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Evaluation of the Cherokee Nation Hepatitis C Virus Elimination Program in the First 22 Months of Implementation
Jorge Mera1, Mary B Williams2,3, Whitney Essex1
1Cherokee Nation Health Services, Tahlequah, Oklahoma.
Insights
The Cherokee Nation
Area of Science:
- Public Health
- Infectious Diseases
- Health Services Research
Background:
- Hepatitis C virus (HCV) infection causes significant mortality in the US, disproportionately affecting American Indian and Alaska Native populations.
- The Cherokee Nation Health Services (CNHS) implemented a community-based HCV elimination program to address this disparity.
Purpose of the Study:
- To evaluate the effectiveness of the Cherokee Nation's HCV elimination program on the cascade of care.
- Assessing improvements in HCV screening, diagnosis, linkage to care, treatment, and cure.
Main Methods:
- A cohort study comparing data from the CNHS pre-elimination program period (October 2012–October 2015) with the initial 22 months of the elimination program (November 2015–August 2017).
- Analysis included American Indian and Alaska Native individuals aged 20–69 years accessing CNHS care.
- Outcomes measured included screening coverage, diagnosis, linkage to care, treatment initiation, and cure rates.
Main Results:
- First-time HCV screening increased from 20.9% to 38.2%.
- Among those with current HCV infection, evaluation reached 83.7%, treatment initiation was 59.3%, and cure was 85.0%.
- The program achieved its 3-year cure goal within 2 years and nearly met the linkage to care goal.
Conclusions:
- The CNHS community-based HCV elimination program significantly improved the cascade of care for HCV infection.
- The program's facilitators and lessons learned offer valuable insights for other organizations aiming for HCV elimination.
- Community-centered approaches are crucial for addressing health disparities in infectious disease control.
Importance:
In 2019, hepatitis C virus (HCV) infection contributed to more deaths in the US than 60 other notifiable infectious diseases combined. The incidence of and mortality associated with HCV infection are highest among American Indian and Alaska Native individuals.
Objective:
To evaluate the association of the Cherokee Nation (CN) HCV elimination program with each element of the cascade of care: HCV screening, linkage to care, treatment, and cure.
Design, Setting, And Participants:
This cohort study used data from the CN Health Services (CNHS), which serves approximately 132 000 American Indian and Alaska Native individuals residing in the 14-county CN reservation in rural northeastern Oklahoma. Data from the first 22 months of implementation (November 1, 2015, to August 31, 2017) of an HCV elimination program were compared with those from the pre-elimination program period (October 1, 2012, to October 31, 2015). The analysis included American Indian and Alaska Native individuals aged 20 to 69 years who accessed care through the CNHS between October 1, 2012, and August 31, 2017. Cure data were recorded through April 15, 2018.
Exposure:
The CN HCV elimination program.
Main Outcomes And Measures:
The main outcomes were the proportions of the population screened for HCV, diagnosed with current HCV infection, linked to care, treated, and cured during the initial 22 months of the elimination program period and the pre-elimination program period. Data from electronic health records and an HCV treatment database were analyzed. The cumulative incidence of HCV infection in this population was estimated using bayesian analyses.
Results:
Among the 74 039 eligible individuals accessing care during the elimination program period, the mean (SD) age was 36.0 (13.5) years and 55.9% were women. From the pre-elimination program period to the elimination program period, first-time HCV screening coverage increased from 20.9% to 38.2%, and identification of current HCV infection and treatment in newly screened individuals increased from a mean (SD) of 170 (40) per year to 244 (4) per year and a mean of 95 (133) per year to 215 (9) per year, respectively. During the implementation period, of the 793 individuals with current HCV infection accessing the CNHS, 664 were evaluated (83.7%), 394 (59.3%) initiated treatment, and 335 (85.0%) had documented cure. In less than 2 years, the 85% 3-year goal was reached for cure (85.0%), and the goal for linkage to care was nearly reached (83.7%), whereas screening (44.1%) and treatment initiation (59.3%) required more time and resources.
Conclusions And Relevance:
This cohort study found that after 22 months of implementation, the CNHS community-based HCV elimination program was associated with an improved cascade of care. The facilitators and lessons learned in this program may be useful to other organizations planning similar programs.