Can a Racial Divide Explain Non-Treatment of HCV among the HIV-HCV Coinfected?

Historically, the use of pharmaceutical therapy for hepatitis C virus (HCV) infection has had a low prevalence among patients coinfected with HIV and HCV.

According to research published in the World Journal of Hepatology, prior to 2011 when direct-acting antivirals (DAAs) became available, only one-third of coinfected patients were deemed eligible for HCV therapy, and less than one-third of eligible patients ever initiated HCV treatment.

Reasons cited for non-initiation of older therapies like pegylated interferon plus ribavirin (pegIFN-RBV) include perceived risks and benefits and medical contraindications such as hepatic decompensation, advanced immunosuppression, and issues with substance abuse or severe depression that pose a risk of nonadherence.

Nearly half of US patients with HIV-HCV coinfection are African-American. Studies involving older HCV regimens like pegIFN-RBV have shown that coinfected African-Americans are significantly less likely to receive HCV therapy than Caucasians. While there is a body of research on the treatment barriers faced by the general HIV-HCV patient population, not much information exists on barriers specific to people of color.

Researchers at the University of North Carolina conducted a retrospective study looking at the race and ethnicity of patients with HIV-HCV. They set out to identify any barriers to HCV treatment that differentially affect people of color, but they found none. Instead, the researchers identified 3 categories of reasons for HCV non-treatment that did not vary significantly by a patient’s race or ethnicity.

Methods

The study involved a cohort of 171 coinfected, HCV treatment-naïve adult patients with at least 1 outpatient visit between 2004 and 2011. Researchers chose this study period to capture the time when pegIFN-RBV was the standard combination regimen for most patients with HIV-HCV coinfection.

Relationships between demographic variables, clinical characteristics, and documented reasons for non-initiation of HCV therapy were evaluated through descriptive analyses and multivariate logistic regression models. Odds ratios and 95% confidence intervals were used to determine statistically significant results.

The median age of cohort patients was 46, and 74% were male. Seventy-four percent of patients were African-American, 19% were Caucasian, and 7% were Hispanic or another race or ethnicity. More than one-third (37%) of patients lacked health insurance.

Reasons for HCV Therapy Non-Initiation

Reasons for non-initiation of HCV therapy did not vary significantly by race or ethnicity.

For about half of all patients, researchers found at least 1 documented non-modifiable medical reason to not treat HCV. Patient death was the most common, followed by advanced immunosuppression.

Two-thirds of all patients had at least 1 modifiable reason against HCV therapy (range 66% to 69% across all racial/ethnic groups). Psychiatric illness and use of injection drugs or cocaine were the most common of these, followed by alcohol use and severe depression.

Authors reported that non-medical reasons also were common across all racial/ethnic groups. Personal and social reasons were most prevalent, and economic reasons were least prevalent, at least in documented charts.

All told, the study concluded that patients with HIV-HCV coinfection tend to have multiple reasons for not using HCV therapy, regardless of race or ethnicity.

These observations were made in the context of interferon-based regimens, although the authors believe that addressing the same barriers can be useful in the era of first-line DAA regimens.