Programming Connection

Check Hep C 


New York City, USA
2019

Check Hep C is a community-based program in New York City focused on linkage to care and patient navigation for hepatitis C treatment for high-risk populations, including people who use drugs. This program is based out of community health centres (CHCs) and needle and syringe programs (NSPs). Patient navigators support individuals through the testing, diagnosis and treatment process. This program successfully linked 85% of people diagnosed with a current hepatitis C infection to care in year one. Thirty percent of program participants who were diagnosed with hepatitis C infection were cured in year two of the program.

Program description1,2

The Check Hep C program was rolled out at CHCs and harm reduction programs located in low-income neighbourhoods with high rates of hepatitis C, serving predominantly minority populations. The CHCs provided onsite hepatitis C care and treatment, harm reduction programs and social services. The core program component was a patient navigator at each site who helped support patients through hepatitis C treatment and care. Navigators assessed patient needs for physical and mental health, substance use and social support.

Individuals were recruited to the program via outreach at the participating CHCs and NSPs and in the community. Upon entering the program, patients received a point-of-care antibody test. The point-of-care test produced screening results within the same appointment. If the test result was positive, blood was drawn during the same appointment for the confirmatory RNA test. Confirmatory RNA test results were typically available within seven days.

If patients were diagnosed with chronic hepatitis C infection, they were referred to a patient navigator located at the CHC or NSP. Participants at CHCs had access to onsite clinical care, whereas patients evaluated at NSPs were connected to external clinical care. A care plan for each participant was created on the basis of their assessment. Patient navigators were trained to provide comprehensive linkage-to-care services, including:

  • creating and following a care plan for each patient
  • making medical appointments for clients and accompanying them if needed
  • case management to address barriers to care
  • counselling for treatment readiness and adherence
  • health education and linkage to other services
  • enrollment into benefits programs and assistance with insurance

Results

A study1 (2012 to 2013) on year one of the program looked at the Check Hep C program’s ability to perform screening and confirmatory tests, link people to care and initiate treatment (only interferon-based treatment was available at the time of this study). The study was conducted at 12 sites including CHCs and NSPs. A patient was considered linked to care if they attended a minimum of one hepatitis C medical appointment after diagnosis.

  • A total of 4,751 individuals were tested for hepatitis C infection, with 512 (11%) having a confirmed, current infection.
  • Of those with a current infection, 435 (85%) individuals attended at least one hepatitis C medical appointment.  

The study followed patients who were linked to care onsite at a CHC. Of the 157 patients linked to care in year one:

  • 30% were considered treatment candidates
  • 9% initiated treatment
  • 4% were cured (43% of those who started treatment were cured)

A separate study on year two of the program from 2014 to 20152 followed participants after they had already been diagnosed with a chronic hepatitis C infection. This study was conducted in two CHCs and two NSPs that had participated in year one of the program. Sixty-one percent of participants were born between 1945 and 1965, 73% were male (26% female and 1% transgender), 49% reported being dependent on non-injection drugs in the past year, including opioid substitution therapy, and 28% reported having a mental health condition. Of the 388 participants enrolled in the program:

  • 77% completed a hepatitis C medical evaluation (linked to care)
  • 61% were eligible for treatment (using direct-acting antivirals [DAAs])
  • 33% started treatment
  • 30% were cured (91% of those who started treatment were cured)

This 30% cure rate represents a two-fold increase over the estimated 12% to 15% cure rate overall in New York City.3

Participants evaluated onsite at CHCs were significantly more likely to be eligible for treatment (86%) than participants who were referred for offsite services (76%) and were more than twice as likely to initiate treatment (46%) than offsite participants (25%). No significant differences were reported in cure rates between the two groups.

Some participants more likely to start treatment than others

In the 2012 to 2013 study,1 many participants were not considered to be candidates for treatment because they had other conflicting health conditions, they did not have liver fibrosis, they had ongoing alcohol or drug use issues or they were lost to follow-up. This resulted in low overall treatment numbers. At the time of this study, only interferon-based treatment was available. The authors suggest that many providers were waiting for new, more effective DAA treatments to become available before prescribing treatment. 

By 2014 to 2015, DAA treatments had become available, although strict guidelines set by health insurers prevented many patients from accessing the drugs. Reasons for ineligibility included active drug use, conflicting health conditions and current alcohol use. Participants with more severe fibrosis (F3 or F4 fibrosis score) were twice as likely to begin treatment as those with less severe fibrosis (F1 or F2), and those born between 1945 and 1965 were twice as likely to start treatment as all other age groups. Participants who were homeless, used injection drugs, used alcohol or had a chemical dependence were less likely to start treatment than those who were housed and/or who didn’t use substances.

What does this mean for service providers?

People who use drugs continue to experience significant barriers to treatment such as lack of access to healthcare, and stigma and discrimination associated with substance use. Linkage to care is even more essential because new DAA treatments are highly effective and easy to complete and they can be accessed with few restrictions in Canada. This study shows that high hepatitis C cure rates can be achieved in populations that have not been traditionally well-served by the healthcare system when health navigation is part of their care plan.

Patient navigators played a central role in this program in helping clients navigate the HCV continuum of care, including testing, diagnosis and treatment. There is typically significant patient drop-off at each stage and using a patient navigator helped to mitigate this.

The Check Hep C program model also demonstrates the effectiveness of point-of-care testing followed by immediate blood draws for confirmatory testing. Because this testing can all be done in one appointment (followed by a seven-day wait for RNA results), a hepatitis C diagnosis can be made in a shorter time, reducing the risk of losing a patient to follow-up.

Related resources

Hepatitis C point of care testing: What is its impact on testing and linkage to care?

HepTLC – evidence brief

Patient Navigation – evidence brief

Ontario Hepatitis C Team: The Ottawa Hospital and Regional Hepatitis Program – case study

Practice Guidelines in Peer Health Navigation for People Living with HIV

References

  1. Ford MM, Jordan AE, Johnson N et al. Check Hep C: a community-based approach to hepatitis C diagnosis and linkage to care in high-risk populations. Journal of Public Health Management and Practice. 2018:24(1):41–8.
  2. 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. 2017:64(5):685–91.
  3. 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.