Enhancing the care cascade for hepatitis C infection in marginalised populations

Abstract

Background: Morbidity and mortality associated with hepatitis C virus (HCV) infection is rising globally. Direct-acting antiviral (DAA) therapy provides an opportunity to address this burden. HCV elimination goals are dependent on improving the HCV care cascade among marginalised populations, particularly people who inject drugs (PWID). Aims: This research aimed to assess the feasibility and outcomes of strategies to enhance HCV testing and diagnosis, liver disease assessment and treatment uptake in PWID and homeless people pre- and post-access to DAA therapy. Methods: Chapter 2 presents a systematic review of interventions to enhance HCV testing, linkage to care and treatment uptake among PWID using a search of electronic databases covering interventional studies published before July 2016. Relative risk ratios were generated for included studies. Chapters 3 to 5 draw on an observational cohort study of HCV screening and linkage to care, LiveRLife. Chapter 3 evaluates the acceptability and preferences of a simplified HCV RNA diagnostic algorithm. Acceptability of finger-stick HCV RNA testing and self-reported preferences were assessed (n=565). Chapters 4 and 5 characterise the HCV care cascade among PWID and homeless people. HCV RNA prevalence, liver fibrosis distribution and treatment uptake were evaluated among people attending homelessness services (n=202) and PWID (n=839) enrolled in LiveRLife. Key Findings: The systematic review indicated interventions that enhanced the HCV care cascade included onsite-testing, facilitated referral and integration of HCV care within drug treatment and psychiatric services delivered by multi-disciplinary teams. The HCV diagnostic acceptability study found that a majority of participants (65%) preferred finger-stick testing over venepuncture, with preference for results in 60 minutes. In homeless and PWID LiveRLife populations, high HCV RNA prevalence and significant liver fibrosis were observed. HCV treatment uptake increased considerably in the DAA era among homeless people (49%) and PWID (38%); however, concerted efforts are needed for further improvements. Conclusion: DAA therapy has rapidly improved the HCV cascade of care among marginalised populations, but major gaps remain. Further innovations, including simplified models of care with rapid HCV diagnosis and linkage to treatment, are required to achieve HCV elimination targets by 2030