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HCV Barriers to Care/IDUs-HIV-coinfected/Marginalized Patient Populations/IDUs
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Download the PDF here
Download the PDF here
Download the PDF here
from Jules: many of these barriers to HCV care discussed below were written t apply to HIV coinfected but also apply to HCV mono infected-
"......negative referral bias of physicians when making HCV treatment decisions in vulnerable populations with ongoing barriers to care [22,28,29].....some physicians have suboptimal knowledge about HCV and its treatment......low perceived need for treatment due to a lack of realization that fibrosis is advanced (given that liver disease may not have been appropriately assessed) or a belief that other comorbid diseases should take precedence We believe that the HIV primary care model could be useful in other settings and countries burdened by the high prevalence of HCV and difficult to treat urban, poor, marginalized populations that require both more efficacious HCV therapies and newer collaborative models of care such as the one described here......important barriers to HCV care include unemployment or employment responsibilities, unstable housing, lack of transportation, parental responsibilities, poverty, incarceration, stigma, and inadequate access to healthcare (in uninsured or underinsured patients"
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The Forgotten Component in the Staging and Management of HIV/Hepatitis C Virus-Coinfected Patients
Clin Infect Dis. (April 23 2014)
Correspondence: Edward Cachay, MD, University of California, San Diego, 200 W Arbor Drive, San Diego, CA
To the Editor-I read with great interest the recent article by Dr Martel-Laferriere and collaborators [1]. The study emphasized important messages for human immunodeficiency virus (HIV) and infectious diseases physicians who are increasingly treating hepatitis C virus (HCV) among HIV-infected patients [2]: promptly recognize cirrhosis, regularly screen for cirrhosis-related complications, avoid potential medical interactions, educate your patients regarding toxins or habits that may contribute to further liver damage, and consider referral of your HIV/HCV-coinfected patients for liver transplant evaluation when indicated.
However, an essential part of managing HIV/HCV-coinfected patients is identifying ongoing barriers to care. Our HIV/HCV-coinfected patients have a high prevalence of poverty, drug abuse, unstable housing, and neuropsychiatric diseases that affect their overall engagement in care [2: see below]. They often have low health literacy, feel marginalized, and are uninsured [3: see below]. Not surprisingly, only 5%-7% of HIV/HCV-coinfected patients are cured of HCV in the United States and Europe [4-6]. At the Owen Clinic at the University of California, San Diego, approximately 12% of our patients who attend an initial clinic visit for HCV treatment do not return for HCV care [7; The Hepatitis C Cascade of Care Among HIV Infected Patients Following Diagnosis of HCV Infection - (03/24/14)]. Furthermore, the main reason for not initiating HCV therapy among those who completed HCV clinical staging is ongoing barriers to care [7]. Therefore, we teach medical students, residents, and infectious diseases fellows that complete staging and management of HCV in an HIV-infected patient requires 4 components: (1) assessment of HIV control and medical interactions; (2) liver staging status and prevention of cirrhosis-related complications; (3) addressing concurrent medical comorbidities; and (4) ascertainment of ongoing barriers to care.
I believe that the routine medical evaluation of any HIV/HCV-coinfected patient must include the assessment of potential ongoing barriers to care, which ultimately can preclude successful initiation and completion of HCV therapy in the forthcoming highly effective interferon-free era.
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Breaking Down the Barriers to Hepatitis C Virus (HCV) Treatment Among Individuals With HCV/HIV Coinfection: Action Required at the System, Provider, and Patient Levels
Jason Grebely,1 Megan Oser,2 Lynn E. Taylor,3 and Gregory J. Dore1
1The Kirby Institute, University of New South Wales, Sydney, Australia; 2Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical
School, Boston, Massachusetts; and 3Department of Medicine, Brown University, Providence, Rhode Island
HCV treatment uptake remains unacceptably low.......Among studies in Canada and the United States, only 1%-7% of those with HCV/HIV coinfection (the majority PWID) have received HCV treatment.......Compared with those with HCV infection alone, PWID with HCV/HIV coinfection have demonstrated lower rates for acceptance of clinical referral [10], willingness to undergo HCV treatment [11], and HCV treatment uptake [11].
.........At the practitioner level, perceptions about poor adherence, ongoing substance use, relapse to substance use, risk of exacerbating comorbid psychiatric disease and potential risk of reinfection have often been used as reasons for withholding therapy [4]. Many physicians are unwilling to treat patients actively using drugs
.......Advances in HCV therapy will have a limited impact on the burden of HCV-related disease at the population-level unless barriers to HCV education, screening, evaluation, and treatment are addressed and treatment uptake increases. This review will outline barriers to HCV care in HCV/HIV coinfection, with a particular emphasis on persons who inject drugs, proposing strategies to enhance HCV treatment uptake and outcomes.
some physicians have suboptimal knowledge about HCV and its treatment, which may be due to limited training and inexperience with HCV treatment in coinfection. In some settings, there is also a low perceived need for treatment due to a lack of realization that fibrosis is advanced (given that liver disease may not have been appropriately assessed) or a belief that other comorbid diseases should take precedence. There are also clear misconceptions about HCV treatment in those with ongoing substance use.
At the patient level, major barriers for accessing HCV care include poor knowledge and inaccurate perceptions about HCV infection and its treatment [4, 11, 19]. Poor knowledge, combined with the absence of noticeable symptoms and perceptions about HCV infection being a benign disease, results in a low perceived need for treatment [4, 12, 20]. Other important barriers to HCV care include unemployment or employment responsibilities, unstable housing, lack of transportation, parental responsibilities, poverty, incarceration, stigma, and inadequate access to healthcare (in uninsured or underinsured patients [4, 21]). Given that HCV prevalence is often higher among ethnic minorities, racial and ethnic disparities in access to healthcare also complicate HCV care.
Furthermore, patients may intentionally avoid assessment and treatment because of the "horror stories" about liver biopsies and HCV treatment propagated within peer networks [12]. In addition, persons with HCV/HIV co-infected coinfection may have other medical comorbid conditions (eg, cardiovascular disease) which may require more immediate attention. Sociodemographic and cognitive-affective factors may lead to forgotten appointments and poor adherence to the HCV evaluation and treatment process [12]. Patient-provider relationships often have an important influence on whether patients embark on HCV treatment [12, 20, 21].
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Increasing Hepatitis C treatment uptake among HIV-infected patients using an HIV primary care model
Edward R Cachay1,3*, Lucas Hill2, Craig Ballard2, Bradford Colwell2, Francesca Torriani1,3, David Wyles1,3 and
William C Mathews1
Abstract
Background: Access to Hepatitis C (HCV) care is low among HIV-infected individuals, highlighting the need for new models to deliver care for this population.
Methods: Retrospective cohort analysis that compared the number of HIV patients who initiated HCV therapy: hepatology (2005-2008) vs. HIV primary care model (2008-2011). Logistic-regression modeling was used to ascertain factors associated with HCV therapy initiation and achievement of sustained viral response (SVR).
Results: Of 196 and 163 patients that were enrolled in the HIV primary care and hepatology models, 48 and 26 were treated for HCV, respectively (p = 0.043). The HIV/HCV-patient referral rate did not differ during the two study periods (0.10 vs. 0.12/patient-yr, p = 0.18). In unadjusted analysis, predictors (p < 0.05) of HCV treatment initiation included referral to the HIV primary care model (OR: 1.7), a CD4+ count ≥400/mm3 (OR: 1.8) and alanine aminotranferase level ≥63U/L (OR: 1.9). Prior psychiatric medication use correlated negatively with HCV treatment initiation (OR: 0.6, p = 0.045). In adjusted analysis the strongest predictor of HCV treatment initiation was CD4+ count (≥400/mm3, OR: 2.1, p = 0.01). There was no significant difference in either clinic model (primary care vs. hepatology) in the rates of treatment discontinuation due to adverse events (29% vs. 16%), loss to follow-up (8 vs. 8%), or HCV SVR (44 vs. 35%).
Conclusions: Using a HIV primary care model increased the number of HIV patients who initiate HCV therapy with comparable outcomes to a hepatology model.
The idea of using an HIV primary care model for the treatment of HCV is not new [8,14-17]. However, a novel component of our approach was the integration of HIV clinical pharmacists to enhance protocol adherence and patient safety. Undoubtedly, the role of the pharmacists is becoming more prominent since the introduction of HCV direct acting antivirals in co-infected individuals, where attention to medication interactions is particularly important [18].
The fact that 10% of patients in both cohorts presented with advanced cirrhosis and were not eligible for HCV therapy highlights the importance of reducing disparities in access to HCV care in the HIV population [3,25]. New HCV therapies offer higher chances of cure, simpler and hopefully less toxic regimens [26,27]. However, to scale up HCV treatment among the HIV infected population, we will need an inclusive collaborative approach that reduces the negative referral bias of physicians when making HCV treatment decisions in vulnerable populations with ongoing barriers to care [22,28,29]. We believe that the HIV primary care model could be useful in other settings and countries burdened by the high prevalence of HCV and difficult to treat urban, poor, marginalized populations that require both more efficacious HCV therapies and newer collaborative models of care such as the one described here [30].
In conclusion, in this exploratory analysis, the use of an HIV primary care model supported by pharmacists specialized in HIV care increased the number of patients who initiate and successfully finish HCV therapy with comparable virological outcomes to a subspecialty hepatology model, highlighting the importance of increasing the absolute number of HIV-infected patients treated for HCV at any given time.
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