Findings from this study reveal that a majority of HIV/HCV co-infected patients are recommended PEG-IFN/RBV treatment by primary care providers over the course of receiving care, although like other studies, 7-10,37
only a minority of patients had actually received treatment. The data reveal that factors influencing provider decisions to offer or defer treatment are multifaceted. Provider HCV treatment decision making is influenced by patient factors including the patient's stability of HIV disease and psychosocial readiness for treatment. However, the provider's decision process is not only influenced by patient characteristics, but also aspects of the provider's clinical practice, attitudes towards HCV treatment and philosophy about patient treatment readiness.
Having a CD4 count above 200 and low HIV viral load were bivariate correlates of having been offered treatment, as treatment response is positively correlated with CD4 count,38
and PEG- IFN/RBV can temporary deplete CD4 cells,17
rendering clients vulnerable to opportunistic infections if they have severe immunosuppression. However, some patients had been offered treatment with CD4 counts below even 100, which is consistent with some Hepatitis Research Network clinical trials, and highlights how even patients whose immune system is severely compromised can still be considered appropriate for treatment. Also, the vast majority of all participants were on ART when treatment was offered, which can help limit the risks associated with treatment for patients with low CD4 counts. Provider decisions to offer treatment were not related to our measures of HCV disease, including HCV genotype and HCV RNA, which are correlates of treatment response;11-13
however, we did not have measures of liver fibrosis. Psychosocial indicators of patient treatment readiness, such as mental health, substance use, and adherence to clinical appointments and ART have been shown to be associated with HCV treatment eligibility in several other studies.9,10
However, in this study depression treatment status for current depression and patient knowledge of the goals and potential costs and benefits of treatment were the only psychosocial variables associated with whether or not treatment was recommended. Past history of depression, or current depression that was being managed with treatment, were not limiting factors to being recommended treatment, which is consistent with data suggesting that such factors are not necessarily impediments to HCV treatment response.27-29
Greater HCV knowledge may be an indicator of patient self-advocacy or motivation for treatment,32
at least in the perception of providers, and may explain in part its relationship to the offering of treatment; however, this relationship could also be bidirectional, with patients who are offered treatment consequently developing greater knowledge about the disease and treatment from their provider or through actively seeking out information.
The other patient characteristic associated with treatment being offered was race or ethnicity. African American and Hispanic patients, who together comprise the majority of the study sample, were less likely to be offered HCV treatment compared to Caucasian patients, even after controlling for other significant correlates. This finding may reflect health disparities that are commonly seen among minority ethnic groups in the United States.39
However, data show lower response rates to PEG-IFN/RBV among African American and Hispanic patients,40-42
and this could tip the cost-benefit ratio in the favor of the potential burden on patients in the minds of providers.
Provider decisions of whether or not to recommend HCV treatment to an individual patient are not solely predicated upon characteristics of the patient, but also provider-related variables. Having a smaller weekly patient load was associated with a greater likelihood of recommending treatment, which may be a proxy for how availability of time for the provider to manage what is often complex treatment can influence provider treatment decisions. Years in practice at the study site was also associated with provider decisions to offer treatment, suggesting that greater experience in providing care may translate into greater comfort offering and managing HCV treatment. In bivariate analysis, treatment offers were more likely when the provider had a lower threshold for gauging patient readiness, which may also be an indicator of how urgent the provider considers HCV treatment in general.33
The primary limitation of the study findings is the largely retrospective nature of the study design, and associated reliance on available chart abstracted data or current assessments that may not be reflective of the conditions present when treatment was offered. While a prospective design that measured variables at the time the treatment decision was actually made would be optimal, such a design was not feasible in terms of time and resources. The findings cannot be considered generalizable to all co-infected patients, although nearly all co-infected patients who attended the clinic during the study enrollment period did participate. Also, we were unable to reliably abstract data regarding medical comorbidities from patient's charts, and therefore cannot account for the role of this important factor in provider decision making. Furthermore, with newer, more efficacious (but perhaps even more burdensome) treatments soon to be available,43
it is unknown how this will affect provider decisions about the balance of the costs and benefits of treatment.
With HCV treatment rates continuing to be steadily low among HIV co-infected patients, the results of this study highlight both patient and provider variables that influence provider decisions to recommend treatment. Program administrators and intervention developers with an intent to increase treatment uptake should focus not only on factors that improve patient readiness for treatment, but also provider attitudes and comfort level regarding treatment, as well as patient load and time availability. With changes to HCV treatment soon to emerge, and its uncertain effects on both the benefits and burden associated with treatment, further evaluation of factors influencing treatment decision making and treatment uptake will be needed to promote optimal HCV care management among HIV co-infected patients.