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Snow K, MacLachlan JH, Rowe S, Higgins N, Cowie BC. The cascade of care for hepatitis C in Victoria, Australia: a data linkage cohort study. Intern Med J 2024; 54:1146-1154. [PMID: 38504432 DOI: 10.1111/imj.16361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 02/01/2024] [Indexed: 03/21/2024]
Abstract
BACKGROUND Highly effective hepatitis C therapies are available in Australia. However, people living with hepatitis C face various barriers to accessing care and treatment. AIMS To identify gaps in the cascade of care for hepatitis C and generate estimates of the number living with untreated infection according to population group, using a representative longitudinal study population. METHODS We linked hepatitis C notification data from Victoria to national pathology, prescribing and death registry data. We assessed receipt of key clinical services in a large cohort who tested positive for hepatitis C from 1 January 2000 to 31 December 2016, with follow-up to 30 June 2018. We estimated the number still living with hepatitis C, adjusting for spontaneous clearance and mortality. RESULTS The cohort comprised 45 391 people positive for hepatitis C. Of these, 13 346 (29%) received treatment and an estimated 28% (95% confidence interval (CI): 26-30%) were still living with chronic infection at 30 June 2018, with the remainder still living following spontaneous clearance (30%, 95% CI: 29-32%) or having died (12%, 95% CI: 12-12%). Half (50%) of those still living with hepatitis C were born from 1965 to 1980, and 74% first tested positive before 2011. CONCLUSIONS Despite an enabling policy environment and subsidised therapy, many people in this cohort were not treated. Increased measures may be needed to engage people in care, including those who acquired hepatitis C more than 10 years ago.
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Affiliation(s)
- Kathryn Snow
- WHO Collaborating Centre for Viral Hepatitis, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Jennifer H MacLachlan
- WHO Collaborating Centre for Viral Hepatitis, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Department of Infectious Diseases, University of Melbourne, Melbourne, Victoria, Australia
| | - Stacey Rowe
- Victorian Government Department of Health, Melbourne, Victoria, Australia
- School of Population Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Nasra Higgins
- Victorian Government Department of Health, Melbourne, Victoria, Australia
| | - Benjamin C Cowie
- WHO Collaborating Centre for Viral Hepatitis, The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Department of Infectious Diseases, University of Melbourne, Melbourne, Victoria, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Basoulis D, Mastrogianni E, Eliadi I, Papadopoulou M, Psichogiou M. HCV-HIV co-infection in people who inject drugs: Barriers to treatment and cure of HCV infection in the era of DAAs, a prospective study in Athens, Greece. HIV Med 2024. [PMID: 39031579 DOI: 10.1111/hiv.13681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 05/29/2024] [Indexed: 07/22/2024]
Abstract
OBJECTIVES HIV/hepatitis C virus (HCV) co-infection among people who inject drugs (PWID) remains a global health problem. The goal of our study was to evaluate, in a real-world setting, success rates of sustained virological response (SVR) using direct-acting antivirals (DAAs) to treat a population of PWID living with HCV/HIV. METHODS This was a prospective single-center observational study. We collected demographic, socioeconomic, and clinical data pertaining to HIV and HCV infection in PWID with several barriers to care. We identified risk factors for SVR failure. RESULTS Among 130 individuals retained to HIV care, we planned HCV treatment in 119/130 (91.5%); 106/119 (89.1%) started treatment with DAAs and 100/106 (94.3%) completed treatment. People not starting treatment were more often in active opioid drug use (odds ratio [OR] 0.25; 95% confidence interval [CI] 0.07-0.97, p = 0.045) and benzodiazepine abuse (OR 0.25; 95% CI 0.07-0.95, p = 0.042). Only 86/100 (86%) were tested for SVR at 12 weeks (SVR12) and 72/86 (83.7%) achieved SVR. PWID in opioid substitution programmes tended to return for SVR12 testing more often (54.7% vs. 30%, p = 0.081). Individuals in active opioid drug use (OR 0.226; 95% CI 0.064-0.793, p = 0.02) or with poor adherence (OR 0.187; 95% CI 0.043-0.814, p = 0.025) were less likely to achieve SVR. At the end of our study period, 113/119 (95%) treatment-eligible patients remained alive. HCV infection was cured in 68/113 (61.1%) people. CONCLUSIONS Our findings underscore the importance of prioritizing combatting substance use to achieve HCV elimination goals. A systematic approach with effort to overcome barriers to receiving and completing treatment and encourage to enrol in opioid substitution programmes if not possible to completely abstain from use, can help increase chances of HCV cure.
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Affiliation(s)
- Dimitris Basoulis
- 1st Department of Internal Medicine, Laiko General Hospital, Athens, Greece
| | | | - Irene Eliadi
- 1st Department of Internal Medicine, Laiko General Hospital, Athens, Greece
| | | | - Mina Psichogiou
- 1st Department of Internal Medicine, Laiko General Hospital, Athens, Greece
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Yeoh YKJ, Dore GJ, Lockart I, Danta M, Flynn C, Blackmore C, Levy MT, George J, Alavi M, Hajarizadeh B. Temporal change in aetiology and clinical characteristics of hepatocellular carcinoma in a large cohort of patients in New South Wales, Australia. Intern Med J 2024; 54:602-612. [PMID: 37819787 DOI: 10.1111/imj.16252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 09/17/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Viral hepatitis, alcohol-related liver disease (ARLD) and nonalcoholic fatty liver disease (NAFLD) are the main risk factors for hepatocellular carcinoma (HCC) in many countries. In Australia, given the access to hepatitis C virus (HCV) direct-acting antiviral (DAA) therapy since 2016, a temporal change in HCC aetiology was hypothesized. This study evaluated the temporal change in the aetiology and characteristics of HCC in New South Wales (NSW). METHODS Patients diagnosed with HCC, admitted to three public hospitals in NSW between 2008 and 2021, were included in the analyses. We assessed the annual frequency of each HCC aetiology and the distribution of HCC characteristics in participants. RESULTS Among 1370 patients, the most common HCC etiologies were HCV (n = 483, 35%), ARLD (n = 452, 33%), NAFLD (n = 347, 25%) and hepatitis B virus (n = 301, 22%). The proportion of HCV-related HCC was the highest in 2011-2016 (41%) and significantly declined to 30% in 2017-2021 (odds ratio [OR], 0.53 [95% confidence interval (CI), 0.35-0.79]; P = 0.002). The proportion of HCC diagnosed at an early stage (Barcelona Clinic Liver Cancer stage O/A) increased from 41% in 2008-2009 to 56% in 2020-2021 (OR per annum, 1.05 [95% CI, 1.02-1.08]; P = 0.002), and the proportion of patients receiving potentially curative HCC management increased from 29% in 2008-2009 to 41% in 2020-2021 (OR per annum, 1.06 [95% CI, 1.03-1.10]; P < 0.001). CONCLUSION The contribution of HCV to HCC burden has been decreasing in the DAA era, suggesting the role of HCV elimination in decreasing HCC risk. Increasing frequency of less advanced HCC at diagnosis over time suggests improved HCC surveillance.
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Affiliation(s)
| | - Gregory J Dore
- The Kirby Institute, UNSW, New South Wales, Sydney, Australia
- St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Ian Lockart
- St Vincent's Clinical School, UNSW, New South Wales, Sydney, Australia
- St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Mark Danta
- St Vincent's Clinical School, UNSW, New South Wales, Sydney, Australia
- St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Ciara Flynn
- St Vincent's Clinical School, UNSW, New South Wales, Sydney, Australia
| | - Conner Blackmore
- Liverpool Hospital, Sydney, New South Wales, Australia
- South Western Clinical School, UNSW, New South Wales, Sydney, Australia
| | - Miriam T Levy
- Liverpool Hospital, Sydney, New South Wales, Australia
- South Western Clinical School, UNSW, New South Wales, Sydney, Australia
| | - Jacob George
- Storr Liver Centre, Westmead Hospital and The Westmead Institute for Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Maryam Alavi
- The Kirby Institute, UNSW, New South Wales, Sydney, Australia
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Tomic D, Salim A, George J, Magliano DJ, Shaw JE. Liver disease mortality and hospitalisations among people with type 2 diabetes mellitus: A population-based study. Liver Int 2024; 44:508-517. [PMID: 38010999 DOI: 10.1111/liv.15794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/12/2023] [Accepted: 11/07/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND AND AIMS The burden of liver disease among people with diabetes at a population level is unknown. We explored the burden and trends of liver disease mortality and hospitalisations among Australians with diabetes. METHODS We linked Australians with type 2 diabetes on the National Diabetes Services Scheme to the National Death Index for 2002-2019 to determine trends in the proportion of deaths due to liver disease, overall and by subcategory. We also determined the leading reasons and risk factors for liver disease hospitalisations in those with diabetes over this period. Finally, we compared the burden of liver disease hospitalisations among those with diabetes to the general population using excess hospitalisations per 100 000 person-years. RESULTS Among Australians with type 2 diabetes (n = 1 122 431) liver diseases accounted for between 1.5% and 1.9% of deaths between 2002 and 2019, roughly one-third of the proportion of deaths caused by kidney disease. The proportion of deaths due to inflammatory liver diseases among those with diabetes increased from .08% in 2002 to .27% in 2019. Alcohol-related liver disease accounted for the greatest share (22.7%) of liver disease hospitalisation in those with diabetes, but the number of hospitalisations for this condition declined over time. Compared to the general population, men (RR 3.63, 95% CI 3.44-3.84) and women (RR 4.49, 4.21-4.78) with diabetes were at higher risk of hospitalisation for fibrosis and cirrhosis; however, this did not translate to a substantial excess risk per 100 000 population. CONCLUSIONS Better screening methods for liver disease among people with diabetes should be developed and implemented into practice.
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Affiliation(s)
- Dunya Tomic
- Diabetes and Population Health, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Agus Salim
- Diabetes and Population Health, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
- School of Mathematics and Statistics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Jacob George
- Storr Liver Centre, Westmead Institute for Medical Research, Westmead Hospital and University of Sydney, Sydney, New South Wales, Australia
| | - Dianna J Magliano
- Diabetes and Population Health, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jonathan E Shaw
- Diabetes and Population Health, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Dawe J, Hughes M, Christensen S, Walsh L, Richmond JA, Pedrana A, Wilkinson AL, Owen L, Doyle JS. Evaluation of a person-centred, nurse-led model of care delivering hepatitis C testing and treatment in priority settings: a mixed-methods evaluation of the Tasmanian Eliminate Hepatitis C Australia Outreach Project, 2020-2022. BMC Public Health 2023; 23:2289. [PMID: 37985979 PMCID: PMC10662700 DOI: 10.1186/s12889-023-17066-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 10/25/2023] [Indexed: 11/22/2023] Open
Abstract
INTRODUCTION Australia has experienced sustained reductions in hepatitis C testing and treatment and may miss its 2030 elimination targets. Addressing gaps in community-based hepatitis C prescribing in priority settings that did not have, or did not prioritise, hepatitis C testing and treatment care pathways is critical. METHODS The Tasmanian Eliminate Hepatitis C Australia Outreach Project delivered a nurse-led outreach model of care servicing hepatitis C priority populations in the community through the Tasmanian Statewide Sexual Health Service, supported by the Eliminating Hepatitis C Australia partnership. Settings included alcohol and other drug services, needle and syringe programs and mental health services. The project provided clients with clinical care across the hepatitis C cascade of care, including testing, treatment, and post-treatment support and hepatitis C education for staff. RESULTS Between July 2020 and July 2022, a total of 43 sites were visited by one Clinical Nurse Consultant. There was a total of 695 interactions with clients across 219 days of service delivery by the Clinical Nurse Consultant. A total of 383 clients were tested for hepatitis C (antibody, RNA, or both). A total of 75 clients were diagnosed with hepatitis C RNA, of which 95% (71/75) commenced treatment, 83% (62/75) completed treatment and 52% (39/75) received a negative hepatitis C RNA test at least 12 weeks after treatment completion. CONCLUSIONS Providing outreach hepatitis C services in community-based services was effective in engaging people living with and at-risk of hepatitis C, in education, testing, and care. Nurse-led, person-centred care was critical to the success of the project. Our evaluation underscores the importance of employing a partnership approach when delivering hepatitis C models of care in community settings, and incorporating workforce education and capacity-building activities when working with non-specialist healthcare professionals.
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Affiliation(s)
- Joshua Dawe
- Disease Elimination, Burnet Institute, Melbourne, Australia.
| | - Megan Hughes
- Sexual Health Service Tasmania, Hobart, Australia
| | | | - Louisa Walsh
- Disease Elimination, Burnet Institute, Melbourne, Australia
- Centre for Health Communication and Participation, La Trobe University, Melbourne, Australia
| | | | - Alisa Pedrana
- Disease Elimination, Burnet Institute, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Anna L Wilkinson
- Disease Elimination, Burnet Institute, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Louise Owen
- Sexual Health Service Tasmania, Hobart, Australia
| | - Joseph S Doyle
- Disease Elimination, Burnet Institute, Melbourne, Australia
- Department of Infectious Diseases, Alfred Health and Monash University, Melbourne, Australia
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Hobday S, Valerio H, Combo T, Monaghan R, Scott C, Silk D, Murray C, Read P, Henderson C, Degenhardt L, Treloar C, Dore GJ, Grebely J, Martinello M. Evaluating the prevalence of current hepatitis C infection and treatment among Aboriginal and Torres Strait Islander peoples who inject drugs in Australia: The ETHOS engage study. Drug Alcohol Rev 2023; 42:1617-1632. [PMID: 37556376 PMCID: PMC10946462 DOI: 10.1111/dar.13723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 06/21/2023] [Accepted: 06/26/2023] [Indexed: 08/11/2023]
Abstract
INTRODUCTION Evaluating progress towards hepatitis C virus (HCV) elimination among Aboriginal and Torres Strait Islander peoples is critical given the disproportionate burden of infection. We examined factors associated with current HCV infection and self-reported treatment among Aboriginal and Torres Strait Islander (hereafter referred to as Aboriginal peoples) and non-Aboriginal peoples who inject drugs (PWID) in Australia. METHODS ETHOS Engage is an observational cohort study of PWID attending drug treatment and needle and syringe programs in Australia. Participants underwent point-of-care HCV RNA testing (Xpert HCV RNA Viral Load Fingerstick) and completed a questionnaire including self-reported history of HCV treatment. RESULTS Between May 2018 and June 2021, 2395 participants were enrolled and 555 (23%) identified as Aboriginal (median age 42 years, 58% were men, 63% injected drugs in last month, 76% ever incarcerated). HCV RNA prevalence was 23% among Aboriginal PWID (24% in 2018-2019 and 21% in 2019-2021; p = 0.44), and 21% among non-Aboriginal PWID (24% in 2018-2019 and 16% in 2019-2021; p < 0.001). Self-reported HCV treatment was 65% among Aboriginal PWID (63% in 2018-2019 and 69% in 2019-2021; p = 0.30), and 70% among non-Aboriginal PWID (67% in 2018-2019 and 75% in 2019-2021; p < 0.001). Among Aboriginal PWID, current HCV infection was associated with recently injecting drugs and receiving opioid agonist treatment, and self-reported HCV treatment was negatively associated with younger age, homelessness and recently injecting drugs. DISCUSSION AND CONCLUSIONS Equitable access to HCV care and prevention is needed to ensure Australia meets its elimination targets among Aboriginal PWID.
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Affiliation(s)
- Steven Hobday
- The Kirby InstituteUniversity of New South WalesSydneyAustralia
| | - Heather Valerio
- The Kirby InstituteUniversity of New South WalesSydneyAustralia
| | - Troy Combo
- Infectious Disease Implementation Science GroupBurnet InstituteMelbourneAustralia
- Poche Centre for Indigenous Health, University of QueenslandBrisbaneAustralia
| | - Robert Monaghan
- The Kirby InstituteUniversity of New South WalesSydneyAustralia
| | - Clarke Scott
- Nepean Blue Mountains Local Health District, NSW HealthPenrithAustralia
| | - David Silk
- The Kirby InstituteUniversity of New South WalesSydneyAustralia
| | | | - Phillip Read
- The Kirby InstituteUniversity of New South WalesSydneyAustralia
- Kirketon Road CentreSydneyAustralia
| | | | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW SydneySydneyAustralia
| | - Carla Treloar
- Centre for Social Research in HealthUniversity of New South WalesSydneyAustralia
| | - Gregory J. Dore
- The Kirby InstituteUniversity of New South WalesSydneyAustralia
| | - Jason Grebely
- The Kirby InstituteUniversity of New South WalesSydneyAustralia
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Jiang N, Bruneau J, Makarenko I, Minoyan N, Zang G, Høj SB, Larney S, Martel-Laferrière V. HCV treatment initiation in the era of universal direct acting antiviral coverage - Improvements in access and persistent barriers. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 113:103954. [PMID: 36758334 DOI: 10.1016/j.drugpo.2023.103954] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 01/04/2023] [Accepted: 01/05/2023] [Indexed: 02/10/2023]
Abstract
BACKGROUND Barriers to HCV treatment initiation persisted after the introduction of direct-acting antivirals (DAAs) in Canada among people who inject drugs (PWID); whether DAA universal coverage lifted these barriers remain unknown. We assessed the evolution of HCV treatment initiation and associated factors among PWID in Montreal, Canada, comparing eras of IFN-based regimens (2011-2013), of DAA restricted access (2014-02/2018), and universal coverage (03/2018-03/2020). METHODS We included chronically HCV-infected participants followed in a community-based PWID cohort in Montreal, Canada between 2011 and 03/2020 and collected data at 3-month intervals. Time-updated Cox regressions were conducted to examine 9 variables of interest associated with treatment initiation overall and for each of the three eras. RESULTS Of 276 participants, 126 initiated treatment during follow-up. Yearly initiation increased from 3% in 2011 to 19% in 2016, and 54% in 2018. PWID aged >40 (vs. ≤40) were twice as likely to initiate treatment in 2014-02/2018 (HR: 2.02 95%CI: [1.24-3.28]) but not in other periods (2011-2013: 0.55 [0.25-1.22]; 03/2018-03/2020: 1.14 [0.59-2.22])). Odds of initiation were lower for men than women in all periods, with women three times more likely to be treated under universal coverage (0.30 [0.11-0.77] vs 2011-2013: 0.67 [0.25-1.78] and 2014-02/2018: 0.75 [0.42-1.35]). Recent incarceration was negatively associated with initiation throughout all periods (2011-2013: 0.57 [0.13-2.43]; 2014-03/2018: 0.39 [0.17-0.91]; 03/2018-03/2020: 0.25 [0.07-0.83]). Barriers associated with high injection frequency appear to have diminished since DAA introduction (2014-02/2018: 0.71 [0.42-1.20]; 03/2018-03/2020: 1.05 [0.52-2.11] vs. 2011-2013: 0.26 [0.08-0.88]). Contact with a primary care physician and engagement in opioid agonist therapy were positively associated with treatment initiation, though estimates were attenuated under universal coverage relative to previous eras. CONCLUSION Treatment initiation rates have increased since the introduction of universal DAA coverage, though barriers such as incarceration persist.
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Affiliation(s)
- Nathalie Jiang
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), 900 rue St-Denis, Montréal, Québec, H2×0A9, Canada
| | - Julie Bruneau
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), 900 rue St-Denis, Montréal, Québec, H2×0A9, Canada; Département de Médecine Familiale et Médecine d'Urgence, Université de Montréal, C.P. 6128, succursale Centre-ville, Montréal, Québec, H3C 3J7, Canada
| | - Iuliia Makarenko
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), 900 rue St-Denis, Montréal, Québec, H2×0A9, Canada; Department of Family Medicine, McGill University, 845 rue Sherbrooke Ouest, Montreal, Quebec, H3A 0G4, Canada
| | - Nanor Minoyan
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), 900 rue St-Denis, Montréal, Québec, H2×0A9, Canada; École de Santé Publique de l'Université de Montréal, 7101 Avenue du Parc, Montréal, Québec, H3N 1×9, Canada
| | - Geng Zang
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), 900 rue St-Denis, Montréal, Québec, H2×0A9, Canada
| | - Stine Bordier Høj
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), 900 rue St-Denis, Montréal, Québec, H2×0A9, Canada
| | - Sarah Larney
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), 900 rue St-Denis, Montréal, Québec, H2×0A9, Canada
| | - Valérie Martel-Laferrière
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), 900 rue St-Denis, Montréal, Québec, H2×0A9, Canada; Département de Microbiologie, Infectiologie et Immunologie, Université de Montréal, C.P. 6128, succursale Centre-ville, Montréal, Québec, H3C 3J7, Canada.
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Carson JM, Barbieri S, Matthews GV, Dore GJ, Hajarizadeh B. National trends in retreatment of HCV due to reinfection or treatment failure in Australia. J Hepatol 2023; 78:260-270. [PMID: 36152766 DOI: 10.1016/j.jhep.2022.09.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 08/19/2022] [Accepted: 09/05/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND & AIMS Population-level uptake of direct-acting antiviral (DAA) treatment for hepatitis C virus (HCV) infection, including retreatment, can be estimated through administrative pharmaceutical dispensation data. However, the reasons for retreatment are not captured in these data. We developed a machine learning model to classify retreatments as reinfection or treatment failure at a national level. METHODS Retreatment data from the REACH-C cohort (n = 10,843 treated with DAAs; n = 320 retreatments with known reason), were used to train a random forest model. Nested cross validation was undertaken to assess model performance and to optimise hyperparameters. The model was applied to data on DAA retreatment dispensed during 2016-2021 in Australia, to identify the reason for retreatment (treatment failure or reinfection). RESULTS Average predictive accuracy, precision, sensitivity, specificity and F1-score for the model were 96.3%, 96.5%, 96.3%, 96.3% and 96.3%, respectively. Nationally, 95,272 individuals initiated DAAs, with treatment uptake declining from 32,454 in 2016 to 6,566 in 2021. Of those treated, 6,980 (7%) were retreated. Our model classified 51.8% (95% CI 46.7-53.6%; n = 3,614) of cases as reinfection and 48.2% (95% CI 46.4-53.3%; n = 3,366) as treatment failure. Retreatment for reinfection increased steadily over the study period from 14 in 2016 to 1,092 in 2020, stabilising in 2021. Retreatment for treatment failure increased from 73 in 2016 to 1,077 in 2019, then declined to 515 in 2021. Among individuals retreated for treatment failure, 50% had discontinued initial treatment. CONCLUSIONS We used a novel methodology with high classification accuracy to evaluate DAA retreatment patterns at a national level. Increases in retreatment uptake for treatment failure corresponded to the availability of pangenotypic and salvage regimens. Increasing retreatment uptake for reinfection likely reflects increasing reinfection incidence. IMPACT AND IMPLICATIONS This study used machine learning methodologies to analyse national administrative data and characterise trends in HCV retreatment due to reinfection and treatment failure. Retreatment for reinfection increased over time, reflecting increasing numbers of people at risk for reinfection following HCV cure. Increased retreatment for treatment failure corresponded to the availability of pangenotypic and salvage DAA regimens. The findings of this study can be used by public health agencies and policy makers to guide and assess HCV elimination strategies, while the novel methodology for monitoring trends in HCV retreatment has the potential to be used in other settings, and health conditions.
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Fomiatti R, Shaw F, Fraser S. 'It's a different way to do medicine': Exploring the affordances of telehealth for hepatitis C healthcare. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 110:103875. [PMID: 36257085 DOI: 10.1016/j.drugpo.2022.103875] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 09/27/2022] [Accepted: 09/29/2022] [Indexed: 11/07/2022]
Abstract
While the use of telehealth was common in hepatitis C healthcare in Australia in remote and regional areas prior to the COVID-19 pandemic, it has been used more broadly to improve access to hepatitis C heathcare during the pandemic. Despite its widespread uptake, little research has explored how telehealth shapes hepatitis C healthcare. In this article, we draw on the concept of affordances (Latour, 2002) and interviews with 25 healthcare practitioners to explore the emergent possibilities for hepatitis C care that take shape through telehealth. Despite suggestions that telehealth is comparable to in-person care, healthcare practitioners' accounts suggest that telehealth significantly changes the nature of their experience of providing healthcare for hepatitis C. According to these service practitioners, while it increased access to hepatitis C healthcare during the pandemic, it also afforded narrower, less personal healthcare encounters, with a focus on simple and singular issues, and reduced opportunities for communication and rapport. These affordances also discouraged the use of interpreters and by extension the inclusion of patients from non-English speaking backgrounds. However, the data collected also suggest that telehealth has the potential to afford more informal and relaxed healthcare environments and dispositions between healthcare practitioners and patients, potentially disrupting classic practitioner-patient power dynamics. In concluding, the article considers how telehealth models of care might better afford quality hepatitis C healthcare and care beyond COVID-19 pandemic conditions.
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Affiliation(s)
- Renae Fomiatti
- School of Humanities and Social Sciences, Deakin University; Australian Research Centre in Sex, Health and Society, La Trobe University.
| | - Frances Shaw
- ARC Centre of Excellence for Automated Decision-Making and Society, Swinburne University of Technology
| | - Suzanne Fraser
- Australian Research Centre in Sex, Health and Society, La Trobe University; Centre for Social Research in Health, University of New South Wales
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Tan C, Luo X, Ong BS, Lin L, Ng K. Real-world impact of a subsidy decision of sofosbuvir-velpatasvir for treatment of chronic hepatitis C on clinical practice and patient outcomes. JGH Open 2022; 7:48-54. [PMID: 36660045 PMCID: PMC9840192 DOI: 10.1002/jgh3.12850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 11/08/2022] [Accepted: 11/18/2022] [Indexed: 12/02/2022]
Abstract
Background and Aim Sofosbuvir-velpatasvir was recommended for subsidy to treat chronic hepatitis C in Singapore in 2018. We measured the impact of the subsidy decision on clinical practice and patient outcomes. Specifically, we looked at pre- and post-subsidy changes in the utilization and prescribing pattern of chronic hepatitis C treatment and the real-world clinical effectiveness. Method Utilization trends and prescribing patterns were assessed using aggregated drug utilization data from public hospitals' dispensing systems and clinical data from the national electronic health record database, respectively. An audit was conducted to evaluate sustained virological response rate 12 weeks post treatment (SVR12). Results Use of sofosbuvir-velpatasvir increased sharply since its subsidy listing and dropped subsequently, whereas the utilization of comparator drugs remained low. Prescribing rate of sofosbuvir-velpatasvir increased from 13.7% in the pre-subsidy period to 90.2% in the post-subsidy period; 39.1% of patients previously on pegylated interferon and ribavirin switched to sofosbuvir-velpatasvir following its subsidy listing. In the audit, 365 out of 375 patients (97.3% [95% confidence interval: 95.1-98.6%]) achieved SVR12. Conclusion The subsidy decision led to increased accessibility to patients and intended changes in clinical practice. Sofosbuvir-velpatasvir was also clinically effective in the real world. These findings augur well for the continued eradication of chronic hepatitis C infection in Singapore.
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Affiliation(s)
- Chee‐Kiat Tan
- Department of Gastroenterology and HepatologySingapore General HospitalSingapore
| | - Xue‐Shi Luo
- Agency for Care Effectiveness, Ministry of HealthSingapore
| | | | - Liang Lin
- Agency for Care Effectiveness, Ministry of HealthSingapore
| | - Kwong‐Hoe Ng
- Agency for Care Effectiveness, Ministry of HealthSingapore
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11
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Bartlett SR, Verich A, Carson J, Hosseini‐Hooshyar S, Read P, Baker D, Post JJ, Finlayson R, Bloch M, Doyle JS, Shaw D, Hellard M, Martinez M, Marks P, Dore GJ, Matthews GV, Applegate T, Martinello M. Patterns and correlates of hepatitis C virus phylogenetic clustering among people living with HIV in Australia in the direct‐acting antiviral era: A molecular epidemiology study among participants in the CEASE cohort. Health Sci Rep 2022; 5:e719. [PMID: 36000082 PMCID: PMC9388196 DOI: 10.1002/hsr2.719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 06/15/2022] [Accepted: 06/19/2022] [Indexed: 12/02/2022] Open
Abstract
Background and Aims In moving towards the elimination of hepatitis C virus (HCV) infection among people living with HIV, understanding HCV transmission patterns may provide insights to guide and evaluate interventions. In this study, we evaluated patterns of, and factors associated with HCV phylogenetic clustering among people living with HIV/HCV co‐infection in Australia in the direct‐acting antiviral era. Methods HCV RNA was extracted from dried blood spot (DBS) samples collected between 2014 and 2018 in the CEASE cohort study. The HCV Core‐E2 region was amplified by a polymerase chain reaction and Sanger sequenced. Maximum likelihood phylogenetic trees (1000 bootstrap replicates) were used to identify patterns of clustering (3% genetic distance threshold). Mixed‐effects logistic regression was used to determine correlates of phylogenetic clustering. Factors assessed were sexual risk behavior, education, injecting drug use, housing, employment, HIV viral load, age, sex, and sexuality. Results Phylogenetic trees were reconstructed for HCV subtype 1a (n = 139) and 3a (n = 63) sequences, with 29% (58/202) in a pair or cluster. Overall (n = 202), phylogenetic clustering was positively associated with younger age (under 40; adjusted odds ratio [aOR] 2.52, 95% confidence interval [CI] 1.20–5.29), and among gay and bisexual men (n = 168), was positively associated with younger age (aOR 2.61, 95% CI 1.10–6.19), higher education (aOR 2.58, 95% CI 1.09–6.13), and reporting high‐risk sexual behavior (aOR 3.94, 95% CI 1.31–11.84). During follow‐up, five reinfections were observed, but none were in phylogenetic clusters. Conclusion This study found a high proportion of phylogenetic relatedness, predominantly among younger people and gay and bisexual men reporting high‐risk sexual behavior. Despite this, few reinfections were observed, and reinfections demonstrated little relationship with known clusters. These findings highlight the importance of rapid HCV treatment initiation, together with monitoring of the phylogeny.
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Affiliation(s)
- Sofia R. Bartlett
- British Columbia Centre for Disease Control Vancouver British Columbia Canada
- School of Population and Public Health University of British Columbia Vancouver British Columbia Canada
| | - Andrey Verich
- The Kirby Institute, UNSW Sydney Sydney New South Wales Australia
| | - Joanne Carson
- The Kirby Institute, UNSW Sydney Sydney New South Wales Australia
| | | | - Phillip Read
- Kirketon Road Centre Sydney New South Wales Australia
| | - David Baker
- East Sydney Doctors Sydney New South Wales Australia
| | - Jeffrey J. Post
- The Albion Centre Sydney New South Wales Australia
- Department of Infectious Diseases Prince of Wales Hospital Sydney New South Wales Australia
- Prince of Wales Clinical School University of New South Wales Sydney Sydney New South Wales Australia
| | | | - Mark Bloch
- Holdsworth House Medical Practice Sydney New South Wales Australia
| | - Joseph S. Doyle
- Department of Infectious Diseases Alfred Health & Monash University Melbourne Victoria Australia
- Burnet Institute, Melbourne Victoria Australia
| | - David Shaw
- Royal Adelaide Hospital Adelaide South Australia Australia
| | - Margaret Hellard
- Department of Infectious Diseases Alfred Health & Monash University Melbourne Victoria Australia
- Burnet Institute, Melbourne Victoria Australia
| | - Maria Martinez
- The Kirby Institute, UNSW Sydney Sydney New South Wales Australia
| | - Philippa Marks
- The Kirby Institute, UNSW Sydney Sydney New South Wales Australia
| | - Gregory J. Dore
- The Kirby Institute, UNSW Sydney Sydney New South Wales Australia
- St Vincent's Hospital Sydney New South Wales Australia
| | - Gail V. Matthews
- The Kirby Institute, UNSW Sydney Sydney New South Wales Australia
- St Vincent's Hospital Sydney New South Wales Australia
| | - Tanya Applegate
- The Kirby Institute, UNSW Sydney Sydney New South Wales Australia
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12
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Lu Y, Windsor C, Hollingdrake O. A Scoping Review of Nursing Roles in Hepatitis C Virus Telehealth. J Nurse Pract 2022. [DOI: 10.1016/j.nurpra.2022.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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13
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Trends in decompensated cirrhosis and hepatocellular carcinoma among people with a hepatitis B notification in New South Wales. JHEP Rep 2022; 4:100552. [PMID: 36119722 PMCID: PMC9478454 DOI: 10.1016/j.jhepr.2022.100552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 07/01/2022] [Accepted: 07/19/2022] [Indexed: 01/27/2023] Open
Abstract
Background & Aims Population-level trends and factors associated with HBV-related decompensated cirrhosis (DC), hepatocellular carcinoma (HCC), and liver-related mortality are crucial to evaluate the impacts of therapeutic interventions. Methods Trends in HBV-DC and -HCC diagnoses and liver-related mortality in New South Wales, Australia, were determined through linkage of HBV notifications (1993-2017) to hospital admissions (2001-2018), mortality (1993-2018), and cancer registry (1994-2014) databases. Late HBV notification was defined as notification at or within 2 years of a DC or HCC diagnosis. Cox proportional-hazards regression and multivariable logistic regression analyses were performed to evaluate associated factors. Results Among 60,660 people with a HBV notification, 1,276 (2.0%) DC and 1,087 (1.8%) HCC diagnoses, and 1,219 (2.0%) liver-related deaths were documented. Since the early 2000s, the number of DC and HCC diagnoses increased; however, age-standardised incidence decreased from 2.64 and 1.95 in 2003 to 1.14 and 1.09 per 1,000 person-years in 2017, respectively. Similarly, age-standardised liver mortality decreased from 2.60 in 2003 to 1.14 per 1,000 person-years in 2017. Among people with DC and HCC diagnoses, late HBV notification declined from 41% and 40% between 2001-2009 to 29% and 25% in 2010-2018, respectively. Predictors of DC diagnosis included older age (birth <1944, adjusted hazard ratio [aHR] 2.06, 95% CI 1.57–2.69), alcohol use disorder (aHR 4.82, 95% CI 3.96–5.87) and HCV co-infection (aHR 1.88, 95% CI 1.53–2.31). Predictors of HCC diagnosis included older age (birth <1944, aHR 3.94, 95% CI 2.91–5.32) and male sex (aHR 3.79, 95% CI 3.05–4.71). Conclusion In an era of improved antiviral therapies, the risk of HBV-related liver morbidity and mortality has declined. HCV co-infection and alcohol use disorder are key modifiable risk factors associated with the burden of HBV. Lay summary Rising hepatitis B-related morbidity and mortality is a major public health concern. However, the development of highly effective medicines against hepatitis B virus (HBV) has brought renewed optimism for its elimination by 2030. This study shows a steady decline in HBV-related liver morbidity and mortality in New South Wales, Australia. Moreover, late hepatitis notification has also declined, allowing individuals with HBV to have access to timely antiviral treatment. Despite this, hepatitis C co-infection and alcohol use disorder are key modifiable risk factors associated with HBV disease burden. To attain the desired benefits from highly effective antiviral treatment, managing comorbidities, including hepatitis C and high alcohol use, must improve among individuals with hepatitis B. The World Health Organization has set a 65% HBV mortality reduction target by 2030. Since the early 2000s, diagnoses of decompensated cirrhosis and HCC increased, but age-standardised incidence rates decreased. Age-standardised liver mortality rates decreased from 2.64 in 2003 to 0.97 per 1,000 person-years in 2017. Late HBV notification declined from 41% and 40% during 2001-2009 to 28% and 26% in 2010-2018, respectively. Hepatitis C co-infection and alcohol-use disorder are key modifiable risk factors associated with HBV disease burden.
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Conway A, Valerio H, Alavi M, Silk D, Treloar C, Hajarizadeh B, Marshall AD, Martinello M, Milat A, Dunlop A, Murray C, Prain B, Henderson C, Amin J, Read P, Marks P, Degenhardt L, Hayllar J, Reid D, Gorton C, Lam T, Christmass M, Wade A, Montebello M, Dore GJ, Grebely J. A Testing Campaign Intervention Consisting of Peer-Facilitated Engagement, Point-of-Care HCV RNA Testing, and Linkage to Nursing Support to Enhance Hepatitis C Treatment Uptake among People Who Inject Drugs: The ETHOS Engage Study. Viruses 2022; 14:1555. [PMID: 35891535 PMCID: PMC9316739 DOI: 10.3390/v14071555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/08/2022] [Accepted: 07/14/2022] [Indexed: 11/17/2022] Open
Abstract
This study evaluated HCV treatment initiation among people who inject drugs (PWID) following an intervention of campaign days involving peer connection, point-of-care HCV RNA testing, and linkage to nursing support. ETHOS Engage is an observational cohort study of PWID attending 25 drug treatment clinics and needle and syringe programs in Australia (May 2018-September 2019). Point-of-care results were provided to the nurse, facilitating confirmatory testing and treatment. The study aimed to evaluate treatment uptake and factors associated with treatment at 24 months post-enrolment. There were 317 people with current HCV infection and eligible for treatment (median age 43, 65% male, 15% homeless, 69% receiving opioid agonist treatment, 70% injected in last month). Overall, 15% (47/317), 27% (85/317), 38% (120/317), and 49% (155/317) of people with current HCV infection had initiated treatment at 3-, 6-, 12-, and 24-months following testing, respectively. Homelessness (adjusted hazard ratio (aHR): 0.40; 95% confidence interval: 0.23, 0.71) and incarceration in the past 12 months (vs. never, aHR:0.46; 0.28, 0.76) were associated with decreased treatment initiation in the 24 months post-enrolment. This testing campaign intervention facilitated HCV treatment uptake among PWID. Further interventions are needed to achieve HCV elimination among people experiencing homelessness or incarceration.
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Affiliation(s)
- Anna Conway
- The Kirby Institute, UNSW Sydney, Sydney, NSW 2052, Australia; (H.V.); (M.A.); (D.S.); (B.H.); (A.D.M.); (M.M.); (P.M.); (G.J.D.); (J.G.)
- Centre for Social Research in Health, UNSW Sydney, Sydney, NSW 2052, Australia;
| | - Heather Valerio
- The Kirby Institute, UNSW Sydney, Sydney, NSW 2052, Australia; (H.V.); (M.A.); (D.S.); (B.H.); (A.D.M.); (M.M.); (P.M.); (G.J.D.); (J.G.)
| | - Maryam Alavi
- The Kirby Institute, UNSW Sydney, Sydney, NSW 2052, Australia; (H.V.); (M.A.); (D.S.); (B.H.); (A.D.M.); (M.M.); (P.M.); (G.J.D.); (J.G.)
| | - David Silk
- The Kirby Institute, UNSW Sydney, Sydney, NSW 2052, Australia; (H.V.); (M.A.); (D.S.); (B.H.); (A.D.M.); (M.M.); (P.M.); (G.J.D.); (J.G.)
| | - Carla Treloar
- Centre for Social Research in Health, UNSW Sydney, Sydney, NSW 2052, Australia;
| | - Behzad Hajarizadeh
- The Kirby Institute, UNSW Sydney, Sydney, NSW 2052, Australia; (H.V.); (M.A.); (D.S.); (B.H.); (A.D.M.); (M.M.); (P.M.); (G.J.D.); (J.G.)
| | - Alison D. Marshall
- The Kirby Institute, UNSW Sydney, Sydney, NSW 2052, Australia; (H.V.); (M.A.); (D.S.); (B.H.); (A.D.M.); (M.M.); (P.M.); (G.J.D.); (J.G.)
- Centre for Social Research in Health, UNSW Sydney, Sydney, NSW 2052, Australia;
| | - Marianne Martinello
- The Kirby Institute, UNSW Sydney, Sydney, NSW 2052, Australia; (H.V.); (M.A.); (D.S.); (B.H.); (A.D.M.); (M.M.); (P.M.); (G.J.D.); (J.G.)
| | - Andrew Milat
- Centre for Epidemiology and Evidence, NSW Health, Sydney, NSW 2065, Australia;
| | - Adrian Dunlop
- Hepatitis NSW, Surry Hills, NSW 2010, Australia;
- Drug and Alcohol Clinical Services, Hunter New England Local Health District, Newcastle, NSW 2300, Australia
| | - Carolyn Murray
- Population Health Strategy & Performance, NSW Health, Sydney, NSW 2065, Australia; (C.M.); (B.P.)
| | - Bianca Prain
- Population Health Strategy & Performance, NSW Health, Sydney, NSW 2065, Australia; (C.M.); (B.P.)
| | | | - Janaki Amin
- Department of Health Systems and Populations, Macquarie University, Sydney, NSW 2109, Australia;
| | - Phillip Read
- Kirketon Road Centre, Sydney, NSW 2010, Australia;
| | - Pip Marks
- The Kirby Institute, UNSW Sydney, Sydney, NSW 2052, Australia; (H.V.); (M.A.); (D.S.); (B.H.); (A.D.M.); (M.M.); (P.M.); (G.J.D.); (J.G.)
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW 2052, Australia;
| | - Jeremy Hayllar
- Alcohol and Drug Service, Metro North Mental Health, Metro North Hospital and Health Service, Brisbane, QLD 4029, Australia;
| | - David Reid
- Drug and Alcohol Service, Illawarra Shoalhaven Local Health District, Wollongong, NSW 2500, Australia;
| | - Carla Gorton
- Cairns Sexual Health Service, Cairns, QLD 4870, Australia;
| | - Thao Lam
- Drug Health, Western Sydney Local Health District, Sydney, NSW 2145, Australia;
| | - Michael Christmass
- Next Step Community Alcohol and Drug Service, Perth, WA 6004, Australia;
- National Drug Research Institute, Curtin University, Perth, WA 6102, Australia
| | - Alexandra Wade
- Mid North Coast Liver Clinic, Mid North Coast Local Health District, Coffs Harbour, NSW 2450, Australia;
- Drug and Alcohol Services, Mid North Coast Local Health District, Coffs Harbour, NSW 2450, Australia
| | - Mark Montebello
- North Sydney Local Health District, Sydney, NSW 2077, Australia;
| | - Gregory J. Dore
- The Kirby Institute, UNSW Sydney, Sydney, NSW 2052, Australia; (H.V.); (M.A.); (D.S.); (B.H.); (A.D.M.); (M.M.); (P.M.); (G.J.D.); (J.G.)
| | - Jason Grebely
- The Kirby Institute, UNSW Sydney, Sydney, NSW 2052, Australia; (H.V.); (M.A.); (D.S.); (B.H.); (A.D.M.); (M.M.); (P.M.); (G.J.D.); (J.G.)
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Yousafzai MT, Alavi M, Valerio H, Hajarizadeh B, Grebely J, Dore GJ. Timely Hepatitis C RNA Testing and Treatment in the Era of Direct-Acting Antiviral Therapy among People with Hepatitis C in New South Wales, Australia. Viruses 2022; 14:v14071496. [PMID: 35891474 PMCID: PMC9319806 DOI: 10.3390/v14071496] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/14/2022] [Accepted: 06/30/2022] [Indexed: 01/27/2023] Open
Abstract
This study aimed to identify the factors associated with timely (within four weeks) HCV RNA testing and timely (within six months) DAA initiation following HCV notification in the DAA era. We conducted a cohort study of people with an HCV notification in NSW, Australia. Notifications of positive HCV serology were linked to administrative datasets. Weights were applied to account for spontaneous clearance. Logistic regression analyses were performed. Among 5582 people with an HCV notification during 2016–2017, 3867 (69%) were tested for HCV RNA, including 2770 (50%) who received timely testing. Among an estimated 3925 people with chronic HCV infection, 2372 (60%) initiated DAA therapy, including 1370 (35%) who received timely treatment. Factors associated with timely HCV RNA testing included age (≥30 years), female sex, non-Aboriginal ethnicity, country of birth being Australia, and no history of drug dependence. Factors associated with timely treatment were age (≥30 years), male sex, non-Aboriginal ethnicity, country of birth being Australia, no history of drug dependence, and HCV/HIV co-infection. In the DAA era, 50% of people with an HCV notification did not receive timely HCV RNA testing. Most people with an HCV infection received therapy; however, DAA initiation was delayed among many.
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16
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Ortiz-Paredes D, Amoako A, Ekmekjian T, Engler K, Lebouché B, Klein MB. Interventions to Improve Uptake of Direct-Acting Antivirals for Hepatitis C Virus in Priority Populations: A Systematic Review. Front Public Health 2022; 10:877585. [PMID: 35812487 PMCID: PMC9263261 DOI: 10.3389/fpubh.2022.877585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 06/06/2022] [Indexed: 11/16/2022] Open
Abstract
Background & Objective Access to Hepatitis C (HCV) care remains suboptimal. This systematic review sought to identify existing interventions designed to improve direct-acting antiviral (DAA) uptake among HCV infected women, people who inject drugs (PWID), men who have sex with men (MSM), and Indigenous peoples. Methods Studies published in high- and middle-income countries were retrieved from eight electronic databases and gray literature (e.g., articles, research reports, theses, abstracts) were screened by two independent reviewers. Identified interventions were summarized using textual narrative synthesis. Results After screening 3,139 records, 39 studies were included (11 controlled comparative studies; 36 from high-income countries). Three groups of interventions were identified: interventions involving patients; providers; or the healthcare system. Interventions directed to patients included care co-ordination, accelerated DAA initiation, and patient education. Interventions involving providers included provider education, telemedicine, multidisciplinary teams, and general practitioner-led care. System-based interventions comprised DAA universal access policies and offering HCV services in four settings (primary care, secondary care, tertiary care, and community settings). Most studies (30/39) described complex interventions, i.e., those with two or more strategies combined. Most interventions (37/39) were tailored to, or studied among, PWID. Only one study described an intervention that was aimed at women. Conclusions Combining multiple interventions is a common approach for supporting DAA initiation. Three main research gaps were identified, specifically, a lack of: (1) controlled trials estimating the individual or combined effects of interventions on DAA uptake; (2) studies in middle-income countries; and (3) interventions tailored to women, MSM, and Indigenous people.
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Affiliation(s)
- David Ortiz-Paredes
- Center for Outcome Research and Evaluation, Research Institute of the McGill University Health Center, Montreal, QC, Canada
| | - Afia Amoako
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
| | - Taline Ekmekjian
- Medical Libraries, McGill University Health Center, Montreal, QC, Canada
| | - Kim Engler
- Center for Outcome Research and Evaluation, Research Institute of the McGill University Health Center, Montreal, QC, Canada
| | - Bertrand Lebouché
- Center for Outcome Research and Evaluation, Research Institute of the McGill University Health Center, Montreal, QC, Canada
- Department of Family Medicine, McGill University, Montreal, QC, Canada
- Division of Infectious Diseases/Chronic Viral Illness Service, Department of Medicine, Glen site, McGill University Health Center, Montreal, QC, Canada
| | - Marina B. Klein
- Division of Infectious Diseases/Chronic Viral Illness Service, Department of Medicine, Glen site, McGill University Health Center, Montreal, QC, Canada
- CIHR Canadian HIV Trials Network, Vancouver, BC, Canada
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Carson JM, Hajarizadeh B, Hanson J, O'Beirne J, Iser D, Read P, Balcomb A, Davies J, Doyle JS, Yee J, Martinello M, Marks P, Matthews GV, Dore GJ. Retreatment for hepatitis C virus direct acting antiviral therapy virological failure in primary and tertiary settings: the REACH-C cohort. J Viral Hepat 2022; 29:661-676. [PMID: 35583922 PMCID: PMC9542502 DOI: 10.1111/jvh.13705] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 04/29/2022] [Accepted: 05/04/2022] [Indexed: 12/12/2022]
Abstract
Virological failure occurs in a small proportion of people treated for hepatitis C virus (HCV) with direct-acting antiviral (DAA) therapies. This study assessed retreatment for virological failure in a large real-world cohort. REACH-C is an Australian observational study (n=10843) evaluating treatment outcomes of sequential DAA initiations across 33 health services between March 2016 to June 2019. Virological failure retreatment data were collected until October 2020. Of 408 people with virological failure (81% male; median age 53; 38% cirrhosis; 56% genotype 3), 213 (54%) were retreated once; 15 were retreated twice. A range of genotype specific and pangenotypic DAAs were used to retreat virological failure in primary (n=56) and tertiary (n=157) settings. Following sofosbuvir/velpatasvir/voxilaprevir availability in 2019, the proportion retreated in primary care increased from 21% to 40% and median time to retreatment initiation declined from 294 to 152 days. Per-protocol (PP) sustained virological response (SVR12) was similar for people retreated in primary and tertiary settings (80% vs 81%; p=1.000). In regression analysis, sofosbuvir/velpatasvir/voxilaprevir (vs. other regimens) significantly decreased likelihood of second virological failure (PP SVR12 88% vs. 77%; adjusted odds ratio [AOR] 0.29; 95%CI 0.11-0.81); cirrhosis increased likelihood (PP SVR12 69% vs. 91%; AOR 4.26; 95%CI 1.64-11.09). Indigenous Australians had lower likelihood of retreatment initiation (AOR 0.36; 95%CI 0.15-0.81). Treatment setting and prescriber type were not associated with retreatment initiation or outcome. Virological failure can be effectively retreated in primary care. Expanded access to simplified retreatment regimens through decentralised models may increase retreatment uptake and reduce HCV-related mortality.
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Affiliation(s)
| | | | - Josh Hanson
- The Kirby InstituteUNSW SydneySydneyNew South WalesAustralia
- Cairns and Hinterland Hospital and Health ServiceCairnsQueenslandAustralia
| | - James O'Beirne
- Sunshine Coast Hospital and Health ServiceSunshine CoastQueenslandAustralia
- University of the Sunshine CoastSunshine CoastQueenslandAustralia
| | - David Iser
- Scope GastroenterologyMelbourneVictoriaAustralia
| | - Phillip Read
- Kirketon Road CentreSydneyNew South WalesAustralia
| | - Anne Balcomb
- Prince Street MedicalOrangeNew South WalesAustralia
| | - Jane Davies
- Menzies School of Health ResearchDarwinNorthern TerritoryAustralia
- Royal Darwin HospitalDarwinNorthern TerritoryAustralia
| | - Joseph S. Doyle
- Burnet InstituteMelbourneVictoriaAustralia
- Department of Infectious DiseasesThe Alfred and Monash UniversityMelbourneVictoriaAustralia
| | - Jasmine Yee
- The Kirby InstituteUNSW SydneySydneyNew South WalesAustralia
| | | | - Philippa Marks
- The Kirby InstituteUNSW SydneySydneyNew South WalesAustralia
| | - Gail V. Matthews
- The Kirby InstituteUNSW SydneySydneyNew South WalesAustralia
- St Vincent's HospitalSydneyNew South WalesAustralia
| | - Gregory J. Dore
- The Kirby InstituteUNSW SydneySydneyNew South WalesAustralia
- St Vincent's HospitalSydneyNew South WalesAustralia
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Silano JA, Treloar C, Leadbeatter K, Davidson S, Doidge J. Peer-facilitated treatment access for hepatitis C: the Live Hep C Free project. Harm Reduct J 2022; 19:40. [PMID: 35449106 PMCID: PMC9026617 DOI: 10.1186/s12954-022-00619-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 03/21/2022] [Indexed: 01/29/2023] Open
Abstract
Background This commentary explores the lessons learned during implementation of a peer-facilitated hepatitis C virus (HCV) testing and treatment access project called the Live Hep C Free (LHCF) project in contributing to micro-elimination efforts.
Case presentation The LHCF project aims to facilitate access to on-the-spot HCV testing, treatment, and care in priority settings through partnership between a peer worker (PW) and a clinical nurse. Since the start of the project in January 2018, 4515 people were engaged about HCV and encouraged to access on-site HCV health care, and over 1000 people were screened for HCV and liver health, while almost 250 people accessed HCV treatment through the project. This commentary is intended to prompt discussion about incorporating peer-centred HCV health programs into priority sites. HCV care-delivery models such as the LHCF project can continue to contribute to micro-elimination of HCV in key settings to increase treatment uptake amongst high prevalence and/or marginalised populations and support progress toward national elimination targets. Conclusions The LHCF project has been able to highlight the benefits of incorporating trustworthy, efficient, and convenient peer-centred health services to engage and support vulnerable populations through HCV testing and treatment, particularly individuals who have historically been disconnected from the health care system. Additional attention is needed to ensure ongoing funding support to sustain the project and deliver at scale and in expanding evaluation data to examine the operation and outcomes of the project in more detail.
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Hosseini‐Hooshyar S, Alavi M, Martinello M, Valerio H, Tillakeratne S, Matthews GV, Dore GJ. Evaluation of the hepatitis C cascade of care among people living with HIV in New South Wales, Australia: A data linkage study. J Viral Hepat 2022; 29:271-279. [PMID: 35175671 PMCID: PMC9306975 DOI: 10.1111/jvh.13658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/31/2022] [Accepted: 02/06/2022] [Indexed: 12/09/2022]
Abstract
People living with HIV (PLHIV) are a priority population to receive hepatitis C virus (HCV) screening and treatment. We aimed to characterize the HCV care cascade among PLHIV between 2010 and 2018 and to compare HCV testing and treatment uptake pre- and post-availability of direct-acting antivirals (DAAs) in New South Wales (NSW), Australia. Records of all HCV notifications (1993-2017) were linked to HIV notifications, deaths, hospitalizations, incarcerations, opioid agonist therapy, HCV RNA testing and treatment databases. Numbers and proportions were calculated for all stages of the care cascade and factors associated with HCV testing, and DAA treatment uptake were evaluated using logistic regression. From 383 individuals with HCV notification (2009-2017), 349 (91%) were ever HCV RNA tested, 285 (74%) had an indicator of chronic HCV infection, and from those eligible for treatment, 210 (74%) received HCV treatment. HCV testing was recorded for 85% pre-DAA era and reached a cumulative proportion of 90% post-DAA while treatment uptake had a 10-fold increase from 7% pre- to 73% post-DAA era. Younger age (adjusted odds ratio [aOR] 0.98; 95% CI 0.96-0.99), female gender (aOR 1.87; 95% CI 1.10-3.19), and rural region residence at notification (aOR 1.56; 95% CI 1.03-2.36) were associated with not receiving HCV testing. No identified factor was associated with not receiving treatment post-DAA era. Removing barriers to HCV testing, expanding treatment to a variety of settings and continuous education and harm reduction are essential to achieve HCV elimination among PLHIV in Australia.
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Affiliation(s)
| | - Maryam Alavi
- The Kirby InstituteUNSW SydneySydneyNew South WalesAustralia
| | | | - Heather Valerio
- The Kirby InstituteUNSW SydneySydneyNew South WalesAustralia
| | | | | | - Gregory J. Dore
- The Kirby InstituteUNSW SydneySydneyNew South WalesAustralia
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20
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Amin J, Vaccher S, Templeton DJ, Bavinton B B, Jin F, ZablotskaI I, Matthews G, Oglvie E, Yeung B, Ooi C, Dharan N, Baker DA, Read P, Grulich AE. Low prior exposure and incidence of hepatitis C in HIV negative gay and bisexual men taking PrEP: findings from the EPIC-NSW prospective implementation study. Clin Infect Dis 2022; 75:1497-1502. [PMID: 35352102 DOI: 10.1093/cid/ciac231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The use of pre-exposure prophylaxis (PrEP) for the prevention of HIV has raised concerns of increased sexual risk behaviours. These behaviours may be associated with increased incidence of sexually acquired hepatitis C (HCV) among gay and bisexual men (GBM). METHODS The Expanded PrEP Implementation in Communities-New South Wales (EPIC-NSW) study was a cohort study of daily co-formulated tenofovir disoproxil fumarate and emtricitabine for HIV prevention. We recruited 9596 people at high risk of HIV acquisition from 31 clinics across New South Wales and the Australia Capital Territory in Australia. We report prior exposure to HCV and incidence in this cohort between 2016 and 2019. RESULTS At least one HCV test result was available for 8658 (90.2%) participants. These individuals had a median age of 34 years (IQR 28-43), most of whom were male (8530, 98.5%), identified as gay (7944, 91.8%), and were born in Australia (51.8%). Prior exposure to HCV was detected among 81 participants at baseline (0.9%, 95% CI 0.7 to 1.2%). Twenty of 8577 participants were diagnosed with incident infection (rate 0.2/100 person years (95%CI 0.1 to 0.3/100py)). They were significantly older (median age 41 years vs 34 years, p=0.044), and more likely to report methamphetamine use at baseline (IRR 2.7 (95%CI 1.00-7.2)) than those without incident infection. CONCLUSIONS In this population of PrEP users, HCV prior exposure and incidence were low. With high levels of HCV and HIV testing and treatment, the dual goals of HIV and HCV elimination could be achieved in this population.
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Affiliation(s)
- Janaki Amin
- Department of Health Systems and Populations, Macquarie University, Sydney, New South Wales, Australia.,The Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia
| | - Stefanie Vaccher
- The Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia
| | - David J Templeton
- Department of Sexual Health Medicine and Sexual Assault Medical Service, Sydney Local Health District, and Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | | | - Fengyi Jin
- The Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia
| | - Iryna ZablotskaI
- Western Sydney Sexual Health Centre & Sydney Medical School - Westmead, University of Sydney, Sydney, New South Wales, Australia
| | - Gail Matthews
- The Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia
| | - Erin Oglvie
- The Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia
| | - Barbra Yeung
- The Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia
| | - Catriona Ooi
- Clinic 16, St Leonards, Sydney, New South Wales, Australia
| | - Nila Dharan
- The Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia
| | - David A Baker
- East Sydney Doctors, Darlinghurst, Sydney, New South Wales, Australia
| | - Phillip Read
- Kirketon Road Centre, Kings Cross, Sydney, New South Wales, Australia
| | - Andrew E Grulich
- The Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia
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21
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Whiteley D, Speakman EM, Elliott L, Jarvis H, Davidson K, Quinn M, Flowers P. Developing a primary care-initiated hepatitis C treatment pathway in Scotland: a qualitative study. Br J Gen Pract 2022; 72:BJGP.2022.0044. [PMID: 35606160 PMCID: PMC9423057 DOI: 10.3399/bjgp.2022.0044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/10/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The ease of contemporary hepatitis C virus (HCV) therapy has prompted a global drive towards simplified and decentralised treatment pathways. In some countries, primary care has become an integral component of community-based HCV treatment provision. In the UK, however, the role of primary care providers remains largely focused on testing and diagnosis alone. AIM To develop a primary care-initiated HCV treatment pathway for people who use drugs, and recommend theory-informed interventions to help embed that pathway into practice. DESIGN AND SETTING A qualitative study informed by behaviour change theory. Semi-structured interviews were undertaken with key stakeholders (n = 38) primarily from two large conurbations in Scotland. METHOD Analysis was three-stage. First, a broad pathway structure was outlined and then sequential pathway steps were specified; second, thematic data were aligned to pathway steps, and significant barriers and enablers were identified; and, third, the Theoretical Domains Framework and Behaviour Change Wheel were employed to systematically develop ideas to enhance pathway implementation, which stakeholders then appraised. RESULTS The proposed pathway structure spans broad, overarching challenges to primary care-initiated HCV treatment. The theory-informed recommendations align with influences on different behaviours at key pathway steps, and focus on relationship building, routinisation, education, combating stigmas, publicising the pathway, and treatment protocol development. CONCLUSION This study provides the first practicable pathway for primary care-initiated HCV treatment in Scotland, and provides recommendations for wider implementation in the UK. It positions primary care providers as an integral part of community-based HCV treatment, providing workable solutions to ingrained barriers to care.
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Affiliation(s)
- David Whiteley
- Department of Nursing and Community Health, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow
| | | | - Lawrie Elliott
- Department of Nursing and Community Health, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow
| | - Helen Jarvis
- Newcastle University, Newcastle; GP partner, the Bellingham Practice, Northumberland
| | | | | | - Paul Flowers
- School of Psychological Sciences and Health, University of Strathclyde, Glasgow
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22
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Yee J, Carson JM, Hajarizadeh B, Hanson J, O'Beirne J, Iser D, Read P, Balcomb A, Doyle JS, Davies J, Martinello M, Marks P, Dore GJ, Matthews GV. High Effectiveness of Broad Access Direct-Acting Antiviral Therapy for Hepatitis C in an Australian Real-World Cohort: The REACH-C Study. Hepatol Commun 2022; 6:496-512. [PMID: 34729957 PMCID: PMC8870316 DOI: 10.1002/hep4.1826] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 07/29/2021] [Accepted: 08/24/2021] [Indexed: 12/15/2022] Open
Abstract
Australia was one of the first countries with unrestricted access to government subsidized direct-acting antiviral (DAA) therapy for adults with chronic hepatitis C virus. This study assessed real-world DAA treatment outcomes across a diverse range of Australian clinical services and evaluated factors associated with successful treatment and loss to follow-up. Real-world Effectiveness of Antiviral therapy in Chronic Hepatitis C (REACH-C) consisted a national observational cohort of 96 clinical services including specialist clinics and less traditional settings such as general practice. Data were obtained on consecutive individuals who commenced DAAs from March 2016 to June 2019. Effectiveness was assessed by sustained virological response ≥12 weeks following treatment (SVR) using intention-to-treat (ITT) and per-protocol (PP) analyses. Within REACH-C, 10,843 individuals initiated DAAs (male 69%; ≥50 years 52%; cirrhosis 22%). SVR data were available in 85% (9,174 of 10,843). SVR was 81% (8,750 of 10,843) by ITT and 95% (8,750 of 9,174) by PP. High SVR (≥92%) was observed across all service types and participant characteristics. Male gender (adjusted odds ratio [aOR] 0.56, 95% confidence interval [CI] 0.43-0.72), cirrhosis (aOR 0.52, 95% CI 0.41-0.64), recent injecting drug use (IDU; aOR 0.64, 95% CI 0.46-0.91) and previous DAA treatment (aOR 0.50, 95% CI 0.28-0.90) decreased the likelihood of achieving SVR. Multiple factors modified the likelihood of loss to follow-up including IDU ± opioid agonist therapy (OAT; IDU only: aOR 1.75, 95% CI 1.44-2.11; IDU + OAT: aOR 1.39, 95% CI 1.11-1.74; OAT only, aOR 1.36; 95% CI 1.13-1.68) and age (aOR 0.97, 95% CI 0.97-0.98). Conclusion: Treatment response was high in a diverse population and through a broad range of services following universal access to DAA therapy. Loss to follow-up presents a real-world challenge. Younger people who inject drugs were more likely to disengage from care, requiring innovative strategies to retain them in follow-up.
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Affiliation(s)
- Jasmine Yee
- The Kirby InstituteUNSW AustraliaSydneyNSWAustralia
| | | | | | - Joshua Hanson
- The Kirby InstituteUNSW AustraliaSydneyNSWAustralia.,Cairns HospitalCairnsQLDAustralia
| | - James O'Beirne
- Sunshine Coast University HospitalSunshine CoastQLDAustralia
| | - David Iser
- Scope GastroenterologyMelbourneVICAustralia
| | | | | | - Joseph S Doyle
- Burnet InstituteMelbourneVICAustralia.,The Alfred and Monash UniversityDepartment of Infectious DiseasesMelbourneVICAustralia
| | - Jane Davies
- Royal Darwin HospitalDarwinAustralia.,Menzies School of Health ResearchDarwinAustralia
| | - Marianne Martinello
- The Kirby InstituteUNSW AustraliaSydneyNSWAustralia.,Blacktown Mount Druitt HospitalBlacktownNSWAustralia.,St Vincent's HospitalSydneyNSWAustralia
| | | | - Gregory J Dore
- The Kirby InstituteUNSW AustraliaSydneyNSWAustralia.,St Vincent's HospitalSydneyNSWAustralia
| | - Gail V Matthews
- The Kirby InstituteUNSW AustraliaSydneyNSWAustralia.,St Vincent's HospitalSydneyNSWAustralia
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23
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Howell J, Majumdar A, Fink MA, Byrne M, McCaughan G, Strasser SI, Crawford M, Hodgkinson P, Stuart KA, Tallis C, Chen J, Wigg A, Jones R, Jaques B, Jeffrey G, Adams L, Wallace MC, Munn S, Gane E, Thompson AJ, Gow P. Turning the Tide on Hepatitis C Virus-Related Liver Transplantation: The Return on Investment in Hepatitis C Virus Treatment in Australia and New Zealand. Liver Transpl 2022; 28:236-246. [PMID: 34624175 DOI: 10.1002/lt.26329] [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: 06/21/2021] [Revised: 08/08/2021] [Accepted: 08/31/2021] [Indexed: 01/13/2023]
Abstract
Introduction of universal access to direct-acting antiviral (DAA) therapy for hepatitis C virus (HCV) in Australia and New Zealand on March 1st , 2016, has had a major impact on the number of people with chronic HCV infection, but the impact on liver transplantation rates is unknown. We conducted a retrospective registry study including all adult liver transplantations from the Australia and New Zealand Liver and Intestinal Liver Transplant Registry (ANZLITR) data set. Interrupted time series analysis determined the impact of DAAs in 2016 on the number of HCV liver transplantations per year. Cox regression analysis was used to determine the impact of DAAs on post-liver transplantation survival. Between January 1, 1990, and December 31, 2019 5318 adult liver transplantations were performed, and 29% (1531) were for HCV infection. Prior to the introduction of DAAs, there was a mean increase of 3.5 adult liver transplantations performed for HCV per annum, but between 2016 and 2019 there was a mean decrease of 7.9 adult liver transplantations per annum (P < 0.001). Similarly, the proportion of liver transplantations performed for HCV increased from 9% (1990) to 33% in 2016 and then fell to 23% in 2019 (P < 0.001). The number and proportion of patients with HCV added to the liver transplantation waiting list also fell in 2016 (P < 0.001) when compared with other indications. The introduction of DAAs was associated with a 31% reduction in death after liver transplantation, adjusted for age at transplant and hepatocellular carcinoma (HCC; hazard ratio [HR], 0.69; 95% confidence interval [CI], 0.48-0.99; P = 0.047). The number of adult liver transplantations performed for HCV-related liver cirrhosis and HCC has reduced since the introduction of universal access to DAAs in 2016 in Australia and New Zealand.
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Affiliation(s)
- Jess Howell
- Department of Medicine, University of Melbourne, Melbourne, Australia.,Department of Gastroenterology, St. Vincent's Hospital Melbourne, Melbourne, Australia.,Disease Elimination Department, Burnet Institute, Melbourne, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Avik Majumdar
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Sydney, Australia.,AW Morrow GE and Liver Centre, University of Sydney, Sydney, Australia
| | - Michael A Fink
- Victorian Liver Transplant Unit, Austin Health, Melbourne, Australia.,Department of Surgery, Austin Health, The University of Melbourne, Melbourne, Australia
| | - Mandy Byrne
- Victorian Liver Transplant Unit, Austin Health, Melbourne, Australia
| | - Geoff McCaughan
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Sydney, Australia.,AW Morrow GE and Liver Centre, University of Sydney, Sydney, Australia
| | - Simone I Strasser
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Sydney, Australia.,AW Morrow GE and Liver Centre, University of Sydney, Sydney, Australia
| | - Michael Crawford
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Sydney, Australia.,AW Morrow GE and Liver Centre, University of Sydney, Sydney, Australia
| | - Peter Hodgkinson
- Queensland Liver Transplant Service, Princess Alexandra Hospital and Queensland Children's Hospital, Brisbane, Australia
| | - Katherine A Stuart
- Queensland Liver Transplant Service, Princess Alexandra Hospital and Queensland Children's Hospital, Brisbane, Australia
| | - Caroline Tallis
- Queensland Liver Transplant Service, Princess Alexandra Hospital and Queensland Children's Hospital, Brisbane, Australia
| | - John Chen
- South Australian Liver Transplant Unit, Flinders Medical Centre, Adelaide, Australia
| | - Alan Wigg
- South Australian Liver Transplant Unit, Flinders Medical Centre, Adelaide, Australia
| | - Robert Jones
- Victorian Liver Transplant Unit, Austin Health, Melbourne, Australia.,Department of Surgery, Austin Health, The University of Melbourne, Melbourne, Australia
| | - Bryon Jaques
- WA Liver Transplant Service, Sir Charles Gairdner Hospital, Perth, Australia
| | - Gary Jeffrey
- WA Liver Transplant Service, Sir Charles Gairdner Hospital, Perth, Australia.,Medical School, University of Western Australia, Perth, Australia
| | - Leon Adams
- WA Liver Transplant Service, Sir Charles Gairdner Hospital, Perth, Australia.,Medical School, University of Western Australia, Perth, Australia
| | - Michael C Wallace
- WA Liver Transplant Service, Sir Charles Gairdner Hospital, Perth, Australia.,Medical School, University of Western Australia, Perth, Australia
| | - Stephen Munn
- New Zealand Liver Transplant Service, Auckland City Hospital and Starship Children's Hospital, Auckland, New Zealand
| | - Ed Gane
- New Zealand Liver Transplant Service, Auckland City Hospital and Starship Children's Hospital, Auckland, New Zealand.,Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Alex J Thompson
- Department of Medicine, University of Melbourne, Melbourne, Australia.,Department of Gastroenterology, St. Vincent's Hospital Melbourne, Melbourne, Australia
| | - Paul Gow
- Department of Medicine, University of Melbourne, Melbourne, Australia.,Victorian Liver Transplant Unit, Austin Health, Melbourne, Australia
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24
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Lockart I, Hajarizadeh B, Buckley N, Davison S, Prakoso E, Levy MT, George J, Dore GJ, Danta M. All-cause hepatocellular carcinoma survival in the era of direct-acting antiviral therapy. J Gastroenterol Hepatol 2021; 36:3515-3523. [PMID: 34520088 DOI: 10.1111/jgh.15687] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 08/20/2021] [Accepted: 09/04/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIM Hepatitis C virus (HCV) cure with direct-acting antiviral (DAA) therapy improves survival in patients with HCV-related hepatocellular carcinoma (HCC). We hypothesized that HCV-HCC survival has increased in the DAA era, more than other aetiologies of HCC. We aimed to evaluate survival following HCC diagnosis in the pre-DAA and DAA eras, across each aetiology of HCC. METHODS Patients with HCC at three tertiary referral hospitals were included retrospectively (January 2008 to December 2019). Patients were categorized as HCV-HCC, hepatitis B virus (HBV)-HCC, or non-viral HCC. For each aetiology, the risk of death following incident HCC among patients diagnosed in the DAA era (2015-2019) was compared with patients diagnosed in the pre-DAA era (2008-2014). RESULTS Among 1161 patients, there were 422 (36%) patients with HCV-HCC, 227 (20%) with HBV-HCC, and 512 (44%) with non-viral HCC. In adjusted analysis, the risk of death was lower in patients with HCV-HCC diagnosed in 2015-2019, compared with patients diagnosed in 2008-2014 (adjusted hazard ratio [aHR]: 0.68; 95% confidence interval [CI]: 0.52-0.89; P = 0.005). In contrast, there was no difference in the risk of death between time periods for patients with HBV-HCC (HR: 0.91; 95% CI: 0.64-1.29; P = 0.602) or non-viral HCC on adjusted analysis (aHR: 0.92; 95% CI: 0.74-1.15; P = 0.476). Although patients with HBV-HCC had better survival compared with patients with HCV-HCC in 2008-2014 (aHR: 0.74; 95% CI: 0.55-0.98; P = 0.037), this difference disappeared in 2015-2019 (aHR: 1.26; 95% CI: 0.90-1.77; P = 0.175). CONCLUSIONS Hepatitis C virus-related HCC survival has increased in the DAA era, whereas adjusted survival remained stable for HBV-HCC and non-viral HCC.
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Affiliation(s)
- Ian Lockart
- St Vincent's Clinical School, Faculty of Medicine, UNSW Sydney, Sydney, New South Wales, Australia.,St Vincent's Hospital, Sydney, New South Wales, Australia
| | | | - Niamh Buckley
- St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Scott Davison
- Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Emilia Prakoso
- Liverpool Hospital, Sydney, New South Wales, Australia.,Central Clinical School, The Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Miriam T Levy
- Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Jacob George
- Storr Liver Centre, Westmead Institute for Medical Research, University of Sydney and Westmead Hospital, Sydney, New South Wales, Australia
| | - Gregory J Dore
- St Vincent's Hospital, Sydney, New South Wales, Australia.,The Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia
| | - Mark Danta
- St Vincent's Clinical School, Faculty of Medicine, UNSW Sydney, Sydney, New South Wales, Australia.,St Vincent's Hospital, Sydney, New South Wales, Australia
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25
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Lim AG, Stone J, Hajarizadeh B, Byrne M, Chambers GM, Martin NK, Grebely J, Dore GJ, Lloyd AR, Vickerman P. Evaluating the Prevention Benefit of HCV Treatment: Modeling the SToP-C Treatment as Prevention Study in Prisons. Hepatology 2021; 74:2366-2379. [PMID: 34105797 DOI: 10.1002/hep.32002] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 06/03/2021] [Accepted: 06/03/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS Between 2014 and 2019, the SToP-C trial observed a halving in HCV incidence in four Australian prisons following scale-up of direct-acting antiviral (DAA) therapy. However, the contribution of HCV treatment to this decline is unclear because the study did not have a control group. We used modeling to consider this question. APPROACH AND RESULTS We parameterized and calibrated a dynamic model of HCV transmission in prisons to data from each SToP-C prison on incarceration dynamics, injecting drug use, HCV prevalence trends among prison entrants, baseline HCV incidence before treatment scale-up, and subsequent HCV treatment scale-up. The model projected the decrease in HCV incidence resulting from increases in HCV treatment and other effects. We assessed whether the model agreed better with observed reductions in HCV incidence overall and by prison if we included HCV treatment scale-up, and its prevention benefits, or did not. The model estimated how much of the observed decrease in HCV incidence was attributable to HCV treatment in prison. The model projected a decrease in HCV incidence of 48.5% (95% uncertainty interval [UI], 41.9-54.1) following treatment scale-up across the four prisons, agreeing with the observed HCV incidence decrease (47.6%; 95% CI, 23.4-64.2) from the SToP-C trial. Without any in-prison HCV treatment, the model indicated that incidence would have decreased by 7.2% (95% UI, -0.3 to 13.6). This suggests that 85.1% (95% UI, 72.6-100.6) of the observed halving in incidence was from HCV treatment scale-up, with the remainder from observed decreases in HCV prevalence among prison entrants (14.9%; 95% UI, -0.6 to 27.4). CONCLUSIONS Our results demonstrate the prevention benefits of scaling up HCV treatment in prison settings. Prison-based DAA scale-up should be an important component of HCV elimination strategies.
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Affiliation(s)
- Aaron G Lim
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Jack Stone
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | | | - Marianne Byrne
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Georgina M Chambers
- Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
| | - Natasha K Martin
- Division of Global Public Health, University of California San Diego, San Diego, CA
| | - Jason Grebely
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Gregory J Dore
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Andrew R Lloyd
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Peter Vickerman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
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26
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Kwon JA, Dore GJ, Hajarizadeh B, Alavi M, Valerio H, Grebely J, Guy R, Gray RT. Australia could miss the WHO hepatitis C virus elimination targets due to declining treatment uptake and ongoing burden of advanced liver disease complications. PLoS One 2021; 16:e0257369. [PMID: 34529711 PMCID: PMC8445464 DOI: 10.1371/journal.pone.0257369] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 08/28/2021] [Indexed: 11/25/2022] Open
Abstract
Australia was one of the first countries to introduce government-funded unrestricted access to direct-acting antiviral (DAA) therapy, with 88,790 treated since March 2016. However, treatment uptake is declining which could potentially undermine Australia's progress towards the WHO HCV elimination targets. Using mathematical modelling, we updated estimates for those living with chronic HCV in Australia, new cases of decompensated cirrhosis (DC), hepatocellular carcinoma (HCC), and liver-related mortality among the HCV-cured and viraemic populations from 2015 to 2030. We considered various DAA treatment scenarios incorporating annual treatment numbers to 2020, and subsequent uptake per year of 6,790 (pessimistic), 8,100 (intermediate), and 11,310 (optimistic). We incorporated the effects of excess alcohol consumption and reduction in progression to DC and HCC among cirrhosis-cured versus viraemic individuals. At the end of 2020, we estimated 117,810 Australians were living with chronic HCV. New cases per year of DC, HCC, and liver-related mortality among the HCV viraemic population decreased rapidly from 2015 (almost eliminated by 2030). In contrast, the growing population size of those cured with advanced liver disease meant DC, HCC, and liver-related mortality declined slowly. The estimated reduction in liver-related mortality from 2015 to 2030 in the combined HCV viraemic and cured population is 25% in the intermediate scenario. With declining HCV treatment uptake and ongoing individual-level risk of advanced liver disease complications, including among cirrhosis-cured individuals, Australia is unlikely to achieve all WHO HCV elimination targets by 2030.
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Affiliation(s)
- Jisoo A. Kwon
- Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia
| | - Gregory J. Dore
- Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia
| | | | - Maryam Alavi
- Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia
| | - Heather Valerio
- Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia
| | - Jason Grebely
- Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia
| | - Rebecca Guy
- Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia
| | - Richard T. Gray
- Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia
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27
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Stafford F, Dore GJ, Clackett S, Martinello M, Matthews GV, Grebely J, Balcomb AC, Hajarizadeh B. Prescribing of direct-acting antiviral therapy by general practitioners for people with hepatitis C in an unrestricted treatment program. Med J Aust 2021; 215:332-333. [PMID: 34346057 DOI: 10.5694/mja2.51204] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 11/13/2020] [Indexed: 11/17/2022]
Affiliation(s)
| | | | - Shawn Clackett
- The Kirby Institute, UNSW Sydney, Sydney, NSW.,Centre for Population Health, NSW Health, Sydney, NSW
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28
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Cunningham EB, Hajarizadeh B, Amin J, Hellard M, Bruneau J, Feld JJ, Cooper C, Powis J, Litwin AH, Marks P, Dalgard O, Conway B, Moriggia A, Stedman C, Read P, Bruggmann P, Lacombe K, Dunlop A, Applegate TL, Matthews GV, Fraser C, Dore GJ, Grebely J. Reinfection Following Successful Direct-acting Antiviral Therapy for Hepatitis C Virus Infection Among People Who Inject Drugs. Clin Infect Dis 2021; 72:1392-1400. [PMID: 32166305 DOI: 10.1093/cid/ciaa253] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 03/10/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The aim of this analysis was to calculate the incidence of hepatitis C virus (HCV) reinfection and associated factors among 2 clinical trials of HCV direct-acting antiviral treatment in people with recent injecting drug use or currently receiving opioid agonist therapy (OAT). METHODS Participants who achieved an end-of-treatment response in 2 clinical trials of people with recent injecting drug use or currently receiving OAT (SIMPLIFY and D3FEAT) enrolled between March 2016 and February 2017 in 8 countries were assessed for HCV reinfection, confirmed by viral sequencing. Incidence was calculated using person-time of observation and associated factors were assessed using Cox proportional hazard models. RESULTS Seventy-three percent of the population at risk of reinfection (n = 177; median age, 48 years; 73% male) reported ongoing injecting drug use. Total follow-up time at risk was 254 person-years (median, 1.8 years; range, 0.2-2.8 years). Eight cases of reinfection were confirmed for an incidence of 3.1/100 person-years (95% confidence interval [CI], 1.6-6.3) overall and 17.9/100 person-years (95% CI, 5.8-55.6) among those who reported sharing needles/syringes. Younger age and needle/syringe sharing were associated with HCV reinfection. CONCLUSIONS These data demonstrate the need for ongoing monitoring and improved strategies to prevent HCV reinfection following successful treatment among people with ongoing injecting drug use to achieve HCV elimination. CLINICAL TRIALS REGISTRATION NCT02336139 and NCT02498015.
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Affiliation(s)
- Evan B Cunningham
- The Kirby Institute, University of New South Wales Sydney, Sydney, Australia
| | - Behzad Hajarizadeh
- The Kirby Institute, University of New South Wales Sydney, Sydney, Australia
| | - Janaki Amin
- The Kirby Institute, University of New South Wales Sydney, Sydney, Australia.,Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Margaret Hellard
- The Burnet Institute, Melbourne, Australia.,Department of Infectious Disease, The Alfred Hospital, Melbourne, Australia
| | - Julie Bruneau
- Centre Hospitalier de l'Université de Montréal, Montreal, Canada
| | | | | | - Jeff Powis
- South Riverdale Community Health Centre, Toronto, Canada
| | - Alain H Litwin
- Albert Einstein College of Medicine, New York, New York, USA
| | - Philippa Marks
- The Kirby Institute, University of New South Wales Sydney, Sydney, Australia
| | | | - Brian Conway
- Vancouver Infectious Diseases Center, Vancouver, Canada
| | - Alberto Moriggia
- Fondazione Epatocentro Ticino, Lugano, Switzerland.,Ingrado Addiction Services, Lugano, Switzerland
| | - Catherine Stedman
- Christchurch Hospital and University of Otago, Christchurch, New Zealand
| | - Phillip Read
- The Kirby Institute, University of New South Wales Sydney, Sydney, Australia.,Kirketon Road Centre, Sydney, Australia
| | | | - Karine Lacombe
- Inserm UMR-S1136, Sorbonne Université, Hôpital Saint-Antoine, Paris, France
| | - Adrian Dunlop
- Newcastle Pharmacotherapy Service, Newcastle, Australia
| | - Tanya L Applegate
- The Kirby Institute, University of New South Wales Sydney, Sydney, Australia
| | - Gail V Matthews
- The Kirby Institute, University of New South Wales Sydney, Sydney, Australia.,St Vincent's Hospital, Sydney, Australia
| | - Chris Fraser
- Coolaid Community Health Centre, Victoria, Canada
| | - Gregory J Dore
- The Kirby Institute, University of New South Wales Sydney, Sydney, Australia.,St Vincent's Hospital, Sydney, Australia
| | - Jason Grebely
- The Kirby Institute, University of New South Wales Sydney, Sydney, Australia
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29
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Heard E, Smirnov A, Massi L, Selvey LA. Personal, provider and system level barriers and enablers for hepatitis C treatment in the era of direct-acting antivirals: Experiences of patients who inject drugs accessing treatment in general practice settings in Australia. J Subst Abuse Treat 2021; 127:108460. [PMID: 34134878 DOI: 10.1016/j.jsat.2021.108460] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 04/23/2021] [Accepted: 05/04/2021] [Indexed: 12/28/2022]
Abstract
Direct acting antiviral (DAA) treatment has made the elimination of hepatitis C virus (HCV) a realisable global public health goal and people who inject drugs are a key target population. This study investigates barriers and enablers to DAA treatment of HCV in general practice settings in Australia, from the patient perspective. Semi-structured interviews were conducted with 28 patients; of these patients, seventeen participants were currently on opioid agonist therapy, and four were currently injecting drugs. Thematic data analysis was undertaken and a personal, provider and systems framework was used to describe the barriers and enablers to DAA treatment. Results suggest a range of initiatives are required to support the uptake of DAA in general practice settings. These include the provision of formalised peer information and support, and increasing the accessibility of blood tests and liver assessment on-site. Further, there remains a need to address stigma and discrimination affecting people who inject drugs in community healthcare settings.
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Affiliation(s)
- Emma Heard
- School of Public Health, The University of Queensland, 288 Herston Road, Herston 4006, QLD, Australia.
| | - Andrew Smirnov
- School of Public Health, The University of Queensland, 288 Herston Road, Herston 4006, QLD, Australia.
| | - Luciana Massi
- School of Public Health, The University of Queensland, 288 Herston Road, Herston 4006, QLD, Australia.
| | - Linda A Selvey
- School of Public Health, The University of Queensland, 288 Herston Road, Herston 4006, QLD, Australia.
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30
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Hajarizadeh B, Grebely J, Byrne M, Marks P, Amin J, McManus H, Butler T, Cunningham EB, Vickerman P, Martin NK, McHutchison JG, Brainard DM, Treloar C, Chambers GM, Grant L, Mcgrath C, Lloyd AR, Dore GJ. Evaluation of hepatitis C treatment-as-prevention within Australian prisons (SToP-C): a prospective cohort study. Lancet Gastroenterol Hepatol 2021; 6:533-546. [PMID: 33965006 DOI: 10.1016/s2468-1253(21)00077-7] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 02/25/2021] [Accepted: 02/25/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Limited empirical evidence exists for the effectiveness of hepatitis C virus (HCV) treatment-as-prevention. The Surveillance and Treatment of Prisoners with hepatitis C (SToP-C) study aimed to assess the effect of HCV treatment-as-prevention in the prison setting. METHODS SToP-C was a prospective study, including a before-and-after analysis, within a cohort of people incarcerated in two maximum-security prisons (male) and two medium-security prisons (one male, one female) in New South Wales, Australia. All prison inmates aged at least 18 years were eligible for enrolment. After HCV testing, participants were monitored for risk behaviours and HCV infection, among three sub-populations: uninfected (HCV antibody-negative); previously infected (HCV antibody-positive, HCV RNA-negative); and infected (HCV antibody and HCV RNA-positive). Uninfected participants were followed up every 3-6 months to detect HCV primary infection and previously infected participants were followed up every 3-6 months to detect re-infection. Participants with HCV infection were assessed for treatment, initially standard-of-care treatment (administered by prison health services) from 2014 to mid-2017, then direct-acting antiviral (DAA) treatment scale-up from mid-2017 onwards (12 weeks of sofosbuvir plus velpatasvir, administered through SToP-C). Participants were followed up until study closure in November, 2019. The primary study outcome was HCV incidence before and after DAA treatment scale-up among participants at risk of HCV primary infection or re-infection. This study is registered with ClinicalTrials.gov, NCT02064049. FINDINGS Between Oct 30, 2014, and Sept 30, 2019, 3691 participants were enrolled in the SToP-C study. 719 (19%) participants had detectable HCV RNA, 2240 (61%) were at risk of primary HCV infection, and 725 (20%) were at risk of re-infection at baseline. DAA treatment was initiated in 349 (70%) of 499 eligible participants during the treatment scale-up period. The HCV incidence analysis comprised 1643 participants at risk of HCV infection or re-infection during longitudinal follow-up (median age 33 years [IQR 27-42]; 1350 [82%] male). 487 (30%) of 1643 participants reported injecting drugs in prison. HCV incidence decreased from 8·31 per 100 person-years in the pre-treatment scale-up period to 4·35 per 100 person-years in the post-treatment scale-up period (incidence rate ratio [IRR] 0·52 [95% CI 0·36-0·78]; p=0·0007). The incidence of primary infection decreased from 6·64 per 100 person-years in the pre-treatment scale-up period to 2·85 per 100 person-years in the post-treatment scale-up period (IRR 0·43 [95% CI 0·25-0·74]; p=0·0019), whereas the incidence of re-infection decreased from 12·36 per 100 person-years to 7·27 per 100 person-years (0·59 [0·35-1·00]; p=0·050). Among participants reporting injecting drugs during their current imprisonment, the incidence of primary infection decreased from 39·08 per 100 person-years in the pre-treatment scale-up period to 14·03 per 100 person-years in the post-treatment scale-up period (IRR 0·36 [95% CI 0·16-0·80]; p=0·0091), and the incidence of re-infection decreased from 15·26 per 100 person-years to 9·34 per 100 person-years (0·61 [0·34-1·09]; p=0·093). The adjusted analysis (adjusted for age, Indigenous Australian ethnicity, duration of stay in prison, previous imprisonment, injecting drug use status, and prison site) indicated a significant reduction in the risk of HCV infection between the pre-DAA treatment scale-up and post-DAA treatment scale-up periods (adjusted hazard ratio 0·50 [95% CI 0·33-0·76]; p=0·0014). INTERPRETATION DAA treatment scale-up was associated with reduced HCV incidence in prison, indicative of a beneficial effect of HCV treatment-as-prevention in this setting. These findings support broad DAA treatment scale-up within incarcerated populations. FUNDING Australian National Health and Medical Research Council Partnership Project Grant and Gilead Sciences.
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Affiliation(s)
| | - Jason Grebely
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Marianne Byrne
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Pip Marks
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Janaki Amin
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia; Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
| | - Hamish McManus
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Tony Butler
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | | | - Peter Vickerman
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Natasha K Martin
- Population Health Sciences, University of Bristol, Bristol, UK; Division of Infectious Diseases & Global Public Health, University of California San Diego, San Diego, CA, USA
| | | | | | - Carla Treloar
- Centre for Social Research in Health, UNSW Sydney, Sydney, NSW, Australia
| | | | - Luke Grant
- Corrective Services NSW, Sydney, NSW Australia
| | - Colette Mcgrath
- Justice Health and Forensic Mental Health Network, NSW Health, Sydney, NSW, Australia
| | - Andrew R Lloyd
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Gregory J Dore
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia.
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Affiliation(s)
- Gregory J Dore
- Infectious diseases physician, St Vincent's Hospital, Sydney
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32
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Ho H, Janjua NZ, McGrail KM, Harrison M, Law MR. The impact of public coverage of newer hepatitis C medications on utilization, adherence, and costs in British Columbia. PLoS One 2021; 16:e0247843. [PMID: 33647068 PMCID: PMC7920374 DOI: 10.1371/journal.pone.0247843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 02/12/2021] [Indexed: 12/04/2022] Open
Abstract
Background Sofosbuvir and ledipasvir-sofosbuvir are both newer direct-acting antiviral agents for the treatment of hepatitis C. The high list prices for both drugs have led to concern about the budget impact for public drug coverage programs. Therefore, we studied the impact of public prescription drug coverage for both drugs on utilization, adherence, and public and private expenditure in British Columbia, Canada. Methods We used provincial administrative claims data from January 2014 to June 2017 for all individuals historically tested for either hepatitis C and/or human immunodeficiency virus. Using interrupted time series analysis, we examined the impact of public insurance coverage on treatment uptake, adherence (proportion of days covered), and public and private expenditures. Results Over our study period, 4,462 treatment initiations were eligible for analysis (1,131 sofosbuvir and 3,331 ledipasvir-sofosbuvir, which include 19 patients initiated on both treatments). We found the start of public coverage for sofosbuvir and ledipasvir-sofosbuvir increased treatment uptake by 154%. Adherence rates were consistently high and did not change with public coverage. Finally, public expenditure increased after the policy change, and crowded out some private expenditure. Conclusion Public coverage for high-cost drugs for hepatitis C dramatically increased use of these drugs, but did not reduce adherence. From a health policy perspective, public payers should be prepared for increased treatment uptake following the availability of public coverage. However, they should not be concerned that populations without private insurance coverage will be less adherent and not finish their treatment course.
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Grants
- FDN-148412 CIHR
- NHC-348216 CIHR
- PHE-337680 CIHR
- PJT-156066 CIHR
- Canadian Institutes of Health Research
- Canadian Agency for Drugs and Technologies in Health
- Canada Research Chairs
- Michael Smith Foundation for Health Research
- Amgen Canada, AstraZeneca Canada, Eli Lilly Canada, GlaxoSmithKline, Merck Canada, Novartis Pharmaceuticals Canada, Pfizer Canada, Boehringer Ingelheim (Canada), Hoffman-La Roche, LifeScan Canada, and Lundbeck Canada
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Affiliation(s)
- Harriet Ho
- The Centre for Health Services and Policy Research, School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
- * E-mail:
| | - Naveed Z. Janjua
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
- School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Health Evaluation and Outcomes Sciences, St. Paul’s Hospital, Vancouver, British Columbia, Canada
| | - Kimberlyn M. McGrail
- The Centre for Health Services and Policy Research, School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Mark Harrison
- Centre for Health Evaluation and Outcomes Sciences, St. Paul’s Hospital, Vancouver, British Columbia, Canada
- Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Michael R. Law
- The Centre for Health Services and Policy Research, School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
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33
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Patel AA, Bui A, Prohl E, Bhattacharya D, Wang S, Branch AD, Perumalswami PV. Innovations in Hepatitis C Screening and Treatment. Hepatol Commun 2021; 5:371-386. [PMID: 33681673 PMCID: PMC7917266 DOI: 10.1002/hep4.1646] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 10/20/2020] [Accepted: 11/01/2020] [Indexed: 12/11/2022] Open
Abstract
New therapies offer hope for a cure to millions of persons living with hepatitis C virus (HCV) infection. HCV elimination is a global goal that will be difficult to achieve using the traditional paradigms of diagnosis and care. The current standard has evolved toward universal HCV screening and treatment, to achieve elimination goals. There are several steps between HCV diagnosis and cure with major barriers along the way. Innovative models of care can address barriers to better serve hardly reached populations and scale national efforts in the United States and abroad. Herein, we highlight innovative models of HCV care that aid in our progress toward HCV elimination.
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Affiliation(s)
- Arpan A. Patel
- Division of Digestive DiseasesDavid Geffen School of Medicine at UCLALos AngelesCAUSA
- Greater Los Angeles Veterans Affairs Medical CenterLos AngelesCAUSA
| | - Aileen Bui
- Division of General Internal MedicineDavid Geffen School of Medicine at UCLALos AngelesCAUSA
| | - Eian Prohl
- Division of General Internal MedicineDavid Geffen School of Medicine at UCLALos AngelesCAUSA
| | - Debika Bhattacharya
- Greater Los Angeles Veterans Affairs Medical CenterLos AngelesCAUSA
- Division of Infectious DiseasesDavid Geffen School of Medicine at UCLALos AngelesCAUSA
| | - Su Wang
- Saint Barnabas Medical CenterLivingstonNJUSA
- World Hepatitis AllianceLondonUnited Kingdom
| | - Andrea D. Branch
- Division of Liver DiseasesIcahn School of Medicine at Mount SinaiNew YorkNYUSA
| | - Ponni V. Perumalswami
- Division of Liver DiseasesIcahn School of Medicine at Mount SinaiNew YorkNYUSA
- Division of Gastroenterology and HepatologyUniversity of MichiganAnn ArborMichiganUSA
- Veterans Affairs Ann Arbor Healthcare SystemAnn ArborMichiganUSA
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34
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Cost effectiveness of treatment models of care for hepatitis C: the South Australian state-wide experience. Eur J Gastroenterol Hepatol 2020; 32:1381-1389. [PMID: 31895911 DOI: 10.1097/meg.0000000000001659] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIM The objective was to study the long-term (lifetime) cost effectiveness of four different hepatitis C virus (HCV) treatment models of care (MOC) with directly acting antiviral drugs. METHODS A cohort Markov model-based probabilistic cost-effectiveness analysis (CEA) was undertaken extrapolating to up to 30 years from cost and outcome data collected from a primary study involving a real-life Australian cohort. In this study, noncirrhotic patients treated for HCV from 1 March 2016 to 28 February 2017 at four major public hospitals and liaising sites in South Australia were studied retrospectively. The MOC were classified depending on the person providing patient workup, treatment and monitoring into MOC1 (specialist), MOC2 (mixed specialist and hepatitis nurse), MOC3 (hepatitis nurse) and MOC4 (general practitioner, GP). Incremental costs were estimated from the Medicare perspective. Incremental outcomes were estimated based on the quality-adjusted life years (QALY) gained by achieving a sustained virological response. A cost-effectiveness threshold of Australian dollar 50 000 per QALY gained, the implicit criterion used for assessing the cost-effectiveness of new pharmaceuticals and medical services in Australia was assumed. Net monetary benefit (NMB) estimates based on this threshold were calculated. RESULTS A total of 1373 patients, 64% males, mean age 50 (SD ±11) years, were studied. In the CEA, MOC4 and MOC2 clearly dominated MOC1 over 30 years with lower costs and higher QALYs. Similarly, NMB was the highest in MOC4, followed by MOC2. CONCLUSION Decentralized care using GP and mixed consultant nurse models were cost-effective ways of promoting HCV treatment uptake in the setting of unrestricted access to new antivirals.
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Dore GJ, Valerio H, Grebely J. Creating an environment for equitable access to direct-acting antiviral therapy for people who inject drugs with hepatitis C. Liver Int 2020; 40:2353-2355. [PMID: 33021345 DOI: 10.1111/liv.14661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Gregory J Dore
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | | | - Jason Grebely
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
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36
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Affiliation(s)
- Gregory J Dore
- From the Kirby Institute, UNSW Sydney, and St. Vincent's Hospital - both in Sydney (G.J.D.); and Philadelphia FIGHT Community Health Centers and the Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (S.T.)
| | - Stacey Trooskin
- From the Kirby Institute, UNSW Sydney, and St. Vincent's Hospital - both in Sydney (G.J.D.); and Philadelphia FIGHT Community Health Centers and the Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (S.T.)
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37
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Hsiang JC, Sinnaswami P, Lee MY, Zhang MM, Quek KE, Tan KH, Wong YM, Thurairajah PH. Point-of-care hepatitis C screening with direct access referral to improve linkage of care among people with substance misuse: a pilot randomised study. Singapore Med J 2020; 63:86-92. [PMID: 32729280 DOI: 10.11622/smedj.2020116] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Linkage to care among people with substance misuse remains a barrier to the elimination of the hepatitis C virus (HCV). We aimed to determine if point-of-care (PoC) education, screening and staging for liver disease with direct access to hospitals would improve linkage to care among this group. METHODS All participants were offered PoC education and HCV screening. HCV-positive participants were randomised to standard care (controls) or direct access, which provided a direct pathway to hospitals. Linkage to care was determined by reviewing electronic medical records. Linkage of care cascade was defined as attendance at the specialist clinic, confirmation of viraemia by HCV RNA testing, discussion about HCV treatment and initiation of treatment. RESULTS 351 halfway house residents were screened. The overall HCV prevalence was 30.5% (n = 107), with 69 residents in the control group and 38 in the direct access group. The direct access group had a significantly higher percentage of cases linked to specialist review for confirmatory RNA testing (63.2% vs. 40.6%, p = 0.025), HCV treatment discussion (p = 0.009) and treatment initiation (p = 0.01) compared to the controls. Overall, only 12.6% (n = 13) had treatment initiation during follow-up. PoC HCV screening with direct access referral had significantly higher linkage to HCV treatment initiation (adjusted odds ratio 9.13, p = 0.005) in multivariate analysis. CONCLUSION PoC HCV screening with direct access improves linkage to care and simplifies the HCV care cascade, leading to improved treatment uptake. PoC education, screening, diagnosis and treatment may be an effective strategy to achieving HCV micro-elimination in this population.
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Affiliation(s)
- John Chen Hsiang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore.,Department of Gastroenterology, Sengkang General Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Pream Sinnaswami
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Mui Yok Lee
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Meng Meng Zhang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Kwang Ee Quek
- Clinical Trials and Research Unit, Changi General Hospital, Singapore
| | - Keng Hwee Tan
- Clinical Trials and Research Unit, Changi General Hospital, Singapore
| | - Yew Meng Wong
- Clinical Trials and Research Unit, Changi General Hospital, Singapore
| | - Prem Harichander Thurairajah
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,National University Hospital, Singapore
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38
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Low hepatitis C virus reinfection rate despite ongoing risk following universal access to direct-acting antiviral therapy among people living with HIV. AIDS 2020; 34:1347-1358. [PMID: 32590433 DOI: 10.1097/qad.0000000000002562] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE(S) To evaluate changes in injecting and sexual risk behaviours, and hepatitis C virus (HCV) reinfection incidence among people with HIV/HCV coinfection following unrestricted access to direct-acting antiviral therapy in Australia. DESIGN Prospective observational cohort study (2014-2018). METHODS Among people enrolled in the Control and Elimination of HCV from HIV-infected individuals within Australia study, changes in injecting and sexual behaviour were evaluated, including injecting drug use (IDU) in the last 6 months and last month, frequency of IDU and equipment sharing, condom-less anal intercourse with casual male partner(s), and group sex. HCV reinfection incidence was evaluated with follow-up through May 2018. RESULTS Overall, 272 HIV/HCV antibody-positive participants [median age; 50 years, 96% male, 83% identified as gay and bisexual men (GBM)] had behavioural data at enrolment and follow-up (median 2.91 years) available for analysis. The proportion reporting IDU in the last 6 months remained stable from enrolment (35%) to follow-up (39%). Among GBM, the proportion reporting condom-less anal intercourse with casual partner(s) at enrolment (48%) and follow-up (46%) was also similar. Reinfection was detected in five individuals (all GBM) during total follow-up of 474 person-years for an overall incidence of 1.05 per 100 person-years (95% confidence interval, 0.44-2.53). CONCLUSION No change was observed in levels of injecting or sexual risk behaviour for HCV infection following unrestricted access to direct-acting antiviral therapy in an Australian HIV/HCV cohort. Incidence of HCV reinfection was low potentially reflecting high levels of treatment coverage within this population. Continued screening and rapid retreatment of reinfection will be required to maintain progress towards elimination.
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39
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Saeed S, Strumpf E, Moodie EEM, Wong L, Cox J, Walmsley S, Tyndall M, Cooper C, Conway B, Hull M, Martel-Laferriere V, Gill J, Wong A, Vachon ML, Klein MB. Eliminating Structural Barriers: The Impact of Unrestricted Access on Hepatitis C Treatment Uptake Among People Living With Human Immunodeficiency Virus. Clin Infect Dis 2020; 71:363-371. [PMID: 31504327 PMCID: PMC7353326 DOI: 10.1093/cid/ciz833] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 08/27/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND High costs of direct-acting antivirals (DAAs) have led health-care insurers to limit access worldwide. Using a natural experiment, we evaluated the impact of removing fibrosis stage restrictions on hepatitis C (HCV) treatment initiation rates among people living with human immunodeficiency virus (HIV), and then examined who was left to be treated. METHODS Using data from the Canadian HIV-HCV Coinfection Cohort, we applied a difference-in-differences approach. Changes in treatment initiation rates following the removal of fibrosis stage restrictions were assessed using a negative binomial regression with generalized estimating equations. The policy change was then specifically assessed among people who inject drugs (PWID). We then identified the characteristics of participants who remained to be treated using a modified Poisson regression. RESULTS Between 2010-2018, there were a total of 585 HCV initiations among 1130 eligible participants. After removing fibrosis stage restrictions, DAA initiations increased by 1.8-fold (95% confidence interval [CI] 1.3-2.4) controlling for time-invariant differences and secular trends. Among PWID the impact appeared even stronger, with an adjusted incidence rate ratio of 3.6 (95% CI 1.8-7.4). However, this increased treatment uptake was not sustained. At 1 year following universal access, treatment rates declined to 0.8 (95% CI .5-1.1). Marginalized participants (PWID and those of indigenous ethnicity) and those disengaged from care were more likely to remain HCV RNA positive. CONCLUSIONS After the removal of fibrosis restrictions, HCV treatment initiations nearly doubled immediately, but this treatment rate was not sustained. To meet the World Health Organization elimination targets, the minimization of structural barriers and adoption of tailored interventions are needed to engage and treat all vulnerable populations.
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Affiliation(s)
- Sahar Saeed
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada
- Research Institute of the McGill University Health Centre, Montreal, Canada
| | - Erin Strumpf
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada
- Department of Economics, McGill University, Montreal, Canada
| | - Erica E M Moodie
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada
| | - Leo Wong
- Research Institute of the McGill University Health Centre, Montreal, Canada
| | - Joseph Cox
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada
- Research Institute of the McGill University Health Centre, Montreal, Canada
| | - Sharon Walmsley
- University Health Network, University of Toronto, Toronto, Canada
- Canadian Institute for Health Research, Canadian Human Immunodeficiency Virus Trials Network,, Vancouver, Canada
| | - Mark Tyndall
- British Columbia Centre for Disease Control, University of British Columbia, Vancouver, Canada
| | - Curtis Cooper
- Canadian Institute for Health Research, Canadian Human Immunodeficiency Virus Trials Network,, Vancouver, Canada
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Brian Conway
- Vancouver Infectious Diseases Centre, Vancouver, Canada
| | - Mark Hull
- Canadian Institute for Health Research, Canadian Human Immunodeficiency Virus Trials Network,, Vancouver, Canada
- British Columbia Centre of Excellence, St. Paul’s Hospital, Vancouver, Canada
| | - Valerie Martel-Laferriere
- Departement de Microbiologie et Infectiologie, Centre Hospitalier de l’Université de Montréal, Montreal, Canada
| | - John Gill
- Southern Alberta Human Immunodeficiency Virus Clinic, Calgary, Canada
| | | | | | - Marina B Klein
- Research Institute of the McGill University Health Centre, Montreal, Canada
- Canadian Institute for Health Research, Canadian Human Immunodeficiency Virus Trials Network,, Vancouver, Canada
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Brain D, Mitchell J, O’Beirne J. Cost-effectiveness analysis of an outreach model of Hepatitis C Virus (HCV) assessment to facilitate HCV treatment in primary care. PLoS One 2020; 15:e0234577. [PMID: 32555696 PMCID: PMC7299404 DOI: 10.1371/journal.pone.0234577] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 05/27/2020] [Indexed: 12/27/2022] Open
Abstract
The effects of hepatitis C virus (HCV), such as morbidity and mortality associated with cirrhosis and liver cancer, is a major public health issue in Australia. Highly effective treatment has recently been made available to all Australians living with HCV. A decision-analytic model was developed to evaluate the cost-effectiveness of the hepatology partnership, compared to usual care. A Markov model was chosen, as it is state-based and able to include recursive events, which accurately reflects the natural history of the chronic and repetitive nature of HCV. Cost-effectiveness of the new model of care is indicated by the incremental cost-effectiveness ratio (ICER), where the mean change to costs associated with the new model of care is divided by the mean change in quality adjusted life-years (QALYs). Ten thousand iterations of the model were run, with the majority (73%) of ICERs representing cost-savings. In comparison to usual care, the intervention improves health outcomes (22.38 QALYs gained) and reduces costs by $42,122 per patient. When compared to usual care, a partnership approach to management of HCV is cost-effective and good value for money, even when key model parameters are changed in scenario analyses. Reduction in costs is driven by improved efficiency of the new model of care, where more patients are treated in a timely manner, away from the expensive tertiary setting. From an economic perspective, a reduction in hospital-based care is a positive outcome and represents a good investment for decision-makers who wish to maximise health gain per dollar spent.
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Affiliation(s)
- David Brain
- Australian Centre for Health Services Innovation, Melbourne, Australia
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia
- * E-mail:
| | - Jonathan Mitchell
- Sunshine Coast University Hospital, Britinya, Australia
- Sunshine Coast Health Institute, University of the Sunshine Coast, Britinya, Australia
| | - James O’Beirne
- Sunshine Coast University Hospital, Britinya, Australia
- Sunshine Coast Health Institute, University of the Sunshine Coast, Britinya, Australia
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Binka M, Janjua NZ, Grebely J, Estes C, Schanzer D, Kwon JA, Shoukry NH, Kwong JC, Razavi H, Feld JJ, Krajden M. Assessment of Treatment Strategies to Achieve Hepatitis C Elimination in Canada Using a Validated Model. JAMA Netw Open 2020; 3:e204192. [PMID: 32374397 PMCID: PMC7203608 DOI: 10.1001/jamanetworkopen.2020.4192] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 03/04/2020] [Indexed: 12/19/2022] Open
Abstract
Importance Achievement of the World Health Organization (WHO) target of eliminating hepatitis C virus (HCV) by 2030 will require an increase in key services, including harm reduction, HCV screening, and HCV treatment initiatives in member countries. These data are not available for Canada but are important for informing a national HCV elimination strategy. Objective To use a decision analytical model to explore the association of different treatment strategies with HCV epidemiology and HCV-associated mortality in Canada and to assess the levels of service increase needed to meet the WHO elimination targets by 2030. Design, Setting, and Participants Study participants in this decision analytical model included individuals with hepatitis C virus infection in Canada. Five HCV treatment scenarios (optimistic, very aggressive, aggressive, gradual decrease, and rapid decrease) were applied using a previously validated Markov-type mathematical model. The optimistic and very aggressive treatment scenarios modeled a sustained annual treatment of 10 200 persons and 14 000 persons, respectively, from 2018 to 2030. The aggressive, gradual decrease, and rapid decrease scenarios assessed decreases in treatment uptake from 14 000 persons to 10 000 persons per year, 12 000 persons to 8500 persons per year, and 12 000 persons to 4500 persons per year, respectively, between 2018 and 2030. Main Outcomes and Measures Hepatitis C virus prevalence and HCV-associated health outcomes were assessed for each of the 5 treatment scenarios with the goal of identifying strategies to achieve HCV elimination by 2030. Results An estimated mean 180 142 persons (95% CI, 122 786-196 862 persons) in Canada had chronic HCV infection at the end of 2017. The optimistic and gradual decrease scenarios estimated a decrease in HCV prevalence from 180 142 persons to 37 246 persons and 37 721 persons, respectively, by 2030. Relative to 2015, this decrease in HCV prevalence was associated with 74%, 69%, and 69% reductions in the prevalence of decompensated cirrhosis, hepatocellular carcinoma, and liver-associated mortality, respectively, leading to HCV elimination by 2030. More aggressive treatment uptake (very aggressive scenario) could result in goal achievement up to 3 years earlier than 2030, although a rapid decrease in the initiation of treatment (rapid decrease scenario) would preclude Canada from reaching the HCV elimination goal by 2030. Conclusions and Relevance The study findings suggest that Canada could meet the WHO goals for HCV elimination by 2030 by sustaining the current national HCV treatment rate during the next decade. This target will not be achieved if treatment uptake is allowed to decrease rapidly.
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Affiliation(s)
- Mawuena Binka
- British Columbia Centre for Disease Control, Vancouver, Canada
| | - Naveed Z. Janjua
- British Columbia Centre for Disease Control, Vancouver, Canada
- Canadian Network on Hepatitis C, Montreal, Quebec, Canada
- University of British Columbia, Vancouver, Canada
| | - Jason Grebely
- Canadian Network on Hepatitis C, Montreal, Quebec, Canada
- Kirby Institute, University of New South Wales Sydney, Sydney, Australia
| | - Chris Estes
- Center for Disease Analysis, Lafayette, Colorado
| | - Dena Schanzer
- Canadian Network on Hepatitis C, Montreal, Quebec, Canada
| | - Jisoo A. Kwon
- Kirby Institute, University of New South Wales Sydney, Sydney, Australia
| | - Naglaa H. Shoukry
- Canadian Network on Hepatitis C, Montreal, Quebec, Canada
- Centre de Recherche du Centre Hospitalier de l’Universite de Montreal, Montreal, Quebec, Canada
| | - Jeffrey C. Kwong
- Canadian Network on Hepatitis C, Montreal, Quebec, Canada
- ICES, Toronto, Ontario, Canada
| | - Homie Razavi
- Center for Disease Analysis, Lafayette, Colorado
| | - Jordan J. Feld
- Canadian Network on Hepatitis C, Montreal, Quebec, Canada
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| | - Mel Krajden
- British Columbia Centre for Disease Control, Vancouver, Canada
- Canadian Network on Hepatitis C, Montreal, Quebec, Canada
- University of British Columbia, Vancouver, Canada
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42
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43
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Martinello M, Hajarizadeh B, Dore GJ. Hepatitis C elimination in Australia: progress and challenges. Med J Aust 2020; 212:362-363. [DOI: 10.5694/mja2.50584] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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44
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Douglas MW, Tay ESE, Wang DS, Ong ATL, Wilson C, Phu A, Kok J, Dwyer DE, Bull RA, Lloyd AR, Applegate TL, Dore GJ, Howe AY, Harrigan R, George J. Impact of an Open Access Nationwide Treatment Model on Hepatitis C Virus Antiviral Drug Resistance. Hepatol Commun 2020; 4:904-915. [PMID: 32490325 PMCID: PMC7262285 DOI: 10.1002/hep4.1496] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 02/07/2020] [Indexed: 12/21/2022] Open
Abstract
Direct acting antivirals (DAAs) have revolutionized hepatitis C virus (HCV) treatment, but drug resistance could undermine proposed global elimination targets. Real‐world studies are needed to inform the impact of widespread DAA treatment on antiviral resistance in the community. The prevalence and range of posttreatment resistance‐associated substitutions (RASs) was determined in Australian patients with open access to DAAs through a wide range of prescribers. NS3, NS5A, and NS5B regions were amplified by polymerase chain reaction and analyzed by population sequencing. Clinically relevant RASs were identified using online databases (ReCALL and Geno2Pheno[hcv]). Of 572 samples, 60% were from genotype 3 and 27% from genotype 1a. Ninety‐two percent of people failed a DAA regimen containing an NS5A inhibitor, including 10% with a pangenotype regimen. NS5A RASs were detected in 72% of people with genotype 1 and 80% with genotype 3. For genotype 1, there was a range of RASs across the NS5A region, while for genotype 3, the Y93H RAS predominated (72%). The prevalence of NS3 RASs was higher in people exposed to an NS3 inhibitor (35% vs. 3.9%; P < 0.0001). NS5B resistance was rare, with a single case of sofosbuvir resistance. Multiclass drug resistance was found in 33% of people exposed to both NS3 and NS5A inhibitors. Conclusion: The high prevalence of NS5A RASs among people failing DAA therapy reinforces the importance of specific retreatment regimens, ideally guided by resistance testing. The impact of multiclass drug resistance on retreatment in people exposed to both NS3 and NS5A inhibitors needs to be assessed in real‐world studies. Surveillance for increasing antiviral resistance during treatment scale‐up is essential to maintain the efficacy of current DAA regimens.
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Affiliation(s)
- Mark W Douglas
- Storr Liver Centre The Westmead Institute for Medical Research The University of Sydney and Westmead Hospital Sydney Australia.,Centre for Infectious Diseases and Microbiology Westmead Hospital Sydney Australia.,Marie Bashir Institute for Infectious Diseases and Biosecurity University of Sydney Sydney Australia
| | - Enoch S E Tay
- Storr Liver Centre The Westmead Institute for Medical Research The University of Sydney and Westmead Hospital Sydney Australia.,Centre for Infectious Diseases and Microbiology Laboratory Services NSW Health Pathology-Institute of Clinical Pathology and Medical Research Westmead Hospital Westmead Australia
| | - Dao Sen Wang
- Storr Liver Centre The Westmead Institute for Medical Research The University of Sydney and Westmead Hospital Sydney Australia
| | - Adrian T L Ong
- Storr Liver Centre The Westmead Institute for Medical Research The University of Sydney and Westmead Hospital Sydney Australia.,Centre for Infectious Diseases and Microbiology Westmead Hospital Sydney Australia
| | - Caroline Wilson
- Storr Liver Centre The Westmead Institute for Medical Research The University of Sydney and Westmead Hospital Sydney Australia
| | - Amy Phu
- Storr Liver Centre The Westmead Institute for Medical Research The University of Sydney and Westmead Hospital Sydney Australia
| | - Jen Kok
- Centre for Infectious Diseases and Microbiology Laboratory Services NSW Health Pathology-Institute of Clinical Pathology and Medical Research Westmead Hospital Westmead Australia
| | - Dominic E Dwyer
- Marie Bashir Institute for Infectious Diseases and Biosecurity University of Sydney Sydney Australia.,Centre for Infectious Diseases and Microbiology Laboratory Services NSW Health Pathology-Institute of Clinical Pathology and Medical Research Westmead Hospital Westmead Australia
| | - Rowena A Bull
- The Kirby Institute University of New South Wales Sydney Australia
| | - Andrew R Lloyd
- The Kirby Institute University of New South Wales Sydney Australia
| | | | - Gregory J Dore
- The Kirby Institute University of New South Wales Sydney Australia
| | - Anita Y Howe
- British Columbia Centre for Disease Control BC Canada
| | | | - Jacob George
- Storr Liver Centre The Westmead Institute for Medical Research The University of Sydney and Westmead Hospital Sydney Australia.,Marie Bashir Institute for Infectious Diseases and Biosecurity University of Sydney Sydney Australia
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45
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Gilliver R, Kearley J, Read P. Preparing for a syndemic: incorporating opioid overdose management into routine care for people who inject drugs initiating hepatitis C treatment. Intern Med J 2020; 50:382-383. [DOI: 10.1111/imj.14755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 05/28/2019] [Accepted: 06/08/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Rosie Gilliver
- Kirketon Road CentreSouth Eastern Sydney Local Health District Sydney New South Wales Australia
| | - John Kearley
- Kirketon Road CentreSouth Eastern Sydney Local Health District Sydney New South Wales Australia
| | - Phillip Read
- Kirketon Road CentreSouth Eastern Sydney Local Health District Sydney New South Wales Australia
- Kirby InstituteUNSW Australia Sydney New South Wales Australia
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46
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Bajis S, Grebely J, Hajarizadeh B, Applegate T, Marshall AD, Ellen Harrod M, Byrne J, Bath N, Read P, Edwards M, Gorton C, Hayllar J, Cock V, Peterson S, Thomson C, Weltman M, Jefferies M, Wood W, Haber P, Ezard N, Martinello M, Maher L, Dore GJ. Hepatitis C virus testing, liver disease assessment and treatment uptake among people who inject drugs pre- and post-universal access to direct-acting antiviral treatment in Australia: The LiveRLife study. J Viral Hepat 2020; 27:281-293. [PMID: 31698545 DOI: 10.1111/jvh.13233] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 09/04/2019] [Accepted: 10/07/2019] [Indexed: 02/06/2023]
Abstract
Gaps in hepatitis C virus (HCV) testing, diagnosis, liver disease assessment and treatment uptake among people who inject drugs (PWID) persist. We aimed to describe the cascade of HCV care among PWID in Australia, prior to and following unrestricted access to direct-acting antiviral (DAA) treatment. Participants enrolled in an observational cohort study between 2014 and 2018 provided fingerstick whole-blood samples for dried blood spot, Xpert HCV Viral Load and venepuncture samples. Participants underwent transient elastography and clinical assessment by a nurse or general practitioner. Among 839 participants (mean age 43 years), 66% were male (n = 550), 64% (n = 537) injected drugs in the previous month, and 67% (n = 560) reported currently receiving opioid substitution therapy. Overall, 45% (n = 380) had detectable HCV RNA, of whom 23% (n = 86) received HCV treatment within 12 months of enrolment. HCV treatment uptake increased from 2% in the pre-DAA era to 38% in the DAA era. Significant liver fibrosis (F2-F4) was more common in participants with HCV infection (38%) than those without (19%). Age 50 years or older (aOR, 2.88; 95% CI, 1.18-7.04) and attending a clinical follow-up with nurse (aOR, 3.19; 95% CI, 1.61-6.32) or physician (aOR, 11.83; 95% CI, 4.89-28.59) were associated with HCV treatment uptake. Recent injection drug use and unstable housing were not associated with HCV treatment uptake. HCV treatment uptake among PWID has increased markedly in the DAA era. Evaluation of innovative and simplified models of care is required to further enhance treatment uptake.
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Affiliation(s)
- Sahar Bajis
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Jason Grebely
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | | | | | - Alison D Marshall
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia.,Centre for Social Research in Health, UNSW Sydney, Sydney, NSW, Australia
| | | | - Jude Byrne
- Australian Injecting and Illicit Drug Users League, Canberra, ACT, Australia
| | - Nicky Bath
- NSW Users and AIDS Association, Sydney, NSW, Australia
| | | | - Michael Edwards
- South Western Sydney Local Health District Drug Health Services, Sydney, NSW, Australia
| | - Carla Gorton
- Cairns Sexual Health Service, Cairns, QLD, Australia
| | - Jeremy Hayllar
- Alcohol and Drug Service, Metro North Mental Health, Metro North Hospital and Health Service, Brisbane, QLD, Australia
| | - Victoria Cock
- Drug and Alcohol Services of South Australia, Adelaide, SA, Australia
| | | | - Claire Thomson
- Bayside Alcohol and Drug Services, Cleveland, QLD, Australia
| | | | | | - William Wood
- Sydney Medically Supervised Injecting Centre, Sydney, NSW, Australia
| | - Paul Haber
- Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Nadine Ezard
- Alcohol and Drug Service, St Vincent's Hospital, Sydney, NSW, Australia.,Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia
| | | | - Lisa Maher
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia.,Burnet Institute, Melbourne, Vic, Australia
| | - Gregory J Dore
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
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47
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Effectiveness of implementing a decentralized delivery of hepatitis C virus treatment with direct-acting antivirals: A systematic review with meta-analysis. PLoS One 2020; 15:e0229143. [PMID: 32084187 PMCID: PMC7034833 DOI: 10.1371/journal.pone.0229143] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 01/30/2020] [Indexed: 12/13/2022] Open
Abstract
Direct-acting agents (DAAs) for hepatitis C virus (HCV) treatment are safe and highly effective. Few studies described the sustained virologic response rates of treatment conducted by non-specialists. We performed a systematic review and meta‐analysis to evaluate the effectiveness of decentralized strategies of HCV treatment with DAAs. PubMed, Embase, Scopus and LILACS were searched until March-2019. Studies were screened by two researchers according to the following inclusion criteria: HCV treatment using DAAs on real-life cohort studies or clinical trials conducted by non-specialized health personnel. The primary endpoint was the sustained virologic response rate at week 12 after the end-of-treatment (SVR12), which is binary at the patient level. Data were extracted in duplicate using electronic-forms and quality appraisal was performed with the NIH Quality Assessment Tool. Heterogeneity was assessed by I2 statistics. Random-effects meta-analysis models were used for pooling SVR12 rates. Publication bias was assessed using funnel plots. Among the 130 selected studies, nine papers were included for quantitative synthesis. The quality-appraisal was good for two, fair for three and poor for four studies. The pooled relative risk (RR) of SVR12 was not statistically different between decentralized strategy and treatment by specialists [RR = 1.05; 95% confidence interval (95% CI): 0.98–1.1; I2 = 45% (95% CI: 0–84%), p = 0.145]. SVR12 rate for decentralized HCV treatment was 81% [SVR12 95% CI: 72–89%; I2 = 93% (95% CI: 88–96%)] and 95% [SVR12 95%CI: 92–98%; I2 = 77% (95% CI: 52–89%)] with intention to treat analysis and per-protocol analysis, respectively. SVR12 rates using DAAs managed by non-specialized health personnel were satisfactory and similar to those obtained by specialists. This new delivery strategy can improve access to HCV treatment, especially in resource-limited settings. PROSPERO #: CRD42019122609.
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48
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Iranpour N, Dore GJ, Martinello M, Matthews GV, Grebely J, Hajarizadeh B. Estimated uptake of hepatitis C direct-acting antiviral treatment among individuals with HIV co-infection in Australia: a retrospective cohort study. Sex Health 2020; 17:223-230. [DOI: 10.1071/sh19101] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 12/20/2019] [Indexed: 12/15/2022]
Abstract
Background
Unrestricted access to direct-acting antiviral (DAA) therapy for hepatitis C virus (HCV) infection has been available in Australia since March 2016. Individuals with HIV–HCV co-infection are at a greater risk of liver fibrosis progression. This study estimated DAA treatment uptake among individuals with HIV–HCV co-infection, during the first year of DAA treatment access in Australia. Methods: Pharmaceutical Benefits Scheme (PBS) data on dispensed DAA and antiretroviral therapy (ART) prescriptions from March 2016 to March 2017 were used for analysis. Results: During March 2016 to March 2017, a total of 935 individuals with HIV–HCV co-infection were receiving ART and initiated DAA treatment, with 93% to 97% completing their prescribed course. Estimated DAA treatment uptake in the HIV–HCV-infected population was 41% (935/2290). Most were men (94%). Median age was 50 years. DAA treatment was initiated by specialists in 64% of cases (n = 602), and by general practitioners (GPs) in 25% of cases (n = 238). The proportion of individuals initiated on DAA by GPs increased from 20% in March–April 2016 to 26% in January–March 2017. Most specialists (77%) and GPs (72%) initiated DAA treatment for one to three patients. Among individuals initiated on DAA by GPs, 68% received their ART prescription from the same GP. Conclusions: A high level of DAA treatment uptake and completion was observed among individuals with HIV–HCV co-infection during the first year of DAA treatment access. The proportion of individuals prescribed DAA by GPs increased over time; this is important for broadened access.
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Bartlett SR, Yu A, Chapinal N, Rossi C, Butt Z, Wong S, Darvishian M, Gilbert M, Wong J, Binka M, Alvarez M, Tyndall M, Krajden M, Janjua NZ. The population level care cascade for hepatitis C in British Columbia, Canada as of 2018: Impact of direct acting antivirals. Liver Int 2019; 39:2261-2272. [PMID: 31444846 DOI: 10.1111/liv.14227] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 08/14/2019] [Accepted: 08/19/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Population-level monitoring of hepatitis C virus (HCV) infected people across cascades of care identifies gaps in access and engagement in care and treatment. We characterized the population-level care cascade for HCV in British Columbia (BC), Canada before and after introduction of Direct Acting Antiviral (DAA) treatment. METHODS BC Hepatitis Testers Cohort (BC-HTC) includes 1.7 million individuals tested for HCV, HIV, reported cases of hepatitis B, and active tuberculosis in BC from 1990 to 2018 linked to medical visits, hospitalizations, cancers, prescription drugs and mortality data. We defined six HCV care cascade stages: (a) antibody diagnosed; (b) RNA tested; (c) RNA positive; (d) genotyped; (e) initiated treatment; and (f) achieved sustained virologic response (SVR). RESULTS We estimated 61 127 people were HCV antibody positive in BC in 2018 (undiagnosed: 7686, 13%; diagnosed: 53 441, 87%). Of those diagnosed, 83% (44 507) had HCV RNA testing, and of those RNA positive, 90% (28 716) were genotyped. Of those genotyped, 61% (17 441) received therapy, with 90% (15 672) reaching SVR. Individuals from older birth cohorts had lower progression to HCV RNA testing. While people who currently inject drugs had the highest proportional progression to RNA testing, this group had the lowest proportional treatment uptake. CONCLUSIONS Although gaps in HCV RNA and genotype testing after antibody diagnosis exist, the largest gap in the care cascade is treatment initiation, despite introduction of DAA treatment and removal of treatment eligibility restrictions. Further interventions are required to ensure testing and treatment is equitably accessible in BC.
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Affiliation(s)
- Sofia R Bartlett
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada.,Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada.,Kirby Institute, University of New South Wales Australia, Sydney, NSW, Australia
| | - Amanda Yu
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada
| | - Nuria Chapinal
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada
| | - Carmine Rossi
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada.,Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Zahid Butt
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Stanley Wong
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada
| | - Maryam Darvishian
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Mark Gilbert
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Jason Wong
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Mawuena Binka
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada.,Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Maria Alvarez
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada
| | - Mark Tyndall
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Mel Krajden
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada.,Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Naveed Z Janjua
- British Columbia Centre for Disease Control (BCCDC), Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
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50
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Read P, Gilliver R, Kearley J, Lothian R, Cunningham EB, Chronister KJ, Dore GJ. Treatment adherence and support for people who inject drugs taking direct-acting antiviral therapy for hepatitis C infection. J Viral Hepat 2019; 26:1301-1310. [PMID: 31299127 DOI: 10.1111/jvh.13175] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 05/02/2019] [Accepted: 06/17/2019] [Indexed: 12/12/2022]
Abstract
A community-based public health facility in Sydney, Australia, the Kirketon Road Centre (KRC), provides health care to people who inject drugs (PWID), homeless and other marginalized people. Since March 2016, KRC has provided treatment for chronic hepatitis C virus (HCV) with direct-acting antivirals (DAAs). We aimed to evaluate treatment adherence amongst clients taking DAAs in a highly marginalized population. All clients who commenced DAA therapy prior to March 2018 at KRC were included in this observational cohort with a subset of clients attending daily or weekly for enhanced adherence support and dosing. Demographic, behavioural, clinical measures and medication dosing were recorded, and adherence was calculated as the proportion of doses taken during the expected treatment duration. Factors associated with adherence were examined using logistic regression. A total of 242 individuals commenced DAA therapy, of whom 79 (32%) received enhanced adherence support. Enhanced support was associated with homelessness, daily injecting, Aboriginality, mental health co-morbidity and poly-drug use (all P < .001). Overall adherence was 86%, and 92% of patients missed one or more doses (median 10, IQR 4-24). At least 90% adherence during planned duration was seen in 38%, but increased to 66% by continuing therapy beyond planned duration. Intention-to-treat SVR12 was 68% and 66% in the enhanced adherence support sub-population, with 29% lost to follow-up by SVR12 testing. There were only 2 (0.8%) documented virological failures. Per-protocol SVR12 was 99% and 96% in the enhanced adherence support sub-population. In conclusion, adherence support may benefit those with multiple markers of marginalization. Extension of therapy beyond planned duration is a pragmatic strategy to enhance completion. Strategies to improve follow-up, particularly post-treatment are required.
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Affiliation(s)
- Phillip Read
- Kirketon Road Centre, South Eastern Sydney Local Health District, Sydney, NSW, Australia.,Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Rosie Gilliver
- Kirketon Road Centre, South Eastern Sydney Local Health District, Sydney, NSW, Australia
| | - John Kearley
- Kirketon Road Centre, South Eastern Sydney Local Health District, Sydney, NSW, Australia
| | - Rebecca Lothian
- Kirketon Road Centre, South Eastern Sydney Local Health District, Sydney, NSW, Australia
| | | | - Karen J Chronister
- Kirketon Road Centre, South Eastern Sydney Local Health District, Sydney, NSW, Australia
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