Direct-Acting Antivirals Improve Access to Care and Cure for Patients With HIV and Chronic HCV Infection

Abstract

BackgroundDirect-acting antivirals (DAA) as curative therapy for hepatitis C virus (HCV) infection offer >95% sustained virologic response (SVR), including in patients with human immunodeficiency virus (HIV) infection. Despite improved safety and efficacy of HCV treatment, challenges remain, including drug-drug interactions between DAA and antiretroviral therapy (ART) and restrictions on access by payers.MethodsWe performed a retrospective cohort study of all HIV/HCV co-infected and HCV mono-infected patients captured in care at our institution from 2011–2015, reflecting the DAA era, to determine treatment uptake and SVR, and to elucidate barriers to accessing DAA for co-infected patients.ResultsWe identified 9290 patients with HCV mono-infection and 507 with HIV/HCV co-infection. Compared to mono-infected patients, co-infected patients were younger and more likely to be male and African-American. For both groups, treatment uptake improved from the DAA/pegylated interferon (PEGIFN)-ribavirin to IFN-free DAA era. One-third of co-infected patients in the IFN-free DAA era required ART switch and nearly all remained virologically suppressed after 6 months. We observed SVR >95% for most patient subgroups including those with co-infection, prior treatment-experience, and cirrhosis. Predictors of access to DAA for co-infected patients included Caucasian race, CD4 count ≥200 cells/mm3, HIV virologic suppression and cirrhosis. Time to approval of DAA was longest for patients insured by Medicaid, followed by private insurance and Medicare.ConclusionsDAA therapy has significantly improved access to HCV treatment and high SVR is independent of HIV status. However, in order to realize cure for all, barriers and disparities in access need to be urgently addressed.

Trends in hepatitis C treatment initiation among HIV/hepatitis C virus-coinfected men engaged in primary care in a multisite community health centre in Maryland: a retrospective cohort study

“…Surprisingly, recent studies have shown that the uptake rates of DAA treatment remained alarmingly low in the USA and other high-income countries 22–24 32–35. The results from multiple community-based healthcare systems in the USA revealed that, although the treatment rates significantly improved from pre-DAA to post-DAA era, only about one in five HCV-infected patients embarked on DAA therapy 32 33.…”

“…The results from multiple community-based healthcare systems in the USA revealed that, although the treatment rates significantly improved from pre-DAA to post-DAA era, only about one in five HCV-infected patients embarked on DAA therapy 32 33. For HCV/HIV-coinfected patients, the uptake rates of DAA treatment were <20%, with African Americans and Medicaid holders having much lower treatment rates 22 24. In Europe, the rates were similarly low, ranging from <10% to 25%, depending on the countries 23 34…”

“…Due to the poor efficacy, extended course of treatment and considerable side effects associated with IFN-based therapy, many patients were deferred for new IFN-free DAA treatment in the years before the approval of the regimens for treating HCV in HIV-coinfected patients in 2015 19–21. Despite removal of many barriers of IFN-based therapy, recent studies have shown that treatment uptake remained low in era of DAA regimens 22–24. In addition to new barriers, such as high cost, that have emerged with DAA therapy, it is possible that some barriers of the IFN era persist 25 26.…”

Validation of a modified Berger HIV stigma scale for use among patients with hepatitis C virus (HCV) infection

“…Difficulty parameters varied across the polytomous response categories, with the lowest threshold (b 1 ) indicating the "easiest" (mean -1.489; range -10.527 to -0.109), difficulty progressing as level of stigma endorsement (b 2 ) increased (mean 0.189; range -3.894 to -1.652), and the upper thresholds (b 3 ) all positive (mean 2.146; range 0.842 to 5.785; Table 2). Five items (2,8,12,22,36) were flagged for differential item functioning between patients monoinfected with HCV vs coinfected with HCV/ HIV. Items with low factor loadings and those flagged for differential item functioning were removed, resulting in a 33-item scale (S1 Appendix).…”

“…HCV-associated mortality now exceeds death from 60 other combined notifiable infectious diseases, including human immunodeficiency virus (HIV) infection [2]. Despite national action plans to eliminate HCV infection as a major public health threat by 2030 [5][6][7], fewer than half of HCV-infected persons in the US have been diagnosed or are aware of their infection [8], and treatment uptake remains <15% [9][10][11][12][13], undermining public health efforts.…”