Photo Credit: Alona Siniehina
Less than a quarter of patients with HCV receive direct-acting antiviral therapy within 6 months of diagnosis.
“Since 2014, we have had access to incredibly effective, safe, curative treatments for HCV,” Shashi Kapadia, MD, notes. “However, several studies have shown that we are not successfully delivering treatment to those in need. Ideally, if we were able to detect and treat HCV quickly and at high rates, we could eliminate ongoing transmission. One of the best ways to prevent transmission is to make sure people with the disease are treated.”
For a study published in JAMA Network Open, Dr. Kapadia and colleagues examined variations among Medicaid enrollees who received direct-acting antiviral (DAA) therapy for the first 6 months after an HCV diagnosis. “We wanted to know whether we were successfully delivering HCV treatment to people enrolled in Medicaid and if there were any groups less likely to access treatment,” Dr. Kapadia says.
The investigators examined Medicaid claims from 2017- 2019 across 50 states, Washington, DC, and Puerto Rico. They included patients aged 18-64 who received a new diagnosis of HCV in 2018 and the first half of 2019. Receipt of a prescription for DAA therapy within 6 months of diagnosis served as the primary outcome measure.
Treatment Within 6 Months of Diagnosis Uncommon
The study included 87,652 individuals (49% women; 46% non-Hispanic White). Nearly half of the participants (49%) had an injection drug use-related diagnosis. Only 20% of all patients received DAA therapy within 6 months of HCV diagnosis (n=17,927).
“For many physicians and patients, HCV is not a priority because it doesn’t cause a lot of symptoms until later in the disease,” Dr. Kapadia explains. “Our study shows how this attitude plays out nationally: Many people do not get treated in a timely way, even though treatment is safe and effective.”
Factors associated with greater treatment initiation included being a man (OR, 1.24; 95% CI, 1.16-1.33), while age (18-29; OR, 0.65 95% CI, 0.50-0.85) and injection drug use-related diagnoses (OR, 0.84; 95% CI, 0.75-0.94) were associated with reduced treatment initiation (Table).
The researchers also adjusted for the individuals’ state of residence, because different states’ Medicaid programs were likely to have different policies related to HCV treatment coverage. After this adjustment, Asian race (OR, 0.50; 95 CI, 0.40-0.64), American Indian or Alaska Native race (OR, 0.68; 95% CI, 0.55-0.84), and Hispanic ethnicity (OR, 0.81; 95% CI, 0.71-0.93) were associated with lower treatment initiation. Accounting for known state Medicaid prior authorization requirements did not reduce these disparities.
“Even though treatment uptake was low overall, we were further dismayed to see that women, young people, people who use drugs, and members of some racial and ethnic groups were less likely to receive timely treatment,” Dr. Kapadia says.
Addressing Barriers to Improve HCV Treatment
The disparities in access are one of the primary points to address in future work, he continues. “It’s important to monitor these patterns and address systemic barriers. For example, people who use drugs may have lower rates of treatment in part because of prior authorization policies that require them to prove their sobriety, even though that is not necessary to cure HCV. Advocates have been fighting against these policies for a decade and have successfully changed them in many states, but there is still work to do.”
Dr. Kapadia also reiterated the importance of starting treatment before HCV progresses.
“One thing that clinicians can do is to try to make it easier for patients to access HCV treatment. Tools like telemedicine or e-consults, for example, can bring specialty expertise to the patient, cutting out the need to travel to a specialist.”
Finally, he emphasizes the importance of “active and ongoing” monitoring.
“Right now, we don’t have a robust system in place, and it’s unlikely that we ever will unless there is funding. We should be able to monitor HCV in something closer to real-time to understand how we’re doing. I’d like to see other studies, particularly clinical interventions, that focus not just on whether patients who start treatment get cured—we know they usually do—but instead on strategies to make it more likely that people with HCV can start treatment more quickly and easily.”
