Similarities in Hepatitis C Patient Profiles Over a Decade in an Urban GI Clinic

Abstract

INTRODUCTION: There is considerable uncertainty with respect to predicting the liver disease status of African American (AA) patients with Hepatitis C seen in the current era of highly effective direct acting anti-virals (DAA). This uncertainty is due to the complex interplay between the identification of patients early in their disease progression by screening, the fact that many AA patients failed earlier interferon based therapy, duration of the HCV viremia in AA patients, the possible variation In disease course in AA as compared to other races, and potential early mortality of AA patients due to liver disease. Understanding the evolution of HCV infection as defined by comparing previous and current patient populations provides information relevant to both therapeutic and health costs decisions. METHODS: We selected patients from a 24 month period between 2002 and 2003 (Epoch 1; n = 414) to compare with patients seen in the same GI clinic between 2012 and 2013 (Epoch 2; n=405). Epoch 1 was the beginning of the peg-interferon and ribavirin treatment era and Epoch 2 reflects the patient population seen when DAA therapy was first available. RESULTS: Epoch 2 patients were older (59.7 vs 50.3 years) with a similar gender distribution (55% vs 59% male). Consistent with the change in clinic demographics, more AA patients were seen in Epoch 2 (89%) as compared to Epoch 1 (77%). There was no significant difference between hepatic fibrosis as assessed by APRI (1.1 vs 0.9) or FIB-4 (2.4 vs 2.6) but there was an increase in intermediate degree of fibrosis as defined by liver biopsy. The majority of Epoch 2 patients were still naïve to treatment (96% Epoch 1 vs 61% Epoch 2) and a similar proportion had cirrhosis (15% Epoch 1 vs 17% Epoch 2) at the time of first visit in the different time periods. CONCLUSIONS: The patients in Epoch 2 from this urban GI referral clinic are older and the majority of them had not been treated or had not responded to treatment. This age demographic continues to reflect patients who were likely infected during the 1960's-1980's which is when HCV infection became widespread. Epoch 2 patients also do not have more advanced liver disease as defined either by significant fibrosis or cirrhosis as compared to Epoch 1. Possible explanations include that Epoch 2 patients' disease was detected earlier by surveillance, progressed very slowly to advanced liver disease, or had a high mortality that resulted in a decline in patients with advanced disease. The role of access to therapy in patients not treated remains to be determined and the increased effectiveness of DAA are predicted to increase the number of AA patients seeking and accepting treatment.

Racial disparity in age and genotype defines urban hepatitis C patient profiles in the recent direct-acting antiviral era

“…1-4 While the number of treated patients has increased, the number of untreated, infected patients continues to be significant. [5][6][7][8][9][10][11][12][13] A study of predominantly African American (AA) patients in our university medical practice, during the interferon era (2002)(2003) and prior to the introduction of DAAs (2012-2013), confirmed that the AA population was within the age cohort for our patients through 2013. 5 While this aging cohort has traditionally represented the bulk of patients with HCV, the possibility that younger patients will be identified in recent populations is an important area of investigation.…”

“…[5][6][7][8][9][10][11][12][13] A study of predominantly African American (AA) patients in our university medical practice, during the interferon era (2002)(2003) and prior to the introduction of DAAs (2012-2013), confirmed that the AA population was within the age cohort for our patients through 2013. 5 While this aging cohort has traditionally represented the bulk of patients with HCV, the possibility that younger patients will be identified in recent populations is an important area of investigation. 6 New infections with HCV continue to occur in the United States, with an estimated 2.4million Americans living with HCV in 2018.…”

Racial Disparity in HCV Demographics and Treatment Between Interferon Era (2002–2003) and Direct Acting Anti-viral Era (2019)

“…While there are publications describing patients in each era, few address patients seen in the same clinical setting in two eras [19][20][21][22][23], and none that report on patients seen 17 years apart. Observations from these studies demonstrate an overall aging of the population along with an increase in the percentage of younger patients in the DAA era.…”

Real World Response to Direct Acting Antivirals DAA in African Americans Treated in a Non-Gastroenterology Setting

“…Chronic Hepatitis C CHC) affects 2.4 million people in the United States and is one of the leading causes of cirrhosis, hepatocellular carcinoma and liver transplantation [1][2][3][4] . African Americans (AA) who are more likely to be infected with hepatitis C than Caucasians, comprise 23% of infected population, are more likely to develop hepatocellular carcinoma than non-AA populations in the United States, and are more likely to be infected with hepatitis C genotype [5][6][7][8][9][10] . Ribavirin/Interferon based regimens were less effective in the African American population which helped to contribute to the increased numbers of AA patients with CHC [11][12][13][14][15][16] .…”