EPIDEMIOLOGY OF HEPATITIS C

In 1989, a small enveloped RNA virus was discovered to be the cause of hepatitis C, a transfusion-associated condition that had until then been called non-A non-B hepatitis (after etiologic exclusion of hepatitis A virus and hepatitis B virus [HBV]) (Choo et al., 1989). HCV infects 2.5-4.7 million people in the United States, and more than 185 million people worldwide (Edlin et al., 2015; Mohd Hanafiah et al., 2013). In addition to contaminated blood transfusions, HCV is primarily spread from person to person by injection drug use, and, less commonly, through sex (particularly among HIV positive men who have sex with men) or from mother to child (Ray and Thomas, 2015).

Most HCV infected people are unaware of their condition. About one-third of infections resolve spontaneously in the first year, the rest continue and become chronic (Cox et al., 2005; Mosley et al., 2005). Both people with resolved infection and those with chronic infection test positive for antibodies to HCV, whereas only those with chronic hepatitis C have consistently detectable HCV RNA in the blood (a test often called viral load) at a level of about 3.2 million IU/mL with 96 percent having a viral load greater than 400,000 IU/mL (Afdhal et al., 2014a; Ferenci et al., 2014; Kowdley et al., 2014; Thomas et al., 2000b; Zeuzem et al., 2014). Chronic HCV infection can progress to end-stage liver disease, including liver cancer. HCV can also cause serious problems in organ systems other than the liver, including cryoglobulinemic vasculitis, metabolic bone disease, kidney disease, cardiovascular disease, and hematologic malignancies (Cacoub et al., 2015; Lee et al., 2012). In the United States, HCV is the leading cause of end-stage liver disease requiring liver transplantation, and mortality attributed to HCV is expected to continue rising during the next 10 years (Luu, 2015; McNamara et al., 2014). Though effective treatment is now available, its impact will be muted without expanded measures for screening, disease surveillance, enrolling and retaining patients in care, and patient management (Durham et al., 2016).

THE FEASIBILITY OF ELIMINATING THE PUBLIC HEALTH PROBLEM OF HEPATITIS C

As the previous chapter describes, disease elimination is a matter of reducing the reproductive number (abbreviated R₀) of a pathogen to a value less than one and maintaining this value until new infections cease. HCV has an R₀ of about 2, which is to say its transmission is not especially efficient, and a modest reduction in transmission efficiency could end the public health problem of HCV (Pybus et al., 2001). If a quarter of a million people were treated for HCV in the United States in 2015, the treatment rate would exceed the annual infection rate by about 10-fold (Durham et al., 2016). But as the disease burden falls more on difficult-to-treat populations, this could change. Already the rate of new infections appears to be rising substantially, probably driven by increasing injection drug use among young people in at least seven states (CDC, 2013; Zibbell et al., 2015).

Biologically, HCV is a tractable target for eradication. There is no known non-human reservoir and, unlike HIV and HBV, there is no latent cellular reservoir (Ray et al., 2013). Pharmacologic treatment with direct-acting antivirals can truly cure an infected person, treatment-based elimination is an option (Pawlotsky, 2014). At the same time, reinfection is a possibility until either risk of transmission can be eliminated or prophylaxis is available via antiviral drug or vaccine. Such risk undermines progress toward HCV elimination (Simmons et al., 2016). Therefore, the committee concludes that elimination of hepatitis C as a public health problem in the United States is feasible, though there are several conditions on this statement.

Although the biology of the virus and medicines available to treat it would seem to favor the feasibility of elimination, there are serious barriers to this goal. Like hepatitis B, Hepatitis C is generally asymptomatic both during the acute and chronic phase. This epidemiological challenge is aggravated by the heavy concentration of HCV infections in difficult-to-reach populations, including people who inject drugs and the homeless, as well as marginalized groups such as the incarcerated. These groups are not generally represented, sometimes systematically under-represented, in national surveillance surveys such as NHANES (Edlin et al., 2015). Also, the curative treatment that holds the best promise to destroy the viral reservoir is exceedingly expensive. This expense raises concerns about the feasibility of widespread treatment (Durham et al., 2016). In any case, a prophylactic vaccination would make elimination more manageable, especially for a disease that disproportionately effects people who have limited access to medical care. A prophylactic vaccine may be an essential missing piece of the effort to eliminate hepatitis C. Similarly, if current trends in incidence continue, a single-dose curative treatment (as opposed to the current 8- to 12-week therapy) could be invaluable in ending chronic infection among patients often out of contact with the health system.

As with hepatitis B, eliminating the public health problem of hepatitis C in the United States is a matter of ending transmission and reducing the burden of disease among people already infected. The curative treatments available for HCV make the elimination of chronic infection another possibility. This chapter discusses each of these goals in turn and identifies factors crucial to the success of each goal. After analyzing the problem of hepatitis C in the United States, the committee concluded that control is feasible in the relatively short term. Eliminating the public health problem of hepatitis C will take more time, and require considerable public will, resources, and attention to the barriers mentioned in Table 3-1. Past success with other infectious diseases suggest that a prophylactic vaccine would greatly increase the likelihood and durability of progress toward elimination, especially given the disproportionate burden of HCV among people with the least engagement with the health system. Table 3-1 gives an overview of the committee's main points and the conclusions presented in this chapter.

TABLE 3-1

The Feasibility of Eliminating Hepatitis C as a Public Health Problem in the United States with Critical Factors for Success and Crosscutting Problems.

ENDING TRANSMISSION OF HEPATITIS C

Eliminating hepatitis C will require stopping transmission of the virus. In the United States, people who inject drugs have the highest risk of transmitting the virus (Alter, 1997). A strategy to stop transmission in this group should give attention to both reducing the risk of contracting HCV among people who are not infected and to reducing the likelihood of transmission among those who are (Edlin and Winkelstein, 2014; Grebely and Dore, 2014; Hellard et al., 2014). Preventing infection among people who use drugs was key to reducing incidence of HIV, but appears less effective for HCV (Palmateer et al., 2010; Wright and Tompkins, 2006). This is because HCV is more transmissible than HIV (Alter, 2006). Even without sharing a needle, HCV can be spread through shared equipment such tourniquets (Hagan et al., 2001).

Nevertheless, there is some evidence that HCV transmission can be reduced through primary prevention efforts. In a 2011 review, Hagan and colleagues found little evidence that behavioral interventions, substance-abuse treatment, opioid-replacement therapy, or syringe programs reduced incidence of HCV when any one program was implemented alone (Hagan et al., 2011). However, two studies that employed multiple strategies (both including opioid replacement, one with counseling, the other with syringe exchange) reduced HCV incidence among drug injectors by about 75 percent (Hagan et al., 2011). A pooled analysis from the United Kingdom, however, suggested that syringe exchange and opioid replacement could each be effective in reducing infection by about 50 percent when implemented independently, provided the syringe exchange reached a large amount of the target population (Turner et al., 2011). When these programs were combined, their reduction on HCV incidence was near 80 percent, similar to the estimate in the Hagan review (Turner et al., 2011).

There is reason to believe that needle and syringe exchange programs, counselling, and opioid replacement therapy (collectively called harm reduction services) can help reduce the transmission of HCV especially among younger people and those who have more recently begun injecting (Mehta et al., 2011; Tseng et al., 2007). Cities with strong needle and syringe exchange programs, including New York and San Francisco, have seen significant declines in HCV prevalence (Des Jarlais et al., 2005; Tseng et al., 2007). The higher prevalence of HCV among older injectors and those who have been injecting longer suggests that the programs delayed, but did not prevent, the infection (Mehta et al., 2011). The longer time to infection may also prove a valuable window in which to reach young people who inject drugs with information about preventing infection or treating substance use disorders (Mehta et al., 2011). The recent lifting of Congress' ban on use of federal funds for syringe exchange (with the caveat that the funds cannot be used on needles or syringes) may allow for expanding harm reduction programs.

Comprehensive drug and alcohol programs will be critical to any HCV elimination program. Such programs may be complicated. Injecting drug use is becoming more common in rural areas and small towns, not the just densely populated cities where such programs have a history (Suryaprasad et al., 2014; Zibbell et al., 2015). Adapting harm reduction strategies to rural and suburban areas could be challenging. Mathematical models suggest that high-coverage—referring to both the number of injectors reached in a geographical area and the number of syringes exchanged relative to injections made—is important in needle and syringe exchange programs (Day and Topp, 2011). Furthermore, needle and syringe exchange programs in combination with opioid replacement therapy can reduce HCV prevalence, but it takes many years to see these effects (Vickerman et al., 2012). In areas where harm reduction programs have been going on for many years, additional reductions in prevalence may be difficult without the introduction of new, more effective interventions, such as widespread treatment or use of a vaccine.

Treatment as Prevention and Reducing Reinfection

The simple, safe, and curative HCV treatments that came onto the market in 2014 changed not only the prognosis for individual hepatitis C patients, but also the strategy for interrupting transmission. Treating infected patients as a way to prevent disease spread is an established clinical and epidemiological principle in HIV (Cohen et al., 2011; Tanser et al., 2013). The promise of direct-acting, combination antiviral treatments for hepatitis C is even better, as these therapies can cure the vast majority of infections and can do so in relatively short time.

Modelling studies, many based on populations outside the United States, indicate that treating hepatitis C in people who inject drugs would reduce disease prevalence by 20 to 80 percent (Durier et al., 2012; Hellard et al., 2012; Martin et al., 2011). In Vancouver, where about 5 out of 1,000 drug-injecting hepatitis C patients are treated per year, treating an additional 71 patients per year would halve the burden of hepatitis C (Martin et al., 2013b). More recent models suggest that a fourfold increase in treatment of hepatitis C (from about 100,000 to 400,000 patients per year) could prevent more than 250,000 deaths and more than 500,000 cases of cirrhosis per year (Durham et al., 2016). As the burden of disease is heaviest among people who inject drugs, a 90 percent reduction in prevalence in the United States would require screening 20 percent of injection drug users and treating about a third of those infected (Durham et al., 2016) (see Box 3-1).

BOX 3-1

Case Study on Cherokee Nation Health Services HCV Elimination Project.

Translating these models' promise into tangible results is complicated for several reasons. First, there may be error in the models introduced by the assumption of random mixing² among people in a population. In reality, only a fraction of hepatitis C patients are actively transmitting the virus. The most infectious candidates are those currently using injection drugs, a relatively young and frequently incarcerated population (Hagan et al., 2004; Zeiler et al., 2010). Though hepatitis C passes only rarely from mother to child, pregnant women with HCV could transmit it to their children. Among people infected with both HCV and HIV the otherwise low risk of sexual transmission rises, so HIV+ people are also seen as higher risk for transmission. Treating hepatitis C in high-risk transmitters, an otherwise healthy group who could become reinfected, would prevent no immediate deaths. Preventing deaths means treating the patients at greatest risk of cirrhosis and end-stage liver disease: older people, often no longer sharing needles or injecting drugs at all, beyond child bearing age, and with fewer sexual partners (Hagan et al., 2004; Kirk et al., 2013). So while the direct-acting antiviral treatments can both prevent hepatitis C deaths and interrupt new infections, meeting these goals requires attention to widely different patient populations. Furthermore, treatment models assume that cases identified in screening programs would complete a course of treatment under appropriate medical supervision, but national data suggest that only about one-third of people who screen positive for HCV antibody receive any follow-up care (Holmberg et al., 2013). Patients themselves may be reluctant to pursue treatment. Hepatitis C infection is mostly asymptomatic, encouraging the perception that it is not serious especially when weighed against the common and severe side effects of pre-2012 pegylated interferon and ribavirin treatment (Edlin et al., 2005; Mehta et al., 2008). The new direct-acting antiviral treatments are far more easily tolerated, but the misconception may persist, or concern with HCV be simply overshadowed by poverty and the comorbidities of addiction (Grebely et al., 2008; Mehta et al., 2008; Treloar et al., 2010). Providers may share in the reluctance to treat or even screen people actively using injection drugs out of a belief that they would not cooperate with treatment or be quickly reinfected (Lambert et al., 2011; Osilla et al., 2011).

The Threat of Reinfection

Reinfection is a barrier to using hepatitis C treatment as a tool to end transmission. Curative treatments are new, and research on reinfection after direct-acting antiviral therapy is limited (van de Ven et al., 2015). There is some evidence that risk of reinfection is relatively low, however. A 2013 analysis pooled data from seven studies on reinfection with HCV following treatment-induced sustained virologic response in men who have sex with men and people who inject drugs (Grady et al., 2013). The overall pooled estimate or risk of reinfection was between 0.91 and 6.12 percent per 100 person-years (Grady et al., 2013). The authors observed that the baseline incidence of HCV in the population appeared to influence this rate. So in places where HCV infection was rare, the risk of reinfection in high-risk patients was lower than in places where the background incidence of HCV was high (Grady et al., 2013). It is also not easy to distinguish between relapse after sustained virologic response and true reinfection. Patients from high-risk groups may be more likely to be infected with more than one strain of HCV. In these cases one strain may respond to treatment, while another persists (Grady et al., 2013).

Frequency of infectious contacts after being cured and the background HCV prevalence in the subpopulation both influence the risk of reinfection (Grebely et al., 2012). Phylogenetic analysis indicates that HCV transmission clusters among people with a reported injecting relationship (Sacks-Davis et al., 2012). Treating all infections within an injecting group—accomplished by encouraging patients to bring their friends for treatment—has promise to reduce prevalence among the drug-injecting subpopulation by 7 percentage points more than traditional treatment strategies and is currently being tested in Australia (Hellard et al., 2014, 2015).

Harm Reduction

Active drug users drive the bulk of hepatitis C transmission in the United States (Alter, 2002, 2007; Bruggmann and Grebely, 2015). The expansion of harm reduction services holds particular promise to interrupt transmission in this group. Recent models indicate that preceding hepatitis C therapy with a 40 percent increase in harm reduction services could decrease the treatment rate required to halve chronic hepatitis C prevalence over 10 years (Martin et al., 2013a).

The people most likely to transmit the virus are young and injecting drugs—people who are not well connected to health or social services. Reaching this group will be challenging, but there may be transferrable strategies from HIV (e.g., mobile testing and treatment, community and peer support, cash incentives) to encourage compliance with treatment (Chang et al., 2013). There is also the matter of addressing the root causes of drug addiction, and linking hepatitis C treatment to social and mental health services.

Key Findings and Conclusions

• In the United States, people who inject drugs are most likely to transmit hepatitis C virus (HCV).
• Harm reduction services can help reduce the transmission of HCV especially among younger people and those who have more recently started injecting.
• The effectiveness of harm reduction depends on the number of injectors reached and the number of syringes exchanged relative to total injections made. Most harm-reduction models were designed in cities where coverage was relatively easy to maintain, but injection drug use is becoming more common in rural areas and small towns. Adapting harm reduction to less densely populated places will be challenging.
• Direct-acting antivirals can both prevent hepatitis C deaths and interrupt transmission, but meeting these goals requires attention to widely different patient populations.
• Reinfection after cure is possible, but since the curative treatments are new, research on reinfection is limited.

ELIMINATING CHRONIC HEPATITIS C

There are 2.7 to 4.7 million people in the United States with chronic hepatitis C (Ward and Mermin, 2015). The disease disproportionately affects people aged 40 to 59, the same age group already experiencing the increased burden of chronic disease brought on by age. The burden of HCV is also felt more among the poor and less educated; fewer than half of people with HCV infection have incomes greater than twice the poverty level or education beyond high school (Denniston et al., 2014). Even these estimates might be biased toward the relatively stable and affluent, as prisoners and homeless people, known risk groups for HCV, are not included in national surveys (Denniston et al., 2014).

Managing chronic disease is challenging for reasons discussed later in this chapter. Both the chronic disease patient and his or her providers need to be involved in an ongoing process from diagnosis through continued monitoring and treatment. This process is sometimes called the care cascade or treatment cascade (HHS, 2015b). For people living with chronic hepatitis C, the care cascade starts with diagnosis and links to care. Once in care, patients should have HCV RNA confirmatory testing and genotyping and undergo liver fibrosis staging to help inform their prognosis and make decisions regarding antiviral therapy. Lastly, they must be prescribed HCV treatment and adhere to that treatment to the point of sustained virologic response (Yehia et al., 2014). National guidelines outline the appropriate care for patients along this continuum (Ghany et al., 2009, 2011; Yee et al., 2012).

The concept of a care cascade as a diagram showing the proportion of patients accounted for at every step of treatment, provides a framework for evaluating hepatitis C services over time and within patient subgroups. The effects of new screening efforts or antiviral drugs can be shown clearly on such a diagram (Moyer, 2013; Smith et al., 2012; Thomas, 2012). One recent meta-analysis made clear that the sharpest drop in the continuum from infection to sustained virologic response was in the diagnosis of HCV infection (Yehia et al., 2014) (see Figure 3-1).

FIGURE 3-1

The treatment cascade for chronic hepatitis C virus infection in the United States. NOTE: HCV, hepatitis C virus; RNA, ribonucleic acid; SVR, sustained virologic response; VA, Department of Veterans Affairs. SOURCE: Yehia et al., 2014.

In 2012, the CDC recommended one-time HCV testing for everyone born between 1945 and 1965, regardless of other risk factors, because this group is thought to account for three-fourths of all HCV infections in the country (Smith et al., 2012). The same recommendation called for referral of newly identified HCV-infected people to care (Smith et al., 2012). This recommendation may be better observed in the breach than in practice. CDC and NHANES research suggests that only about half of HCV infected people are aware of their condition (Denniston et al., 2012). Among those who are aware, about 57 percent carry health insurance, compared to 43 percent of those unaware of their infection (Denniston et al., 2012).

As Figure 3-1 illustrates, the prescription of antiviral therapy is another drop-off on the HCV care cascade, though recent developments in treatment may be reducing this decline. A retrospective analysis of Department of Veterans Affairs data found that the 2011 introduction of boceprevirbased combination therapies nearly doubled the monthly volume of patients treated (Gidwani et al., 2015). The advent of all-oral, highly efficacious, and tolerable direct-acting antivirals has shortened treatment duration. Shorter treatment means less opportunity to lose track of patients during therapy; the better tolerability of the treatments should allow for improved compliance. The best strategies for retaining patients in care are still unclear, however.

REDUCING MORBIDITY AND MORTALITY FROM HEPATITIS C

People living with HCV—especially those with cirrhosis—are at a substantially increased risk of death. HCV-infected people participating in the NHANES survey between 1988 and 1994 and followed though 2006 had a 2.4 times higher all-cause mortality rate and a 26.5 times higher liver-related mortality rate ration compared to HCV negative people (El-Kamary et al., 2011). Models that assume absence of treatment suggest that incident cases of end stage liver disease among HCV-infected people will peak between 2030 and 2035 with 379,600 cumulative deaths by 2030 and 1,071,229 cumulative deaths by 2060 (Rein et al., 2011).

HCV related cirrhosis is also a leading indication for liver transplantation in the United States. The Scientific Registry of Transplant Recipients from 2012 gives HCV-related cirrhosis as the underlying cause for listing 4,612 patients (about 30 percent of the list), resulting in 1,402 liver transplants (OPTN/SRTR, 2014). If untreated prior to liver transplantation, HCV will reinfect the transplanted organ resulting in decreased patient and graft survival. Efforts to cure HCV in patients with decompensated cirrhosis may help avoid need for liver transplantation. If transplantation is still required, HCV cure after transplant prolongs graft survival (Joshi et al., 2014).

HCV also causes considerable morbidity, including complications not related to liver disease. HCV-related cryoglobulinemia has been associated with cutaneous and visceral vasculitis, and glomerulonephritis, as well as B-cell non-Hodgkin's lymphoma (Negro et al., 2015). Because the liver and heart function together to ensure a healthy blood flow, liver damage can cause cardiovascular problems. HCV patients have increased risk of cardiovascular ailments such as carotid plaques, insulin resistance, diabetes, and hypertension (Petta et al., 2012; Younossi et al., 2013).

HCV also hurts patients through less tangible reductions to quality of life. When compared to uninfected and HBV-infected controls, HCV patients reported significantly more fatigue, low energy, and body pain (Foster et al., 1998). Fatigue and cognitive impairment are common in people with hepatitis C (Cacoub et al., 2002; Weissenborn et al., 2004). Though sickness can itself be a cause of depression, when compared to other people with liver disease, hepatitis C patients had worse quality of life and more depressive feelings, even after viral clearance (Tillmann et al., 2011).

CROSSCUTTING BARRIERS TO HEPATITIS C ELIMINATION

Any progress toward reducing transmission of HCV, toward eliminating chronic infection, or to reducing the morbidity and mortality attributable to chronic infection could be impeded by certain systemic barriers. Problems with disease surveillance, enrolling and managing patients in care, the cost of the curative treatment necessary to eliminate chronic infection, stigma, and motivation to eliminate the disease could also pose serious impediments to progress against the infection.

Surveillance

Chapter 2 describes problems with viral hepatitis surveillance in the United States. A 2010 Institute of Medicine (IOM) report on hepatitis and liver cancer recommended improving national surveillance for these viruses, but to date the CDC funds such programs in only seven jurisdictions (HHS, 2015a; IOM, 2010).

Surveillance for viral hepatitis could improve understanding of the true burden of disease across the care cascade. Identifying acute cases is essential to identifying an outbreak and instituting control measures, especially for nosocomial outbreaks or ones connected to medical care (Apostolou et al., 2015). Follow-up on acute cases can also help identify changes in the pattern of the HCV epidemic. If, for example, the public health officer sees a spike in infections among young people who inject drugs or among HIV+ men who have sex with men then they can adapt preventative measures accordingly (Breskin et al., 2015; Onofrey et al., 2011).

Challenges to conducting acute surveillance for HCV abound, however. First of all, the unsafe injection of drugs drives most transmission in the United States (Alter, 1997). People who inject drugs are less likely to receive medical care, and are therefore less commonly reported to the health department. Identifying acute HCV cases is also an imprecise process. The Massachusetts health department recently found that of 183 patients clinically diagnosed with HCV over ten years, only one would have met the case definition required for inclusion in national statistics (Onofrey et al., 2015). (See Box 3-2 for case definitions.) As the CDC bases its estimates of HCV incidence on reported acute cases, overly restrictive definitions and inconsistencies in clinical or laboratory reporting could lead to an amplified underestimate of true disease burden (Onofrey et al., 2015). Without a simple test for acute cases this problem will likely persist, as will the challenge of identifying asymptomatic cases.

BOX 3-2

Council of State and Territorial Epidemiologists Definitions for Case Classification of Hepatitis C Infection.

Identifying spikes in acute infection is important, and a reasonable expectation for a surveillance system. But a good understanding of chronic hepatitis C prevalence in an area is essential for allocating resources for prevention and treatment. Estimates of national prevalence are derived from the NHANES, Aside from the sampling limitations of the NHANES discussed earlier, the survey does not distinguish between differences in disease burden among different jurisdictions (Edlin et al., 2015). A more accurate response to the epidemic would require better local data, which could give a more accurate picture of the full, local care cascade, not just the acute infections.

Surveillance for HCV requires a strong public health infrastructure; chronically infected people often need multiple assays every year for years. The volume of testing needs to move through the system promptly to allow for real-time follow-up on potential outbreaks. A proper understanding of HCV burden would also attempt to capture the consequences of chronic infection, linking surveillance to health insurance claims, electronic health records, and birth, death, and cancer registries. There is also a need for deliberate attention to those populations at high risk for the disease: people who inject drugs, the homeless, and incarcerated. A system that can promptly identify seroconversion in these groups has the chance to react to new outbreaks and spot trends in how the disease is transmitted. Contact tracing, a common practice in outbreaks of sexually transmitted disease such as syphilis and HIV, may be a useful practice for HCV as well.

Enrolling and Retaining Patients in Hepatitis C Care

Once patients are referred to care, the challenge of managing them over time remains. HCV might be particularly difficult to manage because of the demands it puts on primary care. A 2014 survey found that about half of primary care physicians were already at full capacity, about a third reported being overextended and overworked (The Physicians Foundation, 2014). In general these providers are obliged to give more attention to acute and urgent problems than to the management of chronic disease (Bodenheimer et al., 2002). This burden on the health system could impede progress toward the elimination of hepatitis C.

A concern with redesigning the health system to meet the needs of the chronically ill is the essence of Edward Wagner's chronic care model described in Box 3-3 (Glasgow et al., 2001; Wagner et al., 2001). These principles have been shown to be useful in clinical practice. A 2009 review found that the chronic care model improved patient outcomes or the care process; when diabetic care conformed to the model, for example, HbA1c score and risk of heart disease decreased (Coleman et al., 2009; Parchman et al., 2007). Granted, research on the chronic care model often has many component interventions. It can be difficult to separate the benefits directly due to the chronic care model from those due to an observer bias, but the research suggests that the model has promise to greatly improve outcomes for patients with chronic disease (Coleman et al., 2009; Landon et al., 2004).

BOX 3-3

Wagner's Chronic Care Model.

It is also possible that patient navigators, lay health workers who can help patients overcome barriers in the health system, can help HCV-infected people stay in care. The patient navigator model has been shown effective in managing chronic conditions such as HIV and cancer (Vargas and Cunningham, 2006; Wells et al., 2008). The strategy has not yet been fully evaluated for HCV, though. Recent work in Philadelphia found that patient navigators can greatly facilitate diagnosis and retention in care of patients identified through community screening (Trooskin et al., 2015). Another Philadelphia group demonstrated that routine HCV testing and referral could be successfully integrated with ambulatory care for poor and homeless people (Coyle et al., 2015). Medical assistants helped relieve the burden on clinicians and other health center staff by guiding patients through their appointments and follow up. They also used reflex HCV testing technology to ensure that anti-HCV-positive patients received HCV RNA testing; the reflex technology also has the advantage of providing HCV antibody and RNA test results in one visit. Intensive services carried out by a patient navigator further increased the number of HCV-infected patients who received their results and were referred and seen by a specialist (Coyle et al., 2015).

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