Liver International ISSN 1478-3223
REVIEW ARTICLE
Treatment of chronic hepatitis C virus infection in the United States: some remaining obstacles Gloria Searson1, Ellen S. Engelson2, Damaris Carriero1,3 and Donald P. Kotler1,2 1 Coalition on Positive Health Empowerment, New York, NY, USA 2 Division of Gastroenterology, Department of Medicine, St. Luke’s and Roosevelt Hospitals, Icahn School of Medicine at Mount Sinai, New York, NY, USA 3 Center for Liver Disease and Transplantation, Columbia University Medical Center, New York, NY, USA
Keywords alcoholism – chronic liver disease – effectiveness research – health disparities – substance abuse
Correspondence Donald P. Kotler, MD, Gastrointestinal Division, S&R 12, 1111 Amsterdam Avenue, St. Luke’s-Roosevelt Hospital Center, New York, NY 10025, USA Tel: +212-523-3670 Fax: +212-523-3678 e-mail: [email protected] Received 27 June 2013 Accepted 6 January 2014 DOI:10.1111/liv.12467 Liver Int. 2014: 34: 668–671
Abstract Hepatitis C infection is an important problem in inner city neighbourhoods, which suffer from multiple health disparities. Important factors in this population include alcoholism and substance abuse, mental illness and homelessness, which may be combined with mistrust, poor health literacy, limited access to healthcare and outright discrimination. Systemic barriers to effective care include a lack of capacity to provide comprehensive care, insufficient insurance coverage, poor coordination among caregivers and between caregivers and hospitals, as well as third party payers. These barriers affect real world treatment effectiveness as opposed to treatment efficacy, the latter reflecting the world of clinical trials. The components of effectiveness include efficacious medications, appropriate diagnosis and evaluation, recommendation for therapy, access to therapy, acceptance of the diagnosis and its implications by the patient and adherence to the recommended therapy. Very little attention has been given to assisting the patient to accept the diagnosis and adhere to therapy, i.e. care coordination. For this reason, care coordination is an area in which greater availability could lead to greater acceptance/ adherence and greater treatment effectiveness.
These are exciting times in the field of hepatitis C virus (HCV) infection. After many years of ominous predictions, the outlook for HCV-infected patients has improved substantially with the introduction of directacting agents (1, 2). However, it is too soon to declare victory. It has even been said that we are only ‘at the end of the beginning’ of the struggle (3). There are several remaining obstacles. The purpose of this paper is to enumerate and discuss some of the remaining barriers to effective HCV treatment in the United States, predominantly from an inner city perspective. The medical and economic burdens of HCV have been increasing for the past three decades (4, 5), and will continue to rise for the next 15 years. The burden of managing HCV-infected patients will fall increasingly on public institutions, i.e. inner city hospitals, clinics and community health centres, and the costs will shift progressively to public payers, such as Medicaid and Medicare (5). Official estimates of disease prevalence in The text was adapted from a presentation by Ms Searson at a CDC Workshop: Bridging the Sciences, Atlanta, GA, September 12–14, 2012.
668
the United States range from around 4 million (6) to as high as 7 million (7). The largest subgroup, comprising almost 80%, was born between 1945 and 1965 (8). Other cohorts of HCV-infected individuals exist, including immigrants, patients with sexually transmitted HCV infection, plus other routes of transmission, including nosocomial. A majority are unaware of their HCV serostatus (9). There are multiple obstacles to access effective antiviral therapy in all countries, with variations within and between them for different subgroups of patients. The barriers can be classified as virologic, host and systemic. Virological factors will not be considered here. Host factors may be modifiable or non-modifiable. In addition to age, sex and HIV co-infection, genetic factors exist, such as the IL28B polymorphism, which partially explain the observed racial variation in treatment response (10). While hepatitis C has its highest prevalence in a cohort defined by birth year, it is an especially important problem in African-American communities. The authors’ institutions treat residents of Harlem and surrounding neighbourhoods in New York City, which have high prevalence rates for HCV infection and other Liver International (2014) © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Searson et al.
comorbidities (11). Similar conditions exist in many inner city environments in the United States. It is not appropriate to discuss HCV infection in African-Americans without noting the presence of health disparities in general. In a recent publication, Williams and colleagues noted that overall death rates in AfricanAmericans are 30% higher than in Caucasians (12), with higher death rates for 10 of the 15 leading causes of death, though not for cirrhosis. Health disparities also exist in HCV infection, in terms of higher prevalence (6) and poorer response to therapy (13). Despite these facts, African-Americans have long been under-represented in clinical trials (14). To identify and reduce such disparity, the FDA Safety and Innovation Act, recently passed by Congress, requires the FDA to report annually on the inclusion of subjects by age, sex, race and ethnicity in clinical trials supporting applications of new drugs and medical devices (15). Important host factors that are potentially modifiable include substance abuse, mental illness and homelessness. A comorbidity that has received very little attention is alcoholism. Alcohol accelerates hepatic fibrosis in mono- and co-infected patients with HCV infection (16, 17). A prospective, case–control study published in 1999, of chronic viral hepatitis, alcoholism and the development of chronic liver disease at Harlem Hospital Center (18) showed that the combination of HCV infection and heavy alcohol intake, but not HCV infection or alcoholism alone, significantly promoted the development of chronic liver disease. The cohort was followed up for 4 years and death rates were numerically higher in the HCV plus alcohol group. The authors called for greater attention to the management of alcoholism to mitigate the development of chronic liver disease, even in the absence of effective anti-HCV therapy at the time. In a review of HCV-infected patients followed over a 15-year period in clinics in Scotland, the fraction of cirrhosis attributable to any alcohol intake was estimated at 36%, and at 61% for heavy drinkers (19). Importantly, since active alcoholism is an absolute contraindication to anti-HCV therapy, the subgroup at most risk of disease progression often is excluded from treatment. Recent studies from Switzerland and France have demonstrated reasonable rates of sustained viral response in alcohol-dependent patients (20, 21). Poorer responses to anti-HCV therapy in the US VA system were felt to be related more to poorer treatment adherence than a direct effect of alcohol intake (22). Maintaining adherence to treatment may be as important or even a more important goal than enforcing abstinence. A study to test this hypothesis would be one comparing the effects of abstinence and harm reduction. However, while determining the relative importance of HCV and of alcohol intake, including amount, drinking pattern and chronicity, in liver disease progression is of interest, the ultimate goal of therapy should be to cure both conditions. Liver International (2014) © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Obstacles to treating hepatitis C infection
Other host factors may also affect treatment adherence. Simoni et al. analysed 13 studies in HIV infection that used electronic drug monitoring. Demographic variables such as sex, age, economic status, education level, plus depression and substance abuse, did not fully explain a lower level of adherence observed in AfricanAmerican subjects (23). The authors cited evidence that mistrust, poor health literacy, inequalities in access to healthcare, as well as outright discrimination might be responsible for the differences. Patient mistrust acts synergistically with nihilism and stigmatization to confound attempts at therapy. Patients whose clinical problems are related to socially unacceptable behaviours may be especially prone to feeling stigmatized, while caregivers may unconsciously express bias. Cultural competences, which involve developing attitudes, behaviours and policies that enable effective work in cross-cultural situations, are routine medical education and core competency initiatives, but have not overcome the prevailing host barriers. The host barriers to effective treatment may become institutionalized, so that caregivers do not aggressively promote and patients do not aggressively seek proven therapies. These biases may be resistant to change. A substantial proportion of patients currently presenting for HCV testing are aware of their HCV status or of the presence of liver disease (G. Searson, personal observations). In many cases, patients had been told by a healthcare provider one, two or three decades ago that they were going to be OK or that their liver tests were relatively normal and not to worry, and now are being told that they have a serious disease. It is especially difficult for the medical establishment to engage patients who exist outside the formal healthcare system. The Affordable Care Act may be helpful in expanding coverage to some people, but it will not aid people who harbour a fundamental mistrust in the healthcare system. Community-based organizations may be helpful in this situation; fostering trust by helping people to feel at ease through non-judgmental treatment; creating an environment where people may be more truthful about personal matters: self-worth, future prospects or even existential concerns. Systemic barriers to effective care are multiple and diverse. Perhaps the most important is the lack of capacity of our system to provide comprehensive care to our patients. Mental health issues especially often are unrecognized, overlooked or undertreated. In HIV infection, Ryan White funding allowed the development of a comprehensive care model, with resources devoted to social work needs, including food and shelter, as well as mental health needs. Such support is not available for HCVinfected patients. Lack of insurance, or insufficient insurance coverage, is common among HCV-infected patients (24). Poor coordination between caregivers and hospitals and between caregivers and third party payers may lead to unanticipated treatment interruptions. Few institutions
669
Searson et al.
Obstacles to treating hepatitis C infection
have a centralized system for toxicity management, relying on standard emergency services. However, a visit to an Emergency Department or a hospital admission is likely to lead to treatment interruption for a patient irrespective of the presenting complaint. Few hospitals have direct-acting anti-HCV agents on formulary and the patient is ‘supposed to’ bring his/her outpatient medications to the hospital, which may not occur in the face of an emergency. There are two ways to evaluate treatment success: efficacy and effectiveness. Most discussions are centred on the notion of treatment efficacy, which can be defined as the number cured/number treated, and which reflects the world of clinical trials. Inclusion and exclusion criteria minimize the host factors interfering with therapy while the study design and pharmaceutical support minimize the systemic obstacles to therapy. A more accurate measure of treatment success from a public health standpoint is treatment effectiveness, which can be defined as the number cured/number infected. Its importance is seen in the example of alcoholism. As discussed above, alcoholism increases the risk for developing chronic liver disease, but is a contraindication for therapy, including inclusion in clinical trials. For this reason, alcoholism does not affect measured treatment efficacy though it markedly reduces treatment effectiveness, as might be measured by the prevention of chronic liver disease. Measured rates of effectiveness for pegylated interferon and ribavirin averaged 3.5% in clinical experience (25, 26), while the effectiveness in the registration trials ranged from 12 to 17%, and efficacy in the same trials averaged around 45% (25). Recent and emerging advances in therapy will allow the role of new regimens on treatment effectiveness to be determined, especially the application of interferonfree regimens. Treatment efficacy for genotype 1, treatment-na€ıve patients in clinical trials averaged 40–50%, using pegylated interferon and ribavirin (27), compared to around 75% in trials also using a directing agent (1). However, real world results in an inner city population in New York City showed an efficacy of 14% in genotype 1 patients. In addition, a recent presentation showed an SVR rate of 43% using a direct-acting agent in a similar patient group (28). Treatment effectiveness, including cost effectiveness will require closing the gap between clinical trials and real world results. Depending on the specific community, net effectiveness also may require improvements in the prevention of risk behaviours, which may lead to reinfection after SVR (29). Furthermore, improvements in efficacy are irrelevant for a patient who remains unengaged with the formal healthcare system. One can divide treatment effectiveness into several components (30). Effective therapy includes the availability of efficacious medications as well as a system to evaluate patients appropriately, recommend therapy, provide access to therapy, as well as patient compliance
670
with the evaluation and recommendations as well as adherence to therapy. Developing efficacious medications is the task of the pharmaceutical industry, while making diagnoses and treatment recommendations plus providing access to therapy are tasks for the healthcare system. Accepting the diagnosis and adhering to therapy is the job of the patient and patient advocates. While great effort has gone into developing efficacious therapies and an increasing amount of attention is being given to screening, diagnosis and evaluation, less attention has been placed on treatment access and very little attention has been given to assisting the patient to accept the diagnosis and adhere to therapy, i.e. care coordination. For this reason, care coordination is an area in which greater availability, supported by a currently non-existent funding source, could lead to greater acceptance/adherence and greater treatment effectiveness. The elements of care coordination, which include individual counselling, education, behaviour modification and other support, are the same for the management of many diseases. In summary, if we can overcome the obstacles to care delineated above, then treatment effectiveness will equal efficacy. Acknowledgements
Financial support: None. Conflict of interest: The authors do not have any disclosures to report. References 1. Jacobson IM, McHutchison JG, Dusheiko G, et al. Telaprevir for previously untreated chronic hepatitis C virus infection. N Engl J Med 2010; 364: 2405–16. 2. Poordad F, McCone J, Bacon BR, et al. Boceprevir for untreated chronic HCV genotype 1 infection. N Engl J Med 2011; 364: 1195–206. 3. Dieterich D. The end of the beginning for hepatitis C treatment. Hepatology 2012; 55: 664–5. 4. Davis GL, Alter MJ, El-Serag H, Poynard T, Jennings LW. Aging of hepatitis C virus (HCV)-infected persons in the United States: a multiple cohort model of HCV prevalence and disease progression. Gastroenterology 2010; 138: 513–21. 5. Pyenson B, Fitch K, Iwasaki K. Consequences of Hepatitis C Virus: Costs of a Baby Boomer Epidemic of Liver Disease. New York: Milliman, 2009. 6. Armstrong GL, Wasley A, Simard EP, et al. The prevalence of hepatitis C virus infection in the United States, 1999 through 2002. Ann Intern Med 2006; 144: 705–14. 7. Edlin BR. Perspective: test and treat this silent killer. Nature 2011; 474: S18–9. 8. Smith BD, Morgan RL, Beckett GA, et al. Hepatitis C virus testing of persons born during 1945 to 1965: recommendations from the Centers for Disease Control and Prevention. Ann Intern Med 2012; 157: 817–22. 9. Denniston MM, Klevens RM, McQuillan GM, Jiles RB. Awareness of infection, knowledge of hepatitis C, and medical follow-up among individuals testing positive
Liver International (2014) © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Searson et al.
10. 11.
12. 13.
14. 15.
16. 17.
18. 19.
20.
for hepatitis C: National Health and Nutrition Examination Survey 2001-2008. Hepatology 2012; 55: 1652– 61. Ge D, Fellay J, Thompson AJ, et al. Genetic variation in IL28B predicts hepatitis C treatment-induced viral clearance. Nature 2009; 461: 399–401. New York City Department of Health and Mental Hygiene, Division of Disease Control, Bureau of Communicable Diseases. Hepatitis A, B, C Surveillance Report, 2006-2007. Williams DR. Miles to go before we sleep: racial inequities in health. J Health Soc Behav 2012; 53: 279–95. Conjeevaram HS, Fried MW, Jeffers LJ, et al. Peginterferon and ribavirin treatment in African American and Caucasian American patients with hepatitis C genotype 1. Gastroenterology 2006; 131: 470–7. Howell C, Jeffers L, Hoofnagle JH. Hepatitis C in African Americans: summary of a workshop. Gastroenterology 2000; 119: 1385–96. 112th Congress. Public Law 112-144. Food and Drug Administration Safety and Innovation Act. 2012. http:// www.gpo.gov/fdsys/pkg/PLAW-112publ144/pdf/PLAW112publ144.pdf Poynard T, Bedossa P, Opolon P. Natural history of liver fibrosis progression in patients with chronic hepatitis C. Lancet 1997; 349: 825–32. Benhamou Y, Bochet M, Di Martino V, et al. Liver fibrosis progression in human immunodeficiency virus and hepatitis C virus coinfected patients. The Multivirc Group. Hepatology 1999; 30: 1054–8. Frieden TR, Ozick L, McCord C, et al. Chronic liver disease in central Harlem: the role of alcohol and viral hepatitis. Hepatology 1999; 29: 883–8. Innes HA, Hutchinson SJ, Barclay S, et al. Quantifying the fraction of cirrhosis attributable to alcohol among chronic hepatitis C virus patients: implications for treatment costeffectiveness. Hepatology 2013; 57: 451–60. Bruggmann P, Dampz M, Gerlach T, Kravecz L, Falcato L. Treatment outcome in relation to alcohol consumption
Liver International (2014) © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Obstacles to treating hepatitis C infection
21.
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during hepatitis C therapy: an analysis of the Swiss hepatitis C s. Drug Alcohol Depend 2010; 110: 167–71. Le Lan C, Guillygomarc’h A, Danielou H, et al. A multidisciplinary approach to treating hepatitis C with interferon and ribavirin in alcohol-dependent patients with ongoing abuse. J Hepatol 2012; 56: 334–40. Anand BS, Currie S, Dieperink E, et al. Alcohol use and treatment of hepatitis C virus: results of a national multicenter study. Gastroenterology 2006; 130: 1607–16. Simoni JM, Huh D, Wilson IB, et al. Racial/ethnic disparities in ART adherence in the United States: findings from the MACH14 study. J Acquir Immune Defic Syndr 2012; 60: 466–70. Stepanova M, Kanwal F, El-Serag HB, Younossi ZM. Insurance status and treatment candidacy of hepatitis C patients: analysis of population-based data from the United States. Hepatology 2011; 53: 737–45. Feuerstadt P, Bunim AL, Garcia H, et al. Effectiveness of hepatitis C treatment with pegylated interferon and ribavirin in urban minority patients. Hepatology 2010; 51: 1137–43. Kramer J, Kanwal F, Richardson P, Mei M, El-Serag HB. Gaps in achievement of effectiveness of HCV treatment in national VA practice. J Hepatology 2012; 56: 320–5. Fried MW, Shiffman ML, Reddy KR, et al. Peginterferon alfa-2a plus ribavirin for chronic hepatitis C virus infection. N Engl J Med 2002; 347: 975–82. Bichoupan K, Martel-Laferriere V, Ng M, et al. Real world costs of telaprevir-based triple therapy, including costs of managing adverse events, at Mount Sinai Medical Center, NY: $147,000 per EOT. 48th Annual Meeting, European Association for the Study of Liver Disease. Amsterdam, April 24–28, 2013: A795. Martin TC, Martin NK, Hickman M, et al. Hepatitis C reinfection: incidence and treatment outcome among HIV-positive MSM. AIDS 2013; 27: 2551–7. Osiri M. Equity-oriented toolkit: community effectiveness. WHO Collaborating Center for Health Technology Assessment 2004; 1–11.
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REVIEW ARTICLE
Treatment of chronic hepatitis C virus infection in the United States: some remaining obstacles Gloria Searson1, Ellen S. Engelson2, Damaris Carriero1,3 and Donald P. Kotler1,2 1 Coalition on Positive Health Empowerment, New York, NY, USA 2 Division of Gastroenterology, Department of Medicine, St. Luke’s and Roosevelt Hospitals, Icahn School of Medicine at Mount Sinai, New York, NY, USA 3 Center for Liver Disease and Transplantation, Columbia University Medical Center, New York, NY, USA
Keywords alcoholism – chronic liver disease – effectiveness research – health disparities – substance abuse
Correspondence Donald P. Kotler, MD, Gastrointestinal Division, S&R 12, 1111 Amsterdam Avenue, St. Luke’s-Roosevelt Hospital Center, New York, NY 10025, USA Tel: +212-523-3670 Fax: +212-523-3678 e-mail: [email protected] Received 27 June 2013 Accepted 6 January 2014 DOI:10.1111/liv.12467 Liver Int. 2014: 34: 668–671
Abstract Hepatitis C infection is an important problem in inner city neighbourhoods, which suffer from multiple health disparities. Important factors in this population include alcoholism and substance abuse, mental illness and homelessness, which may be combined with mistrust, poor health literacy, limited access to healthcare and outright discrimination. Systemic barriers to effective care include a lack of capacity to provide comprehensive care, insufficient insurance coverage, poor coordination among caregivers and between caregivers and hospitals, as well as third party payers. These barriers affect real world treatment effectiveness as opposed to treatment efficacy, the latter reflecting the world of clinical trials. The components of effectiveness include efficacious medications, appropriate diagnosis and evaluation, recommendation for therapy, access to therapy, acceptance of the diagnosis and its implications by the patient and adherence to the recommended therapy. Very little attention has been given to assisting the patient to accept the diagnosis and adhere to therapy, i.e. care coordination. For this reason, care coordination is an area in which greater availability could lead to greater acceptance/ adherence and greater treatment effectiveness.
These are exciting times in the field of hepatitis C virus (HCV) infection. After many years of ominous predictions, the outlook for HCV-infected patients has improved substantially with the introduction of directacting agents (1, 2). However, it is too soon to declare victory. It has even been said that we are only ‘at the end of the beginning’ of the struggle (3). There are several remaining obstacles. The purpose of this paper is to enumerate and discuss some of the remaining barriers to effective HCV treatment in the United States, predominantly from an inner city perspective. The medical and economic burdens of HCV have been increasing for the past three decades (4, 5), and will continue to rise for the next 15 years. The burden of managing HCV-infected patients will fall increasingly on public institutions, i.e. inner city hospitals, clinics and community health centres, and the costs will shift progressively to public payers, such as Medicaid and Medicare (5). Official estimates of disease prevalence in The text was adapted from a presentation by Ms Searson at a CDC Workshop: Bridging the Sciences, Atlanta, GA, September 12–14, 2012.
668
the United States range from around 4 million (6) to as high as 7 million (7). The largest subgroup, comprising almost 80%, was born between 1945 and 1965 (8). Other cohorts of HCV-infected individuals exist, including immigrants, patients with sexually transmitted HCV infection, plus other routes of transmission, including nosocomial. A majority are unaware of their HCV serostatus (9). There are multiple obstacles to access effective antiviral therapy in all countries, with variations within and between them for different subgroups of patients. The barriers can be classified as virologic, host and systemic. Virological factors will not be considered here. Host factors may be modifiable or non-modifiable. In addition to age, sex and HIV co-infection, genetic factors exist, such as the IL28B polymorphism, which partially explain the observed racial variation in treatment response (10). While hepatitis C has its highest prevalence in a cohort defined by birth year, it is an especially important problem in African-American communities. The authors’ institutions treat residents of Harlem and surrounding neighbourhoods in New York City, which have high prevalence rates for HCV infection and other Liver International (2014) © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Searson et al.
comorbidities (11). Similar conditions exist in many inner city environments in the United States. It is not appropriate to discuss HCV infection in African-Americans without noting the presence of health disparities in general. In a recent publication, Williams and colleagues noted that overall death rates in AfricanAmericans are 30% higher than in Caucasians (12), with higher death rates for 10 of the 15 leading causes of death, though not for cirrhosis. Health disparities also exist in HCV infection, in terms of higher prevalence (6) and poorer response to therapy (13). Despite these facts, African-Americans have long been under-represented in clinical trials (14). To identify and reduce such disparity, the FDA Safety and Innovation Act, recently passed by Congress, requires the FDA to report annually on the inclusion of subjects by age, sex, race and ethnicity in clinical trials supporting applications of new drugs and medical devices (15). Important host factors that are potentially modifiable include substance abuse, mental illness and homelessness. A comorbidity that has received very little attention is alcoholism. Alcohol accelerates hepatic fibrosis in mono- and co-infected patients with HCV infection (16, 17). A prospective, case–control study published in 1999, of chronic viral hepatitis, alcoholism and the development of chronic liver disease at Harlem Hospital Center (18) showed that the combination of HCV infection and heavy alcohol intake, but not HCV infection or alcoholism alone, significantly promoted the development of chronic liver disease. The cohort was followed up for 4 years and death rates were numerically higher in the HCV plus alcohol group. The authors called for greater attention to the management of alcoholism to mitigate the development of chronic liver disease, even in the absence of effective anti-HCV therapy at the time. In a review of HCV-infected patients followed over a 15-year period in clinics in Scotland, the fraction of cirrhosis attributable to any alcohol intake was estimated at 36%, and at 61% for heavy drinkers (19). Importantly, since active alcoholism is an absolute contraindication to anti-HCV therapy, the subgroup at most risk of disease progression often is excluded from treatment. Recent studies from Switzerland and France have demonstrated reasonable rates of sustained viral response in alcohol-dependent patients (20, 21). Poorer responses to anti-HCV therapy in the US VA system were felt to be related more to poorer treatment adherence than a direct effect of alcohol intake (22). Maintaining adherence to treatment may be as important or even a more important goal than enforcing abstinence. A study to test this hypothesis would be one comparing the effects of abstinence and harm reduction. However, while determining the relative importance of HCV and of alcohol intake, including amount, drinking pattern and chronicity, in liver disease progression is of interest, the ultimate goal of therapy should be to cure both conditions. Liver International (2014) © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Obstacles to treating hepatitis C infection
Other host factors may also affect treatment adherence. Simoni et al. analysed 13 studies in HIV infection that used electronic drug monitoring. Demographic variables such as sex, age, economic status, education level, plus depression and substance abuse, did not fully explain a lower level of adherence observed in AfricanAmerican subjects (23). The authors cited evidence that mistrust, poor health literacy, inequalities in access to healthcare, as well as outright discrimination might be responsible for the differences. Patient mistrust acts synergistically with nihilism and stigmatization to confound attempts at therapy. Patients whose clinical problems are related to socially unacceptable behaviours may be especially prone to feeling stigmatized, while caregivers may unconsciously express bias. Cultural competences, which involve developing attitudes, behaviours and policies that enable effective work in cross-cultural situations, are routine medical education and core competency initiatives, but have not overcome the prevailing host barriers. The host barriers to effective treatment may become institutionalized, so that caregivers do not aggressively promote and patients do not aggressively seek proven therapies. These biases may be resistant to change. A substantial proportion of patients currently presenting for HCV testing are aware of their HCV status or of the presence of liver disease (G. Searson, personal observations). In many cases, patients had been told by a healthcare provider one, two or three decades ago that they were going to be OK or that their liver tests were relatively normal and not to worry, and now are being told that they have a serious disease. It is especially difficult for the medical establishment to engage patients who exist outside the formal healthcare system. The Affordable Care Act may be helpful in expanding coverage to some people, but it will not aid people who harbour a fundamental mistrust in the healthcare system. Community-based organizations may be helpful in this situation; fostering trust by helping people to feel at ease through non-judgmental treatment; creating an environment where people may be more truthful about personal matters: self-worth, future prospects or even existential concerns. Systemic barriers to effective care are multiple and diverse. Perhaps the most important is the lack of capacity of our system to provide comprehensive care to our patients. Mental health issues especially often are unrecognized, overlooked or undertreated. In HIV infection, Ryan White funding allowed the development of a comprehensive care model, with resources devoted to social work needs, including food and shelter, as well as mental health needs. Such support is not available for HCVinfected patients. Lack of insurance, or insufficient insurance coverage, is common among HCV-infected patients (24). Poor coordination between caregivers and hospitals and between caregivers and third party payers may lead to unanticipated treatment interruptions. Few institutions
669
Searson et al.
Obstacles to treating hepatitis C infection
have a centralized system for toxicity management, relying on standard emergency services. However, a visit to an Emergency Department or a hospital admission is likely to lead to treatment interruption for a patient irrespective of the presenting complaint. Few hospitals have direct-acting anti-HCV agents on formulary and the patient is ‘supposed to’ bring his/her outpatient medications to the hospital, which may not occur in the face of an emergency. There are two ways to evaluate treatment success: efficacy and effectiveness. Most discussions are centred on the notion of treatment efficacy, which can be defined as the number cured/number treated, and which reflects the world of clinical trials. Inclusion and exclusion criteria minimize the host factors interfering with therapy while the study design and pharmaceutical support minimize the systemic obstacles to therapy. A more accurate measure of treatment success from a public health standpoint is treatment effectiveness, which can be defined as the number cured/number infected. Its importance is seen in the example of alcoholism. As discussed above, alcoholism increases the risk for developing chronic liver disease, but is a contraindication for therapy, including inclusion in clinical trials. For this reason, alcoholism does not affect measured treatment efficacy though it markedly reduces treatment effectiveness, as might be measured by the prevention of chronic liver disease. Measured rates of effectiveness for pegylated interferon and ribavirin averaged 3.5% in clinical experience (25, 26), while the effectiveness in the registration trials ranged from 12 to 17%, and efficacy in the same trials averaged around 45% (25). Recent and emerging advances in therapy will allow the role of new regimens on treatment effectiveness to be determined, especially the application of interferonfree regimens. Treatment efficacy for genotype 1, treatment-na€ıve patients in clinical trials averaged 40–50%, using pegylated interferon and ribavirin (27), compared to around 75% in trials also using a directing agent (1). However, real world results in an inner city population in New York City showed an efficacy of 14% in genotype 1 patients. In addition, a recent presentation showed an SVR rate of 43% using a direct-acting agent in a similar patient group (28). Treatment effectiveness, including cost effectiveness will require closing the gap between clinical trials and real world results. Depending on the specific community, net effectiveness also may require improvements in the prevention of risk behaviours, which may lead to reinfection after SVR (29). Furthermore, improvements in efficacy are irrelevant for a patient who remains unengaged with the formal healthcare system. One can divide treatment effectiveness into several components (30). Effective therapy includes the availability of efficacious medications as well as a system to evaluate patients appropriately, recommend therapy, provide access to therapy, as well as patient compliance
670
with the evaluation and recommendations as well as adherence to therapy. Developing efficacious medications is the task of the pharmaceutical industry, while making diagnoses and treatment recommendations plus providing access to therapy are tasks for the healthcare system. Accepting the diagnosis and adhering to therapy is the job of the patient and patient advocates. While great effort has gone into developing efficacious therapies and an increasing amount of attention is being given to screening, diagnosis and evaluation, less attention has been placed on treatment access and very little attention has been given to assisting the patient to accept the diagnosis and adhere to therapy, i.e. care coordination. For this reason, care coordination is an area in which greater availability, supported by a currently non-existent funding source, could lead to greater acceptance/adherence and greater treatment effectiveness. The elements of care coordination, which include individual counselling, education, behaviour modification and other support, are the same for the management of many diseases. In summary, if we can overcome the obstacles to care delineated above, then treatment effectiveness will equal efficacy. Acknowledgements
Financial support: None. Conflict of interest: The authors do not have any disclosures to report. References 1. Jacobson IM, McHutchison JG, Dusheiko G, et al. Telaprevir for previously untreated chronic hepatitis C virus infection. N Engl J Med 2010; 364: 2405–16. 2. Poordad F, McCone J, Bacon BR, et al. Boceprevir for untreated chronic HCV genotype 1 infection. N Engl J Med 2011; 364: 1195–206. 3. Dieterich D. The end of the beginning for hepatitis C treatment. Hepatology 2012; 55: 664–5. 4. Davis GL, Alter MJ, El-Serag H, Poynard T, Jennings LW. Aging of hepatitis C virus (HCV)-infected persons in the United States: a multiple cohort model of HCV prevalence and disease progression. Gastroenterology 2010; 138: 513–21. 5. Pyenson B, Fitch K, Iwasaki K. Consequences of Hepatitis C Virus: Costs of a Baby Boomer Epidemic of Liver Disease. New York: Milliman, 2009. 6. Armstrong GL, Wasley A, Simard EP, et al. The prevalence of hepatitis C virus infection in the United States, 1999 through 2002. Ann Intern Med 2006; 144: 705–14. 7. Edlin BR. Perspective: test and treat this silent killer. Nature 2011; 474: S18–9. 8. Smith BD, Morgan RL, Beckett GA, et al. Hepatitis C virus testing of persons born during 1945 to 1965: recommendations from the Centers for Disease Control and Prevention. Ann Intern Med 2012; 157: 817–22. 9. Denniston MM, Klevens RM, McQuillan GM, Jiles RB. Awareness of infection, knowledge of hepatitis C, and medical follow-up among individuals testing positive
Liver International (2014) © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Searson et al.
10. 11.
12. 13.
14. 15.
16. 17.
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