Obstacles to HCV infection screening and treatment _ multicentric by hcj


									Obstacles to HCV clinical care among HCV and HCV-HIV
infected patients : GYMKHANA survey
TAULERA (1), A.WAJSBROT (1) and the GYMKHANA study group (3).
(1) GERVIH (Groupe d'études et de Recherche sur le VIH) – Paris, France
(2) CEMKA-EVAL, Bourg la Reine, France
(3) GYMKHANA study group

9th EACS. October 25-29, 2003. Warsaw. Poland.

Contact information:
Dr Michelle BENTATA
Hôpital AVICENNE, 125 route de Stalingrad 93009 Bobigny cedex, France.
Tel : 00 33 1 48 95 51 44
Fax : 00 33 1 48 95 58 56
E-mail: hiv.bentata@avc.ap-hop-paris.fr

Hepatitis C Virus (HCV) infection is often undectected and its clinical care suboptimal. To that end,
clinical care of these patients requires a close collaboration between hospital practitioners (HP) and
general practitioners (GP). In addition, unsolved socioeconomic factors are an hindrance to it.

Gymkhana survey attempted to identify the obstacles to screening or treatment in patients at risk for
or infected by HCV or co-infected with HCV and HIV (Human Immunodeficiency Virus).

Methods :
One week multicentric survey. The survey was conducted by 80 GP and 21 HP belonging to 11
HCV-HIV specialized care networks (Gymkhana study group). All the out-patients more than 18
years old who agreed to were included. The study was conducted during the 6 following days of the
second week of December 2002.
13 risk factors were chosen by a panel of investigators. The patients first filled up an auto-
questionnaire on their risk factors. Then the practitioner filled up for each patient a medical
questionnaire regarding the difficulties of patient management with at least one predefined risk
The 5 major risk factors were defined as associated with a prevalence of HCV more than 2% by
ANAES (National Agency of Accreditation and Health Evaluation).
Major risk factors :                                Minor risk factors :
Transfusion before 1992                             tatoos and piercing and earrings
Hemophilia                                          intranasal drug use
Dialysis                                            inmates or former inmates
Intraveinous drug use                               HCV infected sexual partners
HIV seropositivy.                                   HCV patient in the immediate family
                                                    Medical care in developping countries
                                                    (Asia, Middle East, Africa, South America)
                                                    Health care workers
                                                    Fibroscopy, coloscopy or coelioscopy

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Results :
4 935 subjects were included. Among them, 686 (13.9%) were HIV infected patients.
4 237 (85.8%) were identified as having at least one risk factor:
           o 1 525 (36.0%) had at least one major risk factor
           o 2 712 (64.0%) had at least one minor risk factor but no major risk factor,
           o 675 (15.9%) persons had earrings without any other risk factor
698 (14.2%) had no risk factor at all

1. Description of the population

                               Socio-demographic data of the patients

                                                                         n=4 935 (%)
                                 Item unfilled                                24
            Sex                  males                                  2 226 (45.3%)
                                 females                                2 685 (54.7%)
                                 mean                                         44.8
                                 Standard deviation                           16.7
                                 Item unfilled                                265
                                 Primary school                         1 056 (22.7%)
            School level
                                 Secondary school                       2 051 (44.0%)
                                 Post graduate school                   1 563 (33.3%)
                                 Item unfilled or no social insurance         234
            Social insurance
                                 Social insurance                       4 701 (95.2%)

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  Distribution of risk factors among patients with at least one of the 13 risk factors (n=4 237)
                                                                                     %          %
                                                                           n        (on     (on 4 935)
    Major factors
    1. I have perhaps received a transfusion before 1992                 679      16,0%        13,8%
    2.   I'm in dialysis                                                  12       0,3%         0,2%
    3.   I have already used intravenous drugs                           451      10,6%         9,1%
    4.   I'm HIV positive                                                686      16,2%        13,9%
    5.   I'm a hemophiliac                                                 9       0,2%         0,2%
    Minor factors
    6. I used intranasal drugs                                           651      15,4%        13,2%
    7. Tatoos, piercing, scarification, mesotherapy, acupuncture,        3 124   73,7%         63,3%
            * Earrings only                                              675      15,9%        13,7%
    8. I have been in jail                                               267       6,3%        5,4%
    9. Fibroscopy, coloscopy, coelioscopy                                1 682    39,7%        34,1%
    10. One of my sexual partners is or was HCV infected                 256       6,0%        5,2%
    11. One member of my close family is HCV infected                    266       6,3%        5,4%
    12. I'm a health care worker                                         268       6,3%        5,4%
    13. I received medical care in developping countries                 625      14,8%        12,7%

2. Description of the screening

The medical questionnaire regarding the difficulties of the patients’ clinical care was completed for
only 4137 patients among 4237 (97.6%) who declared to have one or more risk factors:
    1 488 of the 1 525 patients with almost one major risk factor;
    674 of the 686 patients infected by HIV
    658 of the 675 patients who had earings as the only risk factor

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Screening among 4 137 patients having one or more risk factors and with a fulfilled
medical questionnaire
                                           HIV infected             HIV non
                                             patients           infected patients
                                              N=674                  N=3463
 HCV test prescribed
    No                                       43 (6,4%)           2 497 (72,1%)          2 540 (61.4%)
    Yes                                    631 (93,6%)               966 (27,9%)        1 597 (38.6%)
          Results received by the
            No                               14 (2,2%)               134 (13,9%)         148 (9,3%)
            Yes                             617 (97,8%)              832 (86,1%)        1 449 (90,7%)
                   Test result:
                      Négative                  402                     634                 1 036
                      Positive            215/617 (34.8%)       198/832 (23.8%) 413/1449 (28.5%)


If we only consider the 5 major factors, on 1 488 patients with at least one major risk factor, only
1 018 (68.4%) were screened for HCV, while among 674 HIV infected patients 631 (93.6%) were
screened (p<0.001).
If we consider the 658 patients who had only earrings, 61 ( 9.3%) were tested for HCV.

As a whole, 2 540 patients, (61,4%) with one ore more risk factor didn't have had a
screening for HCV. The reasons are listed in the following table.

   Your patient has an HCV risk factor and did'nt have had a screening at this day. Why ?

                                                                                               n (%)
First consultation the day of the study                                                     385 (15,2%)
You are familiar with the patient, but you did'nt know the risk factor or your
                                                                                           1 794 (70,6%)
did'nt spot it was a risk factor before
You knew the risk factor but you didn’t prescribe the test                                   195 (7.7%)
You thought that an other physician prescribed the test.                                     102 (4,0%)
The patient is addicted to drugs or alcohool and you assess that the diagnosis and or
                                                                                             16 (0,6%)
treatment needs to be delayed
You have assessed that the relationship with the patient is not good enough at this
                                                                                             36 (1,4%)
day to propose the test
Social problems are not solved yet                                                           19 (0,7%)
The patient has an other medical problem and you think that the HCV treatment or
                                                                                             104 (4,1%)
diagnosis is not the first priority
Others                                                                                       47 (1,9%)

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The screening of HCV infection appears insufficient, even if the study has been
conducted in specialized networks of practitioners, seeing that almost one third of
patients with one or more major risk factors has not been screened at the time of the
However, in HIV infected patients the screening has been satisfying.

3. Results of the screening

   970 patients had at least one of the 5 major risk factors and a known result of screening.
    Among them, 385 (37.5%) were infected by HCV.
   477 patients had at least one of the 8 minor risk factors but no major risk factor and a
    known result of screening. Among them, 26 (5,5%) were infected by HCV.
   61 patients had only earrings as a risk factor, none was infected by HCV.

  As a whole, 413 patients were HCV infected, that is 28.5% of the 1 449 screened patients :
                    198 (47.9%) coinfected with HIV;
                    215 (52.1%) monoinfected with HCV.

4. Step by step clinical care
Once a patient was known as infected by HCV, the practitioner fulfilled a medical questionnaire
with four main steps:
(1) biological data : transaminases, RNA-HCV and genotype ;
(2) consultation with a specialist in hepatology ;
(3) liver biopsy when indicated ;
(4) HCV treatment when indicated.

246/413 patients (59.6%) had an adequate clinical care has defined by consensus conferences
167/413 patients (40.4%) had not, because of one or several reasons :

                           Main stopping steps in HCV infected patients

                                                    VIH +        VIH -    p           Total
                                                    (n=93)      (n=74)               (n=167)
         Blood test was not ordered                4 (4.3%)   9 (12.2%) NS          13 (7.9%)
         Blood test was ordered but not done       3 (3.2%) 13 (17.6%) 0,002       16 (9.6%)
         Consultation with a specialist did not   10 (10.8%) 17 (23.0%) 0,03       27 (16.2%)
         take place
         Liver biopsy was not ordered             45 (48.4%) 14 (18.9%) <0.001 59 (35.4%)
         Liver biopsy was ordered but not done    12 (12.9%) 10 (13.5%)  NS    22 (13.2%)
         Treatment was not initiated              17 (18.3%) 8 (10.8%)   NS     25 (15%)
         Unknown                                   2 (2.2%)   3 (4.1%)   NS      5 (3%)

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                                     Reasons for unoptimal care

                                               VIH infected    VIH non       p            Total
                                                 (n=93)        infected                  (n=167)
        Frightened, negligent or forgetfull    42 (45.1%)     43 (58.1%)    ns          85 (50.9%)
        Serious physical impairment            25 (26.9%)     5 (6.8%)     <0.001       30 (18.0%)
        Serious drug addiction or alcoholism   17 (18.3%)     8 (10.8%)      ns         25 (15.0%)
        Poor relationship between the           8 (8.6%)      7 (9.5%)       ns          15 (9.0%)
        physician and the patient
        Unsolved social problem                 7 (7.5%)       5 (6.8%)     ns          12 (7.2%)
        Carelessness of the practitioner        2 (2.2%)       2 (2.7%)     ns          4 (2.4%)

In more than half of the patients, the most important obstacle for unoptimal care is
negligence, forgetfulness or fear of the patients. In comparison the negligence of the
physician appears very low. However, a poor relationship between the physician and
the patient is not uncommon.
Physical impairment represents almost a quarter of the obstacles. Main difference
between mono and co-infected patients consists in serious medical additional problems
in HIV patients.

Conclusions :
Concerted efforts have to be done to improved recognition of risk
factors for HCV infection.
Our study allows to spot some realizable goals as to achieve a
better relationship between patients and practitioners or to resolved
social or addictive problems.
However, physical impairment remains the major impeachment to
global clinical care and treatment notably in co-infected patients. An
earlier medical intervention in the history of HCV infection especially
in HIV-HCV co-infected patients, could be required.

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GYMKHANA study group :

ARES 92 : Docteur Isabelle CAHITTE, Docteur Jean-Paul GROS, Docteur E. HIRAUX, Docteur
Martine LALANDE, Docteur Bruno LANDI, Docteur Thierry MAZARS, Docteur Emmanuel
MORTIER, Docteur Michel NOUGAIREDE, Docteur Jean-François PERDRIEAU, Docteur Anne
Fédération Réseaux Marseillais : Docteur Pierre ASSAS, Docteur BENYAHYA Sydney, Docteur
François BRUN, Docteur Marie-Pierre DROGOUL, Docteur Simon HAKOUN, Docteur André
MADRID, Docteur Jean-Louis MATTEI, Docteur Saadia MOKHTARI, Docteur Pierre MOURS,
Docteur Patrick PHILIBERT, Docteur Isabelle RAVAUX, Docteur Frank TOLLINCHI.
LYON THEMIS : Docteur Stéphane BERENI, Docteur Irène CHEVALLIER, Docteur Pierre
CHIARELLO, Docteur François JEANBLANC, Docteur Jean-Jacques JOURDAIN, Docteur
Djamila MAKHLOUFI, Docteur Jean-François PLASKOWSKI, Docteur Geneviève RETONAZ,
Docteur Xavier-Jacques WEBER.
Paris Nord : Docteur Jean-Pierre AUBERT, Docteur Ghislaine AUDRAN, Docteur Jean-Claude
BOUIX, Docteur Jean-Claude BOUROVITCH, Docteur Catherine CHAUMIE, Docteur Luc DE
MASSE, Docteur Sylvie LARIVEN, Docteur Caroline LASCOUX-COMBE, Docteur Maïté
LAVIELLE, Docteur Nadine LAZIMI, Docteur Diane PONSCARME, Docteur Olivier TAULERA
Réseau 93 Centre : Docteur François BAUDOUX, Docteur Michelle BENTATA, Docteur Marie-
Odile BERTRAND, Docteur Brigitte BRY, Mrs Véronique FAVRET, Mrs Patrica HONORE,
Docteur Elizabeth JACQ, Docteur Caroline PAVLOWSKY, Docteur Soline RIANDEY, Docteur
Milivoj SABO, Docteur Marie-Eve VINCENS.
Réseau 93 Ouest : Docteur Marie ALLAIN, Docteur Anne CLARISSOU, Docteur Thibault
HEIMBURGER, Docteur Denis MECHALI,                Docteur Chantal PRAT, Docteur Annie
Réseau RMHV : Docteur Joseph BENSIMHON, Docteur Bernard CARDON, Docteur Mady
DENANTES, Docteur Marie GOUJON, Docteur Gérard ISRAEL, Docteur Anne LAPENNE,
Docteur Régis MISSONNIER, Docteur Gilles PIALOUX, Docteur Anne RETHACKER,
Professeur Willy ROZENBAUM, Docteur Jean-Paul VINCENSINI.
Réseau Ville Hôpital Pluriel : Docteur Evelyne BOURSE, Docteur Pierre CHEVOJON, Docteur
Annette DELABAR, Docteur Jean-Jacques JALLADEAU, Docteur Philippe LEFEVRE, Docteur
Christian MONGIN, Docteur Anne-Carole de SINGLY
REZOPAU : Docteur Philippe ANTIPHON, Docteur Gérard ATTIA, Docteur Michel
BEAUMONT, Docteur Thierry DUTOYA, Docteur Georges LANUSSE-CAZALE, Docteur
Christophe LOUET, Docteur Laurent MAGOT.
RVH Avignon : Dr O BOULAT, Docteur Michel CADART, Docteur Joël PEYRE, Docteur Gilles
PICHANCOURT, Docteur Philippe REGARD, Dr AM TOUCHAIS, Docteur Martine TOULET,
Docteur Jean-Luc VIDAL, Docteur Alain WAJSBROT.
Solidarité CRETEIL : Docteur Jonas BESSAN, Docteur Bernard ELGHOZI, Docteur Brigitte
ELHARRAR, Docteur Valérie GARRAIT, Docteur Oliver HOUIS, Docteur Patrick INGRAIN,
Docteur Jean-Louis LEMOINE, Docteur André TARDIEU.

This study has been supported by Roche France.

Dépistage de l’hépatite C, populations à dépister et modalités du dépistage. Recommandations du
comité d’experts de l’ANAES. ANAES janvier 2001. http://www.anaes.fr

                                          Poster EACS                                  7

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