Telemedicine HCV Treatment in Department of Corrections Results in High SVR in Era of Direct-acting Antivirals

Taseen A. Syed; Reena Cherian; Shawn Lewis; Richard K. Sterling

Disclosures

J Viral Hepat. 2020;28(1):209-212. 

In This Article

Discussion

The results of our study demonstrate that though AASLD-IDSA guidelines have evolved over time, HCV treatment in the DOC via telemedicine is highly effective and feasible with near 100% treatment compliance and SVR-12 of 97%, irrespective of the patient characteristics, underlying genotype or DAA used. DAAs are an effective way of treating HCV infection due to shorter duration, fewer side effects and high SVR. However, a major barrier for treating HCV in incarcerated individuals is the lack of local expertise. As a result, less than 1% inmates with HCV have been treated and number of inmates treated among different states is variable.[8] Despite of the cost, studies have shown that HCV treatment is both feasible and cost-effective. Our telemedicine programme was established after meeting with Virginia DOC administrations, physicians and pharmacists. The programme had pretreatment screening process, treatment criteria and protocol as per AASLD-IDSA's updated guidelines. Through a well-communicated process, we were able to overcome multiple barriers. An educational session is conducted annually for the DOC provider, and telephone sessions were arranged for any additional questions or concerns.

In addition to retrospective design, a limitation to our study was selection bias of inmates referred for treatment by the facility provider. Most of the DOC facilities across the state including Virginia DOC tests for HCV in those with elevated liver enzymes or a reported high-risk behaviour. However, an opt-out approach of testing HCV on entering prison can improve diagnosis of HCV-infected individuals. Because the DOC, similar to many practices once DAA became available, initially prioritized those with advanced fibrosis for treatment, our treatment cohort was biased. However, the Virginia DOC has since adjusted their fibrosis threshold to allow lesser degrees of fibrosis to be treated. Despite the change over time, our SVR remained high. Additionally, the degree of fibrosis was determined with noninvasive tests including FIB-4 or elastography rather than histology itself. Fibrosis-based treatment was cost-effective at previous drug costs but after implementation of federal drug discount pricing programme, treatment with DAA is more cost-effective at current drug pricing. In addition, because we did not treat those with HCC or hepatic decompensation, our results are not generalizable to all HCV patients in the DOC. We did monitor compliance at each visit, and if any subject missed more than 1–2 days during treatment, it was extended by those days to complete the planned duration. However, despite our diligence, therefore we were only able to document 'near' 100% adherence. Additionally, although any side effects of therapy were collected as part of the routine telemedicine visit, those data were not collected as part of this retrospective analysis. However, no patient stopped DAA due to intolerance or adverse events which may reflect patient selection and exclusion of those with decompensated disease. Finally, we do not have data on reinfection rates while incarcerated or upon release.

The high prevalence of HCV infection in prison microenvironment should be considered an opportunity to eradicate HCV in DOC population. The benefit of treating HCV with current DAAs lies in its feasibility and cost-effectiveness at current drug pricing. The success of treatment depends on the collaboration of health professionals and correctional facilities through telemedicine clinics. With increasing experience of treating HCV through telemedicine, future studies expanding therapy to more challenging populations such as those with decompensation can be considered.

processing....