High HCV cure rates for people who use drugs treated with direct acting antiviral therapy at an urban primary care clinic

Broadening and strengthening the health providers caring for patients with chronic hepatitis C may improve continuity of care

BACKGROUND

Direct-acting antiviral (DAA) therapies for hepatitis C virus infection (HCV) lead to excellent rates of sustained virological response (SVR). However, loss to follow-up (LTFU) for SVR testing remains a challenge. We examine factors associated with LTFU in a real-world setting.

METHODS

Adults who received DAA therapy for HCV in one of 26 centers across Australia during 2016-2021 were followed up for 2 years. Data sources included the patient medical records and the national Pharmaceutical and Medicare Benefits Schemes. Linkage to Medicare provided utilization data of other health-care providers and re-treatment with DAAs. LTFU was defined as no clinic attendance for SVR testing by at least 52 weeks after DAA treatment commencement. Multivariable logistic regression assessed factors associated with LTFU.

RESULTS

In 3619 patients included in the study (mean age 52.0 years; SD = 10.5), 33.6% had cirrhosis (69.4% Child-Pugh class B/C), and 19.3% had HCV treatment prior to the DAA era. Five hundred and fifteen patients (14.2%) were LTFU. HCV treatment initiation in 2017 or later (adj-OR = 2.82, 95% confidence interval [CI] 2.25-3.54), younger age (adj-OR = 2.63, 95% CI 1.80-3.84), Indigenous identification (adj-OR = 1.99, 95% CI 1.23-3.21), current injection drug use or opioid replacement therapy (adj-OR = 1.66, 95% CI 1.25-2.20), depression treatment (adj-OR = 1.49, 95% CI 1.17-1.90), and male gender (adj-OR = 1.31, 95% CI 1.04-1.66) were associated with LTFU.

CONCLUSIONS

These findings stress the importance of strengthening the network of providers caring for patients with HCV. In particular, services targeting vulnerable groups of patients such as First Nations Peoples, youth health, and those with addiction and mental health disorders should be equipped to treat HCV.

Barriers to Hepatitis C Treatment and Interest in Telemedicine-Based Care Among Clients of a Syringe Access Program

Background

Sharing equipment for injection drug use is the most common mode of hepatitis C virus (HCV) transmission in the United States, yet people who inject drugs (PWID) historically have low rates of HCV treatment. New strategies are needed to expand access to HCV treatment among PWID. Co-locating HCV treatment at syringe access programs (SAPs) reduces barriers to treatment, and telemedicine-based treatment programs could expand access further.

Methods

To evaluate interest in a co-localized or telemedicine-based program at an SAP in Denver, Colorado, we surveyed 171 SAP clients to understand barriers to HCV treatment and comfort with various appointment modalities.

Results

Eighty-nine of the surveyed SAP clients (52%), 50 of whom had not completed treatment, reported current or prior HCV infection. The most commonly cited reasons for not seeking HCV treatment were ongoing drug use, logistic barriers, and medical system barriers. Eighty-eight percent of clients with HCV reported that they would be more likely to get treatment if they were able to do so at the SAP, and the rate was higher among people who reported reluctance to seek medical care in general (98% vs 77%, P = .011). In-person appointments were preferred, though 77% of respondents were comfortable with a video appointment. However, only 60% of SAP clients reported having access to a phone, and fewer (48%) had access to video capability.

Conclusions

These findings suggest that telemedicine-based treatment at an SAP could improve access to HCV treatment, but successful implementation would require attention to barriers impacting clients' ability to participate in telemedicine appointments.

Does a simplified algorithm and integrated HCV care model improve linkage to care, retention, and cure among people who inject drugs? A pragmatic quality improvement randomized controlled trial protocol

BACKGROUND

As many as 2.4 million Americans are affected by chronic Hepatitis C Virus (HCV) in the United States.In 2018, the estimated number of adults with a history of HCV infection in San Diego County was 55,354 (95% CI: 25,411-93,329). This corresponded to a seroprevalence of 2.1% (95% CI: 2.1-3.4%). One-third of infections were among PWID. Published research has demonstrated that direct-acting antivirals (DAAs) have high efficacy and can now be used by primary care providers to treat HCV. In addition, limited evidence exists to support the effectiveness of simplified algorithms in clinical trial and real-world settings. Even with expanded access to HCV treatment in primary care settings, there are still groups, especially people who inject drugs (PWID) and people experiencing homelessness, who experience treatment disparities due to access and treatment barriers. The current study extends the simplified algorithm with a streetside 'one-stop-shop' approach with integrated care (including the offer of buprenorphine prescriptions and abscess care) using a mobile clinic situated adjacent to a syringe service program serving many homeless populations. Rates of HCV treatment initiation and retention will be compared between patients offered HCV care in a mobile clinic adjacent to a syringe services program (SSP) and homeless encampment versus those who are linked to a community clinic's current practice of usual care, which includes comprehensive patient navigation.

METHODS

A quasi-experimental, prospective, interventional, comparative effectiveness trial with allocation of approximately 200 patients who inject drugs and have chronic HCV to the "simplified care" pathway (intervention group) or the "usual care" pathway (control group). Block randomization will be performed with a 1:1 randomization.

DISCUSSION

Previous research has demonstrated acceptable outcomes for patients treated using simplified algorithms for DAAs and point-of-care testing in mobile medical clinics; however, there are opportunities to explore how these new, innovative systems of care impact treatment initiation rates or other HCV care cascade outcomes among PWID.

TRIAL REGISTRATION

We have registered our study with ClinicalTrials.gov, a resource of the United States National Library of Medicine. This database contains research studies from United States and other countries around the world. Our study has not been previously published. The ClinicalTrials.gov registration identifier is NCT04741750.

Harm reduction in undergraduate and graduate medical education: a systematic scoping review

BACKGROUND

Substance use increasingly contributes to early morbidity and mortality, which necessitates greater preparation of the healthcare workforce to mitigate its harm. The purpose of this systematic scoping review is to: 1) review published curricula on harm reduction for substance use implemented by undergraduate (UME) and graduate medical education (GME) in the United States and Canada, 2) develop a framework to describe a comprehensive approach to harm reduction medical education, and 3) propose additional content topics for future consideration.

METHODS

PubMed, Scopus, ERIC: Education Resources Information Center (Ovid), and MedEdPORTAL were searched. Studies included any English language curricula about harm reduction within UME or GME in the United States or Canada from 1993 until Nov 22, 2021. Two authors independently reviewed and screened records for data extraction. Data were analyzed on trainee population, curricula objectives, format, content, and evaluation.

RESULTS

Twenty-three articles describing 19 distinct educational programs across the United States were included in the final sample, most of which created their own curricula (n = 17). Data on educational content were categorized by content and approach. Most programs (85%) focused on introductory substance use knowledge and skills without an understanding of harm reduction principles. Based on our synthesis of the educational content in these curricula, we iteratively developed a Harm Reduction Educational Spectrum (HRES) framework to describe curricula and identified 17 discrete content topics grouped into 6 themes based on their reliance on harm reduction principles.

CONCLUSIONS

Harm reduction is under-represented in published medical curricula. Because the drug supply market changes rapidly, the content of medical curricula may be quickly outmoded thus curricula that include foundational knowledge of harm reduction principles may be more enduring. Students should be grounded in harm reduction principles to develop the advanced skills necessary to reduce the physical harm associated with drugs while still simultaneously recognizing the possibility of patients' ongoing substance use. We present the Harm Reduction Educational Spectrum as a new framework to guide future healthcare workforce development and to ultimately provide the highest-quality care for patients who use drugs.

Evaluation of a person-centred, nurse-led model of care delivering hepatitis C testing and treatment in priority settings: a mixed-methods evaluation of the Tasmanian Eliminate Hepatitis C Australia Outreach Project, 2020-2022

INTRODUCTION

Australia has experienced sustained reductions in hepatitis C testing and treatment and may miss its 2030 elimination targets. Addressing gaps in community-based hepatitis C prescribing in priority settings that did not have, or did not prioritise, hepatitis C testing and treatment care pathways is critical.

METHODS

The Tasmanian Eliminate Hepatitis C Australia Outreach Project delivered a nurse-led outreach model of care servicing hepatitis C priority populations in the community through the Tasmanian Statewide Sexual Health Service, supported by the Eliminating Hepatitis C Australia partnership. Settings included alcohol and other drug services, needle and syringe programs and mental health services. The project provided clients with clinical care across the hepatitis C cascade of care, including testing, treatment, and post-treatment support and hepatitis C education for staff.

RESULTS

Between July 2020 and July 2022, a total of 43 sites were visited by one Clinical Nurse Consultant. There was a total of 695 interactions with clients across 219 days of service delivery by the Clinical Nurse Consultant. A total of 383 clients were tested for hepatitis C (antibody, RNA, or both). A total of 75 clients were diagnosed with hepatitis C RNA, of which 95% (71/75) commenced treatment, 83% (62/75) completed treatment and 52% (39/75) received a negative hepatitis C RNA test at least 12 weeks after treatment completion.

CONCLUSIONS

Providing outreach hepatitis C services in community-based services was effective in engaging people living with and at-risk of hepatitis C, in education, testing, and care. Nurse-led, person-centred care was critical to the success of the project. Our evaluation underscores the importance of employing a partnership approach when delivering hepatitis C models of care in community settings, and incorporating workforce education and capacity-building activities when working with non-specialist healthcare professionals.

Inpatient Hepatitis C Treatment Coordination and Initiation for Patients Who Inject Drugs

BACKGROUND

With hepatitis C (HCV) incidence rising due to injection drug use, people who inject drugs (PWID) are a priority population for direct-acting antivirals (DAA). However, significant barriers exist. At our institution, hospitalized PWID were screened for HCV but not effectively linked to care.

AIM

To improve retention in HCV care among hospitalized PWID.

SETTING

Quaternary academic center in the Southeast US from August 2021 through August 2022.

PARTICIPANTS

Hospitalized PWID with HCV.

PROGRAM DESCRIPTION

E-consultation-prompted care coordination and HCV treatment with outpatient telehealth.

PROGRAM EVALUATION

Care cascades were constructed to assess retention and HCV treatment, with the primary outcome defined as DAA completion or sustained virologic response after week 4. Of 28 patients, 11 started DAAs inpatient, 8 initiated outpatient, and 9 were lost to follow-up or transferred care. Overall, 82% were linked to care and 52% completed treatment. For inpatient initiators, 73% achieved the outcome. Of non-inpatient initiators, 71% were linked to care, 53% started treatment, and 36% achieved the outcome.

DISCUSSION

Inpatient HCV treatment coordination, including DAA initiation, and telehealth follow-up, was feasible and highly effective for hospitalized PWID. Future steps should address barriers to inpatient DAA treatment and expand this model to other similar patient populations.

Social Networks, Stigma, and Hepatitis C Care Among Women Who Inject Drugs: Findings from A Community Recruited Sample

This study explores the role of perceived HCV stigma and social networks on HCV care among people who inject drugs (PWID) of both sexes, and solely among women who inject drugs (WWID). Data were from 269 HCV positive PWID, community-recruited through street-based outreach in Baltimore, MD. We defined HCV stigma based on participants' perceptions of treatment by others and their need to conceal their HCV status. Among WWID, HCV stigma was linked with decreased odds of undergoing liver disease staging (aOR = 0.33, 95% CI: 0.13,0.85) or to have attempted to get the HCV cure (aOR = 0.39, CI: 0.16,0.97), these associations were not evident in the overall sample with both sexes. Social network characteristics were significant correlates of HCV care in the overall sample, and these associations were stronger among WWID. WWID with more HCV positive social network members had higher odds of an HCV-related healthcare visit in the prior 12 months (aOR = 4.28, CI: 1.29,14.17) and to have undergone liver disease staging (aOR = 2.85, CI: 1.01,8.05). WWID with more social network members aware of the HCV cure were more likely to report an attempt at obtaining the HCV cure (aOR = 5.25, CI: 1.85,14.89). Our results suggest complexity in the role of social networks and stigma on HCV care.

Challenges to Achieving HCV Micro-Elimination in People With HIV in the United States: Provider Perspectives and the Role of Implicit Bias

The prevalence of HIV/HCV (hepatitis C virus) co-infection is high particularly in persons who inject drugs (PWID) and is increasing because of the evolving opioid epidemic in the United States. The introduction of effective antiviral medications for HCV has raised the strategic goal of HCV micro-elimination, and efforts to understand the barriers to treatment are critical. In this study, we explored the provider perspective of factors that inhibit HCV micro-elimination efforts in people with HIV (PWH), including the role of implicit bias and related stigma in providers' health care decision making. We used the mixed-methods approach of nominal group technique (NGT) with 14 participants from 11 different clinics engaged in two virtual focus group sessions (n = 5 and n = 9). Responses from the NGTs were rank ordered during the sessions to identify providers' perspectives of major barriers and facilitators, then identified possible implicit bias after the NGTs concluded. There were 12 responses given for micro-elimination barriers with the three most prioritized being housing instability, medication nonadherence concerns, and inability to motivate patients. Of these, eight were categorized as potential implicit biases. Among the 14 responses given for facilitators of treatment, the three major solutions included distributive models of care, improved provider knowledge, and increased patient engagement. Although the solutions offered were insightful, there was consensus that the individual lives of patients were the root cause of most barriers to care. We recommend further research on behavioral design interventions that promote patients' involvement in decision making and focus on patients' eligibility criteria for HCV treatment as opposed to providers' perceived barriers to treatment.

Improving HIV and HCV Testing in Substance Use Disorder Programs (SUDs) That Provide Medications for Opiate Use Disorder (MOUD): Role of Addressing Barriers and Implementing Universal and Site-Specific Approaches

Introduction. National strategies to end the HIV epidemic and eliminate hepatitis c (HCV) through a syndemic approach require improvements in testing for HIV and HCV. Given the intersection of the opioid crisis with HIV and HCV acquisition, substance use disorder (SUD) treatment centers providing medications for opiate use disorder (MOUD) provide a critical opportunity to expand testing. Rates of testing in MOUD clinics have been suboptimal. Method. We employed the Nominal Group Technique (NGT), Ishikawa cause and effect diagrams, and individualized Quality Improvement (QI) efforts at two SUD clinics (SUD A and B) in Connecticut (CT) as part of an HRSA-funded grant focused on improving HCV cure in persons with HIV/HCV coinfection. Baseline and longitudinal data were collected on rates of HIV and HCV testing and positivity as well as linkage to treatment. Results. Between April 1, 2019, and May 31, 2021, for SUD A and B respectively, HIV testing increased from 13% to 90% and 33% to 83%; HCV testing increased from 4% to 90% and 30% to 82%, with few reported cases of HIV/HCV coinfection. HCV testing revealed new and prior diagnoses at both sites, with subsequent referrals for treatment. Qualitative assessments identified best practices which included the institution of formal policies and procedures, streamlining of testing logistics, designation of a site champion, and broadening relevant education to staff and clients. Conclusion. Strategic assessment of barriers and facilitators to HIV and HCV testing at MOUD clinics can lead to improved testing and referral rates that are key to improving the cascade of care for both diseases.

Shorter Duration Hepatitis C Virus Treatment is Associated with Better Persistence to Prescription Refills in People Who Inject Drugs: A Real-World Study

INTRODUCTION

Direct-acting antiviral (DAA) therapy is highly effective in curing hepatitis C virus (HCV) infection in people who inject drugs (PWID). Previous studies showed declining persistence to DAA therapy over the course of treatment. This study compares real-world medication persistence to prescription refills for 8- versus 12-week DAA in treatment-naïve PWID with chronic HCV with compensated cirrhosis or without cirrhosis.

METHODS

Symphony Health's claims database was used to collect data from patients with chronic HCV aged ≥ 12 years who were prescribed 8- or 12-week DAA therapy between August 2017 and November 2020 and had a diagnosis of addicted drug use within 6 months prior to index date. Eligible patients had medical/pharmacy claims in the 6 months before and 3 months after the first index medication fill date (i.e., index date). Patients completing all refills (8-week = 1 refill, 12-week = 2 refills) were deemed persistent. The percentage of persistent patients in each group, and at each refill step, was determined; outcomes were also assessed in a subgroup of Medicaid-insured patients.

RESULTS

This study assessed 7203 PWID with chronic HCV (8-week, 4002; 12-week, 3201). Patients prescribed 8-week DAA treatment were younger (42.9 ± 12.4 vs 47.5 ± 13.2, P < 0.001) and had fewer comorbidities (P < 0.001). Patients receiving 8- versus 12-week DAA had greater refill persistence (87.9% vs 64.4%, P < 0.001). Similar percentages of patients missed their first refill (8-week, 12.1% vs 12-week, 10.8%); nearly 25% of patients receiving 12-week DAA missed their second refill. After baseline characteristics were controlled, patients prescribed 8- versus 12-week DAA were more likely to be persistent (odds ratio [95% confidence interval] 4.3 [3.8, 5.0]). Findings in the Medicaid-insured subgroup were consistent.

CONCLUSION

Patients prescribed 8- vs 12-week DAA therapy had significantly greater prescription refill persistence. Most nonpersistence was due to missed second refills, highlighting the potential benefit of shorter treatment durations in this population.

Timing of hepatitis C treatment initiation and retention in office-based opioid treatment with buprenorphine: a retrospective cohort study

BACKGROUND

This study examined associations between receipt of hepatitis C (HCV) treatment and retention in office-based opioid treatment (OBOT) care.

METHODS

We conducted a retrospective cohort study of HCV-infected patients who initiated OBOT treatment between December 2015 and March 2021 to characterize HCV treatment and assess associations with OBOT retention. HCV treatment was characterized as no treatment, early treatment (< 100 days since OBOT initiation) or late treatment (≥ 100 days). We evaluated associations between HCV treatment and cumulative days in OBOT. A secondary analysis using Cox Proportional Hazards regression was done to determine the rate of discharge over time when comparing those who did versus did not receive HCV treatment as a time-varying covariate. We also analyzed a subset of patients retained at least 100 days in OBOT care and evaluated whether HCV treatment during that period was associated with OBOT retention beyond 100 days.

RESULTS

Of 191 HCV-infected OBOT patients, 30% initiated HCV treatment, of whom 31% received early treatment and 69% received late treatment. Median cumulative duration in OBOT was greater among those who received HCV treatment (any: 398 days, early: 284 days and late: 430 days) when compared to those who did not receive treatment (90 days). Compared to no HCV treatment, there were 83% (95% CI: 33-152%, P < 0.001), 95% (95% CI: 28%-197%, p = 0.002 and 77% (95% CI: 25-153%, p = 0.002) more cumulative days in OBOT for any, early and late HCV treatment, respectively. HCV treatment was associated with a lower relative hazard for discharge/drop-out, although results did not meet statistical significance (aHR = 0.59;95% CI: 0.34-1.00; p = 0.052). Among the subset of 84 patients retained in OBOT at least 100 days, 18 received HCV treatment during that period. Compared to those who did not receive treatment within the first 100 days, those who received treatment had 57% (95% CI: -3%-152%, p = 0.065) more subsequent days in OBOT.

CONCLUSIONS

A minority of HCV-infected patients received HCV treatment after initiating OBOT treatment, but those who did had better retention. Further efforts are needed to facilitate rapid HCV treatment and evaluate whether early HCV treatment improves OBOT engagement.

Hepatitis C Guidance 2023 Update: AASLD-IDSA Recommendations for Testing, Managing, and Treating Hepatitis C Virus Infection

The Infectious Diseases Society of America and the American Association for the Study of Liver Diseases have collaboratively developed evidence-based guidance regarding the diagnosis, management, and treatment of hepatitis C virus (HCV) infection since 2013. A panel of clinicians and investigators with extensive infectious diseases or hepatology expertise specific to HCV infection periodically review evidence from the field and update existing recommendations or introduce new recommendations as evidence warrants. This update focuses on changes to the guidance since the previous 2020 published update, including ongoing emphasis on recommended universal screening; management recommendations for incomplete treatment adherence; expanded eligibility for simplified chronic HCV infection treatment in adults with minimal monitoring; updated treatment and retreatment recommendations for children as young as 3 years old; management and treatment recommendations in the transplantation setting; and screening, treatment, and management recommendations for unique and key populations.

Injecting practices during and after hepatitis C treatment and associations with not achieving cure among persons who inject drugs

BACKGROUND

Persons who inject drugs (PWID) are a key population for hepatitis C virus (HCV) treatment. Study aims were to describe injection practices of PWID during HCV treatment with direct-acting antivirals (DAAs) and assess whether injection practices were associated with not achieving a sustained virologic response (SVR).

METHODS

Secondary analysis of the HERO Study (ClinicalTrials.gov, NCT02824640), a pragmatic randomized trial in 8 U.S. states to evaluate the effectiveness of HCV care models among active PWID seen in opioid treatment programs and community clinics. Frequency, sharing and reuse of injecting equipment were assessed at baseline, end-of-treatment (EOT) and quarterly visits up to 60 weeks post-treatment. Generalized Estimating Equations logistic regression models with linear spline were used to compare trends in injecting behaviors during vs. post-treatment. Multivariable logistic regression models explored associations between injecting behaviors during treatment and lack of SVR.

RESULTS

Among 501 participants, 27% were female, 35% were non-white, mean age was 44 (SD 11.5) years and nearly half (49%) were unhoused. At baseline, 41% reported receptive sharing of injecting equipment, declining to 16% at EOT visit. Receptive sharing of cookers, rinses, or needles/syringes during treatment was associated with a nearly 5-fold increase in not achieving SVR (adjusted odds ratio (aOR)=4.83; 95% CI: 2.26, 10.28) as was reuse of one's own needles/syringes (aOR=2.37; 95% CI: 1.11, 4.92).

CONCLUSIONS

PWID in the HERO study adopted safer injecting behaviors during DAA treatment; receptive sharing of injecting equipment and reuse of one's own equipment during treatment were associated with not achieving cure.

Liver Disease and Poor Adherence Limit Hepatitis C Cure: A Real-World Australian Treatment Cohort

BACKGROUND AND AIMS

In 2016, direct-acting antiviral (DAA) treatment for hepatitis C (HCV) became available through Australia's universal health care system, with the aim of HCV elimination. We report real-world effectiveness of DAA HCV treatment in Australia from a clinically well-informed cohort, enriched for cirrhosis and prior HCV treatment.

METHODS

3413 patients were recruited from 26 hospital liver clinics across Australia from February 2016 to June 2020. Clinical history and sustained viral response (SVR) were obtained from medical records and data linkage to the Australian Pharmaceutical Benefits Scheme. Factors associated with SVR were assessed by multivariable logistic regression (MVR).

RESULTS

At recruitment, 32.2% had cirrhosis (72.9% Child Pugh class B/C), and 19.9% were treatment experienced. Of the 2,939 with data, 93.3% confirmed SVR. 137 patients received second-line therapy. Patients with cirrhosis had lower SVR rate (88.4 vs. 95.8%; p < 0.001). On MVR, failure to achieve SVR was associated with Genotype 3 (adj-OR = 0.42, 95%CI 0.29-0.61), male gender (adj-OR = 0.49, 95%CI 0.31-0.77), fair/poor adherence (adj-OR = 0.52, 95%CI 0.28-0.94), cirrhosis (adj-OR = 0.57, 95%CI 0.36-0.88), FIB-4 > 3.25 (adj-OR = 0.52, 95%CI 0.33-0.83) and MELD score ≥ 20 (adj-OR = 0.25, 95%CI 0.08-0.80). Consistent results were seen in cirrhotic sub-analysis.

CONCLUSIONS

Excellent SVR rates were achieved with DAAs in this real-world cohort of patients with chronic HCV infection. More advanced liver disease and clinician impression of poor adherence were associated with HCV treatment failure. Supports to improve liver fibrosis assessment skills for non-specialist DAA prescribers in the community and to optimize patient adherence are likely to enable more effective pursuit of HCV elimination in Australia.

Patient-centred models of hepatitis C treatment for people who inject drugs: a multicentre, pragmatic randomised trial

BACKGROUND

To achieve WHO targets for the elimination of hepatitis C virus (HCV) as a public threat, an increased uptake of HCV treatment among people who inject drugs (PWID) is urgently needed. Optimal HCV co-located treatment models for PWID have not yet been identified. We aimed to compare two patient-centred models of HCV care in PWID with active drug use.

METHODS

We did a pragmatic randomised controlled trial at eight US cities in eight opioid treatment programmes and 15 community health centres. PWID actively injecting within 90 days of study entry were randomly assigned (1:1) to either patient navigation or modified directly observed therapy (mDOT) using computer-generated variable block sizes of 2-6 stratified by city, clinical settings, and cirrhosis status. The randomisation code was concealed, in a centralised REDCap database platform, from all investigators and research staff except for an authorised data manager at the data coordinating centre. All participants received a fixed-dose combination tablet (sofosbuvir 400 mg plus velpatasvir 100 mg) orally once daily for 12 weeks. The primary outcome was sustained virological response (SVR; determined by chart review between 70 days and 365 days after end of treatment and if unavailable, by study blood draws), and secondary outcomes were treatment initiation, adherence (measured by electronic blister packs), and treatment completion. Analyses were conducted within the modified intention-to-treat (mITT; all who initiated treatment), intention-to-treat (all who were randomised), and per-protocol populations. This trial is registered with ClinicalTrials.gov, NCT02824640.

FINDINGS

Between Sept 15, 2016, and Aug 14, 2018, 1891 individuals were screened and 1136 were excluded (213 declined to participate and 923 did not meet the eligibility criteria). We randomly assigned 755 participants to patient navigation (n=379) or mDOT (n=376). In the mITT sample of participants who were randomised and initiated treatment (n=623), 226 (74% [95% CI 69-79]) of 306 participants in the mDOT group and 236 (76% [69-79]) of 317 in the patient navigation group had an SVR, with no significant difference between the groups (adjusted odds ratio [AOR] 0·97 [95% CI 0·66-1·42]; p=0·35). In the ITT sample (n=755), 226 (60% [95% CI 55-65]) of 376 participants in the mDOT group and 236 (62% [57-67]) of 379 in the patient navigation group had an SVR (AOR 0·92 [0·68-1·25]; p=0·61) and in the per-protocol sample (n=501), 226 (91% [87-94]) of 248 participants in the mDOT group and 235 (93% [89-96]) of 253 in the patient navigation group had an SVR (AOR 0·79 [0·41-1·55]; p=0·44). 306 (81%) of 376 participants in the mDOT group and 317 (84%) of 379 participants in the patient navigation group initiated treatment (AOR 0·86 [0·58-1·26]; p=0·44) and, among those, 251 (82%) participants in the mDOT group and 264 (83%) participants in the patient navigation group completed treatment (AOR 0·90 [0·58-1·39]; p=0·63). Mean daily adherence was higher in the mDOT group (78% [95% CI 75-81]) versus the patient navigation group (73% [70-77]), with a difference of 4·7% ([1·9-7·4]; p=0·0010). 421 serious adverse events were reported (217 in the mDOT group and 204 in the patient navigation group), with the most common being hospital admission (176 in the mDOT group vs 161 in the patient navigation group).

INTERPRETATION

In this trial of active PWID, both models resulted in high SVR. Although adherence was significantly higher in the mDOT group versus the patient navigation group, there was no significant difference in SVR between the groups. Increases in adherence and treatment completion were associated with an increased likelihood of SVR. These results suggest that active PWID can reach high SVRs in diverse settings with either mDOT or patient navigation support.

FUNDING

Patient-Centered Outcomes Research Institute, Gilead Sciences, Quest Diagnostics, Monogram Biosciences, and OraSure Technologies.

Integrated care model and point of care diagnostics facilitate Hepatitis C treatment among patients receiving opioid agonist therapy: a retrospective review of medical records

Background

Hepatitis C virus (HCV) is common among individuals in opioid agonist therapy (OAT). HCV treatment has previously been unavailable for most HCV positive OAT patients in Finland. The removal of treatment restrictions and attempts to reach HCV elimination goals have increased the number of OAT patients needing HCV treatment. The objectives of this study were 1) to characterize Finnish HCV positive OAT patients and evaluate their eligibility for HCV treatment at addiction service units, and 2) to retrospectively review the outcomes of treated patients.

Methods

The study focused on HCV positive OAT patients (n = 235). Demographics and clinical parameters were retrospectively reviewed using the patients’ medical records. The eligibility of providing HCV treatment to patients at addiction service units were evaluated based on patients’ clinical characteristics, such as liver function and patterns of substance use. The outcomes of patients receiving HCV treatment were reviewed.

Results

Of HCV antibody positive OAT patients, 75% had chronic HCV. Of 103 HCV patients screened for liver fibrosis either with Fibroscan or APRI (aspartate aminotransferase to platelet ratio index), 83 patients (81%) had no indication of severe liver damage. Point of care (POC) HCV tests were used for 46 patients to lower the threshold of attending laboratory testing. All patients preferred POC testing to conventional blood testing.

Twenty patients had received HCV treatment, 19 completed the treatment and achieved sustained virologic response (SVR) at the end of the treatment. Of the 18 patients available for evaluation of SVR at 12 weeks after the treatment (SVR12), 17 achieved SVR12.

Conclusions

The integrated model consisting of HCV diagnostics and treatment at the addiction service unit was successfully implemented within normal OAT practice.

Improving hepatitis C screening and access to treatment

ABSTRACT

The rising prevalence of opioid use disorder and injection drug use has resulted in an increasing incidence of chronic hepatitis C virus (HCV) infection. Although older adults historically have represented the bulk of HCV infections in the United States, demographics have shifted and most new infections are presenting in younger patients. As a result, screening guidelines for HCV have evolved, moving toward a near-universal screening paradigm. Rates of screening and linkage to care remain low, attributed to the fact that underserved populations are disproportionately affected and often have limited access to specialty care. Collaborative models to treat HCV using primary care providers have been proposed to facilitate linkage to care and reduce transmission.

Treatment for hepatitis C virus with direct acting antiviral agents: Perspectives and treatment experiences of people who inject drugs

INTRODUCTION

Increasingly, people who inject drugs (PWID) infected with hepatitis C virus (HCV) are gaining access to highly effective direct-acting antiviral agents (DAAs). Although past studies examined patient experiences with interferon-based treatments, few have explored patient experiences with these new generation therapeutics. Research and real world experience indicate that many PWID can be successfully treated with the new DAAs. Yet a substantial minority fail to complete treatment or achieve only suboptimal adherence. This qualitative study examines experiences with treatment among participants in Project HERO, a large multisite trial designed to compare treatment delivery methods for DAAs. We explored treatment experiences among HERO participants, with the goal of understanding potential barriers to treatment engagement and completion.

METHODS

We conducted qualitative interviews with a sample of 21 participants, including 14 who completed HCV treatment and 7 participants who discontinued treatment before the end of the 12-week medication course. The first phase of the analysis was descriptive, examining participants' life experiences, histories of disease and treatment seeking, experiences with the program, and barriers to treatment completion. The second phase of the analysis examined differences between completers and noncompleters.

RESULTS

Participants offered a variety of reasons for seeking treatment. Both groups of participants reported highly positive experiences of the HERO trial. Participants described research staff as caring, respectful, and nonjudgmental. Substance use was reported by both groups, yet completers described "manageable" substance use, while noncompleters described substance use that sapped their energy and motivation. Shame over drug use was a barrier to treatment completion. Homelessness and a reported lack of social support were much more common in the noncompleter group.

CONCLUSIONS

Reasons for noncompletion were not related to features of the clinical trial or treatment program. Our results indicate the importance of: 1) recognizing and addressing severe social and economic challenges such as homelessness; and 2) building a program culture of respect and compassion in treatment programs for PWID infected with HCV.

Randomized clinical trial: Direct-acting antivirals as treatment for hepatitis C in people who inject drugs: Delivered in needle and syringe programs via directly observed therapy versus fortnightly collection

Hepatitis C virus (HCV) treatment in people who inject drugs (PWID) is delivered within settings frequented by PWID, such as needle and syringe programs (NSP). The optimal direct-acting antiviral (DAA) dispensing regimen among NSP clients is unknown. This study compared cures (Sustained virologic response 12 weeks post-treatment, [SVR₁₂ ]) across three dispensing schedules to establish non-inferiority of fortnightly dispensing versus directly observed therapy. The ADVANCE HCV study was a randomized, unblinded trial, recruiting PWID attending NSP in Tayside, Scotland, between January 2018 and November 2019. HCV-positive participants were randomized to receive DAAs via directly observed therapy, fortnightly provision or fortnightly provision with psychological intervention. A modified intention to treat analysis was used to identify differences in cures between the three treatment regimes. The study was registered with clinicaltrials.gov; NCT03236506. A total of 110 participants completed the study. 33 participants received directly observed therapy, with 90.91% SVR₁₂ ; 37 received fortnightly provision, with 86.49% SVR₁₂ and 40 received fortnightly provision and psychological intervention at treatment initiation, with 92.50% SVR₁₂ . Analysis showed no significant difference in SVR₁₂ (p = 0.67). This study did not demonstrate a statistically significant difference in cure rate between groups. This provides evidence of the non-inferiority of fortnightly dispensing of direct-acting antivirals (DAAs) compared to directly observed therapy among PWID. It suggests that tight control of adherence through directly observed therapy dispensing of DAAs among this population offers no therapeutic advantage. Therefore, less restrictive dispensing patterns can be used, tailored to patient convenience.

Hepatitis C treatment outcomes for Australian First Nations Peoples: equivalent SVR rate but higher rates of loss to follow-up

Background

First Nations Peoples of Australia are disproportionally affected by hepatitis C (HCV) infection. Through a prospective study we evaluated the outcome of direct-acting antiviral (DAA) therapy among First Nations Peoples with HCV infection.

Methods

Adults who initiated DAA therapy at one of 26 hospitals across Australia, 2016–2019 were included in the study. Clinical data were obtained from medical records and the Pharmaceutical and Medicare Benefits Schemes. Outcomes included sustained virologic response (SVR) and loss to follow-up (LTFU). A multivariable analysis assessed factors associated with LTFU.

Results

Compared to non-Indigenous Australians (n = 3206), First Nations Peoples (n = 89) were younger (p < 0.001), morel likely to reside in most disadvantaged (p = 0.002) and in regional/remote areas (p < 0.001), and had similar liver disease severity. Medicines for mental health conditions were most commonly dispensed among First Nations Peoples (55.2% vs. 42.8%; p = 0.022). Of 2910 patients with follow-up data, both groups had high SVR rates (95.3% of First Nations Peoples vs. 93.2% of non-Indigenous patients; p = 0.51) and ‘good’ adherence (90.0% vs. 86.9%, respectively; p = 0.43). However, 28.1% of First Nations Peoples were LTFU vs. 11.2% of non-Indigenous patients (p < 0.001). Among First Nations Peoples, younger age (adj-OR = 0.93, 95% CI 0.87–0.99) and treatment initiation in 2018–2019 vs. 2016 (adj-OR = 5.14, 95% CI 1.23–21.36) predicted LTFU, while higher fibrosis score was associated with better engagement in HCV care (adj-OR = 0.71, 95% CI 0.50–0.99).

Conclusions

Our data showed that First Nations Peoples have an equivalent HCV cure rate, but higher rates of LTFU. Better strategies to increase engagement of First Nations Peoples with HCV care are needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02416-5.

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

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

Treating the Hardest to Treat: Reframing the Hospital Admission as an Opportunity to Initiate Hepatitis C Treatment

BACKGROUND

Chronic hepatitis C (CHC) is traditionally treated in the outpatient setting. Despite the excellent tolerability, shortened treatment duration, and high cure rates of newer direct-acting antivirals (DAAs), many vulnerable patients remain untreated due to issues with linkage to care.

AIMS

This study sought to reframe and establish the hospital admission as a unique opportunity to initiate antiviral treatment for patients with CHC, particularly those with psychosocial or linkage to care issues.

METHODS

Patients with untreated CHC were identified either on the Psychiatry or Med/Surg wards at the Veterans Affairs Palo Alto Health Care System (VAPAHCS). If found to be appropriate for treatment initiation, patients were started on antivirals during their hospitalization and followed closely while inpatient and after discharge to assess for sustained virologic response (SVR), treatment tolerability, and treatment completion.

RESULTS

Overall, 36% (23) of potential treatment candidates were initiated on DAA treatment during their hospitalization. Of these patients, 91.3% had documented treatment completion with an intention-to-treat and modified intention-to-treat SVR rate of 91.3% and 100%, respectively.

CONCLUSIONS

We establish the hospital admission as a valuable opportunity for HCV treatment initiation, yielding excellent treatment outcomes in those who would not otherwise be treated and achieved a modified intention-to-treat response rate of 100%.

Nonadherence to Ledipasvir/Sofosbuvir Did Not Predict Sustained Virologic Response in a Randomized Controlled Trial of Human Immunodeficiency Virus/Hepatitis C Virus Coinfected Persons Who Use Drugs

BACKGROUND

Eliminating hepatitis C virus (HCV) will require effective treatment delivery to persons with substance use disorders (SUDs). We evaluated the relationship between ledipasvir/sofosbuvir treatment persistence (receiving 84 tablets), adherence, and sustained virologic response (SVR) in persons with human immunodeficiency virus (HIV)/HCV coinfection.

METHODS

Of the 144 participants with HIV/HCV and SUDs, 110 initiated a 12-week treatment course under 1 of 3 conditions (usual care, peer mentors, and cash incentives). We used self-report, pharmacy pill counts, and expected date of refill to examine adherence. Persistent participants were categorized as high adherence (taking ≥90% of doses) or low adherence (taking <90% of doses).

RESULTS

Most participants persisted on treatment after initiation (n = 105), with 95% (n = 100) achieving SVR. One third (34%) of participants had moderate/heavy alcohol use by the biomarker phosphatidylethanol ([Peth] ≥50 ng/mL), and 44% had urine toxicology positive for cocaine or heroin at enrollment. The proportion of persons with high adherence was 72% (n = 76), and the proportion of persons with low adherence was 28%. Although low adherence was associated with moderate/heavy alcohol use by PEth (relative risk = 2.77; 95% confidence interval, 1.50-5.12), SVR did not vary according to adherence (P = .702), and most participants (97%) with low adherence achieved SVR.

CONCLUSIONS

Treatment persistence led to high SVR rates among persons with HIV/HCV, despite imperfect adherence and SUDs.

Infectious Complications of Injection Drug Use

The opioid overdose epidemic is one of the leading causes of death in adults. Its devastating effects have included not only a burgeoning overdose crisis but also multiple converging infectious diseases epidemics. The use of both opioids and other substances through intravenous (IV) administration places individuals at increased risks of infectious diseases ranging from invasive bacterial and fungal infections to human immunodeficiency virus (HIV) and viral hepatitis. In 2012, there were 530,000 opioid use disorder (OUD)-related hospitalizations in the United States (US), with $700 million in costs associated with OUD-related infections. The scale of the crisis has continued to increase since that time, with hospitalizations for injection drug use-related infective endocarditis (IDU-IE) increasing by as much as 12-fold from 2010 to 2015. Deaths from IDU-IE alone are estimated to result in over 7,260,000 years of potential life lost over the next 10 years. There have been high-profile injection-related HIV outbreaks, and injection drug use (IDU) is now the most common risk factor for hepatitis C virus (HCV). As this epidemic continues to grow, clinicians in all aspects of medical care are increasingly confronted with infectious complications of IDU. This review will describe the pathogenesis, clinical syndromes, epidemiology, and models of treatment for common infectious complications among persons who inject drugs (PWIDs).

Reported Barriers to Hepatitis C Treatment among Pregnant and Early-Parenting Mothers Undergoing Substance Use Disorder Treatment in One U.S. State

Nationwide, the prevalence of the hepatitis C virus (HCV) has risen in recent years. At least 90% of infected persons must be treated to achieve global elimination targets. The current study aimed to explore barriers to, and facilitators of, direct-acting antiviral (DAA) HCV treatment uptake amongst pregnant and early-parenting women undergoing comprehensive substance use treatment. Twenty participants with documented HCV antibody positivity were recruited from two substance use treatment centers in central Kentucky. Semi-structured interviews were conducted to explore knowledge about HCV, previous experiences, and intentions to seek care. Themes were extracted using an inductive analytical approach. Most participants were aware of the dangers posed by HCV infection. However, there was a high degree of misinformation about transmission mechanisms and treatment eligibility requirements. Low priority for HCV treatment also surfaced as a barrier to treatment uptake. Participants reported being unable to seek care due to time and resource limitations in the presence of a highly demanding treatment process. Findings from the current study suggest that more work is needed to eliminate residual barriers that limit access to HCV treatment among pregnant and early-parenting women in treatment for substance use disorder.

Impact of Co-occurring Drug Use, Hazardous Alcohol Use, and Mental Health Disorders on Drug Use Patterns in People With HIV and Hepatitis C Virus Infection

Drug use, hazardous alcohol use, and mental health disorders are prevalent among people with HIV and hepatitis C virus (HCV) infection. Co-occurrence of alcohol use and depression negatively impacts substance use patterns. Nevertheless, HCV treatment provides a promising opportunity to identify and address co-occurring drug use, hazardous alcohol use, and mental health disorders.

Economic impact of applying the AASLD-IDSA simplified treatment algorithm on the real-world management of hepatitis C

BACKGROUND: The American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) recommended in May 2019 that patients with hepatitis C virus (HCV) could be assessed for treatment initiation with a simplified treatment algorithm. This approach uses standard blood and fibrosis tests, rather than genotype testing, to guide the initiation of pan-genotypic direct-acting antiviral agents (DAAs) sofosbuvir/velpatasvir (SOF/VEL) or glecaprevir/pibrentasvir (GLE/PIB) treatment. OBJECTIVE: To compare health care resource utilization (HCRU) and costs for patients who initiated treatment via the simplified vs nonsimplified algorithm (genotype testing). METHODS: We identified adults with commercial and Medicare Advantage coverage who were diagnosed with HCV who initiated SOF/VEL or GLE/PIB from July 1, 2016, through August 31, 2019, in a nationally representative US administrative claims database. The index date was defined as the first pharmacy SOF/VEL or GLE/PIB fill date. Continuous enrollment 12 months before and ≥6 months after index date was required. Patients with claims for hepatitis B, HIV, decompensated liver, or prior DAAs were excluded. Patients were propensity score-matched (1:1) and grouped as "simplified" or "nonsimplified." HCV-related HCRU and costs were compared for the post-matched groups. RESULTS: 3,539 HCV patients were included, and 16.6% initiated SOF/VEL or GLE/PIB via the simplified algorithm. Pre-matched treatments were SOF/VEL (52.8%) and GLE/PIB (47.2%). More than half (55.7%) of SOF/VEL and 44.3% of GLE/PIB patients started treatment via the simplified algorithm. HCV patients initiating via the simplified algorithm were more likely to be male (65.1% vs 60.6%; P = 0.041), commercially insured (53.3% vs 46.5%; P = 0.003), and in the Midwest (25.7% vs 19.3%; P < 0.001) vs nonsimplified patients. The nonsimplified group had more liver disease (52.1% vs 46.9%; P = 0.019), metabolic disorders (45.8% vs 39.2%; P = 0.003), and dyslipidemia (39.9% vs 35.4%; P = 0.041) vs the simplified group. Of the index prescriptions, 58.9% were written by gastroenterology or infectious disease specialists, and 68.1% (simplified) vs 75.4% (nonsimplified) had a specialist visit within 90 days prior to index DAA fill (P < 0.001). Matching resulted in 584 well-matched patients in each group. At post-match baseline, the simplified treatment group had significantly lower median (interquartile range [IQR]) HCV-related medical health care costs vs the matched nonsimplified group: $373 ($201-$684) vs $727 ($456-$1,185; P < 0.001). Median noninpatient/emergency department health plan-paid costs were also significantly lower in the simplified cohort ($257 vs $504; P < 0.001). During follow-up, medical HCV-related health care costs were similar across the groups. CONCLUSIONS: This study compared economic outcomes of HCV treatment initiation via the simplified and nonsimplified algorithms. The simplified approach resulted in lower use of health care resources, greater cost savings, and greater ability of patients to access care from both specialist and nonspecialist providers. While additional studies are needed, these early findings suggest a feasible path for simplified HCV treatment in real-world managed care settings. DISCLOSURES: Funding support for this study was provided by Gilead Sciences, Inc. Majethia, Lee, Mozaffari, Wolf, and Hsiao are employees of Gilead Sciences, Inc. Bunner and Chastek are employees of Optum Life Sciences, which received funding from Gilead Sciences, Inc. to conduct this study. Bunner owns stock in UnitedHealth group, parent company of Optum. A poster based on selected data from this study was presented at the AMCP 2021 Virtual Meeting, April 12-16, 2021.

Disparities in Treatment with Direct-Acting Hepatitis C Virus Antivirals Persist Among Adults Coinfected with HIV and Hepatitis C Virus in US Clinics, 2010-2018

Human immunodeficiency virus (HIV) and hepatitis C virus (HCV) coinfection carries substantial risk for all-cause mortality and liver-related morbidity and mortality, yet many persons coinfected with HIV/HCV remain untreated for HCV. We explored demographic, clinical, and sociodemographic factors among participants in routine HIV care associated with prescription of direct-acting antivirals (DAAs). The HIV Outpatient Study (HOPS) is an ongoing longitudinal cohort study of persons with HIV in care at participating clinics since 1993. There are currently eight study sites in six US cities. We analyzed medical records data of HOPS participants diagnosed with HCV since June 2010. Sustained virological response (SVR) was documented with first undetectable HCV viral load (VL). We assessed factors associated with being prescribed DAAs by multi-variable logistic regression and described the cumulative rate of SVR. Among 306 eligible participants, 131 (43%) were prescribed DAA therapy. Factors associated with greater odds of being prescribed DAA were older age, private health insurance, higher CD4 cell count, being a person who injects drugs, and receiving care at publicly funded sites (p < 0.05). Of 127 (97%) participants with at least 1 follow-up HCV VL, 110 (87%) achieved SVR at 12 weeks. Of the total 131 participants, 123 (94%) eventually achieved SVR. Less than half of HIV/HCV coinfected patients in HOPS have been prescribed DAAs. Interventions are needed to address deficits in DAA prescription, including among patients with public or no health insurance, younger age, and lower CD4 cell count.

Influence of psychiatric disorders and opioid substitution therapy on hepatitis C treatment with direct-acting antivirals in people who inject drugs

INTRODUCTION

The effectiveness of the hepatitis C virus (HCV) treatment seems to be lower in people who inject drugs (PWID). We analyze the influence of various factors as psychiatric disorders and opioid substitution therapy (OST) on the treatment with direct-acting antivirals (DAA) in this collective.

PATIENTS AND METHODS

Three hundred thirty-two PWID patients were treated with DAA in 12 Spanish hospitals between 2004 and 2020. They were catalogued in recent and former consumers (if the last consumption was in the last 3 years) and several variables were included, evaluating the effectiveness of the treatment according to the viral load 12 weeks after the end of the treatment with the parameter «sustained viral response» (SVR12).

RESULTS

23.4% were recent consumers and 27.7% were on OST. The 41.5% had any diagnosis of psychiatric disorder. SVR12 was 84.04%, ascending to 96.21% when excluded from the analyses the patients lost to follow-up (12.7%). SVR12 was lower due to an increase in the loss to follow-up in recent consumers and other factors like OST, being in prison the last 5 years, naïve patients, generalized anxiety disorder and benzodiazepine consumption.

CONCLUSIONS

The effectiveness of the HCV treatment with DAA in PWID is similar than in general population in patients whit an appropriate follow-up. It is important to maintain a closer follow-up in patients on OST, recent consumers and those with psychiatric disorders.

Hepatitis C Treatment by Nonspecialist Providers in the Direct-acting Antiviral Era

BACKGROUND

Hepatitis C virus (HCV) remains under-treated in the United States and treatment by nonspecialist providers can expand access. We compare HCV treatment provision and treatment completion between nonspecialist and specialist providers.

METHODS

This retrospective study used claims data from the Healthcare Cost Institute from 2013 to 2017. We identified providers who prescribed HCV therapy between 2013 and 2017, and patients enrolled in private insurance or Medicare Advantage who had pharmacy claims for HCV treatment. We measured HCV treatment completion, determined based on prescription fills for the minimum expected duration of the antiviral regimen. Using propensity score-weighted regression, we compared the likelihood of early treatment discontinuation by the type of treating provider.

RESULTS

The number of providers prescribing HCV treatment peaked in 2015 and then declined. The majority were gastroenterologists, although the proportion of general medicine providers increased to 17% by 2017. Among the 23,463 patients analyzed, 1008 (4%) discontinued before the expected minimum duration. In the propensity score-weighted analysis, patients treated by general medicine physicians had similar odds of treatment discontinuation compared with those treated by gastroenterologists [odds ratio (OR)=1.00, 95% confidence interval (CI): 0.99-1.01, P=0.45]. Results were similar when comparing gastroenterologists to nonphysician providers (OR=1.00, 95% CI: 0.99-1.01, P=0.53) and infectious diseases specialists (OR=1.00, 95% CI: 0.99-1.01, P=0.71).

CONCLUSIONS

HCV treatment providers remain primarily gastroenterologists, even in the current simplified treatment era. Patients receiving treatment from general medicine or nonphysician providers had a similar likelihood of treatment completion, suggesting that removing barriers to the scale-up of treatment by nonspecialists may help close treatment gaps for hepatitis C.

'Treat my whole person, not just my condition': qualitative explorations of hepatitis C care delivery preferences among people who inject drugs

Background

The advent of direct-acting antivirals (DAAs)—a form of hepatitis C (HCV) treatment associated with shorter treatment course and greater efficacy—offers an unprecedented opportunity to eliminate HCV, but only if care delivery systems are developed to extend treatment to people who inject drugs (PWID). To support the design of a community-pharmacy program, we explored perspectives of PWID with chronic HCV with regard to barriers, motivators, preferences, and prior experiences related to HCV treatment and pharmacists.

Methods

We conducted semi-structured interviews with people living with HCV who reported active injection drug use. Participants were recruited from local community service and clinical organizations in the Seattle, Washington region, and focus groups and interviews were conducted in-person or via phone/video-conference. Rapid Assessment Process was used to analyze qualitative data. Dual coders used structured templates to summarize findings and engaged in iterative review to identify themes.

Results

Among the 40 participants, 65% were male, 52.5% were white, and 80% were not stably housed. On average, participants had been injecting drugs for 14 years and living with HCV for 6 years. Analyses revealed 3 themes: (1) limited knowledge regarding HCV and DAA treatments; (2) barriers/motivators for receiving treatment included fear of side effects, prior stigmatizing behaviors from physicians, and desire to protect relatives and the PWID community from HCV transmission; and (3) preferences for HCV care delivery, including a need for person-centered, low-barrier, and collaborative treatment integrated with other care (e.g. primary care and addiction treatment) for PWID. Participants were generally receptive to a community-pharmacy model for HCV treatment, but prior interactions with pharmacists were mixed and there were some concerns expressed that care delivered by pharmacists would not be equivalent to that of physicians.

Conclusions

Even in the direct-acting antivirals era, people who inject drugs still face major barriers to hepatitis C treatment which may be reduced by providing low-barrier points of access for care through pharmacists. Key recommendations for community-pharmacy design included providing care team training to reduce stigma and ensuring care team structures and culture target PWID-specific needs for education and engagement.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13722-021-00260-8.

Barriers to hepatitis C treatment among secondary needle and syringe program clients and opportunities to intervene

BACKGROUND

At least 160,000 Australians are living with hepatitis C (HCV), many of whom are people who inject drugs and access needle and syringe programs (NSP). Secondary NSPs provide injecting equipment via health services that are not dedicated to the provision of services to people who inject drugs; these sites could be a suitable space to increase engagement of people who inject drugs in HCV treatment. Drawing on data from a pilot study exploring the potential of upscaling linkage to HCV care in secondary NSPs, the aim of this research was to explore barriers and enablers to HCV treatment for clients who use these services.

METHODS

We interviewed 34 people who inject drugs (who self-reported HCV positivity) from six secondary NSPs in urban and regional Victoria, Australia in 2018. Fifty per cent were male, with ages ranging from 33 to 58. Twenty-two (65%) had never received HCV treatment and none had experience with direct-acting antiviral (DAA) treatment. Interviews were transcribed and analysed thematically. Field notes from a program evaluation with feedback from secondary NSP staff was also used as a secondary data source.

RESULTS

Five themes encompassing a set of contrasting barriers and enablers to accessing HCV care through secondary NSPs were uncovered. Themes included 'misinformation' vs. 'multiple trusted information sources; 'lack of symptoms and motivation' vs. 'benefits of cure'; 'competing priorities' vs. 'willingness and readiness to be cured'; 'unsupportive relationships with staff' vs. 'supportive relationships with staff'; and 'inaccessibility and stigma in health services' vs. 'enhanced support'. Secondary program evaluation data also highlighted that secondary NSP staff were under-resourced and had limited capacity to implement HCV care linkage and information.

CONCLUSION

We identified contrasting barriers and opportunities for accessing DAAs among a sample of secondary NSP clients and staff. Interventions that consider individual, provider and health system level factors are needed if secondary NSP services are to become a suitable setting to initiate conversations with clients around HCV treatment and provide linkages to care.

Phylogenetic and Phylodynamic Analyses of HCV Strains Circulating among Patients Using Injectable Drugs in Central Italy

Approximately 71 million people worldwide are infected with the hepatitis C virus (HCV). Injectable drug use represents the most common route of transmission in Europe and other developed countries. We studied the molecular characteristics of the HCV infection among mono-infected people who used drugs (PWUD) in Italy. Among 208 PWUD with anti-HCV antibodies, 101 (48.6%) were HCV RNA-positive, the majority (47%) were infected with the HCV genotype (Gt)1a, followed by Gt3a (34.9%), Gt4 (9.1%), Gt1b (4.5%), and Gt2 (4.5%). Bayesian phylogenetic analyses of clustered HCV NS5B sequences from 66 HCV-positive PWUDs with available plasma samples indicated age and neighborhood proximity as the most common characteristics between closely related HCV strains. Population dynamics, as measured by a coalescent Bayesian skyline analysis, revealed an increase in HCV Gt1a infections from the mid-1980s to mid-1990s. While HCV Gt3a infections were first detected in the 1980s, patient numbers with this genotype subtype remained relatively constant. For both Gt1a and Gt3a, Birth–Death Bayesian Skyline analyses produced higher reproduction numbers post 2014. For earlier time intervals, slow growths were observed for both Gt1a and Gt3a with reproduction numbers (Re) of approximately 1. The evolutionary rates for Gt1a and Gt3a were estimated as 2.23 × 10⁻⁴ and 3.85 × 10⁻⁴, respectively.

Association Between Opioid Agonist Therapy and Testing, Treatment Uptake, and Treatment Outcomes for Hepatitis C Infection Among People Who Inject Drugs: A Systematic Review and Meta-analysis

BACKGROUND

People who inject drugs (PWID) experience barriers to accessing testing and treatment for hepatitis C virus (HCV) infection. Opioid agonist therapy (OAT) may provide an opportunity to improve access to HCV care. This systematic review assessed the association of OAT and HCV testing, treatment, and treatment outcomes among PWID.

METHODS

Bibliographic databases and conference presentations were searched for studies that assessed the association between OAT and HCV testing, treatment, and treatment outcomes (direct-acting antiviral [DAA] therapy only) among PWID (in the past year). Meta-analysis was used to pool estimates.

RESULTS

Of 9877 articles identified, 22 studies conducted in Australia, Europe, North America, and Thailand were eligible and included. Risk of bias was serious in 21 studies and moderate in 1 study. Current/recent OAT was associated with an increased odds of recent HCV antibody testing (4 studies; odds ratio (OR), 1.80; 95% confidence interval [CI], 1.36-2.39), HCV RNA testing among those who were HCV antibody-positive (2 studies; OR, 1.83; 95% CI, 1.27-2.62), and DAA treatment uptake among those who were HCV RNA-positive (7 studies; OR, 1.53; 95% CI, 1.07-2.20). There was insufficient evidence of an association between OAT and treatment completion (9 studies) or sustained virologic response following DAA therapy (9 studies).

CONCLUSIONS

OAT can increase linkage to HCV care, including uptake of HCV testing and treatment among PWID. This supports the scale-up of OAT as part of strategies to enhance HCV treatment to further HCV elimination efforts.

Care Facilitation Advances Movement Along the Hepatitis C Care Continuum for Persons With Human Immunodeficiency Virus, Hepatitis C, and Substance Use: A Randomized Clinical Trial (CTN-0064)

Background

Direct-acting antivirals can cure hepatitis C virus (HCV). Persons with HCV/HIV and living with substance use are disadvantaged in benefiting from advances in HCV treatment.

Methods

In this randomized controlled trial, participants with HCV/HIV were randomized between February 2016 and January 2017 to either care facilitation or control. Twelve-month follow-up assessments were completed in January 2018.

Care facilitation group participants received motivation and strengths-based case management addressing retrieval of HCV viral load results, engagement in HCV/HIV care, and medication adherence. Control group participants received referral to HCV evaluation and an offer of assistance in making care appointments. Primary outcome was number of steps achieved along a series of 8 clinical steps (eg, receiving HCV results, initiating treatment, sustained virologic response [SVR]) of the HCV/HIV care continuum over 12 months postrandomization.

Results

Three hundred eighty-one individuals were screened and 113 randomized. Median age was 51 years; 58.4% of participants were male and 72.6% were Black/African American. Median HIV-1 viral load was 27 209 copies/mL, with 69% having a detectable viral load. Mean number of steps completed was statistically significantly higher in the intervention group vs controls (2.44 vs 1.68 steps; χ ² [1] = 7.36, P = .0067). Men in the intervention group completed a statistically significantly higher number of steps than controls. Eleven participants achieved SVR with no difference by treatment group.

Conclusions

The care facilitation intervention increased progress along the HCV/HIV care continuum, as observed for men and not women. Study findings also highlight continued challenges to achieve individual-patient SVR and population-level HCV elimination.

Clinical Trials Registration

NCT02641158.

Exploring how hospitalization can alter hepatitis c virus treatment prioritization and trajectories in people who use drugs: A qualitative analysis

Background: People who use drugs (PWUD) have high rates of hepatitis C virus (HCV) infection. Hospitalization can be a time for PWUD to engage in addiction treatment, but little is known about how hospitalization shapes HCV treatment readiness. We aimed to describe how hospitalization and addiction medicine consult service (AMCS) can alter HCV prioritization of inpatient PWUD with HCV. Methods: We conducted a qualitative study consisting of semi-structured interviews (n = 27) of hospitalized adults with addiction and HCV infection seen by an AMCS at a single, urban, academic center. Interviews were audio-recorded, transcribed, and coded iteratively at the semantic level, and analyzed for themes. Results: Of the 27 participants, most identified as Caucasian (85%), male gender (67%), and they primarily used opioids (78%); approximately half (48%) reported HCV diagnosis over 5 years ago. We identified three main themes around hospitalization altering the prioritizations and HCV treatment preferences for PWUD: (1) HCV treatment non-engaged (2) HCV treatment urgency, and (3) HCV treatment in the future. Those wanting to treat HCV-whether urgently or in the future-shared the overlapping theme of hospitalization as a reachable moment for their addiction and HCV. These participants recognized the long-term benefits of addressing HCV and connected their hospitalization to substance use. Conclusion: In our study, PWUD with HCV expressed varying and competing priorities and life circumstances contributing to three main HCV treatment trajectories. Our results suggest ways hospitalization can serve as an HCV touchpoint for PWUD, especially in the context of addressing substance use, and could be used when designing and implementing targeted interventions to improve the HCV care continuum for PWUD.

Safety of Patients with Hepatitis C Virus Treated with Glecaprevir/Pibrentasvir from Clinical Trials and Real-World Cohorts

INTRODUCTION

More than 70 million people are estimated to be infected with hepatitis C virus (HCV) globally. If left untreated, HCV infection can lead to complications such as extensive liver fibrosis, cirrhosis, and hepatocellular carcinoma (HCC). Evolution of treatments has resulted in highly effective and well-tolerated all-oral direct-acting antivirals. The pangenotypic regimen of glecaprevir/pibrentasvir is approved for treating HCV for patients without cirrhosis or with compensated cirrhosis (CC). Guidelines have evolved to simplify treatment to enable non-specialists to manage and treat HCV-infected patients. Simultaneously, such treatment algorithms provide guidance on the pretreatment identification of small subsets of patients who may require specialist treatment and long-term follow-up for advanced liver disease, including those at risk of developing HCC. This study describes the safety profile of glecaprevir/pibrentasvir in patients identified using previously described noninvasive laboratory measures who may be eligible for treatment by non-liver specialists.

METHODS

This post hoc analysis of glecaprevir/pibrentasvir in patients, identified by noninvasive laboratory measures, intended to exclude patients with advanced liver disease and severe renal impairment, who can be managed within non-liver specialist settings. Patients were included from clinical trials and real-world studies of glecaprevir/pibrentasvir for HCV treatment. Baseline demographics, clinical characteristics, and safety assessments, including adverse events and laboratory abnormalities, were summarized.

RESULTS

Data across these large-scale studies confirm that glecaprevir/pibrentasvir is well tolerated across different patient populations, with fewer than 0.1% of patients experiencing a serious adverse event related to treatment drugs, and few patients developing HCC during or after treatment.

CONCLUSION

The safety profile of glecaprevir/pibrentasvir enhances the confidence of non-liver specialists to treat the majority of HCV-infected patients, and provides an opportunity to expand the treater pool, potentially increasing diagnosis and treatment rates for HCV, contributing to elimination of HCV.

Hepatitis C treatment outcomes among patients treated in co-located primary care and addiction treatment settings

BACKGROUND

Persons with substance use disorders face major barriers to hepatitis C virus (HCV) treatment. Co-location of addiction and HCV treatment is appealing, yet there are limited data on outcomes using this model. This study evaluated HCV outcomes of patients treated with direct-acting antivirals (DAAs) by primary care providers in two sites of co-located addiction/HCV care.

METHODS

The study conducted a retrospective chart review for all patients receiving DAA treatment from 2016 to 2018 at 1) a hospital-based primary care clinic with an office-based buprenorphine program, and 2) a primary care clinic within an opioid treatment program (i.e. methadone clinic). The study classified patients into 3 groups according to treatment status: buprenorphine maintenance, methadone maintenance, or neither. Descriptive analyses compared patient demographics, clinical characteristics, adherence to monitoring and treatment, and the primary outcome of sustained virologic response at 12 weeks (SVR12), defined as an undetectable HCV viral load at least 12 weeks after completing treatment.

RESULTS

This study included 50 patients who initiated DAA treatment. The majority of patients were unemployed (74.0%), did not smoke tobacco (54.0%), and had psychiatric comorbidities (80.0%). Many also experienced homelessness during treatment (22.0%) and experienced previous incarceration (36.0%). Only a few had recently injected drugs (4.0%). Seven of 7 (100%) patients were treated with buprenorphine, 21 of 24 (87.5%) patients were treated with methadone, and 17 of 19 (89.5%) patients receiving no opioid addiction treatment fully completed HCV DAA treatment. When including patients with missing SVR12 data with the cohort that did not achieve cure, we observe that 44 of 50 patients (88.0%) achieved SVR12. Excluding patients missing SVR12 data, we observed that 44 of 46 patients (95.7%) achieved SVR12.

CONCLUSION

Persons with substance use disorders treated with DAAs in co-located primary care and addiction treatment settings can achieve high rates of cure despite significant comorbidities and barriers. DAA treatment should be expanded to co-located HCV and addiction settings.

Hepatitis C Care Cascades for 3 Populations at High Risk: Low-income Trans Women, Young People Who Inject Drugs, and Men Who Have Sex With Men and Inject Drugs

BACKGROUND

To achieve elimination of hepatitis C virus (HCV) infection, limited resources can be best allocated through estimation of "care cascades" among groups disproportionately affected. In San Francisco and elsewhere, these groups include young (age ≤ 30 years) people who inject drugs (YPWID), men who have sex with men who inject drugs (MSM-IDU), and low-income trans women.

METHODS

We developed cross-sectional HCV care cascades for YPWID, MSM-IDU, and trans women using diverse data sources. Population sizes were estimated using an inverse variance-weighted average of estimates from the peer-reviewed literature between 2013 and 2019. Proportions of past/current HCV infection, diagnosed infection, treatment initiation, and evidence of cure (sustained virologic response at 12 weeks posttreatment) were estimated from the literature using data from 7 programs and studies in San Francisco between 2015 and 2020.

RESULTS

The estimated number of YPWID in San Francisco was 3748; 58.4% had past/current HCV infection, of whom 66.4% were diagnosed with current infection, 9.1% had initiated treatment, and 50% had confirmed cure. The corresponding figures for the 8135 estimated MSM-IDU were: 29.4% with past/current HCV infection, 70.3% diagnosed with current infection, 28.4% initiated treatment, and 38.9% with confirmed cure. For the estimated 951 low-income trans women, 24.8% had past/current HCV infection, 68.9% were diagnosed with current infection, 56.5% initiated treatment, and 75.5% had confirmed cure.

CONCLUSIONS

In all 3 populations, diagnosis rates were relatively high; however, attention is needed to urgently increase treatment initiation in all groups, with a particular unmet need among YPWID.

Hepatitis C Virus (HCV) Care Continuum Outcomes and HCV Community Viral Loads Among Patients in an Opioid Treatment Program

BACKGROUND

Hepatitis C virus (HCV) remains endemic among people who use drugs (PWUD). Measures of HCV community viral load (CVL) and HCV care continuum outcomes may be valuable for ascertaining unmet treatment need and for HCV surveillance and control.

METHODS

Data from patients in an opioid treatment program during 2013-2016 were used to (1) identify proportions of antibody and viral load (VL) tested, linked-to-care, and treated, in 2013-2014 and 2015-2016, and pre- and postimplementation of qualitative reflex VL testing; (2) calculate engaged-in-care HCV CVL and "documented" and "estimated" unmet treatment need; and (3) examine factors associated with linkage-to-HCV-care.

RESULTS

Among 11 267 patients, proportions of HCV antibody tested (52.5% in 2013-2014 vs 73.3% in 2015-2016), linked-to-HCV-care (15.7% vs 51.8%), and treated (12.0% vs 44.7%) all increased significantly. Hispanic ethnicity was associated with less linkage-to-care, and Manhattan residence was associated with improved linkage-to-care. The overall engaged-in-care HCV CVL was 4 351 079 copies/mL (standard deviation = 7 149 888); local HCV CVLs varied by subgroup and geography. Documented and estimated unmet treatment need decreased but remained high.

CONCLUSIONS

After qualitative reflex VL testing was implemented, care continuum outcomes improved, but gaps remained. High rates of unmet treatment need suggest that control of the HCV epidemic among PWUD will require expansion of HCV treatment coverage.

Effectiveness of a Decentralized Hub and Spoke Model for the Treatment of Hepatitis C Virus in a Federally Qualified Health Center

Hepatitis C virus (HCV) is a major cause of cirrhosis, liver cancer, and mortality in the United States. We assessed the effectiveness of decentralized HCV treatment delivered by nurse practitioners (NPs), primary care physicians (PMDs), or an infectious disease physician (ID MD) using direct-acting antivirals in a Federally Qualified Health Center (FQHC) in urban San Diego, CA. We conducted a cross-sectional analysis of 1,261 patients who received treatment from six NPs, 10 PMDs, and one ID MD practicing in 10 clinics between January 2014 and January 2020. Care was delivered based on the Extension for Community Healthcare Outcomes (Project ECHO) model with one hub and nine spokes. HCV was deemed cured if a patient had a sustained virologic response (SVR) after 12 weeks of treatment (SVR12). We evaluated differences in the prevalence of cure between provider types and hub or spoke status using Poisson regression. Patients were 34% Latino, 16% black, 63% were aged >50 years, and 59% were homeless; 53% had advanced fibrosis, 69% had genotype 1, and 5% were coinfected with human immunodeficiency virus. A total of 943 patients achieved SVR12 (96% per protocol and 73% intention to treat). Even after adjustment for demographics, resources, and disease characteristics, the prevalence of cure did not differ between the ID MD and PMDs (prevalence ratio [PR], 1.00; 95% confidence interval [CI], 0.95-1.04) or NPs (PR, 1.01; 95% CI, 0.96-1.05). Similarly, there were no differences between the hub and spokes (PR, 1.01; 95% CI, 0.98-1.04). Conclusion: Among a low-income and majority homeless cohort of patients at urban FQHC clinics, HCV treatment administered by nonspecialist providers was not inferior to that provided by a specialist.

Age and gender-specific hepatitis C continuum of care and predictors of direct acting antiviral treatment among persons who inject drugs in Seattle, Washington

BACKGROUND

Direct acting antivirals (DAAs) have revolutionized management of hepatitis C virus (HCV), but treatment uptake remains low among persons who inject drugs (PWID). We report the continuum of care for HCV and describe predictors of treatment with DAAs among PWID in Seattle.

METHODS

We analyzed data from the 2018 Seattle area National HIV Behavioral Surveillance (NHBS) survey of PWID. Persons ≥18 years of age who injected drugs in the past year and completed the core NHBS survey, a local survey supplement, and rapid HCV antibody testing were included. Among those who screened HCV antibody positive, we calculated proportions and 95 % confidence intervals for self-reported steps along the HCV care continuum. Multivariable logistic regression was used to calculate the adjusted odds (AOR) of having received DAA therapy.

RESULTS

The sample included 533 PWID, 376 (71 %) of whom tested positive for antibodies to HCV. Among those who were HCV antibody positive, 94 % reported any prior HCV test, 81 % reported a prior confirmatory test, and 68 % reported a prior HCV diagnosis. Of those diagnosed, 26 % had undergone treatment and 18 % had been cured. In a multivariate model, being one year older (AOR 1.05 per year, 1.01-1.08) was predictive of DAA treatment, while homelessness (AOR 0.39, 0.19-0.80) and female gender (AOR 0.36, 0.16-0.78) were associated with a lower odds of DAA therapy.

CONCLUSIONS

Despite widespread HCV testing among PWID in Seattle, treatment uptake remains low in the DAA era. In particular, treatment of women, younger adults and persons living homeless is lagging behind.

Patient Centeredness in Hepatitis C Direct-Acting Antiviral Treatment Delivery to People Who Inject Drugs: A Scoping Review

Background and Objective

Patient-centered care (PCC) is crucial for value-based care. We aimed to assess PCC dimensions addressed in hepatitis C virus direct-acting antiviral treatment delivery to people who inject drugs.

Methods

We conducted a scoping review to identify the studies that described hepatitis C virus treatment delivery to people who inject drugs in the direct-acting antiviral treatment era. We analyzed the included studies against eight PCC dimensions: (1) access to care; (2) coordination and integration of care; (3) continuity and translation; (4) physical comfort; (5) information, education, and communication; (6) emotional support; (7) involvement of family and friends; and (8) respect for individual patient preferences, perceived needs, and values. Additionally, we assessed the use of patient-centered terminology and the recognition of PCC importance and its relevance to treatment outcomes.

Results

None of the identified 36 studies addressed all PCC dimensions (highest seven, lowest two). Our findings revealed that PCC dimensions are prioritized differently and addressed using different approaches and strategies. Studies that used PCC terminology referred to personalized activities, which does not imply comprehensive PCC. About one-third of the studies acknowledged the importance of patient centeredness and two-thirds recognized its relevance to treatment outcomes.

Conclusions

Our findings suggest more engagement of people who inject drugs and comprehensive involvement of their families and friends in hepatitis C virus treatment journey, decisions, and outcomes. The recognition of PCC importance and its relevance to treatment outcomes in the analyzed studies emphasizes the need for more patient-centered hepatitis C virus treatment for people who inject drugs.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40271-020-00489-6.

Emerging Viral and Bacterial Infections: Within an Era of Opioid Epidemic

The opioid epidemic is a public health crisis that continues to impact healthcare in the United States of America (USA). While changes in opioid prescribing have curbed the medical use of opioids, the increase in nonmedical use, largely driven by injection drug use (IDU), has contributed to the escalating incidence of opioid use disorder (OUD). Furthermore, IDU is associated with high-risk injection practices that can increase the risk of acquiring viral and bacterial infections. Here in this comprehensive review, we aimed to summarize the epidemiology and management of OUD, along with the screening and antimicrobial treatment of associated infections, specifically focused on human immunodeficiency virus, hepatitis C virus, skin and soft tissue infections, endocarditis, and osteomyelitis. Medication-assisted therapy (MAT) and infection guidelines from the USA will be presented.

Hepatitis C Virus Treatment: Simplifying the Simple and Optimizing the Difficult

The availability of safe, efficacious, oral direct-acting antivirals (DAAs) have ushered in a new era of hepatitis C treatment with potential to eliminate hepatitis C as a public health threat. To achieve population-level effectiveness of these oral DAAs, hepatitis C treatment by a wide range of providers in different settings will be essential to increase the number of persons treated. We provide a clinical review of hepatitis C treatment with a focus on practical tools for management of hepatitis C in majority of currently infected individuals who can be easily cured and optimization of treatment for those in whom treatment may not be as simple.

Engagement in the Hepatitis C care continuum among people who use drugs

Despite high rates of Hepatitis C virus (HCV) infection among people who use drugs (PWUDs), access to the HCV care continuum combined with the receipt of medications for addiction treatment in primary care settings remains suboptimal. A qualitative study was conducted among adults admitted for inpatient detoxification for opioid use disorder (OUD) in New York City (n=23) to assess barriers and facilitators with HCV prevention, screening, treatment, interactions with primary care providers, and experiences with integrated care approaches. Study findings yielded six major themes related to HCV care. Major gaps persist in knowledge regarding HCV harm reduction strategies, voluntary HCV testing services, and eligibility for HCV treatment. Treatment coordination challenges reinforce the importance of enhancing linkages to HCV care in key access-points utilized by PWUDs (e.g., emergency rooms, specialty addiction treatment settings). Peer networks combined with frequent patient-physician communication were elicited as important factors in facilitating linkage to HCV care. Additional care coordination needs in primary care settings included access to integrated treatment of HCV and OUD, and administrative support for enrollment in Medicaid, subsidized housing, and access to transportation vouchers.