Hepatitis C care cascade in HIV patients at an urban clinic in the early direct-acting antiviral era

Abstract

Guidelines advocate universal, prompt treatment of hepatitis C (HCV) infection in HIV/HCV co-infected patients, but barriers to uptake of HCV direct-acting antivirals (DAAs) remain unclear in this population. This retrospective study investigated the care cascade from HCV diagnosis to sustained virologic response (SVR) at an urban infectious disease clinic in Saint Louis, Missouri during the first 18 months of interferon-free DAA availability in the United States. Of 1949 HIV patients seen in clinic, 91.9% were screened for HCV and 5.4% (n = 106) had chronic HCV infection with follow-up. Of these 106 co-infected patients, 100 underwent fibrosis testing, 55 were offered DAAs, 38 completed treatment, and 37 achieved SVR. Delayed DAA treatment was associated with no insurance, substance abuse, poor HIV control, and younger age. Providers delayed DAA treatment most commonly for substance abuse, psychiatric disease, and uncontrolled HIV. Mean time to insurance decision from initial prescription was 20.9 ± 29.6 days and mean time to final decision was 29.9 ± 40.1 days. DAAs are highly successful in co-infected patients in this early period but insurance delays and misconceptions from the interferon era can ultimately limit uptake. Addressing these factors in a comprehensive treatment model may bridge disparities and improve real-world SVRs.

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

“…Early studies among both HCV‐monoinfected and HIV/HCV‐coinfected patients found that Hispanic Whites and Blacks were less likely to be treated 21,24,30–32 . Our finding of a lack of race/ethnicity‐based effect modification in the overall cohort is similar to more recent studies, which may be explained by the changing treatment environment, with more aggressive treatment of HIV/HCV‐coinfected patients 22,23 …”

“…Our finding that a history of substance use was associated with a decreased likelihood of DAA prescription is consistent with previous studies. 23,24 The decreased likelihood of DAA prescriptions among patients with a history of substance use might reflect provider reluctance as a result of concern about non-adherence,…”

“…The rate of HCV DAA prescription (43%) was higher than two published estimates from studies of HIV/HCV-coinfected cohorts conducted from 2014 to 2015 (19% and 23%) and lower than two recently reported studies from 2014 to 2016 and 2014 to 2017 (51% and 60%). [20][21][22][23] The higher rates of prescription seen in the studies conducted in more recent years may be because of expanded DAA options, greater provider-driven uptake of DAAs, increased patient demand for treatment, and changes in payor-imposed restrictions (i.e. fewer restrictions) over time.…”

“…21,24,[30][31][32] Our finding of a lack of race/ethnicity-based effect modification in the overall cohort is similar to more recent studies, which may be explained by the changing treatment environment, with more aggressive treatment of HIV/HCV-coinfected patients. 22,23 One unique characteristic of this cohort is that all patients were receiving primary care from a physician trained in HIV care, many of whom are infectious disease physicians. As has been encouraged by others, co-location of HIV and HCV treatment services may improve HCV treatment rates, particularly in populations such as this cohort, which may experience more patient-level barriers to treatment; co-location and treatment by an infectious diseases specialist also allows potential drug-drug interactions between ARVs and DAAs to be more easily addressed and eliminate the barrier imposed by some insurance companies requiring DAAs be prescribed by a specialist.…”

Development of an Interdisciplinary Telehealth Model of Provider Training and Comprehensive Care for Hepatitis C and Opioid Use Disorder in a High-Burden Region

“…Insurance prior authorizations have been a major barrier to HCV treatment in the DAA era, with frequent insurance denial of treatment requiring appeal [ 48 ], diversion of clinical staff time to insurance paperwork [ 49 ], and delays between time of prescription and approval [ 50 ]. Together, these logistical barriers to medication access place a significant burden on staff that may limit clinics’ ability to institute and scale up HCV treatment [ 49 ].…”