Many people with Medicaid coverage are not receiving treatment for hepatitis C, according to study results published in JAMA Network Open. Treatment rates are especially low for women, young adults, Latino and Asian individuals and people who use drugs.
Estimates suggest that more than 2 million people in the United States are living with hepatitis C. Although once most prevalent among baby boomers, hepatitis C has increased among younger people, largely driven by injection drug use. Over time, chronic hepatitis C virus (HCV) infection can lead to serious complications, including cirrhosis, liver cancer and liver failure.
Today’s direct-acting antiviral (DAA) medications are highly effective, curing more than 95% of patients. But many people who need treatment are not getting it. A recent report from the Centers for Disease Control and Prevention found that only a third of people with HCV have been successfully treated. People on Medicare were most likely to be cured, followed by those with commercial insurance, while those on Medicaid and those who were uninsured had the lowest cure rates. More than half of people who inject drugs rely on Medicaid.
Barriers to hepatitis C treatment include lack of awareness, inadequate screening, the high cost of medications and various restrictions on who can be treated—for example, limiting therapy to people with advanced fibrosis, requiring a period of abstinence from drugs and alcohol, requiring management by liver specialists or requiring prior authorization from payers. While many state Medicaid programs have removed such restrictions, some still exist.
For the new study, Shashi Kapadia, MD, of Weill Cornell Medicine, and colleagues looked at Medicaid claims data from 47 states, Washington, DC, and Puerto Rico. This retrospective analysis included data from 87,652 Medicaid enrollees ages 18 to 64 who were newly diagnosed with hepatitis C in 2018. The included participants were continually enrolled in Medicaid for at least a year before and six months after a reported HCV diagnosis and were not dually eligible for Medicare.
Just over half were women, 59% were white, 15% were Black, 11% were Latino and 2% each were Asian and American Indian or Alaskan Native. Most (81%) were from urban areas. The largest subset (44%) was ages 50 to 64, followed by those ages 30 to 49 (41%) and 18 to 29 (15%). More than half (57%) had diagnosis codes associated with injection drug use—for example, overdose or use of methadone or buprenorphin—16% had alcohol use disorder. A small proportion (7%) already had liver cirrhosis, and 5% had HIV coinfection.
Within this group, 20% received DAAs within six months of their HCV diagnosis. Men were 24% more likely to receive treatment than women. DAAs are not yet approved for pregnant people, and pregnancy was associated with a lower likelihood of treatment. People in the 18-to-29 age bracket were 35% less likely to be treated, and people who inject drugs were 16% less likely.
After adjusting for differences among states, including their Medicaid policies, Asians were half as likely to start treatment, American Indians and Alaskan Natives were 32% less likely and Latinos were 19% less likely compared with white or Black people.
Discussing their findings, the study authors noted that the low treatment rate is concerning, in part because people who are not successfully treated can continue to transmit HCV, hampering elimination efforts.
To improve treatment uptake, they recommended integrating hepatitis C care at venues that provide services for young people who inject drugs as well as providing care via telehealth. For Asians, hepatitis C screening and treatment could be integrated into programs focused on hepatitis B, which is common in this group. Women, they suggested, may face increased stigma or providers may be less likely to offer them treatment.
The low rate of treatment for people with cirrhosis and HIV “was both surprising and concerning,” they wrote, as these individuals are more likely to experience serious HCV complications. Although DAAs can be safely used with modern antiretroviral regimens, some health care providers nonetheless may not feel comfortable treating people with HIV and HCV coinfection.
“In this cohort study, we found that the rate of HCV treatment among patients with a new diagnosis of HCV in Medicaid administrative data [is] low and that there are significant disparities among the highest priority groups for HCV elimination—young people, people who inject drugs and females,” the researchers concluded. “The observed racial and ethnic disparities in treatment initiation suggest that continued tracking of these inequities, and understanding of their mechanisms, are needed. Further interventions to improve treatment uptake are also needed in the key populations identified here, in order to achieve the treatment rates needed to eliminate HCV.”
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