Globally, death and illness from hepatitis C are increasing despite new medications, which are called Direct Acting Antivirals (DAAs), that cure over 95% of people treated. The World Health Organization has set targets for the elimination of hepatitis C as a public health threat by the year 2030. Progress is measured across a ‘care cascade’, which is the term used to describe the essential stages of care. There are six main stages of hepatitis C care: antibody testing and diagnosis, RNA testing, RNA diagnosis, genotyping, treatment and cure. For people living with hepatitis C virus infection to reach the point of viral cure, they must go through all six stages of care, however many people lack access to services or face other barriers to care, and have not progressed.
A large population-level integrated database, the BC Hepatitis Testers Cohort was used to determine: (a) at which stages of care people drop out of the cascade of care; and (b) the characteristics of people who are engaged with later stages of care.
Since DAAs were introduced in 2013; the largest improvement as well as the largest remaining gap was observed between the genotyping stage and the treatment stage. This increased from 35% of people genotyped who received treatment before 2013, to 61% of people genotyped receiving treatment (2013-2018). While this is a large improvement, there remain 39% of people who were genotyped who did not receive treatment with DAAs.
People most likely to receive treatment after being genotyped were:
- People diagnosed with liver cancer (84%), cirrhosis (80%) or decompensated cirrhosis (75%)
- People born between 1945 – 1964 (69%) versus people born after 1974 (42%)
- People with no history of injecting drugs (67%) versus people who inject drugs (45%) or who used to inject drugs (55%)
Implications for practice
Understanding the gaps in access to hepatitis C care is necessary to inform strategies to engage people in care. For example, strategies to increase the proportion of people who inject drugs to move from being genotyped to being treated could include integration of HCV treatment in addiction clinics or harm reduction sites, peer support, and patient navigation.
For more information
This study was recently published in Liver International:
SR Bartlett, A Yu, N Chapinal, C Rossi, Z Butt, S Wong, M Darvishian, M Gilbert, J Wong, M Binka, M Alvarez, M Tyndall, M Krajden, NZ Janjua. The population level care cascade for hepatitis C in British Columbia, Canada as of 2018: Impact of Direct Acting Antivirals. Liver International (2019), DOI: 10.1111/liv.14227
The authors wish to thank the people of British Columbia who are represented in the BC Hepatitis Testers Cohort. We are grateful to the BC Hepatitis Testers Cohort team, data stewards, and funders for their continued support. This work was supported by British Columbia Centre for Disease Control and the Canadian Institutes of Health Research [Grant # NHC – 142832 and PHE-141773].