Today in the United States, 25% of HIV-positive people are also infected with hepatitis C (HCV), a blood-borne virus that attacks the liver, eventually leading to cirrhosis and cancer. Unlike HIV, HCV can be cured thanks to a new class of drugs called direct-acting antivirals (DAAs), which were introduced in 2013.
Because coinfection with HIV and HCV more than triples a person's risk for liver disease and complicates HIV treatment management, coinfected people should be prioritized for DAA treatment, according to the AASLD/IDSA guidelines.
"We now have incredible medications that can get rid of HCV in the majority of people that are infected," including people with HIV, said John Nelson, Ph.D., C.N.S., C.P.N.P., program director of the AIDS Education & Training Center National Coordinating Resource Center (AETC NCRC) at Rutgers School of Nursing. "However, we are not seeing great rates of cure simply because people are not being given the [DAA] medication," said Nelson.
To help clinicians and patients navigate the challenges of HIV/HCV coinfection, AETC NCRC has released an infographic that addresses the most common barriers preventing HIV-positive people from curing their HCV infection.
Some of the provider barriers include:
Inconsistent HCV testing
Reluctance to start HCV treatment in people with HIV
Limited experience in treating HIV/HCV coinfection
Insurance-related restrictions
Some of the patient barriers include:
Readiness to begin treatment
Housing instability
Experiencing stigma and discrimination
Living with other comorbidities
Although DAA treatments for HCV are extremely effective, and almost all HIV-positive patients would benefit from treatment, very few people have been cured because of the extraordinarily high cost of DAAs, which has prompted insurance providers and public programs to construct extensive prior-authorization requirements.
According to the World Health Organization (WHO), among the 71 million people living with HCV across the globe in 2015, only 1.1 million (1.4%) had started on treatment. Because of the high price of DAAs, some of which cost up to $95,000 for a full course of treatment, it's difficult for HCV patients and their doctors to convince insurance providers to offer the drugs.
For patients with HIV and HCV, the barriers can be even more complex. In addition to the stigma felt by patients, some providers may be reluctant to treat coinfected patients. Many doctors have been influenced by the challenges of the prior generation of HCV medications, which included interferon and ribavirin. These older HCV medications made it very difficult and sometimes dangerous to attempt to cure HIV/HCV-coinfected patients, prompting many HIV clinicians to adopt a "watch and wait" approach for their patients with HCV, Nelson said.
"All of that has changed now," he said. Because of the wide variety of approved DAA medications and the relatively small risk of drug-drug interactions with the right combination of HIV drugs, new guidelines highly recommend that doctors should try to cure HCV in people with HIV.
"The information has been out for the last few years at least," said Nelson, but still too few coinfected patients are being recommended for treatment. Last year, Nelson's group at Rutgers was asked to develop an HIV/HCV coinfection curriculum for clinicals, and in so doing became aware of fact that the greatest barriers to HCV treatment are policy related rather than treatment related.
Judith Collins, program coordinator of digital media, AETC NCRC, led the effort to create an infographic that would help clinicians navigate this post-DAA world for their HIV-positive patients.
"We thought one way to get the word out about treatment barriers was to leverage Judy's incredible ability to pull a ton of resources together for a visual product," Nelson said. Collins began to collect resources that would eventually lead to an informational brochure for doctors and patients designed to break down the barriers to treatment and illuminate treatment options for anyone unsure about the best path forward.
The infographic, which is called "Barriers to Curing Hepatitis C Virus (HCV) Among Coinfected People Living With HIV (PLWH)" is now complete. Rutgers has made the graphic available for any clinician or patient who would like to learn more about treatment barriers. The full curriculum will be available for clinicians on June 30, Collins said.
Although there are well-established care continuums for both HIV and HCV, far greater disparities exist in the awareness, diagnosis and viral suppression of HCV. One of the main functions of the infographic is to illuminate how and why people with HCV fall out of the care continuum, and how to ensure they receive the treatment they need to cure their infection.
"One of the greatest barriers is that providers cannot get authorization to treat HCV because the cost of the medication is very high, and insurance policies vary state to state, company to company," Nelson said. Those policies, he added, "are not based on what we know about the science and about the need to get our community viral loads down."
Restrictive insurance policies have created an immense administrative burden, especially for smaller clinical practices. Even qualified patients are often rejected for HCV treatment on the first try, Nelson said. Some clinics have resorted to outsourcing the paperwork requirements around prior authorizations, he added.
Nelson and Collins would love to see the infographic hanging up in HIV clinics across the country. "I've learned that visual elements are very effective and very helpful" as teaching tools, said Collins. "We hope that clinicians take the infographic, print it out and share it with their colleagues," she said.