Programming Connection

Check Hep C 

CATIE

2017

A recent study1 shows that a program that provides health navigation for people who have been diagnosed with hepatitis C and who have not been traditionally well-served by the healthcare system has positive impacts on cure rates.

Check Hep C

The Check Hep C program was implemented at four community-based organizations in New York City in neighbourhoods where hepatitis C was prevalent. Two sites were community health centres with hepatitis C care and treatment, harm reduction programs and social services available onsite. Two were harm reduction programs that linked patients to hepatitis C treatment and care offsite but provided ongoing support to ensure continued engagement in hepatitis C care. Each program site had a health navigator  (who was not a peer) who used a comprehensive assessment to evaluate participant needs, physical and mental health, substance use, and social support. A care plan for each participant was created based on their assessment.

All participants were accompanied to appointments if they wanted to be, received alcohol counselling, health education, motivational interviewing, and treatment readiness counselling. Health navigators supported participants through medical evaluation, preparation for treatment, and treatment adherence. Navigators also facilitated insurance and medication authorization support to ensure that care and treatment would be covered. Treatment eligibility was determined by clinicians based on clinical and psychosocial factors.

Check Hep C participants

Between April 2014 and January 2015, Check Hep C enrolled 388 participants into the program. Of the 388 participants:

  • 73% were male, 26% female, and 1% transgender
  • 63% were Hispanic, 29% black, 7% white, and less than 1% classified as other
  • 61% were born between 1945 and 1965; median age was 52
  • 86% received either Medicare or Medicaid
  • 49% reported a current non-injection chemical dependence, including opioid substitution therapy
  • 29% reported using injection drugs in the last 12 months
  • 28% reported a mental health condition
  • 25% reported being homeless at the time of enrollment

Fifty-one percent of clients received clinical care offsite, 44% received onsite clinical care, and 5% were lost to follow up before completing their initial assessment with the health navigator.

30% of all Check Hep C participants were cured

Of the 388 participants enrolled in the program:

  • 77% completed a hepatitis C medical evaluation
  • 61% were eligible for treatment
  • 33% started treatment
  • 30% were cured

Thirty percent of all Check Hep C participants were cured, which represents a two-fold increase over the estimated 12% to 15% cure rate in New York City.2

Participants with onsite care did better than participants with offsite care

Eighty-six percent of patients who received their hepatitis C care onsite and who were medically evaluated were eligible for treatment compared to 73% of patients who were evaluated offsite. Forty-six percent of onsite patients initiated treatment compared to 25% of offsite patients. This represents two times greater odds of initiating treatment in participants with onsite hepatitis C care. The study authors suggest that onsite clinicians may have been more willing than clinicians at offsite locations to treat participants because a health navigator was part of the clinical services team.

Ninety-four percent of patients who initiated treatment in the organizations with onsite hepatitis C care were cured, compared to 86% of participants who received hepatitis C care offsite. Despite the difference, the cure rate among participants at both sites was very high.

However, the number of participants who were cured was significantly different when all 388 participants in Check Hep C were considered. Participants who received their hepatitis C care onsite were twice as likely to be cured compared to participants whose care was offsite (43% vs. 22%).

Some participants more likely to start treatment than others

Across all four sites, participants with more severe fibrosis or cirrhosis (F3 or F4 fibrosis score) were more than twice as likely to start treatment as those with less fibrosis (F0, F1, or F2). This may have been due to insurance policies restricting treatment only for those with high fibrosis scores. Participants born between 1945 and 1965 were also twice as likely to start treatment compared to all other age groups. Women were more likely to start treatment than men.

Participants who were homeless, used injection drugs, used alcohol, or had a chemical dependence were less likely to start treatment than those participants who were housed, and/or who didn’t use substances.

What does this mean for Canadian service providers?

In Canada, hepatitis C continues to be most prevalent among people who inject drugs or who have a history of injecting drugs.3 This population also continues to experience significant barriers to treatment such as lack of access to healthcare, and stigma and discrimination associated with substance use. This study shows that people with hepatitis C who have not been traditionally well-served by the healthcare system can achieve high hepatitis C cure rates in programs that have onsite and offsite clinical care when health navigation is part of their care plan.

There are a number of established Canadian navigation programs that provide health navigation to people with HIV. One program also provides navigation to people with hepatitis C.

Canadian practice guidelines that will support the implementation of new and the strengthening of existing health navigation programs in HIV are being developed. When published in 2017, the guidelines could be adapted to the needs of people with hepatitis C.

References

  1. Ford M, Johnson N, Desai P, et al. From care to cure: Demonstrating a model of clinical patient navigation for hepatitis C care and treatment among high-need patients. Clinical Infectious Diseases. 2017; in press.
  2. Balter S, Stark JH, Kennedy J, et al. Estimating the prevalence of hepatitis C infection in New York City using surveillance data. Epidemiology and Infection. 2014 Feb;142(2):262–9. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3891473/
  3. Trubnikov M, Yan P, Archibald C. Estimated prevalence of HCV infection in Canada, 2011. Canada Communicable Disease Report. 2014 Dec 18;40(19):429–36.  Available from: http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/14vol40/dr-rm40-19/surveillance-b-eng.php