Background
It’s estimated that 71 million people are living with hepatitis C worldwide, and that it leads to almost 400,000 deaths each year.1,2 In Canada and many other countries, marginalized communities, including people who use drugs and people with experience in prisons, are disproportionally affected by hepatitis C. Canada is one of several countries that have committed to World Health Organization (WHO) targets to eliminate hepatitis C by 2030.3
Simplifying approaches to testing and treatment can improve engagement in hepatitis C care, particularly for marginalized populations. This includes decentralizing where testing and treatment take place and task-shifting hepatitis C care to primary care providers from specialists. These measures can help to reach those who experience barriers to hepatitis C diagnosis and care.
This article summarizes a systematic review and meta-analysis that looked at whether decentralization and task-shifting were effective in engaging both specific populations (e.g., people who use drugs) and general populations in care and successfully curing them of hepatitis C.4
What is “decentralization” and “task-shifting” of hepatitis C care?
In recent years, hepatitis C treatment has become increasingly simple and effective with direct-acting antivirals (DAAs).5 This class of drugs has high cure rates, few side effects and short treatment courses and requires less specialized expertise to treat most cases. This has opened opportunities to deliver treatment in new settings and for primary care clinicians instead of specialists to oversee treatment.
Decentralization, in this review, refers to programs that are integrated or delivered in community, primary care or other settings instead of being “centralized” at a hospital or specialty clinic. In this review, examples included harm reduction settings (including opioid substitution therapy and needle syringe programs), HIV clinics and prisons.
The authors of this review classified studies according to the level of decentralization:
- Full decentralization: Both testing and treatment are done in a primary care, community (including harm reduction) or prison setting.
- Partial decentralization: Only testing is done in a primary care, community or prison setting. Treatment is referred to a specialist site.
- No decentralization: Both testing and treatment are done in a specialist site.
Task-shifting, in this review, refers to delivery of care by non-specialist clinicians, such as family doctors or nurse practitioners. This expands the number of providers who can offer hepatitis C care and allows individuals to be engaged with a familiar or trusted provider.
What kind of research did the systematic review include?
This systematic review included the following types of studies, study outcomes and populations:
- Types of studies included randomized controlled trials, non-randomized studies, observational studies and grey literature.
- Study outcomes were steps along the hepatitis C cascade of care, including antibody and viral load (RNA) testing, linkage to care, treatment starts, cure assessment and cure rates.
- Populations included people who use drugs, people with experience in prison, people living with HIV and the general population.
In total, the review included 142 papers, involving a total of 489,996 study participants:
- Eighty papers focused on people who use drugs, 20 on people with experience in prisons, 5 on people co-infected with HIV and 37 on the general population.
- The studies primarily came from the United States (41), Australia (27), the United Kingdom (18) and Canada (17). Twenty papers (14%) came from low- to middle-income countries.
Results for linkage to care, initiation of treatment and cure are presented below. The authors of the review found outcomes related to testing to be broadly similar across provider and setting, so they did not focus on these.
Fully decentralized testing and treatment models had higher rates of linkage to care and treatment starts in certain populations
For people who inject drugs, full decentralization was associated with increased rates of linkage to care and starting treatment, although the differences were not significant:
- Fully decentralized models linked 72% of individuals to care, and 73% started treatment.
- Partially decentralized models linked 53% of individuals to care, and 66% started treatment.
- Models without decentralization linked 47% of individuals to care, and 35% started treatment.
In prisons, full decentralization, where testing and treatment were offered completely within the prison institution, was associated with increased rates of linkage to care and starting treatment, although the differences were not significant:
- Fully decentralized models linked 94% of individuals to care, and 72% started treatment.
- Partially decentralized models linked 50% of individuals to care, and 39% started treatment.
For studies looking at the general population, there was little evidence of differences in linkage to care or treatment start between decentralization levels. The review found insufficient studies looking at linkage to care and treatment starts among people also living with HIV and thus the authors were unable to assess the impact of decentralization in this population.
Cure rates were extremely high regardless of the provider or setting
Cure rates were extremely high regardless of the level of decentralization or the setting in which treatment was delivered; in all cases the cure rate was over 90% for DAA treatment. This was true across all populations and decentralization models.
Cure rates were similarly high regardless of whether testing and treatment were led by non-specialists or specialists. This means that task-shifting works: treatment is still highly successful even when delivered by a non-specialist like a family physician or nurse practitioner.
Strategies that can support decentralization and task-shifting
The authors discussed additional evidence-informed strategies to support decentralization and task-shifting, although these strategies were not a central focus of their review. They include:
- Rapid or point-of-care testing to support faster diagnosis
- Dried blood spot testing to expand the reach of testing
- Engagement of people with lived experience as peer workers in programs
- Mobile outreach (i.e., van outreach, site visits, street outreach) to bring services directly to people
- Testing and treatment delivered through community pharmacies
- Tele-mentoring to provide remote clinical training and support for primary care providers
Implications for service providers in Canada
This review and meta-analysis demonstrates the value of decentralization and task-shifting as key approaches in delivering community-based hepatitis C care. In particular, they can expand the reach of treatment to marginalized populations who have significant barriers to accessing healthcare. Integrating these approaches where people are already regularly accessing services (i.e., harm reduction sites offering opioid substitution therapy) can increase the likelihood that people will be engaged and retained in hepatitis C care. This study also demonstrates the feasibility of delivering these services in settings like prisons and harm reduction sites, where non-specialist clinical staff can lead care with extremely high cure rates.
In Canada, most hepatitis C care is still overseen by specialists; however, decentralized models with non-specialist providers are starting to emerge. To expand the number of providers who can oversee testing and treatment, a first step is to increase training for primary care providers. This could include tele-mentoring programs delivered by specialists to provide remote support for primary care providers.
These approaches are also key to achieving elimination of hepatitis C in Canada. People who use drugs and people with experience in prison are priority populations to reach to prevent and cure cases of hepatitis C. These approaches align with recommendations from the WHO around simplifying hepatitis C care to achieve elimination.6
What is a systematic review and meta-analysis?
Systematic reviews are important tools to inform evidence-based programming. A systematic review is a critical summary of the available evidence on a specific topic. It uses a well-defined search strategy to identify all the studies related to a specific research question. Relevant studies can then be assessed for quality and summarized to identify key findings and limitations.
A meta-analysis is a method to pool numerical data from multiple studies. If the studies included in a systematic review contain numerical data, authors can use statistical methods to calculate summary (“pooled”) estimates. These pooled estimates can provide a better overall picture of the topic being studied.
Related resources
Just diagnosed: Important things to know when you have hepatitis C
Curing hepatitis C: What you need to know
Hepatitis C Treatment Program at Moss Park Consumption and Treatment Service – case study
References
- World Health Organization. Global health sector strategy on viral hepatitis 2016–2021. Geneva: World Health Organization; 2016. Available from: https://apps.who.int/iris/handle/10665/246177
- World Health Organization. Global hepatitis report, 2017. Geneva: World Health Organization; 2017. Available from: https://www.who.int/publications/i/item/global-hepatitis-report-2017
- Canadian Network on Hepatitis C. Blueprint to inform Hepatitis C elimination efforts in Canada. Montreal: Canadian Network on Hepatitis C; 2019. Available from: https://www.canhepc.ca/sites/default/files/media/documents/blueprint_hcv_2019_05.pdf
- Oru E, Trickey A, Shirali R et al. Decentralisation, integration, and task-shifting in hepatitis C virus infection testing and treatment: a global systematic review and meta-analysis. The Lancet. 2021;9(4):E431-E445.
- CATIE. Hepatitis C: an in-depth guide. Toronto: CATIE; 2020. Available from: https://www.catie.ca/en/practical-guides/hepc-in-depth/treatment/choosing-drug-combination-chronic-hepatitis-c
- World Health Organization. Guidelines for the care and treatment of persons diagnosed with chronic hepatitis C virus infection. Geneva: World Health Organization; 2018. Available from: https://www.who.int/publications/i/item/9789241550345
About the author(s)
Christopher Hoy is CATIE’s manager of hepatitis C community programming and works to build hepatitis C programming capacity for frontline service providers. Christopher has previously worked in public health communications and policy roles and has a master of public health.