Evaluation of the Cherokee Nation Hepatitis C Virus Elimination Program in the First 22 Months of Implementation

Abstract

Importance: In 2019, hepatitis C virus (HCV) infection contributed to more deaths in the US than 60 other notifiable infectious diseases combined. The incidence of and mortality associated with HCV infection are highest among American Indian and Alaska Native individuals.

Objective: To evaluate the association of the Cherokee Nation (CN) HCV elimination program with each element of the cascade of care: HCV screening, linkage to care, treatment, and cure.

Design, setting, and participants: This cohort study used data from the CN Health Services (CNHS), which serves approximately 132 000 American Indian and Alaska Native individuals residing in the 14-county CN reservation in rural northeastern Oklahoma. Data from the first 22 months of implementation (November 1, 2015, to August 31, 2017) of an HCV elimination program were compared with those from the pre-elimination program period (October 1, 2012, to October 31, 2015). The analysis included American Indian and Alaska Native individuals aged 20 to 69 years who accessed care through the CNHS between October 1, 2012, and August 31, 2017. Cure data were recorded through April 15, 2018.

Exposure: The CN HCV elimination program.

Main outcomes and measures: The main outcomes were the proportions of the population screened for HCV, diagnosed with current HCV infection, linked to care, treated, and cured during the initial 22 months of the elimination program period and the pre-elimination program period. Data from electronic health records and an HCV treatment database were analyzed. The cumulative incidence of HCV infection in this population was estimated using bayesian analyses.

Results: Among the 74 039 eligible individuals accessing care during the elimination program period, the mean (SD) age was 36.0 (13.5) years and 55.9% were women. From the pre-elimination program period to the elimination program period, first-time HCV screening coverage increased from 20.9% to 38.2%, and identification of current HCV infection and treatment in newly screened individuals increased from a mean (SD) of 170 (40) per year to 244 (4) per year and a mean of 95 (133) per year to 215 (9) per year, respectively. During the implementation period, of the 793 individuals with current HCV infection accessing the CNHS, 664 were evaluated (83.7%), 394 (59.3%) initiated treatment, and 335 (85.0%) had documented cure. In less than 2 years, the 85% 3-year goal was reached for cure (85.0%), and the goal for linkage to care was nearly reached (83.7%), whereas screening (44.1%) and treatment initiation (59.3%) required more time and resources.

Conclusions and relevance: This cohort study found that after 22 months of implementation, the CNHS community-based HCV elimination program was associated with an improved cascade of care. The facilitators and lessons learned in this program may be useful to other organizations planning similar programs.

Figure 1.. Individuals Aged 20 to 69 Years Screened for Hepatitis C Virus (HCV) Antibodies During the 3 Months Preceding the Elimination Program and During the Elimination Period

^aThe universal screening policy was implemented at the Cherokee Nation Health Services (CNHS) on November 1, 2015. ^bLaboratory-triggered screening (LTS) was initiated at WW Hastings (WWH) Hospital in December 2015. ^cUse of in-house tests for HCV antibody screening was initiated at satellite clinics on January 1, 2016. ^dPoint-of-care testing was initiated at WWH Hospital dental clinic in March 2016. ^eDiscontinuation of LTS occurred on March 31, 2016. ^fResumption of LTS with consent to treat on file occurred on May 19, 2016. ^gPoint-of-care testing was initiated at 1 satellite dental clinic in June 2016. ^hUse of electronic health record reminders in the new CNHS electronic health record system was initiated on July 19, 2016 (LTS with consent to treat on file was discontinued). ⁱPhysician training on use of the new EHR reminder occurred in July and August 2016. Point-of-care testing was implemented at WWH Hospital Behavioral Health Clinic in August 2016 but was not implemented systematically.

Figure 2.. Cascade of Care Among Individuals Accessing the Cherokee Nation Health Services (CNHS) at Least Once With Estimated and Diagnosed Current Hepatitis C Virus (HCV) Infection During the Elimination Period

The first bar represents the estimated number of people with current HCV infection in the CNHS population who accessed care at least once from November 1, 2015, to August 31, 2017 (n = 1652), not only those screened as reported in Table 1 and in the eMethods in the Supplement. The second bar represents individuals with current HCV infection (n = 808), including 447 individuals newly diagnosed during the elimination period, 92 individuals newly diagnosed in the elimination period with a previous antibody test outside the CNHS, 254 individuals diagnosed before November 2015, and 15 individuals who were identified but who could not be evaluated and followed-up because they either cleared the virus (n = 7), or died before evaluation (n = 2), were not identified (n = 1), or were not Native American or Alaska Native individuals (n = 5). The third bar represents individuals evaluated (n = 664) during the elimination period, including those diagnosed during the elimination period (n = 456) and those diagnosed with current infection before November 1, 2015 (n = 208). The proportion evaluated was calculated as the number of individuals evaluated (n = 664) divided by the number of individuals seen at the CNHS who were diagnosed with current HCV infection and accessed care at least once during the elimination period (n = 793) but does not include the 15 individuals who could not be followed up as specified above. The fourth bar represents individuals treated during the elimination program period (n = 394), including individuals diagnosed during the elimination program period (n = 205) and those diagnosed before November 2015 (n = 189). The fifth bar represents individuals cured under the intent to treat approach during the elimination program period (n = 335), including individuals diagnosed during the elimination program period (n = 170) and those diagnosed before November 2015 (n = 165).

Figure 3.. American Indian and Alaska Native Individuals Aged 20 to 69 Years Accessing Cherokee Nation Health Services (CNHS) Care Who Had No Prior Hepatitis C Virus (HCV) Screening and Newly Screened Individuals in Each Period by Sex and Birth Cohort

The orange dots correspond to numbers of individuals accessing care at the CNHS who were not yet screened in each respective period.