Originally coined to describe the continuum of care—and the gaps in care—for people with HIV, the term cascade of care is now used for hepatitis C and other diseases.
The cascade and number of steps required to achieve viral suppression were underscored in a recent meta-analysis of hepatitis C in the United States. Baligh Yehia and Vincent Lo Re from the University of Pennsylvania Perelman School of Medicine and colleagues analyzed gaps in hepatitis C care by performing a medical literature review to estimate the number of people who completed each step. Study findings were previously presented in part at the 2014 Conference on Retroviruses and Opportunistic Infections (CROI) in March and published July 2 in the journal, PLoS ONE.
The researchers took a “snapshot in time” of hepatitis care that can be used by healthcare professionals, researchers, and policymakers by looking at MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews and finding articles published between January 2003 and July 2013 that contained information about:
• the total number of people with chronic hepatitis C virus (HCV) infection and proportions who were diagnosed and aware of their infection,
• those who had access to outpatient care,
• patients who had a confirmed HCV RNA viral load measurement, underwent liver biopsy for fibrosis staging,
• patients who were prescribed HCV treatment, and
• patients who achieved sustained virological response (SVR), or a lasting cure.
Out of more than 9,500 articles reviewed, ten met the inclusion criteria. Studies were excluded if they focused on specific populations—such as homeless patients or IV drug users—involved only a single site, were conducted outside the U.S., or only included data collected prior to 2000. The study’s authors admit that these omissions made the study more generalized to the public, and also concede that they are a limitation of the study.
“All of this information was already out there, but we put it together in one place,” Baligh Yehia, an assistant professor at the University of Pennsylvania School of Medicine tells A&U. “The idea was to provide a framework for monitoring how well we are treating (HCV).”
The results: The medical community hasn’t been doing very well. Yehia and his fellow researchers estimated that fewer than ten percent of Americans with chronic hepatitis C have been successfully treated and have achieved SVR. When different steps on the cascade of care were considered in the meta-analysis, significant drop-offs showed up. Overall, of the estimated 3.5 million people with chronic hepatitis C in the U.S., the meta-analysis showed:
• Fifty percent (1.7 million people) were diagnosed and aware of their infection.
• Forty-three percent (1.5 million people) had access to outpatient care.
• Twenty-seven percent (950,000 people) received confirmatory HCV RNA testing.
• Seventeen percent (580,000 people) underwent fibrosis staging.
• However, just sixteen percent (550,000 people) were prescribed antiviral treatment.
• Only nine percent (330,000 people) achieved SVR.
Yehia, who has a background in HIV, tells A&U that these findings will become particularly useful as new screening efforts and direct-acting antiviral drugs become more common and available.
“With HIV, we initially worked hard to get effective therapies. Once we had those, we started looking at how to reach more people who needed those therapies. Now, with hep C, we have some very effective therapies that can actually provide a cure with shorter durations of treatment and minimal side effects. So now we need to start looking upstream. What are the bottlenecks to SVR and how can we remove them?”
Some of those bottlenecks to SVR are clear in the study. Most obviously, and not surprisingly, half of the people with HCV don’t know they have it. The fact that people often remain asymptomatic until severe liver damage is done is one reason for this. There’s also a big gap between access to outpatient care and confirmation testing for HCV.
Yehia admits that there are many variables in care and treatment that already may be helping to close the gaps in the treatment cascade. Three such changes—the new CDC screening guideline that recommends testing all Baby Boomers; the Affordable Care Act bringing more previously uninsured people into the medical system; and the anticipated affordability of the new medications—could bring that pathetic SVR rate out of single digits soon. But Yehia and his colleagues agree that just because powerful and effective meds are available, their availability alone won’t slow down the epidemic.
“We need to see more nuanced cascades, and to do that we will need to study those who are co-infected, homeless, drug users…people who were excluded in this study,” Yehia says. “To make sure that the maximum number of people [with HCV] can achieve SVR, we first need to understand who they are and where they might be falling out of the cascade of care.”
Larry Buhl is a radio news reporter, screen- writer, and novelist living in Los Angeles. His podcast on employment issues, “Labor Pains,” can be found at www.laborpainspodcast.com.