Veterans Co-Infected with HCV and HIV Use Healthcare System at a Higher Rate

A team of researchers at the University of California has found that veterans infected with both hepatitis C and human immunodeficiency virus sought treatment more often than those infected with just one of the viruses.

The study, conducted by researchers at the University of California, San Francisco; University of California; San Diego; Duke Medical Center; Duke Clinical Research Institute; and Durham Veterans Affairs Medical Center, used data from the Clinical Case Registry, a nationwide database of HCV- and HIV-infected veterans that tracks lab results, medical procedures, prescriptions, and diagnosis codes.

The study found that visits to emergency departments and outpatient facilities increased among all three groups (those with HCV, those with HIV, and those with both HCV and HIV), while the rate of admission to hospitals remained steady. However, veterans who had both HCV and HIV made more visits to healthcare facilities than veterans who had just one of the diseases. Patients with both diseases are known to have an increased risk of other conditions, including diabetes and kidney disease. Liver disease, of course, is a common result of HCV infection, and co-infected patients have a higher risk of severe liver problems than those who have HCV only.

Interestingly, although HCV is a primary cause of liver disease, with HIV often exacerbating it, a full 39% of hospital admissions for co-infected veterans were not due to liver problems but to mental health and/or substance issues. Another 16% of admissions were attributed to infections unrelated to AIDS, 9% were due to cardiovascular disease, and 7.5% could be blamed on gastrointestinal problems unrelated to the liver. Less than 4% of admissions were due to HCV-associated diagnoses such as liver disease.

Why are so many co-infected veterans found to suffer from psychiatric problems and substance abuse? “[This is] likely related to the fact that patients with psychiatric disease are more likely to exhibit high-risk behaviors, including using drugs and having multiple sexual partners, which increases their risk of exposure to HIV and/or HCV,” says study author Susanna Naggie, MD, an infectious disease specialist and assistant professor of medicine at Duke University Medical Center.

Data on outpatient visits and inpatient admissions among people infected with either HIV, HCV, or both has been notoriously inconsistent, with conclusions difficult to draw. For instance, the number of outpatient visits made by co-infected veterans in this study stands in contrast to the findings of a previous five-year study conducted at the University of North Carolina. In that study, patients with HIV made more outpatient appointments than patients co-infected with HIV and HCV, who in turn made more outpatient appointments than those infected only with HCV. That study, however, looked at data from a broad sample of ambulatory care centers and did not include information specifically on veterans. It’s possible, according to the authors of the more recent 11-year study, that HIV-positive patients in the VA system have access to a higher level of comprehensive care for their disease compared with HIV-infected people in the general population.

In any case, the clear increase in outpatient and emergency-room visits over the timeline of the study—particularly in the co-infected group—along with a steady rate of inpatient admissions in all three cohorts, means more resources certainly will be needed in the VA system. Dr. Naggie refers to a “high burden of psychiatric disease in the VA, and in particular in this population.” She adds that it’s critical for the VA to continue to prioritize the mental health issues and substance abuse issues that drive many of these patients to seek help.

Laurie Saloman, MS, is a health writer with more than 20 years of experience working for both consumer and physician-focused publications. She is a graduate of Brandeis University and the Medill School of Journalism at Northwestern University. She lives in New Jersey with her family.