Results of Hepatitis C Birth-Cohort Testing and Linkage to Care in Selected U.S. Sites, 2012-2014

We have reached single-visit testing, diagnosis, and treatment for hepatitis C infection, now what?

INTRODUCTION

Progress toward hepatitis C virus (HCV) elimination is impeded by low testing and treatment due to the current diagnostic pathway requiring multiple visits leading to loss to follow-up. Point-of-care testing technologies capable of detecting current HCV infection in one hour are a 'game-changer.' These tests enable diagnosis and treatment in a single visit, overcoming the barrier of multiple visits that frequently leads to loss to follow-up. Combining point-of-care HCV antibody and RNA tests should improve cost-effectiveness, patient/provider acceptability, and testing efficiency. However, implementing HCV point-of-care testing programs at scale requires multiple considerations.

AREAS COVERED

This commentary explores the need for point-of-care HCV tests, diagnostic strategies to improve HCV testing, key considerations for implementing point-of-care HCV testing programs, and remaining challenges for point-of-care testing (including operator training, quality management, connectivity and reporting systems, regulatory approval processes, and the need for more efficient tests).

EXPERT OPINION

It is exciting that single-visit testing, diagnosis, and treatment for HCV infection have been achieved. Innovations afforded through COVID-19 should facilitate the accelerated development of low-cost, rapid, and accurate tests to improve HCV testing. The next challenge will be to address barriers and facilitators for implementing point-of-care testing to deliver them at scale.

Point-of-care HCV RNA testing improves hepatitis C testing rates and allows rapid treatment initiation among people who inject drugs attending a medically supervised injecting facility

BACKGROUND

To achieve hepatitis C virus (HCV) elimination targets, simplified care engaging people who inject drugs is required. We evaluated whether fingerstick HCV RNA point-of-care testing (PoCT) increased the proportion of clients attending a supervised injecting facility who were tested for hepatitis C.

METHODS

Prospective single-arm study with recruitment between 9 November 2020 and 28 January 2021 and follow-up to 31 July 2021. Clients attending the supervised injecting facility were offered HCV RNA testing using the Xpert® HCV Viral Load Fingerstick (Cepheid, Sunnyvale, CA) PoCT. Participants with a positive HCV RNA test were prescribed direct acting antiviral (DAA) therapy. The primary endpoint was the proportion of clients who engaged in HCV RNA PoCT, compared to a historical comparator group when venepuncture-based hepatitis C testing was standard of care.

RESULTS

Among 1618 clients who attended the supervised injecting facility during the study period, 228 (14%) engaged in PoCT. This was significantly higher than that observed in the historical comparator group (61/1,775, 3%; p < 0.001). Sixty-five (28%) participants were HCV RNA positive, with 40/65 (62%) receiving their result on the same day as testing. Sixty-one (94%) HCV RNA positive participants were commenced on DAA therapy; 14/61 (23%) started treatment on the same day as diagnosis. There was no difference in the proportion of HCV RNA positive participants commenced on treatment with DAA therapy when compared to the historical comparator group (61/65, 94% vs 22/26, 85%; p = 0.153). However, the median time to treatment initiation was significantly shorter in the PoCT cohort (2 days (IQR 1-20) vs 41 days (IQR 22-76), p < 0.001). Among participants who commenced treatment and had complete follow-up data available, 27/36 (75%) achieved hepatitis C cure.

CONCLUSIONS

HCV RNA PoCT led to a significantly higher proportion of clients attending a supervised injecting facility engaging in hepatitis C testing, whilst also reducing the time to treatment initiation.

Hepatitis C care cascade in a large academic healthcare system, 2012 to 2018

To determine the hepatitis C virus (HCV) care cascade among persons who were born during 1945 to 1965 and received outpatient care on or after January 2014 at a large academic healthcare system. Deidentified electronic health record data in an existing research database were analyzed for this study. Laboratory test results for HCV antibody and HCV ribonucleic acid (RNA) indicated seropositivity and confirmatory testing. HCV genotyping was used as a proxy for linkage to care. A direct-acting antiviral (DAA) prescription indicated treatment initiation, an undetectable HCV RNA at least 20 weeks after initiation of antiviral treatment indicated a sustained virologic response. Of the 121,807 patients in the 1945 to 1965 birth cohort who received outpatient care between January 1, 2014 and June 30, 2017, 3399 (3%) patients were screened for HCV; 540 (16%) were seropositive. Among the seropositive, 442 (82%) had detectable HCV RNA, 68 (13%) had undetectable HCV RNA, and 30 (6%) lacked HCV RNA testing. Of the 442 viremic patients, 237 (54%) were linked to care, 65 (15%) initiated DAA treatment, and 32 (7%) achieved sustained virologic response. While only 3% were screened for HCV, the seroprevalence was high in the screened sample. Despite the established safety and efficacy of DAAs, only 15% initiated treatment during the study period. To achieve HCV elimination, improved HCV screening and linkage to HCV care and DAA treatment are needed.

Patient characteristics and neighborhood attributes associated with hepatitis C screening and positivity in Philadelphia

Among patients of an urban primary care network in Philadelphia with a universal hepatitis C virus (HCV) screening policy for patients born during 1945-1965, we examined whether being unscreened and HCV positivity were associated with attributes of the census tracts where patients resided, which we considered as proxies for social health determinants. For patients with at least one clinic visit between 2014 and mid-2017, we linked demographic and HCV screening information from electronic health records with metrics that described the census tracts where patients resided. We used generalized estimating equations to estimate adjusted relative risk ratios (aRRs) for being unscreened and HCV positive. Overall, 28% of 6,906 patients were unscreened. Black race, male gender, and residence in census tracts with relatively high levels of violent crime, low levels of educational attainment and household incomes, and evidence of residential segregation by Hispanic ethnicity were associated with lower aRRs for being unscreened. Among screened patients, 9% were HCV positive. Factors associated with lower risks of being unscreened were, in general, associated with higher HCV positivity. Attributes of census tracts where patients reside are probably less apparent to clinicians than patients' gender or race but might reflect unmeasured patient characteristics that affected screening practices, along with preconceptions regarding the likelihood of HCV infection based on prior screening observations or implicit biases. Approaching complete detection of HCV-infected people would be hastened by focusing on residents of census tracts with attributes associated with higher infection levels or, if known, higher infection levels directly.

Time to HCV Treatment Disfavors Patients Living with HIV/HCV Co-infection: Findings from a Large Urban Tertiary Center

This study aimed to assess time to hepatitis C (HCV) treatment (i.e., the time between the initial clinic visit for HCV evaluation and the HCV treatment start date), to compare clinical characteristics between patients who received HCV treatment ≥ and < 6 months, and to identify predictors of longer time to HCV treatment in patients living with HCV. This study conducted a retrospective secondary analysis of patients living with HCV mono-infection and HIV/HCV co-infection who received HCV treatment with DAAs (n=214) at a HIV Clinic. Binomial logistic regression was used to identify predictors of longer time to treatment (i.e., ≥ 6 months). The median time to HCV treatment was 211 days. Compared to patients who were treated < 6 months, a higher proportion of patients who were treated ≥ 6 months had HIV/HCV co-infection (31% vs. 49%, p=0.01) and chronic kidney disease (8% vs. 18%, p=0.03). In multivariate analysis, HIV/HCV co-infection was positively associated with a longer time to HCV treatment (adjusted odds ratio, aOR=2.0, p=0.03). Time to HCV treatment disparities between African American and White American did not emerge from the analysis, but time to HCV treatment disfavored patients living with HIV/HCV co-infection. Studies are needed to identify and eliminate factors that disfavor patients living with HIV/HCV co-infection.

Novel Hepatitic C Virus (HCV) Diagnosis and Treatment Delivery Systems: Facilitating HCV Elimination by Thinking Outside the Clinic

The World Health Organization has set a goal to eliminate hepatitis C virus (HCV) infection as public health threat by 2030. Although the advent of highly effective and tolerable direct-acting antiviral therapy has paved the way for HCV elimination, most people with HCV infection remain undiagnosed and untreated globally, with striking disparities between high-income and low- to middle-income countries. Novel decentralized and cost-effective "test-and-treat" strategies are critically needed to identify the millions of people unaware of their status and link them to treatment.

Evaluation of true point of care molecular assay using fingerstick capillary whole blood for diagnosis of hepatitis C infection

At present, the available point of care (POC) molecular assays for hepatitis C are not considered as true POC due to sample collection and processing requiring minimal laboratory infrastructure. A new POC Xpert HCV VL Fingerstick (Xpert FS) precludes such requirements where specimen collected by simple fingerstick can be loaded directly into the test cartridge with results available within 60 min. The present study compared the performance of this assay for HCV RNA quantitation using both capillary whole blood (CWB) and venous whole blood (VWB) with plasma HCV RNA performed on Abbott Real Time HCV PCR. CWB via fingerstick and VWB via venipuncture collected from serologically confirmed HCV-infected participants were loaded into Xpert HCV VL WB for viral load estimation. Simultaneously Abbott Real Time HCV PCR assay was also performed using plasma (reference method). Among the enrolled participants (n=157), the mean age was 46.22±14.79 years and 63 % were male. HCV RNA was detected in 100 cases (63.7 %), median 5.69 (IQR: 5.00-6.32)log₁₀IU ml^-1 on the reference method. Xpert FS showed 100 % sensitivity and specificity using both CWB and VWB. The median viral loads detected in CWB and VWB were 5.52 (IQR: 4.59-6.15) and 5.48 (IQR: 4.61-6.07)log₁₀IU ml^-1, respectively. Xpert FS offers potential as true POC enabling accurate diagnosis in a single patient visit to the health-care facility, hence may reduce the number of dropouts with a confirmed diagnosis. However, further real-time studies with larger sample size are warranted.

Routine Screening and Linkage to Care for Hepatitis C Virus in an Urban Safety-Net Health System, 2017-2019

OBJECTIVE

Hepatitis C virus (HCV) is a major threat to public health in the United States. We describe and evaluate an HCV screening and linkage-to-care program, including emergency department, inpatient, and outpatient settings, in an urban safety-net health system in Chicago.

METHODS

Sinai Health System implemented a universal HCV screening program in September 2016 that offered patient navigation services (ie, linkage to care) to patients with a positive result for HCV on an RNA test. We collected data from February 1, 2017, through January 31, 2019, on patient demographic characteristics, risk factors, and various outcomes (eg, number of patients screened, test results, proportions of new diagnoses, number of patients eligible for patient navigation services, and proportion of patients who attended their first medical appointment). We also examined outcomes by patients' knowledge of infection.

RESULTS

Of 21 018 people screened for HCV, 6% (1318/21 018) had positive test results for HCV antibody, 68% (878/1293) of whom had positive HCV RNA test results. Of these 878 patients, 68% were born during 1945-1965, 68% were male, 65% were Black, 19% were Latino, 55% were newly diagnosed, and 64% were eligible for patient navigation services. Risk factors included past or current drug use (53%), unemployment (30%), and ever incarcerated (21%). Of 562 patients eligible for navigation services, 281 (50%) were navigated to imaging services, and 203 (72%) patients who completed imaging attended their first medical appointment.

CONCLUSION

Patient navigation played a critical role in linkage success, but securing stable, long-term financial support for patient navigators is a challenge.

French hepatitis C care cascade: substantial impact of direct-acting antivirals, but the road to elimination is still long

BACKGROUND

Hepatitis C virus (HCV) elimination by 2030, as targeted by the World Health Organization (WHO), requires that 90% of people with chronic infection be diagnosed and 80% treated. We estimated the cascade of care (CoC) for chronic HCV infection in mainland France in 2011 and 2016, before and after the introduction of direct-acting antivirals (DAAs).

METHODS

The numbers of people (1) with chronic HCV infection, (2) aware of their infection, (3) receiving care for HCV and (4) on antiviral treatment, were estimated for 2011 and 2016. Estimates for 1) and 2) were based on modelling studies for 2011 and on a virological sub-study nested in a national cross-sectional survey among the general population for 2016. Estimates for 3) and 4) were made using the National Health Data System.

RESULTS

Between 2011 and 2016, the number of people with chronic HCV infection decreased by 31%, from 192,700 (95% Credibility interval: 150,900-246,100) to 133,500 (95% Confidence interval: 56,900-312,600). The proportion of people aware of their infection rose from 57.7 to 80.6%. The number of people receiving care for HCV increased by 22.5% (representing 25.7% of those infected in 2016), while the number of people on treatment increased by 24.6% (representing 12.1% of those infected in 2016).

CONCLUSIONS

This study suggests that DAAs substantially impact CoC. However, access to care and treatment for infected people remained insufficient in 2016. Updating CoC estimates will help to assess the impact of new measures implemented since 2016 as part of the goal to eliminate HCV.

The Consensus Hepatitis C Cascade of Care: Standardized Reporting to Monitor Progress Toward Elimination

Cascade-of-care (CoC) monitoring is an important component of the response to the global hepatitis C virus (HCV) epidemic. CoC metrics can be used to communicate, in simple terms, the extent to which national and subnational governments are advancing on key targets, and CoC findings can inform strategic decision-making regarding how to maximize the progression of individuals with HCV to diagnosis, treatment, and cure. The value of reporting would be enhanced if a standardized approach were used for generating CoCs. We have described the Consensus HCV CoC that we developed to address this need and have presented findings from Denmark, Norway, and Sweden, where it was piloted. We encourage the uptake of the Consensus HCV CoC as a global instrument for facilitating clear and consistent reporting via the World Health Organization (WHO) viral hepatitis monitoring platform and for ensuring accurate monitoring of progress toward WHO's 2030 hepatitis C elimination targets.

Evaluation of the Aptima HCV Quant Dx Assay for Hepatitis C Virus RNA Detection from Fingerstick Capillary Dried Blood Spot and Venepuncture-Collected Samples

BACKGROUND

Simplified diagnostic strategies are needed increase hepatitis C virus (HCV) testing to determine active infection and link people into treatment. Collection methods such as dried blood spots (DBS) have advantages over standard phlebotomy, especially within marginalized populations.

METHODS

We evaluated the diagnostic performance of the Aptima HCV Quant assay for the quantification and detection of HCV RNA from paired DBS and venepuncture samples. Specimens were collected from participants enrolled in an Australian observational study. We compared HCV RNA detection from DBS against venepuncture samples (gold standard).

RESULTS

One hundred sixty-four participants had paired samples and HCV RNA was detected in 45 (27% [95% confidence interval, 21%-35%]) by the Aptima assay in venepuncture samples. Sensitivity of the Aptima assay for HCV RNA quantification from DBS (≥10 IU/mL in plasma) was 100% and specificity was 100%. Sensitivity for HCV RNA detection from DBS was 95.6% and specificity was 94.1%. A small bias in plasma over DBS was observed with good agreement (R2 = 0.96).

CONCLUSIONS

The Aptima HCV Quant assay detects active infection from DBS samples with acceptable diagnostic performance and is clinically comparable to plasma. These data will strengthen the case for the registration of a DBS kit insert claim, enabling future clinical utility.

Assessing the Effectiveness of Strategies in US Birth Cohort Screening for Hepatitis C Infection

Chronic hepatitis C infection in the USA is a highly morbid condition and current guidelines recommend one-time screening among the birth cohort (1945-1965). Understanding strategies to optimize screening can help inform future hepatitis C virus (HCV) screening guidelines. A focused literature search was performed using PubMed and manual abstract review from major hepatology conferences over the past 2 years. The search strategy involved using Medical Subject Headings terms for hepatitis C, screening, birth cohort, baby boomers, and 1945-1965. The review was limited to data from the USA. A total of 327 articles were identified and 36 abstracts were included, with studies published between 2012-2019. Strategies including clinician education, electronic medical record alerts, reflex HCV RNA testing, point-of-care testing, multisite (outpatient, inpatient, emergency department, endoscopy suite) initiatives, direct patient solicitation, and utilization of non-physician providers have increased HCV screening rates. However, broad implementation remains less than optimal. Barriers include lack of patient acceptance to screening and engagement in the HCV care cascade. The Veterans Affairs Healthcare System has achieved higher birth cohort screening rates through an integrated approach requiring high-level engagement by leadership and institutional commitment. Multiple strategies for increasing birth cohort screening have been successful, but overall rates of HCV screening remain low. These strategies can inform public health efforts to implement emerging national recommendations for expansion of HCV screening to all U.S. adults age 18 or older.

Time to Detection of Hepatitis C Virus Infection With the Xpert HCV Viral Load Fingerstick Point-of-Care Assay: Facilitating a More Rapid Time to Diagnosis

Background

Xpert HCV Viral Load Fingerstick assay (Xpert HCV VL FS) is a point-of-care test quantifying HCV RNA in &lt;1 hour, enabling same-visit diagnosis and treatment.

Methods

This study evaluated time to HCV RNA detection using the Xpert HCV VL FS assay. Fingerstick whole-blood samples were collected from participants in an observational cohort in Australia.

Results

In May 2018–2019, 1468 participants were enrolled, 1426 had Xpert HCV VL FS testing performed, and 1386 had a valid result. HCV RNA was detected in 23% (325/1386). Among people with undetectable HCV RNA (n = 1061), median time to result was 57 minutes. Among people with detectable HCV RNA (n = 325), median time to HCV RNA detection was 32 minutes and 80% (261/325) had a detectable HCV RNA result in ≤40 minutes. Median time to HCV RNA detection was dependent on HCV RNA level.

Conclusions

A quicker HCV diagnosis could be achieved by monitoring the time when HCV RNA is first detected with the Xpert HCV VL FS test, rather than HCV RNA quantification, although the current platform does not allow for this. These findings could facilitate new strategies to reduce waiting times for an HCV diagnosis and improve linkage to treatment.

Improved Hepatitis C Cure Cascade Outcomes Among Urban Baby Boomers in the Direct-Acting Antiviral Era

OBJECTIVES

We compared outcomes of the hepatitis C virus (HCV) cure cascade (ie, the path a patient follows from diagnosis to cure), including antiviral treatment outcomes, from 2 HCV screening programs. Our objective was to assess whether treatment uptake and HCV cure rates improved in the cohort screened after the release of all-oral HCV direct-acting antiviral therapies.

METHODS

We retrospectively compared outcomes of the HCV cure cascade from a cohort of newly diagnosed patients screened during 2012-2014 (period 1) with outcomes from a cohort of newly diagnosed patients screened during 2015-2016 (period 2) at Grady Health System in Atlanta, Georgia. Cure cascade outcomes included HCV antibody (anti-HCV) and RNA testing, linkage to care, antiviral treatment, and sustained virologic response.

RESULTS

During period 1, 412 of 5274 (7.8%) persons screened were anti-HCV positive, and 264 (69.3%) of those tested were RNA positive. During period 2, 462 of 7137 (6.5%) persons screened were anti-HCV positive, and 240 (59.3%) of those tested were RNA positive (P = .003). The percentage of newly diagnosed patients who were treated during period 2 (64.0%) was 3 times that of newly diagnosed patients treated during period 1 (21.2%; P < .001). Both cohorts had similarly high levels of linkage to care (95.8% during period 1, 95.4% during period 2) and cure (92.6% during period 1, 95.5% during period 2).

CONCLUSIONS

Over time, the prevalence of anti-HCV and HCV RNA positivity declined substantially, and linkage-to-care and cure rates remained high. Treatment uptake increased significantly after the introduction of all-oral direct-acting antiviral therapy. These findings suggest that combining large-scale screening initiatives with treatment programs can speed progress toward HCV elimination.

Defining the hepatitis C cure cascade in an Urban health system using the electronic health record

Hepatitis C virus (HCV) infection is a public health threat. The electronic health record (EHR) can be used to monitor patients along the HCV cure cascade and highlight opportunities for interventions to improve cascade outcomes. We developed an HCV patient registry using data from Grady Health System's (GHS) EHR and performed a cross-sectional analysis of 72 745 GHS patients who received anti-HCV testing from 2004 to 2016. We created a testing cascade: (1) anti-HCV reactive, (2) HCV RNA tested and (3) HCV RNA detectable; and a cure cascade: (1) HCV RNA detectable, (2) engaged in care, (3) treatment prescribed, (4) sustained virologic response (SVR) tested and (5) SVR documented. A total of 9893 (14%) had reactive anti-HCV tests of 72 745 patients tested, 5109 (52%) of these had HCV RNA tested, and 4224 (43%) were HCV RNA detectable. A total of 2738 (65%) of 4224 with detectable RNA were engaged in care, 909 (22%) were prescribed antiviral therapy, and 354 (8%) achieved SVR. Factors associated with HCV treatment included cirrhosis, tobacco use, depression, diabetes, obesity, alcohol use, male gender, black race and Medicare insurance. Uninsured patients were significantly less likely to be prescribed HCV treatment. In conclusion, using EHR data, we identified high anti-HCV prevalence and noted gaps in HCV RNA testing, linkage to care and treatment. The EHR can be used to evaluate the effectiveness of targeted interventions to overcome these gaps.

Race and Hepatitis C Care Continuum in an Underserved Birth Cohort

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

PATIENTS

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

MAIN MEASURES

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

RESULTS

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

CONCLUSIONS

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

Approaches for simplified HCV diagnostic algorithms

Introduction

In the light of the advances in HCV antiviral therapy, global control of HCV infection becomes feasible but depends on the capacity of countries to identify infected people and to offer them treatment. To achieve the WHO goal which targets a diagnosis rate of 90% by 2030, simplification of screening and diagnosis will be crucial.

Methods

Published literature, unpublished data and expert consensus were used to determine key parameters, including point‐of‐care, rapid diagnostic testing, screening, the use of HCV core Ag and dried blood spots; starting from 2008 until November 2017. In addition, a manual search was undertaken to detect relevant papers or websites related to specific data from countries which underwent or are planning a programme of HCV elimination.

Results

Several strategies have been developed and evaluated these last years to simplify and facilitate access to screening and diagnosis, the development of reliable HCV core antigen tests and new nucleic acid amplification technologies for use in decentralized settings. In high prevalence settings, a one‐step screening and diagnosis strategy could simplify diagnostic algorithms provided the cost is reduced. Finally, genotyping may no longer be required in the context of availability of pangenotypic antiviral therapy.

Conclusions

Despite relevant advances in HCV screening and diagnosis, the overall diagnosis package is still too expensive today and efforts must be made to allow generalized implementation of reliable tests in low and middle income countries. These efforts will be key factors to foster a real public health approach to HCV elimination.

Perceived barriers related to testing, management and treatment of HCV infection among physicians prescribing opioid agonist therapy: The C-SCOPE Study

The aim of this analysis was to evaluate perceived barriers related to HCV testing, management and treatment among physicians practicing in clinics offering opioid agonist treatment (OAT). C-SCOPE was a study consisting of a self-administered survey among physicians practicing at clinics providing OAT in Australia, Canada, Europe and the United States between April and May 2017. A 5-point Likert scale (1 = not a barrier, 3 = moderate barrier, 5 = extreme barrier) was used to measure responses to perceived barriers for HCV testing, evaluation and treatment across the domains of the health system, clinic and patient. Among the 203 physicians enrolled (40% USA, 45% Europe, 14% Australia/Canada), 21% were addiction medicine specialists, 29% psychiatrists and 69% were metro/urban. OAT physicians in this study reported poor access to on-site venepuncture (35%), point-of-care HCV testing (16%), and noninvasive liver disease assessment (25%). Only 30% of OAT physicians reported personally treating HCV infection. Major perceived health system barriers to HCV management included the lack of funding for noninvasive liver disease testing, long wait times to see an HCV specialist, lack of funding for new HCV therapies, and reimbursement restrictions based on drug/alcohol use. Major perceived clinic barriers included the lack of peer support programmes and/or HCV case managers to facilitate linkage to care, the need to refer people off-site for noninvasive liver disease staging, the lack of support for on-site phlebotomy and the lack of on-site delivery of HCV therapy. This study highlights several important modifiable barriers to enhance HCV testing, evaluation and treatment among PWID attending OAT clinics.

Leveraging the electronic health record to eliminate hepatitis C: Screening in a large integrated healthcare system

Highly efficacious and tolerable treatments that cure hepatitis C viral (HCV) infection exist today, increasing the feasibility of disease elimination. However, large healthcare systems may not be fully prepared for supporting recommended actions due to knowledge gaps, inadequate infrastructure and uninformed policy direction. Additionally, the HCV cascade of care is complex, with many embedded barriers, and a significant number of patients do not progress through the cascade and are thus not cured. The aim of this retrospective cohort study was to evaluate a large healthcare system's HCV screening rates, linkage to care efficiency, and provider testing preferences. Patients born during 1945-1965, not previously HCV positive or tested from within the Electronic Health Record (EHR), were identified given that three-quarters of HCV-infected persons in the United States are from this Birth Cohort (BC). In building this HCV testing EHR prompt, non-Birth Cohort patients were excluded as HCV-specific risk factors identifying this population were not usually captured in searchable, structured data fields. Once completed, the BC prompt was released to primary care locations. From July 2015 through December 2016, 11.5% of eligible patients (n = 9,304/80,556) were HCV antibody tested (anti-HCV), 3.8% (353/9,304) anti-HCV positive, 98.1% (n = 311/317) HCV RNA tested, 59.8% (n = 186/311) HCV RNA positive, 86.6% (161/186) referred and 76.4% (n = 123/161) seen by a specialist, and 34.1% (n = 42/123) cured of their HCV. Results from the middle stages of the cascade in this large healthcare system are encouraging; however, entry into the cascade-HCV testing-was performed for only 11% of the birth cohort, and the endpoint-HCV cure-accounted for only 22% of all infected. Action is needed to align current practice with recommendations for HCV testing and treatment given that these are significant barriers toward elimination.

Hepatitis C Screening: Barriers to Linkage to Care

Background and Aims: Hepatitis C (HCV) is a medical and public health concern. Once infected individuals are identified, management includes not only education but also the use of antiviral therapy. Although screening for HCV is readily available, barriers exist which prevent assessment and treatment in individuals potentially infected with HCV.

Methods: This is a retrospective study of patients screened for HCV within the University of California, Los Angeles Health Care System between February 22 and July 9, 2018. We defined linkage to care as: 1) confirmatory HCV RNA test after screening HCV antibody test found a positive result; and 2) follow-up appointment for treatment was established with a specialist. Demographic and baseline laboratory values were collected. Factors potentially associated with prohibiting linkage of care were evaluated.

Results: During the study period, 17,512 individuals were screened for HCV. A total of 238 (1.35%) were found to have detectable HCV antibodies. Of the individuals with detectable HCV antibodies, 48 (20%) did not undergo confirmatory testing with viral levels. Of the 190 individuals who underwent further testing, 70 patients were noted to be viremic. Among them, 17 of the 70 (24%) were not linked to a specialist for further care. Younger patients (p = 0.02) and people who inject drugs (p = 0.02) were less likely to be referred for specialty care.

Conclusions: The results of our study highlight that younger patients and people who inject drugs are less likely to be referred to specialty care for HCV treatment. Efforts are needed to engage these populations.

Development of a Comprehensive Dataset of Hepatitis C Patients and Examination of Disease Epidemiology in the United States, 2013-2016

INTRODUCTION

Chronic infection with hepatitis C virus (HCV) is a leading cause of liver disease and infectious disease deaths. While recent and emerging treatment options for HCV patients have enabled higher rates of sustained virologic response (SVR), the demographic, clinical, geographic, and payer characteristics of the estimated 3.4 million chronic HCV patients in the USA are poorly understood. The goal of this study was to create a dataset describing the current HCV patient landscape in the USA.

METHODS

Data from two large national laboratory companies representing the majority of US patients screened for HCV antibody and/or tested for HCV RNA from 2013 through 2016 were organized into the present study dataset. Age, gender, payer channel, 3-digit ZIP code and ordering physician specialty, and 3-digit ZIP code information were available for all patients. Among RNA-positive patients, additional clinical characteristics included HCV genotype, fibrosis stage, renal function, and HIV status. Initiating treatment and attaining cure were imputed using data-driven algorithms based on successive RNA viral load measurements.

RESULTS

The number of RNA-positive HCV patients increased from 200,066 patients in 2013 to 469,550 in 2016. The availability of clinical data measurements and rates of treatment initiation increased over the study period, indicating improved care engagement for HCV patients. Treatment and cure rates varied by age, disease severity, geographic location, and payer channel. Sensitivity and specificity of the cure prediction algorithms were consistently above 0.90, validating the robustness of the data imputation approach.

CONCLUSION

This is the largest, most comprehensive dataset available to describe the current US HCV patient landscape. Our results highlight that the epidemiology of HCV is evolving with an increasing number of patients who are younger and have milder disease than described in previous years. Results of this study should help guide efforts toward the elimination of HCV in this country. Future work will focus on factors associated with varying treatment and cure patterns and describing recent changes in the HCV patient landscape.

FUNDING

AbbVie. Plain language summary available for this article.

Pharmacist-initiated hepatitis C virus screening in a community pharmacy to increase awareness and link to care at the medical center

OBJECTIVE

To describe the design and implementation of a pharmacist-led hepatitis C virus (HCV) screening and education program in a community pharmacy with a protocol for linkage to care at the affiliated hepatology clinic for patients born between 1945 and 1965.

SETTING

Outpatient pharmacy affiliated with the University of Illinois Hospital and Health Sciences System.

PRACTICE DESCRIPTION

The community pharmacist resident conducted the HCV screening at the health system-based community pharmacy.

PRACTICE INNOVATION

Community pharmacists provided patients with HCV screening and education while patients waited for their prescriptions to be ready or upon appointment. Patients were given a questionnaire before and after HCV education to assess the impact of pharmacist-provided education on patient knowledge. A protocol was developed to link patients with a positive HCV antibody test result to care with a hepatologist for confirmatory testing at a follow-up appointment at the medical center.

EVALUATION

Investigators assessed the feasibility of providing the screening and education, recorded the number of patients screened, and recorded the differences in the questionnaire responses before and after education.

RESULTS

Pharmacist-led HCV screening services were implemented successfully at the community pharmacy. All patients had a negative antibody result; therefore, linkage to care at the medical center, although available, was not necessary. The self-reported posttest HCV knowledge scores were significantly higher than pretest scores.

CONCLUSION

This article outlines the methodology for providing a multidisciplinary HCV screening, education, and referral program in a community pharmacy affiliated with a medical center. Pharmacist-initiated HCV screening in a community pharmacy can assist with identifying patients at risk for HCV infection and provide patients with linkage to care in the health system. This report may encourage community pharmacists to conduct future prospective trials to evaluate clinical and economic outcomes of community-based HCV screenings.

Improving Hepatitis C Identification: Technology Alone Is Not the Answer

An estimated 3 to 5 million Americans are chronically infected with hepatitis C virus (HCV), and approximately 75% of those persons were born between 1945 and 1965 (the so-called baby boomer generation). Because of the largely asymptomatic nature of HCV, up to 50% of those infected are unaware of their disease. Risk-based testing has been largely ineffective. Based on prevalence data, the Centers for Disease Control and Prevention and other organizations recommend a onetime HCV antibody test for all baby boomers. However, uptake of this recommendation requires significant changes in clinical practice for already busy primary care clinicians. We studied the effectiveness of a quality improvement initiative based on continuous audit and feedback combined with education for improving testing in alignment with guidelines; the control group was a cohort of clinicians whose only reminder was an institution-wide electronic health record prompt. Our data show improved testing rates among all clinician groups, but more significant improvement occurred among providers who received continuous feedback about their clinical performance coupled with education.

Hepatitis C: Review of the Epidemiology, Clinical Care, and Continued Challenges in the Direct Acting Antiviral Era

PURPOSE OF REVIEW

This review highlights key studies and recently published data, policies, and recommendations related to hepatitis C virus (HCV) epidemiology, transmission, and treatment.

RECENT FINDINGS

HCV is a leading cause of liver-related deaths, cirrhosis, and hepatocellular carcinoma. Since 2011 and accelerating since 2013, new, safe, tolerable, and curative therapies have considerably altered clinical and public health frameworks related to the prevention, control and clinical management of HCV. Nevertheless, there are several populations in the United States that are important to consider because of disparities in HCV prevalence and transmission risk. Adults born during 1945-1965 have an estimated anti-HCV antibody prevalence of ~3%, which is six times higher than among other adults, are often unaware of their infections, and are at increased risk of having HCV-associated morbidity and mortality from decades of chronic infection. Since the early 2000s, increasing incidence of acute HCV infections among young, white, non-urban people who inject drugs have been reported. Despite promising therapeutic advances, significant challenges remain for reducing HCV-associated morbidity and mortality.

SUMMARY

The high burden of HCV and significant health consequences associated with chronic infection make HCV a critical public health priority. Advances in HCV treatment have created new opportunities for reducing HCV-associated morbidity and mortality. These treatments are safe, well-tolerated, and highly effective; however, benefits cannot be realized without a significant increase in the number of persons tested for HCV so that all chronically infected individuals can be aware of their diagnosis and linked to appropriate clinical care.

Impact of an Electronic Medical Record-Based System to Promote Human Immunodeficiency Virus/Hepatitis C Virus Screening in Public Hospital Primary Care Clinics

Background

United States guidelines recommend that all adolescents and adults be tested for human immunodeficiency virus (HIV) and that persons born between 1945 and 1965 be tested for hepatitis C virus (HCV).

Methods

We used electronic medical record (EMR) data to identify patients in 3 primary care clinics in Seattle, Washington who met national criteria for routine HCV or HIV testing and had no documented history of prior testing. Clinic staff received daily lists of untested patients with scheduled appointments. We used generalized linear models to compare the percentage of patients tested and newly diagnosed with HIV and HCV in the 18 months before and during the intervention.

Results

A total of 16784 patients aged 18–64 and 9370 patients born between 1945 and 1965 received care from January 2011 to December 2015. Comparing the preintervention and intervention periods, the percentage of previously untested patients tested for HIV and HCV increased from 14.9% to 30.8% and from 18.0% to 35.5%, respectively (P < .0001 for both). Despite this increase in testing, there was no change in the percentage of patients newly diagnosed with HIV (0.7% in both periods, P = .96) or HCV (3.6% vs 3.7%, P = .81). We estimate that 1.2%–15% of HCV-infected primary care patients in our medical center are undiagnosed.

Conclusions

EMR-based HCV/HIV testing promotion increased testing but not case finding among primary care patients in our medical center. In our institution, most HCV-infected patients are already diagnosed, primarily through risk-based and clinical screening, highlighting the need to concentrate future efforts on increasing HCV treatment.

Hepatitis C Point-of-Care Screening in Retail Pharmacies in the United States

Background and Aims: Approximately half of adults with hepatitis C in the United States do not know their infection status, and the majority of persons who know they are positive for hepatitis C virus (HCV) antibodies fail to receive care. We conducted a screening program in retail pharmacies and calculated the percentages of anti-HCV-positive individuals and how many subsequently entered a pathway to care. Methods: At 45 Walgreens retail pharmacies in 9 US cities, direct store advertising was used to recruit individuals for HCV antibody testing. Participants were at least 18 years old with at least 1 HCV risk factor, such as being born between 1945 and 1965. One day per week at each site, a phlebotomist obtained consent from interested participants and performed the testing. Within 3 business days, an HCV management specialist contacted anti-HCV-positive individuals and provided test results and a pathway for obtaining HCV RNA testing. During the following 21 to 28 days, the same HCV management specialist telephoned individuals to determine whether they underwent an HCV RNA test. Results: Between September 2015 and February 2016, 1298 individuals consented. Two patients withdrew consent after testing. In all, 8% (103/1296) were HCV antibody-positive; of them, 91 (88%) were contacted by an HCV management specialist. During the 21- to 28-day follow-up, 56 individuals (62%; 56/91) were reached by an HCV management specialist, and 29 (52%; 29/56) confirmed that an HCV RNA test was ordered. Conclusions: These results provide evidence in support of point-of-care HCV screening in retail pharmacies for at-risk individuals in the United States.

Barriers to Treatment Access for Chronic Hepatitis C Virus Infection: A Case Series

Restrictive policies on access to new, curative hepatitis C treatments represent a substantial barrier to treating patients infected with hepatitis C. This case series demonstrates challenges experienced by patients and practitioners in accessing these treatments and highlights several strategies for navigating the treatment preauthorization process.