Race and Hepatitis C Care Continuum in an Underserved Birth Cohort

Abstract

BACKGROUND: Birth cohort screening is recommended for hepatitis C virus (HCV) and underserved populations are disproportionally affected by HCV. Little is known about the influence of race on the HCV care continuum in this population. OBJECTIVE: To assess the cascade of HCV care in a large racially diverse and underserved birth cohort. DESIGN: Retrospective cohort study using electronic medical record data abstracted until August 31, 2017. PATIENTS: 34,810 patients born between 1945 and 1965 engaged in primary care between October 1, 2014, and October 31, 2016, within the safety-net clinics of the San Francisco Health Network. MAIN MEASURES: Rate of hepatitis C testing, hepatitis C treatment, and response to therapy. RESULTS: Cohort characteristics were as follows: median age 59 years, 57.6% male, 25.5% White (20.6% Black, 17.7% Latino, 33.0% Asian/Pacific Islander (API), 2% other), and 32.6% preferred a non-English language. 99.7% had an HCV test (95.4% HCV antibody, 4.3% HCVRNA alone). Among HCV antibody-positive patients (N = 4587), 22.9% were not tested for confirmatory HCVRNA. Among viremic patients (N = 3673), 20.8% initiated HCV therapy, 90.6% achieved sustained virologic response (SVR) and 8.1% did not have a SVR test. HCV screening and treatment were highest in APIs (98.7 and 34.7% respectively; p < 0.001). Blacks had the highest chronic HCV rate (22.2%; p < 0.001). Latinos had the lowest SVR rate (81.3%; p = 0.01). On multivariable analysis, API race (vs White, OR 1.20; p = 0.001), presence of HIV co-infection (OR 1.58; p = 0.02), presence of chronic kidney disease (OR 0.47; p < 0.001), English (vs non-English) as preferred language (OR 0.54; p = 0.002), ALT (OR 0.39 per doubling; p < 0.001), and HCVRNA (OR 0.83 per 10-fold increase; p < 0.001) were associated with HCV treatment. CONCLUSIONS: Despite near-universal screening, gaps in active HCV confirmation, treatment, and verification of cure were identified and influenced by race. Tailored interventions to engage and treat diverse and underserved populations with HCV infection are needed.

Hepatitis C Screening in an Underserved U.S. Cohort of Reproductive Age Women

“…Latina and Asian women in particular were 26%‐55% less likely to receive HCV screening than white women. Although the reasons for this negative association are unclear and may reflect unmeasured factors, it may be related to cultural preferences, social stigma, language barriers that pose difficulty in navigating health systems, and inability or unwillingness to access health care . An additional factor to consider is the higher rates of nontraditional risk factors (such as acupuncture) for HCV infection in Asian populations that may increase the risk of HCV, but may not be recognized as a risk factor by providers .…”

“…This is a retrospective cohort study of a primary care registry that includes electronic medical records of reproductive age women who accessed primary care at least once at one of 12 clinics in the San Francisco Health Network, within the San Francisco Department of Public Health, between December 1, 2016, and December 1, 2018 . Reproductive age women were defined as any female patient between the ages of 15 and 44 years as of December 1, 2018 .…”

Underserved Does Not Mean Undeserved: Unfurling the HCV Care in the Safety Net

“…Despite this high screening rate and expanded access to HCV therapy both within liver specialty and primary care settings in this system, only 20.8% of those with documented viremia initiated HCV treatment. Although overall 90.6% achieved SVR, younger age and absence of HIV coinfection were associated with lack of SVR testing that occurred in 8% of those who completed treatment 15 . Wong et al evaluated 29,544 patients chronically infected with HCV across four health systems including two safety-net institutions in the U.S. from January 1, 2011 to February 28, 2017 16 .…”

“…Continued efforts should be made to increase the rates of HCV screening in underserved populations followed by enrollment into comprehensive treatment and surveillance programs for those newly diagnosed with HCV. We retrospectively evaluated 34,810 birth cohort underserved patients engaged in primary care within the San Francisco’s safety-net healthcare system from October 1, 2014 to October 31, 2016 15 . In this cohort, 99.7% had evidence of HCV screening and 13.8% were HCV antibody positive.…”

Evaluation of a Multifaceted Intervention to Reduce Health Disparities in Hepatitis C Screening: A Pre‐Post Analysis

“…Similarly, another study demonstrated increased HCV screening from 1.09 to 2.53 per 100,000 person‐years after release of US Preventive Service Task Force (USPSTF) guidelines, with the most dramatic increase occurring in the Northeast compared to other regions of the country . Despite these increases in HCV screening among baby boomer patients, disparities exist with some subgroups based on age, racial/ethnic minority status, gender, primary care visits, and comorbidities …”