Treat Early or Wait and Monitor? A Qualitative Analysis of Provider Hepatitis C Virus Treatment Decision-Making in the Context of HIV Coinfection

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AIDS patient care and STDs (Impact Factor: 3.5). 09/2009; 23(9):715-25. DOI: 10.1089/apc.2009.0049
Source: PubMed


Liver disease is a leading cause of death among patients with HIV coinfected with hepatitis C (HCV); yet, studies show that less than 10% receive HCV treatment, in part because of limited treatment response, high treatment toxicity, and psychosocial barriers to treatment readiness. Using a process model framework, we sought to explore the factors and processes by which providers make HCV treatment decisions for HIV-coinfected patients. We conducted 22 semistructured interviews with primary care providers and support staff at three HIV clinics in Los Angeles, California, in which rates of HCV treatment uptake varied from 10% to 38%. Providers agreed that stable HIV disease, favorable genotype, and significant signs of liver disease progression are all signs of need for treatment. However, two divergent treatment approaches emerged for genotype 1 and 4 patients with minimal disease, and in definitions of patient readiness. Providers with lower treatment rates preferred to delay treatment in hopes of better future treatment options, and were more conservative in requiring complete mental health screens and treatment and abstinence from substance use. Conversely, providers with higher treatment rates viewed all patients as needing treatment as soon as possible, and defined readiness more leniently, with some willing to treat even in the context of untreated depression and drug use, so long as ability to adhere well was demonstrated. Regardless of whether an aggressive or cautious approach to treatment is used, development of effective programs for promoting patient treatment readiness is critical to ensuring greater treatment uptake.

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Available from: Matthew Bidwell Goetz
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    • "Despite recent and emerging advances in treatment, barriers to care persist, particularly for HCV care. The most common barriers are at the systems level (e.g., limited infrastructure for assessment and treatment, accessing care, high treatment costs), provider level (e.g., perceptions of poor patient adherence, concerns for active drug abusers, lack of experience treating patients), and at the patient level (e.g., lack of knowledge, misconceptions, level of motivation) [20,34]. Potential strategies to improve engagement in care include routine HCV testing and linking patients to care immediately following diagnosis. "
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    ABSTRACT: Few studies have explored how utilization of outpatient services differ for HIV/HCV coinfected patients compared to HIV or HCV monoinfected patients. The objectives of this study were to (1) compare annual outpatient clinic visit rates between coinfected and monoinfected patients, (2) to compare utilization of HIV and HCV therapies between coinfected and monoinfected patients, and (3) to identify factors associated with therapy utilization. Data were from the 2005-2010 U.S. National Hospital Ambulatory Medical Care Surveys. Clinic visits with a primary or secondary ICD-9-CM codes for HIV or HCV were included. Coinfection included visits with codes for both HIV and HCV. Monoinfection only included codes for HIV or HCV, exclusively. Patients <15 years of age at time of visit were excluded. Predictors of HIV and HCV therapy were determined by logistic regressions. Visits were computed using survey weights. 3,021 visits (11,352,000 weighted visits) met study criteria for patients with HIV/HCV (8%), HIV (70%), or HCV (22%). The HCV subgroup was older in age and had the highest proportion of females and whites as compared to the HIV/HCV and HIV subgroups. Comorbidities varied significantly across the three subgroups (HIV/HCV, HIV, HCV): current tobacco use (40%, 27%, 30%), depression (32%, 23%, 24%), diabetes (9%, 10%, 17%), and chronic renal failure (<1%, 3%, 5%), (p < 0.001 for all variables). Annual visit rates were highest in those with HIV, followed by HIV/HCV, but consistently lower in those with HCV. HIV therapy utilization increased for both HIV/HCV and HIV subgroups. HCV therapy utilization remained low for both HIV/HCV and HCV subgroups for all years. Coinfection was an independent predictor of HIV therapy, but not of HCV therapy. There is a critical need for system-level interventions that reduce barriers to outpatient care and improve uptake of HCV therapy for patients with HIV/HCV coinfection.
    Full-text · Article · Apr 2014 · BMC Infectious Diseases
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    • "A few provider surveys have revealed reasons for classifying patients as ineligible for IRT (Fultz et al., 2003; Thompson et al., 2005). However, there is a lack of data on how providers' treatment decisions are shaped by their assessment of IRT's side effects against its effectiveness (see exception, Wagner et al., 2009). "
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    ABSTRACT: Despite the high prevalence of hepatitis C virus (HCV) infection among injection drug users also infected with human immunodeficiency virus (HIV), and the synergistic adverse effect of the two diseases on patients' health and survival, research on the clinical management of these patients and particularly the low uptake of HCV therapy is limited. We conducted qualitative interviews with 17 HIV providers from two urban public hospitals. We discovered that the limitations of the current state of medical knowledge, the severe side effects of HIV and HCV therapies, and the psychosocial vulnerability of HIV/HCV-coinfected patients combined with their resistance to becoming informed about HCV posed significant challenges for providers. To contend with these challenges, providers incorporated key dimensions of patient-centered medicine in their practice, such as considering their patients' psychosocial profiles and the meaning patients assign to being coinfected, and finding ways to engage their patients in a therapeutic alliance.
    Preview · Article · Aug 2011 · Qualitative Health Research
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    • "All rights reserved. doi:10.1016/j.drugalcdep.2010.11.016 chiatric effects of interferon, re-infection and the short-term threat of drug use (Davis and Rodrigue, 2001; Wagner et al., 2009). In 2002, IDU was retracted as a treatment contraindication by the National Institute of Health and in 2004 by the American Association for the Study of Liver Disease (National Institute of Health, 2002; Strader et al., 2004). "
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    ABSTRACT: A minority of HIV/HCV coinfected patients with opiate addiction undergo HCV treatment. HCV therapy for HCV-monoinfected methadone maintenance (MM) recipients is safe and effective. We evaluated treatment efficacy and adherence to pegylated interferon (pegIFN) among HIV/HCV coinfected MM recipients. HCV treatment-naïve, HIV-infected persons 18-65 years with chronic HCV genotype 1 on MM were prospectively enrolled in an HCV treatment study at two HIV clinics. At weekly visits pegIFN alfa-2a injections were directly administered. Daily MM recipients had morning ribavirin delivered with methadone at off-site methadone clinics. Weekly take-home MM recipients took ribavirin unsupervised. Target enrollment was 30 participants. During 18 recruitment months, 11 participants were enrolled, 6 of whom received daily methadone. Mean age was 46, 64% were female, 5 were Caucasian, 4 Black and 2 Hispanic. At baseline, 82% had high HCV RNA and 55% had stage 2 fibrosis or greater. The majority (91%) were on HAART, and 82% had undetectable HIV RNA with a median CD4(+) of 508cells/μL. All had polysubstance use history, non-substance-based psychiatric diagnoses and were on psychotropic medications pre-enrollment. Two (18%) participants achieved a Sustained Virologic Response (SVR). Two completed 48 treatment weeks, 5 were withdrawn due to adverse events, 2 dropped out prematurely and 2 had treatment discontinued for virologic non-response. Of on-treatment weeks, adherence to pegIFN was >99%. SVR rate was comparable to historic controls for coinfected genotype 1 patients, with optimal pegIFN adherence. Adverse effects often prevented therapy completion in this population.
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