Continuum of Hepatitis C Testing and Care in Philadelphia

BACKGROUND:  Hepatitis C virus (HCV) is the primary cause of chronic hepatitis disease in the United States (US).  A Hepatitis C (HCV)-positive person will ideally have access to quality health care and move through the entire HCV continuum of care from initial antibody (Ab) screening to RNA confirmation to engagement and retention in medical care and treatment when indicated. Unfortunately, recent studies in National Health and Nutrition Examination Survey (NHANES) and Chronic Hepatitis Cohort Study (CHeCS) show that many patients do not progress through this continuum. However, the generalizability of these sources has been questioned. Our study assesses the continuum of HCV care in Philadelphia using surveillance data for January 2010 to December 2013 obtained by the Philadelphia Department of Public Health. 

METHODS:  The number of individuals living in Philadelphia during 2010-2013 was approximated using 2010 US Census counts and 2012 American Community Survey (ACS) population change estimates.  The expected HCV seroprevalence in Philadelphia was calculated by applying NHANES prevalences to local census data and homeless and incarcerated population estimates.  HCV test results received through passive surveillance were used to determine where HCV positive individuals fell on the continuum.  We defined the continuum of engagement in HCV care as follows: 1) Patients screened for HCV antibody (Ab) only, 2) Patients with HCV Ab and confirmatory RNA but not in care, 3) RNA confirmed patients who are in care, 4) RNA confirmed patients who are in care and have received or are currently receiving HCV treatment.  An HCV patient in care was defined as someone who had 2 or more HCV RNA tests ordered on different dates or had at least 1 test ordered by a gastroenterologist, hepatologist, or infectious disease specialist. 

RESULTS:  Of the approximately 1,584,848 Philadelphia residents in 2010-2013, 47,207 (2.9%) were infected with HCV. We received positive HCV tests for 20,743 unique individuals, of whom 10,730 (52%) had their infection confirmed by HCV RNA testing.  For individuals whose HCV disease was confirmed, 6,329 (59%) were determined to be in care and only 506 (8%) had or were currently receiving HCV medication.

CONCLUSIONS:  This continuum of engagement in HCV care provides a 'real-life' snapshot of how this disease is being managed in a major US urban center.  Many patients are lost at each step of care, highlighting the need to raise awareness about hepatitis testing, referral, patient support, and reporting among health care professionals and at-risk populations.