Seaman A, King C A, Kaser T, Geduldig A, Ronan W, Cook R, Chan B, Levander X A, Priest K C, Korthuis P T
Department of Medicine, Section of Addiction Medicine, Oregon Health & Science University, Portland, Oregon, United States; Hepatitis C Elimination Program, Central City Concern, Portland, Oregon, United States.
Dept. of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, Oregon, United States.
Int J Drug Policy. 2021 Oct;96:103359. doi: 10.1016/j.drugpo.2021.103359. Epub 2021 Jul 27.
Reaching World Health Organization hepatitis C (HCV) elimination targets requires diagnosis and treatment of people who use drugs (PWUD) with direct acting antivirals (DAAs). PWUD experience challenges engaging in HCV treatment, including needing multiple provider and laboratory appointments. Women, minoritized racial communities, and homeless individuals are less likely to complete treatment.
We implemented a streamlined opt-out HCV screening and linkage-to-care program in two healthcare for the homeless clinics and a medically supported withdrawal center. Front-line staff initiated a single-order reflex laboratory bundle combining screening, confirmation, and pre-treatment laboratory evaluation from a single blood draw. Multinomial logistic regression models identified characteristics influencing movement through each stage of the HCV treatment cascade. Multiple logistic regression models identified patient characteristics associated with HCV care cascade progression and Cox proportional hazards models assessed time to initiation of DAAs.
Of 11,035 clients engaged in services between May 2017 and March 2020, 3,607 (32.7%) were screened. Of those screened, 1,020 (28.3%) were HCV PCR positive. Of those with detectable RNA, 712 (69.8%) initiated treatment and 670 (94.1%) completed treatment. Of those initiating treatment, 407 (57.2%) achieved SVR12. There were eight treatment failures and six reinfections. In the unadjusted model, the bundle intervention was associated with increased care cascade progression, and in the survival analysis, decreased time to initiation; these differences were attenuated in the adjusted model. Women were less likely to complete treatment and SVR12 labs than men. Homelessness increased likelihood of screening and diagnosis but was negatively associated with completing SVR12 labs. Presence of opioid and stimulant use disorder diagnoses predicted increased care cascade progression.
The laboratory bundle and referral pathways improved treatment initiation, time to initiation, and movement across the cascade. Despite overall population improvements, women and homeless individuals experienced important gaps across the HCV care cascade.
要实现世界卫生组织丙型肝炎（HCV）消除目标，需要使用直接抗病毒药物（DAA）对吸毒者（PWUD）进行诊断和治疗。吸毒者在接受HCV治疗时面临诸多挑战，包括需要多次就诊于医疗服务提供者和实验室。女性、少数族裔社区成员以及无家可归者完成治疗的可能性较小。
我们在两家无家可归者医疗诊所和一个医学支持的戒毒中心实施了一项简化的选择退出式HCV筛查及与护理衔接项目。一线工作人员启动了一个单项反射实验室套餐，通过一次抽血完成筛查、确认和治疗前实验室评估。多项逻辑回归模型确定了影响HCV治疗流程各阶段进展的特征。多重逻辑回归模型确定了与HCV护理流程进展相关的患者特征，Cox比例风险模型评估了开始使用DAA的时间。
在2017年5月至2020年3月期间接受服务的11,035名客户中，3,607人（32.7%）接受了筛查。在接受筛查的人群中，1,020人（28.3%）HCV PCR检测呈阳性。在RNA可检测到的人群中，712人（69.8%）开始治疗，670人（94.1%）完成治疗。在开始治疗的人群中，407人（57.2%）实现了持续病毒学应答12周（SVR12）。有8例治疗失败和6例再感染。在未调整模型中，套餐干预与护理流程进展增加相关，在生存分析中，与开始治疗时间缩短相关；在调整模型中，这些差异有所减弱。女性完成治疗和SVR12检测的可能性低于男性。无家可归增加了筛查和诊断的可能性，但与完成SVR12检测呈负相关。存在阿片类药物和兴奋剂使用障碍诊断预示着护理流程进展增加。
实验室套餐和转诊途径改善了治疗启动、开始治疗时间以及整个流程的进展。尽管总体人群有所改善，但女性和无家可归者在HCV护理流程中仍存在重大差距。
