Cohesion Among Health Services
The HCV care continuum spans multiple specialties and healthcare providers. Screening may involve a general practitioner, public health agency or emergency department (ED). A radiology referral is often needed for fibrosis staging by transient elastography and screening for liver masses concerning for HCC. Treatment and further management most commonly occur via a specialist provider, often a hepatologist or an infectious disease physician. Navigating this complex array of providers is difficult for those at the highest risk for HCV, particularly people who inject drugs (PWID) and people experiencing homelessness (PEH). Increased cohesion among health services, through physical proximity or integrated care, has the potential to improve care retention.
Barriers to retention are reduced by spatially co-localizing screening, evaluation and treatment steps in the HCV care continuum alongside primary care. This forms a centralized system of care services, tailored to the needs of vulnerable populations at the highest risk for HCV. This includes PWID, for whom co-localized care in substance abuse treatment centres, correctional facilities and needle exchange programmes has improved the delivery of HCV services for this population.
Removing travel between different HCV healthcare services improves linkage to care. In a study of a five-member network of Federal Qualified Health Centers (FQHCs), patients screened at FQHCs providing both HCV screening and treatment were nearly three times more likely to undergo a medical evaluation and twice as likely to receive fibrosis staging, as compared with patients screened HCV seropositive (HCV+) at a FQHC offering only HCV screening.
Integrated Case Management
Given that HCV is prevalent among PEH, PWID and the birth cohort (persons born between January 1, 1945 and December 31, 1965), HCV+ patients are often the members of underserved and/or elderly populations with multiple comorbidities. Approximately a quarter of treatment non-initiation by the provider could be attributed to psychiatric illness or alcohol and other drug use. As such, integrated case management, beyond HCV therapy, is essential.
Integrated management predominantly consists of psychiatric and substance abuse services, targeting known risk factors of failed treatment initiation. The use of a multi-disciplinary team shows promise at improving linkage to care, initiating antiviral therapy and achieving SVR.[21–23] One study examined a Queensland, Australia, community-based HCV treatment centre serving PWID through integrated harm reduction services (needle exchange programmes), drug and alcohol counselling and medical care. Of those participants who initiated DAAs, 96% completed treatment, 92% adhered to follow-up and 80% achieved SVR. Structural and behavioural interventions, including integrated case management, appear to be successful in addressing barriers to treatment adherence.
J Viral Hepat. 2022;29(8):588-595. © 2022 Blackwell Publishing