Why 88% of US military veterans with HCV are not treated
Authors: Bennet Cecil
Journal: Journal of Hepatology (2012)

Gaps in the achievement of effectiveness of HCV treatment in national VA practiceJournal of HepatologyVol. 56Issue 2PreviewAntiviral treatment for hepatitis C virus (HCV) has high efficacy rates for achieving sustained viral response (SVR) in randomized controlled trials (RCTs) (40–80%); however, it can be lower in community-based practice settings. We wanted to determine the effectiveness of HCV treatment in Veterans Administration (VA) hospitals nationwide. Full-Text PDF Reply to: "Treatment of veterans with hepatitis C in the United States Department of Veterans Affairs"Journal of HepatologyVol. 59Issue 1PreviewI would like to thank Dr. Ross. Full-Text PDF Open AccessTreatment of veterans with hepatitis C in the United States Department of Veterans AffairsJournal of HepatologyVol. 59Issue 1PreviewAs Director of the National Hepatitis C Program for the United States Department of Veterans Affairs [VA], the largest provider of care in the United States for HCV, I would like to respond to the statements by Dr. Bennett Cecil in the October 2012 issue of the Journal of Hepatology about access to and quality of care for HCV-infected Veterans in VA care [1]. Full-Text PDF Open Access The article in the February issue of the Journal of Hepatology reported that less than 12% of American military veterans identified with HCV were treated with antiviral therapy [[1]Kramer J.R. Kanwal F. Richardson P. Mei M. El-Serag H.B. Gaps in the achievement of effectiveness of HCV treatment in national VA practice.J Hepatol. 2012; 56: 320-325Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar]. The Veterans Administration does not want to spend adequate funds to cure patients with hepatitis C. Dr. Kenneth Kizer, Under Secretary for Health in the US Department of Veterans Affairs (VA), gave HCV a high priority but unfortunately he left the VA in 1999. Subsequent leadership has not shown enthusiasm for treating HCV.The Director of Pharmacy and the Chief of Staff at my local VA hospital told me that I spent too much money treating HCV. Boceprevir and telaprevir are both on the hospital formulary but telaprevir prescriptions are routinely denied because it is more expensive. Patients must jump multiple hurdles before qualifying for antiviral therapy. No one would refuse to give coronary artery stents or bypass grafts to a veteran who smokes but veterans who do not completely abstain from alcohol for three months are refused antiviral therapy. In spite of difficulties, 585 of 1372 (43%) HCV RNA positive patients received antiviral therapy between 1998 and 2010 at our local VA hospital; 226 of 583 treated (39%) achieved SVR [[2]Cecil B, Lavelle M. US Military Veterans with SVR have improved survival. In: Poster Presentation #431 AASLD San Francisco, CA, November 5, 2011.Google Scholar]. 36% of deaths were from HCC or liver failure. Veterans with sustained viral response had substantially improved survival. Effective antiviral therapy improves prognosis [3George S.L. Bacon B.R. Brunt E.M. Mihindukulasuriya K.L. Hoffmann J. Di Bisceglie A.M. Clinical, virologic, histologic, and biochemical outcomes after successful HCV therapy: a 5-year follow-up of 150 patients.Hepatology. 2009; 49: 729-738Crossref PubMed Scopus (310) Google Scholar, 4Backus L.I. Boothroyd D.B. Phillips B.R. Belperio P. Halloran J. Mole L.A. A sustained virologic response reduces risk of all-cause mortality in patients with hepatitis C.Clin Gastroenterol Hepatol. 2011; 9: 509-516Abstract Full Text Full Text PDF PubMed Scopus (389) Google Scholar]. Less than 2% of Americans die from liver disease, but more than one third of veterans with HCV die prematurely from complications of cirrhosis [2Cecil B, Lavelle M. US Military Veterans with SVR have improved survival. In: Poster Presentation #431 AASLD San Francisco, CA, November 5, 2011.Google Scholar, 5Xu J. Kochanek K.D. Murphy S.L. Tejada-Vera B. Deaths: final data for 2007.NVSR. 2010; 58: 1-88Google Scholar]. According to a 2010 national VA report, deaths in veterans with HCV have more than tripled, "Between 2000 and 2008, the annual number of all cause deaths recorded for Veterans with chronic HCV rose from 1259 (1129 per 100,000 in VHA care) to 5967 (4049 per 100,000 in VHA care), respectively" [[6]<http://www.hepatitis.va.gov/pdf/HCV-State-of-Care-2010.pdf>.Google Scholar].Legislation should be passed allowing veterans with HCV to prequalify for their choice of Medicaid or Medicare so that they can obtain antiviral therapy in the private sector. Since Dr. Kizer is no longer in charge of the VA, it is very clear that the VA is not going to treat very many of them.Conflict of interestSpeakers Bureau Vertex Pharmaceuticals. The article in the February issue of the Journal of Hepatology reported that less than 12% of American military veterans identified with HCV were treated with antiviral therapy [[1]Kramer J.R. Kanwal F. Richardson P. Mei M. El-Serag H.B. Gaps in the achievement of effectiveness of HCV treatment in national VA practice.J Hepatol. 2012; 56: 320-325Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar]. The Veterans Administration does not want to spend adequate funds to cure patients with hepatitis C. Dr. Kenneth Kizer, Under Secretary for Health in the US Department of Veterans Affairs (VA), gave HCV a high priority but unfortunately he left the VA in 1999. Subsequent leadership has not shown enthusiasm for treating HCV. The Director of Pharmacy and the Chief of Staff at my local VA hospital told me that I spent too much money treating HCV. Boceprevir and telaprevir are both on the hospital formulary but telaprevir prescriptions are routinely denied because it is more expensive. Patients must jump multiple hurdles before qualifying for antiviral therapy. No one would refuse to give coronary artery stents or bypass grafts to a veteran who smokes but veterans who do not completely abstain from alcohol for three months are refused antiviral therapy. In spite of difficulties, 585 of 1372 (43%) HCV RNA positive patients received antiviral therapy between 1998 and 2010 at our local VA hospital; 226 of 583 treated (39%) achieved SVR [[2]Cecil B, Lavelle M. US Military Veterans with SVR have improved survival. In: Poster Presentation #431 AASLD San Francisco, CA, November 5, 2011.Google Scholar]. 36% of deaths were from HCC or liver failure. Veterans with sustained viral response had substantially improved survival. Effective antiviral therapy improves prognosis [3George S.L. Bacon B.R. Brunt E.M. Mihindukulasuriya K.L. Hoffmann J. Di Bisceglie A.M. Clinical, virologic, histologic, and biochemical outcomes after successful HCV therapy: a 5-year follow-up of 150 patients.Hepatology. 2009; 49: 729-738Crossref PubMed Scopus (310) Google Scholar, 4Backus L.I. Boothroyd D.B. Phillips B.R. Belperio P. Halloran J. Mole L.A. A sustained virologic response reduces risk of all-cause mortality in patients with hepatitis C.Clin Gastroenterol Hepatol. 2011; 9: 509-516Abstract Full Text Full Text PDF PubMed Scopus (389) Google Scholar]. Less than 2% of Americans die from liver disease, but more than one third of veterans with HCV die prematurely from complications of cirrhosis [2Cecil B, Lavelle M. US Military Veterans with SVR have improved survival. In: Poster Presentation #431 AASLD San Francisco, CA, November 5, 2011.Google Scholar, 5Xu J. Kochanek K.D. Murphy S.L. Tejada-Vera B. Deaths: final data for 2007.NVSR. 2010; 58: 1-88Google Scholar]. According to a 2010 national VA report, deaths in veterans with HCV have more than tripled, "Between 2000 and 2008, the annual number of all cause deaths recorded for Veterans with chronic HCV rose from 1259 (1129 per 100,000 in VHA care) to 5967 (4049 per 100,000 in VHA care), respectively" [[6]<http://www.hepatitis.va.gov/pdf/HCV-State-of-Care-2010.pdf>.Google Scholar]. Legislation should be passed allowing veterans with HCV to prequalify for their choice of Medicaid or Medicare so that they can obtain antiviral therapy in the private sector. Since Dr. Kizer is no longer in charge of the VA, it is very clear that the VA is not going to treat very many of them. Conflict of interestSpeakers Bureau Vertex Pharmaceuticals. Speakers Bureau Vertex Pharmaceuticals.