Download Evaluation of Combination Regimens in GT1

Barriers to Treatment in HCV/HIV Co-infection
Todd Wills, MD
ETAC Infectious Disease Specialist
HEPATITIS C TREATMENT EXPANSION INITIATIVE
MULTISITE CONFERENCE CALL
APRIL 17, 2013
Assessment of Alcohol and
Substance Abuse
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Ongoing Alcohol use? Amount?
Ongoing Substance Abuse? Amount?
How much use is acceptable?
What are individual clinic protocols?
Evaluating and Modifying Obesity
• Obesity is associated with nonalcoholic fatty
liver disease and steatosis
• Insulin resistance may diminish response to
interferon
• ? Weight criteria for treatment initiation
• ? What are individial clinic protocols?
Indicators of Decompensated
Cirrhosis
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Development of ascites
Variceal hemmorhage
Hepatic encephalopathy*
Jaundice
Hepatocellular carcinoma*
– Screen via ultrasound every 6 months for patients with cirrhosis or
bridging fibrosis
– * can occur even in incomplete cirrhosis
Morgan T, Hepatitis Annual Update 2009.
clinicaloptions.com – accessed 3.12.11
Evalution of Liver Status and
Transplantation Referral
• Prognosis via MELD (Model for end stage liver
disease) score should be assessed periodically
• Calculator available at:
• http://www.mayoclinic.org/mel/mayomodel6.html
• Score greater than 10 indicates need for possible
liver transplantation referral
Absolute Contraindications to
Therapy
• Uncontrolled active major psychiatric illness
• Hepatic decompensation (hepatic encephalopathy,
coagulopathy, or ascites)
• Uncontrolled HIV with advanced
immunosuppression (CD4 < 100 cells/mm3)
• Known allergy or severe adverse reaction to
interferon and/or ribavirin
Absolute Contraindications to
Therapy
• Women who are pregnant, nursing, or are of childbearing potential and not able to practice
contraception
• Men who have pregnant partners or partners of
child-bearing potential and unwilling to practice
contraception during treatment and for 6 months
after treatment ends
• Active, untreated autoimmune disease (e.g.,
systemic lupus erythematosis) known to be
exacerbated by peginterferon and ribavirin
Relative Contraindications to
Treatment
• Significant hematologic abnormality: hemoglobin <
10.0 g/dl, absolute neutrophilcount < 1,000/μl, or
platelet count < 50,000/μl
• CD4 <200 cells/mm3
• Patients on dialysis or with a creatinine clearance
<50 mL/min
• Uncontrolled diabetes mellitus
• Patients concurrently receiving zidovudine
Relative Contraindications to
Treatment
• Autoimmune disorders (systemic lupus erythematosus,
rheumatoid arthritis)
• Active substance use or ongoing alcohol use if interference
with adherence is anticipated
• Untreated mental health disorder
• Hemoglobinopathies (e.g., thalassemia major and sickle cell
anemia)
• Sarcoidosis
• Solid organ transplantation patients
Overcoming Barriers to Treatment
Initiation
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Substance Abuse Counselors
Opioid Dependence Treatment
Patient Education
Peer-Based Counseling
Group Counseling
Clinic Based Injections
Any other specific clinic strategies?
Opioid Dependence Treatment
• methadone maintenance treatment
– diminishes and often eliminate opioid use
• buprenorphine
– office-based pharmacotherapy for opioid
addiction
– Physicians who complete a defined training can
apply for a waiver to the Drug Addiction
Treatment Act of 2000
National Institutes of Health Effective medical treatment of opiate
addiction. NIH Consensus Statement 1997;15(6):1-38. Available
at:http://odp.od.nih.gov/consensus/cons/108/108_intro.htm
Center for Substance Abuse Treatment Buprenorphine physician
training events. Rockville, MD: Substance Abuse and Mental Health
Services Administration, US Department of Health and Human
Services; Available at:http://buprenorphine.samhsa.gov/training.html
Alcohol Use Intervention
• Brief interventions by medical providers
focused on problem use of alcohol
– client-centered counseling
– reflective listening
– nonjudgmental demeanor
– Core elements include:
• assessing current levels of consumption
• providing education regarding risks
• assessing and facilitating motivation to alter alcohol
consumption
Bhattacharya R, Shuhart MC Hepatitis C and alcohol: interactions,
outcomes and implications. J Clin Gastroenterol 2003;36:242-52
Patient Support Services
• Providing essential support services helps
improve patient retention:
• case management
• transportation
• housing for the homeless
Sherer R, Stieglitz K, Narra J, et al. HIV multidisciplinary teams
work: support services improve access to and retention in HIV
primary care. AIDS Care2002;14(Suppl 1):31-44.
Patient Support Services
• Specialized tools to improve adherence:
– electronic reminder system
– directly observed therapy
– cash incentives for attending scheduled
medical appointments
Lorvick J, Edlin BR Program and abstracts of the 128th annual
meeting of the American Public Health Association
(Boston). Washington, DC: American Public Health
Association; 2000. Effectiveness of incentives in health
interventions: what do we know from the literature?
Jani AA, Bishai WR, Cohn SE, et al American Public Health
Association and Health Resources and Services
Administration. 2004. Adherence to HIV treatment regimens:
recommendations for best practices. Available
at:http://www.apha.org/ppp/hiv/Best_Practices_new.pdf