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Several approaches have been attempted to overcome disparities and improve management of HCV in diverse ethnic populations. Many of you will be familiar with Project ECHO (Extension for Community Healthcare Outcomes), founded by Dr Sanjeev Arora of the University of New Mexico, Albuquerque, United States, and first outlined in the New England Journal of Medicine in 2011.17,18
The ECHO program offers primary-care providers from underserved areas—providers who may have less experience with HCV management—the opportunity to participate in weekly HCV clinics via video conference, called “knowledge networks.” The participants also receive education in the form of didactic lectures by interdisciplinary experts.
The value of this approach was shown in the study. In total, 519 patients with HCV received standard treatment (according to the ECHO clinical protocol), with the duration of treatment based on genotype, which was later extended for those patients with slow time to response. Two cohorts were prospectively observed: those patients treated solely in the University of New Mexico HCV clinic and those treated through the ECHO program.
Of the 407 evaluable patients, 58.2% of ECHO patients demonstrated SVR, which was similar to the rate of response of 57.5% for the University of New Mexico HCV clinic patients. In addition, there was no difference in SVR rates for Hispanic patients compared with non-Hispanic patients, which can be seen as a success given that the study cohort was predominately Hispanic.
The ECHO program is essentially about a model for upskilling HCPs who are not used to managing a particular disease, especially in geographic regions without easy patient access to healthcare or in rural areas. As of 2011, there were 16 community sites and 5 prisons delivering HCV care using the ECHO model, but the model has spread around the world and is used for various diseases, from HIV to COVID-19.
The bidirectional educational capacity to learn from each other, to upskill local HCPs who treat patients from diverse ethnic backgrounds about HCV screening and management while learning from skilled professionals and from the patients themselves, is extremely important.
Other potential ways to overcome disparities in HCV awareness, screening, and care, include providing education and services at places where immigrant populations feel comfortable and can access, such as community centers and places of religious worship. As was noted in the earlier slide about language barriers, information about HCV could also be disseminated via language-specific newspapers or local radio programs. There has been some success in various communities in the United Kingdom using this strategy.
Also, we must engage local community leaders. Community leaders are people who are active in the community, who have the trust of community members and who can reduce stigma through influential messaging. This is major goal for health advocacy in terms of how to reduce stigma and break down barriers.
How do we screen in community settings? Who do we target? What kind of infection rates are we expecting to find? I think screening is not as straightforward as setting up in a mosque, gurdwara, or a community center and testing everyone who comes in. I think that there are more clever ways to go about it.
The slide illustrates a study published a few years ago by Uddin and colleagues.19 The researchers were interested in determining whether second-generation immigrants born in low-prevalence countries had similar risk of infection as first-generation immigrants, either due to travel or to repeat exposure to family and community members with chronic infection.
This study was conducted at 5 sites in the United Kingdom that were selected because of the large populations of immigrants from India, Pakistan, and Bangladesh. Local HCPs and community leaders were involved. In total, 4381 first-generation immigrants, 446 second-generation immigrants, and 6 third-generation immigrants from India, Bangladesh, or Pakistan were tested. HCV prevalence was low in those first-generation immigrants born in India and Bangladesh. In those first-generation immigrants born in Pakistan, the prevalence of HCV antibodies was 2.7%. Of interest, researchers found that among the 300 second-generation immigrants from Pakistan, none had viral hepatitis, suggesting that prevalence of HCV was based on country of origin and even region within country (as there was marked variation by region).
This goes back to the idea of country of birth being important. Asking patients up front about regular travel back to “home” regions, as well as any medical treatment received in the countries of origin, is important, especially because medical records are poorly kept in many of the countries of focus.
Outside of focused and intentional HCV testing, opportunistic testing could lead to improvements in care. The idea of testing in emergency departments has gained quite a lot of traction in the United Kingdom.
The slide highlights a study presented recently at the International Liver Congress in June 2021.20 This study, performed at the Emergency Department of Leeds Teaching Hospital, examined use of automatic evaluation for HIV, HBV, and HCV of biochemistry samples for unrelated health issues. In total, 16,053 samples were obtained, and test orders were automatically modified. Screening identified 156 people with HCV as identified by RNA analysis. Of these, 148 patients had active HCV viremia. Of interest, 4.1% (n = 6) of these 148 had no risk factor other than country of origin (ie, an area of high endemic prevalence). This is important as we often identify individuals for HCV screening based on risk factors, not necessarily country of origin.
There are inherent biases within this study, in that patients with a history of intravenous drug use, for example, who presented to the emergency department but had poor venous access may not have had blood tests performed, leading to potential underrepresentation of risk and of infection rates. However, this study provided data about the cost-effectiveness of this screening method, which is important data.
Of more importance, HCV management is, by and large, highly cost-effective, regardless of the setting. Demonstrating cost-effectiveness is not difficult, and payers often rely on these data when determining reimbursement for therapy or education.
Another thing that has emerged quite clearly from other data presented at the International Liver Congress is that determining the SVR at 4 weeks post-treatment (SVR4) for those patients who do not have advanced fibrosis (specifically cirrhosis), is almost 100% concordant with what the SVR might be at week 12.21 Therefore, a negative SVR4 effectively demonstrates cure for the vast majority of these patients.
For me, and this is very much a personal opinion, the ideal screening and treatment of people with HCV outside of healthcare institutions and in areas with diverse ethnic groups involves the following steps.
A point-of-care test with the ability to return results within 30 minutes is optimal. Oral antibody testing for HCV allows you to provide a result within 20 minutes, and this can be followed by a finger prick with a point-of-care RNA that provides result within 1 hour. Within 1-2 hours you can provide accurate and comprehensive results. You can even simultaneously test for HBV and HIV with a pinprick and a dry blood–spot test, removing the reliance on a full blood draw, which often is a logistic barrier for testing performed outside of healthcare institutions. I think the simpler you can keep the testing, the greater impact you will have. Any positive patient should be counseled regarding test results, which would include collection of a brief but focused medical history, including current medications.
There should be clear establishment of a means of contact, whether that be via mobile phone, friend, or local leader. I think, ideally, the next contact should be focused on HCV treatment initiation, either through telemedicine—whether that be video or just telephone— or a face-to-face appointment if possible. At that point, a fibrosis test could be performed, but current practice—especially during the COVID-19 pandemic—favors treatment with pangenotypic DAAs in lieu of testing because these agents are active for all stages of fibrosis. Nevertheless, real-time results from a transient elastography, which provide the patient with a liver fibrosis score, can be very helpful.
During the COVID-19 pandemic, we have established that SVR can be accomplished remotely. Patients can send dry blood spot tests through their local mail or post, and cure can be confirmed via several forms of communication.
And so, we will not see equitable HCV-care outcomes until we examine the current care systems and barriers and perform an honest critique regarding necessary changes. We must improve care delivery in community settings, focusing on convenience for the individuals we are serving through innovative approaches and increased use of opportunistic testing. Opportunistic testing should be offered in primary care, community pharmacies, and localities such as emergency departments. We also must be savvier regarding exploration and documentation of cost effectiveness, as well as of whether lobbying for improved care could be beneficial. Having a longer-term view of inequities in HCV management could only benefit patients and healthcare systems. For example, today’s undocumented immigrant with HCV could be tomorrow’s state-insured or federally insured citizen who, following decompensation of disease, requires a costly transplant.
There are multiple barriers that prevent people from accessing HCV testing and treatment, regardless of healthcare system. These barriers are especially pronounced if individuals are from an ethnic minority background.
We need more nuanced approaches to target those who might be at higher risk of HCV transmission, and HCPs must improve their understanding of the importance of ethnicity and country of birth. In addition, where we test is as important as who we test. Enlisting knowledgeable HCPs and influential community leaders is important to reducing barriers and stigma. Whether through programs such as ECHO or on more general- or community-based levels, increased education about risks, transmission, and management is essential.
We also need more research to optimize screening strategy in primary care in areas with significant numbers of ethnic minorities. There are ongoing studies being conducted within the United Kingdom and elsewhere in the world that are concentrating on establishing cost-effectiveness of management strategies. These data will reassure payers and, by extension, enable wider implementation of proven strategies.