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People with mental health and substance use issues still less likely to receive HCV therapy

Michael Carter
24 July 2018

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 to treatment.”

DAAs have 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 treatment.

Investigators 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.

The investigators 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.

Almost two-thirds 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 era.

Overall, people 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 disease.

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.”


Jain MK et al. Has access to HCV therapy changed for patients with mental health or substance use disorders in the DAA period? Hepatology, online edition,, 2018.