Identifying barriers and facilitators of the inclusion of pregnant individuals in hepatitis C treatment programs in the United States

Hepatitis C virus detection and management after implementation of universal screening in pregnancy

BACKGROUND

Accurately identifying cases of hepatitis C virus has important medical and public health consequences. In the setting of rising hepatitis C virus prevalence and highly effective treatment with direct-acting antivirals, the Society for Maternal-Fetal Medicine guidelines recently changed to recommend universal screening for hepatitis C virus during pregnancy. However, there is little data on the influence of this policy change on case identification and management.

OBJECTIVE

We aimed to examine the influence of universal hepatitis C virus screening on our patient population. Our primary objective was to determine if there was a difference in the detected hepatitis C virus prevalence after the policy change. Our secondary objectives were to determine which factors were associated with a positive test for hepatitis C virus and to examine postpartum management of pregnant patients living with hepatitis C virus, including the (1) gastroenterology referral rate, (2) treatment rate, (3) infantile hepatitis C virus screening rate, and (4) factors associated with being referred for treatment.

STUDY DESIGN

We conducted a single-center, retrospective cohort study of deliveries that occurred before (July 2018-June 2020) and after (July 2020-December 2021) the implementation of universal hepatitis C virus screening. Information on hepatitis C virus and HIV status, if patients were screened for hepatitis C virus, history of intravenous drug use, and basic demographic information were abstracted from the electronic medical records. A subset of patients was administered a questionnaire regarding hepatitis C virus risk factors. For all patients who tested positive for hepatitis C virus, information on if they were referred for treatment in the postpartum period and if their infant was screened for hepatitis C virus were abstracted from the electronic medical records.

RESULTS

A total of 8973 deliveries occurred during this study period. A total of 71 (0.79%) patients had a detectable viral load. With implementation of universal screening, hepatitis C virus screening rates increased from 5.78% to 77.25% of deliveries (P<.01). The hepatitis C virus prevalence rates before and after universal screening was implemented were 0.78% and 0.81%, respectively (P=.88). There were significant demographic shifts in our pregnant population over this time period, including a reduction in intravenous drug use. A subset of 958 patients completed a hepatitis C virus risk factor questionnaire, in addition to undergoing universal hepatitis C virus screening. Ten patients screened positive with universal screening; only 8 of these individuals would have been identified with risk-based screening. Among the patients with a detectable viral load, 67.61% were referred for treatment and 18.75% were treated. A multivariate logistic regression model indicated that intravenous drug use was associated with significantly decreased odds of being referred for treatment (odds ratio, 0.14; 95% confidence interval, 0.04-0.59; P=.01). At the time of our evaluation, 52 infants were at least 18 months old and thus eligible for hepatitis C virus screening. Among these infants, 8 (15.38%) were screened for hepatitis C virus, and all were negative.

CONCLUSION

Following the practice shift, we saw a significant increase in hepatitis C virus screening during pregnancy. However, postpartum treatment and infant screening remained low. Intravenous drug use was associated with a decreased likelihood of being referred for treatment. Pregnancy represents a unique time for hepatitis C virus case identification, although better linkage to care is needed to increase postpartum treatment.

Barriers and facilitators of integrated hepatitis B, C, and HIV screening among pregnant mothers and their newborns attending maternal and newborn clinics in Koboko District, Uganda: A qualitative inquiry of providers' perspective

Background

HIV and HBV remain significant public health challenges characterized by high prevalence, morbidity, and mortality, especially among women of reproductive age in Uganda. However, both HIV and HBV patients are managed in separate clinics with separate staff even though they all receive ART. Patients with HBV do not receive routine counselling and education, and there are limited resources for laboratory investigation coupled with a high loss to follow-up. This study set out to "assess barriers and facilitators of integrated viral hepatitis B C and HIV care model to optimize screening uptake among mothers and newborns at health facilities in Koboko District, west Nile sub-region, Uganda".

Methods

A cross-sectional grounded theory qualitative approach was employed in an institutional setting (HC IIIs). Data was audio recorded using a recording device during the key informant interviews and was transcribed after all interviews were conducted. Data was then analyzed using framework analysis.

Results

The following facilitated integration: High prevalence, and therefore burden of hepatitis B infection in West Nile region, team spirit by the health workers, reduced long waiting time, availability of medical products such as HBV and HCV test kits, integration of HBV and HIV into HMIS2 form and availability of support from implementing partners such as Infectious Dease Institute which offered mentorship and training on integration and support supervision.

Conclusion

Barriers to integration included; knowledge gap among health care workers, lack of transport for patients, language barriers during health education, inadequate human resources for health, stock-out of testing kits for HBV and HCV, lack of HMIS 2 column to capture HCV data, lack of funds to facilitate follow up of patients after referral for further investigation upon suspected cases of HBV and HCV. The study participants recommended; Promoting the integration of HBV, HCV, and HIV into routine health services; ensuring a constant supply of HBV, and HCV test kits to avoid stock-out; Engaging VHTs/Community health volunteers to support follow-up of patients and conducting health care workers performance reviews; addressing the issue of inadequate human resource; and finally dealing with misconceptions at community level about HBV and HCV diseases which hinder access to services.