What is the cost-effectiveness of hepatitis C treatment for injecting drug users on methadone maintenance in New Zealand?

A Systematic Review of Simulation Models to Track and Address the Opioid Crisis

The opioid overdose crisis is driven by an intersecting set of social, structural, and economic forces. Simulation models offer a tool to help us understand and address this complex, dynamic, and nonlinear social phenomenon. We conducted a systematic review of the literature on simulation models of opioid use and overdose up to September 2019. We extracted modeling types, target populations, interventions, and findings. Further, we created a database of model parameters used for model calibration, and evaluated study transparency and reproducibility. Of the 1,398 articles screened, we identified 88 eligible articles. The most frequent types of models were compartmental (36%), Markov (20%), system dynamics (16%), and Agent-Based models (16%). Over a third evaluated intervention cost-effectiveness (40%), and another third (39%) focused on treatment and harm reduction services for people with opioid use disorder (OUD). More than half (61%) discussed calibrating their models to empirical data, and 31% discussed validation approaches used in their modeling process. From the 63 studies that provided model parameters, we extracted the data sources on opioid use, OUD, OUD treatment, cessation/relapse, emergency medical services, and mortality parameters. This database offers a tool that future modelers can use to identify potential model inputs and evaluate comparability of their models to prior work. Future applications of simulation models to this field should actively tackle key methodological challenges, including the potential for bias in the choice of parameter inputs, investment in model calibration and validation, and transparency in the assumptions and mechanics of simulation models to facilitate reproducibility.

Is hepatitis C virus elimination possible among people living with HIV and what will it take to achieve it?

INTRODUCTION

The World Health Organization targets for hepatitis C virus (HCV) elimination include a 90% reduction in new infections by 2030. Our objective is to review the modelling evidence and cost data surrounding feasibility of HCV elimination among people living with HIV (PLWH), and identify likely components for elimination. We also discuss the real-world experience of HCV direct acting antiviral (DAA) scale-up and elimination efforts in the Netherlands.

METHODS

We review modelling evidence of what intervention scale-up is required to achieve WHO HCV elimination targets among HIV-infected (HIV+) people who inject drugs (PWID) and men who have sex with men (MSM), review cost-effectiveness of HCV therapy among PLWH and discuss economic implications of elimination. We additionally use the real-world experience of DAA scale-up in the Netherlands to illustrate the promise and potential challenges of HCV elimination strategies in MSM. Finally, we summarize key components of the HCV elimination response among PWLH.

RESULTS AND DISCUSSION

Modelling indicates HCV elimination among HIV+ MSM and PWID is potentially achievable but requires combination treatment and either harm reduction or behavioural risk reductions. Preliminary modelling indicates elimination among HIV+ PWID will require elimination efforts among PWID more broadly. Treatment for PLWH and high-risk populations (PWID and MSM) is cost-effective in high-income countries, but costs of DAAs remain a barrier to scale-up worldwide despite the potential low production price ($50 per 12 week course). In the Netherlands, universal DAA availability led to rapid uptake among HIV+ MSM in 2015/16, and a 50% reduction in acute HCV incidence among HIV+ MSM from 2014 to 2016 was observed. In addition to HCV treatment, elimination among PLWH globally also likely requires regular HCV testing, development of low-cost accurate HCV diagnostics, reduced costs of DAA therapy, broad treatment access without restrictions, close monitoring for HCV reinfection and retreatment, and harm reduction and/or behavioural interventions.

CONCLUSIONS

Achieving WHO HCV Elimination targets is potentially achievable among HIV-infected populations. Among HIV+ PWID, it likely requires HCV treatment scale-up combined with harm reduction for both HIV+ and HIV- populations. Among HIV+ MSM, elimination likely requires both HCV treatment and behaviour risk reduction among the HIV+ MSM population, the latter of which to date has not been observed. Lower HCV diagnostic and treatment costs will be key to ensuring scale-up of HCV testing and treatment without restriction, enabling elimination.

A systematic review of health economic models of opioid agonist therapies in maintenance treatment of non-prescription opioid dependence

BACKGROUND

Opioid dependence is a chronic condition with substantial health, economic and social costs. The study objective was to conduct a systematic review of published health-economic models of opioid agonist therapy for non-prescription opioid dependence, to review the different modelling approaches identified, and to inform future modelling studies.

METHODS

Literature searches were conducted in March 2015 in eight electronic databases, supplemented by hand-searching reference lists and searches on six National Health Technology Assessment Agency websites. Studies were included if they: investigated populations that were dependent on non-prescription opioids and were receiving opioid agonist or maintenance therapy; compared any pharmacological maintenance intervention with any other maintenance regimen (including placebo or no treatment); and were health-economic models of any type.

RESULTS

A total of 18 unique models were included. These used a range of modelling approaches, including Markov models (n = 4), decision tree with Monte Carlo simulations (n = 3), decision analysis (n = 3), dynamic transmission models (n = 3), decision tree (n = 1), cohort simulation (n = 1), Bayesian (n = 1), and Monte Carlo simulations (n = 2). Time horizons ranged from 6 months to lifetime. The most common evaluation was cost-utility analysis reporting cost per quality-adjusted life-year (n = 11), followed by cost-effectiveness analysis (n = 4), budget-impact analysis/cost comparison (n = 2) and cost-benefit analysis (n = 1). Most studies took the healthcare provider's perspective. Only a few models included some wider societal costs, such as productivity loss or costs of drug-related crime, disorder and antisocial behaviour. Costs to individuals and impacts on family and social networks were not included in any model.

CONCLUSION

A relatively small number of studies of varying quality were found. Strengths and weaknesses relating to model structure, inputs and approach were identified across all the studies. There was no indication of a single standard emerging as a preferred approach. Most studies omitted societal costs, an important issue since the implications of drug abuse extend widely beyond healthcare services. Nevertheless, elements from previous models could together form a framework for future economic evaluations in opioid agonist therapy including all relevant costs and outcomes. This could more adequately support decision-making and policy development for treatment of non-prescription opioid dependence.

Prioritization of HCV treatment in the direct-acting antiviral era: An economic evaluation

BACKGROUND & AIMS

We determined the optimal HCV treatment prioritization strategy for interferon-free (IFN-free) HCV direct-acting antivirals (DAAs) by disease stage and risk status incorporating treatment of people who inject drugs (PWID).

METHODS

A dynamic HCV transmission and progression model compared the cost-effectiveness of treating patients early vs. delaying until cirrhosis for patients with mild or moderate fibrosis, where PWID chronic HCV prevalence was 20, 40 or 60%. Treatment duration was 12weeks at £3300/wk, to achieve a 95% sustained viral response and was varied by genotype/stage in alternative scenarios. We estimated long-term health costs (in £UK=€1.3=$1.5) and outcomes as quality adjusted life-years (QALYs) gained using a £20,000 willingness to pay per QALY threshold. We ranked strategies with net monetary benefit (NMB); negative NMB implies delay treatment.

RESULTS

The most cost-effective group to treat were PWID with moderate fibrosis (mean NMB per early treatment £60,640/£23,968 at 20/40% chronic prevalence, respectively), followed by PWID with mild fibrosis (NMB £59,258 and £19,421, respectively) then ex-PWID/non-PWID with moderate fibrosis (NMB £9,404). Treatment of ex-PWID/non-PWID with mild fibrosis could be delayed (NMB -£3,650). In populations with 60% chronic HCV among PWID it was only cost-effective to prioritize DAAs to ex-PWID/non-PWID with moderate fibrosis. For every one PWID in the 20% chronic HCV setting, 2 new HCV infections were averted. One extra HCV-related death was averted per 13 people with moderate disease treated. Rankings were unchanged with reduced drug costs or varied sustained virological response/duration by genotype/fibrosis stage.

CONCLUSIONS

Treating PWID with moderate or mild HCV with IFN-free DAAs is cost-effective compared to delay until cirrhosis, except when chronic HCV prevalence and reinfection risk is very high.

A systematic review of modelling approaches in economic evaluations of health interventions for drug and alcohol problems

Background

The overarching goal of health policies is to maximize health and societal benefits. Economic evaluations can play a vital role in assessing whether or not such benefits occur. This paper reviews the application of modelling techniques in economic evaluations of drug and alcohol interventions with regard to (i) modelling paradigms themselves; (ii) perspectives of costs and benefits and (iii) time frame.

Methods

Papers that use modelling approaches for economic evaluations of drug and alcohol interventions were identified by carrying out searches of major databases.

Results

Thirty eight papers met the inclusion criteria. Overall, the cohort Markov models remain the most popular approach, followed by decision trees, Individual based model and System dynamics model (SD). Most of the papers adopted a long term time frame to reflect the long term costs and benefits of health interventions. However, it was fairly common among the reviewed papers to adopt a narrow perspective that only takes into account costs and benefits borne by the health care sector.

Conclusions

This review paper informs policy makers about the availability of modelling techniques that can be used to enhance the quality of economic evaluations for drug and alcohol treatment interventions.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1368-8) contains supplementary material, which is available to authorized users.

Viral hepatitis among drug users in methadone maintenance: associated factors, vaccination outcomes, and interventions

Drug users are at high risk of viral Hepatitis A, B, and C. The prevalence of Hepatitis A, Hepatitis B, and Hepatitis C, associated factors, and vaccine seroconversion among drug treatment program participants in a randomized controlled trial of hepatitis care coordination were examined. Of 489 participants, 44 and 47% required Hepatitis A/Hepatitis B vaccinations, respectively; 59% were Hepatitis C positive requiring linkage to care. Factors associated with serologic statuses, and vaccine seroconversion are reported; implications for strategies in drug treatment settings are discussed. Results suggest generalizable strategies for drug treatment programs to expand viral hepatitis screening, prevention, vaccination, and linkage to care.

Global systematic review of the cost-effectiveness of indigenous health interventions

BACKGROUND

Indigenous populations around the world have consistently been shown to bear a greater burden of disease, death and disability than their non-Indigenous counterparts. Despite this, little is known about what constitutes cost-effective interventions in these groups. The objective of this paper was to assess the global cost-effectiveness literature in Indigenous health to identify characteristics of successful and unsuccessful interventions and highlight areas for further research.

METHODS AND FINDINGS

A systematic review of the published literature was carried out. MEDLINE, PSYCINFO, ECONLIT, EMBASE and CINAHL were searched with terms to identify cost-effectiveness evaluations of interventions in Indigenous populations around the world. The WHO definition was followed in identifying Indigenous populations. 19 studies reporting on 27 interventions were included in the review. The majority of studies came from high-income nations with only two studies of interventions in low and middle-income nations. 22 of the 27 interventions included in the analysis were found to be cost-effective or cost-saving by the respective studies. There were only two studies that focused on Indigenous communities in urban areas, neither of which was found to be cost-effective. There was little attention paid to Indigenous conceptions of health in included studies. Of the 27 included studies, 23 were interventions that specifically targeted Indigenous populations. Outreach programs were shown to be consistently cost-effective.

CONCLUSION

The comprehensive review found only a small number of studies examining the cost-effectiveness of interventions into Indigenous communities around the world. Given the persistent disparities in health outcomes faced by these populations and commitments from governments around the world to improving these outcomes, it is an area where the health economics and public health fields can play an important role in improving the health of millions of people.

The long-term effectiveness of methadone maintenance treatment in prevention of hepatitis C virus among illicit drug users: a modeling study

Background:

Chronic infection with hepatitis C virus (HCV) is increasingly recognized as a major global health problem. Illicit injection drug use is an important risk factor for the rising hepatitis C virus (HCV) prevalence in IR Iran.

Objectives:

The objective of this study was to determine the long-term effectiveness (total quality adjusted life years (QALYs) gained) of methadone maintenance treatment (MMT program) in prevention of HCV infection among injecting drug users (IDUs).

Materials and Methods:

A number of Markov models were developed to model morbidity and mortality among IDUs. The input data used in modeling were collected by a self-reported method from 259 IDUs before registration and one year after MMT and also from previous studies. One way and probabilistic sensitivity analyses were done to show the effects of uncertainty in parameters on number of life years and QALYs saved. The expected consequences were estimated using a life-time time horizon for the two strategies including implementation and not implementation of the MMT program.

Results:

Our model estimated that total number of discounted life years lived per IDU with and without the MMT program would be 5.15 (5.05 - 5.25) and 4.63 (4.42 - 4.81), respectively. The model also estimated that total number of discounted QALYs lived per IDU with and without the MMT program would be 4.11 (3.86 - 4.41) and 2.45 (2.17 - 2.84). Simulation results indicated that all differences in life years and QALYs lived between the two strategies were statistically significant (p < 0.001). Based on our model, total discounted life years and QALYs saved in a cohort of 1000 IDUs were 1790 (1520 - 2090) and 1590 (1090- 2090), respectively.

Conclusions:

Considering the high prevalence of illicit injecting drug use in Iran and MMT effectiveness in prevention of HCV infection, it is necessary to develop MMT centers at regional and national levels.

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.

Evaluation of an integrated care service facility for people living with hepatitis C in New Zealand

INTRODUCTION

People living with hepatitis C are a highly marginalised population who may not readily access health care. Existing models of hepatitis C care may not meet the needs of these patients. This research evaluates the experiences of patients attending an innovative hepatitis C clinic that offers integrated care and service delivery.

METHOD

Surveys were completed by 120 clients and comprised of questions relating to changes in lifestyle habits since attending the clinic, hepatitis C knowledge, hepatitis C treatment and experiences with health care staff at the clinic.

RESULTS

The majority of respondents indicated that attendance at the clinic has provided them with the information to better manage their hepatitis C and had given them confidence to make lifestyle changes. Participants demonstrated a very high knowledge of hepatitis C and reported experiencing a less discriminatory environment at the clinic compared to other health care settings. Respondents who had been attending the clinic for more than 6 months were significantly more likely to indicate a desire to commence hepatitis C treatment over the next 5 years.

DISCUSSION

The findings point to the importance of integrated care in the community setting in providing clients with a positive experience of health care, which appears to increase their skills and desire to better manage their hepatitis C.

Cost effectiveness of hepatitis C-related interventions targeting substance users and other high-risk groups: a systematic review

BACKGROUND AND OBJECTIVE

In developed countries, injection drug users have the highest prevalence and incidence of hepatitis C virus (HCV) infection. Clinicians and policy makers have several options for reducing morbidity and mortality related to HCV infection, including preventing new infections, screening high-risk populations, and optimizing uptake and delivery of antiviral therapy. Cost-effectiveness analyses provide an estimate of the value for money associated with adopting healthcare interventions. Our objective was to determine the cost effectiveness of hepatitis C interventions (prevention, screening, treatment) targeting substance users and other groups with a high proportion of substance users.

METHODS

We conducted a systematic search of MEDLINE, EMBASE, CINAHL, HealthSTAR and EconLit, and the grey literature. Studies were critically appraised using the Drummond and Jefferson, Neumann et al. and Philips et al. checklists. We developed and applied a quality appraisal instrument specific to cost-effectiveness analyses of HCV interventions. In addition, we summarized cost-effectiveness estimates using a single currency and year ($US, year 2009 values).

RESULTS

Twenty-one economic evaluations were included, which addressed prevention (three), screening (ten) and treatment (eight). The quality of the analyses varied greatly. A significant proportion did not incorporate important aspects of HCV natural history, disease costs and antiviral therapy. Incremental cost-effectiveness ratios (ICERs) ranged from dominant (less costly and more effective) to $US603,352 per QALY. However, many ICERs were less than $US100,000 per QALY. Screening and treatment interventions involving pegylated interferon and ribavirin were generally cost effective at the $US100,000 per QALY threshold, with the exception of some subgroups, such as immune compromised patients with genotype 1 infections.

CONCLUSIONS

No clear consensus emerged from the studies demonstrating that prevention, screening or treatment provides better value for money as each approach can be economically attractive in certain subgroups. More high-quality economic evaluations of preventing, identifying and treating HCV infection in substance users are needed.

Clients' perceptions of opioid substitution treatment: an input to improving the quality of treatment

Despite the emphasis on providing high quality mental health and addiction treatment, there has been relatively little consideration given to examining clients' perceptions of addiction treatment (consumer satisfaction) as a quality improvement strategy. The present article reports on a survey of a representative sample of 93 clients receiving opioid substitution treatment (OST). Employed participants reported higher treatment satisfaction and a pattern of positive associations was found between satisfaction and general health, mental health, social functioning, lower methadone doses, and participants' ratings of their treatment progress. Lower satisfaction was associated with higher frequency of benzodiazepine use, and, for women, longer treatment duration. Māori participants rated their treatment progress as lower than that of non-Māori. Results strongly endorse recording participants' comments to provide a deeper understanding of survey item ratings. The study findings highlight the need for a research focus on the roles of mental health and other registered nurses who work with people receiving OST in specialist service and primary care settings, and endorse a partnership approach to future research in this area. The pattern of findings arising from this study suggests key strategies for improving the flexibility and client responsiveness of OST.

Consumer and treatment provider perspectives on reducing barriers to opioid substitution treatment and improving treatment attractiveness

In New Zealand approximately 4600 people receive opioid substitution treatment (OST) for opioid dependence, primarily methadone maintenance treatment. This study explored ways in which OST could be improved, given the significant waiting times for treatment. Two parallel surveys were conducted: 1) peer interviews with 85 regular daily or almost daily opioid drug users (51.8% receiving OST, 18.8% not currently receiving OST, and 29.4% never received OST) and; 2) a census of all 18 specialist OST service providers. When asked how OST might be improved, the four categories most commonly cited by the opioid users were 'better treatment by staff', 'more flexibility', 'better takeaway arrangements', and 'decreased waiting time'. Both opioid users and specialist services rated 'restricted takeaways' and 'having to go on a waiting list' in the top three perceived barriers to OST. Almost all services reported significant resource issues and barriers to the transfer of stable clients from specialist services to continuing treatment in primary care. The findings from this study indicate how OST can be made more accessible and attractive and thus achieve better uptake and retention.

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.

Long-term effectiveness and cost-effectiveness of antiviral treatment in hepatitis C

We systematically reviewed the evidence for long-term effectiveness and cost-effectiveness of antiviral treatment in patients with chronic hepatitis C. We performed a systematic literature search on the long-term effectiveness and cost-effectiveness of AVT in hepatitis C (1990-March 2007), and included health technology assessment (HTA) reports, systematic reviews, long-term clinical trials, economic studies conducted alongside clinical trials and decision-analytic modelling studies. All costs were converted to 2005euro. Antiviral therapy with peginterferon plus ribavirin in treatment-naïve patients with chronic hepatitis C was the most effective (3.6-4.7 life years gained [LYG]) treatment and was reasonably cost-effective (cost-saving to 84 700euro/quality adjusted life years [QALY]) when compared to interferon plus ribavirin. Some results also suggest cost-effectiveness (below 8400euro/(QALY) of re-treatment in nonresponders/relapsers. Results for patients with persistently normal alanine aminotransferase (ALT) levels or with special co-morbidities (e.g. HIV) or risk profiles were rare. We conclude that antiviral therapy may prolong life, improve long-term health-related quality-of-life and be reasonably cost-effective in treatment-naïve patients with chronic hepatitis C as well as in former relapsers/nonresponders. Further research is needed in patients with specific co-morbidities or risk profiles.

Relapse to Injecting Drug Use: A Hepatitis C Treatment Concern

In light of current initiatives to increase hepatitis C treatment uptake amongst current and former injectors, this article aims to explore the barriers and facilitators to treatment uptake from the patient's perspective. Semistructured interviews were conducted with people living with hepatitis C in Auckland, New Zealand and Sydney, Australia in 2004 and 2006. This article explores in detail one significant issue that has not so far been addressed in the social research literature about decision making for hepatitis C treatment. This is the concern expressed by a quarter of the 34 ex-injecting participants regarding the potential for hepatitis C treatment to cause a relapse to injecting drug use. The connection between hepatitis C treatment and relapse to injecting drug use is supported by a substantial clinical literature. Thus the proposed expansion of hepatitis C treatment into alcohol and other drug settings needs to be undertaken with caution.

Critical issues in the treatment of hepatitis C virus infection in methadone maintenance patients

AIMS

Hepatitis C virus (HCV) infection is a common chronic complication of injection drug use. Methadone maintenance programs contain large numbers of patients infected with HCV. This paper reviews HCV infection with emphasis on the medical care of HCV-infected, or HCV and human immunodeficiency virus co-infected, patients on methadone or buprenorphine maintenance.

METHODS

Literature searches using PubMed, PsycINFO and SocINDEX were used to identify papers from 1990-present on antiviral therapy for HCV in methadone maintenance patients and on liver transplantation in methadone maintenance patients.

RESULTS

Injection drug use is the most significant risk factor for HCV infection in most western countries. The prevalence of HCV antibody is high in injection drug users (53-96%) and in patients enrolled in methadone maintenance programs (67-96%). Studies of antiviral therapy for HCV in methadone maintenance patients show rates of sustained virological response (SVR), defined as negative HCV-RNA 24 weeks after the end of treatment, of 28-94%. In studies with contrast groups, no significant differences in SVR between methadone and contrast groups were found. Excellent completion rates of antiviral therapy (72-100%) were found in five of six studies. There are many barriers to methadone maintenance patients' receiving antiviral therapy, and research on overcoming barriers is discussed. Liver transplantation has been successful in methadone maintenance patients but has not been utilized widely.

CONCLUSION

High quality medical care for all aspects of HCV infection can be provided to methadone maintenance patients. The literature supports the effectiveness of such services, but the reality is that most patients do not receive them.

Controversies in and challenges to our understanding of hepatitis C

Discovered in 1989, the hepatitis C virus (HCV) continues to cause significant morbidity and mortality world-wide despite a huge research commitment to defining and understanding the virus and the disease it causes. This paper discusses a number of areas where progress in the management of the HCV have not kept pace with the scientific understanding of the HCV. It is suggested that in the fields of HCV prevention and providing access to treatment, practice falls short of what could be achieved. The role of alcohol in the pathogenesis of HCV liver injury is discussed. Discrimination against those with HCV infection and particularly those in prison settings fails to match good clinical practice. The complicated processes of sharing information between specialty groups is also discussed in an attempt to optimise knowledge dissemination in this field.

Treatment of hepatitis C virus infection in intravenous drug users

BACKGROUND

Hepatitis C virus (HCV) infection is common among intravenous drug users, and because of the long latent period, HCV liver disease is set to increase.

OBJECTIVES

We sought to examine practice guidelines regarding treatment of HCV in drug users and to review the evidence for current practices.

METHODS

A structured search of the Pubmed database, websites of the National Institute for Clinical Excellence and national and international expert groups and opinion of independent experts in the field.

RESULTS AND CONCLUSIONS

All those infected with HCV need to be assessed to ascertain whether they have active ongoing viral replication and the extent of liver damage. HCV-infected individuals should be educated about the modes of transmission and means of reducing the risk of infecting others. They should also be advised to avoid cofactors (especially alcohol) that accelerate the progression of liver disease. Specific treatment with antivirals can cause viral clearance and prevent the progression of liver disease. Therapy is effective in those on opiate-replacement treatments and also in motivated individuals who continue to use intravenous drugs. The decision whether to treat drug users should be made jointly by specialists in the management of viral hepatitis and addiction on a case-by-case basis. Current combination drug regimens are expensive but are claimed to be cost-effective, and are certainly much less costly than managing end-stage liver disease. In addition to satisfactory sustained viral response rates, other benefits such as a beneficial effect on drug habit, self-esteem and rehabilitation have been reported. Encouraging suitable drug users to take-up and comply with treatment seems to be more easily achieved in supportive drug dependency unit settings (rather than the more formal surroundings of a hospital clinic).