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Extending Treatment for HCV Infection to HIV-HCV Coinfected
Individuals with Psychiatric Illness and Drug Dependence
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Clinical Infectious Diseases 2003;36:1501-1502
Lynn E. Taylor,1 Beth Schwartzapfel,1 Scott Allen, 2 Gene Jacobs,3 and Jennifer Mitty1. 1The Miriam Hospital, 2Rhode Island Department of Corrections, and 3Family Service of Rhode Island, Providence, Rhode Island
This correspondence by Lynn Taylor and the group in Rhode Island explains their program of support services provided for HIV/HCV coinfected patients at their hepatitis C clinic, and it exemplifies the types of support services needed in a hepatitis C and coinfection clinic to address the needs of difficult to treat patients. Following the Taylor correspondence is the Fleming abstract and some excerpts from FlemingÕs paper.
SIR: We read the recent article by Fleming et al. with interest. We, too, provide care for hepatitis C virus (HCV) infection for persons coinfected with HIV and HCV. Missed appointments in our hepatitis C clinic limit treatment for our patients, as Fleming et al. report. Of 103 individuals referred to our clinic between January 2000 and December 2002, only 57 (55%) attended at least 1 appointment, and 74 (39%) of 191 total appointments were not kept. Psychiatric and substance abuse disorders are also common among our patient population. Of 57 patients evaluated, 100% had a history of addiction, 40% were using illicit drugs at the time of first consultation, and 86% had a history of psychiatric illness.
However, we do not believe that illicit drug use in the preceding 6 months or active psychiatric disease are reasons to withhold treatment for HCV infection. These criteria effectively preclude treatment for the majority of patients who are coinfected. These co-occurring illnesses represent a challenge rather than a barrier. Fleming et al. suggest increasing the
proportion of patients eligible for treatment by concentrating on psychiatric and addiction care and administering IFN. We have developed such a program. Evaluation includes assessment of psychiatric illness and addiction so that these conditions can be stabilized prior to and throughout treatment for HCV infection. Partnership with a community agency permits provision of coordinated psychiatric care, counseling, and case management. A dedicated nurse administers pegylated IFN, packs ribavirin in pill boxes, and manages routine side effects. Weekly nursing assessments, plus home visits by case managers, allow for adverse effects to be rapidly identified and addressed. More serious concerns are managed by the physicians. Case managers provide transportation to the clinic for patients to receive injections; these visits are synchronized with phlebotomy appointments and a coinfection support group meeting.
Thus far, 11 patients have initiated therapy with the support of this intervention. Nine (82%) have a psychiatric diagnosis, primarily depression. One hundred percent have a history of addiction. None have stopped treatment due to mood disturbance or a substance abuserelated issue. Seven patients continue to undergo therapy. Treatment was stopped
for one patient because of thrombocytopenia, for another patient because of elevated lactate levels without acidosis (this patient nevertheless had a sustained virological response), and for another patient at 24 weeks due to lack of virologic response. One patient was lost to follow-up when her prison term, which she was serving in her home, came to an end, and she dropped out of medical care; for the other 10 patients, there has been 100% adherence to IFN therapy, with no missed injections. All patients report increased quality of life during treatment. As more patients are treated and studied, we hope the reasons for this will become clear.
Our experience suggests that observed treatment is an ideal way to extend HCV medications to persons coinfected with HIV and HCV. Pegylated IFN can easily be administered weekly for a finite period. Appointments for administration of injections provide an opportunity for consideration and prompt treatment of side effects and provide an opportunity for monitoring of and assistance with the linked diseases of addiction and psychiatric illness. Addressing adverse effects before they become intolerable seems to optimize both the patient's adherence to the treatment and their safety while undergoing it. We agree that partnership with methadone programs is the next step. This may allow observed ribavirin dosing, as well as side-effect and safety monitoring, to be made available to those without access to a home outreach program.
Fleming Paper and Excerpts
Abstract: One hundred eighty human immunodeficiency virus (HIV) and hepatitis C virus (HCV)coinfected patients were prospectively evaluated for suitability for interferon and ribavirin therapy. Of the 149 patients with chronic HCV infection who completed the evaluation, 44 (30%) were eligible for treatment and 105 (70%) were ineligible, with the main barriers being missed clinic visits, active psychiatric illness, active drug or alcohol use, decompensated liver disease, or medical illness. Fleming, Boston Medical Center; Clinical Infectious Diseases 2003;36:97-100.
..Decompensated liver disease was seen in 13% at presentation, reinforcing the prevalence of liver-related morbidity in HCV- and HIV-coinfected.patients....Our data highlight the numerous barriers to HCV treatment in this inner-city minority population. Of the ineligible
patients, one-third had medical problems, whereas the remaining two-thirds had psychiatric or behavioral problems, including poor compliance and ongoing substance abuse, that excluded them. Strategies to improve the proportion of coinfected patients eligible for HCV treatment will therefore need to concentrate on substance abuse treatment, optimizing
psychiatric care, and improving the possibility of compliance by linking HCV treatment and methadone use with programs to supervise and administer IFN. Earlier referral for HCV evaluation and treatment, before the development of severe liver disease, or to HIV- or HAART-related complications will also be required. In addition, the relative success in treating patients with non-HCV genotype 1 disease suggests that to achieve higher treatment rates, IFN treatment must be perceived as both efficacious and tolerable. Addressing the barriers to IFN therapy among coinfected patients is necessary if the recent advances in HCV treatment are to be replicated in the HIV- and HCV-coinfected population.
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