The rate of treatment of chronic hepatitis C in patients co-infected with HIV in an urban medical centre

Mental Disorders and Interferon Nontreatment in Hepatitis C Virus Infection-a Population Based Cohort Study

OBJECTIVE

This study investigates the association between mental disorders and interferon nontreatment in patients with chronic hepatitis C virus (HCV) infection in a large national sample.

METHODS

Using the National Health Insurance Research Database of Taiwan, we conducted a nationwide population-based study. Each case was matched to five controls by age, sex, urbanization, and income. Conditional logistic regression was used to assess odds of HCV nontreatment in different mental disorders.

RESULTS

From 1999 to 2013, we identified 92,970 subjects with HCV infection and 15,495 HCV cases (16.7%) had received IFN therapy. Other than chronic obstructive pulmonary disease, the medical diseases and mental disorders were significantly different between IFN and non-IFN treated HCV patients. After adjusting for medical diseases, depressive disorder and anxiety disorder was positively associated with receiving IFN therapy. Patients with schizophrenia, bipolar disorders and alcohol use disorders were significantly less likely to receive interferon. Antidepressant exposure (cumulative daily exposure or cumulative daily dose) was associated with lower odds of IFN treatment.

CONCLUSION

Our nationwide cohort study demonstrated that INF nontreatment rate was lower in certain mental disorders. Antidepressant exposure might lower the chance of receiving IFN treatment. Our results may help to identify and to overcome the obstacles for HCV treatment and further apply to DAAs regimen.

Trends in hepatitis C treatment initiation among HIV/hepatitis C virus-coinfected men engaged in primary care in a multisite community health centre in Maryland: a retrospective cohort study

OBJECTIVES

Little is known about the cascade of hepatitis C care among HIV/hepatitis C virus (HCV)-coinfected patients in community-based clinics. Thus, we analysed our data from the interferon era to understand the barriers to HCV treatment, which may help improve getting patients into treatment in the direct-acting antivirals era.

DESIGN

Retrospective cohort study.

SETTING

Four HIV clinics of a multisite community health centre in the USA.

PARTICIPANTS

1935 HIV-infected men with >1 medical visit to the clinic between 2011 and 2013. Of them, 371 had chronic HCV and were included in the analysis for HCV care continuum during 2003-2014.

OUTCOME MEASURES

HCV treatment initiation was designated as the primary outcome for analysis. Multivariate logistic regression was performed to identify factors associated with HCV treatment initiation.

RESULTS

Among the 371 coinfected men, 57 (15%) initiated HCV treatment. Entering care before 2008 (adjusted OR [aOR, 3.89; 95% CI, 1.95 to 7.78), higher educational attainment (aOR, 3.20; 95% CI, 1.59 to 6.44), HCV genotype 1 versus non-1 (aOR, 0.21; 95% CI, 0.07 to 0.65) and HIV suppression (aOR, 2.13; 95% CI, 1.12 to 4.06) independently predicted treatment initiation. Stratification by entering care before or after 2008 demonstrated that higher educational attainment was the only factor independently associated with treatment uptake in both periods (aOR, 2.79; 95% CI, 1.13 to 6.88 and aOR, 4.10; 95% CI, 1.34 to 12.50, pre- and post-2008, respectively). Additional associated factors in those entering before 2008 included HCV genotype 1 versus non-1 (aOR, 0.09; 95% CI, 0.01 to 0.54) and HIV suppression (aOR, 2.35; 95% CI, 1.04 to 5.33).

CONCLUSIONS

Some traditional barriers predicted HCV treatment initiation in those in care before 2008; however, the patients' level of educational attainment remained an important factor even towards the end of the interferon era. Further studies will need to determine whether educational attainment persists as an important determinant for initiating direct-acting antiviral therapies.

Integrating comprehensive hepatitis C virus care within a residential substance use disorder treatment program

BACKGROUND AND AIMS

Although central to the hepatitis C virus (HCV) epidemic, many patients with both substance use disorders (SUD) and HCV have difficultly engaging in treatment for either condition. To facilitate HCV care in Veterans with active SUD, a comprehensive HCV screening, education, referral, and treatment program was integrated into a VA residential SUD treatment program.

METHODS

Evaluation of HCV screening, education, referral, and treatment initiative among admissions to a residential SUD treatment program from December 2014 to April 2018.

RESULTS

To date, 97.49% (582/597) of admissions to the program have been screened for HCV infection, with 12.71% (74/582) of the cases confirmed HCV-positive, and 100% (74/74) of the positive cases being connected or re-connected to the infectious disease clinic for further evaluation and, if appropriate, to begin HCV pharmacotherapy. Importantly, 18.92% (14/74) of the HCV-positive cases were newly diagnosed and would have likely gone undetected without this program. Of the HCV-positive cases, 78.38% (58/74) have received pharmacotherapy, with a sustained virologic response rate of 82.76% (48/58).

CONCLUSIONS

Integrating comprehensive HCV care within a residential SUD treatment program using a collaborative care model can substantially increase the detection of previously undiagnosed infections, facilitate linkage to care, and promote HCV treatment uptake among HCV-infected Veterans with SUD.

Direct acting antiviral treatment of chronic hepatitis C in Denmark: factors associated with and barriers to treatment initiation

OBJECTIVES

We describe factors associated with and barriers to initiation of Direct Acting Antiviral (DAA) treatment in patients with chronic hepatitis C, who fulfill national fibrosis treatment guidelines in Denmark.

MATERIALS AND METHODS

In this nationwide cohort study, we included patients with chronic hepatitis C from The Danish Database for Hepatitis B and C (DANHEP) who fulfilled fibrosis treatment criteria. Factors associated with treatment initiation and treatment failure were determined by logistic regression analyses. Medical records were reviewed from patients who fulfilled fibrosis treatment criteria, but did not initiate DAA treatment to determine the cause.

RESULTS

In 344 (49%) of 700 patients, who fulfilled treatment criteria, factors associated with DAA treatment initiation were transmission by other routes than injecting drug use odds ratio (OR) 2.13 (CI: 1.38-3.28), previous treatment failure OR 2.58 (CI: 1.84-3.61) and ALT above upper limit of normal OR 1.60 (CI: 1.18-2.17). The most frequent reasons for not starting treatment among 356 (51%) patients were non-adherence to medical appointments (n = 107/30%) and ongoing substance use (n = 61/17%). Treatment failure with viral relapse occurred in 19 (5.5%) patients, who were more likely to have failed previous treatment OR 4.53 (CI: 1.59-12.91).

CONCLUSIONS

In this nationwide cohort study, we found non-adherence to medical appointments and active substance use to be major obstacles for DAA treatment initiation. Our findings highlight the need for interventions that can overcome these barriers and increase the number of patients who can initiate and benefit from curative DAA treatment.

Hepatitis C Virus Elimination in the Human Immunodeficiency Virus-Coinfected Population: Leveraging the Existing Human Immunodeficiency Virus Infrastructure

The objective of this review is to consider how existing human immunodeficiency virus (HIV) infrastructure may be leveraged to inform and improve hepatitis C virus (HCV) treatment efforts in the HIV-HCV coinfected population. Current gaps in HCV care relevant to the care continuum are reviewed. Successes in HIV treatment are then applied to the HCV treatment model for coinfected patients. Finally, the authors give examples of HCV treatment strategies for coinfected patients in both domestic and international settings.

Barriers to treatment of failed or interferon ineligible patients in the era of DAA: single center study

BACKGROUND/AIMS

Interferon-based treatment is not appropriate for a large number of patients with chronic hepatitis C for various medical and social reasons. Newly developed directly acting antivirals (DAAs) have been used to treat chronic hepatitis C without severe adverse effects and have achieved a sustained viral response (SVR) rate of 80-90% with short treatment duration. We were interested to determine whether all patients who failed to respond to or were ineligible for interferon-based therapy could be treated with DAAs.

METHODS

Medical records of patients with positive serum anti-hepatitis C virus (HCV) or HCV RNA between January 2009 and December 2013 were reviewed. Demographic, clinical, and treatment data were collected for analysis.

RESULTS

A total of 876 patients were positive for both anti-HCV and HCV RNA. Of these, 244 patients were eligible for interferon, although this was associated with relapse in 39 (16%) of patients. In total, 130 patients stopped interferon therapy (67% adverse effects, 28% non-adherent, 4% malignancy, 1% alcohol abuse) and 502 patients were ineligible (66% medical contraindications, 25% non-adherent, 5% socioeconomic problems). Among 671 patients who were ineligible for or failed to respond to interferon therapy, more than 186 (27.7%) could not be treated with DAA due to financial, social, or cancer-related conditions.

CONCLUSIONS

Newly developed DAAs are a promising treatment for patients with chronic hepatitis C who are ineligible for or failed to respond to interferon-based therapy. Nevertheless, not all chronic hepatitis C patients can be treated with DAAs due to various reasons.

Association of opioid agonist therapy with the initiation of antiretroviral therapy - a systematic review

OBJECTIVES

People who inject drugs are at high risk of HIV infection but often face barriers in accessing medical care including access to antiretroviral therapy (ART). Evidence is available about the effectiveness of opioid agonist therapy on drug dependency and risk behaviors. However, it remains scattered regarding access to ART among HIV-positive people who inject drugs. We conducted a systematic review to examine the association of opioid agonist therapy with ART initiation among HIV-positive people who inject drugs.

METHODS

We searched the literature for evidence from seven databases. We conducted a narrative synthesis and meta-analysis to examine the association of opioid agonist therapy with ART initiation.

RESULTS

Five out of 2,901 identified studies met the inclusion criteria. Three out of five studies reported that, HIV-positive people receiving opioid agonist therapy initiated ART more than those not receiving opioid agonist therapy. In meta-analysis, opioid agonist therapy was associated with ART initiation among HIV positive people who inject drugs (pooled odds ratio: 1.68; 95% confidence interval: 1.03-2.73).

CONCLUSIONS

Opioid agonist therapy is positively associated with ART initiation among HIV-positive people who inject drugs. It is important to scale up opioid agonist therapy among people who inject drugs to improve their ART initiation.

Non-initiation of hepatitis C virus antiviral therapy in patients with human immunodeficiency virus/hepatitis C virus co-infection

AIM

To assess whether reasons for hepatitis C virus (HCV) therapy non-initiation differentially affect racial and ethnic minorities with human immunodeficiency virus (HIV)/HCV co-infection.

METHODS

Analysis included co-infected HCV treatment-naïve patients in the University of North Carolina CFAR HIV Clinical Cohort (January 1, 2004 and December 31, 2011). Medical records were abstracted to document non-modifiable medical (e.g., hepatic decompensation, advanced immunosuppression), potentially modifiable medical (e.g., substance abuse, severe depression, psychiatric illness), and non-medical (e.g., personal, social, and economic factors) reasons for non-initiation. Statistical differences in the prevalence of reasons for non-treatment between racial/ethnic groups were assessed using the two-tailed Fisher's exact test. Three separate regression models were fit for each reason category. Odds ratios and their 95%CIs (Wald's) were computed.

RESULTS

One hundred and seventy-one patients with HIV/HCV co-infection within the cohort met study inclusion. The study sample was racially and ethnically diverse; most patients were African-American (74%), followed by Caucasian (19%), and Hispanic/other (7%). The median age was 46 years (interquartile range = 39-50) and most patients were male (74%). Among the 171 patients, reasons for non-treatment were common among all patients, regardless of race/ethnicity (50% with ≥ 1 non-modifiable medical reason, 66% with ≥ 1 potentially modifiable medical reason, and 66% with ≥ 1 non-medical reason). There were no significant differences by race/ethnicity. Compared to Caucasians, African-Americans did not have increased odds of non-modifiable [adjusted odds ratio (aOR) = 1.47, 95%CI: 0.57-3.80], potentially modifiable (aOR = 0.72, 95%CI: 0.25-2.09) or non-medical (aOR = 0.90, 95%CI: 0.32-2.52) reasons for non-initiation.

CONCLUSION

Race/ethnicity alone is not predictive of reasons for HCV therapy non-initiation. Targeted interventions are needed to improve access to therapy for all co-infected patients, including minorities.

Characteristics and Prospects for Hepatitis C Therapy of an HIV-HCV Coinfected Population Followed at a Reference HIV Center

PURPOSE

A cross-sectional study was performed during 2004 at a large HIV clinic in Spain to identify HIV-HCV coinfected individuals who might be candidates for HCV therapy.

METHOD

Plasma HCV RNA levels were measured in 405 anti-HCV antibody positive patients. Spontaneous HCV clearance had occurred in 11.4%. Overall, 165 (40.1%) of HCV-HIV coinfected patients had already been exposed to interferon (IFN)-based therapies. Excluding those currently on treatment, the majority of them had either failed (64/142; 45.1%) or not completed therapy (25/142; 17.6%). Other 103 (25.4%) chronic HCV carriers refused treatment or were not considered as appropriate candidates, most often due to low CD4 counts or severe neuropsychiatric conditions. Treatment was deemed feasible and planned in the near future in 91 (22.5%) patients. Unfavorable HCV genotypes (1 and 4) were significantly more frequent in this group of individuals ready for HCV treatment compared to those who had cleared HCV in the past following IFN-based therapies.

RESULTS

Spontaneous clearance of the HCV infection was low in HIV-coinfected patients. One third of our HIV-HCV coinfected population had already been exposed to HCV therapy, but only a minority had achieved sustained HCV clearance. Half of patients with active HCV replication never exposed to IFN were not considered as appropriate candidates for HCV therapy.

CONCLUSION

More flexible criteria would considerably increase the number of patients to be treated with IFN-based therapy. The majority of patients ready to initiate HCV therapy have a poor therapeutic profile.

Barriers to hepatitis C antiviral therapy in HIV/HCV co-infected patients in the United States: a review

This review synthesized the literature for barriers to HCV antiviral treatment in persons with HIV/HCV co-infection. Searches of PubMed, Embase, CINAHL, and Web of Science were conducted to identify relevant articles. Articles were excluded based on the following criteria: study conducted outside of the United States, not original research, pediatric study population, experimental study design, non-HIV or non-HCV study population, and article published in a language other than English. Sixteen studies met criteria and varied widely in terms of study setting and design. Hepatic decompensation was the most commonly documented absolute/nonmodifiable medical barrier. Substance use was widely reported as a relative/modifiable medical barrier. Patient-level barriers included nonadherence to medical care, refusal of therapy, and social circumstances. Provider-level barriers included provider inexperience with antiviral treatment and/or reluctance of providers to refer patients for treatment. There are many ongoing challenges that are unique to managing this patient population effectively. Documenting and evaluating these obstacles are critical steps to managing and caring for these individuals in the future. In order to improve uptake of HCV therapy in persons with HIV/HCV co-infection, it is essential that barriers, both new and ongoing, are addressed, otherwise, treatment is of little benefit.

Hepatitis C treatment eligibility among HIV-hepatitis C virus coinfected patients in Oregon: a population-based sample

Approximately 287,000 individuals in the USA are coinfected with HIV and hepatitis C. Recently, new hepatitis C regimens have become available, increasing rates of sustained virologic response in the monoinfected, with studies evaluating their success in the coinfected under way. Previous investigators estimated eligibility for hepatitis C therapy among the coinfected patients, but all had significant methodological limitations. Our study is the first to use a multi-year, statewide, population-based sample to estimate treatment eligibility, and the first to estimate eligibility in the setting of an interferon-free regimen. In a population-based sample of 161 patients infected with HIV and hepatitis C living in Oregon during 2007-2010, 21% were eligible for hepatitis C therapy. Despite the anticipation surrounding an interferon-sparing regimen, eligibility assuming an interferon-free regimen increased only to 26%, largely due to multiple simultaneous contraindications. Obesity was described for the first time as being associated with decreased eligibility (OR: 0.11). Active alcohol abuse was the most common contraindication (24%); uncontrolled mental health (22%), recent injection drug use (21%), poor antiretroviral adherence (22%), and infection (21%) were also common excluding conditions. When active drug or alcohol abuse was excluded as contraindications to therapy, the eligibility rate was 34%, a 62% increase. Assuming an interferon-free regimen and the exclusion of active drug or alcohol abuse as contraindications to therapy, the eligibility rate increased to 42%. Despite the availability of direct-acting anti-viral regimens, eligibility rates in HIV-hepatitis C virus (HCV) coinfection are modest. Many factors precluding hepatitis C therapy are reversible, and targeted interventions could result in increased eligibility.

The new paradigm of hepatitis C therapy: integration of oral therapies into best practices

Emerging data indicate that all-oral antiviral treatments for chronic hepatitis C virus (HCV) will become a reality in the near future. In replacing interferon-based therapies, all-oral regimens are expected to be more tolerable, more effective, shorter in duration and simpler to administer. Coinciding with new treatment options are novel methodologies for disease screening and staging, which create the possibility of more timely care and treatment. Assessments of histologic damage typically are performed using liver biopsy, yet noninvasive assessments of histologic damage have become the norm in some European countries and are becoming more widespread in the United States. Also in place are new Centers for Disease Control and Prevention (CDC) initiatives to simplify testing, improve provider and patient awareness and expand recommendations for HCV screening beyond risk-based strategies. Issued in 2012, the CDC recommendations aim to increase HCV testing among those with the greatest HCV burden in the United States by recommending one-time testing for all persons born during 1945-1965. In 2013, the United States Preventive Services Task Force adopted similar recommendations for risk-based and birth-cohort-based testing. Taken together, the developments in screening, diagnosis and treatment will likely increase demand for therapy and stimulate a shift in delivery of care related to chronic HCV, with increased involvement of primary care and infectious disease specialists. Yet even in this new era of therapy, barriers to curing patients of HCV will exist. Overcoming such barriers will require novel, integrative strategies and investment of resources at local, regional and national levels.

Influence of healthcare-associated factors on the efficacy of hepatitis C therapy

Hepatitis C infection is a complex entity associated with sizable morbidity and mortality, with great social and economic consequences that put a heavy potential burden on healthcare systems allover the world. Despite the great improvement of hepatitis C virus (HCV) therapy and its high clinical efficacy, major influencing factors are still hindering and diminishing the effectiveness of hepatitis C treatment. This minimizes the quality of life of the infected patients and reduces the outcome of such therapy, particularly in certain groups of patients such as intravenous drug users and patients coinfected with human immune deficiency virus (HIV). A variety of factors were evolved either at patient individual level, healthcare providers, community surrounding levels, or healthcare setting systems. Analyzing and understanding these factors could help to improve HCV interventions and, thus, reduce the burden of such infection. The objectives of this paper were to highlight such factors and outline the holistic approaches that could be used to overcome such factors.

Engaging HIV-HCV co-infected patients in HCV treatment: the roles played by the prescribing physician and patients' beliefs (ANRS CO13 HEPAVIH cohort, France)

Background

Treatment for the hepatitis C virus (HCV) may be delayed significantly in HIV/HCV co-infected patients. Our study aims at identifying the correlates of access to HCV treatment in this population.

Methods

We used 3-year follow-up data from the HEPAVIH ANRS-CO13 nationwide French cohort which enrolled patients living with HIV and HCV. We included pegylated interferon and ribavirin-naive patients (N = 600) at enrolment. Clinical/biological data were retrieved from medical records. Self-administered questionnaires were used for both physicians and their patients to collect data about experience and behaviors, respectively.

Results

Median [IQR] follow-up was 12[12-24] months and 124 patients (20.7%) had started HCV treatment. After multiple adjustment including patients' negative beliefs about HCV treatment, those followed up by a general practitioner working in a hospital setting were more likely to receive HCV treatment (OR[95%CI]: 1.71 [1.06-2.75]). Patients followed by general practitioners also reported significantly higher levels of alcohol use, severe depressive symptoms and poor social conditions than those followed up by other physicians.

Conclusions

Hospital-general practitioner networks can play a crucial role in engaging patients who are the most vulnerable and in reducing existing inequities in access to HCV care. Further operational research is needed to assess to what extent these models can be implemented in other settings and for patients who bear the burden of multiple co-morbidities.

Factors associated with specialist assessment and treatment for hepatitis C virus infection in New South Wales, Australia

Assessment and treatment for hepatitis C virus (HCV) in the community remains low. We evaluated factors associated with HCV specialist assessment and treatment in a cross-sectional study to evaluate treatment considerations in a sample of 634 participants with self-reported HCV infection in New South Wales, Australia. Participants having received HCV specialist assessment (n = 294, 46%) were more likely to be have been older (vs <35 years; 35-44 OR 1.64, P = 0.117; 45-54 OR 2.00, P = 0.024; ≥55 OR 5.43, P = 0.002), have greater social support (vs low; medium OR 3.07, P = 0.004; high OR 4.31, P < 0.001), HCV-related/attributed symptoms (vs none; 1-10 OR 3.89, P = 0.032; 10-21 OR 5.01, P = 0.010), a diagnosis of cirrhosis (OR 2.40, P = 0.030), have asked for treatment information (OR 1.91, P = 0.020), have greater HCV knowledge (OR 2.49, P = 0.001), have been told by a doctor to go onto treatment (OR 3.00, P < 0.001), and less likely to be receiving opiate substitution therapy (OR 0.10, P < 0.001) and never to have seen a general practitioner (OR 0.24, P < 0.001). Participants having received HCV treatment (n = 154, 24%) were more likely to have greater fibrosis (vs no biopsy; none/minimal OR 3.45, P = 0.001; moderate OR 11.47, P < 0.001; severe, OR 19.51, P < 0.001), greater HCV knowledge (OR 2.57; P = 0.004), know someone who has died from HCV (OR 2.57, P = 0.004), been told by a doctor to go onto treatment (OR 3.49, P < 0.001), were less likely to have been female (OR 0.39, P = 0.002), have recently injected (OR 0.42, P = 0.002) and be receiving opiate substitution therapy (OR 0.22, P < 0.001). These data identify modifiable patient-, provider- and systems-level barriers associated with HCV assessment and treatment in the community that could be addressed by targeted interventions.

Gender differences in clinical, immunological, and virological outcomes in highly active antiretroviral-treated HIV-HCV coinfected patients

OBJECTIVE

The influence of biological sex on human immunodeficiency virus (HIV) antiretroviral treatment outcome is not well described in HIV-hepatitis C (HCV) coinfection.

METHODS

We assessed patients' clinical outcomes of HIV-HCV coinfected patients initiating antiretroviral therapy attending the Ottawa Hospital Immunodeficiency Clinic from January 1996 to June 2008.

RESULTS

We assessed 144 males and 39 females. Although similar in most baseline characteristics, the CD4 count was higher in females (375 vs 290 cells/muL). Fewer females initiated ritonavir-boosted regimens. The median duration on therapy before interruption or change was longer in males (10 versus 4 months) (odds ratio [OR] 1.40 95% confidence interval: 0.95-2.04; P = 0.09). HIV RNA suppression was frequent (74%) and mean CD4 count achieved robust (over 400 cells/muL) at 6 months, irrespective of sex. The primary reasons for therapy interruption in females and males included: gastrointestinal intolerance (25% vs 19%; P = 0.42); poor adherence (22% vs 15%; P = 0.31); neuropsychiatric symptoms (19% vs 5%; P = 0.003); and lost to follow-up (3% vs 13%; P = 0.08). Seven males (5%) and no females discontinued therapy for liver-specific complications. Death rate was higher in females (23% vs 7%; P = 0.003).

CONCLUSION

There are subtle differences in the characteristics of female and male HIV-HCV coinfected patients that influence HIV treatment decisions. The reasons for treatment interruption and change differ by biological sex. This knowledge should be considered when starting HIV therapy and in efforts to improve treatment outcomes.

Equitable access to HCV care in HIV-HCV co-infection can be achieved despite barriers to health care provision

Language barrier, race, immigration status, mental health illness, substance abuse and socioeconomic status are often not considered when evaluating hepatitis C virus (HCV) sustained virological response (SVR) in human immunodeficiency virus (HIV) infection. The influence of these factors on HCV work-up, treatment initiation and SVR were assessed in an HIV–HCV coinfected population and compared to patients with HCV mono-infection. The setting was a publicly funded, urban-based, multidisciplinary viral hepatitis clinic. A clinical database was utilized to identify HIV and HCV consults between June 2000 and June 2007. Measures of access to HCV care (ie, liver biopsy and HCV antiviral initiation) and SVR as a function of the above variables were evaluated and compared between patients with HIV–HCV and HCV. HIV–HCV co-infected (n = 106) and HCV mono-infected (n = 802) patients were evaluated. HIV–HCV patients were more often white (94% versus 84%) and male (87% versus 69%). Bridging fibrosis or cirrhosis on biopsy was more frequent in HIV–HCV (37% versus 22%; P = 0.03). HIV infection itself did not influence access to biopsy (50% versus 52%) or treatment initiation (39% versus 38%). Race, language barrier, immigration status, injection drug history and socioeconomic status did not influence access to biopsy or treatment. SVR was 54% in HCV and 30% in HIV–HCV (P = 0.003). Genotype and HIV were the only evaluated variables to predict SVR. Within the context of a socialized, multidisciplinary clinic, HIV–HCV co-infected patients received similar access to HCV work-up and care as HCV mono-infected patients. SVR is diminished in HIV–HCV co-infection independent of language barrier, race, immigration status, or socioeconomic status.

Factors associated with uptake of treatment for recent hepatitis C virus infection in a predominantly injecting drug user cohort: The ATAHC Study

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.

Optimizing assessment and treatment for hepatitis C virus infection in illicit drug users: a novel model incorporating multidisciplinary care and peer support

OBJECTIVES

We evaluated assessment and treatment for hepatitis C virus (HCV) among illicit drug users accepting referral to a weekly HCV peer-support group at a multidisciplinary community health centre.

METHODS

From March 2005 to 2008, HCV-infected individuals were referred to a weekly peer-support group and assessed for HCV infection. A retrospective chart review of outcomes 3 years after the initiation of the group was conducted (including HCV assessment and treatment).

RESULTS

Two hundred and four HCV antibody-positive illicit drug users accepted referral to a weekly HCV peer-support group. Assessment for HCV occurred in 53% of patients(n= 109), with 13% (n= 14) having initiated or completed treatment for HCV infection before attending the support group, evaluation ongoing in 10% (n= 11) and treatment deferred/not indicated in 25% (n= 27). The major reasons for HCV treatment deferral included early disease (30%),drug dependence (37%), other medical (11%) or psychiatric comorbidities (4%). Sixty-eight percent of those deferred for reasons other than early liver disease showed multiple reasons for treatment deferral. The first 4 weeks of support group attendance predicted successful HCV assessment (odds ratio: 6.03, 95% confidence interval:3.27-11.12, P < 0.001). Overall, 28% (n= 57) received treatment. Among individuals having completed pegylated-interferon and ribavirin therapy with appropriate follow-up (n =19), the rate of sustained virologic response was 63% (12/19), despite illicit drug use in 53%.

CONCLUSION

A high proportion of illicit drug users accepting referral to a weekly HCV peer-support group at a multidisciplinary health centre were assessed and treated for HCV infection. Peer support coupled with multidisciplinary care is an effective strategy for engaging illicit drug users in HCV care.

HCV treatment decision-making substance use experiences and hepatitis C treatment decision-making among HIV/HCV Coinfected Adults

Hepatitis C virus (HCV) infection is a major source of morbidity and mortality among substance users and persons living with human immunodeficiency virus (HIV) infection. Treatment for chronic HCV infection involves complex decision-making. These decisions are even more complicated in persons with HIV and substance use related problems. A secondary analyses of qualitative data collected in the United States (2004-2005) with 31 HIV/HCV coinfected adults (48% women; mean age 44.7 years) revealed three themes related to substance use (substance use evolution, revolving door: going back out and reconstructing life) and two HCV treatment decision-making themes (HCV infection treatment issues: not a priority, fear, misinformation and get clean and try it). Study limitations and implications are discussed.

Limited uptake of hepatitis C treatment among injection drug users

We characterized hepatitis C virus (HCV) treatment knowledge, experience and barriers in a cohort of community-based injection drug users (IDUs) in Baltimore, MD. In 2005, a questionnaire on HCV treatment knowledge, experience and barriers was administered to HCV-infected IDUs. Self-reported treatment was confirmed from medical records. Of 597 participants, 71% were male, 95% African-American, 31% HIV co-infected and 94% were infected with HCV genotype 1; 70% were aware that treatment was available, but only 22% understood that HCV could be cured. Of 418 who had heard of treatment, 86 (21%) reported an evaluation by a provider that included a discussion of treatment of whom 30 refused treatment, 20 deferred and 36 reported initiating treatment (6% overall). The most common reasons for refusal were related to treatment-related perceptions and a low perceived need of treatment. Compared to those who had discussed treatment with their provider, those who had not were more likely to be injecting drugs, less likely to have health insurance, and less knowledgeable about treatment. Low HCV treatment effectiveness was observed in this IDU population. Comprehensive integrated care strategies that incorporate education, case-management and peer support are needed to improve care and treatment of HCV-infected IDUs.

Quality of life, symptomatology and healthcare utilization in HIV/HCV co-infected drug users in Miami

HIV/HCV co-infection is becoming one of the main causes of death in HIV+ persons. We determined quality of life, clinical symptoms and health care utilization in HIV mono-infected and HIV/HCV co-infected chronic drug users. After consenting 218 HIV+ drug users, a physical examination and questionnaires on demographics, quality of life, drugs of abuse, and healthcare utilization were completed. Blood was drawn for HCV status, CD4 cell count, HIV viral load, CBC and chemistry. HIV/HCV co-infected participants had significantly higher risk of having poorer perceived outlook and health, presented significantly more frequent depression and physical symptoms, and used significantly more healthcare services than those infected with HIV only, after adjusting for age, gender, ethnicity, CD4 cell count, and viral load. Diminished quality of life in the HIV/HCV co-infected group was explained by increased frequency of depression, physical symptoms, healthcare utilization, and poor access to HCV treatment in this population.

Current approaches to HCV infection in current and former injection drug users

Injection drug use (IDU) accounts for 75% of incident cases of hepatitis C virus (HCV) infection in the developed world. Of those infected with HCV, up to 80% will go on to develop chronic disease. Intervention with effective treatment in eligible subjects will limit the impact of the long-term consequences of infection. The use of combination therapy with pegylated interferon and ribavirin may lead to a cure in up to 80% of treated individuals who carry genotype 2 or 3 isolates. Such individuals account for up to 45% of certain cohorts, such as in the inner city of Vancouver. Historically, many IDUs have not received treatment for HCV infection even if it were medically indicated. Recent data (including our own) suggest that, in the right context, response rates similar to those reported in clinical trials of HCV therapy can be achieved in IDUs, even with ongoing drug use. This is all the more important given that prior infection may protect against re-infection even in the presence of ongoing risk behaviors for HCV transmission. The keys to a successful program appear to be appropriate patient selection as well as the delivery of care within an appropriate setting, preferably with a multidisciplinary team in a way that addresses the issue of addiction and other conditions simultaneously. The development of such programs may be quite complex, but the ultimate benefit (for the treated population and for society as a whole) is certainly worth the effort.

Barriers to hepatitis C virus treatment in a Canadian HIV-hepatitis C virus coinfection tertiary care clinic

BACKGROUND

Despite demonstrated efficacy in HIV-hepatitis C virus (HCV) coinfection, not all patients initiate, complete or achieve success with HCV antiviral therapy.

PATIENTS AND METHODS

All HIV-HCV coinfected patient consults received at The Ottawa Hospital Viral Hepatitis Clinic (Ottawa, Ontario) between June 2000 and September 2006 were identified using a clinical database. A descriptive analysis of primary and contributing factors accounting for why patients did not initiate HCV therapy, as well as the therapeutic outcomes of treated patients, was conducted.

RESULTS

One hundred two consults were received. Sixty-seven per cent of patients did not initiate HCV therapy. The key primary reasons included: HIV therapy was more urgently needed (22%), loss to follow-up (12%), patients were deemed unlikely to progress to advanced liver disease (18%) and patient refusal (12%). Many patients had secondary factors contributing to the decision not to treat, including substance abuse (23%) and psychiatric illness (14%). Overall, 59% of untreated patients (40 of 68) were eventually lost to follow-up. Thirty-three per cent of referred patients started HCV therapy. Twenty-seven of 42 courses (64%) were interrupted prematurely for reasons such as virological nonresponse (48%), psychiatric complications (10%) and physical side effects (7%). Of all treatment recipients, 12 of 42 full courses of therapy were completed and three remained on HCV medication. Overall, eight of the 102 coinfected patients studied (8%) achieved a sustained virological response.

DISCUSSION

Not all HIV-HCV coinfected patients who are deemed to be in need of HCV treatment are initiating therapy. Only a minority of patients who do receive treatment achieve success. Implementation of HIV treatment, patient retention, attention to substance abuse and mental health care should be the focus of efforts designed to increase HCV treatment uptake and success. This can be best achieved within a multidisciplinary model of health care delivery.

Awareness of hepatitis C infection among women with and at risk for HIV

BACKGROUND

Treatment guidelines recommend all HIV/HCV-co-infected persons be considered for hepatitis C virus (HCV) treatment, yet obstacles to testing and accessing treatment for HCV continue for women.

OBJECTIVE

To assess awareness of HCV, and describe diagnostic referrals and HCV treatment among women in the Women's Interagency HIV Study (WIHS).

DESIGN

Prospective epidemiologic cohort.

PARTICIPANTS

Of 3,768 HIV-infected and uninfected women in WIHS, 1,166 (31%) were HCV antibody positive.

MEASUREMENTS AND MAIN RESULTS

Awareness of HCV infection and probability of referrals for diagnostic evaluations and treatment using logistic regression. Follow-up HCV information was available for 681 (390 died, 15 withdrew, 80 missed visit) in 2004. Of these 681, 522 (76.7%) reported knowing their HCV diagnosis. Of these, 247 of 522 (47.3%) stated their providers recommended a liver biopsy, whereas 139 of 247 or 56.3% reported having a liver biopsy. A total of 170 of 522 (32.6%) reported being offered treatment and 74.1% (n = 126 of 170) reported receiving HCV treatment. In multivariate regression analyses, African-American race, Hispanic/Latina ethnicity, poverty, and current crack/cocaine/heroin use were negatively associated with treatment referrals, whereas elevated alanine aminotransferase (ALT) was associated with increased likelihood of referral and increased likelihood of treatment.

CONCLUSION

One quarter of women with HCV in this cohort were not aware of their diagnosis. Among those aware of their HCV, 1 in 4 received liver biopsy and treatment for HCV. Both provider and patient education interventions regarding HCV testing and HCV treatment options and guidelines are needed to enhance HCV awareness and participation in HCV evaluation and treatment.

Early initiation of antiretroviral therapy: the current best way to reduce liver-related deaths in HIV/hepatitis C virus-coinfected patients

Approximately 25% to 35% of HIV-infected persons in developed countries are coinfected with hepatitis C virus (HCV). HCV liver disease is accelerated by HIV coinfection, especially at low CD4 cell counts. Highly active antiretroviral therapy (HAART) dramatically reduces HIV-related mortality, and liver disease has emerged as a major cause of death in HIV/HCV-coinfected persons. Anti-HCV therapy with pegylated interferon plus ribavirin can cure HCV infection in up to 40% of coinfected patients; however, only approximately 10% of coinfected patients are considered candidates. Hence, HCV therapy cures approximately 4% of coinfected patients. Eleven cohort studies have shown that HAART is associated with a reduced rate of progression of HCV liver disease, and 4 of these studies have demonstrated a reduction in liver-related mortality. Although offering HCV therapy to the few eligible HIV/HCV-coinfected patients is important, early initiation of HAART in coinfected patients has a greater public health impact in reducing liver-related mortality than in curing HCV infection in approximately 4% of these patients.

Treatment uptake and outcomes among current and former injection drug users receiving directly observed therapy within a multidisciplinary group model for the treatment of hepatitis C virus infection

Injection drug use accounts for the majority of incident and prevalent cases of hepatitis C virus (HCV) infection. However, very few injection drug users (IDUs) have received treatment for this condition given issues of medical or psychiatric co-morbidity, ongoing substance abuse and a widely held belief that such individuals will not be able to adhere to the requirements of therapy, including regular medical follow-up. With this in mind, we sought to evaluate HCV treatment uptake and outcomes among current and former IDUs attending a weekly peer support group and receiving directly observed HCV therapy. Utilizing the existing infrastructure for the management of addictive disease, we have developed a model of "one-stop shopping" whereby the treatment of addiction, HCV and other medical conditions are fully integrated, with the collaboration of nurses, counsellors, addiction specialists, infectious disease specialists, primary care physicians and researchers. Subjects interested in receiving treatment for HCV infection were referred to a weekly peer-support group and evaluated for treatment. Patients received therapy with pegylated interferon-alpha2a or -alpha2b, both in combination with ribavirin. All injections were directly observed. Overall, we observed a high uptake of HCV treatment among attendees, with 51 percent either receiving or about to receive therapy. To date, 18 patients have initiated treatment for HCV infection and 12 have completed therapy. Overall, 8/12 (67 percent) subjects achieved an end of treatment response (genotype 1, 67 percent; genotypes 2/3, 67 percent), despite ongoing drug use in 75 percent of patients during treatment. These data demonstrate that with the appropriate programs in place, a high uptake of HCV treatment can be achieved among IDUs referred to a peer-support group. Moreover, the treatment of HCV in current and former IDUs within a multidisciplinary DOT program can be successfully undertaken, resulting in ETRs similar to those reported in randomized controlled trials.

Limited effectiveness of antiviral treatment for hepatitis C in an urban HIV clinic

OBJECTIVE

To evaluate predictors and trends of referral for hepatitis C virus (HCV) care, clinic attendance and treatment in an urban HIV clinic.

DESIGN AND METHODS

A retrospective cohort analysis in which 845 of 1318 co-infected adults who attended the Johns Hopkins HIV clinic between 1998 and 2003 after an on-site viral hepatitis clinic was opened, attended regularly (>/= 1 visit/year for >/= 2 years). Logistic regression was used to examine predictors of referral.

RESULTS

A total of 277 (33%) of 845 were referred for HCV care. Independent predictors of referral included percentage elevated alanine aminotransferase levels [adjusted odds ratio (AOR) for 10% increase,1.16; 95% confidence interval (CI), 1.10-1.22] and CD4 cell count > 350 cells/microl (AOR, 3.20; 95% CI, 2.10-4.90), while injection drug use was a barrier to referral (AOR, 0.26; 95% CI, 0.11-0.64). Overall referral rate increased from < 1% in 1998 to 28% in 2003; however, even in 2003, 65% of those with CD4 cell count > 200 cells/microl were not referred. One hundred and eighty-five (67%) of 277 referred kept their appointment, of whom 32% failed to complete a pre-treatment evaluation. Of the remaining 125, only 69 (55%) were medically eligible for treatment, and 29 (42%) underwent HCV treatment. Ninety percent of 29 were infected with genotype 1 and 70% were African American; six (21%) achieved sustained virologic response (SVR). Only 0.7% of the full cohort achieved SVR.

CONCLUSIONS

Although the potential for SVR and the recent marked increase in access to HCV care are encouraging, overall effectiveness of anti-HCV treatment in this urban, chiefly African American, HCV genotype 1 HIV clinic is extremely low. New therapies and treatment strategies are an urgent medical need.

Treatment rates in patients with chronic hepatitis C after liver biopsy

Hepatitis C virus (HCV) infection is a major health problem in the United States. Only about 30% of patients infected with HCV are being treated despite the development of increasingly effective therapies. The aims of this study were to determine the rate of treatment for patients with HCV after undergoing liver biopsy, to assess any change in their treatment rates over recent years and to delineate the reasons for nontreatment. We retrospectively reviewed the charts of all HCV patients who had liver biopsies at Beth Israel Medical Center, New York between 1998 and 2002. The data gathered included patient demographics, stage of liver fibrosis, insurance information, treatment history and reasons for nontreatment. There were 433 liver biopsies done for chronic hepatitis C between 1998 and 2002. Of those, 267 (61%) were men. The mean age was 47 years (range, 18-72). Only 159 (37%) patients were treated after liver biopsy. Overall there were no significant differences in the treatment rates from 1999 to 2002. The common reasons for nontreatment included minimal/mild disease (stage 0-1 fibrosis, 38%), lost to follow-up or noncompliance (31%) and patient refusal (22%). Older patients more frequently had co-morbid conditions (P = 0.009). Younger age and female gender correlated with minimal disease on biopsy (P = 0.004 and 0.01, respectively). Men were lost to follow-up more frequently than women (37%vs 22%, P = 0.01). Multivariate analysis showed that age and gender were both independent predictors of minimal disease. Patients having Medicaid with or without Medicare were significantly more likely to be treated than patients with private or commercial insurance or patients with Medicare alone. A minority of HCV infected patients were treated even after having undergone liver biopsy. The proportion of HCV patients being treated after liver biopsy has been relatively stable despite advances in therapeutic success. Liver histology frequently identified patients with mild disease in whom antiviral therapy was deemed not urgent.

Barriers to treatment of hepatitis C in HIV/HCV-coinfected adults with alcohol problems

BACKGROUND

Alcohol use and human immune deficiency virus (HIV) infection are both associated with accelerated progression of hepatitis C virus (HCV) disease and reduced response rates to interferon therapy. In this study, we assessed the prevalence of barriers to interferon treatment in a population of HIV/HCV-coinfected patients with current or past alcohol problems and the extent to which they received treatment to address the barriers.

METHODS

This is a cross-sectional, descriptive analysis of baseline data from a prospective study assessing the impact of HCV and alcohol use on HIV disease progression. Using consensus guidelines, subjects were categorized as having absolute, relative, or no contraindications to interferon therapy for HCV. Absolute contraindications to treatment included heavy alcohol use, decompensated liver disease, CD4 cell count <100 cells/microL, recent needle sharing, and suicidal ideation. Relative contraindications included moderate alcohol use, recent injection drug use, depressive symptoms, and CD4 cell count from 100 to 199 cells/microL.

RESULTS

Of 401 HIV-infected subjects, 200 were HCV RNA-positive. Fifty-three percent had an absolute contraindication to interferon therapy, 35% a relative but no absolute contraindication, and only 12% had no contraindication. Of those with an absolute contraindication, 61% reported heavy drinking and the majority (88%) had multiple contraindications. These contraindications were present despite the fact that over 50% were in receipt of substance abuse and mental health treatment.

CONCLUSIONS

Continued alcohol and drug use as well as depressive symptoms are the major barriers to interferon therapy in HCV/HIV-coinfected subjects and these barriers persist despite high treatment rates for these problems. Therefore, more intensive treatments of alcohol, drug, and mental health issues are needed to improve HCV treatment eligibility in HCV/HIV-coinfected persons.