Hepatitis C treatment wanting at VA: while nearly 200,000 veterans are afflicted with the liver disease, relatively few are receiving care

VFW Magazine, Sept, 2003 by Allison Wright

For the past seven years, the Department of Veterans Affairs (VA) has taken its battle against the hepatitis C virus (HCV) seriously, pouring hundreds of millions of dollars into research on how to respond to a disease that is widespread among veterans.

Between January 1996 and February 2003, VA identified 215,000 veterans with the hepatitis C infection. Of those, 21,500 (10%) have since died from various causes.

A profile of those infected reveals that 97% are males. Their average age is 53. Among those with documented era of service, 68.5% served during the Vietnam era and 20.3% during the post-Vietnam/Gulf War period. Only 8.5% served amidst the Korean War or Cold War era. A mere 2.7% of hepatitis C patients served in WWII or immediately thereafter.

But they all have one thing in common.

The problem is "almost no one is getting treated," said Dr. Mark Willenbring, director of the Addictive Disorders Section at the Minneapolis VA Medical Center and co-director of the Minneapolis Hepatitis C Resource Center (HCRC), one of four VA facilities dedicated to hepatitis C care.

The biggest obstacle to treatment is VA's policy of excluding veterans with mental health or substance abuse problems from receiving antiviral HCV therapy. (VA estimates that 89% of HCV patients have either past or present mental-health or substance-abuse problems.)

"People with mental health and addiction disorders have historically been excluded from clinical trials and models of care because they are very complex patients with multiple problems," said Willenbring, adding that this practice is not unique to hepatitis C or to the VA care system.

"The very high prevalence of psychiatric and addiction disorders among patients with HCV has been regarded as the number one [treatment] problem. It's a real struggle for liver doctors, and not just in the VA."

The doctor in charge of VA's program sees it as a matter of developing the right tools.

"Until recently, hepatitis C antiviral treatment was felt to be inadvisable in patients with psychiatric disorders and recent or ongoing substance abuse problems, including alcohol use," said Michael Rigsby, director of VA's National Hepatitis C program. "This was based on concerns that such treatment might not be safe for these patients and that the efficacy of antiviral therapy would be diminished.

"However, there has been a recent change, reflected in VA treatment recommendations and in the recent National Institute of Health (NIH) consensus statement, toward individualizing decisions about treating these patients. In general, such conditions, which are commonly encountered in patients with hepatitis C, are no longer felt to be absolute barriers to effective antiviral therapy.

"One of the highest priorities of the Hepatitis C Resource Center program is to develop ways to more effectively engage hepatitis C patients who also have substance abuse or mental health problems in treatment for hepatitis C. And to provide them with antiviral therapy if indicated," Rigsby said.

"Treatment for hepatitis C is a broad concept that includes dealing with many other conditions, including depression, alcohol use and other medical conditions. The services and tools needed to achieve the best results from antiviral therapy in patients with mental health or substance use disorders are still being developed."

Faulty Assumptions

Clinicians and other health professionals have assumed in the past that patients with substance-use disorders would not stick with treatment regimens, would neglect to take their medicine as instructed or would drop out of treatment, said Guadalupe Garcia-Tsao, director of the Connecticut VA Hepatitis C Resource Center.

"In fact, there are few studies to back up this impression," she said. "Although some studies have shown a negative impact of substance use on treatment adherence, others have shown little or no effect."

Studies also show that veterans with mental illnesses and substance-use disorders respond just as well to antiviral drugs as do veterans without the disorders. Assumptions by some clinicians that many intravenous drug users would get re-infected with HCV after completing treatment also have been proved wrong. Research presented by Willenbring and his Minneapolis HCRC colleagues during a recent American Psychiatric Association conference provides evidence.

These findings, in part, helped spur VA into revising its HCV treatment guidelines in late November 2002 to include consideration of veterans with psychiatric and substance-use disorders. Also, in June 2002, the NIH's consensus conference recommended that active injection drug use and alcohol abuse "should not" be used to exclude patients from antiviral therapy.

"Only recently have we begun to question the practice of excluding these patients from treatment," Willenbring said. "There is an attitude that they are undeserving. But we are dedicated to fighting inappropriate exclusion and inappropriate therapeutic pessimisms."

Willenbring said specialists in mental health and addiction services are critical to bringing down the wall of intimidation that hovers between patients and providers.