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

Patients' access to and acceptance of community-based hepatitis C testing and treatment in Myanmar: A mixed-method study

Hepatitis C (HCV) infection elimination in low- and middle-income countries requires decentralised HCV services to increase testing and linkage to care. The CT2 Study investigated patients' views of access to and acceptance of two community-based HCV care models in Myanmar using a mixed-methods approach. Point-of-care HCV testing and general practitioner-initiated HCV treatment were provided at two community clinics in Yangon, Myanmar-the Burnet Institute's (BI) clinic focused on people who inject drugs (PWID), and the Myanmar Liver Foundation's (MLF) clinic focused on people with liver-related diseases. Study staff administered quantitative questionnaires to 633 participants receiving anti-HCV antibody testing. Purposive sampling was used to recruit 29 participants receiving direct-acting antiviral treatment for qualitative interviews. Among participants completing quantitative questionnaires, almost all reported the clinic location was convenient (447/463, 97%), waiting time was acceptable (455/463, 98%), and HCV antibody and RNA testing methods were acceptable (617/632, 98% and 592/605, 97% respectively). Nearly all participants were satisfied with their clinic's services (444/463, 96%) and preferred same-day test results (589/632, 93%). BI clinic participants were more confident that they understood HCV antibody and RNA results; MLF clinic participants were more comfortable disclosing their risk behaviour to staff and had slightly higher satisfaction with the overall care, privacy and secure storage of their information. In qualitative interviews, participants reported that flexible appointment scheduling, short wait times and rapid return of results increased the clinic's accessibility. The simplified point-of-care testing and treatment procedures and supportive healthcare providers contributed to participants' acceptance of the HCV care model. This decentralised community-based HCV testing and treatment model was highly accessible and acceptable to CT2 participants. Prioritizing patient-centred care, rapid provision of results, flexible appointments and convenient clinic locations can promote accessible and acceptable services which may in turn help accelerate progress in reaching HCV elimination targets.

An on-site community-based model for hepatitis C screening, diagnosis, and treatment among people who inject drugs in Kerman, Iran: The Rostam study

BACKGROUND

People who inject drugs (PWID) are at high risk for hepatitis C virus (HCV) infection and its complications in many countries, including Iran. This pilot study aimed to evaluate the effect of a community-based HCV model of care on HCV testing and treatment initiation among PWID in Kerman, Iran.

METHODS

This study is part of the Rostam study and is a non-randomized trial evaluating the effect of on-site HCV- antibody rapid testing, venipuncture for HCV RNA testing, and treatment eligibility assessment on HCV testing and treatment initiation among PWID. Recruitment, interviews, and HCV screening, diagnosis, and treatment were all conducted at a community-based drop-in center (DIC) serving PWID clients.

RESULTS

A total of 171 PWID (median age of 39 years and 89.5% male) were recruited between July 2018 and May 2019. Of 62 individuals who were HCV antibody positive, 47 (75.8%) were HCV RNA positive. Of RNA-positive individuals, 36 (76.6%) returned for treatment eligibility assessment. Of all the 36 participants eligible for treatment, 34 (94.4%) initiated HCV antiviral therapy. A sustained virologic response at 12 weeks post-treatment was 76.5% (26/34) in the intention-to-treat (ITT group) analysis and 100% (23/23) in the per-protocol (PP group) analysis.

CONCLUSION

Our integrated on-site community-based HCV care model within a DIC setting suggested that HCV care including HCV testing and treatment uptake can be successfully delivered outside of hospitals or specialized clinics; a model which is more likely to reach PWID and can provide significant progress towards HCV elimination among this population.

Integrating Hepatitis C Care for opioid substitution treatment patients attending general practice: Feasibility, Clinical and Cost Effectiveness (Preprint)

Background

Objective

Methods

Results

Conclusions

Australia could miss the WHO hepatitis C virus elimination targets due to declining treatment uptake and ongoing burden of advanced liver disease complications

Australia was one of the first countries to introduce government-funded unrestricted access to direct-acting antiviral (DAA) therapy, with 88,790 treated since March 2016. However, treatment uptake is declining which could potentially undermine Australia’s progress towards the WHO HCV elimination targets. Using mathematical modelling, we updated estimates for those living with chronic HCV in Australia, new cases of decompensated cirrhosis (DC), hepatocellular carcinoma (HCC), and liver-related mortality among the HCV-cured and viraemic populations from 2015 to 2030. We considered various DAA treatment scenarios incorporating annual treatment numbers to 2020, and subsequent uptake per year of 6,790 (pessimistic), 8,100 (intermediate), and 11,310 (optimistic). We incorporated the effects of excess alcohol consumption and reduction in progression to DC and HCC among cirrhosis-cured versus viraemic individuals. At the end of 2020, we estimated 117,810 Australians were living with chronic HCV. New cases per year of DC, HCC, and liver-related mortality among the HCV viraemic population decreased rapidly from 2015 (almost eliminated by 2030). In contrast, the growing population size of those cured with advanced liver disease meant DC, HCC, and liver-related mortality declined slowly. The estimated reduction in liver-related mortality from 2015 to 2030 in the combined HCV viraemic and cured population is 25% in the intermediate scenario. With declining HCV treatment uptake and ongoing individual-level risk of advanced liver disease complications, including among cirrhosis-cured individuals, Australia is unlikely to achieve all WHO HCV elimination targets by 2030.

Promoting treatment for hepatitis C in people who inject drugs: A review of the barriers and opportunities

BACKGROUND

People who inject drugs (PWIDs) comprise a significant amount of the population who are also positive for hepatitis C virus (HCV) around the world. Even though there is evidence that patients who currently inject drugs do not display altered treatment adherence or medication effectiveness, health care providers are still hesitant to treat this patient population based on perceived threats and barriers.

OBJECTIVES

This literature review informs of the perceived barriers associated with PWID in receiving HCV treatment and supports recommendations to address these barriers.

DATA SOURCES

For this review, eight scholarly articles rated levels I A through II B using John Hopkins Evidence-Based Practicing ratings consisting of randomized controlled trials, systematic reviews, and meta-analyses were selected. Both qualitative and quantitative data contributed to identifying perceived barriers and suggested course of action that should be taken to increase HCV treatment uptake among PWID.

CONCLUSIONS

The three main perceived barriers are evidence of barriers to treatment in the PWID populations and include increased risk of reinfection, low adherence to treatment, and decreased response to treatment. Removal of these barriers by increasing education about HCV disease and treatment options to both patients and health care workers and changing current policy in health care settings to provide enhanced access to HCV treatment for PWID can promote an opportunity for successful treatment of these patients.

IMPLICATIONS FOR PRACTICE

There is a significant need for HCV treatment among PWID. Opportunities for successful treatment exist and should be adopted.

High HCV cure rates among people who inject drugs and have suboptimal adherence: A patient-centered approach to HCV models of care

BACKGROUND

Though people who inject drugs (PWID) make up the majority of the hepatitis C virus (HCV) epidemic, concerns about adherence often exclude PWID from receiving direct-acting antiviral (DAA) medication. The most effective models of HCV care to promote sustained virologic response (SVR) and high adherence need to be evaluated.

METHODS

We conducted a prospective cohort study in three opioid treatment programs (OTPs) in the Bronx, NY. Participants, in collaboration with providers, chose one of three models of onsite care: directly observed therapy (mDOT), group treatment (GT), or self-administered individual treatment (SIT).  SVR12, daily adherence, and participant characteristics were compared between groups.

RESULTS

Of 61 participants, the majority were male (62%) and Latino (67%), with a mean age of 53 (SD 9). Participants received DAAs via one of three models of care: mDOT (21%), GT (25%), or SIT (54%). The majority (59%) used illicit drugs during treatment. Overall, SVR12 was 98% with no differences between models of care: mDOT (100%), GT (100%), and SIT (97%) (p = 1.0). Overall, daily adherence was 73% (SD 16); 86% among those who chose mDOT compared to 71% among those who chose GT (p<0.01) and 73% among those who chose SIT (p<0.01).

CONCLUSION

Despite ongoing illicit drug use and suboptimal adherence, SVR12 was high among PWID treated onsite at an OTP using any one of three models of care. Shared decision making in real world settings may be key to choosing the appropriate model of care for PWID.

HepCare Ireland-a service innovation project

Hepatitis C virus (HCV) remains a major cause of morbidity and death worldwide, with prevalence highest among people who inject drugs (PWID), homeless populations and prisoners. The World Health Organization has published targets to be achieved by 2030 as part of its global health sector strategy to eliminate viral hepatitis. Recent innovations in testing and treatment of HCV mean such goals are achievable with effective infrastructure, political will and funding. 'HepCare Europe' was a 3-year, EU-funded project involving four member states. It sought to develop, implement and evaluate interventions to improve HCV outcomes through multiple-level interventions, running between 2016 and 2019. This paper aims to summarize the methods and present the aggregate cascade of care figures for the Irish components of HepCare. 'HepCare Ireland' contained five integrated work packages: HepCheck, HepLink, HepFriend, HepEd and HepCost. Interventions included intensified screening, community-based assessment, linkage to specialist care, peer training and support, multidisciplinary educational resources and cost-effectiveness analysis. A total of 812 participants were recruited across the three clinical work packages in Ireland. Two hundred and fifty-seven (31.7%) of the tested participants had an HCV antibody-positive result, with 162 (63.0%) testing positive for HCV RNA. At the time of writing (6th of November 2019), 57 (54.8%) of participants put on treatment had achieved SVR12, with 44 (42.3%) still undergoing treatment. In HepCheck, HepLink. HepEd and HepFriend, we demonstrate a series of interventions to improve Irish HCV outcomes. Our findings highlight the benefits of multilevel interventions in HCV care.

Integrating hepatitis C care for at-risk groups (HepLink): baseline data from a multicentre feasibility study in primary and community care

OBJECTIVES

To examine HCV prevalence and management among people who inject drugs (PWID) attending primary care and community-based health services at four European sites using baseline data from a multicentre feasibility study of a complex intervention (HepLink).

METHODS

Primary care and community-based health services in Dublin, London, Bucharest and Seville were recruited from the professional networks of the HepLink consortium. Patients were eligible to participate if aged ≥18 years, on opioid substitution treatment or at risk of HCV (i.e. injecting drug use, homeless or incarcerated), and attended the service. Data on patient demographics and prior HCV management were collected on participants at baseline.

RESULTS

Twenty-nine primary care and community-based health services and 530 patients were recruited. Baseline data were collected on all participants. Participants' mean age ranged from 35 (Bucharest) to 51 years (London), with 71%-89% male. Prior lifetime HCV antibody testing ranged from 65% (Bucharest) to 95% (Dublin) and HCV antibody positivity among those who had been tested ranged from 78% (Dublin) to 95% (Bucharest). Prior lifetime HCV RNA testing among HCV antibody-positive participants ranged from 17% (Bucharest) to 84% (London). Among HCV antibody- or RNA-positive participants, prior lifetime attendance at a hepatology/infectious disease service ranged from 6% (London) to 50% (Dublin) and prior lifetime HCV treatment initiation from 3% (London) to 33% (Seville).

CONCLUSIONS

Baseline assessment of the HCV cascade of care among PWID attending primary care and community-based health services at four European sites identified key aspects of the care cascade at each site that need to be improved.

HepCare Europe: a service innovation project. HepCheck: enhancing HCV identification and linkage to care for vulnerable populations through intensified outreach screening. A prospective multisite feasibility study

Objectives

Hepatitis C is one of the main causes of chronic liver diseases worldwide. One of the major barriers to effecting EU- and WHO-mandated HCV elimination by 2030 is underdiagnosis. Community-based screening strategies have been identified as important components of HCV models of care. HepCheck Europe is a large-scale intensified screening initiative aimed at enhancing identification of HCV infection among vulnerable populations and linkage to care.

Methods

Research teams across four European countries were engaged in the study and rolled out screening to high-risk populations in community addiction, homeless and prison services. Screening was offered to 2822 individuals and included a self-administered questionnaire, HCV antibody and RNA testing, liver fibrosis assessment and referral to specialist services.

Results

There was a 74% (n=2079) uptake of screening. The majority (85.8%, n=1783) were male. In total 44.6% (n=927) of the sample reported ever injecting drugs, 38.4% (n=799) reported ever being homeless and 27.9% (n=581) were prisoners. In total 397 (19%) active HCV infections were identified and 136 (7% of total sample and 34% of identified active infections) were new cases. Of those identified with active HCV infection, 80% were linked to care, which included liver fibrosis assessment and referral to specialist services.

Conclusions

HepCheck’s screening and linkage to care is a clear strategy for reaching high-risk populations, including those at highest risk of transmission who are not accessing any type of care in the community. Elimination of HCV in the EU will only be achieved by such innovative, patient-centred approaches.

Estimating the Consensus hepatitis C Cascade of Care among people who inject drugs in Australia: Pre and post availability of direct acting antiviral therapy

Background Monitoring the hepatitis C virus (HCV) cascade of care (CoC) among people who inject drugs (PWID) is an essential component of the response to World Health Organisation's (WHO) hepatitis elimination goals. This study aimed to estimate the Consensus hepatitis C CoC among PWID using data collected in Australia prior to and after the introduction of unrestricted direct-acting antiviral (DAA) therapy in March 2016. Methods The Australian Needle Syringe Program Survey is a cross-sectional bio-behavioural surveillance system that recruits >2000 PWID annually. Using data from 2015 and 2019, HCV antibody and ribonucleic acid (RNA) test results from dried blood spots were combined with self-reported data on HCV diagnostic testing and treatment to project HCV Consensus CoC indicators at a population-level among Australian PWID. Results Among an estimated 75,000 people who inject drugs on a regular basis in Australia, the number with active HCV infection declined from 32,619 (44%) in October 2015 to 12,679 (17%) in October 2019. The majority (78% in 2015 and 2019) of PWID reported HCV diagnosis, while the proportion of those diagnosed who were treated increased from 3% in 2015 to 47% in 2019. Among those treated, the proportion who were HCV RNA negative and assumed to have been successfully treated (cured), increased from 27% in 2015 to 88% in 2019. Conclusion This study demonstrates remarkable HCV CoC progress among PWID in Australia following availability of DAA therapy. There was a substantial increase in the proportion of HCV diagnosed PWID who initiated treatment and were cured, while the number of PWID with active HCV infection more than halved over a 3.5 year period. Estimates of the Consensus hepatitis C CoC among PWID is required to monitor progress toward WHO HCV elimination goals.

Provider Perceptions of Hepatitis C Treatment Adherence and Initiation

BACKGROUND

Significant disparities in hepatitis C (HCV) treatment existed in the interferon treatment era, such that patients with mental health and substance use disorders were less likely to be treated. We aimed to evaluate whether these perceptions continue to influence HCV treatment decisions.

METHODS

We e-mailed HCV providers a survey to assess their perceptions of barriers to HCV treatment adherence and initiation. We assessed the frequency of perceived barriers and willingness to initiate HCV treatment in patients with these barriers. We identified a group of providers more willing to treat patients with perceived barriers to adherence and determined the associated provider characteristics using Spearman's rho and Wilcoxon rank-sum tests.

RESULTS

A total of 103 providers (29%) responded to the survey. The most commonly endorsed perceived barriers to adherence were homelessness (65%), ongoing drug (58%), and ongoing alcohol use (33%). However, 90%, 68%, and 90% of providers were still willing to treat patients with these comorbidities, respectively. Ongoing drug use was the most common reason providers were never or rarely willing to initiate HCV treatment. Providers who were less willing to initiate treatment more frequently endorsed patient-related determinants of adherence, while providers who were more willing to initiate treatment more frequently endorsed provider-based barriers to adherence (e.g., communication).

CONCLUSIONS

Most responding providers were willing to initiate HCV treatment in all patients, despite the presence of perceived barriers to adherence or previous contraindications to interferon-based treatments. Ongoing substance use remains the most prominent influencer in the decision not to treat.

Nurse case management to improve the hepatitis C care continuum in HIV co-infection: Results of a randomized controlled trial

The opportunity to eliminate hepatitis C virus (HCV) is at hand, but challenges remain that negatively influence progress through the care continuum, particularly for persons co-infected with HIV who are not well engaged in care. We conducted a randomized controlled trial to test the effect of nurse case management (NCM) on the HCV continuum among adults co-infected with HIV compared to usual care (UC). Primary outcomes included linkage to HCV care (attendance at an HCV practice appointment within 60 days) and time to direct-acting antiviral (DAA) initiation (censored at 6 months). Sixty-eight participants were enrolled (NCM n = 35; UC n = 33). Participants were 81% Black/African American, 85% received Medicaid, 46% reported illicit drug use, 41% alcohol use, and 43% had an undetectable HIV viral load. At day 60, 47% of NCM participants linked to HCV care compared to 25% of UC participants (P = .031; 95% confidence bound for difference, 3.2%-40.9%). Few participants initiated DAAs (12% NCM; 25% UC). There was no significant difference in mean time to treatment initiation (NCM = 86 days; UC = 110 days; P = .192). Engagement in HCV care across the continuum was associated with drinking alcohol, knowing someone who cured HCV and having a higher CD4 cell count (P < .05). Our results support provision of NCM as a successful strategy to link persons co-infected with HIV to HCV care, but interventions should persist beyond linkage to care. Capitalizing on social networks, treatment pathways for patients who drink alcohol, and integrated substance use services may help improve the HCV care continuum.

Framework for community-based models for treating hepatitis C virus

Objective Although community-based models for treating hepatitis C virus (HCV) are widely recognised for reaching more people who require treatment, little is known about their organisational and operational elements. This study aimed to address this gap and develop a framework for designing, implementing and evaluating community-based models for treating HCV. Methods This study was a systematic review in which 17 databases were searched for published and unpublished studies. The final search of databases was performed in September 2017. A qualitative inductive thematic approach was used to extract and categorise organisational and operational elements of community-based models for treating HCV. Results Data analysis yielded 13 organisational and operational elements that were categorised into three domains: support for patients, support for healthcare providers and service delivery facilitation. In the support for patients domain, support was categorised into four elements: peer support, psychological assessment and support, social assessment and support and adherence support. In the support for healthcare providers domain, the elements included the provision of educational opportunities for HCV care providers, specialist mentoring, decision making support and rewarding and recognition for HCV care providers. Finally, the service delivery facilitation domain included seven elements that target service-level enablers for community-based HCV treatment, including essential infrastructure, policy implementation and collocation and collaboration with other related services. Conclusion This framework for understanding the components of models of community-based HCV treatment may be used as a guide for designing, implementing and evaluating models of care in support of HCV elimination. HCV care providers and patients need to be supported to improve their engagement with the provision of community-based treatment. In addition, evidence-based strategies to facilitate service delivery need to be included. What is known about the topic? Community-based models for treating HCV are widely recognised as having the advantage of reaching more people who require treatment. These types of models aim to remove barriers related to accessibility and acceptability associated with tertiary centre-based HCV treatment. What does this paper add? Community-based models for treating HCV use various organisational and operational elements to improve the accessibility, effectiveness and acceptability of these services. The elements we identified target three main domains: support for patients with HCV, support for HCV care providers and service delivery facilitation. The importance of these organisational and operational elements designed to improve health and health services outcomes of community-based models for treating HCV is strongly influenced by context, and dependent on both the setting and target population. What are the implications for practitioners? Health policy makers and practitioners need to consider a patient’s psychosocial and economic status and provide support when needed. To successfully deliver HCV treatment in community settings, HCV care providers need to be trained and supported, and need to establish linkages, collaborations or colocations with other related services.

Community Screening, Identification, and Referral to Primary Care, for Hepatitis C, B, and HIV Among Homeless Persons in Los Angeles

People experiencing homelessness are disproportionally affected by drug and alcohol use and by their serious health consequences. In this study, 137 adults from the "UCLA/ARG/RAND Homeless Hepatitis Study" who were sampled from shelters and meal programs in the Skid Row of Los Angeles and screened for HIV or HCV or HBV infection. Those who tested positive for these infections were counseled about their infections and referred to primary care. They were followed-up at 1 month with interviews to identify rates, and predictors, of seeking primary care. Participants were 87.5% male, mean age of 48.6 years (SD: 8.2); most were Black (77.4%) and were chronically homeless (> 12 months). A majority (70%) had a regular source of care; 78% were lifetime marijuana users, 56% were lifetime cocaine users and 51% had injected intravenously during the past year. Among this sample, 118 participants (86.1%) tested seropositive for HCV infection, 79 (57.7%) HBV infection and 18 (13.1%) HIV infection. At 1-month follow-up, 102 participants (74.5%) attended the clinic they were referred to. The only variable associated with attending the clinic was having slept in a shelter during the previous night versus other sleeping conditions [Odds ratio (95% CI): 3 .0 (1.07-8.42), p = 0.03]. This model offers a simple and efficacious approach to seeking, testing, counseling, and referral to treatment of community-based adults experiencing homelessness with HIV, HCV and/or HBV infection and linking them to primary care. Being sheltered may be the key facilitator for homeless seeking primary care.

HepCare Europe-A service innovation project. HepCheck: Characteristics of the patient population with active infection as defined by HCV RNA

BACKGROUND

Hepatitis C virus (HCV) is a main cause of chronic liver disease worldwide and is consistently under-diagnosed. Community-based screening initiatives, such as HepCheck, have been identified as important components of HCV care. HepCheck focuses on screening and identifying HCV RNA-positive cases in high-risk populations and linking them to care as part of a larger European project to improve HCV care (HepCare).

METHODS

HCV testing with a self-administered questionnaire was offered to 2822 individuals.

RESULTS

There were 2079 patients screened. Overall, 397 (19%) of the total screened cohort were identified as having active HCV infections as measured by HCV RNA PCR. The patients were mostly male (84%), white (88%), and had a history of injecting drug use (IDU) (86%), homelessness (58%), and tattooing (42%). There were 136 new cases (7% of the total sample and 34% of identified active infections). Romania had the highest proportion of newly identified cases with 87%, then Ireland with 60%, and Spain with 43%; the UK had the lowest proportion of new cases at 10%.

CONCLUSIONS

For those lost to follow-up, a major strategy is re-engagement. For those newly diagnosed, the 'seek and treat' approach is a key strategy. Thus, different priorities are defined for different countries.

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.

Integrated Care for the Use of Direct-acting Antivirals in Patients With Chronic Hepatitis C and Substance Use Disorder

OBJECTIVES

Since little is currently known about predictors of response to direct-acting antiviral agents (DAAs) in people who inject drugs, we undertook an analysis of patients attending a hepatitis clinic with addiction services (outpatient clinics and inpatient services) to examine the outcomes associated with the treatment of difficult-to-manage patients with substance use. Our experience was based on integrated care.

METHOD

A retrospective analysis was undertaken of 50 patients with hepatitis C virus (HCV) and a history of addiction who received treatment with DAAs, according to European guidelines. These regimens were sofosbuvir/ledipasvir for 8 weeks (n = 3), sofosbuvir/ledipasvir ± ribavirin for 12 weeks (n = 19), sofosbuvir/daclatasvir for 12 weeks (n = 20), sofosbuvir/simeprevir (n = 1), or sofosbuvir/daclatasvir for 24 weeks (n = 7). Characteristics of patients who did versus did not achieve a sustained virologic response (SVR) 12 weeks after treatment were compared by univariate analysis.

RESULTS

Forty-two patients (84%) were male; mean age was 46.2 ± 7.3 years. Genotypes were 1 (n = 21), 2 (n = 4), 3 (n = 18), 4 (n = 6), or 6 (n = 1). Most patients were treatment-naïve (n = 38). Five patients had coinfection with human immunodeficiency virus (n = 4) or hepatitis B (n = 1), 28 (56%) had evidence of cirrhosis on FibroScan (>12.5 kPa), and 34 (68%) were receiving opioid substitution therapy. Psychiatric disease, illicit drug use, unemployment, and homelessness/precarious housing were common. Forty-five patients (90%) achieved SVR, 2 were lost to follow-up, and 3 had treatment relapse.

CONCLUSIONS

SVR was not significantly associated with sociodemographic or virological characteristics, treatment, social environment, alcohol/drug use, and adherence. Although adherence was slightly worse than in "usual" patients, it did not affect the SVR rate. In these difficult-to-manage patients with HCV and substance use disorder, the real-world SVR rate (90%) was similar to that in nonaddicted populations.

Hepatitis C virus screening and treatment in Irish prisons from nurse managers' perspectives - a qualitative exploration

Background

Prisoners carry a greater burden of physical, communicable and psychiatric disease compared to the general population. Prison health care structures are complex and provide challenges and opportunities to engage a marginalised and poorly served group with health care including Hepatitis C Virus (HCV) screening, assessment and treatment. Optimising HCV management in prisons is a public health priority. Nurses are the primary healthcare providers in most prisons globally. Understanding the barriers and facilitators to prisoners engaging in HCV care from the perspectives of nurses is the first step in implementing effective strategies to eliminate HCV from prison settings. The aim of this study was to identify the barriers and facilitators to HCV screening and treatment in Irish prisons from a nurse perspective and inform the implementation of a national prison-based HCV screening program.

Methods

A qualitative study using focus group methodology underpinned by grounded theory for analysis in a national group of nurse managers (n = 12).

Results

The following themes emerged from the analysis; security and safety requirements impacting patient access, staffing and rostering issues, prison nurses’ skill set and concerns around phlebotomy, conflict between maintaining confidentiality and concerns for personal safety, peer workers, prisoners’ lack of knowledge, fear of treatment and stigma, inter-prison variations in prisoner health needs and health service delivery and priority, linkage to care, timing of screening and stability of prison life.

Conclusions

Prison nurses are uniquely placed to identify barriers and facilitators to HCV screening and treatment in prisoners and inform changes to health care practice and policy that will optimise the public health opportunity that incarceration provides.

Real-world study of hepatitis C treatment with direct-acting antivirals in patients with drug abuse and opioid agonist therapy

Background: Limited data exist evaluating the treatment outcomes with direct-acting antivirals (DAAs) in patients with drug use in the community setting. We aim to assess the treatment response of DAAs in this subset of patients with or without the opioid agonist therapy (OAT). Methods: All the hepatitis C virus (HCV) infected patients treated with DAAs were retrospectively analyzed. Patients were stratified into two groups by the presence or absence of abusing alcohol, cocaine and heroin. All the patients who were assigned to the abuser group had positive urine toxicology with one of the drugs during the DAA treatment. The primary assessment was the sustained virologic response (SVR12) at 12 weeks post-treatment (SVR12). Results: Among the 314 patients, 152, 128 and 58 were patients with drug use, non-drug use and receiving OAT. Among the patients with injectable or non-injectable drug use treatment, completion rate was 99% (151/152) and SVR12 was 93.4%. Among the patients with no drug use treatment, completion rate was 95% (122/128) and SVR12 was 88.3%. Among patients receiving OAT alone, SVR12 was 100%, and in patients with OAT + other drug use, SVR12 was 96.5%. None of the patients included in this study discontinued the treatment due to adverse events associated with treatment medications. Conclusions: In this community-based study, DAAs are safe, effective with high overall SVR12 in patients with active drug use (injectable and non-injectable) and OAT enrolled patients. These results support the removal of drug use as a barrier to DAA therapy.

High response and re-infection rates among people who inject drugs treated for hepatitis C in a community needle and syringe programme

To achieve WHO hepatitis C virus (HCV) elimination targets by 2030, mathematical models suggest there needs to be significant scale-up of treatment among people who inject drugs (PWID). We tested whether people who actively inject drugs can be recruited and treated successfully through a community needle and syringe programme (NSP), and assessed rates of re-infection. 105 HCV RNA positive participants were enrolled prospectively. Participants were recruited from the largest NSP in Dundee over 42 months. 94/105 individuals commenced treatment. Genotype 1 (G1) individuals (n = 37) were treated with peg-interferon+ribavirin+Simepravir/Telaprevir. Genotype 2/3 (G2/3) (n = 57) received peg-interferon+ribavirin. Weekly study visits took place within the NSP. Mean age of participants was 34.0 years (SD 6.9), 71.3% (61/94) were male. One in five (20/94) participants were homeless. 68.1% (64/94) were on OST (opiate substitution therapy) at enrolment; participants injected median 6.5 times/wk. In terms of clinical outcomes, >80% treatment adherence was 71.3% (67/94). There was no difference in SVR-12 rates by genotype: 81.0% (30/37) for G1 and 82.5% (47/55) for G2/3. At 18 months post-treatment, 15/77 participants were reinfected, followed up over 69.8 person-years, yielding a re-infection rate of 21.5/100 person-years (95% CI 13.00-35.65). This trial demonstrates that HCV treatment can be delivered successfully to the target population of treatment as prevention strategies. We report higher rates of re-infection than existing estimates among PWID. Scale-up of HCV treatment should be pursued alongside a comprehensive programme of harm reduction interventions to help minimize re-infection and reduce HCV transmission.

Directly observed hepatitis C treatment with opioid substitution therapy in community pharmacies: A qualitative study

BACKGROUND

The hepatitis C virus (HCV) will only be eliminated through successful engagement with people who inject drugs (PWID), however some of this population experience socioeconomic and individual issues that can lead to poor HCV treatment adherence. A key sub-group of (PWID) are those who receive opioid substitution therapy (OST). In Australia, OST is most often delivered under direct supervision by a community pharmacist every day or multiple times a week. This regular interaction could be an ideal opportunity to enhance direct-acting antiviral (DAA) treatment adherence under directly observed therapy (DOT) by the pharmacist.

AIM

The aim of this study was to explore the perspectives of OST patients with a lived experience of HCV to understand whether or not dispensing DAAs in the same way as, or simultaneously with OST would benefit HCV treatment.

METHODS

Data collection occurred from June to August 2017. Semi-structured interviews were conducted with a sample of PWID living with HCV and on OST programs (n = 12) in Melbourne, Australia. Interviews were voice recorded and transcribed in verbatim. Interpretive phenomenology guided analysis of the data.

RESULTS

Themes reported by participants that provide insight into the suitability of DOT of DAAs include: Adherence and non-adherence to DAA treatment; Mixed views towards DOT of DAAs; Experiences and perceptions of OST providers; and Perceived stigma in the pharmacy.

CONCLUSIONS

Community pharmacies offering OST may be an effective place for DOT of HCV treatment, but is likely only to benefit people who face significant challenges to adherence. We suggest that a positive pharmacist-patient relationship, high OST adherence, and commitment to reducing stigma in the pharmacy would be necessary for the intervention to be effective. Further research is needed to evaluate the expanded-role of community pharmacies in improving DAA adherence and eliminating HCV.

Clinical effectiveness, cost effectiveness and acceptability of community-based treatment of hepatitis C virus infection: A mixed method systematic review

Several community-based models for treating hepatitis C virus (HCV) infection have been implemented to improve treatment accessibility and health outcomes. However, there is a lack of knowledge regarding how well these models achieve the desired goals. We conducted a mixed-method systematic review of quantitative and qualitative evidence about clinical effectiveness, cost effectiveness and acceptability of community-based HCV treatment models. Seventeen databases were researched for published and unpublished studies. Methodological quality was assessed using The Joanna Briggs Institute Critical Appraisal tools. Quantitative findings were synthesized in narrative form and qualitative findings were synthesized using meta-synthesis. Forty-two quantitative and six qualitative studies were included. No relevant cost effectiveness studies were found. Five categories of community-based models were identified: telehealth, integration of HCV and addiction services, integration of HCV and HIV services, integration of HCV and primary care, and implementation by a home care and health care management company. The range of reported outcomes included; end of treatment response: 48.7% to 96%, serious side effects: 3.3% to 27.8%, sustained virological response: 22.3% to 95.5%, relapse: 2.2% to 16.7%, and treatment completion: 33.4% to 100%. Inconsistent measures of uptake and adherence were used; uptake ranged from 8.3% to 92%, and 68.4% to 100% of patients received ≥80% of prescribed doses. Patient reported experiences included trusted and supportive care providers, safe and trusted services, easily accessible care, and positive psychological and behavioural changes. The clinical effectiveness and acceptability reported from the included studies are similar to or better than reported outcomes from systematic reviews of studies in tertiary settings. Studies of the cost effectiveness of community-based models for treating HCV are needed.

Hepatitis C services at harm reduction centres in the European Union: a 28-country survey

Background

In the context of the WHO’s 2016 Viral Hepatitis Strategy and the introduction of treatment that can cure more than 95% of cases with hepatitis C virus (HCV) infection, the European Joint Action on HIV and Co-infection Prevention and Harm Reduction (HA-REACT) undertook a study in the member states of the European Union (EU). It aimed to determine service providers’ understanding of the current services in their respective countries and the barriers experienced by PWID in accessing HCV testing, care and treatment services in their country.

Methods

In 2017, 38 purposively selected harm reduction service providers completed a 26-item English-language online survey addressing the availability, accessibility and funding of HCV services at harm reduction centres. HCV-related data and reported findings were extracted by country or by responding organization.

Results

Responses were received from all EU member states. Respondents from 23 countries reported that HCV tests are offered by harm reduction services in their countries, and eight countries reported that addiction specialists in their countries are able to prescribe HCV therapy. Almost half of the respondents (45%) said that their respective organizations had established referral systems with centres providing HCV treatment.

Conclusions

Not all EU member states have harm reduction services that provide HCV tests, and many do not have established referral systems with treatment providers. Moreover, the inability of addiction specialists to prescribe HCV treatment points to missed opportunities to make treatment more accessible. Further, discrepancies were noted between the available HCV services and stakeholders’ knowledge about their availability.

Real life experiences in HCV management in 2018

INTRODUCTION

Hepatitis C virus (HCV) infection is a major cause of chronic liver disease, with approximately 71 million chronically infected individuals worldwide. Treatment of chronic hepatitis C has considerably improved in the last few years thanks to the introduction of direct-acting antivirals able to achieve sustained virological response in more than 95% of patients. Successful anti-HCV treatment can halt liver disease progression and solve the HCV-related extra-hepatic manifestations, eventually reducing liver-related and overall mortality. Areas covered: With the aim to respond to unmet needs in patient's identification, universal access to antiviral therapy and treatment optimization in specific setting of HCV-infected patients, a group of Italian experts met in Stresa in May 2018. The summary of the considerations arising from this meeting and the final statements are reported in this paper. Expert commentary: All the advances on HCV cure may have a real clinical impact not only in individual patients but also at the social health level if they are applied to all infected patients, independently from the stage of liver disease. Further improvements are needed in order to attain HCV elimination, such as the development of an enhanced screening program working in parallel to the present treatment options.

Association between rapid utilisation of direct hepatitis C antivirals and decline in the prevalence of viremia among people who inject drugs in Australia

BACKGROUND & AIMS

The World Health Organization (WHO) established targets to eliminate hepatitis C virus (HCV) infection as a public health threat by 2030. Evidence that HCV treatment can lower viraemic prevalence among people who inject drugs (PWID) is limited. Broad accessibility of direct-acting antiviral (DAA) therapy in Australia, since March 2016, provides an opportunity to assess the efficacy of these treatments at a population level in a real-world setting.

METHODS

Data from Australia's annual bio-behavioural surveillance examined treatment uptake and estimated viraemic prevalence among PWID attending needle syringe programs nationally between 2015 and 2017. Multivariate logistic regression identified variables independently associated with HCV treatment among those considered eligible (anti-HCV positive excluding HCV RNA negative with no self-reported history of HCV treatment) in 2017.

RESULTS

Annual samples ranged from 1,995-2,380 PWID. Anti-HCV prevalence declined from 57% (2015) to 49% (2017, χ²p trend <0.001), with 40-56% of anti-HCV positive respondents providing sufficient sample for HCV RNA testing. Between 2015 and 2017, treatment uptake among those eligible increased from 10% to 41% (χ²p trend <0.001) and viraemic prevalence among the overall sample declined from 43% to 25% (χ²p trend <0.001). In multivariable analysis, older age (≥50 years adjusted odds ratio [aOR] 1.82; 95% CI 1.09-3.06;p = 0.023 and 44-49 years aOR 1.75; 95% CI 1.03-3.00;p = 0.038 vs. ≤37 years) and history of opioid substitution therapy (aOR 2.06; 95% CI 1.30-3.26; p = 0.002) were independently associated with treatment.

CONCLUSIONS

This study confirms PWID are willing to initiate treatment when HCV DAA therapy is available and provides population-level evidence of a decline in viraemic prevalence among people most at risk of ongoing HCV transmission. Scaled up surveillance and monitoring are required to evaluate progress toward WHO HCV elimination goals.

LAY SUMMARY

The World Health Organization's goal to reduce hepatitis C virus incidence by 80% will be difficult to achieve without widespread scale up and a corresponding reduction in viraemic prevalence among those most at risk of onward transmission. Our results indicate that a population-level reduction in viraemic prevalence is achievable through high levels of treatment and cure among people who inject drugs.

Hepatitis C Testing, Status and Treatment among Marginalized People Who Use Drugs in an Inner City Setting: An Observational Cohort Study

BACKGROUND

Chronic hepatitis C virus (HCV) infection is common among people who inject drugs (PWID) and is associated with morbidity and premature death. Although HCV can be cured, treatment may be inaccessible. We studied HCV testing, status and treatment among marginalized people who use drugs in Ottawa, Canada, a setting with universal insurance coverage for physician services.

METHODS

We analyzed data from the Participatory Research in Ottawa: Understanding Drugs study, a cross-sectional, peer-administered survey of people who use drugs from 2012 to 2013. We linked responses to population-based health administrative databases and used multivariable Poisson regression to identify factors independently associated with self-reported HCV testing, self-reported positive HCV status, and database-determined engagement in HCV treatment.

RESULTS

Among 663 participants, 562 (84.8%) reported testing for HCV and 258 (45.9%) reported HCV-positive status. In multivariable analysis, HCV-positive status was associated with female gender (RR 1.27; 95%CI 1.04 to 1.55), advancing age (RR 1.03/year; 95%CI 1.02 to 1.04), receiving disability payments (RR 1.42; 95%CI 1.06 to 1.91), injecting drugs (RR 5.11; 95%CI 2.64 to 9.91), ever injecting with a used needle (RR 1.30; 95%CI 1.12 to 1.52), and ever having taken methadone (RR 1.26; 95%CI 1.05 to 1.52). Of HCV positive participants, 196 (76%) were engaged in primary care but only 23 (8.9%) had received HCV therapy. Conclusions/Importance: Although HCV testing and positive status rates are high among PWID in our study, few have received HCV treatment. Innovative initiatives to increase access to HCV treatment for PWID are urgently needed.

Variation in hepatitis C virus treatment uptake between Canadian centres in the era of direct-acting antivirals

BACKGROUND

Patients co-infected with HIV and hepatitis C virus (HCV) are a priority target for HCV treatment. The simplicity and efficacy of direct-acting antivirals (DAA) should help overcome patient, provider, and structural barriers to scaling up treatment.

METHODS

We estimated between-centre variation in DAA treatment uptake among 1734 patients enrolled at the 18 centres of the Canadian Co-Infection Cohort-a prospective cohort of adults co-infected with HIV and HCV. We then compared this variation to that observed during the interferon era. Time to treatment uptake was modeled using a Weibull time-to-event model adjusting for centre and patient characteristics thought to have an impact on treatment initiation in the DAA era.

RESULTS

At the time of administrative censoring (December 31, 2016), 981 cohort participants were eligible for second-generation DAA therapy (HCV RNA positive after November 21, 2013) of whom 278 initiated DAAs (16 patients per 100 person-years). Patients with low monthly income, Indigenous ethnicity, recent injection drug use, HCV genotype 3, or unknown HCV genotype were less likely to start treatment. After adjusting for patient characteristics, the estimated between-centre variance (σ²) was 0.29 (95% credible interval [CrI]: 0.09-0.89), considerably lower than during the interferon era (σ² = 0.87, 95% CrI: 0.49-1.5). This between-centre variance was further reduced by the addition of centre-level effects for jurisdiction (σ² = 0.15, 95% CrI: 0.02-0.60).

CONCLUSION

Much of the variation in treatment uptake between centres can now be attributed to regional differences. This suggests that after the introduction of DAAs, treatment barriers have shifted towards prescribing and reimbursement restrictions based on liver fibrosis, which vary by jurisdiction. The removal of these restrictions, however, will need to be paired with strategies to overcome patient-level barriers, which continue to prevent marginalized people and active substance users from accessing treatment.

Direct-acting antiviral therapy for hepatitis C infection among people receiving opioid agonist treatment or heroin assisted treatment

BACKGROUND

Treating chronic hepatitis C virus (HCV) infection among PWID (people who inject drugs) is crucial to achieve the WHO goal of HCV elimination, as this population is highly affected and carries a high risk of transmission. The aim of our study was to provide real-life data on HCV treatment among PWID either in opioid agonist treatment (OAT) or in heroin-assisted treatment (HAT) in a low-threshold access primary care-based addiction medicine institution.

METHODS

We conducted a retrospective chart analysis of patients treated with direct-acting antivirals (DAA) between 10/2014 and 08/2017 in the Arud outpatient clinics in Zurich, Switzerland. We reported patient and treatment characteristics and substance use. The outcomes were sustained virological response (SVR) by intention-to-treat (ITT) and modified ITT (mITT) analyses, excluding patients with missing SVR data.

RESULTS

We included 64 patients in our analysis. Forty-two (66%) were in OAT, and 22 (34%) were in HAT. Twenty-six patients (41%) reported harmful alcohol use, and 9 patients (14%) reported injecting drug use during DAA treatment. Every patient completed the treatment. Fifty-nine out of 64 achieved SVR resulting in an ITT SVR rate of 92.2%. Two patients had virological failure. Three patients were lost to follow-up between the end of treatment and SVR12 visit. Excluding these 3 patients, our study showed an mITT SVR rate of 96.7%.

CONCLUSION

PWID can be treated with DAA treatment integrated in OAT and HAT with an excellent SVR rate. OAT and HAT programs should offer integrated HCV treatment to their patients.

Hepatitis C virus prevention and care for drug injectors: the French approach

After France removed hepatitis C treatment reimbursement restrictions on 25 May 2016, an expert report presented recommendations, which focused on vulnerable groups including people who inject drugs (PWID). This commentary presents the key points of the chapter with a particular focus on policy. Thanks to the official lifting of restrictions based on disease stage and to the excellent efficacy and tolerance of the new DAA (Direct-Acting Antivirals) among PWID, the main issue is to improve the HCV care cascade. In France, many HCV-infected PWID, especially active/current PWID, remain undiagnosed and unlinked to care. Our challenge is to improve HCV screening by point of care testing (POCT), outreach methods with mobile teams, rapid tests, FibroScan, etc. and to provide PWID with appropriate services in all the settings they attend, such as drug treatment or harm reduction services, social services, prisons, etc. Another important issue is the prevention of reinfection through comprehensive and long-term follow-up. The report recommends a new national policy: testing and treating PWID as a priority, since this is the best way to eliminate HCV infection. It requires a global strategy consisting of combined and long-term interventions: prevention, outreach, screening, DAA, drug treatment programs including opiate substitution treatment (OST) and various harm reduction programs, including needle exchange programs (NEP). Ideally, these services should be delivered in the same place with an integrated approach. This should lead to meeting the national objective set by the government of eliminating hepatitis C by 2025.

Hepcare Europe - bridging the gap in the treatment of hepatitis C: study protocol

BACKGROUND

Hepatitis C (HCV) infection is highly prevalent among people who inject drugs (PWID). Many PWID are unaware of their infection and few have received HCV treatment. Recent developments in treatment offer cure rates >90%. However, the potential of these treatments will only be realised if HCV identification among PWID with linkage to treatment is optimised. This paper describes the Hepcare Europe project, a collaboration between five institutions across four member states (Ireland, UK, Spain, Romania), to develop, implement and evaluate interventions to improve the identification, evaluation and treatment of HCV among PWID.

METHODS

A service innovation project and a mixed-methods, pre-post intervention study, Hepcare will design and deliver interventions in Dublin, London, Seville and Bucharest to enhance PWID engagement and retention in the cascade of HCV care.

RESULTS

The feasibility, acceptability, potential efficacy and cost-effectiveness of these interventions to improve care processes and outcomes among PWID will be evaluated.

CONCLUSION

Hepcare has the potential to make an important impact on patient care for marginalised populations who might otherwise go undiagnosed and untreated. Lessons learned from the study can be incorporated into national and European guidelines and strategies for HCV.

Developing a community HCV service: project ITTREAT (integrated community-based test - stage - TREAT) service for people who inject drugs

Background and aims Majority of the individuals with hepatitis C virus (HCV) infection in England are people who inject drugs, a vulnerable and disenfranchised cohort with poor engagement with secondary care. Our aim is to describe our experiences in setting up a successful nurse led HCV service at a substance misuse service (SMS).

METHODS

We justify the need for a community HCV service and review the different community based models. Our experiences in engaging with stakeholders, obtaining funding, service set up, challenges faced and key recommendations are discussed. Finally, a summary of interim clinical outcomes is presented.

RESULTS

A successful community based "one-stop" nurse led HCV service was set up in Dec 2013 at a large SMS. It provides all aspects of care (blood borne virus screening, non-invasive assessment of hepatic fibrosis, Hepatology input, HCV treatment, peer mentor, social and psychiatrist support, and opiod substitution) at one site. Interim clinical data indicate high service uptake with HCV treatment outcomes comparable to secondary care.

CONCLUSIONS

The advent of direct acting antivirals provides a unique opportunity for HCV elimination in England by 2030. Our "one-stop" integrated and multidisciplinary community HCV model suggests that HCV care can be successfully delivered outside of a hospital setting and warrants national adoption.

Sofosbuvir-Based Direct-Acting Antiviral Therapies for HCV in People Receiving Opioid Substitution Therapy: An Analysis of Phase 3 Studies

Background

Hepatitis C virus (HCV) direct-acting antiviral therapy is effective among people receiving opioid substitution therapy (OST), but studies are limited by small numbers of nongenotype 1 (GT1) patients. The aim of this study was to evaluate the treatment completion, adherence, SVR12, and safety of sofosbuvir-based therapies in HCV patients receiving and not receiving OST.

Methods

Ten phase 3 studies of sofosbuvir-based regimens included ION (ledipasvir/sofosbuvir ± ribavirin for 8, 12, or 24 weeks in GT1), ASTRAL (sofosbuvir/velpatasvir for 12 weeks in GT1-6), and POLARIS (sofosbuvir/velpatasvir and sofosbuvir/velpatasvir/voxilaprevir in GT1-6). Patients with clinically significant drug use (last 12 months) or noncannabinoids detected at screening were ineligible.

Results

Among 4743 patients, 4% (n = 194) were receiving OST (methadone; n = 113; buprenorphine, n = 75; other, n = 6). Compared with those not receiving OST (n = 4549), those receiving OST (n = 194) were younger (mean age, 48 vs 54), more often male (73% vs 61%), GT3 (38% vs 17%), treatment-naïve (78% vs 65%), and cirrhotic (36% vs 23%). Among those receiving and not receiving OST, there was no significant difference in treatment completion (97% vs 99%, P = .06), SVR12 (94% vs 97%, P = .06), relapse (0.5% vs 2.1%, P = .19), adverse events (78% vs 77%, P = .79), or serious adverse events (3.6% vs 2.4%, P = .24). There was no difference in SVR12 in patients with cirrhosis (99% vs 95%, P = .25) or those with G3 (95% vs 95%, P = .77) in those receiving OST. Among patients receiving OST, SVR12 was high among those receiving methadone (95%) and buprenorphine (96%).

Conclusion

Sofosbuvir-based therapies are effective and safe in patients receiving OST.

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.

Healthcare contact and treatment uptake following hepatitis C virus screening and counseling among rural Appalachian people who use drugs

BACKGROUND

Hepatitis C virus (HCV) remains a major contributor to morbidity and mortality worldwide. Since 2009, Kentucky has led the United States in cases of acute HCV, driven largely by injection drug use in rural areas. Improved treatment regimens hold promise of mitigating the impact and transmission of HCV, but numerous barriers obstruct people who inject drugs (PWID) from receiving care, particularly in medically underserved settings.

METHODS

503 rural people who use drugs were recruited using respondent-driven sampling and received HCV screening and post-test counseling. Presence of HCV antibodies was assessed using enzyme immunoassay of dried blood samples. Sociodemographic and behavioral data were collected using computer-based questionnaires. Predictors of contacting a healthcare provider for follow-up following HCV-positive serotest and counseling were determined using discrete-time survival analysis.

RESULTS

150 (59%) of 254 participants reported contacting a healthcare provider within 18 months of positive serotest and counseling; the highest probability occurred within six months of serotesting. 35 participants (14%) reported they were seeking treatment, and 21 (8%) reported receiving treatment. In multivariate time-dependent modeling, health insurance, internet access, prior substance use treatment, meeting DSM-IV criteria for generalized anxiety disorder, and recent marijuana use increased the odds of making contact for follow-up. Participants meeting criteria for major depressive disorder and reporting prior methadone use, whether legal or illegal, were less likely to contact a provider.

CONCLUSION

While only 8% received treatment after HCV-positive screening, contacting a healthcare provider was frequent in this sample of rural PWID, suggesting that the major barriers to care are likely further downstream. These findings offer insight into the determinants of engaging the cascade of medical treatment for HCV and ultimately, treatment-as-prevention. Further study and increased resources to support integrated interventions with effectiveness in other settings are recommended to mitigate the impact of HCV in this resource-deprived setting.

Primary Care and Hepatology Provider-Perceived Barriers to and Facilitators of Hepatitis C Treatment Candidacy and Adherence

BACKGROUND

Provider perceptions regarding barriers to and facilitators of hepatitis C (HCV) treatment initiation and adherence have not been fully evaluated in the interferon-free treatment era. New treatments have provided opportunities for non-specialists to treat HCV, underscoring the importance of understanding primary care provider (PCP) and specialist perspectives.

METHODS

Based on qualitative sampling principles, 12 PCPs and 12 hepatology providers (HPs) from the VA Pittsburgh Healthcare System completed audio-recorded semi-structured interviews. Qualitative analysts coded perceived barriers and facilitators from the interviews with 100% double coding. Codes were thematized and analyzed using Atlas.ti.

RESULTS

Key barriers to treatment described by HPs and PCPs included patients' substance use disorders, mental health, transportation availability, history of non-adherence, and concern about side effects. PCPs also focused on medication cost as a system-based barrier. The main facilitators of treatment initiation and adherence described by both HPs and PCPs were provider education and encouragement. HPs focused almost exclusively on provider-based facilitators, while PCPs noted patient-based facilitators including past adherence, media exposure to information about HCV medications, a desire to clear the virus, and positive feedback regarding treatment response.

CONCLUSIONS

Providers generally focused on perceived patient-level barriers to HCV treatment initiation and adherence, as well as provider-level facilitators; PCPs additionally noted patient preferences and system-level issues that guide decision making regarding treatment initiation. While HPs focused almost exclusively on provider-level facilitators, PCPs additionally focused on patient-level facilitators of treatment. These data provide novel insights and suggest focusing on patient, provider, and system-level strategies to further improve HCV treatment initiation and adherence.

Belgian experience with direct acting antivirals in people who inject drugs

BACKGROUND AND AIM

Hepatitis C viral infection (HCV) has become a curable disease due to the development of direct acting antivirals (DAA). The WHO has set a target to eliminate HCV completely. Therefore, people who inject drugs (PWID) also need to be treated. In this study, we compared the real-life uptake and outcome of DAA treatment for HCV in PWID and non-PWID.

METHODS

We performed a nation-wide, retrospective cohort study in 15 hospitals. All patients who were treated with simeprevir-sofosbuvir, daclatasvir-sofosbuvir, or ombitasvir/paritaprevir ritonavir-dasabuvir between December 2013 and November 2015 were included.

RESULTS

The study population consisted of 579 patients: 115 PWID (19.9%) and 464 non-PWID (80.1%). Of the PWID 18 were active PWID (15.6%), 35 still received opiate substitution therapy (OST) (30.4%) and 62 were former PWID without OST (53.9%). PWID were more infected with genotype 1a and 3 (p=0.001). There were equal rates of side-effects (44.7% vs. 46.6%; p=0.847), similar rates of treatment completion (95.7% vs 98.1%; p=0.244) and SVR (93.0% vs 94.8%; p=0.430) between PWID and non-PWID, respectively.

CONCLUSION

PWID, especially active users, are underserved for DAA treatment in real life in Belgium. Reimbursement criteria based on fibrosis stage make it difficult to treat PWID. Treatment adherence is similar in PWID and the general population, even in patients with active abuse. DAA were safe and effective in PWID despite the higher prevalence of difficult-to-treat genotypes. Based on these data more efforts to treat PWID are needed and policy changes are necessary to reach the WHO targets.

Changes in risk behaviours during and following treatment for hepatitis C virus infection among people who inject drugs: The ACTIVATE study

BACKGROUND

The risk of hepatitis C virus (HCV) reinfection due to continued injecting risk behaviours might remain a barrier to HCV treatment among people who inject drugs. We aimed to evaluate changes in risk behaviours during and following HCV treatment among people with ongoing injecting drug use or receiving opioid substitution treatment (OST).

METHODS

ACTIVATE was an international multicentre clinical trial conducted between 2012 and 2014. Participants with HCV genotypes 2/3 infection were treated with peg-interferon/ribavirin for 12 or 24 weeks and completed a self-administered behavioural questionnaire at each study visit. The impact of time in treatment and follow-up on longitudinally measured recent (past month) behavioural outcomes was evaluated using generalized estimating equations.

RESULTS

Among 93 enrolled participants (83% male, median age 41 years), 55 (59%) had injected in the past month. Any injecting drug use decreased during HCV treatment and follow-up (OR 0.89 per incremental study visit; 95% CI 0.83-0.95). No significant changes were found in ≥daily injecting (OR 0.98; 95% CI 0.89-1.07), use of non-sterile needles (OR 0.94; 95% CI 0.79-1.12), sharing of injecting paraphernalia (OR 0.87; 95% CI 0.70-1.07) or non-injecting drug use (OR 1.01; 95% CI 0.92-1.10). Hazardous alcohol use decreased throughout (OR 0.56; 95% CI 0.40-0.77) and OST increased between enrolment and end of treatment (OR 1.48; 95% CI 1.07-2.04).

CONCLUSIONS

Recent injecting drug use and hazardous alcohol use decreased, while OST increased during and following HCV treatment among participants with ongoing injecting drug use. These findings support further expansion of HCV care among PWID.

Financial Incentives for Adherence to Hepatitis C Virus Clinical Care and Treatment: A Randomized Trial of Two Strategies

BACKGROUND

Although rates of sustained virologic response (SVR) after hepatitis C virus (HCV) treatment with direct-acting antivirals (DAAs) surpass 90% in trials and some more "real world" settings, some patients, such as those with substance use disorders, will be challenged to adhere to HCV care.

METHODS

To assess the feasibility of 2 strategies for financially incentivizing adherence to HCV care, patients with a substance use history prescribed 12 weeks of a sofosbuvir-containing regimen were randomized to either fixed or lottery-based monetary incentives for attending clinic appointments, pill count adherence >90%, and SVR achievement. Electronic medication monitoring provided an objective measure of DAA adherence.

RESULTS

Fifty-nine participants were randomized to the lottery (n = 31) or fixed-incentive (n = 28) arms. All 31 (100%) in the lottery arm and 24 of 28 (86%) in the fixed arm completed 12 weeks of therapy. By intent-to-treat, 93% in the lottery arm and 92% in the fixed arm achieved SVR (estimated difference: 0.5%; 95% confidence interval, -17.5 to 18.8). Overall, 92% of scheduled visits were attended without significant differences between arms. The mean adherence ratio (days with ≥1 bottle opening:monitored days) was 0.91 for lottery and 0.92 for fixed arms.

CONCLUSIONS

In this pilot, fixed- and lottery-based financial incentives were successfully implemented and accepted by patients with a substance use history. High levels of HCV therapy and care adherence, as well as rates of SVR, were observed. Financial incentives may be useful to support treatment adherence in patients with substance use disorders and should be tested in a larger, randomized, controlled trial.

Patient-reported outcomes with direct-acting antivirals for the treatment of chronic hepatitis C: current knowledge and outstanding issues

Patient-reported outcomes (PROs) play a key role in the evaluation of direct-acting antivirals (DAA) for the treatment of chronic hepatitis C (CHC). The main PROs of particular interest in CHC include quality of life (QoL), fatigue and its functional repercussions, work productivity, adherence to treatment, and risk behaviors. Areas covered: This study summarizes the body of knowledge regarding PROs in CHC with DAA-based therapy. Outstanding related issues are presented and discussed. Expert commentary: Current knowledge on PROs with CHC mainly relies on clinical trial data. All-oral DAA regimens are associated with minimal QoL impairment and symptom burden, rapid recovery once treatment has ended, and improvement in PROs for a non-negligible proportion of treated patients, especially HCV clearers. Further research is needed to analyze both long-term changes in PROs, and PROs in specific populations including people who use drugs, comorbid patients and patients at risk of reinfection.

Chronic hepatitis C burden and care cascade in Australia in the era of interferon-based treatment

BACKGROUND AND AIM

Interferon-free direct-acting antiviral regimens for hepatitis C virus (HCV) infection have been recently available in Australia, beginning a new era in clinical and public health management of HCV infection. This study provided updated estimates of the HCV infection care cascade and burden in Australia as a reliable platform for assessing the future impact of interferon-free therapies.

METHODS

A modeling approach was applied to estimate the number of individuals living with chronic HCV infection and with various liver disease stages. Data from national registries of HCV notification and liver transplantation, literature review, and expert consensus informed the model parameters. HCV notification and Pharmaceutical Benefits Scheme data were used to estimate the number of HCV diagnosed individuals and treatment uptake.

RESULTS

In 2014, an estimated 230 470 individuals (range: 180 490-243 990) were living with HCV, among whom 75% were diagnosed (n = 172 720; range: 156 720-188 770), 20% had ever received treatment (n = 45 000; range: 39 280-50 720), and 11% had been cured (n = 24 750; range: 21 520-27 990). Among individuals with HCV infection, the proportion with hepatic fibrosis stage ≥F3 doubled during the last decade, increasing from 9% (n = 18 580) in 2004 to 19% (n = 44,730) in 2014. Individuals initiating HCV treatment increased from 1100 in 1997 to 3840 in 2007, plateaued until 2010 and decreased to 2790 in 2014.

CONCLUSIONS

The burden of HCV-related liver disease has increased markedly. Although the proportion diagnosed was high, treatment uptake remained low, with no increase over the last 7 years. Reducing the HCV burden in Australia requires scale-up of interferon-free HCV therapies.