Is it justifiable to withhold treatment for hepatitis C from illicit-drug users?

Hepatitis Risk in Diabetes Compared to Non-Diabetes and Relevant Factors: A Cross-Sectional Study with National Health and Nutrition Examination Survey (NHANES), 2013-2018

This study aimed to identify the development of hepatitis B or C infection in diabetes patients compared to those without and to elucidate factors associated with the prevalence of hepatitis B or C infection in diabetes. We conducted a cross-sectional study using data from the National Health and Nutrition Examination Survey (NHANES) 2013-2018. As evaluation factors, we included variables such as age, race, illicit drug use, and poverty. The diabetic group had a significantly higher prevalence of hepatitis B or C infection than the non-diabetic group (odds ratio (OR) = 1.73; 95% confidence interval (CI), 1.36-2.21, p < 0.01). In multivariate Cox regression, non-poverty and non-illicit drug use were lower risk factors contributing to hepatitis development in diabetes (hazard ratio (HR) = 0.50; 95% CI, 0.32-0.79, p < 0.01, and HR = 0.05; 95% CI, 0.03-0.08, p < 0.01, respectively). Logistic regression also showed that these factors were significant contributors to hepatitis development in the diabetic group (p < 0.01). In patients with diabetes, the development of hepatitis was higher than that in those without, and hepatitis development was influenced by poverty and illicit drug use. This may provide supporting evidence of response strategies for diabetes to care for hepatitis development in advance.

Innovative Approaches to Engaging Homeless and Marginally Housed Patients in Care: a Case Study of Hepatitis C

BACKGROUND

Homeless and marginally housed (HAMH) individuals experience significant health disparities compared to housed counterparts, including higher hepatitis C virus (HCV) rates. New direct-acting antiviral (DAA) medications dramatically increased screening and treatment rates for HCV overall, but inequities persist for HAMH populations.

OBJECTIVE

This study examines the range of policies, practices, adaptations, and innovations implemented by Veteran Affairs Medical Centers (VAMCs) in response to Veterans Health Administration (VHA)'s 2016 HCV funding allocation to expand provision of HCV care.

DESIGN

Ethnographic site visits to six US VAMCs varying in size, location, and availability of Homeless Patient-Aligned Care Teams. Semi-structured qualitative interviews informed by the HCV care continuum were conducted with providers, staff, and HAMH patients to elicit experiences providing and receiving HCV care. Semi-structured field note templates captured clinical care observations. Interview and observation data were analyzed to identify cross-cutting themes and strategies supporting tailored HCV care for HAMH patients.

PARTICIPANTS

Fifty-six providers and staff working in HCV and/or homelessness care (e.g., infectious disease providers, primary care providers, social workers). Twenty-five patients with varying homeless experiences, including currently, formerly, or at risk of homelessness (n=20) and stably housed (n=5).

KEY RESULTS

All sites experienced challenges with continued engagement of HAMH individuals in HCV care, which led to the implementation of targeted care strategies to better meet their needs. Across sites, we identified 35 unique strategies used to find, engage, and retain HAMH individuals in HCV care.

CONCLUSIONS

Despite highly effective, widely available HCV treatments, HAMH individuals continue to experience challenges accessing HCV care. VHA's 2016 HCV funding allocation resulted in rapid adoption of strategies to engage and retain vulnerable patients in HCV treatment. The strategies identified here can help healthcare institutions tailor and target approaches to provide sustainable, high-quality, equitable care to HAMH individuals living with HCV and other chronic illnesses.

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

BACKGROUND

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

OBJECTIVES

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

DATA SOURCES

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

CONCLUSIONS

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

IMPLICATIONS FOR PRACTICE

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

A Guide to the Economics of Hepatitis C Virus Cure in 2017

This commentary reviews the core principals of cost-effectiveness and applies them to the rapidly evolving context of hepatitis C virus treatment in the United States. The article provides a foundation of evidence that hepatitis C virus treatment provides good economic value, even though it is expensive, and even when treating people who inject drugs who are at high risk for hepatitis C virus reinfection. The price of medications has decreased, but the high price continues to limit access to care. This wedge between cost effectiveness and affordability stands front and center as one of the leading obstacles to elimination.

Treatment of Chronic Hepatitis C in Patients Receiving Opioid Agonist Therapy: A Review of Best Practice

Injection drug use is the most common transmission route for hepatitis C. High rates of infection are observed among individuals on opioid agonist therapy. Although people who inject drugs carry the highest burden, few have initiated treatment. We present a comprehensive review of the evidence on the efficacy of HCV medications, drug-drug interactions, and barriers to and models of care. Studies have demonstrated comparable efficacy for individuals who are on opioid agonist therapy compared with those who are not. We propose that a strategy of treatment and cure-as-prevention is imperative in this population to curb the hepatitis C epidemic.

Debating Medical Utility, Not Futility: Ethical Dilemmas in Treating Critically Ill People Who Use Injection Drugs

Physicians who care for critically ill people with opioid use disorder frequently face medical, legal, and ethical questions related to the provision of life-saving medical care. We examine a complex medical case that illustrates these challenges in a person with relapsing injection drug use. We focus on a specific question: Is futility an appropriate and useful standard by which to determine provision of life-saving care to such individuals? If so, how should such determinations be made? If not, what alternative decisionmaking framework exists? We determine that although futility has been historically utilized as a justification for withholding care in certain settings, it is not a useful standard to apply in cases involving people who use injection drugs for non-medical purposes. Instead, we are welladvised to explore each patient's situation in a holistic approach that includes the patient, family members, and care providers in the decision-making process. The scope of the problem illustrated demonstrates the urgent need to definitively improve outcomes in people who use injection drugs. Increasing access to high quality medication-assisted treatment and psychiatric care for individuals with opioid use disorder will help our patients achieve a sustained remission and allow us to reach this goal.

Perceived benefits of the hepatitis C peer educators: a qualitative investigation

BACKGROUND

Although opioid-dependent patients are disproportionately impacted by hepatitis C (HCV), many do not receive treatment. In addition to HCV treatment-access barriers, substance-using patients may be reluctant to pursue treatment because of wariness of the medical system, lack of knowledge, or stigma related to HCV treatment. Implementation of a formal peer education program is one model of reducing provider- and patient-level barriers to HCV treatment, by enhancing mutual trust and reducing stigma.

METHODS

We used thematic qualitative analysis to explore how 30 HCV patients and peer educators perceived a HCV peer program within an established methadone maintenance program in the USA.

RESULTS

Participants unanimously described the program as beneficial. Participants described the peer educators' normalization and dispelling of myths and fears around HCV treatment, and their exemplification of HCV treatment success, and reductions in perceived stigma. Peer educators described personal benefits.

CONCLUSIONS

These findings indicate that HCV peer educators can enhance HCV treatment initiation and engagement within opioid substitution programs.

Retention in buprenorphine treatment is associated with improved HCV care outcomes

Persons who inject drugs, most of whom are opioid dependent, comprise the majority of the HCV infected in the United States. As the national opioid epidemic unfolds, increasing numbers of people are entering the medical system to access treatment for opioid use disorder, specifically with buprenorphine. Yet little is known about HCV care in patients accessing buprenorphine-based opioid treatment. We sought to determine the HCV prevalence, cascade of care, and the association between patient characteristics and completion of HCV cascade of care milestones for patients initiating buprenorphine treatment. We reviewed electronic health records of all patients who initiated buprenorphine treatment at a primary-care clinic in the Bronx, NY between January 2009 and January 2014. Of the 390 patients who initiated buprenorphine treatment, 123 were confirmed to have chronic HCV infection. The only patient characteristic associated with achieving HCV care milestones was retention in opioid treatment. Patients retained (vs. not retained) in buprenorphine treatment were more likely to be referred for HCV specialty care (63.1% vs. 34.0%, p<0.01), achieve an HCV-specific evaluation (40.8% vs. 21.3%, p<0.05), be offered HCV treatment (22.4% vs. 8.5%, p<0.05), and initiate HCV treatment (9.2% vs. 6.4%, p=0.6). Given the current opioid epidemic in the US and the growing number of people receiving buprenorphine treatment, there is an unprecedented opportunity to access and treat persons with HCV, reducing HCV transmission, morbidity and mortality. Retention in opioid treatment may improve linkage and retention in HCV care; innovative models of care that integrate opioid drug treatment with HCV treatment are essential.

Community nurse-led initiation of antiviral therapy for chronic hepatitis C in people who inject drugs does not increase uptake of or adherence to treatment

BACKGROUND

Chronic hepatitis C is common in people who inject drugs (PWID) and this population serves as a reservoir for infection. Treatment levels are low among this group, ranging from 1 to 19%. We explored whether a nurse-initiated community treatment model increased uptake of and adherence to interferon-based therapies.

METHODS

This was a cluster randomized trial of nurse-initiated versus physician-initiated antiviral therapy with pegylated interferon and ribavirin for hepatitis C virus in community clinics (trial registration: ISRCTN07774040).

RESULTS

The proportion of participants initiating treatment during follow-up was 10% with nurse-initiated (6/62) and 9% with physician-initiated (6/76) therapy. Adherence was similar in both groups, with only one patient in each arm not adhering to therapy. There were no serious adverse events, but interferon-related side effects were common. Drug and alcohol use did not change during therapy.

CONCLUSION

Despite easy access to antiviral therapy, uptake of treatment was poor, with no significant difference between the groups. Nurse-led initiation of interferon-based antiviral therapy in PWID did not lead to increased uptake of, response to or adherence with treatment. Further service improvement is unlikely to increase the proportion of PWID undergoing antiviral therapy for hepatitis C virus and early adoption of interferon-free regimens may increase the proportion initiating and completing treatment.

The Role of Physicians’ Attitudes and the Provision of Hepatitis C Virus Treatment to People Who Inject Drugs

Inadequate hepatitis C virus (HCV) assessment and treatment among people who inject drugs (PWID) is a result of patient, provider and health system level barriers. Low HCV treatment rates continue even though guidelines have been revised to consider HCV treatment among PWID on a case-by-case basis. If accessibility to HCV treatment were increased, especially to PWID this would greatly decrease the pool of communicable disease. In order to successfully control and prevent HCV infection PWID must be actively engaged in the treatment process. Physicians’ attitudes towards HCV treatment can be represented in studies as views that are directly perceived by the physician or indirectly as perceived by the patient who is under the care of the physician. The current review focuses on examining both the indirect and direct views of physician’s attitudes in treating HCV-infected PWID and examines how this influences and impacts provision of HCV treatment. A review of the literature suggests that physician’s have varied attitudes towards their patients who use recreational drugs and who are HCV positive. Moreover it is the negative associations between HCV and drug use that can impact HCV treatment accessibility and affect the number of people who can actively begin treatment.

Co-occurring Depression, Chronic Pain and Substance Use Disorders in People with Hepatitis C

Chronic infection with Hepatitis C virus (HCV) is common and can result in serious and sometimes fatal liver complications. The impact of HCV on the liver can be further complicated by medical and psychological comorbidities. Depression, substance use, and pain syndromes are frequent co-morbid conditions in people with HCV and diminish functioning, quality of life, and treatment compliance. Understanding the underlying biological mechanisms of these comorbid conditions within the context of HCV may help elucidate factors contributing to their co-occurrence, perhaps mediatedviapro-inflammatory cytokines. The current review provides a synthesis of the literature on depression, substance use disorders and chronic pain in the presence of HCV. The review includes studies conducted with both veteran and civilian populations. The implications for assessment and antiviral treatment of HCV will be considered.

Access to treatment for hepatitis C virus infection: time to put patients first

Sound health policy puts patients first. Antiviral regimens approved in 2014 revolutionised treatment of hepatitis C virus (HCV) infection. Most patients can now be cured. These new regimens, however, were priced at US$83 320-150 000 for a 3-month course. Public and private payers in the USA responded by limiting coverage to patients with advanced fibrosis or cirrhosis, keeping the drugs from being used to prevent those stages. These restrictions defy medical guidelines, lack scientific justification, and undermine public health efforts to stem transmission. Instead of reducing barriers to care, the system has erected new ones. As drug makers and payers battle over billions of dollars, the needs of patients have been cast aside. Physicians and governments have a duty to make sure health policy is driven by the needs of patients and public health. In this Personal View, I call upon these groups to lead the creation of a national consensus among all stakeholders that will allow the advances in therapeutics for HCV infection to be put to work to end the epidemic.

Reducing barriers to hepatitis C treatment among drug users: an integrated hepatitis C peer education and support program

This report describes an innovative HCV Peer Educator Program that facilitates education, support, and engagement in HCV treatment among patients in an opioid treatment program. Integrating peer educators in a collaborative manner with close supervision holds promise as a model to reduce barriers to HCV treatment among drug users.

High hepatitis C virus prevalence among drug users in Iran: systematic review and meta-analysis of epidemiological evidence (2001-2012)

OBJECTIVE

Drug users, particularly drug injectors, are at elevated risk of blood-borne diseases. This study systematically reviewed the prevalence of hepatitis C virus (HCV) mono-infection and its co-infections with human immunodeficiency virus (HIV) and hepatitis B virus (HBV) in drug users in Iran.

METHODS

Searches were conducted in international, regional, and Iranian databases. Documents were screened, data extracted, and pooled point prevalence and 95% confidence intervals (CI) were calculated.

RESULTS

Overall, 13,821 subjects (87.4% male) with an average age of 32.4 years (95% CI 31-33 years) from 24 original studies were included in the analysis. The pooled HCV prevalence (95% CI) among drug users with and without an injection history was 45% (37-54%) and 8% (4-13%), respectively. The pooled HCV prevalences (95% CI) among individuals with vs. without a history of imprisonment and needle sharing were 58% (39-77%) vs. 44% (20-68%) and 56% (41-71%) vs. 49% (26-71%), respectively. The prevalence of HCV/HIV co-infection among injectors was 11% (95% CI 5-16%).

CONCLUSIONS

HCV prevalence is high in drug users in Iran, especially among those with a history of injection drug use, needle sharing, and imprisonment. Drug user-focused HCV prevention and treatment programs are urgently needed.

An international perspective on using opioid substitution treatment to improve hepatitis C prevention and care for people who inject drugs: Structural barriers and public health potential

People who inject drugs (PWID) are central to the hepatitis C virus (HCV) epidemic. Opioid substitution treatment (OST) of opioid dependence has the potential to play a significant role in the public health response to HCV by serving as an HCV prevention intervention, by treating non-injection opioid dependent people who might otherwise transition to non-sterile drug injection, and by serving as a platform to engage HCV infected PWID in the HCV care continuum and link them to HCV treatment. This paper examines programmatic, structural and policy considerations for using OST as a platform to improve the HCV prevention and care continuum in 3 countries-the United States, Estonia and Viet Nam. In each country a range of interconnected factors affects the use OST as a component of HCV control. These factors include (1) that OST is not yet provided on the scale needed to adequately address illicit opioid dependence, (2) inconsistent use of OST as a platform for HCV services, (3) high costs of HCV treatment and health insurance policies that affect access to both OST and HCV treatment, and (4) the stigmatization of drug use. We see the following as important for controlling HCV transmission among PWID: (1) maintaining current HIV prevention efforts, (2) expanding efforts to reduce the stigmatization of drug use, (3) expanding use of OST as part of a coordinated public health approach to opioid dependence, HIV prevention, and HCV control efforts, (4) reductions in HCV treatment costs and expanded health system coverage to allow population level HCV treatment as prevention and OST as needed. The global expansion of OST and use of OST as a platform for HCV services should be feasible next steps in the public health response to the HCV epidemic, and is likely to be critical to efforts to eliminate or eradicate HCV.

Successful treatment of chronic hepatitis C with triple therapy in an opioid agonist treatment program

BACKGROUND

People who inject drugs (PWID) constitute 10 million people globally with hepatitis C virus, including many opioid agonist treatment patients. Little data exist describing clinical outcomes for patients receiving HCV treatment with direct-acting antiviral agents (DAAs) in opioid agonist treatment settings.

METHODS

In this retrospective observational study, we describe clinical outcomes for 50 genotype-1 patients receiving HCV treatment with triple therapy: telaprevir (n=42) or boceprevir (n=8) in combination with pegylated interferon and ribavirin on-site in an opioid agonist treatment program.

RESULTS

Overall, 70% achieved an end of treatment response (ETR) and 62% achieved a sustained virological response (SVR). These treatment outcomes are nearly equivalent to previously published HCV outcomes shown in registration trials, despite high percentages of recent drug use prior to treatment (52%), ongoing drug use during treatment (45%) and psychiatric comorbidity (86%). Only 12% (n=6) discontinued antiviral treatment early for non-virological reasons. Four patients received a blood transfusion, and one discontinued telaprevir due to severe rash.

CONCLUSIONS

These data demonstrate that on-site HCV treatment with direct-acting antiviral agents is effective in opioid agonist treatment patients including patients who are actively using drugs. Future interferon-free regimens will likely be even more effective. Opioid agonist treatment programs represent an opportunity to safely and effectively treat chronic hepatitis C, and PWID should have unrestricted access to DAAs.

Association between hepatitis C virus and opioid use while in buprenorphine treatment: preliminary findings

BACKGROUND

The prevalence of hepatitis-C-virus (HCV) infections is high among opioid-dependent individuals. Prior research on the simultaneous treatment of both conditions has primarily assessed success as it pertains to HCV. However, it has been noted that favorable substance use therapy outcomes may improve the likelihood of HCV-treatment initiation and success. Therefore, current guidelines for the treatment of HCV among illicit drug users suggest that treatment for addiction be given the highest priority.

OBJECTIVES

To determine whether opioid-dependent participants in a clinical trial of buprenorphine-treatment tapering regimens, who tested positive for the HCV antibody, experienced significantly different levels of opioid abstinence than those not infected.

METHODS

Data came from the National Drug Abuse Treatment Clinical Trial Network study 0003. 516 eligible opioid-dependent participants were randomized to either a 7-day or 28-day buprenorphine tapering schedule following a 4-week buprenorphine stabilization period. Generalized estimating equations were used to test the research question.

RESULTS

Participants with the HCV antibody were significantly less likely to submit opioid-negative urine analyses during and/or immediately following active treatment [OR = 0.69; CI = 0.51-0.93], indicating a higher rate of opioid use among this group.

CONCLUSION

Individualized opioid-dependence treatment strategies may be required for opioid-dependent individuals who test positive for the HCV antibody in order to ensure resources for both opioid-dependence and HCV therapies are used efficiently.

Heroin use promotes HCV infection and dysregulates HCV-related circulating microRNAs

Hepatitis C virus (HCV) infection is common among injection drug users (IDUs). There is accumulating evidence that circulating microRNAs (miRNAs) are associated with HCV infection and disease progression. The present study was undertaken to determine the in vivo impact of heroin use on HCV infection and HCV-related circulating miRNA expression. Using the blood specimens from four groups of the study subjects (HCV-infected individuals, heroin users with/without HCV infection, and healthy volunteers), we found that HCV-infected heroin users had significantly higher viral load than HCV-infected non-heroin users (p = 0.0004). Measurement of HCV-related circulating miRNAs in plasma showed that miRs-122, 141, 29a, 29b, and 29c were significantly increased in the heroin users with HCV infection, whereas miR-351, an HCV inhibitory miRNA, was significantly decreased in heroin users as compared to control subjects. Further investigation identified a negative correlation between the plasma levels of miR-29 family members and severity of HCV infection based on aspartate aminotransferase to platelet ratio index (APRI). In addition, heroin use and/or HCV infection also dysregulated a panel of plasma miRNAs. Taken together, these data for the first time revealed in vivo evidence that heroin use and/or HCV infection alter circulating miRNAs, which provides a novel mechanism for the impaired innate anti-HCV immunity among IDUs.

Are there national strategies, plans and guidelines for the treatment of hepatitis C in people who inject drugs? A survey of 33 European countries

BACKGROUND

Hepatitis C virus (HCV) infection represents a major global health problem, which in high-income countries now mostly affects people who inject drugs (PWID). Many studies show that the treatment of HCV infection is as successful among PWID as among other populations and recently PWID have been included in the international guidelines for the treatment of HCV infection. The aim of this survey was to collect data from European countries on the existence of national strategies, action plans and clinical guidelines for HCV treatment in the general population and PWID in particular.

METHODS

Thirty-three European countries were invited to participate. Data on available national strategies, action plans and guidelines for HCV treatment in general population and in PWID specifically were collected prospectively by means of a structured electronic questionnaire and analyzed accordingly.

RESULTS

All of the 33 invited European countries participated in the survey. Twenty-two responses came from non-governmental organizations, six from public health institutions, four from university institutions and one was an independent consultant. Fourteen (42.4%) of the countries reported having a national strategy and/or national action plan for HCV treatment, from which ten of them also reported having a national strategy and/or national action plan for treatment of HCV infection in PWID. Nearly three-quarters reported having national HCV treatment guidelines. PWID were included in the majority (66.7%) of the guidelines. Fourteen (42.4%) countries reported having separate guidelines for the treatment of HCV infection in PWID.

CONCLUSIONS

Given the high burden of HCV-related morbidity and mortality in PWID in Europe, the management of HCV infection should become a healthcare priority in all European countries, starting with developing or using already-existing national strategies, action plans and guidelines for this population.

Clinical outcomes in a cohort of anti-hepatitis C virus-positive patients with significant barriers to treatment referred to a Norwegian outpatient clinic

OBJECTIVE

Patient selection and management of chronic hepatitis C (CHC) in Norwegian outpatient clinics is not well studied. The aim of the study was to characterize CHC patients referred to a large university hospital in Norway, identify treatment barriers, and investigate the course and outcomes of treatment.

MATERIAL AND METHODS

In this retrospective observational cohort study, all anti-HCV-positive patients referred to Haukeland University Hospital, Bergen, for treatment evaluation during the period 2007-2010 were included. Demographics, clinical, laboratory, and treatment results were obtained from electronic medical records.

RESULTS

A total of 256 patients were included. The patients were young (mean age 36 ± 10.3), with a high prevalence of genotypes 3 (55%) and 1 (43%) and low levels of fibrosis (77% <F2). The majority of patients were former or current injection drug users (85%). Treatment uptake among patients attending the clinic was 47% (n = 91). Treatment was significantly less common in patients who were unemployed, those who had nonattendances during clinical evaluation, those with genotypes 1 or 4, those ≥50 years of age, and patients with no biopsy. For patients initiating treatment, the total sustained virologic response (SVR) rate was 63% (by complete case analysis 73%). For genotypes 1 and 3, SVR was achieved in 44% and 75%, respectively, by intention to treat.

CONCLUSIONS

A high treatment uptake of CHC patients in a cohort with high prevalence of injection drug use was found. Young age, low degrees of fibrosis, and good patient attendance ensured a high rate of SVR.

Characteristics and impact of methamphetamine use in patients with chronic hepatitis C

OBJECTIVES

Methamphetamine (MA) use has increased in the United States in the last 20 years and is a risk factor for hepatitis C virus(HCV) infection. The purpose of this study was to determine the characteristics and HCV infection outcomes of patients with a history of MA use.

METHODS

Subjects consisted of newly entered patients in the Veterans Affairs (VA) HCV registry at a single VA medical center from January 1, 2004, to June 30, 2004, and from January 1, 2007, to June 30, 2007. Univariate and multivariate analyses related to HCV infection antiviral treatment outcomes through 2010 was performed.

RESULTS

A total of 198 consecutive eligible HCV registry patients were analyzed, and 40% had a history of MA use. Of patients with MA use history, 46% (36/79) had active use (within 6 months) at initial contact. Active MA users were significantly younger (mean age, 45.5 years), with more concomitant drug use (86%), compared with patients without MA use (mean age, 53.5 years; 42% minority; 29% other drug use). Overall, 71% of the 198 patients reported a history of problematic alcohol use, and 47% of those reported active abuse. Logistic regression analyses indicated that MA use did not significantly adversely affect antiviral treatment initiation, completion, or sustained virological response rates compared with that in patients without MA use. Active alcohol users had lower treatment initiation than patients without alcohol use.

CONCLUSIONS

MA use is common in recent US veterans with HCV infection and occurs in younger patients with polysubstance use. Prior history or active MA use does not seem to adversely affect HCV infection clinic treatment compared with that in HCV-infected patients without MA use.

Factors associated with uptake, adherence, and efficacy of hepatitis C treatment in people who inject drugs: a literature review

INTRODUCTION AND METHODS

Hepatitis C virus (HCV) infections are highly prevalent amongst people who inject drugs (PWID). Despite well documented evidence of its effectiveness, suggested cost-effectiveness, and potential to reduce HCV prevalence rates, the uptake of antiviral HCV treatment by PWID is low. This nonsystematic literature review describes factors associated with the uptake, adherence, and efficacy of HCV treatment among PWID and discusses strategies to increase their uptake of treatment.

RESULTS

Low HCV treatment uptake among PWID is associated with a number of patient-related and provider-related barriers. Beliefs and fears about low efficacy and adverse effects on the patient's part are common. A substantial number of factors are associated with the chaotic lifestyle and altered social functioning of PWID, which are often associated with decompensation or relapsing into drug addiction. This may lead to perceived low adherence with treatment and low efficacy on the provider's part too, where lack of support, inadequate management of addiction, and other drug-related problems and poor treatment of side effects have been described. Practical issues such as the accessibility of treatment and finances also play a role. Strategies to improve the HCV treatment rate among PWID involve pretreatment management and assessment, a multidisciplinary approach, management of side effects, and enhanced education and counseling.

CONCLUSION

Specific factors are associated with poorer treatment outcomes in PWID on the side of both the patient and the treatment system. However, given that PWID can achieve treatment adherence and sustained virologic response rates comparable with those in nondrug users, drug use per se should not be considered a criterion for exclusion from treatment. Further development of measures leading to higher uptake of treatment and adherence in PWID and appropriate adaptation of HCV treatment guidelines represent important tools in this regard.

Reinforced biographies among women living with hepatitis C

In a growing body of social research it is suggested that hepatitis C virus (HCV) infection is a low priority for people who inject drugs. We expand on the evidence to explore the link between identity and health using biographical adaptation theories. We examined experiences of HCV infection and illness among women who inject drugs, women who are no longer injecting drugs, and women who have never injected drugs. We investigated the relationship between identity and illness experience and found that illness does not simply dislocate one's biographical trajectory. For women who used drugs the shared symbolism of HCV infection was understood and accepted via a self-identity linked to poverty and experience of injecting drugs. Rather than disrupting their expected life trajectory, the narratives of most women incorporated the disease experience within their life story, confirming their identity as a person who injected drugs and as someone with constant and serious life stressors.

Assessing the cost-effectiveness of treating chronic hepatitis C virus in people who inject drugs in Australia

BACKGROUND AND AIM

To assess the cost-effectiveness of hepatitis C virus treatment with pegylated interferon alfa-2a and ribavirin in current and former people who inject drugs (PWID).

METHODS

A decision analytic model simulated the lifetime costs and outcomes of four treatment options: early treatment with mild fibrosis, standard treatment with moderate fibrosis, late treatment with compensated cirrhosis, and no treatment. Treatment modalities were simulated across current, former, and never-injector cohorts of 1000 hypothetical patients with chronic hepatitis C virus. The main outcome measures were incremental costs ($AUD) per quality-adjusted life years (QALYs) gained, and incremental cost-effectiveness ratios (ICERs) were calculated for each cohort.

RESULTS

Treatment of current PWID during mild fibrosis resulted in a discounted average gain of 1.60 QALYs (95% confidence interval 0.93-2.26) for an added cost of $12,723 ($11,153-$14,396) compared with no treatment, yielding an ICER of $7941 per QALY gained ($6347-$12,017). Former PWID gained 1.80 QALYs (1.29-2.33) for $10,441 ($8843-$12,074) for early treatment compared with no treatment, resulting in an ICER of $5808 per QALY gained ($5189-$6849). Never-injectors gained 2.33 QALYs (1.87-2.80) for $9290 ($7642-$10,912) compared with no treatment-an ICER of $3985 per QALY gained ($3896-$4080). Early treatment was more cost-effective than late treatment in all cohorts.

CONCLUSIONS

Despite comorbidities, increased mortality, and reduced adherence, treatment of both current and former PWID is cost-effective. Our estimates fall below the unofficial Australian cost-effectiveness threshold of $AUD 50,000 per QALY for public subsidies. Scaling up treatment for PWID can be justified on purely economic grounds.

Hepatitis C screening: getting it right

Hepatitis C is the most prevalent bloodborne viral disease in the United States and the deadliest. This year, the U.S. Preventive Services Task Force (USPSTF) will update its 2004 hepatitis C guideline, which recommends against screening asymptomatic adults for hepatitis C. This guideline has hampered public health efforts to encourage screening and identify and refer infected persons for care by declaring that such interventions were not supported by the evidence. A draft revision of the guideline, released on November 26, 2012, concludes that testing persons born between 1945 and 1965 probably has at least a small net benefit, but stops short of definitively recommending that this cohort be screened. This article examines the Task Force's process for writing its guidelines. It recommends that the Task Force adopt a balanced approach to evaluating the benefits and harms of screening; use the preponderance of the evidence as a standard for evaluating interventions that target serious public health problems; be transparent about the value judgments that go into its decisions; consider the wide variation in disease prevalence in diverse patient populations; and recommend screening asymptomatic adults for hepatitis C.

CONCLUSION

By taking a broader view of the evidence, the Task Force can write new guidelines that will serve efforts to curb the hepatitis C epidemic, rather than frustrate them.

Best strategies for global HCV eradication

Worldwide eradication of hepatitis C virus (HCV) is possible through a combination of prevention education, universal clinical and targeted community screening, effective linkage to care and treatment with promising new direct-acting antiviral drug regimens. Universal screening should be offered in all healthcare visits, and parallel community screening efforts should prioritize high-prevalence, high-transmission populations including injection drug users, prison inmates and those with HIV/HCV co-infection. Increasing awareness of HCV infection through screening, improving treatment uptake and cure rates by providing linkage to care and more effective treatment, and ultimately combining education efforts with vaccination campaigns to prevent transmission and reinfection can slow and eventually stop the 'silent epidemic'.

Concurrent group treatment for hepatitis C: implementation and outcomes in a methadone maintenance treatment program

Chronic hepatitis C virus (HCV) infection is highly prevalent among current and former drug users. However, the minority of patients enrolled in drug treatment programs have initiated HCV treatment. New models are needed to overcome barriers to care. In this retrospective study, we describe the implementation and outcomes of 42 patients treated in a concurrent group treatment (CGT) program. Patients participated in weekly provider-led group treatment sessions which included review of side effects; discussion of adherence and side effect management; administration of interferon injections; brief physical examination; and ended with brief meditation. Of the first 27 patients who initiated CGT, 42% achieved a sustained viral response. In addition, 87% (13/15) of genotype-1 infected patients treated with direct acting antiviral agent achieved an undetectable viral load at 24 weeks. The CGT model may be effective in overcoming barriers to treatment and improving adherence and outcomes among patients enrolled in drug treatment programs.

Together … to take care: multidisciplinary management of hepatitis C virus treatment in randomly selected drug users with chronic hepatitis

Hepatitis C Virus (HCV) infection is treated with peg-interferon α2a or α2b and ribavirin. International studies show that drug user adherence to treatment is 40% to 60% and increases if the patient is in addiction treatment. The aim of the Together To Take Care (TTTC) study was to achieve better adherence to HCV therapy in randomly selected drug users, who are considered "difficult to treat." The secondary aim of the TTTC Study Group was to standardize a method for a multidisciplinary management of the liver disease in drug users. The TTTC group data were matched with a control group. Adherence: The 93.7% of patients followed therapy prescribed; of the patients infected by HCV genotype (gt) 3, all completed therapy as scheduled. For the 48-week treatment group, 66.7% of patients completed therapy (2 of 9 patients stopped treatment for breakthrough). Toxicological results: 10 (62.5%) patients were negative in the toxicological tests (opiates, cocaine, and alcohol). Virological results: 8 of 16 patients were infected by HCV gt 1, and 8 were infected by gt 3; 2 of 16 (12.5%) patients were human immunodeficiency virus (HIV) coinfected (1 HCV gt 1a and 1 HCV gt 3). All patients: 11 of 16 (68.75%) patients were HCV ribonucleic acid undetectable 24 weeks after completing therapy (sustained virological response, SVR). Gt 1: 4 of 8 (50.0%) showed SVR. Gt 3: 7 of 8 (87.5%) showed SVR. Overall, the HCV gt 3 patients had 87.5% probability of SVR, whereas gt 1 patients had 50% probability of SVR (gt 3/gt 1 patients odds ratio = 7). The results were analyzed by Fisher exact test. Our results show that good healthcare management plays an important role in increasing patients' adherence to therapy. In the project "TTTC," the patients work with the physicians to take responsibility for their health and acquire self-efficacy and self-awareness, thanks to the special care.

Intravenous drug use: not a barrier to achieving a sustained virological response in HCV infection

Hepatitis C virus (HCV) is commonly transmitted by intravenous drug use (IDU) but drug users are under represented in many treatment cohorts, this is because of the assumption of lowered treatment success. We assessed HCV treatment outcomes in active intravenous drug users and patients on opiate substitution therapy. The Tayside HCV treatment database was retrospectively analysed for consecutively treated patients based on risk factor for acquisition of HCV. Primary end point was sustained virological response (SVR). Two hundred and ninety-one consecutively treated patients were assessed. The overall SVR rate was 55.3%. The SVR rates by risk factor were; Non-IDU 61.4%, Ex-IDU 54.8% and Active IDU 47.1% (P = n/s). In the groups G1 patients SVR was; Non-IDU 52.7%, Ex-IDU 30.7% and active IDU 35.4% (P = n/s). In the non-G1 patients: non-IDU 65.1%, Ex-IDU 76.7% and active IDU 53.5%. Ex-IDU had a significantly better SVR than active IDU, other differences were not significant. Our results demonstrate that SVR rates in the active drug users and those on opiate substitution therapy can be achieved which are comparable with non-IDU infected individuals. Intravenous drug use in those engaged with treatment services should not be seen as a barrier to treatment of HCV.

Cost-effectiveness of hepatitis C virus antiviral treatment for injection drug user populations

Injecting drug use is the main risk of hepatitis C virus (HCV) transmission in most developed countries. HCV antiviral treatment (peginterferon-α + ribavirin) has been shown to be cost-effective for patients with no reinfection risk. We examined the cost-effectiveness of providing antiviral treatment for injecting drug users (IDUs) as compared with treating ex/non-IDUs or no treatment. A dynamic model of HCV transmission and disease progression was developed, incorporating: a fixed number of antiviral treatments allocated at the mild HCV stage over 10 years, no retreatment after treatment failure, potential reinfection, and three baseline IDU HCV chronic prevalence scenarios (20%, 40%, and 60%). We performed a probabilistic cost-utility analysis estimating long-term costs and outcomes measured in quality adjusted life years (QALYs) and calculating the incremental cost-effectiveness ratio (ICER) comparing treating IDUs, ex/non-IDUs, or no treatment. Antiviral treatment for IDUs is the most cost-effective option in the 20% and 40% baseline chronic prevalence settings, with ICERs compared with no treatment of £ 521 and £ 2,539 per QALY saved, respectively. Treatment of ex/non-IDUs is dominated in these scenarios. At 60% baseline prevalence, treating ex/non-IDUs is slightly more likely to be the more cost-effective option (with an ICER compared with no treatment of £ 6,803), and treating IDUs dominated due to high reinfection. A sensitivity analysis indicates these rankings hold even when IDU sustained viral response rates as compared with ex/non-IDUs are halved.

CONCLUSION

Despite the possibility of reinfection, the model suggests providing antiviral treatment to IDUs is the most cost-effective policy option in chronic prevalence scenarios less than 60%. Further research on how HCV treatment for injectors can be scaled up and its impact on prevalence is warranted.

A randomized controlled trial of an integrated care intervention to increase eligibility for chronic hepatitis C treatment

OBJECTIVES

Mental health and substance abuse (MH/SA) comorbidities are the most oft-cited reasons for deferral from peginterferon (PegIFN) therapy for chronic hepatitis C virus (HCV). We sought to determine whether an integrated care intervention (INT) for patients deferred from PegIFN owing to MH/SA could improve subsequent treatment eligibility rates.

METHODS

In this randomized controlled trial, 101 HCV patients who were evaluated at two hepatology centers and deferred from antiviral therapy owing to MH/SA were enrolled. Participants were randomized to an INT (N=50) or standard of care (SC; N=51). The INT group received counseling and case management for up to 9 months. All participants underwent 3-, 6-, and 9-month clinical follow-up visits, where hepatologists, masked to group, re-evaluated patients for treatment eligibility. Standardized mood and alcohol use instruments were administered to all participants to aid clinicians in treatment decisions.

RESULTS

Of 101 participants, the mean age was 48 years and 50% were men, 61% Caucasian, and 77% genotype 1. Patients were initially deferred owing to psychiatric issues (35%), alcohol abuse (31%), drug abuse (9%), or more than one of these reasons (26%). In an intent-to-treat analysis, 42% (21/50) of INT participants became eligible for therapy compared to 18% (9/51) of SC participants (P=0.009, relative risk (RR)=2.38, 95% confidence interval (CI) (1.21, 4.68)). When baseline predictors significant at P<0.10 in univariate models were entered into multivariate models adjusted for treatment group, only baseline depression remained significant (P=0.05, RR=0.98, 95% CI (0.96, 1.00)). With the exception of a model adjusted for genotype, treatment group remained significant in all models.

CONCLUSIONS

This trial suggests that INTs can increase eligibility for HCV treatment and expand treatment to the underserved population with MH/SA comorbidities.

Addressing the HIV-related needs of substance misusers in New York State: the benefits and barriers to implementing a "one-stop shopping" model

Substance misusers are at risk for contracting HIV/AIDS, and substance user treatment programs (SUTPs) are uniquely situated to address their HIV-related needs. In New York State, some SUTPs have implemented a centralized model of substance user treatment and HIV care. We synthesize past literature and use data from semistructured interviews with SUTP staff, analyzed with qualitative software, to describe implementation barriers. These interviews were conducted in 2003-2004 at three SUTPs in Texas and New York as part of a study funded by the National Institutes of Health. With study limitations noted, main implications include a need for a combined medical-addiction treatment philosophy to facilitate multidisciplinary care.

Notions of Injecting Drug Users' Candidacy for Hepatitis C Treatment: Conflicting Provider, Patient, and Public Health Perspectives

Uptake of hepatitis C treatment by injecting drug users (IDUs) remains low and little is known about factors influencing treatment uptake by ethnic minority groups. The influence of notions of “candidacy” on “accomplishing” access to antiviral treatment are explored using data from an ethnographic study. Fieldwork and in-depth interviews were conducted with 72 Indo-Chinese IDUs. Cultural contexts, everyday realities of drug use and marginalization, and disengagement from the health system produced notions of candidacy in participants' local worlds. Among the minority assessed for treatment, adjudications of candidacy were perceived to be influenced by power dynamics. Demonstrating abstinence from drug use was understood to be central to establishing legitimate claims for candidacy, suggesting conflicting provider, patient, and public health perspectives. Further research is needed to identify drivers of institutional notions of candidacy and determine ways to ensure these do not produce discriminatory practices and policies that exclude and disadvantage particular groups.

Infectious disease comorbidities adversely affecting substance users with HIV: hepatitis C and tuberculosis

The linkage between drug use, particularly injection drug use, and HIV/AIDS, hepatitis C (HCV), and tuberculosis (TB) has been recognized since the beginning of the HIV pandemic. These comorbid conditions affect drug users worldwide and act synergistically, with resultant adverse biologic, epidemiologic, and clinical consequences. Prevention, care, and treatment of TB and HCV can be successful, and both diseases can be cured. Special clinical challenges among drug users, however, can result in increased morbidity, mortality, and decreased therapeutic success. Among these are limited disease screening, inadequate and insensitive diagnostics, difficult treatment regimens with varying toxicities, and complicated pharmacokinetic and pharmacodynamic drug interactions. These may result in delayed diagnosis, deferred treatment initiation, and low completion rates, with the potential for generation and transmission of drug resistant organisms. Strategies to address these challenges include outreach programs to engage substance abusers in nonmedical settings, such as prisons and the streets, active screening programs for HIV, HCV, and TB, increased and broadened clinician expertise, knowledge and avoidance of drug interactions, attention to infection control, use of isoniazid preventive therapy, and creative strategies to insure medication adherence. All of these require structural changes directed at comprehensive prevention and treatment programs and increased collaboration and integration of needed services for substance abusers.

Hepatitis C treatment eligibility and comorbid medical illness in methadone maintenance (MMT) and non-MMT patients: a case-control study

Comorbid medical illness is common in patients with chronic hepatitis C (HCV) infection and in methadone treatment (MMT) patients, yet little is known about the impact of medical illness on HCV treatment eligibility. Medical illness and HCV treatment eligibility were compared in a case-control study of 80 MMT patients entering an HCV treatment trial and 80 matched non-MMT patients entering HCV treatment in a gastroenterology clinic. 91% of MMT and 85% of non-MMT patients had chronic medical conditions. Despite similar medical severity ratings, a significantly higher proportion (77%) of non-MMT patients were eligible for HCV treatment than were MMT patients (56%) (p<.01). Specific comorbid medical and psychiatric illness led to ineligibility in only 18% of MMT and 16% of non-MMT patients. However, failure to complete the medical evaluation process was significantly (p<.001) more likely to cause ineligibility among MMT patients (19%) than non-MMT patients (0%).

Optimal targeting of Hepatitis C virus treatment among injecting drug users to those not enrolled in methadone maintenance programs

BACKGROUND

This work used mathematical modelling to explore effective policy for Hepatitis C virus (HCV) treatment in Australia in the context of methadone maintenance treatment (MMT).

METHOD

We consider two models to depict HCV in the population of injecting drug users (IDU) within Australia. The first model considers the IDU population as a whole. The second model includes separate components for those that are or are not enrolled in MMT. The impact of different levels of HCV treatment and its allocation dependent on MMT status were then determined in terms of the steady state levels of each of these models.

RESULTS

Although increasing levels of HCV treatment decrease chronic infection prevalence, initially numbers of acutely infected can rise. This is caused by the high rate of reinfection. We find that no matter the extent of HCV treatment, HCV prevalence cannot be eliminated without limiting risk behaviour. Assuming equal adherence to HCV therapy between MMT and non-MMT, over 84% of HCV treatment should be allocated to those not in MMT. Only if adherence to HCV therapy in non-MMT patients falls below 44% of that in MMT then treatment should be preferentially directed to those in MMT.

CONCLUSIONS

Contrary to generally held beliefs regarding HCV treatment the majority of therapy should be allocated to those that are still actively injecting. This is due to rates of reinfection and to the high turnover of individuals in MMT. Higher adherence to HCV therapy in MMT would need to be achieved before this changed.

Cost effectiveness and quality of life considerations in the treatment of hepatitis C infection

Chronic hepatitis C1 is a common cause of liver disease worldwide. It is a slow and progressive condition which can lead to decompensated cirrhosis and hepatocellular carcinoma. Hepatitis C virus1 impairs quality of life (QOL) even in the absence of chronic liver disease, but its relative silent nature can lead to a delay in diagnosis. The current standard of care of treatment is pegylated interferon and ribavarin. This achieves a sustained virological response (SVR), which is a cure of infection, in up to 80% of patients depending on viral genotype. The attainment of SVR improves survival, avoids long-term complications, and improves QOL. But treatment is not only expensive; there are issues of tolerability and adverse effects. This has led to a multitude of cost effective analysis and health technology assessment on HCV treatment. This overview discusses the natural history of the virus infection and its effect on the patients’ QOL. It focuses on the treatment options available, their efficacy, and cost effectiveness. It reviews the evaluations that suggest combination therapy is cost effective and explores the assumptions and limitations of these studies in real world treatment arenas.

Upregulation of SOCS-3 and PIAS-3 impairs IL-12-mediated interferon-gamma response in CD56 T cells in HCV-infected heroin users

Background

CD56⁺ T cells are abundant in liver and play an important role in host innate immunity against viral infections, including hepatitis C virus (HCV) infection, a common infection among heroin abusers. We thus investigated the in vivo impact of heroin use or heroin use plus HCV infection on the CD56⁺ T cell frequency and function.

Methodology/Principal Findings

A total of 37 heroin users with (17) or without (20) HCV infection and 17 healthy subjects were included in the study. Although there was no significant difference in CD56⁺ T cell frequency in PBMCs among three study groups, CD56⁺ T cells isolated from the heroin users had significantly lower levels of constitutive interferon-gamma (IFN-γ) expression than those from the normal subjects. In addition, when stimulated by interleukin (IL)-12, CD56⁺ natural T cells from HCV-infected heroin users produced significantly lower levels of IFN-γ than those from the normal subjects. This diminished ability to produce IFN-γ by CD56⁺ T cells was associated with the increased plasma HCV viral loads in the HCV-infected heroin users. Investigation of the mechanisms showed that although heroin use or heroin use plus HCV infection had little impact on the expression of the key positive regulators (IL-12 receptors, STAT-1, 3, 4, 5, JAK-2, and TYK-2) in IL-12 pathway, heroin use or heroin use plus HCV infection induced the expression of suppressor of cytokine signaling protein-3 (SOCS-3) and protein inhibitors of activated STAT-3 (PIAS-3), two key inhibitors of IL-12 pathway.

Conclusion/Significance

These findings provide compelling in vivo evidence that heroin use or heroin use plus HCV infection impairs CD56⁺ T cell-mediated innate immune function, which may account for HCV infection and persistence in liver.

Methadone maintenance patients' knowledge, attitudes, beliefs, and experiences concerning treatment for hepatitis C virus infection

Hepatitis C virus (HCV) knowledge, attitudes, beliefs, and experiences (KABE) of 64 HCV antibody positive methadone maintenance treatment (MMT) patients were assessed in conjunction with acceptability of an on-site semi-structured HCV education session, HCV RNA diagnostic testing, HCV treatment motivational assessment, and initiation of HCV treatment. The KABE interviews were conducted in 2006 and 2007 in an urban New York State MMT clinic in affiliation with a NIDA-funded HCV research project. The majority had basic knowledge of HCV disease, but poor understanding of HCV testing and treatment. While the majority of participants expressed fear of HCV treatment side effects, 88% accepted HCV RNA testing and 78% expressed willingness to start HCV treatment with the majority of chronically infected choosing to start HCV treatment medications. Study limitations and implications are discussed.

Peginterferon/ribavirin treatment achieves a higher compliance rate than interferon/ribavirin combination in patients chronically infected with HCV on methadone maintenance

INTRODUCTION

Chronic hepatitis C virus infection (HCV) is the most common infectious disease among intravenous drug users.

AIMS

To determine and compare compliance rates between two groups of chronic HCV patients from the methadone substitution program of the National Greek Organization Against Drugs treated with either pegylated interferon alpha-2b/ribavirin or with interferon alpha-2b/ribavirin during 48 weeks of therapy and 24 weeks of follow-up. Furthermore, to evaluate the efficacy of each treatment modality.

METHODS

Forty-five consecutive methadone maintenance (MM) patients (group A, 36 males, nine females) were treated with pegylated interferon alpha-2b (weight-based dosing 1.5 microg/kg/week) and ribavirin 1000-1200 mg/day orally. Sixty-five consecutive MM patients (group B, 52 males, 13 females) were treated with interferon alpha-2b (6 MIU, three times/week) and ribavirin with the doses reported above. During the study, all patients were followed up periodically by hepatologists, internists, and psychiatrists.

RESULTS

Baseline characteristics were similar between the two groups. Thirty-four out of 45 patients (75.6%) from group A and 31 of 65 patients (47.7%) from group B completed therapy (P =0.006). Thirty-two (71.1%) patients from group A and 27 patients (41.5%) from group B were followed-up until the end of week 72 (P = 0.004). At the end of the follow-up, sustained virologic response was achieved in 23 of 45 (51.1%) patients from group A and 21 of 65 patients (32.3%) from group B (P =0.075).

CONCLUSION

Pegylated interferon alpha-2b/ribavirin treatment achieved a significantly higher compliance rate than interferon alpha-2b/ribavirin in MM patients with chronic HCV infection. After 24 weeks of follow-up, response rates were similar for patients who were compliant to treatment for both groups.

[Management of patients with hepatitis C by French psychologists and psychiatrists: a practical investigation]

INTRODUCTION

A first part of this survey showed that up to 19% of patients with hepatitis C virus did not receive optimal treatment because of a psychiatric problem (psychiatric disorders or addictive behaviours) and that less than 50% of the managing clinicians worked with a psychiatrist or a psychologist in these cases. The aim of the second part of the survey was to describe the current practices provided by the psychiatrists and the psychologists to HCV infected patients as well as the knowledge and expectations of professionals in this area.

PATIENTS AND METHODS

Forty-seven psychiatrists and 43 psychologists who were or were not working with French reference poles for hepatitis C virus responded to a questionnaire of their practices.

RESULTS

Analysis of the 90 questionnaires showed that psychiatric and/or psychological care was not systematic. Psychiatrists and psychologists should be given more information and specific training about this topic.

CONCLUSION

Psychiatric and psychological care of chronic hepatitis C virus infected patients should be improved. French reference poles should also become "references" for psychiatric care.

Factors influencing long-term changes in mental health after interferon-alpha treatment of chronic hepatitis C

BACKGROUND

Antiviral treatment with interferon-alpha (IFN-alpha) is associated with several acute psychiatric side effects. Little is known about long-term effects on mental health after treatment independent from viral response and the influence of pre-existing psychiatric risk-factors.

AIM

To evaluate long-term effects of antiviral treatment with interferon-alpha (IFN-alpha) on mental health in patients with psychiatric risk factors.

METHOD

We prospectively investigated long-term mental health changes in 81 hepatitis C virus-infected patients. Psychiatric outcome was measured with the Montgomery-Asberg Depression Scale (MADRS), Brief Psychiatric Rating Scale, the Global Social Functioning Scale and the Global Clinical Impression Scale 6 months after the end of antiviral treatment with IFN-alpha and ribavirin.

RESULTS

Six months after antiviral therapy, 49% of the patients showed a worsening and 27.2% an improvement of depression scores. The most important predictor for a long-term improvement of depression scores was a pre-treatment MADRS score > or =5 (OR 14.21, 95% CI: 2.51-81.30). Patients with pre-existing psychiatric disorders (OR = 0.117, 95% CI: 0.024-0.558), methadone substitution (OR = 0.20, 95% CI: 0.045-0.887) or genotype 2/3 (OR = 0.341, 95% CI: 0.138-0.845) were significantly less likely to show a long-term worsening of depressive symptoms.

CONCLUSIONS

Pre-existing psychiatric risk factors increase the chance for a long-term improvement and reduce the risk for a long-term worsening of mental health after antiviral treatment of chronic hepatitis C with IFN-alpha.

Antiviral completion rates and sustained viral response in hepatitis C patients with and without preexisting major depressive disorder

BACKGROUND

Despite evidence suggesting that the majority of patients with hepatitis C virus (HCV) have psychiatric and substance use disorders, patients with these comorbidities have historically been excluded from antiviral therapy for HCV.

OBJECTIVE

The authors compared antiviral completion and sustained virologic response (SVR) rates between hepatitis C (HCV) patients with versus those without preexisting major depressive disorder (MDD).

METHOD

The authors performed a chart review of HCV patients (30 with MDD and 25 control subjects) who attended an optional HCV education class and signed informed consent allowing collection of clinical data.

RESULTS

The MDD group had completion and SVR rates similar to those of control subjects. Neuropsychiatric side effects and reasons for discontinuation of treatment were not different between groups.

CONCLUSION

Patients with MDD can be safely and effectively treated with antiviral therapy.

Psychiatric problems in patients infected with hepatitis C before and during antiviral treatment with interferon-alpha: a review

OBJECTIVE

Neuropsychiatric symptoms are common in patients with chronic hepatitis C (CHC) and can potentially be exacerbated by interferon-alpha treatment. Such symptoms can contribute to problems with treatment adherence, which can significantly compromise epidemiological virus control. This review summarizes current knowledge about the etiology, course, and management of neuropsychiatric symptoms in patients with CHC.

METHOD

Studies were identified using computerized searches, with further references obtained from the bibliographies of the reviewed articles.

RESULTS

Psychopathological syndromes that occur during interferon-alpha treatment frequently have atypical features that may complicate their recognition using standard diagnostic criteria. In addition, prospective studies in this area often exclude patients with psychiatric disorders and have methodological disparities that make it difficult to develop guidelines for management of psychiatric side effects induced by interferon-alpha. Despite the high prevalence of chronic hepatitis C virus (HCV) infection in patients with psychiatric and substance use disorders, neuropsychiatric concerns often lead to the exclusion of such patients from interferon-alpha treatment, inappropriately depriving them of the potential benefits of this therapy.

CONCLUSION

Consultation-liaison psychiatrists should become familiar with the clinical spectrum of presentations associated with HCV infection as well as with related neuropsychiatric symptoms in order to promote the creation of multidisciplinary teams who specialize in the care of patients with HCV infections. More studies are needed to define neuropsychiatric syndromes that can be induced by interferon-alpha and to clarify best assessment and treatment procedures for these syndromes. It is also important to create and evaluate psychoeducational programs for all patients with chronic HCV infections, even those with low risk of complications, in order to promote adherence to therapy and optimize patients' quality of life.