Treating Hepatitis C Within Real-world Telemedicine Addiction Care

Abstract

Objectives:

Individuals receiving treatment for opioid use disorder (OUD) represent a key population for hepatitis C diagnosis and treatment. Integrating hepatitis C treatment within telemedicine addiction care offers a new opportunity to reach this population.

Methods:

We conducted a chart review of individuals prescribed hepatitis C treatment within a telemedicine treatment program for OUD. Patient medical records were reviewed to extract details on demographics, hepatitis C history, medication prior authorization, initiation and completion, and viral clearance testing.

Results:

Sixty-three treatment-naïve patients were prescribed antiviral therapy for hepatitis C by their addiction treatment medical providers with a median age of 36, 41% of patients identifying as female, and 57% insured by Medicaid. Approximately 1 in 5 patients were denied prior authorization for antiviral therapy. Among 63 patients initially prescribed medication, 33 (52%) completed treatment.

Conclusions:

Telehealth programs for addiction are a feasible platform for expanding hepatitis C treatment to patients with OUD. Policies to reduce restrictions on antiviral coverage by payers could increase medication access through telehealth.

In 2023, the Biden-Harris administration issued a call to action to eliminate hepatitis C virus (HCV), which causes over 15,000 deaths in the United States annually despite the availability of highly effective direct-acting antiviral (DAA) medication.¹ A key component of this plan is to improve access to HCV diagnosis and treatment for patients who are receiving treatment for substance use disorders.¹ Given the challenges in delivering substance use treatment and HCV treatment in primary care settings, alternative care delivery models may hold promise. Telemedicine has expanded access to medications for opioid use disorder (OUD), and the potential to leverage telemedicine OUD treatment for HCV treatment has been explored in clinical trials.^2–4 However, there is wide variability among telehealth providers in practice, and providers may or may not inquire about HCV status or recommend testing at labs; thus, there is ample opportunity to adapt and scale the delivery of HCV treatment within real-world telehealth settings. Here we describe our experience delivering HCV treatment within a fully telemedicine-based OUD treatment program.

METHODS

Using electronic health records, we conducted a retrospective cohort study of patients receiving telemedicine treatment for OUD who were prescribed HCV treatment by their OUD care provider. Patients were enrolled in care at a multistate practice for substance use disorder treatment.^5,6 Patients connect through a web-based platform for video-based visits with medical and behavioral health providers, as well as counselor-led and peer-led support groups. In addition, patients can receive care for comorbidities, such as anxiety, depression, insomnia, HCV, and preexposure prophylaxis for HIV, with patients completing laboratory tests at external facilities as needed. Approval for this retrospective chart review with a waiver of informed consent was obtained under expedited review by an external Institutional Review Board (Solutions IRB; FWA00021831). This report follows the “Strengthening the Reporting of Observational Studies in Epidemiology” reporting guideline for cohort studies.

Patients were included in the chart review if they were at least 18 years old, had a primary diagnosis of OUD, and were prescribed a DAA between November 1, 2021, and March 1, 2024, by a provider in Michigan, Ohio, Texas, Florida, or New Jersey. The medical records of each patient were reviewed to extract details on demographics, OUD medication use, HCV history, DAA prior authorization (PA), initiation and completion, and clinical outcomes, including viral clearance testing. Reasons for a patient’s not starting or completing DAA treatment were recorded from chart notes, including concerns regarding or experiences of side effects, medication delivery issues after prescribing, and discharges before initiating or completing treatment. We calculated descriptive statistics for patient characteristics and the HCV cascade of care was described through the count and proportion of patients completing each component of treatment. The HCV cascade of care included the following elements: prescribed HCV medication, approval of PA or PA not required, initiation of HCV treatment, completion of HCV treatment, completion of follow-up laboratories, and viral clearance.

RESULTS

Sixty-three patients were prescribed DAAs, with 41% of patients identifying as female (n = 26), 57% insured by Medicaid (n = 36), and a median age of 36.0 years (IQR: 32–41). All were HCV treatment-naïve as determined through provider inquiry according to clinic protocols and were prescribed buprenorphine for OUD. Over half of patients had a concurrent diagnosis of anxiety (n = 34, 54%), and 43% had a concurrent diagnosis of depression (n = 27). Two-thirds of patients were diagnosed with HCV before starting telemedicine OUD care. Approximately half had their HCV medication prescribed within the first 6 months of OUD treatment and 11% used the same pharmacy to fill their OUD and HCV prescriptions (Table 1).

TABLE 1.

Demographic Characteristics of Members Prescribed Treatment for Hepatitis C (n = 63)

Variable	n (%)
Age, median (IQR)	36.0 (32–41)
Sex (M)	37 (59)
Race
White race	47 (98)
Multiple races	1 (2)
Ethnicity
Hispanic/Latino	1 (2)
Not Hispanic/Latino	42 (98)
State
New Jersey	12 (19)
Michigan	16 (25)
Ohio	27 (43)
Florida	4 (6)
Texas	4 (6)
Unemployed	14 (23)
Unstable housing	10 (17)
Single/unpartnered	24 (39)
Insurance type
Commercial	23 (37)
Medicaid	36 (57)
Self pay	4 (6)
Anxiety diagnosis	34 (54)
Depression diagnosis	27 (43)
Current nicotine use	55 (87)
Alcohol use disorder	7 (11)
Cannabis use disorder	10 (16)
Stimulant use disorder	10 (16)
Time from enrollment to prescription (mo)
0–6	28 (45)
7–12	14 (23)
12+	20 (32)
Time from prescription to viral clearance testing (wk)
≤20	5 (29)
>20	12 (71)
Length of HCV Infection (n=31 patients), median (IQR)	6 years (3–11)
Self-reported HCV	41 (65)
Elevated ALT	52 (84)
Elevated AST	44 (72)
Fibrosis stage before treatment
Ishak 0–1	57 (93)
Ishak 2–3	4 (7)
Fibrosis-4 score ≥1.45	3 (5)
HCV genotype
1	40 (68)
2	5 (8)
3	13 (22)
4	1 (2)
Treatment naive	63 (100)
HCV medication
sofosbuvir/velpatasvir	28 (44)
glecaprevir/pibrentasvir	35 (56)
Used same pharmacy for OUD treatment	7 (11)

Alanine transaminase over 25 for females and 33 for males.

Aspartate transaminase over 36 for females and 20 for males.

ALT indicates alanine transaminase; AST, aspartate transaminase; HCV, hepatitis C virus; OUD, opioid use disorder.

Of those prescribed DAAs, 23.8% of patients (n = 15) did not require insurance PA, while 57.1% of patients received PA approval (n = 36), and 19.1% of patients were denied PA (n = 12). The most common denial reasons were not meeting the insurance provider’s medical necessity criteria or requiring a consultation from a specialist.

Of those with insurance coverage, 78.4% of patients initiated a course of HCV medication (n = 40), and 82.5% of those who started completed treatment (n = 33; (Fig. 1). The most common reasons for not initiating medication use were concerns about side effects (n = 3), being discharged from care (n = 2), and encountering a medication delivery issue (n = 2). The most common reasons for not completing the course of therapy were side effects (n = 2) and being discharged from care (n = 2). Of those who completed a course of treatment, 51.5% completed post-treatment viral load testing (n = 17), of whom 5 (29%) completed testing within 20 weeks of their prescription, and all (100%) achieved viral clearance.

FIGURE 1.

HCV cascade of care for hepatitis C treatment within telemedicine addiction treatment. HCV indicates hepatitis C virus; PA, prior authorization.

DISCUSSION

Our report is the first, to our knowledge, to describe the feasibility of delivering HCV treatment within a real-world, fully telemedicine program for OUD. We reached patients with a median age of 36, and 52% of total patients completed HCV treatment. However, 37% of patients did not initiate treatment, largely due to insurance barriers. The small percentage of patients who used the same pharmacy to fill their HCV and OUD medications was likely due to an organic relationship that developed with a specialty pharmacy that provided support for PAs and could ship HCV medications to multiple states.

Other studies have explored facilitating HCV treatment through telehealth as an adjunct to in-person treatment for substance use and reported completion rates between 74% and 93% among older populations with average ages between 45 and 55.^2,3,7 Although only 63.4% of patients prescribed treatment initiated DAA therapy compared with over 90% in a randomized trial of telemedicine versus in-person HCV treatment, our study is unique in that it assessed real-world outcomes outside of trial conditions and did not require insurance coverage of DAAs for patient inclusion.² A few limitations may affect the generalizability of these findings. First, our study uses a small sample receiving treatment for HCV at a single telehealth practice. Second, our study involved patients with OUD receiving buprenorphine and HCV treatment outcomes may differ among patients who have OUD but do not receive medications for OUD or who have other substance use disorders. Finally, our ability to track participants through HCV treatment was dependent upon the availability of information tracked in electronic health records. In particular, posttreatment viral load testing was difficult to track as testing had to be completed at external laboratories, and patients using telemedicine may have faced barriers to completing in-person testing. Nevertheless, despite these limitations, our findings support the overall clinical feasibility of translating HCV treatment within telemedicine OUD care from a research-based trial setting to real-world practice.

In future studies assessing HCV treatment through telehealth substance use treatment programs, care management services could be implemented to support patients through insurance authorization processes, filling prescriptions at the pharmacy, and completing posttreatment viral load testing. In addition, at a policy level, insurance companies could expand coverage for HCV antiviral therapy without PA processes to make the process of initiating treatment more simple and timely for patients.

CONCLUSIONS

Our findings support telehealth OUD treatment programs representing a valuable opportunity to expand HCV treatment for patients with substance use disorders in real-world practice. We suggest reducing restrictions on DAA payer coverage to further improve treatment initiation and completion outcomes.