The rise in injection drug use in the rural US has led to an increase in admissions for injection-related conditions. Hepatitis C (HCV) infection is prevalent amongst people who inject drugs and might be diagnosed during such episodes of acute care. Linkage to care and initiation of treatment for hepatitis C in this group has been difficult, especially in rural settings lacking comprehensive care for people with substance use disorder (SUD).
We reviewed the charts of patients admitted to an inpatient service at Dartmouth-Hitchcock Medical Center (DHMC) who had positive HCV serology in 2016. We determined the proportion of patients who had follow up testing for HCV RNA, were referred, followed up and initiated treatment for HCV by the end of 2017.
In 2016, 504 inpatients at DHMC were screened with an HCV antibody test, of which 65 (13%) were positive. Of these, 50 (77%) had follow up HCV RNA testing, resulting in 38 (76%) patients with detectable viremia. Of the 53 patients with detected (38) or unknown viremia (15), 5 died on the index admission, 1 was discharged to a hospice, 16 were referred to the DHMC hepatology (GI) clinic and 11 to the DHMC infectious disease (ID) clinic, but 20 received no referral. Thirty-two (60%) patients had an active SUD, and 7 (13%) were in remission.
Through December 31, 2017, 15 (31%) of the surviving 48 patients had no further follow up in the Dartmouth-Hitchcock Health System. Fourteen (29%) patients followed up in the GI clinic, 11 (23%) followed up in the ID clinic and 8 (17%) had subsequent encounters in clinics for conditions other than HCV. Only 5 (10%) patients were treated for HCV and achieved sustained virologic response (SVR), all of which had followed up in the GI clinic.
The odds of follow-up or treatment were independent of a history of SUD. Providers frequently deferred treatment due to ongoing substance use or a focus on more urgent medical issues. Insurance coverage for direct-acting antivirals was evolving during the study period, preventing treatment in some patients.
Only 10% of patients screened positive for HCV during an inpatient admission to a rural academic medical center received treatment for HCV in the year following their diagnosis. Linkage to care, patient engagement and provider perceptions have to improve to achieve elimination of HCV.
D. De Gijsel,