Although one of the major providers of HIV care in the US is testing a majority of its patients for coinfection with hepatitis C virus (HCV), it is referring few of these patients for specialist HCV care, and only counselling a third that they should stop drinking alcohol, according to a study published in the April 15 2003 edition of Clinical Infectious Diseases (now available online).
Between summer 1999 and summer 2000, 881 HIV-positive patients in the Veteran Aging 3-Site Cohort (VAC 3) were recruited to an observational study to examine the testing of HIV-positive patients for HCV, rates of referral for specialist HCV care, and the proportion of patients receiving HCV diagnostic tests and therapy.
Veterans Affairs (VA) is one of the largest providers of HIV care in the US, with all former US services personnel eligible to receive free treatment. The current study involved three large sites.
Both patients and their healthcare providers were asked to complete surveys which enquired about adherence, symptoms, quality of life, drug and alcohol use, and medical and psychiatric health problems. Clinical information was obtained from a database, and details of medications prescribed to patients were available from records kept at a central pharmacy.
The average age of patients was nearly 49. The overwhelming majority, 98.8% were male, and 66.5% were of non-white race. A third had injecting drug use as their risk activity for HIV infection, 36% reported sex with another man and 24% said their only risk activity was heterosexual sex.
Average baseline CD4 count was 330 cells/mm3, with 71% of patients having a CD4 count above 200 cells/mm3. A viral load below 500 copies/ml was considered undetectable, with 46.5% of patients achieving this.
Nearly all patients, 99.1%, were receiving medical care from an infectious diseases specialist, with 57.5% under the care of an attending physician, the US equivalent of a consultant. Doctors reported that 11.4% of patients drank alcohol and 9.1% used illegal drugs.
HCV testing and therapy
Of the 881 patients in the study, 700 (79.5%) were tested for HCV, meeting the VA target that at least 60% of patients with HIV should be evaluated for HCV. White patients were slightly more likely than non-whites to be tested for HCV. Patients with a history of injecting drug use were no more likely to be tested for HCV . Indeed the only factors found be be associated with an increased likelihood of HCV testing were abnormal liver function and a higher level of perceived adherence (less than one missed dose in the past month).
In total, 300 patients were HCV-positive, but of these only 65 had an HCV viral load test conducted, and only 90 were referred to see an HCV specialist.
Anti-HCV therapy was indicated for 38 patients not referred to specialist HCV services. The average CD4 cell count in this group was 381 cells/mm3, 45% had a viral load below 500 copies/ml (average 900 copies/ml). However, none of these patients had a liver biopsy or received anti-HCV therapy.
Amongst the 90 patients referred to an HCV specialist, 27 were eligible for HCV therapy. Average CD4 cell count was 310 cells/mm3, with average HIV viral load below 50 copies/ml. Liver biopsies were performed on twelve patients and two of these patients received pegylated interferon. Neither was also given ribavirin.
Alcohol and drug use
A little under 30% of HIV-HCV coinfected patients reported drinking alcohol. Only 29% of these patients that they had ever been counselled to stop drinking alcohol as its use could accelerate HCV disease progression.
Illegal drug use was reported by 16.3% of patients, with only 12.3% of these patients saying that their doctors had expressed concern about this.
Mental health problems were reported by 25% of patients, but only 64% of these received treatment for depression, and doctors failed to notice depressive symptoms in a further 93 patients.
Conclusions
The investigators note that even though VA doctors were meeting targets for HCV testing, they were “largely unaware of illicit drug and alcohol use and depression among their HCV-infected patients.”
Further only 22% of patients had their HCV viral load determined, and only 30% were referred to an HCV specialist. Liver biopsies were also infrequently performed, and only “only one quarter of HCV-positive patients who were actively drinking alcohol were told to stop or reduce their intake”.
However, the investigators also note that anti-HCV therapy was contraindicated in most patients, probably accounting for the low levels of referral to specialist services and the very small number of patients receiving therapy. The low frequency of liver biopsy, the investigators suggest, may “reflect disagreement about the need for a liver biopsy for patients with HCV being considered for treatment.” (See link below to recent aidsmap news story on alternatives to liver biopsy.)
Regarding the very limited use of anti-HCV therapy, the investigators suggest that this may be because the beneficial effects of pegylated interferon were uncertain at the time of this study.
Finally the investigators recommend that “future efforts should be directed at increasing the detection and treatment of alcohol use, illicit drug use, and depression to avoid their untoward effects and to allow a greater number of patients to be eligible for hepatitis C therapy.”
Further information on this website
Hepatitis C - Overview
Hepatitis C - Factsheet
HIV and hepatitis - Booklet in the information for HIV-positive people series (PDF)
Is a liver biopsy really needed in an HIV/HCV patients? - News story
Fultz SL et al. Testing, referral, and treatment patterns for hepatitis C virus coinfection in a cohort of veterans with human immunodeficiency virus infection. Clinical Infectious Diseases, 36 (on-line edition), 2003.