Optimizing Hepatitis C Virus (HCV) Treatment in a US Colocated HCV/Opioid Agonist Therapy Program

Background

A minority of patients with opioid use disorder are treated for hepatitis C virus infection (HCV). While colocated HCV and opioid agonist therapy (OAT) along with harm reduction can facilitate prevention and cascade to cure, there are few real-world examples of such embedded care models in the United States in the direct-acting antiviral (DAA) era.

Methods

We conducted a retrospective chart review to determine sustained virologic response (SVR) and reinfection rates during the first 5-year period of DAA availability among individuals tested and treated on-site at Rhode Island’s only nonprofit methadone maintenance program.

Results

Of 275 who initiated DAAs, the mean age (range) was 43 (22–71) years, 34.5% were female, 57.5% had genotype 1a, 23.3% had cirrhosis, and 92% were Medicaid recipients. SVR was 85.0% (232/273), while modified intent-to-treat SVR was 93.2% (232/249); 17 patients did not achieve SVR, 2 awaited SVR 12 weeks post-end-of-treatment, and 24 were lost to follow-up. Thirty reinfections were identified over 375.5 person-years of follow-up (rate, 7.99/100 person-years). The median time to first reinfection (interquartile range) was 128 (85.25–202.5) days. Before July 1, 2018, 72 patients accessed DAAs over 3.7 years; after Medicaid DAA restrictions were lifted, 109 patients accessed DAAs over 1.3 years. The Prior Authorization (PA) process requires many steps, differing across 11 RI insurers, taking 45–120 minutes per patient.

Conclusions

DAA treatment was effective among a marginalized population in an urban colocated OAT/HCV program. Removing DAA restrictions facilitates treatment initiation. The PA process remains a modifiable barrier to expanding capacity in the United States.

A Modifiable Barrier to Hepatitis C Virus Elimination in Rhode Island: The Prior Authorization Process for Direct-Acting Antiviral Agents

Hepatitis C virus (HCV) is disproportionately prevalent among different groups of marginalized populations in Rhode Island (RI). Although direct-acting antiviral (DAA) agents are safe and cure HCV, RI payers limit access to these life-saving medications using prior authorizations (PAs). We assessed RI DAA-specific PA criteria. The authors reviewed payers' websites and/or called payers to obtain, describe, and analyze DAA PA forms, and approval and appeal processes. While some information was consistently required, we observed substantial differences among payers' requirements. All PA forms require at least one piece of data that is clinically superfluous for DAA prescription. These include post-treatment laboratory results, prescriber requirements, documentation of co-treatment of substance use disorders, and repeat diagnostic tests. Post-approval barriers also exist; DAA PAs are time-limited, and DAAs can only be obtained from preferred pharmacies. The PA process requires many steps, differing across RI payers, taking 45-120 minutes per patient. To achieve HCV elimination, DAA PA forms and processes should be standardized, streamlined, and ultimately removed.