Integrated Care Improves Hepatitis C Treatment of Hard-to-Reach Patients


Patients with psychological and substance use problems are less likely to stay engaged in hepatitis C care.

An integrated care program succeeded in providing Hepatitis C virus (HCV) treatment to patients in real-world settings who were unlikely to respond to traditional outreach efforts.

Erik Groessl, PhD (pictured), of the San Diego Veterans Affairs (VA) Heathcare System in San Diego, pointed out that a substantial number of patients do not seek, accept, or remain in treatment for HCV (hepatitis C virus) despite having coverage of treatment costs and likelihood of a cure with direct acting antivirals (DAAs).

"HCV-infected individuals with psychological and/or substance use problems have been shown to be less likely to stay engaged in hepatitis C care, and they often have trouble adhering to ongoing treatment regimens or recommendations," Groessl told MD Magazine. "So although the new antiviral medications have fewer side effects, it is important to provide additional case management support to help these patients get the care they need."

Groessl and colleagues at the San Diego VA identified 79 subjects who had screened positive for HCV, as well as having symptoms of depression, post-traumatic stress disorder (PTSD) or substance use disorder. These comorbidities, along with homelessness were prominent among factors associated with non-engagement in HCV care in previous VA studies.

Patients were randomized to an Integrated Care (IC) or Usual Care (UC) program to facilitate initiating and completing HCV treatment and attaining sustained viral response (SVR). The IC consisted of brief psychological interventions and case management prior to and during HCV clinic treatment.

The UC followed VA treatment guidelines for required standard of care, with HCV clinic staff referring patients after screening to mental health and/or substance use clinics. Treatment of both groups within the clinic involved medication management and monitoring of response and risk factors.

Screening at the HCV clinic included the Beck Depression Inventory (BDI), with symptoms of depression marked by scores of at least 10; the VA Primary Care PTSD Screen, with PTSD indicated by endorsement of at least items; and self-reported active drug use — excluding marijuana — in the prior 6 months on the Drug Use Questionnaire.

The investigators reported that IC participants were twice as likely to initiate HCV treatment than those receiving UC (45%, versus 23%). The proportion of patients completing treatment and attaining SVR was the same in both groups. Intent-to-treat analysis with all randomized patients — including those who did not initiate treatment — estimated a 2.3 times greater rate of attaining SVR in the IC group (30%) than in the UC group (13%), although the difference was not statistically significant.

"The results presented support the use of Integrated Care strategies for optimizing the number of patients that successfully complete antiviral therapy while conserving limited resources," the researchers wrote.

Groessi noted the burden of HCV is increasing, with many people having gone more than 2 decades without knowing they have it.

“The process of being fully evaluated for HCV antiviral treatment can be complex and lengthy,” Groessi said. “The medications are expensive, so it behooves us to ensure all patients closely adhere to these treatments to avoid wasting resources.”

The study, “HCV Integrated Care: A Randomized Trial to Increase Treatment Initiation and SVR with Direct Acting Antivirals,” was published online in the International Journal of Hepatology.

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