An analysis from British Columbia, Canada shows that older people,
individuals with HIV co-infection, people with cirrhosis and – to some
extent – people who inject drugs have been significantly more likely to
receive direct-acting antiviral (DAA) treatments, compared to the older
interferon-based treatments. The findings show that in the current era,
treatment uptake has improved for groups who tended not to receive
interferon-based treatments, Naveed Janjua and colleagues write in the
August issue of the Journal of Viral Hepatitis.
individuals living in economically deprived neighbourhoods remained
significantly less likely to receive treatment, although healthcare is
publicly funded and free of charge to patients in British Columbia.
the era of interferon-based treatments for hepatitis C, the rate of
treatment uptake was low (below 15%) and especially so for certain
population groups, including people living with HIV and people who
inject drugs. Some of the barriers to treatment included increased
side-effects and healthcare providers’ expectations of poor adherence.
The availability of short course, highly effective and well-tolerated
DAAs could be expected to remove barriers and increase treatment rates.
- direct-acting antiviral (DAA)
A drug which prevents hepatitis C from reproducing by blocking certain steps in its lifecycle.
come from a cohort of all people reported as having hepatitis C in
British Columbia between 1990 and 2013, with data on drug prescriptions
up to 2015. A total of 11,886 people received treatment:
received an interferon-based regimen, including people receiving
telaprevir or boceprevir with pegylated interferon/ribavirin.
- 3.8% received a combination of DAAs with ribavirin or pegylated interferon/ribavirin.
- 9.8% received DAAs only (in most cases, ledipasvir/sofosbuvir).
main analysis compared individuals receiving DAAs only with individuals
receiving older interferon-based regimens. In multivariable analysis,
the odds of being treated were increased for people between 45 and 54
years (adjusted odds ratio 2.7, 95% confidence interval 1.7-4.4) and
people over 55 years (aOR: 15.2, 95% CI: 9.5-24.2).
HIV co-infection had three times the odds of receiving DAAs (aOR: 3.0,
95% CI: 2.3-3.8). To a lesser extent, the odds of receiving DAAs were
also higher for those with cirrhosis (aOR: 1.8, 95% CI: 1.5-2.2) and
diabetes (aOR: 1.3, 95% CI: 1.1-1.5).
Similarly, those with a
history of injection drug use had slightly higher odds of receiving DAAs
(aOR: 1.3, 95% CI: 1.1-1.7), as did individuals on opioid substitution
therapy (aOR: 1.3, 95% CI: 1.0-1.7).
The authors note that these
findings contrast with studies from other settings, in which people with
a history of substance use were less likely to receive DAA treatment.
Although research has shown good adherence and virological outcomes in
people who inject drugs, clinicians and policy makers may be concerned
about the potential for reinfection if a person continues to inject
drugs. “Changes in the cost of treatment and developing treatment
programs that reduce the risk of reinfection will be needed to overcome
barriers to HCV treatment with DAAs among PWIDs [people who inject
drugs],” they say.
Finally, compared to patients from the
most-privileged neighbourhoods, the odds of receiving DAAs were lower
for patients in materially deprived neighbourhoods. Whereas the aOR for
those in the second quintile was 1.0 (95% CI: 0.8-1.2), for those in the
fifth quintile (the most deprived) it was 0.7 (95% CI: 0.6-0.9). This
is despite free access to healthcare in British Columbia. The
researchers call for interventions to reduce these inequalities.
findings indicate an improvement in treatment uptake in the DAA era for
population groups who were traditionally not treated with
interferon-based treatments,” the authors conclude.