Liver health events: an indigenous community-led model to enhance HCV screening and linkage to care.

Despite high prevalence of hepatitis C virus (HCV), linkage to care and treatment for Indigenous people is low. In an Indigenous community in Saskatchewan, Canada a retrospective review identified 200 individuals (∼12% prevalence) had HCV antibodies though majority lacked ribonucleic acid (RNA) testing, and few received treatment despite availability of an effective cure. Following Indigenous oral traditions, focus group discussions were held with key community members and leadership. Participants emphasized the need for a community-based screening and treatment programme. A team of community members, peers and healthcare professionals developed a streamlined screening pathway termed 'liver health event' (LHE) to reduce stigma, reach undiagnosed, re-engage previously diagnosed, and ensure rapid linkage to care/treatment. LHEs began December 2016. Statistics were tracked for each event. As of July 2019, there were 10 LHEs with 540 participants, 227 hepatitis C tests and 346 FibroScans completed. This represented 294 unique individuals, of which 64.3% were tested, and of those, 40.8% were Ab positive. Among those positive for antibodies, 41.7% had active hepatitis C infections, and among these, 90% were linked to care, and 14 new positive individuals were identified. Following the success of LHEs, these were adapted and implemented in 10 other communities in this region, resulting in 17 additional LHEs. This intervention is reaching the undiagnosed and linking clients to care through a low-barrier and de-stigmatizing approach. It has facilitated collaboration, knowledge exchange and mentorship between Indigenous communities, significantly impacting health outcomes of Indigenous people in this region.

Individuals residing in geographically isolated Indigenous communities often face multiple barriers trying to access healthcare services in Saskatchewan Canada. Consequently, many individuals who have HCV antibody (Ab), often lack confirmatory RNA test and experience delays in linkage to HCV treatment. A collective decision was made by pertinent stakeholders including community members, peers, community healthcare staff, Chief and leadership to improve access to screening and linkage to HCV treatment in community. A streamlined HCV screening pathway referred to as LHEs was developed by an Indigenous community. Since implementation in December 2016, 10 LHEs were delivered in community, with 540 participant visits, 227 hepatitis C tests conducted, and 346 FibroScans completed. Out of 294 unique individuals who attended, 64.3% were tested, and of those, 40.8% were Ab positive. Among those positive for antibodies, 41.7% had active hepatitis C infections, and among these, 90% were linked to care, and 14 new positive individuals were identified. Following the success of the LHEs in reaching the undiagnosed, this screening pathway has been adapted and implemented in at least 10 additional Indigenous communities in Saskatchewan, Canada.

Achieving Hepatitis C Elimination By Using Person-Centered, Nurse-Led Models of Care: A Discussion of Four International Case Studies.

Nurse-led models of care are an important strategy in the management of patients with chronic disease because of the person-centered approach that allows the needs of the individual to be prioritized and addressed in accessible settings. Hepatitis C is caused by a blood-borne virus that can cause liver disease and liver cancer; it predominantly affects marginalized populations, including people who inject drugs. Since 2013, all oral, direct-acting antiviral regimens have been available to cure hepatitis C. Nurses are well placed to be involved in the delivery of hepatitis C testing and treatment because of their extensive reach within marginalized communities and holistic approach to patient care. Four case studies of nurse-led models of care operating in Australia, Canada, the United Kingdom, and the United States are presented to illustrate the important role nurses have in delivering accessible, person-centered hepatitis C testing and treatment. Each case study demonstrates the success of overcoming barriers to hepatitis C testing and treatment such as geographic isolation, incarceration, social marginalization, and inflexible healthcare systems. Achieving the global target to eliminate hepatitis C by 2030 will require the nursing profession to embrace its role as the first point of contact to the healthcare system for many members of marginalized communities potentially at risk of hepatitis C. Nurses are well placed to reduce barriers and facilitate access to healthcare by scaling up activities focused on hepatitis C testing and treatment.

Reinfection with hepatitis C virus following sustained virological response in injection drug users.

BACKGROUND AND AIM: Despite that 60-90% of injection drug users (IDUs) are infected with hepatitis C virus (HCV) infection, IDUs are often denied therapy based on concerns of reinfection following treatment. However, there are little data in this regard. We evaluated HCV re-infection following sustained virologic response (SVR) among HCV-infected IDUs having received HCV treatment in a multidisciplinary program. METHODS: Following treatment, participants were encouraged to return at follow-up intervals of 1 year and illicit drug use histories were obtained. In those with SVR, HCV RNA testing by PCR was performed to determine if relapse or reinfection occurred. RESULTS: Among 58 receiving HCV treatment between January 2002 and December 2006, 60% (35 of 58) achieved an SVR. Patients were followed for a median of 2.0 years following SVR (range, 0.4-5.0 years), with ongoing illicit and injection drug use reported in 54% (19 of 35) and 46% (16 of 35). Of the 35 with SVR, 28 remained HCV RNA negative during follow-up (80%), with four lost to follow-up and one dying of hepatocellular carcinoma and two cases of reinfection were observed (2 of 35). The rates of reinfection were 3.2 per 100 p-y (95% CI:0.4, 11.5) overall and 5.3 per 100 p-y (95% CI:0.6, 19.0) among those reporting injecting following SVR (n = 16). One of two participants with HCV re-infection spontaneously cleared virus following reinfection. CONCLUSION: The rate of reinfection following treatment for HCV infection among current and former IDUs engaged in a multidisciplinary program is low.

Treatment of Hepatitis C Virus Infection in Marginalized Populations.

NPs should be given a more significant role in this effort.

Factors associated with lost to follow-up after hepatitis C treatment delivered by primary care teams in an inner-city multi-site program, Vancouver, Canada.

BACKGROUND: Treatment of hepatitis c virus (HCV) with direct-acting-antivirals (DAAs) by family physicians in primary care and addiction settings may allow treatment expansion to inner-city populations, including people who inject drugs (PWID). Real-world data however, suggests high rates of non-attendance to SVR 12 testing. This study examines outcomes of HCV treatment delivered by family physicians working in interdisciplinary treatment programs, integrated into inner-city primary care clinics. METHODS: In this prospective cohort, participants completed baseline questionnaires, including questions on demographics and substance use. Participants were recorded as achieving a sustained virologic response (SVR 12) if HCV RNA was undetectable 12 weeks following end of therapy, and were recorded as lost to follow-up (LTFU) if they did not present for an HCV follow-up visit. SVR was calculated in intention to treat (ITT) as well as modified intention to treat (mITT) analysis, which excluded those who completed treatment but had no SVR 12 result. A logistic regression model assessed factors associated with LTFU. RESULTS: Of 138 individuals included in the analysis, 52% were on opioid agonist therapy (OAT), 75% reported a history of injection drug use (IDU), with 25% reporting IDU in the month prior to treatment initiation. ITT SVR across all sites and genotypes was 86% and mITT was 95%. There was a significant difference in mITT for those reporting recent IDU compared to those who did not (87% vs 99% p = 0.03). While 13% were LTFU at SVR 12, participants receiving OAT in the same clinic as HCV treatment were less likely to be LTFU (aOR 0.09(0.02-0.46)). CONCLUSION: HCV treatment by family physicians, along with interdisciplinary teams, can be successful in inner-city populations in the era of DAAs; however, follow-up after treatment is a challenge. Integrating OAT in the same location as HCV treatment may help to improve follow-up.

Restrictions for reimbursement of direct-acting antiviral treatment for hepatitis C virus infection in Canada: a descriptive study.

BACKGROUND: In Canada, interferon-free, direct-acting antiviral hepatitis C virus (HCV) regimens are costly. This presents challenges for universal drug coverage of the estimated 220 000 people with chronic HCV infection nationwide. The study objective was to appraise criteria for reimbursement of 4 HCV direct-acting antivirals in Canada. METHODS: We reviewed the reimbursement criteria for simeprevir, sofosbuvir, ledipasvir-sofosbuvir and paritaprevir-ritonavir-ombitasvir plus dasabuvir in the 10 provinces and 3 territories. Data were extracted from April 2015 to June 2016. The primary outcomes extracted from health ministerial websites were: 1) minimum fibrosis stage required, 2) drug and alcohol use restrictions, 3) HIV coinfection restrictions and 4) prescriber type restrictions. RESULTS: Overall, 85%-92% of provinces/territories limited access to patients with moderate fibrosis (Meta-Analysis of Histologic Data in Viral Hepatitis stage F2 or greater, or equivalent). There were no drug and alcohol use restrictions; however, several criteria (e.g., active injection drug use) were left to the discretion of the physician. Quebec did not reimburse simeprevir and sofosbuvir for people coinfected with HIV; no restrictions were found in the remaining jurisdictions. Prescriber type was restricted to specialists in up to 42% of provinces/territories. INTERPRETATION: This review of criteria of reimbursement of HCV direct-acting antivirals in Canada showed substantial interjurisdictional heterogeneity. The findings could inform health policy and support the development and adoption of a national HCV strategy.

Optimizing assessment and treatment for hepatitis C virus infection in illicit drug users: a novel model incorporating multidisciplinary care and peer support.

OBJECTIVES: We evaluated assessment and treatment for hepatitis C virus (HCV) among illicit drug users accepting referral to a weekly HCV peer-support group at a multidisciplinary community health centre. METHODS: From March 2005 to 2008, HCV-infected individuals were referred to a weekly peer-support group and assessed for HCV infection. A retrospective chart review of outcomes 3 years after the initiation of the group was conducted (including HCV assessment and treatment). RESULTS: Two hundred and four HCV antibody-positive illicit drug users accepted referral to a weekly HCV peer-support group. Assessment for HCV occurred in 53% of patients(n= 109), with 13% (n= 14) having initiated or completed treatment for HCV infection before attending the support group, evaluation ongoing in 10% (n= 11) and treatment deferred/not indicated in 25% (n= 27). The major reasons for HCV treatment deferral included early disease (30%),drug dependence (37%), other medical (11%) or psychiatric comorbidities (4%). Sixty-eight percent of those deferred for reasons other than early liver disease showed multiple reasons for treatment deferral. The first 4 weeks of support group attendance predicted successful HCV assessment (odds ratio: 6.03, 95% confidence interval:3.27-11.12, P < 0.001). Overall, 28% (n= 57) received treatment. Among individuals having completed pegylated-interferon and ribavirin therapy with appropriate follow-up (n =19), the rate of sustained virologic response was 63% (12/19), despite illicit drug use in 53%. CONCLUSION: A high proportion of illicit drug users accepting referral to a weekly HCV peer-support group at a multidisciplinary health centre were assessed and treated for HCV infection. Peer support coupled with multidisciplinary care is an effective strategy for engaging illicit drug users in HCV care.