The proportion of
people with chronic hepatitis C virus (HCV) infection who receive antiviral
treatment has increased substantially since the introduction of direct-acting antivirals (DAAs), investigators from the United States report in Hepatology. However, people with
mental health and/or substance abuse disorders continue to be less
likely to receive treatment than other groups. The cumulative probability of
treatment was just below 14% for people with these disorders compared to
almost 22% for people without them.
“We found that in
the post-DAA period only 1 in 5 of those with CHC [chronic hepatitis C] was
being treated,” note the authors. “Those with MH/SUD [mental health and/or substance abuse disorders] were less likely to
receive HCV treatment compared to those without these disorders. The odds of
being treated for HCV among with MH/SUD improved from the pre-DAA to post-DAA
period but still reflects a significantly lower likelihood of obtaining access
revolutionised HCV treatment. They typically have cure rates in excess of 90%,
a short treatment course and a mild side-effect profile, representing a major
advance on previous interferon-based treatment.
In order to
eliminate HCV as a major health problem, the World Health Organization (WHO)
has set the target of curing 80% of people with chronic HCV by 2030.
Twenty-eight countries have targets for HCV elimination and nine are on course
to achieve this goal.
In the US, the
National Viral Hepatitis Action Plan has set the goal of curing 90% of people
with chronic HCV by 2030. But in 2014, only 9% of people had received
wanted to see if treatment rates had increased since the introduction of DAAs
in 2014. They especially wanted to establish if the chances of treatment had
improved for people with mental health and/or substance abuse disorders, a
group with historically low rates of therapy.
conducted a retrospective analysis of 29,544 adults with laboratory
confirmed chronic HCV infection who received care at four treatment centres
across the US between 2011 and 2017.
The participants were
divided according to their period of care: pre-DAAs (2011-2013) or after the
introduction of DAAs (2014-2016). The extent and predictors of HCV treatment in
the two treatment eras was compared.
Overall, 17% of
people had their HCV treated. Treatment rates increased significantly after
the introduction of DAAs. In the pre-DAA era, only 3.5% of people received
HCV therapy. But this leapt to almost 22% after DAAs became available in 2014.
of people (59%) had a mental health and/or substance use diagnosis. In the
pre-DAA era, 39% of these people were treated, increasing to 46% in the DAA
with mental health and/or substance abuse disorders were less likely than
people without these conditions to be treated in both the pre-DAA era (AOR =
0.46; 95% CI, 0.36-0.60) and the period after DAAs were introduced (AOR = 0.63;
95% CI, 0.55-0.71). Closer analysis showed that the probability of therapy did not
differ according to the presence of major depression, but was significantly
lower for those with anxiety, mood disorders, alcohol problems and cocaine use.
“Current DAA have
no contraindication with MH/SUD,” comment the authors. “Despite…guidance which
explicitly recommends HCV treatment for those with MH/SUD co-morbidities, data
from our health care settings shows that we are not achieving this goal.”
There was also
evidence that people with more serious liver disease were being prioritised
for therapy in the DAA era. The probability of therapy was significantly higher
for people with non-alcoholic fatty liver disease (AOR = 1.39; 95% CI,
1.05-1.83), cirrhosis (AOR = 2.00; 95% CI, 1.74-232) and liver transplant (AOR
= 2.72; 95% CI, 1.87-3.94) compared to individuals with less advanced liver
There were also
demographic disparities in the probability of treatment, with those of white
race, middle-aged individuals and with commercial insurance having a higher probably
of treatment than other groups.
“The goal of HCV
elimination requires a strategy that increases access to those with co-morbid
illnesses especially those with mental health and substance use, uninsured or
underinsured populations, and all racial/ethnic minorities,” conclude the
investigators. “Until we can address these disparities in access, we will not
achieve the WHO goal of viral elimination by 2030.”