Peer support in small towns: A decentralized mobile Hepatitis C virus clinic for people who inject drugs

Background & aims: New models of HCV care are needed to reach people who inject drugs (PWID). The primary aim was to evaluate HCV treatment uptake among HCV RNA positive individuals identified by point-of-care (POC) testing and liver disease assessment in a peer-driven decentralized mobile clinic. Methods: This prospective study included consecutive patients assessed in a mobile clinic visiting 32 small towns in Southern Norway from November 2019 to November 2020. The clinic was staffed by a bus driver and a social educator offering POC HCV RNA testing (GeneXpert®), liver disease staging (FibroScan® 402) and peer support. Viremic individuals were offered prompt pan-genotypic treatment prescribed by local hospital-employed specialists following a brief telephone assessment. Results: Among 296 tested individuals, 102 (34%) were HCV RNA positive (median age 51 years, 77% male, 24% advanced liver fibrosis/cirrhosis). All participants had a history of injecting drug use, 71% reported past 3 months injecting, and 37% received opioid agonist treatment. Treatment uptake within 6 months following enrolment was achieved in 88%. Treatment uptake was negatively associated with recent injecting (aHR 0.60; 95% CI 0.36-0.98), harmful alcohol consumption (aHR 0.44; 95% CI 0.20-0.99), and advanced liver fibrosis/cirrhosis (aHR 0.44; 95% CI 0.25-0.80). HCV RNA prevalence increased with age (OR 1.81 per 10-year increase; 95% 1.41-2.32), ranging from 3% among those <30 years to 55% among those ≥60 years. Conclusions: A peer-driven mobile HCV clinic is an effective and feasible model of care that should be considered for broader implementation to reach PWID outside the urban centres. Keywords: hepatitis C virus; peer support; people who inject drugs; point of care; treatment. © 2022 The Authors. Liver International published by John Wiley & Sons Ltd.publishedVersio

Hepatitis C treatment uptake among people who inject drugs in Oslo, Norway: A registry-based study

Background Improving HCV treatment uptake among people who inject drugs (PWID) is crucial to achieving the WHO elimination targets. The aims were to evaluate HCV treatment uptake and HCV RNA prevalence in a large cohort of PWID in Norway. Methods Registry-based observational study where all users of the City of Oslo's low-threshold social and health services for PWID between 2010–2016 ( n = 5330) were linked to HCV notifications (1990–2019) and dispensions of HCV treatment, opioid agonist treatment (OAT) and benzodiazepines (2004–2019). Cases were weighted to account for spontaneous HCV clearance. Treatment rates were calculated using person-time of observation, and factors associated with treatment uptake were analysed using logistic regression. HCV RNA prevalence was estimated among individuals alive by the end of 2019. Results Among 2436 participants with chronic HCV infection (mean age 46.8 years, 30.7% female, 73.3% OAT), 1118 (45.9%) had received HCV treatment between 2010–2019 (88.7% DAA-based). Treatment rates increased from 1.4/100 PY (95% CI 1.1–1.8) in the pre-DAA period (2010–2013) to 3.5/100 PY (95% CI 3.0–4.0) in the early DAA period (2014–2016; fibrosis restrictions) and 18.4/100 PY (95% CI 17.2–19.7) in the late DAA period (2017–2019; no restrictions). Treatment rates for 2018 and 2019 exceeded a previously modelled elimination threshold of 50/1000 PWID. Treatment uptake was less likely among women (aOR 0.74; 95% CI 0.62–0.89) and those aged 40–49 years (aOR 0.74; 95% CI 0.56–0.97), and more likely among participants with current OAT (aOR 1.21; 95% CI 1.01–1.45). The estimated HCV RNA prevalence by the end of 2019 was 23.6% (95% CI 22.3–24.9). Conclusion Although HCV treatment uptake among PWID increased, strategies to improve treatment among women and individuals not engaged in OAT should be addressed.This research received funding from the following sources. KM receives research grants from the South-Eastern Norway Regional Health Authority , grant number: 2020011 . The funding sponsor has not been involved in study design, collection of data, analysis/interpretation of data, in the writing of the article, or in the decision to submit the article for publication.publishedVersio

The Consensus Hepatitis C Cascade of Care:standardized reporting to monitor progress toward elimination

Cascade-of-care (CoC) monitoring is an important component of the response to the global hepatitis C virus (HCV) epidemic. CoC metrics can be used to communicate, in simple terms, the extent to which national and subnational governments are advancing on key targets, and CoC findings can inform strategic decision-making regarding how to maximize the progression of individuals with HCV to diagnosis, treatment, and cure. The value of reporting would be enhanced if a standardized approach were used for generating CoCs. We have described the Consensus HCV CoC that we developed to address this need and have presented findings from Denmark, Norway, and Sweden, where it was piloted. We encourage the uptake of the Consensus HCV CoC as a global instrument for facilitating clear and consistent reporting via the World Health Organization (WHO) viral hepatitis monitoring platform and for ensuring accurate monitoring of progress toward WHO's 2030 hepatitis C elimination targets.</p

Mortality, morbidity and treatment uptake related to hepatitis C among people who have injected drugs in Norway

Background: Exposure to hepatitis C virus (HCV) implies for 60–80% of the patients a chronic infection which mainly affects the liver. Chronic hepatitis C (CHC) is estimated to affect 130 millions globally. In most of the Western world injecting drug use is the main cause of exposure to HCV. In Scandinavia about 0.5% of people between 15 and 70 years of age are affected, and in Norway that means that about 20,000 persons is estimated to have CHC. The natural course of CHC among PWID – with their high competing risk of death – is not sufficiently known. The aims of these studies were to elucidate both all-cause and liver related mortality, and progression of lifer fibrosis among PWID with CHC, as well as to estimate the rate of antiviral treatment uptake in this population and mortality according to treatment uptake. Methods and patients: The studies were executed within a cohort of 864 patients admitted to Statens klinikk for narkomane (The National Clinic for Drug Abusers) during the period 1970–1984. Frozen sera from 635 patients were stored at the Department for Virology at the Norwegian Institute of Public Health in Oslo. Of these 535 had been exposed to HCV (anti-HCV positive), and HCV RNA could be analysed with PCR-technique among 523, who comprised the study cohort in Paper 1. The patients were followed-up through register linkage to the Norwegian Causes of death registry, the Cancer registry of Norway, the Nordic Liver Transplantation Registry and the Norwegian Prescription Database. Antiviral treatment before 2004 was explored through linkage to Scandinavian treatment studies which in that period included about half the treated cases. In Paper 1 and Paper 2 the patients with CHC (anti-HCV positive/HCV RNA positive) were compared to those exposed to HCV with spontaneous clearance of the virus (anti-HCV positive/HCV RNA negative). Paper 1 was a longitudinal study of all-cause mortality and causes of death from the admission to drug abuse treatment in 1970–1984 followed-up until December 31, 2008, as well as of liver related mortality of the same patients from HCV-exposure to the same date. In Paper 2 liver tissue from autopsies were examined at the Institute of Forensic Medicine at the University of Oslo (now Department of Forensic Pathology, Division of Forensic Sciences at NIPH). The stage of liver fibroses was related to CHC and duration of the infection. In Paper 3 antiviral treatment uptake among the 245 CHC-patients alive in Norway January 1, 1997 was followed up until December 31, 2012. Mortality rate was compared in periods after versus before or without treatment. Results: Paper 1: Of 523 anti-HCV positive patients 389 (62.7%) had CHC. All-cause mortality rate was 1.85/100 person-years (PY); among males 2.11, and among females 1.39. Mortality rates were not affected by CHC the first 25 years after the admission to SKN. The main causes of death were intoxication (45%), suicide (9%) and accident (8%). Among patients with CHC 10/134 (7.5%) deaths were liverrelated; one had two years before death been liver-transplanted for end-stage liver disease. Among patients dying after 50 years of age, liver-related cause of death was as common as intoxication. Among HCV RNA negative patients 2/86 (2.3%) deaths were liver-related, both of which were associated with chronic hepatitis B. Paper 2: None of the 26 CHC-patients who were autopsied shorter than 15 years after HCV-exposure had advanced fibrosis (F3) or cirrhosis (F4). Among those who were autopsied 15-25 years after HCV-exposure 4/18 (22%) had F3 or F4, and among those autopsied more than 25 years after exposure 6/17 (35%) had F3 or F4. Among patients without chronic hepatitis there was one death with F4, autopsied 33 years after exposure to HCV. Paper 3: Of the 245 CHC-patients followed-up from 1997 to 2012 47 (19.2%) had received antiviral treatment. Among the patients alive by December 31, 2012 44/158 (27.2%) had received such treatment. The reason for the different proportions was much higher mortality among those who had not received treatment, mainly due to intoxications. Liver disease was cause of death for 13/81 (16%) of the untreated patients. Conclusions: CHC had no substantial influence on all-cause mortality among PWID the first 25 years after admission for drug abuse treatment 1974–1984. After 50 years of age liver disease became a major cause of death among PWID with CHC exposed to HCV in their late teens or early 20s. Among those autopsied more than 25 years after HCV-exposure 1/3 had advanced liver fibrosis or cirrhosis. Only 1/5 of the PWID with CHC received antiviral treatment during follow-up 1997–2012. It is of great importance for later liver morbidity and mortality in this group to increase antiviral treatment uptake, particularly among those with advanced fibrosis or cirrhosis

The Consensus Hepatitis C Cascade of Care: standardized reporting to monitor progress toward elimination

Cascade-of-care (CoC) monitoring is an important component of the response to the global hepatitis C virus (HCV) epidemic. CoC metrics can be used to communicate in simple terms the extent to which national and subnational governments are advancing on key targets, and CoC findings can inform strategic decision-making regarding how to maximize the progression of HCV-infected individuals to diagnosis, treatment and cure. The value of reporting would be enhanced if reporting entities utilized a standardized approach for generating their CoCs. We have described the Consensus HCV CoC that we developed to address this need and have presented findings from Denmark, Norway and Sweden, where it was piloted. We encourage the uptake of the Consensus HCV CoC as a global instrument for facilitating clear and consistent reporting via the World Health Organization (WHO) viral hepatitis monitoring platform and ensuring the accurate monitoring of progress toward WHO's 2030 hepatitis C elimination target