Inexpensive interventions can boost engagement with key stages of viral hepatitis care continuum

Several cheap interventions can significantly boost engagement with the continuum of care for viral hepatitis, a systematic literature review and a series of meta-analyses published in The Lancet Infectious Diseases show. Programmes led by lay health workers boosted uptake of testing for hepatitis B virus (HBV) and co-ordinated mental health, substance abuse and hepatology services were associated with improved outcomes at several stages in the hepatitis C virus (HCV) care cascade. The investigators believe their findings have practical implications, especially for resource-limited countries with a high burden of viral hepatitis, as inexpensive interventions can have a meaningful impact on engagement in care and outcomes.

“Our systematic review demonstrates that operational interventions can improve retention in the chronic viral hepatitis care continuum,” comment the authors. “Included studies were diverse with a range of interventions targeting both patients and providers.”

Highly effective oral therapies are now available for the treatment of both HBV and HCV, and the World Health Organization (WHO) has set a target for the elimination of viral hepatitis as a global health threat by 2030, with a 65% reduction in deaths.

However, most people with chronic viral hepatitis are unaware of their infection status. There is also evidence of low testing uptake and poor rates of retention in care. Moreover, low- and middle-income countries have the highest burden of viral hepatitis and often have under-resourced health systems and hepatology services.

An understanding of the operational interventions that boost engagement with the care continuum for viral hepatitis (testing, linkage to care, retention in care, treatment uptake, adherence, treatment completion and viral control or cure) is therefore essential, especially if the ambitious WHO elimination target is to be attained.

Investigators therefore performed a systematic review of studies reporting on the outcome of operational interventions addressing engagement with key steps of the viral hepatitis care continuum. Where possible, they performed meta-analyses to identify which interventions were successful.

Research published in English before December 2014 was reviewed. Only peer-reviewed randomised controlled trials or controlled non-randomised studies were eligible for inclusion.

The researchers identified 56 eligible studies, 41 for HCV and 18 for HBV. Only one study was conducted in a low- or middle-income country.

A total of 16 studies assessed interventions to promote HBV testing, all targeting high-risk populations. Lay health worker HBV test promotion interventions increased testing rates significantly (RR = 2.68; 95% CI, 1.82-3.93).

Only two studies reported on outcomes related to HBV linkage to care. One assessed a letter with information about local services, the other compared referral rates before and after introduction of an electronic patient referral system. No studies reported on outcomes related to HBV treatment uptake, adherence or viral suppression.

Uptake of HCV testing was examined in 13 studies. All the interventions were led by healthcare providers and conducted in a healthcare or social services setting. Clinician reminders to prompt HCV testing during clinical visits increased testing rates compared to no reminder (RR = 3.70; 95% CI, 1.81-7.57). HCV education with onsite testing by healthcare professionals at facilities serving high-risk groups also boosted testing (RR 2.77; 95% 1.11-6.93).

Linkage to HCV care was reported in eight studies. Interventions that provided guided referral increased patient attendance with an HCV specialist (RR = 1.57; 95% CI, 1.03-2.41). Psychological counselling and motivational therapy for mental health or substance abuse issues together with referral to mental health services increased the number of referred patients eligible for treatment (OR = 3.42; 95% CI, 1.81-6.49).

Eight studies reported on HCV treatment uptake interventions. Co-ordinated mental health, substance abuse and hepatitis treatment services did not significantly increase treatment uptake (RR = 1.36; 95% CI, 0.94-1.97).

Interventions to increase adherence to HCV therapy were the subject of 21 studies. Co-ordinated services were shown to increase rates of treatment completion (RR = 1.22; 95% CI, 1.05-1.41). Two meta-analyses assessed the effect of nurse-led educational sessions on adherence and the completion of therapy. Such interventions did not significantly increase adherence but did have a significant effect on treatment completion rates (1.14; 95% CI, 1.05-1.23).

Twenty studies reported sustained virological response (SVR) as the outcome. Co-ordinated mental health, substance abuse and hepatitis treatment services improved SVR rates (1.21; 95% CI, 1.07-1.38) and nurse-led education about HCV therapy also had a positive impact (OR = 1.93; 95% CI, 1.44-2.59).

The authors believe their findings have three policy implications. First, they suggest HBV and HCV services can be combined, as “similar programmatic structures might suit the management of both infections.” Second, several of the effective interventions identified in their research are cheap and could be implemented in resource-limited settings. Finally, the interventions described are systems based, dependent on organisation of programmes, not the quality of hospital care or availability of medicines.