Suppressing the Hepatitis C Virus: Barriers to Care

In 2014 FDA approved effective and less toxic oral medications to eradicate Hepatitis C. This is challenging physicians to identify and treat patients. Since July 2012 faculty and residents at an internal medicine community clinic have been screening patients and have currently developed a registry of 170 patients with Hepatitis C. The patients are tracked for access to treatment and progression to cirrhosis and hepatocellular carcinoma.  The clinic serves a predominantly African American population, sees 3,000 patients per year and has a Hepatitis C prevalence of 8.1% in the “baby boomer” generation.  At present 20 patients have completed treatment with a sustained virologic response (SVR), 80 are eligible for treatment and undergoing testing for severity of fibrosis, 37 have antibody to Hepatitis C but are pending confirmatory studies and 10 patients could start treatment but are pending treatment for substance use or medical comorbid conditions. In addition, 7 patients have died, 4 have been lost to follow-up and 6 have spontaneously converted.  The experience in working with this cohort has identified barriers to care in the clinic which include:

• Patients are untested or unaware of their diagnosis
• Fear of toxicity of treatment based on experiences with interferon based regimens
• Cost of new medications including insurance deductibles and copays
• Insurance companies’ requirements for staging severity by fibrosis scores (F0-4) before approving medications only for advanced disease (F3,4) despite broader recommendations from professional societies.
• Insurance companies’ requirements that only subspecialists in Gastroenterology and Infectious Disease can prescribe the medications
• Completing treatment of comorbid conditions and surgeries prior to committing to 3 months of treatment
• Need to develop a support network with specialty pharmacies and alcohol and substance abuse programs

Identifying and assessing a patient for treatment requires a complex assessment of the medical conditions, severity of fibrosis and necrosis and psychosocial issues. A patient who is ready for treatment has required 6-10 encounters prior to starting medication. Treatment by a specialist further delays the start of treatment. Experts predict that there are not enough specialists to treat the 2-4 million patients expected to be eligible over the next 5-10 years. Integrating the management of Hepatitis C into primary care training is thus essential to the future management of uncomplicated cases. The presenter will combine case studies with updated registry data to assess “real world” barriers to Hepatitis C patients.