Reveals Wide Variation in Clinicians' Approaches to Hepatitis C Treatment in People
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
10, 2009 advance online edition of AIDS Patient Care and STDs.|
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.
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.
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.
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.
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.
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%.
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.
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.
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."
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.
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).