The Cascade of Care for an Australian Community-Based Hepatitis C Treatment Service

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Abstract

Background

Hepatitis C treatment uptake in Australia is low. To increase access to hepatitis C virus treatment for people who inject drugs, we developed a community-based, nurse-led service that linked a viral hepatitis service in a tertiary hospital to primary care clinics, and resulted in hepatitis C treatment provision in the community.

Methods

A retrospective cohort study of patients referred to the community hepatitis service was undertaken to determine the cascade of care. Logistic regression analyses were used to identify predictors of hepatitis C treatment uptake.

Results

Four hundred and sixty-two patients were referred to the community hepatitis service; 344 attended. Among the 279 attendees with confirmed chronic hepatitis C, 257 (99%) reported ever injecting drugs, and 124 (48%) injected in the last month. Of 201 (72%) patients who had their fibrosis staged, 63 (31%) had F3-F4 fibrosis. Fifty-five patients commenced hepatitis C treatment; 26 (47%) were current injectors and 25 (45%) had F3-F4 fibrosis. Nineteen of the 27 (70%) genotype 1 patients and 14 of the 26 (54%) genotype 3 patients eligible for assessment achieved a sustained virologic response. Advanced fibrosis was a significant predictor of treatment uptake in adjusted analysis (AOR 2.56, CI 1.30–5.00, p = 0.006).

Conclusions

Our community hepatitis service produced relatively high rates of fibrosis assessment, hepatitis C treatment uptake and cure, among people who inject drugs. These findings highlight the potential benefits of providing community-based hepatitis C care to people who inject drugs in Australia–benefits that should be realised as direct-acting antiviral agents become available.

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Most cited references 22

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Outcomes of treatment for hepatitis C virus infection by primary care providers.

Sanjeev Arora, Karla Thornton, Glen H. Murata … (2011)

The Extension for Community Healthcare Outcomes (ECHO) model was developed to improve access to care for underserved populations with complex health problems such as hepatitis C virus (HCV) infection. With the use of video-conferencing technology, the ECHO program trains primary care providers to treat complex diseases. We conducted a prospective cohort study comparing treatment for HCV infection at the University of New Mexico (UNM) HCV clinic with treatment by primary care clinicians at 21 ECHO sites in rural areas and prisons in New Mexico. A total of 407 patients with chronic HCV infection who had received no previous treatment for the infection were enrolled. The primary end point was a sustained virologic response. A total of 57.5% of the patients treated at the UNM HCV clinic (84 of 146 patients) and 58.2% of those treated at ECHO sites (152 of 261 patients) had a sustained viral response (difference in rates between sites, 0.7 percentage points; 95% confidence interval, -9.2 to 10.7; P=0.89). Among patients with HCV genotype 1 infection, the rate of sustained viral response was 45.8% (38 of 83 patients) at the UNM HCV clinic and 49.7% (73 of 147 patients) at ECHO sites (P=0.57). Serious adverse events occurred in 13.7% of the patients at the UNM HCV clinic and in 6.9% of the patients at ECHO sites. The results of this study show that the ECHO model is an effective way to treat HCV infection in underserved communities. Implementation of this model would allow other states and nations to treat a greater number of patients infected with HCV than they are currently able to treat. (Funded by the Agency for Healthcare Research and Quality and others.).

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Treatment of hepatitis C virus infection among people who are actively injecting drugs: a systematic review and meta-analysis.

M E Hellard, Craig S Hutchinson, Joseph Doyle … (2013)

Although guidelines recommend that people who inject drugs (PWID) should not be excluded from hepatitis C (HCV) treatment, some services remain reluctant to treat PWID. The aim of this review was to investigate sustained virologic response (SVR), adherence, discontinuation, and HCV reinfection among PWID. A search of Medline, Embase, and Cochrane databases (between 2002 and January 2012) was conducted for primary articles/conference abstracts examining HCV treatment outcomes in PWID. Meta-analysis was used to obtain pooled estimates of SVR, adherence, discontinuation, and HCV reinfection. Ten primary articles and 1 conference abstract met the inclusion criteria. Across 6 studies (comprising 314 drug users, of whom 141 [45%] were PWID), pooled SVR was 56% (95% confidence interval [CI], 50%-61%) for all genotypes, 37% (95% CI, 26%-48%) for genotypes 1/4, and 67% (95% CI, 56%-78%) for genotypes 2/3. Pooled 80/80/80 adherence was 82% (95% CI, 74%-89%) across 2 studies, and pooled treatment discontinuation was 22% (95% CI, 16%-27%) across 4 studies. Across 5 studies (comprising 131 drug users) examining reinfection, pooled risk was 2.4 (95% CI, .9-6.1) per 100 person-years. HCV treatment outcomes are acceptable in PWID, supporting treatment guidelines. The pooled estimate of HCV reinfection risk was low, but there was considerable uncertainty around this estimate. Further studies on the risk of reinfection are needed to assess the long-term effectiveness of HCV treatment in PWID.

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Limited uptake of hepatitis C treatment among injection drug users.

S Strathdee, Ravi Kavasery, B Genberg … (2008)

We characterized hepatitis C virus (HCV) treatment knowledge, experience and barriers in a cohort of community-based injection drug users (IDUs) in Baltimore, MD. In 2005, a questionnaire on HCV treatment knowledge, experience and barriers was administered to HCV-infected IDUs. Self-reported treatment was confirmed from medical records. Of 597 participants, 71% were male, 95% African-American, 31% HIV co-infected and 94% were infected with HCV genotype 1; 70% were aware that treatment was available, but only 22% understood that HCV could be cured. Of 418 who had heard of treatment, 86 (21%) reported an evaluation by a provider that included a discussion of treatment of whom 30 refused treatment, 20 deferred and 36 reported initiating treatment (6% overall). The most common reasons for refusal were related to treatment-related perceptions and a low perceived need of treatment. Compared to those who had discussed treatment with their provider, those who had not were more likely to be injecting drugs, less likely to have health insurance, and less knowledgeable about treatment. Low HCV treatment effectiveness was observed in this IDU population. Comprehensive integrated care strategies that incorporate education, case-management and peer support are needed to improve care and treatment of HCV-infected IDUs.

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Author and article information

Contributors

Naglaa H. Shoukry: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, CA USA )

ISSN (Electronic): 1932-6203

Publication date (Electronic): 12 November 2015

Publication date Collection: 2015

Volume: 10

Issue: 11

Electronic Location Identifier: e0142770

Affiliations

[1 ]Centre for Population Health, Burnet Institute, Melbourne, Victoria, Australia

[2 ]School of Public Health and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, Victoria, Australia

[3 ]Department of Infectious Diseases, The Alfred, Melbourne, Victoria, Australia

[4 ]Department of Gastroenterology, St Vincent’s Hospital, Melbourne, Victoria, Australia

[5 ]Department of Gastroenterology, The Alfred, Melbourne, Victoria, Australia

[6 ]Department of Medicine, Monash University, Melbourne, Victoria, Australia

[7 ]Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia

University of Montreal Hospital Research Center (CRCHUM), CANADA

Author notes

Competing Interests: AG: no conflict to declare. JD, MH: research/grant support from Gilead, AbbVie. SR: consulting/advisory capacity AbbVie, MSD, Gilead, Janssen, BMS, Roche; speakers bureau BMS, Roche; research/grant support Roche, AbbVie. AW, DM: speakers fee Roche research/grant support AbbVie. AT: research/grant support Merck, Roche, Gilead Sciences, BMS, AbbVie; consulting/advisory capacity AbbVie, Merck, Roche Diagnostics, Gilead Sciences, Spring Bank pharmaceuticals, Arrowhead Pharmaceuticals; Speakers fee AbbVie, Roche Diagnostics, Bristol Myers Squibb, Gilead Sciences. This does not alter the authors' adherence to PLOS ONE policies on sharing data and materials.

Conceived and designed the experiments: AJW MEH. Performed the experiments: AJW DMM. Analyzed the data: AJW JSD MEH. Wrote the paper: AJW DMM JSD AG SKR AJT MEH.

* E-mail: amanda.wade@ 123456burnet.edu.au

Article

Publisher ID: PONE-D-15-25998

DOI: 10.1371/journal.pone.0142770

PMC ID: 4642931

PubMed ID: 26562516

SO-VID: ee34ba8a-ae1f-4de0-a463-c275ec5a919d

License:

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

History

Date received : 15 June 2015

Date accepted : 27 October 2015

Page count

Figures: 2, Tables: 2, Pages: 12

Funding

AW is a recipient of a National Health and Medical Research Council postgraduate scholarship (GNT1093846). JD, MH, and AT acknowledge support from the National Health and Medical Research Council. The authors gratefully acknowledge the contribution to this work of Victorian Operational Infrastructure Support Program funding for the Burnet Institute. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Data Availability As data relevant to this study are line listed, the Alfred Hospital Human Ethics Committee has placed restrictions on the dataset and it cannot be made publicly available. Interested readers may send requests to the Alfred Hospital Human Ethics Committee to obtain the data. Requests for the data may be sent to amanda.wade@ 123456burnet.edu.au .

The Cascade of Care for an Australian Community-Based Hepatitis C Treatment Service

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Abstract

Background

Methods

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Conclusions

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Point-Of-Care Testing for Hepatitis

Most cited references 22

Outcomes of treatment for hepatitis C virus infection by primary care providers.

Treatment of hepatitis C virus infection among people who are actively injecting drugs: a systematic review and meta-analysis.

Limited uptake of hepatitis C treatment among injection drug users.

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