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Cozen ML, Ryan JC, Shen H, Cheung R, Kaplan DE, Pocha C, Brau N, Aytaman A, Schmidt WN, Pedrosa M, Anand BS, Chang KM, Morgan T, Monto A. Improved Survival Among all Interferon-α-Treated Patients in HCV-002, a Veterans Affairs Hepatitis C Cohort of 2211 Patients, Despite Increased Cirrhosis Among Nonresponders. Dig Dis Sci 2016; 61:1744-56. [PMID: 27059981 PMCID: PMC5308124 DOI: 10.1007/s10620-016-4122-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 03/06/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND As the era of interferon-alpha (IFN)-based therapy for hepatitis C ends, long-term treatment outcomes are now being evaluated. AIM To more fully understand the natural history of hepatitis C infection by following a multisite cohort of patients. METHODS Patients with chronic HCV were prospectively enrolled in 1999-2000 from 11 VA medical centers and followed through retrospective medical record review. RESULTS A total of 2211 patients were followed for an average of 8.5 years after enrollment. Thirty-one percent of patients received HCV antiviral therapy, 15 % with standard IFN/ribavirin only, 16 % with pegylated IFN/ribavirin, and 26.7 % of treated patients achieved sustained virologic response (SVR). Cirrhosis developed in 25.8 % of patients. Treatment nonresponders had a greater than twofold increase in the hazard of cirrhosis and hepatocellular carcinoma, compared to untreated patients, whereas SVR patients were only marginally protected from cirrhosis. Nearly 6 % developed hepatocellular carcinoma, and 27.1 % died during the follow-up period. Treated patients, regardless of response, had a significant survival benefit compared to untreated patients (HR 0.58, CI 0.46-0.72). Improved survival was also associated with college education, younger age, lower levels of alcohol consumption, and longer duration of medical service follow-up-factors typically associated with treatment eligibility. CONCLUSIONS As more hepatitis C patients are now being assessed for all-oral combination therapy, these results highlight that patient compliance and limiting harmful behaviors contribute a significant proportion of the survival benefit in treated patients and that the long-term clinical benefits of SVR may be less profound than previously reported.
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Affiliation(s)
- Myrna L Cozen
- San Francisco VA Medical Center and University of California San Francisco, 4150 Clement St #111B, San Francisco, CA, 94121, USA
| | - James C Ryan
- San Francisco VA Medical Center and University of California San Francisco, 4150 Clement St #111B, San Francisco, CA, 94121, USA
| | - Hui Shen
- San Francisco VA Medical Center and University of California San Francisco, 4150 Clement St #111B, San Francisco, CA, 94121, USA
| | - Ramsey Cheung
- Palo Alto VA Medical Center and Stanford University, 3801 Miranda Ave, GI/Hepatology #154C, Palo Alto, CA, 94304-1207, USA
| | - David E Kaplan
- Philadelphia VA Medical Center and University of Pennsylvania, A212 Medical Research, University and Woodland Ave, Philadelphia, PA, 19104, USA
| | - Christine Pocha
- Minneapolis VA Medical Center, 1 Veterans Drive, GI, Minneapolis, MN, 55417, USA
| | - Norbert Brau
- Bronx VA Medical Center, 130 W. Kingsbridge Rd, Bronx, NY, 10468, USA
| | - Ayse Aytaman
- New York Harbor Brooklyn and Manhattan VA Medical Centers, 800 Poly Pl, Brooklyn, NY, 11209, USA
| | - Warren N Schmidt
- Iowa City VA Medical Center and the University of Iowa, 200 Hawkins Dr, Iowa City, IA, 52242, USA
| | - Marcos Pedrosa
- Boston VA Health Care System and AbbVie Pharmaceuticals, 85 E. Concord St. #7700, Boston, MA, 02118, USA
| | - Bhupinderjit S Anand
- Houston VA Medical Center and Baylor University, Digestive Disease Section, #111D, 2002 Holcombe Blvd, Houston, TX, 77030-4211, USA
| | - Kyong-Mi Chang
- Philadelphia VA Medical Center and University of Pennsylvania, A212 Medical Research, University and Woodland Ave, Philadelphia, PA, 19104, USA
| | - Timothy Morgan
- Long Beach VA Medical Center and University of California Irvine, #111G, 5901 E. 7th Street, Long Beach, CA, 90822-5201, USA
| | - Alexander Monto
- San Francisco VA Medical Center and University of California San Francisco, 4150 Clement St #111B, San Francisco, CA, 94121, USA.
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Deborah Friedman N, Green JH, Weber HM, Stephen S, Lane SE, Ting AY, Watson JP. Hepatitis C virus treatment in the 'real-world': how well do 'real' patients respond? J Clin Exp Hepatol 2014; 4:214-20. [PMID: 25755563 PMCID: PMC4284209 DOI: 10.1016/j.jceh.2014.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 07/05/2014] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Published clinical trials of the treatment of HCV are largely multicentre prospective pharmaceutical trials. Patients in clinical trials tend to have more favorable outcomes than patients in the 'real-world', due to strict patient selection and differences in treatment conditions and available resources. OBJECTIVES To assess the outcomes of Hepatitis C infected patients treated at the Barwon Health Liver Clinic with combination Pegylated interferon (PEG-IFN) and Ribavirin (RBV) therapy and to determine factors associated with a treatment response. METHODS Retrospective review of patients who received treatment for Hepatitis C at our institution's Liver Clinic from January 2001-September 2011. Patient demographics, comorbidities, treatment-related parameters and side effects were extracted from medical records and analyzed. RESULTS A total of 190 patients (120 male, 70 female) with a mean age of 42.8 years (range 20-68 years) commenced treatment. The most common genotype was genotype 3 (48.9%), followed by genotype 1 (42.6%). 150 of 190 patients (78.9%) completed treatment and had end of treatment data available. 107 of 182 patients, (58.8%) for whom sustained virologic response (SVR) rate data was available achieved an SVR. Overall response rates were; 46.9%, 68.8% and 62.4% in genotypes 1, 2 and 3 respectively. The response rate was significantly lower in 29 patients with documented cirrhosis (20.7%). Age, diabetes and alcohol abuse did not predict treatment response in our cohort. Side effects reported in 81.6% of patients included general malaise, hematological disturbance and psychiatric issues, and necessitated cessation of therapy in 16 patients (8.4%) and dose reduction in 26 patients (13.7%). CONCLUSIONS Response rates to combination PEG-IFN and RBV therapy at our institution are comparable to other 'real-world' and pharmaceutical registration trials. Side effects of combination therapy were prominent but resulted in fewer discontinuations of therapy compared to pharmaceutical trials.
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Key Words
- DAAs, directly acting agents
- ETR, end of treatment response
- HCV, hepatitis C virus
- IVDU, intravenous drug use
- NSW, new South Wales
- PCR, polymerase chain reaction
- PEG-IFN, pegylated interferon
- RBV, ribavirin
- RNA, ribonucleic acid
- SVR, sustained virologic response
- hepatitis C
- peginterferon alfa-2a
- peginterferon alfa-2b
- ribavirin
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Affiliation(s)
- N. Deborah Friedman
- Department of Infectious Diseases, Geelong, Victoria, Australia,Department of Medicine, Geelong, Victoria, Australia,Address for correspondence: N. Deborah Friedman, Infectious Diseases Physician, Principal Research Fellow, Barwon Health, PO Box 281, Geelong VIC 3220. Tel.: +61 (0) 3 42152033.
| | - Joanne H. Green
- Deakin University School of Medicine, Geelong, Victoria, Australia
| | - Hanna M. Weber
- Deakin University School of Medicine, Geelong, Victoria, Australia
| | - Shiny Stephen
- Deakin University School of Medicine, Geelong, Victoria, Australia
| | - Stephen E. Lane
- Department of Medicine, Geelong, Victoria, Australia,Deakin University School of Medicine, Geelong, Victoria, Australia
| | - Alvin Y. Ting
- Department of Gastroenterology, Barwon Health, Geelong, Victoria, Australia
| | - Jonathan P. Watson
- Department of Medicine, Geelong, Victoria, Australia,Department of Gastroenterology, Barwon Health, Geelong, Victoria, Australia,Deakin University School of Medicine, Geelong, Victoria, Australia
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3
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Drechsler H, Zhang S, Holodniy M, Bedimo R. CD4 counts and mortality in virologically suppressed US veterans. J Int Assoc Provid AIDS Care 2014; 13:120-6. [PMID: 24378517 DOI: 10.1177/2325957413512153] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We used the Veterans Health Administration (VA) HIV Clinical Case Registry (CCR) to evaluate the association between annual CD4 averages and all-cause mortality in HIV-infected veterans during their initial episode of suppressive highly active antiretroviral therapy (HAART). We observed 1083 deaths in 14 769 patients. Unadjusted mortality rates in the top and bottom CD4 quintiles differed significantly from the mid CD4 strata. Mortality in the top CD4 quintile (≥720 cells/mm(3)) was 14.1/1000 patient-years, 95% confidence interval (CI): 10.1-18.2, compared with 20.4 (CI: 15.5-25.3) in the next lower CD4 stratum (530-719 cells/mm(3)). This difference was significant in Cox proportional hazards model, controlling for demographics, hepatitis co-infections, low-level viremia, HAART adherence, and refill rates of individual antiretrovirals (HR: 1.4, CI: 1.13-1.73). Our results support early HAART initiation as advocated by the current US treatment guidelines for HIV infection.
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Russell M, Pauly MP, Moore CD, Chia C, Dorrell JM, Cunanan RJ, Witt G. The impact of lifetime drug use on hepatitis C treatment outcomes in insured members of an integrated health care plan. Drug Alcohol Depend 2014; 134:222-227. [PMID: 24262649 PMCID: PMC3888084 DOI: 10.1016/j.drugalcdep.2013.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Revised: 09/07/2013] [Accepted: 10/01/2013] [Indexed: 11/15/2022]
Abstract
BACKGROUND The relation of drug use to HCV treatment outcome in an insured household population has not been previously reported. METHODS Lifetime frequencies of marijuana use and non-medical use of stimulants, sedatives, and opioids; hallucinogens; and inhalants were retrospectively assessed in 259 privately insured members of an integrated health care plan treated for chronic hepatitis C virus infection (HCV+) with pegylated interferon alpha and ribavirin and examined with respect to rates of sustained virological response (SVR). RESULTS The majority of patients reported chronic use of multiple illegal drugs; 61.6% reported injection drug use (IDU); 79.5% abstained from drug use during the six months prior to HCV treatment. Total frequency of individual drugs, multiple drugs, and length of abstention from drugs prior to HCV treatment were not related to impaired SVR rates. Sustained viral responses were obtained in 80.2% of patients with HCV genotype 2/3 and 45.1% of patients with genotype 1/4/6. Marijuana use during HCV treatment, reported by 8.5% of patients, was associated with higher treatment adherence (95.5% compared with 78.9%, p=0.045), but lower SVR rates (40.9% compared with 62.5%, p=0.041). In addition, drug use during HCV treatment was associated with significantly higher relapse rates, 18.8% compared with 7.7% (p=0.053). CONCLUSION A history of chronic illegal drug use should not be considered a deterrent to HCV treatment in members of an integrated health care plan who are motivated to seek treatment and closely monitored, but drug use during HCV treatment, including marijuana use, should be discouraged.
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Affiliation(s)
- Marcia Russell
- Prevention Research Center, 1995 University Avenue, Suite 450, Berkeley, CA 94704, United States.
| | - Mary Patricia Pauly
- Department of Gastroenterology and Hepatology, Kaiser Permanente North Valley Medical Center, 2025 Morse Avenue, Sacramento, CA 95825
| | - Charles Denton Moore
- Kaiser Permanente Health Plan, Chemical Dependency Recovery Program, 2829 Watt Avenue, Suite 150, Sacramento, CA 95821
| | - Constance Chia
- Kaiser Permanente Health Plan, Chemical Dependency Recovery Program, 2829 Watt Avenue, Suite 150, Sacramento, CA 95821
| | - Jennifer Mary Dorrell
- Kaiser Permanente Health Plan, Chemical Dependency Recovery Program, 2829 Watt Avenue, Suite 150, Sacramento, CA 95821
| | - Renee Junko Cunanan
- Department of Gastroenterology and Hepatology, Kaiser Permanente North Valley Medical Center, 2025 Morse Avenue, Sacramento, CA 95825
| | - Gayle Witt
- Department of Gastroenterology and Hepatology, Kaiser Permanente North Valley Medical Center, 2025 Morse Avenue, Sacramento, CA 95825
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5
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Taylor LE, Swan T, Matthews GV. Management of hepatitis C virus/HIV coinfection among people who use drugs in the era of direct-acting antiviral-based therapy. Clin Infect Dis 2013; 57 Suppl 2:S118-24. [PMID: 23884059 PMCID: PMC3722078 DOI: 10.1093/cid/cit326] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Where active antiretroviral therapy (ART) is accessible, human immunodeficiency virus (HIV) is a survivable illness and effective ART can reduce HIV transmission. Chronic hepatitis C virus (HCV) has emerged as a threat to the survival of individuals harboring both HCV and HIV, due to high prevalence and aggressive disease course. The HCV/HIV coinfection epidemic has been driven by people who inject drugs (PWID), although incident HCV is rising among HIV-infected men who have sex with men in the absence of drug injection. Coinfected individuals warrant aggressive treatment of both viruses; although early ART initiation is recommended to reduce the rate of liver disease progression, the most effective way to decrease HCV-related morbidity and mortality in coinfection is to achieve HCV viral eradication. Direct-acting antiviral (DAA) agents will soon revolutionize HCV treatment. Clinical data are needed regarding the efficacy of DAAs in coinfected PWID. Drug-drug interaction studies between ART, DAAs, and opiate substitution therapy must be expedited. Coinfected PWID should have equitable and universal access to HIV/AIDS, HCV, and addiction prevention, care, and treatment. Essential basic steps include improving screening for both infections and engaging coinfected PWID in HIV and HCV care early after diagnoses. Developing strategies to expand access to HCV therapy for coinfected PWID is imperative to stem the HCV epidemic and limit the morbidity and mortality of those at greatest risk for HCV disease progression. The ultimate goal must be the elimination of HCV from all coinfected PWID.
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Affiliation(s)
- Lynn E Taylor
- Department of Medicine, Brown University, Providence, Rhode Island, USA.
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6
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North CS, Hong BA, Adewuyi SA, Pollio DE, Jain MK, Devereaux R, Quartey NA, Ashitey S, Lee WM, Lisker-Melman M. Hepatitis C treatment and SVR: the gap between clinical trials and real-world treatment aspirations. Gen Hosp Psychiatry 2013; 35:122-8. [PMID: 23219917 DOI: 10.1016/j.genhosppsych.2012.11.002] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Revised: 11/05/2012] [Accepted: 11/06/2012] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Despite the remarkable improvements in pharmacologic treatment efficacy for hepatitis C (HCV) reported in published clinical trials, published research suggests that, in "real-world" patient care, these medical outcomes may be difficult to achieve. This review was undertaken to summarize recent experience in the treatment of HCV in clinical settings, examining the course of patients through the stages of treatment and barriers to treatment encountered. METHOD A comprehensive and representative review of the relevant literature was undertaken to examine HCV treatment experience outside of clinical trials in the last decade. This review found 25 unique studies with data on course of treatment and/or barriers to treatment in samples of patients with HCV not preselected for inclusion in clinical trials. RESULTS Results were examined separately for samples selected for HCV infection versus HCV/HIV coinfection. Only 19% of HCV-selected and 16% of HCV/HIV-coinfection selected patients were considered treatment eligible and advanced to treatment; even fewer completed treatment (13% and 11%, respectively) or achieved sustained virologic response (3% and 6%, respectively). Psychiatric and medical ineligibilities were the primary treatment barriers. CONCLUSION Only by systematically observing and addressing potentially solvable medical and psychosocial barriers to treatment will more patients be enrolled in and complete HCV therapy.
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Affiliation(s)
- Carol S North
- The VA North Texas Health Care System, Dallas, TX, USA.
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Prevalence and Characteristics of Herpes Simplex Virus Type-2 Coinfection in Veterans With Hepatitis C. Am J Med Sci 2012; 344:436-40. [DOI: 10.1097/maj.0b013e31824585bd] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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8
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Sylvestre DL. Hepatitis C viral infection in drug users. Clin Liver Dis (Hoboken) 2012; 1:81-83. [PMID: 31186855 PMCID: PMC6499272 DOI: 10.1002/cld.72] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Revised: 06/20/2012] [Indexed: 02/04/2023] Open
Affiliation(s)
- Diana L. Sylvestre
- Department of Medicine, University of California San Francisco, San Francisco, CA
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9
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Wagner G, Osilla KC, Garnett J, Ghosh-Dastidar B, Bhatti L, Witt M, Goetz MB. Provider and patient correlates of provider decisions to recommend HCV treatment to HIV co-infected patients. ACTA ACUST UNITED AC 2012; 11:245-51. [PMID: 22564797 DOI: 10.1177/1545109712444163] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Despite low uptake of hepatitis C virus (HCV) treatment among HIV co-infected patients, few studies have examined the factors that contribute to provider decisions to recommend treatment. Surveys of 173 co-infected patients and their primary care providers, as well as patient chart data, were collected at 3 HIV clinics in Los Angeles; 73% of the patients had any history of being recommended HCV treatment. Multivariate predictors of being offered treatment included being Caucasian, greater HCV knowledge, receiving depression treatment if depressed, and one's provider having a lower weekly patient load and more years working at the study site. These findings suggest that provider decisions to recommend HCV treatment are influenced by patient factors including race and psychosocial treatment readiness, as well as characteristics of their own practice and treatment philosophy. With changes to HCV treatment soon to emerge, further evaluation of factors influencing treatment decisions is needed to improve HCV treatment uptake.
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10
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Clark BT, Garcia-Tsao G, Fraenkel L. Patterns and predictors of treatment initiation and completion in patients with chronic hepatitis C virus infection. Patient Prefer Adherence 2012; 6:285-95. [PMID: 22536063 PMCID: PMC3333810 DOI: 10.2147/ppa.s30111] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Guidelines for hepatitis C (HCV) strongly recommend antiviral treatment for patients with more severe liver disease given their increased risk of developing cirrhosis and other liver-related complications. Despite the proven benefits of therapy, 70%-88% of patients chronically infected with HCV do not undergo treatment. The goal of this paper is to describe patterns of treatment initiation among patients with both mild and severe disease and to assess the factors that are associated with treatment initiation and completion. METHODS Subjects completed previously validated questionnaires to ascertain sociodemographic characteristics, choice predisposition, and clinical characteristics prior to meeting with the hepatologist to discuss treatment initiation and were followed for 12 months. We examined the association between patient characteristics and treatment patterns controlling for liver disease severity. RESULTS Of the 148 eligible subjects entered into our study, 55 (37%) initiated treatment during the 12-month follow-up period. Of the 86 subjects with severe liver disease, 43 (50%) initiated treatment. Financial barriers and geographic access to care were the most common reasons for treatment deferral. Of the 55 patients initiating treatment, 24 (44%) discontinued treatment, with intolerance of side effects being the most common reason for discontinuation. After adjusting for liver disease severity, patient choice predisposition (prior to discussion with their provider) was strongly associated with initiation of treatment, while sociodemographic characteristics were not. CONCLUSION Treatment initiation did align with current recommendations (patients with severe disease were more likely to initiate treatment), however, rates of treatment initiation and completion were low. Patient choice predisposition is the strongest predictor of treatment initiation, independent of disease severity. Improving individualized treatment outcomes for patients with chronic HCV requires efforts at identifying patients' choice predisposition, and improving access for those wishing to initiate therapy.
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Affiliation(s)
- Brian T Clark
- Veterans Administration, Connecticut Healthcare System, West Haven
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
- Correspondence: Brian T Clark, Yale School of Medicine, Department of Internal Medicine, PO Box 208033, New Haven, CT 06520, USA, Tel +1 203 932 5711 ext 5914, Fax +1 203 937 4392, Email
| | - Guadalupe Garcia-Tsao
- Veterans Administration, Connecticut Healthcare System, West Haven
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Liana Fraenkel
- Veterans Administration, Connecticut Healthcare System, West Haven
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
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11
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Melia MT, Muir AJ, McCone J, Shiffman ML, King JW, Herrine SK, Galler GW, Bloomer JR, Nunes FA, Brown KA, Mullen KD, Ravendhran N, Ghalib RH, Boparai N, Jiang R, Noviello S, Brass CA, Albrecht JK, McHutchison JG, Sulkowski MS. Racial differences in hepatitis C treatment eligibility. Hepatology 2011; 54:70-8. [PMID: 21488082 PMCID: PMC3736356 DOI: 10.1002/hep.24358] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
UNLABELLED Black Americans are disproportionally infected with hepatitis C virus (HCV) and are less likely than whites to respond to treatment with peginterferon (PEG-IFN) plus ribavirin (RBV). The impact of race on HCV treatment eligibility is unknown. We therefore performed a retrospective analysis of a phase 3B multicenter clinical trial conducted at 118 United States community and academic medical centers to evaluate the rates of and reasons for HCV treatment ineligibility according to self-reported race. In all, 4,469 patients were screened, of whom 1,038 (23.2%) were treatment ineligible. Although blacks represented 19% of treated patients, they were more likely not to be treated due to ineligibility and/or failure to complete required evaluations (40.2%) than were nonblack patients (28.5%; P < 0.001). After the exclusion of persons not treated due to undetectable HCV RNA or nongenotype 1 infection, blacks were 65% less likely than nonblacks to be eligible for treatment (28.1% > 17.0%; relative risk, 1.65; 95% confidence interval, 1.46-1.87; P < 0.001). Blacks were more likely to be ineligible due to neutropenia (14% versus 3%, P < 0.001), anemia (7% versus 4%, P = 0.02), elevated glucose (8% versus 3%, P < 0.001), and elevated creatinine (5% versus 1%, P < 0.001). CONCLUSION Largely due to a higher prevalence of neutropenia and uncontrolled medical conditions, blacks were significantly less likely to be eligible for HCV treatment. Increased access to treatment may be facilitated by less conservative neutrophil requirements and more effective care for chronic diseases, namely, diabetes and renal insufficiency.
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Affiliation(s)
- Michael T Melia
- Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
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12
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Physicians' attitudes and practice toward treating injection drug users with hepatitis C: results from a national specialist survey in Canada. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2011; 25:135-9. [PMID: 21499577 DOI: 10.1155/2011/810108] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND In Canada, more than 70% of new cases of hepatitis C virus (HCV) infection per year involve injection drug users (IDUs) and, currently, there is no consensus on how to offer them medical care. OBJECTIVE To examine the characteristics of Canadian specialist physicians and their likelihood to provide treatment to HCV patients who are IDUs. METHODS A nationwide, cross-sectional study was conducted in the specialty areas of hepatology, gastroenterology and infectious diseases to examine HCV services. The questionnaire requested information regarding basic demographics, referral pathways and opinions (yes⁄no), and examined how a physician's treatment regimen is influenced by factors such as treatment eligibility, HCV care management and barriers to providing quality service. RESULTS Despite the fact that the majority of prevalent and incident cases of HCV are associated with injection drug use, very few specialist physicians actually provide the necessary therapy to this population. Only 19 (19.79%) comprehensive service providers were likely to provide treatment to a current IDU who uses a needle exchange on a regular basis. The majority of comprehensive service providers (n=86 [89.58%]) were likely to provide treatment to a former IDU who was stable on substitution therapy. On bivariate analysis, factors associated with the likelihood to provide treatment to current IDUs included physicians' type, ie, infectious disease specialists compared with noninfectious specialists (OR 3.27 [95% CI 1.11 to 9.63]), and the size of the community where they practice (OR 4.16 [95% CI 1.36 to 12.71] [population 500,000 or greater versus less than 500,000]). Results of the multivariate logistic regression analysis were largely consistent with the results observed in the bivariate analyses. After controlling for other confounding variables, only community size was significantly associated with providing treatment to current IDUs (OR 3.89 [95% CI 1.06 to 14.26] [population 500,000 or greater versus less than 500,000]). CONCLUSION The present study highlighted the reluctance of specialists to provide treatment to current IDUs infected with HCV. Providing treatment services for HCV-infected substance abusers is challenging and there are many treatment barriers. However, effective delivery of treatment to this population will help to limit the spread of HCV. The present study clearly identified a need for improved HCV treatment accessibility for IDUs.
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13
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Gidding HF, Law MG, Amin J, Macdonald GA, Sasadeusz JJ, Jones TL, Strasser SI, George J, Dore GJ. Predictors of deferral of treatment for hepatitis C infection in Australian clinics. Med J Aust 2011; 194:398-402. [DOI: 10.5694/j.1326-5377.2011.tb03029.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2010] [Accepted: 03/08/2011] [Indexed: 11/17/2022]
Affiliation(s)
- Heather F Gidding
- National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, NSW
| | - Matthew G Law
- National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, NSW
| | - Janaki Amin
- National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, NSW
| | - Graeme A Macdonald
- University of Queensland Diamantina Institute, Princess Alexandria Hospital, Brisbane, QLD
| | - Joe J Sasadeusz
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, VIC
| | - Tracey L Jones
- Hepatitis Service, John Hunter Hospital, Newcastle, NSW
- School of Nursing and Midwifery, University of Newcastle, Newcastle, NSW
| | - Simone I Strasser
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, University of Sydney, Sydney, NSW
- Central Clinical School (Medicine), University of Sydney, Sydney, NSW
| | - Jacob George
- Storr Liver Unit, Westmead Millennium Institute and Westmead Hospital, University of Sydney, Sydney, NSW
| | - Gregory J Dore
- National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, NSW
- HIV, Immunology, Infectious Diseases Clinical Services Unit, Sydney, NSW
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Gazdag G, Horváth G, Szabó O, Ungvari GS. Difficulties with interferon treatment in former intravenous drug users. Braz J Infect Dis 2011. [DOI: 10.1016/s1413-8670(11)70164-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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15
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The Use of Psychoeducation for a Patient with Hepatitis C and Psychiatric Illness in Preparation for Antiviral Therapy: A Case Report and Discussion. J Clin Psychol Med Settings 2011; 18:99-107. [DOI: 10.1007/s10880-011-9227-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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16
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Hepatitis C testing and treatment among active drug users in Amsterdam: results from the DUTCH-C project. Eur J Gastroenterol Hepatol 2011; 23:23-31. [PMID: 21042221 DOI: 10.1097/meg.0b013e328340c451] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Although hepatitis C virus (HCV) treatment has shown to be effective, uptake of treatment among active drug users is still low. The Drug Users Treatment for Chronic Hepatitis-C project aims to offer active drug users in Amsterdam HCV testing and treatment using a multidisciplinary approach. METHODS The study population comprises drug users participating in the Amsterdam Cohort Studies and drug users referred to the Drug Users Treatment for Chronic Hepatitis-C unit. Drug users were offered HCV testing and, if chronically infected, medical and psychiatric screening and HCV treatment. Various specialists collaborated to provide optimal care. We assessed test-uptake and treatment-uptake and outcomes. RESULTS Four hundred and ninety-seven Amsterdam Cohort Studies drug users were offered HCV testing: 449 out of 497 (90%) accepted. HCV antibodies were found in 267 out of 449 (60%): 183 out of 267 (69%) were HCV-viremic and 49 out of 183 (27%) were HIV-co-infected. Of the 134 HCV-monoinfected patients, 102 (76%) initiated additional medical screening and 44 started treatment by 1 July 2009. Sixty-two drug users referred from methadone clinics were also HCV-monoinfected, of whom 14 started treatment by 1 July 2009. In total 58 persons were treated: 16 (27%) with genotype 1 or 4, 42 (72%) with genotype 2 or 3. Eighty-four percent used methadone, 97% used drugs (heroin, cocaine or amphetamine) at least once in the 6 months before treatment, 19% were active injectors. Sixty-two percent used alcohol, 41% had psychiatric disease other than substance abuse. Of the 57 individuals with sufficient follow-up, 37 (65%) achieved sustained virological response. CONCLUSION In a multidisciplinary setting, HIV-negative drug users with chronic HCV infection can be treated successfully despite active drug or alcohol use and psychiatric diseases. Therefore, access to HCV therapy using an integrated approach should be increased for this population.
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Hepatitis C management: the challenge of dropout associated with male sex and injection drug use. Eur J Gastroenterol Hepatol 2011; 23:32-40. [PMID: 21048503 DOI: 10.1097/meg.0b013e3283414122] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Anecdotal reports of poor patient compliance with hepatitis C disease management exist yet little data are available on the true rates of dropout. AIMS To examine all referrals made to an urban tertiary care liver centre for hepatitis C virus (HCV) management, track subsequent progress and identify dropout trends. METHODS A cross-sectional retrospective review was conducted to examine the HCV referrals received on 2000 through 2007. The demographic, clinical and treatment data were derived from medical charts and the hospital information system. RESULTS A total of 588 individuals were referred for HCV disease management. The repeated referrals yielded 742 cases for analysis. Of the 742 referrals received, 141 (19%) failed to attend their initial appointment, 180 dropped out from early outpatient management, 29 failed to attend liver biopsy and 81 defected from subsequent outpatient follow-up. In total, 451 (61%) dropouts occurred. In those treated, a sustained viral response rate of 74% was observed (18/30 genotype 1; 4/5 genotype 2; 40/49 genotype 3). Statistically significant associations between history of injection drug use and dropout immediately after the referral (P<0.001), dropout from early outpatient management (P<0.001) and dropout over entire span of disease management (P<0.001) were observed. Male sex was also associated with dropout from disease management (P<0.05). CONCLUSIONS An exceptionally high rate of dropout exists within the HCV disease management framework, particularly in the early stages of service delivery. Dropout was associated with sex and positive history of injection drug use. The study findings have led to the development of innovative approaches helping to optimize the disease management in this population. These developments are discussed.
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Grebely J, Petoumenos K, Matthews GV, Haber P, Marks P, Lloyd AR, Kaldor JM, Dore GJ, Hellard M. Factors associated with uptake of treatment for recent hepatitis C virus infection in a predominantly injecting drug user cohort: The ATAHC Study. Drug Alcohol Depend 2010; 107:244-9. [PMID: 19926405 PMCID: PMC2853739 DOI: 10.1016/j.drugalcdep.2009.09.015] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2009] [Revised: 09/18/2009] [Accepted: 09/22/2009] [Indexed: 12/14/2022]
Abstract
Despite that the majority of hepatitis C virus (HCV) infection occurs among injection drug users (IDUs), little is known about HCV treatment uptake in this group, particularly during recent infection. We evaluated uptake of treatment for recent HCV infection, including associated factors, within a population predominantly made up of IDUs. The Australian Trial in Acute Hepatitis C was a study of the natural history and treatment of recent HCV infection. All participants with detectable HCV RNA at screening were offered HCV treatment, assessed for eligibility and those initiating treatment were identified. Logistic regression analyses were used to identify predictors of HCV treatment uptake. Between June 2004 and February 2008, 163 were enrolled, with 146 positive for HCV RNA at enrolment. The mean age was 35 years, 77% (n=113) participants had ever injected illicit drugs and 23% (n=34) reported having ever received methadone or buprenorphine treatment. The uptake of HCV treatment was 76% (111 of 146) among those who were eligible on the basis of positive HCV RNA. Estimated duration of HCV infection (OR=1.03 per week, 95% CI=1.00-1.06, P=0.035) and log(10) HCV RNA (OR=1.92 per log(10) increase, 95% CI=1.36-2.73, P<0.001) were independently associated with treatment uptake whereas injection drug use was not. This study demonstrates that a high uptake of HCV treatment can be achieved among participants with recently acquired HCV infection. Decisions about whether to initiate treatment for recently acquired HCV were mainly driven by clinical factors, rather than factors related to sociodemographics or injecting behaviors.
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Affiliation(s)
- J Grebely
- National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, 376 Victoria Street, Darlinghurst, Sydney, NSW 2010, Australia.
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Zanini B, Lanzini A. Antiviral Treatment for Chronic Hepatitis C in Illicit drug Users: A Systematic Review. Antivir Ther 2009. [DOI: 10.1177/135965350901400410] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
According to recent World Health Organization data, approximately 170–200 million people worldwide are infected with hepatitis C virus (HCV). At present, illicit drug users (IDUs) constitute the largest group of individuals infected with HCV in industrial countries. Between 50% and 90% of IDUs are estimated to be positive for anti-HCV antibodies and most of the new infections occur in IDUs. The aim of our review is to focus on tertiary prevention of HCV infection among IDUs. We review strategies to prevent HCV infection and disease progression, attitude to antiviral treatment, access to specific HCV therapy and data of efficacy and safety of antiviral treatment among IDUs.
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Affiliation(s)
- Barbara Zanini
- Gastroenterology Unit, University and Spedali Civili of Brescia, Brescia, Italy
| | - Alberto Lanzini
- Gastroenterology Unit, University and Spedali Civili of Brescia, Brescia, Italy
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Maru DSR, Bruce RD, Basu S, Altice FL. Clinical outcomes of hepatitis C treatment in a prison setting: feasibility and effectiveness for challenging treatment populations. Clin Infect Dis 2008; 47:952-61. [PMID: 18715156 PMCID: PMC4847716 DOI: 10.1086/591707] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND More than one-third of people in the United States with hepatic C virus (HCV) infection pass through the correctional system annually. Data are lacking on outcomes of treatment with pegylated interferon plus ribavirin (PEG-RBV) in correctional settings. METHODS During 2002-2006, we analyzed patients in the Connecticut Department of Correction who received PEG-RBV. We assessed the rates of sustained virological response, hospitalization, and use of medications to treat psychiatric disorders and anemia. RESULTS Of 138 treatment-naive patients referred for treatment, 68 (49%) were approved. Overall, sustained virological response occurred in 47.1% of patients (for HCV genotype 1, 43.1%; for HCV genotypes 2 and 3, 58.8%). Only 9 patients (13%) discontinued treatment because of adverse effects. Multiple regression analysis revealed that not achieving a sustained virological response was correlated with HCV genotype 1 infection plus cirrhosis (adjusted odds ratio, 12.9; 95% confidence interval, 1.1-148) and baseline major depression (adjusted odds ratio, 3.4; 95% confidence interval, 1.01-11.6), but not with HIV infection, a baseline HCV RNA level >or=400,000 IU/mL, or black race. Compared with baseline, the rate of prescription of a new mood stabilizer (2.2 vs. 0.8 prescriptions per person-year) or an opioid (1.8 vs. 0.5 prescriptions per person-year) was higher during treatment, whereas there was no change in the rate of prescription of benzodiazepines and antipsychotic medications. CONCLUSIONS These results support the feasibility and clinical effectiveness of PEG-RBV for the treatment of chronic HCV infection in correctional facilities.
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Affiliation(s)
- Duncan Smith-Rohrberg Maru
- Yale AIDS Program, Yale University School of Medicine, New Haven, Connecticut
- Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut
| | | | - Sanjay Basu
- Yale AIDS Program, Yale University School of Medicine, New Haven, Connecticut
- Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut
| | - Frederick L. Altice
- Yale AIDS Program, Yale University School of Medicine, New Haven, Connecticut
- Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut
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