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.
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
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.
- sustained virological response (SVR)
Undetectable hepatitis C RNA after treatment has come to an end. Usually SVR refers to RNA remaining undetectable for 24 weeks (six months) after ending treatment and is considered to be a cure. SVR4 and SVR12 refer to RNA remaining undetectable for 4 and 12 weeks respectively.
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.
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
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.
in English before December 2014 was reviewed. Only peer-reviewed randomised
controlled trials or controlled non-randomised studies were eligible for
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
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).
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).
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).
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