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Gaps HCV Testing & Care in VA System
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"Testing, Referral, and Treatment Patterns for Hepatitis C Virus
Coinfection in a Cohort of Veterans with Human Immunodeficiency
Virus Infection"
Excerpts from: Clinical Infectious Diseases 2003;36:1039-1046
"In the VA system HIV care providers are not testing all their patients for HCV... recent National Institutes of Health treatment guidelines for hepatitis C... recommend that HIV-positive patients be evaluated and treated in the same manner as HIV-negative patients.. only 25 (28.7%) of the hepatitis C patients who were currently drinking alcohol reported that they had been advised to stop..(16.3%) reported current illicit drug use...12.5%) of these patients reported that their doctors were concerned about their drug use... providers failed to recognize depression in 93 patients..."
"...all HIV-positive patients should be tested for HCV because of its implications for clinical management. Many coinfected patients may not be currently eligible for antiviral treatment, but all are eligible for alcohol screening and counseling. They are also all eligible for other interventions, both to mitigate contraindications to antiviral treatment and to improve monitoring of hepatic toxicity in HIV treatment.."
The authors said: "Although VA health care providers appear to be testing most HIV-positive patients (80%) for HCV and are making efforts to address contraindications to antiviral treatment, very few patients are receiving antiviral therapy. Further, providers are largely unaware of current illicit drug and alcohol use and depression among their HCV-coinfected patients.. the proportion of patients tested varied widely by provider and provider type,
with one-third of the individual providers examined testing <60% of their patients, leaving many HIV-infected patients with an unknown HCV status.. of the 300 patients who tested positive for HCV, only 22% had HCV RNA levels determined and only 30% were referred to a gastroenterology service for evaluation... although VA guidelines for treatment of hepatitis C recommend that patients undergo a liver biopsy, we found a low frequency of liver biopsy in this sample..
"..there were 19,000 HIV-positive veterans in the VA system last year and that 29% of these are currently coinfected with HCV... only 138 patients in the entire VA system have received pegylated IFN or ribavirin (IFN-2b; Rebetron) along with HIV antiretrovirals.. this represents an HCV treatment rate of 2.5%.. not dramatically different from that found in our earlier data...'
the authors also say: "the VA population is especially well suited to a study of HIV and HCV coinfection". If that's the case the HIV care system in the US appears to be doing a horrible job of providing care for HCV in HIV-infected individuals.. future efforts should be directed at increasing the detection and treatment of alcohol use, illicit drug use, and depression to avoid their untoward effects and to allow a greater number of patients to be eligible for hepatitis C therapy".
From Jules Levin: PHS Guidelines recommend HIV-infected individuals be tested for HCV. This study from the VA reflects inadequate care systems for HCV and is a reflection of our HIV system, which is inadequate and nor prepared to deal with the problems associated with HCV/HIV coinfection. Let's not forget estimated ranges of coinfection in HIV are 20-30%, that's 200,000 to 300,000 indivuduals. It's also estimated from studies that 60-90% of HIV-infected individuals by IVDU have HCV. And data strongly suggests HCV and related liver complications are the leading cause of death in HIV. Better systems of care are needed and they can provide a support and care system that would improve care and testing inadequacies in the VA system and throughout the HIV care system. Similar care inadequacies are seen all over the US regarding care for HCV in HIV-infected populations.
Hepatitis C virus (HCV) coinfection is common among HIV-infected patients (33%54.7%) and substantially complicates medical management. Testing for HCV is important for HIV-infected patients, because interventions are indicated for all coinfected patients whether or not they are likely to undergo pharmacological treatment. Specifically, all HCV-infected patients should be advised to stop consuming alcohol, because alcohol use both accelerates the course of hepatitis C and increases the risk of subsequent hepatocellular carcinoma. Further, many contraindications common in coinfected patients can and should be addressed, including active depression and current drug abuse. Finally, initiating highly active antiretroviral therapy for a coinfected patient can increase HCV load and increase transaminase levels. Thus, all HIV-infected patients should be tested for HCV so that the presence of coinfection can be actively considered in clinical management.
Although the optimal pharmacological treatment for coinfected persons has not been determined, the most recent National Institutes of Health treatment guidelines for hepatitis C do not consider HIV coinfection a contraindication
to treatment. Instead, guidelines recommend that HIV-positive patients be evaluated and treated in the same manner as HIV-negative patients. These guidelines also encourage health care providers to screen all patients for alcohol use, regardless of whether they are candidates for pharmacological treatment, and to screen all patients with indications for treatment for illicit drug use and depression.
Despite the common occurrence of HIV and HCV coinfection, testing practices for HIV-positive patients have yet to be determined. The US Department of Veterans Affairs (VA), which has identified hepatitis C as a high-priority
condition for improved detection and management, has recently instituted nationwide guidelines. Because the VA has placed an emphasis on the detection and appropriate management of hepatitis C, it may offer a valuable laboratory
in which to study current management issues and remaining barriers to treatment of coinfected patients. The purpose of this study was to examine the current management practices, including testing, referral, and treatment, for HCV coinfection among HIV-positive veterans enrolled in the Veterans Aging 3-Site Cohort Study (VACS-3).
Abstract: We examined testing, referral, and treatment of patients with hepatitis C among HIV-infected patients in the Veterans Aging 3-Site Cohort Study by using patient- and provider-completed surveys and laboratory, pharmacy, and administrative records from the Department of Veterans Affairs electronic medical record. Of 881 human immunodeficiency virus-positive patients, 43% were coinfected with hepatitis C virus. Of these, 88 (30%) reported current alcohol consumption. Only one-third were counseled to reduce or stop alcohol consumption. Coinfected patients with indications for hepatitis C treatment had a high rate of contraindications, including both medical and psychiatric comorbidities. Of the 65 patients with indications for hepatitis C therapy and free of contraindications for treatment, only 18% underwent liver biopsy and 3% received IFN. Although treatment indications are common in this population, contraindications are also common. Health care providers are often unaware of alcohol consumption that may accelerate the course of hepatitis C, increase the risk of hepatocellular carcinoma, and reduce treatment efficacy.
Demographic characteristics
Eight hundred eighty-one patients were enrolled in the VACS-3 study,
representing 85% of the HIV-positive patients seen in this interval. The median age of the participants was 48.7 years (range, 28.179.2 years; table 1). As expected for a VA patient population, the majority (98.8%) were male. Nonwhite patients constituted 66.5% of the study population. HIV risk factors were intravenous drug use for 33.6% of patients, heterosexual exposure for 23.4%, and men who have sex with men exposure in 36.2%. Patients could be classified as having >1 risk factor. At baseline, the median CD4 cell count was 330 cells/mm3(range, 21880 cells/mm3), and the median CD4 cell nadir was 177 cells/mm3 (range, 11280 cells/mm3). Current CD4 cell count was >200 cells/mm3 for 71.1% of patients. HIV RNA was undetectable (<500 copies/mL) in 46.7% of patients. The majority of patients (99.1%) identified an infectious diseases-trained provider as their primary provider. The majority of health care
providers (88.5%) were physicians; 3.1% were registered nurses, and 8.4% were classified as "other." Attending physicians were named as the primary provider in 57.5% of surveys. Providers reported that alcohol was currently used by 11.4% of patients, and illicit drugs were used by 9.1%. Patient self-report demonstrated that 351 patients (40%) currently used alcohol and 113 (13%) currently used illicit drugs.
Of the 881 patients in the VACS-3 study, 700 (79.5%) underwent testing for HCV. When the 9 providers with the largest case loads were compared with the rest of the providers combined, the OR for performing tests varied from 0.23 to 10.5 (overall, P < .0005, by likelihood ratio test). Three (33%) of the 9 providers tested <60% of their patients.
Antiviral treatment for HCV
Of the 300 patients who tested positive for HCV, only 65 (21.7%) had HCV
RNA levels determined, and 90 (30.0%) were seen by the gastroenterology service. Referrals occurred at all 3 sites; referral rates ranged from 20% to 37% of HCV-positive patients. Of the 210 patients who were not seen by the
gastroenterology service, 67 (31.9%) had no indication for treatment. Of the remaining 143 patients, 105 (73.4%) had at least 1 contraindication to treatment; accordingly, 38 (26.6%) patients were eligible for antiviral treatment across the 3 sites. The 38 patients eligible for antiviral treatment had a median CD4 cell count of 381 cells/mm3 (range, 39890 cells/mm3) and a median CD4 cell nadir of 166 cells/mm3. Median HIV load was 904 copies/mL (range, <40 to 143,757 copies/mL), with 45% having an undetectable HIV load. None of these patients underwent liver biopsy or received prescriptions for IFN or ribavirin.
Other indicated treatments
Of the 300 patients who were HCV-positive, 88 (29.8%) reported current
alcohol consumption. The providers recognized that 29 (33%) of these patients were currently drinking alcohol (, 0.07; sensitivity, 18%; specificity, 93%). Only 25 (28.7%) of the hepatitis C patients who were currently drinking alcohol reported that they had been advised to stop. Patients who were HCV-positive were more likely to report having been told to reduce their consumption of alcohol than were HCV-negative patients (28.7% and 15.1%, respectively; P
< .0005).
Of the 300 HCV-positive patients, 48 (16.3%) reported current illicit drug use. Health care providers recognized this in 18 (37.5%) of these patients (, 0.06; sensitivity, 29%; specificity, 94%). Only 6 (12.5%) of these patients reported
that their doctors were concerned about their drug use. HCV-positive patients were more likely to report that their providers were concerned about their drug use than were patients not infected with HCV (12.5% vs. 0%; P = .02).
Antibodies to hepatitis B surface antigen were tested in 281 (93.7%) of the 300 hepatitis C patients. Four (1.4%) had a positive result. Antidepressants were prescribed for 48 (64%) of the 75 patients with provider-acknowledged
depression. However, providers failed to recognize depression in 93 patients (58% of patients with a Center for Epidemiologic StudiesDepression score of >10).
Probably the most important limitation of this study is the inability to evaluate patient or provider preferences. It is possible that many patients with a positive HCV antibody test result had discussions with their health care providers and chose not to undergo treatment, obviating the need for referral to a gastroenterology service or performance of a liver biopsy. It is also possible that providers believed that antiviral treatment of coinfected patients was burdensome and/or ineffective. Because the beneficial effect of combination treatment with IFN and ribavirin was not completely
appreciated during the time course of this study, it is possible that the known low response rate to IFN monotherapy
influenced patient and provider attitudes toward antiviral treatment for hepatitis C. However, additional data from the Pharmacy Benefits Management Group indicate that only 138 patients in the entire VA system have received pegylated IFN or ribavirin (IFN-2b; Rebetron) along with HIV antiretrovirals. Given that there were 19,000 HIV-positive veterans in the VA system last year and that 29% of these are currently coinfected with HCV on the basis of
International Classification of Diseases, Ninth Revision codes (L. Backus, personal communication), this represents an HCV treatment rate of 2.5%not dramatically different from that found in our earlier data.
As with any study done in a VA patient population, there may be some concern about the generalizability of these results outside the VA. However, the VA population is especially well suited to a study of HIV and HCV coinfection
because, as is the case in our population, patients coinfected with HCV and HIV are commonly nonwhite and have a substantial burden of medical and psychiatric comorbidities.
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