Management of HCV and HIV infections among people who inject drugs. Curr Opin HIV AIDS. 2011;6:501-507. [PMID: 22001894 DOI: 10.1097/coh.0b013e32834bcb36]

Risk Factors Associated With Unsuccessful Linkage to Outpatient Hepatitis C Care

Background Modern direct-acting antivirals (DAAs) can treat and cure hepatitis C virus (HCV) infection. Treatment of HCV at a population level has the potential to decrease the prevalence of chronic HCV infection and sequela. Unfortunately, many patients fall off the HCV treatment cascade and do not complete HCV treatment. As social determinants of health (SDHs) affect HCV acquisition, we sought to evaluate factors that may limit successful linkage to outpatient HCV care. Methods We conducted a case-control study by matching patients who missed and those who attended their outpatient HCV visits in 2018. We matched cases in a 1:1 ratio using propensity scores. Results Of 1,539 patients, 161 (10.5%) did not attend their HCV clinic appointment. Factors associated with a missed HCV visit on bivariate testing included identifying as Black (p=0.03), housing instability (p<0.001), transportation difficulty (p<0.001), history of medication non-adherence (p<0.001), and undergoing screening during an inpatient admission (p<0.001). Multivariate testing found transportation difficulty (p<0.001) and inpatient admission (p=0.002) to be associated with missing their HCV appointment. Patients who attended their HCV visit were more likely to be alive by the end of 2018 (p=0.07). Conclusion Patients who missed an initial scheduled infectious disease (ID) clinic appointment for HCV treatment had higher rates of housing instability, transportation difficulties, and medication non-adherence. Patients diagnosed with HCV infection should be provided additional support as appropriate to address the social determinants of health that may limit linkage to outpatient HCV care.

Hepatitis C Elimination: Opportunities and Challenges in 2023

Hepatitis C Virus (HCV) infection is a leading etiology of liver cirrhosis and its associated complications, namely, decompensated cirrhosis. As such, hepatitis C potentially necessitates liver transplantation and may result in death. Recently, HCV treatment has evolved. Current HCV treatment is effective in curing HCV; some of the agents are pan-genotypic. Numerous countries have adopted an initiative to eliminate HCV. Achieving elimination poses many challenges; it requires improved availability and accessibility of pan-genotypic therapy. Barriers exist at the level of the collective healthcare system and at the level of the individual healthcare providers and patients. Therefore, organized national and local efforts are needed. Surmounting these barriers calls for interventions concerning screening, linkage to care, and treatment delivery. Pertinent barriers include inadequate availability of screening, ill-equipped laboratory testing before treatment, and insufficient access to treatment. Interventions should seek to decentralize laboratory testing and treatment provision, increase funding for resources and personnel, and spread awareness. Special consideration should be allocated to at-risk populations, such as intravenous drug users, refugees, and prisoners. Computerized medical filing and telemedicine have the potential to refine HCV management by enhancing detection, availability, accessibility, and cost-effectiveness.

Treatment of hepatitis C virus infection in people with opioid use disorder: a real-world study of elbasvir/grazoprevir in a US Department of Veterans Affairs population

Background: Hepatitis C virus (HCV) infections in the United States have increased in recent years, with the most rapid rise among people who inject drugs (PWIDs). Historically, there have been concerns regarding treatment adherence among PWIDs with HCV infection, leading to undertreatment of this population and increased HCV transmission. Elbasvir (EBR)/grazoprevir (GZR) has demonstrated high rates of virologic cure (sustained virologic response [SVR]) in clinical trials enrolling PWIDs with HCV infection. Objective: To evaluate the real-world effectiveness of EBR/GZR in HCV genotype (GT) 1-infected patients with a diagnosis of opioid use disorder. Methods: A retrospective analysis of electronic medical records from the US Department of Veterans Affairs Corporate Data Warehouse. Adults with chronic HCV GT1 infection, ≥1 prescription for EBR/GZR, and ≥1 clinic visit were included. All patients had ≥1 ICD-9/10 code of opioid use disorder. SVR was the primary outcome. Results: 419 patients were included; 97.1% had a history of any illicit drug use and 40.8% were receiving medication for opioid use disorder (MOUD). SVR was achieved by 96.9% (406/419) of all patients, 97.0% (350/361) of those receiving EBR/GZR for 12 weeks, and 95.3% (163/171) of those receiving MOUD. SVR in patients receiving psychiatric medications ranged from 96.1% (221/230) in those taking antidepressant medications to 98.5% (128/130) in those taking mood stabilizers. Conclusion: In this real-world setting, high rates of virologic cure were achieved in patients with HCV GT1 infection on MOUD receiving EBR/GZR for 12 weeks, including patients with multiple comorbidities and high rate of psychiatric medication use.

Viral hepatitis: A narrative review of hepatitis A–E

Viral hepatitis continues to be a major health concern leading to hepatic decompensation ranging from acute hepatitis to cirrhosis and hepatocellular carcinoma. The hepatic and extrahepatic manifestations are not only debilitating but also associated with a significant economic burden. Over the last two decades, the field of virology has made significant breakthroughs leading to a better understanding of the pathophysiology of viral hepatitis, which in turn has led to new therapeutic options. The advent of direct-acting antiviral agents changed the landscape of hepatitis C virus (HCV) therapy, and new drugs are in the pipeline for chronic hepatitis B virus (HBV) treatment. There has also been a significant emphasis on screening and surveillance programs, widespread availability of vaccines, and linkage of care. Despite these efforts, significant gaps persist in care, and there is a pressing need for increased collaboration and teamwork across the globe to achieve a reduction of disease burden and elimination of HBV and HCV.

Plasma Virome Reveals Blooms and Transmission of Anellovirus in Intravenous Drug Users with HIV-1, HCV, and/or HBV Infections

Intravenous drug users (IDUs) are a high-risk group for HIV-1, hepatitis C virus (HCV), and hepatitis B virus (HBV) infections, which are the leading causes of death in IDUs. However, the plasma virome of IDUs and how it is influenced by above viral infections remain unclear. Using viral metagenomics, we determined the plasma virome of IDUs and its association with HIV-1, HCV, and/or HBV infections. Compared with healthy individuals, IDUs especially those with major viral infections had higher viral abundance and diversity. Anelloviridae dominated plasma virome. Coinfections of multiple anelloviruses were common, and anelloviruses from the same genus tended to coexist together. In this study, 4,487 anellovirus ORF1 sequences were identified, including 1,620 (36.1%) with less than 69% identity to any known sequences, which tripled the current number. Compared with healthy controls (HC), more anellovirus sequences were observed in neg-IDUs, and HIV-1, HCV, and/or HBV infections further expanded the sequence number in IDUs, which was characterized by the emergence of novel divergent taxons and blooms of resident anelloviruses. Pegivirus was mainly identified in infected IDUs. Five main pegivirus transmission clusters (TCs) were identified by phylogenetic analysis, suggesting a transmission link. Similar anellovirus profiles were observed in IDUs within the same TC, suggesting transmission of anellome among IDUs. Our data suggested that IDUs suffered higher plasma viral burden especially anelloviruses, which was associated with HIV-1, HCV, and/or HBV infections. Blooms in abundance and unprecedented diversity of anellovirus highlighted active evolution and replication of this virus in blood circulation, and an uncharacterized role it may engage with the host.

IMPORTANCE Virome is associated with immune status and determines or influences disease progression through both pathogenic and resident viruses. Increased viral burden in IDUs especially those with major viral infections indicated the suboptimal immune status and high infection risks of these population. Blooms in abundance and unprecedented diversity of anellovirus highlighted its active evolution and replication in the blood circulation, and sensitive response to other viral infections. In addition, transmission cluster analysis revealed the transmission link of pegivirus among IDUs, and the individuals with transmission links shared similar anellome profiles. In-depth monitoring of the plasma virome in high-risk populations is not only needed for surveillance for emerging viruses and transmission networks of major and neglected bloodborne viruses, but also important for a better understanding of commensal viruses and their role it may engage with immune system.

Against All Odds? Addiction History Associated with Better Viral Hepatitis Care: A Dutch Nationwide Claims Data Study

The elimination of viral hepatitis in target populations is crucial in reaching WHO viral hepatitis elimination goals. Several barriers for the treatment of viral hepatitis in people with addictive disorders have been identified, yet nationwide data on hepatitis healthcare utilization (HCU) in these patients are limited. We investigated whether a history of addictive disorder is associated with suboptimal hepatitis HCU, indicating failure to receive diagnostic care or treatment. We identified all newly referred viral hepatitis patients in the Netherlands between 2014 and 2019 by query of the Dutch national hospital claims database. Each patient’s first year of HBV or HCV care activities was collected and clustered in two categories, ‘optimal’ or ‘suboptimal’ hepatitis HCU. Optimal HCU includes antiviral therapy. We tested the association between addiction history and HCU, adjusted for sex, age, migrant status, and comorbidity. In secondary analyses, we explored additional factors affecting hepatitis HCU. We included 10,513 incident HBV and HCV patients, with 13% having an addiction history. Only 47% of all patients achieved optimal hepatitis HCU. Addiction history was associated with less suboptimal HCU (adjusted OR = 0.73, 95% CI = 0.64–0.82). Migration background was associated with suboptimal HCU (OR = 1.62, 95% CI = 1.50–1.76). This study shows that addiction history is associated with higher viral hepatitis HCU; thus, this population performs better compared to non-addicted patients. However, less than 50% of all patients received optimal hepatitis care. This study highlights the need to improve hepatitis HCU in all patients, with a focus on migrant populations. Linkage to care in the addicted patients is not studied here and may be a remaining obstacle to be studied and improved to reach WHO viral hepatitis elimination goals.

Hepatitis C reinfection by treatment pathway among people who inject drugs in Tayside, Scotland

The efficacy of direct-acting antivirals (DAA) provides an excellent opportunity to scale up HCV diagnosis and treatment, achieving the WHO target of HCV elimination by 2030. However, HCV reinfection among people who inject drugs (PWID) remains a concern and may impede elimination efforts. We assessed reinfection rates among PWID across six specialized treatment pathways, following DAA-based and interferon-based therapies in Tayside, Scotland. Data were collected retrospectively for every treatment episode that resulted in a sustained viral response (SVR) after undergoing treatment. Reinfection rates were calculated for each treatment pathway: hospital outpatient clinic; community pharmacy; drug treatment outreach; prison clinic; nurse-led outreach clinic; and injection equipment provision site. Reinfection is defined as a positive RNA test result after SVR. Incidences of reinfection are expressed in 100 person-years (PYs). In total, 916 treatment episodes met selection criteria. Of these, 100 reinfections were identified, generating an overall reinfection rate of 5.27 per 100 PYs (95%CI: 4.36-6.38). The hospital outpatient clinic had the lowest reinfection incidence (1.81 per 100 PYs, 95%CI: 1.11-2.93), with the injection equipment provision site treatment pathway having the highest reinfection incidence (19.89 per 100 PYs, 95%CI: 14.91-26.54). The incidence of reinfection among those treated with interferon-based therapies and those treated with DAA-based therapies was 4.93 per 100 PYs (95%CI: 3.97-6.11) and 7.17 per 100 PYs (95%CI: 4.75-10.82), respectively. Specialized treatment pathways in Tayside yield varying reinfection incidence rates, with different subpopulations of patients at varying risk of reinfection post-SVR. Results suggest that resources should be targeted at the injection equipment provision site pathway in order to reduce the incidence of reinfection and achieve elimination targets. The study found comparable rates of reinfection following interferon-based and DAA-based therapies, providing support for widening access to treatment services.

On-site testing and case management to improve hepatitis C care in drug users: a prospective, longitudinal, multicenter study in the DAA era

Background

Screening and treatment of hepatitis C virus (HCV) infection in people who use drugs (PWUD) remains insufficient. Reducing the burden of HCV infection in PWUD requires interventions focusing on the different steps of the HCV care cascade.

Methods

We performed a prospective, multicenter study, evaluating the impact of an HCV care model on the HCV care cascade among PWUD attending an addiction care center in Belgium between 2015 and 2018. Interventions within the care model consisted of pre-test counseling, on-site HCV screening and case management services. A multiple logistic regression model was performed to identify the independent factors influencing the outcomes.

Results

During the study period, 441 PWUD were registered at the addiction care center, 90% (395/441) were contacted, 88% (349/395) were screened for HCV infection. PWUD were more likely to be screened if they had ever injected drugs (p < .001; AOR 6.411 95% CI 3.464–11.864). In 45% (157/349), the HCV antibody (Ab) test was positive, and in 27% (94/349) HCV RNA was positive. Within the Belgian reimbursement criteria (fibrosis stage ≥ F2), 44% (41/94) were treated. Specialist evaluation at the hospital was lower for PWUD receiving decentralized opioid agonist therapy (p = .005; AOR 0.430 95% CI 0.005–0.380), PWUD with unstable housing in the past 6 months before inclusion (p = .015; AOR 0.035 95% CI 0.002–0.517) or if they were recently incarcerated (p = .001; AOR 0.010 95% CI 0.001–0.164).

Conclusions

This HCV care model demonstrated high screening, linkage to care, and treatment initiation among PWUD in Belgium. Using the cascade of care to guide interventions is easy and necessary to monitor results. This population needs guidance, not only for screening and treatment initiation but also for the long-term follow-up since one in six had cirrhosis and could develop hepatocellular carcinoma. Further interventions are necessary to increase linkage to care and treatment initiation. Universal access to direct-acting antiviral therapy from 2019 will contribute to achieving HCV elimination in the PWUD population.

Trial registration

Clinical trial registration details: www.clinicaltrials.gov (NCT03106194).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11608-9.

Achieving Hepatitis C Elimination By Using Person-Centered, Nurse-Led Models of Care: A Discussion of Four International Case Studies

Nurse-led models of care are an important strategy in the management of patients with chronic disease because of the person-centered approach that allows the needs of the individual to be prioritized and addressed in accessible settings. Hepatitis C is caused by a blood-borne virus that can cause liver disease and liver cancer; it predominantly affects marginalized populations, including people who inject drugs. Since 2013, all oral, direct-acting antiviral regimens have been available to cure hepatitis C. Nurses are well placed to be involved in the delivery of hepatitis C testing and treatment because of their extensive reach within marginalized communities and holistic approach to patient care. Four case studies of nurse-led models of care operating in Australia, Canada, the United Kingdom, and the United States are presented to illustrate the important role nurses have in delivering accessible, person-centered hepatitis C testing and treatment. Each case study demonstrates the success of overcoming barriers to hepatitis C testing and treatment such as geographic isolation, incarceration, social marginalization, and inflexible healthcare systems. Achieving the global target to eliminate hepatitis C by 2030 will require the nursing profession to embrace its role as the first point of contact to the healthcare system for many members of marginalized communities potentially at risk of hepatitis C. Nurses are well placed to reduce barriers and facilitate access to healthcare by scaling up activities focused on hepatitis C testing and treatment.

Factors affecting hepatitis C treatment intentions among Aboriginal people in Western Australia: a mixed-methods study

Objective The aim of this study was to identify the hepatitis C treatment intentions of Aboriginal people living with hepatitis C virus (HCV) in Western Australia. Methods This study used a mixed-methods design. In the cross-sectional survey, 123 Aboriginal people who inject drugs and self-report as living with hepatitis C completed a purpose-designed questionnaire. In the qualitative phase, 10 participants were interviewed about the factors influencing their future intentions to undertake hepatitis C treatment. Results Analysis of the survey data revealed significant associations between an intention to undertake hepatitis C treatment and support, community attachment, stable housing and stigma. In addition, there was a high overall level of expressed intention to undertake HCV treatment, with 54% of participants responding positively. Analysis of the qualitative data supported quantitative findings, revealing concerns about stigma, lack of social support and unstable housing as factors affecting the intention to undertake hepatitis C treatment. Conclusion This mixed methods study with Aboriginal people living with self-reported HCV indicates interventions focused on reducing stigma and unstable housing could positively affect hepatitis C treatment intentions. These findings have implications for developing holistic programs to promote and support people on hepatitis C treatment. What is known about the topic? Substantial knowledge gaps need to be resolved if HCV elimination among Aboriginal Australians is to be achieved. Current research has prioritised non-Aboriginal communities. What does this paper add? This study found that stigma and unstable housing require attention if Aboriginal Australians are to obtain the full benefits of direct acting antiviral (DAA) hepatitis C treatment. What are the implications for practitioners? Reducing stigma (in the primary healthcare setting) and providing access to stable housing are vital components of supportive, non-judgemental and culturally appropriate care for Aboriginal people. This study highlights the importance of education for nurses and other primary care providers to increase engagement in the hepatitis cascade of care. To achieve this, scaling-up of HCV treatment engagement, trained Aboriginal community healthcare workers and HCV treatment advocates must mobilise and support Aboriginal people to avoid the negative effects of stigma, build positive and enabling relationships and reinforce positive attitudes towards DAA hepatitis C treatment.

Personal, provider and system level barriers and enablers for hepatitis C treatment in the era of direct-acting antivirals: Experiences of patients who inject drugs accessing treatment in general practice settings in Australia

Direct acting antiviral (DAA) treatment has made the elimination of hepatitis C virus (HCV) a realisable global public health goal and people who inject drugs are a key target population. This study investigates barriers and enablers to DAA treatment of HCV in general practice settings in Australia, from the patient perspective. Semi-structured interviews were conducted with 28 patients; of these patients, seventeen participants were currently on opioid agonist therapy, and four were currently injecting drugs. Thematic data analysis was undertaken and a personal, provider and systems framework was used to describe the barriers and enablers to DAA treatment. Results suggest a range of initiatives are required to support the uptake of DAA in general practice settings. These include the provision of formalised peer information and support, and increasing the accessibility of blood tests and liver assessment on-site. Further, there remains a need to address stigma and discrimination affecting people who inject drugs in community healthcare settings.

Cost-effectiveness of Hepatitis C Virus Treatment Models for People Who Inject Drugs in Opioid Agonist Treatment Programs

BACKGROUND

Many people who inject drugs in the United States have chronic hepatitis C virus (HCV). On-site treatment in opiate agonist treatment (OAT) programs addresses HCV treatment barriers, but few evidence-based models exist.

METHODS

We evaluated the cost-effectiveness of HCV treatment models for OAT patients using data from a randomized trial conducted in Bronx, New York. We used a decision analytic model to compare self-administered individual treatment (SIT), group treatment (GT), directly observed therapy (DOT), and no intervention for a simulated cohort with the same demographic characteristics of trial participants. We projected long-term outcomes using an established model of HCV disease progression and treatment (hepatitis C cost-effectiveness model: HEP-CE). Incremental cost-effectiveness ratios (ICERs) are reported in 2016 US$/quality-adjusted life years (QALY), discounted 3% annually, from the healthcare sector and societal perspectives.

RESULTS

For those assigned to SIT, we projected 89% would ever achieve a sustained viral response (SVR), with 7.21 QALYs and a $245 500 lifetime cost, compared to 22% achieving SVR, with 5.49 QALYs and a $161 300 lifetime cost, with no intervention. GT was more efficient than SIT, resulting in 0.33 additional QALYs and a $14 100 lower lifetime cost per person, with an ICER of $34 300/QALY, compared to no intervention. DOT was slightly more effective and costly than GT, with an ICER > $100 000/QALY, compared to GT. In probabilistic sensitivity analyses, GT and DOT were preferred in 91% of simulations at a threshold of <$100 000/QALY; conclusions were similar from the societal perspective.

CONCLUSIONS

All models were associated with high rates of achieving SVR, compared to standard care. GT and DOT treatment models should be considered as cost-effective alternatives to SIT.

A platform in the use of medicines to treat chronic hepatitis C (PLATINUM C): protocol for a prospective treatment registry of real-world outcomes for hepatitis C

BACKGROUND

Safe, highly curative, short course, direct acting antiviral (DAA) therapies are now available to treat chronic hepatitis C. DAA therapy is freely available to all adults chronically infected with the hepatitis C virus (HCV) in Australia. If left untreated, hepatitis C may lead to progressive hepatic fibrosis, cirrhosis and hepatocellular carcinoma. Australia is committed to eliminating hepatitis as a public health threat by 2030 set by the World Health Organization. However, since the introduction of funded DAA treatment, uptake has been suboptimal. Australia needs improved strategies for testing, treatment uptake and treatment completion to address the persisting hepatitis C public health problem. PLATINUM C is a HCV treatment registry and research platform for assessing the comparative effectiveness of alternative interventions for achieving virological cure.

METHODS

PLATINUM C will prospectively enrol people with active HCV infection confirmed by recent detection of HCV ribonucleic acid (RNA) in blood. Those enrolled will agree to allow standardised collection of demographic, lifestyle, treatment, virological outcome and other relevant clinical data to better inform the future management of HCV infection. The primary outcome is virological cure evidenced by sustained virological response (SVR), which is defined as a negative HCV PCR result 6 to 18 months after initial prescription of DAA therapy and no less than 12 weeks after the completion of treatment. Study participants will be invited to opt-in to medication adherence monitoring and quality of life assessments using validated self-reported instruments (EQ-5D-5L).

DISCUSSION

PLATINUM C is a treatment registry and platform for nesting pragmatic trials. Data collected will inform the design, development and implementation of pragmatic trials. The digital infrastructure, study procedures and governing systems established by the registry will allow PLATINUM C to support a wider research platform in the management of hepatitis C in primary care.

TRIAL REGISTRATION

The trial is registered with the Australia and New Zealand Clinical Trials Register ( ACTRN12619000023156 ). Date of registration: 10/01/2019.

HCV treatment barriers among HIV/HCV co-infected patients in the US: a qualitative study to understand low uptake among marginalized populations in the DAA era

BACKGROUND

Well-tolerated, highly effective HCV treatment, known as direct-acting antivirals (DAAs), is now recommended for all people living with HCV, providing the tools for HCV elimination. We sought to understand treatment barriers among low-income HIV/HCV coinfected patients and providers with the goal of increasing uptake.

METHODS

In 2014, we conducted 26 interviews with HIV/HCV co-infected patients and providers from a San Francisco clinic serving underinsured and publically-insured persons to explore barriers impacting treatment engagement and completion. Interview transcripts were coded, and a thematic analysis was conducted to identify emerging patterns.

RESULTS

Conditions of poverty-specifically, meeting basic needs for food, shelter, and safety-undermined patient perceptions of self-efficacy to successfully complete HCV treatment programs. While patient participants expressed interest in HCV treatment, the perceived burden of taking daily medications without strong social support was an added challenge. This need for support contradicted provider assumptions that, due to the shorter-course regimens, support is unnecessary in the DAA era.

CONCLUSIONS

Interferon-free treatments alone are not sufficient to overcome social-structural barriers to HCV treatment and care among low-income HIV/HCV co-infected patients. Support for patients with unmet social needs may facilitate treatment initiation and completion, particularly among those in challenging socioeconomic situations.

From peer-based to peer-led: redefining the role of peers across the hepatitis C care pathway: HepCare Europe

BACKGROUND

HCV infection disproportionately affects underserved populations such as homeless individuals, people who inject drugs and prison populations. Peer advocacy can enable active engagement with healthcare services and increase the likelihood of favourable treatment outcomes.

OBJECTIVES

This observational study aims to assess the burden of disease in these underserved populations and describe the role of peer support in linking these individuals to specialist treatment services.

METHODS

Services were identified if they had a high proportion of individuals with risk factors for HCV, such as injecting drug use or homelessness. Individuals were screened for HCV using point-of-care tests and a portable FibroScan. All positive cases received peer support for linkage to specialist care. Information was gathered on risk factors, demographics and follow-up information regarding linkage to care and treatment outcomes.

RESULTS

A total of 461 individuals were screened, of which 197 (42.7%) were chronically infected with HCV. Referral was made to secondary care for 176 (89.3%) and all received peer support, with 104 (52.8%) individuals engaged with treatment centres. Of these, 89 (85.6%) started treatment and 76 (85.4%) had a favourable outcome. Factors associated with not being approved for treatment were recent homelessness, younger age and current crack cocaine injecting.

CONCLUSIONS

Highly trained peer support workers working as part of a specialist outreach clinical team help to identify a high proportion of individuals exposed to HCV, achieve high rates of engagement with treatment services and maintain high rates of treatment success amongst a population with complex needs.

We know DAAs work, so now what? Simplifying models of care to enhance the hepatitis C cascade

Globally, some 71 million people are chronically infected with hepatitis C virus (HCV). Marginalized populations, particularly people who inject drugs (PWID), have low testing, linkage to care and treatment rates for HCV. Several models of care (MoCs) and service delivery interventions have the potential to improve outcomes across the HCV cascade of care, but much of the relevant research was carried out when interferon-based treatment was the standard of care. Often it was not practical to scale-up these earlier models and interventions because the clinical care needs of patients taking interferon-based regimens imposed too much of a financial and human resource burden on health systems. Despite the adoption of highly effective, all-oral direct-acting antiviral (DAA) therapies in recent years, approaches to HCV testing and treatment have evolved slowly and often remain rooted in earlier paradigms. The effectiveness of DAAs allows for simpler approaches and has encouraged countries where the drugs are widely available to set their sights on the ambitious World Health Organization (WHO) HCV elimination targets. Since a large proportion of chronically HCV-infected people are not currently accessing treatment, there is an urgent need to identify and implement existing simplified MoCs that speak to specific populations' needs. This article aims to: (i) review the evidence on MoCs for HCV; and (ii) distil the findings into recommendations for how stakeholders can simplify the path taken by chronically HCV-infected individuals from testing to cure and subsequent care and monitoring.

Development of an evidence-based model of rapid testing, counseling and referral patients with HIV, HVC and other STDs in Mexican addiction treatment centers

Introduction. Efforts to identify new cases of HIV, HVC and other STIs, through the application of quick tests, focus on people who inject drugs, without taking into account the fact that the use of alcohol and other drugs of abuse inhibits decision making, increasing the transmission of STIs through risky sexual practices. Accordingly, it is necessary to have detection algorithms that consider people who use multiple drugs to improve the identification of new cases and their subsequent linkage with health services. Objective. This paper describes the development process of the OPB-APR model for the detection, counseling and referral of people with HIV and other STIs at addiction treatment centers. Method. The procedure is divided into three phases: 1. A literature review to identify the basic concepts of HIV and other STIs, substance use, risky sexual behaviors, quick tests, and specialized psychological counseling; 2. A feasibility study in which a health professional is trained to implement the OPB-APR model; 3. Drafting of the final version. Results. The final version of the OPB-APR model was obtained, which describes standardized procedures for detection, counseling and referral to health services. Discussion and conclusions. The OPB-APR model aims to strengthen the public health system by increasing the coverage of services for the detection of HIV, HCV and other STIs. The above through the implementation of standardized procedures among specialized and non-specialized health professionals of addiction care centers.

Impact of Hepatitis C treatment on behavioural change in relation to drug use in people who inject drugs: A systematic review

BACKGROUND

A systematic review was conducted to determine the impact of Hepatitis C (HCV) treatment on substance use behaviour in people who inject drugs (PWID).

METHODS

A search for peer reviewed journal articles from 1991 to present day was conducted using the following databases: PubMed, EMBASE, CINAHL and PsycINFO. Studies were appraised against the following inclusion criteria: recruitment of PWID for HCV treatment (either interferon alpha or direct acting antivirals based); measurement of behavioural change in relation to drug use; studies published in English.

RESULTS

Five studies investigating the impact of HCV treatment on behavioural change in relation to drug use amongst PWID were identified. Studies investigated the impact of HCV treatment on past month injecting drug use (four studies), injecting frequency (two studies), needle and syringe borrowing (two studies) and injecting equipment sharing (three studies). Three of the four studies assessing impact of treatment on past month injecting frequency found treatment significantly reduced the odds of participants reporting past month injecting at follow up. One study found that there was significant reduction in weekly injecting frequency between enrolment, treatment and follow up. No association was found between treatment engagement and needle and syringe borrowing. Two out of three studies reported a significant decrease in injecting equipment sharing between enrolment, treatment and follow up.

CONCLUSIONS

Comparison and synthesis of results was challenging due to heterogeneity between studies. Moreover, four out of the five selected studies were conducted during the interferon era of treatment, possibly limiting the generalisability of the current review's results to the new DAA treatment era. However, it is likely that engaging in treatment has a positive impact upon patients' injecting drug use and injection equipment sharing behaviour. This raises the possibility that this may be an opportune time for further harm reduction measures.

Improving engagement with healthcare in hepatitis C: a randomised controlled trial of a peer support intervention

BACKGROUND

Peer support can enable patient engagement with healthcare services, particularly for marginalised populations. In this randomised controlled trial, the efficacy of a peer support intervention at promoting successful engagement with clinical services for chronic hepatitis C was assessed.

METHODS

In London, UK, potential participants were approached through outreach services for problematic drug use and homelessness. Individuals positive for hepatitis C virus (HCV) after confirmatory testing were randomised using an online service to the intervention (peer support) or standard of care. The primary outcome of interest was successful engagement with clinical hepatitis services. The study was non-blinded. Absolute differences were calculated using a generalised linear model and the results compared to logistic regression.

RESULTS

Three hundred sixty-four individuals consented to participate. One hundred one had chronic hepatitis C and were randomised, 63 to receive the intervention (peer support). A successful outcome was achieved by 23 individuals in this arm (36.5%) and seven (18.4%) receiving the standard of care, giving an absolute increase of 18.1% (95% confidence interval 1.0-35.2%, p value = 0.04). This was mirrored in the logistic regression (odds ratio 2.55 (0.97-6.70), p = 0.06). No serious adverse events were reported.

CONCLUSIONS

Peer support can improve the engagement of patients with chronic HCV with healthcare services.

TRIAL REGISTRATION

ISRCTN24707359 . Registered 19th October 2012.

Detecting spatial clusters of HIV and hepatitis coinfections

BACKGROUND

People with HIV infection in the United States are often affected by chronic viral hepatitis. These coinfected people with either HBV or HCV are at increased risk for serious, life-threatening complications. Coinfections with viral hepatitis may also complicate the delivery of anti-retroviral therapy (ART) by escalating the risk of drug-related hepatoxicity. According to the Centers for Disease Control and Prevention (CDC), approximately 10 percent of people with HIV in the United States also have HBV, and 25 percent also have HCV coinfection. With the advent of highly active antiretroviral therapy (HAART) and the increased life-expectancy of HIV patients, clinicians are more likely to be confronted with issues related to co-infection and the management challenges that they present, especially in resource-limited settings. The purpose of this analysis was to identify geographical clusters of HIV- (HBV/HCV) co-infection and compared to the geographical clusters of not co-infected using DC, Department of Health surveillance data. The results of the analysis will be used to target resources to areas at risk.

METHODS

HIV and Hepatitis surveillance data were matched among cases diagnosed between 1980 and 2016. HIV-hepatitis co-infected and the not co-infected spatial clusters were detected using discrete Poisson model. Kulldorff's spatial scan statistic method was implemented in the free software tool called SaTScan which has been widely adopted for detecting disease cluster. The analysis was conducted by tracts, but for visualization, ease of interpretation and assist in policy making the tract map was overlaid with the ward map using ArcGIS 10.5.1.

RESULTS

Between 1980 and 2016, there were 12,965 diagnosed cases of HIV, of which 2,316 HIV/Hepatitis matches were identified. Of the 2316 co-infected people living in DC, 25 percent (N = 590) of people had HBV, and 75 percent (N = 1,726) had HCV. Out of 12,965 diagnosed cases, remaining 10,649 did not have any co-infections (not co-infected). IDU (27.16 percent) and MSM (32.86 percent) were the highest mode of transmission for co-infected population. African-American were reported 83.64 percent (N = 1,937) among co-infection population. Three clusters were identified for both co-infected population in DC. The largest cluster radius for co-infected analysis covers wards 6, 7 and 8 as well as large parts of 2 and 5 (p < 0.001). Multiple clusters were identified for not co-infected population (p < 0.001). IDU (n = 450) was the highest mode of transmission for the co-infected clusters. For all clusters combined of not co-infected population highest mode of transmission were MSM (n = 2,534). This analysis also showed racial disparity, economic deprivation and lack of education were prominent in the co-infected clusters.

CONCLUSION

We identified locations of high risk clusters where enhanced hepatitis and HIV prevention, treatment, and care can help combat the epidemic. The clusters radius expands into the neighboring state of Maryland as well. The findings from this analysis will be used to target area based public health policy and healthcare interventions for HIV-hepatitis. It is recommended based on the analysis that needle exchange programs can successfully control new HIV infections as well as hepatitis co-infections.

Hepatitis C infection substantially reduces survival of alcohol-dependent patients

Background

Heavy alcohol use is associated with life-threatening complications including progressive liver disease. We aimed to analyze the impact of hepatitis C virus (HCV) infection on survival and liver-related death in alcohol-dependent patients.

Patients and methods

This is a longitudinal study in patients seeking treatment of alcohol abuse between 2000 and 2010. Information on alcohol use characteristics, alcoholic liver disease, and HCV infection were obtained at entry. Cumulated mortality and causes of death were ascertained through clinical records and death registry.

Results

A total of 819 patients (81.6% men) underwent ethanol detoxification; age was 44 (inter-quartile range [IQR] 38-51) years; the duration of heavy alcohol use was 14 (IQR 6-24) years; and the alcohol consumption was 190 (IQR 120-250) g/day. The prevalence of HCV infection was 15.8%. There were 129 (16.9%) deaths during 5,117 persons-year (p-y) of follow-up (median follow-up 6.4 [IQR 4.3-9.2] years); 31 (24.6%) deaths were observed among the HCV-positive patients, and 98 (15.4%) deaths were observed among the HCV-negative patients. The mortality rate was significantly (P=0.03) higher among the HCV-positive patients (3.84×100 p-y; 95% confidence interval [CI]: 2.70, 5.46) than among the HCV-negative patients (2.27×100 p-y; 95% CI: 1.86, 2.77). Survival times for the HCV infected patients were 34% shorter (time ratio relative to HCV negative: 0.66; 95% CI: 0.51, 0.86). The main causes of death in the HCV-positive and -negative patients were liver-related mortality (48.4%) and neoplasia (22.4%), respectively. The liver-related mortality was significantly higher among the HCV-positive patients (adjusted sub-distribution hazard ratio [asHR] 3.65; 95% CI: 1.72, 7.78; P=0.001).

Conclusion

HCV infection compromises the survival of patients with alcohol abuse/dependence. The new direct antiviral agents for the treatment of HCV infection may result in better clinical outcomes.

Mapping the Barriers and Facilitators of HCV Treatment Initiation in Methadone Maintenance Therapy Patients: Implications for Intervention Development

An estimated 70-90% of current methadone users have Hepatitis C (HCV). Current treatments have few side effects and can cure infection in 8-12 weeks, but less than 10% of methadone patients initiate treatment. Engaging this group in treatment is an important strategy to lower both morbidity and mortality from liver disease and eliminate a significant reservoir of HCV in communities. To understand how to address this treatment gap we used commercial marketing techniques called perceptual mapping and vector message modeling to analyze survey data from 100 HCV+ methadone patients from four centers in Philadelphia. Results were used to understand barriers and facilitators to treatment initiation and to devise targeted message strategies to adapt to a mobile health communication intervention. Results indicate that focusing on how treatment can make one feel "in charge", positive interactions with healthcare providers, the positive attributes of the new vs. old HCV treatments, and providing strategies to address tangible barriers to getting treatment, would be important to address in a communication intervention. These marketing methods allow for focusing on specific variables to "move" the group toward a treatment decision, making them an innovative technique to use in developing highly targeted health communication messages.

Access to treatment for Hepatitis C among injection drug users: results from the cross-sectional HOPE IV study

Background

Evidence suggests that Greece is among the European countries with increased trend in HCV prevalence among injecting drug users (IDUs) from 2008 to 2014. Nonetheless, the access of IDUs to treatment for Hepatitis C Virus (HCV) is very limited while the risk of co-infection and transmission remains high. In an effort to better understand the inhibitors to HCV treatment, the present study aimed to investigate the main barriers to access in a sample of IDUs.

Methods

The cross-sectional study was carried out between July and September 2015 using a 23-items questionnaire. Participants were recruited from urban primary services, mobile health vans, community health services, day-care centers as well as during street work, located in Athens, Greece. Inclusion criteria were age above 18 years, understanding and speaking Greek sufficiently, HCV diagnosis, intravenous drug use. Data collection was carried out by health professionals of Praksis, a non-governmental organization. For the comparisons of proportions chi-square and Fisher’s exact tests were used.

Results

The study sample consisted of 101 HCV patients, 68% male. More than 80% of study participants experienced barriers in accessing their doctor and medication during the past 12 months. The most common obstacles in accessing a doctor were “delay in making the appointment and “difficulties in going to the doctor due to health condition or lack of means of transport”. Access to physician or medication was not differed according to gender, but significant differences were found according to economic status and health insurance coverage. 56.1% of participants reported loss or treatment delay due to barriers to treatment. The majority of participants had deteriorated financial status, health status, access to health services and medication, higher financial burden for health services, worse mental health and lower adherence to medical instructions in 2015 compared to 2009.

Conclusions

The findings from the present study revealed that the vast majority of IDUs experience significant barriers in seeking HCV care in Greece, thus highlighting the need for immediate action in this particular area due to the high risk of co-infection and transmission.

Adherence to response-guided pegylated interferon and ribavirin for people who inject drugs with hepatitis C virus genotype 2/3 infection: the ACTIVATE study

BACKGROUND

The aims of this analysis were to investigate treatment completion and adherence among people with ongoing injecting drug use or receiving opioid substitution therapy (OST) in a study of response-guided therapy for chronic HCV genotypes 2/3 infection.

METHODS

ACTIVATE was a multicenter clinical trial recruited between 2012 and 2014. Participants with genotypes 2/3 were treated with directly observed peg-interferon alfa-2b (PEG-IFN) and self-administered ribavirin for 12 (undetectable HCV RNA at week 4) or 24 weeks (detectable HCV RNA at week 4). Outcomes included treatment completion, PEG-IFN adherence, ribavirin adherence, and sustained virological response (SVR, undetectable HCV RNA >12 weeks post-treatment).

RESULTS

Among 93 people treated, 59% had recently injected drugs (past month), 77% were receiving OST and 56% injected drugs during therapy. Overall, 76% completed treatment. Mean on-treatment adherence to PEG-IFN and ribavirin were 98.2% and 94.6%. Overall, 6% of participants missed >1 dose of PEG-IFN and 31% took <95% of their prescribed ribavirin., Higher treatment completion was observed among those receiving 12 vs. 24 weeks of treatment (97% vs. 46%, P < 0.001) while the proportion of participants with 95% on-treatment ribavirin adherence was similar between groups (67% vs. 72%, P = 0.664). Receiving 12 weeks of therapy was independently associated with treatment completion. No factors were associated with 95% RBV adherence. Neither recent injecting drug use at baseline nor during therapy was associated with treatment completion or adherence to ribavirin. In adjusted analysis, treatment completion was associated with SVR (aOR 23.9, 95% CI 2.9-193.8).

CONCLUSIONS

This study demonstrated a high adherence to directly observed PEG-IFN and self-administered ribavirin among people with ongoing injecting drug use or receiving OST. These data also suggest that shortening therapy from 24 to 12 weeks can lead to improved treatment completion. Treatment completion was associated with improved response to therapy. ACTIVATE trial registration number: NCT01364090 - May 31, 2011.

Beyond the 90-90-90: refocusing HIV prevention as part of the global HIV response

INTRODUCTION

The remarkable expansion in availability of antiretroviral therapy (ART) over the past two decades has transformed HIV infection into a manageable chronic condition. People with HIV infection now live long and healthy lives on treatment that is simpler, safer and cheaper. According to UNAIDS estimates, the global coverage of ART reached 46% in 2015, resulting in a 26% decrease in annual HIV-related deaths since 2010. Such success has positioned treatment access at the centre of the global HIV response as a way to prevent mortality, morbidity and HIV transmission through a "Treat All" approach. Continuing expansion of treatment is needed to further reduce HIV-related mortality. This progress with treatment, however, masks a stagnation in the estimated annual number of new HIV infections. Continuing levels of HIV incidence despite treatment scale-up stem from several factors, which should be addressed in order to prevent new infections and decrease the numbers of people requiring treatment in the future.

DISCUSSION

ART can only reach those already diagnosed, and although it is unclear what proportion of new infections occur during acute and early infection prior to treatment initiation, phylogenetic studies suggest that it might be substantial. Thus, better testing approaches to reach the 40% of people with undiagnosed HIV infection as early as possible are critical. New approaches to reach men, young people and key populations, where HIV risk is highest and HIV prevention, testing and treatment coverage is lowest, are also needed. Overall coverage of effective prevention interventions remains low, enabling HIV transmission to occur, or time is required to show population-level effects. For example, the full impact of the medical male circumcision intervention will be seen once a larger proportion of men in age cohorts with high incidence are circumcised. Finally, strategically focused pre-exposure prophylaxis interventions have the potential to prevent HIV acquisition among populations at substantial risk, averting treatment costs in coming years.

CONCLUSIONS

The United Nations (UN) targets to end AIDS include the "90-90-90" targets for HIV diagnosis, treatment and viral suppression. While 90-90-90 has been widely emphasized and adopted by countries and international funders, the focus thus far has largely been on increasing access to ART - the second "90." A similar emphasis on achieving UN HIV prevention targets and adequate funding for meeting these is essential, alongside treatment, in order to reduce population-level incidence and change the trajectory of the HIV epidemic over the long term.

Inability to access health and social services associated with mental health among people who inject drugs in a Canadian setting

BACKGROUND

People who inject drugs (PWID) face barriers to healthcare due to reasons including comorbidity. We evaluated access to health and social services by three of the most prevalent comorbid conditions among PWID: HIV, hepatitis C (HCV), and mental health, in an urban setting in Canada.

METHODS

Data were derived from prospective cohorts of community-recruited PWID between 2005 and 2015. HIV and HCV serostatuses were based on antibody tests, while mental health conditions and inability to access health and social services (barriers to access) were determined by participants' self-report. We employed generalized linear mixed models controlling for confounders to examine associations between health conditions and barriers to access.

RESULTS

Among 2494 participants, 1632 (65.4%) reported barriers to access at least once over a median of seven (IQR: 3, 12) semi-annual assessments. Mental health conditions were independently associated with increased odds of reporting barriers (adjusted Odds Ratio (aOR): 1.45, 95% Confidence Interval (CI): 1.32, 1.58), while HIV was not (aOR: 0.96, 95% CI: 0.85, 1.08), and HCV was associated with decreased odds (aOR: 0.80, 95% CI: 0.69, 0.93). The associations between mental health conditions and barriers to access were consistent among PWID without HIV/HCV (aOR: 1.35, 95% CI: 1.10, 1.65), with HCV mono-infection (aOR: 1.55, 95% CI: 1.37, 1.75), and HCV/HIV co-infection (aOR: 1.36, 95% CI: 1.15, 1.60).

CONCLUSIONS

Targeted strategies to seek and treat mental health conditions in settings that serve PWID, and assist PWID with mental health conditions in navigating healthcare system may improve the publicly-funded health and social services.

Facilitators of HCV treatment adherence among people who inject drugs: a systematic qualitative review and implications for scale up of direct acting antivirals

BACKGROUND

While the public health benefits of new HCV treatments depend on treatment adherence, particularly among people who inject drugs (PWID), several social and medical factors can jeopardize treatment adherence. The aim of this study is to examine the qualitative literature on facilitators to HCV treatment adherence among PWID.

METHODS

We searched six databases to identify qualitative research studies on HCV treatment adherence facilitators among PWID. Two reviewers independently extracted and analyzed data using PRISMA guidelines and the CASP tool to evaluate study quality.

RESULTS

From ten studies representing data from 525 participants, three major themes emerged across studies: logistical facilitators within health systems enhanced HCV treatment adherence, positive social interactions between PWID and staff provided positive feedback during treatment, and HCV treatment may complicate the addiction recovery process.

CONCLUSIONS

Although PWID face several barriers to adherence, we identified treatment adherence facilitators that could be incorporated into clinical practice.

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.

Treatment for hepatitis C virus infection among people who inject drugs attending opioid substitution treatment and community health clinics: the ETHOS Study

AIMS

To estimate adherence and response to therapy for chronic hepatitis C virus (HCV) infection among people with a history of injecting drug use. A secondary aim was to identify predictors of HCV treatment response.

DESIGN

Prospective cohort recruited between 2009 and 2012. Participants were treated with peg-interferon alfa-2a/ribavirin for 24 (genotypes 2/3, G2/3) or 48 weeks (genotype 1, G1).

SETTING

Six opioid substitution treatment (OST) clinics, two community health centres and one Aboriginal community-controlled health organization providing drug treatment services in New South Wales, Australia.

PARTICIPANTS

Among 415 people with a history of injecting drug use and chronic HCV assessed by a nurse, 101 were assessed for treatment outcomes (21% female).

MEASUREMENTS

Study outcomes were treatment adherence and sustained virological response (SVR, undetectable HCV RNA >24 weeks post-treatment).

FINDINGS

Among 101 treated, 37% (n = 37) had recently injected drugs (past 6 months) and 62% (n = 63) were receiving OST. Adherence ≥ 80% was 86% (n = 87). SVR was 74% (75 of 101), with no difference observed by sex (males: 76%, females: 67%, P = 0.662). In adjusted analysis, age < 35 (versus ≥ 45 years) [adjusted odds ratio (aOR) = 5.06, 95% confidence interval (CI) = 1.47, 17.40] and on-treatment adherence ≥ 80% independently predicted SVR (aOR = 19.41, 95% CI = 3.61, 104.26]. Recent injecting drug use at baseline was not associated with SVR.

CONCLUSIONS

People with a history of injecting drug use and chronic hepatitis C virus attending opioid substitution treatment and community health clinics can achieve adherence and responses to interferon-based therapy similar to other populations, despite injecting drugs at baseline. Younger age and adherence are predictive of improved response to hepatitis C virus therapy.

Understanding decisions made about hepatitis C treatment by couples who inject drugs

Efforts to increase the number of people having hepatitis C virus (HCV) treatment require understanding how to best deliver services to meet consumers' needs. The general health literature has examined the role that partners can play in supporting health outcomes. This study examines the experiences of couples who inject drugs in relation to knowledge of, decisions about and management of HCV treatment. This is a qualitative interview study of people who inject drugs in couples. Participants were recruited from harm reduction services in two major Australian cities. Couples were interviewed separately. Data were examined using the couple as the unit of analysis and to identify patterns of experience related to the HCV serostatus of couples. Knowledge of HCV and HCV treatment was low and variable but showed some relationship to serostatus. Decisions about HCV treatment were deeply informed by concerns regarding treatment side effects. Positive concordant couples considered 'staging' treatment to ensure that each partner could (in turn) care for the other. People with HCV in serodiscordant relationships may need specific support regarding HCV treatment information. Within positive concordant partnerships, our data indicated the need to support the HCV-positive 'carer' during their partner's treatment. Changing treatment regimens, and their anticipated lower side effect profiles, will need to be actively promoted to ensure that couples understand how these changes affect their treatment options.

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.

Access to hepatitis C treatment for people who inject drugs in low and middle income settings: Evidence from 5 countries in Eastern Europe and Asia

BACKGROUND

People who inject drugs (PWID) are disproportionately affected by the hepatitis C (HCV) epidemic. Of the estimated 16 million PWID worldwide, approximately 8 million live with chronic HCV, and around 26% and 23% of the global HCV infections among PWID occur in East/Southeast Asia and Eastern Europe respectively. Globally, few PWID have access to treatment for HCV.

METHODS

We conducted a systematic literature review and internet survey in 2014 to document the burden of disease, access to diagnosis and treatment and the existence of national policy and treatment guidelines for HCV. We included Georgia, Russia, Ukraine, Myanmar and Indonesia as countries with injection drug use epidemics.

FINDINGS

HCV antibody prevalence among the general population ranged from 0.80% in Indonesia to 5% in Georgia, and among PWID from 48.1% in Myanmar to 92% in Georgia. PWID carried a significant burden of disease, ranging from 2.7% in Indonesia to 40.4% in Russia. Yearly treatment uptake was under 1% for the general population and PWID in all countries. Diagnostic tools and disease staging investigations as well as pegylated interferon/ribavirin treatment were available at a range of prices. Despite policy and treatment protocols for HCV in the majority of countries, strategies focusing on PWID were largely absent.

CONCLUSION

PWID are a priority group for treatment, and access to treatment should be based on sound national policy, accessible public treatment programmes and functional surveillance systems.

Assessment and delivery of treatment for hepatitis C virus infection in an opioid substitution treatment clinic with integrated peer-based support in Newcastle, Australia

BACKGROUND

Among people who inject drugs (PWID), the prevalence of hepatitis C virus (HCV) infection is high; however HCV treatment uptake remains low. New models of care are needed to address the growing burden of HCV-related disease in PWID and to understand the barriers to assessment and treatment of HCV. This study evaluated assessment and treatment for HCV infection among PWID attending an opioid substitution treatment (OST) clinic with an integrated peer support worker model.

METHODS

Clients with a history of IDU and chronic HCV infection, attending the Newcastle Pharmacotherapy Service, Newcastle Australia, were recruited as part of a multisite prospective observational study (the ETHOS Cohort). Additional chart review was conducted for clients not enrolled in the ETHOS Cohort. A peer support worker was introduced to complement and extend services offered by the clinical team. Client contacts and assessments with a nurse and/or peer worker were evaluated, including those who commenced HCV treatment.

RESULTS

A total of 1447 clients attended the OST service during February 2009 and June 2014. Of these, 378 (26%) were assessed by a nurse and 242 (17%) by a clinician. HCV treatment was commenced by 20 (5%) participants and 15 (75%) achieved a sustained virological response (SVR). During May 2009 and July 2011, 332 nurse contacts and 726 peer worker contacts were evaluated. The nurse-led contacts were related to HCV treatment (50%) and review of pathology tests (34%), whereas peer worker contacts included discussion about HCV treatment (75%), education, counselling and/or support (53%) and general discussion about HCV infection (59%).

CONCLUSION

These data demonstrate that peer support workers facilitate broader discussion about HCV treatment, education and/or support, allowing nurses to focus on HCV-related assessment and treatment. HCV treatment uptake was very low in this cohort, but SVR was high. The integration of peer support workers in treatment programs within OST clinics may address barriers to HCV care, but further studies are needed to assess their impact on assessment and treatment outcomes.

Protease inhibitors to treat hepatitis C in the Swiss HIV Cohort Study: high efficacy but low treatment uptake

OBJECTIVES

Direct-acting antiviral agents (DAAs) have become the standard of care for the treatment of chronic hepatitis C virus (HCV) infection. We aimed to assess treatment uptake and efficacy in routine clinical settings among HIV/HCV coinfected patients after the introduction of the first generation DAAs.

METHODS

Data on all Swiss HIV Cohort Study (SHCS) participants starting HCV protease inhibitor (PI) treatment between September 2011 and August 2013 were collected prospectively. The uptake and efficacy of HCV therapy were compared with those in the time period before the availability of PIs.

RESULTS

Upon approval of PI treatment in Switzerland in September 2011, 516 SHCS participants had chronic HCV genotype 1 infection. Of these, 57 (11%) started HCV treatment during the following 2 years with either telaprevir, faldaprevir or boceprevir. Twenty-seven (47%) patients were treatment-naïve, nine (16%) were patients with relapse and 21 (37%) were partial or null responders. Twenty-nine (57%) had advanced fibrosis and 15 (29%) had cirrhosis. End-of-treatment virological response was 84% in treatment-naïve patients, 88% in patients with relapse and 62% in previous nonresponders. Sustained virological response was 78%, 86% and 40% in treatment-naïve patients, patients with relapse and nonresponders, respectively. Treatment uptake was similar before (3.8 per 100 patient-years) and after (6.1 per 100 patient-years) the introduction of PIs, while treatment efficacy increased considerably after the introduction of PIs.

CONCLUSIONS

The introduction of PI-based HCV treatment in HIV/HCV-coinfected patients improved virological response rates, while treatment uptake remained low. Therefore, the introduction of PIs into the clinical routine was beneficial at the individual level, but had only a modest effect on the burden of HCV infection at the population level.

Human rights and access to hepatitis C treatment for people who inject drugs

BACKGROUND

People who inject drugs (PWID) achieve adherence to and outcomes from hepatitis C virus (HCV) treatment comparable to other patients. Nonetheless, this population has been excluded from treatment by regulation or practice. Approval of safer and more effective oral HCV medicines should offer greater treatment options for PWID, although high medicine prices have led to continued treatment rationing and exclusion in developed countries. In middle-income countries (MICS), treatment is largely unavailable and unaffordable for most PWID.

METHODS

Human rights analysis, with its emphasis on the universal and interconnected nature of the economic, social and political spheres, offers a useful framework for HCV treatment reform. Using peer-reviewed and grey literature, as well as community case reports, we discuss barriers to treatment, correlate these barriers to rights violations, and highlight examples of community advocacy to increase treatment for PWID.

RESULTS

Structural drivers of lack of treatment access for PWID include stigma in health settings; drug use status as a criterion for treatment exclusion; requirements for fees or registration by name as a drug user prior to treatment initiation; and incarceration/detention in prisons and rehabilitation centers where treatment is unavailable. High medicine prices force further exclusion of PWID, with cost containment masked as concern about treatment adherence. These barriers correlate to multiple rights violations, including of the rights to privacy; non-discrimination; health; freedom of information; fair trial; and freedom from cruel, inhuman and degrading treatment.

CONCLUSIONS

Needed reforms include decriminalization of drug use, possession of drugs and drug injecting equipment; removal of exclusionary or discriminatory treatment protocols; approaches to strengthen links between health providers and increase participation of PWID in treatment design and implementation; and measures to increase transparency in government/pharmaceutical company negotiations and reduce treatment price.

Addressing viral hepatitis in the opiate substitution setting: an integrated nursing model of care

Despite the availability of effective therapies for hepatitis C virus (HCV) and B virus (HBV), only a minority of infected patients receive treatment. In the general population, morbidity and mortality associated with chronic HCV is now successfully being addressed through the use of antiviral therapy. In Australia, an estimated 41% to 68% of people who inject drugs (PWID) are HCV positive, and between 28% and 59% of users are estimated to have been exposed to HBV. Although current treatment guidelines suggest that active drug use should not preclude people from HCV treatment, uptake of therapy thus far has been low. Patient, physician, social, and logistical-related barriers contribute to the low uptake of HCV treatment among PWID. Traditional means of managing HCV infection—referral to secondary or tertiary health centers—historically has a poor track record in increasing therapy uptake among this population. The same is true for people with chronic HBV who inject drugs. Close to 50,000 Australians receive opioid substitution therapy (OST) through a range of services, including public and private clinics, thus this setting is an ideal target for identifying and treating people at risk for and already infected with HBV and HCV. Over the last 11 years, a nursing model of care initiated by a teaching hospital in Sydney, Australia that integrates viral hepatitis screening, assessment, and treatment into the OST setting has enhanced access to services among the marginalized injecting drug use population.

Predictors of accessing antiretroviral therapy among HIV-positive drug users in China's National Methadone Maintenance Treatment Programme

AIMS

The objective of this study was to examine factors that predict antiretroviral therapy (ART) access among eligible, HIV-positive methadone maintenance treatment (MMT) clients. We also tested the hypothesis that sustained MMT participation increases the likelihood of accessing ART.

DESIGN

A nation-wide cohort study conducted from 1 March 2004 to 31 December 2011.

SETTING

MMT clients were followed from the time of their enrolment in China's national MMT programme until their death or the study end date.

PARTICIPANTS

Our cohort comprised 7111 ART-eligible, HIV-positive MMT clients, 49.2% of whom remained ART-naive and 50.8% of whom received ART.

MEASUREMENTS

Demographic variables, drug use history, MMT programme participation and HIV-related clinical characteristics of study participants who remained naive to ART and those who accessed ART were compared by univariate and multivariable analysis.

FINDINGS

Predictors of accessing ART among this cohort included being retained in MMT at the time of first meeting ART eligibility [adjusted odds ratio (AOR)=1.84, confidence interval (CI)=1.54-2.21, P<0.001] compared to meeting ART eligibility before entering MMT (AOR=0.98, CI=0.80-1.21, P=0.849) or previously entering MMT and dropping out before meeting ART eligibility. Additional predictors were CD4≤200 cells/μl when ART-eligibility requirement was first met (AOR=1.81, CI=1.61-2.05, P<0.001 compared to CD4=201-350 cells/μl), and being in a stable partner relationship (married/cohabitating: AOR=1.14, CI=1.01-1.28, P=0.030).

CONCLUSIONS

Retained participation in methadone maintenance treatment increases the likelihood that eligible clients will access antiretroviral therapy. These results highlight the potential benefit of colocalization of methadone maintenance treatment and antiretroviral therapy services in a 'one-stop-shop' model.

The 3rd Canadian Symposium on Hepatitis C Virus: expanding care in the interferon-free era

Hepatitis C virus (HCV) currently infects approximately 250,000 individuals in Canada and causes more years of life lost than any other infectious disease in the country. In August 2011, new therapies were approved by Health Canada that have achieved higher response rates among those treated, but are poorly tolerated. By 2014⁄2015, short-course, well-tolerated treatments with cure rates >95% will be available. However, treatment uptake is poor due to structural, financial, geographical, cultural and social barriers. As such, 'Barriers to access to HCV care in Canada' is a crucial topic that must be addressed to decrease HCV disease burden and potentially eliminate HCV in Canada. Understanding how to better care for HCV-infected individuals requires integration across multiple disciplines including researchers, clinical services and policy makers to address the major populations affected by HCV including people who inject drugs, baby boomers, immigrants and Aboriginal and⁄or First Nations people. In 2012, the National CIHR Research Training Program in Hepatitis C organized the 1st Canadian Symposium on Hepatitis C Virus (CSHCV) in Montreal, Quebec. The 2nd CSHCV was held in 2013 in Victoria, British Columbia. Both symposia were highly successful, attracting leading international faculty with excellent attendance leading to dialogue and knowledge translation among attendees of diverse backgrounds. The current article summarizes the 3rd CSHCV, held February 2014, in Toronto, Ontario.

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.

Continued low uptake of treatment for hepatitis C virus infection in a large community-based cohort of inner city residents

BACKGROUND & AIMS

Despite advances in HCV treatment, recent data on treatment uptake is sparse. HCV treatment uptake and associated factors were evaluated in a community-based cohort in Vancouver, Canada.

METHODS

The CHASE study is a cohort of inner city residents recruited from January 2003-June 2004. HCV status and treatment were retrospectively and prospectively determined through data linkages with provincial virology and pharmacy databases. Logistic regression analyses were used to identify factors associated with HCV treatment uptake.

RESULTS

Among 2913, HCV antibody testing was performed in 2405, 64% were HCV antibody-positive (n = 1533). Individuals with spontaneous clearance (18%, n = 276) were excluded. Among the remaining 1257 HCV antibody-positive participants (mean age 42, 71% male), 29% were Aboriginal. At enrolment, the majority reported recent injecting (60%) and non-injecting drug use (87%). Between January 1998 and March 2010, 6% (77 of 1257) initiated HCV treatment. In adjusted analyses, Aboriginal ethnicity [adjusted odds ratio (AOR) 0.23; 95% CI 0.10, 0.51] and crack cocaine use (AOR 0.61; 95% CI 0.37, 0.99) were associated with a decreased odds of receiving HCV treatment, while methamphetamine injecting (AOR 0.16; 95% CI 0.02, 1.18) trended towards a lower odds of receiving treatment. HCV treatment uptake ranged from 0.2 (95% CI 0.0, 0.7) per 100 person-years (PYs) in 2003 to 1.6 (95% CI 0.9, 2.6) per 100 PYs in 2009.

CONCLUSION

HCV treatment uptake remains low in this large community-based cohort of inner city residents with a high HCV prevalence and access to universal healthcare.