A cascade-of-care analysis of the country's largest tribally-operated health system showed clear gaps in progressing patients with HCV from diagnosis to completed treatment.
A hepatitis C virus (HCV) elimination program designed by the Oklahoma Cherokee National Health Services (CNHS) to mitigate disease burden in American Indian or Alaska Native persons could be applicable for health systems managing patients from that background, according to new research.
In data from a team of CNHS investigators, an HCV elimination program that targets improvement of screening, treatment and curative strategies for a population of ≥1400 was associated with a 99% cure rate among patients who completed their care.
The findings additionally showed a clear gap between patients who were identified for HCV treatment in the program and those who initiated care; compounded with the high success rate of treatment, investigators stressed the importance of tailored public health strategies for uniquely impacted and historically neglected HCV patient populations including those of American Indian or Alaska Native background.
“Although linkage to care has been successful, treatment initiation continues to be a barrier to achieving HCV elimination within the Cherokee Nation,” they wrote.
Led by Whitney Essex, MSN, the team of investigators sought to assess the progress of the CNHS HCV elimination program initiated in 2015. Their data included 5 years of program implementation across the CNHS’ 11 health care facilities across the Oklahoma reservation. The largest tribally-operated health system in the US, it serves ≥100,000 American Indian or Alaska Native persons.
The HCV elimination program entails universal screening, primary HCV workforce expansion and harm reduction services. Essex and colleagues analyzed the program as a cascade of care, with reported proportions of persons completing stages including HCV diagnosis, linkage to HCV care, initiated HCV treatment, sustained virology response visit at ≥12 weeks (SVR12) and reported cure from disease.
From November 2015 – October 2020, investigators observed 1423 patients with an HCV diagnosis; 870 (61.1%) were male and 360 (26.0%) were aged 51 – 60 years old. Another 189 (13.3%) of patients met criteria for advanced liver disease or cirrhosis.
Of diagnosed patients, 1227 (86.2%) were linked to HCV care; another three-fourths (n = 871 [71.0%]) had initiated HCV treatment. Of those patients, 702 (80.6%) returned for an SVR12 visit; all but 4 (99.4%) achieved laboratory-confirmed sustained virologic response indicating cured disease.
Investigators noted that 800 patients (91.8%) completed treatment once initiated; another 17 of that group initiated and completed the HCV regimen following the study period’s conclusion. Of the 98 patients who completed treatment but did not return for their SVR12 visit, 40 (40.8%) had evidence of sustained virologic response in a prior visit.
Essex and colleagues noted their findings align with a 2022 global systematic review of HCV elimination strategies; overall, just about half of all patients diagnosed with HCV at the CNHS achieved sustained virologic response over a 5-year period.
“Given the high rate of treatment success with direct-acting antivirals, it is likely that the majority of persons who initiated treatment were also cured,” they wrote. “Thus, although linkage to care has been successful, treatment initiation continues to be a barrier to achieving HCV elimination within the Cherokee Nation.”
Though the findings were limited by a potential lack of generalizability, as well as a lack of observation of non-CNHS care for patients with HCV, investigators concluded that their findings elucidate a need address the gaps of cascading HCV care in patient populations including American Indian or Alaska Native persons.
“For CNHS, emphasis on treatment initiation should be a priority. Future research should explore barriers to linkage to care, initiating treatment after HCV evaluation, completing treatment, and returning for the SVR12 visit among American Indian or Alaskan Native persons, as well as interventions to address these barriers.”