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Waddell CJ, Saldana CS, Schoonveld MM, Meehan AA, Lin CK, Butler JC, Mosites E. Infectious Diseases Among People Experiencing Homelessness: A Systematic Review of the Literature in the United States and Canada, 2003-2022. Public Health Rep 2024; 139:532-548. [PMID: 38379269 PMCID: PMC11344984 DOI: 10.1177/00333549241228525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024] Open
Abstract
Homelessness increases the risk of acquiring an infectious disease. We conducted a systematic review of the literature to identify quantitative data related to infectious diseases and homelessness. We searched Google Scholar, PubMed, and SCOPUS for quantitative literature published from January 2003 through December 2022 in English from the United States and Canada. We excluded literature on vaccine-preventable diseases and HIV because these diseases were recently reviewed. Of the 250 articles that met inclusion criteria, more than half were on hepatitis C virus or Mycobacterium tuberculosis. Other articles were on COVID-19, respiratory syncytial virus, Staphylococcus aureus, group A Streptococcus, mpox (formerly monkeypox), 5 sexually transmitted infections, and gastrointestinal or vectorborne pathogens. Most studies showed higher prevalence, incidence, or measures of risk for infectious diseases among people experiencing homelessness as compared with people who are housed or the general population. Although having increased published data that quantify the infectious disease risks of homelessness is encouraging, many pathogens that are known to affect people globally who are not housed have not been evaluated in the United States or Canada. Future studies should focus on additional pathogens and factors leading to a disproportionately high incidence and prevalence of infectious diseases among people experiencing homelessness.
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Affiliation(s)
- Caroline J. Waddell
- Office of Readiness and Response, Centers for Disease Control and Prevention, Atlanta, GA, USA
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Carlos S. Saldana
- Division of Infectious Disease, School of Medicine, Emory University, Atlanta, GA, USA
| | - Megan M. Schoonveld
- Office of Readiness and Response, Centers for Disease Control and Prevention, Atlanta, GA, USA
- Oak Ridge Institute for Science and Education, US Department of Energy, Oak Ridge, TN, USA
| | - Ashley A. Meehan
- Office of Readiness and Response, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Christina K. Lin
- Department of Medicine, School of Medicine, Emory University, Atlanta, GA, USA
| | - Jay C. Butler
- Office of Readiness and Response, Centers for Disease Control and Prevention, Atlanta, GA, USA
- Division of Infectious Disease, School of Medicine, Emory University, Atlanta, GA, USA
| | - Emily Mosites
- Office of Readiness and Response, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Bredenberg E, Callister C, Dafoe A, Holliman BD, Rowan SE, Calcaterra SL. Subspecialty physicians' perspectives on barriers and facilitators of hepatitis C treatment: a qualitative study. Harm Reduct J 2024; 21:140. [PMID: 39054530 PMCID: PMC11271208 DOI: 10.1186/s12954-024-01057-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 07/11/2024] [Indexed: 07/27/2024] Open
Abstract
INTRODUCTION The hepatitis C virus (HCV) causes chronic and curable disease with a substantial burden of morbidity and mortality across the globe. In the United States (US) and other developed countries, incidence of HCV is increasing and people who inject drugs are disproportionately affected. However, HCV treatment rates amongst patients with substance use disorders (SUD) are suboptimal. In this study, we aimed to understand the perspectives of subspecialist physicians who care for substantial numbers of patients with HCV, including addiction medicine, infectious diseases, and hepatology physicians, to better understand barriers and facilitators of HCV treatment. METHODS We recruited subspecialty physicians via purposive and snowball sampling and conducted semi-structured interviews with 20 physicians at 12 institutions across the US. We used a mixed deductive and inductive approach to perform qualitative content analysis with a rapid matrix technique. RESULTS Three major themes emerged: (1) Perceptions of patient complexity; (2) Systemic barriers to care, and (3) Importance of multidisciplinary teams. Within these themes, we elicited subthemes on the effects of patient-level factors, provider-level factors, and insurance-based requirements. CONCLUSION Our results suggest that additional strategies are needed to reach the "last mile" untreated patients for HCV care, including decentralization and leverage of telehealth-based interventions to integrate treatment within primary care clinics, SUD treatment facilities, and community harm reduction sites. Such programs are likely to be more successful when multidisciplinary teams including pharmacists and/or peer navigators are involved. However, burdensome regulatory requirements continue to hinder this expansion in care and should be eliminated.
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Affiliation(s)
- Erin Bredenberg
- Division of Hospital Medicine, University of Colorado School of Medicine, 4th Floor, Leprino Building 12401 E 17th Ave, Aurora, CO, 80045, USA.
| | - Catherine Callister
- Division of Hospital Medicine, University of Colorado School of Medicine, 4th Floor, Leprino Building 12401 E 17th Ave, Aurora, CO, 80045, USA
| | - Ashley Dafoe
- Adult and Child Center for Health Outcomes Research and Delivery Science, Aurora, CO, USA
| | - Brooke Dorsey Holliman
- Adult and Child Center for Health Outcomes Research and Delivery Science, Aurora, CO, USA
| | - Sarah E Rowan
- Denver Health and Hospital Authority, Denver, CO, USA
- Division of Infectious Diseases, University of Colorado, Aurora, CO, USA
| | - Susan L Calcaterra
- Division of Hospital Medicine, University of Colorado School of Medicine, 4th Floor, Leprino Building 12401 E 17th Ave, Aurora, CO, 80045, USA
- Adult and Child Center for Health Outcomes Research and Delivery Science, Aurora, CO, USA
- Division of General Internal Medicine, University of Colorado, Aurora, CO, USA
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DeCamillis RB, Hekman AL, Priest DH. Screening for hepatitis C as part of an opioid stewardship quality improvement initiative: Identifying infected patients and analyzing linkage to care. Clin Liver Dis (Hoboken) 2024; 23:e0118. [PMID: 38283305 PMCID: PMC10810596 DOI: 10.1097/cld.0000000000000118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/07/2023] [Indexed: 01/30/2024] Open
Abstract
Screening patients with opioid use disorder (OUD) for HCV can potentially decrease morbidity and mortality if HCV-infected individuals are linked to care. We describe a quality improvement initiative focused on patients with OUD, incorporating an electronic health record decision-support tool for HCV screening across multiple health care venues, and examining the linkage to HCV care. Of 5829 patients with OUD, 4631 were tested for HCV (79.4%), (compared to a baseline of 8%) and 1614 (27.7%) tested positive. Two hundred and thirty patients had died at the study onset. Patients tested in the acute care and emergency department settings were more likely to test positive than those in the ambulatory setting (OR = 2.21 and 2.49, p < 0.001). Before patient outreach, 279 (18.2%) HCV-positive patients were linked to care. After patient outreach, 326 (23.0%) total patients were linked to care. Secondary end points included mortality and the number of patients who were HCV-positive who achieved a cure. The mortality rate in patients who were HCV-positive (12.2%) was higher than that in patients who were HCV-negative (7.4%) (OR = 1.72, p < 0.001) or untested patients (6.2%) (OR = 2.10, p<0.001). Of the 326 with successful linkage to care, 113 (34.7%) had a documented cure. An additional 55 (16.9%) patients had a possible cure, defined as direct acting antiviral ordered but no follow-up documented, known treatment in the absence of documented sustained viral response lab draw, or documentation of cure noted in outside medical records but unavailable laboratory results. A strategy utilizing electronic health record decision-support tools for testing patients with OUD for HCV was highly effective; however, linking patients with HCV to care was less successful.
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Brooks R, Wegener M, Freeman B, Fowles C, Madden LM, Tetrault JM, Nichols L, Altice FL, Villanueva M. Improving HIV and HCV Testing in Substance Use Disorder Programs (SUDs) That Provide Medications for Opiate Use Disorder (MOUD): Role of Addressing Barriers and Implementing Universal and Site-Specific Approaches. Health Promot Pract 2023; 24:1018-1028. [PMID: 37439759 DOI: 10.1177/15248399231169791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
Introduction. National strategies to end the HIV epidemic and eliminate hepatitis c (HCV) through a syndemic approach require improvements in testing for HIV and HCV. Given the intersection of the opioid crisis with HIV and HCV acquisition, substance use disorder (SUD) treatment centers providing medications for opiate use disorder (MOUD) provide a critical opportunity to expand testing. Rates of testing in MOUD clinics have been suboptimal. Method. We employed the Nominal Group Technique (NGT), Ishikawa cause and effect diagrams, and individualized Quality Improvement (QI) efforts at two SUD clinics (SUD A and B) in Connecticut (CT) as part of an HRSA-funded grant focused on improving HCV cure in persons with HIV/HCV coinfection. Baseline and longitudinal data were collected on rates of HIV and HCV testing and positivity as well as linkage to treatment. Results. Between April 1, 2019, and May 31, 2021, for SUD A and B respectively, HIV testing increased from 13% to 90% and 33% to 83%; HCV testing increased from 4% to 90% and 30% to 82%, with few reported cases of HIV/HCV coinfection. HCV testing revealed new and prior diagnoses at both sites, with subsequent referrals for treatment. Qualitative assessments identified best practices which included the institution of formal policies and procedures, streamlining of testing logistics, designation of a site champion, and broadening relevant education to staff and clients. Conclusion. Strategic assessment of barriers and facilitators to HIV and HCV testing at MOUD clinics can lead to improved testing and referral rates that are key to improving the cascade of care for both diseases.
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Affiliation(s)
- Ralph Brooks
- Yale University School of Medicine, New Haven, CT, USA
| | | | | | - Cathy Fowles
- Recovery Network of Programs, Inc. (RNP), Bridgeport, CT, USA
| | - Lynn M Madden
- Yale University School of Medicine, New Haven, CT, USA
- APT Foundation, New Haven, CT, USA
| | - Jeanette M Tetrault
- Yale University School of Medicine, New Haven, CT, USA
- APT Foundation, New Haven, CT, USA
| | - Lisa Nichols
- Yale University School of Medicine, New Haven, CT, USA
| | - Frederick L Altice
- Yale University School of Medicine, New Haven, CT, USA
- APT Foundation, New Haven, CT, USA
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Rowan SE, Haukoos J, Kamis KF, Hopkins E, Gravitz S, Lyle C, Al-Tayyib AA, Gardner EM, Galbraith JW, Hsieh YH, Lyons MS, Rothman RE, White DAE, Morgan JR, Linas BP, Sabel AL, Wyles DL. The Determining Effective Testing in Emergency Departments and Care Coordination on Treatment Outcomes (DETECT) for Hepatitis C (Hep C) Linkage-to-Care Trial: rationale and design of an emergency department-based randomized clinical trial of linkage-to-care strategies for hepatitis C. Trials 2023; 24:63. [PMID: 36707909 PMCID: PMC9880363 DOI: 10.1186/s13063-022-07018-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 12/15/2022] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Hepatitis C (HCV) poses a major public health problem in the USA. While early identification is a critical priority, subsequent linkage to a treatment specialist is a crucial step that bridges diagnosed patients to treatment, cure, and prevention of ongoing transmission. Emergency departments (EDs) serve as an important clinical setting for HCV screening, although optimal methods of linkage-to-care for HCV-diagnosed individuals remain unknown. In this article, we describe the rationale and design of The Determining Effective Testing in Emergency Departments and Care Coordination on Treatment Outcomes (DETECT) for Hepatitis C (Hep C) Linkage-to-Care Trial. METHODS The DETECT Hep C Linkage-to-Care Trial will be a single-center prospective comparative effectiveness randomized two-arm parallel-group superiority trial to test the effectiveness of linkage navigation and clinician referral among ED patients identified with untreated HCV with a primary hypothesis that linkage navigation plus clinician referral is superior to clinician referral alone when using treatment initiation as the primary outcome. Participants will be enrolled in the ED at Denver Health Medical Center (Denver, CO), an urban, safety-net hospital with approximately 75,000 annual adult ED visits. This trial was designed to enroll a maximum of 280 HCV RNA-positive participants with one planned interim analysis based on methods by O'Brien and Fleming. This trial will further inform the evaluation of cost effectiveness, disparities, and social determinants of health in linkage-to-care, treatment, and disease progression. DISCUSSION When complete, the DETECT Hep C Linkage-to-Care Trial will significantly inform how best to perform linkage-to-care among ED patients identified with HCV. TRIAL REGISTRATION ClinicalTrials.gov ID: NCT04026867 Original date: July 1, 2019 URL: https://clinicaltrials.gov/ct2/show/NCT04026867.
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Affiliation(s)
- Sarah E. Rowan
- grid.241116.10000000107903411Division of Infectious Diseases, Denver Health Medical Center and University of Colorado School of Medicine, Denver, CO USA ,grid.239638.50000 0001 0369 638XPublic Health Institute at Denver Health, Denver, CO USA
| | - Jason Haukoos
- grid.241116.10000000107903411Department of Emergency Medicine, Denver Health Medical Center and University of Colorado School of Medicine, 777 Bannock Street, Mail Code 0108, Denver, CO 80204 USA ,grid.414594.90000 0004 0401 9614Department of Epidemiology, Colorado School of Public Health, Aurora, CO USA ,Colorado Social Emergency Medicine Collaborative, Denver, CO USA
| | - Kevin F. Kamis
- grid.239638.50000 0001 0369 638XPublic Health Institute at Denver Health, Denver, CO USA
| | - Emily Hopkins
- grid.241116.10000000107903411Department of Emergency Medicine, Denver Health Medical Center and University of Colorado School of Medicine, 777 Bannock Street, Mail Code 0108, Denver, CO 80204 USA ,Colorado Social Emergency Medicine Collaborative, Denver, CO USA
| | - Stephanie Gravitz
- grid.241116.10000000107903411Department of Emergency Medicine, Denver Health Medical Center and University of Colorado School of Medicine, 777 Bannock Street, Mail Code 0108, Denver, CO 80204 USA ,Colorado Social Emergency Medicine Collaborative, Denver, CO USA
| | - Carolynn Lyle
- grid.241116.10000000107903411Department of Emergency Medicine, Denver Health Medical Center and University of Colorado School of Medicine, 777 Bannock Street, Mail Code 0108, Denver, CO 80204 USA ,Colorado Social Emergency Medicine Collaborative, Denver, CO USA
| | - Alia A. Al-Tayyib
- grid.239638.50000 0001 0369 638XPublic Health Institute at Denver Health, Denver, CO USA ,grid.414594.90000 0004 0401 9614Department of Epidemiology, Colorado School of Public Health, Aurora, CO USA
| | - Edward M. Gardner
- grid.241116.10000000107903411Division of Infectious Diseases, Denver Health Medical Center and University of Colorado School of Medicine, Denver, CO USA ,grid.239638.50000 0001 0369 638XPublic Health Institute at Denver Health, Denver, CO USA
| | - James W. Galbraith
- grid.410721.10000 0004 1937 0407Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, MS USA
| | - Yu-Hsiang Hsieh
- grid.21107.350000 0001 2171 9311Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD USA
| | - Michael S. Lyons
- grid.412332.50000 0001 1545 0811Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH USA
| | - Richard E. Rothman
- grid.21107.350000 0001 2171 9311Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD USA
| | - Douglas A. E. White
- grid.414076.00000 0004 0427 1107Department of Emergency Medicine, Highland Hospital, Alameda Health System, Oakland, CA USA
| | - Jake R. Morgan
- grid.189504.10000 0004 1936 7558Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA USA ,Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV, Boston, MA USA
| | - Benjamin P. Linas
- Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV, Boston, MA USA ,grid.189504.10000 0004 1936 7558Division of Infectious Diseases, Boston University School of Medicine, Boston, MA USA
| | - Allison L. Sabel
- grid.239638.50000 0001 0369 638XDepartment of Patient Safety and Quality, Denver Health, Denver, CO USA ,grid.414594.90000 0004 0401 9614Department of Biostatistics, Colorado School of Public Health, Aurora, CO USA
| | - David L. Wyles
- grid.241116.10000000107903411Division of Infectious Diseases, Denver Health Medical Center and University of Colorado School of Medicine, Denver, CO USA
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Wang AE, Hsieh E, Turner BJ, Terrault N. Integrating Management of Hepatitis C Infection into Primary Care: the Key to Hepatitis C Elimination Efforts. J Gen Intern Med 2022; 37:3435-3443. [PMID: 35484367 PMCID: PMC9551010 DOI: 10.1007/s11606-022-07628-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 04/18/2022] [Indexed: 11/24/2022]
Abstract
Elimination of hepatitis C virus (HCV), a leading cause of liver disease in the USA and globally, has been made possible with the advent of highly efficacious direct acting antivirals (DAAs). DAA regimens offer cure of HCV with 8-12 weeks of a well-tolerated once daily therapy. With increasingly straightforward diagnostic and treatment algorithms, HCV infection can be managed not only by specialists, but also by primary care providers. Engaging primary care providers greatly increases capacity to diagnose and treat chronic HCV and ultimately make HCV elimination a reality. However, barriers remain at each step in the HCV cascade of care from screening to evaluation and treatment. Since primary care is at the forefront of patient contact, it represents the ideal place to concentrate efforts to identify barriers and implement solutions to achieve universal HCV screening and increase curative treatment.
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Affiliation(s)
- Allison E Wang
- Department of Internal Medicine, University of Southern California, Los Angeles, CA, USA
| | - Eric Hsieh
- Department of Internal Medicine, University of Southern California, Los Angeles, CA, USA
| | - Barbara J Turner
- Department of Internal Medicine, University of Southern California, Los Angeles, CA, USA
| | - Norah Terrault
- Department of Internal Medicine, University of Southern California, Los Angeles, CA, USA.
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, University of Southern California, Los Angeles, CA, USA.
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Hepatitis C treatment outcomes among patients treated in co-located primary care and addiction treatment settings. J Subst Abuse Treat 2021; 131:108438. [PMID: 34098298 DOI: 10.1016/j.jsat.2021.108438] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 01/22/2021] [Accepted: 04/21/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Persons with substance use disorders face major barriers to hepatitis C virus (HCV) treatment. Co-location of addiction and HCV treatment is appealing, yet there are limited data on outcomes using this model. This study evaluated HCV outcomes of patients treated with direct-acting antivirals (DAAs) by primary care providers in two sites of co-located addiction/HCV care. METHODS The study conducted a retrospective chart review for all patients receiving DAA treatment from 2016 to 2018 at 1) a hospital-based primary care clinic with an office-based buprenorphine program, and 2) a primary care clinic within an opioid treatment program (i.e. methadone clinic). The study classified patients into 3 groups according to treatment status: buprenorphine maintenance, methadone maintenance, or neither. Descriptive analyses compared patient demographics, clinical characteristics, adherence to monitoring and treatment, and the primary outcome of sustained virologic response at 12 weeks (SVR12), defined as an undetectable HCV viral load at least 12 weeks after completing treatment. RESULTS This study included 50 patients who initiated DAA treatment. The majority of patients were unemployed (74.0%), did not smoke tobacco (54.0%), and had psychiatric comorbidities (80.0%). Many also experienced homelessness during treatment (22.0%) and experienced previous incarceration (36.0%). Only a few had recently injected drugs (4.0%). Seven of 7 (100%) patients were treated with buprenorphine, 21 of 24 (87.5%) patients were treated with methadone, and 17 of 19 (89.5%) patients receiving no opioid addiction treatment fully completed HCV DAA treatment. When including patients with missing SVR12 data with the cohort that did not achieve cure, we observe that 44 of 50 patients (88.0%) achieved SVR12. Excluding patients missing SVR12 data, we observed that 44 of 46 patients (95.7%) achieved SVR12. CONCLUSION Persons with substance use disorders treated with DAAs in co-located primary care and addiction treatment settings can achieve high rates of cure despite significant comorbidities and barriers. DAA treatment should be expanded to co-located HCV and addiction settings.
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