Hepatitis C virus control among persons who inject drugs requires overcoming barriers to care

Despite a high prevalence of hepatitis C virus(HCV)infection,the vast majority of persons who inject drugs(PWID)have not engaged in HCV care due to a large number of obstacles.Education about the infection among both PWID and providers remains an important challenge as does discrimination faced by PWID in conventional health care settings.Many providers also remain hesitant to prescribe antiviral therapy due to concerns about adherence and relapse to drug use resulting in reinfection.Presently,however,as a result of improvements in treatment efficacy combined with professional society and government endorsement of HCV treatment for PWID,a pressing need exists to develop strategies to engage these individuals into HCV care.In this article,we propose several strategies that can be pursued in an attempt to engage PWID into HCV management.We advocate that multidisciplinary approaches that utilize health care practitioners from a wide range of specialties,as well as co-localization of medical services,are strategies likely to result in increased numbers of PWID entering into HCV management.Pursuit of HCV therapy after stabilization through drug treatment is an additional strategy likely to increase PWID engagement into HCV care.The full impact of direct acting antivirals for HCV will only be realized if innovative approaches are pursued to engage all HCV infected individuals into treatment.     

Network‐based recruitment of people who inject drugs for hepatitis C testing and linkage to care

Although oral direct‐acting agent (DAA) therapies have the potential to reduce the burden of hepatitis C virus (HCV) infection, treatment uptake remains low, particularly among people who inject drugs (PWID). This study examined the feasibility of an innovative peer‐based recruitment strategy to engage PWID in HCV testing and treatment. We interviewed an initial set of HCV antibody‐positive PWID as ‘primary indexes’ to gather demographic, drug use, health information and drug network characteristics. Primary indexes were then briefly educated on HCV and its treatment and encouraged to recruit their injection drug ‘network members’ for HCV testing and linkage to care. Eligible network members were enrolled as ‘secondary indexes’ and completed the same index study procedures. In sum, 17 of 36 primary indexes initiated the recruitment of 64 network members who were HCV antibody positive and eligible to become indexes. In multivariable analysis, successful recruitment of at least one network member was positively associated with prior HCV treatment (OR 2.80; CI [1.01, 7.72]), daily or more injection drug use (OR 2.38; CI [1.04, 5.47]), and a higher number of injection drug network members (OR 1.20; CI [1.01, 1.42]). Among the 69 participants with chronic HCV not previously linked to HCV care at enrolment, 91% (n = 63) completed a linkage to HCV care appointment, 45% (n = 31) scheduled an appointment with an HCV provider, and 20% (n = 14) initiated HCV therapy. These findings suggest a potential benefit for peer‐driven, network‐based interventions focused on HCV treatment‐experienced PWID as a mechanism to increase HCV linkage to care.     

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 com-monly caused by hepatitis C virus(HCV) infection. Although people who inject drugs(PWID) are the ma-jor source for HCV infection, they were excluded from antiviral treatments until recently. Nowadays there is incontrovertible evidence in favor of treating these pa-tients, and substitution therapy and active substance use are no longer contraindications for antiviral treat-ment. The viral clearance in PWID after HCV antiviral treatment with interferon or pegylated interferon com-bined with ribavirin is comparable to the viral clearance in non-substance users. Furthermore, multidisciplinary approaches to delivering treatment to PWID are ad-vised, 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 exchangeprograms 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 treat-ment efficacies and data supporting their success, HCV assessment of PWID and initiation of antiviral treatment remains low. However, the proportion of PWID as-sessed 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 strate-gies, 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 detect-ing 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 evi-dence concerning HCV infection and treatment strate-gies in PWID.     

Dynamic modelling of hepatitis C virus transmission among people who inject drugs: a methodological review

Equipment sharing among people who inject drugs (PWID) is a key risk factor in infection by hepatitis C virus (HCV). Both the effectiveness and cost–effectiveness of interventions aimed at reducing HCV transmission in this population (such as opioid substitution therapy, needle exchange programmes or improved treatment) are difficult to evaluate using field surveys. Ethical issues and complicated access to the PWID population make it difficult to gather epidemiological data. In this context, mathematical modelling of HCV transmission is a useful alternative for comparing the cost and effectiveness of various interventions. Several models have been developed in the past few years. They are often based on strong hypotheses concerning the population structure. This review presents compartmental and individual‐based models to underline their strengths and limits in the context of HCV infection among PWID. The final section discusses the main results of the papers.     

Venous access and care: harnessing pragmatics in harm reduction for people who inject drugs

Aim To explore the facilitators of long‐term hepatitis C avoidance among people who inject drugs. Design We employed a qualitative life history design. Setting Recruitment took place through low‐threshold drug services and drug user networks in South East and North London. Participants were interviewed at the recruitment services or in their homes. Participants The sample comprised 35 people who inject drugs, 20 of whom were hepatitis C antibody‐negative. Participants' average injecting trajectory was 19 years (6–33), with 66% primarily injecting heroin, and 34% a crack and heroin mix. Nine (26%) of the sample were female and the average age was 39 years (23–53). Measurements Two interviews were conducted with each participant, with the second interview incorporating reference to a computer‐constructed life history time‐line. Interview accounts were audiorecorded, transcribed verbatim and analysed thematically. Findings Hepatitis C risk awareness was recent and deprioritized by the majority of participants. The facilitation of venous access and care was an initial and enduring rationale for safe injecting practices. Difficult venous access resulted in increased contamination of injecting environments and transitions to femoral injecting. Participants expressed an unmet desire for non‐judgemental venous access information and advice. Conclusions Harm reduction interventions which attend to the immediate priorities of people who inject drugs, such as venous access and care, have the potential to re‐engage individuals who are jaded or confused by hepatitis C prevention messages.     

Uptake of hepatitis C treatment among people who inject drugs attending Needle and Syringe Programs in Australia, 1999–2011

The majority of new and existing cases of hepatitis C virus (HCV) infection occur among people who inject drugs (PWID). Despite safe and efficacious HCV antiviral therapy, uptake remains low in this population. This study examined trends in HCV treatment uptake among a large national sample of PWID attending Australian Needle and Syringe Programs between 1999 and 2011. Annual cross‐sectional sero‐surveys conducted among PWID since 1995 involve completion of a self‐administered questionnaire and provision of a dried blood spot for HCV antibody testing. Multivariate logistic regression identified variables independently associated with HCV treatment uptake among 9478 participants with both self‐reported and serologically confirmed prior HCV infection. Between 1999 and 2011, the proportion currently receiving treatment increased from 1.1% to 2.1% (P < 0.001), while the proportion having ever received treatment increased from 3.4% to 8.6% (P < 0.001). Men were significantly more likely than women to have undertaken HCV treatment (P = 0.002). Among men, independent predictors of HCV treatment uptake were homosexual identity and older age; among women, independent predictors included homosexual identity and an incarceration history. Despite increases in HCV treatment among Australian PWID between 1999 and 2011, uptake remains low. Strategies are required to increase the proportion of PWID assessed and treated for HCV infection to address the increasing burden of disease. Specific approaches that target women may also be warranted. Continued surveillance of HCV treatment uptake among PWID will be important to monitor the roll‐out of simple, safe and more effective HCV treatments expected to be available in the future.     

Hepatitis C infection and other drug‐related harms among inpatients who injected drugs in Turkey

Hepatitis C virus (HCV) is easily spread among those who share drug injection equipment. Due to the ease of contraction and growing prevalence of HCV in Eastern Europe, the aims of this study focused on describing risky injection practices as well as the prevalence of HCV, HIV and hepatitis B virus (HBV) among people who inject drugs (PWID) who were admitted to public and private drug treatment centres in Turkey from 2012 to 2013. Other aims included identifying correlates of needle sharing and HCV infection. Of the 4694 inpatients who ever injected drugs and the 3914 who injected in the past 30 days, nearly all (98%) reported heroin as their drug of choice, the vast majority reported ever sharing a needle (73.4% and 79.3%), and the mean age at first injection was 23 years. Of current PWID, 51.9% were HCV‐positive, 5.9% were HBV‐positive and only 0.34% of lifetime PWID were HIV‐positive. Predictors of increased needle sharing include younger age, being unemployed, having lesser education and reporting heroin as a drug of choice. Significant predictors of HCV infection included being 40 years or older, receiving treatment in the Mediterranean region of Turkey, reporting heroin as a primary substance, a longer duration of drug use and sharing needles. With this information, it is essential to improve access to clean injection equipment in Turkey, to focus on improving education on clean injection practices and to enhance efforts in testing and treating HCV‐positive PWID.     

Examining hepatitis C virus testing practices in primary care clinics

Prior studies found that hepatitis C virus (HCV) risk assessment and testing in primary care clinics were suboptimal. We aimed to determine the actual HCV testing rate among patients with HCV risk factors and to identify variables predictive of testing. In order to do so, we performed a prospective cohort study among patients seen in four urban primary care clinics. At the initial visit, patients were given a questionnaire that listed HCV risk factors and they were instructed to check 'yes' or 'no' if they did or did not have a risk factor, respectively. Patients then handed this questionnaire to their physician during their initial visit. Among those who acknowledged having a HCV risk factor via the questionnaire, we determined the subsequent HCV testing rate and calculated adjusted odds ratios (aOR) with 95% confidence intervals (CI) to identify variables predictive of testing. Of the 578 individuals who acknowledged having a HCV risk factor via the questionnaire, only 8% (46/578) were tested for HCV within 2 months of their initial visit. Among those tested, 11% (5/46) had a positive HCV antibody test result. The only variable predictive of HCV testing after adjusting for confounders was having a specific HCV risk factor identified and documented in the chart by physicians [16% (26/159) vs 5% (20/419); aOR 4.5, 95% CI 2.1-9.5]. In summary, 92% of patients with a HCV risk factor were not tested for HCV in the primary care setting, and efforts to improve such rates are clearly warranted.     

Risk factors for hepatitis C virus infection among homeless adults

OBJECTIVE: To describe the prevalence of hepatitis C virus (HCV) infection in a sample of homeless and impoverished adults and examine risk factors for HCV infection in the overall sample and as a function of injection drug use. DESIGN: Assays were conducted on stored sera. Sociodemographic characteristics and risky sexual activity were measured by content-specific items. Substance use was measured by a structured questionnaire. HCV antibodies were tested by enzyme-linked immunosorbent assay; a confirmatory level was defined by recombinant immunoblot assay. SETTINGS: Shelters ( N = 36) and outdoor locations in Los Angeles. PARTICIPANTS: Eight hundred eighty-four homeless women and/or partners or friends. RESULTS: Among this sample of 884 homeless and impoverished adults, 22% were found to be HCV infected. Lifetime injection drug users (IDUs) (cocaine, crack, and methamphetamine) and recent daily users of crack were more likely than nonusers or less-frequent users of these drugs to be HCV-infected. Similar results were found for those who had been hospitalized for a mental health problem. Among non-injection drug users and persons in the total sample, those who reported lifetime alcohol abuse were more likely than those who did not to be HCV infected. Controlling for sociodemographic characteristics, multiple logistic regression analyses revealed IDUs have over 25 times greater odds of having HCV infection than non-IDUs. HCV infection was also predicted by older age, having started living on one's own before the age of 18, and recent chronic alcohol use. Males and recent crack users had about one and a half times greater odds of HCV infection when compared to females and non-chronic crack users. CONCLUSIONS: Targeted outreach for homeless women and their partners, including HCV testing coupled with referrals to HCV and substance abuse treatments, may be helpful.     

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.     

Efficacy of an eConsult service to cure hepatitis C in primary care

In 2016, an eConsult service was developed within a safety net health system to expand access to hepatitis C (HCV) treatment in the primary care setting. The eConsult system provides individualized treatment recommendations from specially trained primary care pharmacists and primary care physicians to primary care providers with less experience in the rapidly changing treatment of HCV. Since its launch, this service has had a large impact in expanding care to a largely homeless and low-income urban population within our health system. We now aim to evaluate its efficacy in curing HCV. In this retrospective cohort study, we describe rates of sustained virologic response 12 weeks after treatment completion (SVR12) for those who received primary care-based HCV treatment through the eConsult system with those who were treated in primary care independent of an eConsult from 2017 to 2019. We found there was no significant difference in the proportion of patients who achieved SVR12 between the two groups. Overall, >90% of patients who received treatment achieved SVR12. Approximately 40% of patients treated for HCV received an eConsult, suggesting utility of the eConsult in expanding access and coordinating treatment for patients within our network.     

Unreported alcohol use was common but did not impact hepatitis C cure in HIV‐infected persons who use drugs

We investigated the prevalence and impact of heavy alcohol use on the hepatitis C virus (HCV) care continuum amongst HIV/HCV co‐infected persons who use drugs. In the CHAMPS study, 144 HIV/HCV co‐infected persons were randomized to contingent cash incentives, peer mentors and usual care to evaluate the impact on HCV care. Alcohol use was ascertained using the 10‐item AUDIT (hazardous: male ≥8, female ≥4) and phosphatidylethanol (PEth) (heavy: ≥50 ng/mL), an alcohol biomarker. Log binomial regression was used to evaluate the association between heavy alcohol use and failure to initiate treatment and to achieve sustained virologic response (SVR). Of the 135 participants with PEth data, median age was 55 years, 59% were male, 92% were Black, 91% reported a history of drug use, and 97% were on antiretroviral therapy. Hazardous drinking was reported on AUDIT by 28% of participants, and 35% had heavy alcohol use by PEth. Of the 47 individuals with a PEth ≥50 ng/mL, 23 (49%) reported no or minimal alcohol use by AUDIT. HCV treatment was initiated in 103 of 135 participants, and SVR was achieved in 92%. PEth ≥50 ng/mL (Relative Risk [RR] 0.72, 95% CI 0.35‐1.48) was not significantly associated with failure to initiate HCV treatment or failure to achieve SVR (RR 0.85, 95% CI 0.46‐1.57).In conclusion, alcohol use was common and frequently not detected by self‐report. However, heavy alcohol use, even when measured objectively, was not associated with failure to initiate HCV treatment or to achieve cure.