Breaking barriers to hepatitis C treatment in the DAA era

A large percentage of patients with established care for hepatitis C virus (HCV) infections do not receive continuing treatments with ground-breaking direct-acting antiviral (DAA) agents, according to a new study.

New DAA treatments offer an unprecedented opportunity to provide a cure for HCV, and have shown in clinical trials to eliminate HCV in more than 95% of patients, with low rates of adverse events. But several barriers exist to anti-viral treatment in real-world settings.

“There are still existing gaps in how to reach the HCV-infected population,” Fasiha Kanwal, MD, professor of medicine at Baylor College of Medicine in Houston, Texas, told Medical Economics. “Some factors are modifiable, such as inadequate treatment of alcohol and drug users, with better education. Other factors need a different strategy, including better outreach.”

The researchers published their results in the November 2017 Alimentary Pharmacology & Therapeutics.

Kanwal and colleagues used clinical data from a retrospective cohort of HCV-infected patients with previously established HCV care in the U.S. Department of Veterans Affairs (VA) to examine predictors of follow-up in HCV clinics and DAA treatment. Then they conducted a structured review of medical charts of HCV patients to determine reasons for lack of follow-up and treatment.

Of the 84,221 veterans identified who were previously seen in HCV clinics during the pre-DAA era, 47,165 (56%) followed-up in HCV specialty clinics, but only 13,532 (28.7%) received DAAs.

“The VA system provides easy access to treatment and makes an effort to link patients to care far better than anywhere else. Even in this system, it is not easy for patients to get treatment,” said Kanwal. Surprisingly, a significant proportion of patients moved away and did not get continuing care, she said.

Specifically, patients with less severe liver disease, those with ongoing alcohol and drug use, and those with multiple co-morbidities had lower odds of being re-seen and treated than their counterparts. The odds of having a repeat visit and treatment were also lower for patients with non-genotype 1 infection, hepatocellular carcinoma and those who were homeless.

Patients with ongoing alcohol and drug use have traditionally been excluded from anti-viral treatment based on the premise these patients would not comply with long, toxic treatments and the risks of re-infection with ongoing drug use. “With previous treatments the response rate was lower, but that is not the case with DAAs,” said Kanwal. “Previously accepted contraindications are no longer barriers to treatment.”

Also, physicians had been trained not to treat HCV patients with comorbidities.

“We have a different paradigm now. Most patients are able to comply with 12-week DAA treatment,” said Kanwal. “If primary care physicians see HCV patients, they should treatment them. If need be, refer to a specialist.”

Physician practices need a system to provide population-based care for HCV patients. Kanwal has begun a quality-of-care project at the Houston VA to reach out to the HCV community, leveraging population health tools to identify patients and link them back to care.