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Latinos & HCV: unequal opportunity for treatment
  from Jules: HCV is characterized by the variety of unique patient populations which dictates response to therapy, access to care and the countless ethnic health disparities including knowledge about the disease. HCV and HCV/HIV coinfection disproportionately affects African-Americans & Latinos, but also injection drug users (IDUs) and in HIV at least 90% of HCV/HIV coinfected were infected through IDU. These marginalized patient populations have less access to good care, or any care at all, have more difficulty gaining access to care, navigating the care system, having a good relationship with a clinician and therefore are less likely to receive treatment & respond less well to treatment, not to mention the language & economic barriers latinos face in receiving healthcare. Poor people are historically more disenfranchised from the healthcare system, they & IDUs historically never received family education to get healthcare as most of us did & therefore may show up at emergency rooms when they have symptoms & good care may be too late at that time. These patient populations are a serious barrier as the new orally administered HCV drugs start coming to the pharmacy. In 2011 the first 2 orally administered HCV protease inhibitors are expected to be in the pharmacy and in 3-drug combination therapy will raise HCV treatment cure rates by 50% and much higher in early responders; recent studies of these 2 new drugs in combination with peginterferon/ribavirin showed whites & blacks achieved 90% cure rates if they had good early responses (after 1-2 months of therapy). Overcoming the social & cultural barriers to provide good access to care for these difficult to treat marginalized patients will be a big challenge that should be met by city, state & federal governments, but so far there is little indication governments will meet this challenge. For years federal funding for HCV has been absent despite extensive lobbying & education to Congress & federal agencies, and federal authorities have not said they are willing to commit dollars to this need. But we are know entering a new era where HCV can be cured and cure rates will approach 90% as the new drugs become available, but only for patients who can access good care. Following the 2 new HCV protease inhibitors next year there are 20 additional orally administered HCV drugs in earlier development & many of them will also become available over the coming 5 years with the expectation that combinations of 2, 3, and 4 of these drugs will cure 90% of patients whether they are white, black or latino. A major sea-change is that up until now therapy was only one, peginterferon+ribavirin, and blacks & latinos had significantly lower response rates to these therapies, BUT blacks & latinos appear to respond equally well to the new orally administered antiviral drugs' peg/rbv is more of an immune-based therapy and pegIFN is delivered by a subcutaneous injection, delivering therapy by pills will also make therapy more convenient & tolerable & successful. Public authorities must begin to address the ethnic barriers to care in order to provide equal opportunity to cure HCV, this can only be done by committing dollars. HCV is curable, unlike other viral diseases and thus the development of all these new oral drugs allowing in theory the possibility to cure most HCV-infected patients is perhaps THE major medical milestone of the last 100 years, BUT not unless we provide this opportunity to the masses of ethnically & culturally marginalized patients who are disproportionately affected.
"Latinos were more likely to be treatment candidates, but less likely to actually initiate treatment......Latinos discontinued treatment prematurely more often.....Multivariate analysis found Latino race and history of recent alcohol use to be associated with early treatment discontinuation..... .....The severity of the liver disease and the association to metabolic syndrome medical conditions justify that Latinos be considered a special population with urgent need of intervention strategies.....new cases in African Americans and Latinos are increasing.....HCV infection as a severe public health concern in Latinos....evidence suggests that Latinos have decreased efficacy to treatment with Peg IFN and RBV........Latinos are the largest minority in the USA and have high rates of HCV infection as well as other viral infections It is projected that by the year 2040 there will be 87.5 million Hispanic individuals, comprising 22.3% of the population"
Latinos and Chronic Hepatitis C: A Singular Population
Culturally structured educational programs to achieve earlier diagnosis and treatment in Latinos with HCV infection are badly needed. ... www.natap.org/2008/HCV/051908_05.htm
Chronic Hepatitis C in Latinos: Natural History, Treatment ...
Moreover, Latinos with HIV infection were more likely to be coinfected with HCV (19.3% in Latinos vs 10.9% in whites) (18). In our study, Latinos with ... www.natap.org/2005/HCV/092905_03.htm
Latinos are the largest minority in the USA and have higher rates of HCV infection. The course of chronic hepatitis C in Latinos is more aggressive, with higher risk to develop cirrhosis than any other ethnic group or race. Available information suggests that more rapid progression of liver disease is aggravated by decreased efficacy to treatment with available therapies. The causes for more aggressive progression and decreased efficacy of treatment are complex. Factors related to metabolic syndrome, insulin resistance, and hepatic steatosis are important, as well as genetic differences, not only for metabolic syndrome but for immune responses to interferon. In addition, there are substantial barriers for Latinos to access medical care. Language, cultural differences, and socioeconomic factors, including lack of medical insurance, more frequent use of alcohol, and possible medical care provider bias, are significant obstacles to diagnosis and treatment. The severity of the liver disease and the association to metabolic syndrome medical conditions justify that Latinos be considered a special population with urgent need of intervention strategies. In this article we present all the available evidence on epidemiology, natural history of chronic hepatitis C, and efficacy of anti-HCV therapy in Latinos infected with HCV.
information from the literature review suggests that Hispanics/Latinos have an overall prevalence rate for chronic hepatitis C of 2.6%, have faster liver fibrosis progression rates, are infected at an earlier age, are more likely to be HIV-co-infected, and show significantly higher alanine transaminase (ALT), aspartate transaminase (AST ), and bilirubin levels. They also have more portal inflammation than do Caucasians and African-Americans and a higher prevalence of cirrhosis than do African-Americans—more so in Hispanic women than in Hispanic men. Transfusion, tattoos, and iatrogenic transfer are risk factors that need to be assessed.
Chronic Hepatitis C in Latinos
The natural history of chronic hepatitis C and treatment response are different between blacks and Caucasians, but little comparable data is available about Latinos.
A cross-sectional secondary analysis to investigate differences between 421 anti-HCV-positive, treatment-naēve, HCV-viremic Latinos and 2,510 Caucasians in 24 VA medical centers enrolled in a prospective study.
Latinos were infected at a younger age and were less likely to have blood contact during combat, surgery, and needle stick injury, but were more frequently HIV coinfected (20.4%vs 3.9%, p< 0.0001) and prior HAV infection (39.9%vs 26.4%, p= 0.0001).
Latinos were more likely to be treatment candidates, but less likely to actually initiate treatment. Liver histology (123 Latinos, 743 Caucasians) showed no difference in fibrosis or fibrosis rate, but steatosis (54.7% vs 43.2%, p= 0.038) was more common in Latinos.
Eighty-eight Latinos and 481 Caucasians were subsequently treated with interferon-ribavirin: body mass index (BMI), duration of infection, baseline tests, liver histology and genotype distribution were similar.
Compared with Caucasians, Latinos discontinued treatment prematurely more often (39.8%vs 28.9%, p= 0.043) and tended to have lower sustained virological response (SVR) rates (14.8%vs 22.5%, p= 0.10).
Multivariate analysis found Latino race and history of recent alcohol use to be associated with early treatment discontinuation, whereas genotype and viral load but not ethnicity to be associated with SVR.
In conclusion, the authors write, "Latinos were infected younger, more frequently HIV coinfected, more likely to meet criteria for antiviral therapy yet less likely to initiate treatment and had a trend toward lower SVR rates than Caucasians, but not in severity of liver disease."
"Latino ethnicity was associated with early discontinuation but not as an independent predictor of SVR."
R C Cheung and others (for the VA HCV-001 Study Group). The American Journal of Gastroenterology 100(10): 2186- 2194. October 2005.
U.S. Organ Transplant Program Caters To Hispanics
Published November 28, 2010
| Fox News Latino
He's a a latino doctor and you can almost hear the pride in his voice when he reads the statistic. Dr. Juan Carlos Caicedo says that kidney transplants for Hispanics have almost doubled at his Chicago hospital, and some of the patients come from as far away as Puerto Rico, Texas and Florida.
The reason? They are all interested in the only known transplant program in the United States conducted entirely in Spanish and tailored to the unique needs of Hispanic patients.
The clinic offers care in a "culturally-sensitive manner" to the largest minority population in the United States, proponents of the program say.
"I realized there was a big Hispanic community that was not receiving the attention it needed," said Caicedo, a transplant surgeon and director of the program at Northwestern Memorial Hospital. "Something that really surprised me was hearing a patient say that he had called 10 different transplant centers, but because they all answered the phone in English, he would hang up. He was scared."
The program began in December of 2006 and since then the number of kidney transplants in Hispanic patients at the hospital has grown from 22 in 2005 to 41 so far this year. The clinic is now expanding to include liver operations.
Such specialization showcases the need to attend to a growing ethnic minority with a high incidence of obesity, Hepatitis B and Hepatitis C, all of which can lead to organ transplantation, Caicedo said.
There are more than 90,000 people on the waiting list to get a kidney in the country. Of those, nearly 16,000 are Hispanic, said Ellie Schlam, director of external communications for the National Kidney Foundation.
About 11 percent -- or five million -- of the 47 million Hispanics in the country have diabetes, added Schlam. "And about one-third of the cases of diabetes in Hispanic Americans are undiagnosed," she said.
Anybody with kidney or liver problems who arrives at Northwestern Memorial and prefers to be attended in Spanish is directed to the program. Seventy-five percent of Hispanic patients prefer to be attended in Spanish, said Caicedo, who was born in Bogotá, Colombia.
A patient will not move up on a transplant waiting-list by entering the program: it merely offers specialized attention to Hispanic families, in which "sometimes the grandmother is the one who will give the blessing to go ahead with an operation," said Caicedo.
The clinic has 24 staff members -- nurses, nephrologists, cardiologists, social workers and accountants, among others -- who speak Spanish. It also offers educational sessions in Spanish "where entire families can be present to learn about the disease and treatment options," the hospital said in a statement in August, when it announced its expansion to include liver transplants.
Hispanics rank second on the wait list for liver transplants, according to the United Network for Organ Sharing (UNOS).
So far, about 170 patients have been attended by the Hispanic Transplant Program, not all of them requiring the operation, said Caicedo.
Amparo Cossio, a 68-year-old Mexican immigrant, was told she needed a kidney transplant. Her son chose the hospital because Cossio, who suffered diabetes and kidney failure, understood Spanish better than English. After being on the wait list for a month, doctors told Cossio that her niece María Antonieta could donate her kidney to her.
"I knew about doctors who worked on this program and who spoke Spanish," said the retiree, who was born in San Luis de Potosí and worked for years as a clerk in shopping stores in Chicago. "I felt good. They would tell us in Spanish how everything worked, and there I learned about my relatives having to do tests to see if we were compatible."
The operation occurred in August 2009. Cossio said she is fine, but still recovering.
Estanislao Garcia, 63, was diagnosed with cancer and liver cirrhosis. After nearly two years on the wait list, the Mexican immigrant and father of five received a liver at the hospital from a dead donor a few months ago.
His wife Adelita, 53, said they met four Spanish-speaking doctors, including Caicedo. "That was a relief for me. It helped us," she said.
A transplant costs tens of thousands of dollars. Patients who join the program normally have medical insurance to cover costs of the treatment and the transplant.
But the situation can be very different for some low-income immigrants.
Low income Hispanic immigrants, especially if undocumented, might not have the means to cover medical expenses, which means they are not able to access the waiting list to get a new kidney or liver.
In the midst of a debate over immigration reform and recently approved health care reform, some experts wonder if it would be worth paying for transplants for undocumented immigrants, instead of keeping them on expensive dialysis treatments covered by taxpayer money.
"It would be cheaper. In two years the operation would be covered, and the government would save more than with dialysis," said Raiza Mendoza, coordinator of Hispanic outreach for the non-profit Gift of Hope, Organ and Tissue Donor Network, in Illinois.
Mendoza said Hispanics historically do not donate organs at high rates, so she tries to "inspire" them to become donors.
"It was very intelligent to offer a transplant program in Spanish. Hispanics are shy when it comes to confronting a language they don't know about," she said. "This has been incredibly positive."
Based on reporting by the Associated Press
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