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Midgard H, Malme KB, Pihl CM, Berg-Pedersen RM, Tanum L, Klundby I, Haug A, Tveter I, Bjørnestad R, Olsen IC, Finbråten AK, Dalgard O. Opportunistic Treatment of Hepatitis C Infection Among Hospitalized People Who Inject Drugs (OPPORTUNI-C): A Stepped Wedge Cluster Randomized Trial. Clin Infect Dis 2024; 78:582-590. [PMID: 37992203 PMCID: PMC10954343 DOI: 10.1093/cid/ciad711] [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: 07/24/2023] [Revised: 09/28/2023] [Accepted: 11/17/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND We aimed to evaluate the efficacy of opportunistic treatment of hepatitis C virus (HCV) infection among hospitalized people who inject drugs (PWID). METHODS We performed a pragmatic, stepped wedge cluster randomized trial recruiting HCV RNA positive individuals admitted for inpatient care in departments of internal medicine, addiction medicine, and psychiatry at three hospitals in Oslo, Norway. Seven departments were sequentially randomized to change from control conditions (standard of care referral to outpatient care) to intervention conditions (immediate treatment initiation). The primary outcome was treatment completion, defined as dispensing the final package of the prescribed treatment within six months after enrolment. RESULTS A total of 200 HCV RNA positive individuals were enrolled between 1 October 2019 and 31 December 2021 (mean age 47.4 years, 72.5% male, 60.5% injected past 3 months, 20.4% cirrhosis). Treatment completion was accomplished by 67 of 98 (68.4% [95% confidence interval {CI}: 58.2-77.4]) during intervention conditions and by 36 of 102 (35.3% [95% CI: 26.1-45.4]) during control conditions (risk difference 33.1% [95% CI: 20.0-46.2]; risk ratio 1.9 [95% CI: 1.4-2.6]). The intervention was superior in terms of treatment completion (adjusted odds ratio [aOR] 4.8 [95% CI: 1.8-12.8]; P = .002) and time to treatment initiation (adjusted hazard ratio [aHR] 4.0 [95% CI: 2.5-6.3]; P < .001). Sustained virologic response was documented in 60 of 98 (61.2% [95% CI: 50.8-70.9]) during intervention and in 66 of 102 (64.7% [95% CI: 54.6-73.9]) during control conditions. CONCLUSIONS An opportunistic test-and-treat approach to HCV infection was superior to standard of care among hospitalized PWID. The model of care should be considered for broader implementation. Clinical Trials Registration. NCT04220645.
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Affiliation(s)
- Håvard Midgard
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
- Department of Infectious Diseases, Akershus University Hospital, Lørenskog, Norway
| | - Kristian Braathen Malme
- Department of Infectious Diseases, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Charlotte Meinich Pihl
- Department of Medicine, Lovisenberg Diaconal Hospital, Oslo, Norway
- Unger-Vetlesen Institute, Lovisenberg Diaconal Hospital, Oslo, Norway
| | | | - Lars Tanum
- Department for Research and Development in Mental Health, Akershus University Hospital, Lørenskog, Norway
- Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Ingvild Klundby
- Department of Microbiology, Oslo University Hospital, Oslo, Norway
| | - Anne Haug
- Department of Acute Medicine, Oslo University Hospital, Oslo, Norway
| | - Ida Tveter
- Department of Infectious Diseases, Oslo University Hospital, Oslo, Norway
| | | | - Inge Christoffer Olsen
- Department of Research Support for Clinical Trials, Oslo University Hospital, Oslo, Norway
| | - Ane-Kristine Finbråten
- Department of Medicine, Lovisenberg Diaconal Hospital, Oslo, Norway
- Unger-Vetlesen Institute, Lovisenberg Diaconal Hospital, Oslo, Norway
| | - Olav Dalgard
- Department of Infectious Diseases, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Roder C, Cosgrave C, Mackie K, Roberts SK, Hellard ME, Wade AJ, Doyle JS. Leave No-One Behind: A Retrospective Study of Hepatitis C Testing and Linkage to Care for Hospital Inpatients. Viruses 2023; 15:v15040913. [PMID: 37112893 PMCID: PMC10141486 DOI: 10.3390/v15040913] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/28/2023] [Accepted: 03/31/2023] [Indexed: 04/05/2023] Open
Abstract
Hospital admissions are a missed opportunity to engage people living with hepatitis C virus (HCV) into care. This study aimed to describe the proportion of hospital inpatients and emergency department (ED) patients identified with hepatitis C who were subsequently linked to care and treatment at a metropolitan health service in Melbourne, Australia. Data were collected retrospectively from hospital databases (admissions, notifiable diseases, and pharmacy) for all adults admitted or attending the ED with separation coding indicating hepatitis C infection from March 2016 to March 2019. There were 2149 patients with at least one separation with hepatitis C coding. 15.4% (331/2149) had a documented antibody test, 4.6% (99/2149) had a documented RNA test, and 8.3% (179/2149) had a DAA prescription dispensed by hospital pharmacy. Antibody positivity was 95.2% (315/331) and RNA (when completed) was detected in 37.4% (37/99). Hepatitis specialist units had the highest rate of hepatitis C coded separations and RNA testing (39/88; 44.3%), mental health had the highest rate of antibody testing (70/276; 25.4%). Emergency had the lowest rate of antibody testing (101/1075; 13.7%) and the third highest rate of RNA testing (32/94; 34.1%), but the highest rate of RNA detected (15/32; 46.9%). This study highlights key steps to improve the care cascade. Simplified diagnostic pathways, expansion of hepatitis C care services, and clear in-hospital pathways to link patients to care would be beneficial in this setting. To scale up hepatitis C testing and treatment as part of national elimination strategies, hospital systems need to target interventions to their local data.
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Affiliation(s)
- Christine Roder
- Disease Elimination Program, Burnet Institute, Melbourne 3004, Australia
- Centre for Innovation in Infectious Disease and Immunology Research (CIIDIR), Deakin University, Geelong 3220, Australia
- Barwon South West Public Health Unit, Barwon Health, Geelong 3220, Australia
| | - Carl Cosgrave
- Barwon South West Public Health Unit, Barwon Health, Geelong 3220, Australia
| | - Kathryn Mackie
- Barwon South West Public Health Unit, Barwon Health, Geelong 3220, Australia
| | - Stuart K. Roberts
- Department of Gastroenterology, Alfred Health and Monash University, Melbourne 3004, Australia
| | | | - Amanda J. Wade
- Disease Elimination Program, Burnet Institute, Melbourne 3004, Australia
- Centre for Innovation in Infectious Disease and Immunology Research (CIIDIR), Deakin University, Geelong 3220, Australia
- Barwon South West Public Health Unit, Barwon Health, Geelong 3220, Australia
| | - Joseph S. Doyle
- Disease Elimination Program, Burnet Institute, Melbourne 3004, Australia
- Department of Infectious Disease, Alfred Health and Monash University, Melbourne 3004, Australia
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Burton HJ, Khatiwada A, Chung D, Meissner EG. Association of Referral Source and Substance Use with Hepatitis C Virus Outcomes at a Southern Academic Medical Center. South Med J 2022; 115:352-357. [PMID: 35649518 DOI: 10.14423/smj.0000000000001402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
OBJECTIVES Therapeutic advances make the cure of chronic hepatitis C virus (HCV) infection achievable for individuals aware of their diagnosis who can access care. Identifying barriers to accessing care is critical to achieve population-level HCV elimination and improve the cascade of care from diagnosis to cure. METHODS To identify barriers to HCV care, we performed a retrospective observational analysis of outcomes for patients with chronic HCV referred to an infectious diseases clinic at an academic medical center in Charleston, South Carolina between January 1, 2015 and January 1, 2020. We categorized outcomes in the cascade of care between "never presenting for evaluation" and "completed treatment with documented cure." Patient demographic factors, referral source, ZIP code of residence, insurance status, clinical characteristics, antiviral regimen, psychiatric and substance use history, and route of infection were assessed for associations with care outcomes. RESULTS Of 407 referrals, 32% of patients never presented for an initial evaluation, an outcome that was associated with active substance use, mental health disease, and referral from an emergency department or obstetrics-gynecology provider. Of the patients who presented for an initial evaluation, 78% of patients initiated treatment. Active substance use was the only variable associated with lack of therapy initiation after presenting for an initial evaluation (odds ratio 2.5, 95% confidence interval 1.07-5.84). Once treatment had been initiated, no clinical or demographic variables were associated with odds of achieving documented or presumed HCV cure. CONCLUSIONS Active substance use, mental health disease, and referral from an emergency department or obstetrics-gynecology provider were associated with a lower odds of presenting for evaluation and initiation of HCV treatment. Innovative models to improve access to care and increase outreach to vulnerable populations will be essential to eliminate HCV.
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Affiliation(s)
- H Jensie Burton
- From the Department of Medicine, Division of Infectious Diseases, Medical University of South Carolina, Charleston, the Division of Biostatistics and Bioinformatics, National Jewish Health, Denver, Colorado, and the Department of Biomedical Informatics, Ohio State University, Columbus
| | - Aastha Khatiwada
- From the Department of Medicine, Division of Infectious Diseases, Medical University of South Carolina, Charleston, the Division of Biostatistics and Bioinformatics, National Jewish Health, Denver, Colorado, and the Department of Biomedical Informatics, Ohio State University, Columbus
| | - Dongjun Chung
- From the Department of Medicine, Division of Infectious Diseases, Medical University of South Carolina, Charleston, the Division of Biostatistics and Bioinformatics, National Jewish Health, Denver, Colorado, and the Department of Biomedical Informatics, Ohio State University, Columbus
| | - Eric G Meissner
- From the Department of Medicine, Division of Infectious Diseases, Medical University of South Carolina, Charleston, the Division of Biostatistics and Bioinformatics, National Jewish Health, Denver, Colorado, and the Department of Biomedical Informatics, Ohio State University, Columbus
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Pawlotsky JM, Ramers CB, Dillon JF, Feld JJ, Lazarus JV. Simplification of Care for Chronic Hepatitis C Virus Infection. Semin Liver Dis 2020; 40:392-402. [PMID: 32725611 DOI: 10.1055/s-0040-1713657] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
In 2016, the World Health Organization (WHO) set a target for eliminating viral hepatitis as a major public health threat by 2030. However, while today's highly effective and well-tolerated pangenotypic direct-acting antiviral regimens have maximized simplification of hepatitis C virus (HCV) treatment, there remain a plethora of barriers to HCV screening, diagnosis, and linkage to care. As of 2017, only 19% of the estimated 71 million individuals living with chronic HCV worldwide were diagnosed and in 2015 to 2016, only 21% of diagnosed individuals had accessed treatment. Simplification and decentralization of the HCV care cascade would bolster patient engagement and support the considerable scale-up needed to achieve WHO targets. Recent developments in HCV screening and diagnosis, together with reduced pretreatment assessment and on-treatment monitoring requirements, can further streamline the care continuum, ensuring patients are linked to care quickly and earlier in the disease course, and minimize clinic visits.
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Affiliation(s)
- Jean-Michel Pawlotsky
- Department of Virology, National Reference Center for Viral Hepatitis B, C and D, Henri Mondor Hospital, University of Paris-Est-INSERM U955, Créteil, France
| | - Christian B Ramers
- Division of Infectious Diseases, Department of Medicine, UC San Diego School of Medicine, La Jolla, California
| | - John F Dillon
- Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Dundee, United Kingdom
| | - Jordan J Feld
- Toronto Centre for Liver Disease, University Health Network, Sandra Rotman Centre for Global Health, Toronto, ON, Canada
| | - Jeffrey V Lazarus
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain
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Midgard H, Finbråten AK, Malme KB, Berg-Pedersen RM, Tanum L, Olsen IC, Bjørnestad R, Dalgard O. Opportunistic treatment of hepatitis C virus infection (OPPORTUNI-C): study protocol for a pragmatic stepped wedge cluster randomized trial of immediate versus outpatient treatment initiation among hospitalized people who inject drugs. Trials 2020; 21:524. [PMID: 32539853 PMCID: PMC7294626 DOI: 10.1186/s13063-020-04434-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 05/19/2020] [Indexed: 12/13/2022] Open
Abstract
Background Scaled-up direct-acting antiviral (DAA) treatment of hepatitis C virus (HCV) infection among people who inject drugs (PWID) is crucial to reach the World Health Organization HCV elimination targets within 2030. One of the critical obstacles to HCV care in this population is the lack of treatment models within specialist healthcare adapted to marginalized individuals. Methods OPPORTUNI-C is a pragmatic stepped wedge cluster randomized trial comparing the efficacy of immediate initiation of HCV treatment with the current standard of care among PWID admitted for inpatient care. Screening for HCV RNA will be performed as soon as possible after admission. The intervention includes immediate non-invasive liver disease assessment, counseling, and initiation of pan-genotypic DAA treatment with individualized follow-up. Standard of care is a referral to outpatient care at discharge. To mimic usual clinical practice as closely as possible, we will use a pragmatic clinical trial approach utilizing clinical infrastructure, broad eligibility criteria, flexible intervention delivery, clinically relevant outcomes, and collection of data readily available from the electronic patient files. The stepped wedge design involves a sequential rollout of the intervention over 16 months, in which seven participating clusters will be randomized from standard of care to intervention in a stepwise manner. Randomization will be stratified according to cluster size to keep high prevalence clusters separated. The trial will include approximately 220 HCV RNA positive individuals recruited from departments of internal medicine, addiction medicine, and psychiatry at Akershus University Hospital, Oslo University Hospital, and Lovisenberg Diaconal Hospital, Oslo, Norway. Individuals not able or willing to give informed consent and those with ongoing HCV assessment or treatment will be excluded. The primary outcome is treatment completion, defined as dispensing of the final prescribed DAA package from the pharmacy within 6 months after inclusion. Secondary outcomes include treatment uptake, virologic response, reinfection incidence, and resistance-associated substitutions. Discussion Representing a novel model of care suited to reach and engage marginalized PWID in HCV care, this study will inform HCV elimination efforts locally and internationally. If the model proves efficacious and feasible, it should be considered for broader implementation, replacing the current standard of care. Trial registration ClinicalTrials.gov, NCT04220645. Registered on 7 January 2020.
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Affiliation(s)
- H Midgard
- Department of Infectious Diseases, Akershus University Hospital, Lørenskog, Norway. .,Department of Gastroenterology, Oslo University Hospital, Oslo, Norway.
| | - A K Finbråten
- Department of Medicine, Lovisenberg Diaconal Hospital, Oslo, Norway.,Unger-Vetlesen Institute, Lovisenberg Diaconal Hospital, Oslo, Norway
| | - K B Malme
- Department of Infectious Diseases, Akershus University Hospital, Lørenskog, Norway
| | - R M Berg-Pedersen
- Department of Illicit drug use, Oslo University Hospital, Oslo, Norway
| | - L Tanum
- Department for Research and Development in Mental Health, Akershus University Hospital, Nordbyhagen, Norway.,Oslo Metropolitan University, Oslo, Norway
| | - I C Olsen
- Department of Research Support for Clinical Trials, Oslo University Hospital, Oslo, Norway
| | | | - O Dalgard
- Department of Infectious Diseases, Akershus University Hospital, Lørenskog, Norway.,Institute of clinical Medicine, University of Oslo, Oslo, Norway
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