Identifying Barriers to the Treatment of Chronic Hepatitis C Infection

Abstract

Background and Aims: Chronic hepatitis C (CHC) viral infection has a major impact on our health care system. The emergence of direct-acting antiviral agents (DAA) has made treatment simple (oral), efficacious, and safe. However, treatment is expensive and access is variable. Despite great treatment outcomes, only a minority of patients with CHC receive antiviral therapy. This study identifies the barriers to treatment in CHC infection. Methods: Study recruited all hepatitis C antibody-positive patients between 2012 and 2016 from a large academic teaching hospital in New York City. Demographic information, clinical data, and insurance information were reviewed. Statistical analysis performed with OR and p < 0.05 reported. Result: A total of 1,548 patients with hepatitis C antibody-positive titer were included in the initial analysis. One thousand and twenty-four patients were forwarded to the final analysis after exclusion of 524 patients (for distant resolved hepatitis C viral [HCV] infection [n = 42], patients cured with interferon-based regimens [n = 94], patients with comorbid conditions [n = 176], and patients with an incomplete medical chart [n = 212]). In the intention to treat cohort of 1,024 patients, 204 patients achieved a sustained virological response after receiving DAAs (n = 204/1,024 – 20%). The majority of patients had not received DAAs (n = 816/1,024 patients – 80%). Multiple factors resulted in hepatitis C viral infection (HCV) patients not receiving DAAs including the following primary factors: (a) lost to follow-up clinic visits and poor adherence to clinic appointments (n = 548 [67%]; p value <0.0001), (b) active substance abuse (alcoholism and IV drug abuse; n = 165 [20%]; p value 0.22), (c) patients with significant psychiatric illness (n = 103 [12.7%]; p value 0.015), and subgroup analysis revealed that 188 (188/1,024 – 12%) patients had human immunodeficiency virus-1 (HIV-1) and HCV coinfection. Majority of HCV/HIV coinfected patients had not received DAAs (n = 176 [97%]; p value <0.0001, OR 4.46). The etiology of nontreatment in coinfected HIV/HCV patients was 73.3% poor adherence, 11.5% active substance abuse including alcohol and IV drug use, and 9% significant psychiatric illness and 6.2% multiple reasons for not receiving HCV treatment. Conclusion: Multifactorial barriers are preventing hepatitis C patients from receiving effective DAA therapy. Primary factors include poor compliance, substance abuse, and significant psychiatric illness, with significant overlap between these groups. Subgroup analysis showed a substantial number of high-risk patients with HIV/HCV coinfection did not receive DAA therapy. A multidisciplinary clinic approach with a hepatologist, ID physicians, social worker, and behavioral health psychologist and case manager should provide a solution to improve diagnosis and treatment with DAA.

Barriers to initiation of hepatitis C virus therapy in Germany: A retrospective, case-controlled study

“…Several other studies have also investigated potential barriers to HCV treatment. Concerns regarding adherence of patients to both treatment and care appointments are supported by other retrospective studies of patients with CHC that have shown as many as 30-67% of patients diagnosed with CHC and not initiating treatment did so as a result of poor adherence to clinic appointments or loss to follow-up [27,37]. Similar to this study, others have also shown that advanced age [25], comorbidities (in particular psychiatric illness), as well as alcohol and drug abuse [37], can be associated with nontreatment in patients with CHC [27,28].…”

“…Concerns regarding adherence of patients to both treatment and care appointments are supported by other retrospective studies of patients with CHC that have shown as many as 30-67% of patients diagnosed with CHC and not initiating treatment did so as a result of poor adherence to clinic appointments or loss to follow-up [27,37]. Similar to this study, others have also shown that advanced age [25], comorbidities (in particular psychiatric illness), as well as alcohol and drug abuse [37], can be associated with nontreatment in patients with CHC [27,28]. One recent study detailing physician attitudes towards CHC treatment in patients receiving opioid agonist treatment (OAT) in the United States, cited the perceived need for stable alcohol use and OAT, concerns regarding adherence, and challenging and marginalised patient lives as potential barriers to CHC treatment in this population [29].…”

“…Despite the wide availability of effective DAAs to treat HCV, a substantial proportion of patients diagnosed with CHC infection are still not initiating indicated treatment [27][28][29][30]. Patient preference seems to play a key role in this lack of initiation in clinical practice.…”

From Structural Studies to HCV Vaccine Design

“…Since 2014, a second generation of the DAAs have become available with a cure rate of better than 95%. Nonetheless, DAA treatment faces several challenges: (a) HCV infection can remain asymptomatic for years [ 6 ], and during this time many infections go undiagnosed while patients suffer from sustained liver damage; (b) DAA treatments do not prevent reinfections [ 7 ]; (c) DAA-resistant viruses can emerge; (d) patients with advanced liver disease remain at risk of liver cancer; and (e) HCV is highly prevalent in developing countries and among marginalized populations where access to HCV diagnosis and treatment is limited [ 8 ]. Indeed, many at-risk groups (e.g., PWIDs) spread the infection faster than they are being cured.…”

The Role of the Liver-Specific microRNA, miRNA-122 in the HCV Replication Cycle

“…In 2015, the release of interferon-free direct acting antiviral (DAA) therapy revolutionized HCV treatment and all DAA treatments now regularly achieve SVR rates to over 95% with few side effects [ 6 ]. However, identifying and treating individuals who do not know they are infected, poor adherence to therapy, and high therapy cost are barriers to worldwide elimination of HCV [ 7 , 8 , 9 ]. In addition, the high mutation rate of the virus may lead to the development of DAA resistance and a vaccine will be required to eliminate HCV infections worldwide [ 10 ].…”