Response to Commentary on Jiang et al

We are writing in response to the Letter to the Editor from Munaiba Ahmad regarding our article “Simplified treatment of hepatitis C during the COVID-19 pandemic: retrospective analysis of the British Columbia Hepatitis C Network.” We would like to thank the author for their interest in our paper, emphasizing the importance of simplifying the treatment of the hepatitis C virus (HCV) in British Columbia.

We would like to clarify a few points raised by the author. Regarding the statement that there is a “clear gap” in gender ratio between pre-pandemic and pandemic populations of 62% and 65% male patients, respectively, our chi-square analysis (Table 1) did not demonstrate any statistically significant difference in the gender ratio. Further, the authors stated that our study did not consider treatment in female persons; our study included female persons who comprised 36% of the total population, as shown in Table 1. We agree that considering factors such as gender, ethnicity, and socio-economic status, which can lead to disparities in care due to systemic issues, is an important topic worthy of further analysis. However, our study was a retrospective study with predetermined variables focused on treatment details, so socio-demographic data, including ethnicity and occupation, were not available for analysis. Given that social determinants of health have a complex interplay, we believe these would be best studied in a prospective setting in the future with a specific study design to avoid confounding.

The letter suggested that the overall trends of reduced substance use and higher loss to follow-up (LTF) during the pandemic demonstrated that substance use does not correlate with LTF. First, as discussed in our manuscript, the pandemic was a major cause of LTF, and the population captured in our retrospective study included fewer patients with substance use during the pandemic, as many could not be linked to care. This was an unfortunate clinical scenario during the pandemic and accounts for these temporal trends. Thus, to account for the confounding of the pandemic, our analysis was designed to specifically examine factors associated with LTF during the pandemic population only, which showed a statistically significant association with substance use (Table 3). Thus, demonstrating that indeed these persons were LFU as suggested by our paper. Regarding the author's suggestion that safe injection sites can determine LTF, while one harm reduction service (Insite) remained open, this single supervised injection site in downtown Vancouver cannot mitigate the complex and multiple systemic barriers that a diverse population of substance users face when trying to access health care across our province. Furthermore, the delivery of services to substance users was overall negatively impacted by closures, reduced hours, reduced capacity, and longer wait times during the pandemic (1). Further, as clinicians who have worked closely with this specific population, we would emphasize that not all persons utilize safe injection sites, and the goal of our study was to include a comprehensive population.

Finally, while Ahmad interprets our findings based on statistics of persons with drug use in Canada, those studies are an overview of a heterogeneous and geographically diverse population. As discussed in our manuscript, our results are in keeping with the BC Hepatitis Tests Cohort, a comprehensive database that has been extensively published, which also takes into account local complexities in HCV treatment (2–4).

We appreciate the author's interest in HCV treatment strategies in our local BC population. We hope this letter emphasizes that our patients require a multifaceted clinical approach to address complex barriers, which deserve examination beyond singular factors or overall trends.