1. Cascade of care for persons newly diagnosed
anti-HCV positive 2002 – 2014, England
Ruth Simmons1,3, Georgina Ireland1, Lukasz Cieply1, Samreen Ijaz2,3, Sema Mandal1,3, Sam Lattimore1,3
1. Immunisation, Hepatitis and Blood Safety Department, PHE, London, 2. Blood Borne Virus Unit, PHE, London, 3. The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections at University College London, UK (
FRI-427
INTRODUCTION
RESULTS
DISCUSSION
Clinical pathways for persons with Hepatitis C are important to quantify. Understanding and managing factors that influence the uptake of healthcare interventions, continuity of care and outcomes among persons with HCV impact the overall aim to reduce onward transmission and disease outcomes such as cirrhosis and death.
These data indicate that the proportion of testing occurring in primary care is increasing over time. Although testing was more likely to be conducted in GP surgeries and GUM clinics, higher positivity rates are still associated with settings attended by persons at high risk of HCV, i.e. drug dependency services and prisons.
3 out of 4 persons testing positive for anti-HCV were referred for confirmation of an active HCV infection. Testing for RNA was more likely if conducted as a reflex test within the laboratory, and does not necessarily indicate engagement into secondary care.
Treatment among those positive for HCV RNA was suboptimal with only 2 out of 5 persons on treatment within 1 year of a positive RNA. Differences in treatment initiation between setting of diagnosis is notable, with primary care and drug services worse than GUM and secondary care, even though drug services have the highest positivity rates. These findings are likely a function of non-referrals in these services and hard to access services.
The recent roll out of DAAs which are injection-free, easier to tolerate and of shorter treatment duration are likely to transform the treatment landscape, increasing treatment coverage among those chronically infected. Continued efforts are needed to understand and improve the cascade of care for HCV within England.
In England, hepatitis C (HCV) now mainly affects current or past injecting drug users. Referral and treatment and care of HCV infected patients can be challenging due to the difficulty of health worker and patient engagement, long and complex treatments that are not well-tolerated, and subsequent retention in care. Improvements to care and health outcomes are expected through the introduction of new effective and easier to tolerate direct acting antivirals.
Recommendations for persons with a positive anti-HCV diagnosis include confirmation of an active infection through RNA testing, a referral for secondary care, followed by an initial assessment of disease stage, with monitoring prior to, during and after treatment.
Using testing data we investigate the care and management of those tested for HCV in England. We assess the proportion of persons with an RNA test following a positive anti-HCV result, then subsequently accessing treatment.
73% of persons diagnosed anti-HCV positive had an RNA test within 6 months, of which 3 out of 4 were conducted within 7 days of their anti-HCV test.
67% of those tested for RNA had an active infection, of which the majority (71%) presented in primary care.
Evidence of treatment was estimated using an algorithm identifying three or more sequential RNA test results within a 390 day period, suggestive of monitoring during treatment.
Information for treatment was only available for persons testing between 2002 and 2012, of which 38% of those with an active infection 6 months following an anti-HCV test, had evidence of treatment within 1 year of their positive RNA result.
SVR was achieved by 78% of those on treatment, representing 30% of those with an active infection.
Figure 1. Map of sentinel surveillance centres in 2013
Between 2002 and 2014, 3,118,165 samples were tested for anti-HCV, with the proportion of anti-HCV tests conducted in primary care has increasing over time (figure 2).
143,874 samples were found to be positive, corresponding to 80,285 persons.
METHODS
Demographic information and all HCV testing undertaken by a network of 24 sentinel laboratories within England (Figure 1) between 2002 and 2014 were extracted from the sentinel surveillance program of blood born viruses.
All persons with a hepatitis C-specific antibody test (anti-HCV) were collated with subsequent HCV RNA tests where available. All reference testing were excluded. Persons with no previous testing information, or a previous positive RNA result were excluded. The following patient pathway was described: RNA test within 6 months of a positive anti-HCV result, positive RNA result within 6 months of a positive anti-HCV result, treatment within 12 months of the positive RNA result, and whether SVR was achieved.
Tests were grouped into 7 specialities based on requesting department reported by the laboratory; general practice, drug misuse services, genitourinary medicine, prisons, occupational health, accident and emergency department, and secondary care.
Figure 3: Care pathway among persons newly HCV diagnosed by year of
anti-HCV date, England:
By service of anti-HCV diagnosis, there was little difference in the proportion of persons with an RNA test within 6 months.
A positive HCV-RNA test within 6 months was more likely among persons presenting for a test within drug dependency services (77%), followed by genitourinary medicine (74%), and prisons (74%).
Evidence of treatment within 1 year of a positive RNA was highest in persons initially presenting at a GUM (42%), or in secondary care (30%).
SVR was less likely to be achieved among those initially testing in an emergency department (25%), and prisons (57%). All other services SVR was achieved by >70%.
Figure 2: Proportion of persons testing for anti-HCV by service group in
England:
Funding
4867 persons diagnosed anti-HCV positive met the criteria for a new HCV diagnosis.
Two out of three new anti-HCV positive persons were diagnosed in primary care.
30% of tests conducted in primary care were in genitourinary medicine, followed by 28% in general practice, 25% in drug dependency units, 13% in prisons, 2% in accident and emergency, and 2% through occupational health.
The research was funded by the National Institute for Health Research Health Protection Research Unit [NIHR HPRU] in Blood Borne and Sexually Transmitted Infections at UCL in partnership with PHE and in collaboration with the London School of Hygiene and Tropical Medicine.
ACKNOWLEDGEMENTS
We wish to thank all the staff in participating sentinel laboratories, including the IT, medical and scientific staff who supported this surveillance programme on an on-going basis. The sentinel surveillance of the hepatitis testing study was funded by the English Department of Health (study reference AIDB 2/30) until September 2009, after which the programme became part of PHE’s core surveillance.
2014