Large-Scale, Primary Care-Based Hepatitis C Treatment in an Urban, Medically Underserved Patient Population.

Hepatitis C virus (HCV) infection is a critical public health concern in the United States. HCV is highly curable, but access to care is limited for many patients. Primary care models can expand access to HCV care. The Grady Liver Clinic (GLC) is a primary care-based HCV clinic founded in 2002. During 20 years, using a multidisciplinary team, the GLC expanded its operations in response to advances in HCV screening and treatment. We describe the clinic model, patient population, and treatment outcomes of the clinic from 2015 through 2019. During this period, 2689 patients were seen in the GLC, and 77% (n = 2083) initiated treatment. Eighty-five percent (1779 of 2083) of patients who started treatment completed treatment and were tested for cure, and 1723 (83% of the total treated cohort, 97% of those tested for cure) were cured. Building on a successful primary care-based treatment model, the GLC dynamically responded to the changes in HCV screening and treatment guidelines, continually increasing access to HCV care. The GLC serves as a model of primary care-based HCV care that aims to achieve HCV microelimination in a safety-net health system. Our findings support the notion that for the United States to achieve elimination of HCV by 2030, generalists can and should provide HCV care, particularly in medically underserved patient populations.

Differences in inpatient and outpatient hepatitis C virus prevalence and linkage to care rates in a safety net hospital hepatitis C screening program.

BACKGROUND AND AIM: Routine screening for hepatitis C virus (HCV) infection is crucial in identifying the 50% of infected persons unaware of their infection. We added an inpatient screening initiative to our successful outpatient HCV screening program in an urban, safety-net hospital. METHODS: From March 2017 to December 2019, HCV screening was performed in inpatient and outpatient settings at Grady Health System. We compared care cascade outcomes, including anti-HCV testing, RNA testing, and linkage to care (LTC) between these settings. RESULTS: A total of 29 751 patients were tested for anti-HCV: 8883 inpatients and 20 868 outpatients. The anti-HCV population was predominantly Black (76.2%) and male (67.9%). The total anti-HCV prevalence was 8.9%, with 14% of inpatients and 6.7% of outpatients testing positive. RNA testing was performed on 86%. The prevalence of active HCV infection was 59.3% in those that were anti-HCV positive; inpatient prevalence was 66%, and outpatient was 53.8%. Of those with active infection, 67.5% were linked to care (57.3% of inpatients and 77.8% of outpatients). CONCLUSION: We found significant differences in prevalence of anti-HCV and LTC rates between inpatients and outpatients during an HCV screening program. Higher anti-HCV prevalence among inpatients may be due a higher prevalence of non-birth year HCV risk factors. LTC rates were lower in the inpatient setting despite a robust linkage strategy. The striking prevalence of HCV in both settings warrants continued screening, expansion to additional settings, and novel strategies to improve inpatient linkage rates, especially in the setting of new universal HCV screening guidelines.

Improved Hepatitis C Cure Cascade Outcomes Among Urban Baby Boomers in the Direct-Acting Antiviral Era.

OBJECTIVES: We compared outcomes of the hepatitis C virus (HCV) cure cascade (ie, the path a patient follows from diagnosis to cure), including antiviral treatment outcomes, from 2 HCV screening programs. Our objective was to assess whether treatment uptake and HCV cure rates improved in the cohort screened after the release of all-oral HCV direct-acting antiviral therapies. METHODS: We retrospectively compared outcomes of the HCV cure cascade from a cohort of newly diagnosed patients screened during 2012-2014 (period 1) with outcomes from a cohort of newly diagnosed patients screened during 2015-2016 (period 2) at Grady Health System in Atlanta, Georgia. Cure cascade outcomes included HCV antibody (anti-HCV) and RNA testing, linkage to care, antiviral treatment, and sustained virologic response. RESULTS: During period 1, 412 of 5274 (7.8%) persons screened were anti-HCV positive, and 264 (69.3%) of those tested were RNA positive. During period 2, 462 of 7137 (6.5%) persons screened were anti-HCV positive, and 240 (59.3%) of those tested were RNA positive (P = .003). The percentage of newly diagnosed patients who were treated during period 2 (64.0%) was 3 times that of newly diagnosed patients treated during period 1 (21.2%; P < .001). Both cohorts had similarly high levels of linkage to care (95.8% during period 1, 95.4% during period 2) and cure (92.6% during period 1, 95.5% during period 2). CONCLUSIONS: Over time, the prevalence of anti-HCV and HCV RNA positivity declined substantially, and linkage-to-care and cure rates remained high. Treatment uptake increased significantly after the introduction of all-oral direct-acting antiviral therapy. These findings suggest that combining large-scale screening initiatives with treatment programs can speed progress toward HCV elimination.

A difficult case to swallow: herpes esophagitis after epidural steroid injection.

Herpes esophagitis due to infection with herpes simplex virus typically occurs in immunocompromised patients such as those with human immunodeficiency virus, malignancy, and those undergoing immunosuppressive therapy. Albeit rare, herpes esophagitis can occur in immunocompetent patients as a primary infection. We present a case of herpes esophagitis after corticosteroid treatment for back pain including epidural steroid injections. Corticosteroids, especially local injections, are a common treatment for chronic back pain, but they are not without risk. Epidural steroid injections can have systemic effects, which may go unrecognized and underappreciated. Although local infections have been reported after administering these injections, systemic immune suppression may allow for unexpected infections such as herpes esophagitis. Given the widespread use of epidural steroid injections, physicians should reevaluate the potential for harm when considering this treatment.