Disparities in care demonstrated by liver disease rates

Washington -- Health disparities aren't disappearing. Blacks, Hispanics and American Indians are at least twice as likely to have diabetes as whites; blacks are twice as likely to have hepatitis C as whites but much less likely to be referred for a needed liver transplant; and minority populations overall continue to shoulder a disproportionate burden of death and disability from cardiovascular disease.

Since many members of minority groups also contract these diseases earlier than do whites, their lives are often shortened by 10 or more years from what should be expected. Life expectancy rates for black men in particular continue to lag well behind those for whites, according to the Centers for Disease Control and Prevention.

"Don't children deserve to know their grandparents?" asked B. Waine Kong, PhD, CEO of the Assn. of Black Cardiologists. Dr. Kong was speaking at the Third Annual Leadership Summit on Health Disparities held April 11-12 in Washington, D.C. The summit was sponsored by the AMA and the National Minority Health Month Foundation to focus on ways to close the health care gap.

"Raising awareness and implementing evidence-based solutions are important steps toward ending inequality in health care," said AMA President J. Edward Hill, MD. "Our nation's physicians must strive to ensure that all patients receive the highest quality of health care."

The AMA has joined with several other medical groups to encourage physicians to examine their own practices to ensure that they provide equal care to all patients.

For example, physicians may need to go the extra mile to diagnose hepatitis C, a disease that affects many more blacks and Hispanics than whites, said Richard Sterling, MD, associate professor of medicine at Virginia Commonwealth University School of Medicine in Richmond. "People don't come in saying, 'I have hepatitis C,' and some doctors don't go looking for it."

The disease is also 90% more likely to become chronic among blacks than among whites, according to the CDC.

Treatment response

In addition, research has shown that blacks respond less well to treatment for hepatitis C than do whites, perhaps because blacks are more likely to be infected with HCV genotype 1, which is more difficult to treat than are genotypes 2 and 3, noted Dr. Sterling. Ninety percent of blacks with hepatitis C have genotype 1 compared to 70% of whites.

A treatment course can last for as long as a year, thus raising the issue of access to care as well -- another important consideration in eliminating health disparities, said Dr. Sterling.

Blacks are also less able to clear the virus spontaneously, and once they have cirrhosis, they have a greater chance for developing liver cancer than do whites and are more likely to die from that disease, he said.

There is still a great deal to learn about the way members of different racial and ethnic groups respond to treatment but not enough data to draw solid conclusions, said several summit participants. There is a need to boost minority enrollment in clinical trials, said Gary Puckrein, PhD, executive director of the National Minority Health Month Foundation. "We won't get good evidence-based medicine until there is more minority enrollment in clinical trials."

In the case of hepatitis C, additional data on blacks should soon be available from the Viral Resistance to Antiviral Therapy of Chronic Hepatitis C trial, or VIRAHEP-C, a multicenter trial launched in 2003 by the National Institute of Diabetes and Digestive and Kidney Diseases to determine how well blacks respond to treatment compared to whites.

In a related matter, black patients are less likely to gain access to a lifesaving liver transplant. Despite the prevalence of liver diseases among minorities, the vast majority of the 17,000 people on the waiting list for liver transplants are white. Although survival rates among those who receive transplants are the same regardless of the individual's race or ethnicity, the number of minority patients referred for transplants is low, said Dr. Sterling.

Concern also centers on the high rate of co-infection with the hepatitis C virus and HIV, said Carroll Leevy, MD, assistant director of the Liver Center at the New Jersey Medical School in Newark.

HCV and HIV are the two most prevalent bloodborne infections in the United States and, of the approximately 1 million people estimated to have HIV, about 300,000 are also infected with HCV, and many are minorities, he added.

The diseases have changed direction over the past several years, he noted. In 1991, only 10% of people who died from AIDS also had end-stage-liver disease, predominately from hepatitis C infection. However, by 1998, half of the people who died with AIDS actually died from end-stage liver disease, said Dr. Leevy.

As more effective antiretroviral therapies became available, the average AIDS patient was living 15 years and more, but more were dying from hepatitis C.

"Our goal is to get patients' HIV viral loads as close to zero as possible and then give them interferon-based therapy in an attempt to eliminate the hepatitis C virus," he said.

With many more people living with AIDS, there is a need to beware of complacency, cautioned Robert Gallo, MD, founder and director of the Institute of Human Virology at the University of Maryland, and co-discoverer of HIV. There is still a need for basic research that allows science to keep pace with viral resistance and any toxicity that could result from decades of therapy with a combination of potent drugs. "So far, science is keeping up," he said.

There is also a need for an effective vaccine, said Dr. Gallo. His institute and Wyeth have recently teamed up to that end, and progress is being made. "We have some of the problems solved."