Department of Medicine, Division of Infectious Diseases/Chronic Viral Illness Service, Glen site, McGill University Health Centre, Montreal, Canada.
Department of Medicine, Division of Infectious Diseases/Chronic Viral Illness Service, Glen site, McGill University Health Centre, Montreal, Canada; Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Switzerland; Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada.
Int J Drug Policy. 2019 Mar;65:41-49. doi: 10.1016/j.drugpo.2018.08.012. Epub 2018 Dec 26.
Patients co-infected with HIV and hepatitis C virus (HCV) are a priority target for HCV treatment. The simplicity and efficacy of direct-acting antivirals (DAA) should help overcome patient, provider, and structural barriers to scaling up treatment.
We estimated between-centre variation in DAA treatment uptake among 1734 patients enrolled at the 18 centres of the Canadian Co-Infection Cohort-a prospective cohort of adults co-infected with HIV and HCV. We then compared this variation to that observed during the interferon era. Time to treatment uptake was modeled using a Weibull time-to-event model adjusting for centre and patient characteristics thought to have an impact on treatment initiation in the DAA era.
At the time of administrative censoring (December 31, 2016), 981 cohort participants were eligible for second-generation DAA therapy (HCV RNA positive after November 21, 2013) of whom 278 initiated DAAs (16 patients per 100 person-years). Patients with low monthly income, Indigenous ethnicity, recent injection drug use, HCV genotype 3, or unknown HCV genotype were less likely to start treatment. After adjusting for patient characteristics, the estimated between-centre variance (σ) was 0.29 (95% credible interval [CrI]: 0.09-0.89), considerably lower than during the interferon era (σ = 0.87, 95% CrI: 0.49-1.5). This between-centre variance was further reduced by the addition of centre-level effects for jurisdiction (σ = 0.15, 95% CrI: 0.02-0.60).
Much of the variation in treatment uptake between centres can now be attributed to regional differences. This suggests that after the introduction of DAAs, treatment barriers have shifted towards prescribing and reimbursement restrictions based on liver fibrosis, which vary by jurisdiction. The removal of these restrictions, however, will need to be paired with strategies to overcome patient-level barriers, which continue to prevent marginalized people and active substance users from accessing treatment.
同时感染艾滋病毒和丙型肝炎病毒（HCV）的患者是 HCV 治疗的重点目标。直接作用抗病毒药物（DAA）的简单性和有效性应有助于克服患者、提供者和结构性障碍，从而扩大治疗规模。
我们在加拿大合并感染队列的 18 个中心的 1734 名患者中，估算了 DAA 治疗的中心间接受率。该队列为同时感染 HIV 和 HCV 的成年人前瞻性队列。然后，我们将这种变化与干扰素时代观察到的变化进行了比较。使用威布尔时间事件模型来对治疗开始时间进行建模，该模型调整了中心和患者特征，这些特征被认为在 DAA 时代对治疗启动有影响。
在行政截止日期（2016 年 12 月 31 日）时，有 981 名队列参与者有资格接受第二代 DAA 治疗（2013 年 11 月 21 日后 HCV RNA 阳性），其中 278 名开始使用 DAA（每 100 人年 16 例）。月收入低、土著民族、近期注射吸毒、HCV 基因型 3 或未知 HCV 基因型的患者更有可能不开始治疗。在调整了患者特征后，估计的中心间方差（σ）为 0.29（95%可信区间[CrI]：0.09-0.89），远低于干扰素时代（σ=0.87，95% CrI：0.49-1.5）。通过加入司法管辖区的中心水平效应（σ=0.15，95% CrI：0.02-0.60），进一步降低了中心间的方差。
现在，中心间治疗接受率的差异很大程度上可以归因于地区差异。这表明，在 DAA 推出后，治疗障碍已转向基于肝纤维化的处方和报销限制，这些限制因司法管辖区而异。然而，要消除这些限制，还需要与克服患者层面障碍的策略相配合，这些障碍继续阻止边缘化人群和活跃的药物使用者获得治疗。
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