Active intravenous drug use during chronic hepatitis C therapy does not reduce sustained virological response rates in adherent patients

Barriers and Facilitators of Hepatitis C Care in Persons Coinfected with Human Immunodeficiency Virus

Hepatitis C virus (HCV) and human immunodeficiency virus (HIV) are often co-transmitted. Viral coinfection results in worse outcomes. Persons who inject drugs (PWIDs) face barriers to medical treatment, but HCV treatment is indicated and effective even with ongoing active drug use. We aimed to assess access to HCV care and treatment results in patients coinfected with HIV-HCV. This is a real-world retrospective single-center study of patients followed in the HIV clinic between 2002 and 2018. Linkage to care was defined as achieving care cascade steps: (1) hepatology clinic visit, (2) receiving prescription of anti-HCV treatment, and (3) documentation of sustained virologic response (SVR). Of 1660 patients with HIV, 254 with HIV-HCV coinfection were included. Only 39% of them achieved SVR. The rate limiting step was the engagement into hepatology care. Being a PWID was associated with ~50% reduced odds of achieving study outcomes, active drug use was associated with ~90% reduced odds. Older age was found to facilitate treatment success. Once treated, the rate of SVR was high in all populations. HCV is undertreated in coinfected young PWIDs. Further efforts should be directed to improve access to care in this marginalized population.

Viral hepatitis: A narrative review of hepatitis A–E

Viral hepatitis continues to be a major health concern leading to hepatic decompensation ranging from acute hepatitis to cirrhosis and hepatocellular carcinoma. The hepatic and extrahepatic manifestations are not only debilitating but also associated with a significant economic burden. Over the last two decades, the field of virology has made significant breakthroughs leading to a better understanding of the pathophysiology of viral hepatitis, which in turn has led to new therapeutic options. The advent of direct-acting antiviral agents changed the landscape of hepatitis C virus (HCV) therapy, and new drugs are in the pipeline for chronic hepatitis B virus (HBV) treatment. There has also been a significant emphasis on screening and surveillance programs, widespread availability of vaccines, and linkage of care. Despite these efforts, significant gaps persist in care, and there is a pressing need for increased collaboration and teamwork across the globe to achieve a reduction of disease burden and elimination of HBV and HCV.

HCV compliance and treatment success rates are higher with DAAs in structured HCV clinics compared to general hepatology clinics

The real-world cure rates for hepatitis C (HCV) with direct-acting antivirals (DAAs) based on intention-to-treat (ITT) analysis may be lower than reported in the literature because of non-compliance.To determine whether patients treated in a structured outpatient HCV clinic (SHC) had higher compliance and treatment success rates compared to those treated in general hepatology clinics (GHC).In this study, we compared the treatment and compliance success rates of 488 and 840 patients treated in the SHC and GHC, respectively. The SHC required a pre-treatment clinic visit when patients picked up their initial medication, and received detailed education of the treatment plan and follow-up. In the GHC, the medications were delivered to patients' homes, and there was less formal education. Compliance success was defined as a combination of treatment completion and obtaining at least 1 post-treatment viral load at week 4 or 12. Treatment success was defined as either SVR4 or SVR12.Fifty of 488 (10.3%) patients from the SHC and 163 of 840 (19.4%) patients from the GHC were lost to follow-up (P < .0001). sustained virological response (SVR) rates were similar in compliant patients in both the SHC (419/438, 95.6%) and GHC (642/677, 94.8%), but treatment success rates by intention to treat (ITT) (overall 79.9%) were higher in SHC compared to GHC (85.9% vs 76.4%, P < .0001). Multivariate analysis showed that female patients (P = .01), older age (P = .0005), treatment in SHC (OR 1.7, 95% CI 1.2, 2.3, P = .0008), and sofosbuvir/simeprevir compared to sofosbuvir/ledipasvir had higher odds of compliance success; elbasvir/grazoprevir or dasabuvir/ombitasvir/paritaprevir/ritonavir had lower odds of compliance success compared to sofosbuvir/ledipasvir. Female patients (P = .02), older age (P < .0001), previous treatment (P = .03), treatment in SHC (OR 1.7, 95% CI 1.2, 2.3, P = .0008), and sofosbuvir/ledipasvir compared to sofosbuvir/velpatasvir, sofosbuvir, or elbasvir/grazoprevir had higher odds of treatment success. With 1:1 matching, the SHC group still had significantly higher odds than the GHC group of achieving treatment and compliance success.Our study shows that the effectiveness of HCV treatment could be improved by coordinating treatment in a structured HCV clinic.

Reinfection in a large cohort of prison inmates with sustained virological response after treatment of chronic hepatitis C in Catalonia (Spain), 2002-2016

BACKGROUND

Prisoners and other high-risk patients who show a sustained virological response (SVR) after treatment for hepatitis C virus (HCV) can become reinfected. We aimed to calculate the rate of HCV reinfection in a large cohort of inmates with SVR and to determine factors that predict reinfection.

METHODS

We included all inmates treated for hepatitis C in Catalonia (Spain) from January 2002 to December 2016 who achieved SVR and in whom viral load was subsequently determined. The incidence rate was calculated per 100 person-years (100 py) of follow up. Risk factors associated with reinfection were evaluated by bivariate log-rank test and multivariate Cox regression. Hazard ratio (HR) and their 95% confidence intervals (CI) were calculated.

RESULTS

602 patients were included, with a mean age of 37.9 years: 95% were men, 74.1% had a history of intravenous drug use (IDU) and 28.7% were HIV-infected. Patients were followed for a total of 2154.9 years (average 3.58 ± 3.1 years). 63 (10.5%) had HCV reinfection. 41 (65.1%) presented different genotype/subgenotype, 8 the initial genotype/subgenotype, and in 14 (22.2%) the genotype could not be determined. Of the 21 reinfected patients who were interviewed, 20 (95.2%) reported IDU after antiviral treatment, and 7 (33.3%) during treatment. The overall incidence of reinfection was 2.9 cases per 100 py. All reinfections occurred in patients with IDU history. At multivariate level, HIV infection was associated with reinfection (HR = 3.03; CI:1.82-5.04).

CONCLUSION

In HIV-infected inmates with IDU history, the rate of reinfection of HCV post-SVR is very high. Prisons play a key role in the detection and treatment of infection and reinfection by HCV and in the post-treatment monitoring in these patients, which should be combined with counseling and the optimization of the harm reduction programs. Effective control of these vulnerable groups favours the elimination of the HCV infection.

Direct acting antiviral-based treatment of hepatitis C virus infection among people who inject drugs in Georgia: A prospective cohort study

BACKGROUND

People who inject drugs (PWID) are often excluded from HCV treatment programs due to concerns about their ability to adhere to care. Georgia has a high prevalence of HCV infection (5.4% of chronic cases in general population) with an epidemic concentrated among PWID. We evaluated adherence to care and sustained virologic response (SVR) among PWID in Georgia.

METHODS

In this observational study, participants with recent injecting drug use (previous 6 months) and chronic HCV attending a needle- and syringe-program were included. Participants received sofosbuvir and ribavirin +/- pegylated interferon, with peer-based support during treatment. The primary endpoint was undetectable HCV RNA 12 weeks post-treatment (SVR12). Factors associated with SVR were assessed using logistic regression.

RESULTS

Among 244 participants [HCV genotype (GT) 3, 52%; GT2, 25%; GT1, 19%; mixed GT, 4%]; 55% had cirrhosis. Overall, 24% were receiving OST and 50% injected drugs in the previous month. 98% (239 of 244) completed treatment, with 88% (210 of 239) having never delayed a medical appointment and 79% (189 of 239) never missing a dose of medication. Overall, SVR was 84.8% (207 of 244). SVR was 88.5% (207 of 234) among participants who attended 12-week follow up appointment for HCV RNA testing. In multivariate analyses, SVR was significantly associated with adherence (no missed doses) to treatment [vs. missed doses; adjusted OR (aOR) 2.77; 95% confidence interval (95%CI), 1.01-7.51), and genotype (vs. GT1; GT2, aOR 0.27; 95%CI 0.06-1.21; GT3, aOR 1.09; 95%CI 0.27-4.50; and mixed GT, aOR 0.14; 95%CI 0.02-0.97).

CONCLUSION

In this real-life study in a middle-income country, PWID treated for HCV and receiving a simple peer-support intervention demonstrated an excellent treatment response and good adherence, not associated with injecting drug use during treatment and OST at treatment initiation.

The Mexican consensus on the treatment of hepatitis C

The aim of the Mexican Consensus on the Treatment of HepatitisC was to develop clinical practice guidelines applicable to Mexico. The expert opinion of specialists in the following areas was taken into account: gastroenterology, infectious diseases, and hepatology. A search of the medical literature was carried out on the MEDLINE, EMBASE, and CENTRAL databases through keywords related to hepatitisC treatment. The quality of evidence was subsequently evaluated using the GRADE system and the consensus statements were formulated. The statements were then voted upon, using the modified Delphi system, and reviewed and corrected by a panel of 34 voting participants. Finally, the level of agreement was classified for each statement. The present guidelines provide recommendations with an emphasis on the new direct-acting antivirals, to facilitate their use in clinical practice. Each case must be individualized according to the comorbidities involved and patient management must always be multidisciplinary.

Increasing Prevalence of Hepatitis C among Hospitalized Children Is Associated with an Increase in Substance Abuse

OBJECTIVE

To evaluate the impact of substance abuse on pediatric hepatitis C virus (HCV) prevalence, we examined geographic and demographic data on inpatient hospitalizations in children with HCV.

STUDY DESIGN

We examined hospitalizations in children using the Kids' Inpatient Database, a part of the Healthcare Cost and Utilization Project. We identified cases using the International Classification of Diseases, 9th edition, codes for HCV infection during 2006, 2009, and 2012. Nonparametric tests for trend were used to calculate trend statistics.

RESULTS

From 2006 to 2012 nationally, the number of hospitalizations of children with HCV increased 37% (2.69 to 3.69 per 10 000 admissions; P < .001). The mean age of children hospitalized was 17.6 years (95% CI, 17.4-17.8). HCV cases among those 19-20 years of age represented 68% of the total HCV diagnoses, with a 54% increase over the years sampled (P < .001 for trend). The burden of HCV in children was highest in whites, those in the lowest income quartile, and in the Northeast and Southern regions of the US (all P < .0001). The prevalence of substance use among children with HCV increased from 25% in 2006 to 41% in 2012 (P < .001).

CONCLUSION

The increases of HCV in hospitalized children are largely in teenagers, highly associated with substance abuse, and concentrated in Northeast and Southern states. These results strongly suggest that public health efforts to prevent and treat HCV will also need to include adolescents.

Treatment with direct-acting antiviral agents of hepatitis C virus infection in injecting drug users: A prospective study

In this prospective study, we evaluated the effectiveness and tolerability of novel therapies against hepatitis C virus (HCV) in a cohort of PWID enrolled at our centre from April 2015 to July 2016. In this analysis, a total of 174 patients were included: eleven (6.3%) were treated with pegylated interferon (PEG-IFN) and ribavirin (RBV) containing regimens, 163 (93.7%) with IFN-free treatments. RBV has been used in 70 patients (40.2%); 59 (33.9%) patients were in opioid substitution therapy (OST) with methadone or buprenorphine. Overall, sustained virological response (SVR) has been observed in 162 subject (93.1%), breakthrough (BT) in three (1.7%), relapse in one (0.6%) and dropout in eight (4.6%). Treatment was interrupted for clinical conditions in seven patients: six (3.4%) had hepatic decompensation and one died for hepatocellular carcinoma (HCC). In multivariate analysis, predictive factors of treatment failure were as follows: albumin level below 3 g/dL (OR=7.190; 95% IC=1.236-41.837; P<.001), MELD score >10 (OR=5.886; 95% IC=1.411-35.994; P<.001) and years of HCV infection >20 (OR=1.286; 95% IC=0.556-9.455; P=.016). In conclusion, treatment with DAAs was effective and well tolerated in PWID; cirrhotic subjects with MELD > 10 and albumin low level showed a higher risk of developing serious adverse events and treatment failure.

High HCV cure rates for people who use drugs treated with direct acting antiviral therapy at an urban primary care clinic

BACKGROUND

Though direct acting antivirals (DAAs) promise high cure rates, many providers and payers remain concerned about successful treatment for people who use drugs (PWUD), even among those engaged in opioid agonist treatment (OAT). The efficacy of DAAs among PWUD in real-world settings is unclear.

METHODS

We conducted a cohort study of patients initiating HCV treatment between January 2014 and August 2015 (n=89) at a primary care clinic in the Bronx, NY. Onsite HCV treatment with DAAs was performed by an HCV specialist, with support from a care coordinator funded by the NYC Department of Health. We identified four categories of drug use and drug treatment: (1) no active drug use/not receiving OAT (defined as non-PWUD); (2) no active drug use/receiving OAT; (3) active drug use/not receiving OAT; and (4) active drug use/receiving OAT. The primary outcome was SVR at 12 weeks post-treatment.

RESULTS

Overall SVR rates were 95% (n=41/43) for non-PWUD and 96% (n=44/46) for patients actively using drugs and/or receiving OAT [p=0.95]. There were no differences in SVR rates by drug use or drug treatment category. Compared to non-PWUD, those with no active drug use/receiving OAT had 100% SVR (n=15/15; p=1.0), those actively using drugs/not receiving OAT had 90% SVR (n=9/10; p=0.47), and those actively using drugs/receiving OAT had 95% SVR (20/21; p=1.0).

CONCLUSION

Regardless of active drug use or OAT, patients who received DAA therapy at an urban primary care clinic achieved high HCV cure rates. We found no clinical evidence to justify restricting access to HCV treatment for patients actively using drugs and/or receiving OAT.

American Gastroenterological Association Institute Clinical Practice Update-Expert Review: Care of Patients Who Have Achieved a Sustained Virologic Response After Antiviral Therapy for Chronic Hepatitis C Infection

Chronic hepatitis C virus infection is well-recognized as a common blood-borne infection with global public health impact affecting 3 to 5 million persons in the United States and more than 170 million persons worldwide. Chronic hepatitis C virus infection is associated with significant morbidity and mortality due to complications of liver cirrhosis and hepatocellular carcinoma. Current therapies with all-oral direct-acting antiviral agents are associated with high rates of sustained virologic response (SVR), generally exceeding 90%. SVR is associated with a reduced risk of liver cirrhosis, hepatic decompensation, need for liver transplantation, and both liver-related and all-cause mortality. However, a subset of patients who achieve SVR will remain at long-term risk for progression to cirrhosis, liver failure, hepatocellular carcinoma, and liver-related mortality. Limited evidence is available to guide clinicians on which post-SVR patients should be monitored vs discharged, how to monitor and with which tests, how frequently should monitoring occur, and for how long. In this clinical practice update, available evidence and expert opinion are used to generate best practice recommendations on the care of patients with chronic hepatitis C virus who have achieved SVR.

Contingency Management Interventions for HIV, Tuberculosis, and Hepatitis Control Among Individuals With Substance Use Disorders: A Systematized Review

Hepatitis, HIV and tuberculosis are significant and costly public health problems that disproportionately affect individuals with substance use disorders (SUDs). Incentive-based treatment approaches (i.e., contingency management; CM) are highly effective at reducing drug use. The primary aim of this report is to review the extant literature that examines the efficacy of CM interventions for the prevention, diagnosis and treatment of hepatitis, HIV and tuberculosis among individuals with SUDs. A literature search identified 23 controlled studies on this topic. In approximately 85% of the studies, CM produced significantly better adherence to prevention, diagnosis and treatment-related medical services, with adherence rates averaging almost 35% higher among patients receiving incentives vs. control condition participants. Findings from these studies parallel the results of a meta-analysis of CM interventions for the treatment of SUDs. The results also suggest that the principles that underlie the efficacy of CM generalize across infectious disease and substance abuse treatment behaviors. The application of additional principles from the literature on CM for treatment of SUDs to interventions targeting infectious disease control would be beneficial. Further development and dissemination of these interventions has the potential to greatly impact public health.

Facilitators of HCV treatment adherence among people who inject drugs: a systematic qualitative review and implications for scale up of direct acting antivirals

BACKGROUND

While the public health benefits of new HCV treatments depend on treatment adherence, particularly among people who inject drugs (PWID), several social and medical factors can jeopardize treatment adherence. The aim of this study is to examine the qualitative literature on facilitators to HCV treatment adherence among PWID.

METHODS

We searched six databases to identify qualitative research studies on HCV treatment adherence facilitators among PWID. Two reviewers independently extracted and analyzed data using PRISMA guidelines and the CASP tool to evaluate study quality.

RESULTS

From ten studies representing data from 525 participants, three major themes emerged across studies: logistical facilitators within health systems enhanced HCV treatment adherence, positive social interactions between PWID and staff provided positive feedback during treatment, and HCV treatment may complicate the addiction recovery process.

CONCLUSIONS

Although PWID face several barriers to adherence, we identified treatment adherence facilitators that could be incorporated into clinical practice.

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

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

High Proportion of HIV-HCV Coinfected Patients with Advanced Liver Fibrosis Requiring Hepatitis C Treatment in Haiphong, Northern Vietnam (ANRS 12262)

Rationale and Aims

Screening and treatment for chronic hepatitis C are very limited in Vietnam and clinical data on HCV-related liver disease in HIV-coinfected people are almost inexistent. This study aimed to assess the severity of liver fibrosis and its risk factors in HIV-HCV coinfected patients in Haiphong, Northern Vietnam.

Methods

A cross-sectional study was conducted at a HIV outpatient clinic. Consecutive HIV treated adults with positive HCV serology completed a standardised epidemiological questionnaire and had a comprehensive liver assessment including hepatic elastography (Fibroscan^®, Echosens).

Results

From February to March 2014, 104 HIV-HCV coinfected patients receiving antiretroviral therapy (ART) were prospectively enrolled (99 males, median age: 35.8 (32.7–39.6) years, median CD4 count: 504 (361–624) /mm³. Of them, 93 (89.4%) had detectable HCV RNA (median 6.19 (4.95–6.83 Log₁₀ IU/mL). Patients were mainly infected with genotypes 1a/1b (69%) and genotypes 6a/6e (26%). Forty-three patients (41.3%) had fibrosis ≥F2 including 24 patients (23.1%) with extensive fibrosis (F3) and/or cirrhosis (F4). In univariate analysis, excessive alcohol consumption, estimated time duration from HCV infection, nevirapine and lopinavir-based ARV regimen and CD4 nadir were associated factors of extensive fibrosis/cirrhosis. Alcohol abuse was the only independent factor of extensive fibrosis in multivariate analysis. Using Fibroscan^® as a gold standard, the high thresholds of AST-to-platelet ratio index (APRI) and fibrosis-4 score (FIB-4) had very good performances for the diagnosis of extensive fibrosis/cirrhosis (Se: 90 and 100%, Sp:84 and 81%, AUROCs = 0.93, 95%CI: 0.86–0.99 and 0.96 (0.92–0.99), respectively).

Conclusion

In this study, nearly 25% of HIV-HCV coinfected patients successfully treated with ART have extensive fibrosis or cirrhosis, and therefore require urgently HCV treatment.

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.

Extracellular vesicles from infected cells: potential for direct pathogenesis

Infections that result in natural or manmade spread of lethal biological agents are a concern and require national and focused preparedness. In this manuscript, as part of an early diagnostics and pathogen treatment strategy, we have focused on extracellular vesicles (EVs) that arise following infections. Although the field of biodefense does not currently have a rich resource in EVs literature, none the less, similar pathogens belonging to the more classical emerging and non-emerging diseases have been studied in their EV/exosomal contents and function. These exosomes are formed in late endosomes and released from the cell membrane in almost every cell type in vivo. These vesicles contain proteins, RNA, and lipids from the cells they originate from and function in development, signal transduction, cell survival, and transfer of infectious material. The current review focuses on how different forms of infection exploit the exosomal pathway and how exosomes can be exploited artificially to treat infection and disease and potentially also be used as a source of vaccine. Virally-infected cells can secrete viral as well as cellular proteins and RNA in exosomes, allowing viruses to cause latent infection and spread of miRNA to nearby cells prior to a subsequent infection. In addition to virally-infected host cells, bacteria, protozoa, and fungi can all release small vesicles that contain pathogen-associated molecular patterns, regulating the neighboring uninfected cells. Examples of exosomes from both virally and bacterially infected cells point toward a re-programming network of pathways in the recipient cells. Finally, many of these exosomes contain cytokines and miRNAs that in turn can effect gene expression in the recipient cells through the classical toll-like receptor and NFκB pathway. Therefore, although exosomes do not replicate as an independent entity, they however facilitate movement of infectious material through tissues and may be the cause of many pathologies seen in infected hosts.

Recommendations for the management of hepatitis C virus infection among people who inject drugs

In high income countries, the majority of new and existing hepatitis C virus (HCV) infections occur among people who inject drugs (PWID). In many low and middle income countries large HCV epidemics have also emerged among PWID populations. The burden of HCV-related liver disease among PWID is increasing, but treatment uptake remains extremely low. There are a number of barriers to care which should be considered and systematically addressed, but should not exclude PWID from HCV treatment. The rapid development of interferon-free direct-acting antiviral (DAA) therapy for HCV infection has brought considerable optimism to the HCV sector, with the realistic hope that therapeutic intervention will soon provide near optimal efficacy with well-tolerated, short duration, all oral regimens. Further, it has been clearly demonstrated that HCV treatment is safe and effective across a broad range of multidisciplinary healthcare settings. Given the burden of HCV-related disease among PWID, strategies to enhance HCV assessment and treatment in this group are urgently needed. These recommendations demonstrate that treatment among PWID is feasible and provide a framework for HCV assessment and care. Further research is needed to evaluate strategies to enhance testing, linkage to care, treatment, adherence, viral cure, and prevent HCV reinfection among PWID, particularly as new interferon-free DAA treatments for HCV infection become available.

HCV treatment rates and sustained viral response among people who inject drugs in seven UK sites: real world results and modelling of treatment impact

Hepatitis C virus (HCV) antiviral treatment for people who inject drugs (PWID) could prevent onwards transmission and reduce chronic prevalence. We assessed current PWID treatment rates in seven UK settings and projected the potential impact of current and scaled-up treatment on HCV chronic prevalence. Data on number of PWID treated and sustained viral response rates (SVR) were collected from seven UK settings: Bristol (37-48% HCV chronic prevalence among PWID), East London (37-48%), Manchester (48-56%), Nottingham (37-44%), Plymouth (30-37%), Dundee (20-27%) and North Wales (27-33%). A model of HCV transmission among PWID projected the 10-year impact of (i) current treatment rates and SVR (ii) scale-up with interferon-free direct acting antivirals (IFN-free DAAs) with 90% SVR. Treatment rates varied from <5 to over 25 per 1000 PWID. Pooled intention-to-treat SVR for PWID were 45% genotypes 1/4 [95%CI 33-57%] and 61% genotypes 2/3 [95%CI 47-76%]. Projections of chronic HCV prevalence among PWID after 10 years of current levels of treatment overlapped substantially with current HCV prevalence estimates. Scaling-up treatment to 26/1000 PWID annually (achieved already in two sites) with IFN-free DAAs could achieve an observable absolute reduction in HCV chronic prevalence of at least 15% among PWID in all sites and greater than a halving in chronic HCV in Plymouth, Dundee and North Wales within a decade. Current treatment rates among PWID are unlikely to achieve observable reductions in HCV chronic prevalence over the next 10 years. Achievable scale-up, however, could lead to substantial reductions in HCV chronic prevalence.

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.

Discrimination by health care workers versus discrimination by others: countervailing forces on HCV treatment intentions

Hepatitis C virus (HCV) infection is a major public health burden. Despite recent advances in HCV treatment, uptake remains low, particularly amongst people who inject drugs. HCV-related stigma and discrimination are common, especially within the health care sector. This research examines a more nuanced approach for how HCV-related stigma and discrimination impacts treatment access and uptake. Based on a social identity framework, we explore whether perceived HCV-related discrimination is associated with attempts to remove the stigma of being HCV-positive via HCV treatment intentions. Based on the results of prior research it was also hypothesised that the source of discrimination (health care workers versus others), and whether the discrimination is perceived to be directed to oneself or to the HCV-positive group, will differentially impact treatment intentions. The sample consisted of 416 people living with HCV in New South Wales, Australia, who acquired HCV from injecting drugs. Participants were asked about their experiences of perceived discrimination directed towards themselves versus their HCV-positive group and perceived discrimination within the health care sector. Findings indicate that discrimination towards the self is a more powerful indicator of treatment intentions than discrimination aimed at the HCV-positive group. This finding is consistent with social identity theory suggesting that people from low status groups are motivated to change their stigmatised status when it is possible to do so. The source of the perceived discrimination also matters, however, as participants who report experiencing discrimination from health workers have lowered intentions to engage with HCV treatment in the future. In combination, the results indicate that while perceived discrimination is commonly understood to act as a barrier to treatment uptake, the relationship is actually more complex than previously conceptualised.

Directly observed pegylated interferon plus self-administered ribavirin for the treatment of hepatitis C virus infection in people actively using drugs: a randomized controlled trial

BACKGROUND

This study investigated the efficacy and safety of directly observed pegylated interferon (peg-IFN) alfa-2a plus self-administered ribavirin (RBV) for the treatment of hepatitis C virus (HCV) among people with active drug use.

METHODS

A randomized, open-label, parallel group trial of immediate vs delayed treatment with peg-IFN alfa-2a plus RBV in participants with recent injection drug and/or crack cocaine use (prior 3 months). The primary end point was sustained virologic response (SVR).

RESULTS

Sixty-six participants were randomized (immediate treatment, n = 48; delayed treatment, n = 18). Loss to follow-up was comparable among those randomized to immediate and delayed treatment (23% vs 33%, P = .389). In a post hoc intent-to-treat analysis of all randomized individuals, the SVR was 65% (95% confidence interval [CI], 49%-78%; 31/48) in those randomized to immediate treatment as compared to 39% (95% CI, 17%-64%; 7/18) in those randomized to delayed treatment (P = .060). Among those who received delayed treatment (12/18), SVR was 58% (7/12). Among 60 participants who received at least 1 dose of study medication, SVR was 63% (95% CI, 50%-75%, n = 38). Recent drug use at baseline (past month) did not impact completion or SVR. Discontinuation due to adverse events occurred in 7%. The HCV reinfection rate was 2.8 per 100 person-years (95% CI, 0.0-14.5 person-years) with 1 reinfection observed among 23 remaining in follow-up post-SVR (median, 1.8 years; range, 0.5-1.8 years).

CONCLUSIONS

Among people actively using drugs treated with directly observed peg-IFN alfa-2a plus self-administered RBV, SVR is comparable to that seen in clinical trials of non-drug users, and the rate of HCV reinfection is low.

Psychoeducation improves hepatitis C virus treatment during opioid substitution therapy: a controlled, prospective multicenter trial

BACKGROUND

People who inject drugs (PWID) have a high prevalence of hepatitis C virus (HCV) infection. However, PWID are considered "difficult to treat," requiring a specifically adapted treatment setting, including psychosocial support.

METHODS

In this prospective, German trial, the impact of psychoeducation (PE) on retention and sustained virologic response (SVR) during HCV therapy among PWID was evaluated. We included 198 patients in opiate substitution therapy, who fulfilled indications for antiviral treatment. All patients received pegylated interferon alfa-2a and ribavirin therapy. Patients in the intervention group (n = 82) received manualized PE sessions.

RESULTS

In patients with HCV genotype 1 or 4 (GT 1/4), PE was associated with increased treatment completion (76% vs 55%, P = .038), whereas PE had no such effect among GT 2/3 patients, who showed fewer dropouts and higher SVR rates. Among GT 1/4 patients, a minimum of 5 PE sessions was associated with increased SVR (71% vs 48%, P = .037). Multivariate regression analyses confirmed the impact of PE in GT 1/4 and revealed further predictors for retention and SVR, such as preexisting mental distress and adverse events.

CONCLUSIONS

In patients with a higher risk of dropout due to GT 1/4 or mental distress, PE was shown to improve retention and SVR. PE is an effective supportive intervention for HCV therapy among PWID.

Recommendations for the management of hepatitis C virus infection among people who inject drugs

In the developed world, the majority of new and existing hepatitis C virus (HCV) infections occur among people who inject drugs (PWID). The burden of HCV-related liver disease in this group is increasing, but treatment uptake among PWID remains low. Among PWID, there are a number of barriers to care that should be considered and systematically addressed, but these barriers should not exclude PWID from HCV treatment. Furthermore, it has been clearly demonstrated that HCV treatment is safe and effective across a broad range of multidisciplinary healthcare settings. Given the burden of HCV-related disease among PWID, strategies to enhance HCV assessment and treatment in this group are urgently needed. These recommendations demonstrate that treatment among PWID is feasible and provides a framework for HCV assessment, management, and treatment. Further research is needed to evaluate strategies to enhance assessment, adherence, and SVR among PWID, particularly as new treatments for HCV infection become available.

The state of hepatitis B and C in the Mediterranean and Balkan countries: report from a summit conference

The burden of disease due to chronic viral hepatitis constitutes a global threat. In many Balkan and Mediterranean countries, the disease burden due to viral hepatitis remains largely unrecognized, including in high-risk groups and migrants, because of a lack of reliable epidemiological data, suggesting the need for better and targeted surveillance for public health gains. In many countries, the burden of chronic liver disease due to hepatitis B and C is increasing due to ageing of unvaccinated populations and migration, and a probable increase in drug injecting. Targeted vaccination strategies for hepatitis B virus (HBV) among risk groups and harm reduction interventions at adequate scale and coverage for injecting drug users are needed. Transmission of HBV and hepatitis C virus (HCV) in healthcare settings and a higher prevalence of HBV and HCV among recipients of blood and blood products in the Balkan and North African countries highlight the need to implement and monitor universal precautions in these settings and use voluntary, nonremunerated, repeat donors. Progress in drug discovery has improved outcomes of treatment for both HBV and HCV, although access is limited by the high costs of these drugs and resources available for health care. Egypt, with the highest burden of hepatitis C in the world, provides treatment through its National Control Strategy. Addressing the burden of viral hepatitis in the Balkan and Mediterranean regions will require national commitments in the form of strategic plans, financial and human resources, normative guidance and technical support from regional agencies and research.

Exosome-mediated transmission of hepatitis C virus between human hepatoma Huh7.5 cells

Recent evidence indicates there is a role for small membrane vesicles, including exosomes, as vehicles for intercellular communication. Exosomes secreted by most cell types can mediate transfer of proteins, mRNAs, and microRNAs, but their role in the transmission of infectious agents is less established. Recent studies have shown that hepatocyte-derived exosomes containing hepatitis C virus (HCV) RNA can activate innate immune cells, but the role of exosomes in the transmission of HCV between hepatocytes remains unknown. In this study, we investigated whether exosomes transfer HCV in the presence of neutralizing antibodies. Purified exosomes isolated from HCV-infected human hepatoma Huh7.5.1 cells were shown to contain full-length viral RNA, viral protein, and particles, as determined by RT-PCR, mass spectrometry, and transmission electron microscopy. Exosomes from HCV-infected cells were capable of transmitting infection to naive human hepatoma Huh7.5.1 cells and establishing a productive infection. Even with subgenomic replicons, lacking structural viral proteins, exosome-mediated transmission of HCV RNA was observed. Treatment with patient-derived IgGs showed a variable degree of neutralization of exosome-mediated infection compared with free virus. In conclusion, this study showed that hepatic exosomes can transmit productive HCV infection in vitro and are partially resistant to antibody neutralization. This discovery sheds light on neutralizing antibodies resistant to HCV transmission by exosomes as a potential immune evasion mechanism.

The effect of stimulant use on antiviral treatment in an integrated hepatitis clinic

OBJECTIVE

The objective was to determine the impact of stimulant use on antiviral treatment for chronic hepatitis C patients in an integrated hepatitis clinic.

METHODS

A retrospective chart review of 449 consecutive patients seen in an integrated hepatitis clinic that included co-located mental health clinicians was performed. Psychiatric measures included drug use questionnaire, Beck Depression Inventory (BDI), Alcohol Use Disorders Identification Test-Consumption questions (AUDIT-C), urine drug screen and antiviral treatment outcomes. Patients with stimulant use were compared to patients with no drug use, other drug users and an unknown drug use group using χ(2) and analysis of variance tests.

RESULTS

Over 15% of hepatitis C patients presenting to the clinic were using stimulants. Stimulant users had higher BDI and AUDIT-C scores. They were more likely to be followed by a co-located mental health clinician than other groups and were just as likely to initiate and finish antiviral therapy.

CONCLUSIONS

Recent stimulant use is common in hepatitis C patients presenting to a hepatitis clinic. Stimulant users were more depressed and used alcohol to a greater degree than nonusers but were as likely to start antiviral therapy. An integrated mental health/medical care approach appears to be effective in addressing this difficult-to-treat population.

Perceptions of drug users regarding hepatitis C screening and care: a qualitative study

BACKGROUND

Illicit drug users have a high prevalence of HCV and represent the majority of newly infected persons in the U.S. Despite the availability of effective HCV treatment, few drug users have been evaluated or treated for HCV. Racial and ethnic minorities have a higher incidence and prevalence of HCV and higher HCV-related mortality. Factors contributing to poor engagement in care are incompletely understood.

METHODS

Fourteen mixed-gender focus groups of either African American or Latino/a drug users (N = 95) discussed barriers to HCV testing and treatment. Themes were identified through content analysis of focus group discussions.

RESULTS

Many drug users were tested for HCV in settings where they were receiving care. Outside of these settings, most were unaware of voluntary test sites. After testing HCV positive, drug users reported not receiving clear messages regarding the meaning of a positive HCV test, the impact of HCV infection, or appropriate next steps including HCV clinical evaluations. Many drug users perceived treatment as unimportant because they lacked symptoms, healthcare providers minimized the severity of the diagnosis, or providers did not recommend treatment. Mistrust of the motivations of healthcare providers was cited as a barrier to pursuing treatment. Social networks or social interactions were a source of HCV-related information and were influential in shaping drug users perceptions of treatment and its utility.

CONCLUSION

Drug users perceived a paucity of settings for self-initiated HCV testing and poor provider-patient communication at test sites and during medical encounters. Notably, drug users reported having an unclear understanding about the meaning of a positive HCV test, the health implications of HCV infection, the importance of clinical evaluations and monitoring, and of treatment options for HCV. Efforts to improve the delivery of clinical messages about HCV infection for drug users at test settings and clinical encounters are needed.

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.

Treatment of chronic hepatitis C infection among current and former injection drug users within a multidisciplinary treatment model at a community health centre

The aim of the present prospective observational study was to assess uptake and success of hepatitis C virus (HCV) treatment among a group of former and current injection drug users with chronic HCV infection at the Street Health Centre in Kingston, Ontario. The Street Health Centre offers hepatitis C education, assessment and treatment within a multidisciplinary, integrated and collaborative treatment model of care delivered by primary care professionals. The study enrolled a convenience sample of 34 patients. Seventy per cent of study patients had no postsecondary education, 85% were unemployed and one-third were unstably housed. A majority of study patients self-reported mental health problems. Of the 14 patients who initiated antiviral treatment in the study period, eight (57%) achieved sustained virological response. Regardless of virological outcome, patients who initiated treatment showed positive trends toward increased social and psychiatric stability, and decreases in high-risk behaviours. These results suggest that not only is successful treatment of chronic HCV infection in current and former injection drug users with concurrent psychiatric disorders possible, but the benefits of such treatment delivered in a community-based, multidisciplinary, primary care model may extend beyond narrowly defined virological outcomes.

Natural killer cell activity and function in chronic HCV-infected patients during peg interferon and ribavirin: early effects of active substance use

In Western countries, chronic hepatitis C virus (HCV)-infection mostly affects former and active substance users. The effect of active substance use on interferon (IFN)-responsiveness and therapy efficacy is not well understood. In this study, we compared natural killer (NK) cell activity and function in healthy controls and chronic HCV-infected patients with and without active substance use, as well as the early effects of antiviral therapy with peg-IFN and ribavirin. No differences were observed between chronic HCV patients and healthy individuals in the number and frequencies of CD56(dim) and CD56(bright) NK cells. Also, IL-12/18-induced IFN-gamma production by NK cells was comparable between all groups, whereas the cytotoxic ability of NK cells (granzyme and CD107a levels) was more potent in HCV-infected patients as compared to healthy controls, and highest in non-substance users. Moreover, at baseline, the activation of NK cells was significantly lower in HCV-infected patients who used substances, when compared to healthy individuals. Therapy-induced viral load reduction assessed early at day 7 showed a similar decline in substance users and non-substance use HCV patients, with 25% substance users and 17% non-substance users testing HCV-RNA negative at day 7. Furthermore, early during IFN-based therapy, NK cells from HCV patients remained responsive to IFN, and only a minor decline in the degree of STAT-1 phosphorylation was observed irrespective of substance use. These findings were further supported by comparable in vitro p-STAT-1 induction in all three experimental groups. Despite subtle differences at baseline between healthy individuals and chronic HCV patients, we observed that active substance use in chronic HCV-infected patients did not affect the immune responsiveness to IFN early after start of treatment, and thus, we found no evidence - from an immunological point of view - that antiviral therapy of our cohort of HCV-infected patients with active substance use is less efficient.

Determinants of hepatitis C virus treatment completion and efficacy in drug users assessed by meta-analysis

BACKGROUND

Hepatitis C virus (HCV)-infected drug users (DUs) have largely been excluded from HCV care. We conducted a systematic review and meta-analysis of the literature on treatment completion and sustained virologic response (SVR) rates in DUs. We assessed the effects of different treatment approaches and services to promote HCV care among DUs as well as demographic and viral characteristics.

METHODS

Studies of at least 10 DUs treated with pegylated interferon/ribavirin that reported SVR were analyzed. Heterogeneity was assessed (Cochran test) and investigated (meta-regression), and pooled rates were estimated (random effects).

RESULTS

Thirty-six studies comprising 2866 patients were retrieved. The treatment completion rate among DUs was 83.4% (95% confidence interval [CI], 77.1%-88.9%). Among studies that included addiction-treated and untreated patients during HCV therapy, the higher the proportion of addiction-treated patients, the higher the HCV treatment completion rate (P < .0001). After adjusting for human immunodeficiency virus (HIV)/HCV coinfection, sex, and treatment of addiction, support services during antiviral therapy increased treatment completion (P < .0001). The pooled SVR rate was 55.5% (95% CI, 50.6%-60.3%). Genotype 1/4 (P = .0012) and the proportion of HIV-coinfected DUs (P = .0173) influenced the SVR rate. After adjusting for HCV genotype 1/4 and HIV/HCV coinfection, the SVR rate was positively correlated with involvement of a multidisciplinary team (P < .0001).

CONCLUSIONS

Treatment of addiction during HCV therapy results in higher treatment completion. Our pooled SVR rate is similar to that obtained in registration trials in the general population. Treatment of addiction during HCV therapy will likely be important for HCV-infected DUs undergoing treatment with more complex regimens including direct-acting antivirals.

Accessing Hepatitis C patients who are difficult to reach: it is time to overcome barriers

With the arrival of simple, efficient and safe interferon-free treatment regimens, hepatitis C virus (HCV) therapy will have the potential to be successfully used for the majority of infected patients and prevent the associated morbidity and mortality. With the current treatment uptake rates, only a very small proportion of HCV-infected patients are reached. Paradoxically, treatment rates are lowest in the most affected at-risk group - people who inject drugs (PWID) - which is the major driving force behind the spread of HCV infection. To conquer the increasing problem of HCV-related liver disease, many existing but modifiable obstacles, which prevent detection, assessment and treatment uptake, have to be overcome in this population. This review article summarizes the existing literature on the most relevant barriers preventing HCV care and describes measures to overcome these obstacles.

HIV and viral hepatitis C coinfection in people who inject drugs: implications of new direct acting antivirals for hepatitis C virus treatment

PURPOSE OF REVIEW

The recent major shift toward oral direct acting hepatitis C virus (HCV) treatments has the potential to revolutionize the global response to HCV. People who inject drugs (PWID) are a large key affected population who stand to benefit from these new medications.

RECENT FINDINGS

There is a large number of new drug classes and targets with activity against HCV. Although effective for HCV treatment in monoinfection and coinfection with HIV, most direct-acting antivirals (DAAs) remain within the research pipeline, with only two having achieved regulatory approval to date. Clinical trial data are not available regarding HCV treatment for PWID with DAAs. This article reviews clinical data on HCV treatment for a number of promising compounds in HCV monoinfection and coinfection with HIV and discusses the barriers facing PWID in scale-up and roll-out of DAAs in the coming years.

SUMMARY

DAAs have the potential to revolutionize HCV treatment. There will be significant access barriers for people who inject drugs to these new medications.

Tangible resources for preparing patients for antiviral therapy for chronic hepatitis C

BACKGROUND

Chronic hepatitis C (HCV) infected patients with coexisting mental health and/or substance abuse issues face significant barriers to treatment and are often deferred. This paper sought to highlight critical pre-treatment strategies and provide tangible resources for HCV clinicians to facilitate preparation and successful treatment of these patients.

METHODS

Guided by the clinical experience of our liver center, a large, tertiary academic medical center, and informed by the extant literature, we summarize pre-treatment strategies and specific resources and recommendations for HCV providers.

RESULTS

Four key pre-treatment strategies include: 1) screening for mental health/substance abuse issues using brief, reliable and validated instruments; 2) locating and establishing collaborative care with mental health and substance abuse specialists; 3) using a motivational interviewing communication style; and 4) addressing adherence-related issues.

CONCLUSIONS

HCV clinicians are in a unique position to prepare patients with coexisting mental health and/or substance abuse issues for antiviral therapy.

Time to rethink antiviral treatment for hepatitis C in patients with coexisting mental health/substance abuse issues

BACKGROUND

A new era has dawned in the treatment of chronic hepatitis C (HCV) virus with the use of direct-acting antiviral medications augmenting combination therapy. Unfortunately, the significant impact of improvements may not be realized if antiviral treatment is not expanded to include a larger proportion of patients, many of whom have coexisting mental health and/or substance abuse issues and have been historically deferred from treatment.

METHODS

We reviewed the extent literature on HCV treatment for individuals with co-occurring mental health and/or substance abuse issues.

RESULTS

A number of empirically-based arguments exist in favor of treating HCV-infected individuals with mental health and/or substance abuse issues within the context of multidisciplinary team approaches. Integrated, collaborative, or hybrid models of care are just a few examples of multidisciplinary approaches that can combine the care of HCV treating providers with mental health and/or addictions providers to safely and effectively treat these patients. Collectively, these arguments and the empirical evidence that supports them, provides a strong rationale for why expanding antiviral therapy to these patients is critical and timely.

CONCLUSIONS

A decade of evidence suggests that HCV-infected individuals with mental health and/or substance abuse issues can safely and effectively undergo antiviral treatment when delivered through multidisciplinary care settings. Multidisciplinary approaches that combine HCV treating providers with mental health, addictions, and other support systems can facilitate preparation and successful treatment of these patients on antiviral therapy.

Should active injecting drug users receive treatment for chronic hepatitis C?

CONTEXT

Accumulating data propose that active injecting drug users might not differ from the general population in terms of sustained virological response when adherent to therapy for chronic hepatitis C. However, current guidelines contain restrictive recommendations for therapy in this group of patients.

OBJECTIVE

Therefore, we evaluated a cohort of chronic hepatitis C patients regarding the potent influence of active drug using on initial informed consent, compliance and sustained virological response to treatment.

METHOD

For that purpose, 162 consecutive patients (of which 62 active injecting drug users), who had been evaluated during the last 6 years in our center for chronic hepatitis C and proposed to receive treatment with pegylated interferon alpha and ribavirin, were enrolled. Initial informed consent, compliance, and sustained virological response as well as data regarding age, gender, body mass index, genotype, viral load, coinfection with HBV/HDV/HIV, administered interferon alpha (2a or 2b), liver function tests, liver histology, urban residence, ethnicity, and concomitant use of alcohol were collected and analyzed in respect with injecting drug using.

RESULTS

Injecting drug using was positively correlated with male gender (P<0.001), young age (P<0.001), native origin (P = 0.043), and concomitant use of alcohol (P<0.001). Comparable initial informed consent (P = 0.836), compliance (P = 0.879), and sustained virological response (P = 0.132) were observed between injecting drug users and non- injecting drug users. The results were confirmed using a multiple regression model.

CONCLUSION

Our data further support that active injecting drug users do not constitute a distinct chronic hepatitis C patient group in terms of initial informed consent, compliance, or sustained virological response. Therefore, injecting drug using should not be a major determinant influencing the decision for treatment of chronic hepatitis C in eligible patients.

Current therapies for chronic hepatitis C

Hepatitis C virus affects more than 180 million people worldwide and as many as 4 million people in the United States. Given that most patients are asymptomatic until late in the disease progression, diagnostic screening and evaluation should be performed in patients who display high-risk behaviors associated with acquisition of hepatitis C. Chronic hepatitis C is associated with cirrhosis, hepatic failure, and death; therefore, treatment is aimed at reducing these complications, as well as improving quality of life and minimizing adverse effects. The American Association for the Study of Liver Diseases Practice Guidelines on the Diagnosis, Management, and Treatment of Hepatitis C represent the gold standard for guidance on the management of hepatitis C. Standard treatment for hepatitis C is peginterferon alpha in combination with ribavirin. Currently, two pegylated interferon products are approved by the U.S. Food and Drug Administration for the treatment of hepatitis C. The duration of therapy with peginterferon and ribavirin is dictated by viral genotype and virologic response. Additional therapies are under investigation for treatment of chronic hepatitis C and show early promise of comparative efficacy and fewer adverse effects. Special considerations in certain populations, including patients coinfected with human immunodeficiency virus, those with end-stage renal disease, injection drug users, pregnant women, and pediatric patients, should guide treatment decisions.

Evolution of HCV incidence in drug users in France

Over the last 40 years, the dynamics of hepatitis C virus (HCV) infection in drug users has been affected by the illicit drug market, the health environment including the devastating impact of the HIV/AIDS epidemic which erupted in the 1980s, and the diffusion of substitution treatment beginning in 1995. The purpose of this literature review is to present the dynamics of HCV infection in drug users in France over the last 40 years. Two prevalence studies of HCV infection in the general population were conducted by the French Institute for Public Health Surveillance in 1994 and 2004 and were the touchstone data sources for this analysis. Hypotheses constructed from the findings of these two studies were examined in light of results reported by multicentre prevalence and incidence studies in drug-user populations. The incidence of HCV infection in drug users in France reached a peak in the late 1980s or early 1990s after a lengthy period of epidemic expansion. Implementation of a risk reduction policy enabled a very significant reduction in the incidence of HCV infection in drug users over the last 20 years, leading to incidence figures which are now 10–15% of the 1990 estimate.

Hepatitis C testing and treatment among active drug users in Amsterdam: results from the DUTCH-C project

BACKGROUND

Although hepatitis C virus (HCV) treatment has shown to be effective, uptake of treatment among active drug users is still low. The Drug Users Treatment for Chronic Hepatitis-C project aims to offer active drug users in Amsterdam HCV testing and treatment using a multidisciplinary approach.

METHODS

The study population comprises drug users participating in the Amsterdam Cohort Studies and drug users referred to the Drug Users Treatment for Chronic Hepatitis-C unit. Drug users were offered HCV testing and, if chronically infected, medical and psychiatric screening and HCV treatment. Various specialists collaborated to provide optimal care. We assessed test-uptake and treatment-uptake and outcomes.

RESULTS

Four hundred and ninety-seven Amsterdam Cohort Studies drug users were offered HCV testing: 449 out of 497 (90%) accepted. HCV antibodies were found in 267 out of 449 (60%): 183 out of 267 (69%) were HCV-viremic and 49 out of 183 (27%) were HIV-co-infected. Of the 134 HCV-monoinfected patients, 102 (76%) initiated additional medical screening and 44 started treatment by 1 July 2009. Sixty-two drug users referred from methadone clinics were also HCV-monoinfected, of whom 14 started treatment by 1 July 2009. In total 58 persons were treated: 16 (27%) with genotype 1 or 4, 42 (72%) with genotype 2 or 3. Eighty-four percent used methadone, 97% used drugs (heroin, cocaine or amphetamine) at least once in the 6 months before treatment, 19% were active injectors. Sixty-two percent used alcohol, 41% had psychiatric disease other than substance abuse. Of the 57 individuals with sufficient follow-up, 37 (65%) achieved sustained virological response.

CONCLUSION

In a multidisciplinary setting, HIV-negative drug users with chronic HCV infection can be treated successfully despite active drug or alcohol use and psychiatric diseases. Therefore, access to HCV therapy using an integrated approach should be increased for this population.

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

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