Comparison of the Hepatitis C Continua of Care Between Hepatitis C Virus/HIV Coinfected and Hepatitis C Virus Mono-Infected Patients in Two Treatment Eras During 2008-2015

The British HIV Association national clinical audit 2021: Management of HIV and hepatitis C coinfection

OBJECTIVES

We aimed to describe clinical policies for the management of people with HIV/hepatitis C virus (HCV) coinfection and to audit routine monitoring and assessment of people with HIV/HCV coinfection attending UK HIV care.

METHODS

This was a clinic survey and retrospective case-note review. HIV clinics in the UK participated in the audit from May to July 2021 by completing an online questionnaire regarding their clinic's policies for the management of people with HIV/HCV coinfection, and by contributing to a case-note review of people living with HIV with detectable HCV RNA who were under the care of their service.

RESULTS

Ninety-five clinics participated in the clinic survey; of these, 15 (15.8%) were regional specialist centres, 19 (20.0%) were HIV services with their own coinfection clinics, 40 (42.1%) were HIV services that referred coinfected individuals to a local hepatology service and 20 (21.1%) were HIV services that referred to a regional specialist centre. Eighty-one clinics provided full caseload estimates; of the approximately 3951 people with a history of HIV/HCV coinfection accessing their clinics, only 4.9% were believed to have detectable HCV RNA, 3.15% of whom were already receiving or approved for direct-acting antiviral (DAA) treatment. In total, 29 (30.5%) of the clinics reported an impact of COVID-19 on coinfection care, including delays or reductions in the frequency of services, monitoring, treatment initiation and appointments, and changes to the way that treatment was dispensed. Case-note reviews were provided for 283 people with detectable HCV RNA from 74 clinics (median age 42 years, 74.6% male, 56.2% HCV genotype 1, 22.3% HCV genotype 3). Overall, 56% had not received treatment for HCV, primarily due to lack of engagement in care (54.7%) and/or being uncontactable (16.4%).

CONCLUSIONS

Our findings show that the small number of people with HIV with detectable HCV RNA in the UK should mean that it is possible to achieve HCV micro-elimination. However, more work is needed to improve engagement in care for those who are untreated for HCV.

The Hepatitis C Care Cascade During the Direct-Acting Antiviral Era in a United States Commercially-Insured Population

Background

Periodic surveillance of the hepatitis C virus (HCV) care cascade is important for tracking progress toward HCV elimination goals, identifying gaps in care, and prioritizing resource allocation. In the pre-direct-acting antiviral (DAA) era, it was estimated that 50% of HCV-infected individuals were diagnosed and that 16% had been prescribed interferon-based therapy. Since then, few studies utilizing nationally representative data from the DAA era have been conducted in the United States.

Methods

We performed a cross-sectional study to describe the HCV care cascade in the United States using the Optum de-identified Clinformatics® Data Mart Database to identify a nationally representative sample of commercially insured beneficiaries between January 1, 2014 and December 31, 2019. We estimated the number of HCV-viremic individuals in Optum based on national HCV prevalence estimates and determined the proportion who had: (1) recorded diagnosis of HCV infection, (2) recorded HCV diagnosis and underwent HCV RNA testing, (3) DAA treatment dispensed, and (4) assessment for cure.

Results

Among 120,311 individuals estimated to have HCV viremia in Optum during the study period, 109,233 (90.8%; 95% CI, 90.6%–91.0%) had a recorded diagnosis of HCV infection, 75,549 (62.8%; 95% CI, 62.5%–63.1%) had a recorded diagnosis of HCV infection and underwent HCV RNA testing, 41,102 (34.2%; 95% CI, 33.9%–34.4%) were dispensed DAA treatment, and 25,760 (21.4%; 95% CI, 21.2%–21.6%) were assessed for cure.

Conclusions

Gaps remain between the delivery of HCV-related care and national treatment goals among commercially insured adults. Efforts are needed to increase HCV treatment among people diagnosed with chronic HCV infection to achieve national elimination goals.

Low Utilization of Direct-Acting Antiviral Agents in a Large National Cohort of HIV and HCV Coinfected Medicare Patients in the United States: Implications for HCV Elimination

Hepatitis C virus (HCV) infection is common in people living with HIV/AIDS (PLWHA). The advent of direct-acting antiviral agents (DAAs) has made HCV elimination a realistic goal. We conducted a retrospective cohort study using the US Medicare Fee-For-Service claims data and outpatient prescription drug data to assess the HCV DAA initiation and completion among newly diagnosed HIV-HCV-coinfected Medicare patients enrolled in 2014-2016. DAA initiation was defined as filling at least 1 prescription of DAAs during 2014-2016. DAA completion was defined as taking an 8-week or longer DAA treatment course for patients without cirrhosis and a 12-week or longer treatment duration for those with cirrhosis. Among 12 152 HIV-HCV-coinfected Medicare patients, 20.9% received the DAA treatment in 2014-2016. The average time from HCV diagnosis to DAA initiation was 277 days. The overall DAA completion rate was 92% among 2537 patients who used DAAs. Interventions are needed to improve DAA uptake in PLWHA.

Direct-Acting Antiviral Hepatitis C Treatment Cascade and Barriers to Treatment Initiation Among US Men and Women With and Without HIV

BACKGROUND

People with HIV are disproportionately coinfected with hepatitis C virus (HCV) and experience accelerated liver-related mortality. Direct-acting antivirals (DAAs) yield high sustained virologic response (SVR) rates, but uptake is suboptimal. This study characterizes the DAA-era HCV treatment cascade and barriers among US men and women with or at risk for HIV.

METHODS

We constructed HCV treatment cascades using the Women's Interagency HIV Study (women, 6 visits, 2015-2018, n = 2447) and Multicenter AIDS Cohort Study (men, 1 visit, 2015-2018, n = 2221). Cascades included treatment-eligible individuals (ie, HCV RNA-positive or reported DAAs). Surveys captured self-reported clinical (eg, CD4), patient (eg, missed visits), system (eg, appointment access), and financial/insurance barriers.

RESULTS

Of 323/92 (women/men) treatment eligible, most had HIV (77%/70%); 69%/63% were black. HIV-positive women were more likely to attain cascade outcomes than HIV-negative women (39% vs 23% initiated, 21% vs 12% SVR); similar discrepancies were noted for men. Black men and substance users were treated less often. Women initiating treatment (vs not) reported fewer patient barriers (14%/33%). Among men not treated, clinical barriers were prevalent (53%).

CONCLUSIONS

HIV care may facilitate HCV treatment linkage and barrier navigation. HIV-negative individuals, black men, and substance users may need additional support.

CLINICAL TRIALS REGISTRATION

NCT00000797 (Women's Interagency HIV Study); NCT00046280 (Multicenter AIDS Cohort Study).

Epidemiological trends in HCV transmission and prevalence in the Viennese HIV+ population

BACKGROUND & AIMS

Human immunodeficiency virus (HIV)/hepatitis C virus (HCV) coinfection is common in people who inject drugs (PWIDs). Recently, 'high-risk' behaviour among men who have sex with men (MSM) has emerged as another main route of HCV transmission. We analysed temporal trends in HCV epidemiology in a cohort of Viennese HIV+ patients.

METHODS

Hepatitis C virus parameters were recorded at HIV diagnosis (baseline [BL]) and last visit (follow-up [FU]) for all HIV+ patients attending our HIV clinic between January 2014 and December 2016. Proportions of HIV+ patients with anti-HCV(+) and HCV viraemia (HCV-RNA(+)) at BL/FU were assessed and stratified by route of transmission.

RESULTS

In all, 1806/1874 (96.4%) HIV+ patients were tested for HCV at BL. Anti-HCV(+) was detected in 93.2% (276/296) of PWIDs and in 3.7% (31/839) of MSM. After a median FU of 6.9 years, 1644 (91.0%) patients underwent FU HCV-testing: 167 (90.3%) of PWIDs and 49 (6.7%) of MSM showed anti-HCV(+). Among 208 viraemic HCV-RNA(+) patients at BL, 30 (14.4%) had spontaneously cleared HCV, 76 (36.5%) achieved treatment-induced eradication and 89 (42.8%) remained HCV-RNA(+) at last FU. Among 1433 initially HCV-naive patients, 45 (3.5%) acquired de-novo HCV infection (11.1% PWIDs/80.0% MSM; incidence rate (IR) 0.004%; 95% confidence interval [CI] 0.0%-0.022%) and 14 had HCV reinfections (85.7% PWIDs/14.3% other; IR 0.001%; 95% CI 0.0%-0.018%) during a median FU of 6.7 years (interquartile range 7.4).

CONCLUSION

Hepatitis C virus testing was successfully implemented in the Viennese HIV(+) patients. Anti-HCV(+) prevalence remained stable in HIV+ PWIDs but almost doubled in HIV+ MSM. De-novo HCV infection occurred mostly in MSM, while HCV reinfections were mainly observed in PWIDs. HCV treatment uptake was suboptimal with 42.8% remaining HCV-RNA(+) at FU.

Validation of a modified Berger HIV stigma scale for use among patients with hepatitis C virus (HCV) infection

BACKGROUND

Stigma around hepatitis C virus (HCV) infection is an important and understudied barrier to HCV prevention, treatment, and elimination. To date, no validated instrument exists to measure patients' experiences of HCV stigma. This study aimed to revise the Berger (2001) HIV stigma scale and evaluate its psychometric properties among patients with HCV infection.

METHODS

The Berger HIV stigma scale was revised to ask about HCV and administered to patients with HCV (n = 270) in Philadelphia, Pennsylvania. Scale reliability was evaluated as internal consistency by calculating Cronbach's alpha. Exploratory factor analysis was performed to evaluate construct validity by comparing item clustering to the Berger HIV stigma scale subscales. Item response theory was employed to further evaluate individual items and to calibrate items for simulated computer adaptive testing sessions in order to identify potential shortened instruments.

RESULTS

The revised HCV Stigma Scale was found to have good reliability (α = 0.957). After excluding items for low loadings, the exploratory factor analysis indicated good construct validity with 85% of items loading on pre-defined factors. Analyses strongly suggested the predominance of an underlying unidimensional factor solution, which yielded a 33-item scale after items were removed for low loading and differential item functioning. Adaptive simulations indicated that the scale could be substantially shortened without detectable information loss.

CONCLUSIONS

The 33-item HCV Stigma Scale showed sufficient reliability and construct validity. We also conducted computer adaptive testing simulations and identified shortened six- and three-item scale alternatives that performed comparably to the original 40-item scale.

Race and Hepatitis C Care Continuum in an Underserved Birth Cohort

BACKGROUND

Birth cohort screening is recommended for hepatitis C virus (HCV) and underserved populations are disproportionally affected by HCV. Little is known about the influence of race on the HCV care continuum in this population.

OBJECTIVE

To assess the cascade of HCV care in a large racially diverse and underserved birth cohort.

DESIGN

Retrospective cohort study using electronic medical record data abstracted until August 31, 2017.

PATIENTS

34,810 patients born between 1945 and 1965 engaged in primary care between October 1, 2014, and October 31, 2016, within the safety-net clinics of the San Francisco Health Network.

MAIN MEASURES

Rate of hepatitis C testing, hepatitis C treatment, and response to therapy.

RESULTS

Cohort characteristics were as follows: median age 59 years, 57.6% male, 25.5% White (20.6% Black, 17.7% Latino, 33.0% Asian/Pacific Islander (API), 2% other), and 32.6% preferred a non-English language. 99.7% had an HCV test (95.4% HCV antibody, 4.3% HCVRNA alone). Among HCV antibody-positive patients (N = 4587), 22.9% were not tested for confirmatory HCVRNA. Among viremic patients (N = 3673), 20.8% initiated HCV therapy, 90.6% achieved sustained virologic response (SVR) and 8.1% did not have a SVR test. HCV screening and treatment were highest in APIs (98.7 and 34.7% respectively; p < 0.001). Blacks had the highest chronic HCV rate (22.2%; p < 0.001). Latinos had the lowest SVR rate (81.3%; p = 0.01). On multivariable analysis, API race (vs White, OR 1.20; p = 0.001), presence of HIV co-infection (OR 1.58; p = 0.02), presence of chronic kidney disease (OR 0.47; p < 0.001), English (vs non-English) as preferred language (OR 0.54; p = 0.002), ALT (OR 0.39 per doubling; p < 0.001), and HCVRNA (OR 0.83 per 10-fold increase; p < 0.001) were associated with HCV treatment.

CONCLUSIONS

Despite near-universal screening, gaps in active HCV confirmation, treatment, and verification of cure were identified and influenced by race. Tailored interventions to engage and treat diverse and underserved populations with HCV infection are needed.

Hepatitis C care cascade in HIV patients at an urban clinic in the early direct-acting antiviral era

Guidelines advocate universal, prompt treatment of hepatitis C (HCV) infection in HIV/HCV co-infected patients, but barriers to uptake of HCV direct-acting antivirals (DAAs) remain unclear in this population. This retrospective study investigated the care cascade from HCV diagnosis to sustained virologic response (SVR) at an urban infectious disease clinic in Saint Louis, Missouri during the first 18 months of interferon-free DAA availability in the United States. Of 1949 HIV patients seen in clinic, 91.9% were screened for HCV and 5.4% (n = 106) had chronic HCV infection with follow-up. Of these 106 co-infected patients, 100 underwent fibrosis testing, 55 were offered DAAs, 38 completed treatment, and 37 achieved SVR. Delayed DAA treatment was associated with no insurance, substance abuse, poor HIV control, and younger age. Providers delayed DAA treatment most commonly for substance abuse, psychiatric disease, and uncontrolled HIV. Mean time to insurance decision from initial prescription was 20.9 ± 29.6 days and mean time to final decision was 29.9 ± 40.1 days. DAAs are highly successful in co-infected patients in this early period but insurance delays and misconceptions from the interferon era can ultimately limit uptake. Addressing these factors in a comprehensive treatment model may bridge disparities and improve real-world SVRs.

Hepatitis C care continuum and associated barriers among people who inject drugs in Chennai, India

BACKGROUND

Little is known regarding barriers to hepatitis C virus (HCV) treatment among people who inject drugs (PWID) in low-resource settings, particularly in the era of direct-acting antiviral therapies.

METHODS

Between March, 2015-August, 2016, a cross-sectional survey was administered to community-based PWID in Chennai, India to examine the HCV care continuum and associated barriers. Adjusted prevalence ratios (APR) were estimated by multivariable Poisson regression with robust variance.

RESULTS

All participants were male (n = 541); 152 participants had HCV mono-infection and 61 participants had HIV/HCV co-infection. Only one HCV mono-infected and one HIV/HCV co-infected participant was linked to HCV care. Overall, there was moderate knowledge of HCV disease but poor knowledge of HCV treatment. Higher total knowledge scores were negatively associated with HIV/HCV co-infection (vs. HCV mono-infection), though this was not statistically significant in adjusted analysis (APR = 0.71 [95%CI = 0.47-1.06]). Participants ≥45 years (APR = 0.73 [95%CI = 0.58-0.92]) and participants with HIV/HCV co-infection (APR = 0.64 [95%CI = 0.47-0.87]) were less willing to take weekly interferon injections for 12 weeks. Willingness to undergo HCV treatment improved with decreasing duration of therapy, higher perceived efficacy, and use of pills vs. interferon, though willingness to use interferon improved with decreasing duration of therapy. Most participants preferred daily visits to a clinic for HCV treatment versus receiving a month's supply. Participants ≥45 years (vs. <45 years; APR = 0.70 [95%CI = 0.56-0.88]) and participants with HIV/HCV co-infection (APR = 0.75 [95%CI = 0.57-0.98]) were less likely to intend on seeking HCV care. Common reasons for not having already seen a provider for HCV treatment differed by HIV status, and included low perceived need for treatment (HCV-mono-infected), competing money/health priorities and costs/fears about treatment (HIV/HCV-co-infected).

CONCLUSION

Residual gaps in HCV knowledge and continuing negative perceptions related to interferon-based therapy highlight the need to scale-up educational initiatives. Readiness for HCV treatment was particularly low among HIV/HCV co-infected and older PWID, emphasizing the importance of tailored treatment strategies.