HEPATITIS C VIRUS INFECTION: BARRIERS TO TREATMENT

Lakhan P1, Pokino L1, Sendall C1, Clark P1 2 3 4, Askew D1 2, Chong D1, Hayman N1 2 1 Southern Queensland Centre of Excellence in Aboriginal and Torres Strait Islander Primary Health Care,

2 The University of Queensland School of Medicine, 3 The Princess Alexandra Hospital,4 QIMR Berghofer Medical Research Institute

BACKGROUND• TheSouthernQueenslandCentreofExcellence(CoE)inAboriginalandTorresStraitIslanderPrimary HealthCareaimstoprovidequalityandculturallysafeprimaryhealthcaretotheAboriginalandTorres StraitIslandercommunity.DespitefacilitatingaccesstotreatmentsforHepatitisCVirus(HCV),few patientsattendingtheCoELiverClinichadreceivedtreatmentin2014.

STUDY AIMToidentifyfactors,includingpersonalandsocialaspectsthatwereinhibitiveintreatingpatientswithHCVinfectionattendingtheCoEPrimaryHealthCareclinic.

METHODSSteps of data collection:• ElectronicGPClinicmedicalrecordssoftwarepackage,Practix,wassearchedtoidentifyallpatientswith adiagnosisofHepatitisCinNovember2014.

• RetrospectiveauditofelectronicmedicalrecordsofpatientswhowereHCVRNAPCRpositive.Data extractedandsimultaneouslyrecordedelectronicallyonaformdevelopedinMicrosoftAccess softwareprogramforthefollowing: o DetailsofmostrecentHCVRNAPCRpathologytest o Socio-demographiccharacteristics o Treatmentdetails o Presenceofco-morbidities,lifestyleriskfactors,liverdisease.

• StudywasapprovedbytheInalaCommunityJuryforAboriginalandTorresStraitIslanderHealth Research.MetroSouthHumanResearchEthicsCommitteedeemedthisaqualityassuranceproject.

Data analysisSTATA©version14.1wasusedfordataanalysisforallpatients,thenseparatelyforAboriginalandTorresStraitIslanderpatients.

RESULTS219patientshadadiagnosisofHepatitisClistedintheirmedicalrecords,186patientshadHCVPCRtesting,Fig1.

Poster produced by Media & Communications, Princess Alexandra Hospital, 2016

• Therateofnewly-diagnosedHCVisincreasinginAustralia’sIndigenouspopulation(130per100000 Indigenouspopulationin2008to166in2012),whiletherateisdecreasinginthenon-Indigenous population(51per100000in2008to40in2012)12.

REFERENCES1. Commonwealth of Australia, Department of the Prime Minister and Cabinet, Closing the Gap Prime Minister’s Report 2016, http://closingthegap.dpmc.gov.au/assets/pdfs/closing_the_gap_report_2016.pdf. Accessed 17/8/2016.2. Australian Government Department of Health. Fourth National Aboriginal & Torres Strait Islander blood-borne viruses and sexually transmissible infections strategy 2014-2017. Available at www.health.gov.au/internet/main/publishing.nsf/content/ohp-bbvs-atsi. Accessed 15/8/2016.3. Treloar C, Jackson C, Gray, R et al. (2016). Care and treatment of hepatitis c among Aboriginal people in New South Wales, Australia: implications for implementation of new treatments. Ethnicity & Health. 21 (1): 39-57.

CONCLUSIONS• ManagementofHCVinthiscommunity–basedclinicismadeamidstcomplexpersonalandsocial environments.• Ahighproportionofpatientsinthisstudyexperiencedmentalhealthconditions,conflictand domesticviolence,andlifestyleriskfactors.Manyofthesefactorsmayposebarrierstotreatment, evenwithnewerHCVtherapies.• Thestudyhighlightstheneedtoaddressthebroaderproblemsofaddiction,forexampletrauma,to addresssubstanceabuseandassociatedriskybehaviours,suchassharingofneedles.• AholisticapproachisessentialforadequatetreatmentofHCVinfection.

Figure 1:HCVinfectionstatus;treatment(pre-2016)detailsforpatientswithdiagnosisofHepatitisCinpatients’medicalrecords-November2014.

PATIENTS WITH HCV RNA PCR POSITIVE RESULTSSample• 113patientshadHCVRNAPCRpositiveresults(50%weregenotype3).• 95/113(84%)patientsself-identifiedashavinganAboriginaland/orTorresStraitIslanderbackground.• Table1describesthesocio-demographiccharacteristicsofallpatients.• AseparateanalysisforpatientsfromAboriginalandTorresStraitIslanderbackgroundshowedeither none,ora1-2%percentagedifferenceformostvariables,exceptforthe50%(versus46%for‘All’ patients)livingwithotherfamilymembers.• Fig1.describesdetailsofreferrals/treatmentforpatientsinHCVnegativeandpositivegroups.

Table 1: Socio-demographic characteristics of patients with HCV RNA PCR positive results*

Characteristic HCV RNA PCR positiveAgemedian(mean,±SD,min-max),years 38(39;9.7,7-63)Gender n %Male 75/113 66EthnicityAboriginal 90/113 79TorresStraitIslander 2/113 2Aboriginal&TorresStraitIslander 3/113 3Non-Aboriginal/TorresStraitIslander 18/113 16Regular Attendance at Clinic(≥3visitsinlasttwoyears) 69/113 61Living ConditionHomelessnessorOvercrowdingpresent 6/81 7Living ArrangementLivingalone 4/54 7Livingwithspouse,orspouse&children 15/54 28Livingwithotherfamilymembersincludingownchildren 25/54 46Livingwithfriends/sharedaccommodation,hostel,undercareofDepartmentofChildren’sServices

10/54 19

Table 2: Patient-associated and other factors present among patients with HCV RNA PCR positive *

HCV RNA PCR positiven %

Patient-associated factors1. ComorbiditiesDepression 71/99 72Anxiety 56/92 61Othercurrentmentalillness 28/92 30Historyofprevioussuicide/selfharmattempt 15/65 23Fattyliver 18/32 56Cirrhosisofliver 7/33 21Primarycarcinomaofliver 1/32 3Hypertension 10/90 11Diabetes 9/90 10IschaemicHeartDisease 4/91 42. Lifestyle-associated factorsCurrentsmoker 94/108 87Alcoholabuse 39/97 40AlcoholicLiverDisease 4/26 15Usinganopiate 22/77 29Onreplacementopiate 19/82 23CurrentIntravenousDrugUser 36/77 47PastIntravenousDrugUser 89/93 96BodyMassIndex(kg/m2) <18.5 1/89 1.018.5-25(normalhealthyweight) 45/89 51 >25 43/89 48Other factorsHistoryofincarceration 72/105 69Conflictanddomesticviolence 33/81 41*Datanotavailableforallpatients,analysisconductedwithavailabledata.

219 patients with diagnosis of Hepatitis C (Data missing n=10)

HCV RNA PCR negative n=71/209; 34%

Treatment details

Outof67patientswithavailabledata:13/67(19%)hadclearedthroughtreatment.

54/67(81%)didnotrequiretreatment(self-clearedorantibodypositiveonly)

HCV RNA PCR positive n= 113/209; 54%

Treatment details, n=107

45/107(42%)referredfortreatment2/45commencedtreatment 1/2treatmentincompletedue tointolerancetotreatmentside-effects(datamissingn=1)

Reasons for non-treatment of referred patients (n=43/45)

2/43refusedtreatment 16/43didnotattendtreatmentappointment 16/43doctordecisionnottotreat 9/43datamissing

No confirmed PCRn =25/209; 12%

*Somedatawasmissingforallvariablesforthe113patients;analysisisconductedwithavailabledata.

DISCUSSION• ThisstudyhasidentifiedthevulnerabilityofthisgroupofpatientswithHCVinfection.Majorityof patientsexperiencedmentalillnessesandincarceration.Highproportionsofpatientsexperienced conflictanddomesticviolence,andlifestyleriskfactorssuchasaddictiontocigarettes,alcoholand intravenousdrugsuse.

• Atleastone-fifthofpatientshadacirrhoticliver,highlightingtheurgencyoftreatmenttoavoid long-termliverdamageanditsconsequencesonhealthstatusandqualityoflife.

• ThehighincarcerationrateincreasesriskofHCVtransmission,withunsafeinjectingandtattooing practicesinprisonsoccurringinahighlyprevalentreservoirofinfection.

• Whilenewermedicationshaveovercomemanyofthebarriersassociatedwiththepreviousdrugs, successfultreatmentandavoidanceofre-infectionreliesonmanycomplexsocialandbehaviouralfactors.

• SuccessfultreatmentofHCVrequiresaholisticpatient-centeredapproach,utilizingotherstrengths suchasconnectionstocommunity,culture,andfamilydynamicsinpreventingintravenousdruguse, andsimultaneoustreatment/preventionofbroaderissuesofdrugandalcoholaddiction,mentalillness, conflictanddomesticviolence,andincarceration3.

• Informationonsocialdeterminantsofhealthwasnotobtainedinthisstudy.Theassociationbetween education,employment,mentalillness,incarceration,exposuretotraumaandabuse,domestic violence,andHCVneedstobeexploredtopreventHCVinfectionsamongthisgroupofvulnerable Indigenouspatients.

Possible barriers to accessing treatments• PatientswithHCVinfectionsufferedfromothercomorbidities;lifestyle-associatedanddomesticfactors thatcouldinfluencetreatmentdecisions,Table2.• SeparateanalysisofpatientsfromAboriginalandTorresStraitIslanderbackgroundshowedeithernone, ora1-2%percentagedifferenceformostvariables,exceptforpresenceof:depression(60%),fattyliver (48%),conflictanddomesticviolence(35%).