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Spencer H, Leichtling G, Babiarz J, Fox CB, Herink M, Cooper J, Jones K, Gailey T, Leahy J, Cook R, Seaman A, Korthuis PT. Peer-Assisted Telemedicine for Hepatitis C (PATHS): Process evaluation results from a State Opioid Response-funded program. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024:209510. [PMID: 39243982 DOI: 10.1016/j.josat.2024.209510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 08/05/2024] [Accepted: 08/27/2024] [Indexed: 09/09/2024]
Abstract
INTRODUCTION The opioid crisis and the hepatitis C virus epidemic perpetuate and potentiate each other in a syndemic with escalating morbidity. Policy-driven funding can help resolve the syndemic through collaborative solutions that rapidly translate evidence-based interventions into real-world applications. METHODS We report development and programmatic evaluation of Peer-Assisted Telemedicine for Hepatitis C (PATHS), which utilizes State Opioid Response (SOR) funding to scale-up a positive randomized trial of peer-assisted telemedicine HCV treatment. PATHS employs staff within an academic medical center and partners with people with lived experience of drug use, "peers," to recruit rural-dwelling people who use drugs living with HCV. PATHS staff record patient data by abstracting clinical records or directly communicating with patients and peers. Peers are funded by a separate SOR-supported program administered through the state health authority. Peers support patients through HCV screening, treatment initiation via telemedicine, adherence, and cure. RESULTS Between March 2021 and June 2024, PATHS expanded to 18 of Oregon's 36 counties. In that time, PATHS diagnosed 198 rural PWUD with HCV. One hundred sixty-seven (84.3 %) linked to telemedicine and of these, 145 (86.8 %) initiated treatment. Of those who initiated treatment, 91 (62.8 %) completed treatment, of which 61 (67.0 %) are cured. CONCLUSIONS By rapidly translating a clinical innovation in HCV treatment to achieve highly effective real-world results, PATHS models how policy-driven funding can facilitate collaboration between community partners, academic medical centers, and state health departments to end the opioid-HCV syndemic.
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Affiliation(s)
- Hunter Spencer
- Oregon Health & Science University, Division of General Internal Medicine & Geriatrics, Portland, OR, United States of America.
| | | | - Jane Babiarz
- Oregon Health & Science University, Division of General Internal Medicine & Geriatrics, Portland, OR, United States of America
| | - Christopher B Fox
- Oregon Health & Science University, Division of General Internal Medicine & Geriatrics, Portland, OR, United States of America
| | - Megan Herink
- Oregon State University, College of Pharmacy, Corvallis, OR, United States of America
| | - Joanna Cooper
- Oregon Health & Science University, Division of General Internal Medicine & Geriatrics, Portland, OR, United States of America
| | - Kelly Jones
- Oregon Health & Science University, Division of General Internal Medicine & Geriatrics, Portland, OR, United States of America
| | - Tonhi Gailey
- Oregon Health & Science University, Division of General Internal Medicine & Geriatrics, Portland, OR, United States of America
| | - Judith Leahy
- Oregon Health Authority, Behavioral Health Services, Health Systems Division, United States of America
| | - Ryan Cook
- Oregon Health & Science University, Division of General Internal Medicine & Geriatrics, Portland, OR, United States of America
| | - Andrew Seaman
- Oregon Health & Science University, Division of General Internal Medicine & Geriatrics, Portland, OR, United States of America; Central City Concern, Portland, OR, United States of America
| | - P Todd Korthuis
- Oregon Health & Science University, Division of General Internal Medicine & Geriatrics, Portland, OR, United States of America
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Mezzacappa C, Kim NJ, Vutien P, Kaplan DE, Ioannou GN, Taddei TH. Screening for Hepatocellular Carcinoma and Survival in Patients With Cirrhosis After Hepatitis C Virus Cure. JAMA Netw Open 2024; 7:e2420963. [PMID: 38985470 PMCID: PMC11238019 DOI: 10.1001/jamanetworkopen.2024.20963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 05/05/2024] [Indexed: 07/11/2024] Open
Abstract
Importance The risk of hepatocellular carcinoma (HCC) declines over time after hepatitis C virus (HCV) cure by direct-acting antiviral (DAA) therapies. Liver society guidelines recommend continuing HCC screening for these patients, but data on screening outcomes are lacking. Objective To evaluate the association of HCC screening after HCV cure with overall survival. Design, Setting, and Participants This cohort study evaluated patients with HCV cirrhosis who achieved DAA-induced HCV cure in the Veterans Affairs health care system between January 2014 and December 2022. Data analysis occurred from October 2023 to January 2024. Exposures The percentage of time spent up to date with recommended HCC screening was calculated by year of follow-up and during the 4 years preceding HCC diagnosis (the detectable asymptomatic phase). Main Outcomes and Measures The primary outcome was overall survival after HCC diagnosis and was compared by percentage of time spent up to date with screening using Kaplan-Meier analyses and Cox proportional hazards regression. Early-stage HCC at diagnosis and curative treatment were secondary outcomes assessed using logistic regression. Results A total of 16 902 individuals were included (median [IQR] age, 64.0 [60.5-67.4] years; 16 426 male [97.2%]), of whom 1622 developed HCC. The cumulative incidence of HCC declined from 2.4% (409 of 16 902 individuals) to 1.0% (27 of 2833 individuals) from year 1 to year 7 of follow-up. Being up to date with screening for at least 50% of time during the 4 years preceding HCC diagnosis was associated with improved overall survival (log-rank test of equality over strata P = .002). In multivariate analysis, each 10% increase in follow-up spent up to date with screening was associated with a 3.2% decrease in the hazard of death (hazard ratio, 0.97; 95% CI, 0.95-0.99). There was a statistically significant interaction between time since HCV cure and screening, with no association observed among those who received a diagnosis of HCC more than 5 years after HCV cure. Each 10% of time spent up to date with screening was associated with a 10.1% increased likelihood of diagnosis with early-stage HCC (95% CI, 6.3%-14.0%) and a 6.8% increased likelihood of curative treatment (95% CI, 2.8%-11.0%). Conclusions and Relevance In this cohort study of persons with HCV-related cirrhosis who achieved HCV cure and subsequently developed HCC, remaining up to date with screening was associated with improved overall survival, supporting the screening of eligible individuals.
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Affiliation(s)
- Catherine Mezzacappa
- Division of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut
- Gastroenterology Section, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Nicole J. Kim
- Division of Gastroenterology, University of Washington, Seattle
- Gastroenterology Division, VA Puget Sound Health Care System, Seattle, Washington
| | - Philip Vutien
- Division of Gastroenterology, University of Washington, Seattle
- Gastroenterology Division, VA Puget Sound Health Care System, Seattle, Washington
| | - David E. Kaplan
- Division of Gastroenterology and Hepatology, University of Pennsylvania School of Medicine, Philadelphia
- Gastroenterology Section, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - George N. Ioannou
- Division of Gastroenterology, University of Washington, Seattle
- Gastroenterology Division, VA Puget Sound Health Care System, Seattle, Washington
| | - Tamar H. Taddei
- Division of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut
- Gastroenterology Section, VA Connecticut Healthcare System, West Haven, Connecticut
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Kapadia SN, Aponte-Melendez Y, Rodriguez A, Pai M, Eckhardt BJ, Marks KM, Fong C, Mateu-Gelabert P. "Treated like a Human Being": perspectives of people who inject drugs attending low-threshold HCV treatment at a syringe service program in New York City. Harm Reduct J 2023; 20:95. [PMID: 37501180 PMCID: PMC10375754 DOI: 10.1186/s12954-023-00831-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 07/16/2023] [Indexed: 07/29/2023] Open
Abstract
BACKGROUND Hepatitis C virus (HCV) treatment can effectively cure HCV among people who inject drugs (PWID). Perspectives of PWID treated in innovative models can reveal program features that address barriers to treatment, and guide implementation of similar models. METHODS We interviewed 29 participants in the intervention arm of a randomized trial. The trial enrolled PWID with HCV in New York City from 2017 to 2020 and tested the effectiveness of a low-threshold HCV treatment model at a syringe services program. Participants were purposively sampled and interviewed in English or Spanish. The interview guide focused on prior experiences with HCV testing and treatment, and experiences during the trial. Interviews were inductively coded and analyzed using thematic analysis. RESULTS Before enrollment, participants reported being tested for HCV in settings such as prison, drug treatment, and emergency rooms. Treatment was delayed because of not being seen as urgent by providers. Participants reported low self-efficacy, competing priorities, and systemic barriers to treatment such as insurance, waiting lists, and criminal-legal interactions. Stigma was a major factor. Treatment during the trial was facilitated through respect from staff, which overcame stigma. The flexible care model (allowing walk-ins and missed appointments) helped mitigate logistical barriers. The willingness of the staff to address social determinants of health was highly valued. CONCLUSION Our findings highlight the need for low-threshold programs with nonjudgmental behavior from program staff, and flexibility to adapt to participants' needs. Social determinants of health remain a significant barrier, but programs' efforts to address these factors can engender trust and facilitate treatment. Trial registration NCT03214679.
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Affiliation(s)
- Shashi N Kapadia
- Division of Infectious Diseases, Weill Cornell Medicine, 1300 York Avenue Ste A-421, New York, NY, 10065, USA.
| | - Yesenia Aponte-Melendez
- Department of Community Health and Social Sciences, CUNY Graduate School of Public Health and Health Policy, 55 W 125th Street, New York, NY, 10027, USA
- New York University Rory Meyers College of Nursing, 433 First Avenue, New York, NY, 10010, USA
| | - Alicia Rodriguez
- Department of Community Health and Social Sciences, CUNY Graduate School of Public Health and Health Policy, 55 W 125th Street, New York, NY, 10027, USA
| | - Melinda Pai
- Division of Infectious Diseases, Weill Cornell Medicine, 1300 York Avenue Ste A-421, New York, NY, 10065, USA
| | - Benjamin J Eckhardt
- Division of Infectious Diseases, New York University Grossman School of Medicine, 550 First Avenue, New York, NY, 10016, USA
| | - Kristen M Marks
- Division of Infectious Diseases, Weill Cornell Medicine, 1300 York Avenue Ste A-421, New York, NY, 10065, USA
| | - Chunki Fong
- Department of Community Health and Social Sciences, CUNY Graduate School of Public Health and Health Policy, 55 W 125th Street, New York, NY, 10027, USA
| | - Pedro Mateu-Gelabert
- Department of Community Health and Social Sciences, CUNY Graduate School of Public Health and Health Policy, 55 W 125th Street, New York, NY, 10027, USA
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Abstract
This Viewpoint introduces a proposed 5-year program from the Biden-Harris administration that would use direct-acting antivirals to eliminate hepatitis C in the United States.
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Sofikitou EM, Markatou M, Koutras MV. Multivariate semiparametric control charts for mixed-type data. Stat Methods Med Res 2023; 32:671-690. [PMID: 36788007 DOI: 10.1177/09622802221142528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
A useful tool that has gained popularity in the Quality Control area is the control chart which monitors a process over time, identifies potential changes, understands variations, and eventually improves the quality and performance of the process. This article introduces a new class of multivariate semiparametric control charts for monitoring multivariate mixed-type data, which comprise both continuous and discrete random variables (rvs). Our methodology leverages ideas from clustering and Statistical Process Control to develop control charts for MIxed-type data. We propose four control chart schemes based on modified versions of the KAy-means for MIxed LArge KAMILA data clustering algorithm, where we assume that the two existing clusters represent the reference and the test sample. The charts are semiparametric, the continuous rvs follow a distribution that belongs in the class of elliptical distributions. Categorical scale rvs follow a multinomial distribution. We present the algorithmic procedures and study the characteristics of the new control charts. The performance of the proposed schemes is evaluated on the basis of the False Alarm Rate and in-control Average Run Length. Finally, we demonstrate the effectiveness and applicability of our proposed methods utilizing real-world data.
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Affiliation(s)
- Elisavet M Sofikitou
- Department of Biostatistics, School of Public Health & Health Professions, State University of New York at Buffalo, Buffalo, NY, USA
| | - Marianthi Markatou
- Department of Biostatistics, School of Public Health & Health Professions, State University of New York at Buffalo, Buffalo, NY, USA
| | - Markos V Koutras
- Department of Statistics & Insurance Science, School of Finance & Statistics, 69000University of Piraeus, Pireas, Greece
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Jiang X, Song HJ, Chang CY, Wilson D, Guo J, Lo-Ciganic WH, Park H. Disparities in Access to Hepatitis C Treatment Among Arizona Medicaid Beneficiaries With Chronic Hepatitis C. Med Care 2023; 61:81-86. [PMID: 36453625 PMCID: PMC9839474 DOI: 10.1097/mlr.0000000000001801] [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] [Indexed: 12/02/2022]
Abstract
BACKGROUND High costs of direct-acting antivirals (DAAs) have led to their restricted access for patients with hepatitis C virus (HCV). OBJECTIVE The aim was to assess how HCV treatment access and predictors of HCV treatment changed in the post-DAA period compared with pre-DAA period. METHODS A retrospective cohort study using Arizona Medicaid data was conducted for patients with HCV to compare treatment initiation rates between pre-DAA (January 2008-October 2013) and post-DAA (November 2013-December 2018) periods. Multivariable logistic regression was used, controlling for demographic and clinical variables. RESULTS Twenty-four thousand and ninety and 28,756 patients during the pre-DAA and post-DAA periods were identified. Overall, 12.6% were treated in the post-DAA period compared with 7.8% in the pre-DAA period ( P <0.001). The relative increase in the HCV treatment initiation rate from the pre-DAA to the post-DAA period was significant greater for Black beneficiaries compared with White beneficiaries ( P =0.002). Hispanic beneficiaries were less likely to be treated in the post-DAA period [adjusted odds ratios (aOR): 0.88; CI: 0.79-0.98] compared with White beneficiaries. Those with mental illness (aOR: 0.71; 95% CI: 0.63-0.80) and substance use disorders (aOR: 0.63; 95% CI: 0.58-0.68) were less likely to be treated in the post-DAA period. CONCLUSIONS Although treatment initiation increased and disparities for Black beneficiaries compared with White beneficiaries attenuated in the post-DAA period, only 13% of Arizona Medicaid patients with HCV received DAA treatment. Disparities in DAA access remained among Hispanic patients and those with mental illness and substance use disorders.
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Affiliation(s)
- Xinyi Jiang
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Hyun Jin Song
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Ching-Yuan Chang
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Debbie Wilson
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Jingchuan Guo
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Wei-Hsuan Lo-Ciganic
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, Florida, USA
| | - Haesuk Park
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, Florida, USA
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Pembroke TPI, John G, Puyk B, Howkins K, Clarke R, Yousuf F, Czajkowski M, Godkin A, Salmon J, Yeoman A. Rising incidence, progression and changing patterns of liver disease in Wales 1999-2019. World J Hepatol 2023; 15:89-106. [PMID: 36744166 PMCID: PMC9896508 DOI: 10.4254/wjh.v15.i1.89] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 11/17/2022] [Accepted: 01/01/2023] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Liver disease incidence and hence demand on hepatology services is increasing.
AIM To describe trends in incidence and natural history of liver diseases in Wales to inform effective provision of hepatology services.
METHODS The registry is populated by International Classification of Diseases-10 (ICD-10) code diagnoses for residents derived from mortality data and inpatient/day case activity between 1999-2019. Pseudo-anonymised linkage of: (1) Causative diagnoses; (2) Cirrhosis; (3) Portal hypertension; (4) Decompensation; and (5) Liver cancer diagnoses enabled tracking liver disease progression.
RESULTS The population of Wales in 2019 was 3.1 million. Between 1999 and 2019 73054 individuals were diagnosed with a hepatic disorder, including 18633 diagnosed with cirrhosis, 10965 with liver decompensation and 2316 with hepatocellular carcinoma (HCC). Over 21 years the incidence of liver diseases increased 3.6 fold, predominantly driven by a 10 fold increase in non-alcoholic fatty liver disease (NAFLD); the leading cause of liver disease from 2014. The incidence of cirrhosis, decompensation, HCC, and all-cause mortality tripled. Liver-related mortality doubled. Alcohol-related liver disease (ArLD), autoimmune liver disease and congestive hepatopathy were associated with the highest rates of decompensation and all-cause mortality.
CONCLUSION A 10 fold increase in NAFLD incidence is driving a 3.6 fold increase in liver disease in Wales over 21 years. Liver-related morbidity and mortality rose more slowly reflecting the lower progression rate in NAFLD. Incidence of ArLD remained stable but was associated with the highest rates of liver-related and all-cause mortality.
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Affiliation(s)
- Thomas Peter Ignatius Pembroke
- Department of Gastroenterology and Hepatology, University Hospital of Wales, Cardiff CF14 4XN, United Kingdom
- Division of Infection and Immunity, Cardiff University, Cardiff CF14 4XW, United Kingdom
| | - Gareth John
- Digital Health and Care Wales, NHS Wales, Cardiff CF11 9AD, United Kingdom
| | - Berry Puyk
- Digital Health and Care Wales, NHS Wales, Cardiff CF11 9AD, United Kingdom
| | - Keith Howkins
- Digital Health and Care Wales, NHS Wales, Cardiff CF11 9AD, United Kingdom
| | - Ruth Clarke
- Digital Health and Care Wales, NHS Wales, Cardiff CF11 9AD, United Kingdom
| | - Fidan Yousuf
- Gwent Liver Unit, Royal Gwent Hospital, Newport NP20 2UB, United Kingdom
| | - Marek Czajkowski
- Gwent Liver Unit, Royal Gwent Hospital, Newport NP20 2UB, United Kingdom
| | - Andrew Godkin
- Department of Gastroenterology and Hepatology, University Hospital of Wales, Cardiff CF14 4XN, United Kingdom
- Division of Infection and Immunity, Cardiff University, Cardiff CF14 4XW, United Kingdom
| | - Jane Salmon
- Public Health Wales, NHS Wales, Cardiff CF10 4BZ, United Kingdom
| | - Andrew Yeoman
- Gwent Liver Unit, Royal Gwent Hospital, Newport NP20 2UB, United Kingdom
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Selph MJ, Hassinger C, Ahuja D. Interdisciplinary Care Coordination in Chronic Viral Hepatitis C. J Nurse Pract 2022. [DOI: 10.1016/j.nurpra.2022.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Kamis KF, Wyles DL, Minturn MS, Scott T, McEwen D, Hurley H, Prendergast SJ, Gunter J, Rowan SE. A retrospective, descriptive study of hepatitis C testing, prevalence, and care continuum among adults on probation. HEALTH & JUSTICE 2022; 10:26. [PMID: 35947313 PMCID: PMC9363270 DOI: 10.1186/s40352-022-00191-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 07/30/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Despite constituting the largest segment of the correctional population, individuals on court-ordered probation remain largely unstudied with respect to hepatitis C virus (HCV) testing and linkage-to-care. We conducted a retrospective, descriptive analysis to estimate prevalence of diagnosed HCV and the subsequent HCV care cascade among a cohort of individuals enrolled in an adult probation program over a 25-month period in Denver, Colorado. METHODS We utilized probabilistic matching with first and last name, sex, and birthdate to identify individuals enrolled in probation between July 1, 2016 and July 30, 2018 who had a medical record at the participating safety-net healthcare institution as of December 31, 2019. Electronic medical record data were queried for evidence of HCV testing and care through June 30, 2021. The state HCV registry was also queried for prevalence of reported HCV cases among the cohort. RESULTS This cohort included 8,903 individuals; 6,920 (78%) individuals had a medical record at the participating institution, and of these, 1,037 (15%) had ever been tested for HCV (Ab or RNA) and 308 (4% of those with a medical record, 30% of those tested) had detectable HCV RNA. Of these, 105 (34%) initiated HCV treatment, 89 (29%) had a subsequent undetectable HCV viral load, and 65 (21%) had documentation of HCV cure. Eleven percent of the total cohort had records of positive HCV Ab or RNA tests in the state HCV registry. CONCLUSIONS This study demonstrates the importance of HCV screening and linkage-to-care for individuals enrolled in probation programs. A focus on this population could enhance progress towards HCV elimination goals.
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Affiliation(s)
- Kevin F Kamis
- Public Health Institute at Denver Health, Denver Health and Hospital Authority, 601 Broadway, 8th floor, MC 2800, Denver, CO, 80203-3407, USA.
| | - David L Wyles
- Division of Infectious Diseases, Denver Health Medical Center and University of Colorado School of Medicine, Aurora, CO, USA
| | - Matthew S Minturn
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Tracy Scott
- LGBTQ+ Health Services, Denver Health and Hospital Authority, Denver, CO, USA
| | - Dean McEwen
- Public Health Institute at Denver Health, Denver Health and Hospital Authority, 601 Broadway, 8th floor, MC 2800, Denver, CO, 80203-3407, USA
| | - Hermione Hurley
- Public Health Institute at Denver Health, Denver Health and Hospital Authority, 601 Broadway, 8th floor, MC 2800, Denver, CO, 80203-3407, USA
- Division of Infectious Diseases, Denver Health Medical Center and University of Colorado School of Medicine, Aurora, CO, USA
- Center for Addiction Medicine, Denver Health and Hospital Authority, Denver, CO, USA
| | | | - Jessie Gunter
- Colorado Department of Public Health & Environment, Denver, CO, USA
| | - Sarah E Rowan
- Public Health Institute at Denver Health, Denver Health and Hospital Authority, 601 Broadway, 8th floor, MC 2800, Denver, CO, 80203-3407, USA.
- Division of Infectious Diseases, Denver Health Medical Center and University of Colorado School of Medicine, Aurora, CO, USA.
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Eckhardt B, Mateu-Gelabert P, Aponte-Melendez Y, Fong C, Kapadia S, Smith M, Edlin BR, Marks KM. Accessible Hepatitis C Care for People Who Inject Drugs: A Randomized Clinical Trial. JAMA Intern Med 2022; 182:494-502. [PMID: 35285851 PMCID: PMC8922207 DOI: 10.1001/jamainternmed.2022.0170] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/24/2021] [Indexed: 12/11/2022]
Abstract
Importance To achieve hepatitis C elimination, treatment programs need to engage, treat, and cure people who inject drugs. Objective To compare a low-threshold, nonstigmatizing hepatitis C treatment program that was colocated at a syringe service program (accessible care) with facilitated referral to local clinicians through a patient navigation program (usual care). Design, Setting, and Participants This single-site randomized clinical trial was conducted at the Lower East Side Harm Reduction Center, a syringe service program in New York, New York, and included 167 participants who were hepatitis C virus RNA-positive and had injected drugs during the prior 90 days. Participants enrolled between July 2017 and March 2020. Data were analyzed after all patients completed 1 year of follow-up (after March 2021). Interventions Participants were randomized 1:1 to the accessible care or usual care arm. Main Outcomes and Measures The primary end point was achieving sustained virologic response within 12 months of enrollment. Results Among the 572 participants screened, 167 (mean [SD] age, 42.0 [10.6] years; 128 (77.6%) male, 36 (21.8%) female, and 1 (0.6) transgender individuals; 8 (4.8%) Black, 97 (58.5%) Hispanic, and 53 (32.1%) White individuals) met eligibility criteria and were enrolled, with 2 excluded postrandomization (n = 165). Baseline characteristics were similar between the 2 arms. In the intention-to-treat analysis, 55 of 82 participants (67.1%) in the accessible care arm and 19 of 83 participants (22.9%) in the usual care arm achieved a sustained virologic response (P < .001). Loss to follow-up (12.2% [accessible care] and 16.9% [usual care]; P = .51) was similar in the 2 arms. Of the participants who received therapy, 55 of 64 (85.9%) and 19 of 22 (86.3%) achieved a sustained virologic response in the accessible care and usual care arms, respectively (P = .96). Significantly more participants in the accessible care arm achieved all steps in the care cascade, with the greatest attrition in the usual care arm seen in referral to hepatitis C virus clinician and attending clinical visit. Conclusions and Relevance In this randomized clinical trial, among people who inject drugs with hepatitis C infection, significantly higher rates of cure were achieved using the accessible care model that focused on low-threshold, colocated, destigmatized, and flexible hepatitis C care compared with facilitated referral. To achieve hepatitis C elimination, expansion of treatment programs that are specifically geared toward engaging people who inject drugs is paramount. Trial Registration ClinicalTrials.gov Identifier: NCT03214679.
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Affiliation(s)
| | - Pedro Mateu-Gelabert
- City University of New York Graduate School of Public Health and Health Policy, New York
| | | | - Chunki Fong
- City University of New York Graduate School of Public Health and Health Policy, New York
| | | | | | - Brian R. Edlin
- National Development and Research Institute, New York, New York
- US Centers for Disease Control and Prevention, Atlanta, Georgia
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Mirzazadeh A, Facente SN, Burk K, Kahn JG, Morris MD. Hepatitis C mortality trends in San Francisco: can we reach elimination targets? Ann Epidemiol 2022; 65:59-64. [PMID: 34700016 PMCID: PMC9293250 DOI: 10.1016/j.annepidem.2021.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 10/01/2021] [Accepted: 10/16/2021] [Indexed: 01/03/2023]
Abstract
PURPOSE Hepatitis C virus (HCV) is the most common blood-borne infection in the United States, and a leading cause of liver disease, transplant, and mortality. CDC HCV elimination goals include reducing HCV-related mortality by 65% (from 2015) by 2030. METHODS We used vital registry data (CDC WONDER) to estimate overall and demographic-specific HCV-related mortality from 1999 to 2019 in San Francisco and then used an exponential model to project progress toward HCV elimination. Local trends were compared to state and national trends. RESULTS Between 1999 and 2019, there were 1819 HCV-related deaths in San Francisco, representing an overall age-adjusted mortality rate of 9.4 (95% CI 9.0, 9.9) per 100,000 population. The age-adjusted HCV-related mortality rates were significantly higher among males (13.7), persons aged 55 years and older (28.0), Black and/or African Americans (32.2) compared to other racial groups, and Hispanic/Latinos (11.6) compared to non-Hispanic and/or Latinos. Overall and in most subgroups, mortality rates were lowest between 2015 and 2019. Since 2015, San Francisco observed a significantly larger reduction in agbe-adjusted HCV-related mortality than California or the U.S. Projected age-adjusted HCV-related mortality rates for San Francisco for 2020 and 2030 were 4.7 (95% CI 3.5, 6.2) and 1.1 (95% CI 0.7, 1.8), respectively. CONCLUSIONS Based on trends between 2015 and 2019, San Francisco, California, and the U.S. are projected to achieve 65% reduction in HCV-mortality at or before 2030. Based on current trends, San Francisco is projected to achieve this goal earlier.
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Affiliation(s)
- Ali Mirzazadeh
- Department of Epidemiology and Biostatistics, University of California, San Francisco,Institute for Global Health Sciences, University of California, San Francisco,Corresponding author. Department of Epidemiology and Biostatistics, University of California, 550 16th street, San Francisco, CA 94158. (A. Mirzazadeh)
| | - Shelley N. Facente
- Facente Consulting, San Francisco, CA,School of Public Health, University of California, Berkeley
| | - Katie Burk
- Community Health Equity and Promotion Branch, San Francisco Department of Public Health, San Francisco, CA
| | - James G. Kahn
- Philip R Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco
| | - Meghan D. Morris
- Department of Epidemiology and Biostatistics, University of California, San Francisco,Institute for Global Health Sciences, University of California, San Francisco,School of Public Health, University of California, Berkeley
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12
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Kamis KF, Wyles DL, Minturn MS, Scott T, McEwen D, Hurley H, Prendergast SJ, Rowan SE. Hepatitis C Testing and Linkage to Care Among Adults on Probation in a Large US City. Open Forum Infect Dis 2021; 9:ofab636. [PMID: 35111867 PMCID: PMC8802802 DOI: 10.1093/ofid/ofab636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 12/15/2021] [Indexed: 12/09/2022] Open
Abstract
Background Despite constituting the largest segment of the correctional population, individuals on probation remain largely unstudied with respect to hepatitis C virus (HCV) testing and linkage to care. We implemented an HCV testing and patient navigation program at an adult probation department. Methods Adults were tested at a local probation department with a rapid point-of-care HCV antibody (Ab) assay followed by a laboratory-based HCV ribonucleic acid (RNA) assay if anti-HCV positive. All individuals received counseling rooted in harm reduction principles. Individuals testing positive for HCV Ab were immediately linked to a patient navigator in person or via telephone. The patient navigator assisted patients through cure unless the patient was lost to follow-up. Study participation involved an optional survey and optional point-of-care human immunodeficiency virus test. Results Of 417 individuals tested, 13% were HCV Ab positive and 65% of those tested for HCV RNA (34 of 52) had detectable HCV RNA. Of the 14 individuals who linked to an HCV treatment provider, 4 completed treatment, as measured by pharmacy fill documentation in the electronic medical record, and 1 obtained sustained virologic response. One hundred ninety-three individuals tested for HIV; none tested positive. Conclusions The study cohort had a higher HCV seroprevalence than the general population (13% vs 2%), but linkage to care, completion of HCV treatment, and successful test-of-cure rates were all low. This study indicates that HCV disproportionately impacts adults on probation and prioritizing support for testing and linkage to care could improve health in this population. Colocalization of HCV treatment within probation programs would reduce the barrier of attending a new institution and could be highly impactful.
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Affiliation(s)
- Kevin F Kamis
- Public Health Institute at Denver Health, Denver Health and Hospital Authority, Denver, Colorado, USA
| | - David L Wyles
- Division of Infectious Diseases, Denver Health Medical Center and University of Colorado School of Medicine, Denver, Colorado, USA
| | - Matthew S Minturn
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Tracy Scott
- LGBTQ+ Health Services, Denver Health and Hospital Authority, Denver, Colorado, USA
| | - Dean McEwen
- Public Health Institute at Denver Health, Denver Health and Hospital Authority, Denver, Colorado, USA
| | - Hermione Hurley
- Public Health Institute at Denver Health, Denver Health and Hospital Authority, Denver, Colorado, USA
- Division of Infectious Diseases, Denver Health Medical Center and University of Colorado School of Medicine, Denver, Colorado, USA
- Center for Addiction Medicine, Denver Health and Hospital Authority, Denver, Colorado, USA
| | | | - Sarah E Rowan
- Public Health Institute at Denver Health, Denver Health and Hospital Authority, Denver, Colorado, USA
- Division of Infectious Diseases, Denver Health Medical Center and University of Colorado School of Medicine, Denver, Colorado, USA
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13
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Tully DC, Hahn JA, Bean DJ, Evans JL, Morris MD, Page K, Allen TM. Identification of Genetically Related HCV Infections Among Self-Described Injecting Partnerships. Clin Infect Dis 2021; 74:993-1003. [PMID: 34448809 DOI: 10.1093/cid/ciab596] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND The current opioid epidemic across the United States has fueled a surge in the rate of new hepatitis C virus (HCV) infections among young persons who inject drugs (PWIDs). Paramount to interrupting transmission is targeting these high-risk populations and understanding the underlying network structures facilitating transmission within these communities. METHODS Deep sequencing data were obtained for 52 participants from 32 injecting partnerships enrolled in the U-Find-Out (UFO) Partner Study, which is a prospective study of self-described injecting dyad partnerships from a large community-based study of HCV infection in young adult PWIDs from San Francisco. Phylogenetically linked transmission events were identified using traditional genetic-distance measures and viral deep sequence phylogenies reconstructed to determine the statistical support of inferences and the direction of transmission within partnerships. RESULTS Using deep sequencing data, we found that 12 of 32 partnerships were genetically similar and clustered. Three additional phylogenetic clusters were found describing novel putative transmission links outside of the injecting relationship. Transmission direction was inferred correctly for 5 partnerships with the incorrect transmission direction inferred in more than 50% of cases. Notably, we observed that phylogenetic linkage was most often associated with a lower number of network partners and involvement in a sexual relationship. CONCLUSIONS Deep sequencing of HCV among self-described injecting partnerships demonstrates that the majority of transmission events originate from outside of the injecting partnership. Furthermore, these findings caution that phylogenetic methods may be unable to routinely infer the direction of transmission among PWIDs especially when transmission events occur in rapid succession within high-risk networks.
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Affiliation(s)
- Damien C Tully
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom.,Center for Mathematical Modelling of Infectious Disease, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Judith A Hahn
- Department of Medicine, University of California, San Francisco, California, USA
| | - David J Bean
- Ragon Institute of MGH, MIT and Harvard, Cambridge, Massachusetts, USA
| | - Jennifer L Evans
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - Meghan D Morris
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - Kimberly Page
- Department of Internal Medicine, University of New Mexico Health Center, Albuquerque, New Mexico, USA
| | - Todd M Allen
- Ragon Institute of MGH, MIT and Harvard, Cambridge, Massachusetts, USA
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14
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Hall EW, Schillie S, Vaughan AS, Jones J, Bradley H, Lopman B, Rosenberg ES, Sullivan PS. County-Level Variation in Hepatitis C Virus Mortality and Trends in the United States, 2005-2017. Hepatology 2021; 74:582-590. [PMID: 33609308 PMCID: PMC8456961 DOI: 10.1002/hep.31756] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/23/2020] [Accepted: 01/19/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND AIMS Since 2013, the national hepatitis C virus (HCV) death rate has steadily declined, but this decline has not been quantified or described on a local level. APPROACH AND RESULTS We estimated county-level HCV death rates and assessed trends in HCV mortality from 2005 to 2013 and from 2013 to 2017. We used mortality data from the National Vital Statistics System and used a Bayesian multivariate space-time conditional autoregressive model to estimate age-standardized HCV death rates from 2005 through 2017 for 3,115 U.S. counties. Additionally, we estimated county-level, age-standardized rates for persons <40 and 40+ years of age. We used log-linear regression models to estimate the average annual percent change in HCV mortality during periods of interest and compared county-level trends with national trends. Nationally, the age-adjusted HCV death rate peaked in 2013 at 5.20 HCV deaths per 100,000 persons (95% credible interval [CI], 5.12, 5.26) before decreasing to 4.34 per 100,000 persons (95% CI, 4.28, 4.41) in 2017 (average annual percent change = -4.69; 95% CI, -5.01, -4.33). County-level rates revealed heterogeneity in HCV mortality (2017 median rate = 3.6; interdecile range, 2.19, 6.77), with the highest rates being concentrated in the West, Southwest, Appalachia, and northern Florida. Between 2013 and 2017, HCV mortality decreased in 80.0% (n = 2,274) of all U.S. counties with a reliable trend estimate, with 25.8% (n = 803) of all counties experiencing a decrease larger than the national decline. CONCLUSIONS Although many counties have experienced a shift in HCV mortality trends since 2013, the magnitude and composition of that shift have varied by place. These data provide a better understanding of geographic differences in HCV mortality and can be used by local jurisdictions to evaluate HCV mortality in their areas relative to surrounding areas and the nation.
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Affiliation(s)
- Eric W. Hall
- Department of EpidemiologyRollins School of Public HealthEmory UniversityAtlantaGA
| | - Sarah Schillie
- Immunization Services DivisionCenters for Disease Control and PreventionAtlantaGA
| | - Adam S. Vaughan
- Division for Heart Disease and Stroke PreventionCenters for Disease Control and PreventionAtlantaGA
| | - Jeb Jones
- Department of EpidemiologyRollins School of Public HealthEmory UniversityAtlantaGA
| | - Heather Bradley
- Department of Epidemiology and BiostatisticsSchool of Public HealthGeorgia State UniversityAtlantaGA
| | - Ben Lopman
- Department of EpidemiologyRollins School of Public HealthEmory UniversityAtlantaGA
| | - Eli S. Rosenberg
- Department of Epidemiology and BiostatisticsSchool of Public HealthUniversity at AlbanyAlbanyNY
| | - Patrick S. Sullivan
- Department of EpidemiologyRollins School of Public HealthEmory UniversityAtlantaGA
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15
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Sheu MJ, Liang FW, Lin CY, Lu TH. Changes in liver-related mortality by etiology and sequelae: underlying versus multiple causes of death. Popul Health Metr 2021; 19:22. [PMID: 33926463 PMCID: PMC8082829 DOI: 10.1186/s12963-021-00249-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 03/31/2021] [Indexed: 01/14/2023] Open
Abstract
Background The expanded definition of liver-related deaths includes a wide range of etiologies and sequelae. We compared the changes in liver-related mortality by etiology and sequelae for different age groups between 2008 and 2018 in the USA using both underlying and multiple cause of death (UCOD and MCOD) data. Methods We extracted mortality data from the CDC WONDER. Both the absolute (rate difference) and relative (rate ratio and 95% confidence intervals) changes were calculated to quantify the magnitude of change using the expanded definition of liver-related mortality. Result Using the expanded definition including secondary liver cancer and according to UCOD data, we identified 68,037 liver-related deaths among people aged 20 years and above in 2008 (29 per 100,000) and this increased to 90,635 in 2018 (33 per 100,000), a 13% increase from 2008 to 2018. However, according to MCOD data, the number of deaths was 113,219 (48 per 100,000) in 2008 and increased to 161,312 (58 per 100,000) in 2018, indicating a 20% increase. The increase according to MCOD was mainly due to increase in alcoholic liver disease and secondary liver cancer (liver metastasis) for each age group and hepatitis C virus (HCV) and primary liver cancer among decedents aged 65–74 years. Conclusion The direction of mortality change (increasing or decreasing) was similar in UCOD and MCOD data in most etiologies and sequelae, except secondary liver cancer. However, the extent of change differed between UCOD and MCOD data.
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Affiliation(s)
- Ming-Jen Sheu
- Division of Gastroenterology and Hepatology, Chi Mei Medical Center, Tainan, Taiwan.,Department of Medicinal Chemistry, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Fu-Wen Liang
- Department of Public Health, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ching-Yih Lin
- Division of Gastroenterology and Hepatology, Chi Mei Medical Center, Tainan, Taiwan
| | - Tsung-Hsueh Lu
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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16
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Sheu MJ, Liang FW, Lu TH. Hepatitis C virus infection mortality trends according to three definitions with special concern for the baby boomer birth cohort. J Viral Hepat 2021; 28:317-325. [PMID: 33141497 DOI: 10.1111/jvh.13436] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 10/20/2020] [Accepted: 10/23/2020] [Indexed: 12/31/2022]
Abstract
We examined mortality trends of hepatitis C virus (HCV) infection in the United States in 1999-2018 according to the following definitions: HCV as the underlying cause of death (UCOD), HCV mentioned anywhere on the death certificate (mentioned), and HCV recorded in Part 1 of the death certificate. By using entity axis information in mortality multiple-cause files, we ascertained the position of HCV on the death certificate. Joinpoint regression analysis was used to evaluate changes in HCV mortality rates according to the definitions. The age-standardized HCV mortality rates (deaths per 100,000 people) in terms of UCOD, mentioned, and Part 1 were, respectively, 1.36, 2.87 and 1.94, in 1999; increased to 1.90, 5.09 and 2.96 in 2013; and declined to 0.98, 3.77 and 2.29 in 2018. The mentioned/UCOD mortality ratio was 2.11 in 1999 and increased to 3.86 in 2018. The mentioned/Part 1 ratio was almost identical (ie 1.48 in 1999 and 1.65 in 2018). The extent of decline from 2014 to 2018 differed according to the definitions; the annual per cent changes for UCOD, mentioned, and Part 1 were -14.6%, -7.1% and -9.8%, respectively. For the same age group, the baby boomer subcohort 1950-1954 had the highest mortality rates among the subcohorts (1945-1949, 1955-1959 and 1960-1964). HCV mortality according to HCV in Part 1 of the death certificate-the explicit opinion of a certifying physician that HCV played a substantial role and directly caused death-differed from that according to HCV as UCOD and HCV mentioned.
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Affiliation(s)
- Ming-Jen Sheu
- Division of Gastroenterology and Hepatology, Chi Mei Medical Center, Tainan, Taiwan.,Department of Medicinal Chemistry, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Fu-Wen Liang
- Department of Public Health, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tsung-Hsueh Lu
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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17
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Mera J, Williams MB, Essex W, McGrew KM, Boeckman L, Gahn D, Miller A, Durham D, Fox J, David C, Ritter T, Jones S, Bouse S, Galvani A, Ward JW, Drevets DA, Carabin H. Evaluation of the Cherokee Nation Hepatitis C Virus Elimination Program in the First 22 Months of Implementation. JAMA Netw Open 2020; 3:e2030427. [PMID: 33337496 PMCID: PMC7749444 DOI: 10.1001/jamanetworkopen.2020.30427] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 10/22/2020] [Indexed: 12/23/2022] Open
Abstract
Importance In 2019, hepatitis C virus (HCV) infection contributed to more deaths in the US than 60 other notifiable infectious diseases combined. The incidence of and mortality associated with HCV infection are highest among American Indian and Alaska Native individuals. Objective To evaluate the association of the Cherokee Nation (CN) HCV elimination program with each element of the cascade of care: HCV screening, linkage to care, treatment, and cure. Design, Setting, and Participants This cohort study used data from the CN Health Services (CNHS), which serves approximately 132 000 American Indian and Alaska Native individuals residing in the 14-county CN reservation in rural northeastern Oklahoma. Data from the first 22 months of implementation (November 1, 2015, to August 31, 2017) of an HCV elimination program were compared with those from the pre-elimination program period (October 1, 2012, to October 31, 2015). The analysis included American Indian and Alaska Native individuals aged 20 to 69 years who accessed care through the CNHS between October 1, 2012, and August 31, 2017. Cure data were recorded through April 15, 2018. Exposure The CN HCV elimination program. Main Outcomes and Measures The main outcomes were the proportions of the population screened for HCV, diagnosed with current HCV infection, linked to care, treated, and cured during the initial 22 months of the elimination program period and the pre-elimination program period. Data from electronic health records and an HCV treatment database were analyzed. The cumulative incidence of HCV infection in this population was estimated using bayesian analyses. Results Among the 74 039 eligible individuals accessing care during the elimination program period, the mean (SD) age was 36.0 (13.5) years and 55.9% were women. From the pre-elimination program period to the elimination program period, first-time HCV screening coverage increased from 20.9% to 38.2%, and identification of current HCV infection and treatment in newly screened individuals increased from a mean (SD) of 170 (40) per year to 244 (4) per year and a mean of 95 (133) per year to 215 (9) per year, respectively. During the implementation period, of the 793 individuals with current HCV infection accessing the CNHS, 664 were evaluated (83.7%), 394 (59.3%) initiated treatment, and 335 (85.0%) had documented cure. In less than 2 years, the 85% 3-year goal was reached for cure (85.0%), and the goal for linkage to care was nearly reached (83.7%), whereas screening (44.1%) and treatment initiation (59.3%) required more time and resources. Conclusions and Relevance This cohort study found that after 22 months of implementation, the CNHS community-based HCV elimination program was associated with an improved cascade of care. The facilitators and lessons learned in this program may be useful to other organizations planning similar programs.
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Affiliation(s)
- Jorge Mera
- Cherokee Nation Health Services, Tahlequah, Oklahoma
| | - Mary B. Williams
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City
- Department of Family and Community Medicine, School of Community Medicine, University of Oklahoma Health Sciences Center, Tulsa
| | - Whitney Essex
- Cherokee Nation Health Services, Tahlequah, Oklahoma
| | - Kaitlin M. McGrew
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City
| | - Lindsay Boeckman
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City
| | - David Gahn
- Cherokee Nation Health Services, Tahlequah, Oklahoma
| | - Anna Miller
- Cherokee Nation Health Services, Tahlequah, Oklahoma
| | - David Durham
- Center for Infectious Diseases Modeling and Analysis, Yale School of Public Health, New Haven, Connecticut
| | - Jan Fox
- Oklahoma State Department of Health, Oklahoma City
| | - Crystal David
- Cherokee Nation Health Services, Tahlequah, Oklahoma
- Oklahoma State University Center for Health Sciences, Tulsa
| | - Tara Ritter
- Cherokee Nation Health Services, Tahlequah, Oklahoma
| | - Stephen Jones
- Cherokee Nation Health Services, Tahlequah, Oklahoma
| | - Sally Bouse
- Oklahoma State Department of Health, Oklahoma City
| | - Alison Galvani
- Center for Infectious Diseases Modeling and Analysis, Yale School of Public Health, New Haven, Connecticut
| | - John W. Ward
- Coalition for Global Hepatitis Elimination, The Task Force for Global Health, Decatur, Georgia
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Douglas A. Drevets
- Section of Infectious Diseases, Department of Internal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City
- Medical Services, Department of Veterans Affairs Medical Center, Oklahoma City, Oklahoma
| | - Hélène Carabin
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City
- Département de Pathologie et Microbiologie, Université de Montréal, Montréal, Quebec, Canada
- Département de Médecine Sociale et Préventive, Université de Montréal, Montréal, Quebec, Canada
- Centre de Recherche en Santé Publique, Montréal, Quebec, Canada
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18
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Abadie R, Dombrowski K. "Caballo": risk environments, drug sharing and the emergence of a hepatitis C virus epidemic among people who inject drugs in Puerto Rico. Harm Reduct J 2020; 17:85. [PMID: 33097062 PMCID: PMC7582446 DOI: 10.1186/s12954-020-00421-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 10/06/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sharing drug injection equipment has been associated with the transmission of HCV among PWID through blood contained in the cooker and cotton used to prepare and divide up the drug solution. While epidemiologists often subsume this practice under the sharing of "ancillary equipment," more attention should be paid to the fact that indirect sharing takes place within the process of joint drug acquisition and preparation. METHODS We employed an ethnographic approach observing active PWID (N = 33) in four rural towns in Puerto Rico in order to document drug sharing arrangements involved in "caballo", as this practice is locally known. We explored partners' motivation to engage in drug sharing, as well as its social organization, social roles and existing norms. FINDINGS Findings suggest that drug sharing, is one of the main drivers of the HCV epidemic in this population. Lack of financial resources, drug packaging, drug of choice and the desire to avoid the painful effects of heroin withdrawal motivates participants' decision to partner with somebody else, sharing injection equipment-and risk-in the process. Roles are not fixed, changing not only according to caballo partners, but also, power dynamics. CONCLUSION In order to curb the HCV epidemic, harm reduction policies should recognize the particular sociocultural contexts in which people inject drugs and make decisions about risk. Avoiding sharing of injection equipment within an arrangement between PWID to acquire and use drugs is more complex than assumed by harm reduction interventions. Moving beyond individual risk behaviors, a risk environment approach suggest that poverty, and a strict drug policy that encourage users to carry small amounts of illicit substances, and a lack of HCV treatment among other factors, contribute to HCV transmission.
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Affiliation(s)
- R Abadie
- Department of Anthropology, University of Nebraska-Lincoln, 839 Oldfather Hall, Lincoln, NE, 68588, USA.
| | - K Dombrowski
- Department of Anthropology, University of Vermont, 72 University Place, Burlington, VE, 05405, USA
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