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Cook C, Reid L, Elsharkawy AM, Radley A, Smith S, McPherson S, Crockford D, Dillon JF, Wright M, Morris D, Malik H, Keall S, Powell J, Catt J, Hampton H, Boothman H, Shah S, Spear J, Ustianoski A, John P, Stevens H, Khakoo SI, Parkes J, Buchanan RM. The implementation of a hepatitis C testing service in community pharmacies: I-COPTIC consensus statement. Public Health 2024; 232:153-160. [PMID: 38781782 DOI: 10.1016/j.puhe.2024.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 03/21/2024] [Accepted: 04/09/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVES This aimed to develop a blueprint for an effective community pharmacy Hepatitis C virus (HCV) testing service by producing a consensus statement. STUDY DESIGN This was a modified Delphi process. METHODS We recruited a heterogenous panel of experts (who had been involved in the setup or delivery of a community pharmacy HCV testing service) by purposive and chain referral methods. We had three rounds of a modified Delphi process. The first was a series of questions with free text responses and was analysed using thematic analysis, and the second and third were statements for the respondents to rate using a 7-point Likert scale. Consensus was predefined in a published protocol, and the results were reviewed by a public and patient involvement panel before the statement was finalised. RESULTS We had 24 participants, including community and hospital-based pharmacists, local pharmaceutical committee members, charity representatives (Hepatitis C Trust), local clinical service lead, nurse specialists and doctors. The response rate of the first, second and third rounds were 100%, 96% and 88%, respectively. After the third round, we had 60 statements that reached consensus. We discussed the accepted statements with a patient and public involvement group. We used these statements to produce the I-COPTIC statement and a graphical summary. CONCLUSIONS We developed a blueprint for the design of a gold standard community pharmacy HCV testing service. We believe this will support the successful implementation of community pharmacy testing for HCV. Community pharmacy testing is an important service to help achieve and maintain HCV elimination.
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Affiliation(s)
- C Cook
- University of Southampton, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, UK.
| | - L Reid
- Hepatitis C Trust, 72 Weston Street, London, SE1 3QG, UK.
| | - A M Elsharkawy
- Liver Unit and NIHR Biomedical Research Centre at University Hospitals Birmingham NHS Trust and University of Birmingham, Edgbaston, Birmingham, B15 2TH, UK.
| | - A Radley
- NHS Tayside/University of Dundee, Nethergate, Dundee, DD1 4HN, UK.
| | - S Smith
- Hepatitis C Trust, 72 Weston Street, London, SE1 3QG, UK.
| | - S McPherson
- Liver Unit and NIHR Biomedical Research Centre, The Newcastle Upon Tyne Hospitals NHS Foundation Trust and Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK.
| | - D Crockford
- Community Pharmacy South Central, Sentinel House, Harvest Crescent, Fleet, Hampshire, GU51 2UZ, UK.
| | - J F Dillon
- University of Dundee, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK.
| | - M Wright
- University Hospitals Southampton, Tremona Road, Southampton, SO16 6YD, UK.
| | - D Morris
- Hepatitis C Trust, 72 Weston Street, London, SE1 3QG, UK.
| | - H Malik
- Carter's Chemist 114-116 Fowler Street, Southshields, NE33 1PZ, UK.
| | - S Keall
- Community Pharmacy Tees Valley, UK.
| | - J Powell
- Community Pharmacy Surrey and Sussex, PO Box 1061A, Surbiton, KT1 9HJ, UK.
| | - J Catt
- Kings College Hospital, Denmark Hill, London, SE5 9RS, UK.
| | - H Hampton
- Royal Cornwall Hospital, Treliske, Truro, Cornwall, TR1 3LJ, UK.
| | - H Boothman
- St George's NHS Foundation Trust, Blackshaw Road, Tooting, London, SW17 0QT, UK.
| | - S Shah
- Kings College Hospital, Denmark Hill, London, SE5 9RS, UK.
| | - J Spear
- University Hospital of Leicester, University Road, Leicester, LE1 7RH, UK.
| | - A Ustianoski
- Manchester University Foundation Trust & University of Manchester UK, Regional Infectious Diseases Unit, North Manchester General Hospital, Delaunays Road, Manchester, M8 5RB, UK.
| | - P John
- University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK.
| | - H Stevens
- University of Southampton, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, UK.
| | - S I Khakoo
- University of Southampton, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, UK.
| | - J Parkes
- University of Southampton, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, UK.
| | - R M Buchanan
- University of Southampton, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, UK.
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Fontaine G, Presseau J, Bruneau J, Etherington C, Thomas IM, Hung JHC, van Allen Z, Patey AM, Kareem A, Mortazhejri S, Høj SB, Boyer-Legault G, Grimshaw JM. Using an intersectionality lens to explore barriers and enablers to hepatitis C point-of-care testing: a qualitative study among people who inject drugs and service providers. Int J Equity Health 2024; 23:124. [PMID: 38886803 PMCID: PMC11184812 DOI: 10.1186/s12939-024-02209-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 05/31/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND Hepatitis C virus (HCV) infection is a significant global health burden, particularly among people who inject drugs. Rapid point-of-care HCV testing has emerged as a promising approach to improve HCV detection and linkage to care in harm reduction organizations such as needle and syringe programs. The objective of this study was to use an intersectionality lens to explore the barriers and enablers to point-of-care HCV testing in a needle and syringe program. METHODS A qualitative study was conducted using semi-structured interviews with clients (people who inject drugs) and service providers in a large community organization focused on the prevention of sexually transmitted and blood borne infections and harm reduction in Montreal, Canada. An intersectionality lens was used alongside the Theoretical Domains Framework to guide the formulation of research questions as well as data collection, analysis, and interpretation. RESULTS We interviewed 27 participants (15 clients, 12 providers). For clients, four themes emerged: (1) understanding and perceptions of HCV testing, (2) the role of an accessible and inclusive environment, (3) the interplay of emotions and motivations in decision-making, and (4) the impact of intersectional stigma related to HCV, behaviors, and identities. For providers, five themes emerged: (1) knowledge, skills, and confidence for HCV testing, (2) professional roles and their intersection with identity and lived experience, (3) resources and integration of services, (4) social and emotional factors, and (5) behavioral regulation and incentives for HCV testing. Intersectional stigma amplified access, emotional and informational barriers to HCV care for clients. In contrast, identity and lived experience acted as powerful enablers for providers in the provision of HCV care. CONCLUSION The application of an intersectionality lens provides a nuanced understanding of multilevel barriers and enablers to point-of-care HCV testing. Findings underscore the need for tailored strategies that address stigma, improve provider roles and communication, and foster an inclusive environment for equitable HCV care. Using an intersectionality lens in implementation research can offer valuable insights, guiding the design of equity-focused implementation strategies.
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Affiliation(s)
- Guillaume Fontaine
- Centre for Implementation Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada.
- Ingram School of Nursing, Faculty of Medicine and Health Sciences, McGill University, 680 Rue Sherbrooke O #1800, Montréal, QC, H3A 2M7, Canada.
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Sir Mortimer B. Davis Jewish General Hospital, CIUSSS West-Central Montreal, 3755 Chem. de La Côte-Sainte-Catherine, Montréal, QC, H3T 1E2, Canada.
- Viral Hepatitis Clinical Research Program, Kirby Institute, UNSW Sydney, UNSW, Wallace Wurth Building (C27), Cnr High St & Botany St, Kensington, NSW, 2052, Australia.
| | - Justin Presseau
- Centre for Implementation Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON, K1G 5Z3, Canada
- School of Psychology, University of Ottawa, 136 Jean-Jacques Lussier, Vanier Hall, Ottawa, ON, K1N 6N5, Canada
| | - Julie Bruneau
- Research Centre, Université de Montréal Hospital Centre, 900 Saint Denis St, Montreal, QC, H2X 0A9, Canada
- Department of Family and Emergency Medicine, Université de Montréal, 2900, Boulevard Édouard-Montpetit, Montréal, QC, H3T 1J4, Canada
| | - Cole Etherington
- Centre for Implementation Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
| | - Isabella M Thomas
- Centre for Implementation Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
| | - Jui-Hsia Cleo Hung
- Centre for Implementation Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON, K1G 5Z3, Canada
| | - Zack van Allen
- Centre for Implementation Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
- School of Psychology, University of Ottawa, 136 Jean-Jacques Lussier, Vanier Hall, Ottawa, ON, K1N 6N5, Canada
| | - Andrea M Patey
- Centre for Implementation Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON, K1G 5Z3, Canada
- School of Rehabilitation Therapy, Queen's University, Louise D Acton Building, 31 George St, Kingston, ON, K7L 3N6, Canada
| | - Ayesha Kareem
- Centre for Implementation Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
| | - Sameh Mortazhejri
- Centre for Implementation Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON, K1G 5Z3, Canada
| | - Stine Bordier Høj
- Research Centre, Université de Montréal Hospital Centre, 900 Saint Denis St, Montreal, QC, H2X 0A9, Canada
| | - Geneviève Boyer-Legault
- Direction of Community Services, CACTUS Montréal, 1300 Rue Sanguinet, Montréal, QC, H2X 3E7, Canada
| | - Jeremy M Grimshaw
- Centre for Implementation Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON, K1G 5Z3, Canada
- Department of Medicine, University of Ottawa, 45 Smyth Road, Ottawa, ON, K1H8M5, Canada
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Gunn J, O'Keefe D, Draper BL, Djordjevic F, Ryan K, Kerr P, Elsum I, Gold J, Layton C, Chan K, Dietze P, Higgs P, Doyle J, Stoové MA, Hellard M, Pedrana A. The eliminate hepatitis C (EC) experience study: baseline characteristics of a cohort of people who inject drugs in Melbourne, Australia. BMJ Open 2023; 13:e071665. [PMID: 37400235 DOI: 10.1136/bmjopen-2023-071665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2023] Open
Abstract
OBJECTIVES Direct-acting antivirals provide an opportunity to eliminate hepatitis C virus (HCV) as a public health threat in Australia, yet barriers to care remain. In this study, we use baseline data from a longitudinal cohort of people who inject drugs to understand differences in participant characteristics and explore experiences of stigma, health service utilisation and health literacy between three care cascade groups. DESIGN Cross-sectional. SETTING Community and private primary healthcare services in Melbourne, Australia. PARTICIPANTS Participants completed baseline surveys between 19 September 2018 and 15 December 2020. We recruited 288 participants; the median age was 42 years (IQR: 37-49 years) and 198 (69%) were male. At baseline, 103 (36%) self-reported being 'not engaged in testing', 127 (44%) had HCV RNA positivity but were 'not engaged in treatment' and 58 (20%) were 'engaged in HCV treatment'. OUTCOME MEASURES Descriptive statistics were used to present the baseline demographics, health service utilisation and experiences of stigma data. We explored differences in these scales between participant demographics using χ2 test or fisher's exact tests, and differences between health literacy scores using one-way analysis of variance tests. RESULTS A majority were in regular contact with multiple health services, and most had previously been identified as at-risk of HCV. In the 12 months preceding baseline, 70% reported any experiences of stigma related to injecting drug use. Assessment of health literacy data identified gaps for those 'not engaged in testing' and 'not engaged in treatment' across two relevant domains: 'ability to appraise health information' and 'ability to actively engage with healthcare providers'. CONCLUSION In eliminate hepatitis C experience, lower HCV testing and treatment may be explained by experiences of stigmatisation or gaps in health literacy. Enhanced interventions targeting people who inject drugs to promote HCV care are needed.
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Affiliation(s)
- Jack Gunn
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Daniel O'Keefe
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Bridget Louise Draper
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Filip Djordjevic
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Kathleen Ryan
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Phoebe Kerr
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Imogen Elsum
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Judy Gold
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Chloe Layton
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Kico Chan
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Paul Dietze
- School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
- National Drug Research Institute, Curtin University, Perth, Western Australia, Australia
- Behaviours and Health Risks Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Peter Higgs
- Behaviours and Health Risks Program, Burnet Institute, Melbourne, Victoria, Australia
- Department of Public Health, La Trobe University, Bundoora, Victoria, Australia
| | - Joseph Doyle
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Mark A Stoové
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Margaret Hellard
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
- Department of Infectious Diseases, The Alfred and Monash University, Melbourne, Victoria, Australia
- Doherty Institute and Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Alisa Pedrana
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
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4
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Shaw F, Fomiatti R, Farrugia A, Fraser S. Proper distance in the age of social distancing: Hepatitis C treatment, telehealth and questions of care and responsibility. SOCIOLOGY OF HEALTH & ILLNESS 2023; 45:19-36. [PMID: 36214600 PMCID: PMC10092018 DOI: 10.1111/1467-9566.13558] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 08/02/2022] [Indexed: 06/16/2023]
Abstract
During the COVID-19 pandemic, telehealth has played a prominent role in the treatment of hepatitis C. As part of a qualitative study on the accessibility and effectiveness of telehealth for hepatitis C treatment during this period in Australia, this article considers how health-care practitioners and patients experience and manage their proximity to each other in telehealth encounters of care. Comparisons between telehealth and in-person health-care tend to focus on measures of patient satisfaction rather than qualitative changes in treatment relationships. Media scholar Silverstone (Digital media revisited: Theoretical and conceptual innovations in digital domains, MIT Press, 2003) uses the term 'proper distance' to theorise how ethical relationships are mediated by technology. Drawing on this concept, we explore how patients and health-care practitioners understand telehealth as affecting distance and proximity. We find that both groups express some ambivalence about the impact of telehealth on relationships, on the one hand expecting and privileging simple, transactional relationships, and on the other hand, expressing concerns about the loss of more intimate relationships in health care and about 'missing something' while providing health care. Given that proximity is important to the development of ethical relationships in health care, we conclude with some considerations for establishing and sustaining attentive and responsive relationships in telehealth.
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Affiliation(s)
- Frances Shaw
- Australian Research Centre in Sex, Health and SocietyLa Trobe UniversityMelbourneVictoriaAustralia
- ARC Centre of Excellence for Automated Decision‐Making and SocietySwinburne University of TechnologyHawthornVictoriaAustralia
| | - Renae Fomiatti
- Australian Research Centre in Sex, Health and SocietyLa Trobe UniversityMelbourneVictoriaAustralia
- School of Humanities and Social SciencesFaculty of Arts and EducationDeakin UniversityBurwoodVictoriaAustralia
| | - Adrian Farrugia
- Australian Research Centre in Sex, Health and SocietyLa Trobe UniversityMelbourneVictoriaAustralia
| | - Suzanne Fraser
- Australian Research Centre in Sex, Health and SocietyLa Trobe UniversityMelbourneVictoriaAustralia
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5
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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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6
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Selfridge M, Barnett T, Lundgren K, Guarasci K, Milne R, Drost A, Fraser C. Treating people where they are: Nurse-led micro-elimination of hepatitis C in supported housing sites for networks of people who inject drugs in Victoria, Canada. Public Health Nurs 2022; 39:1009-1016. [PMID: 35537120 DOI: 10.1111/phn.13092] [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: 02/14/2022] [Revised: 04/19/2022] [Accepted: 04/21/2022] [Indexed: 11/28/2022]
Abstract
To achieve the World Health Organization's goal of eliminating hepatitis C (HCV) by 2030 requires enhanced HCV testing and treatment among people who use drugs (PWUD). Micro-elimination of HCV is a strategy to target HCV testing and treatment efforts to specific segments of the population. From February to December 2018 nurses initiated a "seek & treat" micro-elimination approach, increasing outreach and removing barriers to accessing HCV treatment in a clinic setting by testing and treating individuals, including PWUD, where they live. The aim of this study was to evaluate the proportion of clients with HCV antibodies and HCV RNA and the response to direct acting agent (DAA therapy) among people who live at or have social connections to local supportive housing sites through this nurse-led micro-elimination project in Victoria, Canada. A chart review of electronic medical records and case management documentation was used to collect relevant data of participants treated with DAA therapy, identified through specific housing site testing and outreach interventions. In total, 180 people were tested for HCV antibodies, 72 (40%) were antibody positive: 51 (28%) were RNA positive, 13 (7%) had spontaneously cleared and 8 (4%) had been previously treated. Of the 51 that were currently living with HCV, 43 people were started on treatment, 39 have achieved sustained virologic response (SVR). By providing treatment to clients in their homes and with their friends, clinicians have been able to treat clients, including those with limited contact with the health care system.
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Affiliation(s)
- Marion Selfridge
- Cool Aid Community Health Centre, Victoria, Canada.,University of Victoria, Victoria, Canada
| | | | | | | | | | - Anne Drost
- Cool Aid Community Health Centre, Victoria, Canada
| | - Chris Fraser
- Cool Aid Community Health Centre, Victoria, Canada.,University of British Columbia, Victoria, Canada
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7
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Alfranca R, Salvans M, López C, Giralt C, Ramírez M, Calvo F. Hepatitis C in homeless people: reaching a hard-to-reach population. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2021; 113:529-532. [PMID: 33494612 DOI: 10.17235/reed.2021.7737/2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE the aim of this study was to analyze the process of detection and treatment of hepatitis C in individuals experiencing homelessness (IEH). METHODS an analytical cross-sectional study was performed in a Primary Care center. The center screened and registered patients with a positive hepatitis C antibody test and referred them to the Digestive Service. RESULTS finally, 8.3 % presented with a positive HCV antibody test, of which six were patients who had already received treatment. Of those who had not received treatment, one patient was successfully treated; 30.8 % of the total could not be located or did not wish to participate. CONCLUSION community coordination and the use of rapid tests would improve detection.
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Affiliation(s)
- Rebeca Alfranca
- Centro de Atención Primaria Santa Clara. Institut Català de la Salut
| | - Mercè Salvans
- Centro de Atención Primaria Santa Clara. Institut Català de la Salut
| | - Carmen López
- Unidad de Hepatitis, Hospital Universitari de Girona Doctor Josep Trueta
| | - Cristina Giralt
- Centro de Atención Primaria Blanes. Institut Català de la Salut
| | - Marissa Ramírez
- Centro de Atención y Seguimiento a las Drogodependencias de Girona. Institut d'Assistència Sanitària
| | - Fran Calvo
- Pedagogia, Institut de Recerca sobre Qualitat de Vida. Universitat de Girona, España
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8
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Harris M, Guy D, Picchio CA, White TM, Rhodes T, Lazarus JV. Conceptualising hepatitis C stigma: A thematic synthesis of qualitative research. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 96:103320. [PMID: 34261587 DOI: 10.1016/j.drugpo.2021.103320] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 04/20/2021] [Accepted: 05/23/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Stigma is an important element in the experience of living with chronic viral hepatitis B (HBV) and C (HCV), impacting healthcare access and uptake as well as health outcomes. Conceptualisations of stigma in research are, however, often assumed and implicit. This study aimed to synthesise and critically engage with the qualitative literature to provide an overarching conceptualisation of stigma as it pertains to viral hepatitis. METHODS We critically reviewed qualitative literature that mobilised concepts or theories of stigma in relation to viral hepatitis. We searched seven electronic databases for peer-reviewed literature from 2000 to 2019. Given a dearth of conceptual literature on HBV stigma, we conducted a thematic analysis of concepts deployed to theorise stigma in relation to HCV. RESULTS We found 13 studies that conceptualised stigma in relation to HCV, yet none for HBV. We synthesise the analytical findings of these studies and explore how HCV is theorised in relation to four themes: 'identity', 'embodiment', 'institutionalisation', and 'structuration'. Taken together, these themes illustrate the way in which HCV stigma manifests as the confluence of normative assumptions of socially unacceptable practices relating to HCV, such as injecting drug use and sexual behaviours; attitudes towards socially excluded populations; and fears of contracting a contagious and chronic illness. As such, operating within political, social, and economic systems, HCV stigma can act to silence the needs of those with HCV through misrecognising the multifaceted identities of individuals with HCV and structural determinants of health. Stigma, which is built and perpetuated by institutional arrangements, as well as in social processes and policies, shapes deservedness to, as well as engagements with, health and social care. CONCLUSION While commonly employed as a framing concept, much research lacks explicit theoretical or critical engagement on how stigma is conceptualised. There is a tendency for qualitative, empirical research to focus on risk factors shaping individual behaviour change, rather than on risk contexts and socio-structural change. Approaches to address stigma in relation to HCV must consider how stigma operates throughout social processes and is embedded in systems of power and normalised in institutional operating systems.
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Affiliation(s)
- Magdalena Harris
- Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH
| | - Danielle Guy
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Calle del Rossellón 132, ES-08036 Barcelona, Spain
| | - Camila A Picchio
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Calle del Rossellón 132, ES-08036 Barcelona, Spain
| | - Trenton M White
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Calle del Rossellón 132, ES-08036 Barcelona, Spain
| | - Tim Rhodes
- Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH
| | - Jeffrey V Lazarus
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Calle del Rossellón 132, ES-08036 Barcelona, Spain; Faculty of Medicine, University of Barcelona, Barcelona, Spain.
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9
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Age and gender-specific hepatitis C continuum of care and predictors of direct acting antiviral treatment among persons who inject drugs in Seattle, Washington. Drug Alcohol Depend 2021; 220:108525. [PMID: 33461152 PMCID: PMC7938869 DOI: 10.1016/j.drugalcdep.2021.108525] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 12/11/2020] [Accepted: 12/23/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Direct acting antivirals (DAAs) have revolutionized management of hepatitis C virus (HCV), but treatment uptake remains low among persons who inject drugs (PWID). We report the continuum of care for HCV and describe predictors of treatment with DAAs among PWID in Seattle. METHODS We analyzed data from the 2018 Seattle area National HIV Behavioral Surveillance (NHBS) survey of PWID. Persons ≥18 years of age who injected drugs in the past year and completed the core NHBS survey, a local survey supplement, and rapid HCV antibody testing were included. Among those who screened HCV antibody positive, we calculated proportions and 95 % confidence intervals for self-reported steps along the HCV care continuum. Multivariable logistic regression was used to calculate the adjusted odds (AOR) of having received DAA therapy. RESULTS The sample included 533 PWID, 376 (71 %) of whom tested positive for antibodies to HCV. Among those who were HCV antibody positive, 94 % reported any prior HCV test, 81 % reported a prior confirmatory test, and 68 % reported a prior HCV diagnosis. Of those diagnosed, 26 % had undergone treatment and 18 % had been cured. In a multivariate model, being one year older (AOR 1.05 per year, 1.01-1.08) was predictive of DAA treatment, while homelessness (AOR 0.39, 0.19-0.80) and female gender (AOR 0.36, 0.16-0.78) were associated with a lower odds of DAA therapy. CONCLUSIONS Despite widespread HCV testing among PWID in Seattle, treatment uptake remains low in the DAA era. In particular, treatment of women, younger adults and persons living homeless is lagging behind.
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10
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Oru E, Trickey A, Shirali R, Kanters S, Easterbrook P. Decentralisation, integration, and task-shifting in hepatitis C virus infection testing and treatment: a global systematic review and meta-analysis. LANCET GLOBAL HEALTH 2021; 9:e431-e445. [PMID: 33639097 PMCID: PMC7966682 DOI: 10.1016/s2214-109x(20)30505-2] [Citation(s) in RCA: 103] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 09/17/2020] [Accepted: 11/09/2020] [Indexed: 12/11/2022]
Abstract
Background Increasing access to hepatitis C virus (HCV) care and treatment will require simplified service delivery models. We aimed to evaluate the effects of decentralisation and integration of testing, care, and treatment with harm-reduction and other services, and task-shifting to non-specialists on outcomes across the HCV care continuum. Methods For this systematic review and meta-analysis, we searched PubMed, Embase, WHO Global Index Medicus, and conference abstracts for studies published between Jan 1, 2008, and Feb 20, 2018, that evaluated uptake of HCV testing, linkage to care, treatment, cure assessment, and sustained virological response at 12 weeks (SVR12) in people who inject drugs, people in prisons, people living with HIV, and the general population. Randomised controlled trials, non-randomised studies, and observational studies were eligible for inclusion. Studies with a sample size of ten or less for the largest denominator were excluded. Studies were categorised according to the level of decentralisation: full (testing and treatment at same site), partial (testing at decentralised site and referral elsewhere for treatment), or none. Task-shifting was categorised as treatment by specialists or non-specialists. Data on outcomes across the HCV care continuum (linkage to care, treatment uptake, and SVR12) were pooled using random-effects meta-analysis. Findings Our search identified 8050 reports, of which 132 met the eligibility criteria, and an additional ten reports were identified from reference citations and grey literature. Therefore, the final synthesis included 142 studies from 34 countries (20 [14%] studies from low-income and middle-income countries) and a total of 489 996 patients (239 446 [49%] from low-income and middle-income countries). Rates of linkage to care were higher with full decentralisation compared with partial or no decentralisation among people who inject drugs (full 72% [95% CI 57–85] vs partial 53% [38–67] vs none 47% [11–84]) and among people in prisons (full 94% [79–100] vs partial 50% [29–71]), although the CIs overlap for people who inject drugs. Similarly, treatment uptake was higher with full decentralisation compared with partial or no decentralisation (people who inject drugs: full 73% [65–80] vs partial 66% [55–77] vs none 35% [23–48]; people in prisons: full 72% [48–91] vs partial 39% [17–63]), although CIs overlap for full versus partial decentralisation. The results in the general population studies were more heterogeneous. SVR12 rates were high (≥90%) across different levels of decentralisation in all populations. Task-shifting of care and treatment to a non-specialist was associated with similar SVR12 rates to treatment delivered by specialists. There was a severe or critical risk of bias for 46% of studies, and heterogeneity across studies tended to be very high (I2>90%). Interpretation Decentralisation and integration of HCV care to harm-reduction sites or primary care showed some evidence of improved access to testing, linkage to care, and treatment, and task-shifting of care and treatment to non-specialists was associated with similarly high cure rates to care delivered by specialists, across a range of populations and settings. These findings provide support for the adoption of decentralisation and task-shifting to non-specialists in national HCV programmes. Funding Unitaid.
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Affiliation(s)
- Ena Oru
- Department of Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - Adam Trickey
- Population Health Sciences, University of Bristol, Bristol, UK
| | | | - Steve Kanters
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Philippa Easterbrook
- Department of Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland.
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11
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Roche R, Simmons R, Crawshaw AF, Fisher P, Pareek M, Morton W, Shryane T, Poole K, Verma A, Campos-Matos I, Mandal S. What do primary care staff know and do about blood borne virus testing and care for migrant patients? A national survey. BMC Public Health 2021; 21:336. [PMID: 33573638 PMCID: PMC7877334 DOI: 10.1186/s12889-020-10068-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 12/14/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND UK migrants born in intermediate to high prevalence areas for blood borne viruses (BBV) including hepatitis B, hepatitis C and HIV are at increased risk of these infections. National guidance from Public Health England (PHE) and National Institute for Health and Care Excellence (NICE) recommends primary care test this population to increase diagnoses and treatment. We aimed to investigate primary care professionals' knowledge of entitlements, and perceptions of barriers, for migrants accessing healthcare, and their policies, and reported practices and influences on provision of BBV testing in migrants. METHODS A pre-piloted questionnaire was distributed between October 2017 and January 2018 to primary care professionals attending the Royal College of General Practitioners and Best Practice in Primary Care conferences, via a link in PHE Vaccine Updates and through professional networks. Survey results were analysed to give descriptive statistics, and responses by respondent characteristics: profession, region, practice size, and frequency of seeing migrant patients. Responses were considered on a per question basis with response rates for each question presented with the results. RESULTS Four hundred fourteen questionnaires were returned with responses varying by question, representing an estimated 5.7% of English GP practices overall. Only 14% of respondents' practices systematically identified migrant patients for testing. Universal opt-out testing was offered to newly registering migrant patients by 18% of respondents for hepatitis B, 17% for hepatitis C and 21% for HIV. Knowledge of healthcare entitlements varied; fewer clinical staff knew that general practice consultations were free to all migrants (76%) than for urgent care (88%). Performance payment structure (76%) had the greatest reported influence on testing, followed by PHE and Clinical Commissioning Group recommendations (73% each). Language and culture were perceived to be the biggest barriers to accessing care. CONCLUSIONS BBV testing for migrant patients in primary care is usually ad hoc, which is likely to lead to testing opportunities being missed. Knowledge of migrants' entitlements to healthcare varies and could affect access to care. Interventions to improve professional awareness and identification of migrant patients requiring BBV testing are needed to reduce the undiagnosed and untreated burden of BBVs in this vulnerable population.
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Affiliation(s)
- Rachel Roche
- Blood Safety, Hepatitis, Sexually Transmitted Infections (STI) and HIV Service, National Infection Service, Public Health England, 61 Colindale Avenue, London, NW9 5EQ, UK.
- The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections at University College London, Gower St, London, WC1E 6BT, UK.
| | - Ruth Simmons
- Blood Safety, Hepatitis, Sexually Transmitted Infections (STI) and HIV Service, National Infection Service, Public Health England, 61 Colindale Avenue, London, NW9 5EQ, UK
- The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections at University College London, Gower St, London, WC1E 6BT, UK
| | - Alison F Crawshaw
- Migration Health, Health Improvement, Public Health England, Wellington House, 133-155 Waterloo Road, London, SE1 8UG, UK
- Institute for Infection and Immunity, St George's, University of London, Cranmer Terrace, Tooting, London, SW17 0RE, UK
| | - Pip Fisher
- University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - Manish Pareek
- Department of Respiratory Sciences, University of Leicester, University Road, Leicester, LE1 7RH, UK
| | - Will Morton
- Public Health England Yorkshire and the Humber, 2nd Floor, Blenheim House, Duncombe Street, Leeds, LS1 4PL, UK
| | - Theresa Shryane
- Public Health England North West, 2nd Floor, 3 Piccadilly Place, London Road, Manchester, M1 3BN, UK
| | - Kristina Poole
- Public Health England North West, 2nd Floor, 3 Piccadilly Place, London Road, Manchester, M1 3BN, UK
| | - Arpana Verma
- University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - Ines Campos-Matos
- Migration Health, Health Improvement, Public Health England, Wellington House, 133-155 Waterloo Road, London, SE1 8UG, UK
- Institute of Epidemiology and Healthcare, University College London (UCL), 1-19 Torrington Place WC1E 7HB, London, UK
| | - Sema Mandal
- Blood Safety, Hepatitis, Sexually Transmitted Infections (STI) and HIV Service, National Infection Service, Public Health England, 61 Colindale Avenue, London, NW9 5EQ, UK
- The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections at University College London, Gower St, London, WC1E 6BT, UK
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12
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Falade-Nwulia O, Gicquelais RE, Astemborski J, McCormick SD, Kirk G, Sulkowski M, Thomas DL, Mehta SH. Hepatitis C treatment uptake among people who inject drugs in the oral direct-acting antiviral era. Liver Int 2020; 40:2407-2416. [PMID: 32770638 PMCID: PMC7706292 DOI: 10.1111/liv.14634] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 06/22/2020] [Accepted: 07/20/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Increased uptake of hepatitis C virus (HCV) treatment among people who inject drugs (PWID) will be critical to achieve HCV elimination goals. There are limited data on HCV treatment uptake among PWID recruited from community-based settings in the HCV direct-acting antiviral (DAA) era. METHODS We analysed data from PWID with HCV newly recruited into the Baltimore, Maryland-based AIDS Linked to the IntraVenous Experience (ALIVE) cohort between 2015 and 2018. We characterized the HCV care continuum and evaluated factors associated with HCV treatment uptake. RESULTS Of the 418 PWID with HCV, the median age was 49 years and most (88%) reported recent injection drug use (IDU). Overall, 23% had ever been evaluated by a provider for HCV treatment, 17% ever initiated DAA treatment and 13% were cured of HCV infection. Treatment uptake approximately doubled between 2015 and 2018 (13% to 26%, P = .01). In multivariable analyses, HIV infection (adjusted Odds Ratio [aOR] 2.5 [95% Confidence Interval (CI) 1.3, 4.8]), current employment (aOR 4.1 [CI 1.2, 14.4]), having a primary care provider (aOR 4.3 [CI 1.2, 14.9) and longer duration of IDU (aOR 1.3 [CI 1.1, 1.6]) were positively associated with HCV treatment. PWID with a lower annual income (≤$5000) were less likely to have initiated HCV treatment (aOR 0.5 [CI 0.3, 0.98]). CONCLUSIONS Although HCV treatment uptake among PWID in this community-based setting in the DAA era remains suboptimal, it is encouraging that treatment uptake has increased in recent years. Innovative strategies are needed to reach all PWID infected with HCV.
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Affiliation(s)
| | - Rachel E. Gicquelais
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jacquie Astemborski
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sean D. McCormick
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Greg Kirk
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Mark Sulkowski
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David L. Thomas
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Shruti H. Mehta
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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13
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Haridy J, Iyngkaran G, Nicoll A, Muller K, Wilson M, Wigg A, Ramachandran J, Nelson R, Bloom S, Sasadeusz J, Watkinson S, Colman A, Altus R, Tilley E, Stewart J, Hebbard G, Liew D, Tse E. Outcomes of community-based hepatitis C treatment by general practitioners and nurses in Australia via remote specialist consultation. Intern Med J 2020; 51:1927-1934. [PMID: 32892478 DOI: 10.1111/imj.15037] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 06/13/2020] [Accepted: 08/16/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND & AIMS A unique model of care was adopted in Australia following introduction of universal subsidised direct-acting antiviral (DAA) access in 2016 in order to encourage rapid scale-up of treatment. Community-based medical practitioners and integrated hepatitis nurses initiated DAA treatment with remote hepatitis specialist approval of the planned treatment without physical review. We aimed to evaluate outcomes of community-based treatment of hepatitis C (HCV) through this remote consultation process in the first 12 months of this model of care. METHODS A retrospective chart review of patients undergoing community-based HCV treatment from general practitioners and integrated hepatitis nurse consultants through the remote consultation model in three state jurisdictions in Australia from 1 March 2016 to 28 February 2017. RESULTS SVR12 was confirmed in 383/588 (65.1%) subjects intended for treatment with a median follow-up time of 12 months (IQR 9-14 months). The SVR12 test was not performed in 159/588 (27.0%) and 307/588 (52.2%) did not have liver biochemistry rechecked following treatment. Subjects who completed follow-up exhibited high SVR12 rates (383/392,97.7%). Nurse-led treatment was associated with higher confirmation of SVR12 (73.7% v 62.4%, p = 0.01) and liver biochemistry testing post treatment (57.5% v 45.0%, p = 0.01). CONCLUSIONS Community-based management of HCV through remote specialist consultation may be an effective model of care. Failure to check SVR12, recheck liver biochemistry and appropriate surveillance in patients with cirrhosis may emerge as significant issues requiring further support, education and refinement of the model to maximise effectiveness of future elimination efforts. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- James Haridy
- Department of Medicine, University of Melbourne, Parkville, Australia.,Department of Gastroenterology and Hepatology, Royal Melbourne Hospital, Parkville, Australia.,Department of Gastroenterology, Eastern Health, Box Hill, Australia
| | - Guru Iyngkaran
- Department of Medicine, University of Melbourne, Parkville, Australia.,Department of Gastroenterology and Hepatology, Royal Melbourne Hospital, Parkville, Australia.,Department of Gastroenterology, Royal Darwin Hospital, Darwin, Australia
| | - Amanda Nicoll
- Department of Medicine, University of Melbourne, Parkville, Australia.,Department of Gastroenterology, Eastern Health, Box Hill, Australia.,Eastern Health Clinical School, Monash University, Melbourne, Australia
| | - Kate Muller
- Hepatology and Liver Transplantation Unit, Flinders Medical Centre, Adelaide, Australia
| | - Mark Wilson
- Department of Gastroenterology, Royal Hobart Hospital, Hobart, Australia
| | - Alan Wigg
- Hepatology and Liver Transplantation Unit, Flinders Medical Centre, Adelaide, Australia
| | - Jeyamani Ramachandran
- Hepatology and Liver Transplantation Unit, Flinders Medical Centre, Adelaide, Australia
| | - Renjy Nelson
- School of Medicine, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia.,Department of Infectious Diseases, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Stephen Bloom
- Department of Gastroenterology, Eastern Health, Box Hill, Australia.,Eastern Health Clinical School, Monash University, Melbourne, Australia
| | - Joseph Sasadeusz
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, Australia
| | - Sally Watkinson
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, Australia
| | - Anton Colman
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, Australia
| | - Rosalie Altus
- Hepatology and Liver Transplantation Unit, Flinders Medical Centre, Adelaide, Australia
| | - Emma Tilley
- Hepatology and Liver Transplantation Unit, Flinders Medical Centre, Adelaide, Australia
| | - Jeffrey Stewart
- Hepatology and Liver Transplantation Unit, Flinders Medical Centre, Adelaide, Australia.,Department of Infectious Diseases, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Geoff Hebbard
- Department of Gastroenterology and Hepatology, Royal Melbourne Hospital, Parkville, Australia
| | - Danny Liew
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Edmund Tse
- School of Medicine, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia.,Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, Australia
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14
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Radley A, de Bruin M, Inglis SK, Donnan PT, Hapca A, Barclay ST, Fraser A, Dillon JF. Clinical effectiveness of pharmacist-led versus conventionally delivered antiviral treatment for hepatitis C virus in patients receiving opioid substitution therapy: a pragmatic, cluster-randomised trial. Lancet Gastroenterol Hepatol 2020; 5:809-818. [PMID: 32526210 DOI: 10.1016/s2468-1253(20)30120-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 04/03/2020] [Accepted: 04/07/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Highly effective direct-acting antiviral drugs provide the opportunity to eliminate hepatitis C virus (HCV) infection, but established pathways can be ineffective. We aimed to examine whether a community pharmacy care pathway increased treatment uptake, treatment completion, and cure rates for people receiving opioid substitution therapy, compared with conventional care. METHODS This cluster-randomised trial was done in Scottish community pharmacies. Before participants were recruited, pharmacies were randomly assigned (1:1) to refer patients with evidence of HCV antibodies to conventional care or offered them care in the pharmacy (pharmacist-led care). Pharmacies were stratified by location. All pharmacies were trained to offer dried blood spot testing. All eligible participants had received opioid substitution therapy for approximately 3 months, and those eligible to receive treatment in the pharmacist-led care pathway were HCV PCR positive, were infected with HCV genotype 1 or 3, and were willing to have a pharmacist supervise their antiviral drug administration. Neither pharmacists nor patients were masked to treatment allocation. In both groups, assessment blood samples were taken, infection with HCV was confirmed, and daily oral ledipasvir-sofosbuvir (90 mg ledipasivir plus 400 mg sofosbuvir) for 8 weeks for genotype 1 or daily oral sofosbuvir (400 mg) plus oral daclatasvir (60 mg) for 12 weeks for genotype 3 was prescribed by a nurse (conventional care group) or pharmacist (pharmacist-led care group). In the conventional care group, the patient received care at a treatment centre. Once prescribed, medication in both groups was delivered as daily modified directly observed therapy alongside opioid substitution therapy in the participants' pharmacy where treatment was observed on 6 days per week. The primary outcome was the number of patients with sustained virological response 12 weeks after completion of treatment (SVR12) as a proportion of the number of people receiving opioid substitution therapy at participating pharmacies. Participants were monitored at each visit for nausea and fatigue; other adverse events were recorded as free text. Secondary outcomes compared key points on treatment pathway between the two groups. These key points were the proportion of patients having dry blood spot testing, the proportion of patients initiating HCV treatment, the proportion of patients completing the 8 or 12 week HCV course of treatment, and the proportion of patients with sustained virological response at 12 months. This study is registered with ClinicalTrials.gov, NCT02706223. FINDINGS 56 pharmacies were randomly assigned (28 to each group; one pharmacy withdrew from the conventional care group). The 55 participating pharmacies included 2718 patients receiving opioid substitution therapy (1365 in the pharmacist-led care group and 1353 in the conventional care group). More patients met the primary endpoint of SVR12 in the pharmacist-led care group (98 [7%] of 1365) than in the conventional care group (43 [3%] of 1353; odds ratio 2·375, 95% CI 1·555-3·628, p<0·0001). More users of opioid substitution therapy in the pharmacist-led care group versus the conventional care group agreed to dry blood spot testing (245 [18%] of 1365 vs 145 [11%] of 1353, 2·292, 0·968-5·427, p=0·059); initiated treatment (112 [8%] of 1365 vs 61 [4%] of 1353, 1·889, 1·276-2·789, p=0·0015) and completed treatment (108 [8%] of 1365 vs 58 [4%] of 1353, 1·928, 1·321-2·813, p=0·0007). The data for sustained virological response at 12 months are not reported in this study: patients remain in follow-up for this outcome. No serious adverse events were recorded. INTERPRETATION Using pharmacists to deliver an HCV care pathway made testing and treatment more accessible for patients, improved engagement, and maintained high treatment success rates. The use of this pathway could be a key part of an integrated and effective approach to HCV elimination at a community level. FUNDING Partnership between the Scottish Government, Gilead Sciences, and Bristol-Myers Squib.
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Affiliation(s)
- Andrew Radley
- NHS Tayside, Directorate of Public Health, Kings Cross Hospital, Dundee, UK; University of Dundee, Ninewells Hospital and Medical School, Dundee, UK.
| | - Marijn de Bruin
- Radboud University Medical Center, Radboud Institute of Health Sciences, Nijmegen, Netherlands; University of Aberdeen, Institute of Applied Health Sciences, Aberdeen, UK
| | - Sarah K Inglis
- University of Dundee, Tayside Clinical Trials Unit, Dundee, UK
| | - Peter T Donnan
- University of Dundee, Tayside Clinical Trials Unit, Dundee, UK
| | - Adrian Hapca
- University of Dundee, Tayside Clinical Trials Unit, Dundee, UK
| | - Stephen T Barclay
- NHS Greater Glasgow and Clyde, Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK; Glasgow Caledonian University, Department of Life Sciences, Glasgow, UK
| | - Andrew Fraser
- NHS Grampian, Aberdeen Royal Infirmary, Foresterhill Health Campus, Aberdeen, UK
| | - John F Dillon
- University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
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15
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Phillips C, Schulkind J, O'Sullivan M, Edelman N, Smith HE, Verma S, Jones CJ. Improving access to care for people who inject drugs: Qualitative evaluation of project ITTREAT-An integrated community hepatitis C service. J Viral Hepat 2020; 27:176-187. [PMID: 31566851 DOI: 10.1111/jvh.13214] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 08/08/2019] [Accepted: 08/31/2019] [Indexed: 12/11/2022]
Abstract
Achieving hepatitis C virus (HCV) elimination by 2030 requires an increased linkage to care for people who inject drugs (PWID). Project ITTREAT was established to mitigate barriers to HCV care by providing an integrated service within a local drug and alcohol treatment centre. This study aimed to explore the experiences of clients and staff involved in Project ITTREAT and assess the facilitators and barriers to a community-based HCV service. Between October 2014 and April 2016, drug and alcohol treatment attendees were interviewed using one-to-one semi-structured interviews. Drug and alcohol treatment staff took part in focus groups. All data were recorded, transcribed verbatim and analysed using thematic content analysis. Fifteen drug and alcohol treatment attendees with current/previous HCV infection were interviewed, and 15 staff members contributed across two focus groups. Drug and alcohol treatment staff and attendees reported that Project ITTREAT facilitated access to HCV care by mitigating previous negative hospital-based experiences. Other key facilitators were positive narratives around HCV care, and drug and alcohol treatment attendees being well engaged in their drug/alcohol recovery. Barriers included a lack of stability in drug and alcohol treatment attendees, negative discourse around testing/treatment and stigma associated with attending the drug and alcohol treatment to access HCV treatment in some who had successfully achieved drug rehabilitation. Our findings indicate the positive impact of an integrated and personalized community-based service delivered by a dedicated hepatitis nurse. This played a crucial role in reducing barriers to HCV care for PWID. Our work also highlights areas for future investment including non-DAT-based community services and increasing awareness of new treatments amongst this cohort.
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Affiliation(s)
- Clare Phillips
- Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospital NHS Trust, Brighton, UK
| | - Jasmine Schulkind
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK
| | - Margaret O'Sullivan
- Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospital NHS Trust, Brighton, UK
| | - Natalie Edelman
- Department of Primary Care & Public Health, Brighton & Sussex Medical School, Brighton, UK
| | - Helen E Smith
- Department of Primary Care & Public Health, Brighton & Sussex Medical School, Brighton, UK.,Family Medicine and Primary Care, Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Singapore
| | - Sumita Verma
- Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospital NHS Trust, Brighton, UK.,Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK
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16
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Pourmarzi D, Hall L, Smirnov A, Hepworth J, Rahman T, FitzGerald G. Framework for community-based models for treating hepatitis C virus. AUST HEALTH REV 2020; 44:459-469. [DOI: 10.1071/ah18220] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 05/01/2019] [Indexed: 12/16/2022]
Abstract
Objective
Although community-based models for treating hepatitis C virus (HCV) are widely recognised for reaching more people who require treatment, little is known about their organisational and operational elements. This study aimed to address this gap and develop a framework for designing, implementing and evaluating community-based models for treating HCV.
Methods
This study was a systematic review in which 17 databases were searched for published and unpublished studies. The final search of databases was performed in September 2017. A qualitative inductive thematic approach was used to extract and categorise organisational and operational elements of community-based models for treating HCV.
Results
Data analysis yielded 13 organisational and operational elements that were categorised into three domains: support for patients, support for healthcare providers and service delivery facilitation. In the support for patients domain, support was categorised into four elements: peer support, psychological assessment and support, social assessment and support and adherence support. In the support for healthcare providers domain, the elements included the provision of educational opportunities for HCV care providers, specialist mentoring, decision making support and rewarding and recognition for HCV care providers. Finally, the service delivery facilitation domain included seven elements that target service-level enablers for community-based HCV treatment, including essential infrastructure, policy implementation and collocation and collaboration with other related services.
Conclusion
This framework for understanding the components of models of community-based HCV treatment may be used as a guide for designing, implementing and evaluating models of care in support of HCV elimination. HCV care providers and patients need to be supported to improve their engagement with the provision of community-based treatment. In addition, evidence-based strategies to facilitate service delivery need to be included.
What is known about the topic?
Community-based models for treating HCV are widely recognised as having the advantage of reaching more people who require treatment. These types of models aim to remove barriers related to accessibility and acceptability associated with tertiary centre-based HCV treatment.
What does this paper add?
Community-based models for treating HCV use various organisational and operational elements to improve the accessibility, effectiveness and acceptability of these services. The elements we identified target three main domains: support for patients with HCV, support for HCV care providers and service delivery facilitation. The importance of these organisational and operational elements designed to improve health and health services outcomes of community-based models for treating HCV is strongly influenced by context, and dependent on both the setting and target population.
What are the implications for practitioners?
Health policy makers and practitioners need to consider a patient’s psychosocial and economic status and provide support when needed. To successfully deliver HCV treatment in community settings, HCV care providers need to be trained and supported, and need to establish linkages, collaborations or colocations with other related services.
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17
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Lazarus JV, Pericàs JM, Picchio C, Cernosa J, Hoekstra M, Luhmann N, Maticic M, Read P, Robinson EM, Dillon JF. We know DAAs work, so now what? Simplifying models of care to enhance the hepatitis C cascade. J Intern Med 2019; 286:503-525. [PMID: 31472002 DOI: 10.1111/joim.12972] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Globally, some 71 million people are chronically infected with hepatitis C virus (HCV). Marginalized populations, particularly people who inject drugs (PWID), have low testing, linkage to care and treatment rates for HCV. Several models of care (MoCs) and service delivery interventions have the potential to improve outcomes across the HCV cascade of care, but much of the relevant research was carried out when interferon-based treatment was the standard of care. Often it was not practical to scale-up these earlier models and interventions because the clinical care needs of patients taking interferon-based regimens imposed too much of a financial and human resource burden on health systems. Despite the adoption of highly effective, all-oral direct-acting antiviral (DAA) therapies in recent years, approaches to HCV testing and treatment have evolved slowly and often remain rooted in earlier paradigms. The effectiveness of DAAs allows for simpler approaches and has encouraged countries where the drugs are widely available to set their sights on the ambitious World Health Organization (WHO) HCV elimination targets. Since a large proportion of chronically HCV-infected people are not currently accessing treatment, there is an urgent need to identify and implement existing simplified MoCs that speak to specific populations' needs. This article aims to: (i) review the evidence on MoCs for HCV; and (ii) distil the findings into recommendations for how stakeholders can simplify the path taken by chronically HCV-infected individuals from testing to cure and subsequent care and monitoring.
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Affiliation(s)
- J V Lazarus
- Barcelona Institute for Global Health (ISGlobal), Barcelona, Spain
| | - J M Pericàs
- Infectious Diseases and Clinical Microbiology Territorial Direction, Translational Research Group on Infectious Diseases of Lleida (TRIDLE), Biomedical Research Institute Dr Pifarré Foundation, Lleida, Spain
| | - C Picchio
- Barcelona Institute for Global Health (ISGlobal), Barcelona, Spain
| | - J Cernosa
- Clinic for Infectious Diseases and Febrile Illnesses, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - M Hoekstra
- Barcelona Institute for Global Health (ISGlobal), Barcelona, Spain
| | - N Luhmann
- Médecins du Monde France, Paris, France
| | - M Maticic
- Clinic for Infectious Diseases and Febrile Illnesses, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - P Read
- Kirketon Road Centre, Sydney, NSW, Australia
| | - E M Robinson
- Division of Molecular and Clinical Medicine, School of Medicine, Ninewells Hospital, University of Dundee, Dundee, UK
| | - J F Dillon
- Division of Molecular and Clinical Medicine, School of Medicine, Ninewells Hospital, University of Dundee, Dundee, UK
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18
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Radley A, Robinson E, Aspinall EJ, Angus K, Tan L, Dillon JF. A systematic review and meta-analysis of community and primary-care-based hepatitis C testing and treatment services that employ direct acting antiviral drug treatments. BMC Health Serv Res 2019; 19:765. [PMID: 31660966 PMCID: PMC6819346 DOI: 10.1186/s12913-019-4635-7] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 10/14/2019] [Indexed: 12/23/2022] Open
Abstract
Background Direct Acting Antiviral (DAAs) drugs have a much lower burden of treatment and monitoring requirements than regimens containing interferon and ribavirin, and a much higher efficacy in treating hepatitis C (HCV). These characteristics mean that initiating treatment and obtaining a virological cure (Sustained Viral response, SVR) on completion of treatment, in non-specialist environments should be feasible. We investigated the English-language literature evaluating community and primary care-based pathways using DAAs to treat HCV infection. Methods Databases (Cinahl; Embase; Medline; PsycINFO; PubMed) were searched for studies of treatment with DAAs in non-specialist settings to achieve SVR. Relevant studies were identified including those containing a comparison between a community and specialist services where available. A narrative synthesis and linked meta-analysis were performed on suitable studies with a strength of evidence assessment (GRADE). Results Seventeen studies fulfilled the inclusion criteria: five from Australia; two from Canada; two from UK and eight from USA. Seven studies demonstrated use of DAAs in primary care environments; four studies evaluated integrated systems linking specialists with primary care providers; three studies evaluated services in locations providing care to people who inject drugs; two studies evaluated delivery in pharmacies; and one evaluated delivery through telemedicine. Sixteen studies recorded treatment uptake. Patient numbers varied from around 60 participants with pathway studies to several thousand in two large database studies. Most studies recruited less than 500 patients. Five studies reported reduced SVR rates from an intention-to-treat analysis perspective because of loss to follow-up before the final confirmatory SVR test. GRADE assessments were made for uptake of HCV treatment (medium); completion of HCV treatment (low) and achievement of SVR at 12 weeks (medium). Conclusion Services sited in community settings are feasible and can deliver increased uptake of treatment. Such clinics are able to demonstrate similar SVR rates to published studies and real-world clinics in secondary care. Stronger study designs are needed to confirm the precision of effect size seen in current studies. Prospero: CRD42017069873.
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Affiliation(s)
- Andrew Radley
- NHS Tayside, Directorate of Public Health, Kings Cross Hospital, Clepington Road, Dundee, DD3 8EA, UK. .,University of Dundee, Division of Cardiovascular Medicines and Diabetes Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK.
| | - Emma Robinson
- University of Dundee, Division of Cardiovascular Medicines and Diabetes Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
| | - Esther J Aspinall
- School of Health and Life Sciences, Glasgow Caledonian University Glasgow and Health Protection Scotland, NHS National Services, Scotland, UK
| | - Kathryn Angus
- Institute for Social Marketing, Faculty of Health Sciences and Sport University of Stirling, Stirling, FK9 4LA, UK
| | - Lex Tan
- University of Dundee, Division of Cardiovascular Medicines and Diabetes Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
| | - John F Dillon
- University of Dundee, Division of Cardiovascular Medicines and Diabetes Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
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19
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Boyd A, Duchesne L, Lacombe K. Research gaps in viral hepatitis. J Int AIDS Soc 2019; 21 Suppl 2:e25054. [PMID: 29633564 PMCID: PMC5978714 DOI: 10.1002/jia2.25054] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Accepted: 12/20/2017] [Indexed: 12/21/2022] Open
Abstract
Introduction The World Health Organization has aimed for global elimination of both hepatitis B virus (HBV) and hepatitis C virus (HCV) by 2030. Treatments available to cure HCV and control HBV, as well as vaccination to prevent HBV infection, have certainly allowed for such bold goals, yet the final steps to usher in elimination require further evidence. Discussion We broadly discuss the needs for three major public health approaches. First, an effective vaccine exists for HBV and mass‐vaccination campaigns have resulted in decreases in hepatitis B surface antigen seroprevalence and overall rates of liver‐related morality. Still, HBV vaccination coverage is poor in certain regions of the world, while the reasons for such low coverage require further study. A prophylactic vaccine is probably needed to eliminate HCV, but is not being readily developed. Second, identifying HBV/HCV infected individuals remains a priority to increase awareness of disease status, particularly for key populations. Research evaluating large‐scale implementation of novel, rapid and mobile point‐of‐care tests would be helpful to determine whether increased awareness is achievable in these settings. Third, antiviral therapy allows for strong HBV suppression and HCV cure, while its access depends on financial factors among many others. Although there is strong evidence to treat key populations and specific groups with progressed disease, as stated in current guidelines, the advantages of extending treatment eligibility to decrease onward spread of HBV/HCV infection and prevent further burden of disease are lacking “real world” evidence. Novel anti‐HBV treatments are being developed to target intrahepatocellular HBV replication, but are still in the early phases of clinical development. Each of the strategies mentioned above has specific implications for HIV infection. Conclusions There are certainly effective tools to combat the spread of viral hepatitis and treat infected individuals – yet how they are able to reach key populations, and the infrastructure required to do so, continue to represent the largest research gap when evaluating the progress towards elimination. Continuously adapted and informed research is required to establish the priorities in achieving elimination goals.
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Affiliation(s)
- Anders Boyd
- INSERM, UMR_S1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France.,Department of Infectious Diseases, Research and Prevention, Public Health Service of Amsterdam, Amsterdam, Netherlands
| | - Léa Duchesne
- INSERM, UMR_S1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France
| | - Karine Lacombe
- Department of Infectious and Tropical Diseases, Saint-Antoine Hospital, AP-HP, Paris, France.,Sorbonne Universités, INSERM, UPMC Univ Paris 06, Institut Pierre Louis d'épidémiologie et de Santé Publique (IPLESP UMRS 1136), Paris, France
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20
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Schulkind J, Stephens B, Ahmad F, Johnston L, Hutchinson S, Thain D, Ward Z, Vickerman P, Hickman M, Dillon JF. High response and re-infection rates among people who inject drugs treated for hepatitis C in a community needle and syringe programme. J Viral Hepat 2019; 26:519-528. [PMID: 30422370 DOI: 10.1111/jvh.13035] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 10/11/2018] [Indexed: 12/12/2022]
Abstract
To achieve WHO hepatitis C virus (HCV) elimination targets by 2030, mathematical models suggest there needs to be significant scale-up of treatment among people who inject drugs (PWID). We tested whether people who actively inject drugs can be recruited and treated successfully through a community needle and syringe programme (NSP), and assessed rates of re-infection. 105 HCV RNA positive participants were enrolled prospectively. Participants were recruited from the largest NSP in Dundee over 42 months. 94/105 individuals commenced treatment. Genotype 1 (G1) individuals (n = 37) were treated with peg-interferon+ribavirin+Simepravir/Telaprevir. Genotype 2/3 (G2/3) (n = 57) received peg-interferon+ribavirin. Weekly study visits took place within the NSP. Mean age of participants was 34.0 years (SD 6.9), 71.3% (61/94) were male. One in five (20/94) participants were homeless. 68.1% (64/94) were on OST (opiate substitution therapy) at enrolment; participants injected median 6.5 times/wk. In terms of clinical outcomes, >80% treatment adherence was 71.3% (67/94). There was no difference in SVR-12 rates by genotype: 81.0% (30/37) for G1 and 82.5% (47/55) for G2/3. At 18 months post-treatment, 15/77 participants were reinfected, followed up over 69.8 person-years, yielding a re-infection rate of 21.5/100 person-years (95% CI 13.00-35.65). This trial demonstrates that HCV treatment can be delivered successfully to the target population of treatment as prevention strategies. We report higher rates of re-infection than existing estimates among PWID. Scale-up of HCV treatment should be pursued alongside a comprehensive programme of harm reduction interventions to help minimize re-infection and reduce HCV transmission.
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Affiliation(s)
| | - Brian Stephens
- Department of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Farsana Ahmad
- Department of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Linda Johnston
- Department of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Sharon Hutchinson
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Donna Thain
- NHS Tayside, Ninewells Hospital and Medical School, Dundee, UK
| | - Zoe Ward
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Peter Vickerman
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Matt Hickman
- Population Health Sciences, University of Bristol, Bristol, UK
| | - John F Dillon
- Department of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
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21
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Høj SB, Jacka B, Minoyan N, Artenie AA, Bruneau J. Conceptualising access in the direct-acting antiviral era: An integrated framework to inform research and practice in HCV care for people who inject drugs. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 72:11-23. [PMID: 31003825 DOI: 10.1016/j.drugpo.2019.04.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 03/22/2019] [Accepted: 04/01/2019] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Stine Bordier Høj
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900 rue St-Denis, Montréal, Québec, H2X 0A9, Canada.
| | - Brendan Jacka
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900 rue St-Denis, Montréal, Québec, H2X 0A9, Canada
| | - Nanor Minoyan
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900 rue St-Denis, Montréal, Québec, H2X 0A9, Canada; École de Santé Publique de l'Université de Montréal, 7101 Avenue du Parc, Montréal, Québec, H3N 1X9, Canada
| | - Andreea Adelina Artenie
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900 rue St-Denis, Montréal, Québec, H2X 0A9, Canada; École de Santé Publique de l'Université de Montréal, 7101 Avenue du Parc, Montréal, Québec, H3N 1X9, Canada
| | - Julie Bruneau
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900 rue St-Denis, Montréal, Québec, H2X 0A9, Canada; Département de Médicine Familiale et Médecine d'Urgence, Faculté de médecine, Université de Montréal, C.P. 6128, succursale Centre-ville, Montréal, Québec, H3C 3J7, Canada.
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22
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Gunn J, Higgs P. Directly observed hepatitis C treatment with opioid substitution therapy in community pharmacies: A qualitative study. Res Social Adm Pharm 2019; 16:1298-1301. [PMID: 31003763 DOI: 10.1016/j.sapharm.2019.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 03/22/2019] [Accepted: 04/07/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND The hepatitis C virus (HCV) will only be eliminated through successful engagement with people who inject drugs (PWID), however some of this population experience socioeconomic and individual issues that can lead to poor HCV treatment adherence. A key sub-group of (PWID) are those who receive opioid substitution therapy (OST). In Australia, OST is most often delivered under direct supervision by a community pharmacist every day or multiple times a week. This regular interaction could be an ideal opportunity to enhance direct-acting antiviral (DAA) treatment adherence under directly observed therapy (DOT) by the pharmacist. AIM The aim of this study was to explore the perspectives of OST patients with a lived experience of HCV to understand whether or not dispensing DAAs in the same way as, or simultaneously with OST would benefit HCV treatment. METHODS Data collection occurred from June to August 2017. Semi-structured interviews were conducted with a sample of PWID living with HCV and on OST programs (n = 12) in Melbourne, Australia. Interviews were voice recorded and transcribed in verbatim. Interpretive phenomenology guided analysis of the data. RESULTS Themes reported by participants that provide insight into the suitability of DOT of DAAs include: Adherence and non-adherence to DAA treatment; Mixed views towards DOT of DAAs; Experiences and perceptions of OST providers; and Perceived stigma in the pharmacy. CONCLUSIONS Community pharmacies offering OST may be an effective place for DOT of HCV treatment, but is likely only to benefit people who face significant challenges to adherence. We suggest that a positive pharmacist-patient relationship, high OST adherence, and commitment to reducing stigma in the pharmacy would be necessary for the intervention to be effective. Further research is needed to evaluate the expanded-role of community pharmacies in improving DAA adherence and eliminating HCV.
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Affiliation(s)
- Jack Gunn
- Disease Elimination, Burnet Institute, Melbourne, VIC, Australia.
| | - Peter Higgs
- Disease Elimination, Burnet Institute, Melbourne, VIC, Australia; Department of Public Health, La Trobe University, Melbourne, VIC, Australia
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23
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Harney BL, Whitton B, Lim C, Paige E, McDonald B, Nolan S, Pemberton D, Hellard ME, Doyle JS. Quantitative evaluation of an integrated nurse model of care providing hepatitis C treatment to people attending homeless services in Melbourne, Australia. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 72:195-198. [PMID: 30981613 DOI: 10.1016/j.drugpo.2019.02.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 02/27/2019] [Accepted: 02/28/2019] [Indexed: 01/18/2023]
Abstract
BACKGROUND The prevalence of hepatitis C virus (HCV) has been reported to be high among people experiencing homelessness. People who are homeless often have multiple needs that may take precedence over HCV testing and treatment. We quantitatively evaluated the outcomes of a service providing HCV treatment to people attending homeless services. METHODS Clients attending homeless services were referred to a nurse specialising in HCV-related care. The nurse provided HCV testing, education and case-management while prescriptions were provided by an affiliated doctor. Logistic regression was used to explore factors associated with treatment commencement. RESULTS Fifty-two clients referred (78%) underwent testing, thirty-nine were HCV-RNA positive among whom 18 (46%) reported sleeping rough and 29 (74%) reported injecting drug use; 66% had injected less than three months ago. Twenty-four (62%) clients commenced treatment, of whom thirteen (54%) had a sustained virological response test; all were cured. Treatment commencement was lower among people who reported sleeping rough (aOR 0.15, 95%CI 0.029-0.73). There was no difference in treatment commencement based on injecting drugs (aOR 1.06, 95%CI 0.21-5.2). CONCLUSION Most clients' commenced treatment and the majority were successfully cured using a dedicated nursing service. Clients who reported sleeping rough may still face personal and/or system level barriers to HCV treatment.
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Affiliation(s)
- Brendan L Harney
- Department of Infectious Diseases, Alfred Health & Monash University, 85 Commercial Road, Melbourne, Victoria, 3004, Australia; Disease Elimination Program, Burnet Institute, 85 Commercial Road, Melbourne, Victoria, 3004, Melbourne, Australia.
| | - Bradley Whitton
- Department of Infectious Diseases, Alfred Health & Monash University, 85 Commercial Road, Melbourne, Victoria, 3004, Australia
| | - Cheryl Lim
- Department of Infectious Diseases, Alfred Health & Monash University, 85 Commercial Road, Melbourne, Victoria, 3004, Australia; Star Health, 341 Coventry St, South Melbourne, Victoria, 3205, Australia
| | - Emma Paige
- Department of Infectious Diseases, Alfred Health & Monash University, 85 Commercial Road, Melbourne, Victoria, 3004, Australia
| | - Belinda McDonald
- Star Health, 341 Coventry St, South Melbourne, Victoria, 3205, Australia
| | - Sarah Nolan
- Star Health, 341 Coventry St, South Melbourne, Victoria, 3205, Australia; Launch Housing, 52 Haig St, Southbank, Victoria, 3205, Australia
| | - David Pemberton
- Star Health, 341 Coventry St, South Melbourne, Victoria, 3205, Australia; Launch Housing, 52 Haig St, Southbank, Victoria, 3205, Australia
| | - Margaret E Hellard
- Department of Infectious Diseases, Alfred Health & Monash University, 85 Commercial Road, Melbourne, Victoria, 3004, Australia; Disease Elimination Program, Burnet Institute, 85 Commercial Road, Melbourne, Victoria, 3004, Melbourne, Australia
| | - Joseph S Doyle
- Department of Infectious Diseases, Alfred Health & Monash University, 85 Commercial Road, Melbourne, Victoria, 3004, Australia; Disease Elimination Program, Burnet Institute, 85 Commercial Road, Melbourne, Victoria, 3004, Melbourne, Australia
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24
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Novel non-invasive score to predict cirrhosis in the era of hepatitis C elimination: A population study of ex-substance users in Singapore. Hepatobiliary Pancreat Dis Int 2019; 18:143-148. [PMID: 30558838 DOI: 10.1016/j.hbpd.2018.12.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 11/28/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Chronic hepatitis C infection is common among people with history of substance use. Liver fibrosis assessment is a barrier to linkage to care, particularly among those with history of substance users. The use of non-invasive scores can be helpful in predicting liver cirrhosis in the era of HCV elimination, especially in countries where transient elastography (TE) is not available. We compared the commonly used non-invasive scores with a novel non-invasive score in predicting liver cirrhosis in this population. METHODS HCV patients with history of substance use between 2011 and 2016 were analyzed. All patients had TE for liver fibrosis assessment. Clinical performance of established non-invasive scores for fibrosis assessment and novel score were compared. Youden's index was used to determine optimal cut-off of the novel score. RESULTS A total of 579 patients were included. In multivariate logistic regression, cirrhosis on TE was associated with age (P = 0.002), aspartate aminotransferase (AST) (P = 0.004), and platelet count (P < 0.001), but not alanine aminotransferase (ALT) (P = 0.896). These form the components of modified AST-to-platelet ratio index (APRI) score. Modified APRI was superior to APRI in predicting cirrhosis (AUROC, 0.796 vs. 0.770, P = 0.007), but not fibrosis-4 score (FIB-4) (P = 1.00). Modified APRI at cut-off of 4 has sensitivity, specificity and negative predictive value (NPV) of 94.4%, 26.9% and 92.6%, respectively, and at 19, has sensitivity, specificity and positive predictive value (PPV) of 33.3%, 96.2% and 77.1%, respectively. FIB-4 has a NPV and PPV of 88.6%, 41.8% and 78.5%, 77.6%, at cut-off of 1.45 and 3.25, respectively. Using the cut-off of 4 and 14 for modified APRI, 32.5% of patients can be correctly classified and misses out only 5.6% of cirrhosis patients. CONCLUSIONS Modified APRI score is superior in predicting cirrhosis in HCV population, with 32.5% of the population being correctly classified using cut-off of 4 and 14. Further studies are required to validate the findings.
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Cooke GS, Andrieux-Meyer I, Applegate TL, Atun R, Burry JR, Cheinquer H, Dusheiko G, Feld JJ, Gore C, Griswold MG, Hamid S, Hellard ME, Hou J, Howell J, Jia J, Kravchenko N, Lazarus JV, Lemoine M, Lesi OA, Maistat L, McMahon BJ, Razavi H, Roberts T, Simmons B, Sonderup MW, Spearman CW, Taylor BE, Thomas DL, Waked I, Ward JW, Wiktor SZ. Accelerating the elimination of viral hepatitis: a Lancet Gastroenterology & Hepatology Commission. Lancet Gastroenterol Hepatol 2019; 4:135-184. [PMID: 30647010 DOI: 10.1016/s2468-1253(18)30270-x] [Citation(s) in RCA: 335] [Impact Index Per Article: 67.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 08/10/2018] [Accepted: 08/13/2018] [Indexed: 01/26/2023]
Abstract
Viral hepatitis is a major public health threat and a leading cause of death worldwide. Annual mortality from viral hepatitis is similar to that of other major infectious diseases such as HIV and tuberculosis. Highly effective prevention measures and treatments have made the global elimination of viral hepatitis a realistic goal, endorsed by all WHO member states. Ambitious targets call for a global reduction in hepatitis-related mortality of 65% and a 90% reduction in new infections by 2030. This Commission draws together a wide range of expertise to appraise the current global situation and to identify priorities globally, regionally, and nationally needed to accelerate progress. We identify 20 heavily burdened countries that account for over 75% of the global burden of viral hepatitis. Key recommendations include a greater focus on national progress towards elimination with support given, if necessary, through innovative financing measures to ensure elimination programmes are fully funded by 2020. In addition to further measures to improve access to vaccination and treatment, greater attention needs to be paid to access to affordable, high-quality diagnostics if testing is to reach the levels needed to achieve elimination goals. Simplified, decentralised models of care removing requirements for specialised prescribing will be required to reach those in need, together with sustained efforts to tackle stigma and discrimination. We identify key examples of the progress that has already been made in many countries throughout the world, demonstrating that sustained and coordinated efforts can be successful in achieving the WHO elimination goals.
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Affiliation(s)
- Graham S Cooke
- Division of Infectious Diseases, Imperial College London, London, UK.
| | | | | | - Rifat Atun
- Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA; Harvard Medical School, Harvard University, Boston, MA, USA
| | | | - Hugo Cheinquer
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | | | - Jordan J Feld
- Toronto Center for Liver Disease, Toronto General Hospital, Toronto, Canada
| | | | - Max G Griswold
- Institute of Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | | | | | - JinLin Hou
- Hepatology Unit and Department of Infectious Diseases, Nanfang Hospital, Guangzhou, China
| | - Jess Howell
- Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, VIC, Australia
| | - Jidong Jia
- Liver Research Center, Beijing Friendship Hospital, Beijing, China
| | | | - Jeffrey V Lazarus
- Health Systems Research Group, Barcelona Institute for Global Health (ISGlobal), Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Maud Lemoine
- Division of Surgery and Cancer, Imperial College London, London, UK
| | | | | | - Brian J McMahon
- Liver Disease and Hepatitis Program, Alaska Native Tribal Health Consortium, Anchorage, AL, USA
| | - Homie Razavi
- Center for Disease Analysis Foundation, Lafayette, CO, USA
| | | | - Bryony Simmons
- Division of Infectious Diseases, Imperial College London, London, UK
| | - Mark W Sonderup
- Division of Hepatology, Department of Medicine, University of Cape Town, South Africa
| | - C Wendy Spearman
- Division of Hepatology, Department of Medicine, University of Cape Town, South Africa
| | | | - David L Thomas
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Imam Waked
- National Liver Institute, Menoufiya University, Egypt
| | - John W Ward
- Program for Viral Hepatitis Elimination, Task Force for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Stefan Z Wiktor
- Department of Global Health, University of Washington, Seattle, WA, USA
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26
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Radley A, de Bruin M, Inglis SK, Donnan PT, Dillon JF. Clinical effectiveness of pharmacy-led versus conventionally delivered antiviral treatment for hepatitis C in patients receiving opioid substitution therapy: a study protocol for a pragmatic cluster randomised trial. BMJ Open 2018; 8:e021443. [PMID: 30552244 PMCID: PMC6303565 DOI: 10.1136/bmjopen-2017-021443] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 05/08/2018] [Accepted: 10/23/2018] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Hepatitis C virus (HCV) infection affects 0.7% of the general population, and up to 40% of people prescribed opioid substitution therapy (OST) in Scotland. In conventional care, less than 10% of OST users are tested for HCV and less than 25% of these initiate treatment. Community pharmacists see this group frequently to provide OST supervision. This study examines whether a pharmacist-led 'test & treat' pathway increases cure rates for HCV. METHODS AND ANALYSIS This protocol describes a cluster-randomised trial where 60 community pharmacies provide either conventional or pharmacy-led care. All pharmacies offer dried blood spot testing (DBST) for HCV. Participants have attended the pharmacy for OST for 3 months; are positive for HCV genotype 1 or 3; are not co-infected with HIV and/or hepatitis B; have no decompensated liver disease; are not pregnant. For conventional care, pharmacists refer HCV-positive participants to a local centre for assessment. In the pharmacy-led arm, pharmacists assess participants themselves in the pharmacy. Drug prescribing is by nurse prescribers (conventional arm) or pharmacist prescribers (pharmacy-led arm). Treatment in both arms is delivered as daily modified directly observed therapy in a pharmacy. Primary trial outcome is number of sustained virological responses at 12 weeks after treatment completion. Secondary trial outcomes are number of tests taken; treatment uptake; completion; adherence; re-infection. An economic evaluation will assess potential cost-effectiveness. Qualitative research interviews with clients and health professionals assess acceptability of a pharmacist-led pathway. ETHICS AND DISSEMINATION This protocol has been ethically approved by the East of Scotland Research Ethics Committee 2 (15/ES/0086) and complies with the Declaration of Helsinki and principles of Good Clinical Practice. Caldicott guardian approval was given on 16 December 2016 to allow NHS Tayside to pass information to the cluster community pharmacies about the HCV test status of patients that they are seeing to provide OST supervision. NHS R&D approvals have been obtained from each health board taking part in the study. Informed consent is obtained before study enrolment and only anonymised data are stored in a secured database, enabling an audit trail. Results will be submitted to international peer-reviewed journals and presented at international conferences. TRIAL REGISTRATION NUMBER NCT02706223; Pre-results.
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Affiliation(s)
- Andrew Radley
- Directorate of Public Health, NHS Tayside, Kings Cross Hospital, Dundee, UK
| | - Marijn de Bruin
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Sarah K Inglis
- Tayside Clinical Trials Unit, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Peter T Donnan
- Tayside Clinical Trials Unit, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - John F Dillon
- Division of Molecular and Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
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27
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Wade AJ, McCormack A, Roder C, McDonald K, Davies M, Scott N, Wardrop M, Athan E, Hellard ME. Aiming for elimination: Outcomes of a consultation pathway supporting regional general practitioners to prescribe direct-acting antiviral therapy for hepatitis C. J Viral Hepat 2018; 25:1089-1098. [PMID: 29660212 DOI: 10.1111/jvh.12910] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 03/01/2018] [Indexed: 12/09/2022]
Abstract
To increase access to treatment, the Australian government enabled general practitioners (GPs) to prescribe direct-acting antivirals (DAAs) to treat hepatitis C virus (HCV)-in consultation with a specialist if inexperienced in HCV management. This study describes the establishment and outcomes of a remote consultation pathway supporting GPs to treat HCV. Key stakeholders from primary and tertiary healthcare services in the Barwon South Western region developed and implemented an HCV remote consultation pathway. Pharmaceutical Benefits Schedule prescription data were used to evaluate GP DAA prescription 12 months pre-and post- pathway implementation. A retrospective review of patients referred for remote consultation for 12 months post- pathway inception was undertaken to determine the care cascade. HCV treatment initiation by GPs increased after implementation of the remote consultation pathway. In the 12-month study period, 74 GPs referred 169 people for remote consultation; 114 (67%) were approved for GP DAA treatment; 48 (28%) were referred for specialist assessment. In total, 119 (71%) patients commenced DAA; 69 were eligible for SVR12 assessment. Post-treatment HCV RNA data were available for 52 (75%) people; 37 achieved SVR12; 15 achieved SVR ranging from week 5 to 11 post-treatment. No treatment failure was detected. Collaborative development and implementation of a remote consultation pathway has engaged regional GPs in managing HCV. Follow-up post-treatment could be improved; however, no treatment failure has been documented. To eliminate HCV as a public health threat, it is vital that specialists support GPs to prescribe DAA.
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Affiliation(s)
- A J Wade
- Department of Infectious Disease, Barwon Health, Geelong, Vic., Australia.,Disease Elimination Program, Burnet Institute, Melbourne, Vic., Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic., Australia
| | - A McCormack
- School of Medicine, Deakin University, Geelong, Vic., Australia
| | - C Roder
- School of Medicine, Deakin University, Geelong, Vic., Australia
| | - K McDonald
- Western Victoria Primary Health Network, Geelong, Vic., Australia
| | - M Davies
- Western Victoria Primary Health Network, Geelong, Vic., Australia.,Drug and Alcohol Services, Barwon Health, Geelong, Vic., Australia
| | - N Scott
- Disease Elimination Program, Burnet Institute, Melbourne, Vic., Australia
| | - M Wardrop
- Department of Infectious Disease, Barwon Health, Geelong, Vic., Australia
| | - E Athan
- Department of Infectious Disease, Barwon Health, Geelong, Vic., Australia.,School of Medicine, Deakin University, Geelong, Vic., Australia
| | - M E Hellard
- Disease Elimination Program, Burnet Institute, Melbourne, Vic., Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic., Australia
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28
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van Driel ML, Lim D, Clark PJ. Hepatitis C in Australia - a role for general practitioners? Med J Aust 2018; 207:53. [PMID: 28701119 DOI: 10.5694/mja17.00323] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 05/18/2017] [Indexed: 12/18/2022]
Affiliation(s)
| | - David Lim
- Flinders Rural Health South Australia, Victor Harbor, SA
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29
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Wade AJ, Doyle JS, Gane E, Stedman C, Draper B, Iser D, Roberts SK, Kemp W, Petrie D, Scott N, Higgs P, Agius PA, Roney J, Stothers L, Thompson AJ, Hellard ME. Community-based provision of direct-acting antiviral therapy for hepatitis C: study protocol and challenges of a randomized controlled trial. Trials 2018; 19:383. [PMID: 30012192 PMCID: PMC6048874 DOI: 10.1186/s13063-018-2768-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 06/27/2018] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND To achieve the World Health Organization hepatitis C virus (HCV) elimination targets, it is essential to increase access to treatment. Direct-acting antiviral (DAA) treatment can be provided in primary healthcare services (PHCS), improving accessibility, and, potentially, retention in care. Here, we describe our protocol for assessing the effectiveness of providing DAAs in PHCS, and the impact on the HCV care cascade. In addition, we reflect on the challenges of conducting a model of care study during a period of unprecedented change in HCV care and treatment. METHODS Consenting patients with HCV infection attending 13 PHCS in Australia or New Zealand are randomized to receive DAA treatment at the local tertiary institution (standard care arm), or their PHCS (intervention arm). The primary endpoint is the proportion commenced on DAAs and cured. Treatment providers at the PHCS include: hepatology nurses, primary care practitioners, or, in two sites, a specialist physician. All PHCS offer opioid substitution therapy. DISCUSSION The Prime Study is the first real-world, randomized, model of care study exploring the impact of community provision of DAA therapy on HCV-treatment uptake and cure. Although the study has faced challenges unique to this period of time characterized by changing treatment and service delivery, the data gained will be of critical importance in shaping health service policy that enables the elimination of HCV. TRIAL REGISTRATION ClinicalTrials.gov , ID: NCT02555475 . Registered on 15 September 2015.
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Affiliation(s)
- A. J. Wade
- Disease Elimination Program, Burnet Institute, 85 Commercial Rd, Melbourne, VIC 3004 Australia
- School of Population Health and Preventive Medicine, Monash University, Melbourne, VIC Australia
| | - J. S. Doyle
- Disease Elimination Program, Burnet Institute, 85 Commercial Rd, Melbourne, VIC 3004 Australia
- Department of Infectious Diseases, The Alfred, Melbourne, VIC Australia
| | - E. Gane
- New Zealand Liver Transplant Unit, Auckland City Hospital, Auckland, New Zealand
| | - C. Stedman
- Department of Gastroenterology, Christchurch Hospital, and University of Otago, Christchurch, New Zealand
| | - B. Draper
- Disease Elimination Program, Burnet Institute, 85 Commercial Rd, Melbourne, VIC 3004 Australia
| | - D. Iser
- Department of Infectious Diseases, The Alfred, Melbourne, VIC Australia
| | - S. K. Roberts
- Department of Gastroenterology, The Alfred, Melbourne, VIC Australia
- Department of Medicine, Monash University, Melbourne, VIC Australia
| | - W. Kemp
- Department of Gastroenterology, The Alfred, Melbourne, VIC Australia
- Department of Medicine, Monash University, Melbourne, VIC Australia
| | - D. Petrie
- Centre for Health Economics, Monash University, Melbourne, VIC Australia
| | - N. Scott
- Disease Elimination Program, Burnet Institute, 85 Commercial Rd, Melbourne, VIC 3004 Australia
| | - P. Higgs
- Disease Elimination Program, Burnet Institute, 85 Commercial Rd, Melbourne, VIC 3004 Australia
- School of Population Health and Preventive Medicine, Monash University, Melbourne, VIC Australia
- Department of Public Health, La Trobe University, Bundoora, VIC Australia
| | - P. A. Agius
- Disease Elimination Program, Burnet Institute, 85 Commercial Rd, Melbourne, VIC 3004 Australia
- Department of Infectious Diseases, The Alfred, Melbourne, VIC Australia
- Judith Lumley Centre, La Trobe University, Melbourne, VIC Australia
| | - J. Roney
- Department of Infectious Diseases, The Alfred, Melbourne, VIC Australia
| | - L. Stothers
- Department of Gastroenterology, St Vincent’s Hospital, Melbourne, VIC Australia
| | - A. J. Thompson
- Department of Medicine, University of Melbourne, Melbourne, VIC Australia
- Department of Gastroenterology, St Vincent’s Hospital, Melbourne, VIC Australia
| | - M. E. Hellard
- Disease Elimination Program, Burnet Institute, 85 Commercial Rd, Melbourne, VIC 3004 Australia
- Department of Infectious Diseases, The Alfred, Melbourne, VIC Australia
- School of Population Health and Preventive Medicine, Monash University, Melbourne, VIC Australia
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30
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Delile JM, de Ledinghen V, Jauffret-Roustide M, Roux P, Reiller B, Foucher J, Dhumeaux D. Hepatitis C virus prevention and care for drug injectors: the French approach. HEPATOLOGY, MEDICINE AND POLICY 2018; 3:7. [PMID: 30288330 PMCID: PMC5987624 DOI: 10.1186/s41124-018-0033-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 05/29/2018] [Indexed: 12/14/2022]
Abstract
After France removed hepatitis C treatment reimbursement restrictions on 25 May 2016, an expert report presented recommendations, which focused on vulnerable groups including people who inject drugs (PWID). This commentary presents the key points of the chapter with a particular focus on policy. Thanks to the official lifting of restrictions based on disease stage and to the excellent efficacy and tolerance of the new DAA (Direct-Acting Antivirals) among PWID, the main issue is to improve the HCV care cascade. In France, many HCV-infected PWID, especially active/current PWID, remain undiagnosed and unlinked to care. Our challenge is to improve HCV screening by point of care testing (POCT), outreach methods with mobile teams, rapid tests, FibroScan, etc. and to provide PWID with appropriate services in all the settings they attend, such as drug treatment or harm reduction services, social services, prisons, etc. Another important issue is the prevention of reinfection through comprehensive and long-term follow-up. The report recommends a new national policy: testing and treating PWID as a priority, since this is the best way to eliminate HCV infection. It requires a global strategy consisting of combined and long-term interventions: prevention, outreach, screening, DAA, drug treatment programs including opiate substitution treatment (OST) and various harm reduction programs, including needle exchange programs (NEP). Ideally, these services should be delivered in the same place with an integrated approach. This should lead to meeting the national objective set by the government of eliminating hepatitis C by 2025.
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Affiliation(s)
- Jean-Michel Delile
- Comité d’étude et d’information sur la drogue et les addictions (CEID), 20, place Pey-Berland, 33000 Bordeaux, France
| | | | - Marie Jauffret-Roustide
- Cermes 3 (Inserm U988/CNRS UMR 8211/EHESS/Paris Descartes University) and French National Public Health Agency, Paris, France
| | - Perrine Roux
- Inserm UMR1252/IRD/SESSTIM/Aix-Marseille University/ORS PACA, Marseille, France
| | - Brigitte Reiller
- Comité d’étude et d’information sur la drogue et les addictions (CEID), 20, place Pey-Berland, 33000 Bordeaux, France
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31
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Scott N, Hainsworth SW, Sacks-Davis R, Pedrana A, Doyle J, Wade A, Hellard M. Heterogeneity in hepatitis C treatment prescribing and uptake in Australia: a geospatial analysis of a year of unrestricted treatment access. J Virus Erad 2018. [DOI: 10.1016/s2055-6640(20)30253-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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32
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Scott N, Hainsworth SW, Sacks-Davis R, Pedrana A, Doyle J, Wade A, Hellard M. Heterogeneity in hepatitis C treatment prescribing and uptake in Australia: a geospatial analysis of a year of unrestricted treatment access. J Virus Erad 2018. [PMID: 29682303 DOI: 10.1016/s0168-8278(18)30505-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Background and aim Direct-acting antiviral (DAA) treatments became available for all people living with hepatitis C virus (HCV) in Australia in March 2016. We assess variations in treatment rates and prescribing patterns across Australia's 338 Statistical Area 3 (SA3) geographical units. Methods Geocoded DAA treatment initiation data were analysed for the period 1 March 2016 to 30 June 2017. Regression models tested associations between the population demographics and healthcare service coverage of geographical areas and (a) their treatment rates; and (b) the proportion of prescriptions written by specialists compared to non-specialists. Results Across the 320 areas (95%) recording treatments, a median 76 (interquartile range [IQR] 35-207, range 4-3834) per 100,000 were initiated, corresponding to an estimated median 7.9% (IQR 2.9-23.6%, range 0-100%) treatment uptake. Major cities, areas of socioeconomic advantage and areas with lower proportions of the population born overseas had the highest per capita treatment rates. Non-specialists prescribed 46% (20,323/44,382) of treatment initiations. Prescriptions were written by non-specialists only in 163 areas (51%), while in other areas a median 40.0% (IQR 21.8-62.5%) of prescriptions were written by non-specialists. Non-specialist prescribing was higher in regional areas, as well as areas that had greater proportions of Indigenous Australians. Conclusions High national-level treatment uptake of 20% in Australia masks underlying health system limitations; more than half of geographical areas may have treated less than 8% of people living with HCV. Areas of socioeconomic disadvantage and areas with a higher proportion of the population born overseas may need targeting with interventions to improve treatment uptake.
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Affiliation(s)
| | - Samuel W Hainsworth
- Disease Elimination Program, Burnet Institute, Melbourne, VIC 3004, Australia
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33
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McDermott CL, Lockhart CM, Devine B. Outpatient directly observed therapy for hepatitis C among people who use drugs: a systematic review and meta-analysis. J Virus Erad 2018; 4:118-122. [PMID: 29682305 PMCID: PMC5892673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Objective: We conducted a meta-analysis of randomised studies that assessed the effectiveness of directly observed hepatitis C medication therapy delivered in outpatient clinics compared to treatment as usual. Methods: We completed a systematic literature review up to the end of August 2017, including online databases, study abstracts and references of pertinent articles. We assessed the results of randomised studies using the Cochrane Collaboration risk of bias assessment tool, and observational studies using the ROBINS-I tool. From each study, we extracted the number of patients who did or did not attain sustained virological response (SVR). We utilised a DerSimonian and Laird random effects model for our meta-analysis. This study is registered with PROSPERO (CRD42014012957). Results: We included six studies with 407 patients in our systematic review; four of those studies (215 patients) used randomisation and were included in our meta-analysis. Overall effect estimates showed that compared to treatment as usual, directly observed therapy demonstrated significantly higher odds of SVR attainment (odds ratio 2.01, 95% confidence interval 1.13-3.59). Conclusion: Among people who use drugs, directly observed therapy may lead to higher odds of attaining SVR. Further research on the best ways to use directly observed therapy to administer HCV therapy to people who use drugs is warranted.
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Affiliation(s)
- Cara L McDermott
- Cara L McDermott,
University of Washington School of Medicine, Fred Hutchinson Cancer Research Center,
1100 Fairview Avenue North, Mailstop M3-B232,
Seattle,
WA98109,
USA
| | - Catherine M Lockhart
- Biologics and Biosimilars Collective Intelligence Consortium,
Alexandria, VA,
USA
| | - Beth Devine
- CHOICE Institute, School of Pharmacy,
University of Washington,
Seattle,
WA,
USA
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34
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McDermott CL, Lockhart CM, Devine B. Outpatient directly observed therapy for hepatitis C among people who use drugs: a systematic review and meta-analysis. J Virus Erad 2018. [DOI: 10.1016/s2055-6640(20)30255-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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35
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Pedrana AE, Sacks-Davis R, Doyle JS, Hellard ME. Pathways to the elimination of hepatitis C: prioritising access for all. Expert Rev Clin Pharmacol 2017; 10:1023-1026. [DOI: 10.1080/17512433.2017.1383894] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Alisa E. Pedrana
- Disease Elimination Program, Burnet Institute, Melbourne, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Rachel Sacks-Davis
- Disease Elimination Program, Burnet Institute, Melbourne, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Australia
| | - Joseph S. Doyle
- Disease Elimination Program, Burnet Institute, Melbourne, Australia
- Department of Infectious Diseases, The Alfred and Monash University, Melbourne, Australia
| | - Margaret E. Hellard
- Disease Elimination Program, Burnet Institute, Melbourne, Australia
- Department of Infectious Diseases, The Alfred and Monash University, Melbourne, Australia
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36
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Gelson W, Alexander G. Is elimination of hepatitis C from the UK by 2030 a realistic goal? Br Med Bull 2017; 123:59-67. [PMID: 28605444 DOI: 10.1093/bmb/ldx017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 06/08/2017] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Highly effective, combination therapy for chronic hepatitis C virus (HCV) infection is now available. Current cure rates are close to 100% and applicable to all patients irrespective of race, age, severity of liver disease or viral genotype. Remarkably for persistent infection, current treatment is recommended for as little as 12 weeks; recent studies suggest even shorter courses. In contrast to interferon-based therapy, present regimens have few side effects and serious adverse events are rare. The success and safety of these regimens has stimulated interest in the possible eventual elimination of HCV. Barriers to elimination include cost of drugs and finding patients in the community less likely to interact with medical services who are a potential reservoir of infection. SOURCES OF DATA Pubmed. AREAS OF AGREEMENT Antiviral agents already available are highly effective. AREAS OF CONTROVERSY The cost of the newer antiviral agents is very high, restricting treatment numbers in the UK in 2015/16 and focusing therapy on those patients with significant fibrosis. Recently, patients with less severe disease have been offered therapy, but delivery may be slowed by high costs. Many believe that insufficient pressure has been brought to bear to reduce costs. Eventual elimination will depend first on reducing treatment costs for those known to have chronic HCV infection and then finding patients in the community with infection unaware of their illness or reluctant/unable to engage with medical services. AREAS FOR DEVELOPING RESEARCH Determining the most effective strategies to identify 'invisible' patients in the community with chronic HCV infection.
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Affiliation(s)
- Will Gelson
- Cambridge University Hospitals NHS Foundation Trust, Hill's Road, Cambridge, CB2 0QQ, UK
| | - Graeme Alexander
- Cambridge University Hospitals NHS Foundation Trust, Hill's Road, Cambridge, CB2 0QQ, UK.,UCL Institute for Liver & Digestive Health with the Royal Free Hospital Trust, Pond St, Hampstead, London, NW3 2QG, UK
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37
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Janjua NZ, Islam N, Wong J, Yoshida EM, Ramji A, Samji H, Butt ZA, Chong M, Cook D, Alvarez M, Darvishian M, Tyndall M, Krajden M. Shift in disparities in hepatitis C treatment from interferon to DAA era: A population-based cohort study. J Viral Hepat 2017; 24:624-630. [PMID: 28130810 DOI: 10.1111/jvh.12684] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 12/22/2016] [Indexed: 12/15/2022]
Abstract
We evaluated the shift in the characteristics of people who received interferon-based hepatitis C virus (HCV) treatments and those who received recently introduced direct-acting antivirals (DAAs) in British Columbia (BC), Canada. The BC Hepatitis Testers Cohort includes 1.5 million individuals tested for HCV or HIV, or reported cases of hepatitis B and active tuberculosis in BC from 1990 to 2013 linked to medical visits, hospitalization, cancer, prescription drugs and mortality data. This analysis included all patients who filled at least one prescription for HCV treatment until 31 July 2015. HCV treatments were classified as older interferon-based treatments including pegylated interferon/ribavirin (PegIFN/RBV) with/without boceprevir or telaprevir, DAAs with RBV or PegIFN/RBV, and newer interferon-free DAAs. Of 11 886 people treated for HCV between 2000 and 2015, 1164 (9.8%) received interferon-free DAAs (ledipasvir/sofosbuvir: n=1075; 92.4%), while 452 (3.8%) received a combination of DAAs and RBV or PegIFN/RBV. Compared to those receiving interferon-based treatment, people with HIV co-infection (adjusted odds ratio [aOR]: 2.96, 95% CI: 2.31-3.81), cirrhosis (aOR: 1.77, 95% CI: 1.45-2.15), decompensated cirrhosis (aOR: 1.72, 95% CI: 1.31-2.28), diabetes (aOR: 1.30, 95% CI: 1.10-1.54), a history of injection drug use (aOR: 1.34, 95% CI: 1.09-1.65) and opioid substitution therapy (aOR: 1.30, 95% CI: 1.01-1.67) were more likely to receive interferon-free DAAs. Socio-economically marginalized individuals were significantly less likely (most deprived vs most privileged: aOR: 0.71, 95% CI: 0.58-0.87) to receive DAAs. In conclusion, there is a shift in prescription of new HCV treatments to previously excluded groups (eg HIV-co-infected), although gaps remain for the socio-economically marginalized populations.
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Affiliation(s)
- N Z Janjua
- British Columbia Centre for Disease Control, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - N Islam
- British Columbia Centre for Disease Control, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - J Wong
- British Columbia Centre for Disease Control, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - E M Yoshida
- Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - A Ramji
- Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - H Samji
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Z A Butt
- British Columbia Centre for Disease Control, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - M Chong
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - D Cook
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - M Alvarez
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - M Darvishian
- British Columbia Centre for Disease Control, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - M Tyndall
- British Columbia Centre for Disease Control, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - M Krajden
- British Columbia Centre for Disease Control, Vancouver, BC, Canada.,Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
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38
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Pourmarzi D, Hall L, Rahman T, Lim D, FitzGerald G. Clinical effectiveness, cost-effectiveness and acceptability of community-based management of chronic hepatitis C: a mixed methods systematic review protocol. ACTA ACUST UNITED AC 2017; 15:914-931. [DOI: 10.11124/jbisrir-2016-003103] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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39
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Gilman M, Littlewood R. A Pilot Survey of Hepatitis C Knowledge and Awareness of Novel Treatment Options Engaged with Narcotics Anonymous: How Can Group Therapy Help? ACTA ACUST UNITED AC 2017. [DOI: 10.1080/1556035x.2016.1258684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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