Barriers to hepatitis C direct-acting antiviral therapy among HIV/hepatitis C virus-coinfected persons

Abstract

Background and aim: Direct-acting antivirals (DAAs) have increased hepatitis C virus (HCV) treatment opportunities for vulnerable HIV/HCV coinfected persons. The aim of this study was to identify the frequency of and potential barriers to DAA prescription in HIV/HCV patients during the first few years of DAA availability in the United States.

Methods: The AIDS Healthcare Foundation electronic medical record system was queried to identify all HCV viremic HIV-infected patients in care at AIDS Healthcare Foundation Healthcare centers in January 2015-August 2017 and compare characteristics by receipt of a DAA prescription. Multivariate logistic regression analyses were conducted to examine factors associated with DAA prescription.

Results: Of 826 eligible patients, 355 (43%) were prescribed a DAA; among those not prescribed a DAA, 301 (64%) had well-controlled HIV (HIV RNA ≤ 200 copies per mL). In multivariate logistic regression analysis, patients with a history of substance use (odds ratio [OR], 0.51 [95% confidence interval 0.35-0.73]) or on select HIV antiretroviral regimens were less likely to be prescribed a DAA. Those who had well-controlled HIV (OR, 5.03 [3.06-8.27]), CD4 + T cell count >200 cells per mm³ (OR, 1.85 [1.04-3.30]), estimated glomerular filtration rate >60 mL/min/1.73 m² (OR, 3.32 [1.08-10.15]), or established care prior to January 2015 (OR, 1.57 [1.08-2.29] were more likely to be prescribed a DAA.

Conclusions: In addition to lack of HIV suppression, select antiretroviral regimens, substance use, and kidney disease appeared to limit DAA prescription in the early interferon-free DAA era. Many were not prescribed DAAs despite HIV suppression. Further research is needed to determine if the observed associations persist today.

Keywords: AIDS/HIV; Access to care; Antiretroviral therapy; Direct-acting antiviral (DAA) therapy; Disparities; HCV treatment; Substance use.

Figure 1.. Study Eligibility

ICD: International Classification of Diseases; HIV: human immunodeficiency virus; HCV: hepatitis C virus; EMR: Electronic Medical Record; AHF: AIDS Health Foundation; and DAA: Direct Acting Antiviral.

Figure 2.. Total number and type of HCV DAA prescriptions at Aids Healthcare Foundation over time (by quarter, January 2015 – August 2017)

HCV: hepatitis C virus; DAA Direct Acting Antiviral; SOF: Sofosbuvir; LDV: Ledipasvir; RBV: Ribavirin; OBV: Ombitasvir; PTV/r: Paritaprevir/ritonavir; DSV: Dasabuvir; DCV: Daclatasvir; EBR: Elbasvir; GZR: Grazoprevir; and VEL: Velpatasvir.

Figure 3.. Multiple logistic regression model for the odds of a patient being prescribed a DAA by patient characteristic (n=727)

ALT: alanine aminotransferase; AA: African-American; HIV: human immunodeficiency virus; eGFR: Estimated Glomerular filtration rate; AHF: AIDS Health Foundation; INSTI: integrase strand transfer inhibitor; TDF: tenofovir disoproxil fumarate; ABC: abacavir; COBI: cobicistat; TAF: tenofovir alafenamide; PI: protease inhibitor; NNRTI: non-nucleoside reverse transcriptase inhibitor; OR: odds ratio; LCL: lower confidence limit; UCL: upper confidence limit.