The Population Level Cascade of Care for Hepatitis C in British Columbia, Canada: The BC Hepatitis Testers Cohort (BC-HTC).
BACKGROUND
Population-level monitoring of hepatitis C virus (HCV) infected people across the cascade of care identifies gaps in access and engagement in care and treatment. We characterized a population-level cascade of care for HCV in British Columbia (BC), Canada and identified factors associated with leakage at each stage.


METHODS
The BC Hepatitis Testers Cohort (BC-HTC) includes 1.5million individuals tested for HCV, HIV, reported cases of hepatitis B, and active tuberculosis in BC from 1990 to 2013 linked to medical visits, hospitalizations, cancers, prescription drugs and mortality data. We defined six HCV cascade of care stages: 1) estimated population prevalence; 2) HCV diagnosed; 3) HCV RNA tested; 4) genotyped; 5) initiated treatment; and 6) achieved sustained virologic response (SVR).


RESULTS
We estimated that 73,203 people were HCV antibody positive in BC in 2012 (undiagnosed: 18,301, 25%; diagnosed: 54,902, 75%). Of these, 56%(40,656) had HCV RNA testing; 34%(26,300) were genotyped; 12%( 8532 ) had received interferon-based therapy and 7%(5197) had SVR. Males, older birth cohorts, and HBV coinfected were less likely to undergo HCV RNA testing. Among those with chronic HCV infection, 32% had received liver-related care. Retention in liver care was more likely in those with HIV, cirrhosis, and drug/alcohol use and less likely in males and HBV coinfected.


CONCLUSIONS
Although there are gaps in HCV RNA testing and genotyping after HCV diagnosis, the major gap in the cascade of care was low treatment initiation. People with comorbidities progressed through the cascade of testing and care but few received treatment.
British Columbia Centre for Disease Control (BCCDC), 655 West 12th Avenue, Vancouver, BC V5Z 4R4, Canada; School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada. Electronic address: naveed.janjua@bccdc.ca.
Naveed Z
NZ
Janjua
British Columbia Centre for Disease Control (BCCDC), 655 West 12th Avenue, Vancouver, BC V5Z 4R4, Canada.
Margot
M
Kuo
British Columbia Centre for Disease Control (BCCDC), 655 West 12th Avenue, Vancouver, BC V5Z 4R4, Canada.
Amanda
A
Yu
British Columbia Centre for Disease Control (BCCDC), 655 West 12th Avenue, Vancouver, BC V5Z 4R4, Canada.
Maria
M
Alvarez
British Columbia Centre for Disease Control (BCCDC), 655 West 12th Avenue, Vancouver, BC V5Z 4R4, Canada.
Stanley
S
Wong
British Columbia Centre for Disease Control (BCCDC), 655 West 12th Avenue, Vancouver, BC V5Z 4R4, Canada.
Darrel
D
Cook
British Columbia Centre for Disease Control (BCCDC), 655 West 12th Avenue, Vancouver, BC V5Z 4R4, Canada; School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada.
Jason
J
Wong
Kirby Institute, University of New South Wales Australia, Sydney, NSW 2052, Australia.
Jason
J
Grebely
British Columbia Centre for Disease Control (BCCDC), 655 West 12th Avenue, Vancouver, BC V5Z 4R4, Canada; School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada.
Zahid A
ZA
Butt
British Columbia Centre for Disease Control (BCCDC), 655 West 12th Avenue, Vancouver, BC V5Z 4R4, Canada; School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada.
Hasina
H
Samji
Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver, BC V5Z 1M9, Canada.
Alnoor
A
Ramji
British Columbia Centre for Disease Control (BCCDC), 655 West 12th Avenue, Vancouver, BC V5Z 4R4, Canada; School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada.
Mark
M
Tyndall
British Columbia Centre for Disease Control (BCCDC), 655 West 12th Avenue, Vancouver, BC V5Z 4R4, Canada; Department of Pathology and Laboratory Medicine, University of British Columbia, 2211 Wesbrook Mall, Vancouver, BC V6Z 1Y6, Canada.
Mel
M
Krajden
D000328:Adult; D000368:Aged; D000998:Antiviral Agents / Q000627:therapeutic use; D001955:British Columbia / Q000453:epidemiology; D015331:Cohort Studies; D060085:Coinfection; D003695:Delivery of Health Care; D005260:Female; D005838:Genotype; D016174:Hepacivirus / Q000235:genetics; D006526:Hepatitis C / Q000175:diagnosis / Q000453:epidemiology* / Q000628:therapy / Q000821:virology; D006801:Humans; D008297:Male; D008875:Middle Aged; D058889:Molecular Typing; D011159:Population Surveillance; D015995:Prevalence; D012367:RNA, Viral; D016896:Treatment Outcome
D000998:Antiviral Agents; D012367:RNA, Viral
Cascade of care; Engagement with care; Hepatitis C; Linkage with care; Prevalence; Testing; Treatment