Psychosocial Obstacles to Hepatitis C Treatment Initiation Among Patients in Care: A Hitch in the Cascade of Cure

Abstract

for the Chronic Hepatitis Cohort Study (CHeCS) Investigators There are limited data examining the relationship between psychosocial factors and receipt of direct-acting antiviral (DAA) treatment among patients with hepatitis C in large health care organizations in the United States. We therefore sought to determine whether such factors were associated with DAA initiation. We analyzed data from an extensive psychological, behavioral, and social survey (that incorporated several health-related quality of life assessments) coupled with clinical data from electronic health records of patients with hepatitis C enrolled at four health care organizations during 2017-2018. Of 2,681 patients invited, 1,051 (39.2%) responded to the survey; of 894 respondents eligible for analysis, 690 (77.2%) initiated DAAs. Mean follow-up among respondents was 9.2 years. Compared with DAA recipients, nonrecipients had significantly poorer standardized scores for depression, anxiety, and life-related stressors as well as poorer scores related to physical and mental function. Lower odds of DAA initiation in multivariable analysis (adjusted by age, race, sex, study site, payment provider, cirrhosis status, comorbidity status, and duration of follow-up) included Black race (adjusted odds ratio [aOR], 0.59 vs. White race), perceived difficulty getting medical care in the preceding year (aOR, 0.48 vs. no difficulty), recent injection drug use (aOR, 0.11 vs. none), alcohol use disorder (aOR, 0.58 vs. no alcohol use disorder), severe depression (aOR, 0.42 vs. no depression), recent homelessness (aOR, 0.36 vs. no homelessness), and recent incarceration (aOR, 0.34 vs. no incarceration). Conclusion: In addition to racial differences, compared with respondents who initiated DAAs, those who did not were more likely to have several psychological, behavioral, and social impairments. Psychosocial barriers to DAA initiation among patients in care should also be addressed to reduce hepatitis C-related morbidity and mortality. (Hepatology Communications 2020;0:1-12). P ublic health prevention and control of hepatitis C entails identification of infected persons through universal testing, followed by linkage to clinical services and ensuring that persons linked to care receive and complete effective treatment. (1-5) On an individual level, eradication of hepatitis C virus (HCV) infection eliminates the possibility of HCV transmission to others and reduces morbidity and mortality from HCVattributable hepatic and extrahepatic disease among persons who no longer engage in transmission-associated behaviors. (4) Despite radical improvement in the treatment of HCV infection since the release of secondgeneration direct-acting antiviral (DAA) medications, uptake of these drugs in many U.S. general health care

Care Facilitation Advances Movement Along the Hepatitis C Care Continuum for Persons With Human Immunodeficiency Virus, Hepatitis C, and Substance Use: A Randomized Clinical Trial (CTN-0064)

“…The study’s high retention rates speak positively to participants’ adherence to study visits and thus suggest the need to further address structural and systemic issues that are complex and difficult to overcome even with a CF. These factors would include long waiting times, medication costs, social service needs (eg, unstable housing), and policies requiring sobriety that may serve as formidable barriers to forward movement along the HCV and HIV care continua [ 14 , 15 , 47 ].…”

“…Progress along the HCV continuum compared with the HIV care continuum has been slow, thus making HCV elimination among historically disadvantaged populations, including PWUD, hard to achieve [ 13 ]. Reasons for this delay include lack of knowledge about and awareness of HCV, long wait times for HCV care evaluation (due to treatment prioritization that frequently excludes PWUD as well as state-level restrictions and policies that limit access to care for PWUD), low perceived need for and interest in HCV treatment, provider stigma at the health care system level and internalized stigma at the patient level, cost-related factors due to high drug costs and restrictive payer policies that often lead to absolute denial of DAA regimens by insurers (including commercial insurance and Medicaid/Medicare), and long-standing psychosocial factors, such as unstable housing, lower education level, mental health disorders, and incarceration [ 14–20 ]. Efficacious interventions that overcome barriers, incorporate harm reduction, and facilitate movement along an integrated care continuum are needed.…”

Depressive symptoms are no longer a barrier to HCV treatment initiation in the HIV–HCV co-infected population in Canada

“…Studies in both the IFN and DAA eras conducted in people with chronic HCV infection have found psychiatric illness among the barriers to linkage to care, treatment initiation and adherence [9], [24][25][26][27]. Whether depressive symptoms continue to prevent treatment initiation in the second-generation DAA era is unknown, especially in the coinfected population, which has higher prevalence of depression.…”

Clinical and economic burden of nonalcoholic steatohepatitis in Saudi Arabia, United Arab Emirates and Kuwait

“…NASH is becoming one of the most common causes of HCC [ 7 , 14 ], and is the second leading reason for LT in the USA [ 15 ]. Recent studies have quantified the enormity of the clinical and economic burden of NAFLD/NASH, with associated HCRU and costs, particularly in AF-NASH, predicting these costs will grow [ 16 – 20 ].…”