The Cascade of Care for Hepatitis C Treatment in Rwanda: A Retrospective Cohort Study of the 2017–2019 Mass Screening and Treatment Campaign
Abstract
:1. Background
2. Materials and Methods
2.1. Study Context
2.2. Study Design
2.3. Study Sites and Population
2.4. Data Sources
2.5. Cascade of Care
2.5.1. Screening
2.5.2. HCV RNA Testing
2.5.3. Treatment
2.6. Outcome Variables
2.7. Other Variables
2.8. Data Analysis
3. Results
3.1. Descriptive Characteristics
3.2. Cascade of Care
3.3. Anti-HCV Seroprevalence
3.4. HCV RNA Testing
3.5. Dropout at HCV RNA Testing
3.6. Treatment Success (Achieving SVR)
3.7. Dropout at Final SVR Test
4. Discussion
4.1. Anti-HCV Screening and HCV RNA Testing
4.2. Treatment Initiation and Success
4.3. HCV RNA and SVR Testing Dropout
4.4. Limitations
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Outcome | Numerator | Denominator |
---|---|---|
Proportion of patients who were anti-HCV positive | Number of patients with a positive HCV antibody test | Number of patients screened |
HCV RNA viremia rate | Number of patients who tested HCV RNA positive | Number of patients who screened positive for anti-HCV with HCV RNA test conducted |
Proportion of patients who dropped out of care before HCV RNA viremia testing | Number of patients who screened positive for anti-HCV and did not return for an HCV RNA test | Number of patients who screened positive for anti-HCV |
Proportion of patients who initiated treatment | Number of patients who initiated treatment with available records in hospital registers | Number of patients who were confirmed HCV RNA positive |
Proportion of patients who achieved SVR (treatment success) | Number of patients whose HCV viral load result was below 20 copies/mL within 12–24 weeks post-treatment and returned for SVR test | Number of patients who completed treatment with available records and returned for SVR assessment (excluding those who died) |
Proportion of patients who did not return for SVR tests | Number of patients who initiated treatment and did not come back for SVR assessment | Number of patients who initiated treatment with available records in the registers (excluding those who died) |
Total Sample | Anti-HCV Positive | HCV RNA Testing | ||||||
---|---|---|---|---|---|---|---|---|
Variables | Total Sample | Total (%) | Total Number Screened Anti-HCV Positive | Anti-HCV Positive (%) | Total Number HCV RNA Tested | HCV RNA Positive (%) | Total Dropouts | Dropout (%) |
Age | ||||||||
<44 | 426,186 | 59.4 | 9378 | 19.4 | 3324 | 13.3 | 686 | 15.1 |
44–54 | 112,264 | 15.6 | 6165 | 12.8 | 2977 | 11.9 | 265 | 5.8 |
55–64 | 100,439 | 14 | 9918 | 20.6 | 5498 | 22 | 340 | 7.5 |
64+ | 78,493 | 10.9 | 22,848 | 47.3 | 13,203 | 52.8 | 3252 | 71.6 |
Sex | ||||||||
Female | 555,389 | 68.4 | 32,159 | 66.5 | 16,442 | 65.7 | 3259 | 68.1 |
Male | 256,701 | 31.6 | 16,580 | 33.5 | 8587 | 34.3 | 1528 | 31.9 |
SES categories | ||||||||
Category 1 | 104,681 | 12.2 | 8077 | 23.3 | 4971 | 19.9 | 1163 | 25.5 |
Category 2 | 260,537 | 30.3 | 12,211 | 35.2 | 6854 | 27.4 | 1510 | 33.1 |
Category 3 or 4 or unknown | 495,583 | 57.6 | 14,456 | 41.6 | 8201 | 52.7 | 1888 | 41.3 |
Marital status | ||||||||
Single | 109,552 | 15.1 | 1625 | 4.9 | 910 | 4.8 | 126 | 4.6 |
Married or in union | 461,231 | 63.6 | 21,522 | 64.9 | 11,911 | 63.4 | 1707 | 62 |
Separated/divorced/widowed | 153,919 | 21.2 | 9927 | 30.2 | 5972 | 31.8 | 920 | 33.4 |
Health insurance | ||||||||
No insurance | 161,853 | 18.8 | 7867 | 15.9 | 172 | 19.3 | 1045 | 21.8 |
Community insurance | 657,067 | 76.3 | 40,076 | 81.1 | 19,517 | 78 | 3643 | 76.1 |
Private or other government insurance (RAMA/RSSB) | 41,881 | 4.9 | 1437 | 3 | 694 | 2.8 | 99 | 2.1 |
Diabetes status | ||||||||
No | 694,243 | 99 | 32,956 | 98 | 18,681 | 97.5 | 2835 | 98.9 |
Yes | 7353 | 1 | 676 | 2 | 475 | 2.5 | 32 | 1.1 |
HTA status | ||||||||
No | 448,936 | 97.7 | 30,204 | 92.5 | 17,626 | 90.2 | 1845 | 92.4 |
Yes | 10,653 | 2.3 | 2455 | 7.5 | 1915 | 9.8 | 152 | 7.6 |
Renal failure status | ||||||||
No | 453,150 | 98.8 | 30,926 | 98.1 | 18,461 | 98.7 | 2078 | 97.9 |
Yes | 5365 | 1.2 | 592 | 1.9 | 247 | 1.3 | 44 | 2.1 |
HIV status | ||||||||
Negative | 680,082 | 97.1 | 31,789 | 94.6 | 17,719 | 92.8 | 2836 | 98.6 |
Positive | 20,071 | 2.9 | 1806 | 5.4 | 1371 | 7.2 | 40 | 1.4 |
HBV result | ||||||||
Negative | 829,644 | 97 | 42,548 | 97.7 | 20,278 | 98.7 | 4323 | 97.6 |
Positive | 25,652 | 3 | 984 | 2.3 | 267 | 1.3 | 105 | 2.4 |
Family History of viral hepatitis C | ||||||||
No | 837,090 | 97.2 | 32,317 | 95.4 | 17,962 | 96 | 4709 | 98.4 |
Yes | 23,711 | 2.8 | 1543 | 4.6 | 1006 | 4 | 78 | 1.6 |
Ever been traditionally operated on | ||||||||
No | 597,913 | 85.1 | 26,955 | 79.3 | 15,598 | 80.4 | 2312 | 81.7 |
Yes | 104,688 | 14.9 | 7020 | 20.7 | 3801 | 19.6 | 517 | 18.3 |
Ever been transfused | ||||||||
No | 683,769 | 97.3 | 32,931 | 96.9 | 18,770 | 96.8 | 2759 | 97.5 |
Yes | 18,729 | 2.7 | 1047 | 3.1 | 617 | 3.2 | 70 | 2.5 |
Ever been medically operated on | ||||||||
No | 665,094 | 94.7 | 32,108 | 94.3 | 18,430 | 94.7 | 2674 | 94.6 |
Yes | 37,518 | 5.3 | 1945 | 5.7 | 1022 | 5.3 | 152 | 5.4 |
Ever been diagnosed with liver disease | ||||||||
No | 399,965 | 98.3 | 18,211 | 97.58 | 15,000 | 97.9 | 895 | 98.2 |
Yes | 6947 | 1.7 | 452 | 2.42 | 310 | 2.1 | 16 | 1.8 |
HBV vaccination | ||||||||
Partially or fully vaccinated | 53,723 | 6.24 | 5245 | 31.3 | 4519 | 32.8 | 66 | 1.4 |
Not vaccinated | 807,078 | 93.76 | 43,435 | 68.7 | 20,512 | 67.2 | 4721 | 98.6 |
Unadjusted Model | Adjusted Model † | ||||
---|---|---|---|---|---|
Variables | N | OR | 95% CI | OR | 95% CI |
Age | |||||
<44 | 426,186 | 1 | 1.00, 1.00 | 1 | 1.00, 1.00 |
44–54 | 112,264 | 2.53 | 2.44, 2.61 | 2.41 | 2.33, 2.50 |
55–64 | 100,439 | 4.66 | 4.52, 4.80 | 4.45 | 4.31, 4.60 |
64+ | 78,493 | 18.1 | 17.64, 18.61 | 15.1 | 14.67, 15.59 |
Missing | 143,419 | 0.064 | 0.06, 0.07 | 0.0093 | 0.01, 0.01 |
SES | |||||
Category 1 | 104,681 | 1 | 1.00, 1.00 | 1 | 1.00, 1.00 |
Category 2 | 260,537 | 0.66 | 0.64, 0.68 | 0.84 | 0.81, 0.87 |
Category 3 or 4 or unknown | 336,580 | 0.59 | 0.58, 0.61 | ||
Missing | 159,003 | 1.45 | 1.40, 1.50 | ||
Marital status | |||||
Single | 109,552 | 1 | 1.00, 1.00 | 1 | 1.00, 1.00 |
Married or in union | 461,231 | 2.9 | 2.75, 3.06 | 1.47 | 1.39, 1.55 |
Separated/divorced/widowed | 153,919 | 3.59 | 3.39, 3.79 | 1.25 | 1.18, 1.33 |
Missing | 136,099 | 6.69 | 6.33, 7.07 | 6.5 | 5.95, 7.11 |
HIV | |||||
No | 680,082 | 1 | 1.00, 1.00 | 1 | 1.00, 1.00 |
Yes | 20,071 | 2.2 | 2.09, 2.32 | 1.91 | 1.80, 2.03 |
Missing | 160,648 | 1.55 | 1.51, 1.59 | 0.91 | 0.76, 1.08 |
Family history of viral hepatitis | |||||
No | 677,376 | 1 | 1.00, 1.00 | 1 | 1.00, 1.00 |
Yes | 23,711 | 1.27 | 1.21, 1.35 | 1.1 | 1.04, 1.18 |
Missing | 159,714 | 1.48 | 1.44, 1.52 | 1.51 | 1.20, 1.90 |
Ever been traditionally operated on | |||||
No | 597,913 | 1 | 1.00, 1.00 | 1 | 1.00, 1.00 |
Yes | 104,688 | 1.52 | 1.48, 1.56 | 1.31 | 1.27, 1.36 |
Missing | 158,200 | 1.55 | 1.51, 1.59 | 0.23 | 0.17, 0.32 |
Unadjusted Model | Adjusted Model † | ||||
---|---|---|---|---|---|
Variables | N | OR | 95% CI | OR | 95% CI |
Age | |||||
<44 | 8803 | 1 | 1.00, 1.00 | 1 | 1.00, 1.00 |
44–54 | 5991 | 1.5 | 1.36, 1.58 | 1.65 | 1.51, 1.80 |
55–64 | 9744 | 1.8 | 1.69, 1.93 | 1.89 | 1.75, 2.04 |
>64 | 19,164 | 2.7 | 2.51, 2.82 | 2.88 | 2.67, 3.10 |
Missing | 191 | 0.2 | 0.11, 0.25 | 0.33 | 0.20, 0.53 |
Social Economic Status | |||||
Category 1 | 7061 | 1 | 1.00, 1.00 | 1 | 1.00, 1.00 |
Category 2 | 10,957 | 0.7 | 0.67, 0.77 | 0.8 | 0.74, 0.87 |
Category 3 or 4 or unknown | 12,839 | 0.7 | 0.66, 0.76 | 0.78 | 0.72, 0.85 |
Missing | 13,036 | 0.3 | 0.32, 0.36 | 0.3 | 0.27, 0.33 |
Sex | |||||
Female | 28,834 | 1 | 1.00, 1.00 | 1 | 1.00, 1.00 |
Male | 15,059 | 1.1 | 1.04, 1.13 | 1.34 | 1.27, 1.42 |
Marital status | |||||
Single | 1528 | 1 | 1.00, 1.00 | 1 | 1.00, 1.00 |
Married or in union | 20,191 | 1.3 | 1.12, 1.41 | 0.85 | 0.75, 0.97 |
Separated/divorced/widowed | 9292 | 1.5 | 1.30, 1.66 | 0.84 | 0.73, 0.97 |
Missing | 12,882 | 0.7 | 0.59, 0.75 | 1.24 | 1.04, 1.49 |
Hepatitis B Ag results | |||||
Negative | 38,922 | 1 | 1.00, 1.00 | 1 | 1.00, 1.00 |
Positive | 880 | 0.5 | 0.39, 0.55 | 0.53 | 0.44, 0.65 |
Missing | 4091 | 15 | 13.29, 16.60 | 109.4 | 95.49, 125.34 |
HIV | |||||
No | 29,622 | 1 | 1.00, 1.00 | 1 | 1.00, 1.00 |
Yes | 1789 | 2 | 1.80, 2.31 | 2.51 | 2.20, 2.87 |
Missing | 12,482 | 0.4 | 0.42, 0.46 | 0.49 | 0.41, 0.58 |
Hypertension | |||||
No | 29,048 | 1 | 1.00, 1.00 | 1 | 1.00, 1.00 |
Yes | 2323 | 2.3 | 1.99, 2.54 | 2.05 | 1.80, 2.34 |
Missing | 12,522 | 0.4 | 0.33, 0.37 | 0.12 | 0.11, 0.14 |
Ever been traditionally operated on | |||||
No | 25,212 | 1 | 1.00, 1.00 | 1 | 1.00, 1.00 |
Yes | 6623 | 1 | 0.90, 1.02 | 0.9 | 0.84, 0.97 |
Missing | 12,058 | 0.4 | 0.41, 0.46 | 0.66 | 0.45, 0.97 |
Ever been medically operated on | 43,893 | ||||
No | 30,066 | 1 | 1.00, 1.00 | 1 | 1.00, 1.00 |
Yes | 1853 | 0.7 | 0.60, 0.74 | 0.66 | 0.58, 0.74 |
Missing | 12,755 | 0.4 | 0.41, 0.45 | 1.67 | 0.98, 2.83 |
HBV vaccination status | |||||
Partially or fully vaccinated | 5635 | 1 | 1.00, 1.00 | 1 | 1.00, 1.00 |
Not vaccinated | 38,258 | 0.3 | 0.29, 0.34 | 0.49 | 0.45, 0.53 |
Unadjusted Model | Adjusted Model † | ||||
---|---|---|---|---|---|
Variables | N | OR | 95% CI | OR | 95% CI |
Age | |||||
<44 | 8987 | 1 | 1.00, 1.00 | 1 | 1.00, 1.00 |
44–54 | 6250 | 0.6 | 0.51, 0.69 | 0.5 | 0.42, 0.59 |
55–64 | 10,081 | 0.48 | 0.42, 0.55 | 0.4 | 0.35, 0.47 |
>64 | 22,927 | 2.53 | 2.31, 2.77 | 4.54 | 4.03, 5.12 |
Missing | 435 | 14.23 | 10.78, 18.78 | 491 | 328.16, 734.68 |
Social Economic Status | |||||
Category 1 | 8224 | 1 | 1.00, 1.00 | 1 | 1.00, 1.00 |
Category 2 | 12,462 | 0.66 | 0.60, 0.72 | 0.77 | 0.70, 0.86 |
Category 3 or 4 or unknown | 14,747 | 0.7 | 0.64, 0.76 | 0.95 | 0.86, 1.05 |
Missing | 13,247 | 0.066 | 0.06, 0.08 | 0.011 | 0.01, 0.01 |
Sex | |||||
Female | 32,100 | 1 | 1.00, 1.00 | 1 | 1.00, 1.00 |
Male | 16,580 | 0.86 | 0.81, 0.92 | 0.87 | 0.80, 0.95 |
Health insurance | |||||
No insurance | 7867 | 1 | 1 | 1.00, 1.00 | |
Community insurance | 39,312 | 0.71 | 0.65, 0.76 | 1.7 | 1.40, 2.06 |
Private or other government insurance (RAMA/RSSB) | 1501 | 0.41 | 0.32, 0.51 | 1.13 | 0.82, 1.56 |
HIV | |||||
No | 32,449 | 1 | 1.00, 1.00 | 1 | 1.00, 1.00 |
Yes | 1829 | 0.27 | 0.19, 0.37 | 0.37 | 0.25, 0.54 |
Missing | 14,402 | 1.34 | 1.25, 1.43 | 0.18 | 0.10, 0.31 |
Diabetes | |||||
No | 33,611 | 1 | 1.00, 1.00 | 1 | 1.00, 1.00 |
Yes | 693 | 0.68 | 0.47, 0.99 | 0.57 | 0.43, 0.76 |
Missing | 14,376 | 1.43 | 1.34, 1.54 | 1.6 | 1.07, 2.40 |
Family history of viral hepatitis C | |||||
No | 32,958 | 1 | 1.00, 1.00 | 1 | 1.00, 1.00 |
Yes | 1583 | 0.57 | 0.45, 0.72 | 0.63 | 0.41, 0.98 |
Missing | 14,139 | 1.44 | 1.35, 1.54 | 0.28 | 0.16, 0.50 |
HBV vaccination status | |||||
Partially or fully vaccinated | 5701 | 1 | 1.00, 1.00 | 1 | 1.00, 1.00 |
Not vaccinated for hepatitis B | 42,979 | 6.62 | 5.15, 8.51 | 8.77 | 6.66, 11.54 |
Treatment Failure | Dropout at SVR Assessment Stage | |||||||||
---|---|---|---|---|---|---|---|---|---|---|
N | Unadjusted model | Adjusted model † | Unadjusted model | Adjusted model † | ||||||
OR | 95% CI | OR | 95% CI | N | OR | 95% CI | OR | 95% CI | ||
Baseline viral load | 9332 | 1.12 | 1.04, 1.39 | 1.14 | 1.02, 1.28 | - | - | - | - | - |
Age | ||||||||||
<44 | 1227 | 1 | 1.00, 1.00 | 1 | 1.00, 1.00 | 1591 | 1 | 1.00, 1.00 | 1 | 1.00, 1.00 |
44–54 | 1262 | 1.02 | 0.79, 1.32 | 1.34 | 0.93, 1.91 | 1571 | 1.02 | 0.83, 1.26 | 1.1 | 0.88, 1.39 |
55–64 | 2343 | 0.94 | 0.75, 1.18 | 1.18 | 0.86, 1.63 | 2968 | 0.96 | 0.80, 1.15 | 1.11 | 0.91, 1.35 |
64+ | 4500 | 0.94 | 0.76, 1.15 | 1.12 | 0.82, 1.53 | 6754 | 1.9 | 1.63, 2.23 | 1.42 | 1.17, 1.72 |
Sex | ||||||||||
Female | 5654 | 1 | 1.00, 1.00 | 1 | 1.00, 1.00 | 7939 | 1 | 1.00, 1.00 | 1 | 1.00, 1.00 |
Male | 3678 | 1.01 | 0.87, 1.16 | 1.1 | 0.90, 1.33 | 4945 | 0.81 | 0.73, 0.90 | 0.76 | 0.67, 0.85 |
SES | ||||||||||
Category 1 | 1835 | 1 | 1.00, 1.00 | 1 | 1.00, 1.00 | 2573 | 1 | 1.00, 1.00 | 1 | 1.00, 1.00 |
Category 2 | 2541 | 0.97 | 0.79, 1.18 | 0.98 | 0.76, 1.25 | 3296 | 0.89 | 0.77, 1.03 | 0.96 | 0.82, 1.14 |
Category 3 or 4 or unknown | 3224 | 1.15 | 0.95, 1.40 | 1.13 | 0.88, 1.45 | 5174 | 0.64 | 0.56, 0.73 | 0.73 | 0.62, 0.84 |
Missing | 1732 | 1.41 | 1.12, 1.78 | 0.61 | 0.43, 0.86 | 1841 | 3.58 | 3.01, 4.26 | 2.53 | 2.08, 3.08 |
HIV positive | ||||||||||
No | 7795 | 1 | 1.00, 1.00 | 1 | 1.00, 1.00 | 11,075 | 1 | 1.00, 1.00 | 1 | 1.00, 1.00 |
Yes | 922 | 0.8 | 0.62, 1.03 | 1.09 | 0.81, 1.46 | 1125 | 0.31 | 0.25, 0.38 | 0.3 | 0.24, 0.38 |
Missing | 615 | 5.92 | 4.73, 7.40 | 0.77 | 0.20, 3.01 | 684 | 0.076 | 0.05, 0.13 | 0.059 | 0.03, 0.11 |
HBV Ag positive | ||||||||||
No | 8873 | 1 | 1.00, 1.00 | 1 | 1.00, 1.00 | 12,291 | 1 | 1.00, 1.00 | 1 | 1.00, 1.00 |
Yes | 140 | 1.27 | 0.79, 2.05 | 1.11 | 0.57, 2.18 | 274 | 0.86 | 0.57, 1.31 | 0.6 | 0.37, 0.99 |
Missing | 319 | 2.8 | 2.00, 3.92 | 1.48 | 0.84, 2.63 | 319 | 0.73 | 0.54, 0.99 | 0.79 | 0.50, 1.22 |
Cirrhotic | ||||||||||
No | 8898 | 1 | 1.00, 1.00 | 1 | 1.00, 1.00 | 12,440 | 1 | 1.00, 1.00 | 1 | 1.00, 1.00 |
Yes | 434 | 1.12 | 0.81, 1.54 | 1.71 | 1.20, 2.43 | 444 | 0.066 | 0.03, 0.13 | 0.059 | 0.03, 0.12 |
Family history of viral hepatitis C | ||||||||||
No | 8220 | 1 | 1.00, 1.00 | 1 | 1.00, 1.00 | 11,376 | 1 | 1.00, 1.00 | 1 | 1.00, 1.00 |
Yes | 437 | 1.57 | 1.17, 2.12 | 1.57 | 1.10, 2.25 | 721 | 0.42 | 0.30, 0.57 | 0.14 | 0.08, 0.24 |
Missing | 675 | 5.96 | 4.79, 7.42 | 3.62 | 1.07, 12.31 | 787 | 0.66 | 0.53, 0.81 | 0.18 | 0.08, 0.39 |
Ever been medically operated on | ||||||||||
No | 8351 | 1 | 1.00, 1.00 | - | - | 1 | 1.00, 1.00 | 1 | 1.00, 1.00 | |
Yes | 306 | 1.34 | 0.90, 1.97 | - | - | 0.57 | 0.47, 0.68 | 0.39 | 0.27, 0.56 | |
Missing | 675 | 5.8 | 4.71, 7.29 | - | - | 1.21 | 0.56, 1.40 | 1.44 | 0.89, 2.32 | |
HBV vaccination status | ||||||||||
Not vaccinated | 6985 | - | - | - | 1 | 1.00, 1.00 | 1 | 1.00, 1.00 | ||
Partially or fully vaccinated | 2347 | - | - | - | - | 0.11 | 0.09, 0.13 | 0.14 | 0.11, 0.16 |
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Nisingizwe, M.P.; Makuza, J.D.; Janjua, N.Z.; Bansback, N.; Hedt-Gauthier, B.; Serumondo, J.; Remera, E.; Law, M.R. The Cascade of Care for Hepatitis C Treatment in Rwanda: A Retrospective Cohort Study of the 2017–2019 Mass Screening and Treatment Campaign. Viruses 2023, 15, 661. https://doi.org/10.3390/v15030661
Nisingizwe MP, Makuza JD, Janjua NZ, Bansback N, Hedt-Gauthier B, Serumondo J, Remera E, Law MR. The Cascade of Care for Hepatitis C Treatment in Rwanda: A Retrospective Cohort Study of the 2017–2019 Mass Screening and Treatment Campaign. Viruses. 2023; 15(3):661. https://doi.org/10.3390/v15030661
Chicago/Turabian StyleNisingizwe, Marie Paul, Jean Damascene Makuza, Naveed Z. Janjua, Nick Bansback, Bethany Hedt-Gauthier, Janvier Serumondo, Eric Remera, and Michael R. Law. 2023. "The Cascade of Care for Hepatitis C Treatment in Rwanda: A Retrospective Cohort Study of the 2017–2019 Mass Screening and Treatment Campaign" Viruses 15, no. 3: 661. https://doi.org/10.3390/v15030661
APA StyleNisingizwe, M. P., Makuza, J. D., Janjua, N. Z., Bansback, N., Hedt-Gauthier, B., Serumondo, J., Remera, E., & Law, M. R. (2023). The Cascade of Care for Hepatitis C Treatment in Rwanda: A Retrospective Cohort Study of the 2017–2019 Mass Screening and Treatment Campaign. Viruses, 15(3), 661. https://doi.org/10.3390/v15030661