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    • br Conflicts of Interest br Author Contributions br

    2018-11-07


    Conflicts of Interest
    Author Contributions
    Acknowledgements
    Introduction Hepatitis C virus (HCV) is a major global public health problem. Although HCV incidence is declining, morbidity and mortality related to chronic HCV infection are increasing (Aspinall et al., 2015; Kuo et al., 2015). In many countries worldwide, the majority of infected individuals acquired the HCV decades ago, and are now increasingly presenting with serious liver-related illnesses including decompensated cirrhosis and hepatocellular carcinoma (Janjua et al., 2015). Potentially curative interferon based treatments have been available for >15years, but <15% of those infected had been treated. HCV cure is associated with reduced morbidity and mortality (Simmons et al., 2015; Singal et al., 2010). Availability of well-tolerated, short-course (8–12weeks), interferon-free, direct-acting antiviral (DAA) drugs with cure rates approaching 95% is expected to be a game changer in preventing progressive liver disease (Smith et al., 2015; Smith and Lim, 2015). However, for these drugs to have major population-level impact on morbidity and mortality, screening efforts must reach undiagnosed individuals, diagnosed individuals must be linked with care and people remain engaged with care to be assessed for and receive treatment. The cascade of care has been used to monitor the progress of HIV programs aimed at reducing the epidemic impact on individuals and populations (Nosyk et al., 2014). Monitoring the HCV affected population across stages of a cascade of care (diagnosis, linkage with care, treatment, and cure) at a broader population level provides a measure of program effectiveness and identifies service and access gaps. Population-level program progress and effectiveness data is critical to policy makers for forecasting budgetary impacts of treatment with very expensive drugs. The HCV cascade of care has been presented for specific population groups such as US veterans or small LY2857785 programs for people who inject drugs (PWID) but not for an overall population (Maier et al., 2016; Viner et al., 2015; Wade et al., 2015). In British Columbia (BC), DAAs became available in 2014 and are publicly-funded for people with advanced liver disease (≥F2 METAVIR or equivalent). The data presented in this paper based on all tested and diagnosed individuals in BC characterized the population-level HCV cascade of care in BC, Canada, and identified factors associated with leakage at each stage. This provides a population-based benchmark for monitoring the progress of hepatitis care programming to guide policy in British Columbia which can also be used as a framework for other jurisdictions internationally.
    Methods
    Results
    Discussion This population-based study characterized the cascade of HCV care in British Columbia, Canada. A large proportion of antibody positive persons received HCV RNA testing (75%) and subsequent genotyping (80%). In recent years, HCV RNA testing has increased to >80% of those diagnosed. However, only a small proportion initiated HCV treatment and were subsequently cured. Males, older birth cohorts, and those with HBV coinfection were less likely to undergo HCV RNA testing while those with a history of illicit drug use were less likely to be genotyped. People with HIV, cirrhosis, problem drug or alcohol use were more likely to be in liver care while males and those with HBV coinfection were less likely to be retained in care. In summary, most people moved along the testing continuum, but retention in care and treatment initiation were major gaps. People with major comorbidities have been more engaged in the testing continuum, but few had initiated treatment in the interferon era. These findings have important implications for HCV prevention, care and treatment programs. We demonstrated that linked administrative datasets that integrate data from various sources similar to the BC-HTC could be used to monitor the progress of HCV infected individuals across the cascade of care to assess program effectiveness in providing services at various stages of the cascade. We identified characteristics (demographic, comorbidities, co-infections, socioeconomic and geographic disparities) of HCV patients who did not progress to the next stage of care that could be used to realign services and programs to target individuals not progressing and falling behind along the cascade. The cascade was presented at the provincial level but is replicable for regions within BC to assess local program progress to inform interventions for improvements. In summary, the cascade serves as an instrument to guide the policy to achieve the World Health Organization\'s goal of HCV elimination (World Health Organization, 2016).