Curing your Patients from Hepatitis C: Addressing Complex Needs with Simplified Treatment Approaches - Episode 7
The panelists discuss adherence in HCV treatment.
Anthony Martinez, MD: We’ve seen in these high-risk groups, some of these options. The cure rate is essentially the same as in the general population, whether it’s in clinical trials or real-world data. We have a lot of information that this is a very treatable group of individuals, even when we’re talking about injection drug use. You talked, Mark, a little bit about provider bias. And a lot of the pushback that we get is around adherence and potential for reinfection. Tipu, can you talk to us a little bit about both of those things, that you treat a lot of people who are actively using drugs. Where do we stand in terms of adherence in your clinic? And talk to us a little bit about reinfection.
Tipu V. Khan, MD: So I think it’s all in the way we sell it, right? [In these] patients, especially with early hepatitis C, [it] is a silent disease. They don’t know they have it; it doesn’t bother them. So why should I worry about that right now? Right now I got to deal with my substance use disorder, or my drug court, or my child and family stuff I got to deal with. So why do I have to worry about my hepatitis C? So the first thing I do is I try to make sure they understand the significance of the chronicity of the disease and the natural progression. And I like to use the story of Uncle Joey. I use this with all my patients, it’s great. And I tell them, well, tell me if this sounds familiar. Have you ever had someone that you know that maybe drank a lot of alcohol 20, 30 years ago and now they’ve got a big belly, they get fluid taken out once in a while, sometimes they’re a little yellow or confused? Almost always. Someone’s like, oh yeah, that sounds like my Uncle Joey. Well, did you know that hepatitis C can also cause cirrhosis, which is what Uncle Joey has? But the difference between you and Uncle Joey is I can cure your hepatitis C now, so you don’t end up looking like Uncle Joey 20 to 30 years from now, with a simple treatment regimen. What do you think about that? Using some basic motivational interviewing, and to have a patient say, no, that doesn’t sound good, [then] they’re on board. Yeah, let’s get that treated. So once we have that, we prep the stage for the treatment. We see adherence rates, like you said, go up. They’re the same as the general population and patients will pick [up] their medications. So in our population in addiction medicine, we see adherence rates that are as high if not equal to the general population, but it’s because we sell it that way. We got to prep them on the disease state and help them understand what comes after that. And once they do, they take their medications, reinfection rates in those who use drugs are higher than the general population, but the nice thing is once you’ve proven they’re cured, you’re treating them like they’re infected all over again, and you offer that treatment again. But I think the important point, which I think all of us here agree, [is] that we need to integrate our risk reduction and harm reduction strategies along with that. So let’s get your opioid use disorder or your stimulant use disorder treated with appropriate medications for that. But if you’re not ready for that yet in your stages of change, let’s talk about harm-reduction modalities, needle exchange, clean injection practices, injecting with others, not sharing needles, making sure you have someone around you, all these harm-reduction strategies that we emphasize, I think will also lower the reinfection rates in general with those struggling with the substance use disorder.
Anthony Martinez, MD: I think one of the key elements, one of the key pillars for achieving hepatitis C elimination, is that harm-reduction piece because that’s essentially synonymous with reinfection prevention. In our clinic, our adherence rates among high-risk people who inject drugs [is] about 91%. That’s actually about 10% higher than the general population. And it’s the same model, the same clinic. They inherently know how to adhere to a regimen. Reinfection rates, they hover around 6% in the in the literature, but the key thing is maintenance of that medically assisted therapy. And when patients, it seems that when they maintain that, the reinfection rates, they fall down to about 2.5%. People do miss dosages, though; adherence is an everybody issue. This is not unique to people who inject drugs or people who may have substance use disorder. Mark, how do you handle missed dosages? What do you do?
Mark Sulkowski, MD: It’s an interesting point. We talk a lot about adherence. And I think that you’re going back to HIV; there were some early studies that said you had to take 95% of your medication. And when we started in hepatitis C, we kind of thought the same thing. But then we went from clinical trials with these great response rates, 99%, and we translated them to the community-based practice. And quickly, studies started to get published saying we’re at 99% as well and really great response rates. And when you step back and look at it, you realize that there is a bit of forgiveness in hepatitis C. First of all, it’s curable, meaning that at some point, there’s no hepatitis C left in the liver. And when you look back at some of the early studies, it doesn’t always take to 12 weeks. In fact, some people are cured in as short as 4 weeks. It’s some in 6 weeks, some in 8 weeks. We treat for 8 and 12 [weeks] because we want to get to 99%. And then the other advantage we have is the liver is where all of these medicines go in first pass, and we’re treating an infection of liver cells. So I think there’s some intrinsic advantages to a curable disease that lowers the adherence barrier, makes it more forgivable, if you will. That said, we never want to promote nonadherence, sure. So I think that we really should focus on adherence. We should develop strategies to help people take all their medications, but we shouldn’t allow our concerns about another person or a patient’s ability to take medication be a barrier to treating them.
Anthony Martinez, MD: Sure, and we’ve seen a lot of data that’s emerged about variable adherence with the various regimens that are available. And it appears based on the data, and again, we don’t obviously want to promote a message that nonadherence is OK, but it appears that even if a dosage is missed, that the more important aspect is that persistence in continuing the regimen to completion. Can you just expand on that a little bit?
Mark Sulkowski, MD: Well, actually, you touched on a really important point, and that’s persistence. Finishing the medications, recognizing that within a liver cell, you probably have some drug present for a couple of days to cover a break, but it is important to finish the therapy. And at least in my practice, one of the biggest barriers we have to persistence is the insistence on filling 1 month at a time. It’s 8 weeks, you give someone 28 days, and then you make them fill again at the end of that month. And that’s a major problem with persistence. So I think that we need to do everything we can to ensure that we’re going to empower the patients to complete the recommended duration of therapy. And if they miss those, it’s encouraging them to persist and giving them tools so they can finish their regimen. If you do that, you’re likely to get a cured patient.
Nancy Reau, MD: Can I just add that you know that, but I still have clinicians that will call me and say, “This person stopped [or] missed a dose. Should I stop their therapy?” And so I think that when we’re talking about education, especially as we recruit these new providers, it’s important that they understand that persistence piece to not stop treatment because person missed a dose or even a week; you want to really try to plow on. Now there are some loose rules as to exactly how much, and a 4-month gap is probably not correct. But we want to make sure that our providers feel comfortable continuing treatment despite a variable adherence.
Anthony Martinez, MD: So I think, in general, the takeaway is keep going. Keep going and get them through the regimen until the end.
Transcript was AI-generated and edited for clarity.