Point-of-care HCV RNA testing improves hepatitis C testing rates and allows rapid treatment initiation among people who inject drugs attending a medically supervised injecting facility.

BACKGROUND: To achieve hepatitis C virus (HCV) elimination targets, simplified care engaging people who inject drugs is required. We evaluated whether fingerstick HCV RNA point-of-care testing (PoCT) increased the proportion of clients attending a supervised injecting facility who were tested for hepatitis C. METHODS: Prospective single-arm study with recruitment between 9 November 2020 and 28 January 2021 and follow-up to 31 July 2021. Clients attending the supervised injecting facility were offered HCV RNA testing using the Xpert® HCV Viral Load Fingerstick (Cepheid, Sunnyvale, CA) PoCT. Participants with a positive HCV RNA test were prescribed direct acting antiviral (DAA) therapy. The primary endpoint was the proportion of clients who engaged in HCV RNA PoCT, compared to a historical comparator group when venepuncture-based hepatitis C testing was standard of care. RESULTS: Among 1618 clients who attended the supervised injecting facility during the study period, 228 (14%) engaged in PoCT. This was significantly higher than that observed in the historical comparator group (61/1,775, 3%; p < 0.001). Sixty-five (28%) participants were HCV RNA positive, with 40/65 (62%) receiving their result on the same day as testing. Sixty-one (94%) HCV RNA positive participants were commenced on DAA therapy; 14/61 (23%) started treatment on the same day as diagnosis. There was no difference in the proportion of HCV RNA positive participants commenced on treatment with DAA therapy when compared to the historical comparator group (61/65, 94% vs 22/26, 85%; p = 0.153). However, the median time to treatment initiation was significantly shorter in the PoCT cohort (2 days (IQR 1-20) vs 41 days (IQR 22-76), p < 0.001). Among participants who commenced treatment and had complete follow-up data available, 27/36 (75%) achieved hepatitis C cure. CONCLUSIONS: HCV RNA PoCT led to a significantly higher proportion of clients attending a supervised injecting facility engaging in hepatitis C testing, whilst also reducing the time to treatment initiation.

Eliminating hepatitis C in Australia: a novel model of hepatitis C testing and treatment for people who inject drugs at a medically supervised injecting facility.

OBJECTIVE: To evaluate the feasibility of testing and treating people who inject drugs at a supervised injecting facility for hepatitis C virus (HCV) infection. DESIGN: Retrospective cohort study. SETTING, PARTICIPANTS: People who inject drugs who attended the Melbourne supervised injecting facility, 30 June 2018 - 30 June 2020. MAIN OUTCOME MEASURES: Proportion of people tested for hepatitis C; proportions of people positive for anti-HCV antibody and HCV RNA, and of eligible people prescribed direct-acting antiviral (DAA) treatment; sustained virological response twelve weeks or more after treatment completion. RESULTS: Of 4649 people who attended the supervised injecting facility during 2018-20, 321 were tested for hepatitis C (7%); 279 were anti-HCV antibody-positive (87%), of whom 143 (51%) were also HCV RNA-positive. Sixty-four of 321 had previously been treated for hepatitis C (20%), 21 had clinically identified cirrhosis (7%), eight had hepatitis B infections (2%), and four had human immunodeficiency virus infections (1%). In multivariate analyses, people tested for hepatitis C were more likely than untested clients to report psychiatric illness (adjusted odds ratio [aOR], 9.65; 95% confidence interval [CI], 7.26-12.8), not have a fixed address (aOR, 1.59; 95% CI, 1.18-2.14), and to report significant alcohol use (aOR, 1.57; 95% CI, 1.06-2.32). The median number of injecting facility visits was larger for those tested for hepatitis C (101; interquartile range [IQR], 31-236) than for those not tested (20; IQR, 3-90). DAA treatment was prescribed for 126 of 143 HCV RNA-positive clients (88%); 41 of 54 with complete follow-up data were cured (76%). CONCLUSIONS: People who attend supervised injecting facilities can be tested and treated for hepatitis C on site. Models that provide streamlined, convenient hepatitis C care promote engagement with treatment in a group in which the prevalence of hepatitis C is high.

A multi-site, nurse-coordinated hepatitis C model of care in primary care and community services in Melbourne, Australia.

BACKGROUND: Hepatitis C virus (HCV) treatment through primary care and community-based services will be a critical component of HCV elimination. We evaluated a nurse-coordinated programme providing care across eight sites and analysed progression through the HCV care cascade. METHODS: People-accessing services from six primary care clinics, a homeless crisis accommodation provider and a mental health service were directly referred to nurses or engaged by nurses during regular clinic visits. Nurses supported HCV testing, treatment and follow-up. The prescription was provided by affiliated clinicians. Logistic regression was used to examine factors associated with treatment commencement and sustained virological response (SVR) testing. RESULTS: Of 640 people referred to and/or engaged by the nurses from January 2017 to July 2019, 518 had an HCV RNA test of whom 381 (74%) were HCV RNA positive. Treatment was commenced by 281 (74%) people of whom 161 had an SVR test, 157 (97.5%) were cured. Opioid agonist therapy was associated with treatment commencement (aOR 2.68, 95% CI 1.48-4.88). People who were homeless/unstably housed were less likely to commence treatment (aOR 0.45, 95% CI 0.23-0.87). Treatment prescription from a specialist (aOR 2.39, 95% CI 1.20-4.74) and recent injection drug use (<6 months) (aOR 2.15, 95% CI 1.07-4.31) was associated with SVR testing. CONCLUSION: A nurse-coordinated model of care led to high levels of HCV treatment uptake and cure amongst people attending primary care and community services. More tailored models of care may be beneficial for people who are homeless or have unstable housing. These results support primary care and community-based hepatitis C treatment.

Hepatitis C treatment in a co-located mental health and alcohol and drug service using a nurse-led model of care.

Hepatitis C virus (HCV) is more prevalent among people with experience of severe mental illness compared to the general population, due in part to higher levels of injecting drug use. Delivering HCV care through mental health services may reduce barriers to care and improve outcomes. A nurse-led HCV program was established in a co-located mental health and addiction service in Melbourne, Australia. People with a history of injecting drug use, including current use, were referred for HCV testing by nurses, with support provided on-site from a general practitioner and remotely from infectious disease and hepatology specialists. A nurse practitioner, general practitioner or specialists were able to prescribe HCV treatment. One-hundred and thirty people were referred to the nurse-led service, among whom 112 (86%) were engaged in care. Of those 112, 84 (75%) were found to have detectable HCV RNA, 70 (83%) commenced treatment; 28 (40%) prescriptions were nurse initiated, 19 (27%) were general practitioner initiated and 20 (29%) were prescribed from hospital clinics or elsewhere. All people with an SVR result (48/70) achieved HCV cure (intention to treat SVR 69%, per-protocol SVR 100%). Treatment commencement was highest among people prescribed opioid agonist therapy (28/29, 96%) compared to those who were not (18/26, 69%). In conclusion, a nurse-led, HCV service for people with severe mental illness including pathways to specialist support when needed can achieve high treatment uptake and cure. Further implementation work is required to improve treatment uptake, particularly among people not prescribed opioid agonist therapy, and to improve follow-up for SVR testing.

Quantitative evaluation of an integrated nurse model of care providing hepatitis C treatment to people attending homeless services in Melbourne, Australia.

BACKGROUND: The prevalence of hepatitis C virus (HCV) has been reported to be high among people experiencing homelessness. People who are homeless often have multiple needs that may take precedence over HCV testing and treatment. We quantitatively evaluated the outcomes of a service providing HCV treatment to people attending homeless services. METHODS: Clients attending homeless services were referred to a nurse specialising in HCV-related care. The nurse provided HCV testing, education and case-management while prescriptions were provided by an affiliated doctor. Logistic regression was used to explore factors associated with treatment commencement. RESULTS: Fifty-two clients referred (78%) underwent testing, thirty-nine were HCV-RNA positive among whom 18 (46%) reported sleeping rough and 29 (74%) reported injecting drug use; 66% had injected less than three months ago. Twenty-four (62%) clients commenced treatment, of whom thirteen (54%) had a sustained virological response test; all were cured. Treatment commencement was lower among people who reported sleeping rough (aOR 0.15, 95%CI 0.029-0.73). There was no difference in treatment commencement based on injecting drugs (aOR 1.06, 95%CI 0.21-5.2). CONCLUSION: Most clients' commenced treatment and the majority were successfully cured using a dedicated nursing service. Clients who reported sleeping rough may still face personal and/or system level barriers to HCV treatment.