Treatment of hepatitis C infection in injection drug users

New hope for hepatitis C virus: Summary of global epidemiologic changes and novel innovations over 20 years

Hepatitis C virus (HCV) is a global health concern associated with significant morbidity and mortality. Before the approval of second-generation direct-acting antiviral agents (DAAs), interferon therapy and liver transplantation constituted the mainstay of treatment. The introduction of well-tolerated oral DAAs in late 2013 has revolutionized HCV management with over 95% cure rates. The predominance of HCV-related liver transplantations has declined following the widespread approval of DAAs. Despite the unparallel efficacy observed among these novel therapies, pharmaceutical costs continue to limit equitable access to healthcare and likely contribute to the differential HCV infection rates observed globally. To reduce the burden of disease worldwide, essential agenda items for all countries must include the prioritization of integrated care models and access to DAAs therapies. Through transparent negotiations with the pharmaceutical industry, the consideration for compassionate release of medications to promote equitable division of care is paramount. Here we provide a literature review of HCV, changes in epidemiologic trends, access issues for current therapies, and global inequities in disease burden.

Hepatitis C treatment uptake among patients who have received methadone substitution treatment in the Republic of Georgia

OBJECTIVES

There is a dearth of research on hepatitis C virus (HCV) treatment uptake among people who inject drugs (PWIDs) and receive methadone substitution treatment (MST) in Eastern Europe and Central Asia countries. This study contributed to addressing that gap. We examined and identified factors that may affect HCV treatment uptake among PWID who received MST in the Republic of Georgia.

STUDY DESIGN

The design of the study is retrospective cohort study.

METHODS

We conducted HCV care cascade analysis by matching the data from the web-based national hepatitis C program registry (ELIM C) and the MST treatment database between January 1, 2015, and December 31, 2018. Using the World Health Organization's (WHO) Consensus HCV cascade of care (CoC) global instrument, we assessed the progress made toward the country's 2020 and WHO's 2030 hepatitis C elimination targets for the subpopulation of MST patients.

RESULTS

Overall, 10,498 individuals have been dispensed methadone during the study period. A total of 6828 MST beneficiaries had HCV screening, of whom 5843 (85.6%) tested positive; 5476 (93.7%) were tested for HCV viremia, and 5275 (96.3%) were confirmed with chronic HCV infection. More than 75% (n = 4000) of HCV-infected MST patients initiated HCV treatment, and 3772 (94.3%) completed the treatment. Of those eligible for sustained virologic response assessment, 71.0% (2641/3715) were evaluated, and the reported cure rate was 96.1% (2537). The study found the odds of patients starting HCV treatment differed by the type of facility they were screened at and whether they were registered as PWID at the screening sites. The patients screened at centers with integrated HCV treatment services had higher treatment uptake rates than those screened at other centers.

CONCLUSIONS

As the cumulative HCV treatment uptake and cure rates among MST patients with HCV infection are high (75.8% and 96.1%, respectively), the MST patients might become the first microelimination target population in which hepatitis C elimination will be achieved in Georgia. The study found the type of screening facility and whether MST patients registered themselves as PWID or not had significant effects on MST patients starting HCV treatment. At the same time, the study did not find gender and age to be significant predictors of MST patients starting HCV treatment. MST patients used different types of health facilities to get screened for HIV. Many of them did not register themselves as PWID when screened for HIV. The existence of only a few harm reduction sites with integrated HCV treatment services, a high level of stigma, and the criminalization of drug use might have incentivized MST patients to self-navigate across the HCV care continuum with the rest of the population. The implementation of focused, harm reduction, integrated HCV treatment with good peer and professional adherence support at treatment sites could help reach the hepatitis C elimination goals among MST patients.

Reinfection in a large cohort of prison inmates with sustained virological response after treatment of chronic hepatitis C in Catalonia (Spain), 2002-2016

BACKGROUND

Prisoners and other high-risk patients who show a sustained virological response (SVR) after treatment for hepatitis C virus (HCV) can become reinfected. We aimed to calculate the rate of HCV reinfection in a large cohort of inmates with SVR and to determine factors that predict reinfection.

METHODS

We included all inmates treated for hepatitis C in Catalonia (Spain) from January 2002 to December 2016 who achieved SVR and in whom viral load was subsequently determined. The incidence rate was calculated per 100 person-years (100 py) of follow up. Risk factors associated with reinfection were evaluated by bivariate log-rank test and multivariate Cox regression. Hazard ratio (HR) and their 95% confidence intervals (CI) were calculated.

RESULTS

602 patients were included, with a mean age of 37.9 years: 95% were men, 74.1% had a history of intravenous drug use (IDU) and 28.7% were HIV-infected. Patients were followed for a total of 2154.9 years (average 3.58 ± 3.1 years). 63 (10.5%) had HCV reinfection. 41 (65.1%) presented different genotype/subgenotype, 8 the initial genotype/subgenotype, and in 14 (22.2%) the genotype could not be determined. Of the 21 reinfected patients who were interviewed, 20 (95.2%) reported IDU after antiviral treatment, and 7 (33.3%) during treatment. The overall incidence of reinfection was 2.9 cases per 100 py. All reinfections occurred in patients with IDU history. At multivariate level, HIV infection was associated with reinfection (HR = 3.03; CI:1.82-5.04).

CONCLUSION

In HIV-infected inmates with IDU history, the rate of reinfection of HCV post-SVR is very high. Prisons play a key role in the detection and treatment of infection and reinfection by HCV and in the post-treatment monitoring in these patients, which should be combined with counseling and the optimization of the harm reduction programs. Effective control of these vulnerable groups favours the elimination of the HCV infection.

Integrated models of care for people who inject drugs and live with hepatitis C virus: A systematic review

BACKGROUND

Despite the key role that people who inject drugs (PWID) play in the hepatitis C virus (HCV) epidemic, HCV treatment rates among this population have been historically low. Integrated models of HCV and substance use care have the potential to overcome some barriers to access; however, the evidence base is uncertain. This systematic review assesses the impacts of integrated HCV and substance use services on engagement in HCV care among PWID.

METHODS

We searched five databases up to December 2018 to identify original quantitative studies evaluating the impacts of co-location of HCV and substance use services on engagement in the HCV cascade of care among adult PWID. We conducted a narrative synthesis, categorizing models based on patient entry point (a: HCV facility, b: substance use disorder (SUD) facility, and c: other facilities), and levels of integrated services offered (a: HCV/substance use testing only, b: HCV/substance use treatment, and c: testing/treatment + other services).

RESULTS

A total of 46 articles corresponding to 44 original studies were included. Almost all studies (n = 42) were conducted in high-income countries and only six studies in the Direct-Acting Antiviral (DAA) era. Twenty-six studies discussed the integration of services at SUD facilities, one at HCV facilities, and seventeen at other facilities. Analysis of included studies indicated that overall integrated care resulted in improved engagement in HCV care (e.g., testing, treatment uptake and cure). However, the quality of evidence was predominantly low to moderate.

CONCLUSIONS

Available evidence suggests that integration of HCV and substance use services may improve engagement along the continuum of HCV care among PWID. Given limitations in data quality, and very few studies conducted in the DAA era and in low- and middle-income settings, further research is urgently needed to inform strategies to optimize HCV care access and outcomes among PWID globally.

Molecular diagnosis of occult hepatitis C virus infection in Iranian injection drug users

Occult HCV infection (OCI) has been described as the presence of hepatitis C virus (HCV) genomic RNA in hepatocytes and/or peripheral blood mononuclear cell (PBMC) specimens and the lack of HCV genomic RNA and anti-HCV antibodies (Abs) in plasma samples. Injection drug users (IDUs) are the most important high-risk group for infection with blood-borne viruses, particularly HCV. The purpose of this study was to determine the presence of OCI in IDUs. A prospective cross-sectional study of 126 consecutive Iranian IDUs was performed from March 2017 to January 2018. PBMCs were separated from blood samples from the participants, and after extraction of the viral RNA from the plasma and PBMC specimens, HCV RNA was detected in the samples using RT-nested PCR by amplification of the 5'-NTR of HCV. HCV genotyping was carried out using restriction a fragment length polymorphism (RFLP) assay. The viral RNA was amplified using RT-nested PCR with specific primers for the NS5B gene, and the PCR products were sequenced to confirm the results obtained by HCV RNA detection and HCV genotyping. Out of the 126 IDUs studied, 105 (83.3%) were negative for anti-HCV Abs and HCV RNA in plasma samples, whereas HCV RNA was detected in the PBMC samples of six (5.7%) participants, indicating that these individuals had OCI. Moreover, HCV genomic RNA was detected in PBMC samples from five (23.8%) of the 21 IDUs studied who were positive for anti-HCV Abs and negative for HCV genomic RNA in plasma specimens. These IDUs also had OCI. The HCV genotypes in the PBMC samples from the subjects with OCI were determined. Six (54.5%) subjects were infected with HCV subtype 3a, and five (45.5%) were infected with HCV subtype 1a. This study showed that 8.7% of the Iranian IDUs had OCI, and therefore, a study focusing on the diagnosis of OCI in these individuals can be valuable and informative.

Hepatitis C cascade of care among people who inject drugs in Vancouver, Canada

BACKGROUND

People who inject drugs (PWID) have high rates of hepatitis C virus (HCV) infection. Little is known about the rates of diagnosis and treatment for HCV among PWID. Therefore, this study aims to characterize the cascade of care in Vancouver, Canada, to improve HCV treatment access and delivery for PWID.

METHODS

Data were derived from 3 prospective cohort studies of PWID in Vancouver, Canada, between December 2005 and May 2015. The progression of participants was identified through 5 steps in the cascade of care: (1) chronic HCV; (2) linkage to HCV care; (3) liver disease assessment; (4) initiation of treatment; and (5) completion of treatment. Predictors of undergoing liver disease assessment for HCV treatment were identified using a multivariable extended Cox regression model.

RESULTS

Among 1571 participants with chronic HCV, 1359 (86.5%) had ever been linked to care, 1257 (80.0%) had undergone liver disease assessment, 163 (10.4%) had ever started HCV treatment, and 71 (4.5%) had ever completed treatment. In multivariable analyses, human immunodeficiency virus (HIV) seropositivity, use of methadone maintenance therapy, and hospitalization in the past 6 months were independently and positively associated with undergoing liver disease assessment (all P < .001), whereas daily heroin injection was independently and negatively associated with undergoing liver disease assessment (P < .001).

CONCLUSIONS

Among this cohort of PWID, few had been started on or completed treatment for HCV. These findings highlight the need to improve the prescribing of HCV treatment among PWID with active substance use.

Reasons to wait or to treat naive patients affected by chronic hepatitis C with low fibrosis stage and genotypes 2 or 3

Background

New interferon (IFN)-free therapies are not currently available for all patients with chronic hepatitis C due to higher costs; in Italy, patients with genotype 2 (GT2) or GT3 without severe fibrosis can choose between wait or treatment with pegylated (PEG)-IFN and ribavirin. This study wants to examine the real rate of patients that accept or refused this therapy and the reasons related to decision.

Methods

This prospective, observational analysis was performed at our centre between January 2014 and June 2015. Epidemiological, social and clinical data were collected in medical records; reasons for treatment acceptance/refusal were recorded through a questionnaire. Eligible patients were: naïve, with genotypes 2 or 3, fibrosis stage F0-F2.

Results

In total 132 patients were included: 34 with GT2, 98 with GT3. Patients with GT3 were younger, with prevalent sex male and mostly with active intravenous drug use. 53 patients accepted the treatment option (40.1%): 12 with GT2 (22%), 41 GT3 (41.8%) (P < 0.001). 79 patients refused (59.8%): 22 with GT2 (64.7%), 57 with GT3 (58.2) (P < 0.001). Fear of side-effects (OR = 1.774; 95% CI = 1.089-2.117; P = 0.016) and active alcoholism (OR = 1.144; 95% CI = 1.012-2.006; P = 0.025) were predictive factors for treatment refusal in GT3, whereas the presence of extrahepatic manifestations in GT2 (OR = 1.911; 95% CI = 1.124-2.912; P = 0.019) and the will to eradicate the infection in GT3 (OR = 2.140; 95% CI = 1.120-3.445; P = 0.008) were predictive of treatment acceptance.

Conclusions

Dual therapy is the only option for these subjects; however the motivation of patients and major socio-economic conditions were strictly related to decision of acceptance or refusal.

Integrated Models of Care for People Living with Hepatitis C Virus and a Substance Use Disorder: Protocol for a Systematic Review

Background

People living with a substance use disorder (SUD) are a key population within the hepatitis C virus (HCV) epidemic. While integrated and community-based models of care have shown positive outcomes among this population, the literature has been primarily focused on the HIV context. This paper outlines a systematic review protocol on the impact of various integrated models of care, which includes HCV and SUD services, on various treatment, and health-related outcomes among this population.

Objective

The objective of this review is to determine the impact of integrated models of care on HCV and addiction treatment and health-related outcomes for adults living with HCV and an SUD.

Methods

We will search 5 databases, article reference lists, and abstracts from relevant conferences that investigate the impact of integrated models of care on treatment and health-related outcomes among people living with HCV and an SUD. Database searches will be conducted and titles, abstracts, and the full-text of the relevant studies will be independently reviewed in separate stages. The methodological quality of included studies will be assessed using a validated tool. Data from included articles will be extracted using a standardized form and synthesized in a narrative account.

Results

For this project, we have received funding from the Canadian Institute of Health Research. To date, we have completed the search strategy, reviewed the titles, abstracts, and full-texts. Grading the selected studies and qualitative synthesis of the results are currently under way, and we expect the final results to be submitted for publication in the fall of 2018.

Conclusions

The systematic review will describe different integrated models of care that could be effective in improving the health and well-being of people living with HCV and an SUD. Results of this review could also identify quality improvement strategies to minimize the health and cost burden imposed on patients, healthcare professionals, and the healthcare system.

Trial Registration

PROSPERO CRD42017078445; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=78445 (Archived by WebCite at http://www.webcitation.org/6z4YnkE9G)

Treatment and primary prevention in people who inject drugs for chronic hepatitis C infection: is elimination possible in a high-prevalence setting?

AIMS

To project the impact of scaling-up oral anti-viral therapy and harm reduction on chronic hepatitis C (CHC) prevalence and incidence among people who inject drugs (PWID) in Greece, to estimate the relationship between required treatment levels and expansion of harm reduction programmes to achieve specific targets and to examine whether hepatitis C virus (HCV) elimination among PWID is possible in this high-prevalence setting.

DESIGN

A dynamic discrete time, stochastic individual-based model was developed to simulate HCV transmission among PWID incorporating the effect of HCV treatment and harm reduction strategies, and allowing for re-infection following treatment.

SETTING/PARTICIPANTS

The population of 8300 PWID in Athens Metropolitan area.

MEASUREMENTS

Reduction in HCV prevalence and incidence in 2030 compared with 2016.

FINDINGS

Moderate expansion of HCV treatment (treating 4-8% of PWID/year), with a simultaneous increase of 2%/year in harm reduction coverage (from 44 to 72% coverage over 15 years), was projected to reduce CHC prevalence among PWID in Athens by 46.2-94.8% in 2030, compared with 2016. CHC prevalence would reduce to below 10% within the next 4-5 years if annual HCV treatment numbers were increased up to 16-20% PWID/year. The effect of harm reduction on incidence was more pronounced under lower treatment rates.

CONCLUSIONS

Based on theoretical model projections, scaled-up hepatitis C virus treatment and harm reduction interventions could achieve major reductions in hepatitis C virus incidence and prevalence among people who inject drugs in Athens, Greece by 2030. Chronic hepatitis C could be eliminated in the next 4-5 years by increasing treatment to more than 16% of people who inject drugs per year combined with moderate increases in harm reduction coverage.

Outcomes from a large 10 year hepatitis C treatment programme in people who inject drugs: No effect of recent or former injecting drug use on treatment adherence or therapeutic response

BACKGROUND AND AIMS

People who inject drugs (PWID) are historically viewed as having "difficult to treat" hepatitis C disease, with perceived inferior treatment adherence and outcomes, and concerns regarding reinfection risk. We evaluated for differences in treatment adherence and response to Peginterferon-alfa-2a/Ribavirin (Peg-IFNα/RBV) in a large urban cohort with and without a history of remote or recent injection drug use.

METHODS

Patient data was retrospectively reviewed for 1000 consecutive patients-608 former (no injecting drug use for 6 months of therapy), 85 recent (injecting drug use within 6 months) PWID, and 307 non-drug users who were treated for chronic hepatitis C with Peg-IFNα/RBV. The groups were compared for baseline characteristics, treatment adherence, and outcome.

RESULTS

There was no significant difference in treatment non-adherence between the groups (8.4% in PWID vs 6.8% in non-PWIDs; RR = 1.23, CI 0.76-1.99). The overall SVR rate in PWID (64.2%) was not different from non-PWIDs (60.9%) [RR = 1.05, 95% CI 0.95-1.17]. There was no significant difference in SVR rates between the groups controlling for genotype (48.4% vs 48.4% for genotype 1; 74.9 vs 73.3% for genotype 3). Former and recent PWID had similar adherence rates.

CONCLUSIONS

PWID have comparable treatment adherence and SVR rates when compared to non-drug users treated with Peg-IFNα/RBV. These data support a public health strategy of HCV treatment and eradication in PWID in the DAA era.

Community nurse-led initiation of antiviral therapy for chronic hepatitis C in people who inject drugs does not increase uptake of or adherence to treatment

BACKGROUND

Chronic hepatitis C is common in people who inject drugs (PWID) and this population serves as a reservoir for infection. Treatment levels are low among this group, ranging from 1 to 19%. We explored whether a nurse-initiated community treatment model increased uptake of and adherence to interferon-based therapies.

METHODS

This was a cluster randomized trial of nurse-initiated versus physician-initiated antiviral therapy with pegylated interferon and ribavirin for hepatitis C virus in community clinics (trial registration: ISRCTN07774040).

RESULTS

The proportion of participants initiating treatment during follow-up was 10% with nurse-initiated (6/62) and 9% with physician-initiated (6/76) therapy. Adherence was similar in both groups, with only one patient in each arm not adhering to therapy. There were no serious adverse events, but interferon-related side effects were common. Drug and alcohol use did not change during therapy.

CONCLUSION

Despite easy access to antiviral therapy, uptake of treatment was poor, with no significant difference between the groups. Nurse-led initiation of interferon-based antiviral therapy in PWID did not lead to increased uptake of, response to or adherence with treatment. Further service improvement is unlikely to increase the proportion of PWID undergoing antiviral therapy for hepatitis C virus and early adoption of interferon-free regimens may increase the proportion initiating and completing treatment.

High variability of HIV and HCV seroprevalence and risk behaviours among people who inject drugs: results from a cross-sectional study using respondent-driven sampling in eight German cities (2011-14)

BACKGROUND

People who inject drugs (PWID) are at increased risk of acquiring and transmitting HIV and Hepatitis C (HCV) due to sharing injection paraphernalia and unprotected sex. To generate seroprevalence data on HIV and HCV among PWID and related data on risk behaviour, a multicentre sero- and behavioural survey using respondent driven sampling (RDS) was conducted in eight German cities between 2011 and 2014. We also evaluated the feasibility and effectiveness of RDS for recruiting PWID in the study cities.

METHODS

Eligible for participation were people who had injected drugs within the last 12 months, were 16 years or older, and who consumed in one of the study cities. Participants were recruited, using low-threshold drop-in facilities as study sites. Initial seeds were selected to represent various sub-groups of people who inject drugs (PWID). Participants completed a face-to-face interview with a structured questionnaire about socio-demographics, sexual and injecting risk behaviours, as well as the utilisation of health services. Capillary blood samples were collected as dried blood spots and were anonymously tested for serological and molecular markers of HIV and HCV. The results are shown as range of proportions (min. and max. values (%)) in the respective study cities. For evaluation of the sampling method we applied criteria from the STROBE guidelines.

RESULTS

Overall, 2,077 PWID were recruited. The range of age medians was 29-41 years, 18.5-35.3 % of participants were female, and 9.2-30.6 % were foreign born. Median time span since first injection were 10-18 years. Injecting during the last 30 days was reported by 76.0-88.4 % of participants. Sharing needle/syringes (last 30 days) ranged between 4.7 and 22.3 %, while sharing unsterile paraphernalia (spoon, filter, water, last 30 days) was reported by 33.0-43.8 %. A majority of participants (72.8-85.8 %) reported incarceration at least once, and 17.8-39.8 % had injected while incarcerated. Between 30.8 and 66.2 % were currently in opioid substitution therapy. Unweighted HIV seroprevalence ranged from 0-9.1 %, HCV from 42.3-75.0 %, and HCV-RNA from 23.1-54.0 %. The implementation of RDS as a recruiting method in cooperation with low-threshold drop in facilities was well accepted by both staff and PWID. We reached our targeted sample size in seven of eight cities.

CONCLUSIONS

In the recruited sample of mostly current injectors with a long duration of injecting drug use, seroprevalence for HIV and HCV varied greatly between the city samples. HCV was endemic among participants in all city samples. Our results demonstrate the necessity of intensified prevention strategies for blood-borne infections among PWID in Germany.

The Role of Physicians’ Attitudes and the Provision of Hepatitis C Virus Treatment to People Who Inject Drugs

Inadequate hepatitis C virus (HCV) assessment and treatment among people who inject drugs (PWID) is a result of patient, provider and health system level barriers. Low HCV treatment rates continue even though guidelines have been revised to consider HCV treatment among PWID on a case-by-case basis. If accessibility to HCV treatment were increased, especially to PWID this would greatly decrease the pool of communicable disease. In order to successfully control and prevent HCV infection PWID must be actively engaged in the treatment process. Physicians’ attitudes towards HCV treatment can be represented in studies as views that are directly perceived by the physician or indirectly as perceived by the patient who is under the care of the physician. The current review focuses on examining both the indirect and direct views of physician’s attitudes in treating HCV-infected PWID and examines how this influences and impacts provision of HCV treatment. A review of the literature suggests that physician’s have varied attitudes towards their patients who use recreational drugs and who are HCV positive. Moreover it is the negative associations between HCV and drug use that can impact HCV treatment accessibility and affect the number of people who can actively begin treatment.

Evaluation of HCV treatment in people who actively inject drugs

Aim: HCV treatment in people who actively inject drugs (PWID) (active PWID) is sometimes withheld. We propose that active PWID can be treated for HCV in the right setting. Methods: HCV-infected active PWID were evaluated at a multidisciplinary clinic in an observational study. The primary end point was a sustained virologic response following HCV therapy. Results: We included 40 active PWID, of which 63% used heroin, 70% used cocaine and 37% received all-oral regimens. With a mean follow-up of 570 days, 78% subjects achieved sustained virologic response (93% on all-oral regimens; p < 0.05), with no recurrent viremia. Conclusion: Active PWID can be effectively treated for HCV, especially with all-oral regimens and rates of recurrent viremia can be reduced in a multidisciplinary healthcare setting.

Evidence-based interventions to enhance assessment, treatment, and adherence in the chronic Hepatitis C care continuum

BACKGROUND

With the explosion of newly available direct acting antiviral (DAA) Hepatitis C virus (HCV) treatments that demonstrate 95% sustained virologic response (SVR) rates, evidence-based strategies are urgently needed to achieve real-world effectiveness in challenging patient populations. While HIV is incurable, lessons from over 30 years of experience overcoming obstacles to the HIV treatment cascade could be applied to the HCV context.

METHODS

Using Institute of Medicine guidelines, we conducted a systematic review of published interventions from PubMed, Medline, GoogleScholar, EmBASE, and PsychInfo bibliographic databases and citation indices. Abstracts were first screened by three independent reviewers and studies were included if they involved original research, described a specific intervention, were published in English in a peer-reviewed journal between 2001 and 2014, and had full text available.

RESULTS

Evidence-based interventions to enhance HCV assessment, treatment, and adherence generally fell into one of 4 categories, including those involving: (1) diagnosis or case-finding; (2) linkage to HCV care; (3) pre-therapeutic evaluation or treatment initiation; or (4) treatment adherence. While most available eligible studies described interventions using non-contemporary interferon-based HCV treatments, future research will need to address how these interventions apply to the context of well-tolerated, simple, oral treatment regimens. In some cases, we explored how HIV-specific interventions might be modified to fit the HCV spectrum of care engagement.

CONCLUSIONS

Evidence-based interventions should be strategically incorporated into HCV treatment implementation efforts to most effectively deliver treatment and maximize treatment outcomes.

Recommendations for the management of hepatitis C virus infection among people who inject drugs

In high income countries, the majority of new and existing hepatitis C virus (HCV) infections occur among people who inject drugs (PWID). In many low and middle income countries large HCV epidemics have also emerged among PWID populations. The burden of HCV-related liver disease among PWID is increasing, but treatment uptake remains extremely low. There are a number of barriers to care which should be considered and systematically addressed, but should not exclude PWID from HCV treatment. The rapid development of interferon-free direct-acting antiviral (DAA) therapy for HCV infection has brought considerable optimism to the HCV sector, with the realistic hope that therapeutic intervention will soon provide near optimal efficacy with well-tolerated, short duration, all oral regimens. Further, it has been clearly demonstrated that HCV treatment is safe and effective across a broad range of multidisciplinary healthcare settings. Given the burden of HCV-related disease among PWID, strategies to enhance HCV assessment and treatment in this group are urgently needed. These recommendations demonstrate that treatment among PWID is feasible and provide a framework for HCV assessment and care. Further research is needed to evaluate strategies to enhance testing, linkage to care, treatment, adherence, viral cure, and prevent HCV reinfection among PWID, particularly as new interferon-free DAA treatments for HCV infection become available.

Mixed HCV infection and reinfection in people who inject drugs--impact on therapy

The majority of new and existing cases of HCV infection in high-income countries occur among people who inject drugs (PWID). Ongoing high-risk behaviours can lead to HCV re-exposure, resulting in mixed HCV infection and reinfection. Assays used to screen for mixed infection vary widely in sensitivity, particularly with respect to their capacity for detecting minor variants (<20% of the viral population). The prevalence of mixed infection among PWID ranges from 14% to 39% when sensitive assays are used. Mixed infection compromises HCV treatment outcomes with interferon-based regimens. HCV reinfection can also occur after successful interferon-based treatment among PWID, but the rate of reinfection is low (0-5 cases per 100 person-years). A revolution in HCV therapeutic development has occurred in the past few years, with the advent of interferon-free, but still genotype-specific regiments based on direct acting antiviral agents. However, little is known about whether mixed infection and reinfection has an effect on HCV treatment outcomes in the setting of new direct-acting antiviral agents. This Review characterizes the epidemiology and natural history of mixed infection and reinfection among PWID, methodologies for detection, the potential implications for HCV treatment and considerations for the design of future studies.

New Hopes for HIV and HCV Coinfection in 2004

An increase in liver-related causes of death in HIV-positive patients who are coinfected with the hepatitis C virus (HCV) has been acknowledged over the last few years, particularly since the mid 1990s, when the natural history of HIV infection started to improve with the use of highly active antiretroviral therapy (HAART). Chronic hepatitis C is very common among HIV-infected patients who were infected through intravenous drugs use or contaminated blood products (e.g., hemophiliacs). The bidirectional interferences between HIV and HCV modify the natural history of both infections. Moreover, interactions between anti-HIV and anti-HCV drugs are of concern, and a lower response to anti-HCV therapy limits its benefit in HIV-coinfected patients. Although a slower HCV RNA decay is seen in coinfected patients after standard therapy is initiated with pegylated interferon plus ribavirin, the stopping rule at week 12 that is recommended for HCV-monoinfected individuals seems to be equally valid in HIV-positive patients. This finding is of great value, because it allows treatment to be offered in the absence of contraindication (e.g., low CD4 count, alcohol abuse, etc.) but discontinued as early as 12 weeks when no chances of cure are predicted, which saves costs and deleterious side effects. HAART therapy seems to temper somehow the negative impact exerted by HIV infection over HCV-related liver fibrosis. Liver transplantation is currently the best option for HIV-infected patients with end-stage liver disease. However, the management of patients on the waiting list and after transplantation carries significant new challenges. New anti-HCV drugs are urgently needed and new strategies with the currently available drugs need to be assessed to reduce the negative impact of hepatitis C in HIV-coinfected individuals.

Barriers to care and treatment for patients with chronic viral hepatitis in Europe: a systematic review

BACKGROUND & AIMS

Despite the availability of effective therapies for hepatitis B (HBV) and C virus (HCV), only a minority of these patients receive treatment. We systematically reviewed published data on barriers to management for chronic HBV/HCV patients in Europe.

METHODS

Literature search to identify studies including adult patients with chronic HBV/HCV infection from European countries and data on barriers to treatment.

RESULTS

Twenty-five studies including 6253 chronic HBV and 19,014 HCV patients were identified, of which only two were from Eastern Europe. The mean rate of no treatment in HBV patients was 42% being higher in North-Western European countries than Italy (56% vs. 39%, P < 0.001). Immigrants represented the most common barrier to HBV treatment. The mean rate of no treatment in HCV RNA-positive patients was 57%, being highest in Romania (89%), intermediate in France (79%) and lower though still high in other European countries (52%, P < 0.001). The predominant barriers to HCV treatment were lack of financial resources in Romania and direct/indirect limitations of interferon-alfa and/or parenteral drug and alcohol abuse in other countries. The mean rate of no treatment was highest in HCV RNA-positive parenteral drug users (72%) and intermediate in those with HCV-HIV co-infection (64%).

CONCLUSIONS

A substantial proportion of diagnosed chronic HBV and the majority of diagnosed HCV patients remain untreated. The rates and most importantly the reasons of barriers to treatment in chronic HBV/HCV patients vary widely among European countries supporting the need for country-specific national strategies, resource allocation and implementation of global management policies.

Eligibility of persons who inject drugs for treatment of hepatitis C virus infection

In this decade, an increase is expected in end-stage liver disease and hepatocellular carcinoma, most commonly caused by hepatitis C virus (HCV) infection. Although people who inject drugs (PWID) are the major source for HCV infection, they were excluded from antiviral treatments until recently. Nowadays there is incontrovertible evidence in favor of treating these patients, and substitution therapy and active substance use are no longer contraindications for antiviral treatment. The viral clearance in PWID after HCV antiviral treatment with interferon or pegylated interferon combined with ribavirin is comparable to the viral clearance in non-substance users. Furthermore, multidisciplinary approaches to delivering treatment to PWID are advised, and their treatment should be considered on an individualized basis. To prevent the spread of HCV in the PWID community, recent active PWID are eligible for treatment in combination with needle exchange programs and substitution therapy. As the rate of HCV reinfection is low after HCV antiviral treatment, there is no need to withhold HCV treatment due to concerns about reinfection alone. Despite the advances in treatment efficacies and data supporting their success, HCV assessment of PWID and initiation of antiviral treatment remains low. However, the proportion of PWID assessed and treated for HCV is increasing, which can be further enhanced by understanding the barriers to and facilitators of HCV care. Removing stigmatization and implementing peer support and group treatment strategies, in conjunction with greater involvement by nurse educators/practitioners, will promote greater treatment seeking and adherence by PWID. Moreover, screening can be facilitated by noninvasive methods for detecting HCV antibodies and assessing liver fibrosis stages. Recently, HCV clearance has become a major endpoint in the war against drugs for the Global Commission on Drug Policy. This review highlights the most recent evidence concerning HCV infection and treatment strategies in PWID.

A systematic review of Hepatitis C virus treatment uptake among people who inject drugs in the European Region

BACKGROUND

Fifteen million adults in the World Health Organization European Region are estimated to have active hepatitis C infection. Intravenous drug use is a major hepatitis C transmission route in this region, and people who inject drugs (PWID) constitute a high-risk and high-prevalence population. A systematic review was conducted to assess levels of hepatitis C treatment uptake among PWID in Europe.

METHODS

Searches in MEDLINE and EMBASE were carried out for articles in any language published between 1 January 2000 and 31 December 2012. Articles were included in the review if they presented original research findings about hepatitis C treatment uptake levels among people who reported injecting drugs currently or formerly, as well as those who reported using drugs currently or formerly (mode of consumption not specified). Treatment uptake data were extracted if uptake was measurable in relation to the number of patients who either: (a) tested HCV antibody-positive; (b) tested positive for HCV-RNA; or (c) tested positive for HCV-RNA and met additional treatment criteria.

RESULTS

Twenty-five articles from 12 countries were included in the review. Among groups of drug-using study participants who were hepatitis C antibody-positive, the median treatment uptake level was 17%, and among those who were hepatitis C RNA-positive, the median was 30%. In the 11 studies reporting specifically on treatment uptake among current and former injecting drug users, hepatitis C RNA-positive study populations had a median treatment uptake level of 32%. Only one study reported on treatment uptake for current drug users.

CONCLUSIONS

This systematic review indicates that hepatitis C treatment uptake is relatively low among drug users in several European countries, and also points to considerable knowledge gaps regarding treatment uptake levels in this population. There was large variability in treatment uptake levels, suggesting that there may be major differences between and within countries in relation to treatment availability, drug-using populations in need of treatment, and the existence of integrated health care services targeting drug users. Stronger national hepatitis C treatment policies are needed, along with efforts to increase knowledge and reduce misconceptions among physicians regarding the feasibility and importance of treating drug users who have hepatitis C.

Hepatitis C virus infection epidemiology among people who inject drugs in Europe: a systematic review of data for scaling up treatment and prevention

BACKGROUND

People who inject drugs (PWID) are a key population affected by hepatitis C virus (HCV). Treatment options are improving and may enhance prevention; however access for PWID may be poor. The availability in the literature of information on seven main topic areas (incidence, chronicity, genotypes, HIV co-infection, diagnosis and treatment uptake, and burden of disease) to guide HCV treatment and prevention scale-up for PWID in the 27 countries of the European Union is systematically reviewed.

METHODS AND FINDINGS

We searched MEDLINE, EMBASE and Cochrane Library for publications between 1 January 2000 and 31 December 2012, with a search strategy of general keywords regarding viral hepatitis, substance abuse and geographic scope, as well as topic-specific keywords. Additional articles were found through structured email consultations with a large European expert network. Data availability was highly variable and important limitations existed in comparability and representativeness. Nine of 27 countries had data on HCV incidence among PWID, which was often high (2.7-66/100 person-years, median 13, Interquartile range (IQR) 8.7-28). Most common HCV genotypes were G1 and G3; however, G4 may be increasing, while the proportion of traditionally 'difficult to treat' genotypes (G1+G4) showed large variation (median 53, IQR 43-62). Twelve countries reported on HCV chronicity (median 72, IQR 64-81) and 22 on HIV prevalence in HCV-infected PWID (median 3.9%, IQR 0.2-28). Undiagnosed infection, assessed in five countries, was high (median 49%, IQR 38-64), while of those diagnosed, the proportion entering treatment was low (median 9.5%, IQR 3.5-15). Burden of disease, where assessed, was high and will rise in the next decade.

CONCLUSION

Key data on HCV epidemiology, care and disease burden among PWID in Europe are sparse but suggest many undiagnosed infections and poor treatment uptake. Stronger efforts are needed to improve data availability to guide an increase in HCV treatment among PWID.

Barriers to hepatitis C antiviral therapy in HIV/HCV co-infected patients in the United States: a review

This review synthesized the literature for barriers to HCV antiviral treatment in persons with HIV/HCV co-infection. Searches of PubMed, Embase, CINAHL, and Web of Science were conducted to identify relevant articles. Articles were excluded based on the following criteria: study conducted outside of the United States, not original research, pediatric study population, experimental study design, non-HIV or non-HCV study population, and article published in a language other than English. Sixteen studies met criteria and varied widely in terms of study setting and design. Hepatic decompensation was the most commonly documented absolute/nonmodifiable medical barrier. Substance use was widely reported as a relative/modifiable medical barrier. Patient-level barriers included nonadherence to medical care, refusal of therapy, and social circumstances. Provider-level barriers included provider inexperience with antiviral treatment and/or reluctance of providers to refer patients for treatment. There are many ongoing challenges that are unique to managing this patient population effectively. Documenting and evaluating these obstacles are critical steps to managing and caring for these individuals in the future. In order to improve uptake of HCV therapy in persons with HIV/HCV co-infection, it is essential that barriers, both new and ongoing, are addressed, otherwise, treatment is of little benefit.

Recommendations for the management of hepatitis C virus infection among people who inject drugs

In the developed world, the majority of new and existing hepatitis C virus (HCV) infections occur among people who inject drugs (PWID). The burden of HCV-related liver disease in this group is increasing, but treatment uptake among PWID remains low. Among PWID, there are a number of barriers to care that should be considered and systematically addressed, but these barriers should not exclude PWID from HCV treatment. Furthermore, it has been clearly demonstrated that HCV treatment is safe and effective across a broad range of multidisciplinary healthcare settings. Given the burden of HCV-related disease among PWID, strategies to enhance HCV assessment and treatment in this group are urgently needed. These recommendations demonstrate that treatment among PWID is feasible and provides a framework for HCV assessment, management, and treatment. Further research is needed to evaluate strategies to enhance assessment, adherence, and SVR among PWID, particularly as new treatments for HCV infection become available.

HIV-1 coinfection profoundly alters intrahepatic chemokine but not inflammatory cytokine profiles in HCV-infected subjects

The pathogenesis of accelerated liver damage in subjects coinfected with hepatitis C virus (HCV) and human immunodeficiency virus type 1 (HIV-1) remains largely unknown. Recent studies suggest that ongoing chronic liver inflammation is responsible for the liver injury in HCV-infected patients. We aimed to determine whether HIV-1 coinfection altered intrahepatic inflammatory profiles in HCV infection, thereby hastening liver damage. We used a real-time RT-PCR-based array to comparatively analyze intrahepatic inflammation gene profiles in liver biopsy specimens from HCV-infected (n = 16), HCV/HIV-1-coinfected (n = 8) and uninfected (n = 8) individuals. We then used human hepatocytes to study the molecular mechanisms underlying alternations of the inflammatory profiles. Compared with uninfected individuals, HCV infection and HCV/HIV-1 coinfection markedly altered expression of 59.5% and 50.0% of 84 inflammation-related genes tested, respectively. Among these genes affected, HCV infection up-regulated the expression of 24 genes and down-regulated the expression of 26 genes, whereas HCV/HIV-1 coinfection up-regulated the expression of 21 genes and down-regulated the expression of 21 genes. Compared with HCV infection, HCV/HIV-1 coinfection did not dramatically affect intrahepatic gene expression profiles of cytokines and their receptors, but profoundly altered expression of several chemokine genes including up-regulation of the CXCR3-associated chemokines. Human hepatocytes produced these chemokines in response to virus-related microbial translocation, viral protein stimulation, and antiviral immune responses.

Conclusions

HIV-1 coinfection profoundly alters intrahepatic chemokine but not cytokine profiles in HCV-infected subjects. The altered chemokines may orchestrate the tissue-specific and cell-selective trafficking of immune cells and autoimmunity to accelerate liver disease in HCV/HIV-1 coinfection.

Targeted hepatitis C screening among ex-injection drug users in the community

BACKGROUND AND AIM

Chronic hepatitis C virus (HCV) infection is one of the leading causes of cirrhosis and hepatocellular carcinoma worldwide. It is highly prevalent among injection drug users (IDUs) but is often undiagnosed because they represent an underprivileged group that faces multiple barriers to medical care. Here, we report the results of the New Life New Liver Project, which provides targeted HCV screening and education for ex-IDUs in the community.

METHODS

Patients were recruited through the social worker networks and referrals by fellow ex-IDUs, and rapid diagnosis was based on point-of-care anti-HCV testing at rehabilitation centers.

RESULTS

From 2009 to 2012, we served 234 subjects. One hundred thirty (56%) subjects were anti-HCV positive. The number needed to screen to detect one patient with positive anti-HCV was 1.8 (95% confidence interval, 1.6-2.0). However, only 69 (53%) HCV patients attended subsequent follow-up at regional hospitals, and 26 (20%) received antiviral therapy. Patients who attended follow-up were older, had higher education level and more active disease as evidenced by higher alanine aminotransferase, HCV RNA, and liver stiffness measurement by transient elastography.

CONCLUSIONS

Targeted screening in ex-IDUs is effective in identifying patients with HCV infection in the community. Improvement in the referral system and introduction of interferon-free regimens are needed to increase treatment uptake.

Hepatitis C treatment for multimorbid patients with substance use disorder in a primary care-based integrated treatment centre: a retrospective analysis

OBJECTIVES/BACKGROUND

The population of people who use drugs (PWUD) has the highest prevalence of hepatitis C virus (HCV) infections in Europe. PWUD are multimorbid patients who are difficult to integrate into existing healthcare systems. In our study, we evaluated the feasibility of providing HCV treatment within opioid maintenance treatment (OMT) programmes offering integrated primary care-based health services under one roof.

METHODS

We evaluated 66 charts of patients in four outpatient clinics (OMT) with HCV treatment (between 2002 and 2010). Fourteen of the patients were treated with heroin and nine patients had an HIV coinfection. Data on the socioeconomic characteristics and quality of life were assessed. We counted the number of consultations in the clinic to assess how much supportive care the patients needed.

RESULTS

Overall, 62% of all patients (41 out of 66) achieved a sustained virological response (SVR). A total of 84% of patients with genotype 3 achieved an SVR. Sixty-four percent of patients treated with heroin achieved an SVR. The majority of patients (71%) used illicit drugs during HCV treatment and over 80% were diagnosed with psychiatric comorbidities. Comparisons of patient characteristics according to SVR or non-SVR showed that a longer duration of OMT, more consultations per week during HCV treatment and poor self-reported physical condition were associated with non-SVR.

CONCLUSION

We conclude that offering HCV treatment in an integrated primary care-based setting with OMT and individualized use of different supporting strategies allows for treatment success rates in the population of PWUD that is comparable to the ones in the population of patients without drug use. Heroin maintenance treatment programmes offer a feasible and safe setting for providing HCV treatment.

Factors associated with uptake, adherence, and efficacy of hepatitis C treatment in people who inject drugs: a literature review

INTRODUCTION AND METHODS

Hepatitis C virus (HCV) infections are highly prevalent amongst people who inject drugs (PWID). Despite well documented evidence of its effectiveness, suggested cost-effectiveness, and potential to reduce HCV prevalence rates, the uptake of antiviral HCV treatment by PWID is low. This nonsystematic literature review describes factors associated with the uptake, adherence, and efficacy of HCV treatment among PWID and discusses strategies to increase their uptake of treatment.

RESULTS

Low HCV treatment uptake among PWID is associated with a number of patient-related and provider-related barriers. Beliefs and fears about low efficacy and adverse effects on the patient's part are common. A substantial number of factors are associated with the chaotic lifestyle and altered social functioning of PWID, which are often associated with decompensation or relapsing into drug addiction. This may lead to perceived low adherence with treatment and low efficacy on the provider's part too, where lack of support, inadequate management of addiction, and other drug-related problems and poor treatment of side effects have been described. Practical issues such as the accessibility of treatment and finances also play a role. Strategies to improve the HCV treatment rate among PWID involve pretreatment management and assessment, a multidisciplinary approach, management of side effects, and enhanced education and counseling.

CONCLUSION

Specific factors are associated with poorer treatment outcomes in PWID on the side of both the patient and the treatment system. However, given that PWID can achieve treatment adherence and sustained virologic response rates comparable with those in nondrug users, drug use per se should not be considered a criterion for exclusion from treatment. Further development of measures leading to higher uptake of treatment and adherence in PWID and appropriate adaptation of HCV treatment guidelines represent important tools in this regard.

"It gives me a sense of belonging": providing integrated health care and treatment to people with HCV engaged in a psycho-educational support group

BACKGROUND

Injection drug use (IDU) increases the risk of contracting hepatitis C virus (HCV) yet very few people living with HCV access effective, and potentially curative, treatments. The East Toronto Hepatitis C Program (ETHCP) was developed in 2006 and provides health care, treatment and support to people living with HCV who have complex mental health, physical health and psychosocial needs. The program is anchored in a 16-18 week psychosocial support group located within one of the 3 participating community-based health clinics. The objective of this study was to explore the experiences of individuals engaged in the ETHCP psycho-educational group.

METHODS

This phenomenological qualitative study consisted of semi-structured in-depth interviews with twenty randomly selected program participants.

RESULTS

The three dominant themes that emerged from the analysis were program structure, group cohesion and group as agent for change. The ETHCP "one-stop shopping" model provided a stable foundation allowing for the development of group cohesion. Group cohesion was marked by the formation of intense relationships creating a safe and non-judgmental environment where participants could self-reflect, make social connections and feel cared for and accepted. Three types of relationships characterized group cohesion: relationship to self, relationships with individual group members and relationship to group as a whole. Within the nurturing group environment, participants could challenge themselves and others, ultimately enabling change.

CONCLUSION

The results of our qualitative study suggest that it is the formation of strong group cohesion that facilitated participants' behavioural change, regardless of their level of substance use. The structure of the group provided stability and was characterized by consistent weekly meetings, knowledge exchange and the provision of multiple services in one location. The support from peers and staff allowed participants to develop personal goals. Participants began to see themselves in a new and changed way; expressing this change in a variety of positive behaviours.

Successful integration of hepatitis C evaluation and treatment services with methadone maintenance

OBJECTIVES

Despite high rates of hepatitis C virus (HCV) infection, relatively few current or former injection drug users receive evaluation and treatment for HCV. Here, we demonstrate the feasibility and effectiveness of integrating HCV care and methadone maintenance treatment (MMT). We hypothesized that colocation of these services would result in improved access to and utilization of HCV care.

METHODS

In this retrospective observational study, all patient charts from a single MMT clinic were reviewed 2 years after HCV care and MMT were integrated. Information obtained included screening for and counseling about HCV infection status, on-site HCV treatment and outcomes, and demographic and substance abuse data.

RESULTS

Two hundred ninety-one patient charts were reviewed. Two hundred eighty-one (99%) patients were screened for HCV antibody (HCV-Ab), and 188 (65%) were positive. Forty-nine (17%) patients were HIV/HCV coinfected. Ninety-eight percent of the HCV-Ab-positive patients received HCV counseling. Hundred fifty-nine (85%) of the HCV-Ab-positive patients were eligible to receive further evaluation and treatment for HCV on site, and 125 (78%) accepted. Hundred eighteen (94%) patients were tested for chronic HCV, and 83 were determined to have chronic HCV. Twenty-five patients received liver biopsy; low-stage disease was found in 7 patients. Twenty-one patients initiated HCV treatment. Sustained viral response was achieved in 8 patients. Seventeen patients had contraindications to HCV treatment. Further workup was prevented or delayed in 45 patients for various reasons, most commonly due to personal choice (29 patients).

CONCLUSIONS

This study demonstrates that current and former injection drug users can be engaged successfully in evaluation and treatment of HCV infection when these services are collocated with MMT.

The effect of stimulant use on antiviral treatment in an integrated hepatitis clinic

OBJECTIVE

The objective was to determine the impact of stimulant use on antiviral treatment for chronic hepatitis C patients in an integrated hepatitis clinic.

METHODS

A retrospective chart review of 449 consecutive patients seen in an integrated hepatitis clinic that included co-located mental health clinicians was performed. Psychiatric measures included drug use questionnaire, Beck Depression Inventory (BDI), Alcohol Use Disorders Identification Test-Consumption questions (AUDIT-C), urine drug screen and antiviral treatment outcomes. Patients with stimulant use were compared to patients with no drug use, other drug users and an unknown drug use group using χ(2) and analysis of variance tests.

RESULTS

Over 15% of hepatitis C patients presenting to the clinic were using stimulants. Stimulant users had higher BDI and AUDIT-C scores. They were more likely to be followed by a co-located mental health clinician than other groups and were just as likely to initiate and finish antiviral therapy.

CONCLUSIONS

Recent stimulant use is common in hepatitis C patients presenting to a hepatitis clinic. Stimulant users were more depressed and used alcohol to a greater degree than nonusers but were as likely to start antiviral therapy. An integrated mental health/medical care approach appears to be effective in addressing this difficult-to-treat population.

Statement of the American Society Of Addiction Medicine Consensus Panel on the use of buprenorphine in office-based treatment of opioid addiction

OBJECTIVES

Opioid addiction affects over 2 million patients in the United States. The advent of buprenorphine and the passage of the Drug Addiction Treatment Act in 2000 have revolutionized the opioid treatment delivery system by granting physicians the ability to administer office-based opioid treatment (OBOT), thereby giving patients greater access to treatment. The purpose of this consensus panel was to synthesize the most current evidence on the use of buprenorphine in the office-based setting and to make recommendations that will enable and allow additional physicians to begin to treat opioid-addicted individuals.

METHODS

Literature published from 2000 to 2009 was searched using the PubMed search engine and yielded over 375 articles published in peer-reviewed journals, including some that were published guidelines. These articles were submitted to a consensus panel composed of researchers, educators, and clinicians who are leaders in the field of addiction medicine with specific expertise in the use of OBOT. The panel discussed results and agreed upon consensus recommendations for several facets of OBOT.

RESULTS

: On the basis of the literature review and consensus discussions, the panel developed a series of findings, conclusions, and recommendations regarding the use of buprenorphine in office-based treatment of opioid addiction.

CONCLUSIONS

Therapeutic outcomes for patients who self-select office-based treatment with buprenorphine are essentially comparable to those seen in patients treated with methadone programs. There are few absolute contraindications to the use of buprenorphine, although the experience and skill levels of treating physicians can vary considerably, as can access to the resources needed to treat comorbid medical or psychiatric conditions--all of which affect outcomes. It is important to conduct a targeted assessment of every patient to confirm that the provider has resources available to meet the patient's needs. Patients should be assessed for a broad array of biopsychosocial needs in addition to opioid use and addiction, and should be treated, referred, or both for help in meeting all their care needs, including medical care, psychiatric care, and social assistance. Current literature demonstrates promising efficacy of buprenorphine, though further research will continue to demonstrate its effectiveness for special populations, such as adolescents, pregnant women, and other vulnerable populations. Since the time of this review, several new studies have provided new data to continue to improve our understanding of the safety and efficacy of buprenorphine for special patient populations.

An overview and evaluation of combining an addiction liaison nurse outpatient service with hepatitis C outpatient clinics in Glasgow, Scotland

A new purpose-built facility for the care of patients with Hepatitis C was opened at Gartnavel General Hospital in Glasgow, Scotland, in 2009, bringing together infectious diseases and gastroenterology disciplines. An addiction liaison nurse outpatient service was established alongside existing Hepatitis C outpatient clinics in October 2010. This service supports staff and patients with Hepatitis C and addiction issues. The purpose of this study was to evaluate the usefulness of combining the Addiction Liaison Nurse outpatient service with the Hepatitis C outpatient clinic. Two methods were used in data collection. A brief questionnaire asking staff their view on the addiction liaison service and addiction issues with regard to Hepatitis C was distributed and completed by personnel assigned to the clinics. Staff were also queried about their view on the number and quality of referrals generated by the addiction liaison clinic. The results from the questionnaire indicate that staff agreed that patients should be abstinent from alcohol and illicit drugs before and during treatment of Hepatitis C. Further research is called for with regard to abstinence from alcohol and drugs before and during Hepatitis C treatment.

Together … to take care: multidisciplinary management of hepatitis C virus treatment in randomly selected drug users with chronic hepatitis

Hepatitis C Virus (HCV) infection is treated with peg-interferon α2a or α2b and ribavirin. International studies show that drug user adherence to treatment is 40% to 60% and increases if the patient is in addiction treatment. The aim of the Together To Take Care (TTTC) study was to achieve better adherence to HCV therapy in randomly selected drug users, who are considered "difficult to treat." The secondary aim of the TTTC Study Group was to standardize a method for a multidisciplinary management of the liver disease in drug users. The TTTC group data were matched with a control group. Adherence: The 93.7% of patients followed therapy prescribed; of the patients infected by HCV genotype (gt) 3, all completed therapy as scheduled. For the 48-week treatment group, 66.7% of patients completed therapy (2 of 9 patients stopped treatment for breakthrough). Toxicological results: 10 (62.5%) patients were negative in the toxicological tests (opiates, cocaine, and alcohol). Virological results: 8 of 16 patients were infected by HCV gt 1, and 8 were infected by gt 3; 2 of 16 (12.5%) patients were human immunodeficiency virus (HIV) coinfected (1 HCV gt 1a and 1 HCV gt 3). All patients: 11 of 16 (68.75%) patients were HCV ribonucleic acid undetectable 24 weeks after completing therapy (sustained virological response, SVR). Gt 1: 4 of 8 (50.0%) showed SVR. Gt 3: 7 of 8 (87.5%) showed SVR. Overall, the HCV gt 3 patients had 87.5% probability of SVR, whereas gt 1 patients had 50% probability of SVR (gt 3/gt 1 patients odds ratio = 7). The results were analyzed by Fisher exact test. Our results show that good healthcare management plays an important role in increasing patients' adherence to therapy. In the project "TTTC," the patients work with the physicians to take responsibility for their health and acquire self-efficacy and self-awareness, thanks to the special care.

Study of the effect of antiviral therapy on homocysteinemia in hepatitis C virus- infected patients

BACKGROUND

Hepatitis C virus (HCV) infection is one of the leading causes of chronic liver disease (CLD). About 80% of those exposed to the virus develop a chronic infection. Hyperhomocysteinemia, which is an independent risk factor for atherosclerotic vascular disease and thromboembolism, may develop in HCV-infected patients although altered alanine amino transferase (ALT) enzyme levels are generally associated with damage to liver cells. The gold standard therapy for chronic hepatitis C patients is pegylated interferon combined with an anti-viral drug (ribavirin). The current study aimed to investigate the effect of antiviral therapy on plasma homocysteine (Hcy) levels in HCV patients in addition to other parameters.

METHODS

532 HCV-infected patients and 70 healthy controls were recruited for the study. All patients were subjected to laboratory investigations including HCV-RNA levels, complete blood cell counts, serum levels of homocysteine, ALT, alkaline phosphatase (ALP), lipid profile and liver ultrasonographic examination. The outcome of treatment with pegylated interferon α plus ribavirin treatment and sustained virologic response (SVR) was determined 6-9 months post-therapy.

RESULTS

Hyperhomocysteinemia was found in 91.35% of HCV-infected patients. The difference in plasma Hcy concentrations reached statistical significance between the patient and control groups. ALT, cholesterol and triglycerides (TGs) levels were found higher than normal in the patients group. After receiving a combined therapy for 24 weeks, 43.66% patients showed an SVR (responders); 30.98% patients were non-responders while 25.35% patients initially responded to therapy but again retrieved positive status of HCV infection six months post-therapy (relapse-cirrhotic patients). The mean levels of plasma Hcy, ALT and ALP were significantly reduced in responders within 10 weeks of therapy when compared with non-responders and relapse-cirrhotic patients.

CONCLUSION

Elevated homocysteine levels in serum due to HCV infection can be reduced to normal range with the standard interferon α plus ribavirin treatment. This study highlights the significance of the measurement of serum homocysteine levels in the diagnosis and monitoring of HCV infection treatment in addition to other laboratory parameters.

Public health issues of hepatitis C virus infection

Hepatitis C virus (HCV) is a leading cause of liver disease worldwide, as 130-170 million individuals are chronically infected and 350,000 patients die every year from HCV infection. The HCV prevalence varies widely among countries being highest in several African and Eastern Mediterranean countries. The incidence of new HCV infections may be declining in developed countries, but there is still a large reservoir of chronic infections. The most important mode of HCV transmission has been injecting drug use in developed countries with low prevalence and unsafe therapeutic injections in developing countries with moderate-high prevalence. Since there are no systematic screening policies, most patients remain undiagnosed. Even among diagnosed patients, a minority receives treatment due to several barriers to therapy. Given the high efficacy of treatment, public health authorities should recognise the importance of HCV and make resources available for the implementation of effective primary prevention, screening and management policies.

Provider and patient correlates of provider decisions to recommend HCV treatment to HIV co-infected patients

Despite low uptake of hepatitis C virus (HCV) treatment among HIV co-infected patients, few studies have examined the factors that contribute to provider decisions to recommend treatment. Surveys of 173 co-infected patients and their primary care providers, as well as patient chart data, were collected at 3 HIV clinics in Los Angeles; 73% of the patients had any history of being recommended HCV treatment. Multivariate predictors of being offered treatment included being Caucasian, greater HCV knowledge, receiving depression treatment if depressed, and one's provider having a lower weekly patient load and more years working at the study site. These findings suggest that provider decisions to recommend HCV treatment are influenced by patient factors including race and psychosocial treatment readiness, as well as characteristics of their own practice and treatment philosophy. With changes to HCV treatment soon to emerge, further evaluation of factors influencing treatment decisions is needed to improve HCV treatment uptake.

Chronic hepatitis C: Treat or wait? Medical decision making in clinical practice

AIM: To analyzes the decision whether patients with chronic hepatitis C virus (HCV) infection are treated or not.

METHODS: This prospective cohort study included 7658 untreated patients and 6341 patients receiving pegylated interferon α 2a/ribavirin, involving 434 physicians/institutions throughout Germany (377 in private practice and 57 in hospital settings). A structured questionnaire had to be answered prior to the treatment decision, which included demographic data, information about the personal life situation of the patients, anamnesis and symptomatology of hepatitis C, virological data, laboratory data and data on concomitant diseases. A second part of the study analyzes patients treated with pegylated interferon α2a. All questionnaires included reasons against treatment mentioned by the physician.

RESULTS: Overall treatment uptake was 45%. By multivariate analysis, genotype 1/4/5/6, HCV-RNA ≤ 520 000 IU/mL, normal alanine aminotransferase (ALT), platelets ≤ 142 500/μL, age > 56 years, female gender, infection length > 12.5 years, concomitant diseases, human immunodeficiency virus co-infection, liver biopsy not performed, care in private practice, asymptomatic disease, and unemployment were factors associated with reduced treatment rate. Treatment and sustained viral response rates in migrants (1/3 of cohort) were higher than in German natives although 1/3 of migrants had language problems. Treatment rate and liver biopsy were higher in clinical settings when compared to private practice and were low when ALT and HCV-RNA were low.

CONCLUSION: Some reasons against treatment were medically based whereas others were related to fears, socio-economical problems, and information deficits both on the side of physicians and patients.

Management of HCV and HIV infections among people who inject drugs

PURPOSE OF REVIEW

Despite a high burden of hepatitis C virus (HCV) and HIV infection among IDUs and the advent of effective therapies, assessment and treatment remain limited. The current review focuses on the management of HCV and HIV among IDUs, focusing particularly on recent strategies to enhance assessment, uptake and response to HCV and HIV treatment.

RECENT FINDINGS

There are compelling data demonstrating that with the appropriate programs, treatment for HIV and HCV among IDUs is successful. However, assessment and treatment for HCV and HIV lags far behind the numbers of IDUs who could benefit from therapy, related to systems, provider and patient-related barriers to care. Strategies for enhancing assessment and treatment for HCV and HIV have been developed, including novel models integrating HCV/HIV care within existing community-based and drug and alcohol clinics, innovative methods for education delivery (including peer-support models) and directly observed therapy.

SUMMARY

As we move forward, research must move beyond demonstrating that HCV and HIV infections can be successfully treated among IDUs. There is clear evidence that this is both feasible and effective. Novel strategies to enhance assessment, uptake and response to treatment should be evaluated among IDUs to elucidate mechanisms to enhance care for this underserved population.

Barriers to hepatitis C treatment

Despite the availability of highly effective therapy for hepatitis C virus (HCV) infection, few patients receive treatment. Barriers arising at multiple levels, from diagnosis to specialist referral, may impede the delivery of hepatitis C care. At the patient level, lack of awareness, fear of side effects, poor adherence and comorbid conditions may prevent treatment. For providers, limited knowledge, lack of availability and communication difficulties may be problematic. At the government and payer level, a lack of promotion, surveillance and funding may interfere. Each of these barriers needs to be addressed if wider implementation of antiviral therapy is to be achieved.

Treatment for hepatitis C virus genotype 1 infection in HIV-infected individuals on methadone maintenance therapy

BACKGROUND

A minority of HIV/HCV coinfected patients with opiate addiction undergo HCV treatment. HCV therapy for HCV-monoinfected methadone maintenance (MM) recipients is safe and effective. We evaluated treatment efficacy and adherence to pegylated interferon (pegIFN) among HIV/HCV coinfected MM recipients.

METHODS

HCV treatment-naïve, HIV-infected persons 18-65 years with chronic HCV genotype 1 on MM were prospectively enrolled in an HCV treatment study at two HIV clinics. At weekly visits pegIFN alfa-2a injections were directly administered. Daily MM recipients had morning ribavirin delivered with methadone at off-site methadone clinics. Weekly take-home MM recipients took ribavirin unsupervised. Target enrollment was 30 participants.

RESULTS

During 18 recruitment months, 11 participants were enrolled, 6 of whom received daily methadone. Mean age was 46, 64% were female, 5 were Caucasian, 4 Black and 2 Hispanic. At baseline, 82% had high HCV RNA and 55% had stage 2 fibrosis or greater. The majority (91%) were on HAART, and 82% had undetectable HIV RNA with a median CD4(+) of 508cells/μL. All had polysubstance use history, non-substance-based psychiatric diagnoses and were on psychotropic medications pre-enrollment. Two (18%) participants achieved a Sustained Virologic Response (SVR). Two completed 48 treatment weeks, 5 were withdrawn due to adverse events, 2 dropped out prematurely and 2 had treatment discontinued for virologic non-response. Of on-treatment weeks, adherence to pegIFN was >99%.

CONCLUSIONS

SVR rate was comparable to historic controls for coinfected genotype 1 patients, with optimal pegIFN adherence. Adverse effects often prevented therapy completion in this population.

Can antiviral therapy for hepatitis C reduce the prevalence of HCV among injecting drug user populations? A modeling analysis of its prevention utility

BACKGROUND & AIMS

Hepatitis C virus antiviral treatment is effective for individual patients but few active injecting drug users are treated. We considered the utility of antiviral treatment for primary prevention of hepatitis C.

METHODS

A hepatitis C transmission model among injecting drug users was developed, incorporating treatment (62.5% average sustained viral response) with no retreatment after initial treatment failure, potential re-infection for those cured, equal genotype setting (genotype 1:genotype 2/3), and no immunity. In addition, we examined scenarios with varied treatment response rates, immunity, or retreatment of treatment failures.

RESULTS

In the baseline scenario, annually treating 10 infections per 1000 injecting drug users results in a relative decrease in hepatitis C prevalence over 10 years of 31%, 13%, or 7% for baseline (untreated endemic chronic infection) prevalences of 20%, 40%, or 60%, respectively. Sensitivity analyses show that including the potential for immunity has minimal effect on the predictions; prevalence reductions remain even if SVR is assumed to be 25% lower among active IDU than current evidence suggests; retreatment of treatment failures does not alter the short-term (<5 years) projections, but does increase treatment gains within 20 years; hepatitis C free life years gained from treating active injecting drug users are projected to be higher than from treating non-injecting drug users for prevalences below 60%.

CONCLUSIONS

Despite the possibility of re-infection, modest rates of hepatitis C treatment among active injecting drug users could effectively reduce transmission. Evaluating and extending strategies to treat hepatitis C among active injectors are warranted.

Physicians' attitudes and practice toward treating injection drug users with hepatitis C: results from a national specialist survey in Canada

BACKGROUND

In Canada, more than 70% of new cases of hepatitis C virus (HCV) infection per year involve injection drug users (IDUs) and, currently, there is no consensus on how to offer them medical care.

OBJECTIVE

To examine the characteristics of Canadian specialist physicians and their likelihood to provide treatment to HCV patients who are IDUs.

METHODS

A nationwide, cross-sectional study was conducted in the specialty areas of hepatology, gastroenterology and infectious diseases to examine HCV services. The questionnaire requested information regarding basic demographics, referral pathways and opinions (yes⁄no), and examined how a physician's treatment regimen is influenced by factors such as treatment eligibility, HCV care management and barriers to providing quality service.

RESULTS

Despite the fact that the majority of prevalent and incident cases of HCV are associated with injection drug use, very few specialist physicians actually provide the necessary therapy to this population. Only 19 (19.79%) comprehensive service providers were likely to provide treatment to a current IDU who uses a needle exchange on a regular basis. The majority of comprehensive service providers (n=86 [89.58%]) were likely to provide treatment to a former IDU who was stable on substitution therapy. On bivariate analysis, factors associated with the likelihood to provide treatment to current IDUs included physicians' type, ie, infectious disease specialists compared with noninfectious specialists (OR 3.27 [95% CI 1.11 to 9.63]), and the size of the community where they practice (OR 4.16 [95% CI 1.36 to 12.71] [population 500,000 or greater versus less than 500,000]). Results of the multivariate logistic regression analysis were largely consistent with the results observed in the bivariate analyses. After controlling for other confounding variables, only community size was significantly associated with providing treatment to current IDUs (OR 3.89 [95% CI 1.06 to 14.26] [population 500,000 or greater versus less than 500,000]).

CONCLUSION

The present study highlighted the reluctance of specialists to provide treatment to current IDUs infected with HCV. Providing treatment services for HCV-infected substance abusers is challenging and there are many treatment barriers. However, effective delivery of treatment to this population will help to limit the spread of HCV. The present study clearly identified a need for improved HCV treatment accessibility for IDUs.

Clinical experience with the treatment of hepatitis C infection in patients on opioid pharmacotherapy

AIMS

To evaluate the efficacy, safety and adherence to hepatitis C (HCV) therapy in patients attending tertiary hepatitis clinics who are receiving opioid replacement therapy.

DESIGN

A non-randomized, open-label study. Participants were treated with pegylated interferon alpha-2a and weight-based ribavirin for 24 weeks (genotype non-1, n = 31) or 48 weeks (genotype 1, n = 22).

SETTING

Four tertiary hospital hepatitis clinics in Australia.

PARTICIPANTS

Fifty-three patients with chronic HCV who were receiving opioid replacement therapy.

MEASUREMENTS

Patients were monitored for virological response, adverse events and adherence. They were also screened for psychiatric illness prior to and throughout the study utilizing two validated instruments: the Mini International Neuropsychiatric Interview (MINI) and Beck Depression Interview (BDI)-II.

FINDINGS

The overall sustained virological response (SVR) rate was 57% (71% genotype non-1 versus 36% genotype 1), and was similar in active injectors (63%) and non-injectors (53%). The psychological profile of patients based on validated instruments did not change on therapy. The pattern and frequency of adverse effects were comparable to non-opioid replacement patients. Eighty-five per cent of patients were adherent to therapy by 80/80/80 criteria and only two patients who had an end-of-treatment response relapsed, one of whom was not an active injector.

CONCLUSIONS

Patients on opioid replacement therapy, even if they continue to inject actively, can achieve comparable sustained virological response rates to other populations with pegylated interferon alpha-2a and ribavirin therapy, suffer no excess rates of adverse effects or psychological complications and have good adherence to therapy.

Evolution of HCV incidence in drug users in France

Over the last 40 years, the dynamics of hepatitis C virus (HCV) infection in drug users has been affected by the illicit drug market, the health environment including the devastating impact of the HIV/AIDS epidemic which erupted in the 1980s, and the diffusion of substitution treatment beginning in 1995. The purpose of this literature review is to present the dynamics of HCV infection in drug users in France over the last 40 years. Two prevalence studies of HCV infection in the general population were conducted by the French Institute for Public Health Surveillance in 1994 and 2004 and were the touchstone data sources for this analysis. Hypotheses constructed from the findings of these two studies were examined in light of results reported by multicentre prevalence and incidence studies in drug-user populations. The incidence of HCV infection in drug users in France reached a peak in the late 1980s or early 1990s after a lengthy period of epidemic expansion. Implementation of a risk reduction policy enabled a very significant reduction in the incidence of HCV infection in drug users over the last 20 years, leading to incidence figures which are now 10–15% of the 1990 estimate.

Hepatitis C testing and treatment among active drug users in Amsterdam: results from the DUTCH-C project

BACKGROUND

Although hepatitis C virus (HCV) treatment has shown to be effective, uptake of treatment among active drug users is still low. The Drug Users Treatment for Chronic Hepatitis-C project aims to offer active drug users in Amsterdam HCV testing and treatment using a multidisciplinary approach.

METHODS

The study population comprises drug users participating in the Amsterdam Cohort Studies and drug users referred to the Drug Users Treatment for Chronic Hepatitis-C unit. Drug users were offered HCV testing and, if chronically infected, medical and psychiatric screening and HCV treatment. Various specialists collaborated to provide optimal care. We assessed test-uptake and treatment-uptake and outcomes.

RESULTS

Four hundred and ninety-seven Amsterdam Cohort Studies drug users were offered HCV testing: 449 out of 497 (90%) accepted. HCV antibodies were found in 267 out of 449 (60%): 183 out of 267 (69%) were HCV-viremic and 49 out of 183 (27%) were HIV-co-infected. Of the 134 HCV-monoinfected patients, 102 (76%) initiated additional medical screening and 44 started treatment by 1 July 2009. Sixty-two drug users referred from methadone clinics were also HCV-monoinfected, of whom 14 started treatment by 1 July 2009. In total 58 persons were treated: 16 (27%) with genotype 1 or 4, 42 (72%) with genotype 2 or 3. Eighty-four percent used methadone, 97% used drugs (heroin, cocaine or amphetamine) at least once in the 6 months before treatment, 19% were active injectors. Sixty-two percent used alcohol, 41% had psychiatric disease other than substance abuse. Of the 57 individuals with sufficient follow-up, 37 (65%) achieved sustained virological response.

CONCLUSION

In a multidisciplinary setting, HIV-negative drug users with chronic HCV infection can be treated successfully despite active drug or alcohol use and psychiatric diseases. Therefore, access to HCV therapy using an integrated approach should be increased for this population.