Medicaid expansion has led to earlier stage diagnoses in several cancers but has not been studied in hepatocellular carcinoma (HCC), a disease with complex risk factors. We examined the effect of Medicaid expansion on the diagnosis of HCC and associations with county-level social vulnerability.Patients with HCC <65 years of age were identified from the SEER database (2010-2016). County-level social vulnerability factors were obtained from the CDC SVI and BRFSS. A Difference-in-Difference analysis evaluated change in early-stage diagnoses (stage I-II) between expansion and non-expansion states. A Difference-in-Difference-in-Difference analysis evaluated expansion impact among counties with higher proportions of social vulnerability.Of 19,751 patients identified, 81.5% were in expansion states. Uninsured status decreased in expansion states (6.3%-2.4%, p < 0.0001) and remained unchanged in non-expansion states (12.7%-14.8%, p = 0.43). There was no significant difference in the incidence of early-stage diagnoses between expansion states and non-expansion states. Results were consistent when accounting for social vulnerability.Medicaid expansion was not associated with earlier stage diagnoses in patients with HCC, including those with higher social vulnerability. Unlike other cancers, expanded access did not translate into higher utilization of care in HCC, suggesting barriers on a multitude of levels. 

Beyond Insurance Status: The Impact of Medicaid Expansion on the Diagnosis of Hepatocellular Carcinoma

Hepatitis C virus (HCV) and human immunodeficiency virus (HIV) are often co-transmitted. Viral coinfection results in worse outcomes. Persons who inject drugs (PWIDs) face barriers to medical treatment, but HCV treatment is indicated and effective even with ongoing active drug use. We aimed to assess access to HCV care and treatment results in patients coinfected with HIV-HCV. This is a real-world retrospective single-center study of patients followed in the HIV clinic between 2002 and 2018. Linkage to care was defined as achieving care cascade steps: (1) hepatology clinic visit, (2) receiving prescription of anti-HCV treatment, and (3) documentation of sustained virologic response (SVR). Of 1660 patients with HIV, 254 with HIV-HCV coinfection were included. Only 39% of them achieved SVR. The rate limiting step was the engagement into hepatology care. Being a PWID was associated with ~50% reduced odds of achieving study outcomes, active drug use was associated with ~90% reduced odds. Older age was found to facilitate treatment success. Once treated, the rate of SVR was high in all populations. HCV is undertreated in coinfected young PWIDs. Further efforts should be directed to improve access to care in this marginalized population.

https://www.mdpi.com/1660-4601/19/22/15237/pdf?version=1668757917

Barriers and Facilitators of Hepatitis C Care in Persons Coinfected with Human Immunodeficiency Virus

Abstract Background Chronic infection with the hepatitis C virus (HCV) remains a worldwide health problem. As a result, the World Health Organization (WHO) has set elimination targets by 2030. This study aims to examine the position of Belgium in meeting the WHO's targets by 2030. Methods A Markov disease progression model, constructed in Microsoft Excel, was utilized to quantify the size of the HCV-infected population, by the liver disease stages, from 2015 to 2030. Two scenarios were developed to (1) forecast the disease burden in Belgium under the 2019 Base and (2) see what is needed to achieve the WHO targets. Results It was estimated that the number of HCV RNA-positive individuals in Belgium in 2015 was 18,800. To achieve the WHO goals, Belgium needs to treat at least 1200 patients per year. This will only be feasible if the number of screening tests increases. Conclusions Belgium is on target to reach the WHO targets by 2030 but will have to make sustained efforts. However, eradicating HCV requires policy changes to significantly increase prevention, screening, and treatment, alongside public health promotion, to raise awareness among high-risk populations and health care providers. 

/pdf/ten-years-countdown-to-hepatitis-c-elimination-in-belgium-a-3jleeni0.pdf

Ten years countdown to hepatitis C elimination in Belgium: a mathematical modeling approach

Hepatitis C (HCV) is an infectious disease caused by a virus primarily affecting the liver. Approximately 70-80% of HCV-infected individuals develop a chronic HCV infection. If left untreated, progressive liver damage results in liver cirrhosis in 20-30% of individuals after 20-30 year. Individuals with cirrhosis are at risk of developing ... read more hepatocellular carcinoma, bleeding of gastroesophageal varices, and liver failure. Globally, an estimated 58 million persons were living with a chronic HCV infection in 2020. The Netherlands has a relatively low HCV prevalence, with an estimated 23.000 persons ever chronically HCV-infected in 2016. Populations with a relatively high HCV prevalence in the Netherlands are migrants from HCV-endemic countries, mainly in Africa, Eastern Europe and Asia, people with a history of injecting drug use, men who have sex with men, and people with inherited bleeding disorders such as haemophilia. Before 2014, antiviral therapy used for HCV had to be given for six to twelve months, had severe side-effects and a relatively limited efficacy. In 2014, a new type of HCV therapy became available, so-called direct-acting antivirals (DAA). After eight to twelve weeks of treatment with DAA >95% of treated individuals is cured, while side-effects are limited. Due to the introduction of this effective therapy, the World Health Organisation announced the ambition to eliminate HCV as a global public health threat before 2030. The aim of this thesis was to describe remaining challenges for HCV elimination in the era of direct-acting antivirals. The thesis consists of three parts, divided into several chapters. Part I focuses on challenges for HCV elimination in people with haemophilia. Chapter 2 is a narrative review describing the history and current situation regarding viral hepatitis in people with haemophilia. In Chapter 3, liver-related complications of long-term HCV infection in people with inherited bleeding disorders are reported, mainly focusing on the setting following successful antiviral treatment. In Chapter 4, the health-related quality of life of people with haemophilia after successful HCV treatment is described and compared with the quality of life of people with haemophilia who were never chronically HCV-infected. Part II describes challenges for HCV elimination in people living with HIV. In Chapter 5, the prevalence of HCV-viremia in people living with HIV in the Netherlands between 2000 and 2019 is described, followed by an analysis of barriers to DAA-uptake during unrestricted access. Chapter 6 is an international cohort study in which DAA-uptake during unrestricted access was compared between several countries and factors associated with remaining DAA-untreated over time were analysed. In the European, cross-sectional study reported in Chapter 7, data from several cohorts were combined to assess DAA efficacy among individuals with HIV/HCV originating from Sub-Saharan Africa or Southeastern Asia. Part III concerns challenges for HCV elimination in the Netherlands in general. Chapter 8 is a nationwide retrieval project aiming to re-engage previously diagnosed but lost to follow-up individuals with care. Chapter 9 is a nationwide study aiming to evaluate DAA efficacy and prevalence of resistance-associated substitutions in patients treated for a non-epidemic HCV genotype in the Netherlands. In Chapter 10, literature regarding liver-related complications following DAA-based HCV eradication in patients with cirrhosis is reviewed and summarised, to determine whether we should continue surveillance for hepatocellular carcinoma and gastroesophageal varices in these patients. Chapter 11 is a modelling study in which the progress towards HCV elimination in the Netherlands is estimated according to several scenarios. Finally, the general discussion (Chapter 12) discusses the current HCV epidemiology in the Netherlands, remaining challenges for HCV elimination in several key populations as well as the Netherlands in general, and policy changes required to advance HCV elimination in the Netherlands. show less 

Remaining challenges for hepatitis C virus elimination in the era of direct-acting antiviral agents

The World Health Organization has set tremendous goals to eliminate viral hepatitis by 2030. However, most countries are currently off the track for achieving these goals. Microelimination is a more effective and practical approach that breaks down national elimination targets into goals for smaller and more manageable key populations. These key populations share the characteristics of being highly prevalent for and vulnerable to hepatitis C virus (HCV) infection. Microelimination allows for identifying HCV-infected people and linking them to care more cost-effectively and efficiently. In this review, we discuss the current obstacles to and progress in HCV microelimination in special populations, including uremic patients undergoing hemodialysis, people who inject drugs, incarcerated people, people living in hyperendemic areas, men who have sex with men with or without human immunodeficiency virus (HIV) infection, transgender and gender-diverse populations, and sex workers. Scaling up testing and treatment uptake to achieve HCV microelimination may facilitate global HCV elimination by 2030.

HCV Microelimination for High-risk Special Populations.

Screening and treatment of hepatitis C virus (HCV) infection in people who use drugs (PWUD) remains insufficient. Reducing the burden of HCV infection in PWUD requires interventions focusing on the different steps of the HCV care cascade. We performed a prospective, multicenter study, evaluating the impact of an HCV care model on the HCV care cascade among PWUD attending an addiction care center in Belgium between 2015 and 2018. Interventions within the care model consisted of pre-test counseling, on-site HCV screening and case management services. A multiple logistic regression model was performed to identify the independent factors influencing the outcomes. During the study period, 441 PWUD were registered at the addiction care center, 90% (395/441) were contacted, 88% (349/395) were screened for HCV infection. PWUD were more likely to be screened if they had ever injected drugs (p < .001; AOR 6.411 95% CI 3.464–11.864). In 45% (157/349), the HCV antibody (Ab) test was positive, and in 27% (94/349) HCV RNA was positive. Within the Belgian reimbursement criteria (fibrosis stage ≥ F2), 44% (41/94) were treated. Specialist evaluation at the hospital was lower for PWUD receiving decentralized opioid agonist therapy (p = .005; AOR 0.430 95% CI 0.005–0.380), PWUD with unstable housing in the past 6 months before inclusion (p = .015; AOR 0.035 95% CI 0.002–0.517) or if they were recently incarcerated (p = .001; AOR 0.010 95% CI 0.001–0.164). This HCV care model demonstrated high screening, linkage to care, and treatment initiation among PWUD in Belgium. Using the cascade of care to guide interventions is easy and necessary to monitor results. This population needs guidance, not only for screening and treatment initiation but also for the long-term follow-up since one in six had cirrhosis and could develop hepatocellular carcinoma. Further interventions are necessary to increase linkage to care and treatment initiation. Universal access to direct-acting antiviral therapy from 2019 will contribute to achieving HCV elimination in the PWUD population. Clinical trial registration details: www.clinicaltrials.gov
 (
 NCT03106194
 ).

/pdf/on-site-testing-and-case-management-to-improve-hepatitis-c-112zy5tcv3.pdf

On-site testing and case management to improve hepatitis C care in drug users: a prospective, longitudinal, multicenter study in the DAA era.

Targeted screening for hepatitis C viral (HCV) infection is not yet widely executed in Belgium. When performed in people who use drugs (PWUD), it is mainly focused on those receiving opiate agonist therapy (OAT). We wanted to reach out to a population of difficult to reach PWUD not on centralized OAT, using non-invasive screening as a bridge to re-integration in medical care supported by facilitated referral to a specialist. This was a prospective, multicenter cohort study in PWUD not enrolled in a centralized OAT program in a community-based facility in Limburg or OAT program in a community-based facility in Antwerp, Belgium, from October 2018 until October 2019. Two study teams recruited participants using an outreach method at 18 different locations. Participants were tested for HCV antibodies (Ab) by finger prick, and risk factors were assessed through a face-to-face questionnaire. Univariate analyses were used to assess the association between HCV Ab and each risk factor separately. A generalized linear mixed model was used to investigate the association between the different risk factors and HCV.
 In total, 425 PWUD were reached with a mean age of 41.6 ± 10.8, and 78.8% (335/425) were men. HCV Ab prevalence was 14.8% (63/425). Fifty-six (88.9%) PWUD were referred, of whom 37 (66.1%) were linked to care and tested for HCV RNA. Twenty-nine (78.4%) had a chronic HCV infection. Treatment was initiated in 17 (58.6%) patients. The adjusted odds for HCV Ab were highest in those with unstable housing 6 months before inclusion (p < .001, AOR 8.2 CI 95% 3.2–23.3) and in those who had ever shared paraphernalia for intravenous drug use (p < .001, AOR 6.2 CI 95% 2.5–16.0). An important part tested positive for HCV. Treatment could be started in more than half of the chronically infected referred and tested positive for HCV-RNA. Micro-elimination is necessary to achieve the World Health Organization goals by 2030. However, it remains crucial to screen and link a broader group of PWUD to care than to focus solely on those who inject drugs. Trial registration: clinicaltrials.gov NCT04363411, Registered 27 April 2020—Retrospectively registered. https://clinicaltrials.gov/ct2/show/NCT04363411?term=NCT04363411&draw=2&rank=1

/pdf/identification-and-treatment-of-viral-hepatitis-c-in-persons-ffplwwvn66.pdf

Identification and treatment of viral hepatitis C in persons who use drugs: a prospective, multicenter outreach study in Flanders, Belgium.

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On-site testing and case management to improve hepatitis C care in drug users: a prospective, longitudinal, multicenter study in the DAA era.

Identification and treatment of viral hepatitis C in persons who use drugs: a prospective, multicenter outreach study in Flanders, Belgium.