Awareness of Hepatitis C Test Results Among Reported Cases in Los Angeles County, 2021-2022

Abstract

Despite curative hepatitis C virus (HCV) treatments, only one-third of cases receive treatment nationally. To evaluate how demographic and clinical characteristics were associated with HCV test result awareness and treatment completion, we analyzed programmatic data of a linkage-to-care program in Los Angeles County. Among 512 respondents, 433 (85%) were aware of their positive test result; of those, 138 (32%) received treatment. Black or African American people were less likely (adjusted prevalence odds ratio [APOR] = 0.43; 95% CI, 0.20-0.92) to be aware of their positive test result than White people. Among those aware of their test results, treatment completion was more likely when a specialist physician ordered the HCV test (APOR = 2.13; 95% CI, 1.03-4.41) than when a primary care provider ordered it, and people with symptoms of liver disease were less likely to complete treatment (APOR = 0.16; 95% CI, 0.08-0.35) than people without symptoms. Clinical and community notification and linkage programs, with a focus on racial and ethnic minority populations, will be necessary to bridge the gap between awareness and treatment initiation among Los Angeles County residents.

Introduction

Hepatitis C virus (HCV) is a leading cause of infectious disease–related death in the United States. In 2019, 14 200 people died from HCV-related liver disease. ¹ Although highly effective treatments are available, ² only about one-third of people received treatment in 2019. ³ As of 2023, data from the National Health and Nutrition Examination Survey ⁴ indicated that 40% of people with HCV in the United States were unaware of their infection. ⁵ Test result disclosure and HCV status awareness are important first steps toward treatment. Knowledge of test results empowers informed decisions, leading to better management and successful outcomes for patients. To increase treatment initiation rates in Los Angeles, the University of Southern California and the Los Angeles County Department of Public Health created a linkage-to-treatment program for Los Angeles County residents with a reported positive HCV RNA test result. Using deidentified data from this program, we analyzed HCV test result awareness and treatment completion, recognizing that identifying factors associated with test result awareness and subsequent treatment completion is essential. ⁵

Methods

Data Collection

We analyzed deidentified data generated by Project HCV Connect, ⁶ a community outreach and linkage-to-care program. Project HCV Connect case workers used the county-wide HCV case registry to contact individuals to inform them of their HCV test result, offer HCV education, and, if untreated, provide resources for treatment. Data collected included demographic characteristics, health insurance type, treatment status, and symptoms of liver disease at the time of outreach. For this analysis, we used deidentified programmatic data from people who had a confirmed positive HCV RNA test result reported from January 2021 through April 2022. ⁶ We determined the specialty of health care providers using a Google search and classified them as primary care (eg, internal medicine, family medicine, osteopathic physicians), specialist physician (eg, infectious diseases, gastroenterologists), or other. Case workers collected and stored data using REDCap version 13.9.1 (REDCap Consortium).

Statistical Analysis

The primary outcome was hepatitis C test result awareness, and the secondary outcome was treatment completion among those aware of their test result. We used Pearson and Fisher exact χ² tests, as necessary, to determine the association between each variable and result awareness. We used logistic regression to determine the maximum likelihood estimates between all variables and awareness of a positive HCV test result. To avoid missing potential predictors in the multivariable analysis, we included only variables with a P value ≤.25 in the univariable analysis. Based on this assumption, we included race and ethnicity and ordering physician in the model. We conducted an additional exploratory multivariable analysis including all sociodemographic variables. A second multivariable logistic regression for the secondary outcome included age group, sex assigned at birth, ordering physician type, current symptom status, and health insurance type. We considered a 2-sided P value ≤.05 to be statistically significant. We analyzed data using SAS version 9.4 (SAS Institute, Inc). We reported log binomial adjusted prevalence odds ratios (APORs) with 95% CIs.

Ethical Considerations

The Los Angeles County Department of Public Health Institutional Review Board approved this project as an exempt nonresearch public health activity under application board project 2023-05-012. These analyses are part of quality improvement and used deidentified data exported from the main secure database. Interviewees’ consent was not required.

Results

Case workers attempted to contact 2799 people with a positive HCV RNA test result during the analysis period. Of those, 512 (18%) were successfully contacted and included in the analysis (Table 1). Among the analytical sample (n = 512), 433 (85%) were aware of their positive HCV test result; of these, 138 (32%) were treated. None of the people unaware of their test results were treated. Demographic characteristics of those unsuccessfully contacted and comparisons are included in eTable 1 in the Supplement.

Table 1.

Demographic, Medical Care, and Clinical Characteristics of Contacted People With HCV Infection, by Infection Awareness and Treatment Completion Status, Los Angeles County, 2021-2022.

	Total population (N = 512), no. (%)			Aware cohort (n = 433), no. (%)
Characteristic	Aware of HCV test result (n = 433)	Unaware of HCV test result (n = 79)	P value	Treated (n = 138)	Untreated (n = 295)	P value
Sex assigned at birth			.61 a			.83 a
Male	274 (84)	53 (16)		52 (33)	107 (67)
Female	159 (86)	26 (14)		86 (31)	188 (69)
Race and ethnicity			.10 b
White	109 (90)	12 (10)		35 (32)	74 (68)	.01 a
Hispanic or Latino	174 (85)	30 (15)		45 (26)	129 (74)
Black or African American	82 (79)	21 (21)		22 (27)	60 (73)
Asian	22 (85)	4 (15)		10 (45)	12 (55)
Other c	46 (79)	12 (21)		26 (57)	20 (43)
Age group, y			.75 a			.25 a
18-29	38 (86)	6 (14)		7 (18)	31 (82)
30-44	114 (87)	17 (13)		41 (36)	73 (64)
45-64	212 (84)	41 (16)		69 (33)	143 (67)
≥65	69 (82)	15 (18)		21 (30)	48 (70)
Treatment status			<.01 b
Treated	138 (100)	0		NA	NA
Not treated	295 (79)	79 (21)		NA	NA
Health insurance type d	424	79	.58 b	131	293	.14 a
Public	255 (84)	47 (16)		69 (27)	186 (73)
Private	90 (87)	14 (13)		35 (39)	55 (61)
Other	57 (79)	15 (21)		21 (37)	36 (63)
None	22 (88)	3 (12)		6 (27)	16 (73)
Symptom status			.33 a			<.01 a
Symptomatic e	172 (83)	36 (17)		25 (15)	147 (85)
Not symptomatic	261 (86)	43 (14)		113 (43)	148 (57)
Ordering physician type d	249	48	.13 b	80	169	<.05 b
Primary care provider	126 (86)	20 (14)		38 (30)	88 (70)
Specialist physician	81 (85)	14 (15)		35 (43)	46 (57)
Other physician f	42 (75)	14 (25)		7 (17)	35 (83)

Abbreviations: HCV, hepatitis C virus; NA, not applicable.

^aPearson χ² test. P ≤ .05 was considered significant.

^bFisher exact χ² test. P ≤ .05 was considered significant.

^cIncludes multiracial, American Indian or Alaska Native, and Native Hawaiian or Other Pacific Islander.

^dMissing data for this characteristic.

^eSymptoms include yellowing of the skin or eyes, swelling of the stomach, spider-like spots on the skin, easy bruising, prolonged bleeding when brushing teeth, vomiting blood, blood in the stool, swelling of the legs, redness of the palms, and itchy skin.

^fAll other physician specialties or provider types.

The primary multivariable analysis demonstrated that individuals identifying as Black or African American were less likely (APOR = 0.43; 95% CI, 0.20-0.92) to be aware of their positive HCV test result than individuals identifying as White (Table 2). We found no significant associations between HCV test result awareness and other characteristics. The secondary outcome multivariable analysis found that among individuals aware of their test result, those whose tests were ordered by a specialist physician had higher odds (APOR = 2.13; 95% CI, 1.03-4.41) of completing treatment than those whose tests were ordered by a primary care provider. Additionally, people who reported symptoms of liver disease were less likely (APOR = 0.16; 95% CI, 0.08-0.35) to report treatment completion than people who did not report such symptoms. We found no statistically significant associations between other characteristics and treatment completion (Table 2, eTable 2 in the Supplement).

Table 2.

Multivariable Logistic Regression Analysis of HCV Test Result Awareness and Treatment Completion With Selected Demographic Characteristics, Los Angeles County, 2021-2022.

Characteristic	APOR (95% CI)
Total cohort vs test result awareness
Specialty vs primary care	0.90 (0.42-1.91)
Hispanic or Latino vs White	0.64 (0.32-1.31)
Black or African American vs White	0.43 (0.20-0.92)
Asian vs White	0.63 (0.19-2.20)
Aware cohort vs treatment completion
30-44 vs 18-29 y	2.94 (0.78-11.10)
45-64 vs 18-29 y	2.80 (0.78-9.98)
≥65 vs 18-29 y	1.09 (0.24-4.89)
Male vs female	1.26 (0.64-2.52)
Asian vs White	3.81 (0.68-21.15)
Black or African American vs White	1.24 (0.43-3.57)
Hispanic or Latino vs White	1.54 (0.62-3.85)
Other race or ethnicity vs White	2.06 (0.61-7.03)
Private health insurance vs no health insurance	1.97 (0.38-10.14)
Public health insurance vs no health insurance	1.39 (0.29-6.64)
Other health insurance vs no health insurance	2.06 (0.37-11.46)
Symptomatic vs not symptomatic	0.16 (0.08-0.35)
Specialty vs primary care ordering provider	2.13 (1.03-4.41)
Unknown vs primary care	0.40 (0.11-1.43)
Other vs primary care	2.15 (0.25-18.56)

Abbreviations: APOR, adjusted prevalence odds ratio; HCV, hepatitis C virus.

Discussion

We used deidentified data generated during a linkage-to-treatment program based in Los Angeles County to evaluate the frequency of HCV test result awareness and understand correlates of treatment completion. Most participants were aware of their positive HCV test result, but only 32% of those aware had received treatment, similar to national estimates (33%) of treatment completion. ³ To our knowledge, no similar analysis has been conducted in Los Angeles County. Despite high awareness, additional community-level efforts are needed to increase treatment uptake.

Test result awareness is an essential first step toward treatment. Few studies have measured awareness of HCV test results among people who have completed an HCV test. National Health and Nutrition Examination Survey data showed improvements in awareness of HCV infection, from 54.2% in 2013-2014 to 60.5% in 2017-2018,^5,7 possibly due to expanded universal screening recommendations for all adults, ⁸ although these estimates do not account for institutionalized populations or individuals experiencing homelessness, 2 groups with a high incidence of HCV infection. In contrast, awareness in our population-level cohort was high (85%), which could be attributed to local efforts following the Centers for Disease Control and Prevention’s universal screening recommendations in 2020. ⁸ Despite the high awareness rate, treatment rates remain low, highlighting a critical gap. Health care providers should ensure that patients are informed of results and offered treatment, while community linkage programs may further support this effort.

Awareness alone may not ensure treatment initiation. In a prior study conducted by our team, individuals with HCV infection reported that (1) either treatment was not a health priority or they were facing other health priorities, (2) they faced health insurance–related challenges, and (3) they did not often receive treatment recommendations from health care providers. ⁹ Additional studies have outlined factors that can constrain access to treatment, such as type of health insurance, ³ prior health insurance authorization requirements and plan restrictions, ¹⁰ and limited access to care and to health care providers, as well as personal factors, including stigma, substance use, mental health disorders, and incarceration. ¹ Although raising HCV awareness is important, elimination efforts will stall without addressing these barriers. In fact, expanding health insurance coverage of HCV medications and loosening treatment eligibility restrictions has been shown to increase treatment uptake. ¹¹

Our findings indicate that further efforts to increase awareness of positive HCV test results may be necessary among racial and ethnic minority groups. Black or African American people in our study were less likely than their White counterparts to be aware of their positive HCV test results, a finding that likely contributes to the low hepatitis C treatment rates in this group. ¹² Future research should further examine the impact of race and ethnicity on awareness of results and treatment. Nationally, Black or African American people experience a high rate of HCV-associated death. ¹³ Addressing these disparities will require coordinated community and health system efforts, including improving education, reducing stigma, and increasing trust. ¹⁴

Training primary care providers in hepatitis C management may also increase treatment completion. In our analysis, people who were aware of their positive HCV test result were more likely to receive treatment when the test was ordered by a specialist physician than by a primary care provider, which is consistent with prior findings. ³ Historically, HCV treatment was managed by gastroenterologists or infectious disease specialists, but recent simplified treatment guidelines ¹⁵ provide an opportunity to increase access to treatment within primary care. Expanding training programs and support initiatives, such as project ECHO, ¹⁶ could increase health care provider clinical capacity and confidence in treatment.

Surveyed cases reporting symptoms of liver disease were less likely to receive treatment than those not reporting such symptoms. Because we contacted individuals >6 months after their test results, acute infection was unlikely. Our hypothesis is that these individuals may have poorer overall health than asymptomatic people or may face competing health conditions that complicate access to treatment. However, our survey captured limited medical information, preventing us from evaluating this hypothesis.

Our study had several limitations. First, the modest survey participation rate (18%) limited the generalizability of our findings. Our cohort was representative for sex and age but differed in race and ethnicity, while housing and health insurance status was unavailable. The cohort was also limited to those with phone access. These factors may have led to an underestimation of awareness and treatment rates and introduced confounding in associations with study outcomes, as individuals that we could not reach may have been unaware of their diagnoses. Second, we were unable to adjust for additional variables in the model with HCV awareness due to a low sample size, resulting in low precision of estimates. Third, we grouped ordering physicians by information obtained through Google searches, which might have resulted in less accurate categorization. Fourth, survey responses were self-reported by program participants and, therefore, may have been subject to self-report bias.

Conclusion

Hepatitis C elimination is a public health priority.^17,18 Achieving national goals requires identifying infected individuals, ensuring awareness of their status, and facilitating treatment. Our findings highlight a gap between awareness of test results and treatment initiation and emphasize the need for strengthened linkage-to-treatment programs.