Toward ending hepatitis C virus infection: What are the next steps?

Family medicine-directed hepatitis C care and barriers to treatment: a mixed-methods study

BACKGROUND

Antivirals for the treatment of hepatitis C virus (HCV) infection are effective, but many patients remain untreated and treatment is not yet routine in primary care. We evaluated the characteristics of patients who engaged in HCV treatment, and clinician perspectives on the barriers and facilitators to treatment.

METHODS

Our mixed-method, parallel-design study was conducted at a multisite primary care centre in downtown Toronto. In a retrospective chart review, we searched records from 2011 to 2017 to collect quantitative data, including HCV infection status and HCV treatment status. To contextualize the data, we conducted in-depth interviews with select physicians between Aug. 1 and Nov. 1, 2017, and analyzed the transcripts using content analysis.

RESULTS

Of the 40 381 charts reviewed, 727 patients (1.8%, 95% confidence interval [CI] 1.7%-1.9%) were infected with HCV, and 542 (74.6%) had HCV infection requiring treatment. Of those, 255 patients (47.0%) had engaged in treatment. Patients who had engaged in treatment were more likely to be male (odds ratio [OR] 1.63, 95% CI 1.10-2.42), older (OR 1.04 per year increase in age, 95% CI 1.02-1.05) and housed (OR 2.2, 95% CI 1.36-3.75), and they were more likely not to have engaged in injection drug use (OR 1.87, 95% CI 1.33-2.63). Based on interviews with 8 physicians, treatment barriers included a lack of knowledge about HCV treatment, concerns that patients would not adhere to medications and challenges related to medication access. Facilitators of treatment included access to specialist consultation, pharmacist support and primary care treatment guidelines. Common themes that emerged in both quantitative and qualitative components were the roles of unstable housing and intravenous drug use as barriers to engaging in and completing treatment.

INTERPRETATION

Our study captured provider-identified barriers to HCV care and the key factors related to retention in HCV care, including gender, age, housing status and experience with drug use. Successful primary-care-led HCV treatment programs may incorporate specialist and pharmacy support and focus on younger, female, underhoused populations and people who use drugs.

Hepatitis C virus infection in Saskatchewan First Nations communities: Challenges and innovations

Hepatitis C virus (HCV) infection has become a major public health issue in Canada, and especially in Saskatchewan First Nations (FNs) communities. One of the challenges in eliminating hepatitis C in Canada is accessing hard-to-reach populations, such as FNs people living on reserves. In Canada, HCV is a notifiable disease but complete and timely surveillance of HCV data is not always possible in remote communities. In addition, national surveillance data are insufficient for determining the number of cases of hepatitis C among FNs populations, because many provinces do not collect information according to ethnicity. Statistics for FN communities are available federally through the First Nations and Inuit Health Branch (FNIHB) in partnership with the communities and the province. There are multiple factors associated with the high rates of HCV in FNs communities, including barriers in accessing preventive services, early diagnosis and treatment. These access issues are largely attributable to issues with geographical remoteness, transportation, education and awareness, and a health care system designed around urban health. New and innovative ways of delivering information and services, such as the mobile hepatitis C clinic (Liver Health Days) and the community-driven Sexually Transmitted Bloodborne Infections (STBBI) Know Your Status program, are proving invaluable in remote FNs communities. Extending these in-community and community-driven programs to other FNs communities and to the prison population could be invaluable in working towards the World Health Organization elimination goals of hepatitis C virus for all.