Despite the availability of a cure, many people living with hepatitis C are not being tested, diagnosed, linked to care and treated for hepatitis C. A study of the American hepatitis C continuum of care found that only 50% of people living with hepatitis C are aware of their status, 43% have accessed care, 27% have a confirmed RNA-positive test result, 16% have been prescribed treatment, and 9% have achieved a cure (sustained virological response).
Canada does not have a similar snapshot of the hepatitis C continuum of care. However, we do know there is a significant drop off between the estimated number of people living with chronic hepatitis C and those that are aware of their status. The Public Health Agency of Canada estimates that 44% of people living with chronic hepatitis C don’t know it.
Community-based programs that provide comprehensive screening, diagnosis and linkage services for people at high risk for hepatitis C may improve engagement across the continuum of care. Do One Thing is an intervention in an under-served neighbourhood of Philadelphia that provides comprehensive hepatitis C and HIV services, including patient navigation, to help participants access and remain in specialist care. The study evaluated the hepatitis C component of the program, which showed the intervention to be effective in engaging a population who may experience significant barriers to hepatitis C screening, diagnosis and linkage to care.
Do One Thing
Participants in Do One Thing were recruited, tested and counselled in the community. Rapid hepatitis C testing was done using a finger-prick blood test. Participants who tested hepatitis C antibody positive were offered immediate onsite blood draws for confirmatory testing to determine chronic infection. All participants who had a reactive rapid test result met with a patient navigator and were subsequently contacted with their confirmatory test results.
Participants who tested hepatitis C RNA positive on the confirmatory test were supported by a patient navigator to ensure they obtained health insurance, if necessary; found a primary care provider, if necessary; and requested specialist referrals from their primary care providers. Navigators also made phone calls and sent text messages to remind participants about appointments, made home visits, provided transit vouchers, and accompanied participants to all associated medical appointments to reduce barriers to care.
Results
Between December 2012 and February 2014, program participants were followed and outcomes were assessed. Fifty-eight percent of chronically infected participants had an alcohol abuse disorder; 47% had a history of injection drug use; 72% had a history of inhalation drug use; and 80% had serious psychiatric disorders, which suggest a population that may have significant barriers to getting and staying in care.
Screening and diagnosis
Between December 2012 and February 2014, the program screened 1,301 participants for hepatitis C antibodies. During this period, 52 people were found to be antibody positive for hepatitis C (3.9%). Four participants (8%) were already engaged in hepatitis C care and were not offered confirmatory testing. The remaining 48 participants (100%) accepted confirmatory testing but only 42 tests were actually conducted. Thirty-six out of 42 (86%) participants who completed confirmatory testing had chronic hepatitis C infection (and all but one received the results). This means the seroprevalence of chronic hepatitis C in the participants was about 3%.
Linkage to care
A number of care outcomes necessary to access treatment were measured, including getting health insurance, finding a primary care provider and getting linked to hepatitis C specialist care. Over the 16 months of the study
- 9 out of the 12 participants (75%) who did not have health insurance obtained it after their hepatitis C diagnosis (66% already had insurance at the time of diagnosis)
- 29 out of 32 participants (90%) who obtained or already had health insurance found a primary care provider
- 23 out of 29 (79%) participants with a primary care provider were referred to hepatitis C specialist care
- 21 out of 23 (91%) participants with a referral to a hepatitis C specialist attended their appointment
Retention in care
Seventeen out of 21 (81%) participants linked to hepatitis C specialty care were retained in care. Ninety-five percent of clients in specialty care underwent disease staging, including liver ultrasound and fibrosis assessment. These tests are important to determine whether treatment should be initiated or can be delayed.
Treatment
Twelve out of 17 (71%) participants retained in hepatitis C care started treatment. Overall, 12 out of 36 participants (33%) with chronic hepatitis C infection initiated therapy.
Conclusion
Do One Thing shows that people with chronic hepatitis C will engage in hepatitis C-specific care when offered community-based rapid screening and diagnosis, and patient navigation services across the continuum of care. The program shows that its chief strengths—its rootedness in the community and its comprehensive nature—result in high rates of screening, diagnosis, linkage to care and engagement in care, and show promising rates of treatment initiation.
—Logan Broeckaert
References
- Yehia BR, Schranz AJ, Umscheid CA, Lo Re V. The Treatment Cascade for Chronic Hepatitis C Virus Infection in the United States: A Systematic Review and Meta-Analysis. Rizza SA, editor. PLoS ONE. 2014 Jul 2;9(7):e101554.
- Trubnikov M, Yan P, Archibald C. Estimated prevalence of Hepatitis C Virus infection in Canada, 2011. Canadian Communicable Disease Report. 2014 Dec 18;40(19).
- Trooskin TB, Poceta J, Towey CM, Yolken A, Rose JS, Luqman NL. Results from a Geographically Focused, Community-Based HCV Screening, Linkage to Care and Patient Navigation Program. Journal of General Internal Medicine. 2015; in press.