The Forgotten Component in the Staging and Management of HIV/Hepatitis C Virus–Coinfected Patients

T O THE E DITOR —I read with great interest the recent article by Dr Martel-Laferriere and collaborators [1]. The study empha- sized important messages for human immunodeﬁciency virus (HIV) and in- fectious diseases physicians who are increasingly treating hepatitis C virus (HCV) among HIV-infected patients [2]: promptly recognize cirrhosis, regularly screen for cirrhosis-related complica- tions, avoid potential medical interac- tions, educate your patients regarding toxins or habits that may contribute to further liver damage, and consider refer- ral of your HIV/HCV-coinfected patients for liver transplant evaluation when indicated. However, an essential part of manag- ing 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 engage- ment 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 CID 2014:59 (15 July) CORRESPONDENCE Notes Disclaimer. The funders had no role in letter design, data collection, preparation of the manu- script, 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 certi- ﬁes 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. Edward R. Cachay Department of Medicine, Owen Clinic, University of California, San Diego References 1. Martel-Laferriere V, Wong M, Dieterich DT. HIV/hepatitis C virus-coinfected patients and cirrhosis: how to diagnose it and what to do next? Clin Infect Dis 2014; 58:840–7. 2. Cachay ER, Hill L, Ballard C, et al. Increasing hepatitis C treatment uptake among HIV- infected patients using an HIV primary care model. AIDS Res Ther 2013; 10:9. 3. Grebely J, Oser M, Taylor LE, Dore GJ. Break- ing down the barriers to hepatitis C virus Downloaded from http://cid.oxfordjournals.org/ at University of California, San Diego on July 31, 2014 The Forgotten Component in the Staging and Management of HIV/Hepatitis C Virus– Coinfected Patients who attend an initial clinic visit for HCV treatment do not return for HCV care [7]. Furthermore, the main reason for not ini- tiating HCV therapy among those who completed HCV clinical staging is ongo- ing barriers to care [7]. Therefore, we teach medical students, residents, and in- fectious diseases fellows that complete staging and management of HCV in an HIV-infected patient requires 4 compo- nents: (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) ascertain- ment of ongoing barriers to care. I believe that the routine medical evalu- ation 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 forth- coming highly effective interferon-free era.