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Veterans and Hepatitis C


By: VA Research Currents

The hepatitis C virus (HCV) is the leading cause of liver disease in the United States and is a common cause of cirrhosis and hepatocellular carcinoma (cancer of the liver). HCV also is the primary reason for liver transplants in the United States.

At least 4 million people in this country are infected with HCV, and approximately 3 million Americans are chronically infected. Chronic hepatitis C infection is a major healthcare burden for American veterans, and HCV is more prevalent among veterans than the general population.

Risk

HCV is transmitted through blood or body fluids from an infected person, therefore, people infected with HCV should not donate blood, organs, tissues, or semen.

Not everyone with HCV exhibits symptoms. In fact 80% of those who are infected have no signs or symptoms. So, who should be tested? People at risk for HCV infection should discuss testing with their doctor, and those at high risk include:

  • Injection drug users
  • Recipients of blood clotting factors made before 1987.

Those at intermediate risk include:

  • Hemodialysis (kidney) patients,
  • Recipients of blood and/or solid organs before 1992,
  • Persons with undiagnosed liver problems
  • Infants born to infected mothers.

Currently, most infections are due to illegal injection drug use. The hepatitis C virus is not spread by sneezing, coughing, hugging, food or water, sharing eating utensils or drinking glasses, or casual contact.

Signs and Symptoms

After initial exposure, the virus can be detected in blood within 1 to 3 weeks and is present at the onset of symptoms. The signs and symptoms of HCV can include:

  • Jaundice
  • Fatigue,
  • Dark urine,
  • Abdominal pain,
  • Loss of appetite
  • Nausea

Treatment

People who test positive for HCV should be evaluated by their health care provider for liver disease. Interferon and ribavirin are two drugs that are used to treat chronic hepatitis C. Interferon can be taken alone or in combination with ribavirin. Combination therapy is the current treatment of choice and has a high success rate. Interferon and combination therapy can result in serious side effects (e.g., thyroid disease, depression, kidney failure, etc.) that should be reviewed by patients and their doctors.

Research

The Veterans Healthcare Administration (VHA) is committed to improving the care of veterans infected with HCV. Recently, four VA Hepatitis C Resource Centers, located in Minneapolis, San Francisco, Seattle/Portland, and West Haven, were established as part of VA’s National Hepatitis C Program. These centers will develop best practices in clinical care delivery, patient education, provider education, prevention, and program evaluation. As part of this VA-wide effort, HSR&D and its investigators have several ongoing studies that focus on hepatitis C.

Patients with Hepatitis C Report Poor Communication with their Physicians

More than 40% of patients who have hepatitis C virus (HCV) report communications problems with their physicians. To determine the prevalence and nature of healthcare-related communication problems, researchers conducted a study of 322 patients with HCV receiving treatment in a large mid-western teaching hospital. After completing extensive interviews and surveys with patients, investigators analyzed the relationship between communication problems and possible predictors. Overall, they found that 23% of the patients questioned their physician’s competence, in contrast to generally high rates of satisfaction with medical care, and 42% reported communication problems. Of those who reported communication problems, 69% identified the main issue as being poor communication skills on the part of their physicians. Patients felt rushed, ignored, misunderstood, and reported being treated unkindly. Also of those who reported communication problems, 56% felt their physicians were unable to diagnose or treat their disease, and 22% felt stigmatized by the physician – as sexually promiscuous, or as a drug abuser. Socioeconomic characteristics, current substance or alcohol abuse, and psychiatric diagnoses were not predictors of physician/patient conflict. However, emotional problems and low social support were more common among those reporting conflict. Researchers suggest that educational materials should be developed concerning not just the medical, but also the social and communication needs of these patients.

Comorbid Medical Disease Common Among Veterans with HCV

HSR&D investigators evaluated 4,462 veterans who were HCV positive in order to evaluate the epidemiology of hepatitis C virus infection among veterans and to determine the proportion of patients that may be better candidates for interferon and ribavirin therapy. Patients who participated were enrolled at 21 VA medical centers: 97% were male, 29% were African American, 77% Vietnam-era veterans, and 39% had an annual income of $10,000 or less. Results of this study show that risk factors for HCV included cocaine use (68%), injection drug use (60%), and more than 20 lifetime sexual partners (38%). Findings also indicate that ongoing substance abuse, active psychiatric disease, and comorbid medical diseases are common among veterans with HCV, and that these factors are predictors of not being a suitable candidate for interferon-based treatment. Moreover, of the patients who were considered a treatment candidate, only 54% agreed to receive treatment. Researchers suggest that a multidisciplinary collaboration is needed to overcome barriers to care and to improve treatment candidacy.

Determining Patient Preferences for the Treatment of Hepatitis C

Because treatment for HCV is not universally effective and may be associated with serious risks of toxicity, effective communication of treatment "trade-offs" and an understanding of patient preferences are critical steps in determining a course of treatment. In this ongoing HSR&D study, researchers are developing practical tools and methods that can be applied to improve patient education about antiviral treatment for HCV, elicit patient treatment preferences (i.e., whether or not to accept antiviral treatment), and facilitate decision-making for individual patients. It is anticipated that the results of this project will help physicians better understand patient treatment preferences, and will improve patient education and the process of informed consent. 8

Additional Resources:

Centers for Disease Control and Prevention (CDC) online at http://www.cdc.gov/hepatitis or by phone at 1-888-4HEP-CDC.