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Wang AE, Hsieh E, Turner BJ, Terrault N. Integrating Management of Hepatitis C Infection into Primary Care: the Key to Hepatitis C Elimination Efforts. J Gen Intern Med 2022; 37:3435-3443. [PMID: 35484367 PMCID: PMC9551010 DOI: 10.1007/s11606-022-07628-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 04/18/2022] [Indexed: 11/24/2022]
Abstract
Elimination of hepatitis C virus (HCV), a leading cause of liver disease in the USA and globally, has been made possible with the advent of highly efficacious direct acting antivirals (DAAs). DAA regimens offer cure of HCV with 8-12 weeks of a well-tolerated once daily therapy. With increasingly straightforward diagnostic and treatment algorithms, HCV infection can be managed not only by specialists, but also by primary care providers. Engaging primary care providers greatly increases capacity to diagnose and treat chronic HCV and ultimately make HCV elimination a reality. However, barriers remain at each step in the HCV cascade of care from screening to evaluation and treatment. Since primary care is at the forefront of patient contact, it represents the ideal place to concentrate efforts to identify barriers and implement solutions to achieve universal HCV screening and increase curative treatment.
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Affiliation(s)
- Allison E Wang
- Department of Internal Medicine, University of Southern California, Los Angeles, CA, USA
| | - Eric Hsieh
- Department of Internal Medicine, University of Southern California, Los Angeles, CA, USA
| | - Barbara J Turner
- Department of Internal Medicine, University of Southern California, Los Angeles, CA, USA
| | - Norah Terrault
- Department of Internal Medicine, University of Southern California, Los Angeles, CA, USA.
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, University of Southern California, Los Angeles, CA, USA.
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Predicting the presence of depressive symptoms in the HIV-HCV co-infected population in Canada using supervised machine learning. BMC Med Res Methodol 2022; 22:223. [PMID: 35962372 PMCID: PMC9375382 DOI: 10.1186/s12874-022-01700-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 07/28/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Depression is common in the human immunodeficiency virus (HIV)-hepatitis C virus (HCV) co-infected population. Demographic, behavioural, and clinical data collected in research settings may be of help in identifying those at risk for clinical depression. We aimed to predict the presence of depressive symptoms indicative of a risk of depression and identify important classification predictors using supervised machine learning. METHODS We used data from the Canadian Co-infection Cohort, a multicentre prospective cohort, and its associated sub-study on Food Security (FS). The Center for Epidemiologic Studies Depression Scale-10 (CES-D-10) was administered in the FS sub-study; participants were classified as being at risk for clinical depression if scores ≥ 10. We developed two random forest algorithms using the training data (80%) and tenfold cross validation to predict the CES-D-10 classes-1. Full algorithm with all candidate predictors (137 predictors) and 2. Reduced algorithm using a subset of predictors based on expert opinion (46 predictors). We evaluated the algorithm performances in the testing data using area under the receiver operating characteristic curves (AUC) and generated predictor importance plots. RESULTS We included 1,934 FS sub-study visits from 717 participants who were predominantly male (73%), white (76%), unemployed (73%), and high school educated (52%). At the first visit, median age was 49 years (IQR:43-54) and 53% reported presence of depressive symptoms with CES-D-10 scores ≥ 10. The full algorithm had an AUC of 0.82 (95% CI:0.78-0.86) and the reduced algorithm of 0.76 (95% CI:0.71-0.81). Employment, HIV clinical stage, revenue source, body mass index, and education were the five most important predictors. CONCLUSION We developed a prediction algorithm that could be instrumental in identifying individuals at risk for depression in the HIV-HCV co-infected population in research settings. Development of such machine learning algorithms using research data with rich predictor information can be useful for retrospective analyses of unanswered questions regarding impact of depressive symptoms on clinical and patient-centred outcomes among vulnerable populations.
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Le E, Chee G, Kwan M, Cheung R. Treating the Hardest to Treat: Reframing the Hospital Admission as an Opportunity to Initiate Hepatitis C Treatment. Dig Dis Sci 2022; 67:1244-1251. [PMID: 33770327 DOI: 10.1007/s10620-021-06941-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 03/06/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND Chronic hepatitis C (CHC) is traditionally treated in the outpatient setting. Despite the excellent tolerability, shortened treatment duration, and high cure rates of newer direct-acting antivirals (DAAs), many vulnerable patients remain untreated due to issues with linkage to care. AIMS This study sought to reframe and establish the hospital admission as a unique opportunity to initiate antiviral treatment for patients with CHC, particularly those with psychosocial or linkage to care issues. METHODS Patients with untreated CHC were identified either on the Psychiatry or Med/Surg wards at the Veterans Affairs Palo Alto Health Care System (VAPAHCS). If found to be appropriate for treatment initiation, patients were started on antivirals during their hospitalization and followed closely while inpatient and after discharge to assess for sustained virologic response (SVR), treatment tolerability, and treatment completion. RESULTS Overall, 36% (23) of potential treatment candidates were initiated on DAA treatment during their hospitalization. Of these patients, 91.3% had documented treatment completion with an intention-to-treat and modified intention-to-treat SVR rate of 91.3% and 100%, respectively. CONCLUSIONS We establish the hospital admission as a valuable opportunity for HCV treatment initiation, yielding excellent treatment outcomes in those who would not otherwise be treated and achieved a modified intention-to-treat response rate of 100%.
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Affiliation(s)
- Elizabeth Le
- Department of Medicine, VA Palo Alto Health Care System, 3801 Miranda Ave (111), Palo Alto, CA, 94304, USA.
| | - Grace Chee
- Pharmacy Service, VA Palo Alto Health Care System, 3801 Miranda Ave, Palo Alto, CA, 94304, USA
| | - Miki Kwan
- Department of Medicine, VA Palo Alto Health Care System, 3801 Miranda Ave (111), Palo Alto, CA, 94304, USA
| | - Ramsey Cheung
- Division of Gastroenterology and Hepatology, Department of Medicine, VA Palo Alto Health Care System (111), 3801 Miranda Ave, Palo Alto, CA, 94304, USA.,Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University, Stanford, CA, 94305, USA
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Ifeachor AP, Houck KK, Schulte S, Ansara E, Johnson AJ, Carr TA, Liangpunsakul S. HCV eradication in veterans with underlying mental health disorders and substance use. J Am Pharm Assoc (2003) 2020; 60:1037-1043.e3. [PMID: 32948462 DOI: 10.1016/j.japh.2020.08.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 08/14/2020] [Accepted: 08/17/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Hepatitis C virus (HCV) disproportionately affects those with mental health disorders and those with substance use, and the increasing HCV transmission in the United States is driven by the opioid epidemic. However, patients with a mental health disorder, substance use, or combination of both historically have had limited access to HCV treatment. The goal of our study was to compare sustained virologic response (SVR) rates of HCV treatment with direct-acting antivirals (DAAs) between subjects with and without a mental health disorder, substance use, or combination of both. METHODS We performed a retrospective chart review at 1 Veterans affairs medical center of patients enrolled in the hepatitis C pharmacy clinic who completed DAA treatment from August 17, 2013 to August 17, 2017. The participants (N = 833 patients) were categorized into 2 groups: those with at least 1 mental health disorder, substance use, or combination of both and those without. Baseline variables relevant to HCV treatment, DAA regimen, number of documented efforts to engage patients, and SVR data were collected. RESULTS Of the 833 study participants, 579 patients had a mental health disorder, substance use, or combination of both. The 3 most prevalent disorders were patient-reported substance use (n = 333), substance-related and addictive disorders (n = 176), and depressive disorders (n = 159). The SVR rates and number of documented efforts to engage patients before and during treatment through SVR laboratory completion between those with a mental health disorder, substance use, or combination of both and those without were not statically significant. CONCLUSION DAA-based HCV treatment is highly effective with SVR rates exceeding 95% in the entire study cohort, including patients with or without mental health disorders, substance use, or combination of both.
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Proeschold-Bell RJ, Evon DM, Yao J, Niedzwiecki D, Makarushka C, Keefe KA, Patkar AA, Mannelli P, Garbutt JC, Wong JB, Wilder JM, Datta SK, Hodge T, Naggie S, Fried MW, Muir AJ. A Randomized Controlled Trial of an Integrated Alcohol Reduction Intervention in Patients With Hepatitis C Infection. Hepatology 2020; 71:1894-1909. [PMID: 31803945 PMCID: PMC7288780 DOI: 10.1002/hep.31058] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 11/15/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Hepatitis C virus (HCV) and alcohol use are patient risk factors for accelerated fibrosis progression, yet few randomized controlled trials have tested clinic-based alcohol interventions. APPROACH AND RESULTS A total of 181 patients with HCV and qualifying alcohol screener scores at three liver center settings were randomly assigned to the following: (1) medical provider-delivered Screening, Brief Intervention, and Referral to Treatment (SBIRT), including motivational interviewing counseling and referral out for alcohol treatment (SBIRT-only), or (2) SBIRT plus 6 months of integrated colocated alcohol therapy (SBIRT + Alcohol Treatment). The timeline followback method was used to assess alcohol use at baseline and 3, 6, and 12 months. Coprimary outcomes were alcohol abstinence at 6 months and heavy drinking days between 6 and 12 months. Secondary outcomes included grams of alcohol consumed per week at 6 months. Mean therapy hours across 6 months were 8.8 for SBIRT-only and 10.1 for SBIRT + Alcohol Treatment participants. The proportion of participants exhibiting full alcohol abstinence increased from baseline to 3, 6, and 12 months in both treatment arms, but no significant differences were found between arms (baseline to 6 months, 7.1% to 20.5% for SBIRT-only; 4.2% to 23.3% for SBIRT + Alcohol Treatment; P = 0.70). Proportions of participants with any heavy drinking days decreased in both groups at 6 months but did not significantly differ between the SBIRT-only (87.5% to 26.7%) and SBIRT + Alcohol Treatment (85.7% to 42.1%) arms (P = 0.30). Although both arms reduced average grams of alcohol consumed per week from baseline to 6 and 12 months, between-treatment effects were not significant. CONCLUSIONS Patients with current or prior HCV infection will engage in alcohol treatment when encouraged by liver medical providers. Liver clinics should consider implementing provider-delivered SBIRT and tailored alcohol treatment referrals as part of the standard of care.
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Affiliation(s)
- Rae Jean Proeschold-Bell
- Duke Global Health Institute, Duke University, Box 90392, Durham, NC 27708-0392, USA
- Duke Center for Health Policy & Inequalities Research, Duke University, Box 90392, Durham, NC 27708-0392, USA
| | - Donna M. Evon
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, CB# 7584, Chapel Hill, NC 27599-7584, USA
| | - Jia Yao
- Duke Center for Health Policy & Inequalities Research, Duke University, Box 90392, Durham, NC 27708-0392, USA
| | - Donna Niedzwiecki
- Department of Biostatistics and Bioinformatics, Duke University, Box 2721 Durham, NC 27710, USA
| | - Christina Makarushka
- Duke Center for Health Policy & Inequalities Research, Duke University, Box 90392, Durham, NC 27708-0392, USA
| | - Kelly A. Keefe
- Duke Center for Health Policy & Inequalities Research, Duke University, Box 90392, Durham, NC 27708-0392, USA
| | - Ashwin A. Patkar
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, 2213 Elba Street, Suite 165, Durham, NC 27705, USA
- Department of Community and Family Medicine, Duke University Medical Center, 2213 Elba Street, Suite 165, Durham, NC, USA, 27705, USA
| | - Paolo Mannelli
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, 2213 Elba Street, Suite 165, Durham, NC 27705, USA
| | - James C. Garbutt
- UNC School of Medicine Bowles Center for Alcohol Studies and UNC Department of Psychiatry, University of North Carolina at Chapel Hill, NC 27514, USA
| | - John B. Wong
- Division of Clinical Decision Making, Department of Medicine, Tufts Medical Center, 800 Washington St #302, Boston, MA 02111, USA
| | - Julius M. Wilder
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, DUMC 3913, Durham, NC 27710, USA
- Duke Clinical Research Institute, 2400 Pratt Street, Rm. 0311, Terrace Level, Durham, NC 27705, USA
| | - Santanu K. Datta
- Department of Medicine, Duke University, 411 West Chapel Hill St, Suite 500, Durham, NC 27701, USA
| | - Terra Hodge
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, DUMC 3913, Durham, NC 27710, USA
| | - Susanna Naggie
- Duke Clinical Research Institute, 2400 Pratt Street, Rm. 0311, Terrace Level, Durham, NC 27705, USA
- Duke University School of Medicine, Infectious Diseases, Durham, NC 27710, USA
- Durham VA Medical Center, Durham, NC 27705, USA
| | - Michael W. Fried
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, CB# 7584, Chapel Hill, NC 27599-7584, USA
| | - Andrew J. Muir
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, DUMC 3913, Durham, NC 27710, USA
- Duke Clinical Research Institute, 2400 Pratt Street, Rm. 0311, Terrace Level, Durham, NC 27705, USA
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Boodram B, Kaufmann M, Aronsohn A, Hamlish T, Peregrine Antalis E, Kim K, Wolf J, Rodriguez I, Millman AJ, Johnson D. Case Management and Capacity Building to Enhance Hepatitis C Treatment Uptake at Community Health Centers in a Large Urban Setting. FAMILY & COMMUNITY HEALTH 2020; 43:150-160. [PMID: 32079971 DOI: 10.1097/fch.0000000000000253] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
An estimated 4.1 million people in the United States are infected with hepatitis C virus (HCV). In 2014, the Hepatitis C Community Alliance to Test and Treat (HepCCATT) collaborative was formed to address hepatitis C in Chicago. From 2014 to 2017, the HepCCATT Case Management Program case managed 181 HCV-infected people and performed on-site capacity building at a 6-site community health center (CHC) that produced codified protocols, which were translated into a telehealth program to build capacity within CHCs to deliver hepatitis C care. HepCCATT's innovative approach to addressing multilevel barriers is a potential model for increasing access to hepatitis C care and treatment.
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Affiliation(s)
- Basmattee Boodram
- School of Public Health (Dr Boodram and Ms Kaufmann) and Cancer Center (Dr Hamlish), University of Illinois at Chicago; Department of Internal Medicine, University of Michigan, Ann Arbor and Sarcoma Alliance for Research Through Collaboration, Ann Arbor, Michigan (Dr Peregrine Antalis); University of Chicago Medicine, Chicago, Illinois (Drs Aronsohn and Johnson and Ms Rodriguez); Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania (Ms Kim); Caring Ambassadors Program, Inc, Chicago, Illinois (Ms Wolf); and Centers for Disease Control and Prevention, Atlanta, Georgia (Dr Millman)
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Verma M, Horrow J, Navarro V. A Behavioral Health Program for Alcohol Use Disorder, Substance Abuse, and Depression in Chronic Liver Disease. Hepatol Commun 2019; 3:646-655. [PMID: 31061953 PMCID: PMC6492470 DOI: 10.1002/hep4.1328] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 01/22/2019] [Indexed: 01/19/2023] Open
Abstract
Alcohol use disorder, substance abuse, and depression are illnesses that deteriorate the quality of life (QOL) of patients with chronic liver disease (CLD). Screening and behavioral health programs integrated into routine practice can mitigate the deleterious effects of such illnesses but have not been adopted in hepatology practices. We implemented a behavioral health program based on the Screening, Brief Intervention, and Referral to Treatment (SBIRT) model and assessed its acceptability and effectiveness in improving QOL. This was a quality improvement study. Patients with CLD and a scheduled outpatient visit in the hepatology clinic were screened while waiting for their appointment. All patients who screened positive for any of the three illnesses were offered a brief intervention (BI) at the point of care and at 3 months by a trained social worker. The BI used the principles of motivational interviewing and cognitive behavioral therapy. Severity of illness was assessed at baseline, 3 months, and 6 months. Participants completed an acceptability survey at 6 months. We screened 303 patients; 61.7% were positive for any of the three illnesses assessed. Among the positive patients, depression was most common (48.4%), alcohol and substance abuse were each 26%. For the 95 patients who underwent BI, QOL improved from baseline to 3 and 6 months (P < 0.001) and patients with depression improved the most. Depression was the only independent predictor of change in QOL over time. Of the enrolled patients, 82% agreed BIs improved their overall care and 87% indicated a desire to continue with the behavioral program. Conclusion: An outpatient behavioral health program based on the SBIRT model is acceptable to patients with CLD and may help improve QOL over time.
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Affiliation(s)
- Manisha Verma
- Department of Digestive Diseases and Transplantation Einstein Medical Center Philadelphia PA
| | - Jay Horrow
- Department of Anesthesiology and Perioperative Medicine Drexel University Philadelphia PA
| | - Victor Navarro
- Department of Digestive Diseases and Transplantation Einstein Medical Center Philadelphia PA
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Chossegros P, Di Nino F. Associating conditional cash transfer to universal access to treatment could be the solution to the HCV epidemic among drug users (DUs). Harm Reduct J 2018; 15:63. [PMID: 30541570 PMCID: PMC6292040 DOI: 10.1186/s12954-018-0264-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Accepted: 03/06/2018] [Indexed: 11/11/2022] Open
Abstract
Background To understand the limits of HCV screening programs to reach all drug users (DUs). Method The association of the recruitment of a representative sample of a population of DUs in a specific area with the use of a questionnaire that included 250 items allowed the use of uni- and multifactorial analysis to explore the relationship between HCV screening and dimensions until now restricted to qualitative studies. Results We recruited, in less than 2 months, 327 DUs representing about 6% of the total population of DUs. They belonged to a single community whose drug use was the only common characteristic. While almost all DUs (92.6%) who had access to care providers had been screened, this proportion was much lower in out-of-care settings (64%). HCV prevalence among those who had performed a test was low (22.8%). For DUs, the life experience of hepatitis C has not changed in the last 10 years. Screening, studied for the first time according to this life experience, was not influenced by a rational knowledge of the risk taken or the knowledge of treatment efficacy, showing a gap between DUs’ representations and medical recommendations which explains the low level of active screening. Police crackdown on injections, disrupting the previous illusion of safe practices, was the only prior history leading to active screenings. Screenings were related to an access to care providers. GPs held a preponderant position as a source of information and care by being able to give appropriate answers regarding hepatitis C and prescribing opioid substitution treatments (OST). If 48 % of DUs screened positive for HCV had been treated, half of them had been prescribed before 2006. Conclusion While hepatitis has become a major issue for society and, consequently, for services for DUs (SDUs) and GPs, it is not the case for DUs. A widespread screening, even in a city where the offer of care is diversified and free, seems unlikely to reach a universal HCV screening over a short time. The model of respondent-driven sampling recruitment could be a new approach to conditional cash transfer, recruiting and treating DUs who remain outside the reach of care providers, a prerequisite for the universal access to HCV treatments to impact the HCV epidemic.
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Affiliation(s)
- Philippe Chossegros
- UHSI de Lyon, Centre Hospitalier Lyon SUD, Hospices Civils de LYON, Chemin du Grand Revoyet, 69495, Pierre-Bénite, France.
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Proeschold-Bell RJ, Evon DM, Makarushka C, Wong JB, Datta SK, Yao J, Patkar AA, Mannelli P, Hodge T, Naggie S, Wilder JM, Fried MW, Niedzwiecki D, Muir AJ. The Hepatitis C-Alcohol Reduction Treatment (Hep ART) intervention: Study protocol of a multi-center randomized controlled trial. Contemp Clin Trials 2018; 72:73-85. [PMID: 30006024 PMCID: PMC6711183 DOI: 10.1016/j.cct.2018.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 05/25/2018] [Accepted: 07/09/2018] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Among patients with hepatitis C virus (HCV) infection, alcohol synergistically increases the risk of cirrhosis, hepatocellular carcinoma, and death. Randomized controlled trials of integrated models of HCV-alcohol treatment have been recommended but only performed in patients with severe alcohol use disorders. OBJECTIVES This pragmatic randomized controlled trial seeks to compare clinical effectiveness and cost-effectiveness of integrated alcohol treatment compared to enhanced treatment as usual (TAU) on alcohol consumption and economic outcomes among patients ever infected with HCV. METHODS Patients recruited from three liver centers who had current or prior chronic HCV and qualifying alcohol screener scores were randomly assigned to enhanced TAU or the Hepatitis C-Alcohol Reduction Treatment (Hep ART) intervention. All patients received enhanced TAU, consisting of a patient-administered alcohol screener and care from medical providers who were trained in Screening, Brief Intervention and Referral to Treatment (SBIRT), including brief motivational interviewing counseling. The Hep ART intervention combined enhanced TAU with up to six months of integrated co-located individual and/or group therapy that provided motivational, cognitive, and behavioral strategies to reduce alcohol consumption. The Timeline Followback (TLFB) Method was used to evaluate alcohol use at baseline, 3, 6, and 12 months. Primary outcomes are alcohol abstinence and fewer heavy drinking days, and for the cost-effectiveness analysis, measures included grams of alcohol consumed. DISCUSSION This study will determine whether Hep ART, a six-month integrated alcohol treatment, compared to enhanced TAU, is both clinically effective and cost-effective in patients with a history of comorbid HCV and alcohol use.
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Affiliation(s)
- Rae Jean Proeschold-Bell
- Duke Global Health Institute, Duke University, Box 90392, Durham, NC 27708-0392, USA; Duke Center for Health Policy & Inequalities Research, Duke University, Box 90392, Durham, NC 27708-0392, USA.
| | - Donna M Evon
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, CB# 7584, Chapel Hill, NC 27599-7584, United States.
| | - Christina Makarushka
- Duke Center for Health Policy & Inequalities Research, Duke University, Box 90392, Durham, NC 27708-0392, USA.
| | - John B Wong
- Division of Clinical Decision Making, Tufts Medical Center, 800 Washington St #302, Boston, MA 02111, USA.
| | - Santanu K Datta
- Department of Medicine, Duke University, 411 West Chapel Hill St, Suite 500, Durham, NC 27701, USA.
| | - Jia Yao
- Duke Center for Health Policy & Inequalities Research, Duke University, Box 90392, Durham, NC 27708-0392, USA.
| | - Ashwin A Patkar
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, 2213 Elba Street, Suite 165, Durham, NC 27705, United States; Department of Community and Family Medicine, Duke University Medical Center, 2213 Elba Street, Suite 165, Durham, NC 27705, United States.
| | - Paolo Mannelli
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, 2213 Elba Street, Suite 165, Durham, NC 27705, United States.
| | - Terra Hodge
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, DUMC 3913, Durham, NC 27710, USA.
| | - Susanna Naggie
- Duke University School of Medicine, Infectious Diseases, Durham, NC 27710, USA; Duke Clinical Research Institute, 2400 Pratt Street, Rm. 0311, Terrace Level, Durham, NC 27705, USA; Durham VA Medical Center, Durham, NC 27705, USA.
| | - Julius M Wilder
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, DUMC 3913, Durham, NC 27710, USA; Duke Clinical Research Institute, 2400 Pratt Street, Rm. 0311, Terrace Level, Durham, NC 27705, USA.
| | - Michael W Fried
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, CB# 7584, Chapel Hill, NC 27599-7584, United States.
| | - Donna Niedzwiecki
- Department of Biostatistics and Bioinformatics, Duke University, Box 2721, Durham, NC 27710, United States.
| | - Andrew J Muir
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, DUMC 3913, Durham, NC 27710, USA; Duke Clinical Research Institute, 2400 Pratt Street, Rm. 0311, Terrace Level, Durham, NC 27705, USA.
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Espinosa C, Jhaveri R, Barritt AS. Unique Challenges of Hepatitis C in Infants, Children, and Adolescents. Clin Ther 2018; 40:1299-1307. [PMID: 30107999 DOI: 10.1016/j.clinthera.2018.07.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 07/13/2018] [Accepted: 07/16/2018] [Indexed: 12/23/2022]
Abstract
PURPOSE Hepatitis C, a chronic disease with deadly consequences, is no longer predominantly a disease of older people. METHODS A limited search was conducted of the relevant literature on 2 topics: (1) the impact of hepatitis C on infants exposed by vertical transmission; and (2) the impact of hepatitis C infection on infected children and adolescents. The findings were supplemented by the first-hand experience of the authors. FINDINGS Young people, including women of childbearing age, infants, children, and adolescents, are being especially affected by hepatitis C infection secondary to the intravenous drug use and opioid epidemic. Unfortunately, estimates of disease in young populations are all misleading because universal screening has not been implemented. IMPLICATIONS Lack of implementation of policies for screening and therapy on most affected populations will be responsible for perpetuation of this infection. In the era of highly effective therapy and a regimen that is approved by the US Food and Drug Administration for children, this outcome is unacceptable.
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Affiliation(s)
- Claudia Espinosa
- Division of Pediatric Infectious Disease, University of Louisville School of Medicine, Louisville, Kentucky.
| | - Ravi Jhaveri
- Division of Infectious Disease, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina
| | - A Sidney Barritt
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina
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Evon DM, Stewart PW, Amador J, Serper M, Lok AS, Sterling RK, Sarkar S, Golin CE, Reeve BB, Nelson DR, Reau N, Lim JK, Reddy KR, Di Bisceglie AM, Fried MW. A comprehensive assessment of patient reported symptom burden, medical comorbidities, and functional well being in patients initiating direct acting antiviral therapy for chronic hepatitis C: Results from a large US multi-center observational study. PLoS One 2018; 13:e0196908. [PMID: 30067745 PMCID: PMC6070182 DOI: 10.1371/journal.pone.0196908] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 04/23/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Symptom burden, medical comorbidities, and functional well-being of patients with chronic hepatitis C virus (HCV) initiating direct acting antiviral (DAA) therapy in real-world clinical settings are not known. We characterized these patient-reported outcomes (PROs) among HCV-infected patients and explored associations with sociodemographic, liver disease, and psychiatric/substance abuse variables. METHODS AND FINDINGS PROP UP is a large US multicenter observational study that enrolled 1,600 patients with chronic HCV in 2016-2017. Data collected prior to initiating DAA therapy assessed the following PROs: number of medical comorbidities; neuropsychiatric, somatic, gastrointestinal symptoms (PROMIS surveys); overall symptom burden (Memorial Symptom Assessment Scale); and functional well-being (HCV-PRO). Candidate predictors included liver disease markers and patient-reported sociodemographic, psychiatric, and alcohol/drug use features. Predictive models were explored using a random selection of 700 participants; models were then validated with data from the remaining 900 participants. The cohort was 55% male, 39% non-white, 48% had cirrhosis (12% with advanced cirrhosis); 52% were disabled or unemployed; 63% were on public health insurance or uninsured; and over 40% had markers of psychiatric illness. The median number of medical comorbidities was 4 (range: 0-15), with sleep disorders, chronic pain, diabetes, joint pain and muscle aches being present in 20-50%. Fatigue, sleep disturbance, pain and neuropsychiatric symptoms were present in over 60% and gastrointestinal symptoms in 40-50%. In multivariable validation models, the strongest and most frequent predictors of worse PROs were disability, unemployment, and use of psychiatric medications, while liver markers generally were not. CONCLUSIONS This large multi-center cohort study provides a comprehensive and contemporary assessment of the symptom burden and comorbid medical conditions in patients with HCV treated in real world settings. Pain, fatigue, and sleep disturbance were common and often severe. Sociodemographic and psychiatric markers were the most robust predictors of PROs. Future research that includes a rapidly changing population of HCV-infected individuals needs to evaluate how DAA therapy affects PROs and elucidate which symptoms resolve with viral eradication. TRIAL REGISTRATION (Clinicaltrial.gov: NCT02601820).
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Affiliation(s)
- Donna M. Evon
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, United States of America
- * E-mail:
| | - Paul W. Stewart
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Jipcy Amador
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Marina Serper
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Anna S. Lok
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Richard K. Sterling
- Division of Gastroenterology, Hepatology & Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, United States of America
| | - Souvik Sarkar
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California Davis, Davis, California, United States of America
| | - Carol E. Golin
- Division of General Medicine and Clinical Epidemiology, Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, United States of America
- Department of Health Behaviors, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Bryce B. Reeve
- Department of Population Health Sciences, Duke University, Durham, North Carolina, United States of America
| | - David R. Nelson
- Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, University of Florida, Gainesville, Florida, United States of America
| | - Nancy Reau
- Department of Internal Medicine, Section of Hepatology, Rush University, Chicago, Illinois, United States of America
| | - Joseph K. Lim
- Digestive Diseases, Department of Internal Medicine, Yale University, New Haven, Connecticut, United States of America
| | - K. Rajender Reddy
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Adrian M. Di Bisceglie
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Saint Louis University, St. Louis, Missouri, United States of America
| | - Michael W. Fried
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, United States of America
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12
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Hepatitis C Management Simplification From Test to Cure: A Framework for Primary Care Providers. Clin Ther 2018; 40:1234-1245. [PMID: 29983266 DOI: 10.1016/j.clinthera.2018.05.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 05/09/2018] [Accepted: 05/09/2018] [Indexed: 12/23/2022]
Abstract
This article proposes a strategy for primary care providers to begin treating patients with hepatitis C virus (HCV). We are motivated by the need to expand HCV treatment and by developments that have simplified treatment for most patients. This article presents 5 steps to achieving quality HCV treatment in the primary care setting: (1) accurate diagnosis via reflex testing; (2) risk stratification and identifying comorbidities via pretreatment evaluation; (3) simple, once-daily, pan-genotypic HCV treatment regimens; (4) minimized on-treatment monitoring: and (5) posttreatment monitoring and high-quality care for comorbidities such as cirrhosis and injection drug use. We provide indications for referral to specialists: notably children, patients with genotype 3 and cirrhosis, advanced liver or kidney disease, previous treatment failures, drug interactions with recommended regimens, and hepatitis B co-infection. Finally, potential barriers for providers are discussed, as well as further research findings and policy interventions that can promote HCV treatment in the primary care setting. We believe that a substantial portion of patients with HCV can be treated safely and effectively by nonspecialists and that the engagement of primary care providers is critical to efforts to end the HCV epidemic.
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13
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Evon DM, Golin CE, Ruffin R, Ayres S, Fried MW. Novel patient-reported outcomes (PROs) used in a pilot and feasibility study of a Cognitive Behavioral Coping Skills (CBCS) group intervention for patients with chronic hepatitis C. Pilot Feasibility Stud 2018; 4:92. [PMID: 29983993 PMCID: PMC6020443 DOI: 10.1186/s40814-018-0285-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Accepted: 05/02/2018] [Indexed: 02/06/2023] Open
Abstract
Background Patients with chronic hepatitis C virus (HCV) experience reduced quality of life, HCV-associated symptoms, comorbid conditions, and treatment side effects. The Cognitive Behavioral Coping Skills group intervention for HCV (CBCS-HCV) was developed using the Stage Model of Behavioral Therapies Research. Intervention development and initial feasibility testing in wave 1 participants were previously reported. The primary objective of this subsequent pilot with wave 2–3 participants was to investigate the effect sizes and clinical improvements in patient-reported outcomes (PROs) and trial and intervention feasibility. Methods A pilot feasibility two-arm randomized controlled trial using block randomization to assign patients to CBCS-HCV or standard of care was conducted. Participants attended nine group sessions: four before HCV treatment and five during treatment. PRO data were collected at five time points: before the CBCS intervention (T1), immediately before HCV treatment (T2), during HCV treatment (T3, T4), and 1 month post-intervention/post-HCV treatment (T5). PROs included quality of life, perceived stress, HCV symptoms, and medication adherence. Cohen’s d was used to estimate within-group changes (WGCs) and between-group differences (BGDs), with d > 0.35 considered potentially clinically significant. Potential mechanisms of change were also evaluated. Results Several WGCs and BGDs (ES > .35) suggest that the CBCS-HCV may promote improvements in PROs: psychological stress, depression, anger, anxiety, sleep disturbance, and fatigue. The intervention did not appear to impact social functioning, pain, or medication adherence. Cognitive behavioral skills and group therapy dynamics, but not HCV treatment self-efficacy, may mediate improvements in PROs. Most aspects of the study trial, including intervention implementation, were feasible. Patient acceptance and retention were exceptional. The greatest feasibility challenge was due to patients needing to initiate treatment as soon as medications were obtained, but often before a full block could be created in wave 3. Challenges with PRO data collection were identified that will be resolved in future studies. Conclusions The CBCS-HCV intervention warrants future investigation in an efficacy trial to evaluate improvements in selected PROs. The next step is to pilot test the CBCS-HCV delivered via telehealth to an expanded pool of patients to reduce patient barriers, hone technical logistics, and improve intervention reach and effectiveness. Trial registration NCT03057236 Retrospectively registered.
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Affiliation(s)
- Donna M Evon
- 1Division of Gastroenterology and Hepatology, University of North Carolina, CB# 7584, 8010 Burnett-Womack, Chapel Hill, NC 27599 USA
| | - Carol E Golin
- 2Department of Medicine, University of North Carolina, Chapel Hill, NC USA.,3Department of Health Behavior, University of North Carolina, Chapel Hill, NC USA
| | | | - Shauna Ayres
- 3Department of Health Behavior, University of North Carolina, Chapel Hill, NC USA
| | - Michael W Fried
- 1Division of Gastroenterology and Hepatology, University of North Carolina, CB# 7584, 8010 Burnett-Womack, Chapel Hill, NC 27599 USA
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14
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Patel K, Maguire E, Chartier M, Akpan I, Rogal S. Integrating Care for Patients With Chronic Liver Disease and Mental Health and Substance Use Disorders. Fed Pract 2018; 35:S14-S23. [PMID: 30766391 PMCID: PMC6375404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Mental health disorders are common among patients with chronic liver disease, and current literature supports the use of better screening and providing integrated or multidisciplinary care where possible.
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Affiliation(s)
- Krupa Patel
- is an Assistant Professor and is a Resident at University of Pittsburgh in Pennsylvania. is a Gastroenterologist at Baylor Scott & White Health, Texas. is a Health Communications Researcher at the Center for Healthcare Organization and Implementation Research at Bedford VAMC in Massachusetts. is the Deputy Director and the National Infectious Diseases Officer and Ms. Maguire is Communications Lead at the Veterans Health Administration, Office of Specialty Care Services, HIV, Hepatitis, and Related Conditions Programs. Dr. Rogal is a Gastroenterologist, Transplant Hepatologist, and an Investigator at the Center for Health Equity Research and Promotion at VA Pittsburgh Healthcare System
| | - Elizabeth Maguire
- is an Assistant Professor and is a Resident at University of Pittsburgh in Pennsylvania. is a Gastroenterologist at Baylor Scott & White Health, Texas. is a Health Communications Researcher at the Center for Healthcare Organization and Implementation Research at Bedford VAMC in Massachusetts. is the Deputy Director and the National Infectious Diseases Officer and Ms. Maguire is Communications Lead at the Veterans Health Administration, Office of Specialty Care Services, HIV, Hepatitis, and Related Conditions Programs. Dr. Rogal is a Gastroenterologist, Transplant Hepatologist, and an Investigator at the Center for Health Equity Research and Promotion at VA Pittsburgh Healthcare System
| | - Maggie Chartier
- is an Assistant Professor and is a Resident at University of Pittsburgh in Pennsylvania. is a Gastroenterologist at Baylor Scott & White Health, Texas. is a Health Communications Researcher at the Center for Healthcare Organization and Implementation Research at Bedford VAMC in Massachusetts. is the Deputy Director and the National Infectious Diseases Officer and Ms. Maguire is Communications Lead at the Veterans Health Administration, Office of Specialty Care Services, HIV, Hepatitis, and Related Conditions Programs. Dr. Rogal is a Gastroenterologist, Transplant Hepatologist, and an Investigator at the Center for Health Equity Research and Promotion at VA Pittsburgh Healthcare System
| | - Imo Akpan
- is an Assistant Professor and is a Resident at University of Pittsburgh in Pennsylvania. is a Gastroenterologist at Baylor Scott & White Health, Texas. is a Health Communications Researcher at the Center for Healthcare Organization and Implementation Research at Bedford VAMC in Massachusetts. is the Deputy Director and the National Infectious Diseases Officer and Ms. Maguire is Communications Lead at the Veterans Health Administration, Office of Specialty Care Services, HIV, Hepatitis, and Related Conditions Programs. Dr. Rogal is a Gastroenterologist, Transplant Hepatologist, and an Investigator at the Center for Health Equity Research and Promotion at VA Pittsburgh Healthcare System
| | - Shari Rogal
- is an Assistant Professor and is a Resident at University of Pittsburgh in Pennsylvania. is a Gastroenterologist at Baylor Scott & White Health, Texas. is a Health Communications Researcher at the Center for Healthcare Organization and Implementation Research at Bedford VAMC in Massachusetts. is the Deputy Director and the National Infectious Diseases Officer and Ms. Maguire is Communications Lead at the Veterans Health Administration, Office of Specialty Care Services, HIV, Hepatitis, and Related Conditions Programs. Dr. Rogal is a Gastroenterologist, Transplant Hepatologist, and an Investigator at the Center for Health Equity Research and Promotion at VA Pittsburgh Healthcare System
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15
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Treatment of Hepatitis C during Pregnancy-Weighing the Risks and Benefits in Contrast to HIV. Curr HIV/AIDS Rep 2018; 15:155-161. [DOI: 10.1007/s11904-018-0386-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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16
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Increasing Prevalence of Hepatitis C among Hospitalized Children Is Associated with an Increase in Substance Abuse. J Pediatr 2018; 192:159-164. [PMID: 29106926 DOI: 10.1016/j.jpeds.2017.09.016] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 08/22/2017] [Accepted: 09/08/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate the impact of substance abuse on pediatric hepatitis C virus (HCV) prevalence, we examined geographic and demographic data on inpatient hospitalizations in children with HCV. STUDY DESIGN We examined hospitalizations in children using the Kids' Inpatient Database, a part of the Healthcare Cost and Utilization Project. We identified cases using the International Classification of Diseases, 9th edition, codes for HCV infection during 2006, 2009, and 2012. Nonparametric tests for trend were used to calculate trend statistics. RESULTS From 2006 to 2012 nationally, the number of hospitalizations of children with HCV increased 37% (2.69 to 3.69 per 10 000 admissions; P < .001). The mean age of children hospitalized was 17.6 years (95% CI, 17.4-17.8). HCV cases among those 19-20 years of age represented 68% of the total HCV diagnoses, with a 54% increase over the years sampled (P < .001 for trend). The burden of HCV in children was highest in whites, those in the lowest income quartile, and in the Northeast and Southern regions of the US (all P < .0001). The prevalence of substance use among children with HCV increased from 25% in 2006 to 41% in 2012 (P < .001). CONCLUSION The increases of HCV in hospitalized children are largely in teenagers, highly associated with substance abuse, and concentrated in Northeast and Southern states. These results strongly suggest that public health efforts to prevent and treat HCV will also need to include adolescents.
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17
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Martin-Subero M, Diez-Quevedo C. Mental disorders in HIV/HCV coinfected patients under antiviral treatment for hepatitis C. Psychiatry Res 2016; 246:173-181. [PMID: 27718466 DOI: 10.1016/j.psychres.2016.09.041] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 07/27/2016] [Accepted: 09/24/2016] [Indexed: 12/14/2022]
Abstract
This paper aims to review the epidemiology and management of mental disorders in human immunodeficiency virus (HIV)/hepatitis C virus (HCV) coinfected patients, the need for antiviral therapy in this specific population, and current treatment strategies for HIV/HCV patients with psychiatric and/or substance use disorders. This is a narrative review. Data was sourced from electronic databases and was not limited by language or date of publication. HIV infection has become a survivable chronic illness. Prevalence of HCV infection among HIV-infected patients is high ranging from 50% to 90%. Patients with psychiatric diseases have also an increased risk for HIV/HCV coinfection. The most effective strategy to decrease HCV-related morbidity and mortality in coinfection is to achieve viral eradication. Although psychiatric symptoms often appear during antiviral treatment and may be associated with the use of interferon-alpha (IFN-α), recent evidence suggests that many patients with comorbid mental and substance use disorders can be treated safely. Recent data indicate that IFNα-induced psychiatric side effects have a similar prevalence in HIV/HCV coinfected patients than in monoinfected patients and they can be managed and even prevented successfully with psychopharmacological strategies in the frame of a multidisciplinary team. New antivirals offer INF-free therapies for this specific population.
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Affiliation(s)
- Marta Martin-Subero
- FIDMAG Research Foundation, Barcelona, Spain; Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona, Badalona, Spain.
| | - Crisanto Diez-Quevedo
- Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona, Badalona, Spain; Department of Psychiatry, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
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18
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Rogal SS, Arnold RM, Chapko M, Hanusa BV, Youk A, Switzer GE, Sevick MA, Bayliss NK, Zook CL, Chidi A, Obrosky DS, Zickmund SL. The Patient-Provider Relationship Is Associated with Hepatitis C Treatment Eligibility: A Prospective Mixed-Methods Cohort Study. PLoS One 2016; 11:e0148596. [PMID: 26900932 PMCID: PMC4763474 DOI: 10.1371/journal.pone.0148596] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 12/17/2015] [Indexed: 12/11/2022] Open
Abstract
Hepatitis C virus (HCV) treatment has the potential to cure the leading cause of cirrhosis and hepatocellular carcinoma. However, only those deemed eligible for treatment have the possibility of this cure. Therefore, understanding the determinants of HCV treatment eligibility is critical. Given that effective communication with and trust in healthcare providers significantly influences treatment eligibility decisions in other diseases, we aimed to understand patient-provider interactions in the HCV treatment eligibility process. This prospective cohort study was conducted in the VA Pittsburgh Healthcare System. Patients were recruited after referral for gastroenterology consultation for HCV treatment with interferon and ribavirin. Consented patients completed semi-structured interviews and validated measures of depression, substance and alcohol use, and HCV knowledge. Two coders analyzed the semi-structured interviews. Factors associated with patient eligibility for interferon-based therapy were assessed using multivariate logistic regression. Of 339 subjects included in this analysis, only 56 (16.5%) were deemed eligible for HCV therapy by gastroenterology (GI) providers. In the multivariate logistic regression, patients who were older (OR = 0.96, 95%CI = 0.92-0.99, p = .049), reported concerns about the GI provider (OR = 0.40, 95%CI = 0.10-0.87, p = 0.02) and had depression symptoms (OR = 0.32, 95%CI = 0.17-0.63, p = 0.001) were less likely to be eligible. Patients described barriers that included feeling stigmatized and poor provider interpersonal or communication skills. In conclusion, we found that patients' perceptions of the relationship with their GI providers were associated with treatment eligibility. Establishing trust and effective communication channels between patients and providers may lower barriers to potential HCV cure.
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Affiliation(s)
- Shari S. Rogal
- Center for Health Equity Research and Promotion, Veteran’s Administration, Pittsburgh Healthcare Service, Pittsburgh, Pennsylvania, United States of America
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- * E-mail:
| | - Robert M. Arnold
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Michael Chapko
- Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veteran’s Administration Healthcare Service, Seattle, Washington, United States of America
| | - Barbara V. Hanusa
- Center for Health Equity Research and Promotion, Veteran’s Administration, Pittsburgh Healthcare Service, Pittsburgh, Pennsylvania, United States of America
| | - Ada Youk
- Center for Health Equity Research and Promotion, Veteran’s Administration, Pittsburgh Healthcare Service, Pittsburgh, Pennsylvania, United States of America
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Galen E. Switzer
- Center for Health Equity Research and Promotion, Veteran’s Administration, Pittsburgh Healthcare Service, Pittsburgh, Pennsylvania, United States of America
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Mary Ann Sevick
- Department of Population Health, New York University School of Medicine, New York, New York, United States of America
| | - Nichole K. Bayliss
- Center for Health Equity Research and Promotion, Veteran’s Administration, Pittsburgh Healthcare Service, Pittsburgh, Pennsylvania, United States of America
| | - Carolyn L. Zook
- School of Medicine, Oregon Health Sciences University, Portland, Oregon, United States of America
| | - Alexis Chidi
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - David S. Obrosky
- Center for Health Equity Research and Promotion, Veteran’s Administration, Pittsburgh Healthcare Service, Pittsburgh, Pennsylvania, United States of America
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Susan L. Zickmund
- Center for Health Equity Research and Promotion, Veteran’s Administration, Pittsburgh Healthcare Service, Pittsburgh, Pennsylvania, United States of America
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
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Personality disorders among Spanish prisoners starting hepatitis C treatment: Prevalence and associated factors. Psychiatry Res 2015; 230:749-56. [PMID: 26602229 DOI: 10.1016/j.psychres.2015.11.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Revised: 09/05/2015] [Accepted: 11/10/2015] [Indexed: 12/23/2022]
Abstract
The purpose of this study was to assess the prevalence of personality disorders (PDs) and their associated factors in prisoners who initiate chronic hepatitis C (CHC) treatment in 25 Spanish prisons. The Personality Diagnostic Questionnaire-4 was used to diagnose PDs according to DSM-IV criteria. Factors potentially associated with a PD diagnosis were evaluated by logistic regression analysis. Two hundred and fifty-five patients were initially assessed and 62 (24.3%) were excluded due to an incomplete or invalid self-report screening questionnaire. PD prevalence was 70.5%, with antisocial PD being the most prevalent (46.1%). In terms of PD clusters, the most prevalent was cluster-B (55.4%). PD diagnosis was associated with HCV genotypes 1, 2, or 3 (odds ratio [OR] 2.14, 95% confidence interval [CI] 1.02-4.49). Patients with a cluster-B PD were more likely to be infected with HCV genotypes 1, 2, or 3 (OR 2.37, 95% CI 1.08-5.23) and be HIV-infected (OR 2.20, 95% CI 1.10-4.39), to report past-year injection drug use (OR 7.17, 95% CI 1.49-34.58), and to have stage 3 or 4 fibrosis (OR 2.16, 95% CI 1.06-4.49). The prevalence of PDs in Spanish prisoners who initiate CHC treatment is very high. PD management issues should be considered in treating CHC patients in prisons.
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Kwong J, Epstein R. Expanding capacity for hepatitis C treatment in the United States: team-based care and use of nonphysician providers. J Int Assoc Provid AIDS Care 2015; 14:112-5. [PMID: 25787687 DOI: 10.1177/2325957414560065] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Hepatitis C treatment is rapidly evolving with significant improvements in patient outcomes. With an estimated prevalence of over 3 million persons living with chronic hepatitis C in the United States, it is anticipated that there will be an increase in the number of persons seeking care and treatment for chronic hepatitis C infection. Current systems of care may be overburdened with people seeking care for chronic hepatitis C virus (HCV). Interprofessional models of care have been shown to be feasible and effective in treating different populations affected by chronic HCV. Use of interprofessional teams, integrated models of care, and greater use of nonphysician providers offer a potential solution for expanding capacity to comprehensive HCV treatment and care in the United States.
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Affiliation(s)
- Jeffrey Kwong
- Columbia University School of Nursing, New York, NY, USA
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21
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Abstract
GOALS To investigate the role of self-efficacy (SE) during hepatitis C virus (HCV) treatment. BACKGROUND Adherence to chronic HCV treatment is critical. SE is an important predictor of medication adherence in a number of chronic disease populations and medication regimens, but its role during HCV treatment remains unknown. STUDY Data from the prospective Virahep-C study were analyzed to examine relationships between SE and patient-driven deviations (ie, missed doses measured using electronic pill caps, and nonpersistence) from adherence to HCV antiviral treatment. SE was measured using the 17-item HCV Treatment Self-Efficacy scale. This measure provides a global estimate of a patient's confidence to undergo and adhere to HCV treatment, and can estimate SE in 4 underlying domains: communication SE (ie, confidence to communicate with health care provider), physical coping SE (ie, confidence to cope with physical side effects), psychological coping SE (ie, confidence to cope with psychiatric side effects), and treatment adherence SE (ie, confidence to take all medications as prescribed and attend doctor visits). Generalized estimating equations and Cox proportional hazards models were used to assess associations between SE and missed doses and nonpersistence, respectively. RESULTS SE was associated with being in a relationship, educated, privately insured, and less depressed. Higher communication SE at TW24 reduced the risk of missed doses between TW24 and TW48. Higher baseline treatment adherence SE reduced the likelihood of nonpersistence between baseline and TW24. CONCLUSIONS SE's relationship to HCV treatment adherence has promising clinical and research implications.
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Clark JA, Gifford AL. Resolute efforts to cure hepatitis C: Understanding patients' reasons for completing antiviral treatment. Health (London) 2014; 19:473-89. [PMID: 25377666 DOI: 10.1177/1363459314555237] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Antiviral treatment for hepatitis C is usually difficult, demanding, and debilitating and has long offered modest prospects of successful cure. Most people who may need treatment have faced stigma of an illness associated with drug and alcohol misuse and thus may be deemed poor candidates for treatment, while completing a course of treatment typically calls for resolve and responsibility. Patients' efforts and their reasons for completing treatment have received scant attention in hepatitis C clinical policy discourse that instead focuses on problems of adherence and patients' expected failures. Thus, we conducted qualitative interviews with patients who had recently undertaken treatment to explore their reasons for completing antiviral treatment. Analysis of their narrative accounts identified four principal reasons: cure the infection, avoid a bad end, demonstrate the virtue of perseverance through a personal trial, and achieve personal rehabilitation. Their reasons reflect moral rationales that mark the social discredit ascribed to the infection and may represent efforts to restore creditable social membership. Their reasons may also reflect the selection processes that render some of the infected as good candidates for treatment, while excluding others. Explication of the moral context of treatment may identify opportunities to support patients' efforts in completing treatment, as well as illuminate the choices people with hepatitis C make about engaging in care.
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Affiliation(s)
- Jack A Clark
- Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA; Boston University School of Public Health, Boston, MA, USA
| | - Allen L Gifford
- Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA; Boston University School of Public Health, Boston, MA, USA
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23
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Schaefer M, Sarkar R, Diez-Quevedo C. Management of mental health problems prior to and during treatment of hepatitis C virus infection in patients with drug addiction. Clin Infect Dis 2014; 57 Suppl 2:S111-7. [PMID: 23884058 DOI: 10.1093/cid/cit266] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Psychiatric comorbidity is a common problem in patients with substance use disorders. Patients with psychiatric diseases and/or substance abuse have an increased risk for hepatitis C virus (HCV) infection. Furthermore, psychiatric problems occur frequently during antiviral treatment and may be associated with the use of interferon alpha (IFN-α) but also with the primary psychiatric condition. As a consequence, substance abuse and/or acute psychiatric problems are still important reasons for nontreatment of chronic HCV infection. However, prospective and controlled data from recent years showed that if an interdisciplinary treatment is provided, patients with substance use disorders and/or psychiatric diseases do not differ regarding sustained virologic response or IFN-α-associated complications such as depression when compared with controls. Moreover, depression as the most important acute IFN-α-associated psychiatric adverse event can be acutely treated or even prevented by antidepressant pretreatment. Other, more rare but severe complications such as mania, psychotic symptoms, or delirium need individual psychiatric interventions.
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Affiliation(s)
- Martin Schaefer
- Department of Psychiatry, Psychotherapy and Addiction Medicine, Kliniken Essen-Mitte, Essen, Germany.
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Hepatitis C antiviral treatment outcomes are comparable between clinical trial participants and recipients of standard-of-care therapy: an analysis of trial effect. Eur J Gastroenterol Hepatol 2013; 25:1177-82. [PMID: 23652916 DOI: 10.1097/meg.0b013e32836238b2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Trial effect refers to the impact of clinical trial participation on treatment outcomes. Little literature exists evaluating the magnitude and direction of trial effect in hepatitis C virus (HCV). METHODS A single-center, retrospective study on HCV antiviral therapy recipients was conducted. Sustained virologic response (SVR), virologic response at treatment weeks 4 and 12, dose interruptions, and adverse events were compared between clinical trial participants and standard-of-care antiviral recipients between September 2000 and November 2011. RESULTS A total of 449 patients were evaluated (trial: 89, nontrial: 360). Patients were matched for age (trial: 47 years, nontrial: 45 years), sex (male: trial, 74%; nontrial, 72%), and ethnicity (white: trial, 87%; nontrial, 78%). The groups differed in the incidence of genotype 1 infection (trial: 83%, nontrial 53%; P<0.001), liver biopsy rates (trial: 98%, nontrial: 66%; P<0.001), and history of psychiatric illness (trial: 30%, nontrial: 53%; P<0.001). On intent-to-treat analysis, SVR rates were found to be similar (trial: 51%, nontrial: 54%; P=0.86), even when stratified for genotype (G1: trial, 47%; nontrial, 47%; P=0.78). Interferon dose reductions (trial: 18%, nontrial: 6%; P<0.01) were more likely in trial patients, whereas treatment discontinuation because of side effects (trial: 8%, nontrial: 18%; P<0.02) was less likely in them. No differences in safety issues were identified. CONCLUSION Overall, a trial effect resulting in improved or diminished SVR rates was not identified. Other potential positive and negative variables should be focused upon for HCV patients deliberating between clinical trial participation and receiving standard-of-care treatment.
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Michel N, Patel AN, Martel-Laferriere V, Perumalswami P. A 50-Year-Old Male with Cirrhosis, HCV, Alcohol-Use Disorder, and Unexpected Decline While on DAA Therapy. Psychiatr Ann 2013. [DOI: 10.3928/00485713-20130906-07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
Worldwide, an estimated 130-170 million people have HCV infection. HCV prevalence is highest in Egypt at >10% of the general population and China has the most people with HCV (29.8 million). Differences in past HCV incidence and current HCV prevalence, together with the generally protracted nature of HCV disease progression, has led to considerable diversity in the burden of advanced liver disease in different countries. Countries with a high incidence of HCV or peak incidence in the recent past will have further escalations in HCV-related cirrhosis and hepatocellular carcinoma (HCC) over the next two decades. Acute HCV infection is difficult to detect because of the generally asymptomatic nature of the disease and the marginalization of at-risk populations. Around 25% of patients with acute HCV infection undergo spontaneous clearance, with increased rates among those with favourable IL28B genotypes, acute symptoms and in women. The remaining 75% of patients progress to chronic HCV infection and are subsequently at risk of progression to hepatic fibrosis, cirrhosis and HCC. Chronic hepatitis C generally progresses slowly in the initial two decades, but can be accelerated during this time as a result of advancing age and co-factors such as heavy alcohol intake and HIV co-infection.
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Grebely J, Oser M, Taylor LE, Dore GJ. Breaking down the barriers to hepatitis C virus (HCV) treatment among individuals with HCV/HIV coinfection: action required at the system, provider, and patient levels. J Infect Dis 2013; 207 Suppl 1:S19-25. [PMID: 23390301 DOI: 10.1093/infdis/jis928] [Citation(s) in RCA: 158] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The majority of hepatitis C virus (HCV) and human immunodeficiency virus (HIV) coinfection occurs among persons who inject drugs. Rapid improvements in responses to HCV therapy have been observed, but liver-related morbidity rates remain high, given notoriously low uptake of HCV treatment. Advances in HCV therapy will have a limited impact on the burden of HCV-related disease at the population-level unless barriers to HCV education, screening, evaluation, and treatment are addressed and treatment uptake increases. This review will outline barriers to HCV care in HCV/HIV coinfection, with a particular emphasis on persons who inject drugs, proposing strategies to enhance HCV treatment uptake and outcomes.
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Affiliation(s)
- Jason Grebely
- The Kirby Institute, University of New South Wales, Sydney, Australia.
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Barritt AS, Fried MW. Maximizing opportunities and avoiding mistakes in triple therapy for hepatitis C virus. Gastroenterology 2012; 142:1314-1323.e1. [PMID: 22537438 PMCID: PMC3683992 DOI: 10.1053/j.gastro.2012.02.013] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2011] [Revised: 02/13/2012] [Accepted: 02/13/2012] [Indexed: 12/11/2022]
Abstract
Recently developed drugs and innovative strategies for the treatment of chronic infection with genotype 1 hepatitis C virus (HCV) have become the standard of care. The protease inhibitors telaprevir (Incivek) and boceprevir (Victrelis) are the first direct-acting antiviral (DAA) agents approved, and many more are being developed. These drugs substantially increased rates of sustained virologic response in treatment-naïve and -experienced patients, in conjunction with peginterferon and ribavirin (triple therapy), in phase 3 trials. The efficacy of triple therapy depends on appropriate selection of patients, although the population of patients that receive triple therapy could be expanded as the risk/benefit ratio improves. Attention to details that reflect the standard of care, such as appropriate dosing, anticipation of adverse effects, and strict adherence to stopping rules, will insure the success of these drugs and lead the way for new combination therapies.
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