Disparities in Hepatitis C Linkage to Care in the Direct Acting Antiviral Era: Findings From a Referral Clinic With an Embedded Nurse Navigator Model

Socio-economic factors associated with loss to follow-up among individuals with HCV: A Dutch nationwide cross-sectional study

BACKGROUND AND AIMS

The path to hepatitis C virus (HCV) elimination is complicated by individuals who become lost to follow-up (LTFU) during care, particularly before receiving effective HCV treatment. We aimed to determine factors contributing to LTFU and whether LTFU is associated with mortality.

METHODS

In this secondary analysis, we constructed a database including individuals with HCV who were either LTFU (data from the nationwide HCV retrieval project, CELINE) or treated with directly acting antivirals (DAA) (data from Statistics Netherlands) between 2012 and 2019. This database was linked to mortality data from Statistics Netherlands. Determinants associated with being LTFU versus DAA-treated were assessed using logistic regression, and mortality rates were compared between groups using exponential survival models. These analyses were additionally stratified on calendar periods: 2012-2014, 2015-2017 and 2018-2019.

RESULTS

About 254 individuals, LTFU and 5547 DAA-treated were included. Being institutionalized (OR = 5.02, 95% confidence interval (CI) = 3.29-7.65), household income below the social minimum (OR = 1.96, 95% CI = 1.25-3.06), receiving benefits (OR = 1.74, 95% CI = 1.20-2.52) and psychiatric comorbidity (OR = 1.51, 95% CI = 1.09-2.10) were associated with LTFU. Mortality rates were significantly higher in individuals LTFU compared to those DAA-treated (2.99 vs. 1.15/100 person-years (PY), p < .0001), while in those DAA-treated, mortality rates slowly increased between 2012-2014 (.22/100PY) and 2018-2019 (2.25/100PY).

CONCLUSION

In the Netherlands, individuals who are incarcerated/institutionalized, with low household income, or with psychiatric comorbidities are prone to being LTFU, which is associated with higher mortality. HCV care needs to be adapted for these vulnerable individuals.

A novel, nurse-led 'one stop' clinic for patients with liver cirrhosis results in fewer liver-related unplanned readmissions and improved survival

OBJECTIVE

Delivering effective secondary preventive and integrated care has the potential to break the revolving-door phenomenon of frequent readmissions in patients with advanced chronic liver disease. To address this, we launched the Care Coordination of Liver Disease (CCoLD) pilot, a novel nurse-led cirrhosis clinic in Western Sydney.

METHODS AND ANALYSIS

Following an index presentation to Blacktown or Mount Druitt hospitals (BMDH), patients (n = 89, matched by age, sex, and MELD-NA) were consecutively either followed up by the CCoLD clinical nurse consultant (intervention cohort) or received standard care (control cohort). Controlled evaluation of the impact of the nurse-led clinic was carried out for a 3-month period including readmission rates, survival, and cost effectiveness.

RESULTS

The inaugural nurse-led clinic led to improvement in patient-level outcomes including a reduction in unplanned liver-related readmissions (2.08% for intervention cohort vs 12.2% for control cohort, p < 0.01), and mortality at 30 days (0% for intervention cohort vs 7.3% for control cohort, p = 0.03). Similar trends were observed at 90 days from index discharge. No deaths were observed in the intervention cohort as compared to the control cohort at 90 days (0% versus 7.3%, p = 0.03), while unplanned liver-related readmissions were 10.41% for the intervention cohort vs 19.5% for the control cohort (p = 0.115). Moreover, time to readmission was significantly longer in the intervention cohort, resulting in an overall cost-effective intervention.

CONCLUSION

These findings highlight the significant impact of optimised care-coordination. A nurse-led clinic can deliver patient-centred, goal-directed, and cost-effective secondary prevention and care. A multicentre randomised trial for wider evaluation of these findings is warranted.

Innovative Approaches to Engaging Homeless and Marginally Housed Patients in Care: a Case Study of Hepatitis C

BACKGROUND

Homeless and marginally housed (HAMH) individuals experience significant health disparities compared to housed counterparts, including higher hepatitis C virus (HCV) rates. New direct-acting antiviral (DAA) medications dramatically increased screening and treatment rates for HCV overall, but inequities persist for HAMH populations.

OBJECTIVE

This study examines the range of policies, practices, adaptations, and innovations implemented by Veteran Affairs Medical Centers (VAMCs) in response to Veterans Health Administration (VHA)'s 2016 HCV funding allocation to expand provision of HCV care.

DESIGN

Ethnographic site visits to six US VAMCs varying in size, location, and availability of Homeless Patient-Aligned Care Teams. Semi-structured qualitative interviews informed by the HCV care continuum were conducted with providers, staff, and HAMH patients to elicit experiences providing and receiving HCV care. Semi-structured field note templates captured clinical care observations. Interview and observation data were analyzed to identify cross-cutting themes and strategies supporting tailored HCV care for HAMH patients.

PARTICIPANTS

Fifty-six providers and staff working in HCV and/or homelessness care (e.g., infectious disease providers, primary care providers, social workers). Twenty-five patients with varying homeless experiences, including currently, formerly, or at risk of homelessness (n=20) and stably housed (n=5).

KEY RESULTS

All sites experienced challenges with continued engagement of HAMH individuals in HCV care, which led to the implementation of targeted care strategies to better meet their needs. Across sites, we identified 35 unique strategies used to find, engage, and retain HAMH individuals in HCV care.

CONCLUSIONS

Despite highly effective, widely available HCV treatments, HAMH individuals continue to experience challenges accessing HCV care. VHA's 2016 HCV funding allocation resulted in rapid adoption of strategies to engage and retain vulnerable patients in HCV treatment. The strategies identified here can help healthcare institutions tailor and target approaches to provide sustainable, high-quality, equitable care to HAMH individuals living with HCV and other chronic illnesses.

Risk factors for loss to follow-up after the start of direct-acting antiviral treatment for hepatitis C virus infection

Background and Aim

Direct-acting antivirals (DAAs) have recently been developed to treat hepatitis C virus (HCV) infection. Additionally, interferon-free DAA treatment has improved liver function and reduced the risk of hepatocellular carcinoma (HCC) following HCV eradication. Previous studies on HCV have focused mainly on the treatment rate and the risk of developing HCC, and less attention has been given to loss to follow-up (LTFU) after DAA treatment. Therefore, the present study aimed to identify the definitive risk factors for LTFU after the start of DAA treatment.

Methods

Between September 2017 and March 2022, 296 patients receiving glecaprevir and pibrentasvir for HCV infection were enrolled in this study. The incidence of LTFU following DAA treatment and the risk factors contributing to LTFU were identified using the patients' clinical characteristics.

Results

In the present study, 75 patients (25.3%) interrupted their follow-up visits. Multivariate logistic analysis revealed a history of injection drug use (hazard ratio [HR], 1.81; P = 0.017), treatment duration (8 weeks) (HR, 3.51; P = 0.0033), and age <70 years (HR, 1.9; P = 0.0422) as independent factors associated with LTFU after the start of DAA treatment.

Conclusion

Young patients and those with injection drug use are likely to discontinue their follow-up visits after the start of DAA treatment for HCV infection. Therefore, these patients require strict supervision.

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

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

Predictors of linkage to hepatitis C virus care among people living with HIV with hepatitis C infection and the impact of loss to HIV follow‐up

Objective

Half of the people living with HIV (PLWH) with hepatitis C virus (HCV) remain untreated for HCV. We examined predictors of HCV linkage to care among PLWH and the impact of HIV lost to care.

Design and methods

We conducted a retrospective review of PLWH/HCV from our HIV clinics between 2014 and 2017, and examined predictors of HCV linkage to care. We used the Kaplan–Meier method to estimate the probability of HIV retention and HCV linkage over time.

Results

Of 615 PLWH/HCV, 34% linked to HCV care and 21% were cured. Higher odds of linkage to HCV care were among blacks (adjusted odds ratio [aOR]: 2.95, 95% confidence interval [CI]: 1.59, 5.47), prior injection drug users (IDUs; aOR: 2.89, 95% CI: 1.39, 6.01), Medicare (aOR: 3.09, 95% CI: 1.56, 6.11), and cirrhotics (aOR: 2.80, 95% CI: 1.52, 5.14). Reduced odds for linkage were in active IDU (aOR: 0.16, 95% CI: 0.05, 0.45) and those seen by an advanced practice provider (aOR: 0.53, 95% CI: 0.30, 0.92). The main reason for failure to link to HCV care was lost to HIV care. At 3 years, the overall probability of being retained in HIV care was 53%; among those who had an HCV evaluation visit, it was 75% vs. 41% with no HCV evaluation visit. Accounting for loss to follow‐up, PLWH/HCV had a 65% probability of having an HCV evaluation at 3 years.

HCV is a curable infection in those with or without HIV. Yet, high proportions of people living with HIV with HCV remain untreated for HCV, leading to complications of liver disease and death. Our study found that only one‐third of HIV/HCV patients were linked to HCV care. The main reason for not linking to HCV care was that increasing numbers of patients drop out of HIV care over time. Our study suggests that early focus on HCV treatment would increase the number of patients cured, but it is unclear whether this would impact retention in HIV care.

Hepatitis C: Problems to extinction and residual hepatic and extrahepatic lesions after sustained virological response

Loss of follow-up or reinfections hinder the expectations of hepatitis C eradication despite the existence of highly effective treatments. Moreover, the elimination of the infection does not imply the reversion of those chronic alterations derived from the previous infection by hepatitis C virus (HCV). This review analyzes the risk factors associated with loss to follow-up in diagnosis or treatment, and the possibility of reinfection. Likewise, it assesses the residual alterations induced by chronic HCV infection considering the liver alterations (inflammation, fibrosis, risk of decompensation, hepatocellular carcinoma, liver transplantation) and, on the other hand, the comorbidities and extrahepatic manifestations (cryoglobulinemia, non-Hodgkin lymphoma, peripheral insulin resistance, and lipid, bone and cognitive alterations). Peculiarities present in subjects coinfected with human immunodeficiency virus are analyzed in each section.

Results of a Hepatitis C Micro-Elimination Program in Two Addiction Centers Among Subjects With Substance Use Disorder

Objectives:

We aimed to evaluate a hepatitis C (HCV) micro-elimination program in 2 addiction centers among subjects with substance use disorders (SUD).

Methods:

The program was based on simplifying the diagnosis of HCV infections by avoiding referral to primary care for the diagnosis and performing the necessary tests at the point of care (ie, the addition center) and simplifying the patient pathway by directly referring patients to the specialized care for treatment. Descriptive and multivariate analyses are presented.

Results:

Of the 1497 subjects included in the program, 327 reported that they were anti-HCV-positive. Among the 1170 patients who were offered the HCV rapid antibody test, 180 (15.4%) did not perform the test. Performing the HCV rapid antibody test only contributed ten patients (3%) to the 337 who were anti-HCV-positive. A high proportion (147 out of 327 [45%]) of subjects who reported being anti-HCV-positive also reported that they had not been treated for HCV. Among the 67 subjects who were HCV-RNA-positive and were referred for treatment, 53 (79%) ultimately received and completed antiviral treatment. Unfortunately, we did not find any factors associated with not performing dry blood testing, and the factors associated with not performing the HCV rapid antibody test were difficult to interpret, and the model showed low goodness of fit.

Conclusions:

Our results suggest that a micro-elimination program focused on patients with SUD attending an addiction center is not effective for screening the presence of hepatitis C but is successful for linking patients with hepatitis C to antiviral treatment.

Disparities in risk perception and low harm reduction services awareness, access, and utilization among young people with newly reported hepatitis C infections in California, 2018

Background

Newly reported hepatitis C virus (HCV) infections in California increased 50% among people 15–29 years of age between 2014 and 2016. National estimates suggest this increase was due to the opioid epidemic and associated increases in injection drug use. However, most of California’s 61 local health jurisdictions (LHJs) do not routinely investigate newly reported HCV infections, so these individuals’ risk factors for infection are not well understood. We sought to describe the demographics, risk behaviors, and utilization of harm reduction services in California’s fastest-rising age group of people with newly reported hepatitis C infections to support targeted HCV prevention and treatment strategies.

Methods

California Department of Public Health invited LHJs to participate in enhanced surveillance if they met criteria indicating heightened population risk for HCV infection among people ages 15–29. From June–December 2018, eight LHJs contacted newly reported HCV cases by phone using a structured questionnaire.

Results

Among 472 total HCV cases who met the inclusion criteria, 114 (24%) completed an interview. Twenty-seven percent of respondents (n = 31) had ever been incarcerated, of whom 29% received a tattoo/piercing and 39% injected drugs while incarcerated. Among people who injected drugs (PWID)—36% (n = 41) of all respondents—68% shared injection equipment and many lacked access to harm reduction services: 37% knew of or ever used a needle exchange and 44% ever needed naloxone during an overdose but did not have it. Heroin was the most frequently reported injected drug (n = 30), followed by methamphetamine (n = 18). Pre-diagnosis HCV risk perception varied significantly by PWID status and race/ethnicity: 76% of PWID vs. 8% of non-PWID (p < 0.001), and 44% of non-Hispanic White respondents vs. 22% of people of color (POC) respondents (p = 0.011), reported thinking they were at risk for HCV before diagnosis. Eighty-nine percent of all respondents reported having health insurance, although only two had taken HCV antiviral medications.

Conclusions

Among young people with HCV, we found limited pre-diagnosis HCV risk perception and access to harm reduction services, with racial/ethnic disparities. Interventions to increase harm reduction services awareness, access, and utilization among young PWID, especially young PWID of color, may be warranted.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11492-3.

Hepatitis C Micro-Elimination beyond Prison Walls: Navigator-Assisted Test-and-Treat Strategy for Subjects Serving Non-Custodial Sentences

BACKGROUND AND AIMS

The Spanish prison population includes two groups: people in prison and those who are serving non-custodial sentences. The latter has not yet been studied. This study aims to describe this population and the results of a test-and-treat strategy for hepatitis C including a holistic health assessment.

METHOD

This prospective study included all subjects serving non-custodial sentences at the Center for Social Integration. It was assisted by the medical team, a navigator, and a systematic screening of HCV (Hepatitis C Virus) performed by point-of-care tests. All cases with active infection are evaluated using telemedicine by a specialist to prescribe antiviral treatment. The navigator facilitates continuity for medical and social assistance.

RESULTS

The screening rate reached 92.8% (548/590). HCV seroprevalence and viraemia prevalence were 8% (44) and 2.9% (16), respectively. Regarding comorbidities: problems related to drug dependence were detected in 264 (48.2%), suspected serious mental disorder in 44 (8.3%), and previous stay in prison in 122 cases (22.2%). The navigator monitored 59 (15.2%) patients regarding HCV treatment or comorbidities. All patients (10/10) completing 12 weeks follow-up achieved sustained virological response.

CONCLUSIONS

The population serving non-custodial sentences is a challenging group with a high prevalence of HCV infection. Micro-elimination programs using point of care diagnostic tests, telemedicine, and a navigator are necessary in this underserved vulnerable population.

A Review of Chronic Comorbidities in Adults Living With HIV: State of the Science

ABSTRACT

People living with HIV are living longer, high-quality lives; however, as they age, this population is at increased risk for developing chronic comorbidities, including cardiovascular disease, certain types of cancer (e.g., lung, anal, and liver), and diabetes mellitus. The purpose of this state-of-the-science review is to provide an evidence-based summary on common physical comorbidities experienced by people living and aging with HIV. We focus on those chronic conditions that are prevalent and growing and share behavioral risk factors that are common in people living with HIV. We will discuss the current evidence on the epidemiology, physiology, prevention strategies, screening, and treatment options for people living with HIV across resource settings.

Linkage to specialty care in the hepatitis C care cascade

Quality gaps exist in the hepatitis C virus (HCV) care process from diagnosis to cure. To better understand current gaps and to identify targets for quality improvement, we constructed an HCV care cascade in a patient-centered medical home (PCMH) with an emphasis on the specialty referral process. We performed a retrospective study of HCV-infected patients in a PCMH using electronic health record (EPIC) data. Patients with a first positive HCV RNA between 2012 and 2019 were included. With an adaptation to analyze linkage to specialty care, we created an HCV care cascade that included the following: (1) a positive HCV RNA, (2) referral to a specialty provider, (3) a scheduled specialty appointment, (4) attendance at a specialty visit, (5) prescription for HCV therapy, and (6) evidence of sustained virological response (SVR). Patient and referring clinician characteristics were analyzed at each step of the care pathway, and the proportion of patients completing each step was calculated. Of the 256 HCV RNA-positive patients, 229 (89.5%) received a specialty referral; 215 (84.0%) had an appointment scheduled; 178 (69.5%) attended the specialty appointment; 116 (45.3%) were prescribed antiviral therapy; and 87 (34.1%) had documented SVR during the study period. Of the 178 patients attending a specialty visit, 62 (34.8%) did not receive a prescription, and the barrier most often noted was the desire for further workup (40.3%). Gaps occur at all stages of the HCV care continuum, with drop-offs in care occurring both before and after linkage to specialty care.

A qualitative study of perceived barriers to hepatitis C care among people who did not attend appointments in the non-urban US South

BACKGROUND

Most people diagnosed with hepatitis C virus (HCV) have not linked to care, despite the availability of safe and effective treatment. We aimed to understand why people diagnosed with HCV have not pursued care in the non-urban Southern United States.

METHODS

We conducted a survey and semi-structured interview with participants referred to an HCV clinic who did not attend an appointment between 2014 and 2018. Our clinic is located in a non-urban region of Virginia at a university hospital. Qualitative data collection was guided by the Health Belief Model (HBM). Data was analyzed using qualitative content analysis to identify key factors influencing patient perceptions regarding HCV and pursuit of care.

RESULTS

Over half of previously referred patients (N = 200) could not be reached by phone. Eleven participants enrolled, including 7 men and 4 women. Based on survey responses, unreliable transportation, unstable housing, substance use, and lack of insurance were common. Participants demonstrated good knowledge of HCV disease, complications, and treatment. On qualitative analysis of semi-structured interviews, final themes emerged from within and between HBM constructs. Emerging themes influencing patient perceptions included (1) structural barriers, (2) stigma, (3) prior experiences of HCV disease and treatment, (4) discordance between the recognized severity of HCV and expected impacts on one's own health, and (5) patient-provider relationship. Substance use was not identified to be a barrier to care.

CONCLUSIONS

Participants perceived individual and structural barriers to linking to care. A strong HCV knowledge base was not sufficient to motivate pursuit of care. Efforts to improve linkage to care must address barriers at multiple levels, and system-level changes are needed. As the majority of previously referred patients could not be contacted by phone, current approaches to patient engagement are not effective for reaching these populations. Expansion of HCV care to primary care settings with an established patient-provider relationship or co-located treatment within substance use treatment programs may serve to increase access to HCV treatment.

Development of an Interdisciplinary Telehealth Model of Provider Training and Comprehensive Care for Hepatitis C and Opioid Use Disorder in a High-Burden Region

BACKGROUND

Hepatitis C virus (HCV) and the opioid epidemic disproportionately affect the Appalachian region. Geographic and financial barriers prevent access to specialty care. Interventions are needed to address the HCV-opioid syndemic in this region.

METHODS

We developed an innovative, collaborative telehealth model in Southwest Virginia featuring bidirectional referrals from and to comprehensive harm reduction (CHR) programs and office-based opioid therapy (OBOT), as well as workforce development through local provider training in HCV management. We aimed to (1) describe the implementation process of provider training and (2) assess the effectiveness of the telehealth model by monitoring patient outcomes in the first year.

RESULTS

The provider training model moved from a graduated autonomy model with direct specialist supervision to a 1-day workshop with parallel tracks for providers and support staff followed by monthly case conferences. Forty-four providers and support staff attended training. Eight providers have begun treating independently. For the telehealth component, 123 people were referred, with 62% referred from partner OBOT or CHR sites; 103 (84%) attended a visit, 93 (76%) completed the treatment course, and 61 (50%) have achieved sustained virologic response. Rates of sustained virologic response did not differ by receipt of treatment for opioid use disorder.

CONCLUSIONS

Providers demonstrated a preference for an in-person training workshop, though further investigation is needed to determine why only a minority of those trained have begun treating HCV independently. The interdisciplinary nature of this program led to efficient treatment of hepatitis C in a real-world population with a majority of patients referred from OBOTs and CHR programs.