Point-of-care hepatitis C screening with direct access referral to improve linkage to care among halfway house residents: a pilot randomised study

INTRODUCTION@#Linkage to care among individuals with substance misuse remains a barrier to the elimination of the hepatitis C virus (HCV). We aimed to determine whether point-of-care (PoC) education, screening and staging for liver disease with direct access to hospitals would improve linkage to care among this group. @*METHODS@#All participants were offered PoC education and HCV screening. HCV-positive participants were randomised to standard care (controls) or direct access, which provided a direct pathway to hospitals. Linkage to care was determined by reviewing electronic medical records. Linkage of care cascade was defined as attendance at the specialist clinic, confirmation of viraemia by HCV RNA testing, discussion about HCV treatment and initiation of treatment. @*RESULTS@#351 halfway house residents were screened. The overall HCV prevalence was 30.5% (n = 107), with 69 residents in the control group and 38 in the direct access group. The direct access group had a significantly higher percentage of cases linked to specialist review for confirmatory RNA testing (63.2% vs. 40.6%, p = 0.025), HCV treatment discussion (p = 0.009) and treatment initiation (p = 0.01) compared to the controls. Overall, only 12.6% (n = 13) had treatment initiation during follow-up. PoC HCV screening with direct access referral had significantly higher linkage to HCV treatment initiation (adjusted odds ratio 9.13, p = 0.005) in multivariate analysis. @*CONCLUSION@#PoC HCV screening with direct access improves linkage to care and simplifies the HCV care cascade, leading to improved treatment uptake. PoC education, screening, diagnosis and treatment may be an effective strategy to achieving HCV micro-elimination in this population.

Mapping an HIV Treatment Program to Identify Barriers to Linkage in HIV Care in Resource Limited Settings.

Aims: To develop a practical method to evaluate and address failures to linkage to care for HIV treatment so as to achieve better access to antiretroviral therapy in resource limited settings. Study Design: A mixed methods analysis to identify and quantify failure to linkage to care involving intensive program mapping, retrospective quantification of retention data, and statistical analysis. Place and Duration of Study: AIC Kijabe Hospital, Kijabe Kenya. Data were collected from January 1 to December 31, 2011. Data collection and analysis was conducted in February 2012. Methodology: First a series of successive interviews of all levels of care providers was used to create a program map and identify linkage points. Following this, data registries were identified and cases at each linkage point were quantified. Simple statistical analysis of retention data were then completed and trends analyzed by Kaplan-Meier survival analysis. Results: Less than 20% of eligible cases testing positive for HIV were enrolled in the treatment program. Most cases enrolled received CD4 testing (78.9%). Most eligible enrolled patients were initiated on ART (82.2%). Patients referred from VCT (voluntary testing) were more likely to be enrolled, receive CD4 testing, and be initiated on therapy. Cases enrolled in the program within 7 days of HIV diagnosis had improved time to initiation of therapy (43 days vs 79 days, p<.001). Cases who received a CD4 test within seven days of diagnosis also had improved time to initiation of therapy (47 vs 77 days, p=.01). Conclusion: This method proved effective to identify, prioritize, and problem solve to improve linkages to care in our setting. Further evaluation should include prospective studies to identify facilitators to linkage and test interventions.