By Annette M. Boyle
LOS ANGELES – Nearly 40% of veterans receiving antiretroviral therapy for human immunodeficiency virus (HIV) infection also have hepatitis C virus (HCV), yet many of them never are treated for the underlying condition.
Patients often are considered ineligible because of concerns that HCV therapy could worsen psychiatric conditions or that the difficulty of the additional drug regimen would lead to non-adherence, according to a recent study that looked at HCV treatment at three HIV clinics in Los Angeles, including a VA facility.
In fact, providers consider only 30% of dual-infected patients eligible for HCV treatment and just 10% of patients actually undergo treatment, according to a recent study published in the Journal of the International Association of Physicians in AIDS Care.1
Yet, as life expectancy for HIV-positive patients has increased, HCV-related liver failure has emerged as a leading cause of death among co-infected patients — in one study of co-infected VA patients in Houston, accounting for 47% of deaths.2
In the Los Angeles study, researchers conducted cross-sectional surveys of 14 primary care providers and 173 HCV co-infected patients at the Greater Los Angeles VAMC and two other Los Angeles HIV clinics. The VA had offered treatment to 66% of co-infected survey participants, more than twice the national average but less than the 85% and 77% of participants offered treatment at the other two clinics.
While the VA’s Management and Treatment of Hepatitis C Virus Infection in HIV-Infected Adults guideline advises that “all patients infected with HCV be considered for treatment, including those who are also co-infected with HIV,” researchers found that, in practice, both patient and physician characteristics factored into the decision to recommend HCV treatment.3
Despite some evidence that patients struggling with substance abuse issues or depression can successfully undertake the HCV course of therapy, physicians often consider these patients ineligible, fearing treatment “may lead to psychiatric deterioration, relapse into substance abuse, and treatment non-adherence and discontinuation,” noted the researchers.
Depression is Treatment Issue
In this study, recommendation of HCV treatment correlated specifically with depression treatment status for current depression.
“Past history of depression, or current depression that was being managed with treatment, was not the limiting factor to being recommended treatment, which is consistent with data suggestion that such factors are not necessarily impediments to HCV treatment response,” wrote the authors.
“Depression is a very common comorbidity in this population. It affects over 50% of patients with HIV and even more of those who also have HCV,” said Maggie Czarnogorski, MD, deputy director of the VA’s HIV, Hepatitis and Public Health Pathogens Programs. “The HCV regimens are not easy to take and they can exacerbate depression, suppress appetite and generally affect mood, which makes them challenging for those with mental health issues.”
Rather than eliminate depressed patients from consideration for treatment, however, the VA recommends working with patients to improve their baseline mental health status and supporting them through the treatment.
“We really advocate for hepatologists to work closely with HIV patients to optimize their mental health before they start treatment. In addition, we’ve been piloting integrating psychologists in hepatology clinics. Currently, four VAMC’s have post-doctoral fellows in psychology” to address these issues, Czarnogorski told U.S. Medicine.
Patients in the study with a CD4 count above 200 and with a low HIV viral load were more likely to have been offered HCV treatment. Physicians may recommend treatment to this subpopulation more because pegylated-interferon and ribavirin, used to treat HCV, can temporarily reduce CD4 counts, making patients more vulnerable to other infections. Higher levels of CD4 can been beneficial in preventing that.
Czarnogorski noted that “research shows that co-infected patients have a lower response to treatment for hepatitis C, overall. They have the best response if HIV is stable and virally suppressed.”
In the study, some physicians considered patients with very low CD4 levels eligible for treatment, although, consistent with clinical trials conducted by the Hepatitis Research Network, few patients with CD4 levels below 100 usually are offered treatment.
While dual-infected patients can be treated when HIV is more advanced, they typically do better when treated earlier, said Czarnogorski, making prompt identification of both infections critical.
“We’ve really promoted routine screening for HIV. Everyone with HIV should be screened for HCV, as well. Once a patient is identified with both infections, it is very important to start ART right away and for the providers treating HIV and HCV to work together to coordinate treatment efforts,” she said.