Huge gap between clinical efficacy and community effectiveness in the treatment of chronic hepatitis C: a nationwide survey in Taiwan

Abstract

Peginterferon/ribavirin provides a substantially high treatment efficacy for chronic hepatitis C virus (HCV) infections in Asians. Whether the clinical efficacy can be translated to community effectiveness remains unclear. The disease awareness, treatment accessibility, recommendations, acceptance, and barriers to anti-HCV treatment were explored to clarify the issue with a 3-step nationwide investigation in Taiwan. A crude HCV-infected population was estimated using databases from 3 large-scale surveillance studies and age-/geographic-specific population database. HCV awareness and accessibility were investigated at the patient level in 58,129 residents. The recommendations/acceptances and barriers to treatment at the provider level were evaluated using a prospective, nationwide approach to 89 gastroenterologists/hepatologists. The estimated 10-year interval age-adjusted anti-HCV-seropositive population is 745,109 (3.28%), with an anticipated HCV-viremic population of 554,361. Of anti-HCV-seropositive subjects, 36.2% had disease awareness. Among those with awareness, 39.6% had accessibility. The recommendation/acceptance rate of antiviral therapy was 70.6%. The treatment rate was 10.1% and 13.7% for the anti-HCV-seropositive and HCV-viremic population, respectively. With an anticipated treatment success rate of 80% in Taiwan, 8.1% of the anti-HCV-seropositive and 10.9% of the HCV-viremic population achieved successful treatment. The major treatment barriers were fear of adverse effects (37%), major disorders (17.6%), ineligibility for insurance reimbursement (17.6%), and lack of therapy awareness (11.3%). Despite the high rates of treatment response and nationwide coverage of insurance reimbursement, there remains a large gap between clinical efficacy and community effectiveness in anti-HCV treatment in Taiwan. Increasing disease awareness/treatment accessibility and introducing new therapeutic strategies with high tolerability are warranted.

FIGURE 1

Estimated number of HCV population and community effectiveness of anti-HCV therapy in Taiwan. The numbers of anti-HCV-seropositive population, HCV-viremic population, patients with disease awareness, disease accessibility, recommendation and acceptance of antiviral therapy and successful antiviral therapy (community effectiveness) were listed on the left side. The percentages of each category among anti-HCV-seropositive population and among HCV-viremic population were listed on the right side. (A) Diagnosis of HCV infection by anti-HCV and HCV RNA were assumed at 100%. (B) Clinical efficacy with adjustment for treatment adherence was set at 80%. (C) Retreatment of HCV was not included in the current model. (D) Each percentage was calculated as the number divided by anti-HCV-seropositive population or HCV viremic population, respectively.

FIGURE 2

Causes for not being treated with anti-HCV therapy in clinics (n = 1,375).

FIGURE 3

The reasons for not receiving antiviral therapy by age and clinic characteristics. (A) Fear of adverse effects. (B) Ineligible for insurance reimbursement. (C) Ineligible for major disorders. (D) Therapy unawareness. ^∗ Adjusted P value: the effects of age/clinic characteristics for those reasons without receiving antiviral therapy after adjustment for risk factors. ^† The number (n/N) was showed in the parentheses.