Successful integration of hepatitis C evaluation and treatment services with methadone maintenance. J Addict Med. 2010;4:20-26. [PMID: 20485532 DOI: 10.1097/adm.0b013e3181add3de]

Hepatitis C Cascade of Care in a Multidisciplinary Substance Use Bridge Clinic Model in Tennessee

Many barriers prevent individuals with substance use disorders from receiving hepatitis C virus (HCV) treatment. This study describes 96 patients with active HCV treated in an opioid use disorder bridge clinic model. Of 33 patients who initiated treatment, 25 patients completed treatment, and 13 patients achieved sustained virologic response.

Point-of-care HCV RNA testing improves hepatitis C testing rates and allows rapid treatment initiation among people who inject drugs attending a medically supervised injecting facility

BACKGROUND

To achieve hepatitis C virus (HCV) elimination targets, simplified care engaging people who inject drugs is required. We evaluated whether fingerstick HCV RNA point-of-care testing (PoCT) increased the proportion of clients attending a supervised injecting facility who were tested for hepatitis C.

METHODS

Prospective single-arm study with recruitment between 9 November 2020 and 28 January 2021 and follow-up to 31 July 2021. Clients attending the supervised injecting facility were offered HCV RNA testing using the Xpert® HCV Viral Load Fingerstick (Cepheid, Sunnyvale, CA) PoCT. Participants with a positive HCV RNA test were prescribed direct acting antiviral (DAA) therapy. The primary endpoint was the proportion of clients who engaged in HCV RNA PoCT, compared to a historical comparator group when venepuncture-based hepatitis C testing was standard of care.

RESULTS

Among 1618 clients who attended the supervised injecting facility during the study period, 228 (14%) engaged in PoCT. This was significantly higher than that observed in the historical comparator group (61/1,775, 3%; p < 0.001). Sixty-five (28%) participants were HCV RNA positive, with 40/65 (62%) receiving their result on the same day as testing. Sixty-one (94%) HCV RNA positive participants were commenced on DAA therapy; 14/61 (23%) started treatment on the same day as diagnosis. There was no difference in the proportion of HCV RNA positive participants commenced on treatment with DAA therapy when compared to the historical comparator group (61/65, 94% vs 22/26, 85%; p = 0.153). However, the median time to treatment initiation was significantly shorter in the PoCT cohort (2 days (IQR 1-20) vs 41 days (IQR 22-76), p < 0.001). Among participants who commenced treatment and had complete follow-up data available, 27/36 (75%) achieved hepatitis C cure.

CONCLUSIONS

HCV RNA PoCT led to a significantly higher proportion of clients attending a supervised injecting facility engaging in hepatitis C testing, whilst also reducing the time to treatment initiation.

Investigating hepatitis C screening among people receiving opioid agonist treatment: A retrospective audit study

Background

Estimates of the prevalence of hepatitis C virus (HCV) amongst people who inject drugs are in the range of 50%. Opioid Agonist Treatment (OAT) clinics have a large proportion of people who inject drugs. These clinics, therefore, present an excellent opportunity to identify and treat patients with HCV. Despite this, it remains unclear as to how well these clinics screen patients for HCV.

Aim

This study aims to quantify the rate of HCV screening of patients that enrolled into treatment at an OAT clinic attached to a large teaching hospital in NSW.

Methods

A retrospective audit of the electronic medical record of patients commencing OAT at the clinic was performed to determine the rate of HCV screening.

Findings

During the audit period, there were 99 episodes of care that involved the commencement of OAT at the clinic, for patients who had a history of injecting drugs. Successful screening for HCV occurred in 56% (55/99) of these episodes. Of those screened, 26% were ribonucleic acid positive. Analysis of demographics did not reveal a statistically significant difference between those that were screened and those that were not.

Discussion

This study revealed a suboptimal rate of HCV screening at the OAT clinic. To improve the screening rate, the clinic could consider providing dried blood spot testing at the initial nurse assessment or having a clinician capable of venepuncture at the clinic.

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

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

An on-site community-based model for hepatitis C screening, diagnosis, and treatment among people who inject drugs in Kerman, Iran: The Rostam study

BACKGROUND

People who inject drugs (PWID) are at high risk for hepatitis C virus (HCV) infection and its complications in many countries, including Iran. This pilot study aimed to evaluate the effect of a community-based HCV model of care on HCV testing and treatment initiation among PWID in Kerman, Iran.

METHODS

This study is part of the Rostam study and is a non-randomized trial evaluating the effect of on-site HCV- antibody rapid testing, venipuncture for HCV RNA testing, and treatment eligibility assessment on HCV testing and treatment initiation among PWID. Recruitment, interviews, and HCV screening, diagnosis, and treatment were all conducted at a community-based drop-in center (DIC) serving PWID clients.

RESULTS

A total of 171 PWID (median age of 39 years and 89.5% male) were recruited between July 2018 and May 2019. Of 62 individuals who were HCV antibody positive, 47 (75.8%) were HCV RNA positive. Of RNA-positive individuals, 36 (76.6%) returned for treatment eligibility assessment. Of all the 36 participants eligible for treatment, 34 (94.4%) initiated HCV antiviral therapy. A sustained virologic response at 12 weeks post-treatment was 76.5% (26/34) in the intention-to-treat (ITT group) analysis and 100% (23/23) in the per-protocol (PP group) analysis.

CONCLUSION

Our integrated on-site community-based HCV care model within a DIC setting suggested that HCV care including HCV testing and treatment uptake can be successfully delivered outside of hospitals or specialized clinics; a model which is more likely to reach PWID and can provide significant progress towards HCV elimination among this population.

Client resistance to hepatitis C treatment initiation in opioid agonist treatment clinics in Sydney, Australia: A qualitative study

INTRODUCTION

Opioid agonist treatment (OAT) clinics play a key role in achieving elimination of hepatitis C virus (HCV) globally. Previous research has identified barriers to HCV treatment uptake in OAT clinics; however, most studies were conducted prior to the introduction of direct-acting antiviral treatments (DAA). It remains unclear whether progress has been made in responding to barriers and what challenges persist in this setting.

METHODS

Semi-structured in-depth interviews were conducted with staff (n = 20) and clients (n = 15) in two OAT clinics in Sydney, Australia. Interviews were transcribed verbatim and analysed using constant comparative methods.

RESULTS

Despite progress in integrating hepatitis C care in the clinics, competing priorities, concerns about side-effects, distrust of staff, health problems and difficulties accessing testing and medication persisted as key reasons why clients had not initiated treatment. Most clients preferred to postpone treatment and focus on other priorities and some highlighted lack of medical evidence for urgent treatment. Pressure on services to achieve elimination targets within set time frames was a primary driver of repeated offers of treatment by staff and the framing of clients' preferences for postponing treatment, as a barrier.

DISCUSSION AND CONCLUSION

Current timelines for HCV elimination targets may have galvanised services into action but may have also created tensions at the coalface due to disparities between staff and clients' priorities. The involvement of peer workers and mechanisms to ensure continued follow up with clients about DAA treatments is required. Public health timelines for HCV elimination need to be informed by affected communities' priorities.

Optimizing HIV prevention and treatment outcomes for persons with substance use in Central Asia: what will it take?

Purpose of review

To summarize the status of HIV and substance use in Central Asia and discuss potential ways to move forward to effective epidemic control among people who inject drugs (PWID) in the region and beyond.

Recent findings

PWID and their partners remain the population most affected by HIV in Central Asia. Lack of effective substance use prevention and treatment options and limited involvement of PWID-led community-based organizations in HIV programs, combined with the requirement for official registration, stigma and discrimination of PWID, and criminalization of drug use remain key barriers to effective HIV prevention and treatment.

Summary

Sustainable HIV epidemic control among PWID will not be feasible without decriminalization of drug use, addressing stigma and discrimination and policy changes to enhance uptake of HIV-related prevention, treatment and support services by PWID. It is also critical to ensure adoption of innovations, particularly those that combine evidence-based biomedical, behavioral and structural interventions tailored to the needs of the PWID.

Hepatitis C Virus Treatment Status and Barriers among Patients in Methadone Maintenance Treatment Clinics in Guangdong Province, China: A Cross-Sectional, Observational Study

We aimed to evaluate the status and barriers related to hepatitis C virus (HCV) treatment among Chinese methadone maintenance treatment (MMT) clients, and the willingness and barriers of patients to accept directly observed treatment (DOT) service and oral direct-acting antivirals (DAAs). We conducted a cross-sectional survey from July to October 2017 in Guangdong Province, China, involving 678 HCV antibody-positive MMT patients. If they reported being infected with HCV, then their HCV treatment experience, willingness to use DOT and DAAs, along with any barriers, were collected. Logistic regression analysis was used to identify the correlates of initiating HCV treatment. Among those reporting HCV infection (54%, 366/678), 39% (144/366) initiated treatment; however, 38% (55/144) interrupted and 55% (79/135) delayed treatment for 15 months. Seventy-five percent (273/366) and 53% (195/366) were willing to use DOT and DAAs, respectively. Unaffordable medical costs and insignificant symptoms were the major barriers to HCV treatment and accepting DOT or DAAs. The lack of a stable residence, being a woman, and having ever injected drugs were all associated with a low probability of initiating treatment (p < 0.05). This study highlights a limited uptake of HCV treatment among MMT patients, and a need to strengthen the popularity of DOT and DAAs and integrate them into Chinese MMT clinics.

Temporal associations between medication adherence for patients with schizophrenia and opioid dependence: A 17-year Canadian Cohort Study

The current study investigated whether a previously reported beneficial effect of methadone maintenance therapy (MMT) on antiretroviral adherence is also present in relation to antipsychotic treatment for schizophrenia. Administrative data were linked over a 17-year period for 1996 people who were dually diagnosed with schizophrenia and opioid dependence and, as an indicator of further marginalization, experienced at least one episode of correctional supervision in British Columbia. Adherence was estimated using the medication possession ratio (MPR ≥ 0.80), calculated in each 120-day period beginning with the first date of concurrent use of MMT and antipsychotic medication. Generalized Estimating Equations were used to estimate the association between independent and dependent variables. The probability of antipsychotic adherence doubled in periods that were preceded by a period of MMT adherence (AOR: P: 2.07; 95% CI: 1.90-2.26). Subgroup and sensitivity analyses yielded results similar to those derived through the primary analysis, examining: conviction history; length of follow-up; initiation of MMT prior to antipsychotic induction; excluding participants who died during the study period; and restricted to participants who received methadone exclusively as part of a MMT program. Despite a strong temporal association between MMT and antipsychotic adherence, overall MPRs for both prescriptions remained <0.50 throughout the study period. Antipsychotic adherence was more than twice as likely following periods of adherence to MMT among dually-diagnosed patients. Research is needed to identify the conditions responsible for MMT adherence, and to further clarify the relationship between opioid agonist treatment and antipsychotic pharmacotherapy in this vulnerable and under-studied population.

The Hepatitis C Awareness Through to Treatment (HepCATT) study: improving the cascade of care for hepatitis C virus-infected people who inject drugs in England

BACKGROUND AND AIMS

Previous studies have shown low rates of diagnosis and treatment of hepatitis C virus (HCV) infection in people who inject drugs (PWID). Our aims were to test the effect of a complex intervention [Hepatitis C Awareness Through to Treatment (HepCATT)] in drug and alcohol clinics-primarily, on engagement of HCV-positive PWID with therapy and, secondarily, on testing for HCV, referral to hepatology services and start of HCV treatment.

DESIGN AND SETTING

A non-randomized pilot study in three specialist addiction clinics in England comparing an intervention year (starting between September 2015 and February 2016) with a baseline year (2014), together with three control clinics.

PARTICIPANTS

Analysis included all attendees at the intervention and control specialist addiction clinics identified as PWID.

INTERVENTION

The intervention comprised the placement of a half-time facilitator in each clinic for 12 months with the brief to increase diagnosis of HCV infection within clients at those services and the engagement of diagnosed individuals with an appropriate care pathway. The facilitator undertook various activities, which could include training of key workers, direct interaction with clients, streamlining and support for hepatology appointments and introduction of dried blood-spot testing.

MEASUREMENTS

For each clinic and period, we obtained the total number of clients and, as relevant, their status as PWID, tested for HCV, known HCV-positive, engaged with HCV therapy or treated.

FINDINGS

Compared with baseline, there was strong evidence that engagement with HCV therapy in the intervention year increased (P < 0.001) more in the HepCATT centres than controls, up ⁺ 31 percentage points [95% confidence interval (CI) = 19-43] versus -12 (CI = -31 to ⁺ 6) and odds ratio (OR) = 9.99 (CI = 4.42-22.6) versus 0.35 (CI = 0.08-1.56). HepCATT centres also had greater increases in HCV testing (OR = 3.06 versus 0.78, P < 0.001), referral to hepatology (OR = 9.60 versus 0.56, P < 0.001) and treatment initiation (OR = 9.5 versus 0.74, P < 0.001).

CONCLUSIONS

Introducing a half-time facilitator into drug and alcohol clinics in England increased engagement of HCV-positive people who inject drugs with hepatitis C virus care pathways, with increased uptake also of testing, referral to hepatology and initiation of treatment.

Integrated models of care for people who inject drugs and live with hepatitis C virus: A systematic review

BACKGROUND

Despite the key role that people who inject drugs (PWID) play in the hepatitis C virus (HCV) epidemic, HCV treatment rates among this population have been historically low. Integrated models of HCV and substance use care have the potential to overcome some barriers to access; however, the evidence base is uncertain. This systematic review assesses the impacts of integrated HCV and substance use services on engagement in HCV care among PWID.

METHODS

We searched five databases up to December 2018 to identify original quantitative studies evaluating the impacts of co-location of HCV and substance use services on engagement in the HCV cascade of care among adult PWID. We conducted a narrative synthesis, categorizing models based on patient entry point (a: HCV facility, b: substance use disorder (SUD) facility, and c: other facilities), and levels of integrated services offered (a: HCV/substance use testing only, b: HCV/substance use treatment, and c: testing/treatment + other services).

RESULTS

A total of 46 articles corresponding to 44 original studies were included. Almost all studies (n = 42) were conducted in high-income countries and only six studies in the Direct-Acting Antiviral (DAA) era. Twenty-six studies discussed the integration of services at SUD facilities, one at HCV facilities, and seventeen at other facilities. Analysis of included studies indicated that overall integrated care resulted in improved engagement in HCV care (e.g., testing, treatment uptake and cure). However, the quality of evidence was predominantly low to moderate.

CONCLUSIONS

Available evidence suggests that integration of HCV and substance use services may improve engagement along the continuum of HCV care among PWID. Given limitations in data quality, and very few studies conducted in the DAA era and in low- and middle-income settings, further research is urgently needed to inform strategies to optimize HCV care access and outcomes among PWID globally.

Intensive Models of Hepatitis C Care for People Who Inject Drugs Receiving Opioid Agonist Therapy: A Randomized Controlled Trial

BACKGROUND

Many people who inject drugs (PWID) are denied treatment for hepatitis C virus (HCV) infection, even if they are receiving opioid agonist therapy (OAT). Research suggests that HCV in PWID may be treated effectively, but optimal models of care for promoting adherence and sustained virologic response (SVR) have not been evaluated in the direct-acting antiviral (DAA) era.

OBJECTIVE

To determine whether directly observed therapy (DOT) and group treatment (GT) are more effective than self-administered individual treatment (SIT) in promoting adherence and achieving SVR among PWID receiving OAT.

DESIGN

Three-group, randomized controlled trial conducted from October 2013 to April 2017. (ClinicalTrials.gov: NCT01857245).

SETTING

Three OAT programs in Bronx, New York.

PARTICIPANTS

Persons aged 18 years and older with genotype 1 HCV infection who were willing to receive HCV therapy on site in the OAT program. Of 190 persons screened, 158 were randomly assigned to a study group and 150 initiated treatment: DOT (n = 51), GT (n = 48), and SIT (n = 51).

INTERVENTION

2 intensive interventions (DOT and GT) and 1 control condition (SIT).

MEASUREMENTS

Primary: adherence, measured by using electronic blister packs. Secondary: HCV treatment completion and SVR 12 weeks after treatment completion.

RESULTS

Mean age was 51 years; 65% of participants had positive results on urine drug testing during the 6 months before treatment, and 75% reported ever injecting drugs. Overall adherence, estimated from mixed-effects models using the daily timeframe, was 78% (95% CI, 75% to 81%) and was greater among participants randomly assigned to DOT (86% [CI, 80% to 92%]) than those assigned to SIT (75% [CI, 70% to 81%]; difference, 11% [CI, 5% to 18%]; Bonferroni-corrected P = 0.001). No significant difference in adherence was observed between participants randomly assigned to GT (80% [CI, 74% to 86%]) and those assigned to SIT (difference, 4.7% [CI, -2% to 11%]; Bonferroni-corrected P = 0.29). The HCV treatment completion rate was 97%, with no differences among groups (P = 0.53). Overall SVR was 94% (CI, 89% to 97%); the SVR rate was 98% in the DOT group, 94% in the GT group, and 90% in the SIT group (P = 0.152).

LIMITATION

These findings may not be generalizable to PWID not enrolled in OAT programs.

CONCLUSION

All models of onsite HCV care delivered to PWID in OAT programs resulted in high SVR, despite ongoing drug use. Directly observed therapy was associated with greater adherence than SIT.

PRIMARY FUNDING SOURCE

National Institute on Drug Abuse and Gilead Sciences.

HIV Serostatus and Having Access to a Physician for Regular Hepatitis C Virus Care Among People Who Inject Drugs

BACKGROUND

People who inject drugs (PWIDs) and who are living with HIV and hepatitis C virus (HCV) infection are vulnerable to a range of health-related harms, including liver cirrhosis, hepatocellular carcinoma, and death. There is limited evidence describing how HIV serostatus shapes access to a physician for regular HCV care among PWID.

SETTING

Data were collected through the Vancouver Injection Drug Users Study (VIDUS), the AIDS Care Cohort to evaluate Exposure to Survival Services (ACCESS), and the At-Risk Youth Study (ARYS), 3 prospective cohorts involving people who use illicit drugs in Vancouver, Canada, between 2005 and 2015.

METHODS

Using generalized estimating equations, we examined the relationship between HIV-seropositivity and having access to a physician for regular HCV care. We conducted a mediation analysis to examine whether this association was mediated by increased frequency of engagement in health care.

RESULTS

In total, 1627 HCV-positive PWID were eligible for analysis; 582 (35.8%) were HIV-positive at baseline; and 31 (1.9%) became HIV-positive during follow-up. In multivariable analyses, after adjusting for a range of confounders, HIV serostatus [adjusted odds ratio = 1.99; 95% confidence interval: 1.77 to 2.24] was significantly associated with having access to HCV care. Approximately 26% of the effect was due to mediation.

CONCLUSION

Our results demonstrate a positive relationship between HIV-seropositivity and having access to a physician for regular HCV care, which is partially explained through increased frequency of engagement in health care. These findings highlight the need to address patterns of inequality in access to HCV care among PWID.

Hepatitis C continuum of care and utilization of healthcare and harm reduction services among persons who inject drugs in Seattle

BACKGROUND

To describe the "continuum of care" for hepatitis C virus (HCV) and related health service utilization among persons who inject drugs (PWID) in the Seattle metropolitan area.

METHODS

The study analyzed data from the 2015 National HIV Behavioral Surveillance system focused on PWID, which included local questions on HCV treatment and testing. We calculated respondent driven sampling (RDS)-adjusted percentages of participants who had completed each step of the care continuum and compared healthcare harm reduction services among participants who were HCV + vs. HCV- using bivariate analyses.

RESULTS

513 PWID were screened for HCV antibodies (Ab). Of those, 59.7% were HCV Ab+. Among those HCV Ab+, 86.4% had been tested for HCV at least once; 69.9% reported a previous diagnosis. Of those diagnosed, 55.9% had received a confirmatory test, 17.2% had ever received any medications for HCV, and 7.2% had completed treatment. The majority of HCV Ab + participants had seen a health care provider in the past 12 months (85.6%).

CONCLUSIONS

There is a large gap between HCV screening and treatment among Seattle area PWID.

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.

Telementoring with project ECHO: a pilot study in Europe

The Extension of Community Healthcare Outcomes (ECHO) project is a novel educational intervention designed in New Mexico to transfer subspecialty knowledge about hepatitis C virus (HCV) to primary care providers, thereby increasing patient access to HCV care. The ECHO model has been shown to deliver educational benefits and to result in good treatment outcomes for HCV-infected individuals in the USA; however, this approach has not been assessed in a European setting.

We sought to evaluate the feasibility, acceptability and implementation of the ECHO model in Ireland using a pilot study. We present a descriptive review of recruitment, participation, retention and cost of the intervention as well as a qualitative review of the views of participants on the barriers, benefits and acceptability of the ECHO model. In the original Project ECHO in New Mexico, geographical distance posed the greatest barrier to accessing HCV care. In Ireland, people who inject drugs (PWID) were identified by interviewees as the main group facing barriers to accessing specialist HCV care. State-employed doctors and nurses caring for large numbers of HCV-infected PWID in opiate substitution treatment centres and homeless hostels were successfully recruited to participate in the project. Self-employed general practitioners did not participate, due mainly to a lack of time and the absence of reimbursement for participation. Practitioners who participated in the pilot reported benefits to themselves and their patients and would like to continue to participate in similar multidisciplinary, multisite educational interventions in the future.

A quasi-experimental evaluation of dried blood spot testing through community pharmacies in the Tayside region of Scotland

OBJECTIVE

Comparison of uptake of dried blood spot testing (DBST) for hepatitis C virus (HCV) infection between community pharmacies and established services.

DESIGN

Quantitative evaluation of a service development with qualitative process evaluation undertaken in parallel.

SETTING

Six pharmacies from 36 community pharmacies within Dundee City, a large urban settlement with high levels of socioeconomic deprivation.

PARTICIPANTS

Patients in receipt of opioid substitution therapy (OST) not tested for HCV within 12 months. The 6 pharmacies provided OST for approximately 363 patients from a cohort of 1385 patients within Dundee City.

INTERVENTION

Provision of DBST by pharmacists.

MAIN OUTCOME MEASURE

Receipt of DBST between January and December 2014.

RESULTS

43 of 143 service users with no record of testing from the 6 community pharmacies accepted DBST. Of 561 from the remaining 1022 service users with no record of testing, 75 were tested for HCV (30% vs 13%). The OR for increased uptake of testing within the 6 pharmacies was 2.25 (95% CI 1.48 to 3.41, Z statistic=3.81, p=<0.0001) compared with other services. The DBST taken by the pharmacies provided 12 patients with a reactive test. The process evaluation identified key themes important to staff and recipients of the service. A logic model was constructed.

LIMITATIONS

Non-experimental service evaluation performed in community pharmacies records service activity in one location across a single time period.

INTERPRETATION

Some evidence that DBST from community pharmacies may be feasible. Service users received the service positively. Staff reported that DBST was straightforward and achievable.

Tensions in relation: How peer support is experienced and received in a hepatitis C treatment intervention

BACKGROUND

Peer support and involvement is recognised as a vital component of hepatitis C (HCV) treatment provision for marginalised populations, such as people who inject drugs (PWID). Developments in HCV treatments enable increased provision in community settings - expanding the possibilities for meaningful peer involvement in HCV treatment plans. To date, HCV peer support has generally been viewed as a positive intervention, with little critical reflection on the ways social structures, policies, health and drug services and social identity impact on how peer support is experienced and received.

METHODS

We report on the qualitative component of a UK-based intervention designed to increase HCV diagnosis and treatment in primary care and drug treatment settings. Data were collected between 2014 and 2016. Pre-intervention, a total of 35 PWID clients took part in nine in-depth interviews and four focus groups. In addition, 22 drug services and intervention providers took part in two focus groups and nine interviews. Post-intervention, one focus group and eight interviews were conducted with 13 PWID clients, and four focus groups and ten interviews were conducted with 26 drug services and intervention providers. Our data generation and thematic analysis focused on the peer education and buddy support component of the intervention.

RESULTS

Participants had common expectations of the peer role (to 'just be there') and its occupants' attributes (empathy, trustworthy, etc.). However, in practice, peers faced constraints on realising these expectations. A 'recovery' dominated drug treatment ethos in the UK appeared to influence the selection of 'recovery champions' as peers for the intervention. This created tensions in relations with clients, particularly when risk-adverse discourses were internalised by the peers. Peers were poorly integrated and supported within the service, affecting opportunities to relate and build trust with clients. Thus, the scope for peer support to impact on the nature and extent of clients' testing and treatment for HCV was limited.

CONCLUSION

The efficacy of peer involvement can be constrained by organisational structures and boundaries - especially regarding who is deemed to be 'a peer'. Peer programmes take time and care to implement and weave into wider recovery and harm reduction frameworks.

Medical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection

Direct-acting antivirals for hepatitis C virus infection may revolutionize treatment among persons with substance use disorders. Despite persons with substance use disorders having the highest hepatitis C virus prevalence and incidence, the vast majority have not engaged into care for the infection. Previously, interferon-based treatments, with substantial side effects and the propensity to exacerbate mental health conditions, were major disincentives to pursuit of care for the infection. Direct-acting antivirals with viral eradication rates of >90%, significantly improved side effect profiles, and shorter treatment duration are dramatic improvements over prior treatment regimens that should promote widespread hepatitis C virus care among persons with substance use disorders. The major unmet need is strategies to promote persons with substance use disorders engagement into care for hepatitis C virus. Although physical integration of treatment for substance use and co-occurring conditions has been widely advocated, it has been difficult to achieve. Telemedicine offers an opportunity for virtual integration of behavioral and medical treatments that could be supplemented by conventional interventions such as hepatitis C virus education, case management, and peer navigation. Furthermore, harm reduction and strategies to reduce viral transmission are important to cease reinfection among persons with substance use disorders. Widespread prescription of therapy for hepatitis C virus infection to substance users will be required to achieve the ultimate goal of global virus elimination. Combinations of medical and behavioral interventions should be used to promote persons with substance use disorders engagement into and adherence with direct-acting antiviral-based treatment approaches. Ultimately, either physical or virtual colocation of hepatitis C virus and substance use treatment has the potential to improve adherence and consequently treatment efficacy.

Examination of the Hepatitis C Virus care continuum among individuals with an opioid use disorder in substance use treatment

BACKGROUND

Hepatitis C Virus (HCV) risk is elevated for individuals with an opioid use disorder (OUD). Routine HCV testing is recommended for high-risk individuals, including those with an injection drug use history. HCV antibody testing addresses the first step in the HCV treatment care cascade, with uptake and completion of HCV treatment among individuals with chronic HCV as the optimal care cascade endpoint. The aim of this study was to characterize self-reported HCV treatment cascade outcomes among individuals with an OUD in outpatient medication assisted treatment (MAT).

METHODS

Individuals receiving methadone or buprenorphine treatment (N=202, 67.8% female, M age=35.0, SD=8.4) completed a brief, anonymous paper-and-pencil survey examining self-reported history of HCV testing, diagnosis, and treatment. Descriptive statistics characterized HCV treatment cascade outcomes.

RESULTS

A majority (79.3%) endorsed a lifetime HCV testing history; 34.9% were tested for HCV during the past year. Of those with a lifetime HCV testing history, 42.7% indicated they have been told they have HCV (n=67/157), with 21% (n=14/67) of those individuals reporting that they have been told they have chronic HCV, and 71.4% (n=10/14) of those with chronic HCV reporting receipt of HCV treatment.

DISCUSSION

Results underscore gaps in the HCV care continuum among individuals with OUD in MAT. Interventions to increase uptake of HCV testing, communication of HCV diagnostic and treatment information by medical providers, linkage to HCV medical care, and uptake and adherence to HCV treatment are urgently needed, particularly among individuals with an OUD in MAT.

Behavioral and quality-of-life outcomes in different service models for methadone maintenance treatment in Vietnam

BACKGROUND

Integrating HIV/AIDS and methadone maintenance treatment (MMT) services with existing health care delivery system is critical in sustaining efforts to fight HIV/AIDS in large injection-driven epidemics. However, efficiency of different integrative service models is unknown. This study assessed behavioral and health-related quality-of-life (HRQOL) outcomes of MMT in four service delivery models and explored factors associated with these outcomes of interest.

METHODS

A cross-sectional survey was conducted in two HIV epicenters in Vietnam: Hanoi and Nam Dinh Province. All patients in five selected MMT clinics were invited to participate, and 1016 were interviewed (80-90% response rate).

RESULTS

Respondents had a mean age of 35.8, taken MMT for average 16.5 months and 3.3% on MMT for 36-60 months. The MMT integrated with rural district health center (DHC) has the highest prevalence of concurrent drug use (11.3%). The percentage of condom use (last sexual intercourse) with primary and casual partners was lowest in the MMT at urban DHCs. Patients at the rural DHC reported very high proportions of pain/discomfort (37.8%), anxiety/depression (43.1%), and mobility (13.3%). In regression models, poorer HRQOL outcomes were found in MMT models in the rural areas or without general health care, and among those patients who were HIV positive, reported concurrent drug use, and had higher numbers of previous drug rehabilitation episodes. Mobility and anxiety/depression are factors that increased the likelihood of concurrent drug use among MMT patients.

CONCLUSIONS

Outcomes of MMT were diverse across different integrative service models. Policies on rapid expansion of the MMT program in Vietnam should also emphasize on the integration with comprehensive health care services including psychological supports for patients.

Treatment for hepatitis C virus infection among people who inject drugs attending opioid substitution treatment and community health clinics: the ETHOS Study

AIMS

To estimate adherence and response to therapy for chronic hepatitis C virus (HCV) infection among people with a history of injecting drug use. A secondary aim was to identify predictors of HCV treatment response.

DESIGN

Prospective cohort recruited between 2009 and 2012. Participants were treated with peg-interferon alfa-2a/ribavirin for 24 (genotypes 2/3, G2/3) or 48 weeks (genotype 1, G1).

SETTING

Six opioid substitution treatment (OST) clinics, two community health centres and one Aboriginal community-controlled health organization providing drug treatment services in New South Wales, Australia.

PARTICIPANTS

Among 415 people with a history of injecting drug use and chronic HCV assessed by a nurse, 101 were assessed for treatment outcomes (21% female).

MEASUREMENTS

Study outcomes were treatment adherence and sustained virological response (SVR, undetectable HCV RNA >24 weeks post-treatment).

FINDINGS

Among 101 treated, 37% (n = 37) had recently injected drugs (past 6 months) and 62% (n = 63) were receiving OST. Adherence ≥ 80% was 86% (n = 87). SVR was 74% (75 of 101), with no difference observed by sex (males: 76%, females: 67%, P = 0.662). In adjusted analysis, age < 35 (versus ≥ 45 years) [adjusted odds ratio (aOR) = 5.06, 95% confidence interval (CI) = 1.47, 17.40] and on-treatment adherence ≥ 80% independently predicted SVR (aOR = 19.41, 95% CI = 3.61, 104.26]. Recent injecting drug use at baseline was not associated with SVR.

CONCLUSIONS

People with a history of injecting drug use and chronic hepatitis C virus attending opioid substitution treatment and community health clinics can achieve adherence and responses to interferon-based therapy similar to other populations, despite injecting drugs at baseline. Younger age and adherence are predictive of improved response to hepatitis C virus therapy.

Expanding capacity for hepatitis C treatment in the United States: team-based care and use of nonphysician providers

Hepatitis C treatment is rapidly evolving with significant improvements in patient outcomes. With an estimated prevalence of over 3 million persons living with chronic hepatitis C in the United States, it is anticipated that there will be an increase in the number of persons seeking care and treatment for chronic hepatitis C infection. Current systems of care may be overburdened with people seeking care for chronic hepatitis C virus (HCV). Interprofessional models of care have been shown to be feasible and effective in treating different populations affected by chronic HCV. Use of interprofessional teams, integrated models of care, and greater use of nonphysician providers offer a potential solution for expanding capacity to comprehensive HCV treatment and care in the United States.

Assessment and delivery of treatment for hepatitis C virus infection in an opioid substitution treatment clinic with integrated peer-based support in Newcastle, Australia

BACKGROUND

Among people who inject drugs (PWID), the prevalence of hepatitis C virus (HCV) infection is high; however HCV treatment uptake remains low. New models of care are needed to address the growing burden of HCV-related disease in PWID and to understand the barriers to assessment and treatment of HCV. This study evaluated assessment and treatment for HCV infection among PWID attending an opioid substitution treatment (OST) clinic with an integrated peer support worker model.

METHODS

Clients with a history of IDU and chronic HCV infection, attending the Newcastle Pharmacotherapy Service, Newcastle Australia, were recruited as part of a multisite prospective observational study (the ETHOS Cohort). Additional chart review was conducted for clients not enrolled in the ETHOS Cohort. A peer support worker was introduced to complement and extend services offered by the clinical team. Client contacts and assessments with a nurse and/or peer worker were evaluated, including those who commenced HCV treatment.

RESULTS

A total of 1447 clients attended the OST service during February 2009 and June 2014. Of these, 378 (26%) were assessed by a nurse and 242 (17%) by a clinician. HCV treatment was commenced by 20 (5%) participants and 15 (75%) achieved a sustained virological response (SVR). During May 2009 and July 2011, 332 nurse contacts and 726 peer worker contacts were evaluated. The nurse-led contacts were related to HCV treatment (50%) and review of pathology tests (34%), whereas peer worker contacts included discussion about HCV treatment (75%), education, counselling and/or support (53%) and general discussion about HCV infection (59%).

CONCLUSION

These data demonstrate that peer support workers facilitate broader discussion about HCV treatment, education and/or support, allowing nurses to focus on HCV-related assessment and treatment. HCV treatment uptake was very low in this cohort, but SVR was high. The integration of peer support workers in treatment programs within OST clinics may address barriers to HCV care, but further studies are needed to assess their impact on assessment and treatment outcomes.

Assessing the Long-Term Impact of Treating Hepatitis C Virus (HCV)-Infected People Who Inject Drugs in the UK and the Relationship between Treatment Uptake and Efficacy on Future Infections

Objective

The prevalence of the hepatitis C virus (HCV) remains high amongst people who inject drugs (PWID) and accounts for the majority of newly acquired infections. This study aims to quantify the value of treatment amongst PWID with more efficacious treatments and at increased uptake rates, with respect to the avoidance of future infections and subsequent long-term complications of HCV.

Methods

A dynamic HCV transmission and disease progression model was developed, incorporating acute and chronic infection and their long-term complications (decompensated cirrhosis, cancer, liver transplant and mortality), with the potential for HCV transmission to other PWID prior to successful treatment. The model was populated with prevalence and therapy data from a UK setting. Scenarios of current standard of care (SoC) treatment efficacy and uptake were compared to anticipated sustained virologic response (SVR) rates of 90–100% and increased uptake over varied horizons.

Results

SoC led to modest reductions in prevalence; >5% after 200 years. New treatments achieving 90% SVR could reduce prevalence below 5% within 60 years at current uptake rates or within 5 years if all patients are treated. Amongst 4,240 PWID, chronic HCV infections avoided as a result of increasing treatment uptake over the period 2015–2027 ranged from 20–580 and 34–912 with SoC and 90% SVR rates respectively. The reduction in downstream HCV infections due to increasing treatment uptake resulted in an approximate discounted gain of 300 life-years (from avoiding reduced life expectancy from HCV infection) and a gain of 1,700 QALYs (from avoiding the disutility of HCV infection and related complications), with a projected £5.4 million cost saving.

Conclusion

While improved SVR profiles led to reductions in modelled prevalence, increased treatment uptake was the key driver of future infections avoided. Increased treatment among PWID with new more efficacious therapies could significantly change the future dynamics, cost and health burden of HCV-related disease.

Opioid substitution therapy is associated with increased detection of hepatitis C virus infection: a 15-year observational cohort study

BACKGROUND

Strategies are needed to enhance screening of hepatitis C virus (HCV) infection among people who inject drugs to improve engagement in HCV treatment, and stem the growing burden of HCV-related morbidity and mortality.

METHODS

We linked routinely collected data on enrolment in opioid substitution therapy (OST) and HCV notifications. We calculated rates of incident HCV notifications, and compared rates in and out of OST.

RESULTS

Following adjustment for sex, age and calendar period, rates of incident HCV notification were significantly higher during periods of OST, compared to periods out of OST (adjusted incident rate ratio: 1.91; 95% confidence interval: 1.86, 1.97). This effect was seen across multiple treatment periods.

CONCLUSIONS

HCV screening in OST settings increases detection of HCV infection among people who inject drugs.

Evaluation of two community-controlled peer support services for assessment and treatment of hepatitis C virus infection in opioid substitution treatment clinics: The ETHOS study, Australia

AIM

Peer support services have been shown to be beneficial in increasing uptake and adherence to treatment in other areas but few examples of these services exist in hepatitis C (HCV) care. This study examined the performance of two community-controlled peer support services operating within a larger study aimed at increasing access to HCV care and treatment for opiate substitution treatment (OST) clients, ETHOS.

METHODS

Semi-structured interviews were conducted in two clinics with three groups of participants: clients (n=31), staff (n=8) and peer workers (n=3) and examined the operation of the service in relation to process, outputs and impacts.

RESULTS

There was a very strong positive response to the peer worker services reported by staff and clients who had and had not interacted with a peer worker. A number of changes were reported that were not explicit goals of the service including providing access to additional services for clients and staff, peer workers acting as mediators between clients and staff and a less tangible notion of a changing "feel" of the clinic to a more positive and client-friendly social and physical space. Explicit goals of the service were also reported in peer workers supporting clients to consider and prepare for treatment (via blood tests and other assessments) as well as provide information and support about treatment.

CONCLUSIONS

The peer support service was acceptable to clients and clinic staff. All groups of participants noted that the service met its goals of engaging clients, building trusting relationships and providing instrumental support for clients to access HCV treatment. Peer workers may also contribute to more effective deployment of health resources by preparing clients for clinical engagement with HCV health workers.

Eligibility of persons who inject drugs for treatment of hepatitis C virus infection

In this decade, an increase is expected in end-stage liver disease and hepatocellular carcinoma, most commonly caused by hepatitis C virus (HCV) infection. Although people who inject drugs (PWID) are the major source for HCV infection, they were excluded from antiviral treatments until recently. Nowadays there is incontrovertible evidence in favor of treating these patients, and substitution therapy and active substance use are no longer contraindications for antiviral treatment. The viral clearance in PWID after HCV antiviral treatment with interferon or pegylated interferon combined with ribavirin is comparable to the viral clearance in non-substance users. Furthermore, multidisciplinary approaches to delivering treatment to PWID are advised, and their treatment should be considered on an individualized basis. To prevent the spread of HCV in the PWID community, recent active PWID are eligible for treatment in combination with needle exchange programs and substitution therapy. As the rate of HCV reinfection is low after HCV antiviral treatment, there is no need to withhold HCV treatment due to concerns about reinfection alone. Despite the advances in treatment efficacies and data supporting their success, HCV assessment of PWID and initiation of antiviral treatment remains low. However, the proportion of PWID assessed and treated for HCV is increasing, which can be further enhanced by understanding the barriers to and facilitators of HCV care. Removing stigmatization and implementing peer support and group treatment strategies, in conjunction with greater involvement by nurse educators/practitioners, will promote greater treatment seeking and adherence by PWID. Moreover, screening can be facilitated by noninvasive methods for detecting HCV antibodies and assessing liver fibrosis stages. Recently, HCV clearance has become a major endpoint in the war against drugs for the Global Commission on Drug Policy. This review highlights the most recent evidence concerning HCV infection and treatment strategies in PWID.

Barriers and facilitators for assessment and treatment of hepatitis C virus infection in the opioid substitution treatment setting: insights from the ETHOS study

Provision of hepatitis C virus (HCV) assessment and treatment via opioid substitution treatment (OST) clinics has been posed as an effective means of engaging populations with high HCV prevalence. This study explores OST client and health professional reports concerning barriers and facilitators affecting the delivery and uptake of HCV care and treatment within OST settings. In-depth interviews were conducted with 57 clients, 16 staff from four NSW clinics participating in the Australian ETHOS study and three peer workers. Client participants included those who had not had HCV assessment; those who had HCV assessment only; and those who were awaiting or undertaking HCV treatment. A clear difference in decisions about HCV treatment emerged between participant groups. For those who have not been assessed, barriers to engaging with HCV care included the perception that they were physically well, were not experiencing HCV symptoms, had other life priorities and were concerned about the side effects and tolerability of treatment. Those who had engaged with care expressed motivations stemming from seeing friends becoming unwell, wanting to live longer and hearing positive stories of treatment. For those interested in HCV treatment, issues related to both provider and setting were important, such as presence of an engaged clinician, an accessible treatment pathway and availability of support. In this integrated care model, some barriers to HCV care and treatment (particularly those relating to health provider and the system) are minimized. In this setting, HCV treatment remained an unattractive option for a significant number of clients. Providing ways for those without HCV symptoms to be assessed for liver damage may be important to open up alternative conversations about HCV care. Further, the importance of a changing discourse of treatment is apparent from these data and could be enhanced by peer communication that provides information about successful treatment experiences.

Assessment and treatment of hepatitis C virus infection among people who inject drugs in the opioid substitution setting: ETHOS study

BACKGROUND

Access to hepatitis C virus (HCV) treatment remains extremely limited among people who inject drugs (PWID). HCV assessment and treatment was evaluated through an innovative model for the provision of HCV care among PWID with chronic HCV infection.

METHODS

Enhancing Treatment for Hepatitis C in Opioid Substitution Settings (ETHOS) was a prospective observational cohort. Recruitment was through 5 opioid substitution treatment (OST) clinics, 2 community health centers, and 1 Aboriginal community controlled health organization in New South Wales, Australia.

RESULTS

Among 387 enrolled participants, mean age was 41 years, 71% were male, and 15% were of Aboriginal ethnicity. Specialist assessment was undertaken in 191 (49%) participants, and 84 (22%) commenced interferon-based treatment. In adjusted analysis, HCV specialist assessment was associated with non-Aboriginal ethnicity (adjusted odds ratio [AOR], 4.02; 95% confidence interval [CI], 2.05-7.90), no recent benzodiazepine use (AOR, 2.06; 95% CI, 1.31-3.24), and non-1 HCV genotype (AOR, 2.13; 95% CI, 1.32-3.43). In adjusted analysis, HCV treatment was associated with non-Aboriginal ethnicity (AOR, 4.59; 95% CI, 1.49-14.12), living with the support of family and/or friends (AOR, 2.15; 95% CI, 1.25-3.71), never receiving OST (AOR, 4.40; 95% CI, 2.27-8.54), no recent methamphetamine use (AOR, 2.26; 95% CI, 1.12-4.57), and non-1 HCV genotype (AOR, 3.07; 95% CI, 1.67-5.64).

CONCLUSIONS

HCV treatment uptake was relatively high among this highly marginalized population of PWID. Potentially modifiable factors associated with treatment include drug use and social support.

Models of care for the management of hepatitis C virus among people who inject drugs: one size does not fit all

One of the major obstacles to hepatitis C virus (HCV) care in people who inject drugs (PWID) is the lack of treatment settings that are suitably adapted for the needs of this vulnerable population. Nevertheless, HCV treatment has been delivered successfully to PWID through various multidisciplinary models such as community-based clinics, substance abuse treatment clinics, and specialized hospital-based clinics. Models may be integrated in primary care--all under one roof in either addiction care units or general practitioner-based models--or can occur in secondary or tertiary care settings. Additional innovative models include directly observed therapy and peer-based models. A high level of acceptance of the individual life circumstances of PWID rather than rigid exclusion criteria will determine the level of success of any model of HCV management. The impact of highly potent and well-tolerated interferon-free HCV treatment regimens will remain negligible as long as access to therapy cannot be expanded to the most affected risk groups.

Can hepatitis C virus infection be eradicated in people who inject drugs?

People who inject drugs (PWID) represent the core of the hepatitis C virus (HCV) epidemic in many countries and HCV-related disease burden continues to rise. There are compelling data demonstrating that with the appropriate programs, treatment for HCV infection among PWID is successful, with responses to therapy similar those observed in large randomized controlled trials in non-PWID. However, assessment and treatment for HCV infection lags far behind the numbers who could benefit from therapy, related to systems-, provider- and patient-related barriers to care. The approaching era of interferon-free directly acting antiviral therapy has the potential to provide one of the great advances in clinical medicine. Simple, tolerable and highly effective therapy will likely address many of these barriers, thereby enhancing the numbers of PWID cured of HCV infection. This commentary will consider why we should strive for the eradication of HCV infection among PWID, whether eradication of HCV infection among PWID is feasible, components that would be needed to achieve eradication of HCV infection in PWID, potential settings and strategies required to establish programs targeted towards eradicating HCV infection among PWID and the feasibility of eradication versus elimination of HCV infection among PWID. This article forms part of a symposium in Antiviral Research on "Hepatitis C: next steps toward global eradication."

Client and staff experiences of a co-located service for hepatitis C care in opioid substitution treatment settings in New South Wales, Australia

BACKGROUND

Internationally, there are ongoing efforts to increase access to hepatitis C (HCV) assessment and treatment to counter a generally low uptake of treatment among people with a history of injecting drug use. The aim of this qualitative study was to examine client and staff attitudes towards and experience of co-location of HCV and opioid substitution treatment (OST) services.

METHODS

In-depth interviews were conducted with 57 clients and 19 staff from four NSW clinics participating in the Australian ETHOS study.

RESULTS

Client and staff participants typically welcomed integrated treatment, citing issues of convenience, reduced travel time and costs, persistent cues to engagement and immediacy of access to care. Positive attitudes towards the initiative were expressed even by clients who had not engaged with HCV care. Providing co-located care largely avoided the negative, stigmatising or discriminatory experiences that participants reported encountering in settings less familiar with people who use drugs. A minority of client participants expressed concerns about the lack of privacy and/or confidentiality available in the co-located model, preferring to seek HCV care elsewhere.

CONCLUSIONS

The co-location of HCV care in OST clinics was welcomed by the large majority of participants in this study. Besides issues of convenience, the appeal of the co-located service centred on the familiarity of existing relationships between clients and staff in the OST setting. While some clients remained distrustful of OST and chose not to take up HCV care in this setting, the co-located treatment model was overwhelmingly successful amongst both client and staff participants.

Hepatitis C treatment for multimorbid patients with substance use disorder in a primary care-based integrated treatment centre: a retrospective analysis

OBJECTIVES/BACKGROUND

The population of people who use drugs (PWUD) has the highest prevalence of hepatitis C virus (HCV) infections in Europe. PWUD are multimorbid patients who are difficult to integrate into existing healthcare systems. In our study, we evaluated the feasibility of providing HCV treatment within opioid maintenance treatment (OMT) programmes offering integrated primary care-based health services under one roof.

METHODS

We evaluated 66 charts of patients in four outpatient clinics (OMT) with HCV treatment (between 2002 and 2010). Fourteen of the patients were treated with heroin and nine patients had an HIV coinfection. Data on the socioeconomic characteristics and quality of life were assessed. We counted the number of consultations in the clinic to assess how much supportive care the patients needed.

RESULTS

Overall, 62% of all patients (41 out of 66) achieved a sustained virological response (SVR). A total of 84% of patients with genotype 3 achieved an SVR. Sixty-four percent of patients treated with heroin achieved an SVR. The majority of patients (71%) used illicit drugs during HCV treatment and over 80% were diagnosed with psychiatric comorbidities. Comparisons of patient characteristics according to SVR or non-SVR showed that a longer duration of OMT, more consultations per week during HCV treatment and poor self-reported physical condition were associated with non-SVR.

CONCLUSION

We conclude that offering HCV treatment in an integrated primary care-based setting with OMT and individualized use of different supporting strategies allows for treatment success rates in the population of PWUD that is comparable to the ones in the population of patients without drug use. Heroin maintenance treatment programmes offer a feasible and safe setting for providing HCV treatment.

Hepatitis C virus treatment for prevention among people who inject drugs: Modeling treatment scale-up in the age of direct-acting antivirals

Substantial reductions in hepatitis C virus (HCV) prevalence among people who inject drugs (PWID) cannot be achieved by harm reduction interventions such as needle exchange and opiate substitution therapy (OST) alone. Current HCV treatment is arduous and uptake is low, but new highly effective and tolerable interferon-free direct-acting antiviral (DAA) treatments could facilitate increased uptake. We projected the potential impact of DAA treatments on PWID HCV prevalence in three settings. A dynamic HCV transmission model was parameterized to three chronic HCV prevalence settings: Edinburgh, UK (25%); Melbourne, Australia (50%); and Vancouver, Canada (65%). Using realistic scenarios of future DAAs (90% sustained viral response, 12 weeks duration, available 2015), we projected the treatment rates required to reduce chronic HCV prevalence by half or three-quarters within 15 years. Current HCV treatment rates may have a minimal impact on prevalence in Melbourne and Vancouver (<2% relative reductions) but could reduce prevalence by 26% in 15 years in Edinburgh. Prevalence could halve within 15 years with treatment scale-up to 15, 40, or 76 per 1,000 PWID annually in Edinburgh, Melbourne, or Vancouver, respectively (2-, 13-, and 15-fold increases, respectively). Scale-up to 22, 54, or 98 per 1,000 PWID annually could reduce prevalence by three-quarters within 15 years. Less impact occurs with delayed scale-up, higher baseline prevalence, or shorter average injecting duration. Results are insensitive to risk heterogeneity or restricting treatment to PWID on OST. At existing HCV drug costs, halving chronic prevalence would require annual treatment budgets of US $3.2 million in Edinburgh and approximately $50 million in Melbourne and Vancouver.

CONCLUSION

Interferon-free DAAs could enable increased HCV treatment uptake among PWID, which could have a major preventative impact. However, treatment costs may limit scale-up, and should be addressed.

The new paradigm of hepatitis C therapy: integration of oral therapies into best practices

Emerging data indicate that all-oral antiviral treatments for chronic hepatitis C virus (HCV) will become a reality in the near future. In replacing interferon-based therapies, all-oral regimens are expected to be more tolerable, more effective, shorter in duration and simpler to administer. Coinciding with new treatment options are novel methodologies for disease screening and staging, which create the possibility of more timely care and treatment. Assessments of histologic damage typically are performed using liver biopsy, yet noninvasive assessments of histologic damage have become the norm in some European countries and are becoming more widespread in the United States. Also in place are new Centers for Disease Control and Prevention (CDC) initiatives to simplify testing, improve provider and patient awareness and expand recommendations for HCV screening beyond risk-based strategies. Issued in 2012, the CDC recommendations aim to increase HCV testing among those with the greatest HCV burden in the United States by recommending one-time testing for all persons born during 1945-1965. In 2013, the United States Preventive Services Task Force adopted similar recommendations for risk-based and birth-cohort-based testing. Taken together, the developments in screening, diagnosis and treatment will likely increase demand for therapy and stimulate a shift in delivery of care related to chronic HCV, with increased involvement of primary care and infectious disease specialists. Yet even in this new era of therapy, barriers to curing patients of HCV will exist. Overcoming such barriers will require novel, integrative strategies and investment of resources at local, regional and national levels.

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.

Hepatitis C treatment access and uptake for people who inject drugs: a review mapping the role of social factors

Background

Evidence documents successful hepatitis C virus (HCV) treatment outcomes for people who inject drugs (PWID) and interest in HCV treatment among this population. Maximising HCV treatment for PWID can be an effective HCV preventative measure. Yet HCV treatment among PWID remains suboptimal. This review seeks to map social factors mediating HCV treatment access.

Method

We undertook a review of the social science and public health literature pertaining to HCV treatment for PWID, with a focus on barriers to treatment access, uptake and completion. Medline and Scopus databases were searched, supplemented by manual and grey literature searches. A two step search was taken, with the first step pertaining to literature on HCV treatment for PWID and the second focusing on social structural factors. In total, 596 references were screened, with 165 articles and reports selected to inform the review.

Results

Clinical and individual level barriers to HCV treatment among PWID are well evidenced. These include patient and provider concerns regarding co-morbidities, adherence, and side effect management. Social factors affecting treatment access are less well evidenced. In attempting to map these, key barriers fall into the following domains: social stigma, housing, criminalisation, health care systems, and gender. Key facilitating factors to treatment access include: combination intervention approaches encompassing social as well as biomedical interventions, low threshold access to opiate substitution therapy, and integrated delivery of multidisciplinary care.

Conclusion

Combination intervention approaches need to encompass social interventions in relation to housing, stigma reduction and systemic changes in policy and health care delivery. Future research needs to better delineate social factors affecting treatment access.

Missed opportunities for hepatitis C testing in opioid treatment programs

HCV has surpassed HIV as a cause of death in the United States and is particularly prevalent among injection drug users. I examined the availability of on-site HCV testing in a nationally representative sample of opioid treatment programs. Nearly 68% of these programs had the staff required for HCV testing, but only 34% offered on-site testing. Availability of on-site testing increased only slightly with the proportion of injection drug users among clients. The limited HCV testing services in opioid treatment programs is a key challenge to reducing HCV in the US population.

Perceived barriers to hepatitis C therapy for patients receiving opioid agonist treatment

OBJECTIVES

To explore attitudes toward hepatitis C antiviral therapy in a real-world setting, we asked patients in opioid agonist treatment who were offered antiviral therapy about perceived barriers to initiating therapy.

METHODS

We recruited patients in opioid agonist treatment who had previously been offered cost-free hepatitis C antiviral therapy in a clinical trial. We collected demographic and open-ended interview data. The semistructured interview guide included questions about attitudes toward hepatitis C therapy and barriers to initiating treatment. Each interview was audio recorded and transcribed verbatim. We used the qualitative editing method to analyze the interview transcripts.

RESULTS

We enrolled 19 patients who had been approached to initiate hepatitis C therapy in a clinical trial. All participants were low-income men, with one third self-identifying as racial minorities. When asked about possible barriers to treatment, multiple problems emerged, including the fear of treatment side effects, difficulties with health care providers, limited access to medical care and health information, and misperceptions about antiviral therapy.

CONCLUSIONS

Despite intense educational efforts, concerns over antiviral therapy, relations with providers, and access to the health care system remain critical barriers. These factors should be addressed to improve antiviral therapy rates for patients receiving opioid agonist treatment.

High prevalence but low awareness of hepatitis C virus infection among heroin users who received methadone maintenance therapy in Taiwan

BACKGROUND

This study investigates the prevalence and correlates of hepatitis C virus (HCV) infections among heroin dependent individuals who received methadone maintenance therapy in Taiwan. Also, we investigate users' awareness of HCV.

METHODS

Participants were 773 heroin users entering the methadone maintenance treatment (MMT) program at Tsaotun Psychiatric Center in Taiwan. The presence of HCV antibodies was detected. Multivariate logistic regression was used to identify the relationship between HCV infection and correlates.

RESULTS

The prevalence of HCV infection was 90.8%. All participants who were HIV-positive were also infected with HCV. Multivariate logistic regression analysis showed that the route of heroin administration (injection), HIV-infection, and criminal records were significantly related to HCV infection. Few (34.8%) HCV positive heroin users were aware of their infection.

CONCLUSION

An extremely high prevalence of HCV infection but low awareness of their infection status was found among MMT patients in Taiwan. These findings highlight the importance of education regarding risky behaviors and the necessity for HCV treatment for this population in Taiwan.