Improving hepatitis C direct-acting antiviral access and uptake: A role for patient-reported outcomes and lived experience

'I'm not hep C free': afterlives of hepatitis C in the era of cure

Since the advent of more effective, new-generation treatment for hepatitis C, immense resources have been devoted to delivering cure to as many people with the virus as possible. The scale-up of treatment aims to prevent liver disease, liver cancer and onward transmission of hepatitis C, but social research shows that people also approach treatment with its social promises in mind, including the hope that it might reduce or eradicate stigma from their lives. Such hopes reflect broader ideas about medical cure, which is seen as an end point to illness and its effects, and capable of restoring the self to a (previous) state of health and well-being. But what does cure mean among people for whom treatment does not produce an end to the social effects of a heavily stigmatised disease? While new treatments promise to eliminate hepatitis C, accounts of post-cure life suggest that hepatitis C can linger in various ways. This article draws on interviews with people who have undergone treatment with direct-acting antivirals (n=30) in Australia to explore the meanings they attach to cure and their experiences of post-cure life. We argue that dominant biomedical understandings of cure as an 'ending' and a 'restoration' can foreclose insight into the social and other effects of illness that linger after medical cure, and how individuals grapple with those afterlives. Drawing on recent conceptual re-framings of cure from medical anthropology and disability studies, we suggest that thinking at the limits of 'curative reason' helps to better address the afterlives of chronic illness. In the case of hepatitis C, reconceptualising cure could inform improved and less stigmatising ways of addressing people's post-cure needs. And in the era of hepatitis C elimination, such reconceptualisation is increasingly important as the cohort of people undergoing treatment and cure expands worldwide.

Complicating cure: How Australian criminal law shapes imagined post-hepatitis C futures

In recent years, highly tolerable and effective drugs have emerged promising a radical new 'post-hepatitis C' world. Optimism about medical cure potentially overlooks discrimination and stigma associated with hepatitis C and injecting drug use. Legal frameworks are especially relevant to hepatitis futures, since the law has the potential to reinforce or alleviate stigma and discrimination. This article explores how hepatitis C figures in Australian criminal law and with what potential effects. Drawing on Bruno Latour's work on legal veridiction, Alison Kafer's work on futurity and disability and case law data collected for a major study on hepatitis C and post-cure lives, we explore how the criminal law handles hepatitis C in the age of cure. We find that law complicates cure, constituting hepatitis C as disabling despite the advent of effective cures. The law steadfastly maintains its own approach to disease, disability and illness, untouched by medical and scientific developments, in ways that might complicate straightforwardly linear imaginaries of cure, transformation and progress of the kind that dominate biomedicine. We explore the implications of these tensions between law and medicine.

Patient-reported outcomes with direct-acting antiviral treatment for hepatitis C in West and Central Africa (TAC ANRS 12311 trial)

Background & Aims

Patient-reported outcomes (PROs) are poorly documented for patients with chronic hepatitis C on direct-acting antiviral (DAA) treatment in low-to-middle-income countries. We documented PROs during and after DAA treatment in participants of the TAC ANRS 12311 trial (West and Central Africa).

Methods

Trial participants received a 12-week regimen containing either sofosbuvir plus ribavirin (HCV genotype 2, n = 40), or sofosbuvir plus ledipasvir (HCV genotypes 1 and 4, n = 80). Health-related quality of life (SF-12), fatigue (Piper Fatigue scale), and self-reported symptoms (35-symptom list) were assessed at enrolment (Week (W) 0), during treatment (W2, W4, W8 and W12) and after treatment (W24 and W36). These PROs were compared between W0 and W36 (Wilcoxon signed-rank or McNemar tests). Mixed-effects linear regression models helped identify correlates of physical and mental quality of life component summaries (PCS and MCS) in a longitudinal analysis.

Results

Most PROs were significantly improved 24 weeks after treatment end (W36), without significant differences between treatment groups. For the post-treatment period, multivariable analysis showed significant increases in PCS for patients with cirrhosis and in MCS for patients in the sofosbuvir plus ribavirin group. A higher number of self-reported symptoms at W0 was associated with lower PCS and MCS, older age and cirrhosis with lower PCS, and male sex and HCV cure with higher PCS.

Conclusions

Sofosbuvir-based DAA therapy was associated with a significant improvement in PROs 6 months after treatment end in patients with chronic HCV infection from Central and West Africa. These findings may guide HCV treatment providers in low-to-middle-income countries to deliver pre-treatment information concerning the benefits of DAAs beyond viral eradication.

ClinicalTrialsgov Identifier

NCT02405013.

Impact and implications

Perceptions and experiences (i.e. "patient-reported outcomes") of patients with chronic hepatitis C receiving direct-acting antivirals (DAAs) are poorly documented in the African setting. This study shows significant improvements in health-related quality of life, fatigue, and self-reported symptoms 24 weeks after the end of a 12-week sofosbuvir-based DAA regimen in 120 patients from Central and West Africa. These findings substantially add to the body of knowledge about DAA therapy in the African setting. Treatment providers should be encouraged to inform patients of the benefits of DAAs beyond viral eradication, to increase treatment adherence and retention in care.

"Like a pickle that's been unpickled": Emotional, identity and behavioural transformations throughout hepatitis C treatment

BACKGROUND

Little is known about the emotional experience and benefits of undertaking direct acting antiviral (DAA) treatment for hepatitis C. A better understanding of individual treatment outcomes can inform acceptable treatment delivery and promotion. We aimed to explore participant-perceived emotional benefits and transformations throughout DAA treatment among people who inject drugs, who were initiating treatment.

METHODS

Participants were recruited from either a community based clinical trial or community health clinics. Semi structured interviews were conducted with each participant before, during and following treatment. Interviews focussed on treatment perceptions, physical and mental wellbeing and modifiable health behaviours. Interviews were recorded, transcribed verbatim and thematically analysed. Participant and cohort matrices were produced to assess at which time point themes were present and whether themes changed or remained stable over time.

RESULTS

This paper presents analysis from 19 participants interviewed between 2017-2019. Most participants were male, with no or mild fibrosis. At baseline, all but one participant had injected drugs in the past month. Three themes relating to the emotional wellbeing and behaviour change described a common treatment experience; 'hopes for better wellbeing', 'lifting the weight' and 'closing the chapter'. Participants were hopeful treatment would improve their emotional wellbeing. Hopes were actualised during treatment as participants began to feel uncertainty and stress easing. Completing treatment improved some participants perceptions of self. Some participants consciously changed their injecting behaviours during treatment.

CONCLUSION

Undertaking and completing treatment was an emotionally and behaviourally transformative period. Participant perceived benefits should be used to inform how treatment benefit is conceptualised and how treatment is promoted in primary care settings.

Hepatitis C cure as a 'gathering': Attending to the social and material relations of hepatitis C treatment

Since the advent of direct-acting antiviral hepatitis C treatments, widespread enthusiasm about disease elimination has emerged. This article examines experiences of hepatitis C treatment and cure in this period. Mobilising Fraser and Seear's (Making disease, making citizens: The politics of hepatitis C, Ashgate, 2011) approach to hepatitis C as a 'gathering', we analyse cure not as a biomedical phenomenon but as a social and material event. To do so, we take a Science and Technology Studies-inspired approach to analyse three complementary cases drawn from an Australian project on experiences of hepatitis C, treatment and cure. First, we analyse the ways a friendship between two women combines with adjustments to treatment access to produce a gathering that makes cure possible. Second, we analyse the forces that gather and distribute responsibility when a cure does not occur in a context shaped by oversimplified treatment logics. Third, we analyse a gathering of relations in which hepatitis C lingers, thereby limiting the cure's possible transformative effects. We argue that, even in an era defined by highly effective medicines, the hepatitis C cure is not necessarily straightforward, but an unpredictable gathering constituted by a fragile coalescing of social and material forces.

Exploring hepatitis C virus testing and treatment engagement over time in Melbourne, Australia: a study protocol for a longitudinal cohort study (EC-Experience Cohort study)

INTRODUCTION

The advent of direct acting antiviral therapy for hepatitis C virus (HCV) means the elimination of HCV is possible but requires sustained effort to achieve. Between 2016 and 2019, 44% of those living with HCV were treated in Australia. However, treatment uptake has declined significantly. In Australia, people who inject drugs (PWID) are the population most at risk of HCV acquisition. Eliminating HCV in Australia will require nuanced understanding of the barriers to HCV treatment experienced by PWID and tailored interventions to address these barriers. The EC-Experience Cohort study aims to explore the barriers and enablers reported by PWID to engagement in HCV care.

METHODS AND ANALYSIS

The EC-Experience Cohort study is a prospective cohort of PWID, established in Melbourne, Australia in 2018. Participants are assigned into three study groups: (1) those not currently engaged in HCV testing; (2) those diagnosed with HCV but not currently engaged in treatment and (3) those completed treatment. Participants complete a total of four interviews every 6 months across an 18-month study period. Predictors of experience of key outcome events along the HCV care cascade will be explored over time.

ETHICS AND DISSEMINATION

Ethical approval for the EC-Experience Cohort study was obtained by the Alfred Hospital Ethics Committee in Melbourne, Australia (Project Number: HREC/16/Alfred/164). All eligible participants are assessed for capacity to consent and partake in a thorough informed consent process. Results from the EC-Experience Cohort study will be disseminated via national and international scientific and public health conferences and peer-reviewed journal publications. Data from the EC-Experience Cohort study will improve the current understanding of the barriers to HCV care for PWID and guide the tailoring of service provision for specific subgroups. Understanding the barriers and how to increase engagement in care of PWID is critical to achieve HCV elimination goals.

Patient-reported experiences with direct acting antiviral therapy in an integrated model of hepatitis C care in homeless shelters

BACKGROUND AND AIM:

Patient reported experience (PRE) is critical for engagement in hepatitis C (HCV) therapy in hard to reach populations. However, there is no data on patient reported experience with DAA therapy among homeless patients accessing shelters. We assessed PRE with DAA treatment following implementation of HCV therapy within homeless shelters in two diverse regions in the United States.

METHODS:

In a study of integrated HCV testing and treatment in four homeless shelters in San Francisco (SF) and Minnesota (MN), 66 patients received DAA therapy from 11/2018–4/2020. PREs were assessed at the end of therapy with constructs: satisfaction with communication with their HCV treatment provider, receipt of social support during therapy, perceived stigma associated with HCV infection, and their overall satisfaction with DAA therapy. Descriptive statistics and factors associated with satisfaction with HCV therapy were assessed.

RESULTS:

At end of therapy, 41 patients completed the questionnaire (response rate was 62%). Median age was 56 years, 74.4% were men, 44% White (45% Black, 6% Latino), 35% had more than a high school diploma, 65% had a history of IV drug use, 56% had received SUD treatment, and 12% were co-infected with HIV. During DAA treatment, the majority of patients lived in shelters, 37% used illicit drugs, 24% consumed alcohol, and 14% received psychiatric treatment. Patient reported experience with DAA therapy were as follows: 100% agreed or strongly agreed that HCV providers seemed non-judgmental, 98% reported that their provider seemed to care about them, 98% reported that people close to them had been supportive of their care, and 98% were satisfied with their HCV treatment. There were no patient level or clinical predictors associated with PREs of stigma, perceived lack of social support or satisfaction with DAA treatment.

CONCLUSIONS:

Nearly all (>95%) homeless patients receiving integrated HCV testing and therapy within homeless shelters felt supported and reported favorable views toward their providers and a high level of satisfaction with DAA treatment. As patient reported experience is key for engagement in HCV therapy, our onsite treatment intervention within shelters can serve as a model of HCV care to enhance treatment uptake in patients experiencing homelessness.

Symptoms and functioning improve after chronic hepatitis C cure as assessed by the Memorial Symptom Assessment Scale and PROMIS measures

The benefits of chronic hepatitis C viral (HCV) cure on various aspects of patients’ health experiences may be under-appreciated. The aim of this study was to conduct an in-depth evaluation of change in a comprehensive set of patient-reported symptoms and aspects of life functioning after achieving HCV cure using validated instruments. Patients completed the 32-item Memorial Symptom Assessment Scale (MSAS) and several Patient-Reported Outcomes Measurement Information System^® (PROMIS^®) measures prior to DAA treatment and up to 10 months after viral cure. Pre- and post-MSAS scores for all 32 individual symptoms, three subscales, and a total symptom score, and several PROMIS T-scores were compared. The total MSAS score, Physical subscale and Psychological subscale scores all improved by 28 to 33% (p<0.01) and numerous previously unidentified HCV-associated symptoms improved by 30 to 100% from baseline scores. Significant improvements in gastrointestinal, mood, sleep, fatigue, and cognition concerns, as well as stigma were observed using the PROMIS measures by 5 to 11%. Improvements in previously unidentified symptoms, stigma, and other aspects of life functioning provide additional support for the substantial personal benefits bestowed upon individuals who are cured of HCV, and support health policy, payer, and pharmaceutical decisions to ubiquitiously treat all people infected with this life-impairing infectious disease.

Patient-reported outcomes of the Treatment and Prevention Study: A real-world community-based trial of direct-acting antivirals for hepatitis C among people who inject drugs

The impact of hepatitis C cure with direct-acting antivirals (DAAs) on patient-reported outcomes (PROs) in community settings remains unclear. We aimed to assess changes in PROs over time and whether treatment was associated with sustained improved PROs in a cohort of people who inject drugs. This study is a sub-analysis of the Treatment and Prevention Study, a nurse-led trial where people who inject drugs and their injecting partners were recruited in a community setting, in Melbourne, Australia. Three participant groups were characterized: treatment, untreated and non-viremic (hepatitis C RNA negative at screening). PROs included assessment of health-related quality of life using the Short Form-8 (SF-8) Survey and life satisfaction using Personal Wellbeing Index (PWI). PROs were measured at baseline and every 12 weeks until week 84. Generalized estimating equations were used to measure whether treatment was associated with longitudinal PRO change. A total of 215 participants were included in this analysis. PWI scores were significantly higher at week 12 for both treatment group (p = 0.0309) and non-viremic group (p = 0.0437) compared to baseline. However, treatment was not associated with longitudinal change in PRO scores. In conclusion, we found DAA treatment did not significantly improve PRO scores compared to those not receiving treatment and without hepatitis C. The measures used in this study may not be sensitive enough to capture the hepatitis C specific improvements in quality of life that treatment affords or factors other than treatment may be influencing quality of life scores in this cohort.

'I'm over the moon!': patient-perceived outcomes of hepatitis C treatment

Understanding patient-perceived outcomes is crucial for assessing the effectiveness and acceptability of hepatitis C virus (HCV) treatment. This study aimed to explore patient-perceived outcomes of receiving direct-acting antivirals (DAAs). This study was a part of a mixed-methods case study of the Prince Charles Hospital program for improving access to HCV treatment in community settings. Data were collected using semi-structured interviews with nine patients who were in different stages of their treatment for HCV. The participants were recruited using purposive sampling. All interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis. Patients emphasised 'having more energy' when reporting improvements in their physical health following treatment. They also reported a newly developed sense of freedom and hope. Improved physical and mental health empowered them to start a healthy lifestyle and to practise self-protection from the risk of re-infection. Patients highlighted their desire to help other patients to receive treatment, which was connected to their experience of the services that they received and their perceived health outcomes. Patients expect and experience various outcomes that are related to the physical, psychological and social aspects of living with, and being cured of HCV. Emphasis on the short-term outcomes of receiving HCV treatment may improve HCV treatment uptake and adherence rates.

Conceptualising access in the direct-acting antiviral era: An integrated framework to inform research and practice in HCV care for people who inject drugs

As direct-acting antiviral (DAA) therapy costs fall and eligibility criteria are relaxed, people who inject drugs (PWID) will increasingly become eligible for HCV treatment. Yet eligibility does not necessarily equate to access. Amidst efforts to expand treatment uptake in this population, we seek to synthesise and clarify the conceptual underpinnings of access to health care for PWID, with a view to informing research and practice. Integrating dominant frameworks of health service utilisation, care seeking processes, and ecological perspectives on health promotion, we present a comprehensive theoretical framework to understand, investigate and intervene upon barriers and facilitators to HCV care for PWID. Built upon the concept of Candidacy, the framework describes access to care as a continually negotiated product of the alignment between individuals, health professionals, and health systems. Individuals must identify themselves as candidates for services and then work to stake this claim; health professionals serve as gatekeepers, adjudicating asserted candidacies within the context of localised operating conditions; and repeated interactions build experiential knowledge and patient-practitioner relationships, influencing identification and assertion of candidacy over time. These processes occur within a complex social ecology of interdependent individual, service, system, and policy factors, on which other established theories provide guidance. There is a pressing need for a deliberate and nuanced theory of health care access to complement efforts to document the HCV 'cascade of care' among PWID. We offer this framework as an organising device for observational research, intervention, and implementation science to expand access to HCV care in this vulnerable population. Using practical examples from the HCV literature, we demonstrate its utility for specifying research questions and intervention targets across multiple levels of influence; describing and testing plausible effect mechanisms; and identifying potential threats to validity or barriers to research translation.