Real-life HCV management in US urban center
Posted on April 9, 2015
Study provides a “real-life” snapshot of how HCV infection is being addressed in a major US urban center
Acute hepatitis C infection is asymptomatic in 60-70% of individuals. Many people only learn that they are HCV-positive decades later, after their disease has progressed to cirrhosis, hepatocellular carcinoma, or liver failure. Unfortunately, 50-75% of people chronically infected with HCV remain unaware of their infection. Even if the result of a screening test is positive, confirmatory nucleic acid testing for hepatitis C RNA is required. Otherwise, physicians are not able to differentiate those with persistent infection from the 15-25% of people whose infection resolved after exposure to the virus.
The continuum of engagement in HCV care (HCV management) at a population level was assessed in a recent study published in the journal Hepatology, using data obtained by the Hepatitis Surveillance Program at the Philadelphia Department of Public Health (PDPH) (Vinker K et al. Hepatology. 2015 Mar;61(3):783-9). Healthcare providers and laboratories in Philadelphia are mandated to report all positive test results to the Health Department, regardless of risk, insurance status, or testing facility. All individuals with first positive HCV test reports from January 2010 through December 2013 were assessed in this study.
Based on calculations using seroprevalence estimates from NHANES and high risk populations, the authors anticipated receiving an HCV test on 28,990 individuals during the study period.
- Positive HCV Ab tests were received for 13,596/28,990 (47%) unique individuals during 2010-2013
Consistent with national estimates, fewer than half of city residents likely to be infected with HCV were identified by Health Department surveillance. One likely reason for the large prevalence of underdiagnosis of HCV-infected persons is lack of testing. Barriers to testing remain at both the patient and provider levels.
- Only 6,383 (22% of total estimate of 28,990) of those had their infection confirmed by HCV RNA testing
- The average time between the HCV Ab screening and RNA confirmatory test was 51 days
Health Department staff are working with local healthcare providers to raise awareness of HCV reflex confirmatory testing. Reflex confirmatory testing is additional testing automatically performed on an aliquot of the original specimen in response to a positive rapid screening Ab result. For those individuals in the study who had confirmed HCV disease, only 1,745 (6% of total estimate of 28,990) were in care, as measured by having two tests within 6 months or a test ordered by a specialist
- Based on interviews with HCV patients first identified during 2013 and their health care providers, 956 (3% of total estimate of 28,990) individuals were estimated to have been or currently receiving anti-HCV therapy
While only a few HCV-infected residents are successfully mobilized from screening through confirmatory testing and into care and treatment, this study does indicate that the CDC’s new HCV baby boomer recommendation is helping to promote routine testing. Significantly fewer individuals received their first positive HCV test in the months before the baby boomer testing recommendations than in the months following (P <0.001). However, only a slightly higher, non-significant proportion of patients tested in the post-baby boomer recommendation era received confirmatory HCV RNA testing. Interestingly, the mean time from HCV Ab screening to RNA confirmatory test dropped from 81 days in the pre- to 15 days in the post-baby boomer testing era (P <0.00001).
The proportion of HCV infected baby boomers patients (45-64 years of age) increased from Stage 1 to Stage 4 of the continuum of engagement. The majority of patients at Stage 1 (patients tested for HCV Ab) were white (49%), while the majority changed to black (approximately 48%) as patients passed Stage 2 (patients tested for HCV AB and confirmatory RNA) and were currently at Stage 3 (HCV RNA confirmed patients who are in medical care), or Stage 4 (HCV RNA confirmed patients who are in care and have received or are currently receiving specific antiviral treatment).
- The proportion of male patients was higher among those who had received or who were receiving HCV treatment (Stage 4) than earlier stages of the continuum (P <0.001).
- A larger proportion of individuals 44 years of age and younger were in the HCV Ab only group (41%), as compared to individuals in Stages 2, 3, and 4 (31%, 22%, and 21%, respectively; P <0.0001)
This study indicates that only a small proportion of individuals with confirmed HCV infection (15%) have received antiviral treatment. The authors speculated that given the time, cost, and side-effects associated with the HCV drug regimens available at the time, many specialists treated only those patients with the most urgent needs and “warehoused” all others until the newest HCV drugs became available towards the end of last year. To promote movement through the continuum of HCV care, state and local health departments need to devise ways to improve surveillance and enhance screening and linkage and retention in HCV care services.