treatment and should emphasize that the treatment is successful in only about 50% of cases and that the side effects can be severe. For genotype 1 patients, it may be preferable first to do a liver biopsy to determine the degree of liver involvement and scarring before making a decision about whether treatment should be considered sooner rather than later. The AASLD provides hepatitis C–specific treatment guidelines, including how to select appropriate candidates for treatment and guidance on which antiviral medications to use (Ghany et al., 2009). Patients who do not want immediate referral or treatment should be followed every 6 months with a full liver panel and yearly CBC tests. Finally, primary care providers should counsel patients to abstain from, or at least limit, alcohol consumption because heavy alcohol use is the greatest contributor to the rate of progressive liver fibrosis. Patients who have a history of heavy alcohol intake should receive counseling.

Studies have found racial and ethnic disparities in the evaluation of and treatment for HCV infection (Butt et al., 2007; Rousseau et al., 2008). One study of veterans reported similar rates of referral and liver biopsy for HCV-infected persons of various racial populations but found that blacks were less likely than whites to have complete laboratory evaluations, including viral genotyping, and to receive antiviral treatment (Rousseau et al., 2008). Because patient characteristics that are associated with not responding to treatment generally are associated with not receiving treatment, it is difficult to ascertain from available research findings the degree to which lower uptake into treatment represents discrimination against minority populations or appropriate implementation of treatment guidelines. For example, in another study of veterans, less treatment was received by minority-groups members and by persons who were older, who had a history of drug and alcohol use, or who had comorbid illnesses (Butt et al., 2007).

Chronic HCV infection has been found to be an important cause of liver-related death in Alaska Natives (Wise et al., 2008). The federal government is responsible by treaty laws to provide medical care at no cost to American Indians and Alaska Natives, but the amount spent per person is far less than that spent for Medicare and Medicaid recipients or for incarcerated persons, and is not enough to pay for treatment for HCV infection in many tribal health-care systems. There is evidence that not all patients who initiate therapy complete it. Over 80% of participants in clinical trials completed the HCV antiviral therapy. However, researchers found that in a large national cohort of veterans less than one-fourth of the patients who began treatment for chronic hepatitis C completed a 48-week course. The major predictors of treatment noncompletion were pretreatment anemia and depression (Butt et al., 2009). Treatment completion rates appear to vary among ethnic and racial populations. For example, a study found that Hispanic patients were more likely to be candidates for treatment but were

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