Hepatitis C Infection & Alcohol Use Disorder: Identifying Barriers to Treatment in a Vulnerable Population

Introduction: Alcohol use disorder (AUD) is common among individuals with hepatitis C virus (HCV) infection. Although alcohol use should not preclude HCV treatment, lower treatment rates have been reported for individuals with AUD. The reasons for this remain unclear. This study aimed to evaluate the HCV care cascade and identify barriers to treatment in this population. Methods: Adults with a first positive HCV RNA between 1/1/2017-12/31/2022 were identified at our center. AUD was defined by International Classification of Diseases- 10th Edition (ICD-10) code or an alcohol-related complication in the year prior. Progression through the HCV care cascade was compared between individuals with and without AUD. Characteristics associated with linkage to care (specialty clinic visit or treatment) and treatment were evaluated. Medical records were reviewed to identify treatment barriers. Comparisons were performed using chi-square tests or Cochrane-Armitage tests for trend in ordered groups. Results: A total of 4,003 individuals with HCV were identified, and 746 (18.6%) had AUD. Individuals with AUD were significantly less likely to be linked to care or treated compared to those without AUD (Figure 1). They were similarly likely to be referred for treatment (49.3% vs 48.0%, P=0.54), though less likely to have an appointment scheduled (56.7% vs 66.8%, P< 0.001) or be seen by a specialist (36.3% vs 51.8%, P< 0.001). Characteristics associated with linkage to care and treatment among individuals with AUD included access to a PCP, commercial insurance, proximity to a center, lack of comorbid substance use, and diagnosis in the outpatient setting (Table 1). Common barriers to treatment included lack of referral (26%), lack of appointment (20%), cancelation or no-show (16%), and loss to follow-up (12%). Some were seen but not treated due to need for potential liver transplant (18%) or hepatocellular carcinoma (8%). Alcohol and substance use were cited as treatment barriers in 5% and 2.5% of cases, respectively. Conclusion: At our institution, individuals with AUD were less likely to be linked to care for HCV and receive treatment compared to individuals without AUD. Alcohol use precluded treatment in few cases, while primary barriers were instead challenges engaging with the healthcare system and severity of liver disease. Reducing the burden of HCV among individuals with AUD will require both systems-level interventions and patient-tailored strategies that facilitate transitions of care and access to timely treatment.Figure 1.: Linkage to Care and Treatment for HCV in Patients With and Without Alcohol Use Disorder. Table 1. - Characteristics Associated with Linkage to Care and Treatment After HCV Diagnosis in Patients with alcohol use disorder (AUD) Linkage to Care (n=464) No Linkage to Care (n=282) P-value Treatment (n=306) No Treatment (n=440) P-value PCP < 0.001 < 0.001 Yes 74.6 (390) 25.4 (133) 49.5 (259) 50.5 (264) No 33.2 (74) 66.8 (149) 21.1 (47) 78.9 (176) Insurance < 0.001 < 0.001 Commercial 77.5 (86) 22.5 (25) 56.8 (63) 43.2 (48) Medicare 71.6 (146) 28.4 (58) 48.5 (99) 51.5 (105) Medicaid 59.7 (138) 40.3 (93) 30.3 (70) 69.7 (161) Other 38.9 (7) 61.1 (11) 16.7 (3) 83.3 (15) Self-Pay 47.8 (87) 52.2 (95) 39.0 (71) 61.0 (111) Distance From Center 0.046 0.002 0-10 miles 66.7 (150) 33.3 (75) 48.4 (109) 51.6 (116) 10-25 miles 64.7 (112) 35.3 (61) 42.8 (74) 57.2 (99) 25-50 miles 59.2 (93) 40.8 (64) 36.9 (58) 63.1 (99) >50 miles 58.1 (104) 41.9 (75) 34.1 (61) 65.9 (118) Co-morbidities Opioid Use Disorder 44.6 (78) 55.4 (97) < 0.001 29.1 (51) 70.9 (124) < 0.001 Diagnosis Location < 0.001 < 0.001 Outpatient 80.3 (334) 19.7 (82) 56.0 (233) 44.0 (183) Inpatient 39.8 (126) 60.2 (191) 22.4 (71) 77.6 (246) Emergency Department 30.8 (4) 69.2 (9) 15.4 (2) 84.6 (11)