The development of direct-acting antivirals (DAAs) in the past decade has revolutionized hepatitis C treatment. However, there are significant inequities in access to this potentially lifesaving treatment, particularly for patients with alcohol use disorder, a new study suggests. \nDAAs are highly effective at treating hepatitis C infection regardless of a patient’s alcohol use. However, the new study across over 100,000 patients within the Veterans Health Administration revealed that patients with both hepatitis C infection and a diagnosed alcohol use disorder—whether they were currently drinking or not—had a lower chance of receiving DAA treatment. The team, led by Yale School of Medicine’s Lamia Haque, MD, MPH, assistant professor of medicine (digestive diseases) published their findings in JAMA Network Open on December 14.\n“Patients who have alcohol and other substance use disorders are often marginalized in the medical system and experience barriers to care, largely due to stigma,” says Haque. “DAA treatment is indicated almost universally for patients who have hepatitis C infection and it is important for us to ensure that all patients, including those with alcohol and other substance use disorders, receive these lifesaving treatments.”\nDirect-acting Antivirals Can Cure Hepatitis C\nHepatitis C is a virus that infects the liver and is transmitted through exposure to infected blood. In recent years, the most common cause of new hepatitis C infections has been injection drug use. Most cases are asymptomatic, but over time, the disease can cause injury and inflammation of the liver, leading to scarring, or cirrhosis, as well as liver cancer. Complications of cirrhosis can be life-threatening and require liver transplantation.\nPrevious treatments for hepatitis C often caused intolerable side effects and had much lower efficacy. The availability of DAAs beginning in 2013 offered patients a new therapy with mild, if any, side effects that eradicated infections in over 90 percent of cases. The treatment is associated with a myriad of benefits, including greater survival and lower rates of liver injury, liver cancer, and cirrhosis. Previous studies have shown that patients with any level of alcohol consumption also have high cure rates with DAAs, and there are no national guidelines that discourage DAA treatment for patients who drink alcohol.\n“Patients who drink alcohol or have alcohol use disorder in addition to hepatitis C infection are at a higher risk of having liver-related complications,” says Haque. “So it’s particularly troubling that this group of patients are also less likely to get treatment. It is also troubling that patients with other drug use disorders, psychiatric conditions, as well as minoritized patients, including those identifying as Black or Hispanic, are less likely to receive treatment.”\nPatients With Alcohol Use Disorder Face Lower Chance of Accessing Treatment\nTo assess the relationship between alcohol use and the receipt of DAA treatment, the team examined the electronic health data of the 133,753 patients who were positive for hepatitis C within the Veterans Health Administration between 2014 and 2017. They divided the cohort into five categories based on their alcohol use pattern: abstinent without a history of alcohol use disorder, abstinent with a history of alcohol use disorder, lower-risk drinking, at-risk drinking, and current alcohol use disorder. Then, they looked at whether individuals in these groups received DAA treatment within one year and three years since becoming eligible. \nThe team found patients who had an alcohol use disorder — whether abstinent or not — had a lower chance of receiving DAA treatment. Haque hypothesizes that among other factors, stigma, misconceptions, and non-evidence-based clinical practices may contribute to this discrepancy. “Because of the stigma associated with alcohol use disorder as well as assumptions regarding adherence, some clinicians have been reluctant to initiate DAAs for patients with alcohol or other substance use disorders,” she says. \nIt is important for us to ensure that all patients, including those with alcohol and other substance use disorders, receive these lifesaving treatments.Lamia Haque, MD, MPHFurthermore, in the private sector, payors often required patients to demonstrate abstinence before providing coverage for the medication. Although patients at the Veterans Health Administration, which committed very early on to providing DAA treatment for all veterans with hepatitis C infection and has overall been successful in implementing this care, do not face the same insurance barriers, the study shows that patients with alcohol use disorder as well as other subgroups were still less likely to receive this care.\n “Although it is important for clinicians to provide holistic care for patients with hepatitis C infection, including treatment of alcohol and other substance use disorders when indicated, requiring abstinence or engagement in addiction treatment prior to DAA initiation may lead to delays and unintended harm,” Haque says. “Attitudes and practices are slowly changing, however much more work will be needed to address clinician, patient, and system-level barriers.”\nHaque, a liver and addiction medicine doctor, has strong research interests in improving care for patients with addiction and liver disease. She hopes her work will pave the way for more effective models of care that can improve outcomes for patients with alcohol and other substance use disorders who also have liver diseases such as hepatitis C infection or alcohol-associated liver disease.\n“There’s a great need to be able to integrate care for patients with co-occurring addiction and liver diseases so that patients have access to both forms of lifesaving treatment,” she says. “Going forward, my plan is to use approaches informed by implementation science to help hepatology clinicians provide better care for patients with addiction and liver disease.” \nOther Yale faculty include David Fiellin, MD, Amy Justice, MD, PhD, Janet Tate, MPH, ScD, E. Jennifer Edelman, MD, MHS, Jeanette Tetrault, MD, Joseph Lim, MD, and Denise Esserman, PhD.