Blacktown Mount Druitt HospitalBlacktownNSWAustralia.,St Vincent's HospitalSydneyNSWAustralia
| | | | - Gregory J Dore
- The Kirby InstituteUNSW AustraliaSydneyNSWAustralia.,St Vincent's HospitalSydneyNSWAustralia
| | - Gail V Matthews
- The Kirby InstituteUNSW AustraliaSydneyNSWAustralia.,St Vincent's HospitalSydneyNSWAustralia
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23
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Ortiz-Paredes D, Amoako A, Lessard D, Engler K, Lebouché B, Klein MB. Potential interventions to support HCV treatment uptake among HIV co-infected people in Canada: Perceptions of patients and health care providers. CANADIAN LIVER JOURNAL 2022; 5:14-30. [DOI: 10.3138/canlivj-2021-0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 08/28/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND: Increasing direct-acting antiviral (DAA) treatment uptake is key to eliminating HCV infection as a public health threat in Canada. People living with human immunodeficiency virus (HIV) and hepatitis C (HCV) co-infection face barriers to HCV treatment initiation. We sought to identify interventions that could support HCV treatment initiation based on patient and HCV care provider perspectives. METHODS: Eleven people living with HIV with a history of HCV infection and 12 HCV care providers were recruited for this qualitative descriptive study. Participants created ranked-ordered lists of potential interventions during nominal groups ( n = 4) and individual interviews ( n = 6). Following the nominal group technique, transcripts and intervention lists underwent thematic analysis and ranking scores were merged to create consolidated and prioritized lists from patient and provider perspectives. RESULTS: Patient participants identified a total of eight interventions. The highest-ranked interventions were multidisciplinary clinics, HCV awareness campaigns and patient education, nurse- or pharmacist-led care, peer involvement, and more and better-prepared health professionals. Provider participants identified 11 interventions. The highest-ranked were mobile outreach, DAA initiation at pharmacies, a simplified process of DAA prescription, integration of primary and specialist care, and patient-centred approaches. CONCLUSION: Participants proposed alternatives to hospital-based specialist HCV care, which require increasing capacity for nurses, pharmacists, primary care providers, and peers to have more direct roles in HCV treatment provision. They also identified the need for structural changes and educational initiatives. In addition to optimizing HCV care, these interventions might result in broader benefits for the health of HIV–HCV co-infected people.
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Affiliation(s)
- David Ortiz-Paredes
- Centre for Outcome Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Afia Amoako
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - David Lessard
- Centre for Outcome Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Kim Engler
- Centre for Outcome Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Bertrand Lebouché
- Centre for Outcome Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada
- Department of Medicine, Division of Infectious Diseases/Chronic Viral Illness Service, Glen site, McGill University Health Centre, Montreal, Quebec, Canada
| | - Marina B Klein
- Department of Medicine, Division of Infectious Diseases/Chronic Viral Illness Service, Glen site, McGill University Health Centre, Montreal, Quebec, Canada
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24
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Von den Hoff DW, Berden FAC, Drenth JPH, Schellekens AFA. Implementation of a decentralized hepatitis C care pathway for people who use drugs in Dutch addiction care. Study protocol for the Hepatitis C: chain of addiction care (CAC) project. Addict Sci Clin Pract 2022; 17:67. [PMID: 36451175 PMCID: PMC9710026 DOI: 10.1186/s13722-022-00350-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 11/16/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND People who use drugs (PWUD) are at high risk for hepatitis C virus (HCV) infection and its complications. Given the high prevalence rate of HCV in PWUD, the World Health Organization (WHO) emphasizes PWUD as a target population for HCV elimination. The introduction of pangenotypic direct acting antivirals (DAAs) greatly simplifies HCV treatment, which encourages integration of HCV treatment in primary care. Facilitating low threshold HCV care for PWUD by implementing decentralized models is crucial for HCV elimination. AIMS With this study we aim to (1) eliminate 90% of identified HCV infections in Dutch addiction care, using a decentralized PWUD-HCV care model, and (2) identify facilitators and barriers for successful implementation of the model using interviews. METHODS We will perform a multicenter mixed-method study on HCV treatment in addiction care. In a prospective observational study we will examine HCV-related outcomes in PWUD receiving HCV treatment as part of addiction care. The primary outcome is viral elimination, defined as percentage of identified HCV positive patients cured with DAAs. In parallel, we will perform a qualitative study to explore facilitators and barriers for implementation of fully decentralized HCV-PWUD care. We will interview addiction care professionals and board members about their experience with HCV-care as part of addiction care. DISCUSSION This study will show effectiveness of integration of HCV care within addiction care, and provide insight in facilitators and barriers to implement integrated HCV-addiction care. The results will provide recommendations for implementation and maintenance of the decentralized HCV pathway, which can facilitate scaling-up to contribute to reaching WHO HCV elimination goals. Trial registration NCT05401136.
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Affiliation(s)
- Daan W. Von den Hoff
- grid.10417.330000 0004 0444 9382Department of Gastroenterology and Hepatology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Floor A. C. Berden
- grid.10417.330000 0004 0444 9382Department of Gastroenterology and Hepatology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Joost P. H. Drenth
- grid.10417.330000 0004 0444 9382Department of Gastroenterology and Hepatology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Arnt F. A. Schellekens
- grid.10417.330000 0004 0444 9382Department of Psychiatry, Cognition and Behaviour, Radboud University Medical Center, Netherlands and Nijmegen Institute for Scientist-Practitioners in Addiction and Donders Institute for Brain, Radboud University, Nijmegen, The Netherlands
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25
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Effectiveness of treatment for hepatitis C virus reinfection following direct acting antiviral therapy in the REACH-C cohort. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 96:103422. [PMID: 34426040 DOI: 10.1016/j.drugpo.2021.103422] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 07/07/2021] [Accepted: 08/06/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Direct acting antiviral (DAA) therapy is highly effective for hepatitis C virus (HCV) infection, but reinfection following treatment may compromise benefits of cure. This study assessed the real-world effectiveness of treatment for reinfection. METHODS Real-world effectiveness of antiviral therapy in chronic hepatitis C (REACH-C) is an observational study evaluating treatment outcomes following sequential DAA initiations across 33 health services in Australia between March 2016-June 2019. Reinfection was defined by post-treatment genotype switch or HCV viraemia after sustained virologic response (SVR12). RESULTS Of the 10,843 individuals initiating DAA therapy post-treatment viraemia was reported in 526 of whom 99 were reinfections. Treatment for reinfection occurred in 88 individuals. In those with available treatment outcomes, SVR12 was similar to initial treatment in the overall REACH-C cohort (95% vs 95%; p = 0.745) and comparable across primary, tertiary, and prison settings. Classifying unknown treatment outcomes as failures, SVR12 for treatment of reinfection was lower than initial treatment in REACH-C (67% vs 81%; p = 0.002), due to higher lost to follow-up. CONCLUSIONS Treatment of reinfection is highly effective and can be delivered in non-specialist settings. Access to treatment for reinfection in high-risk populations is crucial to HCV elimination.
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26
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Tsui JI, Barry MP, Austin EJ, Sweek EW, Tung E, Hansen RN, Ninburg M, Scott JD, Glick SN, Williams EC. 'Treat my whole person, not just my condition': qualitative explorations of hepatitis C care delivery preferences among people who inject drugs. Addict Sci Clin Pract 2021; 16:52. [PMID: 34384494 PMCID: PMC8358259 DOI: 10.1186/s13722-021-00260-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 08/03/2021] [Indexed: 12/20/2022] Open
Abstract
Background The advent of direct-acting antivirals (DAAs)—a form of hepatitis C (HCV) treatment associated with shorter treatment course and greater efficacy—offers an unprecedented opportunity to eliminate HCV, but only if care delivery systems are developed to extend treatment to people who inject drugs (PWID). To support the design of a community-pharmacy program, we explored perspectives of PWID with chronic HCV with regard to barriers, motivators, preferences, and prior experiences related to HCV treatment and pharmacists. Methods We conducted semi-structured interviews with people living with HCV who reported active injection drug use. Participants were recruited from local community service and clinical organizations in the Seattle, Washington region, and focus groups and interviews were conducted in-person or via phone/video-conference. Rapid Assessment Process was used to analyze qualitative data. Dual coders used structured templates to summarize findings and engaged in iterative review to identify themes. Results Among the 40 participants, 65% were male, 52.5% were white, and 80% were not stably housed. On average, participants had been injecting drugs for 14 years and living with HCV for 6 years. Analyses revealed 3 themes: (1) limited knowledge regarding HCV and DAA treatments; (2) barriers/motivators for receiving treatment included fear of side effects, prior stigmatizing behaviors from physicians, and desire to protect relatives and the PWID community from HCV transmission; and (3) preferences for HCV care delivery, including a need for person-centered, low-barrier, and collaborative treatment integrated with other care (e.g. primary care and addiction treatment) for PWID. Participants were generally receptive to a community-pharmacy model for HCV treatment, but prior interactions with pharmacists were mixed and there were some concerns expressed that care delivered by pharmacists would not be equivalent to that of physicians. Conclusions Even in the direct-acting antivirals era, people who inject drugs still face major barriers to hepatitis C treatment which may be reduced by providing low-barrier points of access for care through pharmacists. Key recommendations for community-pharmacy design included providing care team training to reduce stigma and ensuring care team structures and culture target PWID-specific needs for education and engagement. Supplementary Information The online version contains supplementary material available at 10.1186/s13722-021-00260-8.
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Affiliation(s)
- Judith I Tsui
- Department of Medicine, Division of General Internal Medicine, University of Washington, Box 359780 - 325 9th Avenue, Seattle, WA, 98104, USA.
| | - Michael P Barry
- Department of Epidemiology, University of Washington, Seattle, WA, USA.,HIV/STD Program, Public Health - Seattle & King County, Seattle, WA, USA
| | - Elizabeth J Austin
- Department of Surgery, University of Washington, Seattle, WA, USA.,Department of Health Services, University of Washington, Seattle, WA, USA
| | - Elsa W Sweek
- Department of Surgery, University of Washington, Seattle, WA, USA.,Department of Health Services, University of Washington, Seattle, WA, USA.,Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research & Development, VA Puget Sound, Seattle, WA, USA
| | - Elyse Tung
- Department of Pharmacy, University of Washington, Seattle, WA, USA.,Kelley-Ross Pharmacy Group, Seattle, WA, USA
| | - Ryan N Hansen
- Department of Pharmacy, University of Washington, Seattle, WA, USA.,Kelley-Ross Pharmacy Group, Seattle, WA, USA
| | | | - John D Scott
- Department of Medicine, Division of General Internal Medicine, University of Washington, Box 359780 - 325 9th Avenue, Seattle, WA, 98104, USA
| | - Sara N Glick
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA.,HIV/STD Program, Public Health - Seattle & King County, Seattle, WA, USA
| | - Emily C Williams
- Department of Health Services, University of Washington, Seattle, WA, USA.,Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research & Development, VA Puget Sound, Seattle, WA, USA
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27
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Bartlett SR, Wong S, Yu A, Pearce M, MacIsaac J, Nouch S, Adu P, Wilton J, Samji H, Clementi E, Velasquez H, Jeong D, Binka M, Alvarez M, Wong J, Buxton J, Krajden M, Janjua NZ. The impact of current opioid agonist therapy on hepatitis C virus treatment initiation among people who use drugs from in the DAA era: A population-based study. Clin Infect Dis 2021; 74:575-583. [PMID: 34125883 DOI: 10.1093/cid/ciab546] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Evidence that opioid agonist therapy (OAT) is associated with increased odds of hepatitis C virus (HCV) treatment initiation among people who use drugs (PWUD) is emerging. The objective of this study was to determine the association between current OAT and HCV treatment initiation among PWUD in a population-level linked administrative dataset. METHODS The British Columbia (BC) Hepatitis Testers Cohort was used for this study, which includes all people tested for or diagnosed with HCV in BC, linked to medical visits, hospitalizations, laboratory, prescription drug, and mortality data from 1992 until 2019. PWUD with injecting drug use or opioid use disorder and chronic HCV infection were identified for inclusion in this study. HCV treatment initiation was the main outcome, and subdistribution proportional hazards modeling was used to assess the relationship with current OAT. RESULTS 13,803 PWUD with chronic HCV were included in this study. Among those currently on OAT at the end of the study period, 47% (2,704/5,770) had started HCV treatment, whereas 22% (1778/8033) of those not currently on OAT has started HCV treatment .. Among PWUD with chronic HCV infection, current OAT was associated with higher likelihood of HCV treatment initiation in time to event analysis (adjusted hazard ratio 1.84 [95%CI, 1.50, 2.26]). CONCLUSIONS Current OAT was associated with a higher likelihood of HCV treatment initiation. However, many PWUD with HCV currently receiving OAT have yet to receive HCV treatment. Enhanced integration between substance use care and HCV treatment is needed to improve the overall health of PWUD.
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Affiliation(s)
- Sofia R Bartlett
- British Columbia Centre for Disease Control, Vancouver, BC, Canada.,Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Stanley Wong
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Amanda Yu
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Margo Pearce
- British Columbia Centre for Disease Control, Vancouver, BC, Canada.,School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Julia MacIsaac
- Division of Addiction Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Susan Nouch
- Department of Family and Community Practice, Vancouver Coastal Health, Vancouver, BC, Canada.,Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Prince Adu
- British Columbia Centre for Disease Control, Vancouver, BC, Canada.,School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - James Wilton
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Hasina Samji
- British Columbia Centre for Disease Control, Vancouver, BC, Canada.,Faculty of Health Sciences, Simon Fraser University, Vancouver, BC, Canada
| | - Emilia Clementi
- British Columbia Centre for Disease Control, Vancouver, BC, Canada.,School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Hector Velasquez
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Dahn Jeong
- British Columbia Centre for Disease Control, Vancouver, BC, Canada.,School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Mawuena Binka
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Maria Alvarez
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Jason Wong
- British Columbia Centre for Disease Control, Vancouver, BC, Canada.,School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jane Buxton
- British Columbia Centre for Disease Control, Vancouver, BC, Canada.,School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Mel Krajden
- British Columbia Centre for Disease Control, Vancouver, BC, Canada.,Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Naveed Z Janjua
- British Columbia Centre for Disease Control, Vancouver, BC, Canada.,School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
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28
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Harney BL, Brereton R, Whitton B, Pietrzak D, Paige E, Roberts SK, Birks S, Saraf S, Hellard ME, Doyle JS. Hepatitis C treatment in a co-located mental health and alcohol and drug service using a nurse-led model of care. J Viral Hepat 2021; 28:771-778. [PMID: 33599036 DOI: 10.1111/jvh.13487] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 02/01/2021] [Indexed: 12/13/2022]
Abstract
Hepatitis C virus (HCV) is more prevalent among people with experience of severe mental illness compared to the general population, due in part to higher levels of injecting drug use. Delivering HCV care through mental health services may reduce barriers to care and improve outcomes. A nurse-led HCV program was established in a co-located mental health and addiction service in Melbourne, Australia. People with a history of injecting drug use, including current use, were referred for HCV testing by nurses, with support provided on-site from a general practitioner and remotely from infectious disease and hepatology specialists. A nurse practitioner, general practitioner or specialists were able to prescribe HCV treatment. One-hundred and thirty people were referred to the nurse-led service, among whom 112 (86%) were engaged in care. Of those 112, 84 (75%) were found to have detectable HCV RNA, 70 (83%) commenced treatment; 28 (40%) prescriptions were nurse initiated, 19 (27%) were general practitioner initiated and 20 (29%) were prescribed from hospital clinics or elsewhere. All people with an SVR result (48/70) achieved HCV cure (intention to treat SVR 69%, per-protocol SVR 100%). Treatment commencement was highest among people prescribed opioid agonist therapy (28/29, 96%) compared to those who were not (18/26, 69%). In conclusion, a nurse-led, HCV service for people with severe mental illness including pathways to specialist support when needed can achieve high treatment uptake and cure. Further implementation work is required to improve treatment uptake, particularly among people not prescribed opioid agonist therapy, and to improve follow-up for SVR testing.
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Affiliation(s)
- Brendan L Harney
- Department of Infectious Diseases, Alfred Health and Monash University, Melbourne, Vic, Australia.,Disease Elimination Program, Burnet Institute, Melbourne, Vic, Australia
| | - Rebecca Brereton
- St Kilda Road & Southcity Clinic, Alfred Community Mental & Addiction Health, Melbourne, Vic, Australia
| | - Bradley Whitton
- Department of Infectious Diseases, Alfred Health and Monash University, Melbourne, Vic, Australia
| | - Danusia Pietrzak
- St Kilda Road & Southcity Clinic, Alfred Community Mental & Addiction Health, Melbourne, Vic, Australia
| | - Emma Paige
- Department of Infectious Diseases, Alfred Health and Monash University, Melbourne, Vic, Australia
| | - Stuart K Roberts
- Department of Gastroenterology, Alfred Health, Melbourne, Vic, Australia.,Department of Medicine, Monash University, Melbourne, Vic, Australia
| | - Susanne Birks
- St Kilda Road & Southcity Clinic, Alfred Community Mental & Addiction Health, Melbourne, Vic, Australia
| | - Sudeep Saraf
- St Kilda Road & Southcity Clinic, Alfred Community Mental & Addiction Health, Melbourne, Vic, Australia
| | - Margaret E Hellard
- Department of Infectious Diseases, Alfred Health and Monash University, Melbourne, Vic, Australia.,Disease Elimination Program, Burnet Institute, Melbourne, Vic, Australia
| | - Joseph S Doyle
- Department of Infectious Diseases, Alfred Health and Monash University, Melbourne, Vic, Australia.,Disease Elimination Program, Burnet Institute, Melbourne, Vic, Australia
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29
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Amoako A, Ortiz-Paredes D, Engler K, Lebouché B, Klein MB. Patient and provider perceived barriers and facilitators to direct acting antiviral hepatitis C treatment among priority populations in high income countries: A knowledge synthesis. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 96:103247. [PMID: 33853727 DOI: 10.1016/j.drugpo.2021.103247] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 03/19/2021] [Accepted: 03/25/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Direct acting antivirals (DAAs) have increased cure rates for hepatitis C virus (HCV) infection; however, there are several obstacles to the uptake of DAAs in populations where substance use contributes to HCV risk. This synthesis aimed to identify the patient and provider perceived barriers and facilitators to DAA treatment initiation in key patient subgroups-people who inject drugs (PWID), men who have sex with men (MSM), and Indigenous people. METHODS We systematically searched seven databases and conducted a gray literature search for studies that qualitatively explored patient and provider perceived barriers and facilitators to DAA treatment in our populations of interest. Selected studies were published after 2013 when second generation DAAs became available. The titles, abstracts, and subsequently full texts were screened by two independent reviewers and critically appraised. Barriers and facilitators to DAA treatment uptake were then extracted and thematically synthesized. RESULTS 2144 titles and abstracts were identified and screened; 29 full texts were subsequently reviewed. Twelve qualitative studies were finally included. Among providers, perceived barriers to DAA treatment uptake included lack of resources and lack of provider knowledge on HCV while facilitators to treatment provision included simplicity of DAA regimens and professional identity as a doctor to advocate for patients. Among patients, perceived barriers to treatment uptake included current drug use, concerns about side effects of DAAs, stigma, gaps in community care, competing social responsibilities and mental health issues while facilitators included having a trustworthy provider and access to multidisciplinary HCV care. CONCLUSION Despite simplicity of DAAs, many structural barriers to optimal HCV care continue to be experienced by patients and providers. In highlighting nuanced patient and provider perceived barriers and facilitators, this review underscores the need to involve participatory methods in the design and evaluation of interventions to best improve access to care.
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Affiliation(s)
- Afia Amoako
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, 1020 Pine Avenue West Montreal, Quebec, H3A 1A2, Canada.
| | - David Ortiz-Paredes
- Centre for Outcomes Research & Evaluation, Research Institute of the McGill University Health Centre, 5252 boul. de Maisonneuve Montreal, H4A 3S5, Canada.
| | - Kim Engler
- Centre for Outcomes Research & Evaluation, Research Institute of the McGill University Health Centre, 5252 boul. de Maisonneuve Montreal, H4A 3S5, Canada.
| | - Bertrand Lebouché
- Centre for Outcomes Research & Evaluation, Research Institute of the McGill University Health Centre, 5252 boul. de Maisonneuve Montreal, H4A 3S5, Canada; Department of Family Medicine, McGill University, 5858 Côte-des-Neiges Road Montreal, Quebec, H3S 1Z1, Canada; Department of Medicine, Division of Infectious Diseases/Chronic Viral Illness Service, Glen site, McGill University Health Centre, 1001, Decarie Boulevard - D02.4110, Montreal, Quebec, H4A 3J1, Canada; Canadian Institutes of Health Research Strategy for Patient-Oriented Research (CIHR/SPOR) Mentorship Chair in Innovative Clinical Trials in HIV, Montreal, Canada.
| | - Marina B Klein
- Department of Medicine, Division of Infectious Diseases/Chronic Viral Illness Service, Glen site, McGill University Health Centre, 1001, Decarie Boulevard - D02.4110, Montreal, Quebec, H4A 3J1, Canada; CIHR Canadian HIV Trials Network, 588 - 1081 Burrard Street, Vancouver, British Columbia, V6Z 1Y6, Canada.
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Trooskin SB, Dore G, Kostman J. We Must Do Better: Addressing HCV Treatment Barriers in Persons Who Inject Drugs in the United States. J Infect Dis 2021; 222:S773-S781. [PMID: 33245349 DOI: 10.1093/infdis/jiaa574] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
The opioid epidemic in the United States, along with a lack of adequate harm reduction services, has contributed to a sharp rise in hepatitis C virus (HCV) infections. Despite considerable evidence of the effectiveness of HCV treatment in people who inject drugs (PWID), and recommendations from clinical guidelines to prioritize treatment in PWID, there are multiple barriers to broad uptake of HCV treatment. These barriers exist at the systems level, as well as at the level of medical providers and patients. Interventions to remove treatment barriers in the United States include harm reduction services, simplifying HCV testing algorithms, improved linkage to HCV care services, and application of new treatment models including colocating services at substance use disorder treatment programs. By following the lead of other countries who have addressed the barriers to HCV treatment, the United States has opportunities to do better in addressing the consequences of the opioid epidemic, including chronic HCV infection.
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Affiliation(s)
- Stacey B Trooskin
- Philadelphia FIGHT Community Health Centers, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gregory Dore
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Jay Kostman
- Philadelphia FIGHT Community Health Centers, Philadelphia, Pennsylvania, USA
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Goodyear T, Brown H, Browne AJ, Hoong P, Ti L, Knight R. "I want to get better, but…": identifying the perceptions and experiences of people who inject drugs with respect to evolving hepatitis C virus treatments. Int J Equity Health 2021; 20:81. [PMID: 33740984 PMCID: PMC7977167 DOI: 10.1186/s12939-021-01420-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 03/04/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND The advent of highly tolerable and efficacious direct-acting antiviral (DAA) medications has transformed the hepatitis C virus (HCV) treatment landscape. Yet, people who inject drugs (PWID) - a population with inequitably high rates of HCV and who face significant socio-structural barriers to healthcare access - continue to have disproportionately low rates of DAA uptake. The objective of this study is to explore how PWID with lived experience of HCV perceive and experience DAA treatment, in a setting with universal coverage of these medications since 2018. METHODS Informed by a critical interpretive framework, we thematically analyze data from in-depth, semi-structured interviews conducted between January and June 2018 in Vancouver, Canada, with a purposive sample (n = 56) of PWID at various stages (e.g., pre, peri, post) of DAA treatment. RESULTS The analysis yielded three key themes: (i) life with HCV, (ii) experiences with and perceptions of evolving HCV treatments, and (iii) substance use and the uptake of DAA treatments. First, participants described how health and healthcare conditions, such as the deprioritizing of HCV (e.g., due to: being asymptomatic, healthcare provider inaction, gatekeeping) and catalysts to care (e.g., symptom onset, treatment for co-morbidities) shaped DAA treatment motivation and access. Second, participants described how individual and community-level accounts of evolving HCV treatments, including skepticism following negative experiences with Interferon-based treatment and uncertainty regarding treatment eligibility, negatively influenced willingness and opportunities to access DAAs. Concurrently, participants described how peer and community endorsement of DAAs was positively associated with treatment uptake. Third, participants favoured HCV care that was grounded in harm reduction, which included the integration of DAAs with other substance use-related services (e.g., opioid agonist therapy, HIV care), and which was often contrasted against abstinence-focused care wherein substance use is framed as a contraindication to HCV treatment access. CONCLUSIONS These findings underscore several equity-oriented healthcare service delivery and clinician adaptations that are required to scale up DAAs among PWID living with HCV, including the provision of harm reduction-focused, non-stigmatizing, integrated, and peer-led care that responds to power differentials.
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Affiliation(s)
- Trevor Goodyear
- School of Nursing, University of British Columbia, Vancouver, Canada
- British Columbia Centre on Substance Use, 400-1045 Howe St, V6Z 2A9, Vancouver, BC, Canada
| | - Helen Brown
- School of Nursing, University of British Columbia, Vancouver, Canada
| | - Annette J Browne
- School of Nursing, University of British Columbia, Vancouver, Canada
| | - Peter Hoong
- British Columbia Centre on Substance Use, 400-1045 Howe St, V6Z 2A9, Vancouver, BC, Canada
| | - Lianping Ti
- British Columbia Centre on Substance Use, 400-1045 Howe St, V6Z 2A9, Vancouver, BC, Canada
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Rod Knight
- British Columbia Centre on Substance Use, 400-1045 Howe St, V6Z 2A9, Vancouver, BC, Canada.
- Department of Medicine, University of British Columbia, Vancouver, Canada.
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Whiteley D, Speakman E, Elliott L, Davidson K, Hamilton E, Jarvis H, Quinn M, Flowers P. Provider-related barriers and enablers to the provision of hepatitis C treatment by general practitioners in Scotland: A behaviour change analysis. J Viral Hepat 2021; 28:528-537. [PMID: 33215781 PMCID: PMC7898327 DOI: 10.1111/jvh.13443] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/30/2020] [Accepted: 11/08/2020] [Indexed: 12/16/2022]
Abstract
The ease of direct-acting antiviral (DAA) medications for hepatitis C virus (HCV) has provided an opportunity to decentralize HCV treatment into community settings. However, the role of non-specialist clinicians in community-based pathways has received scant attention to date. This study examined barriers and enablers to expanding the role of general practitioners (GPs) in HCV treatment provision, using simple behaviour change theory as a conceptual framework. A maximum variation sample of 22 HCV treatment providers, GPs and HCV support workers participated in semi-structured interviews. Data were inductively coded, and the resulting codes deductively mapped into three principal components of behaviour change: capability, opportunity and motivation (COM-B). By this process, a number of provider- and systemic-level barriers and enablers were identified. Key barriers included the pre-treatment assessment of liver fibrosis, GP capacity and the 'speciality' of HCV care. Enablers included the simplicity of the drugs, existing GP/patient relationships and the provision of holistic care. In addition to these specific factors, the data also exposed an overarching provider understanding of 'HCV treatment' as triumvirate in nature, incorporating the assessment of liver fibrosis, the provision of holistic support and the treatment of disease. This understanding imposes a further fundamental barrier to GP-led treatment as each of these three components needs to be individually addressed. To enable sustainable models of HCV treatment provision by GPs, a pragmatic re-examination of the 'HCV treatment triumvirate' is required, and a paradigm shift from the 'refer and treat' status quo.
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Affiliation(s)
- David Whiteley
- School of Health and Social CareEdinburgh Napier UniversityEdinburghUK
| | | | - Lawrie Elliott
- Department of Nursing and Community HealthSchool of Health and Life SciencesGlasgow Caledonian UniversityGlasgowUK
| | | | | | - Helen Jarvis
- Population and Health Sciences InstituteNewcastle UniversityNewcastleUK,West Road Medical CentreNewcastleUK
| | | | - Paul Flowers
- School of Psychological Sciences and HealthUniversity of StrathclydeGlasgowUK
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ASSOUMOU SA, SIAN CR, GEBEL CM, LINAS BP, SAMET JH, BERNSTEIN JA. Patients at a drug detoxification center share perspectives on how to increase hepatitis C treatment uptake: A qualitative study. Drug Alcohol Depend 2021; 220:108526. [PMID: 33465604 PMCID: PMC8064807 DOI: 10.1016/j.drugalcdep.2021.108526] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 12/16/2020] [Accepted: 12/19/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND The US opioid crisis is associated with a surge in hepatitis C virus (HCV) infections among persons who inject drugs (PWID), and yet the uptake of HCV curative therapy among PWID is low. PURPOSE To explore potential solutions to overcome barriers to HCV treatment uptake among individuals at a drug detoxification center. METHODS Qualitative study with in-depth interviews and thematic analysis of coded data. RESULTS Patients (N = 24) had the following characteristics: mean age 37 years; 67 % White, 13 % Black, 8 % Latinx, 4 % Native Hawaiian/Pacific Islander, 8 % other; 71 % with a history of injecting drugs. Most patients with a positive HCV test had not pursued treatment due to few perceived immediate consequences from a positive test and possible complications arising in a distant poorly imagined future. Active substance use was a major barrier to HCV treatment uptake because of disruptions to routine activities. In addition, re-infection after treatment was perceived as inevitable. Patients had suggestions to improve HCV treatment uptake: high-intensity wraparound care characterized by frequent interactions with supportive services; same-day/walk-in options; low-barrier access to substance use treatment; assistance with navigating the health care system; attention to immediate needs, such as housing; and the opportunity to select an approach that best fits individual circumstances. CONCLUSIONS Active substance use was a major barrier to treatment initiation. To improve uptake, affected individuals recommended that HCV treatment be integrated within substance use treatment programs. Such a model should incorporate patient education within low-barrier, high-intensity wraparound care, tailored to patients' needs and priorities.
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Affiliation(s)
- Sabrina A. ASSOUMOU
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, USA,Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - Carlos R. SIAN
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, MA, USA
| | | | - Benjamin P. LINAS
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, USA,Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, MA, USA,Boston University School of Public Health, Boston, MA, USA
| | - Jeffrey H. SAMET
- Boston University School of Public Health, Boston, MA, USA,Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA, USA
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Tadrous M, Mason K, Dodd Z, Guyton M, Powis J, McCormack D, Gomes T. Prescribing trends in direct-acting antivirals for the treatment of hepatitis C in Ontario, Canada. CANADIAN LIVER JOURNAL 2021; 4:51-58. [DOI: 10.3138/canlivj-2020-0025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 09/06/2020] [Indexed: 01/17/2023]
Abstract
Background: Direct-acting antivirals (DAA) offer an opportunity to cure hepatitis C. Reimbursement for DAAs has changed on two occasions since their inclusion on the Ontario public formulary. Whether these changes have appreciably modified prescribing patterns and increased access to DAAs is unknown. Methods: We conducted a repeated cross-sectional study of DAA reimbursement by the Ontario Public Drug Programs from January 1, 2012, to December 31, 2018, to summarize the use of DAAs in Ontario and describe changes in DAA prescribing physician specialties over this period. We measured the total number of users quarterly. Results are reported overall and by prescriber type. Results: A total of 27,116 individuals received a publicly funded prescription for a DAA from the first quarter (Q1) of 2012 to the fourth quarter (Q4) of 2018. Nearly two-thirds ( n = 17,813; 65.7%) of all DAAs were prescribed by gastroenterologists, hepatologists, or infectious disease specialists. Use of DAAs over time appears to have had three major phases in uptake: ( 1 ) the introduction of DAA treatments on the Ontario public drug formulary as a prior authorization benefit in Q1 2015, ( 2 ) expanded listing of all DAAs as limited-use products on the formulary in Q1 2017, and ( 3 ) the introduction of newer DAAs in Q2 2018. Conclusions: Changes in listing of these agents had a direct impact on the use of DAAs overall. Generally, broader listing expanded access but did not appear to shift utilization patterns to primary care prescribers. Further understanding of who is not receiving treatment is needed.
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Affiliation(s)
- Mina Tadrous
- Women’s College Research Institute, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Kate Mason
- South Riverdale Community Health Centre, Toronto, Ontario, Canada
| | - Zoë Dodd
- South Riverdale Community Health Centre, Toronto, Ontario, Canada
| | | | - Jeff Powis
- Sherbourne Health, Toronto, Ontario, Canada
| | | | - Tara Gomes
- ICES, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
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Catlett B, Bajis S, Starr M, Dore GJ, Hajarizadeh B, Cunningham PH, Applegate TL, Grebely J. Evaluation of the Aptima HCV Quant Dx Assay for Hepatitis C Virus RNA Detection from Fingerstick Capillary Dried Blood Spot and Venepuncture-Collected Samples. J Infect Dis 2020; 223:818-826. [PMID: 32710758 DOI: 10.1093/infdis/jiaa442] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 07/21/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Simplified diagnostic strategies are needed increase hepatitis C virus (HCV) testing to determine active infection and link people into treatment. Collection methods such as dried blood spots (DBS) have advantages over standard phlebotomy, especially within marginalized populations. METHODS We evaluated the diagnostic performance of the Aptima HCV Quant assay for the quantification and detection of HCV RNA from paired DBS and venepuncture samples. Specimens were collected from participants enrolled in an Australian observational study. We compared HCV RNA detection from DBS against venepuncture samples (gold standard). RESULTS One hundred sixty-four participants had paired samples and HCV RNA was detected in 45 (27% [95% confidence interval, 21%-35%]) by the Aptima assay in venepuncture samples. Sensitivity of the Aptima assay for HCV RNA quantification from DBS (≥10 IU/mL in plasma) was 100% and specificity was 100%. Sensitivity for HCV RNA detection from DBS was 95.6% and specificity was 94.1%. A small bias in plasma over DBS was observed with good agreement (R2 = 0.96). CONCLUSIONS The Aptima HCV Quant assay detects active infection from DBS samples with acceptable diagnostic performance and is clinically comparable to plasma. These data will strengthen the case for the registration of a DBS kit insert claim, enabling future clinical utility.
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Affiliation(s)
- Beth Catlett
- Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia.,New South Wales State Reference Laboratory for HIV, St Vincent's Centre for Applied Medical Research, Darlinghurst, Sydney, New South Wales, Australia
| | - Sahar Bajis
- Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia
| | - Mitchell Starr
- New South Wales State Reference Laboratory for HIV, St Vincent's Centre for Applied Medical Research, Darlinghurst, Sydney, New South Wales, Australia
| | - Gregory J Dore
- Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia
| | | | - Philip H Cunningham
- Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia.,New South Wales State Reference Laboratory for HIV, St Vincent's Centre for Applied Medical Research, Darlinghurst, Sydney, New South Wales, Australia
| | | | - Jason Grebely
- Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia
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Chevaliez S, Wlassow M, Volant J, Roudot-Thoraval F, Bachelard A, Poiteau L, Trabut JB, Hézode C, Bourdel A, Dominguez S. Assessing Molecular Point-of-Care Testing and Dried Blood Spot for Hepatitis C Virus Screening in People Who Inject Drugs. Open Forum Infect Dis 2020; 7:ofaa196. [PMID: 32617372 PMCID: PMC7314587 DOI: 10.1093/ofid/ofaa196] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 05/23/2020] [Indexed: 12/15/2022] Open
Abstract
Background Injecting drug use is a major driver of hepatitis C virus (HCV) spread worldwide, and the World Health Organization (WHO) has identified people who inject drugs (PWID) as a key population to target for HCV screening and care. Point-of-care (POC) hepatitis C tests and dried blood spot (DBS) sampling offer benefits for the management of patients with HCV infection by increasing HCV testing and linkage to care in different nonclinical settings. The aims of this prospective study were to evaluate the feasibility and the acceptability of use HCV ribonucleic acid (RNA) POC and fingerstick DBS testing in social-medical risk-reduction centers and to describe the cascade of care among PWID in France. Methods Between June 2018 and February 2019, 89 consecutive HCV-seropositive PWID attending 2 drug treatment services and 1 supervised consumption room in inner Paris were invited to participate in further evaluation, undergoing a clinical review with a liver assessment and blood tests including fingerstick capillary whole blood POC HCV RNA testing and fingerstick DBS sampling. Results Of the 89 participants enrolled, HCV RNA was detected in 34 (38.6%) participants. Fingerstick whole blood POC RNA testing and HCV RNA detection from DBS sample were feasible and acceptable among PWID with no major difference in terms of HCV RNA detection rate. Overall, 16 participants received pan-genotypic antiviral treatment. The proportion of PWID with sustained virologic response at 12 weeks was 81.2%, with data for 3 patients still pending. Conclusions One-step screening strategy based on the detection of HCV RNA would engage people in care for treatment scale-up and HCV elimination.
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Affiliation(s)
- Stéphane Chevaliez
- National Reference Center for Viral Hepatitis B, C, and D, Department of Virology, Hôpital Henri Mondor, Université Paris-Est, Créteil, France.,INSERM U955, Créteil, France
| | - Mélanie Wlassow
- National Reference Center for Viral Hepatitis B, C, and D, Department of Virology, Hôpital Henri Mondor, Université Paris-Est, Créteil, France.,INSERM U955, Créteil, France
| | | | - Françoise Roudot-Thoraval
- INSERM U955, Créteil, France.,Department of Hepatology, Hôpital Henri Mondor, Université Paris-Est, Créteil, France
| | - Antoine Bachelard
- Department of Infectious Diseases, Hôpital Henri Mondor, Université Paris-Est, Créteil, France
| | - Lila Poiteau
- National Reference Center for Viral Hepatitis B, C, and D, Department of Virology, Hôpital Henri Mondor, Université Paris-Est, Créteil, France.,INSERM U955, Créteil, France
| | - Jean-Baptiste Trabut
- INSERM U955, Créteil, France.,Service d'Addictologie, Hôpital Henri Mondor, Université Paris-Est, Créteil, France
| | - Christophe Hézode
- INSERM U955, Créteil, France.,Department of Hepatology, Hôpital Henri Mondor, Université Paris-Est, Créteil, France
| | | | - Stéphanie Dominguez
- Department of Infectious Diseases, Hôpital Henri Mondor, Université Paris-Est, Créteil, France
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Goodyear T, Ti L, Carrieri P, Small W, Knight R. "Everybody living with a chronic disease is entitled to be cured": Challenges and opportunities in scaling up access to direct-acting antiviral hepatitis C virus treatment among people who inject drugs. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 81:102766. [PMID: 32416525 DOI: 10.1016/j.drugpo.2020.102766] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/10/2020] [Accepted: 04/11/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Recent advances in the safety, tolerability, and efficacy of hepatitis C virus (HCV) treatments have led to the introduction of policy changes that include, in some settings, universal coverage of direct-acting antiviral (DAA) treatment for people living with HCV. However, people who inject drugs (PWID), a population with disproportionately high rates of HCV, often experience significant social and structural barriers to care, including when seeking treatment and care for blood-borne viruses. The objective of this study is to identify implementation challenges and opportunities for improving HCV-related care and scaling up DAA treatment for PWID living with HCV in a setting with universal DAA coverage since 2018. METHODS Informed by a critical interpretive framework, this study thematically analyzes data from in-depth, semi-structured interviews conducted between October 2018 and February 2019 with a purposive sample of 15 expert stakeholders (e.g., clinicians, community-based organization representatives, policy makers) related to HCV care or research in British Columbia, Canada. RESULTS Our analysis revealed two key thematics: First, participants described existing challenges for scaling up DAA treatment, including how contextual factors (e.g., housing, stigma) restrict opportunities for PWID to engage in care. Participants also described how strained and compartmentalized health services are onerous to navigate for patients. Second, participants described opportunities for improving HCV-related care through various structural interventions (e.g., improved housing, decriminalization of substance use), and enhanced and more accessible models of care (e.g., decentralized, integrated, outreach-focused, and peer- and nurse-led services). CONCLUSIONS These findings emphasize that several key service delivery and system-level adaptations are required in order to equitably scale up access of DAAs to PWID living with HCV, including policies and programs that are responsive to socio-structural determinants of health.
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Affiliation(s)
- Trevor Goodyear
- British Columbia Centre on Substance Use, Vancouver, Canada; School of Nursing, University of British Columbia, Vancouver, Canada; School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Lianping Ti
- British Columbia Centre on Substance Use, Vancouver, Canada; Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Patrizia Carrieri
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Économiques & Sociales de la Santé & Traitement de l'Information Médicale, Marseille, France; ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur, Marseille, France
| | - Will Small
- British Columbia Centre on Substance Use, Vancouver, Canada; Centre for Applied Research in Mental Health and Addiction, Faculty of Health Sciences, Simon Fraser University, Vancouver, Canada
| | - Rod Knight
- British Columbia Centre on Substance Use, Vancouver, Canada; Department of Medicine, University of British Columbia, Vancouver, Canada.
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