Coordinated Care in Poor Neighborhoods Overcomes Some Barriers to Hepatitis C Treatment
High proportions of hepatitis C (HCV) patients in poor New York City neighborhoods had mental health conditions, alcohol or drug use histories or HIV infection. But a comprehensive, coordinated care program implemented by the New York City Department of Health appeared to reduce those barriers to HCV therapy.
People with substance abuse histories, mental health conditions or psychosocial risks have a lower chance of starting potentially curative direct-acting antiviral (DAA) therapy for HCV infection. To lower barriers to HCV care, the NYC Department of Health designed a comprehensive care program and began implementing that program, Project INSPIRE, in target neighborhoods. Project INSPIRE aims to (1) integrate primary care and behavioral health management; (2) provide care coordination and navigation; (3) offer treatment readiness and medication support; (4) use telementoring to connect primary care clinicians, addiction specialists and infectious disease providers with HCV specialists; and (5) develop a payment model of HCV care reimburseable by Medicaid or Medicare.
The program targeted HCV-positive Medicaid or Medicare beneficiaries in low-income areas of upper Manhattan and the South Bronx, aiming to enroll 3200 participants between January 2015 and February 2017. This analysis covered the period from January 2015 through March 2016, when Project INSPIRE had enrolled 1708 participants, 53% of the goal. Hispanics made up the largest proportion of participants (48%), followed by blacks (35%), whites (12%) and others (5%). Three-quarters of participants (73%) were born between 1945 and 1965, 20% after 1965 and 7% before 1945.
Among 1503 participants evaluated for mental health, 20% had depression, 17% multiple conditions and 5% serious mental illness. One in five participants (19%) currently used alcohol, 64% ever injected drugs and 27% reported treatment for substance abuse.
In bivariate analysis involving 1480 participants, those with a mental health condition had one-third lower odds of starting HCV therapy (odds ratio [OR] 0.66, 95% confidence interval [CI] 0.55 to 0.83, P = .0003). People with HIV infection were 67% more likely to start HCV therapy (OR 1.67, 95% CI 1.31 to 2.14, P < .0001), and participants with prior HCV therapy were 45% more likely to start (OR 1.45, 95% CI 1.10 to 1.92, P = .007).
Low service level (defined by comprehensive assessment of patient risk history and health characteristics) was associated with 47% higher odds of starting HCV therapy in bivariate analysis (OR 1.47, 95% CI 1.17 to 1.84, P = .0007). Two factors lowered chances of starting therapy in bivariate analysis: ever injecting drugs (OR 0.79, 95% CI 0.62 to 0.99, P = .05) and being in a substance abuse treatment program (OR 0.69, 95% CI 0.54 to 0.88, P = .003).
Multivariable logistic regression identified three factors that raised odds of starting HCV therapy: HIV infection (adjusted OR [aOR] 1.62, 95% CI 1.21 to 2.16, P = .0012), HCV treatment experience (aOR 1.37, 95% CI 1.01 to 1.87, P = .04) and low service level (aOR 1.44, 95% CI 1.11 to 1.87, P = .006).
In bivariate analysis involving 329 participants, only a history of substance abuse treatment lowered odds of attaining sustained virologic response (SVR) to HCV therapy. Factors not associated with chances of attaining SVR were mental health condition, HIV infection, diabetes, HCV treatment experience, cirrhosis, current alcohol use, ever injecting drugs and service level.
Among 1506 Project INSPIRE enrollees who completed medical evaluation, 1362 (90%) were judged eligible for HCV therapy, 1034 (76% of 1362) began therapy and 979 (72% of 1362) completed therapy. Among the 979 who completed HCV therapy, 700 (71.5%) achieved SVR 12 weeks after treatment ended (SVR12), 110 were still within 12 weeks of stopping therapy and 106 were awaiting SVR testing.
The researchers stressed that patients with mental health conditions and drug-use histories were no less likely than others to start HCV therapy, a result "indicating success in reducing barriers to care." Odds of completing treatment did not differ by patient group, and only enrollment in a substance abuse program lowered odds of achieving SVR. The Department of Health noted that 90% of patients were found eligible to begin HCV therapy, but only 76% have done so.
Mark Mascolini writes about HIV and hepatitis virus infection.