Diagnosed, Staged and Untreated: Hepatitis C Fibrosis Severity by Transient Elastography (TE) in an Inner City Clinic

Background: TE by Fibroscan® is a validated non -invasive method of fibrosis assessment in pts with chronic HCV. TE is increasingly used by insurance companies to prioritize patients for HCV treatment based on fibrosis severity. We report on our clinical experience in the first year (March 2014-March 2015) of assessing fibrosis by fibroscan among HCV patients (pts) with or without HIV co-infection. Methods: Fibroscans were performed by trained operators on all chronic HCV+ patients referred to the CORE Center hepatitis clinic for fibrosis staging. Scans with at least 10 valid measurements and IQR <30% were considered valid. Fibrosis (F) stage based on TE scores classified as: F4 (Cirrhosis) >12.5 kPa; F3; 9.512.4kPa, F2; 7.1-9.4 KPa and F0-F1: <7.1kPa. In Illinois Medicaid coverage for HCV medications is restricted to pts with cirrhosis. For most Medicare pts coverage is provided at >F1 and privately insured pts are covered at any fibrosis stage. Results: Among 590 HCV+ pts with TE scans, median (IQR) age was 57 (51-61) years, 67% were male. 64% were black, 16% white and 15% Hispanic. 259 (44%) were co-infected with HIV. HIV+ pts were more likely to be male 75% vs 59% (p<0.001) and less likely to be white 13% vs 19% (p=0.002). The median TE score was 8.1 kPa; fibrosis stage 2 and did not differ significantly by HIV status 7.9 in HIV+ vs 8.7 HIV(p=0.1). 240 (41%) were stage F0-F1, 19% F2, 12% F3 and 168 (28%) stage 4/cirrhosis. Insurance coverage was as follows; Medicaid/managed care 63%, Medicare 17%, uninsured 14% and private insurance 6%. Medicare patients were older and uninsured patients were more likely to be Hispanic (p<0.001). Based on fibrosis stage, 100% of privately insured pts, 62%-100% of Medicare patients, 51% of uninsured pts (if medication assistance initiated at >F2) were eligible for HCV medication coverage vs. only 28% of Medicaid patients. Conclusions: In our inner city clinic which serves predominantly non-white patients, 40% of pts referred for HCV care had severe fibrosis (F3/F4); 28% had cirrhosis. Access to HCV medications remains a significant barrier to treatment with only 28% of patients on Medicaid eligible for HCV medications. Gaps in the HCV diagnosis-to-cure cascade and disparities in long term HCVrelated outcomes will persist unless access to HCV treatment is universal. BACKGROUND