By Liz Highleyman

In the U.S., veterans have a disproportionately high rate of hepatitis C virus (HCV) infection, and a considerable number are also coinfected with HIV. A majority of veterans receive care from Veterans Affairs (VA) health facilities, and the type of therapy they are offered -- or not offered -- has a major impact on overall treatment outcomes.

Two recent presentations looked at hepatitis C treatment eligibility and uptake among HCV monoinfected and HIV-HCV coinfected veterans.

ERCHIVES

In the first study, presented last week at the 48th International Conference on Antimicrobial Agents and Chemotherapy (ICAAC 2008), researchers assembled a national cohort of HCV-infected veterans in care from 1998-2003 -- dubbed the Electronically Retrieved Cohort of HCV-Infected Veterans, or ERCHIVES -- using the VA National Patient Care Database, Pharmacy Benefits Management database, and the Decision Support Systems database.

HCV monoinfected and HCV-HIV coinfected veterans were compared for treatment indications and eligibility using current treatment guidelines.

Results

• 27,452 of the 86,814 HCV monoinfected patients (32%) and 1225 of the 3636 HIV-HCV coinfected patients (34%) had adequate clinical and laboratory data available.

• Of these, 20,302 (74%) and 1036 (85%), respectively, had indications for anti-HCV therapy.

• Within this subset, 10,061 of HCV monoinfected patients (50%) and 693 of HIV-HCV coinfected patients (67%) had at least 1 contraindication to treatment.

• Overall, anemia, decompensated liver disease, chronic obstructive pulmonary disease (COPD), renal failure, and recent alcohol or drug use were the most common contraindications to anti-HCV therapy, followed by coronary artery disease, uncontrolled diabetes, and severe psychiatric disorders.

• Anemia -- a potential side effect of certain antiretroviral drugs, especially zidovudine (AZT; Retrovir) -- was a contraindication for 43% of coinfected patients compared with 18% of HCV monoinfected patients.

• Renal (kidney) failure, which occurs at a higher rate in African-Americans, was about twice as likely to be a contraindication for coinfected patients (20% vs 9%).

• Liver decompensation was also a contraindication nearly twice as often for coinfected patients (29% vs 16%).

• Excluding patients with contraindications left 10,241 HCV monoinfected individuals (50%) and 343 coinfected patients (33%) considered eligible for treatment.

• Among those eligible, 2229 of the HCV monoinfected patients (22%) and 47 of the HIV-HCV coinfected patients (14%) actually received any treatment for hepatitis C.

Based on these findings, the investigators concluded that, "Most veterans with HCV are not eligible for treatment according to the current guidelines."

However, they noted that several of the contraindications are modifiable (for example, treatment for anemia), and suggested that "aggressive management of those may improve treatment prescription rates."

Univ. of Pittsburgh, Pittsburgh, PA; VA Pittsburgh Hlth.care System, Pittsburgh, PA; VA Connecticut Hlth.Care System, New Haven, CT.

Patient, Provider, and Facility Characteristics

Not only patient characteristics, but also factors attributable to providers and healthcare facilities influence whether HIV-HCV coinfected veterans received hepatitis C treatment, according to data presented this week at the 59th Annual Meeting of the American Association for the Study of Liver Diseases (AASLD) in San Francisco.

In this retrospective cohort study, investigators used national administrative and clinical data from the VA Hepatitis C Clinical Case Registry to identify hepatitis C patients with active viremia (detectable HCV RNA) and documented HIV infection who visited a VA facility at least twice between 1999 and 2004.

Using hierarchical logistic regression analysis with patients clustered according to assigned primary care providers and then within facilities, they determined patient, provider, and facility-level predictors of receiving hepatitis C treatment within 2 years of HCV diagnosis.

Results

• Of the 7103 HIV-HCV coinfected veterans in the cohort, 10% received anti-HCV treatment within 2 years of diagnosis.

• Patient factors associated with low treatment rates included:

• Black race/ethnicity (odds ratio [OR] 0.5);
• Hispanic race/ethnicity (OR 0.6);
• Male sex (OR 0.4);
• Diagnosis of drug use (OR 0.7);
• Diagnosis of psychosis (OR 0.6);
• Infection with HCV genotype 1 or 4 (OR 0.6);
• HIV viral load > 50,000 (OR 0.2).

• Patients were more likely to receive hepatitis C treatment if the following factors were present:

• Diagnosed with HCV in recent years (OR 1.3 for 2002 vs 1999);
• Persistently high ALT (OR 2.2);
• High hemoglobin (OR 1.2);
• Diagnosis of cirrhosis (OR 2.4);
• CD4 count of 200-499 vs < 200 cells/mm3 (OR 1.7).

• Patients seen at facilities with more than 1 clinic site were less likely to receive treatment (OR 0.8).

• Conversely, patients seen by a HCV specialist were more likely to receive treatment (OR 4.4).

"Our analysis identified several patient, provider, and facility level predictors of treatment in HCV in veterans with HCV-HIV coinfection," the researchers concluded.

"Patient-level factors are not the sole determinant of receipt of treatment in patients with HCV-HIV coinfection," they continued. "Identification of the provider and facility characteristics associated with low HCV treatment rates in patients with HCV-HIV coinfection may allow targeting of interventions to increase those rates."

Lead investigator Jennifer Kramer cautioned, however, that "it is difficult to draw conclusions to all patients with HCV-HIV coinfection because the VA cohort tends to be predominately male and relatively low income."

Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX; John Cochran Veteran Affairs Medical Center and School of Medicine, St. Louis University, St. Louis, MO.

11/04/08

References

AA Butt, K Mcginnis, M Skanderson, and others. HCV Treatment Eligibility in ERCHIVES (Electronically Retrieved Cohort of HCV Infected Veterans). 48th International Conference on Antimicrobial Agents and Chemotherapy (ICAAC 2008). Washington, DC. October 25-28, 2008. Abstract V-1634.

JR Kramer, F Kanwal, TP Giordano, and others. Patient, Provider, and Facility Characteristics of HCV Antiviral Treatment among US Veterans with HCV-HIV Coinfection. 59th Annual Meeting of the American Association for the Study of Liver Diseases (AASLD 2008). San Francisco. October 31-November 4, 2008. Abstract 121.

Other source
AASLD. Why are some veterans who are coinfected with hepatitis C and HIV more likely to be treated for HCV than others? Press release. November 2, 2008.