Evidence-based interventions to enhance assessment, treatment, and adherence in the chronic Hepatitis C care continuum

Hepatitis C-related knowledge and attitude among adults on probation in a large US city

BACKGROUND

Hepatitis C virus (HCV) continues to cause significant morbidity and mortality within the US, and disproportionately impacts those involved with the criminal justice system. Despite this, knowledge and attitudes regarding HCV treatment among adults on probation have not been well studied. We conducted a cross-sectional survey of adults on probation accessing on-site HCV testing and linkage services at the adult probation department in Denver, Colorado. The survey assessed general knowledge of HCV and HCV treatment, as well as attitudes surrounding HCV treatment that might reflect medical mistrust. We used bivariate and multivariable logistic regression to identify factors associated with previous HCV testing, previous HCV treatment, and HCV antibody positivity at the time the survey was conducted.

RESULTS

A total of 402 participants completed all or a portion of the survey. 69% of the participants were cis-gender men; 29% were white, 27% were Black, and 30% were Hispanic/Latinx. Fewer than half of participants correctly identified that HCV infection is commonly asymptomatic (46%), that there is currently no vaccine that prevents HCV (19%), and that reinfection after treatment is possible (47%). Very few participants felt that side-effects (9%) or cost of treatment (10%) were barriers to care. Many participants believed that racial disparities exist in the treatment of HCV (59%). The belief that people who use substances are treated inequitably by health care providers was also commonly reported (35% of participants). Self-reported injection drug use and higher HCV-related knowledge were positively associated with previous testing for HCV. Higher HCV-related knowledge was positively associated with HCV antibody positivity at the time of survey completion, though the magnitude of the association was small.

CONCLUSION

Interventions are needed to increase knowledge of HCV, to improve access to HCV testing and treatment, and to reduce bias associated with HCV and substance use within the probation population.

Risk Factors Associated With Unsuccessful Linkage to Outpatient Hepatitis C Care

Background Modern direct-acting antivirals (DAAs) can treat and cure hepatitis C virus (HCV) infection. Treatment of HCV at a population level has the potential to decrease the prevalence of chronic HCV infection and sequela. Unfortunately, many patients fall off the HCV treatment cascade and do not complete HCV treatment. As social determinants of health (SDHs) affect HCV acquisition, we sought to evaluate factors that may limit successful linkage to outpatient HCV care. Methods We conducted a case-control study by matching patients who missed and those who attended their outpatient HCV visits in 2018. We matched cases in a 1:1 ratio using propensity scores. Results Of 1,539 patients, 161 (10.5%) did not attend their HCV clinic appointment. Factors associated with a missed HCV visit on bivariate testing included identifying as Black (p=0.03), housing instability (p<0.001), transportation difficulty (p<0.001), history of medication non-adherence (p<0.001), and undergoing screening during an inpatient admission (p<0.001). Multivariate testing found transportation difficulty (p<0.001) and inpatient admission (p=0.002) to be associated with missing their HCV appointment. Patients who attended their HCV visit were more likely to be alive by the end of 2018 (p=0.07). Conclusion Patients who missed an initial scheduled infectious disease (ID) clinic appointment for HCV treatment had higher rates of housing instability, transportation difficulties, and medication non-adherence. Patients diagnosed with HCV infection should be provided additional support as appropriate to address the social determinants of health that may limit linkage to outpatient HCV care.

Challenges to Achieving HCV Micro-Elimination in People With HIV in the United States: Provider Perspectives and the Role of Implicit Bias

The prevalence of HIV/HCV (hepatitis C virus) co-infection is high particularly in persons who inject drugs (PWID) and is increasing because of the evolving opioid epidemic in the United States. The introduction of effective antiviral medications for HCV has raised the strategic goal of HCV micro-elimination, and efforts to understand the barriers to treatment are critical. In this study, we explored the provider perspective of factors that inhibit HCV micro-elimination efforts in people with HIV (PWH), including the role of implicit bias and related stigma in providers' health care decision making. We used the mixed-methods approach of nominal group technique (NGT) with 14 participants from 11 different clinics engaged in two virtual focus group sessions (n = 5 and n = 9). Responses from the NGTs were rank ordered during the sessions to identify providers' perspectives of major barriers and facilitators, then identified possible implicit bias after the NGTs concluded. There were 12 responses given for micro-elimination barriers with the three most prioritized being housing instability, medication nonadherence concerns, and inability to motivate patients. Of these, eight were categorized as potential implicit biases. Among the 14 responses given for facilitators of treatment, the three major solutions included distributive models of care, improved provider knowledge, and increased patient engagement. Although the solutions offered were insightful, there was consensus that the individual lives of patients were the root cause of most barriers to care. We recommend further research on behavioral design interventions that promote patients' involvement in decision making and focus on patients' eligibility criteria for HCV treatment as opposed to providers' perceived barriers to treatment.

Evaluation of serological assays for SARS-CoV-2 antibody testing from dried blood spots collected from cohorts with prior SARS-CoV-2 infection

Background

Dried blood spot (DBS) specimens are a useful serosurveillance tool particularly in hard-to-reach populations but their application for detecting SARS-CoV-2 infection is poorly characterised.

Objectives

To compare detection of naturally acquired SARS-CoV-2 antibodies in paired DBS and serum specimens using commercially available serological immunoassays.

Study Design

Specimens were collected through St Vincent's Hospital observational post COVID-19 cohort study (ADAPT). Laboratory spotted DBS from venepuncture were initially tested on seven assays, a DBS validation completed on three with clinically collected fingerstick DBSs tested on one.

Results

Sensitivity for Euroimmun nucleocapsid (NCP) IgG ELISA from laboratory spotted DBS (n=145), Euroimmun spike, IgG ELISA from laboratory spotted DBS (n=161), and Binding Site total antibody ELISA from clinically collected fingerstick DBS (n=391) was 100% (95% CI: 95.8-100%), 100% (95% CI: 95.8-100%) and 92.9% (95% CI: 89.5-95.5%), respectively. Specificity was 66.2% (95% CI: 53.6-77.0%), 96% (95% CI: 88.7-99.1%) and 98.8% (95% CI: 93.3-99.9%), respectively. All three assays’ results displayed a strong positive correlation between DBS compared to paired serum.

Conclusions

The Binding Site™ spike total antibody and Euroimmun™ spike IgG ELISAs provided good analytical performance, demonstrating that DBS specimens could facilitate specimen collection in the epidemiological surveillance of SARS-CoV-2 infection. This is highly applicable in populations and settings where venepuncture is problematic (including community based regional/remote settings, nursing homes, prisons, and schools).

Interventions to increase linkage to care and adherence to treatment for hepatitis C among people who inject drugs: A systematic review and practical considerations from an expert panel consultation

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Integrated care and cooperation between service providers optimize the HCV care continuum among people who inject drugs.

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Results suggest that people who inject drugs with HCV infection can be effectively linked and treated with direct-acting antivirals regimens in settings outside of hospital.

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Interventions that facilitate HCV care must be implemented at settings where people who inject drugs are already accessing services.

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The experts' reflections complement the findings of the literature review and inform public health practice by considering the heterogeneity of health systems and national regulatory frameworks.

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Higher quality studies investigating interventions addressing the entire care cascade from testing to cure and prevention of reinfections among highly vulnerable populations are urgently needed.

Background

Methods

Results

Conclusions

Disparities in the quality of care for chronic hepatitis C among Medicare beneficiaries

Purpose

Chronic hepatitis C virus (HCV) infection is an important public health concern. Limited information exists on disparities in the quality of HCV care. We examine disparities in genotype or quantitative HCV ribonucleic acid testing before and after starting HCV treatment, and screening for hepatocellular carcinoma (HCC) in HCV patients with cirrhosis.

Methods

This national study included Medicare beneficiaries with HCV between 2014 and 2017. We used bivariate probit to estimate the probability of receiving recommended tests before and after HCV treatment by patient race/ethnicity, urban/rural residence, and socioeconomic status. We used multivariate logistic regression to estimate adjusted odds ratios (aOR) of HCC screening among beneficiaries with cirrhosis by patient factors.

Findings

Of 41,800 Medicare patients with HCV treatment, 93.47% and 84.99% received pre- and post-treatment testing. Patients in racial minority groups had lower probabilities of pre- and post-treatment testing than whites. Rural residents were less likely to receive a post-treatment test (Coef. = -0.06, 95% CI: -0.11, -0.01). Among HCV patients with cirrhosis, 40% (24,021) received at least one semi-annual HCC screening during the study period. The odds of HCC screening were 14% lower in rural than in urban patients (aOR = 0.86, 95% CI: 0.80, 0.92), lower in African Americans (aOR = 0.93, 95% CI: 0.90, 0.96), but higher among Hispanics than in whites (aOR = 1.09, 95% CI: 1.04, 1.15). There was no significant association between ZIP-level income or education and HCC screening.

Conclusions

Disparities in the quality of HCV care existed by patient race/ethnicity, urban/rural residence, and socioeconomic status. Continued efforts are needed to improve the quality of care for all HCV patients—especially rural patients and racial/ethnic minorities.

Diagnostic accuracy of assays using point-of-care testing or dried blood spot samples for the determination of HCV RNA: a systematic review

BACKGROUND

Fingerstick point-of-care and dried-blood-spot (DBS) HCV RNA testing increases testing uptake and linkage to care. This systematic review evaluated the diagnostic accuracy of point-of-care testing and DBS to detect HCV RNA.

METHODS

Bibliographic databases and conference presentations were searched for eligible studies. Meta-analysis was used to pool estimates.

RESULTS

Of 359 articles identified, 43 studies were eligible and included. When comparing the Xpert HCV Viral Load Fingerstick assay to venous blood samples (7 studies with 987 samples), the sensitivity and specificity for HCV RNA detection was 99% (95% CI:98%-100%) and 99% (95% CI:96%-100%) and for HCV RNA quantification was 100% (95% CI:93%-100%) and 100% (95% CI:94%-100%). The proportion of invalid results following Xpert HCV Viral Load Fingerstick testing was 6% (95% CI:3%-11%). When comparing DBS to venous blood samples (28 studies with 3988 samples), the sensitivity and specificity for HCV RNA detection was 97% (95% CI:95%-98%) and 100% (95% CI:98%-100%) and for HCV RNA quantification was 98% (95% CI:96%-99%) and 100% (95% CI:95%-100%).

CONCLUSION

Excellent diagnostic accuracy was observed across assays for detection of HCV RNA from fingerstick and DBS samples. The proportion of invalid results following Xpert HCV Viral Load Fingerstick testing highlights the importance of operator training and quality assurance programs.

A cluster randomized controlled trial of a MedicineInsight Educational Quality Improvement Programme to improve the diagnosis and treatment of chronic hepatitis C in general practice (the EQUIP-HEPC trial)

The availability of direct-acting antivirals (DAAs) sparked efforts to eliminate hepatitis C virus (HCV) in Australia. We evaluated whether an educational intervention of a 1-h discussion among staff using audit and feedback data from the MedicineInsight GP programme would improve DAA uptake. Of 296 eligible general practices in MedicineInsight, 11% opted out. Randomization stratified by practice caseload allocated 130 practices to the intervention arm and 129 to control. The primary outcome was the number of patients started on DAAs over 6 months using the negative binomial regression model adjusted for DAA prescription history and clustering by practice. Data for analysis were available for 78% of practices, which included 101 practices and 2469 DAA-naive patients with confirmed/possible HCV in the intervention arm, and 100 practices and 2466 patients in the control arm. At baseline, 49.5% of practices had prescribed ≥1 DAA in the past year; 18.9% of HCV patients had already been treated with DAAs; the mean age of DAA-naive HCV patients was 43 years old, and 57% were men. Over 6 months, 43 patients in the intervention arm and 36 in the control arm started DAAs (adjusted IRR 1.19; 95% CI 0.67-2.11, p = 0.55). In the first 3 months, 27 vs 16 patients started DAAs (adjusted IRR 1.77, 0.88-3.58; p = 0.111). Few patients were started on DAAs, and a facilitated discussion in HCV management did not lead to a significant increase. Alternative measures, such as incentivizing GP initiations or patients, are suggested to address remaining barriers to DAA uptake in Australian primary care. Australian New Zealand Clinical Trial Registry (ANZCTR) Registration Number: ACTRN12619000508178p.

Validation of a tool to assess effectiveness of peer-recruitment for hepatitis C testing and linkage to care among people who inject drugs

OBJECTIVE

People who inject drugs (PWID) have high hepatitis C virus (HCV) infection prevalence but low rates of HCV treatment uptake. To better harness the potential of peer-led social network-based interventions to increase HCV treatment uptake among PWID, simple tools that can help identify individuals with the potential to function effectively as peer-mentors who support network members to get HCV tested and linked to care are needed.

METHODS

Data from a survey administered to index PWID enrolled in a social network-based intervention, in which they were invited to recruit drug use network members for HCV testing and linkage to care, was analyzed. Constructs derived from exploratory factor analysis were validated through confirmatory factor analysis (CFA). We used logistic regression analysis to assess the association between scores in identified constructs and subsequent effectiveness in the peer mentor role, defined as recruiting at least one network member for HCV testing and linkage to care in the 12 weeks following survey completion.

RESULTS

Among 100 PWID with median age 53 years, 74% male, and 71% Black, CFA resulted in a multidimensional three-factor survey with 4 questions related to opinion leadership, 3 questions related to perceived HCV-related stigma, and 3 questions related to HCV communication comfort and care support willingness. Only self-designated opinion leadership was associated with effectiveness in the peer mentor role (adjusted odds ratio 3.76 (95% Confidence interval CI 1.01, 14.0)).

CONCLUSION

We developed and validated a simple tool with potential to ease and improve the efficiency of peer-led social network interventions.

Development and Validation of a Questionnaire to Measure Medication Adherence to Direct-Acting Agents in Patients with Hepatitis C

This study aims to develop a new self-report tool (HCV-AD) measuring adherence factors, intentional or unintentional, during Hepatitis C Virus (HCV) treatment with direct-acting antivirals (DAA) aiming to achieve high efficacy, otherwise resulting in drug resistance and treatment failure. Two phases were conducted: in the first phase, items were generated based on an extensive literature review, and, in the second phase, a prospective cohort study was conducted using HCV patients from Gastroenterology Department from University County Hospital of Craiova, Romania (n = 222), to evaluate the validity and reliability of the questionnaire. A number of 19 items were generated following a systematic review and through expert opinion. The internal consistency reliability was evaluated using Cronbach’s alpha. The construct validity was assessed using correlations with two other instruments: visual analog scale (VAS) and medication possession ratio (MPR). The final questionnaire (HCV-AD10) was derived through exploratory factor analysis, with 82% of total variance explained. This instrument appeared as a reliable and valid measure for medication adherence, with Cronbach’s alpha (0.867) and significant high positive correlations between adherence scores calculated with HCV-AD10 and VAS (ρ = 0.61, p < 0.001) or with HCV-AD10 and MPR (ρ = 0.75, p < 0.001). This research would make a worthwhile contribution to HCV management.

Impact of Drug Use Policy on the Appropriate Use of Direct Acting Antiviral Agents for Hepatitis C in Saudi Arabia

Background:

Ministry of National Guard–Health Affairs in Saudi Arabia developed a new policy for the use of direct antiviral agents (DAAs) for hepatitis C. The present study was conducted to evaluate prescribers' compliance and the impact of the policy on DAAs appropriate use.

Materials and Methods:

This study was conducted at King Abdul Aziz Medical City in Jeddah, Saudi Arabia. The study compares patients' data during 1 year before and 1 year after policy initiation. The primary outcomes were compliance to monitoring parameters, appropriateness of treatment and treatment eligibility. Secondary outcomes included sustained virologic response at 12 weeks, documentation of potential drug–drug interactions and treatment costs. Independent samples t-test and Chi-square test were used when applicable. A P < 0.05 was considered statistically significant.

Results:

One hundred and three patients were included in analysis (46 before and 57 after policy). Prescriber compliance to baseline monitoring parameters was 67.4% before policy and 82.5% after-policy (P = 0.076). International normalized ratio (INR) was requested in 84.8% of cases before policy compared to 96.5% after-policy (P = 0.036). Treatment options offered to patients were appropriate in 52.2% of cases before policy and in 82.5% after-policy (P = 0.001).

Conclusion:

There is a significant improvement in the baseline monitoring of INR. Treatment options offered after policy implementation were significantly more appropriate.

Barriers to Completing Therapy for Hepatitis C with Direct-Acting Antivirals: A Real-Life Experience from a Single Treatment Center in Egypt

Introduction

Interferon-based therapies against the hepatitis C virus had a poor adherence profile. On the other hand, new direct-acting antivirals (DAAs) are orally administered medications, show high efficacy against the hepatitis C virus in addition to a high safety profile. Therefore, adherence to this treatment is expected to improve. Assessment for treatment adherence is mandatory to assess the feasibility of achieving viral hepatitis elimination.

Aim

The study aims to assess the adherence rate and causes of non-adherence in Egyptian hepatitis C patients who received interferon-free treatment regimens.

Methods

Retrospective data analysis for 668 hepatitis C patient’s records from August 2014 to October 2019 was done. Assessment of treatment adherence was done by revising the records and phone calls. However, 172 patients were excluded due to the absence of contact data. Rest of patients (n = 496) was categorized into 2 groups: Adherent (n = 432) and non-adherent (n = 64). For whom comparative analysis was done.

Results

The adherent group (87%) achieved 100 % sustained virological response after 12 weeks (SVR 12). Non-adherence was reported in 12.9% of patients. Low awareness was the main cause of non-adherence (43.75%). BMI was the only significant risk factor for poor adherence (P = .04). Other Patient demographics, clinical, and laboratory data didn’t show any significant differences between both groups.

Conclusion

Interferon-free regimens are tolerable. Raising awareness is mandatory for proper treatment adherence and, subsequently, good clinical outcomes.

Novel Hepatitic C Virus (HCV) Diagnosis and Treatment Delivery Systems: Facilitating HCV Elimination by Thinking Outside the Clinic

The World Health Organization has set a goal to eliminate hepatitis C virus (HCV) infection as public health threat by 2030. Although the advent of highly effective and tolerable direct-acting antiviral therapy has paved the way for HCV elimination, most people with HCV infection remain undiagnosed and untreated globally, with striking disparities between high-income and low- to middle-income countries. Novel decentralized and cost-effective "test-and-treat" strategies are critically needed to identify the millions of people unaware of their status and link them to treatment.

Does access to care play a role in liver cancer survival? The ten-year (2006-2015) experience from a population-based cancer registry in Southern Italy

Background

Hepatocellular carcinoma (HCC) is the most frequent primary invasive cancer of the liver. During the last decade, the epidemiology of HCC has been continuously changing in developed countries, due to more effective primary prevention and to successful treatment of virus-related liver diseases.

The study aims to examine survival by level of access to care in patients with HCC, for all patients combined and by age.

Methods

We included 2018 adult patients (15–99 years) diagnosed with a primary liver tumour, registered in the Palermo Province Cancer Registry during 2006–2015, and followed-up to 30 October 2019. We obtained a proxy measure of access to care by linking each record to the Hospital Discharge Records and the Ambulatory Discharge Records.

We estimated net survival up to 5 years after diagnosis by access to care (“easy access to care” versus “poor access to care”), using the Pohar-Perme estimator. Estimates were age-standardised using International Cancer Survival Standard (ICSS) weights. We also examined survival by access to care and age (15–64, 65–74 and ≥ 75 years).

Results

Among the 2018 patients, 62.4% were morphologically verified and 37.6% clinically diagnosed. Morphologically verified tumours were more frequent in patients aged 65–74 years (41.6%), while tumours diagnosed clinically were more frequent in patients aged 75 years or over (50.2%). During 2006–2015, age-standardised net survival was higher among HCC patients with “easy access to care” than in those with “poor access to care” (68% vs. 48% at 1 year, 29% vs. 11% at 5 years; p < 0.0001). Net survival up to 5 years was higher for patients with “easy access to care” in each age group (p < 0.0001). Moreover, survival increased slightly for patients with easier access to care, while it remained relatively stable for patients with poor access to care.

Conclusions

During 2006–2015, 5-year survival was higher for HCC patients with easier access to care, probably reflecting progressive improvement in the effectiveness of health care services offered to these patients.

Our linkage algorithm could provide valuable evidence to support healthcare decision-making in the context of the evolving epidemiology of hepatocellular carcinoma.

Peer to peer communication about hepatitis C treatment amongst people who inject drugs: A longitudinal qualitative study

BACKGROUND

Little is known about how information on direct-acting antiviral treatment for hepatitis C circulates through peer networks of people who inject drugs. In this study we aimed to explore what and how treatment-related information is shared between people undergoing treatment and their peers.

METHODS

Participants were recruited from two general practice clinics and the community-based hepatitis C Treatment and Prevention Study. Semi-structured interviews were conducted with each participant (N = 20) before, during and following treatment. Interviews explored hepatitis C treatment experiences, key sources of DAA information and the impact of receiving and sharing knowledge. Inductive thematic analysis was conducted. Time sequential matrices were generated to understand thematic change over time.

RESULTS

Fifty-four interviews were conducted with 20 participants across seven field-sites in Melbourne, Australia. Key themes were: 'peers as a source treatment information', 'do it together' and 'becoming a treatment advocate'. Peers were a crucial trusted source of information. Positive treatment anecdotes were important for building confidence in and motivation to initiate treatment. Many participants adopted a 'treatment advocate' role in their close peer networks, which was described as empowering. Some participants described benefits of undertaking treatment alongside members of their close network.

CONCLUSION

Findings illustrate the importance of close peers in shaping treatment perceptions and engagement. This will be important in designing health promotion messaging and interventions to increase treatment uptake.

The Consensus Hepatitis C Cascade of Care: Standardized Reporting to Monitor Progress Toward Elimination

Cascade-of-care (CoC) monitoring is an important component of the response to the global hepatitis C virus (HCV) epidemic. CoC metrics can be used to communicate, in simple terms, the extent to which national and subnational governments are advancing on key targets, and CoC findings can inform strategic decision-making regarding how to maximize the progression of individuals with HCV to diagnosis, treatment, and cure. The value of reporting would be enhanced if a standardized approach were used for generating CoCs. We have described the Consensus HCV CoC that we developed to address this need and have presented findings from Denmark, Norway, and Sweden, where it was piloted. We encourage the uptake of the Consensus HCV CoC as a global instrument for facilitating clear and consistent reporting via the World Health Organization (WHO) viral hepatitis monitoring platform and for ensuring accurate monitoring of progress toward WHO's 2030 hepatitis C elimination targets.

Prevalence and high risk behaviours associated with HCV testing among people who inject drugs: a systematic review and Meta-analysis

BACKGROUND

Hepatitis C diagnosis could be a gateway to behavioral change and subsequent decline in transmission among people who inject drugs (PWIDs). We assessed the association between the social determinants of PWID, their risk behaviors and hepatitis C testing.

METHODS

We searched for studies in English published before May 1, 2020, on PubMed, Scopus, Cochrane, and Web of Science to identify primary studies on the factors associated with hepatitis C virus (HCV) testing among PWID. After reviewing for study duplicates, the full-text of selected articles were assessed for eligibility using Population, Intervention, Comparator, Outcomes (PICO) criteria. i) population: individuals who report injecting drugs; ii) intervention: HCV testing in the past year; iii) comparator: PWIDs who did not have an HCV test; iv) outcome: HCV testing among PWIDs and v) study type: cross-sectional, cohort, and case-control studies. Two independent reviewers (author BA and AB) chose the references in a two-phased monitoring process. The authors gathered data from selected papers, including the surname of the first author, publication date, participant demographic data (age, sex, and level of education) and other characteristics like previous HCV testing, past treatment attempts, duration of injecting drug use and condomless sex. We used fixed and random-effects meta-analysis models to estimate the pooled prevalence, pooled odds ratio (OR), and 95% confidence intervals. The data were analyzed using Stata 12.0 software.

RESULTS

After a detailed assessment of over 12,000 articles, a total of 16 studies containing 38,952 participants met the eligibility criteria. Our findings showed a pooled prevalence rate of 61.01% (95% CI, 34.65-84.32%) for recent HCV testing among PWIDs. Being female (OR = 1.69, 95%CI = 1.13, 2.26), aged > 30 years, (OR = 2.61, 95%CI = 1.66-3.56) having past treatment attempt (OR = 2.24, 95%CI = 1.80-2.68), and reporting a previous test (OR = 2.03, 95%CI = 1.23-2.82). were significantly associated with having a recent HCV test.,,. Finding of present study was that unprotected sex had a negative association with HCV testing. Those PWIDs who had unprotected sex were 0.56 times less likely to have completed HCV testing during last year (OR = 0.56, 95%CI = 0.33-0.78).

CONCLUSION

Prevention programs that address age > 30 years, being female, past treatment attempt, previous testing of safe sexual practices, are strongly recommended to prioritize HCV risk reduction strategies.

Evaluation of the Aptima HCV Quant Dx Assay for Hepatitis C Virus RNA Detection from Fingerstick Capillary Dried Blood Spot and Venepuncture-Collected Samples

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.

Integrating primary and secondary care to optimize hepatitis C treatment: development and evaluation of a multidisciplinary educational Masterclass series

Background

It is increasingly being recognized that the elimination of HCV requires a multidisciplinary approach and effective cooperation between primary and secondary care.

Objectives

As part of a project (HepCare Europe) to integrate primary and secondary care for patients at risk of or infected with HCV, we developed a multidisciplinary educational Masterclass series for healthcare professionals (HCPs) working in primary care in Dublin and Bucharest. This article aims to describe and evaluate the series and examine how this model might be implemented into practice.

Methods

GPs and other HCPs working in primary care, addiction treatment services and NGOs were invited to eight 1 day symposia (HCV Masterclass series), examining the burden and management of HCV in key populations. Peer-support sessions were also conducted, to give people affected by HCV and community-based organizations working with those directly affected, an update on the latest developments in HCV treatment.

Results

One hundred percent of participants ‘strongly agreed’ or ‘agreed’ that the Masterclass helped them to appreciate the role of integrated services in ‘the management of patients with HCV’. One hundred percent of participants indicated the importance of a ‘designated nurse to liaise with hospital services’. An improvement of knowledge regarding HCV management of patients with high-risk behaviour was registered at the end of the course.

Conclusions

Integrated approaches to healthcare and improving the knowledge of HCPs and patients of the latest developments in HCV treatment are very important strategies that can enhance the HCV care pathway and treatment outcomes.

Progress Toward Hepatitis C Virus Elimination: Therapy and Implementation

The World Health Organization has called for the elimination of hepatitis C virus (HCV) as a public health threat by 2030. Highly effective direct-acting antiviral agents provide the therapeutic tools required for elimination. In the absence of a vaccine, HCV elimination will require enhanced primary prevention and an increase in the proportions of people diagnosed and treated. Given that globally only 20% of people with chronic HCV are diagnosed, and around 5% have initiated HCV treatment, the task ahead is enormous. But, global public health needs optimism, and countries currently on track for HCV elimination provide a pathway forward.

A Colocalized Hepatitis C Virus Clinic in a Primary Care Practice Improves Linkage to Care in a High Prevalence Population

BACKGROUND

There is an urgent need to increase patient access to treatment of chronic hepatitis C virus (HCV) infection. We developed a colocalized HCV clinic integrated within a primary care practice. We report the prevalence of HCV and evaluate the impact of the integrated clinic on the HCV cascade of care.

METHODS

We performed a retrospective study of patients with chronic HCV infection from 2 clinic practices, an integrated clinic practice and a similar nonintegrated clinic practice, between July 2015 and July 2016. Demographic, clinical, and HCV testing data were reviewed to estimate the prevalence of chronic HCV and to construct a cascade of care.

RESULTS

A total of 8405 primary care patients were included; 4796 (57.1%) received an HCV antibody test and 390 (8.1%) were positive. A total of 310 patients with chronic HCV were included in the analysis. There were 119 patients eligible for linkage to care in the nonintegrated clinic, of which 80 (67.2%) were referred, 38 (31.9%) were linked, and 18 (15.1%) initiated treatment during the study period. Among the 70 patients eligible for linkage to care in the integrated clinic practice, 51 (72.9%) were referred, 38 (54.3%) were linked, and 16 (22.9%) initiated treatment. In a multivariable analysis, patients in the integrated clinic practice had significantly higher odds of being linked to care than patients in the nonintegrated clinic practice (adjusted odds ratio [OR] 2.5, 95% confidence interval [CI] = 1.3-4.8).

CONCLUSIONS

We found a high seroprevalence of chronic HCV within our clinic population and demonstrate that a HCV clinic integrated into a primary care center increases linkage to care for patients with chronic HCV.

Nurse case management to improve the hepatitis C care continuum in HIV co-infection: Results of a randomized controlled trial

The opportunity to eliminate hepatitis C virus (HCV) is at hand, but challenges remain that negatively influence progress through the care continuum, particularly for persons co-infected with HIV who are not well engaged in care. We conducted a randomized controlled trial to test the effect of nurse case management (NCM) on the HCV continuum among adults co-infected with HIV compared to usual care (UC). Primary outcomes included linkage to HCV care (attendance at an HCV practice appointment within 60 days) and time to direct-acting antiviral (DAA) initiation (censored at 6 months). Sixty-eight participants were enrolled (NCM n = 35; UC n = 33). Participants were 81% Black/African American, 85% received Medicaid, 46% reported illicit drug use, 41% alcohol use, and 43% had an undetectable HIV viral load. At day 60, 47% of NCM participants linked to HCV care compared to 25% of UC participants (P = .031; 95% confidence bound for difference, 3.2%-40.9%). Few participants initiated DAAs (12% NCM; 25% UC). There was no significant difference in mean time to treatment initiation (NCM = 86 days; UC = 110 days; P = .192). Engagement in HCV care across the continuum was associated with drinking alcohol, knowing someone who cured HCV and having a higher CD4 cell count (P < .05). Our results support provision of NCM as a successful strategy to link persons co-infected with HIV to HCV care, but interventions should persist beyond linkage to care. Capitalizing on social networks, treatment pathways for patients who drink alcohol, and integrated substance use services may help improve the HCV care continuum.

Integrating HCV testing with HIV programs improves hepatitis C outcomes in people who inject drugs: A cluster-randomized trial

BACKGROUND & AIMS

There have been calls to integrate HCV testing into existing services, including harm reduction and HIV prevention and treatment, but there are few empirical trials to date. We evaluated the impact of integrating HCV testing/education into integrated care centers (ICCs) delivering HIV services to people who inject drugs (PWID) across India, using a cluster-randomized trial.

METHODS

We compared ICCs with usual care in the PWID stratum (12 sites) of a 22-site cluster-randomized trial. In 6 sites, ICCs delivering HIV testing, harm reduction, other preventive services and linkage to HIV treatment were scaled from opioid agonist therapy centers and operated for 2 years. On-site rapid HCV antibody testing was integrated after 1 year. To assess impact, we conducted baseline and evaluation surveys using respondent-driven sampling (RDS) across the 12 sites (n = 11,993 recruited at baseline; n = 11,721 recruited at evaluation). The primary outcome was population-level self-reported HCV testing history.

RESULTS

At evaluation, HCV antibody prevalence ranged from 7.2-76.6%. Across 6 ICCs, 5,263 ICC clients underwent HCV testing, of whom 2,278 were newly diagnosed. At evaluation, PWID in ICC clusters were 4-fold more likely to report being tested for HCV than in usual care clusters, adjusting for baseline testing (adjusted prevalence ratio [aPR] 3.69; 95% CI 1.34-10.2). PWID in ICC clusters were also 7-fold more likely to be aware of their HCV status (aPR 7.11; 95% CI 1.14-44.3) and significantly more likely to initiate treatment (aPR 9.86; 95% CI 1.52-63.8).

CONCLUSIONS

We provide among the first empirical data supporting the integration of HCV testing into HIV/harm reduction services. To achieve elimination targets, programs will need to scale-up such venues to deliver comprehensive HCV services. CLINICALTRIALS.

GOV IDENTIFIER

NCT01686750.

LAY SUMMARY

Delivering hepatitis C virus (HCV) testing to people who inject drugs (PWID) in places where they also have access to HIV prevention and treatment services is an effective way to improve uptake of HCV testing among communities of PWID. To achieve the World Health Organization's ambitious elimination targets, integrated programs will need to be scaled up to deliver comprehensive HCV services.

Rationale and design of a randomized pragmatic trial of patient-centered models of hepatitis C treatment for people who inject drugs: The HERO study

BACKGROUND

Although people who inject drugs (PWID) having the highest incidence and prevalence of hepatitis C virus (HCV) in the US, HCV treatment is rarely provided to PWID due to assumptions about poor adherence and reinfection risk. As direct-acting antiviral agents (DAAs) have achieved sustained virologic response (SVR) rates of 95% or more, evidence-based strategies are urgently needed to demonstrate real-world effectiveness in marginalized patient populations such as PWID. The objectives of this study are: 1) to determine whether either of two patient-centered treatment models - patient navigation (PN) or modified directly observed therapy (mDOT) - results in more forward movement along the HCV care cascade including treatment initiation, adherence, and SVR; 2) using quantitative and qualitative methods, to understand factors associated with lack of treatment uptake, poor adherence (<80%), failure to achieve SVR, DAA resistance, and HCV reinfection.

METHODS

The HERO study is a multi-site, pragmatic randomized clinical trial conducted in eight states where 754 HCV-infected PWID were randomly assigned to either PN or mDOT.

CONCLUSIONS

This study addresses an urgent need for timely and accurate information on optimal models of care to promote HCV treatment initiation, adherence, treatment completion and SVR among PWID, as well as rates and factors associated with reinfection and resistance after treatment. This clinical trial has the potential to provide valuable information on how to reduce the burden of the HCV epidemic in PWID.

Disparities in Hepatitis C Linkage to Care in the Direct Acting Antiviral Era: Findings From a Referral Clinic With an Embedded Nurse Navigator Model

Background: Direct acting antivirals (DAAs) have simplified and expanded access to Hepatitis C virus (HCV) treatment. Only 17% of the 2.4 million Americans with HCV have linked to HCV care. We aimed to evaluate linkage to care (LTC) in a non-urban HCV referral clinic with a nurse navigator model and identify disparities in LTC. Methods: A single-center retrospective cohort analysis was performed among all patients referred to an infectious diseases HCV clinic between 2014 and 2018. The primary outcome was LTC, defined as attendance at a clinic appointment. A multivariable Poisson regression model estimated the association of variables with LTC. Results: Among 824 referred patients, 624 (76%) successfully linked to care and 369 (45%) successfully achieved sustained virologic response. Forty-six percent of those referred were uninsured. On multivariable analysis, LTC rates were higher among women (Incidence Rate Ratio [IRR] 1.11, 95% CI 1.03-1.20, p-value = 0.01) and people with cirrhosis (IRR 1.20, 95% CI 1.11-1.30, p-value < 0.001). Lower LTC rates were found for young people (<40 years; IRR 0.88, 95% CI 0.79-0.98, p-value = 0.02) and uninsured people (IRR 0.85, 95% CI 0.77-0.94, p-value = 0.002). Among those without LTC, 10% were incarcerated. Race, proximity to care, substance use, and HIV status were not associated with LTC. Conclusions: Using an embedded nurse navigator model, high LTC rates were achieved despite the prevalence of barriers, including a high uninsured rate. Disparities in LTC based on age, sex, and insurance status are present. Substance use was not associated with LTC. Future interventions to improve care should include expanded access to insurance and programs bridging care for incarcerated populations.

We know DAAs work, so now what? Simplifying models of care to enhance the hepatitis C cascade

Globally, some 71 million people are chronically infected with hepatitis C virus (HCV). Marginalized populations, particularly people who inject drugs (PWID), have low testing, linkage to care and treatment rates for HCV. Several models of care (MoCs) and service delivery interventions have the potential to improve outcomes across the HCV cascade of care, but much of the relevant research was carried out when interferon-based treatment was the standard of care. Often it was not practical to scale-up these earlier models and interventions because the clinical care needs of patients taking interferon-based regimens imposed too much of a financial and human resource burden on health systems. Despite the adoption of highly effective, all-oral direct-acting antiviral (DAA) therapies in recent years, approaches to HCV testing and treatment have evolved slowly and often remain rooted in earlier paradigms. The effectiveness of DAAs allows for simpler approaches and has encouraged countries where the drugs are widely available to set their sights on the ambitious World Health Organization (WHO) HCV elimination targets. Since a large proportion of chronically HCV-infected people are not currently accessing treatment, there is an urgent need to identify and implement existing simplified MoCs that speak to specific populations' needs. This article aims to: (i) review the evidence on MoCs for HCV; and (ii) distil the findings into recommendations for how stakeholders can simplify the path taken by chronically HCV-infected individuals from testing to cure and subsequent care and monitoring.

HCV-infected individuals have higher prevalence of comorbidity and multimorbidity: a retrospective cohort study

Background

Almost 1% of Canadians are hepatitis C (HCV)-infected. The liver-specific complications of HCV are established but the extra-hepatic comorbidity, multimorbidity, and its relationship with HCV treatment, is less well known. We describe the morbidity burden for people with HCV and the relationship between multimorbidity and HCV treatment uptake and cure in the pre- and post-direct acting antiviral (DAA) era.

Methods

We linked adults with HCV at The Ottawa Hospital Viral Hepatitis Program as of April 1, 2017 to provincial health administrative data and matched on age and sex to 5 Ottawa-area residents for comparison. We used validated algorithms to identify the prevalence of mental and physical health comorbidities, as well as multimorbidity (2+ comorbidities). We calculated direct age- and sex-standardized rates of comorbidity and comparisons were made by interferon-based and interferon-free, DAA HCV treatments.

Results

The mean age of the study population was 54.5 years (SD 11.4), 65% were male. Among those with HCV, 4% were HIV co-infected, 26% had liver cirrhosis, 47% received DAA treatment, and 57% were cured of HCV. After accounting for age and sex differences, the HCV group had greater multimorbidity (prevalence ratio (PR) 1.38, 95% confidence interval (CI) 1.20 to 1.58) and physical-mental health multimorbidity (PR 2.71, 95% CI 2.29–3.20) compared to the general population. Specifically, prevalence ratios for people with HCV were significantly higher for diabetes, renal failure, cancer, asthma, chronic obstructive pulmonary disease, substance use disorder, mood and anxiety disorders and liver failure. HCV treatment and cure were not associated with multimorbidity, but treatment prevalence was significantly lower among middle-aged individuals with substance use disorders despite no differences in prevalence of cure among those treated.

Conclusion

People with HCV have a higher prevalence of comorbidity and multimorbidity compared to the general population. While HCV treatment was not associated with multimorbidity, people with substance use disorder were less likely to be treated. Our results point to the need for integrated, comprehensive models of care delivery for people with HCV.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-4315-6) contains supplementary material, which is available to authorized users.

Implementing a Comprehensive HCV Clinic within an HIV Clinic: A Model of Care for HCV Micro-elimination

BACKGROUND

Among the 1.2 M persons living with HIV in the United States, 25% are co- infected with HCV. The availability of effective direct antiviral agents (DAAs) makes the goal of HCV elimination feasible, but implementation requires improvements to the HCV treatment cascade, especially linkage to and initiation of treatment in underserved populations.

METHODS

In this retrospective review, a cohort of patients receiving care at a hospital-based HIV clinic in New Haven, CT (1/1/2014-3/31/2017) with chronic HCV infection not previously treated with DAAs were followed longitudinally. Patients were referred to a co-located multi-disciplinary team. Standardized referral and treatment algorithms, electronic medical record templates were developed; monthly meetings were held; a registry was created to review progress.

RESULTS

Of 173 patients, 140 (80.9%) were 50-70 years old; 115 (66.5%) male; 99 (57.2%) African-American, 43 (24.9%) White, 23 (13.3%) Hispanic. Comorbidities included: cirrhosis (25.4%); kidney disease (17.3%) mental health issues (60.7%); alcohol abuse (30.6%); active drug use (54.3%). Overall, 161 (93.1%) were referred, 147 (85%) linked, 122 (70.5%) prescribed DAAs, 97 (56.1%) had SVR12. Comparison between those with SVR12 and those unsuccessfully referred, linked or treated, showed that among those not-engaged in HCV care, there was a higher proportion of younger (mean age 54.2 vs 57 years old, p=0.022), female patients (p= 0.001) and a higher frequency of missed appointments.

CONCLUSIONS

Establishing a co-located HCV clinic within an HIV clinic resulted in treatment initiation in 70.5% and SVR12 in 56.1%. This success in a hard-to-treat population is a model for achieving WHO micro-elimination goals.

Scaling Up Hepatitis C Prevention and Treatment Interventions for Achieving Elimination in the United States: A Rural and Urban Comparison

In the United States, hepatitis C virus (HCV) transmission is rising among people who inject drugs (PWID). Many regions have insufficient prevention intervention coverage. Using modeling, we investigated the impact of scaling up prevention and treatment interventions on HCV transmission among PWID in Perry County, Kentucky, and San Francisco, California, where HCV seroprevalence among PWID is >50%. A greater proportion of PWID access medication-assisted treatment (MAT) or syringe service programs (SSP) in urban San Francisco (established community) than in rural Perry County (young, expanding community). We modeled the proportion of HCV-infected PWID needing HCV treatment annually to reduce HCV incidence by 90% by 2030, with and without MAT scale-up (50% coverage, both settings) and SSP scale-up (Perry County only) from 2017. With current MAT and SSP coverage during 2017-2030, HCV incidence would increase in Perry County (from 21.3 to 22.6 per 100 person-years) and decrease in San Francisco (from 12.9 to 11.9 per 100 person-years). With concurrent MAT and SSP scale-up, 5% per year of HCV-infected PWID would need HCV treatment in Perry County to achieve incidence targets-13% per year without MAT and SSP scale-up. In San Francisco, a similar proportion would need HCV treatment (10% per year) irrespective of MAT scale-up. Reaching the same impact by 2025 would require increases in treatment rates of 45%-82%. Achievable provision of HCV treatment, alongside MAT and SSP scale-up (Perry County) and MAT scale-up (San Francisco), could reduce HCV incidence.

HCV compliance and treatment success rates are higher with DAAs in structured HCV clinics compared to general hepatology clinics

The real-world cure rates for hepatitis C (HCV) with direct-acting antivirals (DAAs) based on intention-to-treat (ITT) analysis may be lower than reported in the literature because of non-compliance.To determine whether patients treated in a structured outpatient HCV clinic (SHC) had higher compliance and treatment success rates compared to those treated in general hepatology clinics (GHC).In this study, we compared the treatment and compliance success rates of 488 and 840 patients treated in the SHC and GHC, respectively. The SHC required a pre-treatment clinic visit when patients picked up their initial medication, and received detailed education of the treatment plan and follow-up. In the GHC, the medications were delivered to patients' homes, and there was less formal education. Compliance success was defined as a combination of treatment completion and obtaining at least 1 post-treatment viral load at week 4 or 12. Treatment success was defined as either SVR4 or SVR12.Fifty of 488 (10.3%) patients from the SHC and 163 of 840 (19.4%) patients from the GHC were lost to follow-up (P < .0001). sustained virological response (SVR) rates were similar in compliant patients in both the SHC (419/438, 95.6%) and GHC (642/677, 94.8%), but treatment success rates by intention to treat (ITT) (overall 79.9%) were higher in SHC compared to GHC (85.9% vs 76.4%, P < .0001). Multivariate analysis showed that female patients (P = .01), older age (P = .0005), treatment in SHC (OR 1.7, 95% CI 1.2, 2.3, P = .0008), and sofosbuvir/simeprevir compared to sofosbuvir/ledipasvir had higher odds of compliance success; elbasvir/grazoprevir or dasabuvir/ombitasvir/paritaprevir/ritonavir had lower odds of compliance success compared to sofosbuvir/ledipasvir. Female patients (P = .02), older age (P < .0001), previous treatment (P = .03), treatment in SHC (OR 1.7, 95% CI 1.2, 2.3, P = .0008), and sofosbuvir/ledipasvir compared to sofosbuvir/velpatasvir, sofosbuvir, or elbasvir/grazoprevir had higher odds of treatment success. With 1:1 matching, the SHC group still had significantly higher odds than the GHC group of achieving treatment and compliance success.Our study shows that the effectiveness of HCV treatment could be improved by coordinating treatment in a structured HCV clinic.

Direct-Acting Antivirals for Hepatitis C: Predictors of Early Discontinuation in the Real World

BACKGROUND

The treatment for hepatitis C virus (HCV) infection has evolved over time, and direct-acting antivirals (DAA) have revolutionized HCV therapy.

OBJECTIVES

To (a) assess early treatment discontinuation and (b) identify predictors of early discontinuation in a cohort of patients receiving second-generation DAAs.

METHODS

We identified HCV patients newly prescribed simeprevir/sofosbuvir (SIM/SOF), ledipasvir/sofosbuvir (LDV/SOF), ombitasvir/paritaprevir/ritonavir + dasabuvir (OPrD), sofosbuvir/velpatasvir (SOF/VEL), elbasvir/grazoprevir (EBR/GZR), and glecaprevir/pibrentasvir (GLE/PIB) between 2014 and 2017. Early discontinuation was defined as duration of therapy less than 8 weeks. Multivariable logistic regression was performed to evaluate the association of drug regimens and potential predictive factors to early discontinuation.

RESULTS

We identified 26,098 DAA-treated patients: 67.8% with LDV/SOF, 9.9% with OPrD, 8.5% with SIM/SOF, 7.8% with SOF/VEL, 5.2% with EBR/GZR, and 0.8% with GLE/PIB. With approval of new therapies in 2016 and 2017, use of OPrD, LDV/SOF, and SIM/SOF declined substantially. At baseline, there was some heterogeneity of past HCV drug use and comorbidity across groups; patients on SIM/SOF had the highest frequency of previous interferon, cirrhosis, and decompensated cirrhosis. Most HCV patients received therapy for 8-12 weeks; fewer patients went through 16-week and 24-week therapy courses. Early discontinuation rates (95% CI) were 7.1% (6.0-8.2) for SIM/SOF, 3.2% (2.9-3.5) for LDV/SOF, 9.6% (8.5-10.7) for OPrD, 3.1% (2.3-3.8) for SOF/VEL, 4.2% (3.1-5.3) for EBR/GZR, and 2.5% (0.3-4.7) for GLE/PIB. In multivariable analyses, versus OPrD, patients starting other drug regimens were less likely to discontinue therapy early. Early discontinuation was more common in women, patients with baseline anemia, and Medicare and Medicaid patients.

CONCLUSIONS

These real-world data confirm low rates of early discontinuation in users of second-generation DAAs. Future research focusing on socio-economic and sex/gender issues may help further optimize care for patients with HCV.

DISCLOSURES

This study was funded by the Canadian Institutes of Health Research. Klein has received grants for investigator-initiated trials from ViiV Healthcare, Janssen, Gilead, and Merck, as well as consulting fees from ViiV Healthcare, Merck, and AbbVie. Feld has received research support and/or scientific consulting fees from AbbVie, Contravir, Enanta, Gilead, Janssen, Merck, and Wako. All other authors have no conflicts of interest to declare. Results from this study were presented as a poster at the 34th International Conference of Phamacoepidemiology and Therapeutic Risk Management; August 22-26, 2018; Prague, Czech Republic.

The Hepatitis C Awareness Through to Treatment (HepCATT) study: improving the cascade of care for hepatitis C virus-infected people who inject drugs in England

BACKGROUND AND AIMS

Previous studies have shown low rates of diagnosis and treatment of hepatitis C virus (HCV) infection in people who inject drugs (PWID). Our aims were to test the effect of a complex intervention [Hepatitis C Awareness Through to Treatment (HepCATT)] in drug and alcohol clinics-primarily, on engagement of HCV-positive PWID with therapy and, secondarily, on testing for HCV, referral to hepatology services and start of HCV treatment.

DESIGN AND SETTING

A non-randomized pilot study in three specialist addiction clinics in England comparing an intervention year (starting between September 2015 and February 2016) with a baseline year (2014), together with three control clinics.

PARTICIPANTS

Analysis included all attendees at the intervention and control specialist addiction clinics identified as PWID.

INTERVENTION

The intervention comprised the placement of a half-time facilitator in each clinic for 12 months with the brief to increase diagnosis of HCV infection within clients at those services and the engagement of diagnosed individuals with an appropriate care pathway. The facilitator undertook various activities, which could include training of key workers, direct interaction with clients, streamlining and support for hepatology appointments and introduction of dried blood-spot testing.

MEASUREMENTS

For each clinic and period, we obtained the total number of clients and, as relevant, their status as PWID, tested for HCV, known HCV-positive, engaged with HCV therapy or treated.

FINDINGS

Compared with baseline, there was strong evidence that engagement with HCV therapy in the intervention year increased (P < 0.001) more in the HepCATT centres than controls, up ⁺ 31 percentage points [95% confidence interval (CI) = 19-43] versus -12 (CI = -31 to ⁺ 6) and odds ratio (OR) = 9.99 (CI = 4.42-22.6) versus 0.35 (CI = 0.08-1.56). HepCATT centres also had greater increases in HCV testing (OR = 3.06 versus 0.78, P < 0.001), referral to hepatology (OR = 9.60 versus 0.56, P < 0.001) and treatment initiation (OR = 9.5 versus 0.74, P < 0.001).

CONCLUSIONS

Introducing a half-time facilitator into drug and alcohol clinics in England increased engagement of HCV-positive people who inject drugs with hepatitis C virus care pathways, with increased uptake also of testing, referral to hepatology and initiation of treatment.

Changes to the national strategies, plans and guidelines for the treatment of hepatitis C in people who inject drugs between 2013 and 2016: a cross-sectional survey of 34 European countries

BACKGROUND

Hepatitis C virus (HCV) infection is the leading cause of cirrhosis, end-stage liver disease and hepatocellular carcinoma (HCC) worldwide. In Europe, people who inject drugs (PWID) represent the majority of HCV infections, but are often excluded from treatment. The aim of this study was to report on national HCV strategies, action plans and guidelines in European countries that include HCV treatment for the general population as well as for PWID. Data on access to direct-acting antivirals (DAAs) were also collected.

METHODS

In 2016, 38 non-governmental organisations, universities and public health institutions that work with PWID in 34 European countries were invited to complete a 16-item online survey about current national HCV treatment policies and guidelines. Data from 2016 were compared to those from 2013 for 33 European countries, and time trends are presented. Differences in the data were analysed. Data from 2016 on general access to DAAs in PWID are presented separately.

RESULTS

The response rate was 100%. Fourteen countries (42%) reported having a national HCV strategy covering HCV treatment; 12 of these addressed HCV treatment for PWID. Respondents from ten countries (29%) reported having a national HCV action plan. PWID were specifically included in seven of them. Twenty-nine countries (85%) reported having national HCV treatment guidelines. PWID were specifically included in 23 (79%) of them. Compared to 2013, respondents reported that an additional seven countries (25%) had national strategies, an additional eight countries (29%) had action plans and an additional six countries (19%) had HCV treatment guidelines. However, PWID were not included in two, four and six of those countries, respectively. DAAs were reported to be available in 91% of the study countries, with restrictions reported in 71% of them.

CONCLUSION

Respondents reported that fewer than half of the European countries in this study had a national HCV strategy and/or action plan, with even fewer including PWID. However, when compared to 2013, the number of such countries had slightly increased. Although PWID are often addressed in clinical guidelines, strategic action is needed to increase access to HCV treatment for this group and the situation should be regularly monitored.

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

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

Life projects: the transformative potential of direct-acting antiviral treatment for hepatitis C among people who inject drugs

BACKGROUND AND OBJECTIVES

People who inject drugs (PWID) are disproportionately affected by chronic hepatitis C (HCV) in high-income countries. The advent of direct-acting antivirals (DAAs) makes treatment of this underserved population more possible than ever. The dearth of programs adapted to the needs of PWID and stigma associated with drug use and chronic HCV pose significant barriers to the effective uptake of treatment among this population. We employed "life projects" as a conceptual framework to examine the social incentives of PWID being treated for HCV. This study advances the existing literature on the transformative potential of HCV treatment among PWID, explores how these transformations may affect treatment success, and discusses implications for decisions around whether and when to treat PWID.

METHODS

We conducted in-depth interviews with participants of a pilot clinical trial testing the effective delivery of DAA treatment to PWID within two healthcare for the homeless clinic settings - one group receiving opioid agonist therapy (OAT) and another group frequenting a needle and syringe exchange program (NSP). A purposive sample of 27 participants was selected based on place of care. Interviews were transcribed, coded, and analysed for patterns using a priori domains and emergent themes.

RESULTS

Participants in both treatment groups described significant life projects that motivated them to complete HCV treatment. These projects included social redemption, strengthening of relationships, pursuit of abstinence from substance use, and harm reduction. These themes were consistent between treatment groups, though more participants in the syringe exchange group relied on harm reduction than on pursuing abstinence to prevent reinfection after achieving virologic cure.

CONCLUSION

Understanding the incentives that propel PWID to complete HCV treatment could help to enhance treatment uptake and adherence through dedicated programs that address current barriers to care.

Hepatitis C Screening: Barriers to Linkage to Care

Background and Aims: Hepatitis C (HCV) is a medical and public health concern. Once infected individuals are identified, management includes not only education but also the use of antiviral therapy. Although screening for HCV is readily available, barriers exist which prevent assessment and treatment in individuals potentially infected with HCV.

Methods: This is a retrospective study of patients screened for HCV within the University of California, Los Angeles Health Care System between February 22 and July 9, 2018. We defined linkage to care as: 1) confirmatory HCV RNA test after screening HCV antibody test found a positive result; and 2) follow-up appointment for treatment was established with a specialist. Demographic and baseline laboratory values were collected. Factors potentially associated with prohibiting linkage of care were evaluated.

Results: During the study period, 17,512 individuals were screened for HCV. A total of 238 (1.35%) were found to have detectable HCV antibodies. Of the individuals with detectable HCV antibodies, 48 (20%) did not undergo confirmatory testing with viral levels. Of the 190 individuals who underwent further testing, 70 patients were noted to be viremic. Among them, 17 of the 70 (24%) were not linked to a specialist for further care. Younger patients (p = 0.02) and people who inject drugs (p = 0.02) were less likely to be referred for specialty care.

Conclusions: The results of our study highlight that younger patients and people who inject drugs are less likely to be referred to specialty care for HCV treatment. Efforts are needed to engage these populations.

Hepatitis C services at harm reduction centres in the European Union: a 28-country survey

Background

In the context of the WHO’s 2016 Viral Hepatitis Strategy and the introduction of treatment that can cure more than 95% of cases with hepatitis C virus (HCV) infection, the European Joint Action on HIV and Co-infection Prevention and Harm Reduction (HA-REACT) undertook a study in the member states of the European Union (EU). It aimed to determine service providers’ understanding of the current services in their respective countries and the barriers experienced by PWID in accessing HCV testing, care and treatment services in their country.

Methods

In 2017, 38 purposively selected harm reduction service providers completed a 26-item English-language online survey addressing the availability, accessibility and funding of HCV services at harm reduction centres. HCV-related data and reported findings were extracted by country or by responding organization.

Results

Responses were received from all EU member states. Respondents from 23 countries reported that HCV tests are offered by harm reduction services in their countries, and eight countries reported that addiction specialists in their countries are able to prescribe HCV therapy. Almost half of the respondents (45%) said that their respective organizations had established referral systems with centres providing HCV treatment.

Conclusions

Not all EU member states have harm reduction services that provide HCV tests, and many do not have established referral systems with treatment providers. Moreover, the inability of addiction specialists to prescribe HCV treatment points to missed opportunities to make treatment more accessible. Further, discrepancies were noted between the available HCV services and stakeholders’ knowledge about their availability.

Hepatitis C continuum of care and utilization of healthcare and harm reduction services among persons who inject drugs in Seattle

BACKGROUND

To describe the "continuum of care" for hepatitis C virus (HCV) and related health service utilization among persons who inject drugs (PWID) in the Seattle metropolitan area.

METHODS

The study analyzed data from the 2015 National HIV Behavioral Surveillance system focused on PWID, which included local questions on HCV treatment and testing. We calculated respondent driven sampling (RDS)-adjusted percentages of participants who had completed each step of the care continuum and compared healthcare harm reduction services among participants who were HCV + vs. HCV- using bivariate analyses.

RESULTS

513 PWID were screened for HCV antibodies (Ab). Of those, 59.7% were HCV Ab+. Among those HCV Ab+, 86.4% had been tested for HCV at least once; 69.9% reported a previous diagnosis. Of those diagnosed, 55.9% had received a confirmatory test, 17.2% had ever received any medications for HCV, and 7.2% had completed treatment. The majority of HCV Ab + participants had seen a health care provider in the past 12 months (85.6%).

CONCLUSIONS

There is a large gap between HCV screening and treatment among Seattle area PWID.

Hepatitis C Testing, Status and Treatment among Marginalized People Who Use Drugs in an Inner City Setting: An Observational Cohort Study

BACKGROUND

Chronic hepatitis C virus (HCV) infection is common among people who inject drugs (PWID) and is associated with morbidity and premature death. Although HCV can be cured, treatment may be inaccessible. We studied HCV testing, status and treatment among marginalized people who use drugs in Ottawa, Canada, a setting with universal insurance coverage for physician services.

METHODS

We analyzed data from the Participatory Research in Ottawa: Understanding Drugs study, a cross-sectional, peer-administered survey of people who use drugs from 2012 to 2013. We linked responses to population-based health administrative databases and used multivariable Poisson regression to identify factors independently associated with self-reported HCV testing, self-reported positive HCV status, and database-determined engagement in HCV treatment.

RESULTS

Among 663 participants, 562 (84.8%) reported testing for HCV and 258 (45.9%) reported HCV-positive status. In multivariable analysis, HCV-positive status was associated with female gender (RR 1.27; 95%CI 1.04 to 1.55), advancing age (RR 1.03/year; 95%CI 1.02 to 1.04), receiving disability payments (RR 1.42; 95%CI 1.06 to 1.91), injecting drugs (RR 5.11; 95%CI 2.64 to 9.91), ever injecting with a used needle (RR 1.30; 95%CI 1.12 to 1.52), and ever having taken methadone (RR 1.26; 95%CI 1.05 to 1.52). Of HCV positive participants, 196 (76%) were engaged in primary care but only 23 (8.9%) had received HCV therapy. Conclusions/Importance: Although HCV testing and positive status rates are high among PWID in our study, few have received HCV treatment. Innovative initiatives to increase access to HCV treatment for PWID are urgently needed.

Hepatitis C elimination among people who inject drugs: Challenges and recommendations for action within a health systems framework

The burden of hepatitis C infection is considerable among people who inject drugs (PWID), with an estimated prevalence of 39%, representing an estimated 6.1 million people who have recently injected drugs living with hepatitis C infection. As such, PWID are a priority population for enhancing prevention, testing, linkage to care, treatment and follow-up care in order to meet World Health Organization (WHO) hepatitis C elimination goals by 2030. There are many barriers to enhancing hepatitis C prevention and care among PWID including poor global coverage of harm reduction services, restrictive drug policies and criminalization of drug use, poor access to health services, low hepatitis C testing, linkage to care and treatment, restrictions for accessing DAA therapy, and the lack of national strategies and government investment to support WHO elimination goals. On 5 September 2017, the International Network of Hepatitis in Substance Users (INHSU) held a roundtable panel of international experts to discuss remaining challenges and future priorities for action from a health systems perspective. The WHO health systems framework comprises six core components: service delivery, health workforce, health information systems, medical procurement, health systems financing, and leadership and governance. Communication has been proposed as a seventh key element which promotes the central role of affected community engagement. This review paper presents recommended strategies for eliminating hepatitis C as a major public health threat among PWID and outlines future priorities for action within a health systems framework.

Promising practices for the prevention of liver cancer: a review of the literature and cancer plan activities in the National Comprehensive Cancer Control Program

INTRODUCTION

Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are risk factors for hepatocellular carcinoma, a type of primary liver cancer, and are most prevalent in people born 1945-1965. Relatively little information is available for liver cancer prevention, compared to other cancers. In this review, we provide a summary of current promising public health practices for liver cancer prevention from the literature, as well as liver cancer-related initiatives in the National Comprehensive Cancer Control Program (NCCCP).

METHODS

Two types of source materials were analyzed for this review: published literature (2005-present), and current cancer plans from the NCCCP (2005-2022). A search strategy was developed to include a review of several scientific databases. Of the 73 articles identified as potentially eligible, 20 articles were eligible for inclusion in the review. Eligible articles were abstracted using a data abstraction tool. Three independent keyword searches on 65 NCCCP plans were conducted. Keyword searches within each of the plans to identify activities related to liver cancer were conducted. Relevant information was abstracted from the plans and saved in a data table.

RESULTS

Of the 20 eligible articles, 15 articles provided information on interventions related to liver cancer and hepatitis B or hepatitis C prevention. All 15 of the intervention articles were related to hepatitis; 13 were hepatitis B-focused, two were hepatitis C-focused, and 14 focused on Asian/Pacific Islander American populations. The independent keyword search of NCCCP plans produced 46 results for liver, 27 results for hepatitis, and 52 results for alcohol. Two plans included activities related to liver cancer. Twenty-four plans included activities related to hepatitis.

DISCUSSION

A majority of the intervention articles published focused on HBV infection in Asian/Pacific Islander American populations, and a small percentage of NCCCP plans included liver-related content. The findings from this review will inform the development of an Action Plan on liver cancer prevention for the NCCCP, which will assist programs with the adoption and uptake of promising practices for the prevention of liver cancer.

Hepatitis C Continuum of Care in a Treatment Center in Sub-Saharan Africa

BACKGROUND

Hepatitis C virus (HCV) infection is a major public health challenge in Cameroon with over three million people infected. Government efforts to improve care and treatment are unsatisfactory and need to be assessed. We aimed at studying the several steps along the HCV continuum of care in one of two hepatitis treatment centers in Cameroon.

METHODS

We undertook a retrospective chart review of anti-HCV positive individuals, who attended the Douala general hospital between 2008 and 2015. We defined the HCV treatment cascade as follows: step 1-HCV RNA testing, step 2-complete pre-therapeutic evaluation (genotyping and liver fibrosis markers), step 3-initiation of treatment, step 4-treatment completion, and step 5-sustained virological response (SRV). Each successive step in the HCV care continuum was dependent on passing through the previous step.

RESULTS

The mean age of the 669 anti-HCV antibody positive individuals was 57 (sd: ±13) years. Females were 52.8% of the study population. 410 (61.3%) were tested for HCV RNA. Three hundred and sixty-six (54.7%) were confirmed to have viral replication (HCV RNA positive). One hundred and eighty (26.9%) did a complete pre-therapeutic evaluation (both HCV genotyping and liver fibrosis assessment included). Eighty-one (12.1%) initiated treatment with pegylated interferon/ribavirin. Seventy-two (10.8%) completed treatment and 44 (6.6%) had SVR. Sociodemographic characteristics including age, gender, marital status, having medical insurance, and profession were associated with attaining later steps in the care cascade.

CONCLUSION

This study shows that HCV continuum of care and treatment is less optimal at the Douala general hospital and is highly impacted by socio-economic factors. Continued efforts are needed to improve HCV care.

Take Charge, Get Cured: The development and user testing of a culturally targeted mHealth decision tool on HCV treatment initiation for methadone patients

OBJECTIVE

This paper describes the development of a mobile health tool to facilitate Hepatitis C (HCV) treatment decision making in methadone patients.

METHODS

Using an iterative, formative evaluation framework, we used commercial marketing techniques to create 3D maps of survey data to develop culturally relevant messaging that was concept tested. The resulting tool was then user tested and results were used to modify the tool.

RESULTS

The "Take Charge, Get Cured" tool was developed with surveys (n = 100), perceptual mapping analysis, concept testing (n = 5), and user testing (n = 10). "Think aloud" sessions were audio recorded and surveys given. Patients thought the goal of the tool was to encourage treatment and it was aimed to the needs of methadone patients. Means of 6.7-7 (on a 7 point scale) were observed for survey items related to ease of use, content, and satisfaction.

CONCLUSION

The iterative development was essential to ensuring a culturally targeted tool, specific to the needs of HCV + methadone patients. There was a high level of acceptance for the tool.

PRACTICE IMPLICATIONS

Our study indicates that using a formative evaluation strategy is essential for development of highly targeted patient communication, especially in hard-to-reach populations.

Acceptability and preferences of point-of-care finger-stick whole-blood and venepuncture hepatitis C virus testing among people who inject drugs in Australia

BACKGROUND

Uptake of hepatitis C virus (HCV) testing remains inadequate globally. Simplified point-of-care tests should enhance HCV diagnosis and elimination. We aimed to assess the acceptability of finger-stick and venepuncture HCV RNA testing among people who inject drugs (PWID).

METHODS

Participants were enrolled in an observational cohort study with recruitment at 13 sites between June 2016 and February 2018. Capillary whole-blood collected by finger-stick and plasma collected by venepuncture were performed for Xpert^® HCV viral load testing. Participants completed a questionnaire on acceptability of, and preferences for, blood collection methods.

RESULTS

Among 565 participants (mean age, 44 years; 69% male), 64% reported injecting drugs in the last month, and 63% were receiving opioid substitution treatment. Eighty three percent reported that finger-stick testing was very acceptable. Overall, 65% of participants preferred finger-stick over venepuncture testing, with 61% of these preferring to receive results in 60 min. The most common reason for preferring finger-stick over venepuncture testing was it was quick (62%) followed by venous access difficulties (21%). The main reasons for preferring venepuncture over finger-stick testing were that it was quick (61%) and accurate (29%). Females were more likely to prefer finger-stick testing than males (adjusted OR 1.96; 95% CI 1.30, 2.99; p = 0.002). Among people with recent (previous month) injecting drug use, Aboriginal and/or Torres Strait Islander people were less likely than non-Aboriginal people to prefer finger-stick testing (adjusted OR 0.57; 95% CI 0.34, 0.9; p = 0.033).

CONCLUSIONS

Finger-stick whole-blood collection is acceptable to people who inject drugs, with males and Aboriginal and/or Torres Strait Islander people with recent injecting drug use less likely to prefer finger-stick testing. Further research is needed to evaluate interventions integrating simplified point-of-care HCV testing to engage people in care in a single-visit, thereby facilitating HCV treatment scale-up.

Direct-acting antiviral therapy for hepatitis C infection among people receiving opioid agonist treatment or heroin assisted treatment

BACKGROUND

Treating chronic hepatitis C virus (HCV) infection among PWID (people who inject drugs) is crucial to achieve the WHO goal of HCV elimination, as this population is highly affected and carries a high risk of transmission. The aim of our study was to provide real-life data on HCV treatment among PWID either in opioid agonist treatment (OAT) or in heroin-assisted treatment (HAT) in a low-threshold access primary care-based addiction medicine institution.

METHODS

We conducted a retrospective chart analysis of patients treated with direct-acting antivirals (DAA) between 10/2014 and 08/2017 in the Arud outpatient clinics in Zurich, Switzerland. We reported patient and treatment characteristics and substance use. The outcomes were sustained virological response (SVR) by intention-to-treat (ITT) and modified ITT (mITT) analyses, excluding patients with missing SVR data.

RESULTS

We included 64 patients in our analysis. Forty-two (66%) were in OAT, and 22 (34%) were in HAT. Twenty-six patients (41%) reported harmful alcohol use, and 9 patients (14%) reported injecting drug use during DAA treatment. Every patient completed the treatment. Fifty-nine out of 64 achieved SVR resulting in an ITT SVR rate of 92.2%. Two patients had virological failure. Three patients were lost to follow-up between the end of treatment and SVR12 visit. Excluding these 3 patients, our study showed an mITT SVR rate of 96.7%.

CONCLUSION

PWID can be treated with DAA treatment integrated in OAT and HAT with an excellent SVR rate. OAT and HAT programs should offer integrated HCV treatment to their patients.

Hepatitis C virus status awareness and test results confirmation among people who inject drugs in Ukraine

BACKGROUND

Among the estimated 340,000 people who inject drugs (PWID) in Ukraine, HCV prevalence is approximately 70%. As HCV treatment availability increases, an assessment of the HCV treatment cascade is needed to guide HCV prevention and treatment strategies.

METHODS

Opioid dependent PWID were interviewed and tested for HIV and HCV in five Ukrainian cities from January 2014 to March 2015. Logistic regression was used to examine the independent correlates of two cascade steps: a) anti-HCV positive status awareness; b) chronic HCV confirmation; and of c) annual HCV testing for PWID.

RESULTS

Among 1613 PWID, 1002 (62.1%) had anti-HCV positive test result, of which 568 (56.7%) were aware of it before the study and 346 (34.5%) reported previous confirmatory testing for chronic HCV. Independent correlates of being aware they had anti-HCV positivity included: current [AOR: 3.08; 95%CI: 2.16-4.40] or prior [AOR: 1.85; 95%CI: 1.27-2.68] opioid agonistic treatment (OAT) experience, relative to no prior OAT, living in Lviv [AOR: 0.50; 95%CI: 0.31-0.81] or Odesa [AOR: 2.73; 95%CI: 1.51-4.93] relative to Kyiv and being aware of having HIV [AOR: 4.10; 95%CI: 2.99-5.62]. Independent correlates of confirming HCV infection among those who were aware of their anti-HCV positive status included: current OAT [AOR: 2.00; 95%CI: 1.24-3.23], relative to prior OAT, the middle income category [AOR: 1.74, 95%CI: 1.15-2.63], relative to the lowest, and receiving ART [AOR: 4.54; 95%CI: 2.85-7.23]. Among 1613 PWID, 918 (56.9%) were either HCV negative or not aware of their HCV positive status, of which 198 (21.6%) reported recent anti-HCV test (during last 12 month). Recent anti-HCV test in this group was associated with current [AOR: 7.17; 95%CI: 4.63-11.13] or prior [AOR: 2.24; 95%CI: 1.32-3.81] OAT experience, relative to no prior OAT.

CONCLUSION

Encouraging PWID to participate in OAT may be an effective strategy to diagnose and link PWID who are HCV positive to care. Among HIV negative participants, regular HCV testing may be ensured by participation in OAT. More studies are needed to assess HCV treatment utilization among PWID in Ukraine and OAT as a possible way to retain them in treatment.

A qualitative assessment of the acceptability of hepatitis C remote self-testing and self-sampling amongst people who use drugs in London, UK

Background

Hepatitis C (HCV) diagnosis and care is a major challenge for people who use illicit drugs, and is characterised by low rates of testing and treatment engagement globally. New approaches to fostering engagement are needed. We explored the acceptability of remote forms of HCV testing including self-testing and self-sampling among people who use drugs in London, UK.

Methods

A qualitative rapid assessment was undertaken with people who use drugs and stakeholders in London, UK. Focus groups were held with men who have sex with men engaged in drug use, people who currently inject drugs and people who formerly injected drugs (22 participants across the 3 focus groups). Stakeholders participated in semi-structured interviews (n = 5). We used a thematic analysis to report significant themes in participants’ responses.

Results

We report an overarching theme of ‘tension’ in how participants responded to the acceptability of remote testing. This tension is evident across four separate sub-themes we explore. First, choice and control, with some valuing the autonomy and privacy remote testing could support. Second, the ease of use of self testing linked to its immediate result and saliva sample was preferred over the delayed result from a self administered blood sample tested in a laboratory. Third, many respondents described the need to embed remote testing within a supportive care pathway. Fourth, were concerns over managing a positive result, and its different meanings, in isolation.

Conclusions

The concept of remote HCV testing is acceptable to some people who use drugs in London, although tensions with lived experience of drug use and health system access limit its relevance. Future development of remote testing must respond to concerns raised in order for acceptable implementation to take place.