Date of Award

January 2015

Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Onyema Ogbuagu

Subject Area(s)

Medicine, Public health

Abstract

BACKGROUND: Despite the availability of effective therapies for the treatment of chronic hepatitis C virus (HCV) infection, therapeutic benefits have yet to be experienced by patients affected by the disease, including human immunodeficiency virus (HIV) infected individuals. The aims of this study were to describe the continuum of hepatitis C care among HIV/HCV coinfected patients and identify barriers to achieving optimal management outcomes.

DESIGN AND METHODS: We conducted a retrospective analysis of HIV/HCV coinfected patients under care at an urban HIV referral clinic, comprising patients identified with HCV infection from 2002-2014. Electronic medical records of eligible patients were reviewed, capturing demographic and clinical data. Logistic regression analyses were used to identify predictors of failing to achieve optimal outcomes along key points on the continuum of care.

RESULTS: Of 135 patients in the study, 62% were male, and median age was 56 years. Predominant racial groups were black (48.9%) and white (32.6%), and 91.8% had some form of public insurance. A significant proportion had psychiatric and substance abuse comorbidities that impacted treatment candidacy, including depression (40%), active alcohol abuse (16.3%), and ongoing illicit drug use (22.2%). The majority of patients had HCV genotype 1 disease (1a - 47%, 1b -11.1%), 91.9% were on antiretroviral therapy, and 65% had HIV viral loads < 20 copies/ml. 24.4% of subjects had cirrhosis, 27% of whom had a history of decompensated disease. The continuum of care showed that of 135 study subjects, 71% were referred for treatment, 67% had a treatment evaluation, 36% were eligible for treatment, 21% were prescribed treatment, and only 13% achieved post-treatment sustained virologic response (SVR). More than half (54%) of patients not referred for HCV treatment evaluation were deemed not to be candidates for treatment by their providers. Predictors of not being referred for HCV treatment evaluation were female gender (odds ratio: 0.240, 95% confidence interval: 0.064 - 0.907, p = 0.035), depression (OR: 0.215, CI: 0.057 - 0.812, p = 0.023), and high HIV viral load (for each 1 log increase in viral load, OR: .608, CI: 0.373 - 0.992, p = 0.046). Predictors of not being prescribed HCV treatment were high HIV viral load (OR: 0.106, 95% CI: 0.025 - 0.458, p = 0.003), and having an acquired immunodeficiency syndrome (AIDS) diagnosis by both CD4 count criteria and history of opportunistic infections (OR: 0.037, 95% CI: 0.001 - 0.924, p = 0.045).

CONCLUSIONS: The number of patients achieving HCV cure remains suboptimal. The benefits of available and effective HCV therapies will not be realized unless effective measures are implemented for dealing with barriers to care. More studies are needed to explore ways to improve modifiable factors associated with suboptimal HCV management outcomes.

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