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and Hepatitis.com
Coverage of
the 13th Annual Conference on Retroviruses and Opportunistic Infections February 5 - 8, 2006, Denver, CO |
Barriers
to Treating
HCV in HIV-coinfected
Patients Overcoming
the barriers
that stand in
the way of providing
medical care
to those who
need it can
sometimes be
difficult. This
difficulty is
reflected in
a study from
Johns Hopkins,
one of the premier
centers for
the treatment
of HIV and hepatitis
in the The
study evaluated
predictors and
trends of referral
for hepatitis
C virus (HCV)
care, clinic
attendance,
and treatment
uptake in the
Johns Hopkins
HIV clinic,
which provides
care for >3000
HIV-infected
persons of whom
~50% are HCV-co-infected.
In 1998, an on-site viral hepatitis clinic was opened; however, while between 1998-2003 845 HIV/HCV-co-infected adults regularly attended the HIV clinic, few ended up getting on HCV treatment and only 6 – or 0.7% of the eligible population – achieved a sustained virologic success. How did such a prestigious center end up with such disastrous results? The problems begin with referral and patient attendance at appointments. Of the 845 HIV/HCV patients eligible for treatment, 277 (33%) were referred for care and 185 (67%) kept their appointment. Independent predictors of referral and attendance (p <0.05) were markers of liver disease including percentage elevated alanine aminotransferase (ALT) levels, markers of controlled HIV including undetectable HIV RNA, CD4 >350 cells/mL and use of ART, and being in psychiatric care. Further, in a subsample participating in confidential surveys, patient illicit drug use was a barrier to referral and attendance. Of 185 who entered care, 32% failed to complete a pre-treatment medical evaluation. Of the remaining 125, 44(35%) were ineligible for treatment: 19 had end-stage liver disease, 9 were HCV RNA negative, and 16 had AIDS/<2-year life expectancy. Of the 81 eligible, 47% had mild fibrosis (F1-2) and 23% had cirrhosis (F5-6) on biopsy and 29 (36%) initiated HCV treatment of whom 6 (21% of the treated population) achieved sustained virologic response. Reasons for not treating were mild liver disease (58%), psychiatric illness (12%), alcohol/drug use (12%), and patient refusal (15%). The
authors note
that referrals
increased in
2003, but that
more than one-half
of patients
with a CD4>350
still are not
being referred.
The authors
conclude, “Substantial
barriers at
the provider-level
(non-referral
of some patients
with high CD4)
and the individual
(active drug
use) still exist
even when cost
and access are
not issues.
A case management-based
approach to
HCV care may
improve treatment
uptake and diminish
losses to follow-up
in this population.” 02/14/06 Reference
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