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Survey Reveals Wide Variation in Clinicians' Approaches to Hepatitis C Treatment in People with HIV

Although clinicians generally agree about what factors indicate a need for hepatitis C treatment, they diverge in terms of actual practice, with 1 group preferring to delay interferon-based therapy while waiting for better future options, and the other urging prompt treatment for most patients, according to a report in the August 10, 2009 advance online edition of AIDS Patient Care and STDs.

By Liz Highleyman

Standard therapy for chronic hepatitis C virus (HCV) infection using pegylated interferon plus ribavirin produces a sustained response in only about half
of treated individuals, with lower response rates for "hard to treat" patients including those with HCV genotypes 1 or 4 and those coinfected with HIV.

Treatment is associated with difficult side effects -- including flu-like symptoms and depression -- in a large proportion of patients. Furthermore, many clinicians have traditionally hesitated to treat non-abstinent drug and alcohol users due to concerns about poor adherence and response. For all these reasons, it is estimated that only about 10% of hepatitis C patients receive treatment.

A majority of people with chronic hepatitis C never develop advanced liver disease, and treatment is only indicated for patients experiencing -- or thought to be at risk for -- disease progression. Because liver damage appears to progress more rapidly in HIV positive individuals, some experts recommend earlier treatment for HIV-HCV coinfected patients.

Several directly targeted agents that act against various stages of the HCV lifecycle are in development, including the HCV protease inhibitors telaprevir and boceprevir. Some of these new therapies may offer a better rate of response with a shorter duration of therapy and fewer side effects, leading some patients and providers to adopt a "wait and watch" approach.

A Southern California collaboration -- including researchers from the AIDS Healthcare Foundation and the Veterans Administration -- sought to explore the factors and processes by which medical providers make decisions about hepatitis C treatment for HIV-HCV coinfected patients.

The researchers conducted 22 semi-structured interviews with primary care providers and support staff at 3 HIV clinics in Los Angeles, where rates of hepatitis C treatment uptake varied from 10% to 38%.

Results

In general, providers agreed that stable HIV disease (suppressed viral load and relatively high CD4 cell count), favorable HCV genotypes (2 or 3), and significant signs of liver disease progression are all indicators of a need for treatment.

However, 2 divergent treatment approaches emerged for patients with genotypes 1 or 4 with minimal liver disease:

Providers with lower treatment rates preferred to delay therapy in hopes of better future treatment options, and were more conservative in requiring complete mental health screens, and abstinence and treatment of substance use.

Providers with higher treatment rates viewed most or all patients as needing treatment as soon as possible, and defined readiness more leniently, with some willing to treat patients with uncontrolled depression and active drug use if they appeared able to achieve good adherence.

"Regardless of whether an aggressive or cautious approach to treatment is used," the study authors wrote, "development of effective programs for promoting patient treatment readiness is critical to ensuring greater treatment uptake."

RAND Corporation, Santa Monica, CA; AIDS Healthcare Foundation, Los Angeles, CA; Greater Los Angeles Veterans Administration, Los Angeles, CA; Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA.

8/21/09

Reference
G Wagner, G Ryan, K Chan Osilla, and others. Treat Early or Wait and Monitor? A Qualitative Analysis of Provider Hepatitis C Virus Treatment Decision-Making in the Context of HIV Coinfection. AIDS Patient Care and STDs. August 10, 2009 [Epub ahead of print]. (Abstract).