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Hepatitis C Cascade Studies Show Gaps in Testing and Treatment


About half of people with hepatitis C are aware of their infection but less than 10% have been successfully treated and achieved sustained virological response, according to a meta-analysis presented at the recent Conference on Retroviruses and Opportunistic Infections (CROI 2014). A related study found that among HIV/HCV coinfected people, 40% had been referred to hepatitis C care but only 4% were cured.

The "treatment cascade" was developed to describe gaps in care for people with HIV. A similar concept is now also being used for hepatitis C. Nationwide, according to a report by Scott Holmberg from the CDC and colleagues in the May 16, 2013, New England Journal of Medicine, 50% of people with chronic hepatitis C have been diagnosed (1.6 million out of an estimated total of 3.2 million), 32%-38% are referred to care, 7%-11% start treatment, and 5%-6% are cured.

At CROI, Baligh Yehia and Vincent Lo Re from the University of Pennsylvania and colleagues presented an analysis of gaps in HCV care, using a medical literature review to estimate the number of people with chronic hepatitis C in the U.S. who completed each step along a proposed HCV treatment cascade.

The researchers searched MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews for English-language articles published between January 2003 and July 2013. Relevant articles addressed the total number of people with chronic HCV infection and proportions who were diagnosed and aware of their infection, had access to outpatient care, had a confirmed HCV RNA measurement, underwent liver disease staging by 
biopsy, were prescribed HCV treatment, and achieved sustained viral response (SVR), or continued undetectable HCV RNA after finishing treatment -- considered a cure. Studies that involved only a single site or did not collect data after 2000 were excluded. Out of more than 9000 articles reviewed, 10 met the inclusion criteria.

Overall, 3.5 million people are estimated have chronic HCV infection in the U.S. Half are diagnosed and aware of their infection and 43% have access to outpatient care. Overall, 27% received confirmatory HCV RNA testing and 17% underwent biopsy fibrosis staging. However, just 16% are prescribed antiviral therapy and 9% achieve SVR.

"This review identifies large gaps between current practice and treatment goals for people with chronic HCV infection, and highlights multiple opportunities for improved engagement along the HCV treatment cascade," the researchers concluded. "The advent of new direct-acting antiviral agents will help shorten treatment duration, increasing the number of people offered treatment, and improve HCV cure rates."

HIV/HCV Coinfection

Oluwatoyin Adeyemi from the Cook County Health and Hospitals System and colleagues conducted a single-site study of hepatitis C evaluation and treatment rates among patients seen at the CORE Center in Chicago. This major HIV center -- which treats 25%-30% of all people with HIV in the region -- has had an on-site hepatitis clinic since 2001.

The researchers performed a retrospective electronic chart review of HIV/HCV coinfected patients seen at the center between January 2006 and December 2013, focusing on an active cohort who had their last visit since January 2011. About three-quarters were men, more than two-thirds were black, 14% were white, and the median age was 54 years. Nearly 90% were below the federal poverty level, 60% were uninsured, about 35% were on Medicaid or Medicare, and fewer than 2% had private insurance.

Among 1112 active patients with positive HCV antibody tests, 67% had an HCV RNA test done and 57% had an HCV genotype test -- revealing that 81% had genotype 1. 40% had a hepatitis clinical evaluation and 27% had a liver biopsy. However, only 14% started treatment and just 4% achieved SVR.

"The vast majority of HIV/HCV coinfected patients in our clinic have not received HCV [treatment]," the researchers concluded.

"Patient specific issues including adherence with clinic visits...and adequate HIV control...likely contribute to lack of HCV evaluation and treatment," they continued. "Poor efficacy and side effect profiles of HCV [treatment] prior to 2014 are also major barriers to HCV [treatment] and we expect to see an increase in patient and provider interest in HCV treatment with new HCV [treatment] options."

Edward Cachay from the University of California at San Diego and colleagues also looked at the cascade of care for HIV/HCV coinfected people.

This retrospective cohort study included coinfected patients receiving care at the UCSD Owen Clinic between 2008 and 2012. More than 80% were men, two-thirds were white, and the median age was 48 years. They were classified based on whether they were referred or not referred for HCV treatment.

Out of 748 HCV antibody positive patients, 562 had active chronic hepatitis C as indicated by detectable HCV viral load. About half of patients (54%) were referred for HCV treatment and 50% attended at least 1 clinic visit for hepatitis C evaluation. But only 16% initiated HCV therapy and 7% were cured.

Patients referred for hepatitis C treatment were significantly more likely to be white, to have undetectable HIV viral load, and to have a higher median CD4 count. People with a history of injection drug use, ongoing drug or alcohol use, unstable housing, ongoing psychiatric disorders, and malignancies other than liver cancer were less likely to be referred.

The most common reasons for not starting HCV treatment after clinical staging included barriers to care such as ongoing drug or alcohol use, uncontrolled psychiatric disorders, or uncontrolled HIV disease (40%), desire for interferon-free therapy (25%), end-stage liver disease (18%), and prior interferon null response (8%).

"The most important predictor of non-referral for HCV therapy was not being engaged in care," the researchers concluded. "Even in the presence of effective, safer and shorter [interferon]-sparing treatment options, 4 out of 10 people living with HIV coinfected with HCV may not benefit from HCV therapy unless ongoing barriers to care are effectively managed."



BR Yehia, A Schranz, C Umscheild, and V Lo Re. The Treatment Cascade for People With Chronic Hepatitis C Virus Infection in the United States. 21st Conference on Retroviruses and Opportunistic Infections (CROI 2014). Boston, March 3-6, 2014. Abstract 669.

OM Adeyemi, S Effinger, B Go, et al. The CORE HCV Cascade a Decade Later: Looking Ahead To an IFN-Free Era. 21st Conference on Retroviruses and Opportunistic Infections (CROI 2014). Boston, March 3-6, 2014. Abstract 671.

ER Cachay, L Hill, D Wyles, et al. The Hepatitis C Cascade of Care Among HIV-Infected Patients Following Diagnosis of HCV Infection. 21st Conference on Retroviruses and Opportunistic Infections (CROI 2014). Boston, March 3-6, 2014. Abstract 672.