Transcript: Vincent Lo Re, MD, on the Challenges of Managing Hepatitis C Virus

Amanda Balbi: Hello everyone, and welcome to another installment of Podcasts360—your go-to resource for medical news and clinical updates. I’m your moderator, Amanda Balbi with Consultant360 Specialty Network.

Nearly 2.4 million individuals in the United States—1% of the adult population—were living with hepatitis C virus (or HCV) from 2013 through 2016, according to estimates from the Centers for Disease Control and Prevention. In 2016, the World Health Organization committed to eliminating viral hepatitis as a public health threat by setting goals of reducing mortality by 65% and reducing new infections by 80% by 2030, compared with 2015 rates.

With us today to talk more about HCV is Dr Vincent Lo Re, who is an associate professor of medicine (Infectious Diseases) and Epidemiology at the University of Pennsylvania, senior scholar in the Penn Center for Clinical Epidemiology and Biostatistics, and codirector of the Penn Center for AIDS Research Clinical Core.

Thank you so much for joining me today, Dr Lo Re.

Once a diagnosis of HCV is made, follow-up appointments are necessary to manage treatments and monitor progress. What are some common pitfalls in HCV management?

Vincent Lo Re: Well, depending on whether or not you have reflective HCV RNA testing, You know that that one of the gaps is people who have a diagnosis are antibody positive may not come back for RNA confirmatory testing so that leaves a gap in care.

There still are gaps in care with regard to people who actively use alcohol, who actively inject drugs. And there's been a number of studies now that have shown that even with high levels of alcohol use, over 90% of patients who received direct-acting antiviral drugs can still achieve a sustained virologic response or cure of their hepatitis C.

The same thing has been shown with people who inject drugs. And so, it's somewhat disconcerting when I hear about patients who have been turned away from health care and told you need to abstain from using alcohol or drugs before we can consider you for hepatitis C treatment, because there are data that show that these patients will still adhere if they're coming to visits to receive hepatitis C therapy.

Obviously, this is going to be one of the higher-prevalence groups automatically in terms of hepatitis C that we want to treat and cure. So, I think that that too is a pitfall in hepatitis C management—this failure to treat patients with coexisting either alcohol or drug use.

Another common pitfall is that you have patients who will initially show up for hepatitis C treatment evaluation and still, in many areas around the country, they will be recommended to go forward with antiviral therapy, but the insurer will deny their therapy for substance abuse for alcohol use.

And that insurer denial is another challenge and pitfall. Our group has been studying this over the last several years. Initially, there were issues in denials more common in Medicaid beneficiaries than in Medicare commercial insurances. Then we repeated that study in 2017 and showed that actually over the change in time, more commonly, then the private insurers were denying either because of substance abuse or alcohol use.

Those kinds of lack of reimbursement for hepatitis C antivirals is another pitfall. And it's incredibly frustrating, disconcerting to patients to have the desire go forward with making clinical appointments, following up with clinical appointments, and then having your insurer deny you this medication.

These are probably some of the most common pitfalls at this point.

Amanda Balbi: HCV is now curable, but reinfection is common over time. What are your best practices for reducing the risk of reinfection?

Vincent Lo Re: The highest incidence of reinfection typically occurs in individuals either who are in debt off injecting drugs or men who have sex with men. Those are really the most common subgroups for which hepatitis C reinfection currently is an issue.

I tell all of the patients that I care for, and I would encourage your sole providers, that hepatitis C antibody is not protective against reinfection. It is critical to educate your patients at the time that they are preparing to start treatment that even if they cure, they could be reinfected if risk behaviors recur. They could be reinfected even with the same genotype, the same strain of hepatitis C.

We need more studies that examine and test interventions to reduce potential for hepatitis C reinfection. This is still a fertile area for research at this point and whether that is education alone, education in concert with other interventions like working with allies in various programs on, I don't know what at this point.

I don't think we know yet what's the optimal approach, but at present, to me, education is the key. Letting patients know that reinfections can occur with hepatitis C if risk behaviors recur. And I educate about the risk behaviors resumption of injection or intranasal drug use, particularly in hopes to reduce the likelihood for reinfection.

I will tell you that, obviously, unprotected sex is another risk behavior, and educating patients about using protection also is another approach.

Amanda Balbi: Thank you so much for speaking with me today and answering all my questions.

Vincent Lo Re: Well, it was my pleasure. And I hope that some of the information that was gleaned in this conversation will help other health care providers to treat more patients with hepatitis C and get them through the hepatitis C care continuum, so that we can reduce the overall prevalence of hepatitis C and reduce the likelihood of end-stage liver disease and other liver complications.