A Pilot Study of Rapid Hepatitis C Testing in Probation and Parole Populations in Rhode Island

People in community corrections are a population with unmet need for viral hepatitis care

To reach World Health Organization elimination targets for hepatitis C, different strategies are needed to reach people who have not yet been diagnosed and treated. In the context of declining treatment initiation rates, innovation in service design and delivery is necessary: testing and treatment needs to be offered to people in non-traditional settings. The community corrections (probation and parole) population is larger than the prison population, which has high prevalence of hepatitis C and-in some countries-established diagnosis and treatment programs. In this Viewpoint we identify a gap in hepatitis C care for people under community correctional supervision, a group who have either never been imprisoned or need continuity of healthcare provided in prison. We propose that offering hepatitis C screening and treatment would benefit this population, and accelerate progress to hepatitis C elimination.

Hepatitis C Epidemiology in a Large Urban Jail: A Changing Demographic

OBJECTIVES

Nearly 1 in 3 people with hepatitis C virus (HCV) infection pass through the criminal justice system annually; the system is a crucial location for HCV screening, education, and linkage to care. We aimed to (1) determine the prevalence and incidence of HCV antibody positivity and (2) evaluate the demographic characteristics of people with HCV in a large urban jail.

METHODS

We offered universal opt-out HCV testing to any person undergoing a routine blood test at the Dallas County Jail from June 2015 through December 2019 (N = 14 490). We extracted data on demographic characteristics from the electronic medical record and collected data on risk factors from people with HCV antibody positivity. We performed univariate and multivariate analyses.

RESULTS

The prevalence of HCV antibody positivity was 16.7%; the incidence was 13.5 cases per 1000 person-years. HCV antibody positivity was significantly associated with older age (P < .001), female sex (P = .004), non-Hispanic White race versus non-Hispanic Black race (P < .001), and being released to prison versus not (P < .001). Among people born after 1965, those who were HCV antibody-positive were more frequently non-Hispanic White and Hispanic women, whereas among those born in 1965 or before, those who were HCV antibody-positive were more frequently non-Hispanic Black men.

CONCLUSIONS

The high prevalence and incidence of HCV antibody positivity in a large county jail argue for routine, universal HCV testing and prevention counseling in criminal justice settings. Changing demographic characteristics mirror those of the national injection drug use epidemic and shed insight into designing interventions for risk reduction, education, linkage to care, and treatment.

A retrospective, descriptive study of hepatitis C testing, prevalence, and care continuum among adults on probation

BACKGROUND

Despite constituting the largest segment of the correctional population, individuals on court-ordered probation remain largely unstudied with respect to hepatitis C virus (HCV) testing and linkage-to-care. We conducted a retrospective, descriptive analysis to estimate prevalence of diagnosed HCV and the subsequent HCV care cascade among a cohort of individuals enrolled in an adult probation program over a 25-month period in Denver, Colorado.

METHODS

We utilized probabilistic matching with first and last name, sex, and birthdate to identify individuals enrolled in probation between July 1, 2016 and July 30, 2018 who had a medical record at the participating safety-net healthcare institution as of December 31, 2019. Electronic medical record data were queried for evidence of HCV testing and care through June 30, 2021. The state HCV registry was also queried for prevalence of reported HCV cases among the cohort.

RESULTS

This cohort included 8,903 individuals; 6,920 (78%) individuals had a medical record at the participating institution, and of these, 1,037 (15%) had ever been tested for HCV (Ab or RNA) and 308 (4% of those with a medical record, 30% of those tested) had detectable HCV RNA. Of these, 105 (34%) initiated HCV treatment, 89 (29%) had a subsequent undetectable HCV viral load, and 65 (21%) had documentation of HCV cure. Eleven percent of the total cohort had records of positive HCV Ab or RNA tests in the state HCV registry.

CONCLUSIONS

This study demonstrates the importance of HCV screening and linkage-to-care for individuals enrolled in probation programs. A focus on this population could enhance progress towards HCV elimination goals.

Utilizing the Probation Office as an Opportunity to Screen for Cardiometabolic Outcomes: A Feasibility Study

This cross-sectional study examined whether the probation office setting was feasible to screen adults on probation for cardiometabolic risk factors, measure risk profiles, and estimate the prevalence of obesity, hypertension, hypercholesterolemia, and diabetes. During June and August 2019, screening included blood pressure, anthropometrics, total and high-density lipoprotein (HDL) cholesterol, and glucose. A survey included demographics, medical history, and current medication. The participation rate was 36% (N = 202). The screening identified 5% had hypercholesterolemia, 38% of men and 50% of women had low HDL cholesterol, 70% had overweight/obesity, 31% of men and 55% of women had elevated waist circumferences, and 26.7% had Stage 1 hypertension. Of individuals with a history of hypertension (n = 74), 77% had elevated blood pressure. Of those with a history of diabetes (n = 27), 22% had hyperglycemia, independent of whether they reported being prescribed medication. The screening identified 11% with Stage 2 hypertension, 27% with Stage 1 hypertension, 22% with elevated blood pressure, and 5% with hyperglycemia. Our findings suggest it is feasible to identify individuals at high risk for cardiometabolic disorders during routine probation office visits. These data can then be used to provide referrals for treatment to improve long-term health outcomes.

Feasibility of hepatitis C virus testing and linkage in community supervision offices: Great potential but persistent challenges

BACKGROUND

Persons involved with the justice system have an elevated risk of hepatitis C virus (HCV) yet remain marginalized from treatment. Efforts to eliminate HCV will require targeted interventions within the justice system effective at providing diagnosis and treatment.

METHODS

We implemented a novel HCV screening and treatment intervention for persons under community supervision in Rhode Island, USA during April 2018--March 2020. Participants received rapid point-of-care HCV antibody testing onsite and referral to community laboratory and treatment services as indicated. We assessed the HCV care cascade to identify areas for improvement.

RESULTS

Overall, 483 individuals were screened for HCV antibody; 85 (18%) were positive. A minority of participants with positive HCV antibody tests (n=25/85, 29%) presented to community laboratories for confirmatory testing. Among participants that received HCV viral load results and linked to a treatment provider (n=12), four initiated treatment, three had record of completing treatment, and two were confirmed to have achieved cure.

CONCLUSION

Linkage to HCV viral load testing and treatment was challenging in this community supervision population, with substantial loss to follow-up at each step of the HCV cascade. Community supervision remains an important venue for case identification but substantial barriers to accessing HCV treatment exist. Innovative HCV diagnosis and treatment strategies are needed for community supervision populations.

Hepatitis C Testing and Linkage to Care Among Adults on Probation in a Large US City

Background

Despite constituting the largest segment of the correctional population, individuals on probation remain largely unstudied with respect to hepatitis C virus (HCV) testing and linkage to care. We implemented an HCV testing and patient navigation program at an adult probation department.

Methods

Adults were tested at a local probation department with a rapid point-of-care HCV antibody (Ab) assay followed by a laboratory-based HCV ribonucleic acid (RNA) assay if anti-HCV positive. All individuals received counseling rooted in harm reduction principles. Individuals testing positive for HCV Ab were immediately linked to a patient navigator in person or via telephone. The patient navigator assisted patients through cure unless the patient was lost to follow-up. Study participation involved an optional survey and optional point-of-care human immunodeficiency virus test.

Results

Of 417 individuals tested, 13% were HCV Ab positive and 65% of those tested for HCV RNA (34 of 52) had detectable HCV RNA. Of the 14 individuals who linked to an HCV treatment provider, 4 completed treatment, as measured by pharmacy fill documentation in the electronic medical record, and 1 obtained sustained virologic response. One hundred ninety-three individuals tested for HIV; none tested positive.

Conclusions

The study cohort had a higher HCV seroprevalence than the general population (13% vs 2%), but linkage to care, completion of HCV treatment, and successful test-of-cure rates were all low. This study indicates that HCV disproportionately impacts adults on probation and prioritizing support for testing and linkage to care could improve health in this population. Colocalization of HCV treatment within probation programs would reduce the barrier of attending a new institution and could be highly impactful.

A randomized pilot study assessing the acceptability of rapid point-of-care hepatitis C virus (HCV) testing among male inmates in Montreal, Canada

BACKGROUND

The Oraquick^Ⓡ fingerprick point-of-care hepatitis C virus antibody (HCV-Ab) test is favoured to venipuncture among people who inject drugs; however, its acceptability in prison populations is unknown. We aimed to compare the acceptability of the Oraquick^Ⓡ versus standard venipuncture among people in prison.

METHODS

From October to December 2019, 280 sentenced male inmates at L'Établissement de Détention de Montréal (Quebec, Canada) were screened for participation, 150 excluded due to prior HCV screening, and 52 refused participation. The remaining 78 were randomized 1:1 to opt-out HCV-Ab screening with OraQuick^Ⓡ or venipuncture (n = 39 each). Acceptability was determined by the proportion accepting to undergo screening.

RESULTS

The majority of participants (median age 33 years) reported a history of drug use (76%; 8% injection drug use); 47% perceived their HCV risk to be moderate/high. All inmates randomized to Oraquick^Ⓡ accepted testing while 87% accepted venipuncture. Among those who accepted Oraquick^Ⓡ vs. venipuncture, 100% vs. 97% were satisfied with the test, 97% vs. 94% would recommend the same test, and 100% vs. 76% would choose the same test again.

CONCLUSION

Adult incarcerated men in Canada were both more likely to accept Oraquick^Ⓡ compared to venipuncture, and to choose Oraquick^Ⓡ for future HCV screening.

Influence of social determinants of health and substance use characteristics on persons who use drugs pursuit of care for hepatitis C virus infection

BACKGROUND

Social determinants of health (SDOH), i.e., social, behavioral and environmental factors, are increasingly recognized for their important influence on health outcomes. Data are limited on the influence of SDOH, substance use characteristics, and their interactions on pursuit of hepatitis C virus (HCV) care among individuals with opioid use disorder (OUD). Linkage to HCV care remains low in this population despite high HCV prevalence and incidence.

AIMS

To investigate the influence of SDOH, substance use factors, and their interactions on HCV treatment uptake among OUD patients in a methadone treatment program.

METHODS

Information on patient demographics, SDOH, substance use characteristics, and co-morbid medical conditions were obtained from the paper and electronic medical records of OUD patients on methadone. We applied multiple correspondence analysis, k-means algorithm, and logistic regression with least absolute shrinkage and selection operator penalty to identify variables and clusters associated with pursuit of HCV care.

RESULTS

Data from 161 patients (57% male, 60% Caucasian, mean age 45 years) were evaluated. Being employed, the absence of support systems, and a history of foster care were the strongest positive predictors of treatment pursuit. The use of crack/cocaine as the initial illicit substance, criminal activity without incarceration, and the absence of a family history of chemical dependency were the strongest negative predictors. We identified clusters among persons with OUD based upon their likelihood to pursue HCV management.

CONCLUSION

Utilizing data from the medical record, we were able to identify factors positively and negatively associated with linkage-to-care for HCV. We were also able to divide patients into clusters of factors associated with linkage-to-care for HCV. These results could be used to identify individuals with OUD based upon their readiness for HCV care.

Application of a discrete choice experiment approach to support the design of a hepatitis C testing service in primary care

BACKGROUND

Ascertaining the acceptability of healthcare provision to service users is an important factor in promoting service uptake, especially for populations who are reluctant to access care. This study identified the attributes of a Hepatitis C (HCV) testing service for people prescribed Opioid Substitution Therapy (OST) and used their expressed preferences to guide design of a service, using an applied health economics approach.

MATERIALS AND METHODS

Preferences of OST users were elicited using a discrete choice experiment. Important attributes for HCV testing were partly pre-determined by the research question and also identified using literature review and focus groups. Predetermined attributes included choice of provider and financial incentives. Other important attributes were place of testing; travel distance; attitudes and staff undertaking testing; waiting time for test results and incentive payment. The relative importance of defined attributes was assessed in 103 OST users attending 6 pharmacies from Dundee.

RESULTS

OST users preferred testing at their "own pharmacy", by their drug worker, followed by their general practitioner (GP). Use of another pharmacy was the least preferred option. Being treated with dignity and respect was valued most highly, with waiting time for test results and travel distance also important. Financial incentives were not considered important.

CONCLUSIONS

This study provides evidence that OST users prefer testing at their own pharmacy. The addition of a pharmacy to the providers offering HCV testing may increase uptake and support policies to eliminate HCV from our communities. Being treated with dignity and respect was highly valued and this suggests that testing uptake can be increased by developing positive relationships between OST users and test providers. Financial incentives were not found to be important.

Survey of programmatic experiences and challenges in delivery of hepatitis B and C testing in low- and middle-income countries

Background

There have been few reports on programmatic experience of viral hepatitis testing and treatment in resource-limited settings. To inform the development of the 2017 World Health Organization (WHO) viral hepatitis testing guidance and in particular the feasibility of proposed recommendations, we undertook a survey across a range of organisations engaged with hepatitis testing in low- and middle-income countries (LMICs). Our objective was to describe current hepatitis B and C testing practices across a range of settings in different countries, as well as key barriers or challenges encountered and proposed solutions to promote testing scale-up.

Methods

Hepatitis testing programmes in predominantly LMICs were identified from the WHO Global Hepatitis Programme contacts database and through WHO regional offices, and invited to participate. The survey comprised a six-part structured questionnaire: general programme information, description of hepatitis testing, treatment and care services, budget and funding, data on programme outcomes, and perceptions on key barriers encountered and strategies to address these.

Results

We interviewed 22 viral hepatitis testing programmes from 19 different countries. Nine were from the African region; 6 from the Western Pacific; 4 from South-East Asia; and 3 from Eastern Europe. All but four of the programmes were based in LMICs, and 10 (45.5%) were supported by non-governmental or international organizations. All but two programmes undertook targeted testing of specific affected populations such as people living with HIV, people who inject drugs, sex workers, health care workers, and pregnant women. Only two programmes focussed on routine testing in the general population. The majority of programmes were testing in hospital-based or other health facilities, particularly HIV clinics, and community-based testing was limited. Nucleic acid testing (NAT) for confirmation of HCV and HBV viraemia was available in only 30% and 18% of programmes, respectively. Around a third of programmes required some patient co-payment for diagnosis. The most commonly identified challenges in scale-up of hepatitis testing were: limited community awareness about viral hepatitis; lack of facilities or services for hepatitis testing; no access to low cost treatment, particularly for HCV; absence of national guidance and policies; no dedicated budget for hepatitis; and lack of trained health care and laboratory workers.

Conclusions

At this early stage in the global scale-up of testing for viral hepatitis, there is a wide variation in testing practices and approaches across different programmes. There remains limited access to NAT to confirm viraemia, and patient self-payment for testing and treatment is common. There was consensus from implementing organizations that scale-up of testing will require increased community awareness, health care worker training, development of national strategies and guidelines, and improved access to low cost NAT virological testing.

Electronic supplementary material

The online version of this article (10.1186/s12879-017-2767-0) contains supplementary material, which is available to authorized users.