Spotlight on improving HCV care

Two studies this month focused on interventions to improve the cascade of care for patients with hepatitis C virus (HCV).

The first study, a systematic review and meta-analysis, found several nonpharmaceutical interventions that improved outcomes in patients with HCV. Researchers looked at 148 unique studies (47 randomized controlled trials and 101 nonrandomized studies) that assessed the efficacy of interventions to improve the following primary outcomes in adults: HCV antibody testing, HCV RNA testing, linkage to HCV care, and direct-acting antiviral treatment initiation. Results were published March 15 by The Lancet Gastroenterology & Hepatology.

Medical chart reminders, clinician education, and point-of-care antibody testing significantly improved at least three study outcomes versus a comparator or control. Interventions that simplified HCV testing (including dried blood spot testing, point-of-care antibody testing, reflex RNA testing, and opt-out screening) significantly improved testing outcomes versus a comparator or control. Other interventions that significantly improved testing outcomes included enhanced patient and clinician support through patient education, clinician care coordination, and clinician education. Finally, integrated care and patient navigation or care coordination significantly improved linkage to care and the uptake of direct-acting antiviral treatment versus a comparator or control. Many studies included in the analysis of testing and linkage to care were conducted in the era of interferon-based HCV treatment, among other limitations, the authors noted.

An accompanying editorial noted that local, collaborative efforts will increase the chances of meeting the World Health Organization's target of eliminating HCV as a public health threat by 2030. “To realise the benefits of direct-acting antivirals, clinicians should know the HCV care cascade of their area and implement or support targeted interventions to achieve micro-elimination,” the editorialists wrote.

The second study, a randomized clinical trial, found that an accessible care model may be better than facilitated referral at curing HCV, specifically in individuals who inject drugs. Researchers conducted the trial at a syringe service program in New York City. From July 2017 to March 2020, they enrolled 165 participants who were HCV RNA-positive and had injected drugs during the prior 90 days. They randomized half of the participants to receive a care model characterized by low-threshold, nonstigmatizing care co-located in a syringe service program (accessible care) and half to receive facilitated referral to local clinicians through a patient navigation program (usual care). The accessible care model featured flexible appointment scheduling and a supportive harm reduction framework, which worked with clients to help them identify and pursue their own personal health goals without pressuring them to abstain from drugs or engage in drug treatment. The primary end point was achieving sustained virologic response within 12 months of enrollment. Results were published March 14 by JAMA Internal Medicine.

In the intention-to-treat analysis, 55 of 82 participants (67.1%) in the accessible care arm and 19 of 83 (22.9%) in the usual care arm achieved a sustained virologic response (P<0.001). Loss to follow-up was similar between groups (12.2% in the accessible care arm and 16.9% in the usual care arm; P=0.51). Of those who received therapy, 55 of 64 (85.9%) and 19 of 22 (86.3%) achieved a sustained virologic response in the accessible care and usual care arms, respectively (P=0.96). Significantly more participants in the accessible care arm achieved all steps in the care cascade, with the greatest attrition in the usual care arm seen in referral to an HCV clinician and attending a clinical visit. Among other limitations, the study was conducted at a single site and in an urban setting with a high concentration of harm reduction services and minimal state restrictions on prescribing of HCV direct-acting antivirals, the authors noted.