Racial Disparities in HCV Incidence and Treatment Outcomes
The incidence rate of HCV infection is 2 times greater in US African Americans compared with US non-Hispanic whites (3% vs 1.5%, respectively).
Although the introduction of direct-acting antivirals (DAAs) transformed the treatment of hepatitis C virus (HCV), significant challenges in managing HCV infection in high-risk populations still remain.
A recent review article pointed out that "African Americans [AAs] in the US are twice as likely to be infected with HCV compared to the non-Hispanic-white US population (3% vs 1.5%)."1 AAs are also more likely to be infected with genotype 1 HCV, less likely to respond well to interferon-based therapies, and more likely to develop HCV-related complications such as hepatocellular carcinoma.1,2
A study examining HCV-associated all-cause mortality in the US population found that the mortality rate of Mexican Americans with chronic HCV was approximately 7 times higher than that in HCV-negative individuals.3 A different study conducted in a cohort on HCV-infected US veterans found that Hispanics with HCV had a significantly higher risk of developing cirrhosis and hepatocellular carcinoma than non-Hispanic whites.4
In an interview with Infectious Disease Advisor, Elana Rosenthal, MD, assistant professor of medicine at the Institute of Human Virology, University of Maryland School of Medicine in Baltimore, and Paul H. Naylor, PhD, adjunct associate professor at the Department of Internal Medicine/Gastroenterology, Wayne State University School of Medicine in Detroit, Michigan, discussed the latest insights on racial disparities in HCV incidence and treatment outcomes.
Infectious Disease Advisor: Which comorbidities increase the risk for mortality from HCV infection?
Infectious Disease Advisor: What are some of the potential reasons for observed racial disparities in HCV treatment outcomes?
Infectious Disease Advisor: How is the community of medical professionals and researchers addressing this problem?
Infectious Disease Advisor: In a review paper published recently in Hepatic Medicine: Evidence and Research, you analyzed data from published studies and medical records reporting treatment response of HCV-infected AA patients to a combination of LDV/SOF. What did you find?
Paul H. Naylor, PhD: We were excited to confirm in a real-world setting that AA patients treated with the new DAAs (eg, LDV/SOF) have a similar high response rate as non-AA patients. In view of the previous racial disparity in interferon-based treatment and the considerable adverse effects, these observations should provide an incentive for AA patients to seek treatment.
Infectious Disease Advisor: What are some of the reasons why interferon-based therapy is less effective in HCV-infected AAs than combination therapy with DAAs?
Dr Naylor: Although it is not completely understood why interferon-based therapies were less effective in HCV-infected AAs, it is most likely that different mechanisms of action account for the disparity. Interferon required the host immune response to act in concert with the antiviral activity, and genetic differences in the host immune response were most likely the reason for the lack of effectiveness in AA patients. The DAAs act directly on the virus and prevent its replication, thus stemming its growth directly. They do not rely on the immune response for their effectiveness, and thus, genetic differences between individuals are not likely to be relevant to virus clearance.
Infectious Disease Advisor: What types of studies still need to be conducted to learn more about racial disparities in HCV treatment outcomes and ways to address them?
Dr Naylor: The most pressing issues with respect to racial disparities reside in the medical system, rather than the patient. AA patients are less likely than Caucasians in the United States to be aware of new treatment opportunities and are also more likely to be seen in economically restricted medical treatment systems. For example, in many states, Medicare patients who are predominately AA were, and to varying extent still are, restricted in their access to DAA treatment. Also, as HCV is often described as a silent virus because its manifestation of disease often occurs when liver disease is acute, patients need to be screened and identified before significant disease development. Again, AA patients who are less likely to have access to medical care may not be screened. This is especially important because recent reports indicate that fewer than 15% of US patients in the recommended screening population (adults born between the years of 1946 and 1945) have been tested to determine their hepatitis C status.
- Naylor PH, Mutchnick M. Decreasing racial disparity with the combination of ledipasvir-sofosbuvir for the treatment of chronic hepatitis C. Hepat Med. 2017;9:13-16.
- Devhare PB, Steele R, Di Bisceglie AM, et al. Differential expression of microRNAs in hepatitis C virus-mediated liver disease between African Americans and Caucasians: Implications for racial health disparities. Gene Expr. 2017;17:89-98.
- Emmanuel B, Shardell MD, Tracy L, et al. Racial disparity in all-cause mortality among hepatitis C virus-infected individuals in a general US population, NHANES III. J Viral Hepat. 2017;24:380-388.
- El-Serag HB, Kramer J, Duan Z, Kanwal F. Racial differences in the progression to cirrhosis and hepatocellular carcinoma in HCV-infected veterans. Am J Gastroenterol. 2014;109:1427-1435.
- Tang L, Parker A, Flores Y, et al. Treatment of hepatitis C with 8 weeks of ledipasvir/sofosbuvir: Highly effective in a predominantly black male patient population [published online October 30, 2017]. J Viral Hepat. doi:10.1111/jvh.12796.