Novel Screening Strategies for HIV, Hepatitis B and C Infection

Abstract Title: Novel Screening Strategies for HIV, Hepatitis B and C Infection. Author: Dr Sarah O?Connell Introduction: Despite prevention measures in place, rates of HIV infection have failed to decline in Ireland in recent years. From 2015 to 2016, a 6% increase was seen in notifications of newly diagnosed HIV infection. High numbers of chronic hepatitis B infection continue to be diagnosed in Ireland every year and rates of newly diagnosed hepatitis C infection have fallen slightly in recent years. The HIV UNAIDS 90-90-90 plan outlines a target for 2020, where 90% of those with HIV infection be diagnosed, 90% of those are linked to care and 90% of those are on effective anti-retroviral therapy. The National Hepatitis C Treatment Programme aims to see progression towards eradication of hepatitis C by 2026. Risk based screening nationally are the most common screening practices in Ireland. I proposed to undertake a research programme to understand current HIV presentation patterns and the current landscape of blood borne virus cascade of care, to introduce a pilot blood borne virus screening programme, to examine the feasibility and acceptability of such a programme and to examine the sero-prevalence of infection in a high-prevalence cohort. I aimed to understand the demographics of those diagnosed, measure linkage to care rates, monitor patients through their treatment pathways and examine ways to improve the testing and follow up service. Methods: Retrospective cohort studies examining HIV, hepatitis B and C retention in care rates and treatment outcomes were undertaken at our centre. A nested case control study examining factors associated with non-retention in HIV care was performed. A retrospective cohort study of those who presented with late HIV infection at our centre from 2002 and 2014 was then performed. A cross sectional pilot study was then undertaken, where 10,000 patient samples in St James?s Hospital Emergency Department were tested on an opt-out basis for HIV, hepatitis B and C infection. Uptake rate of testing was recorded. Given high rates of poor engagement to hepatitis C care, a retrospective cohort study of those with known hepatitis C infection was then performed to understand factors associated with non-engagement in hepatitis C care. Success of this pilot study led to the implementation of blood-borne virus testing as routine care. Referrals to the Department of Genito-Urinary Medicine and Infectious Diseases were recorded and tracked to monitor retention in care and triage/treatment outcomes. A quality improvement programme was then undertaken to explore ways to improve hepatitis C retention in care. Results: Patients with heterosexual mode of acquisition and of an older age were more likely to present at a late point in their HIV illness, suggesting a non-risk based HIV screening approach is necessary. In our BBV cohort, retention in HIV care rates are comparable with international standards, but can be improved upon to meet the UNAIDS 90-90-90 target. Hepatitis B and C retention in care rates are poor. No significant demographic is associated with hepatitis B disengagement from care and reasons for disengaging are poorly understood. Results of a nested case-control study showed that the non-Irish, heterosexual population are more likely to disengage from HIV care. Following the introduction of a pilot ED opt-out BBV study, a high feasibility and acceptability rate was found. High sero-prevalence for all 3 infections was found, and a high proportion of those with previously known hepatitis C were not attending care. Cases were diagnosed and linked/re-linked to care. Factors associated with non-engagement in hepatitis C care included active intravenous drug use. Success of this pilot project led to the introduction of routine testing in the ED. Results show ongoing overall high sero-prevalence rates. A quality improvement programme was introduced to find ways to improve the poor hepatitis C retention in care rate. This programme provided the team with valuable experience in Quality Improvement tools that can be used to deliver quality healthcare. Conclusion: Patients need to be diagnosed with BBV infections they are unaware of, and linked to care. We have shown that this is possible, and the healthcare infrastructure in place can serve these patients well. We need to make improvements in our healthcare service in the areas of BBV retention in care and increased BBV testing overall. Improved healthcare staff education around the need for widespread BBV testing, the need to understand predictors of non-retention in care and the need for increased awareness of HIV clinical indicant conditions is required. Lastly, BBV screening programmes need to be expanded nationally to allow for widespread testing