Enhancing engagement in hepatitis C care among people who inject drugs

Effectiveness and safety of glecaprevir/pibrentasvir for 8 weeks in the treatment of patients with acute hepatitis C: A single-arm retrospective study

BACKGROUND AND AIMS

No direct-acting antiviral is currently approved for acute HCV infection, delaying treatment. We investigated the effectiveness and safety of 8-week glecaprevir/pibrentasvir (G/P) in patients with acute HCV infection.

APPROACH AND RESULTS

This noninterventional, single-arm, retrospective chart review was designed to enroll adults/adolescents with acute HCV infection. Analyses were conducted on a full analysis set (FAS; all enrolled) and modified FAS (FAS excluding nonvirologic failures). The primary end point (modified FAS) was sustained virologic response at posttreatment week 12 (SVR12) with superiority to 92.6% threshold determined by historic chronic HCV G/P SVR12 rates. Secondary end points (FAS) included SVR12, on-treatment virologic failure, posttreatment relapse, and reinfection. Adverse events and safety laboratory values were assessed.Overall, 202 adults were enrolled; in the modified FAS, 150/151 (99.3%; 95% CI: 96.3-99.9) achieved SVR12, demonstrating superiority to efficacy threshold. In the FAS, the SVR12 rate was 74.3% and the on-treatment virologic failure rate was 0%. Relapse and reinfection rates after the final treatment visit (FAS) were 0.5% and 3%, respectively; 39 patients had missing SVR12 data. No on-treatment alanine aminotransferase elevations > 3 × upper limit of normal with total bilirubin > 2 × upper limit of normal were reported. All 53 patients with alanine aminotransferase Grade ≥ 2 at baseline improved to Grade 0/1 on treatment. No adverse eventss of hepatic decompensation/failure or leading to G/P discontinuation occurred. Two patients had serious adverse events unrelated to G/P.

CONCLUSIONS

Eight-week G/P therapy was effective and well-tolerated in patients with acute HCV infection. Data support further investigation of G/P in acute HCV to shorten care cascades, reduce transmission, and support HCV elimination.

Optimising community health services in Australia for populations affected by stigmatised infections: What do service users want?

Stigma in health services undermines diagnosis, treatment and successful health outcomes for all communities, but especially for those affected by blood-borne viruses and sexually transmitted infections (STIs). This study sought to examine experiences in accessing and receiving health services, including what characteristics promoted better health, safety and well-being for people with blood-borne viruses or STIss. It conducted 46 in-depth interviews with people who inject drugs, gay men and other men who have sex with men, sex workers, people in custodial settings, culturally and linguistically diverse people, Indigenous Australians and young people in one Australian urban community setting. Findings reveal that stigma persists in the provision of healthcare services, and that previous experiences of discrimination or fear of mistreatment may result in a reluctance to continue to access services. On-going staff training and education are important to ensure healthcare environments are welcoming and inclusive. Specialised services and services that employed peers were seen as favourable. Attending different services for different health needs created particular access challenges and undermined participant ability to engage in more holistic healthcare. The fragmented structure of health services was thus seen as a barrier to accessing health services, and stronger collaboration between health services is recommended.

'Not just one box that you tick off' - Deconstructing the hepatitis C care cascade in the interferon-free direct acting antiviral era from the client perspective

BACKGROUND

To achieve hepatitis C viral (HCV) elimination targets set by the World Health Organisation, pillars of the HCV care cascade are often referenced to track progress. The aim of this qualitative study was to explore the limitations of the care cascade framework through the real-world accounts of 'HCV journeys' among people who inject drugs (PWID), with particular attention to the intersection of PWID agency and structural determinants in the healthcare system.

METHODS

An in-depth analysis was conducted on five case studies to better understand participant experiences 'behind the cascade pillars'. The five case studies were drawn from the ETHOS Engage cohort as exemplars of the real-world complexities of people's HCV cascade journeys. Inclusion criteria for the qualitative study were participant has voluntarily signed the informed consent form, aged ≥18 years, HCV antibody positive by self-report, clients of selected sites participating in the ETHOS Engage cohort, and sufficiently proficient in English to participate in an interview. Thirty-four semi-structured interviews were conducted with participants who had received or had not received HCV treatment to identify barriers and facilitators to HCV care.

RESULTS

Participants 'housed' at the 'HCV RNA diagnosed pillar' (n = 2; Will; Julie) reported withholding their HCV serostatus in certain healthcare settings for fear that disclosure would lead to discriminatory decision-making from their treating physician. among participants who had completed treatment (n = 3; Corey; John; Nora) two reported still being unsure of their HCV status >6 months post-treatment. Ongoing feelings of frustration and shame were expressed in this 'post-cure care pillar' due to a perceived lack of quality care from clinic services and continued uneasiness when discussing drug use and reinfection while receiving opioid agonist treatment (OAT). Both case 'categories' described often tenuous therapeutic relationships with their physicians and recommended task-shifting to nurses and trusted case workers for ongoing care.

CONCLUSION

The care cascade provides a linear, two dimensional snapshot of clinical targets. Our findings illuminate structural barriers not visible behind its 'static' pillars, presenting insights into experiences among PWID otherwise dismissed as 'disengaged' or 'lost to follow-up'.

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.

Barriers and facilitators to engaging in hepatitis C management and DAA therapy among general practitioners and drug and alcohol specialists-The practitioner experience

BACKGROUND

Since the advent of interferon-free, direct-acting antiviral (DAA) therapies for hepatitis C virus (HCV) infection, prescriber restrictions have been removed worldwide, permitting HCV management outside of hospital-based clinics. To date, there is limited knowledge of the practitioner experience with DAA treatments, particularly among those new to HCV care. The aim of this qualitative study was to investigate barriers and facilitators for HCV management among general practitioners (GPs) who prescribe opioid agonist therapy (OAT) and drug and alcohol specialists.

METHODS

In-depth, semi-structured telephone interviews were conducted between September 2018 and April 2019. Practitioners from across Australia were purposively sampled and questioned on barriers and facilitators to HCV management in their clinic(s). Data were coded and analysed with iterative categorisation and thematical analysis.

RESULTS

Thirty practitioners were interviewed. Participants expressed professional fulfillment in managing HCV care and many benefited from specialist mentorship. Most participants expressed frustration with ongoing implementation barriers, notably, a lack of onsite phlebotomy services and liver disease staging equipment. Poor venous access among persons who inject drugs was elucidated as a major barrier to treatment initiation. Some participants did not receive clinic manager support to engage in HCV care.

CONCLUSION

To achieve HCV targets set by WHO by 2030, practitioners require additional implementation support. As HCV testing remains a barrier to linkage to care, practitioners should be kept well-informed of diagnostic developments. Findings also underscore the importance of initial specialist mentorship with further evidence needed for practitioners based in rural regions.