To the Editor—I read with great interest the recent article by Dr Martel-Laferrière and collaborators [1]. The study emphasized important messages for human immunodeficiency virus (HIV) and infectious diseases physicians who are increasingly treating hepatitis C virus (HCV) among HIV-infected patients [2]: promptly recognize cirrhosis, regularly screen for cirrhosis-related complications, avoid potential medical interactions, educate your patients regarding toxins or habits that may contribute to further liver damage, and consider referral of your HIV/HCV-coinfected patients for liver transplant evaluation when indicated.
However, an essential part of managing HIV/HCV-coinfected patients is identifying ongoing barriers to care. Our HIV/HCV-coinfected patients have a high prevalence of poverty, drug abuse, unstable housing, and neuropsychiatric diseases that affect their overall engagement in care [2]. They often have low health literacy, feel marginalized, and are uninsured [3]. Not surprisingly, only 5%–7% of HIV/HCV-coinfected patients are cured of HCV in the United States and Europe [4–6]. At the Owen Clinic at the University of California, San Diego, approximately 12% of our patients who attend an initial clinic visit for HCV treatment do not return for HCV care [7]. Furthermore, the main reason for not initiating HCV therapy among those who completed HCV clinical staging is ongoing barriers to care [7]. Therefore, we teach medical students, residents, and infectious diseases fellows that complete staging and management of HCV in an HIV-infected patient requires 4 components: (1) assessment of HIV control and medical interactions; (2) liver staging status and prevention of cirrhosis-related complications; (3) addressing concurrent medical comorbidities; and (4) ascertainment of ongoing barriers to care.
I believe that the routine medical evaluation of any HIV/HCV-coinfected patient must include the assessment of potential ongoing barriers to care, which ultimately can preclude successful initiation and completion of HCV therapy in the forthcoming highly effective interferon-free era.
Notes
Disclaimer. The funders had no role in letter design, data collection, preparation of the manuscript, or decision to publish.
Financial support. This work was supported in part by the Clinical Investigation Core of the University of California, San Diego Center for AIDS Research (CFAR) (AI036214), the CFAR Network of Integrated Clinical Systems (R24 AI067039-01A1), and the Pacific AIDS Education and Training Center.
Potential conflicts of interest. Author certifies no potential conflicts of interest.
The author has submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
References
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