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

Alcohol Consumption and Hepatitis C Virus (HCV) RNA Levels in HIV/HCV Coinfected Patients

BACKGROUND

The impact of Hepatitis C virus (HCV) RNA levels on the evolution of chronic HCV infection-related liver damage is controversial. Heavy alcohol use is believed to have a deleterious impact on the course of HCV disease, but current knowledge about the possible effect of alcohol use on HCV RNA levels in HIV/HCV coinfected patients is limited.

METHODS

We examined 107 HIV/HCV-infected individuals with current or past unhealthy alcohol use to assess the association between alcohol consumption (any drinking vs. abstinent) and HCV RNA levels.

RESULTS

Participants were 75% male, with a mean age of 43 years, and 63% were on antiretroviral therapy. Mean (SD) log HIV RNA was 3.1 (1.4) and mean (SD) log HCV RNA was 6.1 (0.8). Past-month alcohol use was present in 38% of participants. In a multivariable linear regression analysis we found no significant differences in mean log HCV RNA levels between those reporting alcohol use and those who were abstinent [β (95%CI): -0.04 (-0.34, 0.26), p = 0.79)]. There was no significant association between any heavy drinking day and HCV RNA level (0.07, 95% CI: (-0.24, 0.38), p = 0.66).

CONCLUSIONS

We did not detect significant associations between alcohol use and HCV RNA levels among HIV/HCV coinfected patients.

Patients at a drug detoxification center share perspectives on how to increase hepatitis C treatment uptake: A qualitative study

BACKGROUND

The US opioid crisis is associated with a surge in hepatitis C virus (HCV) infections among persons who inject drugs (PWID), and yet the uptake of HCV curative therapy among PWID is low.

PURPOSE

To explore potential solutions to overcome barriers to HCV treatment uptake among individuals at a drug detoxification center.

METHODS

Qualitative study with in-depth interviews and thematic analysis of coded data.

RESULTS

Patients (N = 24) had the following characteristics: mean age 37 years; 67 % White, 13 % Black, 8 % Latinx, 4 % Native Hawaiian/Pacific Islander, 8 % other; 71 % with a history of injecting drugs. Most patients with a positive HCV test had not pursued treatment due to few perceived immediate consequences from a positive test and possible complications arising in a distant poorly imagined future. Active substance use was a major barrier to HCV treatment uptake because of disruptions to routine activities. In addition, re-infection after treatment was perceived as inevitable. Patients had suggestions to improve HCV treatment uptake: high-intensity wraparound care characterized by frequent interactions with supportive services; same-day/walk-in options; low-barrier access to substance use treatment; assistance with navigating the health care system; attention to immediate needs, such as housing; and the opportunity to select an approach that best fits individual circumstances.

CONCLUSIONS

Active substance use was a major barrier to treatment initiation. To improve uptake, affected individuals recommended that HCV treatment be integrated within substance use treatment programs. Such a model should incorporate patient education within low-barrier, high-intensity wraparound care, tailored to patients' needs and priorities.

Motivation to Quit Drinking in Individuals Coinfected with HIV and Hepatitis C

Alcohol consumption is common among individuals coinfected with HIV and hepatitis C (HCV) despite the uniquely harmful effects in this population. Limited research has examined factors that could influence drinking reduction or cessation among HIV/HCV coinfected persons; this study investigates motivation to quit. Participants were 110 alcohol-consuming HIV/HCV coinfected patients recruited from medical clinics. Participants self-reported 90-day drinking frequency and intensity; alcohol-related problems; reasons to quit drinking; reasons to drink; and motivation to quit drinking. Participants consumed alcohol on 54.1 (± 26.9) of the past 90 days. In a multivariate model that controlled for demographic variables, motivation to quit drinking was directly associated with alcohol-related problems (β_y·x = 0.35, p = .007) and reasons to quit drinking (β_y·x = 0.23, p = .021), and inversely associated with drinking for enhancement (β_y·x = - 0.36, p = .004). This study identified several factors associated with motivation to quit drinking in a sample of alcohol-consuming HIV/HCV patients.

Unreported alcohol use was common but did not impact hepatitis C cure in HIV-infected persons who use drugs

We investigated the prevalence and impact of heavy alcohol use on the hepatitis C virus (HCV) care continuum amongst HIV/HCV co-infected persons who use drugs. In the CHAMPS study, 144 HIV/HCV co-infected persons were randomized to contingent cash incentives, peer mentors and usual care to evaluate the impact on HCV care. Alcohol use was ascertained using the 10-item AUDIT (hazardous: male ≥8, female ≥4) and phosphatidylethanol (PEth) (heavy: ≥50 ng/mL), an alcohol biomarker. Log binomial regression was used to evaluate the association between heavy alcohol use and failure to initiate treatment and to achieve sustained virologic response (SVR). Of the 135 participants with PEth data, median age was 55 years, 59% were male, 92% were Black, 91% reported a history of drug use, and 97% were on antiretroviral therapy. Hazardous drinking was reported on AUDIT by 28% of participants, and 35% had heavy alcohol use by PEth. Of the 47 individuals with a PEth ≥50 ng/mL, 23 (49%) reported no or minimal alcohol use by AUDIT. HCV treatment was initiated in 103 of 135 participants, and SVR was achieved in 92%. PEth ≥50 ng/mL (Relative Risk [RR] 0.72, 95% CI 0.35-1.48) was not significantly associated with failure to initiate HCV treatment or failure to achieve SVR (RR 0.85, 95% CI 0.46-1.57).In conclusion, alcohol use was common and frequently not detected by self-report. However, heavy alcohol use, even when measured objectively, was not associated with failure to initiate HCV treatment or to achieve cure.

Examination of using alcohol to cope, depressive symptoms, and perceived social support in persons with HIV and Hepatitis C

Depression is common among people living with HIV (PLWH) and some likely turn to alcohol to cope with this emotional distress. Using alcohol to cope is associated with increased alcohol use, persistent longitudinal alcohol use, and alcohol-related problems. This association is particularly concerning among PLWH who are co-infected with Hepatitis C (HCV) because alcohol adds to the damage already caused by HCV. Despite data showing the associated risks of using alcohol to cope, scant research has examined factors that might contribute to coping-based alcohol use in HIV-HCV patients, such as limited social support. Baseline data from a randomized trial of strategies to reduce alcohol use in co-infected HIV and HCV adult patients (n=110) were analyzed. Multiple linear regression models were used to estimate the association between using alcohol to cope, depression, and four aspects of social support, controlling for demographic variables. Results showed that using alcohol to cope was not significantly correlated with social support but was significantly correlated with depressive symptoms. In fact, depressive symptoms and severity of alcohol consumption accounted for nearly 45% of the variance related to coping-based alcohol use. These data highlight the central role of depression in the coping motives-alcohol use relationship among co-infected patients.

Significant reductions in alcohol use after hepatitis C treatment: results from the ANRS CO13-HEPAVIH cohort

BACKGROUND AND AIMS

Few data exist on changes to substance use patterns before and after hepatitis C virus (HCV) treatment. We used longitudinal data of HIV-HCV co-infected individuals to examine whether receiving pegylated interferon (Peg-IFN)-based therapy irrespective of HCV clearance could modify tobacco, cannabis and alcohol use.

DESIGN

A prospective cohort of HIV-HCV co-infected individuals was enrolled from 2006. Participants' clinical data were retrieved from medical records and socio-demographic and behavioural characteristics were collected by yearly self-administered questionnaires.

SETTING

Data were collected across 17 hospitals in France.

PARTICIPANTS

All HIV-HCV co-infected patients who initiated HCV treatment during follow-up and answered items regarding substance use in at least one yearly questionnaire (258 patients, 671 visits).

INTERVENTION

HCV treatment consisted of Peg-IFN-based regimens.

MEASUREMENTS

Four time-varying outcomes: hazardous alcohol use (Alcohol Use Disorders Identification Test-C > 3/4 for women/men), number of alcohol units/month, binge drinking, cannabis and tobacco use. Mixed models assessed the effect of HCV treatment status (not yet treated, treated and HCV-cleared, treated and HCV-chronic) on each outcome.

FINDINGS

A significant decrease (more than 60% reduction) in both hazardous alcohol use and binge drinking and a reduction of 10 alcohol units/month was observed after HCV treatment (irrespective of HCV clearance). No significant effect of HCV treatment status was found on tobacco use and regular cannabis use, but HCV 'clearers' reported less non-regular use of cannabis.

CONCLUSIONS

Hepatitis C virus (HCV) treatment appears to help HIV-HCV co-infected patients reduce alcohol use.

Alcohol use disorder and its impact on chronic hepatitis C virus and human immunodeficiency virus infections

Alcohol use disorder (AUD) and hepatitis C virus (HCV) infection frequently co-occur. AUD is associated with greater exposure to HCV infection, increased HCV infection persistence, and more extensive liver damage due to interactions between AUD and HCV on immune responses, cytotoxicity, and oxidative stress. Although AUD and HCV infection are associated with increased morbidity and mortality, HCV antiviral therapy is less commonly prescribed in individuals with both conditions. AUD is also common in human immunodeficiency virus (HIV) infection, which negatively impacts proper HIV care and adherence to antiretroviral therapy, and liver disease. In addition, AUD and HCV infection are also frequent within a proportion of patients with HIV infection, which negatively impacts liver disease. This review summarizes the current knowledge regarding pathological interactions of AUD with hepatitis C infection, HIV infection, and HCV/HIV co-infection, as well as relating to AUD treatment interventions in these individuals.

Treating Hepatitis C in a Ryan White-Funded HIV Clinic: Has the Treatment Uptake Improved in the Interferon-Free Directly Active Antiviral Era?

Now that highly efficacious, interferon-free (IFN-free), direct acting antivirals (DAA) for the treatment of hepatitis C (HCV) have closed the gap between treatment and cure, identifying barriers that prevent initiation of treatment is more crucial than ever. This is a retrospective study utilizing Electronic Medical Records and Prior Authorization Records to identify HCV treatment gaps, including predictors for intention-to-treat and treatment initiation in the first 15 months of a Ryan White funded human immunodeficiency virus (HIV)/HCV co-infection clinic. This study included 128 adults ≥ 18 years old with HIV and chronic HCV infection who had visited the treatment center at least once since January 2013. Provider intent-to-treat was used to differentiate patients actively considered for treatment based on documentation kept by a multidisciplinary HCV team. Members of this group who had gone on to initiate treatment were identified. Baseline characteristics were compared. Rates of active treatment consideration and treatment initiation were 30% and 14%, respectively. HCV treatment-naïve individuals were less likely to be considered for treatment [risk ratio (RR) 1.58, 95% confidence interval (CI) 1.07-2.32] and initiate therapy (RR 2.33, 95% CI 0.97-5.60). Advanced liver disease had no significant association. Black race (RR 1.96, 95% CI 0.90-4.25) and Medicaid insurance holders (RR 1.90, 95% CI 0.95-3.82) tended to be less likely to initiate therapy. The availability of IFN-free DAA regimens has yet to increase HCV treatment uptake in our HIV/HCV co-infected population. Barriers to HCV treatment initiation have shifted from medical contraindications to socioeconomic variables.

Systematic review of the pharmacological treatment of alcohol use disorders in individuals infected with hepatitis C

Treating alcohol use disorders (AUD) is critical in individuals suffering from hepatitis C infection (HCV). Aside from psychosocial interventions, pharmacological treatment is effective for decreasing alcohol consumption and promoting abstinence. However, unique factors belonging to HCV-infected individuals, such as baseline hepatic vulnerability and possible ongoing hepatitis C treatment, complicate AUD drug therapy. The goal of this review is to systematically identify, summarize, and evaluate the existing evidence on the pharmacological management of AUD in HCV-infected individuals. MEDLINE, Embase, PsycINFO, and the Cochrane Central Register of Controlled Trials were searched for English- and French-language articles published from 1993 to December 2013. The search criteria focused on clinical trials and observational studies assessing the efficacy and/or safety of pharmacological management of AUD in patients infected with HCV. Of 421 identified studies, three were included for analysis. Two were observational studies assessing the safety of disulfiram. One was a randomized controlled trial assessing the efficacy and safety of baclofen. There is paucity of data regarding the efficacy and safety of pharmacological treatment of AUD in HCV-infected individuals, with studies being small series and showing significant heterogeneity. No strong recommendations can be made based on the current studies as to which pharmacological option should be preferred in this sub-population.

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.

Chronic hepatitis C virus infection is associated with all-cause and liver-related mortality in a cohort of HIV-infected patients with alcohol problems

AIMS

To assess the association between hepatitis C virus (HCV) infection and overall and liver-related death in human immunodeficiency virus (HIV)-infected patients with alcohol problems.

DESIGN

We analyzed data from a cohort of HIV-infected adults with current or past alcohol problems enrolled between 2001 and 2003, searching for causes of death until 2010 using the National Death Index.

SETTING AND PARTICIPANTS

Participants were HIV-infected adults with current or past alcohol problems, recruited in Boston, MA from HIV clinics at two hospitals, homeless shelters, drug treatment programs, subject referrals, flyers and another cohort study with comparable recruitment sites.

MEASUREMENTS

The primary and secondary outcomes were all-cause and liver-related mortality, respectively. The main independent variable was hepatitis C virus (HCV) RNA status (positive versus negative). Mortality rates and Kaplan-Meier survival curves were calculated by HCV status for both overall and liver-related mortality. Cox proportional hazards models were used to assess the association between HCV infection and overall and liver-related death, adjusting for alcohol and drug use over time.

FINDINGS

A total of 397 adults (50% HCV-infected) were included. As of 31 December 2009, 83 cohort participants had died (60 HCV-infected, 23 HCV-uninfected; log-rank test P < 0.001), and 26 of those deaths were liver-related (21 HCV-infected, five HCV-uninfected; log-rank test P < 0.001). All-cause and liver-related mortality rates were 4.68 and 1.64 deaths per 100 person-years for HCV-infected patients and 1.65 and 0.36 per 100 person-years for those without HCV, respectively. In the fully adjusted Cox model, HCV infection was associated with both overall [hazard ratio (HR) = 2.55, 95% confidence interval (CI) = 1.50-4.33, P < 0.01], and liver-related mortality (HR = 3.24, 95% CI = 1.18-8.94, P = 0.02].

CONCLUSION

Hepatitis C virus infection is associated independently with all-cause and liver-related mortality in human immunodeficiency virus-infected patients with alcohol problems, even when accounting for alcohol and other drug use.

Patient perspectives on hepatitis C and its treatment

OBJECTIVE

Much of the research to date on barriers to treatment for patients with hepatitis C has approached the problem from either the perspective of the medical provider or the healthcare system.

METHODS

To better understand these barriers from the patients' perspectives, nine exploratory focus groups of patients with hepatitis C (N=48) were conducted in 2008 and 2009, using a hybrid qualitative analysis.

RESULTS

Eight content categories emerged. Treatment-related issues, including barriers to care, were most emphasized, representing nearly one-half of the entire content. Need for accurate disease-related information was also extensively discussed. Social factors were important, including considerable focus on stigma. Participants described coping abilities including faith and perseverance.

CONCLUSION

Areas of concern expressed in these focus groups represent underexplored areas that may warrant additional attention or areas for intervention and investigation, such as exploring differences between perceptions of patients and providers regarding the hepatitis C treatment process and addressing barriers to care.

Knowledge and attitudes about hepatitis C virus (HCV) infection and its treatment in HCV mono-infected and HCV/HIV co-infected adults

Hepatitis C virus (HCV) treatment is rapidly changing but little is known about patients' attitudes and knowledge about HCV. This study used a cross-sectional survey to examine the relationship between HCV knowledge and attitudes towards HCV in patients with HCV mono-infection and HIV/HCV co-infection. Subsequently, an education intervention was developed with an abridged version of the cross-sectional survey administered before and after the education session to assess changes in knowledge and attitudes. 292 people participated in the cross-sectional survey, and 87 people participated in the education intervention. In the cross-sectional survey, the mean knowledge score regarding HCV was low (<50% of the total possible score). Mono-infected and co-infected individuals shared similar knowledge deficits and attitudes towards HCV despite having distinct demographic differences. Attitudes endorsed by patients included the following: 57% feared the consequences of HCV on their life, 37% felt HCV was not fatal, 27% did not believe they needed HCV medication, 21% felt ashamed of having HCV and 16% felt HCV treatment was not important. Attitudes that reflected indifference and shame towards HCV were associated with lower knowledge scores (HCV knowledge score of 15.1 vs. 17.5, P < 0.01 for indifference and 15.3 vs. 17.2 for shame, P = 0.02). The education intervention improved knowledge scores but did not modify the assessed attitudes. Intervention studies are needed to effectively change attitudes towards HCV infection and treatment.

Use of the Alcohol Use Disorders Identification Test (AUDIT) to determine the prevalence of alcohol misuse among HIV-infected individuals

The aim of the paper is to evaluate alcohol misuse among an inner city adult HIV clinic population with AUDIT (Alcohol Use Disorders Identification Test). A cross-sectional HIV outpatient clinic analysis between 28 February 2011 and 11 March 2011 was carried out. AUDIT, demographic and clinical data were collected. Univariate analysis was performed to look for the associations between variables. Backward stepwise multivariate analyses were performed on significant variables from the univariate analysis to assess for predictors of alcohol dependence. In total, 111 patients were included (60% uptake of clinic attendees); 66% were men and 26% were hepatitis C virus (HCV) co-infected. The median AUDIT score was 5 (within normal range). Thirty-four 'AUDIT positive' cases were identified: five (4.5%) indicated consumption of hazardous levels of alcohol; 21 (19%) indicated harmful levels of alcohol; and eight (7%) were likely alcohol dependent. Younger age (<40 years old) was significantly associated with AUDIT positivity (P = 0.006). On multivariate analysis younger age (P = 0.045, odds ratio 13.8) and lower level of education (P = 0.006, odds ratio 6.7) were predictive of scores indicative of alcohol dependence (AUDIT ≥20). In conclusion, younger age and lower educational levels were associated with scores consistent with alcohol dependence. AUDIT was well tolerated and easy to administer in this outpatient HIV clinic population.

Challenges in the treatment of chronic hepatitis C in the HIV/HCV-coinfected patient

Hepatitis C virus (HCV) and HIV are common coinfections that convey a shortened lifespan, mostly related to liver disease. Treatment against HCV in the coinfected patient is notoriously more complex and challenging. There are no optimal treatment algorithms for HIV/HCV coinfected patients as efficacy of approved anti-HCV therapies is low with relevant side effects. The use of direct-acting antivirals for anti-HCV therapy has the potential to improve therapeutic efficacy, but also increase side effects and drug-drug interactions. In spite of all of this, the most important and significant fact is that chronic hepatitis C is potentially curable, and the eradication of the HCV infection is a crucial outcome in this population. The establishment of a productive collaboration among the regulatory agencies, the medical community and the pharmaceutical industry could lead to faster access to more effective HCV therapies for the coinfected patient and eventually stop the progression of liver disease in these patients.

Hepatitis C treatment and SVR: the gap between clinical trials and real-world treatment aspirations

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.

Alcohol, HIV/AIDS, and Liver Disease

Globally, there are over 33 million persons living with HIV/AIDS resulting in 1.8 million deaths annually. While the rate of HIV transmission is slowing, it is estimated that 2.6 million new infections occur yearly [1]. In the United States, there are approximately 1.2 million living with HIV/AIDS, with 50,000 new HIV infections and 17,000 deaths from the disease annually [2]. For those who can obtain effective antiretroviral therapy (ART), HIV/AIDS has become a chronic disease with life expectancies over 30 years [3]. Research in the last 10 years has revealed the importance of alcohol in the HIV/AIDS epidemic. Alcohol use, in moderate or hazardous amounts, has been associated with increased acquisition of HIV infection, progression of HIV infection, deleterious effects on HIV treatment, and acceleration in the comorbidities of HIV infection [4–9]. Yet alcohol remains the “forgotten drug” of the HIV/AIDS epidemic [10].

10-year trends in the diagnosis and treatment of hepatitis C and concomitant mental health disorders: 1995 to 2005

OBJECTIVE

To evaluate trends in the rate and timing of treatment for hepatitis C in those with and without mental health comorbidities.

METHOD

Data from the population-based Olmsted County Hepatitis C Registry in Minnesota were linked to patients' medical records to identify the dates and duration of any hepatitis C-specific therapy as well as all diagnoses of mental health comorbid conditions prior to initiation of therapy. The most common mental health conditions, major depressive disorder, alcohol dependence, and intravenous drug use, were assessed separately. The registry includes all Olmsted County residents with a physician diagnosis of hepatitis C or non-A/non-B hepatitis (ICD-9 criteria) from January 1, 1990, through December 31, 2005.

RESULTS

The age-adjusted prevalence of diagnosed hepatitis C increased markedly between 1995 and 2000 (15.5/10,000 persons to 27.0/10,000 persons) but changed little between 2000 and 2005 (27.0 to 27.9/10,000 persons). The number of people with comorbid hepatitis C and depressive disorder (including minor depression) increased significantly between 1995 and 2005 from 18% to over 35% of all people with diagnosed hepatitis C. Treatment rates more than doubled between 1995 and 2005, while the time from diagnosis to treatment decreased during that same period. By 2005, major depressive disorders were associated with a high rate of reasonably prompt treatment. There were no gender differences in treatment rates or time to treatment when other comorbidities and age were included in the analyses.

CONCLUSIONS

From 1995 to 2005, rates of treatment for hepatitis C among people with and without comorbid mental health problems increased. Rates of increase were higher among those with depression and hepatitis C than among those with hepatitis C and drug abuse or other mental health diagnoses. Even with this progress in treating those with multiple diagnoses, over 75% of people with hepatitis C remain untreated.

Chronic hepatitis C: Treat or wait? Medical decision making in clinical practice

AIM: To analyzes the decision whether patients with chronic hepatitis C virus (HCV) infection are treated or not.

METHODS: This prospective cohort study included 7658 untreated patients and 6341 patients receiving pegylated interferon α 2a/ribavirin, involving 434 physicians/institutions throughout Germany (377 in private practice and 57 in hospital settings). A structured questionnaire had to be answered prior to the treatment decision, which included demographic data, information about the personal life situation of the patients, anamnesis and symptomatology of hepatitis C, virological data, laboratory data and data on concomitant diseases. A second part of the study analyzes patients treated with pegylated interferon α2a. All questionnaires included reasons against treatment mentioned by the physician.

RESULTS: Overall treatment uptake was 45%. By multivariate analysis, genotype 1/4/5/6, HCV-RNA ≤ 520 000 IU/mL, normal alanine aminotransferase (ALT), platelets ≤ 142 500/μL, age > 56 years, female gender, infection length > 12.5 years, concomitant diseases, human immunodeficiency virus co-infection, liver biopsy not performed, care in private practice, asymptomatic disease, and unemployment were factors associated with reduced treatment rate. Treatment and sustained viral response rates in migrants (1/3 of cohort) were higher than in German natives although 1/3 of migrants had language problems. Treatment rate and liver biopsy were higher in clinical settings when compared to private practice and were low when ALT and HCV-RNA were low.

CONCLUSION: Some reasons against treatment were medically based whereas others were related to fears, socio-economical problems, and information deficits both on the side of physicians and patients.

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.

Challenges facing providers caring for HIV/HCV-coinfected patients

Despite the high prevalence of hepatitis C virus (HCV) infection among injection drug users also infected with human immunodeficiency virus (HIV), and the synergistic adverse effect of the two diseases on patients' health and survival, research on the clinical management of these patients and particularly the low uptake of HCV therapy is limited. We conducted qualitative interviews with 17 HIV providers from two urban public hospitals. We discovered that the limitations of the current state of medical knowledge, the severe side effects of HIV and HCV therapies, and the psychosocial vulnerability of HIV/HCV-coinfected patients combined with their resistance to becoming informed about HCV posed significant challenges for providers. To contend with these challenges, providers incorporated key dimensions of patient-centered medicine in their practice, such as considering their patients' psychosocial profiles and the meaning patients assign to being coinfected, and finding ways to engage their patients in a therapeutic alliance.

Substance abuse treatment utilization among adults living with HIV/AIDS and alcohol or drug problems

This is a prospective cohort study to identify factors associated with receipt of substance abuse treatment (SAT) among adults with alcohol problems and HIV/AIDS. Data from the HIV Longitudinal Interrelationships of Viruses and Ethanol study were analyzed. Generalized estimating equation logistic regression models were fit to identify factors associated with any service utilization. An alcohol dependence diagnosis had a negative association with SAT (adjusted odds ratio [AOR] = 0.36, 95% confidence interval [95% CI] = 0.19-0.67), as did identifying sexual orientation other than heterosexual (AOR = 0.46, CI = 0.29-0.72) and having social supports that use alcohol/drugs (AOR = 0.62, CI = 0.45-0.83). Positive associations with SAT include presence of hepatitis C antibody (AOR = 3.37, CI = 2.24-5.06), physical or sexual abuse (AOR = 2.12, CI = 1.22-3.69), social supports that help with sobriety (AOR = 1.92, CI = 1.28-2.87), homelessness (AOR = 2.40, CI = 1.60-3.62), drug dependence diagnosis (AOR = 2.64, CI = 1.88-3.70), and clinically important depressive symptoms (AOR = 1.52, CI = 1.08-2.15). While reassuring that factors indicating need for SAT among people with HIV and alcohol problems (e.g., drug dependence) are associated with receipt, nonneed factors (e.g., sexual orientation, age) that should not decrease likelihood of receipt of treatment were identified.

Determinants of the underreporting of alcohol consumption by HIV/HCV co-infected patients during face-to-face medical interviews: the role of the physician

OBJECTIVES

The objective of this study was to assess to what extent HIV/HCV co-infected patients underreport alcohol use to their physician with respect to self-reports from self-administered questionnaires (SAQ) and identify correlates of alcohol underreporting during face-to-face medical interviews (FMI).

DESIGN

ANRS-CO13-HEPAVIH is a French multi-center cohort of HIV/HCV co-infected patients.

METHODS

Data were collected at enrolment using both SAQ and FMI while clinical data were retrieved from medical records. Alcohol consumption was assessed through SAQ and compared with FMI patient reports. Correlates of underreporting alcohol consumption during FMI with respect to SAQ were identified using logistic regression analysis.

RESULTS

Among 544 patients, 37% were classified as alcohol abusers according to AUDIT-C in the SAQ. During FMI, 14% underreported alcohol consumption. The following correlates were independently associated with underreporting alcohol consumption in FMI: not receiving HIV treatment, being followed up by a hepatologist for HCV infection and reporting a history of injecting drug use.

CONCLUSIONS

These results highlight the difficulties in alcohol consumption assessment which HCV specialists may face when suggesting to their HIV/HCV co-infected patients that they cease drinking completely. Patient awareness about the real need to reduce their alcohol use before starting HCV therapy may also contribute to underreporting. Innovative strategies for alcohol risk-reduction, including the promotion of controlled consumption and access to multidisciplinary teams, should be implemented for HIV/HCV co-infected patients in order to reduce barriers to HCV treatment.

Physicians' attitudes and practice toward treating injection drug users with hepatitis C: results from a national specialist survey in Canada

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.

Eligibility and feasibility of the treatment of chronic hepatitis C in a Cohort of Italian HIV-positive patients at a single HIV reference center

Chronic hepatitis C is frequent and aggressive among HIV-positive patients; evaluation for anti-hepatitis C virus (HCV)-specific therapy is mandatory, but it has many limitations, due to efficacy, tolerability but also applicability. The objective of our retrospective analysis was to evaluate the eligibility and feasibility of anti-HCV therapy in HIV/HCV-coinfected patients followed at the II Department of Infectious Diseases, L. Sacco Hospital, Milan, Italy, from 2000 to March 2010. In our database, 545 HIV/HCV-coinfected patients were present, representing 40% of our whole HIV population, and 421 included in the analysis. One hundred twenty-four patients were excluded because of loss to follow-up (81) or deceased (43). Forty-eight patients spontaneously cleared HCV during follow-up (11%). Ninety-nine patients received anti-HCV therapy (26%), while the majority was excluded for several reasons (mainly concomitant diseases and low CD4(+) cell count). Globally, we found that in at least one third of untreated patients modifiable barriers to treatment were present. The access to therapy was significantly associated with the absence of history of intravenous drug use (p=0.01), a higher CD4(+) cells count at nadir (p=0.01), the presence of more than 6 HAART regimens (p=0.04), higher alanine aminotransferase (ALT) levels (p<0.0001), HCV genotype 2 or 3 (p=0.005). In a multivariate analysis, the same factors remained significantly associated with anti-HCV therapy. In conclusion, the feasibility of anti-HCV therapy in HIV/HCV-coinfected patients, in our highly specialized center, is approximately 26%. Relative contraindications, such as substance abuses, mild and controlled concomitant conditions, and low compliance are common and modifiable in order to reconsider patients as suitable for therapy.

HIV infection and the liver: the importance of HCV-HIV coinfection and drug-induced liver injury

Hepatitis C virus-Human immunodeficiency virus (HCV-HIV) coinfections are identified in up to 30% of patients infected with HIV and in 8% of patients infected with HCV. Now that progression of HIV and deaths due to AIDS can be prevented by highly active antiretroviral therapy (HAART), it is clear that HCV coinfection is associated with accelerated progression to cirrhosis and increased liver-related morbidity and mortality. Antiviral therapy with pegylated interferon and ribavirin for HCV in HCV-HIV coinfected patients is less successful than in patients with HCV monoinfection, and HAART can cause drug-induced liver injury. Multiple barriers limit the number of HCV-HIV coinfected patients who receive antiviral therapy for HCV, and the role of orthotopic liver transplantation (OLT) in HIV monoinfected and HCV-HIV coinfected patients remains controversial. Clinical trials of HCV-specific protease or polymerase inhibitors combined with pegylated interferon and ribavirin are needed urgently in coinfected patients, both before and after OLT.

Cross-sectional epidemiology of hepatitis C virus detection and treatment in HIV-infected patients

BACKGROUND

Sustained virologic response to peginterferon plus ribavirin reduces liver-related complications and mortality in patients co-infected with HIV and hepatitis C virus. Therefore, the presence of any barriers to start hepatitis C virus therapy should be identified and eliminated in order to recruit all eligible patients.

METHODS

Cross-sectional study. In a HIV referral clinic we assessed the proportion of patients eligible for hepatitis C virus evaluation and treatment according to consensus guidelines.

RESULTS

We identified 134 patients with hepatitis C virus and HIV co-infection. Twenty-one patients were excluded from the analysis due to never attending the HIV clinic (n=12) or having hepatitis C virus RNA not detectable (n=9). In the remaining 113 patients, only 61% had identification of hepatitis C virus genotype and quantification of hepatitis C viral load. Thirty-six patients started peginterferon plus ribavirin, and 16 (44%) achieved sustained virologic response. Seventy-seven patients did not receive treatment for hepatitis C virus due to the presence of medical contraindications (n=22), provider barriers (n=15), or patient barriers (n=40). Multivariate analysis identified lower education degree (odds ratio: 4.53; 95% confidence intervals: 1.36-15.16, p=0.014) and patient civil status single, separated or widower (odds ratio: 4.81; 95% confidence intervals: 1.54-14.99, p=0.007) as the independent determinants associated to not initiating therapy for hepatitis C virus infection in patients with barriers.

CONCLUSION

A minor proportion of HIV-infected patients received appropriate assessment and treatment for hepatitis C virus infection. Social disadvantages require multidisciplinary models of health care to improve hepatitis C virus treatment initiation and success.

Care of hepatitis C virus infection in human immunodeficiency virus-infected patients: modifications in three consecutive large surveys between 2004 and 2009

BACKGROUND & AIMS

To analyze the care of HCV infection in HIV-HCV coinfected patients and its progression between 2004 and 2009.

METHODS

Three hundred eighty HIV-HCV coinfected patients were prospectively included from November 22 to 29, 2004 (2004 survey), 416 patients from April 3 to 10, 2006 (2006 survey), and 419 patients from June 15 to 22, 2009 (2009 survey).

RESULTS

The rate of liver biopsy decreased (14% vs. 38% vs. 56%), while the use of non-invasive liver damage tests increased (47% vs. 24% vs. ND) in the 2009, 2006, and 2004 surveys, respectively. The rate of patients that had never been treated for HCV infection progressively decreased in the 2009, 2006, and 2004 surveys (37%, 42%, and 54%). The main reasons for HCV non-treatment changed as HCV treatment was deemed less questionable and the lack of liver biopsy became a very rare reason (6%, 18%, and 34%). Among patients treated for HCV infection, the rate of sustained virological response increased (49%, 29%, and 29%). The main factors independently associated with HCV treatment were a liver fibrosis score > or =F2 (odds ratio=3.5; 95% CI 2.1-5.7), a liver biopsy activity grade > or =A2 (2.7; 1.4-5.3), a CD4 cell count > or =350 ml (2.7; 1.6-4.4), European origin (2.1; 1.3-3.4), daily alcohol consumption<30 g (2.1; 1.2-3.8), and male gender (2.0; 1.2-3.3).

CONCLUSION

Compared to the 2004 and 2006 surveys, the 2009 coinfected patients had liver damage assessment more frequently, more patients had received HCV treatment and more patients had achieved a sustained virological response.

Longitudinal trends in hazardous alcohol consumption among women with human immunodeficiency virus infection, 1995-2006

Hazardous alcohol consumption among women with human immunodeficiency virus (HIV) infection is associated with several adverse health and behavioral outcomes, but the proportion of HIV-positive women who engage in hazardous drinking over time is unclear. The authors sought to determine rates of hazardous alcohol consumption among these women over time and to identify factors associated with this behavior. Subjects were 2,770 HIV-positive women recruited from 6 US cities who participated in semiannual follow-up visits in the Women's Interagency HIV Study from 1995 to 2006. Hazardous alcohol consumption was defined as exceeding daily (> or =4 drinks) or weekly (>7 drinks) consumption recommendations. Over the 11-year follow-up period, 14%-24% of the women reported past-year hazardous drinking, with a slight decrease in hazardous drinking over time. Women were significantly more likely to report hazardous drinking if they were unemployed, were not high school graduates, had been enrolled in the original cohort (1994-1995), had a CD4 cell count of 200-500 cells/mL, were hepatitis C-seropositive, or had symptoms of depression. Approximately 1 in 5 of the women met criteria for hazardous drinking. Interventions to identify and address hazardous drinking among HIV-positive women are urgently needed.

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.

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.

Treatment of hepatitis C virus in human immunodeficiency virus infected patients in "real life": modifications in two large surveys between 2004 and 2006

BACKGROUND/AIMS

To analyze the barriers to HCV treatment in HIV-HCV co-infected patients and their evolution between 2004 and 2006.

METHODS

Three hundred and eighty HIV-HCV co-infected patients were prospectively included in surveys from November 22 to 29, 2004 (2004 survey), and 416 from April 3 to 10, 2006 (2006 survey).

RESULTS

Patients in 2006 compared to those in 2004 had negative HCV RNA more often (24% vs. 12%). The rate of liver biopsy was similar (56% vs. 54%) while 24% had had a non-invasive liver damage assessment. The rate of previous treatment for HCV infection was higher (48% vs. 26%). The main reasons for HCV non-treatment have changed: HCV treatment deemed questionable (44% vs. 53%), lack of liver biopsy (18% vs. 33%), physicians' conviction of poor patient compliance (20% vs. 30%). In both surveys, HCV treated patients were more often of European origin, had better control of HIV infection, and had a liver damage assessment more often.

CONCLUSIONS

The care of HIV-HCV co-infected patients has changed significantly in "real life". These results underline the importance of continuing efforts to educate physicians and patients in order to increase the access of co-infected patients to HCV treatment.

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.

Adherence to hepatitis C treatment in recovering heroin users maintained on methadone

OBJECTIVES

Injection drug users are often denied hepatitis C (HCV) treatment due to concerns about adherence, despite limited data about the impact of such common issues as psychiatric illness and intercurrent drug use. We sought to define the impact of these and other potential adherence barriers in a real-world sample of recovering drug users.

METHODS

We conducted a prospective observational study of 71 methadone-maintained patients who received interferon and ribavirin combination therapy in a community-based clinic with expertise in treating addictive disorders. Adherence measures were conducted with monthly interview, medication counts, and urine toxicology testing.

RESULTS

Overall, 48 (68%) were adherent, and adherent patients were significantly more likely to achieve a sustained virologic response (42 vs. 4% in nonadherent patients). Patients with and without a prior psychiatric history were similarly adherent (64 vs. 72%, respectively, P>0.5), and the initiation of new psychiatric medications during HCV treatment was associated with improved adherence overall (P=0.02) and in patients that did not report a preexisting psychiatric diagnosis (P=0.04). Trend towards reduced adherence in patients without a period of abstinence was seen before initiating HCV treatment, 46 vs. 72% of those who had been abstinent for at least 1 month (P=0.10). Although occasional drug users were similarly adherent to those who were completely abstinent, patients who relapsed to regular drug use showed a significantly lower level of adherence (P=0.03).

CONCLUSIONS

We conclude that the majority of methadone-maintained drug users can adhere to HCV treatment, even those with psychiatric illness and relatively limited pretreatment drug abstinence. Lack of pre-HCV treatment drug abstinence and regular drug use during HCV treatment may be relative barriers to medication adherence, but the initiation of psychiatric medications during HCV treatment may be a helpful intervention. This report provides further evidence for an individualized approach to HCV treatment that does not categorically exclude patients with potential barriers such as mental illness and limited drug abstinence.

Management of chronic hepatitis C: consensus guidelines

Since the last consensus conference on the management of chronic viral hepatitis, a number of studies looking at modifications of the standard course of treatment have been published. These changes have been sufficiently substantive to warrant review to determine whether any changes in the recommended treatment algorithms are needed. A consensus development conference was held in January 2007, and the present document highlights the results of the presentations and discussion about these issues. It reviews the epidemiology of hepatitis C in Canada, treatment of acute hepatitis C and new algorithms in chronic hepatitis C, including retreatment of previous treatment failures. In addition, sections on management of hepatitis C in special populations have been updated. There is also a section on the use of hematopoietic growth factors to help manage patients on therapy. The document should be read in conjunction with the previous document to identify changes. Some recommendations made in the previous document remain and are not discussed here.

Alcohol and the liver

PURPOSE OF REVIEW

This review aims to acquaint the reader with advances in 2006 in the epidemiology, genetics, detection, pathogenesis and treatment of alcoholic liver disease.

RECENT FINDINGS

Important discoveries have been made in pathogenesis and mechanism of disease, with great emphasis on the many pathways leading to oxidative stress, and the novel mechanism of endoplasmic reticulum stress that is proving to be important in the pathogenesis of many liver diseases. The reliability of ethyl glucuronide and other biomarkers for the detection of alcohol abuse is being better established. There have been no treatment advances for alcoholic liver disease but, on balance, steroids are still favored for carefully selected patients with alcoholic hepatitis. Many compounds tested in rodents may now be available for consideration for clinical trials. Criteria for patient selection and refusal for liver transplantation are being established but the 6 months abstinence rule still holds.

SUMMARY

Insights are being made into the pathogenesis of alcoholic liver disease but safe and effective therapies for both alcoholic hepatitis and alcoholic cirrhosis have yet to be discovered.