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VA Health Services Research
An Integrated Care Model for Improving HCV Patient Outcomes

Samuel B. Ho MD
VA San Diego Healthcare System, San Diego, CA
San Diego, CA
Funding Period: November 2008 - October 2013

The prevalence of hepatitis C virus (HCV) infection among VA patients is 3x higher than in the general population. Recent VA data indicate that only about 14% of all HCV-infected VA patients have ever received antiviral therapy

U.S. National Institutes of Health
VA Clinical trial HCV & Depression

Hepatitis C Translating Initiatives for Depression Into Effective Solutions (HEPTIDES)
This study is sponsored by Department of Veterans Affairs and currently recruiting participants.
Verified November 2012 Identifier:NCT01143896
First received: June 11, 2010 Last updated: November 1, 2012 Last verified: November 2012

However, ~70% of veterans with CHC are considered ineligible for antiviral treatment. Most of these patients are excluded due to the presence of co-existing depression and substance use. The proposed project will adapt and adopt an evidence-based collaborative depression care model in CHC clinics. Read more:

Why 88% of US Military Veterans with HCV are not Treated by the Veterans Administration

Dr. Ben Cecil, is a physician that specializes in hepatitis C virus (HCV Disease). He is employed by the Louisville, KY Veterans Affairs hospital.  Recently, he responded to a study published in the February Journal of Hepatology stating, "The Veterans Administration does not want to spend adequate funds to cure patients with hepatitis C. The high priority to treat Veterans has changed since Dr. Kenneth Kizer, Under Secretary for Health in the US Department of Veterans Affairs (VA), left the VA in 1999. The subsequent leadership has not shown enthusiasm for treating HCV".

The Houston VA study that Dr. Cecil responded to, "Gaps in the achievement of effectiveness of HCV treatment in national VA practice", identified 99,166 patients with HCV disease. Of those, 11.6% received PEG-INF with ribavirin and only 6.4% completed treatment. Overall, only 3.5% of the entire HCV cohort had a documented sustained viral response (SVR).

Dr. Cecil points out between 2000 and 2008, the annual number of all cause deaths recorded for Veterans with chronic HCV rose from 1259 (1129 per 100,000 in VHA care) to 5967 (4049 per 100,000 in VHA care), respectively.”  Less than 2% of Americans die from liver disease, but more than one third (36%) of veterans with HCV die prematurely from complications of cirrhosis.

In 2008, VHA clinicians cared for over 147,000 veterans with chronic HCV disease. Treating 4500 patients with HCV in 20 months is only 225 patients per month. The VA is currently treating less than 2% of infected veterans per year the new antiviral drugs, Boceprevir and Telaprevir.

Dr Cecil says the trend "not to treat", is expected to continue despite the more effective drugs now available. The Director of Pharmacy and the Chief of Staff at his local VA hospital told him that he spent too much money treating HCV. Boceprevir and Telaprevir, are both on the hospital formulary but Telaprevir prescriptions are routinely denied because it is more expensive. Patients must jump multiple hurdles before qualifying for antiviral therapy.

It will take the VA more than fifty years to treat all of the HCV patients. The allocated $100 million provided for antiviral therapy over 20 months is $5 million per month. The amount of money is clearly inadequate to treat 147,000 veterans with HCV Disease. Dr. Cecil insists this is why legislation should be passed so that all veterans with HCV immediately pre-qualify for their choice of Medicaid or Medicare. Veterans could then obtain antiviral therapy in the private sector instead of waiting for the VA to treat 2% of them each year. Now, many are trapped in the VA system while their curable disease progresses to liver cancer, liver failure and death.

Dr. David Ross with National Hepatitis C Program for Veterans Health Administration, in Washington, DC, responded to Dr. Cecil's remarks in the Journal. He discredits Dr. Cecil as being just another VA clinician who is clueless to actual findings. He closes by saying, "As a VA clinician who provides care for Veterans with HCV, I am proud of VA’s HCV Program, which is recognized as a national leader in the integrated care of patients with this disease [10]. Although there is always room for improvement in any therapeutic service in any health care system, VA has been striving to deliver high-quality, evidence -based care to as many Veterans with HCV as possible, and will continue to do so.

David Ross
National Hepatitis C Program,
Office of Public Health /Clinical Public Health,
Veterans Health Administration, Washington, DC, USA
George Washington University School of Medicine and Health Sciences, Washington, DC, USA
E-mail address:

HCVets are asked to contact representatives for an explanation how the VA can continue to blow it's own horn in the face of denied treatment for Veterans with HCV Disease, . Tell your representatives we need funding to treat  As Dr. Cecil says, it will take 50 years to treat everyone.

Send this message today! Help save the lives of Veterans with HCV Disease.

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Read the articles 88% of US military veterans with HCV are not treated

Journal of Hepatology Home

Gaps in the achievement of effectiveness of HCV treatment in national VA practice

Journal of Hepatology
Volume 56, Issue 2 , Pages 320-325, February 2012
Received 18 January 2011 ,Revised 2 May 2011 ,Accepted 20 May 2011

Background & Aims

Antiviral treatment for hepatitis C virus (HCV) has high efficacy rates for achieving sustained viral response (SVR) in randomized controlled trials (RCTs) (40–80%); however, it can be lower in community-based practice settings. We wanted to determine the effectiveness of HCV treatment in Veterans Administration (VA) hospitals nationwide.


Using the nationwide VA HCV Clinical Case Registry (CCR), we examined a cohort of veterans who had HCV viremia between 2000 and 2005 and identified patients who received pegylated-interferon (PEG-INF) and ribavirin. The duration of treatment and proportion of patients completing treatment was calculated. The effectiveness of treatment was measured as the proportion of patients who achieved SVR (negative viremia at least 12weeks after the end of treatment) in the entire cohort, and among patients who initiated and completed treatment.


We identified 99,166 patients with HCV viremia. Of those, 11.6% received PEG-INF with ribavirin and 6.4% completed treatment. Contraindications were present in 57.2% of the patients that did not receive treatment. SVR was documented in 39.9% and 58.3% of patients who completed treatment; 23.6% and 50.6% of patients who initiated treatment; and 3.9% and 11.2% of the entire HCV cohort for genotype 1 or 4 and 2 or 3, respectively. Overall, only 3.5% of the entire HCV viremic cohort had a documented SVR.


Treatment effectiveness for HCV is low. In addition to fixed factors, such as race and virus genotype, the drop in effectiveness is due to low rates of antiviral treatment initiation and treatment completion.

Dr. Cecil Remarks: "Gaps in the achievement of effectiveness of HCV treatment in national VA practice"


Download PDF  Dr. David Ross, the VA Director of the National Hepatitis C Program, reply to Dr. Cecil

Download PDF  Dr. Cecil's reply to Dr. Ross