Nurse Case Management to Improve the Hepatitis C Care Continuum in HIV Co-Infection: A Randomized Controlled Trial
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Date
2018-07-02
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Johns Hopkins University
Abstract
Background. All-oral direct acting antivirals (DAAs) provide an unprecedented opportunity to eliminate hepatitis C virus (HCV) as a public health threat. But challenges across the care continuum persist. These challenges are particularly poignant for persons co-infected with HIV who are high-priority to cure but not well engaged in HCV care. Strategies to improve the HCV care continuum for this population are urgently needed.
Methods. The Care2Cure study was a single-blinded randomized controlled trial to test the effect of a multi-component HCV nurse case management intervention (nurse-initiated referral, strengths-based education, patient navigation, and care coordination) on linkage to HCV care and time to DAA initiation. Adults co-infected with HIV/HCV not engaged in HCV care were recruited from an urban, outpatient infectious disease practice.
Results. Between July 2016 and February 2018, 68 participants were randomized to receive nurse case management (n=35) or an HCV fact sheet (n=33) in addition to usual care. Participants were primarily Black/African-American (81%) and low income (98% on public health insurance). At day 60, 47% of nurse case management participants linked to HCV care, compared to 25% of usual care participants (p=0.036 by z test for difference in proportions; confidence bound 3.2%-40.9%). There was no significant difference in time to treatment initiation by Kaplan Meier estimates. In logistic regression, participants who drank alcohol were more likely to schedule an HCV appointment (adjusted odds ratio [aOR]=3.8), attend the appointment (aOR=3.8), and be prescribed DAAs (aOR=4.2). Knowing someone who cured HCV increased the likelihood of being prescribed (aOR=5.2) and initiating (aOR=8.0) DAAs. A higher CD4 cell count was associated with greater odds of scheduling an HCV appointment (aOR=1.002). Participants taking medication-assisted treatment (MAT) were less likely to be prescribed DAAs (aOR=0.25).
Conclusions. These results support provision of nurse case management to link adults co-infected with HIV to HCV care. Interventions that continue from linking to care through cure are needed to achieve HCV elimination in this high-priority population. Capitalizing on social networks and treatment pathways for patients drinking alcohol may help improve the HCV care continuum. Integrated substance use and HCV care to engage patients taking MAT should be considered.
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Keywords
case management, health care utilization, hepatitis C, HIV, randomized controlled trial