Racial/Ethnic and Socioeconomic Disparities in Initiation of Direct-Acting Antiviral Agents for Hepatitis C Virus in an Insured Population

Abstract

Abstract Background: The high cost of direct-acting antiviral agents (DAAs) for hepatitis C virus (HCV) infection may present a barrier to access, thus contributing to disparities in treatment. However, few real-world data exist on factors associated with DAA uptake. Methods: We conducted an observational study of Kaiser Permanente Northern California members with HCV infection, defined as a positive HCV RNA test or an HCV genotype, during the recent DAA era (i.e., October 2014–December 2016). To evaluate factors independently associated with DAA initiation, an adjusted Poisson model included age, sex, race/ethnicity, census-based neighborhood deprivation index, HCV genotype, advanced fibrosis (i.e., Fibroscan ≥9.5 kPa, if available; else FIB-4 >3.25), prior HCV treatment, drug abuse diagnosis, smoking, alcoholic drinks per week, HIV infection, and hepatitis B virus infection. Results: We identified 18,140 HCV-infected individuals, of whom 6167 (34%) initiated DAA treatment. Treatment was less likely among Black (risk ratio [RR] 0.83, 95% confidence interval [CI]: 0.79-0.88) and Hispanic individuals (RR 0.92, 95% CI: 0.87-0.98) compared with White individuals, and among individuals with greater neighborhood-level economic disadvantage (quartile 3 vs. 1: RR 0.89, 95% CI: 0.85-0.94; quartile 4 vs. 1: RR 0.79, 95% CI: 0.75-0.83). Treatment was also less likely among those with a history of drug abuse (RR 0.87, 95% CI: 0.82-0.91), smoking (RR 0.84, 95% CI: 0.80-0.87), or more alcoholic drinks per week (1–7 vs. 0 drinks: RR 0.88, 95% CI: 0.82-0.93; 8-16 vs. 0 drinks: RR 0.72, 0.63-0.82); ≥17 vs. 0 drinks: RR 0.63, 95% CI: 0.49-0.80). There was a higher likelihood of treatment among individuals with advanced fibrosis (RR 1.39, 95% CI: 1.34-1.44), HCV genotype 1 (RR 1.97, 95% CI: 1.87-2.08), no prior HCV treatment (RR 1.44, 95% CI: 1.37-1.52), or HIV infection (RR 1.19, 95% CI: 1.08-1.30). Conclusion: Although clinical factors appear to drive HCV treatment decisions, racial/ethnic and socioeconomic disparities exist in DAA uptake. Lifestyle factors, such as alcohol use and drug abuse, may also influence patient or provider decision-making regarding DAA initiation. Strategies are needed to ensure equitable access to DAAs, even in insured populations. Disclosures All authors: No reported disclosures