Expanded Hepatitis C Virus (HCV) Testing and Linkage to Care: Program Implementation to Overcome Barriers to Engagement in Care

Abstract

Background. HCV screening was integrated into an existing program for expanded HIV testing and linkage to care (LTC), but HCV poses unique challenges and barriers. These include diagnosis confirmation, patient notification, LTC, and provider capacity to accommodate large numbers of chronically infected patients. We describe programmatic adaptations made to address these challenges. Methods. We incorporated HCV screening into a routine HIV testing and LTC program from 1 January 2014 to 30 April 2016. The HIV LTC coordinators oversaw screening, confirmatory testing, and patient notification. Patients with a confirmed diagnosis and an APRI score >0.5 were scheduled for a transient liver elastography. Patients with stage 4 fibrosis were linked to hepatology. The rest were linked to HCV treaters in ID and Primary Care. We compared LTC outcomes by clinical sites and patient demographics with descriptive statistics and chi-square (chi2) analysis. Results. Testing volumes increased from 2935 in 2013 to 5177 for 2014 (76%), 6510 in 2015 (122%), and 2272 from 1 January 2016 to 30 March 2016 (6816 annualized, 132%). Sero-positivity decreased from 7.6% in 2014 to 4.6% in 2015, to 4.3% in 2016, reflecting screening rather than risk-based testing. Confirmatory HCV PCR testing was conducted on 556 of 690 sero-positive patients (81%), with 67% testing positive and 33% negative. Of 373 confirmed cases, 138 (37%) have been linked with HCV care provider. Only 26 (7%) have received medication prior authorization and been treated. Of those not linked to care, 47 (20%) were ineligible for linkage (death, terminal illness, other), refused treatment, or repeatedly missed visits despite case follow up. LTC was higher for patients diagnosed in primary care and subspecialty clinics compared to ED or inpatient (chi2 = 48.6, p < 0.001). LTC was greater for patients with private insurance or Medicare versus patients with Medicaid or self-pay (chi2 = 12.6, p = 0.03). Conclusion. Despite progress, barriers to engagement in HCV care persist. Reflex confirmatory testing is needed. Improved LTC is needed, especially for patients diagnosed in the ED or inpatient setting and those covered under Medicaid or self-pay. Treatment uptake remains low, but triage pathways can prioritize treatment of patients with advanced disease.