[Viva] Fwd: Programming Connection spotlights evidence briefs

shelly tognazzini shetognazzini at gmail.com
Mon Feb 4 08:24:07 PST 2019 

Interesting study stats on Hep C. Good morning😊

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From: CATIE <mailer at catie.ca>
Date: Mon, Feb 4, 2019, 8:21 AM
Subject: Programming Connection spotlights evidence briefs
To: <shetognazzini at gmail.com>


Check HepC

Shared experience. Stronger programs.
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*Evidence Brief*

Evidence briefs review a single study on a specific HIV or hepatitis C
prevention, testing, treatment, care or support program. Evidence briefs
provide a summary of up-to-date and peer-reviewed literature that includes
both Canadian and international programming.
*Check Hep C*
New York City, USA
2018

Check Hep C is a community-based program in New York City focused on
linkage to care and patient navigation for hepatitis C treatment for
high-risk populations, including people who use drugs. This program is
based out of community health centres (CHCs) and needle and syringe
programs (NSPs). Patient navigators support individuals through the
testing, diagnosis and treatment process. This program successfully linked
85% of people diagnosed with a current hepatitis C infection to care in
year one. Thirty percent of program participants who were diagnosed with
hepatitis C infection were cured in year two of the program.

*Program description1,2 *

The Check Hep C program was rolled out at CHCs and harm reduction programs
located in low-income neighbourhoods with high rates of hepatitis C,
serving predominantly minority populations. The CHCs provided onsite
hepatitis C care and treatment, harm reduction programs and social
services. The core program component was a patient navigator at each site
who helped support patients through hepatitis C treatment and care.
Navigators assessed patient needs for physical and mental health, substance
use and social support.

Individuals were recruited to the program via outreach at the participating
CHCs and NSPs and in the community. Upon entering the program, patients
received a point-of-care antibody test. The point-of-care test produced
screening results within the same appointment. If the test result was
positive, blood was drawn during the same appointment for the confirmatory
RNA test. Confirmatory RNA test results were typically available within
seven days.

If patients were diagnosed with chronic hepatitis C infection, they were
referred to a patient navigator located at the CHC or NSP. Participants at
CHCs had access to onsite clinical care, whereas patients evaluated at NSPs
were connected to external clinical care. A care plan for each participant
was created on the basis of their assessment. Patient navigators were
trained to provide comprehensive linkage-to-care services, including:

   - creating and following a care plan for each patient
   - making medical appointments for clients and accompanying them if needed
   - case management to address barriers to care
   - counselling for treatment readiness and adherence
   - health education and linkage to other services
   - enrollment into benefits programs and assistance with insurance

*Results*

A study1 (2012 to 2013) on year one of the program looked at the Check Hep
C program’s ability to perform screening and confirmatory tests, link
people to care and initiate treatment (only interferon-based treatment was
available at the time of this study). The study was conducted at 12 sites
including CHCs and NSPs. A patient was considered linked to care if they
attended a minimum of one hepatitis C medical appointment after diagnosis.

   - A total of 4,751 individuals were tested for hepatitis C infection,
   with 512 (11%) having a confirmed, current infection.
   - Of those with a current infection, 435 (85%) individuals attended at
   least one hepatitis C medical appointment.

The study followed patients who were linked to care onsite at a CHC. Of the
157 patients linked to care in year one:

   - 30% were considered treatment candidates
   - 9% initiated treatment
   - 4% were cured (43% of those who started treatment were cured)

A separate study on year two of the program from 2014 to 20152 followed
participants after they had already been diagnosed with a chronic hepatitis
C infection. This study was conducted in two CHCs and two NSPs that had
participated in year one of the program. Sixty-one percent of participants
were born between 1945 and 1965, 73% were male (26% female and 1%
transgender), 49% reported being dependent on non-injection drugs in the
past year, including opioid substitution therapy, and 28% reported having a
mental health condition. Of the 388 participants enrolled in the program:

   - 77% completed a hepatitis C medical evaluation (linked to care)
   - 61% were eligible for treatment (using direct-acting antivirals [DAAs])
   - 33% started treatment
   - 30% were cured (91% of those who started treatment were cured)

This 30% cure rate represents a two-fold increase over the estimated 12% to
15% cure rate overall in New York City.3

Participants evaluated onsite at CHCs were significantly more likely to be
eligible for treatment (86%) than participants who were referred for
offsite services (76%) and were more than twice as likely to initiate
treatment (46%) than offsite participants (25%). No significant differences
were reported in cure rates between the two groups.

*Some participants more likely to start treatment than others*

In the 2012 to 2013 study,1 many participants were not considered to be
candidates for treatment because they had other conflicting health
conditions, they did not have liver fibrosis, they had ongoing alcohol or
drug use issues or they were lost to follow-up. This resulted in low
overall treatment numbers. At the time of this study, only interferon-based
treatment was available. The authors suggest that many providers were
waiting for new, more effective DAA treatments to become available before
prescribing treatment.

By 2014 to 2015, DAA treatments had become available, although strict
guidelines set by health insurers prevented many patients from accessing
the drugs. Reasons for ineligibility included active drug use, conflicting
health conditions and current alcohol use. Participants with more severe
fibrosis (F3 or F4 fibrosis score) were twice as likely to begin treatment
as those with less severe fibrosis (F1 or F2), and those born between 1945
and 1965 were twice as likely to start treatment as all other age groups.
Participants who were homeless, used injection drugs, used alcohol or had a
chemical dependence were less likely to start treatment than those who were
housed and/or who didn’t use substances.

*What does this mean for service providers?*

People who use drugs continue to experience significant barriers to
treatment such as lack of access to healthcare, and stigma and
discrimination associated with substance use. Linkage to care is even more
essential because new DAA treatments are highly effective and easy to
complete and they can be accessed with few restrictions in Canada. This
study shows that high hepatitis C cure rates can be achieved in populations
that have not been traditionally well-served by the healthcare system when
health navigation is part of their care plan.

Patient navigators played a central role in this program in helping clients
navigate the HCV continuum of care
<https://catie.us16.list-manage.com/track/click?u=89abcbccf295c7b8d9a92cf09&id=68b88e7748&e=3006f90030>,
including testing, diagnosis and treatment. There is typically significant
patient drop-off at each stage and using a patient navigator helped to
mitigate this.

The Check Hep C program model also demonstrates the effectiveness of
point-of-care testing followed by immediate blood draws for confirmatory
testing. Because this testing can all be done in one appointment (followed
by a seven-day wait for RNA results), a hepatitis C diagnosis can be made
in a shorter time, reducing the risk of losing a patient to follow-up.

*Related resources*

Hepatitis C point of care testing: What is its impact on testing and
linkage to care?
<https://catie.us16.list-manage.com/track/click?u=89abcbccf295c7b8d9a92cf09&id=42f18d92e2&e=3006f90030>
HepTLC
<https://catie.us16.list-manage.com/track/click?u=89abcbccf295c7b8d9a92cf09&id=d294a8c9cb&e=3006f90030>–
evidence brief
Patient Navigation
<https://catie.us16.list-manage.com/track/click?u=89abcbccf295c7b8d9a92cf09&id=dd34a55b58&e=3006f90030>
– evidence brief
Ontario Hepatitis C Team: The Ottawa Hospital and Regional Hepatitis Program
<https://catie.us16.list-manage.com/track/click?u=89abcbccf295c7b8d9a92cf09&id=47fbd1dc68&e=3006f90030>
– case study
Practice Guidelines in Peer Health Navigation for People Living with HIV
<https://catie.us16.list-manage.com/track/click?u=89abcbccf295c7b8d9a92cf09&id=859688a623&e=3006f90030>

*References*

   1. Ford MM, Jordan AE, Johnson N et al. Check Hep C: a community-based
   approach to hepatitis C diagnosis and linkage to care in high-risk
   populations. *Journal of Public Health Management and Practice. *
   2018:24(1):41–8.
   2. Ford M, Johnson N, Desai P et al. From care to cure: demonstrating a
   model of clinical patient navigation for hepatitis C care and treatment
   among high-need patients. *Clinical Infectious Diseases*.
   2017:64(5):685–91.
   3. Balter S, Stark JH, Kennedy J et al. Estimating the prevalence of
   hepatitis C infection in New York City using surveillance data.
*Epidemiology
   and Infection*. 2014 Feb;142(2):262–9.


For more evidence briefs on linkage to care programming, see the Programming
Connection
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.

The Programming Connection is an online collection of innovative HIV and
hepatitis C program models.  If you have any feedback or know of a
successful program in your region, please contact us at:
programmingconnection at catie.ca.
*eduCATIE.ca
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CATIE offers open online courses through eduCATIE.ca to build knowledge of
HIV and hepatitis C science. Courses are self-directed and are designed for
service providers who prefer to learn on their own time and at their own
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[image: CATIE, Canada's source for HIV and hepatitis C information]
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