Housing, Insurance Are Key Factors in Success of HCV Treatment

Jacob Ziff (Icahn)

People with unstable housing are most likely to not complete treatment for hepatitis C virus (HCV), and patients whose primary insurance is Medicaid are less likely to return for sustained virologic response (SVR) testing, according to a new study of more than 300 patients with HCV.

The report highlights the opportunities, but also the limitations, of comprehensive primary care centered on harm-reduction.

Corresponding author Jacob Ziff, a medical school student at the Icahn School of Medicine at Mt. Sinai, and colleagues, sought to better understand how social determinants of health impact the success of treatment for patients with HCV. To find out, they conducted a retrospective cohort analysis of patients who began treatment using direct-acting antivirals (DAAs) at the Respectful and Equitable Access to Comprehensive Healthcare (REACH) primary care program at Mt. Sinai. The clinic is located in East Harlem, New York, an area with a high prevalence of HCV. It aims to provide wide-ranging services to meet the needs of patients who currently use or previously used drugs, including medical, mental health, social work, and patient navigation services.

The study’s cohort included 329 patients who began therapy with DAAs between December 2014 and March 2018. Those patients were tracked for 2 primary endpoints: HCV treatment completion and return for SVR testing 12 weeks after the completion of testing. Those outcomes were analyzed alongside a range of factors, such as substance use, psychiatric history, housing instability, and treatment regimen, in order to see what correlations might exist.

Overall, 92% of patients completed the treatment. Of those, only one factor emerged as a significant predictor of treatment completion: housing. Those with unstable housing were significantly less likely to complete treatment (odds ratio [OR], 0.3; 95% confidence interval [CI], 0.1-0.9).

Among the 302 patients who completed treatment, three-quarters returned for SVR assessment. Again, just one factor appeared to correlate with a patient’s likelihood of return. In this case, it was having Medicaid as their primary insurances, compared to other insurances (OR, 0.3; 95% CI, 0.1-0.7).

Ziff told HCP Live that, since the REACH model is built on addressing social determinants of health, he was not surprised to find that actionable barriers to treatment—those the clinic was designed and well-positioned to address—were not predictive of outcomes.

“There is a large body of research that demonstrates that patients with active substance use can do equally well on HCV treatment as compared to those without, when provided with adequate support and resources,” he said.

Unfortunately, he added, housing instability and Medicaid status, “are much less readily mutable” than other factors. And insofar as the success of the patients in this study was due to the comprehensive approach of the REACH model, he conceded that not every clinic will be able to provide the same level of support.

Ziff said the study demonstrates how public policy can support and bolster healthcare providers, but can also limit access to care, such as when states place restrictions on Medicaid authorization for HCV treatment. However, he said providers still have room to work around the constraints.

“[I]t is vital that we as healthcare providers not only try to push for policy that improves our community’s health, but that we also seek and utilize practices that allow us to navigate within the existing policy paradigm in order to best serve our patients,” he said.

Such efforts include things like patient navigation, using the Psychosocial Readiness Evaluation and Preparation for Hepatitis C Treatment (PREP-C) tool, and streamlining prior authorization.

“So yes, while unstable housing and Medicaid seem like more upstream, less actionable problems for us as healthcare providers to impact, it is at the very least our responsibility to adjust our care in the attempt to balance the resulting inequities that result from [the upstream problems] in current treatment,” he said.

The study, "Predictors of hepatitis C treatment outcomes in a harm reduction-focused primary care program in New York City," was published online in Harm Reduction Journal.