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Treating Hepatitis C in Individuals With Previous
Incarceration: The Veterans Health Administration, 2012-2019
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Download the PDF here
Feb 2023
Laura Hawks, MD, MPH, Emily A. Wang, MD, MAS, Adeel A. Butt, MD, MS, Stephen Crystal, PhD, MA, D. Keith McInnes, ScD, MS, Vincent Lo Re III, MD, MSCE, Emily J. Cartwright, MD, Lisa B. Puglisi, MD, Lamia Y. K. Haque, MD, MPH, Joseph K. Lim, MD, Amy C. Justice, MD, PhD, and Kathleen A. McGinnis, DrPH, MS
• 90%+ SVR Rates for all: previously incarcerated & those not previously incarcerated - no difference in SVR rates.
• Of those with and those without previous incarceration, respectively, 40% and 21% had detectable HCV, 59% and 65% underwent treatment (P = .07); 92% and 94% of those who completed treatment achieved sustained virologic response.
• The VHA's provision of universal and systematized delivery of HCV treatment can be used as a model for increasing both resources and public health infrastructure to combat HCV and other infectious diseases, in addition to reducing disparities
To determine whether the Veterans Health Administration's (VHA) hepatitis C (HCV) treatment campaign reached marginalized populations, we compared HCV care by previous incarceration status with Veterans Aging Cohort Study data.
This model can serve as an example for other health care systems to achieve high rates of HCV cure. Tactics that can be applied to other systems include broad testing and treatment eligibility and reflex testing for positive screens, expanding prescribing privileges to include pharmacists, broadening telehealth services, integrating HCV treatment into opioid treatment programs and homeless shelters, and minimizing cost sharing.
PURPOSE: After the development of a highly effective and tolerated treatment of HCV, the VHA pursued a goal of universal treatment in an effort to eradicate HCV in its patient population.2 To understand whether individuals with previous incarceration were included in these efforts, we used data from VACS to compare the HCV treatment cascade steps between those with and those without previous incarceration. Because the cohort was initially designed to study HIV, we also ran analyses comparing the treatment cascade steps between those with and those without HIV, stratified by previous incarceration status.
Of those with and those without previous incarceration, respectively, 40% and 21% had detectable HCV, 59% and 65% underwent treatment (P = .07); 92% and 94% of those who completed treatment achieved sustained virologic response. The VHA HCV treatment effort was successful and other systems should replicate those efforts. (Am J Public Health. 2023;113(2):162-165. https://doi.org/10.2105/AJPH.2022.307152)
The VHA's provision of universal and systematized delivery of HCV treatment can be used as a model for increasing both resources and public health infrastructure to combat HCV and other infectious diseases, in addition to reducing disparities. For the United States to achieve the World Health Organization's goal of HCV eradication by 2030, urgent attention should be paid to understanding which VHA-initiated efforts could be replicated in other health care systems or used for public health strategies outside the VHA.
The VHA has recommended broad testing eligibility and reflex confirmation testing since at least 2012.1 Treatment eligibility has been expanded to include patients regardless of fibrosis stage or comorbid substance use disorders, and treatment is provided at minimal out-of-pocket cost.1
Of the 3109 VACS participants included in this study, 1817 (58%) reported a history of incarceration. HCV screening was conducted in 99% of those with and those without previous incarceration; and VL confirmation occurred for 99% and 98% of those with and those without previous incarceration, respectively. HCV prevalence was 40% and 21% among those with and those without previous incarceration, respectively (P < .001).
INTERVENTION AND IMPLEMENTATION
The VHA developed hepatitis C innovation teams to identify and minimize barriers to treatment of difficult to reach populations by implementing direct outreach programs, increasing staffing for patients experiencing homelessness, expanding pharmacy prescribing privileges, expanding telehealth services, and integrating HCV treatment into opioid treatment programs.2 As of December 2017, the VHA treated approximately 70% of all those across their system with HCV viremia.3
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