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Etoori D, Cococcia S, Srivastava A, Flanagan S, Nixon G, Bobba S, Warner A, Sennett K, Sabin C, Morgan S, Rosenberg WM. The Camden and Islington Viral Hepatitis Identification Tool (CIVHIT): Use of a Clinical Database Case-Finding Tool for Hepatitis B, Hepatitis C and HIV in Primary Care. J Viral Hepat 2025; 32:e14027. [PMID: 39445612 PMCID: PMC11883453 DOI: 10.1111/jvh.14027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 09/05/2024] [Accepted: 10/07/2024] [Indexed: 10/25/2024]
Abstract
Despite the availability of effective treatment and vaccines for hepatitis B virus (HBV) and C virus (HCV), many people are still infected and remain unaware of their infection. The Camden and Islington Viral Hepatitis Identification Tool (CIVHIT), a computer-based search tool, was introduced in 60 general practices (GPs) in April 2014 to support identification, testing and treatment of individuals at high risk for blood-borne viruses (BBVs). CIVHIT searched electronic medical records (EMRs), flagging all those with codes linked to risk factors or medical conditions associated with BBVs. CIVHIT was associated with a 78.5% increase in BBV tests in primary care in both boroughs. This translated to a 55.8% rise in new diagnoses. HBV testing saw the largest increase resulting in twice as many people diagnosed. Only 23.2% of HBV and 14.9% of HCV-positive tests were referred to secondary care. In an index practice, the most common flag was a history of STIs (477/719, 66.3%). Individuals with previous or current drug use and those with a known hepatitis contact were more likely to be offered a test compared to those flagged due to a history of STI. HIV and HBV testing was lower in males following a test offer. There was an increased likelihood of testing for HBV and HCV with increasing age. Additionally, individuals with previous or current drug use and individuals with a known hepatitis contact were more likely to test for HCV compared to individuals flagged due to STI history. CIVHIT shows promise to assist with the elimination of BBVs.
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Affiliation(s)
- David Etoori
- National Institute for Health and Care Research (NIHR) Health Protection Research Unit (HPRU) in Blood‐Borne and Sexually Transmitted Infections at UCL in Partnership With the UK Health Security Agency (UKHSA), Royal Free CampusLondonUK
| | - Sara Cococcia
- Division of Medicine & Royal Free London NHS Foundation Trust, Institute for Liver and Digestive HealthUniversity College LondonLondonUK
- Gastroenterology and Endoscopy UnitCardinal Massaia HospitalAstiItaly
| | - Ankur Srivastava
- Division of Medicine & Royal Free London NHS Foundation Trust, Institute for Liver and Digestive HealthUniversity College LondonLondonUK
| | | | - Grainne Nixon
- North‐East & Central London Health Protection Team, Public Health EnglandLondonUK
| | - Satya Bobba
- North Central London Integrated Care System, Laylock PDCLondonUK
| | | | | | - Caroline Sabin
- National Institute for Health and Care Research (NIHR) Health Protection Research Unit (HPRU) in Blood‐Borne and Sexually Transmitted Infections at UCL in Partnership With the UK Health Security Agency (UKHSA), Royal Free CampusLondonUK
| | - Sarah Morgan
- North Central London Integrated Care System, Laylock PDCLondonUK
- Hampstead Group PracticeLondonUK
| | - William M. Rosenberg
- National Institute for Health and Care Research (NIHR) Health Protection Research Unit (HPRU) in Blood‐Borne and Sexually Transmitted Infections at UCL in Partnership With the UK Health Security Agency (UKHSA), Royal Free CampusLondonUK
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Ward Z, Simmons R, Fraser H, Trickey A, Kesten J, Gibson A, Reid L, Cox S, Gordon F, Mc Pherson S, Ryder S, Vilar J, Miners A, Williams J, Emmanouil B, Desai M, Coughlan L, Harris R, Foster GR, Hickman M, Mandal S, Vickerman P. Impact and cost-effectiveness of scaling up HCV testing and treatment strategies for achieving HCV elimination among people who inject drugs in England: a mathematical modelling study. THE LANCET REGIONAL HEALTH. EUROPE 2025; 49:101176. [PMID: 39759576 PMCID: PMC11699733 DOI: 10.1016/j.lanepe.2024.101176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2024] [Revised: 11/24/2024] [Accepted: 11/28/2024] [Indexed: 01/07/2025]
Abstract
Background England aims to reach the World Health Organization (WHO) elimination target of decreasing HCV incidence among people who inject drugs (PWID) to <2 per 100 person-years (/100pyrs) by 2030. We assessed what testing and treatment strategies will achieve this target and whether they are cost-effective. Methods A dynamic deterministic HCV transmission model among PWID was developed for four England regions, utilising data on the scale-up of HCV treatment among PWID in prisons, drug treatment centres (DTC, where opioid agonist therapy is provided), and any other setting (e.g., primary care). The model projected whether the elimination target will be reached with existing testing and treatment initiatives ('status quo' model, SQ), or whether improvements are needed from 2024. Cost data was collated through practitioners' interviews and published literature. The mean incremental cost-effectiveness ratio (ICER per quality adjusted life year (QALY) saved, 50-year time horizon; 3.5% discount rate) of SQ (assumes counterfactual of no treatment scale-up post-2015) and improved model (counterfactual: SQ model) was compared to a willingness-to-pay threshold of £20,000/QALY saved. Findings The SQ model projects HCV incidence will decrease by 79.7-98.6% (range of medians) over 2015-2030 to 0.2-2.2/100pyrs, with an ICER of £308-1609/QALY saved across the regions. There is >80% probability of achieving the incidence target in three regions, and 40% probability in the other region. If annual testing in DTC increases to 80% (from 27%) or 75% of people get tested during their prison stay (from 55%) from 2024 in the lower impact region, then their probability increases to >65%, with both strategies being highly cost-effective. Interpretation Many England regions could reach the WHO HCV elimination target by 2030 under existing testing and treatment pathways. Scaling up of testing in DTC or prisons will help achieve this target and is highly cost-effective. Funding NIHR.
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Affiliation(s)
- Zoe Ward
- Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Hannah Fraser
- Bristol Medical School, University of Bristol, Bristol, UK
- The National Institute for Health and Care Research (NIHR) Health Protection Research Unit (HPRU) in Behavioural Science and Evaluation, University of Bristol, Bristol, UK
| | - Adam Trickey
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Jo Kesten
- Bristol Medical School, University of Bristol, Bristol, UK
- The National Institute for Health and Care Research (NIHR) Health Protection Research Unit (HPRU) in Behavioural Science and Evaluation, University of Bristol, Bristol, UK
- The National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | | | | | - Sean Cox
- The Hepatitis C Trust, London, UK
| | | | | | - Stephen Ryder
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Javier Vilar
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Alec Miners
- London School of Hygiene and Tropical Medicine, London, UK
| | - Jack Williams
- London School of Hygiene and Tropical Medicine, London, UK
| | | | | | | | | | | | - Matthew Hickman
- Bristol Medical School, University of Bristol, Bristol, UK
- The National Institute for Health and Care Research (NIHR) Health Protection Research Unit (HPRU) in Behavioural Science and Evaluation, University of Bristol, Bristol, UK
| | | | - Peter Vickerman
- Bristol Medical School, University of Bristol, Bristol, UK
- The National Institute for Health and Care Research (NIHR) Health Protection Research Unit (HPRU) in Behavioural Science and Evaluation, University of Bristol, Bristol, UK
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Etoori D, Simmons R, Desai M, Foster GR, Stuart A, Sabin C, Mandal S, Rosenberg W. Results from a retrospective case finding and re-engagement exercise for people previously diagnosed with hepatitis C virus to increase uptake of directly acting antiviral treatment. BMC Public Health 2024; 24:2427. [PMID: 39243047 PMCID: PMC11378625 DOI: 10.1186/s12889-024-19919-3] [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: 11/14/2023] [Accepted: 08/28/2024] [Indexed: 09/09/2024] Open
Abstract
BACKGROUND Direct acting antivirals (DAAs) for the Hepatitis C virus (HCV) have shifted the World Health Organisation global strategic focus to the elimination of HCV by 2030. In England, the UK Health Security Agency (UKHSA) led a national 'patient re-engagement exercise', using routine surveillance data, which was delivered through the HCV Operational Delivery Networks (ODNs) with support from National Health Service England (NHSE), to help find and support people with a positive HCV PCR test result to access treatment. We report a quantitative evaluation of outcomes of this exercise. METHODS Individuals with a recorded positive HCV antibody or PCR result between 1996 and 2017 were identified using UKHSA's records of HCV laboratory diagnosis. Linkage with established health-care datasets helped to enhance patient identification and minimise attempts to contact deceased or previously treated individuals. From September to November 2018 each ODN was provided with a local list of diagnosed individuals. ODNs were asked to perform further data quality checks through local systems and then write to each individual's GP to inform them that the individual would be contacted by the ODN to offer confirmatory HCV PCR testing, assessment and treatment unless the GP advised otherwise. Outcomes of interest were receipt of treatment, a negative PCR result, and death. Data were collected in 2022. RESULTS Of 176,555 individuals with a positive HCV laboratory report, 55,329 individuals were included in the exercise following linkage to healthcare datasets and data reconciliation. Participants in the study had a median age of 51 years (IQR: 43, 59), 36,779 (66.5%) were males, 47,668 (86.2%) were diagnosed before 2016 and 11,148 (20.2%) lived in London. Of the study population, 7,442 (13.4%) had evidence of treatment after the re-engagement exercise commenced, 6,435 (11.6%) were reported as PCR negative (96% had no previous treatment records), 4,195 (7.6%) had prescription data indicating treatment before the exercise commenced or were reported to have been treated previously by their ODN, and 2,990 (5.4%) had died. The status of 32,802 (59.3%) people remains unknown. CONCLUSIONS A substantial number of those included had treatment recorded after the exercise commenced, however, many more remain unengaged. Evaluation of the exercise highlighted areas that could be streamlined to improve future exercises.
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Affiliation(s)
- David Etoori
- Centre for Clinical Research, Epidemiology, Modelling and Evaluation (CREME), Institute for Global Health, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK.
- National Institute for Health and Care Research (NIHR) Health Protection Research Unit (HPRU) in Blood-borne and Sexually Transmitted Infections at UCL in partnership with the UK Health Security Agency (UKHSA), Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK.
| | - Ruth Simmons
- National Institute for Health and Care Research (NIHR) Health Protection Research Unit (HPRU) in Blood-borne and Sexually Transmitted Infections at UCL in partnership with the UK Health Security Agency (UKHSA), Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
- Sexually Transmitted Infections and HIV Division, Blood Safety, Health Security Agency, 61 Colindale Avenue, NW9 5EQ, Hepatitis, London, UK
| | - Monica Desai
- National Institute for Health and Care Research (NIHR) Health Protection Research Unit (HPRU) in Blood-borne and Sexually Transmitted Infections at UCL in partnership with the UK Health Security Agency (UKHSA), Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
- Sexually Transmitted Infections and HIV Division, Blood Safety, Health Security Agency, 61 Colindale Avenue, NW9 5EQ, Hepatitis, London, UK
| | | | - Avelie Stuart
- Sexually Transmitted Infections and HIV Division, Blood Safety, Health Security Agency, 61 Colindale Avenue, NW9 5EQ, Hepatitis, London, UK
| | - Caroline Sabin
- Centre for Clinical Research, Epidemiology, Modelling and Evaluation (CREME), Institute for Global Health, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
- National Institute for Health and Care Research (NIHR) Health Protection Research Unit (HPRU) in Blood-borne and Sexually Transmitted Infections at UCL in partnership with the UK Health Security Agency (UKHSA), Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Sema Mandal
- National Institute for Health and Care Research (NIHR) Health Protection Research Unit (HPRU) in Blood-borne and Sexually Transmitted Infections at UCL in partnership with the UK Health Security Agency (UKHSA), Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
- Sexually Transmitted Infections and HIV Division, Blood Safety, Health Security Agency, 61 Colindale Avenue, NW9 5EQ, Hepatitis, London, UK
| | - William Rosenberg
- National Institute for Health and Care Research (NIHR) Health Protection Research Unit (HPRU) in Blood-borne and Sexually Transmitted Infections at UCL in partnership with the UK Health Security Agency (UKHSA), Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
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Gliddon HD, Ward Z, Heinsbroek E, Croxford S, Edmundson C, Hope VD, Simmons R, Mitchell H, Hickman M, Vickerman P, Stone J. Has the HCV cascade of care changed among people who inject drugs in England since the introduction of direct-acting antivirals? THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024:104324. [PMID: 38218700 PMCID: PMC7616700 DOI: 10.1016/j.drugpo.2024.104324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 12/31/2023] [Accepted: 01/03/2024] [Indexed: 01/15/2024]
Abstract
BACKGROUND In England, over 80 % of those with hepatitis C virus (HCV) infection have injected drugs. We quantified the HCV cascade of care (CoC) among people who inject drugs (PWID) in England and determined whether this improved after direct-acting antivirals (DAAs) were introduced. METHODS We analysed data from nine rounds of national annual cross-sectional surveys of PWID recruited from drug services (2011-2019; N = 12,320). Study rounds were grouped as: 'Pre-DAAs' (2011-2014), 'Prioritised DAAs' (2015-2016) and 'Unrestricted DAAs' (2017-2019). Participants were anonymously tested for HCV antibodies and RNA and completed a short survey. We assessed the proportion of PWID recently (current/previous year) tested for HCV. For participants ever HCV treatment eligible (past chronic infection with history of treatment or current chronic infection), we assessed the CoC as: HCV testing (ever), received a positive test result, seen a specialist nurse/doctor, and ever treated. We used logistic regression to determine if individuals progressed through the CoC differently depending on time-period, whether time-period was associated with recent testing (all participants) and lifetime HCV treatment (ever eligible participants), and predictors of HCV testing and treatment in the Unrestricted DAAs period. RESULTS The proportion of ever HCV treatment eligible PWID reporting lifetime HCV treatment increased from 12.5 % in the Pre-DAAs period to 25.6 % in the Unrestricted DAAs period (aOR:2.40, 95 %CI:1.95-2.96). There were also increases in seeing a specialist nurse/doctor. The largest loss in the CoC was at treatment for all time periods. During the Unrestricted DAAs period, recent (past year) homelessness (vs never, aOR:0.66, 95 %CI:0.45-0.97), duration of injecting (≤3 years vs >3 years; aOR:0.26, 95 %CI:0.12-0.60), never (vs current, aOR:0.31, 95 %CI:0.13-0.75) or previously being prescribed OAT (vs current, aOR:0.67, 95 %CI:0.47-0.95), and never using a NSP (vs past year, aOR:0.27, 95 %CI:0.08-0.89) were negatively associated with lifetime HCV treatment. The proportion of PWID reporting recent HCV testing was higher during Unrestricted DAAs (56 %) compared to Pre-DAAs (48 %; aOR:1.28, 95 %CI:1.06-1.54). CONCLUSION COC stages from seeing a specialist onwards improved after DAAs became widely available. Further improvements in HCV testing are needed to eliminate HCV in England.
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Affiliation(s)
- H D Gliddon
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom; National Public Health Specialty Training Programme, South West, United Kingdom
| | - Z Ward
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom; NIHR Health Protection Research Unit in Behavioural Science and Evaluation at University of Bristol, United Kingdom
| | - E Heinsbroek
- Blood Safety, Hepatitis, Sexually Transmitted Infections and HIV Service, UK Health Security Agency, London, United Kingdom
| | - S Croxford
- National Public Health Speciality Training Programme, West Midlands, United Kingdom
| | - C Edmundson
- Blood Safety, Hepatitis, Sexually Transmitted Infections and HIV Service, UK Health Security Agency, London, United Kingdom
| | - V D Hope
- Public Health Institute, Liverpool John Moores University, Liverpool, United Kingdom
| | - R Simmons
- Blood Safety, Hepatitis, Sexually Transmitted Infections and HIV Service, UK Health Security Agency, London, United Kingdom
| | - H Mitchell
- Blood Safety, Hepatitis, Sexually Transmitted Infections and HIV Service, UK Health Security Agency, London, United Kingdom
| | - M Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom; NIHR Health Protection Research Unit in Behavioural Science and Evaluation at University of Bristol, United Kingdom
| | - P Vickerman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom; NIHR Health Protection Research Unit in Behavioural Science and Evaluation at University of Bristol, United Kingdom
| | - J Stone
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom; NIHR Health Protection Research Unit in Behavioural Science and Evaluation at University of Bristol, United Kingdom.
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Nardone A, Nerlander L, Duffell E, Valenciano M, Buti M, Marcos-Fosch C, Nemeth-Blažić T, Popovici O, Vince A, Filip PV, Filipec T, Kosanović Ličina ML, Luksic B, Nonković D, Pop CS, Radu F, Teodorescu I, Topan AV. A pilot sentinel surveillance system to monitor treatment and treatment outcomes of chronic hepatitis B and C infections in clinical centres in three European countries, 2019. Euro Surveill 2023; 28:2200184. [PMID: 36757314 PMCID: PMC9912376 DOI: 10.2807/1560-7917.es.2023.28.6.2200184] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
Abstract
BackgroundThe World Health Organization European Action Plan 2020 targets for the elimination of viral hepatitis are that > 75% of eligible individuals with chronic hepatitis B (HBV) or hepatitis C (HCV) are treated, of whom > 90% achieve viral suppression.AimTo report the results from a pilot sentinel surveillance to monitor chronic HBV and HCV treatment uptake and outcomes in 2019.MethodsWe undertook retrospective enhanced data collection on patients with a confirmed chronic HBV or HCV infection presenting at one of seven clinics in three countries (Croatia, Romania and Spain) for the first time between 1 January 2019 and 30 June 2019. Clinical records were reviewed from date of first attendance to 31 December 2019 and data on sociodemographics, clinical history, laboratory results, treatment and treatment outcomes were collected. Treatment eligibility, uptake and case outcome were assessed.ResultsOf 229 individuals with chronic HBV infection, treatment status was reported for 203 (89%). Of the 80 individuals reported as eligible for treatment, 51% (41/80) were treated of whom 89% (33/37) had achieved viral suppression. Of 240 individuals with chronic HCV infection, treatment status was reported for 231 (96%). Of 231 eligible individuals, 77% (179/231) were treated, the majority of whom had received direct acting antivirals (99%, 174/176) and had achieved sustained virological response (98%, 165/169).ConclusionTreatment targets for global elimination were missed for HBV but not for HCV. A wider European implementation of sentinel surveillance with a representative sample of sites could help monitor progress towards achieving hepatitis control targets.
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Affiliation(s)
| | - Lina Nerlander
- European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden
| | - Erika Duffell
- European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden
| | | | - Maria Buti
- Hospital Universitario Valle Hebrón & CIBEREHD del Instituto Carlos III, Barcelona, Spain
| | - Cristina Marcos-Fosch
- Hospital Universitario Valle Hebrón & CIBEREHD del Instituto Carlos III, Barcelona, Spain
| | | | | | - Adriana Vince
- University Hospital for Infectious Diseases, Medical School University of Zagreb, Croatia
| | | | - Tajana Filipec
- Clinical Hospital Merkur, School of Medicine, University of Zagreb, Zagreb, Croatia
| | | | - Boris Luksic
- Clinical Hospital Centre Split, School of Medicine University of Split, Split, Croatia
| | - Diana Nonković
- Teaching Institute of Public Health Split and Dalmatia county, University Department of Health Studies, Split, Croatia
| | | | - Fabiana Radu
- University Emergency Hospital, Bucharest, Romania
| | | | - Adriana Violeta Topan
- “Iuliu Hatieganu” University of Medicine and Pharmacy, Hospital of Infectious Diseases, Cluj-Napoca, Romania
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Huang MH, Sun HY, Ho SY, Chang SY, Hsieh SM, Sheng WH, Chuang YC, Huang YS, Su LH, Liu WC, Su YC, Hung CC. Recently acquired hepatitis C virus infection among people living with human immunodeficiency virus at a university hospital in Taiwan. World J Gastroenterol 2021; 27:6277-6289. [PMID: 34712032 PMCID: PMC8515799 DOI: 10.3748/wjg.v27.i37.6277] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 07/13/2021] [Accepted: 09/02/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Little is known about the engagement in hepatitis C virus (HCV) care and completion of HCV treatment in people living with human immunodeficiency virus (HIV) (PLWH) who have HCV coinfection in the Asia-Pacific region. Examining the HCV care cascade can identify barriers to the completion of HCV treatment and facilitate achievement of HCV micro-elimination in PLWH.
AIM To investigate the care cascade of incident HCV infections among PLWH in Taiwan.
METHODS PLWH with incident HCV infections, defined as HCV seroconversion, were retrospectively identified by sequential anti-HCV testing of all archived blood samples at National Taiwan University Hospital between 2011 and 2018. All PLWH with incident HCV infections were followed until December 31, 2019. The care cascade of HCV examined included all incident HCV-infected patients, the percentages of anti-HCV antibodies detected by HIV-treating physicians in clinical care, plasma HCV RNA load tested, HCV RNA positivity diagnosed, referral to treatment assessment made, anti-HCV treatment initiated, and sustained virologic response achieved. Those who had HCV seroconversion during the interferon (IFN) era (2011–2016) and the direct-acting antiviral (DAA) era (2017–2018) were analyzed separately. The duration of HCV viremia—from the date of seroconversion to viral clearance by treatments or until the end of observation—and the incidence of sexually transmitted infections (STIs) during the HCV viremic period were estimated.
RESULTS During the study period, 287 of 3495 (8.2%) PLWH (92.3% being men who have sex with men) who were HCV-seronegative at baseline developed HCV seroconversion by retrospective testing of all archived blood samples. Of the 287 incident HCV infections, 277 (96.5%) had anti-HCV antibodies detected by HIV-treating physicians, 270 (94.1%) had plasma HCV RNA determined and 251 (87.5%) tested positive for HCV RNA. Of those with HCV viremia, 226 (78.7%) were referred to treatment assessment, 215 (74.9%) initiated anti-HCV treatment, and 202 (70.4%) achieved viral clearance. Compared with that in the IFN era, the median interval from HCV seroconversion by retrospective testing to detection of HCV seropositivity by HIV-treating physicians was significantly shorter in the DAA era {179 d [interquartile range (IQR) 87-434] vs 92 d (IQR 57-173); P < 0.001}. The incidence rate of STIs in the DAA vs the IFN era was 50.5 per 100 person-years of follow-up (PYFU) and 38.5 per 100 PYFU, respectively, with an incidence rate ratio of 1.31 (95% confidence interval 0.96-1.77), while the duration of HCV viremia was 380 d (IQR 274-554) and 735 d (IQR 391-1447) (P < 0.001), respectively.
CONCLUSION While anti-HCV therapies are effective in achieving viral clearance, our study suggests more efforts are needed to expedite the linkage of PLWH diagnosed with incident HCV infections to HCV treatment.
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Affiliation(s)
- Miao-Hui Huang
- Department of Internal Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien 970410, Taiwan
| | - Hsin-Yun Sun
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei 100008, Taiwan
| | - Shu-Yuan Ho
- Department of Laboratory Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei 100008, Taiwan
| | - Sui-Yuan Chang
- Department of Laboratory Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei 100008, Taiwan
- Department of Clinical Laboratory Sciences and Medical Biotechnology, National Taiwan University College of Medicine, Taipei 100233, Taiwan
| | - Szu-Min Hsieh
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei 100008, Taiwan
| | - Wang-Huei Sheng
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei 100008, Taiwan
| | - Yu-Chung Chuang
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei 100008, Taiwan
| | - Yu-Shan Huang
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei 100008, Taiwan
| | - Li-Hsin Su
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei 100008, Taiwan
| | - Wen-Chun Liu
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei 100008, Taiwan
| | - Yi-Ching Su
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei 100008, Taiwan
| | - Chien-Ching Hung
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei 100008, Taiwan
- Department of Tropical Medicine and Parasitology, National Taiwan University College of Medicine, Taipei 100233, Taiwan
- Department of Medical Research, China Medical University Hospital and China Medical University, Taichung 404394, Taiwan
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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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French hepatitis C care cascade: substantial impact of direct-acting antivirals, but the road to elimination is still long. BMC Infect Dis 2020; 20:759. [PMID: 33059617 PMCID: PMC7559725 DOI: 10.1186/s12879-020-05478-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 10/05/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Hepatitis C virus (HCV) elimination by 2030, as targeted by the World Health Organization (WHO), requires that 90% of people with chronic infection be diagnosed and 80% treated. We estimated the cascade of care (CoC) for chronic HCV infection in mainland France in 2011 and 2016, before and after the introduction of direct-acting antivirals (DAAs). METHODS The numbers of people (1) with chronic HCV infection, (2) aware of their infection, (3) receiving care for HCV and (4) on antiviral treatment, were estimated for 2011 and 2016. Estimates for 1) and 2) were based on modelling studies for 2011 and on a virological sub-study nested in a national cross-sectional survey among the general population for 2016. Estimates for 3) and 4) were made using the National Health Data System. RESULTS Between 2011 and 2016, the number of people with chronic HCV infection decreased by 31%, from 192,700 (95% Credibility interval: 150,900-246,100) to 133,500 (95% Confidence interval: 56,900-312,600). The proportion of people aware of their infection rose from 57.7 to 80.6%. The number of people receiving care for HCV increased by 22.5% (representing 25.7% of those infected in 2016), while the number of people on treatment increased by 24.6% (representing 12.1% of those infected in 2016). CONCLUSIONS This study suggests that DAAs substantially impact CoC. However, access to care and treatment for infected people remained insufficient in 2016. Updating CoC estimates will help to assess the impact of new measures implemented since 2016 as part of the goal to eliminate HCV.
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HEPCARE EUROPE- A case study of a service innovation project aiming at improving the elimination of HCV in vulnerable populations in four European cities. Int J Infect Dis 2020; 101:374-379. [PMID: 32992012 DOI: 10.1016/j.ijid.2020.09.1445] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 09/18/2020] [Accepted: 09/22/2020] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES Hepatitis C Virus (HCV) is a significant cause of chronic liver disease. Among at-risk populations, access to diagnosis and treatment is challenging. We describe an integrated model of care, Hepcare Europe, developed to address this challenge. METHODS Using a case-study approach, we describe the cascade of care outcomes at all sites. Cost analyses estimated the cost per person screened and linked to care. RESULTS A total of 2608 participants were recruited across 218 clinical sites. HCV antibody test results were obtained for 2568(98•5%); 1074(41•8%) were antibody-positive, 687(60•5%) tested positive for HCV-RNA, 650(60•5%) were linked to care, and 319(43•5%) started treatment. 196(61•4%) of treatment initiates achieved a Sustained Viral Response (SVR) at dataset closure, 108(33•9%) were still on treatment, eight (2•7%) defaulted from treatment, and seven (2•6%) had virologic failure or died. The cost per person screened varied from €194 to €635, while the cost per person linked to care varied from €364 to €2035. CONCLUSIONS Hepcare enhanced access to HCV treatment and cure, and costs were affordable in all settings, offering a framework for scale-up and reproducibility.
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Ward Z, Reynolds R, Campbell L, Martin NK, Harrison G, Irving W, Hickman M, Vickerman P. Cost-effectiveness of the HepCATT intervention in specialist drug clinics to improve case-finding and engagement with HCV treatment for people who inject drugs in England. Addiction 2020; 115:1509-1521. [PMID: 31984606 PMCID: PMC10762643 DOI: 10.1111/add.14978] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 10/04/2019] [Accepted: 01/17/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND AIMS People who inject drugs (PWID) are at high risk of hepatitis C virus (HCV) infection; however, ~50% are undiagnosed in England and linkage-to-care is poor. This study investigated the cost-effectiveness of an intervention (HepCATT) to improve case-finding and referral to HCV treatment compared with standard-of-care pathways in drug treatment centres in England. DESIGN HCV transmission and disease progression model with cost-effectiveness analysis using a health-care perspective. Primary outcome and cost data from the HepCATT study parameterized the intervention, suggesting that HepCATT increased HCV testing in drug treatment centres 2.5-fold and engagement onto the HCV treatment pathway 10-fold. A model was used to estimate the decrease in HCV infections and HCV-related deaths from 2016, with costs and health benefits (quality-adjusted life-years or QALYs) tracked over 50 years. Univariable and probabilistic sensitivity analyses (PSA) were undertaken. SETTING England-specific epidemic with 40% prevalence of chronic HCV among PWID. PARTICIPANTS PWID attending drug treatment centres. INTERVENTION Nurse facilitator in drug treatment centres to improve the HCV care pathway from HCV case-finding to referral and linkage to specialist care. Comparator was the standard-of-care HCV care pathway. MEASUREMENTS Incremental cost-effectiveness ratio (ICER) in terms of cost per QALY gained through improved case-finding. FINDINGS Over 50 years per 1000 PWID, the HepCATT intervention could prevent 75 (95% central interval 37-129) deaths and 1330 (827-2040) or 51% (30-67%) of all new infections. The mean ICER was £7986 per QALY gained, with all PSA simulations being cost-effective at a £20 000 per QALY willingness-to-pay threshold. Univariable sensitivity analyses suggest the intervention would become cost-saving if the cost of HCV treatment reduces to £3900. If scaled up to all PWID in England, the intervention would cost £8.8 million and decrease incidence by 56% (33-70%) by 2030. CONCLUSIONS Increasing hepatitis C virus infection case-finding and treatment referral in drug treatment centres could be a highly cost-effective strategy for decreasing hepatitis C virus incidence among people who inject drugs.
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Affiliation(s)
- Zoe Ward
- Population Health Sciences, Bristol Medical School, University of Bristol, UK
| | - Rosie Reynolds
- Population Health Sciences, Bristol Medical School, University of Bristol, UK
| | - Linda Campbell
- Population Health Sciences, Bristol Medical School, University of Bristol, UK
| | - Natasha K. Martin
- Division of Infectious Diseases and Global Public Health, University of California, San Diego, CA, USA
| | | | - William Irving
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, UK
| | - Peter Vickerman
- Population Health Sciences, Bristol Medical School, University of Bristol, UK
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Ward Z, Campbell L, Surey J, Platts S, Glass R, Hickman M, Story A, Vickerman P. The cost-effectiveness of an HCV outreach intervention for at-risk populations in London, UK. J Antimicrob Chemother 2020; 74:v5-v16. [PMID: 31782503 PMCID: PMC6883400 DOI: 10.1093/jac/dkz451] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background HCV disproportionately affects marginalized communities such as homeless populations and people who inject drugs (PWID), posing a challenge to traditional health services. The HepFriend initiative in London is a model of care utilizing HCV outreach screening and peer support to link vulnerable individuals to HCV treatment in secondary care. Objectives To assess the cost-effectiveness of the HepFriend initiative from a healthcare provider perspective, compared with standard-of-care pathways (consisting of testing in primary care and other static locations, including drug treatment centres, and linkage to secondary care). Methods Cost-effectiveness analysis using a dynamic HCV transmission and disease progression model among PWID and those who have ceased injecting, including housing status and drug treatment service contact. The model was parameterized using London-specific surveillance and survey data, and primary intervention cost and effectiveness data (September 2015 to June 2018). Out of 461 individuals screened, 197 were identified as HCV RNA positive, 180 attended secondary care and 89 have commenced treatment to date. The incremental cost-effectiveness ratio (ICER) was determined using a 50 year time horizon. Results For a willingness-to-pay threshold of £20000 per QALY gained, the HepFriend initiative is cost-effective, with a mean ICER of £9408/QALY, and would become cost saving at 27% (£10525 per treatment) of the current drug list price. Results are robust to variations in intervention costs and model assumptions, and if treatment rates are doubled the intervention becomes more cost-effective (£8853/QALY). Conclusions New models of care that undertake active case-finding with enhanced peer support to improve testing and treatment uptake amongst marginalized and vulnerable groups could be highly cost-effective and possibly cost saving.
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Affiliation(s)
- Zoe Ward
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Linda Campbell
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | | | - Rachel Glass
- HIV & STI Department, National Infection Service, Public Health England, London, UK
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Alistair Story
- Institute of Global Health, University College London, London, UK
| | - Peter Vickerman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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12
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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: 59] [Impact Index Per Article: 11.8] [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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Kendall CE, Fitzgerald M, Donelle J, Kwong JC, Galanakis C, Boyd R, Cooper CL. A cross-sectional study of prolonged disengagement from clinic among people with HCV receiving care in a low-threshold, multidisciplinary clinic. CANADIAN LIVER JOURNAL 2020; 3:212-223. [PMID: 35991860 PMCID: PMC9202788 DOI: 10.3138/canlivj.2019-0020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 09/22/2019] [Indexed: 08/31/2024]
Abstract
Background Disengagement from care can affect treatment outcomes of patients with hepatitis C virus (HCV). We assessed the extent and determinants of disengagement among HCV patients receiving care at the Ottawa Hospital Viral Hepatitis Program (TOHVHP). Methods We linked clinical data of adult patients, categorized as ever or never disengaged from clinic (no TOHVHP encounters over 18 months), receiving care between April 1, 2002, and October 1, 2015, to provincial health administrative databases and calculated primary care use in the year after disengagement. We used adjusted Cox proportional hazards models to analyze variables associated with disengagement. Results Those disengaged from care (n = 657) were younger at presentation (46.6 [SD 11.1] versus 51.9 [SD 11.0] years), p < 0.001) and had lower comorbidity. After multivariable adjustment, we observed lower hazards of disengagement among those with higher compared with lower fibrosis scores (F3, hazard ratio [HR] 0.21 [95% CI 0.08-0.57]; F4, HR 0.32 [95% CI 0.19-0.55]) and those treated compared with never treated (received direct-acting antivirals [DAAs], HR 0.71 [95% CI 0.58-0.88]; received interferon but not DAA, HR 0.66 [95% CI 0.55-0.80]). We found no association with mental health or substance use disorders. In the year after disengagement, 74.3% (n = 488), 37.1% (n = 244), and 17.7% (n = 116) had at least one family physician visit, emergency department visit, and hospitalization, respectively. Conclusions Better integration of HCV specialty and primary care could improve disengagement rates among people with HCV.
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Affiliation(s)
- Claire E Kendall
- Bruyère Research Institute, Ottawa, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada
| | | | | | - Jeffrey C Kwong
- ICES, Toronto, Ontario, Canada
- Public Health Ontario, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Centre for Vaccine Preventable Diseases, University of Toronto, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
| | - Chrissi Galanakis
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Rob Boyd
- Sandy Hill Community Health Centre, Ottawa, Ontario, Canada
| | - Curtis L Cooper
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Abstract
SUMMARY In this paper we build on work investigating the feasibility of human immunodeficiency virus (HIV) testing in emergency departments (EDs), estimating the prevalence of hepatitis B, C and HIV infections among persons attending two inner-London EDs, identifying factors associated with testing positive in an ED. We also undertook molecular characterisation to look at the diversity of the viruses circulating in these individuals, and the presence of clinically significant mutations which impact on treatment and control.Blood-borne virus (BBV) testing in non-traditional settings is feasible, with emergency departments (ED) potentially effective at reaching vulnerable and underserved populations. We investigated the feasibility of BBV testing within two inner-London EDs. Residual samples from biochemistry for adults (⩾18 years) attending The Royal Free London Hospital (RFLH) or the University College London Hospital (UCLH) ED between January and June 2015 were tested for human immunodeficiency virus (HIV)Ag/Ab, anti-hepatitis C (HCV) and HBsAg. PCR and sequence analysis were conducted on reactive samples. Sero-prevalence among persons attending RFH and UCLH with residual samples (1287 and 1546), respectively, were 1.1% and 1.0% for HBsAg, 1.6% and 2.3% for anti-HCV, 0.9% and 1.6% for HCV RNA, and 1.3% and 2.2% for HIV. For RFH, HBsAg positivity was more likely among persons of black vs. white ethnicity (odds ratio 9.08; 95% confidence interval 2.72-30), with anti-HCV positivity less likely among females (0.15, 95% CI 0.04-0.50). For UCLH, HBsAg positivity was more likely among non-white ethnicity (13.34, 95% CI 2.20-80.86 (Asian); 8.03, 95% CI 1.12-57.61 (black); and 8.11, 95% CI 1.13-58.18 (other/mixed)). Anti-HCV positivity was more likely among 36-55 year olds vs. ⩾56 years (7.69, 95% CI 2.24-26.41), and less likely among females (0.24, 95% CI 0.09-0.65). Persons positive for HIV-markers were more likely to be of black vs. white ethnicity (4.51, 95% CI 1.63-12.45), and less likely to have one ED attendance (0.39, 95% CI 0.17-0.88), or female (0.12, 95% CI 0.04-0.42). These results indicate that BBV-testing in EDs is feasible, providing a basis for further studies to explore provider and patient acceptability, referral into care and cost-effectiveness.
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15
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Roberts K, Macleod J, Metcalfe C, Hollingworth W, Williams J, Muir P, Vickerman P, Clement C, Gordon F, Irving W, Waldron CA, North P, Moore P, Simmons R, Miners A, Horwood J, Hickman M. Cost effectiveness of an intervention to increase uptake of hepatitis C virus testing and treatment (HepCATT): cluster randomised controlled trial in primary care. BMJ 2020; 368:m322. [PMID: 32102782 PMCID: PMC7190058 DOI: 10.1136/bmj.m322] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate the effectiveness and cost effectiveness of a complex intervention in primary care that aims to increase uptake of hepatitis C virus (HCV) case finding and treatment. DESIGN Pragmatic, two armed, practice level, cluster randomised controlled trial and economic evaluation. SETTING AND PARTICIPANTS 45 general practices in South West England (22 randomised to intervention and 23 to control arm). Outcome data were collected from all intervention practices and 21/23 control practices. Total number of flagged patients was 24 473 (about 5% of practice list). INTERVENTION Electronic algorithm and flag on practice systems identifying patients with HCV risk markers (such as history of opioid dependence or HCV tests with no evidence of referral to hepatology), staff educational training in HCV, and practice posters/leaflets to increase patients' awareness. Flagged patients were invited by letter for an HCV test (with one follow-up) and had on-screen pop-ups to encourage opportunistic testing. The intervention lasted one year, with practices recruited April to December 2016. MAIN OUTCOME MEASURES Primary outcome: uptake of HCV testing. SECONDARY OUTCOMES number of positive HCV tests and yield (proportion HCV positive); HCV treatment assessment at hepatology; cost effectiveness. RESULTS Baseline HCV testing of flagged patients (six months before study start) was 608/13 097 (4.6%) in intervention practices and 380/11 376 (3.3%) in control practices. During the study 2071 (16%) of flagged patients in the intervention practices and 1163 (10%) in control practices were tested for HCV: overall intervention effect as an adjusted rate ratio of 1.59 (95% confidence interval 1.21 to 2.08; P<0.001). HCV antibodies were detected in 129 patients from intervention practices and 51 patients from control practices (adjusted rate ratio 2.24, 1.47 to 3.42) with weak evidence of an increase in yield (6.2% v 4.4%; adjusted risk ratio 1.40, 0.99 to 1.95). Referral and assessment increased in intervention practices compared with control practices (adjusted rate ratio 5.78, 1.6 to 21.6) with a risk difference of 1.3 per 1000 and a "number needed to help" of one extra HCV diagnosis, referral, and assessment per 792 (95% confidence interval 558 to 1883) patients flagged. The average cost of HCV case finding was £4.03 (95% confidence interval £2.27 to £5.80) per at risk patient and £3165 per additional patient assessed at hepatology. The incremental cost effectiveness ratio was £6212 per quality adjusted life year (QALY), with 92.5% probability of being below £20 000 per QALY. CONCLUSION HepCATT had a modest impact but is a low cost intervention that merits optimisation and implementation as part of an NHS strategy to increase HCV testing and treatment. TRIAL REGISTRATION ISRCTN61788850.
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Affiliation(s)
- Kirsty Roberts
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - John Macleod
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR Health Protection Research Unit (HPRU) in Evaluation of Interventions, University of Bristol, Bristol, UK
| | - Chris Metcalfe
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Randomised Trials Collaboration (BRTC), Population Health Sciences, Bristol Medical School, Bristol, UK
| | - Will Hollingworth
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jack Williams
- Department of Health Service Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
- NIHR HPRU in Blood Borne Viruses and STI, University College London, London, UK
| | - Peter Muir
- Public Health Laboratory Bristol, National Infection Service, Public Health England, Pathology Sciences Building, Southmead Hospital, Bristol, UK
| | - Peter Vickerman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR Health Protection Research Unit (HPRU) in Evaluation of Interventions, University of Bristol, Bristol, UK
| | - Clare Clement
- NIHR Health Protection Research Unit (HPRU) in Evaluation of Interventions, University of Bristol, Bristol, UK
| | - Fiona Gordon
- University Hospitals Bristol, Bristol Royal Infirmary, Bristol, UK
| | - Will Irving
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, University Hospital Nottingham, Nottingham, UK
| | | | - Paul North
- Public Health Laboratory Bristol, National Infection Service, Public Health England, Pathology Sciences Building, Southmead Hospital, Bristol, UK
| | - Philippa Moore
- Public Health Laboratory Bristol, National Infection Service, Public Health England, Pathology Sciences Building, Southmead Hospital, Bristol, UK
| | - Ruth Simmons
- NIHR HPRU in Blood Borne Viruses and STI, University College London, London, UK
- National Infection Service, Public Health England, London, UK
| | - Alec Miners
- Department of Health Service Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
- NIHR HPRU in Blood Borne Viruses and STI, University College London, London, UK
| | - Jeremy Horwood
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR Health Protection Research Unit (HPRU) in Evaluation of Interventions, University of Bristol, Bristol, UK
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR Health Protection Research Unit (HPRU) in Evaluation of Interventions, University of Bristol, Bristol, UK
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Yedinak JL, Goedel WC, Paull K, Lebeau R, Krieger MS, Thompson C, Buchanan AL, Coderre T, Boss R, Rich JD, Marshall BDL. Defining a recovery-oriented cascade of care for opioid use disorder: A community-driven, statewide cross-sectional assessment. PLoS Med 2019; 16:e1002963. [PMID: 31743335 PMCID: PMC6863520 DOI: 10.1371/journal.pmed.1002963] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 10/14/2019] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND In light of the accelerating and rapidly evolving overdose crisis in the United States (US), new strategies are needed to address the epidemic and to efficiently engage and retain individuals in care for opioid use disorder (OUD). Moreover, there is an increasing need for novel approaches to using health data to identify gaps in the cascade of care for persons with OUD. METHODS AND FINDINGS Between June 2018 and May 2019, we engaged a diverse stakeholder group (including directors of statewide health and social service agencies) to develop a statewide, patient-centered cascade of care for OUD for Rhode Island, a small state in New England, a region highly impacted by the opioid crisis. Through an iterative process, we modified the cascade of care defined by Williams et al. for use in Rhode Island using key national survey data and statewide health claims datasets to create a cross-sectional summary of 5 stages in the cascade. Approximately 47,000 Rhode Islanders (5.2%) were estimated to be at risk for OUD (stage 0) in 2016. At the same time, 26,000 Rhode Islanders had a medical claim related to an OUD diagnosis, accounting for 55% of the population at risk (stage 1); 27% of the stage 0 population, 12,700 people, showed evidence of initiation of medication for OUD (MOUD, stage 2), and 18%, or 8,300 people, had evidence of retention on MOUD (stage 3). Imputation from a national survey estimated that 4,200 Rhode Islanders were in recovery from OUD as of 2016, representing 9% of the total population at risk. Limitations included use of self-report data to arrive at estimates of the number of individuals at risk for OUD and using a national estimate to identify the number of individuals in recovery due to a lack of available state data sources. CONCLUSIONS Our findings indicate that cross-sectional summaries of the cascade of care for OUD can be used as a health policy tool to identify gaps in care, inform data-driven policy decisions, set benchmarks for quality, and improve health outcomes for persons with OUD. There exists a significant opportunity to increase engagement prior to the initiation of OUD treatment (i.e., identification of OUD symptoms via routine screening or acute presentation) and improve retention and remission from OUD symptoms through improved community-supported processes of recovery. To do this more precisely, states should work to systematically collect data to populate their own cascade of care as a health policy tool to enhance system-level interventions and maximize engagement in care.
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Affiliation(s)
- Jesse L. Yedinak
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island, United States of America
| | - William C. Goedel
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island, United States of America
| | - Kimberly Paull
- Executive Office of Health and Human Services, State of Rhode Island, Cranston, Rhode Island, United States of America
| | - Rebecca Lebeau
- Executive Office of Health and Human Services, State of Rhode Island, Cranston, Rhode Island, United States of America
| | - Maxwell S. Krieger
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island, United States of America
| | - Cheyenne Thompson
- Executive Office of Health and Human Services, State of Rhode Island, Cranston, Rhode Island, United States of America
| | - Ashley L. Buchanan
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, United States of America
| | - Tom Coderre
- Office of the Governor, State of Rhode Island, Providence, Rhode Island, United States of America
| | - Rebecca Boss
- Department of Behavioral Healthcare, Developmental Disabilities and Hospitals, State of Rhode Island, Cranston, Rhode Island, United States of America
| | - Josiah D. Rich
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island, United States of America
- Department of Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island, United States of America
| | - Brandon D. L. Marshall
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island, United States of America
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17
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Williams J, Miners A, Harris R, Mandal S, Simmons R, Ireland G, Hickman M, Gore C, Vickerman P. Cost-Effectiveness of One-Time Birth Cohort Screening for Hepatitis C as Part of the National Health Service Health Check Program in England. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2019; 22:1248-1256. [PMID: 31708061 DOI: 10.1016/j.jval.2019.06.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/14/2019] [Accepted: 06/28/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND AND OBJECTIVES Birth cohort screening for the hepatitis C virus (HCV) has been implemented in the US, but there is little evidence of its cost-effectiveness in England. We aim to evaluate the cost-effectiveness of one-time HCV screening for individuals born between 1950 and 1979 as part of the National Health Service health check in England, a health check for adults aged 40 to 74 years in primary care. METHODS A Markov model was developed to analyze add-on HCV testing to the National Health Service health check for individuals in birth cohorts between 1950 and 1979, versus current background HCV testing only, over a lifetime horizon. The model used data from a back-calculation model of the burden of HCV in England, sentinel surveillance of HCV testing, and published literature. Results are presented from a health service perspective in pounds in 2017, as incremental cost-effectiveness ratios per quality-adjusted life years gained. RESULTS The base-case incremental cost-effectiveness ratios ranged from £7648 to £24 434, and £18 681 to £46 024, across birth cohorts when considering 2 sources of HCV transition probabilities. The intervention is most likely to be cost-effective for those born in the 1970s, and potentially cost-effective for those born from 1955 to 1969. The model results were most sensitive to the source of HCV transition probabilities, the probability of referral and receiving treatment, and the HCV prevalence among testers. The maximum value of future research across all birth cohorts was £11.3 million at £20 000 per quality-adjusted life years gained. CONCLUSION Birth cohort screening is likely to be cost-effective for younger birth cohorts, although considerable uncertainty exists for other birth cohorts. Further studies are warranted to reduce uncertainty in cost-effectiveness and consider the acceptability of the intervention.
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Affiliation(s)
- Jack Williams
- Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, England, UK; The National Institute for Health Research Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections at University College London, England, UK.
| | - Alec Miners
- Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, England, UK; The National Institute for Health Research Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections at University College London, England, UK
| | - Ross Harris
- National Infection Service, Public Health England, Colindale, England, UK
| | - Sema Mandal
- The National Institute for Health Research Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections at University College London, England, UK; National Infection Service, Public Health England, Colindale, England, UK
| | - Ruth Simmons
- The National Institute for Health Research Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections at University College London, England, UK; National Infection Service, Public Health England, Colindale, England, UK
| | - Georgina Ireland
- The National Institute for Health Research Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections at University College London, England, UK; National Infection Service, Public Health England, Colindale, England, UK
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, England, UK; The National Institute for Health Research Health Protection Research Unit in Evaluation of Interventions, England, UK
| | | | - Peter Vickerman
- The National Institute for Health Research Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections at University College London, England, UK; Population Health Sciences, Bristol Medical School, University of Bristol, England, UK; The National Institute for Health Research Health Protection Research Unit in Evaluation of Interventions, England, 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: 9.7] [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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Jang ES, Ki M, Choi HY, Kim KA, Jeong SH. The change in the nationwide seroprevalence of hepatitis C virus and the status of linkage to care in South Korea from 2009 to 2015. Hepatol Int 2019; 13:599-608. [PMID: 31432446 DOI: 10.1007/s12072-019-09975-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 07/29/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hepatitis C virus (HCV) requires epidemiological monitoring to estimate its disease burden and to develop countermeasures. This study aimed to investigate the difference between the 2015 and 2009 nationwide anti-HCV seroprevalence and to determine linkage to care estimates in South Korea. METHODS A total 268,422 examinees ≥ 20 years old were included in 2015 from 33 medical institutions nationwide. Electronically extracted data were retrospectively analyzed to calculate the age-, sex-, and area-adjusted anti-HCV prevalence. Seroprevalence in 2015 was measured using the same method as that in 2009. For anti-HCV-positive subjects, medical records were reviewed to see whether HCV RNA testing or antiviral treatment was performed. RESULTS Adjusted anti-HCV prevalence was 0.60% (95% confidence interval, 0.57-0.63) based on general Korean population in 2015. It showed an increasing trend according to age; 0.23% in thirties, 0.38% in forties, 0.63% in fifties, 1.08% in sixties, and 1.65% in those aged ≥ 70 years. From 2009 to 2015, the adjusted anti-HCV prevalence decreased by 30%, with odds ratio of 0.70 (95% CI 0.70-0.71). There was significant intranational regional variation and changing pattern of seroprevalence. Among 1359 anti-HCV-positive subjects, HCV RNA test was performed in 60% and 25.4% had positivity. Treatment-initiated and cured rates in 2015 were 18.5% and 10.9%, respectively. CONCLUSIONS Anti-HCV prevalence in South Korea was 0.6% in 2015, showing a 30% decrease from that in 2009. Although the HCV RNA testing rate was increased since 2009, this remains suboptimal. Moreover, the treatment uptake rate should be improved in South Korea.
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Affiliation(s)
- Eun Sun Jang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro, 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, South Korea
| | - Moran Ki
- Department of Cancer Control and Population Health, Graduate School of Cancer Science and Policy, National Cancer Center, Goyang, Gyeonggi, South Korea
| | - Hwa Young Choi
- Department of Cancer Control and Population Health, Graduate School of Cancer Science and Policy, National Cancer Center, Goyang, Gyeonggi, South Korea
| | - Kyung-Ah Kim
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Gyeonggi, South Korea
| | - Sook-Hyang Jeong
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro, 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, South Korea.
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20
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Ireland G, Simmons R, Hickman M, Eastwood B, Ramsay M, Mandal S. Mapping the hepatitis C cascade of care in people attending drug treatment services in England: A data linkage study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 72:55-60. [PMID: 31257040 DOI: 10.1016/j.drugpo.2019.06.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 06/07/2019] [Accepted: 06/07/2019] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Hepatitis C (HCV) infection in England primarily affects people who inject drugs (PWID). We describe persons HCV tested, estimate incidence and establish the cascade of care (CoC) for people engaging with drug services. METHODS Persons testing for HCV in drug services in Sentinel Surveillance of Blood Borne Virus Testing (SSBBV) between 2008 and 2016 were linked with people attending drug services in the National Drug and Treatment Monitoring System (NDTMS). We describe risk characteristics, establish the CoC, and estimate HCV incidence in PWID diagnosed in drug services. RESULTS Of 46,721 persons tested for anti-HCV in SSBBV in drug services, 29,773 (63.7%) linked to NDTMS. Of these, 9100 (30.6%) were antiV positive and anti-HCV positivity was 45.0% in persons reporting urgent housing problems and 43.8% in persons reporting ever injecting. Among persons anti-HCV positive, half had ≥1 positive anti-HCV test. For persons' first anti-HCV positive between 2008 and 2013 (n = 3123), 74.9% were HCV RNA tested, of whom 71.2% were RNA positive, and of these, 14.0% had evidence of interferon-based treatment, with 52.8% achieving cure. Among PWID, HCV incidence was 8.7 per 100 person-years (95% CI: 8.1-9.2). CONCLUSION Through record linkage of surveillance datasets, we estimated the HCV CoC for people attending drug services, providing a benchmark from which to monitor the impact of strategies to scale-up prevention, testing, and curative treatment with direct acting antivirals. Our study highlights wasteful repeated testing and poor linkage to care for this high risk population which need to be addressed.
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Affiliation(s)
- G Ireland
- National Infection Service, Public Health England, UK; The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections at University College London, UK.
| | - R Simmons
- National Infection Service, Public Health England, UK; The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections at University College London, UK
| | - M Hickman
- The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Evaluation of Interventions at University of Bristol, UK; Population Health Sciences, Bristol Medical School, UK
| | - B Eastwood
- Alcohol, Drugs, Tobacco and Justice Division, Health Improvement Directorate, Public Health England, UK
| | - M Ramsay
- National Infection Service, Public Health England, UK
| | - S Mandal
- National Infection Service, Public Health England, UK; The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections at University College London, UK
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21
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O'Neil CR, Buss E, Plitt S, Osman M, Coffin CS, Charlton CL, Shafran S. Achievement of hepatitis C cascade of care milestones: a population-level analysis in Alberta, Canada. Canadian Journal of Public Health 2019; 110:714-721. [PMID: 31222618 DOI: 10.17269/s41997-019-00234-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 05/27/2019] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Despite highly effective directly acting antiviral (DAA) therapy for hepatitis C virus (HCV), many patients do not receive treatment. We characterized the achievement of cascade of care milestones within 2 years of diagnosis among the Alberta population and evaluated variables associated with engagement at each stage. METHODS All Albertans with a first-time positive HCV antibody between 2009 and 2014 were included in this retrospective study. We determined which patients received follow-up testing (HCV RNA and HCV genotype), referral to hepatitis specialty care, and antiviral prescription, and achieved SVR within 2 years of diagnosis. Factors associated with achieving cascade milestones were identified by multivariable logistic regression analysis. RESULTS Of 6154 patients with HCV antibody and complete follow-up, 4238 (68.9%) had HCV RNA testing, 2360 (38.3%) had HCV genotyping, 2096 (34.1%) were assessed by a specialist, 711 (11.6%) were prescribed treatment and 207 (3.4%) achieved SVR within 2 years of diagnosis. Independent variables associated with reduced likelihood of achieving cascade milestones were Indigenous heritage (adjusted odds ratio (AOR) 0.53 (0.41-0.68) for HCV RNA testing), unstable housing (AOR 0.50 (0.32-0.79) for specialist assessment) and alcohol misuse (AOR 0.61 (0.38-0.99) for antiviral prescription). Men, older patients, patients with a higher income and patients with more advanced liver disease were more likely to achieve cascade of care milestones. CONCLUSION At each stage of patient engagement, opportunities for improvement were identified. Understanding the local cascade of care and factors associated with achieving cascade milestones will help prioritize initiatives to facilitate access to DAA therapy in Alberta.
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Affiliation(s)
- Conar R O'Neil
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada.
| | - Emily Buss
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Sabrina Plitt
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada.,Centre for Communicable Disease and Infection Control, Public Health Agency of Canada, Ottawa, Ontario, Canada
| | - Mariam Osman
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada.,Alberta Health, Edmonton, Alberta, Canada
| | - Carla S Coffin
- Calgary Liver Unit, Division of Gastroenterology and Hepatology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Carmen L Charlton
- Provincial Laboratory for Public Health, Edmonton, Alberta, Canada.,Division of Diagnostic and Applied Microbiology, Department of Laboratory Medicine and Pathology, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Stephen Shafran
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
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22
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Guise A, Witzel TC, Mandal S, Sabin C, Rhodes T, Nardone A, Harris M. A qualitative assessment of the acceptability of hepatitis C remote self-testing and self-sampling amongst people who use drugs in London, UK. BMC Infect Dis 2018; 18:281. [PMID: 29914381 PMCID: PMC6006927 DOI: 10.1186/s12879-018-3185-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 06/06/2018] [Indexed: 12/22/2022] Open
Abstract
Background Hepatitis C (HCV) diagnosis and care is a major challenge for people who use illicit drugs, and is characterised by low rates of testing and treatment engagement globally. New approaches to fostering engagement are needed. We explored the acceptability of remote forms of HCV testing including self-testing and self-sampling among people who use drugs in London, UK. Methods A qualitative rapid assessment was undertaken with people who use drugs and stakeholders in London, UK. Focus groups were held with men who have sex with men engaged in drug use, people who currently inject drugs and people who formerly injected drugs (22 participants across the 3 focus groups). Stakeholders participated in semi-structured interviews (n = 5). We used a thematic analysis to report significant themes in participants’ responses. Results We report an overarching theme of ‘tension’ in how participants responded to the acceptability of remote testing. This tension is evident across four separate sub-themes we explore. First, choice and control, with some valuing the autonomy and privacy remote testing could support. Second, the ease of use of self testing linked to its immediate result and saliva sample was preferred over the delayed result from a self administered blood sample tested in a laboratory. Third, many respondents described the need to embed remote testing within a supportive care pathway. Fourth, were concerns over managing a positive result, and its different meanings, in isolation. Conclusions The concept of remote HCV testing is acceptable to some people who use drugs in London, although tensions with lived experience of drug use and health system access limit its relevance. Future development of remote testing must respond to concerns raised in order for acceptable implementation to take place.
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Affiliation(s)
- Andy Guise
- London School of Hygiene and Tropical Medicine, London, UK. .,School of Population Health and Environmental Sciences, Guy's campus, King's College London, Addison House, London, UK.
| | - T Charles Witzel
- SIGMA Research, London School of Hygiene and Tropical Medicine, Tavistock Place, London, UK
| | - Sema Mandal
- Public Health England, Wellington House, Waterloo Road, London, UK.,National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Blood Borne and Sexually Transmitted Infections at UCL in collaboration with Public Health England, London, UK
| | - Caroline Sabin
- National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Blood Borne and Sexually Transmitted Infections at UCL in collaboration with Public Health England, London, UK. .,Institute for Global Health, UCL, London, UK.
| | - Tim Rhodes
- London School of Hygiene and Tropical Medicine, London, UK.,National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Blood Borne and Sexually Transmitted Infections at UCL in collaboration with Public Health England, London, UK
| | - Anthony Nardone
- Public Health England, Wellington House, Waterloo Road, London, UK.,National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Blood Borne and Sexually Transmitted Infections at UCL in collaboration with Public Health England, London, UK
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