Cascade of Hepatitis C Virus Care Among Patients With Substance Use Disorders

Abstract

Introduction:

Hepatitis C virus (HCV) testing is recommended for people at high risk for infection, including those with substance use disorders (SUD). Little is known about the cascade of HCV care (including testing, diagnosis, and treatments) among patients with SUD in real-world clinical practice. This study aims to characterize the HCV cascade of care and identify the factors associated with HCV testing and diagnosis among Florida Medicaid beneficiaries with SUD.

Methods:

A retrospective cohort analysis of Florida Medicaid data (2013–2018) was conducted in 2020 for patients aged 18–64 years with a newly diagnosed SUD (year 2012 was used to ascertain 1-year prior enrollment). A generalized estimating equation identified factors associated with HCV testing; multivariable logistic model identified factors associated with HCV diagnosis.

Results:

Of the 156,770 patients with SUD, 18% were tested for HCV at least once. Among the tested patients, 8% had HCV diagnoses. Among the 2,177 patients having an HCV diagnosis, 11% initiated HCV treatments and 96% of them completed the HCV treatments. Factors associated with being less likely to receive HCV testing included being male (AOR=0.73, 95% CI=0.71, 0.75) and White (AOR=0.85, 95% CI=0.83, 0.87), whereas individuals who were male (AOR=1.49, 95% CI=1.35, 1.66) and White (AOR=2.71, 95% CI=2.38, 3.08) were more likely to be diagnosed with HCV. The odds of receiving HCV testing significantly increased annually (AOR=1.06, 95% CI=1.05, 1.07).

Conclusions:

Future studies are warranted to investigate barriers for access to HCV testing and treatment among Florida Medicaid beneficiaries with SUD, especially for White male individuals.

INTRODUCTION

Hepatitis C virus (HCV) is the most common chronic bloodborne infection in the U.S. It is estimated that 45%–85% of the 4.1 million patients with chronic HCV are not aware of their HCV status owing to its asymptomatic nature.^1–4 Those with chronic HCV may experience progression of their liver disease to advanced liver disease (cirrhosis and hepatocellular carcinoma) and may unknowingly transmit the virus to others. The primary risk factor for HCV infection is through shared supplies for intranasal and intravenous drug use.⁵ As the U.S. is currently facing an opioid epidemic, the number of new cases of HCV continues to increase among those who engage in high-risk activities.^6,7 Patients with an alcohol use disorder are more likely to engage in other high-risk behaviors including injection drug use, resulting in an increased risk for HCV.^8,9 Therefore, 60%–90% of individuals with substance use disorders (SUD, defined as an alcohol use disorder, use of illicit substances, or the misuse of legal substances) are reported to contract HCV during their lifetime.^10–14

Like much of the U.S., Florida has been impacted by the opioid epidemic (ranked third for drug-related death in 2017).¹⁵ Florida reported a 79% increase in the rate of new cases of acute HCV from 2013 to 2017.¹⁶ This increase in new cases is likely associated with the opioid crisis and ranked Florida as the state with the third highest number of people living with an HCV infection in 2016.^15,17

The opioid epidemic and accompanying HCV epidemic highlight the significance of accessible HCV testing and treatment.¹⁸ Such interventions are even more relevant now that there are highly effective treatments available for HCV.¹⁹ These new effective treatments, all-oral direct-acting antiviral (DAA) treatments, were introduced in 2014 and shown to overcome many of the contraindications associated with the use of injectable interferon among those with SUD, allowing them to achieve equally high sustained virologic response (SVR) rates as treated patients without SUD.^20,21 Additionally, DAA treatment completion and SVR are associated with decreased advanced liver disease, reduced extrahepatic manifestations, and a significant survival benefit as well as decreased HCV reinfection rates compared with primary infection rates and decreased injection equipment sharing.^22–30 Therefore, to maximize the benefits of curative treatment and achieve the WHO’s goal of elimination of HCV by 2030,^31,32 attention must be given to understanding the cascade of HCV care —including testing, diagnosis, and treating with DAAs—among those with SUD who may also suffer from HCV.

Thus, this study aims to characterize the cascade of HCV care and identify factors associated with HCV testing and diagnosis among Florida Medicaid beneficiaries newly diagnosed with SUD. This study focuses on Florida Medicaid because Medicaid is one of the largest payors for SUD services in the U.S. and is the largest healthcare payer in Florida.^33,34

METHODS

A retrospective cohort study was conducted using the Florida Medicaid claims data from January 2012 to December 2018. However, 2012 data were used only to ensure that there was a 1-year enrollment prior to the study to make sure the first diagnosis was captured. The Florida Medicaid claims data include enrollment information, healthcare services, and prescription drugs dispensed for >4 million beneficiaries enrolled in the Florida Medicaid program. This study was approved by the University of Florida IRB.

Study Sample

This study was limited to patients aged 18–64 years who had ≥1 year of continuous enrollment (with a <30-day gap in coverage) prior to the date of the first SUD diagnosis or receiving initial treatment for SUD. By adapting a recent, valid algorithm,³⁵ this study considered patients as having SUD if they met ≥1 of the following criteria: (1) they had ≥1 inpatient or outpatient claim of drug or alcohol use disorders using ICD-9/ICD-10 codes (Appendix Table 1) or (2) they had a record of (clinically administered) methadone, buprenorphine, acamprosate, or naltrexone for either opioid use disorder or alcohol use disorder as defined by the presence of the relevant National Drug Codes or Current Procedural Terminology codes (Appendix Table 2).^36,37

The first SUD diagnosis date or the first SUD treatment date was assigned as the index date. This study excluded patients if they had acute or chronic HCV diagnoses or they received any HCV treatment including interferon-based or DAA-based treatments prior to the index date.

Measures

This study defined patients as having received their HCV testing if they had a record for HCV antibody testing or HCV RNA testing identified by Current Procedural Terminology codes (Appendix Table 3).^38–42 This study first measured whether patients received HCV testing or not during each calendar year (binary outcome). For example, if 1 patient received 1 HCV test in 2014 and 2015 separately, the patient was considered to have HCV testing in 2014 and in 2015 (Appendix Figure 1).

This study calculated the numbers of HCV testing episodes each patient received per calendar year (count outcome). Because HCV testing can take place multiple times to confirm, HCV testing claims (either HCV antibody or HCV RNA tests) were grouped within the 30 days following the first HCV testing claim as 1 HCV testing episode. If there was another HCV testing obtained in the following 30-day period, it represented another HCV testing episode (Appendix Figure 2).⁴²

Follow-up for receipt of HCV testing started from the index date and continued until patients had a diagnosis of acute or chronic HCV, end of enrollment, or the end of the study (December 31, 2018), whichever came first. This study used 1 inpatient or 2 outpatient ICD-9/ICD-10 specific diagnoses to identify patients with acute or chronic HCV and the 2 outpatient HCV diagnoses had to be on separate days within 1 year (Appendix Table 1).⁴³

Among beneficiaries with an acute or chronic HCV diagnosis, this study identified those who initiated interferon-free DAAs (Appendix Table 4).^44,45 Patients were considered to have discontinued early if the observed treatment duration was shorter than the expected treatment duration (a 30-day gap was allowed),⁴⁵ which was based on 2017 American Association for the Study of Liver Disease/Infectious Disease Society of America treatment guidelines.⁴⁶

Statistical Analysis

Descriptive statistics were used to summarize patient demographics, clinical characteristics, and behavioral factors among patients with newly diagnosed SUD. The frequency and percentage of each step of the cascade of HCV care (HCV testing, diagnosis, and linkage to DAAs) was calculated. This study performed a series of subgroup analyses by age, sex, race, having HIV diagnosis, receipt of blood transfusion, injection drug use,⁴⁷ baby boomers who were born during 1945–1965, and pregnancy status.

To determine covariates associated with receipt of HCV testing and to counter the effect of time, a multivariable generalized estimating equation model with a binomial distribution, a logit link, and an exchangeable within-group correlation structure was applied (Appendix 1). AORs with the corresponding 95% CIs were calculated. To identify covariates associated with the number of HCV testing episodes, another multivariable generalized estimating equation model for the count outcome with a Poisson distribution to estimate adjusted rate ratios with corresponding 95% CIs was specified.⁴⁸ For the HCV diagnosis outcome (binary outcome), a multivariable logistic model to identify covariates associated with the HCV diagnosis (either acute or chronic HCV) was used. All covariates were listed in Appendix Table 1. Variance inflation factors were used to assess the multicollinearity between covariates to prevent overfitting the model for each analysis. For each analysis, all covariates were kept, as no covariates violated the variance inflation factor rules.⁴⁹ Two-tailed tests with significance level set at 0.05 were defined. All statistical analyses were performed using SAS, version 9.4.

RESULTS

There were 156,770 Florida Medicaid beneficiaries with newly diagnosed SUD from 2013 to 2018 (Table 1). Young people aged 18–35 years (46%), female beneficiaries (60%), and White people (51%) accounted for the majority. More than 60% of patients with SUD had other substance-related use disorders, 28% had an alcohol use disorder, and 23% had an opioid use disorder. Among patients with SUD, 11% received psychotherapy, 7% received HIV testing, and 5% received SUD treatment.

Table 1.

Characteristics of Florida Medicaid Beneficiaries With Newly Diagnosed Substance Use Disorders (SUD), 2013–2018^a

Characteristic	Beneficiaries, n (%)
Total	156,770 (100%)
Age, years, mean(SD)	39 (14)
Age category, years
18–35	71,964 (46%)
36–50	40,927 (26%)
51–64	43,879 (28%)
Sex
Female	94,179 (60%)
Male	62,591(40%)
Race
White	80,532 (51%)
Black or African American	45,801 (29%)
Other racesb	29,742 (19%)
Asian	695 (0.4%)
Type of SUD
Opioid use disorder	36,412 (23%)
Alcohol use disorder	43,544 (28%)
Other substance-related use disorders	94,215 (60%)
Clinical conditions
Pregnancy <45 years old	14,273 (9%)
Cirrhosis	1,294 (0.8%)
Hepatitis B virus	283 (0.2%)
HIV	2,280 (2%)
Smoking	37,797 (24%)
Behaviors
HIV test	11,349 (7%)
Psychotherapy	16,877 (11%)
The receipt of syringe with sterile needle	342 (0.2%)
Receipt of blood transfusion	4,027 (3%)
Number of HCV testing before SUD (Mear±SD)	0.2 (0.6)
SUD treatment	6,979 (5%)

^aThe authors used 2013–2018 data to establish the new SUD cohort, whereas the 2012 data were used to ensure at least 1 year of continuous enrollment prior to the first SUD diagnosis or receiving initial treatment for SUD.

^bOther races include American Indian or Alaska Native, Native Hawaiian or other Pacific islander, or multiple races, or people who refused to answer, or unknown race.

HCV, hepatitis C virus; SUD, substance use disorders.

As shown in Figure 1, of the 156,770 Florida Medicaid beneficiaries with SUD, 27,744 (18%) patients were tested for HCV at least once. Of these, 96% underwent HCV antibody testing first and the remining 4% underwent HCV RNA testing first (HCV RNA testing could be ordered first if doctors suspected on a patients’ initial presentation that they may have contracted HCV³⁹). Of those with HCV antibody testing, 55% (n=14,764) received the HCV antibody test with reflex where they were automatically tested for HCV RNA if the HCV antibody test was positive and the other 9% (n=2,359) received HCV RNA testing as confirmation. Among this group, 114 (0.4%) were diagnosed with acute HCV and 1,824 (7%) were diagnosed with chronic HCV. Of those who received HCV RNA testing first, 23 (2%) were diagnosed with acute HCV and 299 (28%) patients were diagnosed with chronic HCV. Among patients diagnosed with either acute or chronic HCV (n=2,177), 245 (11%) initiated interferon-free DAAs. Of those who initiated interferon-free DAAs, <4% discontinued them, indicating that 96% of them completed DAAs. (The authors did not report the numbers <11 owing to the Centers for Medicare and Medicaid Services cell size suppression policy.)

Figure 1.

The cascade of HCV care among patients with SUD (2013−2018).^a

Notes: 26,668 patients received HCV antibody test first; of them, 9% (n=2,359) received HCV RNA testing later as confirmation. Among 2,123 chronic HCV patients, 83 patients diagnosed with acute HCV developed chronic HCV. These were included when calculating the number of newly diagnosed chronic HCV patients. When calculating the number of either acute or chronic HCV patients, the 83 duplicates were deleted.

^aWe used 2013−2018 data to establish the new SUD cohort, whereas the 2012 data were used to ensure at least 1 year of continuous enrollment prior to the first SUD diagnosis or receiving initial treatment for SUD.

^b18%: The percentage represents the number of patients who were tested divided by the total number of patients.

^c8%: The percentage represents the number of patients who were newly diagnosed with HCV divided by the total number of patients who were tested for HCV.

^d11%: The percentage represents the number of patients who initiated DAAs divided by the total number of patients who were newly diagnosed with HCV.

^e96%: The percentage represents the number of patients who completed DAAs divided by the total number of patients who initiated DAAs. Due to the Centers for Medicare & Medicaid Services cell size suppression policy, n=236 is not the specific number but an approximate estimate.

SUD, substance use disorders; DAA, all-oral direct-acting antiviral, RNA, rsibonucleic acid; HCV, hepatitis C virus.

The cascade of HCV care varied by patient characteristics as well as high-risk characteristics among patients with SUD (Appendix Table 5). For example, among the 2,280 patients with SUD and HIV, 44% (n=993) were tested for HCV. Of the tested patients, 5% (n=50) were newly diagnosed with HCV and of the diagnosed HCV patients, few patients initiated DAAs; among the 122,706 who were identified as injection drug users, 18% were tested, 8% were found to have HCV, and 11% initiated treatment.

Results of the multivariable generalized estimating equation model for the receipt of HCV testing are summarized in Table 2. Significant factors associated with decreased odds of receiving HCV testing included: being male (AOR=0.73, 95% CI=0.71, 0.75) and White (AOR=0.85, 95% CI=0.83, 0.87).

Table 2.

Factors Associated With Receipt of HCV Testing Using GEE Model (Binary Outcome)

Factor	AOR (95% CI)
Year (2013–2018)a	1.06 (1.05, 1.07)
Raceb
White versus Black	0.85 (0.83, 0.87)
Asian versus Black	0.92 (0.91, 0.93)
Othersc versus Black	1.08 (1.07, 1.10)
Hispanic versus Non-Hispanic	0.98 (0.96, 1.00)
Male versus femaleb	0.73 (0.71, 0.75)
Age (ref: 51–64 years)b
18–35	0.98 (0.95, 1.01)
36–50	0.99 (0.97, 1.00)
Clinical conditionsd
Pregnancy	0.97 (0.92, 1.02)
HIV	2.11 (1.96, 2.28)
Cirrhosis	1.71 (1.51, 1.95)
Hepatitis B virus	1.57 (1.23, 1.99)
Smoking	1.06 (1.03, 1.09)
Type of SUD (ref: other substances alone)b
Alcohol alone	1.02 (1.01, 1.03)
Opioid alone	1.04 (1.02, 1.06)
Opioid + alcohol	1.06 (1.03, 1.09)
Other substances + alcohol	1.08 (1.04, 1.12)
Other substances + opioid	1.10 (1.05, 1.15)
Other substances + opioid+ alcohol	1.12 (1.06, 1.18)
Behaviorsd
Receipt of blood transfusion	1.31 (1.22, 1.40)
Receipt of HIV test	2.09 (2.00, 2.18)
Receipt of syringe with sterile needle	2.09 (2.00, 2.18)
Receipt of psychotherapy	1.16 (1.11, 1.21)
SUD treatmentb	1.14 (1.07, 1.21)

^aThe authors used 2013–2018 data to establish the new SUD cohort, whereas the 2012 data were used to ensure at least 1 year of continuous enrollment prior to the first SUD diagnosis or receiving initial treatment for SUD.

^bRace, sex, age, type of SUD and SUD treatment were measured at the index date when patients were newly diagnosed with SUD.

^cOther races include American Indian or Alaska Native, Native Hawaiian or other Pacific islander, or multiple races, or people who refused to answer, or unknown race.

^dClinical conditions and patient behaviors were measured 1 year before the index date when patients were newly diagnosed with SUD.

HCV, hepatitis C virus; SUD, substance use disorders; GEE, generalized estimating equation.

Patients were more likely to receive HCV testing if they were diagnosed with HIV (AOR=2.11, 95% CI=1.96, 2.28), hepatitis B virus (AOR=1.57, 95% CI=1.23, 1.99), and cirrhosis (AOR=1.71, 95% CI=1.51, 1.95); received HIV testing (AOR=2.09, 95% CI=2.00, 2.18), used syringes with sterile needles (AOR=2.09, 95% CI=2.00, 2.18); received medication for opioid use disorder or alcohol use disorder (AOR=1.14, 95% CI=1.07, 1.21); and received a blood transfusion (AOR=1.31, 95% CI=1.22, 1.40). Additionally, the odds of receiving HCV testing significantly increased each year from 2013 to 2018 after other covariates were adjusted (AOR=1.06, 95% CI=1.05, 1.07). Factors associated with the numbers of HCV tests were consistent with those associated with the receipt of HCV testing (Appendix Table 6).

The baseline characteristics associated with HCV diagnosis between patients with SUD who were and were not tested were measured 1 year prior to the date of the first HCV test post SUD diagnosis (Appendix Table 7).

In the multivariable logistic regression results shown in Table 3, among patients with SUD who were tested for HCV, patients were more likely to be diagnosed with HCV if they were White (AOR=2.71, 95% CI=2.38, 3.08) compared with Black, male (AOR=1.49, 95% CI=1.35, 1.66), and had another substance-related disorder in combination with an opioid use disorder (AOR=3.38, 95% CI=2.88, 3.96) or other substance use disorder combined with alcohol and opioid use disorder (AOR=2.05, 95% CI=1.47, 2.85) compared with having another substance-related disorder alone. Additionally, receiving medication for an opioid use disorder or alcohol use disorder (AOR=2.18, 95% CI=1.89, 2.53), undergoing HIV testing (AOR=1.33, 95% CI=1.17, 1.52), having cirrhosis (AOR=1.79, 95% CI=1.36, 2.35), and having hepatitis B virus (AOR=2.60, 95% CI=1.66, 4.08) were significantly associated with increased odds of newly diagnosed HCV among those with SUD who were tested for HCV.

Table 3.

Factors Associated With Newly Diagnosed HCV Among Medicaid Beneficiaries With SUD Who Received HCV Testing Using a Multivariable Logistic Model

Factors	HCV (N=2,177)a AOR (95% CI)
Race
White versus Black	2.71 (2.38, 3.08)
Hispanic versus Non-Hispanic	0.45 (0.35, 0.58)
Male versus female	1.49 (1.35, 1.66)
Age (ref: 51–64 years)b
18–35 years	0.61 (0.54, 0.69)
36–50 years	0.63 (0.55, 0.71)
Clinical conditionsc
Pregnancy	1.34 (1.14, 1.57)
HIV	0.77 (0.57, 1.03)
Cirrhosis	1.79 (1.36, 2.35)
Hepatitis B virus	2.60 (1.66, 4.08)
Smoking	1.05 (0.95, 1.16)
Type of SUD (ref: other substances alone)
Alcohol alone	1.17 (1.02, 1.33)
Opioid alone	1.82 (1.59, 2.09)
Opioid + alcohol	1.50 (1.12, 2.00)
Other substances + alcohol	1.63 (1.31, 2.04)
Other substances + opioid	3.38 (2.88, 3.96)
Other substances + opioid+ alcohol	2.05 (1.47, 2.85)
Behaviorsc
Receipt of blood transfusion	0.86 (0.68, 1.09)
Receipt of HIV test	1.33 (1.17, 1.52)
Receipt of syringe with sterile needle	1.23 (0.56, 2.72)
Receipt of psychotherapy	1.00 (0.88, 1.14)
SUD treatment	2.18 (1.89, 2.53)
Number of HCV testing	0.88 (0.83, 0.94)

^aEither acute or chronic HCV; 83 patients diagnosed with acute HCV developed chronic HCV. When the authors calculated the number of cases of either acute or chronic HCV, this study deleted the 83 duplicates, ending up with 2,177 patients.

^bAge was measured at the date when patients with SUD received the first HCV testing.

^cClinical conditions and patient behaviors were measured 1 year before the first HCV testing after patients were newly diagnosed with SUD.

HCV, hepatitis C virus; SUD, substance use disorders.

Factors separately associated with acute or chronic HCV are detailed in the Appendix Table 8.

DISCUSSION

This is the first study to evaluate the cascade of HCV care among patients with SUD using population-based Florida Medicaid data. In this large statewide retrospective cohort study, <20% of Florida Medicaid beneficiaries with newly diagnosed SUD were tested for HCV following their SUD diagnosis despite an increase in testing during the study period. Although higher HCV testing rates were observed among patients with SUD combined with other high-risk characteristics such as HIV (44%), blood transfusion (24%), and pregnancy (23%), the overall testing rate is still suboptimal especially in light of the recently updated Centers for Disease Control and Prevention and U.S. Preventive Services Task Force recommendations for universal HCV testing for all adults aged 18–79 years and more frequent testing for those with high-risk behaviors.^3,5 Nevertheless, the HCV testing rate among the Florida Medicaid population with SUD seems to be higher relative to the general population and would be in line with testing for people with high-risk behaviors.^2,41,42

Additionally, among those diagnosed with either acute or chronic HCV, only 1 of 9 were prescribed DAAs who presently are recommended to warrant DAAs.^44,50 The Florida Medicaid policy on reimbursement of DAAs in addition to other multilevel issues led to this low DAA initiation rate.⁴⁵ Nevertheless, 96% completed DAAs. The findings indicate that significant opportunities exist to improve HCV testing, diagnosis, and initiation of DAAs among people with newly diagnosed SUD.

To assist in improving testing, this study identified those most likely to not receive HCV testing. This study found that although White male individuals with SUD were more likely to be diagnosed with HCV, they were the least likely to be tested for HCV, which is striking as these characteristics also are predominant among those most affected by the opioid epidemic.^33,51 Although the findings are consistent with previous studies,^47,52 the reasons for the low HCV testing among this population is unclear. To increase HCV knowledge among this group, more research is needed to investigate barriers for access to HCV testing among White male individuals with SUD.

This study found that patients with SUD who received syringes with sterile needles were more than twice as likely to be tested. This recognizes the public question of whether syringe service programs encourage people to utilize more illicit drugs; however, like this study, other studies have provided extensive evidence demonstrating that comprehensive syringe service programs actually serve as a bridge to HIV and HCV testing, SUD treatment programs, and other health services.^53–56 Given Florida’s passage of a bill authorizing a syringe exchange program in 2019, long-term studies are needed to determine the program’s effectiveness on the improvement of HCV testing and diagnosis among patients with SUD.

Consistent with previous studies, patients with HIV or who had already received HIV testing were twice as likely to have received HCV testing.^2,57,58 This finding is potentially related to physician knowledge about the coexistence of HCV and HIV, as in the U.S., approximately 25% of people with HIV are coinfected with HCV likely due to both populations sharing similar routes of transmission.^58,59 Additionally, this study would suggest that expansion of bundled testing for all bloodborne pathogens will likely also increase the number of patients diagnosed with HCV as those with hepatitis B virus were 1.5 times more likely to be tested for HCV and almost 3 times as likely to be diagnosed with HCV.

Finally, this study found that despite only 4.5% of those newly diagnosed with SUD receiving medication-assisted treatment for their disorder, they were 20% more likely to have undergone testing and 2 times more likely to be diagnosed with HCV. These results provide information on another important opportunity where improvement for HCV testing and diagnosis can be made. This study suggests that substance abuse treatment centers should fully integrate HCV testing into their intake process so as to increase HCV diagnosis and care. Consideration should be given to potential integrated care models where healthcare professionals (including infectious disease specialists, addiction specialists, primary care physicians, nurse practitioners, and clinical pharmacists) coordinate SUD and HCV care in clinical settings as this approach has been highlighted in other studies.^60–66 However, recognizing that in Florida only 5.3% of drug treatment is paid by Medicaid funding,⁶⁷ the resources to support substance treatment programs will need to be increased substantially before a potential increase in HCV testing/diagnosis can be realized.

This study has several limitations. First, as ICD-9/10 codes and pharmacy claims were used to identify patients with SUD and those with acute or chronic HCV, this study may have underestimated the number of targeted individuals, although validated algorithms were used.^35,43 Administrative claims data are used for billing purposes and thus, this study was unable to determine the HCV testing or SVR results. However, this study can surmise that the group who completed their treatment course (96%) had a high chance of obtaining SVR based on prior literature where SVR rates were found to be high (≥95%) and similar between those with and without SUD.^68–70 Additionally, as Florida Medicaid has not accepted federal funding to expand coverage to all low-income adults, this study may not be generalizable to states with expanded Medicaid, commercial insurers, or to the uninsured population.⁷¹ Finally, this study could not ascertain several important variables such as where the Medicaid beneficiaries resided (e.g., urban versus rural location), which may be associated with receiving HCV testing.⁴⁷

CONCLUSIONS

Despite a small increase in HCV testing from 2013 to 2018, among Florida Medicaid beneficiaries with SUD, HCV testing was substantially low such that only 18% of them were tested. Of those diagnosed with chronic or acute HCV, only 11% received DAAs but 96% of them completed DAAs. This study underscores the urgent need to identify innovative strategies to enhance the cascade of HCV care, and suggest that patients with SUD—especially those at high risk of HCV infection such as White male individuals, those who receive SUD medication assisted treatment, those with hepatitis B virus, and those with polysubstance use disorders— should be closely followed for HCV testing and HCV diagnosis. Future studies are warranted to investigate barriers to access to HCV testing and treatment among Medicaid beneficiaries with SUD.