Hepatitis C care cascade among patients with and without tuberculosis: Nationwide observational cohort study in the country of Georgia, 2015–2020
Open Access
- 4 May 2023
- journal article
- research article
- Published by Public Library of Science (PLoS) in PLoS Medicine
- Vol. 20 (5), e1004121
- https://doi.org/10.1371/journal.pmed.1004121
Abstract
The Eastern European country of Georgia initiated a nationwide hepatitis C virus (HCV) elimination program in 2015 to address a high burden of infection. Screening for HCV infection through antibody testing was integrated into multiple existing programs, including the National Tuberculosis Program (NTP). We sought to compare the hepatitis C care cascade among patients with and without tuberculosis (TB) diagnosis in Georgia between 2015 and 2019 and to identify factors associated with loss to follow-up (LTFU) in hepatitis C care among patients with TB. Using national ID numbers, we merged databases of the HCV elimination program, NTP, and national death registry from January 1, 2015 to September 30, 2020. The study population included 11,985 adults (aged ≥18 years) diagnosed with active TB from January 1, 2015 through December 31, 2019, and 1,849,820 adults tested for HCV antibodies between January 1, 2015 and September 30, 2020, who were not diagnosed with TB during that time. We estimated the proportion of patients with and without TB who were LTFU at each step of the HCV care cascade and explored temporal changes. Among 11,985 patients with active TB, 9,065 (76%) patients without prior hepatitis C treatment were tested for HCV antibodies, of which 1,665 (18%) had a positive result; LTFU from hepatitis C care was common, with 316 of 1,557 (20%) patients with a positive antibody test not undergoing viremia testing and 443 of 1,025 (43%) patients with viremia not starting treatment for hepatitis C. Overall, among persons with confirmed viremic HCV infection, due to LTFU at various stages of the care cascade only 28% of patients with TB had a documented cure from HCV infection, compared to 55% among patients without TB. LTFU after positive antibody testing substantially decreased in the last 3 years, from 32% among patients diagnosed with TB in 2017 to 12% among those diagnosed in 2019. After a positive HCV antibody test, patients without TB had viremia testing sooner than patients with TB (hazards ratio [HR] = 1.46, 95% confidence intervals [CI] [1.39, 1.54], p < 0.001). After a positive viremia test, patients without TB started hepatitis C treatment sooner than patients with TB (HR = 2.05, 95% CI [1.87, 2.25], p < 0.001). In the risk factor analysis adjusted for age, sex, and case definition (new versus previously treated), multidrug-resistant (MDR) TB was associated with an increased risk of LTFU after a positive HCV antibody test (adjusted risk ratio [aRR] = 1.41, 95% CI [1.12, 1.76], p = 0.003). The main limitation of this study was that due to the reliance on existing electronic databases, we were unable to account for the impact of all confounding factors in some of the analyses. LTFU from hepatitis C care after a positive antibody or viremia test was high and more common among patients with TB than in those without TB. Better integration of TB and hepatitis C care systems can potentially reduce LTFU and improve patient outcomes both in Georgia and other countries that are initiating or scaling up their nationwide hepatitis C control efforts and striving to provide personalized TB treatment.Funding Information
- Fogarty International Center (D43TW007124)
- National Institutes of Health (K24AI114444)
- National Institutes of Health (P30AI168386)
- National Institutes of Health (P30AI050409)
- National Institutes of Health (U19AI111211)
This publication has 53 references indexed in Scilit:
- Re-inventing adherence: toward a patient-centered model of care for drug-resistant tuberculosis and HIVThe International Journal of Tuberculosis and Lung Disease, 2016
- Launch of a Nationwide Hepatitis C Elimination Program — Georgia, April 2015Morbidity and Mortality Weekly Report (MMWR), 2015
- Hepatitis C Virus Therapeutic Development: In Pursuit of "Perfectovir"Clinical Infectious Diseases, 2015
- Hepatitis C virus: Virology, diagnosis and treatmentWorld Journal of Hepatology, 2015
- Natural history of hepatitis CJournal of Hepatology, 2014
- Hepatitis C Virus Co-Infection Increases the Risk of Anti-Tuberculosis Drug-Induced Hepatotoxicity among Patients with Pulmonary TuberculosisPLOS ONE, 2013
- Prevalence of tuberculosis, hepatitis C virus, and HIV in homeless people: a systematic review and meta-analysisThe Lancet Infectious Diseases, 2012
- Multiple Imputation for Missing Data: Fully Conditional Specification Versus Multivariate Normal ImputationAmerican Journal of Epidemiology, 2010
- Choice and Interpretation of Statistical Tests Used When Competing Risks Are PresentJournal of Clinical Oncology, 2008
- Diagnosis, management, and treatment of hepatitis CJournal of Hepatology, 2004