Recommendations on hepatitis C screening for adults

Background: Antivirals for the treatment of hepatitis C virus (HCV) infection are effective, but many patients remain untreated and treatment is not yet routine in primary care. We evaluated the characteristics of patients who engaged in HCV treatment, and clinician perspectives on the barriers and facilitators to treatment. Methods: Our mixed-method, parallel-design study was conducted at a multisite primary care centre in downtown Toronto. In a retrospective chart review, we searched records from 2011 to 2017 to collect quantitative data, including HCV infection status and HCV treatment status. To contextualize the data, we conducted in-depth interviews with select physicians between Aug. 1 and Nov. 1, 2017, and analyzed the transcripts using content analysis. Results: Of the 40 381 charts reviewed, 727 patients (1.8%, 95% confidence interval [CI] 1.7%-1.9%) were infected with HCV, and 542 (74.6%) had HCV infection requiring treatment. Of those, 255 patients (47.0%) had engaged in treatment. Patients who had engaged in treatment were more likely to be male (odds ratio [OR] 1.63, 95% CI 1.10-2.42), older (OR 1.04 per year increase in age, 95% CI 1.02-1.05) and housed (OR 2.2, 95% CI 1.36-3.75), and they were more likely not to have engaged in injection drug use (OR 1.87, 95% CI 1.33-2.63). Based on interviews with 8 physicians, treatment barriers included a lack of knowledge about HCV treatment, concerns that patients would not adhere to medications and challenges related to medication access. Facilitators of treatment included access to specialist consultation, pharmacist support and primary care treatment guidelines. Common themes that emerged in both quantitative and qualitative components were the roles of unstable housing and intravenous drug use as barriers to engaging in and completing treatment. Interpretation: Our study captured provider-identified barriers to HCV care and the key factors related to retention in HCV care, including gender, age, housing status and experience with drug use. Successful primary-care-led HCV treatment programs may incorporate specialist and pharmacy support and focus on younger, female, underhoused populations and people who use drugs.

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“… 16 Our results support current Canadian recommendations, which recommend screening of those with a history of injection drug use. 32 …”

Section: Discussionmentioning

confidence: 99%

Family medicine–directed hepatitis C care and barriers to treatment: a mixed-methods study

Aesch

Craig-Neil

Shah

et al. 2021

cmajo

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“…Recently, the Canadian Task Force on Preventative Health Care recommended against birth-cohort screening for HCV due to a lack of high-quality evidence on the effectiveness of screening, high resource implications and financial barriers to accessing treatment [ 19 ]. However, the prevalence estimates used in the Task Force recommendations were markedly lower than the ones presented here, and were based on modeling studies rather than population-level seroprevalence data.…”

Section: Discussionmentioning

confidence: 99%

“…The cost-effectiveness of this strategy has been demonstrated [ 17 ], and has been recommended by the Canadian Liver Foundation for those born between 1945–1975, [ 18 ] and others [ 8 ]. However, recently published guidelines from the Canadian Task Force on Preventative Health Care have recommended against screening asymptomatic adults, including the birth-cohort born between 1945–1975 [ 19 ].…”

Section: Introductionmentioning

confidence: 99%

Population-based estimate of hepatitis C virus prevalence in Ontario, Canada

Bolotin¹,

Feld²,

Garber³

et al. 2018

PLoS ONE

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BackgroundHepatitis C virus (HCV) is the most burdensome infectious illness in Canada. Current screening strategies miss a significant proportion of cases, leaving many undiagnosed. Elevated HCV prevalence in those born between 1945 and 1965 has prompted calls for birth-cohort screening in this group. However, Canada lacks population-level data to support this recommendation. We performed a serosurvey to obtain population-based HCV prevalence estimates in Ontario residents born between 1945–1974, to generate evidence for birth-cohort screening recommendations.MethodsWe tested anonymized residual sera in five-year age-sex bands from Ontario for anti-HCV antibody. We performed descriptive epidemiological analysis and used a logistic regression model to determine HCV risk-factors.ResultsOf 10,006 sera analyzed, 155 (1.55%, 95% confidence interval (CI) 1.32, 1.81) were positive for HCV antibody. Individuals born between 1950–1964 had a significantly higher combined prevalence of 1.92% (95% CI 1.56, 2.34) compared to 1.14% (95% CI 0.69, 1.77) (p = 0.04) for those born between 1970–1974. For males, comprising 107/155 (69.03%) of positive samples, the highest prevalence was 3.00% (95% CI 1.95, 4.39) for the 1960–1964 birth-cohort. For females, the highest prevalence was 1.56% (95% CI 0.83, 2.65) for those born between 1955–1959. Male sex was significantly associated with positive HCV serostatus.InterpretationHCV prevalence in Ontario is highest among those in this birth cohort, and higher than previous estimates. The prevalence estimates presented in our study provide important data to underpin birth-cohort screening recommendations.

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“…Recently, hepatologists have issued hepatitis C screening recommendations for Canadian baby-boomers [20]. However, hepatitis C screening in Canada has only been recommended for high-risk individuals by the Public Health Agency of Canada [21], partly due to the uncertain prospective financial burden of a publicly funded screening and treatment policy. An accurate estimate of the national prevalence rate of CHC and the proportion undiagnosed is therefore needed to reliably predict the disease burden and to perform economic evaluations of population screening and disease eradication strategies.…”

Section: Discussionmentioning

confidence: 99%

A model-based framework for chronic hepatitis C prevalence estimation

et al. 2019

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Chronic hepatitis C (CHC) continues to be a highly burdensome disease worldwide. The often-asymptomatic nature of early-stage CHC means that the disease often remains undiagnosed, leaving its prevalence highly uncertain. This generates significant uncertainty in the planning of hepatitis C eradication programs to meet WHO targets. The aim of this work is to establish a mathematical framework for the estimation of a geographic locale’s CHC prevalence and the proportion of its CHC population that remains undiagnosed. A Bayesian MCMC approach is taken to infer these populations from the observed occurrence of CHC-related events using a recently published natural history model of the disease. Using the Canadian context as a specific example, this study estimates that in 2013, the CHC prevalence rate in Canada was 0.63% (95% CI: 0.53% - 0.72%), with 27.1% (95% CI: 19.3% - 36.1%) of the infected population undiagnosed.

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Recommendations on hepatitis C screening for adults

Cited by 57 publications

References 66 publications

Family medicine–directed hepatitis C care and barriers to treatment: a mixed-methods study

Family medicine–directed hepatitis C care and barriers to treatment: a mixed-methods study

Population-based estimate of hepatitis C virus prevalence in Ontario, Canada

A model-based framework for chronic hepatitis C prevalence estimation

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