Structural Bone Deficits in HIV/HCV-Coinfected, HCV-Monoinfected, and HIV-Monoinfected Women

Re, Vincent Lo; Lynn, Kenneth; Stumm, Emily; Long, Jin; Nezamzadeh, Melissa S.; Baker, Joshua F.; Hoofnagle, Andrew N.; Kapalko, Angela; Mounzer, Karam; Zemel, Babette S.; Tebas, Pablo; Kostman, Jay R.; Leonard, Mary B.

doi:10.1093/infdis/jiv147

Cited by 24 publications

(10 citation statements)

References 53 publications

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“…29 A separate analysis among HIV/HCV-coinfected patients in the Swiss HIV Cohort Study found that deferring treatment from METAVIR stage F2 until stage F3 or F4 increased the risk of liver-related death 2-fold and 5-fold, respectively. 30 Denial of DAA treatment can also lead to ongoing HCV-associated inflammation, which might increase the risk of extra-hepatic complications, including bone, 31,32 kidney, 33,34 cardiovascular, 35 and neuropsychiatric disease. 36 Further, failure to treat and cure chronic HCV can lead to continued risk of HCV transmission.…”

Section: Discussionmentioning

confidence: 99%

Disparities in Absolute Denial of Modern Hepatitis C Therapy by Type of Insurance

Gowda

Urick

et al. 2016

Clinical Gastroenterology and Hepatology

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116

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Background & Aims The high costs of direct-acting antiviral (DAA) agents to treat chronic hepatitis C virus (HCV) infection have resulted in denials of treatment, but it is not clear whether patients’ access to these therapies differs with their type of insurance. Methods We conducted a prospective cohort study among all patients who had a DAA prescription submitted between November 1, 2014 and April 30, 2015 to Burman’s Specialty Pharmacy, which provides HCV pharmacy services to patients in Delaware, Maryland, New Jersey, and Pennsylvania. We determined the incidence of absolute denial of DAA prescription, defined as lack of approval of prescription fill by the insurer, according to type of insurance (US Medicaid, US Medicare, commercial insurance). Multivariable Poisson regression was used to estimate adjusted relative risks (RRs) of absolute denial associated with patient characteristics. Results Among 2321 patients prescribed a DAA regimen (503 covered by Medicaid; 795 by Medicare; 1023 by commercial insurance), 377 (16.2%) received an absolute denial. The most common reasons for absolute denial were insufficient information to assess medical need (134 [35.5%]) and lack of medical necessity (132 [35.0%]). A higher proportion of patients covered by Medicaid received an absolute denial (233 [46.3%]) than those covered by Medicare (40 [5.0%]; P<.001) or commercial insurance (104 [10.2%]; P<.001). Medicaid insurance (adjusted RR, 4.14; 95% confidence interval, 3.38–5.08) and absence of cirrhosis (adjusted RR, 1.96; 95% confidence interval, 1.53–2.50) were associated with absolute denial. Conclusions There are significant disparities in access to DAA-based treatments for HCV infection among patients with different types of insurance. Nearly half of Medicaid beneficiaries in Delaware, Maryland, New Jersey, and Pennsylvania were denied access to these drugs for chronic HCV infection.

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Section: Discussionmentioning

confidence: 99%

Disparities in Absolute Denial of Modern Hepatitis C Therapy by Type of Insurance

Gowda

Urick

et al. 2016

Clinical Gastroenterology and Hepatology

Self Cite

116

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“…reported reduced trabecular bone density and trabecular and cortical thickness in both the radius and tibia in 30 young American African and Hispanic men; reduced bone stiffness was also demonstrated at these sites using finite element analysis . Finally, women co‐infected with HCV/HIV have been shown to have significantly lower trabecular volumetric BMD and smaller cortical dimensions in the tibia, compared to healthy subjects . In all these studies, the majority of subjects were established on ART, and whether the observed changes reflect bone loss during initiation of therapy is unclear.…”

Section: Mechanisms Of Bone Fragility and Fracture In Hiv Infection (mentioning

confidence: 99%

HIV infection and bone disease

Compston

2016

J Intern Med

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The success of antiretroviral therapy in treating HIV infection has greatly prolonged life expectancy in affected individuals, transforming the disease into a chronic condition. A number of HIV-associated non-AIDS comorbidities have emerged in the ageing HIV-infected population, including osteoporosis and increased risk of fracture. The pathogenesis of fracture is multifactorial with contributions from both traditional and HIV-specific risk factors. Significant bone loss occurs on initiation of antiretroviral therapy but stabilizes on long-term therapy. Fracture risk assessment should be performed in HIV-infected individuals and bone mineral density measured when indicated. Lifestyle measures to optimize bone health should be advised and, in individuals at high risk of fracture, treatment with bisphosphonates considered.

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“…As mentioned above, although not associated with significantly lower BMD than HIV or HCV mono-infection in most studies [27,31,32,57,58], HIV/HCV co-infection has been consistently shown to predict much greater fracture risk than HIV mono-infection (hazard ratios ranging from 1.2 to 2.4) [2,6,8]. This suggests that BMD might be inadequately assessing fracture risk in this population.…”

Section: Introductionmentioning

confidence: 96%

“…Among HIV-infected patients, BMD further decreases 2–6% over the first two years of antiretroviral therapy (ART) initiation [23–25]. HCV coinfection has been associated with further reductions in BMD among HIV-infected patients in some [26–30], but not all studies [30–33]. These findings raise the possibility that the higher fracture risk observed in patients with chronic HCV infection might not be due to low BMD alone, but could involve other mechanism(s).…”

Section: Introductionmentioning

confidence: 99%

“…Using tibial HRpQCT, Lo Re et al [33] conducted a cross-sectional analysis of 50 HIV/HCV-coinfected, 51 HCV-monoinfected, and 50 HIV-monoinfected women. The study found that compared with 263 healthy reference patients, HIV/HCV co-infected women had decreased tibial trabecular volumetric BMD, diminished cortical dimensions, and significant endocortical bone loss.…”

Section: Introductionmentioning

confidence: 99%

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Hepatitis C virus coinfection as a risk factor for osteoporosis and fracture

Bedimo

Maalouf

2016

Current Opinion in HIV and AIDS

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Purpose of Review With increased survival of HIV-infected patients, osteoporotic fractures have developed as a major cause of morbidity in these patients, and chronic hepatitis C virus (HCV) co-infection has emerged as a significant contributor to this increased fracture risk. This article reviews the epidemiologic and clinical evidence for osteoporosis and increased fracture risk among HIV/HCV co-infected patients, as well as potential mechanisms for these outcomes with HCV co-infection. Recent Findings Epidemiologic studies suggest that HIV/HCV co-infected patients exhibit a 3-fold increased fracture incidence compared to uninfected controls, and 1.2–2.4-fold increased fracture risk compared to HIV mono-infected patients. Recent reports suggest that chronic HCV co-infection is independently associated with reduced bone mineral density in HIV, but that it is not associated with significantly increased bone turnover. The deleterious impact of chronic HCV on BMD and fracture risk occurs even in the absence of advanced liver fibrosis or cirrhosis. New tools to assess bone quality, including the trabecular bone score, high resolution peripheral quantitative computed tomography, and in vivo microindentation, may help improve understanding of the mechanisms of HCV-associated skeletal fragility. The impact of approved anti-osteoporosis medications and direct-acting antivirals for the treatment of chronic HCV infection on patients’ bone health remain to be studied. Summary Chronic HCV infection is an independent risk factor for osteoporosis and fractures among HIV-infected patients, even prior to the development of cirrhosis. The underlying mechanisms are being unraveled, but major questions persist regarding the optimal evaluation and management of bone health in HIV/HCV co-infected patients.

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Structural Bone Deficits in HIV/HCV-Coinfected, HCV-Monoinfected, and HIV-Monoinfected Women

Cited by 24 publications

References 53 publications

Disparities in Absolute Denial of Modern Hepatitis C Therapy by Type of Insurance

Disparities in Absolute Denial of Modern Hepatitis C Therapy by Type of Insurance

HIV infection and bone disease

Hepatitis C virus coinfection as a risk factor for osteoporosis and fracture

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