Commentary on Jiang et al

I am writing to express our appreciation and commend the valuable contribution of the article “Simplified Treatment of Hepatitis C During the COVID-19 Pandemic: Retrospective Analysis of the British Columbia Hepatitis C Network” by Jiang et al (1). The study provided thought-provoking insights into the impact of a streamlined approach to hepatitis C virus (HCV) treatment during an unprecedented global health crisis. One of the key takeaways from this study is the success of decentralizing HCV care: minimizing diagnostic burdens by optimizing telemedicine.

However, as we consider integrating simplified HCV treatment into routine practice beyond the pandemic, some challenges require further exploration. Firstly, the study highlights the increased rate of loss to follow-up (LTF) in patients who had active (7 [12%] LTF versus 17 [6%] retained patients) and prior substance use during the pandemic. More LTF patients were on opioid agonist therapy, which contradicts Table 1: Clinico-demographic characteristics, which indicates that substance abuse was lower during the pandemic than it was pre-pandemic (1). British Columbia is home to estimated 47,600 persons who inject drugs (PWID) (2), and North America's first legally sanctioned supervised injection facility, Insite, remained operational during the pandemic, offering a consistent point of access to harm reduction services for PWID, likely mitigating some of the usual challenges related to LTF for PWID by providing essential harm-reduction services. Thus, the suggestion that LTF was correlated to substance abuse seems invalid.

Furthermore, the study (1) does not account for ethnic influences on treatment response as racial disparities remain a significant concern among the Indigenous population of Canada, as those living in off-reserve communities often face barriers to accessing timely and adequate treatment due to geographic and systemic health care limitations. Studies show it can take 288 days to follow up initial HCV antibody testing with next-step labs for Indigenous people living in off-reserve communities, versus 68 days for those residing in an on-reserve community in Canada (3). To add to the importance of racial influence, studies have shown that African Americans are less responsive to HCV treatment when compared with Caucasian individuals (4) and have a significantly lower chance of receiving liver transplantation, which is the only definitive treatment for end-stage liver disease. Furthermore, the study does not take into consideration the gender ratio. Although mentioning that gender was similar between groups, with 299 (62%) and 244 (65%) males in pre-PG and PG, respectively, there is a clear gap in the ratio pre-pandemic and pandemic (1). The study also did not consider HCV treatment in female patients during the pandemic. Patients’ field of work is also an important factor, as health care workers are more prone to HCV due to occupational exposure; this was especially true during the pandemic due to lapses in infection control practices; additionally, the increased risk of outbreaks of bloodborne viruses, including HCV, among health care workers continues (5).

All these factors should be taken into consideration since these disparities may be influenced by various factors, including systemic issues in provincial health care across the nation, gender and ethnic backgrounds, as well as socio-economic and lifestyle challenges.