Barriers to hepatitis C direct‐acting antiviral therapy among HIV/hepatitis C virus‐coinfected persons

Abstract

Background and Aim: Direct-acting antivirals (DAAs) have increased hepatitis C virus (HCV) treatment opportunities for vulnerable HIV/HCV coinfected persons. The aim of this study was to identify the frequency of and potential barriers to DAA prescription in HIV/HCV patients during the first few years of DAA availability in the United States. Methods: The AIDS Healthcare Foundation electronic medical record system was queried to identify all HCV viremic HIV-infected patients in care at AIDS Healthcare Foundation Healthcare centers in January 2015-August 2017 and compare characteristics by receipt of a DAA prescription. Multivariate logistic regression analyses were conducted to examine factors associated with DAA prescription. Results: Of 826 eligible patients, 355 (43%) were prescribed a DAA; among those not prescribed a DAA, 301 (64%) had well-controlled HIV (HIV RNA ≤ 200 copies per mL). In multivariate logistic regression analysis, patients with a history of substance use (odds ratio [OR], 0.51 [95% confidence interval 0.35-0.73]) or on select HIV antiretroviral regimens were less likely to be prescribed a DAA. Those who had well-controlled HIV (OR,]), CD4 + T cell count >200 cells per mm 3 (OR, 1.85 [1.04-3.30]), estimated glomerular filtration rate >60 mL/min/1.73 m 2 (OR, 3.32 [1.08-10.15]), or established care prior to January 2015 (OR, were more likely to be prescribed a DAA. Conclusions: In addition to lack of HIV suppression, select antiretroviral regimens, substance use, and kidney disease appeared to limit DAA prescription in the early interferon-free DAA era. Many were not prescribed DAAs despite HIV suppression. Further research is needed to determine if the observed associations persist today.

Barriers and Facilitators of Hepatitis C Care in Persons Coinfected with Human Immunodeficiency Virus

“…Once the linkage to specialist care was done, the rate of achieving the next step in care cascade (receiving a prescription) was close to 100%. These findings are concordant with previous studies, reporting an HCV prescription rate between 43% and 60% in HIV-HCV-coinfected patients [ 19 , 20 , 21 ] and a rate of SVR that is identical to mono-infected population [ 22 ]. This significant gap in linkage to specialist care, described in our and previous studies, emphasizes the importance of decentralization of HCV care, bringing HCV treatment to HIV clinical providers, general practitioners, or addiction care centers and was shown to improve treatment rates [ 23 , 24 ].…”

Clinician barriers, perceptions, and practices in treating patients with hepatitis C virus and substance use disorder in the United States

“…Similarly, many states dropped restrictions on sobriety after this study was conducted, while some states still require screening and counseling regarding substance use concurrent with HCV treatment ( Harvard Law School Center for Health Law and Policy Intervention, 2022 ). However, there is also evidence suggesting that, in general, clinicians involved in HCV care have little experience working with people with SUD, which often leads to distorted beliefs about the adherence capacity of these patients ( Trooskin et al, 2020 , Jatt et al, 2021 ) and unfounded concerns of reinfection ( Trooskin et al, 2020 ). These beliefs may be derived from stigmatization and discrimination ( Simoncini et al, 2021 , Trooskin et al, 2020 , Jatt et al, 2021 , Higashi et al, 2020 ).…”

“…However, there is also evidence suggesting that, in general, clinicians involved in HCV care have little experience working with people with SUD, which often leads to distorted beliefs about the adherence capacity of these patients ( Trooskin et al, 2020 , Jatt et al, 2021 ) and unfounded concerns of reinfection ( Trooskin et al, 2020 ). These beliefs may be derived from stigmatization and discrimination ( Simoncini et al, 2021 , Trooskin et al, 2020 , Jatt et al, 2021 , Higashi et al, 2020 ). The lack of experience and the discomfort among clinicians were reflected in our findings.…”

Characteristics associated with receipt of treatment among patients diagnosed with chronic hepatitis C virus

“…15 Our results are also congruent with previous findings that patients with chronic HCV are less likely to receive treatment if they have an overall higher burden of medical comorbidities, 9 which tend to increase with age, or psychiatric conditions, including drug/alcohol use disorders. 6,9,10,12,16 The undertreatment observed among these groups is concerning, given that HCV treatment-and in particular achievement of SVR-has been shown to have substantial benefits among patients with chronic HCV, including reduced rates of infection transmission, all-cause mortality, cirrhosis and HCC 4,[17][18][19][20] ; regression of fibrosis 18,21 ; lower chance of developing comorbidities for which patients with chronic HCV have increased risk, 18 such as Type 2 diabetes 22 ; improved health-related quality of life 18 ; and lower healthcare utilisation and costs. 18,23 Undertreatment thus represents a lost opportunity to not only reduce the HCV-related burden on the healthcare system but thereby improve global health.…”

“…6,7 Given the demonstrated benefits of successful HCV treatmentincluding lower all-cause mortality and reduced rates of cirrhosis and HCC 8 -improved understanding of factors that contribute to inequities in treatment access among patients with chronic HCV has been an area of active research. African American or Hispanic race/ethnicity, [9][10][11] for example, is among those characteristics that have been associated with lower rate of receiving treatment for chronic HCV, in addition to reduced access to medical care, 10 drug/alcohol use disorders 6,[9][10][11][12] and comorbidity burden. 9 However, previous analyses of this topic were generally limited to particular geographical regions or hospital systems.…”