Hepatitis C treatment uptake and response among human immunodeficiency virus/hepatitis C virus-coinfected patients in a large integrated healthcare system

Abstract

U.S guidelines recommend that patients coinfected with HIV and hepatitis C virus (HCV) be prioritized for HCV treatment with direct-acting antiviral agents (DAAs), but the high cost of DAAs may contribute to disparities in treatment uptake and outcomes. We evaluated DAA initiation and effectiveness in HIV/HCV-coinfected patients in a U.S.-based healthcare system during October 2014–December 2017. Of 462 HIV/HCV-coinfected patients, 276 initiated DAAs (70% cumulative proportion treated over 3 years). Lower likelihood of DAA initiation was observed among patients with Medicare (government-sponsored insurance) vs. commercial insurance (aRR=0.62, 95% CI=0.46-0.84), patients with drug abuse diagnoses (aRR=0.72, 95% CI=0.54-0.97), patients with CD4 count <200 vs. ≥500 (aRR=0.45, 95% CI=0.23-0.91) and patients without prior HCV treatment (aRR=0.68, 95% CI=0.48-0.97). There were no significant differences in DAA initiation by age, sex, race/ethnicity, socioeconomic status, HIV-transmission risk, alcohol use, smoking, fibrosis level, HIV RNA levels, ART use, hepatitis B infection, or number of outpatient visits. 95% of patients achieved SVR. We found little evidence of sociodemographic disparities in DAA initiation among HIV/HCV-coinfected patients, and SVR rates were high. Efforts are needed to increase DAA uptake among coinfected Medicare enrollees, patients with drug abuse diagnoses, patients with low CD4 count, and patients receiving first-time HCV treatment.

Barriers to hepatitis C direct‐acting antiviral therapy among HIV/hepatitis C virus‐coinfected persons

“…Early studies among both HCV‐monoinfected and HIV/HCV‐coinfected patients found that Hispanic Whites and Blacks were less likely to be treated 21,24,30–32 . Our finding of a lack of race/ethnicity‐based effect modification in the overall cohort is similar to more recent studies, which may be explained by the changing treatment environment, with more aggressive treatment of HIV/HCV‐coinfected patients 22,23 …”

“…21,24,[30][31][32] Our finding of a lack of race/ethnicity-based effect modification in the overall cohort is similar to more recent studies, which may be explained by the changing treatment environment, with more aggressive treatment of HIV/HCV-coinfected patients. 22,23 One unique characteristic of this cohort is that all patients were receiving primary care from a physician trained in HIV care, many of whom are infectious disease physicians. As has been encouraged by others, co-location of HIV and HCV treatment services may improve HCV treatment rates, particularly in populations such as this cohort, which may experience more patient-level barriers to treatment; co-location and treatment by an infectious diseases specialist also allows potential drug-drug interactions between ARVs and DAAs to be more easily addressed and eliminate the barrier imposed by some insurance companies requiring DAAs be prescribed by a specialist.…”

“…The rate of HCV DAA prescription (43%) was higher than two published estimates from studies of HIV/HCV-coinfected cohorts conducted from 2014 to 2015 (19% and 23%) and lower than two recently reported studies from 2014 to 2016 and 2014 to 2017 (51% and 60%). [20][21][22][23] The higher rates of prescription seen in the studies conducted in more recent years may be because of expanded DAA options, greater provider-driven uptake of DAAs, increased patient demand for treatment, and changes in payor-imposed restrictions (i.e. fewer restrictions) over time.…”

Predictors of linkage to hepatitis C virus care among people living with HIV with hepatitis C infection and the impact of loss to HIV follow‐up

“…In previous studies, PLWH who are successfully engaged in HIV care were more likely to initiate HCV therapy 10,23,38,39 . Although our study did not show that having a detectable viral load decreased the odds of completing an HCV evaluation visit, there was a trend in that direction.…”

Psychosocial Obstacles to Hepatitis C Treatment Initiation Among Patients in Care: A Hitch in the Cascade of Cure

“…During 2014 through 2017, cumulative DAA uptake among Kaiser Permanente Northern California patients with HIV/HCV coinfection was 70%. ( 41 ) These patients received health care planning support from case managers and were prioritized for hepatitis C treatment, which was coordinated within each medical facility by a lead infectious disease clinician and a system‐wide hepatitis C task force comprised of clinicians, researchers, and community‐based advocates. Improving DAA uptake may be more challenging among a less unified hepatitis C population (i.e., not otherwise united by a shared clinical condition, such as HIV coinfection) in private sector health care organizations.…”