Cascade of Care for Hepatitis C Virus (HCV) infected patients in an Urban Community Health Center in Massachusetts in the era of Direct Acting Antivirals (DAAs)

Abstract

Background. Despite increased focus on understanding the HCV cascade of care, data is limited in the DAA era, particularly in an urban community health setting. We aimed to study the HCV cascade of care at an urban community health center in the DAA era and to identify barriers to linkage to care, referral and treatment of HCV. Methods. We performed a retrospective review of patients with a positive HCV antibody and a visit at Dimock Community Health Center from October 31, 2014 to November 1, 2016. Data were abstracted from medical records for demographic details, medical and psychiatric comorbidities, substance abuse information and HCV specific characteristics such as genotype, HIV/Hepatitis B co-infection, and fibrosis scoring. Data were also abstracted for 52 patients actively engaged in HCV care with prior positive testing or who tested positive during the study period. Descriptive statistics, pair wise comparisons with Chi -Square, Fischer's exact and T-test were used to identify characteristics associated with referral and treatment of HCV infection. Results. 107 patients with positive HCV antibody were identified. HCV RNA was sent for 87 (81 %) and was detectable in 53 of 87 (61 %). Forty-two (48 %) were referred to care and 31 (36 %) were seen by infectious disease or hepatology. Fifteen (17.2 %) were approved for treatment. Age > 35, stable housing, and the absence of anxiety and hypertension were significantly associated with referral for HCV treatment. Of the patients who were HCV RNA positive, 32% were not referred for HCV treatment; the main reasons for non-referral were loss to follow-up and co-morbidities. Of the 52 patients actively engaged in HCV care, 49 had detectable HCV RNA. Twenty-eight (47 %) started treatment, and 10 (20 %) are awaiting insurance approval. Nineteen (68 %) patients have completed treatment and 9 remain on treatment. Conclusion. In this community based study, loss to follow-up and comorbidities led to non-engagement in care for 31% of patients with positive HCV RNA. When engaged in care, treatment success rates were comparable to other real-world studies. Our study suggests that specific interventions at different points in care may overcome loss from, or non-engagement in care. Opportunities exist for patient and provider education targeting high-risk populations at opioid substitution clinics and needle exchanges.