Psychiatric care of the patient with hepatitis C: a review of the literature

Microelimination of Hepatitis C in patients with substance use and dual disorders - a Portuguese study

Chronic hepatitis C is a serious condition with relevant public health implications. In Portugal, the prevalence of detectable HCV antibodies is about 0,54%, with higher values in risk groups. Compared to the general population, the prevalence of HCV infection is higher in individuals with psychiatric disorders. There are no studies reporting the prevalence of HCV antibodies in Portuguese psychiatric patients, or in patients with substance use disorders.We carried an observational, prospective study during a period of one year, for patients followed at the Dual Pathology Outpatient and Inpatient Unity of the Coimbra Hospital and University Center, and patients were tested for HCV antibodies. Of 149 patients, 17.4% had positive HCV antibodies and 7.38% had detectable HCV RNA. Patients with confirmed CHC were mostly male inpatients, aged 50 to 59 years, and reported unprotected sex with more than one concurrent partner in the previous six months; their main psychiatric diagnosis was "Disorders due to use of multiple specified psychoactive substances, including medications".This study reports a very high prevalence of positive HCV antibodies and confirmed CHC in patients followed in the Dual Pathology Outpatient and Inpatient Unity. This prevalence is higher than in general Portuguese population.

Chronic Hepatitis C Virus Infection, Extrahepatic Disease and the Impact of New Direct-Acting Antivirals

Chronic hepatitis C virus infection is an important cause of liver cirrhosis, hepatocellular carcinoma and death. Furthermore, it is estimated that about 40-70% of patients develop non-hepatic alterations in the course of chronic infection. Such manifestations can be immune-related conditions, lymphoproliferative disorders and metabolic alterations with serious adverse events in the short and long term. The introduction of new Direct-Acting Antivirals has shown promising results, with current evidence indicating an improvement and remission of these conditions after a sustained virological response.

Real-world effectiveness and safety of direct-acting antivirals in hepatitis C virus patients with mental disorders

BACKGROUND

It is estimated that 58 million people worldwide are infected with the hepatitis C virus (HCV). Patients with severe psychiatric disorders could not be treated with previously available interferon-based therapies due to their unfavorable side effect profile. This has changed with the introduction of direct-acting antivirals (DAA), although their real-life tolerance and effectiveness in patients with different psychiatric disorders remain to be demonstrated.

AIM

To evaluate the effectiveness and safety of DAA in patients with various mental illnesses.

METHODS

This was a retrospective observational study encompassing 14272 patients treated with DAA for chronic hepatitis C in 22 Polish hepatology centers, including 942 individuals diagnosed with a mental disorder (anxiety disorder, bipolar affective disorder, depression, anxiety-depressive disorder, personality disorder, schizophrenia, sleep disorder, substance abuse disorder, and mental illness without a specific diagnosis). The safety and effectiveness of DAA in this group were compared to those in a group without psychiatric illness (n = 13330). Antiviral therapy was considered successful if serum ribonucleic acid (RNA) of HCV was undetectable 12 wk after its completion [sustained virologic response (SVR)]. Safety data, including the incidence of adverse events (AEs), serious AEs (SAEs), and deaths, and the frequency of treatment modification and discontinuation, were collected during therapy and up to 12 wk after treatment completion. The entire study population was included in the intent-to-treat (ITT) analysis. Per-protocol (PP) analysis concerned patients who underwent HCV RNA evaluation 12 wk after completing treatment.

RESULTS

Among patients with mental illness, there was a significantly higher percentage of men, treatment-naive patients, obese, human immunodeficiency virus and hepatitis B virus-coinfected, patients with cirrhosis, and those infected with genotype 3 (GT3) while infection with GT1b was more frequent in the population without psychiatric disorders. The cure rate calculated PP was not significantly different in the two groups analyzed, with a SVR of 96.9% and 97.7%, respectively. Although patients with bipolar disorder achieved a significantly lower SVR, the multivariate analysis excluded it as an independent predictor of treatment non-response. Male sex, GT3 infection, cirrhosis, and failure of previous therapy were identified as independent negative predictors. The percentage of patients who completed the planned therapy did not differ between groups with and without mental disorders. In six patients, symptoms of mental illness (depression, schizophrenia) worsened, of which two discontinued treatments for this reason. New episodes of sleep disorders occurred significantly more often in patients with mental disorders. Patients with mental illness were more frequently lost to follow-up (4.2% vs 2.5%).

CONCLUSION

DAA treatment is safe and effective in HCV-infected patients with mental disorders. No specific psychiatric diagnosis lowered the chance of successful antiviral treatment.

Statewide Assessment of the Hepatitis C Virus Care Cascade for Incarcerated Persons in Vermont

OBJECTIVES

Incarcerated persons in the United States have a high burden of hepatitis C virus (HCV) infection. This study assessed the impact of a statewide effort in Vermont to treat HCV in this group.

METHODS

We performed a retrospective, observational cohort study of all HCV-infected persons who were imprisoned in Vermont during the 19-month study period (December 2018-June 2020). The cascade of care comprised opt-out HCV screening, full access to direct-acting antiviral treatment (without hepatic fibrosis-based treatment restrictions), HCV specialist involvement, and medication-assisted treatment for patients with opioid use disorder. The primary outcome was sustained virologic response at 12 weeks after treatment completion (SVR12).

RESULTS

The study included 217 HCV-infected patients; the median age was 35 years (range, 18-73 years), 89% were male, 76% had opioid use disorder, 67% had a psychiatric comorbidity, and 9% had cirrhosis. Of the 217 patients, 98% had a liver fibrosis assessment, 59% started direct-acting antiviral treatment, 55% completed direct-acting antiviral treatment, and 51% achieved documented SVR12. Of the 129 HCV-infected persons who started direct-acting antiviral treatment, 92% completed therapy and 86% achieved documented SVR12. Psychiatric comorbidity was not significantly associated with achieving SVR12 (odds ratio = 0.67; 95% CI, 0.27-1.65; P = .38), nor was receiving medication-assisted treatment for patients with opioid use disorder (odds ratio = 1.45; 95% CI, 0.62-2.56; P = .45).

CONCLUSIONS

This study reports the highest SVR12 rate achieved in a state incarcerated population to date. HCV treatment in incarcerated populations is a practical and efficacious strategy that should serve a foundational role in HCV elimination.

Neuropsychological profile of patients with infectious disease: characterization and comparison of patients with HIV, HTLV, and HCV

Understanding the effect of the HIV, HTLV-1, and HCV viruses on cognitive aspects can help in the better characterization of dementia, as well as the best conducts to be suitable for rehabilitation. Thus, the present study aimed to characterize and compare the neuropsychological profile of 3 groups of patients with infectious diseases: HIV, HTLV, and HCV. The results of neuropsychological assessments and depression assessment of 325 people treated at a referral hospital for infectious diseases were analyzed, being 120 HIV carriers (74 (61.7%) men) with an average age of 47.5 years (SD = 10.3), 65 patients with HTLV-1 (16 (24.6%) men) with a mean age of 49.9 years (SD = 12.9), and 87 HCV patients (47 (54%) men) with a mean age of 55.5 years (SD = 11.2). In addition, 54 people (26 (48.1%) men) with negative serology who made up the control group were evaluated. The results of the statistical evaluation of the sociodemographic factors of the four groups (HIV, HTLV-1, HCV, and control) showed that in addition to age, schooling was a significant factor among them and may have a strong influence on the performance of cognitive tests. The HTLV-1 group had the lowest neurocognitive performance and also the highest rate of depressive symptoms.

Neurological and psychiatric effects of hepatitis C virus infection

Hepatitis C virus (HCV) infection is widespread and affects 71 million people worldwide. Although hepatic manifestations are the most frequent, ranging from chronic hepatitis to cirrhosis and hepatocellular carcinoma, it is also associated with several extrahepatic manifestations. Infected patients may present non-specific neurological symptoms, regardless of the presence of liver cirrhosis. Several pathogenetic mechanisms underlying neurological symptoms have been hypothesized: neuroinvasion, immune-mediated damage, neurotransmitter alterations and cryoglobulinemia. Alterations of the central nervous system include cerebral vasculopathy, acute or subacute encephalopathy and inflammatory disorders. HCV infection may be responsible for neuropathies, of which the most frequent form is symmetrical axonal sensory or sensory-motor polyneuropathy which causes loss of leg sensitivity and weakness. Up to 50% of patients with HCV infection may experience cognitive decline and psychological disorders, such as depression and fatigue. HCV associated neurocognitive disorder is independent of the presence of liver cirrhosis and affects different domains than in patients with hepatic encephalopathy. It can be studied using specific tests that mainly explore executive functions, verbal learning and verbal recall. These disorders significantly reduce the quality of life. The new antiviral therapies improve the extrahepatic symptoms of HCV infection and their success depends on the achievement of sustained virological response. However, the effect of therapy may differ depending on the type of organ involved; neurological symptoms can be irreversible if there is organic liver damage. The aim of this review is to provide a critical overview of physiopathological mechanisms, diagnostic and therapeutic strategies of the neurological and psychiatric effects of HCV infection.

Evaluation of depression, anxiety and quality of life in hepatitis C patients who treated with direct acting antiviral agents

BACKGROUND/AIMS

Hepatitis C virus (HCV) infection is known to impair the quality of life (QoL). Increased levels of anxiety and depression have been found in HCV infection with a prevalence of 28% and 33%, respectively. Our aim was to investigate depression, anxiety, and QoL of chronic hepatitis C (CHC) patients before and after treatment with a direct-acting antiviral agent (DAAA).

MATERIALS AND METHODS

In this study, enrolled CHC patients who had undergone DAAA treatment in our out-patient clinic. We administered the Hospital Anxiety and Depression (HAD) questionnaire to measure the severity of the anxiety and depression symptoms and the Short Form-36 (SF-36) questionnaire to measure the QoL at the beginning and at the end of the treatment.

RESULTS

Pretreatment anxiety and depression scores showed a statistically significant difference from the post treatment scores (p=0.000 and p=0.029 respectively). When we compared the SF-36 subitems before and after the treatment, a statistical significance was found in physical functioning (p=0.026), physical role limitation (p=0.009), bodily pain (p=0.011), general health (p=0.017), social functioning (p=0.006), and emotional role limitation (p=0.007). Also, an improvement was seen in the vitality (p=0.488) and mental health (p=0.714), which was not statistically significant.

CONCLUSION

Depression got minimally worse in the male group despite an improvement in CHC. Anxiety scores were improved with treatment in the cirrhotic and non-cirrhotic groups significantly. A decrease in anticipatory anxiety may be related to the high treatment success with DAAA. Nearly all the subitems of the QoL scores were improved after treatment and these were more common in the female group. Elimination of HCV may itself decrease the number of patients who need psychiatric treatment.

Efficacy and safety of glecaprevir/pibrentasvir in patients with chronic HCV infection and psychiatric disorders: An integrated analysis

Although direct-acting antivirals (DAAs) for chronic hepatitis C virus (HCV) infection are highly efficacious and safe, treatment initiation is often limited in patients with neuropsychiatric disorders due to concerns over reduced treatment adherence and drug-drug interactions. Here, we report adherence, efficacy, safety and patient-reported outcomes (PROs) from an integrated analysis of registrational studies using the pangenotypic DAA regimen of glecaprevir and pibrentasvir (G/P). Patients with chronic HCV genotypes 1-6 infection with compensated liver disease (with or without cirrhosis) receiving G/P for 8, 12 or 16 weeks were included in this analysis. Patients were classified as having a psychiatric disorder based on medical history and/or co-medications. Primary analyses assessed treatment adherence, efficacy (sustained virologic response at post-treatment week 12; SVR12), safety and PROs. Among 2522 patients receiving G/P, 789 (31%) had a psychiatric disorder with the most common diagnoses being depression (64%; 506/789) and anxiety disorders (27%; 216/789). Treatment adherence was comparably high (>95%) in patients with and without psychiatric disorders. SVR12 rates were 97.3% (768/789; 95% CI = 96.2-98.5) and 97.5% (1689/1733; 95% CI = 96.7-98.2) in patients with and without psychiatric disorders, respectively. Among patients with psychiatric disorders, SVR12 rates remained >96% by individual psychiatric diagnoses and co-medication classes. Overall, most adverse events (AEs) were mild-to-moderate in severity with serious AEs and AEs leading to G/P discontinuation occurring at similarly low rates in both patient populations. In conclusion, G/P treatment was highly efficacious, well-tolerated and demonstrated high adherence rates in patients with chronic HCV infection and psychiatric disorders.

Budgetary impact analysis of a primary care-based hepatitis C treatment program: Effects of 340B Drug Pricing Program

PURPOSE

Safety-net health systems, which serve a disproportionate share of patients at high risk for hepatitis C virus (HCV) infection, may use revenue generated by the federal drug discount pricing program, known as 340B, to support multidisciplinary care. Budgetary impacts of repealing the drug-pricing program are unknown. Our objective was to conduct a budgetary impact analysis of a multidisciplinary primary care-based HCV treatment program, with and without 340B support.

METHODS

We conducted a budgetary impact analysis from the perspective of a large safety-net medical center in Boston, Massachusetts. Participants included 302 HCV-infected patients (mean age 45, 75% male, 53% white, 77% Medicaid) referred to the primary care-based HCV treatment program from 2015-2016. Main measures included costs and revenues associated with the treatment program. Our main outcomes were net cost with and without 340B Drug Pricing support.

RESULTS

Total program costs were $942,770, while revenues totaled $1.2 million. With the 340B Drug Pricing Program the hospital received a net revenue of $930 per patient referred to the HCV treatment program. In the absence of the 340B program, the hospital would lose $370 per patient referred. Ninety-seven percent (68/70) of patients who initiated treatment in the program achieved a sustained virologic response (SVR) at a net cost of $4,150 each, among this patient subset.

CONCLUSIONS

The 340B Drug Pricing Program enabled a safety-net hospital to deliver effective primary care-based HCV treatment using a multidisciplinary care team. Efforts to sustain the 340B program could enable dissemination of similar HCV treatment models elsewhere.

Identifying cirrhosis, decompensated cirrhosis and hepatocellular carcinoma in health administrative data: A validation study

Background

To evaluate screening and treatment strategies, large-scale real-world data on liver disease-related outcomes are needed. We sought to validate health administrative data for identification of cirrhosis, decompensated cirrhosis and hepatocellular carcinoma among patients with known liver disease.

Methods

Primary patient data were abstracted from patients of the Toronto Center for Liver Disease with viral hepatitis (2006–2014), and all patients with liver disease from the Kingston Health Sciences Centre Hepatology Clinic (2013). We linked clinical information to health administrative data and tested a range of coding algorithms against the clinical reference standard.

Results

A total of 6,714 patients had primary chart data abstracted. A single physician visit code for cirrhosis was sensitive (98–99%), and a single hospital diagnostic code for cirrhosis was specific (91–96%). The most sensitive algorithm for decompensated cirrhosis was one cirrhosis code with any of: a hospital diagnostic code, death code, or procedure code for decompensation (range 88–99% across groups). The most specific was one cirrhosis code and one hospital diagnostic code (range 89–98% across groups). Two physician visit codes or a single hospital diagnostic code, death code, or procedure code combined with a code for cirrhosis were sensitive and specific for hepatocellular carcinoma (sensitivity 94–96%, specificity 93–98%).

Conclusion

These sensitive and specific algorithms can be used to define patient cohorts or detect clinical outcomes using health administrative data. Our results will facilitate research into the adequacy of screening and treatment for patients with chronic viral hepatitis or other liver diseases.

New direct-acting antivirals for hepatitis C treatment and neuropsychiatric symptoms in psychiatric risk groups

Objectives

The new direct-acting antivirals (DAAs) have changed chronic hepatitis C virus (HCV) treatment perspectives by achieving success rates in all genotypes and by reducing the associated adverse effects in comparison to pegylated interferon α regimens. These adverse effects include depression, insomnia and suicidal intention, which make it difficult to treat psychiatric risk groups. The objectives of this study were to evaluate the neuropsychiatric symptoms during HCV treatment with DAAs in standard multidisciplinary clinical practice in psychiatric risk groups and to assess the risk factors associated with neuropsychiatric symptoms in this study population.

Methods

A prospective cross-sectional study was performed of all consecutive patients with psychiatric risk and HCV infection who completed treatment with the new DAAs at the ambulatory care pharmacy. We recorded demographic and clinical data, neuropsychiatric symptoms, emergency consultations, admissions to the psychiatric unit and interventions to manage neuropsychiatric symptoms. Statistical analysis was used to assess the association between neuropsychiatric symptoms and clinical data.

Results

We included 48 patients with psychiatric risk and detected 36 neuropsychiatric symptoms in 17 (35.4%) patients, with a mean of 0.75 neuropsychiatric symptoms per patient. However, no studied risk factors for developing neuropsychiatric symptoms were found in this population.

Conclusions

We found a moderate prevalence of neuropsychiatric symptoms in the psychiatric risk group. The neuropsychiatric symptoms more frequently reported were insomnia (17%), irritability (15%) and depression (13%). Neuropsychiatric symptoms in patients with psychiatric risk can occur during treatment with DAAs but less frequently than with pegylated interferon α regimens, and so is a safe treatment for these patients.

Neuropsychiatric Aspects of Infectious Diseases: An Update

Among the critically ill, infectious diseases can play a significant role in the etiology of neuropsychiatric disturbances. All critical care physicians are familiar with delirium as a secondary complication of systemic infection. This article focuses on key infectious diseases that commonly and directly produce neuropsychiatric symptoms, including direct infection of the central nervous system, human immunodeficiency virus infection, and AIDS.

Loss to follow-up in anti-HCV-positive patients in a Brazilian regional outpatient clinic

Loss to follow-up (LF), which refers to patients who started care but voluntary stopped it, is a problem for patients with chronic disease. We aimed to estimate the rate of LF among patients seropositive for hepatitis C virus (HCV) and identify possible demographic and lifestyle risk factors associated with LF. From January 2009 through December 2012, 1010 anti-HCV-positive patients were included in the study. Among participants, 223 (22.1%) met the case definition for LF (more than 1-year elapsed since the last clinical appointment). Among 787 patients who remained in follow-up, 372 (47.2%) were discharged after undetectable HCV RNA, 88 (11.1%) were transferred (and remained on regular follow-up at the destination), and 25 (3.1%) died. According to univariate analysis, male gender, absence of a life partner, black race, psychiatric illness, previous alcohol abuse, previous or current recreational drug use, and previous or current smoking were significantly associated with LF. In multivariate analysis, absence of a life partner (adjusted odds ratio (AOR)=1.44; 95% confidence interval (95%CI)=1.03–2.02), black race (AOR=1.81, 95%CI=1.12–2.89), psychiatric illness (AOR=1.77, 95%CI=1.14–2.73), and the presence of at least one lifestyle risk factor (pertaining to substance abuse) (AOR=1.95, 95%CI=1.29–2.94) were independently associated with LF. Our study provides an estimate of the incidence of LF among anti-HCV-positive patients and identifies risk factors associated with this outcome. In addition, these results can help clinicians recognize patients at risk for LF, who require additional support for the continuity of care.

Hepatitis C virus and neurological damage

Chronic hepatitis C virus (HCV) infection exhibits a wide range of extrahepatic complications, affecting various organs in the human body. Numerous HCV patients suffer neurological manifestations, ranging from cognitive impairment to peripheral neuropathy. Overexpression of the host immune response leads to the production of immune complexes, cryoglobulins, as well as autoantibodies, which is a major pathogenic mechanism responsible for nervous system dysfunction. Alternatively circulating inflammatory cytokines and chemokines and HCV replication in neurons is another factor that severely affects the nervous system. Furthermore, HCV infection causes both sensory and motor peripheral neuropathy in the mixed cryoglobulinemia as well as known as an important risk aspect for stroke. These extrahepatic manifestations are the reason behind underlying hepatic encephalopathy and chronic liver disease. The brain is an apt location for HCV replication, where the HCV virus may directly wield neurotoxicity. Other mechanisms that takes place by chronic HCV infection due the pathogenesis of neuropsychiatric disorders includes derangement of metabolic pathways of infected cells, autoimmune disorders, systemic or cerebral inflammation and alterations in neurotransmitter circuits. HCV and its pathogenic role is suggested by enhancement of psychiatric and neurological symptoms in patients attaining a sustained virologic response followed by treatment with interferon; however, further studies are required to fully assess the impact of HCV infection and its specific antiviral targets associated with neuropsychiatric disorders.

Clinical utility of pharmacogenomics in the management of hepatitis C

Hepatitis C virus (HCV) was identified for the first time more than 20 years ago. Since then, several studies have highlighted the complicated aspects of this viral infection in relation to its worldwide prevalence, its clinical presentation, and its therapeutic response. Recently, two landmark scientific breakthroughs have moved us closer to the successful eradication of chronic HCV infection. First, response rates in treatment-naïve patients and in prior non-responders to pegylated-interferon-α and ribavirin therapy are increasing as a direct consequence of the development of direct-acting antiviral drugs. Secondly, the discovery of single-nucleotide polymorphisms near the interleukin 28B gene significantly related to spontaneous and treatment-induced HCV clearance represents a milestone in the HCV therapeutic landscape. The implementation of this pharmacogenomics finding as a routine test for HCV-infected patients has enhanced our understanding of viral pathogenesis, has encouraged the design of ground-breaking antiviral treatment regimens, and has become useful for pretreatment decision making. Nowadays, interleukin 28B genotyping is considered to be a key diagnostic tool for the management of HCV-infected patients and will maintain its significance for new combination treatment schemes using direct-acting antiviral agents and even in interferon-free regimens. Such pharmacogenomics insights represent a challenge to clinicians, researchers, and health administrators to transform this information into knowledge with the aim of elaborating safer and more effective therapeutic strategies specifically designed for each patient. In conclusion, the individualization of treatment regimens for patients with hepatitis C, that may lead to a universal cure in future years, is becoming a reality due to recent developments in biomarker and genomic medicine. In light of these advances, we review the scientific evidence and clinical implications of recent findings related to host genetic factors in the management of HCV infection.

Hepatitis C, mental health and equity of access to antiviral therapy: a systematic narrative review

INTRODUCTION

Access to hepatitis C (hereafter HCV) antiviral therapy has commonly excluded populations with mental health and substance use disorders because they were considered as having contraindications to treatment, particularly due to the neuropsychiatric effects of interferon that can occur in some patients. In this review we examined access to HCV interferon antiviral therapy by populations with mental health and substance use problems to identify the evidence and reasons for exclusion.

METHODS

We searched the following major electronic databases for relevant articles: PsycINFO, Medline, CINAHL, Scopus, Google Scholar. The inclusion criteria comprised studies of adults aged 18 years and older, peer-reviewed articles, date range of (2002-2012) to include articles since the introduction of pegylated interferon with ribarvirin, and English language. The exclusion criteria included articles about HCV populations with medical co-morbidities, such as hepatitis B (hereafter HBV) and human immunodeficiency virus (hereafter HIV), because the clinical treatment, pathways and psychosocial morbidity differ from populations with only HCV. We identified 182 articles, and of these 13 met the eligibility criteria. Using an approach of systematic narrative review we identified major themes in the literature.

RESULTS

Three main themes were identified including: (1) pre-treatment and preparation for antiviral therapy, (2) adherence and treatment completion, and (3) clinical outcomes. Each of these themes was critically discussed in terms of access by patients with mental health and substance use co-morbidities demonstrating that current research evidence clearly demonstrates that people with HCV, mental health and substance use co-morbidities have similar clinical outcomes to those without these co-morbidities.

CONCLUSIONS

While research evidence is largely supportive of increased access to interferon by people with HCV, mental health and substance use co-morbidities, there is substantial further work required to translate evidence into clinical practice. Further to this, we conclude that a reconsideration of the appropriateness of the tertiary health service model of care for interferon management is required and exploration of the potential for increased HCV care in primary health care settings.

Neuropsychiatric and psychosocial issues of patients with hepatitis C infection: a selective literature review

CONTEXT

We briefly reviewed the evidence on the association of hepatitis C (HCV) infection with several aspects of mental and psychosocial health.

EVIDENCE ACQUISITION

Medline was searched with appropriate keywords. The primary sources were the systematic reviews. If systematic reviews were not available for a subject, then the most relevant and methodologically sound original studies were selected.

RESULTS

HCV infection is associated with poorer health-related quality of life, and physical, mental, and social health. A part of impaired health of these patients is related to cirrhosis, intravenous drug use, co morbid psychiatric disorders, stigmatization, poor social support, alcohol abuse, and interferon treatment. However, HCV itself is also associated with poorer health status particularly in the physical and cognitive domains, which might be related to brain alterations induced by the virus. Interferon treatment is an important cause of depression in HCV patients and sometimes is associated with irritability, manic episode, or acute confusional state. Social health of HCV patients is significantly impaired by stigmatization, poor social support, psychiatric comorbidties, and impaired coping. Psychosocial impairment of HCV patients significantly impairs their treatment adherence. A supportive and nonjudgmental multidisciplinary team is required for optimal management of these patients.

CONCLUSIONS

Patients with HCV infection had complex neuropsychiatric and psychosocial problems. These problems are challenges for management of HCV infection, affect the patient's care significantly, and might alter the course of the disease. A multidisciplinary approach, a supportive environment, and a nonjudgmental healthcare team are required for optimal medical and psychosocial management of patients with HCV.

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.