Lesley Miller

A comparison of liver disease mortality with HIV and overdose mortality among Georgia prisoners and releasees: a 2-decade cohort study of prisoners incarcerated in 1991.

OBJECTIVES We investigated whether eventual causes of death among a cohort of inmates imprisoned in the southeastern United States differed from those in previous prisoner studies. METHODS We matched 23 510 prisoners in Georgia, a state with historically low levels of heroin consumption but moderate amounts of injection drug use, who were incarcerated on June 30, 1991, to death registries through 2010. Main exposure was 4-year time intervals over 2 decades of observation; main outcome was mortality from liver disease, HIV, and overdose. RESULTS Although the HIV-related mortality rate exceeded that from liver-related conditions before 2003, liver disease subsequently surpassed HIV as a cause of death. Among 3863 deaths, 22 (0.6%) occurred within 2 weeks after release from prison. Of these, only 2 were caused by accidental poisoning (likely drug overdose). Cardiovascular disease and cancer were the most frequent causes of death in this aging cohort. CONCLUSIONS Our study design deemphasized immediate deaths but highlighted long-term sequelae of exposure to viral hepatitis and alcohol. Treating hepatitis C and implementing interventions to manage alcohol use disorders may improve survival among prisoners in the Southeast.

Brief Report: Risk Factors for Pneumococcal Vaccine Refusal in Adults

AbstractBACKGROUND: Invasive pneumococcal disease is a significant cause of morbidity and mortality in the United States. Despite availability of an effective vaccine, many patients refuse vaccination. OBJECTIVE: To investigate patient characteristics and features of the patient-provider relationship associated with pneumococcal vaccine refusal. DESIGN: Case-control study using chart review. PATIENTS: Five hundred adults from the medical clinics of a 1,000-bed inner-city teaching hospital. MEASUREMENTS AND MAIN RESULTS: Independent risk factors for pneumococcal vaccine refusal included patient-provider gender discordance (odds ratio (OR)=2.09, 95% confidence interval (CI) 1.07 to 4.09); a visit to a not-usual provider at the time of vaccine offering (OR=2.26, 95% CI 1.13 to 4.49); never having received influenza vacination (OR=7.44, 95% CI 3.76 to 14.76); prior pneumococcal vaccine refusals (OR=3.45, 95% CI 1.60 to 7.43); and a history of ever having refused health maintenance tests (OR=2.86, 95% CI 1.40 to 5.84). CONCLUSIONS: We have identified both patient factors and factors related to the patient-provider relationship that are risk factors for pneumococcal vaccine refusal. By identifying patients at risk for pneumococcal vaccine refusal, efforts to increase vaccination rates can be better targeted.

Highly Successful Hepatitis C Virus (HCV) Treatment Outcomes in Human Immunodeficiency Virus/HCV-Coinfected Patients at a Large, Urban, Ryan White Clinic.

Abstract Background The introduction of direct-acting antivirals (DAAs) created a major paradigm shift in the treatment of chronic hepatitis C. Currently, there is little “real-world” data regarding hepatitis C virus (HCV) treatment outcomes in the human immunodeficiency virus (HIV)/HCV-coinfected population. Methods This retrospective cohort study examined HCV treatment outcomes of HIV/HCV-coinfected patients at a large, urban, Ryan White-funded clinic caring for an underserved population. All HIV patients initiating HCV treatment from January 1, 2013 to November 30, 2015 were included in the analysis. The primary end point was sustained virologic response 12 weeks after the end of therapy (SVR12). Results A total of 172 patients initiated HCV treatment within the study period: 79% were male, 83% were black, 95% were HCV genotype 1, 79% were HCV treatment naive, and 16% had cirrhosis. At baseline, median CD4 was 494 cells/μL (interquartile range, 316–722) and 92% had HIV ribonucleic acid less than 40 copies/mL. The most common DAA initiated was ledipasvir/sofosbuvir (LDV/SOF) (85%), with 92% receiving 12 weeks of treatment. Overall, SVR12 was 93% by intention-to-treat analysis and 98% by per-protocol analysis. The majority of patients on LDV/SOF did not report any adverse effect. One patient in the ribavirin plus SOF group discontinued treatment due to adverse effect. Conclusions In a cohort of mainly black, male, HIV/HCV-coinfected patients at a large, urban, Ryan White clinic, HCV treatment with DAAs resulted in high SVR12 rates and was well tolerated despite real-world challenges including medication access barriers and drug interaction concerns.

High-Yield Birth-Cohort Hepatitis C Virus Screening and Linkage to Care among Underserved African Americans, Atlanta, Georgia, 2012–2013:

Objective. Hepatitis C virus (HCV) infection disproportionately affects certain populations, including those born between 1945 and 1965 (i.e., baby boomers) and African Americans. As part of the Hepatitis Testing and Linkage to Care initiative, which promoted hepatitis B and hepatitis C screening, posttest counseling, and linkage to care at 34 U.S. sites, we conducted routine HCV screening to identify previously undiagnosed, primarily African American baby boomers with chronic hepatitis C infection and link them to care. Methods. We launched the Internal Medicine Trainees Identifying and Linking to Treatment for Hepatitis C (TILT-C) initiative at the Grady Memorial Hospital Primary Care Center and Grady Liver Clinic in Atlanta, Georgia, in October 2012, and present results from the first year. TILT-C faculty implemented an electronic medical record prompt and conducted educational sessions to boost HCV screening. A project coordinator tracked testing outcomes and linked HCV-positive patients to care. Results. Of 2,894 patients tested for anti-HCV, 201 (6.9%) tested positive. Men had a significantly higher (p<0.001) prevalence of HCV infection than women, with 106 of 1,091 (9.7%) men compared with 95 of 1,803 (5.3%) women testing anti-HCV positive. A total of 174 of 201 (86.6%) anti-HCV-positive patients received HCV ribonucleic acid (RNA) testing. Of 124 patients with a positive HCV RNA test, 122 were referred to care and 120 attended the first appointment. Conclusion. The TILT-C screening program was feasible and effective in detecting previously undiagnosed HCV infection and linking patients to care. The unexpectedly high prevalence of HCV infection in this primarily African American, baby boomer population underscores the need for aggressive HCV screening efforts in similar populations.

Apportioning blame in the North American hepatitis C virus epidemic

A novel investigation into the North American spread of hepatitis C virus permits blame shifting, which the authors Jeff rey Joy and colleagues hope will increase the number of baby boomers who undergo testing. The medical community can now take its share of the responsibility for hepatitis C virus infection in its conversations with the 1945–65 birth cohort. Joy and colleagues off er evidence that the era of high rates of transmission and rapid expansion of hepatitis C virus infections was from 1940 to 1960, when reuse of glass and metal syringes was common medical practice. It was the medical community that inadvertently spread the virus in North America via nosocomial transmission. Current thinking attributes the high seroprevalence of hepatitis C virus among baby boomers to the risky individual behavior of the Woodstock generation in the late 1960s. But by that time, which brought widespread experimentation with drugs, expansion was already slowing down. The authors conclude that attributing the spread of hepatitis C virus to the medical establishment, rather than youthful behavior long outgrown by most baby boomers, could justify changing the message around screening of baby boomers. Joy and coworkers posit that the greatest expansion of North America’s most common genotype occurred between 1940 and 1960. Using phylogenetic analysis of genotype 1a sequences, they showed that diversity in the genes for fi ve key proteins of the virus exploded in this period, but remained relatively stable after 1960. They reconstructed the demographic history of the epidemic by inferring the time at which a common ancestor virus strain emerged. After screening 45 316 samples from the National Center for Biotechnology Information GenBank nucleotide database dating from around 1980 onwards, the team established the age of the various mutations and then determined the population size at given points in time. The Bayesian skyline plots shown in fi gure 1 of the Article have a y axis that is related to the number of infected individuals and their frequency of transmitting their strains of hepatitis C virus to others. The x axis represents time. The steep increases occur during periods of frequent transmission from multiple infected patients to multiple new patients. The plots slope upward most steeply from 1940 to 1960. The steep downward slopes coincide with the AIDS epidemic and subsequent harm reduction by injection drug users, followed by development of a serological test for hepatitis C virus, which virtually eliminating transmission via blood transfusion. Destigmatising the origin of the expansion could radically change the conversation between clinicians and patients before and after hepatitis C virus testing, as well as the public health message to Americans around screening for baby boomers. Adding nosocomial exposure as an alternative risk to injection drug use, “even if only once”, can remove the cloud of suspicion and mutual mistrust related to historical intravenous drug use that often permeates these exchanges. Baby boomers came of age when nosocomial transmission could have been rampant. For this additional reason, rather than just individual behavior, all Americans born between 1945 and 1965 should be tested, say the authors. This change of message, while eff ective, could backfi re. By accepting responsibility for the pre-1960 spread, the medical establishment might increase stigma for patients born after the uptake of disposable syringes and safer clinical practices. We may claim responsibility up to the 1960s, when medical injection practices changed, or the 1990s, when blood transfusion became safer, but for Millennials and Generation Y, stigma might increase. Also, screening by birth cohort might already be outlasting its usefulness in some populations. In a study of prisons, most inmates with hepatitis C virus infection were born after 1965. Although the United States Preventative Services Task Force recommends testing for anyone who has been incarcerated, this recommendation is absent from Centers for Disease Control and Prevention recommendations. With many cases identifi ed outside the birth cohort, a universal screening strategy has been proposed. Lowering the cost of hepatitis C virus testing could lead to routine, universal testing becoming the norm, making birth cohort testing obsolete. Last, the novel method used in this study could be replaced by an even newer, more precise technology; AP /A P/ Pr es s A ss oc ia tio n Im ag es

Abstract A22: Programmatic implementation of hepatocellular carcinoma prevention through hepatitis C testing, secondary prevention, and treatment for a medically and minority underserved population

This study assessed the programmatic implementation of a multi-disciplinary program to prevent hepatocellular carcinoma through hepatitis C (HCV) testing, secondary prevention among diagnosed individuals (defined as interventions that prevent further progression of liver disease), and treatment within a medically and minority underserved clinic. The Lewis Cancer & Research Pavilion (LCRP) at St. Joseph9s/Candler Health System is a Community Cancer Center and regional destination for cancer care in coastal Georgia. LCRP disparities efforts focus on cancer prevention, screening, and facilitating access to cancer care at two clinics for underserved and uninsured, low-income, predominately African American and Hispanic populations. Because the primary cause of hepatocellular carcinoma is cirrhosis from chronic hepatitis infection, in 2014 the LCRP began implementing Centers for Disease Control and Prevention (CDC) recommendations for HCV testing as a cancer prevention activity at the clinics. As HCV patients were identified, it became clear that disease specific protocols needed to be developed in order to improve nurse practitioners9 clinical practice. Barriers identified and addressed during program implementation included: 1) perception that expensive HCV treatment is inaccessible for uninsured patients, 2) lack of knowledge of CDC clinical testing guidelines resulting in inaccurate HCV diagnosis 3) lack of knowledge of secondary prevention and treatment leading to inappropriate clinical care for HCV+ patients, and 4) under-utilization of Electronic Medical Record (EMR) and other data tracking tools to enhance clinical care. The LCRP and clinical team identified available community and statewide resources, physician champions, and education resources. A multi-disciplinary team developed protocols for secondary prevention activities while a clinical team implemented clinical testing and treatment algorithms using CDC, American Association for the Study of Liver Diseases (AASLD), and Infectious Diseases Society of American (IDSA) guidelines. These initiatives are consistent with CDC efforts to move HCV management to community-based health-care providers within primary care with supportive training and supervision by HCV care specialists. The clinic conducted a baseline chart audit of patients with HCV documented in their medical record. At baseline, CDC testing algorithms to confirm diagnosis were followed in 14% of patients who received the initial HCV+ antibody test. Six months after implementation of testing algorithms and other clinical and programmatic improvements, 44% of birth cohort patients (patients born between 1945 and 1964) were screened in compliance with CDC guidelines. Average age of HCV+ patients was 51, 58% were African American, 41% Caucasian, 62% female, and 38% male. Secondary prevention activities including hepatitis A & B vaccines, referral for alcohol and/or substance abuse counseling, depression and mental health screening, and identification of prevention and/or treatment barriers were initiated during the first six months of 2014 with 34% of HCV+ patients. Prevention activities conducted concurrently with treatment planning. Nurse practitioners at the clinic obtained co-management HCV treatment support from an internal medicine and primary care physician. This cancer prevention program demonstrated improvement in HCV testing, prevention, and treatment within a primary-care nurse-managed community clinic. The inter-disciplinary approach outlined in this model utilized evidence based guidelines and diagnostic algorithms. Application of secondary prevention activities and effective data tracking increased overall programmatic success, and ultimately contributes to the prevention of hepatocellular carcinoma among disparate populations. Citation Format: Sarah E. Dobra, Nidsa Baker, Lesley Miller, Lauren Stokes. Programmatic implementation of hepatocellular carcinoma prevention through hepatitis C testing, secondary prevention, and treatment for a medically and minority underserved population. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr A22.

Su1038 APRI As a Non-Invasive and Inexpensive Predictor of Hepatic Fibrosis in a Primarily Uninsured African American Population With Chronic Hepatitis C

Background Chronic hepatitis C may be associated with cirrhosis, liver failure, and hepatocellular carcinoma. Recent studies have suggested histologic regression of cirrhosis in patients with sustained virologic response to anti-viral therapy. Objective Perform a meta-analysis of studies to determine the impact of sustained virologic response on the reversibility of cirrhosis after anti-viral therapy. Methods We used PubMed and Cochrane Library databases to identify all studies that assessed the association between SVR and cirrhosis regression in patients with HCV. Data was extracted regarding patient demographics, clinical characteristics, liver biopsy length, duration between biopsies, fibrosis scoring system, baseline biopsy score, anti-viral therapy, length of treatment, viral genotype, baseline viral load, and regression of cirrhosis. Six studies totaling 443 patients were included. Results Of the 443 patients with cirrhosis, 137 achieved a SVR. Of these 137 patients who achieved an SVR, 73 (53%) patients had regression of cirrhosis. The risk ratio of cirrhosis regression was 2.69 (Confidence Interval [CI] 1.45-4.97, p<0.01) in patients who achieved a SVR. The risk of cirrhosis regression was consistently in favor of patients who achieved a SVR regardless of the length of the biopsy or whether the biopsy was reviewed by a single or multiple pathologists. The risk ratio of cirrhosis regression was related to the duration of follow up between biopsies. The relative risk ratio for regression of cirrhosis in studies in which the mean or median time for the follow-up liver biopsy was greater than 36 months was 4.33 (CI 1.1-17.0, p= 0.04) as compared to a relative risk ratio of 1.79 (CI 1.26-2.29, p<0.01) in studies with a mean or median time between the follow-up biopsy of less than 36 months. Conclusions Our results suggest that the majority of patients with cirrhosis who achieve a SVR have regression of their cirrhosis. Time between biopsies appears to be an important determinant of the likelihood of cirrhosis regression, with more regression likely with longer follow up.