Original Article

Association of Referral Source and Substance Use with Hepatitis C Virus Outcomes at a Southern Academic Medical Center

Authors: H. Jensie Burton, MD, Aastha Khatiwada, PhD, Dongjun Chung, PhD, Eric G. Meissner, MD, PhD

Abstract

Objectives: Therapeutic advances make the cure of chronic hepatitis C virus (HCV) infection achievable for individuals aware of their diagnosis who can access care. Identifying barriers to accessing care is critical to achieve population-level HCV elimination and improve the cascade of care from diagnosis to cure.

Methods: To identify barriers to HCV care, we performed a retrospective observational analysis of outcomes for patients with chronic HCV referred to an infectious diseases clinic at an academic medical center in Charleston, South Carolina between January 1, 2015 and January 1, 2020. We categorized outcomes in the cascade of care between “never presenting for evaluation” and “completed treatment with documented cure.” Patient demographic factors, referral source, ZIP code of residence, insurance status, clinical characteristics, antiviral regimen, psychiatric and substance use history, and route of infection were assessed for associations with care outcomes.

Results: Of 407 referrals, 32% of patients never presented for an initial evaluation, an outcome that was associated with active substance use, mental health disease, and referral from an emergency department or obstetrics-gynecology provider. Of the patients who presented for an initial evaluation, 78% of patients initiated treatment. Active substance use was the only variable associated with lack of therapy initiation after presenting for an initial evaluation (odds ratio 2.5, 95% confidence interval 1.07–5.84). Once treatment had been initiated, no clinical or demographic variables were associated with odds of achieving documented or presumed HCV cure.

Conclusions: Active substance use, mental health disease, and referral from an emergency department or obstetrics-gynecology provider were associated with a lower odds of presenting for evaluation and initiation of HCV treatment. Innovative models to improve access to care and increase outreach to vulnerable populations will be essential to eliminate HCV.
Posted in: Liver Disease6

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References

1. Hofmeister MG, Rosenthal EM, Barker LK, et al. Estimating prevalence of hepatitis C virus infection in the United States, 2013-2016. Hepatology 2019;69:1020–1031.
 
2. Liang TJ, Ward JW. Hepatitis C in injection-drug users—a hidden danger of the opioid epidemic. N Engl J Med 2018;378:1169–1171.
 
3. Kim HS, Yang JD, El-Serag HB, et al. Awareness of chronic viral hepatitis in the United States: an update from the National Health and Nutrition Examination Survey. J Viral Hepat 2019;26:596–602.
 
4. Thomas DL. Global elimination of chronic hepatitis. N Engl J Med 2019; 380:2041–2050.
 
5. Daniel KE, Saeian K, Rizvi S. Real-world experiences with direct-acting antiviral agents for chronic hepatitis C treatment. J Viral Hepat 2020;27: 195–204.
 
6. Cachay ER, Mena A, Morano L, et al. Predictors of hepatitis C treatment failure after using direct-acting antivirals in people living with human immunodeficiency virus. Open Forum Infect Dis 2019;6:ofz070.
 
7. Janjua NZ, Darvishian M, Wong S, et al. Effectiveness of ledipasvir/sofosbuvir and sofosbuvir/velpatasvir in people who inject drugs and/or those in opioid agonist therapy. Hepatol Commun 2019;3:478–492.
 
8. Naggie S, Ramers CB. Sustained virologic response in people who inject drugs and/or whoare on opioid agonist therapy: is 90% enough? Hepatol Commun 2019;3:453–455.
 
9. Ing Lorenzini K, Girardin F. Direct-acting antiviral interactions with opioids, alcohol or illicit drugs of abuse in HCV-infected patients. Liver Int 2020;40: 32–44.
 
10. Eletreby R, El-Serafy M, Anees M, et al. Sofosbuvir-containing regimens are safe and effective in the treatment of HCV patients with moderate to severe renal impairment. Liver Int 2020;40:797–805.
 
11. Gaur N, Malhotra V, Agrawal D, et al. Sofosbuvir-velpatasvir fixed drug combination for the treatment of chronic hepatitis C infection in patients with end-stage renal disease and kidney transplantation. J Clin Exp Hepatol 2020;10:189–193.
 
12. Buckley GJ, Strom BL. A national strategy for the elimination of viral hepatitis emphasizes prevention, screening, and universal treatment of hepatitis C. Ann Intern Med 2017;166:895–896.
 
13. Safreed-Harmon K, Blach S, Aleman S, et al. The consensus hepatitis C cascade of care: standardized reporting to monitor progress toward elimination. Clin Infect Dis 2019;69:2218–2227.
 
14. Spradling PR, Zhong Y, Moorman AC, et al. Psychosocial obstacles to hepatitis C treatment initiation among patients in care: a hitch in the cascade of cure. Hepatol Commun 2021;5:400–411.
 
15. Kim NJ, Holguin D, Bush D, et al. Hepatitis C screening in an underserved U.S. cohort of reproductive age women. Hepatol Commun 2019;3: 1183–1190.
 
16. US Preventive Services Task Force. Screening for hepatitis C virus infection in adolescents and adults: US Preventive Services Task Force recommendation statement. JAMA 2020;323:970–975.
 
17. Aleman S, Soderholm J, Busch K, et al. Frequent loss to follow-up after diagnosis of hepatitis C virus infection: a barrier towards the elimination of hepatitis C virus. Liver Int 2020;40:1832–1840.
 
18. Miller LS, Millman AJ, Lom J, et al. Defining the hepatitis C cure cascade in an urban health system using the electronic health record. J Viral Hepat 2020;27:13–19.
 
19. Castrejon M, Chew KW, Javanbakht M, et al. Open Forum Infect Dis 2017; 4:ofx109.
 
20. Turner BJ, Rochat A, Lill S, et al. Hepatitis C virus screening and care: complexity of implementation in primary care practices serving disadvantaged populations. Ann Intern Med 2019;171:865–874.
 
21. Patel EU, Mehta SH, Boon D, et al. Limited coverage of hepatitis C virus testing in the United States, 2013-2017. Clin Infect Dis 2019;68:1402–1405.
 
22. Blanding DP, Moran WP, Bian J, et al. Linkage to specialty care in the hepatitis C care cascade. J Investig Med 2021;69:324–332.
 
23. Cowan E, Hardardt J, Brandspiegel S, et al. Care cascade of patients with hepatitis C and HIV identified by emergency department screening. J Viral Hepat 2021;28:1484–1487.
 
24. Yanes-Lane M, Dussault C, Linthwaite B, et al. Using the barriers and facilitators to linkage to HIV care to inform hepatitis C virus (HCV) linkage to care strategies for people released from prison: findings from a systematic review. J Viral Hepat 2020;27:205–220.
 
25. Lo Re V 3rd, Gowda C, Urick PN, et al. Disparities in absolute denial of modern hepatitis C therapy by type of insurance. Clin Gastroenterol Hepatol 2016;14:1035–1043.
 
26. Desai S, McWilliams JM. Consequences of the 340B drug pricing program. N Engl J Med 2018;378:2053–2054.
 
27. Rosenberg ES, Rosenthal EM, Hall EW, et al. Prevalence of hepatitis C virus infection in US states and the District of Columbia, 2013 to 2016. JAMA Netw Open 2018;1:e186371.
 
28. van Dijk M, Drenth JPH, HepNed Study Group. Loss to follow-up in the hepatitis C care cascade: A substantial problem but opportunity for microelimination. J Viral Hepat 2020;27:1270–1283.
 
29. Akiyama MJ, Norton BL, Arnsten JH, et al. Intensive models of hepatitis C care for people who inject drugs receiving opioid agonist therapy: a randomized controlled trial. Ann Intern Med 2019;170:594–603.
 
30. Dore GJ, Feld JJ, Thompson A, et al. Simplified monitoring for hepatitis C virus treatment with glecaprevir plus pibrentasvir, a randomised noninferiority trial. J Hepatol 2020;72:431–440.
 
31. Patel AA, Bui A, Prohl E, et al. Innovations in hepatitis C screening and treatment. Hepatol Commun 2021;5:371–386.
 
32. Rojas SA, Godino JG, Northrup A, et al. Effectiveness of a decentralized hub and spoke model for the treatment of hepatitis C virus in a federally qualified health center. Hepatol Commun 2021;5:412–423.
 
33. Scott J, Fagalde M, Baer A, et al. A population-based intervention to improve care cascades of patients with hepatitis C virus infection. Hepatol Commun 2021;5:387–399.
 
34. Yang N, Muir A. Coordination, cost, and changing epidemiology— considerations in the hepatitis C care cascade. Hepatol Commun 2021;5: 355–357.
 
35. Chiong F, Post J. Opportunistic assessment and treatment of people with hepatitis C virus infection admitted to hospital for other reasons: a prospective cohort study. Int J Drug Policy 2019;65:50–55.