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Hepatitis C care cascade among patients with and without tuberculosis: Nationwide observational cohort study in the country of Georgia, 2015–2020

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Baliashvili, Davit, Blumberg, Henry M., Gandhi, Neel R., Averhoff, Francisco, Benkeser, David, Shadaker, Shaun, Gvinjilia, Lia, Turdziladze, Aleksandre, Tukvadze, Nestani, Chincharauli, Mamuka, Butsashvili, Maia, Sharvadze, Lali, Tsertsvadze, Tengiz, Zarkua, Jaba, Kempker, Russell R.·2023·PLOS Medicine
DOI 10.1371/journal.pmed.1004121PMC PMC10194957

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Abstract

Background: 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. Methods and findings: 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. Conclusions: 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.

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Metadata

Authors
Baliashvili, D., Blumberg, H. M., Gandhi, N. R., Averhoff, F., Benkeser, D., Shadaker, S., Gvinjilia, L., Turdziladze, A., Tukvadze, N., Chincharauli, M., Butsashvili, M., Sharvadze, L., Tsertsvadze, T., Zarkua, J., & Kempker, R. R.
Affiliations
  • Emory University (US)
  • Centers for Disease Control and Prevention (US)
  • National Center for Disease Control and Public Health (GE)
  • National Center for Tuberculosis and Lung Disease (GE)
  • University of Georgia (GE)
  • AIDS and Clinical Immunology Research Center (GE)
Corresponding author
Baliashvili, Davit
ORCID
Venue
PLOS Medicine
Publisher
Public Library of Science (PLoS)
Published
2023-05-04
Volume
20
Issue
5
Pages
e1004121
ISSN
  • 1549-1277 (ISSN-L)
  • 1549-1676
DOI
10.1371/journal.pmed.1004121
PMC
PMC10194957
OpenAlex
W4368617656
Cited by
0
References
1
FWCI
0.00
Type
journal article
Language
en
Update notices
new_version (2023-05-18)
Open access
Licence
Locations
  • PLoS Medicine (publishedVersion, public-domain)
  • medRxiv (acceptedVersion)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Funders
  • Fogarty International Center (D43TW007124)
  • National Institutes of Health (K24AI114444, P30AI168386, P30AI050409, U19AI111211)
Topics
  • Health Sciences › Medicine › Hepatology › Hepatitis C virus research
  • Health Sciences › Medicine › Infectious Diseases › Tuberculosis Research and Epidemiology
  • Health Sciences › Medicine › Gastroenterology › Helicobacter pylori-related gastroenterology studies
Keywords
hepatitis C, tuberculosis, cascade of care, loss to follow-up, HCV antibody screening, HCV viremia, HCV treatment initiation, HCV cure, Georgia, Eastern Europe, HIV/HCV coinfection
MeSH terms
Adolescent, Adult, Georgia, Hepatitis C, Humans, Tuberculosis, Viremia, Cohort Studies, Hepacivirus, Tuberculosis, Multidrug-Resistant, Hepatitis C Antibodies

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