Interventions in the HCV care continuum
Posted on June 22, 2015
New systematic review in the journal International Journal of Drug Policy discusses published evidence-based interventions to enhance assessment, treatment, and adherence in the chronic Hepatitis C care continuum. Authors note that primary care settings represent key opportunities for HCV care linkage interventions, often within clinics that have prolonged engagement with homeless, substance using populations, or people who inject drugs.
The new short-course, direct acting antiviral (DAA) regimens are relatively simple, well-tolerated, and are associated with >95% cure rates. However, HCV prevalence can only be reduced if available treatment is not only expanded, but targeted to those most likely to transmit the virus. A systematic review of published evidence-based interventions to enhance assessment, treatment, and adherence in the chronic Hepatitis C care continuum, was recently published in the journal International Journal of Drug Policy (Meyer JP et al. Int J Drug Policy. 2015 May 17. [Epub ahead of print]). The purpose of this systematic review of published scientific literature was to identify and synthesize data on those evidence-based interventions that strategically target one or more steps along the chronic HCV care continuum. Authors of this review state that in order to ultimately achieve SVR, individuals with chronic HCV infection must traverse the following steps:
- Be tested for, diagnosed with, and made aware of their HCV infection
- Engage with a healthcare provider with treatment knowledge and capacity
- Be evaluated for treatment
- Initiate treatment
- Adhere to and complete treatment
- Prevent re-infection
The first intervention strategy discussed in this review is diagnosis and case-finding. According to current US clinical guidelines, routine chronic HCV screening is recommended for all individuals born between 1945 and 1965, and those with specific risk behaviors, exposures, and comorbid conditions, including injection drug use, hemodialysis, incarceration, and HIV. Authors note that uptake of these guidelines is limited by a lack of targeted outreach strategies, and by providers’ limited incorporation of current guidelines into clinical practice. In other global settings, screening recommendations do not include the age-specific risk group.
- Screening-related interventions such as free counselling and testing, point-of-care testing, streamlined screen-test-immunize-reduce risk-refer protocols, dried blood spot testing, and provider education with nursing support, demonstrate high rates of uptake and case-finding when specifically applied to high-risk individuals in specific settings, including people who inject drugs (PWID) in needle and syringe exchange programs, patients in a primary care clinic with certified methadone prescribers, patients in specialty addiction treatment clinics and prison, patients in a mobile medical clinic, and individuals with co-occurring substance use and serious psychiatric disorders in community mental health programs.
For this review, linkage-to-care interventions were broadly defined as those with the common purpose of shifting HCV-diagnosed individuals towards HCV-specific care for further evaluation and treatment. With the simplicity of treatment with newer DAAs, however, treatment may move towards primary care venues. The authors note that it is currently unclear as to how ‘‘linkage to care’’ interventions will apply to less-specialized care settings including rural settings, where specialty services are largely unavailable.
- A multidisciplinary approach that combines medical and addiction treatment with intensive social support is common to all linkage-to-care interventions including those based on treatment settings such as addiction treatment centers providing opioid agonist treatments, primary care, and correctional settings.
- Primary care settings represent key opportunities for HCV care linkage interventions, often within clinics that have prolonged engagement with homeless, substance using populations, or PWIDs.
- In primary care settings where providers lacked experience in treating HCV, the Extension for Community Healthcare Outcomes model (Project ECHO) provided tele-health consultation that demonstrated equivalent SVR rates between remote tele-health sites and a specialty HCV clinic in an academic center (Arora, S et al. New Engl J Med. 364(23), 2199–2207)
Regarding pre-therapeutic evaluation/treatment initiation, HCV treatment is often deferred or not recommended for active PWIDs. Providers often unjustifiably defer HCV treatment for PWIDs because of concerns about treatment adherence, neuropsychiatric tolerability, or risk of re-infection, especially in the setting of ongoing drug injection, but often treatment is deferred because of perpetuated stigma against PWIDs. The authors of this review go on to discuss how PWIDs might benefit the most from HCV treatment, especially since they have the highest risk of transmission to others, and can achieve SVR if adequately supported through the treatment initiation process.
Once patients are successfully diagnosed, linked to care, and initiated on treatment, adherence to therapy needs to be optimized. Authors note that it’s currently unclear as to what level of adherence is optimal to achieve SVR with the new non-interferon-based regimens, which are more potent and possibly durable, and are associated with lower pill burdens and shorter treatment courses. However, the authors also note that DAA regimens have potentially lower barriers to developing genotypic resistance. While a number of studies describe multidisciplinary support programs to promote treatment adherence, retention, and completion, exactly how adherence issues impact DAA use and effectiveness outside of clinical trials remains a question to be addressed by real-world studies such as HCV-TARGET and TRIO.
The authors of this systematic review conclude the following: “In this systematic review, we described a variety of specific interventions designed to propel the HCV cascade of care and maximize dissemination of effective treatments. EBIs should be strategically incorporated into HCV treatment implementation efforts to most effectively deliver treatment and maximize treatment outcomes. Well-executed action plans, appropriate resource allocation, and comprehensive public health policies are urgently needed to translate the promise of clinical trial efficacy into real-world effectiveness.”