Obstacles to Hepatitis C Therapy: Effective Regimens Are Not Enough

Obstacles to Hepatitis C Therapy: Effective Regimens Are Not Enough

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Hepatitis C Virus Epidemiology, Pathogenesis, Diagnosis, and Natural History

Donald P. Kotler, MD - 6/4/2013 

Although the outlook for HCV-infected patients who enter treatment has improved substantially with the introduction of direct-acting agents, various host factors remain as barriers to effective management for some patients. My colleagues and I treat patients in the New York City community of Harlem and its surrounding neighborhoods. As most providers in similar communities are aware, we face challenges including higher rates of comorbidities such as alcoholism, lower response rates to current therapies, and disparities of access to healthcare. Our conclusion is that many patients will not derive the full potential benefit from advances in HCV therapy unless all of these factors are addressed.

Each Patient Brings Their Own Unique Challenges
The patients from our community are affected by a number of important host-related factors that influence their access to and the outcomes of medical care in general and HCV treatment in particular.

Substance abuse, particularly alcoholism, is a significant problem for our patients and is especially concerning since active alcoholism represents a significant challenge to anti-HCV therapy. Surprisingly, alcoholism has received little attention, despite the fact that it accelerates hepatic fibrosis. A prospective, case-controlled study performed at Harlem Hospital Center approximately 20 years ago demonstrated that the combination of HCV infection and heavy alcohol intake, but neither HCV infection nor alcoholism alone, significantly promoted the development of chronic liver disease. Whereas those results suggest the need for greater attention to the management of alcoholism, they also illustrate the presence of a subgroup of patients at serious risk of disease progression who typically are excluded from treatment. Recent studies from the United States and Europe have documented the ability to successfully treat patients with a history of alcoholism, typically by providing some form of integrated care. Maintaining adherence to anti-HCV treatment may be as important or even a more important goal than enforcing abstinence from alcohol intake.

In our community, other patient-related factors may also affect treatment adherence including mistrust of the healthcare system, poor health literacy, inequalities in access to healthcare, as well as outright discrimination. For our patients, these factors might be responsible for poorer adherence as well as poorer outcomes of therapy. This atmosphere of mistrust works in concert with patients’ nihilism and perceived stigma to confound attempts at therapy. Although efforts to improve cultural competence in managing patients and combating host-related obstacles to effective therapy are now routine medical education and core competency initiatives, the reality is that these barriers still exist. The lack of faith may extend beyond the patient and become imbedded in the local healthcare system. A culture of low expectations may influence caregivers so that they do not aggressively promote therapy to their patients. As with all cultures, these biases may be resistant to change.

Stumbling Over Institutional Steps
We have found that it is especially difficult for the medical establishment to engage patients who exist outside the formal healthcare system, especially when the individual harbors a fundamental mistrust in the healthcare system. We have found that some of this mistrust may be mitigated by effective community-based organizations that foster trust by establishing an environment in which people are treated in a nonjudgmental manner.

In addition to efficacious medications, effective HCV therapy also requires appropriate diagnosis and evaluation, recommendation for therapy, access to therapy, acceptance of the diagnosis and its implications by the patient, and adherence to therapy. Medication development is the purview of the pharmaceutical industry, and it has vigorously pursued them, but the diagnosis, treatment recommendations, and treatment access are tasks for the healthcare system and those of us at the front line of care. Our patients bear the responsibility of accepting the diagnosis and adhering to therapy and form the other basis for successful therapeutic outcomes. An increasing amount of attention is being given to screening and linkage to care, but less attention has been placed on assuring treatment access and very little attention has been given to care coordination. To the extent that care coordination and community involvement enhance acceptance and adherence, they will avoid the wasted resources associated with refusal of care and early treatment suspension, as well as liver disease progression.

Your Thoughts?
Do you share our concerns that many patients are effectively excluded from successful treatment by these host-related factors? What is your experience with patients in your communities? Have you tried any interventions to overcome these barriers in your patients? We are keen to hear your experiences.

Topics: HCV - Outcome