Variation between Canadian centres in the uptake of treatment for hepatitis C by patients coinfected with HIV: a prospective cohort study

Abstract

Background: Uptake of treatment for hepatitis C virus (HCV) is low in Canada despite its publicly funded health care system. We explored the uptake of HCV treatment within the Canadian Co-infection Cohort to determine if some treatment centres have been more successful than others at starting patients with HIV-HCV coinfection on HCV treatment. Methods:We estimated the variation between 16 centres in the uptake of HCV treatment using a Weibull time-to-event model with adjustment for patient characteristics that are thought likely to influence the uptake of treatment. We asked the principal investigator at each centre about access to hepatitis-related specialists and services and the importance of various criteria when determining if a patient with HIV-HCV coinfection should receive treatment for HCV. Results:Among 681 untreated patients in the Canadian Co-infection Cohort, 163 patients with HIV-HCV coinfection started HCV treatment over a period of 1827 patient-years (9 per 100 patient-years). Even after adjustment for case mix, there was still appreciable variation in treatment uptake between centres, with mean hazard ratios of 0.43 (95% credible interval 0.11-1.3) and 3.6 (95% credible interval 1.7-8.4) for the centres least and most likely to start an average patient with HIV-HCV coinfection on HCV treatment. The most important criteria reported by principal investigators for determining eligibility for treatment were severity of fibrosis, current psychiatric comorbidities, current alcohol intake, past HCV treatment and a history of reinfection with HCV. However, the opinions were wide-ranging: 8 of the 15 criteria elicited both the responses "less important" and "very important." Interpretation:The magnitude of the centre effects and diverse opinions about the importance of treatment eligibility criteria suggest that provider-related barriers to HCV treatment uptake are as important as patient-related barriers. AbstractCMAJ OPEN, 1(3) E107 Research CMAJ OPENare infected with HCV. 11,12 In a recent survey, 80% of Canadian physicians who specialize in HCV said that they were not likely to provide HCV treatment to active injection drug users. 13 Injection drug users are often considered ineligible for treatment because of poor adherence to care, psychiatric illness or ongoing use of drugs or alcohol. 14,15 Even if eligible, patients with HCV may be reluctant to start treatment. 16 In the United States, patients are less likely to be offered and to accept HCV treatment if they are older, male, not white, infected with a difficult-to-treat HCV genotype, have psychiatric illness, or if they use drugs or alcohol. [17][18][19] Many studies have evaluated these patient-related barriers to treatment, 20,21 which are difficult to overcome. Provider and institutional barriers are also important; 17,22 these are perhaps more amenable to intervention. Although having access to an experienced provider is clearly important for the uptake of HCV treatment, [17][18][19] it is not clear what other provider and institutional bar...

Disparities in direct acting antivirals uptake in HIV‐hepatitis C co‐infected populations in Canada

“…In high‐income countries, HIV‐HCV co‐infection affects marginalized populations who are often socially disenfranchised with many competing priorities. Lower SES, substance abuse and mental illness have previously been associated with barriers to accessing healthcare . Results from our study provide evidence that patient‐related factors (IDU, low income and alcohol use) remain barriers to HCV treatment initiation in the DAA era.…”

“…Even though IDU has been characterized as a chronic relapsing brain disease, PWID may continue to face stigma and discrimination from health professionals . It is also possible providers may have concerns about poor adherence and reinfections among PWID . Based on successful HCV treatment trials and economic analyses, international guidelines now recommend that treating PWID should be made a priority .…”

Daclatasvir plus Sofosbuvir, with or without Ribavirin, in Real-World Patients with HIV–HCV Coinfection and Advanced Liver Disease

“…Daclatasvir plus sofosbuvir, with or without ribavirin, in real-world patients with HIV-HCV coinfection and advanced liver disease Introduction Historically, uptake of HCV treatment by HIV-HCVcoinfected patients has been limited [4,5], largely due to the poor outcomes previously observed with interferon (INF)-based regimens [6][7][8], concerns about treatmentlimiting interactions with combination antiretroviral therapy (cART), and a high prevalence of comorbidities with negative implications for treatment adherence -such as psychiatric conditions and chemical dependency. The development of INF-free therapies for HCV based on next-generation direct-acting antiviral agents (DAAs) has greatly improved response and tolerability in HIV-HCV coinfection [9][10][11][12].…”

How Generalizable Are the Results From Trials of Direct Antiviral Agents to People Coinfected With HIV/HCV in the Real World?

“…To reduce the clinical and healthcare burden of advanced liver disease, coinfected individuals need to be treated and cured of HCV [ 5 – 7 ]. Unfortunately, fewer than 10% of coinfected individuals have ever been treated [ 8 , 9 ].…”