Breakthroughs in Hepatitis C Treatment Spark Need for Improved Patient Engagement and Medication Adherence
This week, we turn your attention to an overlooked and neglected disease that deserves a closer look. Contributing author Julia Hill is an MPH student at the Gillings School of Global Public Health at UNC Chapel Hill.
In the United States, deaths due to Hepatitis C outnumber deaths caused by HIV, and yet, it’s not something that we hear much about. According to the CDC, chronic Hepatitis C is the most common blood-borne infectious disease, affecting approximately 3.2 million Americans.
Unlike Hepatitis A and B, there is no vaccine for the Hepatitis C virus. Once contracted, Hepatitis C often becomes a chronic condition. Over the course of decades, Hepatitis C gradually damages the liver, eventually causing organ failure or cancer, leading ultimately to liver transplantation or death.
Although treatment options for Hepatitis C can cure patients of the virus, there are substantial barriers to treatment uptake and adherence. Medications can cause serious physical and psychological side effects, including severe flu-like symptoms, fatigue, and suicidal ideation. Additionally, Hepatitis C disproportionately affects vulnerable populations that are more likely to experience practical and psychosocial barriers that impede treatment uptake and adherence.
Between December 2013 and December 2014, the FDA approved three breakthrough Hepatitis C drugs that have fewer side effects, a better cure rate, and reduced treatment duration to three months. The new treatments may be more tolerable, but daily medication adherence may still be a struggle for people who face barriers to care, such as psychosocial issues, steep treatment costs ($83,319 – $94,500), and health care navigation. Nevertheless, the arrival of these new treatments provides a renewed impetus to promote behavior change models that can increase treatment uptake and completion.
Peer Support for Hepatitis C Treatment Uptake
The literature on peer support and Hepatitis C is limited but promising. The majority of evidence has focused on treatment uptake, not adherence, as the side effects and low cure rate for existing treatments led patients to prefer waiting to treat. The literature has mostly focused on injection drug users, as they have very high rates of Hepatitis C infection. They have historically been excluded from being offered Hepatitis C treatment due to substance abuse and mental health issues, as well as fear of re-infection.
For example, Grebely and colleagues found that peer support, along with directly observed therapy, increased treatment uptake among Canadian injection drug users. In 2013, Crawford and Bath reviewed multiple peer support models for Hepatitis C treatment among injection drug users, and found that peer support has been successful in increasing treatment knowledge and uptake.
Peer Support for Hepatitis C Medication Adherence
Although peer support for Hepatitis C medication adherence has not been closely examined, a growing body of research suggests that peer support is effective in improving medication adherence for persons with HIV. In 2011, a systematic review of 117 global HIV peer support studies found that research on peer support and HIV has increased over time. Some of those studies showed positive results for the effect of peer support on medication adherence.
While HIV and Hepatitis C vary in some ways, such as possibility of cure, some transmission routes, and treatment options, the two viruses also share some noteworthy similarities. They are both infectious diseases that develop into chronic conditions for decades or a lifetime. Both diseases require aggressive treatments, people with both diseases experience stigma, and there is overlap in the type of patients who are at risk (sometimes leading to co-infection). Given the similarities between the disease experiences of HIV and Hepatitis C, there is reason to believe that peer support would be equally effective for Hepatitis C medication adherence as it has been for HIV.
In 2007, a randomized controlled trial conducted by Simoni and colleagues found that people living with HIV who received peer support reported higher medication adherence and social support, as well as lower depressive symptoms. As part of that intervention, peer supporters were specifically trained to address barriers to medication adherence. Qualitative research conducted in the same year found that peer support programs aided HIV medication adherence tangentially by decreasing social isolation, and increasing feelings of empowerment and growth.
Optimism about the Future of Hepatitis C
With the arrival of breakthrough drugs for Hepatitis C, care providers can look to peer support for improving treatment uptake and adherence. For some, multidisciplinary care appears to be an attractive setting for the integration of peer support services. Grebely’s recent research showed promising results with an integrated peer support and multidisciplinary care model, with many Hepatitis C patients starting and completing treatment. Grebely also studied HIV and Hepatitis C co-infection, and argued that peer support models should play a central role in comprehensive care for Hepatitis C patients.
An example of a successful model of peer support for both Hepatitis C medication uptake and adherence can be found in the OASIS clinic in Oakland, California. OASIS clinic has long provided Hepatitis C peer support for its clients, who are primarily injection drug users, and has been shown to increase patient treatment uptake and completion.
In the new era of more effective Hepatitis C treatment, the question is no longer “Will Hepatitis C patients get treated?”, but “How can Hepatitis C patients best be supported in their efforts to start and complete treatment?” Peer support from “someone like me” – those with experience navigating the health care system and with Hepatitis C treatment – may be the linchpin in supporting and increasing adherence to the new medications.