Elimination of hepatitis C virus infection among PWID: The beginning of a new era of interferon-free DAA therapy

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.

Hepatitis C virus care cascade among people who inject drugs in puerto rico: Minimal HCV treatment and substantial barriers to HCV care

Background

People who inject drugs (PWID) in Puerto Rico are disproportionately affected by the hepatitis C virus (HCV) epidemic. However, there is a scarcity of data on the HCV care cascade among PWID in Puerto Rico. This study aims to describe the HCV cascade of care among PWID in Puerto Rico, identify gaps, and explore barriers to HCV care.

Methods

Participants were recruited using respondent-driven sampling and tested for both HCV antibodies (Ab) and RNA (ribonucleic acid) using rapid testing and dried blood spot samples (DBS). The cascade of care was estimated based on the DBS HCV Ab and RNA results, as well as self-reported data on HCV screening, linkage to care, treatment uptake and sustained virologic response collected through a questionnaire. The cascade was constructed sequentially, with each step using the number of people from the preceding step as the base denominator. The survey also assessed participants' perceived barriers to HCV care.

Results

Out of 150 participants, 126 (84%) had previously been HCV screened, 87% (109/126) were HCV Ab positive, 72% (79/109) were RNA positive,48% (38/79) were linked to care, 32% (12/38) initiated treatment, 58% (7/12) finished treatment, and 71% (5/7) achieved SVR. Barriers to HCV care included concerns about drug abstinence requirements, access to transportation, stigma in healthcare settings, and lack of knowledge about HCV treatment sites.

Conclusion

This study provides insights into the HCV cascade of care among PWID in Puerto Rico for the first time and highlights limited diagnosis, treatment uptake, and barriers to care.

Clinician barriers, perceptions, and practices in treating patients with hepatitis C virus and substance use disorder in the United States

The likelihood of clinicians prescribing direct-acting antiviral (DAA) therapy for patients with chronic hepatitis C virus (HCV) and substance use disorder (SUD) was assessed via a survey emailed throughout the United States to clinicians (physicians and advanced practice providers) in gastroenterology, hepatology, and infectious disease specialties. Clinicians' perceived barriers and preparedness and actions associated with current and future DAA prescribing practices of HCV-infected patients with SUD were assessed. Of 846 clinicians presumably receiving the survey, 96 completed and returned it. Exploratory factor analyses of perceived barriers indicated a highly reliable (Cronbach alpha = 0.89) model with five factors: HCV stigma and knowledge, prior authorization requirements, and patient- clinician-, and system-related barriers. In multivariable analyses, after controlling for covariates, patient-related barriers (P < 0.01) and prior authorization requirements (P < 0.01) were negatively associated with the likelihood of prescribing DAAs. Exploratory factor analyses of clinician preparedness and actions indicated a highly reliable (Cronbach alpha = 0.75) model with three factors: beliefs and comfort level; action; and perceived limitations. Clinician beliefs and comfort levels were negatively associated with the likelihood of prescribing DAAs (P = 0.01). Composite scores of barriers (P < 0.01) and clinician preparedness and actions (P < 0.05) were also negatively associated with the intent to prescribe DAAs.

Conclusion

These findings underscore the importance of addressing patient-related barriers and prior authorization requirements-significant problematic barriers-and improving clinicians' beliefs (e.g., medication-assisted therapy should be prescribed before DAAs) and comfort levels for treating patients with HCV and SUD to enhance treatment access for patients with both HCV and SUD.

Combining treatment for chronic hepatitis C with opioid agonist therapy is an effective microelimination strategy for people who inject drugs with high risk of non-adherence to antiviral therapy

Background & aims

Despite effective direct-acting antivirals (DAAs), hepatitis C virus (HCV) prevalence is high among people who inject drugs (PWIDs) and non-adherence to therapy remains a major obstacle towards HCV elimination in this subpopulation. To overcome this issue, we have combined ongoing opioid agonist therapy (OAT) with DAAs in a directly-observed therapy (DOT) setting.

Method

From September 2014 until January 2021 PWIDs at high risk of non-adherence to DAA therapy, who were also on OAT, were included into this microelimination project. Individuals received their OAT and DAAs under supervision of healthcare workers as DOT in a pharmacy or low-threshold facility.

Results

In total, 504 HCV RNA-positive PWIDs on OAT (387 men, 76.8%; median age: 38 years [IQR 33-45], HIV: 4.6%; hepatitis B: 1.4%) were included into this study. Two thirds reported ongoing intravenous drug use (IDU) and half of them had no permanent housing. Only 41 (8.1%) were lost to follow-up and two (0.4%) died of reasons unrelated to DAA toxicity. Overall, 90.7% of PWIDs achieved sustained virological response 12 weeks after treatment (SVR12) (95% CI: 88.1-93.2%). By excluding those lost to follow-up and hose who had died of causes unrelated to DAAs, the SVR12 rate was 99.1% (95% CI: 98.3-100.0%; modified intention-to-treat analysis). Four PWIDs (0.9%) experienced treatment failure. Over a median follow-up of 24 weeks (IQR 12-39), 27 reinfections (5.9%) were observed in individuals with the highest IDU rates (81.2%). Importantly, even though some were lost to follow-up, all completed their DAA treatment. By using DOT, adherence to DAAs was excellent with only a total of 86 missed doses (0.3% of 25,224 doses).

Conclusions

In this difficult-to-treat population of PWIDs with high rates of IDU , coupling DAA treatment to OAT in a DOT setting resulted in high SVR12 rates equivalent to conventional treatment settings in non-PWID populations.

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.

Supportive Interventions During Treatment of Chronic Hepatitis C: A Review of the Literature

There are an estimated 3 million people living with chronic hepatitis C, yet many have limited access to healthcare and treatment due to a variety of behavioral/lifestyle determinants of health. The aim of this literature review was to examine care models and innovations for people successfully treated from 2011 to 2018. We searched PubMed, PsycINFO, and CINAHL to identify care models for people undergoing treatment of chronic hepatitis C. Ten articles met criteria for inclusion and included multiple types of care models, including nurse initiated (n = 2), telemedicine care (n = 3), group visit (n = 1), concurrent treatment (n = 1), community health center care (n = 1), and integrated care (n = 2). Eight of the studies focused on people with mental health challenges and/or substance use disorder. Sustained virological response was the primary outcome of all studies; adherence was a secondary outcome measured in 8 studies.This search occurred during a period where treatment moved from interferon-based therapy to all-oral direct-acting antiviral medications, representing a paradigm shift in treatment of chronic hepatitis C. As new treatments offer cure for up to 95% of patients, these studies provided strong evidence of benefit for innovative care models for patients with mental health and substance use disorder to complete treatment.

Cascade of Hepatitis C Virus Care Among Patients With Substance Use Disorders

INTRODUCTION

Hepatitis C virus testing is recommended for people at high risk for infection, including those with substance use disorders. Little is known about the cascade of hepatitis C virus care (including testing, diagnosis, and treatments) among patients with substance use disorders in real-world clinical practice. This study aims to characterize the hepatitis C virus cascade of care and identify the factors associated with hepatitis C virus testing and diagnosis among Florida Medicaid beneficiaries with substance use disorders.

METHODS

A retrospective cohort analysis of Florida Medicaid data (2013-2018) was conducted in 2020 for patients aged 18-64 years with newly diagnosed substance use disorders (year 2012 was used to ascertain 1-year previous enrollment). A generalized estimating equation identified the factors associated with hepatitis C virus testing; a multivariable logistic model identified the factors associated with hepatitis C virus diagnosis.

RESULTS

Of the 156,770 patients with substance use disorders, 18% were tested for hepatitis C virus at least once. Among the tested patients, 8% had hepatitis C virus diagnoses. Among the 2,177 patients having a hepatitis C virus diagnosis, 11% initiated hepatitis C virus treatments, and 96% of them completed the hepatitis C virus treatments. Factors associated with being less likely to receive hepatitis C virus testing included being male (AOR=0.73, 95% CI=0.71, 0.75) and White (AOR=0.85, 95% CI=0.83, 0.87), whereas individuals who were male (AOR=1.49, 95% CI=1.35, 1.66) and White (AOR=2.71, 95% CI=2.38, 3.08) were more likely to be diagnosed with hepatitis C virus. The odds of receiving hepatitis C virus testing significantly increased annually (AOR=1.06, 95% CI=1.05, 1.07).

CONCLUSIONS

Future studies are warranted to investigate the barriers to access hepatitis C virus testing and treatment among Florida Medicaid beneficiaries with substance use disorders, especially for White male individuals.

Expert stakeholder perspectives on the acceptability of treatment-as-prevention in prison: a qualitative substudy of the 'Surveillance and Treatment of Prisoners with Hepatitis C' project (SToP-C)

BACKGROUND AND AIMS

Mathematical modelling has demonstrated the theoretical feasibility of HCV treatment-as-prevention strategies in custodial settings, yet limited empirical data exists. The Australian 'Surveillance and Treatment of Prisoners with Hepatitis C' study is the world's first trial of hepatitis C virus (HCV) treatment-as-prevention in prison. This study aimed to analyse how expert stakeholders involved in the Australian HCV response assessed the acceptability of HCV treatment-as-prevention in prison using interview data from the SToP-C qualitative substudy.

DESIGN AND SETTING

Qualitative analysis using semi-structured interviews in Australia.

PARTICIPANTS

Nineteen key HCV experts.

MEASUREMENTS

Drawing upon Sekhon's theoretical framework of acceptability, data were organized thematically under four component constructs of acceptability: affective attitude; ethicality; opportunity costs; and perceived effectiveness.

FINDINGS

Most differences in participant assessments of acceptability were a matter of relative emphasis and prioritization rather than absolute polarity. Nonetheless, a small minority of participants was overtly critical of the approach. Arguing against the focus on treatment, they instead advocated for prevention-as-prevention, including the improvement and expansion of existing harm reduction measures.

CONCLUSIONS

Qualitative analysis of expert stakeholder assessments of the acceptability of hepatitis C virus treatment-as-prevention in Australian prisons found no opposition to the universal rollout of direct-acting anti-virals, but most voiced concern regarding the lack of effective primary prevention in Australian prisons.

Detection of active hepatitis C in a single visit and linkage to care among marginalized people using a mobile unit in Madrid, Spain

BACKGROUND

The burden of hepatitis C virus (HCV) infection among marginalized people in Spain is high, despite the fact that HCV prevalence has decreased in recent years. We aimed to assess the effectiveness of a simplified point-of-care (PoC) model for screening for active HCV infection via a mobile unit and subsequent linkage to care with the assistance of navigators.

METHODS

We carried out a prospective study on 2001 participants from Madrid, Spain. A nurse and a navigator/educator screened for hepatitis C in a mobile unit, using the OraQuick HCV Rapid Antibody Test and Xpert HCV VL Fingerstick assay. Participants with active HCV were referred to the hospital the same day with a navigator for evaluation and treatment of HCV.

RESULTS

Overall, 1621 (81%) participants had not been exposed to HCV, 380 (18.9%) were positive for HCV antibodies, and 136 (6.8%) had active hepatitis C. Among the latter, 134 (98.5%) received the HCV screening results, 133 (97.8%) had an appointment at the hospital, 126 (92.8%) were seen by a physician once they were at the hospital, and 105 (77.2%) started HCV treatment. Being over 50 years old and a person who uses drugs, particularly people who inject drugs (PWID), was directly associated with active hepatitis C (p<0.05). PWID were the only patients with HCV reinfection (4.3% in people without recent injecting drug use and 5.9% in people with recent injecting drug use). Among PWID, no income and daily alcohol intake were also directly associated with active hepatitis C. People with recent injecting drug use showed the lowest rates of attendance at the hospital (91.8%) and starting HCV treatment (70.4%).

CONCLUSION

HCV screening using a two-step PoC-based strategy and its linkage to care was extremely efficient for identifying and treating marginalized people with active hepatitis C, thanks to the use of a mobile unit with personnel and technical equipment, an interdisciplinary team, and collaboration between institutions.

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

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

The use of all-oral direct-acting antivirals in hepatitis C virus-infected patients with substance use disorders

BACKGROUND: There is evidence that barriers exist for the initiation of direct-acting antiviral (DAA) treatment for hepatitis C virus (HCV) for those with substance use disorders (SUDs). However, real world clinical evidence of DAA treatment initiation following receipt of a prescription and continuation among those with SUDs and HCV is lacking. OBJECTIVES: To (1) compare HCV treatment initiation (prescription fill) rates and early discontinuation rates between HCV-infected patients with and without SUDs in the DAA era, and (2) identify patient-level factors associated with HCV treatment initiation and early discontinuation in patients with SUDs. METHODS: A retrospective cohort analysis of the MarketScan databases (January 2012-December 2018) was conducted for newly diagnosed treatment naïve HCV-infected patients (age ≥ 18) with and without SUDs. We used multivariable Cox regression to estimate adjusted hazard ratios (aHRs) with 95% confidence intervals of treatment initiation and early discontinuation in those with SUDs versus those without. RESULTS: We identified a total of 29,228 newly diagnosed HCV-infected patients (6,385 with SUDs and 22,843 without SUDs). Overall, DAA treatment initiation for patients with SUDs was significantly lower than that for those without SUDs (24% vs 34%; P < 0.01). After adjusting for demographics and clinical characteristics, patients with SUDs were less likely to initiate DAA treatments than those without SUDs (aHR, 0.87 [0.82-0.92]). There was no difference in discontinuation of DAA treatment between those with and without SUDs (4% vs 3%: aHR, 1.13 [0.81-1.60]). Among patients with SUDs (n = 6,385), lower rates of initiating DAA treatment was associated with younger age, and comorbidities including alcoholic liver disease (ALD; aHR, 0.44 [0.33-0.57), chronic kidney disease (CKD) (aHR, 0.52 [0.36-0.75]), and hepatitis B virus (HBV; aHR, 0.64 [0.44-0.92]). DAA treatment discontinuation was associated with younger age, ribavirin (RBV) therapy (aHR, 3.78 [2.21-6.47]), and cirrhosis diagnosis (aHR, 2.42 [1.21-4.84]) but not SUD treatment (aHR, 0.68 [0.34-1.34]). CONCLUSIONS: HCV-infected patients with SUDs had significantly lower treatment initiation rates, especially in young females and those with ALD, CKD, and HBV. No difference was found in DAA discontinuation. However, younger patients with RBV treatment and/or cirrhosis were more likely to stop treatment. Interventions directed towards these groups are needed to enhance DAA initiation and treatment maintenance among HCV-infected patients with SUDs. DISCLOSURES: Research reported in this publication was supported in part by the National Institute on Drug Abuse of the National Institutes of Health under award number K01DA045618 (to Park). The other authors have nothing to disclose that may present a potential conflict of interest.

Linkage to care strategy for the micro-elimination of hepatitis C among parenteral drug users on methadone replacement therapy in Gipuzkoa

INTRODUCTION

parenteral drug users (PDUs) are a population with a high prevalence of infection with the hepatitis C virus (HCV) and significant difficulties to access to treatment. Opioid replacement therapy programs regularly monitor these individuals.

OBJECTIVE

to effectively treat this population using a directly observed therapy (DOT) and bringing resources closer to the methadone dispensing center in Gipuzkoa (Bitarte).

METHODS

all methadone users that were positive for anti-HCV antibodies were included in the study. Using a simplified circuit, a hepatologist visits the center with a Fibroscan® device and requests treatment following assessment. Treatment is dispensed at the addict center, under the supervision of a psychiatrist and nursing staff. Prevalence, population characteristics and circuit effectiveness were assessed.

RESULTS

Bitarte monitors 660 individuals. Of these, 73.6 % were positive for antibodies against HCV. The prevalence of viremic infection is 62.5 %. The predominant genotype was 1a, followed by 3. A total of 38.5 % had advanced fibrosis (F3 and F4) and 38 % of users admitted to active heroin use. In all, 82.07 % (174/212) of the population received treatment and 97 % had sustained viral response (SVR) after 12 weeks. No re-infections were recorded.

CONCLUSIONS

the prevalence of viremic HCV infection among PDUs under treatment with methadone is 62 %. The linkage to care strategy was effective and > 80 % of the population with an active infection have been treated so far.

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.

Excitable models: Projections, targets, and the making of futures without disease

In efforts to control disease, mathematical models and numerical targets play a key role. We take the elimination of a viral infection as a case for exploring mathematical models as 'evidence-making interventions'. Using interviews with mathematical modellers and implementation scientists, and focusing on the emergence of models of 'treatment-as-prevention' in hepatitis C control, we trace how projections detach from their calculative origins as social and policy practices. Drawing on the work of Michel Callon and others, we show that modelled projections of viral elimination circulate as 'qualculations', taking flight via their affects, including as anticipation. Modelled numerical targets do not need 'actual numbers' or precise measurements to perform their authority as evidence of viral elimination or as situated matters-of-concern. Modellers grapple with the ways that their models transform in policy and social practices, apparently beyond reasonable calculus. We highlight how practices of 'holding-on' to projections in relation to imaginaries of 'evidence-based' science entangle with the 'letting-go' of models beyond calculus. We conclude that the 'virtual precision' of models affords them fluid evidence-making potential. We imagine a different mode of modelling science in health, one more attuned to treating projections as qualculative, affective and relational, as excitable matter.

Considering treatment-as-prevention scale-up for Australian prisons: a qualitative sub-study of expert stakeholders from the Australian 'surveillance and treatment of prisoners with hepatitis C' project (SToP-C)

Background

With direct-acting antivirals dramatically reshaping the public health response to the hepatitis C virus (HCV), prisons are set to play a critical role in elimination efforts. Despite the theoretical demonstration of HCV treatment-as-prevention in prison in mathematical modeling, limited empirical data exist. The Australian ‘Surveillance and Treatment of Prisoners with Hepatitis C’ project (SToP-C) is the world’s first trial of HCV treatment-as-prevention in prison. Drawing on interviews with HCV expert stakeholders, this paper explores the factors respondents identified as crucial to the success of future scale-up. Accounting for such perspectives matters because of the influence expert discourse has in shaping implementation.

Methods

Semi-structured interviews were conducted with nineteen HCV experts working across key policy, advocacy, research and clinical dimensions of the Australian HCV response. Data were coded using qualitative data management software (NVivo 11). Analysis proceeded via a hybrid deductive and inductive approach.

Results

Notwithstanding concerns regarding the lack of primary prevention in Australian prisons, stakeholders reported broad levels of support for the intervention and for the future scale-up of HCV treatment. A number of considerations, both external and internal to the prison system, were identified as key. The principal external factor was an enabling political-cum-policy environment; internal factors included: obtaining support from prisons’ executive and custodial staff; promoting health within a security-first institutional culture; allocating time for treatment within prisoners’ tightly regulated schedules; ensuring institutional stability during treatment given the routine movement of prisoners between prisons; prioritizing the availability of retreatment given the paucity of primary prevention; and securing sufficient clinical space for treatment.

Conclusion

The challenges to implementation are considerable, ranging from macrolevel concerns to in-prison logistical matters. Nonetheless, we argue that prisons remain an obvious setting for treatment scale-up, not only for prevention and potential elimination benefit, but for the treatment opportunities they afford a socially disadvantaged and underserved population. While noting widespread concerns among respondents regarding the paucity of primary prevention in Australian prisons, results indicate broad levels of support among expert stakeholders for HCV treatment scale-up in prison.

"Stigma is where the harm comes from": Exploring expectations and lived experiences of hepatitis C virus post-treatment trajectories among people who inject drugs

BACKGROUND

The advent of direct-acting antiviral (DAA) medications has facilitated opportunities to treat hepatitis C virus (HCV) among people who inject drugs (PWID). However, there remains a need for data about how to optimally support PWID throughout DAA post-treatment trajectories, including with regard to re-infection prevention. The objective of this study is therefore to identify how PWID with lived experience of HCV describe their expectations and experiences related to health and social outcomes, contexts, and substance use practices following completion of DAA treatment.

METHODS

We thematically analyzed data from in-depth, semi-structured interviews, conducted between January and June 2018, in Vancouver, Canada, with a purposive sample (n = 50) of PWID at various stages of DAA treatment (e.g., pre, peri, post).

RESULTS

Our analysis yielded three themes. First, while participants had hoped to experience holistic enhancements in wellbeing following HCV cure, discussions of actual post-treatment experiences tended to be located in physical health (e.g., increased energy). Second, participants often pointed to the ways in which HCV-related and other stigmas had restricted opportunities for health and healthcare access. Participants therefore identified stigma-reduction as a key motivator of HCV cure, and while reductions in internalized stigma were sometimes achieved, participants underscored that other forms of enacted stigma (e.g., related to: substance use, HIV, poverty) had continued to feature prominently in their post-treatment lives. Third, participants described considerable knowledge about how to prevent HCV re-infection following cure, but they also expressed apprehensiveness about how socio-structural barriers, including stigma and criminalization, could interfere with harm reduction and re-infection prevention efforts.

CONCLUSIONS

DAAs are transforming the health and wellbeing of some PWID. Yet, HCV-related policy must extend beyond the scale-up of DAAs to include concerted public health investments, including anti-stigma efforts and improvements to the social welfare system, to meaningfully advance equity in PWID's post-treatment trajectories and outcomes.

Medical provider stigma experienced by people who use drugs (MPS-PWUD): Development and validation of a scale among people who currently inject drugs in New York City

BACKGROUND

Stigmatizing attitudes towards people who use drugs (PWUD) impact their access and retention in health care. Current measures of PWUD stigma in medical settings are limited. Therefore, we developed and validated theMedical Provider Stigma Experienced by PWUD (MPS-PWUD) scale.

METHODS

As part of an ongoing clinical trial, we recruited HCV RNA positive people who inject drugs in New York City. Based on 164 participants, principal component analysis (PCA) was conducted on fifteen stigma items answered on a 5-point Likert scale. We evaluated internal consistency using Cronbach's alpha coefficient and assessed construct validity by comparing stigma levels with willingness to communicate health concerns with medical providers and likelihood to seek HCV treatment.

RESULTS

PCA identified a 9-item scale with two components of stigmatization that explained 60.8 % of the total variance and overall high internal consistency (alpha = 0.90). Theenacted stigma (alpha = 0.90) consisted of 6 scale items related to the medical providers' stigmatizing actions or perceptions. The internalized stigma component (alpha = 0.84) included 3 scale items related to PWUD's shame or drug use disclosure. As hypothesized, higher levels of either stigma were associated with less likelihood to openly communicate with medical providers (p < 0.005). Participants with a higher level of enacted stigma were less likely to seek HCV treatment (p = 0.011).

CONCLUSIONS

The validated MPS-PWUD scale could help healthcare providers, harm reduction services and researchers measure stigma experienced by PWUD in medical settings in efforts to minimize the impact of stigma on limiting access to and retention of care for PWUD.

"I want to get better, but…": identifying the perceptions and experiences of people who inject drugs with respect to evolving hepatitis C virus treatments

BACKGROUND

The advent of highly tolerable and efficacious direct-acting antiviral (DAA) medications has transformed the hepatitis C virus (HCV) treatment landscape. Yet, people who inject drugs (PWID) - a population with inequitably high rates of HCV and who face significant socio-structural barriers to healthcare access - continue to have disproportionately low rates of DAA uptake. The objective of this study is to explore how PWID with lived experience of HCV perceive and experience DAA treatment, in a setting with universal coverage of these medications since 2018.

METHODS

Informed by a critical interpretive framework, we thematically analyze data from in-depth, semi-structured interviews conducted between January and June 2018 in Vancouver, Canada, with a purposive sample (n = 56) of PWID at various stages (e.g., pre, peri, post) of DAA treatment.

RESULTS

The analysis yielded three key themes: (i) life with HCV, (ii) experiences with and perceptions of evolving HCV treatments, and (iii) substance use and the uptake of DAA treatments. First, participants described how health and healthcare conditions, such as the deprioritizing of HCV (e.g., due to: being asymptomatic, healthcare provider inaction, gatekeeping) and catalysts to care (e.g., symptom onset, treatment for co-morbidities) shaped DAA treatment motivation and access. Second, participants described how individual and community-level accounts of evolving HCV treatments, including skepticism following negative experiences with Interferon-based treatment and uncertainty regarding treatment eligibility, negatively influenced willingness and opportunities to access DAAs. Concurrently, participants described how peer and community endorsement of DAAs was positively associated with treatment uptake. Third, participants favoured HCV care that was grounded in harm reduction, which included the integration of DAAs with other substance use-related services (e.g., opioid agonist therapy, HIV care), and which was often contrasted against abstinence-focused care wherein substance use is framed as a contraindication to HCV treatment access.

CONCLUSIONS

These findings underscore several equity-oriented healthcare service delivery and clinician adaptations that are required to scale up DAAs among PWID living with HCV, including the provision of harm reduction-focused, non-stigmatizing, integrated, and peer-led care that responds to power differentials.

Direct-Acting Antiviral Treatment Use Remains Low Among Florida Medicaid Beneficiaries With Chronic Hepatitis C

Medicaid prior authorization (PA) policies for treatment of hepatitis C virus (HCV) with direct-acting antiviral (DAA) therapy are changing. We aimed to evaluate effects of changes in PA requirements on treatment uptake and to determine the factors associated with DAA treatment among Florida Medicaid beneficiaries with HCV. This is a retrospective cohort analysis of Florida's Medicaid administrative claims and electronic medical records (2013-2018). A total of 14,063 newly diagnosed patients with HCV were grouped based on human immunodeficiency virus (HIV) co-infection and/or a substance use disorder (SUD) (7,735 HCV mono-infected with a SUD, 5,180 HCV mono-infected without a SUD, 564 HCV/HIV co-infected with a SUD, and 584 HCV/HIV co-infected without a SUD). Although the treatment rate increased three-fold after June 1, 2016, when a fibrosis-stage restriction was eliminated, only 8% received DAAs. Compared to HCV mono-infected without a SUD, HCV mono-infected with a SUD and HCV/HIV co-infected with a SUD were 47% (adjusted hazard ratio, 0.53; 95% confidence interval, 0.47-0.60) and 59% (adjusted hazard ratio, 0.41; 95% confidence interval, 0.28-0.61) less likely to initiate DAAs. Those with HCV/HIV/SUD did not experience a DAA initiation increase after a fibrosis-stage restriction was eliminated. Compared with Whites, Blacks were less likely to receive DAAs but were more likely to complete treatment. Use of medication-assisted therapy was low, despite those on medication-assisted therapy being 60% more likely to initiate DAA therapy and no more likely to discontinue therapy. Conclusion: Despite changes in Florida's Medicaid PA requirements for DAA treatment, only 8% received treatment. Disparities in treatment access were found among patients with HIV and a SUD, and who were Black.

HCV screening based on dried blood samples and linkage to care in people who use drugs: A prospective study

BACKGROUND

The burden of hepatitis C virus (HCV) infection among people who use drugs (PWUDs) is considerable. We aimed to screen for HCV infection using the fingerstick dried blood spot (DBS) test and to describe the cascade of hepatitis C care among PWUDs in Madrid, Spain. We also evaluated the prevalence of hepatitis B virus (HBV) and hepatitis D virus (HDV) in this population.

METHODS

We carried out a prospective study and collected samples and epidemiological data using a mobile unit. Viral infections were tested by immunoassay and RT-PCR assay. PWUDs with a positive result were contacted and referred to a specialized health center to confirm and treat the HCV infection.

RESULTS

We studied 529 PWUD samples; 49.7% were from persons who had previously used injection drugs (IDUs). Of these, 152 (28.7%) were positive for HCV antibodies, 122 (23.1%) for HCV RNA, 23 (4.3%) for HBsAg, and two (0.4%) for HDV antibodies (8.7% of those with hepatitis B). People who inject drugs (PWID) more frequently had positive HCV antibody titers (52% vs. 7.3%; p<0.001) and a positive HCV RNA test result (40.2% vs. 7.3%; p<0.001) than non-PWID. The time from sample collection to test results was 19 days. The next 104 individuals (85.2%) with active HCV infection were contacted to report their HCV test results. Of these, 63 (51.6%) had an appointment, 62 (50.8%) were evaluated in the hospital, and 56 (45.9%) started HCV therapy.

CONCLUSION

HCV screening using fingerstick DBS was an excellent tool for determining HCV prevalence and other chronic hepatitis viruses (HBV and HDV) in PWUDs. However, linkage to care was limited, mainly with respect to the initiation of HCV therapy.

Reported Low Uptake of HCV Testing among People Who Inject Drugs in Urban Vietnam

Background

HCV testing is an important first step for treatment and prevention, particularly for those who are highly vulnerable to HCV infection such as people who inject drugs (PWID). In settings where direct-acting antiretroviral medicines are becoming more available, limited information exists about who and where to target to increase the prevalence of HCV testing among PWID. This study is aimed at understanding the prevalence of HCV testing uptake and its determinants of medical services and risk behaviors.

Methods

From February 2016 to April 2017, a sample of 509 PWID was interviewed using a structured questionnaire on their history of HCV testing, confirmation, services using in the previous year as well as HCV-related knowledge, and risk behaviors. Multiple logistic regression identified factors associated with ever being tested for HCV before enrollment in the program.

Results

Approximately 33% reported ever testing for HCV. Most cited sources of testing are public hospitals and general clinics (68.9%) and outpatient clinics (18.9%). Having ever tested for HCV was positively associated with accessing health services within the prior 12 months (aOR = 2.25; 95% CI 1.11-4.58), being currently enrolled in a methadone treatment program (aOR = 2.35; 95% CI 1.34-4.08), and/or on ART treatment (aOR = 2.30; 95% CI 1.30-4.08). Those who ever delayed in seeking healthcare services for any reason were less likely to get tested for HCV (aOR = 0.54; 95% CI 0.35-0.84).

Conclusion

HCV testing prevalence is low among PWID in Hanoi despite a very high prevalence of HCV infection. To improve the cascade of HCV testing, it is critical that intervention programs scale up linkages among methadone, outpatient clinics, and HCV services, take steps to reduce stigma and discrimination in both community and, especially, in health care settings, and increase awareness of HCV for PWID by integrating HCV into routine counseling at health care services.

Telemedicine successfully engages marginalized rural hepatitis C patients in curative care

BACKGROUND

Rurally located individuals living with hepatitis C virus (HCV) face barriers to engagement and retention in care. Telemedicine technologies coupled with highly curative direct acting antiviral (DAA) treatments may increase accessibility to HCV care while achieving high sustained virologic response (SVR) rates. We compared clinical and socio-economic characteristics, SVR, and loss to follow-up among telemedicine (TM), mixed delivery (MD), and outpatient clinic (OPC) patients receiving care through The Ottawa Hospital Viral Hepatitis Program (TOHVHP).

METHODS

TOHVHP clinical database was used to evaluate patients engaging HCV care between January 1, 2012, and December 31, 2016. SVR rates by HCV care delivery method (TM versus OPC versus MD) were calculated.

RESULTS

Analysis included 1,454 patients who engaged with TOHVHP at least once. Patients were aged almost 50 years on average and were predominately male and Caucasian. A greater proportion of TM patients were rurally based, were Indigenous, had a history of substance use, and had previously been incarcerated. Per-protocol DAA SVR rates for TM, OPC, and MD patients were 100% (26/26), 93% (440/472), and 94% (44/47), respectively. Loss-to-follow-up rates for HCV-treated TM and MD patients were higher (27% [10/37], 95% CI 0.58 to 0.88, and 11% [7/62], 95% CI 0.81 to 0.97, respectively) than for those followed exclusively in the OPC (5% [39/800], 95% CI 0.94 to 0.97).

CONCLUSIONS

TM can successfully engage, retain, and cure rurally based HCV patients facing barriers to care. Strategies to improve TM retention of patients initiating HCV antiviral treatment are key to optimizing the impact of this model of care.

"Everybody living with a chronic disease is entitled to be cured": Challenges and opportunities in scaling up access to direct-acting antiviral hepatitis C virus treatment among people who inject drugs

BACKGROUND

Recent advances in the safety, tolerability, and efficacy of hepatitis C virus (HCV) treatments have led to the introduction of policy changes that include, in some settings, universal coverage of direct-acting antiviral (DAA) treatment for people living with HCV. However, people who inject drugs (PWID), a population with disproportionately high rates of HCV, often experience significant social and structural barriers to care, including when seeking treatment and care for blood-borne viruses. The objective of this study is to identify implementation challenges and opportunities for improving HCV-related care and scaling up DAA treatment for PWID living with HCV in a setting with universal DAA coverage since 2018.

METHODS

Informed by a critical interpretive framework, this study thematically analyzes data from in-depth, semi-structured interviews conducted between October 2018 and February 2019 with a purposive sample of 15 expert stakeholders (e.g., clinicians, community-based organization representatives, policy makers) related to HCV care or research in British Columbia, Canada.

RESULTS

Our analysis revealed two key thematics: First, participants described existing challenges for scaling up DAA treatment, including how contextual factors (e.g., housing, stigma) restrict opportunities for PWID to engage in care. Participants also described how strained and compartmentalized health services are onerous to navigate for patients. Second, participants described opportunities for improving HCV-related care through various structural interventions (e.g., improved housing, decriminalization of substance use), and enhanced and more accessible models of care (e.g., decentralized, integrated, outreach-focused, and peer- and nurse-led services).

CONCLUSIONS

These findings emphasize that several key service delivery and system-level adaptations are required in order to equitably scale up access of DAAs to PWID living with HCV, including policies and programs that are responsive to socio-structural determinants of health.

How to think with models and targets: Hepatitis C elimination as a numbering performance

The field of public health is replete with mathematical models and numerical targets. In the case of disease eliminations, modelled projections and targets play a key role in evidencing elimination futures and in shaping actions in relation to these. Drawing on ideas within science and technology studies, we take hepatitis C elimination as a case for reflecting on how to think with mathematical models and numerical targets as 'performative actors' in evidence-making. We focus specifically on the emergence of 'treatment-as-prevention' as a means to trace the social and material effects that models and targets make, including beyond science. We also focus on how enumerations are made locally in their methods and events of production. We trace the work that models and targets do in relation to three analytical themes: governing; affecting; and enacting. This allows us to situate models and targets as technologies of governance in the constitution of health, which affect and are affected by their material relations, including in relation to matters-of-concern which extend beyond calculus. By emphasising models and targets as enactments, we draw attention to how these devices give life to new enumerated entities, which detach from their calculative origins and take flight in new ways. We make this analysis for two reasons: first, as a call to bring the social and enumeration sciences closer together to speculate on how we might think with models and targets differently and more carefully; and second, to encourage an approach to science which treats evidencing-making interventions, such as models and targets, as performative and political.

Hepatitis C Virus Prevalence in 50 U.S. States and D.C. by Sex, Birth Cohort, and Race: 2013-2016

Hepatitis C virus (HCV) infection is a leading cause of liver-related morbidity and mortality, and more than 2 million adults in the United States are estimated to be currently infected. Reducing HCV burden will require an understanding of demographic disparities and targeted efforts to reduce prevalence in populations with disproportionate disease rates. We modeled state-level estimates of hepatitis C prevalence among U.S. adults by sex, birth cohort, and race during 2013-2016. National Health and Nutrition Examination Survey data were used in combination with state-level HCV-related and narcotic overdose-related mortality data from the National Vital Statistics System and estimates from external literature review on populations not sampled in the National Health and Nutrition Examination Survey. Nationally, estimated hepatitis C prevalence was 1.3% among males and 0.6% among females (prevalence ratio [PR] = 2.3). Among persons born during 1945 to 1969, prevalence was 1.6% compared with 0.5% among persons born after 1969 (PR = 3.2). Among persons born during 1945 to 1969, prevalence ranged from 0.7% in North Dakota to 3.6% in Oklahoma and 6.8% in the District of Columbia. Among persons born after 1969, prevalence was more than twice as high in Kentucky, New Mexico, Oklahoma, and West Virginia compared with the national average. Hepatitis C prevalence was 1.8% among non-Hispanic black persons and 0.8% among persons of other races (PR = 2.2), and the magnitude of this disparity varied widely across jurisdictions (PR range: 1.3-7.8). Overall, 23% of prevalent HCV infections occurred among non-Hispanic black persons, whereas 12% of the population was represented by this racial group. These estimates provide information on prevalent HCV infections that jurisdictions can use for understanding and monitoring local disease patterns and racial disparities in burden of disease.

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

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

A systematic review and meta-analysis of community and primary-care-based hepatitis C testing and treatment services that employ direct acting antiviral drug treatments

Background

Direct Acting Antiviral (DAAs) drugs have a much lower burden of treatment and monitoring requirements than regimens containing interferon and ribavirin, and a much higher efficacy in treating hepatitis C (HCV). These characteristics mean that initiating treatment and obtaining a virological cure (Sustained Viral response, SVR) on completion of treatment, in non-specialist environments should be feasible. We investigated the English-language literature evaluating community and primary care-based pathways using DAAs to treat HCV infection.

Methods

Databases (Cinahl; Embase; Medline; PsycINFO; PubMed) were searched for studies of treatment with DAAs in non-specialist settings to achieve SVR. Relevant studies were identified including those containing a comparison between a community and specialist services where available. A narrative synthesis and linked meta-analysis were performed on suitable studies with a strength of evidence assessment (GRADE).

Results

Seventeen studies fulfilled the inclusion criteria: five from Australia; two from Canada; two from UK and eight from USA. Seven studies demonstrated use of DAAs in primary care environments; four studies evaluated integrated systems linking specialists with primary care providers; three studies evaluated services in locations providing care to people who inject drugs; two studies evaluated delivery in pharmacies; and one evaluated delivery through telemedicine. Sixteen studies recorded treatment uptake. Patient numbers varied from around 60 participants with pathway studies to several thousand in two large database studies. Most studies recruited less than 500 patients. Five studies reported reduced SVR rates from an intention-to-treat analysis perspective because of loss to follow-up before the final confirmatory SVR test. GRADE assessments were made for uptake of HCV treatment (medium); completion of HCV treatment (low) and achievement of SVR at 12 weeks (medium).

Conclusion

Services sited in community settings are feasible and can deliver increased uptake of treatment. Such clinics are able to demonstrate similar SVR rates to published studies and real-world clinics in secondary care. Stronger study designs are needed to confirm the precision of effect size seen in current studies. Prospero: CRD42017069873.

Competing priorities and second chances - A qualitative exploration of prisoners' journeys through the Hepatitis C continuum of care

High levels of undiagnosed and untreated HCV infection exist in prison populations globally. Prisons are a key location to identify, treat and prevent HCV infection among people who inject drugs (PWID). Understanding prisoners’ lived experiences of the HCV continuum of care informs how HCV care can be effectively delivered to this marginalised and high-risk population. This study aimed to explore Irish prisoners’ experience of prison and community-based HCV care. We conducted one-to-one interviews with 25 male prisoners with chronic HCV infection. Data collection and analysis was informed by grounded theory. The mean age of participants and first incarceration was 39.5 and 18.3 years respectively. The mean number of incarcerations was eight. The following themes were identified: medical and social factors influencing engagement (fear of treatment and lack of knowledge, HCV relevance and competing priorities), adverse impact of HCV on health and wellness, positive experience of prison life and health care and the transformative clinical and non-clinical changes associated with HCV treatment and cure. Findings suggest that prison release was associated with multiple stressors including homelessness and drug dependence which quickly eroded the health benefits gained during incarceration. The study generated a substantive theory of the need to increase the importance of HCV care among the routine competing priorities associated with the lives of PWID. HCV infected prisoners often lead complex lives and understanding their journeys through the HCV continuum can inform the development of meaningful HCV care pathways. Many challenges exist to optimising HCV treatment uptake in this group and incarceration is an opportunity to successfully engage HCV infected prisoners who underutilise and are underserved by community-based medical services. Support and linkage to care on release is essential to optimising HCV management.

Hepatitis C virus infection in Irish drug users and prisoners - a scoping review

BACKGROUND

Hepatitis C infection is a major public health concern globally. In Ireland, like other European countries, people who use drugs (PWUD) and prisoners carry a larger HCV disease burden than the general population. Recent advances in HCV management have made HCV elimination across Europe a realistic goal. Engaging these two marginalised and underserved populations remains a challenge. The aim of this review was to map key findings and identify gaps in the literature (published and unpublished) on HCV infection in Irish PWUD and prisoners.

METHODS

A scoping review guided by the methodological framework set out by Levac and colleagues (based on previous work by Arksey & O'Malley).

RESULTS

A total of 58 studies were identified and divided into the following categories; Epidemiology, Guidelines and Policy, Treatment Outcomes, HCV-related Health Issues and qualitative research reporting on Patients' and Health Providers' Experiences. This review identified significantly higher rates of HCV infection among Irish prisoners and PWUD than the general population. There are high levels of undiagnosed and untreated HCV infection in both groups. There is poor engagement by Irish PWUD with HCV services and barriers have been identified. Prison hepatology nurse services have a positive impact on treatment uptake and outcomes. Identified gaps in the literature include; lack of accurate epidemiological data on incident infection, untreated chronic HCV infection particularly in PWUD living outside Dublin and those not engaged with OST.

CONCLUSION

Ireland like other European countries has high levels of undiagnosed and untreated HCV infection. Collecting, synthesising and identifying gaps in the available literature is timely and will inform national HCV screening, treatment and prevention strategies.

Elimination of hepatitis C virus infection among people who use drugs: Ensuring equitable access to prevention, treatment, and care for all

There have been major strides towards the World Health Organization goal to eliminate hepatitis C virus (HCV) infection as a global public health threat. The availability of simple, well-tolerated direct-acting antiviral therapies for HCV infection that can achieve a cure in >95% of people has provided an important tool to help achieve the global elimination targets. Encouragingly, therapy is highly effective among people receiving opioid agonist therapy and people who have recently injected drugs. Moving forward, major challenges include ensuring that new infections are prevented from occurring and that people who are living with HCV are tested, linked to care, treated, receive appropriate follow-up, and have equitable access to care. This editorial highlights key themes and articles in a special issue focusing on the elimination of HCV among people who inject drugs. An overarching consideration flowing from this work is how to ensure equitable access to HCV treatment and care for all. This special issue maps the field in relation to: HCV prevention; the cascade of HCV care; strategies to enhance testing, linkage to care, and treatment uptake; and HCV treatment and reinfection. In addition, papers draw attention to the 'risk environments' and socio-ecological determinants of HCV acquisition, barriers to HCV care, the importance of messaging around the side-effects of new direct-acting antiviral therapies, the positive transformative potential of treatment and cure, and the key role of community-based drug user organizations in the HCV response. While this special issue highlights some successful efforts towards HCV elimination among people who inject drugs, it also highlights the relative lack of attention to settings in which resources enabling elimination are scarce, and where elimination hopes and potentials are less clear, such as in many low and middle income countries. Strengthening capacity in areas of the world where resources are more limited will be a critical step towards ensuring equity for all so that global HCV elimination among PWID can be achieved.

Evaluation of contingency management as a strategy to improve HCV linkage to care and treatment in persons attending needle and syringe programs: A pilot study

BACKGROUND

A greater proportion of HCV-infected people who inject drugs (PWID) need to be linked to care for HCV antiviral treatment. This study sets out to evaluate the efficacy of contingency management (CM) for improving HCV linkage to care, treatment initiation, adherence, and cure for PWID recruited from a needle and syringe program.

METHODS

Between March 2015 and April 2016, 20 participants were enrolled into the CM arm, and then subsequently enrolled 20 participants in the enhanced standard of care (eSOC) arm. Participants in the eSOC arm received an expedited appointment and a round-trip transit card. Participants enrolled in the CM arm received eSOC plus $25 for up to ten HCV clinical visits and $10 for each returned weekly medication blister pack. Adherence was measured via electronic blister packs.

RESULTS

Overall the median age was 47 years; most were men (67%) and Hispanic (69%). There were no significant differences in demographic characteristics between participants in the study arms. In the CM arm 74% were linked to HCV care, compared to 30% in the eSOC arm (p = 0.01). In the CM arm, 75% (9/12) of treatment eligible participants initiated treatment, compared to 100%(4/4) in the eSOC arm (p = 0.53). All patients (9/9) achieved cure in the CM arm, as compared to 75% (3/4) of patients in the eSOC arm. There were no differences in adherence between study arms.

CONCLUSIONS

In this pilot study, contingency management led to higher rates of HCV linkage to care for PWID, as compared to standard of care. CM should be considered as a possible intervention to improve the HCV treatment cascade for PWID.

High rates of early HCV reinfection after DAA treatment in people with recent drug use attended at mobile harm reduction units

BACKGROUND AND AIMS

The World Health Organization recently called for the elimination of hepatitis C virus (HCV) and has identified people who inject drugs (PWID) as a key target population. Clinical trials analyzing currently available all-oral regimens have demonstrated a high degree of efficacy in this population, with a relatively low reinfection rate. There is an urgent need to confirm these data in a harm reduction and active consumption setting. The primary aim of this study was to evaluate the HCV reinfection rate in people with recent drug use followed at low-threshold mobile harm reduction units.

METHOD

We included people with recent drug use (smoked or injected heroin/cocaine in the previous 6 months) who received HCV treatment and were attended at two low-threshold mobile harm reduction units over 19 months. Sustained virologic response was assessed 12 weeks after therapy (SVR12). The incidence density of HCV reinfection was defined as the number of reinfections per 100-person years (PY) using person-time of observation and was stratified by drug consumption at initiation of HCV treatment. Cox proportional hazard regression analysis was used to assess factors associated with reinfection.

RESULTS

During the study period, 160 people who used drugs in the past 6 months completed HCV therapy. 122 (73.9%) and 88 (53.3%) reported injecting drug use in the 6 months and 30 days prior to HCV treatment, respectively. The overall SVR12 was 68% in the ITT analysis (reinfection = failure) and 90.7% in the modified intent-to-treat analysis (considering reinfections as response and removing people who were missing SVR data). The cohort at-risk for reinfection (n = 121) included 47 (39.2%) people who initiated HCV treatment with recently reported abstinence. Reinfection was identified in 10 persons (8.3%), and the median time to reinfection was 7.2 (IQR 4.2-18) months. Total follow-up time at-risk was 101.1-PY (median 0.6 years, IQR 0.3-1.3). The overall incidence of reinfection was 9.8 per 100-PY (95% CI 4.7,18.2). The incidence of reinfection was higher amongst those who had injected drugs in the previous 6 months (16.7 [95%CI 8.0; 30.7] per 100-PY) and in the previous 30 days (18.9 [95% CI 8.1; 37.2] per 100-PY). In the adjusted analysis, only injecting drugs use in the month prior to initiation of HCV therapy was associated with reinfection (aHR 8.7, 95%CI 1.0; 73.6; p 0.04).

CONCLUSION

High efficacy of HCV treatment, was found in people with recent drug use attended and followed at low-threshold mobile harm reduction units. The high rate of early HCV reinfections in this setting should promote surveillance for reinfection at 7-month intervals after ending the treatment or earlier.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Low rate of reinfection among a cohort of people who use drugs successfully treated for hepatitis C virus infection in Vancouver, Canada

INTRODUCTION

Concerns about reinfection may be limiting HCV treatment uptake among people who use drugs (PWUD), with rates of 17.1/100 person-years in some cohorts. The aim of this study was to evaluate reinfection following successful treatment for hepatitis C virus infection in a cohort of people who inject drugs in Vancouver, Canada.

METHODS

We identified a cohort of HCV-infected PWUD treated at our centre. Following cure, patients were maintained in long-term follow-up in a multidisciplinary program to address their medical, psychological, social, and addiction-related needs. HCV RNA measurements were repeated every 6 months, and ongoing drug use was documented. The primary outcome of this analysis was the occurrence of reinfection.

RESULTS

243 recent PWUD (use within 6 months of treatment initiation) have achieved SVR and maintained in long-term follow-up. Ongoing drug use post-treatment was documented in 195 individuals. Key characteristics: mean age 53 years, 25% female, 78% treatment naïve, 17% cirrhotic. Reinfection occurred in 4 cases, all in patients with ongoing drug use. This incidence was 1.05/100 [95% 0.8-5.2] person years based on 379 person-years of follow-up in individuals currently using drugs.

CONCLUSION

Approaches including long-term maintenance in multidisciplinary care may optimize long-term outcomes of HCV treatment in PWUD.

Lower HCV treatment uptake in women who have received opioid agonist therapy before and during the DAA era: The ANRS FANTASIO project

BACKGROUND

In the era of direct-acting antivirals (DAA) for the treatment of hepatitis C virus (HCV) infection, HCV treatment uptake remains insufficiently documented in key populations such as people with opioid dependence. Access to opioid agonist therapy (OAT) is facilitated in France through delivery in primary care, and individuals with opioid dependence can be identified as those receiving OAT. Women with opioid dependence are especially vulnerable because of associated sex-related stigma, discrimination, and marginalization, all of which negatively interfere with access to HCV prevention and care. This study, based on data collected between 2012 and 2016 in France, aimed to assess whether (i) chronically HCV-infected women with opioid dependence had lower rates of HCV treatment uptake than their male counterparts during the same period (i.e., study period), and (ii) the advent of DAA resulted in increased treatment uptake rates in these women.

METHODS

Individuals with opioid dependence were identified as those receiving OAT at least once during the study period. Analyses were based on exhaustive anonymous care delivery data from the French national healthcare reimbursement database. We used multinomial logistic regression to estimate sex-based disparities in HCV treatment uptake (DAA or pegylated-interferon (Peg-IFN)-based treatment versus no treatment) while accounting for potential confounders.

RESULTS

The study sample comprised 27,127 individuals, including 5640 (20.8%) women. Median [interquartile range] age was 45 [40-49] years. Between 2012 and 2016, 70.9 (women: 77.2; men: 69.3), 17.3 (14.2; 18.2) and 11.7% (8.6%; 12.5%) of the study sample received, respectively, no HCV treatment, DAA and Peg-IFN-based treatment only. After multiple adjustment for potential confounders, women were 41% (adjusted odds-ratio (AOR) [95% confidence interval (CI]): 0.59[0.53-0.65]) and 28% (0.72[0.66-0.78]) less likely than men to have had Peg-IFN-based and DAA treatment, respectively.

CONCLUSION

Despite increased HCV treatment uptake in women with opioid dependence in the DAA era, rates remain lower than for men. In the coming years, access to DAA treatment will continue to increase in France thanks to a forthcoming simplified model of HCV care which includes primary care as an entry point. Nevertheless, a greater understanding of sex-specific barriers to HCV care and the implementation of appropriate sex-specific measures remain a priority.

Treatment cascade for hepatitis C virus in young adult people who inject drugs in San Francisco: Low number treated

OBJECTIVE

To understand the number of young adult people who inject drugs (PWID) with hepatitis C virus (HCV) infection accessing direct-acting antiviral (DAA) treatment and their barriers and facilitators to treatment uptake.

METHODS

Using prospective cohort data from young adult PWID in San Francisco with newly identified HCV infection, we calculated the number who: (i) accepted referral to DAA therapy, (ii) initiated DAA therapy, (iii) completed DAA therapy, and (iv) achieved sustained virologic response (SVR) or cure. Behavioral survey data identified possible barriers and facilitators to DAA therapy.

RESULTS

Of 60 young adult PWID with new HCV infection identified between February 2015 and January 2018, thirty accepted a referral to HCV care; five initiated and completed HCV treatment and achieved cure. Barriers to DAA uptake included fear of medical establishments, competing basic needs, and delaying care because they were feeling well.

CONCLUSION

While few HCV-positive young adult PWID engaged in DAA therapy, all those who did achieved cure. Youth-tailored services that overcome the stigma and marginalization related to injection drug use are needed to improve treatment uptake.

Transitioning from interferon-based to direct antiviral treatment options: A potential shift in barriers and facilitators of treatment initiation among people who use drugs?

BACKGROUND

Multiple barriers for accessing hepatitis C virus (HCV) treatment were identified during the interferon-based (IFN) treatment era for people who inject drugs (PWID). Whether these barriers persist since the introduction of IFN-free direct-acting antiviral (DAA) agents in Canada remains to be documented. This study examined temporal trends in HCV treatment initiation and associated factors during the transition from INF-based to all-oral DAA regimens.

METHODS

The study population was drawn from a prospective cohort of PWID in Montreal, Canada. At three-month/one-year intervals between 2011 and 2017, participants with chronic HCV infection completed an interviewer-administered questionnaire on socio-demographic characteristics, drug use and health service utilisation, including HCV treatment. Time-updated Cox multivariate regression models, stratified by DAA + INF (2011-2013) and all-oral DAA (2014-2017) availability periods, were conducted to examine associations between time to HCV treatment initiation and associated barriers and facilitators.

RESULTS

Of 308 participants (85% male, median age 42 [IQR: 33, 50]), 80 (26%) initiated HCV treatment during 915 person-years (PY). Incidence rates increased from 1.6 /100 PY (95%CI:0.9-2.6) in 2011 to 12.7 (10.6-15.1) in 2017 (p-trend = 0.0012). In multivariate analyses, visiting a primary care physician (2011-2013: aHR = 3.63[1.21-10.9]; 2014-2017: 2.52[1.10-5.77]) and frequent injection (0.23[0.05-0.99] and 0.49[0.24-0.99]) were consistently associated with treatment initiation. Participants aged >40 (2.27[1.24-4.13]), receiving opioid agonist therapy (OAT) (2.17[1.19-3.94]), and reporting prior HCV treatment (3.00[1.75-5.15]) were more likely to initiate treatment in the all-oral DAA period.

CONCLUSION

Treatment initiation increased between 2011 and 2017, but still remains low among PWID. Primary care visiting was a key facilitator regardless of the period, while engagement in OAT and health services, indicated by prior HCV treatment, increased the likelihood of treatment initiation in the DAA era. These findings suggest that access to health services is essential but not enough to scale up treatment in this population.

"Towards eliminating viral hepatitis": Examining the productive capacity and constitutive effects of global policy on hepatitis C elimination

In 2016 the World Health Organization published the first global health strategy to address viral hepatitis, setting a goal of eliminating viral hepatitis as a major public health threat by 2030. While the field has been motivated by this goal, to date there has been little critical attention paid to the productive capacity and constitutive effects of this policy. How is governing taking place through the mechanism of this global strategy, and how are its goals and targets shaping what is made thinkable (indeed, what is made as the real) about hepatitis C and its elimination? And with what effects? Taking the Global Health Sector Strategy on Viral Hepatitis, 2016-2021 as a text for analysis, we draw on poststructural thinking on problematisation and governmental technologies to examine how 'elimination' - as a proposal - constitutes the problem of hepatitis C. We critically consider the conceptual logics underpinning the elimination goal and targets, and the multiple material-discursive effects of this policy. We examine how governing takes place through numbers, by analysing 'target-setting' (and its accompanying practices of management, quantification and surveillance) as governmental technologies. We consider how the goal of elimination makes viral hepatitis visible and amenable to structuring, action and global management. Central to making viral hepatitis visible and manageable is quantification. Viral hepatitis is made as a problem requiring urgent global health management not through the representation of its effects on bodies or situated communities but rather through centralising inscription practices and comparison of estimated rates. It is important to remain alert to the multiple makings of hepatitis C and draw attention to effects which might be obscured due to a primary focus on quantification and management. To do so is to recognise the ontopolitical effects of governmental technologies, especially for communities 'targeted' by these strategies (including people who inject drugs).

Increasing hepatitis C virus screening in people who inject drugs in Switzerland using rapid antibody saliva and dried blood spot testing: A cost-effectiveness analysis

People who inject drugs (PWID) are a key high-risk group for Hepatitis C Virus (HCV) infection due to the sharing of needles and drug-preparation equipment. However, only approximately 50% of PWID are currently screened for HCV in Switzerland. At present, screening of PWID occurs in general practice via venepuncture. Compared to venepuncture, screening via rapid antibody saliva and dried blood spot (DBS) tests is well adapted to PWID, who typically have difficult venous access. The cost-effectiveness of an increased access screening programme of PWID (increased screening using rapid antibody saliva tests and DBS tests [semi-quantitative viraemia and viral genotype]) was analysed through a decision tree screening model combined with the outputs of a Markov treatment model. Sensitivity and scenario analyses examined the uncertainty of results. At a willingness to pay (WTP) threshold of CHF 100 000 (USD 105 000) per quality-adjusted life year (QALY), the increased access screening programme was cost-effective compared to current screening, with a base case incremental cost-effectiveness ratio of CHF 7 940 (USD 8337) per QALY. The net monetary benefit was CHF 959 802 668 (USD 1 007 792 801) for the PWID population and CHF 94 469 (USD 99 192) per person. The increased access screening programme had a 97.0% probability of being cost-effective compared to the current screening method at the WTP threshold of CHF 100 000 (USD 105 000). The results showed an increased access screening programme that uses tests which are better suited to the PWID population to be more cost-effective, due to the increased uptake that rapid antibody saliva and DBS tests generate.

Hepatitis C virus screening and treatment in Irish prisons from a governor and prison officer perspective - a qualitative exploration

BACKGROUND

Prisons are a key location to access Hepatitis C Virus (HCV) infected people who inject drugs (PWID). Prison health care structures are complex and optimising health care delivery to this high need, marginalised and underserved population remains challenging. Despite international guidelines recommending that prisons are a priority location for HCV screening and treatment levels of prisoner engagement in HCV care remain low. Competing priorities between security and healthcare is a key feature of prison health care. A collaborative approach to health care delivery in prisons can maximise the benefits for prisoners, staff and the wider community.

AIM

To identify the barriers and enablers to HCV screening and treatment in Irish prisons and inform the implementation of a HCV screening program within the Irish Prison Services (IPS).

METHODS

Qualitative study using focus group methodology underpinned by grounded theory.

RESULTS

The following themes emerged from the analysis: priority of safety and security, staffing and resources, concerns about personal risk, lack of knowledge, concerns around confidentiality, prisoners' fear of treatment and stigma, timing of screening, use of peer workers, in-reach hepatology and fibroscanning services. The primary role of prison security is to ensure the safety of staff and prisoners with a secondary but important supporting role in health care delivery. Maintaining adequate staffing levels and the provision of training and education were seen as priorities and impacted on prison officers' fear for personal safety and risk of HCV transmission. Opt-out screening and peer support workers had high levels of support among participants.

CONCLUSION

Upscaling HCV management in prisons requires an in-depth understanding of all barriers and facilitators to HCV screening and treatment. Engaging prison officers in the planning and delivery of health care initiatives is a key strategy to optimising the public health opportunity that prisons provides.

Clinical effectiveness of pharmacy-led versus conventionally delivered antiviral treatment for hepatitis C in patients receiving opioid substitution therapy: a study protocol for a pragmatic cluster randomised trial

INTRODUCTION

Hepatitis C virus (HCV) infection affects 0.7% of the general population, and up to 40% of people prescribed opioid substitution therapy (OST) in Scotland. In conventional care, less than 10% of OST users are tested for HCV and less than 25% of these initiate treatment. Community pharmacists see this group frequently to provide OST supervision. This study examines whether a pharmacist-led 'test & treat' pathway increases cure rates for HCV.

METHODS AND ANALYSIS

This protocol describes a cluster-randomised trial where 60 community pharmacies provide either conventional or pharmacy-led care. All pharmacies offer dried blood spot testing (DBST) for HCV. Participants have attended the pharmacy for OST for 3 months; are positive for HCV genotype 1 or 3; are not co-infected with HIV and/or hepatitis B; have no decompensated liver disease; are not pregnant. For conventional care, pharmacists refer HCV-positive participants to a local centre for assessment. In the pharmacy-led arm, pharmacists assess participants themselves in the pharmacy. Drug prescribing is by nurse prescribers (conventional arm) or pharmacist prescribers (pharmacy-led arm). Treatment in both arms is delivered as daily modified directly observed therapy in a pharmacy. Primary trial outcome is number of sustained virological responses at 12 weeks after treatment completion. Secondary trial outcomes are number of tests taken; treatment uptake; completion; adherence; re-infection. An economic evaluation will assess potential cost-effectiveness. Qualitative research interviews with clients and health professionals assess acceptability of a pharmacist-led pathway.

ETHICS AND DISSEMINATION

This protocol has been ethically approved by the East of Scotland Research Ethics Committee 2 (15/ES/0086) and complies with the Declaration of Helsinki and principles of Good Clinical Practice. Caldicott guardian approval was given on 16 December 2016 to allow NHS Tayside to pass information to the cluster community pharmacies about the HCV test status of patients that they are seeing to provide OST supervision. NHS R&D approvals have been obtained from each health board taking part in the study. Informed consent is obtained before study enrolment and only anonymised data are stored in a secured database, enabling an audit trail. Results will be submitted to international peer-reviewed journals and presented at international conferences.

TRIAL REGISTRATION NUMBER

NCT02706223; Pre-results.

Barriers and facilitators to hepatitis C (HCV) screening and treatment-a description of prisoners' perspective

BACKGROUND

Hepatitis C virus (HCV) infection is a global epidemic with an estimated 71 million people infected worldwide. People who inject drugs (PWID) are overrepresented in prison populations globally and have higher levels of HCV infection than the general population. Despite increased access to primary health care while in prison, many HCV infected prisoners do not engage with screening or treatment. With recent advances in treatment regimes, HCV in now a curable and preventable disease and prisons provide an ideal opportunity to engage this hard to reach population.

AIM

To identify barriers and enablers to HCV screening and treatment in prisons.

METHODS

A qualitative study of four prisoner focus groups (n = 46) conducted at two prison settings in Dublin, Ireland.

RESULTS

The following barriers to HCV screening and treatment were identified: lack of knowledge, concerns regarding confidentiality and stigma experienced and inconsistent and delayed access to prison health services. Enablers identified included; access to health care, opt-out screening at committal, peer support, and stability of prison life which removed many of the competing priorities associated with life on the outside. Unique blocks and enablers to HCV treatment reported were fear of treatment and having a liver biopsy, the requirement to go to hospital and in-reach hepatology services and fibroscanning.

CONCLUSION

The many barriers and enablers to HCV screening and treatment reported by Irish prisoners will inform both national and international public health HCV elimination strategies. Incarceration provides a unique opportunity to upscale HCV treatment and linkage to the community would support effectiveness.

Prevalence of Hepatitis C Virus Infection in US States and the District of Columbia, 2013 to 2016

IMPORTANCE

Infection with hepatitis C virus (HCV) is a major cause of morbidity and mortality in the United States, and incidence has increased rapidly in recent years, likely owing to increased injection drug use. Current estimates of prevalence at the state level are needed to guide prevention and care efforts but are not available through existing disease surveillance systems.

OBJECTIVE

To estimate the prevalence of current HCV infection among adults in each US state and the District of Columbia during the years 2013 to 2016.

DESIGN, SETTING, AND PARTICIPANTS

This survey study used a statistical model to allocate nationally representative HCV prevalence from the National Health and Nutrition Examination Survey (NHANES) according to the spatial demographics and distributions of HCV mortality and narcotic overdose mortality in all National Vital Statistics System death records from 1999 to 2016. Additional literature review and analyses estimated state-level HCV infections among populations not included in the National Health and Nutrition Examination Survey sampling frame.

EXPOSURES

State, accounting for birth cohort, biological sex, race/ethnicity, federal poverty level, and year.

MAIN OUTCOMES AND MEASURES

State-level prevalence estimates of current HCV RNA.

RESULTS

In this study, the estimated national prevalence of HCV from 2013 to 2016 was 0.84% (95% CI, 0.75%-0.96%) among adults in the noninstitutionalized US population represented in the NHANES sampling frame, corresponding to 2 035 100 (95% CI, 1 803 600-2 318 000) persons with current infection; accounting for populations not included in NHANES, there were 231 600 additional persons with HCV, adjusting prevalence to 0.93%. Nine states contained 51.9% of all persons living with HCV infection (California [318 900], Texas [202 500], Florida [151 000], New York [116 000], Pennsylvania [93 900], Ohio [89 600], Michigan [69 100], Tennessee [69 100], and North Carolina [66 400]); 5 of these states were in Appalachia. Jurisdiction-level median (range) HCV RNA prevalence was 0.88% (0.45%-2.34%). Of 13 states in the western United States, 10 were above this median. Three of 10 states with the highest HCV prevalence were in Appalachia.

CONCLUSIONS AND RELEVANCE

Using extensive national survey and vital statistics data from an 18-year period, this study found higher prevalence of HCV in the West and Appalachian states for 2013 to 2016 compared with other areas. These estimates can guide state prevention and treatment efforts.

Eliminating hepatitis C: The importance of frequent testing of people who inject drugs in high-prevalence settings

Modelling suggests that more frequent screening of people who inject drugs (PWID) and an improved care cascade are required to achieve the WHO hepatitis C virus (HCV) elimination target of an 80% reduction in incidence by 2030. We determined the testing frequencies (2-yearly, annually, 6-monthly and 3-monthly) and retention in care required among PWID to achieve the HCV incidence reduction target through treatment as prevention in low (25%), medium (50%) and high (75%) chronic HCV prevalence settings. Mathematical modelling of HCV transmission among PWID, capturing testing, treatment and other features of the care cascade were employed. In low-prevalence settings, 2-yearly antibody testing of PWID was estimated to reach the elimination target by 2027-2030 depending on retention in care, with annual testing reducing the time by up to 3 years. In medium-prevalence settings, if close to 90% testing coverage were achieved, then annual antibody testing of PWID would be sufficient. If testing coverage were lower (80%), 6-monthly antibody testing with at least 70% retention in care or annual HCV RNA/cAg testing would be required. In high-prevalence settings, even 3-monthly HCV RNA/cAg testing of PWID was unable to achieve the incidence reduction target. Thus, for geographical areas or subpopulations with high prevalence, WHO incidence targets are unlikely to be met without 3-monthly RNA/cAg testing accompanied by other prevention measures. Novel testing strategies, such as rapid point-of-care antibody testing or replacing antibody testing with RNA/cAg tests as a screening tool, can provide additional population-level impacts to compensate for imperfect follow-up or testing coverage.

"I'm obviously not dying so it's not something I need to sort out today": Considering hepatitis C treatment in the era of direct acting antivirals

BACKGROUND

People who inject drugs are the group at greatest risk of hepatitis C virus (HCV) infection. The advent of new direct-acting antiviral (DAA) treatment provides opportunities for increased uptake of therapy.

METHODS

We conducted in-depth interviews with thirty HCV positive participants from the SuperMIX cohort study. Interviews were transcribed, coded, and analysed for emerging themes and similarities between participants. General descriptions and critical interpretation of themes were generated and selective quotes extracted verbatim to best illustrate the critical themes.

RESULTS

Participants described their experiences of living with HCV, their knowledge of HCV treatment accessibility, and information on the types of support ain themes: Understanding the need for treatment; Knowledge and framing of treatment access; and Support during treatment.

CONCLUSION

The new, highly effective DAAs for the treatment of HCV are heralded as the potential beginning of HCV elimination, especially in settings where scale up is high. Our data from active PWID show that the availability of DAA medications in and of themselves is likely not to be enough to ensure that PWID will come forward for HCV treatment in sufficient numbers to drive elimination.

Hepatitis C virus reinfection after successful treatment with direct-acting antiviral therapy in a large population-based cohort

BACKGROUND & AIMS

Direct-acting antiviral therapies (DAA) are an important tool for hepatitis C virus (HCV) elimination. However, reinfection among people who inject drugs (PWID) may hamper elimination targets. Therefore, we estimated HCV reinfection rates among DAA-treated individuals, including PWID.

METHODS

We analyzed data from the British Columbia Hepatitis Testers Cohort which included ∼1.7 million individuals screened for HCV in British Columbia, Canada. We followed HCV-infected individuals treated with DAAs who achieved a sustained virologic response (SVR) and had ≥1 subsequent HCV RNA measurement to April 22nd, 2018. Reinfection was defined as a positive RNA measurement after SVR. PWID were identified using a validated algorithm and classified based on recent (<3 years) or former (≥3 years before SVR) use. Crude reinfection rates per 100 person-years (PYs) were calculated. Poisson regression was used to model adjusted incidence rate ratios (IRRs) and 95% CIs.

RESULTS

Of 4,114 individuals who met the inclusion criteria, most were male (n = 2,692, 65%), born before 1965 (n = 3,411, 83%) and were either recent (n = 875, 21%) or former PWID (n = 1,793, 44%). Opioid-agonist therapy (OAT) was received by 19% of PWID. We identified 40 reinfections during 2,767 PYs. Reinfection rates were higher among recent (3.1/100 PYs; IRR 6.7; 95% CI 1.9-23.5) and former PWID (1.4/100 PYs; IRR 3.7; 95% CI 1.1-12.9) than non-PWID (0.3/100 PYs). Among recent PWID, reinfection rates were higher among individuals born after 1975 (10.2/100 PYs) and those co-infected with HIV (5.7/100 PYs). Only one PWID receiving daily OAT developed reinfection.

CONCLUSIONS

Population-level reinfection rates remain elevated after DAA therapy among PWID because of ongoing exposure risk. Engagement of PWID in harm-reduction and support services is needed to prevent reinfections.

LAY SUMMARY

Direct-acting antivirals are an effective tool for the treatment of hepatitis C virus, enabling the elimination of the virus. However, some patients who have been successfully treated with direct-acting antivirals are at risk of reinfection. Our findings showed that the risk of reinfection was highest among people with recent injection drug use. Among people who inject drugs, daily use of opioid-agonist therapy was associated with a lower risk of reinfection.

Pathways to ensure universal and affordable access to hepatitis C treatment

Direct-acting antivirals (DAAs) have dramatically changed the landscape of hepatitis C treatment and prevention. The World Health Organization has called for the elimination of hepatitis C as a public health threat by 2030. However, the discrepancy in DAA prices across low-, middle- and high-income countries is considerable, ranging from less than US$ 100 to approximately US$ 40,000 per course, thus representing a major barrier for the scale-up of treatment and elimination. This article describes DAA pricing and pathways to accessing affordable treatment, providing case studies from Australia, Egypt and Portugal. Pathways to accessing DAAs include developing comprehensive viral hepatitis plans to facilitate price negotiations, voluntary and compulsory licenses, patent opposition, joint procurement, and personal importation schemes. While multiple factors influence the price of DAAs, a key driver is a country's capacity and willingness to negotiate with pharmaceutical companies. If negotiations do not lead to a reasonable price, governments have the option to utilise flexibilities outlined in the Agreement on Trade-Related Aspects of Intellectual Property Rights. Affordable access to DAAs is underpinned by collaboration between government, civil society, global organisations and pharmaceutical companies to ensure that all patients can access treatment. Promoting these pathways is critical for influencing policy, improving access to affordable DAAs and achieving hepatitis C elimination.